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Although some adults with autism spectrum disorder (ASD) require intensive and specialized ASD treatment, there is little research on how these adults experience the recovery process. Recovery is defined as the significant improvement in general functioning compared to the situation prior  to treatment.
This qualitative study describes the recovery process from the perspective of adults on the autism spectrum during intensive inpatient treatment. Semi-structured interviews (n = 15) were carried out and analyzed according to the principles of grounded theory.
Our results indicate that, given the specific characteristics of autism, therapeutic interventions and goal-oriented work cannot be carried out successfully, and the recovery process cannot begin, if no good working relationship has been established, and if care is not organized in ways that a person on the autism spectrum finds clear and predictable.
Volume 15 - 2024 | <a class="ArticleLayoutHeader__info__doi" href="https://doi.org/10.3389/fpsyt.2024.1383138">https://doi.org/10.3389/fpsyt.2024.1383138</a>
Introduction: Although some adults with autism spectrum disorder (ASD) require intensive and specialized ASD treatment
there is little research on how these adults experience the recovery process
Recovery is defined as the significant improvement in general functioning compared to the situation prior  to treatment
Methods: This qualitative study describes the recovery process from the perspective of adults on the autism spectrum during intensive inpatient treatment
Semi-structured interviews (n&#x2009;=&#x2009;15) were carried out and analyzed according to the principles of grounded theory
given the specific characteristics of autism
therapeutic interventions and goal-oriented work cannot be carried out successfully
if no good working relationship has been established
and if care is not organized in ways that a person on the autism spectrum finds clear and predictable
In Dutch Mental Health Care (MHC) all referrals to mental health care must be made by a general practitioner (GP) either to basic mental health care (for common mental disorders)
or to specialized mental health care (for severe mental disorders)
Specialized MHC can be either in an outpatient or inpatient setting
The latter is reserved for very serious problems
These referral procedures also apply to people with Autism Spectrum Disorders (ASD)
in case of persistent and severe psychiatric problems in patients with ASD that cannot be treated effectively in general mental health care
psychologist or psychiatrist to a mental health care setting specialized in ASD However
the capacity of these specialized ASD facilities is very limited
especially regarding the inpatient services
with corresponding limited opportunities for placement and treatment
For a significant proportion of adults who experience problems associated with ASD
treatment in regular mental health care is sufficient
a smaller number requires more intensive and autism-specialized treatment
particularly those with severe symptoms and co-occurring conditions
the process of recovery is difficult and often prolonged
Dutch mental health care offers specialized treatment for persons on the autism spectrum in both outpatient and inpatient settings
The rationale for these specialized setting is the assumption that persons with autism can benefit more from regular therapeutic interventions when they feel understood and accepted
Therefore these settings invest in a sound therapeutic milieu
and a trusting relationship between clients and staff prior to addressing comorbid conditions with state of the art interventions tailored to the needs of the individual client
Although we believe that this approach enhances recovery
no systematic study to date has examined the recovery process of adults on the autism spectrum who receive intensive inpatient treatment in mental health care
Many questions therefore remain unanswered
treatment and contextual factors contribute towards a successful path to recovery
this qualitative study on the recovery of adults on the autism spectrum investigated personal process of recovery and the factors that influence it
The main research question was: How does the process of recovery of adults on the autism spectrum develop during intensive inpatient treatment
and which personal and environmental factors contribute to this process
The aim of the research was to gain more insight into the process of recovery of adults with ASD during intensive inpatient treatment
we aimed for inductively developing a theoretical model of the process of recovery More knowledge in this area can contribute to the proper organization of personalized treatment
supporting the personal recovery process and providing opportunities to promote functioning and quality of life
This sub-study was part of a larger research project exploring the factors that influence treatment intensity and recovery in people on the autism spectrum
To examine the process of recovery from a theoretical and interactional perspective
it followed a qualitative design using the grounded method approach
It was reviewed and approved by the Medical Ethics Review Committee at Amsterdam University Medical Center (UMC
It was also approved by the local scientific review board of the participating mental health institutions
The study involved two institutions for mental health care in the Netherlands: Dimence Institute of Mental Health in Deventer and the Leo Kannerhuis Centre for Autism in Oosterbeek
Both institutions provide care for normal to high IQ patients
from five departments with different intensities of treatment and autism-specialization: two ASD-specific High-Intensive Care (ASD-HIC) wards
and three general High-Intensive Care (general HIC) wards
The ASD-HIC wards provided autism-specific treatment
and also a longer average length of stay than a general HIC ward
Treatment in ASD-HIC wards was based less on uniform protocols
but more on personalized treatment and on care that was in tailored to participants&#x2019; specific autism and co-occurring conditions
living situation and personal characteristics
On regular HIC-wards people are admitted who need acute psychiatric care for a wide range of psychiatric conditions
Table&#xa0;1 Inclusion and exclusion criteria for participation in the study
After receiving information about this study
mental health practitioners at the participating departments invited persons who met the inclusion criteria to participate in the study
36 persons received written and oral information on the research project
15 agreed to participate and gave informed consent
Ten participants were treated in an ASD-HIC and five in a general HIC
Data was collected between July 2017 and January 2019
a focus-group interview was organized with three adults on the autism spectrum
This interview aimed to explore the central theme of our study: the recovery process in adults on the autism spectrum
we constructed a substantiated interview protocol with a topic list for the individual interviews
To determine whether the structure and language use was clear for participants in the study
a support-staff member with ASD reviewed the protocol and topic list
The interviews were semi-structured with open-ended questions
All interviews were conducted during face-to-face conversations within two months of discharge
This was considered to be a timeframe within which participants would be able to recall their experiences during the process of recovery
including the factors that had contributed to their recovery
According to the participant&#x2019;s preference
the location of the interview was either the participant&#x2019;s home or the treatment setting
The interviews were conducted by two researchers (HB and a research assistant) who had both been trained in qualitative interviewing techniques
In line with the principles of grounded theory
data collection and data analysis alternated to allow interim results to guide subsequent interviews
Data collection continued until sufficient data saturation had been achieved
the model appeared to be sufficiently robust
The robustness of the model was confirmed during the analysis of the three subsequent interviews
where no new code words could be added to the code tree and no new information could be added to the existing code words
the research team agreed that sufficient data saturation had been achieved after 15 interviews
The interviews were audio-recorded and transcribed verbatim. Their analysis followed the documented procedures of grounded theory (<a href="#B26">26</a>)
As well as the use of open and focused coding
this included the constant comparison technique
an approach that allows concepts to emerge from the data rather than from placing the data in a preconceived framework
The principal investigator (HB) was already familiar with the verbal data
she then read the transcripts line by line
subsequently analyzing the first three interviews with two authors (HB and BvM) and a research assistant
The remaining interviews were analyzed by the first author (HB)
with continuous discussion and feedback sessions with the research team
MAXQDA Plus 12 &#xa9; software was used for the analysis
the researcher kept a logbook in which she described and justified the choices regarding the methodology and the actual execution of the study
These notes were discussed periodically within the research team
Participants&#x2019; records were used to collect personal characteristics and background data (<a href="#T2">Table&#xa0;2</a>). Fifteen adults diagnosed with ASD participated in this study. They were aged 19 &#x2013; 47 years (mean = 28.0, SD = 8.47). There were 10 women and five men. Ten participants had been treated in an ASD-HIC setting and five in a general HIC setting. Twelve of the 15 participants had one or more co-occurring conditions (<a href="#T2">Table 2</a>)
Table&#xa0;2 Sample characteristics (n=15)
Figure&#xa0;1 Model of recovery of patients with ASD during intensive inpatient treatment
Before the intensive inpatient treatment &#x2013; and therefore before the start of the recovery process &#x2013; many participants experienced the world as confusing
The following paragraphs explain the themes related to this confusing world
Most participants retrospectively reported having had limited insight into themselves and into the impact of autism on their functioning in daily life
sensory overstimulation often led to a preoccupation with burdensome thoughts and feelings
As this increased stress and limited their ability to think clearly and act purposefully
they had experienced difficulties in carrying out meaningful daily activities
Participants also reported that their information-processing was significantly different compared to other people
This gave them the feeling that they were not well understood by the outside world &#x2013; which they
They reported that challenging and often stressful interactions with people in their immediate environment reinforced their feelings of confusion and not being understood
They lost control over their own functioning
which led them to avoid other people and withdraw from social life
and persisted in their withdrawal even when things were not going well
Efforts to meet the perceived demands of the outside world often resulted in behavior they assumed to be socially appropriate
Most participants reported that establishing the diagnosis of ASD had been significantly delayed because of their care providers&#x2019; limited expertise with autism
This contributed to the experience of receiving inadequate treatment
the treatment and care provided did not sufficiently meet their needs
Some also felt that the care was not well-enough organized
and that long waiting times made intensive and specialist treatment insufficiently accessible
they often experienced a lack of treatment continuity
Participants reported that the factors outlined above had a negative impact on their working alliance with care providers: they often felt that they were unacknowledged or misunderstood as human beings with specific problems and needs related to autism
This in turn further increased their feelings of confusion and loss of control over their lives
inadequate treatment and poor organization of care caused them both to distrust and be disappointed in care providers and treatment programs
they increasingly avoided contact with care providers and hesitated to share personal matters with them
participants felt they were increasingly losing control over their lives
and many developed behavioral problems as a way of dealing with their problems and feelings of stress
Most participants also reported co-occurring conditions
Some reported that their psychiatric conditions restricted them from carrying out activities during the day
and that the resulting inactivity and social isolation often caused their psychiatric conditions to increase
In combination with psychiatric and behavioral problems
stressful living conditions led to admission to an HIC
Some participants stated explicitly that they found these emergency admissions to be very traumatizing
as both treatment and care failed to meet their needs
Participants identified two important preconditions for a successful recovery process that led to a better understanding of themselves and those around them: (a) a good working alliance with care providers
and (b) clear and predictable organization of care
a) Good working alliance with care providers
Participants stated that the quality of the working alliance had a great impact on their process of recovery
It was crucial for them to experience both that their care providers really wanted to understand them in their specific circumstances and context
and that they also understood the problems and challenges the participants encountered
Given that the participants often had difficulty putting their own problems and functioning into words
it was also important that their care providers took the time and made the effort to understand them as well as possible
They therefore appreciated it when care providers took a genuine interest in their experiences and lives by listening carefully and asking questions until they fully understood what the participants were saying and experiencing
This made participants feel heard and understood
and also increased their trust in care providers and the treatment program
Participants appreciated care providers who properly assessed and discussed their functioning and needs
responding proactively to problems and providing feedback
This gave them more insight into themselves
it contributed to a better overview of the situation
most participants on a general HIC ward who had barely experienced recovery
reported that their functioning was not well understood
and their needs had not been met properly by the care providers
The attitude of most care providers was non-directive
a satisfying working alliance was not possible
Participants felt unsafe and did not trust the care provider
and their psychological and behavioral problems increased
due to their difficulty in dealing with unpredictability and adequately overseeing situations
it was necessary for them that care providers helped to understand social and other situations and gave feedback on how they performed
Participants stated that feelings of unpredictability and the associated feelings of uncertainty were reduced by jointly drawing up a plan with concrete goals and steps for treatment
which allowed them and others to know what was going to happen
this gave them more overall control over their lives
Care providers&#x2019; communication style had an important impact on the participants&#x2019; recovery
Some participants stated that the process of recovery was limited if care providers failed to explain what they were going to do
or to keep appointments; or if they were unclear or unpredictable
This created confusion and loss of overview and control
Due to their difficulties with information processing
it was very important to participants that care providers communicated clearly
Participants reported that the experience of being valued by care providers was crucial to their recovery process
Important elements of this were equality in contact
and offering participants enough room to make their own choices
If there was an equal and helping relationship
and participants dared to show their vulnerability
This created a space in which they could discuss their treatment needs
which contributed to a higher acceptance of treatment and thus greater adherence
By leading to greater insight into themselves and their autism
this gave them more control over their lives
which had a positive influence on reducing psychological and behavioral problems
Some participants experienced an unequal relationship with caregivers who were judgmental and gave participants no room to make their own choices
As this made it impossible to be open and honest in their communication
it may have led to increased behavioral problems
Participants saw the organization of care as a second important precondition
as it had a major influence on their process of recovery
Participants who had been in ASD-HIC reported that the availability and accessibility of specialized autism care was essential to recovery: it provided greater insight into their impairments and functioning
not only for people on the autism spectrum
They also reported that this specialized treatment was essential to maintaining their improvement after clinical discharge
especially as people on the autism spectrum often find it difficult to generalize what they have learned into another context
Participants from a general HIC ward did not receive specialized autism care; most barely experienced recovery
they did not receive appropriate treatment for their problems
Participants from an ASD-HIC ward stated that treatment duration and planning had been very important to their recovery
they felt that they needed sufficient time to get used to the ward before they were able to participate fully in the treatment program
it was important for them to start therapies at an early stage in order to complete them as much as possible in the time available for inpatient treatment
People on the autism spectrum found it important to have continuity of care providers
It were particularly participants from general HIC
who reported that confusion and distrust had been created by insufficient continuity of care
characterized by high numbers and changing of care providers
Participants considered proper coordination between care providers
institutions and people from their social networks important for the recovery process
especially the coordination of the transition from inpatient to outpatient treatment
To ensure that a patient received well-organized
all the parties involved needed to know what was expected of them
This provided clarity and overview for everyone involved
Some participants reported that the process of recovery had been hindered by insufficient coordination
The texts in italics in paragraphs below elaborate the process of recovery shown in the boxes in the central part of <a href="#f1">Figure&#xa0;1</a>
due mainly to the perceived severity of their problems and their often long and difficult treatment histories
most participants were pessimistic about the treatment provided and their chances of getting their lives back on track
Since all or most of their earlier treatments and personal efforts had failed
they saw ASD-HIC treatment as a last resort &#x2013; their only hope
As they also believed there would be no further options for treatment if this did not work out
they experienced considerable fear and pressure
the two preconditions referred to above &#x2013; a good working alliance with care providers
and the clear and predictable organization of care &#x2013; were met to a relatively high degree
they experienced well organized care and they felt acknowledged and understood as people with very individual characteristics
This promoted personal feelings of trust and safety
which further increased their trust in treatment and care providers
participants reported that they opened up to treatment and dared to express vulnerability
This manifested itself in various ways: by being open and honest with themselves and those around them
being vulnerable and open to treatment created hope and new prospects for treatment and their own future
These feelings were reinforced by positive experiences and the first successes in treatment
Because they had regained hope and prospects
participants were more confident about actively collaborating with their care providers towards the treatment objectives
Participants stated that they took new initiatives and tried things out by working toward these objectives step by step
