Health promotion lifestyle interventions for weight management in psychosis: a systematic review and meta-analysis of randomised controlled trials

One-year efficacy of a lifestyle behavioural intervention on physical and mental health in people with severe mental disorders: results from a randomized controlled trial

This multicentric randomized controlled trial (RCT), carried out in six Italian University mental health sites, aims to test the efficacy of a six-month psychosocial intervention (LYFESTYLE) on Body Mass Index (BMI), body weight, waist circumference, fasting glucose, triglycerides, cholesterol, Framingham and HOmeostasis Model Assessment of insulin resistance (HOMA-IR) indexes in patients with schizophrenia, bipolar disorder, and major depression. Moreover, the efficacy of the intervention has also been tested on several other physical and mental health domains. Patients were randomly allocated to receive the six-month experimental intervention (LIFESTYLE) or a behavioural control intervention. All enrolled patients were assessed at baseline and after one year. We recruited 401 patients (206 in the experimental and 195 in the control group) with a diagnosis of schizophrenia or other psychotic disorder (29.9%), bipolar disorder (43.3%), or major depression (26.9%). At one year, patients receiving the experimental intervention reported an improvement in body mass index, body weight, waist circumference, HOMA-IR index, anxiety and depressive symptoms and in quality of life. Our findings confirm the efficacy of the LIFESTYLE intervention in improving physical and mental health-related outcomes in patients with severe mental illnesses after one year.

Staff supported community outings among forensic mental health patients: patient characteristics, rehabilitative goals, and (the absence of) adverse outcomes

Mental health professionals are tasked with making difficult clinical decisions in treatment settings. In the forensic system, decision making regarding staff supervised community outings (SSCOs) provides a significant challenge due to the need to balance patient liberties, mental health recovery, and public safety. This study explored the characteristics and rehabilitative nature of SSCOs, characteristics of patients attending SSCOs, and any adverse events that occurred during the outings. Employing a cross-sectional design, 110 patients who participated in SSCOs over a one-year period from a Canadian Forensic Psychiatric Hospital were included. Clinical records were reviewed to capture patient and SSCO variables. Descriptive analyses were used to calculate participant, risk, SSCO, and adverse event characteristics. Qualitative analysis was used to explore the purpose of SSCOs and rehabilitative progress that occurred during the outings. Patients attending SSCOs were comprised of long-stay patients with over half having committed a violent index offence. Almost 75% of patients had a moderate/high risk for violence and 50% of the patients had a moderate/high risk of absconding. During the study period, 463 SSCOs were completed. Most outings focused on developing skills for daily living and staff comments suggested many patients developed skills in these areas. Despite considerable risk profiles and public concern regarding forensic patients having community access, there was a single occurrence of unauthorized leave and no instances of violence or substance use. This research can disrupt stigma, demonstrating that SSCOs support a specific rehabilitative intent, promote community reintegration, and maintain public safety.

Shared and unique characteristics of metabolic syndrome in psychotic disorders: a review

Introduction

People with psychosis spectrum disorders (PSD) face an elevated risk of metabolic syndrome (MetS), which may reduce their life expectancy by nearly 20%. Pinpointing the shared and specific characteristics and clinical implications of MetS in PSD is crucial for designing interventions to reduce this risk, but an up-to-date review on MetS across the psychosis spectrum is lacking.

Methods

This narrative review fills this gap by examining the clinical literature on characteristics and implications of MetS in both distinct PSD and transdiagnostically, i.e., across traditional categorical diagnoses, with a focus on psychiatric and cardio-metabolic management.

Results

We discuss common and specific characteristics of MetS in PSD, as well as factors contributing to MetS development in PSD patients, including unhealthy lifestyle factors, genetic predisposition, pro-inflammatory state, drugs consumption, antipsychotic medication, and psychotic symptoms. We highlight the importance of early identification and management of cardio-metabolic risk in PSD patients, as well as the existing gaps in the literature, for instance in the screening for MetS in younger PSD patients. We compare hypotheses-generating clinical associations and characteristics of MetS in different PSD, concluding by reviewing the existing recommendations and challenges in screening, monitoring, and managing MetS in PSD.

Conclusion

Early identification and management of MetS are crucial to mitigate the long-term cardio-metabolic toll in PSD patients. Interventions should focus on healthy lifestyle and appropriate pharmacological and behavioral interventions. Further translational and clinical research is needed to develop targeted interventions and personalized treatment approaches for this vulnerable population, aiming at improving physical health and overall well-being.

Prevalence of lifestyle cardiovascular risk factors and estimated framingham 10-year risk scores of adults with psychotic disorders compared to controls at a referral hospital in Eldoret, Kenya

INTRODUCTION

Lifestyle factors such as smoking, alcohol use, suboptimal diet, and inadequate physical activity have been associated with increased risk of cardiovascular diseases. There are limited data on these risk factors among patients with psychosis in low- and middle-income countries.

OBJECTIVES

This study aimed to establish the prevalence of lifestyle cardiovascular risk factors, and the 10-year cardiovascular risk scores and associated factors in patients with psychosis compared to controls at Moi Teaching and Referral Hospital in Eldoret, Kenya.

METHODS

A sample of 297 patients with schizophrenia, schizoaffective disorder, or bipolar mood disorder; and 300 controls matched for age and sex were included in this analysis. A study specific researcher-administered questionnaire was used to collect data on demographics, antipsychotic medication use, smoking, alcohol intake, diet, and physical activity. Weight, height, abdominal circumference, and blood pressure were also collected to calculate the Framingham 10-year Cardiovascular Risk Score (FRS), while blood was drawn for measurement of glucose level and lipid profile. Pearson's chi-squared tests and t-tests were employed to assess differences in cardiovascular risk profiles between patients and controls, and a linear regression model was used to determine predictors of 10-year cardiovascular risk in patients.

RESULTS

Compared to controls, patients with psychosis were more likely to have smoked in their lifetimes (9.9% vs. 3.3%, p = 0.006) or to be current smokers (13.8% vs. 7%, p = 0.001). Over 97% of patients with psychosis consumed fewer than five servings of fruits and vegetables per week; 78% engaged in fewer than three days of vigorous exercise per week; and 48% sat for more than three hours daily. The estimated 10-year risk of CVD was relatively low in this study: the FRS in patients was 3.16, compared to 2.93 in controls. The estimated 10-year cardiovascular risk in patients was significantly associated with female sex (p = 0.007), older patients (p < 0.001), current tobacco smoking (p < 0.001), and metabolic syndrome (p < 0.001).

CONCLUSION

In the setting of Eldoret, there is suboptimal physical exercise and intake of healthy diet among patients with psychosis and controls. While the estimated risk score among patients is relatively low in our study, these data may be useful for informing future studies geared towards informing interventions to promote healthy lifestyles in this population.

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.

Nurse-led lifestyle intervention in a cohort of schizophrenia patients treated with clozapine

Patients diagnosed with schizophrenia are characterized by early mortality compared to the general population. The main cause of this premature death reflects medical complications linked to metabolic syndrome (MetS). The use of antipsychotics such as clozapine is associated with weight gain and metabolic disturbances in certain predisposed individuals. Non-pharmacological interventions for weight control have become a key element for secondary prevention in the health of patients diagnosed with schizophrenia. Here, we aim to evaluate the physical health effects of a nurse-led non-pharmacological intervention program in patients with a diagnosis of schizophrenia treated with clozapine. Thirty-one outpatients from the outpatient clinical facility of Hospital Clinic in Barcelona, Spain diagnosed with schizophrenia and other psychotic disorders receiving clozapine treatment were enrolled in a prospective interventional study, comprising an 8-week group program of therapeutic education in a healthy lifestyle. MetS factors, physical activity, diet, and lifestyle were evaluated at baseline, post-intervention (8 weeks), and 3 months after the program. Weight, body mass index, high-density lipoprotein cholesterol, and diet patterns displayed significant differences post-intervention and after 3 months, while only waist, hip perimeter, and lifestyle improved post-intervention. Our results suggest the effectiveness of the lifestyle intervention in patients under clozapine treatment despite its long-time differential effect. Strategies to prevent weight gain and metabolic decline will help prevent premature cardiometabolic disease in this vulnerable population.

