1. Improving Mental Health by Sharing Knowledge
Positive
psychology in
primary care
Marijke Ruiter
Odile Smeets
Brigitte Boon

2. • Mentaalvitaal.nl; online psycho
education & exercises
• Psyfit.nl; self help program
• Mini interventions for complaints on
stress, sleeping problems and
worrying
© Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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Positive psychology in primary care
& Discussion:
share your ideas!

3. • A lot of patients have light psycho social
problems, related to life problems
• Physical complaints can have a relation with
psycho social problems, like stress and sleeping
problems
• Focus in primary care is on reducing complaints.
Mental, or emotional, fitness and resilience can
be an important addition
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Primary Care ECPP 2014
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Primary care

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Primary Care ECPP 2014
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Portal mentaalvitaal.nl
the site for reliable information on
mental health

5. Target groups?
1. Adults > 18 years old
2. How can I improve my emotional condition?
Anyone working on well-being and mental
resilience (health promotion, prevention)
3. How can I deal with everyday problems like
stress, feelings of sadness, worrying?
4. Where can I find information about mental
disorders for myself or my relatives?
5. As an adjunct in the treatment of (mild) mental
problems (relapse prevention, recovery)
6. Supplementation on the care of people with
chronic (psychiatric) diseases (quality of life)
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© Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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6. Mentaalvitaal.nl is:
• A free website with reliable information on
mental health
• Everyone looking for information, tips and
advices on mental health
• Accessible self-management portal
• Exercises, based on CBT, mindfullness
and positive psychology
• Online interventions
• Offline help
• Proposition: 'How can I feel and stay mentally
fit, in such a way that I can cope well with
life's challenges and setbacks?'
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© Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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7. © Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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Read more about moods and mental disorders

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Primary Care ECPP 2014
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Searching for:
Assertiveness
Balance
Energy
Flow
Happiness
Mindfullness
Relaxation
Optimism ….
Suffer from:
Fear
Loneliness
Negative thoughts
Insecurity
Worrying
Sleeping problems
Sadness ….
Mental disorders:
ADHD
Autism
Depression
Anxiety
Borderline personality
disorder
Schizofrenia
Alcohol addiction
Read more about …

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Primary Care ECPP 2014
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Read more about Worrying
Introduction of the
subject
Concrete tips to
worry less
What to do if
worrying gets too
serious
Referral to exercise “Stop worrying”

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Primary Care ECPP 2014
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Online exercises
Exercise “Stop
Worrying”

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Primary Care ECPP 2014
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Tools & Therapy
• Exercises
• Referral to
online
selftest and
treatment
programs
• Decision
making tool:
selection on
theme,
support,
costs of the
programs

12. • 92% of the respondents score mentaalvitaal.nl 7
or higher (on a scale from 1 – 10)
• 37% reports that the information on the website
helped partly or fully to reduce complaints
• 85% want to return at mentaalvitaal.nl and 92%
would recommend mentaalvitaal to relatives
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Primary Care ECPP 2014
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Customer satisfaction survey

13. • I refer my patients to specific information
about worrying, or stress for example, and
discuss it in my next appointment
• I often refer to the online relaxation
exercises
• I referred a patient to the online program
Psyfit.nl for mental fitness and I’ll hope
she will learn to use “helping thoughts”
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Primary Care ECPP 2014
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Reactions of professionals in
primary care

14. 1. Personal mission statement and goal
setting
2. Think optimistically
3. Hold grip on your life
4. Live here and now
5. Invest in relationships
6. Live healthy
Not only grounded on positive psychology, but also based on
principles from mindfulness, cognitive behavioral therapy
and healthy lifestyle advices
© Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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Six principles for mental fitness and
resilience

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Primary Care ECPP 2014
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Psyfit.nl: mental fitness online
Measurement of
moods during the
week
6 principles: 6
modules:
1. Mission & goals
2. Positive
feelings
3. Hold grip on
your life
4. Live here and
now
5. Positive
relationships
6. Thinking and
feeling

16. • 6 modules mental fitness
• One module of 4 weeks with self test,
psycho-education and exercise
• Films of experts
• E-mail reminding
• “Moodmeter”: measurement of daily
moods
• Forum exchange and support
• Tip of the day
• Help desk
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Primary Care ECPP 2014
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Psyfit:

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Primary Care ECPP 2014
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Introduction: What am I going to
learn?

