When we think of lifestyle interventions for people with severe mental illness (SMI), we don’t often understand the implications a clinical diagnosis of SMI might have on physical health. We understand that some severe mental illnesses increase risk of suicidality, which is, of course, a very serious risk. However, what many people don’t understand is the impact of SMI on overall health, and its association with premature mortality, i.e., early death.
Severe Mental Illness and Premature Mortality
Research shows the presence of a severe mental illness (SMI) can reduce life expectancy by 10 to 20 years. The primary reason for premature mortality among people with serious mental illness is the increased incidence of cardiometabolic disorders, including:
- Type 2 diabetes
- Cardiovascular disease
- Stroke
- Heart attack
A variety of factors contribute to the increased rates of premature mortality identified in patients with severe mental illness. These factors include:
- Sedentary lifestyle:
- Lack of regular exercise and physical activity
- Smoking:
- Tobacco use increases risk of a long list of physical diseases and conditions
- Poor diet:
- High caloric intake
- High intake of fats and sugars
- Insufficient attention to basic healthcare, which can lead to long-term disease
- Side effects of antipsychotic medication
- Genetic factors
- Insufficient access to high-quality healthcare
These facts tell us something most of us already know: many people with SMI could improve their physical and mental health by implementing crucial lifestyle changes in an organized, consistent manner, based on evidence and best practices from behavioral and exercise sciences. And while many treatment centers provide education on lifestyle changes as part of treatment programs for people with SMI, they’re rarely implemented with the care and attention reserved for traditional approaches to treatment.
That’s why a new research effort in Holland caught our attention: they analyzed the impact of a systematic lifestyle intervention called STRIDE on the health of people with serious mental illness.
Let’s take a look at the study.
Lifestyle Changes Vs. Treatment as Usual: Which Improved Overall Health?
In the study “Effectiveness of a Lifestyle Intervention for People With a Severe Mental Illness in Dutch Outpatient Mental Health Care: A Randomized Clinical Trial,” researchers posed a simple, straightforward question:
“What is the effectiveness of lifestyle intervention among people with severe mental illness compared with treatment as usual?”
To find an answer, the research team recruited 224 patients who met the following criteria:
- Diagnosis of severe mental illness, including:
- Schizophrenia/psychotic disorder
- Bipolar disorder
- Depressive disorder
- Anxiety disorder
- Personality disorder
- Presence of physical health issues, including:
- Diabetes 1 or 2
- Hypertension
- Chronic obstructive pulmonary disease (COPD)
- High body mass index (average BMI of 35)
- Elevated cholesterol
- Elevated triglycerides
The research team divided the patients into two groups. One group received treatment as usual, called the TAU group. This group received typical treatment, which includes psychotherapy, medication, counseling, peer support, and advice about lifestyle changes. The second group participated in an intervention called STRIDE, based on a successful intervention called Dietary Approaches to Stop Hypertension (DASH) and enhanced as part of a program called the Severe Mental Illness Lifestyle Evaluation (SMILE).
About the Intervention: The STRIDE Approach
Researchers data from both groups on the following metrics at baseline, six months after the beginning of treatment, and 12 months after the beginning of treatment
- Body weight
- Body mass index
- Cholesterol levels
- Triglyceride levels
Here’s how the stride intervention worked:
- Weekly 2-hour meetings over 6 months
- Participants kept records on:
- Food, beverages, and calories consumed
- Fruit, vegetable, and low -fat dairy intake
- Fiber and fat intake
- Minutes exercised per day
- Hours of sleep per night
- Clinicians gave participants the following goals, with specific advice on how to meet or exceed them:
- Reduce overall caloric intake
- Engage in at least 25 minutes of moderate activity per day, with an emphasis on walking
- Increased fruit, vegetable, and low-fat dairy intake
- Improve quality of sleep
- During the weekly two-hour sessions, participants received instruction in the following areas:
- Behavioral self-management
- Problem solving
- Exercise basics
- Managing high-risk eating situation
- Peer support and community building
The goal of the intervention was to improve overall health, and thereby decrease risk of early mortality associated with severe mental illness. The primary difference between this intervention and the standard lifestyle changes approach common in mental health treatment is its systematized, consistent, and organized nature. In most cases, lifestyle changes are advised. In this case, lifestyle changes were presented as an integral part of a treatment plan, rather than a suggestion of afterthought.
Let’s see what the research team learned.
Lifestyle Intervention for People With Severe Mental Illness: The Results
Spoiler alert: the intervention worked for body weight and body mass index but had little to no impact on lab test outcomes for cholesterol or triglycerides. In addition, at the end of the 12-month study period, the STRIDE intervention showed no statistical advantage over TAU for self-reported changes in sleep patterns, exercise patterns, or dietary habits.
Here’s the data on the successful components of the intervention:
Body Weight (Averages):
- Baseline to 3 months:
- STRIDE group lost 4.63 more pounds than the TAU group
- Baseline to 6 months:
- STRIDE group lost 5.29 more pounds than the TAU group
- Baseline to 3 months:
- STRIDE group lost 4.63 more pounds than the TAU group
- Baseline to 12 months:
- STRIDE group lost 7.3 more pounds than the TAU group
Body Mass Index:
- Baseline to 3 months:
- No measurement taken
- Baseline to 6 months:
- STRIDE group decrease 0.8 more points than the TAU group
- Baseline to 12 months:
- STRIDE group lost 1.1 more points than the TAU group
These results are far more robust than previous research on lifestyle interventions among people with severe mental illness and high body weight/body mass index. Researchers indicate a possible explanation: the high level of positive, assertive community outreach among the STRIDE group, as compared to the TAU group.
We’ll discuss this below.
How This Study Helps Us Treat Patients With Severe Mental Illness (SMI)
The first thing learned from this study is that simply advising patients with SMI to change their daily habits is less effective than giving them an organized, systematic approach to changing their lifestyle habits. The body weight and BMI differences between the STRIDE group and the TAU group show this clearly: patients need more than advice, they need a practical, step-wise plan to make lifestyle changes that have a measurable impact on body weight and BMI.
The second thing we learned is the power of community and peer support in creating lifestyle changes. Patients in the STRIDE group met with peers and clinicians once a week. Both clinicians and researchers report a supportive atmosphere that influenced the behavioral decisions of the program participants. For us, this means we can prioritize leveraging this power in adjunct therapies, including those that emphasize the importance of exercise and nutrition. Creating a positive peer environment with compassionate accountability impacts behavior: this is something we can keep in mind when organizing our educational workshops on exercise and nutrition.
Finally, this study foregrounds the importance of proactive community engagement. When providers work to meet patients where they are, with tools they can use immediately, outcomes improve: this is something we remind ourselves every day.
Gianna Melendez
Jodie Dahl, CpHT