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Clinical psychologists may work in a variety of settings, but the challenges of working in private practice can be beyond the experience of a trainee. Thus the chapter outlines the conduct in a private practice. It describes the important role of promotion and community education to engage with key stakeholders. The chapter highlights the added value of an evidence-based approach to practice and quality improvement, as they improve accountability and allow the demonstration of effectiveness. The chapter discusses the impact of the need to monitor costs and to adopt a business mentality. It concludes by describing two models for maintaining research engagement while in private practice.
People with psychotic disorders receive mental healthcare services mainly for their psychiatric care needs. However, patients often experience multiple physical or social wellbeing-related care needs as well. This study aims to identify care needs, investigate their changes over time and examine their association with mental healthcare consumption and evidence-based pharmacotherapy.
This study combined annually obtained routine outcome monitoring (ROM) data with care consumption data of people with a long-term psychotic illness receiving treatment in four Dutch mental healthcare institutes between 2012 and 2016. Existing treatment algorithms were used to determine psychiatric, physical and social wellbeing-related care needs based on self-report questionnaires, semi-structured interviews and physical parameters. Care consumption was measured in hours of outpatient mental healthcare consumption per year. Generalised estimating equation models were used to calculate odds ratios of care needs and their associations with time, mental healthcare consumption and medication use.
Participants (n = 2054) had on average 7.4 care needs per measurement and received 25.4 h of care per year. Physical care needs are most prevalent and persistent and people with more care needs receive more mental healthcare. Care needs for psychotic symptoms and most social wellbeing-related care needs decreased, whereas the chance of being overweight significantly increased with subsequent years of care. Several positive associations were found between care needs and mental healthcare consumption as well as positive relations between care needs and evidence-based pharmacotherapy.
This longitudinal study present a novel approach in identifying care needs and their association with mental healthcare consumption and pharmacotherapy. Identification of care needs in this way based on ROM can assist daily clinical practice. A recovery-oriented view and a well-coordinated collaboration between clinicians and general practitioners together with shared decisions about which care needs to treat, can improve treatment delivery. Special attention is required for improving physical health in psychosis care which, despite appropriate pharmacotherapy and increasing care consumption, remains troublesome.
There is an increasing interest in integrative (mental) health care and a growth in centers offering such services, but a paucity of research on patient characteristics, diagnosis, treatments offered, the effects of those treatments and patient satisfaction.
To examine the course of mental health outcomes in the context of the nature and quality of care of outpatients at a center for integrative psychiatry in the Netherlands, as well as relevant sociodemographic, clinical, and treatment-related moderators of this course.
Baseline patient demographics, clinical and treatment characteristics of 537 patients with a completed care episode between 2012 and 2019 were assessed. Satisfaction and mental health treatment outcomes were examined using routine outcome monitoring and analyzed with multilevel intention-to-treat models.
Two thirds of patients were woman (median age 41 years), predominantly with a primary diagnosis of mood or anxiety disorder. Mean number of treatment sessions was 49 (SD=94) and total clinical time was 54 hours (SD=109). Mean treatment duration was 460 days (SD=407). Ninety percent of the sample filled out one or more assessment(s). Of the individuals with a baseline assessment, 50% completed a follow-up. Significant improvements in symptomatology, social functioning, interpersonal functioning, wellbeing, resilience and quality of life were found. Clinical and scientific interpretation, moderator analyses and patient satisfaction will be presented at the conference.
Although no definite conclusions can be drawn due to the naturalistic design and missing data, especially at follow-up, patients seem to improve on all measured domains, including psychopathology, functioning and wellbeing.
Generalizability of antidepressant efficacy trials (AETs) to daily practice is questioned because of their very stringent patient selection. This study aims to determine eligibility for AETs of out-patients suffering from major depression in a routine out-patient setting and investigates influence of eligibility on treatment outcome.
Data collection (n=1653) was performed through routine outcome monitoring by independent trained research nurses. The Mini-International Neuropsychiatric Interview Plus and the Dimensional Assessment of Personality Pathology, short Dutch version were used for diagnostic assessment and personality pathology screening. The Montgomery–Asberg Depression Rating Scale (MADRS) was used for assessment of baseline severity and treatment outcome. Eligibility was assessed by stepwise application of commonly used exclusion criteria. Influence of eligibility on treatment outcome was investigated in a subsample of the 1653 patients who had at least one follow-up assessment (n=626). Eligible and non-eligible patients were compared on proportion of response (50% reduction) and remission on MADRS (MADRS⩽10).
Altogether, 17–25% of the patients were eligible for AETs. The most common reasons for exclusion would be ‘not meeting minimum baseline severity’ and ‘presence of co-morbid Axis I disorder’. Eligible and non-eligible patients did not differ in treatment outcome. Only ‘meeting the minimum baseline severity’ is associated with remission.
The majority of ‘real life’ out-patients are not eligible for AETs. However, the influence of eligibility on treatment outcome seems to be small. This suggests that stringent patient selection by eligibility criteria is not the major reason for lack of generalizability of AETs. Exclusion of less severely depressed patients from the analyses resulted in better treatment outcome. Milder depression is highly prevalent in daily practice and more research into treatment effectiveness in milder depression is warranted.
Pre-adult onset of major depressive disorder (MDD) may predict a more severe phenotype of depression. As data from naturalistic psychiatric specialty care settings are scarce, we examined phenotypic differences between pre-adult and adult onset MDD in a large sample of consecutive out-patients.
Altogether, 1552 out-patients, mean age 39.2±11.6 years, were diagnosed with current MDD on the Mini-International Neuropsychiatric Interview Plus diagnostic interview as part of the usual diagnostic procedure. A total of 1105 patients (71.2%) had complete data on all variables of interest. Pre-adult onset of MDD was defined as having experienced the signs and symptoms of a first major depressive episode before the age of 18 years. Patients were stratified according to the age at interview (20–40/40–65 years). Correlates of pre-adult onset were analysed using logistic regression models adjusted for age, age squared and gender.
Univariate analyses showed that pre-adult onset of MDD had a distinct set of demographic (e.g. less frequently living alone) and clinical correlates (more co-morbid DSM-IV – Text Revision diagnoses, more social phobia, more suicidality). In the multivariate model, we found an independent association only for a history of suicide attempts [odds ratio (OR) 3.15, 95% confidence intervals (CI) 1.97–5.05] and current suicidal thoughts (OR 1.81, 95% CI 1.26–2.60) in patients with pre-adult versus adult onset MDD.
Pre-adult onset of MDD is associated with more suicidality than adult onset MDD. Age of onset of depression is an easy to ascertain characteristic that may help clinicians in weighing suicide risk.
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