Participants said that active participation in treatment gave them increased insight into themselves
Growing confidence in care providers and treatment
contributed significantly to a more goal-oriented attitude
This in turn contributed to greater understanding of their functioning
and greater awareness of own abilities and limitations
some participants realized that their goals and their expectations of themselves and of treatment had been too high
Most participants reported that increased understanding of their autism raised awareness of their disrupted or delayed information processing
their overstimulation and their specific thinking patterns
Participants became more aware of their different information processing
which in turn increased their scope for self-regulation
They learned to take their personal characteristics into account
for example by allowing themselves sufficient time to process information
and to properly prepare and structure social situations and possible changes
They did so by trying to think in advance what was going to happen
by timely planning of appointments and activities
Participants reported that their self-regulation also increased
as they were better able to identify and regulate tension and overstimulation by setting limits to their activities and looking for distractions
their self-regulation also increased because they had greater insight into and control over their thinking patterns
The blockages in their thinking had decreased
and they were more likely to discontinue negative or black-and-white thinking
due their increased trust in their own judgements and choices
they were better able to take control of their own lives
they also realized that they needed support for effective functioning
during treatment they developed skills such as discussing thoughts
and asking for help and clarification when necessary
participants reported that they were better able to accept their autism diagnosis and themselves
and also their capabilities and limitations
This allowed them to adapt their lives accordingly
by adjusting goals and expectations based on their actual functioning and by accepting help from others
The result was improved autism management in daily life
Participants said it was crucial to their recovery that they had established a good daytime structure
with a good balance between rest and activity
they had noted a decrease in their psychological and behavioral problems throughout their recovery process
with control over themselves and their surroundings gradually increasing
they had found themselves in an increasingly orderly world
it was striking that this process of recovery was experienced mainly by participants from ASD-HIC and much less by those from general HIC
who indicated that the process of recovery had not been initiated
as the two essential conditions were usually missing: the establishment of a good working alliance
Although some participants from general HIC had nonetheless had positive experiences with individual care providers who were able to establish a good working alliance
a more coherent treatment context with better conditions for recovery had been experienced by significantly more participants in specialized ASD-HIC
The primary objective of our study was to investigate the process of recovery of adults on the autism spectrum during intensive inpatient treatment
Our model shows that participants experienced a world of confusion before intensive inpatient treatment
A world in which they had difficulties understanding themselves or others
and where they felt they were not well understood by the people around them
This significant mismatch between patients and others
both in their personal network and with care providers
resulted in a history of ineffective treatment
Previous research confirms that persons on the autism spectrum often struggle to find services appropriate to their specific needs (<a href="#B11">11</a>)
The treatment currently provided in general mental health care facilities in the Netherlands seems insufficiently adapted to the specific needs of some persons on the autism spectrum
Care providers in general mental health care seem to have less insight into persons on the autism spectrum
Eventually a reciprocal effect on the working alliance becomes apparent: both the care providers as well people on the autism spectrum can experienced challenges in understanding each other
the interaction between them can be greatly affected
Due to the mismatch they experience between supply and demand
these people on the autism spectrum lose control over themselves and their surroundings
there is no linearity and coherence between the different populations in mental health care and it is necessary to conduct research into recovery in various populations
one of the reasons people on the autism spectrum adopt a rigid stance in life is to help them create a foothold in an unpredictable world
But although sticking to one&#x2019;s own rules and convictions may seem to reduce the confusion caused by the perceived unpredictability of others and limited understanding of one&#x2019;s own lived experiences
it often clashes with the ideas of those without autism
To be willing to accept alternative perceptions on reality from someone else
a person on the autism spectrum needs a trustworthy relationship
This need is not just restricted to specialized autism treatment per se: the ability to develop such relationships should also be viewed as a basic competence of every care provider
Given the importance of the quality of interpersonal contact for people on the autism spectrum
it is unsurprising that participants in the specialized ASD-HIC wards generally experienced better working alliances than those in the general HIC wards
ASD-HIC care providers are trained to combine these basic competencies with their autism expertise
To exchange and further develop their own autism expertise and expertise in their broader discipline
the care providers at the two ASD-HICs wards participating in this study collaborated closely and intensively on autism-specific treatment
a clear and predictable organization of care is important for recovery
This can also be achieved more easily in an ASD-HIC ward
as the content and organization of care are both more focused on autism than in a general HIC
where a wide range of psychiatric conditions must be dealt with
As our findings confirmed that predictability is a key element in the process of recovery
It is clear that the thorough intake phase before admission makes an important contribution to the conducive organization of care which participants experienced on the ASD-HIC wards
almost unconditional admission to a general HIC
this offered participants ample time to familiarize themselves with the unit
This may also explain why 80% of admissions to the general HIC are involuntary
the length of treatment may have contributed to the recovery process
the average stay at an ASD-HIC unit allowed for more time to establish a good working alliance and create understanding of how ASD impacts a person&#x2019;s life than is possible in the few weeks or months in general HIC
As an ASD-HIC meets the conditions for recovery better than a general HIC
the many referrals and long waiting lists are unsurprising
A strength of the study is that a topic list for the interviews was developed in advance and was based on discussions in focus groups representing three perspectives
experts by experience on the autism spectrum
A second strength is that very little previous research has examined the recovery of persons in this target group
A third is that we studied recovery in various contexts by including participants from different settings in intensive inpatient treatment
A final strength is the cyclical nature of the data collection and analyses
Our attainment of data saturation showed the sample size to be sufficient
A limitation is that the data presented are partial and concern only adults with need for admission High Intensive Care units due the severity of their autism symptoms
Another limitation is that the generalizability of our results is restricted by our selection of two target group of adults on the autism spectrum: those in a general HIC
The selected groups were very specific for the Dutch mental health care setting
which may not be easily translated to mental health care situations outside The Netherlands
the main conclusion is that adults with ASD emphasized that their need for being understood and accepted by caregivers - particularly with regard to their specific autism characteristics- is a prerequisite for treatment
Although this opinion was elicited in this specialist setting
we have no reason to assume that this need is different in other settings
Another possible limitation is that the interviews were conducted two months after discharge
which may have been too soon to establish how participants functioned in daily life after intensive inpatient treatment
this interval was chosen deliberately in order to avoid recall bias
Within the current mental health system in the Netherlands
treatment is based on standard protocols without either a comprehensive contextual assessment or an in-depth assessment of existing problems from the person&#x2019;s perspective
Although this may be effective for the majority of the mental health population
this standard protocol-based approach is less appropriate for most people on the autism spectrum
as it assumes that there is agreement on the interpretations of existing problems and care needs
which is by no means the case for people on the autism spectrum
it is important to explore together with the adults what the actual problems and related care needs are
paying explicit attention to their needs and lived experiences
people on the autism spectrum need to feel accepted and understood
Communication with them should therefore be tailored to their individual abilities and limitations &#x2013; a reminder that comprehensive assessments and the establishment of a good therapeutic relationship lay the foundations for a proper recovery process
Given the many referrals and long waiting lists
it is not possible to treat all eligible persons within a specialized ASD-HIC ward
as these specialized facilities are limited in number
We therefore recommend that knowledge and competencies regarding proper assessments
effective communication and the overall facilitation of recovery of people on the autism spectrum are transferred to regular HIC units and other teams within regular mental health care
We also recommend that professionals at specialized ASD-HIC settings are made available for consultation in complex cases in regular mental health care
Such consultation and support from specialized ASD-HIC wards would also contribute to the transfer of specialist knowledge and competencies
Before goal-oriented treatment can be provided
it is vital for people on the autism spectrum that a basis of trust is established
Such trust explains the advantages of prolonged treatment in ASD-HIC
persons are referred to another treatment setting after their crisis has stabilized
meaning that they once again have to get used to new care providers without first achieving the necessary basis in trust
We therefore recommend not only that care is provided using a care program or care pathway
but that a care provider is available who can follow each person on the autism spectrum through different settings and care pathways
There are two important preconditions for initiating the process of recovery of people on the autism spectrum during intensive inpatient treatment: a good working alliance with care providers
and a clear and predictable organization of care
These preconditions should be met before therapy and goal-oriented treatment can be carried out successfully
It is important for the recovery of people on the autism spectrum that they discover how autism affects their thinking
functioning and interaction with those around them
and that they learn in treatment how to apply these insights in their daily lives
By learning to regulate themselves in daily life
they will gain better control over their lives and become less dependent on care providers
Treatment should therefore focus on collaboratively exploring existing problems and related care needs
and on determining how these can be dealt with differently in daily life
The raw data supporting the conclusions of this article will be made available by the authors
The studies involving humans were approved by Medical Ethics Review Committee at Amsterdam University Medical Center (UMC
The studies were conducted in accordance with the local legislation and institutional requirements
The participants provided their written informed consent to participate in this study
The author(s) declare financial support was received for the research
This study was funded by Dimence Institute of Mental Health as part of a PhD project
The recruitment of participants was facilitated by one ASD-specific High-Intensive Care ward at the Leo Kannerhuis
by one ASD-specific High-Intensive Care ward at Dimence
and by three general High-Intensive Care wards at Dimence
all of which also provided accommodation for the interviews
We are grateful to research assistant Monique Duizer for conducting and coding some of the interviews
We would like to thank all the participants for the time and effort they contributed to this study
which could not have been accomplished without them
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations
Any product that may be evaluated in this article
or claim that may be made by its manufacturer
is not guaranteed or endorsed by the publisher
The Supplementary Material for this article can be found online at: <a href="https://www.frontiersin.org/articles/10.3389/fpsyt.2024.1383138/full#supplementary-material">https://www.frontiersin.org/articles/10.3389/fpsyt.2024.1383138/full#supplementary-material</a>
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Received: 06 February 2024; Accepted: 24 May 2024;Published: 07 June 2024
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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)
To systematically review the use of PROs and their measures
and quantify the effects of lifestyle interventions in patients with SMI on these PROs
Five electronic databases were searched (PubMed/Medline
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
or both for patients with SMI were included
A total of 11.267 unique records were identified from the database search
of which 21 were suitable for meta-analyses
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)
We found a small effect on depression severity (g = 0.30
I2 = 65.2%) and a moderate effect on anxiety severity (g = 0.56
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
This can lead researchers to be sceptical about the implementation of these interventions in clinical practice
the use of PROs in evaluation of lifestyle interventions has not been systematically evaluated and quantified yet
The aim of this study is to systematically review the use of PROs and their patients-reported outcome measures (PROMs) in the evaluation of lifestyle interventions aiming at the promotion of healthy diet and physical activity for patients with SMI
We will furthermore quantify the effects of lifestyle interventions for SMI on three important PROs
To identify any additional relevant studies
we systematically screened reference lists of key systematic reviews that were retrieved from the search string that was originally used as an orientation on currently available reviews on the topic
We included randomised controlled trials (RCTs) only
Studies of all languages and publication dates were considered
We used the following four main domains of inclusion criteria to assess eligibility of the studies
we included studies focusing on schizophrenia spectrum disorders or other psychotic disorders
or depressive disorder when chronicity was indicated
or dementia as primary diagnosis were excluded
The included studies investigated lifestyle interventions focussing primarily on promoting physical activity
We focussed on non-pharmacological interventions promoting weight loss
Studies with nonactive or minimally active control conditions were considered eligible (e.g
treatment as usual or waitlist control group)
In the first round of selection, titles and abstracts were screened for eligibility using the Rayyan screening tool [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 24" title="Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210." href="/articles/10.1186/s12888-022-03854-x#ref-CR24" id="ref-link-section-d420289982e814">24</a>]
Literature was screened on the basis of our inclusion and exclusion criteria by the first author (LP)
two other researchers (MA and BvM) independently screened a smaller sample of each 5% of all records (n = 1.145)
Selection criteria were defined in greater detail which ultimately led to consensus
a selection of articles that were cases of doubt (n = 160) and were screened by only one researcher (LP) in the first round
These underwent a second screening by two researchers for a definite decision (LP and MA)
Disagreements in inclusion and exclusion were resolved by discussion
Disagreements or uncertainties were discussed with the senior researcher (BvM)
In the second round of screening, each full-text article was screened independently by two researchers (LP and JK). Disagreements were resolved by discussion or decision by a third and fourth researcher (MA and BvM). An overview of the study selection process can be found in the PRISMA flow diagram (Fig. <a data-track="click" data-track-label="link" data-track-action="figure anchor" href="/articles/10.1186/s12888-022-03854-x#Fig1">1</a>).
</a>PRISMA flow diagram of study search and selection
The process of data extraction was carried out by two persons independently (LP and JK)
The data was extracted using a standardised data extraction file which was developed beforehand
The following items were extracted for description of study characteristics: first author
data for quality assessment and meta-analysis was extracted
and risk of bias assessment was done by two independent researchers (JK and LP)
Discrepancies were once again resolved by discussion
The risk of bias for each domain was scored as either low
and an overall judgement for each study was made
we made a distinction between high-risk studies and ‘lower-risk’ studies
The fourth domain was removed for this purpose
as it was expected to score as ‘high risk’ in any case because of the inability of blinding in lifestyle intervention trials
Studies were labelled ‘lower risk of bias’ when at least three of the remaining domains scored low risk and none of the domains scored high risk
The model divides outcomes into five categories: biological and physiological variables
We considered the model while analysing the concepts of the different PROs and in deciding which ones should be pooled in the meta-analysis
we chose the most frequently used PROMs that measured the health status of a patient rather than health behaviour
as we considered those as most relevant and meaningful for patients
and anxiety severity were considered the most important outcomes
a total of 5.907 participants were enrolled across studies
The studies were published from 2005 until 2020 and 56% (n = 20) were published during the past 5 years
The studies had a sample size ranging from 13 to 814 participants (mean/median = 164/101)
The mean age of the participants ranged from 31 to 60 years
The percentage of male participants ranged from 14 to 100% (mean/median = 56/52)
The main primary diagnoses were schizophrenia spectrum disorders or psychotic disorders in 86% of the included trials (n = 32)
Other primary diagnoses were bipolar disorder (n = 2) and major depressive disorder (n = 2)
Participants were recruited from outpatient settings in 86% of all trials (n = 31)
in some trials from inpatient clinics (n = 4)
Duration of the interventions ranged from 5 weeks to 12 months
All control conditions were nonactive or minimally active
the validity and reliability of 17% of PROMs remained questionable (n = 12)
This was mostly true for self-reported measures of physical activity and dietary behaviour
We included a total of 21 studies for meta-analysis, some of which included outcomes of more than one analysis. Outcomes of all meta-analyses can be found in Table <a data-track="click" data-track-label="link" data-track-action="table anchor" href="/articles/10.1186/s12888-022-03854-x#Tab2">2</a> and forest plots in Fig. <a data-track="click" data-track-label="link" data-track-action="figure anchor" href="/articles/10.1186/s12888-022-03854-x#Fig3">3</a>.
