[Data-guided learning from suicidal incidents by using KEHR SUICIDE. A practice example in a Dutch mental health care facility]. / Datagestuurd leren van suïcidale incidenten met KEHR SUICIDE: GGz Eindhoven als praktijkvoorbeeld.

BACKGROUND: Specific and systematic data on health care providers' behaviour is needed to futher improve the care provided to suicidal patiënts in mental health care facilities.
METHOD: Explorative observational study of all suicidal incidents (n=50) that occurred in a Dutch mental health care facility over a one year period. Incidents were evaluated using KEHR SUICIDE, a questionnaire that assesses to what extent health care providers' conduct was compliant to the suicide practice guideline in the context of patients' suicidal behaviour. Associations between health care providers' and patients' features and guideline compliant behaviours of health care providers were calculated by logistic regression models.
RESULTS: Health care providers showed less guideline compliant behaviour when the patient had a psychotic, substance abuse or development disorder or had no axis 1 disorder. A positive association was found between guideline compliant behaviour and the extent to which the incident had been expected. CONCLUSION Guideline compliant behaviour of mental health care providers appears to be related to the axis 1 disorder of patients in a Dutch mental health care facility. Still, the application of guideline compliant behaviour concerning suïcide incidents shows room for improvement. KEHR SUICIDE is shown to be a helpful tool for multidisciplinary evaluation of suicidal incidents as it provides specific, ready-made information by which mental health care facilities can guide, examine and adjust suicide prevention policy. The outcomes provide hypotheses that may be examined in future research.

[Suicidal behaviour and attempted suicide occurring during assessment by the outreach psychiatric emergency service]. / Het vóórkomen van suïcidaal gedrag en suïcidepogingen bij de psychiatrische crisisdienst.

BACKGROUND: The outreach emergency psychiatric service plays an important role in recognising, arranging interventions and preventing suicide and suicidal behaviour. However, little is known about the assessments that members of the emergency team make when faced with patients showing suicidal behaviour.
AIM: To describe the relationships that are revealed between patient characteristics, suicidal thoughts and attempted suicide during assessments made by the emergency psychiatric service in The Hague.
METHOD: The emergency service kept a detailed record of 14,705 consultations. We compared the characteristics of patients who had suicidal thoughts with those of patients who had no such thoughts and we also compared the characteristics of patients who had attempted to commit suicide with those of patients who had not. We drew these comparisons by using logistic regression models, adjusting for clustering.
RESULTS: 32.2% of the patients showed signs of suicidal behaviour and 9.2 % appeared likely to attempt suicide. Suicidal behaviour occurred most often in patients with depression. Suicidal patients were more often admitted to hospital than were non-suicidal patients and they were more likely to have been referred by a general practitioner or a general hospital. Medication was the most frequent means employed in attempts to commit suicide.
CONCLUSION: In about one third of the consultations of the outreach emergency psychiatric service, the patient showed suicidal behaviour. The actions and the policy of the emergency psychiatric service with regard to suicidal behaviour were diverse and dependent on factors that could change over the course of time.

[An evaluation of a new Dutch suicide prevention tool (KEHR); datadriven evaluation and learning]. / Pilotstudie naar kwalitatieve evaluatie van het handelen rond suïcide (KEHR); datagestuurd evalueren en leren.

