[Assessment of guideline adherence and quality of care with routine outcome monitoring data]. / Meten van naleving van richtlijnen en behandelkwaliteit met data van routine outcome monitoring.

BACKGROUND: Treatment guidelines are widely used nowadays but it is not really clear whether or to what extent patients in routine care benefit from these guidelines.
AIM: To achieve a twofold objective: to measure in a routine clinical setting, the overall level of adherence to clinical guidelines by using a set of process indicators that are independent of the disorder under study, and to measure the clinical and psychosocial correlates of adherence among outpatients suffering from mood, anxiety and somatoform disorders.
METHOD: We developed a set of quality indicators and tested the set over a period of three years in a randomly selected sample of 300 outpatients who were about to receive treatment for a mood, anxiety and somatoform disorder. We used routine outcome monitoring (ROM) data to determine risk factors for non-adherence and to identify patients whose treatment outcomes were likely poor.
RESULTS: A high percentage of indicators were positive, indicating that many elements of treatment in this routine clinical practice had been carried out according to the guidelines. We observed that the combined treatment group showed significantly lower adherence than the two other treatment groups. Low-adherence was predicted independently by a low score on the vitality subscale of the SF-36. No significant differences relating to the degree of adherence were found in socio-demographic variables, comorbidity and the scores on the BSI subscales. Predictor indicators for poor treatment outcome included higher age, a comorbid axis I diagnosis, a number of dysfunctional personality traits and a (reported) poor general health status.
CONCLUSION: It is possible to assess guideline adherence by means of our set of process indicators that were independent of all type of disorder involved. Most factors hampering adherence could be identified. An understanding of the factors that affect treatment adherence to treatment guidelines may help to prevent non-adherence and can contribute to both the quality and the cost-effectiveness of care.

Mental problems among first-year conservatory students compared with medical students.

Musical education and the musical profession can be stressful, which may make musicians vulnerable for stress-related disorders. To determine if music students are particularly at risk for mental problems, we used the Standardised Assessment of Personality-Abbreviated Scale (SAPAS) and the Symptom Questionnaire (SQ48S) to compare symptoms in first-year conservatory students (n=33) and first-year medical students (n=43). On the SAPAS, we found that medical students have significantly more difficulty making and keeping friends (p=0.015). Also, we observed a trend that conservatory students lose their temper more easily (p=0.040). Both student groups showed high scores for the personality trait "perfectionism." On the SQ48, we observed a trend that both conservatory and medical students experience more psychological problems than the general population, but there were no significant differences between conservatory students and medical students in the total scores of both questionnaires.

[Automutilation of the palate in a psychiatric patient]. / Automutilatie van het palatum bij een psychiatrische patiënt.

A 46-year-old man with a history of alcohol abuse was referred to an oral and maxillofacial surgeon with a large necrotic wound with raised edges on the palate. After history taking, radiography and clinical assessment, together with a psychiatrist, the lesion was diagnosed as an automutilation resulting from a period of alcohol abstinence. After a period of care in a medical centre, the lesion improved quickly. Following this treatment, the patient was admitted to a psychiatric treatment centre for supplemental treatment of his addiction problems.

[Empirical evidence for the effectiveness of Routine Outcome Monitoring. A study of the literature]. / Empirische evidence voor de effectiviteit van routine outcome monitoring; een literatuuronderzoek.

BACKGROUND: Routine Outcome Monitoring ROM is an important instrument for measuring the effectiveness of treatment and has been implemented in the Dutch mental health care system. AIM: To review the effectiveness of ROM with regard to diagnosis, treatment, and other outcomes. METHOD: The literature study focused on randomised controlled trials RCT's of ROM performed on patients of all age groups, some being general patients, others being psychiatric patients. The main search words were 'routine outcome monitoring' or 'routine outcome measurement'. RESULTS: 52 RCTs on adult patients were included in the study; 45 of these trials were performed on patients with mental health problems, but not always in a psychiatric setting or as primary outcome measure. rom appears to have positive effects on diagnosis and treatment and on the communication between patient and therapist. Other results were less clear. CONCLUSION: ROM seems to be particularly effective for the monitoring of treatments which have not been entirely successful. Further research needs to be done into the clinical and cost-effectiveness of ROM when used with adults and children who have mental health problems.

