Reprint of: Negative symptoms predict high relapse rates and both predict less favorable functional outcome in first episode psychosis, independent of treatment strategy.

BACKGROUND: In first episode psychosis (FEP) baseline negative symptoms (BNS) and relapse both predict less favorable functional outcome. Relapse-prevention is one of the most important goals of treatment. Apart from discontinuation of antipsychotics, natural causes of relapse are unexplained. We hypothesized that BNS, apart from predicting worse functional outcome, might also increase relapse risk. METHODS: We performed a post-hoc analysis of 7-year follow-up data of a FEP cohort (n = 103) involved in a dose-reduction/discontinuation (DR) vs. maintenance treatment (MT) trial. We examined: 1) what predicted relapse, 2) what predicted functional outcome, and 3) if BNS predicted relapse, whether MT reduced relapse rates compared to DR. After remission patients were randomly assigned to DR or MT for 18 months. Thereafter, treatment was uncontrolled. OUTCOMES: BNS and duration of untreated psychosis (DUP) predicted relapse. Number of relapses, BNS, and treatment strategy predicted functional outcome. BNS was the strongest predictor of relapse, while number of relapses was the strongest predictor of functional outcome above BNS and treatment strategy. Overall and within MT, but not within DR, more severe BNS predicted significantly higher relapse rates. Treatment strategies did not make a difference in relapse rates, regardless of BNS severity. INTERPRETATION: BNS not only predicted worse functional outcome, but also relapses during follow-up. Since current low dose maintenance treatment strategies did not prevent relapse proneness in patients with more severe BNS, resources should be deployed to find optimal treatment strategies for this particular group of patients.

Negative symptoms predict high relapse rates and both predict less favorable functional outcome in first episode psychosis, independent of treatment strategy.

BACKGROUND: In first episode psychosis (FEP) baseline negative symptoms (BNS) and relapse both predict less favorable functional outcome. Relapse-prevention is one of the most important goals of treatment. Apart from discontinuation of antipsychotics, natural causes of relapse are unexplained. We hypothesized that BNS, apart from predicting worse functional outcome, might also increase relapse risk. METHODS: We performed a post-hoc analysis of 7-year follow-up data of a FEP cohort (n = 103) involved in a dose-reduction/discontinuation (DR) vs. maintenance treatment (MT) trial. We examined: 1) what predicted relapse, 2) what predicted functional outcome, and 3) if BNS predicted relapse, whether MT reduced relapse rates compared to DR. After remission patients were randomly assigned to DR or MT for 18 months. Thereafter, treatment was uncontrolled. OUTCOMES: BNS and duration of untreated psychosis (DUP) predicted relapse. Number of relapses, BNS, and treatment strategy predicted functional outcome. BNS was the strongest predictor of relapse, while number of relapses was the strongest predictor of functional outcome above BNS and treatment strategy. Overall and within MT, but not within DR, more severe BNS predicted significantly higher relapse rates. Treatment strategies did not make a difference in relapse rates, regardless of BNS severity. INTERPRETATION: BNS not only predicted worse functional outcome, but also relapses during follow-up. Since current low dose maintenance treatment strategies did not prevent relapse proneness in patients with more severe BNS, resources should be deployed to find optimal treatment strategies for this particular group of patients.

Personal Recovery Among Service Users Compared With Siblings and a Control Group: A Critical Note on Recovery Assessment.

