Clinical Staging for Personality Disorders in Older Adults.

OBJECTIVE: This scientific research aimed to investigate the feasibility of implementing a clinical staging (CS) model for personality disorders (PDs) in older adults. The CS model could provide valuable insights into the life course of personality pathology, prognosis, and treatment decisions for PDs in older adults. METHODS/DESIGN: The study employed an international Delphi methodology with three rounds and involved 21 experts. RESULTS: Consensus was achieved on 12 out of 17 statements, confirming the viability of a CS model for PDs in older adults. The proposed model incorporates the Alternative Model for PDs, criterion A, and integrates life course information, distinguishing between chronic PD, re-emergent PD, late-onset PD, and past PD. CONCLUSION: The findings suggest that international experts support the implementation of a CS model for PDs in older adults, considering both the severity of personality functioning and the retrospective life course of PD expression.

Efficacy of a digitally supported regional systems intervention for suicide prevention (SUPREMOCOL) in Noord-Brabant, the Netherlands.

OBJECTIVE: We evaluated the effect of a digitally supported systems intervention for suicide prevention (SUPREMOCOL) in Noord-Brabant, the Netherlands. METHOD: Non-randomized stepped wedge trial design (SWTD). Stepwise implementation in the five subregions of the systems intervention. Pre-post analysis for the whole province (Exact Rate Ratio Test, Poisson count). SWTD Hazard Ratios of suicides per person-years for subregional analysis of control versus intervention conditions over five times three months. Sensitivity analysis. RESULTS: Suicide rates dropped 17.8% (p = .013) from 14.4 suicides per 100,000 before the start of implementation of the systems intervention (2017), to 11.9 (2018) and 11.8 (2019) per 100, during implementation; a significant reduction (p = .043) compared to no changes in the rest of the Netherlands. Suicide rates dropped further by 21.5% (p = .002) to 11.3 suicides per 100,000 during sustained implementation in 2021. Sensitivity analysis confirmed the reduction (p = .02). The SWTD analysis over 15 months in 2018-2019 did not show a significant association of this reduction with implementation per subregional level, probably due to insufficient power given the short SWTD timeframe for implementation and low suicide rates per subregion. CONCLUSIONS: During the SUPREMOCOL systems intervention, over four years, there was a sustained and significant reduction of suicides in Noord-Brabant.

Validation of the work stress screener (WOSS-13) and resilience at work scale (ReWoS-24).

OBJECTIVE: Work stress is a global issue with countries such as the UK requiring organisations to protect employees. Work stress can be beneficial (challenging) or harmful (overwhelming), and characteristics such as resilience are thought to mitigate some of the negative effects. This paper describes the validation of two new scales. The WOSS-13 was designed to measure both benign and harmful experiences of work stress, while the ReWoS-24 captures information about individual and team resilience. METHODS: For both scales the assessment of individual items, domains captured by scale items, reliability and validity were completed using data from a survey of 1980 individuals from the University of York, England. A sub-sample of respondents (N = 609) provided additional data for retest purposes. Analyses were performed using these two samples. RESULTS: Responses to scale items were found to be normally distributed. Confirmatory factor analysis indicated the WOSS-13 was comprised of three subscales: positive work-related affect/stress, general positive affect and harmful stress. The ReWoS-24 is presented as four sub-scales: general well-being, well-being at work, satisfaction with job performance and team resilience. All subscales demonstrated good internal consistency (Cronbach's alpha ≥0.80). Both scales complement existing measures of stress and mental health. CONCLUSION: The findings suggest that the WOSS-13 is a valid and reliable measure which enables the assessment of both benign and harmful forms of work stress. The ReWoS-24 is a valid and reliable measure of individual and team resilience. These scales could be used in workplaces to assess for and mitigate against, harmful work stress.

Identifying the top research priorities in medically not yet explained symptoms (MNYES): a James Lind Alliance priority setting partnership.

