Cultural competence of mental health practitioners in the Netherlands.

BACKGROUND: The importance of providing mental health from a transcultural perspective in establishing a therapeutic alliance is recognized. However, it is currently unknown how many mental health practitioners in the Netherlands feel capable of providing mental healthcare from a transcultural perspective, or if they are familiar with the Cultural Formulation Interview (CFI). The CFI is a tool used in mental health care to gather culturally relevant patient information, enhancing cultural sensitivity in treatment. It is also unknown if there is a difference between psychiatrist and psychiatry residents in terms of their cultural competence. AIMS: This study aimed to assess the self-appraised cultural competence of Dutch psychiatrist and psychiatry residents, including their knowledge of the CFI, and the need for further training. METHODS: A cross-sectional study was conducted among psychiatrists and psychiatry residents by means of an online questionnaire. RESULTS: Ninety-seven mental health practitioners completed the questionnaire. Of the psychiatrists 70% and of the residents 76% reported that treating patients from cultural backgrounds different from their own background is challenging. Only 44% of psychiatrists and 34% of residents considered themselves sufficiently culturally competent, and 56% and 47% respectively, were uninformed about the CFI. The majority of psychiatrists and residents (70 vs 84%) indicated a need for more training in cultural competence. CONCLUSION: The majority of psychiatrists and residents in The Netherlands considered treating patients from different cultural backgrounds a challenge, reported feeling insufficiently culturally competent, lacked experience with the cultural formulation interview and reported a need for more training in cultural competence.

[Muscarinic M1 and/or M4 receptor agonists as potential novel treatments for psychoses]. / Muscarine 1- en/of 4-receptoragonisten als potentieel nieuwe behandeling voor psychosen.

BACKGROUND: Research suggests that cholinergic muscarinic 1 (M1) and/or muscarinic 4 (M4) receptors may be involved in the pathophysiology of psychotic disorders. Agonistic modulation of these receptors can offer new treatment options. AIM: To provide an overview of current research on the role of cholinergic M1 and M4 receptors in the development and treatment of psychoses, with special attention to the development of new drugs such as xanomeline and emraclidine. METHOD: To obtain an overview, we searched for English-language studies published in PubMed, Embase, and PsycInfo up until June 1, 2023. We examined the role and effects of M1 and/or M4 agonists in schizophrenia. Additionally, we consulted clinical trial registers. RESULTS: Our search strategy resulted in nine published articles on five clinical studies. These studies revealed that reduced presence of M1 receptors, primarily in the frontal cortex, and M4 receptors, primarily in the basal ganglia, are associated with psychoses. M1 and M4 receptors modulate dopaminergic activity in the ventral tegmentum and striatum through various pathways. Several M1 and/or M4 agonists, partial agonists, and positive allosteric modulators (PAMs) have been developed. Drugs exhibiting agonistic activity on M1 and/or M4 receptors, such as xanomeline-trospium (phase 2 and 3 studies) and emraclidine (phase 1b studies), have shown positive effects on cognitive and potentially negative symptoms in patients with schizophrenia. CONCLUSION: M1 and/or M4 receptor agonists show potential as new treatment strategies for individuals with psychotic disorders. Although initial studies with xanomeline-trospium and emraclidine have shown positive results, further research is needed to assess their long-term efficacy, safety, and tolerability before these new medications can be evaluated.

[The influence of maternal choline supplementation on fetal brain development and the risk of psychotic symptoms]. / De invloed van maternale cholinesuppletie op foetale hersenontwikkeling en het risico op psychose.

BACKGROUND: Choline is an essential micronutrient important for fetal brain development. Research suggests that maternal choline supplementation during pregnancy may reduce the risk of developing neuropsychiatric disorders such as psychosis in offspring. AIM: To provide a narrative review of evidence from the literature for the possible prevention of neuropsychiatric problems such as psychosis by maternal choline supplementation. METHOD: A narrative review of the literature obtained after searches in PubMed, Embase and PsycINFO. RESULTS: Nutritional studies indicate that most pregnant women do not receive sufficient dietary choline. This may have adverse effects on fetal brain development. A total of 8 studies were identified; 4 animal and 4 clinical studies. Beneficial effects of maternal choline supplementation were found on fetal brain development, including cognitive and psychosocial functioning of children. No evidence of (serious) side effects was found. Due to the relatively short duration and limited size of the studies, no conclusions could be drawn about the role of maternal choline supplementation in the prevention of neuropsychiatric problems such as psychosis. CONCLUSION: Maternal choline supplementation and/or a choline-rich diet during pregnancy should be further investigated because of evidence of beneficial effects on infant mental functioning, low cost and few side effects. There is no evidence that maternal choline supplementation can prevent psychotic symptoms in offspring.

