Ben F. M. Wijnen

Background: After remission from a first episode psychosis (FEP), international clinical guidelines recommend continuation of antipsychotic medication for at least 1 year, although many patients wish to reduce or discontinue medication due to side effects or long‐term health concerns. Evidence on the cost‐effectiveness of early dose reduction or discontinuation compared to continuation remains limited. Methods: A trial‐based cost‐utility analysis was conducted alongside the ongoing HAMLETT study, in which 347 remitted FEP participants were randomized to either early guided dose reduction or discontinuation or maintenance treatment for 1 year. Both healthcare and societal perspectives over a 24‐month time horizon were considered. Health outcomes were expressed as quality‐adjusted life years (QALYs) derived from the EQ‐5D‐5L questionnaire using Dutch valuation tariffs. Costs were estimated using patient reported healthcare utilization and administrative pharmacy data. Incremental costs and effects were analysed using seemingly unrelated regression with uncertainty assessed through nonparametric bootstrapping and multiple sensitivity analyses. Results: Early dose reduction or discontinuation was associated with lower quality‐adjusted life years and higher or comparable costs compared with maintenance treatment over the 2‐year analysis period. In the base‐case societal perspective analysis, incremental costs were €23,563 and incremental effects were −0.077 QALYs, resulting in an incremental net monetary benefit of ‐€27,430 at a willingness‐to‐pay threshold of €50,000 per QALY at 24 months. Results were consistent across several scenarios with only approximately 9% probability that early dose reduction or discontinuation was cost‐effective at the assumed willingness‐to‐pay threshold. However, a sex‐at‐birth subgroup analysis suggested a small and uncertain positive incremental net monetary benefit among female participants. Conclusion: Over a 24‐month period, early dose reduction or discontinuation of antipsychotic medication after remission from a FEP is unlikely to be cost‐effective compared with maintenance treatment from both healthcare and societal perspectives. Whether longer term functional improvements associated with early dose reduction translate into cost‐effective benefits remains uncertain and requires follow‐up. Trial Registration: EudraCT number: 2017‐002406‐12

Introduction: To promote recovery of individuals with severe mental illness and reduce fragmentation of care, network partners collaborated to develop a cross-domain, multi-agency approach by integrating Flexible Assertive Community Treatment (FACT) teams with municipal District Social Services (DSS), referred to as FACT+DSS teams.Aim: To describe how team members experienced the implementation of the FACT+DSS teams by team members, including perceived effects on various themes such as service delivery, network collaboration, the target population, and facilitators and barriers to implementation.Methods: A qualitative study using semi-structured interviews (N = 15) was conducted to explore the experiences of team members in two new FACT+DSS teams in the Netherlands using thematic analysis.Results: The FACT+DSS approach was experienced to improve service access, continuity of care, case-finding and client enrolment (care-avoiders), time efficiency for team members, and strengthen network collaboration. Identified barriers and facilitators underlined the importance of strong leadership, ownership, equality, direct relationships, and professional expertise.Conclusion: Participants experienced the FACT+DSS approach as a highly positive development, improving network collaboration and recovery-oriented care for clients. Our findings may contribute to the development and implementation of FACT (and related practices) as an integrated multi-agency approach.

The RECOVER-E project supported the shift away from mental health care provided in institutional settings (treatment as usual, TAU) towards community-based mental healthcare by introducing multidisciplinary community mental health teams (CMHT) for people with schizophrenia, bipolar disorder, and severe depression across five sites in Bulgaria, Croatia, Montenegro, North Macedonia, and Romania. This paper presents the cost-effectiveness of CMHT compared to TAU. Data from all five RECOVER-E trials (N = 931) was used to compute healthcare costs and societal costs which included additional patient and family costs, and costs stemming from productivity losses. Outcomes were incremental cost-effectiveness ratio's (ICER) for gaining a QALY and gaining a treatment responder (based on WHODAS 2.0). Compared to TAU, CMHT had small incremental effects favouring CMHT (QALY: M = 0·023, SD = 0·013; Response: M = 0·093, SD = 0·034). The incremental costs were higher in CMHT than in TAU as seen from both the societal and healthcare perspective (societal costs: M=€1,892, SD=€950; healthcare costs: M = 1,125, SD=€720). The ICER for gaining a QALY was €82,261 and €48,913 as seen from the societal and healthcare perspective, respectively. These ICERs were well above the willingness to pay threshold of €20,000 for gaining a QALY. A similar picture arose with treatment response as outcome. Overall CMHT appeared to be more effective but also more costly, with the additional cost outweighing the benefits across countries, except in Bulgaria, which may highlight that cost-effectiveness is likely to be context dependent. Therefore, a recommendation for scaling up or sustaining CMHT must also depend on arguments other than health-economic alone, such as medical ethical, equity and human rights considerations. Bulgaria: NCT03922425, Croatia: NCT03862209, Macedonia: NCT03892473, Montenegro: NCT03837340, Romania NCT03884933.

