Biomedical subjects

Maarten W J Koeter

Publications and source records attributed to Maarten W J Koeter.

At least 19 recordsLinked to original sources

PubMed2006

Adjuvant occupational therapy for work-related major depression works: randomized trial including economic evaluation.

BACKGROUND: Major depression has far-reaching consequences for work functioning and absenteeism. In most cases depression is treated by medication and clinical management. The addition of occupational therapy (OT) might improve outcome. We determined the cost-effectiveness of the addition of OT to treatment as usual (TAU). METHOD: Sixty-two adults with major depression and a mean absenteeism of 242 days were randomized to TAU (out-patient psychiatric treatment) or TAU+OT [6 months, including (i) diagnostic phase with occupational history and work reintegration plan, and (ii) therapeutic phase with individual sessions and group sessions]. Main outcome domains were depression, work resumption, work stress and costs. Assessments were at baseline and at 3, 6, 12 and 42 months. RESULTS: The addition of OT to TAU: (i) did not improve depression outcome, (ii) resulted in a reduction in work-loss days during the first 18 months, (iii) did not increase work stress, and (iv) had a 75.5% probability of being more cost-effective than TAU alone. CONCLUSION: Addition of OT to good clinical practice does not improve depression outcome, improves productivity without increasing work stress and is superior to TAU in terms of cost-effectiveness.

Absenteeism↗

PubMed2006

Medication adherence in schizophrenia: exploring patients', carers' and professionals' views.

One of the major clinical problems in the treatment of people with schizophrenia is suboptimal medication adherence. Most research focusing on determinants of nonadherence use quantitative research methods. These studies have some important limitations in exploring the decision-making process of patients concerning medication. In this study we explore factors influencing medication adherence behavior in people with schizophrenia using concept mapping. Concept mapping is a structured qualitative method and was performed in 4 European countries. Participants were 27 patients with schizophrenia, 29 carers, and 28 professionals of patients with schizophrenia. Five clinically relevant themes were identified that affect adherence: medication efficacy, external factors (such as patient support and therapeutic alliance), insight, side effects, and attitudes toward medication. Importance ratings of these factors differed significantly between professionals and carers and patients. Professionals, carers, and patients do not have a shared understanding of which factors are important in patients' medication adherence behavior. Adherence may be positively influenced if professionals focus on the positive aspects of medication, on enhancing insight, and on fostering a positive therapeutic relationship with patients and carers.

Adult↗

PubMed2006

Static and dynamic patient characteristics as predictors of criminal recidivism: A prospective study in a Dutch forensic psychiatric sample.

If clinicians in forensic psychiatry want to reduce risk of reoffending in their patients, they require insight into dynamic risk factors, and evidence that these add predictive power to static risk indicators. Predictors need to be evaluated under clinically realistic circumstances. This study aimed to validate dynamic and static variables as predictors of reconviction in a naturalistic outcome study. Data on static and dynamic risk factors were collected for 151 patients discharged from Dutch forensic psychiatric hospitals. Community follow-up was prospective, with a 5.5 year minimum. A prediction model was developed using Cox regression analysis. The magnitude of the predictive power of this model was estimated using receiver operating characteristic (ROC) analysis. The final prediction model contained four static and no dynamic predictors. The model's ROC area under the curve was .79 (95% CI .69-.89). Clinical risk ratings were non-predictive. Post hoc analyses exploring the influence of subgroups of patients did not yield better models. It is concluded that a small set of static predictors yielded a good estimate of future reconvictions; inclusion of dynamic predictors did not add predictive power.

Crime↗

PubMed2006

Autobiographical memory in the euthymic phase of recurrent depression.

The authors investigated autobiographical memory specificity in subjects who formerly had depression. In 122 euthymic patients with at least two previous major depressive episodes, memory specificity was significantly impaired compared to matched control participants but not related to residual symptoms and illness characteristics, was not differentially affected by cognitive therapy, and was also not predictive of relapse/recurrence during the 2-year follow-up. However, memory specificity was associated with age, education, and immediate and delayed memory recall. The results suggest that memory specificity may reflect a global cognitive impairment that remains in patients who (formerly) had depression but does not constitute a trait marker for vulnerability for relapse/recurrence.

Adult↗

PubMed2006

Measuring craving: an attempt to connect subjective craving with cue reactivity.