BACKGROUND: Multidisciplinary evaluation of suicide cases effectively decreases the suicide rate in mental health care. A new suicide prevention tool (KEHR) can be used in this connection. KEHR has been developed on the basis of the Dutch multidisciplinary practice guideline on the assessment and treatment of suicidal behaviour. The guideline can serve as a frame of reference for the multidisciplinary evaluation of suicide cases. KEHR aims to provide professionals with a better method for preventing suicide. AIM: To describe and evaluate the recently developed KEHR strategy for reducing the number of suicide cases in mental health care. METHOD: Naturalistic and observational study. In the course of a year 22 out of 23 suicide cases that had occurred in the pilot institution were evaluated with the help of the KEHR system. Outcomes were discussed with members of multidisciplinary teams. Quantitative and qualitative methods were used in the evaluation process. RESULTS: Professionals from the main disciplines involved were very willing to use the new tool and were prepared to reflect on their views on the outcomes. The professionals were ready to learn from the suicide cases. Data collected with the tool provided information that can be used to improve guideline adherence. However, the use of KEHR did not lead automatically to the formulation of adjustments and improvements relating to suicidal patients. A specific procedure for improving individual and team performance needs to be developed and tested thoroughly. CONCLUSION: KEHR is a promising strategy for improving and enhancing the guideline on the diagnosis and treatment of suicidal behaviour of patients in mental health care. Special procedures need to be developed and studied in order to implement the improvements deemed necessary as a result of the pilot study. The KEHR tool (in the Dutch language) is accessible to mental health care workers after online registration (www.mijnkehr.nl).

Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands.

OBJECTIVE: To study the effect of travel time, at the start or during labour, from home to hospital on mortality and adverse outcomes in pregnant women at term in primary and secondary care. DESIGN: Population-based cohort study from 2000 up to and including 2006. SETTING: The Netherlands Perinatal Registry. POPULATION: A total of 751,926 singleton term hospital births. METHODS: We assessed the impact of travel time by car, calculated from the postal code of the woman's residence to the 99 maternity units, on neonatal outcome. Logistic regression modelling with adjustments for gestational age, maternal age, parity, ethnicity, socio-economic status, urbanisation, tertiary care centres and volume of the hospital was used. MAIN OUTCOME MEASURES: Mortality (intrapartum, and early and late neonatal mortality) and adverse neonatal outcomes (mortality, Apgar <4 and/or admission to a neonatal intensive care unit). RESULTS: The mortality was 1.5 per 1000 births, and adverse outcomes occurred in 6.0 per 1000 births. There was a positive relationship between longer travel time (≥20 minutes) and total mortality (OR 1.17, 95% CI 1.002-1.36), neonatal mortality within 24 hours (OR 1.51, 95% CI 1.13-2.02) and with adverse outcomes (OR 1.27, 95% CI 1.17-1.38). In addition to travel time, both delivery at 37 weeks of gestation (OR 2.23, 95% CI 1.81-2.73) or 41 weeks of gestation (OR 1.52, 95% CI 1.29-1.80) increased the risk of mortality. CONCLUSIONS: A travel time from home to hospital of 20 minutes or more by car is associated with an increased risk of mortality and adverse outcomes in women at term in the Netherlands. These findings should be considered in plans for the centralisation of obstetric care.

[Suicidal tendencies, a disorder that crosses boundaries between disciplines]. / Suïcidaliteit--een stoornis die specialismen overstijgt.

BACKGROUND: Suicidality is considered to be a facultative symptom of certain psychiatric disorders. AIM: To provide evidence in support of the view that suicidality is not only a symptom of other disorders or comorbid with them but is often a disorder in its own right. METHOD: We conducted a review of the literature. RESULTS: Suicidality manifests itself as a disorder in its own right without any one-to-one relationships with other psychiatric or somatic disorders or illnesses. CONCLUSION: Suicidality has specific features of its own such as susceptibility to interindividual contagion. By preventing suicide we may be able to forestall the development of other types of ill-health and thus improve the quality of the life that has been saved.

[Relief for surviving relatives following a suicide]. / Opvang van de nabestaanden na een suïcide.

After the suicide of a 43-year-old woman with known depression, a 41-year-old paraplegic man who recently developed diarrhoea and a 41-year-old woman with probable depression with symptoms of psychosis, the general practitioners of the surviving relatives offered a sympathetic ear, answered questions and prescribed sedatives and/or follow-up counselling. Completed suicide occurs 1500 times each year in the Netherlands and is strongly associated with psychiatric morbidity as well as psychological features like hopelessness and inability to solve problems. Generally, this irreversible act ofdespair can lead to existential difficulties in surviving relatives. Following a loss, acceptance of reality is essential to initiating effective emotional processing. The general practitioner is often first and foremost involved in providing support and comfort to bereaved families, during which many questions about the cause of death are brought up. The general practitioner helps the family to reconstruct the rationale behind the suicide in order to initiate effective emotional processing. In addition, the general practitioner can assess the risk of psychiatric morbidity, including suicidal behaviour, in surviving relatives.

