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BackgroundThe Internet is used increasingly for both suicide research and prevention. To optimize online assessment of suicidal patients, there is a need for short, good-quality tools to assess elevated risk of future suicidal behavior. Computer adaptive testing (CAT) can be used to reduce response burden and improve accuracy, and make the available pencil-and-paper tools more appropriate for online administration. ObjectiveThe aim was to test whether an item response–based computer adaptive simulation can be used to reduce the length of the Beck Scale for Suicide Ideation (BSS). MethodsThe data used for our simulation was obtained from a large multicenter trial from The Netherlands: the Professionals in Training to STOP suicide (PITSTOP suicide) study. We applied a principal components analysis (PCA), confirmatory factor analysis (CFA), a graded response model (GRM), and simulated a CAT. ResultsThe scores of 505 patients were analyzed. Psychometric analyses showed the questionnaire to be unidimensional with good internal consistency. The computer adaptive simulation showed that for the estimation of elevation of risk of future suicidal behavior 4 items (instead of the full 19) were sufficient, on average. ConclusionsThis study demonstrated that CAT can be applied successfully to reduce the length of the Dutch version of the BSS. We argue that the use of CAT can improve the accuracy and the response burden when assessing the risk of future suicidal behavior online. Because CAT can be daunting for clinicians and applied scientists, we offer a concrete example of our computer adaptive simulation of the Dutch version of the BSS at the end of the paper.

Abstract Background In 2012, in The Netherlands a multidisciplinary practice guideline for the assessment and treatment of suicidal behavior was issued. The release of guidelines often fails to change professional behavior due to multiple barriers. Structured implementation may improve adherence to guidelines. This article describes the design of a study measuring the effect of an e-learning supported Train-the-Trainer program aiming at the training of the full staff of departments in the application of the guideline. We hypothesize that both professionals and departments will benefit from the program. Method In a multicenter cluster randomized controlled trial, 43 psychiatric departments spread over 10 regional mental health institutions throughout The Netherlands will be clustered in pairs with respect to the most prevalent diagnostic category of patients and average duration of treatment. Pair members are randomly allocated to either the experimental or the control condition. In the experimental condition, the full staff of departments, that is, all registered nurses, psychologists, physicians and psychiatrists (n = 532, 21 departments) will be trained in the application of the guideline, in a one-day small interactive group Train-the-Trainer program. The program is supported by a 60-minute e-learning module with video vignettes of suicidal patients and additional instruction. In the control condition (22 departments, 404 professionals), the guideline shall be disseminated in the traditional way: through manuals, books, conferences, internet, reviews and so on. The effectiveness of the program will be assessed at the level of both health care professionals and departments. Discussion We aim to demonstrate the effect of training of the full staff of departments with an e-learning supported Train-the-Trainer program in the application of a new clinical guideline. Strengths of the study are the natural setting, the training of full staff, the random allocation to the conditions, the large scale of the study and the willingness of both staff and management to participate in the study. Trial registration Dutch trial register: NTR3092

In health systems with strongly developed primary care, such as in the Netherlands, effectively engaging primary care professionals (PCPs) in suicide prevention is a key strategy. As part of the national Suicide Prevention Action Network (SUPRANET), a program was offered to PCPs in six regions in the Netherlands in 2017–2018 to more effectively engage them in suicide prevention. This implementation study aimed to evaluate to what extent SUPRANET was helpful in supporting PCPs to apply suicide prevention practices. From March to May 2018, 21 semi-structured interviews have been carried out with PCPs and other non-clinical professionals from SUPRANET regions in the Netherlands. Verbatim transcripts were analysed using the grounded theory approach. Data was structured using the Consolidated Framework for Implementation Research, which enabled identifying facilitating and challenging factors for PCPs to carry out suicide prevention practices. An important challenge included difficulties in assessing suicide risk (intervention characteristics) due to PCPs' self-perceived incompetence, burdensomeness of suicide and limited time and heavy workload of PCPs. Another important limitation was collaboration with mental health care (outer setting), whereas mental health nurses (inner setting) and SUPRANET (implementation process) were facilitating factors for applying suicide prevention practices. With regard to SUPRANET, especially the training was positively evaluated by PCPs. PCPs expressed a strong need for improving collaboration with specialized mental health care, which was not provided by SUPRANET. Educating PCPs on suicide prevention seems beneficial, but is not sufficient to improve care for suicidal patients. Effective suicide prevention also requires improved liaison between mental health services and primary care, and should therefore be the focus of future suicide prevention strategies aimed at primary care. [ABSTRACT FROM AUTHOR]