BACKGROUND: Better insight into craving may contribute to the development of more efficient relapse prevention strategies. Inconsistent findings on the relation between craving and relapse may be due to difficulties in the measurement of craving. These difficulties are accounted for by 3 interrelated problems: lack of consensus regarding the definition of craving, the use of different time frames (craving now vs craving in the past), and lack of concordance between self-reported craving and psychophysiological measures of cue reactivity. The aim of this study is to develop and validate a new self-report questionnaire for the assessment of the core aspects of craving, taking into account different time frames and emphasizing the psychophysiological aspects of craving. It is hypothesized that this questionnaire will show higher concordance with measures of cue reactivity than existing self-report craving questionnaires. METHODS: Based on a semantic mapping sentence, a 24-item self-report questionnaire was developed: the Jellinek Alcohol Craving Questionnaire (JACQ). The questionnaire was tested in 2 samples of treatment-seeking alcohol-dependent patients (sample A, n = 251; sample B, n = 48). Psychometric properties were examined in sample A and cross-validated in sample B. The associations with psychophysiological and neuroendocrine measures of cue reactivity were studied in sample B. RESULTS: The JACQ consists of 1 dimension with the following 4 aspects: (1) emotional urge, (2) physical sensations, (3) temptation to drink, and (4) uncontrolled thoughts. All (sub)scales had a good internal consistency (alpha = 0.77-0.95) and were highly intercorrelated (r = 0.57-0.86). Craving-past correlated low with craving-now (r = 0.32). Craving-now (sub)scales showed a moderate association with heart rate (0.46-0.49), but not with respiration rate, skin conductance, or cortisol production in saliva following cue exposure. In contrast, craving-past (sub)scales showed a moderate association with cortisol production in saliva (0.15-0.42) following cue exposure. Remarkably, the physical symptoms scale did not show stronger association with psychophysiological and neuroendocrine measures than the other subscales. CONCLUSIONS: The JACQ reliably measures 1 dimension including 4 aspects of craving for distinct time frames. Despite the presence of a special subscale for physical sensations, only moderate relationships were found between self-reported craving and biological indicators of cue reactivity. These findings suggest individual differences between alcoholics in the detection and/or reporting of cue-related psychophysiological signs as indicators of cue reactivity. Further research should focus on the nature of these individual differences. In addition, more research is needed on the relative predictive validity of subjective phenotypic indicators of craving (such as self-reported craving) versus objective endophenotypic indicators of craving (such as physiological measures of cue reactivity) for example in the prediction of relapse.

Adult↗

PubMed2006

Differential predictors of response to preventive cognitive therapy in recurrent depression: a 2-year prospective study.

BACKGROUND: Major depressive disorder is a recurrent disease. Brief cognitive therapy (CT), added to either regular care or medication, is helpful in preventing relapse/recurrence. Little is known which type of persons benefit from preventive CT, the so called 'aptitude treatment interaction' effect. METHOD: The present cohort included exclusively patients with at least two previous episodes remitted on various types of treatments (n = 172). They were assessed within a clinical trial comparing treatment as usual (TAU) with preventive CT added to TAU. Differential demographic, illness-related, psychological and biological risk factors in postponing recurrence by preventive CT were examined. RESULTS: Significant aptitude-treatment-interaction effects were found for the number of previous episodes, daily hassles and life events, avoidant coping, gender, and morning cortisol levels. Preventive CT seemed ineffective in patients with life events (as more frequently reported by women in our study) and in patients with high episode number characterized by higher levels of avoidant coping. Generic predictors indicate that in CT, as in TAU, patients with more residual depressive symptomatology and higher levels of dysfunctional attitudes profit less from preventive CT. CONCLUSION: The finding that preventive CT protects against the influence of a consistently found risk factor of relapse/recurrence, i.e. the number of depressive episodes, underlines the potential of psychological preventive interventions. Preventive CT seemed to be especially effective in reducing presumably internally provoked, relapse/recurrence but may be quite ineffective in reducing externally provoked relapse/recurrence. CT possibly prevents either stress generation or disrupts kindling effects. Kindling effects probably cannot be disrupted in patients with higher levels of avoidant coping who experienced a high number of episodes, and patients who experienced life events.

Adult↗

PubMed2006

Prediction of recurrence in recurrent depression and the influence of consecutive episodes on vulnerability for depression: a 2-year prospective study.