OBJECTIVE: One way to boost the implementation of a recovery-oriented practice in psychiatric care may be by including outcome measures assessing recovery. However, the five core processes of personal recovery-connectedness, hope and optimism about the future, identity, meaning in life, and empowerment (collectively known as CHIME)-are not service user-specific and can be relevant to nonservice users as well. It is unknown whether recovery processes are measurably different among users and nonusers of mental health services. This study aimed to compare scores on the 24-item Recovery Assessment Scale (RAS) among service users with psychosis (in remission and not in remission), their siblings, and a control group, after the validation of the RAS Dutch version. METHODS: Psychometric evaluation and comparative analyses (analysis of variance and tests of clinical significance) were performed on data from service users (N=581), their siblings (N=632), and control group members (N=372) in the longitudinal Genetic Risk and Outcome in Psychosis study in the Netherlands. RESULTS: Results showed that the psychometric validity of the RAS Dutch version was adequate. A significant, moderate effect was found for the RAS total score (F=31.73, df=3 and 1,559, p<0.001; Cohen's f=0.25). However, clinical significance analysis showed that a substantial number of service users had recovered, including those in remission and those not in remission, and that substantial numbers of siblings and control group members had not recovered. CONCLUSIONS: The findings call into question the usefulness of the RAS in outcome assessment, given that the differences detected in recovery between service users, siblings, and control group members had limited clinical relevance.

Searching for the optimal number of response alternatives for the distress scale of the four-dimensional symptom questionnaire.

BACKGROUND: The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report questionnaire designed to measure distress, depression, anxiety, and somatization. Prior to computing scale scores from the item scores, the three highest response alternatives ('Regularly', 'Often', and 'Very often or constantly present') are usually collapsed into one category to reduce the influence of extreme responding on item- and scale scores. In this study, we evaluate the usefulness of this transformation for the distress scale based on a variety of criteria. METHODS: Specifically, by using the Graded Response Model, we investigated the effect of this transformation on model fit, local measurement precision, and various indicators of the scale's validity to get an indication on whether the current practice of recoding should be advocated or not. In particular, the effect on the convergent- (operationalized by the General Health Questionnaire and the Maastricht Questionnaire), divergent- (operationalized by the Neuroticism scale of the NEO-FFI), and predictive validity (operationalized as obtrusion with daily chores and activities, the Biographical Problem list and the Utrecht Burnout Scale) of the distress scale was investigated. RESULTS: Results indicate that recoding leads to (i) better model fit as indicated by lower mean probabilities of exact test statistics assessing item fit, (ii) small (<.02) losses in the sizes of various validity coefficients, and (iii) a decrease (DIFF (SE's) = .10-.25) in measurement precision for medium and high levels of distress. CONCLUSIONS: For clinical applications and applications in longitudinal research, the current practice of recoding should be avoided because recoding decreases measurement precision for medium and high levels of distress. It would be interesting to see whether this advice also holds for the three other domains of the 4DSQ.

A Smart Screening Device for Patients with Mental Health Problems in Primary Health Care: Development and Pilot Study.

BACKGROUND: Adequate recognition of mental health problems is a prerequisite for successful treatment. Although most people tend to consult their general practitioner (GP) when they first experience mental health problems, GPs are not very well equipped to screen for various forms of psychopathology to help them determine clients' need for treatment. OBJECTIVE: In this paper, the development and characteristics of CATja, a computerized adaptive test battery built to facilitate triage in primary care settings, are described, and first results of its implementation are reported. METHODS: CATja was developed in close collaboration with GPs and mental health assistants (MHAs). During implementation, MHAs were requested to appraise clients' rankings (N=91) on the domains to be tested and to indicate the treatment level they deemed most appropriate for clients before test administration. We compared the agreement between domain score appraisals and domain score computed by CATja and the agreement between initial (before test administration) treatment level advice and final treatment level advice. RESULTS: Agreements (Cohen kappas) between MHAs' appraisals of clients' scores and clients' scores computed by CATja were mostly between .40 and .50 (Cohen kappas=.10-.20), and the agreement between "initial" treatment levels and the final treatment level advised was .65 (Cohen kappa=.55). CONCLUSIONS: Using CATja, caregivers can efficiently generate summaries of their clients' mental well-being on which decisions about treatment type and care level may be based. Further validation research is needed.

Study protocol for a prospective cohort study examining the predictive potential of dynamic symptom networks for the onset and progression of psychosis: the Mapping Individual Routes of Risk and Resilience (Mirorr) study.

