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Background. Current ultra-high-risk (UHR) criteria appear insufficient to predict imminent onset of first-episode psychosis, as a meta-analysis showed that about 20% of patients have a psychotic outcome after 2 years. Therefore, we aimed to develop a stage-dependent predictive model in UHR individuals who were seeking help for co-morbid disorders. Method. Baseline data on symptomatology, and environmental and psychological factors of 185 UHR patients (aged 14-35 years) participating in the Dutch Early Detection and Intervention Evaluation study were analysed with Cox proportional hazard analyses. Results. At 18 months, the overall transition rate was 17.3%. The final predictor model included five variables: observed blunted affect [hazard ratio (HR) 3.39, 95% confidence interval (CI) 1.56-7.35, p < 0.001], subjective complaints of impaired motor function (HR 5.88, 95% CI 1.21-6.10, p = 0.02), beliefs about social marginalization (HR 2.76, 95% CI 1.14-6.72, p = 0.03), decline in social functioning (HR 1.10, 95% CI 1.01-1.17, p = 0.03), and distress associated with suspiciousness (HR 1.02, 95% CI 1.00-1.03, p = 0.01). The positive predictive value of the model was 80.0%. The resulting prognostic index stratified the general risk into three risk classes with significantly different survival curves. In the highest risk class, transition to psychosis emerged on average 58 months earlier than in the lowest risk class. Conclusions. Predicting a first-episode psychosis in help-seeking UHR patients was improved using a stage-dependent prognostic model including negative psychotic symptoms (observed flattened affect, subjective impaired motor functioning), impaired social functioning and distress associated with suspiciousness. Treatment intensity may be stratified and personalized using the risk stratification. [ABSTRACT FROM AUTHOR]

BackgroundAlthough there is evidence for the effectiveness of interventions for psychosis among ultra-high-risk (UHR) groups, health economic evaluations are lacking. This study aimed to determine the cost effectiveness and cost–utility of cognitive–behavioural therapy (CBT) to prevent first-episode psychosis.MethodThe Dutch Early Detection and Intervention Evaluation study was a randomized controlled trial of 196 UHR patients with an 18-month follow-up. All participants were treated with routine care (RC) for non-psychotic disorders. The experimental group (n = 95) received add-on CBT to prevent first-episode psychosis. We report the intervention, medical and travel costs, as well as costs arising from loss of productivity. Treatment response was defined as psychosis-free survival and quality-adjusted life years (QALYs) gained.ResultsIn the cost-effectiveness analysis, the proportion of averted psychoses was significantly higher in the CBT condition (89.5% v. 76.2%). CBT showed a 63.7% probability of being more cost effective, because it was less costly than RC by US$844 (£551) per prevented psychosis. In the cost–utility analysis, QALY health gains were slightly higher for CBT than for RC (0.60 v. 0.57) and the CBT intervention had a 52.3% probability of being the superior treatment because, for equal or better QALY gains, the costs of CBT were lower than those of RC.ConclusionsAdd-on preventive CBT for UHR resulted in a significant reduction in the incidence of first psychosis. QALY gains show little difference between the two conditions. The CBT intervention proved to be cost saving. [ABSTRACT FROM AUTHOR]

BackgroundMetacognitive training (MCT) for patients with psychosis is a psychological group intervention that aims to educate patients about common cognitive biases underlying delusion formation and maintenance, and to highlight their negative consequences in daily functioning.MethodIn this randomized controlled trial, 154 schizophrenia spectrum patients with delusions were randomly assigned to either MCT + treatment as usual (TAU) or TAU alone. Both groups were assessed at baseline, and again after 8 and 24 weeks. The trial was completed fully by 111 patients. Efficacy was measured with the Psychotic Symptom Rating Scales (PSYRATS) Delusions Rating Scale (DRS), and with specific secondary measures referring to persecutory ideas and ideas of social reference (the Green Paranoid Thoughts Scale, GPTS), cognitive insight (the Beck Cognitive Insight Scale, BCIS), subjective experiences of cognitive biases (the Davos Assessment of Cognitive Biases Scale, DACOBS) and metacognitive beliefs (the 30-item Metacognitions Questionnaire, MCQ-30). Economic analysis focused on the balance between societal costs and health outcomes (quality-adjusted life years, QALYs).ResultsBoth conditions showed a decrease of delusions. MCT was not more efficacious in terms of reducing delusions, nor did it change subjective paranoid thinking and ideas of social reference, cognitive insight or subjective experience of cognitive biases and metacognitive beliefs. The results of the economic analysis were not in favour of MCT + TAU.ConclusionsIn the present study, MCT did not affect delusion scores and self-reported cognitive insight, or subjective experience of cognitive biases and metacognitive beliefs. MCT was not cost-effective. [ABSTRACT FROM AUTHOR]

