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In a 1-2 page paper, written in APA format using proper spelling/grammar, address the following: Summarize the article. Explain the implications of the research findings as they pertain to understanding mental illness
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Read the following peer reviewed journal article:
•
Brown, S., & Chan, K. (2006). A randomized controlled trial of a brief health promotion
intervention in a population with serious mental illness. Journal of Mental Health, 15(5), 543-549.
doi:10.1080/09638230600902609
Link to Article
In a 1-2 page paper, written in APA format using proper spelling/grammar, address the following:
1. Summarize the article.
2. Explain the implications of the research findings as they pertain to understanding mental illness.
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regarding APA format as well as APA referencing and citation procedures.
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Jstudent_exampleproblem_101504
Journal of Mental Health,
October 2006; 15(5): 543 – 549
A randomized controlled trial of a brief health promotion
intervention in a population with serious mental illness
S. BROWN & K. CHAN
Mental Health Group, University of Southampton, Southampton, UK
Abstract
Background: People with serious mental illness have high rates of mortality and physical morbidity.
Some of this is due to unhealthy lifestyle factors. Many mental health services are beginning to develop
health promotion interventions for this population but these have not, to date, been properly evaluated.
Aims: To measure whether a brief health promotion intervention delivered by a non-specialist worker
can deliver useful health gains in a population with serious mental illness.
Method: A randomized controlled trial (RCT) of a particular health promotion package using
physiological measures and validated research instruments to measure outcome.
Results: The study population had an unhealthy lifestyle at outset. The intervention produced small
but statistically significant gains in exercise and weight loss with a trend to improved subjective well
being. There was a high drop out rate.
Conclusions: People with serious mental illness are an appropriate target group for health promotion
activities. They are concerned about their health and interested in trying to improve it. This
intervention produced significant health gains but probably did not engage enough patients to justify
incorporation into standard treatment packages.
Declaration of interest: The authors do not identify any conflict of interest. The principal researcher
undertook the study as part of her undergraduate education. The study interventions were based on
the Lilly Meaningful Day package which was supplied by Lilly. We received no other support from
Lilly or any other commercial organization.
Keywords: Mental illness, health promotion, lifestyle
Introduction
People with serious mental illness have a significantly raised mortality from natural causes
(Harris & Barraclough, 1998). The excess natural mortality is best explained by altered
exposure to environmental risk factors (Kendler, 1986). Some, such as exposure to
antipsychotic drugs, is a direct consequence of mental illness, some results from unhealthy
lifestyle (Brown et al., 2000). This population have higher rates of obesity, smoke more, take
less exercise and have a poorer diet than the general population (McCreadie et al., 1998;
Brown et al., 1999).
Health promotion can produce significant health gains in the general population and is an
important part of the UK government’s overall health strategy. Exercise is helpful in
reducing symptoms of depression (Lawlor & Hopker, 2001) in addition to its cardiovascular
benefits. Nevertheless the physical health of people with serious mental illness has been
Correspondence: Dr Steve Brown, Canon House, 6 Canon Street, Shirley, Southampton SO15 5PQ, UK.
Tel: þ44 (0)2380 878051. Fax: þ44 (0)2380 878079. E-mail: Steve.Brown@wht.nhs.uk
ISSN 0963-8237 print/ISSN 1360-0567 online Ó Shadowfax Publishing and Informa UK Ltd.
DOI: 10.1080/09638230600902609
544
S. Brown & K. Chan
neglected until recently (Kendrick, 1996). Mental health practitioners are slowly becoming
aware of the importance of physical health issues. Lifestyle advice is recommended as a
standard intervention for patients experiencing antipsychotic related weight gain (Connolly
& Kelly, 2005). Health promotion and exercise schemes have been introduced in many UK
mental health services. There is anecdotal evidence that these interventions are effective and
valued by patients (Faulkner & Sparkes, 1999) but there are no good RCTs which evaluate
exercise or lifestyle interventions in this population (Faulkner & Biddle, 1999; Bradshaw
et al., 2005). This is probably in part because such studies are difficult to do well but the
consequence is that scarce resources are being channelled into interventions of unproven
efficacy.
