Improving the Physical Health of Adults with Serious Mental Illness (SMI)

Summary

People with serious mental illness (SMI) such as schizophrenia and bipolar disorder die 13 to 30 years earlier than the general population, largely due to preventable medical conditions like obesity, type-2 diabetes, and cardiovascular disease.^1–6 Racial and ethnic minorities with SMI face additional health risks. For example, people who identify as Hispanic or black and experience SMI have a higher risk of obesity and type-2 diabetes when compared to non-Hispanic whites with SMI.^7,8 Racial and ethnic minorities with SMI also must contend with additional and unique barriers to accessing and receiving high-quality medical care for these chronic medical conditions, including language barriers, mistrust of the health care system, and the intersection of stigma toward mental illness, racism, and discrimination.

To address these challenges, mental health care researcher Dr. Leopoldo J. Cabassa gathered a multidisciplinary team of doctors, social workers, psychiatrists, sociologists, anthropologists, and people with lived experiences with SMI. Together, they set out to eliminate health and healthcare inequities among racial and ethnic minorities with SMI by blending implementation science, health disparities research, and community-engaged scholarship.

The first project, Bridges to Better Health and Wellness (B2BHW), focuses on adapting and testing a health care manager intervention for Hispanics with SMI who are at risk for cardiovascular disease.⁹  B2BHW is a 12-month program delivered by master-level social workers in outpatient mental health clinics. It aims to connect patients to primary care services, such as vaccinations, and increase their use by enhancing patients’ involvement in their health care. A pilot study tested B2BHW with 29 participants at an outpatient mental health clinic in Northern Manhattan that serves mainly Hispanic patients. The pilot project found that B2BHW improved Hispanic patients’ involvement in their health care, their self-efficacy in talking with primary care doctors and managing chronic medical conditions, and increased self-reported use of preventive primary care services.¹⁰

The second project, Peer-Led Group Healthy Lifestyle Balance (PGLB), focuses on bringing healthy lifestyle interventions to people’s doorsteps by delivering the program in supportive housing agencies, which provide affordable housing with wrap-around services such as mental health or substance use treatment, life skills, or community support services like child care. The intervention is delivered by other people with lived experiences with SMI, known as peer specialists. The program served more than 250 participants, who were mostly racial/ethnic minorities (81.7%), at three supportive housing sites in the northeast.¹¹ More PGLB participants lost weight, improved cardiorespiratory fitness, and reduced cardiovascular disease risk at 12 and 18 months compared to people receiving usual medical care, although the differences were not statistically significant.¹¹

Significance

Up to now, most clinical trials of healthy lifestyle interventions used clinical staff to deliver the interventions.¹¹ Dr. Cabassa and his team leverages different points of contact with the health care system to expand care to new provider groups. The B2BHW project uses master-level social workers to connect patients to primary care services, an expanding workforce that now provides most of the mental health care in the U.S.¹² The PGLB project also explores connecting primary care to a growing service sector for people with serious mental illness, supportive housing.¹³ The goal is to enhance relevance and increase patient engagement with their health care by developing interventions that are accessible and can be delivered in routine practice settings.

The studies also focus on populations that are not normally included in research. For example, Latinos are usually underrepresented in these types of studies, so up to now there was little to no evidence indicating that these interventions could benefit this population.¹²

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Developed guidelines and materials for training and supervising peer specialists to deliver health interventions for people with SMI in supportive housing agencies. demonstrated.

Clinical

Guidelines

Developed a treatment manual and guidelines for training and supervising health care managers to deliver B2BHW in public outpatient mental health clinics. demonstrated.

Clinical

Guidelines

Created culturally and linguistically appropriate patient education tools and materials (e.g., personal health record, health-related fotonovelas for diabetes) for increasing patients’ involvement in their healthcare. demonstrated.

Community

Health education resources

Improved health care delivery by connecting people with SMI to primary care services through additional providers, including master-level social workers and peer specialists in supportive housing. demonstrated.

Community

Health care delivery

Increased preventive primary care (e.g., vaccinations, screening) and patients’ involvement in their own medical care.¹⁰ demonstrated.

Community

Disease prevention & reduction

Overweight or obese people with SMI reported weight loss, increased in cardiorespiratory fitness, and reduced risk for cardiovascular disease.¹¹ demonstrated.

Community

Disease prevention & reduction

This research has clinical and community implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.

Clinical

Across the two projects, the research team developed several new guidelines for health care providers. As part of the PGLB project, the research team created guidelines and materials to train and supervise peer specialists to deliver healthy lifestyle interventions for people with SMI in supportive housing agencies. The team also developed a treatment manual and guidelines for training and supervising health care managers to deliver B2BHW in public outpatient mental health clinics.

Community

To increase patients’ involvement in their healthcare through the B2BHW project, the research team created culturally and linguistically appropriate patient education tools and materials, including a personal health record and health-related fotonovelas for diabetes. Materials are available in both English and Spanish.¹² The project improved health care delivery by connecting people with SMI to primary care services through additional providers, including master-level social workers and peer specialists in supportive housing. Both projects demonstrated disease prevention and reduction benefits, including increased use of preventive primary care (e.g., vaccinations, screening), increased involvement in their own medical care (e.g., talking with primary care doctors and managing chronic medical conditions), weight loss, increased cardiorespiratory fitness, and reduced risk of cardiovascular disease.^10,11

Lessons Learned

The research team realized the importance of developing and implementing evidence-based interventions with, for, and in the community to improve the physical health of people with serious mental illness. The team focused on reach and representation from the very beginning to ensure the fit between the intervention, the population of interest, and the context in which the interventions are implemented. They discovered that peer specialists can successfully deliver a manualized health lifestyle intervention for people with serious mental illness with the appropriate training, support, resources, and supervision. Supportive housing agencies were also an important channel to deliver the intervention. Using multiple evidence-based interventions that focus on improving health behaviors as well as the access and quality of healthcare services is important to reduce health inequities among people with serious mental illness from historically marginalized racial and ethnic communities.