The use of a Cumulative Needs for Care Monitor for individual treatment v. care as usual for patients diagnosed with severe mental illness, a cost-effectiveness analysis from the health care perspective.

AIMS: To study the systematic assessment of need for care and clinical parameters for use in treatment plans in patients diagnosed with severe mental illness. METHODS: The Cumulative Needs for Care Monitor (CNCM) includes various validated instruments, such as the Camberwell Assessment of Need. A Markov-type cost-effectiveness model (health care perspective, 5-year time horizon) was used to compare CNCM with care as usual (CAU). Two studies were used to determine model parameters: a before­after study (n = 2155) and a matched-control study (n = 937). RESULTS: The CNCM may lead to a gain in psychiatric functioning according to the models. CNCM patients remain in (outpatient) care, while CAU patients drop out more frequently. There is only a small difference in inpatient care. As a result, average costs per patient in the CNCM group are between €2809 (before­after model) and €5251 (matched-control model) higher. The iCER was between €45 127 and €57 839 per life year without psychiatric dysfunction gained. CONCLUSIONS: CNCM may be only cost-effective when willingness to pay for a life year without psychiatric dysfunction is higher than €45 000. However, this result is highly sensitive to the level of psychiatric dysfunctioning in patients who do not receive care.

[Routine outcome monitoring and benchmarking: how can treatment results be compared in a responsible manner?]. / Routine outcome monitoring en benchmarking: hoe kunnen we behandelresultaten op een zorgvuldige manier vergelijken?

BACKGROUND: The structural measurement of the results of treatment under the Dutch mental health services and a comparison of these results between mental health centres help to provide insight into the effectiveness of treatment in general practice. AIM: To provide an overview of the issues that require attention when the results of mental health centres are being compared. METHOD: Documentation, policy information and practical experience with routine outcome monitoring were analysed. RESULTS: We describe the problems that can arise when results obtained by mental health centres are compared and we suggest some solutions for these problems. Important factors that have emerged from our study are as follows: working with routine outcome monitoring is a process of natural growth and involves experiences with several solutions and the making of definitive choices on the basis of experience. CONCLUSION: It is instructive to compare mental health centres with each other and with regards to so-called 'best practices' (benchmarking). However, mental health centres draw on a differing wide mix of patients and use different measurement procedures and instruments. In this article we express the view that in the near future it should be possible to draw meaningful comparisons.

Association of treatment delay, migration and urbanicity in psychosis.

BACKGROUND: Several factors may contribute to duration of untreated psychosis (DUP): patient-delay, referral-delay and treatment-delay caused by mental health care services (MHS-delay). In order to find the most effective interventions to reduce DUP, it is important to know what factors in these pathways to care contribute to DUP. AIM: To examine the relationship of the constituents of treatment delay, migration status and urbanicity. METHOD: In first episode psychotic patients (n=182) from rural, urban and highly urbanized areas, DUP, migration status and pathways to care were determined. RESULTS: Mean DUP was 53.6 weeks (median 8.9, SD=116.8). Patient-delay was significantly longer for patients from highly urbanized areas and for first generation immigrants. MHS-delay was longer for patients who were treated already by MHS for other diagnoses. CONCLUSIONS: Specific interventions are needed focusing on patients living in highly urbanized areas and first generation immigrants in order to shorten patient delay. MHS should improve early detection of psychosis in patients already in treatment for other diagnosis.

Function assertive community treatment (FACT) and psychiatric service use in patients diagnosed with severe mental illness.

AIM: Previous work suggests that the Dutch variant of assertive community treatment (ACT), known as Function ACT (FACT), may be effective in increasing symptomatic remission rates when replacing a system of hospital-based care and separate community-based facilities. FACT guidelines propose a different pattern of psychiatric service consumption compared to traditional services, which should result in different costing parameters than care as usual (CAU). METHODS: South-Limburg FACT patients, identified through the local psychiatric case register, were matched with patients from a non-FACT control region in the North of the Netherlands (NN). Matching was accomplished using propensity scoring including, among others, total and outpatient care consumption. Assessment, as an important ingredient of FACT, was the point of departure of the present analysis. RESULTS: FACT patients, compared to CAU, had five more outpatient contacts after the index date. Cost-effectiveness was difficult to assess. CONCLUSION: Implementation of FACT results in measurable changes in mental health care use.

