Search

Background: There are regional differences in the Netherlands in the numbers of emergency compulsory admissions (Inbewaringstelling: IBS). We looked at three 24/7 facilities to investigate the relationships between patient and consultation characteristics on the one hand, and numbers of emergency compulsory admissions on the other, against the background of the level of urbanisation., Method: We compared emergency consultations in 18-64 year olds in Apeldoorn, Amsterdam and Rotterdam between 2012 and 2016 in terms of socio-demographic, procedural and clinical characteristics, and in terms of outcome. We used the Severity of Psychiatric Illness Scale (SPI) to determine disorder severity., Results: Apeldoorn had as many consultations per 100,000 inhabitants as the highly urbanised city of Rotterdam. GPs there referred 68% of patients, compared with 25% in Amsterdam and 50% in Rotterdam. In Apeldoorn, 17% of the patients were psychotic, compared with 35% in the other regions. In addition, 66% of the patients there had a low SPI score, compared with 40% in the large cities. Amsterdam and Rotterdam had 3.5 times higher risk of emergency compulsory admissions as Apeldoorn. After adjustment for socio-demographic, procedural and clinical characteristics, this difference with Apeldoorn was 1.5 for Amsterdam and 2.6 for Rotterdam. SPI score and psychotic disorder were found to be the most important predictors of IBS admission., Conclusion: Differences in consultation numbers, referral patterns and the location of consultations indicate that there are regional differences in the position of the 24/7 facility in the mental health care system. The numbers of emergency compulsory emissions were related in part to the level of urbanisation and the associated epidemiological differences but probably also to differences in the position of the crisis facility in the mental health care system. Differences in admission numbers were primarily linked to differences in diagnostic characteristics and disorder severity and, to a lesser extent, to referral patterns and socio-demographic characteristics. However, these variables did not explain all the observed inter-regional differences.

Background: The high and intensive care (HIC) model provides a framework for acute admission wards and is being implemented since 2013 by all mental healthcare institutions in the Netherlands., Aim: To investigate how the HIC model has been implemented between 2014 and 2018 and how the implementation of the HIC model is associated to coercive measures., Method: Between 2014 and 2018, 79 audits were organized in two phases within 25 institutions to measure the degree of implementation of HIC using a model fidelity scale, the HIC monitor. HIC monitor scores were compared to data on coercion to determine the relationship between implementation of the HIC model and coercive measures., Results: Scores on the HIC monitor increased over time, especially in terms of vision, hospitality and facilities. However, a third of wards scored lower on the HIC monitor in the second audit compared to the first audit. Institutions that score higher use less seclusion and use less forced medication., Conclusion: Progress in the implementation of the HIC model is visible and institutions that are further in the implementation of the HIC model apply less coercion. Securing implementation proves difficult. Attention should be paid to the national staff shortage and systematic evaluation of coercion.

Background: The setting for providing assertive treatment (AT) has changed during the last 30 years in The Netherlands from assertive community treatment (ACT) and flexible assertive community treatment (FACT) to municipalities. The provision of AT varies between municipalities., Aim: Describing the concept of AT, the nature and size of the target group, and the reasons why people with severe mental illness (SMI) do not seek treatment and the place of AT in mental health care., Method: We used literature en available quantitative data., Results: AT regularly provided by mental health care is required in patients with SMI and social problems who do not seek treatment. When mental health care and social care collaborate on the level of the patient, treatment and handling of social problems can strengthen each other. This collaboration prevents discontinuity of care and breaking a trusting relationship because patients do not need to be transferred from social service to mental health care or vice versa. AT is on the continuum of voluntarily to compulsory care.AT provided by mental health care (usually provided by FACT-teams) is indicated for SMI patients with social problems and who do not seek treatment. The size of the target group is around 5000 - 20.000 patients in The Netherlands. Reasons not to seek help for people with SMI include within person factor, mental health related factors, or factors related to the interaction of SMI patients and mental health. We advocate for AT to become a regular part of mental health care, and for mental health care and social domain professionals to collaborate on case level. Acting this way, mental health treatment and addressing social problems can reinforce each other and discontinuity of care and breaking a trusting relationship can be prevented. AT is on the continuum of voluntary to involuntary treatment. That is why we suggest AT to be a better term than assertive outreach., Conclusion: It is a given fact that not all patients with SMI and social problems seek treatment. By making AT a regular part of mental health services, we prevent discontinuity of care and we fill the gap between voluntarily and compulsory care.

