Bobbi Jo H. Yarborough

The STRIDE Weight Loss and Lifestyle Intervention for Individuals Taking Antipsychotic Medications: A Randomized Trial

OBJECTIVES The STRIDE study assessed whether a lifestyle intervention, tailored for individuals with serious mental illnesses, reduced weight and diabetes risk. The authors hypothesized that the STRIDE intervention would be more effective than usual care in reducing weight and improving glucose metabolism. METHOD The study design was a multisite, parallel two-arm randomized controlled trial in community settings and an integrated health plan. Participants who met inclusion criteria were ≥18 years old, were taking antipsychotic agents for ≥30 days, and had a body mass index ≥27. Exclusions were significant cognitive impairment, pregnancy/breastfeeding, recent psychiatric hospitalization, bariatric surgery, cancer, heart attack, or stroke. The intervention emphasized moderate caloric reduction, the DASH (Dietary Approaches to Stop Hypertension) diet, and physical activity. Blinded staff collected data at baseline, 6 months, and 12 months. RESULTS Participants (men, N=56; women, N=144; mean age=47.2 years [SD=10.6]) were randomly assigned to usual care (N=96) or a 6-month weekly group intervention plus six monthly maintenance sessions (N=104). A total of 181 participants (90.5%) completed 6-month assessments, and 170 (85%) completed 12-month assessments, without differential attrition. Participants attended 14.5 of 24 sessions over 6 months. Intent-to-treat analyses revealed that intervention participants lost 4.4 kg more than control participants from baseline to 6 months (95% CI=-6.96 kg to -1.78 kg) and 2.6 kg more than control participants from baseline to 12 months (95% CI=-5.14 kg to -0.07 kg). At 12 months, fasting glucose levels in the control group had increased from 106.0 mg/dL to 109.5 mg/dL and decreased in the intervention group from 106.3 mg/dL to 100.4 mg/dL. No serious adverse events were study-related; medical hospitalizations were reduced in the intervention group (6.7%) compared with the control group (18.8%). CONCLUSIONS Individuals taking antipsychotic medications can lose weight and improve fasting glucose levels. Increasing reach of the intervention is an important future step.

A Primary Care–Based, Multicomponent Lifestyle Intervention for Overweight Adolescent Females

BACKGROUND AND OBJECTIVE: Most clinic-based weight control treatments for youth have been designed for preadolescent children by using family-based care. However, as adolescents become more autonomous and less motivated by parental influence, this strategy may be less appropriate. This study evaluated a primary care–based, multicomponent lifestyle intervention specifically tailored for overweight adolescent females. METHODS: Adolescent girls (N = 208) 12 to 17 years of age (mean ± SD: 14.1 ± 1.4 years), with a mean ± SD BMI percentile of 97.09 ± 2.27, were assigned randomly to the intervention or usual care control group. The gender and developmentally tailored intervention included a focus on adoptable healthy lifestyle behaviors and was reinforced by ongoing feedback from the teen’s primary care physician. Of those randomized, 195 (94%) completed the 6-month posttreatment assessment, and 173 (83%) completed the 12-month follow-up. The primary outcome was reduction in BMI z score. RESULTS: The decrease in BMI z score over time was significantly greater for intervention participants compared with usual care participants (−0.15 in BMI z score among intervention participants compared with −0.08 among usual care participants; P = .012). The 2 groups did not differ in secondary metabolic or psychosocial outcomes. Compared with usual care, intervention participants reported less reduction in frequency of family meals and less fast-food intake. CONCLUSIONS: A 5-month, medium-intensity, primary care–based, multicomponent behavioral intervention was associated with significant and sustained decreases in BMI z scores among obese adolescent girls compared with those receiving usual care.

Recovery From Serious Mental Illness: Trajectories, Characteristics, and the Role of Mental Health Care

OBJECTIVE The objective was to identify trajectories of recovery from serious mental illnesses. METHODS A total of 177 members (92 women; 85 men) of a not-for-profit integrated health plan participated in a two-year mixed-methods study of recovery (STARS, the Study of Transitions and Recovery Strategies). Diagnoses included schizophrenia, schizoaffective disorder, bipolar disorder, and affective psychosis. Data sources included self-reported standardized measures, interviewer ratings, qualitative interviews, and health plan data. Recovery was conceptualized as a latent construct, and factor analyses and factor scores were used to calculate recovery trajectories. Individuals with similar trajectories were identified through cluster analyses. RESULTS Four trajectories were identified-two stable (high and low levels of recovery) and two fluctuating (higher and lower). Few demographic or diagnostic factors differentiated clusters at baseline. Discriminant analyses for trajectories found differences in psychiatric symptoms, physical health, satisfaction with mental health clinicians, resources and strains, satisfaction with medications, and mental health service use. Those with higher scores on recovery factors had fewer psychiatric symptoms, better physical health, greater satisfaction with mental health clinicians, fewer strains and greater resources, less service use, better quality of care, and greater satisfaction with medication. Consistent predictors of trajectories included psychiatric symptoms, physical health, resources and strains, and use of psychiatric medications. CONCLUSIONS Having access to good-quality mental health care-defined as including satisfying relationships with clinicians, responsiveness to needs, satisfaction with psychiatric medications, receipt of services at needed levels, support in managing deficits in resources and strains, and care for general medical conditions-may facilitate recovery. Providing such care may improve recovery trajectories.