This meta-analysis is based on 19 studies (n = 3.129 participants) that evaluated the effect of lifestyle interventions on QoL in patients with SMI
We performed the main analysis calculating combined effect sizes for studies that used more than one outcome measure for QoL
The pooled effect size for quality of life is Hedges’ g = 0.13 (95% CI = − 0.02 to 0.27)
showing no significant increase in QoL in in the intervention groups
We analysed how the effects would change based on the selection of outcomes with the lower or higher effect size for studies using more than one PROM for QoL
The analysis combining the lowest effect sizes indicated no effect (g = 0.1; 95% CI = − 0.05 to 0.24)
the analysis combining the highest effect sizes indicated a small and statistically significant effect (g = 0.18; 95% CI = 0.02 to 0.33; p = 0.03)
There was high heterogeneity among QoL studies (Q = 57.6
The null hypothesis of all studies sharing the same common effect size
The I2-statistic is 68.7% (95% CI = 46 to 79)
meaning that more than half of the variance in the observed effect reflects the variance of true effects
the meta-analysis was based on nine studies (n = 790 participants)
We found a small significant effect on depression severity with a pooled effect size of g = 0.29 (95% CI = 0.00 to 0.58
Heterogeneity appeared to be high among studies evaluating depression severity (Q = 23.0
We did not perform any subgroup analyses on this outcome as the number of studies was too low
The meta-analysis on the effects of lifestyle interventions on the severity of anxiety summarized four studies (n = 121 participants)
We calculated a pooled effect size of g = 0.56 (95% CI = 0.16 to 0.95)
indicating a moderate and statistically significant effect (p = 0.006)
The I2-statistic was 0% (95% CI = 0 to 68)
five subgroup analyses were performed on the following variables: study region
we defined a cut-off value of above 60% for high attendance
we used the same four domains as for identifying the ‘lower risk’ studies
Risk of bias was significantly associated with the effect size (p = 0.01)
Studies with a higher risk of bias seemed to show larger effect sizes than those with a lower risk of bias (g = 0.27 compared to − 0.06)
higher attendance was significantly associated with higher effect sizes (p = 0.01)
showing an effect size of g = 0.46 in the high attendance group compared to − 0.02 in the low attendance group
Studies from the Asian/ Pacific area tended to have a higher effect size compared to other regions (g = 0.23; compared to Europe g = 0.12
Asian studies overlapped to some extend with the ‘higher risk’ of bias studies
Interventions with longer duration (9-12 months) tended to have a lower pooled effect size (g = − 0.05
In the exploratory analysis we found that interventions including mainly structured high intensity physical activity had a large pooled effect size (g = 0.92)
The GRADE assessment shows an overall very low quality of the evidence, caused by the high risk of bias, unexplained heterogeneity, and indirectness due to time differences in outcomes (Supplementary Material, Table <a data-track="click" data-track-label="link" data-track-action="supplementary material anchor" href="/articles/10.1186/s12888-022-03854-x#MOESM1">S3</a>)
In this systematic review and meta-analysis
we examined the use of PROs and PROMs in lifestyle intervention trials for people with SMI
We analysed the effect of three PROs that were used in lifestyle intervention trials for people with SMI
We identified 36 studies of which 21 were used for meta-analysis
The most commonly evaluated PROs were quality of life
often reported as secondary or exploratory outcomes
The included studies showed a large variety of different PROMs
only seven of the 36 studies had a lower risk of bias
with a Hedges’ g = 2.32 (95% CI = 1.15 to 3.49)
those studies used highly social exercise interventions
soccer practice and Greek traditional dancing
Including these kinds of interactive and social activities in lifestyle interventions could help patients to stay motivated and could increase compliance with
and thus the success of lifestyle interventions
Exploratory analysis revealed high effects for interventions mainly consisting of structured high intensity PA
Although the two outlier studies contributed to this high effect size
the remaining studies likewise showed large effects
These findings should be confirmed with larger samples
It is also important to note that due to the focus of our review
our findings cannot be generalized to other types of lifestyle interventions
such as smoking cessation or sleep interventions
This highlights the issue of implementation errors that could be a possible explanation for the lack of effects
on the level of the patient or care providers
which influences the effectiveness of a lifestyle intervention
as these studies tended to have higher risk of bias
Another possible explanation could be the stricter adherence to interventions in the Asian culture
Our systematic review had several strengths
this paper is the first systematic review and meta-analysis focussing entirely on the evaluation of PROs among lifestyle interventions in patients with SMI
we published a predefined study protocol in the beginning of the study period
we conducted a comprehensive and extensive literature search with the support of an expert information specialist
in which no restrictions in terms of language or publication date were applied
our search strategy could have included more diet-related search terms
we included only RCTs as these represent the best quality of evidence
almost all trials were of a high risk of bias which together with a range of other factors contributed to an overall very low quality of the evidence
the lack of power in the meta-analyses of the severity of depression and anxiety weakened the confidence in these results
Study selection was in large parts performed by a single searcher
We tried to limit the possible bias arising the selection procedure by double-screening a sample of 10% of the articles
and by discussing articles of doubt with two or more researchers
we cannot exclude the possibility of missing studies as we excluded non-randomized trials and included published studies only
Unpublished studies could have contributed to a smaller effect
which we tried to simulate in the adjustment of meta-analysis results for QoL by imputing the missing studies
We furthermore cannot exclude the possibility of missing studies in our search
because PROMs are often reported as secondary outcomes or supplementary material
This complicates tracing down these studies in the first phase of study selection while inspecting titles and abstracts
This error could only have been prevented by retrieving the method sections and supplementary materials of eligible studies during the first screening phase
we did not believe that this would have been a workable option due to the large number of studies we retrieved
they can still be useful to categorise patients into certain groups and to create awareness of the patient’s health behaviour
the PROMIS system has the potential to facilitate clinical practice and research in the assessment of PROs
The current systematic review and meta-analysis informs mental health professionals on the use of PROs and PROMs in the evaluation of lifestyle intervention trials
and on the effects of lifestyle interventions in patients with SMI on quality of life
Despite small and clinically non-significant effects on physical health parameters
lifestyle interventions can however positively affect PROs such as depression and anxiety symptoms
making them more relevant for clinical practice
Comprehensive knowledge of both the clinical and patient-reported outcomes of these programs is necessary in order to choose appropriate treatment for the SMI patient group
All data generated or analysed during this study are included in this published article [and its <a data-track="click" data-track-label="link" data-track-action="supplementary material anchor" href="/articles/10.1186/s12888-022-03854-x#MOESM1">supplementary information files</a>] and the original studies’ publications
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
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Life expectancy among persons with schizophrenia or bipolar affective disorder
Mortality in mental disorders and global disease burden implications
Physical illness in patients with severe mental disorders
impact of medications and disparities in health care
Risk of metabolic syndrome and its components in people with schizophrenia and related psychotic disorders
bipolar disorder and major depressive disorder: a systematic review and meta-analysis
The lancet psychiatry commission: a blueprint for protecting physical health in people with mental illness
Premature mortality among adults with schizophrenia in the United States
Sedentary behavior and physical activity levels in people with schizophrenia
bipolar disorder and major depressive disorder: a global systematic review and meta-analysis
Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice
Dietary intake of people with severe mental illness: systematic review and meta-analysis
Smoking and quitting behaviours by mental health conditions in Great Britain (1993-2014)
Lifestyle interventions for weight Management in People with serious mental illness: a systematic review with Meta-analysis
and Meta-regression analysis exploring the mediators and moderators of treatment effects
The impact of pharmacological and non-pharmacological interventions to improve physical health outcomes in people with schizophrenia: a meta-review of meta-analyses of randomized controlled trials
Lifestyle interventions for weight loss among overweight and obese adults with serious mental illness: a systematic review and meta-analysis
Patient-reported outcome measures: use in medical product development to support labeling claim
Silver Spring: US Food and Drug Administration; 2009
Patient-reported outcomes in meta-analyses – part 1: assessing risk of bias and combining outcomes
The importance of patient-reported outcomes in clinical trials and strategies for future optimization
Patient-reported outcomes in schizophrenia
Guidelines for inclusion of patient-reported outcomes in clinical trial protocols: The SPIRIT-PRO extension
The impact of patient-reported outcome (PRO) data from clinical trials: a systematic review and critical analysis
The PRISMA 2020 statement: an updated guideline for reporting systematic reviews
Consensus over de definitie van mensen met een ernstige psychische aandoening (EPA) en Hun aantal in Nederland
[consensus on the definition of people with severe mental illness (EPA) and their number in the Netherlands.]
Rayyan—a web and mobile app for systematic reviews
GRADE: an emerging consensus on rating quality of evidence and strength of recommendations
Linking clinical variables with health-related quality of life: a conceptual model of patient outcomes
Statistical power analysis for the behavioral sciences
Meta-analyses in mental health research: A practical guide; 2016
A psychoeducational program for weight loss in patients who have experienced weight gain during antipsychotic treatment with olanzapine
A 6-month randomized controlled trial to test the efficacy of a lifestyle intervention for weight gain management in schizophrenia
Randomized controlled trial of a healthy lifestyle intervention among smokers with psychotic disorders
Clinically significant improved fitness and weight loss among overweight persons with serious mental illness
Pragmatic replication trial of health promotion coaching for obesity in serious mental illness and maintenance of outcomes
Soccer practice as an add-on treatment in the management of individuals with a diagnosis of schizophrenia
Psychoeducational intervention focused on healthy living improves psychopathological severity and lifestyle quality in psychiatric patients: preliminary findings from a controlled study
Physical health promotion in patients with functional psychoses receiving community psychiatric services: results of the PHYSICO-DSM-VR study
Effects of behavioral therapy on weight loss in overweight and obese patients with schizophrenia or schizoaffective disorder
A randomized controlled trial of a brief health promotion intervention in a population with serious mental illness
Behavioral interventions for antipsychotic medication-associated obesity: a randomized
Nutritional intervention to prevent weight gain in patients commenced on olanzapine: a randomized controlled trial
Effectiveness of a community-based nurse-led lifestyle-modification intervention for people with serious mental illness and metabolic syndrome
Influence of a lifestyle intervention among persons with a psychiatric disability: a cluster randomised controlled trail on symptoms
Randomised control trial of the effectiveness of an integrated psychosocial health promotion intervention aimed at improving health and reducing substance use in established psychosis (IMPaCT)
"MOVE!" outcomes of a weight loss program modified for veterans with serious mental illness
A randomized controlled trial on the psychophysiological effects of physical exercise and tai-chi in patients with chronic schizophrenia
Structured lifestyle education for people with schizophrenia
schizoaffective disorder and first-episode psychosis (STEPWISE): randomised controlled trial
Effect of lifestyle coaching versus care coordination versus treatment as usual in people with severe mental illness and overweight: two-years follow-up of the randomized CHANGE trial
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The CHANGE trial: no superiority of lifestyle coaching plus care coordination plus treatment as usual compared to treatment as usual alone in reducing risk of cardiovascular disease in adults with schizophrenia spectrum disorders and abdominal obesity
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a cluster randomized controlled pragmatic trial
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A randomized controlled trial undertaken to test a nurse-led weight management and exercise intervention designed for people with serious mental illness who take second generation antipsychotics
and health-related self-efficacy among people with serious mental illness: The STRIDE study
The MOS 36-item short-form health survey (SF-36)
A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity
International physical activity questionnaire: 12-country reliability and validity
Dietary intervention in primary care: validity of the DINE method for diet assessment
Psychometric properties of the Beck depression inventory: twenty-five years of evaluation
The symptom check-List-90-R (SCL-90-R): a German validation study
What is the threshold for a clinically relevant effect
The effects of lifestyle interventions on (long-term) weight management
cardiometabolic risk and depressive symptoms in people with psychotic disorders: a meta-analysis
A meta-review of "lifestyle psychiatry": the role of exercise
diet and sleep in the prevention and treatment of mental disorders
diet and educational interventions for metabolic syndrome in persons with schizophrenia: a systematic review
Dietary modification in the treatment of schizophrenia spectrum disorders: a systematic review
Effectiveness of interventions for weight loss for people with serious mental illness: a systematic review and Meta-analysis
The validity and value of self-reported physical activity and Accelerometry in people with schizophrenia: a population-scale study of the UK biobank
Assessing validity of retrospective recall of physical activity in individuals with psychosis-like experiences
Traditional self-reported dietary instruments are prone to inaccuracies and new approaches are needed
Application of the National Institutes of Health patient-reported outcome measurement information system (PROMIS) to mental health research
Development of a computer adaptive test for depression based on the Dutch-Flemish version of the PROMIS item Bank
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Caroline Planting for her contribution and support in the database search
This systematic review and meta-analysis was funded by a grant of the Netherlands Organization for Health Research and Development (ZonMw); grant number 80–84300–98-72012
The funder had no control over any methodological aspect of the study nor did they have any input on the conduct
analysis interpretation or publication of the study results
Faculty of Science &amp; Amsterdam Public Health Research Institute
Neuro- and Developmental Psychology &amp; Amsterdam Public Health Research Institute
Amsterdam Public Health Research Institute
BvM and LP set up the study protocol and performed the study selection
MA and LP collaborated with Caroline Planting to conduct the literature search
LP and JK performed the data extraction and assessed the risk of bias
LP performed the statistical analysis under support of AvS
and the final version was approved by all authors
The authors declare that they have no competing interests
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations
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unless otherwise stated in a credit line to the data
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de Wolf suffered an injury from a practice crash
but now it seems he is ready to race next weekend in the penultimate round of the MXGP series in Maggiora as he won both motos in round thirteen of the OPEN Dutch Championship in Meijel
The Neestan Husqvarna rider set the fastest lap in time practice
followed by a solid victory in the first moto after catching Jaap Jenssen for the lead in the first stages of the race before making a huge gap over his rivals
de Wolf put the holeshot and from there he led every lap until the checkered flag to sail a perfect 1-1 on his return
Fantic rider Boris Blanken was second overall via 2-3 while Championship leader Kjeld Struuman (KTM) rounded the podium with a 3-4
This is a great comeback for de Wolf who is expected to see him in the final two rounds of the MGP World Championship as well as the Motocross of Nations in Ernée representing Team Netherlands in the MX2 class alongside Calvin Vlaanderen and Glenn Coldenhoff
Pistella was a 19-year-old infantryman moving around Holland in October 1944 with Company B of the U.S
the Pittsburgh native lost a gold bracelet bearing his name and serial number
four days after his promotion to private first class
Pistella lost his life in a German mortar attack during the three-day Battle of Meijel
forces defended the Dutch town against repeated Nazi attacks
A family in Holland was using a metal detector in a field in 2009 when they discovered Pistella's bracelet
That personal item soon will be delivered to Pistella's great-nephew
Wallace said he was shocked when he learned on Halloween of the bracelet's discovery
but think could never happen,'' Wallace said
I'm ecstatic it was found and they can return it here to family."
