Lifestyle Intervention for People With Severe Obesity and Serious Mental Illness

Nurse Counseling versus IEC Material on Maintenance of Healthy Lifestyle for Outpatients Receiving Antipsychotics: A Randomized Control Trial

Background

A healthy lifestyle is important for recovery, coping with life's stresses, minimizing the occurrence and impact of health issues, and improving quality of life. Maintaining a healthy lifestyle may help in preventing or delaying the onset of many health problems.

Methods

A quantitative research approach with a randomized control trial (RCT) was adopted. 130 outpatients were randomized to experimental and control groups. The data were analyzed by SPSS version 28.8 and R software.

Results

Waist circumference (WC) significantly differed between the experimental group and the control group (F = 14.87, P < .001). There was a decreasing trend in weight in the experimental group across the three time points (baseline to the second assessment), as compared to the control group (F = 4.29, P = .01). Quality of health of the subjects as measured by the visual analog scale (VAS) of the Euro Quality Of Life (EQ5D) significantly differed (F = 87.47, P < .001). Post-intervention, the percentage showed marked improvement in the experimental group.

Conclusion

The results of this study support that counseling about a healthy lifestyle is effective as long-term strategies to avoid weight gain, engagement in adequate physical activity, taking nutritious food and maintaining healthy sleep can, in the long run, prevent metabolic syndrome. These interventions can be delivered at a low cost, are safer and practically feasible and may have a long-term impact on the quality of life.

Adaptation of the Barriers, Attitudes, Confidence, and Knowledge Scale (M-BACK-Tr) into Turkish culture to assess the metabolic health of psychiatric professionals and investigation of Its psychometric characteristics

AIM

The aim was to evaluate the validity and reliability of the "Barriers, Attitudes, Confidence, and Knowledge Scale for Assessing Metabolic Health" (M-Back-Tr) to determine the barriers, attitudes, confidence, and knowledge status of psychiatry professionals in the assessing of metabolic syndrome.

METHODS

This methodological study was conducted with 304 psychiatric nurses who were working in public and private healthcare institutions between March and June 2023. Translation and back-translation were made into the Turkish language during the adaptation process and it was found that there was no semantic shift between the versions. While the validity of M-Back-Tr was tested with content validity, construct validity, and convergent validity, its internal reliability and Split-Half Test Reliability were examined for reliability.

RESULTS

The structure of M-Back-Tr, which consists of 4 dimensions (i.e., Barriers, Attitudes, Confidence, Knowledge) and 16 items, was confirmed in Turkish culture. This structure can explain 73 % of the variance in the related concept. The minimum score that can be taken from each sub-dimension is 4 and the maximum is 20. The Cronbach α value of the sub-dimensions of the scale was found to be between 0.79 and 0.91.

CONCLUSION

The study findings showed that the M-Back-Tr is a valid and reliable measurement tool that can be used in Turkish culture.

Baseline BMI is associated with clinical symptom improvements in first-episode schizophrenia: a longitudinal study

Background: There is sufficient evidence of the high prevalence of obesity in schizophrenia (SZ) compared to the general population. Previous studies have reported that weight gain correlated with the response to antipsychotics in patients with SZ. Nonetheless, the relationship between body mass index (BMI) and therapeutic benefits remains unclear. This study was designed to investigate the association between baseline BMI and improvements in clinical symptoms after treatment with antipsychotics in first-episode and medication-naïve SZ (FEMNS). Methods: A total of 241 FEMNS patients were enrolled and received risperidone over 12 weeks. The severity of symptoms was assessed by the Positive and Negative Syndrome Scale (PANSS) and BMI was measured at baseline and 12-week follow-up. Results: We found that risperidone treatment raised the body weight of FEMNS patients and baseline BMI was negatively correlated with the improvement in negative symptoms (r = -0.14, p = 0.03) after 12-week treatment. Linear regression analysis indicated that baseline BMI was an independent predictor of response to risperidone in the early stage of SZ. Conclusion: The current study suggests a close relationship between baseline BMI and improvement in negative symptoms in SZ.

Weight Self-Efficacy and Recovery Among African-Americans With Serious Mental Illness and High Body Weight

ABSTRACT

Many African-Americans with serious mental illness fail to engage in evidence-based programs that positively affect weight management. We examined how having a weight-related physical illness correlated with self-efficacy, recovery, and quality of life by contrasting illnesses with symptoms that are obviously perceived ( e.g. , sleep apnea and pain related to weight) versus those that are not ( e.g. , hypertension). African-Americans with serious mental illness who were overweight (body mass index ≥25) completed the Weight Efficacy Lifestyle Questionnaire, Recovery Assessment Scale, and Quality of Life Scale in this study assessing the impact of a program on weight and health. Silent weight-related physical disorders were not found to correlate with quality of life, recovery, or weight self-efficacy. Differences in recovery were found in people with versus without sleep apnea and weight-related pain. Findings suggest future directions for affirming approaches to promote engagement among African-Americans with serious mental illness in weight management programs.

Secondary analysis of a university-based weight loss program in on-campus versus off-campus employees

Introduction

Many barriers prevent individuals from regularly engaging in physical activity (PA), including lack of time and access to facilities. Providing free gym membership close to one's work may alleviate both time and financial barriers, increase PA, and result in greater weight loss. The purpose of this secondary analysis was to determine if gym usage, self-reported leisure PA, and weight loss differed between participants working on the University of Colorado Anschutz Medical Campus (ON) versus working off-campus (OFF) during a 6-month weight loss trial.

Methods

117 adults (ON, n = 62; OFF, n = 55) with overweight or obesity received free gym memberships for the duration of trial. Average gym check ins/week, self-report leisure PA, weight, and fat and lean mass were compared between groups.

