A systematic review of behavioural smoking cessation interventions for people with severe mental ill health-what works?

Psychosocial Management of First-Episode Psychosis and Schizophrenia: Synopsis of the US Department of Veterans Affairs and US Department of Defense Clinical Practice Guidelines

BACKGROUND

Despite the large number of people treated for first-episode psychosis and schizophrenia within the Departments of Defense (DOD) and Veterans Affairs (VA), neither the DOD nor VA had established formal recommendations for the treatment of these conditions. This gap led Congress to require the development of clinical practice guidelines (CPG) for the treatment of schizophrenia. This paper reports on the psychosocial and rehabilitative recommendations presented in the VA/DOD Clinical Practice Guidelines for Management of First-Episode Psychosis and Schizophrenia.

STUDY DESIGN

The CPG was developed by an interdisciplinary panel of mental health and primary care providers from DOD and VA following methods specified by the VA/DOD Evidence-Based Practice Guideline Work Group. The panel formulated key questions and identified critical outcomes that guided a comprehensive search of the literature published from November 2011 to December 2021. The evidence considered was limited to systematic reviews, meta-analyses, and randomized clinical trials. Recommendations were based on the evaluation of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods.

STUDY RESULTS

The review process produced 4 psychosocial/rehabilitative treatment recommendations for first-episode psychosis (early intervention services, family interventions, individual placement and support (IPS), and cognitive behavioral therapy for psychosis) and 11 recommendations for schizophrenia (family and caregiver services, assertive community treatment, IPS, smoking cessation, skills training, cognitive training, psychotherapies, aerobic exercise, yoga, weight management, and telephone-based care management).

CONCLUSIONS

The VA/DOD CPG reflects the expansion of treatments for first-episode psychosis and schizophrenia and highlights the challenges in developing clinical practice guidelines.

Implementation of a smoking cessation intervention for people with severe mental illness in ambulatory mental healthcare (KISMET): A process evaluation

BACKGROUND

Recently, a cluster-randomised controlled trial was conducted within Dutch ambulatory mental healthcare to assess the effectiveness of a one-year smoking cessation intervention consisting of group sessions, peer support and pharmacological treatment (KISMET). This article presents its process evaluation, exploring the perceptions of patients and mental healthcare professionals (MHPs) regarding the implementation of KISMET.

METHODS

We conducted a mixed methods study, including 26 semi-structured interviews (10 MHPs and 16 patients) following the RE-AIM framework. Qualitative data was thematically analysed with MAXQDA software. We collected additional data on inclusion, drop-out and assessed treatment adherence during on-site observations.

RESULTS

Recruitment and subsequent retention of patients in the RCT was found to be challenging (58% drop-out at one-year follow-up). MHPs suggested more motivational enhancement techniques to aid recruitment and reduce study attrition. The intervention components were generally assessed positively. Patients experienced the group and peer support sessions as supportive and beneficial. Inconsistent group attendance was demotivating and disrupted implementation. Pharmacological treatment was found to be helpful, although MHPs mentioned the treating psychiatrist or clinical nurse specialist need to facilitate better to ensure medication supply. The handbook offered MHPs excellent guidance and significantly contributed to treatment fidelity. Surprisingly, the carbon monoxide monitoring (originally included in the study protocol for research purposes) was appraised as a motivational tool. Finally, shortage of staff, limited collaboration and high turnover were barriers for the delivery of the intervention. Implementation heavily depends on the quality of the collaboration between MHPs and patients, as well as the infrastructure created by the organisation.

CONCLUSION

This study demonstrates the benefits, unique demands and challenges of a smoking cessation intervention for people with SMI. Results could guide and improve the implementation of smoking cessation interventions in mental healthcare settings. Fostering a culture of connectivity through team development, along with the provision of supportive and communicative supervision is critical for the effective recruitment and retention in smoking cessation studies in psychiatric care.

Effectiveness and Adherence of Pharmacological vs. Non-Pharmacological Technology-Supported Smoking Cessation Interventions: An Umbrella Review

