An exploration of suicidal ideation and attempts, and care use and unmet need among suicide-ideators in a Belgian population study.

BACKGROUND: Suicidal ideation, or thinking about death and suicide, is common across all layers of society. The aim of this paper is to add to the understanding of suicidal ideation in the general population, as well as help-seeking behaviors and perceived unmet mental health needs among those who report suicidal thoughts. METHODS: The research is part of a representative population-based survey study of mental wellbeing in Antwerp (Flanders, Belgium) carried out in 2021. A total of 1202 participants between 15 and 80 years old answered the Ask Suicide-Screening Questions (ASQ), and an additional question about suicide plans. Participation was by invitation only and possible online or via a postal paper questionnaire. Univariate and multivariate logistic regression analyses were used to explore the association between both current suicidal ideation and self-reported lifetime suicide attempt with the sociodemographic factors age, gender, educational level, origin and financial distress. Moreover, formal care use for mental health was examined among those experiencing suicidal ideation, and logistic regression analyses were used to assess associated sociodemographic factors. Finally, perceived unmet mental health needs were assessed among suicide ideators. RESULTS: The point-prevalence of suicidal ideation was 8.6% and was higher among younger age groups and individuals reporting financial distress. The lifetime-prevalence of suicide attempts is 6.5% and was higher in younger people and individuals with a primary educational level and with financial distress. About half (45.6%) of those with suicidal ideation consulted a professional for mental health problems in the past twelve months. Men and those with a primary educational level were less likely to seek help. Half of suicide ideators without care use perceived some need for mental health care, and a third of suicide ideators who used care perceived the obtained help as insufficient, resulting in a population prevalence of 3.6% suicide ideators with a fully or partially perceived unmet need. CONCLUSIONS: The prevalence of suicide attempts, suicidal ideation and unmet needs among suicide-ideators is high in this Belgian sample. Mental health care need perception in suicide ideators needs further investigation.

How do people living with chronic conditions and their informal caregivers experience primary care? A phenomenological-hermeneutical study.

AIMS AND OBJECTIVES: Gaining insight in how people living with chronic conditions experience primary healthcare within their informal network. BACKGROUND: The primary healthcare system is challenged by the increasing number of people living with chronic conditions. To strengthen chronic care management, literature and policy plans point to a person-centred approach of care (PCC). A first step to identify an appropriate strategy to implement PCC is to gain more insight into the care experiences of these people and their informal caregivers. DESIGN: A phenomenological-hermeneutical philosophy is used. The study is in line with the Consolidated Criteria for Reporting Qualitative Research Guidelines (COREQ). METHOD: In-depth, semi-structured interviews with people living with chronic conditions and informal caregiver dyads (PCDs) (n = 16; 32 individuals) were conducted. An open-ended interview guide was used to elaborate on the PCDs' experiences regarding primary care. A purposive, maximal variation sampling was applied to recruit the participants. RESULTS: Based on sixteen PCDs' reflections, ten themes were identified presenting their experiences with primary care and described quality care as listening and giving attention to what people with chronic conditions want, to what they strive for, and above all to promote their autonomy in a context wherein they are supported by a team of formal caregivers, family and friends. CONCLUSION: To meet the PCDs' needs, self-management should be addressed in an interprofessional environment in which the PCD is an important partner. The findings may facilitate a shift to encourage PCDs in their strengths by enabling them to share their personal goals and by working towards meaningful activities in team collaboration. RELEVANCE TO CLINICAL PRACTICE: Three strategies-self-management support, goal-oriented care, and interprofessional collaboration-have been suggested to improve the PCDs' primary care experiences. These strategies could guide nursing practice in using more and improve high-quality nursing care.

Clinically assessed and perceived unmet mental health needs, health care use and barriers to care for mental health problems in a Belgian general population sample.

