Background. – Antidepressants are frequently prescribed in patients with psychotic disorders, but little is known about their effects in routine clinical practice. The objective was to investigate the prescribing patterns of antidepressants in relation to the course of depressive symptoms in patients with psychotic disorders. Methods. – A cohort of 214 Dutch patients with psychotic disorders received two assessments of somatic and psychiatric health, including a clinician-rated screening for depressive symptoms, as part of annual routine outcome monitoring. Results. – Depressive symptoms were prevalent among 43% (93) of the patients. Antidepressants were prescribed for 40% (86) of the patients and the majority 83% (71) continued this therapy after one year. Multivariable analysis showed that patients with more severe psychopathology had a higher risk to develop depressive symptoms the following year (OR [95% CI] = 0.953 [0.912–0.995]). For patients with depressive symptoms at baseline, polypharmacy was a potential risk factor to keep having depressive symptoms (OR [95% CI] = 1.593 [1.123–2.261]). Antidepressant use was not an independent predictor in both analyses. Conclusions. – Routine outcome monitoring in patients with psychotic disorders revealed a high prevalence of depressive symptoms. Antidepressants were frequently prescribed and continued in routine clinical practice. 2010 Elsevier Masson SAS. All rights reserved. * Corresponding author. Tel.: +31 50 3638205; fax: +31 50 3632772. E-mail address: k.taxis@rug.nl (K. Taxis). 0924-9338/$ – see front matter 2010 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2010.10.007 describing the course of depressive symptoms do not report details of prescribing patterns of antidepressant therapy [4,12,35,39]. It is unclear how many patients with persistent depressive symptoms continue to use antidepressants or remain untreated with antidepressants. The current naturalistic study is based on a cohort of patients with schizophrenia or related psychotic disorders, assessed during yearly routine outcome measurements. The aim is to investigate the course of depressive symptoms in relation to prescribing patterns of antidepressants in schizophrenia during oneyear follow-up.

Background: Depressive symptoms require accurate recognition and monitoring in clinical practice of patients with schizophrenia.Depression instruments developed for use in depressed patients may not discriminate depressive symptoms from negative psychotic symptoms.Objective: We reviewed depression instruments on their reliability and validity in patients with schizophrenia.Methodology: A systematic literature search was carried out in three electronic databases.Psychometric properties were extracted for those instruments of which reliability, divergent, concurrent and predictive validity were reported in one or more publications.Results: Forty-eight publications described the reliability and validity of six depression instruments in patients with schizophrenia.The only self-report was the Beck Depression Inventory (BDI).The Brief Psychiatric Rating Scale-Depression subscale (BPRS-D), Positive and Negative Syndrome Scale-Depression subscale (PANSS-D), Hamilton Rating Scale for Depression (HAMD), Montgomery Asberg Depression Rating Scale (MADRS) and Calgary Depression Scale for Schizophrenia (CDSS) were clinician rated.All instruments were reliable for the measurement of depressive symptoms in patients with schizophrenia.The CDSS most accurately differentiated depressive symptoms from other symptoms of schizophrenia (divergent validity), correlated well with other depression instruments (concurrent validity), and was least likely to miss cases of depression or misdiagnose depression (predictive validity).Conclusions: We would recommend to use the CDSS for the measurement of depressive symptoms in research and in daily clinical practice of patients with schizophrenia.A valid selfreport instrument is to be developed for the use in clinical practice.