Wallace exchanged emails recently with Nicole Sproncken
a board member with the Foundation For Adopting Graves at the Netherlands American Cemetery in Margraten
Sproncken knew about the Dutch family having the bracelet and made attempts to contact Wallace
has seen a photo of the bracelet and said it looks like a personal item
The bracelet has his great-uncle's name on the front
and serial number and "12-25-43'' inscription on the back
"We don't know if it was found in Holland close to where he was killed,'' Wallace said
Wallace believes the bracelet might have been a Christmas gift from a family member
who is buried at Calvary Cemetery in Pittsburgh
From researching the military morning reports of Pistella's company and the memoirs of another soldier in Pistella's company
Wallace was able to determine how his great uncle died
"Morning reports detailed what the company does every day
combat casualties and what went on,'' Wallace said
"It was bitter combat with high casualties defending that town of Meijel,'' Wallace said
American forces defended the town against a series of German attacks
Pistella died during a German mortar attack on the battle's final day
Wallace's research of another soldier's memoirs indicates Pistella was "seriously injured and died a few moments later in the arms of a comrade,'' Wallace said
Pistella was listed as missing in action after the battle and his body was not found until a few weeks later
His remains were exhumed in 1949 and returned to his family for burial in Pittsburgh
Wallace was in contact through email with members of the family in Holland who found the bracelet
who has his great-uncle's Purple Heart Medal and citation letter
the flag presented to Pistella's family at his 1949 burial
"We're very excited to get something personal of his memory that was found,'' Wallace said
Ron Leonardi can be reached at 870-1680 or by email
Follow him on twitter at twitter.com/ETNleonardi
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Street poetry. Once you are open to its existence, you cannot unsee it. Sometimes large and very present, other times more discrete and modest. In 2016, the website <a href="http://www.straatpoezie.nl">www.straatpoezie.nl</a> was launched by dr
Kila van der Starre as part of a dissertation
during which different forms of poetry in public space were investigated
The website is a crowdsourced database with over 3000 entries of poetry to be found on the streets in The Netherlands and Belgium
On the market square of a small town in a sparsely populated part of the Netherlands
Just outside the core of this village begins national park De Peel
&quot;an infinite space with unequalled fauna and flora
This small piece of text comes from the song &#8221;De Peel in Brand&#8221; (The Peel on fire) by the Limburg band Rowwen Hèze
It describes how a small boy found the fog in nature reserve De Peel combined with the red evening sun to resemble a fire
Even though the choice for this fragment about De Peel was not without controversy (the band is not from Meijel&#8230;) the choice for this literary work of art situated in Meijel makes sense
The town profilates itself als the front gate of the national park
you see indeed that it is closely related to De Peel
Regardless of the motivations behind a certain (fragment of a) poem or even song
it is interesting to investigate whether the poems that are chosen in the streetscape somehow reflect on or represent a part of its surroundings
One of the most straightforward ways (for now) is to check if and how often particular words appear in a certain condition
In this article we&#8217;re going to zoom in on the presence of two specific words
&#8216;stad&#8217; (city) and &#8216;zee&#8217; (sea)
given the condition of the poem being located in an urban area or not
One of the hypotheses could read that &#8216;sea&#8217; appears in the vicinity of the sea
in poems where the power and attraction of the sea is celebrated
And poems with &#8216;city&#8217; will mostly appear in urban areas
After all &#8211; why would you praise (or even name) the city when you&#8217;re somewhere in a non city-like environment
let me use the dataset for my own research purposes when I contacted her
we&#8217;re going to have a look at the data (a new dataset can surprise you in many ways)
a polygon is uploaded of all urban areas in the world
which we&#8217;ll delimit by latitude/longitude so only The Netherlands and Belgium are visible
we create two separate dataframes with the words &#8216;sea&#8217; en &#8216;city&#8217;
it is immediately noticeable how large the differences are between the filled-in fields of the entries
Some entries have only the two mandatory fields filled in
while others have complete stories under &#8216;Relation with location&#8217;
&#8216;Remarks&#8217; and &#8216;More info&#8217;
An NLP-scientist feasts on different text columns like this
The next step is to import a polygon of all urban areas in The Netherlands and Belgium:
The left one is the polygon we just imported
we need to merge the latitude and longitude of each entry
to make sure that the distribution urban/non-urban is not too skewed
When counting the values in the column &#8216;Is_urban&#8217;
we obtain the ratio 1886 (urban) to 1014 (non-urban)
so roughly 2/3 of the entries is located in an urban area
we can create a dataframe with any word we want to see where on the map in The Netherlands or Belgium they are used
Let&#8217;s take &#8216;sea&#8217; and &#8216;city&#8217; like we discussed in the introduction
When we select poems with the word &#8216;zee&#8217; (sea)
we see that -surprisingly- only a tiny part of the poems that contain the word sea are actually located in the vicinity of the sea
An interim conclusion is that poems not just reflect on or represent their surroundings; they could also state the absent
is whether these poems are situated along other types of natural waters like lakes and rivers
When selecting poems with the word &#8216;stad&#8217; (city)
we see that most poems are indeed to be found in urban areas
on the Wadden Islands (in the left picture
the four collective dots left-under &#8216;sea&#8217;)
In the next article, we&#8217;re diving into the poets behind fragments of street <a href="https://towardsdatascience.com/tag/poetry/" title="Poetry">Poetry</a>
nationality and active years of these writers
Step-by-step code guide to building a Convolutional Neural Network 
Here&#8217;s how to use Autoencoders to detect signals with anomalies in a few lines of&hellip; 
Solving the resource constrained project scheduling problem (RCPSP) with D-Wave&#8217;s hybrid constrained quadratic model (CQM) 
An illustrated guide on essential machine learning concepts 
Derivation and practical examples of this powerful concept 
Columns on TDS are carefully curated collections of posts on a particular idea or category&hellip; 
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Photo by: Ben SolomonTigers Fifth After American Championship's Second Round Apr 26
Memphis sophomore Lars Van Meijel fired a second-round 68 as the Tigers climbed to fifth in the team standings at the American Athletic Conference Men's Golf Championship being played at Black Diamond golf resort in Lecanto
With the threat of inclement weather forecasted this week
the American's 54-hole championship was adjusted to a two-day format with 36 holes on Sunday and the final 18 holes slated for Monday on Black Diamond's Ranch Course
The Tigers carded an opening round 296 Sunday morning but below par rounds by van Meijel and junior teammate <a href="/roster.aspx?rp_id=1514" rel="smarttag" rev="1514"><a href="/roster.aspx?rp_id=1522" rel="smarttag" rev="1522">Thomas Perrot</a></a> during Sunday afternoon's second round of play helped move the Tigers to fifth place after finishing the first 18 holes of the tournament in sixth place
van Meijel made the biggest climb of the tournament field Sunday afternoon
ninth hole highlighted a four-under par 68
van Meijel climbed 17 spots and into a tie for sixth with 18 holes to play
van Meijel is eight strokes back of second-round leader Ryan Fricker of USF who shot consecutive 67s on Sunday
Fricker has a four-stroke lead over UCF's Linus Vaisananen who moved into second after shooting a 68 Sunday afternoon
Fricker is one of three USF golfers in the top-10 as the No
18 Bulls are 19-under for the tournament and have a 16-stroke lead over second place UCF
Memphis has some work to do to climb any further in the tournament standings
36 Houston has a two-round score of 575 and No
Just behind Memphis with a two-round 587 score is Cincinnati
which is currently sixth while Tulsa is in seventh with a 589
In addition to van Meijel's second round,teammate Perrot birdied three of the second round's final five holes to shoot a one-under par 71 and is currently tied for 11th with a two-round score of 143 (+1). <a href="/roster.aspx?rp_id=1512" rel="smarttag" rev="1512"><a href="/roster.aspx?rp_id=1520" rel="smarttag" rev="1520">Eithel McGowen</a></a> is currently tied for 23rd at 148 (+4)
Memphis is slated to begin final-round play Monday at 8 a.m
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Since anxiety and depressive disorders often recur
self-management competencies are crucial for improving the long-term course of anxiety and depressive disorders
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
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
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
Participants are discharged from mental healthcare services
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
semi-structured qualitative individual interviews and focus group interviews will be conducted with patients and mental health professionals
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
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
Retrospectively registered in the Netherlands Trial Register (<a href="https://www.trialregister.nl/trial/7366">NTR7574</a>; 25 October 2018)
People with recurrent anxiety and depression should be supported in performing self-management strategies
The fact that depression and anxiety are often comorbid
and relapse into another disorder frequently occurs (from anxiety to depression and vice versa)
highlights the need to target both anxiety and depression in a single relapse prevention programme
We therefore developed a relapse prevention programme that can be offered in general practices by MHPs to patients with (partially) remitted anxiety or depression
This programme aims to support self-management skills and provides tools for monitoring symptoms
The E-health modules can be individually tailored to the needs of patients
and is combined with regular contact with the MHP
The aim of the present study is to implement and evaluate this guided self-help online relapse prevention programme for patients who are completely or partially in remission from anxiety and/or depressive disorders
and who previously received treatment in mental healthcare services
This study will provide insight into: 1) the extent to which patients make use of the relapse prevention programme; 2) the factors that influence the use of the programme; 3) the association between usage intensity and course of symptoms; 4) barriers and facilitators in implementation of the programme; and 5) how patients evaluate the programme
The methods section is divided into three parts: 1) the development of the relapse prevention programme; 2) the content of the relapse prevention programme; and 3) the study design
Our online programme therefore consists of a personal relapse prevention plan and flexible E-health modules aiming at the promotion of self-management skills
The MHP can individually tailor the programme in conjunction with the patient
Some optional modules were added at the request of patients
such as healthy food and physical exercise
These modules contain psychoeducation and the ability to plan healthy behaviour
with the aim of increasing physical and mental health
Preliminary versions of the E-health modules were reviewed by the members of the research team and E-health developers
the patient panel reviewed the modules and provided feedback
This feedback was thoroughly discussed and processed by the researchers
For example: more lengthy text parts were placed in ‘read more’ menus
and the possibility to print text was added
the adjusted content was released to the online platform
The modules include short videos on what to expect in the module, written information, exercises, and clinical examples of fictional patients. In all modules except the psychoeducation modules, patients have the possibility to ask for feedback from the MHP. For a more detailed overview of the contents of the E-health programme, see Table <a data-track="click" data-track-label="link" data-track-action="table anchor" href="/articles/10.1186/s12888-019-2034-6#Tab1">1</a>
It takes about 30–60 min to complete each module
patients draft plans related to the specific content of that module
by offering the possibility to print out the plans
Patients receive reminders via email regarding the completion of modules in the E-health platform
They also receive a newsletter every 6 weeks to keep them involved in the programme by providing information about numbers of included patients
experiences of other patients and interesting articles or facts about anxiety and depression
The MHP has access to the patient’s account
and can check whether the patient has been using the diary to monitor symptoms of anxiety and depression
the MHP can monitor the patient’s individual use of the different modules
MHPs can provide feedback on the completed modules and start a conversation in the E-health platform with the patient
The MHP and the patient will have at least one face-to-face contact during the nine-month period of the study
and are encouraged to meet each other every 3 months
the patient and MHP will start drawing up the relapse prevention plan (if not yet available) and decide on the frequency and number of contacts
the outcomes of the ‘mood and anxiety diary’
the use of the available modules and possible questions will be discussed
The time required for the first contact is 45 min
The MHP can actively support the patient in using the online programme and provide online feedback at the request of the patient
In this mixed-methods observational cohort study
the relapse prevention programme we developed will be implemented and evaluated
This programme is targeted at patients who have been discharged from mental healthcare services
and are in complete or partial remission from an anxiety or depressive disorder
This relapse prevention programme is called ‘GET READY’ and offers access to an E-health platform
combined with regular contact with a MHP for a period of 9 months
General practices will be included in this study
Eligible patients completed mental health treatment for anxiety or depression and are in (partial) remission
Patients will complete online questionnaires at baseline
individual interviews and focus group interviews will be held with patients as well as MHPs to evaluate the programme and its implementation
The term ‘full remission’ indicates that no more than minimal symptoms are present and DSM-IV criteria for a disorder have not been fulfilled
‘partial remission’ also indicates that DSM-IV criteria for a disorder have not been fulfilled
but that more than minimal symptoms are present
This study will be performed in two settings:
General practices throughout the Netherlands
with the participation of approximately 50 MHPs
Patients follow the programme at home via an E-health platform
accompanied by face-to-face contact with the MHPs
Ambulatory mental healthcare services with the participation of eligible patients whose GP is not willing to participate in this study
A trained MHP will deliver the relapse prevention programme using the same protocol as in the participating general practices
We aim to recruit 50 MHPs throughout the Netherlands
and via the professional networks of the researchers
For the MHPs working in a general practice
the GP agrees that the MHP participates in this study
Informed consent will be obtained from the MHPs before inclusion
Inclusion criteria are: patients have completed their treatment for anxiety and/or depression within the last 2 years
have a score on the Global Assessment of Functioning scale (GAF) of 50 or higher
and have sufficient command of the Dutch language
Patients are excluded if they participate in another structured psychological intervention
when they do not have access to the internet
or when the severity of a comorbid psychiatric disorder requires specialised treatment
Each MHP is requested to include all patients that completed mental health treatment for anxiety and depression and meet the inclusion criteria
MHPs will be asked to identify eligible patients through their patient files
MHPs invite potentially eligible patients for a consultation to discuss participation in the study
to provide information about the study and to check whether patients meet the inclusion criteria
the researcher contacts the patient and sends the baseline questionnaire
When patients have completed the baseline questionnaire
they receive access to the E-health platform
Eight days after sending the invitation for login
the researchers check if the patient has logged in
they contact the patient to offer technical or practical support
Patients who completed their treatment and are recruited via mental healthcare services
will be contacted by the researchers directly
These patients will be supported during the GET READY programme by a MHP working in the ambulatory mental healthcare
Each MHP participates in a four-hour training course
focusing on the background and relevance of relapse prevention in anxiety and depressive disorders and potential effective intervention strategies regarding relapse prevention
the content and use of the E-health platform is explained
information is provided about the study protocol
This training course will be given by either a psychologist or psychiatrist (both part of the research team)
together with the first author of this paper
including a protocol in which the following topics are described: recruitment of patients
the content of the face-to-face contact with patients
instructions on how to complete the case registration forms
The package also includes invitation and information letters for patients
The researchers offer monthly individual consultation via phone to the MHPs to support them in recruiting patients
Every month the MHPs receive a newsletter to update them on the study and motivate them to continue including patients
Patients are asked to complete four online questionnaires: at baseline (T0)
It takes approximately 20–30 min to complete the questionnaires
Patients receive email invitations and if they do not complete the questionnaire
patients are requested to complete the ‘mood &amp; anxiety diary’ every week to rate their level of anxiety and depression
They can complete the diary on their smartphone or on a computer
the MHP completes a case registration form
This form contains information on the duration and content of the face-to-face contact
and whether additional appointments were made
Data will be collected regarding the use of the E-health platform data (number of logins
and number of diary entries) and the frequency of contact with the MHPs
registered via the case registration forms
Sociodemographic characteristics and clinical variables of patients will be assessed at baseline, see Table <a data-track="click" data-track-label="link" data-track-action="table anchor" href="/articles/10.1186/s12888-019-2034-6#Tab2">2</a>
patients are asked to estimate their risk of relapse
and to indicate the expected effect of the programme
It consists of 45 items describing strategies that patients use to cope with anxiety and depression
Each item is rated on a 5-point Likert scale ranging from 1 (not at all) to 5 (a lot)
The total score can be calculated by summing the individual scores
Anxiety and mood data are also collected in the weekly diary
Mood is measured by asking ‘how would you rate your mood today?
Anxiety is measured by asking ‘how would you rate the intensity of anxiety today?
