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Contains fulltext : 248656.pdf (Publisher’s version ) (Closed access) BACKGROUND: Sex differences in incidence and/or presentation of schizophrenia (SCZ), major depressive disorder (MDD), and bipolar disorder (BIP) are pervasive. Previous evidence for shared genetic risk and sex differences in brain abnormalities across disorders suggest possible shared sex-dependent genetic risk. METHODS: We conducted the largest to date genome-wide genotype-by-sex (G×S) interaction of risk for these disorders using 85,735 cases (33,403 SCZ, 19,924 BIP, and 32,408 MDD) and 109,946 controls from the PGC (Psychiatric Genomics Consortium) and iPSYCH. RESULTS: Across disorders, genome-wide significant single nucleotide polymorphism-by-sex interaction was detected for a locus encompassing NKAIN2 (rs117780815, p = 3.2 × 10(-8)), which interacts with sodium/potassium-transporting ATPase (adenosine triphosphatase) enzymes, implicating neuronal excitability. Three additional loci showed evidence (p < 1 × 10(-6)) for cross-disorder G×S interaction (rs7302529, p = 1.6 × 10(-7); rs73033497, p = 8.8 × 10(-7); rs7914279, p = 6.4 × 10(-7)), implicating various functions. Gene-based analyses identified G×S interaction across disorders (p = 8.97 × 10(-7)) with transcriptional inhibitor SLTM. Most significant in SCZ was a MOCOS gene locus (rs11665282, p = 1.5 × 10(-7)), implicating vascular endothelial cells. Secondary analysis of the PGC-SCZ dataset detected an interaction (rs13265509, p = 1.1 × 10(-7)) in a locus containing IDO2, a kynurenine pathway enzyme with immunoregulatory functions implicated in SCZ, BIP, and MDD. Pathway enrichment analysis detected significant G×S interaction of genes regulating vascular endothelial growth factor receptor signaling in MDD (false discovery rate-corrected p < .05). CONCLUSIONS: In the largest genome-wide G×S analysis of mood and psychotic disorders to date, there was substantial genetic overlap between the sexes. However, significant sex-dependent effects were enriched for genes related to neuronal development and immune and vascular functions across and within SCZ, BIP, and MDD at the variant, gene, and pathway levels.

Objective: This article describes the development and testing of the Functional Recovery tool (FR tool), a short instrument for assessing functional recovery during routine outcome monitoring of people living with serious mental illnesses. Methods: To assess functional recovery, mental health professionals conducted semistructured interviews with people living with serious mental illnesses on three areas of social functioning: daily living and self-care, work and study, and social contacts. Functioning in each of these areas over the past 6 months was rated on a 3-point scale: 0 (independent), 1 (partially independent), and 2 (dependent). The dichotomous overall outcome of the tool is defined as independent functioning in all areas. We analyzed interrater and test–retest reliability, sensitivity to change, and correlations with constructs that are assumed to be similar to the FR tool (quality of life in daily living, work, and social contacts) or divergent from it (symptomatic functioning). Results: The FR tool was administered to 840 individuals with serious mental illnesses in Dutch mental health care services, 523 of whom were followed up for 1 year (response rate 62%). The tool was easy to complete and was appropriate for policy evaluation and practice. However, when it was combined with more elaborate instruments, it added little extra clinical information. Interrater and test–retest reliability, convergent and discriminant validity, and sensitivity to change were rated sufficient to good. Conclusions and Implications for Practice: The FR tool could be a useful measure of functional recovery in addition to current measures of symptomatic remission and personal recovery in routine outcome monitoring. (PsycINFO Database Record (c) 2018 APA, all rights reserved)

Objective: Despite the increasing recognition in clinical practice of body image problems in other than appearance related mental disorders, the question remains how aspects of body image are affected in different disorders. The aim of this study was to measure body image in patients with a variety of mental disorders and to compare scores with those in the general population in order to obtain more insight in the relative disturbance of body image in the patients group compared to healthy controls. In a further exploration associations with self-reported mental health, quality of life and empowerment were established as well as the changes in body image in patients over time.Methods: 176 women and 91 men in regular psychiatric treatment completed the Dresden Body Image Questionnaire, the Outcome Questionnaire, the Manchester Short Assessment of Quality of Life and the Mental Health Confidence Scale. Measurements were repeated after four months.Results: Patients with mental disorders, especially those with post-traumatic stress disorder (PTSD), scored significantly lower on body image, with large effect sizes, in comparison with the healthy controls. Scores of patients from different diagnostic groups varied across domains of body image, with body acceptance lowest in the group with eating disorders, and sexual fulfillment extremely low in PTSD. Vitality did not differ significantly between the various disorders. Gender differences were large for body acceptance and sexual fulfillment and small for vitality. Associations of body image with self-reported mental health, quality of life and empowerment were moderate to strong. After four months of treatment positive changes in body image were observed.Conclusions: Negative body image is a common problem occurring in most patients with mental disorders. Diagnosis-specific profiles emerge, with PTSD being the most affected disorder. Body acceptance and sexual fulfillment were the most differentiating aspects of body image between diagnoses. Changes in body image occur over the course of treatment. (C) 2017 Elsevier Inc. All rights reserved.

The aim of this study was to develop and validate the Adult Social Behavior Questionnaire (ASBQ), a multidimensional Autism Spectrum Disorder (ASD) questionnaire that contains both a self report version and a version to be completed by someone close. Psychometric qualities, convergence between self report and other report ratings, and scores in a group diagnosed with ASD and multiple comparison groups were examined.Principal Component Analyses yielded a structure with six dimensions (reduced contact, reduced empathy, reduced interpersonal insight, violation of social conventions, insistence on sameness, and sensory stimulation/motor stereotypies) for both self- and other-report versions. Reliability estimates and correlations between self- and other-ratings were good and the score profile on the 44-item ASBQ differentiated a group with ASD from a non clinical group and patients with depression, schizophrenia and ADHD.We conclude that the ASBQ is a short and easy to apply questionnaire that captures the heterogeneous nature of ASD. It yields a score profile among six ASD problem domains both from the perspective of the patient and from a significant other. (C) 2016 Elsevier Ltd. All rights reserved.

