Marko Barendregt’s research while affiliated with Advanced Mental Health Care Inc. and other places

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Publications (13)


Provider effects and their confidence intervals obtained by the multilevel model
Scatterplot of ranks obtained by single-level linear regression and multilevel regression
Comparing single-level and multilevel regression analysis for risk adjustment of treatment outcomes in common mental health disorders
  • Article
  • Publisher preview available

February 2019

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60 Reads

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4 Citations

Journal of Public Health

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Marko Barendregt

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Jos Twisk

Aim The aim of this paper is to compare single-level and multilevel regression analysis to obtain risk-adjusted outcomes from mental health care providers. Subject and methods The study population consisted of adult patients receiving treatment for common mental health disorders. The outcome was self-reported symptom level at post-test. Risk adjustment models were developed using single- and multilevel regression analysis. In the multilevel approach, a random intercept for each provider was included. The intraclass correlation coefficient was used to estimate the proportion of variability in treatment outcome between providers. Spearman correlation coefficient of ranks was used to compare results between the two approaches. Results The effects of most casemix variables on outcomes were similar for the two models. The ranking of providers in both methods was also quite similar (ρ = .99). The multilevel model estimated that 5.4% of total variability in adjusted post-test scores was explained by the provider factor. Conclusions The findings of risk adjustment of mental health outcomes are quite robust for the use of single-level or multilevel regression analysis in the current study. However, given the small but significant amount of variation in outcomes that is attributable to providers, the multilevel approach is recommended for dealing with outcomes when patients are clustered within providers.

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Table 1 Descriptive statistics sample (N=31.849)
Table 2 Regression coefficients from simple and multiple regression analyses
Table 3 Regression coefficients of case mix variables in the final risk adjustment model a Variable Dataset
a Unadjusted change scores for each provider. b Adjusted changes scores for each provider
Risk adjustment of self-reported clinical outcomes in Dutch mental health care

June 2017

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234 Reads

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13 Citations

Journal of Public Health

Aim A meaningful comparison of clinical outcomes of mental health care providers requires risk adjustment of case mix variables that affect treatment outcome. The first goal of the present study was to describe the risk adjustment method we applied to routine outcome monitoring data in The Netherlands. Second, the consequences of risk adjustment for the ranking of providers were investigated. Subject and methods Using an observational study design, pre- and posttest self-report assessments of symptoms were obtained for 31,849 adults with common mental health problems, such as mood and anxiety disorders. Regression analyses were performed to predict the posttest symptom level using socio-demographics and clinical characteristics as predictors. Results Results showed that the posttest level of symptoms was best predicted by the symptom level at baseline, followed by the baseline level of functioning, age, socioeconomic status and some diagnoses. For the majority of the providers, risk adjustment did not markedly change their ranking. Conclusion The baseline level of symptoms is the best predictor of the posttest level. The other investigated case mix variables only have a modest influence on the performance of providers. Risk adjustment is particularly necessary when consequences are related to the performance of an individual provider. These results contribute to the limited literature on risk adjustment in mental health care by using a large national data set.


Comparing Methods to Denote Treatment Outcome in Clinical Research and Benchmarking Mental Health Care: Comparing Methods to Denote Treatment Outcome

April 2015

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288 Reads

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34 Citations

Clinical Psychology & Psychotherapy

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Marko Barendregt

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Arco de Heer

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[...]

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Approaches based on continuous indicators (the size of the pre-to-post-test change; effect size or ΔT) and on categorical indicators (Percentage Improvement and the Jacobson-Truax approach to Clinical Significance) are evaluated to determine which has the best methodological and statistical characteristics, and optimal performance, in comparing outcomes of treatment providers. Performance is compared in two datasets from providers using the Brief Symptom Inventory or the Outcome Questionnaire. Concordance of methods and their suitability to rank providers is assessed. Outcome indicators tend to converge and lead to a similar ranking of institutes within each dataset. Statistically and conceptually, continuous outcome indicators are superior to categorical outcomes as change scores have more statistical power and allow for a ranking of providers at first glance. However, the Jacobson-Truax approach can complement the change score approach as it presents outcome information in a clinically meaningful manner. Copyright © 2015 John Wiley & Sons, Ltd. When comparing various indicators or treatment outcome, statistical considerations designate continuous outcomes, such as the effect size of the pre-post change (effect size or ΔT) as the optimal choice. Expressing outcome in proportions of recovered, changed, unchanged or deteriorated patients has supplementary value, as it is more easily interpreted and appreciated by clinicians, managerial staff and, last but not the least, by patients. If categorical outcomes are used with small datasets, true differences in institutional performance may get obscured due to diminished power to detect differences. With sufficient data, outcome according to continuous and categorical indicators converge and lead to similar rankings of institutes' performance. Copyright © 2015 John Wiley & Sons, Ltd.


