[Show abstract][Hide abstract] ABSTRACT: There is an increasing interest in cognitive-behavioural therapy (CBT) interventions targeting negative symptoms in schizophrenia. To date, CBT trials primarily focused on positive symptoms and investigated change in negative symptoms only as a secondary outcome. To enhance insight into factors contributing to improvement of negative symptoms, and to identify subgroups of patients that may benefit most from CBT directed at ameliorating negative symptoms, we reviewed all available evidence on these outcomes.
Psychological Medicine 05/2014; · 5.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Non-compliance with medication constitutes a large problem in medicine. Recently the results of a cluster randomised controlled trial were published in which financial incentives were offered to patients with psychotic disorders. The objective of this study was to test if financial incentives effectively improved adherence to maintenance treatment with depot antipsychotics. The financial incentives increased acceptance of depot medication but did not lead to any clinical benefits. Therefore, the implementation of contingency management using financial incentives is not yet desirable.
Nederlands tijdschrift voor geneeskunde 01/2014; 158(4):A7309.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND AND OBJECTIVES: The treatment of negative symptoms in schizophrenia is a major challenge for mental health care. One randomized controlled trial found that cognitive therapy for low-functioning patients reduced avolition and improved functioning, using an average of 50.5 treatment sessions over the course of 18 months. The aim of our current pilot study was to evaluate whether 20 sessions of Cognitive Behavioral Therapy for negative symptoms (CBT-n) would reduce negative symptoms within 6 months. Also, we wanted to test the cognitive model of negative symptoms by analyzing whether a reduction in dysfunctional beliefs mediated the effects on negative symptoms. METHOD: In an open trial 21 adult outpatients with a schizophrenia spectrum disorder with negative symptoms received an average of 17.5 sessions of CBT-n. At baseline and end-of-treatment, we assessed negative symptoms (PANSS) and dysfunctional beliefs about cognitive abilities, performance, emotional experience, and social exclusion. Bootstrap analysis tested mediation. RESULTS: The dropout rate was 14% (three participants). Intention-to-treat analyses showed a within group effect size of 1.26 on negative symptoms (t = 6.16, | Sig = 0.000). Bootstrap analysis showed that dysfunctional beliefs partially mediated the change. LIMITATIONS: The uncontrolled design induced efficacy biases. Also, the sample was relatively small, and there were no follow-up assessments. CONCLUSIONS: CBT-n may be effective in reducing negative symptoms. Also, patients reported fewer dysfunctional beliefs about their cognitive abilities, performance, emotional experience, and social exclusion, and this reduction partially mediated the change in negative symptoms. The reductions were clinically important. However, larger and controlled trials are needed.
Journal of Behavior Therapy and Experimental Psychiatry 02/2013; 44(3):300-306. · 2.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In a population of dually diagnosed patients receiving assertive community treatment we used the theoretical framework of the transtheoretical model to establish (a) the proportions and characteristics of patients who were not motivated for treatment for psychiatric symptoms and substance use, (b) the proportion of patients who moved towards behavioral change after about 1 year, and examine how this change was related with clinical outcome; and (c) the sequence of change processes. Chi square tests and T tests were used to compare the patient characteristics and outcomes of patients who remained in precontemplation with those who progressed. During follow-up, 47 % of the patients came out of the precontemplation phase for treatment of psychiatric symptoms and 38 % for substance use behavior. Those who remained in precontemplation benefited less from treatment. Of those who did move forward, most appeared to become motivated for psychiatric treatment before becoming motivated to reduce substance use.
Community Mental Health Journal 01/2013; · 1.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A significant proportion of clients with psychosis have experienced childhood trauma and suffer from
comorbid posttraumatic stress disorder. Research indicates that exposure to distressing early life events
plays an important role in the emergence and persistence of psychotic symptoms—either directly or
The Two Method Approach of EMDR conceptualization and recent findings on reprocessing
related imagery fit with the existing cognitive models of psychosis. This article presents
a series of preliminary guidelines for conceptualizing EMDR treatment in psychosis, which are based
on both theory and clinical experience and are illustrated with case examples. Several obstacles and
related treatment strategies for using EMDR in psychosis are described. EMDR in psychosis can very
well be combined with other standard interventions such as psychotropic medication and cognitive
Journal of EMDR Practice and Research 01/2013; 7(4):208-224.
