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Abstract Xenon dual-phase time projections chambers (TPCs) have proven to be a successful technology in studying physical phenomena that require low-background conditions. With $$40\,\textrm{t}$$ 40 t of liquid xenon (LXe) in the TPC baseline design, DARWIN will have a high sensitivity for the detection of particle dark matter, neutrinoless double beta decay ( $$0\upnu \upbeta \upbeta $$ 0 ν β β ), and axion-like particles (ALPs). Although cosmic muons are a source of background that cannot be entirely eliminated, they may be greatly diminished by placing the detector deep underground. In this study, we used Monte Carlo simulations to model the cosmogenic background expected for the DARWIN observatory at four underground laboratories: Laboratori Nazionali del Gran Sasso (LNGS), Sanford Underground Research Facility (SURF), Laboratoire Souterrain de Modane (LSM) and SNOLAB. We present here the results of simulations performed to determine the production rate of $${}^{137}$$ 137 Xe, the most crucial isotope in the search for $$0\upnu \upbeta \upbeta $$ 0 ν β β of $${}^{136}$$ 136 Xe. Additionally, we explore the contribution that other muon-induced spallation products, such as other unstable xenon isotopes and tritium, may have on the cosmogenic background.

Abstract We correct an overestimation of the production rate of $$^{137}$$ 137 Xe in the DARWIN detector operated at LNGS. This formerly dominant intrinsic background source is now at a level similar to the irreducible background from solar $$^8$$ 8 B neutrinos, thus unproblematic at the LNGS depth. The projected half-life sensitivity for the neutrinoless double beta decay ( $$0\nu \beta \beta $$ 0 ν β β ) of $$^{136}$$ 136 Xe improves by $$22\%$$ 22 % compared to the previously reported number and is now $$T^{0\nu }_{1/2}= {3.0\times 10^{27}} \hbox { yr}$$ T 1 / 2 0 ν = 3.0 × 10 27 yr (90% C.L.) after 10 years of DARWIN operation.

Introduction Clinicians in mental healthcare have few objective tools to identify and analyse their patient’s care needs. Clinical decision aids are tools that can support this process. Objectives This study examines whether 1) clinicians working with a clinical decision aid (TREAT) discuss more of their patient’s care needs compared to usual treatment, and 2) agree on more evidence-based treatment decisions. Methods Clinicians participated in consultations (n=166) with patients diagnosed with psychotic disorders from four Dutch mental healthcare institutions. Primary outcomes were measured with the modified Clinical Decision-making in Routine Care questionnaire and combined with psychiatric, physical and social wellbeing related care needs. A multilevel analysis compared discussed care needs and evidence-based treatment decisions between treatment as usual (TAU) before, TAU after and the TREAT-condition. Results First, a significant increase in discussed care needs for TREAT compared to both TAU conditions (b = 20.2, SE = 5.2, p = 0.00 and b = 15.8, SE = 5.4, p = 0.01) was found. Next, a significant increase in evidence-based treatments decisions for care needs was observed for TREAT compared to both TAU conditions (b = 16.7, SE = 4.8, p = 0.00 and b = 16.0, SE = 5.1, p = 0.01). Conclusions TREAT improved the discussion about physical health issues and social wellbeing related topics. It also increased evidence-based treatment decisions for care needs which are sometimes overlooked and difficult to treat. Our findings suggest that TREAT makes sense of ROM data and improves guideline-informed care. Disclosure No significant relationships.

Abstract Long-lived radon daughters are a critical background source in experiments searching for low-energy rare events. Originating from radon in ambient air, radioactive polonium, bismuth and lead isotopes plate-out on materials that are later employed in the experiment. In this paper, we examine cleaning procedures for their capability to remove radon daughters from PTFE surfaces, a material often used in liquid xenon TPCs. We find a large difference between the removal efficiency obtained for the decay chains of $$^{222}$$ 222 Rn and $$^{220}$$ 220 Rn. This indicates that the plate-out mechanism has an effect on the cleaning success. While the long-lived $$^{222}$$ 222 Rn daughters can be reduced by a factor of 2, the removal of $$^{220}$$ 220 Rn daughters is up to 10 times more efficient depending on the treatment. Furthermore, the impact of a nitric acid based PTFE cleaning on the liquid xenon purity is investigated in a small-scale liquid xenon TPC.

Abstract We detail the sensitivity of the proposed liquid xenon DARWIN observatory to solar neutrinos via elastic electron scattering. We find that DARWIN will have the potential to measure the fluxes of five solar neutrino components: pp, $$^7$$ 7 Be, $$^{13}$$ 13 N, $$^{15}$$ 15 O and pep. The precision of the $$^{13}$$ 13 N, $$^{15}$$ 15 O and pep components is hindered by the double-beta decay of $$^{136}$$ 136 Xe and, thus, would benefit from a depleted target. A high-statistics observation of pp neutrinos would allow us to infer the values of the electroweak mixing angle, $$\sin ^2\theta _w$$ sin 2 θ w , and the electron-type neutrino survival probability, $$P_{ee}$$ P ee , in the electron recoil energy region from a few keV up to 200 keV for the first time, with relative precision of 5% and 4%, respectively, with 10 live years of data and a 30 tonne fiducial volume. An observation of pp and $$^7$$ 7 Be neutrinos would constrain the neutrino-inferred solar luminosity down to 0.2%. A combination of all flux measurements would distinguish between the high- (GS98) and low-metallicity (AGS09) solar models with 2.1–2.5 $$\sigma $$ σ significance, independent of external measurements from other experiments or a measurement of $$^8$$ 8 B neutrinos through coherent elastic neutrino-nucleus scattering in DARWIN. Finally, we demonstrate that with a depleted target DARWIN may be sensitive to the neutrino capture process of $$^{131}$$ 131 Xe.