[Routine Outcome Monitoring for patients with severe mental illness: a consensus document]. / Routine outcome monitoring voor patiënten met ernstige psychiatrische aandoeningen; een consensusdocument.

BACKGROUND: Routine outcome monitoring (ROM) means the assessment of the patient's condition on a routine basis using instruments. So far there is no consensus about which instruments should be used for ROM with severely mentally ill patients (ROM-SMI). AIM: To reach a consensus about instruments for ROM-SMI in the Netherlands and Belgium and to create possibilities for comparison of ROM data. METHOD: This article discusses the consensus document of the National Remission Working Group for ROM in patients with smi and covers the following topics: reasons for ROM-SMI, domains for ROM-SMI and appropriate instruments, logistics and analyses of the data. RESULTS: Patients with SMI have problems in several domains. These can be assessed by collecting information about psychiatric symptoms, addiction, somatic problems, general functioning, needs, quality of life and care satisfaction. Potential instruments for ROM-SMI are short, valid, reliable and assess several domains, taking the patient's perspective into account, and have been used in national and international research. The working group advises institutions to choose from a limited set of instruments. After the scores have been aggregated and standardised, comparisons can be drawn. ROM-SMI data can be interpreted more meaningfully, if outcome data are supplemented with data regarding patient characteristics and the treatment interventions already applied. CONCLUSION: It should be possible to reach a consensus about instruments for ROM-SMI and the way in which they should be used. The use of identical instruments will lead to improvements in mental health care and create possibilities for comparison (benchmarking) and research.

[The Health of Nation Outcome Scale as clinical outcome indicator in elderly psychiatry]. / De Health of the Nation Outcome Scale als effectmaat in de ouderenpsychiatrie.

The Health of the Nation Outcome Scales65+(HoNOS65+) seems to be a useful instrument for effect measuring in elderly psychiatry. The instrument is implemented as an outcome measure within a psychiatric unit for older persons. From 244 patients a repeated assessment is completed: at the start of the treatment and at discharge. Our goal is to determine the sensitivity of change of the Health of the Nation Outcome Scales65+ for patients who are in treatment for a limited period. The sensitivity of change is examined for outpatients and inpatients and for four diagnostic groups (mood disorders, organic disorders, psychotic disorders and others) according to their DSM-IV diagnoses. Comparisons between first and second assessment were done using pairwise t-tests. Inpatients as well as outpatients showed a significant change between intake and discharge. This also holds for all four diagnostic groups. The conclusion is that the HoNOS 65+ is sensitive to change and meets the criteria for a clinical outcome indicator in elderly psychiatric patients.

Positive and useful auditory vocal hallucinations: prevalence, characteristics, attributions, and implications for treatment.

OBJECTIVE: Auditory hallucinations that are viewed by patients as positive and useful may be barriers to treatment-seeking. The aim was to assess prevalence, impact, and course of, and attributions to, these voices in psychotic and non-psychotic patients. METHOD: One hundred thirty-one patients of a Voices Clinic and 65 members of the Dutch Resonance Foundation were assessed with the Positive and Useful Voices Inquiry. Data were analyzed using Pearson's chi-square, one-way anova, and Crohnbach's alpha statistics. RESULTS: First voices are most often reported as negative. Positive voices occur more among non-psychotic subjects, but the specific characteristics and diagnosis are not significantly associated. Lifetime prevalence of positive and useful voices ranged between 40% and 60%, with varied prevalence rates over time. Positive voices are experienced by subjects as direct addresses in the third person. Perceived control of voices is significantly associated with the wish to preserve them. Attribution of protective power to positive voices has the strongest association with positive experience. CONCLUSION: Many patients express a desire to preserve these voices. Voice characteristics do not allow for validly discriminating psychotic from non-psychotic disorders.

[Implementation of the HoNOS65+]. / Implementatie van het meetinstrument HoNOS65+. Onderzoek op een afdeling voor ouderenpsychiatrie.