[Show abstract][Hide abstract] ABSTRACT: Adherence interventions in psychotic disorders have produced mixed results. Even when an intervention improved adherence, benefits to patients were unclear. Treatment Adherence Therapy (TAT) also improved adherence relative to Treatment As Usual (TAU), but it had no effects on symptoms or quality of life. TAT may or may not reduce healthcare costs.
To determine whether TAT reduces the use of healthcare resources, and thus healthcare costs.
Randomized controlled trial of TAT versus TAU with 98 patients. Interviews were conducted at baseline (T0), six months later, when TAT had been completed (T1) and at six-month follow-up (T2). We have used admission data and part of the Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness (TiC-P). We compared total costs in the TAT group with those in the control group with the help of multivariate analysis of covariance.
TAT did not significantly minimize total costs. In the TAT group, the mean one-year health-treatment cost per patient (including TAT sessions) was € 23 003.64 (SD=19 317.95), whereas in the TAU group it was € 22 489.88 (SD=25 224.57) (F(1)=.652, p=.42). However, there were two significant differences at item-level, both with higher costs for the TAU group: psychiatric nurse contacts and legal proceedings for court-ordered admissions.
Because TAT did not reduce total healthcare costs, it did not contribute to cost-minimization. Its benefits are therefore questionable. No other adherence intervention has included analysis of cost-effectiveness or cost-minimization.
Schizophrenia Research 12/2011; 133(1-3):47-53. · 4.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: While lack of insight is often predictive of antipsychotic nonadherence, some inconsistency in the literature remains unexplained. Verbal memory deficits may moderate the association between insight and adherence. Based on cross-sectional data, outpatients treated with antipsychotics for a psychotic disorder were divided into those with good (n=53) and poor (n=59) memory. Poor insight predicted nonadherence only among the subgroup with relatively good memory (r=0.43; P<0.01), but had no effect in the subgroup with worse memory (r=0.08; ns). Structural equation modelling revealed significant moderation (χ=4.72; df=1; P<0.05), which means that a significantly better model fit was found by allowing the analysis to differentiate between the two memory groups. Thus, poor insight was only associated with poor medication adherence among patients with relatively good memory. We speculate that memory deficits commonly associated with schizophrenia may partly explain why poor insight does not always lead to poor medication adherence.
Journal of Psychiatric Practice 09/2011; 17(5):320-9. · 1.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We investigated whether Assertive Community Treatment (ACT) combined with Integrated Dual Diagnosis Treatment (IDDT) is associated with a decrease in nuisance acts and crime convictions in dual-diagnosis repeated offenders. Forty-three patients were monitored from 21 months before until 12 months after the start of ACT-IDDT, using police data and the Health of the Nation Outcome Scales (HoNOS). Results show that while nuisance acts and convictions increased in the 21 months before the start of ACT-IDDT, nuisance acts decreased and convictions stabilized during the next 12 months. The decrease in nuisance acts was associated with a decrease in substance abuse.
Community Mental Health Journal 05/2011; 48(2):150-2. · 1.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although people with schizophrenia use various coping strategies, it is largely unknown how their coping style contributes to remission of the illness. The concept of recovery style-either by sealing over or integrating-reflects an important distinction. We wanted to examine whether recovery style predicts remission at a 1-year follow-up. We examined the recovery style, insight, therapeutic alliance, and symptoms in 103 patients with psychotic disorders. To assess the remission status, the symptoms were measured at 6 and 12 months. Logistic regression analyses were used. Results showed that scoring an extra category toward integration (six categories exist) increased the odds of remission 1.84-fold (95% confidence interval, 1.11 to 3.03). Insight and therapeutic alliance were not predictive. Although remission was also predicted by positive symptom levels at baseline, this did not influence the effect of recovery style. In conclusion, independently of symptom levels, insight, or therapeutic alliance, an integrating recovery style increases the odds of remission at a 1-year follow-up.