Routine outcome monitoring in the Netherlands: practical experiences with a web-based strategy for the assessment of treatment outcome in clinical practice.

Routine outcome monitoring (ROM) is a method devised to systematically collect data on the effectiveness of treatments in everyday clinical practice. ROM involves documenting the outcome of treatments through repeated assessments. Assistants are employed who perform a baseline assessment comprising a standardized diagnostic interview, administration of rating scales and completion of several self-report measures by the patient. At fixed time intervals, assessments are repeated. Dedicated Web-based software has been developed to assist in this task. ROM informs therapists and patients on the severity of the complaints at intake, and the waxing and waning of symptoms over the course of treatment. Researchers can use ROM for effectiveness research, and managers can use it for benchmarking. The use of ROM for research is illustrated by presenting data on the diagnostic status of patients participating in ROM and data on treatment outcome of a subgroup of patients (with panic disorder) in our database. The results show that implementation of ROM is feasible, and after some initial reservations, most therapists now consider ROM to be a necessary and important adjunct to the clinical treatment. In addition, ROM furthers research as the data can be used to study the phenomenology of psychiatric disorders and the outcome of treatments delivered in everyday practice.

[Care programmes at mental health centres: the degree of adherence in the first phase of treatment]. / Zorgprogramma's in de dagelijkse praktijk: de mate van toepassing in de eerste behandelfase.

BACKGROUND: Most mental health providers in the Netherlands have implemented programmes of care. However, little is known about the extent to which care programmes are adhered to in routine clinical practice. AIM: To investigate the extent to which care programmes are adhered to in routine clinical practice. METHOD: For three consecutive years we randomly selected 100 patients with a unipolar mood disorder, anxiety disorder or somatoform disorder and investigated retrospectively the extent to which care programmes were actually implemented in the first phase of treatment. We used a set of clinical process indicators based on the care programmes. The investigation took place on the premises of one of the 'Rivierduinen' mental health providers. We used patient records and data collected by means of routine outcome monitoring (ROM). RESULTS: Over the three years under study scores for most of the indicators ranged from fair to good. Scores were lower for the indicators 'ROM follow-up measurements' and 'frequency of psychotherapy'. Only the number of routine measurements of the severity of the psychopathology in the diagnostic phase appeared to have increased significantly over the three years under study. CONCLUSION: On the premises of the mental health care provider Rivierduinen where the study was conducted, care programmes during the first phase of treatment for mood disorder, anxiety disorder and somatoform disorders were adhered to reasonably well. Further research will have to concentrate on the subsequent phases of treatment. Another important matter that requires investigation is the relationship between the use of care programmes in daily practice and treatment outcomes.

Effect of thalidomide on chemokine production by human microglia.

Thalidomide, a psychoactive drug that readily crosses the blood-brain barrier, has been shown to possess immunomodulatory attributes, including the inhibition of cytokine production by monocytes and microglia. In this study, we investigated the effect of thalidomide on chemokine production by human microglial cells. Microglial cells were stimulated with lipopolysaccharide, a key cell-wall component of gram-negative bacteria responsible for meningitis, and production of chemokines (regulated upon activation normally T cell expressed and secreted [RANTES], monocyte chemoattractant protein [MCP]-1, macrophage inflammatory protein [MIP]-1beta, and interleukin [IL]-8) was examined by ELISA. Thalidomide treatment was found to cause potent and selective inhibition of IL-8 production in a dose-responsive manner. This inhibition was associated with decreased intracellular IL-8 staining as well as reduced transcription of IL-8 mRNA. In addition, thalidomide treatment of lipopolysaccharide-stimulated microglia inhibited the activation of protein NF-kappaB, a transcription factor known to be important for IL-8 production. These results suggest thalidomide could have a therapeutic role in acute bacterial meningitis through inhibition of IL-8-mediated neutrophil chemotaxis.