Table 1 Descriptive data of patients and duration of pre-to- posttest interval in both datasets
Table 3 Association of outcome indicators with pretest severity and among outcome indicators: DT, PI mod , and JT methods (Kendall's Tau, unless otherwise indicated) 
Table 4 Treatment outcomes of providers using the CBCL 
Denoting treatment outcome in child and adolescent psychiatry: a comparison of continuous and categorical outcomes

September 2014

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111 Reads

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10 Citations

European Child & Adolescent Psychiatry

Various approaches have been proposed to denote treatment outcome, such as the effect size of the pre-to-posttest change, percentage improvement, statistically reliable change, and clinical significant change. The aim of the study is to compare these approaches and evaluate their aptitude to differentiate among child and adolescent mental healthcare providers regarding their treatment outcome. Comparing outcomes according to continuous and categorical outcome indicators using real-life data of seven mental healthcare providers, three using the Child Behavior Checklist and four using the Strengths and Difficulties Questionnaire as primary outcome measure. Within each dataset consistent differences were found between providers and the various methods led to comparable rankings of providers. Statistical considerations designate continuous outcomes as the optimal choice. Change scores have more statistical power and allow for a ranking of providers at first glance. Expressing providers' performance in proportions of recovered, changed, unchanged, or deteriorated patients has supplementary value, as it denotes outcome in a manner more easily interpreted and appreciated by clinicians, managerial staff, and, last but not least, by patients or their parents.


Anti-social personality characteristics and psychotic symptoms: Two pathways associated with offending in schizophrenia

July 2014

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203 Reads

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16 Citations

Criminal Behaviour and Mental Health

Background Several research groups have shown that people with schizophrenia who offend do not form a homogenous group. A three‐group model claimed by Hodgins proposes distinguishing between people who start offending before the onset of psychosis (early starters), after psychosis onset but at age 34 years or under (late starters) and after psychosis onset but at age 35 years or older (late first offenders). Aims This study aimed to test the hypotheses (1) that the personality of early starters and non‐psychotic offenders would be similar, but different from either late‐starter group; (2) that the late‐starter groups would be more likely to have positive psychotic symptoms than non‐criminal patients with schizophrenia; and (3) that symptom types would differentiate the psychotic groups. Methods A retrospective file study was conducted on cases of 97 early starters, 100 late starters and 26 late first offenders all drawn from the Netherlands Institute of Forensic Psychiatry and Psychology (NIFP) archives 1993–2008, 115 non‐psychotic offenders from 2005–2008 NIFP archives and 129 patients with schizophrenia and no criminal history from one general service in Rotterdam. Results Early starters closely resembled the non‐psychotic offenders in their premorbid anti‐social personality characteristics. The two late‐onset offending psychosis groups were more likely to have persecutory and/or grandiose delusions than non‐offenders with psychosis, but so were the early starters. Implications In a first study to compare subgroups of offenders with psychosis directly with non‐psychotic offenders and non‐offenders with psychosis, we found such additional support for a distinction between early and late starters with psychosis that different treatment strategies would seem indicated, focusing on personality and substance misuse for the former but psychotic symptoms for all. It remains to be seen whether the higher rate of alcohol misuse amongst late first offenders is a fundamental distinction or a function of age difference. Copyright © 2014 John Wiley & Sons, Ltd.