Machine learning (ML) is an increasingly popular approach/technique for analyzing "Big Data" and predicting risk behaviors and psychological problems. However, few published critiques of ML as an approach currently exist. We discuss some fundamental cautions and concerns with ML that are relevant when attempting to predict all clinical and forensic risk behaviors (risk to self, risk to others, risk from others) and mental health problems. We hope to provoke a healthy scientific debate to ensure that ML's potential is realized and to highlight issues and directions for future risk prediction, assessment, management, and prevention research. ML, by definition, does not require the model to be specified by the researcher. This is both its key strength and its key weakness. We argue that it is critical that the ML algorithm (the model or models) and the results are both presented and that ML needs to be become machine-assisted learning like other statistical techniques; otherwise, we run the risk of becoming slaves to our machines. Emerging evidence potentially challenges the superiority of ML over other approaches, and we argue that ML's complexity significantly limits its clinical utility. Based on the available evidence, we believe that researchers and clinicians should emphasize identifying, understanding, and explaining (formulating) individual clinical needs and risks and providing individualized management and treatment plans, rather than trying to predict or putting too much trust in predictions that will inevitably be wrong some of the time (and we do not know when). What is the public health significance of this article?: Machine learning is a statistical approach/technique that is increasingly being used in an attempt to improve the accuracy with which risky behaviors and mental health problems are predicted. This article discusses some key considerations for using machine learning and making it even more useful. [ABSTRACT FROM AUTHOR]

Background: Previous research has identified a vulnerability paradox in global mental health: contrary to positive associations at the individual level, lower vulnerability at the country level is accompanied by a higher prevalence in a variety of mental health problems in national populations. However, the validity of the paradox has been challenged, specifically for bias from modest sample sizes and reliance on a survey methodology not designed for cross-national comparisons.AimsTo verify whether the paradox applies to suicide, using data from a sizable country sample and an entirely different data source.Method: We combined data from the World Health Organization 2014 suicide report and the country vulnerability index from the 2016 World Risk Report. Suicide was predicted in different steps based on gender, vulnerability and their interaction, World Bank income categories, and suicide data quality.Results: A negative association between country vulnerability and suicide prevalence in both women and men was found. Suicide rates were higher for men, regardless of country vulnerability. The model predicting suicide in 96 countries based on gender, vulnerability, income and data quality had the best goodness-of-fit compared with other models. The vulnerability paradox is not accounted for by income or data quality, and exists across and within income categories.Conclusions: The study underscores the relevance of country-level factors in the study of mental health problems. The lower mental disorder prevalence in more vulnerable countries implies that living in such countries fosters protective factors that more than compensate for the limitations in professional healthcare capacity.Declaration of interestNone. [ABSTRACT FROM AUTHOR]

Objective: Combine test theory with technology to develop brief, reliable suicide risk measures in the emergency department.Methods: A computer adaptive test for suicide risk was built using the Beck Scale for Suicide Ideation and tested among the emergency department population. Data were analyzed from a sample of 1,350 patients in several Massachusetts emergency departments. The test was built as outlined by the National Institutes of Health Patient-Reported Outcomes Measurement Information System.Results: Of 1,350 patients, 74 (5%) scored above the cutoff of BSS > 2. Item 2, "Wish to die", was the most informative item. When using only Item 2, 20% (n = 15/74) of at-risk patients and 3% (n = 40/1,276) of not-at-risk patients were misclassified. Patients were classified after four items with computer adaptive testing trait estimates highly comparable to those of the full scale. The precision rule model did not reduce the scale.Conclusions: This study models the creation of a computer adaptive test for suicide ideation and marks the start of the development of computer adaptive tests as a novel suicide risk screening tool in the emergency department. Computer adaptive tests hold promise for revolutionizing behavioral health screening by addressing barriers including time and knowledge deficits. [ABSTRACT FROM AUTHOR]

