Natural environments and suicide mortality in the Netherlands: a cross-sectional, ecological study

Background: Natural outdoor environments, such as green spaces (ie, grass, forests, or parks), blue spaces (ie, visible bodies of fresh or salt water), and coastal proximity, have been increasingly shown to promote mental health. However, little is known about how and the extent to which these natural environments are associated with suicide mortality. Our aim was to investigate whether the availability of green space and blue space within people's living environments and living next to the coast are protective against suicide mortality. Methods: In this cross-sectional, ecological study, we analysed officially confirmed deaths by suicide between 2005 and 2014 per municipality in the Netherlands. We calculated indexes to measure the proportion of green space and blue space per municipality and the coastal proximity of each municipality using a geographical information system. We fitted Bayesian hierarchical Poisson regressions to assess associations between suicide risk, green space, blue space, and coastal proximity, adjusted for risk and protective factors. Findings: Municipalities with a large proportion of green space (relative risk 0·879, 95% credibility interval 0·779–0·991) or a moderate proportion of green space (0·919, 0·846–0·998) showed a reduced suicide risk compared with municipalities with less green space. Green space did not differ according to urbanicity in relation to suicide. Neither blue space nor coastal proximity was associated with suicide risk. The geographical variation in the residual relative suicide risk was substantial and the south of the Netherlands was at high risk. Interpretation: Our findings support the notion that exposure to natural environments, particularly to greenery, might have a role in reducing suicide mortality. If confirmed by future studies on an individual level, the consideration of environmental exposures might enrich suicide prevention programmes

What proportion of initially prescribed antidepressants is still being prescribed chronically after 5 years in general practice? A longitudinal cohort analysis

Objectives Antidepressant prescribing almost doubled in the Netherlands between 1996 and 2012, which could be accounted for by longer continuation after the first prescription. This might be problematic given a growing concern of large-scale antidepressant dependence. We aimed to assess the extent and determinants of chronic antidepressant prescribing among patient aged 18 years and older. We hypothesise a relatively large prevalence of chronic (&gt;2 years) prescription.Design A longitudinal observational study based on routinely registered prescription data from general practice.Setting 189 general practices in the Netherlands.Participants 326 025 patients with valid prescription data for all 5 years of the study.Outcome measures Primary outcome measure: the number of patients (N) receiving at least four antidepressant prescriptions in 2011, as well as during each of the four subsequent years. Secondary outcome measure: the above, but specified for selective serotonin reuptake inhibitors and for tricyclic antidepressants.Results Antidepressants were prescribed to almost 7% of our 326 025 participants each year. They were prescribed for depression (38%), anxiety (17%), other psychological disorders (20%) and non-psychological indications (25%). Antidepressants were prescribed in all 5 years to the 42% of the population who had at least four prescriptions dispensed in 2011. Chronic prescribing was higher among women than men, for those aged 45-64 years than for those aged &gt; 65 years and for those treated for depression or anxiety than for non-psychological indications (eg, neuropathic pain). Chronic prescribing also varied markedly among general practices.Conclusion Chronic antidepressant use is common for depression and for anxiety and non-psychological diagnoses. Once antidepressants have been prescribed, general practitioners and other prescribers should be aware of the risks associated with long-term use and should provide annual monitoring of the continued need for therapy.</p

An e-learning supported Train-the-Trainer program to implement a suicide practice guideline. Rationale, content and dissemination in Dutch mental health care

AbstractAn e-learning supported Train-the-Trainer program was developed to implement the Dutch suicide practice guideline in mental health care. Literature on implementation strategies has been restricted to the final reporting of studies with little opportunity to describe relevant contextual, developmental and supporting work that would allow for a better interpretation of results and enhance the likelihood of successful replication of interventions. Therefore, in this paper we describe the theoretical and empirical background, the material and practical starting points of the program. We monitored the number of professionals that were trained during and after a cluster randomized trial in which the effects of the program have been examined.Each element of the intervention (Train-the-Trainer element, one day face-to-face training, e-learning) is described in detail. During the trial, 518 professionals were trained by 37 trainers. After the trial over 5000 professionals and 180 gatekeepers were trained. The e-learning module for trainees is currently being implemented among 30 mental health care institutions in The Netherlands.These results suggest that an e-learning supported Train-the-Trainer program is an efficient way to uptake new interventions by professionals. The face-to-face training was easily replicable so it was easy to adhere to the training protocol. E-learning made the distribution of the training material more viable, although the distribution was limited by problems with ICT facilities. Overall, the intervention was well received by both trainers and trainees. By thoroughly describing the material and by offering all training materials online, we aim at further dissemination of the program

Involving patients and families in the analysis of suicides, suicide attempts, and other sentinel events in mental healthcare: A qualitative study in The Netherlands

