Acta Psychiatr Scand 2013: 128: 251–260 All rights reserved DOI: 10.1111/acps.12096
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd ACTA PSYCHIATRICA SCANDINAVICA
Review
Evaluating interventions to improve somatic health in severe mental illness: a systematic review van Hasselt FM, Krabbe PFM, van Ittersum DG, Postma MJ, Loonen AJM. Evaluating interventions to improve somatic health in severe mental illness: a systematic review. Objective: To present a systematic review of the evaluation of randomized interventions directed toward improving somatic health for patients with severe mental illness (SMI). Method: A systematic search in PubMed, Embase, Cinahl, and PsycInfo was performed. The scope of the search was prospective studies for patients aged 18–70, published from January 2000 till June 2011. Randomized interventions directed toward improving somatic health for patients with SMI were selected. We excluded studies on elderly, children, and studies performed before 2000. Information on population, type of intervention, follow-up, outcome measures, and on authors’ conclusions were drawn from the original articles. Results: Twenty-two original studies were included, presenting four types of interventions: health education (n = 9), exercise (n = 6), smoking cessation (n = 5), and changes in health care organization (n = 2). To evaluate the effect of these studies 93 different outcome measures were used in 16 categories. Conclusion: Many interventions directed toward improving somatic health for patients with SMI have been started. These studies did not apply similar evaluations, and did not use uniform outcome measures of the effect of their interventions. Valuable comparisons on effectiveness are therefore almost impossible.
F. M. van Hasselt1,2, P. F. M.
Krabbe3, D. G. van Ittersum4, M. J. Postma5, A. J. M. Loonen2,6,7 1 Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, 2GGZ WNB, Mental Health Hospital, Bergen op Zoom, 3Department of Epidemiology, University Medical Center Groningen, University of Groningen, 4SHARE, Graduate School Medical Sciences, University of Groningen, 5 Pharmacoepidemiology and Pharmacoeconomics, University of Groningen, 6Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen and 7Delta Chair on Psychiatric Pharmacology, Delta, Mental Health Hospital, Poortugaal, the Netherlands
Key words: mental disorders; health status; health promotion; patient care management Anton J. M. Loonen, University of Groningen, Pharmacotherapy and Pharmaceutical Care, Antonius Deusinglaan 1, 9713 AV Groningen, the Netherlands. E-mail:
[email protected]
Accepted for publication January 18, 2013
Summations
• To improve somatic health in severe mental illness, promotion of exercise, health education, promotion of smoking cessation, and changes in the health-care system are used as types of intervention.
• No uniform evaluation is performed to evaluate these interventions, neither within the same type of intervention nor overall. Evidence-based comparisons on effectiveness are therefore not yet possible.
Considerations
• Our review shows that the effect of similar interventions was usually evaluated with mutually incom•
parable measures. This makes it impossible to compare the outcome effects of similar projects and to aggregate the results to an integral overview. This review aimed to give a broad overview of interventions used to improve somatic health, with the exclusion of medication comparison trials. The beneficial influence of some medication regimes on general somatic health over others is therefore not reflected with this review.