The Lilly ‘Meaningful Day’ package (Lilly, 2002) was devised at the time when the
association between weight gain and atypical antipsychotic drugs was becoming widely
recognized. It was put together by a group of experts in lifestyle and health promotion in
people with serious mental illness and has been effectively promoted to local mental health
services. The package is well designed, has good face validity and is attractive to local
services as it relieves them of the need to develop their own resource packages. At the time of
the study it was probably the basis for most local health promotion work and therefore the
most appropriate package to evaluate.
Aims of the study
The paper describes a RCT designed to test the hypothesis that a brief, community-based
package of lifestyle interventions, can produce significant improvements in weight, diet and
exercise in a population with serious and enduring mental illness. The study also examined
whether the intervention produced changes in substance use and subjective well being.
Subjects
The study had full ethical approval from the Southampton and South West Hants Research
Ethics Committee. It was advertised by poster and by key workers to people on the case load
of the West Southampton Community Mental Health Team (CMHT). The team has a case
load of about 400 individuals. Its operational policy requires that all case loaded patients are
aged 18 – 65 and have ‘‘severe and enduring mental illness’’. In practice this means they
have a primary ICD-10 diagnosis of psychosis, major affective illness or severe personality
disorder.
Potential subjects returned a contact slip to express interest in the study and were then
invited to an introductory interview. Those who attended, wished to continue and gave
informed consent, were then randomised either to an active treatment or control group, by a
concealed computer generated random number programme. The control patients were
offered the health promotion package at the end of the study period.
Intervention
The subjects received six, weekly, 50 minute, one-to-one health promotion sessions
(delivered by KC). These sessions followed the Lilly ‘‘Meaningful Day’’ manual (Lilly,
2002) but were tailored to the needs of the individual (e.g., non-smokers did not receive
material about smoking). The Meaningful Day manual draws on extensive experience of
best practice in delivering health promotion interventions and focuses primarily on weight
reduction. It uses techniques such as motivational interviewing, health education, the use of
Health promotion interventions
545
food and activity diaries and facilitation of access to local community facilities. The six
sessions used in this study covered weight control, healthy eating, exercise, structured daily
activity and substance misuse. Further details are available from the authors.
Method
Subjects were given an initial basic health screening questionnaire. Their height, weight,
blood pressure and resting pulse were measured using standard equipment. The protocol
required that anyone with health problems such as uncontrolled hypertension, severe
cardiac disease, or any other medical condition which the screening doctor thought might be
worsened by unaccustomed exercise, was excluded and referred to their GP.
Lifestyle factors were measured using validated research instruments. Diet was measured
using the DINE questionnaire (Roe et al., 1994) a food frequency-based questionnaire.
Frequency and intensity of exercise was measured using the GODIN questionnaire (Godin
& Shephard, 1985). Psychological health was measured using the Hospital Anxiety and
Depression (HAD) scale (Zigmond & Snaith, 1983). This scale was chosen as it measures
psychological symptoms which occur in a range of conditions and hence was likely to
identify changes in psychological distress in people with different underlying diagnoses. It is
also easily administered and is acceptable to patients.
Subjects were also asked to rate their current physical health, physical fitness and mental
health on a Likert scale graded from 0 (very poor) to 10 (excellent).
The initial measurements were repeated after six sessions of health education (subjects) or
six weeks of treatment as usual (controls). Measurements were made by the same rater who
was blind to the interviewee’s status in the study.
Statistical analysis
The hypothesis was tested using an intention to treat analysis to compare changes in
variables in the subject and control groups. The last recorded data were carried forward as
outcome data for those subjects lost to follow up. Non-parametric statistics were used, as the
sample was small and data not normally distributed. This was done using the SPSS statistics
package (SPSS, 2001).
Subjects
Thirty-nine subjects returned a slip to express a formal interest in the study. Twenty-eight
attended a screening interview and were randomized to treatment (n ¼ 15) or control
(n ¼ 13) groups. No subjects were excluded because of health problems. Only four were
male; they were all randomized to the control group. The groups were not perfectly
matched. The outset variables suggested that the subject group were less healthy and more
distressed than the control group though very few of the differences were statistically
significant (Table I).