[Weight gain and treatment with psychotropic drugs : Background and management]

Psychotropic drug-induced weight gain (PIWG) is a well-known and frequent side effect which is relevant for the prognosis of patients. Individual medications have varying risks for the occurrence of PIWG, and at the same time there are individual risk factors on the part of patients, such as age, gender, metabolic and genetic factors. As the metabolic changes in the context of PIWG result in increased mortality in the long term, it is important to prevent PIWG by appropriate prevention and to intervene in a targeted manner if PIWG has already occurred. Appropriate monitoring is therefore essential. This article provides an overview of underlying mechanisms, risk constellations and possible countermeasures.

Examining Nutrition Knowledge, Skills, and Eating Behaviours in People with Severe Mental Illness: A Cross-Sectional Comparison among Psychiatric Inpatients, Outpatients, and Healthy Adults

Compared to the general population, people with severe mental illness (SMI) have an increased risk of weight gain and metabolic syndrome, but also of malnutrition, in part due to unhealthy lifestyle behaviours. The aim of this cross-sectional study was to identify barriers to healthy eating, including nutrition knowledge and skills in people with SMI. For this purpose, we compared the means of anthropometric data such as body mass index, waist-to-hip ratio, and interview data on nutrition knowledge and skills, health-related variables, eating behaviours, personality, motivation, and attitudes in 65 inpatients and 67 outpatients of the Psychiatric Hospital of the University of Zurich and 64 healthy adults using ANOVA and chi-squared tests. The results showed that patients with SMI had worse nutritional status and lifestyle compared to the healthy controls, including disordered (e.g., night eating) and unhealthy (e.g., high intake of sugary foods) eating habits. However, levels of nutrition knowledge, cooking and food skills, and motivation to eat healthily were not significantly lower in the psychiatric patients than in the healthy adults and were not associated with weight change. Based on our findings, nutritional support for people with SMI is urgently needed and should include not only educational but also behavioural and long-term approaches.

Evaluation and Treatment of Obesity and Its Comorbidities: 2022 Update of Clinical Practice Guidelines for Obesity by the Korean Society for the Study of Obesity

The goal of the 8th edition of the Clinical Practice Guidelines for Obesity is to help primary care physician provide safe, effective care to patients with obesity by offering evidence-based recommendations to improve the quality of treatment. The Committee for Clinical Practice Guidelines comprised individuals with multidisciplinary expertise in obesity management. A steering board of seven experts oversaw the entire project. Recommendations were developed as the answers to key questions formulated in patient/problem, intervention, comparison, outcomes (PICO) format. Guidelines underwent multi-level review and cross-checking and received endorsement from relevant scientific societies. This edition of the guidelines includes criteria for diagnosing obesity, abdominal obesity, and metabolic syndrome; evaluation of obesity and its complications; weight loss goals; and treatment options such as diet, exercise, behavioral therapy, pharmacotherapy, and bariatric and metabolic surgery for Korean people with obesity. Compared to the previous edition of the guidelines, the current edition includes five new topics to keep up with the constantly evolving field of obesity: diagnosis of obesity, obesity in women, obesity in patients with mental illness, weight maintenance after weight loss, and the use of information and communication technology-based interventions for obesity treatment. This edition of the guidelines features has improved organization, more clearly linking key questions in PICO format to recommendations and key references. We are confident that these new Clinical Practice Guidelines for Obesity will be a valuable resource for all healthcare professionals as they describe the most current and evidence-based treatment options for obesity in a well-organized format.

Effect of the GLP-1 receptor agonist semaglutide on metabolic disturbances in clozapine-treated or olanzapine-treated patients with a schizophrenia spectrum disorder: study protocol of a placebo-controlled, randomised clinical trial (SemaPsychiatry)

INTRODUCTION

Clozapine and olanzapine are some of the most effective antipsychotics, but both are associated with weight gain and relevant metabolic disturbances, including pre-diabetes and diabetes. Non-pharmacological/behavioural interventions have had limited effects counteracting these adverse effects. Semaglutide, a glucagon-like peptide 1 receptor agonist, is approved for the treatment of type 2 diabetes and obesity. We will investigate the long-term effects of add-on treatment with semaglutide once a week versus placebo once a week on the metabolic status in pre-diabetic (glycated haemoglobin A1c (HbA1c) 35-47 mmol/mol (5.4%-6.4%) and diabetic (HbA1c 48-57 mmol/mol (6.5%-7.4%)) patients diagnosed with a schizophrenia spectrum disorder who initiated clozapine or olanzapine treatment within the last 60 months.

METHODS AND ANALYSIS

This is a 26-week, double-blinded, randomised, placebo-controlled trial. Altogether, 104 patients diagnosed with a schizophrenia spectrum disorder, aged 18-65 years, with pre-diabetes or diabetes will be randomised to injections of 1.0 mg semaglutide once a week or placebo for 26 weeks. The primary endpoint is change from baseline in HbA1c. Secondary endpoints include changes in body weight, hip and waist circumference and plasma levels of insulin, glucagon, glucose, and C-peptide, insulin sensitivity, beta cell function, hepatic function, fibrosis-4 score, lipid profile, incretin hormones, bone markers, body composition, bone density, proteomic analyses and oxidative stress markers. Together with alcohol, tobacco and drug use, potential effects on the reward value of a sweet-fat stimulus, psychopathology, level of activity and quality of life will also be assessed.

ETHICS AND DISSEMINATION

This study is approved by the Danish Medicines Agency and the regional scientific ethics committee of the Capital Region of Denmark (committee C, #H-20019008) and will be carried out in accordance with International Council for Harmonisation Good Clinical Practice guidelines and the Helsinki Declaration. The results will be disseminated through peer-review publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04892199.

Halting the Metabolic Complications of Antipsychotic Medication in Patients with a First Episode of Psychosis: How Far Can We Go with the Mediterranean Diet? A Pilot Study

Patients with first-episode psychosis (FEP) often adopt unhealthy dietary patterns, with a risk of weight gain and metabolic and cardiovascular disease. In 21 FEP patients receiving nutritional intervention based on the Mediterranean diet (MedDiet), we explored differences in anthropometric and biometric parameters, according to their antipsychotic (AP) medication: AP1, associated with a lower risk, or AP2, associated with a higher risk of weight gain and metabolic complications. The blood biochemical profile was recorded before and after dietary intervention, and dietary habits and body composition were monitored for six months. Following intervention, all of the patients recorded significant increases in the consumption of fruit and vegetables and decreases in red meat and poultry consumption, with closer adherence to the MedDiet and a reduction in the daily intake of calories, carbohydrates, and sodium. Vegetable consumption and energy, protein, and carbohydrate intake were lower in AP1 patients than in AP2 patients. There was no significant weight gain overall. A reduction was demonstrated in total and LDL cholesterol, sodium, urea, and iron (lower in AP1 patients). It was evident that AP medication affected blood levels of lipids, urea, and iron of FEP patients, but MedDiet nutritional intervention led to a significant improvement in their eating habits, with a restriction in weight gain and a decrease in blood sodium and urea.

Systematic review of lifestyle interventions to improve weight, physical activity and diet among people with a mental health condition

BACKGROUND

People with a mental health condition experience an elevated risk of chronic disease and greater prevalence of health and behaviours. Lifestyle interventions aim to reduce this risk by modifying health behaviours such as physical activity and diet. Previous reviews exploring the efficacy of such interventions for this group have typically limited inclusion to individuals with severe mental illness (SMI), with a focus of impact on weight. This review assessed the efficacy of lifestyle interventions delivered in community or outpatient settings to people with any mental health condition, on weight, physical activity and diet.

METHODS

Eligible studies were randomised or cluster-randomised controlled trials published between January 1999 and February 2019 aiming to improve weight, physical activity or diet, for people with any mental health condition. Two reviewers independently completed study screening, data extraction and assessment of methodological quality. Primary outcome measures were weight, physical activity and diet. Secondary outcome measures were body mass index (BMI), waist circumference, sedentary behaviour and mental health. Where possible, meta-analyses were conducted. Narrative synthesis using vote counting based on direction of effect was used where studies were not amenable to meta-analysis.

