Pedometer walking plus motivational interviewing program for Thai schizophrenic patients with obesity or overweight: a 12-week, randomized, controlled trial

Physical activity in adult users of inpatient mental health services: A scoping review

People with severe mental illness engage in considerably less physical activity than those without. They also experience premature mortality of around 10-25 years. A large proportion of these premature deaths are attributed to modifiable behaviours, including physical activity. The inpatient environment provides an opportunity to support people to become more physically active; however, there is limited evidence on which interventions are most successful and what contextual factors affect their delivery. A scoping review was conducted to help understand the extent and type of evidence in this area and identify research gaps. We included studies of physical activity correlates and interventions in adult inpatient mental health services published in peer-reviewed journals. Reviews, meta-analyses, and papers focusing on eating disorder populations were excluded. We searched the MEDLINE, CINAHL, PsycINFO, ASSIA and Web of Science databases for relevant studies published in English. We extracted data on study design, participant characteristics, intervention and control conditions, key findings, and research recommendations. We used a descriptive analytical approach and results are presented in tables and figures. Of 27,286 unique records screened, 210 reports from 182 studies were included. Sixty-one studies reported on correlates of physical activity, and 139 studies reported on physical activity interventions. Most intervention studies used a single-group, pre-post design (40%) and included fewer than 100 participants (86%). Ninety percent of interventions delivered physical activity directly to participants, and 50% included group-based sessions. The duration, type, frequency and intensity of sessions varied. Mental health was the most commonly reported outcome (64%), whereas physical activity was rarely an outcome (13%). Overall, there is a modest but growing body of research on physical activity in adult users of inpatient mental health services. More high-quality trials are needed to advance the field, and future research should target neglected intervention types, outcomes, populations and settings.

The effect of exercise on cognition and clinical symptoms of patients with schizophrenia: A systematic review of randomized controlled trial

Physical activity has been viewed as a potential non-pharmacological therapeutic strategy to improve the clinical symptoms and neurocognitive deficits in patients with schizophrenia. However, there are various types of physical activities, and different exercise prescriptions might produce inconsistent benefits. Thus, this study aimed to conduct a systematic review of exercise interventions for patients with schizophrenia, clarifying the benefits of these interventions on cognitive function and clinical symptoms. This review encompasses six electronic databases, with inclusion criteria including randomized controlled trial designs, participants with schizophrenia, and a comprehensive exercise intervention program. Twenty-seven studies met the inclusion criteria, incorporating data from 1549 patients with schizophrenia. The results highlight that when comparing the exercise intervention group to the non-intervention control group, patients with schizophrenia showed significant improvement in negative symptoms. Structured exercise interventions can help improve the negative symptoms of schizophrenia, filling the gaps where medication falls short. Regarding functional outcomes, exercise interventions aid in enhancing the overall functionality (psychological, social, occupational) of individuals with schizophrenia. The improvement is largely tied to the boost in physical fitness that exercise provides. Based on current findings, exercise interventions assist in enhancing cognitive function in patients with schizophrenia. Notably, significant improvements are observed in higher-order cognitive functions, including processing speed, attention, and working memory. It is recommended to engage in moderate-intensity exercises at least three times a week, with each session lasting a minimum of 30min. Well-structured exercise interventions contribute to enhancing the negative symptoms and cognitive functions in patients with schizophrenia.

Lifestyle intervention based on exercise and behavioural counselling and its effect on physical and psychological health in outpatients with schizophrenia spectrum disorders. An exploratory, pragmatic randomized clinical trial

Patients with Schizophrenia Spectrum Disorders (SSD) often lead unhealthy lifestyles. This pragmatic trial evaluated the effectiveness of a lifestyle intervention, consisting of a 12-week aerobic exercise program and behavioural counselling, in SSD outpatients with metabolic syndrome (MetS). It also aimed to assess persistence of potential effects in a 24-month long-term follow-up. Effectiveness was measured in terms of a wide range of outcomes involving physical and psychological health, quality of life, physical activity and changes in motivation to exercise within the context of the self-determination theory. Our primary outcome was waist circumference change. Thirty-three out of 48 participants completed the study. No differences between groups were found in terms of BMI change or other metabolic parameters. However, the active group (AG) showed improvement regarding waist circumference, negative symptomatology and identified motivation to exercise during the study and follow-up. The AG exhibited changes toward a more active pattern of activity after intervention. Moreover, belonging to the AG was a significant predictor for achieving any degree of clinical improvement after 24-month follow-up. Combined interventions of exercise and behavioural counselling in SSD patients with MetS should be considered as an essential part of the integral treatment in the context of mental health services.

Effectiveness of Short-Term Lifestyle Modification on Reducing Body- Weight-Related Parameters in Persons with Severe Mental Illness: A Randomized Controlled Trial

Background

Persons with severe mental illness (SMI) reportedly have a high mortality rate due to metabolic syndrome (MS). However, lifestyle modification (LM) offers effective management of some components of MS. This study aimed to evaluate the effectiveness of LM in reducing body-weight-related parameters in SMIs.

Method

Eighty participants with SMI were assigned randomly to either LM (n = 40) or treatment as usual (TAU; n = 40) groups using block randomization (eight blocks of n = 10). The LM group and their caregivers received a structured LM package that included nutrition counselling, recommendations on a balanced diet, and physical activity. The two groups were assessed on body weight, body mass index (BMI), waist circumference (WC), waist-hip ratio (WHR), and quality of life (QOL) at baseline and after three months. Thirty-one LM and 33 TAU participants completed the study.

Results

The LM and TAU groups were comparable on sociodemographic and clinical characteristics and baseline variables of body weight, BMI, WC, and WHR (all P > 0.08). Repeated-measures analysis of variance (RM ANOVA) showed that the LM group had significantly reduced body weight, BMI, WC, and WHR (all P < 0.001) than the TAU group. Similarly, the LM group also showed improvement in their QOL (P < 0.001), whereas TAU showed no improvement.

Conclusions

LM is an effective way to reduce body-weight-related parameters of MS and improves the QOL among persons with SMI in the short term. The caregivers' inclusion during LM contributed to the weight reduction. However, the long-term effect of the intervention could not be assessed.

Effectiveness of nutrition and dietary interventions for people with serious mental illness: systematic review and meta-analysis

OBJECTIVE

To review recent published trials of nutrition and dietary interventions for people with serious mental illness; to assess their effectiveness in improving metabolic syndrome risk factors.

STUDY DESIGN

Systematic review and meta-analysis of randomised and non-randomised controlled trials of interventions with a nutrition/diet-related component delivered to people with serious mental illness, published 1 January 2010 - 6 September 2021. Primary outcomes were weight, body mass index (BMI), and waist circumference. Secondary outcomes were total serum cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, triglyceride, and blood glucose levels.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL databases. In addition, reference lists of relevant publications were examined for further additional studies.

DATA SYNTHESIS

Twenty-five studies encompassing 26 intervention arms were included in our analysis. Eight studies were at low or some risk of bias, seventeen were deemed to be at high risk. Eight of seventeen intervention arms found statistically significant intervention effects on weight, ten of 24 on BMI, and seven of seventeen on waist circumference. The pooled effects of nutrition interventions on metabolic syndrome risk factors were statistically non-significant. However, we identified small size effects on weight for interventions delivered by dietitians (five studies; 262 intervention, 258 control participants; standardised mean difference [SMD], -0.28; 95% CI, -0.51 to -0.04) and interventions consisting of individual sessions only (three studies; 141 intervention, 134 control participants; SMD, -0.30; 95% CI, -0.54 to -0.06).

CONCLUSIONS

We found only limited evidence for nutrition interventions improving metabolic syndrome risk factors in people with serious mental illness. However, they may be more effective when delivered on an individual basis or by dietitians.

PROSPERO REGISTRATION

CRD42021235979 (prospective).

The efficacy and safety of exercise and physical activity on psychosis: A systematic review and meta-analysis

Background

Treatment of psychosis typically focuses on medication, but some of these medications can have unintended side effects, exercise has global health benefits, with minimal side effects. The purpose of this systematic review and meta-analysis is to investigate the effectiveness and safety of exercise and physical activity on psychotic symptoms, in people with psychosis when compared to usual care, in a hospital setting.

Methods

A systematic electronic search of the literature was performed in June 2022, in PubMed, Scopus, and PsychINFO with no date restrictions. We included randomized trials (RCTs) with patients with psychosis that received an exercise intervention within a hospital setting. The primary outcome of interest was Positive and Negative Symptom Severity Scale (PANSS) overall score. Secondary outcomes were adverse or serious adverse events.

