Abstract Background Longer duration of untreated psychosis (DUP) is associated with poorer outcome in terms of positive symptoms, relapse rate, and time to remission. In contrast, the association ...with negative symptoms is less consistent. Aims The study had three aims. First, to arrive at a more precise estimate of the correlation between DUP and negative symptoms than previous reviews, by substantially increasing the amount of available data. Second, to see whether the strength of this correlation attenuated over longer follow-up intervals. Third, to determine whether there is a relationship between DUP and changes in negative symptoms. Method Relevant databases were searched for studies published between December 1992 and March 2009 that reported data on DUP and negative symptoms. We obtained individual patient data where possible and calculated summary correlations between DUP and negative symptoms for each study at baseline, short and long-term follow-up. We used multilevel regression analysis to examine whether the effect of DUP on negative symptoms was the greatest in the early stages of illness. Results We included 28 non-overlapping studies from the 402 papers detected by the search strategy. After contacting the authors we obtained individual patient data from 16 of these studies involving 3339 participants. The mean DUP was 61.4 weeks (SD = 132.7, median DUP = 12.0). Shorter DUP was significantly associated with less severe negative symptoms at baseline and also at short (1–2 years) and longer term follow-up (5–8 years) (r = 0.117, 0.180 and 0.202 respectively, p < 0.001). The relationship between improvement in negative symptoms and DUP was found to be non-linear: people with a DUP shorter than 9 months showed substantially greater negative symptom reduction than those with a DUP of greater than 9 months. Conclusions Shorter DUP is associated with less severe negative symptoms at short and long-term follow up, especially when the DUP is less than 9 months. Since there is no effective treatment for negative symptoms, reducing DUP to less than 9 months may be the best way to ameliorate them.
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.
Mental health policy makers encourage the development of electronic decision aids to increase patient participation in medical decision making. Evidence is needed to determine whether these decision ...aids are helpful in clinical practice and whether they lead to increased patient involvement and better outcomes.
This study reports the outcome of a randomized controlled trial and process evaluation of a Web-based intervention to facilitate shared decision making for people with psychotic disorders.
The study was carried out in a Dutch mental health institution. Patients were recruited from 2 outpatient teams for patients with psychosis (N=250). Patients in the intervention condition (n=124) were provided an account to access a Web-based information and decision tool aimed to support patients in acquiring an overview of their needs and appropriate treatment options provided by their mental health care organization. Patients were given the opportunity to use the Web-based tool either on their own (at their home computer or at a computer of the service) or with the support of an assistant. Patients in the control group received care as usual (n=126). Half of the patients in the sample were patients experiencing a first episode of psychosis; the other half were patients with a chronic psychosis. Primary outcome was patient-perceived involvement in medical decision making, measured with the Combined Outcome Measure for Risk Communication and Treatment Decision-making Effectiveness (COMRADE). Process evaluation consisted of questionnaire-based surveys, open interviews, and researcher observation.
In all, 73 patients completed the follow-up measurement and were included in the final analysis (response rate 29.2%). More than one-third (48/124, 38.7%) of the patients who were provided access to the Web-based decision aid used it, and most used its full functionality. No differences were found between the intervention and control conditions on perceived involvement in medical decision making (COMRADE satisfaction with communication: F1,68=0.422, P=.52; COMRADE confidence in decision: F1,67=0.086, P=.77). In addition, results of the process evaluation suggest that the intervention did not optimally fit in with routine practice of the participating teams.
The development of electronic decision aids to facilitate shared medical decision making is encouraged and many people with a psychotic disorder can work with them. This holds for both first-episode patients and long-term care patients, although the latter group might need more assistance. However, results of this paper could not support the assumption that the use of electronic decision aids increases patient involvement in medical decision making. This may be because of weak implementation of the study protocol and a low response rate.