Objectives This paper aims to describe the degree to which general practitioners (GPs) explore suicidal behaviour among depressed patients in the Netherlands. Design An observational study of consultations between GPs and depressed patients. Setting 39 sentinel GP practices within the Netherlands in 2017. Participants Patients with a registration of depression. Primary and secondary outcome measures Primary outcome measure is suicide exploration by the GP. Secondary outcome measures at patient level, assessed by surveying GPs, include prevalence and severity of suicidal thoughts. Secondary outcome measures at GP level include follow-up actions of GP and reasons not to explore suicidality. Results A total of 1034 questionnaires were included in the analyses. GPs assessed and explored suicidality in 44% of patients with depression (66% in patients with a new episode of depression). GPs explored suicidal feelings more often in patients with a new episode of depression (OR 4.027, p<0.001, 95% CI 2.924 to 5.588), male patients (OR 1.709, p<0.001, 95% CI 1.256 to 2.330) or younger patients (OR 1.017, p<0.001, 95% CI 1.009 to 1.026). Multilevel analysis showed that 22% of the variation in suicide exploration is due to differences in GP practice. Thirty-eight per cent of the patients who were asked by their GP, reported (severe) suicidal ideation. Most GPs (68%) did not explore suicidal feelings because they thought the patient would not be suicidal. Conclusion GPs explored suicidal thoughts in less than half of all depressed patients and in two-thirds of patients with a new episode of depression. Suicide prevention training is recommended to enhance suicide exploration. [ABSTRACT FROM AUTHOR]

Background: A reform of Dutch mental health care aimed to substitute care from specialized care to general practice. Since 1 January 2014, Dutch general practitioners (GPs) are no longer allowed to refer patients without a psychiatric disorder to mental health care. Patients with non-complex psychological problems should be treated within general practice.Objective: To explore the feasibility of the Dutch mental health policy.Methods: We conducted an observational case study in a primary health care centre in 2014. The health care centre was a convenience sample; the participating GPs reorganized mental health care in line with the upcoming policy, and invited the researchers to monitor their referrals. We assessed how many patients with mental health problems (n = 408) were allocated to policy-concordant treatment. Additionally, 137 patients (33%) completed a follow up assessment on mental health problems 3 months after baseline.Results: The majority of the patients were allocated to treatment in line with the policy. Almost half of the patients (42%) were treated in a setting that was exactly policy-concordant, while the other half (47%) was treated in a setting that was even less specialized than was allowed. In general, patients showed improvement after 3 months, regardless of (non) policy-concordant treatment. Attrition rate after 3 months was high, probably due to the practical study design.Conclusion: There is potential for substitution of mental health care. Since the studied health care centre was specialized in mental health care, further research should explore if similar results can be found in other general practices. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate developments in antidepressant prescriptions by Dutch general practitioners, alongside the national introduction of mental health nurses. Antidepressant prescriptions are very common in general practice, but are often not in line with recommendations. The recent introduction of mental health nurses may have decreased antidepressant prescriptions, as general practitioners (GPs) have greater potential to offer psychological treatment as a first choice option instead of medication. Material and methods: Anonymised data from the medical records of general practices participating in the NIVEL Primary Care Database in 2011–2015 were analysed in an observational study. We used multilevel logistic regression analyses to determine whether total antidepressant prescriptions and antidepressants prescribed within one week of diagnosing anxiety or depression decreased in the period 2011–2015. We analysed whether changes in antidepressant prescriptions were associated with the employment or consultation of mental health nurses. Results: Antidepressants were prescribed in 30.3% of all anxiety or depression episodes; about half were prescribed within the first week. Antidepressants prescriptions for anxiety or depression increased slightly in the period 2011–2015. The employment of mental health nurses was not associated with a decreased number of prescriptions of antidepressants. Patients who had at least one mental health nurse consultation had fewer immediate prescriptions of antidepressants, but not fewer antidepressants in general. Conclusions: Antidepressant prescriptions are still common in general practice. So far, the introduction of mental health nurses has not decreased antidepressant prescriptions, but it may have a postponing effect. [ABSTRACT FROM AUTHOR]

