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Background and aims: To assess the preferences of Dutch psychiatric patients in three general hospital psychiatric settings for the dress of psychiatrists and patients preference to be addressed by psychiatrists. To assess the associations concerning different clothing styles and the attributes of the patient–doctor relationship. Methods: One hundred and seventy-three adults, in and outpatients (aged 18–89 years) attending the psychiatry departments of three general hospitals, were included during the period June 2015 to May 2016. In these hospitals, the psychiatrist staff has different clothing policies. Data were analyzed with SPSS21. Results: Divided over the three hospitals, 173 patients were included, 96 inpatients and 77 outpatients. The patients' opinions on the psychiatrists' dress differed significantly between the hospitals in line with the local hospital clothing policy (p = 0.002 for the male psychiatrists, p = 0.000 for the female psychiatrists). The patients' ethnicity significantly influenced their preferences for dress and address, as a majority of the patients with a non-Dutch ethnic background expressed a preference for white coats, and address by surname (RR = 2.0, p = 0.003 for male and RR = 2.1 p = 0.002 for female psychiatrists). A significant difference in preference for being addressed by their first names by the psychiatrist was found between Dutch and non-native Dutch patients (RR = 2.6, p = 0.005). According to patients, the male psychiatrist in trousers and a long sleeve shirt and female psychiatrist in casual clothing were most often associated as being the friendliest, a white coat as being the most competent, and wearing smart attire as being the most accessible. Conclusion: Patients' preferences are in line with current local clothing habits. Ethnicity, setting and country influence a patient's preferences. Casual clothing for psychiatrists is assessed as being the friendliest but as the least competent, and white coats are assessed as being the most competent but as being less friendly and less accessible. [ABSTRACT FROM AUTHOR]

Objective: Medical Psychiatry Units (MPUs), also known as Complexity Intervention Units (CIUs), provide care for complex patients suffering from both psychiatric and physical disorders. Because there is no consensus on the indications for admission to an MPU, daily practice and effectiveness research are hampered. This study therefore used a concept mapping approach to investigate which organizational and medical factors determine the decision to admit a patient to an MPU. Methods: The first step of the concept mapping approach was to create a list of factors determining MPU admission from literature. Secondly, clinical experts sorted and ranked these factors. The sorted and ranked data were then analyzed, and a draft conceptual framework was created. A final conceptual MPU admission framework was then drawn during an expert consensus meeting and recommendations for implementation were suggested. Results: Thirteen clinical experts defined 90 factors from literature, which were sorted and ranked by 40 experts from 21 Dutch hospitals. This concept mapping approach resulted in a five-cluster solution for an MPU admission framework based on: 1. Staff competencies and organizational pre-requisites; 2. Patient context; 3. Patient characteristics; 4. Medical needs and capabilities; and 5. Psychiatric symptoms and behavioral problems. Furthermore, three inclusion and two exclusion criteria were formulated to help the clinicians decide whether or not to admit patients to an MPU. These criteria can be implemented in daily practice. Conclusion: Implementing the five criteria derived from this conceptual framework will help make the admission decision for complex patients with psychiatric and physical disorders to an MPU more correct, consistent, and transparent. [ABSTRACT FROM AUTHOR]

Context: Magnetic resonance angiography (MRA) is a rapidly evolving technique that has been reported to be accurate for assessment of lower extremity arterial disease.Objective: To obtain the best available estimates of the diagnostic performance of MRA in patients with lower extremity arterial disease.Data Sources: Studies published from January 1985 through May 2000 in English, German, or French, identified from the MEDLINE, EMBASE, and Current Contents databases.Study Selection: Studies were included that allowed construction of 2 x 2 contingency tables for detection of stenosis greater than 50% or occlusion with MRA or arteriography in patients with claudication or critical ischemia.Data Extraction: Two observers graded the following elements of study quality: consecutively enrolled patients, prospective study design, clear cut-off levels, blinded assessment, and clear description of MRA technique. Summary receiver operating characteristic analysis was performed to examine the influence of year of publication, all methodological criteria, arterial tract, number of subdivisions within arterial tracts, and MRA technique on diagnostic performance.Data Synthesis: Of 3583 studies initially identified, 34 were included that evaluated MRA in 1090 patients (72% men; median age, 65 years). Magnetic resonance angiography was highly accurate for assessment of all lower extremity arteries. Three-dimensional gadolinium-enhanced (3-D Gd) MRA improved diagnostic performance compared with 2-D MRA (relative diagnostic odds ratio, 2.8 [95% confidence interval, 1.2-6.4]), adjusted for number of subdivisions within arterial tracts. The estimated points of equal sensitivity and specificity were 94% and 90% for 3-D Gd MRA and 2-D MRA, respectively.Conclusions: Magnetic resonance angiography is highly accurate for assessment of the entire lower extremity for arterial disease. Three-dimensional Gd-enhanced MRA improves diagnostic performance compared with 2-D MRA. [ABSTRACT FROM AUTHOR]

