In the December issue of “Tijdschrift voor Psychiatrie” Morrens reported on the winners of the prize for best paper in 2013 with a doctor in training in psychiatry as first author. A five-member jury rated a total of 15 papers on theoretics, originality, use of language, structure, and scientific, social and clinical relevancy. The 1250 euro first prize was awarded to the paper “An increase of compulsory admissions in Belgium and the Netherlands: an epidemiological exploration”. According to the jury, the authors demonstrated that the incidence of compulsory admissions per 100,000 inhabitants increased by 42% in Belgium and 25% in the Netherlands. These numbers were singled out eventhough a commentary by me, that was published in the journal’s April issue, pointed out that these percentages cannot be compared because they concern different time periods, 1999-2008 and 2002-2009 respectively. The authors confirmed that the increase in the period 2002-2008 was roughly equal in both countries, i.e. 21% and 20% (Tijdschrift voor Psychiatrie, 2013, 4: 304 - 306). But this was not the most important issue. 

Because of complex problems adolescents often fail to complete their course of treatment. Van der Reijen and colleagues aimed to investigate whether gender and symptom severity predict course of treatment. The English summary is truly puzzling. First of all, the aim of the study does not relate to the background info. Complexity (seen as having both psychiatric and behavioural problems) as background concept is different from symptom severity (many psychiatric problems). Secondly, the method section does not indicate the design or type of analyses. The authors attempted to find out if treatment outcome could be predicted by symptom severity and gender differences “of 127 male adolescent patients” (something went wrong in translation). But summary results include only inter-rater reliability, not symptom and gender differences. Finally, the conclusion is descriptive more than persuasive: “the questionnaire was not able to predict accurately whether patients would complete their treatment”. However, the devil is in the full text…

Sanders and colleagues compare executive and general cognitive functioning in patients with frontotemporal dementia (ftd) and in patients with schizophrenia in later life. These psychiatric conditions need to be differentiated but both lead to cognitive disorders and to executive impairments. The study compared 25 outpatients diagnosed as having ftd with the test results for 31 elderly schizophrenia patients.

Executive and general cognitive functioning scores for the patients with ftd were significantly lower than the scores for patients with schizophrenia (mean differences of 1.6/pooled SD=3.4 and 3.9/pooled SD=3.05; p-values are reported as .04 and <.01 respectively). The study also compared early and late onset within the 31 schizophrenia patients to exclude this factor as confounder - no statistically significant differences were found. The authors conclude that there are differences between patients with ftd and elderly patients with schizophrenia which are not explained by early versus late onset schizophrenia.

All variables, including possible covariates, were tested for normality using Kolmogorov-Smirnov tests, which is not necessary, not appropriate for an ordinal classification of education, and generally not a good idea (Read here why >>). Primairy outcome measures were analysed using t-tests or Mann-Whitney tests “depending on normality, followed by univariate analysis correcting for age” (sic – no ANCOVA or regression analyses were reported). In the result section it is unclear which test were applied and why the authors corrected for age, but not for duration-of-illness (including early versus late onset could result in loss of information). In the discussion section it remains unclear what is indicated by a 2 point difference in executive functioning or a 4 point difference in general cognitive functioning. This are medium to large effects in Cohen’s T-shirt sizes, but are they relevant in clinical practice?

There can be no disagreement with the authors' closing remark that further studies are needed in order to differentiate between the two illnesses.

Frontotemporal dementia and schizophrenia in later life: a comparison of executive and general cognitive functioning – F. Sanders, M.M.J. Smeets-Janssen, P.D. Meesters, A.E. van der Vlies, C.J. Kerssens, Y.A.L. Pijnenburg Tijdschrift voor psychiatrie 54(2012)5, 409-417

 

Voermans et al. investigated aspects of the attention psychiatrists and trainees give to patients’ sexual problems. Psychiatrists and trainees were asked to complete an online questionnaire about the discussion of these problems (response rate 44%).
The authors aimed to discover which factors influence the amount of attention psychiatrists and trainees give to patients’ sexual problems. But logistic regression models covered six questions about attention given to sexual problems. Dependent variables were not dichotomous and in some cases it is not self-evident how the response categories “Almost never”, “Now and then”, “Frequently”, and “Almost always” were re-levelled. Alternative classifications could lead to different results. Independent variables were 10 items from a newly constructed questionnaire. Variable selection was based on back step elimination of items with p-values higher than .05 – however, the Wald statistic is conservative and textbooks advice to use the log likelihood test (see Hosmer & Lemeshow, 2000).

The study showed that about 50% of the respondents spent less than five minutes per week discussing sexual problems with their patients. Feelings of shame and incompetence were identified as the main reasons for this, but no information about model fit was reported. The authors point out that lack of time was not identified as a significant factor, but lack of evidence is no proof of lack of time. The authors acknowledge possible selection bias but assume that among the 56% non-responders there are more psychiatrists and trainees avoiding sexual problems. However, other interpretations are equally likely.

Is there adequate discussion between psychiatrists and their patients regarding patients’ sexual problems? – J.M. Voermans, H.L. Van, J. Peen, M.W. Hengeveld. Tijdschrift voor psychiatrie, 54(2012)1, 9-16

 

The authors investigated the link between patient characteristics, the Camberwell Assessment of Need Short Appraisal Schedule (cansas), early drop-out and treatment duration. Results showed that patients with severe mental illness (smi) who remained under treatment by an assertive community treatment team (N=611) were more frequently male, born outside the Netherlands and had a psychotic or addiction disorder more frequently than patients who had left the act team treatment early (N=430).

Table 1 (see below) shows that 62% of the patients born outside the Netherlands remained in treatment versus 38% drop-outs. That looks like a large 24% difference. However, patient characteristics were summarized in misleading row percentages.

P-values and all that

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