The associations of quality of life and general functioning with trauma, borderline intellectual functioning and mild intellectual disability in outpatients with serious mental illness.

BACKGROUND: Trauma and intellectual disability are highly prevalent in the serious mental ill (SMI). Little is known of their impact on general functioning and quality of life. AIM: This study investigated the association of trauma and intellectual disability (ID) with general functioning and quality of life in SMI. METHODS: Patient characteristics and diagnoses were extracted from electronic patient records. We used the Trauma Screening Questionnaire (TSQ), the Screener for Intelligence and Learning Disabilities (SCIL), the Health of the Nation Outcome Scale (HoNOS) and the Manchester Short Assessment of Quality of Life (MANSA) to asses trauma, intellectual impairment, general functioning and quality of life. Proportions on cut-off scores were analysed with cross-tabulations, questionnaire scores with t-tests. Multivariable associations were determined by logistic regression analysis. RESULTS: 611 patients from an outpatient service were assessed. Trauma and ID were associated with each other (r = -0.207). Trauma was associated with worse general functioning and a lower quality of life. Mild intellectual disability (MID) or borderline intellectual functioning (BIF) were associated with worse general functioning. CONCLUSIONS: For patients with SMI, trauma and ID should be identified early in care to treat the lower general functioning and quality of life it caused.

[High and intensive care as a next step in the reduction of coercion]. / High en intensive care als een volgende stap in dwangreductie.

BACKGROUND: The high and intensive care (HIC) model provides a framework for acute admission wards and is being implemented since 2013 by all mental healthcare institutions in the Netherlands. AIM: To investigate how the HIC model has been implemented between 2014 and 2018 and how the implementation of the HIC model is associated to coercive measures. METHOD: Between 2014 and 2018, 79 audits were organized in two phases within 25 institutions to measure the degree of implementation of HIC using a model fidelity scale, the HIC monitor. HIC monitor scores were compared to data on coercion to determine the relationship between implementation of the HIC model and coercive measures. RESULTS: Scores on the HIC monitor increased over time, especially in terms of vision, hospitality and facilities. However, a third of wards scored lower on the HIC monitor in the second audit compared to the first audit. Institutions that score higher use less seclusion and use less forced medication. CONCLUSION: Progress in the implementation of the HIC model is visible and institutions that are further in the implementation of the HIC model apply less coercion. Securing implementation proves difficult. Attention should be paid to the national staff shortage and systematic evaluation of coercion.

[The predictive value of mild intellectual disability/ borderline intellectual functioning and ptsd for treatment results in severely mentally Ill patients]. / Voorspellende waarde van lichte verstandelijke beperking en PTSS voor behandelresultaten van patiënten met ernstige psychiatrische aandoeningen.

BACKGROUND: Little is known about the influence of mild intellectual disability/borderline intellectual functioning (mid/biF) or posttraumatic stress disorder (ptsd) on treatment results in severely mentally ill (smi).
AIM: To investigate whether screeners determining mid/biF or ptsd are associated with less favorable treatment outcome in smi.
METHOD: The screener for intelligence and learning disabilities (scil) was used to screen for mid/biF. The trauma screening questionnaire (tsq) was used to detect ptsd. Outcomes of these screeners were associated with repeated measures on the health of the nation outcome scales (HoNOS) in 628 smi at the Mental Care Centre of Oost Brabant.
RESULTS: In 628 patients one or more HoNOS was acquired. In 352 (56%) patients a scil was acquired, in 334 (53%) patients a tsq. The largest improvement was observed in patients not meeting the criteria for mid/biF and/or ptsd. Less improvement was observed in patients with ptsd and a suspected iq between 70-85, estimated with the scil. No significant change on the HoNOS was observed in patients with an estimated iq below 70.
CONCLUSION: Routine screening for mid/biF and ptsd symptoms is important for early recognition of the disorder, resulting in providing better treatment interventions for patients with mid/biF and ptsd.

Does high and intensive care reduce coercion? Association of HIC model fidelity to seclusion use in the Netherlands.