INTRODUCTION: Our current ability to predict the course and outcome of early psychotic symptoms is limited, hampering timely treatment. To improve our understanding of the development of psychosis, a different approach to psychopathology may be productive. We propose to reconceptualise psychopathology from a network perspective, according to which symptoms act as a dynamic, interconnected system, impacting on each other over time and across diagnostic boundaries to form symptom networks. Adopting this network approach, the Mapping Individual Routes of Risk and Resilience study aims to determine whether characteristics of symptom networks can predict illness course and outcome of early psychotic symptoms. METHODS AND ANALYSIS: The sample consists of n=100 participants aged 18-35 years, divided into four subgroups (n=4×25) with increasing levels of severity of psychopathology, representing successive stages of clinical progression. Individuals representing the initial stage have a relatively low expression of psychotic experiences (general population), whereas individuals representing the end stage are help seeking and display a psychometric expression of psychosis, putting them at ultra-high risk for transition to psychotic disorder. At baseline and 1-year follow-up, participants report their symptoms, affective states and experiences for three consecutive months in short, daily questionnaires on their smartphone, which will be used to map individual networks. Network parameters, including the strength and directionality of symptom connections and centrality indices, will be estimated and associated to individual differences in and within-individual progression through stages of clinical severity and functioning over the next 3 years. ETHICS AND DISSEMINATION: The study has been approved by the local medical ethical committee (ABR no. NL52974.042.15). The results of the study will be published in (inter)national peer-reviewed journals, presented at research, clinical and general public conferences. The results will assist in improving and fine-tuning dynamic models of psychopathology, stimulating both clinical and scientific progress. TRIAL REGISTRATION NUMBER: NTR6205 ; Pre-results.

Social support in chat sessions for adolescents and young adults living with a family member with mental illness.

Children from families with a mental illness are at risk of developing negative health outcomes. Online interventions are a new way to offer support to these children. The present study utilized a website that had been developed to support Dutch youth who had a family member with a mental illness. The objective was to analyse monitored and unmonitored chatroom conversations among these young people, and specifically to compare supportive messages and self-disclosures of experiences. We electronically imported session transcripts of 34 chatroom conversations into the qualitative analysis software Atlas.ti. A content analysis was performed on 4252 messages from 22 female participants. A correlational analysis was then conducted to identify significant associations between sent and received supportive statements and disclosing statements. We found supporting comments in approximately 34% of the conversations and disclosures of problems in the home in approximately 15-18% of the messages. Participants made approximately twice as many disclosing statements and approximately half as many supportive statements in the monitored sessions compared to the unmonitored sessions. The number of disclosures that were sent was positively correlated with the amount of social support that was received. The number of disclosures sent was negatively correlated with the amount of social support that was sent, but only in the unmonitored sessions. Considering the greater reach of Internet interventions, online chatroom sessions might be provided as complementary to, or as an alternative to, face-to-face groups for supporting youth with a family member who has a mental illness.

Person-fit feedback on inconsistent symptom reports in clinical depression care.

BACKGROUND: Depressive patients can present with complex and different symptom patterns in clinical care. Of these, some may report patterns that are inconsistent with typical patterns of depressive symptoms. This study aimed to evaluate the validity of person-fit statistics to identify inconsistent symptom reports and to assess the clinical usefulness of providing clinicians with person-fit score feedback during depression assessment. METHODS: Inconsistent symptom reports on the Inventory of Depressive Symptomatology Self-Report (IDS-SR) were investigated quantitatively with person-fit statistics for both intake and follow-up measurements in the Groningen University Center of Psychiatry (n = 2036). Subsequently, to investigate the causes and clinical usefulness of on-the-fly person-fit alerts, qualitative follow-up assessments were conducted with three psychiatrists about 20 of their patients that were randomly selected. RESULTS: Inconsistent symptom reports at intake (12.3%) were predominantly characterized by reporting of severe symptoms (e.g. psychomotor slowing) without mild symptoms (e.g. irritability). Person-fit scores at intake and follow-up were positively correlated (r = 0.45). Qualitative interviews with psychiatrists resulted in an explanation for the inconsistent response behavior (e.g. complex comorbidity, somatic complaints, and neurological abnormalities) for 19 of 20 patients. Psychiatrists indicated that if provided directly after the assessment, a person-fit alert would have led to new insights in 60%, and be reason for discussion with the patient in 75% of the cases. CONCLUSIONS: Providing clinicians with automated feedback when inconsistent symptom reports occur is informative and can be used to support clinical decision-making.

