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Background: Clients with severe mental illness (SMI) have overall poor physical health. SMI reduces life expectancy by 5-17 years, primarily due to physical comorbidity linked to cardiometabolic risks that are mainly driven by unhealthy lifestyle behaviours. To improve physical health in clients with SMI, key elements are systematic somatic screening and lifestyle promotion. The nurse-led GILL eHealth was developed for somatic screening and the implementation of lifestyle activities in clients with SMI. Aims of this study are to evaluate the effectiveness of the GILL eHealth intervention in clients with SMI compared to usual care, and to evaluate the implementation process, and the experiences of clients and healthcare providers with GILL eHealth., Methods: The GILL study encompasses a cluster-randomised controlled trial in approximately 20 mental health care facilities in the Netherlands. The randomisation takes place at the team level, assigning clients to the eHealth intervention or the usual care group. The GILL eHealth intervention consists of two complementary modules for somatic screening and lifestyle promotion, resulting in personalised somatic treatment and lifestyle plans. Trained mental health nurses and nurse practitioners will implement the intervention within the multidisciplinary treatment context, and will guide and support the participants in promoting their physical health, including cardiometabolic risk management. Usual care includes treatment as currently delivered, with national guidelines as frame of reference. We aim to include 258 clients with SMI and a BMI of 27 or higher. Primary outcome is the metabolic syndrome severity score. Secondary outcomes are physical health measurements and participants' reports on physical activity, perceived lifestyle behaviours, quality of life, recovery, psychosocial functioning, and health-related self-efficacy. Measurements will be completed at baseline and at 6 and 12 months. A qualitative process evaluation will be conducted alongside, to evaluate the process of implementation and the experiences of clients and healthcare professionals with GILL eHealth., Discussion: The GILL eHealth intervention is expected to be more effective than usual care in improving physical health and lifestyle behaviours among clients with SMI. It will also provide important information on implementation of GILL eHealth in mental health care. If proven effective, GILL eHealth offers a clinically useful tool to improve physical health and lifestyle behaviours., Trial Registration: Clinical trial registration NCT05533749, registration date: 8 September 2022., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Smoking among people with severe mental illness (SMI) is highly prevalent and strongly associated with poor physical health. Currently, evidence-based smoking cessation interventions are scarce and need to be integrated into current mental health care treatment guidelines and clinical practice. Therefore, the present study aims to evaluate the implementation and effectiveness of a smoking cessation intervention in comparison with usual care in people with SMI treated by Flexible Assertive Community Treatment (FACT) teams in the Netherlands., Methods: A pragmatic, cluster-randomised controlled trial with embedded process evaluation will be conducted. Randomisation will be performed at the level of FACT teams, which will be assigned to the KISMET intervention or a control group (care as usual). The intervention will include pharmacological treatment combined with behavioural counselling and peer support provided by trained mental health care professionals. The intervention was developed using a Delphi study, through which a consensus was reached on the core elements of the intervention. We aim to include a total of 318 people with SMI (aged 18-65 years) who smoke and desire to quit smoking. The primary outcome is smoking status, as verified by carbon monoxide measurements and self-report. The secondary outcomes are depression and anxiety, psychotic symptoms, physical fitness, cardiovascular risks, substance use, quality of life, and health-related self-efficacy at 12 months. Alongside the trial, a qualitative process evaluation will be conducted to evaluate the barriers to and facilitators of its implementation as well as the satisfaction and experiences of both patients and mental health care professionals., Discussion: The results of the KISMET trial will contribute to the evidence gap of effective smoking cessation interventions for people treated by FACT teams. Moreover, insights will be obtained regarding the implementation process of the intervention in current mental health care. The outcomes should advance the understanding of the interdependence of physical and mental health and the gradual integration of both within the mental health care system., Trial Registration: Netherlands Trial Register, NTR9783. Registered on 18 October 2021., (© 2023. The Author(s).)

Background: People with severe mental illness (SMI) often suffer from long-lasting symptoms that negatively influence their social functioning, their ability to live a meaningful life, and participation in society. Interventions aimed at increasing physical activity can improve social functioning, but people with SMI experience multiple barriers to becoming physically active. Besides, the implementation of physical activity interventions in day-to-day practice is difficult. In this study, we aim to evaluate the effectiveness and implementation of a physical activity intervention to improve social functioning, mental and physical health., Methods: In this pragmatic stepped wedge cluster randomized controlled trial we aim to include 100 people with SMI and their mental health workers from a supported housing organization. The intervention focuses on increasing physical activity by implementing group sports activities, active guidance meetings, and a serious game to set physical activity goals. We aim to decrease barriers to physical activity through active involvement of the mental health workers, lifestyle courses, and a medication review. Participating locations will be divided into four clusters and randomization will decide the start of the intervention. The primary outcome is social functioning. Secondary outcomes are quality of life, symptom severity, physical activity, cardiometabolic risk factors, cardiorespiratory fitness, and movement disturbances with specific attention to postural adjustment and movement sequencing in gait. In addition, we will assess the implementation by conducting semi-structured interviews with location managers and mental health workers and analyze them by direct content analysis., Discussion: This trial is innovative since it aims to improve social functioning in people with SMI through a physical activity intervention which aims to lower barriers to becoming physically active in a real-life setting. The strength of this trial is that we will also evaluate the implementation of the intervention. Limitations of this study are the risk of poor implementation of the intervention, and bias due to the inclusion of a medication review in the intervention that might impact outcomes., Trial Registration: This trial was registered prospectively in The Netherlands Trial Register (NTR) as NTR NL9163 on December 20, 2020. As the The Netherlands Trial Register is no longer available, the trial can now be found in the International Clinical Trial Registry Platform via: https://trialsearch.who.int/Trial2.aspx?TrialID=NL9163 ., (© 2022. The Author(s).)

