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A significant proportion of patients with a personality disorder do not benefit from treatment. Monitoring treatment progress can help adjust ineffective treatments. This study examined whether early changes in symptoms and personality dysfunction during the first phase of therapy could predict treatment outcomes. Data from 841 patients who received specialized treatment for personality disorders were analyzed. The study focused on whether changes in the Outcome Questionnaire-45.2 (OQ-45.2) symptom distress scale (SD), the General Assessment of Personality Disorder (GAPD), and Severity Indices of Personality Problems (SIPP) in the early phase of therapy predicted post-treatment personality dysfunction, as measured by the SIPP and GAPD. Early changes within a specific SIPP domain were the strongest predictors of post-treatment outcomes in that same domain. Early changes in symptoms significantly predicted outcomes in Self-Control, Relational Functioning, and Identity Integration, while the GAPD predicted outcomes in Self-Control and Social Attunement on the SIPP. For the GAPD, early changes on the GAPD itself, followed by early changes on the OQ-45 SD and the SIPP domain Social Attunement, were significant predictors. Thus, when it comes to personality dysfunction, early changes in a specific domain or measure are the best predictors of outcomes in that same domain. While the OQ-45 predicted some aspects of personality dysfunction, it should not replace disorder-specific measures. Additionally, the SIPP domains and the GAPD should not be used interchangeably to predict each other. In sum, considering these factors, monitoring early change can be useful in assessing progress in the treatment of patients with personality disorders.

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OBJECTIVE: The Mental Health Self-Direction Scale (MHSD) measures the extent to which clients are able to resolve mental problems by themselves. Because this scale had not yet been evaluated, the aims of this paper were (a) to evaluate and improve the MHSD and (b) to explore the sensitivity to change of the improved scale. METHOD: The MHSD was evaluated and improved by means of confirmatory factor analyses of data from one longitudinal and two cross-sectional outpatient sample. Inconsistent items were removed in a stepwise fashion. Subsequently, the scale's sensitivity to change was explored in the longitudinal sample by using latent growth curve models. RESULTS: The original 31-item scale was reduced to a more stable version with 19 items that yielded four factors named: actorship, demoralization, commitment, and understanding. Throughout clients' treatment, actorship and understanding tended to increase; demoralization tended to decrease; and commitment remained consistently high. CONCLUSIONS: The abridged MHSD scale is stable and sensitive to change. It measures the extent to which clients experience and develop self-direction throughout their treatment. With the use of the new MHSD scale, new views on mental health that emphasize clients' ability to actively engage and cope with health-challenges can be incorporated into clinical treatment.

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BACKGROUND: Measurement-Based Care (MBC) is the routine administration of measures, clinicians' review of the feedback and discussion of the feedback with their clients, and collaborative evaluation of the treatment plan. Although MBC is a promising way to improve outcomes in clinical practice, the implementation of MBC faces many barriers, and its uptake by clinicians is low. The purpose of this study was to investigate whether implementation strategies that were developed with clinicians and aimed at clinicians had an effect on (a) clinicians' uptake of MBC and (b) clients' outcomes of MBC. METHODS: We used an effectiveness-implementation hybrid design based on Grol and Wensing's implementation framework to assess the impact of clinician-focused implementation strategies on both clinicians' uptake of MBC and outcomes obtained with MBC for clients in general mental health care. We hereby focused on the first and second parts of MBC, i.e., the administration of measures and use of feedback. Primary outcome measures were questionnaire completion rate and discussion of the feedback with clients. Secondary outcomes were treatment outcome, treatment length, and satisfaction with treatment. RESULTS: There was a significant effect of the MBC implementation strategies on questionnaire completion rate (one part of clinicians' uptake), but no significant effect on the amount of discussion of the feedback (the other part of clinicians' uptake). Neither was there a significant effect on clients' outcomes (treatment outcome, treatment length, and satisfaction with treatment). Due to various study limitations, the results should be viewed as exploratory. CONCLUSIONS: Establishing and sustaining MBC in real-world general mental health care is complex. This study helps to disentangle the effects of MBC implementation strategies on differential clinician uptake, but the effects of MBC implementation strategies on client outcomes need further examination.

