A smoking cessation intervention for people with severe mental illness treated in ambulatory mental health care (KISMET): study protocol of a randomised controlled trial.

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.

The nurse-led GILL eHealth intervention for improving physical health and lifestyle behaviours in clients with severe mental illness: design of a cluster-randomised controlled trial.

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.

Patient-reported outcomes of lifestyle interventions in patients with severe mental illness: a systematic review and meta-analysis.

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 (I2 = 68.7%). We found a small effect on depression severity (g = 0.30, 95% CI = 0.00 to 0.58, I2 = 65.2%) and a moderate effect on anxiety severity (g = 0.56, 95% CI = 0.16 to 0.95, I2 = 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.

Muva physical activity intervention to improve social functioning in people with a severe mental illness: study protocol of a pragmatic stepped wedge cluster randomized trial.

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 .

Implementation of a lifestyle intervention for people with a severe mental illness (SMILE): a process evaluation.

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.

Mental Health Nurses' Perceptions of Their Role in Physical Screening and Lifestyle Coaching for Patients With a Severe Mental Illness: A Qualitative Study.

BACKGROUND: The life expectancy of patients with severe mental illness (SMI) is estimated to be 20 to 30 years shorter than in the general population due to avoidable physical illnesses. This gap is widening. Health care professionals' performance with regard to physical health and lifestyle appears to be suboptimal. AIMS: The purpose of this study is to formulate recommendations to enhance physical care for patients with an SMI. METHODS: A generic descriptive qualitative study was conducted. Fifteen mental health nurses (MHNs) working in community mental health care in the Netherlands were interviewed. Thematic analysis of the data was performed. RESULTS: Most MHNs perceived physical screening and lifestyle interventions to be an important part of their professional role. However, they recognize discrepancy between their perception and actual practice. Most MHNs focus in particular on the psychiatric illness and its consequences for daily living, and they defined the provision of physical health care as a secondary concern. Participants described building a therapeutic relationship as a crucial, however, difficult part of the process of working on physical health promotion. Many MHNs tend to formulate goals and necessary behavioral changes on behalf of their patients, rather than helping them formulate their own goals and activities for themselves. CONCLUSIONS: Building a good therapeutic relationship with patients and supporting patients in defining their own lifestyle goals can enhance nursing physical care. Support by other team members (such as NPs) and managers is needed. In training and education for professionals, the lessons learned in this study should be included.

Agreement between patients and mental healthcare providers on unmet care needs in child and adolescent psychiatry.

PURPOSE: In mental health care, patients and their care providers may conceptualize the nature of the disorder and appropriate action in profoundly different ways. This may lead to dropout and lack of compliance with the treatments being provided, in particular in young patients with more severe disorders. This study provides detailed information about patient-provider (dis)agreement regarding the care needs of children and adolescents. METHODS: We used the Camberwell Assessment of Need (CANSAS) to assess the met and unmet needs of 244 patients aged between 6 and 18 years. These needs were assessed from the perspectives of both patients and their care providers. Our primary outcome measure was agreement between the patient and care provider on unmet need. By comparing a general outpatient sample (n = 123) with a youth-ACT sample (n = 121), we were able to assess the influence of severity of psychiatric and psychosocial problems on the extent of agreement on patient's unmet care needs. RESULTS: In general, patients reported unmet care needs less often than care providers did. Patients and care providers had the lowest extents of agreement on unmet needs with regard to "mental health problems" (k = 0.113) and "information regarding diagnosis/treatment" (k = 0.171). Comparison of the two mental healthcare settings highlighted differences for three-quarters of the unmet care needs that were examined. Agreement was lower in the youth-ACT setting. CONCLUSIONS: Clarification of different views on patients' unmet needs may help reduce nonattendance of appointments, noncompliance, or dropout. Routine assessment of patients' and care providers' perceptions of patients' unmet care needs may also help provide information on areas of disagreement.

Online Self-Management Support for Family Caregivers Dealing With Behavior Changes in Relatives With Dementia (Part 2): Randomized Controlled Trial.

