Keep quality in mind Antipsychotics, aggression and smoking in patients with a psychotic disorder

The aim of this thesis was to measure the quality of the care provided to patients with a psychotic disorder –and thereby identify targets that required more in-depth investigation of the need for improvement (part I). Auditing processes and measuring a small set of outcomes are solid, first steps to start improving care. We identified three potential harms: antipsychotic medication, aggression, and smoking (part II). Regarding antipsychotic medication (part IIa), we systematically reviewed the scientific evidence concerning the long-term mortality risk related to the use of clozapine and other antipsychotics. With respect to aggression (part IIb), we assessed short-term sequences of different types of aggression in patients admitted to a closed psychiatric ward. Also, we systematically reviewed the evidence on the influence of nursing staff’ attitudes and characteristics on coercive measures. Furthermore, we evaluated differences and similarities in the perspectives of patients and staff on aggressive incidents. Regarding smoking (part IIc), we tested several hypotheses explaining the high prevalence of smoking in patients with a psychosis or related disorders. Since we noticed that smoking cessation treatment was lacking, we decided to study the implementation of a smoking cessation program in an academic psychiatric hospital in the Netherlands. Inspired by the wish and the need to change hospital smoking policies, we also reviewed the literature on the risk of aggression after transition to a smoke-free psychiatric hospital. The high burden and worrying outcomes demand a focus on care for individuals with a severe mental illness, including psychotic disorders. For patients and providers, it is essential to keep quality in mind.