Compared to general population rates (Table I) they had a high rate of obesity. They ate
less fibre but also less saturated fat. Only two had taken any exercise strenuous enough to be
of even marginal cardiovascular benefit in the week prior to interview.
The rates of smoking were higher than in the general population but alcohol misuse was
not increased. Subjects viewed themselves as not being particularly physically healthy or
mentally well and as being physically unfit. Their psychological distress as measured by
HAD scores was raised.
546
S. Brown & K. Chan
Table I. Comparison of baseline variables in control and subject groups with reference UK female population data.
Variable
Female gender
Mean age
Mean weight
Mean BMI
Obese (BMI 4 30)
Mean resting pulse
Mean resting systolic BP (mmHg)
Low saturated fat diet ( 83 g/day)
High fibre diet ( 30 g/day)
Smoker
Excess alcohol ( 14 units/week)
Moderate exercise 5/week
Weight gain drugs{
Mean HAD anxiety score
Mean HAD depression score
Mean subject score health (1 – 10)
Mean subject score fitness (1 – 10)
Mean subject score mental health (1 – 10)
Subjects (n ¼ 15) Controls (n ¼ 13)
15 (100%)
45.1 years
90.3 kg
33.3
9 (60%)
78
131
7 (47%)
0
8 (53%)
3 (20%)
0
9 (60%)
12.2
10.7
3.5
1.9
3.9
9 (69%)
41.7 years
86.9 kg
31.4
8 (61%)
76
124
9 (69%)
0
6 (46%)
1 (8%)
0
10 (77%)
10.8
9.9
5.9
3.6
5.1
p
0.02
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
0.01
0.07
NS
Female population data
23%*
123*
41%#
31%#
26%*
18%*
28%*
*Department of Health (2004), #Roe et al. (1994), {Taylor et al. (2003).
Results
The drop out rate was high. Only 7 (47%) subjects and 10 (77%) controls completed the
study. Subjects failed to attend or cancelled at short notice a total of 73 (out of 199)
appointments. The intention to treat analysis showed small but statistically significant
(p 5 .05) improvements in weight and exercise in the subjects compared to the control
group. Those subjects who completed the intervention lost a small but significant amount of
weight (mean of 0.9 kg). There were also trends to significance in improved subjective well
being. Both groups improved their diets by taking more fibre and less saturated fat. There
was no change in other physiological measurements or in substance use (Table II).
Discussion
Bias
The study has limitations which weaken the generalizability of the results. The most
important is that the final sample was too small to reliably detect significant differences in
outcome between the two groups. It is also possible that the repeated statistical tests
produced some false positive results. We therefore cannot be entirely sure that apparently
significant results do not represent chance associations. A larger study might also have
improved the matching of the study groups. Unfortunately the duration of the study was
limited by logistical pressures.
The drop out rate was high in the subject group. This may have been because the subjects
found the intervention to be harder work than they had expected but the data also suggest
that the subject group were less healthy at outset (Table I) and that the least healthy subjects
were most likely to drop out. It can be argued that starting with qualitative or uncontrolled
studies might have defined the patients’ lifestyle problems better and identified possible
retention difficulties. This could also have provided data for a power calculation. We were
Health promotion interventions
547
Table II. Comparison of changes in subject and control group variables from baseline levels.
Variable
Weight (kg)
BMI (kg/m2)
Saturated fat
Fibre
Moderate exercise
Cigarettes/day
Alcohol (units/week)
HAD anxiety
HAD depression
Subject view health
Subject view fitness
Subject view mental health
Mean change
subjects (n ¼ 7)
Mean change
controls (n ¼ 10)
Mann
Witney U
p
70.40
70.02
72.27
þ4.9
þ2.4
70.7
þ0.0
71.4
71.1
þ0.3
þ0.5
þ0.4
þ1.11
þ0.41
73.31
þ1.8
þ0.2
71.0
70.6
þ1.4
þ1.3
70.9
70.6
70.2
47.5
48.5
95
85
58
87
83
70
61
72
60
84
.01*
.02*
.92
.55
.04*
.60
.35
.19
.08
.22
.06
.50
*Significant at 5% level.
however aware that many services already offered this type of health promotion intervention
and we felt that it was important to try and evaluate what was already being delivered in
order to best inform current practice.