BACKGROUND: Mental health problems often remain undetected and untreated. Prior research suggests that this is mainly due to a lack of need-perception and attitudinal barriers. The aim of this study is to examine unmet mental health needs using both a clinically assessed and a self-perceived approach in a Belgian province. METHODS: A cross-sectional survey study with a weighted representative sample of 1208 individuals aged 15 - 80 years old was carried out in 2021 in the province of Antwerp (Belgium). Mental health needs were defined as a positive symptom screening for depression (PHQ-9), anxiety (GAD-7) or alcohol abuse (AUDIT-C and CAGE), combined with experiencing significant dysfunction in daily life. Also 12-month health care use for mental health problems, self-perceived unmet mental health needs and reasons for not seeking (extra) help were assessed. Logistic regression analyses were used to explore the predictors of mental health problems, health care use, and objective and subjective unmet mental health needs. RESULTS: One in five participants had a positive screening on one of the scales, of whom half experienced dysfunction, leading to a prevalence of 10.4% mental health needs. Among those, only half used health care for their mental health, resulting in a population prevalence of 5.5% clinically assessed unmet mental health needs. Fourteen percent of the total sample perceived an unmet mental health need. However, more women and younger people perceived unmet needs, while clinically assessed unmet needs were higher among men and older people. One in six of the total sample used health care for their mental health, most of whom did not have a clinically assessed mental health need. Motivational reasons were most often endorsed for not seeking any help, while a financial barrier was the most important reason for not seeking extra help. CONCLUSIONS: The prevalence of unmet mental health needs is high. Assessed and perceived (unmet) mental health needs are both relevant and complementary, but are predicted by different factors. More research is needed on this discrepancy.

Psychological distress associated with the COVID-19 pandemic and suppression measures during the first wave in Belgium.

BACKGROUND: The COVID-19 pandemic and subsequent suppression measures have had health and social implications for billions of individuals. The aim of this paper is to investigate the risk of psychological distress associated with the COVID-19 pandemic and suppression measures during the early days of the lockdown. We compared the level of psychological distress at the beginning of that period with a pre-pandemic health survey and assessed the psychological effects of exposure to the COVID-19 pandemic and changes in social activity and support. METHODS: An online survey was distributed to the general population in Belgium 3 days after the beginning of the lockdown. 20,792 respondents participated. The psychological distress of the population was measured using the GHQ-12 scale. Social activities and support were assessed using the Social Participation Measure, the Short Loneliness Scale, and the Oslo Social Support Scale. An index of subjective exposure to the COVID-19 pandemic was constructed, as well as a measure of change in occupational status. Measurements were compared to a representative sample of individuals extracted from the Belgian Health Interview Survey of 2018. Bootstrapping was performed and analyses were reweighted to match the Belgian population in order to control for survey selection bias. RESULTS: Half of the respondents reported psychological distress in the early days of the lockdown. A longer period of confinement was associated with higher risk of distress. Women and younger age groups were more at risk than men and older age groups, as were respondents who had been exposed to COVID-19. Changes in occupational status and a decrease in social activity and support also increased the risk of psychological distress. Comparing the results with those of the 2018 Belgian Health Interview shows that the early period of the lockdown corresponded to a 2.3-fold increase in psychological distress (95% CI: 2.16-2.45). CONCLUSIONS: Psychological distress is associated with the consequences of the COVID-19 pandemic and suppression measures. The association is measurable from the very earliest days of confinement and it affected specific at-risk groups. Authorities should consider ways of limiting the effect of confinement on the mental and social health of the population and developing strategies to mitigate the adverse consequences of suppression measures.

COVID-19 is having a destructive impact on health-care workers' mental well-being.