Sexual dysfunction related to psychiatric disorders: a systematic review.

BACKGROUND: Sexual dysfunction is thought to be highly prevalent in patients with psychiatric disorders. Factors such as the use of psychotropic substances (ie, psychopharmaceuticals and drugs), age, or somatic diseases may contribute to sexual problems, but the extent to which psychopathology itself affects sexual functioning is not well understood. AIM: The study sought to provide an overview of the literature on the prevalence of sexual dysfunction in psychotropic-free and somatic disease-free psychiatric patients. METHOD: A systematic review (PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses]) was conducted by 2 authors (TH and AWMP) independently, with the review process being monitored by a third author. Relevant articles on the relationship between sexual dysfunctions and psychopathology were searched in PubMed, Web of Science, and PsycINFO from inception until June 16, 2022. The study methods were entered in the international register of systematic reviews PROSPERO (2021, CRD42021223410). OUTCOMES: The main outcome measures were sexual dysfunction and sexual satisfaction. RESULTS: Twenty-four studies were identified, including a total of 1199 patients. These studies focused on depressive disorders (n = 9 studies), anxiety disorders (n = 7), obsessive- compulsive disorder (OCD) (n = 5), schizophrenia (n = 4), and posttraumatic stress disorder (n = 2). No studies on bipolar disorder were found. Reported prevalence rates of sexual dysfunction in psychiatric disorders were 45% to 93% for depressive disorders, 33% to 75% for anxiety disorders, 25% to 81% for OCD, and 25% for schizophrenia. The most affected phase of the sexual response cycle was sexual desire, in both men and women with depressive disorders, posttraumatic stress disorder, and schizophrenia. Patients with OCD and anxiety disorders most frequently reported dysfunction in the orgasm phase, 24% to 44% and 7% to 48%, respectively. CLINICAL IMPLICATIONS: The high prevalence of sexual dysfunction requires more clinical attention by means of psychoeducation, clinical guidance, sexual anamnesis, and additional sexological treatment. STRENGTHS AND LIMITATIONS: This is the first systematic review on sexual dysfunction in psychotropic-free and somatic disease-free psychiatric patients. Limitations include the small number of studies, small sample sizes, the use of multiple questionnaires (some not validated), which may contribute to bias. CONCLUSION: A limited number of studies identified a high prevalence of sexual dysfunction in patients with a psychiatric disorder, with substantial variation between patient groups in frequency and phase of reported sexual dysfunction.

Maternal choline supplementation during pregnancy to promote mental health in offspring.

AIM: There is increasing interest in the role of choline in brain development, including its possible role in promoting mental health and preventing mental illness. Choline is an essential micronutrient in fetal brain maturation. In more than 90% of pregnant women, choline intake has been found to be lower than the daily-recommended dose. The aim of this article is to review what is known about the effects of maternal choline supplementation on fetal brain development, early child development and mental health. METHODS: A narrative review of the literature. RESULTS: A limited number of studies suggest that maternal choline supplementation during pregnancy may enhance fetal brain development and improve early signs and symptoms that may predispose to mental illness. CONCLUSION: The general low maternal choline intake during pregnancy, expected health benefits and low risks, make a plea for maternal choline supplementation to promote mental health. Choline supplementation may be especially important for pregnant women with a (family) history of severe mental illness and/or alcohol dependence.

[An antipsychotic without dopamine receptor blockade?] / Een antipsychoticum zonder dopamine­receptorblokkade?

