From Evidence to Everyday Care: Implementing and Evaluating a Lifestyle-Focused Approach in Mental Healthcare

People with mental illness (MI) face a substantially reduced life expectancy, up to 15 to 20 years shorter than the general population. This is primarily due to preventable physical conditions, such as cardiovascular disease and diabetes. Unhealthy lifestyle behaviors, including low physical activity, poor sleep, unhealthy diet, and high rates of smoking, contribute significantly to these disparities. Psychiatric symptoms, medication side effects, and limited access to care further complicate lifestyle change. Although lifestyle interventions have demonstrated promising effects in controlled research settings, their translation into routine mental healthcare reamains limited. This dissertation aims to bridge this research-to-practice gap by evaluating both the effectiveness and the implementation of MULTI+, a lifestyle-focused approach for inpatients with MI implemented across 45 sites of GGz Centraal.

MULTI+ is a scale-up of the earlier MULTI approach and focuses on ten core components, including structured daily routine, physical activity, nutrition, reducing substance use, psychoeducation and skills training. These components represent the activities necessary to support healthier lifestyles among people with MI. Because needs, preferences, and resources vary widely, each component is adaptable, enabling tailoring to diverse settings while maintaining a consistent multicomponent structure.

To evaluate MULTI+, an open cohort stepped wedge cluster randomized trials was conducted across three geographically defined clusters transitioning from treatment as usual (TAU) to MULTI+ in six-month steps. This design allowed assessment of both health outcomes and implementation processess within routine care. Primary outcome was change in cardiovascular risk assessed with the QRISK3; secondary outcomes included lifestyle behaviors, mental and somatic health indicators, and implementation outcomes.

The findings illustrate both the promise and challenges of lifestyle-focused care in mental healthcare. Before implementation, patients and professionals reported barriers such as expected drawbacks (e.g., time or energy required), low outcome expectations, limited knowledge of MULTI+, and organizational instability. Some patients viewed MULTI+ as too complicated, while deliverers noted personal burden and structural constraints. These barriers highlight the difficulty of integrating lifestyle into complex settings.

Using network analysis, this dissertation demonstrates strong interrelationships among lifestyle behaviors and mental health outcomes, with sleep and quality of life emerging as central nodes. The degree of implementation was systematically assessed with the LIFE Monitor, a fidelity tool grounded in the ten core components, enabling structured evaluation of adherence across sites. The effectiveness study, based on data from 3603 individuals, found no improvement and even a small deterioration in cardiovascular risk for individuals receiving MULTI+ compared to TAU. Implementation was not associated with the cardiovascular outcomes.

The discussion argues for a realistic and context-sensitive interpretation of effect. In real-world care, maintaining stability and even preventing further deterioration may already represent meaningful progress. The findings call for sustained investment, structural embedding of lifestyle-focused care, and implementation strategies that move beyond the individual to include routines, priorities and broader organizational conditions. Overall, this dissertation illustrates the complexity of improving health outcomes of people with MI, the importance of understanding lifesyle as part of a broader system, and the need for integrated, durable approaches that align evidence with everyday care.