BACKGROUND: Urban upbringing and childhood trauma are both associated with psychotic disorders. However, the association between childhood urbanicity and childhood trauma in psychosis is poorly understood. The urban environment could occasion a background of social adversity against which any effect of childhood trauma increases. Also, any impact of the urban environment on likelihood of exposure to childhood trauma could be stronger in children who later develop psychotic disorder. The aim of this study was twofold: (1) to investigate whether childhood urbanicity moderates the effect of childhood trauma, in a model predicting psychotic disorder; (2) to investigate whether there is an association between the urban environment and childhood trauma and whether this is moderated by genetic liability for psychotic disorder. METHODS: Patients with a diagnosis of non-affective psychotic disorder (n = 1119) and 589 healthy controls from the Netherlands and Belgium were studied. Childhood trauma was assessed with the Dutch version of the Childhood Trauma Questionnaire Short Form. Urban exposure was defined at four levels, considering the population density, using data from Statistics Netherlands and the equivalent database in Belgium. RESULTS: There was a significant interaction between childhood urbanicity on the one hand and childhood trauma on the other, indicating that trauma was significantly associated with psychotic disorder, with increasing odds ratios for higher levels of childhood urbanicity. In addition, there was weak evidence that childhood urbanicity was associated with childhood trauma in the patient group: higher levels of childhood urbanicity were associated with higher trauma scores. CONCLUSION: The urban environment may moderate the risk-increasing effect of childhood trauma for psychotic disorder and childhood urbanicity may be a risk factor for childhood trauma in individuals who later develop psychotic disorder.

Finding clusters in a complex dataset is not straightforward. Different indices were developed to quantify the number of clusters. Their performances were studied using unrealistic simulations, since they were considered at low dimensions. We investigated 14 indices for eight-dimensional data using simulations based on cognition measures. We focused on hierarchical clustering with Ward’s agglomerative technique. Results indicated that Duda and Hart, Hartigan and Gap/pc were best performing. They estimated the number of clusters within ±1 with high probabilities. Duda and Hart index was most consistent, while Gap/pc and WGap/pc together made a good distinction between single and multiple clusters.

Objective: Impaired Theory of Mind (ToM) and insecure (adult) attachment styles have been found in persons with schizophrenia as well as in their healthy siblings. ToM refers to the ability to infer mental states of self and others including beliefs and emotions. Insecure attachment is proposed to underlie impaired ToM, and comprises avoidant (discomfort with close relationships, high value of autonomy) and anxious (separation anxiety, dependency on others) attachment. Insight into the association between attachment style and ToM is clinically relevant, as it enhances our understanding and clinical approach to social dysfunction in schizophrenia. Therefore, we studied the association between insecure attachment styles and ToM in patients with schizophrenia, their siblings, and healthy controls. Methods: A total of 111 patients with a diagnosis in the schizophrenia spectrum, 106 non-affected siblings and 63 controls completed the Psychosis Attachment Measure, the Conflicting Beliefs and Emotions, a subsection of the Wechsler Adult Intelligence Scale, and the Childhood Trauma Questionnaire-Short Form. Severity of symptoms was assessed with the Community Assessment of Psychic Experiences and the Positive and Negative Syndrome Scale. Results: After controlling for sex, intelligence, history of trauma and symptom severity, avoidant attachment was significantly associated with cognitive as well as with affective ToM, showing U-shaped associations, indicating better ToM performance for patients with lower or higher levels of avoidant attachment compared to medium levels. Anxious attachment in patients was associated with more problems in cognitive ToM. Conclusion: The results from this study support the idea that an anxious attachment style is associated with worse ToM performance in patients. Results also suggested a potential protective role of higher levels of avoidant attachment on ToM. These findings bear clinical relevance, as activation of (insecure) attachment mechanisms may affect interpersonal relations, as well as therapeutic working alliance. Further clarification is needed, especially on associations between ToM and avoidant attachment.

BACKGROUND: Body image has implications for psychosocial functioning and quality of life and its disturbance is reported in a broad range of psychiatric disorders. In view of the lack of instruments in Dutch measuring body image as a broad concept, we set out to make an instrument available that reflects the multidimensional character of this construct by including more dimensions than physical appearance. The Dresden Körperbildfragebogen (DBIQ, Dresden Body Image Questionnaire) particularly served this purpose. The DBIQ consists of 35 items and five subscales: body acceptance, sexual fulfillment, physical contact, vitality, and self-aggrandizement. The main objective of the present study was to evaluate the psychometric properties of the Dutch translation of the Dresden Body Image Questionnaire (DBIQ-NL) in a non-clinical sample.METHODS: The psychometric properties of the DBIQ-NL were examined in a non-clinical sample of 988 respondents aged between 18 and 65. We investigated the subscales' internal consistency and test-retest reliability. In order to establish construct validity we evaluated the association with a related construct, body cathexis, and with indices of self-esteem and psychological wellbeing. The factor structure of the DBIQ-NL was examined via confirmatory factor analysis (CFA). The equivalence of the measurement model across sex and age was evaluated by multiplegroup confirmatory factor analyses.RESULTS: Confirmatory factor analyses showed a structure in accordance with the original scale, where model fit was improved significantly by moving one item to another subscale. Multiple group confirmatory factor analysis across sex and age demonstrated partial strong invariance. Internal consistency was good with little overlap between the subscales. Temporal reliability and construct validity were satisfactory.CONCLUSION: Results indicate that the DBIQ-NL is a reliable and valid instrument for non-clinical subjects. This provides a sound basis for further investigation of the DBIQ-NL in a clinical sample.

Background: Shortening the duration of untreated psychosis (DUP) - with the aim of improving the prognosis of psychotic disorders - requires an understanding of the causes of treatment delay. Current findings concerning several candidate risk factors of a longer DUP are inconsistent. Our aim was to identify factors contributing to DUP in a large sample that represents the treated prevalence of non-affective psychotic disorders.Method: Patients with a non-affective psychotic disorder were recruited from mental health care institutes from 2004 to 2008. Of the 1120 patients enrolled, 852 could be included in the present analysis. Examined candidate factors were gender, educational level, migration status, premorbid adjustment and age at onset of the psychotic disorder. DUP was divided into five ordinal categories: less than one month, one month to three months, three months to six months, six months to twelve months and twelve months and over. An ordinal logistic regression analysis was used to identify the risk factors of a longer DUP.Results: Median DUP was less than one month (IQR 2). The factors migration status (p = 0.028), age at onset of the psychotic disorder (p = 0.003) and gender (p = 0.034) were significantly associated with DUP in our analysis.Conclusion: First generation immigrant patients, patients with an early onset of their psychotic disorder and male patients seem at risk of a longer DUP. These findings can assist in designing specific interventions to shorten treatment delay. (C) 2014 Elsevier B.V. All rights reserved.