Background: Lifestyle interventions for severe mental illness (SMI) are known to have small to modest effect on physical health outcomes. Little attention has been given to patient-reported outcomes (PROs)., Aim: To systematically review the use of PROs and their measures, and quantify the effects of lifestyle interventions in patients with SMI on these PROs., Methods: Five electronic databases were searched (PubMed/Medline, Embase, PsycINFO, CINAHL, and Web of Science) from inception until 12 November 2020 (PROSPERO: CRD42020212135). Randomised controlled trials (RCTs) evaluating the efficacy of lifestyle interventions focusing on healthy diet, physical activity, or both for patients with SMI were included. Outcomes of interest were PROs., Results: A total of 11.267 unique records were identified from the database search, 66 full-text articles were assessed, and 36 RCTs were included, of which 21 were suitable for meta-analyses. In total, 5.907 participants were included across studies. Lifestyle interventions had no significant effect on quality of life (g = 0.13; 95% CI = - 0.02 to 0.27), with high heterogeneity (I 2  = 68.7%). We found a small effect on depression severity (g = 0.30, 95% CI = 0.00 to 0.58, I 2  = 65.2%) and a moderate effect on anxiety severity (g = 0.56, 95% CI = 0.16 to 0.95, I 2  = 0%)., Discussion: This meta-analysis quantifies the effects of lifestyle interventions on PROs. Lifestyle interventions have no significant effect on quality of life, yet they could improve mental health outcomes such as depression and anxiety symptoms. Further use of patient-reported outcome measures in lifestyle research is recommended to fully capture the impact of lifestyle interventions., (© 2022. The Author(s).)

Background: Children and adolescents in mental healthcare often perceive their care needs and necessary treatment differently from their clinicians. As such discordance between young patients and clinicians may obstruct treatment adherence and compromise treatment outcomes, it is important to understand the factors associated with it. We therefore investigated the factors associated with patient-clinician discordance with regard to care needs in various areas of functioning., Methods: A cross-sectional study involving 244 children/adolescents aged 6-18 participating with their clinicians in treatment at a specialized mental healthcare center. As a previous study conducted by our research group had found the greatest patient-clinician discordance in three CANSAS care needs-"mental health problems," "information regarding diagnosis and/or treatment," and "making and/or keeping friends"-we used univariable and multivariable statistics to investigate the factors associated with discordance regarding these three care needs., Results: patient-clinician discordance on the three CANSAS items was associated with child, parent, and family/social-context factors. Three variables were significant in each of the three final multivariable models: dangerous behavior towards self (child level); severity of psychiatric problems of the parent (parent level); and growing up in a single-parent household (family/social-context level)., Conclusions: To deliver treatment most effectively and to prevent drop-out, it is important during diagnostic assessment and treatment planning to address the patient's care needs at all three levels: child, parent and family/social context., (© 2022. The Author(s).)

Background: Several interventions have been developed to improve physical health and lifestyle behaviour of people with a severe mental illness (SMI). Recently, we conducted a pragmatic cluster-randomised controlled trial which evaluated the effects of the one-year Severe Mental Illness Lifestyle Evaluation (SMILE) lifestyle intervention compared with usual care in clients with SMI. The SMILE intervention is a 12-month group-based lifestyle intervention with a focus on increased physical activity and healthy food intake. The aim of the current study was to explore the experiences of people with SMI and healthcare professionals (HCPs) regarding implementation feasibility of the SMILE intervention and the fidelity to the SMILE intervention., Methods: A process evaluation was conducted alongside the pragmatic randomized controlled trial. The experiences of clients and HCPs in the lifestyle intervention group were studied. First, descriptive data on the implementation of the intervention were collected. Next, semi-structured interviews with clients (n = 15) and HCPs (n = 13) were performed. Interviews were audiotaped and transcribed verbatim. A thematic analysis of the interview data was performed using MAXQDA software. In addition, observations of group sessions were performed to determine the fidelity to the SMILE intervention using a standardised form., Results: Ten out of 26 HCPs who conducted the group sessions discontinued their involvement with the intervention, primarily due to changing jobs. 98% of all planned group sessions were performed. Four main themes emerged from the interviews: 1) Positive appraisal of the SMILE intervention, 2) Suggestions for improvement of the SMILE intervention 3) Facilitators of implementation and 4) Barriers of implementation. Both clients and HCPs had positive experiences regarding the SMILE intervention. Clients found the intervention useful and informative. The intervention was found suitable and interesting for all people with SMI, though HCPs sometimes had to tailor the intervention to individual characteristics of patients (e.g., with respect to cognitive functioning). The handbook of the SMILE intervention was perceived as user-friendly and helpful by HCPs. Combining SMILE with daily tasks, no support from other team members, and lack of staff and time were experienced as barriers for the delivery of the intervention., Conclusion: The SMILE intervention was feasible and well-perceived by clients and HCPs. However, we also identified some aspects that may have hindered effective implementation and needs to be considered when implementing the SMILE intervention in daily practice., (© 2022. The Author(s).)

