The effectiveness and design of informed choice tools for people with severe mental illness: a systematic review

BACKGROUND

People with severe mental illness (SMI) report difficulty in making health-related decisions. Informed choice tools are designed to guide individuals through a decision-making process.

AIMS

To determine the effectiveness of these tools for people with SMI and to identify what methods and processes may contribute to effectiveness.

METHOD

A systematic electronic search was conducted for studies published between 1996 and January 2018. The search was updated in March 2020. Studies of any design reporting the development or evaluation of any informed choice tool for people with SMI were considered. A structured, narrative synthesis was conducted.

RESULTS

Ten articles describing four tools were identified. Tools were designed to assist with decision-making around bipolar treatment, smoking cessation and disclosure of mental illness in employment situations. Positive changes in decisional conflict, stage of change, knowledge and self-efficacy were reported for two tools, though insufficient data exists for definitive conclusions of effectiveness. Feedback from service users and attention to readability appeared key.

CONCLUSIONS

The evidence base for informed choice tools for people with SMI is limited. Such tools should be developed in stages and include the views of people with SMI at each phase; readability should be considered, and a theoretical framework should be used to facilitate process evaluation.

Impact of incentivizing ASHAs on the outcome of persons with severe mental illness in a rural South Indian community amidst the COVID-19 pandemic

BACKGROUND & OBJECTIVES

Task shifting has been recommended as a strategy to reach out to persons with mental illness and bridge the treatment gap. There is a need to explore task-shifting using existing health staff like Accredited Social Health Activists (ASHAs). We examined the impact of incentivizing ASHAs on the outcome of persons with severe mental illness (SMI) amidst the pandemic.

METHODS

One hundred eighty-four adults with SMI from Jagaluru taluk were enrolled and followed up for a year. They were assessed for disability, work performance, internalized stigma, and illness severity at baseline, six months, and 12 months follow-up. ASHA workers were incentivized to ensure follow-up consultations, address concerns regarding illness/ medication side effects and monitor medication adherence.

RESULTS

Out of the 184 recruited patients, 7 died (non-COVID-19 causes), 22 stopped treatment and did not report for follow-up consultations, 11 shifted to treatment from other centers, and in 1 case, there was a change in diagnosis. 143 (78%) patients with SMI completed the study amidst the COVID-19 pandemic. At one year follow-up, there was a significant reduction in disability, illness severity, self-stigma, and improved work performance.

CONCLUSION

Incentivization of ASHAs helped ensure continuity of care to persons with SMI despite lockdowns and COVID-19 exigencies. It is feasible to involve ASHAs in the treatment of persons with SMI.

The RAS-24: Development and validation of an adherence-to-medication scale for severe mental illness patients

Introduction

Several studies have found that most patients with severe mental illness (SMI) and comorbid (physical) conditions are partially or wholly nonadherent to their medication regimens. Nonadherence to treatment is a serious concern, affecting the successful management of patients with SMIs. Psychiatric disorders tend to worsen and persist in nonadherent patients, worsening their overall health. The study described herein aimed to develop and validate a scale (the Ralat Adherence Scale) to measure nonadherence behaviors in a culturally sensitive way.

Materials and Methods

Guided by a previous study that explored the primary reasons for nonadherence in Puerto Rican patients, we developed a pool of 147 items linked to the concept of adherence. Nine experts reviewed the meaning, content, clarity, and relevance of the individual items, and a content validity ratio was calculated for each one. Forty items remained in the scale's first version. This version was administered to 160 patients (21-60 years old). All the participants had a diagnosis of bipolar disorder, major depressive disorder, or schizoaffective disorder. The STROBE checklist was used as the reporting guideline.

Results

The scale had very good internal consistency (Cronbach's alpha = 0.812). After a factor analysis, the scale was reduced to 24 items; the new scale had a Cronbach's alpha of 0.900.

Conclusions

This adherence scale is a self-administered instrument with very good psychometric properties; it has yielded important information about nonadherence behaviors. The scale can help health professionals and researchers to assess patient adherence or nonadherence to a medication regimen.

A digital patient-reported outcome (electronic patient-reported outcome) system for patients with severe psychiatric disorders: User-centered development study and study protocol of a multicenter-controlled trial

Background

The effective treatment of patients with severe psychiatric disorders primarily relies on subjective reporting of symptoms and side-effects. This information is crucial for a clinician's decision regarding medication adjustment. Treatment adjustment usually happens at a low frequency (∼4-8 weeks). In between points of care, patients are left alone with their symptoms and side-effects. This leads to uncertainty regarding the treatment, non-adherence, possible relapse, and rehospitalization.

Objectives

We aim to design a flexible electronic patient-reported outcome (ePRO) system, which allows patients with severe psychiatric disorders to: (a) record their symptoms using an app; (b) share the data with the clinical team at points of care; and (c) utilize the data to support therapy decisions.