Results

A total of 24 trials were included in this systematic review, with 9 included in the meta-analysis, including 1,426 participants. Aerobic had more pronounced effects when compared to usual care in PANSS positive (-0.23, 95% CI -0.53 to 0.07), negative (-0.38, 95% CI -0.65 to -0.10), general (-0.42, 95% CI -0.71 to -0.13) and overall scores (-0.25, 95% CI -0.52 to 0.03). Yoga when compared to usual care had no difference in PANSS subscale and overall scores. We found no difference on relapsing of psychiatric symptoms or somatic hospitalization when we compared aerobic or yoga to usual care (Risk Ratio, 1.12 95% CI 0.44-2.81).

Conclusion

Aerobic activity as an exercise modality in a hospital setting can be effective in decreasing negative and general psychosis symptom severity scores compared to usual care, however, it was uncertain if the effects were clinically important. More trials are needed to confirm the clinically benefit of aerobic exercise.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42021224997].

Effectiveness of interventions to address obesity and health risk behaviours among people with severe mental illness in low- and middle-income countries (LMICs): a systematic review and meta analysis

Introduction

People with severe mental illness (SMI) are more likely to have obesity and engage in health risk behaviours than the general population. The aims of this study are (1) evaluate the effectiveness of interventions that focus on body weight, smoking cessation, improving sleeping patterns, and alcohol and illicit substance abuse; (2) Compare the number of interventions addressing body weight and health risk behaviours in low- and middle-income countries (LMICs) v. those reported in published systematic reviews focusing on high-income countries (HICs).

Methods

Intervention studies published up to December 2020 were identified through a structured search in the following database; OVID MEDLINE (1946-December 2020), EMBASE (1974-December 2020), CINAHL (1975-2020), APA PsychoINFO (1806-2020). Two authors independently selected studies, extracted study characteristics and data and assessed the risk of bias. and risk of bias was assessed using the Cochrane risk of bias tool V2. We conducted a narrative synthesis and, in the studies evaluating the effectiveness of interventions to address body weight, we conducted random-effects meta-analysis of mean differences in weight gain. We did a systematic search of systematic reviews looking at cardiometabolic and health risk behaviours in people with SMI. We compared the number of available studies of LMICs with those of HICs.

Results

We assessed 15 657 records, of which 9 met the study inclusion criteria. Six focused on healthy weight management, one on sleeping patterns and two tested a physical activity intervention to improve quality of life. Interventions to reduce weight in people with SMI are effective, with a pooled mean difference of -4.2 kg (95% CI -6.25 to -2.18, 9 studies, 459 participants, I 2 = 37.8%). The quality and sample size of the studies was not optimal, most were small studies, with inadequate power to evaluate the primary outcome. Only two were assessed as high quality (i.e. scored 'low' in the overall risk of bias assessment). We found 5 reviews assessing the effectiveness of interventions to reduce weight, perform physical activity and address smoking in people with SMI. From the five systematic reviews, we identified 84 unique studies, of which only 6 were performed in LMICs.

Conclusion

Pharmacological and activity-based interventions are effective to maintain and reduce body weight in people with SMI. There was a very limited number of interventions addressing sleep and physical activity and no interventions addressing smoking, alcohol or harmful drug use. There is a need to test the feasibility and cost-effectiveness of context-appropriate interventions to address health risk behaviours that might help reduce the mortality gap in people with SMI in LMICs.

Aerobic exercise in severe mental illness: requirements from the perspective of sports medicine

Major depression, bipolar disorder, and schizophrenia are severe mental illnesses. Despite receiving psychopharmacological and psychosocial treatments, about half of patients develop a chronic course with residual cognitive and negative symptoms and have a high risk for cardiovascular disease and reduced life expectancy. Therefore, add-on innovative treatment approaches are needed to improve outcome. Aerobic exercise interventions have been shown to improve global functioning, cognition, and negative and depressive symptoms in these patients. The basic mechanism of these exercise-related changes has been reported to be improved brain plasticity, e.g., increased volume of disease-related brain regions such as the hippocampus. The optimal type, duration, and frequency of exercise have not yet been determined and need to be addressed in supervised physical exercise studies. Because of the low physical activity levels, lack of drive related to negative and depressive symptoms, and high prevalence of cardiovascular comorbidities in patients with severe mental illness, besides aiming to improve symptoms of mental illness, exercise interventions should also aim to increase cardiorespiratory fitness, which they should comprehensively assess by direct measurements of maximal oxygen uptake. Based on the recommendations for developing cardiorespiratory fitness by the American College of Sports Medicine, 150 min moderate-intensity training per week or vigorous-intensity exercise training for 75 min per week are appropriate. Most studies have had relatively short intervention periods, so future studies should focus on long-term adherence to exercise by implementing motivational strategies supported by telemedicine and by identifying and targeting typical barriers to exercise in this patient population.

Telephone-delivered health behaviour change support for people with a mental health condition: the coaches' perspective

Background

People with a mental health condition experience a greater prevalence of chronic disease and reduced life expectancy compared to the general population. Modifiable health risk behaviours, such as physical inactivity and poor nutrition are major contributing factors. Population-level health coaching delivering behavioural change support via telephone for healthy eating, physical activity, and weight management is an opportunity utilised by this group to support improvement in healthy lifestyle behaviours. Health coaches offer a valuable perspective into the provision of services to this high-risk group. This study aims to qualitatively explore coaches’ experiences in providing support to these participants, consider factors which may contribute to engagement and outcomes; and potentially inform future service improvement.

Method

A qualitative study design was employed involving semi-structured telephone interviews with six coaches employed in a telephone-based behaviour change support service in New South Wales, Australia, between April and July 2019. Interview data was analysed using an inductive thematic analysis.

Results

Coaches believed that the service was of benefit to people with a mental health condition, however making changes to health risk behaviours was potentially more difficult for this group of service users. Coaches indicated that in supporting this group there was a greater focus on building confidence and readiness to change. They noted that improvement in mental health as a result of physical health changes was an additional ‘measure of success’ of particular relevance. Coaches expressed a desire to receive more mental health training to better deliver coaching to participants with a mental health condition. Program variables such as limited call length were posed as possible barriers to care.

Conclusion

Further training and additional support for coaches, in additon to considering variations to aspects of service delivery may assist in improving engagement and outcomes for participants with mental health conditions. Examining mental health consumers’ experiences when engaging with telephone coaching services would be an important area to address in further research.

Effect of a nurse-led intervention program on the physical health and quality of life of individuals with severe mental illness

PURPOSE

The aim of this study was to investigate the effect of nurse-led intervention programs on patients' physical health, physical activities, healthy lifestyle behaviors, and quality of life.

DESIGN AND METHODS

The research was conducted with a quasi-experimental design. The sample consisted of 33 individuals with severe mental illness. Data were collected with the Healthy Lifestyle Behavior Scale II, the Short Form-36 Quality-of-Life Instrument, and pedometers.

FINDINGS

The individuals in the intervention group showed a statistically significant decrease in waist circumference and increases in the physical activity and nutrition dimensions of healthy lifestyle behaviors and the physical function of quality of life. No statistically significant changes were detected in anthropometric measurements, healthy lifestyle behaviors, or quality-of-life subscales in the control group.

PRACTICE IMPLICATIONS

Mental health nursing and psychiatric nurses should plan and implement interventions to encourage healthy eating and physical activity for patients.

In- and outpatient lifestyle interventions on diet and exercise and their effect on physical and psychological health: a systematic review and meta-analysis of randomised controlled trials in patients with schizophrenia spectrum disorders and first episode of psychosis

Patients with non-affective psychosis often lead unhealthy lifestyles. We performed a systematic review and meta-analysis on non-pharmacological RCTs for improvement of diet and physical activity in non-affective psychosis patients, including first-episode psychosis. A variety of outcomes was analysed, including metabolic, psychopathology, cognitive, functional and quality of life outcomes. Fifty-nine studies were included. An improvement in anthropometric measurements (BMI, weight, waist circumference) was observed post-intervention, persisting after follow-up. Post-intervention benefit was found also for psychotic symptoms severity (also persisting after follow-up), many cognitive domains and physical and global functioning and quality of life. Conversely, no effect was observed in relation to most blood metabolites, blood pressure and non-psychotic psychopathology and spontaneous physical activity. Improvement was generally larger for interventions including exercise, especially moderate/vigorous aerobic exercise, but follow-up maintenance was greater for psychotherapy interventions. Sensitivity analyses limited to chronic stages of psychosis and low risk of bias studies produced comparable results. Further studies are needed to design optimized interventions in this vulnerable population.

