Effect of lifestyle coaching versus care coordination versus treatment as usual in people with severe mental illness and overweight: Two-years follow-up of the randomized CHANGE trial

Treating obesity in patients with depression: a narrative review and treatment recommendation

The high morbidity of obesity and depression pose significant public health concerns, with the prevalence of obesity doubling in the US between 1990 and 2022 and patients frequently presenting with both. Untreated obesity and depression can greatly impact patient health and well-being, as both obesity and depression are associated with a number of comorbidities including sleep apnea, type 2 diabetes mellitus, metabolic syndrome, metabolic dysfunction-associated steatotic liver disease, and cardiovascular disease. This narrative review aims to provide a comprehensive and current overview of the overlapping etiologies between obesity and depression as well as the available treatment options that may be recommended by primary care professionals to treat these patients with concomitant obesity and depression. With the considerable overlap in the population of patients with obesity and depression, as well as the overlap in the neurobiological, hormonal, and inflammatory pathways underlying both diseases, primary care professionals should consider screening patients presenting with obesity for depression. Holistic treatment options, including lifestyle and behavioral modifications, and pharmacotherapy for both depression and obesity and bariatric surgery for obesity are critical to manage both conditions simultaneously. Therefore, due to the overlapping neurobiological pathways and mechanisms responsible for the incidence and progression of both obesity and depression, a holistic treatment plan including strategies with efficacy for both conditions and any additional comorbidities may improve the clinical approach for patients with concomitant obesity and depression.

Impact of nutritional interventions on quality of life in schizophrenia spectrum disorders: a scoping review

OBJECTIVES

Schizophrenia is a chronic condition that requires long-term management. Quality of life is an important outcome measure for individuals diagnosed with schizophrenia; it can be tracked over time allowing evaluation of whether interventions lead to sustainable improvements. Nutrition and dietary interventions are an underutilized treatment for tackling the metabolic consequences of mental illness, which is now recognized as having increased importance in the management of schizophrenia. This study examines the impact of nutrition and dietary interventions on quality of life outcomes for those with schizophrenia.

METHODS

A systematic review of the literature was conducted, assessing the impact of nutritional interventions on quality of life outcomes in individuals with a diagnosis of schizophrenia.

RESULTS

A total of 982 articles were screened, of which nine articles met the inclusion criteria. Quality of life measures varied across studies, which made comparison across studies challenging. Previous studies had relatively small sample sizes and did not have long follow-up durations. Some of the studies found that dietary interventions such as counselling, weight management programs, food diaries and nutritional education improved quality of life, whereas others did not detect any effect.

CONCLUSIONS

The review provides preliminary evidence that nutrition and dietary interventions may benefit quality of life among individuals with schizophrenia. There were however substantial limitations in studies highlighting the need for further research. The paper also highlights the need to standardize assessment tools for future quality-of-life research.

A systematic review of randomized controlled trials in a general practice setting aiming to reduce excess all-cause mortality and enhance cardiovascular health in patients with severe mental illness

OBJECTIVE

People with severe mental illness (SMI) have a reduced life expectancy, primarily due to chronic somatic diseases like cardiovascular disorders. Integrated care in general practice addressing mental and physical health may reduce excess mortality in this population. This review assessed the effectiveness of collaborative care, general integrated care, and physical health interventions in reducing overall mortality in patients with SMI. Secondary outcomes included disease-specific mortality, cardiovascular health indicators, and health-related quality of life.

METHODS

We searched PubMed, PsycINFO, Cochrane Library, and Embase for randomized controlled trials published before April 24, 2024. Eligible studies focused on integrated care interventions targeting somatic health in patients with SMI. Two reviewers independently conducted data extraction and risk of bias assessment. The study was registered with PROSPERO (CRD42022328464).

RESULTS

Of 2904 identified publications, 17 were included (covering 13 studies). Seven studies reported mortality data, with one showing reduced mortality in patients with major depressive disorder receiving collaborative care. No studies examined disease-specific mortality. Nine studies assessed cardiovascular outcomes, with three reporting reduced cardiovascular risk in collaborative care interventions simultaneously targeting depression and cardiovascular factors. Seven studies reported on quality of life, with three finding improvements. Study quality was rated moderate to high.

CONCLUSION

We found low-certainty evidence that collaborative care reduces mortality in depression. There was moderate evidence that collaborative care models, simultaneously addressing mental and cardiovascular health could potentially improve cardiovascular health in depression. The limited number of studies and their focus on depression limit the generalizability of these findings to other SMIs.

Implementation of the healthy heart tool- an algorithm with potential cardiometabolic health benefits in persons with severe mental illness

BACKGROUND

Cardiometabolic diseases are the main causes of death in persons with severe mental illness (SMI), highlighting the need to improve management of cardiovascular risk factors in both primary and specialized health care. The "Healthy Heart Tool" aims at helping health care workers to identify persons at risk, and to initiate proper interventions. Here we investigate if the recommendations in the Healthy Heart Tool are followed one year after implementation and whether implementation of the tool improved cardiometabolic risk factors in SMI.

METHODS

Data from 270 individuals with SMI from six Norwegian hospitals were collected at baseline and at 12 months after implementation of the Healthy Heart Tool throughout the health care services. Changes from baseline to 12 months follow-up were analyzed using chi-square and independent t-tests, whereas implementation effects were analyzed using logistic general linear mixed models.

RESULTS

After implementing the Healthy Heart Tool, significantly more persons received dietary advice and/or salt restriction advice (75.5% vs. 84.8%, p = 0.035). After controlling for Body Mass Index (BMI) ≥ 30 and sex, there was an odds ratio (OR) of 8.9 (95% CI 1.42-55.77) for receiving dietary advice and/or advice on salt reduction. There was a significant reduction (p = 0.016) in numbers of participants with high levels of total serum cholesterol ≥ 5 mmol/ (54.4% vs. 46.3%).

CONCLUSIONS

Implementing the Healthy Heart Tool can increase awareness of cardiovascular risk factors in patients with SMI. The intervention increased the proportion of individuals who received dietary and salt reduction advice and decreased the proportion of individuals with high cholesterol levels. However, due to the small numbers, these results should be interpreted with caution. Nonetheless, the findings suggest that the Healthy Heart Tool may be an effective means for improving the management of cardiovascular risk factors in individuals with SMI in typical clinical settings.