RESULTS

Fifty-seven studies were included (49 SMI only), with 46 contributing to meta-analyses. Meta-analyses revealed significant (< 0.05) effect of interventions on mean weight loss (-1.42 kg), achieving 5% weight loss (OR 2.48), weight maintenance (-2.05 kg), physical activity (IPAQ MET minutes: 226.82) and daily vegetable serves (0.51), but not on fruit serves (0.01). Significant effects were also seen for secondary outcomes of BMI (-0.48 units) and waist circumference (-0.87cm), but not mental health (depression: SMD -0.03; anxiety: SMD -0.49; severity of psychological symptoms: SMD 0.72). Studies reporting sedentary behaviour were not able to be meta-analysed. Most trials had high risk of bias, quality of evidence for weight and physical activity were moderate, while quality of evidence for diet was low.

CONCLUSION

Lifestyle interventions delivered to people with a mental health condition made statistically significant improvements to weight, BMI, waist circumference, vegetable serves and physical activity. Further high-quality trials with greater consistency in measurement and reporting of outcomes are needed to better understand the impact of lifestyle interventions on physical activity, diet, sedentary behaviour and mental health and to understand impact on subgroups.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019137197.

Nutrition programmes for individuals living with disadvantage in supported residential settings: a scoping review

OBJECTIVE

Health inequities such as chronic disease are significantly higher among individuals living with disadvantage compared with the general population and many are reported to be attributable to preventable dietary risk factors. This study provides an overview of the current nutrition interventions for individuals living with extreme disadvantage, in supported residential settings, to develop insights into the development and implementation of policies and practices to promote long-term nutritional health and well-being.

DESIGN

A scoping review searched Scopus, ProQuest, CINAHL Plus, MEDLINE, and Web of Science databases using the terms 'resident', 'nutrition', 'disadvantage', 'intervention' and their synonyms, with particular emphasis on interventions in residential settings.

SETTING

Residential services providing nutrition provision and support.

PARTICIPANTS

People experiencing extreme disadvantage.

RESULTS

From 5262 articles, seven were included in final synthesis. Most interventions focused on building food literacy knowledge and skills. Study designs and outcome measures varied; however, all reported descriptive improvements in behaviour and motivation. In addition to food literacy, it was suggested that interventions need to address behaviour and motivations, programme sustainability, long-term social, physical and economic barriers and provide support for participants during transition into independent living. Socio-economic issues remain key barriers to long-term health and well-being.

CONCLUSIONS

In addition to food literacy education, future research and interventions should consider utilising an academic-community partnership, addressing nutrition-related mental health challenges, motivation and behaviour change and a phased approach to improve support for individuals transitioning into independent living.

Effectiveness of dietary interventions in mental health treatment: A rapid review of reviews

AIM

This rapid review of reviews aimed to determine the extent of research undertaken on the effectiveness of dietary interventions for individuals with a mental disorder.

METHODS

Three databases (MEDLINE, Embase, Cochrane Reviews and Cochrane Trials) were searched to February 2021 for systematic reviews including experimental studies assessing the effectiveness of dietary interventions with physical or mental health related outcomes in adults or children with one or more of: severe mental illness, depression or anxiety, eating disorders, or substance use disorder. Results are presented descriptively.

RESULTS

The number of included reviews was 46 (67% in severe mental illness, 20% in depression and anxiety, 7% in eating disorders, and 7% in substance use disorders). Most reviews were published since 2016 (59%), and included studies conducted in adults (63%). Interventions in the eating disorders and severe mental illness reviews were predominantly education and behaviour change, whereas interventions in the substance use disorders, and depression and anxiety reviews were predominantly supplementation (e.g. omega-3). Twenty-eight and twelve of the reviews respectively reported mental health and dietary outcomes for one or more included studies. Most reviews in severe mental illness, and depression and anxiety reported conclusions supporting the positive effects of dietary intervention, including positive effects on weight-related or mental health outcomes, and on mental health outcomes, respectively.

CONCLUSIONS

A larger number of systematic reviews were identified which evaluated dietary interventions in individuals with severe mental illness, and depression and anxiety, compared with substance use disorders, and eating disorders. Dietary intervention is an important component of the treatment that should be available to individuals living with mental disorders, to support their physical and mental health.

REalist Synthesis Of non-pharmacologicaL interVEntions for antipsychotic-induced weight gain (RESOLVE) in people living with severe mental illness (SMI)

BACKGROUND

People with severe mental illnesses (SMI) such as schizophrenia die on average 15 to 20 years earlier than everyone else. Two thirds of these deaths are from preventable physical illnesses such as hypertension, cardiovascular disease, and diabetes, which are worsened by weight gain. Antipsychotics are associated with significant weight gain. In REalist Synthesis Of non-pharmacologicaL interVEntions (RESOLVE), a realist synthesis, combining primary and secondary data, will be used to understand and explain how, why, for whom, and in what contexts non-pharmacological interventions can help service users to manage antipsychotic-induced weight gain.

METHODS

A five-step approach will be used to develop guidance: 1. Developing the initial programme theory An initial (candidate) programme theory, which sets out how and why outcomes occur within an intervention, will be developed. 2. Developing the search The initial programme theory will be refined using academic and grey literature. The proposed initial sampling frame are as follows: Context: people living with SMI, taking antipsychotics, different types of SMI.

INTERVENTION

non-pharmacological interventions.

MECHANISMS

triggered by the intervention. Outcomes e.g. weight, metabolic adverse events, quality of life, adherence, burden, economic. Searching for relevant documents will continue until sufficient data is found to conclude that the refined programme theory is coherent and plausible. Lived experience (service users) and stakeholder (practitioners) groups will provide feedback. 3. Selection, appraisal and data extraction Documents will be screened against inclusion and exclusion criteria. The text extracted from these documents will be coded as contexts, mechanisms and their relationships to outcomes. 4. Primary data collection Realist interviews with up to 30 service users and informal carers, and 20 practitioners will gather data to support, refute or refine the programme theory. 5. Data analysis A realist logic of analysis will be used to develop and refine the programme theory from secondary and primary data. The analysis will aim to identify practical intervention strategies to change contexts so that key mechanisms are triggered to produce desired outcomes. Guidance will be produced based on these strategies.

DISCUSSION

This realist synthesis aims to develop guidance for service users and practitioners on the most appropriate interventional strategies to manage and limit antipsychotic weight gain.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42021268697.

The effect of lifestyle intervention on cardiometabolic risk factors in mental health rehabilitation hostel residents at-risk: a cluster-randomized controlled 15-month trial

OBJECTIVE

Cardiometabolic disorders contribute to morbidity and mortality in people with severe mental illnesses (SMI), yet lifestyle-intervention efficacy in patients with SMI is unclear. Israel's unique mental-health rehabilitation hostels (MHRHs) provide housing to subjects with SMI. We tested how multi-component lifestyle intervention affects cardiometabolic risk-factors in at-risk SMI populations residing in MHRHs.

METHODS

In a prospective, cluster-randomized, controlled study, six MHRHs, paired by residents' functioning level, were randomized to lifestyle intervention (nutrition education, physical education), or usual care. Subjects recruited included those with ≥1 of: BMI > 25 kg/m²; plasma triglycerides ≥150 mg/dL; HbA1c ≥ 5.7%; fasting plasma glucose ≥ 100 mg/dL and plasma HDL < 40_(men)/ 50_(women) mg/dL. Primary outcome was BMI change after 15 months; other outcomes were plasma lipids levels and glycemic control. Low cooperation in one MHRH pair led to their exclusion, the others were assigned to intervention or control.

RESULTS

Eighty residents were enrolled to intervention groups and 74 to control. Compared to baseline, intervention-arm participants experienced improvements in BMI (-0.83 kg/m² [-1.36, -0.29] _95%CI), triglycerides (-30.60 mg/dL [-49.39, -11.82]_95%CI) and LDL (-15.51 mg/dL [-24.53, -6.50]_95%CI) (all P ≤ 0.003). BMI improvement correlated with number of dietitian consultations (r = -0.30; P = 0.001). No significant differences were found between treatment arms in BMI (-0.46 kg/m² [-1.11, 0.18]_95%CI;P = 0.189), triglycerides (-24.70 mg/dL [-57.66, 8.25]_95%CI), LDL (-9.24 mg/dL [-20.50, 2.03]_95%CI), HDL and glycemic control.

CONCLUSIONS

Lifestyle intervention significantly improved BMI, LDL and triglycerides compared to baseline in at-risk MHRHs residents with SMI, yet compared to usual care the differences did not reach statistical significance. The association between the number of dietitian's consultations and BMI improvement suggests that programs should highlight participants' adherence.