Background: Smoking cessation has a crucial public health role. To overcome non-technological and technology-based smoking cessation intervention limitations, technology-supported programs were developed. Objectives: The present umbrella review aimed to evaluate the long-term effectiveness (≥6 months) of pharmacological vs. non-pharmacological technology-supported smoking cessation interventions on adult daily smokers and the related human health benefits. Methods: Following PRISMA guidelines, the protocol was registered on PROSPERO (CRD42024601824). Fifty systematic reviews were included, evaluated through AMSTAR-2, and qualitatively synthesized. Results: A total of 69,269 smokers underwent pharmacological (39,367) and non-pharmacological (29,902) technology-supported interventions. The biochemically-verified effectiveness assessed as continuous abstinence rates (CARs) and seven-day point prevalence abstinence (PPA) of pharmacological vs. non-pharmacological at 6 and 12 months were, respectively, CARs 9.06% vs. 14.85%, 7-day PPA 17.37% vs. 17.15%; CARs 8.51% vs. 9.08%, 7-day PPA 14.00% vs. 5.63%. The 6-month adherence rates were higher in the non-pharmacological group (41.37% vs. 83.43%). Conclusions: Non-pharmacological technology-supported interventions showed similar effectiveness and higher adherence at 6 months. At 12 months, the CARs were similar despite lower adherence. Adherence quality and consistency may be important for sustained success, probably due to the "reverse causality". Non-pharmacological interventions showed similar effectiveness, lower costs, and shorter durations than pharmacological interventions.

A network approach to lifestyle behaviors and health outcomes in people with mental illness: the MULTI+ study III

BACKGROUND

Unhealthy lifestyle behaviors are prevalent among people with mental illness (MI), affecting their physical and mental health. Most research has focused on the isolated effects of lifestyle behaviors, leaving the interconnectedness between these behaviors and health outcomes unexplored. This study aimed to examine these relationships and identify the most strongly connected lifestyle behavior or health outcome within a network.

METHODS

We conducted a cross-sectional study with 423 inpatients with MI, receiving care as usual. Lifestyle behaviors, physical and mental health outcomes were assessed through questionnaires and routine data. A Gaussian Graphical Model was estimated, and strength centrality was calculated to identify the most influential nodes.

RESULTS

Mean age was 55.5 years, 42% were female, and 41% were diagnosed with schizophrenia. Psychological and physical quality of life (QoL), nighttime sleep problems, and overall sleep quality were the most strongly connected nodes. Sleep was strongly associated with physical QoL. Furthermore, there were negative associations between healthy food intake and cholesterol ratio, and positive associations between daily doses of antipsychotics and length of hospital stay. Node strength was stable (CS(cor = 0.7) = 0.75). No clear pattern emerged among other lifestyle behaviors and health outcomes.

CONCLUSIONS

This study offers insights into the interrelatedness of lifestyle behaviors and health outcomes. Addressing sleep problems could enhance QoL and potentially influence other health outcomes. Psychological and physical QoL were also strongly associated, emphasizing the importance of perceived well-being in health outcomes. Future research could explore causal pathways to identify treatment targets to improve care.

Connecting the dots: Understanding and addressing the metabolic impact of antipsychotic and antidepressant medications

Serious mental disorders such as schizophrenia and major depression are associated with considerable morbidity and mortality, resulting in much shorter life expectancies in those affected. The discovery of antipsychotic medications ushered in improved health outcomes for people with serious mental disorders but also brought about increased morbidity due to their metabolic side effects, including obesity and diabetes mellitus. Antidepressant medications have a more favorable metabolic side effect profile, but some can still cause weight gain and hyperglycemia. In this narrative review, we discuss antipsychotic and antidepressant medications' mechanisms of action, their respective effectiveness in treating psychosis and depression, and their metabolic side effects. In addition, we present therapeutic strategies for minimizing cardiometabolic health risks in patients treated with these medications by applying a comprehensive, biopsychosocial approach.

Implementation of stop smoking support by mental healthcare professionals: cross-sectional analysis of why nothing much happens

Smoking is highly prevalent and persistent among people with mental illness, but implementation of smoking cessation care by mental healthcare professionals (MHCPs) is lagging behind. This study took a broad approach to understanding implementation of stop smoking support (SSS) by MHCPs (N = 220 for main analyses), incorporating background characteristics, psychosocial factors, client factors, and organizational/environmental factors. Variable selection was based on previous work and the Consolidated Framework for Implementation Research. Cross-sectional survey data were collected online in the Netherlands from 2021 to 2022, and analyzed using logistic regression and regression tree analyses. Participants were 81 nurses, 74 psychologists, 40 psychiatrists, 12 child psychologists and 13 other MHCPs; aged 42 on average, 24% male, 14% currently smoked and 32% quit smoking. Results show that most MHCPs do not ask about smoking, do not advise or motivate clients to quit smoking, and do not refer clients motivated to quit to SSS. In order to improve this situation, proactive efforts should be undertaken to target MHCPs' perceptions of clients' responsibility and quit success, preferably through strategies that reach MHCPs regardless of their affinity with SSS, taking MHCPs' profession and own smoking status into account.