Background. Depression is a clinically relevant dimension, associated with both positive and negative symptoms, in patients with schizophrenia. However, in siblings it is unknown whether depression is associated with subclinical positive and negative symptoms. Method. Depressive symptoms and their association with positive and negative symptoms were examined in 813 healthy siblings of patients with a non-affective psychotic disorder, 822 patients and 527 healthy controls. Depressive episodes meeting DSM-IV-TR criteria (lifetime) and depressed mood (lifetime) were assessed with the Comprehensive Assessment of Symptoms and History (CASH) in all three groups. In the patient group, the severity of positive and negative psychosis symptoms was assessed with the CASH. In the siblings and healthy controls, the severity of subclinical psychosis symptoms was assessed with the Community Assessment of Psychic Experiences (CAPE). Results. Patients reported more lifetime depressed mood and more depressive episodes than both siblings and controls. Siblings had a higher chance of meeting lifetime depressive episodes than the controls; no significant differences in depressed mood were found between siblings and controls. In all three groups the number and duration of depressive symptoms were associated with (sub)clinical negative symptoms. In the patients and siblings the number of depressive symptoms was furthermore associated with (sub)clinical positive symptoms. Finally, lifetime depressed mood showed familial clustering but this clustering was absent for lifetime depressive episodes. Conclusions. These findings suggest that a co-occurring genetic vulnerability for both depressive and psychotic symptomatology exists on a clinical and a subclinical level. [ABSTRACT FROM AUTHOR]

BackgroundEthnicity has been associated with different incidence rates and different symptom profiles in young patients with psychotic-like disorders. No studies so far have examined the effect of ethnicity on symptoms in people with an At Risk Mental State (ARMS).MethodIn this cross-sectional study, we analysed the relationship between ethnicity and baseline data on the severity of psychopathology scores in 201 help-seeking patients who met the ARMS criteria and agreed to participate in the Dutch Early Detection and Intervention (EDIE-NL) trial. Eighty-seven of these patients had a non-Dutch ethnicity. We explored the possible mediating role of ethnic identity.ResultsHigher rates of negative symptoms, and of anhedonia in particular, were found in the ethnic minority group. This result could be attributed mainly to the Moroccan-Dutch and Turkish-Dutch subgroups, who also presented with more depression symptoms when the groups were examined separately. The ethnic minority group displayed a lower level of ethnic group identity compared to the immigrants of the International Comparative Study of Ethnocultural Youth (ICSEY). Ethnic identity was inversely related to symptoms in the Moroccan-Dutch patient group.ConclusionsThe prevalence of more severe negative symptoms and depression symptoms in ethnic minority groups deserves more attention, as the experience of attenuated positive symptoms when accompanied by negative symptoms or distress has proven to be predictive for transition to a first psychotic episode. [ABSTRACT FROM PUBLISHER]

Peer support groups are rarely available for patients with psychosis, despite potential clinical and economic advantages of such groups. In this study, 106 patients with psychosis were randomly allocated to minimally guided peer support in addition to care as usual (CAU), or CAU only. No relevant differences between mean total costs of both groups were found, nor were there significant differences in WHOQoL-Bref outcomes. Intervention adherence had a substantial impact on the results. It was concluded that minimally guided peer support groups for psychosis do not seem to affect overall healthcare expenses. Positive results of additional outcomes, including a significant increase in social contacts and esteem support, favour the wider implementation of such groups. [ABSTRACT FROM AUTHOR]

Backgrounds: Many autistic people in mental health are suicidal. This study evaluated the effectiveness of dialectical behavior therapy (DBT) v. treatment as usual (TAU) in reducing suicidal ideation and suicide attempts., Methods: At six Dutch mental health centers, 123 outpatients (18-65 years) with DSM-5 diagnosed autism spectrum disorder (ASD) and suicidal behavior were randomly assigned to the DBT intervention group ( n = 63) or TAU control group ( n = 60). Assessments were conducted at baseline, post-treatment at 6 months and 12-month follow-up. The primary outcomes were severity of suicidal ideation and frequency of suicide attempts. The severity of depression and social anxiety were secondary outcomes., Results: At end-of-treatment, DBT significantly reduced both suicidal ideation ( z = -2.24; p = 0.025; b = -4.41; s.e. = 197.0) and suicide attempts ( z = -3.15; p = 0.002; IRR = 0.046; s.e. = 0.045) compared to TAU, but lost statistical significance at the 12-month follow-up. Depression severity significantly decreased with DBT ( z = -1.99; p = 0.046: b = -2.74; s.e. = 1.37) remaining so at 12 months ( z = -2.46; p = 0.014; b = -3.37; s.e. = 1.37). No effects were observed on social anxiety. Severe adverse events included two suicides in the TAU condition., Conclusions: DBT is an acceptable, safe, and short-term effective intervention to reduce suicidal ideation and suicide attempts in autistic adults with suicidal behavior.

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.

Living well in spite of residual symptoms of mental illness is measured with the construct of personal recovery. The CHIME framework might be suitable to evaluate personal recovery measures and guide instrument choice. Three validated measures were evaluated in Dutch patients with a psychotic disorder (N = 52). We compared the Recovery Assessment Scale (RAS), the Mental Health Recovery Measure (MHRM), and the Netherlands Empowerment List (NEL). The measures were assessed on six criteria: content validity (based on CHIME), convergent validity with a social support measure, internal consistency, floor and ceiling effects, item interpretability, and ease of administration. The MHRM scored high on content validity with a balanced distribution of items covering the CHIME framework. The MHRM and the NEL showed moderate convergent validity with social support. In all three measures, internal consistency was moderate and floor and ceiling effects were absent. The NEL scores demonstrated a high degree of item interpretability. Ease of administration was moderate for all three measures. Finally, the CHIME framework demonstrated good utility as a framework in guiding instrument choice and evaluation of personal recovery measures. The MHRM showed the best overall result. However, differences between measures were minimal. Generalization of the results is limited by cultural and linguistic factors in the assessment for the subjective measures (i.e. content validity and item interpretability). The broad and multidimensional construct of personal recovery might lead to ambiguous interpretations. Scientific consensus on a well-defined personal recovery construct is needed., (© 2020 The Authors. International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd on behalf of Australian College of Mental Health Nurses Inc.)