Abstract The DARWIN observatory is a proposed next-generation experiment to search for particle dark matter and for the neutrinoless double beta decay of $$^{136}$$ 136 Xe. Out of its 50 t total natural xenon inventory, 40 t will be the active target of a time projection chamber which thus contains about 3.6 t of $$^{136}$$ 136 Xe. Here, we show that its projected half-life sensitivity is $$2.4\times {10}^{27}\,{\hbox {year}}$$ 2.4×1027year , using a fiducial volume of 5 t of natural xenon and 10 year of operation with a background rate of less than 0.2 events/(t $$\cdot $$ · year) in the energy region of interest. This sensitivity is based on a detailed Monte Carlo simulation study of the background and event topologies in the large, homogeneous target. DARWIN will be comparable in its science reach to dedicated double beta decay experiments using xenon enriched in $$^{136}$$ 136 Xe.

AbstractQuality and performance are current issues and a strategic priority for the Portuguese National Health Service. Currently, there is a lack of studies in primary health care (PHC) that assess the relationship between the quality and the level of performance of the Primary Health Care Teams. In Portugal, those teams are monitored through the Global Performance Index (GPI), which demonstrates, through a score, the procedures and results obtained by electronic records and the metrics defined for each indicator. This paper aims to analyze the relationship between the perception of the quality of health professionals (service culture; leadership; service strategy; infrastructure and external resources; information and knowledge; processes; service management; human resource planning and skills development, commitment; conditions, satisfaction, performance, and recognition; and results) in the different Primary Health Care teams of the PHC of Central Alentejo—Portugal, and the level of performance of the given teams (care performance; professional training; organizational quality; and services). Self-Perception of Quality Questionnaire for Primary Health Care (SPQQ4PHC) was used as an assessment tool. The population comprises 324 health professionals (Family Doctors, Nurses, and Medical Secretaries) distributed over 34 Primary Health Care Teams. When analyzing the global correlation of the variables in the SPQQ4PHC questionnaire with the GPI, it´s possible to confirm that twenty-one out of twenty-five correlates with the GPI. Thus, this study allowed us to conclude that, as health professionals perceive the quality of the variables increases, the GPI also increases, demonstrating that the dimensions of quality and performance are closely related.

Reprocessing of regional-scale airborne electromagnetic data is used to build a 3D geological model of the Nasia sub-basin, northern Ghana. The resulting 3D geological model consistently integrates all the prior pieces of information brought by electromagnetic data, lithologic logs, ground-based geophysical surveys, and geological knowledge of the terrain. The geo-modeling process is aimed at defining the lithostratigraphy of the area, chiefly to improve the stratigraphic definition of the area, and for hydrogeological purposes. The airborne electromagnetic measurements, consisting of GEOTEM B-field data, were originally collected for mineral exploration purposes. Thus, those B-field data had to be (re)processed and properly inverted as the original survey and data handling were designed for the detection of potential mineral targets and not for detailed geological mapping. These new geophysical inversion results, compared with the original conductivity–depth images, provided a significantly different picture of the subsurface. The new geophysical model led to new interpretations of the geological settings and to the construction of a comprehensive 3D geo-model of the basin. In this respect, the evidence of a hitherto unexposed system of paleovalleys could be inferred from the airborne data. The stratigraphic position of these paleovalleys suggests a distinctly different glaciation history from the known Marinoan events, commonly associated with the Kodjari formation of the Voltaian sedimentary basin. Indeed, the presence of the paleovalleys within the Panabako may be correlated with mountain glaciation within the Sturtian age, though no unequivocal glaciogenic strata have yet been identified. Pre-Marinoan glaciation is recorded in rocks of the Wassangara group of the Taoudéni Basin. The combination of the Marinoan and, possibly, Sturtian glaciation episodes, both of the Cryogenian period, can be an indication of a Neoproterozoic Snowball Earth. Hence, the occurrence of those geological features not only has important socioeconomic consequences – as the paleovalleys can act as reservoirs for groundwater – but also from a scientific point of view, they could be extremely relevant as their presence would require a revision of the present stratigraphy of the area.

We report the performances of a 0.7-μm InP/GaInAs DHBT developed in III-V Lab demonstrating both fT and f MAX of 400 GHz as well as a high fabrication yield and homogeneity on a 3-inch wafer. This technology is used for the fabrication of a very high speed 2:1 multiplexing selector operating up to 212-Gb/s, establishing a speed record. A 5.4-Vpp 100-Gb/s distributed differential selector-driver, as well as a 4.3-Vpp 64-GBd 8-pulse-amplitude-modulation (PAM) (192 Gb/s) high-speed power digital-to-analog converter (DAC) were also realized in this technology.

Forecasting the flow of groundwater requires a hydrostratigraphic model, which describes the architecture of the subsurface. State-of-the-art multiple-point statistical (MPS) tools are readily available for creating models depicting subsurface geology. We present a study of the impact of key parameters related to stochastic MPS simulation of a real-world hydrogeophysical dataset from Kasted, Denmark, using the snesim algorithm. The goal is to study how changes to the underlying datasets propagate into the hydrostratigraphic realizations when using MPS for stochastic modeling. This study focuses on the sensitivity of the MPS realizations to the geophysical soft data, borehole lithology logs, and the training image (TI). The modeling approach used in this paper utilizes a cognitive geological model as a TI to simulate ensemble hydrostratigraphic models. The target model contains three overall hydrostratigraphic categories, and the MPS realizations are compared visually as well as quantitatively using mathematical measures of similarity. The quantitative similarity analysis is carried out exhaustively, and realizations are compared with each other as well as with the cognitive geological model.The results underline the importance of geophysical data for constraining MPS simulations. Relying only on borehole data and the conceptual geology, or TI, results in a significant increase in realization uncertainty. The airborne transient electromagnetic SkyTEM data used in this study cover a large portion of the Kasted model area and are essential to the hydrostratigraphic architecture. On the other hand, the borehole lithology logs are sparser, and 410 boreholes were present in this study. The borehole lithology logs infer local changes in the immediate vicinity of the boreholes, thus, in areas with a high degree of geological heterogeneity, boreholes only provide limited large-scale structural information. Lithological information is, however, important for the interpretation of the geophysical responses. The importance of the TI was also studied. An example was presented where an alternative geological model from a neighboring area was used to simulate hydrostratigraphic models. It was shown that as long as the geological settings are similar in nature, the realizations, although different, still reflect the hydrostratigraphic architecture. If a TI containing a biased geological conceptualization is used, the resulting realizations will resemble the TI and contain less structure in particular areas, where the soft data show almost even probability to two or all three of the hydrostratigraphic units.