Objective: To investigate the effectiveness of behavioral parent training (BPT) as adjunct to routine clinical care (RCC). Method: After a first phase of RCC, 94 children with ...attention-deficit/hyperactivity disorder (ADHD) ages 4-12, all referred to a Dutch outpatient mental health clinic, were randomly assigned to 5 months of BPT plus concurrent RCC (n = 47) or to 5 months of RCC (n = 47) alone. BPT consisted of 12 sessions in group format; RCC included family support and pharmacotherapy when appropriate. Exclusionary criteria were minimized, and children with and without medication could participate. Parent-reported behavioral problems, ADHD symptoms, internalizing problems, and parenting stress were assessed before and after treatment. Follow-up assessment of the BPT + RCC group was completed 25 weeks post-BPT intervention. Repeated-measures analyses of variance were carried out on an intention-to-treat basis. Results: Both groups showed improvements over time on all measures. BPT + RCC was superior to RCC alone in reducing behavioral (p = 0.017) and internalizing (p = 0.042)problems. No outcome differences were found in ADHD symptoms (p = 0.161) and parenting stress (p = 0.643). These results were equal for children with and without medication. Children allocated to RCC alone received more polypharmaceutical treatment. Conclusions: Adjunctive BPT enhances the effectiveness of routine treatment of children with ADHD, particularly in decreasing behavioral and internalizing problems, but not in reducing ADHD symptoms or parenting stress. Furthermore, adjunctive BPT may limit the prescription of polypharmaceutical treatment. (Contains 2 tables.) This study was supported by the University Medical Center, Groningen, Netherlands.
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.
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 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.
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.
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.
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 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.
The same cutoff scores can be used for classifying respondents as having low, moderate and high levels of distress in both settings.
The validity of the calibrated severity scores on the ADOS as reported by Gotham et al. (J Autism Dev Disord 39: 693–705,
2009
), was investigated in an independent sample of 1248 Dutch children with ...1455 ADOS administrations (modules 1, 2 and 3). The greater comparability between ADOS administrations at different times, ages and in different modules, as reached by Gotham et al. with the calibrated severity measures, seems to be corroborated by the current study for module 1 and to a lesser extent for module 3. For module 2, the calibrated severity scores need to be further investigated within a sample that resembles Gotham’s sample in age and level of verbal functioning.
Background:
Relapse is considered the most clear-cut indicator of prognosis in psychosis. Relapse prevention is a major outcome of treatment studies, implicitly assuming relapse causes worse ...outcomes. The predictors of relapse, however, have not been established. Nor do we know what predicts worse functional outcome. Recently, in outcome research attention shifted from relapse and symptomatic outcome towards functional outcome and recovery, though their precise relationship has not been clarified. We hypothesized predictors of relapse might also cause worse functional outcome, relapse being a consequence rather than a cause.
Methods:
Analyzing the 7 years follow-up data of a large (N = 103) first episode of psychosis cohort, previously involved in a dose-reduction/discontinuation trial, we posed the questions of (1) what baseline characteristics predict relapse, (2) what impact does relapse have on symptomatic and functional outcome, and (3) if a common predictor of relapse and outcome would be identified, would medication strategies make a difference to reduce relapse rates?
Results:
The occurrence of relapse was predicted by more severe baseline negative symptoms and longer duration of untreated psychosis (DUP). The number of relapses was predicted by more severe baseline negative symptoms. The consequences (or associations) of relapse were also clear cut: 0 relapses gave a chance of 50/50 to recover, 1 relapse a chance of 25/75, 2 relapses a chance of 19/81, and 3 relapses or more 0/100. However, when examining the impact of medication strategies on relapse survival rates by high and low levels of negative symptoms, and relapse survival rates in patients with high and low levels of negative symptoms by dose reduction or maintenance treatment, it was shown that more negative symptoms were related to high relapse rates in both strategies, and relapse rates were equal across strategies for each of the two negative symptom categories.