from 1 (very relaxed) to 10 (very anxious/tense)’
Also patients will be asked to rate each online module
The original scale was translated into Dutch by the authors
For each of the quantitative research questions
a separate analysis will be performed using log data from the E-health platform
data from the case registration forms that have been completed by the MHPs
To what extent do patients use a tailored relapse prevention programme
The use of the tailored relapse prevention programme will be described
the number of sessions and the number of online and face-to-face conversations with the MHP
Descriptive statistics will be used to provide insight into these aspects of the use of the relapse prevention programme
What factors influence the use of the programme
The use of the tailored relapse prevention programme may differ across patients
We will explore possible differences in usage between groups of patients systematically
clinical symptoms and self-management strategies
What is the association between usage intensity and course of symptoms
This analysis will be performed using a time-lag model
in which the outcome will be assessed using determinants from an earlier measurement (deterioration at timet predicted by usage intensity at timet-1)
since we assume that usage intensity might influence whether deterioration occurs at a later point in time
Because of the observational nature of the data
it will be difficult to draw conclusions about the effects of the relapse prevention programme
we will conduct additional explorative analyses to estimate the association between usage intensity and course of symptoms
All data analysis will be performed using SPSS statistical analysis software
we assume that the effect of X corresponds to a 6% of explained variance of Y (equivalent to the moderate effect
since R2 = r2 = 0.242 = 0.06) above the covariates W and assume a 6% reduction of the total variance in Y of the residual variance due to the use of covariates of W
setting α = 0.05 and the power of 1 – β = 0.80
the sample size calculation shows that 126 patients are needed
Patients will be considered as drop-out when they refuse to complete questionnaires
80% complete at least one follow-up questionnaire)
The individual interviews and focus group interviews are conducted to assess implementation and satisfaction with the programme
Patients will be invited by email and telephone to participate in a semi-structured interview to evaluate their experience with the relapse prevention programme
The interviews will be conducted by two researchers
who will prepare the interviews by performing two test interviews
A senior researcher will provide supervision and participate in the analysis
We aim to conduct 12–15 interviews with patients and 12–15 interviews with MHPs
The final number of interviews depends on when data saturation is achieved
Main topics are: experiences with the relapse prevention programme
useful and less useful aspects of the programme
Input from the E-health platform will be used
and number of online conversations with the MHP
The topic guide will be evaluated and updated after conducting four interviews
The MHPs of patients who participate in the interviews will also be invited by email and telephone to participate in an interview. Besides evaluating the programme (research question 5), implementation barriers and facilitators will be discussed in these interviews (research question 4), see Additional file <a data-track="click" data-track-label="link" data-track-action="supplementary material anchor" href="/articles/10.1186/s12888-019-2034-6#MOESM2">2</a> for the topic guide
These interviews will be conducted in a setting selected by participants and will take approximately 45 min
The input from the individual interviews will be used in these focus group interviews
to discuss desirable changes to the E-health programme
in order to further improve its quality and usability
In order to obtain new perspectives on the evaluative data from the individual interviews
one half of the focus group participants will not have participated in a previous individual interview
The other half of the focus group members will be purposively selected from the patients and MHPs who previously participated in the individual interviews
where the selection is based on the diverging perspectives on using the relapse prevention programme
These focus group interviews will be conducted in a mental healthcare facility and will take approximately 90 min
For each of the qualitative research questions
What are barriers and facilitators in the implementation of the programme
which means that the interviews will be coded for themes
these codes will then be sorted and analyses will be performed using software programme MaxQDA
quotations will be used to illustrate the findings
The evaluation of the programme will be assessed by the semi-structured interviews and focus group interviews with the patients
patients will be asked about their satisfaction with the programme and to rate every module they completed on a scale from 0 to 10
The data from the interviews and focus group interviews will be analysed in the same way as described above (research question 4)
Data from T9 will be analysed using descriptive statistics
Providing relapse prevention for anxiety and depression is important
since these disorders are often chronic and recurrent
In this study we will implement and evaluate a newly developed relapse prevention programme
specifically targeted at patients that are (partially) remitted from an anxiety disorder or depression
The mixed-methods approach in this study will provide valuable insights into how patients use the programme
how usage intensity influences symptoms and how patients evaluate the programme
information on implementation will be provided which may be relevant for broad implementation of the programme
The findings of this study can be used to further refine and adapt the programme as preferred by patients and MHPs
This design is not appropriate to examine efficacy
since only within-group effect sizes can be determined
which might be considered a limitation of this study
the aim of this study was not to examine the efficacy of the programme
a randomized controlled trial should be conducted to determine the efficacy of the programme
Consolidated framework for implementation research
Diagnostic and statistical manual of mental disorders
Guided E-healTh for RElapse prevention in Anxiety and Depression
Inventory of Depressive Symptomatology – self-report
Trimbos/iMTA Questionnaire for Costs Associated with Psychiatric Illness
World Health Organization Disability Assessment Schedule
Recurrence of anxiety disorders and its predictors
Penninx BWJH, Nolen WA, Lamers F, Zitman FG, Smit JH, Spinhoven P, et al. Two-year course of depressive and anxiety disorders: results from the Netherlands study of depression and anxiety (NESDA). J Affect Disord. 2011;133:76–85. <a href="https://doi.org/10.1016/j.jad.2011.03.027" data-track="click_references" data-track-action="external reference" data-track-value="external reference" data-track-label="10.1016/j.jad.2011.03.027">https://doi.org/10.1016/j.jad.2011.03.027</a>
Taylor JH, Jakubovski E, Bloch MH. Predictors of anxiety recurrence in the coordinated anxiety learning and management (CALM) trial. J Psychiatr Res. 2015;65:154–65. <a href="https://doi.org/10.1016/j.jpsychires.2015.03.020" data-track="click_references" data-track-action="external reference" data-track-value="external reference" data-track-label="10.1016/j.jpsychires.2015.03.020">https://doi.org/10.1016/j.jpsychires.2015.03.020</a>
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This study is funded by SIA-RAAK: The Taskforce for Applied Research
part of the Netherlands Organisation for Scientific Research (NWO)
the datasets used and/or analysed during the current study will be available from the corresponding author
Esther Krijnen-de Bruin &amp; Berno van Meijel
Amsterdam Public Health research institute
GGZ inGeest Specialized Mental Health Care
Faculty of Behavioural and Movement Sciences
Department of General Practice &amp; Elderly Care Medicine
GGZ-VS Academy for Masters in Advanced Nursing Practice
AvS and BvM obtained funding for this study
AvB and BvM contributed to the design of the study
AM and BvM coordinated the recruitment of mental health professionals and patients and the data collection
AH performed the sample size calculation and advised in quantitative data analysis
All authors revised and commented on the manuscript
All authors read and approved the final manuscript
The Medical Ethics Committee of the VU University Medical Centre confirmed that the “Medical Research Involving Human Subjects ACT” (WMO) does not apply to this study (registration number 2016.280)
and gave their permission for the execution of the study
The Scientific Research Committee of GGZ inGeest Mental Health Organization approved the research proposal (CWO 2016–023)
Informed consent will be obtained from participants via an online form for the quantitative data
and a separate written informed consent form for the qualitative interviews
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Conclusion: Harnessing active ingredients that target the mechanisms of change “increasing self-efficacy” and “arguing oneself into change” is a good MI strategy for smoking cessation, because it addresses the ambivalence of a patient toward his/her ability to quit, while, after the actual cessation, maintaining the feeling of urgency to persist in not smoking in the patient.
Volume 12 - 2021 | <a class="ArticleLayoutHeader__info__doi" href="https://doi.org/10.3389/fpsyg.2021.599203">https://doi.org/10.3389/fpsyg.2021.599203</a>
Background: For patients with coronary artery disease (CAD)
smoking is an important risk factor for the recurrence of a cardiovascular event
Motivational interviewing (MI) may increase the motivation of the smokers to stop smoking
Data on MI for smoking cessation in patients with CAD are limited
and the active ingredients and working mechanisms of MI in smoking cessation are largely unknown
this study was designed to explore active ingredients and working mechanisms of MI for smoking cessation in smokers with CAD
Methods: We conducted a qualitative multiple case study of 24 patients with CAD who participated in a randomized trial on lifestyle change
One hundred and nine audio-recorded MI sessions were coded with a combination of the sequential code for observing process exchanges (SCOPE) and the motivational interviewing skill code (MISC)
The analysis of the cases consisted of three phases: single case analysis
we calculated the transition probabilities between the use of MI techniques by the coaches and the subsequent patient statements concerning smoking cessation
we observed ingredients that appeared to activate the mechanisms of change
Active ingredients were compositions of behaviors of the coaches (e.g.
supporting self-efficacy and supporting autonomy) and patient reactions (e.g.
in-depth self-exploration and change talk)
interacting over large parts of an MI session
The composition of active ingredients differed among cases
as the patient process and the MI-coaching strategy differed
change talk and self-efficacy appeared to stimulate the mechanisms of change &#x0201C;arguing oneself into change&#x0201D; and &#x0201C;increasing self-efficacy/confidence.&#x0201D;
Conclusion: Harnessing active ingredients that target the mechanisms of change &#x0201C;increasing self-efficacy&#x0201D; and &#x0201C;arguing oneself into change&#x0201D; is a good MI strategy for smoking cessation
because it addresses the ambivalence of a patient toward his/her ability to quit
maintaining the feeling of urgency to persist in not smoking in the patient
NRT only 24%; absolute risk reduction (ARR) = 0.04; 95% CI &#x02212;0.06 to 0.14]
MI may be effective for smoking cessation in patients with CAD
but the research on MI in this patient group is scarce and inconclusive
Overview of randomized trials of MI on smoking cessation in patients with CAD
<a href="#B45">Nock (2007)</a> describes the components of psychological interventions for behavior change (<a href="#T2">Table 2</a>)
behavior change is brought about by the mechanisms of change of the intervention
these mechanisms of change are psychological processes
These processes are caused by active ingredients
and the active ingredients consist of specific clinician and client factors and their interaction
The current study aimed to explore active ingredients and mechanisms of change in MI coaching for smoking cessation in patients with CAD
shortly after they had experienced a cardiac event
we focused on the following questions: (1) Which clinician factors do the coach use
(2) Which client factors are activated by the clinician factors
(3) Does the interaction of clinician factors and client factors lead to a mechanism of change
and (4) Is MI quality related to the use of active ingredients
Model of hypothetical active ingredients and mechanisms of change in MI
One of these lifestyle programs was an MI-based telephone coaching intervention for smoking cessation
performed by the coaches of Luchtsignaal&#x000AE;
Patients who reported to be smokers in the 6 months period before hospital admission were offered the option to enter this program
The Luchtsignaal intervention consists of a maximum of seven MI-based counseling sessions
to coach the patient to stop smoking and to persist in not smoking
The Luchtsignaal coaches used an MI-coaching manual
which describes suggestions for the content of the MI sessions
The manual suggests that the first session should last about 30 min
the MI coaches are encouraged to tune the content and the session duration to the individual patient process
The four Luchtsignaal coaches (two psychologists
and a social worker) were experienced MI coaches
Since we wanted to analyze the MI process within and across sessions
we set three available sessions as the minimum to observe this process
we included cases if at least three sessions had been audio recorded
Written informed consent was obtained from all patients at entry in the RESPONSE-2 study
This included consent to record conversations
The investigation was approved by the Medical Ethics Committee (Amsterdam UMC
we discussed and solved any coding dilemmas
We recoded a random selection of 10% of the sessions (11 sessions) to assess intra-rater agreement
and we independently double coded a random selection of 20% of the sessions (22 sessions) for inter-rater agreement (intra-rater agreement: Kappa behavior codes = 0.80; inter-rater agreement: Kappa behavior codes = 0.82)
a difference of zero or one point on the 7-point scales was considered as agreement or disagreement
the scores were dichotomized as &#x0201C;agreement&#x0201D; and &#x0201C;disagreement&#x0201D; (intra-rater agreement: Kappa global ratings = 1.0; inter-rater agreement: Kappa global ratings = 0.97)
we composed a second worksheet based on our model of hypothetical active ingredients and mechanisms of change
Two co-authors (CL and BvM) verified these steps and checked the decisions made during data analysis
and another co-author (MS) independently double analyzed two cases to check the repeatability of the findings
we checked the original data to resolve the disagreement
All coders and all persons involved in the qualitative analysis were blinded for the outcome &#x0201C;smoking status at 12 months after baseline.&#x0201D;
In the RESPONSE-2 trial (<a href="#B39">Minneboo et al., 2017</a>)
the smoking status of the patients was assessed at baseline and after 12 months
using a urinary cotinine test (UltiMed one step
the Netherlands; detection limit 200 ng/ml)
based on an emerging pattern of smoking cessation in cases in which one or more of the mechanisms of change in MI were observed
we calculated the risk ratio post hoc to verify this possible association
Characteristics of smoking behavior and ambivalence
this part of the &#x0201C;Results&#x0201D; section deals with the question of whether these factors and mechanisms occur in the MI sessions
The next part of the &#x0201C;Results&#x0201D; section is about how the MI coach applies these factors to stimulate active ingredients and mechanisms of change
we first describe the use of MI-conversational techniques and then the MI strategy of the coaches in the four MI processes (engaging
we will relate the occurrence of active ingredients to delivered MI quality
Hypothetical active ingredients (clinician factors and client factors)
and mechanisms of change in 109 MI sessions
Mechanisms of change were mostly preceded by an interaction between a variety of clinician factors and client factors
Example of a clue for the mechanism of change &#x0201C;arguing oneself into change.&#x0201D;
Patient: &#x0201C;Smoking can cause a lot of damage
there was a man with something on his heart valves
it makes you think this could also have happened you know.&#x0201D;
Patient: &#x0201C;He smokes too and things like that
Coach: &#x0201C;What could have happened&#x02026;&#x0201D;
his phone was downstairs and not beside his bed
but shortage of breath and things like that
Coach: &#x0201C;It could have been me.&#x0201D;
but if you&#x00027;re upstairs and your telephone is downstairs
Coach: &#x0201C;What made it so emotional for you?&#x0201D;
Patient: &#x0201C;That something like this may happen
Coach: &#x0201C;The vulnerability.&#x0201D;
Coach: &#x0201C;It&#x00027;s a bit like what happened to you.&#x0201D;
you have to make decisions like to continue living your old life or start living a new life
but let&#x00027;s say I&#x00027;ll have to stay a bit away from food and tasty things
Coach: &#x0201C;It&#x00027;s worth a lot to you actually
it is important for you to stay around.&#x0201D;
Coach: &#x0201C;You&#x00027;re making all sorts of adjustments.&#x0201D;
you won&#x00027;t be around anymore.&#x0201D;
Coach: &#x0201C;So your confidence in not having a cigarette is higher than last time
but if someone would stand in front of me offering me a cigarette
Coach: &#x0201C;So when you think about smoking
you&#x00027;re able to handle this quite well
which makes you trust you won&#x00027;t relapse.&#x0201D;
Patient: &#x0201C;No I won&#x00027;t fall back
but I&#x00027;m 99% sure that I will not have a cigarette
we did not observe clues for a mechanism of change
and there may have been clues for the mechanisms of change in these missing sessions
In the three cases with audio recordings of all sessions
the coaching was prematurely finished before the intervention had been completed
We describe two levels of the applications of the active ingredients of the coaches
The first level is the level of &#x0201C;which conversational techniques do evoke change talk on smoking cessation?&#x0201D; On the second level
we elaborate on the MI strategies of the coaches to trigger the mechanisms of change
Transition probabilitiesab of patient statements following a coach statement
To provide insight on the MI strategy of the coaches
we describe how the MI coaches applied the active ingredients in the MI-processes: engaging
The coach persisted in talking about a subject the patient preferred to avoid
The coach starts the session by asking how things are going
actually,&#x0201D; and continues talking about her holidays
The coach takes the subject back to smoking:
but last time you said: &#x02018;It&#x00027;s going very well.&#x02019; Is that a coincidence
it has not really changed specifically.&#x0201D;
how would you describe more precisely how things are going now?&#x0201D;
if you take it specifically back to not smoking
I may be not as entirely motivated as I was at the start
Coach: &#x0201C;The motivation dips a bit.&#x0201D;
But I don&#x00027;t think it takes a lot of effort not to
it&#x00027;s not an effort not to.&#x0201D;
Coach: &#x0201C;Is it also an intention not to
or has it become an intention to &#x02018;rather not
I&#x00027;ll have a puff&#x02019;?&#x0201D;
it didn&#x00027;t really do something for me
The conversation continues why these puffs may have happened
The coach asks the patient to indicate how she perceives the importance of not smoking as a mark on a ruler from 1 to 10
Patient: &#x0201C;Definitely a high number
Coach: &#x0201C;In the first session it was a 9.&#x0201D;
Well you wrote it down and I don&#x00027;t remember
Coach: &#x0201C;That&#x00027;s why you&#x00027;re less concerned with the why of smoking cessation.&#x0201D;
Patient: &#x0201C;I also put on some weight
my weight shows that I stopped smoking.&#x0201D;
Coach: &#x0201C;You&#x00027;re not smoking
(&#x02026;) Coming back to your motivation
what are the main reasons for a high number
What are the things that you think &#x02018;yes
that is why I stopped smoking.&#x02019;?&#x0201D;
(The patient responds talking about her motives for smoking cessation.)