OBJECTIVES: This study establishes research priorities for medically not yet explained symptoms (MNYES), also known as persistent physical symptoms or medically unexplained symptoms, from the perspective of patients, caregivers and clinicians, in a priority setting partnership (PSP) following the James Lind Alliance (JLA) approach. Research into such symptoms in general has been poorly funded over the years and so far has been primarily researcher-led with minimal input from patients, caregivers and clinicians; and sometimes has been controversial. DESIGN: JLA PSP method. The PSP termed these symptoms MNYES. METHODS: The study was conducted according to the JLA's detailed methodology for conducting priority setting exercises. It involved five key stages: defining the appropriate term for the conditions under study by the PSP Steering Group; gathering questions on MNYES from patients, caregivers and clinicians in a publicly accessible survey; checking these research questions against existing evidence; interim prioritisation in a second survey; and a final multi-stakeholder consensus meeting to determine the top 10 unanswered research questions using the modified nominal group methodology. RESULTS: Over 700 responses from UK patients, caregivers and clinicians were identified in the two surveys and charities contributed from a broad range of medical specialties and primary care. The final top 10 unanswered research questions cover, among others: treatment strategies, personalisation of treatment, collaborative care pathways, training for clinicians and outcomes that matter to patients. INTERPRETATION: The top 10 unanswered research questions are expected to generate much needed, relevant and impactful research into MNYES.

The Association Between Suicide-Related Media Coverage and Suicide: A Cross-Sectional Observational Study.

OBJECTIVE: To examine the association between the publication and content of suicide-related media reports and actual suicide in Noord Brabant, a province of the Netherlands. METHOD: Between April 2017 and March 2018, a retrospective cross-sectional observational study was conducted on suicide-related media reports and incident data regarding suicides. Linear regression, Mann-Whitney U and negative binomial regression analyses were conducted. RESULTS: In Noord-Brabant, a total of 352 people died from suicide during the observation period and 440 reports were identified by using the search terms "suicide", "self-killing", and "self-murder". No associations between media reports and actual suicides were found for any of the analyses performed. CONCLUSIONS: No indications were found for an association between media coverage of suicide and increases or decreases in actual suicides in Noord-Brabant. The descriptive statistics of this study reveal that the regional and national Dutch media are doing well with respect to not including elements in their reports that could encourage copycat behavior, such as simplifying, romanticizing or dramatizing. They could improve on including protective content, for example, providing supportive background information. A recommendation for further research is to evaluate causal relationships between media and actual suicide. A stepped wedge trial might be needed, as this provides an ethical research design to investigate this issue in a controlled setting. Also, in such a study, other variables influencing the decision to attempt suicide should be taken into account as much as possible.

Mindfulness is not associated with dissonant attitudes but enhances the ability to cope with them.

BACKGROUND: Explicit and implicit attitudes have been studied extensively, but there is less attention to reducing dissonance between them. This is relevant because this dissonance (IED) results in distress and has inconsistent effects on behavior, e.g. less physical activity but more smoking. Mindfulness decreases dissonance between self-related explicit and implicit constructs. This study investigates if, and which, specific mindfulness subskills are associated with decreased dissonance between explicit and implicit attitudes, and whether mindfulness subskills moderate the relationship between IED and intention/behavior. METHOD: At baseline and one and three months thereafter, participants' (N = 1476) explicit attitudes, implicit attitudes, red meat consumption (RMC), intention to reduce RMC as well as levels of trait mindfulness were assessed. RESULTS: Mindfulness subskills were not associated with decreased IED. IED was associated with lower RMC and a higher intention to reduce RMC. The mindfulness subskill acceptance buffered the effect of IED on intention, seemingly offering a skill to deal with dissonant attitudes, which was unidentified until now. CONCLUSION: The mindfulness subskill accepting without judgment functions as a way to deal with dissonance. Future research should use this novel finding and investigate whether mindfulness can be used as a buffer in contexts where dissonance results in maladaptive behaviors.

Implicit attitudes and explicit cognitions jointly predict a reduced red meat intake: a three-wave longitudinal study.