Subjects were self-selected and hence probably unrepresentative of the local population
with serious mental illness. Subjects were also aware of their status in the study. We
attempted to maintain rater blindness but in many cases the nature of the intervention
meant that this was not possible. Most of the data was collected by questionnaire and
vulnerable to subjects’ selective reporting of their activity. Furthermore the researchers were
enthusiasts and probably put more effort into engagement and retention than would be
possible in a clinical setting. The sum of these biases probably produced a more positive
outcome than could be expected in an ordinary service.
Conclusions
This study is the first, which we know of, to use a RCT to evaluate previous uncontrolled
evidence that it is possible to make meaningful health gains and behavioural changes in
people with serious mental illness (Byrne et al., 1994; Faulkner & Sparkes 1999; Faulkner &
Biddle, 1999; Faulkner & Biddle, 2001). The study limitations mean that results have to be
interpreted with caution but the headline message is that health promotion interventions can
produce health gains in people with severe and enduring mental illness. At the same time the
size of the health gains and the problems in recruitment and retention mean that this type of
intervention is unlikely to have a major impact on the overall health of this population.
The subjects had unhealthy lifestyles at outset and were therefore an appropriate target
group for health promotion interventions. Those who completed the study rated it as useful
and enjoyable. They were particularly keen on the one-to-one structure of the sessions;
many said they felt too self conscious to get involved in groups or in mainstream health
promotion activity. Nevertheless the drop out and DNA rate was high enough to raise
serious questions about whether this approach would be an effective use of resources in an
ordinary clinical setting.
The interventions used in this study were specifically designed for a population with
serious mental illness and are based on expert input from people working in the area. We are
548
S. Brown & K. Chan
not aware of any better packages and suspect that all education based approaches will
have similar issues around engagement and drop out. It is possible that some people
may have been put off by the manner of the person doing the interventions but we think that
this is unlikely as people who completed the intervention were all complimentary. We
wonder whether the intervention might be more effective if it came from someone with
whom the subject already had an established therapeutic relationship rather than in special
sessions.
Further work is needed to clarify whether different diagnostic groups have different health
and lifestyle issues and hence might require tailored interventions. Nevertheless people with
serious mental illness share many risk factors such as cigarette smoking, obesity and the
consumption of drugs associated with weight gain, so it seems likely that general
interventions will be beneficial. A non diagnosis-specific approach also fits best with
current model of needs driven mental health team interventions. Further large studies are
needed to clarify whether a non diagnosis-specific approach is the best way of delivering this
type of intervention and to identify any patient groups who might need a different form of
intervention.
This study provides further support for suggestions that regular exercise can improve
psychological well being (Lawlor & Hopker, 2001). The use of exercise fits comfortably into
the cognitive behavioural (CBT) model of coping strategies and may be acceptable to
individuals who are not comfortable with talking based treatments.
The health risks of obesity, inactivity and smoking are serious and we need to develop
effective interventions. These results are sufficiently encouraging to suggest that this type of
intervention merits testing in a larger study. Subjects will also need to be followed in longer
studies to establish whether any health gains are sustained.
The high drop out rate, in a cohort self selected for an interest in improving their health,
suggests that this kind of intervention is unlikely to make a big difference to the overall
health of the population with serious mental illness. It is therefore vital that clinicians do
their utmost to prevent the development of unhealthy lifestyles in their patients. This means
looking hard at practices ranging from the prescription of drugs associated with weight gain
to smoking policies to the quality of hospital food and the need to provide detained patients
with access to exercise of their choice. Physical health is an important issue for many people
with serious mental illness and merits a higher priority both in the Department of Health and
in local mental health services.
References
Bradshaw, T., Lovell, K., & Harris, N. (2005). Healthy living interventions and schizophrenia: A systematic review.
Journal of Advanced Nursing, 49, 634 – 654.
Brown S., Birtwistle, J., Roe, L., et al. (1999). The unhealthy lifestyle of people with schizophrenia. Psychological
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