Background: Community-based care for people with severe mental illness increasingly requires far-reaching cooperation between different domains. This cooperation must always be unique and local, and at the same time provide an answer to generic and nationally set goals.
AIM: Offering new insights on collaboration within and between domains.
METHOD: Reflection on developments in the social domain and specialist mental healthcare using relevant literature and recent (inter)national experiences.
RESULTS: It seems possible to provide better integral care by allowing FACT-teams to network together with Social Support partners (e.g. by sharing financial and/or human resources). In this process, networks of care for people with serious mental illness (SMI), develop over various phases and realize new partnerships. The model fidelity scale for FACT-teams was adjusted to facilitate that process. CONCLUSIONS The new FACT model fidelity scale is ready to allow FACT-teams to explore flexible local solutions for partnerships to realize the much-needed multi-domain integrated community care for people with SMI.

Background: Compulsory treatment in mental health care has continuously increased for years. Registration of court ordered compulsory psychiatric care is based upon counts of legal authorisations. These counts do not refer to number of individual persons involved.
AIM: To report the number age-specific prevalence of coercion in psychiatric care, number of persons involved, age distribution and regional differences.
METHOD: Analysis of the number of requests for compulsory care and population size according to the age groups for the years 2013-2017. We used direct age standardisation at the level of jurisdiction regions.
RESULTS: The annual number of unique persons for whom compulsory care was requested was 28% less than the number of requested court orders. The annual increase in compulsory care was 3%. Per specific treatment order the increase during 2013-2017 was 12% for emergency compulsory admissions, 8% for hospital admissions, 10% for extended hospital admissions and 43% for community treatment order.
CONCLUSION: The number of persons for whom compulsory mental care is requested increased on average by 3% each year. Greatest increase was observed for age groups 25-44 years and 80 years and older. After age-standardisation substantial differences remain between jurisdiction regions.

Background: For some time now, East Lille has been working with a relatively modern mental health care system that remarkably resembles Dutch health care with the same values and norms that we want to implement in the Netherlands as well.
AIM: Gaining inspiration to further investigate regional cooperation and 'network care' in Dutch psychiatry.
METHOD: A delegation from the board of f-act-Netherlands and ccaf paid a working visit to Lille.
RESULTS: The basis of the East Lille working method is a charter of shared values developed with all parties, clients, relatives, employees and external professionals, which is signed by every professional. In case of doubt, a change of context or the introduction of new working methods, these values are used first. CONCLUSIONS High quality mental health care develops in dialogue, in which working methods, service delivery models and interventions are linked to each other by means of network care. Through reflection, moral deliberation and appreciative auditing, care is progressively improved. These procedures guarantee a modern process of quality improvement.

Background: In ambulant psychiatric care, intellectual disability (id) is often not recognised. Therefore, a Screener for Intelligence and Learning disabilities (scil) was recently introduced to assist recognition. However, because, current therapy is not adjusted for id-related problems, its effectiveness remains unknown.
AIM: To gain insight into adequate adaptation of interventions by professionals for patients with severe mental illness (smi) and id, to improve the quality of care without the need to develop a completely new program of therapy.
METHOD: A qualitative design (n=15) including 8 interviews and one focus group, among psychiatric practitioners and id experts.
RESULTS: Five main themes were identified to adjust therapy: treatment, communication, inclusion of the network, estimation of support needs and self-management. CONCLUSIONS To align therapy with the requirements of patients with smi and id, a patient-oriented approach to care is necessary. Simple but effective modifications, summarised in a toolkit, appear to contribute to this. To offer appropriate care to patients with smi and id, attention is needed for both a support-oriented and a recovery-oriented approach.