Most studies on the application of geostatistical simulations based on multiple-point statistics (MPS) to hydrogeological modelling focus on relatively fine-scale models and concentrate on the estimation of facies-level structural uncertainty. Much less attention is paid to the use of input data and optimal construction of training images. For instance, even though the training image should capture a set of spatial geological characteristics to guide the simulations, the majority of the research still relies on 2-D or quasi-3-D training images. In the present study, we demonstrate a novel strategy for 3-D MPS modelling characterized by (i) realistic 3-D training images and (ii) an effective workflow for incorporating a diverse group of geological and geophysical data sets. The study covers an area of 2810 km2 in the southern part of Denmark. MPS simulations are performed on a subset of the geological succession (the lower to middle Miocene sediments) which is characterized by relatively uniform structures and dominated by sand and clay. The simulated domain is large and each of the geostatistical realizations contains approximately 45 million voxels with size 100 m × 100 m × 5 m. Data used for the modelling include water well logs, high-resolution seismic data, and a previously published 3-D geological model. We apply a series of different strategies for the simulations based on data quality, and develop a novel method to effectively create observed spatial trends. The training image is constructed as a relatively small 3-D voxel model covering an area of 90 km2. We use an iterative training image development strategy and find that even slight modifications in the training image create significant changes in simulations. Thus, this study shows how to include both the geological environment and the type and quality of input information in order to achieve optimal results from MPS modelling. We present a practical workflow to build the training image and effectively handle different types of input information to perform large-scale geostatistical modelling.

We present an automatic method for parameterization of a 3-D model of the subsurface, integrating lithological information from boreholes with resistivity models through an inverse optimization, with the objective of further detailing of geological models, or as direct input into groundwater models. The parameter of interest is the clay fraction, expressed as the relative length of clay units in a depth interval. The clay fraction is obtained from lithological logs and the clay fraction from the resistivity is obtained by establishing a simple petrophysical relationship, a translator function, between resistivity and the clay fraction. Through inversion we use the lithological data and the resistivity data to determine the optimum spatially distributed translator function. Applying the translator function we get a 3-D clay fraction model, which holds information from the resistivity data set and the borehole data set in one variable. Finally, we use k-means clustering to generate a 3-D model of the subsurface structures. We apply the procedure to the Norsminde survey in Denmark, integrating approximately 700 boreholes and more than 100 000 resistivity models from an airborne survey in the parameterization of the 3-D model covering 156 km2. The final five-cluster 3-D model differentiates between clay materials and different high-resistivity materials from information held in the resistivity model and borehole observations, respectively.

Multiple-point geostatistical simulation (MPS) has recently become popular in stochastic hydrogeology, primarily because of its capability to derive multivariate distributions from a training image (TI). However, its application in three-dimensional (3-D) simulations has been constrained by the difficulty of constructing a 3-D TI. The object-based unconditional simulation program TiGenerator may be a useful tool in this regard; yet the applicability of such parametric training images has not been documented in detail. Another issue in MPS is the integration of multiple geophysical data. The proper way to retrieve and incorporate information from high-resolution geophysical data is still under discussion. In this study, MPS simulation was applied to different scenarios regarding the TI and soft conditioning. By comparing their output from simulations of groundwater flow and probabilistic capture zone, TI from both sources (directly converted from high-resolution geophysical data and generated by TiGenerator) yields comparable results, even for the probabilistic capture zones, which are highly sensitive to the geological architecture. This study also suggests that soft conditioning in MPS is a convenient and efficient way of integrating secondary data such as 3-D airborne electromagnetic data (SkyTEM), but over-conditioning has to be avoided.

Uncertainty of groundwater model predictions has in the past mostly been related to uncertainty in the hydraulic parameters, whereas uncertainty in the geological structure has not been considered to the same extent. Recent developments in theoretical methods for quantifying geological uncertainty have made it possible to consider this factor in groundwater modeling. In this study we have applied the multiple-point geostatistical method (MPS) integrated in the Stanford Geostatistical Modeling Software (SGeMS) for exploring the impact of geological uncertainty on groundwater flow patterns for a site in Denmark. Realizations from the geostatistical model were used as input to a groundwater model developed from Modular three-dimensional finite-difference ground-water model (MODFLOW) within the Groundwater Modeling System (GMS) modeling environment. The uncertainty analysis was carried out in three scenarios involving simulation of groundwater head distribution and travel time. The first scenario implied 100 stochastic geological models all assigning the same hydraulic parameters for the same geological units. In the second scenario the same 100 geological models were subjected to model optimization, where the hydraulic parameters for each of them were estimated by calibration against observations of hydraulic head and stream discharge. In the third scenario each geological model was run with 216 randomized sets of parameters. The analysis documented that the uncertainty on the conceptual geological model was as significant as the uncertainty related to the embedded hydraulic parameters.

Geophysical techniques are increasingly being used as tools for characterising the subsurface, and they are generally required to develop subsurface models that properly delineate the distribution of aquifers and aquitards, salt/freshwater interfaces, and geological structures that affect groundwater flow. In a study area covering 730 km2 across the border between Germany and Denmark, a combination of an airborne electromagnetic survey (performed with the SkyTEM system), a high-resolution seismic survey and borehole logging has been used in an integrated mapping of important geological, physical and chemical features of the subsurface. The spacing between flight lines is 200–250 m which gives a total of about 3200 line km. About 38 km of seismic lines have been collected. Faults bordering a graben structure, buried tunnel valleys, glaciotectonic thrust complexes, marine clay units, and sand aquifers are all examples of geological structures mapped by the geophysical data that control groundwater flow and to some extent hydrochemistry. Additionally, the data provide an excellent picture of the salinity distribution in the area and thus provide important information on the salt/freshwater boundary and the chemical status of groundwater. Although the westernmost part of the study area along the North Sea coast is saturated with saline water and the TEM data therefore are strongly influenced by the increased electrical conductivity there, buried valleys and other geological elements are still revealed. The mapped salinity distribution indicates preferential flow paths through and along specific geological structures within the area. The effects of a future sea level rise on the groundwater system and groundwater chemistry are discussed with special emphasis on the importance of knowing the existence, distribution and geometry of the mapped geological elements, and their control on the groundwater salinity distribution is assessed.