Twelve-month outcomes in overweight/obese users with mental disorders following a multi-element treatment including diet, physical activity, and positive thinking: The real-world "An Apple a Day" controlled trial

The present study aimed to evaluate the 12-month effectiveness of a real-world weight loss transdiagnostic intervention in overweight/obese participants affected by mental disorders under psychopharmacological treatment. We conducted a real-world, controlled, pragmatic outpatient trial. We allocated 58 overweight/obese adults under psychopharmacological treatment from a mental health outpatient unit and 48 overweight/obese adults from a cardiovascular prevention outpatient unit, and assigned them to an intervention or treatment usual as condition (TAU) enriched by life-style advice. Participants in both intervention groups took part in a diet programme (the modified OMNIHeart dietary protocol) and monitoring of regular aerobic activity. A brief group programme ("An Apple a Day" Metacognitive Training, Apple-MCT) was added in the intervention group of participants affected by mental disorders. The primary outcome was weight loss. Secondary outcomes included anthropometric, clinical, and metabolic variables. Psychopathology and health-related quality of life were also evaluated in the psychiatric sample. At 12 months, both intervention groups showed a more marked mean decrease in weight (6.7 kg, SD: 3.57) than the TAU group (0.32 kg, SD: 1.96), and a statistically significant improvement in metabolic variables compared with the control groups. Furthermore, the participants affected by mental disorders included in the intervention group reported improved health-related quality of life. Our findings suggest the need to implement integrated interventions based on a dietary protocol, physical activity, and modification of cognitive style in overweight/obese users with mental disorders.

Design and pilot evaluation of an evidence-based worksheet and clinician guide to facilitate nutrition counselling for patients with severe mental illness

BACKGROUND

Schizophrenia spectrum disorders (SSD) are severe, persistent mental illnesses resulting in considerable disability and premature mortality. Emerging evidence suggests that diet may be a modifiable risk factor in mental illness; however, use of nutritional counselling as a component of psychiatric clinical practice is limited. The objective of this project is the design and evaluate a worksheet and clinician guide for use in facilitating nutritional counseling in the context of existing mental health care.

METHODS

The worksheet and clinician guide were developed based on the results of a recent scoping review on the relationship between diet and mental health symptoms among individuals with SSD. A feedback process involved a focus group with psychiatrists and interviews with individuals with lived experience with psychosis. Participants were asked a series of structured and open-ended questions. Interviews were transcribed and data units were allocated to categories from an existing framework. The comments were used to guide modifications to the worksheet and clinician guide. A brief interview with all participants was completed to gather feedback on the final version.

RESULTS

Five psychiatrist participants and six participants with lived experience completed interviews. Participants provided positive comments related to the worksheet design, complexity and inclusion of interactive components. A novel theme emerged relating to the lack of nutritional counselling in psychiatric training and clinical practice. Many constructive comments were provided which resulted in meaningful revisions and improvements to the worksheet and clinician guide design and content. All participants were satisfied with the final versions.

CONCLUSIONS

A worksheet and clinician guide designed to facilitate nutritional counselling with individuals with SSD was found to be acceptable to all participants following a process of feedback and revision. Further research and dissemination efforts aimed at increasing the use of nutritional counselling in psychiatric practice are warranted.

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.

Metabolic disturbances associated with antipsychotic drug treatment in patients with schizophrenia: State-of-the-art and future perspectives

Metabolic disturbances and obesity are major cardiovascular risk factors in patients with schizophrenia, resulting in a higher mortality rate and shorter life expectancy compared with those in the general population. Although schizophrenia and metabolic disturbances may share certain genetic or pathobiological risks, antipsychotics, particularly those of second generation, may further increase the risk of weight gain and metabolic disturbances in patients with schizophrenia. This review included articles on weight gain and metabolic disturbances related to antipsychotics and their mechanisms, monitoring guidelines, and interventions. Nearly all antipsychotics are associated with weight gain, but the degree of the weight gain varies considerably. Although certain neurotransmitter receptor-binding affinities and hormones are correlated with weight gain and specific metabolic abnormalities, the precise mechanisms underlying antipsychotic-induced weight gain and metabolic disturbances remain unclear. Emerging evidence indicates the role of genetic polymorphisms associated with antipsychotic-induced weight gain and antipsychotic-induced metabolic disturbances. Although many guidelines for screening and monitoring antipsychotic-induced metabolic disturbances have been developed, they are not routinely implemented in clinical care. Numerous studies have also investigated strategies for managing antipsychotic-induced metabolic disturbances. Thus, patients and their caregivers must be educated and motivated to pursue a healthier life through smoking cessation and dietary and physical activity programs. If lifestyle intervention fails, switching to another antipsychotic drug with a lower metabolic risk or adding adjunctive medication to mitigate weight gain should be considered. Antipsychotic medications are essential for schizophrenia treatment, hence clinicians should monitor and manage the resulting weight gain and metabolic disturbances.

Minding metabolism: targeted interventions to improve cardio-metabolic monitoring across early and chronic psychosis

Background

Antipsychotics (APs) increase weight, metabolic syndrome, diabetes and cardiovascular disease. Guidelines recommend cardio-metabolic monitoring at initial assessment, at 3 months and then annually in people prescribed APs.

Aim

To determine the rates of cardio-metabolic monitoring in AP treated early and chronic psychosis and to assess the impact of targeted improvement strategies.

Methods

Medical records were reviewed in two cohorts of first-episode psychosis (FEP) patients before and after the implementation of a physical health parameter checklist and electronic laboratory order set. In a separate group of patients with chronic psychotic disorders, adherence to annual monitoring was assessed before and 3 months after an awareness-raising educational intervention.

Results

In FEP, fasting glucose (39% vs 67%, p=0.05), HbA1c (0% vs 24%, p=0.005) and prolactin (18% vs 67%, p=0.001) monitoring improved. There were no significant differences in weight (67% vs 67%, p=1.0), BMI (3% vs 10%, p=0.54), waist circumference (3% vs 0%, p=1.0), fasting lipids (61% vs 76% p=0.22) or ECG monitoring (67% vs 67%, p=1.0). Blood pressure (BP) (88% vs 57%, p=0.04) and heart rate (91% vs 65%, p=0.03) monitoring dis-improved. Diet (0%) and exercise (<15%) assessment was poor. In chronic psychotic disorders, BP monitoring improved (20% vs 41.4%, p=0.05), whereas weight (17.0% vs 34.1%, p=0.12), BMI (9.7% vs 12.1%, p=1.0), fasting glucose (17% vs 24.3%, p=0.58) and fasting lipids remained unchanged (17% vs 24.3%, p=0.58).

Conclusions

Targeted improvement strategies resulted in a significant improvement in a limited number of parameters in early and chronic psychotic disorders. Overall, monitoring remained suboptimal.

Atypical Antipsychotics and Metabolic Syndrome: From Molecular Mechanisms to Clinical Differences

Atypical antipsychotics (AAPs) are commonly prescribed medications to treat schizophrenia, bipolar disorders and other psychotic disorders. However, they might cause metabolic syndrome (MetS) in terms of weight gain, dyslipidemia, type 2 diabetes (T2D), and high blood pressure, which are responsible for reduced life expectancy and poor adherence. Importantly, there is clear evidence that early metabolic disturbances can precede weight gain, even if the latter still remains the hallmark of AAPs use. In fact, AAPs interfere profoundly with glucose and lipid homeostasis acting mostly on hypothalamus, liver, pancreatic β-cells, adipose tissue, and skeletal muscle. Their actions on hypothalamic centers via dopamine, serotonin, acetylcholine, and histamine receptors affect neuropeptides and 5'AMP-activated protein kinase (AMPK) activity, thus producing a supraphysiological sympathetic outflow augmenting levels of glucagon and hepatic glucose production. In addition, altered insulin secretion, dyslipidemia, fat deposition in the liver and adipose tissues, and insulin resistance become aggravating factors for MetS. In clinical practice, among AAPs, olanzapine and clozapine are associated with the highest risk of MetS, whereas quetiapine, risperidone, asenapine and amisulpride cause moderate alterations. The new AAPs such as ziprasidone, lurasidone and the partial agonist aripiprazole seem more tolerable on the metabolic profile. However, these aspects must be considered together with the differences among AAPs in terms of their efficacy, where clozapine still remains the most effective. Intriguingly, there seems to be a correlation between AAP's higher clinical efficacy and increase risk of metabolic alterations. Finally, a multidisciplinary approach combining psychoeducation and therapeutic drug monitoring (TDM) is proposed as a first-line strategy to avoid the MetS. In addition, pharmacological treatments are discussed as well.