Background: Our objective was to evaluate the diagnostic accuracy of abdominal symptoms in gallstones in studies using ultrasonography or oral cholecystography as the reference standard and to assess the extent to which variability in diagnostic accuracy is explained by patient selection and other characteristics of study design. Methods: A Medline search (1966-1998) was conducted in combination with reference checking for further relevant publications. Two independent assessors selected controlled studies that included patients ≥18 years of age. Articles were excluded if sensitivity and specificity could not be extracted or the included patients were at extraordinary risk for gallstones. Seven abdominal symptoms were evaluated. Modification of the diagnostic accuracy by clinical setting, extent of the disease, blinding, age, and sex was analysed by using logistic regression. Results: A total of 24 publications were included. The symptoms `biliary colic', `radiating pain', and `analgesics used' were consistently related to gallstones. The setting of the study had a significant effect on the diagnostic accuracy of these symptoms. The unadjusted, pooled diagnostic odds ratios, however, were low (2.6 (95% confidence interval, 2.4-2.9), 2.8 (2.2-3.7), and 2 (1.6-2.5), respectively). The diagnostic odds ratio of biliary colic increased with the extent of gallstone disease (13.3 (4.2-42). Conclusions: Although biliary colic was specific for gallstones, 80% of the referred patients with gallstones presented with other abdominal symptoms. There is no current evidence that justifies the use of single abdominal symptoms, other than biliary colic, in the diagnosis of symptomatic gallstones. Further research should focus on the prognosis of patients with non-specific abdominal symptoms and gallstones. [ABSTRACT FROM AUTHOR]

Context: The literature contains a large number of potential biases in the evaluation of diagnostic tests. Strict application of appropriate methodological criteria would invalidate the clinical application of most study results.Objective: To empirically determine the quantitative effect of study design shortcomings on estimates of diagnostic accuracy.Design and Setting: Observational study of the methodological features of 184 original studies evaluating 218 diagnostic tests. Meta-analyses on diagnostic tests were identified through a systematic search of the literature using MEDLINE, EMBASE, and DARE databases and the Cochrane Library (1996-1997). Associations between study characteristics and estimates of diagnostic accuracy were evaluated with a regression model.Main Outcome Measures: Relative diagnostic odds ratio (RDOR), which compared the diagnostic odds ratios of studies of a given test that lacked a particular methodological feature with those without the corresponding shortcomings in design.Results: Fifteen (6.8%) of 218 evaluations met all 8 criteria; 64 (30%) met 6 or more. Studies evaluating tests in a diseased population and a separate control group overestimated the diagnostic performance compared with studies that used a clinical population (RDOR, 3.0; 95% confidence interval [CI], 2.0-4.5). Studies in which different reference tests were used for positive and negative results of the test under study overestimated the diagnostic performance compared with studies using a single reference test for all patients (RDOR, 2.2; 95% CI, 1.5-3.3). Diagnostic performance was also overestimated when the reference test was interpreted with knowledge of the test result (RDOR, 1.3; 95% CI, 1.0-1.9), when no criteria for the test were described (RDOR, 1.7; 95% CI, 1.1-2.5), and when no description of the population under study was provided (RDOR, 1.4; 95% CI, 1.1-1.7).Conclusion: These data provide empirical evidence that diagnostic studies with methodological shortcomings may overestimate the accuracy of a diagnostic test, particularly those including nonrepresentative patients or applying different reference standards. [ABSTRACT FROM AUTHOR]

The article presents a comparison on the efficacies of different pharmacological drugs used for people with psychotic depression. It discusses the method used in the study, data sources and clinical outcomes of the effectiveness of antipsychotic drugs used. The results show that combination drugs improves the clinical response in comparison with placebo and antipsychotic drugs alone.