Background: Cardiovascular disease is the leading cause of the estimated 11-25 years reduced life expectancy for persons with serious mental illness (SMI). This excess cardiovascular mortality is primarily attributable to obesity, diabetes, hypertension, and dyslipidaemia. Obesity is associated with a sedentary lifestyle, limited physical activity and an unhealthy diet. Lifestyle interventions for persons with SMI seem promising in reducing weight and cardiovascular risk. The aim of this study is to evaluate the effectiveness and cost-effectiveness of a lifestyle intervention among persons with SMI in an outpatient treatment setting., Methods: The Serious Mental Illness Lifestyle Evaluation (SMILE) study is a cluster-randomized controlled trial including an economic evaluation in approximately 18 Flexible Assertive Community Treatment (FACT) teams in the Netherlands. The intervention aims at a healthy diet and increased physical activity. Randomisation takes place at the level of participating FACT-teams. We aim to include 260 outpatients with SMI and a body mass index of 27 or higher who will either receive the lifestyle intervention or usual care. The intervention will last 12 months and consists of weekly 2-h group meetings delivered over the first 6 months. The next 6 months will include monthly group meetings, supplemented with regular individual contacts. Primary outcome is weight loss. Secondary outcomes are metabolic parameters (waist circumference, lipids, blood pressure, glucose), quality of life and health related self-efficacy. Costs will be measured from a societal perspective and include costs of the lifestyle program, health care utilization, medication and lost productivity. Measurements will be performed at baseline and 3, 6 and 12 months., Discussion: The SMILE intervention for persons with SMI will provide important information on the effectiveness, cost-effectiveness, feasibility and delivery of a group-based lifestyle intervention in a Dutch outpatient treatment setting., Trial Registration: Dutch Trial Registration NL6660 , registration date: 16 November 2017.

Background: Increasing attention to palliative care for the general population has led to the development of various evidence-based or consensus-based tools and interventions. However, specific tools and interventions are needed for people with severe mental illness (SMI) who have a life-threatening illness. The aim of this systematic review is to summarize the scientific evidence on tools and interventions in palliative care for this group., Methods: Systematic searches were done in the PubMed, Cochrane Library, CINAHL, PsycINFO and Embase databases, supplemented by reference tracking, searches on the internet with free text terms, and consultations with experts to identify relevant literature. Empirical studies with qualitative, quantitative or mixed-methods designs concerning tools and interventions for use in palliative care for people with SMI were included. Methodological quality was assessed using a critical appraisal instrument for heterogeneous study designs. Stepwise study selection and the assessment of methodological quality were done independently by two review authors., Results: Four studies were included, reporting on a total of two tools and one multi-component intervention. One study concerned a tool to identify the palliative phase in patients with SMI. This tool appeared to be usable only in people with SMI with a cancer diagnosis. Furthermore, two related studies focused on a tool to involve people with SMI in discussions about medical decisions at the end of life. This tool was assessed as feasible and usable in the target group. One other study concerned the Dutch national Care Standard for palliative care, including a multi-component intervention. The Palliative Care Standard also appeared to be feasible and usable in a mental healthcare setting, but required further tailoring to suit this specific setting. None of the included studies investigated the effects of the tools and interventions on quality of life or quality of care., Conclusions: Studies of palliative care tools and interventions for people with SMI are scarce. The existent tools and intervention need further development and should be tailored to the care needs and settings of these people. Further research is needed on the feasibility, usability and effects of tools and interventions for palliative care for people with SMI.

Background: Since anxiety and depressive disorders often recur, self-management competencies are crucial for improving the long-term course of anxiety and depressive disorders. However, few relapse prevention programmes are available that focus on improving self-management. E-health combined with personal contact with a mental health professional in general practice might be a promising approach for relapse prevention. In this protocol, the GET READY (Guided E-healTh for RElapse prevention in Anxiety and Depression) study will be described in which a relapse prevention programme is developed, implemented and evaluated. The aim of the study is to determine patients' usage of the programme and the associated course of their symptoms, to examine barriers and facilitators of implementation, and to assess patients' satisfaction with the programme., Methods: Participants are discharged from mental healthcare services, and are in complete or partial remission. They receive access to an E-health platform, combined with regular contact with a mental health professional in general practices. Online questionnaires will be completed at baseline and after 3, 6 and 9 months. Also, semi-structured qualitative individual interviews and focus group interviews will be conducted with patients and mental health professionals., Discussion: This mixed-methods observational cohort study will provide insights into the use of a relapse prevention programme in relation to the occurrence of symptoms, as well as in its implementation and evaluation. Using the results of this study, the relapse prevention programme can be adapted in accordance with the needs of patients and mental health professionals. If this programme is shown to be acceptable, a randomized controlled trial may be conducted to test its efficacy., Trial Registration: Retrospectively registered in the Netherlands Trial Register ( NTR7574 ; 25 October 2018).

