"Difficult patients" in mental health care: a review

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.

How do patients come to be seen as 'difficult'?: a mixed-methods study in community mental health care

Across all health care settings, certain patients are perceived as 'difficult' by clinicians. This paper's aim is to understand how certain patients come to be perceived and labelled as 'difficult' patients in community mental health care, through mixed-methods research in The Netherlands between June 2006 and October 2009. A literature review, a Delphi-study among experts, a survey study among professionals, a Grounded Theory interview study among 'difficult' patients, and three case studies of 'difficult' patients were undertaken. Analysis of the results of these qualitative and quantitative studies took place within the concept of the sick role, and resulted in the construction of a tentative explanatory model. The 'difficult' patient-label is associated with professional pessimism, passive treatment and possible discharge or referral out of care. The label is given by professionals when certain patient characteristics are present and a specific causal attribution (psychological, social or moral versus neurobiological) about the patient's behaviours is made. The status of 'difficult' patient is easily reinforced by subsequent patient and professional behaviour, turning initial unusual help-seeking behaviour into 'difficult' or ineffective chronic illness behaviour, and ineffective professional behaviour. These findings illustrate that the course of mental illness, or at least the course of patients' contact with mental health professionals and services, is determined by patient and professional and reinforced by the social and mental health care system. This model adds to the broader sick role concept a micro-perspective in which attribution and learning principles are incorporated. On a practical level, it implies that professionals need to look into their own role in the perpetuation of difficult behaviours as described here.

Delphi research exploring essential components and preconditions for case management in people with dementia

Background

Case management programmes for home-dwelling people with dementia and their informal carers exist in multiple forms and shapes. The aim of this research was to identify the essential components of case management for people with dementia as well as the preconditions for an effective delivery of case management services.

Method

The method used to carry out the research was a modified four-phase Delphi design. First, a list of potentially essential components and preconditions for the provision of case management was drawn up on the basis of a literature review and a subsequent focus group interview. The list was then validated by experts in a first Delphi survey round, following which the researchers translated the list items into 75 statements. In the second Delphi survey, the experts rated the statements; in the third Delphi round, they rated 18 statements on which no consensus had been reached in the second round.

Results

The experts were able to build consensus on 61 of the 75 statements. Essential components of case management for people with dementia are: information, support and counselling, coordination of the care provided and, to a lesser extent, practical help. A patient-centred approach was found to be one of the key aspects of providing case management services. Essential preconditions are: vision, care relationship, structured methodology, integration of case management into the health care chain, and the case manager's level of training and expertise.

Conclusions

We recommend that, based on the essential components and preconditions referred to above, quality criteria be developed for the provision of case management for people with dementia. Furthermore, we suggest the conduct of additional research to assess the effectiveness of case management in people with dementia.

Childhood trauma and negative memory bias as shared risk factors for psychopathology and comorbidity in a naturalistic psychiatric patient sample

BACKGROUND

Both childhood trauma and negative memory bias are associated with the onset and severity level of several psychiatric disorders, such as depression and anxiety disorders. Studies on these risk factors, however, generally use homogeneous noncomorbid samples. Hence, studies in naturalistic psychiatric samples are lacking. Moreover, we know little about the quantitative relationship between the frequency of traumatic childhood events, strength of memory bias and number of comorbid psychiatric disorders; the latter being an index of severity. The current study examined the association of childhood trauma and negative memory bias with psychopathology in a large naturalistic psychiatric patient sample.

METHODS

Frequency of traumatic childhood events (emotional neglect, psychological-, physical- and sexual abuse) was assessed using a questionnaire in a sample of 252 adult psychiatric patients with no psychotic or bipolar-I disorder and no cognitive disorder as main diagnosis. Patients were diagnosed for DSM-IV Axis-I and Axis-II disorders using a structured clinical interview. This allowed for the assessment of comorbidity between disorders. Negative memory bias for verbal stimuli was measured using a computer task.

RESULTS

Linear regression models revealed that the frequency of childhood trauma as well as negative memory bias was positively associated with psychiatric comorbidity, separately and above and beyond each other (all p < .01).