Background: Combining non-specialists and digital technologies in mental health interventions could decrease the mental healthcare gap in resource scarce countries. This systematic review examined different combinations of non-specialists and digital technologies in mental health interventions and their effectiveness in reducing the mental healthcare gap in low-and middle-income countries., Methods: Literature searches were conducted in four databases (September 2023), three trial registries (January-February 2022), and using forward and backward citation searches (May-June 2022). The review included primary studies on mental health interventions combining non-specialists and digital technologies in low-and middle-income countries. The outcomes were: (1) the mental health of intervention receivers and (2) the competencies of non-specialists to deliver mental health interventions. Data were expressed as standardised effect sizes (Cohen's d) and narratively synthesised. Risk of bias assessment was conducted using the Cochrane risk-of-bias tools for individual and cluster randomised and non-randomised controlled trials., Results: Of the 28 included studies (n = 32 interventions), digital technology was mainly used in non-specialist primary-delivery treatment models for common mental disorders or subthreshold symptoms. The competencies of non-specialists were improved with digital training (d ≤ 0.8 in 4/7 outcomes, n = 4 studies, 398 participants). The mental health of receivers improved through non-specialist-delivered interventions, in which digital technologies were used to support the delivery of the intervention (d > 0.8 in 24/40 outcomes, n = 11, 2469) or to supervise the non-specialists' work (d = 0.2-0.8 in 10/17 outcomes, n = 3, 3096). Additionally, the mental health of service receivers improved through digitally delivered mental health services with non-specialist involvement (d = 0.2-0.8 in 12/27 outcomes, n = 8, 2335). However, the overall certainty of the evidence was poor., Conclusion: Incorporating digital technologies into non-specialist mental health interventions tended to enhance non-specialists' competencies and knowledge in intervention delivery, and had a positive influence on the severity of mental health problems, mental healthcare utilization, and psychosocial functioning outcomes of service recipients, primarily within primary-deliverer care models. More robust evidence is needed to compare the magnitude of effectiveness and identify the clinical relevance of specific digital functions. Future studies should also explore long-term and potential adverse effects and interventions targeting men and marginalised communities., (© 2023. The Author(s).)

Background: More knowledge on the cost-effectiveness of various depression treatment programmes can promote efficient treatment allocation and improve the quality of depression care., Objective: This study aims to compare the real-world cost-effectiveness of an algorithm-guided programme focused on remission to a predefined duration, patient preference-centred treatment programme focused on response using routine care data., Methods: A naturalistic study (n=6295 in the raw dataset) was used to compare the costs and outcomes of two programmes in terms of quality-adjusted life years (QALY) and depression-free days (DFD). Analyses were performed from a healthcare system perspective over a 2-year time horizon. Incremental cost-effectiveness ratios were calculated, and the uncertainty of results was assessed using bootstrapping and sensitivity analysis., Findings: The algorithm-guided treatment programme per client yielded more DFDs (12) and more QALYs (0.013) at a higher cost (€3070) than the predefined duration treatment programme. The incremental cost-effectiveness ratios (ICERs) were around €256/DFD and €236 154/QALY for the algorithm guided compared with the predefined duration treatment programme. At a threshold value of €50 000/QALY gained, the programme had a probability of <10% of being considered cost-effective. Sensitivity analyses confirmed the robustness of these findings., Conclusions: The algorithm-guided programme led to larger health gains than the predefined duration treatment programme, but it was considerably more expensive, and hence not cost-effective at current Dutch thresholds. Depending on the preferences and budgets available, each programme has its own benefits., Clinical Implication: This study provides valuable information to decision-makers for optimising treatment allocation and enhancing quality of care cost-effectively., Competing Interests: Competing interests: SOdV was involved in the design of the algorithm-guided treatment programme investigated in this study. BG was involved in the running of the predefined duration treatment programme investigated in this study. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. Published by BMJ.)

Background: Despite growing concerns about mental health during the COVID-19 pandemic, particularly in people with pre-existing mental health disorders, research has shown that symptoms of depression and anxiety were generally quite stable, with modest changes in certain subgroups. However, individual differences in cumulative exposure to COVID-19 stressors have not been yet considered., Aims: We aimed to quantify and investigate the impact of individual-level cumulative exposure to COVID-19-pandemic-related adversity on changes in depressive and anxiety symptoms and loneliness. In addition, we examined whether the impact differed among individuals with various levels of pre-pandemic chronicity of mental health disorders., Method: Between April 2020 and July 2021, 15 successive online questionnaires were distributed among three psychiatric case-control cohorts that started in the 2000s ( N = 1377). Outcomes included depressive and anxiety symptoms and loneliness. We developed a COVID-19 Adversity Index (CAI) summarising up to 15 repeated measures of COVID-19-pandemic-related exposures (e.g. exposure to COVID-19 infection, negative economic impact and quarantine). We used linear mixed linear models to estimate the effects of COVID-19-related adversity on mental health and its interaction with pre-pandemic chronicity of mental health disorders and CAI., Results: Higher CAI scores were positively associated with higher increases in depressive symptoms, anxiety symptoms and loneliness. Associations were not statistically significantly different between groups with and without (chronic) pre-pandemic mental health disorders., Conclusions: Individual differences in cumulative exposure to COVID-19-pandemic-related adversity are important predictors of mental health, but we found no evidence for higher vulnerability among people with (chronic) pre-pandemic mental health disorders.