Alexithymia is a psychological construct that can be divided into a cognitive and affective dimension. The cognitive dimension is characterized by difficulties in identifying, verbalizing and analysing feelings. The affective dimension comprises reduced levels of emotional experience and imagination. Alexithymia is widely regarded to arise from an impairment of emotion regulation. This is the first functional magnetic resonance imaging (fMRI) study to critically evaluate this by investigating the neural correlates of emotion regulation as a function of alexithymia levels. The aim of the current study was to investigate the neural correlates underlying the two alexithymia dimensions during emotion perception and emotion regulation. Using fMRI, we scanned 51 healthy subjects while viewing, reappraising or suppressing negative emotional pictures. The results support the idea that cognitive alexithymia, but not affective alexithymia, is associated with lower activation in emotional attention and recognition networks during emotion perception. However, in contrast with several theories, no alexithymia-related differences were found during emotion regulation (neither reappraisal nor suppression). These findings suggest that alexithymia may result from an early emotion processing deficit rather than compromised frontal circuits subserving higher-order emotion regulation processes.

Sexual dysfunction is a frequent side effect of antipsychotics, but information is scant regarding the psychometric properties and clinical usefulness of currently existing questionnaires. This systematic review compares the psychometric properties and content of questionnaires for assessment of sexual functioning in patients using antipsychotics. A systematic literature search was performed using three electronic databases (PubMed, Embase, and PsycINFO) with predefined search terms. We identified six validated instruments for assessment of sexual functioning in patients using antipsychotics: the Antipsychotic Non-Neurological Side Effects Rating Scale (ANNSERS), the Arizona Sexual Experience Scale (ASEX), the Antipsychotics and Sexual Functioning Questionnaire (ASFQ), the Changes in Sexual Function Questionnaire-14 (CSFQ-14), the Nagoya Sexual Function Questionnaire (NSFQ), and the Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ). The ASFQ, CSFQ-14, and PRSexDQ cover all stages of sexual functioning, which makes these questionnaires preferable to the other three questionnaires described. The ASFQ and PRSexDQ are clinician-administered and ask for a change in sexual functioning related to medication. The ASFQ assesses improvement as well as deterioration of sexual functioning, and includes items about hyperprolactinemia. The CSFQ-14 is useful when self-report is desired but contains more items.

Emotional deficits are among the core features of schizophrenia and both associative emotional learning and the related ability to verbalize emotions can be reduced. We investigated whether schizophrenia patients demonstrated impaired function of limbic and prefrontal areas during associative emotional learning. Patients and controls filled out an alexithymia questionnaire and performed an associative emotional learning task with positive, negative and neutral picture-word pairs during fMRI scanning. After scanning, they indicated for each pair whether they remembered it We conducted standard GLM analysis and Independent Component Analysis (ICA). Both the GLM results and task-related ICA components were compared between groups. The alexithymia questionnaire indicated more cognitive-emotional processing difficulties in patients than controls, but equal experienced intensity of affective states. Patients remembered less picture-word pairs, irrespective of valence. GLM analysis showed significant visual, temporal, amygdalar/hippocampal, and prefrontal activation in all subjects. ICA identified a network of brain areas similar to GLM, mainly in response to negative stimuli. Neither analysis showed differences between patients and controls during learning. Although in previous studies schizophrenia patients showed abnormalities in both memory and emotion processing, neural circuits involved in cross-modal associative emotional learning may remain intact to a certain degree, which may have potential consequences for treatment. (C) 2013 Elsevier Ireland Ltd. All rights reserved.

Background Cannabis use and childhood maltreatment are independent risk factors for the development of psychotic symptoms. These factors have been found to interact in some but not all studies. One of the reasons may be that childhood maltreatment and cannabis primarily induce psychotic symptoms in genetically susceptible individuals. In this context, an extensively studied psychosis vulnerability gene is catechol-methyl-transferase ( COMT ). Therefore, we aimed to examine whether the COMT Val 158 Met polymorphism (rs4680) moderates the interaction between childhood maltreatment and cannabis use on psychotic symptoms in the general population. Method The discovery sample consisted of 918 individuals from a cross-sectional study. For replication we used an independent sample of 339 individuals from the general population. Results A significant three-way interaction was found between childhood maltreatment, cannabis use, and the COMT genotype (rs4680) in the discovery sample (P = 0.006). Val-homozygous individuals displayed increased psychotic experiences after exposure to both cannabis use and childhood maltreatment compared to Met-heterozygous and Met-homozygous individuals. Supportive evidence was found in the replication sample with similar effect and direction even though the results did not reach statistical significance (P = 0.25). Conclusions These findings suggest that a functional polymorphism in the COMT gene may moderate the interaction between childhood maltreatment and cannabis use on psychotic experiences in the general population. In conclusion, the COMT Val 158 Met polymorphism may constitute a genetic risk factor for psychotic symptoms in the context of combined exposure to childhood maltreatment and cannabis use.

Kurt Schneider defined 'first rank symptoms' (FRS) of psychosis. Previous research found two clusters of FRS: 'loss of ego bound' symptoms (e.g., delusions of external control) and auditory hallucinations (e.g, commenting voices). In patients with a psychosis we investigated whether FRS are a separate cluster within the group of positive symptoms, consisting of two underlying factors that are stable over time. We conducted a principal axis factor analysis (PAF) at baseline (n = 857) and a confirmative factor analysis (CFA) at three-year follow-up (n = 414) on (FRS) symptom score. Also, we investigated the stability of the two-factor structure of FRS over the interval. PAF on 16 items representing positive symptoms at baseline revealed two factors with eigenvalues > 1. FRS-delusional self experience (thought withdrawal, thought broadcasting, thought insertion, and beliefs that impulses and/or actions are controlled by an outside force) clustered in one factor and FRS-auditory hallucinations (auditory hallucinations, conversational voices, and voices commenting on one's actions) in the second factor. Furthermore, CFA on the FRS-items at follow-up confirmed the two-factor structure of FRS. FRS delusional self experience and FRS-auditory hallucinations at baseline were significantly associated with the same factors at three-year follow-up (FRS-delusional self experience: r = 0.38; FRS-auditory hallucinations r = 0.47). Hence, our findings confirm a two-factor structure of first rank symptoms, i.e. FRS-delusional self experience and FRS-auditory hallucinations, with a moderate to large internal coherence within each factor and relative stability over time. Future studies on self-processes may contribute to our understanding of the pathophysiology of first rank symptoms.