BACKGROUND: The coronavirus disease 2019 (COVID-19) may aggravate workplace conditions that impact health-care workers' mental health. However, it can also place other stresses on workers outside of their work. This study determines the effect of COVID-19 on symptoms of negative and positive mental health and the workforce's experience with various sources of support. Effect modification by demographic variables was also studied. METHODS: A cross-sectional survey study, conducted between 2 April and 4 May 2020 (two waves), led to a convenience sample of 4509 health-care workers in Flanders (Belgium), including paramedics (40.6%), nurses (33.4%), doctors (13.4%) and management staff (12.2%). About three in four were employed in university and acute hospitals (29.6%), primary care practices (25.7%), residential care centers (21.3%) or care sites for disabled and mental health care. In each of the two waves, participants were asked how frequently (on a scale of 0-10) they experienced positive and negative mental health symptoms during normal circumstances and during last week, referred to as before and during COVID-19, respectively. These symptoms were stress, hypervigilance, fatigue, difficulty sleeping, unable to relax, fear, irregular lifestyle, flashback, difficulty concentrating, feeling unhappy and dejected, failing to recognize their own emotional response, doubting knowledge and skills and feeling uncomfortable within the team. Associations between COVID-19 and mental health symptoms were estimated by cumulative logit models and reported as odds ratios. The needed support was our secondary outcome and was reported as the degree to which health-care workers relied on sources of support and how they experienced them. RESULTS: All symptoms were significantly more pronounced during versus before COVID-19. For hypervigilance, there was a 12-fold odds (odds ratio 12.24, 95% confidence interval 11.11-13.49) during versus before COVID-19. Positive professional symptoms such as the feeling that one can make a difference were less frequently experienced. The association between COVID-19 and mental health was generally strongest for the age group 30-49 years, females, nurses and residential care centers. Health-care workers reported to rely on support from relatives and peers. A considerable proportion, respectively, 18 and 27%, reported the need for professional guidance from psychologists and more support from their leadership. CONCLUSIONS: The toll of the crisis has been heavy on health-care workers. Those who carry leadership positions at an organizational or system level should take this opportunity to develop targeted strategies to mitigate key stressors of health-care workers' mental well-being.

Unmet mental health needs in the general population: perspectives of Belgian health and social care professionals.

BACKGROUND: An unmet mental health need exists when someone has a mental health problem but doesn't receive formal care, or when the care received is insufficient or inadequate. Epidemiological research has identified both structural and attitudinal barriers to care which lead to unmet mental health needs, but reviewed literature has shown gaps in qualitative research on unmet mental health needs. This study aimed to explore unmet mental health needs in the general population from the perspective of professionals working with vulnerable groups. METHODS: Four focus group discussions and two interviews with 34 participants were conducted from October 2019 to January 2020. Participants' professional backgrounds encompassed social work, mental health care and primary care in one rural and one urban primary care zone in Antwerp, Belgium. A topic guide was used to prompt discussions about which groups have high unmet mental health needs and why. Transcripts were coded using thematic analysis. RESULTS: Five themes emerged, which are subdivided in several subthemes: (1) socio-demographic determinants and disorder characteristics associated with unmet mental health needs; (2) demand-side barriers; (3) supply-side barriers; (4) consequences of unmet mental health needs; and (5) suggested improvements for meeting unmet mental health needs. CONCLUSIONS: Findings of epidemiological research were largely corroborated. Some additional groups with high unmet needs were identified. Professionals argued that they are often confronted with cases which are too complex for regular psychiatric care and highlighted the problem of care avoidance. Important system-level factors include waiting times of subsidized services and cost of non-subsidized services. Feelings of burden and powerlessness are common among professionals who are often confronted with unmet needs. Professionals discussed future directions for an equitable mental health care provision, which should be accessible and targeted at those in the greatest need. Further research is needed to include the patients' perspective of unmet mental health needs.

The engagement of psychiatrists in the assessment of euthanasia requests from psychiatric patients in Belgium: a survey study.

BACKGROUND: Since its legalisation in 2002, the number of times euthanasia has been carried out in response to requests from adults with psychiatric conditions (APC) has continued to increase. However, little is known about why and how psychiatrists become engaged in the assessment of such euthanasia requests. METHODS: A cross-sectional survey study was conducted between November 2018 and April 2019 of 499 psychiatrists affiliated with the Flemish Psychiatry Association. Chi square/Fisher's exact tests were performed to examine if, and to what extent, psychiatrists' backgrounds relate to their concrete experiences. The answers to the open question regarding motives for (non-) engagement were thematically coded. RESULTS: Two hundred one psychiatrists participated, a response rate of 40%. During their careers, 80% of those responding have been confronted with at least one euthanasia request from an APC patient and 73% have become involved in the assessment procedure. Their engagement was limited to the roles of: referring physician (in 44% of the psychiatrists), attending physician (30%), legally required 'advising physician' (22%), and physician participating in the actual administration of the lethal drugs (5%). Within the most recent 12 months of practice, 61% of the respondents have been actively engaged in a euthanasia assessment procedure and 9% have refused at least once to be actively engaged due to their own conscientious objections and/or the complexity of the assessment. The main motive for psychiatrists to engage in euthanasia is the patient's fundamental right in Belgian law to ask for euthanasia and the psychiatrist's duty to respect that. The perception that they were sufficiently competent to engage in a euthanasia procedure was greater in psychiatrists who have already had concrete experience in the procedure. CONCLUSIONS: Although the majority of psychiatrists have been confronted with euthanasia requests from their APC patients, their engagement is often limited to referring the request to a colleague physician for further assessment. More research is needed to identify the determinants of a psychiatrist's engagement in euthanasia for their APC patients and to discover the consequences of their non-, or their restricted or full engagement, on both the psychotherapeutic relationship and the course of the euthanasia request.