BACKGROUND: A new inpatient care model has been developed in the Netherlands: High and Intensive Care (HIC). The purpose of HIC is to improve quality of inpatient mental healthcare and to reduce coercion. METHODS: In 2014, audits were held at 32 closed acute admission wards for adult patients throughout the Netherlands. The audits were done by trained auditors, who were professionals of the participating institutes, using the HIC monitor, a model fidelity scale to assess implementation of the HIC model. The HIC model fidelity scale (67 items) encompasses 11 domains including for example team structure, team processes, diagnostics and treatment, and building environment. Data on seclusion and forced medication was collected using the Argus rating scale. The association between HIC monitor scores and the use of seclusion and forced medication was analyzed, corrected for patient characteristics. RESULTS: Results showed that wards having a relatively high HIC monitor total score, indicating a high level of implementation of the model as compared to wards scoring lower on the monitor, had lower seclusion hours per admission hours (2.58 versus 4.20) and less forced medication events per admission days (0.0162 versus 0.0207). The HIC model fidelity scores explained 27% of the variance in seclusion rates (p < 0.001). Adding patient characteristics to HIC items in the regression model showed an increase of the explained variance to 40%. CONCLUSIONS: This study showed that higher HIC model fidelity was associated with less seclusion and less forced medication at acute closed psychiatric wards in the Netherlands.

Diagnose, indicate, and treat severe mental illness (DITSMI) as appropriate care: A three-year follow-up study in long-term residential psychiatric patients on the effects of re-diagnosis on medication prescription, patient functioning, and hospital bed utilization.

BACKGROUND: While polypharmacy is common in long-term residential psychiatric patients, prescription combinations may, from an evidence-based perspective, be irrational. Potentially, many psychiatric patients are treated on the basis of a poor diagnosis. We therefore evaluated the DITSMI model (i.e., Diagnose, Indicate, and Treat Severe Mental Illness), an intervention that involves diagnosis (or re-diagnosis) and appropriate treatment for severely mentally ill long-term residential psychiatric patients. Our main objective was to determine whether DITSMI affected changes over time regarding diagnoses, pharmacological treatment, psychosocial functioning, and bed utilization. METHODS: DITSMI was implemented in a consecutive patient sample of 94 long-term residential psychiatric patients during a longitudinal cohort study without a control group. The cohort was followed for three calendar years. Data were extracted from electronic medical charts. As well as diagnoses, medication use and current mental status, we assessed psychosocial functioning using the Health of the Nations Outcome Scale (HoNOS). Bed utilization was assessed according to length of stay (LOS). Change was analyzed by comparing proportions of these data and testing them with chi-square calculations. We compared the numbers of diagnoses and medication changes, the proportions of HoNOS scores below cut-off, and the proportions of LOS before and after provision of the protocol. RESULTS: Implementation of the DITSMI model was followed by different diagnoses in 49% of patients, different medication in 67%, some improvement in psychosocial functioning, and a 40% decrease in bed utilization. CONCLUSIONS: Our results suggest that DITSMI can be recommended as an appropriate care for all long-term residential psychiatric patients.

On the Link Between Emotionally Driven Impulsivity and Aggression: Evidence From a Validation Study on the Dutch UPPS-P.

The UPPS-P seems to be a promising instrument for measuring different domains of impulsivity in forensic psychiatric patients. Validation studies of the instrument however, have been conducted only in student groups. In this validation study, three groups completed the Dutch UPPS-P: healthy student ( N = 94) and community ( N = 134) samples and a forensic psychiatric sample ( N = 73). The five-factor structure reported previously could only be substantiated in a confirmatory factor analysis over the combined groups but not in the subsamples. Subgroup sample sizes might be too small to allow such complex analyses. Internal consistency, as assessed by Cronbach's alpha, was high on most subscale and sample combinations. In explaining aggression, especially the initial subscale negative urgency (NU) was related to elevated scores on self-reported aggression in the healthy samples (student and community). The current study is the second study that found a relationship between self-reported NU and aggression highlighting the importance of addressing this behavioural domain in aggression management therapy.

Treatment Outcome, Duration, and Costs: A Comparison of Performance Indicators Using Data from Eight Mental Health Care Providers in The Netherlands.