Background: This study aims to report on the design of a model to determine the cost-effectiveness of prevention and treatment of early psychosis (PsyMod) and to estimate ten-year cost-effectiveness and budget impact of interventions targeting individuals with ultra-high risk (UHR) of developing psychosis or with first episode psychosis (FEP)., Methods: PsyMod was built in parallel with the development of a new standard of care for treatment of early psychosis in the Netherlands. PsyMod is a state-transition cohort simulation model and considers six health states, namely ultra-high risk of psychosis (UHR), FEP, post-FEP, no-UHR, recovery/remission, and death. Results are expressed as total healthcare costs, QALYs, incremental cost-effectiveness ratio (ICER), and budget impact., Results: PsyMod was used to extrapolate budget impact and cost-effectiveness of cognitive behavioural therapy for preventing FEP for individuals at UHR of psychosis (CBTuhr) compared to care as usual. CBTuhr resulted in a per-patient increase of 0.06 QALYs and a per patient cost reduction of €654 (dominant ICER) with a reduction in 5-year healthcare costs of €1,002,166., Conclusions: PsyMod can be used to examine cost-effectiveness and budget impact of interventions targeting prevention and treatment of FEP and is freely available for academic purposes upon request by the authors.

Background: Psychotic experiences, social functioning and general psychopathology are important targets for early intervention in individuals with Ultra-High-Risk state (UHR) and a first-episode psychosis (FEP). Acceptance and Commitment Therapy (ACT) is a promising, next-generation Cognitive Behavioural Therapy (CBT) that aims to modify these targets, but evidence on sustainable change and its underlying mechanisms in individuals' daily lives remains limited. The aim of the INTERACT study is to investigate the efficacy of a novel ecological momentary intervention, Acceptance and Commitment Therapy in Daily Life (ACT-DL) in a multi-centre randomised controlled trial of individuals with UHR or FEP., Methods/design: In a multi-centre randomised controlled trial, individuals aged 16-65 years with UHR or FEP will be randomly allocated to ACT-DL in addition to treatment as usual (TAU) as the experimental condition or a control condition of TAU only, which will include - for the entire study period - access to routine mental health care and, where applicable, CBT for psychosis (CBTp). Outcomes will be assessed at baseline (i.e. before randomisation), post-intervention (i.e. after the 8-week intervention period), and 6-month and 12-month follow-ups (i.e. 6 and 12 months after completing the intervention period) by blinded assessors. The primary outcome will be distress associated with psychotic experiences, while secondary outcomes will include (momentary) psychotic experiences, social functioning and psychopathology. Process measures to assess putative mechanisms of change will include psychological flexibility, stress sensitivity and reward experiences. In addition, acceptability, treatment adherence and treatment fidelity of ACT-DL will be assessed., Discussion: The current study is the first to test the efficacy of ACT-DL in individuals with UHR and FEP. If this trial demonstrates the efficacy of ACT-DL, it has the potential to significantly advance the treatment of people with UHR and FEP and, more generally, provides initial support for implementing mHealth interventions in mental health services., Trial Registration: Netherlands Trial Register, ID: NTR4252. Registered on 26 September 2013.

Aim: The primary aim was to examine differences in baseline symptom expression, neurocognition, social cognition and psychosocial functioning between Dutch, first-generation immigrants and second-generation immigrants with a first-episode psychosis (FEP). The secondary aim was to examine functional and symptomatic change and between-group differences at 12-months follow-up. Associations between migration, baseline characteristics and outcome were explored., Methods: Forty-six Dutch, 56 second-generation- and 60 first-generation immigrant patients completed baseline measures for 6 symptom dimensions (positive symptoms, negative symptoms, neurocognitive functioning, social cognitive functioning, excitement and emotional distress) and 5 domains of psychosocial functioning (general functioning, work and study, relationships, self-care and disturbing behaviour). Functioning and psychotic symptoms were assessed at baseline and 12-months follow-up. ANCOVA and t tests were used to assess between-group differences. General linear models were used to explore within-group differences. Backward-regression was used to explore predictors of outcome., Results: Levels of positive symptoms, excitement and emotional distress did not differ between groups at baseline or follow-up. Dutch patients had lower levels of negative symptoms than both immigrant groups at follow-up. On neurocognition and social cognition, Dutch performed better than second-generation immigrants, who in turn performed better than first-generation immigrants. Psychosocial functioning across all domains at baseline and at 12-months follow-up was similar across groups. Baseline levels of general psychosocial functioning and income were the strongest predictors of outcome at follow-up., Conclusions: Psychosocial functioning and symptom profiles are comparable between Dutch, first-generation immigrant and second-generation immigrant FEP patients, excluding neurocognitive and social cognitive deficits. A range of baseline characteristics predicted outcome., (© 2018 John Wiley & Sons Australia, Ltd.)

