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The aim of this paper is to describe and analyse the Dutch community psychiatric nursing profession. In spite of their large numbers, estimated at 2900, Dutch community psychiatric nurses (CPNs) have contributed little to the international literature. The history of the profession reveals a relatively isolated development, resulting in few connections with nursing and mental healthcare research. Because of various developments in these fields, CPNs appear under threat. A survey design was used to administer a 43-item electronic questionnaire, which yielded a response rate of 40%. The Dutch CPN has a mean age of 48 years, works about 32 h per week and has over 20 years of nursing experience. The Dutch CPN has a caseload of 48 patients, often participates in clinical intervision and hardly works according to evidence-based methods. Dutch community psychiatric nursing is, paradoxically, both thriving and threatened. CPNs seek to maintain a model that pays attention to both social needs and explanations, and to psychiatric diagnoses. This broad orientation may be considered essential to nursing. However, it is also a huge drawback as CPNs have not succeeded to clearly articulate what their profession adds to the care and treatment of psychiatric patients.

Aims: 'difficult patients' may evoke strong feelings in health professionals. The ambivalent attitude of, especially, non-psychotic chronic patients towards psychiatric care may be frustrating and burdensome to professionals. Many of these patients are cared for in non-specialized services, where professionals are often more used to working with psychotic patients. Specific problems with 'difficult' non-psychotic patients may occur, and hamper the quality of care offered. The aim of this research is to determine precisely what problems psychiatric professionals perceive in contact with non-psychotic chronic patients in order to identify starting points for alternative or improved care in non-specialized services., Methods: a modified five-phase Delphi study with three groups of eight participants from was used to identify and prioritize experts' judgments., Results: 46 problems were identified of which some were relevant to one or two subgroups and some were relevant to the entire group., Conclusions: a program that combines a coherent view at services level, with support and increased communication at the interprofessional level (e.g. through regular supervision, sharing of case-loads) may be highly beneficial to non-specialized services.

PURPOSE. The purpose of this study was to describe experiences of caregivers with the Interaction Skills Training Programme, and to evaluate the training effects observed by caregivers. DESIGN AND METHODS. A qualitative research design was applied. Semistructured interviews were conducted with 17 caregivers who had followed the training program. FINDINGS. The research findings clearly confirm the value of the program. Positive effects of the training were reported in terms of: (a) awareness and insightfulness; (b) the attitude of caregivers; (c) the quality of the therapeutic alliance; and (d) job perception. PRACTICE IMPLICATIONS. Training interactive skills may contribute to a better quality of care for chronic psychiatric patients. Based on the qualitative study, implementation of the skills training program can be recommended.

Objective: The study identified problems that professionals perceive in community care of patients with nonpsychotic chronic mental illness., Methods: Eight national experts from the Netherlands participated in a four-phase modified Delphi procedure to identify and rate the urgency of problems in patient care and the extent to which problems were amenable to change., Results: A total of 39 problems were identified in five categories: patients, professionals, their interactions, the family and social system, and the mental health system. Participants noted the many social problems of these patients and their unusual help-seeking behavior. They often perceived these patients as able but unwilling to get better. They also noted that their diagnoses tend to be unclear and shifting and that more precise classifications would help in development of treatments., Conclusions: Elucidating the distinction between the psychiatric symptoms of these patients and their unusual help-seeking behavior may improve diagnosis and patient care.

Aim: This paper is a report of a study to explore problems encountered by mental health professionals in the long-term care of patients with chronic depression., Background: Patients who do not profit from psychopharmacological or psychotherapeutic treatment often need long-term care. Although they experience severe symptoms and loss of functioning, little is known about these people and the care they receive., Method: Experts in chronic depression (n = 8) participated in a four-phase Delphi study in 2006-2007. Problems were elicited through a focus group interview (first round) which was analysed using thematic analysis. The resulting problem list was validated (second round) and scored twice on a 7-point Likert scale (third and fourth rounds) by the participants. Urgency and changeability scores of 35 problems were obtained and a hierarchy of problems was set. In addition, qualitative data from the focus group interview were used to frame the results in the context of long-term care for patients with chronic depression., Results: Problems were subdivided into five areas. Relapses by the patient, a pessimistic attitude by the professional and demoralization in both were major problems. Also noted were the negative societal connotations of chronic depression and the lack of a coherent view on treatment within mental health care., Conclusion: Chronicity of depression may be denied by both patients and professionals, resulting in an overly strong focus on cure and a limited quality of care. The results may be used as a starting point for construction of a best-practice programme to improve long-term care.

Background: Chronic suicidality in patients with borderline personality disorder differs substantially from acute suicidality and therefore requires a different approach. On the basis of a case study and a review of the literature, we argue that treatment should definitely involve the taking of short-term risks for the purpose of achieving long-term success. A thorough assessment of the pros and cons is however a prerequisite for this strategy and some precautions need to be taken.

Objective: This article provides an overview of what is known about "difficult patients" in mental health care. It aims to answer three main questions: What are the defining characteristics of difficult patients, how is the difficulty explained, and which treatment strategies are available?, Methods: A search of the MEDLINE, PsycINFO, and CINAHL databases was conducted for articles published between 1979 and 2004 that had "difficult patients" as their main topic, resulting in 94 eligible articles., Results: Characteristics of difficult patients in psychiatric care were consistent across several studies. Explanations for these difficulties widely varied: individual, interpersonal, and social factors were identified. Interventions were described in little detail and offered relatively few specific guidelines for daily practice, although some general principles are summarized. Difficult patients are classified into three subgroups, and some prevailing discourses on difficult patients in mental health care are discussed., Conclusions: Treatment strategies or settings exist for two of the three groups of difficult patients-those with severe mental illness (unwilling care avoiders) and those with the least severe psychiatric symptoms but the most difficult behaviors (demanding care claimers). The remaining group (ambivalent care seekers), which consists of those who seek care but exhibit ambivalent behaviors that could be interpreted as both difficult and ill, is not supported sufficiently by effective treatment strategies. Further development and research into effective interventions is suggested for this group.

Williams syndrome is a neurodevelopmental disorder caused by the hemizygous deletion of 1.6 Mb on human chromosome 7q11.23. This region comprises the gene CYLN2, encoding CLIP-115, a microtubule-binding protein of 115 kD. Using a gene-targeting approach, we provide evidence that mice with haploinsufficiency for Cyln2 have features reminiscent of Williams syndrome, including mild growth deficiency, brain abnormalities, hippocampal dysfunction and particular deficits in motor coordination. Absence of CLIP-115 also leads to increased levels of CLIP-170 (a closely related cytoplasmic linker protein) and dynactin at the tips of growing microtubules. This protein redistribution may affect dynein motor regulation and, together with the loss of CLIP-115-specific functions, underlie neurological alterations in Williams syndrome.