Assessing performance of mental health services (MHS) providers merely by their outcomes is insufficient. Process factors, such as treatment cost or duration, should also be considered in a meaningful and thorough analysis of quality of care. The present study aims to examine various performance indicators based on treatment outcome and two process factors: duration and cost of treatment. Data of patients with depression or anxiety from eight Dutch MHS providers were used. Treatment outcome was operationalized as case mix corrected pre-to-posttreatment change scores and as reliable change (improved) and clinical significant change (recovered). Duration and cost were corrected for case mix differences as well. Three performance indicators were calculated and compared: outcome as such, duration per outcome, and cost per outcome. The results showed that performance indicators, which also take process variability into account, reveal larger differences between MHS providers than mere outcome. We recommend to use the three performance indicators in a complementary way. Average pre-to-posttreatment change allows for a simple and straightforward ranking of MHS providers. Duration per outcome informs patients on how MHS providers compare in how quickly symptomatic relief is achieved. Cost per outcome informs MHS providers on how they compare regarding the efficiency of their care. The substantial variation among MHS providers in outcome, treatment duration and cost calls for further exploration of its causes, dissemination of best practices, and continuous quality improvement.

Seclusion and enforced medication in dealing with aggression: A prospective dynamic cohort study.

BACKGROUND: In the Netherlands, seclusion is historically the measure of first choice in dealing with aggressive incidents. In 2010, the Mediant Mental Health Trust in Eastern Netherlands introduced a policy prioritising the use of enforced medication to manage aggressive incidents over seclusion. The main goal of the study was to investigate whether prioritising enforced medication over seclusion leads to a change of aggressive incidents and coercive measures. METHODS: The study was carried out with data from 2764 patients admitted between 2007 and 2013 to the hospital locations of the Mediant Mental Health Trust in Eastern Netherlands, with a catchment area of 500,000 inhabitants. Seclusion, restraint and enforced medications as well as other coercive measures were gathered systematically. Aggressive incidents were assessed with the SOAS-R. An event sequence analysis was preformed, to assess the whether seclusion, restraint or enforced medication were used or not before or after aggressive incidents. RESULTS: Enforced medication use went up by 363% from a very low baseline. There was a marked reduction of overall coercive measures by 44%. Seclusion hours went down by 62%. Aggression against staff or patients was reduced by 40%. CONCLUSIONS: When dealing with aggression, prioritising medication significantly reduces other coercive measures and aggression against staff, while within principles of subsidiarity, proportionality and expediency.

Cerebrovascular involvement and clinical presentation of late-life depression, findings from the NESDO study.

OBJECTIVES: The vascular depression hypothesis, which supposes a causal relation of vascular risk factors and vascular disease with depression, has not been definitively accepted. Inconsistent findings may be due to different clinical presentations of depression in older people with and without a clear history of stroke. We therefore aimed to investigate the association between vascular pathology, with and without previous stroke, and different symptom domains of depression. METHOD: For our study, we used baseline data of 378 people aged 60 years and older with a current depression who participated in the Netherlands Study of Depression in Older persons (NESDO), an observational (multicentre) cohort study. Using all information on vascular pathology and risk factors, three classes were operationalized: a first class of depressed older people with previous stroke; a second class of depressed older people with cardiovascular and peripheral arterial diseases, but without stroke; and a third class of depressed older people with no vascular disease. RESULTS: The depressed older people with previous stroke were characterized by more 'motivational' symptoms, which distinguished them from other depressed older people. Inclusion in this stroke group was also associated with having increased prevalence of hypertension, smoking more cigarettes, and lower alcohol consumption. CONCLUSIONS: Our findings suggest that the 'vascular depression' connotation should be reserved for depressed (older) patients with vascular pathology and evident cerebral involvement.

Perceived coercion in persons with mental disorder in India: A cross-sectional study.

BACKGROUND: Little is known about how patients in India perceive coercion in psychiatric care. AIMS: To assess perceived coercion in persons with mental disorder admitted involuntarily and correlate with sociodemographic factors and illness variables. MATERIALS AND METHODS: We administered the short MacArthur Admission Experience Interview Questionnaire to all consecutive involuntary psychiatric patients admitted in 2014 in Mysore, India. Multivariate linear regression was used. RESULTS: Three hundred and one patients participated. "Perceived coercion" subscale scores increased with female gender, nuclear family status, Muslim and Christian religion, lower income, and depressive disorder. It decreased with former coercion, forensic history, and longer illness duration. Drug use increased total scores; the extended family item decreased them. "Negative pressure" increased with male gender, extended family, lower income, forensic history, and longer illness duration. CONCLUSIONS: The study shows perceived coercion is a reality in India. Levels of perceived coercion and the populations affected are similar to high-income countries.