CONCLUSIONS

The results indicate that childhood trauma and negative memory bias may be of importance for a broader spectrum of psychiatric diagnoses, besides the frequently studied affective disorders. Importantly, frequently experiencing traumatic events during childhood increases the risk of comorbid psychiatric disorders.

Recurrent suicide attempts in patients with depressive and anxiety disorders: the role of borderline personality traits

BACKGROUND

The presence of a comorbid borderline personality disorder (BPD) may be associated with an increase of suicidal behaviors in patients with depressive and anxiety disorders. The aim of this study is to examine the role of borderline personality traits on recurrent suicide attempts.

METHODS

The Netherlands Study on Depression and Anxiety included 1838 respondents with lifetime depressive and/or anxiety disorders, of whom 309 reported at least one previous suicide attempt. A univariable negative binomial regression analysis was performed to examine the association between comorbid borderline personality traits and suicide attempts. Univariable and multivariable negative binomial regression analyses were performed to identify risk factors for the number of recurrent suicide attempts in four clusters (type and severity of axis-I disorders, BPD traits, determinants of suicide attempts and socio-demographics).

RESULTS

In the total sample the suicide attempt rate ratio increased with 33% for every unit increase in BPD traits. A lifetime diagnosis of dysthymia and comorbid BPD traits, especially the symptoms anger and fights, were independently and significantly associated with recurrent suicide attempts in the final model (n=309).

LIMITATIONS

The screening of personality disorders was added to the NESDA assessments at the 4-year follow-up for the first time. Therefore we were not able to examine the influence of comorbid BPD traits on suicide attempts over time.

CONCLUSIONS

Persons with a lifetime diagnosis of dysthymia combined with borderline personality traits especially difficulties in coping with anger seemed to be at high risk for recurrent suicide attempts. For clinical practice, it is recommended to screen for comorbid borderline personality traits and to strengthen the patient's coping skills with regard to anger.

Preventive psychiatric admission for patients with borderline personality disorder: a pilot study

PURPOSE

The purpose of this study was to establish the preliminary effects of preventive psychiatric admission of patients with severe borderline personality disorder (BPD) on the rate of agreement over treatment, patient service use, and patient views on the intervention.

DESIGN AND METHODS

A retrospective pre-post test design with quantitative measures and qualitative interviews was used.

FINDINGS

Agreement over treatment increased substantially and significantly, and services use decreased substantially, yet not significantly. Patients were highly content with the intervention.

PRACTICE IMPLICATIONS

Preliminary results indicate that preventive admissions may be easy to use and cost effective with severe BPD patients in mainstream psychiatric services, but more research into the intervention is needed.

Improving communication and practical skills in working with inpatients who self-harm: a pre-test/post-test study of the effects of a training programme

BACKGROUND

Differing perspectives of self-harm may result in a struggle between patients and treatment staff. As a consequence, both sides have difficulty communicating effectively about the underlying problems and feelings surrounding self-harm. Between 2009 and 2011, a programme was developed and implemented to train mental health care staff (nurses, social workers, psychologists, psychiatrists, and occupational therapists) in how to communicate effectively with and care for patients who self-harm. An art exhibition focusing on self-harm supported the programme. Lay experts in self-harm, i.e. people who currently harm themselves, or who have harmed themselves in the past and have the skills to disseminate their knowledge and experience, played an important role throughout the programme.

METHODS

Paired sample t-tests were conducted to measure the effects of the training programme using the Attitude Towards Deliberate Self-Harm Questionnaire, the Self-Perceived Efficacy in Dealing with Self-Harm Questionnaire, and the Patient Contact Questionnaire. Effect sizes were calculated using r. Participants evaluated the training programme with the help of a survey. The questionnaires used in the survey were analysed descriptively.

RESULTS

Of the 281 persons who followed the training programme, 178 completed the questionnaires. The results show a significant increase in the total scores of the three questionnaires, with large to moderate effect sizes. Respondents were positive about the training, especially about the role of the lay expert.

CONCLUSION

A specialised training programme in how to care for patients who self-harm can result in a more positive attitude towards self-harm patients, an improved self-efficacy in caring for patients who self-harm, and a greater closeness with the patients. The deployment of lay experts is essential here.