BACKGROUND: Current antipsychotic treatment is suboptimal. There is an urgent need for new antipsychotics with new mechanisms of action. SEP-363856 is a trace amine-associated receptor 1 (TAAR1) agonist and a serotonin 5-HT1a agonist with potential antipsychotic properties. AIM: To describe the rationale for the development of SEP-363856, the pharmacology of TAAR1/5-HT1a agonists, and the clinical efficacy of SEP-363856. METHOD: A narrative review of the literature using PubMed, Embase and PsychINFO. RESULTS: Six publications were identified, one of which was a phase 2 clinical trial with SEP-363856. This phase 2 study shows that SEP-363856 is an effective and well-tolerated antipsychotic; positive, but also negative symptoms decreased; motor side effects (akathisia) and prolactin increase did not occur, while metabolic side effects hardly occurred. Reported side-effects were somnolence and nausea. The antipsychotic activity of SEP-363856 appears to be (pre)clinical not based on D2 antagonism, but on TAAR1 and 5-HT1a agonism. CONCLUSION: TAAR1 and 5-HT1a agonists such as SEP-363856 may be a treatment option for psychosis. Hopefully they can be further developed into an antipsychotic with a favorable effectiveness and tolerability profile.

[Brexpiprazole for treatment of schizophrenia: a critical literature study]. / Brexpiprazol voor de behandeling van schizofrenie: een kritische literatuurstudie.

Background Brexpiprazole has been registered in the Netherlands and Belgium for the treatment of schizophrenia since 2019. It is a third-generation antipsychotic drug with a number of pharmacological similarities to aripiprazole and cariprazine. Aim To critically evaluate the pharmacology, effectiveness and side effects of brexpiprazole in the treatment of schizophrenia using the hitherto available double-blind, placebo-controlled study. Method A clinically oriented study of the literature. Results Brexpiprazole is effective in the treatment of schizophrenia and has few extrapyramidal side effects, metabolic side effects and moderate weight gain, no QTc prolongation, no sedation, and little influence on blood prolactin levels. Limited dose titration is required when initiated on brexpiprazole. Conclusion Brexpiprazole is a treatment option for schizophrenia, with a relatively favorable side effect profile. The position of brexpiprazole within the current treatment algorithm should become clear through future research and clinical experience. Tijdschrift voor Psychiatrie 63(2021)1, 48-55.

[Decision aid for the treatment of psychotic illness: development of TReatment E-AssisT (TREAT)]. / Beslistool bij de behandeling van psycho-tische aandoeningen: de ontwikkeling van TReatment E-AssisT (TREAT).

BACKGROUND: Use of decision aids in mental health care is increasing and will also be introduced in the Dutch mental healthcare system. We describe the context of this development and discuss how decision aids could facilitate evidence-based psychiatry.
AIM: To describe the development of the decision aid TReatment E-Assist (TREAT) in the Dutch mental healthcare system that aims to optimize treatment of people with a psychotic illness.
METHOD: We describe how the TREAT application works and discuss its potential contribution to the treatment of people with a psychotic illness.
RESULTS: In a pilot study TREAT was judged as user friendly and useful. TREAT seemed to increase the integration of ROM-results in treatment and the advice offered new view points for practioners.
CONCLUSION: TREAT is a novel application which combines routine outcome monitoring results with current treatment guidelines and standards of care in order to generate personalised treatment recommendations in the context of a psychiatric treatment trajectory. A multicentre study is being conducted in different provinces in the Netherlands to investigate the effectiveness of TREAT.

[Cariprazine for acute and maintenance treatment of schizophrenia]. / Cariprazine voor acute en onderhouds-behandeling van schizofrenie.

BACKGROUND: Since 2018, cariprazine has been available for the treatment of schizophrenia on the Dutch and Belgian markets.
AIM: To give an overview of the indications, effectiveness and side effects of cariprazine. To make an inventory of the advantages and disadvantages of this new antipsychotic drug.
METHOD: A clinically oriented literature review of published clinical studies and pharmacodynamic and -kinetic publications.
RESULTS: Cariprazine is unique because of its preferential D3 receptor partial agonist affinity and has, in theory, a beneficial effect on negative symptoms. The antipsychotic has two active metabolites: desmethylcariprazine and didesmethylcariprazine. The long half-life of cariprazine indicates that, in theory, the drug should not be given daily. Cariprazine is metabolized by cyp3a4 and to a lesser extent by cyp2d6 enzymes. Extrapyramidal symptoms and akathisia are relatively frequent side effects. In contrast, metabolic side effects and weight gain have been reported rarely.
CONCLUSION: Cariprazine can be an effective treatment option for schizophrenia. The final positioning of this antipsychotic drug will have to be based on future research.