Staff and caregiver attitude to coercion in India.

OBJECTIVES: The objective of this study was to assess attitudes of Indian psychiatrists and caregivers toward coercion. MATERIALS AND: Methods: The study was conducted at the Department of Psychiatry, Krishna Rajendra Hospital, Mysore, India. Staff Attitude to Coercion Scale (SACS), a 15-item questionnaire, was administered to self-selected psychiatrists across India and caregivers from Mysore to measure attitudes on coercion. Data were analyzed using descriptive statistics and investigating differences in subgroups by means of Chi-square test, Student's t-test, and analysis of variance. Reliability of the SACS was tested in this Indian sample. RESULTS: A total of 210 psychiatrists and 210 caregivers participated in the study. Both groups agreed that coercion was related to scarce resources, security concerns, and harm reduction. Both groups agreed that coercion is necessary, but not as treatment. Older caregivers and male experienced psychiatrists considered coercion related to scarce resources to violate patient integrity. All participants considered coercion necessary for protection in dangerous situations. Professionals and caregivers significantly disagreed on most items. The reliability of the SACS was reasonable to good among the psychiatrists group, but not in the caregiver group (alpha 0.58 vs. 0.07). CONCLUSION: Caregivers and psychiatrists felt that the lack of resources is one of the reasons for coercion. Furthermore, they felt that the need on early identification of aggressive behavior, interventions to reduce aggressiveness, empowering patients, improving hospital resources, staff training in verbal de-escalation techniques is essential. There is an urgent need in the standardized operating procedure in the use of coercive measure in Indian mental health setting.

[Involuntary medication as the intervention of choice: can this be regarded as 'substitution' or as a preventive measure? a prospective cohort study]. / Effect van dwangmedicatie als interventie van eerste keus op separatie en toegepaste dwang; een prospectief cohortonderzoek.

BACKGROUND: Since the Dutch Mental Health Act of 1984 came into effect, seclusion has often been used as the measure of choice for dealing with aggressive or dangerous patients. In 2012 the Ministry of Health formulated a policy whereby seclusion was to be phased out, but not replaced by involuntary medication. In 2007, within the framework of the Mental Health Act, the Argus system of registering coercive measures was introduced in order to monitor the reduction in the use of seclusion and involuntary medication. This article describes, in a longitudinal cohort study, the effect of the policy to reduce aggression by replacing seclusion through the use of involuntary medication or other measures. AIM: To investigate whether, in the long run, a reduction in the use of seclusion will lead to a proportional increase in the use of involuntary medication, and to assess whether this policy can really be termed 'substitution. METHOD: We performed this study by analysing Argus data for the period 2007-2011, relating to 1843 patients being treated by Mediant. ESULTS The changing proportions of seclusion and involuntary medication over time demonstrated that the use of involuntary medication did result in patients being secluded for a shorter period of time. CONCLUSION: In the case of dangerous psychiatric patients, medication, administered forcibly when necessary, is preferable to seclusion as far as subsidiarity, proportionality and expediency are concerned. A strategy whereby medication provides appropriate treatment and seclusion is kept within reasonable limits cannot be termed 'substitution'.

Impact of the physical environment of psychiatric wards on the use of seclusion.

