MA Department of Mental Health
Healthy Changes Initiative
June 17, 2009
Health and Wellness for
Individuals with Serious Mental
Illness; Challenges and
Opportunities
Sally Reyering, M.D.
Sally.reyering@state.ma.us
Agenda
Project rationale
– Mortality data
– SAMSHA and NASMHPD calls to action
Evidence base to support choice of three
target areas of initiative
Outcome measures and evaluation tools
Interventions to achieve outcomes
Mortality Crisis
Recent data from several states have found
that people with serious mental illness
served by our public mental health systems
die, on average, at least 25 years earlier that
the general population.
US Life Expectancy 2008 = 78 years
Serious mental illness = 53 – 57 years
– Comparable to Cameroon, Gabon, Democratic
Republic of Congo
Biggest lifespan disparity in U.S.
Morbidity and Mortality ~ Causes
While suicide and injury account for about
30-40% of excess mortality, about 60% of
premature deaths in persons with
schizophrenia are due to “natural causes”
– Cardiovascular disease
– Diabetes
– Respiratory diseases (including pneumonia
and flu)
– Infectious diseases (including HIV and Hep C)
Premature Mortality by 25 years
Six major causes of death in U.S
and increased relative risk in SMI
–Cardiovascular Disease 3.4 X
–Cancer Maybe lower rates except lung
–Stroke 2x in age < 50
–Respiratory disease 5x
–Accidents higher
–Diabetes 3.4x
Massachusetts Study: Deaths from Heart
Disease by Age Group/DMH Enrollees with
SMI Compared to Massachusetts 1998-2000
40
Rates per 100,000
35
DMH
MA
30
25
20
15
10
5
0
25-34
35-44
45-54
55-64
High Rates of Chronic Illness
70% SMI have a chronic health cond
–Mostly pulmonary disease
50% have two or more
42% severe enough to limit function
34% HPTN
Hep B rates increased 5x; Hep C 11x
Calls for Action
SAMSHA:
– Increase the average life span of those with
mental illness by 10 years in 10 years.
NASMHPD
– 13th Technical Report
CDC, Healthy People 2010
Health and Human Services; HealthierUS
President’s New Freedom Commission
Bazelon Center For Mental Health Law
Factors Associated with Premature
Death
Reduced Use/Inefficient Use of Medical Services
Poverty
Systemic Barriers to Ideal Health Care
– Healthcare systems and financing
Psychotropic medications
Individual health habits
– Smoking
– Inactivity
– Obesity/poor nutrition
Healthy Changes Initiative
The Healthy Changes Initiative is designed to
address the individual’s modifiable risk factors
which result in chronic illness and early death in
individuals with psychiatric disabilities.
– Physical Inactivity
– Overweight/Obesity
– Smoking
“…the recovery paradigm of needed services has
to include the concept of health promotion in
treatment planning and service delivery to
persons with SMI.” Hutchinson et al, 2006
Lifestyle Changes Work in those
with Mental Illness
Addiction Recovery
Smoking Cessation
Prevention and reversal of
antipsychotic induced weight gain
Development of healthy eating and
exercise habits
Physical Activity
www.health.gov/paguidelines
Physical Activity: Benefits
“The health benefits of physical activity are
generally independent of weight.” PAGuidelines
Sedentary lifestyle is an independent risk for
cardiovascular death even in normal weight
individuals.
Moderate intensity exercise without dietary
changes brings reduced incidence of metabolic
syndrome.
Physical Activity: Benefits
Strong evidence
Early death
Coronary artery disease
Stroke
High blood pressure
Adverse lipid profile
Type II Diabetes
Metabolic syndrome
Colon Cancer
Breast Cancer
Prevention of Wt Gain and to
achieve weight loss
Bone health in kids
Function in older adults
Moderate evidence
Hip fracture, falls, bone density
Lung cancer
Endometrial cancer
Maintaining wt loss
Improved sleep quality
Within weeks
Increased cardiorespiratory
fitness
Increased muscular strength
Decreased blood pressure
Decreased depressive
symptoms
Physical Activity
Mental Health Benefits
Strong evidence
Depression reduced in
adults
Cognition improved in
older adults
Other evidence
Anxiety improved
Self-esteem
Overall well-being
Moderate evidence
Depression reduced in
children
Amounts of Exercise
Inactive or sedentary <30 min/wk, <10min/qd
Health benefits accrue at 60 min/wk
Low level 90 min/wk. Even low levels lead to
dramatic decr in risk of premature death
For substantial health benefits 150 min
cumulative moderate intensity exercise a
week.