Lifestyle Interventions for Weight Management in People with Serious Mental Illness: A Systematic Review with Meta-Analysis, Trial Sequential Analysis, and Meta-Regression Analysis Exploring the Mediators and Moderators of Treatment Effects

BACKGROUND

Serious mental illness (SMI) reduces life expectancy, primarily due to somatic comorbidity linked to obesity. Meta-analyses have found beneficial effects of lifestyle interventions in people with SMI and recommended their implementation to manage obesity.

OBJECTIVE

The objective of this systematic review was to assess the benefits and harms of individualized lifestyle interventions for weight in people diagnosed with SMI and to explore potential mediators and moderators of the effect.

METHODS

The protocol was registered at PROSPERO (CRD42016049093). Randomized clinical trials (RCTs) assessing the effect of individualized lifestyle interventions on weight management in people with SMI were included. Primary outcomes were differences in endpoint body mass index (BMI) and the proportion achieving clinically relevant weight loss (≥5%). Secondary outcomes included quality of life, cardiometabolic risk factors, and adverse effects.

RESULTS

We included 41 RCTs (n = 4,267). All trials were at high risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. The experimental interventions reduced the mean difference in BMI by -0.63 kg/m2 (95% confidence interval [CI] = -1.02 to -0.23; p = 0.002; I2 = 70.7%) compared to the control groups. At postintervention follow-up (17 RCTs), the effect size remained similar but was no longer significant (BMI = -0.63 kg/m2; 95% CI = -1.30 to 0.04; p = 0.07; I2 = 48.8%). The risk ratio for losing ≥5% of baseline weight was 1.51 (95% CI = 1.07-2.13; p = 0.02) compared to the control groups. GRADE showed very low or low quality of evidence.

CONCLUSION

There is a statistically significant, but clinically insignificant, mean effect of individualized lifestyle interventions for weight reduction in people with SMI.

Evidence and gap map of studies assessing the effectiveness of interventions for people with disabilities in low-and middle-income countries

Background

There are approximately 1 billion people in the world with some form of disability. This corresponds to approximately 15% of the world's population (World Report on Disability, 2011). The majority of people with disabilities (80%) live in low- and middle-income countries (LMICs), where disability has been shown to disproportionately affect the most disadvantaged sector of the population. Decision makers need to know what works, and what does not, to best invest limited resources aimed at improving the well-being of people with disabilities in LMICs. Systematic reviews and impact evaluations help answer this question. Improving the availability of existing evidence will help stakeholders to draw on current knowledge and to understand where new research investments can guide decision-making on appropriate use of resources. Evidence and gap maps (EGMs) contribute by showing what evidence there is, and supporting the prioritization of global evidence synthesis needs and primary data collection.

Objectives

The aim of this EGM is to identify, map and describe existing evidence of effectiveness studies and highlight gaps in evidence base for people with disabilities in LMICs. The map helps identify priority evidence gaps for systematic reviews and impact evaluations.

Methods

The EGM included impact evaluation and systematic reviews assessing the effect of interventions for people with disabilities and their families/carers. These interventions were categorized across the five components of community-based rehabilitation matrix; health, education, livelihood, social and empowerment. Included studies looked at outcomes such as, health, education, livelihoods, social inclusion and empowerment, and were published for LMICs from 2000 onwards until January 2018. The searches were conducted between February and March 2018. The EGM is presented as a matrix in which the rows are intervention categories (e.g., health) and subcategories (e.g., rehabilitation) and the column outcome domains (e.g., health) and subdomains (e.g., immunization). Each cell lists the studies for that intervention for those outcomes, with links to the available studies. Included studies were therefore mapped according to intervention and outcomes assessed and additional filters as region, population and study design were also coded. Critical appraisal of included systematic review was done using A Measurement Tool to Assess Systematic Reviews' rating scale. We also quality-rated the impact evaluation using a quality assessment tool based on various approaches to risk of bias assessment.

Results

The map includes 166 studies, of which 59 are systematic reviews and 107 impact evaluation. The included impact evaluation are predominantly quasiexperimental studies (47%). The numbers of studies published each year have increased steadily from the year 2000, with the largest number published in 2017.The studies are unevenly distributed across intervention areas. Health is the most heavily populated area of the map. A total of 118 studies of the 166 studies concern health interventions. Education is next most heavily populated with 40 studies in the education intervention/outcome sector. There are relatively few studies for livelihoods and social, and virtually none for empowerment. The most frequent outcome measures are health-related, including mental health and cognitive development (n = 93), rehabilitation (n = 32), mortality and morbidity (n = 23) and health check-up (n = 15). Very few studies measured access to assistive devices, nutrition and immunization. Over half (n = 49) the impact evaluation come from upper-middle income countries. There are also geographic gaps, most notably for low income countries (n = 9) and lower-middle income countries (n = 34). There is a fair amount of evidence from South Asia (n = 73) and Sub-Saharan Africa (n = 51). There is a significant gap with respect to study quality, especially with respect to impact evaluation. There appears to be a gap between the framing of the research, which is mostly within the medical model and not using the social model of disability.

Conclusion

Investing in interventions to improve well-being of people with disabilities will be critical to achieving the 2030 agenda for sustainable development goals. The EGM summarized here provides a starting point for researchers, decision makers and programme managers to access the available research evidence on the effectiveness of interventions for people with disabilities in LMICs in order to guide policy and programme activity, and encourage a more strategic, policy-oriented approach to setting the future research agenda.

Effects of therapeutic lifestyle change mentoring on cardio-metabolic factors for schizophrenia

Considering that the prevalence of cardio-metabolic syndrome in patients with chronic schizophrenia is two or three times higher than the general population, this study aimed to provide patients with schizophrenia using community psychiatric rehabilitation services with therapeutic lifestyle change (TLC) mentoring using a smartphone application and provide inpatients in a psychiatric ward with structured TLC mentoring, to compare improvement in cardio-metabolic factors between the two groups. The home-based community service users using a TLC application were more likely to experience an improvement in their cardio-metabolic factors than the inpatients provided with the structured TLC program.

An appraisal of methodology reporting in lifestyle interventions among people with psychosis: A systematic review

ISSUE ADDRESSED

Lifestyle interventions use nutrition and physical activity behaviour modification techniques to decrease obesity and cardio-metabolic risk in people with psychosis. Evidence on the specific behaviour modification strategies applied to decrease obesity is weakened by inadequate methodology reporting of lifestyle interventions. A systematic review that we conducted earlier highlighted a possible deficiency in reporting; hence we aim to critically appraise lifestyle intervention studies that target weight outcomes for people with psychosis against the methods component of the CONSORT statement for randomised trials of nonpharmacologic treatments.

METHODS COMPONENT

We considered randomised controlled studies which delivered lifestyle interventions to community-dwelling adults with psychotic disorders, and included those with the following outcomes of interest: weight, body mass index, waist circumference and waist-to-hip ratio. The Cochrane Library, MEDLINE/PREMEDLINE, EMBASE, CINAHL, Scopus and PsycINFO were searched for English publications between 1985 and 2018. Methodology and reporting of studies were evaluated using the CONSORT statement for randomised trials of nonpharmacologic treatments.

RESULTS

Thirty-two studies met the inclusion criteria. Critical appraisals revealed that reporting of lifestyle intervention studies was generally incomplete. Fewer than 50% provided the recommended information on trial design, participant characteristics, detail of interventions, outcomes, sample size, randomisation, blinding and statistical methods.

CONCLUSIONS

Application of guidelines, like the CONSORT statement, in future publications of lifestyle interventions for people with psychosis will improve accuracy of reporting. SO WHAT?: Enhanced reporting in lifestyle intervention studies for people with psychosis will promote guideline creation and translation of research, which is likely to positively impact physical health outcomes.

Perspectives on diet and physical activity among urban African Americans with serious mental illness

African Americans are burdened by high rates of obesity that contribute to chronic disease and early mortality. To tailor a weight loss intervention to meet the needs of African Americans with serious mental illness, a community-based participatory research (CBPR) team comprised primarily of African Americans with serious mental illness guided qualitative research to understand factors that affect weight and interventions that may diminish obesity. Data from five focus groups (n = 55) were analyzed to better understand this group's needs. Participants voiced individual, social, and structural barriers to maintaining and achieving a healthy weight and provided perspectives on potential solutions.

Primary care management of cardiovascular risk for people with severe mental illnesses: the Primrose research programme including cluster RCT

Background

Effective interventions are needed to prevent cardiovascular disease (CVD) in people with severe mental illnesses (SMI) because their risk of CVD is higher than that of the general population.

