Joelle C. Ferron

Course of Smoking and Quit Attempts Among Clients With Co-occurring Severe Mental Illness and Substance Use Disorders

OBJECTIVE Approximately three-quarters of people with severe mental illnesses smoke cigarettes, and the rate is even higher among those with co-occurring substance use disorders. This longitudinal study explored patterns of cigarette use and cessation attempts among mental health clients with co-occurring disorders. METHODS Clients participating in a longitudinal study of co-occurring disorders (N=174) were assessed yearly over 11 years for smoking and smoking cessation behaviors, psychiatric symptoms, and other substance use, as well as social, occupational, and other characteristics. Generalized linear mixed-effects models were used to examine smoking cessation outcomes. RESULTS Eighty-nine percent of participants were current smokers at baseline. Seventy-five percent of participants tried to quit at least once over the 11 years of the study, although none received nicotine replacement therapy or bupropion. Only 17% were not smoking at the 11-year follow-up. The presence of a chronic general medical condition predicted a longer duration of not smoking in the past year. Being male and having a high school education or higher were associated with more attempts to quit smoking, as were higher scores on the activation subscale of the Brief Psychiatric Rating Scale, more social contact with non-substance-using friends, and more daily activities. CONCLUSIONS Although many clients with co-occurring serious mental illness and substance use disorders tried to quit each year, few achieved sustained abstinence and none used evidence-based interventions (nicotine replacement therapy or bupropion). Treatment providers need to administer evidence-based interventions to help people quit successfully.

Barriers to exercise among people with severe mental illnesses.

OBJECTIVE Lack of exercise is a risk factor for various negative health outcomes. Some research suggests people with severe mental illnesses are less likely to engage in exercise than the general population. The purpose of this report is to document, analyze, and understand self-identified barriers to exercise that may be especially specific to people living with serious mental illnesses. Producing such knowledge can assist in the development of effective interventions. METHODS Thirty-one people with serious mental illnesses participated in in-depth one-on-one interviews to discuss health behaviors in general and exercise more specifically. The authors then engaged in thematic analysis of data to identify common barriers to exercise. RESULTS Participants reported psychiatric medication side effects, symptoms related to SMI, and physical comorbidities as barriers. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Clinicians should incorporate physical health goals as a part of treatment planning. Agencies also can play a role in increasing exercise through the implementation of programs.

An Electronic Decision Support System to Motivate People With Severe Mental Illnesses to Quit Smoking

OBJECTIVE Rates of cigarette smoking are high among people with severe mental illnesses compared with the general population (45%-90% versus 20%). The authors developed a Web-based computer decision support system that is tailored for use by people with cognitive deficits and is designed to stimulate motivation to quit smoking by using evidence-based treatment. METHODS This initial study used a quasi-experimental design to test the decision support system among a convenience sample of 41 smokers with severe mental illnesses. Researchers interviewed participants at baseline and two months later to assess for behaviors indicative of motivation to quit smoking. A negative binomial regression modeled the outcome and controlled for baseline group differences. RESULTS Participants who used the decision support system were significantly more likely to show any behavioral motivation to quit smoking (such as meet with a clinician to discuss cessation, initiate cessation treatment, or otherwise attempt to quit) (67% versus 35%; χ(2)=4.11, df=41, p=.04). Further, using the decision support system increased by a factor of 2.97, or about 300%, the expected number of ways that a participant showed motivation. CONCLUSIONS The encouraging results of this pilot study indicate that electronic decision supports may facilitate motivation to quit smoking and use of cessation treatment among people with severe mental illnesses.

Do smoking cessation websites meet the needs of smokers with severe mental illnesses

Many people learn about smoking cessation through information on the Internet. Whether people with severe mental illnesses, who have very high rates of smoking, are able to use currently available websites about smoking cessation is unknown. The study reported here assessed whether four smoking cessation websites met usability guidelines and whether they were usable by smokers with severe mental illnesses. Four websites that appeared first on a Google search and represented an array of sponsors were selected. First, five experts rated the websites on adequacy of content in six areas and usability in 20 areas. Second, 16 smokers with severe mental illnesses performed two search tasks on the websites with researchers observing their searches and interviewing them regarding usability. One of the websites was rated by experts as acceptable for content and usability, but most of the participants were unable to navigate this website. The only website that was navigable received poor content ratings by experts. Four easily accessible websites did not meet the needs of smokers with severe mental illnesses. Although the Internet is a promising strategy to provide education about treatments, website developers must attend to the needs and capacities of multiple user groups.

Developing a quit smoking website that is usable by people with severe mental illnesses.

OBJECTIVE Evidence-based treatments may be delivered in computerized, web-based formats. This strategy can deliver the intervention consistently with minimal treatment provider time and cost. However, standard web sites may not be usable by people with severe mental illnesses who may experience cognitive deficits and low computer experience. This manuscript reports on the iterative development and usability testing of a website designed to educate and motivate adults with severe mental illnesses to engage in smoking cessation activities. METHODS Three phases of semi-structured interviews were performed with participants after they used the program and combined with information from screen-recorded usability data. T-tests compared the differences between uses of the first computer program version and a later version. RESULTS Iteratively conducted usability tests demonstrated an increased ease of use from the first to the last version of the website through significant improvement in the percentage of unproductive clicking along with fewer questions asked about how to use the program. The improvement in use of the website resulted from changes such as: integrating a mouse tutorial, increasing font sizes, and increasing button sizes. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The website usability recommendations provide some guidelines for interventionists developing web tools for people who experience serious psychiatric disabilities. In general, insights from the study highlight the need for thoughtful design and usability testing when creating a website for people with severe mental illness.

Healthy eating in persons with serious mental illnesses: understanding and barriers.