Samenvatting Oud MJT, Schuling J, Slooff CJ, Groenier KH, Dekker JH, Meyboom- de Jong B. Zorg voor psychotische patiënten: de taakopvatting van de huisarts. Huisarts Wet 2010;53(3):128-34. Achtergrond Patiënten die een psychose hebben doorgemaakt, hebben meer kans op lichamelijke ziekten maar zijn juist minder geneigd hulp te zoeken. Deze patiënten, maar ook hun familieleden, hebben daarom behoefte aan laagdrempelige steun van de huisarts. Wij wilden weten in hoeverre huisartsen bereid en in staat zijn de somatische, psychische en psychiatrische problemen van deze patiënten te monitoren en waar mogelijk te behandelen, en welke belemmeringen zij hierbij ervaren. Methode Wij stuurden aan een representatieve steekproef, bestaande uit 700 Nederlandse huisartsen, een lijst toe met 66 vragen. De vragen betroffen ‘Mening en taakopvattingen’, ‘Handelen en ervaringen’ en ‘Kenmerken van de huisarts en zijn praktijkorganisatie’. Resultaten Wij ontvingen 186 vragenlijsten (27%) ingevuld retour. De respondenten vonden dat de huisarts het eerste aanspreekpunt is bij een acute verwardheid en achtten zich daar in meerderheid redelijk toe in staat. Ook vonden zij dat het opsporen en behandelen van somatische comorbiditeit bij patiënten in de chronische of residuale fase tot hun kerntaken behoort, naast het verstrekken van steun en informatie aan de familie. In meerderheid bleken zij bereid om de lichamelijke gezondheid van chronisch psychiatrische patiënten periodiek te controleren. Huisartsopleiders en huisartsen met kleinere praktijken maakten vaker dan gemiddeld vervolgafspraken en waren ook vaker bereid de zelfzorg van deze patiënten te controleren. Wel vonden de respondenten dat de samenwerking met de tweedelijns ggz beter kan. Zij zouden graag meer erkenning krijgen voor hun rol als medebehandelaar. Conclusie Huisartsen zijn bereid en in staat hun aandeel te leveren in de zorg voor patiënten met psychotische stoornissen. Dat geldt niet alleen voor de eerste opvang bij een acute verwardheid, maar ook voor het opsporen en behandelen van bijwerkingen en lichamelijke klachten in de chronische fase. Wel is er behoefte aan gerichte nascholing en aan betere samenwerking met de tweede lijn.

Background: The prevalence of diabetes and other somatic co-morbidity is higher in patients with psychotic disorders than in the general population. Annual screening can detect diabetes early to prevent the progression of diabetes, prevent complications and improve the quality of life. This improvement can only be made if the screening leads to treatment of that patient. Aims of the Study: We determined the cost-effectiveness of somatic screening for diabetes in patients with psychotic disorders in a model. In a sample of outpatients the cost and benefits of screening and coordination of care are estimated. Methods: In the model costs were determined for the screening and treatment of detected diabetes cases. The savings and QALY weights due to prevention or postponement of complications was calculated by the model of the CDC Diabetes Cost-Effectiveness Study group. The cost per quality of life adjusted year (QALY) were determined. We compared in a group of psychiatric outpatients the difference between only screening on somatic comorbidity with screening and coordination of care based on screening results. Effects were measured in identified health needs and percentage met needs, costs were estimated based on health care consumption. Results: The cost for screening were €140.79 per patient. Based on literature data it was assumed that diabetes was detected five years earlier than without screening. Treatment cost for diabetes were €2483.60 for five years. Cost savings of €9629.60 and a gain of 0.24 QALY could be achieved through delay of complications for five years. Cost per QALY gained were below €20 000, the threshold generally used in The Netherlands, at an incidence of 1.2% in patients with psychotic disorders with an average age of 38 years. Preliminary results of the implementation of screening will be available March 2011. Conlcusion and Discussion: The screening of patients with psychotic disorders for diabetes is cost-effective. Indirect costs and savings were not included because of the large rate of unemployment in this patient group. The results on the intervention are preliminary results after a pilot study. Implications for Health Care Provision and Use: Annual screening for diabetes in patients with psychotic disorders should be implied in health care programs for patients with psychotic disorders, the way in which in should be implemented is not yet clear. Implications for Further Research: Further research should assess if the model of the CDC is valid for this population. Furthermore research should assess the implementation of preventive health services, like diabetes screening, in psychiatric care facilities.

