Journal Article Annotations
2017, 4th Quarter
Serious Mental Illness
Annotations by Lydia Chwastiak MD, MPH, FAPM, and Oliver Freudenreich, MD, FAPM
- Mind the gap: developing an integrated behavioral health home to address health disparities in serious mental illness
- Sedentary behavior and physical activity levels in people with schizophrenia, bipolar disorder and major depressive disorder: a global systematic review and meta-analysis
PUBLICATION #1 — Serious Mental Illness
Mind the gap: developing an integrated behavioral health home to address health disparities in serious mental illness
Tepper MC, Cohen AM, Progovac AM, et al
Abstract: Psychiatr Serv 2017; 68(12):1217-1224
Objective: This study evaluated the impact of an integrated behavioral health home (BHH) pilot on adults with psychotic and bipolar disorders.
Methods: Quasi-experimental methods were used to compare outcomes before (September 2014-August 2015) and after the intervention (September 2015-August 2016) among ambulatory BHH patients and a control group. Electronic health records were compared between 424 BHH patients (N=369, psychotic disorder; N=55, bipolar disorder) and 1,521 individuals from the same urban, safety-net health system who were not enrolled in the BHH. Groups were weighted by propensity score on the basis of sex, age, race-ethnicity, language, 2010 U.S. Census block group characteristics, Medicare and Medicaid enrollment, and diabetes diagnosis.
Results: BHH patients had fewer total psychiatric hospitalizations and fewer total emergency visits compared with the control group, a difference that was predominantly driven by patients with at least one psychiatric hospitalization or ED visit. There were no differences in medical hospitalizations. Although BHH patients were more likely to receive HbA1c screening, there were no differences between the groups in lipid monitoring. Regarding secondary outcomes, there were no significant differences in changes in metabolic monitoring parameters among patients with diabetes.
Conclusions: Participation in a pilot ambulatory BHH program among patients with psychotic and bipolar disorders was associated with significant reductions in ED visits and psychiatric hospitalizations and increased HbA1c monitoring. This evaluation builds on prior research by specifying intervention details and the clinical target population, strengthening the evidence base for care integration to support further program dissemination.
On PubMed: Psychiatr Serv 2017; 68(12):1217-1224
Type of study: Quasi-experimental, case control
The finding: This observational study aimed to evaluate the impact of a behavioral health home (BHH) on patients with psychosis, with respect to ER and inpatient utilization, and metabolic monitoring and outcomes. These outcomes were examined among 424 BHH patients in a single, urban safety net system in the year before and the year after the implementation of the BHH—and these changes were compared to those of 1521 patients who were not enrolled in a BHH. BHH patients had fewer psychiatric—but not medical—hosptializations, and fewer ER visits. BHH patients were more likely to receive A1c monitoring, but not lipid monitoring and there were no differences in clinical outcomes.
Strength and weaknesses: This report describes outcomes from a large-scale implementation of a behavioral health home. It specifies program elements in more details than previous reports from BHH initiatives.
Weaknesses: This study involved only a single healthcare organization (although a large one), which limits the generalizability of the findings. The quasi-experimental design with pre-post implementation comparison is not as rigorous as a clinical trial. Moreover, the intervention was implemented incrementally over 12 months. Mental health outcomes were not assessed, as these outcomes were not available in the EMR. Dataset was not able to distinguish medical from psychiatric ER visits.
Relevance: This study contributes to the (somewhat limited) existing literature on behavioral health homes by demonstrating significant reduction in ER visits and psychiatric hospitalizations and increased A1c monitoring among those patients enrolled in BHH.
PUBLICATION #2 — Serious Mental Illness
Sedentary behavior and physical activity levels in people with schizophrenia, bipolar disorder and major depressive disorder: a global systematic review and meta-analysis
Vancampfort D, Firth J, Schuch FB, et al
Abstract: World Psychiatry 2017; 16(3):308-315
People with severe mental illness (schizophrenia, bipolar disorder or major depressive disorder) die up to 15 years prematurely due to chronic somatic comorbidities. Sedentary behavior and low physical activity are independent yet modifiable risk factors for cardiovascular disease and premature mortality in these people. A comprehensive meta-analysis exploring these risk factors is lacking in this vulnerable population. We conducted a meta-analysis investigating sedentary behavior and physical activity levels and their correlates in people with severe mental illness. Major electronic databases were searched from inception up to April 2017 for articles measuring sedentary behavior and/or physical activity with a self-report questionnaire or an objective measure (e.g., accelerometer). Random effects meta-analyses and meta-regression analyses were conducted. Sixty-nine studies were included (N=35,682; 39.5% male; mean age 43.0 years). People with severe mental illness spent on average 476.0 min per day (95% CI: 407.3-545.4) being sedentary during waking hours, and were significantly more sedentary than age- and gender-matched healthy controls (p=0.003). Their mean amount of moderate or vigorous physical activity was 38.4 min per day (95% CI: 32.0-44.8), being significantly lower than that of healthy controls (p=0.002 for moderate activity, p<0.001 for vigorous activity). People with severe mental illness were significantly less likely than matched healthy controls to meet physical activity guidelines (odds ratio = 1.5; 95% CI: 1.1-2.0, p<0.001, I2 =95.8). Lower physical activity levels and non-compliance with physical activity guidelines were associated with male gender, being single, unemployment, fewer years of education, higher body mass index, longer illness duration, antidepressant and antipsychotic medication use, lower cardiorespiratory fitness and a diagnosis of schizophrenia. People with bipolar disorder were the most physically active, yet spent most time being sedentary. Geographical differences were detected, and inpatients were more active than outpatients and those living in the community. Given the established health benefits of physical activity and its low levels in people with severe mental illness, future interventions specifically targeting the prevention of physical inactivity and sedentary behavior are warranted in this population.
On PubMed: World Psychiatry 2017; 16(3):308-315
Type of study: Meta-analysis
The finding: This meta-analysis included 69 studies, and over 35,000 people with severe mental illness—and found that individuals with serious mental illness were significantly more sedentary than age- and gender-matched healthy controls (p=0.003). Their mean amount of moderate or vigorous physical activity was significantly lower than that of healthy controls (p=0.002 for moderate activity, p<0.001 for vigorous activity). People with severe mental illness were significantly less likely than matched healthy controls to meet physical activity guidelines (odds ratio = 1.5; 95% CI: 1.1-2.0, p<0.001, I2=95.8).
Strength and weaknesses: The main strength of the study is the rigorous Meta-analytic methods, and the inclusion of data on over 35,000 individuals from research studies around the world.
Weaknesses: The main limitations reflect limitations in the studies that were included in the meta-analysis. First, the vast majority of the included studies relied on data from self-report questionnaires (rather than objective measures of physical activity). Second, the data were cross-sectional and there is a paucity of longitudinal physical activity research. Third, there was limited data on medications which precluded a specific analysis. Finally, there was high heterogeneity across the studies.
Relevance: Cardiovascular disease is the leading cause of premature mortality among people with serious mental illness, and sedentary behavior and lack of physical activity are modifiable risk factors. This meta-analysis provides a comprehensive review of the magnitude of this important risk factor.