Background: Substitution is the shift of care from specialized health care to less expensive and more accessible primary health care. It seems promising for restraining rising mental health care costs. The goal of this study was to investigate a potential for substitution of patients with psychological or social problems, but without severe psychiatric disorders, from Dutch specialized mental health care to primary care, especially family practices. Methods: We extracted anonymized data from two national databases representing primary and specialized care in 2012. We calculated the number of patients with and without psychiatric disorder per 1,000 citizens in three major settings: family practices, primary care psychologists, and specialized care. Family physicians recorded psychopathology using the International Classification of Primary Care, while psychologists and specialists used the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Results: Considerable numbers of patients without a diagnosed DSM-IV psychiatric disorder were treated by primary care psychologists (32.8%) or in specialized care (20.8%). Over half of the patients referred by family physicians to mental health care did not have a psychiatric disorder. Conclusion: A recent reform of Dutch mental health care, including new referral criteria, will likely increase the number of patients with psychological or social problems that family physicians have to treat or support. Enabling and improving diagnostic assessment and treatment in family practices seems essential for substitution of mental health care. [ABSTRACT FROM AUTHOR]

Objectives: To analyse trends in suicidal behaviour as reported by the Dutch sentinel general practices from 1983 to 2013. Second, to examine the relationship between suicidal behaviour and several patient characteristics. Finally, to compare the relationship between suicidal behaviour and patient characteristics before (1983-2007) and after (2008-2013) the start of the crisis. Setting: 40 general practices in the Netherlands during the period 1983-2013. Participants: Patients with an ICPC code of P77 (suicide attempt). Primary and secondary outcomes: Primary outcomes were age-adjusted and gender-specific trends in reported suicides (342) and suicide attempts (1614). Secondary outcomes were the relationship between suicidal behaviour and age, household composition, history of depression, recognition of suicide ideation, treatment before the suicidal behaviour and contact within the past month before suicidal behaviour for the period 1983-2013. Additionally, separate frequencies for the periods 1983-2007 and 2008-2013 were presented. Results: Join-point analyses revealed a significant rise in male suicides from 2008 (b=0.32, SE=0.1, p=0.008), and an increase in male suicide attempts since 2009 (b=0.19, SE=0.04, p<0.001). Female suicidal behaviour showed a steady decrease from 1989 to 2013(b=-0.03, SE=0.007, p<0.0001 for female suicide, b=-0.02, SE=0.002, p<0.001 for female attempts). Before 2007, a history of depression was reported in 65% (168/257) of the suicides. After the start of the recession, a depression was recognised in 44% (22/50) of the patients who died by suicide. Conclusions: Since 2008, there was a rise in the male suicide rate while female suicide behaviour has continued to decline. General practitioners less often reported a history of depression within patients who died due to suicide after 2007 than before. Training in the early recognition of suicide ideation in depressive patients might improve suicide prevention in primary care. [ABSTRACT FROM AUTHOR]