Aim: Although the 16-item version of the Prodromal Questionnaire (PQ-16) is used as a screener in the early detection of psychosis risk, little is known about PQ-16 scores among adolescents referred to the Child and Adolescent Mental Health Services. We assessed such scores in adolescents referred to these services in the Netherlands, and also their associations with age, gender, diagnosis and level of functioning., Methods: The PQ-16 was added to regular intake procedures., Results: The PQ-16 was completed by 176 adolescents (mean age 14.58 years; standard deviation = 1.50; 55.1% females), 34.7% of whom scored above the current cut-off score of ≥6 items. Positive item scores with the highest odds ratio for scoring above the cut-off were related to tasting or smelling things, seeing things and hearing thoughts out aloud. There were no age-, gender- or disorder-related differences in total scores on the PQ-16. Lower Global Assessment of Functioning scores were associated with higher total scores on the PQ-16., Conclusions: The PQ-16 is easy to implement in routine assessment and can be useful to bring up potential psychotic symptoms for further exploration in an early stage, especially in adolescents with low Global Assessment of Functioning scores. The PQ-16 total scores were not confounded by differences in age, gender or disorder. Future research should investigate the true nature of PQ-16 items and whether the item scores and cut-off scores of the PQ-16 in adolescence have any predictive value regarding the development of an ultra high-risk status, a psychotic disorder or other mental disorders., (© 2016 John Wiley & Sons Australia, Ltd.)

Background: In the Netherlands, ethnic minority populations visit their general practitioner (GP) more often than the indigenous population. An explanation for this association is lacking. Recently, health literacy is suggested as a possible explaining mechanism. Internationally, associations between health literacy and health care use, and between ethnicity and health literacy have been studied separately, but, so far, have not been linked to each other. In the Netherlands, some expectations have been expressed with regard to supposed low health literacy of ethnic minority groups, however, no empirical study has been done so far. The objectives of this study are therefore to acquire insight into the level of health literacy of ethnic minorities in the Netherlands and to examine whether the relationship between ethnicity and health care use can be (partly) explained by health literacy., Methods: A questionnaire was sent to a sample of 2.116 members of the Dutch Health Care Consumer Panel (response rate 46%, 89 respondents of non-western origin). Health literacy was measured with the Health Literacy Questionnaire (HLQ) which covers nine different domains. The health literacy levels of ethnic minority groups were compared to the indigenous population. A negative binomial regression model was used to estimate the association between ethnicity and GP visits. To examine whether health literacy is an explaining factor in this association, health literacy and interaction terms of health literacy and ethnicity were added into the model., Results: Differences in levels of health literacy were only found between the Turkish population and the indigenous Dutch population. This study also found an association between ethnicity and GP visits. Ethnic minorities visit their GP 33% more often than the indigenous population. Three domains of the HLQ (the ability to navigate the health care system, the ability to find information and to read and understand health information) partly explained the association between ethnicity and GP visits., Conclusions: In general, there are no differences in health literacy between most of the ethnic minority groups in the Netherlands and the indigenous Dutch population. Only the Turkish population scored significantly lower on several health literacy domains. Some domains of health literacy do explain the association between ethnicity and higher frequency of GP visits. Further research is recommended to understand the pathways through which health literacy impacts health care use.

Background: This study aims to evaluate the long-term cost-effectiveness of add-on cognitive behavior therapy (CBT) for the prevention of psychosis for individuals at ultrahigh risk (UHR) of psychosis., Method: The Dutch Early Detection and Intervention randomized controlled trial was used, comparing routine care (RC; n = 101) with routine care plus CBT for UHR (here called CBTuhr; n = 95). A cost-effectiveness analysis was conducted with treatment response (defined as proportion of averted transitions to psychosis) as an outcome and a cost-utility analysis with quality-adjusted life years (QALYs) gained as a secondary outcome., Results: The proportion of averted transitions to psychosis was significantly higher in the CBTuhr condition (with a risk difference of 0.122; b = 1.324, SEb = 0.017, z = 7.99, P < 0.001). CBTuhr showed an 83% probability of being more effective and less costly than RC by -US$ 5777 (savings) per participant. In addition, over the 4-year follow-up period, cumulative QALY health gains were marginally (but not significantly) higher in CBTuhr than for RC (2.63 vs. 2.46) and the CBTuhr intervention had a 75% probability of being the superior treatment (more QALY gains at lower costs) and a 92% probability of being cost-effective compared with RC at the Dutch threshold value (US$ 24 560; €20 000 per QALY)., Conclusions: Add-on preventive CBTuhr had a high likelihood (83%) of resulting in more averted transitions to psychosis and lower costs as compared with RC. In addition, the intervention had a high likelihood (75%) of resulting in more QALY gains and lower costs as compared to RC., (© The Author 2016. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com)