Methods

In this article, we describe the development process which included the following steps: (a) formation of a co-design team; (b) stakeholder interviews with patients, practitioners, and digital health experts to access needs, requirements, and barriers; (c) prototype conceptualization and design; (d) user acceptance testing and refinement; and (e) finalization of the system for testing in a pilottrial.

Results

We included input from patients with lived experience of psychiatric disorders, clinical team members, software engineers, and researchers. A prototype system was refined, and iterative changes were made before finalization during a series of operational meetings. The system allows patients to digitally self-report their symptoms and provides longitudinal ePRO symptom data for export into the electronic health record.

Conclusions

Routine ePRO collection has the potential to improve outcomes and hereby also reduce health service costs. We have successfully developed a trial-ready ePRO system for severe psychiatric disorders. The findings were incorporated in the planning of a feasibility pilot trial. Assuming feasibility will be established, the system might be subjected to a certification process evaluation of safety and efficacy including a randomized controlled trial.

Frailty and Treatment-Resistant Schizophrenia: A Retrospective Cohort Study

Frailty, a state of reduced physiological reserve, has not been studied in consumers with treatment-resistant schizophrenia, despite known elevated rates of comorbidity and psychosocial impairment. This study applies a frailty index to the electronic medical records of 78 adults with treatment-resistant schizophrenia, aged 18-64 years, to determine the prevalence and characteristics of frailty (defined as a frailty index score > 0.21). The mean frailty index score was 0.24 (SD = 0.091, range = 0.061-0.54), with 52.6% of the population categorised as frail (40.0% in those aged 18-39 years). Frailty was positively correlated with age and psychiatric illness severity. This study provides novel evidence that individuals with treatment-resistant schizophrenia have a high rate of frailty and become frail at a younger age. Routine frailty assessments could be used to trigger the delivery of appropriate interventions, which have the potential to improve life expectancy and quality of life.

The duty of confidentiality during family involvement: ethical challenges and possible solutions in the treatment of persons with psychotic disorders

BACKGROUND

Family involvement during severe mental illness is still poorly implemented, contrary to evidence-based recommendations. Confidentiality issues are among the most prominent barriers, with mental health professionals facing complex ethical, legal, and practical challenges. However, research focusing on this barrier is very sparse. Nested within a cluster-randomised trial to implement guidelines on family involvement for persons with psychotic disorders in community mental health centres, the aim of this sub-study was to explore ethical challenges related to the duty of confidentiality as experienced by mental health professionals, and to explore key measures that might contribute to improving the handling of such challenges.

METHODS

In total 75 participants participated in 21 semi-structured focus groups, including implementation team members at the initial and late phase of the intervention period and clinicians who were not on the implementation teams, at late phase of implementation. We used purposive sampling and manifest content analysis to explore participants' experiences and change processes.

RESULTS

Ethical challenges related to the duty of confidentiality included 1) Uncertainty in how to apply the legislation, 2) Patient autonomy versus a less strict interpretation of the duty of confidentiality, 3) Patient alliance and beneficence versus a less strict interpretation of the duty of confidentiality, 4) How to deal with uncertainty regarding what relatives know about the patients' illness, and 5) Relatives' interests versus the duty of confidentiality. Measures to facilitate better handling of the duty of confidentiality included 1) Training and practice in family involvement, and 2) Standardisation of family involvement practices.

CONCLUSION

When health professionals gained competence in and positive experiences with family involvement, this led to vital changes in how they interpreted and practiced the duty of confidentiality in their ethical reasoning and in clinical practice. Especially, the need to provide sufficient information to the patients about family involvement became evident during the study. To improve the handling of confidentiality issues, professionals should receive training in family involvement and confidentiality statutes followed by practice. Furthermore, family involvement should be standardised, and confidentiality guidelines should be implemented in the mental health services.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

Prevalence of the metabolic syndrome and associated factors among inpatients with severe mental illness in Botswana: a cross-sectional study

INTRODUCTION

The metabolic syndrome, a cluster of inter-related risk factors for cardiovascular diseases is highly prevalent among individuals with obesity and sedentary lifestyle. Chronic psychiatric disorders such as severe mental illness are associated with increased risk for cardiovascular diseases. We aimed to assess the prevalence and correlates of metabolic syndrome among inpatients with severe mental illness in a resource limited setting with high HIV prevalence.

METHODS

This was a cross-sectional study among adult inpatients at a referral psychiatric hospital in Botswana. We used convenience sampling to enrol participants available at the time of the study. The National Cholesterol Education Program Adult Treatment Panel-III (NCEP-ATP III) criteria was used to define the metabolic syndrome. Data were analysed using descriptive statistics as well as multiple logistic regression modelling.