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

Background: Mental health was only modestly affected in adults during the early months of the COVID-19 pandemic on the group level, but interpersonal variation was large., Aims: We aim to investigate potential predictors of the differences in changes in mental health., Method: Data were aggregated from three Dutch ongoing prospective cohorts with similar methodology for data collection. We included participants with pre-pandemic data gathered during 2006-2016, and who completed online questionnaires at least once during lockdown in The Netherlands between 1 April and 15 May 2020. Sociodemographic, clinical (number of mental health disorders and personality factors) and COVID-19-related variables were analysed as predictors of relative changes in four mental health outcomes (depressive symptoms, anxiety and worry symptoms, and loneliness), using multivariate linear regression analyses., Results: We included 1517 participants with ( n = 1181) and without ( n = 336) mental health disorders. Mean age was 56.1 years (s.d. 13.2), and 64.3% were women. Higher neuroticism predicted increases in all four mental health outcomes, especially for worry ( β = 0.172, P = 0.003). Living alone and female gender predicted increases in depressive symptoms and loneliness ( β = 0.05-0.08), whereas quarantine and strict adherence with COVID-19 restrictions predicted increases in anxiety and worry symptoms ( β = 0.07-0.11).Teleworking predicted a decrease in anxiety symptoms ( β = -0.07) and higher age predicted a decrease in anxiety ( β = -0.08) and worry symptoms ( β = -0.10)., Conclusions: Our study showed neuroticism as a robust predictor of adverse changes in mental health, and identified additional sociodemographic and COVID-19-related predictors that explain longitudinal variability in mental health during the COVID-19 pandemic.

Background: Apart from cost-effectiveness, considerations like equity and acceptability may affect health-care priority setting. Preferably, priority setting combines evidence evaluation with an appraisal procedure, to elicit and weigh these considerations., Objective: To demonstrate a structured approach for eliciting and evaluating a broad range of assessment criteria, including key stakeholders' values, aiming to support decision makers in priority setting., Methods: For a set of cost-effective substitute interventions for depression care, the appraisal criteria were adopted from the Australian Assessing Cost-Effectiveness initiative. All substitute interventions were assessed in an appraisal, using focus group discussions and semi-structured interviews conducted among key stakeholders., Results: Appraisal of the substitute cost-effective interventions yielded an overview of considerations and an overall recommendation for decision makers. Two out of the thirteen pairs were deemed acceptable and realistic, that is investment in therapist-guided and Internet-based cognitive behavioural therapy instead of cognitive behavioural therapy in mild depression, and investment in combination therapy rather than individual psychotherapy in severe depression. In the remaining substitution pairs, substantive issues affected acceptability. The key issues identified were as follows: workforce capacity, lack of stakeholder support and the need for change in clinicians' attitude., Conclusions: Systematic identification of stakeholders' considerations allows decision makers to prioritize among cost-effective policy options. Moreover, this approach entails an explicit and transparent priority-setting procedure and provides insights into the intended and unintended consequences of using a certain health technology., Patient Contribution: Patients were involved in the conduct of the study for instance, by sharing their values regarding considerations relevant for priority setting., (© 2021 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Introduction: This study assessed the cost-effectiveness and budget impact of a lifestyle intervention to improve cardiometabolic health in severe mentally ill (SMI) patients in the LION trial., Methods: Patients (n = 244) were randomized to receive either care-as-usual or a lifestyle intervention in which mental health nurses coached patients in changing their lifestyle by using a web tool. Costs and quality of life were assessed at baseline and at 6 and 12 months. Incremental costs per centimeter waist circumference (WC) lost and per Quality-Adjusted Life Year (QALY) gained were assessed. Budget impact was estimated based on three intervention-uptake scenarios using a societal and a third-party payer perspective., Results: Costs and reduction in WC were higher in the intervention (n = 114) than in the control (n = 94) group after 12 months, although not statistically significant, resulting in €1,370 per cm WC lost. QALYs did not differ between the groups, resulting in a low probability of the intervention being cost-effective in cost/QALY gained. The budget impact analysis showed that for a reasonable participation of 43%, total costs were around €81 million over 5 years, or on average €16 million annually (societal perspective)., Conclusions: The intervention is not cost-effective at 12 months and the budget impact over 5 years is substantial. Possibly, 12 months was too short to implement the intervention, improve cardiometabolic health, and reduce care costs. Therefore, the incentive for this intervention cannot be found in short-term financial advantages. However, there may be benefits associated with lifestyle interventions in the long term that remain unclear., Competing Interests: Conflict of interest: The authors declare no conflict of interest., (Copyright © 2020, The Authors.)

Background: Although symptomatic remission is considered the optimal outcome in depression, this is not always achieved. Furthermore, symptom indicators do not fully capture patients' and clinicians' perspectives on remission. Broader indicators of (partial) remission from depression should be considered., Aims: To investigate relevant outcomes of depression treatment in specialist care from patients' and clinicians' perspectives and to investigate whether these perspectives differ from each other., Method: Three focus groups with 11 patients with depression and seven semi-structured interviews with clinicians were conducted exploring their perspectives on remission. All interviews were audio-recorded and transcribed verbatim. We analysed the transcripts thematically using the phenomenologist approach., Results: Independently, both patients and clinicians perceived the following outcomes relevant: restoring social functioning and interpersonal relations, regaining quality of life and achieving personal goals. All clinicians emphasised symptom reduction and satisfaction with treatment as relevant outcomes, whereas the former was not an obvious theme in patients. Unlike clinicians, patients made a clear distinction between treatment outcomes in first versus recurrent/chronic depression., Conclusions: Classically defined study outcomes based on symptom resolution only partly reflect issues considered important by patients and clinicians in specialist depression treatment. Incorporating patients' and clinicians' perspectives in the development of measurable end-points makes them more suitable for use in trials and subsequent translation to clinical practice. Furthermore, evaluating patients' perspectives on treatment outcomes helps in the development of tailored interventions according to patients' needs.