Effects of interventions on smoking cessation: A systematic review and network meta-analysis

A network meta-analysis (NMA) including randomized controlled trials (RCTs) was conducted to evaluate the effects of different interventions on smoking cessation. Studies were collected from online databases including PubMed, EMBASE, Cochrane Library, and Web of Science based on inclusion and exclusion criteria. Eligible studies were further examined in the NMA to compare the effect of 14 interventions on smoking cessation. Thirty-four studies were examined in the NMA, including a total of 14 interventions and 28 733 participants. The results showed that health education (HE; odds ratio ([OR] = 200.29, 95% CI [1.62, 24 794.61])), other interventions (OI; OR = 29.79, 95% CI [1.07, 882.17]) and multimodal interventions (MUIs; OR = 100.16, 95% CI [2.06, 4867.24]) were better than self-help material (SHM). HE (OR = 243.31, 95% CI [1.39, 42531.33]), MUI (OR = 121.67, 95% CI [1.64, 9004.86]) and financial incentive (FI; OR = 14.09, 95% CI [1.21, 164.31]) had positive effects on smoking cessation rate than smoking cessation or quitting APP (QA). Ranking results showed that HE (83.6%) and motivation interviewing (MI; 69.6%) had better short-term effects on smoking cessation. HE and MUI provided more smoking cessation benefits than SHM and QA. FI was more effective at quitting smoking than QA. Also, HE and MI were more likely to be optimal smoking cessation interventions.

Digital interventions targeting excessive substance use and substance use disorders: a comprehensive and systematic scoping review and bibliometric analysis

Addictive substances are prevalent world-wide, and their use presents a substantial and persistent public health problem. A wide range of digital interventions to decrease use and negative consequences thereof have been explored, differing in approach, theoretical grounding, use of specific technologies, and more. The current study was designed to comprehensively map the recent (2015-2022) extant literature in a systematic manner, and to identify neglected and emerging knowledge gaps. Four major databases (Medline, Web of Science Core Collection, and PsychInfo) were searched using database-specific search strategies, combining terms related to clinical presentation (alcohol, tobacco or other drug use), technology and aim. After deduplication, the remaining n=13,917 unique studies published were manually screened in two stages, leaving a final n=3,056 studies, the abstracts of which were subjected to a tailored coding scheme. Findings revealed an accelerating rate of publications in this field, with randomized trials being the most common study type. Several meta-analyses on the topic have now been published, revealing promising and robust effects. Digital interventions are being offered on numerous levels, from targeted prevention to specialized clinics. Detailed coding was at times made difficult by inconsistent use of specific terms, which has important implications for future meta-analyses. Moreover, we identify several gaps in the extant literature - few health economic assessments, unclear descriptions of interventions, weak meta-analytic support for some type of interventions, and limited research on many target groups, settings and new interventions like video calls, chatbots and artificial intelligence - that we argue are important to address in future research.

Using digital technology to promote physical health in mental healthcare: A sequential mixed-methods study of clinicians' views

AIM

Recent years have seen innovation in 'mHealth' tools and health apps for the management/promotion of physical health and fitness across the general population. However, there is limited research on how this could be applied to mental healthcare. Therefore, we examined mental healthcare professionals' current uses and perceived roles of digital lifestyle interventions for promoting healthy lifestyles, physical health and fitness in youth mental healthcare.

METHODS

A sequential, mixed-methods design was used, consisting of a quantitative online survey, followed by qualitative in-depth interviews.

RESULTS

A total of 127 mental healthcare professionals participated in the online survey. Participants had limited mHealth experience, and the majority agreed that further training would be beneficial. Thirteen mental healthcare professionals were interviewed. Five themes were generated (i) digital technology's ability to enhance the physical healthcare; (ii) Conditions for the acceptability of apps; (iii) Limitations on staff capability and time; (iv) Motivation as the principal barrier; and (v) Practicalities around receiving lifestyle data. Systematic integration of data produced novel insights around: (i) staff involvement and needs; (ii) ideal focus and content of digital lifestyle interventions; and (iii) barriers towards implementation (including mental healthcare professionals own limited experience using digital lifestyle interventions, which aligned with the appeal of formal training).

CONCLUSIONS

Overall, digital lifestyle interventions were positively received by mental healthcare professionals, particularly for health behaviour-tracking and mHealth support for exercise and nutrition. Practical suggestions for facilitating their uptake/implementation to improve availability of physical health interventions in mental healthcare are presented.