Background: Despite nutritional benefits, a high consumption of red meat is not without risks as it is linked to the development of certain types of cancer as well as to other non-communicable diseases, such as type II diabetes or cardiovascular diseases. Moreover, the production of meat has negative effects on the environment. Therefore, a transition to a less meat-based diet could be beneficial. It is unclear how explicit cognitions towards red meat consumption and implicit attitudes jointly influence intention and consumption. We tested the additive pattern (both types of cognitions explain unique variance) and interactive pattern (both types interact in the prediction). Method: At baseline (T0; N = 1790) and one (T1; n = 980) and three months thereafter (T2; n = 556), explicit cognitions, red meat consumption, and implicit attitudes were assessed among a Dutch sample. Results: Only explicit cognitions were associated with red meat consumption. Implicit attitudes moderated the effect of self-efficacy on T0-RMC; negative implicit attitudes strengthened this effect. T0-intention was associated with explicit cognitions and implicit attitudes. Additionally, negative implicit attitudes strengthened the effect of social norms on T0 and T2-intention. Regarding red meat consumption, support for the interactive pattern was found. For intention there was support for the interactive and additive pattern. Conclusion: Interventions aiming to reduce red meat consumption in the general public might profit from changing implicit attitudes in addition to explicit cognitions.

Effectiveness of suicide prevention interventions: A systematic review and meta-analysis.

OBJECTIVE: This study provides an estimate of the effect size of suicide prevention interventions and evaluates the possible synergistic effects of multilevel interventions. METHOD: A systematic review and meta-analysis were conducted of controlled studies evaluating suicide prevention interventions versus control published between 2011 and 2017 in PubMed, PsycINFO, and Cochrane databases. Data extraction and risk of bias assessment according to ROBINS criteria were performed by independent assessors. Cohen's delta was calculated by a random meta-analysis on completed and attempted suicides as outcomes. Meta-regression explored a possible synergistic effect in multilevel interventions. PROSPERO ID number: CRD42018094373. RESULTS: The search yielded 16 controlled studies with a total of 252,932 participants. The meta-analysis was performed in 15 studies with 29,071 participants. A significant effect was found for suicide prevention interventions on completed suicides (d = -0.535, 95% CI -0.898; -0.171, p = .004) and on suicide attempts (d = -0.449, 95% CI -0.618; -0.280, p < .001). Regarding the synergistic effect of multilevel interventions, meta-regression showed a significantly higher effect related to the number of levels of the intervention (p = .032). CONCLUSIONS: Suicide prevention interventions are effective in preventing completed and attempted suicides and should be widely implemented. Further research should focus on multilevel interventions due to their greater effects and synergistic potential. Further research is also needed into risk appraisal for completed versus attempted suicide, as the preferred intervention strategy differs with regard to both outcomes.

A regional systems intervention for suicide prevention in the Netherlands (SUPREMOCOL): study protocol with a stepped wedge trial design.

BACKGROUND: In the Netherlands, suicide rates showed a sharp incline and this pertains particularly to the province of Noord-Brabant, one of the southern provinces in the Netherlands. This calls for a regional suicide prevention effort. METHODS/DESIGN: Study protocol. A regional suicide prevention systems intervention is implemented and evaluated by a stepped wedge trial design in five specialist mental health institutions and their adherent chain partners. Our system intervention is called SUPREMOCOL, which stands for Suicide Prevention by Monitoring and Collaborative Care, and focuses on four pillars: 1) recognition of people at risk for suicide by the development and implementation of a monitoring system with decision aid, 2) swift access to specialist care of people at risk, 3) positioning nurse care managers for collaborative care case management, and 4) 12 months telephone follow up. Eligible patients are persons attempting suicide or expressing suicidal ideation. Primary outcome is number of completed suicides, as reported by Statistics Netherlands and regional Public Health Institutes. Secondary outcome is number of attempted suicides, as reported by the regional ambulance transport and police. Suicidal ideation of persons registered in the monitoring system will, be assessed by the PHQ-9 and SIDAS questionnaires at baseline and 3, 6, 9 and 12 months after registration, and used as exploratory process measure. The impact of the intervention will be evaluated by means of the RE-AIM dimensions reach, efficacy, adoption, implementation, and maintenance. Intervention integrity will be assessed and taken into account in the analysis. DISCUSSION: The present manuscript presents the design and development of the SUPREMOCOL study. The ultimate goal is to lower the completed suicides rate by 20%, compared to the control period and compared to other provinces in the Netherlands. Moreover, our goal is to provide specialist mental health institutions and chain partners with a sustainable and adoptable intervention for suicide prevention. TRIAL REGISTRATION: Netherlands Trial Register under registration number NL6935 (5 April 2018). This is the first version of the study protocol (September 2019).