Background: The Flexible act (f-act) has been introduced in the Netherlands since 2004, alongside the Assertive Community Treatment (act) model. An estimate of 400 (f-)act teams concurrently provide care to approximately 70.000 people with serious mental illness. The ccaf has been assessing the model fidelity of act and f-act teams since 2009 to promote the quality and transparency of healthcare for clients with serious mental illness. OBJECTIVE To describe the state of implementation of f-act and associated trends in the Netherlands., METHOD: Analysis of the ccaf database, which holds the data of audits conducted between 2009 and 2014., RESULTS: The audits conducted by ccaf between 2009 and 2014 indicated an adequate implementation of f-act. The team foundations were well organized, featuring a multidisciplinary team structure, management of medication, practical support and investment in healthcare continuity, including during an admission. However, the results regarding participation and recovery were unsatisfactory. Furthermore, the results depicted a decline in the scores concerning a number of areas, including outreach and support of participation and recovery. CONCLUSIONS Although the data indicates an on average satisfactory implementation of f-act in the Netherlands, there are signs that the implementation of f-act is under pressure with relatively fewer home visits, a rising caseload and a reduced investment in recovery and participation. The findings are in accordance with the signs and arguments to adjust the emphasis on reducing hospital admissions, prioritizing the consolidation of outpatient care instead.

Background: Dual diagnosis (substance use disorder combined with a comorbid mental illness) is a common problem. One of the methods to treat this is integrated dual diagnosis treatment (IDDT). IDDT consists of the simultaneous, integrated application of different treatment components. Their efficacy, however, has only been studied separately. As a result, the effectiveness of the IDDT program as a whole remains unclear., Aim: To evaluate the scientific evidence relevant to the effectiveness of IDDT in dual diagnosis patients., Method: A systematic literature review using MEDLINE, Embase and PsycINFO (Prisma guideline)., Results: Six studies were found: a randomised controlled study (RCT), two non-randomised controlled studies, and three uncontrolled pre-post studies . There was a notably large diversity in outcome measures. The results differed significantly, including some studies concluding a significant (additional) effect, while others concluded that there was no indication of a significant effect of IDDT., Conclusion: In clinical practice, IDDT is recommended and chosen frequently as the treatment for patients with dual diagnosis. However, it is remarkable how limited and unthorough the research is pertaining to the effects of the full IDDT program on dual diagnosis.

Background: 'Bewildered persons' have often been in the news over the last few years. There has been much discussion about the meaning of the term 'bewildered persons', the number of people involved, the way the problem should be tackled and the role of the mental health services.
AIM: To look critically at the term 'bewildered persons' and to discuss the suspected increase in numbers and the role of mental health services.
METHOD: Review and discussion of the relevant literature relating to 'bewildered persons' which has been published in the last 25 years.
RESULTS: The term 'bewildered persons' is a general label given by the Dutch police to several groups of people. Suicide rates are rising and more and more people are being compulsorily admitted to psychiatric clinics and hospitals. These factors indicate that increasing numbers of people may now be a danger to themselves and to their fellow-citizens. It is not clear whether the increase in numbers is real or simply reflects the extra attention given by the police. These people may in fact be a new group consisting of persons already known to the mental health services. A national team that aims to improve the care of 'bewildered persons' has made several recommendations to stop the increase: prevention and better cooperation between municipalities and mental health facilities. In our view the mental health services should operate at the front-line of the public mental health service, providing low-threshold diagnostics, assertive outreach and treatment for patients who have mental disorders but are unwilling to accept care or treatment. Such a service requires adequate finance, good cooperative agreements and removal of the bureaucratic and financial barriers that prevent patients from seeking care.
CONCLUSION: 'Bewildered persons' is an umbrella term used to denote people who urgently require care and are a public nuisance and who display disturbing behavior. 'Bewildered persons', who now form a part of the group of people targeted by the public health services, have been around for a long time but have been referred to by different names. They require the structured assistance of integrated care, access to social and medical services and timely diagnosis and treatment. People who have somehow slipped through the net of care facilities should not be left to fend for themselves.

Background: Yulius intensive home treatment (iht) offers six weeks of home-care to psychiatric patients in crisis who would normally be hospitalised.
AIM: To study patient characteristics and the content and outcomes of iht.
METHOD: We followed the handling of 75 consecutive applications for iht. Details were recorded before and after admission to the treatment.
RESULTS: Fifteen patients were referred in order to shorten the period of hospitalisation, and 60 were referred in order to prevent hospitalisation; 59 of the 75 persons admitted for the treatment received iht, and 41 patients finished the six-week module and provided follow-up data. Psychiatric symptoms improved significantly, suicidality was reduced, the caregiver's burden became much lighter and the evaluation by both patient and caregiver was very positive. iht was sufficient to prevent the need for hospitalisation of 75% of the patients referred for reduced hospitalisation, and it was also adequate to prevent the hospitalisation of more than 91% of patients referred for that particular purpose.
CONCLUSION: iht is highly appreciated and is possibly a good alternative to hospitalisation. However, in the future there will have to be randomised, controlled research in order to determine the effectiveness of iht compared to hospitalisation.

