Alcohol use disorder and muscle weakness: Original study of the effect of vitamin D supplementation in ambulatory participants with alcohol use disorder.

INTRODUCTION: Chronic alcohol-related myopathy presents with proximal muscle weakness. We studied the effect of vitamin D supplementation on muscle weakness in adults with alcohol use disorder. METHOD: Randomized controlled trial. Participants were community-dwelling adults with alcohol use disorder. Participants allocated to VIDIO, vitamin D intensive outreach, received bimonthly oral doses of 50,000‒100,000 IU cholecalciferol for 12 months. Participants allocated to CAU, care as usual, received prescriptions of once-a-day tablets containing 800 IU cholecalciferol and 500 mg calcium carbonate. Data included demographic variables, laboratory tests, alcohol use, and rating scales of help-seeking and support. Main outcomes were the participants' quadriceps maximum voluntary contractions (qMVC) and serum-25(OH)vitamin D concentrations, 25(OH)D. RESULTS: In 66 participants, sex ratio 50/16, mean age 51 year, alcohol use was median 52 [IQR 24‒95] drinks per week. Baseline qMVC values were 77% (SD 29%) of reference values. Laboratory tests were available in 44/66 participants: baseline 25(OH)D concentrations were 39.4 (SD 23.7) nmol/L. Thirty-one participants with 25(OH)D concentrations <50 nmol/L received either VIDIO or CAU and improved in qMVC, respectively with mean 51 (P<0.05) and 62 Newton (no P-value because of loss of follow-up) after one year of treatment. Vitamin D status increased with mean +56.1 and +37.4 nmol/L, respectively in VIDIO and CAU. CONCLUSION: The qMVC values improved during vitamin supplementation in adults with vitamin D deficiency and alcohol use disorder. Despite higher 25(OH)D concentrations in VIDIO, in terms of muscle health no advise could be given in favor of one vitamin strategy over the other. TRIAL REGISTRATION: Netherlands Trial Register (NTR) identifier: NTR4114.

Self-report versus performance based executive functioning in people with psychotic disorders.

Background: Although executive functioning is often measured using performance-based measures, these measures have their limits, and self-report measures may provide added value. Especially since these two types of measures often do not correlate with one another. It thus has been proposed they might measure different aspects of the same construct. To explore the differences between a performance-based measure of executive functioning and a self-report measure, we examined their associations in patients with a psychotic disorder with the following: other neurocognitive measures; psychotic symptoms; anxiety and depression symptoms, and daily-life outcome measures. Method: This cross-sectional study consisted of baseline measures collected as part of a cohort study of people with a psychotic disorder (the UP'S study; n = 301). The Behavioral Rating Inventory of Executive Functioning Adult version (BRIEF-A) was used to assess self-rated executive functioning, and the Tower of London (TOL) to assess performance-based executive functioning. Generalized linear models (GLM) were used with the appropriate distribution and link function to study the associations between TOL and BRIEF-A, and the other variables, including the Brief Assessment of Cognition in Schizophrenia (BACS), the Positive and Negative Symptoms Scale-Remission (PANSS-R), the General Anxiety Disorder - 7 (GAD-7), the Patient Health Questionnaire - 9 (PHQ-9) and the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). Model selection was based on the Wald test. Results: The TOL was associated with other neurocognitive measures, such as verbal list learning (ß = 0.24), digit sequencing (ß = 0.35); token motor task (ß = 0.20); verbal fluency (ß = 0.24); symbol coding (ß = 0.43); and a screener for intelligence (ß = 2.02). It was not associated with PANNS-R or WHO-DAS scores. In contrast, the BRIEF-A was associated not with other neurocognitive measures, but with the PANSS-R (ß = 0.32); PHQ-9 (ß = 0.52); and GAD-7 (ß = 0.55); and with all the WHODAS domains: cognition domain (ß = 0.54), mobility domain (ß = 0.30) and selfcare domain (ß = 0.22). Conclusion: Performance-based and self-report measures of executive functioning measure different aspects of executive functioning. Both have different associations with neurocognition, symptomatology and daily functioning measures. The difference between the two instruments is probably due to differences in the underlying construct assessed.

[Differences in the prevalence of acute involuntary admissions between Apeldoorn, Rotterdam and Amsterdam]. / Prevalentie van acute onvrijwillige opnames in Apeldoorn, Rotterdam en Amsterdam.