Belgian psychiatrists' attitudes towards, and readiness to engage in, euthanasia assessment procedures with adults with psychiatric conditions: a survey.

BACKGROUND: Although the Belgian assessment pathway for legal euthanasia requires the engagement of at least one psychiatrist, little is known about psychiatrists' attitudes towards euthanasia for adults with psychiatric conditions (APC). This study aims to gauge psychiatrists' attitudes towards and readiness to engage in euthanasia assessment and/or performance procedures in APC. METHODS: This cross-sectional survey study was performed between November 2018 and April 2019. The survey was sent to a sample of 499 eligible psychiatrists affiliated to the Flemish Association for Psychiatry, a professional association that aims to unite and represent all psychiatrists working in Flanders, the Dutch-speaking, northern part of Belgium. The Association's members comprise an estimated 80-90% of all psychiatrists active in Flanders. Only psychiatrists working with APC (83% of the association's total membership) were included. Factorial Anova and Chi Square tests were performed to examine if and to what extent psychiatrists' backgrounds were associated with, respectively, their attitudes and their readiness to play a role in euthanasia procedures concerning APC. RESULTS: One hundred eighty-four psychiatrists completed the questionnaire (response rate 40.2%); 74.5% agree that euthanasia should remain permissible for APC. However, 68.9% question some of the approaches taken by other physicians during the euthanasia assessment and only half consider euthanasia assessment procedures compatible with the psychiatric care relationship. Where active engagement is concerned, an informal referral (68%) or preliminary advisory role (43.8%) is preferred to a formal role as a legally required advising physician (30.3%), let alone as performing physician (< 10%). CONCLUSION: Although three quarters agree with maintaining the legal option of euthanasia for APC, their readiness to take a formal role in euthanasia procedures appears to be limited. More insight is required into the barriers preventing engagement and what psychiatrists need, be it education or clarification of the legal requirements, to ensure that patients can have their euthanasia requests assessed adequately.

Overgeneral autobiographical memory predicts higher prospective levels of depressive symptoms and intrusions in borderline patients.

Overgeneral memory (OGM), the tendency to retrieve categories of events from autobiographical memory instead of single events, is found to be a reliable predictor for future mood disturbances and post-traumatic symptom severity. Patients with borderline personality disorder (BPD) often report co-morbid episodes of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). Therefore, we investigated whether OGM would predict depression severity and (post-traumatic) stress symptoms in BPD patients. At admission (N = 54) and at six-month follow-up (N ≥ 31), BPD patients completed the Structured Clinical Interview for DSM-IV Disorders, the Assessment of DSM-IV Personality Disorders, the Autobiographical Memory Test, the Beck Depression Inventory-2nd edition (BDI-II), and the Impact of Event Scale. OGM at baseline predicted (a) higher levels of depressive symptoms at follow-up and (b) more intrusions related to a stressful event over and above baseline levels of borderline symptoms, depressive symptoms, and intrusions, respectively. No association was found between memory specificity and event-related avoidance at follow-up. Despite previous findings suggesting that OGM in BPD is less robust than in MDD and PTSD, our results suggest that memory specificity in BPD patients may have some relevance for the course of depressive and stress symptomatology in BPD.

The community pharmacist as a link to psychosocial care services: Findings and lessons from a collaborative project.

The role of pharmacists is increasingly expanding to encompass holistic patient-oriented services, including prevention, health advice, and counseling. Despite this, the pharmacist's role in public psychosocial wellbeing remains understudied. Project #CAVAsa, a collaboration between Flemish Pharmacists' Network and Centers for General Wellbeing (CAW), aimed to strengthen the pharmacist's role in psychosocial care. Through training and supportive materials, pharmacists were equipped to detect, inform, and refer patients to appropriate psychosocial services. Between 2021 and 2024, 387 pharmacies participated, registering 415 patient contacts about psychosocial wellbeing. Key enabling conditions for sustainable integration of pharmacists in psychosocial care include delineating their role, strengthening knowledge and competencies, and facilitating integrated care and collaboration. Further support for pharmacists and other primary care providers in psychosocial care is needed to bridge the gap between the health and social services.