TRIAL REGISTRATIONS

The trial was retrospectively registered in ClinicalTrials.gov 29.01.25, ID NCT06807242.

Neurobiological Mechanisms Link Bipolar Disorder to Cardiovascular Disease: A Retrospective Biobank Study of Adverse Event Risk and Contributory Mechanisms

OBJECTIVE

Individuals with bipolar disorder are at greater risk of developing cardiovascular disease. However, the mechanisms underlying this association remain poorly understood. This study aimed to (1) determine the risk of major adverse cardiovascular events (MACE) after adjusting for important confounders and (2) evaluate the neural, autonomic, and immune mechanisms underlying the link between bipolar disorder and cardiovascular disease.

METHODS

Leveraging the Mass General Brigham Biobank, bipolar disorder and incident MACE were identified using the International Classification of Disease (ICD) codes. Incident MACE events were assessed from enrollment to the date of data lock (December 2020); or to the 10-year period. Health behavior data were derived from optional surveys. Cox regression hazard models were applied.

RESULTS

Of 118,827 Biobank participants, 6009 were diagnosed with bipolar disorder. Those with bipolar disorder (vs. without) demonstrated a higher risk of MACE after adjusting for cardiovascular risk factors (hazard ratio [95% confidence interval] = 1.29 [1.10-1.51], p = 0.002). The relationship remained significant over 10 years after adjustment for unhealthy lifestyle behaviors (1.29 [1.03, 1.61], p = 0.025). Furthermore, SNA, autonomic nervous system, and inflammatory markers each significantly associated with both bipolar disorder and MACE risk. Each of these measures mediated the association between bipolar disorder and MACE (accounting for 3.8%-17.8% of the relationship).

CONCLUSION

This study demonstrates that bipolar disorder associates with heightened cardiovascular risk, even after accounting for cardiovascular risk. Moreover, the findings suggest that neurobiological pathways and perturbations in autonomic and inflammatory pathways may confer cardiovascular risk in bipolar disorder.

Predicting cardiovascular disease in patients with mental illness using machine learning

BACKGROUND

Cardiovascular disease (CVD) is twice as prevalent among individuals with mental illness compared to the general population. Prevention strategies exist but require accurate risk prediction. This study aimed to develop and validate a machine learning model for predicting incident CVD among patients with mental illness using routine clinical data from electronic health records.

METHODS

A cohort study was conducted using data from 74,880 patients with 1.6 million psychiatric service contacts in the Central Denmark Region from 2013 to 2021. Two machine learning models (XGBoost and regularised logistic regression) were trained on 85% of the data from six hospitals using 234 potential predictors. The best-performing model was externally validated on the remaining 15% of patients from another three hospitals. CVD was defined as myocardial infarction, stroke, or peripheral arterial disease.

RESULTS

The best-performing model (hyperparameter-tuned XGBoost) demonstrated acceptable discrimination, with an area under the receiver operating characteristic curve of 0.84 on the training set and 0.74 on the validation set. It identified high-risk individuals 2.5 years before CVD events. For the psychiatric service contacts in the top 5% of predicted risk, the positive predictive value was 5%, and the negative predictive value was 99%. The model issued at least one positive prediction for 39% of patients who developed CVD.

CONCLUSIONS

A machine learning model can accurately predict CVD risk among patients with mental illness using routinely collected electronic health record data. A decision support system building on this approach may aid primary CVD prevention in this high-risk population.

Effectiveness of lifestyle intervention on prevention/management of antipsychotic-induced weight gain among persons with severe mental illness: A systematic review and meta-analysis

Individualized lifestyle interventions using motivational interviewing (MI) approach are recommended for persons with severe mental illness (SMI) for effective weight management. The aim of this meta-analysis was to assess the effectiveness of various lifestyle interventions that addressed obesity among persons with SMI. Twelve RCTs were assessed by individual reviewers using revised cochrane risk-of-bias tool (RoB 2). The standardized mean difference (SMD) was calculated with a 95% CI. The age of participants was between 18 and 70 years. Waist circumference showed an SMD of -0.09 (-0.22, 0.03), weight -0.03 (-0.10, 0.15) and BMI -0.07 (-0.07, 0.22). The findings in this meta-analysis revealed that though lifestyle interventions were statistically insignificant in reducing antipsychotic induced weight gain among persons with SMI, they show changes in intervention group. Psychosocial management along with lifestyle interventions, and MI are effective in the management of antipsychotic induced weight gain.

Health and Wellness Coaching and Sustained Gains: A Rapid Systematic Review

The Transtheoretical Model of Change identifies key stages in behavior change, including a maintenance stage occurring when a behavior has been upheld for at least 6 months. Health and wellness coaching has demonstrated support for health behavior change, but maintenance of gains has received little attention. Our rapid systematic literature review characterizes both the research exploring sustained gains with health and wellness coaching and what is known about sustained gains after the completion of a health and wellness coaching engagement. Guided by The Cochrane Rapid Reviews Methods Group "Interim Guidance," we drew 231 studies from the 2018 and 2020 Sforzo et al "Compendium of the health and wellness coaching literature," and "Addendum…" appendices. Initial screening and coding for inclusion and exclusion criteria yielded 28 studies for data extraction. We examined studies across outcome categories (physiological, behavioral, psychological, and health risk assessment) to determine whether outcome measures were: not sustained; partially sustained; fully sustained; or improved from immediate post-intervention to a later follow-up period. Twenty-five of the 28 studies reviewed demonstrated partially, or fully, sustained or improved outcomes in one or more variables studied, with sustained gains demonstrated across outcome categories, strengthening confidence in HWC as a facilitator of lasting change.