Objectives

(1) Develop and validate risk models for predicting CVD events in people with SMI and evaluate their cost-effectiveness, (2) develop an intervention to reduce levels of cholesterol and CVD risk in SMI and (3) test the clinical effectiveness and cost-effectiveness of this new intervention in primary care.

Design

Mixed methods with patient and public involvement throughout. The mixed methods were (1) a prospective cohort and risk score validation study and cost-effectiveness modelling, (2) development work (focus groups, updated systematic review of interventions, primary care database studies investigating statin prescribing and effectiveness) and (3) cluster randomised controlled trial (RCT) assessing the clinical effectiveness and cost-effectiveness of a new practitioner-led intervention, and fidelity assessment of audio-recorded appointments.

Setting

General practices across England.

Participants

All studies included adults with SMI (schizophrenia, bipolar disorder or other non-organic psychosis). The RCT included adults with SMI and two or more CVD risk factors.

Interventions

The intervention consisted of 8–12 appointments with a practice nurse/health-care assistant over 6 months, involving collaborative behavioural approaches to CVD risk factors. The intervention was compared with routine practice with a general practitioner (GP).

Main outcome measures

The primary outcome for the risk score work was CVD events, in the cost-effectiveness modelling it was quality-adjusted life-years (QALYs) and in the RCT it was level of total cholesterol.

Data sources

Databases studies used The Health Improvement Network (THIN). Intervention development work included focus groups and systematic reviews. The RCT collected patient self-reported and routine NHS GP data. Intervention appointments were audio-recorded.

Results

Two CVD risk score models were developed and validated in 38,824 people with SMI in THIN: the Primrose lipid model requiring cholesterol levels, and the Primrose body mass index (BMI) model with no blood test. These models performed better than published Cox Framingham models. In health economic modelling, the Primrose BMI model was most cost-effective when used as an algorithm to drive statin prescriptions. Focus groups identified barriers to, and facilitators of, reducing CVD risk in SMI including patient engagement and motivation, staff confidence, involving supportive others, goal-setting and continuity of care. Findings were synthesised with evidence from updated systematic reviews to create the Primrose intervention and training programme. THIN cohort studies in 16,854 people with SMI demonstrated that statins effectively reduced levels of cholesterol, with similar effect sizes to those in general population studies over 12–24 months (mean decrease 1.2 mmol/l). Cluster RCT: 76 GP practices were randomised to the Primrose intervention (n = 38) or treatment as usual (TAU) (n = 38). The primary outcome (level of cholesterol) was analysed for 137 out of 155 participants in Primrose and 152 out of 172 in TAU. There was no difference in levels of cholesterol at 12 months [5.4 mmol/l Primrose vs. 5.5 mmol/l TAU; coefficient 0.03; 95% confidence interval (CI) –0.22 to 0.29], nor in secondary outcomes related to cardiometabolic parameters, well-being or medication adherence. Mean cholesterol levels decreased over 12 months in both arms (–0.22 mmol/l Primrose vs. –0.39 mmol/l TAU). There was a significant reduction in the cost of inpatient mental health attendances (–£799, 95% CI –£1480 to –£117) and total health-care costs (–£895, 95% CI –£1631 to –£160; p = 0.012) in the intervention group, but no significant difference in QALYs (–0.011, 95% CI –0.034 to 0.011). A total of 69% of patients attended two or more Primrose appointments. Audiotapes revealed moderate fidelity to intervention delivery (67.7%). Statin prescribing and adherence was rarely addressed.

Limitations

RCT participants and practices may not represent all UK practices. CVD care in the TAU arm may have been enhanced by trial procedures involving CVD risk screening and feedback.

Conclusions

SMI-specific CVD risk scores better predict new CVD if used to guide statin prescribing in SMI. Statins are effective in reducing levels of cholesterol in people with SMI in UK clinical practice. This primary care RCT evaluated an evidence-based practitioner-led intervention that was well attended by patients and intervention components were delivered. No superiority was shown for the new intervention over TAU for level of cholesterol, but cholesterol levels decreased over 12 months in both arms and the intervention showed fewer inpatient admissions. There was no difference in cholesterol levels between the intervention and TAU arms, which might reflect better than standard general practice care in TAU, heterogeneity in intervention delivery or suboptimal emphasis on statins.

Future work

The new risk score should be updated, deployed and tested in different settings and compared with the latest versions of CVD risk scores in different countries. Future research on CVD risk interventions should emphasise statin prescriptions more. The mechanism behind lower costs with the Primrose intervention needs exploring, including SMI-related training and offering frequent support to people with SMI in primary care.

Trial registration

Current Controlled Trials ISRCTN13762819.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 2. See the NIHR Journals Library website for further project information. Professor David Osborn is supported by the University College London Hospital NIHR Biomedical Research Centre and he was also in part supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Barts Health NHS Trust.

Nonpharmacological Interventions for the Treatment of Cardiometabolic Risk Factors in People With Schizophrenia-A Systematic Review

Background: People suffering from schizophrenia are notably vulnerable to cardiometabolic risk factors (CMRF), such as obesity, high blood pressure, hyperglycemia and insulin resistance, high serum triglycerides, and low serum high-density lipoprotein (HDL), which are related to increased mortality and decreased quality of life. The increased risk of "metabolic syndrome" (MS) is related to low physical activity, an unhealthy diet, and side effects of antipsychotic drugs. Nonpharmacological interventions seem to be important in the prevention and therapy of MS. Aim: This paper provides an overview of published studies and a critical analysis of pilot programs involving nonpharmacological measures aimed at prevention and treatment of CMRF in patients with schizophrenia. Material and Method: We searched the PubMed, PsycARTICLES, and Cochrane Library databases to identify clinical trials. We included full-text studies that met the following criteria: age > 18 years, a diagnosis of schizophrenia or schizoaffective disorder, and monitored parameters associated with MS. Results: All 1,555 references were evaluated for inclusion in the review, and 20 met the inclusion criteria. Nonpharmacological interventions led to improvement in physical health and showed a promising potential for implementation in treatment programs dedicated to this particular group of patients. However, a critical analysis revealed limitations, which have implications for the direction of future research. Conclusions: Patients suffering from schizophrenia can benefit from nonpharmacological interventions aimed at counteracting CMRF, improving either metabolic parameters, cardiovascular fitness, or their health perception. Notwithstanding, to achieve long-term effects, future studies should comprise appropriate follow-up procedures.

Impact of lifestyle modification on some components of metabolic syndrome in persons with severe mental disorders: A meta-analysis

BACKGROUND

Metabolic syndrome (MS) is reportedly associated with high mortality from mostly cardiovascular causes in patients with severe mental disorders (SMD). Lifestyle interventions augment effective management of MS in patients with SMD. The present meta-analysis aims at updating the recent evidence on the effectiveness of lifestyle intervention for MS in patients with SMD.

METHOD

A literature search for English Language publications of randomized controlled trials (RCTs) from 2001 to 2016 comparing lifestyle modification (LM) with treatment as usual (TAU) in the management of MS were identified. Using PRISMA guidelines, 19 RCTs reporting data on 1688 SMD and MS patients and providing data on change in Body Weight, Body Mass Index (BMI) and waist circumference (WC) were included. Using random effects model, standardized mean difference between LM and TAU for the mean baseline-to-endpoint change in body weight, BMI and WC was calculated with a 95% confidence limit, on RevMan 5.3. The study was registered with PROSPERO (CRD42016046847).

RESULTS

LM had significantly superior efficacy in the reducing weight (-0.64, 95% CI -0.89, -0.39, Z = 5.03, overall effect p < 0.00001), BMI (-0.68, 95% CI -1.01, -0.35, Z = 4.05, overall effect p < 0.0001), and WC (-0.60, 95% CI -1.17, -0.03, Z = 2.06; overall effect p = 0.04), compared to TAU. LM was significantly more effective than TAU even in short duration (p = 0.0001) and irrespective of the treatment setting.

CONCLUSION

Interventions targeting LM in persons with SMD and MS are effective in reducing body weight, BMI and WC. It must be routinely recommended to all patients with SMD, ideally during commencement stage of second generation antipsychotic treatment.

Effectiveness of Interventions for Weight Loss for People With Serious Mental Illness: A Systematic Review and Meta-Analysis

OBJECTIVE

We examined the effectiveness of weight loss interventions in community-based settings for people with serious mental illness (SMI).

METHOD

Four databases were searched for randomized controlled trials published in 2008 or later that met the criteria for the research question and used weight loss as an outcome measure. Data were extracted, and weight loss was analyzed using a meta-analysis. Similarities and differences in interventions were analyzed qualitatively.