Ambivalent connections: a qualitative study of the care experiences of non-psychotic chronic patients who are perceived as 'difficult' by professionals

BACKGROUND

Little is known about the perspectives of psychiatric patients who are perceived as 'difficult' by clinicians. The aim of this paper is to improve understanding of the connections between patients and professionals from patients' point of view.

METHODS

A Grounded Theory study using interviews with 21 patients from 12 outpatient departments of three mental health care facilities.

RESULTS

Patients reported on their own difficult behaviours and their difficulties with clinicians and services. Explanations varied but could be summarized as a perceived lack of recognition. Recognition referred to being seen as a patient and a person - not just as completely 'ill' or as completely 'healthy'. Also, we found that patients and professionals have very different expectations of one another, which may culminate in a difficult or ambivalent connection. In order to explicate patient's expectations, the patient-clinician contact was described by a stage model that differentiates between three stages of contact development, and three stages of substantial treatment. According to patients, in each stage there is a therapeutic window of optimal clinician behaviour and two wider spaces below and above that may be qualified as 'toxic' behaviour. Possible changes in clinicians' responses to 'difficult' patients were described using this model.

CONCLUSIONS

The incongruence of patients' and professionals' expectations may result in power struggles that may make professionals perceive patients as 'difficult'. Explication of mutual expectations may be useful in such cases. The presented model gives some directions to clinicians how to do this.

Development of an intervention program to increase effective behaviours by patients and clinicians in psychiatric services: Intervention Mapping study

BACKGROUND

Health clinicians perceive certain patients as 'difficult' across all settings, including mental health care. In this area, patients with non-psychotic disorders that become long-term care users may be perceived as obstructing their own recovery or seeking secondary gain. This negative perception of patients results in ineffective responses and low-quality care by health clinicians. Using the concept of illness behaviour, this paper describes the development, implementation, and planned evaluation of a structured intervention aimed at prevention and management of ineffective behaviours by long-term non-psychotic patients and their treating clinicians.

METHODS

The principles of Intervention Mapping were applied to guide the development, implementation, and planned evaluation of the intervention. Qualitative (individual and group interviews), quantitative (survey), and mixed methods (Delphi-procedure) research was used to gain a broad perspective of the problem. Empirical findings, theoretical models, and existing evidence were combined to construct a program tailored to the needs of the target groups.

RESULTS

A structured program to increase effective illness behaviour in long-term non-psychotic patients and effective professional behaviour in their treating clinicians was developed, consisting of three subsequent stages and four substantial components, that is described in detail. Implementation took place and evaluation of the intervention is being carried out.

CONCLUSIONS

Intervention Mapping proved to be a suitable method to develop a structured intervention for a multi-faceted problem in mental health care.

Community mental healthcare for people with severe personality disorder: narrative review

Aims and method

To assess the contents and the theoretical and empirical base of community mental healthcare (CMHC) for people with severe personality disorder. Medline and PsycINFO databases and handbooks were searched from 1980, as well as a recent meta-analysis and systematic review of trials in which CMHC served as the control condition.

Results

Community mental healthcare is a long-term community-based treatment within a supportive atmosphere, aimed at stability rather than change. Mostly offered by community psychiatric nurses, occupational therapists and social workers, it lacks a formal structure, as well as theoretical underpinnings that guide interventions.

Clinical implications

Community mental healthcare might profit from a more systematic application of effective ingredients from other treatments.

Clinical problems in community mental health care for patients with severe borderline personality disorder

The objective of this research was to assess the problems that professionals perceive in the community mental health care for patients with severe borderline personality disorder that do not fit into specialized therapy. A group of national experts (n = 8) participated in a four-phase Delphi-procedure to identify and prioritize the problems. A total of 36 problems reflecting five categories was found: patient-related, professional-related, interaction-related, social system-related, and mental health care-related. Problems with attachment and dependency and social issues were important patient problems while a lack of skills was an important professional problem. Support from the patient's social system and the mental health system were identified as limited, which resulted in both the patient and the professional feeling isolated. Patient, professional, and organisational characteristics of community care differ substantially from those of specialized care. The field is thus in need of a more tailored approach that takes these differences into account.