Background: Recovery colleges (RCs) facilitate peer-supported communities where people with lived experience of mental disruption learn collaboratively, aiming to foster empowerment and personal recovery. While existing (qualitative) research relates RC attendance to positive outcomes, high-quality multi-college quantitative studies evaluating RC effectiveness are scarce. Aims: We examine the extent to which RC attendance impacts empowerment (primary outcome) and other recovery-related outcomes. Method: In this nonrandomised clinical trial (May 2022 to January 2025), RC partakers from four Dutch RCs were compared with controls over 2 years, in annual data collections. Linear mixed model analyses were conducted to investigate interactions between group and time. Exploratory analyses investigated distinguishing characteristics of RC partakers. This study was embedded in a larger project and was pre-registered (clinicaltrials.gov: #NCT05620212). Academic and experiential researchers collaborated in the design, recruitment, and analysis. Results: The sample comprised 91 RC partakers and 182 matched controls. RC partakers faced severe or persistent mental health challenges and attended RCs in multiple capacities (e.g., student and visitor/volunteer). Outcomes were mostly stable over time and did not differ between groups. Hence, no group-specific changes over time were found, as shown by interaction terms that were not statistically significant (e.g., empowerment: estimate T1*RC= 0.02, 95% CI= −0.08–0.13, estimate T2*RC= −0.001, 95% CI= −0.11–0.11). Conclusions: Despite promising qualitative evidence of RC effectiveness, our study found no differences between RC partakers and matched controls in quantitative recovery-related outcomes over time. Factors of influence may be possible pre-study effects, unmeasured confounding, or limitations in how standardised questionnaires capture recovery experiences. Methodologically, the findings raise questions about the operationalisation of effectiveness in the context of personal recovery and flexible, co-created practices such as RCs. Importantly, while this study could not establish measurable effectiveness, this does not automatically imply that RC attendance cannot meaningfully contribute to recovery.

Background and Objective The Dutch costing manual, part of the national guideline for economic evaluations, provides reference prices and standardized cost calculation methods to ensure transparency and comparability. Since its last update in 2015, new evidence, updated cost data, and user needs prompted an updated version to reflect current best practices and expand scope. The aim of this article is to present the update of the costing manual and the introduction of the web application facilitating regular updates. Methods The update of the costing manual followed a three-step approach. First, improvement needs were identified by user surveys and experts. Secondly, methodological guidance was revised using recent literature, national data sources, and expert input. Thirdly, the reference prices were updated. In parallel, a technical web application was developed and tested to facilitate ongoing digital access and regular updates. Results The updated costing manual consists of revised and updated references prices, including expanded intersectoral reference prices (e.g., education and justice). Clearer methodological guidance and improved transparency were established. Testing showed that the web-based application was intuitive to use and accurately reproduced reference prices consistent with the updated costing manual. Conclusions The costing manual was updated in line with the recent guidelines for economic evaluations. The manual is a comprehensive manual for use in costing studies for economic evaluations in healthcare from a societal perspective. The web-based application translated the costing manual into a practical digital tool, automating cost calculations and demonstrated usability, accuracy, and consistency with the manual.

Provides functions and example datasets to run a decision-analytic model for prevention and treatment strategies across depression severity states (sub-clinical, mild, moderate, severe, and recurrent). The package supports scenario analyses (base and alternative inputs) and summarises outcomes such as coverage, adherence, effect sizes, and healthcare costs.

The long-term impact of preventive policies in the Netherlands on the mental health of young adults remains unclear. Therefore, this paper describes the development of a conceptual model of youth mental health that serves as the foundation of a future decision-analytic model. Stakeholders were engaged through three rounds of focus group discussions to indicate the factors of youth mental health that affect the likelihood of developing mental disorders later in life, and the relationships among them. Findings were discussed with stakeholders and in a study team that included members with diverse backgrounds. Literature was used as an additional information source for the relationships among the selected factors. In total, 43 stakeholders participated in the focus group discussions. Eleven factors of youth mental health were regarded as most influential, with 13 relationships among them. The final conceptual model was approved by the stakeholders and the study team. Through integrating stakeholder perspectives and published literature, a conceptual model was created that captures essential factors and relationships affecting (long-term) mental health. Although stakeholder engagement requires extensive planning, it enhanced the model's credibility and validity, and could therefore serve as a complement to other conceptual modeling approaches.

Background: Low self-esteem is an important and potentially modifiable risk factor for the development and outcome of psychotic disorders. The factors involved in low self-esteem in psychotic disorders are not yet fully understood. The current study aims to investigate the cross-sectional and longitudinal associations between (changes in) self-esteem and severity of psychotic symptoms, internalized stigma, negative reaction to antipsychotics, personal recovery, childhood bullying, childhood trauma, and social support in symptomatically remitted first-episode psychosis (FEP) patients. Methods: Data from the ongoing longitudinal Handling Antipsychotic Medication: Long-term Evaluation of Targeted Treatment study were used. Participants were in symptomatic remission for 3–6 months after the FEP. Cross-sectional associations ( N = 299) were investigated through Pearson’s correlations, and longitudinal changes ( N = 238) were investigated via linear regressions with inverse probability weighting. Results: Cross-sectionally, we found that lower self-esteem was related to higher severity of symptoms, higher internalized stigma, higher childhood trauma (specifically emotional neglect), higher childhood bullying, more negative side effects of antipsychotic medication, lower personal recovery, and lower social support. Longitudinally, contrary to our hypothesis, we found that higher baseline internalized stigma, higher childhood trauma (specifically emotional abuse), and a higher baseline negative subjective reaction to antipsychotics predicted an increase in self-esteem after 6 months. Furthermore, a decrease in psychotic symptoms, internalized stigma, and negative subjective reaction to antipsychotics, and an increase in social support predicted an increase in self-esteem. Conclusions: Early intervention programs for psychotic disorders should target factors related to changes in self-esteem. This might improve self-esteem and thereby promote recovery.