Results

ON reported more check-ins than OFF (ON, 0.93 ± 0.16 times/week; OFF, 0.55 ± 0.10 times/week p = 0.038). Both groups reported increased leisure PA, with ON reporting more leisure PA than OFF at month 4. Both groups had reductions in weight and fat mass, which were similar between groups.

Conclusion

Gym usage in both groups was low, suggesting that convenient and free gym access only marginally promoted use of provided facilities, likely having little additional impact on PA and weight change.

CLINICAL TRIAL REGISTRATION

The parent trial was registered at clinicaltrials.gov: NCT02627105.

The psychological journey of weight gain in psychosis

BACKGROUND

Rapid weight gain is common with antipsychotic medication. Lost confidence, low mood and medication non-adherence often follow. Yet, the dynamic interactions between the physical and psychological consequences of weight gain, and implications for intervention, are unknown.

OBJECTIVES

We examined first-person accounts of weight gain to identify preferences for weight change interventions.

DESIGN

A qualitative design was used to explore patients' experiences of weight change in the context of psychosis.

METHOD

Semi-structured interviews, analysed using grounded theory, were conducted with 10 patients with psychosis. Sample validation was conducted with peer researchers with lived experience of psychosis.

RESULTS

Patients described that initially the extent and speed of weight gain was overshadowed by psychotic experiences and their treatment. This led to a shocking realisation of weight gain. The psychological impact of weight gain, most strikingly on the self-concept, was profound. Loss of self-worth and changed appearance amplified a sense of vulnerability. There were further consequences on mood, activity and psychotic experiences, such as voices commenting on appearance, that were additional obstacles in the challenging process of weight loss. Sedative effects of medication also contributed. Unsuccessful weight loss left little hope and few preferences for interventions. Early information about common weight gain trajectories and working with experts-by-experience were valued. Rebuilding self-confidence, efficacy and worth may be a necessary first step.

CONCLUSIONS

The journey of weight gain in patients with psychosis is characterised by loss of self-worth, agency and hope. There are multiple stages in the journey, each with different psychological reactions, that may need different treatment responses.

The Health Improvement Profile for people with severe mental illness: Feasibility of a secondary analysis to make international comparisons

WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: Individuals with severe mental illness (SMI) have elevated risks for physical health problems and low screening rates. No previous studies have compared the physical health promotion needs of people with SMI using the same screening tool across different international settings. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: It appears feasible to use the HIP to profile and compare physical health-related risks in people with SMI across different international settings. The HIP tool identified significant differences in areas of risk across the four countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The HIP could be used to identify unique clusters of health promotion needs in different countries. Use of HIP health checks may support implementation of individualized interventions. ABSTRACT: Introduction To date, no studies have contrasted physical health profiles of people with severe mental illness (SMI) in different countries. Aim To evaluate feasibility of using the Health Improvement Profile (HIP) to compare and contrast physical health and health behaviours of people with SMI from four countries. Method An observational feasibility study using secondary analysis of pooled health state and lifestyle data. Physical health checks using modified versions of HIP were administered in four countries. Results Findings suggest feasibility of HIP screening to profile and compare physical health and health behaviours of people with SMI across international settings. High overall numbers of risk items (red flags) were identified in all but the Thailand sample. Despite some commonalities, there were important differences in health profiles across countries. Discussion This is the first study to demonstrate feasibility of the HIP to compare health risks in individuals with SMI across countries. Future multi-national HIP studies should recruit a fully powered stratified random sample of people with SMI that is representative of each setting. Implications for practice It appears feasible to utilize the HIP to identify specific areas of health risk in different countries, which may help to better focus nursing interventions and use of resources.

Prevalence of Overweight and Obesity in People With Severe Mental Illness: Systematic Review and Meta-Analysis

Aims

1) To determine the pooled prevalence of overweight and obesity in people with severe mental illness (SMI), overall and by type of SMI, geographical region, and year of data collection; and 2) to assess the likelihood of overweight and obesity, in people with SMI compared with the general population.

Methods

PubMed, Medline, EMBASE, and PsycINFO databases were searched to identify observational studies assessing the prevalence of obesity in adults with SMI. Screening, data extraction and risk of bias assessments were performed independently by two co-authors. Random effect estimates for the pooled prevalence of overweight and obesity and the pooled odds of obesity in people with SMI compared with the general population were calculated. Subgroup analyses were conducted for types of SMI, setting, antipsychotic medication, region of the world, country income classification, date of data collection and sex. We assessed publication bias and performed a series of sensitivity analyses, excluding studies with high risk of bias, with low sample size and those not reporting obesity according to WHO classification.

Result

120 studies from 43 countries were included, the majority were from high income countries. The pooled prevalence of obesity in people with SMI was 25.9% (95% C.I. = 23.3-29.1) and the combined pooled prevalence of overweight and obesity was 60.1% (95% C.I. = 55.8-63.1). Sub-Saharan Africa (13.0%, 95%C.I. = 6.7-25.1) and South Asia (17.7%, 95%C.I. = 10.5-28.5) had the lowest prevalence of obesity whilst North Africa and the Middle East (35.8%, 95%C.I. = 23.8-44.8) reported the highest prevalence. People with SMI were 3.04 more likely (95% C.I. = 2.42-3.82) to have obesity than the general population, but there was no difference in the prevalence of overweight. Women with schizophrenia were 1.44 (95% C.I. = 1.25-1.67) times more likely than men with schizophrenia to live with obesity; however, no gender differences were found among those with bipolar disorder.