OBJECTIVE: Depression is a recurring disease. Identifying risk factors for recurrence is essential. The purpose of this study was to identify factors predictive of recurrence and to examine whether previous depressive episodes influence vulnerability for subsequent depression in a sample of remitted recurrently depressed patients. METHOD: Recurrence was examined prospectively using the Structured Clinical Interview for DSM-IV Axis I Disorders in 172 euthymic patients with recurrent depression (DSM-IV) recruited from February 2000 through September 2000. Illness-related characteristics, coping, and stress (life events and daily hassles) were examined as predictors. RESULTS: Risk factors for recurrence were a high number of previous episodes, more residual depressive symptomatology and psychopathology, and more daily hassles. Factors with both an increasing and decreasing pathogenic effect with increasing episode number were detected. CONCLUSION: We found some support for dynamic vulnerability models that posit a change of vulnerability with consecutive episodes. Preventive interventions should be considered in patients with multiple recurrences, focusing on residual symptomatology and specific coping styles.

Activities of Daily Living↗

PubMed2005

Sustained efficacy of dialectical behaviour therapy for borderline personality disorder.

Dialectical Behaviour Therapy (DBT) is considered one of the most promising treatments for borderline personality disorder (BPD). Recently, we reported significantly positive effects of 12 months DBT on parasuicidal behaviour and impulsivity in a mixed group of female BPD patients with and without substance abuse. Fifty-eight women with BPD were randomly assigned to either 52 weeks of DBT or treatment as usual (TAU). Follow-up assessment took place at 78 weeks, i.e., 6 months after discontinuation of DBT. Participants were clinical referrals from addiction treatment and psychiatric services. Outcome measures included parasuicidal behaviour, impulsivity and substance abuse. Six months after treatment discontinuation, the benefits of DBT over TAU in terms of lower levels of parasuicidal and impulsive behaviours, and in alcohol use, sustained. No differences between the treatment conditions were found for drug abuse. In conclusion, DBT seems to have a sustained effect on some of the core symptoms of BPD and on alcohol problems in a mixed population of female borderline patients with and without substance abuse problems.

Adolescent↗

PubMed2005

Preventing relapse/recurrence in recurrent depression with cognitive therapy: a randomized controlled trial.

This article reports on the outcome of a randomized controlled trial of cognitive group therapy (CT) to prevent relapse/recurrence in a group of high-risk patients diagnosed with recurrent depression. Recurrently depressed patients (N = 187) currently in remission following various types of treatment were randomized to treatment as usual, including continuation of pharmacotherapy, or to treatment as usual augmented with brief CT. Relapse/recurrence to major depression was assessed over 2 years. Augmenting treatment as usual with CT resulted in a significant protective effect, which intensified with the number of previous depressive episodes experienced. For patients with 5 or more previous episodes (41% of the sample), CT reduced relapse/recurrence from 72% to 46%. Our findings extend the accumulating evidence that cognitive interventions following remission can be useful in preventing relapse/recurrence in patients with recurrent depression.

Cognitive Behavioral Therapy↗

PubMed2005

The effectiveness of anxiety treatment on alcohol-dependent patients with a comorbid phobic disorder: a randomized controlled trial.

OBJECTIVE: Evidence has emerged which indicates that the post-treatment relapse rate for alcohol-dependent patients with a comorbid anxiety disorder is higher than for alcohol-dependent patients without a comorbid anxiety disorder. The question raised by this evidence is whether the relapse rate in these dually diagnosed patients could be reduced if they were given additional treatment for the comorbid anxiety disorder. We attempted to answer this question by conducting a trial among patients with a double diagnosis of alcohol dependence and agoraphobia or social phobia. METHOD: We conducted a 32-week randomized controlled trial among 96 abstinent patients with a primary diagnosis of alcohol dependence and a comorbid anxiety disorder involving agoraphobia or social phobia. The patients were randomly assigned to an intensive psychosocial relapse-prevention program on its own (n = 49) or in combination with an anxiety treatment program comprising cognitive behavioral therapy (CBT) and optional pharmacotherapy consisting of an SSRI (n = 47). The primary outcome measure was the percentage of patients who suffered an alcohol relapse during a 32-week period. The secondary outcome measures were total abstinence, a reduction in the days of heavy drinking, and less severe anxiety symptoms. RESULTS: Although the additional therapy clearly reduced the anxiety symptoms, it had no significant effect on the alcohol relapse rates. CONCLUSION: Anxiety treatment for alcohol-dependent patients with a comorbid anxiety disorder can alleviate anxiety symptoms, but it has no significant effect on the outcome of alcohol treatment programs.

