Objective: To assess the appropriateness of and variation in intention-to-treat decisions in the management of depression in the Netherlands. Design: Mailed survey with 22 paper cases (vignettes) based on a population study. Setting: A random sample from four professional groups in the Dutch mental healthcare system. Subjects: 264 general practitioners, psychiatrists, psychotherapists, and clinical psychologists. Main outcome measures: Each vignette contained information on a number of patient characteristics taken from three national depression guidelines. The distribution of patient characteristics was based on data from a population study. Respondents were asked to choose the best treatment option and the best treatment setting. For each vignette we examined which of the selected treatments was appropriate according to the recommendations of the three published Dutch clinical guidelines and a panel of experts.Results: 31% of all intention-to-treat decisions were not consistent with the guidelines. Overall, less severe depression, alcohol abuse, psychotic features, and lack of social resources were related to more inappropriate judgements. There was considerable variation between the professional groups: psychiatrists made more appropriate choices than the other professions although they had the highest rate of overtreatment. Conclusions: There is sufficient variation in the intentions to treat depression to give it priority in quality assessment and guideline development. Efforts to achieve appropriate care should focus on treatment indications, referral patterns, and overtreatment.
The model explained nearly half of the decision by mental health professionals to seclude vignette patients. Rater characteristics were at least as important as patient variables, including problem behaviors and diagnosis, and ward features. Because perceived approachability of the patient was a key factor, seclusion reduction policies should focus on supporting professionals in their efforts to manage inpatients with problem behaviors in an appropriate way.
The use of seclusion in psychiatric practice is a controversial issue in the Netherlands, as a number of recent studies have shown seclusion to be a predominant restrictive measure. In contrast to many surrounding countries, Dutch legislation is arranged in such a way that the protection of the physical integrity of the patient is more important than professional considerations with respect to the treatment of severe mental illness. The opening of a new admission ward provided the opportunity to study the effect of a number of preventive measures both before and after admission on the use of seclusion. Two admission wards with the approximately the same staff compilation, the same
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