BACKGROUND: The physical environment is presumed to have an effect on aggression and also on the use of seclusion on psychiatric wards. Multicentre studies that include a broad variety of design features found on psychiatric wards and that control for patient, staff and general ward characteristics are scarce. AIMS: To explore the effect of design features on the risk of being secluded, the number of seclusion incidents and the time in seclusion, for patients admitted to locked wards for intensive psychiatric care. METHOD: Data on the building quality and safety of psychiatric as well as forensic wards (n = 199) were combined with data on the frequency and type of coercive measures per admission (n = 23 868 admissions of n = 14 834 patients) on these wards, over a 12-month period. We used non-linear principal components analysis (CATPCA) to reduce the observed design features into a smaller number of uncorrelated principal components. Two-level multilevel (logistic) regression analyses were used to explore the relationship with seclusion. Admission was the first level in the analyses and ward was the second level. RESULTS: Overall, 14 design features had a significant effect on the risk of being secluded during admission. The 'presence of an outdoor space', 'special safety measures' and a large 'number of patients in the building' increased the risk of being secluded. Design features such as more 'total private space per patient', a higher 'level of comfort' and greater 'visibility on the ward', decreased the risk of being secluded. CONCLUSIONS: A number of design features had an effect on the use of seclusion and restraint. The study highlighted the need for a greater focus on the impact of the physical environment on patients, as, along with other interventions, this can reduce the need for seclusion and restraint.

Differences in seclusion rates between admission wards: does patient compilation explain?

Comparison of seclusion figures between wards in Dutch psychiatric hospitals showed substantial differences in number and duration of seclusions. In the opinion of nurses and ward managers, these differences may predominantly be explained by differences in patient characteristics, as these are expected to have a large impact on these seclusion rates. Nurses assume more admissions of severely ill patients are related to higher seclusion rates. In order to test this hypothesis, we investigated differences in patient and background characteristics of 718 secluded patients over 5,097 admissions on 29 different admission wards over seven Dutch psychiatric hospitals. We performed an extreme group analysis to explore the relationship between patient and ward characteristics and the wards' number of seclusion hours per 1,000 admission hours. In a multivariate and a multilevel analysis, various characteristics turned out to be related to the number of seclusion hours per 1,000 admission hours as well as to the likelihood of a patient being secluded, confirming the nurses assumptions. The extreme group analysis showed that seclusion rates depended on both patient and ward characteristics. A multivariate and multilevel analyses revealed that differences in seclusion hours between wards could partially be explained by ward size next to patient characteristics. However, the largest deal of the difference between wards in seclusion rates could not be explained by characteristics measured in this study. We concluded ward policy and adequate staffing may, in particular on smaller wards, be key issues in reduction of seclusion.

Methodological issues in monitoring the use of coercive measures.

PURPOSE: In many European countries, initiatives have emerged to reduce the use of seclusion and restraint in psychiatric institutions. To study the effects of these initiatives at a national and international level, consensus on definitions of coercive measures, assessment methods and calculation procedures of these coercive measures are required. The aim of this article is to identify problems in defining and recording coercive measures. The study contributes to the development of consistent comparable measurements definitions and provides recommendations for meaningful data-analyses illustrating the relevance of the proposed framework. METHODS: Relevant literature was reviewed to identify various definitions and calculation modalities used to measure coercive measures in psychiatric inpatient care. Figures on the coercive measures and epidemiological ratios were calculated in a standardized way. To illustrate how research in clinical practice on coercive measures can be conducted, data from a large multicenter study on seclusion patterns in the Netherlands were used. RESULTS: Twelve Dutch mental health institutes serving a population of 6.57 million inhabitants provided their comprehensive coercion measure data sets. In total 37 hospitals and 227 wards containing 6812 beds were included in the study. Overall seclusion and restraint data in a sample of 31,594 admissions in 20,934 patients were analyzed. Considerable variation in ward and patient characteristics was identified in this study. The chance to be exposed to seclusion per capita inhabitants of the institute's catchment areas varied between 0.31 and 1.6 per 100.000. Between mental health institutions, the duration in seclusion hours per 1000 inpatient hours varied from less than 1 up to 18h. The number of seclusion incidents per 1000 admissions varied between 79 up to 745. The mean duration of seclusion incidents of nearly 184h may be seen as high in an international perspective. CONCLUSION: Coercive measures can be reliably assessed in a standardized and comparable way under the condition of using clear joint definitions. Methodological consensus between researchers and mental health professionals on these definitions is necessary to allow comparisons of seclusion and restraint rates. The study contributes to the development of international standards on gathering coercion related data and the consistent calculation of relevant outcome parameters.

Aggression and seclusion on acute psychiatric wards: effect of short-term risk assessment.