RESULTS

Seventeen studies and a total of 1,874 participants with various diagnoses of SMI were included in the meta-analysis. The various lifestyle-focused interventions had a significant effect on weight loss with an overall effect size of -0.308 (p < .001).

CONCLUSION

Community-based interventions for people with SMI are effective for weight loss. Occupational therapists can be involved in the provision of weight loss interventions and in the development and study of intervention components that are most effective.

Using motivational techniques to reduce cardiometabolic risk factors in long term psychiatric inpatients: a naturalistic interventional study

BACKGROUND

People with severe mental illness have markedly reduced life expectancy; cardiometabolic disease is a major cause. Psychiatric hospital inpatients have elevated levels of cardiometabolic risk factors and are to a high degree dependent of the routines and facilities of the institutions. Studies of lifestyle interventions to reduce cardiometabolic risk in psychiatric inpatients are few. The current study aimed at assessing the feasibility and effects of a lifestyle intervention including Motivational Interviewing (MI) on physical activity levels, cardiometabolic risk status and mental health status in psychotic disorder inpatients.

METHODS

Prospective naturalistic intervention study of 83 patients at long term inpatient psychosis treatment wards in South-Eastern Norway. Patients were assessed 3-6 months prior to, at start and 6 months after a life-style intervention program including training of staff in MI, simple changes in routines and improvements of facilities for physical exercise. Assessments were done by clinical staff and included level of physical activity, motivation, life satisfaction, symptom levels (MADRS, AES-C, PANSS, and GAF) as well as anthropometric and biochemical markers of cardiometabolic risk. A mixed model was applied to analyze change over time.

RESULTS

A total of 88% of patients received MI interventions, with a mean of 2.5 MI interventions per week per patient. The physical activity level was not increased, but activity level was positively associated with motivation and negatively associated with positive symptoms. Triglyceride levels and number of smokers were significantly reduced and a significant decrease in symptom levels was observed.

CONCLUSIONS

The current results suggest that a simple, low cost life-style intervention program focusing on motivational change is feasible and may reduce symptoms and improve lifestyle habits in psychosis patients in long term treatment facilities. Similar programs may easily be implemented in other psychiatric hospitals.

TRIAL REGISTRATION

ClinicalTrials.gov . NCT03528278 , date of registration: 05/16/2018 (retrospectively registered).

Determination of physical health status and healthy lifestyle behaviors of individuals with mental illness

PURPOSE

The aim of this study is to determine the physical health status and healthy lifestyle behaviors of individuals with mental illness.

DESIGN AND METHODS

A descriptive research design was used. The sample of the study consisted of 115 individuals with mental illness. The Health Lifestyle Behaviors Scale II was used to assess the healthy lifestyle behaviors of the participants.

FINDINGS

Of the individuals, 49.6% were found to have metabolic syndrome. Individuals with mental illness obtained the lowest score from the physical activity dimension of the scale.

PRACTICE IMPLICATIONS

Individuals with mental illness need to receive education and support, especially in terms of nutrition and exercise.

Physical activity and sedentary behaviour research in Thailand: a systematic scoping review

BACKGROUND

The number of deaths per year attributed to non-communicable diseases is increasing in low- and middle-income countries, including Thailand. To facilitate the development of evidence-based public health programs and policies in Thailand, research on physical activity (PA) and sedentary behaviour (SB) is needed. The aims of this scoping review were to: (i) map all available evidence on PA and SB in Thailand; (ii) identify research gaps; and (iii) suggest directions for future research.

METHODS

A systematic literature search was conducted through 10 bibliographic databases. Additional articles were identified through secondary searches of reference lists, websites of relevant Thai health organisations, Google, and Google Scholar. Studies written in Thai or English were screened independently by two authors and included if they presented quantitative or qualitative data relevant to public health research on PA and/or SB.

RESULTS

Out of 25,007 screened articles, a total of 564 studies were included in the review. Most studies included PA only (80%), 6.7% included SB only, and 13.3% included both PA and SB. The most common research focus was correlates (58.9%), followed by outcomes of PA/SB (22.2%), prevalence of PA/SB (12.4%), and instrument validation (3.2%). Most PA/SB research was cross-sectional (69.3%), while interventions (19.7%) and longitudinal studies (2.8%) were less represented. Most studies (94%) used self-reports of PA/SB, and few (2.5%) used device-based measures. Both sexes were examined in most studies (82.5%). Adults were the main target population group (51.1%), followed by older adults (26.9%), adolescents (15.7%), and children (6.3%). Clinical populations were investigated in the context of PA/SB in a relatively large number of studies (15.3%), most frequently those with cardiovascular disease, diabetes, and hypertension (22%, 21%, and 21% respectively).

CONCLUSIONS

The number of Thai papers on PA published per year has been increasing, indicating a growing interest in this research area. More studies using population-representative samples are needed, particularly among children and adolescents, and investigating SB as a health risk factor. To provide stronger evidence on determinants and outcomes of PA/SB, longitudinal studies using standardised measures of PA and SB are required.

The opinions of Turkish mental health nurses on physical health care for individuals with mental illness: A qualitative study

WHAT IS KNOWN ON THE SUBJECT

Individuals with mental illness have significantly higher mortality and morbidity than the general population due to physical illnesses. Mental health nurses play a key role in providing care for common physical problems and protecting and promoting healthy lifestyles. Little is known from previous studies in the international literature about the attitudes, behaviours and thoughts of mental health nurses on providing physical health care.

WHAT THIS PAPER ADDS TO THE EXISTING KNOWLEDGE

Mental health nurses mostly focus on the existing physical health problems of individuals with mental illness. However, mental health nurses do not include practices of disease prevention and physical health promotion for individuals with mental illness. The desire to see positive changes in individuals with mental illness, receiving positive feedback, feeling useful and happy, and feeling satisfied with their profession motivate mental health nurses in terms of providing physical health care.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

The knowledge and skill required of mental health nurses to provide physical health care need to be increased. Institutions should employ expert nurses who are able to guide mental health nurses to provide physical health care. It is important to provide adequate physical infrastructure and human resources to provide better physical health care in mental health services.

ABSTRACT

Background Mental health nurses play an important role in improving the physical health of individuals with mental illnesses. However, there are limited studies of their attitudes and practices about physical health. Therefore, there is a need for qualitative studies to clarify the issue.

AIM

The aim of this study was to determine mental health nurses' opinions about physical health care for individuals with mental illness.

METHODS

This study was carried out in Turkey. A qualitative descriptive approach was taken in the study. The sample consisted of twelve mental health nurses selected by purposeful sampling. In-depth interviews were conducted using a semi-structured interview format. A thematic analysis was used to evaluate the interviews.

RESULTS

Four main themes were determined. (1) The barriers to physical healthcare theme included barriers related to patients, illness and treatment, barriers related to patients' caregivers, barriers related to health professionals and barriers related to the healthcare system. (2) The physical healthcare practices theme included common physical health problems and current nursing practices. (3) Motivators theme included the desire to see positive changes in a patient, receiving positive feedback, feeling useful and happy, having a sense of conscience and feeling satisfied with their profession. (4) The needs for better physical healthcare theme included the nurses' recommendations for better physical health care.

CONCLUSION

Mental health nurses believe that the physical health care provided to individuals with mental illness is not adequate. Many barriers to providing care for physical health, such as having psychiatric symptoms that are not seen as a priority by patients and health personnel, were determined.

IMPLICATIONS FOR PRACTICE

Mental health nurses should integrate physical healthcare practices into their routine care. In addition, mental health nurses' knowledge and skills about physical health care should be improved.

Motivational interviewing: living up to its promise?