Background: To strengthen suicide prevention skills in mental health care in The Netherlands, multidisciplinary teams throughout the country are trained in the application of the new Dutch guideline on the assessment and treatment of suicidal behavior. Previous studies have shown beneficial effects of additional efforts for guideline implementation on professionals’ attitude, knowledge, and skills. However, the effects on patients are equally important, but are rarely measured. The main objective of this study is to examine whether patients of multidisciplinary teams who are trained in guideline application show greater recovery from suicide ideation than patients of untrained teams. Methods/Design: This is a multicentre cluster randomized controlled trial (RCT), in which multidisciplinary teams from mental health care institutions are matched in pairs, and randomly allocated to either the experimental or control condition. In the experimental condition, next to the usual dissemination of the guideline (internet, newsletter, books, publications, and congresses), teams will be trained in the application of the guideline via a 1-day small interactive group training program supported by e-learning modules. In the control condition, no additional actions next to usual dissemination of the guideline will be undertaken. Assessments at patient level will start when the experimental teams are trained. Assessments will take place upon admission and after 3 months, or earlier if the patient is discharged. The primary outcome is suicide ideation. Secondary outcomes are non-fatal suicide attempts, level of treatment satisfaction, and societal costs. Both a cost-effectiveness and cost-utility analysis will be performed. The effects of the intervention will be examined in multilevel models. Discussion: The strengths of this study are the size of the study, RCT design, training of complete multidisciplinary teams, and the willingness of both management and staff to participate. [ABSTRACT FROM AUTHOR]

Background: Successfully implementing eMental health (eMH) interventions in routine mental health care constitutes a major challenge. Reliable instruments to assess implementation progress are essential. The Normalization MeAsure Development (NoMAD) study developed a brief self-report questionnaire that could be helpful in measuring implementation progress. Based on the Normalization Process Theory, this instrument focuses on 4 generative mechanisms involved in implementation processes: coherence, cognitive participation, collective action, and reflexive monitoring.Objective: The aim of this study was to translate the NoMAD questionnaire to Dutch and to confirm the factor structure in Dutch mental health care settings.Methods: Dutch mental health care professionals involved in eMH implementation were invited to complete the translated NoMAD questionnaire. Confirmatory factor analysis (CFA) was conducted to verify interpretability of scale scores for 3 models: (1) the theoretical 4-factor structure, (2) a unidimensional model, and (3) a hierarchical model. Potential improvements were explored, and correlated scale scores with 3 control questions were used to assess convergent validity.Results: A total of 262 professionals from mental health care settings in the Netherlands completed the questionnaire (female: 81.7%; mean age: 45 [SD=11]). The internal consistency of the 20-item questionnaire was acceptable (.62≤alpha≤.85). The theorized 4-factor model fitted the data slightly better in the CFA than the hierarchical model (Comparative Fit Index=0.90, Tucker Lewis Index=0.88, Root Mean Square Error of Approximation=0.10, Standardized Root Mean Square Residual=0.12, χ22=22.5, P≤.05). However, the difference is small and possibly not outweighing the practical relevance of a total score and subscale scores combined in one hierarchical model. One item was identified as weak (λCA.2=0.10). A moderate-to-strong convergent validity with 3 control questions was found for the Collective Participation scale (.47≤r≤.54, P≤.05).Conclusions: NoMAD's theoretical factor structure was confirmed in Dutch mental health settings to acceptable standards but with room for improvement. The hierarchical model might prove useful in increasing the practical utility of the NoMAD questionnaire by combining a total score with information on the 4 generative mechanisms. Future research should assess the predictive value and responsiveness over time and elucidate the conceptual interpretability of NoMAD in eMH implementation practices. [ABSTRACT FROM AUTHOR]