Adult↗

PubMed2005

Matching of treatment-resistant heroin-dependent patients to medical prescription of heroin or oral methadone treatment: results from two randomized controlled trials.

AIMS: To investigate which baseline patient characteristics of treatment-resistant heroin addicts differentially predicted treatment response to medical heroin prescription compared to standard methadone maintenance treatment. DESIGN: Two open-label randomized controlled trials; pooled data. SETTING: Methadone maintenance programmes and heroin treatment centres in six cities in the Netherlands. PARTICIPANTS: Four hundred and thirty heroin addicts. INTERVENTION: Methadone plus injectable heroin or methadone plus inhalable heroin compared to methadone alone prescribed over 12 months: heroin maximum 1000 mg per day, methadone maximum 150 mg per day. MAIN OUTCOME MEASURE: Dichotomous, multi-domain response index, including validated indicators of physical health, mental status and social functioning. FINDINGS: Data of the inhalable and injectable heroin trials were pooled. Intention-to-treat analysis showed that treatment with medically prescribed heroin plus methadone was significantly more effective (51.8% response) than standard methadone maintenance treatment (28.7%) (95% CI of response difference: 14.1-32.2%). Multivariate logistic regression analyses showed that only one of all baseline characteristics was predictive of a differential treatment effect: patients who had previously participated in abstinence-orientated treatment responded significantly better to heroin-assisted treatment than to methadone treatment (61% versus 24%), while patients without experience in abstinence-orientated treatment did equally well in heroin-assisted or methadone maintenance treatment (39% and 38%, respectively). CONCLUSIONS: The effect of heroin-assisted treatment is not dependent on clinical characteristics, with the exception of previous abstinence-orientated treatment: medical prescription of heroin is most effective for those patients who have previously participated in abstinence-orientated treatment.

Administration, Inhalation↗

PubMed2005

Impact of a foot and mouth disease crisis on post-traumatic stress symptoms in farmers.

Culling 27,000 farm animals during an epidemic of foot and mouth disease in The Netherlands in 2001 resulted in substantial psychological distress among Dutch farmers. We investigated the association of exposure to this crisis with symptoms of intrusions and avoidance as found in post-traumatic stress disorder. Survey results from the Impact of Event Scale administered to 661 Dutch dairy farmers showed that about half of those whose animals were culled suffered from severe post-traumatic distress; we conclude that such agricultural crises can have a substantial impact on mental health.

Agricultural Workers' Diseases↗

PubMed2004

Predictors of acamprosate efficacy: results from a pooled analysis of seven European trials including 1485 alcohol-dependent patients.

RATIONALE: Acamprosate is a proven effective intervention in the treatment of alcohol dependence. However, acamprosate prevents lapses or relapses only in a minority of patients. An important question, therefore, is whether there is a specific subgroup of patients who respond particularly well to acamprosate. OBJECTIVES: To identify predictors of acamprosate efficacy. Based upon the available evidence and hypotheses about the mechanisms underlying acamprosate's effects on drinking behavior, the following variables were considered to be potential positive predictors: high physiological dependence at baseline, negative family history of alcoholism, late age-of-onset, serious anxiety symptomatology at baseline, severe craving at baseline, and female gender. METHOD: Potential predictors of acamprosate's efficacy were analyzed in a pooled analysis of data from seven randomized placebo-controlled trials involving a total of 1485 patients with alcohol dependence. Outcome is measured in terms of cumulative abstinence duration (CAD), continuous abstinence (ABST), and time to first relapse (TFR). RESULTS: CAD and ABST were predicted by baseline measures of craving and anxiety, as well as by study and treatment condition. Acamprosate efficacy was not differentially associated with any of the predictor variables. Importantly, the hypotheses were rejected despite the large sample size and sufficient statistical power. COMMENT: The most straight-forward clinical implication of this study is that acamprosate can be considered as a potentially effective pharmacotherapy for all patients with alcohol dependence. The effect size of acamprosate alone is, however, moderate. Some evidence indicates that the combination of acamprosate with naltrexone or disulfiram leads to substantially better outcomes.