Influencing patient sense making; fragments of good MI
the coach ensures the change goal to be central to the conversation
We observed weak guidance from the coach in 19 sessions
which was expressed in superficial conversations with a question-answer pattern
giving too much information and advice not linked to the concerns of the patient
focusing on importance while the concern of the patient was about ability
The effect of weak guidance was visible in a lack of effective use of clinician factors
resulting in the absence of relevant client factors and a lack of progress in the thought processes of the patient on smoking cessation
resulting in a failure to activate relevant client factors
the insufficient evocation seemed to be related to the needs and choices of the patient
one patient wanted to find in-depth psychological reasons for his smoking behavior
and another patient chose to prioritize weight loss as the target behavior instead of smoking cessation
Examples of good (a) and weak (b) evocation
apart from you saying &#x02018;I can smell much better&#x02019;?&#x0201D;
and less-at long last-less stress and things like that.&#x0201D;
Coach: &#x0201C;You sense that you&#x00027;ve calmed&#x02026;&#x0201D;
and then I think I don&#x00027;t have that anymore
Coach: &#x0201C;No complicated maneuverings for a quick smoke.&#x0201D;
Patient: &#x0201C;All just for a quick smoke
it kept me kind of occupied: when will I stand up and smoke
Coach: &#x0201C;It is kind of funny that you experience that
many people feel that smoking makes them relax
but you say actually it is much more relaxed not to smoke.&#x0201D;
you kind of started saying like it also has benefits.&#x0201D;
are there other things you&#x02026;?&#x0201D;
because they know why I&#x00027;ve stopped
and they&#x00027;ve seen how hard it has been for me
you feel you&#x00027;re a much better role model
Coach: &#x0201C;Do you still know why you stopped
Coach: &#x0201C;Especially your heart.&#x0201D;
Most patients related their desire to quit smoking to an important value
Sometimes a family member was mentioned as an important value: &#x0201C;I want to stop for my children.&#x0201D; In a few occasions
the coach elaborated on these values and supported the patient to engage in a more in-depth exploration of the relationship between these values and smoking (client factors &#x0201C;in-depth self-exploration&#x0201D; and &#x0201C;experiencing discrepancy&#x0201D;)
in situations where the health of the patient was discussed
the coaches tended to give information on the physical effects of smoking
leaving the chance of activating these client factors unused
Providing the patient with information played an important role in the sessions
Well-timed- and well-provided information can evoke client factors concerning the sense making of
it is important to provide only these pieces of information the patient wants and needs
This went well when the coach only provided information if the patient explicitly or implicitly permitted the coach to give this information
after which the coach provided the information in clear language and in small amounts
the coach should inquire after the understanding and interpretation of the information by the patient
The absence of this inquiry about the interpretation by the patient was the most common shortcoming in the information exchange
followed by providing too much information at once and providing unsolicited information
These shortcomings impeded activation of relevant client factors and limited the absorption of the essence of the information by the patient
the patient and the coach determined a stop date for smoking
the coach provided user instructions for NRT or varenicline
the coaches enquired after difficult (typical) smoking situations
an explicit activity or coping plan was made
Number of observed clues for mechanisms of change
In this small sample, we found an association between the observed clues for the mechanisms of change and the smoking status of the patient at 12 months (<a href="#T10">Table 10</a>)
with the probability to stop smoking increasing from 20 to 72%
We decided post hoc to calculate the risk ratio of smoking cessation of patients who had exhibited a mechanism of change and found the risk ratio to be 3.6 (95% CI 0.99&#x02013;12.22)
This can be an indication that the MI quality may be related to the application of active ingredients and
As shown in the columns of the summary scores (<a href="#T10">Table 10</a>: columns 4&#x02013;8), coaches asked more closed questions than open questions in the majority of the cases, but they performed very well in offering complex reflections (i.e., reflections that add meaning or emphasis to what the patient has said; <a href="#B36">Miller and Rollnick, 2013</a>)
the quality of the MI delivered was sufficient to good
in which the MI quality was insufficient (Cases 2
We observed many clues for mechanisms of change, clinician factors, and client factors in two of the three cases in which the summary scores indicate insufficient MI quality (<a href="#T10">Table 10</a>
In this sample of 24 cases (109 MI sessions)
we did not see clear patterns linking the application of clinician factors and the appearance of client factors and of clues for the mechanisms of change to the summary scores of the coaches
we explored the components of effective MI for smoking cessation in patients with CAD
We systematically searched for active ingredients (i.e.
clinician factors and client factors and their interactions) and subsequent clues for mechanisms of change
the coaches used eight out of nine clinician factors
None of the coaches employed the ninth clinician factor &#x0201C;creating a change plan,&#x0201D; while this factor is intended to target the self-efficacy of the patient
the (preparations for the) actual smoking cessation
and the coping with difficult smoking situations afterward
often were conversational topics in anticipation of these situations
were restricted to general activity and coping strategies
and they never reached the status of a concrete plan with goals
and concrete coping strategies for potential barriers to remain non-smoking
We observed that the majority of the patients felt ambivalent about their ability to stop smoking
and some patients were also ambivalent about their willingness to stop
This means that a MI strategy directed at the mechanisms of change &#x0201C;increasing self-efficacy&#x0201D; and &#x0201C;arguing oneself into change&#x0201D; seems a good fit for MI coaching for smoking cessation in patients with CAD
Though the clinician factors almost always activated one or more client factors, the interactions between these factors that turn them into active ingredients require a more extensive and more comprehensive strategy, and is more complex, than the mere application of a clinician factor followed by a client factor. For instance, the conversation in <a href="#Box3">Box 3</a> is a good example
There are many clinician factors (trusting relationship/empathy
and supporting autonomy) and many client factors (experiencing a safe environment/opening up
and resolving ambivalence) involved in that conversation
All these factors interacted and became an active ingredient
which activated the mechanism of change &#x0201C;arguing oneself into change.&#x0201D; This means that the activation of a mechanism of change depends on the tailoring of the MI strategy of the coaches to the individual patient process
Many clinician factors and client factors are involved and interact during a larger part of the session or consecutive sessions
the same clinician and client factors did not become an active ingredient
probably due to differences in (among other things) the patient process
we found many clues for the mechanisms of change &#x0201C;arguing oneself into change,&#x0201D; a few for &#x0201C;increasing motivation to change&#x0201D; and one clue for &#x0201C;changing self-perception,&#x0201D; but no clues for &#x0201C;increasing self-efficacy/confidence.&#x0201D; It is plausible that self-efficacy plays a more important role in decreasing alcohol use and in smoking cessation than in medication adherence
we only call (combinations of) clinician factors and client factors &#x0201C;active ingredients&#x0201D; if and when it activates a mechanism of change
we found that the active ingredients comprised a complex interaction
depending on the patient (and maybe also on the coach)
different combinations of clinician and client factors constituted the active ingredients
there seem to be no fixed active ingredients
but the active ingredients seem more fluid and personalized
though it is difficult to determine the exact characteristics of &#x0201C;good MI,&#x0201D; the presence of active ingredients may be a candidate characteristic
there appears to be an association between the patient outcome (smoking status at 12 months) and the presence of observed clues of the mechanisms of change
the sample size of this qualitative study is very small
and the study was not designed to detect such a relationship
we regard this finding as a stimulus for further investigation only
This study attempts to open the &#x0201C;black box&#x0201D; of MI counseling for smoking cessation in patients with CAD
We obtained rich qualitative data on both patient and coach processes to strengthen motivation and commitment for smoking cessation
and we identified two important mechanisms of change in MI for smoking cessation in patients with CAD
This study also addresses an important problem for complex behavioral interventions
namely uncertainty of the exact content of the intervention delivered
Using both quantitative and qualitative research methods
we analyzed in detail both the content and the process of the MI sessions
This made it possible to study the complex interaction between clinician and client factors and the activation of the mechanisms of change
This kind of knowledge is important to understand and enhance the application of MI
our findings add to the debate on what characterizes &#x0201C;good MI.&#x0201D; We identified some shortcomings of the summary scores as a stand-alone criterion for &#x0201C;good MI,&#x0201D; and argue that the presence of active ingredients should be considered as an appropriate addition to the current criteria
An important limitation is that 27.8% of the sessions were not audiotaped; thus they were not available for analysis
The reasons for not audiotaping these sessions were not recorded
There was no documented refusal of permission to record the session
The Luchtsignaal coaches function in a community-based lifestyle program
they coach many people on smoking cessation
Recording these sessions is not part of their routine
and some coaches mentioned that they forgot to record some of the sessions
A likely explanation for the unrecorded sessions is
that the coaches forgot to record the sessions
This limitation forces us to be prudent in interpreting the data of the incomplete cases
especially concerning the presence or absence of active ingredients and mechanisms of change in some of these cases
the analysis of the transition probabilities using GSEQ 5.1 combines all patient statements in one pool
these statements are clustered in 24 coach&#x02013;patient relations
we calculated only the probability of patient change talk and sustain talk immediately following the statements of the coach (lag = 1)
it is likely that the effects of many statements of the coach will last longer
Another limitation is that we did not study the relation between active ingredients, mechanism of change, and the actual smoking status at 12 months. This means that we only took a small step by showing the actual presence of active ingredients and mechanisms of change. For causality, many other steps have to be taken (<a href="#B20">Hill, 1965</a>; <a href="#B21">Kazdin and Nock, 2003</a>; <a href="#B45">Nock, 2007</a>): the right temporal relation
Most active ingredients were observed when the coach adapted his/her MI strategy to the individual patient process of change
This created the possibility of several clinician and client factors to interact in such a way that they form an active ingredient and activate a mechanism of change
The combination of targeting the mechanisms of change &#x0201C;increasing self-efficacy&#x0201D; and &#x0201C;arguing oneself into change&#x0201D; seems a good MI strategy in coaching patients with CAD for smoking cessation
This helps patients to solve their ambivalence about their ability to quit smoking and also strengthen the willingness of the patient to quit
There is more to good quality MI than a trusting relationship and the application of MI-consistent conversational techniques
Although these certainly are prerequisites for effective MI
the presence or absence of active ingredients should also be taken into account
Parts of the dataset generated and analyzed for this study can be found in the Figshare repository: <a href="https://doi.org/10.21943/auas.10265054.v1">https://doi.org/10.21943/auas.10265054.v1</a>
Parts of the datasets generated and analyzed during the current study are not publicly available due to identifying patient information
Data may be available from the corresponding author upon request
but restrictions apply on the availability of these data in accordance with the ethical rules of the Medical Ethical Committee of the Amsterdam UMC
The studies involving human participants were reviewed and approved by the Medical Ethics Committee of the Amsterdam UMC
The patients/participants provided their written informed consent to participate in this study
and BM contributed to the study design and participated in writing the manuscript
This work was supported by a research grant from the Netherlands Organisation for Scientific Research (NWO) to JD
The authors are grateful to Luchtsignaal and the coaches of Luchtsignaal for making MI sessions available for analysis in our study
We also would like to thank the coders in this study
as well as Grace Jenkins for her supportive and constructive comments on our English language use
The Supplementary Material for this article can be found online at: <a href="https://www.frontiersin.org/articles/10.3389/fpsyg.2021.599203/full#supplementary-material">https://www.frontiersin.org/articles/10.3389/fpsyg.2021.599203/full#supplementary-material</a>
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Received: 23 September 2020; Accepted: 18 May 2021; Published: 22 June 2021
Copyright &#x000A9; 2021 Dobber, Snaterse, Latour, Peters, ter Riet, Scholte op Reimer, de Haan and van Meijel. This is an open-access article distributed under the terms of the <a rel="license" href="http://creativecommons.org/licenses/by/4.0/" target="_blank">Creative Commons Attribution License (CC BY)</a>
&#x0002A;Correspondence: Jos Dobber, <a id="encmail">ai50LnAuZG9iYmVyQGh2YS5ubA==</a>
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There is still limited evidence on the effectiveness and implementation of smoking cessation interventions for people with severe mental illness (SMI) in Dutch outpatient psychiatric settings. The present study aimed to establish expert consensus on the core components and strategies to optimise practical implementation of a smoking cessation intervention for people treated by Flexible Assertive Community Treatment (FACT) teams in the Netherlands.
A modified Delphi method was applied to reach consensus on three core components (behavioural counselling, pharmacological treatment and peer support) of the intervention. The Delphi panel comprised five experts with different professional backgrounds. We proposed a first intervention concept. The panel critically examined the evolving concept in three iterative rounds of 90 min each. Responses were recorded, transcribed verbatim and thematically analysed.
This study provides insight into expert consensus on the core components of a smoking cessation intervention for people with SMI. The results of this study were used for the development of a comprehensive smoking cessation program.
Volume 13 - 2022 | <a class="ArticleLayoutHeader__info__doi" href="https://doi.org/10.3389/fpsyt.2022.866779">https://doi.org/10.3389/fpsyt.2022.866779</a>
Background: There is still limited evidence on the effectiveness and implementation of smoking cessation interventions for people with severe mental illness (SMI) in Dutch outpatient psychiatric settings
The present study aimed to establish expert consensus on the core components and strategies to optimise practical implementation of a smoking cessation intervention for people treated by Flexible Assertive Community Treatment (FACT) teams in the Netherlands
Design: A modified Delphi method was applied to reach consensus on three core components (behavioural counselling
pharmacological treatment and peer support) of the intervention
The Delphi panel comprised five experts with different professional backgrounds
The panel critically examined the evolving concept in three iterative rounds of 90 min each
transcribed verbatim and thematically analysed
results yielded that behavioural counselling should focus on preparation for smoking cessation
Pharmacological treatment consisting of nicotine replacement therapy (NRT)
The panel agreed on integrating peer support as a regular part of the intervention
thus fostering emotional and practical support among patients
Treatment of a co-morbid cannabis use disorder needs to be integrated into the intervention if indicated
staff&#x00027;s motivation to support smoking cessation was considered essential
two mental health care professionals will have a central role in delivering the intervention
Conclusions: This study provides insight into expert consensus on the core components of a smoking cessation intervention for people with SMI
The results of this study were used for the development of a comprehensive smoking cessation program
these different notions are possible explanations for the very prevalent co-occurrence of smoking and SMI and describe mechanisms that cause and maintain tobacco addiction
A couple of notions may have impeded the collective process of critically evaluating the association between smoking on the one hand
somatic health and quality of life on the other hand: health care professionals&#x00027; view that smoking may be helpful for people with SMI and therapeutic pessimism regarding both general treatment outcomes and opportunities for successfully quitting smoking
In recent years, the Netherlands, among other countries, has introduced new policy measures to raise awareness regarding the negative impact of tobacco use, and a smoking ban in public areas, including mental health care institutions. As a result of these developments, there is a need for more evidence-based interventions for smoking cessation in mental health care settings (<a href="#B16">16</a>, <a href="#B17">17</a>)
Peer support appears to be particularly relevant in the present population
in which persons often have small social networks
A previous clinical trial on the treatment of tobacco addiction in psychiatric patients, showed that using a combination of these components was superior to care as usual (<a href="#B26">26</a>, <a href="#B27">27</a>)
Despite basic knowledge of the core components of a smoking cessation intervention for patients with SMI
there is a need for additional insights into the specific content of these components (following the most recent practical and scientific knowledge)
on how to better tailor these to the needs of this population
and how to effectively implement them in Dutch mental health care
this is the first study that aims to identify and reach consensus about the structure and content of a smoking cessation intervention offered to people with severe mental illness in an outpatient clinical setting in the Netherlands
We conducted a modified three-round Delphi study with five experts on smoking cessation, with different expertise and backgrounds (<a href="#B29">29</a>). In light of the ongoing COVID-19 pandemic, all rounds were held online via videoconferencing software <a href="https://Zoom.us">Zoom.us</a> between December 2020 and February 2021. Using Zoom for qualitative research is well-accepted and perceived as convenient by researchers and participants (<a href="#B30">30</a>)
We selected five experts aged between 31 and 64
Number of years of experience with treating tobacco addiction in people with SMI ranged from 3 to 10 years
Participants were recruited through the researchers&#x00027; professional networks
Considering that mental health care nurses working in ambulatory mental health teams will be delivering the intervention
we included two clinical nurse specialists with ample clinical experience with smoking cessation among SMI patients
To ensure the incorporation of clients&#x00027; perspectives we included an expert-by-experience
We also included a practising physician/researcher
with comprehensive clinical and research experience on smoking cessation and early psychosis
a senior project leader and consultant of tobacco regulation in mental health care in the Netherlands was included
The overall aim during all three rounds was to reach consensus about the composition of the three central components of the smoking cessation intervention
and strategies to optimise implementation in clinical practise
Participants were invited and informed through an electronic invitation letter
were semi-structured and recorded for analysis
MK prepared the Delphi procedures and processed all responses
To compensate for two participants&#x00027; absence during the group interviews on two occasions
individual interviews were conducted with three of the researchers (TH
BvM moderated the panel sessions while MA moderated the two individual sessions
participants received three documents for preparation:
An overview of the procedures of the Delphi study
as well as a description of what participation in the panel entails
2. The smoking cessation intervention concept describing propositional components and elements of the intervention, including their rationale, theoretical background and context (<a href="#B31">31</a>)
3. Nine open-ended questions to stimulate general feedback on the first concept version (see <a href="#h12">Supplementary Material</a> Interview Guide)
Responses to the open-ended questions were received through e-mail from each participant before the first panel session. In summary, the structure of the three rounds was as follows (see also <a href="#F1">Figure 1</a>):
Round 1: Each question (n = 9) and participants&#x00027; responses were reviewed and discussed
The experts&#x00027; contributions of the first round were then thematically summarised
The focus during this round was on the general structure of the intervention program
Round 2: Participants received 14 new questions based on preliminary outcomes from round 1
Participants also received a new draught of the intervention concept based on the first round
Responses to the 14 open-ended questions were deliberated during round 2
The specific focus during this second round was on the use of e-cigarettes
and the involvement of peers and family members
Round 3: Participants received an overview with preliminary conclusions drawn from the first two rounds and 12 final open questions
on the ratio of individual and group behavioural support
concrete guidelines for pharmacological treatment and how to deal with comorbid cannabis use disorder
Flowchart of the three-round Delphi procedure
Differences in opinions were regarded as opportunities to explore these discrepancies and find compromise for the intervention design and its implementation
and points of disagreement were the starting point for the next round
the panel received a definitive version of the intervention
The panel reached eventual consensus through negotiation
taking into consideration the expected effectiveness of the component
treatment possibilities of clinical staff and practical conditions for implementation in psychiatric institutions
We obtained consent for video and audio recordings beforehand from all participants
Monetary compensation of 1,100 euros for preparation and participation in all three rounds was offered
which participants received after the last round
Thematic analysis was applied (<a href="#B32">32</a>)
Two authors (MK and LJ) transcribed all audio recordings verbatim
The authors familiarised themselves with the data by listening to the interviews
As there was already a predefined intervention concept
Behavioural counselling based on CBT and MI techniques; 2
Peer support) and aspects of practical implementation were defined as an initial framework before coding
the research team reviewed the generated themes and discussed discrepancies if needed
The initial phase of behavioural counselling prepares the patient for the actual quitting moment through psycho-education
assessment of motivation to quit and identification of individual support needs
Although individual counselling was regarded as therapeutically effective and should be actively suggested to patients
there was consensus among the experts to offer group sessions per default once a week
For reasons of limited staff capacity within clinical teams
individual consults are available upon demand
The panel also noted that group sessions could strengthen patients&#x00027; social connectedness and that motivation to quit smoking was enhanced by mutual contacts within the group of patients
This aspect can be additionally reinforced by peer support meetings
such as cognitive overstimulation and concentration problems
should be taken into consideration by introducing sufficient breaks and facilitating new content with
all participants agreed to emphasise relapse prevention and normalisation of relapse as well as the differentiation between relapse and &#x0201C;slips.&#x0201D; While &#x0201C;slips&#x0201D; refer to a momentary give-in to craving (e.g.
