Implementing practice guidelines for anxiety disorders in secondary mental health care: a case study

Contains fulltext : 102611.pdf (publisher's version ) (Open Access)Background: Recent years have seen the large-scale development of clinical practice guidelines for mental disorders in several countries. In the Netherlands, more than ten multidisciplinary guidelines for mental health care have been developed since 2003. The first dealt with the treatment of anxiety disorders. An important question was whether it is feasible to implement these guidelines because implementing practice guidelines is often difficult. Although several implementation interventions have proven effective, there seems to be no ready-made strategy that works in all circumstances. Case description: The Dutch multidisciplinary guidelines for anxiety disorders were implemented in a community mental health care centre, located in the east of the Netherlands. The centre provides secondary outpatient care. The unit within the centre that specializes in the treatment of anxiety disorders has 16 team members with diverse professional backgrounds. Important steps in the process of implementing the guidelines were analysing the care provided before start of the implementation to determine the goals for improvement, and analysing the context and target group for implementation. Based on these analyses, a tailor-made multifaceted implementation strategy was developed that combined the reorganization of the care process, the development of instruction materials, the organization of educational meetings and the use of continuous quality circles to improve adherence to guidelines. Discussion and evaluation: Significant improvements in adherence rates were made in the aspect of care that was targeted for change. An increase was found in the number of patients being provided with recommended forms of psychotherapeutic treatment, ranging from 43% to 54% (p < 0.01). The delivery of adequate pharmacological treatment was not explicitly targeted for change remained constant. Conclusion: The case study presented here shows that the implementation of practice guidelines for anxiety disorders in mental health care is feasible. Based on the results of our study, the implementation model used offers a useful approach to guideline implementation. By describing the exact steps that were followed in detail and providing some of the tools that were used in the study, we hope the replication of this implementation methodology is made more practical for others in the future.10 p

Nederlands/Vlaams toponderzoek: Sneller beter door collaborative stepped care

Contains fulltext : 128603.pdf (publisher's version ) (Open Access

De multidisciplinaire richtlijn voor angststoornissen: De toepasbaarheid en effectiviteit in de dagelijkse klinische praktijk

In Nederland is veel energie gestoken in het ontwikkelen van richtlijnen voor de ggz. Een belangrijke vraag daarbij blijft of het de moeite waard is om te investeren in implementatie van dergelijke richtlijnen in de dagelijkse praktijk. In deze bijdrage, een bewerkte samenvatting van het gelijknamige Engelstalige proefschrift van Maarten van Dijk, wordt antwoord gegeven op deze vraag voor zover van toepassing op de Multidisciplinaire richtlijn angststoornissen. Hierbij worden sterke aanwijzingen gevonden voor: [1] de haalbaarheid van implementatie van deze richtlijn; [2] de juistheid van de hypothese dat het naleven van deze richtlijn tot betere uitkomsten van zorg leidt; [3] het feit dat actieve implementatie vergeleken met passieve disseminatie van deze richtlijn gepaard gaat met betere uitkomsten; [4] de gepastheid van het advies om terughoudend te zijn waar het gaat om de keuze iemand bij voorbaat een behandeling volgens deze richtlijn te onthouden, aangezien moeilijk te voorspellen blijkt wie niet voldoende zal profiteren van een behandeling volgens deze richtlijn

To what extent does the anxiety scale of the Four-Dimensional Symptom Questionnaire (4DSQ) detect specific types of anxiety disorder in primary care? A psychometric study

Contains fulltext : 137106.pdf (publisher's version ) (Open Access)BACKGROUND: Anxiety scales may help primary care physicians to detect specific anxiety disorders among the many emotionally distressed patients presenting in primary care. The anxiety scale of the Four-Dimensional Symptom Questionnaire (4DSQ) consists of an admixture of symptoms of specific anxiety disorders. The research questions were: (1) Is the anxiety scale unidimensional or multidimensional? (2) To what extent does the anxiety scale detect specific DSM-IV anxiety disorders? (3) Which cut-off points are suitable to rule out or to rule in (which) anxiety disorders? METHODS: We analyzed 5 primary care datasets with standardized psychiatric diagnoses and 4DSQ scores. Unidimensionality was assessed through confirmatory factor analysis (CFA). We examined mean scores and anxiety score distributions per disorder. Receiver operating characteristic (ROC) analysis was used to determine optimal cut-off points. RESULTS: Total n was 969. CFA supported unidimensionality. The anxiety scale performed slightly better in detecting patients with panic disorder, agoraphobia, social phobia, obsessive compulsive disorder (OCD) and post traumatic stress disorder (PTSD) than patients with generalized anxiety disorder (GAD) and specific phobia. ROC-analysis suggested that >/=4 was the optimal cut-off point to rule out and >/=10 the cut-off point to rule in anxiety disorders. CONCLUSIONS: The 4DSQ anxiety scale measures a common trait of pathological anxiety that is characteristic of anxiety disorders, in particular panic disorder, agoraphobia, social phobia, OCD and PTSD. The anxiety score detects the latter anxiety disorders to a slightly greater extent than GAD and specific phobia, without being able to distinguish between the different anxiety disorder types. The cut-off points >/=4 and >/=10 can be used to separate distressed patients in three groups with a relatively low, moderate and high probability of having one or more anxiety disorders

Predictors of non-response and persistent functional impairments in treatment adhering to evidence-based practice guidelines for anxiety disorders

