Andrea Fiorillo, MD, PhD

Compared with the general population, patients with serious mental illness (SMI), ie, 

, have higher levels of morbidity, poorer health outcomes, and higher mortality rates.

 In particular, life expectancy is reduced up to 25 years.

 The causes of this premature mortality have been extensively analyzed, and the vast majority is due to the higher incidence of physical health problems, such as cancer as well as cardiovascular, respiratory, metabolic, and infectious diseases.

 The higher mortality rates are due to different factors, which are summarized in the 

This mortality gap between the general population and people with SMI is considered a “public health scandal.”

 Hence, several international organizations have advocated for individual and community-based interventions to reduce mortality in these patients. In particular, the World Health Organization has recently developed international guidelines on how to improve physical health in people with severe psychiatric disorders and has provided a set of actions to be undertaken by national health systems, including control of risk factors, scaling up management in primary health care, and development of national policies.

 According to WHO, since the premature mortality is a complex phenomenon resulting by the interaction of several protective and risk factors, a single approach is likely to be inadequate. A multilevel approach would be more appropriate for the long-term management of physical and mental health conditions.

The role of psychosocial interventions for improving lifestyle behaviors


	Several psychosocial interventions, including behavioral, educational, and psychological components, have been developed worldwide in order to improve lifestyle behaviors in patients with SMIs.

 These approaches, if proved to be effective, would have to be disseminated on a large scale.

Recently developed in Denmark, CHANGE is an intervention that targets physical inactivity, unhealthy dietary habits, and smoking, and is facilitates contact to the general practitioner.

 It is based on the theory of stage of change, motivational interviewing, and an assertive approach adapted from the assertive community treatment. The three methods were incorporated in four manuals with detailed descriptions of the intervention addressing care-coordination, smoking cessation, healthy diet, and increased physical activity. The intervention is led by a coach, who supports the patient in setting up individual goals and paying attention to his or her priorities, values, and life conditions. The coaches are available for short message services, phone calls, or home visits, as needed. They are health professionals (eg, occupational therapists, physiotherapists, dieticians) with clinical training in psychiatry. Findings from the CHANGE trial indicate that intervention was effective in reducing the mean age-standardized 10-year cardiovascular risk.

 have developed the STRIDE intervention, which is a 12-month intervention consisting of three phases:
	1. An intensive phase of weekly group sessions for 6 months covering information on nutrition, physical activity, and lifestyle changes
	2. A maintenance intervention phase, covering the same areas of previous phase through problem solving and motivational enhancement
	3. Individual monthly contacts for the remaining 6 months of the intervention
	Using a manualized protocol, participants are asked to implement a series of specific strategies for achieving changes in behavior, activity level, and weight. In particular, participants are encouraged to routinely monitor food intake, calories, and physical activity, to set reasonable short-term goals, to formulate specific plans, and to develop social support. 

 are available for download and can be easily used in clinical care. Patients who received the STRIDE intervention reported significant weight reduction.

The SHAPE program was developed for obese people with SMIs.

 The intervention includes gym membership, weekly individual meetings with a certified fitness trainer, and information on healthy eating. A motivational component is also included in the program, coupled with a specific focus on the management of psychiatric symptoms that can interfere with exercise and healthy eating. A significant BMI reduction was seen in the patients who took part in the program.

MOVE! is a weight management program developed by the 

, which has been manualized in order to address the needs of veterans with serious mental illness.

 MOVE! is a 6-month weight management approach that includes psychoeducation as well as behavioral and motivational strategies that focus on nutritional counselling, caloric expenditure, and portion control. During the sessions, visual aids are used. Although results from MOVE! participants did not differ from those of the control group, this program has been adapted to be provided through 30 Internet-based interactive educational modules (WebMOVE).

 Compared with patients who received the in-person intervention, those who received the WebMOVE intervention reported a more significant weight loss-highlighting the possible role of the Internet for these programs.

We have recently developed the LYFESTYLE intervention, a new psychosocial approach that aims to improve physical health in people with SMI.

 It is a 5-month group intervention that includes elements taken from psychoeducation, cognitive-behavioral therapy, and motivational interview. At each session, participants are provided with booklets, homework, and daily diaries to keep track of any changes. The sessions end with a 20-minute moderate physical activity. The primary outcome is a reduction of BMI and an improvement on the Framingham and HOMA indexes at the end of the intervention. At 2 years of follow up, these outcome measures are expected to increase and can be considered as an indirect measure of mortality preventionThe multicentric randomized controlled trial that compared the LIFESTYLE intervention with a control informative intervention included 402 patients.