Qualitative analysis of the Meals, Mindfulness, & Moving Forward (M3 ) lifestyle programme: Cultivating a 'safe space' to start on a 'new path' for youth with early episode psychosis

AIM

The Meals, Mindfulness, & Moving Forward (M3 ) programme included nutrition education, hands-on cooking classes, mindfulness meditation practice, physical activities and facilitated group sharing. M3 was designed as a supplement to standard care for youths (age 15-25 years) with first-episode psychosis (FEP) who were clients of coordinated specialty care teams. M3 's primary aim was feasibility by demonstrating high programme attendance; secondary aims included cardiometabolic measures. Data collection included quantitative and qualitative outcomes. The aim of the qualitative study was to understand participants' and study partners' experiences during the programme and to understand programme elements that were helpful for young people to sustain healthy lifestyle choices 6 weeks post-programme.

METHODS

During the last programme session, we conducted two focus groups, one with participants (n = 13) and one with their study partners (n = 11); 6 weeks post-intervention, individual semi-structured interviews were conducted with 11 participants. All interviews were audio recorded and transcribed; grounded theory methods guided thematic analysis.

RESULTS

Main themes from the focus groups included appreciation for a 'non-stigmatizing' environment providing participants and study partners with a sense of 'dignity' that enabled a 'new path'. Six weeks post-intervention, participants reported continued use of mindfulness practice to stay grounded and assist with making healthful lifestyle changes. However, many were unsure of how to sustain these changes long-term.

CONCLUSION

The results suggest that young people with FEP value a non-stigmatizing space that allows for social engagement and facilitates healthy behaviours. Short-term, M3 participants reported behaviour change but wanted on-going support to sustain healthy behaviours.

Prescribing pattern of antipsychotic medication for first-episode psychosis: a retrospective cohort study

OBJECTIVE

Guidelines for antipsychotic use in first-episode psychosis (FEP) recommend that medication be chosen initially on the basis of side effect profile with doses at the lower end of the range. Our objective was to describe the pattern of antipsychotic use in FEP over a period of 21 years in the context of changing clinical guidelines and the development of specialist early intervention in psychosis (EIP) services.

SETTING

A community-based mental health service in South County Dublin (population 187 000) and a large private hospital.

PARTICIPANTS

Participants included 465 patients with FEP (146 from an epidemiological study (1995-1999) and 319 from a specialist EIP service (2005-2016)). Treatment with antipsychotic medication did not exceed 30 days at study entry.

OUTCOME MEASURES

This is a descriptive study of prescribing practices in the context of service development and changing guidelines.

RESULTS

First-generation antipsychotics were prescribed for 65% of the early cohort compared with 4.3% of the EIP cohort. Olanzapine was initially prescribed for 79.7% of EIP patients. Initial doses of medication were frequently low (≤50% British National Formulary (BNF) maximum) in both cohorts (71% and 78.6%). The demographic and clinical factors investigated did not influence the initial choice of antipsychotic medication significantly. Univariate logistic regression analysis suggested inpatient treatment setting was associated with a higher initial dose (>50% BNF maximum) of antipsychotic medication. Increasing dose requirements over the first month of engagement with an EIP service was associated with poorer global functioning at baseline, greater positive symptoms at baseline and the inpatient treatment setting. However, these associations were not seen in the multivariable model.

CONCLUSIONS

Second-generation antipsychotic prescribing predominates, but guidelines are often overlooked when choosing olanzapine notwithstanding lower initial dosages. EIP services should include proactive support for optimising medicines in line with evidence-based guidelines.

The Impact of Pharmacological and Non-Pharmacological Interventions to Improve Physical Health Outcomes in People With Schizophrenia: A Meta-Review of Meta-Analyses of Randomized Controlled Trials

(Reprinted with permission from World Psychiatry 2019;18:53-66).

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.

Depressive symptoms and quality of life in people with a diagnosis of schizophrenia: An exploratory study of the potential mediating role of health-promoting lifestyles

PURPOSE

To examine health-promoting lifestyles mediates the relationship between depressive symptoms and quality of life (QOL) in people with schizophrenia.

DESIGN AND METHODS

A cross-sectional exploratory study design was conducted. Two-hundred and seventy-three participants were administered demographic data, health-promoting lifestyle profile, Beck Depression Inventory II, and World Health Organization Quality of Life-BREF. The Hayes PROCESS macro was employed to analyze data.

FINDINGS

The results showed self-actualization fully mediated the environmental domain of QOL, physical health, psychological health, and social relationships domains were partial mediation.

PRACTICE IMPLICATIONS

This study recommends that professionals reinforce persons' self-actualization when the QOL is affected by depressive symptoms in people with schizophrenia.

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.

Motivational theory-based interventions on health of people with several mental illness: A systematic review and meta-analysis

Motivational theory-based interventions are known to be effective for increasing physical activity (PA) in the general population but their effects in people with severe mental illness are poorly understood. Therefore, we conducted a meta-analysis on the effect of these interventions on PA and cardiometabolic risk factors. A systematic search of randomized controlled trials through 6 databases was carried out from inception to March 2019. Analyses were conducted using random-effect models. Weighted mean difference (WMD) were used as effect size when outcomes had the same units, otherwise Hedge's g was used. Fourteen articles including 2128 participants were identified. Motivational theory-based interventions were effective in increasing PA (g = 0.27, 95%CI[0.03; 0.51], p = .003), reducing weight (WMD = -1.87 kg, 95%CI[-2.98; -0.76], p = .001), body mass index (WMD = -0.82 kg/m², 95%CI[-1.23; -0.41], p = .009), waist circumference (WMD = -1.91 cm, 95%CI[-3.63; -0.18], p = .03) and fasting glucose (g = -0.17, 95%CI[-0.34; -0.001], p = .04). Larger effect sizes were found in interventions based on only one theoretical model of motivation. In conclusion, interventions using motivational theories are effective to improve PA levels and the cardiometabolic health profile of people with severe mental illness. Systematic review registration: CRD42018104445.

Psychosocial therapies in severe mental illness: update on evidence and recommendations

PURPOSE OF REVIEW

To provide an overview of the update of the evidence-based and consensus-based German S3 guideline on psychosocial therapies for severe mental illnesses (SMI), with particular attention to current developments and future research tasks.

RECENT FINDINGS

There has been a significant increase in studies on the effectiveness of psychosocial interventions in treatment of people with SMI. In the guideline a distinction is made between system-level interventions (e.g. multidisciplinary team-based psychiatric community care) and single-handed (nonteam-based) interventions (e.g. psychoeducation). Furthermore, principles of treatment (e.g. recovery-orientation) and self-help interventions (e.g. peer support) are addressed. The update of the guideline includes 33 recommendations and 12 statements. Compared with the first edition, there were upgrades in the recommendation of Supported Employment (A) and Supported Housing (A). Interventions such as peer support (B) and lifestyle interventions (A) were included for the first time. Developments are discussed in the context of most recent literature. Areas for further research are highlighted and fields for next updates such as antistigma interventions and supported parenting were identified.

SUMMARY

The present guideline offers an important opportunity to further improve health services for people with SMI. However, guideline implementation is challenging.

Keeping our staff in mind: Dietary results of a lifestyle intervention targeting mental health staff

ISSUES ADDRESSED

1) Describe the dietary intake of mental health staff within South Eastern Sydney Local Health District and 2) Evaluate the impact of an individualised staff lifestyle program on the following nutrition parameters; (i) energy, (ii) core food groups and (iii) discretionary foods.

METHODS

This was a pragmatic single-arm intervention study, conducted for all staff working in a public mental health service, in Sydney, Australia. A five-session individualised lifestyle intervention delivered over 5 weeks incorporated nutritional counselling delivered by a dietitian. Participants were assessed at baseline, following the intervention, and at follow-up using diet history to assess dietary intake.

RESULTS

Eighty-eight staff completed the dietary intervention and follow-up. An intake of core food groups significantly below national recommendations was reported for total vegetables (-1.75 ± 0.14 serves, P < .001), fruit (-0.29 ± 0.11 serves, P = .01), grains (-1.25 ± 0.20 serves, P < .001) and dairy servings (-1.00 ± 1.08 serves, P < .001), and protein-based foods were significantly above national recommendations (0.2 ± 0.09 serves, P = .03). At completion of the program, energy from discretionary foods was reduced by 460 kJ (95% CI -635 to -285, P < .001), and the serves of total vegetables (0.91 serves, 95% CI 0.59-1.22, P < .001) and dairy (0.31 serves, 95% CI 0.11-0.50, P < .001) were increased significantly.