relapse entails returning to a regular smoking pattern similar or identical to before quitting
Relapse and &#x0201C;slips&#x0201D; need to be addressed explicitly as common parts in overcoming addiction and therefore un-labelling them as a failure
This may be particularly important to reduce feelings of shame
prevent a decrease or total loss of motivation to quit and promote a more flexible approach to smoking cessation in both patients and clinical staff
Experts agreed and recommended a relapse prevention plan for each patient
addressing personal challenges and risk factors for &#x0201C;slips&#x0201D; and relapse
External and internal triggers such as friends/relatives smoking
stress and exacerbation of psychiatric symptoms
These should be discussed with the patient and used as a starting point to formulate &#x0201C;emergency measures,&#x0201D; i.e.
(preventive) actions to be undertaken in case of confrontation with these triggers
Finding new ways to deal with stress and replacing smoking with other stress-relieving activities is especially relevant in the light of emotion dysregulation
depression and potentially decreased tolerance to stress associated with severe mental illness
Participants agreed that medication should be proactively offered to patients in the initial phase to increase chances for successful quitting. Current international guidelines for pharmacological treatment for smoking cessation recommend nicotine replacement therapy (NRT), Varenicline and Bupropion (<a href="#B31">31</a>)
all participants preferred Varenicline and NRT related to their higher effectiveness and fewer side effects
there was agreement about not including mouth spray and inhalators for administering nicotine fast through the mucous membranes and hence potential dependency
Participants did not recommend Bupropion as a first-choice medication because of more side effects and interactions with certain anti-depressants and anti-psychotic medication (e.g.
A psychiatrist with comprehensive knowledge of psychopharmaca and smoking cessation medication needs to supervise medication use
The panel also emphasised the importance of recognising that smoking interferes with the metabolism of some antipsychotic medication by enzymes in liver cells
smokers need higher doses of antipsychotic medication
plasma levels need to be determined and medication dose should be adjusted accordingly to avoid strong side effects or unnecessary high levels of antipsychotic medication
The prospect to potentially reduce medication doses was regarded as an important motivating factor for patients
there was consensus about the importance of psycho-education about supportive medication so as to build up trust and willingness to use medication
there seems to be some reluctance towards medication for smoking cessation because of expected side effects
There was consensus about the relevance of peer support groups
it offers a safe space to exchange experiences
The participants pointed out the motivational role that a peer group can have when quitting to smoke
The panel considered it essential that the expert-by-experience supporting these group meetings had personal experience with mental illness and addiction in the past and should take a facilitating rather than a leading role
The expert-by-experience has the ability to share their own storey with some emotional distance and make room for patients&#x00027; experiences with an accepting and hopeful attitude
Topics during these meetings should be determined by the patients themselves
based on their actual experiences while participating in the smoking cessation program
frequency and duration of the treatment components
Final smoking cessation intervention concept
e-cigarettes have increasingly become an alternative way of nicotine intake
Advantages of e-cigarette use are their potential to reduce harm of combustible cigarettes
and the possibility of easily lowering nicotine dosages
e-cigarette use maintains the habit of smoking and oral fixation
which were described as serious threats to permanent quitting success
e-cigarette use can lead to possible long-term negative health effects
the panel reached consensus on the fact that e-cigarettes should not be actively promoted
proposed as a last resort for patients unresponsive to any treatment offered (i.e.
Cannabis use and the prevalence of cannabis use disorder is high among people with severe mental illness
It can both relieve and trigger psychiatric symptoms
There was agreement that cannabis use has to be treated simultaneously within this intervention since it is often consumed together with tobacco
smoking cannabis has the potential to maintain tobacco dependence at the same time
cannabis use is discouraged in consideration of its main compound tetrahydrocannabinol (THC)
Positive symptoms such as paranoid ideations
hallucinations and cognitive tendencies contributing to delusions and anxiety can be reinforced by THC
The panel acknowledged a potential subjective beneficial effect of cannabis (e.g.
If cannabis is indispensable for the patient
the aim will be to find alternative ways of consumption
Attention needs to be paid to the possibility that
the use of other substances may exacerbate or
mental health care professionals&#x00027; perception of and attitude towards smoking is decisive to the intervention&#x00027;s success
Participants reported treatment pessimism among clinical staff regarding the opportunities for smoking cessation of their patients
The panel supposed that pessimistic attitudes of staff about treatment success are related to increased relapse in this specific population
Such a pessimistic attitude can potentially be transferred&#x02014;implicitly through negligence and lack of support and explicitly through verbal expression of frustration or discouragement&#x02014;to the patient
tobacco addiction is often not included in the primary diagnosis by mental health care professionals
Such diagnostic omission can be an obstacle to offering a structured therapeutic trajectory for smoking cessation and hinder reimbursement for treatment costs from health insurances
mental health care professionals&#x00027; smoking behaviour is crucial for their motivation to address tobacco addiction with their patients and is also conditional for being a positive role model
the panel agreed to select clinical teams for the RCT based on their mind-set and determination about smoking cessation
Two clinical staff members should be appointed based on their motivation
and trained to be responsible for recruiting patients and delivering the smoking cessation intervention
While striving to tailor the intervention as much as possible to the patient&#x00027;s individual needs and personal circumstances
feasibility of its integration into daily clinical routine for clinical staff has to be considered carefully
which is in line with the panel&#x00027;s recommendations
introducing peer support on a regular basis could aid to empower patients during smoking cessation
it is a joint process of clinician and patient to negotiate among treatment goals
the treatment of tobacco dependence in individuals with AUD comes with specific challenges that are outside the scope of this intervention and should be tackled in a specially designed treatment
consensus on many aspects of the development and implementation of a smoking cessation program in people with SMI treated in outpatients clinical setting was reached
implementation in realistic clinical settings might still hold unexpected challenges
which will be assessed in a planned RCT subsequent to this study
participants were highly experienced and specialised in treating mental disorders and comorbid addiction or smoking
the semi-structured online sessions gave sufficient direction to gather the knowledge needed for the design of the intervention while also allowing new content to emerge
the results portray the complex interplay of physical
they can endorse a holistic approach to treatment within mental health care institutions and improve the quality of personalised care
there is already existing general consensus on the effective treatment components for smoking cessation
For specifying the contents of these components
an in-depth qualitative study with a smaller number of experts may be more suitable to yield data that can be translated into an intervention protocol
even though we included an expert-by-experience to integrate the perspectives from a former patient
we did not include a person who is currently in psychological treatment and is also a current smoker
The inclusion of the broad range of patients&#x00027; perspectives
which could have added unique content to the design and implementation of the intervention
we encouraged participants to integrate their knowledge and theory of mind about patients&#x00027; perspectives into their responses
a higher degree of heterogeneity regarding the cultural background of the participants could have increased the intervention&#x00027;s sensitivity for cultural differences in the present patient group
this study provides insight into expert opinions on the most relevant elements of the core components and implementation of a smoking cessation intervention for people with SMI treated by FACT teams in the Netherlands
Future research applying the Delphi method for the design of therapeutic interventions should ensure the inclusion of patients in the panel
The original contributions presented in the study are included in the article/<a href="#h12">Supplementary Material</a>
further inquiries can be directed to the corresponding author/s
MK and LJ processed all received responses
JV contributed intellectually to the final design of the intervention
All authors have read and approved the final manuscript
This work was supported by Stichting tot Steun VCVGZ and the Dutch Ministry of Health
Welfare and Sports (Grant Number 258): KISMET&#x02014;a smoking cessation intervention for people with severe mental illness
We thank all participants for their time and efforts
The Supplementary Material for this article can be found online at: <a href="https://www.frontiersin.org/articles/10.3389/fpsyt.2022.866779/full#supplementary-material">https://www.frontiersin.org/articles/10.3389/fpsyt.2022.866779/full#supplementary-material</a>
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Citation: K&#x000FC;&#x000E7;&#x000FC;kaksu MH
Adriaanse MC and van Meijel B (2022) Developing a Smoking Cessation Intervention for People With Severe Mental Illness Treated by Flexible Assertive Community Treatment Teams in the Netherlands: A Delphi Study
Received: 31 January 2022; Accepted: 16 June 2022; Published: 06 July 2022
Copyright &#x000A9; 2022 K&#x000FC;&#x000E7;&#x000FC;kaksu, Hoekstra, Jansen, Vermeulen, Adriaanse and van Meijel. This is an open-access article distributed under the terms of the <a rel="license" href="http://creativecommons.org/licenses/by/4.0/" target="_blank">Creative Commons Attribution License (CC BY)</a>
&#x0002A;Correspondence: M&#x000FC;ge H. K&#x000FC;&#x000E7;&#x000FC;kaksu, <a id="encmail">bS5rdWN1a2Frc3VAdnUubmw=</a>
“We listen to Irish music and drink Guinness every Friday
The Guinness toucan is seen in Geert&#x27;s home built Irish pub
Geert and Stephan enjoy some Guinness whilst on holiday
It took three years to build Geert&#x27;s Irish pub
Stephan&#x27;s Irish pub is equally impressive
Níall FeiritearSunday WorldThu 16 Mar 2023 at 19:49Geert Rooijakkers and his brother
are Dutch twins who love Ireland so much they built two incredible Irish pubs out their back gardens
Geert spoke to the Sunday World today from his home in Meijel
a town of 7,000 people approximately 25 Km from Eindhoven about their plans for St
we will have friends over and we’re going to drink Guinness and beers and enjoy the day,” said Mr Rooijakkers
The Dutch hero diligently spent many years collecting up souvenirs and trinkets of Irish culture from countries all around Europe
This has not been an easy task by any means
“We began building during summer three years ago
I collected from Ireland and marketplaces in Germany
“It is very difficult because items are expensive and rare to find
we go every year to Dublin for ten years now,” he said
Geert described what those trips mean to him and his brother and what they get up to
“We do Dublin from Monday to Friday when the pubs are not too busy
you see the problem in the Netherlands is it’s hard to get
Mr Rooijakkers also spoke about the banter they have in their home-made bars
the Fields of Athenry is my favourite song
we spend one Friday in his and one Friday in mine
“Maybe some darts but 90pc chat with the music
we’re 100 pc Dutch but we just love Ireland.”