BACKGROUND: In the last few years mental healthcare has had to become increasingly accountable to health insurance companies, the government and patient groups with regard to the efficacy, appropriateness and patient-friendliness of the care provided. Routine outcome assessment, based on various measuring instruments, is likely to become more and more frequent in the years to come. AIM: To assess whether the Health of the Nation Outcome Scales for elderly people (HoNOS65+) can be successfully implemented within a psychiatric unit for older persons, whether the instrument is suitable for use in clinical practice and whether it provides an adequate picture of the older population in general. METHOD: The implementation phase consisted of training 51 social workers within the various sections of the unit. The trained social workers used the HoNOS65+ with 387 patients from various units for older persons within Lentis. RESULTS: The social workers found the HoNOS65+ to be a useful instrument and for each treatment setting and diagnosis it differentiated significantly between types of behaviour problems, symptoms and social problems. CONCLUSION: The HoNOS65+ can be used profitably with individual patients and patient groups and it highlights the problems in relevant areas of psychiatry for older persons.

[Do we really still need psychiatric case registers?]. / Hebben we psychiatrische casusregisters nog wel nodig?

SUMMARY: A question frequently raised in the Netherlands is whether regional case registers have added value compared to national information systems. Research in regional case registers, however, has shown that they have added value based on longitudinal data-gathering, specialised knowledge of the region concerned and data-processing. Regional case registers reflect developments in the total range of services available (cure and care, including clinics to treat alcoholism and drug addiction). Case register research can also aim at developing outcome measures and creating links between mental health care and other health care areas.

Assertive community treatment in the Netherlands: a randomized controlled trial.

OBJECTIVE: Assertive community treatment is rapidly implemented by many European mental health services, but recently the evidence base has been questioned. Positive results of randomized trials in the USA were not replicated in the UK. The question is whether the UK findings are representative for other European countries with modern mental health services. METHOD: Open randomized controlled trial of long-term severely mentally ill patients [Health of the Nation Outcome Scales (HoNOS) total score >or=15], assigned to assertive community treatment (n = 59) or to standard community mental health care (n = 59). PRIMARY OUTCOME: sustained contact; housing stability and admission days. This trial is registered as an International Standard Randomized Clinical Trial, number ISRCTN 11281756. RESULTS: Assertive community treatment was significantly better in sustaining contact with patients, but not in reducing admission days. No differences in housing stability, psychopathology, social functioning or quality of life were found. CONCLUSION: The results are in agreement with UK studies. However, the sustained contact potential of assertive community treatment is important, as too many patients are lost in standard care.

Treatment delay and response rate in first episode psychosis.

OBJECTIVE: There is no consistent evidence of long duration of untreated psychosis (DUP) predicting long time to response (TTR) in first psychosis. This study aims to investigate the predictors of DUP and TTR in a first episode patient population. METHOD: An epidemiologically representative sample of 157 non-affective first psychotic episode patients was interviewed and followed-up for at least half a year. RESULTS: The mean DUP was 46 weeks, the median 31 days. Long DUP was associated with being unemployed before treatment and male gender. Short DUP, having a job, and living with a partner before treatment predicted early response. CONCLUSION: Early intervention likely improves short-term treatment response in first episode psychosis. The best strategy to reduce DUP probably is to direct attention to the substantial number of patients who do not engage in regular treatment.

Adaptive functioning and behaviour problems in relation to level of education in children and adolescents with intellectual disability.

BACKGROUND: The interrelationship between adaptive functioning, behaviour problems and level of special education was studied in 186 children with IQs ranging from 61 to 70. The objective was to increase the insight into the contribution of adaptive functioning and general and autistic behaviour problems to the level of education in children with intellectual disability (ID). METHODS: Children from two levels of special education in the Netherlands were compared with respect to adaptive functioning [Vineland Adaptive Behavior Scales (VABS)], general behaviour problems [Child Behavior Checklist (CBCL)] and autistic behaviour problems [Autism Behavior Checklist (ABC)]. The effect of behaviour problems on adaptive functioning, and the causal relationships between behaviour problems, adaptive functioning and level of education were investigated. RESULTS: Children in schools for mild learning problems had higher VABS scores, and lower CBCL and ABC scores. The ABC had a significant effect on the total age equivalent of the VABS in schools for severe learning problems, the CBCL in schools for mild learning problems. A direct effect of the ABC and CBCL total scores on the VABS age equivalent was found, together with a direct effect of the VABS age equivalent on level of education and therefore an indirect effect of ABC and CBCL on level of education. CONCLUSIONS: In the children with the highest level of mild ID, adaptive functioning seems to be the most important factor that directly influences the level of education that a child attends. Autistic and general behaviour problems directly influence the level of adaptive functioning. Especially, autistic problems seem to have such a restrictive effect on the level of adaptive functioning that children do not reach the level of education that would be expected based on IQ. Clinical implications are discussed.