Background: Monitoring patients' experiences with antipsychotics may help to improve medication adherence and outcome. We aimed to develop a shorter version of a comprehensive 74-item self-report questionnaire suitable for routine monitoring of desired and undesired effects of antipsychotics.Methods: Included were patients with psychotic disorders from seven mental health care organizations in The Netherlands, using antipsychotic medication, who completed the Subjects' Response to Antipsychotics (SRA-74). Exploratory factor analysis (EFA) and similarity analysis based on mutual information were used to identify the latent factor structure of the SRA. Items were reduced according to their metric properties and clinical relevance upon consensus by an expert panel, using a Delphi procedure of three rounds. We determined the internal consistency of the shorter version using Cronbach's alpha.Results: SRA data of N = 1478 patients (mean age of 40 years, 31% females) were eligible for analysis. EFA extracted thirteen factors from the SRA-74, including four factors for desired effects (e. g. recovery of psychosis, cognition and social functioning) and nine factors for undesired effects (e. g. weight gain, flattened affect and increased sleep). Based on this solution 12 items were eliminated for statistical reasons. The expert panel eliminated another 28 items with redundant content, resulting in a 34-item version. The SRA-34 includes 10 desired and 24 clinically relevant undesired effects. Both the subscales for desired and undesired effects have a Cronbach's alpha coefficient of 0.82.Conclusions: The SRA-34 can be used to evaluate desired and undesired effects of antipsychotics in routine clinical practice and research. (C) 2013 Elsevier B. V. All rights reserved.

BackgroundForensic psychiatry aims to reduce recidivism and makes use of risk assessment tools to achieve this goal. Various studies have reported on the predictive qualities of these instruments, but it remains unclear whether their use is associated with actual prevention of recidivism in clinical care.AimsTo test whether an intervention combining risk assessment and shared care planning is associated with a reduction in violent and criminal behaviour.MethodA cluster randomised controlled trial (Netherlands Trial Register number NTR1042) was conducted in three outpatient forensic psychiatric clinics. The intervention comprised risk assessment with the Short Term Assessment of Risk and Treatability (START) and a shared care planning protocol formulated according to shared decision-making principles. The control group received usual care. The outcome consisted of the proportion of clients with violent or criminal incidents at follow-up.ResultsIn total 58 case managers and 632 of their clients were included, in the intervention group (n=310), 65% received the intervention at least once. Findings showed a general treatment effect (22% of clients with an incident at baseline v. 15% at follow-up, PP = 0.15).ConclusionsAlthough risk assessment is common practice in forensic psychiatry, our results indicate that the primary goal of preventing recidivism was not reached through risk assessment embedded in shared decision-making.

BackgroundSeveral factors may contribute to duration of untreated psychosis (DUP): patient-delay, referral-delay and treatment-delay caused by mental health care services (MHS-delay). In order to find the most effective interventions to reduce DUP, it is important to know what factors in these pathways to care contribute to DUP.AimTo examine the relationship of the constituents of treatment delay, migration status and urbanicity.MethodIn first episode psychotic patients (n = 182) from rural, urban and highly urbanized areas, DUP, migration status and pathways to care were determined.ResultsMean DUP was 53.6 weeks (median 8.9, SD=116.8). Patient-delay was significantly longer for patients from highly urbanized areas and for first generation immigrants. MHS-delay was longer for patients who were treated already by MHS for other diagnoses.ConclusionsSpecific interventions are needed focusing on patients living in highly urbanized areas and first generation immigrants in order to shorten patient delay. MHS should improve early detection of psychosis in patients already in treatment for other diagnosis.

Background: Depressive symptoms require accurate recognition and monitoring in clinical practice of patients with schizophrenia. Depression instruments developed for use in depressed patients may not discriminate depressive symptoms from negative psychotic symptoms. Objective: We reviewed depression instruments on their reliability and validity in patients with schizophrenia. Methodology: A systematic literature search was carried out in three electronic databases. Psychometric properties were extracted for those instruments of which reliability, divergent, concurrent and predictive validity were reported in one or more publications. Results: Forty-eight publications described the reliability and validity of six depression instruments in patients with schizophrenia. The only self-report was the Beck Depression Inventory (BDI). The Brief Psychiatric Rating Scale Depression subscale (BPRS-D), Positive and Negative Syndrome Scale Depression subscale (PANSS-D), Hamilton Rating Scale for Depression (HAMD), Montgomery Asberg Depression Rating Scale (MADRS) and Calgary Depression Scale for Schizophrenia (CDSS) were clinician rated. All instruments were reliable for the measurement of depressive symptoms in patients with schizophrenia. The CDSS most accurately differentiated depressive symptoms from other symptoms of schizophrenia (divergent validity), correlated well with other depression instruments (concurrent validity), and was least likely to miss cases of depression or misdiagnose depression (predictive validity). Conclusions: We would recommend to use the CDSS for the measurement of depressive symptoms in research and in daily clinical practice of patients with schizophrenia. A valid self-report instrument is to be developed for the use in clinical practice. (C) 2011 Elsevier B.V. All rights reserved.

BackgroundAntidepressants are frequently prescribed in patients with psychotic disorders, but little is known about their effects in routine clinical practice. The objective was to investigate the prescribing patterns of antidepressants in relation to the course of depressive symptoms in patients with psychotic disorders.MethodsA cohort of 214 Dutch patients with psychotic disorders received two assessments of somatic and psychiatric health, including a clinician-rated screening for depressive symptoms, as part of annual routine outcome monitoring.ResultsDepressive symptoms were prevalent among 43% (93) of the patients. Antidepressants were prescribed for 40% (86) of the patients and the majority 83% (71) continued this therapy after one year. Multivariable analysis showed that patients with more severe psychopathology had a higher risk to develop depressive symptoms the following year (OR [95% CI]=0.953 [0.912–0.995]). For patients with depressive symptoms at baseline, polypharmacy was a potential risk factor to keep having depressive symptoms (OR [95% CI]=1.593 [1.123–2.261]). Antidepressant use was not an independent predictor in both analyses.ConclusionsRoutine outcome monitoring in patients with psychotic disorders revealed a high prevalence of depressive symptoms. Antidepressants were frequently prescribed and continued in routine clinical practice.