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van Hasselt et al. Introduction
Patients with severe mental illness (SMI) have a greater prevalence of somatic morbidity and an increased mortality rate when compared with the general population, and the gap between these two groups is increasing (1–3). This increase is partly caused by suboptimal functioning of the healthcare system for this group of patients. For instance, the focus on reducing morbidity related to cardiovascular disease (CVD) in the general population in the last decades has not benefitted patients with SMI (4). Somatic health of patients with SMI is also adversely affected by the following factors: lifestyle, genetic vulnerability, and side-effects of psychiatric medication (2). Furthermore, SMI and somatic disease cannot be considered as two distinct entities, but they are interrelated, for example, underlying somatic disease can worsen psychiatric symptoms and vice versa (5). Interventions can aim to influence somatic health either directly or indirectly. Direct influence on somatic health is possible with treatment or prevention of somatic disease in a patient, for example, treatment of side-effects of psychiatric medication or development of a healthy life style. Indirect influence on somatic health is possible with interventions creating conditions leading to an increased possibility of earlier detection and treatment of disease for a group of patients. Aims of the study
At this moment, a general overview of the current initiatives on improving somatic health for patients with SMI is lacking. Therefore, it is hard to develop evidence-based policy choices on interventions to improve somatic health in patients with SMI. The aim of this review is to present an overview of randomized interventions and their evaluation, directed toward improving somatic health for patients with SMI. Material and methods
A systematic literature search was performed for reports on interventions directed toward improving somatic health for patients with SMI. The scope of the search involved prospective studies on patients aged 18–70, published from January 2000 till June 2011. A search string was built which combined search terms describing patient population, intervention, outcome, and study type. Search terms for the patient population included: mental disorders, anxiety disorders, dissociative 252
disorders, mood disorders, neurotic disorders, personality disorders, schizophrenia and disorders with psychotic features, somatoform disorders, antipsychotic agents, antidepressive agents, schizophrenia, neurotic disorder, obsessive-compulsive disorder, traumatic stress disorder, and panic disorder. Search terms for intervention involved: body weight, health status, exercise, cardiovascular, metabolic, physical health, and smoking cessation. For outcomes search terms were as follows: treatment outcome, health promotion, improvement, screening, promotion, health education, patient education, patient care management, and follow-up studies. Finally, for study type the terms used were as follows: clinical trial, randomized controlled trial, evaluation study, intervention, and controlled clinical trial. Subject headings were used when possible, and searches were performed for the terms in the title and abstract. The search was performed in PubMed–Medline, Embase, PsycInfo, and Cinahl. A selection of studies was performed independently by two authors (AL, FvH), discrepancies were resolved through discussion. The exclusion criteria were developed to select original prospective randomized studies that were primarily designed to improve somatic health in adult patients with SMI. Excluded were interventions that improve mental health for people with chronic somatic conditions, exclusively 70 years, case studies, study protocol, overview articles, meta-analyses, non-randomized study design; interventions for patients with epilepsy, dementia and/or traumatic brain injury; interventions for mentally handicapped patients, somatisation disorder as primary subject intervention, exercise as treatment for psychiatric disorder, postpartum psychiatry, psychiatric diseases or treatment types generally not considered SMI, clinical trials of specific drugs or specific drug comparisons. Information on population, type of intervention, follow-up, all reported outcome measures, and on authors’ conclusions were drawn from the original articles only. Finally, different interventions were grouped based on their descriptions in types and the outcome measures were grouped in categories based on comparable measures. Results
Our search detected 8215 articles in the four databases; after duplicates were removed 6704 articles remained. Based on abstract 212 manuscripts were completely assessed. Twenty-two original studies were selected, those were described in 24 original articles (6–29). (Table 1). Four types of
Evaluating improving somatic health in SMI intervention were identified: health education, exercise, smoking cessation, and change in health care organization (Table 2). The majority of studies were performed in out-patients (n = 14); the others involved in-patients (n = 4), in- and outpatients (n = 2), and for two studies this is not clear. The populations with SMI were described as follows: patients with schizophrenia or psychosis (n = 9), SMI (n = 5), antipsychotic drug users (n = 2), posttraumatic stress disorder or mood disorder (n = 1), any DSM IV diagnosis (1), anxiety disorder or a combination of these diagnoses (n = 4). The programs that aimed to influence somatic health directly were the health education, exercise, and smoking cessation interventions. Smoking cessation programs often consisted of tailor-made interventions to support smoking reduction and cessation. Programs to improve exercise ranged in their methods by offering a program of activities or only offering access to fitness facilities. Health education interventions aimed to improve knowledge of health behaviour and the health-care system. Two interventions, by the same research group, looked at indirect influence on somatic health. Their intervention consisted of coordinating somatic health care for their patients. For evaluation of the different studies, a total of 93 different outcome measures were used. Grouping of similar outcome measures lead to 16 generic categories of outcome measures (Table 3). The most frequently used categories of outcome measures in all interventions were psychiatric symptoms, cardiometabolic risk factors, and general health. In smoking cessation interventions, all five used a smoking-related outcome-category; four used psychiatric symptoms; and four used healthcare consumption. For the exercise programs, there was not one category used by all interventions. Seven out of nine studies on health education programs used cardiometabolic risk factors, seven used psychiatric symptoms as outcome domain. Discussion
A broad range of randomized interventions directed toward improving somatic health for patients with SMI in the last decade has been initiated. The twenty-two interventions that were detected by our systematic literature review used different methods to influence the somatic health status, but had the common goal of optimizing or preserving the somatic health status. Our review shows that the effect of similar interventions was usually evaluated with mutually incomparable measures.