Health system facilitators and barriers to the integration of mental health services into primary care in the Democratic Republic of the Congo: a multimethod study.

BACKGROUND: The integration of mental health into primary care-i.e., the process by which a range of essential mental health care and services are made available in existing multipurpose health care settings that did not previously provide them-can be facilitated or hindered by several health system factors that are still poorly understood. This study aimed to identify health system facilitators and barriers to the integration of mental health services into primary care in the Democratic Republic of the Congo (DRC) to improve the success rate of integration programs. METHODS: We conducted a multimethod, cross-sectional exploratory study. Stakeholders (managers, health service providers, service users, etc.) from sixteen of the twenty-six provinces of the DRC participated. We collected qualitative data through 31 individual, semistructured, face-to-face key informant interviews. We then collected quantitative data through a population-based survey of 413 respondents. We analyzed the interviews via thematic analysis, assigning verbatims to predefined themes and subthemes. For the survey responses, we performed descriptive analysis followed by binomial logistic regression to explore the associations between the variables of interest. RESULTS: Strong leadership commitment, positive attitudes toward mental health care, the availability of care protocols, mental health task sharing (p < 0.001), and sufficient numbers of primary care providers (PCPs) (p < 0.001) were identified as key health system facilitators of successful integration. However, barriers to integration are mainly related to a poor understanding of what integration is and what it is not, as well as to the poor functionality and performance of health facilities. In addition, stigma, low prioritization of mental health, lack of mental health referents, low retention rate of trained health professionals, lack of reporting tools, lack of standardized national guidelines for integration (p < 0.001), lack of funding (p < 0.001), shortage of mental health specialists to coach PCPs (p < 0.001), and lack of psychotropic medications (p < 0.001) were identified as health system barriers to integration. CONCLUSION: Improving the functionality of primary care settings before integrating mental health care would be beneficial for greater success. In addition, addressing identified barriers, such as lack of funding and mental health-related stigma, requires multistakeholder action across all building blocks of the health system.

Homelessness and housing problems in admitted psychiatric patients in Flanders, Belgium.

Homelessness in psychiatric patients in Flanders, Belgium, has never been investigated. Advocacy groups from patients with lived experience of psychiatric disorders have sounded the alarm on the scarcity of suitable housing options, the strain on psychiatric institutions, and the challenges faced by social service workers. To investigate the extent of the problem a survey on the topic was initiated. A "homelessness-in-mental-health-questionnaire" was designed by experts in the field. The social services of all Flemish psychiatric hospitals and all psychiatric wards in general hospitals were contacted and invited to complete this survey. 24 of 70 contacted services responded. The total number of homeless patients in the inpatient setting on an annual basis are estimated to an average 19.5%. 18% of homeless patients remain longer in admission due to the lack of housing options. 13.7% of homeless psychiatric patients are referred to a community care facility such as an assisted living facility. Social service respondents reported spending an average of 27.4% of their work time on housing issues. The main focus points according to the respondents are the lack of priority measures for homeless psychiatric patients, psychiatric problems as a barrier to housing options and the shortage of adapted housing capacity. The conclusion of this study is the need for comprehensive policy interventions to ensure an adequate supply of suitable social housing for psychiatric patients, accessible mental health care, alternative housing options and crisis accommodation facilities. We propose a 10-point action plan on housing for psychiatric patients for policymakers and politicians.

Fine-tuning the practical relevance of a quality framework for integrated nature-based interventions in healthcare facilities. A qualitative interview study.