Social skills in children with intellectual disabilities with and without autism.

BACKGROUND: Social skills were studied in 363 children with mild intellectual disabilities (ID) and 147 with moderate ID with and without autism (age 4 through 18). The objective was to investigate the value of the Children's Social Behaviour Questionnaire (CSBQ), as a measure of subtle social skills, added to a measure of basic social skills with the Vineland Adaptive Behaviour Scales (VABS), in identifying children with ID with or without autism. METHOD: Children with mild and moderate ID, with and without autistic symptomatology were compared on basic social skills, measured with the Communication and Socialization domains of the VABS, and subtle social skills, measured with the CSBQ. RESULTS: Measuring basic social skills is not sufficient in differentiating between levels of ID. Communicative skills and subtle social skills, that concern overlooking activities or situations and fear of changes in the existing situation, seem to play a far greater role. Additionally, with respect to identifying autistic symptomatology, basic social skills do not contribute, as opposed to communicative skills and the tendency to withdraw from others. CONCLUSIONS: The results implicate that the CSBQ not only has specific value as a measure of subtle social skills to identify pervasive developmental disorders, but that the instrument also has a specific contribution to differentiating between the two levels of ID. Furthermore, our outcomes imply a slight difference between limitations in subtle social skills as mentioned by the AAMR (American Association on Mental Retardation 2002) and limitations in subtle social skills as seen in milder forms of pervasive developmental disorders. Clinical and theoretical implications will be discussed.

The effect of deinstitutionalization on the longitudinal continuity of mental health care in the Netherlands.

BACKGROUND: Deinstitutionalization has been accompanied by a decreasing continuity of care in a number of countries. This study evaluates the effects of the Dutch model for deinstitutionalizing mental health care. METHODS: Details of users and their use of community- and hospital-based services between 1990 and 1999 were retrieved from the Groningen case register. The time between discharge from the hospital and the first subsequent community-based contact was the primary indicator for changes in continuity of care. RESULTS: The total proportion of discharges from hospital-based mental health care followed within 6 months by community-based care increased by 11% due to the improved availability of day treatment and home treatment. In terms of median survival time, aftercare in the years 1998/1999 was delivered more than twice as fast as in the years 1990/1991. CONCLUSIONS: Study results supported the hypothesis in Dutch deinstitutionalization policy that the continuity of mental health care would benefit as to its longitudinal dimension.

Costs of deinstitutionalization in a rural catchment area in The Netherlands.

BACKGROUND: In contrast to many other countries, The Netherlands left the initiative in deinstitutionalizing mental health care to the traditional providers of mental health services. The goal of this study is to determine the effect of this policy on the allocation of mental health care resources to services. METHOD: All 20- to 64-year old users and their use of community- and hospital-based services between 1990 and 1999 were retrieved from the Groningen case register. Service utilization was combined with the direct unit costs of these services for the 1999 price level. Changes in the population as to size and age were taken into account. RESULTS: In 1999 the direct costs of mental health care were Euro 268 per adult inhabitant of the register area, which is 9% higher than in 1990. Costs increased most in the early 1990s before deinstitutionalization policy took effect. From 1993 and onwards the reduced length of stay in the hospital was the main cause for the decreased costs of in-patient care. These savings equalled the increased expenditures for day-treatment, sheltered residences and home-treatment, even though the unit costs of these types of community care are much lower than the unit costs of admissions. This was not caused by an increasing number of new clients, but was a result of longer periods of care during a larger number of years. CONCLUSIONS: These findings are in accordance with Dutch mental health care policy, which aims at prolonged care and aftercare outside the hospital whenever possible.

Propensity to psychiatric and somatic ill-health: evidence from a birth cohort.