Does the discrepancy between implicit and explicit attitudes moderate the relationships between explicit attitude and (intention to) being physically active?

BACKGROUND: Explicit attitudes as well as implicit attitudes have been shown to be associated with physical activity (PA). These two types of attitudes can, however, be discrepant towards the same object or behavior. This study investigated whether there is a discrepancy between explicit and implicit attitudes (IED) regarding physical activity (PA), and whether IED moderates the relationship between explicit attitude and PA, and explicit attitude and PA intention. METHODS: At baseline (T0) and one (T1) and three months (T2) thereafter, students' (N = 340) PA levels, intention, explicit attitudes, further PA determinants, e.g. self-efficacy, were assessed. Implicit attitudes towards PA were assessed by means of a tailored Single-Category Implicit Association task. RESULTS: IED was present but weak. Multiple hierarchical regressions revealed that IED did not moderate the relationship between explicit attitudes and PA or intention. Yet, IED was negatively associated with T0-PA and T1-PA. CONCLUSION: The study revealed the important insight that IED is detrimental for PA. Interventions targeting attitudes to increase PA, should ensure that implicit and explicit attitudes regarding PA are concordant.

Adverse Childhood Experiences (ACE) in outpatients with anxiety and depressive disorders and their association with psychiatric and somatic comorbidity and revictimization. Cross-sectional observational study.

BACKGROUND: This study aims to establish prevalence of Adverse Childhood Experiences (ACE) and their association with somatic comorbidity and adult adverse events (AAE) in outpatients with anxiety or depressive disorders. METHODS: Cross-sectional observational design. Specialty mental health outpatients classified with DSM-IV-TR anxiety or depressive disorder filled-out the ACE-IQ and the AAE-IQ. T-tests, ANOVA, logistic regressions andChi-square analyses were performed and stratified for ACE score ≥4(high) versus ACE <4(low). Gender differences were explored. RESULTS: From May 2015 -November 2016, in 298 consecutive patients 77.2% reported at least one ACE, 58.7% reported multiple ACE (mean 2.92). Scores were highest in Post-Traumatic Stress Disorder (PTSD) and in case of comorbid mental disorders. Somatic comorbidity was not associated with ACE-scores. AAE scores were significantly (t = -9.33, p < .001) higher in the high ACE-group (M = 4.09 SD = 2.42) versus the low-ACE group (M = 1.63 SD = 1.70), indicating general revictimization. An association between sexual ACE and sexual revictimization was found as well (χ2 = 86.14, p < .001).The effects did not differ for males and females. CONCLUSIONS: ACE and AAE are highly prevalent in depressive and anxiety disorders PTSD and psychiatric comorbidity are associated with higher scores, somatic comorbidity is not. Indications for general and sexual revictimization are shown. Further research is needed. LIMITATIONS: Selection bias may have influenced results on somatic comorbidity, as patients with obvious somatic comorbidity usually get referred to other health services. The generalisability of the results may be limited as non-Dutch speaking immigrants were excluded.

A European Research Agenda for Somatic Symptom Disorders, Bodily Distress Disorders, and Functional Disorders: Results of an Estimate-Talk-Estimate Delphi Expert Study.

Background: Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe. Aim: To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Methods: Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings. Results: Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation. Conclusion: Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area in mental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe.

Effectiveness of a multi-facetted blended eHealth intervention during intake supporting patients and clinicians in Shared Decision Making: A cluster randomised controlled trial in a specialist mental health outpatient setting.