Background: People experiencing homelessness often encounter progressive incurable somatic diseases in combination with psychiatric and psychosocial problems, and many need palliative care at the end of their lives. Little is known about how palliative care for this group can be started in good time and provided optimally. The objective of this paper is to give insight into the extent people experiencing homelessness have access to good palliative care., Methods: Qualitative in-depth interviews were held to reconstruct the cases of 19 people experiencing homelessness in the Netherlands. Eight cases concerned persons being in the palliative phase (using the surprise question) and the other 11 cases concerned persons recently died after a period of ill health due to somatic illness. We used purposive sampling until data saturation was reached. The total number of interviews was 52. All interviews were transcribed verbatim and analysed inductively., Results: Three key themes were: 'late access', 'capricious trajectory' and 'complex care'. The first key theme refers to the often delayed start of palliative care, because of the difficulties in recognizing the need for palliative care, the ambivalence of people experiencing homelessness about accepting palliative care, and the lack of facilities with specific expertise in palliative care for them. The second key theme refers to the illness trajectory, which is often capricious because of the challenging behaviour of people experiencing homelessness, an unpredictable disease process and a system not being able to accommodate or meet their needs. The third key theme refers to the complexity of their care with regard to pain and symptom control, psychosocial and spiritual aspects, and the social network., Conclusions: The care for in the palliative phase does not satisfy the core requirements of palliative care since there are bottlenecks regarding timely identification, the social network, and the assessment and management of physical symptoms and psychosocial and spiritual care needs. Education in palliative care of outreach professionals, training staff in shelters in the provision of palliative care, and building a network of palliative care specialists for people experiencing homelessness.

Background: Many patients with an eating disorder report difficulties in regulating their emotions and show a high prevalence of self-injurious behaviour. Several studies have stated that both eating disorder and self-injurious behaviour help emotion regulation, and are thus used as coping mechanisms for these patients. We aimed to determine the prevalence of self-injurious behaviour, its characteristics and its emotion-regulation function in patients with anorexia nervosa or an eating disorder not otherwise specified ( n  = 136)., Methods: A cross-sectional design using a self-report questionnaire. Mann-Whitney U -tests were conducted to compare the background and clinical variables between patients with self-injurious behaviour and patients without this type of behaviour. Changes in emotional state before and after self-injurious behaviour were tested by Wilcoxon signed rank tests., Results: Our results showed a 41% prevalence of self-injurious behaviour in the previous month. Patients who performed self-injurious behaviour had a statistically significant longer treatment history for their eating disorder than those who did not. Whereas 55% of self-injuring patients had a secondary psychiatric diagnosis, only 21% of participants without self-injurious behaviour did. Regarding the impact of self-injurious behaviour, our results showed a significant increase in "feeling relieved" and a significant decrease in "feeling angry at myself", "feeling anxious" and "feeling angry at others". This indicates that self-injurious behaviour can be regarded as an emotion-regulation behaviour. Participants were usually aware of the causes of their self-injurious behaviour acts., Conclusions: Professionals should systematically assess the occurrence of self-injurious behaviour in eating disorder patients, pay special attention to patients with more severe and comorbid psychopathology, and those with a long treatment history. This assessment should be followed by a functional analysis of the self-injurious behaviour and by effective therapeutic interventions alongside the eating disorder treatment., Competing Interests: The study was approved by the research committee at Altrecht Eating Disorders Rintveld, Zeist, The Netherlands [protocol number 1140], in accordance both with the declaration of Helsinki and with the Dutch legislation regarding medical research in health care. All participants voluntarily agreed to participate in the study and gave their written informed consent. Written informed consent for participants aged younger than 18 years was also given by their parents.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: More knowledge about characteristics of children and adolescents who need intensive levels of psychiatric treatment is important to improve treatment approaches. These characteristics were investigated in those who need youth Assertive Community Treatment (youth-ACT)., Method: A cross-sectional study among children/adolescents and their parents treated in either a regular outpatient clinic or a youth-ACT setting in a specialized mental health treatment center in the Netherlands., Results: Child, parent and family/social context factors were associated with treatment intensification from regular outpatient care to youth-ACT. The combination of the child, parent, and family/social context factors adds substantially to the predictive power of the model (Nagelkerke R 2 increasing from 36 to 45% for the three domains separately, to 61% when all domains are combined). The strongest predictors are the severity of psychiatric disorders of the child, parental stress, and domestic violence., Conclusions: Using a wide variety of variables that are potentially associated with treatment intensification from regular outpatient clinic to youth-ACT, we constructed a regression model illustrating a relatively strong relation between the predictor variables and the outcome (Nagelkerke R 2  = 0.61), with three strong predictors, i.e. severity of psychiatric disorders of the child, parental stress, and domestic violence. This emphasizes the importance of a system-oriented approach with primary attention for problem solving and stress reduction within the system, in addition to the psychiatric treatment of the child, and possibly also the parents.

Background: Motivational interviewing (MI) may be an effective intervention to improve medication adherence in patients with schizophrenia. However, for this patient group, mixed results have been found in randomized controlled trials. Furthermore, the process of becoming (more) motivated for long-term medication adherence in patients with schizophrenia is largely unexplored., Method: We performed a qualitative multiple case study of MI-sessions to analyse the interaction process affecting motivation in patients with schizophrenia. Fourteen cases of patients with schizophrenia, who recently experienced a psychotic relapse after medication-nonadherence, were studied, comprising 66 audio-recorded MI-sessions. In the MI-sessions, the patients expressed their cognitions on medication. We used these cognitions to detect the different courses (or patterns) of the patients' ambivalence during the MI-intervention. We distinguished successful and unsuccessful cases, and used the cross-case-analysis to identify success factors to reach positive effects of MI., Results: Based on the expressed cognitions on medication, we found four different patterns of the patient process. We also found three success factors for the intervention, which were a trusting relationship between patient and therapist, the therapist's ability to adapt his MI-strategy to the patient's process, and relating patient values to long-term medication adherence., Conclusions: The success of an MI-intervention for medication adherence in patients with schizophrenia can be explained by well-defined success factors. Adherence may improve if therapists consider these factors during MI-sessions.