RESULTS

A total of 137 participants were enrolled. Of these, 119 (87%) had complete data for the main analysis. The overall prevalence of metabolic syndrome was 22.6% (95% CI 15.9, 30.6) and did not differ significantly by gender or HIV status. Age was significantly associated with the risk of having the metabolic syndrome while gender, body mass index, HIV status, and days of moderate physical activity were not.

CONCLUSION

There was a moderately high prevalence of metabolic syndrome. Thus, the management of individuals with severe mental illness in resource limited settings should include assessment of cardiovascular risk and target modifiable risk factors in this population. Consideration for the patient's age should be made when rationalizing the limited resources available for assessing metabolic syndrome among patients with severe mental illness.

COVID-19 ethnic inequalities in mental health and multimorbidities: protocol for the COVEIMM study

PURPOSE

The COVID-19 pandemic may have exacerbated ethnic health inequalities, particularly in people with multiple long-term health conditions, the interplay with mental health is unclear. This study investigates the impact of the pandemic on the association of ethnicity and multimorbidity with mortality/service use among adults, in people living with severe mental illnesses (SMI).

METHODS

This study will utilise secondary mental healthcare records via the Clinical Record Interactive Search (CRIS) and nationally representative primary care records through the Clinical Practice Interactive Research Database (CPRD). Quasi-experimental designs will be employed to quantify the impact of COVID-19 on mental health service use and excess mortality by ethnicity, in people living with severe mental health conditions. Up to 50 qualitative interviews will also be conducted, co-produced with peer researchers; findings will be synthesised with quantitative insights to provide in-depth understanding of observed associations.

RESULTS

81,483 people in CRIS with schizophrenia spectrum, bipolar or affective disorder diagnoses, were alive from 1st January 2019. Psychiatric multimorbidities in the CRIS sample were comorbid somatoform disorders (30%), substance use disorders (14%) and personality disorders (12%). In CPRD, of 678,842 individuals with a prior probable diagnosis of COVID-19, 1.1% (N = 7493) had an SMI diagnosis. People in the SMI group were more likely to die (9% versus 2% in the non-SMI sample) and were more likely to have mental and physical multimorbidities.

CONCLUSION

The effect of COVID-19 on people from minority ethnic backgrounds with SMI and multimorbidities remains under-studied. The present mixed methods study aims to address this gap.

Evaluation of physical health in an in-patient psychiatric rehabilitation setting

BACKGROUND

The mortality gap between patients with and without serious mental illness (SMI) is around 15-20 years. Here, we aim to identify some of the factors contributing to that gap via poor physical health and sub-optimal medical management.

METHODS

We report the results of a detailed cross-sectional study of physical health parameters in an in-patient rehabilitation population in Scotland, including a consideration of concordance with guidelines and comparisons to healthy populations.

RESULTS

Data was collected from 57 of all 62 in-patients. 42% were obese (compared to 28% of the population), 84% were smokers (vs 16%), 16% were hypertensive, 22% had raised HbA1c, 50% had raised cholesterol, 47% had QRISK >10%. 68% agreed to a full physical health review, 65% agreed to flu vaccination. Completed screening uptake compared to the Scottish population was low: Cervical (30% vs 69%), Bowel (8% vs 64%), Breast (23% vs 72%), Abdominal Aortic Aneurysm (0% vs 78%). Patients generally had up to date recorded weight (100%), blood pressure (98.2%), heart rate (98.2%) and lipids (89.4%), but not ECG's (61.4%) or Diabetes screening (59.6%). Following review, 17 referrals were made to medics/surgeons, 29 to broader specialties, 24 medications were started, 9 stopped and 27 changed: most commonly statins (12 patients), vitamin D (8 patients) and hypoglycemics (5 patients).

CONCLUSIONS

The findings highlight cardiovascular risk factors and cancer screening as specific areas to target for improving poor physical health in populations with SMI. Patients are often willing to engage but specific ways to lower the barriers to screening and treatment are required.

(Cost)-effectiveness and implementation of integrated community-based care for patients with severe mental illness: a study protocol

BACKGROUND

As severe mental illness (SMI) is associated with a high disease burden and persistent nature, patients with SMI are often subjected to long-term mental healthcare and are in need of additional social support services. Community-based care and support services are organized via different providers and institutions, which are often lacking structural communication, resulting in a fragmented approach. To improve the efficiency of care provision and optimize patient wellbeing, an integrated multi-agency approach to community-based mental health and social services has been developed and implemented.

AIM

To present a research protocol describing the evaluation of flexible assertive community teams integrated with social services in terms of effectiveness, cost-effectiveness, and implementation.