Involving patients and families in mental healthcare is becoming more commonplace, but little is known about how they are involved in the aftermath of serious adverse events related to quality of care (sentinel events, including suicides). This study explores the role patients and families have in formal processes after sentinel events in Dutch mental healthcare. We analyzed the existing policies of 15 healthcare organizations and spoke with 35 stakeholders including patients, families, their counselors, the national regulator, and professionals. Respondents argue that involving patients and families is valuable to help deal with the event emotionally, provide additional information, and prevent escalation. Results indicate that involving patients and families is only described in sentinel event policies to a limited extent. In practice, involvement consists mostly of providing aftercare and sharing information about the event by providers. Complexities such as privacy concerns and involuntary admissions are said to hinder involvement. Respondents also emphasize that involvement should not be obligatory and stress the need for patients and families to be involved throughout the process of treatment. There is no one-size-fits-all strategy for involving patients and families after sentinel events. The first step seems to be early involvement during treatment process itself

The effect of an e-learning supported Train-the-Trainer program on implementation of suicide guidelines in mental health care.

AbstractBackgroundRandomized studies examining the effect of training of mental health professionals in suicide prevention guidelines are scarce. We assessed whether professionals benefited from an e-learning supported Train-the-Trainer programme aimed at the application of the Dutch multidisciplinary suicide prevention guideline.Methods45 psychiatric departments from all over the Netherlands were clustered in pairs and randomized. In the experimental condition, all of the staff of psychiatric departments was trained by peers with an e-learning supported Train-the-Trainer programme. Guideline adherence of individual professionals was measured by means of the response to on-line video fragments. Multilevel analyses were used to establish whether variation between conditions was due to differences between individual professionals or departments.ResultsMultilevel analysis showed that the intervention resulted in an improvement of individual professionals. At the 3 month follow-up, professionals who received the intervention showed greater guideline adherence, improved self-perceived knowledge and improved confidence as providers of care than professionals who were only exposed to traditional guideline dissemination. Subgroup analyses showed that improved guideline adherence was found among nurses but not among psychiatrists and psychologists. No significant effect of the intervention on team performance was found.LimitationsThe ICT environment in departments was often technically inadequate when displaying the video clips clip of the survey. This may have caused considerable drop-out and possibly introduced selection bias, as professionals who were strongly affiliated to the theme of the study might have been more likely to finish the study.ConclusionsOur results support the idea that an e-learning supported Train-the-Trainer programme is an effective strategy for implementing clinical guidelines and improving care for suicidal patients.Trial registrationNetherlands Trial Register (NTR3092 www.trialregister.nl)

Comparison of depression care provided in general practice in Norway and the Netherlands: registry-based cohort study (The Norwegian GP-DEP study)

Background Depression is highly prevalent in general practice, and organisation of primary health care probably affects the provision of depression care. General practitioners (GPs) in Norway and the Netherlands fulfil comparable roles. However, primary care teams with a mental health nurse (MHN) supplementing the GP have been established in the Netherlands, but not yet in Norway. In order to explore how the organisation of primary mental care affects care delivery, we aimed to examine the provision of GP depression care across the two countries. Methods Registry-based cohort study comprising new depression episodes in patients aged ≥ 18 years, 2011–2015. The Norwegian sample was drawn from the entire population (national health registries); 297,409 episodes. A representative Dutch sample (Nivel Primary Care Database) was included; 27,362 episodes. Outcomes were follow-up consultation(s) with GP, with GP and/or MHN, and antidepressant prescriptions during 12 months from the start of the depression episode. Differences between countries were estimated using negative binomial and Cox regression models, adjusted for patient gender, age and comorbidity. Results Patients in the Netherlands compared to Norway were less likely to receive GP follow-up consultations, IRR (incidence rate ratio) = 0.73 (95% confidence interval (CI) 0.71–0.74). Differences were greatest among patients aged 18–39 years (adj IRR = 0.64, 0.63–0.66) and 40–59 years (adj IRR = 0.71, 0.69–0.73). When comparing follow-up consultations in GP practices, including MHN consultations in the Netherlands, no cross-national differences were found (IRR = 1.00, 0.98–1.01). But in age-stratified analyses, Dutch patients 60 years and older were more likely to be followed up than their Norwegian counterparts (adj IRR = 1.21, 1.16–1.26). Patients in the Netherlands compared to Norway were more likely to receive antidepressant drugs, adj HR (hazard ratio) = 1.32 (1.30–1.34). Conclusions The observed differences indicate that the organisation of primary mental health care affects the provision of follow-up consultations in Norway and the Netherlands. Clinical studies are needed to explore the impact of team-based care and GP-based care on the quality of depression care and patient outcomes.publishedVersio

Entrapment and suicide risk: the development of the 4-item Entrapment Scale Short-Form (E-SF)

Evidence suggests that suicidal behaviour arises from one's attempt to escape from unbearable situations or unbearable thoughts and feelings. These feelings of entrapment are usually assessed via the 16-item Entrapment Scale, but this is too long for routine use in clinical practice. The aim of this study was to develop a brief version of the full scale that reliably assesses entrapment. We used data collected from a clinical sample (n = 497) of patients following hospital-treated self-harm and a population-based sample (n = 3457) of young adults. Four items were selected that had both the highest factor loading and discriminatory parameters and that covered the theoretical constructs of internal and external entrapment. Correlations between the 4-item short-form and the 16-item full scale were nearly perfect (0.94 for the clinical sample, 0.97 for the population-based sample). When comparing the correlations between the short-form and the full scale with other clinical and psychological scales, the correlations were nearly identical. The 4-item Entrapment Scale Short-Form (E-SF) will provide very comparable information about entrapment for each respondent as the full scale will do. However, its brevity will increase the likelihood that the assessment of entrapment will be implemented into everyday clinical practice

