SPECIAL REPORT: ADDRESSING MORTALITY
Compared with the general population, patients with serious mental illness (SMI), ie, schizophrenia, major depression, and bipolar disorders, have higher levels of morbidity, poorer health outcomes, and higher mortality rates.1 In particular, life expectancy is reduced up to 25 years.2 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.3,4 The higher mortality rates are due to different factors, which are summarized in the Table.
This mortality gap between the general population and people with SMI is considered a “public health scandal.”5 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.6 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.7 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.8 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.8,9
In the US, Green and colleagues,10 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. Manuals 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.11 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 Veterans Health Administration, which has been manualized in order to address the needs of veterans with serious mental illness.12 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).13 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.14 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.15 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.
Dr Fiorillo is Full Professor, and Dr Sampogna and Dr Luciano 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.
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