Comparative analysis of algorithm-guided treatment and predefined duration treatment programmes for depression: exploring cost-effectiveness using routine care data.

BACKGROUND: More knowledge on the cost-effectiveness of various depression treatment programmes can promote efficient treatment allocation and improve the quality of depression care. OBJECTIVE: This study aims to compare the real-world cost-effectiveness of an algorithm-guided programme focused on remission to a predefined duration, patient preference-centred treatment programme focused on response using routine care data. METHODS: A naturalistic study (n=6295 in the raw dataset) was used to compare the costs and outcomes of two programmes in terms of quality-adjusted life years (QALY) and depression-free days (DFD). Analyses were performed from a healthcare system perspective over a 2-year time horizon. Incremental cost-effectiveness ratios were calculated, and the uncertainty of results was assessed using bootstrapping and sensitivity analysis. FINDINGS: The algorithm-guided treatment programme per client yielded more DFDs (12) and more QALYs (0.013) at a higher cost (€3070) than the predefined duration treatment programme. The incremental cost-effectiveness ratios (ICERs) were around €256/DFD and €236 154/QALY for the algorithm guided compared with the predefined duration treatment programme. At a threshold value of €50 000/QALY gained, the programme had a probability of <10% of being considered cost-effective. Sensitivity analyses confirmed the robustness of these findings. CONCLUSIONS: The algorithm-guided programme led to larger health gains than the predefined duration treatment programme, but it was considerably more expensive, and hence not cost-effective at current Dutch thresholds. Depending on the preferences and budgets available, each programme has its own benefits. CLINICAL IMPLICATION: This study provides valuable information to decision-makers for optimising treatment allocation and enhancing quality of care cost-effectively.

Life years lost for users of specialized mental healthcare.

BACKGROUND: Mental disorders are burdensome and are associated with increased mortality. Mortality has been researched for various mental disorders, especially in countries with national registries, including the Nordic countries. Yet, knowledge gaps exist around national differences, while also relatively less studies compare mortality of those seeking help for mental disorders in specialized mental healthcare (SMH) by diagnosis. Additional insight into such mortality distributions for SMH users would be beneficial for both policy and research purposes. We aim to describe and compare the mortality in a population of SMH users with the mortality of the general population. Additionally, we aim to investigate mortality differences between sexes and major diagnosis categories: anxiety, depression, schizophrenia spectrum and other psychotic disorders, and bipolar disorder. METHODS: Mortality and basic demographics were available for a population of N = 10,914 SMH users in the north of The Netherlands from 2010 until 2017. To estimate mortality over the adult lifespan, parametric Gompertz distributions were fitted on observed mortality using interval regression. Life years lost were computed by calculating the difference between integrals of the survival functions for the general population and the study sample, thus correcting for age. Survival for the general population was obtained from Statistics Netherlands (CBS). RESULTS: SMH users were estimated to lose 9.5 life years (95% CI: 9.4-9.6). Every major diagnosis category was associated with a significant loss of life years, ranging from 7.2 (95% CI: 6.4-7.9) years for anxiety patients to 11.7 (95% CI: 11.0-12.5) years for bipolar disorder patients. Significant differences in mortality were observed between male SMH users and female SMH users, with men losing relatively more life years: 11.0 (95% CI: 10.9-11.2) versus 8.3 (95% CI: 8.2-8.4) respectively. This difference was also observed between sexes within every diagnosis, although the difference was insignificant for bipolar disorder. CONCLUSION: There were significant differences in mortality between SMH users and the general population. Substantial differences were observed between sexes and between diagnoses. Additional attention is required, and possibly specific interventions are needed to reduce the amount of life years lost by SMH users.

Cardiovascular risk assessment methods yield unequal risk predictions: a large cross-sectional study in psychiatric secondary care outpatients.