Cannabis use has been found to increase the risk of psychosis. It is unclear whether, after a first psychotic episode has occurred, continued cannabis use is associated with poor functional outcome of psychosis.As part of a randomized, open-label, controlled trial, the association of cannabis use and measures for psychopathology and social role functioning after 2 years of follow-up and for the recently proposed outcome measures of symptomatic remission, functional remission, and clinical recovery was explored in a group of 124 patients suffering from nonaffective first-episode psychosis (diagnosed according to DSM-IV and included from a catchment area in the Netherlands of 3.1 million inhabitants from October 2001 through December 2002). Other patient characteristics that were expected to be independently associated with outcome, among them alcohol and other drug use, were assessed at baseline.Continued cannabis use was not associated with symptomatic or functional remission or clinical recovery. After 2 years, cannabis use was related to certain aspects of social role functioning (economic and social activities; explained variance 5.6% and 8.4%, respectively) but not to psychopathology (Positive and Negative Syndrome Scale Positive, Negative, or General symptoms).Our findings support the notion that continued cannabis use after the onset of a first-episode psychosis is correlated with worse social outcome and should be discouraged whenever possible, but its role in outcome is modest in comparison to other factors.Nederlands Trial Register: http://www.trialregister.nl (ID: NTR 374).

BackgroundPrevious work suggests that exposure to childhood adversity is associated with the combination of delusions and hallucinations. In the present study, associations between (severity of) auditory vocal hallucinations (AVH) and (i) social adversity [traumatic experiences (TE) and stressful events (SE)] and (ii) delusional ideation were examined.MethodA baseline case-control sample of children with and without AVH were re-assessed on AVH after 5 years and interviewed about the experience of social adversity and delusions.ResultsA total of 337 children (mean age 13.1 years, s.d.=0.5) were assessed: 40 children continued to hear voices that were present at baseline (24%, persistent group), 15 heard voices only at follow-up (9%, incident group), 130 children no longer reported AVH that were present at baseline (remitted group) and 152 never heard voices (referent group). Both TE and SE were associated with both incident and persistent AVH, as well as with greater AVH severity and delusional ideation at follow-up. In addition, the combination of AVH and delusions displayed a stronger association with TE and SE compared with either AVH or delusions alone.ConclusionsEarly childhood AVH are mostly benign and transitory. However, experience of social adversity is associated with persistence, severity and onset of new AVH closer to puberty, and with delusional ideation.

Substance abuse and psychotic disorders have a high rate of comorbidity. Both disorders are associated with changes in the dopaminergic transmission in the mesocorticolimbic pathways of the brain. Since antipsychotic medications interact with the dopamine receptors in these pathways, these medications could affect craving for substances. In the current study, the effect of clozapine ( n = 27, mean dosage 350 mg), risperidone ( n = 54, mean dosage 3.46 mg) and olanzapine ( n = 60, mean dosage 13.78 mg) on subjective craving for cannabis was compared in 123 patients with cannabis dependence and psychotic disorder. Patients treated with risperidone reported significantly more craving compared with patients treated with clozapine ( Z = −3.19, p = .001) or olanzapine ( Z = −2.24, p = .025). No significant differences in craving between clozapine and olanzapine were found. These results are in concordance with findings in the literature on this subject and could be explained by differences in three dopamine mediated mechanisms of these compounds: 1) occupancy rate of dopamine D2 receptors, 2) dissociation rate of dopamine D2 receptors, 3) D1/D2 occupancy ratio. Risperidone and clozapine show a maximal difference in D2 receptor occupancy rate, dissociation rate and D1/D2 ratio. Olanzapine is intermediate between risperidone and clozapine in these characteristics.

Objective:This study examined the extent to which treatment plans of service users of community housing programs measure up to rehabilitation principles according to the Choose-Get-Keep model of psychiatric rehabilitation. The study evaluates whether these plans correspond with service-user and key-worker perspectives on unmet needs for care.Methods:A representative sample of key workers and service users of 16 Dutch Regional Institutes for Residential Care (RIRCs) participated in a cross-sectional survey. Sociodemographic and clinical data and an assessment of needs for care of 240 service users were collected. In addition, we received an anonymous copy of each participant's most recent written treatment plan. First, we developed a method to measure adherence to rehabilitation principles of written treatment plans, based on the Choose-Get-Keep model of psychiatric rehabilitation. Next, treatment plans were screened on the degree of adherence, expressed in a score from 0 to 10 for overall quality, and correlated with needs for care.Results:RIRCs mostly seem to succeed in sufficiently integrating rehabilitation principles in their treatment plans. Adherence to rehabilitation principles was neither associated with the service-user perspective nor with the key worker perspective on needs for care.Conclusions and implications for practice:Rehabilitation principles are rather well documented in the majority of written treatment plans, although apparently without substantial consequences for needs for care among the service users. Further research is needed to validate our method and to investigate not only the adherence to rehabilitation principles in written treatment plans, but also in the actual care provision itself.

Objectives: The aims of the present study were (1) to determine the proportion and characteristics of patients treated in Assertive Community Treatment teams who achieve symptomatic remission (SR) and/or functional remission (FR) and (2) to explore the association between both types of remission and (3) their bearing on quality of life (QoL).Methods: Data comprised assessments from 278 patients who were repeatedly assessed using the Positive and Negative Syndrome Scale to assess SR, the Health of the Nation Outcome Scales to assess FR, and a shortened version of the Manchester Short Assessment to assess QoL. chi(2) Tests and a logistic regression analysis were used to analyze the relation between patient and treatment characteristics and achieving SR or FR. A Kruskal-Wallis test, Mann-Whitney U tests, and a logistic regression analysis were used to analyze the relationship between remission status and QoL.Results: After a mean treatment duration of 2.4 years, 26% met the criteria for SR and 30% for FR. Prescription of antipsychotic medication was associated with achieving both SR and FR. Approximately half of the patients who achieved SR also achieved FR. Achieving FR was associated with better QoL. Patients in SR did not have better QoL than did patients not in SR.Conclusions: Remission of symptoms in patients treated in Assertive Community Treatment teams was not a prerequisite for FR or vice versa. FR, not SR, was associated with better QoL. (C) 2012 Elsevier Inc. All rights reserved.

