[Functioning of the acute psychiatric emergency chain in Amsterdam-Amstelland during the COVID-19 pandemic]

BACKGROUND

At the start of the COVID-19 pandemic, there were fears that a higher proportion of patients with a psychiatric disorder would find themselves in crisis due to the threat of COVID-19 and the impact of the restrictions. If the emergency mental health department would become blocked this could work through to emergency rooms (ER). Acute psychiatry is also assessed at the ER due to lack of space in the emergency mental health department, this is called ‘overflow’. There already was the fear that the virus would flood the hospitals with SARS-CoV-2 infected patients. The emergency mental health department and hospitals agreed that the psychiatric assessments and admissions would take place at the mental health departments as much as possible.

AIM

To describe and evaluate the use of measures taken and set up facilities in Amsterdam-Amstelland to minimize psychiatric assessments in the emergency room during the COVID-19 pandemic. Secondly, to present how psychiatric assessments and admissions were conducted safely if there was suspicion or infection with SARS-CoV-2.

METHOD

Use of acute psychiatric crisis monitor, the minutes of regional acute care counsel and literature.

RESULTS

People with a psychiatric crisis were rarely suspected to be infected with SARS-CoV-2. There was always <br />sufficient capacity in COVID-19 wards in the mental health department. During the lockdown, we managed to <br />minimize overflow from the mental health emergency department to emergency rooms. <span class="CharOverride-1">Conclusion</span> During the COVID-19 pandemic effective collaboration between healthcare partners was achieved in Amsterdam-Amstelland, so that psychiatric assessments and admissions with (suspected) COVID-19 could be conducted safely. Interventions to relieve the emergency room from overflow during lockdown were effective.

Tapering with Pharmaceutical GHB or Benzodiazepines for Detoxification in GHB-Dependent Patients: A Matched-Subject Observational Study of Treatment-as-Usual in Belgium and The Netherlands

BACKGROUND

The gamma-hydroxybutyric acid (GHB) withdrawal syndrome often has a fulminant course, with a rapid onset and swift progression of severe complications. In clinical practice, two pharmacological regimens are commonly used to counteract withdrawal symptoms during GHB detoxification: tapering with benzodiazepines (BZDs) or tapering with pharmaceutical GHB. In Belgium, standard treatment is tapering with BZDs, while in the Netherlands, pharmaceutical GHB is the preferred treatment method. Though BZDs are cheaper and readily available, case studies suggest GHB tapering results in less severe withdrawal and fewer complications.

OBJECTIVES

This study aimed to compare two treatments-as-usual in tapering methods on withdrawal, craving and adverse events during detoxification in GHB-dependent patients.

METHODS

In this multicentre non-randomised indirect comparison of two treatments-as-usual, patients with GHB dependence received BZD tapering (Belgian sample: n = 42) or GHB tapering (Dutch sample: n = 42, matched historical sample). Withdrawal was assessed using the Subjective and Objective Withdrawal Scales, craving was assessed with a Visual Analogue Scale and adverse events were systematically recorded. Differences in withdrawal and craving were analysed using a linear mixed-model analysis, with 'days in admission' and 'detoxification method' as fixed factors. Differences in adverse events were analysed using a Chi-square analysis.

RESULTS

Withdrawal decreased over time in both groups. Withdrawal severity was higher in patients receiving BZD tapering (subjective mean = 36.50, standard deviation = 21.08; objective mean = 8.05, standard deviation = 4.68) than in patients receiving pharmaceutical GHB tapering (subjective mean = 15.90; standard deviation = 13.83; objective mean = 3.72; standard deviation = 2.56). No differences in craving were found. Adverse events were more common in the BZD than the GHB group, especially delirium (20 vs 2.5%, respectively).

CONCLUSIONS

These results support earlier work that BZD tapering might not always sufficiently dampen withdrawal in GHB-dependent patients. However, it needs to be taken into account that both treatments were assessed in separate countries. Based on the current findings, tapering with pharmaceutical GHB could be considered for patients with GHB dependence during detoxification, as it has potentially less severe withdrawal and fewer complications than BZD tapering.

[Refeeding syndrome during alcohol detoxification]

Refeeding syndrome (RS) can occur when malnourished patients are reintroduced to carbohydrates. The symptoms are caused by a combination of electrolyte shifts and fluid retention. Symptoms are wide-ranging; some patients may suffer from harmless muscle cramps, others from more severe neurological and cardiological symptoms that can even lead to death. Although alcohol dependence is a risk factor for the development of RS, little attention is being given to this problem in addiction treatment. In this article we report a case of RS that occurred during alcohol detoxification. We also present the results of a pilot study on the incidence of RS during the alcohol detoxification of 12 patients.

[Background and possible use of ROM in mental health care]

BACKGROUND

Routine outcome measurement or monitoring ROM has attracted worldwide attention largely as a result of developments in the field of quality care and scientific research.

AIM

To provide insight into the significance of ROM for Dutch mental health care.

METHOD

We consulted scientific literature on the following subjects: research and its applicability for clinical practice, quality improvement, ROM instruments and their implementation.