TABLE 2 Mean (SD) Scores on the IPAS for All Offenders and Two Subgroups 
Psychometric Evaluation of the Dutch Version of the Impulsive/Premeditated Aggression Scale (IPAS) in Male and Female Prisoners

July 2013

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185 Reads

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15 Citations

International Journal of Forensic Mental Health

Aggressive behavior is traditionally classified into two subtypes, impulsive and premeditated aggression. The Impulsive/Premeditated Aggression Scale (IPAS) is a self-report questionnaire to measure a person's tendency towards these subtypes of aggressive behavior. This study reports on the psychometric quality of the Dutch translation of the IPAS in a sample of 149 male and 70 female prisoners in the Netherlands. Confirmatory Factor Analysis yielded two factors with an item composition quite similar to those found in previous studies: impulsive aggression, 17 items; premeditated aggression, 13 items. For both factors reliable subscales could be composed for males and females: impulsive aggression αmales = .92, αfemales = .94; premeditated aggression αmales = .90 and αfemales = .91. The subscales were highly correlated: r males = .70, r females = .75. It is concluded that the underlying structure of the Dutch version of the IPAS is similar to the original version of the questionnaire, that internal consistency of the two subscales is good, and that the correlation between the two subscales is higher than previously reported. Possible reasons for the high correlation of the subscales are discussed. Additional studies are needed to establish the construct and criterion/predictive validity of the IPAS in the forensic field.


Figure 1: The relationship between type of crime and diminished accountability, valuing absent accountability at 1, strongly diminished accountability 0.75, diminished accountability 0.5, slightly diminished accountability 0.25 and undiminished accountability 0 (ANOVA, X2 = 27.101, p < 0.001)
The relationship between mental disorders and different types of crime

December 2011

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13,034 Reads

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93 Citations

Criminal Behaviour and Mental Health

Previous studies of relationships between mental disorder and crime have tended to group the mental disorders, the crimes or both, leaving uncertainty about a more specific mental disorder: crime relationships. To examine the relationship between types of mental disorder and types of crime in pre-trial defendants. Data were extracted from 21,424 pre-trial forensic psychiatric reports made between 2000 and 2006 in the Netherlands. We compared the prevalence of axis I disorders, personality disorders, intellectual functioning and substance abuse in defendants charged with a range of crimes (homicide, attempted/threatened homicide, assault, battery, rape, sexual crimes, arson and/or property crimes) using chi-square tests. Relationships with diminished accountability, reflecting a direct relationship with underlying mental disorder, were calculated using multivariate regression models, adjusted for age, gender, ethnicity and history of judicial contact. Arson had the strongest relationship with mental disorders in our sample, then assaults, then homicidal attempts or threats. Sexual and property crimes had the weakest relationship with diminished or absent accountability. Diminished accountability had the strongest relationship with psychotic disorders, followed by organic psychosyndromes and developmental disorders, whereas other axis I disorders, personality disorders or an IQ score of <85 points were only moderately related. These relationships varied little according to the type of crime, although tended to be weaker for defendants in property crimes. Cannabis and hard drugs were significantly associated with decreased accountability only in respect of arson. Mental disorders are related to all types of crimes but especially to arson, battery and homicidal attempts or threats, with a court finding of diminished accountability providing some validation for perceived links between the disorder and crime in this study. Copyright


Diagnosis of antisocial personality disorder and criminal responsibility

September 2011

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437 Reads

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28 Citations

International Journal of Law and Psychiatry

The present study empirically investigates whether personality disorders and psychopathic traits in criminal suspects are reasons for diminished criminal responsibility or enforced treatment in high security hospitals. Recently, the tenability of the claim that individuals with personality disorders and psychopathy can be held fully responsible for crimes has been questioned on theoretical bases. According to some interpretations, these disorders are due to cognitive, biological and developmental deficits that diminish the individual's accountability. The current article presents two studies among suspects of serious crimes under forensic evaluation in a Dutch forensic psychiatric observation clinic. The first study examined how experts weigh personality disorders in their conclusions as far as the degree of criminal responsibility and the need for enforced forensic psychiatric treatment are concerned (n=843). The second study investigated associations between PCL-R scores and experts' responsibility and treatment advisements (n=108). The results suggest that in Dutch forensic practice, the presence of a personality disorder decreased responsibility and led to an advice for enforced forensic treatment. Experts also take characteristics of psychopathy concerning impulsivity and (ir)responsibility into consideration when judging criminal accountability. Furthermore, they deem affective deficiencies sufficiently important to indicate suspects' threat to society or dangerousness and warrant a need for forensic treatment.