Objective: To investigate the effect of the Boston Psychiatric Rehabilitation (PR) Approach on attainment of personal rehabilitation goals, social functioning, empowerment, needs for care, and quality of life in people with severe mental illness (SMI) in the Netherlands. Method: A 24-month, multicentre, randomized controlled trial was used to compare the results of PR to care as usual (CAU). Patients with SMI were randomly assigned by a central randomization centre to PR ( n = 80) or CAU ( n = 76). The primary outcome of goal attainment was assessed by independent raters blind to treatment allocation. Measures for secondary outcomes were change in work situation and independent living, the Personal Empowerment Scale, the Camberwell Assessment of Needs, and the World Health Organization Quality of Life assessment. Effects were tested at 12 and 24 months. Data were analyzed according to intention to treat. Covariates were psychiatric centre, psychopathology, number of care contacts, and educational level of the professionals involved. Results: The rate of goal attainment was substantially higher in PR at 24 months (adjusted risk difference: 21%, 95% CI 4% to 38%; number needed to treat [NNT] = 5). The approach was also more effective in the area of societal participation (PR: 21% adjusted increase, CAU: 0% adjusted increase; NNT = 5) but not in the other secondary outcome measures. Conclusions: The results suggest that PR is effective in supporting patients with SMI to reach self-formulated rehabilitation goals and in enhancing societal participation, although no effects were found on the measures of functioning, need for care, and quality of life.

BackgroundIn a baseline study among 7- and 8-year-old children with auditory vocal hallucinations, only limited functional impact was observed.AimsTo assess 5-year course and predictors of auditory vocal hallucinations, as well as 5-year incidence and its risk factors.MethodA sample of 337 children, 12 and 13 years of age, were reassessed on auditory vocal hallucinations and associated symptoms after a mean follow-up period of 5.1 years.ResultsThe 5-year persistence and incidence rates were 24% and 9% respectively, with more new cases arising in urban areas. Both persistent and incident auditory vocal hallucinations were associated with problem behaviour in the clinical range of psychopathology as measured with the Child Behavior Checklist, particularly at follow-up, as well as with other psychotic symptoms, particularly at baseline. Persistence was predicted by baseline auditory vocal hallucinations severity, particularly in terms of external attribution of voices and hearing multiple voices, and was associated with worse primary school test scores and lower secondary school level.ConclusionsFirst onset of auditory vocal hallucinations in middle childhood is not uncommon and is associated with psychopathological and behavioural comorbidity. Similarly, persistence of auditory vocal hallucinations in childhood is not uncommon and is associated with psychopathological, behavioural and cognitive alterations.

Rationale Antipsychotic affinity for the histamine H1 receptor and the muscarinic M3 receptor have been associated with the side effects weight gain, and development of diabetes, respectively. Objectives We investigated polymorphisms of the histamine H1 (HRH1) and muscarinic acetylcholine receptor M3 (CHRM3) receptor genes for an association with body mass index (BMI) and glycated hemoglobin (HbA1c). Methods We included 430 Caucasian patients with a non-affective psychotic disorder using antipsychotics for at least 3 months. Primary endpoints of the study were cross-sectionally measured BMI and HbA1c; secondary endpoints were obesity and hyperglycaemia. Two single-nucleotide polymorphisms (SNPs) in the HRH1 gene, rs346074 and rs346070, and one SNP in the CHRM3 gene, rs3738435, were genotyped. Our primary hypothesis in this study was an interaction between genotype on BMI and antipsychotic affinity for the H1 and M3 receptor. Results A significant association of interaction between haplotype rs346074–rs346070 and BMI (p value 0.025) and obesity (p value 0.005) in patients using high-H1 affinity antipsychotics versus patients using low-H1 affinity antipsychotics was found. There was no association of CHRM3 gene variant rs3738435 with BMI, and we observed no association with HbA1c or hyperglycaemia in any of the variants. Conclusions This study, for the first time, demonstrates a significant association between HRH1 variants and BMI in patients with a psychotic disorder using antipsychotics. In future, genotyping of HRH1 variants may help predicting weight gain in patients using antipsychotics. Electronic supplementary material The online version of this article (doi:10.1007/s00213-011-2211-x) contains supplementary material, which is available to authorized users.

Background Weight gain is one of the major problems in patients using antipsychotic medication, leading to relevant morbidities and reduced compliance to pharmacotherapy. Recently, an association has been reported between a single nucleotide polymorphism (rs1455832) of the roundabout axon guidance receptor, homolog 1 (ROBO1) gene and body mass index (BMI) in persons younger than 30 years. The aim of this study is to investigate the association between BMI and rs1455832 in patients with a psychotic disorder using antipsychotics.Methods A cross-sectional design was used in a pooled sample of Caucasian psychiatric patients obtained from three comparable Dutch psychiatric populations. Patients were eligible for inclusion in this study if they met the Diagnostic and Statistical Manual of Mental Disorders-IV criteria for a nonaffective psychotic disorder, were 18 years or older, and used one or more antipsychotics. Genotyping was performed according to standard protocols. Linear (for BMI) and logistic (for obesity, defined as BMI>30) regression analyses, corrected for age and sex, were applied in the statistical analyses.Results A total of 435 patients were included in this association analyses. The rs1455832 polymorphism studied was significantly associated with BMI and obesity in female patients. Female patients had a statistically significant (P=0.025) decrease of 1.76 kg/m(2) in BMI values per C allele. In contrast to female patients, this association was not exhibited in male patients.Conclusion The rs1455832 polymorphism may play a role in inducing obesity in female patients using antipsychotics. Psychiatr Genet 21:202-207 (C) 2011 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

BackgroundEvidence on cost-effectiveness is important to make well-informed decisions regarding care delivery.AimsTo determine the balance between costs and health outcomes of cognitive–behavioural therapy (CBT) compared with treatment as usual (TAU) in people with schizophrenia who have persistent and recurrent symptoms of psychosis. Trial number: ISRCTN57292778.MethodA total of 216 people were randomised and followed up for 18 months. The primary clinical outcome measure was time functioning within the normal range. Normal functioning was defined as social functioning within the 95% range of the general population and no or minimal suffering and/or no or minimal affect on daily life of persistent psychotic symptoms. The difference in number of days was estimated. Using a societal perspective, cost differences were estimated and combined with clinical outcome to yield an incremental cost-effectiveness ratio (ICER). Uncertainty was accessed using bootstrapping and displayed by means of a cost-effectiveness acceptability curve.ResultsIn the CBT group, participants experienced 183 days of normal social functioning, whereas the TAU group experienced 106 days. The ICER was e47 per day of normal functioning gained. Cognitive–behavioural therapy implies higher costs, yet results in better health outcomes. Sensitivity analyses showed that targeting individuals who have not been hospitalised before receiving CBT results in an ICER of e14 per day normal functioning gained.ConclusionsDays of normal functioning improved in the CBT condition compared with TAU, but this gain in health was associated with additional societal costs.