Association Between Mental Health Burden, Clinical Presentation, and Outcomes in Individuals With Symptomatic Peripheral Artery Disease: A Scientific Statement From the American Heart Association

Along with the rising burden of peripheral artery disease (PAD), mental health concerns are increasingly being recognized as a comorbidity to address in the chronic disease management of symptomatic PAD. Apart from a high prevalence of comorbid mental health conditions, the role of pain and changing health behaviors and the broader impacts of illness and adaptation to living with PAD require specialized behavioral health expertise. This scientific statement builds a case that this expertise should be integrated within the multidisciplinary PAD team. Furthermore, areas such as cognitive dysfunction and palliative care are highlighted as needing psychological interventions. Although much of the evidence of the efficacy of psychological and psychotropic interventions has been extrapolated from other cardiovascular populations, evidence for the role of psychological interventions for behavior change, for example, uptake of exercise regimens, is increasingly being accrued within PAD. Areas for behavioral health needs and interactions with PAD treatment are discussed, including the use of opioids, depression management, anxiety and stress reduction interventions, the use of benzodiazepines and antidepressants, smoking cessation, rehabilitation trajectories after amputation, and the role of cognitive decline for PAD treatment and outcomes. A case summary highlights the stigma around mental health and vascular disease and the fragmentation of care. This scientific statement provides remarks for building a road map for integrated behavioral PAD care and potential solutions to overcome these barriers. Instrumental to reaching these changes are interprofessional advocacy efforts and initiatives that help break down the stigma around mental health and promote evidence-based collaborative, nonhierarchical, and multidisciplinary PAD care.

Neurobiological associations between smoking and internalizing disorders

People with severe mental disorders have a higher mortality rate due to preventable conditions like cardiovascular diseases and respiratory diseases. Nicotine addiction is a preventable risk factor, with tobacco use being twice as high in people with mental disorders. An integrative model that divides mental disorders into externalising, internalising, and thought disorders could be useful for identifying common causalities and risk factors. This review aims to examine the interface between smoking and internalising disorders, specifically schizophrenia, depressive disorders, and anxiety disorders. The review finds that there is a clear association between smoking behaviour and these disorders. Schizophrenia is associated with polymorphisms that result in an imbalance between glutamate and GABA release and abnormalities of dopaminergic pathways. Nicotine improves dopaminergic signalling and balances glutamatergic and GABAergic pathways, improving symptoms and increasing the risk of nicotine dependence. In depressive disorders, smoking is associated with functional changes in brain regions affected by smoking and self-medication. In anxiety disorders, there is a bidirectional relationship with smoking, involving the amygdala and changes in dopaminergic pathways and cortisol production. Smoking poses a threat to people living with psychiatric disorders and calls for further research to assess the interactions between nicotine dependence and internalising and thought disorders.

The detrimental effects of smoking on the course and outcome in adults with bipolar disorder-A narrative review

BACKGROUND

Smoking is a substantial and avoidable risk for physical disability and premature death. Despite a declining tobacco use in the community of developed countries, smoking remains abundant in people with mental disorders. This narrative review highlights the epidemiology, consequences and treatment options of tobacco use disorder (TUD) and nicotine dependence (ND) in people with bipolar disorder (BD).

METHODS

The authors conducted a Medline literature search from 1970 to November 2022 using MeSH terms "bipolar disorder" x "smoking" or "nicotine" or "tobacco" that retrieved 770 results. Search results were complemented by additional literature retrieved from examining cross references and by hand search in text books. Finally, 92 references were considered as essential and selected for the educational purpose of this review.

SUMMARY OF FINDINGS

Lifetime and point prevalence of smoking in people with BD is in the range of 45-70% and thus about 2-3 times more frequent in BD than in community samples. Smoking, TUD and ND have a detrimental impact both on mental and physical health as well as mortality in people with BD. In the absence of large controlled studies in comorbid BD and TUD or ND, pharmacological treatment follows the individual guidance for each disorder. Community-based psychosocial interventions for TUD and ND appear to be suitable in people with BD, too, as well as Cognitive Behavioral (CBT) or Acceptance and Commitment (ACT) based psychotherapies.

CONCLUSIONS

Smoking is a modifiable risk factor causing increased risks both for mental and physical health in BD, and deserves more attention in treatment. More treatment research into pharmacological and psychosocial interventions in comorbid BD and TUD or ND are still needed to deliver evidence-based recommendations to physicians.

The Impact of Increasing Community-Directed State Mental Health Agency Expenditures on Violent Crime

Violent crime remains a prevalent threat to population health within the United States. States offer varying policy approaches to prevent violent crime and support behavioral health, such as community-based programs that include substance use disorder prevention and treatment. Using state mental health agency data, we construct a panel of U.S. states over nine years and apply an instrumental variables empirical model with state and time fixed effects to adjust for policy endogeneity, omitted variable bias, and time trends. We find that a 10% increase in community-directed state mental health agency expenditures yielded nearly a 4% reduction in violent crime rates. Larger magnitude reductions in violent crime rates were associated with the presence of gun control regulations and increases in the proportion of the population completing secondary education. Policymakers should consider the added benefit of violent crime reduction when considering budgetary allocations of community-directed state mental health agency expenditures.