Background: Even though various types of suicidality are observed in clinical practice, suicidality is still considered a uniform concept. To distinguish different types of suicidality and consequently improve detection and management of suicidality, we developed a clinical differentiation model for suicidality. We believe that the model allows for a more targeted assessment of suicidal conditions and improves the use of evidence-based treatment strategies. The differentiation model is based on the experience with suicidality that we have encountered in clinical practice. This model distinguishes 4 subtypes of entrapment leading to suicidality. The earliest description of this model and a proposal for usability research has been previously presented in a book chapter., Objective: In this study, we present the most recent version of the 4-type differentiation model of suicidality and a protocol for a study into the usability of the proposed model., Methods: The 4-type differentiation model of suicidality distinguishes the following subtypes: (1) perceptual disintegration, (2) primary depressive cognition, (3) psychosocial turmoil, and (4) inadequate coping or communication. We plan to test the usability of the 4 subtypes in a pilot study of 25 cases, and subsequently, we will include 75 cases in a follow-up study. We looked at the case notes of 100 anonymized patients with suicidality who presented to mental health care emergency service in The Hague International Center. The summary and conclusions of the letters sent to the patients' general practitioners after suicide risk assessment will be independently rated by 3 psychiatrists and 3 nurse-scientists for absolute and dimensional scores. The Suicidality Differentiation version 2 (SUICIDI-II) instrument, developed for this study, is used for rating all the cases. Intraclass correlation coefficients for absolute and dimensional scores will be calculated to examine type agreement between raters to examine the usability of the model and the feasibility of the SUICIDI-II instrument., Results: We consider the model tentatively valid if the intraclass correlation coefficients are ≥0.70. Subsequently, if the model turns out to be valid, we plan to rate 75 other cases in a follow-up study, according to a similar or adjusted procedure. Study results are expected to be published by the end of 2023., Conclusions: The theoretical roots of the differentiation model stem from classic and contemporary theoretical models of suicidality and from our clinical practice experiences with suicidal behaviors. We believe that this model can be used to adjust the diagnosis, management, treatment, and research of suicidality, in addition to distinguishing different dynamics between practitioners and patients with suicidality and their families., International Registered Report Identifier (irrid): DERR1-10.2196/45438., (©Remco FP de Winter, Connie M Meijer, John H Enterman, Nienke Kool-Goudzwaard, Manuela Gemen, Anne T van den Bos, Danielle Steentjes, Gabrielle E van Son, Mirjam C Hazewinkel, Derek P de Beurs, Marieke H de Groot. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 11.08.2023.)

Background: Outreach psychiatric emergency services play an important role in all stages of a suicidal crisis; however, empirical assessment data are scarce. This study describes characteristics of patients assessed by these services and involved in suicidal crises. Method: During a 5-year period, detailed information from psychiatric emergency service assessments was recorded; 14,705 assessments were included. Characteristics of patients with/without suicidal behavior and with/without suicide attempts were compared. Outcomes were adjusted for clustering of features within individual patients. Results: Suicidal behavior was assessed in 32.2% of patients, of whom 9.2% attempted suicide. Suicidal behavior was most commonly associated with depression or adjustment disorder and these patients were referred to the service by a general practitioner or a general hospital, whereas those who attempted suicide were less likely to be referred by a general practitioner. Those who attempted suicide were more likely to be female and have had a referral by a general hospital. Self-poisoning by medication was the most common method of attempting suicide. Limitations: Bias could be due to missed or incomplete assessments. Primary diagnoses were based on clinical observation at the time of the assessment or on the primary diagnosis previously recorded. In addition, suicidal behavior or attempted suicide might have been underestimated. Conclusions: Suicidal behavior is commonplace in assessments by psychiatric emergency services. Suicidal patients with/without a suicide attempt differed with respect to demographic features, primary diagnoses, and referring entities, but not with respect to treatment policy. About 40% of the suicidal patients with/without an attempt were admitted following assessment.