Reduced insight has been reported in a majority of patients with a psychotic disorder. Most studies have focused on associations with neurocognition, neglecting relations with social cognition. Two hundred seventy patients with nonaffective psychosis participated in this study, which was part of the GROUP (Genetic Risk and OUtcome of Psychosis)-project. Linear regression analyses were performed to investigate the predictive value of composite measures of neurocognition, social cognition, and clinical symptoms. The moderating effect of phase of illness was also investigated. Insight was measured with a composite measure, based on the insight item on the Positive And Negative Syndrome Scale (PANSS) and the Birchwood Insight Scale (BIS). Insight on the BIS and the PANSS correlated significantly (r =. 406). All independent variables correlated with the insight composite measure. The additional effect of social cognition and clinical symptoms were both significant. Phase of illness was a moderating variable: In patients with recent-onset psychosis (ROP), none of the independent variables explained variance. In patients with multiple episode or chronic psychosis, both social cognition and clinical symptoms had additional effects and explained insight, along with neurocognition, together explaining 20% of the variance. These findings indicate that multiple factors are associated with insight in psychosis. Specifically, associations of insight with social cognitive and clinical symptom measures were observed, over and above a contribution of neurocognition. This supports theories that imply a role for deficient emotion recognition and mentalizing in reduced insight. Further studies need to investigate insight in ROP into more detail. © 2010 The Author.

OBJECTIVES: The high incidence of schizophrenia in immigrant ethnic groups in Western Europe may be explained by social stress associated with ethnic minority status. Positive identification with one's own ethnic group is a strong predictor of mental health in immigrants. We investigated whether negative ethnic identity is related to schizophrenia risk in non-Western immigrants.METHODS: Matched case-control study of first-episode schizophrenia, including 100 non-Western immigrant cases, general hospital controls (n=100), and siblings (n=63). Conditional logistic regression analyses were used to investigate associations between schizophrenia and ethnic group identity.RESULTS: Cases had a negative ethnic identity more often than general hospital controls (64% and 35%, respectively, P < .001). After adjustment for marital status, level of education, unemployment, self-esteem, social support, and cannabis use, negative ethnic identity was associated with schizophrenia: odds ratio = 3.29; 95% confidence interval = 1.36-7.92. Cases significantly more often had an assimilated or a marginalized identity and less often had a separated identity. Comparisons between cases and siblings largely confirmed these findings.CONCLUSIONS: Negative identification with the own ethnic group may be a risk factor for schizophrenia in immigrants living in a context of social adversity.

BackgroundHearing voices occurs in middle childhood, but little is known about prevalence, aetiology and immediate consequences.AimsTo investigate prevalence, developmental risk factors and behavioural correlates of auditory vocal hallucinations in 7- and 8-year-olds.MethodAuditory vocal hallucinations were assessed with the Auditory Vocal Hallucination Rating Scale in 3870 children. Prospectively recorded data on pre- and perinatal complications, early development and current problem behaviour were analysed in children with auditory vocal hallucinations and matched controls.ResultsThe 1-year prevalence of auditory vocal hallucinations was 9%, with substantial suffering and problem behaviour reported in 15% of those affected. Prevalence was higher in rural areas but auditory vocal hallucinations were more severe and had greater functional impact in the urban environment. There was little evidence for associations with developmental variables.ConclusionsAuditory vocal hallucinations in 7- and 8-year-olds are prevalent but mostly of limited functional impact. Nevertheless, there may be continuity with more severe psychotic outcomes given the serious suffering in a subgroup of children and there is evidence for a poorer prognosis in an urban environment.

Objective: To examine the utility of the Community Assessment of Psychic Experiences (CAPE)-42, a self-report questionnaire, to improve detection of first-episode psychosis in new referrals to mental health services. Method: At first contact with mental health-care services patients were asked to complete the CAPE-42 and were then routinely diagnosed by a clinician. Standard diagnoses were obtained by means of the mini-Schedule for Clinical Assessment in Neuropsychiatry. Results: Of the 246 included patients, 26 (10.6%) were diagnosed with psychosis according to the mini-Schedule for Clinical Assessment in Neuropsychiatry. Only 10 of them were recognized by clinical routine, and 16 psychotic patients were not properly identified. Using an optimal cut-off of 50 on the frequency or distress dimension of the positive subscale of the CAPE-42 detected 14 of these misdiagnosed patients. The sensitivity of the CAPE-42 at this cut-off point was 77.5 and the specificity 70.5. Conclusion: Systematic screening of patients using a self-report questionnaire for psychotic symptoms improves routine detection of psychotic patients when they first come into contact with mental health services

Introduction: Generally agreed outcome criteria in psychosis are required to evaluate the effectiveness of new treatment strategies. The aim of this study is to explore clinical recovery in first-episode patients, defined by meeting criteria for both symptomatic and functional remission. Method: In a sample of first-episode patients (N = 125), symptomatic and functional remission during the last 9 months of a 2-year follow-up period were examined, as well as recovery and its predictors. Results: Half the patients (52.0%) showed symptomatic remission and a quarter (26.4%) functional remission, while one-fifth (19.2%) met both criteria sets and were considered recovered. Recovery was significantly associated with short duration of untreated psychosis and better baseline functioning. Conclusion: Most functionally remitted patients were also symptomatically remitted, while a minority of symptomatically remitted patients were also functionally remitted. Treatment delay may affect chance of recovery.

While knowledge about symptom presentation of adults with mild ASD, including comorbid psychopathology, is limited, referral of adults with suspected mild PDD is increasing. We report on pilot research investigating whether patients diagnosed with mild ASD (n = 15) and patients who were not diagnosed with ASD (n = 21) differed in terms of (a) AQ scores and (b) Axis I and II disorders, assessed by the SCAN and the IPDE. Additionally, AQ scores were compared with those from non-ASD patients referred to a general outpatient clinic (n = 369). The results showed very few differences between ASD patients and non-ASD patients. Self-report may not differentiate mild ASD patients from non-ASD patients and Axis I and II disorders seem equally prevalent among these two groups.