The treatment of 'difficult' patients in a secure unit of a specialized psychiatric hospital: the patient's perspective

The aim of this study is to obtain insight, from a patient's perspective, into the results and essential components of treatment in specialist settings for so-called 'difficult' patients in mental health care. In cases where usual hospital treatment is not successful, a temporary transfer to another, specialist hospital may provide a solution. We investigated which aspects of specialist treatment available to 'difficult' patients are perceived as essential by the patients and what are the results of this treatment in their perception. A qualitative research design based on the Grounded Theory method was used. To generate data, 14 semi-structured interviews were held with 12 patients who were admitted to a specialist hospital in the Netherlands. Almost all respondents rated the results of the specialist treatment as positive. The therapeutic climate was perceived as extremely strict, with a strong focus on structure, cooperation and safety. This approach had a stabilizing effect on the patients, even at times when they were not motivated. Most patients developed a motivation for change, marked by a growing and more explicit determination of their future goals. We concluded that a highly structured treatment environment aimed at patient stabilization is helpful to most 'difficult' patients.

Collaborative Care for patients with severe borderline and NOS personality disorders: a comparative multiple case study on processes and outcomes

BACKGROUND

Structured psychotherapy is recommended as the preferred treatment of personality disorders. A substantial group of patients, however, has no access to these therapies or does not benefit. For those patients who have no (longer) access to psychotherapy a Collaborative Care Program (CCP) is developed. Collaborative Care originated in somatic health care to increase shared decision making and to enhance self management skills of chronic patients. Nurses have a prominent position in CCP's as they are responsible for optimal continuity and coordination of care. The aim of the CCP is to improve quality of life and self management skills, and reduce destructive behaviour and other manifestations of the personality disorder.

METHODS/DESIGN

Quantitative and qualitative data are combined in a comparative multiple case study. This makes it possible to test the feasibility of the CCP, and also provides insight into the preliminary outcomes of CCP. Two treatment conditions will be compared, one in which the CCP is provided, the other in which Care as Usual is offered. In both conditions 16 patients will be included. The perspectives of patients, their informal carers and nurses are integrated in this study. Data (questionnaires, documents, and interviews) will be collected among these three groups of participants. The process of treatment and care within both research conditions is described with qualitative research methods. Additional quantitative data provide insight in the preliminary results of the CCP compared to CAU. With a stepped analysis plan the 'black box' of the application of the program will be revealed in order to understand which characteristics and influencing factors are indicative for positive or negative outcomes.

DISCUSSION

The present study is, as to the best of our knowledge, the first to examine Collaborative Care for patients with severe personality disorders receiving outpatient mental health care. With the chosen design we want to examine how and which elements of the CC Program could contribute to a better quality of life for the patients.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR2763.

Effective interaction with patients with schizophrenia: qualitative evaluation of the interaction skills training programme

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.

Collaborative Care for Patients With Severe Personality Disorders: Preliminary Results and Active Ingredients From a Pilot Study (Part I)

PURPOSE

To test if a collaborative care program (CCP) with nurses in a coordinating position is beneficial for patients with severe personality disorders.

DESIGN AND METHODS

A pilot study with a comparative multiple case study design using mixed methods investigating active ingredients and preliminary results.

FINDINGS

Most patients, their informal caregivers, and nurses value (parts of) the CCP positively; preliminary results show a significant decrease in severity of borderline symptoms.

PRACTICE IMPLICATIONS

With the CCP, we may expand the supply of available treatments for patients with (severe) personality disorders, but a larger randomized controlled trial is warranted to confirm our preliminary results.

Long-Term Impact of a Tailored Seclusion Reduction Program: Evidence for Change?