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In recent years, there has been an increasing focus on routine outcome monitoring (ROM) to provide feedback on patient progress during mental health treatment, with some systems also predicting the expected treatment outcome. The aim of this study was to elicit patients' and psychologists' preferences regarding how ROM system-generated feedback reports should display predicted treatment outcomes. In a discrete-choice experiment, participants were asked 12-13 times to choose between two ways of displaying an expected treatment outcome. The choices varied in four different attributes: representation, outcome, predictors, and advice. A conditional logistic regression was used to estimate participants' preferences. A total of 104 participants (68 patients and 36 psychologists) completed the questionnaire. Participants preferred feedback reports on expected treatment outcome that included: (a) both text and images, (b) a continuous outcome or an outcome that is expressed in terms of a probability, (c) specific predictors, and (d) specific advice. For both patients and psychologists, specific predictors appeared to be most important, specific advice was second most important, a continuous outcome or a probability was third most important, and feedback that includes both text and images was fourth in importance. The ranking in importance of both the attributes and the attribute levels was identical for patients and psychologists. This suggests that, as long as the report is understandable to the patient, psychologists and patients can use the same ROM feedback report, eliminating the need for ROM administrators to develop different versions.

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Goal setting in psychological treatments may have favourable effects on patients' motivation and treatment outcomes. Therefore, it seems important to detect when patients do not perceive clear treatment goals. The current study presents a questionnaire measuring patients' perceived lack of goal clarity. The cross-sectional study consisted of 742 adult outpatients with diverse mental disorders. Patients completed the perceived lack of goal clarity questionnaire, and additional items measuring goal setting and evaluation, therapeutic alliance, symptom levels, patients' dependency on their treatment, and their expected and needed number of future treatment sessions. Exploratory factor analysis and reliability analyses resulted in a unidimensional and reliable questionnaire (nine items, α = .85). Additional findings showed that 23% of the treatments lacked initial goal setting according to the patients. Also, perceived lack of goal clarity was lower when treatment goals were established explicitly at the start of treatment, were formulated together with the therapist, and were discussed regularly during treatment, and treatment progress was monitored regularly. Moreover, patients reporting their goals as unclear also reported a poorer quality of the therapeutic alliance, higher symptom levels, increased need for future sessions, but also lower levels of care dependency. These findings underscore the importance of perceived goal clarity in psychological treatments, although the relation with actual goal setting remains uncertain.

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This study was aimed at validating the Individual Recovery Outcomes Counter (I.ROC) for deaf, hard-of-hearing, and tinnitus patients in a mental health care setting. There is a need for an accessible instrument to monitor treatment effects in this population. The I.ROC measures recovery, seeing recovery as a process of experiencing a meaningful life, despite the limitations caused by illness or disability. A total of 84 adults referred to 2 specialist mental health centers for deaf, hard-of-hearing, and tinnitus adults in the Netherlands completed the Dutch version of I.ROC and 3 other instruments. A total of 25 patients refused or did not complete the instruments: 50% of patients using sign language and 18% of patients using spoken language. Participants completed the measures at intake and then every 3 months. In this sample I.ROC demonstrated good internal consistency and convergent validity. Sensitivity to change was good, especially over a period of 6 or 9 months. This study provides preliminary evidence that the I.ROC is a valid instrument measuring recovery for hard-of-hearing and tinnitus patients using spoken language. For deaf patients using sign language, specifically those with limited language skills in spoken and written Dutch, more research is needed.

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BACKGROUND: The present study investigates the suitability of various treatment outcome indicators to evaluate performance of mental health institutions that provide care to patients with severe mental illness. Several categorical approaches are compared to a reference indicator (continuous outcome) using pretest-posttest data of the Health of Nation Outcome Scales (HoNOS). METHODS: Data from 10 institutions and 3189 patients were used, comprising outcomes of the first year of treatment by teams providing long-term care. RESULTS: Findings revealed differences between continuous indicators (standardized pre-post difference score ES and ΔT) and categorical indicators (SEM, JTRCI, JTCS, JTRCI&CS, JTrevised) on their ranking of institutions, as well as substantial differences among categorical indicators; the outcome according to the traditional JT approach was most concordant with the continuous outcome indicators. CONCLUSIONS: For research comparing group averages, a continuous outcome indicator such as ES or ΔT is preferred, as this best preserves information from the original variable. Categorical outcomes can be used to illustrate what is accomplished in clinical terms. For categorical outcome, the classical Jacobson-Truax approach is preferred over the more complex method of Parabiaghi et al. with eight outcome categories. The latter may be valuable in clinical practice as it allows for a more detailed characterization of individual patients.