Social psychiatry as an academic discipline and field of clinical practice seems to have lost its prominence and is being incorporated in regular clinical services of mental healthcare and also in various branches of social, genetic, psychiatric or clinical epidemiology. However, the central debate in social psychiatry from its very beginning on how to care best for patients with severe mental illness (SMI) in the community, what to do with mental hospitals as potentially harmful pernicious institutions or with the hospitalization process, has never lost its momentum even in scientific meetings today. Social psychiatry and rehabilitation share a common focus on these issues, e. g. on independent living and working, on participation in society, and on prevention of hospitalization. Rehabilitation as an ideological and somewhat revolutionary movement of users and professionals in wanting to produce a fundamental change of mental healthcare (e. g. no compulsory treatment) and of society (e. g. elimination of stigma) developed its methods away from medicine and psychiatry and also away from testing these methods. Nowadays we observe growing scientific evidence for various psychosocial rehabilitative interventions which could substantiate the original mission of social psychiatry.

Background: Auditory hallucinations are experienced by 60-80% of all patients diagnosed with a schizophrenia spectrum disorder. However, in this patient group, the prevalence of hallucinations in multiple sensory modalities, i.e. multimodal hallucinations (MMHs), is unknown.Aims: To assess the prevalence of MMHs in patients diagnosed with a schizophrenia spectrum disorder, data were analyzed from 750 patients who participated in the Dutch Genetic Risk and Outcome of Psychosis (GROUP) study.Method: We drew on the section of the CASH (Comprehensive Assessment of Symptoms and History) that probes into the lifetime presence of auditory, visual, somatic/tactile, and olfactory hallucinations.Results: A lifetime prevalence of 80% was found in this group for hallucinations in any of these modalities. Within the whole group, 27% of the participants reported unimodal hallucinations and 53% MMHs. There were no significant differences in prevalence rate for Dutch versus migrant participants from Morocco, Turkey, Surinam or the (former) Dutch Antilles.Conclusion: We conclude that MMHs, rather than auditory hallucinations, are the most frequent perceptual symptom of patients diagnosed with a schizophrenia spectrum disorder. Our data also suggest that hallucinations experienced in a single sensory modality (notably auditory ones) stochastically increase the risk for more sensory modalities to join in. We recommend that future studies take into account all 14 sensory modalities in which hallucinations can be experienced. For this we provide a classification of MMHs that allows characterization of their serial versus simultaneous occurrence and their congruent versus incongruent nature. (C) 2016 The Authors. Published by Elsevier B.V.

Cannabis use has been associated with favorable outcomes on metabolic risk factors. The cause of this relation is still unknown. In this study we investigated whether this effect is mediated by the AKT1 gene, as activation of the related enzyme by cannabis may cause metabolic changes.Six Single Nucleotide Polymorphisms (SNPs) of the AKT1 gene (rs1130214, rs1130233, rs2494732, rs2498784, rs3730358, and rs3803300) of patients with psychotic disorders (n = 623) were related to Body Mass Index (BMI), levels of glycosylated hemoglobin (HBA(1c)) and total metabolic risk. Next, mediation analysis was performed with BMI as outcome, cannabis as predictor, and AKT1 as mediator. Cannabis use was inversely related to BMI but not with levels of HBA(1c) and totalmetabolic risk. Moreover, out of 6 AKT1 SNPs, rs2494732 was associated with cannabis use, but AKT1 did not mediate the effect of cannabis on BMI.In conclusion, cannabis use is likely to be associated with a lower BMI in patients with a psychotic disorder. Moreover, AKT1 risk alleles may increase the incidence of cannabis use in patients with a psychotic disorder, but AKT1 does not appear to mediate the effect of cannabis on BMI. (C) 2016 Elsevier B.V. All rights reserved.

Background: Schizophrenia is characterized by positive and negative symptoms, but recently anomalous self-experiences, e.g. exaggerated self-consciousness (hyperreflectivity), receive more attention as an important symptom domain in schizophrenia patients. The semi-structured interview, the Examination of Anomalous Self-Experience (EASE) [Psychopathology 2005;38:236-258], examines experiences of a disturbed sense of self in a sophisticated but time-consuming manner. Therefore, we proposed the Self-Experience Lifetime Frequency scale (SELF), an instrument intended to screen for self-disturbance phenomena. Here we compared scores of patients, their siblings and healthy controls on the SELF. Methods and Sampling: The SELF is composed of a validated screener for symptoms of depersonalization complemented by questions covering several other domains of self-disturbance. A total of 426 patients with a psychotic disorder, 526 of their unaffected siblings, and 297 healthy controls completed the SELF. Patients' scores on the 12 items of the SELF were subjected to an explorative principal axis factor analysis (PAF); composite scores on factor components were compared between the three participant groups. Results: The PAF revealed two components, explaining 43.9 and 9.5% of variance, respectively. The first component represents a disturbance of self-awareness; the second component reflects (milder forms of) diminished self-affection or depersonalization. The two components of the SELF revealed good internal consistency (component 1, α = 0.88; component 2, α = 0.79; ρ = 0.85). Patients showed significantly higher scores on both factor components in comparison with both siblings and controls. No significant differences were found between siblings and controls. Conclusions: The findings of the current study suggest that the SELF comprises two components of self-disturbance. Patients reported more (severe) symptoms of self-disturbance on both components, suggesting that it is feasible to screen for self-disturbance phenomena in patients with psychotic disorders with the SELF. Screening for symptoms of self-disturbance is important since these symptoms are associated with suffering and, moreover, these phenomena may mark the transition from intact to aberrant reality testing.

BackgroundPatient–clinician communication is central to mental healthcare but neglected in research.AimsTo test a new computer-mediated intervention structuring patient–clinician dialogue (DIALOG) focusing on patients' quality of life and needs for care.MethodIn a cluster randomised controlled trial, 134 keyworkers in six countries were allocated to DIALOG or treatment as usual; 507 people with schizophrenia or related disorders were included. Every 2 months for 1 year, clinicians asked patients to rate satisfaction with quality of life and treatment, and request additional or different support. Responses were fed back immediately in screen displays, compared with previous ratings and discussed. Primary outcome was subjective quality of life, and secondary outcomes were unmet needs and treatment satisfaction.ResultsOf 507 patients, 56 were lost to follow-up and 451 were included in intention-to-treat analyses. Patients receiving the DIALOG intervention had better subjective quality of life, fewer unmet needs and higher treatment satisfaction after 12 months.ConclusionsStructuring patient–clinician dialogue to focus on patients' views positively influenced quality of life, needs for care and treatment satisfaction.