Introduction: Integrated nature-based interventions in healthcare facilities are gaining importance as promising health and biodiversity promotion strategies. This type of interventions combines the restoration of biodiversity in the vicinity of the healthcare facility with guiding patients in that natural environment for health outcomes. However, quality appraisal of these interventions is still poorly developed. Based on a recent scoping review, the authors developed a preliminary quality framework in support of healthcare facilities designing, implementing and evaluating integrated nature-based interventions. This present study aims to fine-tune the practical relevance of the quality framework within the emerging practice. Methods: A qualitative interview study was conducted in seven healthcare facilities in Belgium. Using a combination of snowball and purposive sampling, 22 professionals, involved in the integrated nature-based intervention in their facility, participated in the study. The semi-structured interviews were transcribed and imported into NVivo. A deductive and inductive thematic analysis was used to explore the practical relevance of the quality framework. A stakeholders' assembly review and a member checking of the findings were also part of the study. Findings: Twenty-two interviews with nature management coordinators, healthcare professionals, and healthcare managers were conducted by three principal investigators in seven healthcare facilities implementing integrated nature-based interventions. The contextualization and complexity of integrated nature-based interventions in the participating healthcare facilities demonstrated the need for an evidence-based quality framework describing nature-based interventions. The study led to nine quality criteria, confirming the eight quality criteria derived from a previous scoping review, and the identification of a new quality criterion 'Capacity building, leverage and continuity'. These quality criteria have been refined. Finally, a proposal for a quality framework was developed and operationalized in a checklist. Deployment of the quality framework should be embedded in a continuous cyclical, adaptive process of monitoring and adjusting based on evaluations at each phase of an integrated nature-based intervention. Discussion: Bridging the domains of healthcare and nature management in the context of an integrated nature-based intervention in a healthcare facility requires a transdisciplinary approach. Scientific frameworks such as "complex interventions," Planetary Health and One Health can support the co-design, implementation and evaluation of integrated nature-based interventions within a cyclical, adaptive process. In addition, the importance of the quality of the interactions with nature could gain from more sophisticated attention. Finally, the implications for healthcare facilities, policymakers and education are discussed, as well as the strengths and limitations of the study.

Severity and Factors Associated with Depressive Symptoms Among Type 2 Diabetic Patients in Vietnam.

Background: Diabetes and psychiatric disorders often co-occur. The prevalence of depression in a person with diabetes is two times higher than that of the general population. During the last decade, the prevalence of diabetes in Vietnam has nearly doubled. However, there is little data regarding depressive symptoms among people with diabetes. Therefore, this study aims to explore the level of depressive symptoms and its associated factors among patients with type 2 diabetes mellitus in Hanoi, Vietnam. Methodology: A cross-sectional study was conducted among 519 patients diagnosed with type 2 diabetes at the Agricultural General Hospital, one of the largest primary care hospitals for diabetes in Hanoi, Vietnam. Patient Health Questionnaire-9 (PHQ-9) was used to assess the severity of depressive symptoms. Multivariate Tobit and logistic regression models were applied to examine factors associated with the severity of depressive symptoms and medication adherence. Results: Approximately 45.2% of participants were identified as having depressive symptoms at different levels. The proportion of patients with mild, moderate, moderately severe, and severe depressive symptoms is 36.0%, 7.6%, 1.4%, and 0.2% respectively. Regarding the treatment process, patients being treated for their diabetes for a longer time were more likely to have depressive symptoms. Depression was positively linked to currently drinking alcohol (Coef = 1.04; 95% CI = 0.30-1.78), having comorbidities (Coef = 1.08; 95% CI = 0.15; 2.01) and having irregular physical activities (Coef = -1.28; 95% CI = -2.18; -0.38). Patients with severe depressive symptoms (higher PHQ-9 score) were more likely to be non-adherent to their medications in the last month (AOR = 1.30; 95% CI = 1.17; 1.46). Conclusion: Our study shows that a high percentage of patients with diabetes have depressive symptoms. There is a strong association between having depressive symptoms and non-adherence to medications in the last month. To reduce the risk of developing depressive symptoms, depression should be screened at the initial treatment process and patients should be advised to avoid alcohol and to engage in physical activities regularly.

"At the time I only wanted to relieve stress": Exploring motivation for behaviour change in long-term hypnotic users.