Background: Previously, we demonstrated that cognitive behavior therapy for ultra-high risk (called CBTuhr) halved the incidence of psychosis over an 18-month period. Follow-up data from the same study are used to evaluate the longer-term effects at 4 years post-baseline., Method: The Dutch Early Detection and Intervention Evaluation study was a randomized controlled trial of 196 UHR patients comparing CBTuhr with treatment-as-usual (TAU) for comorbid disorders with TAU only. Of the original 196 patients, 113 consented to a 4-year follow-up (57.7%; CBTuhr = 56 vs TAU = 57). Over the study period, psychosis incidence, remission from UHR status, and the effects of transition to psychosis were evaluated., Results: The number of participants in the CBTuhr group making the transition to psychosis increased from 10 at 18-month follow-up to 12 at 4-year follow-up whereas it did not change in the TAU group (n = 22); this still represents a clinically important (incidence rate ratio [IRR] = 12/22 = 0.55) and significant effect (F(1,5) = 8.09, P = .03), favoring CBTuhr. The odds ratio of CBTuhr compared to TAU was 0.44 (95% CI: 0.24-0.82) and the number needed to treat was 8. Moreover, significantly more patients remitted from their UHR status in the CBTuhr group (76.3%) compared with the TAU group (58.7%) [t(120) = 2.08, P = .04]. Importantly, transition to psychosis was associated with more severe psychopathology and social functioning at 4-year follow-up., Conclusions: CBTuhr to prevent a first episode of psychosis in persons at UHR of developing psychosis is still effective at 4-year follow-up. Our data also show that individuals meeting the formal criteria of a psychotic disorder have worse functional and social outcomes compared with non-transitioned cases., Trial Registration: The trial is registered at Current Controlled Trials as trial number ISRCTN21353122 (http://controlled-trials.com/ISRCTN21353122/gaag)., (© The Author 2016. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: Crisis plans are a type of psychiatric advance statement (PAS) that describe how to recognize early signs of a psychiatric crisis and how to handle crisis situations. Although PASs may help reduce the occurrence of crises, their implementation in clinical practice is problematic. This study examined patient and clinician characteristics associated with successful completion of a crisis plan and determined how often a plan was consulted in a crisis situation., Methods: Participants were 139 crisis-prone outpatients and their clinicians recruited in the context of a randomized controlled trial in the Netherlands studying the effects of crisis plans. Multivariate logistic regression analyses examined associations between patient and clinician characteristics and completion of a crisis plan. Descriptive and univariate statistics were used to determine subsequent use of crisis plans., Results: Of the 139 patients, 64% completed a crisis plan. Higher completion rates were associated with a better clinician-rated working alliance, a lower education level of the patient, and fewer years of professional experience of the clinician. Of the 89 patients who completed a crisis plan, 38 later experienced a crisis, and plans were consulted for a third of these patients (34%). For those whose crisis involved involuntary admission, a smaller proportion had their plans consulted, compared with those whose crisis involved an outpatient emergency visit or voluntary admission., Conclusions: PAS completion was associated not only with patient and clinician characteristics but also with a positive working alliance. PAS use did not occur in all cases, especially not when patients were involuntarily admitted.

Background: Instruments are used for routine outcome monitoring of patients with severe mental illness in order to measure psychiatric symptoms, care needs and quality of life. By adding an instrument for measuring functional remission a more complete picture can be given of the complaints, the symptoms and general functioning, which can give direction to providing care for patients with severe mental illness., Aim: To describe the development and testing of a new instrument of functional remission (FR) among people with a psychotic disorder or another serious mental disorder (SMI) as an addition to the symptomatic remission (SR), according to international criteria., Method: The FR-assessment involves assessment by a mental health professional who conducts a semi-structured interview with the patient and his or her family and/or uses patient files relating to the three areas of functioning: daily living and self-care; work, study and housekeeping; and social contacts. These areas are rated on a three-point scale of 0: independent; 1: partially independent; 2: dependent. The assessment covers a period of six months, in accordance with the measurement of symptomatic remission and should be part of regular routine outcome monitoring (ROM) procedures. The FR-instrument was used in 2012 with 840 patients from eight Dutch mental care institutions and included a one-year follow-up among 523 patients (response 62%)., Results: The results showed that the instrument is relatively easily to complete. It was also relevant for clinical practice, although further research is needed because of the raters' low response. Intra- and inter-rater reliability, discriminating and convergent validity, and sensitivity to change were rated sufficient to good., Conclusion: If the FR-instrument becomes part of regular ROM-procedures and is used as a measure of societal participation, it could be a useful addition to current measures of symptomatic remission.

Background: Although crime victimisation is as prevalent in psychiatric patients as crime perpetration (and possibly more so), few European figures for it are available. We therefore assessed its one-year prevalence and incident rates in Dutch severely mentally ill outpatients, and compared the results with victimisation rates in the general population., Method: This multisite epidemiological survey included a random sample of 956 adult severely mentally ill outpatients. Data on victimisation were obtained using the victimisation scale of the Dutch Crime and Victimisation Survey, which assesses crime victimisation over the preceding 12 months. Comparison data were derived from the nationwide survey on safety and victimisation in the Netherlands. Prevalence and incident rates were weighted for sex, age, ethnicity and socioeconomic status, and compared with a general population sample matched by region (N = 38,227)., Results: In the past year, almost half of the severely mentally ill outpatients (47%) had been victim of a crime. After control for demographic differences, prevalence rates of overall and specific victimisation measures were significantly higher in severely mentally ill outpatients than in the general population. The relative rates were especially high for personal crimes such as violent threats (RR = 2.12, 95% CI: 1.72-2.61), physical assaults (RR = 4.85, 95% CI: 3.69-6.39) and sexual harassment and assaults (RR = 3.94, 95% CI: 3.05-5.09). In concordance, severely mentally ill outpatients reported almost 14 times more personal crime incidents than persons from the general population (IRR = 13.68, 95% CI: 12.85-14.56)., Conclusion: Crime victimisation is a serious problem in Dutch severely mentally ill outpatients. Mental-healthcare institutions and clinicians should become aware of their patients' victimisation risk, and should implement structural measures to detect and prevent (re-)victimisation.

