Health Promotion for Behavioral Health Clients
The startling statistic that persons with serious mental illness die on average 25 years earlier than the general population underscores the importance of closely monitoring this population’s physical well-being. Their early deaths are often due to modifiable risk factors, like smoking, obesity and poor nutrition, all of which can be addressed in primary care and mental health settings.
To address the premature death rate of the mentally disordered population, SAMHSA has undertaken a 10 X 10 Wellness Campaign, focusing on wellness to increase the life expectancy of this vulnerable group.
Smoking cessation: 75% of those with mental illness and/or addictions smoke, compared with about 23% of the general population.
According to the CDC, up to 75% of those with mental illness and/or addictions smoke, compared with about 23% of the general population. Smoking-related illnesses cause half of all deaths among people with behavioral disorders. Unfortunately, smokers with mental illness have a greater likelihood of nicotine withdrawal syndrome and, though many are motivated to quit, this population is less likely to be successful due to both the difficult withdrawal and their dependence.
A number of resources are available to help health providers and clients along the path to the clients’ quitting. In California, Smoker’s Helpline (1 800 NO-BUTTS) provides assistance and information for smoking cessation at no charge. Their Powerpoint underscores the high incidence of smoking among persons with mental illness and offers possible interventions to help this population quit. Other resources for smoking cessation can be found at UCSF’s School of Pharmacy and Medicine site, at the California Department of Public Health site and California’s Smoker’s Healthline.
SAMHSA has published a tool kit geared for mental health providers, “Smoking Cessation for People with Mental Illnesses“. The Kit focuses on the “5 A’s” strategy: Ask, Advise, Assess, Assist and Arrange and delves into what each of these five actions entail. The kit also discusses the clinical use of pharmacotherapies for tobacco cessation.
“Integrating Tobacco Treatment within Behavioral Health”, published by the Association for the Treatment of Tobacco Use and Dependence, is geared to helping behavioral health providers establish cessation programs. “Dimensions: Tobacco Free Toolkit“, published by the University of Colorado School of Medicine (2013) stresses that tobacco cessation should be viewed as a process rather than an event. A companion Toolkit focuses ontobacco cessation for behavioral health populations.
Choices, a consumer-driven program addressing smoking cessation, has demonstrated positive results using peer-to-peer counseling: a published study found reduced tobacco use and frequent attempts to quit among participants.
To help providers get reimbursed for their efforts, the American Academy of Family Physicians has drawn up a list ofMedicare billing codes related to smoking cessation. The Centers for Medicare and Medicaid offers guidelines for cessation activities reimbursement under the Affordable Care Act.
Diet and excercise: key challenges and opportunities
It’s a well-known and well-researched fact that many physical problems can be ameliorated through physical activity. “Integrating Physical Activity in to Mental Health Services for Persons with Serious Mental Illness” by Caroline Richardson MD et al (2005) underscores the importance of promoting exercise in this particular population, both to improve physical health and alleviate psychiatric disability. “Weight Management Strategies for Adults and Youth with Behavioral Health Conditions“, prepared by the University of Colorado School of Medicine (2012), reviews relevant literature on this subject.
The Dartmouth Health Promotion Research Team conducted a comprehensive review of published research literature addressing non-pharmacological lifestyle interventions aimed at reducing obesity and improving fitness for people with serious mental illness. Their findings are chronicled in “Research Review of Health Promotion Programs for People with Serious Mental Illness” (January, 2012).
Research review of health promotion programs for people with serious mental illness
SAMHSA’s Center for Integrated Health Solutions, which sponsored the research, published this chart of their findings:
| KEY FINDING | EVIDENCE | RECOMMENDATION |
| Interventions that last longer than 3 months are superior to those of shorter duration. Longer duration is associated with greater overall weight change, and shorter duration programs reported little or no change. | Interventions lasting longer than 3 months were 39% more likely to report statistically significant weight loss (89% versus 64%). | Implementing longer programs will likely heed greater success. Based on comparison data, the intensive phase of programs should last at least 6 months or more, followed by maintenance or ‘booster’ sessions. |
| Programs focused on non-specific wellness education are not successful in achieving results.