International comparative studies show that Dutch seclusion rates are relatively high. Therefore, several programs to change this practice were developed and implemented. The purpose of this study was to examine the impact of a seclusion reduction program over a long time frame, from 2004 until 2013. Three phases could be identified; the phase of development and implementation of the program (2004-2007), the project phase (2008-2010) and the consolidation phase (2011-2013). Five inpatient wards of a mental health institute were monitored. Each ward had one or more seclusion rooms. Primary outcome were the number and the duration of seclusion incidents. Involuntary medication was monitored as well to rule out substitution of one coercive measure by another. Case mix correction for patient characteristics was done by a multi-level logistic regression analysis with patient characteristics as predictors and hours seclusion per admission hours as outcome. Seclusion use reduced significantly during the project phase, both in number (-73%) and duration (-80%) and was not substituted by the use of enforced medication. Patient compilation as analyzed by the multi- level regression seemed not to confound the findings. Findings show a slight increase in number and seclusion days over the last year of monitoring. Whether this should be interpreted as a continuous or temporary trend remains unclear and is subject for further investigation.

Effectiveness of a self-management training for patients with chronic and treatment resistant anxiety or depressive disorders on quality of life, symptoms, and empowerment: results of a randomized controlled trial

BACKGROUND

Anxiety and depressive disorders are common mental disorders. A substantial part of patients does not achieve symptomatic remission after treatment in specialized services. Current care as usual (CAU) for these patients consists of long-term supportive contacts. Termination of CAU is often not considered to be an option due to persistent symptoms, a low level of functioning, and the absence of further treatment options. A new intervention, ZemCAD, offers a program focused on rehabilitation and self-management, followed by referral back to primary care.

METHODS

This multicenter randomized controlled trial was carried out in twelve specialized outpatient mental health care services in the Netherlands. Consenting and eligible patients were invited for the MINI interview and the baseline questionnaire. Assessments were done at 6 (T1), 12 (T2) and 18 (T3) months post baseline. We used linear mixed model analysis (LMM) to ascertain the effectiveness of the ZemCAD group relative to the CAU group on quality of life, symptom severity and empowerment.

RESULTS

In total 141 patients were included. The results at 18-month follow-up regarding to quality of life and symptom severity, showed no significant differences between the ZemCAD group and the CAU group, except on the 'social relationships'-domain (d = 0.37). With regard to empowerment a significant difference between both groups was observed in the total empowerment score and one empowerment dimension (d = 0.45 and d = 0.39, respectively). After the ZemCAD intervention, more patients went from specialized outpatient mental health services back to a less specialized health care setting with less intensive treatment, such as primary care.

CONCLUSION

The findings in this study suggest that patients with chronic and treatment-resistant anxiety and depression using the ZemCAD intervention improve on empowerment but not on symptom severity or quality of life. Since little is known about the effects of rehabilitation and self-management in patients with chronic and treatment resistant anxiety and depressive disorders, this is a first attempt to provide a proof-of-concept study in this under-researched but important field.

TRIAL REGISTRATION

Netherlands Trial Register: NTR3335 , registered 7 March 2012.

A Delphi study of problems in providing community care to patients with nonpsychotic chronic mental illness

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.

Structured assessment of suicide risk in a psychiatric emergency service: Psychometric evaluation of the Nurses' Global Assessment of Suicide Risk scale (NGASR)

BACKGROUND

Risk of suicide is notoriously difficult to assess, and no gold standard is available, in terms of an instrument of first choice. Many different instruments are in use, among which are some that are not properly psychometrically investigated.

AIM

The aim of this study is to establish the psychometric properties of the Dutch version of the Nurses' Global Assessment of Suicide Risk scale (NGASR), and the feasibility of its use in assessing suicide risk. Therefore, our research questions are as follows: what is the reliability, validity, interpretability and feasibility of the NGASR?

METHODS

A psychometric study of acceptability, reliability and predictive validity among 252 patients making use of a concurrent instrument, the Suicide Intention Scale (SIS), concurrent assessment by a physician and 6-month follow-up.

RESULTS

Factor analysis identified five factors. Cronbach's alpha was .45. Intraclass correlation was .92 (95% confidence interval (CI) = .85-.95). Association between total NGASR and SIS was substantial and significant (B = 0.66, standard error of mean (SE) = 0.19, ß = .66, p = .003). NGASR total score had a significant and moderately strong association with judgement by a physician on 'suicidal thoughts' (odds ratio (OR) = 1.24, p = < .001) or 'suicidal thoughts or plans' (OR = 1.35, p = .001). No significant association of NGASR scores and 6-month follow-up of suicidality was found.