This makes it impossible to compare the outcome effects of similar projects and to aggregate the results to an integral overview. It is only possible to make some general remarks on the outcome measures that were applied. High drop-out rates were reported in many interventions. Possibly this drop-out is related to the multiple factors related with health behaviour for patients with SMI. For instance, lower physical activity participation was correlated with the presence of negative symptoms, cardio-metabolic comorbidity, side-effects of antipsychotic medication, lack of knowledge on cardiovascular disease risk factors, no belief in the health benefits, a lower self-efficacy, other unhealthy lifestyle habits, and social isolation (30). Considering this drop-out of individuals, indirect interventions that change the health-care system have theoretically a greater reach than direct individual interventions. However, it should be noted that there is a need for more research on the effect of indirect interventions. Furthermore, changing the health-care system and a direct strategy to improve somatic health can be used in conjunction. Generally speaking, outcome measures should be related to the ultimate goal of improving the future somatic health. If outcome measures are not related to this ultimate goal, evaluation can give no information on effectiveness of the intervention to improve somatic health. For instance, weight change is the most common outcome measure used. Weight reduction or reducing weight gain is related with decreased cardiovascular risk (31, 32). Therefore, weight is an outcome measure that is related to the ultimate goal of improving future somatic health, because it is directly related to cardiovascular risk. It is remarkable that other compiled outcome measures related to (risk of) cardiovascular disease are not widely used. For daily practice the European guideline advises a risk assessment based on cholesterol, smoking status, and blood pressure (33), possibly this could be used in conjunction with weight to present a broader assessment of cardiovascular risk change. We will perform a further critical analysis of outcome measures and advices in a following manuscript. In most studies also the psychiatric condition was evaluated as an outcome measure. We assume that this emphasis on psychiatric measures can be explained by the general medical principal of primum non nocere ‘first, do no harm’. Patients with SMI depend on mental health care for the treatment of their psychiatric disease. This psychiatric disease should not deteriorate, because of factors related to the intervention directed toward improving somatic disease. Therefore, this evalua253
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Population (number†, drop out‡)
In-patients with SMI in a crisis residential unit (n = 309, drop out 36%)
Out-patients with SMI and a chronic somatic condition who volunteered to join the study (n = 80, drop out 18%)
Out-patients recently started with olanzapine treatment (n = 51, drop out 37%)
Out-patients with schizophrenia or schizoaffective disorder with a BMI >30 (n = 18, drop out 33%)
Patients with increased weight due to antipsychotic medication (n = 61, drop out 25%)
Patients with first episode of schizophrenia, who were randomly treated with antipsychotic medication (3 types). (n = 61, drop out 0%)
Study
Health education Chafetz et al. (6)
Druss et al. (7)
Evans et al. (8)
Jean-Baptiste et al. (9)
Khazaal et al. (10)
Alvarez-Jimenez et al. (11)
Table 1. Study description
6
3
Spain
6
USA
Switzerland
6
6
USA
Australia
18
Duration* (months)
USA
Country An individually administered health promotion program to promote skills in selfassessment, selfmonitoring, and self-management of physical health was added to basic primary care Peer led groups on chronic disease selfmanagement, with content tailor made for this specific population Nutrition education in sixone-to-one education sessions by a dietitian, with a focus on setting personal goals Behavioural intervention with group sessions on nutrition, physical activity enhancement, and food provision by reimbursement of selected foods Cognitive behavioural therapy in 12 weekly sessions on eating behaviour with focus on reducing binge-eating symptomatology (episodes of extensive eating without following compensatory behaviour like purging) Tailored behavioural intervention with modules on behavioural interventions, nutrition, and exercise
