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Background: In first episode psychosis (FEP) baseline negative symptoms (BNS) and relapse both predict less favorable functional outcome. Relapse-prevention is one of the most important goals of treatment. Apart from discontinuation of antipsychotics, natural causes of relapse are unexplained. We hypothesized that BNS, apart from predicting worse functional outcome, might also increase relapse risk., Methods: We performed a post-hoc analysis of 7-year follow-up data of a FEP cohort (n = 103) involved in a dose-reduction/discontinuation (DR) vs. maintenance treatment (MT) trial. We examined: 1) what predicted relapse, 2) what predicted functional outcome, and 3) if BNS predicted relapse, whether MT reduced relapse rates compared to DR. After remission patients were randomly assigned to DR or MT for 18 months. Thereafter, treatment was uncontrolled., Outcomes: BNS and duration of untreated psychosis (DUP) predicted relapse. Number of relapses, BNS, and treatment strategy predicted functional outcome. BNS was the strongest predictor of relapse, while number of relapses was the strongest predictor of functional outcome above BNS and treatment strategy. Overall and within MT, but not within DR, more severe BNS predicted significantly higher relapse rates. Treatment strategies did not make a difference in relapse rates, regardless of BNS severity., Interpretation: BNS not only predicted worse functional outcome, but also relapses during follow-up. Since current low dose maintenance treatment strategies did not prevent relapse proneness in patients with more severe BNS, resources should be deployed to find optimal treatment strategies for this particular group of patients., Competing Interests: Declaration of competing interest None of the authors has any conflict of interest., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: Children with Down syndrome (DS) more often have strabismus, refractive errors, accommodative lags and reduced visual acuity (VA) than typically developing children. In this study, we compare the effects of bifocal glasses with those of unifocal glasses in children with DS. Changes in angle of strabismus, accommodation and refractive error were analysed in this paper., Methods: In a multicentre randomized controlled trial, 119 children with DS, aged 2-16, were randomly allocated for bifocal or unifocal glasses (with full correction of refractive error in cycloplegia). The 15 centres, all in the Netherlands, followed the participants for 1 year. Changes in refractive error, accommodative accuracy, strabismus, binocularity and stereopsis were compared across 4 subsequent visits., Results: Refractive errors and accommodative errors showed no significant change throughout the course of our study in either intervention group. The manifest angle of strabismus, however, reduced significantly in the bifocal group. This improvement was observed shortly after the children received their new correction (~6 weeks) (linear regression: t = 3.652, p < 0.001) and remained present in the final measurements after 1 year (linear regression: t = 3.604, p < 0.001). The percentage of children with positive binocularity and stereo tests showed no significant differences between the groups., Conclusion: Bifocals with full correction of refractive error reduce the manifest angle of strabismus within a few weeks. No effects on accommodation, refractive error, stereopsis and binocularity occurred over the course of 1 year., (© 2019 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Purpose: Children with Down syndrome (DS) typically have reduced visual acuity (VA) and accommodation lag, but it is unclear whether prescribed glasses should correct both distance VA (DVA) and near VA (NVA) due to the lack of RCTs. We therefore conducted a multicentre RCT to compare the effects of bifocals designed to correct both DVA and NVA with distance-correcting unifocal glasses in children with DS., Methods: A total of 119 children with DS, aged 2-16, were randomly allocated for bifocal or unifocal glasses (with full correction of refraction error in cycloplegia) in 14 Dutch hospitals and followed during 1 year. VA data were analysed in relation to baseline VA with ancova., Results: Treatment groups showed no differences at baseline. Shortly after receiving new corrections (~6 weeks), uncrowded NVA (bifocals 0.18 ± 0.33 LogMar; unifocals 0.09 ± 0.19 LogMar) and crowded NVA with bifocals (bifocals 0.13 ± 0.36 LogMar; unifocals 0.08 ± 0.33 LogMar) were significantly better than at baseline, but these short-term improvements in NVA were not significantly different between the two treatments (p > 0.151). The 1-year treatment differences were as follows: significantly larger improvement for bifocals compared to unifocals in both uncrowded NVA (bifocals 0.23 ± 0.29 LogMar, unifocals 0.12 ± 0.30 LogMar, p = 0.045) and crowded NVA (bifocals 0.31 ± 0.28 LogMar; unifocals 0.16 ± 0.30 LogMar, p = 0.017). Improvements in DVA were comparable (bifocals 0.07 ± 0.21 LogMar, unifocals 0.08 ± 0.22 LogMar, p = 0.565). Children with poor baseline VA improved more. Accommodation lag stayed unchanged., Conclusion: After one year, bifocals with full correction of ametropia led to significantly larger improvement of both uncrowded NVA and crowded NVA in children with DS with accommodation lag compared to unifocals., (© 2018 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Purpose of Review: Relapse is common in patients with anorexia nervosa. The aim of this study is to systematically review the existing literature on relapse in anorexia nervosa., Recent Findings: A systematic literature search was conducted in PubMed, PsychInfo and CINAHL published up to April 2018. Of the 1527 studies screened, 16 studies were included in the present review., Summary: This analysis shows that, of the patients included in this review, 31% relapsed after treatment. The highest risk of relapse is during the first year after discharge and this risk continues for up to 2 years. An overview was made of all factors significantly associated with a higher risk of relapse, resulting in the following four clusters: eating disorder variables, comorbidity symptoms, process treatment variables and demographic variables. Future research on relapse prevention is necessary to further unravel the mechanisms that might lead to relapse.