Background: No recent information is available concerning the working methods of the ambulatory psychiatric emergency services in The Netherlands.
, Aim: To obtain insight into the working methods of the ambulatory psychiatric emergency services.
, Method: We performed a descriptive research.
, Results: Twenty of the 28 ambulatory psychiatric emergency services participated in our study (more than 71 %). The study revealed that some of the ambulatory psychiatric emergency services used differing procedures. However, all the services had a common target: they dealt with young people, adults and the elderly. In half of the organisations it was the community mental health nurse who initially went alone to visit a prospective patient. There are large differences in the number of face-to-face contacts made by emergency services and in the type of medication provided before the patient was taken by ambulance to a psychiatric hospital.
, Conclusion: In our study we describe the working methods used by several of the ambulatory psychiatric emergency services in the Netherlands. However, our investigation produced only limited information because participating institutions were often unable to provide the information we requested and/or they did not record the methods they had used. More attention needs to be given to the best way of dealing with patients who already have an official 'emergency card'; in addition, more information is required about whether the medication used by the emergency services influenced the subsequent course of the treatment that a patient received. In view of the current situation certain important features of the emergency services such as the quality of care they provided remains underexposed.

Background: Since the introduction of the new Dutch law on compulsory mental health care, the Bopz, there has been a marked increase in the number of compulsory admissions in mental health care in the Netherlands. When the new law underwent its third evaluation in 2002, it was decided that the law no longer reflected current views on the admission policy in mental health care. The draft on a new law on compulsory admissions to mental health care has already been published. One of the goals of the new law is to reduce the number of compulsory hospital admissions and to ensure that patients with mental health problems receive compulsory community care and outpatient care., Aim: To describe and analyse the use of compulsory admissions and community treatment orders (CTOs), and to make recommendations., Method: We analyse the number of CTOs and court-ordered admissions in the Netherlands between 2003 and 2013 on the basis of figures supplied by the Council for the Judiciary., Results: In the period 2003-2013 the number of compulsory emergency admissions increased from 43 to 47 per 100,000 inhabitants. During the same period the number of court-ordered admissions rose from 44 per 100,000 inhabitants in 2003 to 89 per 100,000 in 2013. (These figures include CTOs.) We were unable to perform more detailed studies because of the lack of records giving, for instance, the characteristics of patients who have undergone compulsory admission., Conclusion: Emergency compulsory admissions, CTOs and court-ordered admissions to mental health care continued to rise in the period 2003-2013. There is an urgent need for more detailed registration of the type an duration of compulsory admissions to psychiatric care and for more research into the type of treatment that can prevent the use of coercion to mental health care.

Background: Instruments are used for routine outcome monitoring of patients with severe mental illness in order to measure psychiatric symptoms, care needs and quality of life. By adding an instrument for measuring functional remission a more complete picture can be given of the complaints, the symptoms and general functioning, which can give direction to providing care for patients with severe mental illness., Aim: To describe the development and testing of a new instrument of functional remission (FR) among people with a psychotic disorder or another serious mental disorder (SMI) as an addition to the symptomatic remission (SR), according to international criteria., Method: The FR-assessment involves assessment by a mental health professional who conducts a semi-structured interview with the patient and his or her family and/or uses patient files relating to the three areas of functioning: daily living and self-care; work, study and housekeeping; and social contacts. These areas are rated on a three-point scale of 0: independent; 1: partially independent; 2: dependent. The assessment covers a period of six months, in accordance with the measurement of symptomatic remission and should be part of regular routine outcome monitoring (ROM) procedures. The FR-instrument was used in 2012 with 840 patients from eight Dutch mental care institutions and included a one-year follow-up among 523 patients (response 62%)., Results: The results showed that the instrument is relatively easily to complete. It was also relevant for clinical practice, although further research is needed because of the raters' low response. Intra- and inter-rater reliability, discriminating and convergent validity, and sensitivity to change were rated sufficient to good., Conclusion: If the FR-instrument becomes part of regular ROM-procedures and is used as a measure of societal participation, it could be a useful addition to current measures of symptomatic remission.

