Don't forget : contributions to the assessment and management of suicide attempters in the general hospital

The aim of this thesis was to contribute to better care for suicide attempters by studying several aspects of their assessment and management. In the first part of the thesis, the role of guidelines was studied resulting in suggestions for improvement. In the second part, the role of factors is studied that, as experience in clinical practice suggests may hamper proper assessment and management. From the studies in part 1, it was concluded that the available evidence suggests that guidelines for the assessment and management of suicide attempters differ to a large extent with respect to their content, that only a minority can be recommended based on an evaluation of their quality, and that they are probably not implemented properly. This leads to a plea to update the Dutch guideline, made 15 years ago, and to develop procedures that may promote implementation. From the studies of part 2, it was concluded that professionals should be alert on patients forgetting relevant aspects of the assessment. Furthermore, although a systematic assessment in the hospital is comparable to a reassessment at home, for a subgroup of patients there is concern about their condition after discharge, and their tendency to forget the arrangements made for treatment after discharge from the hospital. So, additional strategies to the assessment in the hospital should be developed. In the Appendix, recommendations are given regarding development and implementation of guidelines for assessment and management of suicide attempters.The study reported in this thesis was performed at Rijnstate Hospital, Arnhem, The Netherlands and was made possible by a grant from ‘Maatschap Psychiaters Alysis’. The publication was financially supported by Rijnstate Hospital, Arnhem, The Netherlands and the Dutch Federation for General Hospital Psychiatry.UBL - phd migration 201

Clinical predictors of seizure threshold in electroconvulsive therapy: a prospective study

At the start and during the course of electroconvulsive therapy (ECT), estimation of the seizure threshold (ST) is useful in weighing the expected effectiveness against the risks of side effects. Therefore, this study explores clinical factors predicting initial ST (IST) and levels of ST during the ECT course. This prospective observational study included patients aged ≥18 years receiving ECT without contraindications for dose titration. At the first and every sixth consecutive ECT session, ST level was measured. Using multivariate linear regression and multilevel models, predictors for IST and change in ST levels were examined. A total of 91 patients (mean age, 59.1 ± 15.0 years; 37 % male; 97 % diagnosis of depression) were included. In multivariable analysis, higher age (β = 0.24; P = 0.03) and bifrontotemporal (BL) electrode placement (β = 0.42; P < 0.001) were independent predictors for higher IST, explaining 49 % of its variation. Also, these two variables independently predicted higher ST levels at different time points during the course. Using multilevel models, absence of a previous ECT course(s) predicted a steeper rise in ST during the course (P = 0.03 for the interaction term time*previous ECT). The age-adjusted dose-titration method is somewhat crude, resulting in some measurement error. Concomitant medication use could have influenced ST levels. Increasing age and BL electrode placement predicted higher (I)ST, which should be taken into account when selecting ECT dosage. Previous ECT course(s) may avoid an increase in ST during the course of ECT

Factors influencing the admission decision for Medical Psychiatry Units: A concept mapping approach

Objective Medical Psychiatry Units (MPUs), also known as Complexity Intervention Units (CIUs), provide care for complex patients suffering from both psychiatric and physical disorders. Because there is no consensus on the indications for admission to an MPU, daily practice and effectiveness research are hampered. This study therefore used a concept mapping approach to investigate which organizational and medical factors determine the decision to admit a patient to an MPU. Methods The first step of the concept mapping approach was to create a list of factors determining MPU admission from literature. Secondly, clinical experts sorted and ranked these factors. The sorted and ranked data were then analyzed, and a draft conceptual framework was created. A final conceptual MPU admission framework was then drawn during an expert consensus meeting and recommendations for implementation were suggested. Results Thirteen clinical experts defined 90 factors from literature, which were sorted and ranked by 40 experts from 21 Dutch hospitals. This concept mapping approach resulted in a five-cluster solution for an MPU admission framework based on: 1. Staff competencies and organizational pre-requisites; 2. Patient context; 3. Patient characteristics; 4. Medical needs and capabilities; and 5. Psychiatric symptoms and behavioral problems. Furthermore, three inclusion and two exclusion criteria were formulated to help the clinicians decide whether or not to admit patients to an MPU. These criteria can be implemented in daily practice. Conclusion Implementing the five criteria derived from this conceptual framework will help make the admission decision for complex patients with psychiatric and physical disorders to an MPU more correct, consistent, and transparent

Don't forget : contributions to the assessment and management of suicide attempters in the general hospital

The aim of this thesis was to contribute to better care for suicide attempters by studying several aspects of their assessment and management. In the first part of the thesis, the role of guidelines was studied resulting in suggestions for improvement. In the second part, the role of factors is studied that, as experience in clinical practice suggests may hamper proper assessment and management. From the studies in part 1, it was concluded that the available evidence suggests that guidelines for the assessment and management of suicide attempters differ to a large extent with respect to their content, that only a minority can be recommended based on an evaluation of their quality, and that they are probably not implemented properly. This leads to a plea to update the Dutch guideline, made 15 years ago, and to develop procedures that may promote implementation. From the studies of part 2, it was concluded that professionals should be alert on patients forgetting relevant aspects of the assessment. Furthermore, although a systematic assessment in the hospital is comparable to a reassessment at home, for a subgroup of patients there is concern about their condition after discharge, and their tendency to forget the arrangements made for treatment after discharge from the hospital. So, additional strategies to the assessment in the hospital should be developed. In the Appendix, recommendations are given regarding development and implementation of guidelines for assessment and management of suicide attempters