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The Treatment Support Measure (TSM) Parent and Youth were created to help clinicians with actionable feedback when youths are not making sufficient progress in treatment. This study examined the psychometric properties of the Dutch TSM Parent and TSM Youth. Parents (n = 172) and youth (n = 122) were recruited at 2 outpatient mental health care institutions. Children of participating parents (50.6% boys) had a mean age of 11.9 years (SD = 3.46; range 4-18). Participating youth (30.3% boys) had a mean age of 15.68 years (SD = 1.75; range 12-18). Participants were asked to complete the TSM and questionnaires measuring related constructs once during treatment. Responses to the TSM Parent items were explained by 9 instead of 5 subscales, and responses to the TSM Youth items were explained by 8 instead of 4 subscales. The internal consistency reliability of both the TSM Parent and the TSM Youth scales was generally good. The convergent validity of the TSM Parent and the TSM Youth was also good, although the divergent validity was less convincing. The criterion validity was inconclusive; the TSM Parent was not able to differentiate between problematic and nonproblematic treatments, but multiple scales of the TSM Youth were able to differentiate between these groups. The TSM Parent and TSM Youth have potential to be helpful tools in clinical practice. They could signal potential barriers to youth progress and direct the conversation between the clinician and youth and parents about adaptation of treatment. KEY PRACTITIONER MESSAGE: This is the first study to investigate the psychometric properties of the Treatment Support Measure (TSM) Parent and Youth versions, which are created to help clinicians with actionable feedback when youths are not making sufficient progress in treatment. The Dutch TSM Parent and TSM Youth have moderate to good psychometric properties. The Dutch TSM Parent and TSM Youth might be helpful tools for use in clinical practice: they contain variables that are related to youth outcome, can signal potential barriers to youth progress, and can direct the conversation between the clinician and the youth and parents about adaptation of treatment. The Dutch TSM Parent and TSM Youth could be added to the regular ROM to facilitate both routine monitoring of outcome and direct and concrete aid to the here-and-now relational processes in treatment.

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BACKGROUND: The Evidence-Based Practice Attitude Scale (EBPAS) was developed in the United States to assess attitudes of mental health and welfare professionals toward evidence-based interventions. Although the EBPAS has been translated in different languages and is being used in several countries, all research on the psychometric properties of the EBPAS within youth care has been carried out in the United States. The purpose of this study was to investigate the psychometric properties of the Dutch version of the EBPAS. METHODS: After translation into Dutch, the Dutch version of the EBPAS was examined in a diverse sample of 270 youth care professionals working in five institutions in the Netherlands. We examined the factor structure with both exploratory and confirmatory factor analyses and the internal consistency reliability. We also conducted multiple linear regression analyses to examine the association of EBPAS scores with professionals' characteristics. It was hypothesized that responses to the EBPAS items could be explained by one general factor plus four specific factors, good to excellent internal consistency reliability would be found, and EBPAS scores would vary by age, sex, and educational level. RESULTS: The exploratory factor analysis suggested a four-factor solution according to the hypothesized dimensions: Requirements, Appeal, Openness, and Divergence. Cronbach's alphas ranged from 0.67 to 0.89, and the overall scale alpha was 0.72. The confirmatory factor analyses confirmed the factor structure and suggested that the lower order EBPAS factors are indicators of a higher order construct. However, Divergence was not significantly correlated with any of the subscales or the total score. The confirmatory bifactor analysis endorsed that variance was explained both by a general attitude towards evidence-based interventions and by four specific factors. The regression analyses showed an association between EBPAS scores and youth care professionals' age, sex, and educational level. CONCLUSIONS: The present study provides strong support for a structure with a general factor plus four specific factors and internal consistency reliability of the Dutch version of the EBPAS in a diverse sample of youth care professionals. Hence, the factor structure and reliability of the original version of the EBPAS seem generalizable to the Dutch version of the EBPAS.