Background: Many organisations are involved in the delivery of psychiatric emergency care to patients in crisis. We therefore refer to these organisations as the Psychiatric Emergency Chain (PEC). The quality of the PEC determines the quality of the psychiatric emergency care in a region. In order to measure the quality of this type of care a monitor has been developed in collaboration with the main stakeholders in the region Western North Brabant (WNB)., Aim: To develop a monitor to measure the quality of a PEC in a region, identify weak spots in the chain and feed back the results to the chain., Method: By searching the literature, studying the primary process in the chain and by having interviews with stakeholders we compiled a questionnaire for monitoring the pec. The monitor was tested in the WNB region and adjusted on the basis of experiences with the respondents. Then the monitor was generalised and tested in another region (Eindhoven and the Kempen) in order to find out whether this instrument might also be applicable to other pecs in the Netherlands., Results: The monitor provided the PEC with a common language for evaluating the chain. The monitor was able to pinpoint particular weak spots and collaboration problems such as the response time required to reach the emergency, communication between and within organisations and domain discussions between different stakeholders. Chain partners used the results of the monitor to negotiate better collaborative agreements and to improve their care., Conclusion: The monitor is able to pinpoint problem areas in the PEC and subsequently to generate feedback to its stakeholders. This creates opportunities for improvement in the PEC. Therefore the monitor is a useful instrument for evaluating a local PEC periodically.

Background: In recent years electronic health records (EHRs) have been introduced on a large scale into mental health care. EHRs have a great number of advantages, one of the main ones being readability. However, very little attention seems to have been paid to the potential disadvantages and risks associated with EHRs., Aim: To point to some of the disadvantages and risks of EHRs, in their present form, particularly in relation to the care of patients with severe mental illness (SMI)., Method: On the basis of clinical experience and relevant literature, we discuss some of the disadvantages and risks associated with EHRs in their current form., Results: In long-term, multidisciplinary and complex treatments of patients with SMI, EHRs in their current form fail to provide the psychiatrist with an adequate overview of the treatment process. This is largely due to the way they are designed: an ever-increasing quantity of information about complex treatment stored in separate files that can only be accessed individually and that contain free text. In mental health care the introduction of new technology, unlike the introduction of new drugs, seems to occur without structured surveillance of the disadvantages and risks involved., Conclusion: EHRs need to be re-designed at the earliest opportunity.

Background: Although compulsory admission (CA) is highly relevant to society, epidemiological data for European countries are scarce and of limited reliability and comparability. In several European countries the incidence of CA seems to be increasing., Aim: To estimate the incidence and evolution of CA in Belgium and the Netherlands by pooling and analysing available epidemiological data., Method: We reviewed the literature systematically, paying particular attention to relevant epidemiological data (in published articles and in grey literature). All data were (re)calculated into yearly incidence rates of CA per 100,000 inhabitants., Results: The incidence of CA increased by 42% in Belgium (1999-2008) and by 25% in the Netherlands (2002-2009), culminating in incidence rates of 47/100,000/y (Belgium, 2008) and 80/100.000/y (Netherlands, 2009). Between-country differences can be attributed partly to differences in the legal systems. More detailed results, regional differences, and problems with the comparison of epidemiological data on CA are discussed., Conclusions: Our data point to a significant increase of the incidence of CA in both Belgium and the Netherlands. To improve the comparability and quality of the data on CA, European countries will need to strive for greater uniformity and standardisation in the way these data are registered.

Background: Patients with severe mental illness (SMI) generally receive long-term treatment. Interrupting treatment or leaving treatment early can lead to problems with the interpretation of routine outcome monitoring (ROM) data., Aim: To describe the link between early drop-out and treatment duration on the one hand, and patient characteristics and scores on a ROM outcome measure, namely the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS), on the other hand., Method: Annual CANSAS assessments of patients in assertive community treatment (ACT)., Results: 2946 CANSAS assessments were performed on 1041 patients who had been treated by an ACT team for an average of 1.4 years since their first ROM assessment. Patients who remained under treatment by an ACT team were more frequently male, born outside the Netherlands and had a psychotic or addiction disorder more frequently than patients who had left the ACT team treatment early. Patients who remained in ACT had, both at the start of treatment and at their last assessment, more unfulfilled needs than patients who had been treated for a shorter period., Conclusion: For the correct interpretation of ROM data for patients with SMI, one needs to have information about patient characteristics and the treatment duration.