Objective: The schizophrenia and other non-affective disorders categories listed in the DSM-IV, are currently under revision for the development of the fifth edition. The aim of the present study is to demonstrate the validity of these categories by investigating possible differences between diagnostic patient subgroups on various measures. Methods: 1064 patients with a diagnosis of non-affective psychosis (schizophrenia N = 731 (paranoid type 82%), schizoaffective N = 63, schizophreniform N = 120, psychosis not otherwise specified/brief psychotic disorder N = 150) participated in this study. Dependent variables were demographic and clinical characteristics, severity of psychopathology, premorbid and current functioning, and indicators of quality of life. Results: Within the diagnostic group of schizophrenia, no significant differences were observed between paranoid schizophrenia, disorganized, and undifferentiated schizophrenia. Patients with schizophrenia experienced more severe psychopathology and had poorer levels of current functioning compared to patients with psychosis not otherwise specified or brief psychotic disorder. Differences between schizophrenia and schizoaffective disorder were less clear. Conclusion: Our results do not support the validity of schizophrenia subtypes. Schizophrenia can be distinguished from brief psychotic disorder and psychotic disorder not otherwise specified. These findings may fuel the actual DSM-V discussion.

BACKGROUND:Negative symptoms in patients with schizophrenia predict a worse social outcome. The treatment options for negative symptoms are extremely limited. Various treatment strategies have been studied in which several types of medication were added to antipsychotics in order to alleviate negative symptoms. AIM:To review the types of medication that have been used to supplement antipsychotic treatment in order to alleviate negative symptoms in patients with schizophrenia. METHOD:By means of PubMed we were able to perform a systematic review of all randomised controlled trials and relevant meta-analyses published up to and including May 2009. RESULTS:The pharmacological mechanisms that were studied in connection with the treatment of negative symptoms were as follows: the modulation of the glutamate system, the modulation of the serotonergic system, the histaminergic system and the dopaminergic system and the influencing by means of antioxidants and hormones. Despite all the methodological problems the modulation of the glutamate system and the blocking of serotonin 5-HT-3/2a receptors may be able to bring about a limited reduction of negative symptoms. The therapeutic results of the pharmacological treatments studied which may be effective is only moderate. CONCLUSION:For the time being the pharmacological addition strategies do not lead us to recommend their use in current clinical practice but they can certainly serve as a basis for further research. medication, negative symptoms, schizophrenia.

BACKGROUND:Routine outcome monitoring (ROM) means the assessment of the patient's condition on a routine basis using instruments. So far there is no consensus about which instruments should be used for ROM with severely mentally ill patients (ROM-SMI).AIM:To reach a consensus about instruments for ROM-SMI in the Netherlands and Belgium and to create possibilities for comparison of ROM data.METHOD:This article discusses the consensus document of the National Remission Working Group for ROM in patients with smi and covers the following topics: reasons for ROM-SMI, domains for ROM-SMI and appropriate instruments, logistics and analyses of the data.RESULTS:Patients with SMI have problems in several domains. These can be assessed by collecting information about psychiatric symptoms, addiction, somatic problems, general functioning, needs, quality of life and care satisfaction. Potential instruments for ROM-SMI are short, valid, reliable and assess several domains, taking the patient's perspective into account, and have been used in national and international research. The working group advises institutions to choose from a limited set of instruments. After the scores have been aggregated and standardised, comparisons can be drawn. ROM-SMI data can be interpreted more meaningfully, if outcome data are supplemented with data regarding patient characteristics and the treatment interventions already applied.CONCLUSION:It should be possible to reach a consensus about instruments for ROM-SMI and the way in which they should be used. The use of identical instruments will lead to improvements in mental health care and create possibilities for comparison (benchmarking) and research.

BACKGROUND: Routine outcome monitoring (rom) means the assessment of the patient's condition on a routine basis using instruments. So far there is no consensus about which instruments should be used for rom with severely mentally ill patients (rom-smi). AIM: To reach a consensus about instruments for rom-smi in the Netherlands and Belgium and to create possibilities for comparison of rom data. METHOD: This article discusses the consensus document of the National Remission Working Group for rom in patients with smi and covers the following topics: reasons for rom-smi, domains for rom-smi and appropriate instruments, logistics and analyses of the data. results Patients with smi have problems in several domains. These can be assessed by collecting information about psychiatric symptoms, addiction, somatic problems, general functioning, needs, quality of life and care satisfaction. Potential instruments for rom-smi are short, valid, reliable and assess several domains, taking the patient's perspective into account, and have been used in national and international research. The working group advises institutions to choose from a limited set of instruments. After the scores have been aggregated and standardised, comparisons can be drawn. rom-smi data can be interpreted more meaningfully, if outcome data are supplemented with data regarding patient characteristics and the treatment interventions already applied. CONCLUSION: It should be possible to reach a consensus about instruments for romsmi and the way in which they should be used. The use of identical instruments will lead to improvements in mental health care and create possibilities for comparison (benchmarking) and research