Conclusion

People with SMI have a markedly high prevalence and higher odds of obesity than the general population. This may contribute to the very high prevalence of physical health conditions and mortality in this group. People with SMI around the world would likely benefit from interventions to reduce and prevent obesity.

Evaluation of an educational wellness program by sex differences in community-dwelling Japanese patients with schizophrenia

This study was a 24-week non-randomized controlled trial aimed at investigating the effects of lifestyle education by sex in patients with schizophrenia. The data was collected and analyzed for 75 subjects at five facilities in Aomori, Japan. Mean weight and BMI decreased in both biologically male and female subjects over a 24-Week study period in the Intervention group, but were maintenance or increase in the control Group. Although, when compared with the control group by ANCOVA (Analysis of Covariance), there were significant differences in body weight, BMI, and body fat percentage in the biologically male participants in the Intervention group, but not in the females. For the biologically males in the Intervention group, sex differences were speculated to affect weight loss strategies, such as using a pedometer to incorporate walking into their daily routine. Thus, when implementing lifestyle improvement education program, it is recommended to implement a program that considers sex differences.

Renewed call for lifestyle interventions to address obesity among individuals with serious mental illness in the COVID-19 era and beyond

Behavioral health has the opportunity to lead the way in using lifestyle interventions to address obesity and health disparities in people with serious mental illness (SMI) in the COVID-19 era. Evidence-based interventions for weight loss in individuals with SMI exist, and the field has developed strategies for implementing these interventions in real-world mental health care settings. In addition to promoting weight loss, lifestyle interventions have the potential to address social isolation and loneliness and other patient-centered outcomes among individuals with SMI, which will be especially valuable for mitigating the growing concerns about loneliness attributed to the COVID-19 pandemic restrictions on in-person encounters. In this commentary, we discuss practice, policy, and research implications related to using evidence-based lifestyle interventions for individuals with SMI during the COVID-19 pandemic and sustaining these programs in the long-term.

Clozapine Management in Schizophrenia Inpatients: A 5-Year Prospective Observational Study of Its Safety and Tolerability Profile

BACKGROUND

Clozapine is well known for its efficacy and clinical superiority compared to other antipsychotics in treatment-resistant schizophrenia (TRS). However, it is frequently underutilized worldwide because of its acute adverse events, as well as for its long-term cardiometabolic and hematological consequences.

OBJECTIVE

The aim of the study was to evaluate 5-year safety in chronic TRS inpatients with continuous clozapine use.

METHODS

Patients with TRS and clozapine treatment were evaluated for 5 years. All participants were assessed using the Brief Psychiatric Rating Scale (BPRS), Glasgow Antipsychotic Side-effect Scale for Clozapine (GASS-C), Social Performance Scale (PSP) and Short Portable Mental Status Questionnaire (SPMSQ). Clinical, cardiometabolic and hematological data were collected periodically. General linear models (GLM) repeated measures controlling for CLZ dose were utilized to determine differences in variables across the time.

RESULTS

Overall, 189 inpatients were screened for study participation. The final sample included twenty-one TRS patients (16 males, 76%) with an average age of 57.6 years, all with 5-year continuous use of clozapine (mean dose 266 mg/day). There was not a significant effect of time on BPRS (p=0.774), PSP (p=0.855) and SPMSQ (p=0.066); differences remained not significant after controlling for CLZ dose (p=0.585, p=0.467 and p=0.105, respectively). No changes were found in blood and clinical parameters except for red blood cell count, which decreased over time (p=0.024; η2= 0.952). Patients reported a significant BMI decrease (-8.98 kg, p=0.008) between baseline and 5 years last observation.

CONCLUSION

The findings show how the application of a structured dietary, clinical and therapeutic monitoring program in psychiatric care facilities could allow the safe and effective long-term cardiometabolic and hematological management of clozapine. The unique role that clozapine plays in the current treatment of patients with TRS requires greater clinical awareness. Although its acute and chronic side effects are notorious, its safety management is feasible and broadens its potential practical application.

The Importance of Belonging to a Context: A Nurse-Led Lifestyle Intervention for Adult Persons with ADHD

Living with attention deficit hyperactivity disorder (ADHD) and mental illness involves an increased risk of lifestyle-related diseases. Although there are several ways to provide support to adult persons with ADHD, there is a lack of non-medical strategies for this purpose. This study explore how adult persons with ADHD with mental illness experienced taking part in a nurse-led lifestyle intervention. Fifteen participants participated in a 52-week lifestyle intervention. The analysis revealed two main categories; Building trusting relationships and Health together. This nurse-led lifestyle intervention could be an alternative or complement to current approaches to promoting health in adults with ADHD.

A nurse-led lifestyle intervention for adult persons with attention-deficit/hyperactivity disorder (ADHD) in Sweden

Introduction: Attention-deficit/hyperactivity disorder (ADHD) is associated with lifestyle-related diseases. Therefore, a nurse-led lifestyle intervention including interpersonal relationships, health education and cognitive support was developed to facilitate healthier lifestyle habits.Aim: The aim was to develop a lifestyle intervention and investigate its impact on mental and physical healthMethod: The 52-week intervention included 35 adults with ADHD. In a pre- and post-test design, symptoms of ADHD were measured with the Adult ADHD Self-Report Scale, quality of life was measured with the Adult ADHD Quality of Life scale and mental health was measured with the Hospital Anxiety and Depression scale. Lifestyle habits and dimensions of health were measured by the Lifestyle-Performance-Health Questionnaire and physical fitness was measured by the VO2 Max Test and calculations of waist circumference and body mass index. Result: Post-tests for a group of 25 persons showed positive changes following the intervention regarding weekly physical activity, quality of life and general and mental health. Lifestyle habit support was found to be important. The impact of the intervention should be confirmed in a long-term study with a control group.Conclusion: This intervention may be beneficial and may be implemented in a primary healthcare setting or in other open care units.