BACKGROUND: Online contacts with a health professional have the potential to support family caregivers of people with dementia. OBJECTIVE: The goal of the research was to study the effects of an online self-management support intervention in helping family caregivers deal with behavior changes of a relative with dementia. The intervention-involving among others personal email contacts with a dementia nurse-was compared with online interventions without these email contacts. METHODS: A randomized controlled trial was conducted with 81 family caregivers of people with dementia who live at home. Participants were randomly assigned to a (1) major self-management support intervention consisting of personal email contacts with a specialist dementia nurse, online videos, and e-bulletins; (2) medium intervention consisting only of online videos and e-bulletins; or (3) minor intervention consisting of only the e-bulletins. The primary outcome was family caregivers' self-efficacy in dealing with behavior changes of the relative with dementia. Secondary outcomes were family caregivers' reports of behavior problems in the people with dementia and the quality of the relationship between the family caregiver and the person with dementia. Measurements were performed at the baseline and at 6 (T1) and 12 weeks (T2) after the baseline. A mixed-model analysis was conducted to compare the outcomes of the 3 intervention arms. RESULTS: Family caregivers participating in the major intervention involving email contacts showed no statistically significant differences in self-efficacy after the intervention compared with the minor intervention involving only e-bulletins (difference -0.02, P=.99). In the adjusted analysis, the medium intervention (involving videos and e-bulletins) showed a negative trend over time (difference -4.21, P=.09) and at T1 (difference -4.71, P=.07) compared with the minor intervention involving only e-bulletins. No statistical differences were found between the intervention arms in terms of the reported behavior problems and the quality of the relationship between the family caregiver and the person with dementia. CONCLUSIONS: The expectation that an online self-management support intervention involving email contacts would lead to positive effects and be more effective than online interventions without personal email contacts was not borne out. One explanation might be related to the fact that not all family caregivers who were assigned to that intervention actually made use of the opportunity for personal email contact. The online videos were also not always viewed. To obtain more definite conclusions, future research involving extra efforts to reach higher use rates is required. TRIAL REGISTRATION: Netherlands Trial Registry NTR6237; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6237 (Archived by WebCite at http://www.webcitation.org/6v0S4fxTC). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.8365.

A Qualitative Study of the Working Alliance between Patient and Community Mental Health Nurse during Interpersonal Community Psychiatric Treatment.

In the Netherlands, long-term community psychiatric treatment for patients with a severe mental illness (SMI) is poorly developed and lacks a structured, goal-centered approach. Often this form of treatment is provided by community mental health nurses (CMHN's).Especially in the group of nonpsychotic patients with SMI, it often leads to care-as-usual with limited proven interventions and an unstructured treatment. Interpersonal Community Psychiatric Treatment (ICPT) was developed to provide this group of patients a focus, a theoretical view, and a methodological structure. A pilot study has been conducted on ICPT. As a result, a randomized controlled trial (RCT) was recently conducted in which this study is part. The pilot study showed improvement on a number of treatment outcomes. However, the working alliance (WA) experienced by the patients, although not significant, was considered to be decreased. The aim of study was to gain insight into how the ICPT-elements shape the WA and the possible self-determination of patients in general.The main part of this mixed-methods study was a qualitative study with a Grounded Theory approach. For the selection of the participants, quantitative data from the current RCT has been used. Semistructured interviews have been conducted with 13 participants, divided over three mental health institutions throughout the Netherlands. Interviews and analysis were alternated, so that the interview topics were developed by constant comparison.Eleven participants were female and 11 participants received social benefit. Six of the participants were above 50 years of age. Four participants suffered either from a depressive or anxiety disorder. Seven participants had a borderline personality disorder. The results are linked to Bordin's theory of the therapeutic alliance, which is agreement on therapeutic tasks, agreement on therapeutic goals, and the quality of the personal bond. The WA could be analyzed from three different perspectives: mutually agreed on goals, tasks, and experienced interpersonal relationship. ICPT had limited influence on the mutually agreed on goals and interpersonal relationship but mainly on the mutually agreed on tasks. In daily practice, ICPT may have a positive influence on the perceived WA.The main factors that affected the perceived WA during ICPT were the tasks that had been mutually agreed on, the use of an agenda, the structure of the sessions, the alliance between the CMHN and the patient, and the patient's own self-determination. There was a limited influence on the mutually agreed on goals and the quality of the personal relationship between the CMHN and the patient. The present research revealed valuable information about the significance of the WA in ICPT and the opinions of the respondents about ICPT and information about what might be helpful or unhelpful in their relationship with their CMHN.