Description of intervention General functioning, general health, psychiatric symptoms, self efficacy
Exercise, general health, health care consumption, process
Cardiometabolic risk factors, psychiatric symptoms
Cardiometabolic risk factors, psychiatric symptoms
Cardiometabolic risk factors, diet, psychiatric symptoms
Cardiometabolic risk factors, psychiatric symptoms
Care as usual
Passive nutritional education in book form
Care as usual
Short education on food and nutrition
Routine care in psychosis program
Outcome domains
Care as usual, basic primary care by a nurse practitioner during admission
Description of control group
Less weight gain (absolute and compared with baseline) was present in the intervention group A smaller proportion of the intervention group had an increase in weight >7%
In the intervention group, more weight loss was observed, and weight decreased more progressively. Also, in the intervention group improvement vin inge-eating symptomatology was observed
This intervention can produce lasting weight loss for patients with schizophrenia with co morbid obesity and improve metabolic indices
In the intervention group, there was less increase in weight, more exercise, and a higher quality of life
Increased capability to manage physical health, improved health related quality of life, and improved physical activity
In the intervention group, physical functioning and self-reported general health increased
Conclusion of study authors
van Hasselt et al.
Knapen et al. (20)
Beebe et al. (18, 19)
Archie et al. (17)
In-patients with a non-psychotic psychiatric disorder (n = 199, drop out 51%)
Out-patients with stable schizophrenia using olanzapine (n = 20, dropout not reported. 90% drop out on attendance) Out-patients with schizophrenia spectrum disorder (n = 97, drop out 23%)
Patients with a DSM IV diagnosis cared for in supported housing and their staff. (n = 46 (patients), drop out 11%)
Out-patients with severe and enduring mental illness who volunteered to join study (n = 39, drop out 39%)
Brown and Chan (14)
Exercise Forsberg et al. (15, 16)
Out-patients with schizophrenia or schizoaffective disorders using olanzapine. (n = 48, drop out 25%)
Out-patients with schizophrenia using antipsychotic medication with a BMI >27 (n = 15, drop out 6%)
Population (number†, drop out‡)
Kwon et al. (13)
Iglesias-Garcõa et al. (12)
Study
Table 1. (Continued)
4
1–4
USA
Belgium
6
Canada
1.5
UK
12
3
South Korea
Sweden
3
Duration* (months)
UK
Country
Individual psychomotor therapy program with twice weekly 45 min of exercise and once weekly 45 min of progressive relaxation
Participation in a walking group and groups on walking technique and motivation
Free access to fitness facility with a personal program
Life style intervention for staff and patients in structured activities
Health promotion in 6 weekly oneto-one standardized health education sessions, primarily on weight reduction, exercise, nutrition and if applicable on smoking reduction
Structured educative program in 12 group sessions on nutrition, exercise, and healthy habits Individual diet and weight management based on cognitive and behavioural therapy
Description of intervention
Cardiometabolic risk factors, psychiatric symptoms, laboratory, side-effects of medication, quality of life Cardiometabolic risk factors, diet, exercise, general health, psychiatric symptoms
Food and exercise diaries without professional guidance
The intervention group walked more minutes per month than the control. No differences were present between groups on motivation. Self efficacy and outcome expectations for exercise increased in the intervention group In the intervention group an improvement in aerobic fitness was achieved, this was not achieved in the control group. Within both group physical self-concept i ncreased
Cardiometabolic risk factors, process
Process, self efficacy, other
No free access to fitness
Time and attention control; groups on medication adherence, smoking, and other health related subjects Standard psychomotor therapy program
Exercise, other
There was no change on the Heart score (risk of cardiometabolic disease) in patients. A remarkable increase on HbA1c occurred, possibly due to laboratory assessment changes. In the intervention group an increased sense of coherence, (the ability to comprehend, manage, and give meaning to inner and outer resources) was reported Even with free access there was no active participation due to lack of motivation