Objectives: Diagnostic pathways are limited. A validated instrument that can triage patients when they are suspected of mild dementia (MD) is necessary to optimise referrals. Method: The MoCA is validated for identifying MD and mild cognitive impairment (MCI) in a cohort of patients suspected of cognitive impairment (CI) after initial assessment in old age psychiatry. The reference standard was the consensus-based diagnoses for MD and MCI, adhering to the international criteria and using suspected patients, but without CI as comparisons (NoCI). Results: The mean MoCA scores differ significantly between the groups: 24(SE: .59) in NoCI, 21(SE: .31) in MCI and 16,7(SE: .45) in MD ( p  < .05). The AUC of MD against non-demented (MCI + NoCI) was 0.83(95%CI: 0.78-0.88) resulting in 90% sensitivity, 65% specificity, 50%PPV and 94%NPV at a "best" cutoff of <21 according the Youden index and respectively 0.77(95%CI: 0.69-0.85), 56%, 73%, 90%, 28% for CI (MD + MCI) against NoCI at <21. Conclusion: 90% of individuals with a MoCA of <21 will have CI (MD + MCI), while 94% with a MoCA of ≥21 will not have dementia. The MoCA can reduce referrals substantially (50%) by selecting who don't need further work up in a memory clinic, even if they were suspected of CI after initial assessment.

Objective/methods: The Montreal Cognitive Assessment (MoCA) is an increasingly used screening tool for cognitive impairment. While it has been validated in multiple settings and languages, most studies have used a biased case-control design including healthy controls as comparisons not representing a clinical setting. The purpose of the present cross-sectional study is to test the criterion validity of the MoCA for mild cognitive impairment (MCI) and mild dementia (MD) in an old age psychiatry cohort (n = 710). The reference standard consists of a multidisciplinary, consensus-based diagnosis in accordance with international criteria. As a secondary outcome, the use of healthy community older adults as additional comparisons allowed us to underscore the effects of case-control spectrum-bias., Results: The criterion validity of the MoCA for cognitive impairment (MCI + MD) in a case-control design, using healthy controls, was satisfactory (area under the curve [AUC] 0.93; specificity of 73% less than 26), but declined in the cross-sectional design using referred but not cognitive impaired as comparisons (AUC 0.77; specificity of 37% less than 26). In an old age psychiatry setting, the MoCA is valuable for confirming normal cognition (greater than or equal to 26, 95% sensitivity), excluding MD (greater than or equal to 21; negative predictive value [NPV] 98%) and excluding MCI (greater than or equal to 26;NPV 94%); but not for diagnosing MD (less than 21; positive predictive value [PPV] 31%) or MCI (less than 26; PPV 33%)., Conclusions: This study shows that validating the MoCA using healthy controls overestimates specificity. Taking clinical and demographic characteristics into account, the MoCA is a suitable screening tool-in an old age psychiatry setting-for distinguishing between those in need of further diagnostic investigations and those who are not but not for diagnosing cognitive impairment., (© 2019 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.)

Background: The mental status examination (MSE) is part of everyday psychiatric practice. However, it is unknown which items of the MSE are considered important and how the MSE is appreciated in the Netherlands.
AIM: To gain insight in the importance of the MSE, and to investigate which items are used in everyday practice.
METHOD: Dutch psychiatrists and residents filled in a questionnaire, using a 5-point Likert scale, where they rated frequency of use and importance of 24 different items of the Dutch MSE. They also reported which items, in their opinion, should be rated 'always', 'on indication only' or 'never'. Finally, the respondents were asked about their need of education and training in the MSE. The data were collected through an online questionnaire, which was distributed through email and the website of the Dutch psychiatric association.
RESULTS: A total of 402 respondents filled in the questionnaire, of which 60.4% were psychiatrists and 39.6% were residents. The MSE was seen as an essential part of the everyday psychiatric practice. The current format was appreciated strongly. In current practice, 10 items of the MSE were 'always' rated by more than 50% of the respondents. Ten items were rated very rarely, if ever. Respondents thought these items should only be rated on specific indication. There was a need for extra training in the MSE amongst residents and psychiatrists.
CONCLUSION: The Dutch MSE, consisting of 24 items, is strongly appreciated by psychiatrists and residents as an essential part of the psychiatric diagnostic process. In the everyday practice only a part of the items are used frequently.