METHODS/DESIGN

A quasi-experimental study will be conducted using prospective and retrospective observational data in patients with severe mental illness. Patients receiving care from three teams, consisting of flexible assertive community treatment and separately provided social support services (care as usual), will be compared to patients receiving care from two teams integrating these mental and social services into a single team. The study will consist of three parts: 1) an effectiveness evaluation, 2) a health-economic evaluation, and 3) a process implementation evaluation. To assess (cost-)effectiveness, both real-world aggregated and individual patient data will be collected using informed consent, and analysed using a longitudinal mixed model. The economic evaluation will consist of a cost-utility analysis and a cost-effectiveness analysis. For the process and implementation evaluation a mixed method design will be used to describe if the integrated teams have been implemented as planned, if its predefined goals are achieved, and what the experiences are of its team members.

DISCUSSION

The integration of health and social services is expected to allow for a more holistic and recovery oriented treatment approach, whilst improving the allocation of scarce resources. This study aims to identify and describe these effects using a mixed-method approach, and support decision-making in the structural implementation of integrating mental and social services.

Muva physical activity intervention to improve social functioning in people with a severe mental illness: study protocol of a pragmatic stepped wedge cluster randomized trial

BACKGROUND

People with severe mental illness (SMI) often suffer from long-lasting symptoms that negatively influence their social functioning, their ability to live a meaningful life, and participation in society. Interventions aimed at increasing physical activity can improve social functioning, but people with SMI experience multiple barriers to becoming physically active. Besides, the implementation of physical activity interventions in day-to-day practice is difficult. In this study, we aim to evaluate the effectiveness and implementation of a physical activity intervention to improve social functioning, mental and physical health.

METHODS

In this pragmatic stepped wedge cluster randomized controlled trial we aim to include 100 people with SMI and their mental health workers from a supported housing organization. The intervention focuses on increasing physical activity by implementing group sports activities, active guidance meetings, and a serious game to set physical activity goals. We aim to decrease barriers to physical activity through active involvement of the mental health workers, lifestyle courses, and a medication review. Participating locations will be divided into four clusters and randomization will decide the start of the intervention. The primary outcome is social functioning. Secondary outcomes are quality of life, symptom severity, physical activity, cardiometabolic risk factors, cardiorespiratory fitness, and movement disturbances with specific attention to postural adjustment and movement sequencing in gait. In addition, we will assess the implementation by conducting semi-structured interviews with location managers and mental health workers and analyze them by direct content analysis.

DISCUSSION

This trial is innovative since it aims to improve social functioning in people with SMI through a physical activity intervention which aims to lower barriers to becoming physically active in a real-life setting. The strength of this trial is that we will also evaluate the implementation of the intervention. Limitations of this study are the risk of poor implementation of the intervention, and bias due to the inclusion of a medication review in the intervention that might impact outcomes.

TRIAL REGISTRATION

This trial was registered prospectively in The Netherlands Trial Register (NTR) as NTR NL9163 on December 20, 2020. As the The Netherlands Trial Register is no longer available, the trial can now be found in the International Clinical Trial Registry Platform via: https://trialsearch.who.int/Trial2.aspx?TrialID=NL9163 .

The Working Alliance as a Mediator Between Fidelity to Strengths Model Case Management and Client Outcomes

OBJECTIVE

The purpose of this study was to examine how the client–case manager working alliance in strengths model case management (SMCM) mediates the relationship between fidelity to the SMCM intervention and clients’ quality of life, hope, and community functioning.

METHODS

In total, 311 people with severe mental illness, served at seven community mental health agencies in Canada, participated in the study. They were new to SMCM and participated in five structured interviews every 4.5 months for 18 months to measure the quality of the client–case manager working alliance and clients’ quality of life, hope, and community functioning. The team-level SMCM fidelity scale was administered six times over 3 years. Ordinary least-squares path analysis was used to test simple mediation models.

RESULTS

Higher fidelity to SMCM was associated with better client outcomes indirectly through the working alliance. Higher SMCM fidelity predicted a stronger working alliance, which in turn predicted greater improvements in client quality of life (at 9 months and 18 months), hope (at 18 months), and community functioning (at 9 months).

CONCLUSIONS

The results support the view that SMCM is an effective intervention. When the intervention was implemented as planned, it fostered stronger working alliances between clients and case managers and contributed to greater improvements in the quality of life, hope, and functioning of people with severe mental illness. The findings of this study highlight the value of ongoing monitoring of implementation fidelity to achieve high-fidelity interventions that may lead to positive client outcomes.

Quality of clinical management of cardiometabolic risk factors in patients with severe mental illness in a specialist mental health care setting

PURPOSE

Cardiometabolic disease in patients with severe mental illness is a major cause of shortened life expectancy. There is sparse evidence of real-world clinical risk prevention practice. We investigated levels of assessments of cardiometabolic risk factors and risk management interventions in patients with severe mental illness in the Norwegian mental health service according to an acknowledged international standard.