Objective: Many patients with schizophrenia are not treated in line with evidence-based guidelines. This study examines the large-scale implementation of the National Multidisciplinary Guideline for schizophrenia in the Netherlands., Design: /st> Observational, prospective study, with repeated measurement., Setting: Thirty mental healthcare teams in different regions of the Netherlands., Participants: Three hundred and fifty-nine clinicians with different professional backgrounds and 1489 patients suffering from schizophrenia., Intervention(s): Six evidence-based interventions for schizophrenia were implemented, in the context of a quality improvement collaborative: assertive community treatment (ACT) or its adapted version functional assertive community treatment (FACT), cognitive behavioural therapy, psycho-education, family interventions, individual placement support and pharmacotherapy., Main Outcome Measure(s): Professional performance, social functioning and relapse rates., Results: Improved professional performance, in line with guidelines. Availability of (F)ACT improved from 23 to 60%. Individual Placement Support improved from 20 to 53%. Complete care plans were composed for 38% of the patients and routine outcome monitoring was introduced in most teams. Social functioning improved slightly (HoNOS mean: from 6.2 to 5.6). Relapse rates did not improve during the course of the study., Conclusions: An intensive implementation programme can result in an improved delivery of evidence-based care, increased continuity of care and slightly improved outcomes for individuals with schizophrenia. More rigorous research designs have to confirm these findings.

Background: Trauma contributes to psychosis and in psychotic disorders post-traumatic stress disorder (PTSD) is often a comorbid disorder. A problem is that PTSD is underdiagnosed and undertreated in people with psychotic disorders. This study's primary goal is to examine the efficacy and safety of prolonged exposure and eye movement desensitization and reprocessing (EMDR) for PTSD in patients with both psychotic disorders and PTSD, as compared to a waiting list. Secondly, the effects of both treatments are determined on (a) symptoms of psychosis, in particular verbal hallucinations, (b) depression and social performance, and (c) economic costs. Thirdly, goals concern links between trauma exposure and psychotic symptomatology and the prevalence of exposure to traumatic events, and of PTSD. Fourthly predictors, moderators, and mediators for treatment success will be explored. These include cognitions and experiences concerning treatment harm, credibility and burden in both participants and therapists., Methods/design: A short PTSD-screener assesses the possible presence of PTSD in adult patients (21- to 65- years old) with psychotic disorders, while the Clinician Administered PTSD Scale interview will be used for the diagnosis of current PTSD. The M.I.N.I. Plus interview will be used for diagnosing lifetime psychotic disorders and mood disorders with psychotic features. The purpose is to include consenting participants (N = 240) in a multi-site single blind randomized clinical trial. Patients will be allocated to one of three treatment conditions (N = 80 each): prolonged exposure or EMDR (both consisting of eight weekly sessions of 90 minutes each) or a six-month waiting list. All participants are subjected to blind assessments at pre-treatment, two months post treatment, and six months post treatment. In addition, participants in the experimental conditions will have assessments at mid treatment and at 12 months follow-up., Discussion: The results from the post treatment measurement can be considered strong empirical indicators of the safety and effectiveness of prolonged exposure and EMDR. The six-month and twelve-month follow-up data have the potential of reliably providing documentation of the long-term effects of both treatments on the various outcome variables. Data from pre-treatment and midtreatment can be used to reveal possible pathways of change., Trial Registration: Trial registration: ISRCTN79584912.

Objective: Cognitive problems and biases play an important role in the development and continuation of psychosis. A self-report measure of these deficits and processes was developed (Davos Assessment of Cognitive Biases Scale: DACOBS) and is evaluated in this study., Methods: An item pool made by international experts was used to develop a self-report scale on a sample of 138 schizophrenia spectrum patients. Another sample of 71 patients was recruited to validate the subscales. A group of 186 normal control subjects was recruited to establish norms and examine discriminative validity., Results: Factor analyses resulted in seven factors, each with six items (jumping to conclusions, belief inflexibility bias, attention for threat bias, external attribution bias, social cognition problems, subjective cognitive problems and safety behavior). All factors independently explained the variance (eigenvalues>2) and total explained variance was 45%. Reliability was good (Cronbach's alpha=.90; split-half reliability=.92; test-retest reliability=.86). The DACOBS discriminates between schizophrenia spectrum patients and normal control subjects. Validity was affirmed for five of seven subscales. The scale 'Subjective Cognitive problems' was not associated with objective cognitive functioning and 'Social cognition problems' was not associated with the Hinting task, but with the scale measuring ideas of social reference., Conclusions: The DACOBS scale, with seven independent subscales, is reliable and valid for use in clinical practice and research., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Purpose: Incidence rates of psychotic disorders are higher in immigrant groups compared to native populations. This increased risk may partly be explained by misdiagnosis. Neurocognitive deficits are a core feature of psychotic disorders, but little is known about the relationship between migration and cognition in psychotic disorders. We examined whether immigrant patients have cognitive deficits similar to non-immigrant patients, in order to investigate the plausibility of misdiagnosis as explanation for increased incidence rates., Methods: Patients who made first contact for non-affective psychotic disorder were assessed in the cognitive domains sustained attention, immediate recall and delayed recall. Immigrant patients were compared to Dutch patients on cognitive performance., Results: 407 Patients diagnosed with a non-affective psychotic disorder completed cognitive assessment (157 Dutch, 250 immigrants). Both Dutch and immigrant patients showed large cognitive deficits. Between-subgroup comparisons revealed large cognitive deficits for immigrants compared to Dutch, especially for immigrants from Morocco, Turkey and other non-Western countries., Conclusions: These results indicate that immigrant status is associated with poorer cognitive functioning in early psychosis. The findings argue against diagnostic bias as an explanation for the increased incidence of psychotic disorders in immigrants.