Background: Motivating patients to discontinue long-term benzodiazepine receptor agonist (BZRA) use for insomnia remains an important challenge in primary care because of the medication's unfavourable risk-benefit profile. Previous studies have shown that understanding the complexity of patients' motivation is crucial to the primary care physician for providing effective interventions efficiently. Theoretical frameworks about behaviour change show that motivation is a multi-layered concept that interacts with other concepts, which aligns with a holistic perspective or implementation of the biopsychosocial model. Aim: Exploring primary care patients' views and ideas on what factors helped or hindered them in discontinuing long-term BZRA use, in relation to motivation as conceptualised in the Behaviour Change Wheel, and associated domains of the Theoretical Domains Framework. Design and setting: A qualitative study with semi-structured interviews in primary care in Belgium between September 2020 and March 2021. Method: Eighteen interviews with long-term hypnotic users were audio recorded, transcribed and thematically analyzed, using the Framework Method. Results: The success of discontinuation interventions does not solely rely on patients' spontaneous sense of striving for improvement. Reinforcement and identity were found to be important domains for motivation. Beliefs about personal capabilities, and about consequences of both BZRA intake and discontinuation, differed between previous and current users. Conclusion: Motivation is a multi-layered concept which is not fixed in time. Patient empowerment and goal setting could help long-term BZRA users to lower their intake. As well as public health interventions that might change social attitudes towards the use of hypnotic medication.

Implementing Blended Care to Discontinue Benzodiazepine Receptor Agonist Use for Insomnia: Process Evaluation of a Pragmatic Cluster Randomized Controlled Trial.

BACKGROUND: Long-term use of benzodiazepine receptor agonists (BZRAs) remains common despite European guidelines advising that these drugs be used in the lowest possible dose and for the shortest possible duration. Half of all BZRAs are prescribed in family practice. This creates a window of opportunity for discontinuation in primary care. Therefore, the effectiveness of blended care for the discontinuation of long-term BZRA use in adult primary care patients with chronic insomnia disorder was tested in a multicenter, pragmatic, and cluster randomized controlled superiority trial in Belgium. In the literature, information on implementing blended care in a primary care setting is scarce. OBJECTIVE: The study aimed to contribute to a framework for the successful implementation of blended care in a primary care setting by increasing our understanding of this complex intervention through an evaluation of e-tool use and views and ideas of participants in a BZRA discontinuation trial. METHODS: Based on a theoretical framework, this study evaluated the processes of recruitment, delivery, and response using 4 components: a survey on recruitment (n=76), semistructured in-depth interviews with patients (n=18), web-based asynchronous focus groups with general practitioners (GPs; n=19), and usage data of the web-based tool. Quantitative data were analyzed descriptively, and qualitative data were analyzed thematically. RESULTS: For recruitment, the most common barriers were refusal by the patient and the lack of digital literacy, while facilitators were starting the conversation and the curiosity of patients. The delivery of the intervention to the patients was diverse, ranging from GPs who never informed the patient about their access to the e-tool to GPs consulting the e-tool in between consultations to have discussion points when the patient visited. Concerning response, patients' and GPs' narratives also showed much variety. For some GPs, daily practice changed because they received more positive reactions than expected and felt empowered to talk more often about BZRA discontinuation. Conversely, some GPs reported no changes in practice or among patients. In general, patients found follow-up by an expert to be the most important component in blended care, whereas GPs deemed the intrinsic motivation of patients to be the key element of success. An important barrier to implementation by the GP was time. CONCLUSIONS: Overall, the participants who had used the e-tool were positive about its structure and content. Nevertheless, many patients desired a more tailored application with feedback from an expert and personal tapering schedules. Strict pragmatic implementation of blended care seems to only reach GPs with an interest in digitalization. Although not superior to usual care, blended care could be a complementary tool that allows tailoring the discontinuation process to the personal style of the GP and the needs of the patient. TRIAL REGISTRATION: ClinicalTrials.gov NCT03937180; https://clinicaltrials.gov/ct2/show/NCT03937180.

Building Bridges between Pharmacy and Psychosocial Care: Supporting and Referring Patients with Psychosocial Needs in a Pilot Study with Community Pharmacists.