METHODS

We collected data from 264 patients residing in six country-wide health trusts for: (a) assessments of cardiometabolic risk and (b) assessments of levels of risk reducing interventions. Logistic regressions were employed to investigate associations between risk and interventions.

RESULTS

Complete assessments of all cardiometabolic risk variables were performed in 50% of the participants and 88% thereof had risk levels requiring intervention according to the standard. Smoking cessation advice was provided to 45% of daily smokers and 4% were referred to an intervention program. Obesity was identified in 62% and was associated with lifestyle interventions. Reassessment of psychotropic medication was done in 28% of the obese patients. Women with obesity were less likely to receive dietary advice, and use of clozapine or olanzapine reduced the chances for patients with obesity of getting weight reducing interventions.

CONCLUSIONS

Nearly nine out of the ten participants were identified as being at cardiometabolic high risk and only half of the participants were adequately screened. Women with obesity and patients using antipsychotics with higher levels of cardiometabolic side effects had fewer adequate interventions. The findings underscore the need for standardized recommendations for identification and provision of cardiometabolic risk reducing interventions in all patients with severe mental illness.

Association of comorbid mental disorders with cardiovascular disease risk in patients with type 2 diabetes: A nationwide cohort study

OBJECTIVE

To examine the association between comorbid mental disorders and cardiovascular disease (CVD) risk among patients with type 2 diabetes.

METHOD

This retrospective cohort study was conducted using the claims data of 2,227,394 South Korean patients with type 2 diabetes. We analyzed the occurrence of CVD including myocardial infarction (MI) and ischemic stroke, CVD-specific mortality, and all-cause mortality according to comorbid mental disorders including depressive disorders, bipolar and related disorders, schizophrenia spectrum disorders, insomnia, and anxiety disorders.

RESULTS

Among the patients, 9.1% had a comorbid mental disorder. The adjusted hazard ratios (aHR) for MI, ischemic stroke, CVD-specific mortality, and all-cause mortality in patients with any mental disorder were 1.20 (95% CI, 1.17-1.24), 1.13 (95% CI, 1.11-1.16), 1.16 (95% CI, 1.12-1.20), and 1.21 (95% CI, 1.19-1.23), respectively. Each mental disorder increased the risk of all outcomes, particularly bipolar and related disorders and schizophrenia spectrum disorders.

CONCLUSION

Comorbid mental disorders increased the CVD risk in patients with type 2 diabetes, with significantly increased risks associated with schizophrenia spectrum disorders (aHR: 1.27 for MI and 1.50 for ischemic stroke) and bipolar and related disorders (aHR: 1.27 for MI and 1.45 for ischemic stroke).

Effectiveness of a community-based peer support service among persons suffering severe mental illness in China

Background

Community-based peer support service is widely and effectively deployed for persons suffering severe mental illness (SMI) in countries with well-developed outpatient mental health systems. The objective of this study is to evaluate the effectiveness of a 1-year peer service project among persons with SMI implemented in China.

Methods

A total of 101 consumers (service recipients) and 66 family caregivers were recruited at baseline from communities located in Beijing and Chengdu. Severity of psychiatric symptoms, personal and social functioning, self-esteem, life satisfaction, and medication adherence were evaluated among consumers. Self-esteem, life satisfaction, anxiety, and depressive symptoms were assessed among family caregivers. Participants were reevaluated at 1 year with the same measures. Changes in outcomes from baseline to 1-year follow-up were examined using paired sample t tests or Stuart-Maxwell tests.

Results

Consumers' psychiatric symptoms were decreased at 1 year (p < 0.001). Their personal and social functioning (p = 0.003) and life satisfaction (p < 0.001) were increased. There were no improvements in self-esteem (p = 0.108) and medication adherence (ps ≥ 0.827) among consumers. For caregivers, no increases were presented in outcomes at the 1-year assessment (ps ≥ 0.164).

Conclusions

The findings suggest that peer support services could be sustainably implemented across China, with positive impacts on the psychiatric symptoms, social functioning, and life satisfaction of participants suffering SMI.

The Impact of a Continuity-of-Care Model From Hospitalization to Outpatient Clinic for Patients With Severe Mental Illness

The authors sought to assess the impact of a continuity-of-care model on quality-of-care measures among hospitalized patients with severe mental illness in Israel. A "continuity-of-care physician" provided psychiatric care to patients during hospitalization and outpatient care after discharge. In the year after the model's implementation, emergency department visits significantly decreased by 32% and rehospitalization rates of patients discharged within 30 and 90 days decreased by 40% and 29%, respectively. The yearly rate of compulsory admissions decreased from 35% to 25%, and the proportion of patients who entered rehabilitation significantly increased (from 9% to 13%). This model shows promise for improving quality of care of patients with severe mental illness admitted to acute psychiatric wards.