Physical health interventions for patients who have experienced a first episode of psychosis: a narrative review

Objectives:

Service users with severe psychiatric illnesses, such as schizophrenia, major depressive disorder and bipolar disorder, are more likely to suffer from ill health. There is evidence that lifestyle interventions, for example, exercise, dietary advice and smoking cessation programmes for service users with severe mental illness can be of health benefit. This review was carried out to identify the literature pertaining to physical health interventions for service users who have experienced a first-episode psychosis (FEP), to examine the nature of the interventions which were carried out and to assess these interventions in terms of feasibility and efficacy.

Methods:

A narrative review was conducted in August 2019 by searching ‘Pubmed’ and ‘Embase’ electronic databases. Studies investigating the effect a physical health intervention had on service users who had experienced a FEP were included in the review.

Results:

Fifteen studies met inclusion criteria: 12 quantitative studies and 3 qualitative. Exercise, dietary advice, smoking cessation and motivational coaching were some of the physical health interventions utilised in the identified studies. Positive effects were seen in terms of physical health markers wherever they were investigated, particularly when the intervention was delivered early. The impact on psychiatric symptoms and longer-term impacts on health were less frequently assessed.

Conclusions:

Physical health interventions have a positive impact on service users who have experienced a FEP. More research is warranted in this area in Ireland. These studies should include controls, have longer follow-up periods and should assess the impact on psychiatric health.

Psychological interventions for psychosis in adolescents

BACKGROUND

Psychosis is an illness characterised by alterations in thoughts and perceptions resulting in delusions and hallucinations. Psychosis is rare in adolescents but can have serious consequences. Antipsychotic medications are the mainstay treatment, and have been shown to be effective. However, there is emerging evidence on psychological interventions such as cognitive remediation therapy, psycho-education, family therapy and group psychotherapy that may be useful for adolescents with psychosis.

OBJECTIVES

To assess the effects of various psychological interventions for adolescents with psychosis.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's study-based Register of Trials including clinical trials registries (latest, 8 March 2019).

SELECTION CRITERIA

All randomised controlled trials comparing various psychological interventions with treatment-as-usual or other psychological treatments for adolescents with psychosis. For analyses, we included trials meeting our inclusion criteria and reporting useable data.

DATA COLLECTION AND ANALYSIS

We independently and reliably screened studies and we assessed risk of bias of the included studies. For dichotomous data, we calculated risk ratios (RRs) and 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous data, we used mean differences (MDs) and the 95% CIs. We used a random-effects model for analyses. We created a 'Summary of findings' table using GRADE.

MAIN RESULTS

The current review includes 7 studies (n = 319) assessing a heterogenous group of psychological interventions with variable risk of bias. Adverse events were not reported by any of the studies. None of the studies was sponsored by industry. Below, we summarise the main results from four of six comparisons, and the certainty of these results (based on GRADE). All scale scores are average endpoint scores. Cognitive Remediation Therapy (CRT) + Treatment-as-Usual (TAU) versus TAU Two studies compared adding CRT to participants' TAU with TAU alone. Global state (CGAS, high = good) was reported by one study. There was no clear difference between treatment groups (MD -4.90, 95% CI -11.05 to 1.25; participants = 50; studies = 1, very low-certainty). Mental state (PANSS, high = poor) was reported by one study. Scores were clearly lower in the TAU group (MD 8.30, 95% CI 0.46 to 16.14; participants = 50; studies = 1; very low-certainty). Clearly more participants in the CRT group showed improvement in cognitive functioning (Memory digit span test) compared to numbers showing improvement in the TAU group (1 study, n = 31, RR 0.58, 95% CI 0.37 to 0.89; very low-certainty). For global functioning (VABS, high = good), our analysis of reported scores showed no clear difference between treatment groups (MD 5.90, 95% CI -3.03 to 14.83; participants = 50; studies = 1; very low-certainty). The number of participants leaving the study early from each group was similar (RR 0.93, 95% CI 0.32 to 2.71; participants = 91; studies = 2; low-certainty). Group Psychosocial Therapy (GPT) + TAU versus TAU One study assessed the effects of adding GPT to participants' usual medication. Global state scores (CGAS, high = good) were clearly higher in the GPT group (MD 5.10, 95% CI 1.35 to 8.85; participants = 56; studies = 1; very low-certainty) but there was little or no clear difference between groups for mental state scores (PANSS, high = poor, MD -4.10, 95% CI -8.28 to 0.08; participants = 56; studies = 1, very low-certainty) and no clear difference between groups for numbers of participants leaving the study early (RR 0.43, 95% CI 0.15 to 1.28; participants = 56; studies = 1; very low-certainty). Cognitive Remediation Programme (CRP) + Psychoeducational Treatment Programme (PTP) versus PTP One study assessed the effects of combining two types psychological interventions (CRP + PTP) with PTP alone. Global state scores (GAS, high = good) were not clearly different (MD 1.60, 95% CI -6.48 to 9.68; participants = 25; studies = 1; very low-certainty), as were mental state scores (BPRS total, high = poor, MD -5.40, 95% CI -16.42 to 5.62; participants = 24; studies = 1; very low-certainty), and cognitive functioning scores (SPAN-12, high = good, MD 2.40, 95% CI -2.67 to 7.47; participants = 25; studies = 1; very low-certainty). Psychoeducational (PE) + Multifamily Treatment (MFT) Versus Nonstructured Group Therapy (NSGT, all long-term) One study compared (PE + MFT) with NSGT. Analysis of reported global state scores (CGAS, high = good, MD 3.38, 95% CI -4.87 to 11.63; participants = 49; studies = 1; very low-certainty) and mental state scores (PANSS total, high = poor, MD -8.23, 95% CI -17.51 to 1.05; participants = 49; studies = 1; very low-certainty) showed no clear differences. The number of participants needing hospital admission (RR 0.84, 95% CI 0.36 to 1.96; participants = 49; studies = 1) and the number of participants leaving the study early from each group were also similar (RR 0.52, 95% CI 0.10 to 2.60; participants = 55; studies = 1; low-certainty).