CONCLUSIONS

A workplace-based well-being program for staff working in the mental health setting coincided with dietary improvements.

SO WHAT

Mental health staff can act as positive role models for clients to promote developing positive physical health behaviours.

Managing Cardiovascular Risk Factors without Medications: What is the Evidence?

In this era of potent medications and interventional cardiovascular (CV) procedures, the importance of beginning with and including Therapeutic Lifestyle Changes (TLC) is frequently forgotten. A major goal of this review article is to show and emphasize that modification of CV risk with nonmedication approaches makes an essential contribution to CV risk reduction. Available information on TLC and modifiable CV risk factors was reviewed and assessed. Modifiable major CV risk factors include diabetes mellitus, hypertension, hyperlipidemia, tobacco abuse, obesity, stress, and a sedentary lifestyle. Age as a major CV risk factor is, of course, not susceptible to modification. A contribution to the control of CV risk factors can occur without the start of medications and there is proof of benefit for beginning with a non-pharmacological approach. TLC can benefit all of the major modifiable CV risk factors and there is good evidence for the additional benefit of supervised and group TLC. TLC includes physical activity, diet, and smoking cessation. Evidence for the benefits of TLC in reducing CV disease events is well established. However, medications must be added in those patients with higher CV risk to obtain maximum cholesterol reduction (lower is better for the low-density lipoprotein cholesterol) and good blood pressure control. The benefit of TLC is frequently forgotten in this era of potent medications and invasive procedures. The benefits of diet and physical activity are emphasized with supporting data. Many motivated patients can prolong their lives significantly by dedication to TLC. Therapeutic Lifestyle Change (TLC) especially encompasses increased physical activity, a healthy diet, and smoking cessation. There is extensive proof for the benefit of TLC in contributing to cardiovascular (CV) disease prevention. CV diseases have strong metabolic and inflammatory components, both of which can be improved by TLC.

Sexual dysfunction and central obesity in patients with first episode psychosis

Background

In recent years the association between sexual dysfunction (SD) and obesity in the general population has drawn major attention. Although sexual dysfunction is common in psychosis, its relationship with weight gain and obesity remains unclear.

Aims

To investigate the association between sexual dysfunction and obesity in a cohort of patients with first episode psychosis.

Method

Sexual function was assessed in a cohort of patients with first episode psychosis using the Sexual Function Questionnaire (SFQ). Anthropometric measures, including weight, BMI, waist, waist–hip ratio were investigated. Additionally, leptin and testosterone were investigated in male patients.

Results

A total of 116 patients (61 males and 55 females) were included. Of these 59% of males and 67.3% of females showed sexual dysfunction (SD) according to the SFQ. In males, higher SFQ scores were significantly correlated with higher BMI (Std. β = 0.36, P = 0.01), higher leptin levels (Std. β = 0.34, P = 0.02), higher waist–hip ratio (Std. β = 0.32, P = 0.04) and lower testosterone levels (Std. β = −0.44, P = 0.002). In contrast, in females, SFQ scores were not associated with any of these factors.

Conclusions

While sexual dysfunction is present in both female and male patients with their first episode of psychosis, only in males is sexual dysfunction associated with increased BMI and waist–hip ratio. The association between SD, BMI, low levels of testosterone and high levels of leptin suggest that policies that lead to healthier diets and more active lifestyles can be beneficial at least, to male patients.

Preventive care for physical activity and fruit and vegetable consumption: a survey of family carer expectations of health service delivery for people with a mental health condition

Background

Chronic disease is a leading cause of death globally, where inadequate fruit and vegetable consumption and inadequate physical activity are consistently implicated as key contributing risk factors for such diseases. People with a mental health condition are reported to experience a higher prevalence of such risks and experience an increased morbidity and mortality from resultant chronic disease. Despite guidelines identifying a need for services accessed by people with a mental health condition to provide care to address such health risk behaviours, sub-optimal care is frequently reported suggesting a need for innovative strategies to increase the provision of physical health care. An exploratory study was conducted to examine: 1) family carers’ expectations of care provision regarding fruit and vegetable consumption and physical activity by health and community services for people with a mental health condition; 2) carer’s own health risk behaviour status and perceptions of the influence of the health risk behaviours on mental health; and 3) possible associations of socio-demographic, clinical and attitudinal factors with carer expectations of care provision for fruit and vegetable consumption and physical activity.

Methods

Family carers (n = 144) of a person with a mental health condition completed a cross-sectional survey. Participants were members of a mental health carer support organisation operating in New South Wales, Australia.

Results

A high proportion of participants considered care for fruit and vegetable consumption and physical activity respectively should be provided by: mental health hospitals (78.5, 82.7%); community mental health services (76.7, 85.9%); general practice (81.1, 79.2%); and non-government organisations (56.2, 65.4%). Most participants perceived adequate fruit and vegetable consumption (55.9%), and physical activity (71.3%) would have a very positive impact on mental health. Carers who perceived adequate fruit and vegetable consumption and physical activity would have a positive impact on mental health were more likely to expect care for such behaviours from some services.

Conclusions

The majority of participants expected care for fruit and vegetable consumption and physical activity be provided by all services catering for people with a mental health condition, reinforcing the appropriateness for such services to provide physical health care for clients in a systematic manner.

Effects of Transcranial Direct Current Stimulation (tDCS) and Approach Bias Modification (ABM) training on food cravings in people taking antipsychotic medication

BACKGROUND

Antipsychotic drug-induced weight gain puts individuals with schizophrenia at increased cardiometabolic risk. As a potential intervention for this problem, we describe the theoretical background and a protocol for a feasibility randomised controlled trial (RCT) of approach bias modification (ABM) training combined with real versus sham (placebo) transcranial direct current stimulation (tDCS). The primary aim of this trial is to obtain information that will guide decision making and protocol development in relation to a future large-scale RCT of ABM and tDCS in this group of participants. Second, the study will assess the preliminary efficacy of ABM + tDCS in reducing food cravings in people who take antipsychotic medication.

METHODS

Thirty adults with a DSM-V diagnosis of schizophrenia or schizoaffective disorder treated with anti-psychotic medication will be randomly allocated to receive five sessions that will combine ABM and real or sham tDCS, in a parallel group design. In this feasibility study, a broad range of outcome variables will be examined. Measures will include food craving, psychopathology (e.g. symptoms of schizophrenia and depression), neuropsychological processes (such as attentional bias and impulsiveness), and the tolerability and acceptability of tDCS. The feasibility of conducting a large-scale RCT of ABM + tDCS and appropriateness of tDCS as a treatment for antipsychotic drug-induced weight gain will be evaluated by assessment of recruitment and retention rates, acceptability of random allocation, blinding success (allocation concealment), completion of treatment sessions and research assessments (baseline, post-treatment and follow-up).

DISCUSSION

The effect sizes generated and other findings from this trial will inform a future large-scale RCT with respect to decisions on primary outcome measures and other aspects of protocol development. In addition, results from this study will provide a preliminary indication of the efficacy of ABM + tDCS treatment for antipsychotic drug-induced weight gain.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN13280178. Registered on 16 October 2018.

Efficacy of a Short Psychoeducational Group Intervention for the Prevention of Cardiovascular Risk in Patients With Severe Mental Disorder: A Randomized Trial

Psychoeducational interventions to improve healthy habits regarding cardiovascular risk (CVR) in people with a severe mental disorder showed scarce results in the literature. In this article, we showed the results of a randomized clinical trial including 80 adult outpatients (mainly psychosis spectrum) with moderate to very high CVR. A short-term psychoeducational group intervention to improve healthy habits regarding CVR was added to their as-usual individual psychoeducational schedule. With an intention-to-treat analysis, we expected improvements in the different parameters. Baseline and 1-year follow-up included CVR factors and indexes (REGICOR, SCORE, and DORICA). Basal characteristics did not show statistically significant differences between the groups. No significant improvements in any of the variables studied were observed in the intervention enriched group compared with the control individual group. Compliance with the sessions was scarce. The satisfaction with the intervention and the acquisition of knowledge were adequate. Moreover, the benefits of both interventions were weak.