A collection of the most promising psychosocial interventions to improve lifestyle behaviors in people with SMIs was recently published.

 All available psychosocial interventions differ in the target population (individuals or groups; diagnostically closed or open to different categories of patients); the inclusion of different psychosocial components in the intervention (eg, motivational, educational, problem-solving, self-help); the type of health professionals involved (eg, psychiatrists, psychologists, nurses, dieticians, personal trainers); the duration of the intervention and the provision of booster sessions.

It is not clear which format yields the best results. In fact, while the individual format prioritizes the motivational component and allows treatment personalization based on the needs of each participant, the group format allows patients to share their experiences and to provide reciprocal support.

Another important consideration is the involvement of a multidisciplinary team. When the intervention is provided by mental health professionals only, its long-term efficacy is low. It is likely that specific components of the interventions (ie, those related to physical activities or diet habits) can be more easily changed by involving professionals with specific knowledge and training. Of course, the cost-to-benefit ratio should always be considered, in particular the costs related to the recruitment of professionals different from those already working in mental health.

Many trials have included a motivational component, which represents the core active ingredient for most psychosocial interventions that aim to improve lifestyle behaviors in patients with SMI. The target of the different proposed approaches varies significantly; in some cases, interventions are focused on diet and healthy food, while in other cases different aspects of lifestyle behaviors (such as smoking, regular physical activity, sleep hygiene) are prioritized. Moreover, the duration of the intervention is very heterogeneous. Some interventions last 3 months, while others can last up to 2 years. With longer interventions, the most relevant difficulties are related to the high rate of patient drop-outs and the excessive workload for clinicians who are involved in the intervention. However, the “minimum effective dosage” is not yet clear.


	Psychosocial interventions that target lifestyle behaviors represent a promising approach for challenging the premature mortality in patients with SMI. However, their use in clinical practice is rare and preventive strategies that can be easily integrated in routine care should be adopted. In particular, clinicians should regularly check lifestyle behaviors of their patients and provide them with adequate information on the positive effects of healthy diet, physical activity, and smoking cessation. Specific training on these aspects should be included in educational curricula for residents and trainees, with a particular focus on motivational interviewing, psychoeducation, and problem-solving. An ideal approach should not be too long and should be conducted by trained mental health clinicians in conjunction with other health professionals. The group format seems to be the best option, as it reduces the costs and increases patients’ motivation. There is still a long way to go, but at least now the way is tracked.

 are Assistant Professors, Department of Psychiatry, University of Campania “L. Vanvitelli,” Naples, Italy. The authors report no conflicts of interest concerning the subject matter of this article.

1. Walker ER, Mcgee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and metaanalysis. 

. 2014;72:334-341.
	2. HjorthÃ¸j C, StÃ¼rup AE, McGrath JJ, Nordentoft M. Years of potential life lost and life expectancy in schizophrenia: a systematic review and meta-analysis. 

. 2017;4:295-301.
	3. Liu NH, Daumit GL, Dua T, et al. Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas.

. 2017;16:30-40.
	4. De Rosa C, Sampogna G, Luciano M, el al. Improving physical health of patients with severe mental disorders: a critical review of lifestyle psychosocial interventions. 

. 2017;17:667-681.
	5. Thornicroft G. Physical health disparities and mental illness: the scandal of premature mortality. 

. 2011;199:441-442.
	6. World Health Organization. 

Guidelines for the Management of Physical Health Conditions in Adults With Severe Mental Disorders

. Geneva, Switzerland; 2018.
	7. Barber S, Thornicroft G. Reducing the mortality gap in people with severe mental disorders: the role of lifestyle psychosocial interventions. 

. 2018;9:463.
	8. Speyer H, NÃ¸rgaard HC, HjorthÃ¸j C, et al. Protocol for CHANGE: a randomized clinical trial assessing lifestyle coaching plus care coordination versus care coordination alone versus treatment as usual to reduce risks of cardiovascular disease in adults with schizophrenia and abdominal obesity. 

. 2015;23:119.
	9. Speyer H, Christian Brix NÃ¸rgaard H, Birk M, et al. The CHANGE trial: no superiority of lifestyle coaching plus care coordination plus treatment as usual compared to treatment as usual alone in reducing risk of cardiovascular disease in adults with schizophrenia spectrum disorders and abdominal obesity. 