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The association between level of personality organization as assessed by theory-driven profile interpretation of the MMPI (Hathaway & McKinley, 1943) Dutch Short Form and treatment outcome was investigated in a naturalistic follow-up study among 121 psychotherapy inpatients who had been treated for their severe personality pathology. Treatment outcome was measured with the Brief Symptom Inventory (De Beurs & Zitman, 2006). Personality organization was associated with severity of psychopathology at baseline, the end of treatment, and 36 months after baseline. At 36 months after baseline, all patients except those with the high-level borderline organization profile and the psychotic borderline profile maintained their improvement. Contrary to expectations, (a) personality organization did not differentiate between patients with successful and unsuccessful out-comes, and (b) patients with a neurotic personality organization did not respond better than those with a borderline personality organization. Because of the small N, conclusions are tentative.

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BACKGROUND: Impulsive acts, parasuicidal behavior, and other therapy disruptive incidents occur frequently in the treatment of patients with personality disorders and increase the risk that patients will drop out of treatment. OBJECTIVE: This study examined the predictive validity of the Minnesota Multiphasic Personality Inventory (MMPI)-2 Restructured Clinical (RC) and Psychopathology Five (PSY-5) Scales for therapy disruptive behavior and compared them with the original clinical scales. METHODS: Using an inventory, the treatment staff recorded the therapy disruptive behavior of 104 patients with personality disorders who were receiving inpatient psychotherapy. RESULTS: Both the RC and the PSY-5 scales predicted several categories of therapy disruptive behavior, and both scales predicted more categories of therapy disruptive behavior than the original clinical scales. Anger outbursts were predicted especially well by a combination of two of the RC scales. CONCLUSIONS: The information about the MMPI-2 obtained in this study may be helpful in case formulation when initiating inpatient treatment for patients with personality disorders.

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Although psychodynamic interviews often provide a broad spectrum of interesting and useful information for the therapist, most of these interviews lack sufficient psychometric quality. So far, the Developmental Profile interview seemed an exception. However, only first-level reliability ratings based on a written account of an interview had been conducted. This study presents the results of a second-level reliability study of the Developmental Profile, based on ratings of videotapes of the Profile interview. A total of 32 videotaped interviews with psychotherapeutic inpatients were rated by three independent raters in compliance with the new version of the Developmental Profile rating manual. Contrary to earlier findings, the authors found insufficient reliability. Results are discussed.

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OBJECTIVE: To investigate which factors predict return to work (RTW) after 3 and 6 months in employees sick-listed due to minor mental disorders. METHODS: Seventy GPs recruited 194 subjects at the start of sick leave due to minor mental disorders. At baseline (T0), 3 and 6 months later (T1 and T2, respectively), subjects received a questionnaire and were interviewed by telephone. Using multivariate logistic regression analyses, we developed three prediction models to predict RTW at T1 and T2. RESULTS: The RTW rates were 38% after 3 months (T1) and 61% after 6 months (T2). The main negative predictors of RTW at T1 were: (a) a duration of the problems of more than 3 months before sick leave; and (b) somatisation. The main negative predictors of RTW at T2 were: (a) a duration of the problems of more than 3 months before sick leave; (b) more than 3 weeks of sick leave before inclusion in the study; and (c) anxiety. The main negative predictors of RTW at T2 for those who had not resumed work at T1 were: (a) more than 3 weeks of sick leave before inclusion in the study; and (b) depression at T1. The predictive power of the models was moderate with AUC-values between 0.695 and 0.763. CONCLUSIONS: The main predictors of RTW were associated with the severity of the problems. A long duration of the problems before the occurrence of sick leave and a long duration of sick leave before seeking help predict a relatively small probability to RTW within 3-6 months. High baseline somatisation and anxiety, and high depression after 3 months make the prospect even worse. Since these predictors are readily assessable with just a few questions and a symptom questionnaire, this opens the opportunity to select high-risk employees for a