Lifestyle Coaching May Be an Effective Treatment for Schizophrenia

This commentary critiques the Danish CHANGE trial, which evaluated 3 levels of outpatient intervention intensity, in a group of outpatients with obesity and schizophrenia. Neither adding care coordination with weekly nurse contacts alone nor combining this treatment with assertive community lifestyle coaching as compared to treatment as usual improved outcomes, which included cardiovascular disease risk calculation, cardiorespiratory fitness, weight, and self-reported behaviors such as smoking, physical activity, and diet. The CHANGE trial investigators appear strongly averse to recommending the development and implementation of lifestyle medicine programs as a major component when treating outpatients with severe mental disorders. The potential dismissal of lifestyle medicine as a component of treatment for severe mental disorders is problematic. Valuable lessons can be learned from more thoroughly analyzing secondary outcomes such as medical and psychiatric hospitalization rates and total health care cost. The CHANGE trial data analysis needs to be expanded beyond the focus on changes in weight and serum cholesterol. Insulin resistance and high refined carbohydrate intake may be major factors in determining both the medical and psychiatric clinical course of schizophrenia. Assertive community lifestyle coaching is a novel treatment modality. Evidence strongly suggests assertive community lifestyle coaching substantially decreases both psychiatric and medical hospitalization rates.

Psychotropic Drug-Related Weight Gain and Its Treatment

Psychotropic drug-related weight gain (PDWG) is a common occurrence and is highly associated with non-initiation, discontinuation, and dissatisfaction with psychiatric drugs. Moreover, PDWG intersects with the elevated risk for obesity and associated morbidity that has been amply reported in the psychiatric population. Evidence indicates that differential liability for PDWG exists for antipsychotics, antidepressants, and anticonvulsants. During the past two decades, agents within these classes have become available with significantly lower or no liability for PDWG and as such should be prioritized. Although lithium is associated with weight gain, the overall extent of weight gain is significantly lower than previously estimated. The benefit of lifestyle and behavioral modification for obesity and/or PDWG in psychiatric populations is established, with effectiveness similar to that in the general population. Metformin is the most studied pharmacological treatment in the prevention and treatment of PDWG, and promising data are emerging for glucagon-like peptide-1 (GLP-1) receptor agonists (e.g., liraglutide, exenatide, semaglutide). Most pharmacologic antidotes for PDWG are supported with low-confidence data (e.g., topiramate, histamine-2 receptor antagonists). Future vistas for pharmacologic treatment for PDWG include large, adequately controlled studies with GLP-1 receptor agonists and possibly GLP-1/glucose-dependent insulinotropic polypeptide co-agonists (e.g., tirzepatide) as well as specific dietary modifications.

A Network Model of Health-Related Changes after a Lifestyle-Enhancing Treatment in Patients with Severe Mental Illness: the MULTI Study VI

Background/Objective

The effects of lifestyle interventions on physical and mental health in people with severe mental illness (SMI) are promising, but its underlying mechanisms remain unsolved. This study aims to examine changes in health-related outcomes after a lifestyle intervention, distinguishing between direct and indirect effects.

Method

We applied network intervention analysis on data from the 18-month cohort Multidisciplinary Lifestyle enhancing Treatment for Inpatients with SMI (MULTI) study in 106 subjects (62% male, mean age=54.7 (SD=10.8)) that evaluated changes in actigraphy-measured physical activity, metabolic health, psychopathology, psychosocial functioning, quality of life and medication use after MULTI (n=65) compared to treatment as usual (n=41).

Results

MULTI is directly connected to decreased negative symptoms and psychotropic medication dosage, and improved physical activity and psychosocial functioning, suggesting a unique and direct association between MULTI and the different outcome domains. Secondly, we identified associations between outcomes within the same domain (e.g., metabolic health) and between the domains (e.g., metabolic health and social functioning), suggesting potential indirect effects of MULTI.

Conclusions

This novel network approach shows that MULTI has direct and indirect associations with various health-related outcomes. These insights contribute to the development of effective treatment strategies in people with severe mental illness.

Relationship between Physical Activity and Health Outcomes in Persons with Psychotic Disorders after Participation in a 2-Year Individualized Lifestyle Intervention

People with psychotic disorders have a significantly increased risk of physical diseases and excessive mortality rates. The aim of the study was to investigate relationships between changes in physical activity, levels of salutogenic health, and glycated hemoglobin among people with psychotic disorders after participation in an individualized lifestyle intervention. The results from analyses showed that self-reported increased physical activity was positively associated with the level of salutogenic health and negatively associated with the level of HbA1c on an individual level. The results indicate that coordinated, individualized, holistic and health-promoting nursing care is crucial to enabling enhanced lifestyle within this vulnerable target group.

Dosing of Health and Wellness Coaching for Obesity and Type 2 Diabetes: Research Synthesis to Derive Recommendations

Health and wellness coaching (HWC) is an effective intervention for lifestyle disease such as obesity and type 2 diabetes. The evolving HWC profession needs recommendations to guide clinical practice, particularly the appropriate dose of coaching. The purpose of this paper was to systematically review and synthesize HWC literature to derive HWC programming recommendations. Of 102 papers retrieved, 88 were retained with data extracted determining HWC session number, frequency, duration, program length, and total coaching load. Differential analysis yielded no statistical difference in programming variables for randomized control trials and other designs, nor for studies with significant findings v. those not finding statistical significance, allowing these data to be pooled. The HWC intervention for obesity was slightly more intense (15 sessions over 7-8 mo) than the diabetes programming (12 sessions over 9-10 mo). On average, HWC programming applied in the peer-reviewed literature was 12-15 sessions of 35-40 min duration over 7-9 months. These recommendations for HWC programming variables are put forth as initial practice guidelines and should be examined with comparative effectiveness study for optimization. HWC best practice guidelines for other patient groups (e.g., heart disease, cancer, and chronic pain) should also be studied once an adequate literature data base is available.

Interventions to Promote the Utilization of Physical Health Care for People with Severe Mental Illness: A Scoping Review

BACKGROUND

The main contributor to excess mortality in severe mental illness (SMI) is poor physical health. Causes include unfavorable health behaviors among people with SMI, stigmatization phenomena, as well as limited access to and utilization of physical health care. Patient centered interventions to promote the utilization of and access to existing physical health care facilities may be a pragmatic and cost-effective approach to improve health equity in this vulnerable and often neglected patient population.

OBJECTIVE/METHODS

In this study, we systematically reviewed the international literature on such studies (sources: literature databases, trial-registries, grey literature). Empirical studies (quantitative, qualitative, and mixed methods) of interventions to improve the utilization of and access to medical health care for people with a SMI, were included.

RESULTS

We identified 38 studies, described in 51 study publications, and summarized them in terms of type, theoretical rationale, outcome measures, and study author's interpretation of the intervention success.