Identifying levels of general distress in first line mental health services: can GP- and eHealth clients' scores be meaningfully compared?

BACKGROUND: The Four-Dimensional Symptom Questionnaire (4DSQ) (Huisarts Wetenschap 39: 538-47, 1996) is a self-report questionnaire developed in the Netherlands to distinguish non-specific general distress from depression, anxiety, and somatization. This questionnaire is often used in different populations and settings and there is a paper-and-pencil and computerized version. METHODS: We used item response theory to investigate whether the 4DSQ measures the same construct (structural equivalence) in the same way (scalar equivalence) in two samples comprised of primary mental health care attendees: (i) clients who visited their General Practitioner responded to the 4DSQ paper-and-pencil version, and (ii) eHealth clients responded to the 4DSQ computerized version. Specifically, we investigated whether the distress items functioned differently in eHealth clients compared to General Practitioners' clients and whether these differences lead to substantial differences at scale level. RESULTS: Results showed that in general structural equivalence holds for the distress scale. This means that the distress scale measures the same construct in both General Practitioners' clients and eHealth clients. Furthermore, although eHealth clients have higher observed distress scores than General Practitioners' clients, application of a multiple group generalized partial credit response model suggests that scalar equivalence holds. CONCLUSIONS: The same cutoff scores can be used for classifying respondents as having low, moderate and high levels of distress in both settings.

The Prodromal Questionnaire: a case for IRT-based adaptive testing of psychotic experiences?

Computerized adaptive tests (CATs) for positive and negative psychotic experiences were developed and tested in N = 5705 help-seeking, non-psychotic young individuals. Instead of presenting all items, CATs choose a varying number of different items during test administration depending on respondents' previous answers, reducing the average number of items while still obtaining accurate person estimates. We assessed the appropriateness of two-parameter logistic models to positive and negative symptoms of the Prodromal Questionnaire (PQ), computed measurement precision of all items and resulting adaptive tests along psychotic dimensions by Real Data Simulations (RDS), and computed indices for criterion and predictive validities of the CATs. For all items, mean absolute differences between observed and expected response probabilities were smaller than 0.02. CAT-POS predicted transition to psychosis and duration of hospitalization in individuals at-risk for psychosis, and CAT-NEG was suggestively related to later functioning. Regarding psychosis risk classifications of help-seeking individuals, CAT-POS performed less than the PQ-16. Adaptive testing based on self-reported positive and negative symptoms in individuals at-risk for psychosis is a feasible method to select patients for further risk classification. These promising findings need to be replicated prospectively in a non-selective sample that also includes non-at-risk individuals. Copyright © 2016 John Wiley & Sons, Ltd.

A Fresh Pair of Eyes: A Blind Observation Method for Evaluating Social Skills of Children with ASD in a Naturalistic Peer Situation in School.

The Social skills Observation Measure (SOM) is a direct observation method for social skills used in naturalistic everyday situations in school. This study describes the development of the SOM and investigates its psychometric properties in 86 children with Autism spectrum disorder, aged 9.8-13.1 years. The interrater reliability was found to be good to excellent. The convergent validity was low in relation to parent and teacher reports of social skills, and also to parent interview on adaptive social functioning. Therefore this direct observation seems to provide additional information on the frequency and quality of social behaviors in daily life situations. As such it contributes to parent and teacher information as a blind measurement to evaluate Social Skills Training.

The Autism Diagnostic Observation Schedule, Module 4: Application of the Revised Algorithms in an Independent, Well-Defined, Dutch Sample (n = 93).