Background: An increasing number of studies in people with mental illness have demonstrated the efficacy of lifestyle interventions for both mental and physical health. However, implementing and sustaining such interventions in routine mental healthcare is challenging.
AIM: To describe implementation barriers and facilitators of various lifestyle interventions in routine mental healthcare.
METHOD: In this paper we summarise the results of three recent doctoral theses and provide recommendations for routine mental healthcare.
RESULTS: Enabling factors and barriers for successful implementation appeared to be universal across various settings and patient populations. Mental healthcare professionals and patients appreciated and supported the lifestyle interventions. A lack of priority, recognition and support on the organisational level were reported as barriers in all the studies. Addressing various lifestyle behaviours simultaneously (e.g. physical activity and diet), personalised to the patients' abilities and preferences, and setting measurable and attainable goals, were important for success. Moreover, involving qualified professionals (e.g. exercise professionals and dietitians with expertise in mental healthcare) and ensuring cooperation between patients and healthcare professionals and disciplines within and outside mental healthcare appeared crucial.
CONCLUSION: Successful implementation of lifestyle interventions in mental healthcare requires changes in culture and behaviour, a long-term strategy and endurance.

Background: Unhealthy lifestyle behaviours contribute to alarming cardiometabolic risk in patients with serious mental illness (SMI). Evidence-based practical lifestyle tools supporting patients and staff in improving patient lifestyle are lacking., Methods: This multi-site randomized controlled pragmatic trial determined the effectiveness of a twelve-month multimodal lifestyle approach, including a web-based tool to improve patients' cardiometabolic health, versus care-as-usual. Using the web tool, nurses (trained in motivational interviewing) assisted patients in assessing their lifestyle behaviours, creating a risk profile and constructing lifestyle goals, which were discussed during fortnightly regular care visits. Twenty-seven community-care and sheltered-living teams were randomized into intervention (N = 17) or control (N = 10) groups, including 244 patients (140 intervention/104 control, 49.2% male, 46.1 ± 10.8 years) with increased waist circumference (WC), BMI or fasting glucose. The primary outcomes concerned differences in WC after six and twelve months intervention, while BMI and metabolic syndrome Z-score were secondary outcome measures., Results: General multilevel linear mixed models adjusted for antipsychotic medication showed that differences in WC change between intervention and control were - 0.15 cm (95%CI: - 2.49; 2.19) after six and - 1.03 cm (95%CI: - 3.42; 1.35) after twelve months intervention; however, the differences were not statistically significant. No intervention effects were found for secondary outcome measures. The intervention increased patients' readiness to change dietary behaviour., Conclusion: A multimodal web-based intervention facilitating nurses to address lifestyle changes in SMI patients did not improve patient cardiometabolic health. Web-tool use was lower than expected and nurses need more lifestyle coaching knowledge and skills. The type of intervention and delivery mode need optimization to realize effective lifestyle care for SMI patients., Trial Registration: Dutch Trial Registry, www.trialregister.nl , NTR3765, 21 December 2012.

Introduction: Although people with a psychotic disorder are approximately four to six times more often victimized than the general population, victimization is not routinely assessed in mental healthcare. This study investigates prevalence, context and risk factors of victimization in patients with a psychotic disorder in the Northern, relatively rural region of the Netherlands. Moreover, disclosure rates and awareness of psychiatrists are examined., Method: Information on personal crime (threats, assaults and sexual violence), property and other forms of crime, the context of victimization and disclosure was routinely assessed in 353 patients with a psychotic disorder who received care at a mental health facility. In addition, involved psychiatrists reported on last year's victimization incidents in their patients., Results: One third of the patients reported victimization in the previous year. More than half of the crimes were committed by someone acquainted and took place in the victim's own home or a place familiar to the victim. Younger age, having a comorbid disorder, drug use and perpetration of a crime were all positively associated with victimization. Approximately half of the reported personal crimes were disclosed to a health care professional but only in 16% of the cases the involved psychiatrist report to know about the incident., Conclusion: This study confirms that people with a history of psychosis have an increased risk of becoming the victim of a crime. Although our results suggest that in fifty percent of cases the patients did share the information with professionals, a substantial proportion of incidents appear to go still unnoticed., Competing Interests: The authors have declared that no competing interests exist.

Introduction: The aim of this study was to objectively assess time spent in physical activity (PA) and sedentary behavior (SB) in patients with schizophrenia compared to healthy controls matched for age, gender and socioeconomic status. Associations between both PA and cardiorespiratory fitness (CRF) and mental and physical health parameters in patients with schizophrenia were examined. Materials and Methods: Moderate and vigorous PA (MVPA), moderate PA, vigorous PA, total and active energy expenditure (TEE and AEE), number of steps, lying down and sleeping time was assessed with SenseWear Pro-2 body monitoring system for three 24-h bouts in patients with schizophrenia ( n = 63) and matched healthy controls ( n = 55). Severity of symptoms (Positive and Negative Syndrome Scale and Montgomery and Åsberg Depression Rating Scale), CRF (peak oxygen uptake, VO 2peak ), body mass index (BMI), and metabolic syndrome were assessed. Results: Patients with schizophrenia performed less MVPA and moderate activity had lower TEE and AEE, spent more time per day lying down and sleeping, and had poorer CRF compared to healthy controls. The amount of MVPA, but especially CRF was associated with severity of negative symptoms in patients with schizophrenia. Only CRF was associated with BMI. Discussion: The current data offer further evidence for interventions aiming to increase physical activity and decrease sedentary behavior. Given strong associations of CRF with both negative symptoms and BMI, treatment aimed at CRF-improvement may prove to be effective.

Background For patients with severe mental illness (SMI) in residential facilities, adopting a healthy lifestyle is hampered by the obesity promoting (obesogenic) environment. Aims To determine the effectiveness of a 12-month lifestyle intervention addressing the obesogenic environment with respect to diet and physical activity to improve waist circumference and cardiometabolic risk factors v. care as usual (Dutch Trial Registry: NTR2720). Method In a multisite cluster randomised controlled pragmatic trial, 29 care teams were randomised into 15 intervention (365 patients) and 14 control teams (371 patients). Intervention staff were trained to improve the obesogenic environment. Results Waist circumference decreased 1.51 cm (95% CI -2.99 to -0.04) in the intervention v. control group after 3 months and metabolic syndrome z -score decreased 0.22 s.d. (95% CI -0.38 to -0.06). After 12 months, the decrease in waist circumference was no longer statistically significantly different (-1.28 cm, 95% CI -2.79 to 0.23, P =0.097). Conclusions Targeting the obesogenic environment of residential patients with SMI has the potential to facilitate reduction of abdominal adiposity and cardiometabolic risk, but maintaining initial reductions over the longer term remains challenging., Competing Interests: Declaration of interestNone., (© The Royal College of Psychiatrists 2017.)