Long-term metabolic and cardiovascular effects of antipsychotic drugs. A meta-analysis of randomized controlled trials

Most of the randomized controlled trials (RCTs) on antipsychotics (APs) have efficacy as their primary endpoint, leading to a lack of evidence on long-term metabolic effects of APs. The aim of the present meta-analysis is to compare different APs for the long-term modification of risk of major adverse cardiovascular events (MACE) and related mortality, in patients with schizophrenia and bipolar disorder. All RCTs found on Medline/Embase of at least 52 weeks up to 19 December 2017, enrolling patients with bipolar disorder or schizophrenia and comparing an AP with another AP or placebo were included. The primary outcome of this analysis was the association of APs with the incidence of cardiovascular death, myocardial infarction (MI), and stroke. 3013 studies were screened, 92 met the selection criteria. MI, stroke and cardiovascular death were reported in 11, 6 and 24 studies, respectively. No significant difference was observed with respect to MI and Stroke; a significantly higher cardiovascular mortality was observed for sertindole when compared to risperidone (Mantel-Haenszel Odds Ratio: 2.56, 95% CI: 1.33 - 5). Long-term cardiovascular effects of APs deserve to be studied more extensively. The request by regulatory authorities of cardiovascular safety data from specifically designed trials would be useful.

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.

The effectiveness of health behavior change interventions in managing physical health in people with a psychotic illness: A systematic review

PURPOSE

People living with psychotic illness disproportionately experience more comorbidities and have a markedly shorter life expectancy compared to the general population. This review evaluates the effectiveness of health behavior change interventions in improving health outcomes in this group.

DESIGN AND METHODS

All studies included objective physical health measures or health behaviors as the main outcome measures and experimental design with baseline and follow-up quantitative data. Only studies of moderate and strong quality were included. Narrative synthesis was undertaken.

FINDINGS

Included studies utilized a range of methodological designs and outcome measures. The majority reported significant intervention effect on most outcome measures.

PRACTICE IMPLICATIONS

Health behavior change interventions can be effective in improving health outcomes in people with psychotic illness, with the potential benefit of improved psychiatric outcomes.

Implementation barriers and facilitators of an integrated multidisciplinary lifestyle enhancing treatment for inpatients with severe mental illness: the MULTI study IV

BACKGROUND

Despite an increase in studies showing the efficacy of lifestyle interventions in improving the poor health outcomes for people with severe mental illness (SMI), routine implementation remains ad hoc. Recently, a multidisciplinary lifestyle enhancing treatment for inpatients with SMI (MULTI) was implemented as part of routine care at a long-term inpatient facility in the Netherlands, resulting in significant health improvements after 18 months. The current study aimed to identify barriers and facilitators of its implementation.

METHODS

Determinants associated with the implementation of MULTI, related to the innovation, the users (patients, the healthcare professionals (HCPs)), and the organisational context, were assessed at the three wards that delivered MULTI. The evidence-based Measurement Instrument for Determinants of Innovations was used to assess determinants (29 items), each measured through a 5-point Likert scale and additional open-ended questions. We considered determinants to which ≥20% of the HCPs or patients responded negatively ("totally disagree/disagree", score < 3) as barriers and to which ≥80% of HCPs or patients responded positively ("agree/totally agree", score > 3) as facilitators. We included responses to open-ended questions if the topic was mentioned by ≥2 HCPs or patients. In total 50 HCPs (online questionnaire) and 46 patients (semi-structured interview) were invited to participate in the study.

RESULTS

Participating HCPs (n = 42) mentioned organisational factors as the strongest barriers (e.g. organisational changes and financial resources). Patients (n = 33) mentioned the complexity of participating in MULTI as the main barrier, which could partly be due to organisational factors (e.g. lack of time for nurses to improve tailoring). The implementation was facilitated by positive attitudes of HCPs and patients towards MULTI, including their own role in it. Open responses of HCPs and patients showed strong commitment, collaboration and ownership towards MULTI.

CONCLUSIONS

This is the first study analysing the implementation of a pragmatic lifestyle intervention targeting SMI inpatients in routine clinical care. Positive attitudes of both HCPs and patients towards such an approach facilitated the implementation of MULTI. We suggest that strategies addressing organisational implementation barriers are needed to further improve and maintain MULTI, to succeed in achieving positive health-related outcomes in inpatients with SMI.

Dietary Intake, Adherence to Mediterranean Diet and Lifestyle-Related Factors in People with Schizophrenia

The purpose of this study was to examine the dietary intake of both inpatients and outpatients with schizophrenia in the Portuguese population as a potential key contributing factor to the poor physical health profiles, and understand the relationship of diet quality to other lifestyle factors. Participants of this cross-sectional study completed a semi quantitative food frequency questionnaire. Diet quality was determined by adherence to the Mediterranean Diet. In addition participants completed the International Physical Activity Questionnaire-Short-Form and Pittsburgh Sleep Quality Index. Tobacco smoking was assessed through a series of general questions. A total of 100 patients (50% inpatients and 28% female) with schizophrenia were included in the final analysis. Patients reported a high consumption of caffeine, while deficits were evident for fibre and folate intakes, when compared to the European Food Safety Authority recommendations. Both inpatients and outpatients reported poor to moderate diet quality. Smokers reported poorer diet quality when compared to non-smokers (p < 0.001). Dietary intake, and its relationship to other lifestyle components, should be considered for intervention, in order to improve physical health of people living with schizophrenia.

Effectiveness of a Community-Based Weight Management Program for Patients Taking Antidepressants and/or Antipsychotics

OBJECTIVE

This study aimed to compare weight loss (WL) outcomes for patients taking antidepressants and/or antipsychotics with those not taking psychiatric medication.

METHODS

A total of 17,519 adults enrolled in a lifestyle WL intervention at the Wharton Medical Clinics in Ontario, Canada, were analyzed. Sex-stratified multivariable linear regression analysis was used to examine the association of taking antidepressants, antipsychotics, both, or neither with WL when adjusting for age, initial weight, and treatment time.

RESULTS

Twenty-three percent of patients were taking at least one psychiatric medication. Patients lost a significant amount of weight (P < 0.0001) regardless of psychiatric medication use. Women taking psychiatric medications lost a similar amount of weight as women who were not (P > 0.05). Conversely, men taking antidepressants lost only slightly less weight than men taking both classes or neither class of psychiatric medication (3.2 ± 0.3 kg vs. 5.6 ± 0.9 kg and 4.3 ± 0.1 kg; P < 0.05). However, taking psychiatric medications that cause weight gain was associated with similar significant decreases in weight as taking medications that are weight neutral or associated with WL for both sexes (P > 0.05).

CONCLUSIONS

Results of this study suggest that those who participate in a weight management program can lose significant amounts of weight regardless of psychiatric medication use.

Barriers to participation in web-based and in-person weight management interventions for serious mental illness

OBJECTIVE

This study examines barriers to participation and retention in 2 modalities (web-based and in-person) of a weight-management intervention tailored for individuals with serious mental illness (SMI).

METHOD

Using a mixed-methods approach, we explored the barriers veterans with SMI face when participating in a web-based (WebMOVE) or in-person (MOVE-SMI) version of the same SMI-adapted MOVE weight-management program. Participants in the randomized controlled trial (n = 277) were recruited from specialty mental health clinics at a Veterans Affairs medical center. Barriers were analyzed across treatment condition and program attendance (engagement) at baseline and follow-up using a generalized lineal model. Post hoc analyses assessed whether changes in the trajectory of barriers over time were associated with engagement. A subsample of participants (n = 48) from the WebMOVE and MOVE-SMI treatment conditions completed a qualitative interview, and 2 coders used open coding to analyze the data.

RESULTS

Although barriers specific to treatment modality existed, most barriers cut across intervention modality, including financial hardship, lack of reliable housing and transportation, comorbid physical and mental health issues, and competing demands on personal time. Results of post hoc analyses found the association between engagement and emotional and motivational factors to be statistically significant.