Similar representations of sequence knowledge in young and older adults: A study of effector independent transfer

Older adults show reduced motor performance and changes in motor skill development. To better understand these changes, we studied differences in sequence knowledge representations between young and older adults using a transfer task. Transfer, or the ability to apply motor skills flexibly, is highly relevant in day-to-day motor activity and facilitates generalization of learning to new contexts. By using movement types that are completely unrelated in terms of muscle activation and response location, we focused on transfer facilitated by the early, visuospatial system.We tested 32 right-handed older adults (65 – 74) and 32 young adults (18 – 30). During practice of a discrete sequence production task, participants learned two 6-element sequences using either unimanual key-presses (KPs) or by moving a lever with lower arm flexion-extension (FE) movements. Each sequence was performed 144 times. They then performed a test phase consisting of familiar and random sequences performed with the type of movements not used during practice. Both age groups displayed transfer from FE to KP movements as indicated by faster performance on the familiar sequences in the test phase. Only young adults transferred their sequence knowledge from KP to FE movements. In both directions, the young showed higher transfer than older adults. These results suggest that the older participants, like the young, represented their sequences in an abstract visuospatial manner. Transfer was asymmetric in both age groups: there was more transfer from FE to KP movements than vice versa. This similar asymmetry is a further indication that the types of representations that older adults develop are comparable to those that young adults develop. We furthermore found that older adults improved less during FE practice, gained less explicit knowledge, displayed a smaller visuospatial working memory capacity and had lower processing speed than young adults. Despite the many differences between young and older adults, the ability to apply sequence knowledge in a flexible way appears to be partly preserved in older adults

MRI characteristics predicting seizure threshold in patients undergoing electroconvulsive therapy: a prospective study

BACKGROUND: In electroconvulsive therapy (ECT), the electrical current must pass the scalp, skull, cerebrospinal fluid (CSF) and brain tissues, to sufficiently exceed the seizure threshold (ST). OBJECTIVE: To investigate the relationship between these anatomical strata of the head and the level of the ST, in both right unilateral (RUL) and bifrontotemporal (BL) ECT. METHODS: Observational prospective study among 74 mainly depressed patients. STs were measured at the 1st (initial ST), 6th, 12th, 18th and 24th session. MRI scans were acquired before the 1st session. Scalp and skull thickness at electrode sites were measured on T2-weighted images. Volumes of intracranial space (ICV), CSF, gray and white matter, and white matter hyperintensities were estimated using whole brain isovoxel T1-weighted images. Separate multivariate regression analyses for RUL (n = 55) and BL (n = 19) treated groups were used to estimate the predictive values of the MRI variables. RESULTS: The patients had a mean age of 57.7 ± 14.8 years, and 39% were men. After adjustment for age, gender and ICV, CSF volume strongly and independently predicted initial ST in both RUL (β = 0.31; P = 0.049) and BL ECT (β = 0.64; P = 0.007). Using multilevel regression analysis, CSF volume was associated with ST during the remaining RUL ECT course (β = 0.20; P = 0.02). CONCLUSIONS: Taking into account the limitations in the titration method and MRI analysis, volume of CSF strongly and independently predicted initial ST. Therefore, the exclusive use of age-based ECT dosing methods may result in suboptimal electrical stimulus dosage in patients with CSF volumes that are not within the average range

Improving the application of a practice guideline for the assessment and treatment of suicidal behavior by training the full staff of psychiatric departments via an e-learning supported Train-the-Trainer program:study protocol for a randomized controlled

<p>Background: In 2012, in The Netherlands a multidisciplinary practice guideline for the assessment and treatment of suicidal behavior was issued. The release of guidelines often fails to change professional behavior due to multiple barriers. Structured implementation may improve adherence to guidelines. This article describes the design of a study measuring the effect of an e-learning supported Train-the-Trainer program aiming at the training of the full staff of departments in the application of the guideline. We hypothesize that both professionals and departments will benefit from the program.</p><p>Method: In a multicenter cluster randomized controlled trial, 43 psychiatric departments spread over 10 regional mental health institutions throughout The Netherlands will be clustered in pairs with respect to the most prevalent diagnostic category of patients and average duration of treatment. Pair members are randomly allocated to either the experimental or the control condition. In the experimental condition, the full staff of departments, that is, all registered nurses, psychologists, physicians and psychiatrists (n = 532, 21 departments) will be trained in the application of the guideline, in a one-day small interactive group Train-the-Trainer program. The program is supported by a 60-minute e-learning module with video vignettes of suicidal patients and additional instruction. In the control condition (22 departments, 404 professionals), the guideline shall be disseminated in the traditional way: through manuals, books, conferences, internet, reviews and so on. The effectiveness of the program will be assessed at the level of both health care professionals and departments.</p><p>Discussion: We aim to demonstrate the effect of training of the full staff of departments with an e-learning supported Train-the-Trainer program in the application of a new clinical guideline. Strengths of the study are the natural setting, the training of full staff, the random allocation to the conditions, the large scale of the study and the willingness of both staff and management to participate in the study.</p>

MRI Characteristics Predicting Seizure Threshold in Patients Undergoing Electroconvulsive Therapy: A Prospective Study

Stress-related psychiatric disorders across the life spa