Dual Recovery Among People With Serious Mental Illnesses and Substance Problems: A Qualitative Analysis

Objective: Individuals with serious mental illnesses are more likely to have substance-related problems than those without mental health problems. They also face more difficult recovery trajectories as they cope with dual disorders. Nevertheless, little is known about individuals’ perspectives regarding their dual recovery experiences. Methods: This qualitative analysis was conducted as part of an exploratory mixed-methods study of mental health recovery. Members of Kaiser Permanente Northwest (a group-model, not-for-profit, integrated health plan) who had serious mental illness diagnoses were interviewed four times over two years about factors affecting their mental health recovery. Interviews were recorded, transcribed, and coded with inductively derived codes. Themes were identified by reviewing text coded “alcohol or other drugs.” Results: Participants (N = 177) had diagnosed schizophrenia/schizoaffective disorder (n = 75, 42%), bipolar I/II disorder (n = 84, 48%), or affective psychosis (n = 18, 10%). At baseline, 63% (n = 112) spontaneously described addressing substance use as part of their mental health recovery. When asked at follow-up, 97% (n = 171) provided codeable answers about substances and mental health. We identified differing pathways to recovery, including through formal treatment, self-help groups or peer support, “natural” recovery (without the help of others), and continued but controlled use of alcohol. We found three overarching themes in participants’ experiences of recovering from serious mental illnesses and substance-related problems: Learning about the effects of alcohol and drugs provided motivation and a foundation for sobriety; achieving sobriety helped people to initiate their mental health recovery processes; and achieving and maintaining sobriety built self-efficacy, self-confidence, improved functioning and a sense of personal growth. Non-judgmental support from clinicians adopting chronic disease approaches also facilitated recovery. Conclusions: Irrespective of how people achieved sobriety, quitting or severely limiting use of substances was important to initiating and continuing mental health recovery processes. Substance abuse treatment approaches that are flexible, reduce barriers to engagement, support learning about effects of substances on mental health and quality of life, and adopt a chronic disease model of addiction may increase engagement and success. Peer-based support like Alcoholics or Narcotics Anonymous can be helpful for people with serious mental illnesses, particularly when programs accept use of mental health medications.

Recruitment for a guided self-help binge eating trial: Potential lessons for implementing programs in everyday practice settings

OBJECTIVE To explore effects of various recruitment strategies on randomized clinical trial (RCT)-entry characteristics for patients with eating disorders within an everyday health-plan practice setting. METHODS Randomly selected women, aged 25-50, in a Pacific Northwest HMO were invited to complete a self-report binge-eating screener for two treatment trials. We publicized the trials within the health plan to allow self-referral. Here, we report differences on eating-disorder status by mode and nature of recruitment (online, mail, self-referred) and assessment (comprehensive versus abbreviated) and on possible differences in enrollee characteristics between those recruited by strategy (self-referred versus study-outreach efforts). RESULTS Few differences emerged among those recruited through outreach who responded by different modalities (internet versus mail), early-versus-late responders, and those enrolling under more comprehensive or abbreviated assessment. Self-referred were more likely to meet binge-eating thresholds and reported higher average BMI than those recruited by outreach and responding by mail; however, in most respects the groups were more similar than anticipated. Fewer than 1% of those initially contacted through outreach enrolled. CONCLUSIONS Aggressive outreach and screening is likely not feasible for broader dissemination in everyday practice settings and recruits individuals with more similar demographic and clinical characteristics to those recruited through more abbreviated and realistic screening procedures than anticipated.

Responding to Pediatric Providers’ Perceived Barriers to Adolescent Weight Management

Primary care clinics are an ideal setting for early identification and possibly treatment of adolescent obesity. However, despite practice recommendations promoting preventive screening and monitoring of obesity, implementation has been modest. In this study, we interviewed providers to determine barriers to managing pediatric obesity, perceived skill in obesity interventions, and interest in additional training. The sensitivity of weight-related discussions and time were the 2 most significant barriers reported. We designed a brief training program, implemented it within a larger randomized controlled trial, and surveyed providers regarding its utility. The training was satisfactory to attendees and led to reported changes in practice patterns. Providers who received more complete training reported greater ease working with overweight teens and greater confidence that they could motivate teen patients to make healthy lifestyle changes compared with those who received less training. A fairly modest training intervention could improve patient care in the primary care setting.

The impact of adverse child and adult experiences on recovery from serious mental illness.