BACKGROUND: There are regional differences in the Netherlands in the numbers of emergency compulsory admissions (Inbewaringstelling: IBS). We looked at three 24/7 facilities to investigate the relationships between patient and consultation characteristics on the one hand, and numbers of emergency compulsory admissions on the other, against the background of the level of urbanisation. METHOD: We compared emergency consultations in 18-64 year olds in Apeldoorn, Amsterdam and Rotterdam between 2012 and 2016 in terms of socio-demographic, procedural and clinical characteristics, and in terms of outcome. We used the Severity of Psychiatric Illness Scale (SPI) to determine disorder severity. RESULTS: Apeldoorn had as many consultations per 100,000 inhabitants as the highly urbanised city of Rotterdam. GPs there referred 68% of patients, compared with 25% in Amsterdam and 50% in Rotterdam. In Apeldoorn, 17% of the patients were psychotic, compared with 35% in the other regions. In addition, 66% of the patients there had a low SPI score, compared with 40% in the large cities. Amsterdam and Rotterdam had 3.5 times higher risk of emergency compulsory admissions as Apeldoorn. After adjustment for socio-demographic, procedural and clinical characteristics, this difference with Apeldoorn was 1.5 for Amsterdam and 2.6 for Rotterdam. SPI score and psychotic disorder were found to be the most important predictors of IBS admission. CONCLUSION: Differences in consultation numbers, referral patterns and the location of consultations indicate that there are regional differences in the position of the 24/7 facility in the mental health care system. The numbers of emergency compulsory emissions were related in part to the level of urbanisation and the associated epidemiological differences but probably also to differences in the position of the crisis facility in the mental health care system. Differences in admission numbers were primarily linked to differences in diagnostic characteristics and disorder severity and, to a lesser extent, to referral patterns and socio-demographic characteristics. However, these variables did not explain all the observed inter-regional differences.

Dutch Mental Health Patients' and Significant Others' Perspectives on Compulsory Treatment at Home: One Size Does Not Fit All.

On January 1, 2020, the Compulsory Mental Health Care Act took effect in the Netherlands. It contains provisions for compulsory community treatment (CCT) and compulsory treatment at home (CTH). In this study, we collected the opinions of patients and their significant others on CTH and on their preferences regarding compulsory care in their homes. Patients and their significant others were involved in the experience-based co-design of a purpose-built online questionnaire. This questionnaire was completed by 624 patients and 531 significant others. Sixty-one percent of the patients and 62% of the significant others did not want compulsory treatment to take place at home but in hospital or elsewhere. Patients' and significant others' opinion showed few differences, except with regard to the involvement of the significant others in CTH. As the respective views of patients and significant others were mixed, we recommend that crisis plans and compulsory treatment plans should be individually tailored to the needs and wishes of patients and their significant others regarding CTH.

Adult Attachment and Personal, Social, and Symptomatic Recovery From Psychosis: Systematic Review and Meta-Analysis.

Despite growing evidence for the role of attachment in psychosis, no quantitative review has yet been published on the relationship in this population between insecure attachment and recovery in a broad sense. We therefore used meta-analytic techniques to systematically appraise studies on the relationship between attachment and symptomatic, social and personal recovery in clients with a psychotic disorder. Using the keywords attachment, psychosis, recovery and related terms, we searched six databases: Embase, Medline Epub (OVID), Psycinfo (OVID), Cochrane Central (trials), Web of Science, and Google Scholar. This yielded 28 studies assessing the associations between adult attachment and recovery outcome in populations with a psychotic disorder. The findings indicated that insecure anxious and avoidant attachment are both associated with less symptomatic recovery (positive and general symptoms), and worse social and personal recovery outcomes in individuals diagnosed with a psychotic disorder. The associations were stronger for social and personal recovery than for symptomatic recovery. Attachment style is a clinically relevant construct in relation to the development and course of psychosis and recovery from it. Greater attention to the relationship between attachment and the broad scope of recovery (symptomatic, social, and personal) will improve our understanding of the illness and efficacy of treatment for this population.

Personal Recovery in People With a Psychotic Disorder: A Systematic Review and Meta-Analysis of Associated Factors.