[The three-monthly paliperidone palmitate depot in the treatment of schizophrenia]. / Het driemaandelijkse paliperidon-palmitaatdepot bij schizofrenie.

BACKGROUND: A three-monthly formulation of intramuscular paliperidone palmitate has been available on the Dutch and Belgian markets since 2016.
AIM: To provide an overview of the indication, effectiveness and side-effects of this injectable three-monthly formulation of paliperidone and to offer considerations for clinical practice.
METHOD: A clinically-oriented literature study.
RESULTS: Three-monthly paliperidone palmitate depot appears to be as effective as the monthly paliperidone depot and has the same profile of side-effects.
CONCLUSION: Three-monthly paliperidone palmitate is an effective treatment option for schizophrenia. However, future research and clinical practice need to clarify the position of this depot in the treatment trajectory.

Relation of inflammatory markers with symptoms of psychotic disorders: a large cohort study.

AIMS: Immunological mechanisms may play a role in symptomatology of patients with a psychotic disorder. Besides metabolic problems and medication use, inflammatory processes that may occur due to the disorder may cause increased inflammatory markers and concurrent psychiatric symptoms. The aim of this study is to investigate whether levels of C-reactive protein (CRP) and white blood cell count (WBC) are related to positive and negative symptoms of psychotic disorders, and whether age, gender, duration of illness, smoking behavior, haloperidol equivalents, mediation use, body mass, and metabolic syndrome affect this relation. METHODS: CRP and WBC values of 2123 patients with a psychotic disorder were related to positive and negative symptoms measured with a psychiatric interview. CRP was analyzed by survival analysis accounting for detection limit and WBC by linear mixed model analysis. In case of a significant association, the confounding factors were added to the model. RESULTS: Both WBC and CRP were related to both positive and negative symptoms, even after correction for age, gender, smoking, use of medication and metabolic problems. Of the covariates, gender, metabolic problems, smoking and statins also showed a strong association with inflammatory markers. CONCLUSIONS: This study in a large patient-group confirmed that inflammatory markers are related to psychotic disorders, particularly negative symptoms. Future studies could use more precise measures of inflammatory markers and measure symptomatic state at specific moments in illness progression.

[Differences in non-native resident psychiatrists and native residents psychiatrists in completion of the psychiatry residency training programmes]. / Verschil in uitval tussen allochtone en autochtone artsen in opleiding tot psychiater; enquête onder opleiders.

BACKGROUND: A relatively small number of psychiatrists in the Netherlands have a non-Dutch origin. We suspect that resident psychiatrists who do not have Dutch as their first language are less likely than native Dutch speakers to complete the psychiatry residency training programmes.
AIM: To find out how often and for what reasons resident psychiatrists do not complete the psychiatry residency training programmes.
METHOD: All course coordinators in the Netherlands were asked to participate in a survey to provide information about the residents who had started but had abandoned the psychiatry residency training programmes between the years 2008 and 2015. They were also asked about factors that had influenced residents to abandon the course.
RESULTS: We were able to obtain data on 37% of the trainees. The data revealed that the number of non-native resident psychiatrists who failed to complete the training course was almost four times higher than the number of native trainee psychiatrists who dropped out before the end of the course. According to the coordinators, possible reasons for this discrepancy are lack of proficiency in Dutch, communication problems and cultural differences.
CONCLUSION: The results of our survey could possibly be used to adjust the training programmes.

[Non-invasive brain stimulation in schizophrenia: hallucinations and negative symptoms]. / Non-invasieve hersenstimulatie bij schizofrenie, gericht op hallucinaties en negatieve symptomen.