Background: Suicidal behaviour is the end result of the complex relation between many factors which are biological, psychological and environmental in nature. Network analysis is a novel method that may help us better understand the complex association between different factors., Aims: To examine the relationship between suicidal symptoms as assessed by the Beck Scale for Suicide Ideation and future suicidal behaviour in patients admitted to hospital following a suicide attempt, using network analysis., Method: Secondary analysis was conducted on previously collected data from a sample of 366 patients who were admitted to a Scottish hospital following a suicide attempt. Network models were estimated to visualise and test the association between baseline symptom network structure and suicidal behaviour at 15-month follow-up., Results: Network analysis showed that the desire for an active attempt was found to be the most central, strongly related suicide symptom. Of the 19 suicide symptoms that were assessed at baseline, 10 symptoms were directly related to repeat suicidal behaviour. When comparing baseline network structure of repeaters ( n =94) with the network of non-repeaters ( n =272), no significant differences were found., Conclusions: Network analysis can help us better understand suicidal behaviour by visualising the complex relation between relevant symptoms and by indicating which symptoms are most central within the network. These insights have theoretical implications as well as informing the assessment and treatment of suicidal behaviour., Declaration of Interest: None., Copyright and Usage: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Background: Efficient screening questionnaires are useful in general practice. Computerized adaptive testing (CAT) is a method to improve the efficiency of questionnaires, as only the items that are particularly informative for a certain responder are dynamically selected., Objective: The objective of this study was to test whether CAT could improve the efficiency of the Four-Dimensional Symptom Questionnaire (4DSQ), a frequently used self-report questionnaire designed to assess common psychosocial problems in general practice., Methods: A simulation study was conducted using a sample of Dutch patients visiting a general practitioner (GP) with psychological problems (n=379). Responders completed a paper-and-pencil version of the 50-item 4DSQ and a psychometric evaluation was performed to check if the data agreed with item response theory (IRT) assumptions. Next, a CAT simulation was performed for each of the four 4DSQ scales (distress, depression, anxiety, and somatization), based on the given responses as if they had been collected through CAT. The following two stopping rules were applied for the administration of items: (1) stop if measurement precision is below a predefined level, or (2) stop if more than half of the items of the subscale are administered., Results: In general, the items of each of the four scales agreed with IRT assumptions. Application of the first stopping rule reduced the length of the questionnaire by 38% (from 50 to 31 items on average). When the second stopping rule was also applied, the total number of items could be reduced by 56% (from 50 to 22 items on average)., Conclusions: CAT seems useful for improving the efficiency of the 4DSQ by 56% without losing a considerable amount of measurement precision. The CAT version of the 4DSQ may be useful as part of an online assessment to investigate the severity of mental health problems of patients visiting a GP. This simulation study is the first step needed for the development a CAT version of the 4DSQ. A CAT version of the 4DSQ could be of high value for Dutch GPs since increasing numbers of patients with mental health problems are visiting the general practice. In further research, the results of a real-time CAT should be compared with the results of the administration of the full scale., (©Tessa Magnée, Derek P de Beurs, Berend Terluin, Peter F Verhaak. Originally published in JMIR Mental Health (http://mental.jmir.org), 21.02.2017.)

Objectives: To investigate care for patients with psychological or social problems provided by mental health nurses (MHNs), and by general practitioners (GPs) with and without MHNs., Design: An observational study with consultations recorded by GPs and MHNs., Setting: Data were routinely recorded in 161-338 Dutch general practices between 2010 and 2014., Participants: All patients registered at participating general practices were included: 624 477 patients in 2010 to 1 392 187 patients in 2014., Outcome Measures: We used logistic and Poisson multilevel regression models to test whether GPs recorded more patients with at least one consultation for psychological or social problems and to analyse the number of consultations over a 5-year time period. We examined the additional effect of an MHN in a practice, and tested which patient characteristics predicted transferral from GPs to MHNs., Results: Increasing numbers of patients with psychological or social problems visit general practices. Increasing numbers of GPs collaborate with an MHN. GPs working in practices with an MHN record as many consultations per patient as GPs without an MHN, but they record slightly more patients with psychological or social problems (OR=1.05; 95% CI 1.02 to 1.08). MHNs most often treat adult female patients with common psychological symptoms such as depressive feelings., Conclusions: MHNs do not seem to replace GP care, but mainly provide additional long consultations. Future research should study to what extent collaboration with an MHN prevents patients from needing specialised mental healthcare., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)