Primary Care and Integrated Behavioural Health

Journal Article Annotations
2021, 2nd Quarter

Primary Care and Integrated Behavioural Health

Annotations by Jai Gandhi, MD
April, 2021

  1. A 12-Week Evidence-Based Education Project to Reduce Cardiovascular and Metabolic Risk in Adults With Serious Mental Illness in the Integrated Care Setting.

    PUBLICATION #1 — Primary Care and Integrated Behavioural Health

    A 12-Week Evidence-Based Education Project to Reduce Cardiovascular and Metabolic Risk in Adults With Serious Mental Illness in the Integrated Care Setting.
    Ashley Fenton, Phyllis Sharps, Karan Kverno, Jill RachBeisel, Marsha Gorth


    The finding:
    A twelve-week diabetes prevention intervention delivered to 29 patients at a single institution demonstrated that patients with serious mental illness (SMI) (defined in this study as a diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder) could experience significant reductions in weight, blood pressure, body mass index (BMI), waist circumference, A1c. These objective improvements were accompanied by increases in patient knowledge about diabetes, and the intervention was deemed feasible and acceptable by the patient attendees.

    Strength and weaknesses:
    Notably, in this study, integrated care is defined by a program where “a primary care nurse practitioner…provides aspects of primary care coordination, health screening, and education for those with SMI.” This is particularly important, as among psychiatric circles, the terms “integrated care” and “collaborative care” have become synonymous with primary care clinics that have provisions for more comprehensive mental health care; “integrated care” in this article integrates a primary care provider into an outpatient psychiatric setting and a residential psychiatric setting. This integrated setting created an opportunity for an important intervention for patients who are often at risk of decreased adherence to medical care. This unique intervention was delivered by a dually trained primary care nurse practitioner and licensed clinical social worker. This dual certification unfortunately limits the generalizability of the study, as the authors acknowledge the utility of a strong medical knowledge base combined with an understanding of group dynamics. Unfortunately, the study does not provide significant detail on the nature of the weekly sessions, the method of development of the sessions, the time commitment for the delivery and development of these sessions, nor the types of educational materials provided from week to week. This limits the reader from attempting to deliver a similar intervention. The small sample size is concerning, as is the lack of any control group, the single site and the lack of information on the utility of the intervention for the outpatient population compared to the residential population. Given the small sample size and the lack of transparency on the data analysis, the residential population may have contributed more significant health gains given the restricted setting and additional supervision the patients may have received from other health providers after each educational setting. The lack of a control group is particularly concerning, as it is entirely possible (if unlikely) this population of patients may have simply made these health gains over this same time period. The short duration of the study additionally leaves more to be desired. It limits the immediate implementation of this type of intervention across psychiatric clinics and psychiatric settings; it is important to know whether a twelve week intervention on health education and a healthy lifestyle leads to persistent health improvement outside of the window of the intervention (as a twelve week intervention is going to be much less costly than an ongoing weekly intervention that is delivered indefinitely). Of particular note, 23 of the patients were categorized as “African American.” Disappointingly, there is not information on how this categorization was reached, and whether or not patients were able to self categorize, select from multiple choice, or categorized by the researchers. This is a pervasive issue in medical literature and warrants close examination and consideration from the readers. The authors note the preponderance of patients categorized as “African American” may limit generalizability, but this information warrants closer consideration and further discussion as minority populations have historically been underrepresented in medical research, and arguable the larger factor limiting generalizability is the implementation of this intervention at a single site.

    C-L psychiatrists are familiar with the increased rates of metabolic disease, obesity, diabetes, and hypertension found in patients with serious mental illness. Increased rates of medical comorbidity are often exacerbated by mental illnesses that impair or confound adequate education and adherence to important medical interventions including changes in diet and changes in physical activity. This project demonstrates that an intervention that could potentially be deployed across mental health clinics and primary care clinics across the country to help decrease the burden of medical illness patients with serious mental illness carry.

    Type of study (EBM guide):
    Uncontrolled clinical trial