BACKGROUND: New approaches are needed in the treatment of characteristic symptoms of schizophrenia such as hallucinations and negative symptoms. Non-invasive brain stimulation can make a useful contribution.
AIM: To discuss the published evidence regarding efficacy and safety of repetitive transcranial magnetic stimulation (rtms) and transcranial direct current stimulation (tdcs) when used in the treatment of auditory verbal hallucinations and negative symptoms.
METHOD: We review and discuss recent meta-analyses and we analyse relevant factors.
RESULTS: On average, when compared to sham-stimulation, rtms was found to have a significant effect on hallucinations and negative symptoms. Nevertheless, the results of some studies were variable and some studies did not report any improvement. There are indications that some factors such as age and distance between scalp and cortex may influence efficiency. There were only a few studies relating to the use of tdcs and none of these reported a clear effect.
CONCLUSION: There is reasonable evidence that rtms is an efficient treatment for hallucinations and negative symptoms, although some variable results have been reported. There is insufficient evidence for conclusions to be drawn about the efficacy of tdcs for the treatment of hallucinations and negative symptoms. However, both simulation methods are safe and largely without side-effects.

[Clinical application of ROM in psychosis]. / Klinische toepassing van ROM bij psychose.

AIM: The use of 'routine outcome monitoring' (ROM) in mental health care has increased widely during the past decade. However, little is known about the use of ROM outcome in daily clinical practice. We investigated to what extent ROM results were reflected in psychotic patients' treatment plans. DESIGN: Cross-sectional study. METHOD: The ROM-Phamous, a ROM-protocol for patients with psychotic disorders in which data is collected on the basis of interviews, questionnaires and physical examination was implemented in the northern Netherlands. A random sample of 100 patients was extracted from the 2010 ROM database (n = 1040), from which we determined the prevalence of a number of problem areas. We then investigated whether these problems were reflected in patients' treatment plans. RESULTS: The sample consisted of 63 men and 37 women, with a mean age of 44 years and a mean duration of illness of 18 years. The prevalence of symptoms and psychosocial problems was 13-37%; the prevalence of cardiovascular risk factors was 11-86%. The majority of problems identified with ROM were not reflected in patients' treatment plans; the opposite also occurred: psychosocial problems, in particular, mentioned in the treatment plans were not always identified with ROM. CONCLUSION: ROM and treatment should ideally be integrated in mental-health services, but currently appear to be separate processes. If improvement of integration of ROM and clinical practice succeeds it could lead to improvement of care for psychiatric patients. Further investigation is warranted. Conflict of interest and financial support: ICMJE forms provided by the authors are available online along with the full text of this article.

Exploring the use of Routine Outcome Monitoring in the treatment of patients with a psychotic disorder.

BACKGROUND: Routine Outcome Monitoring (ROM) has become part of the treatment process in mental health care. However, studies have indicated that few clinicians in psychiatry use the outcome of ROM in their daily work. The aim of this study was to explore the degree of ROM use in clinical practice as well as the explanatory factors of this use. METHODS: In the Northern Netherlands, a ROM-protocol (ROM-Phamous) for patients with a psychotic disorder has been implemented. To establish the degree of ROM-Phamous use in clinical practice, the ROM results of patients (n=204) were compared to the treatment goals formulated in their treatment plans. To investigate factors that might influence ROM use, clinicians (n=32) were asked to fill out a questionnaire about ROM-Phamous. RESULTS: Care domains that were problematic according to the ROM-Phamous results were mentioned in the treatment plan in 28% of cases on average (range 5-45%). The use of ROM-Phamous in the treatment process varies considerably among clinicians. Most of the clinicians find ROM-Phamous both useful and important for good clinical practice. In contrast, the perceived ease-of-use is low and most clinicians report insufficient time to use ROM-Phamous. CONCLUSIONS: More frequent ROM use should be facilitated in clinicians. This could be achieved by improving the fit with clinical routines and the ease-of-use of ROM systems. It is important for all stakeholders to invest in integrating ROM in clinical practice. Eventually, this might improve the diagnostics and treatment of patients in mental health care.

[Mindfulness training for psychiatrists in residency: a pilot study]. / Mindfulnesstraining voor aiossen psychiatrie: een pilotstudie.