Objective: To study the course of the functional status and healthcare needs of patients on a Medical Psychiatric Unit (MPU)., Methods: In a single-centre observational prospective design the Health of the Nation Outcome Scales (HoNOS) and Camberwell Assessment of Needs Short Appraisal Schedule (CANSAS) instruments were administered at admission and discharge. Functional status and healthcare needs were assessed utilizing the HoNOS and CANSAS respectively. The total costs of healthcare claims related to the admission were calculated based on claims data., Results: In total 50 patients were included with a mean improvement of 4.6 on the HoNOS and an effect size of 0.6.The total number of unmet needs fell from 208 to 115. The median costs per decreased HoNOS point were €2.842 and €6.880 per unmet need., Discussion: Many patients improved, but due to a large standard deviation at baseline and a low Cronbach's alpha, only 4 patients showed a reliable improvement on functional status. That substantial remission was achieved was shown by the decrease in unmet needs of 93 (44.7%) for the whole group. These observations support the implementation of MPUs, although more research is warranted to ensure cost-effectiveness., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Evidence is limited regarding the most effective pharmacological treatment for psychotic depression: combination of an antidepressant plus an antipsychotic, monotherapy with an antidepressant or monotherapy with an antipsychotic. This is an update of a review first published in 2005 and last updated in 2009., Objectives: 1. To compare the clinical efficacy of pharmacological treatments for patients with an acute psychotic depression: antidepressant monotherapy, antipsychotic monotherapy and the combination of an antidepressant plus an antipsychotic, compared with each other and/or with placebo.2. To assess whether differences in response to treatment in the current episode are related to non-response to prior treatment., Search Methods: A search of the Cochrane Central Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register (CCDANCTR) was carried out (to 12 April 2013). These registers include reports of randomised controlled trials from the following bibliographic databases: EMBASE (1970-), MEDLINE (1950-) and PsycINFO (1960-). Reference lists of all studies and related reviews were screened and key authors contacted., Selection Criteria: All randomised controlled trials (RCTs) that included participants with acute major depression with psychotic features, as well as RCTs consisting of participants with acute major depression with or without psychotic features, that reported separately on the subgroup of participants with psychotic features., Data Collection and Analysis: Two review authors independently extracted data and assessed risk of bias in the included studies, according to the criteria of the Cochrane Handbook for Systematic Reviews of Interventions. Data were entered into RevMan 5.1. We used intention-to-treat data. For dichotomous efficacy outcomes, the risk ratio (RR) with 95% confidence intervals (CIs) was calculated. For continuously distributed outcomes, it was not possible to extract data from the RCTs. Regarding the primary outcome of harm, only overall dropout rates were available for all studies., Main Results: The search identified 3659 abstracts, but only 12 RCTs with a total of 929 participants could be included in the review. Because of clinical heterogeneity, few meta-analyses were possible. The main outcome was reduction of severity (response) of depression, not of psychosis.We found no evidence for the efficacy of monotherapy with an antidepressant or an antipsychotic.However, evidence suggests that the combination of an antidepressant plus an antipsychotic is more effective than antidepressant monotherapy (three RCTs; RR 1.49, 95% CI 1.12 to 1.98, P = 0.006), more effective than antipsychotic monotherapy (four RCTs; RR 1.83, 95% CI 1.40 to 2.38, P = 0.00001) and more effective than placebo (two identical RCTs; RR 1.86, 95% CI 1.23 to 2.82, P = 0.003).Risk of bias is considerable: there were differences between studies with regard to diagnosis, uncertainties around randomisation and allocation concealment, differences in treatment interventions (pharmacological differences between the various antidepressants and antipsychotics) and different outcome criteria., Authors' Conclusions: Psychotic depression is heavily understudied, limiting confidence in the conclusions drawn. Some evidence indicates that combination therapy with an antidepressant plus an antipsychotic is more effective than either treatment alone or placebo. Evidence is limited for treatment with an antidepressant alone or with an antipsychotic alone.