Acamprosate↗

PubMed2004

The structural coherence of clinically derived dynamic indicators of reoffending risk.

BACKGROUND: Forensic psychiatrists aim to reduce the risk of reoffending through treatment. With few exceptions, research evidence tends to favour risk assessment aids reliant on fixed historical rather than clinical data, but transparency in the making of clinical judgements is lacking. AIMS: To evaluate further a clinically derived 47-item dynamic risk assessment checklist; specifically to test first whether it has a meaningful dimensional structure and, second, the extent to which items and underlying dimensions are associated with a separate, direct clinical judgement of risk of reoffending. METHODS: Data sets from four previous studies on the reliability and validity of the Clinical Inventory of Dynamic Reoffending Risk Indicators (CIDRRI) were merged, yielding 370 cases. The resulting data set was analysed using principal axis (common) factor analysis, with orthogonal (varimax) rotation. In addition, receiver operating characteristic (ROC) curves were calculated. RESULTS: The model of best fit depended on treatment stage; for those in residential treatment it was a six- factor model (responsibility, self-reliance, antisocial/narcissistic traits, treatment compliance, goal attainment and avoidance); for those back in the community a five-actor model in which, effectively, the compliance and goal attainment factors became one, provided a better fit. These dimensions and some individual scale items were associated with clinical judgement of risk of reoffending. CONCLUSIONS AND CLINICAL IMPLICATIONS: This study provides evidence that the CIDRRI is an adequate operationalization of underpinnings of clinical risk assessment, and that these underpinnings are part of meaningful higher-order dimensions. The CIDRRI is a viable instrument for clinical use, taking only 15 minutes to complete and identifying dynamic risk factors, the validity of which needs to be further established.

Adult↗

PubMed2004

Family caregiving in depression: impact on caregivers' daily life, distress, and help seeking.

BACKGROUND: Attention to caregiving consequences has been mainly restricted to schizophrenia, although studies suggest that relatives of depressed patients also experience considerable distress. These studies, however, were conducted on small samples or with nonvalidated instruments. In our study, the caregiving consequences of 260 spouses and relatives of depressed patients were assessed with a well-validated 31-item questionnaire, the Involvement Evaluation Questionnaire (IEQ). METHODS: The IEQ was mailed to spouses and relatives of patients with major depression, dysthymic disorder, or other depressive disorders. Other instruments used were the Ways of Coping Checklist (WCC), a Dutch Social Support Questionnaire, and the Zung Self-rating Depression Scale (SDS). RESULTS: About 25-50% of caregivers worried about the patient's general health, treatment, safety, and future. They had to urge the patient to undertake activities, or took over tasks. There were relational strains, and they felt burdened, especially when the patient was in an acute phase. Caregivers often felt distressed and had to visit a (mental) health practitioner. Also, children were affected; caregivers reported high levels of difficult behavior, loss of appetite, sleeplessness, less playing, and less attention at school. Caregiving consequences occur less often than in schizophrenia, but the patterns are quite comparable. CONCLUSIONS: Caregiving consequences in depression occur frequently and cause distress in caregivers and patient's children. Attention should be paid to support relatives and spouses of depressed patients. Special attention should be paid to patient's children.

Activities of Daily Living↗

PubMed2004

Temporal stability of pathological scratchcard gambling among adult scratchcard buyers two years later.