The cool Dutch man also mentioned his favourite spots during his visits here
photos of us are rare but we take lots of photos of people and places
“Phil Lynott’s grave to visit and then Larry from U2 lives there- we are big fans,” Geert added
The Sunday World notes Mr Rooijakker’s passion for authentic Irish souvenirs
Geert can be contacted through the ‘Guinness Community’ on Facebook
or say hello to the twins on their next trip to Ireland
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By <a href="https://www.fruitnet.com/maura-maxwell/89.bio" rel="author">Maura Maxwell</a>2024-03-04T10:14:00+00:00
Pop Vriend Seeds joined forces with Tozer Ibérica recently to present its new spinach varieties to Spanish growers at a series of open days at Tozer’s Los Olivos trial farm in El Albujón
From its portfolio of almost 50 varieties of spinach
Pop Vriend highlighted three for the next season: Quartz
adapted to the winter of Murcia and with a total resistance to mildew
Pop Vriend presented its ‘Spinach 365’ programme
“With this programme we help producers to supply the same quality of leaf and in the desired quantities to supermarkets throughout the year
bringing greater consistency to supply,” said René van Meijel
The fight against downy mildew and other leaf spot diseases is another threat to spinach crops
To help producers understand their causes and improve the sustainability of crops
Pop Vriend presented its Spot Disease Kit Foliar
it seeks to effectively fight the disease by promoting a collaborative approach that helps develop better tolerances in its assortment of varieties
the Initio nutrient substrate was also present in the test field
Customers were able to see the benefits of this nutrient-rich coating
which provides a strong start to spinach crops
helping them achieve their full growth and yield potential
Initio is already applied to 40 per cent of European spinach orders
Pop Vriend is no longer organised by geographic regions but by client teams
Regional sales director José Carlos Grajeda said this reflected the fact that customer needs and the dynamics of the value chain are not limited by geographical borders
“The interesting debates that arose at the Murcia Open Days between baby leaf producers from different countries and specialists from around the world have shown us this,” he said
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The Youth team of Olympiacos emerged victorious again
defeating JK Tallinna Kalev 1-2 to advance to the third round of the Domestic Champions Path in the UEFA Youth League
With a strong lead from the first-leg score of 5-0
the “red-and-whites” effectively sealed their qualification in the first half
thanks to goals from Pnevmonidis in the 21st minute and Liatsikouras in the 35th
The home side managed only to narrow the gap
Olympiacos will face Trenčín from Slovakia in the next round
Trenčín progressed with two wins over Brno
The first match will be away on November 26
with the return leg scheduled at home on December 11
Olympiacos was relentless in their match against JK Tallinna Kalev
claiming a commanding 5–0 win at their Rentis training center in the first leg of the second round of the UEFA Youth League’s Domestic Champions Path
The young “red-and-white” European champions faced the Estonian side at home
securing a strong lead to advance to the next stage of the competition
Olympiacos opened the scoring through Yousouf after an assist from Papakanellos
who also set up Toufakis’ goal for the 2–0 in the 42’
and Yousouf rounding off the 5–0 victory in the 85th minute
Staffordshire golfer Richard Mansell has spoken of his immense pride over achieving a dream and potentially competing alongside &#x27;hero&#x27; Tiger Woods at the 150th Open
will not be heading to St Andrews after he agonisingly missed out in final qualifying
which took place across four venues this week
had already enjoyed a superb 2022 – achieving three top-10 finishes on the DP World Tour and playing in the US Open
he is heading to the home of golf after earning his place at Hollinwell on Tuesday
It means the former Chase Terrace pupil could mix it up with idol and 15-time major winner Woods
who has outlined his intention to play in Scotland from July 14 to 17
"It was a dream at the start of the year," said Mansell
"It makes me a little bit emotional thinking about it because today (qualifying at Hollinwell) was not easy
"I really didn't have my stuff and just had to grind all day
we were really hoping Tiger was going to be there just to play an event with him
"He's kind of said that he's going to be at St Andrews
you're hopeful you're just in the same event as your hero."
Mansell qualifies for the Open for the second year running
having also made it to the 149th Open at Royal St George's
where he got through to the weekend and finished in a tie for 74th with a six-over-par total
He finished one-under through two rounds at Hollinwell to clinch a spot at St Andrews – level with ex-Shropshire & Herefordshire junior Oliver Farr
will tee it up in the Open for the first time
Rai – T19 in last year's Open – will play no part in next month's event after being cruelly edged out in a three-man play-off at Fairmont St Andrews
The multiple DP World Tour winner and current PGA Tour player fell short against Holland's Lars Van Meijel and Alex Wrigley
The trio all finished two-under-par before the first extra play-off hole saw Rai card a bogey five while van Meijel and Wrigley both managed pars
saw his efforts to qualify this time around thwarted by injury
withdrew during his second round at Royal Lytham & St Annes with a hamstring issue
Staffordshire's Robert Rock failed to quality as he endured a tough day at Hollinwell
Walsall-born Paul Broadhurst bagged himself £88,000 in prize money as he finished tied seventh at the US Senior Open
The 56-year-old – who played in the 1991 Ryder Cup – finished on two-under-par and eight shots back of winner Padraig Harrington
This interview was published in the Dublin Horse Show Magazine in July 2019
DARRAGH Kenny is in the kitchen on the yard when I arrive in Meijel after the 40-minute drive from Eindhoven
It’s the Monday after his first European show of the summer in La Baule
where he finished third in yesterday’s five-star Grand Prix
“Oh hey Jude,” he says as I peak my head through the door and interrupt his lunchtime sandwich-making
We should have gotten you to bring some Irish teabags!”
It’s business as usual in his stable today
even if the American twang is sneaking through in Darragh’s
Balou du Reventon and Important de Muze are on their to Rome for the five-star Nations Cup after excellent performances in La Baule and Darragh is riding young horses
making plans with staff and seeing to issues in the yard
His father Michael is spotted doing jobs on the roof of one shed
while Darragh’s mother Catherine is on a well-deserved holiday
He bought the five-acre Dutch facility and home
which he shares with his girlfriend Jessica Mendoza
The Offaly native seems ahead of his 31 years
but it’s not that long ago since he was winning everything on the Irish circuit before leaving to try and ‘make it’ in America
He grew up at the beautiful Belmont House Stud and was coached all through his young career by his parents
they knew a lot more than I even realised,” he said
“I am very lucky that they are still involved
my father helps me with the farm a lot and my mum helps me with the training
She nearly does a better job with the training than me
so it’s quite enjoyable to have them around
Some days it’s not but most days it is,” he adds with a laugh and a nod to a normal parent-child relationship
It was winning a bursary at the Dublin Horse Show to train with Missy Clark and John Brennan in 2007
which should have given him the initial start in the US
it didn’t work out quite as planned when Kenny had a bad accident on the second day
“I always believe that things happen for a reason and everything is meant to be
and probably at that stage I was too young to even be there
I had a bad fall off a golf cart and ended up in intensive care
"I never actually even got to train with her
Two years later and the Irish were beginning to do big things in Wellington
When Darragh expressed an interest in “seeing the place”
Michael rang Missy and asked could he take up the bursary opportunity now
A week’s visit to her North Run Farm turned into three months and he was bitten by the bug
“I came home and spent the summer in Ireland
I had a lot of good horses and nice success and everything like that
but I realised at one point that if I really wanted to ride at the top level and be very successful
about the business in America and they were very very good to me
they always tried to put good horses underneath me and gave me a good chance.”
That partnership lasted almost five years and he relished every opportunity
first senior cap for Ireland and everything in between
It came to a natural end when Missy and Darragh were going in opposite directions and Oakland Stables was born in September 2012
“I remember I didn’t have so much money and it was a big step
I think for the first three months she worked she never even got paid
But it turned a corner and it got better and better and I was very lucky to have a few good clients and horses and it just kept improving.”
although the pair had done business together for many years
“I had a business partner who helped me start the business
and she then had kids and a family and got busy so we decided it would be better to separate the business and I took the main part of it and went forward
“I’ve been friends with Hardin for 10 years now
and we had already during that point probably owned about 10 horses together
so when they decided to go their separate ways it made the most amount of sense for us to do it together.”
Kenny has been lurking around the very top of the sport ever since his senior debut in 2010
despite losing a number of high profile owners and sponsors along the way
He laughs and cringes when telling the story of that debut
“I actually never even rode on a Division 2 Nations Cup
and I was only talking about this a few days ago when I was in La Baule
I jumped an oxer in the Nations Cup and you had to go around a big corner and there was about 20 strides to the water jump and I ended up jumping straight in the middle of it
His first championship came four years later at the World Equestrian Games in Normandy
The combination finished 12th individually
at a crucial time in the lead up to the Rio Olympic Games
Hyperion Stud took their horses away from Kenny
“We had a great relationship for a while and it worked very well
and then kind of…situations change and you have to move on
Imothep took me to levels I hadn’t been at – jumping in Aachen and on the team in Dublin
Darragh Kenny and Imothep at the 2014 World Equestrian Games in Normandy
Then along came Sans Soucis Z who helped him achieve one of his three lifelong goals when part of the winning Aga Khan team in 2015
I went through a period of time a few years ago where I was having a really difficult time with everything that was going on in my life
I had horses but I didn’t really have horses and I was struggling with it
I was struggling with the direction everything was going
I had a hard time of it,” he explained seriously
sitting back on the kitchen chair and thinking long and hard
“When I was young I had a very good friend of mine die
and then I kind of felt like you have to just ‘live life’ and everything like that
Then I had a really rough end of one year and one of my business partners and very good friends
was killed in a car crash and it just made me realise that
you have to achieve something with your life
It is not just about going out and enjoying it unless you’re not achieving something
“It made me really open my eyes and think ‘you’re being a complete idiot and you’re not thinking about anything’
"You really need to figure out what you’re going to do with your life and what you want from your life
“And I think that was a huge turning point for me in my career and my personal life
that moment definitely changed my life fully
yeah for sure I get upset when I have a bad round and I want it to go better but I just realised that I need to keep working for the next day,” he said with a passion that he hadn’t previously expressed
His attitude is now totally positive and he keeps bouncing back after each knock back
“You know I think … one thing that is good about me now is I always have a long-term outlook on everything
whatever…I think ‘I want to make this last as long as I possibly can’
“McLain (Ward) always talks about how the best riders in the world aren’t just the riders that can win on one horse but that can win on numerous different horses and stay at the top level for a very very long time
I don’t want to be somebody who in two years’ time nobody has ever heard of again
I want to be at the high level for years and years and be competitive
“I have some incredible owners and a few incredible clients right now
We have 25 horses who are under eight years old
we are always thinking about the next group of horses
and of course the Europeans is extremely important to us and it needs to happen and go well
but you also need to think about the future.”
The Europeans are indeed top of his priority list this year and although he is part of the Paris Panthers Global Champions League team
helping Team Ireland qualify for the Tokyo Olympic Games in to the forefront of his mind
Missing out on last September’s World Equestrian Games in Tryon after with selected with Babalou 41 was a big disappointment
“I will do whatever I can for the Global team and that is where I am in a good situation because I have plenty of horses
The horses I am going to aim for the Europeans aren’t going to have to do a lot of the Global shows
“Balou (du Reventon) would be my main aim for the Europeans
he has done amazing things the last year with me and it is only going to get better
We bought the horse in May last year and he was top five in five CSI5* Grands Prix last year and was fantastic in Shanghai earlier this year
My owner has just bought Important de Muze for me to keep
I am going to ride the horse through the Europeans and we will keep him there as a second back-up to Balou
I think he is well capable of doing that and well capable of doing a super job at a championship if needed
“And then probably the horse will be for sale again after the Europeans
but I want to be very strong in the horses that I have for a championship so we don’t miss out opportunity to go to the Olympics
I am very lucky that Ann (Thompson) also has the same thought process
she really wants us to go to the Olympics and for Ireland to do well,” he says about the owner of Balou
With two riders in Europe looking after the close to 25 young horses in his programme
Darragh wants to produce more youngsters himself
That is the direction the business is going
It is so hard to buy a Grand Prix horse or even to find one!”
He also breeds some foals “as a hobby” with William Funnell at the Billy Stud
they breed from them and we own them in partnership together
Currently ranked 17th in the world (at the time of writing)
Kenny is en route to achieving one of his short-term goals of being within the top 10 riders in the Longines world rankings by December
he entered the world's top 10 at number nine.]
At one point I would like to be number one in the world because I think that is a huge achievement
an Olympic medal is one of my biggest dreams; that is everybody’s biggest dream
And then I was lucky enough to win the Nations Cup in Dublin in 2015 and that was also one of the things I wanted to do in my career
I was lucky to have done it at a very young age and hopefully there will be a few more
my short term goal is to be in the top 10 before Geneva [in December]
I would really like to jump the top 10 final in Geneva.”
I remind him that his partner Jessica Mendoza has one up on him
having been travelling reserve for Britain at the 2016 Rio Olympic Games with Spirit T
and she constantly reminds me of that!” he laughs
There is no doubt that Darragh Kenny will give it everything to match that record
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A Polish driver convicted of killing a toddler and her grandparents in a hit-and-run accident in Meije
was given early release so he could return to Poland to be there when his girlfriend gives birth
CDA and VVD parliamentarians are outraged by the man's release
They call for the system for early release to be changed
and extradited to the Netherlands to serve his sentence
the man filed a request for a break in his punishment so that he could go home for the birth of his child
State Secretary Klaas Dijkhoff of Security and Justice advised against releasing the man
But the board of appeals for the Council of Criminal Justice decided to give the man early release as he complied with all the conditions thereof - for example
he already served more than half of his sentence
The council also ruled that the man was doubly punished due to the commotion in the media ans society. According to the council, the commotion and social unrest can't be blamed on the Polish man - it mainly arose because the Polish man was first given community service and one of the victims' relatives <a href="http://nltimes.nl/2016/08/24/polish-fugitive-extradited-netherlands-serve-sentence-fatal-accident/">threw a chair at the judge.</a>
A number of parliamentarians are outraged by this decision
VVD MP Foort van Oosten can understand the relatives disbelief
Dijkhoff "rightly tried to prevent early release" and this shows "that the system is not functioning properly and has to be changed"
CDA parliamentarian Madeleine van Toorenburg said
SP MP Michiel van Nispen called for the rules to be reconsidered for the future
The PVV called the matter a "big scandal" and MP Gidi Markuszower called for the Council to be "fired"
"Now perpetrators are being over protected and victims are abandoned."
Wilco Nienaber played his first competitive round after a long break and the 64 he posted was good enough to share the lead with Alexander Levy in Thursday’s first round of the SDC Open at the Zebula Country Club in Bela-Bela
Nienaber and Levy lead by one over England’s Chris Paisley and Tom Shadbolt
South Africa’s Malcolm Mitchell and Dutchman Lars van Meijel
Defending champion JJ Senekal opened with a round of level par 72
eagle and one bogey look fairly routine as he showed no signs of any competitive rust in setting the pace as the co-leader in this Sunshine Tour and European Challenge Tour co-sanctioned tournament
Wilco Nienaber is the new leader at the clubhouse. 📈<a href="https://twitter.com/hashtag/SDCOpen?src=hash&amp;ref_src=twsrc%5Etfw">#SDCOpen</a> | <a href="https://twitter.com/hashtag/SunshineTour?src=hash&amp;ref_src=twsrc%5Etfw">#SunshineTour</a> | <a href="https://twitter.com/hashtag/GreatnessBeginsHere?src=hash&amp;ref_src=twsrc%5Etfw">#GreatnessBeginsHere</a> <a href="https://t.co/o15s6XFNgZ">pic.twitter.com/o15s6XFNgZ</a>
Frenchman Levy joined him later in the day with a round that included six consecutive birdies
“I took a long break which was really good
I really tried to put the clubs away and rest
I struggled to do so for longer than two weeks though
I played a few rounds but didn’t really focus on a score
Levy was equally delighted with what was also his first competitive round of the year
“I practiced very hard the last few weeks in Dubai and I’m happy with my game today
I missed a few putts on my front nine but I remained patient and that was the key today,” said the five-time DP World Tour winner
Nienaber certainly looked at ease on Thursday and hinted at a few elements to his game that he focused on in preparing for this week
“My distance off the tee certainly helps on this course
You can get lucky when you hit it offline here
I’ve learned to manage that part of my game better
I’m not hitting it full blast the whole time.”
The key to his 64 came on the back nine – his first nine
13th and 14th was a very good par save on the par-four 12th hole
&nbsp;“I hit my tee shot left and was in a thorn bush
I got it out into the bunker and then managed an up-and-down for par
He then took advantage with an eagle on the par-five 15th
“I hit a really good drive and then a wedge to five feet and holed the putt
The par fives here are reachable and scoring on them is key here
Having said that I parred two of them today
but that’s good because it means there’s room for improvement.”
Distracting views for <a href="https://twitter.com/AshleyChesters?ref_src=twsrc%5Etfw">@AshleyChesters</a> 🦒😍<a href="https://twitter.com/hashtag/SDCOpen?src=hash&amp;ref_src=twsrc%5Etfw">#SDCOpen</a> | <a href="https://twitter.com/hashtag/GreatnessBeginsHere?src=hash&amp;ref_src=twsrc%5Etfw">#GreatnessBeginsHere</a> | <a href="https://twitter.com/hashtag/SunshineTour?src=hash&amp;ref_src=twsrc%5Etfw">#SunshineTour</a> <a href="https://t.co/BNRwNRRoLi">pic.twitter.com/BNRwNRRoLi</a>