Background: Personal recovery (PR) is a subjective, multidimensional concept, and quantitative research using PR as an outcome is rapidly increasing. This systematic review is intended to support the design of interventions that contribute to PR in psychotic disorders, by providing an overview of associated factors and their weighted importance to PR: clinical factors, social factors, and socio-demographic characteristics are included, and factors related to the concept of PR (organized into CHIME dimensions). Methods: A systematic literature search was conducted from inception to March 2020. Quantitative studies that had used a validated questionnaire assessing the concept of PR were included. Mean effect sizes for the relationship between PR-scale total scores and related factors were calculated using meta-analyses. Sources of heterogeneity were examined using meta-regression tests. Results: Forty-six studies, that used (a total of) eight PR measures, showed that in clinical factors, affective symptoms had a medium negative association with PR-scale total scores (r = -0.44, 95%CI -0.50 to -0.37), while positive, negative and general symptoms had small negative correlations. No association was found with neuro-cognition. Social factors (support, work and housing, and functioning) showed small positive correlations. Gender and age differences had barely been researched. Large associations were found for PR-scale total scores with the CHIME dimensions hope (r = 0.56, 95%CI 0.48-0.63), meaning in life (r = 0.48, 95%CI 0.38-0.58) and empowerment (r = 0.53, 95%CI 0.42-0.63); while medium associations were found with connectedness (r = 0.34, 95%CI 0.43-0.65) and identity (r = 0.43, 95%CI 0.35-0.50). Levels of heterogeneity were high, sources included: the variety of PR measures, variations in sample characteristics, publication bias, variations in outcome measures, and cultural differences. Discussion: Most interventions in mental healthcare aim to reduce symptoms and improve functioning. With regard to stimulating PR, these interventions may benefit from also focusing on enhancing hope, empowerment, and meaning in life. The strength of these findings is limited by the challenges of comparing separate CHIME dimensions with questionnaires assessing the concept of PR, and by the high levels of heterogeneity observed. Future research should focus on the interaction between elements of PR and clinical and social factors over time.

[Regional differences in compulsory treatment in mental health care in the Netherlands during 2013-2017]. / Gedwongen opnames en ambulante dwang in de ggz: onderzoek naar regionale verschillen tussen arrondissementen, leeftijdsgroepen en unieke personen, 2013-2017.

BACKGROUND: Compulsory treatment in mental health care has continuously increased for years. Registration of court ordered compulsory psychiatric care is based upon counts of legal authorisations. These counts do not refer to number of individual persons involved.
AIM: To report the number age-specific prevalence of coercion in psychiatric care, number of persons involved, age distribution and regional differences.
METHOD: Analysis of the number of requests for compulsory care and population size according to the age groups for the years 2013-2017. We used direct age standardisation at the level of jurisdiction regions.
RESULTS: The annual number of unique persons for whom compulsory care was requested was 28% less than the number of requested court orders. The annual increase in compulsory care was 3%. Per specific treatment order the increase during 2013-2017 was 12% for emergency compulsory admissions, 8% for hospital admissions, 10% for extended hospital admissions and 43% for community treatment order.
CONCLUSION: The number of persons for whom compulsory mental care is requested increased on average by 3% each year. Greatest increase was observed for age groups 25-44 years and 80 years and older. After age-standardisation substantial differences remain between jurisdiction regions.

Need analysis for a new high acuity medical psychiatry unit: which patients are considered for admission?

BACKGROUND: The study aims were: to estimate the proportion of patients with an indication for admission to a new high acuity Medical Psychiatric Unit (MPU), to explore the reasons for MPU-admission according to different health disciplines, and to check for differences in patient characteristics. The results of this study are to be utilized in the proposed establishment of a high-acuity MPU in a University Medical Center. Such a unit currently does not exist at Erasmus MC. METHODS: Hospital in-patients were included if they received psychiatric consultation from the Psychiatric Consultative Service (PCS). As part of the study protocol, psychiatrists, other medical specialists, and nurses determined the need for admission to the proposed MPU. Patient groups were compared with respect to diagnoses, socio-demographic characteristics and patient routing. RESULTS: One hundred and fifty-one patients were included, 43% had an indication for MPU-admission, for the other patients PCS involvement was sufficient. There was agreement on suicide attempts as a reason for MPU-admission. For psychiatrists, the need for further diagnostic evaluation was a common reason for MPU admission, while other medical specialists more often emphasized the need for safety measures. Patients with an unplanned hospital admission had a higher chance of MPU eligibility (OR = 2.72, 95% CI 1.10-6.70). The main psychiatric diagnoses of MPU-eligible patients were organic disorders (including delirium), mood disorders, and disorders related to substance abuse. The most common diagnoses found were similar to those in previous research on MPU populations. CONCLUSION: Different medical disciplines have different views on the advantages of MPUs, while all see the need for such facilities. The proposed MPU should be able to accommodate patients directly from the Emergency Unit, and the MPU should provide specialized diagnostic care in an extra safe environment.

[Medical Psychiatric Units in the Netherlands: an investigation into distribution and quality]. / Medisch-psychiatrische units in Nederland.