Background: Family members who care for patients with severe mental illness experience emotional distress and report a higher incidence of mental illness than those in the general population. They report feeling inadequately prepared to provide the necessary practical and emotional support for these patients. The MAT training, an Interaction-Skills Training program (IST) for caregivers, was developed to meet those needs. This study used a single-arm pretest-posttest design to examine the impact of the training on caregivers' sense of competence (self-efficacy) and burden., Methods: One hundred family caregivers recruited from three mental health institutions participated in the training. Burden was assessed using the Involvement Evaluation Questionnaire, and self-efficacy using the Self-Efficacy Questionnaire. Analysis of variance with repeated measures was used to investigate whether participation in the training changed the level of family caregivers' burden and self-efficacy. Pearson's correlation was used to examine the relationships between self-efficacy and burden., Results: Our results indicate that, after the training, self-efficacy increased significantly over time (p < 0.001) and that burden decreased significantly (p < 0.001). However, the results could not demonstrate the expected association between an increase of self-efficacy and decrease of burden. Caregivers expressed high appreciation for the training., Conclusions: After following the IST program, family caregivers of patients with severe mental illness experienced a greater sense of competence and a significant decrease in burden. The training was greatly appreciated and satisfied caregivers' need to acquire the skills required in complex caregiving situations., Trial Registration: This study was retrospectively registered (14/01/2018) in the ISRCTN registry with study ID ISRCTN44495131 .

Background: Adolescents with fixed orthodontic appliances are at high risk of developing dental caries. To date, new smartphone technologies have seldom been used to support them in the preventive behavior that can help prevent dental caries. After an intervention-mapping process, we developed a smartphone application (the WhiteTeeth app) for preventing dental caries through improved oral-health behavior and oral hygiene. The app, which is intended to be used at home, will help adolescents with fixed orthodontic appliances perform their oral self-care behavior. The app is based on the Health Action Process Approach (HAPA) theory, and incorporates several behavior-change techniques that target the psychosocial factors of oral-health behavior. This article describes the protocol of a randomized controlled trial (RCT) to evaluate the effects of the WhiteTeeth app on oral-health behavior and oral-hygiene outcomes (presence of dental plaque and gingival bleeding) compared with those of care as usual, in patients aged 12-16 with fixed orthodontic appliances., Methods/design: The RCT has two conditions: an experimental group that will receive the WhiteTeeth app in addition to care as usual, and a control group that will only receive care as usual. Care as usual will include routine oral-health education and instruction at orthodontic check-ups. In the western part of the Netherlands 146 participants will be recruited from four orthodontic clinics. Data will be collected during three orthodontic check-ups: baseline (T0), 6 weeks of follow-up (T1) and 12 weeks of follow-up (T2). The primary study outcomes are the presence of dental plaque (measured with a modified Silness and Loë Plaque Index); and gingival bleeding (measured with the Bleeding on Marginal Probing Index). Secondary outcomes include changes in self-reported oral-health behaviors and its psychosocial factors identified by the HAPA theory, such as outcome expectancies, intention, action self-efficacy, coping planning and action control., Discussion: Since the intervention was designed to target psychosocial factors in the motivational and volitional components of the behavior-change process, we hypothesize that the app will cause greater improvements in oral-health behavior and oral hygiene more than traditional oral-health-promotion programs (i.e., care as usual)., Trial Registration: The trial has been registered with the Dutch Trial Register ( NTR6206 : 20 February 2017).

Background: During the past decades deinstitutionalisation policies have led to a transition from inpatient towards community mental health care. Many European countries implement Assertive Community Treatment (ACT) as an alternative for inpatient care for "difficult to reach" children and adolescents with severe mental illness. ACT is a well-organized low-threshold treatment modality; patients are actively approached in their own environment, and efforts are undertaken to strengthen the patient's motivation for treatment. The assumption is that ACT may help to avoid psychiatric hospital admissions, enhance cost-effectiveness, stimulate social participation and support, and reduce stigma. ACT has been extensively investigated in adults with severe mental illness and various reviews support its effectiveness in this patient group. However, to date there is no review available regarding the effectiveness of youth-ACT. It is unknown whether youth-ACT is as effective as it is in adults. This review aims to assess the effects of youth-ACT on severity of psychiatric symptoms, general functioning, and psychiatric hospital admissions., Method: A systematic literature search was conducted in PubMed, Cochrane Library, PsychINFO and CINAHL published up to March 2017. To assess methodological quality of the included studies, the Oxford Centre of Evidence-Based Medicine grading system was used., Results: Thirteen studies were included in this review. There are indications that youth-ACT is effective in reducing severity of psychiatric symptoms, improving general functioning, and reducing duration and frequency of psychiatric hospital admissions., Conclusions: The current literature on youth-ACT is limited but promising. There are indications that youth-ACT is effective in reducing severity of psychiatric symptoms, improving general functioning, and reducing duration and frequency of psychiatric hospital admissions. The effect of youth-ACT may be comparable with the effect of ACT in adults. Similar as in adult ACT, the studies on youth-ACT found effects that vary from small to large. Randomized experimental research designs are needed to further corroborate effectiveness.