OBJECTIVE: To investigate the effectiveness of a multi-facetted blended eHealth intervention, called SDM-Digital Intake (SDM-DI), in which patients and clinicians are supported in Shared Decision Making during the intake process. METHODS: The study is a two-arm matched-paired cluster Randomised Controlled Trial in a specialist mental health outpatient setting with two conditions: SDM-DI and Intake As Usual (IAU). Four intake teams were allocated to each arm. All patients who followed an intake, were asked to participate if they were capable to complete questionnaires. Decisional Conflict (DC), referring to patients' engagement and satisfaction with clinical decisions, was the primary outcome. Secondary outcomes were patient participation, applying Shared Decision Making (SDM), working alliance, treatment adherence and symptom severity. Effects were measured at two weeks (T1) and two months (T2) after intake. Multilevel regression and intention-to-treat analyses were used. Additionally, the influence of subgroups and intervention adherence on DC were explored. RESULTS: At T1, 200 patients participated (47% intervention, 53% control), and at T2 175 patients (47% intervention, 53% control). At T1 and T2, no differences were found between conditions on DC. Subgroup analyses showed that effects of SDM-DI on DC were not modified by primary diagnoses mood, anxiety and personality disorders. Compared to IAU, at T2, patients reported positive effects of SDM-DI on SDM (ß 7.553, p = 0.038, 95%CI:0.403-14.703, d = 0.32) and reduction of symptoms (ß -7.276, p = 0.0497, 95%CI:-14.544--0.008, d = -0.43). No effects were found on patient participation, working alliance and treatment adherence. Exploratory analyses demonstrated that if SDM was applied well, patients reported less DC (ß = -0.457, p = 0.000, 95%CI:-0.518--0.396, d = -1.31), which was associated with better treatment outcomes. CONCLUSION: Although, this trial fails to demonstrate that SDM-DI by itself is sufficient to reduce DC, the results are encouraging for further efforts in improving and implementing the SDM intervention.

A longitudinal study on how implicit attitudes and explicit cognitions synergistically influence physical activity intention and behavior.

BACKGROUND: Strategies to promote physical activity (PA) focus mainly on changing or fostering explicit cognitions and are only modestly effective. Contemporary studies suggest that, as well as explicit cognitions, implicit cognitions influence health behavior, such as PA, and that implicit processes interact with the intention to be active. Relatively little is known about whether implicit processes interact with other explicit cognitions which determine PA intention and behavior, i.e. self-efficacy. The aim of the current study was to investigate the direct effects of explicit cognitions and implicit attitudes on PA behavior as well as interactions between them regarding intention and behavior prediction. METHODS: In a longitudinal study, participants (N = 340) completed self-report measures of explicit cognitions (perceived pros, perceived cons, social norms, social modeling, self-efficacy, intention) and activity levels, as well as a Single-Category Implicit Association Task to measure implicit attitudes towards PA at baseline (T0), and at one (T1) and 3 months thereafter (T2). RESULTS: Hierarchical multiple regressions revealed that T0-positive implicit attitudes moderated the relationship between T0 self-efficacy and T1 PA. Similarly, T0-neutral implicit attitudes were associated with the relationship between T0 intention and T1 PA. Negative implicit attitudes strengthened the negative relationship between perceived cons and intention at baseline; neutral or positive implicit attitudes strengthened the positive relationship between self-efficacy and intention. At the follow-ups, the relationship between social modeling and intention was strengthened by negative implicit attitudes. CONCLUSION: This study revealed important insights into how implicit attitudes and explicit cognitions synergistically predict PA intention and behavior. As well as targeting explicit cognitions, steering a person's implicit attitude towards a more positive one, i.e. by implicit cognitive trainings, could help to increase both PA intention and behavior.

Springtime Peaks and Christmas Troughs: A National Longitudinal Population-Based Study into Suicide Incidence Time Trends in the Netherlands.

BACKGROUND: Time trends are one of the most studied phenomena in suicide research; however, evidence for time trends in the Dutch population remains understudied. Insight into time trends can contribute to the development of effective suicide prevention strategies. METHODS: Time trends in national daily and monthly data of 33,224 suicide events that occurred in the Netherlands from 1995 to 2015 were examined, as well as the influence of age, gender, and province, in a longitudinal population-based design with Poisson regression analyses and Bayesian change point analyses. RESULTS: Suicide incidence among Dutch residents increased from 2007 until 2015 by 38%. Suicide rates peak in spring, up to 8% higher than in summer (p < 0.001). Suicide incidence was 42% lower at Christmas, compared to the December-average (IRR = 0.580, p < 0.001). After Christmas, a substantial increase occurred on January 1, which remained high during the first weeks of the new year. Suicide occurred more than twice as often in men than in women. For both genders, the results indicated a spring time peak in suicide incidence and a trough at Christmas. Suicide rates were highest in the elderly (age group, 80+), and no evidence was found of a differential effect by season in the age groups with regard to suicide incidence. No interaction effect was found with regard to province of residence for both season and Christmas, indicating that no evidence was found that these time trends had differential effects in the Dutch provinces in terms of suicide incidence. CONCLUSION: Evidence was found for time trends in suicide incidence in the Netherlands. It is recommended to plan (mental) health care services to be available especially at high-risk moments, at spring time, and in the beginning of January. Further research is needed to explore the protective effect of Christmas in suicide incidence.