Cross-sectional studies showed a high prevalence of metabolic syndrome in patients with schizophrenia.This study aimed to identify the incidence of metabolic syndrome and its reversal in a non-preselected cohort of chronic psychotic patients in routine practice in one year follow-up and to find variables to describe development and reversal of metabolic syndrome. This cohort study was conducted as part of a disease management program and patients were included if they had two complete assessments in a one year follow-up. We conducted two logistic regressions to find variables to describe the development of metabolic syndrome and the reversal of metabolic syndrome. At the time of the first assessment 35% (n=92) of the 260 included patients had metabolic syndrome. Within one year 21 patients developed metabolic syndrome and 30 patients had it reversed. This was an incidence of 13% (21/168) and a reversal of 33% (30/92). Smoking, family history of cardiovascular diseases, and duration of disease >6years was associated with a higher risk of developing metabolic syndrome as well as abdominal obesity and dyslipidemia. Patients with abdominal obesity had a smaller chance of reversing metabolic syndrome. Other variables included in the logistic regression such as receiving cardiovascular/antidiabetic drug treatment or duration of disease >6years did not alter the risk of reversing the metabolic syndrome. Our study showed that the natural course of metabolic syndrome is dynamic. A considerable number of patients developed or reversed the metabolic syndrome in one year follow-up.

Although it has been suggested that second-generation antipsychotics (SGA) may reduce the rate of prevalent tardive dyskinesia (TD), little is known about the incidence and outcome of TD in those exposed exclusively to SGA. The incidence and subsequent persistence of TD and extrapyramidal symptoms (EPS) was calculated in a cohort of patients with schizophrenia treated predominantly with SGA. This cohort of more than 10,000 patients with schizophrenia was seen six times over a period of two years. Dichotomous measures of EPS and TD were used to calculate the yearly incidence rates of TD and EPS as well as their subsequent cumulative persistence rate in a subset of 9104 and 6285 patients at risk for TD and EPS, respectively. Of 9104 individuals who did not present with TD at baseline, 138 developed TD, yielding a TD incidence rate of 0.74% (95% CI: 0.62, 0.87) and a subsequent cumulative persistence rate of 80%. Of 6285 individuals without EPS at baseline, 464 developed EPS yielding an incidence rate of 3.7% (95% CI: 3.4, 4.0) and a subsequent cumulative persistence rate of 82%. Incidence rates of TD and EPS may be low in the SGA era. However, once emerged, these disorders prove persistent, suggesting strong moderators effects of underlying predisposing factors.

BACKGROUND:Antipsychotics are effective drugs that are prescribed frequently for a large group of patients. However, they also have many side-effects which can lead ultimately to serious somatic complications. These complications fall into various categories: metabolic, cardiovascular, neurobiological, haematological, gastro-intestinal and urogenital.AIM:To make an inventory of the side-effects and advise on ways of monitoring and preventing them. method The multidisciplinary working group on somatic complications arising from the use of antipsychotics (Werkgroep Somatische Complicaties) has collected literature on the subject and has discussed it at a number of consensus meetings. results The most frequent somatic complications are described on the basis of specific risk profiles and advice is given on how to identify these complications and on how to treat them when necessary. It is essential to monitor, systematically and regularly, somatic complications arising from the use of antipsychotics; furthermore, polypharmacy should be avoided. The person ultimately responsible for this is the doctor who has prescribed the antipsychotics. In addition, it is important to draw patients' attention to the general rules for a healthy lifestyle: no smoking, a balanced diet and adequate exercise.CONCLUSION:It is very important that somatic complications should be monitored carefully and accurately. So far, the Netherlands has no official guidelines on ways to identify and treat somatic complications.