Study protocol of a randomized controlled trial evaluating home treatment with peer support for acute mental health crises (HoPe)

BACKGROUND

Home treatment (HT) is a treatment modality for patients with severe mental illness (SMI) in acute mental crises. It is frequently considered equivalent to psychiatric inpatient treatment in terms of treatment outcome. Peer Support (PS) means that people with lived experience of a mental illness are trained to support others on their way towards recovery. While PS is growing in international importance and despite a growing number of studies supporting its benefits, it is still not comprehensively implemented into routine care. The HoPe (Home Treatment with Peer Support) study investigates a combination of both - HT and PS - to provide further evidence for a recovery-oriented treatment of psychiatric patients.

METHODS

In our randomized controlled trial (RCT), HT with PS is compared with HT without PS within a network of eight psychiatric clinical centers from the North, South and East of Germany. We investigate the effects of a combination of both approaches with respect to the prevention of relapse/recurrence defined as first hospitalization after randomization (primary outcome), disease severity, general functioning, self-efficacy, psychosocial health, stigma resistance, recovery support, and service satisfaction (secondary outcomes). A sample of 286 patients will be assessed at baseline after admission to HT care (data point t₀) and randomized into the intervention (HT + PS) and control arm (HT). Follow-Up assessments will be conducted 2, 6 and 12 months after admission (resulting in three further data points, t₁ to t₃) and will be analyzed via intention-to-treat approach.

DISCUSSION

This study may determine the positive effects of PS added to HT, prove additional evidence for the efficacy of PS and thereby facilitate its further implementation into psychiatric settings. The aim is to improve quality of mental health care and patients' recovery as well as to reduce the risk of relapses and hospitalizations for patients with SMI.

TRIAL REGISTRATION

The trial is registered with ClinicalTrials.gov: NCT04336527 , April 7, 2020.

Physical Health Impairment and Exercise as Medicine in Severe Mental Disorders: A Narrative Review

BACKGROUND

Individuals with severe mental disorders (SMDs; schizophrenia spectrum disorders, bipolar disorder, and major depressive disorder) are not only suffering from their mental conditions; they also have an attenuated physical health, augmenting their overall critical condition.

OBJECTIVES

We review and critically appraise the evidence based on (1) key physiological factors relating to aerobic endurance and skeletal muscle strength; (2) implications for physical function and health; and (3) effects of training interventions with different intensities evaluated in individuals with SMDs.

FINDINGS

Reductions in aerobic endurance factors, peak oxygen uptake (VO_2peak) and walking work efficiency, are paralleled by reductions in maximal skeletal muscle strength and power. In turn, the poor aerobic endurance and muscle strength lead to impaired physical function, increased risk of lifestyle-related diseases, and ultimately early death. Exercise has the potential to counteract the attenuated physical health in people with SMDs. While aerobic endurance training is shown to increase VO_2peak due to plasticity of the oxygen transport system, strength training is documented to improve maximal muscle strength, power, and walking work efficiency as a result of adaptations in neuromuscular force developing factors.

CONCLUSIONS

In conclusion, improvements in these key determinants for physical health appear to be achievable in people with SMDs despite many being challenged by motivational difficulties with attending regular exercise and have beneficial implications for physical function during activities of daily living, lifestyle-related diseases, and early death.

Health-related quality of life in severe psychotic disorders during integrated care: 5-year course, prediction and treatment implications (ACCESS II)

Purpose

Studies on outcomes mapping Quality of Life (QoL) as patient-reported outcome over a longer period in severe psychotic disorders are scarce. However, such data would be particularly important for structuring, implementing and operating effective and efficient care models and for promoting satisfaction with care, service engagement and adherence.

Methods

The ACCESS II study is a prospective long-term study of an integrated care model for people with severe psychotic disorders. The model includes Therapeutic Assertive Community Treatment within a cross-sectoral and interdisciplinary network. This publication analyses the course of QoL assessed with the Q-LES-Q-18 using a mixed model for repeated measures.

Results

Mapping the course of QoL in N = 329 participants, there is a significant increase in the first 6 weeks of treatment (early course). Comparison to a published norm show significant lower QoL for severe psychotic disorders. The variable having a traumatic event before the age of 18 was significantly negatively associated with QoL. A decrease in the severity of depressive as well as in positive symptomatology in the first six weeks after admission was associated with increase of QoL.

Conclusion

Results indicate that the overall symptom burden at time of inclusion is not decisive for the perceived QoL in the long-term course while the reduction in the severity of depressive and positive symptoms is important. This means focusing even more on the treatment of depressive symptoms and include traumatherapeutic aspects in the long-term treatment of severe psychotic disorders if needed.