BACKGROUND: Patients with a mental illness are more likely to develop, and die from, cardiovascular diseases (CVD), necessitating optimal CVD-risk (CVR)-assessment to enable early detection and treatment. Whereas psychiatrists use the metabolic syndrome (MetS)-concept to estimate CVR, GPs use absolute risk-models. Additionally, two PRIMROSE-models have been specifically designed for patients with severe mental illness. We aimed to assess the agreement in risk-outcomes between these CVR-methods. METHODS: To compare risk-outcomes across the various CVR-methods, we used somatic information of psychiatric outpatients from the PHAMOUS-, and MOPHAR-database, aged 40-70 years, free of past or current CVD and diabetes. We investigated: (1) the degree-of-agreement between categorical assessments (i.e. MetS-status vs. binary risk-categories); (2) non-parametric correlations between the number of MetS-criteria and absolute risks; and (3) strength-of-agreement between absolute risks. RESULTS: Seven thousand twenty-nine measurements of 3509 PHAMOUS-patients, and 748 measurements of 748 MOPHAR-patients, were included. There was systematic disagreement between the categorical CVR-assessments (all p < 0.036). Only MetS-status versus binary Framingham-assessment had a fair strength-of-agreement (κ = 0.23-0.28). The number of MetS-criteria and Framingham-scores, as well as MetS-criteria and PRIMROSE lipid-scores, showed a moderate-strong correlation (τ = 0.25-0.34). Finally, only the continuous PRIMROSE desk and lipid-outcomes showed moderate strength-of-agreement (ρ = 0.91). CONCLUSIONS: The varying methods for CVR-assessment yield unequal risk predictions, and, consequently, carry the risk of significant disparities regarding treatment initiation in psychiatric patients. Considering the significantly increased health-risks in psychiatric patients, CVR-models should be recalibrated to the psychiatric population from adolescence onwards, and uniformly implemented by health care providers. TRIAL REGISTRATION: The MOPHAR research has been prospectively registered with the Netherlands Trial Register on 19th of November 2014 (NL4779).

Personality traits and coping strategies in recent-onset psychosis: Associations with symptom severity and psychosocial functioning.

BACKGROUND: Personality and coping may be related to symptom severity and psychosocial functioning in patients with recent-onset psychosis. This study aimed to investigate associations of personality traits and coping strategies with concurrent and follow-up symptom severity and functioning in those patients, and identify whether coping mediates relations between personality and symptoms or functioning. METHODS: At baseline, 527 recent-onset psychosis patients (73 % male, mean age = 28 years) received assessments on personality (Neuroticism-Extraversion-Openness - Five-Factor Inventory), coping (Utrecht Coping List), symptom severity (Positive And Negative Syndrome Scale) and psychosocial functioning (Global Assessment of Functioning Scale). Of those, 149 also received symptom and functioning assessments at follow-up. Multivariable linear regression analyses were performed to assess cross-sectional associations of personality and coping with symptoms and functioning at baseline. Longitudinal associations of baseline personality and coping with follow-up symptomatic remission and functioning were analyzed with multivariable linear and binary logistic regression analyses, respectively. Lastly, it was investigated whether coping mediated associations between personality and symptoms or functioning. RESULTS: Higher baseline Agreeableness (B = -0.019, [95%CI: -0.031; -0.007]) and Neuroticism (B = -0.017, [95%CI: -0.028; -0.006]) were associated with lower concurrent symptom severity. Reassuring Thoughts were associated with better functioning at baseline (B = 0.833, [95%CI: 0.272; 1.393]). Neither personality nor coping were associated with follow-up symptomatic remission or functioning. Coping did not mediate associations between personality and symptoms or functioning. CONCLUSION: Only the coping strategy Reassuring Thoughts is associated with better baseline functioning in patients with recent-onset psychosis. Personality traits seem to have limited clinically relevant relations with symptom severity or functioning.

Satisfaction with social connectedness as a predictor for positive and negative symptoms of psychosis: A PHAMOUS study.