Greater benefits accrue at higher levels
300 minutes for weight loss
Physical Activity
CDC
data
Seden
.
Some
activit
y
Reg
activit
y
Gen
pop
36%
Povert NHANES Gen
y
pop
56% Seden. 17%
SMI
31%
23%
Decr
22%
activity
49%
33%
21%
26%
Special Considerations
Physical Activity in indiv. with SMI
Inactive; start low, go slow.
Fear of heart attack with sensation of incr.
HR, R.
Lack of familiarity with the sensation of
muscle soreness.
Traumatic bodily relationships
Balance issues on moving treadmills; med
effects
Cold temperatures and destimulating env
DMH Data
Ne
ve
%
r
Ra
%
Oc
re
ly
ca
sio
%
n.
Co
ns ..
ist
e..
%
No .
Da
ta
40.0%
30.0%
20.0%
10.0%
0.0%
%
Person Exercises 20 or
More Minutes, 3 or More
Days a Week (as assessed
by OT staff on admission)
Physical Activity and Exercise Among Persons New ly Admitted June
1, 2007 through May 31, 2008
New Admissions: 1203 Adult, 48
Adolescents
Adult units only
Adolescent units only
Physical Activity: Outcomes
http://www.healthypeople.gov/
Decrease the number of sedentary individuals <30
min/ week
Increase the number of individuals who engage in
physical activity > 60 min/ week.
Increase the proportion of individuals who engage
in physical activity >90 min/ week.
Increase the proportion of adults who engage in
moderate physical activity >150 min/ week or
vigorous activity for at least >75 min/ week.
Evaluation Tools
Interventions:
Physical Activity
Physical activity opportunities for each patient
– Structured group format
– Milieu changes such as stairs to cafeteria, walking to
appts on campus
Encouragement of walking in all sites.
Enhance and document physical activity
opportunities in vocational and residential settings
Motivational interventions to eliminate culture of
lethargy
Interventions:
Physical Activity
Fitness equipment at every facility, esp aerobic
(exercise bikes, elliptical)
– Staffed for pts and open for staff use
– Relationships with local health clubs for equip.
Access to fitness centers in the community
Education
–
–
–
–
–
Links to obesity and cardiovascular illness and death
Benefits/Barriers
Types/Low cost options
Getting started; Medical Clearance
Posters
Interventions:
Physical Activity
Sponsoring Events to promote Culture Change and
Maintain Focus
– Physical Activity Challenges, Workplace wellness
opportunities for employees
– NAMI Walk
Peer Counselors
– Peers with lived experience key component in change of
culture; Social network inspires group change.
– Increase opportunities for shared wellness opportunities
– Include consumers on area Health and Wellness task
forces
Overweight and Obesity
www.smallsteps.gov
Overweight and Obesity
Definitions:
Healthy Weight
Body Mass Index (BMI) 18-24.9
Overweight;
BMI 25-29.9
Obesity
BMI 30-34.9
Extreme obesity
BMI >35
US population
30% overweight
30% obesity
Health Risks
Premature death
Diabetes type II
Cardiovascular Disease
Dyslipidemia
High blood Pressure
Osteoarthritis
Stroke
Sleep Apnea
Gall Bladder Disease
Asthma
Hirsutism /menstrual irregularities
Social isolation
Surgical complications
Depression
Obesity and Mental Illness
Epidemic in mentally ill
– Multiple studies show increased incidence of overwt. and
obesity in schizophrenia, esp women
– Majority recognize the wt problem, want to/have tried to weigh
less
Certain 2nd gen antipsychotics (SGA) can cause rapid
wt gain (7 -30% of body wt) from 1st sev. months of
therapy up to a yr or longer.