This study examined the discriminative ability of the revised Autism Diagnostic Observation Schedule module 4 algorithm (Hus and Lord in J Autism Dev Disord 44(8):1996-2012, 2014) in 93 Dutch males with Autism Spectrum Disorder (ASD), schizophrenia, psychopathy or controls. Discriminative ability of the revised algorithm ASD cut-off resembled the original algorithm ASD cut-off: highly specific for psychopathy and controls, lower sensitivity than Hus and Lord (2014; i.e. ASD .61, AD .53). The revised algorithm AD cut-off improved sensitivity over the original algorithm. Discriminating ASD from schizophrenia was still challenging, but the better-balanced sensitivity (.53) and specificity (.78) of the revised algorithm AD cut-off may aide clinicians' differential diagnosis. Findings support using the revised algorithm, being conceptually conform the other modules, thus improving comparability across the lifespan.

Self-expressed strengths and resources of children of parents with a mental illness: A systematic review.

The aim of the present study was to explore the strengths children reported to have acquired while coping with their parents illness, and the external factors these children indicated had facilitated their coping process. A systematic literature search was conducted of peer-reviewed papers that focused on self-reported experiences of children with parents who had mental illness, and revealed their strengths and resources. The search included the following databases: MEDLINE, PsycINFO, and CINAHL. Results were filtered according to whether search terms appeared in the title or abstract. Fifty-seven full-text papers were reviewed; 26 of them met the inclusion criteria and were included in the review. The statements were analysed using content analysis. The search identified 160 relevant statements, 38 (24%) of which could be described as self-reported strengths, and 122 (76%) as self-reported resources. According to these statements, the children described themselves as more mature, independent, and empathic than their peers who did not have a parent with a mental illness, and as having acquired several abilities. The statements about resources indicated that the children regarded social support, information, and particularly the support of mental health-care professionals as helpful when living with a parent with a mental illness. Recommendations for nursing actions to support children's ability to cope with their parents' illness are outlined.

Ecological Momentary Assessments and Automated Time Series Analysis to Promote Tailored Health Care: A Proof-of-Principle Study.

BACKGROUND: Health promotion can be tailored by combining ecological momentary assessments (EMA) with time series analysis. This combined method allows for studying the temporal order of dynamic relationships among variables, which may provide concrete indications for intervention. However, application of this method in health care practice is hampered because analyses are conducted manually and advanced statistical expertise is required. OBJECTIVE: This study aims to show how this limitation can be overcome by introducing automated vector autoregressive modeling (VAR) of EMA data and to evaluate its feasibility through comparisons with results of previously published manual analyses. METHODS: We developed a Web-based open source application, called AutoVAR, which automates time series analyses of EMA data and provides output that is intended to be interpretable by nonexperts. The statistical technique we used was VAR. AutoVAR tests and evaluates all possible VAR models within a given combinatorial search space and summarizes their results, thereby replacing the researcher's tasks of conducting the analysis, making an informed selection of models, and choosing the best model. We compared the output of AutoVAR to the output of a previously published manual analysis (n=4). RESULTS: An illustrative example consisting of 4 analyses was provided. Compared to the manual output, the AutoVAR output presents similar model characteristics and statistical results in terms of the Akaike information criterion, the Bayesian information criterion, and the test statistic of the Granger causality test. CONCLUSIONS: Results suggest that automated analysis and interpretation of times series is feasible. Compared to a manual procedure, the automated procedure is more robust and can save days of time. These findings may pave the way for using time series analysis for health promotion on a larger scale. AutoVAR was evaluated using the results of a previously conducted manual analysis. Analysis of additional datasets is needed in order to validate and refine the application for general use.

Autism Diagnostic Interview-Revised (ADI-R) Algorithms for Toddlers and Young Preschoolers: Application in a Non-US Sample of 1,104 Children.