PURPOSE: This study examines satisfaction with social connectedness (SSC) as predictor of positive and negative symptoms in people with a psychotic disorder. METHODS: Data from the Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS) was used from patients assessed between 2014 and 2019, diagnosed with a psychotic disorder (N = 2109). Items about social connectedness of the Manchester short assessment of Quality of Life (ManSA) were used to measure SSC. Linear mixed models were used to estimate the association of SSC with the Positive and Negative Syndrome Scale (PANSS) after one and two years against α = 0.01. Analyses were adjusted for symptoms, time since onset, gender and age. Additionally, fluctuation of positive and negative symptom scores over time was estimated. RESULTS: The mean duration of illness of the sample was 18.8 years (SD 10.7) with >65% showing only small variation in positive and negative symptoms over a two to five-year time period. After adjustment for covariates, SSC showed to be negatively associated with positive symptoms after one year (ß = -0.47, p < 0.001, 95% CI = -0.70, -025) and two years (ß = -0.59, p < 0.001, 95% CI = -0.88, -0.30), and for negative symptoms after one year (ß = -0.52, p < 0.001, 95% CI = -0.77, -0.27). The prediction of negative symptoms was not significant at two years. CONCLUSION: This research indicates that interventions on SSC might positively impact mental health for people with psychosis. SSC is a small and robust predictor of future levels of positive symptoms. Negative symptoms could be predicted by SSC at one year.

Real-World Treatment Costs and Care Utilization in Patients with Major Depressive Disorder With and Without Psychiatric Comorbidities in Specialist Mental Healthcare.

BACKGROUND: The majority of patients with major depressive disorder (MDD) have comorbid mental conditions. OBJECTIVES: Since most cost-of-illness studies correct for comorbidity, this study focuses on mental healthcare utilization and treatment costs in patients with MDD including psychiatric comorbidities in specialist mental healthcare, particularly patients with a comorbid personality disorder (PD). METHODS: The Psychiatric Case Register North Netherlands contains administrative data of specialist mental healthcare providers. Treatment episodes were identified from uninterrupted healthcare use. Costs were calculated by multiplying care utilization with unit prices (price level year: 2018). Using generalized linear models, cost drivers were investigated for the entire cohort. RESULTS: A total of 34,713 patients had MDD as a primary diagnosis over the period 2000-2012. The number of patients with psychiatric comorbidities was 24,888 (71.7%), including 13,798 with PD. Costs were highly skewed, with an average ± standard deviation cost per treatment episode of €21,186 ± 74,192 (median €2320). Major cost drivers were inpatient days and daycare days (50 and 28% of total costs), occurring in 12.7 and 12.5% of episodes, respectively. Compared with patients with MDD only (€11,612), costs of patients with additional PD and with or without other comorbidities were, respectively, 2.71 (p < .001) and 2.06 (p < .001) times higher and were 1.36 (p < .001) times higher in patients with MDD and comorbidities other than PD. Other cost drivers were age, calendar year, and first episodes. CONCLUSIONS: Psychiatric comorbidities (especially PD) in addition to age and first episodes drive costs in patients with MDD. Knowledge of cost drivers may help in the development of future stratified disease management programs.

Sensitivity to change of the Beck Depression Inventory versus the Inventory of Depressive Symptoms.

BACKGROUND: In a previous study which made a comparison between disorder-specific and generic instruments to assess outcome of treatments for depression, the Beck Depression Inventory, Second Edition (BDI-II) seemed to be more sensitive to change than the Inventory of Depressive Symptoms- Self Rating (IDS-SR). METHODS: A set with longitudinal data from Routine Outcome Monitoring (n=144) were analyzed with multilevel models with random intercepts. The sensitivity to change of two disorder-specific instruments, the BDI-II and the IDS-SR, were compared head to head. RESULTS: The BDI-II was more sensitive to change when measuring treatment outcome compared to the IDS-SR. The BDI-II decreases significantly more over time than the IDS-SR: the average decrease per week for the IDS-SR is -.012 (95%CI -0.015, -0.009) and for the BDI-II it is -.017 (95%CI -0.021, -0.014). LIMITATIONS: Conclusions can only be preliminary due to a small sample size. CONCLUSIONS: Treatment outcomes measured with questionnaires may differ depending on the degree of sensitivity to change of the instruments.

Episode detection based on personalized intensity of care thresholds: a schizophrenia case study.