The Journal of nervous and mental disease 05/2011; 199(5):295-300. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To compare the effects of 'Treatment adherence therapy' (TAT) with standard treatment on treatment adherence, symptoms, quality of life, and the number of voluntary or involuntary admissions in patients with a psychotic disorder. TAT is a new treatment that takes into account individual reasons for non-adherence per patient. DESIGN: A randomised controlled trial (RCT) among 109 out-patients who were did not comply well with treatment. This RCT is registered in the Dutch Trial Registry: NTR1159. METHOD: Tests were conducted to assess treatment adherence, symptoms and quality of life before intervention (t0), immediately following 6 months of intervention (t1), and after another 6 months follow-up (t2). These were predominantly performed by blinded interviewers. An 'intention-to-treat' multivariate analysis was used. RESULTS: In comparison with standard treatment TAT had a significantly more beneficial effect on medication adherence (Cohen's d = 0.43) and on treatment compliance (Cohen's d = 0.48). Results for medication adherence remained significant at 6-month follow-up. A trend was also found regarding involuntary admissions (1.9% versus 11.8%). Psychiatric symptoms and quality of life did not improve. CONCLUSION: Treatment Adherence Therapy (TAT) improved treatment adherence, and may have prevented involuntary admissions.
Nederlands tijdschrift voor geneeskunde 01/2011; 155(18):A3135.
[Show abstract][Hide abstract] ABSTRACT: Interventions to improve adherence to treatment in people with psychotic disorders have produced inconclusive results. We developed a new treatment, treatment adherence therapy (TAT), whose intervention modules are tailored to the reasons for an individual's non-adherence.
To examine the effectiveness of TAT with regard to service engagement and medication adherence in out-patients with psychotic disorders who engage poorly.
Randomised controlled study of TAT v. treatment as usual (TAU) in 109 out-patients. Most outcome measurements were performed by masked assessors. We used intention-to-treat multivariate analyses (Dutch Trial Registry: NTR1159).
Treatment adherence therapy v. TAU significantly benefited service engagement (Cohen's d = 0.48) and medication adherence (Cohen's d = 0.43). Results remained significant at 6-month follow-up for medication adherence. Near-significant effects were also found regarding involuntary readmissions (1.9% v. 11.8%, P = 0.053). Symptoms and quality of life did not improve.
Treatment adherence therapy helps improve engagement and adherence, and may prevent involuntary admission.
The British journal of psychiatry: the journal of mental science 12/2010; 197(6):448-55. · 6.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Non-adherence to antipsychotic medication is common and increases the risk of psychotic relapse. A promising intervention may be a strategy wherein financial incentives are offered.
In a pilot study in The Netherlands, five patients with schizophrenia were offered financial incentives for a duration of one year to improve adherence to medication. Adherence and hospital days were measured.
The percentage of accepted depot injections increased from an average of 44% in the previous year to 100% in the year when financial incentives were offered. While patients had been hospitalised for an average of 100.2 days in the previous year, only one was re-admitted for 17 days during the year of the intervention.
The differences in adherence before and after the intervention were large and of clinical significance. However, randomised controlled trials are required to provide conclusive evidence on the effectiveness of offering financial incentives and potential consequences.
[Show abstract][Hide abstract] ABSTRACT: Samenvatting In dit artikel wordt geschetst hoe postpsychotische demoralisatie en zelfstigmatisatie bij patiënten met schizofrenie te
behandelen. Dit wordt geplaatst in de context van een cognitief model van demoralisatie. Hierbij ligt de nadruk op overdreven
negatieve verwachtingen omtrent de eigen capaciteiten en sociale acceptatie. Deze verwachtingen vinden hun basis in de verliezen
en cognitieve achteruitgang die patiënten hebben ondergaan, maar zijn desalniettemin vaak onrealistisch en werken vermijding
en inactiviteit in de hand. Twee patiënten worden beschreven. Beiden hebben ziektebesef en ziekte-inzicht, maar zitten vast
in een toestand van demoralisatie met zelfstigmatiserende ideeën. Bij beide patiënten werd vooruitgang geboekt door creatief
cognitief-gedragstherapeutische technieken toe te passen. Het doel was niet herstel tot hun oorspronkelijk niveau van functioneren,
maar om ze te helpen bij het doorbreken van isolatie en inactiviteit.
Abstract In this article a treatment is presented for post-psychotic demoralisation and self-stigmatization in patients with schizophrenia.