Trail registration

ClinicalTrials.gov (identifier: NCT01888627).

Effectiveness of electroconvulsive therapy in patients lacking decision making capacity: A systematic review and meta-analysis

BACKGROUND

Electroconvulsive therapy (ECT) is provided for patients with severe and often life-threatening illness, who lack decision making capacity to consent to treatment (DMC-T) in clinical settings.

OBJECTIVE

The aim of this study is to summarize previous studies investigating clinical outcomes of ECT in patients lacking DMC-T.

METHODS

A systematic review and meta-analysis of studies reporting clinical outcomes of ECT in patients lacking DMC-T with any psychiatric diagnoses was conducted. The primary outcome was clinical improvement. Secondary outcomes were cognitive outcomes and six month readmission rate. Hedges' g and odds ratios were calculated using a random-effects model. The protocol was registered in Open Science Framework (https://osf.io/rxjkm).

RESULTS

Of 3552 identified articles, 41 studies (n = 1299) were included. Approximately 80% of patients lacking DMC-T responded to ECT, and part of the patients regained capacity to consent and consented to further treatment with ECT. A total of seven studies (n = 1081) were included for meta-analysis. Patients without DMC-T showed superior clinical improvement and less cognitive side effects compared with those with DMC-T, whereas the groups did not show any difference in readmission rate. Several clinical characteristics at baseline and ECT techniques were significantly different between the groups.

CONCLUSION

ECT is equally, if not superiorly, effective in patients lacking DMC-T compared to patients with DMC-T. ECT can potentially enhance patients' autonomy, without increasing the risk of cognitive side effects. These results support the clinical and ethical legitimacy of ECT provision for patients with the most severe illness who lack DMC-T at start of treatment.

Hybrid and Remote Psychosocial Interventions Focused on Weight and Sedentary Behavior Management Among Patients with Severe Mental Illnesses: a Systematic Review

Severe mental illness could be defined through its diagnosis, disability, and duration, and one of their main characteristics is the high prevalence of some clinical conditions such as obesity and metabolic syndrome. Although the promotion of a healthier lifestyle has been demonstrated as an effective strategy to reduce both body mass index and abdominal circumference in this population, there is a lack of studies focusing on digital intervention in this population. The aim of this systematic review was to evaluate the efficacy of studies that used digital technologies to reduce weight, body mass index (BMI) and abdominal circumference in individuals with severe mental illness. This current review also compared remote and hybrid interventions, the effects of those interventions in metabolic biomarkers as well as in the development of a healthier lifestyle. The main findings included the following: (a) the use of digital devices or strategies might be feasible and useful to reduce sedentary behavior among individuals with severe mental illnesses, 2) most interventions used digital pedometers and mobile phone communication (either text messages or phone calls) as main strategies, 3) all remote interventions and six of nine hybrid interventions found significant outcomes in favor of their interventions. In conclusion, even with a limited number of studies promoting healthier lifestyle through digital interventions among individuals with severe mental illnesses, evidence from studies included in this review showed that they might be useful to improve a healthier lifestyle and increase the frequency of physical activity behavior.

The relationship between cognitive functioning, age and employment in people with severe mental illnesses in an urban area in India: A longitudinal study

Although there is substantial evidence of the association between cognitive impairment and work in people with severe mental illnesses (SMI) in developed countries, less is known about this relationship in developing countries such as India. Studies showing higher rates of employment in people with SMI in developing countries than developed ones raise the question of whether cognitive functioning is related to work status and characteristics of work (e.g., wages earned). We conducted a one-year follow-up study to investigate the relationship between employment and cognitive functioning, assessed with the Montreal Cognitive Assessment (MoCA), in 150 participants with SMI (92% schizophrenia) living in an urban area and receiving psychiatric outpatient treatment at a public hospital in India. The MoCA had good internal reliability and test-retest reliability over the one-year period. Better cognitive functioning was associated with younger age, shorter duration of illness, higher education, and male gender. Both younger and older participants with higher cognitive functioning at baseline were more likely to be employed at baseline and one year later. Work status at baseline and one year follow-up was consistently related to executive functions among younger participants, and to attention among older participants, suggesting changes over the course of illness in the importance of specific cognitive domains for achieving satisfactory work performance. The findings suggest that cognitive functioning is associated with employment in people with SMI in India. Attention to impaired cognitive functioning may be critical to improving employment outcomes in this population.