Background: This article presents initial data from the Amsterdam Study of Acute Psychiatry (ASAP) which investigated the factors that play a role in the decision to admit a patient compulsorily to a psychiatric clinic in the Amsterdam area., Aim: To find out how socio-demographic factors, a patient’s psychiatric history and pathway to care influence a patient’s chance of being served with an emergency compulsory admission order during emergency consultation., Methods: We conducted a prospective cohort study of 1970 consecutive patients who consecutively came into contact with the Psychiatric Emergency Service Amsterdam (PESA) in the period September 2004 to September 2006., Results: A patient who had been admitted compulsorily once in the previous five years ran an increased risk of compulsorily admission (or 3.9). Referral by the police or by the mental health services also implied a high risk of a compulsorily admission (or 2.2 and or 2.6 respectively)., Conclusion: A previous compulsorily admission and referral by the police or mental health services were found to be predictors of emergency compulsory admission, irrespective of possible danger to the patient himself and others and irrespective of the patient’s lack of motivation for treatment.

Background: Assertive community treatment (ACT) is one of the most important models for the care and treatment, in the community, of people with severe mental illness (SMI). ACT is concerned primarily with smi-patients who have the most complex problems and it provides care by means of intensive assertive outreach. Function act (FACT) provides care for the entire group of SMI - patients and combines the principles of case management and ACT. For a long time it has been possible to measure the degree of ACT model reliability using the facts reliability scale. Throughout this time, however, a reliability scale for FACT was not available., Aim: To develop a reliability scale for fact teams., Method: Using the knowledge of experts and feedback from fact teams it has been possible to develop a reliability scale for fact teams. The scale was tested and subsequently adapted as a result of 10 pilot trials performed by 10 fact teams., Results: The definitive version of the scale was confirmed in 2008 and is currently used in the field., Conclusion: With the ACT and FACT reliability scales the research field now have two instruments with which teams working with SMI - patients can measure model reliability. The DACTS and FACTS provide opportunities for quality improvement and transparency.

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: In the Netherlands little research has been done on the regional variability in the implementation of the law on Special Admissions to Psychiatric Hospitals (Dutch acronym Bopz)., Aim: To investigate regional variability in the numbers, combinations and characteristics of emergency compulsory admissions and other types of legally authorised admissions., Method: Data from the Bopz information system covering a 12-month period were analysed. Missing data were supplied by the courts in Maastricht, Groningen and Rotterdam., Results: There was regional variability in the way in which compulsory measures were implemented, particularly as far as emergency compulsory admissions were concerned. The relative number of Bopz measures increased in relation to the degree of urbanisation. Rotterdam had the highest percentage of emergency compulsory admissions. Patients in Maastricht and Rotterdam were more often involved in legally authorised admissions only. In Rotterdam an unlinked combination of emergency compulsory admissions and legally authorised admissions was more common. In Maastricht a larger number of patients were admitted because they were a danger to themselves, whereas in Groningen and Rotterdam admissions were also used as a means of safeguarding the public., Conclusion: The number of admissions and the diversity of Bopz measures are highest in urban areas. Regional variations in the way in which compulsory measures are applied persist, but there is room for improvement in the monitoring of the effects of these differences and the types of services that are available.

Background: In recent years in the Netherlands there has been a marked increase in the number of compulsory admissions, particularly those that require court authorisation. Little is known about the decision-making process that precedes the issuing of a court authorisation for compulsory admission., Aim: To obtain more insight into the factors that an independent psychiatrist has to consider when assessing whether he or she should sign a medical certificate that will advise on compulsory admission., Method: Data on clinical and demographic patient characteristics were gathered for 862 commitment applications. Motives for rejection of the application or doubt about the necessity of commitment were collected. results In the case of 9% of the applications, the psychiatrist hesitated about the need for compulsory admission but nevertheless signed the necessary medical certificate. In the case of 3% of the applications, the psychiatrist turned down the application for compulsory admission. The psychiatrist found to reject or query an application less often if a patient presented a direct physical threat to himself or others. The principal reason for rejecting an application for compulsory admission was the possibility that an alternative type of treatment was available., Conclusion: In principle the independent psychiatrist nearly always signs a medical certificate if the clinician treating the patient had requested a court authorisation. Factors that might help to reduce the number of court authorisations are better and earlier use of intensive care services, improved management or the deployment of legal restraints to prevent danger.