BACKGROUND: Short-term structured risk assessment is presumed to reduce incidents of aggression and seclusion on acute psychiatric wards. Controlled studies of this approach are scarce. AIMS: To evaluate the effect of risk assessment on the number of aggression incidents and time in seclusion for patients admitted to acute psychiatric wards. METHOD: A cluster randomised controlled trial was conducted in four wards over a 40-week period (n = 597 patients). Structured risk assessment scales were used on two experimental wards, and the numbers of incidents of aggression and seclusion were compared with two control wards where assessment was based purely on clinical judgement. RESULTS: The numbers of aggressive incidents (relative risk reduction -68%, P<0.001) and of patients engaging in aggression (relative risk reduction RRR = -50%, P<0.05) and the time spent in seclusion (RRR = -45%, P<0.05) were significantly lower in the experimental wards than in the control wards. Neither the number of seclusions nor the number of patients exposed to seclusion decreased. CONCLUSIONS: Routine application of structured risk assessment measures might help reduce incidents of aggression and use of restraint and seclusion in psychiatric wards.

Seclusion: the perspective of nurses.

Knowledge of how nurses experience the process of secluding a patient can be useful in improving the quality of patient care and in the prevention of work related stress in nurses. This study describes personal experiences of nurses throughout the seclusion process. The emotions which came to surface in semi-structured interviews with 8 nurses were categorized in three main themes (Tension, Trust and Power) and a stress response curve was identified in the seclusion process, with specific feelings in each phase. Feelings denied in former studies such as feeling superior, anger and disgust were found in the interviews in this study.

The use of seclusion in the Netherlands compared to countries in and outside Europe.

The use of seclusion in psychiatric practice is a contentious issue in the Netherlands as well as other countries in and outside Europe. The aim of this study is to describe Dutch seclusion data and compare these with data on other countries, derived from the literature. An extensive search revealed only 11 articles containing seclusion rates of regions or whole countries either in Europe, Australia or the United States. Dutch seclusion rates were calculated from a governmental database and from a database covering twelve General Psychiatric Hospitals in the Netherlands. According to the hospitals database, on average one in four hospitalized patients experienced a seclusion episode. The mean duration according to the governmental database is a staggering 16 days. Both numbers seem much higher than comparable numbers in other countries. However, different definitions, inconsistent methods of registration, different methods of data collection and an inconsistent expression of the seclusion use in rates limit comparisons of the rates found in the reviewed studies with the data gathered in the current study. Suggestions are made to improve data collection, to enable better comparisons.

[Physician-assisted suicide of a patient suffering from a psycho-organic disorder]. / Hulp bij zelfdoding bij een patiënt met een organisch-psychiatrische stoornis.

A 71-year-old man suffering from vascular dementia since four years asked for physician-assisted suicide. In the Netherlands physician-assisted suicide, which is forbidden by law, remains an intricate dilemma in medical practice. As far as it concerns untreatable terminal patients who decide to put an end to their lives in agreement with and assisted by their physician, procedures are well defined. The present case may be used as an example in the development of a protocol for physician-assisted suicide in patients who are not terminal in the short term, but who suffer unbearably with no prospect of remission. After the protocol securing various formal and medical consequences was run through, the patient was assisted by handling him a high-dose solution of a barbiturate which he drank himself. The procedure incorporates several second and third opinions. First, the chief psychiatrist of the psychiatric hospital assesses the request. Second, a committee consisting of a number of independent professionals form a second opinion. They have no direct responsibility in the treatment of the patient. The patient also may consult an independent consultant psychiatrist with specific knowledge in the domain of his disorder for a third opinion. This procedure was found legally as well as medically sound, and was approved by the public prosecutor after consultation with the Dutch forum of Procurators-General.

Coping with hearing voices: an emancipatory approach.

A questionnaire comprising 30 open-ended questions was sent to 450 people with chronic hallucinations of hearing voices who had responded to a request on television. Of the 254 replies, 186 could be used for analysis. It was doubtful whether 13 of these respondents were experiencing true hallucinations. Of the remaining 173 subjects, 115 reported an inability to cope with the voices. Ninety-seven respondents were in psychiatric care, and copers were significantly less often in psychiatric care (24%) than non-copers (49%). Four coping strategies were apparent: distraction, ignoring the voices, selective listening to them, and setting limits on their influence.