There was a small weight reduction in the intervention group. An improved diet considering saturated fat and fibers was reported in both groups
In the intervention group reductions in weight and BMI were recorded, no difference in psychiatric status was observed
Both the intervention and the control group had a small waist circumference decrease at the end of the study. Neither the intervention nor the control group presented a difference in weight or BMI
Conclusion of study authors
Cardiometabolic risk factors, exercise, general functioning, process, other
Program for staff and patients on arts and crafts with similar intensity as the intervention
Care as usual
Cardiometabolic risk factors
Outcome domains
Weekly attendance to clinic for anthropometric measures assessment
Description of control group
Evaluating improving somatic health in SMI
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256
Out-patients receiving assertive community treatment, diagnosed with schizophrenia or schizoaffective disorder, who had one or more cardiovascular risk factors (n = 13, drop out 23%)
Marzolini et al. (22)
Out-patients diagnosed with unipolar depression who smoked (n = 322, drop out 0%)
Out-patients with a psychotic disorder who smoke regularly (n = 298, drop out 16%)
Barnett et al. (24)
Baker et al. (25)
Out-patients with military related post traumatic stress disorder who smoked willing to receive counseling on smoking cessation (n = 943, drop out 15%)
In- and out-patients with mood or psychotic disorder using antipsychotic medication since max 24 months having increased in weight (n = 30, drop out 33%)
Skrinar et al. (21)
Smoking cessation McFall et al. (23)
Population (number†, drop out‡)
Study
Table 1. (Continued)
3
Canada
Australia
USA
12
18
18
3
USA
USA
Duration* (months)
Country
Individual sessions on smoking cessation with manualized content by their usual care provider, if desired cessation medication was prescribed. After cessation, follow-up and booster sessions were planned Computer based evaluation were made on readiness to quit smoking. The motivated subgroup received sessions of psychological counseling and nicotine replacement and if necessary other pharmacologic support. Individual smoking cessation program with cognitive behavioural interventions and nicotine replacement with nicotine transdermal patch
Healthy life style exercise group with four exercise groups per week and one health seminar. Personalized training based on pulse measurements Twice weekly exercise for 90 min supervised by a cardiac rehabilitation specialist and member of ACT team. Training was individualized based on heart rat
Description of intervention
Intervention resulted in greater prolonged abstinence than control
Intervention led to more abstinence compared to control. The incremental cost-effectiveness ratio is higher than for quitting programs in the general population
The overall cessation rate was modes and below the rate of smokers without psychiatric burden. This study demonstrates the utility of the intervention among individuals with a psychotic disorder
Health care consumption, tobacco smoking
Behaviour change, general functioning, health care consumption, psychiatric symptoms, tobacco smoking
Participants were handed written stop smoking advice and a list of programs offered
Time and attention control group with access to regular smoking cessation services
In the intervention group, mental health and muscular strength increased. Improvement in functional exercise capacity was associated with improvement in overall mental health and a reduction in depressive symptoms
Health care consumption, process, psychiatric symptoms, tobacco smoking
Cardiometabolic risk factors, process psychiatric symptoms
Care as usual
There was no significant difference between the intervention and the control group. Observed ratings of general health and empowerment improved in the intervention group
Conclusion of study authors
Referral to smoking cessation clinic, conform usual standard of care
Cardiometabolic risk factors, exercise, general health, quality of life, other
Outcome domains
Waiting list
Description of control group
van Hasselt et al.