AIMS: To estimate the 2-year cumulative incidence of pathological scratchcard gambling (PSG) among a representative sample of high-risk scratchcard buyers, to assess the 2-year temporal stability of PSG and scratchcard-related problems and to estimate the adjusted 1-year prevalence for PSG taking into account the temporal dynamics of this diagnosis. DESIGN: A prospective study with two assessments was applied to a non-proportional stratified random sample of 12,222 adult scratchcard buyers in the Netherlands. A cost-effective design was used and only those scratchcard buyers (n=201) who had already experienced some scratchcard-related problems at initial assessment were followed-up 2 years later. PARTICIPANTS: Two independent cohorts of buyers with scratchcard-related problems were followed-up: a cohort of 173 potential problematic scratchcard gamblers (PPSG) at increased risk for PSG and a cohort of 28 pathological scratchcard gamblers. Incidence and prevalence estimates were calculated for the total sample of adult scratchcard buyers and for the Dutch adult population. FINDINGS: Of the PPSG group 6.72% (95% CI 2.30-8.90%) became addicted to scratchcards during the 2-year period. The 2-year cumulative incidence of PSG among Dutch adult scratchcard players was 0.24% (95% CI 0.16-0.34%). The stability of the Diagnostic and Statistical Manual 4th edition (DSM-IV) diagnosis of PSG ranged from 11.1% to 42.9%, depending on whether or not those lost to follow-up were considered to be cases of PSG. Taking into account the dynamics of this disorder, using the most conservative assumption, the adjusted 1-year prevalence of PSG for the total sample of adult scratchcard buyers was 0.33% (95% CI 0.23-0.45%). CONCLUSIONS: PSG proves to be a rare phenomenon among adult scratchcard buyers in the Netherlands. Both incidence and prevalence of the DSM-IV diagnosis PSG were low. Stability of the DSM-IV diagnosis PSG, DSM-IV criteria and South Oaks Gambling Screening-S (SOGS-S) problems were low. Prevalence was stable over the time because incidence and recovery rates were very similar.

Adult↗

PubMed2003

Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials.

OBJECTIVE: To determine whether supervised medical prescription of heroin can successfully treat addicts who do not sufficiently benefit from methadone maintenance treatment. DESIGN: Two open label randomised controlled trials. SETTING: Methadone maintenance programmes in six cities in the Netherlands. PARTICIPANTS: 549 heroin addicts. INTERVENTIONS: Inhalable heroin (n = 375) or injectable heroin (n = 174) prescribed over 12 months. Heroin (maximum 1000 mg per day) plus methadone (maximum 150 mg per day) compared with methadone alone (maximum 150 mg per day). Psychosocial treatment was offered throughout. MAIN OUTCOME MEASURES: Dichotomous, multidomain response index, including validated indicators of physical health, mental status, and social functioning. RESULTS: Adherence was excellent with 12 month outcome data available for 94% of the randomised participants. With intention to treat analysis, 12 month treatment with heroin plus methadone was significantly more effective than treatment with methadone alone in the trial of inhalable heroin (response rate 49.7% v 26.9%; difference 22.8%, 95% confidence interval 11.0% to 34.6%) and in the trial of injectable heroin (55.5% v 31.2%; difference 24.3%, 9.6% to 39.0%). Discontinuation of the coprescribed heroin resulted in a rapid deterioration in 82% (94/115) of those who responded to the coprescribed heroin. The incidence of serious adverse events was similar across treatment conditions. CONCLUSIONS: Supervised coprescription of heroin is feasible, more effective, and probably as safe as methadone alone in reducing the many physical, mental, and social problems of treatment resistant heroin addicts.

Adult↗

PubMed2003

Are scratchcards addictive? The prevalence of pathological scratchcard gambling among adult scratchcard buyers in the Netherlands.

AIMS: To determine the prevalence of regular, potential problematic and pathological scratchcard gambling (PSG) 5 years after the introduction of scratchcards in the Netherlands. DESIGN AND PARTICIPANTS: A non-proportional stratified random sample of 12,222 scratchcard buyers was approached. Regular scratchcard buyers (n = 3342) were asked to fill out the South Oaks Gambling Screen (SOGS). Those with a SOGS score of 3 or more (n = 340) were interviewed with the gambling section of the DSM-IV Diagnostic Interview Schedule (DIS-T). Weighted data were used to obtain unbiased prevalence estimates. FINDINGS: The estimated prevalence of regular and potential problematic scratchcard gambling were 28.4% and 2.68%, respectively. Only 0.24% met DSM-IV criteria for PSG. Of those, only 0.09% were addicted uniquely to scratchcards. The remaining 0.15% were also addicted to other games of chance. Demographic and gambling characteristics of these 'combined' PSG (young men, mainly slot-machine players) resembled characteristics of pathological gamblers in general. In contrast to these 'combined' PSG, 'unique' PSG were mainly women between 25 and 34 years who spent relatively small amounts of money on scratchcards (equivalent to one scratchcard a day). CONCLUSION: Scratchcards have a very low addiction potential among adults in the Netherlands. Given the specific characteristics of the unique PSG and the relatively small amount of money they spent, the appropriateness of DSM criteria for this particular form of gambling can be questioned.

Adolescent↗