CONCLUSIONS

Useful interventions to promote the utilization of physical health care for people with a SMI exist, but still appear to be rare, or at least not supplemented by evaluation studies. The present review provides a map of the evidence and may serve as a starting point for further quantitative effectiveness evaluations of this promising type of behavioral intervention.

Evaluating the implementation of a multidisciplinary lifestyle intervention for people with severe mental illness in sheltered housing: effectiveness-implementation hybrid randomised controlled trial

BACKGROUND

Lifestyle interventions can improve health-related outcomes for people with severe mental illness (SMI), but few studies evaluate this potential in everyday settings. After a successful approach in routine inpatient mental healthcare (MULTI), we sought to replicate this multidisciplinary lifestyle-enhancing support in people with SMI living in sheltered housing (MULTI_sh).

AIMS

To evaluate the effectiveness and implementation of MULTI_sh (trial registration: NCT03157557).

METHOD

In an effectiveness-implementation hybrid cluster-randomised controlled trial, six municipalities with sheltered housing facilities in The Netherlands were randomly assigned to MULTI_sh (n = 3) or treatment as usual (TAU, n = 3). After 12 months, we evaluated effects on metabolic health, sedentary behaviour/physical activity (ActiGraph GT3X+), quality of life (EuroQol 5D, WHOQoL-Bref) and psychopathology (Brief Psychiatric Rating Scale Expanded Version) using multiple regression, adjusting for baseline values and municipalities (intention to treat and per protocol). In addition, implementation fidelity and barriers/facilitators were evaluated (Measurement Instrument for Determinants of Innovation).

RESULTS

Of 177 eligible patients, 74 (42%) could be included in the analyses. Health outcomes did not substantially improve with MULTI_sh (n = 45) compared with TAU (n = 29). MULTI_sh was not implemented as intended. Most patients and all healthcare professionals believed that patients' lifestyle should be part of treatment, but implementation was primarily (in)directly hindered by organisational factors (e.g. staff shortages, complexity of participation, lack of time and difficulty getting patients involved).

CONCLUSIONS

MULTI_sh was not implemented as intended and no clinical health improvements were found. Organisations are decisive in the success or failure of the implementation of lifestyle interventions for people with SMI. More intensive implementation strategies on this level are warranted in sheltered housing.

Improving physical activity and diet in patients with severe mental disorders: Results from the LIFESTYLE multicentric, real-world randomized controlled trial

Aims of the present study are to test the efficacy of a lifestyle group intervention, compared to a brief psychoeducational intervention, on levels of physical activity and dietary habits in a real-world sample of patients with severe mental disorders. The study, funded by the Italian Ministry of Education, has been carried out in six Italian University psychiatric outpatient units. All patients were randomly assigned to the experimental or control group and were assessed through standardized assessment instruments at baseline and six months after randomization. Of the 401 recruited patients, 43.3% had a diagnosis of bipolar disorder, 29.9% of psychosis and 26.9% of major depression. Patients were mainly female (57%), with a mean age of 45.6±11.8 years. Treated patients have almost 8 times the likelihood to show an increase of the total MET (OR: 8.02; p < .001) and of the walking MET (OR: 7.68; p < .001) and are more likely to increase the weekly consumption of vegetables (OR= 1.98, p < .05) and to reduce that of junk food (OR:0.23; p < .05). The present study support the notion that patients with severe mental disorders can improve their lifestyle behaviours and that, with appropriate support, they can achieve a healthy living.

Systematic review of lifestyle interventions to improve weight, physical activity and diet among people with a mental health condition

BACKGROUND

People with a mental health condition experience an elevated risk of chronic disease and greater prevalence of health and behaviours. Lifestyle interventions aim to reduce this risk by modifying health behaviours such as physical activity and diet. Previous reviews exploring the efficacy of such interventions for this group have typically limited inclusion to individuals with severe mental illness (SMI), with a focus of impact on weight. This review assessed the efficacy of lifestyle interventions delivered in community or outpatient settings to people with any mental health condition, on weight, physical activity and diet.

METHODS

Eligible studies were randomised or cluster-randomised controlled trials published between January 1999 and February 2019 aiming to improve weight, physical activity or diet, for people with any mental health condition. Two reviewers independently completed study screening, data extraction and assessment of methodological quality. Primary outcome measures were weight, physical activity and diet. Secondary outcome measures were body mass index (BMI), waist circumference, sedentary behaviour and mental health. Where possible, meta-analyses were conducted. Narrative synthesis using vote counting based on direction of effect was used where studies were not amenable to meta-analysis.

RESULTS

Fifty-seven studies were included (49 SMI only), with 46 contributing to meta-analyses. Meta-analyses revealed significant (< 0.05) effect of interventions on mean weight loss (-1.42 kg), achieving 5% weight loss (OR 2.48), weight maintenance (-2.05 kg), physical activity (IPAQ MET minutes: 226.82) and daily vegetable serves (0.51), but not on fruit serves (0.01). Significant effects were also seen for secondary outcomes of BMI (-0.48 units) and waist circumference (-0.87cm), but not mental health (depression: SMD -0.03; anxiety: SMD -0.49; severity of psychological symptoms: SMD 0.72). Studies reporting sedentary behaviour were not able to be meta-analysed. Most trials had high risk of bias, quality of evidence for weight and physical activity were moderate, while quality of evidence for diet was low.

CONCLUSION

Lifestyle interventions delivered to people with a mental health condition made statistically significant improvements to weight, BMI, waist circumference, vegetable serves and physical activity. Further high-quality trials with greater consistency in measurement and reporting of outcomes are needed to better understand the impact of lifestyle interventions on physical activity, diet, sedentary behaviour and mental health and to understand impact on subgroups.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019137197.

Severe Mental Illness and Cardiovascular Disease: JACC State-of-the-Art Review

People with severe mental illness, consisting of schizophrenia, bipolar disorder, and major depression, have a high burden of modifiable cardiovascular risk behaviors and conditions and have a cardiovascular mortality rate twice that of the general population. People with acute and chronic cardiovascular disease are at a higher risk of developing mental health symptoms and disease. There is emerging evidence for shared etiological factors between severe mental illness and cardiovascular disease that includes biological, genetic, and behavioral mechanisms. This state-of-the art review will describe the relationship between severe mental illness and cardiovascular disease, explore the factors that lead to poor cardiovascular outcomes in people with severe mental illness, propose strategies to improve the cardiovascular health of people with severe mental illness, and present areas for future research focus.