OBJECTIVE The purpose of this study was to compare effects of adverse childhood experiences and adverse adult experiences on recovery from serious mental illnesses. METHODS As part of a mixed-methods study of recovery from serious mental illnesses, we interviewed and administered questionnaires to 177 members of a not-for-profit health plan over a 2-year period. Participants had a diagnosis of bipolar disorder, affective psychosis, schizophrenia, or schizoaffective disorder. Data for analyses came from standardized self-reported measures; outcomes included recovery, functioning, quality of life, and psychiatric symptoms. Adverse events in childhood and adulthood were evaluated as predictors. RESULTS Child and adult exposures to adverse experiences were high, at 91% and 82%, respectively. Cumulative lifetime exposure to adverse experiences (childhood plus adult experiences) was 94%. In linear regression analyses, adverse adult experiences were more important predictors of outcomes than adverse childhood experiences. Adult experiences were associated with lower recovery scores, quality of life, mental and physical functioning and social functioning and greater psychiatric symptoms. Emotional neglect in adulthood was associated with lower recovery scores. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Early and repeated exposure to adverse events was common in this sample of people with serious mental illnesses. Adverse adult experiences were stronger predictors of worse functioning and lower recovery levels than were childhood experiences. Focusing clinical attention on adult experiences of adverse or traumatic events may result in greater benefit than focusing on childhood experiences alone.

The Recovery Group Project: Development of an Intervention Led Jointly by Peer and Professional Counselors

OBJECTIVE The objective of this study was to develop and evaluate a low-cost, strengths-based group intervention led jointly by peer counselors and professional counselors to foster recovery among adults with serious mental illnesses. METHODS Cohort 1 included development of materials and a feasibility pilot, with participants recruited from community mental health centers (CMHCs). Cohorts 2 and 3 included a small randomized controlled trial with participants recruited from members of a not-for-profit, integrated health plan. Cohorts 4 and 5 involved evaluation of the most appropriate length for the intervention with a pre-post design that allowed intervention length to vary between 12 and 18 sessions; participants and peer leaders were recruited from two CMHCs (N=82). RESULTS Participants were very satisfied with the recovery-focused group intervention, preferred a greater number of weekly sessions (17 or 18 sessions), and reported improved outcomes across multiple domains. CONCLUSIONS Using peer-developed materials and a combination of peer and professional counselors as group leaders is feasible to offer and valuable to participants. Outcomes measures suggest that the intervention has potential to facilitate recovery in multiple domains.

Improving lifestyle interventions for people with serious mental illnesses: Qualitative results from the STRIDE study.

OBJECTIVE Individuals with serious mental illnesses are disproportionately affected by overweight and obesity. Understanding the factors that facilitate or hinder lifestyle change in this population could lead to better interventions and improved health outcomes. METHODS A subset of intervention and usual-care participants (n = 84) in the STRIDE randomized trial were interviewed at 3, 9, and 18 months, yielding 101 interviews (some were interviewed more than once). Participants had a mean age of 48.1 (SD = 10.1); 64% were female. Participants had diagnoses of schizophrenia or schizoaffective disorder (41%), bipolar disorder (20%), affective psychoses (37%), or PTSD (2%). Interviews were transcribed verbatim, coded using Atlas.ti, and analyzed for common themes. RESULTS Barriers to behavior change were similar to those described for the general population, including lack of support from significant others, the lure of unhealthy foods, and poor weather impeding exercise. Additional challenges included the effects of psychiatric symptoms, or consequences of symptoms (i.e., social isolation), on ability to make and sustain lifestyle changes. We found a strong preference for ongoing, group-based support to foster a sense of accountability which motivated and helped to sustain behavior changes. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Individuals with serious mental illnesses encounter many of the same barriers to weight loss seen in the general population, but they may be more vulnerable to additional obstacles. Lifestyle change interventions for this population should help participants develop the ability to iteratively cope with fluctuating mood and subsequent changes in motivation to eat healthfully and exercise regularly.

Understanding opioid overdose characteristics involving prescription and illicit opioids: A mixed methods analysis

BACKGROUND Opioid abuse and misuse are significant public health issues. The CDC estimated 72% of pharmaceutical-related overdose deaths in the US in 2012 involved opioids. While studies of opioid overdoses have identified sociodemographic characteristics, agents used, administration routes, and medication sources associated with overdoses, we know less about the context and life circumstances of the people who experience these events. METHODS We analyzed interviews (n=87) with survivors of opioid overdoses or family members of decedents. Individuals experiencing overdoses were members of a large integrated health system. Using ICD codes for opioid overdoses and poisonings, we identified participants from five purposefully derived pools of health-plan members who had: 1) prescriptions for OxyContin(®) or single-ingredient sustained-release oxycodone, 2) oxycodone single-ingredient immediate release, 3) other long-acting opioids, 4) other short-acting opioids, or 5) no active opioid prescriptions. RESULTS Individuals who experienced opioid overdoses abused and misused multiple medications/drugs; experienced dose-related miscommunications or medication-taking errors; had mental health and/or substance use conditions; reported chronic pain; or had unstable resources or family/social support. Many had combinations of these risks. Most events involved polysubstance use, often including benzodiazepines. Accidental overdoses were commonly the result of abuse or misuse, some in response to inadequately treated chronic pain or, less commonly, medication-related mistakes. Suicide attempts were frequently triggered by consecutive negative life events. CONCLUSIONS To identify people at greater risk of opioid overdose, efforts should focus on screening for prescribed and illicit polysubstance use, impaired cognition, and changes in life circumstances, psychosocial risks/supports, and pain control.