WHAT IS KNOWN ON THE SUBJECT?: Substance abuse, poor lifestyle and side effects of medication often occur and cause oral health problems in patients diagnosed with severe mental illness (SMI). Oral health in SMI is related to quality of life, self-esteem, and daily functioning. Despite its importance, oral health in mental health care is still a postponed healthcare pathway. Treatment guidelines on patients after a first episode psychosis (FEP) indicate that interventions are recommended, but clinical advice is lacking. However, no research on the experiences of young adults' oral health after FEP has been conducted. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This study is the first study to gain insight into most important experiences in patients after FEP regarding oral health. After FEP, participants experience many risk factors, for example substance use, poor diet and financial problems, and participants are not able to adequately attend to their oral health. There is a lack of awareness among participants after FEP about oral health and participants do have high burden. After FEP, participants need support and help from their environment to maintain their oral health. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: In FEP, oral health needs more attention to avoid the negative consequences in a later phase of the illness. To fill the gap between patients' needs regarding oral health care and the attention of mental healthcare professionals, the awareness of patients and mental health professionals concerning oral health should be heightened, and clinical interventions to support these needs should be developed., Abstract: Introduction Oral health affects quality of life, self-esteem, physical health and daily functioning. Treatment guidelines on patients after first episode psychosis (FEP) recommend interventions, but clinical interventions are lacking. No research on the experiences of young adults' oral health after FEP has been conducted. Aims This study aimed to explore the lived experiences and needs of patients after FEP with regard to their oral health. Design and Methods Single-centre phenomenological study using open interviews (N = 30). Data were analysed using the Colaizzi method. Results Patients reported oral health problems since their FEP. The problems that patients encountered were dental care in general (e.g., a lack of awareness), risk factors (e.g., substance use, poor diet and financial problems), overall experiences with dentists/dental hygienists and the gap between needs and interventions. Discussion There is a lack of awareness among patients after FEP about oral health while patients are not able to adequately attend to their oral health and patients have high burden on this topic. Implications for mental health nursing To bridge the gap between patients' needs regarding oral health, the awareness of patients and mental health professionals should be heightened, and patients should be better supported by mental health professionals., (© 2018 The Authors. Journal of Psychiatric and Mental Health Nursing Published by John Wiley & Sons Ltd.)