Exploring consensus on how to measure smoking cessation. A Delphi study.

BACKGROUND: Different criteria regarding outcome measures in smoking research are used, which can lead to confusion about study results. Consensus in outcome criteria may enhance the comparability of future studies. This study aims (1) to provide an overview of tobacco researchers' considered preferences regarding outcome criteria in randomized controlled smoking cessation trials, and (2) to identify the extent to which researchers can reach consensus on the importance of these outcome criteria. METHODS: A three-round online Delphi study was conducted among smoking cessation experts. In the first round, the most important smoking cessation outcome measures were collected by means of open-ended questions, which were categorized around self-reported and biochemical validation measures. Experts (n = 17) were asked to name the outcome measures (as well as their assessment method and ideal follow-up period) that they thought were important when assessing smoking-related outcomes. In the second (n = 48) and third rounds (n = 37), a list of outcome measures-identified in the first round-was presented to experts. Asking them to rate the importance of each measure on a seven-point scale. RESULTS: Experts reached consensus on several items. For self-reports, experts agreed that prolonged abstinence (6 or/and 12 months), point prevalence abstinence (7 days), continuous abstinence (6 months), and the number of cigarettes smoked (7 days) are important outcome measures. Experts reached consensus that biochemical validation methods should not always be used. The preferred biochemical validation methods were carbon monoxide (expired air) and cotinine (saliva). Preferred follow-ups included 6 and/or 12 months, with or without intermediate measurements. CONCLUSIONS: Findings suggest only partial compliance with the Russell standard and that more outcome measures may be important (including seven-day point-prevalence abstinence, number of cigarettes smoked, and cotinine when using biochemical validation). This study showed where there is and is not consensus, reflecting the need to develop a more comprehensive standard. For these purposes we provided suggestions for the Russell 2.0 standard.

A digital intake approach in specialized mental health care: study protocol of a cluster randomised controlled trial.

BACKGROUND: Enhancing patient participation is becoming increasingly important in mental health care as patients use to have a dependent, inactive role and nonadherence to treatment is a regular problem. Research shows promising results of initiatives stimulating patient participation in partnership with their clinicians. However, few initiatives targeting both patients' and clinicians' behaviour have been evaluated in randomised trials (RCT). Therefore, in GGz Breburg, a specialized mental health institution, a digital intake approach was developed aimed at exploring treatment needs, expectations and preferences of patients intended to prepare patients for the intake consultations. Subsequently, patients and clinicians discuss this information during intake consultations and make shared decisions about options in treatment. The aim of this trial is to test the efficacy of this new digital intake approach facilitated by Routine Outcome Monitoring (ROM), peer support and training of clinicians as compared to the intake as usual. The primary outcome is decisional conflict about choices in treatment. Secondary outcomes focus on patient participation, shared decision making, working alliance, adherence to treatment and clinical outcomes. METHODS: This article presents the study protocol of a cluster-randomised controlled trial in four outpatient departments for adults with depression, anxiety and personality disorders, working in two different regions. Randomisation is done between two similar intake-teams within each department. In the four intervention teams the new intake approach is implemented. The four control teams apply the intake as usual and will implement the new approach after the completion of the study. In total 176 patients are projected to participate in the study. Data collection will be at baseline, and at two weeks and two months after the intake. DISCUSSION: This study will potentially demonstrate the efficacy of the new digital intake approach in mental health care in terms of the primary outcome the degree of decisional conflict about choices in treatment. The findings of this study may contribute to the roll out of such eHealth initiatives fostering patient involvement in decision making about their treatment. TRIAL REGISTRATION: Trial registration: Dutch Trial Register NTR5677 . Registered 17th January 2016.

A randomized controlled trial of Web-based Attentional Bias Modification to help smokers quit.