This is placed within the context of a cognitive model of demoralisation. Its focus is on patients’ negative expectations
concerning their capabilities and social exclusion. These expectations are based on experiences of loss, shame and cognitive
deterioration. Yet, they are often unrealistic and lead to avoidance and inactivity. The treatments of two patients are described.
Both have insight into their illness, but are trapped in a state of demoralisation and self-stigmatizing thought patterns.
In both patients, progress was achieved by creatively using cognitive behavioural techniques. The goal was not to restore
the patients to their old level of functioning, but rather to help them overcome isolation and inactivity.
[Show abstract][Hide abstract] ABSTRACT: Samenvatting In dit artikel beschrijven wij drie interacties tussen trauma, psychose en PTSS:
Veel patiënten met psychosen hebben in hun leven traumatiserende ervaringen meegemaakt. Deze traumata spelen vaak een belangrijke
rol in hun psychosen en in het ontstaan hiervan.
Het meemaken van een psychose en de psychiatrische behandeling zijn voor veel patiënten levensechte en traumatische ervaringen,
die kunnen leiden tot posttraumatische stressklachten.
Vaak komen psychosen en een posttraumatische stressstoornis gezamenlijk voor, waarbij er sprake is van negatieve wederzijdse
beïnvloeding en voortgaande traumatisering.
Deze drie interacties hebben een hoge klinische relevantie. Er is in de praktijk van de zorg voor patiënten met psychosen
echter weinig aandacht voor traumatisering en comorbide PTSS. Eye Movement Desensitization and Reprocessing (EMDR) is een
behandelmethode die effectief is bij de behandeling van traumata en PTSS. Wij beschrijven per genoemde interactie een behandeling
waarbij EMDR is ingezet. Daarna bespreken wij een aantal factoren die een EMDR-behandeling bij patiënten met psychosen kunnen
bemoeilijken, zoals doorlopende traumatisering door psychotische klachten, cognitieve beperkingen, moeite met oogbewegingen,
belemmeringen door antipsychotische medicatie en verminderde affectieve expressie. Wij sluiten het artikel af met het advies
om in de zorg voor mensen met psychosen aandacht te hebben voor trauma en comorbide PTSS, en patiënten hier ook voor te behandelen.
Abstract In this article we describe three interactions between trauma, psychosis and PTSD:
Many patients suffering from psychosis have been traumatized. This trauma often plays an important role in their psychosis
and the onset thereof.
Having a psychosis and being treated in a psychiatric hospital are traumatic experiences for a lot of patients, and can lead
to posttraumatic stress symptoms; and
Often psychoses and post-traumatic stress disorder occur jointly, reciprocally influencing one another and leading to ongoing
These interactions have a great clinical relevance. In the practice of care for patients with psychosis however there is little
attention for traumatization and co-morbid PTSD. EMDR is a treatment approach that is effective in treating traumas and PTSD.
Per interaction mentioned above we describe a treatment in which EMDR was used. After this we discuss certain factors that
may complicate an EMDR treatment in patients with psychosis, such as ongoing traumatization by psychotic symptoms, cognitive
impairments, difficulty with eye movements, barriers due to anti-psychotic medication, and diminished emotional expression.
We end the article with the advise to be aware of the high prevalence of trauma and co-morbid PTSD in the care for patients
with psychosis and to treat patients for these complaints.
[Show abstract][Hide abstract] ABSTRACT: ObjectivePatients with severe mental illness who are treated in assertive community treatment (ACT) teams are sometimes involuntarily
admitted when they are dangerous to themselves or others, and are not motivated for treatment. However, the consequences of
involuntary admission in terms of psychosocial outcome and treatment motivation are largely unknown. We hypothesized that
involuntary admission would improve psychosocial outcome and not adversely affect their treatment motivation.
MethodsIn the context of routine 6-monthly outcome monitoring in the period January 2003–March 2008, we used the Health of the Nation
Outcome Scales (HoNOS) and a motivation-for-treatment scale to assess 260 severely mentally ill patients at risk for involuntary
admission. Mixed models with repeated measures were used for data analyses.
ResultsDuring the observation period, 77 patients (30%) were involuntarily admitted. Relative to patients who were not involuntarily
admitted, these patients improved significantly in HoNOS total scores (F=17,815, df=1, p<0.001) and in motivation for treatment (F=28.139, df=1, p<0.001). Patients who were not involuntarily admitted had better HoNOS and motivation scores at baseline, but did not improve.