. 2016;15:155-165.
	10. Green CA, Yarborough BJ, Leo MC, et al. The STRIDE weight loss and lifestyle intervention for individuals taking antipsychotic medications: a randomized trial. 

. 2015;172:71-81.
	11. Naslund JA, Aschbrenner KA, Scherer EA, et al. Lifestyle intervention for people with severe obesity and serious mental illness. 

. 2016;50:145-153.
	12. Goldberg RW, Reeves G, Tapscott S, et al. ”MOVE!” Outcomes of a weight loss program modified for veterans with serious mental illness. 

. 2013;64:737–744.
	13. Young AS, Cohen AN, Goldberg R, et al. Improving weight in people with serious mental illness: the effectiveness of computerized services with peer coaches.

. 2017;32(Suppl 1):48-55.
	14. Sampogna G, Fiorillo A, Luciano M, et al. A randomized controlled trial on the efficacy of a psychosocial behavioral intervention to improve the lifestyle of patients with severe mental disorders: study protocol. 

. 2018;9:235.
	15. Fiorillo A, Luciano M, Pompili M, Sartorius N. Reducing the mortality gap in people with severe mental disorders: the role of lifestyle psychosocial interventions. 

. 2019;10:434.
	16. Leucht S, Burkard T, Henderson JH, et al. Physical Illness and Schizophrenia: A Review of the Evidence. Cambridge: Cambridge University Press; 2007.

Articles

The mortality rate is unacceptably high in patient with serious mental illnesses. Several psychosocial interventions have been developed that may benefit these patients.

Psychosocial Interventions to Reduce Premature Mortality in Patients With Serious Mental Illness

Findings indicate that more than 50% of patients hospitalized for a first episode of schizophrenia who had threatened others had displayed overt signs of illness for over a year.

Keep in mind the following when working with patients who are agitated:

Violence in patients with schizophrenia can be prevented if the patient is carefully monitored-before, during, and after hospitalization

Collaboration with the patient is crucial

Treatment personnel should be capable of handling difficult situations

Avoid any personal reaction to things that the agitated patient may do or say

When possible, the clinician should ascertain whether there is any substance and/or alcohol abuse

After discharge, there is an increase of violence risk

Medication-nonadherence may run the risk of agitation and possible aggression

Aggression and Impulsivity in Schizophrenia

,” by Maurizio Pompili, MD, PhD and Andrea Fiorillo, MD, PhD, on which this quiz was based.

1. Humphreys MS, Johnstone EC, MacMillan JF, Taylor PJ. Dangerous behavior preceding first admissions for schizophrenia. 

Poll

What percentage of patients hospitalized for a first episode of schizophrenia who had threatened others had displayed overt signs of illness for over a year?

Mini Quiz: Violence and Psychosis

Although the prevalence of violence is similar in psychiatric patients and in the general population, patients suffering from schizophrenia are often portrayed in the media as being unpredictably aggressive and impulsive. The result is increased stigmatization and poorer treatment outcomes. Multiple factors, including insufficient social support, substance abuse, and symptom exacerbations, can precipitate aggressive behavior. Moreover, failure to treat schizophrenic patients adequately is a major risk factor for aggression.

Aggressive behavior and impulsivity are often found in paranoid schizophrenia and can occur during both acute and chronic phases of the illness. Impulsivity is defined as action without planning or reflection, and it seems to be related to a failure of behavioral filtering outside of consciousness.

Patients with schizophrenia may show dysfunctional impulsivity and impulsive aggression. Although the neurobiological aspects of aggression in patients with schizophrenia are still not well understood, impulsivity and aggression may correlate with frontal and temporal brain abnormalities.

 Psychotic symptoms, such as delusions and hallucinations, with subsequent suspiciousness and hostility, may result in aggressive behavior. Or, aggression may be impulsive and caused by an environmental frustrating event. Patients may be more aggressive and violent during acute episodes.

Schizophrenic patients have less insight, experience greater thought disorder, and have poorer control of their aggressive impulses. Comorbidity with alcohol or other substances of abuse is frequent and complicates the agitation and the impulsivity. Among patients with schizophrenia, MDD, and bipolar disorder, the risk for homicide was found to be increased with comorbid alcohol abuse or dependence.

 categorized the risk factors for aggression into 4 sets of variables:

: history of violence, violent threats or fantasies, age, sex, history of child abuse

: diagnosis, relevant symptoms, treatment adherence

: social support, availability of weapons

: the nature of the alliance with the patient, the potential cognitive bias of the evaluator