Background: Relapse is common among recovered anorexia nervosa (AN) patients. Studies on relapse prevention with an average follow-up period of 18 months found relapse rates between 35 and 41 %. In leading guidelines there is general consensus that relapse prevention in patients treated for AN is a matter of essence. However, lack of methodological support hinders the practical implementation of relapse prevention strategies in clinical practice. For this reason we developed the Guideline Relapse Prevention Anorexia Nervosa. In this study we examine the rate, timing and predictors of relapse when using this guideline., Method: Cohort study with 83 AN patients who were enrolled in a relapse prevention program for anorexia nervosa with 18 months follow-up. Data were analyzed using Kaplan-Meijer survival analyses and Cox regression., Results: Eleven percent of the participants experienced a full relapse, 19 % a partial relapse, 70 % did not relapse. Survival analyses indicated that in the first four months of the program no full relapses occurred. The highest risk of full relapse was between months 4 and 16. None of the variables remained a significant predictor of relapse in the multivariate Cox regression analysis., Conclusion: The guideline offers structured procedures for relapse prevention. In this study the relapse rates were relatively low compared to relapse rates in previous studies. We recommend that all patients with AN set up a personalized relapse prevention plan at the end of their treatment and be monitored at least 18 months after discharge. It may significantly contribute to the reduction of relapse rates.

Background: Self-management is important for family caregivers of people with dementia, especially when they face changes in their relative's behavior and mood, such as depression, apathy, anxiety, agitation and aggression. The aim of this study is to give insight into why these changes in behavior and mood are stressful for family caregivers, what self-management strategies family caregivers use when managing these changes and the stress they experience., Methods: A qualitative study was conducted using four online focus groups with 32 family caregivers of people with dementia living in the Netherlands. Transcripts of the focus group discussions were analyzed using principles of thematic analysis., Results: Managing changes in the behavior and mood of their relative with dementia is stressful for family caregivers because of constantly having to switch, continuously having to keep the person with dementia occupied and distracted, the fact that others see a different side to the relative, and the fact that caregivers know what to do, but are often not able to put this into practice. Caregivers use calming down and stimulation as self-management strategies for influencing the changes in the behavior and mood of their relative. Furthermore, caregivers describe three self-management strategies that let them manage their own stress and keep up the care for their loved ones: looking for distractions, getting rest, and discussing their feelings and experiences., Conclusions: Behavior and mood changes of a person with dementia are stressful for family caregivers. They use several self-management strategies to positively affect the mood and behavior changes, and also to manage their own stress.

Background: Informal caregivers of people with dementia are challenged in managing the consequences of dementia in daily life. The objective of this meta-review was to synthesize evidence from previous systematic reviews about professional self-management support interventions for this group., Methods: In March 2014, searches were conducted in PubMed, CINAHL, Cochrane Library, Embase and PsycINFO. The PRISMA Statement was followed. Interventions were grouped using Martin's targets of self-management, covering 5 targets: relationship with family, maintaining an active lifestyle, psychological wellbeing, techniques to cope with memory changes and information about dementia. Using an evidence synthesis, the outcomes from the included interventions were synthesized and conclusions were drawn about the level of evidence for the effectiveness of interventions within each target., Results: Ten high-quality systematic reviews were selected. Evidence exists for the effectiveness of professional self-management support interventions targeting psychological wellbeing on stress and social outcomes of informal caregivers. In addition, evidence exists for the effectiveness of interventions targeting information on ability/knowledge. Limited evidence was found for the effectiveness of interventions targeting techniques to cope with memory change on coping skills and mood, and for interventions targeting information on the outcomes sense of competence and decision-making confidence of informal caregivers., Conclusions: Scientific evidence exists for the effectiveness of a number of professional self-management support interventions targeting psychological wellbeing and information. Health care professionals could take account of the fact that psycho-education was integrated in most of the self-management support interventions that were found to be effective in this meta-review. Furthermore, longer and more intensive interventions were associated with greater effects.

Background: Differing perspectives of self-harm may result in a struggle between patients and treatment staff. As a consequence, both sides have difficulty communicating effectively about the underlying problems and feelings surrounding self-harm. Between 2009 and 2011, a programme was developed and implemented to train mental health care staff (nurses, social workers, psychologists, psychiatrists, and occupational therapists) in how to communicate effectively with and care for patients who self-harm. An art exhibition focusing on self-harm supported the programme. Lay experts in self-harm, i.e. people who currently harm themselves, or who have harmed themselves in the past and have the skills to disseminate their knowledge and experience, played an important role throughout the programme., Methods: Paired sample t-tests were conducted to measure the effects of the training programme using the Attitude Towards Deliberate Self-Harm Questionnaire, the Self-Perceived Efficacy in Dealing with Self-Harm Questionnaire, and the Patient Contact Questionnaire. Effect sizes were calculated using r. Participants evaluated the training programme with the help of a survey. The questionnaires used in the survey were analysed descriptively., Results: Of the 281 persons who followed the training programme, 178 completed the questionnaires. The results show a significant increase in the total scores of the three questionnaires, with large to moderate effect sizes. Respondents were positive about the training, especially about the role of the lay expert., Conclusion: A specialised training programme in how to care for patients who self-harm can result in a more positive attitude towards self-harm patients, an improved self-efficacy in caring for patients who self-harm, and a greater closeness with the patients. The deployment of lay experts is essential here.