Background: Evidence is limited regarding the most effective pharmacological treatment for psychotic depression: combination of an antidepressant plus an antipsychotic, monotherapy with an antidepressant or monotherapy with an antipsychotic. This is an update of a review first published in 2005 and last updated in 2009., Objectives: 1. To compare the clinical efficacy of pharmacological treatments for patients with an acute psychotic depression: antidepressant monotherapy, antipsychotic monotherapy and the combination of an antidepressant plus an antipsychotic, compared with each other and/or with placebo.2. To assess whether differences in response to treatment in the current episode are related to non-response to prior treatment., Search Methods: A search of the Cochrane Central Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register (CCDANCTR) was carried out (to 12 April 2013). These registers include reports of randomised controlled trials from the following bibliographic databases: EMBASE (1970-), MEDLINE (1950-) and PsycINFO (1960-). Reference lists of all studies and related reviews were screened and key authors contacted., Selection Criteria: All randomised controlled trials (RCTs) that included participants with acute major depression with psychotic features, as well as RCTs consisting of participants with acute major depression with or without psychotic features, that reported separately on the subgroup of participants with psychotic features., Data Collection and Analysis: Two review authors independently extracted data and assessed risk of bias in the included studies, according to the criteria of the Cochrane Handbook for Systematic Reviews of Interventions. Data were entered into RevMan 5.1. We used intention-to-treat data. For dichotomous efficacy outcomes, the risk ratio (RR) with 95% confidence intervals (CIs) was calculated. For continuously distributed outcomes, it was not possible to extract data from the RCTs. Regarding the primary outcome of harm, only overall dropout rates were available for all studies., Main Results: The search identified 3659 abstracts, but only 12 RCTs with a total of 929 participants could be included in the review. Because of clinical heterogeneity, few meta-analyses were possible. The main outcome was reduction of severity (response) of depression, not of psychosis.We found no evidence for the efficacy of monotherapy with an antidepressant or an antipsychotic.However, evidence suggests that the combination of an antidepressant plus an antipsychotic is more effective than antidepressant monotherapy (three RCTs; RR 1.49, 95% CI 1.12 to 1.98, P = 0.006), more effective than antipsychotic monotherapy (four RCTs; RR 1.83, 95% CI 1.40 to 2.38, P = 0.00001) and more effective than placebo (two identical RCTs; RR 1.86, 95% CI 1.23 to 2.82, P = 0.003).Risk of bias is considerable: there were differences between studies with regard to diagnosis, uncertainties around randomisation and allocation concealment, differences in treatment interventions (pharmacological differences between the various antidepressants and antipsychotics) and different outcome criteria., Authors' Conclusions: Psychotic depression is heavily understudied, limiting confidence in the conclusions drawn. Some evidence indicates that combination therapy with an antidepressant plus an antipsychotic is more effective than either treatment alone or placebo. Evidence is limited for treatment with an antidepressant alone or with an antipsychotic alone.

Background: The optimal pharmacological treatment of unipolar psychotic depression is uncertain., Aims: To compare the clinical effectiveness of pharmacological treatments for patients with unipolar psychotic depression., Method: Systematic review and meta-analysis of randomised controlled trials., Results: Ten trials were included in the review. We found no evidence that the combination of an antidepressant with an antipsychotic is more effective than an antidepressant alone. This combination was statistically more effective than an antipsychotic alone., Conclusions: Antidepressant monotherapy and adding an antipsychotic if the patient does not respond, or starting with the combination of an antidepressant and an antipsychotic, both appear to be appropriate options for patients with unipolar psychotic depression. However, clinically the balance between risks and benefits may suggest the first option should be preferred for many patients. Starting with an antipsychotic alone appears to be inadequate.