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Background Insomnia is a very common condition in various populations. Non-pharmacological interventions might offer (safe) alternatives for hypnotics. Aim To evaluate the evidence for efficacy from systematic reviews about non-pharmacological interventions to improve sleep quality in insomnia by a systematic review of systematic reviews and meta-analyses. Search strategy Search strategies were conducted in the Database of Abstracts of Reviews of Effects (2002-July 2008), The Cochrane Database of Systematic Reviews (2000-July 2008) and PubMed (1950-July 2008). Sleep quality was the outcome measure of interest. Selection criteria Systematic reviews about the efficacy of one or more non-pharmacological interventions for insomnia, concerning both adult and elderly populations, were included. Reviews that included studies performed among populations suffering with severe neurological or cognitive impairments or with addictive disorders were excluded. Data analysis Relevant data were extracted. The quality of the reviews found was appraised by using the Overview Quality Assessment Questionnaire. The evidence was appraised and divided into six classes. Results and conclusions Sixteen reviews about 17 interventions were included. Six reviews were of adequate methodological quality. Of these, only one provided an effect size: a moderate effect was found for music-assisted relaxation. Weak evidence indicating a large effect was found for multicomponent cognitive behavioural therapy, progressive muscle relaxation, stimulus control and 'behavioural only'. Weak evidence indicating a moderate effect was found for paradoxical intention. Finally, weak evidence indicating a moderate to large effect was found for relaxation training. Because of the lack of sufficient methodological quality and the lack of calculated effect sizes, most of the included reviews were not suitable for drawing rigorous conclusions about the effect of non-pharmacological interventions on sleep quality in insomniacs. The non-pharmacological treatment of insomnia would benefit from renewed reviews based on a rigorous methodological approach.

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PURPOSE: Description and analysis of the effects and side-effects of integrated mental health care in the Netherlands. CONTEXT OF CASE: Due to a number of large-scale mergers, Dutch mental health care has become an illustration of integration and coherence of care services. This process of integration, however, has not only brought a better organisation of care but apparently has also resulted in a number of serious side-effects. This has raised the question whether integration is still the best way of reorganising mental health care. DATA SOURCES: Literature, data books, patients and professionals, the advice of the Dutch Commission for Mental Health Care, and policy papers. CASE DESCRIPTION: Despite its organisational and patient-centred integration, the problems in the Dutch mental health care system have not diminished: long waiting lists, insufficient fine tuning of care, public order problems with chronic psychiatric patients, etc. These problems are related to a sharp rise in the number of mental health care registrations in contrast with a decrease of registered patients in first-level services. This indicates that care for people with mental health problems has become solely a task for the mental health care services (monopolisation). At the same time, integrated institutions have developed in the direction of specialised medical care (homogenisation). Monopolisation and homogenisation together have put the integrated institutions into an impossible divided position. CONCLUSIONS AND DISCUSSION: Integration of care within the institutions in the Netherlands has resulted in withdrawal of other care providers. These side-effects lead to a new discussion on the real nature and benefits of an integrated mental health care system. Integration requires also a broadly shared vision on good care for the various target groups. This would require a radicalisation of the distinction between care providers as well as a recognition of the different goals of mental health care.

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Background and objectives: Depression is often a recurrent or persistent disorder. Since the majority of depressed patients are treated in primary care, it is clear that to improve long-term outcomes more effective treatments in this setting are needed. The goal of this study was to review the strategies used for improvement of routine treatment in terms of their effects on patient outcome. Methods: We conducted a systematic literature search to identify improvement strategies tested in randomized controlled trials in primary care, reporting at least six months effects on depression course and outcome. Results: Four strategies were identified: (1) training primary care physicians (PCPs) – this appears ineffective (2) supporting PCPs by other professionals – this produces better short term outcomes but does not prevent recurrence (3) organisational quality improvement– this shows improved outcomes at 6 months, and there is some evidence of longer term effectiveness; and (4) recurrence – and chronicity prevention strategies – these have not been shown to be effective. Conclusion: Since effects of the reviewed strategies generally do not seem to persist over time and no clear superiority over usual care has been demonstrated, we conclude that for improving long-term outcome of depression in primary care new directions or even a novel paradigm is needed (AU)