Aims: Timely recognition and treatment of mental disorders with an onset in childhood and adolescence is paramount, as these are characterized by greater severity and longer persistence than disorders with an onset in adulthood. Studies examining time-to-treatment, also referred to as treatment delay, duration of untreated illness or latency to treatment, and defined as the time between disorder onset and initial treatment contact, are sparse and all based on adult samples. The aim of this study was to describe time-to-treatment and its correlates for any health care professional (any care) and secondary mental health care (secondary care), for a broad range of mental disorders, in adolescents., Methods: Data from the Dutch community-based cohort study TRacking Adolescents' Individual Lives Survey (TRAILS; N = 2230) were used. The Composite International Diagnostic Interview (CIDI) was administered to assess DSM-IV disorders, the age of onset, and the age of initial treatment contact with any health care professional in 1584 adolescents of 18-20 years old. In total 43% of the adolescents (n = 675) were diagnosed with a lifetime DSM-IV disorder. The age of initial treatment contact with secondary care was based on administrative records from 321 adolescents without a disorder onset before the age of 10. Descriptive statistics, cumulative lifetime probability plots, and Cox regression analyses were used analyze time-to-treatment., Results: The proportion of adolescents who reported lifetime treatment contact with any care varied from 15% for alcohol dependence to 82% for dysthymia. Regarding secondary care, proportions of lifetime treatment contact were lower for mood disorders and higher for substance dependence. Time-to-treatment for any care varied considerably between and within diagnostic classes. The probability of lifetime treatment contact for mood disorders was above 90%, whereas for other mental disorders this was substantially lower. An earlier age of onset predicted a longer, and the presence of a co-morbid mood disorder predicted a shorter time-to-treatment in general. Disorder severity predicted a shorter time-to-treatment for any care, but not for secondary care. Time-to-treatment for secondary care was shorter for adolescents from low and middle socioeconomic background than for adolescents from a high socioeconomic background., Conclusion: Although the time-to-treatment was shorter for adolescents than for adults, it was still substantial, and the overall patterns were remarkably similar to those found in adults. Efforts to reduce time-to-treatment should therefore be aimed at children and adolescents. Future research should address mechanisms underlying time-to-treatment and its consequences for early-onset disorders in particular.

Background: The cardiometabolic health of persons with a severe mental illness (SMI) is alarming with obesity rates of 45-55% and diabetes type 2 rates of 10-15%. Unhealthy lifestyle behaviours play a large role in this. Despite the multidisciplinary guideline for SMI patients recommending to monitor and address patients' lifestyle, most mental health care professionals have limited lifestyle-related knowledge and skills, and (lifestyle) treatment protocols are lacking. Evidence-based practical lifestyle tools may support both patients and staff in improving patients' lifestyle. This paper describes the Lifestyle Interventions for severe mentally ill Outpatients in the Netherlands (LION) trial, to investigate whether a multidimensional lifestyle intervention using a web tool can be effective in improving cardiometabolic health in SMI patients., Methods/design: The LION study is a 12-month pragmatic single-blind multi-site cluster randomised controlled trial. 21 Flexible Assertive Community Treatment (ACT) teams and eight sheltered living teams of five mental health organizations in the Netherlands are invited to participate. Per team, nurses are trained in motivational interviewing and use of the multidimensional web tool, covering lifestyle behaviour awareness, lifestyle knowledge, motivation and goal setting. Nurses coach patients to change their lifestyle using the web tool, motivational interviewing and stages-of-change techniques during biweekly sessions in a) assessing current lifestyle behaviour using the traffic light method (healthy behaviours colour green, unhealthy behaviours colour red), b) creating a lifestyle plan with maximum three attainable lifestyle goals and c) discussing the lifestyle plan regularly. The study population is SMI patients and statistical inference is on patient level using multilevel analyses. Primary outcome is waist circumference and other cardiometabolic risk factors after six and twelve months intervention, which are measured as part of routine outcome monitoring using standard protocols. Secondary outcomes include depressive and negative symptoms, cost-effectiveness, and barriers and facilitators in intervention implementation., Discussion: Adequate health care should target both mental health and lifestyle behaviours in SMI patients. This trial contributes by studying a 12-month multidimensional lifestyle intervention as a potential evidence based (nursing) tool for targeting multiple lifestyle behaviours in SMI patients., Trial Registration: Nederlands Trialregister NTR3765 (trialregister.nl; registered 21 December 2012).

Aims: The aim of this study was to estimate the effects of lifestyle interventions on bodyweight and other cardiometabolic risk factors in people with psychotic disorders. Additionally, the long-term effects on body weight and the effects on depressive symptoms were examined., Material and Methods: We searched four databases for randomized controlled trials (RCTs) that compared lifestyle interventions to control conditions in patients with psychotic disorders. Lifestyle interventions were aimed at weight loss or weight gain prevention, and the study outcomes included bodyweight or metabolic parameters., Results: The search resulted in 25 RCTs -only 4 were considered high quality- showing an overall effect of lifestyle interventions on bodyweight (effect size (ES)  =  -0.63, p<0.0001). Lifestyle interventions were effective in both weight loss (ES =  -0.52, p<0.0001) and weight-gain-prevention (ES =  -0.84, p = 0.0002). There were significant long-term effects, two to six months post-intervention, for both weight-gain-prevention interventions (ES =  -0.85, p = 0.0002) and weight loss studies (ES =  -0.46, p = 0.02). Up to ten studies reported on cardiometabolic risk factors and showed that lifestyle interventions led to significant improvements in waist circumference, triglycerides, fasting glucose and insulin. No significant effects were found for blood pressure and cholesterol levels. Four studies reported on depressive symptoms and showed a significant effect (ES =  -0.95, p = 0.05)., Conclusion: Lifestyle interventions are effective in treating and preventing obesity, and in reducing cardiometabolic risk factors. However, the quality of the studies leaves much to be desired.