Background: Since 1992 The Netherlands has seen a striking increase in the number of compulsory admissions. There is a danger that coercion will become the dominant form of treatment in the Amsterdam clinics., Aim: To build up a picture of the changes in emergency psychiatry which have contributed to the increase in the number of acute compulsory admissions., Method: A cohort (n = 460) of consultations conducted by the city crisis service in 1983 was compared with a similar cohort (n = 436) of consultations conducted in 2004-2005 based on the following variables: crisis-service procedures, patient characteristics, diagnosis and consultation outcomes., Results: In 2003-2004 more services were involved with psychiatric patients in acute situations in the public domain than were involved in 1983. The number of patients referred by the police almost doubled, rising from 29.3 to 62.7%. In 1983 all consultations took place where the patients were located; in 2004-2005 60% took place at the premises of the crisis service. The number of psychotic patients in the cohort rose from 52 to 63.3%. There was a rise in the number of compulsory admissions (from 16.7 to 20%) and a sharp decline in voluntary admissions (from 25.7 to 7.6%). The total number of admissions following a consultation decreased from 42 to 28%., Conclusions: The front-line outreach service of 1983 has been transformed into a specialist psychiatric emergency department with only a modest outreach component. Voluntary admissions via the consultation service have almost ceased. Further research is needed into the characteristics of the consultations and into the variables that play a role in the use of compulsion in emergency psychiatry.

Background: Little is known about the amount and quality of after-care provided for patients hospitalised as a result of a court authorisation., Aim: To obtain insight into the rate of drop-out from after-care and the quality of after-care., Method: In our study we included all patients in Rotterdam Rijnmond who, in the last 3 months of 2004, had been compulsorily hospitalised for at least one day by reason of a court authorisation. A retrospective study of patients' records let us ascertain whether drop-out from after-care occurred and let us check on the quality of the after-care provided., Results: 214 patients were included. Of these, 33 (15.4%) dropped out of after-care. Prior to discharge, the drop-out group received an outpatient appointment at a local clinic less often and waited longer for their first appointment at that clinic than did the 'non-drop-out' group. The medical records of the drop-out group were less accurate and there was less cooperation between community care and clinical mental health care professionals., Conclusion: The quality of after-care can be improved if community care and clinical health care professionals cooperate more intensively in drawing up conditions for discharge and in arranging the transfer of patients from clinical care to community care. Further investigations are needed to find out whether these steps will have a beneficial effect on the drop-out percentage.

In connection with recent articles about guidelines for dealing with persons attempting suicide, we investigated the quality and continuity of aftercare provided for patients admitted to a mental institution because they have attempted to commit suicide. 25% of patients received no aftercare at all. For most of the others aftercare began within two weeks; 50% of these patients were still receiving care nine months later. Follow-up studies are needed so that we can find out whether the absence of aftercare can cause problems for patients admitted to an institution because they have threatened to commit suicide.

Several social breakdown and self-neglect are both 'danger' criteria in the Dutch act entitled 'Exceptional Admissions to Psychiatric Hospitals', but neither term is clearly defined. On the basis of two patients, it is shown that psychiatrists and judges interpret these 'danger' criteria differently. according to their own views and attitudes. This leads to legal inequality stemming from personal preferences. A better definition of these 'danger' criteria is needed.

Background: In view of the increased rate of psychiatric morbidity in urban areas there is likely to be a relation between urbanisation and the extent to which patients use the care services. It is not yet known whether this relation is particularly strong in the case of long-term service-dependent patients with mental health problems., Aim: To investigate the possible relation between the prevalence of long-term service-dependent patients and the degree of urbanisation and to find out if there are differences in the strength of this relation in the case of different types of long-term patients and between these patients and other psychiatric patients., Method: Data were collected from three psychiatric case registers and from the Statistics Netherlands (cbs). Distinctions were made between three types of long-term patients: 'long stay', 'residential & outpatient' and 'outpatient'. The population was divided into five categories according to the degree of urbanisation in the area of residence. Data were analysed using Poisson regression analysis, corrected for differences in age, sex, marital status and the amount of care available., Results: The incidence rate ratios for the categories 'long stay', 'residential & outpatient' and 'outpatient' and for other patients were significantly higher for each category of urbanisation than for non-urbanised municipalities. There was also a significant positive linear relation. For long stay patients no significant relation was found with the degree of urbanisation. The total ratios for long-term patients were higher than the ratios for other types of patients. The ratios for residential and outpatient were higher than the ratios for outpatient., Conclusion: The prevalence of long-term service-dependent patients in mental health care increases with the degree of urbanisation and this increase is stronger than the increase observed for other patients. Furthermore, the relation with urbanisation for the category residential and outpatient is stronger for the category residential and outpatient than for the long-term outpatients.