Background: Depression in later life is a common mental disorder with a prevalence rate of between 3% and 35% for minor depression and approximately 2% for Major Depressive Disorder (MDD). The most common treatment modalities for MDD are antidepressant medication and psychological interventions. Recently, Behavioral Activation (BA) has gained renewed attention as an effective treatment modality in MDD. Although BA is considered an easy accessible intervention for both patients and health care workers (such as nurses), there is no research on the effectiveness of the intervention in inpatient depressed elderly.The aim of study, described in the present proposal, is to examine the effects of BA when executed by nurses in an inpatient population of elderly persons with MDD., Methods/design: The study is designed as a multi-center cluster randomized controlled trial. BA, described as The Systematic Activation Method (SAM) will be compared with Treatment as Usual (TAU). We aim to include ten mental health care units in the Netherlands that will each participate as a control unit or an experimental unit. The patients will meet the following criteria: (1) a primary diagnosis of Major Depressive Disorder (MDD) according to the DSM-IV criteria; (2) 60 years or older; (3) able to read and write in Dutch; (4) have consented to participate via the informed consent procedure. Based on an effect size d = 0.7, we intend to include 51 participants per condition (n = 102). The SAM will be implemented within the experimental units as an adjunctive therapy to Treatment As Usual (TAU). All patients will be assessed at baseline, after eight weeks, and after six months. The primary outcome will be the level of depression measured by means of the Beck Depression Inventory (Dutch version). Other assessments will be activity level, mastery, costs, anxiety and quality of life., Discussion: To our knowledge this is the first study to test the effect of Behavioral Activation as a nursing intervention in an inpatient elderly population. This research has been approved by the medical research ethics committee for health-care settings in the Netherlands (No. NL26878.029.09) and is listed in the Dutch Trial Register (NTR No.1809).

Background: Bipolar disorder is a severe mental illness with serious consequences for daily living of patients and their caregivers. Care as usual primarily consists of pharmacotherapy and supportive treatment. However, a substantial number of patients show a suboptimal response to treatment and still suffer from frequent episodes, persistent interepisodic symptoms and poor social functioning. Both psychiatric and somatic comorbid disorders are frequent, especially personality disorders, substance abuse, cardiovascular diseases and diabetes. Multidisciplinary collaboration of professionals is needed to combine all expertise in order to achieve high-quality integrated treatment. 'Collaborative Care' is a treatment method that could meet these needs. Several studies have shown promising effects of these integrated treatment programs for patients with bipolar disorder. In this article we describe a research protocol concerning a study on the effects of Collaborative Care for patients with bipolar disorder in the Netherlands., Methods/design: The study concerns a two-armed cluster randomised clinical trial to evaluate the effectiveness of Collaborative Care (CC) in comparison with Care as usual (CAU) in outpatient clinics for bipolar disorder or mood disorders in general. Collaborative Care includes individually tailored interventions, aimed at personal goals set by the patient. The patient, his caregiver, the nurse and the psychiatrist all are part of the Collaborative Care team. Elements of the program are: contracting and shared decision making; psycho education; problem solving treatment; systematic relapse prevention; monitoring of outcomes and pharmacotherapy. Nurses coordinate the program. Nurses and psychiatrists in the intervention group will be trained in the intervention. The effects will be measured at baseline, 6 months and 12 months. Primary outcomes are psychosocial functioning, psychiatric symptoms, and quality of life. Caregiver outcomes are burden and satisfaction with care., Discussion: Several ways to enhance the quality of this study are described, as well as some limitations caused by the complexities of naturalistic treatment settings where not all influencing factors on an intervention and the outcomes can be controlled., Trial Registration: The Netherlands Trial Registry, NTR2600.

Background: Structured psychotherapy is recommended as the preferred treatment of personality disorders. A substantial group of patients, however, has no access to these therapies or does not benefit. For those patients who have no (longer) access to psychotherapy a Collaborative Care Program (CCP) is developed. Collaborative Care originated in somatic health care to increase shared decision making and to enhance self management skills of chronic patients. Nurses have a prominent position in CCP's as they are responsible for optimal continuity and coordination of care. The aim of the CCP is to improve quality of life and self management skills, and reduce destructive behaviour and other manifestations of the personality disorder., Methods/design: Quantitative and qualitative data are combined in a comparative multiple case study. This makes it possible to test the feasibility of the CCP, and also provides insight into the preliminary outcomes of CCP. Two treatment conditions will be compared, one in which the CCP is provided, the other in which Care as Usual is offered. In both conditions 16 patients will be included. The perspectives of patients, their informal carers and nurses are integrated in this study. Data (questionnaires, documents, and interviews) will be collected among these three groups of participants. The process of treatment and care within both research conditions is described with qualitative research methods. Additional quantitative data provide insight in the preliminary results of the CCP compared to CAU. With a stepped analysis plan the 'black box' of the application of the program will be revealed in order to understand which characteristics and influencing factors are indicative for positive or negative outcomes., Discussion: The present study is, as to the best of our knowledge, the first to examine Collaborative Care for patients with severe personality disorders receiving outpatient mental health care. With the chosen design we want to examine how and which elements of the CC Program could contribute to a better quality of life for the patients., Trial Registration: Netherlands Trial Register (NTR): NTR2763.