The effect of using a mobile application ("WhiteTeeth") on improving oral hygiene: A randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of the WhiteTeeth mobile app, a theory-based mobile health (mHealth) program for promoting oral hygiene in adolescent orthodontic patients. METHODS: In this parallel randomized controlled trial, the data of 132 adolescents were collected during three orthodontic check-ups: at baseline (T0), at 6-week follow-up (T1) and at 12-week follow-up (T2). The intervention group was given access to the WhiteTeeth app in addition to usual care (n = 67). The control group received usual care only (n = 65). The oral hygiene outcomes were the presence and the amount of dental plaque (Al-Anezi and Harradine plaque index), and the total number of sites with gingival bleeding (Bleeding on Marginal Probing Index). Oral health behaviour and its psychosocial factors were measured through a digital questionnaire. We performed linear mixed-model analyses to determine the intervention effects. RESULTS: At 6-week follow-up, the intervention led to a significant decrease in gingival bleeding (B = -3.74; 95% CI -6.84 to -0.65) and an increase in the use of fluoride mouth rinse (B = 1.93; 95% CI 0.36 to 3.50). At 12-week follow-up, dental plaque accumulation (B = -11.32; 95% CI -20.57 to -2.07) and the number of sites covered with plaque (B = -6.77; 95% CI -11.67 to -1.87) had been reduced significantly more in the intervention group than in the control group. CONCLUSIONS: The results show that adolescents with fixed orthodontic appliances can be helped to improve their oral hygiene when usual care is combined with a mobile app that provides oral health education and automatic coaching. Netherlands Trial Registry Identifier: NTR6206: 20 February 2017.

Cost-effectiveness of a lifestyle intervention for people with a serious mental illness (SMILE): design of a pragmatic cluster-randomised controlled trial.

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.

A systematic review of palliative care tools and interventions for people with severe mental illness.

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.

The GET READY relapse prevention programme for anxiety and depression: a mixed-methods study protocol.

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).

Unmet care needs, care provision and patient satisfaction in patients with a late life depression: a cross-sectional study.

BACKGROUND: Research has shown that some 30% of total care needs in people with late-life depression (LLD) are unmet. It is not known to what extent patients actually don't receive any care for these needs or consider the care to be insufficient and their satisfaction with the provided care. AIM: The aim of this study is to obtain insight into the care provided in relation to the reported unmet care needs and satisfaction with the total care provided is examined. METHOD: A cross-sectional study of 99 people with LLD in an ambulatory setting. RESULTS: In 67% of patients, at least one unmet need was ascertained. In most cases (80%) care was actually provided for those needs by professionals and/or informal caregivers. Patients were satisfied with the care delivered for 81% of the reported care needs. Satisfaction was lowest for social care needs (67%). For six specific care needs it was demonstrated that dissatisfied patients were significantly more depressed than satisfied patients. CONCLUSION: Even though patients might receive care for certain needs, this does not mean that their needs are met. A substantial proportion of patients with LDD feel that they need additional help for unmet needs.

Support staff's perceptions of discontinuing antipsychotics in people with intellectual disabilities in residential care: A mixed-method study.

BACKGROUND: Although there is little evidence on their efficacy regarding challenging behaviour, antipsychotics are the most used psychotropic drugs in residential intellectually disabled people. Discontinuation is possible for some residential clients with intellectual disabilities. This study aimed to gain insight into support staff's perceptions of discontinuing antipsychotics in residential clients with intellectual disabilities. METHOD: Four focus groups were conducted in this mixed-methods study, followed by a survey. RESULTS: A large majority of support staff perceive antipsychotics to be effective in controlling challenging behaviour. Support staff regarded themselves as willing to contribute to the discontinuation of antipsychotics, but were more confident about achieving reductions. CONCLUSIONS: The attitude of the majority of support staff towards discontinuation provides a good basis for regularly reviewing antipsychotics use. A reduction plan should include preliminary steps, methods of monitoring and evaluating the process, and establishing measures for dealing with possible crises.

Factors associated with treatment intensification in child and adolescent psychiatry: a cross-sectional study.

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 R2 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 R2 = 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.

Evaluation of an interaction-skills training for reducing the burden of family caregivers of patients with severe mental illness: a pre-posttest design.

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 .

Medication adherence in patients with schizophrenia: a qualitative study of the patient process in motivational interviewing.

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.

Access to palliative care for homeless people: complex lives, complex care.

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.

Study protocol of a randomized controlled trial to test the effect of a smartphone application on oral-health behavior and oral hygiene in adolescents with fixed orthodontic appliances.

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).