Study protocol for a pragmatic cluster RCT on the effect and cost-effectiveness of Everyday Life Rehabilitation versus treatment as usual for persons with severe psychiatric disability living in sheltered or supported housing facilities

Background

People with severe psychiatric disabilities and impaired autonomy, living in sheltered or supported housing facilities, often lead sedentary, solitary lives indoors and have significantly poorer health than others in the population. Meaningful everyday activities are important for the recovery towards an enrichening, agentic, social, and hopeful everyday life. The Everyday Life Rehabilitation (ELR) model—a person-centred activity- and recovery-oriented intervention—has shown positive outcomes in feasibility studies, and thus a randomised controlled trial (RCT) is required to establish the effectiveness of ELR, along with calculations of cost-effectiveness.

Methods

The ELR-RCT is a pragmatic, two-parallel-armed cluster RCT evaluating the effect and cost-effectiveness of using ELR from two measurement points over 6 months (pre-post intervention) and in three waves over 3 years. The primary outcome is recovering quality of life (ReQoL) at 6 months, and the secondary outcome is self-perceived recovery and daily functioning (RAS-DS) at 6 months. Additionally, Goal Attainment Scaling (GAS) will be used for the intervention group. Power analysis has been conducted for primary outcome measure. The first wave will include an internal pilot, to be evaluated after 6 months, used as basis for decisions on updating the required sample size and any other need for adaptations before continuing with the full-scale RCT in the second and third wave. All municipalities within a geographic area in northern Sweden, with a minimum of one sheltered or supported housing facility for people with severe psychiatric or neuropsychiatric disability, including access to occupational therapy, will be enrolled. Participants will be block-randomised to receive ELR plus treatment as usual (TAU) or TAU alone for a control period. The control group will thereafter receive delayed ELR. Occupational therapists and housing staff will receive an educational package, manuals, and tools, as well as reflections with colleagues during the intervention period. Housing managers will receive questions for monthly follow-up and coaching with staff.

Discussion

This is a protocol for both an internal pilot and full trial of the first RCT study using the ELR intervention model in sheltered or supported housing facilities, evaluating the effects together with cost-effectiveness.

Trial registration

ClinicalTrials.gov NCT05056415. Registered on 24 September 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06622-0.

Severe mental illness and quality of care for type 2 diabetes: A retrospective population-based cohort study

AIMS

To compare quality of care for type 2 diabetes in people with severe mental illness (SMI) versus no mental illness.

METHODS

We used routinely collected linked data to create a retrospective cohort study. We included 158,901 people diagnosed with type 2 diabetes in Scotland during 2009-2018 of whom 1701 (1%), 768 (0.5%) and 5211 (3%) had a prior hospital admission record for schizophrenia, bipolar disorder, and major depression, respectively. We compared recording of HbA1c, cholesterol, creatinine, blood pressure, urinary albumin, foot examination, retinopathy screening, body mass index and smoking during the first year after diabetes diagnosis using logistic regression and recording of HbA1c and retinopathy screening over longer follow-up using generalised linear mixed effects model, adjusting for confounding factors.

RESULTS

Receipt of care during the first year was generally similar, or better, for people with each SMI than for people without any mental illness. During mean follow up of 4.8 (SD 2.5) years, depression and bipolar disorder were associated with lower odds of receiving retinopathy screening.

CONCLUSIONS

Receipt of diabetes care was similar or better among people with SMI versus without SMI. However, mechanisms to support improved retinopathy screening for people with SMI are needed.

Cancer rates and mortality in people with severe mental illness: Further evidence of lack of parity

BACKGROUND

Severe mental illness (SMI) is associated with poorer physical health, however the relationship between SMI and cancer is complex and previous study findings are inconsistent. Low incidence of cancer in those with SMI has been attributed to premature mortality, though evidence for this is lacking. We aimed to investigate the relationship between SMI and cancer incidence and mortality, and to assess the effect of premature mortality on cancer incidence rates.

METHODS

In this UK-wide matched cohort study using primary care records we calculated incidence and mortality rates of all-cancer, and bowel, lung, breast or prostate cancer, in patients with SMI, compared to matched patients without SMI. We used competing risks regression to account for mortality from other causes.

FINDINGS

69,632 patients had an SMI diagnosis. The rate of all-cancer diagnoses was reduced in those with SMI (Hazard ratio (HR):0·95; 95%CI 0·93-0·98) compared to those without SMI, and particularly in those with schizophrenia (HR:0·82; 95%CI 0·77-0·88) compared to those without SMI. When accounting for the competing risk of premature mortality, incidence remained lower only in patients with schizophrenia. All-cause mortality after cancer was increased in the SMI group, and cancer-specific mortality was increased in those with schizophrenia (hazard ratio: 1.96; 95%CI 1.57-2.44).

INTERPRETATION

Patients with schizophrenia have lower rates of cancer diagnosis but higher all-cause and cancer-specific mortality rates following diagnosis compared to those without SMI. Premature mortality does not explain these differences, suggesting the findings reflect barriers to cancer diagnosis and treatment, which need to be identified and addressed.