Motivational interviewing is a form of psychotherapy in which ambivalence towards an aberrant behaviour is targeted. Rather than challenge the behaviour directly, the clinician encourages the patient to devise a list of problems that are caused by the behaviour and to identify solutions. There are many trials of motivational interviewing, although it has been most studied as treatment for substance misuse. The effect sizes for motivational interviewing are small, they probably diminish over time, the trials often use multiple outcome measures and the outcomes of some very large trials have been disappointing. Large effects are occasionally reported, although these tend to be from small trials conducted by highly motivated research groups and the results tend to diminish when the trials are repeated or enlarged. Nonetheless, motivational interviewing is a well-validated approach supporting and enabling engagement in therapeutic process. It could be argued that even though it might not be as efficacious as a primary/stand-alone means of changing patients’ behaviour, it can still be highly effective when combined with other approaches or used as a conduit to a more intensive therapy.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Effects of Aerobic Exercise on Metabolic Syndrome, Cardiorespiratory Fitness, and Symptoms in Schizophrenia Include Decreased Mortality

Schizophrenia is a severe psychiatric disorder with a lifetime prevalence of about 1%. People with schizophrenia have a 4-fold higher prevalence of metabolic syndrome than the general population, mainly because of antipsychotic treatment but perhaps also because of decreased physical activity. Metabolic syndrome is a risk factor for cardiovascular diseases, and the risk of these diseases is 2- to 3-fold higher in schizophrenia patients than in the general population. The suicide risk is also higher in schizophrenia, partly as a result of depression, positive, and cognitive symptoms of the disease. The higher suicide rate and higher rate of cardiac mortality, a consequence of the increased prevalance of cardiovascular diseases, contribute to the reduced life expectancy, which is up to 20 years lower than in the general population. Regular physical activity, especially in combination with psychosocial and dietary interventions, can improve parameters of the metabolic syndrome and cardiorespiratory fitness. Furthermore, aerobic exercise has been shown to improve cognitive deficits; total symptom severity, including positive and negative symptoms; depression; quality of life; and global functioning. High-intensity interval endurance training is a feasible and effective way to improve cardiorespiratory fitness and metabolic parameters and has been established as such in somatic disorders. It may have more beneficial effects on the metabolic state than more moderate and continuous endurance training methods, but to date it has not been investigated in schizophrenia patients in controlled, randomized trials. This review discusses physical training methods to improve cardiorespiratory fitness and reduce metabolic syndrome risk factors and symptoms in schizophrenia patients. The results of studies and future high-quality clinical trials are expected to lead to the development of an evidence-based physical training program for patients that includes practical recommendations, such as the optimal length and type of aerobic exercise programs and the ideal combination of exercise, psychoeducation, and individual weight management sessions.

Lifestyle interventions for weight loss among overweight and obese adults with serious mental illness: A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to estimate effects of lifestyle intervention participation on weight reduction among overweight and obese adults with serious mental illness.

METHOD

We systematically searched electronic databases for randomized controlled trials comparing lifestyle interventions with other interventions or usual care controls in overweight and obese adults with serious mental illness, including schizophrenia spectrum or mood disorders. Included studies reported change in weight [kg] or body mass index (BMI) [kg/m2] from baseline to follow-up. Standardized mean differences (SMD) were calculated for change in weight from baseline between intervention and control groups.

RESULTS

Seventeen studies met inclusion criteria (1968 participants; 50% male; 66% schizophrenia spectrum disorders). Studies were grouped by intervention duration (≤6-months or ≥12-months). Lifestyle interventions of ≤6-months duration showed greater weight reduction compared with controls as indicated by effect size for weight change from baseline (SMD=-0.20; 95% CI=-0.34, -0.05; 10 studies), but high statistical heterogeneity (I2=90%). Lifestyle interventions of ≥12-months duration also showed greater weight reduction compared with controls (SMD=-0.24; 95% CI=-0.36, -0.12; 6 studies) with low statistical heterogeneity (I2=0%).

CONCLUSION

Lifestyle interventions appear effective for treating overweight and obesity among people with serious mental illness. Interventions of ≥12-months duration compared to ≤6-months duration appear to achieve more consistent outcomes, though effect sizes are similar for both shorter and longer duration interventions.

Improving physical health of patients with severe mental disorders: a critical review of lifestyle psychosocial interventions

INTRODUCTION

People with severe mental disorders have a mortality rate that is more than two times higher than the general population, with at least a decade of potential years of life lost. People with mental disorders have a significantly higher risk of obesity, hyperglycemia and metabolic syndrome, which are related to modifiable risk factors, such as heavy smoking, poor physical activities, and inappropriate unhealthy diet, which can be improved through lifestyle changes. Areas covered: Lifestyle behaviours are amenable to change through the adoption of specific psychosocial interventions, and several approaches have been promoted. In the present review, the authors aim to: 1) critically analyze studies involving multimodal lifestyle interventions; 2) discuss the way forward to integrate these interventions in clinical routine care. Expert commentary: The psychoeducational approaches developed for the improvement of healthy lifestyle behaviours differ for several aspects: 1) the format (individual vs. group); 2) the setting (outpatient vs. inpatient vs. home-based); 3) the professional characteristics of the staff running the intervention (psychiatrists or nurses or dietitians or psychologists); 4) the active ingredients of the intervention (education only or inclusion of motivational interview or of problem solving); 5) the duration of treatment (ranging from 3 months to 2 years).

Examining methods, messengers and behavioural theories to disseminate physical activity information to individuals with a diagnosis of schizophrenia: a scoping review

BACKGROUND

Many individuals with a diagnosis of schizophrenia are not active and lack the necessary knowledge and confidence to become and stay active. To develop effective physical activity promotion interventions, it is necessary to identify credible messengers and effective methods to disseminate physical activity information to this population.

AIMS

The purpose of this scoping review was to identify and examine knowledge mobilization theories, messengers and methods used to disseminate physical activity information to individuals with a diagnosis of schizophrenia.

METHOD

This scoping review followed the methodological framework proposed by Arksey and O'Malley.

RESULTS

In total, 43 studies and 7 reviews identified multiple messengers and methods used to disseminate physical activity information to individuals with a diagnosis of schizophrenia, but few attempts to structure information theoretically. Findings do not point to which messengers or methods are most effective or which theories should be used to construct information interventions. Studies show that physical activity information should be provided in an individualised manner from staff who could easily connect with patients.

CONCLUSIONS

Few researchers have addressed the physical activity information needs of individuals with a diagnosis of schizophrenia. Researchers need to examine and implement effective knowledge mobilization strategies for this population.

Activity monitoring using a mHealth device and correlations with psychopathology in patients with chronic schizophrenia

There are few studies of mobile-Health (mHealth) device application with schizophrenic patients. We aimed to quantitatively assess patient's activity and the relationship between their physical activity and the severity of their psychopathologies. Then we attempted to identify the patients who required intervention and evaluated the feasibility of using the mHealth device. A total of 61 of the 76 available hospitalized patients with chronic schizophrenia who participated in the activity programs were enrolled. They wore a mHealth device for a week to assess their activity (steps/day). The Positive and Negative Syndrome Scale (PANSS) was completed by the subjects. As a result, the positive subscale of the PANSS and the positive and negative factors of the PANSS 5-factor structure showed a predictive value for low levels of physical activity. The group of subjects with a high total PANSS score had a significantly lower level of physical activity than the other groups. In conclusion, physical activity showed a significant association with positive symptoms as well as negative symptoms. The mHealth device showed relatively good feasibility for schizophrenic patients. We should pay more attention to the activity of patients with high PANSS scores.

Wearable devices and mobile technologies for supporting behavioral weight loss among people with serious mental illness

Promoting physical activity is essential for addressing elevated cardiovascular risk and high obesity rates affecting people with serious mental illness. Numerous challenges interfere with exercise participation in this high-risk group including mental health symptoms, low motivation, and limited access to safe and affordable options for physical activity. Wearable devices and mobile health technologies may afford new opportunities for promoting physical activity and supporting behavioral weight loss efforts. This exploratory study examined whether daily step count measured using Fitbit wearable devices was associated with weight loss and improved fitness among individuals with serious mental illness enrolled in a 6-month lifestyle program. Participants (n=34) had a schizophrenia spectrum disorder (23.5%), major depression (50.0%), or bipolar disorder (26.5%), and wore Fitbits most of the days (M=86.2%; SD=18.4%) they were enrolled in the study. At 6-months, higher average daily step count was associated with greater weight loss (F=5.07; df=1,32; p=0.0314), but not improved fitness (F=1.92; df=1,31; p=0.176). These findings demonstrate that encouraging participants with serious mental illness enrolled in lifestyle interventions to collect more steps may contribute to greater weight loss. This suggests that wearable devices may offer a feasible and potentially effective strategy for supporting behavioral weight loss in community mental health settings.

Work out by Walking: A Pilot Exercise Program for Individuals With Schizophrenia Spectrum Disorders

The health benefits of exercise are well documented, yet annual health care costs related to physical inactivity are well within the billions. Furthermore, individuals with schizophrenia spectrum disorders (SSDs) are more likely to lead sedentary lives, exercise less than the general population, and die prematurely from preventable causes. Previous research examining the effects of exercise on individuals with SSDs has been encouraging yet limited in creating accessible and sustainable interventions. The current pilot study developed and evaluated the impact of Work out by Walking (WOW), a multicomponent group walking intervention on the health of 16 individuals with SSDs. Results indicated improvements in indicators of physical health, activity level, social support, and mental health and a high level of program satisfaction. Future research should examine multicomponent group walking programs for individuals with SSDs in larger samples and with the inclusion of a comparison condition.