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BACKGROUND: Sickness absence often occurs in patients with emotional distress or minor mental disorders. In several European countries, these patients are over-represented among those receiving illness benefits, and interventions are needed. The aim of this study was to evaluate the cost-effectiveness of an intervention conducted by social workers, designed to reduce sick leave duration in patients absent from work owing to emotional distress or minor mental disorders. METHODS: In this Randomized Controlled Trial, patients were recruited by GPs. The intervention group (N = 98) received an activating, structured treatment by social workers, the control group (N = 96) received routine GP care. Sick leave duration, clinical symptoms, and medical consumption (consumption of medical staffs' time as well as consumption of drugs) were measured at baseline and 3, 6, and 18 months later. RESULTS: Neither for sick leave duration nor for clinical improvement over time were significant differences found between the groups. Also the associated costs were not significantly lower in the intervention group. CONCLUSIONS: Compared with usual GP care, the activating social work intervention was not superior in reducing sick leave duration, improving clinical symptoms, and decreasing medical consumption. It was also not cost-effective compared with GP routine care in the treatment of minor mental disorders. Therefore, further implementation of the intervention is not justified. Potentially, programmes aimed at reducing sick leave duration in patients with minor mental disorders carried out closer to the workplace (e.g. by occupational physicians) are more successful than programmes in primary care.

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OBJECTIVE: The purpose of this study was to evaluate the effectiveness of an activating intervention designed to reduce sick leave duration in patients with emotional distress or minor mental disorders. METHOD: In a 1.5-year randomized controlled trial, 194 patients with minor mental disorders received either an experimental intervention by social workers or general practitioners' usual care. The intervention focused on understanding causes, developing and implementing problem-solving strategies and promoting early work resumption. Outcome measures were sick leave duration, mental health and physical health (questionnaires included the Hospital Anxiety and Depression Scale, the Four-Dimensional Symptom Questionnaire and SF-36), all measured at baseline at and 3, 6 and 18 months later. Multilevel analyses were used to evaluate differences between groups. RESULTS: The groups did not differ significantly on any of the outcome measures, except that the experimental group reported higher satisfaction with treatment. CONCLUSION: Although the intervention has benefits, it was not successful at its primary goal (i.e., to reduce sick leave duration in patients with emotional distress or minor mental disorders). Programs aimed at the reduction of sick leave duration may yield better results if targeted at patients with more severe emotional problems than at those with exclusively emotional distress or minor mental disorders, or if delivered by caregivers who are closer to the work environment than are social workers, such as occupational physicians.

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BACKGROUND: Although good physician communication is associated with positive patient outcomes, it does not figure in current depression treatment guidelines. We examined the effect of depression treatment, communicative skills and their interaction on patient outcomes for depression in primary care. METHODS: In a cohort of 348 patients with ICD-10 depression in primary care, patient outcomes were studied over 3- and 12-month follow-ups. The association of these outcomes with both depression-specific process of care variables and a nonspecific variable-communicative skillfulness of GP-was examined. Patient outcomes consisted of change from baseline in symptomatology, disability, activity limitation days, and duration of the depressive episode. RESULTS: In accordance with treatment guidelines, some main effects of depression treatment were found, in particular on symptomatology, but these remained small (effect size<0.50). A moderate effect was found for treatment with a sedative, which proved to be related to worse patient outcomes at 12 months. An accurate GP diagnosis of depression and adequate antidepressant treatment were associated with better patient outcomes, but only when provided by GPs with good communicative skills. In contrast to the main effects, these interactions were seen on disability and activity limitation days, not on symptomatology. LIMITATIONS: The study is observational and does not permit firm conclusions about causal relationships. Communicative skillfulness of the GP was assessed by patient report only. CONCLUSION: Neither depression-specific interventions nor good GP communication skills seem to be sufficient for optimal patient improvement. Only the combination of treatments according to guidelines and good communication skills results in an effective antidepressive treatment.

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BACKGROUND: Sub-threshold depression is a prognostic variable for major depression. Interventions in sub-threshold depression may prevent the onset of new cases of major depression. AIMS: To examine the effects of minimal-contact psychotherapy in primary care patients with sub-threshold depression on the onset of major depression, on the reduction in depressive symptoms and on health-related quality of life. METHOD: We conducted a randomised trial in primary care, in which patients screened for sub-threshold depression were randomly assigned to minimal-contact psychotherapy (n=107) or to usual care (n=109). RESULTS: One year after baseline, the incidence of major depressive disorder was found to be significantly lower in the psychotherapy group (12%) than in those receiving usual care (18%). Small but significant effects were also found on depressive symptoms and on aspects of health-related quality of life. CONCLUSIONS: Primary care patients with sub-threshold depression can benefit from minimal-contact psychotherapy.

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