Accountability assessment by ethnicity.
Odds ratios of accountability ratings by ethnicity.
Treatment recommendations by ethnicity.
Pre-trial psychiatric evaluations and ethnicity in the Netherlands

July 2010

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76 Reads

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26 Citations

International Journal of Law and Psychiatry

Black and ethnic minorities (BME) are disproportionally represented in western prisons and forensic psychiatric facilities. The authors wished to determine whether patient-related or services-related factors account for this overrepresentation. This study examined the relationship among the assessments of psychological accountability for a crime, treatment recommendations, and ethnicity among persons accused of a crime and suspected of having a mental disorder. We examined all 21,857 pre-trial psychiatric reports requested by Dutch courts between 2000 and 2006. Ethnicity was classified as Dutch native (n=15,004), Black and minority ethnic (BME) groups (n=6202), and Whites from other western countries (n=638). Accountability assessments and treatment recommendations were compared using chi-square tests and logistic regression models, adjusted for demographic, psychiatric, and judiciary characteristics. Among BME and Whites from other western countries, accountability for the crimes committed was more often judged to be at the extreme ends of the spectrum, that is, "fully responsible" or "not responsible." Compulsory admission to a psychiatric hospital was more frequently recommended for BME persons (OR: 1.38, 95% CI: 1.16-1.64) and Whites from other western countries (OR: 1.54, 95% CI: 1.05-2.27), but not admission to a penitentiary hospital or use of medication. The compulsory admission findings are largely explained by a higher prevalence of psychotic disorders in BME persons (19.8%) and Whites from other western countries (19.3%) as compared to Dutch natives (9.2%). Outpatient treatment was less often recommended for BME persons (OR: 0.81, 95% CI: 0.76-0.87) and Whites from other western countries (OR: 0.83, 95% CI: 0.70-0.99) than for Dutch natives. Both patient-related and services-related factors play a role in the increased admission of BME groups and Whites from other western countries to psychiatric hospitals.



Citations (13)


... The task of adjusting a quantitative measure so comparisons can be made across different values of one or more contextual factors fits into the broader field of risk adjustment, which is popular in both actuarial science (Li et al., 2013) and health (Warmerdam et al., 2018). Several regression tree and random forest approaches have been developed to adjust risk factors in the presence of large numbers of contextual factors (Li et al., 2013) and interactive effects (Buchner, Wasem and Schillo, 2015;van Veen et al., 2017). ...

Reference:

A statistical machine learning approach for benchmarking in the presence of complex contextual factors and peer groups
Comparing single-level and multilevel regression analysis for risk adjustment of treatment outcomes in common mental health disorders

Journal of Public Health

... The OQ-45 measures symptomatic distress (SD), social role, and interpersonal functioning. The SD scale was used for this study to measure general psychopathology (GPP) (Warmerdam et al., 2017). The frequency of symptoms was measured over the past week with a 5-point Likert scale, ranging from 0 (never) to 4 (always). ...

Risk adjustment of self-reported clinical outcomes in Dutch mental health care

Journal of Public Health

... Cohens d ble vurdert mot følgende kriterier: liten (d = ≥ 0,2), medium (d ≥ = 0,5), og stor (d ≥ = 0,8)(Page, 2014), og (2) Jacobson og Truax' metode ble brukt for å kalkulere relabilitetsendringsindeks, som er forskjellen mellom pre-og post test, dividert på standardfeilen(de Beurs et al., 2016). Her ble klinisk signifikans beregnet å vaere en nedgang i IES-R total med 9 poeng eller mer[(59,1-44,8)/1,6 = 9,4]. ...