OBJECTIVE: One of the spearheads of psychiatric healthcare in the Netherlands is hospital care for patients with a psychiatric comorbidity. In 2014, the Netherlands Psychiatric Association published ten field standards for Medical Psychiatric Units (MPUs). We catalogued healthcare in the Netherlands on the basis of these field standards. DESIGN: Telephone screening, followed by a questionnaire investigation. METHOD: In the period May-August 2015, psychiatrists in 90 hospitals in the Netherlands were approached by telephone with 4 screening questions. If the department complied with the screening criteria for an MPU, a structured interview comprising 51 questions followed. The interview script was tested against the field standards using the Delphi method. RESULTS: The screening identified 40 potential MPUs; 37 (92.5%) wards participated in the complete interview. CONCLUSION: MPUs are unevenly distributed across the country; care content is adequate, but education, tighter multidisciplinary cooperation and availability of somatic nursing expertise on every shift could improve care on MPUs. The departments should also pay more attention to care chain arrangements. The field standards are too stringent; these could be improved by defining 'essential care' and application of differentiated assessment of subcriteria.

[Effects on scale and confidence intervals as alternatives to p < 0.05]. / Effecten op schaal en betrouwbaarheidsintervallen als alternatief voor p < 0,05.

BACKGROUND: Researchers and reviewers often use the conventional p < 0.05 as threshold in statistical tests. In many cases, however, the interpretation of p-values is incorrect. AIM: To explain where the 5% norm originates, identify the interpretation problems that often arise and suggest some alternatives. METHOD: On the basis of recent literature we examine the meaning and origin of the p < 0.05 norm. We looked closely at entire articles and short reports in the Tijdschrift voor Psychiatrie, starting with the Jubilee issue of 2008, in order to find examples of methodological problems relating to the routine use of p-values. RESULTS: We found several examples of the problematic use of p-values; these included the testing of a priori unlikely, or even impossible null hypotheses, the reporting of small effects calculations based on erroneous assumptions, and incorrect interpretations of statistical parameters and p-values. CONCLUSION: Research in psychiatry, like research in other disciplines, attaches too much weight to p-values. Guidelines for authors should advise authors to focus explicitly on effect sizes, confidence intervals and the scale on which the results are presented.

[Regional differences in the care and treatment of compulsory admissions in the Netherlands]. / Regionale verschillen in nazorg bij inbewaringstelling.

BACKGROUND: In the Netherlands compulsory admissions are on the increase. However, there are regional differences even when demographic factors are taken into account. AIM: To find out whether there are regional differences in the type and duration of care given to detainees. METHOD: On the basis of case-register data for Groningen, South Limburg, Utrecht and Rotterdam, we monitored the psychiatric history and aftercare that followed emergency compulsory admissions and we analysed the differences between patient groups ('old acquaintances', 'newcomers' and 'passers-by'). RESULTS: Almost 60% of patients were well known to the mental health care service and had previously received psychiatric care. 85% of the patients were still receiving care three months after admission. Even when patient and admission characteristics were taken into account, there were still regional variations in the type and length of mental health care episodes before and after compulsory admission. CONCLUSION: The continuity of health care for emergency admissions in the context of the Dutch Mental Health Act varies from region to region. It remains to be seen whether the situation will change when the new Mental Health Act comes into force.

[Contact with the child and adolescent psychiatric services is determined by cultural and socio-economic differences]. / Contact met de jeugd-ggz is een zaak van culturele én sociaaleconomische verschillen.

BACKGROUND: In the Netherlands access to mental healthcare is not evenly distributed over ethnic groups. Young persons of non-Dutch origin make only limited use of Dutch child and adolescent psychiatric services. AIM: To investigate to what extent differences in the use of child and adolescent psychiatric services are related to ethnic cultural factors or socio-economic position. METHOD: On the basis of data from the Rotterdam psychiatric case register we calculated the incidence-related risks for different ethnic groups and according to income level. Poisson regression analysis enabled us to take into account differences in the composition of the groups according to age and gender. RESULTS: All ethnic groups have less contact than the native population with the psychiatric services, but there is also an effect of income level, irrespective of ethnicity. In the native population the number of persons seeking assistance from the psychiatric services was found to be higher in lower income categories. CONCLUSION: Access to the child and adolescent psychiatric services is influenced by both ethnic and socio-cultural differences.

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

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

[Numbers and patterns in compulsory admissions in 3 Dutch cities; problems in urban areas and regional differences in the implementation of the law on special admissions to psychiatric hospitals]. / Aantallen en patronen van inbewaringstellingen en rechterlijke machtigingen in Maastricht, Groningen en Rotterdam. Bijdrage van stedelijke problematiek aan regionale verschillen in Bopz-maatregelen.