BACKGROUND: Schizophrenia Spectrum Disorder (SSD) is characterized by its chronic, episodic nature. The clear definition of such episodes is essential for various clinical and research purposes. Most current definitions of episodes in SSD are based on either hospitalizations or on symptom scales. Both have drawbacks; symptom scales are measured infrequently, while hospitalization rates are often affected by policy. This study presents an approach for defining episodes in healthcare data that does not suffer such drawbacks. METHODS: Healthcare use of 13,155 SSD patients in the Northern Netherlands with up to 12 years of follow-up was available. Patient-level structural changes in the trend of healthcare use costs were determined using Exponentially Weighted Moving Average (EWMA) control charts. Control charts restart with updated parameters after a detected structural change. Episodes were defined using these structural changes. The resulting episodes were validated by investigating their association with the Global Assessment of Functioning (GAF) scale. RESULTS: The mean number of episodes was 0.61 (sd: 0.60) per patient per year. For the sub-group without hospitalizations this was 0.51 (sd: 0.71). Average episode duration of the sub-group (147 days, sd: 309.4) was similar to that of the full sample (150 days, sd: 305.5). A significant inverse association was identified between GAF scores and the episode-state indicator. CONCLUSIONS: The repeated application of EWMA control charts based on healthcare-intensity is a feasible and promising tool for quantifying patient-level healthcare episodes. The validation using GAF scores indicates that our episode indicator is associated with lower levels of global functioning. Results for individuals without hospitalizations indicate that the method is robust with regard to changes in healthcare policy.

Clinical, societal and personal recovery in schizophrenia spectrum disorders across time: states and annual transitions.

BACKGROUND: Recovery in schizophrenia is a complex process, involving clinical, societal and personal recovery. Until now, studies analysed these domains separately, without examining their mutual relations and changes over time. AIMS: This study aimed to examine different states of recovery and transition rates between states. METHOD: The Pharmacotherapy Monitoring and Outcome Survey (2006-2017) yearly assesses patients with schizophrenia in the Northern Netherlands. Data from 2327 patients with one up to 11 yearly measurements on clinical, societal and personal recovery were jointly analysed with a mixture latent Markov model (MLMM). RESULTS: The selected MLMM had four states that differed in degree and pattern of recovery outcomes. Patients in state 1 were least recovered on any domain (16% of measurements), and partly recovered in states 2 (25%; featured by negative symptoms) and 3 (21%; featured by positive symptoms). Patients in state 4 (38%) were most recovered, except for work, study and housekeeping. At the subsequent measurement, the probability of remaining in the same state was 77-89%, transitioning to a better state was 4-12% and transitioning to a worse state was 4-6%; no transitions occurred between states 1 and 4. Female gender, shorter illness duration and less schizophrenia were more prevalent in better states. CONCLUSIONS: Quite a high recovery rate was present among a substantial part of the measurements (38%, state 4), with a high probability (89%) of remaining in this state. Transition rates in the other states might increase to a more favourable state by focusing on adequate treatment of negative and positive symptoms and societal problems.

The clinical effectiveness of an algorithm-guided treatment program for depression in specialized mental healthcare: A comparison with efficacy trials.

BACKGROUND: Doubts exist on whether effects found in randomized controlled trials (RCTs) are directly generalizable to daily clinical practice. This study aimed (a) to investigate the effectiveness of treatment options within an algorithm-guided treatment (AGT) program for depression and compare their effectiveness with outcomes of efficacy trials and (b) to assess the relation between treatment continuity and outcomes. METHODS: This naturalistic study linked treatment data from January 2012 to November 2014 from a Dutch mental healthcare provider, to routine outcome monitoring (ROM) data (N = 351). Effectiveness of the treatment options (pharmacotherapy, psychotherapy and their combination) was compared to the efficacy reported in the meta-analyses. We included treatment continuity as binary variable "early terminators versus completers of the recommended number of treatment sessions". RESULTS: Remission rates for psychotherapy (38% [95% CI: 32-45]), pharmacotherapy (31% [95% CI: 22-42]) and combination therapy (46% [95% CI: 19-75]) were respectively lower, comparable, and comparable to those reported in the meta-analyses. Similarly, response rates were respectively lower (24% [95% CI: 19-30]), lower (21% [95% CI: 13-31]), and comparable (46% [95% CI: 19-75]) to meta-analyses results. A similar share of early terminators and completers achieved remission and response. LIMITATIONS: A substantial proportion of patients had incomplete ROM data after data linkage. Limited set of patient characteristics to check for selection bias. CONCLUSIONS: Despite the more heterogeneous patient population in clinical practice, the effectiveness of an AGT program, emphasizing strict guideline adherence, approached that found in RCTs. A fixed number of treatment sessions may not suit all individual patients.