Patient-reported outcomes of lifestyle interventions in patients with severe mental illness: a systematic review and meta-analysis

BACKGROUND

Lifestyle interventions for severe mental illness (SMI) are known to have small to modest effect on physical health outcomes. Little attention has been given to patient-reported outcomes (PROs).

AIM

To systematically review the use of PROs and their measures, and quantify the effects of lifestyle interventions in patients with SMI on these PROs.

METHODS

Five electronic databases were searched (PubMed/Medline, Embase, PsycINFO, CINAHL, and Web of Science) from inception until 12 November 2020 (PROSPERO: CRD42020212135). Randomised controlled trials (RCTs) evaluating the efficacy of lifestyle interventions focusing on healthy diet, physical activity, or both for patients with SMI were included. Outcomes of interest were PROs.

RESULTS

A total of 11.267 unique records were identified from the database search, 66 full-text articles were assessed, and 36 RCTs were included, of which 21 were suitable for meta-analyses. In total, 5.907 participants were included across studies. Lifestyle interventions had no significant effect on quality of life (g = 0.13; 95% CI = - 0.02 to 0.27), with high heterogeneity (I² = 68.7%). We found a small effect on depression severity (g = 0.30, 95% CI = 0.00 to 0.58, I² = 65.2%) and a moderate effect on anxiety severity (g = 0.56, 95% CI = 0.16 to 0.95, I² = 0%).

DISCUSSION

This meta-analysis quantifies the effects of lifestyle interventions on PROs. Lifestyle interventions have no significant effect on quality of life, yet they could improve mental health outcomes such as depression and anxiety symptoms. Further use of patient-reported outcome measures in lifestyle research is recommended to fully capture the impact of lifestyle interventions.

Care Management for Serious Mental Illness: A Systematic Review and Meta-Analysis

OBJECTIVE

Persons with serious mental illness face adverse psychiatric and medical outcomes, and their care is associated with a large burden of health care costs. Care management, in which assessment, care planning, and care coordination are provided, is a common model of support, yet the evidence supporting its use among psychiatric populations is mixed. A systematic review and a meta-analysis were undertaken to determine the impact of care management on clinical outcomes, acute care utilization, cost, and satisfaction among adults with serious mental illness.

METHODS

A multidatabase literature search was performed. Articles were included if they compared standard outpatient care plus care management with standard outpatient care alone for adults with serious mental illness and reported on one or more predefined outcomes. Randomized controlled trials (RCTs) and other study designs were permitted for inclusion in the systematic review. The meta-analysis included only RCTs.

RESULTS

For the systematic review, 34 articles representing 28 unique studies were included. Fifteen of these articles, representing 12 unique studies, were included in the meta-analysis, which indicated that care management was associated with small, statistically significant improvements in psychiatric symptoms, overall quality of life (QOL), and mental QOL (Hedges' g range 0.13-0.26). In addition, care management was associated with a small, statistically significant reduction in inpatient psychiatric hospital days (Hedges' g=0.16, p=0.02).

CONCLUSIONS

Care management is associated with fewer psychiatric symptoms and greater QOL for persons with serious mental illness. Further work is needed to determine which components of the intervention are associated with effectiveness.

Cost-Effectiveness of a Multidisciplinary Lifestyle-Enhancing Treatment for Inpatients With Severe Mental Illness: The MULTI Study V

Economic evaluations of lifestyle interventions for people with mental illness are needed to inform policymakers and managers about implementing such interventions and corresponding reforms in routine mental healthcare. We aimed to evaluate changes in healthcare costs 18 months after the implementation of a multidisciplinary lifestyle-enhancing treatment for inpatients with severe mental illness (MULTI) versus treatment as usual (TAU). In a cohort study (n = 114; 65 MULTI, 49 TAU), we retrospectively retrieved cost data in Euros on all patient sessions, ward stay, medication use, and hospital referrals in the quarter year at the start of MULTI (Q1 2014) and after its evaluation (Q3 2015). We used linear regression analyses correcting for baseline values and differences between groups, calculated deterministic incremental cost-effectiveness ratios for previously shown changes in physical activity, metabolic health, psychosocial functioning, and additionally quality of life, and performed probabilistic sensitivity analyses including cost-effectiveness planes. Adjusted regression showed reduced total costs per patient per quarter year in favor of MULTI (B = -736.30, 95%CI: -2145.2 to 672.6). Corresponding probabilistic sensitivity analyses accounting for uncertainty surrounding the parameters showed statistically non-significant cost savings against health improvements for all health-related outcomes in MULTI compared to TAU. It is concluded that MULTI did not increase healthcare costs while improving health outcomes. This indicates that starting lifestyle interventions does not need to be hampered by costs. Potential societal and economic value may justify investment to support implementation and maintenance. Further research is needed to study this hypothesis.

Obesity management in primary care: systematic review exploring the influence of therapeutic alliance

PURPOSE

To identify the influence of the therapeutic alliance on the effectiveness of obesity interventions delivered in primary care.

METHOD

Systematic review of randomized controlled trials of primary care interventions for adult patients living with obesity. Comprehensive search strategy using the terms 'obesity', 'primary care' and 'intervention' of seven databases from 1 January 1998 to March 2018. Primary outcome was difference in weight loss in interventions where a therapeutic alliance was present.

RESULTS

From 10 636 studies, 11 (3955 patients) were eligible. Only one study had interventions that reported all aspects of therapeutic alliance, including bond, goals and tasks. Meta-analysis was not included due to high statistical heterogeneity and low numbers of trials; as per our protocol, we proceeded to narrative synthesis. Some interventions included the regular primary care practitioner in management; very few included collaborative goal setting and most used prescriptive protocols to direct care.

CONCLUSIONS

We were surprised that so few trials reported the inclusion of elements of the therapeutic alliance when relational aspects of primary care are critical for effectiveness. Interventions could be developed to maximize therapeutic relationships and research reports should describe interventions comprehensively.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42018091338 in PROSPERO (International prospective register of systematic reviews).