ConclusionsInvoluntary admission in the context of ACT was associated with improvements in psychosocial outcome and motivation for treatment.
There are no indications that involuntary admission leads to deterioration in psychosocial outcome or worsening of motivation
Social Psychiatry and Psychiatric Epidemiology 01/2010; 45(2):245-252. · 2.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Good insight into illness in patients with schizophrenia is related not only to medication compliance and high service engagement, but also to depression, low self-esteem, and low quality of life. The detrimental effects of insight pose a problem for treatment.
To investigate whether the negative associations of good insight are moderated by perceived stigma.
Respondents were 114 patients with schizophrenia spectrum disorders. We used Analyses of Variance (ANOVA) and Structural Equation Modeling (SEM) to test moderation.
Good insight was associated with high service engagement and high compliance. Also, good insight was associated with depressed mood, low quality of life, and negative self-esteem. This association was strong when stigma was high and weak when stigma was low. SEM showed that the constrained model performed significantly worse than the unconstrained model, in which detrimental associations of insight were free to vary across stigma groups (chi(2)=19.082; df=3; p<.001).
Our results suggest that the associations of insight with depression, low quality of life, and negative self-esteem are moderated by stigma. Patients with good insight who do not perceive much stigmatization seem to be best off across various outcome parameters. Those with poor insight have problems with service engagement and medication compliance. Patients with good insight accompanied by stigmatizing beliefs have the highest risk of experiencing low quality of life, negative self-esteem, and depressed mood. A clinical implication is that when it is attempted to increase insight, perceived stigma should also be addressed.
Schizophrenia Research 08/2009; 115(2-3):363-9. · 4.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Non-compliance with medication often has long-term detrimental effects in patients with schizophrenia. However, when patients are compliant, it is not certain whether they experience short-term improved quality of life. By simultaneously reducing symptoms and increasing side-effects, compliance with antipsychotics may have opposing effects on a patient's perceived quality of life.
This study aimed to identify any clinical-empirical evidence for two pathways between compliance and quality of life.
To evaluate various pathways between compliance (Service Engagement Scale plus a one-item rating), psychotic symptoms (Positive and Negative Syndromes Scale), adverse medication effects (Subjective Wellbeing under Neuroleptics scale), and quality of life (EQ-5D), we used Structural Equation Modeling on cross-sectional data of 114 patients with a psychotic disorder.
Compliance was not directly related to quality of life (r=0.004). The best-fitting model (chi(2)=1.08; df=1) indicated that high compliance was associated with fewer psychotic symptoms (beta=-0.23) and more adverse medication effects (beta=0.22). Symptoms (beta=-0.17) and adverse medication effects (beta=-0.48) were both related to lower quality of life.
Our results suggest that compliance with antipsychotics has two opposing pathways towards quality of life, albeit indirect ones. While compliance was associated with less severe psychotic symptoms, and was thus related to higher quality of life, it was also associated with more adverse medication effects, and was thus related to lower quality of life. However, due to our study design, we cannot draw firm conclusions on causality. Two possible clinical implications of the results for compliance and interventions are discussed.
Schizophrenia Research 07/2009; 113(1):27-33. · 4.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Non-adherence to treatment of patients with psychotic disorders is related to higher rates of relapse, hospitalization, and suicide. Important predictors of non-adherence include poor social structure, cognitive deficits, negative medication attitude, side effects, depression, a sealing-over recovery style, feelings of stigmatization, denial of treatment need, and lack of insight. Attempts to improve adherence have shown that psychoeducation alone is not fully effective, and that motivational interviewing, behavioral strategies, and linking a patient' s personal goals to treatment may increase adherence. Based on the empirical data reviewed, we formed four clusters of possible causes of non-adherence, each of which can be targeted by a specific module of our developed Treatment Adherence Therapy (TAT). These four modules are: self-enhancement, motivational interviewing, medication dosage trials, and behavioral training. An individual patient may benefit from one or more of these modules; and thus the contents of TAT vary in accordance with individual causes of non-adherence. Basically, TAT aims to help patients work out what they want regarding treatment and then support them in following this through. TAT will be investigated in a multicenter randomized clinical trial in the Netherlands, starting March 2006.