Assessment through clinical history still remains the most important way to gauge potential violent behavior in patients with schizophrenia, although it is still impossible to predict with any certainty whether a patient will become aggressive. Dysfunctional impulsivity can be assessed with many self-report questionnaires and several tests of cognitive ability (

Because of the multidimensional etiology of aggression, making treatment decisions can be difficult. The underlying psychosis, poor impulse control, and comorbid substance use all need to be managed. In addition, the personality traits that may have contributed to the violent behavior need to be recognized. Hostility and aggressive behavior during psychosis can result when patients with a thought disorder or persecutory delusion perceive themselves as threatened. Patients with paranoid schizophrenic manifestations of suspiciousness, mistrust, and anger may be particularly challenging for clinicians who need to abstain from questioning the patient’s delusions.

Clinicians need to ensure that a safe place-for themselves and for the patient-is available where they can meet with the patient. In the emergency department, this can be particularly challenging if no dedicated space is available. A crowded place with many other somatic emergencies can impair proper management of aggressive and impulsive behavior. In such settings, administration of sedative agents is often the first-line approach, whereas when quiet rooms are available, there may be more space for collaboration between physicians and patients, leading to less invasive interventions.

Collaboration with the patient is crucial as is an experienced staff capable of handling difficult situations. Staff should respect protocols and avoid any personal reaction to things that the agitated patient may do or say; in addition, the fewer the stimuli the better. When possible, the clinician should ascertain whether there is any substance and/or alcohol abuse.

Violence by schizophrenic patients can be prevented if the patient is carefully monitored-before, during, and after hospitalization. More than 50% of patients hospitalized for a first episode of schizophrenia who had threatened others had displayed overt signs of illness for over a year.

 After discharge, there is an increase of violence risk: aggressions committed by persons with schizophrenia often occur within the first few months of hospital discharge.

 Once a patient with schizophrenia is discharged, he or she may become medication-nonadherent, resulting in symptom recurrence and an increased risk of agitation, impulse discontrol, and possible aggression.

In an acute setting, pharmacological interventions may be necessary, and the clinician may be challenged by the need to administer the maximum dose and at the same time not harm the patient. It is important to monitor vital signs, provide close observation, and assess agitation for at least 24 hours. Adverse events from otherwise good sedative agents can occur because different compounds are administered simultaneously or in addition to previously administered medications.

In the long-term management of aggressive behavior, ascertain whether the potential for violence can be managed with psychotherapy before proceeding with medications. It is important to convey empathy and authenticity: if the agitated patient feels that he is understood and a good therapeutic relationship is in process, he may be less suspicious and defensive.

Although pharmacological treatment may help manage aggressive behavior in schizophrenic patients, it may be difficult to establish the direct effect of each medicine. Drugs are usually used to maintain impulse control and reduce aggressive behavior. Although they may induce paradoxic disinhibition, benzodiazepines, especially lorazepam, are well tolerated and not associated with the extrapyramidal adverse effects typically associated with antipsychotics. Benzodiazepines are very useful in combination therapy with typical or atypical antipsychotics.

In patients with acute psychosis, the use of typical antipsychotics, especially haloperidol, is supported by their strong evidence base and the long and safe history of their intramuscular formulation. Atypical antipsychotics may decrease hostility over the long term. They also are associated with a lower risk of acute extrapyramidal adverse effects, such as dystonia and akathisia, as well as a lower risk of cardiovascular adverse effects, such as QTc prolongation.

Clozapine, olanzapine, risperidone, aripiprazole, ziprasidone, and asenapine are the atypical antipsychotics most often used in the long-term treatment of hostility, impulsivity, and aggression in patients with schizophrenia. Those available in oral dissolving form are particularly useful for ease of administration (avoiding swallowing). Intramuscular formulations of atypical antipsychotics are also beneficial for treating aggressive and impulsive behavior in schizophrenic patients. Long-acting injectable formulations of antipsychotics are available for long-term treatment of patients with schizophrenia and schizoaffective disorder.

 These formulations are particularly beneficial for patients who might have trouble with medication adherence.

Clozapine decreases hostile, aggressive, and violent behavior in the treatment of persistent aggression in patients with schizophrenia. It represents the best long-term medication choice. In one study, after treatment with clozapine, the scores on the hostility item of the Positive and Negative Syndrome Scale were reduced in 157 patients with treatment-resistant schizophrenia.

 However, clozapine is not used for acute episodes because the dose must be titrated slowly during the first 3 weeks of treatment and it is likely that its anti-aggressive effect is not related to its antipsychotic effects.