Introduction: Community pharmacists are accessible primary care providers and therefore in a good position to detect unmet psychosocial needs of their patients and pharmacy visitors. Description: A collaboration between pharmacists and psychosocial work was set up in Flanders, Belgium. Community pharmacists were trained to discuss psychosocial needs, to inform patients about possible help and refer them to a Center for General Wellbeing if needed. During the pilot of the project between October 2021 and January 2022, the feasibility and potential of this collaboration were examined. Discussion: A total of 79 patient contacts about psychosocial wellbeing were reported using an online registration form, the majority of which concerned women. Family problems and mental health problems were most often reported. Focus group discussions with 28 participating pharmacists showed that they experience their role in psychosocial care as fulfilling and of valuable. Patient satisfaction was mentioned to be a major motivating factor, while time and privacy are barriers. Adequate training in psychosocial wellbeing and care was considered crucial. Conclusion: Pharmacists can be valuable partners in the recognition and referral of patients with unmet psychosocial needs. Structural collaborations between community pharmacy and psychosocial care should be further supported.

Psychiatrists and other medical professionals in Belgium show a substantial lack of knowledge about poverty.

The bidirectional relationship between poverty and poor physical and mental health is well-known. All physicians should have sufficient knowledge on poverty as a social determinant and its impact on (mental) health. The knowledge of poverty in physicians is seldom investigated. An online and paper survey was circulated in March/April 2022 in Belgium, to assess physician's opinions about and attitudes toward patients in poverty. Not only was interest in the subject rather low, but there were also substantial contradictions in the responses. The lack of knowledge about poverty among physicians leads to reduced quality of medical care for this target group. This is an individual medical-ethical and societal problem. We suggest 10 point-action plan for policymakers, educational institutions, and physicians.

Physical Healthcare for People with a Severe Mental Illness in Belgium by Long-Term Community Mental Health Outreach Teams: A Qualitative Descriptive Study on Physicians', Community Mental Health Workers' and Patients' Perspectives.

BACKGROUND: People with a severe mental illness (pSMI) often have comorbid physical health problems, resulting in a lower life expectancy compared to the global population. In Belgium, it remains unclear how to approach health disparities in pSMI in a community setting. This study explores the perspectives of both care professionals and patients on physical healthcare in Belgian community mental services, aiming to identify good practices, barriers and points of improvement. METHODS: An exploratory qualitative design that used a semi-structured focus group interview with physicians combined with individual face-to-face interviews with physicians, mental health professionals and patients. RESULTS: We identified care professional-, patient-related and organizational factors, as well as points of improvement. The identified themes linked to care professionals were communication, task distribution, knowledge, time and stigmatization. The co-location of services was the main theme on an organizational level. CONCLUSIONS: As community-based mental health services in Belgium emerged in the past decade, addressing physical health in pSMI is still challenging. Our findings suggest that there is a need for improvement in the current healthcare provision. Multidisciplinary guidelines, shared patient records, enlarging nurses' tasks, providing financial incentives and a structural integration of primary and psychiatric care were perceived as major points of improvement to the current Belgian healthcare organization.

Blended care to discontinue benzodiazepine receptor agonists use in patients with chronic insomnia disorder: a pragmatic cluster randomized controlled trial in primary care.

STUDY OBJECTIVES: International guidelines recommend using benzodiazepine receptor agonists (BZRA) for maximally four weeks. Nevertheless, long-term use for chronic insomnia disorder remains a common practice. This study aimed to test the effectiveness of blended care for discontinuing long-term BZRA use in general practice. METHODS: A pragmatic cluster randomized controlled superiority trial compared blended care to usual care through urine toxicology screening. In the intervention, care by the general practitioner (GP) was complemented by an interactive e-learning program, based on cognitive behavioral therapy for insomnia. Adults using BZRA daily for minimally 6 months were eligible. Participants were clustered at the level of the GP surgery for allocation (1:1). Effectiveness was measured as the proportion of patients who had discontinued at one-year follow-up. Data analysis followed intention-to-treat principles. RESULTS: In total, 916 patients in 86 clusters, represented by 99 GPs, were randomized. Primary outcome data was obtained from 727 patients (79%). At one-year follow-up, 82 patients (18%) in blended care, compared to 91 patients (20%) in usual care, had discontinued. There was no statistically significant effect for the intervention (OR: 0.924; 95% CI: 0.60; 1.43). No adverse events were reported to the research team. CONCLUSIONS: The findings did not support the superiority of blended care over usual care. Both strategies showed clinical effectiveness, with an average of 19% of patients having discontinued at one-year follow-up. Further research is important to study the effect of structurally implementing digital interventions in general practice. CLINICAL TRIAL: Big Bird trial; KCE-17016. This trial is registered at clinicaltrials.gov (NCT03937180).