BACKGROUND: Somatic and psychiatric morbidity may cluster because of reciprocal effects between them but also as a result of common underlying factors. METHODS: The data come from the 1946 MRC birth cohort (N = 5362). Clustering of 20 chronic medical conditions at the participants' 43rd year was analysed using multi-morbidity coefficients. Associations of somatic and psychiatric morbidity at 43 years, with temperament and behaviour, assessed from adolescence to early adulthood, and background variables like paternal social class, were examined using structural equation modelling. The focus was on whether links applied to both morbidity types or one only, and were direct or were indirect, mediated by prior morbidity. RESULTS: Reported chronic medical conditions clustered strongly. Somatic multi-morbidity and psychiatric ill-health at 43 years were associated with temperamental and behavioural features assessed between the subjects' 13th and 26th birthday, like neuroticism and aggression, as well as with external variables like parental death before the participants' 16th birthday. However, only neuroticism holds direct links with somatic as well as with psychiatric ill-health, 28% of the former and 52% of the latter association being independent of the simultaneous presence of the other morbidity type and of participants' health status 7 years earlier. CONCLUSIONS: Personality traits like neuroticism not only raise the risk of psychiatric disorder but also, irrespective of whether manifest psychiatric disorders have developed, of a broad spectrum of chronic somatic diseases. This suggests that clinicians and researchers should focus not only on the psychiatric disorders associated with such personality traits but also on their medical consequences.

Predictors for readmission risk of new patients: the Nordic Comparative Study on Sectorized Psychiatry.

OBJECTIVE: Predictors for readmission risk were investigated in this study, which forms part of the Nordic Comparative Study on Sectorized Psychiatry. METHOD: Included were a total of 837 consecutive 'new' patients (not in contact with the psychiatric services for at least 18 months) admitted to in-patient stay during a period of 1 year to seven psychiatric hospitals in four Nordic countries. RESULTS: Multivariate survival analyses showed that younger age predicted increased readmission risk. Stratifying on gender, diagnostic group and sector revealed a general pattern concerning age which was the only consistent main effect. Living alone and unemployed increased readmission risk in the non-psychosis group, while receipt of aftercare decreased readmission risk in the psychosis group. A curvilinear relationship was found between availability of psychiatric resources and readmission risk: an intermediate amount of resources was associated with increased risk. CONCLUSION: Our findings support a hypothesis that readmission risk is multifactorially determined and that interactions have to be considered.

Continuity of care and readmission in two service systems: a comparative Victorian and Groningen case-register study.

OBJECTIVE: We compared service consumption, continuity of care and risk of readmission in a record linkage follow-up study of cohorts of patients with schizophrenia and related disorders in Victoria (Australia) and in Groningen (The Netherlands). These areas are interesting to compare because mental health care is in a different stage of deinstitutionalization. More beds are available in Groningen and more community resources are available in Victoria. METHOD: The cohorts were followed for 4 years, since discharge from inpatient services using record linkage data available in the psychiatric case-registers in both areas. Survival analysis was used to study continuity of care and risk of readmission. RESULTS: Available indicators showed a higher level of continuity of care in Victoria. While the relative risk of readmission was the same in both areas and not affected by aftercare contact after discharge, the number of days spent in hospital was much higher in the Groningen register area. CONCLUSION: These findings provide further support for earlier reports that the risk of readmission is predominantly affected by attributes of mental illness. However, the duration of admissions, is strongly affected by service system variables, including the provision of continuity of care.

The Nordic Comparative Study on Sectorized Psychiatry--length of in-patient stay.

OBJECTIVE: Length of stay (LOS) of 'first' in-patient episodes was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry. METHOD: A total of 837 consecutive 'new' patients (not in contact with the psychiatric services for at least 18 months) admitted as in-patients during a period of 1 year to seven psychiatric hospitals in four Nordic countries were included. RESULTS: Survival analyses showed considerable differences in LOS between the hospitals, and the factors analysed in this study could not explain this variance. Older age, being female, having no children at home, psychosis, planned admission and out-patient contacts were all associated with increased LOS. CONCLUSION: Stratifying on gender, diagnostic group and hospital revealed a general pattern of associations except for age.