From impact factors to real impact: translating evidence on lifestyle interventions into routine mental health care

The scandal of premature mortality in people with serious mental illness is well established. Despite an increase in studies evaluating the efficacy of lifestyle interventions, translating this evidence into routine clinical care and policies is challenging, in part due to limited effectiveness or implementation research. We highlight the challenge of implementation that is increasingly recognized in clinical practice, advocate for adopting implementation science to study the implementation and systematic update of effective interventions in practice and policy, and provide directions for future research.

Characteristics of Patients in Treatment for Alcohol and Drug Addiction Who Succeed in Changing Smoking, Weight, and Physical Activity: A Secondary Analysis of an RCT on Combined Lifestyle Interventions

INTRODUCTION

Patients addicted to alcohol or drug often have additional unhealthy lifestyles, adding to the high mortality and morbidity in this patient group. Therefore, it is important to consider lifestyle interventions as part of the usual addiction treatment.

OBJECTIVE

The aim was to identify predictors of successful changes in lifestyle risk factors among patients in treatment for alcohol or drug addiction.

METHODS

We conducted a secondary analysis of a trial using a 6-week intensive integrated lifestyle intervention: The very integrated program (VIP). Patients were recruited in Addiction Centres Malmö and Psychiatry Skåne, Sweden. The primary outcome was successful changes in lifestyle, measured as quitting tobacco, exercising 30 min per day, and not being over- or underweight after 6 weeks and 12 months.

RESULTS

A total of 212 patients were included in the RCT, and 128 were included in this secondary analysis: 108 at 6 weeks and 89 at 12 months of follow-up. A total of 69 patients were respondents at both follow-ups. The follow-up rates were 51 and 42%, respectively. More education, having at least 2 lifestyle risk factors and having a high quality of life were predictors of a successful change in lifestyle after 6 weeks. After 12 months, the predictors for a successful outcome were having 3 or more risk factors, while an education level up to 3 years was a negative predictor.

CONCLUSIONS

Having several unhealthy lifestyles in addition to alcohol and drug addiction was a significant predictor of successful lifestyle changes in the short- and long term after the VIP for lifestyle interventions. Likewise, education was significant. The results should be considered in future development and research among this vulnerable group of patients.

Cardiovascular disease in patients with severe mental illness

Individuals diagnosed with schizophrenia or bipolar disorder have a life expectancy 15-20 years shorter than that in the general population. The rate of unnatural deaths, such as suicide and accidents, is high for these patients. Despite this increased proportion of unnatural deaths, physical conditions account for approximately 70% of deaths in patients with either schizophrenia or bipolar disorder, with cardiovascular disease contributing 17.4% and 22.0% to the reduction in overall life expectancy in men and women, respectively. Risk factors for cardiovascular disease, such as smoking, unhealthy diet and lack of exercise, are common in these patients, and lifestyle interventions have been shown to have small effects. Pharmacological interventions to reduce risk factors for cardiovascular disease have been proven to be effective. Treatment with antipsychotic drugs is associated with reduced mortality but also with an increased risk of weight gain, dyslipidaemia and diabetes mellitus. These patients have higher risks of both myocardial infarction and stroke but a lower risk of undergoing interventional procedures compared with the general population. Data indicate a negative attitude from clinicians working outside the mental health fields towards patients with severe mental illness. Education might be a possible method to decrease the negative attitudes towards these patients, thereby improving their rates of diagnosis and treatment.

Evaluation of Very Integrated Program: Health Promotion for Patients With Alcohol and Drug Addiction-A Randomized Trial

BACKGROUND

Compared to the general population, patients with alcohol and drug addiction have an increased risk of additional hazardous lifestyles and suffer from more chronic diseases, adding to their already significantly higher morbidity and mortality. The objective of this study was to test the efficacy of the Very Integrated Program (VIP) on treatment and health outcomes for patients diagnosed with alcohol and drug addiction.

METHODS

Parallel randomized clinical trial with intervention as add-on to addiction care as usual. A total of 322 patients aged 18 years or older were identified, and the study requirements were fulfilled by 219 patients, 7 of whom participated in a pilot. The intervention was a 6-week intensive, tailored, educational program that included motivational interviewing, a smoking cessation program, dietary and physical activity counseling, and patient education. The main outcome measures were substance-free days, time to relapse, and treatment adherence assessed after 6 weeks and 12 months. Secondary outcomes were lifestyle factors, symptoms of comorbidity, and quality of life. Missing data were imputed conservatively by using data closest to the follow-up date and baseline values in patients with no follow-up.

RESULTS

The 212 patients (intervention, n = 113; control, n = 99) were randomized, and 202 had complete data for primary outcomes. After 6 weeks, there were no significant differences between the groups regarding primary or secondary outcomes. At the 12-month follow-up, the patients in the control group had significantly more total substance-free days (139 days; ranging 0 to 365 vs. 265; 0 to 366, p = 0.021)-specifically among the patients with drug addiction-and higher physical and mental quality of life (45 vs. 58, p = 0.049 and 54 vs. 66, p = 0.037), but not in the per-protocol analysis (60 vs. 46, p = 0.52 and 70 vs. 66, p = 0.74). The sensitivity analyses did not support significant differences between the groups.

CONCLUSION

Overall, adding VIP intervention did not improve outcome of the alcohol or drug addiction care or the lifestyle compared to the addiction care alone. This patient group is still in need of effective programs, and new intervention research is required to develop that.