Programs that combine education and activity-based approaches are more successful at achieving weight loss. |
Programs that combine education and activity-based approaches are 34% more likely to report statistically significant weight loss than programs that provide education alone (75% versus 56%). | Education alone will not achieve substantive lifestyle and health behavior change. Wellness education programs result in very modest or no substantive weight loss or fitness outcomes. By implementing programs that consist of guided active participation in weight management activities and physical exercise will improve the likelihood of positive outcomes. |
| Programs that incorporate both nutrition education and exercise are more likely to incite weight loss than programs that focus on nutrition alone. | 81% of the studies with significant body weight findings incorporated both exercise and nutrition into their interventions.
The remaining three studies with significant weight change results focused on nutrition only. |
To achieve weight loss among participants, incorporating both nutrition education and active weight management (i.e., weight monitoring; food diaries) will more likely achieve positive outcomes than focusing exclusively on nutrition education
To address participants’ physical fitness, activity-based programs that provide active, intensive exercise and fitness measurement (e.g., 6-minute walk test, standardized physical activity monitoring) will more likely achieve positive outcomes than programs that provide only education, encouragement, or support for physical activity. |
Additional resources
The Small County Care Integration Quality Improvement Collaborative, an initiative of CIBHS, has helped 13 rural California county mental health departments improve medical outcomes for their clients by concentrating on approaches that can be taken within mental health agencies. Their Change Package includes several suggested strategies, including:
- Train staff to collect vitals on clients at every visit, including weight, height, and blood pressure.
- Acquire medical equipment, including scales and blood pressure cuffs, that mental health staff can use and teach them how to use the equipment.
- Place height and weight scales in a variety of settings (clinics, wellness centers, etc.)
- Teach method for getting accurate health histories and physical health risk inventories.
- Develop a flowchart of the process for monitoring clients physical health (to add steps into their current/usual process)
- Promote the value of physical health with clients and teach them to monitor their chronic conditions
- Teach clients how to take their own blood pressure at home.
- Create mechanisms to track key vitals for clients (e.g. in Wellness Centers),including providing means for clients to keep track of their status
- Acquire or develop and provide to clients physical health guidance and fact sheets
- Identify and assist clients’ in using websites designed to help them track health.
To assist mental health and primary care collaboration in identifying and treating cardiovascular disease among persons with serious mental health disorders, CalMEND in California created a Pre-Work Manual, a Change Package and measurement strategies for counties engaged in its pilot program. The Appalachian Consulting Group has developed the Peer Support Whole Health Training Manual (2009) to encourage healthy life-styles. The Manual contains client questionnaires, learning exercises and suggested activities designed to improve six life-style domains: physical activity, sleep, healthy eating, stress management, service to others and support network.
There has been some concern expressed about having persons who are physically compromised engaging in a physical exercise program. ACE Fit’s website gives tips on assessing the risks and appropriate level of exercise. Horizon House has developed two forms in conjunction with their exercise and wellness program: one is a physician authorizaton for the client’s engaging in exercise and the other is a client consent for exercise participation.
“Wellness Worksheets” by Insel and Roth (2012) contains 295 pages of questionnaires and worksheets related to physical and emotional health as well as setting and reaching health goals.
High Impact Mental Health – Primary Care Research for Patients with Multiple Co-Morbidities (S. Azrin, Psychiatric Services, April, 2014) delves into ways to increase patients efficacy for self-management, improve antidepressant adherence, and optimize telephone depression care, among other topics, for patients with multiple psychiatric and medical co-morbidities.
CIHS’s 2014 “Health Promotion Resource Guide: Choosing Evidence-Based Practices for Resucing Obesity and Improving Fitness for People with Serious Mental Disorder” helps behavioral health administrators, agencies, families and consumers select approaches that have been empirically shown to be effective. The guide contains two companion checklists: Evaluating Health Promotion Programs for Persons with Serious Mental Illness: What Works? and Evaluating Your Organization’s Readiness to Adopt a Health Promotion Program for Persons with Serious Mental Illness.
The leading cause of accelerated mortality is ischemic heart disease. “Nonfasting Screening for Cardiovascular Risk Among Individuals Taking Second Generation Antipsychotics” (E. Vanderlip et al, Psychiatric Services, 2014) outlines newer guidelines for cholesteral and diabetes screening that provide alternatives to fasting blood draws.