The current study aimed to investigate the Autism Diagnostic Interview-Revised (ADI-R) algorithms for toddlers and young preschoolers (Kim and Lord, J Autism Dev Disord 42(1):82-93, 2012) in a non-US sample from ten sites in nine countries (n = 1,104). The construct validity indicated a good fit of the algorithms. The diagnostic validity was lower, with satisfactorily high specificities but moderate sensitivities. Young children with clinical ASD and lower language ability were largely in the mild-to-moderate or moderate-to-severe concern ranges of the ADI-R, nearly half of the older and phrase speech ASD-group fell into the little-to-no concern range. Although broadly the findings support the toddler algorithms, further work is required to understand why they might have different properties in different samples to further inform research and clinical use.

Paternal influences on treatment outcome of behavioral parent training in children with attention-deficit/hyperactivity disorder.

This study aims to explore the influence of paternal variables on outcome of behavioral parent training (BPT) in children with attention-deficit/hyperactivity disorder (ADHD). 83 referred, school-aged children with ADHD were randomly assigned to BPT plus ongoing routine clinical care (RCC) or RCC alone. Treatment outcome was based on parent-reported ADHD symptoms and behavioral problems. Moderator variables included paternal ADHD symptoms, depressive symptoms, and parenting self-efficacy. We conducted repeated measures analyses of variance (ANOVA) for all variables, and then analyzed the direction of interaction effects by repeated measures ANOVA in high and low scoring subgroups. Paternal ADHD symptoms and parenting self-efficacy played a moderating role in decreasing behavioral problems, but not in decreasing ADHD symptoms. Paternal depressive symptoms did not moderate either treatment outcome. BPT is most beneficial in reducing children's behavioral problems when their fathers have high levels of ADHD symptoms or high-parenting self-efficacy.

Adding evidence-based interventions to assertive community treatment: a feasibility study.

OBJECTIVE: This 24-month study, conducted in The Netherlands, examined the feasibility of enhancing the effectiveness of assertive community treatment (ACT) by adding evidence-based interventions. METHODS: A total of 159 patients were randomly assigned to two ACT teams, one providing standard ACT (N585) and an ACT Plus team that also provided evidence-based interventions (N574): psychoeducation, family interventions, individual placement and support, and cognitive behavioral therapy. The interventions were conducted by psychologists and nurse practitioners working independently from the ACT team. RESULTS: Although most patients were judged eligible for each of the four interventions (range 65% to 89%), only 12 of the 74 patients (16%) successfully completed an intervention. Outcomes, such as use of inpatient care, for ACT Plus and standard ACT patients did not differ significantly. CONCLUSIONS: Guidelines for the treatment of schizophrenia should consider the feasibility of delivering evidence-based interventions to difficult-to-engage patients.

E-mental health self-management for psychotic disorders: state of the art and future perspectives.

OBJECTIVE: The aim of this review was to investigate to what extent information technology may support self-management among service users with psychotic disorders. The investigation aimed to answer the following questions: What types of e-mental health self-management interventions have been developed and evaluated? What is the current evidence on clinical outcome and cost-effectiveness of the identified interventions? To what extent are e-mental health self-management interventions oriented toward the service user? METHODS: A systematic review of references through July 2012 derived from MEDLINE, PsycINFO, AMED, CINAHL, and the Library, Information Science and Technology database was performed. Studies of e-mental health self-management interventions for persons with psychotic disorders were selected independently by three reviewers. RESULTS: Twenty-eight studies met the inclusion criteria. E-mental health self-management interventions included psychoeducation, medication management, communication and shared decision making, management of daily functioning, lifestyle management, peer support, and real-time self-monitoring by daily measurements (experience sampling monitoring). Summary effect sizes were large for medication management (.92) and small for psychoeducation (.37) and communication and shared decision making (.21). For all other studies, individual effect sizes were calculated. The only economic analysis conducted reported more short-term costs for the e-mental health intervention. CONCLUSIONS: People with psychotic disorders were able and willing to use e-mental health services. Results suggest that e-mental health services are at least as effective as usual care or nontechnological approaches. Larger effects were found for medication management e-mental health services. No studies reported a negative effect. Results must be interpreted cautiously, because they are based on a small number of studies.