Objectives: The aims of the present study were (1) to determine the proportion and characteristics of patients treated in Assertive Community Treatment teams who achieve symptomatic remission (SR) and/or functional remission (FR) and (2) to explore the association between both types of remission and (3) their bearing on quality of life (QoL)., Methods: Data comprised assessments from 278 patients who were repeatedly assessed using the Positive and Negative Syndrome Scale to assess SR, the Health of the Nation Outcome Scales to assess FR, and a shortened version of the Manchester Short Assessment to assess QoL. χ(2) Tests and a logistic regression analysis were used to analyze the relation between patient and treatment characteristics and achieving SR or FR. A Kruskal-Wallis test, Mann-Whitney U tests, and a logistic regression analysis were used to analyze the relationship between remission status and QoL., Results: After a mean treatment duration of 2.4 years, 26% met the criteria for SR and 30% for FR. Prescription of antipsychotic medication was associated with achieving both SR and FR. Approximately half of the patients who achieved SR also achieved FR. Achieving FR was associated with better QoL. Patients in SR did not have better QoL than did patients not in SR., Conclusions: Remission of symptoms in patients treated in Assertive Community Treatment teams was not a prerequisite for FR or vice versa. FR, not SR, was associated with better QoL., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Routine outcome monitoring (ROM) means the assessment of the patient's condition on a routine basis using instruments. So far there is no consensus about which instruments should be used for ROM with severely mentally ill patients (ROM-SMI)., Aim: To reach a consensus about instruments for ROM-SMI in the Netherlands and Belgium and to create possibilities for comparison of ROM data., Method: This article discusses the consensus document of the National Remission Working Group for ROM in patients with smi and covers the following topics: reasons for ROM-SMI, domains for ROM-SMI and appropriate instruments, logistics and analyses of the data., Results: Patients with SMI have problems in several domains. These can be assessed by collecting information about psychiatric symptoms, addiction, somatic problems, general functioning, needs, quality of life and care satisfaction. Potential instruments for ROM-SMI are short, valid, reliable and assess several domains, taking the patient's perspective into account, and have been used in national and international research. The working group advises institutions to choose from a limited set of instruments. After the scores have been aggregated and standardised, comparisons can be drawn. ROM-SMI data can be interpreted more meaningfully, if outcome data are supplemented with data regarding patient characteristics and the treatment interventions already applied., Conclusion: It should be possible to reach a consensus about instruments for ROM-SMI and the way in which they should be used. The use of identical instruments will lead to improvements in mental health care and create possibilities for comparison (benchmarking) and research.

Objective: This study compared three instruments that are used to measure empowerment of people with psychotic disorders. The study evaluated internal consistency, discriminant and convergent validity, sensitivity to symptom levels, and clinical usefulness., Methods: Fifty patients in the Netherlands were administered the Empowerment Scale (ES), the Personal Empowerment Scale (PES), and the Mental Health Confidence Scale (MHCS)., Results: The MHCS had good internal consistency, whereas the levels for the ES and PES were just below what would be considered acceptable. The instruments demonstrated moderate correlations between total scores; correlations between subscale scores were weaker. Scores for all three instruments were comparably associated with symptom severity., Conclusions: All three instruments measure some aspect of empowerment among persons with severe mental illness. However, empowerment is too broadly defined to allow these instruments to have convergent validity. Among patients with psychotic disorders, the MHCS is recommended because it has good psychometric qualities and is clinically useful.

Purpose: To determine whether the use of relapse prevention plans (RPPs) in nursing practice is an effective intervention in reducing relapse rates among patients with schizophrenia., Design and Methods: Experimental design. Patients with schizophrenia (or a related psychotic disorder) and nurses from three mental health organizations were randomly assigned to either an experimental (RPP) or control condition (care as usual). The primary outcome measure was the psychotic relapses in the research groups., Results: The relapse rates in the experimental and control groups after 1-year follow-up were 12.5% and 26.2%, respectively (p=. 12, ns). The relative risk of a relapse in the experimental versus the control group was 0.48 (ns)., Conclusions: In this study no statistically significant effects of the intervention were found. Effectiveness research in this area should be continued with larger sample sizes and longer follow-up periods.

Mussels are sedentary organisms attached to solid substrata by means of byssus threads. Mussels detached from their substratum tend to reattach by producing new byssus threads. Therefore, in bioassays using mussels, if the test animals are in an unattached status, increased byssogenic activity would expose their soft body parts to the toxic compound used. We test the tolerance of two mussel species (Mytilopsis leucophaeata and Mytilus edulis) to an oxidizing biocide (chlorine) and show that detached mussels are 24-28% less tolerant than byssally attached ones. Detached mussels also showed higher oxygen consumption, filtration rate, foot activity, byssus thread production and byssogenesis index, parameters which are associated with valve opening. A review of literature showed that most of the published data on toxicity against heavy metals and biocides are generated using unattached mussels. The data, therefore, represent an underestimation of the toxicity of the tested compound. Correction data are presented for chlorine tolerance of Dreissena polymorpha, Mytilopsis leucophaeata and Mytilus edulis. The present study suggests the importance of maintaining mussels in their attached status, while undertaking toxicity bioassays.