Impact of a prudent lifestyle on the clinical outcomes of older men with bipolar disorder

Objectives: To determine if the excess mortality associated with Bipolar disorder (BD) is independent of lifestyle.Methods: Prospective study of a community-representative sample of 12,203 men aged 65-85 years followed for 17.7 years. We used the 8-item 'prudence score' to assesses lifestyle behaviours, including the use of alcohol and smoking, physical activity, body mass and key aspects of diet. Scores of 5 or more indicate a prudent lifestyle.Results: 69 (0.6%) men had BD - a larger proportion of them than the remainder of the sample had diabetes, ischaemic heart disease, stroke, chronic respiratory diseases and dementia. The odds of a prudent lifestyle were 40% lower among participants with BD. BD was associated with increased risk of future contact with health services due to ischaemic heart disease and cancer, and respiratory, digestive and renal diseases, although such risk became comparable to that of men without BD for men with BD and a prudent lifestyle. The adjusted mortality hazard associated with the diagnosis of BD was 1.66 (95%CI = 1.20, 2.28), while the mortality hazard associated with a prudent lifestyle was 0.81 (95%CI = 0.78, 0.85). The mortality hazard for men with BD who were also prudent was 0.83 (95%CI = 0.52, 1.30). All analyses were adjusted for sociodemographic measures and prevalent morbidities.Conclusion: The excess morbidity and mortality of older men with BD seems to be mediated by non-prudent lifestyle practices. If future studies can demonstrate that this association is causal, then lifestyle interventions will need to become an integral part of the management of older adults with BD.

Non-pharmacological interventions for preventing weight gain in patients with first episode schizophrenia or bipolar disorder: A systematic review

Weight gain is a side effect of antipsychotic medication and highly prevalent in people with schizophrenia or bipolar disorder, increasing their overall cardio-metabolic risk. We conducted a systematic review on non-pharmacological interventions for preventing/reducing weight gain or increase in waist-circumference in young, newly diagnosed patients with schizophrenia or bipolar disorder. We searched major electronic databases from inception to 04/2019 on RCTs, pre- and post-test studies, and non-randomized controlled clinical trials. From a potential of 2963 hits, eight studies met the inclusion criteria (n = 438, mean age of 18.8 (13-45) years). The interventions comprised supervised and individually adjusted aerobic exercise activities (5 studies), individual lifestyle counselling vs. control condition (2 RCTs), and dietetic counselling and practical training of cooking and shopping (1 study). Physical activity and practical dietetic interventions seem to be more efficient than lifestyle counselling. However, the results shall be taken with caution due to the non-randomized designs and other methodologically deficits in the majority of the included studies.

Implementation barriers and facilitators of an integrated multidisciplinary lifestyle enhancing treatment for inpatients with severe mental illness: the MULTI study IV

BACKGROUND

Despite an increase in studies showing the efficacy of lifestyle interventions in improving the poor health outcomes for people with severe mental illness (SMI), routine implementation remains ad hoc. Recently, a multidisciplinary lifestyle enhancing treatment for inpatients with SMI (MULTI) was implemented as part of routine care at a long-term inpatient facility in the Netherlands, resulting in significant health improvements after 18 months. The current study aimed to identify barriers and facilitators of its implementation.

METHODS

Determinants associated with the implementation of MULTI, related to the innovation, the users (patients, the healthcare professionals (HCPs)), and the organisational context, were assessed at the three wards that delivered MULTI. The evidence-based Measurement Instrument for Determinants of Innovations was used to assess determinants (29 items), each measured through a 5-point Likert scale and additional open-ended questions. We considered determinants to which ≥20% of the HCPs or patients responded negatively ("totally disagree/disagree", score < 3) as barriers and to which ≥80% of HCPs or patients responded positively ("agree/totally agree", score > 3) as facilitators. We included responses to open-ended questions if the topic was mentioned by ≥2 HCPs or patients. In total 50 HCPs (online questionnaire) and 46 patients (semi-structured interview) were invited to participate in the study.

RESULTS

Participating HCPs (n = 42) mentioned organisational factors as the strongest barriers (e.g. organisational changes and financial resources). Patients (n = 33) mentioned the complexity of participating in MULTI as the main barrier, which could partly be due to organisational factors (e.g. lack of time for nurses to improve tailoring). The implementation was facilitated by positive attitudes of HCPs and patients towards MULTI, including their own role in it. Open responses of HCPs and patients showed strong commitment, collaboration and ownership towards MULTI.

CONCLUSIONS

This is the first study analysing the implementation of a pragmatic lifestyle intervention targeting SMI inpatients in routine clinical care. Positive attitudes of both HCPs and patients towards such an approach facilitated the implementation of MULTI. We suggest that strategies addressing organisational implementation barriers are needed to further improve and maintain MULTI, to succeed in achieving positive health-related outcomes in inpatients with SMI.

Health Effects of an Individualized Lifestyle Intervention for People with Psychotic Disorders in Psychiatric Outpatient Services: A Two Year Follow-up

People with psychotic disorders experience to a great extent avoidable physical illnesses and early mortality. The aim of the study was to investigate the potential effects for this group of participating in a lifestyle intervention. A multi-component nurse-led lifestyle intervention using quasi-experimental design was performed. Changes in biomedical and clinical measurements, self-reported health, symptoms of illness and health behavior were investigated. Multilevel modeling was used to statistically test differences in changes over time. Statistically significant changes were found in physical activity, HbA1c and waist circumference. A lifestyle intervention for people with severe mental illness can be beneficial for increasing physical activity.

A systematic review of interventions aimed at improving the cardiovascular health of people diagnosed with personality disorders

PURPOSE

People with personality disorders have significantly reduced life expectancy and increased rates of cardiovascular disease compared to members of the general population. Given that more people die annually of cardiovascular disease across the globe than from any other cause, it is important to identify the evidence for interventions aimed at improving cardiovascular health among people with personality disorders.

METHODS

Systematic literature review. PsycINFO, MEDLINE and EMBASE were searched using NICE Healthcare Databases, as well as CENTRAL and trial registries. We sought to identify randomised controlled trials of interventions pertaining to adults with a primary diagnosis of personality disorder, where the primary outcome measure was cardiovascular health before and after the intervention.

RESULTS

A total of 1740 records were identified and screened by two independent reviewers. No papers meeting the inclusion criteria were identified.

CONCLUSIONS

This systematic review did not identify any randomised controlled trials testing interventions aimed at improving the cardiovascular health of people with personality disorders. Research in this area could have important public health implications, spanning the fields of psychiatry and general medicine.

Outcome of a psychosocial health promotion intervention aimed at improving physical health and reducing alcohol use in patients with schizophrenia and psychotic disorders (MINT)

BACKGROUND

Life expectancy is reduced by 19 years in men and 17 in women with psychosis in Sweden, largely due to cardiovascular disease.

AIM

Assess whether a psychosocial health promotion intervention improves cardiometabolic risk factors, quality of life, and severity of illness in patients with psychotic disorders more than treatment as usual.