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

Life expectancy in patients with schizophrenia is reduced by 20 years for men and 15 years for women compared to the general population. About 60% of the excess mortality is due to physical illnesses, with cardiovascular disease being dominant. CHANGE was a randomized, parallel-group, superiority, multi-centre trial with blinded outcome assessment, testing the efficacy of an intervention aimed to improve cardiovascular risk profile and hereby potentially reduce mortality. A total of 428 patients with schizophrenia spectrum disorders and abdominal obesity were recruited and centrally randomized 1:1:1 to 12 months of lifestyle coaching plus care coordination plus treatment as usual (N=138), or care coordination plus treatment as usual (N=142), or treatment as usual alone (N=148). The primary outcome was 10-year risk of cardiovascular disease assessed post-treatment and standardized to age 60. At follow-up, the mean 10-year risk of cardiovascular disease was 8.4 ± 6.7% in the group receiving lifestyle coaching, 8.5 ± 7.5% in the care coordination group, and 8.0 ± 6.5% in the treatment as usual group (p=0.41). We found no intervention effects for any secondary or exploratory outcomes, including cardiorespiratory fitness, physical activity, weight, diet and smoking. In conclusion, the CHANGE trial did not support superiority of individual lifestyle coaching or care coordination compared to treatment as usual in reducing cardiovascular risk in patients with schizophrenia spectrum disorders and abdominal obesity.

Prevalence and predictors of treatment dropout from physical activity interventions in schizophrenia: a meta-analysis

OBJECTIVE

Physical activity interventions have been shown to improve the health of people with schizophrenia, yet treatment dropout poses an important challenge in this population, and rates vary substantially across studies. We conducted a meta-analysis to investigate the prevalence and predictors of treatment dropout in physical activity interventions in people with schizophrenia.

METHOD

We systematically searched major electronic databases from inception until August 2015. Randomized controlled trials of physical activity interventions in people with schizophrenia reporting dropout rates were included. Two independent authors conducted searches and extracted data. Random-effects meta-analysis and meta-regression analyses were conducted.

RESULTS

In 19 studies, 594 patients with schizophrenia assigned to exercise interventions were investigated (age=37.2 years, 67.5% male, range=37.5%-100%). Trim and fill adjusted treatment dropout rate was 26.7% [95% confidence interval (CI)=19.7%-35.0%], which is more than double than in nonactive control interventions (odds ratio=2.15, 95% CI=1.29-3.58, P=.003). In the multivariate regression, qualification of the professional delivering the intervention (β=-1.06, 95% CI=-1.77 to -0.35, P=.003) moderated treatment dropout rates, while continuous supervision of physical activity approached statistical significance (P=.05).

CONCLUSIONS

Qualified professionals (e.g., physical therapists/exercise physiologists) should prescribe supervised physical activity for people with schizophrenia to enhance adherence, improve psychiatric symptoms and reduce the onset and burden of cardiovascular disease.

Interventions to Address Medical Conditions and Health-Risk Behaviors Among Persons With Serious Mental Illness: A Comprehensive Review

People with serious mental illness (SMI) have mortality rates 2 to 3 times higher than the overall US population, largely due to cardiovascular disease. The prevalence of cardiovascular risk factors such as obesity and diabetes mellitus and other conditions, such as HIV/AIDS, is heightened in this group. Based on the recommendations of a National Institute of Mental Health stakeholder meeting, we conducted a comprehensive review examining the strength of the evidence surrounding interventions to address major medical conditions and health-risk behaviors among persons with SMI. Peer-reviewed studies were identified using 4 major research databases. Randomized controlled trials and observational studies testing interventions to address medical conditions and risk behaviors among persons with schizophrenia and bipolar disorder between January 2000 and June 2014 were included. Information was abstracted from each study by 2 trained reviewers, who also rated study quality using a standard tool. Following individual study review, the quality of the evidence (high, medium, low) and the effectiveness of various interventions were synthesized. 108 studies were included. The majority of studies examined interventions to address overweight/obesity (n = 80). The strength of the evidence was high for 4 interventions: metformin and behavioral interventions had beneficial effects on weight loss; and bupropion and varenicline reduced tobacco smoking. The strength of the evidence was low for most other interventions reviewed. Future studies should test long-term interventions to cardiovascular risk factors and health-risk behaviors. In addition, future research should study implementation strategies to effectively translate efficacious interventions into real-world settings.

A narrative synthesis investigating the use and value of social support to promote physical activity among individuals with schizophrenia

PURPOSE

To review and synthesise the literature detailing the use of social support to facilitate physical activity participation in individuals with schizophrenia.

METHOD

A systematic review of major electronic databases was conducted to identify literature regarding the use of social support to promote physical activity among people with schizophrenia. A narrative synthesis was undertaken in four stages, including development of a theory, developing a preliminary synthesis, exploring relationships and assessing the robustness of the synthesis.

RESULTS

From a total of 110 studies, 23 met the inclusion criteria including 883 individuals with schizophrenia. Informational support was the most documented form of social support, followed by emotional, esteem and tangible. Providers included research personnel, healthcare professionals, family members and peers. Details of the content of the different dimensions of functional support are given. Social support appears to have an important role to help individuals with schizophrenia initiate, comply and adhere with exercise interventions. Social support may have an indirect benefit on weight maintenance. However, due to the limitations of the selected literature, it was difficult ascertain what the (in)direct benefit of social support are on health outcomes.

CONCLUSIONS

Social support appears to play a pivotal role in initiating physical activity as well as ensuring compliance and adherence to physical activity. Future research is required to investigate the optimal type and mode of delivery of social support on health outcomes.

IMPLICATIONS FOR REHABILITATION

Limited evidence is available that considers the role, value and use of social support within physical activity interventions for individuals with schizophrenia. Social support appears most likely to aid an individual's initiation, adherence and compliance to physical activity interventions. There may be an indirect benefit of social support on maintaining or enhancing health outcomes.

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

BACKGROUND

Life expectancy in patients with schizophrenia is reduced by 20 years for males and 15 years for females compared to the general population. About 60% of the excess mortality is due to physical illnesses, with cardiovascular disease being the single largest cause of death.

METHODS/DESIGN

The CHANGE trial is an investigator-initiated, independently funded, randomized, parallel-group, superiority, multi-centre trial with blinded outcome assessment. 450 patients aged 18 years or above, diagnosed with schizophrenia spectrum disorders and increased waist circumference, will be recruited and randomized 1:1:1 to 12-months interventions. We will compare the effects of 1) affiliation to the CHANGE team, offering a tailored, manual-based intervention targeting physical inactivity, unhealthy dietary habits, and smoking, and facilitating contact to their general practitioner to secure medical treatment of somatic comorbidity; versus 2) affiliation to a care coordinator who will secure guideline-concordant monitoring and treatment of somatic comorbidity by facilitating contact to their general practitioner; versus 3) treatment as usual to evaluate the potential add-on effects of lifestyle coaching plus care coordination or care coordination alone to treatment as usual. The primary outcome is the 10-year risks of cardiovascular disease assessed at 12 months after randomization.

DISCUSSION

The premature mortality observed in this vulnerable population has not formerly been addressed specifically by using composite surrogate outcomes for mortality. The CHANGE trial expands the evidence for interventions aiming to reduce the burden of metabolic disturbances with a view to increase life expectancy. Here, we present the trial design, describe the methodological concepts in detail, and discuss the rationale and challenges of the intermediate outcomes.

TRIAL REGISTRATION

Clinical Trials.gov NCT01585493 . Date of registration 27(th) of March 2012.

Structured Walking and Chronic Institutionalized Schizophrenia Inmates: A pilot RCT Study on Quality of Life

BACKGROUND

Lifestyle moderate-intensity physical activity can lower the risk of over twenty chronic health conditions, whilst inactivity reduces daily functioning and physical health of individuals living with schizophrenia. This study conducted in 2014 examines the effect of structured walking participation on QOL, psychosocial functioning and symptoms in Hospital Permai, one of the largest psychiatry institution in Asia

METHOD

Chronic patients with schizophrenia (n=104) who met inclusion criteria were randomised to either a 3-month structured walking intervention or a treatment-as-usual arm. The Positive and Negative Syndrome Scale (PANSS), global functioning (PSP) and QOL (SF-36) were measured at baseline and after the 3-month interval.