AUTHORS' CONCLUSIONS

Most of our estimates of effect for our main outcomes are equivocal. An effect is suggested for only four outcomes in the SOF tables presented. Compared to TAU, CRT may have a positive effect on cognitive functioning, however the same study reports data suggesting TAU may have positive effect on mental state. Another study comparing GPT with TAU reports data suggesting GPT may have a positive effect on global state. However, the estimate of effects for all the main outcomes in our review should be viewed with considerable caution as they are based on data from a small number of studies with variable risk of bias. Further data could change these results and larger and better quality studies are needed before any firm conclusions regarding the effects of psychological interventions for adolescents with psychosis can be made.

Adding Telephone and Text Support to an Obesity Management Program Improves Behavioral Adherence and Clinical Outcomes. A Randomized Controlled Crossover Trial

BACKGROUND

Behavioral treatment strategies improve adherence to lifestyle intervention for adults with obesity, but can be time and resource intensive when delivered via traditional face-to-face care. This study aimed to investigate the efficacy and optimal timing of using telephone calls and text message as adjunctive tools to support a community-based obesity management program.

METHOD

This 8-month randomized controlled crossover trial recruited 61 adults with class III obesity (BMI > 40 kg/m²) enrolled in a publicly funded obesity management service (OMS). Participants were randomly assigned to receive telephone and text message support in addition to standard OMS care, or standard OMS care alone. After 4 months, participants crossed over to the alternative sequence. The technological support was based on self-determination theory. Outcome measures included diet, physical activity, anthropometry, self-efficacy, and treatment self-regulation.

RESULTS

Telephone and text message support improved lifestyle intervention adherence and clinical outcomes when compared with standard care. Participants who received the intervention in the first 4-month period lost 4.87 kg, compared with no weight loss (+ 0.38 kg) in the standard care only group. There was no evidence to indicate an optimal timing of the intervention, with both groups achieving significant results by the end of the intervention.

CONCLUSION

These results suggest a high degree of promise for the incorporation of telephone and text message support into community-based obesity management services. The findings have the potential to improve existing practices and reduce the burden on the health care system by demonstrating a resource-effective improvement to obesity management service delivery.

Adaptation and validation of a scale of self-efficacy and social support for physical activity in Spanish patients with severe mental disorders

BACKGROUND

People with severe mental disorders (SMDs) suffer problems of obesity, a sedentary life, and poor physical condition, mainly due to low levels of physical activity. Self-efficacy (SE) and social support (SS) are important components that influence participation in physical activity.

METHODS

This study adapted a scale to assess SE and SS in promoting physical activity in Spanish people with SMDs, as well as provide preliminary evidence of its validity. One hundred Spanish patients (23% female) with SMDs, between 26 and 61 years old, completed the SE/SS assessment for SMD (SE/SS-ASMD).

RESULTS

The instrument seemed to capture a four-factor structure in people with SMDs. Due to the lack of a gold standard, the scale was related to other instruments with which it might be expected to show a correlation, such as those for physical activity and its quality; however, the levels of correlation found were low (≈0.3). The Internal consistency (Cronbach's α) for the SE-ASMD, SS-ASMD staff, SS-ASMD peers, and SS-ASMD family scales were 0.76, 0.76, 0.80, and 0.80, respectively.

CONCLUSIONS

The psychometric analysis of the SE/SS-ASMD supported its suitability as a new tool for researchers in the area of physical activity among people with SMDs.

Multimodal lifestyle intervention using a web-based tool to improve cardiometabolic health in patients with serious mental illness: results of a cluster randomized controlled trial (LION)

BACKGROUND

Unhealthy lifestyle behaviours contribute to alarming cardiometabolic risk in patients with serious mental illness (SMI). Evidence-based practical lifestyle tools supporting patients and staff in improving patient lifestyle are lacking.

METHODS

This multi-site randomized controlled pragmatic trial determined the effectiveness of a twelve-month multimodal lifestyle approach, including a web-based tool to improve patients' cardiometabolic health, versus care-as-usual. Using the web tool, nurses (trained in motivational interviewing) assisted patients in assessing their lifestyle behaviours, creating a risk profile and constructing lifestyle goals, which were discussed during fortnightly regular care visits. Twenty-seven community-care and sheltered-living teams were randomized into intervention (N = 17) or control (N = 10) groups, including 244 patients (140 intervention/104 control, 49.2% male, 46.1 ± 10.8 years) with increased waist circumference (WC), BMI or fasting glucose. The primary outcomes concerned differences in WC after six and twelve months intervention, while BMI and metabolic syndrome Z-score were secondary outcome measures.

RESULTS

General multilevel linear mixed models adjusted for antipsychotic medication showed that differences in WC change between intervention and control were - 0.15 cm (95%CI: - 2.49; 2.19) after six and - 1.03 cm (95%CI: - 3.42; 1.35) after twelve months intervention; however, the differences were not statistically significant. No intervention effects were found for secondary outcome measures. The intervention increased patients' readiness to change dietary behaviour.