OBJECTIVE: To assess the efficacy of a multiple-sessions Web-based Attentional Bias Modification (ABM) self-help intervention in 434 smokers who made a quit-attempt. METHOD: Respondents were randomized to receive 6 sessions of ABM- or placebo-training in a period of 2 weeks. Smoking-related cognitions (e.g., self-efficacy and intention to quit) and cognitive biases (i.e., attentional and approach bias) for smoking-cues were assessed before training (pretest). Primary outcome-variable was continued abstinence, 6 months after baseline. Bias reduction at the posttraining assessment was the secondary outcome. A 2 × 2 mixed analysis of variance (ANOVA) and logistic regression analyses were conducted using the whole sample (N = 434) as well as subsamples of light to moderate smokers (<15 cigarettes, N = 115) and heavy smokers (15 or more cigarettes, N = 319). Conservative analyses (coding drop-outs as smokers) as well as complete case analyses were conducted. RESULTS: The ABM training had no significant effect regarding bias reduction and no behavioral effects in the whole sample of smokers. Subsample analyses revealed a significant positive effect on continued abstinence in heavy smokers only (complete case analyses: odds ratio [OR] = 3.15; p = .02; confidence interval [CI] = 1.24-7.99; conservative analyses: OR = 2.49; p = .02; CI = 1.13-5.48). CONCLUSION: Web-based ABM training is ineffective in fostering cognitive bias reduction and continued smoking abstinence. However, the positive effects in heavy smokers-as indicated by exploratory subsample analyses-warrant further research into the potential of multiple sessions ABM training to foster continued smoking abstinence in heavy smokers who make a quit-attempt. (PsycINFO Database Record

Impact of Educational Level on Study Attrition and Evaluation of Web-Based Computer-Tailored Interventions: Results From Seven Randomized Controlled Trials.

BACKGROUND: Web-based computer-tailored interventions have shown to be effective in improving health behavior; however, high dropout attrition is a major issue in these interventions. OBJECTIVE: The aim of this study is to assess whether people with a lower educational level drop out from studies more frequently compared to people with a higher educational level and to what extent this depends on evaluation of these interventions. METHODS: Data from 7 randomized controlled trials of Web-based computer-tailored interventions were used to investigate dropout rates among participants with different educational levels. To be able to compare higher and lower educated participants, intervention evaluation was assessed by pooling data from these studies. Logistic regression analysis was used to assess whether intervention evaluation predicted dropout at follow-up measurements. RESULTS: In 3 studies, we found a higher study dropout attrition rate among participants with a lower educational level, whereas in 2 studies we found that middle educated participants had a higher dropout attrition rate compared to highly educated participants. In 4 studies, no such significant difference was found. Three of 7 studies showed that participants with a lower or middle educational level evaluated the interventions significantly better than highly educated participants ("Alcohol-Everything within the Limit": F2,376=5.97, P=.003; "My Healthy Behavior": F2,359=5.52, P=.004; "Master Your Breath": F2,317=3.17, P=.04). One study found lower intervention evaluation by lower educated participants compared to participants with a middle educational level ("Weight in Balance": F2,37=3.17, P=.05). Low evaluation of the interventions was not a significant predictor of dropout at a later follow-up measurement in any of the studies. CONCLUSIONS: Dropout attrition rates were higher among participants with a lower or middle educational level compared with highly educated participants. Although lower educated participants evaluated the interventions better in approximately half of the studies, evaluation did not predict dropout attrition. Further research is needed to find other explanations for high dropout rates among lower educated participants.

Mental health research priorities for Europe.

Mental and brain disorders represent the greatest health burden to Europe-not only for directly affected individuals, but also for their caregivers and the wider society. They incur substantial economic costs through direct (and indirect) health-care and welfare spending, and via productivity losses, all of which substantially affect European development. Funding for research to mitigate these effects lags far behind the cost of mental and brain disorders to society. Here, we describe a comprehensive, coordinated mental health research agenda for Europe and worldwide. This agenda was based on systematic reviews of published work and consensus decision making by multidisciplinary scientific experts and affected stakeholders (more than 1000 in total): individuals with mental health problems and their families, health-care workers, policy makers, and funders. We generated six priorities that will, over the next 5-10 years, help to close the biggest gaps in mental health research in Europe, and in turn overcome the substantial challenges caused by mental disorders.