RESULTS

At 3 month follow-up, there were significant within group differences in QOL (SF-36), psychiatric symptoms (PANSS), and personal and social performance (PSP). There were statistically significant increase in the median SF-36 scores, with increases shown in physical functioning (p<.001), physical role limitations (p<.05), social functioning (p<.01) in the intervention group compared to treatment-as-usual group. Statistically significant reduction of median PANSS score of the intervention group were noted in positive (p<0.001) and negative (p<0.01) symptom, and general psychopathology (p<0.01) scales. Statistically significant increase in the median PSP score (p<0.01) was found in the intervention group compared with the treatment-as-usual group. Between-group differences at post intervention (favouring Intervention) were significant for PANSS positive and SF36 Physical

CONCLUSION

In long stayed chronic inmates, a simple but consistent, organized walking intervention has the potential to bring improvement in functioning, reduction in psychiatric symptoms and quality of Life. The emphasis of rehabilitation should target at lifestyle redesign intervention.

The effects of lifestyle interventions on (long-term) weight management, cardiometabolic risk and depressive symptoms in people with psychotic disorders: a meta-analysis

AIMS

The aim of this study was to estimate the effects of lifestyle interventions on bodyweight and other cardiometabolic risk factors in people with psychotic disorders. Additionally, the long-term effects on body weight and the effects on depressive symptoms were examined.

MATERIAL AND METHODS

We searched four databases for randomized controlled trials (RCTs) that compared lifestyle interventions to control conditions in patients with psychotic disorders. Lifestyle interventions were aimed at weight loss or weight gain prevention, and the study outcomes included bodyweight or metabolic parameters.

RESULTS

The search resulted in 25 RCTs -only 4 were considered high quality- showing an overall effect of lifestyle interventions on bodyweight (effect size (ES)  =  -0.63, p<0.0001). Lifestyle interventions were effective in both weight loss (ES =  -0.52, p<0.0001) and weight-gain-prevention (ES =  -0.84, p = 0.0002). There were significant long-term effects, two to six months post-intervention, for both weight-gain-prevention interventions (ES =  -0.85, p = 0.0002) and weight loss studies (ES =  -0.46, p = 0.02). Up to ten studies reported on cardiometabolic risk factors and showed that lifestyle interventions led to significant improvements in waist circumference, triglycerides, fasting glucose and insulin. No significant effects were found for blood pressure and cholesterol levels. Four studies reported on depressive symptoms and showed a significant effect (ES =  -0.95, p = 0.05).

CONCLUSION

Lifestyle interventions are effective in treating and preventing obesity, and in reducing cardiometabolic risk factors. However, the quality of the studies leaves much to be desired.

A systematic review of controlled interventions to reduce overweight and obesity in people with schizophrenia

OBJECTIVE

Overweight and obesity are generally found among patients with schizophrenia. This may lead to serious implications for health and wellbeing. The aim was to review controlled intervention studies on reducing overweight/obesity and/or reducing physical illness in patients with schizophrenia.

METHOD

A systematic literature search was carried out in the bibliographic databases PubMed (MEDLINE), Embase (Ovid), PsycInfo (Ovid) and Cinahl (Ebsco). We included all randomised and non-randomised clinically controlled studies that compared a non-pharmacological intervention, aimed at weight reduction and/or reducing physical illness, with standard care for patients with schizophrenia.

RESULTS

All 1713 references were evaluated for inclusion in the review. Twenty-three met the inclusion criteria and were categorised into four subgroups according to tested interventions: diet, exercise and cognitive behavioural therapy, or mixed combinations of the three. In this review, interventions showed efficacy in reducing weight and improving physical health parameters confirming that physical health improvement was possible in patients with schizophrenia.

CONCLUSION

The included studies indicate that the interventions reduced weight and improved physical health parameters in patients with schizophrenia.

The potential for motivational interviewing to improve outcomes in the management of diabetes and obesity in paediatric and adult populations: a clinical review

Having good intentions to engage in healthy behaviours, to change our lives in a positive direction and make substantial, lasting changes may not always translate into actions or behaviour that is maintained. Motivational Interviewing is a directive person-centred approach designed to explore ambivalence and activate motivation for change [Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behaviour. London: Guilford Press, 1991]. A key component of a motivational interviewing conversation is to acknowledge that clients have every right to make no change. It uses a guiding communication style which invites people to consider their own situation and find their own solutions to situations that they identify as problematic that are preventing change. Motivational Interviewing was first introduced in adult health addiction services in the early 1980s. It has developed in the physical health specialties, and in the last 20 years or so attention has turned to the potential of Motivational Interviewing in the paediatric setting and the challenges of using it in families with children at differing ages and developmental stages. This article summarizes studies published from 2006 to 2011 of Motivational Interviewing in individuals across the lifespan with type 1 and type 2 diabetes and obesity.

Exercise therapy in adults with serious mental illness: a systematic review and meta-analysis

BACKGROUND

Individuals with serious mental illness are at a higher risk of physical ill health. Mortality rates are at least twice those of the general population with higher levels of cardiovascular disease, metabolic disease, diabetes, and respiratory illness. Although genetics may have a role in the physical health problems of these patients, lifestyle and environmental factors such as levels of smoking, obesity, poor diet, and low levels of physical activity also play a prominent part.

METHODS

We conducted a systematic review and meta-analysis of randomised controlled trials comparing the effect of exercise interventions on individuals with serious mental illness.Searches were made in Ovid MEDLINE, Embase, CINAHL, PsycINFO, Biological Abstracts on Ovid, and The Cochrane Library (January 2009, repeated January 2013) through to February 2013.

RESULTS

Eight RCTs were identified in the systematic search. Six compared exercise versus usual care. One study assessed the effect of a cycling programme versus muscle strengthening and toning exercises. The final study compared the effect of adding specific exercise advice and motivational skills to a simple walking programme. The review found that exercise improved levels of exercise activity (n = 13, standard mean difference [SMD] 1.81, CI 0.44 to 3.18, p = 0.01). No beneficial effect was found on negative (n = 84, SMD = -0.54, CI -1.79 to 0.71, p = 0.40) or positive symptoms of schizophrenia (n = 84, SMD = -1.66, CI -3.78 to 0.45, p = 0.12). No change was found on body mass index compared with usual care (n = 151, SMD = -0.24, CI -0.56 to 0.08, p = 0.14), or body weight (n = 77, SMD = 0.13, CI -0.32 to 0.58, p = 0.57). No beneficial effect was found on anxiety and depressive symptoms (n = 94, SMD = -0.26, CI -0.91 to 0.39, p = 0.43), or quality of life in respect of physical and mental domains.

CONCLUSIONS

This systematic review showed that exercise therapies can lead to a modest increase in levels of exercise activity but overall there was no noticeable change for symptoms of mental health, body mass index, and body weight.

Selection, use and psychometric properties of physical activity measures to assess individuals with severe mental illness: a narrative synthesis

This research provides a critical consideration of the outcome measures used to assess physical activity in individuals with severe mental illness. A narrative synthesis was utilised to provide a simple juxtapose of the current research. A sensitive topic-based search strategy was conducted in order to identify studies that met the eligibility criteria. Fifty two studies met the inclusion criteria and 5 were identified specially as validation studies. The current research identified several methodological shortcomings. The justification and choice of outcome measure used is often weak and only five studies have validated a specific outcome measure of physical activity. Within these validation studies, the validation process often lacked a consideration of agreement between measures. Accelerometers have been most frequently used as a criterion measure, notably the RT3 tri-axial accelerometer. Objective based measures may be best placed to consider physical activity levels, although, methodological considerations for the utilization of such tools is required. Self-report questionnaires have benefits for use in this population but require further validation. Researchers and clinicians need to carefully consider what outcome measure they are using and be aware of the development, scope and purpose of that measure.

Effects of a Walking Program on Self-management and Risk Factors of Metabolic Syndrome in Older Korean Adults

[Purpose] The aim of this study was to determine the effects of a 12-week walking program on increasing an individual’s self-management and decreasing the risk factors of metabolic syndrome in the older adult population. [Subjects] A total of 31 older adults participated in this study. Eighteen participants in the experimental group and 13 controls completed the pretest and posttest measures. A walking exercise and health education were provided for the experimental group. Data were analyzed by ANCOVAs to examine group differences. [Results] At the end of the 12-week study period, the experimental group showed a significant improvement in individuals’ ability to self-manage their health compared to the control group. Also, there were significant differences between the two groups in the total numbers of risk factors of metabolic syndrome, systolic blood pressure and BMI. No significant difference in blood sugar levels, HDL-C, waist circumference, and triglyceride levels were found between the experimental and control group. [Conclusion] This study revealed that a combination of health education and for walking exercise can lead to improved lifestyle management and reduce risk factors of metabolic syndrome for the elderly population of Korea.