– Significant wt increases coincided with clozapine introduction
– Wt gain ranked as top “bad thing” about taking meds in UK
survey
Lifestyle modifications preferred approach
Common Elements of Weight
Reduction Programs
Goal Setting of Realistic short-term goals
Strategies to increase physical activity and
decrease sedentary behavior
Nutritional focus teaching and demo of
healthy eating habits
Self-monitoring of nutritional intake and
physical activities
Measures/Evaluation Tools
Body Mass Index (BMI)
Underweight = 18
Optimal 18.1 -24.9
Overweight 25- 29.9
Obese 30 -39.9
Extremely Obese > 40
DMH
DMH
DMH
DMH
DMH
1%
23%
30%
34%
9%
Abnormal BMI addressed on all treatment
plans
Stages of change approach
Small steps approach
Interventions:
Client Education
Client Education about Nutrition and Weight
Management
Nutrition label reading
Macronutrient information (protein, carbs, fats, fiber)
Eating behaviors and physiology;
recognizing and responding to hunger, slow eating
Substitution of healthy foods for less healthy foods;
emphasis on addition of healthy foods rather than deprivation
Portion size
High calorie drinks
Goal setting; one change at a time.
Grocery shopping
Food preparation
Fast food, restaurant eating
Interventions: Milieu
Vending machines and canteens
– Provision of healthy alternatives
Water
Fresh fruit
Low fat dairy products
Substitute juice for water at med dispensing
Printed materials and posters at cafeteria
Inpatient take out food
– Emphasis on discretionary income, financial aspects
recommended
Engage staff; “biggest loser” contests
TSH: sample size 164
50.0
45.0
40.0
35.0
30.0
9/1/2007
&
12/1/2007
25.0
3/1/2008
6/1/2008
9/1/2008
20.0
15.0
10.0
5.0
0.0
% UW
% Opt
% OW
BMI score
% OB
% EO
Smoking
Cigarette smoking is the single most
preventable cause of morbidity and premature
death in US for past 30 years. CDC
“No other health intervention makes such a
difference.” Schroeder SA
“We cannot in good conscience ignore a
substance and practice that is the leading
cause of morbidity and mortality in our
patients.” (NASMHPD)
Nicotine Dependence among
Seriously Mentally Ill (SMI)
75% of SMI are tobacco
dependent (22% gen pop)
– 85% in schizophrenia
60 - 95% of people with addiction
disorders smoke
44% of all US cigarette
consumption by those with mental
illness/substance abuse (SA)
disorder
Nicotine Dependence among
Seriously Mentally Ill
27% of consumer income went to
cigarettes.
22% of consumers reported that they
started smoking in a psychiatric setting.
– Metro Suburban Area Survey, Mary Ellen Foti, M.D., 1999-2000
40% of staff smoke versus 22% in the
general population. NASMHPD
DMH Inpatient Smoking Data
55% smokers in 12/07 to 45.6% 3/09
53% have moderate to high levels of nicotine addiction where full access
to smoking is limited
54% in the “precontemplation stage”
29% contemplating a change
3% in preparation to quit
3% in action phase
10% in maintenance of past successful quit attempts.
93% of smokers were advised to quit smoking
Outcomes
Decrease number of smokers in every setting.
Increase the number of smokers advancing toward
quitting as measured by stage of change
Precontemplation Contemplation Preparation
Action Maintenance
Increase the number of smokers who have been
given advise to quit.
Increase the number of patients who have smoking
cessation interventions addressed on the treatment
plan.
Clinical and Educational
Interventions
Living and Learning: Tobacco and You group treatment
manual
http://ubhc.umdnj.edu/nav/LearningAboutHealthyLiving.pdf
Motivational enhancement approach
CO monitors, discretionary income tools
Educational events in all settings
Training Tobacco Treatment Specialists
Pharmacotherapy
Substitutes for social aspects of smoking
wellness walks
group physical activities
Precede cigarette lighting on breaks with a walk
Employee groups
Preliminary Results
55% smokers in 12/07
45.6% 3/09
Plans to role out as a Learning
Collaborative to measure
effectiveness of various interventions
(Institute of Healthcare Improvement)
National Wellness Summit
Wellness Pledge
We Envision:
a future in which people with mental
illnesses pursue optimal health, happiness,
recovery, and a full and satisfying life in the
community via access to a range of effective
services, supports, and resources.
We pledge:
to promote wellness for people with mental
illnesses by taking action to prevent and
reduce early mortality by 10 years over the
next 10 year time period.