Comparing Methods to Denote Treatment Outcome in Clinical Research and Benchmarking Mental Health Care: Comparing Methods to Denote Treatment Outcome
  • Citing Article
  • April 2015

Clinical Psychology & Psychotherapy

... It must be considered that the prison context is characterized by a high prevalence of aggressive behaviors (Azevedo et al., 2020;James et al., 2020), and therefore, it is of great importance to have validated instruments in this population to assess aggression, its prevalence and typologies to improve and guarantee greater effectiveness in intervention strategies (Azevedo et al., 2018;Kuyck et al., 2013). In addition, it is relevant to distinguish between the two types of aggression when evaluating the risk of violence, taking into account their influence in the prediction of subsequent crimes (Ennis et al., 2017;Martin et al., 2019;Matlasz et al., 2020;Rouchy et al., 2019;Swogger et al., 2015;Zabala-Baños et al., 2019). ...

Psychometric Evaluation of the Dutch Version of the Impulsive/Premeditated Aggression Scale (IPAS) in Male and Female Prisoners

International Journal of Forensic Mental Health

... Stakeholders may compare different treatments or providers by comparing effect sizes based upon such a generic outcome. In the field of mental healthcare, (the reduction of) symptom severity is often used as an indication of treatment outcome for monitoring individual treatment progress and for benchmarking (de Beurs et al., 2015a(de Beurs et al., , 2015b. On the other hand, assessing patients' progress in treatment may require a more specific outcome. ...

Denoting treatment outcome in child and adolescent psychiatry: a comparison of continuous and categorical outcomes

European Child & Adolescent Psychiatry

... Systematic research on early detection of psychotic symptoms, especially in outpatient forensic mental healthcare settings, is limited. This is problematic because several studies revealed a relationship between psychotic symptoms, violent behavior and acts of crime (Coid et al., 2016;Fazel et al., 2009;van Dongen et al., 2015). ...

Anti-social personality characteristics and psychotic symptoms: Two pathways associated with offending in schizophrenia
  • Citing Article
  • July 2014

Criminal Behaviour and Mental Health

... In addition, if individual music therapists would work in an international quality network of music therapists, apply similar interventions and systematically collect qualitative and quantitative data of their clients with similar questionnaires, large data sets could be organised and more insight might be gained about the efficacy of music therapy. Compared to RCTs, data collection procedures using the systemic N-of-1 design can be applied relatively easily and sustainably to accumulate large pools of data (Beurs & Barendregt, 2008), whereas large-scale RCTs are difficult to organise (Hakvoort et al., 2015). ...

Mogelijkheden voor therapie-effectonderzoek in de tbs-sector: komen tot een evidence base onder zorgprogramma's

... In juvenile justice institutions as well as in other settings where staff are in regular and intensive contact with youths (e.g., hospitals and schools), observations, if collected systematically and reliably, can be a powerful tool to complement assessment protocols (Hintze, 2005;Spaans et al., 2011;Volpe et al., 2005). Literature on structured participant observation, for example by nurses, is consistent with this assertion (Almvik et al., 2000;Chan & Chow, 2014). ...

Diagnosis of antisocial personality disorder and criminal responsibility
  • Citing Article
  • September 2011

International Journal of Law and Psychiatry

... Conflicts are influenced by multitude factors, including poverty, unemployment, inflation, and the overall socio-economic landscape 50 . The pandemic has significantly impacted mental health, which may correlate with changes in crime rates 51,52 .The restrictions imposed during this period have heightened stress and mental burdens due to concerns about safety, welfare, and financial stability, which could contribute to increasing tensions within households 19 . Extended close contact in restricted environments, particularly during lockdowns, may create various negative pressures and emotional responses, potentially leading to conflicts between individuals 5 . ...

The relationship between mental disorders and different types of crime

Criminal Behaviour and Mental Health

... One should keep in mind that in the Swiss law, COT are proposed by a psychiatric expert only when there is reasonable chance to reduce recidivism. As frequently indicated in previous studies, young ethnic-minority male patients with low education are prone to negative assumptions about their potential to evolve positively in medium-security hospitals that may, in fact, preclude the proposal of COT [37][38][39]. Our data suggest that this could not be the case for women. ...

Pre-trial psychiatric evaluations and ethnicity in the Netherlands

International Journal of Law and Psychiatry