Background: Severe mentally ill (SMI) patients have a reduced life expectancy of 13-30 years compared to the general population, largely due to an increased risk of cardiovascular mortality. Unhealthy lifestyle behaviours in SMI patients contribute to this increased risk. The obesogenic living environment of patients in residential facilities may even pose an extra risk. Although several studies have shown positive effects of lifestyle interventions on SMI patients' weight status, studies including residential patients and their obesogenic environment are scarce. This paper describes the Effectiveness of Lifestyle Interventions in PSychiatry trial (ELIPS). The goal of this trial is to improve cardiometabolic health in severe mentally ill residential patients by addressing the obesogenic environment., Methods/design: The ELIPS study is a multi-site cluster randomised controlled trial (RCT) based on the principles of a pragmatic RCT. All residential and long-term clinical care teams of two large mental health care organisations in the North of the Netherlands serving SMI patients are invited to participate. The intervention is aimed at team level. Lifestyle coaches first develop a team specific lifestyle plan that tailors the ELIPS goals and protocol and then train teams on how to create a healthy environment and stimulate healthy behaviours in patients. After three months, teams take over the intervention after they have set out goals to achieve in the following nine months. In this phase, adherence to the lifestyle plan and pre-set goals is monitored. Patients in the control arm receive care as usual. Primary outcome measure is waist circumference at three and 12 months after baseline., Discussion: ELIPS is different from previously published lifestyle intervention studies in three ways. First, it follows the principles of a pragmatic design, which enables the examination of effects in everyday practice. Second, by implementing the intervention at team level, we expect lifestyle activities to be maintained when interventionists leave. Last, by targeting the obesogenic environment we create a prerequisite for any sustainable health improvement, as patients can only make healthy choices in a healthy living environment., Trial Registration: Nederlands Trialregister NTR2720 (Dutch Trial Register, www.trialregister.nl). Registered 27 January 2011.

Objective: This 24-month study, conducted in The Netherlands, examined the feasibility of enhancing the effectiveness of assertive community treatment (ACT) by adding evidence-based interventions., Methods: A total of 159 patients were randomly assigned to two ACT teams, one providing standard ACT (N585) and an ACT Plus team that also provided evidence-based interventions (N574): psychoeducation, family interventions, individual placement and support, and cognitive behavioral therapy. The interventions were conducted by psychologists and nurse practitioners working independently from the ACT team., Results: Although most patients were judged eligible for each of the four interventions (range 65% to 89%), only 12 of the 74 patients (16%) successfully completed an intervention. Outcomes, such as use of inpatient care, for ACT Plus and standard ACT patients did not differ significantly., Conclusions: Guidelines for the treatment of schizophrenia should consider the feasibility of delivering evidence-based interventions to difficult-to-engage patients.

Background: Extensive recruitment effort at baseline increases representativeness of study populations by decreasing non-response and associated bias. First, it is not known to what extent increased attrition occurs during subsequent measurement waves among subjects who were hard-to-recruit at baseline and what characteristics the hard-to-recruit dropouts have compared to the hard-to-recruit retainers. Second, it is unknown whether characteristics of hard-to-recruit responders in a prospective population based cohort study are similar across age group and survey method., Methods: First, we compared first wave (T1) easy-to-recruit with hard-to-recruit responders of the TRacking Adolescents' Individual Lives Survey (TRAILS), a prospective population based cohort study of Dutch (pre)adolescents (at first wave: n = 2230, mean age = 11.09 (SD 0.56), 50.8% girls), with regard to response rates at subsequent measurement waves. Second, easy-to-recruit and hard-to-recruit participants at the fourth TRAILS measurement wave (n = 1881, mean age = 19.1 (SD 0.60), 52.3% girls) were compared with fourth wave non-responders and earlier stage drop-outs on family composition, socioeconomic position (SEP), intelligence (IQ), education, sociometric status, substance use, and psychopathology., Results: First, over 60% of the hard-to-recruit responders at the first wave were retained in the sample eight years later at the fourth measurement wave. Hard-to-recruit dropouts did not differ from hard-to-recruit retainers. Second, extensive recruitment efforts for the web based survey convinced a population of nineteen year olds with similar characteristics as the hard-to-recruit eleven year olds that were persuaded to participate in a school-based survey. Some characteristics associated with being hard-to-recruit (as compared to being easy-to-recruit) were more pronounced among non-responders, resembling the baseline situation (De Winter et al.2005)., Conclusions: First, extensive recruitment effort at the first assessment wave of a prospective population based cohort study has long lasting positive effects. Second, characteristics of hard-to-recruit responders are largely consistent across age groups and survey methods.

Background: The increased use and costs of specialist child and adolescent mental health services (MHS) urge us to assess the effectiveness of these services. The aim of this paper is to compare the course of emotional and behavioural problems in adolescents with and without MHS use in a naturalistic setting., Method and Findings: Participants are 2230 (pre)adolescents that enrolled in a prospective cohort study, the TRacking Adolescents' Individual Lives Survey (TRAILS). Response rate was 76%, mean age at baseline 11.09 (SD 0.56), 50.8% girls. We used data from the first three assessment waves, covering a six year period. Multiple linear regression analysis, propensity score matching, and data validation were used to compare the course of emotional and behavioural problems of adolescents with and without MHS use. The association between MHS and follow-up problem score (β 0.20, SE 0.03, p-value<0.001) was not confounded by baseline severity, markers of adolescent vulnerability or resilience nor stressful life events. The propensity score matching strategy revealed that follow-up problem scores of non-MHS-users decreased while the problem scores of MHS users remained high. When taking into account future MHS (non)use, it appeared that problem scores decreased with limited MHS use, albeit not as much as without any MHS use, and that problem scores with continuous MHS use remained high. Data validation showed that using a different outcome measure, multiple assessment waves and multiple imputation of missing values did not alter the results. A limitation of the study is that, although we know what type of MHS participants used, and during which period, we lack information on the duration of the treatment., Conclusions: The benefits of MHS are questionable. Replication studies should reveal whether a critical examination of everyday care is necessary or an artefact is responsible for these results.