Patients with schizophrenia who smoked (n = 45, drop out not described in numbers. Drop outs were counted as smoker)
George et al. (27)
Out-patients with SMI from the urban community who volunteered to join the study (n = 407, drop out 31%)
12
USA
6
USA
12
9
USA
USA
Duration* (months)
Country
Primary care was integrated with mental health care services. The psychiatry service assumed responsibility for primary medical care Care management by a nurse for patients to overcome barriers to health care and motivate for life style changes
Individual sessions with manualized content on smoking cessation by their usual care provider, if desired cessation medication was prescribed. After cessation, follow-up contact was provided Program to quit smoking developed for patients with schizophrenia
Description of intervention
In the intervention, an increased self-reported general was observed and less complaints on continuity of care. No differences were present between the group in costs of health care
There was more preventive and guideline adherent care observed in intervention group. Increase in experienced mental health, but no increase on experienced physical health in intervention group Cardiometabolic risk factors, psychiatric symptoms, self efficacy, other
Care as usual, written information with details of local primary care providers was supplied
Smoking cessation rates with the nicotine trans dermal patch are modest in schizophrenia. There was no difference between the control and intervention
The intervention was more effective than control. Smoking-cessation interventions can be safely incorporated into routine mental health care for post traumatic stress disorder
Conclusion of study authors
Adherence to guideline, general health, health care consumption, psychiatric symptoms, other
Psychiatric symptoms, side-effects of medication, tobacco smoking
Health care consumption, psychiatric symptoms, tobacco smoking
Outcome domains
Care as usual
Program to quit smoking for general population
Referral to smoking cessation clinic
Description of control group
SMI, severe mental illness. *Duration from baseline till last reported follow-up measure. †Number of participants who were randomized. ‡Percentage that dropped out between randomization and last follow-up measure. Drop out was considered if the last follow-up measure was not attended, or only a minor part of all assessments were performed.
Druss et al. (29)
In-patients from a veterans affairs mental health clinic without primary care provider referred by staff for the intervention (n = 120, drop out 0%)
Out-patient with post traumatic stress disorder currently in treatment who smoked and were willing to receive stop smoking counseling (n = 66, drop out 16%)
McFall et al. (26)
Change in health care organization Druss et al. (28)
Population (number†, drop out‡)
Study
Table 1. (Continued)
Evaluating improving somatic health in SMI
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van Hasselt et al. Table 2. Details of process selected interventions
Type of intervention
Number of selected studies
Duration in months* Range
Number of participants† Range
Drop out percentage‡
Health education Exercise Smoking cessation Change in health care organization
9 6 5 2
2–18 3–12 6–18 12
15–309 13–205 45–943 120–407
0–39 5–90 0–16 0–31
Total
22
2–18
15–943
0–90
*Duration from baseline till last reported follow-up measure. †Number of participants who were randomized. ‡Percentage that dropped out between randomization and last follow-up measure. Drop out was considered if the last follow-up measure was not attended, or only a minor part of the measures.
Table 3. Frequency of use of categories outcome measures Outcome category
One*
Multiple†
Psychiatric symptoms
9
5
Cardiometabolic risk factors General health Process Health care consumption Tobacco smoking Exercise General functioning Quality of life Side-effects of medication
1 2 2 3 0 2 3 3 1
11 4 4 3 5 3 0 0 1
Diet Self efficacy Laboratory Adherence to guideline Behaviour change Other
2 3 0 1 1 5
0 0 1 0 0 1
Examples‡ Beck Depression Inventory, Post Traumatic Stress Disorder checklist Weight, cholesterol, Framingham risk score SF36, basic health screening questionnaire Attendance drop out Health care consumption prescriptions and pharmacy visits Exhaled CO