Background: Regarding the pharmacological treatment of psychotic depression there is uncertainty about the effectiveness of an antidepressant alone compared to the combination of an antidepressant and an antipsychotic., Objectives: To compare the clinical effectiveness of pharmacological treatments for patients with a psychotic depression: antidepressant monotherapy, antipsychotic monotherapy, and the combination of an antidepressant and an antipsychotic, compared with each other and/or with placebo., Search Strategy: (1) The Cochrane Central Register of Controlled Trials (CENTRAL) was screened with the terms depressive disorder and drug treatment (April 2004). (2) MEDLINE (1966 to April 2004) and EMBASE (1980 to April 2004) were searched using terms with regard to treatment of unipolar psychotic depression.(3) Reference lists of related reviews and reference lists of all identified studies were searched.(4) Personal communications., Selection Criteria: All randomised controlled trials (RCTs) with patients with major depression with psychotic features as well as RCTs with patients with major depression with or without psychotic features which reported on the subgroup of patients with psychotic features separately., Data Collection and Analysis: Two reviewers assessed the methodological quality of the included studies, according to the Cochrane Handbook criteria. Data were entered into RevMan 4.2.5. We used intention-to-treat data. For dichotomous efficacy outcomes, the relative risk with 95% confidence intervals (CI) was calculated. For continuously distributed outcomes, it was not possible to extract data from the RCTs. Regarding the primary harm outcome, only overall drop-out rates were available for all studies., Main Results: The search identified 3333 abstracts, but only 10 RCTs with a total of 548 patients could be included in the review. Due to clinical heterogeneity, few meta-analyses were possible. We found no conclusive evidence that the combination of an antidepressant and an antipsychotic is more effective than an antidepressant alone (two RCTs; RR 1.44, 95% CI 0.86 to 2.41), but a combination is more effective than an antipsychotic alone (three RCTs; RR 1.92, 95% CI 1.32 to 2.80). There were no statistically significant differences in the overall drop-out rates between any of the treatments, neither in individual studies nor after pooling of studies., Authors' Conclusions: Treatment with an antipsychotic alone is not a good option. Starting with an antidepressant alone and adding an antipsychotic if the patient does not respond or starting with the combination of an antidepressant and an antipsychotic both appear appropriate options for patients with psychotic depression. In clinical practice the balance between risks and benefits suggests that initial antidepressive monotherapy and adding an antipsychotic if there is inadequate response should be the preferred treatment strategy for many patients. The general lack of available data limits confidence in the conclusions drawn.

Aim: To improve the accuracy and completeness of reporting of studies of diagnostic accuracy in order to allow readers to assess the potential for bias in a study and to evaluate the general isability of its results., Methods: The standards for reporting of diagnostic accuracy (STARD) steering committee searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and extracted potential items into an extensive list. Researchers, editors, and members of professional organisations shortened this list during a 2 day consensus meeting with the goal of developing a checklist and a generic flow diagram for studies of diagnostic accuracy., Results: The search for published guidelines about diagnostic research yielded 33 previously published checklists, from which we extracted a list of 75 potential items. At the consensus meeting, participants shortened the list to a 25-item checklist, by using evidence whenever available. A prototype of a flow diagram provides information about the method of recruitment of patients, the order of test execution and the numbers of patients undergoing the test under evaluation, the reference standard, or both., Conclusions: Evaluation of research depends on complete and accurate reporting. If medical journals adopt the checklist and the flow diagram, the quality of reporting of studies of diagnostic accuracy should improve to the advantage of clinicians, researchers, reviewers, journals, and the public.

The objective of the 'Standards for Reporting of Diagnostic Accuracy' (STARD) initiative is to improve the reporting of studies of diagnostic accuracy, so as to allow readers to assess the potential for bias in a study and to evaluate the generalibility of its results. The group searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies. This was used to draw up a list of potential items. During a consensus meeting, a group of researchers, medical journal editors, and members of professional organisations reduced this list to a usable checklist. Wherever possible, evidence from the literature was used to justify the decisions made. The search for published guidelines about diagnostic research yielded 33 previously published checklists, from which a list of 75 potential items was extracted. At the consensus meeting, participants shortened the list to a 25-item checklist. A generic flow diagram was drawn up to provide guidance on the method for including patients, the order in which tests were to be conducted and the number of patients to undergo the test being evaluated, the reference standard, or both. A scientific publication can only be assessed when the reporting is both correct and complete. Use of the checklist and flow diagram will improve the quality of reports produced, to the advantage of clinicians, researchers, reviewers, journal editors and other interested parties.