CONCLUSIONS

Internal consistency of the NGASR and most of the subscales identified was low. Other indicators of reliability of the NGASR were sufficient, although predictive validity was poor. The NGASR did not outperform other instruments but is easy to use, and may contribute to identification of risk factors, as well as to a more integral assessment of suicide risk.

Substituting specialist care for patients with severe mental illness with primary healthcare. Experiences in a mixed methods study

WHAT IS KNOWN ON THE SUBJECT?: Care planning and coordination are currently insufficiently based on scientific insights due to a lack of knowledge on this topic. Most patients with severe mental illness receive long-term treatment from specialized mental health services. This long-term, highly intensive treatment is not always the best option for two reasons. Firstly, because as long as a patient receives intensive treatment aimed at safety, it is hard for that patient to take full responsibility for their own life. Secondly, because care is not available unlimitedly, some patients are waiting to receive specialist mental healthcare while others who do not need it anymore still receive it. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Most stable patients with severe mental illness can be treated outside of specialized mental health services. Some patients are too dependent on a specific mental healthcare professional to be referred to primary healthcare. In such instances, a referral will most likely lead to destabilization and the referral will therefore be unsuccessful. Patients preferred primary healthcare to specialized mental health services, mainly because of the absence of stigma associated with the latter. There should be more attention for personal recovery (especially the social support system) of patients with severe mental illness who are referred to primary healthcare services. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Most stable patients with severe mental illness can be treated in primary healthcare. Professionals in primary healthcare should keep personal recovery in mind when treating patients, focusing on problem solving skills and also making use of social support systems. ABSTRACT: Aim/question Care planning and coordination are currently insufficiently based on scientific insights due to a lack of knowledge on this topic. In the United Kingdom and the Netherlands, most patients with severe mental illness receive long-term specialized mental healthcare, even when they are stable. This study aims to explore the outcome of these stable patients when they are referred to primary healthcare. Methods Patients (N = 32) receiving specialized mental healthcare that were referred to primary healthcare were interviewed in focus groups, as were the involved professionals (N = 6). Results 84% of the participants still received primary healthcare after 12 months. Despite the successful referral, the patient's personal recovery did not always profit. The participants of the focus groups agreed that some patients were too dependent on a specific mental healthcare professional to be referred to primary healthcare. Discussion Most stable patients with severe mental illness can be referred to primary healthcare. Personal recovery and dependency on a specific healthcare provider should be considered when referring a patient to primary healthcare. Implications for practice Professionals in community mental healthcare teams should consider a referral to primary mental healthcare in stable patients. Professionals in primary healthcare should keep the patient's personal recovery in mind.

Suicide risk, personality disorder and hospital admission after assessment by psychiatric emergency services

BACKGROUND

The main objectives of the mobile Psychiatric Emergency Services (PES) in the Netherlands are to assess the presence of a mental disorder, to estimate risk to self or others, and to initiate continuity of care, including psychiatric hospital admission. The aim of this study was to assess the associations between the level of suicidality and risk of voluntary or involuntary admission in patients with and without a personality disorder who were presented to mobile PES.

METHODS

Observational data were obtained in three areas of the Netherlands from 2007 to 2016. In total, we included 71,707 contacts of patients aged 18 to 65 years. The outcome variable was voluntary or involuntary psychiatric admission. Suicide risk and personality disorder were assessed by PES-clinicians. Multivariable regression analysis was used to explore associations between suicide risk, personality disorder, and voluntary or involuntary admission.

RESULTS

Independently of the level of suicide risk, suicidal patients diagnosed with personality disorder were less likely to be admitted voluntarily than those without such a diagnosis (admission rate .37 versus .46 respectively). However, when the level of suicide risk was moderate or high, those with a personality disorder who were admitted involuntarily had the same probability of involuntary admission as those without such a disorder.

CONCLUSIONS

While the probability of voluntary admission was lower in those diagnosed with a personality disorder, independent of the level of suicidality, the probability of involuntary admission was only lower in those whose risk of suicide was low. Future longitudinal studies should investigate the associations between (involuntary) admission and course of suicidality in personality disorder.