In this article we describe the findings of an exploratory study into the application of early recognition and early intervention methods aimed at prevention of psychotic relapses in patients with schizophrenia. Following the results we described in part 1, we now focus specifically on factors which favourably or adversely affect the use of early recognition and early intervention methods. The following issues will be addressed: (i) information and education; (ii) attitude of health care professionals; (iii) the patient's insight; (iv) acceptance of illness; (v) motivation; (vi) other relevant patient characteristics; and (vii) continuity of care. Finally, the implications of the findings for the development of a nursing intervention protocol will be discussed.

In this article we describe the findings of an exploratory study into the application of early recognition and early intervention methods aimed at prevention of psychotic relapses in patients with schizophrenia. We addressed several models of symptom recognition plans and indicated how patients, healthcare professionals and other persons involved may be able to list and evaluate early warning signs systematically. We also paid attention to the role of the patient's family and to the potential effects of using early recognition and early intervention methods. In a follow-up article (part 2), we will focus more specifically on factors which favourably or adversely affect the use of early recognition and early intervention methods. The results of this exploratory study will be used to design an intervention protocol for nursing staff to serve as a tool for preparing symptoms recognition plans with the individual patient and his/her social network.

On request of the Dutch government a committee of the Health Council of the Netherlands has reviewed the role that results of field research in its broadest sense (i.e., including multi-species toxicity tests in the laboratory, research on model ecosystems et cetera) can play in ecotoxicological risk assessment for the authorisation of pesticides. The Committee believes that field research can provide valuable additional data about the exposure of non-target organisms and the resultant effects at population, community and ecosystem level. However, it frequently is unclear how these data might be used in reaching a decision about authorisation. To solve this problem, it is necessary to specify what is understood by "unacceptable damage". Both more clearly formulated protection goals of the government and a better understanding of the ecological significance of effects are needed to clarify this. Furthermore, the Committee points out that the statistical power of field trials must be sufficient to allow for the detection of changes that might be regarded as ecologically relevant. Finally, it recommends keeping a finger on the pulse in relation to authorised pesticides by monitoring their presence in environmental compartments and by investigating their role in suddenly occurring mortality among conspicuous animal species, such as birds, fish and honeybees. This kind of research forms a safety net for substances that have been wrongly authorised.

In fungi, meiotic drive is observed as spore killing. In the secondarily homothallic ascomycete Podospora anserina it is characterized by the abortion of two of the four spores in the ascus. We have identified seven different types of meiotic drive elements (Spore killers). Among 99 isolates from nature, six of these meiotic drive elements occurred in a local population. Spore killers comprise 23% of the natural population of P. anserina in Wageningen, The Netherlands, sampled from 1991 to 1997. One Spore-killer type was also found in a French strain dating from 1937. All other isolates found so far are sensitive to spore killing. All seven Spore killer types differ in the percentage of asci that show killing and in their mutual interactions. Interactions among Spore killer types showed either mutual resistance or dominant epistasis. Most killer elements could be assigned to linkage group III but are not tightly linked to the centromere.

QSARs are a useful tool for predicting the potential toxic effects of compounds for which no data are available. Within strictly defined limits, QSARs can be applied to assess the potential impact of a spill, to evaluate ecotoxicological effects and environmental fate of organics in waste water and to set priorities for water quality criteria. For a wider application, there is a need for 'worst case' SARs providing a 'safer' estimate of toxicity than QSARs with an optimum fit, which might underestimate toxicity.

The effects of granular activated carbon filtration and of the combination of ozonation and GAC filtration on the quality of Rhine water were studied in a pilot plant. The scope of the study was to compare both systems in relation to the removal of organic contaminants in water, and to the reduction of the side effects of chlorination. The water quality was measured with organic surrogate parameters (organohalogen, -nitrogen, -phosphorus and -sulphur) and in bacterial mutagenicity assays. In this particular setting, the combination of ozonation and GAC filtration was superior in all points to GAC filtration alone. The effects of ozonation are sometimes quite different, depending on the type of water treated. Its positive influence should be confirmed in a local situation. As GAC treatment causes a shift towards formation of more brominated THM after chlorination, special attention was given to this item. A higher inorganic bromide/DOC ratio resulted in higher brominated THM concentrations after chlorination. However, the mutagens formed during chlorination in presence of more inorganic bromide could be inactivated more easily by rat liver homogenate than in the normal setting. The results of this study confirmed earlier findings stating a negative influence of chlorination on water quality.

The induction was studied of sister-chromatid exchanges in gill and testis of fish exposed to Rhine water. The eastern mudminnow, Umbra pygmaea, was chosen because the usefulness of this species with a karyotype of 22 large chromosomes had been demonstrated in cytogenetic mutagenicity testing. Fish exposed to Rhine water for 3 and 11 days showed a 2-fold and 3-fold higher SCE rate resp., compared with fish exposed to ground water of drinking water quality. There was no difference in SCE rate between gill and testicular cells before and after exposure. GLC/MS analysis indicated that different classes of chemical compounds may be involved in the cytogenetic effects found in fish. The mudminnow has proved to be a useful fish species for biological monitoring of mutagens in polluted waters. The SCE test may be a suitable test system to prescreen their mutagenic potential.