18. • Randomized controlled trial
• Outcomes: well-being, depressive
and anxiety symptoms
• Measures: pretest, posttest, follow-
up (6 months)
• Inclusion: moderate well-being and
depressive symptoms
• ITT analysis (sensitivity analysis
completers only and per protocol)
Research design
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Primary Care ECPP 2014
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19. RCT Psyfit, N = 284
Self-registration online
n = 845
Eligibility assessment
n = 744
Excluded n = 455
•No informed consent, n = 9
•Incomplete data, n = 31
•CES-D score too high (>24), n=184
•CES-D score too low (<10) /MHC-
SF too high (flourishing), n=209
•Suicidal thoughts, n = 13
•No internet, n = 5
•Too young, n = 4
Randomization
n = 284
Intervention condition Psyfit
n = 143
Control condition Waiting list
n = 141
2 months loss
to follow up, n
= 70 (24.6%)
Posttest T1 at 2 months n = 89
(62.2%)
Loss to follow-up at 2 months n = 54
(37.8%)
Posttest T2 at 6 months n = 95
(66.4%)
Loss to follow-up at 6 months n = 48
(33.6%) 6 months loss
to follow up n
= 86 (30.3%)
Posttest T1 at 2 months n = 119
(84.4%)
Loss to follow-up at 2 months n = 22
(15.6%)
Posttest T2 at 6 months n = 109
(77.3%)
Loss to follow-up at 6 months n = 32
(22.7%)
Eligibility criteria fulfilled
n = 289
Baseline questionnaire completed
n = 284
Bolier, L., et al. (2013b). An Internet-Based Intervention to Promote Mental Fitness for Mildly
Depressed Adults: Randomized Controlled Trial. J Med Internet Res, 15, e200.
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20. • Drop-out analysis
• Mean age 44 years (21-81), 73%
high-education, 80% female
• Significant enhancement of well-
being and reduction in depressive
symptoms and anxiety symptoms
• Sustained effects at 6 months for
anxiety and depression
• Small effect sizes
Results
© Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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21. Psyfit can be used as an accessible and effective
mental health promotion strategy for a wide
audience in stepped care prevention of depression
General Practitioner and/or “Practise nurses for
mental health” can refer and motivate patients to
this online selfhelp program, and can offer
guidance during the program to raise adherence
and treatment effects
Costs: €29,95 per person
Psyfit in primary care
© Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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22. - Focused selfhelp training modules for complaints:
- 1. stress, 2. sleeplesness, 3. worrying.
- These complaints are connected with depression
and anxiety disorders (Smit et al., 2011) AND
- These complaints are associated with high costs
of care and ab/presenteism (Smit et al., 2011)
- Face to face group interventions followed by
online and migrant-adapted versions
- Online modules exist of 4-5 exercises
- Modules and exercises can be chosen at random
Next step interventions
© Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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23. Sleep better Worry less Le
See ind

24. Sleeping habits (4 exercises, all
done)
Relaxation (5 exercises, 1 done)
Learn how to think positively
(about sleep) ( 5 ex., 2 done)
Worry less (about sleep) (5 ex.)

25. Example: how to distinguish between
positive (“helping”) and negative ( “non-
helping” thoughts

28. Quiz for sorting thoughts into helping and non helping categories

29. • Investigate the effects of the selfhelp
interventions & compare to effects of group
version (wellbeing, depression, anxiety, sleep,
stress, worrying)
• Make a guide for GP/practition nurse (PN):
indications, execution of guided version
• Investigate needs of GP/PN
and conditions for use
(i.e. need to know
what patient does)
• Implement adaptation for
migrant patients
Next plans (2014)
© Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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30. • RCT with 292 participants (half experimental, half
waitlist control)
• >18 years; SES; m/f
• Experiencing complaints: sleep, stress, worrying
• Effects primarily on complaints; depression,
anxiety, wellbeing = secundary outcomes
• Baseline and 3 + 6 mo. follow-up
• KEA
• Process evaluation: feasibility, useability for
participants
• When (cost-)effective and useful for participants:
suited for use in primary care
© Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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Trial online interventions

31. - GP/Practition nurse selects patients with sleeping-
, stress- (anxiety) or worrying problems
- Introduction of the intervention; explanation why
this might help this person
- Instructions for patients how to use the
intervention: log in, fill out forms/questionnaires,
do exercises; have fun!
- Make appointment within 2 weeks to check
progress
- Make appointment within 2 months to check
results i.e. by asking patient about amelioration;
and/or by filling out questionnaires for complaints
and depression/anxiety
Online KMI’s in primary care: an
outline
© Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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32. • Do you have or do you know of
similar websites or interventions in
your field of work?
• What are your experiences?
• What are your thoughts about their
potential use in
primary care?
© Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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Discussion

33. © Trimbos-instituut Positive Psychology in
Primary Care ECPP 2014
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Thank you!
Marijke Ruiter
mruiter@trimbos.nl
Odile Smeets
osmeets@trimbos.nl
Brigitte Boon
bboon@trimbos.nl