"Please tell me what happened": A descriptive study on prevalence, disclosure and characteristics of victimization in people with a psychotic disorder.

INTRODUCTION: Although people with a psychotic disorder are approximately four to six times more often victimized than the general population, victimization is not routinely assessed in mental healthcare. This study investigates prevalence, context and risk factors of victimization in patients with a psychotic disorder in the Northern, relatively rural region of the Netherlands. Moreover, disclosure rates and awareness of psychiatrists are examined. METHOD: Information on personal crime (threats, assaults and sexual violence), property and other forms of crime, the context of victimization and disclosure was routinely assessed in 353 patients with a psychotic disorder who received care at a mental health facility. In addition, involved psychiatrists reported on last year's victimization incidents in their patients. RESULTS: One third of the patients reported victimization in the previous year. More than half of the crimes were committed by someone acquainted and took place in the victim's own home or a place familiar to the victim. Younger age, having a comorbid disorder, drug use and perpetration of a crime were all positively associated with victimization. Approximately half of the reported personal crimes were disclosed to a health care professional but only in 16% of the cases the involved psychiatrist report to know about the incident. CONCLUSION: This study confirms that people with a history of psychosis have an increased risk of becoming the victim of a crime. Although our results suggest that in fifty percent of cases the patients did share the information with professionals, a substantial proportion of incidents appear to go still unnoticed.

The development, validity, and reliability of the auditory vocal hallucination rating scale questionnaire (AVHRS-Q).

PURPOSE: The Auditory Vocal Hallucination Rating Scale Questionnaire (AVHRS-Q) is a short self-report measure assessing several characteristics of auditory vocal hallucinations (AVH) that was derived from a validated clinical interview (the auditory vocal hallucination rating scale; AVHRS). This study investigated the internal reliability, convergent validity, and divergent validity of the AVHRS-Q using two clinical samples. METHODS: In sample I, 32 psychiatric patients with AVH were recruited from an academic hospital service and assessed with the AVHRS and the AVHRS-Q. Data for sample II were retrospectively retrieved from a pseudonymised Routine Outcome Monitoring (ROM) database collected in the context of mental healthcare at the same academic hospital service. Data from 82 psychiatric patients with AVH were retrieved, who completed the AVHRS-Q, and measures of psychological distress (the Outcome Questionnaire; OQ-45, and the Symptom Checklist; SCL-90) and quality of life (the Manchester Short Assessment of Quality of Life; MANSA). RESULTS: The AVHRS-Q showed good internal consistency in both samples. Severity scores of the AVHRS-Q were strongly correlated to the severity scores of the AVHRS (r = 0.90, p < 0.01). The AVHRS-Q and AVHRS did not differ in the identification of mild and severe voice-hearers [X2 (1, N = 32) = 15.71]. AVHRS-Q severity scores had moderate correlations with measures of psychological distress (OQ-45, r = 0.43, p < 0.01; SCL-90, r = 0.50, p < 0.05) and quality of life (MANSA, r = - 0.22, p < 0.01). CONCLUSIONS: The AVHRS-Q demonstrated good reliability, convergent validity, and divergent validity, suggesting it can be applied in both clinical and research settings for a quick and reliable assessment of AVH.

Functional recovery of individuals with serious mental illnesses: Development and testing of a new short instrument for routine outcome monitoring.