Responses of the circadian system of rats to conditioned and unconditioned stimuli.

The circadian systems of rodents respond to light pulses presented during the subjective night with phase shifts and altered cellular activity in the suprachiasmatic nuclei (SCN), including expression of immediate-early genes (IEGs) such as c-fos. A recent study showed that a nonphotic stimulus (an air disturbance generated by a fan) that does not normally induce the expression of c-fos-like immunoreactivity in the SCN of rats can be made to do so after being paired repeatedly with a light pulse in a Pavlovian conditioning paradigm. Furthermore, after conditioning (but not after noncontingent exposure to these stimuli), the fan also induced phase shifts in activity and body temperature rhythms comparable to those produced by light. The authors performed three experiments designed to replicate and extend these findings in rats. In experiment 1, rats were tested for conditioning effects of repeated pairings of a light pulse with a neutral air disturbance under a full photoperiod. In experiment 2, a modified conditioning paradigm was used in which a skeleton photoperiod served as both the entraining zeitgeber and the unconditioned stimulus. Animals in the paired and unpaired training conditions were exposed to both the light pulse and the air disturbance, but the air disturbance signaled the onset of light in the paired condition only. Phase shifts of wheel-running activity rhythms and gene expression in the SCN, intergeniculate leaflet, and paraventricular nucleus of the thalamus were assessed in animals following either of the training conditions or the control procedures. Experiment 3 assessed whether the air disturbance could entrain the circadian activity rhythms of rats with or without previous pairing with light in a classical conditioning paradigm. No evidence for classical conditioning, nor for unconditioned effects of the air disturbance on the circadian system, was found in these studies.

Lateralized neuropsychological functioning in depressive patients before and after drug therapy.

Several decades of research have led to different hypotheses about cognitive functioning in depression; one of the hypotheses states that there is altered functioning of the hemispheres during a depressive episode. Lateralization studies have found diminished neuropsychological functioning in depressive patients; especially right-hemisphere functions seem impaired. In our study we used conventional neuropsychological tests to study shifts in hemispheric functioning. Neuropsychological testing before and after therapy in 52 (for the most part therapy-resistant) depressives showed no substantial effects in lateralized functioning. None of the measures enabled prediction of response to treatment; however 17 different interaction variables were identified, five of which make an unique contribution.

Discrimination of circadian phase in intact and suprachiasmatic nuclei-ablated rats.

This study examined whether the circadian system of rats can serve as a consulted clock for discriminating time of day. Food restricted rats housed in activity wheels were trained to lever press for food in a two-lever T-maze in which the left arm was correct in a morning feeding session, and the right arm in an afternoon session (7 h interval). All six rats learned the task (discrimination ratios > chance on 85-95% of sessions) and exhibited anticipatory wheel running prior to most sessions. Performance was not disrupted by inverting the LD cycle or by omitting 1-3 sessions, indicating that learning was not dependent on light-dark cues, alternation strategies, or physiological states associated with intermeal interval. Five of six additional rats with ablations of the suprachiasmatic nucleus light-entrainable pacemaker acquired the discrimination, indicating that time-of-day cues can be provided by another circadian pacemaker (likely food-entrainable). The results provide the first clear evidence that the circadian system in a mammal can function as a consulted clock that provides discriminative time cues for cognitive processes subserving behavioral plasticity.

Chlormethiazole dependency--a case report.

Although dependency is reported to be one of the side effects of chlormethiazole, very few cases of such dependency have been reported. A detailed report of a female patient with a previous history of other dependencies, and who subsequently became dependent on chlormethiazole, is offered.