Mood stabilizers-anticonvulsants and lithium-are often also prescribed in combination with antipsychotics. Substance abuse comorbidity increases the risk of violent behavior. Atypical antipsychotics and benzodiazepines are recommended for schizophrenic patients with substance abuse comorbidity. (Benzodiazepines are safe and effective sedative agents that do not create problems with addiction in the acute phase, especially when the patient is closely monitored.) Of note is loxapine, a typical antipsychotic, now available to treat agitation in inhalation form. According to preliminary evidence, agitation is reduced within 2 minutes of administration and the effects of a single dose last up to 24 hours.

Aggressive and impulsive behaviors in schizophrenia pose many clinical challenges. The best way to reduce the risk of aggression is with adequate treatment of schizophrenia.

) to assess a patient’s agitation/hostility can help psychiatrists make treatment decisions that will reduce the risk of aggression. Proper training of staff and a structured, calming environment can easily reduce the risk of violence and improve outcomes, ensuring safety for both staff and patients. Understanding treatment protocols provides clinicians with the knowledge for proper management and gives patients better solutions with possibly less invasive interventions.

Dr Pompili is Professor of Suicidology in the department of neurosciences, mental health, and sensory organs at Sapienza University of Rome, and Director of the Suicide Prevention Center at Sant’Andrea Hospital in Rome. Dr Fiorillo is Associate Professor in the department of psychiatry at the University of Naples SUN, Naples, Italy. The authors report no conflicts of interest concerning the subject matter of this article.

 Torrey EF. Stigma and violence: isn’t it time to connect the dots? 

 Hoptman MJ, Antonius D. Neuroimaging correlates of aggression in schizophrenia: an update. 

 Soyka M, Graz C, Bottlender R, et al. Clinical correlates of later violence and criminal offences in schizophrenia. 

 Schanda H, Knecht G, Schreinzer D, et al. Homicide and major mental disorders: a 25-year study. 

 McNiel DE, Binder RL. The relationship between acute psychiatric symptoms, diagnosis, and short-term risk of violence. 

 Humphreys MS, Johnstone EC, MacMillan JF, Taylor PJ. Dangerous behavior preceding first admissions for schizophrenia. 

 Link BG, Andrews H, Cullen FT. The violent and illegal behavior of mental patients reconsidered. 

 Hughes DH, Kleespies PM. Treating aggression in the psychiatric emergency service. 

 Girardi P, Serafini G, Pompili M, et al. Prospective, open study of long-acting injected risperidone versus oral antipsychotics in 88 chronically psychotic patients. 

 Citrome L, Volavka J, Czobor P, et al. Effects of clozapine, olanzapine, risperidone, and haloperidol on hostility among patients with schizophrenia. 

 Kwentus J, Riesenberg RA, Marandi M, et al. Rapid acute treatment of agitation in patients with bipolar I disorder: a multicenter, randomized, placebo-controlled clinical trial with inhaled loxapine. 

 Cook WW, Medley DM. Proposed hostility and pharisaic-virtue scales for the MMPI. 

 Buss AH, Durkee A. An inventory for assessing different kinds of hostility. 

Manual of the Hostility and Direction of Hostility Questionnaire (HDHQ)

. 3rd ed. London: University of London Press; 1967.

 Novaco RW. Anger violence and mental disorder: the development and validation of an assessment procedure. Presented at: Meeting on Risk Special Studies; September 1975; Pittsburgh.

 Bunney WE Jr, Hamburg DA. Methods for reliable longitudinal observation of behavior. 

 Hargreaves WA. Systematic nursing observations of psychopathology. 

 Green RA, Bigelow L, O’Brien P, et al. The Inpatient Behavioral Rating Scale: a 26-item scale for recording nursing observations of patients’ mood and behavior. 

 Squier RW. An acute psychiatric rating scale for the clinical assessment of functionally disturbed inpatients. 

 Kay SR, Wolkenfeld F, Murrill LM. Profiles of aggression among psychiatric patients. II. Covariates and predictors. 

 Plutchik R, van Praag HM. A self-report measure of violence risk, II. 

 Korn ML, Botsis AJ, Kotler M, et al. The Suicide and Aggression Survey: a semistructured instrument for the measurement of suicidality and aggression. 

Author | Andrea Fiorillo, MD, PhD

Articles

Psychosocial Interventions to Reduce Premature Mortality in Patients With Serious Mental Illness

Mini Quiz: Violence and Psychosis

Aggression and Impulsivity in Schizophrenia