OBJECTIVE: This article describes the development and testing of the Functional Recovery tool (FR tool), a short instrument for assessing functional recovery during routine outcome monitoring of people living with serious mental illnesses. METHODS: To assess functional recovery, mental health professionals conducted semistructured interviews with people living with serious mental illnesses on three areas of social functioning: daily living and self-care, work and study, and social contacts. Functioning in each of these areas over the past 6 months was rated on a 3-point scale: 0 (independent), 1 (partially independent), and 2 (dependent). The dichotomous overall outcome of the tool is defined as independent functioning in all areas. We analyzed interrater and test-retest reliability, sensitivity to change, and correlations with constructs that are assumed to be similar to the FR tool (quality of life in daily living, work, and social contacts) or divergent from it (symptomatic functioning). RESULTS: The FR tool was administered to 840 individuals with serious mental illnesses in Dutch mental health care services, 523 of whom were followed up for 1 year (response rate 62%). The tool was easy to complete and was appropriate for policy evaluation and practice. However, when it was combined with more elaborate instruments, it added little extra clinical information. Interrater and test-retest reliability, convergent and discriminant validity, and sensitivity to change were rated sufficient to good. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The FR tool could be a useful measure of functional recovery in addition to current measures of symptomatic remission and personal recovery in routine outcome monitoring. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Predicting Initial Specialist Mental Health Care Use in Adolescence Using Self-, Parent-, and Teacher-Reported Problem Behavior: A Prospective Community-Based Record-Linkage Study.

OBJECTIVE: The aim of this study was to determine the relative importance of self-, parent-, and teacher-reported problem behavior for initial specialist mental health care use in adolescence and the extent to which the relative importance of each informant changes over time. METHODS: Data from the Dutch community-based cohort study TRacking Adolescents' Individual Lives Survey (TRAILS) were linked to administrative records of specialist mental health care organizations. Self-, parent-, and teacher-reported internalizing and externalizing problems were assessed at ages 11, 13, and 16 years, with self-reported problems also assessed at age 19 years. The study included 1,478 adolescents, of whom 19.8% had administrative records between January 2000 (age 9 years) and December 2011 (age 21 years). RESULTS: After effects of internalizing and externalizing problems were adjusted for each other and for sociodemographic correlates, internalizing problems, but not externalizing problems, predicted initial specialist mental health care use. Teacher reports mainly predicted initial specialist care between the ages of 11 and 13 years (hazard ratio [HR] = 1.57; 95% confidence interval [CI], 1.22-2.02; P < .001), parent reports mainly predicted initial specialist care between the ages of 13 and 16 years (HR = 1.47; 95% CI, = 1.13-1.91; P = .004), and self-reports mainly predicted initial specialist care between the ages of 16 and 19 years (HR = 1.61; 95% CI, = 1.25-2.08; P < .001) and between the ages 19 and 21 years (HR = 1.50; 95% CI, 1.10-2.05; P = .011). CONCLUSIONS: Teachers, parents, and adolescents are the driving force behind initial specialist care at consecutive phases in adolescence. Future research should assess whether improving the problem recognition of teachers in secondary education and educating young adults about mental health problems are effective ways of reducing the treatment gap.

Towards a comprehensive routine outcome monitoring program for people with psychotic disorders: The Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS).

BACKGROUND: Patients with psychotic disorders are at risk of developing mental health and social problems, and physical disorders. To monitor and treat these problems when indicated, an annual routine outcome monitoring program, Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS), was developed. This paper presents the background and content of PHAMOUS, implementation of PHAMOUS, characteristics of the patients screened in 2015, and the outcome of patients with three annual screenings between 2011 and 2015. METHODS: PHAMOUS was implemented in four mental health institutions in the Northern Netherlands in 2006. During the PHAMOUS screening, patients are assessed on socio-demographics, psychiatric symptoms, medication, physical parameters, lifestyle, (psycho)social functioning and quality of life, using internationally validated instruments. RESULTS: In 2015, 1955 patients with psychotic disorders were enrolled in the PHAMOUS screening. The majority (72%) was receiving mental healthcare for ten years or longer. A small group was hospitalized (10%) in the past year. Half of the patients were in symptomatic remission. Less than 10% had a paid job. More than half of the patients fulfilled the criteria for metabolic syndrome (54%). The subsample with three annual screenings from 2011 to 2015 (N = 1230) was stable, except the increasing prevalence of high glucose levels and satisfaction with social relationships (Cochran's Q = 16.33, p = .001 resp. Q = 14.79, p = .001). CONCLUSION: The annual PHAMOUS screening enables to follow the mental, physical and social health problems of patients, which offers a good basis for shared-decision making with regard to updating the annual treatment plan, next to a wealth of data for scientific research.