CONCLUSIONS

This study is the 1st to identify barriers in a web-based intervention for SMI. Similar barriers persisted across treatment modalities. Known barriers, particularly socioeconomic barriers, should be addressed to improve engagement and retention of individuals in weight-management interventions adapted for SMI, irrespective of modality. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Increasing physical activity and healthy diet in outpatients with mental disorders: a randomized-controlled evaluation of two psychological interventions

INTRODUCTION

While physical activity (PA) can play an important role in the treatment of mental disorders (MD), large proportions of patients with MD do not meet PA recommendations. The aim of this trial was to evaluate whether structured psychological intervention (MoVo-LISA) is effective in helping outpatients with MD to increase their level of PA. As active control group (CG) we modified MoVo-LISA to target healthy diet behavior.

METHODS

N = 83 outpatients with MD (F1-F4) were randomized to the two conditions. PA (self-report and accelerometry), dietary behavior, social-cognitive determinants of health behavior change, psychiatric symptoms and health-related quality of life were assessed at baseline, 1 and 12 weeks after the intervention.

RESULTS

Significant time*group interaction effects for objectively measured PA, dietary behavior and fruit and vegetable consumption indicated differential effects of the interventions on these outcomes. PA increased in the MoVo-LISA group (IG) from baseline to follow-up while it decreased in CG. IG showed a significant higher level of objectively measured PA at follow-up compared to CG. Dietary behavior and fruit and vegetable consumption significantly increased from baseline to follow-up in CG, but not IG. IG showed a significant increase in some, but not all social cognitive determinants of health behavior change.

CONCLUSIONS

MoVo-LISA is effective in helping outpatients with MD to increase their level of PA in short- and mid-term. The used intervention strategies are effective for the promotion of healthy diet in patients with MD as well.

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.

Changes in physical and psychiatric health after a multidisciplinary lifestyle enhancing treatment for inpatients with severe mental illness: The MULTI study I

Patients hospitalized with severe mental illness (SMI) often have an unhealthy lifestyle. Changing their sedentary behavior and deficiency in physical activity is challenging and effective interventions are lacking. We evaluated changes in sedentary behavior, physical activity, metabolic health and psychotic symptoms after 18 months of Multidisciplinary Lifestyle enhancing Treatment for Inpatients with SMI (MULTI) compared to treatment as usual (TAU) and explored mediation by change in total activity. We measured sedentary behavior and physical activity using accelerometry (ActiGraph GT3X+), reflected in total activity counts. Data on metabolic health and psychotic symptoms were retrieved from routine screening data within our cohort of inpatients with SMI. Of 65 patients receiving MULTI versus 43 receiving TAU, data were analyzed using linear and logistic multilevel regression, adjusting for baseline values of outcome and differences between groups. Compared to TAU, in which no improvements were observed, we found significantly (p < 0.05) improved total activity (B = 0.5 standardized total activity counts per hour), moderate-to-vigorous physical activity (B = 1.8%), weight (B = -4.2 kg), abdominal girth (B = -3.5 cm), systolic blood pressure (B = -8.0 mmHg) and HDL cholesterol (B = 0.1 mmol/l). No changes in psychotic symptoms were observed. Changes in total activity did not mediate metabolic improvements, suggesting that multiple components of MULTI contribute to these improvements. In contrast to previously unsuccessful attempts to change lifestyle behavior in inpatients with SMI in the longer term, MULTI showed to be a feasible treatment to sustainably improve PA and metabolic health.

Meals, Mindfulness, & Moving Forward: A feasibility study to a multi-modal lifestyle approach in early psychosis

AIM

The primary aim was to demonstrate adherence to a novel 6-week lifestyle intervention program ("Meals, Mindfulness, & Moving Forward" [M³ ]) designed to help improve lifestyle practices of youth with a history of at least 1 psychotic episode.

METHODS

M³ used a non-equivalent control group design involving clients from a community early intervention program. Seventeen individuals in the active M³ program and 16 controls were assessed for secondary outcomes at baseline, 6-weeks, and 12-weeks (6 weeks post-intervention) on cardiometabolic and symptomatic outcomes.

RESULTS

The program met its primary aim with 88% (15/17) of participants meeting adherence criteria. Compared with the controls, M³ participants showed significant improvement in positive psychotic symptoms (P = .002).

CONCLUSION

This pilot study showed that young people involved in a community early intervention program adhered to an activity-based lifestyle program which included mindfulness meditation, yoga and nutrition education, warranting further evaluation with a larger sample size.

The impact of pharmacological and non-pharmacological interventions to improve physical health outcomes in people with schizophrenia: a meta-review of meta-analyses of randomized controlled trials

We summarized and compared meta-analyses of pharmacological and non-pharmacological interventions targeting physical health outcomes among people with schizophrenia spectrum disorders. Major databases were searched until June 1, 2018. Of 3,709 search engine hits, 27 meta-analyses were included, representing 128 meta-analyzed trials and 47,231 study participants. While meta-analyses were generally of adequate or high quality, meta-analyzed studies were less so. The most effective weight reduction interventions were individual lifestyle counseling (standardized mean difference, SMD=-0.98) and exercise interventions (SMD=-0.96), followed by psychoeducation (SMD=-0.77), aripiprazole augmentation (SMD=-0.73), topiramate (SMD=-0.72), d-fenfluramine (SMD=-0.54) and metformin (SMD=-0.53). Regarding waist circumference reduction, aripiprazole augmentation (SMD=-1.10) and topiramate (SMD=-0.69) demonstrated the best evidence, followed by dietary interventions (SMD=-0.39). Dietary interventions were the only to significantly improve (diastolic) blood pressure (SMD=-0.39). Switching from olanzapine to quetiapine or aripiprazole (SMD=-0.71) and metformin (SMD=-0.65) demonstrated best efficacy for reducing glucose levels, followed by glucagon-like peptide-1 receptor agonists (SMD=-0.39), dietary interventions (SMD=-0.37) and aripiprazole augmentation (SMD=-0.34), whereas insulin resistance improved the most with metformin (SMD=-0.75) and rosiglitazone (SMD=-0.44). Topiramate had the greatest efficacy for triglycerides (SMD=-0.68) and low-density lipoprotein (LDL)-cholesterol (SMD=-0.80), whereas metformin had the greatest beneficial effects on total cholesterol (SMD=-0.51) and high-density lipoprotein (HDL)-cholesterol (SMD=0.45). Lifestyle interventions yielded small effects for triglycerides, total cholesterol and LDL-cholesterol (SMD=-0.35 to -0.37). Only exercise interventions increased exercise capacity (SMD=1.81). Despite frequent physical comorbidities and premature mortality mainly due to these increased physical health risks, the current evidence for pharmacological and non-pharmacological interventions in people with schizophrenia to prevent and treat these conditions is still limited and more larger trials are urgently needed.

Effect of a 30-Month Health-Promoting Program on the Prevalence of Cardiovascular Risk Factors in Patients With First Episode Schizophrenia

BACKGROUND

Lifestyle interventions aimed at reducing cardiovascular risk factors in patients with first-episode schizophrenia (FES) have shown modest efficacy, probably owing to a short observation period and the presumption of linear trajectories of cardiovascular risk factors.

STUDY QUESTION

How prevalent are abnormal cardiovascular values in patients with FES and how do cardiovascular risk factors develop during a 30-month program?

STUDY DESIGN

A 30-month naturalistic longitudinal study of 136 consecutively referred patients with FES from 2 outpatient clinics. The health-promoting program consisted of individual guidance, group sessions, and normal treatment and care.

MEASURES AND OUTCOMES

The prevalence of abnormal cardiovascular risk factors (body mass index, waist circumference (WC), body fat percentage, systolic and diastolic blood pressure, pulse, total cholesterol, high- and low-density lipoproteins, triglycerides, mean glucose, and visceral adiposity index) was estimated at index. The cardiovascular risk factor trajectories were analyzed with longitudinal mixed-effect models.

RESULTS

The patient with FES showed elevated cardiovascular risk factors at index. Thus, 56.8% of the patients were overweight in different grades and 50.4% had increased WC. A total of 81.8% had high level of body fat and hypertension prevalence with only 20% with normal blood pressure. Important changes during the intervention period were that the risk factors weight and WC were increasing the first 581 and 646 days, after which they decreased. Almost all cardiovascular risk factors worsened initially, improving after 1-2 years.

CONCLUSIONS

Patients with FES show increases in cardiovascular risk factors at index. Short observation periods and the presumption of linear trajectories may indicate that the effect of health-promoting programs is ineffective, as the effects are curvilinear and improvements appear only after 1 year. The implication clinically is the importance of a long intervention period regarding lifestyle modifications to ascertain improvement among patients with FES.