CONCLUSION

A multimodal web-based intervention facilitating nurses to address lifestyle changes in SMI patients did not improve patient cardiometabolic health. Web-tool use was lower than expected and nurses need more lifestyle coaching knowledge and skills. The type of intervention and delivery mode need optimization to realize effective lifestyle care for SMI patients.

TRIAL REGISTRATION

Dutch Trial Registry, www.trialregister.nl , NTR3765, 21 December 2012.

Primary care management of cardiovascular risk for people with severe mental illnesses: the Primrose research programme including cluster RCT

Background

Effective interventions are needed to prevent cardiovascular disease (CVD) in people with severe mental illnesses (SMI) because their risk of CVD is higher than that of the general population.

Objectives

(1) Develop and validate risk models for predicting CVD events in people with SMI and evaluate their cost-effectiveness, (2) develop an intervention to reduce levels of cholesterol and CVD risk in SMI and (3) test the clinical effectiveness and cost-effectiveness of this new intervention in primary care.

Design

Mixed methods with patient and public involvement throughout. The mixed methods were (1) a prospective cohort and risk score validation study and cost-effectiveness modelling, (2) development work (focus groups, updated systematic review of interventions, primary care database studies investigating statin prescribing and effectiveness) and (3) cluster randomised controlled trial (RCT) assessing the clinical effectiveness and cost-effectiveness of a new practitioner-led intervention, and fidelity assessment of audio-recorded appointments.

Setting

General practices across England.

Participants

All studies included adults with SMI (schizophrenia, bipolar disorder or other non-organic psychosis). The RCT included adults with SMI and two or more CVD risk factors.

Interventions

The intervention consisted of 8–12 appointments with a practice nurse/health-care assistant over 6 months, involving collaborative behavioural approaches to CVD risk factors. The intervention was compared with routine practice with a general practitioner (GP).

Main outcome measures

The primary outcome for the risk score work was CVD events, in the cost-effectiveness modelling it was quality-adjusted life-years (QALYs) and in the RCT it was level of total cholesterol.

Data sources

Databases studies used The Health Improvement Network (THIN). Intervention development work included focus groups and systematic reviews. The RCT collected patient self-reported and routine NHS GP data. Intervention appointments were audio-recorded.

Results

Two CVD risk score models were developed and validated in 38,824 people with SMI in THIN: the Primrose lipid model requiring cholesterol levels, and the Primrose body mass index (BMI) model with no blood test. These models performed better than published Cox Framingham models. In health economic modelling, the Primrose BMI model was most cost-effective when used as an algorithm to drive statin prescriptions. Focus groups identified barriers to, and facilitators of, reducing CVD risk in SMI including patient engagement and motivation, staff confidence, involving supportive others, goal-setting and continuity of care. Findings were synthesised with evidence from updated systematic reviews to create the Primrose intervention and training programme. THIN cohort studies in 16,854 people with SMI demonstrated that statins effectively reduced levels of cholesterol, with similar effect sizes to those in general population studies over 12–24 months (mean decrease 1.2 mmol/l). Cluster RCT: 76 GP practices were randomised to the Primrose intervention (n = 38) or treatment as usual (TAU) (n = 38). The primary outcome (level of cholesterol) was analysed for 137 out of 155 participants in Primrose and 152 out of 172 in TAU. There was no difference in levels of cholesterol at 12 months [5.4 mmol/l Primrose vs. 5.5 mmol/l TAU; coefficient 0.03; 95% confidence interval (CI) –0.22 to 0.29], nor in secondary outcomes related to cardiometabolic parameters, well-being or medication adherence. Mean cholesterol levels decreased over 12 months in both arms (–0.22 mmol/l Primrose vs. –0.39 mmol/l TAU). There was a significant reduction in the cost of inpatient mental health attendances (–£799, 95% CI –£1480 to –£117) and total health-care costs (–£895, 95% CI –£1631 to –£160; p = 0.012) in the intervention group, but no significant difference in QALYs (–0.011, 95% CI –0.034 to 0.011). A total of 69% of patients attended two or more Primrose appointments. Audiotapes revealed moderate fidelity to intervention delivery (67.7%). Statin prescribing and adherence was rarely addressed.

Limitations

RCT participants and practices may not represent all UK practices. CVD care in the TAU arm may have been enhanced by trial procedures involving CVD risk screening and feedback.

Conclusions

SMI-specific CVD risk scores better predict new CVD if used to guide statin prescribing in SMI. Statins are effective in reducing levels of cholesterol in people with SMI in UK clinical practice. This primary care RCT evaluated an evidence-based practitioner-led intervention that was well attended by patients and intervention components were delivered. No superiority was shown for the new intervention over TAU for level of cholesterol, but cholesterol levels decreased over 12 months in both arms and the intervention showed fewer inpatient admissions. There was no difference in cholesterol levels between the intervention and TAU arms, which might reflect better than standard general practice care in TAU, heterogeneity in intervention delivery or suboptimal emphasis on statins.

Future work

The new risk score should be updated, deployed and tested in different settings and compared with the latest versions of CVD risk scores in different countries. Future research on CVD risk interventions should emphasise statin prescriptions more. The mechanism behind lower costs with the Primrose intervention needs exploring, including SMI-related training and offering frequent support to people with SMI in primary care.

Trial registration

Current Controlled Trials ISRCTN13762819.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 2. See the NIHR Journals Library website for further project information. Professor David Osborn is supported by the University College London Hospital NIHR Biomedical Research Centre and he was also in part supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Barts Health NHS Trust.