Predicting future suicidal behaviour in young adults, with different machine learning techniques: a population-based longitudinal study

Background: The predictive accuracy of suicidal behaviour has not improved over the last decades. We aimed to explore the potential of machine learning to predict future suicidal behaviour using population-based longitudinal data. Method: Baseline risk data assessed within the Scottish wellbeing study, in which 3508 young adults (18-34 years) completed a battery of psychological measures, were used to predict both suicide ideation and suicide attempts at one-year follow-up. The performance of the following algorithms was compared: regular logistic regression, K-nearest neighbors, classification tree, random forests, gradient boosting and support vector machine. Results: At one year follow up, 2428 respondents (71%) finished the second assessment. 336 respondents (14%) reported suicide ideation between baseline and follow up, and 50 (2%) reported a suicide attempt. All performance metrics were highly similar across methods. The random forest algorithm was the best algorithm to predict suicide ideation (AUC 0.83, PPV 0.52, BA 0.74) and the gradient boosting to predict suicide attempt (AUC 0.80, PPV 0.10, BA 0.69). Limitations: The number of respondents with suicidal behaviour at follow up was small. We only had data on psychological risk factors, limiting the potential of the more complex machine learning algorithms to outperform regular logistical regression. Conclusions: When applied to population-based longitudinal data containing multiple psychological measurements, machine learning techniques did not significantly improve the predictive accuracy of suicidal behavior. Adding more detailed data on for example employment, education or previous health care uptake, might result in better performance of machine learning over regular logistical regression

Internet-delivered interventions for personality disorders - A scoping review

Background: Personality disorders (PDs) form a substantial part of the mental health disease burden. Effective therapies to treat PDs exist, but they are time-consuming, costly, and difficult to scale up. Delivery through the internet could facilitate the scalability of effective treatment methods.Objective: This review summarizes existing evidence on internet-delivered psychotherapy for personality disorders.Methods: Because few randomized controlled trials (RCTs) have been carried out, we conducted a scoping review. We performed a systematic literature search in PubMed, Embase, MEDLINE, CINAHL, PsycInfo, and Cochrane. Studies were selected if they conveyed research findings on internet-delivered PD interventions.Results: Eleven studies were included. The majority (n = 8) focused specifically on borderline personality disorder (BPD) and the other three on PD in general. The most frequently used form of intervention (n = 7) was the addition of a mobile app to a conventional evidence-based face-to-face treatment such as dialectical behavioral therapy (DBT). Most interventions (n = 8) were still in the development and piloting phase; only two RCTs were found. Usability and patient satisfaction were moderate to high in all studies. Three studies demonstrated significant decreases in borderline personality disorder symptoms.The majority of the studies found were pilot or feasibility studies, most involving mobile apps offered in addition to face-to-face treatment. The add-ons were rated feasible, acceptable, and useful by patients. Reported challenges involved technical difficulties such as programming errors and bugs. Only 45% of the included studies reported on changes in PD symptoms, all showing reduction of symptoms and absence of adverse effects.Conclusions: This scoping review found that internet interventions for PD are still under-researched, although initial outcomes show promise. The outcomes also encourage future research in terms of developing internet interventions as an add-on to existing treatments, as well as working toward the creation and testing of more encompassing internet-delivered treatments for PD.</p

Who didn't consult the doctor? Understanding sociodemographic factors in relation to health care uptake before suicide

Objective: This study aimed to establish differences between suicide decedents and a reference population across various health care settings.Methods: This population-wide registration study combined death statistics, sociodemographic data and health care data from Statistics Netherlands. From 2010 to 2016, 12,015 suicide cases and a random reference group of 132,504 were included and assigned to one of the three health care settings; mental health (MH) care, primary care or no care. Logistic regression analyses were performed to determine differences in suicide risk factors across settings.Results: In the 1–2 year period before suicide, 52% of the suicide decedents received MH care, 41% received GP care only and 7% received neither. Although sociodemographic factors showed significant differences across settings, the suicide risk profiles were not profoundly distinctive. A decreasing trend in suicide risk across health care settings became apparent for male gender, income level and being in a one-person or one-parent household, whereas for other factors (middle and older age, non-Western migration background, couples without children and people living in more sparsely populated areas), risk of suicide increased when health care setting became more specialized.Limitations: Because of the data structure, 18 months of suicide decedents’ health care use were compared with two years health care use of the reference group, which likely led to an underestimation of the reported differences.Conclusion: Although there are differences between suicide decedents and a reference group across health care settings, these are not sufficiently distinctive to advocat