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)

Childhood adversity is associated with a range of mental disorders, functional impairment and higher health care costs in adulthood. In this study we evaluated if childhood adversity was predictive of adverse clinical and functional outcomes and health care costs in a sample of patients at ultra-high risk (UHR) for developing a psychosis. Structural Equation Modeling was used to examine the effect of childhood adversity on depression, anxiety, transition to psychosis and overall functioning at 4-year follow-up. In addition, we evaluated economic costs of childhood adversity in terms of health care use and productivity loss. Data pertain to 105 UHR participants of the Dutch Early Detection and Intervention Evaluation (EDIE-NL). Physical abuse was associated with higher depression rates (b=0.381, p=0.012) and lower social functional outcome (b=-0.219, p=0.017) at 4-year follow-up. In addition, emotional neglect was negatively associated with social functioning (b=-0.313, p=0.018). We did not find evidence that childhood adversity was associated with transition to psychosis, but the experience of childhood adversity was associated with excess health care costs at follow-up. The data indicate long-term negative effects of childhood adversity on depression, social functioning and health care costs at follow-up in a sample of UHR patients., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

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: To examine bereaved relatives' experiences from time of diagnosis of incurable cancer until death with specific emphasis on their role in the (end-of-life) decision-making concerning chemotherapy., Design: Qualitative interview study., Setting: Hospital-based., Participants and Methods: In-depth interviews with 15 close relatives of patients who died from non-small cell lung cancer or pancreatic cancer, using a thematic content analysis., Results: All relatives reported that patients' main reason to request chemotherapy was the possibility to prolong life. Relatives reported that patients receiving chemotherapy had more difficulty to accept the incurable nature of their disease than patients who did not. They mostly followed the patients' treatment wish and only infrequently suggested ceasing chemotherapy (because of side effects) despite sometimes believing that this would be a better option. Relatives continuously tried to support the patient in either approaching the death or in attaining hope to continue life satisfactorily. Most relatives considered the chemotherapy period meaningful, since it sparked patients' hope and was what patients wanted. Cessation of chemotherapy caused a relief but coincided with physical deterioration and an increased caregivers' role; many relatives recalled this latter period as more burdensome., Conclusions: Relatives tend to follow patients' wish to continue or cease chemotherapy, without expressing their own feelings, although they were more inclined to opt cessation. They experience a greater caregiver role after cessation and their feelings of responsibility associated with the disease can be exhausting. More attention is needed to reduce relatives' distress at the end of life, also to fully profit from this crucial form of (informal) healthcare., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: To explore the extent to which patients have a directing role in decisions about chemotherapy in the palliative phase of cancer and (want to) anticipate on the last stage of life., Design: Qualitative interview study., Methods: In depth-interviews with 15 patients with advanced colorectal or breast cancer at the medical oncology department in a Dutch teaching hospital; interviews were analysed following the principles of thematic content-analysis., Results: All patients reported to know that the chemotherapy they received was with palliative intent. Most of them did not express the wish for information about (other) treatment options and put great trust in their physicians' treatment advice. The more patients were aware of the severity of their disease, the more they seemed to 'live their life' in the present and enjoy things besides having cancer. Such living in the present seemed to be facilitated by the use of chemotherapy. Patients often considered the 'chemotherapy-free period' more stressful than periods when receiving chemotherapy despite their generally improved physical condition. Chemotherapy (regardless of side-effects) seemed to shift patients' attention away from the approaching last stage of life. Interestingly, although patients often discussed advance care planning, they were reluctant to bring on end-of-life issues that bothered them at that specific moment. Expressing real interest in people 'as a person' was considered an important element of appropriate care., Conclusions: Fearing their approaching death, patients deliberately focus on living in the present. Active (chemotherapy) treatment facilitates this focus, regardless of the perceived side-effects. However, if anxiety for what lies ahead is the underlying reason for treatment, efforts should be made in assisting patients to find other ways to cope with this fear. Simultaneously, such an approach may reduce the use of burdensome and sometimes costly treatment in the last stage of life.