BACKGROUND: In the Netherlands little research has been done on the regional variability in the implementation of the law on Special Admissions to Psychiatric Hospitals (Dutch acronym Bopz). AIM: To investigate regional variability in the numbers, combinations and characteristics of emergency compulsory admissions and other types of legally authorised admissions. METHOD: Data from the Bopz information system covering a 12-month period were analysed. Missing data were supplied by the courts in Maastricht, Groningen and Rotterdam. RESULTS: There was regional variability in the way in which compulsory measures were implemented, particularly as far as emergency compulsory admissions were concerned. The relative number of Bopz measures increased in relation to the degree of urbanisation. Rotterdam had the highest percentage of emergency compulsory admissions. Patients in Maastricht and Rotterdam were more often involved in legally authorised admissions only. In Rotterdam an unlinked combination of emergency compulsory admissions and legally authorised admissions was more common. In Maastricht a larger number of patients were admitted because they were a danger to themselves, whereas in Groningen and Rotterdam admissions were also used as a means of safeguarding the public. CONCLUSION: The number of admissions and the diversity of Bopz measures are highest in urban areas. Regional variations in the way in which compulsory measures are applied persist, but there is room for improvement in the monitoring of the effects of these differences and the types of services that are available.

[Drop-out from after-care following compulsory hospitalisation--how serious is the problem?]. / Drop-out na gedwongen opname--hoe groot is het probleem?

BACKGROUND: Little is known about the amount and quality of after-care provided for patients hospitalised as a result of a court authorisation. AIM: To obtain insight into the rate of drop-out from after-care and the quality of after-care. METHOD: In our study we included all patients in Rotterdam Rijnmond who, in the last 3 months of 2004, had been compulsorily hospitalised for at least one day by reason of a court authorisation. A retrospective study of patients' records let us ascertain whether drop-out from after-care occurred and let us check on the quality of the after-care provided. RESULTS: 214 patients were included. Of these, 33 (15.4%) dropped out of after-care. Prior to discharge, the drop-out group received an outpatient appointment at a local clinic less often and waited longer for their first appointment at that clinic than did the 'non-drop-out' group. The medical records of the drop-out group were less accurate and there was less cooperation between community care and clinical mental health care professionals. CONCLUSION: The quality of after-care can be improved if community care and clinical health care professionals cooperate more intensively in drawing up conditions for discharge and in arranging the transfer of patients from clinical care to community care. Further investigations are needed to find out whether these steps will have a beneficial effect on the drop-out percentage.

Exploring continuity of care in patients with alcohol use disorders using time-variant measures.

BACKGROUND/AIMS: We used time-variant measures of continuity of care to study fluctuations in long-term treatment use by patients with alcohol-related disorders. METHODS: Data on service use were extracted from the Psychiatric Case Register for the Rotterdam Region, The Netherlands. Continuity measures were calculated for each day over a 2-year observation period. Repeated measures analysis was used to identify factors that influence continuity of care over time. RESULTS: Continuity of care was higher for patients with more severe disorders. Though quantity of care was high for patients with long problem history during the first year of treatment, it decreased strongly in the second year. The intervals between treatment contacts were shorter for women, especially young ones, than for men. CONCLUSION: Time-variant measures showed differences in continuity of care that would not have been revealed if more aggregated measures of service use had been used.

Changing patterns in emergency involuntary admissions in the Netherlands in the period 2000-2004.

BACKGROUND: In England, rates of involuntary admissions increased in subgroups of patients. It is unknown whether this is true in other European countries. AIMS: To establish whether the increase in emergency commitments was uniform across subgroups of patients and dangerousness criteria used to justify commitment in The Netherlands. METHOD: National data on all commitments in the period 2000-2004. RESULTS: Commitments increased from 40.2 to 46.5 (16%) per 100,000 inhabitants. Controlling for population changes in age and sex, relatively large increases were found in patients over 50 years (25-40% increase), in patients with dementia (59%), 'other organic mental disorders' (40%) and substance abuse (36%). 'Arousing aggression', increased most strongly as a dangerousness criterion for commitment (30%). CONCLUSION: Changing patterns of commitments in The Netherlands and England might indicate a wider European shift in diagnoses and reasons for admission of committed patients.

[Continuity of care following suicide-related compulsory admission]. / Continuïteit van zorg na inbewaringstelling met suïcidedreiging.

In connection with recent articles about guidelines for dealing with persons attempting suicide, we investigated the quality and continuity of aftercare provided for patients admitted to a mental institution because they have attempted to commit suicide. 25% of patients received no aftercare at all. For most of the others aftercare began within two weeks; 50% of these patients were still receiving care nine months later. Follow-up studies are needed so that we can find out whether the absence of aftercare can cause problems for patients admitted to an institution because they have threatened to commit suicide.

[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.