METHODS

A pragmatic intervention trial testing a manual-based multi-component health promotion intervention targeting patients with psychosis. The Swedish intervention was adapted from IMPaCT therapy, a health-promotion program based on motivational interviewing and cognitive behavioral therapy, designed to be incorporated into routine care. The intervention group consisted of 119 patients and the control group of 570 patients from specialized psychosis departments. Outcome variables were assessed 6 months before intervention during the run-in period, again at the start of intervention, and 12 months after the intervention began. The control group received treatment as usual.

RESULTS

The intervention had no significant effect on any of the outcome variables. However, BMI, waist circumference, systolic BP, heart rate, HbA1c, general health, and Clinical Global Impressions Scale score improved significantly during the run-in period before the start of the active intervention (observer effect). The multi-component design meant that treatment effects could only be calculated for the intervention as a whole.

CONCLUSION

The results of the intervention are similar to those of the U.K. IMPaCT study, in which the modular health-promotion intervention had little effect on cardiovascular risk indicators. However, in the current study, the run-in period had a positive effect on cardiometabolic risk factors.

Mental health care professionals' accounts of actions and responsibilities related to managing physical health among people with severe mental illness

BACKGROUND

Life expectancy of people with severe mental illness (SMI) is greatly shortened compared to the general population, and despite extensive research, this issue is unsolved. Although it is widely recognised that people with SMI need support from health care services to manage health related issues, profound health inequalities exist within provision of health care. The aim of this study was to examine how mental health care professionals accounted for their actions and responsibilities related to managing physical health issues among people with SMI.

METHODS

Three focus groups were conducted with 22 mental health care professionals, employed at three mental health care locations. Participants' situated accounts were subjected to discourse analysis.

RESULTS

Participants accounted for actions and responsibilities in three typical ways; 1) by positioning people with SMI as difficult to motivate and actively resisting intervention, 2) by positioning people with SMI as so impaired that intervention was futile, and 3) by arguing they are undertreated for physical conditions and might have physical illnesses that staff are not aware of because of prominent mental illness. These discursive strategies seemed to legitimise situations where participants described not responding to physical health issues, and to downplay potential trouble in situations where participants described not succeeding in facilitating lifestyle changes or promoting compliance to treatment of physical conditions.

DISCUSSION AND CONCLUSION

Mental health care professionals need to increase their awareness of latent discriminating attitudes towards people with SMI. Such attitudes are suggested to reinforce barriers for people with SMI receiving physical health care.

Is it possible for people with severe mental illness to sit less and move more? A systematic review of interventions to increase physical activity or reduce sedentary behaviour

Individuals with severe mental illness (SMI) (schizophrenia-spectrum, bipolar disorder and major depressive disorder) die 10-20 years prematurely due to physical disorders such as cardiovascular disease. Physical activity (PA) is effective in preventing and managing these conditions in the general population, however individuals with SMI engage in substantially less PA and more sedentary behaviour (SB) compared to healthy counterparts. Furthermore, the effectiveness of intervening to increase PA or reduce SB in SMI populations is unknown. Therefore, we systematically reviewed studies measuring changes in PA or SB following behavioural interventions in people with SMI. A systematic search of major databases was conducted from inception until 1/3/2018 for behavioural interventions reporting changes in PA or SB in people with SMI. From 3018 initial hits, 32 articles were eligible, including 16 controlled trials (CT's; Treatment n = 1025, Control n = 1162) and 16 uncontrolled trials (n = 655). Of 16 CTs, seven (47%) reported significant improvements in PA, although only one found changes with an objective measure. Of 16 uncontrolled trials, 3 (20%) found improvements in PA (one with objective measurement). No intervention study had a primary aim of changing SB, nor did any note changes in SB using an objective measure. In conclusion, there is inconsistent and low quality evidence to show that interventions can be effective in changing PA or SB in this population. Future robust randomized controlled trials, using objectively-measured PA/SB as the primary outcome, are required to determine which behavioural interventions are effective in improving the sedentary lifestyles associated with SMI. Systematic review registration- PROSPERO registration number CRD42017069399.

What is the risk-benefit ratio of long-term antipsychotic treatment in people with schizophrenia?

The long-term benefit-to-risk ratio of sustained antipsychotic treatment for schizophrenia has recently been questioned. In this paper, we critically examine the literature on the long-term efficacy and effectiveness of this treatment. We also review the evidence on the undesired effects, the impact on physical morbidity and mortality, as well as the neurobiological correlates of chronic exposure to antipsychotics. Finally, we summarize factors that affect the risk-benefit ratio. There is consistent evidence supporting the efficacy of antipsychotics in the short term and mid term following stabilization of acute psychotic symptoms. There is insufficient evidence supporting the notion that this effect changes in the long term. Most, but not all, of the long-term cohort studies find a decrease in efficacy during chronic treatment with antipsychotics. However, these results are inconclusive, given the extensive risk of bias, including increasing non-adherence. On the other hand, long-term studies based on national registries, which have lower risk of bias, find an advantage in terms of effectiveness during sustained antipsychotic treatment. Sustained antipsychotic treatment has been also consistently associated with lower mortality in people with schizophrenia compared to no antipsychotic treatment. Nevertheless, chronic antipsychotic use is associated with metabolic disturbance and tardive dyskinesia. The latter is the clearest undesired clinical consequence of brain functioning as a potential result of chronic antipsychotic exposure, likely from dopaminergic hypersensitivity, without otherwise clear evidence of other irreversible neurobiological changes. Adjunctive psychosocial interventions seem critical for achieving recovery. However, overall, the current literature does not support the safe reduction of antipsychotic dosages by 50% or more in stabilized individuals receiving adjunctive psychosocial interventions. In conclusion, the critical appraisal of the literature indicates that, although chronic antipsychotic use can be associated with undesirable neurologic and metabolic side effects, the evidence supporting its long-term efficacy and effectiveness, including impact on life expectancy, outweighs the evidence against this practice, overall indicating a favorable benefit-to-risk ratio. However, the finding that a minority of individuals diagnosed initially with schizophrenia appear to be relapse free for long periods, despite absence of sustained antipsychotic treatment, calls for further research on patient-level predictors of positive outcomes in people with an initial psychotic presentation.