RESULTS

ROM means that the outcomes of treatment and care are measured routinely as part of the plan-do-check-act cycle aimed at quality improvement. Measurement instruments are selected on clinical, scientific and practical grounds. ROM can be used in four main ways: for the treatment of individual patients, for the testing of policy, for benchmarking and for research. With regards to the implementation of rom, a combined top-down, bottom-up approach is preferable to an entirely top-down or bottom-up approach.

CONCLUSION

ROM can help to improve the quality of mental health care because it involves the standardized use of outcome measures and comprehensive databases.

[The use of HoNOS in the treatment of patients]

BACKGROUND

In order to use outcome scores for making decisions about treatment, practitioners need to know the course of scores of several groups of patients.

AIM

To test the applicability of methods for computing cut-off scores and individual changes.

METHOD

Using Health of the Nation Outcome Scales (HoNOS), we analysed repeated assessments of 699 adults and 414 elderly patients in different treatment settings.

RESULTS

Mean HoNOS scores and cut-off scores differentiated between patient groups reasonably well. Scores and threshold values for elderly patients were relatively high. The reliable change index showed few individual changes even for groups where change was expected. The effect size and the standard error of measurement were found to be more sensitive to change.

CONCLUSION

More research is needed before the findings can be generalised.

[ROM in adult psychiatry: an evaluation of measurement instruments]

BACKGROUND

An evaluation of the most commonly used ROM measures in Dutch psychiatry is lacking, both for severe mental illnesses and for common psychiatric disorders.

AIM

To provide an overview of the characteristics and quality of outcome measures.

METHOD

A literature study yielded six outcome measures. The psychometrical, clinical and practical aspects of these scales are described.

RESULTS

The measures are suitable and are of adequate quality.

DISCUSSION

It remains to be seen if any of the outcome measures are suitable for both serious and less serious mental illnesses. The use of a combination of a self-rating scale and an observerrating scale that measure symptoms and domains of functioning may be the most promising choice.

[Validation of two measuring instruments for routine outcome monitoring in psychiatry: the HORVAN study]

BACKGROUND

Transparency in psychiatry can be increased by the use of routine outcome monitoring (rom) instruments. Instruments should be easy to use and take very little time to complete; they also need to have psychometric qualities, be sensitive to change, and provide information about patients' symptoms, and about interpersonal and social functioning.

AIM

To investigate to what extent the combination of Health of the Nation Outcome Scales (HoNOS) and the Outcome Questionnaire (OQ) in the Dutch situation meets the above-mentioned quality criteria and to examine how the combination relates to the Symptom CheckList (SCL-­90).

METHOD

Data for 148 patients collected at three measurement moments were available for analysis. The psychometric qualities of the instruments and their sensitivity to change were checked carefully.

RESULTS

The three scales showed high values for internal consistency (Cronbach's alpha). The HoNOS total score and the subscales of the OQ correlated reasonably well with the SCL­-90 total score (convergence validity). At the first measurements, patients with a comorbid diagnosis had the lowest scores (discrimination validity). The clinically significant change between T1 and T2 and between T2 and T3 was sufficiently high for all three measuring instruments.

CONCLUSION

The combination of the HoNOS rating scale and the self­-report list OQ seems to be suitable for ROM in psychiatry.

Do integrated mental healthcare organisations facilitate process quality in the treatment of people with schizophrenia and related psychoses?

OBJECTIVE

The objective of this study is to investigate the influence of mergers of ambulatory and mental healthcare organisations on the process quality of care for persons suffering from schizophrenia or related psychoses.

THEORY

On the basis of the theory of Donabedian we assume the relationships between three types of quality in healthcare: structure quality, process quality and outcome quality. This study focuses on the influences of structure quality, i.e. years since merger and catchment area size upon process quality.

METHODS

Criteria according to Tugwell for evaluating healthcare were used to describe the process quality of schizophrenia care, resulting in a process quality questionnaire with 6 subscales and 21 items. Leading psychiatrists of 31 Dutch mental healthcare organisations, covering 89% of the country, answered the questionnaire. Both programmes and documents from the responding institutions and schizophrenia projects were analysed. Correlations of two determinants, age of the merged organisation and catchment area size, were made with total scale scores and the sub scores of the questionnaire.

RESULTS

The response rate was 97% (31/32). Twenty-two organisations (71%) had a score of more than 50% on the used scale, 8 (29%) scored less. Two evidence-based interventions were implemented in more than 50% of the organisations, three in less than 50%. A low degree of implementation occurs in establishing care for people with schizophrenia from ethnic minorities, standardising diagnostic procedures and continuity of care. No significant relationship between the age of the merged organisation ('age') and the total process quality of schizophrenia care was found, however, the relationships between age and the subscales availability of interventions and integrated treatment were significant. No association was found between the size of the MHO's catchment area and any of the used subscales.

CONCLUSIONS

The age of integration of residential and ambulatory mental health institutions correlates significantly with two subscales of process quality of schizophrenia care, i.e. availability of interventions and treatment. Catchment area size is not significantly associated with process quality or any of the subscales. Despite the mentioned positive effects, the overall picture of schizophrenia care is not very positive. Additional forces other than merely integration of ambulatory and residential services are needed for the further implementation of evidence-based interventions, diagnostic standards and continuity of care. The development of a national 'schizophrenia standard' (like in other countries) in relation with implementation plans and strategies to evaluate care on a regional level is recommended as well as further research on patient outcomes in relation to mergers of mental healthcare organisations.