Conclusion:
Baseline negative symptoms both predict occurrence and number of relapses; baseline negative symptoms were also one of the prominent predictors of non-recovery at 7-years of follow-up in a previous study (1). It appears that baseline negative symptoms reflect both a vulnerability to relapse, and to functional decline (nonrecovery). Relapse prevention by medication strategies (dose reduction or maintenance treatment) does not seem to be effective, since only baseline negative symptoms determine relapse rates. Not relapse rates determine outcome, but baseline negative symptoms, causing both high relapse rates and worse outcome.
Reference
1. Lex Wunderink, Roeline Nieboer, Durk Wiersma, Sjoerd Sytema, Fokko Nienhuis, Recovery in remitted first episode psychosis at 7-years of follow-up of an early dose-reduction/discontinuation or maintenance treatment strategy, JAMA Psychiatry, ISSN: 2168–6238, 2013 Sep, Vol 70 (9), pp 913–20, PMID: 2382 4214.
Short-term outcome studies of antipsychotic dose-reduction/discontinuation strategies in patients with remitted first-episode psychosis (FEP) showed higher relapse rates but no other disadvantages ...compared with maintenance treatment; however, long-term effects on recovery have not been studied before.
To compare rates of recovery in patients with remitted FEP after 7 years of follow-up of a dose reduction/discontinuation (DR) vs maintenance treatment (MT) trial.
Seven-year follow-up of a 2-year open randomized clinical trial comparing MT and DR.
One hundred twenty-eight patients participating in the original trial were recruited from 257 patients with FEP referred from October 2001 to December 2002 to 7 mental health care services in a 3.2 million-population catchment area. Of these, 111 patients refused to participate and 18 patients did not experience remission. PARTICIPANTS After 7 years, 103 patients (80.5%) of 128 patients who were included in the original trial were located and consented to follow-up assessment.
After 6 months of remission, patients were randomly assigned to DR strategy or MT for 18 months. After the trial, treatment was at the discretion of the clinician.
Primary outcome was rate of recovery, defined as meeting the criteria of symptomatic and functional remission. Determinants of recovery were examined using logistic regression analysis; the treatment strategy (MT or DR) was controlled for baseline parameters.
The DR patients experienced twice the recovery rate of the MT patients (40.4% vs 17.6%). Logistic regression showed an odds ratio of 3.49 (P = .01). Better DR recovery rates were related to higher functional remission rates in the DR group but were not related to symptomatic remission rates.
Dose reduction/discontinuation of antipsychotics during the early stages of remitted FEP shows superior long-term recovery rates compared with the rates achieved with MT. To our knowledge, this is the first study showing long-term gains of an early-course DR strategy in patients with remitted FEP. Additional studies are necessary before these results are incorporated into general practice.
isrctn.org Identifier: ISRCTN16228411.
Effectiveness of services for patients diagnosed with severe mental illness (SMI) may improve when treatment plans are needs based. A regional Cumulative Needs for Care Monitor (CNCM) introduced ...diagnostic and evaluative tools, allowing clinicians to explicitly assess patients' needs and negotiate treatment with the patient. We hypothesized that this would change care consumption patterns.
Psychiatric Case Registers (PCR) register all in-patient and out-patient care in the region. We matched patients in the South-Limburg PCR, where CNCM was in place, with patients from the PCR in the North of the Netherlands (NN), where no CNCM was available. Matching was accomplished using propensity scoring including, amongst others, total care consumption and out-patient care consumption. Date of the CNCM assessment was copied to the matched controls as a hypothetical index date had the CNCM been in place in NN. The difference in care consumption after and before this date (after minus before) was analysed.
Compared with the control region, out-patient care consumption in the CNCM region was significantly higher after the CNCM index date regardless of treatment status at baseline (new, new episode, persistent), whereas a decrease in in-patient care consumption could not be shown.
Monitoring patients may result in different patterns of care by flexibly adjusting level of out-patient care in response to early signs of clinical deterioration.
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