Offspring of depressed and anxious patients: Help-seeking after first onset of a mood and/or anxiety disorder.

BACKGROUND: Offspring of patients with depressive and/or anxiety disorders are at high risk of developing a similar disorder themselves. Early recognition and treatment may have substantial effects on prognosis. The main aim of this study was to examine the time to initial help-seeking and its determinants in offspring after the first onset of a mood and/or anxiety disorder. METHODS: Data are presented of 215 offspring with a mood and/or anxiety disorder participating in a cohort study with 10 year follow-up. We determined age of disorder onset and age of initial help-seeking. Offspring characteristics (gender, IQ, age of onset, disorder type, suicidal ideation) and family characteristics (socioeconomic status, family functioning) were investigated as potential predictors of the time to initial help-seeking. RESULTS: The estimated overall proportion of offspring of depressed/anxious patients who eventually seek help after onset of a mood and/or anxiety disorder was 91.9%. The time to initial help-seeking was more than two years in 39.6% of the offspring. Being female, having a mood disorder or comorbid mood and anxiety disorder (relative to anxiety) and a disorder onset in adolescence or adulthood (relative to childhood) predicted a shorter time to initial help-seeking. LIMITATIONS: Baseline information relied on retrospective reports. Age of onsets and age of initial help-seeking may therefore be subject to recall bias. CONCLUSION: Although most offspring eventually seek help after onset of a mood/anxiety disorder, delays in help-seeking were common, especially in specific subgroups of patients. This information may help to develop targeted strategies to reduce help-seeking delays.

Persistent Low Rates of Treatment of Metabolic Risk Factors in People With Psychotic Disorders: A PHAMOUS Study.

OBJECTIVE: People with psychotic disorders have an increased metabolic risk and a shortened life expectancy compared to the general population. Two large studies showed that metabolic disorders were untreated in a majority of the patients. Since then, guidelines have urged monitoring of metabolic health. This study examined the course of metabolic disorders over time in people with psychotic disorders and investigated current treatment rates. METHODS: A total of 1,259 patients with psychotic disorders, as defined by the DSM-IV, from 4 Dutch mental health institutions participated in 3 yearly assessments of the Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS) between 2006 and 2014. Patients' metabolic parameters were measured, and the use of pharmacologic treatment for hypertension (systolic blood pressure ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg), dyslipidemia (5% ≤ Systematic COronary Risk Evaluation [SCORE] risk < 10% and low-density lipoprotein [LDL] cholesterol level ≥ 2.5 mmol/L or SCORE risk ≥ 10% and LDL cholesterol level ≥ 1.8 mmol/L and/or triglycerides ≥ 2.3 mmol/L), and hyperglycemia (hemoglobin A1c concentration > 7% and/or fasting glucose concentration ≥ 7.2 mmol/L) was recorded. RESULTS: Prevalence of the metabolic syndrome, as defined by the National Cholesterol Education Program criteria, was > 50% at each assessment. On the basis of the European Society of Cardiology guidelines, pharmacotherapy for metabolic disorders was recommended for 52%-59% of the patients at each assessment. Treatment rates with antihypertensive (from 31% to 38%, P < .001) pharmacotherapy increased throughout the assessments. However, half of the patients were not treated for their metabolic risk factors while being monitored for 3 years or longer. Older patients were more likely to receive treatment, and patients who received treatment had lower blood pressure and lower cholesterol and triglyceride concentrations than patients not receiving the recommended treatment. CONCLUSIONS: Metabolic risk factors are still seriously undertreated in people with psychotic disorders. Better adherence to and better implementation of guidelines about monitoring and treating metabolic disorders in psychiatry are crucial.