Background: 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., Objective: 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., Methods: 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., Results: 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., Conclusions: 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 examine the utility of the Community Assessment of Psychic Experiences (CAPE)-42, a self-report questionnaire, to improve detection of first-episode psychosis in new referrals to mental health services., Method: At first contact with mental health-care services patients were asked to complete the CAPE-42 and were then routinely diagnosed by a clinician. Standard diagnoses were obtained by means of the mini-Schedule for Clinical Assessment in Neuropsychiatry., Results: Of the 246 included patients, 26 (10.6%) were diagnosed with psychosis according to the mini-Schedule for Clinical Assessment in Neuropsychiatry. Only 10 of them were recognized by clinical routine, and 16 psychotic patients were not properly identified. Using an optimal cut-off of 50 on the frequency or distress dimension of the positive subscale of the CAPE-42 detected 14 of these misdiagnosed patients. The sensitivity of the CAPE-42 at this cut-off point was 77.5 and the specificity 70.5., Conclusion: Systematic screening of patients using a self-report questionnaire for psychotic symptoms improves routine detection of psychotic patients when they first come into contact with mental health services., (© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Asia Pty Ltd.)

Background: Detection of psychotic disorders is an important issue, since early treatment might improve prognosis. Timely diagnosis of psychotic disorders depends on recognition of psychotic symptoms and their interpretation. The aim of this study is to examine to what extent reported psychotic symptoms are accounted for in clinical diagnosis., Methods: The medical files of all patients who had a first contact with one of two mental health care services (N = 6477) were screened for reported psychotic symptoms and subsequent clinical diagnosis. Patients who reported psychotic symptoms and who were diagnosed with a psychotic disorder were followed-up for two years to register prescription of antipsychotic treatment and continuity of care., Results: In the files of 242 (3.7%) patients specific psychotic symptoms were recorded. 37% of these patients were diagnosed with a non-affective psychotic disorder, 7% with other psychotic disorders and 56% with non-psychotic disorders or no diagnosis at all. About 90% of the patients diagnosed with a psychotic disorder did receive any prescription of antipsychotics, and about 50% were in continuous care during the first 2 years., Conclusion: Relatively large proportions of patients presenting with psychotic symptoms were diagnosed with a non-psychotic diagnosis or not diagnosed at all. This applies also to patients reporting at least two or more psychotic symptoms. Although we did not verify the appropriateness of clinical diagnosis, these findings are an indication that psychotic disorders may be underdetected. Improving the diagnostic process in mental health care services may be the most obvious way to promote early intervention in psychosis.

Background: Research into the risk factors for schizophrenia has once again drawn attention to the geographical differences in the incidence and gender distribution of schizophrenia. The incidence - as recorded by the mental health care services - of non-affective psychotic disorders in the Netherlands is unknown., Aim: To ascertain the mental-health-care recorded incidence of non-affective psychotic disorders in Friesland and Twente in 2002., Method: The medical files of all adults who made their first contact with mental health care services in 2002 (n = 6,477) via two clinics in the Netherlands were screened for psychotic symptoms. All patients with psychotic symptoms (n = 242) were included and the clinical diagnosis was recorded. Thirty months later the most recent clinical diagnosis was recorded again. results Within six months of their first contact 75 patients were diagnosed with non-affective disorder. This diagnosis was still valid after 30 months. These results demonstrate an incidence of 2.2/10,000 inhabitants. The male-female ration was 1.8:1. The incidence of psychotic disorder did not differ significantly between the two regions under study., Conclusion: The incidence found corresponds to the incidence reported in earlier Dutch studies; it lies on the 75th percentile of the cumulative incidence given in an international review.

Background: Modern psychiatry emphasises the negative aspects of hearing voices. However, experience shows that some patients find these voices positive or useful., Aim: To describe the life-time prevalence of hearing voices in a group of patients and the course of this phenomenon and to find out whether these patients find the hearing of voices positive and/or useful., Method: The study population consisted of patients and former patients of the Voices Outpatient Department of the Groningen University Medical Centre. For this study the Positive and Useful Voices Inquiry, a self-report questionnaire was developed., Results: The life-time prevalence of positive voices was 52%, whereas the life-time prevalence of useful voices was 40%. In the majority of patients the number of positive voices decreased and the number of useful remained the same. Positive voices provided protection, reassurance or companionship. Useful voices gave advice, assist with daily activities or decision-making. Thirty two percent of the patients wished to continue hearing positive voices, 40% wished to continue hearing useful voices. These wishes were correlated to patients feeling that they have control over these voices., Conclusion: The prevalence of positive and useful voices is quite considerable and is therefore therapeutically relevant. A substantial proportion of the patients wishes to continue hearing these types of voices.