Effectiveness and cost-effectiveness of a self-management training for patients with chronic and treatment resistant anxiety or depressive disorders: design of a multicenter randomized controlled trial

BACKGROUND

Many patients with anxiety or depressive disorders achieve no remission of their symptoms after evidence-based treatment algorithms. They develop a chronic course of the disorder. Current care for these patients usually consists of long-term supportive contacts with a community psychiatric nurse and pharmacological management by a psychiatrist. Data on the effectiveness of these treatments is lacking. A psychosocial rehabilitation approach, where self-management is an increasingly important part, could be more suitable. It focuses on the restoration of functioning and enhancement of patients' autonomy and responsibility. Treatment with this focus, followed by referral to primary care, may be more (cost-)effective.

METHODS

A multicenter randomized controlled trial is designed for twelve participating specialized outpatient mental health services in the Netherlands. Patients with chronic and treatment resistant anxiety or depressive disorders, currently receiving supportive care in specialized outpatient mental health care, are asked to participate. After inclusion, patients receive the baseline questionnaire and are randomized to the intervention group or the usual care control group. The intervention focuses on rehabilitation and self-management and is provided by a trained community psychiatric nurse, followed by referral to primary care. Measurements take place at 6, 12, and 18 months after baseline. This study evaluates both the effectiveness (on quality of life, symptom severity, and empowerment), and cost-effectiveness of the intervention compared to usual care. In addition, a questionnaire is designed to get insight in which self-management strategies patients use to manage their disorder, and in the experiences of patients with the change of care setting.

DISCUSSION

In this study we evaluate the effectiveness and cost-effectiveness of a self-management intervention for patients with chronic and treatment resistant anxiety or depressive disorders in specialized outpatient mental health care. The results of this study may provide a first 'proof-of-concept' in this under-researched but important field, and might be relevant for a large group of patients in the context of a transition of the Dutch health care system.

TRIAL REGISTRATION

Netherlands Trial Register: NTR3335 , registered 7 March 2012.

Seclusion as a necessary vs. an appropriate intervention: a vignette study among mental health nurses

In a vignette study, mental health nurses were asked to score vignettes on necessity and appropriateness using a Likert scale. Sixty-nine clinical nurses from four mental health institutes scored 64 vignettes on necessity (there is no alternative) and appropriateness (seclusion supports patients' treatment) of seclusion simultaneously. Data analysis focused on the differences between both scores, and included general linear model analysis, t-test statistics and Kendall's tau. The t-test resulted in a significantly higher score on necessity than on appropriateness. Differences between both scores could be explained for 32% by a combination of nurse characteristics and vignette variables. Necessity and appropriateness were found to be strongly associated with each other, showing that underpinning patterns were largely the same. This research enhances the understanding of underlying factors that influence the decision of nurses to use seclusion. This is essential for the development of interventions aimed at the reduction of seclusion use in mental health practice.

Perceived Need for Care and Health Care Utilization Among Depressed and Anxious Patients With and Without Suicidal Ideation

Background: Information is scarce concerning the perceived needs and the amount of health-care utilization of persons with suicidal ideation (SI) compared to those without SI. Aims: To describe the needs and health care use of persons with and without SI and to investigate whether these differences are associated with the severity of the axis-I symptomatology. Method: Data were obtained from 1,699 respondents with a depressive and/or anxiety disorder who participated in the Netherlands Study of Depression and Anxiety. Persons with and without SI were distinguished. Outcome variables were perceived needs and health-care utilization. We used multivariate regression in two models: (1) adjusted only for sociodemographic variables and (2) adjusted additionally for severity of axis-I symptomatology. Results: Persons with SI had higher odds for both unmet and met needs in almost all domains and made more intensive use of mental-health care. Differences in needs and health-care utilization of persons with and without SI were strongly associated with severity of axis I symptomatology. Conclusions: Our results validate previous findings about perceived needs and health-care use of persons with SI. The results also suggest that suicidal persons are more seriously ill, and that they need more professional care, dedication, and specialized expertise than anxious and depressed persons without SI, especially in the domains of information and referral.