Background: Little is known about the perspectives of psychiatric patients who are perceived as 'difficult' by clinicians. The aim of this paper is to improve understanding of the connections between patients and professionals from patients' point of view., Methods: A Grounded Theory study using interviews with 21 patients from 12 outpatient departments of three mental health care facilities., Results: Patients reported on their own difficult behaviours and their difficulties with clinicians and services. Explanations varied but could be summarized as a perceived lack of recognition. Recognition referred to being seen as a patient and a person - not just as completely 'ill' or as completely 'healthy'. Also, we found that patients and professionals have very different expectations of one another, which may culminate in a difficult or ambivalent connection. In order to explicate patient's expectations, the patient-clinician contact was described by a stage model that differentiates between three stages of contact development, and three stages of substantial treatment. According to patients, in each stage there is a therapeutic window of optimal clinician behaviour and two wider spaces below and above that may be qualified as 'toxic' behaviour. Possible changes in clinicians' responses to 'difficult' patients were described using this model., Conclusions: The incongruence of patients' and professionals' expectations may result in power struggles that may make professionals perceive patients as 'difficult'. Explication of mutual expectations may be useful in such cases. The presented model gives some directions to clinicians how to do this.

Background: Health clinicians perceive certain patients as 'difficult' across all settings, including mental health care. In this area, patients with non-psychotic disorders that become long-term care users may be perceived as obstructing their own recovery or seeking secondary gain. This negative perception of patients results in ineffective responses and low-quality care by health clinicians. Using the concept of illness behaviour, this paper describes the development, implementation, and planned evaluation of a structured intervention aimed at prevention and management of ineffective behaviours by long-term non-psychotic patients and their treating clinicians., Methods: The principles of Intervention Mapping were applied to guide the development, implementation, and planned evaluation of the intervention. Qualitative (individual and group interviews), quantitative (survey), and mixed methods (Delphi-procedure) research was used to gain a broad perspective of the problem. Empirical findings, theoretical models, and existing evidence were combined to construct a program tailored to the needs of the target groups., Results: A structured program to increase effective illness behaviour in long-term non-psychotic patients and effective professional behaviour in their treating clinicians was developed, consisting of three subsequent stages and four substantial components, that is described in detail. Implementation took place and evaluation of the intervention is being carried out., Conclusions: Intervention Mapping proved to be a suitable method to develop a structured intervention for a multi-faceted problem in mental health care.

Background: Case management programmes for home-dwelling people with dementia and their informal carers exist in multiple forms and shapes. The aim of this research was to identify the essential components of case management for people with dementia as well as the preconditions for an effective delivery of case management services., Method: The method used to carry out the research was a modified four-phase Delphi design. First, a list of potentially essential components and preconditions for the provision of case management was drawn up on the basis of a literature review and a subsequent focus group interview. The list was then validated by experts in a first Delphi survey round, following which the researchers translated the list items into 75 statements. In the second Delphi survey, the experts rated the statements; in the third Delphi round, they rated 18 statements on which no consensus had been reached in the second round., Results: The experts were able to build consensus on 61 of the 75 statements. Essential components of case management for people with dementia are: information, support and counselling, coordination of the care provided and, to a lesser extent, practical help. A patient-centred approach was found to be one of the key aspects of providing case management services. Essential preconditions are: vision, care relationship, structured methodology, integration of case management into the health care chain, and the case manager's level of training and expertise., Conclusions: We recommend that, based on the essential components and preconditions referred to above, quality criteria be developed for the provision of case management for people with dementia. Furthermore, we suggest the conduct of additional research to assess the effectiveness of case management in people with dementia.

Background: Psychological distress (i.e. depression and anxiety) is a strong predictor of functional status and other aspects of quality of life in autologous stem cell transplantation following high-dose chemotherapy. Treatment of psychological distress is hypothesized to result in improvement of functional status and other aspects of quality of life. The aim is to evaluate the outcome of stepped care for psychological distress on functional status and other aspects of quality of life in patients with hematological malignancy treated with autologous stem cell transplantation., Methods/design: The study is designed as a randomized clinical trial with 2 treatment arms: a stepped care intervention program versus care as usual. Patients are randomized immediately pre transplant. Stepped care and care as usual are initiated after a 6 weeks buffer period. Outcome is evaluated at 13, 30, and 42 weeks post transplant.In the experimental group, the first step includes an Internet-based self-help program. If psychological distress persists after the self-help intervention, the second step of the program is executed, i.e. a diagnostic evaluation and a standardized interview, yielding a problem analysis. Based on this information, a contract is made with the patient and treatment is provided consisting of individual face-to-face counseling, medication, or referral to other services. Care as usual comprises an interview with the patient, on ad hoc basis; emotional support and advice, on ad hoc basis; if urgent problems emerge, the patient is referred to other services.Primary outcome variables are psychological distress and functional status. Data are analyzed according to the intention to treat-principle., Discussion: This study has several innovative characteristics. First, the outcome of the intervention for psychological distress in patients with hematological malignancy treated with autologous stem cell transplantation is evaluated in a randomized controlled study. Second, the impact of the intervention on functional status is evaluated: it is hypothesized that reduction of psychological distress results in improved functional status. Furthermore, the intervention concerns an Internet-based treatment in the first step. Finally, the intervention is characterized by an emphasis on self-management, efficiency, and a multi-disciplinary approach with nurses taking up a central role., Trial Registration: NTR1770.