Background: People are under the impression that there are differences between regions and between psychiatrists and judges in the criteria that are applied with regard to compulsory admission under the Dutch Act on Special Admissions to Psychiatric Hospitals (Bopz)., Aim: To find out how the legal criteria are currently put into operation, what topics come up for discussion and what evidence the judge generally requires in order to have recourse to compulsory admission., Method: All judgments pronounced between 2002 and June 11 2005 and published in the journal Bopz Jurisprudence (bj) were analysed juridically. results In two-thirds of the cases the judge followed the advice of the psychiatrist and decided on compulsory admission. The required admission was refused for formal judicial reasons or because circumstances during the court hearing differed from those prevailing at the time when the medical report was drawn up. There was very little discussion about psychiatric disturbances or about the seriousness of the danger involved, but no objective criteria on this subject exist., Conclusions: The jurisprudence suggests that within the boundaries of the legally defined criteria there is still room for manoeuvre and negotiation with regard to compulsory admission applications under the Bopz Act. It is very important that the psychiatrist fully underpins his findings and draws up his application in accordance with the requirements of the Bopz Act and satisfies the judge's need for detailed information. The development and utilisation of instruments for assessing the degree of danger and the severity of the psychiatric disturbance within the framework of the Bopz could be a useful supplement to the law in its current form.

Summary: A question frequently raised in the Netherlands is whether regional case registers have added value compared to national information systems. Research in regional case registers, however, has shown that they have added value based on longitudinal data-gathering, specialised knowledge of the region concerned and data-processing. Regional case registers reflect developments in the total range of services available (cure and care, including clinics to treat alcoholism and drug addiction). Case register research can also aim at developing outcome measures and creating links between mental health care and other health care areas.

Three psychiatric patients are dangerously close to social breakdown as a result of financial problems. They are incapable of improving their living conditions because they lack insight and have only very limited problem-solving ability. Measures such as legal guardianship or legal restraint empower someone to make decisions on behalf of the patient and keep the patient from social breakdown. The measures are additional to other forms of coercion that can be used in the treatment of patients with severe psychiatric disorders and social problems.

Background: In evaluations of the Act on Special Admissions to Psychiatric Hospitals in The Netherlands (Dutch acronym BOPZ) hardly any attention has been given to the use of mental health care services before and after a compulsory admission., Aim: To investigate whether patterns of care before and after compulsory admissions can be considered as indicators of the quality of care provided by the mental health services., Method: For 623 patients with first-time acute compulsory admissions in Rotterdam, the use of the care services was monitored over a period of 12 months before and after admission. The outcomes were compared for 3 different patient groups: 'old acquaintances', 'newcomers' and 'passers-by'. In order to identify differences before an after the introduction of the BOPZ Act of 1994, we compared the use made of care facilities by patients admitted between 1992 and 1993 and between 1996 and 1997., Results: More than one third of the patients admitted to acute compulsory care leaves the psychiatric hospital within three weeks. The average length of stay is more than two months and in more than half of the cases the first contact with mental health services occurs within one week after discharge. Within one year after the compulsory admission more than one third of patients is re-admitted and after one year more than fifty percent of patients are still receiving mental health care. Intensive care is targeted particularly at the patient group referred to as 'old acquaintances'. Following the introduction of the BOPZ Act the percentage of suicide-threats and cases of self-neglect increased. The number ofcompulsory re-admissions increased as well., Conclusion: The research results provide an encouraging picture of the quality of care provided before and after compulsory admissions. However, the cases which fail to receive mental health care before emergency compulsory admission and miss out on outpatient follow-up emphasise the needfor alternative measures such as an earlier conditional compulsory admission (voorwaardelijke machtiging) and more intensive outpatient treatment.