Personality and coping in first episode psychosis linked to mental health care use.

A body of literature focuses on associations of neuroticism, extraversion, passive coping and active coping with the course of psychotic illness. Less is known about other personality and coping variables - and underlying causal mechanisms between variables remain unclear. We explored causal effects from personality, coping and symptoms on mental health care consumption over two years in 208 first episode patients. Causal inference search algorithms lead to formation of a hypothetical causal model based on presumptions on (non-)mutuality between variables and consistent with data. Structural equation modelling estimated effect sizes conditionally on the causal model. Our observed model implies that none of the coping or personality variables have any effect on the number of days of hospitalisation, whereas general psychopathology symptoms do have a direct positive effect. For ambulatory care it is proposed that openness to experience, depressive symptoms and age have direct positive effects. Reassuring thoughts as a coping strategy seems to have a direct negative effect on the use of ambulatory care and mediates indirect effects of other personality and coping variables on ambulatory care. Furthermore, while previously established relations between personality and symptoms are confirmed by our model, it challenges traditional ideas about causation between personality and symptoms.

Cannabis use in people with severe mental illness: The association with physical and mental health--a cohort study. A Pharmacotherapy Monitoring and Outcome Survey study.

OBJECTIVE: In the general population cannabis use is associated with better cardiometabolic outcomes. Patients with severe mental illness frequently use cannabis, but also present increased cardiometabolic risk factors. We explore the association between cannabis use and cardiometabolic risk factors in patients with severe mental illness. METHOD: A total of 3169 patients with severe mental illness from a Dutch cohort were included in the study. The association of cannabis use with body mass index, waist circumference, blood pressure, cholesterol, triglycerides, glucose, glycated hemoglobin and Positive and Negative Syndrome Scale was examined with separate univariate AN(C)OVA. Changes in metabolic risk factors and Positive and Negative Syndrome Scale were examined after a follow-up interval of 9-24 months, for patients who continued, discontinued, started or were never using cannabis between the two assessments. RESULTS: Cannabis users at baseline had lower body mass index, smaller waist circumference, lower diastolic blood pressure, and more severe psychotic symptoms than non-users. Patients who discontinued their cannabis use after the first assessment had a greater increase in body mass index, waist circumference, diastolic blood pressure and triglyceride concentrations than other patients, and the severity of their psychotic symptoms had decreased more compared to continued users and non-users. CONCLUSION: Extra attention should be paid to the monitoring and treatment of metabolic parameters in patients who discontinue their cannabis use.

Quality of care and its determinants in longer term mental health facilities across Europe; a cross-sectional analysis.

BACKGROUND: The Quality Indicator for Rehabilitative Care (QuIRC) is an international, standardised quality tool for the evaluation of mental health facilities that provide longer term care. Completed by the service manager, it comprises 145 items that assess seven domains of care: living environment; treatments and interventions; therapeutic environment; self-management and autonomy; social interface; human rights; and recovery based practice. We used the QuIRC to investigate associations between characteristics of longer term mental health facilities across Europe and the quality of care they delivered to service patients. METHODS: QuIRC assessments were completed for 213 longer term mental health units in ten countries that were at various stages of deinstitutionalisation of their mental health services. Associations between QuIRC domain scores and unit descriptive variables were explored using simple and multiple linear regression that took into account clustering at the unit and country level. RESULTS: We found wide variation in QuIRC domain scores between individual units, but across countries, fewer than a quarter scored below 50 % on any domains. The quality of care was higher in units that were smaller, of mixed sex, that had a defined expected maximum length of stay and in which not all patients were severely disabled. CONCLUSIONS: This is the first time longer term mental health units across a number of European countries have been compared using a standardised measure. Further use of the QuIRC will allow greater understanding of the quality of care in these units across Europe and provide an opportunity to monitor pan-European quality standards of care for this vulnerable patient group.