Effects of a behavioural weight loss intervention in people with serious mental illness: Subgroup analyses from the ACHIEVE trial

BACKGROUND

Persons with serious mental illnesses (SMI) such as schizophrenia and bipolar disorder have an increased risk of obesity and related chronic diseases and die 10-20years earlier than the overall population, primarily due to cardiovascular disease. In the ACHIEVE trial, a behavioural weight loss intervention led to clinically significant weight loss in persons with SMI. As the field turns its attention to intervention scale-up, it is important to understand whether the effectiveness of behavioural weight loss interventions for people with SMI, like ACHIEVE, differ for specific subgroups.

METHODS

This study examined whether the effectiveness of the ACHIEVE intervention differed by participant characteristics (e.g. age, sex, race, psychiatric diagnosis, body mass index) and/or their weight-related attitudes and behaviours (e.g. eating, food preparation, and shopping habits). We used likelihood-based mixed effects models to examine whether the baseline to 18 month effects of the ACHIEVE intervention differed across subgroups.

RESULTS

No statistically significant differences were found in the effectiveness of the ACHIEVE intervention across any of the subgroups examined.

CONCLUSIONS

These findings suggest that the ACHIEVE behavioural weight loss intervention is broadly applicable to the diverse population of individuals with SMI.

Case study of an adaptation and implementation of a Diabetes Prevention Program for individuals with serious mental illness

The Diabetes Prevention Program (DPP) is an evidence-based lifestyle intervention developed to decrease the risk for type 2 diabetes and promote weight loss in individuals at risk for diabetes. Individuals with serious mental illness have a greater risk for developing diabetes compared with the general population. In this article, the authors provide a detailed description of the adaptation process of the DPP for individuals with serious mental illness (DPP-SMI). The adaptation process was based on a cultural adaptation framework for modifying evidence-based interventions. To assess the effectiveness of the DPP-SMI, 11 individuals from a community mental health residential agency completed a 22-session pilot study of the adapted program and provided physiological measures before and after the intervention. As primary outcomes, participants were expected to report decreased body weight and increased physical activity per week. Completers had an average weight loss of 19 lbs (8%) and their physical activity increased from 161 to 405 min per week. These preliminary results together with participants' feedback informed further refinement of the DPP-SMI. This case study supports that individuals with serious mental illness can benefit from the DPP-SMI, which is tailored to meet the unique needs of this population group.

Impact of community lifestyle intervention on anthropometric parameters and body composition among overweight and obese women: findings from the MyBFF@home study

BACKGROUND

The prevalence of overweight and obesity among Malaysian women remained high over the past three decades. Collaboration with existing community at-risk may be feasible for wide-scale prevention of overweight and obesity in the country. The aims of this study were to examine the impact of community-based lifestyle intervention among overweight and obese women on their anthropometric and body composition changes as compared to the usual care group.

METHODS

This was a quasi-experimental study conducted in low-cost flats in Kuala Lumpur, Malaysia. A total of 255 overweight and obesity individuals aged between 18 to 59 years old were assigned to either the lifestyle intervention group (n = 169) or the usual care group (n = 146) over a period of 6 months. Individuals in the intervention group received 6 individual lifestyle counselling comprised of physical activity, diet counselling and self-monitoring components aimed to achieve at least 5% weight loss while individuals in the usual care group obtained six sessions of health care seminars from health care providers. These individuals were then followed-up for another 6 months without any intervention as part of maintenance period.

RESULTS

An intention-to-treat analysis of between-groups at 6-month of intervention (β, 95% CI) revealed greater changes in weight among intervention individuals' (- 1.09 kg vs. -0.99; p < 0.018) as compared to the control group. These changes were not sustained during the maintenance phase (between 6 and 12 months). Overall significant improvement at 12th month was found for visceral fat (- 0.78 vs. -0.64; p-value = 0.017), although no significant changes between groups were detected either during intervention or maintenance phase (p > 0.05). Individuals in the intervention group showed a significant increase for skeletal muscle mass (0.13 kg) than those individuals in the control group (- 0.37 kg), p = 0.033, throughout the study period.

CONCLUSION

This study provides evidence that an overweight and obesity prevention program can be implemented in a community setting, with some reduction of several anthropometric and body composition parameters.

Implementation of a Lifestyle Intervention for People With Serious Mental Illness in State-Funded Mental Health Centers

OBJECTIVE

The purpose of this study was to evaluate health outcomes of a state-supported implementation in community mental health settings of an evidence-based lifestyle intervention for overweight and obese adults with serious mental illness.

METHODS

Weight and fitness outcomes were evaluated for 122 overweight or obese adults with serious mental illness in four community mental health centers (CMHCs) that were participating in a phased statewide implementation of the In SHAPE lifestyle intervention. Six- and 12-month outcomes were compared between two CMHCs that implemented In SHAPE in the first 12 months and two CMHCs with similar characteristics that implemented In SHAPE in a subsequent phase in the statewide implementation 12 months later.

RESULTS

Participants in the two In SHAPE sites (N=63 participants) lost significantly more weight (p=.003) and showed greater improvement in fitness (p=.011) compared with participants at the two usual care control sites (N=59 participants). At six months, nearly half (49%) of In SHAPE participants and at 12 months more than half (60%) of In SHAPE participants showed clinically significant cardiovascular risk reduction defined as ≥5% weight loss or improved fitness (>50 m [164 feet] increase on the six-minute walk test). The difference between the In SHAPE and control groups was not statistically significant.

CONCLUSIONS

This natural experiment demonstrated promising public health benefits of a practical implementation of health promotion programming for overweight and obese adults with serious mental illness and offers a potential model for reducing risk of early mortality among individuals served by state-funded mental health centers nationwide.