BACKGROUND: Medical students and psychiatrists in residency run a high risk for burnout. Furthermore, while at medical school, students seem to experience a reduction in empathy; this seems to be linked to a high level of stress. Interventions based on mindfulness training appear to reduce stress and increase empathy in medical students. Trainees in psychiatric residency might also benefit from mindfulness training.
AIM: To assess the effects that a mindfulness course has on perceived stress and empathy in psychiatrists in residency.
METHOD: In this pilot study 13 trainees in psychiatric residency participated in an eight-week course in mindfulness. Before and after the training, 11 of the participants completed questionnaires relating to their empathy, perceived stress and mindfulness.
RESULTS: Participants reported experiencing considerably more empathy after their course than before it. Perceived stress also diminished, but not significantly.
CONCLUSION: The results support our suggestion that mindfulness training can be a valuable part of the curriculum for trainees in psychiatric residency.

[A study of cost-effectiveness of treating serious mental illness: challenges and solutions]. / Doelmatigheidsonderzoek bij mensen met een ernstige psychische aandoening: uitdagingen en oplossingen.

BACKGROUND People with serious mental illness (SMI) often suffer high healthcare costs and enduring loss of quality of life. Increasing our understanding of the cost-effectiveness of people with SMI is important when striving for optimal health at affordable costs. AIM To describe aspects that can be important for cost-effectiveness research targeting people with SMI. METHOD These aspects are demonstrated by considering pro-active care, rehabilitation and involuntary treatment RESULTS The possible involvement of a large number of stakeholders outside of healthcare requires cost-effectiveness research to also map the costs and benefits outside of healthcare, preferably for each stakeholder specifically. Availability of data, the possibility to combine datasets, and ways to deal with dropouts require extra attention. CONCLUSION Cost-effectiveness research targeting people with SMI could be enhanced when solutions are found for the availability of data inside and outside of healthcare and when dropout can be compensated for by other sources of data, such that costs and benefits for each stakeholder can be estimated more reliably.

The prevalence of visual hallucinations in non-affective psychosis, and the role of perception and attention.

BACKGROUND: Little is known about visual hallucinations (VH) in psychosis. We investigated the prevalence and the role of bottom-up and top-down processing in VH. The prevailing view is that VH are probably related to altered top-down processing, rather than to distorted bottom-up processing. Conversely, VH in Parkinson's disease are associated with impaired visual perception and attention, as proposed by the Perception and Attention Deficit (PAD) model. Auditory hallucinations (AH) in psychosis, however, are thought to be related to increased attention. METHOD: Our retrospective database study included 1119 patients with non-affective psychosis and 586 controls. The Community Assessment of Psychic Experiences established the VH rate. Scores on visual perception tests [Degraded Facial Affect Recognition (DFAR), Benton Facial Recognition Task] and attention tests [Response Set-shifting Task, Continuous Performance Test-HQ (CPT-HQ)] were compared between 75 VH patients, 706 non-VH patients and 485 non-VH controls. RESULTS: The lifetime VH rate was 37%. The patient groups performed similarly on cognitive tasks; both groups showed worse perception (DFAR) than controls. Non-VH patients showed worse attention (CPT-HQ) than controls, whereas VH patients did not perform differently. CONCLUSIONS: We did not find significant VH-related impairments in bottom-up processing or direct top-down alterations. However, the results suggest a relatively spared attentional performance in VH patients, whereas face perception and processing speed were equally impaired in both patient groups relative to controls. This would match better with the increased attention hypothesis than with the PAD model. Our finding that VH frequently co-occur with AH may support an increased attention-induced 'hallucination proneness'.

[Trauma treatment in a patient with a psychotic disorder]. / Traumabehandeling bij patiënte met psychotische stoornis.

Until recently, patients suffering from both a psychotic disorder and a post-traumatic stress disorder (PTSD) were hardly ever treated for their PTSD. Many clinicians considered that the reliving of the trauma during treatment could increase the risk of psychotic decompensation. We describe a trauma-focused cognitive behavioural therapy that was used to treat a 43-year-old patient diagnosed with both schizoaffective disorder and comorbid PTSD. After five sessions the patient no longer experienced PTSD symptoms.