Background: Several countries have developed guidelines for anxiety disorders containing algorithms that summarize the recommended treatment steps for these disorders. It is important to know which patients have a poor prognosis for treatment according to such algorithms. Aims: To investigate the predictive power of variables known to be able to influence treatment prognosis in situations where practice guidelines for anxiety disorders are adhered to. Method: To study the predictive power of variables that are known to be able to influence treatment prognosis, 81 patients who participated in a guideline implementation study and whose treatment was found to adhere to available guidelines were selected. Using logistic regression analysis two models were constructed: one to predict treatment nonresponse; another to predict persistent functional impairments at the 1-year follow-up. Results: The final prediction model for treatment non-response contains only gender and secondary gain variables. It appears that: males have a higher likelihood (p=.074), and patients that report hopes of obtaining external benefits by seeking treatment have a lower likelihood (p=.054) of showing treatment non-response at the 1-year follow-up. The discriminatory power of this model was found to be poor, however. The model for persistent functional impairments includes gender, satisfaction with the accessibility of healthcare services and the presence of a comorbid anxiety disorder. It appears that: males (p=.87) and patients who express dissatisfaction with the accessibility of care (p=.008) have a higher likelihood, and that; patients who suffer from an additional comorbid anxiety disorder have a lower likelihood (p=.079) of persistent functional impairments. The discriminatory power of this model is excellent. Conclusion: It remains difficult to predict which anxiety disorder patients will not benefit from treatment that is tailored according to available practice guideline recommendations, therefore no one should be prevented from being offered such treatment, if one removes barriers in attending treatment

Toetsen, vergelijken en verbeteren: Procesindicatoren voor de zorg aan patiënten met een angststoornis

Item does not contain fulltextA set of process indicators is presented to make it possible to work in a focused fashion on improving the quality of the care for patients with an anxiety disorder. The Basic Set of Achievement Indicators for Mental Health Care and Addiction Care was launched in 2006, an instrument that makes it possible to test the quality of care. If it is used properly, this makes it feasible to compare mental health facilities, especially as regards the results of the care. The set of process indicators is described based on its use in actual practice.13 p

Implementatie van de multidisciplinaire richtlijn angststoornissen: Een voorbeeld uit de praktijk

Item does not contain fulltextVan het gebruik van evidence-based behandelingsrichtlijnen wordt verwacht dat ze de kwaliteit van zorg verbeteren. In de dagelijkse praktijk worden beschikbare richtlijnen echter slecht gebruikt, omdat de implementatie dikwijls een moeilijk proces blijkt te zijn. Eind 2004 startte een onderzoek naar de implementatie van de landelijke multidisciplinaire richtlijn voor de behandeling van angststoornissen in een GGZ-instelling in het oosten van Nederland. De gegevensverzameling voor deze studie loopt nog steeds. Het doel van dit artikel is een blik te werpen op het implementatieproces dat de onderzoekers doorliepen. Stap voor stap, het model van Grol & Wensing (2001) volgend, laten ze zien hoe de implementatie van de richtlijn werd aangepakt. Dit artikel presenteert enkele voorlopige resultaten die bemoedigend lijken te zijn voor de mogelijkheden om de richtlijn succesvol te implementeren. Mogelijke knelpunten voor de implementatie worden ook beschreven.13 p

Infant-Related Intrusive Thoughts of Harm in the Postpartum Period: A Critical Review

BACKGROUND: Besides the expected warm and joyful thoughts, a new mother can be disturbed by sudden frightening thoughts or images of harm done to her baby: harming intrusions, an obsessive phenomenon. Its high prevalence and possible consequences in functioning and in mother-child bonding makes it desirable that clinicians are well informed regarding the current state of knowledge about harming intrusions. OBJECTIVE: To provide a comprehensive review of all studies that have investigated harming intrusions in postpartum women. DATA SOURCES: A systematic search was performed for primary (MEDLINE, PsycINFO) and secondary (Cochrane Library, National Guideline Clearinghouse, American Psychiatric Association) literature, with data range from inception to April 2015. To provide a complete overview, the approach of the topic by Medical Subject Headings (MeSH) terms and keywords was broad. STUDY SELECTION: Studies in Dutch or English with a clear description of method, covering 1 of our main domains of interest-prevalence, assessment, differential diagnosis, etiology, consequences, and treatment-were selected. DATA EXTRACTION: Two authors extracted quantitative and qualitative data fitting in the domains of interest. RESULTS AND CONCLUSIONS: Fifty articles were included. The prevalence of harming intrusions is up to 100% in both women with and without psychiatric disorders. Stress and cognitive misinterpretation are important keys in its appearance and severity. Literature consistently states that isolated harming intrusions contain no increased risk of violence; instead, compulsive behavior is very common. Psychoeducation is found to release a lot of distress; so might cognitive-behavioral therapy and psychotropic medications

Effectiveness of the implementation of guidelines for anxiety disorders in specialized mental health care

Contains fulltext : 155141.pdf (publisher's version ) (Closed access)OBJECTIVE: To examine the effect of implementing anxiety disorders guidelines on guideline adherence and patient outcomes in specialized mental health care. METHOD: A treatment setting in which guidelines were implemented (intervention condition) was compared with one in which guidelines were only disseminated (control condition). RESULTS: Of 61.7% of 81 intervention-condition patients received treatment according to the guidelines vs. 40.6% of 69 control-condition patients (P = 0.01). At 1-year follow-up, intervention-condition patients showed a greater decrease in anxiety symptoms (d = 0.48, P < 0.05); higher percentages of response (52.6% vs. 33.8%; P = 0.025) and remission (33.3% vs.16.9%; P = 0.026); and a greater decrease in the rate of phobic avoidance (d = 0.34, P < 0.05). At 2-year follow-up, control-condition patients had experienced a longer period of treatment, which had eroded most of these differences, except for phobic avoidance. CONCLUSION: Systematic guideline implementation results in earlier gains and shorter treatment times