Educational nurse-led lifestyle intervention for persons with mental illness

Although persons with severe mental illness face an increased risk of mortality and of developing negative health outcomes, research has shown that lifestyle interventions can sufficiently support their health. In response, this study examined a nurse-led lifestyle intervention developed in cooperation with members of municipal and county councils to gauge its impact on the quality of life, cognitive performance, walking capacity, and body composition of persons with severe mental illness. Lasting 26 weeks and involving 38 persons with severe mental illness, the intervention prioritised two components: the interpersonal relationships of persons with severe mental illness, staff, and group leaders and group education about physical and mental health. Pre-post intervention measurements of quality of life collected with the Manchester Short Assessment of Quality of Life, cognitive performance with the Frontal Systems Behaviour Scale, walking capacity with a 6-min walk test, and body composition in terms of waist circumference and body mass index were analysed using a nonparametric test Wilcoxon signed-rank test. Results suggest that the intervention afforded significant improvements in the health-related variables of quality of life, cognitive performance, walking capacity, and waist circumference for persons with severe mental illness. However, long-term studies with control groups and that examine parameters related to cardiovascular risk factors are essential to ensure the sustained impact of the intervention.

The Validity and Reliability Characteristics of the M-BACK Questionnaire to Assess the Barriers, Attitudes, Confidence, and Knowledge of Mental Health Staff Regarding Metabolic Health of Mental Health Service Users

Background

Addressing the burden of poor physical health and the subsequent gap in life expectancy experienced by people with mental illness is a major priority in mental health services. To equip mental health staff with the competence to deliver evidence-based interventions, targeted staff training regarding metabolic health is required. In order to evaluate the effectiveness of staff training regarding metabolic health, we aimed to develop a succinct measure to determine the barriers, attitudes, confidence, and knowledge of health practitioners through the development and test–retest reliability of the Metabolic-Barriers, Attitudes, Confidence, and Knowledge Questionnaire (M-BACK).

Methods

The M-BACK questionnaire was developed to evaluate the impact of specialized training in metabolic health care for mental health nurses. Content of the M-BACK was developed from a literature review and refined by an expert review panel and validated via a piloting process. To determine the test–retest reliability of the M-BACK, 31 nursing students recruited from the University of Notre Dame, Sydney completed the questionnaire on two separate occasions, 7 days apart. Intraclass correlation coefficients (ICCs) were calculated for the total score, as well as each of the four domains.

Results

Pilot testing was undertaken with a sample of 106 mental health nurses with a mean age 48.2, ranging from 24 to 63 years of age, who participated in six training courses. Questionnaire development resulted in a 16-item instrument, with each item is scored on a five-point Likert scale ranging from “strongly disagree” to “strongly agree.” Test–retest reliability of the M-BACK was completed by 30 of 31 nursing students recruited, ICCs ranged from 0.62 to 0.96.

Conclusion

The M-BACK is a reliable measure of the key elements of practitioner perceptions of barriers, and their knowledge, attitudes, and confidence regarding metabolic monitoring in people with mental illness. It can be used to assess the effectiveness of interventions aimed at increasing uptake of metabolic monitoring, a key component of programs to reduce the life expectancy gap in people living with severe mental illness.

Improving physical health of patients with severe mental disorders: a critical review of lifestyle psychosocial interventions

INTRODUCTION

People with severe mental disorders have a mortality rate that is more than two times higher than the general population, with at least a decade of potential years of life lost. People with mental disorders have a significantly higher risk of obesity, hyperglycemia and metabolic syndrome, which are related to modifiable risk factors, such as heavy smoking, poor physical activities, and inappropriate unhealthy diet, which can be improved through lifestyle changes. Areas covered: Lifestyle behaviours are amenable to change through the adoption of specific psychosocial interventions, and several approaches have been promoted. In the present review, the authors aim to: 1) critically analyze studies involving multimodal lifestyle interventions; 2) discuss the way forward to integrate these interventions in clinical routine care. Expert commentary: The psychoeducational approaches developed for the improvement of healthy lifestyle behaviours differ for several aspects: 1) the format (individual vs. group); 2) the setting (outpatient vs. inpatient vs. home-based); 3) the professional characteristics of the staff running the intervention (psychiatrists or nurses or dietitians or psychologists); 4) the active ingredients of the intervention (education only or inclusion of motivational interview or of problem solving); 5) the duration of treatment (ranging from 3 months to 2 years).

Use of a Wearable Activity Device in Rural Older Obese Adults: A Pilot Study

Objective: Assess the feasibility and acceptability of Fitbit for supporting behavioral change in rural, older adults with obesity. Method: Eight adults aged ≥65 with a body mass index (BMI) ≥30kg/m² were recruited from a rural practice and provided a Fitbit Zip device for 30 days. Participants completed validated questionnaires/interviews. Results: Mean age was 73.4 ± 4.0 years (50% female) with a mean BMI of 34.5 ± 4.5kg/m². We observed reductions in exercise confidence (sticking to it: 34.5 ± 3.3 to 30.9 ± 4.3, p = .04; making time: 18.9 ± 1.3 to 17.0 ± 2.6, p = .03) but no changes in patient activation (45.4 ± 4.3 vs. 45.0 ± 3.9). All reported high satisfaction, seven (87.5%) found Fitbit easy to use, and five (62.5%) found the feedback useful. The majority (n = 6 [75.0%]) were mostly/very satisfied with the intervention. Consistent themes emerged regarding the benefit of self-monitoring and participant motivation. Common concerns included finding time to exercise and lack of a peer group. Conclusion: Use of Fitbit is feasible/acceptable for use among older rural obese adults but may lead to reduced confidence.