OBJECTIVE To explore the understanding of a healthy diet and the barriers to healthy eating in persons with serious mental illnesses. METHODS In-depth semi-structured qualitative interviews about health behaviors were conducted in 31 individuals with serious mental illnesses. Participants were recruited from a mental health center in Chicago, Illinois, and ranged in age from 30 to 61 years old. RESULTS Most participants described healthy eating as consuming fruits and vegetables, using low fat cooking methods, and limiting sweets, sodas, fast food, and/or junk food. Internal barriers to nutritional change included negative perceptions of healthy eating, the decreased taste and satiation of healthy foods, difficulty changing familiar eating habits, eating for comfort, and the prioritization of mental health. External barriers were the reduced availability and inconvenience of healthy foods, social pressures, and psychiatric medication side effects. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE This study revealed several modifiable barriers to healthy eating. Interventions that addressed these could aid in improving the diet and lowering the risk of cardiovascular disease in this population. Recommendations are to provide healthy eating education that is individualized, emphasizes the health consequences of poor eating, and provides opportunities to prepare and taste healthy foods. Family and friends should be included in all educational efforts. At community mental health centers and group homes, only healthy foods should be offered. Lastly, practitioners should encourage eating a healthy diet, inquire about eating in response to emotions, and explore the impact of psychiatric medications on eating behaviors.

EFFECTIVELY IMPLEMENTING PSYCHIATRIC ADVANCE DIRECTIVES TO PROMOTE SELF-DETERMINATION OF TREATMENT AMONG PEOPLE WITH MENTAL ILLNESS.

Statutes on psychiatric advance directives (PADs) allow competent individuals to document instructions for future mental health treatment in the event of an incapacitating crisis. PADs are aimed at promoting a stronger sense of patient self-determination, considered a central tenet of psychosocial rehabilitation and recovery; however, it is unknown what factors (if any) lead psychiatric patients with PADs to experience this benefit long term. The current study involves examination of 1 year effects on perceived treatment self-determination among 125 people with mental disorders who completed PADs via a 1-on-1 facilitated PAD intervention. Descriptive analyses showed participants documented medically relevant information that would assist doctors in a crisis and participants reported a high level of satisfaction with the facilitated PAD intervention. Multivariate analyses demonstrated that increased sense of autonomy at 1 year was predicted by race, understanding PADs, and verbal memory. Results provide useful guidance for administrators and clinicians, suggesting that PADs show promise in helping empower people with mental illness, especially African-American clients. Further, findings indicate that optimal implementation of PADs will be achieved when facilitated intervention assists people with mental illness to better understand what PADs are and to remember they have a PAD at the time they are experiencing a psychiatric crisis.

A review of research on smoking cessation interventions for adults with schizophrenia spectrum disorders

Background: Recent studies show that 75–85% of people with schizophrenia spectrum disorders in the United States smoke cigarettes, compared with 23% of the general population. Moreover, people with these illnesses on average have life expectancies 25 years lower than the general population, and smoking is a contributor. Aims: To review intervention research and evaluate the methods and clinical findings associated with attempts to eliminate, or reduce, smoking in people with schizophrenia spectrum disorders. Methods: PubMed and PsychInfo were searched from early 1990 through 2007 with select keywords. Thirteen treatment studies addressing smoking cessation interventions in people with schizophrenia spectrum disorders or severe mental illness were identified. Results: Nicotine replacement therapy, psychosocial interventions, and bupropion have been studied. Overall, treatment compliance was moderate, quit rates were low, and relapse to smoking was high. Modest evidence supports the efficacy of bupropion an...

Smoking and Quitting Beliefs, Attitudes, and Behaviors Among Smokers With Severe Mental Illness From Three Race/Ethnicity Groups

Objective: Most people with severe mental illness do not use evidence-based smoking cessation treatments. Ethnic and racial identification among people with severe mental illness may add complexity to their participation in smoking cessation interventions. The purpose of this qualitative study was to explore smoking and smoking cessation attitudes, beliefs, and behaviors among three race/ethnicity groups of smokers with severe mental illness. Methods: Researchers inquired into day-to-day smoking activities and quit attempts in six focus groups with 36 randomly selected African American, Latino, and White smokers with severe mental illness. Transcripts were reviewed to identify prominent themes, and first-person perspectives were selected to provide a description of smoking norms, motivation to quit, and sources of quit information. Results: Participants of all three race/ethnicity groups reported that multiple facets of their lives contributed to smoking initiation and maintenance, including the belief that smoking was a key strategy for coping with mental illness symptoms, reinforcement within institutional living situations and treatment environments, and lack of resources to obtain effective treatments. African Americans and Latinos with severe mental illnesses tended to seek advice about smoking from a broad social network of family and friends and expressed misinformation about and mistrust of medical cessation treatments. Conclusions: Smoking cessation policies and interventions for smokers with severe mental illness should be tailored to address the smoking culture in mental health settings and the variation in health-seeking attitudes and behaviors across race/ethnicity groups.

A qualitative study of how individuals with severe mental illness assess smoking risks

Background: This qualitative paper describes perceptions of smoking risk and ways of thinking about risk for 31 persons with a Severe Mental Illness (SMI). Research has shown that many people with SMI want to quit smoking, and, like many other disadvantaged groups, make many quit attempts. Aim: The authors undertook a qualitative study to explore views and experiences about smoking and quitting, within a general context of what it means to them to live a healthy lifestyle. Method: A purposive sample of former smokers, current smokers, and individuals who had never smoked was chosen to participate in a semi-structured interview. Questions targeted various lifestyle domains, narrowing to focus more specifically on smoking habits, attempts to quit, and thoughts about the future in relation to health and smoking. Techniques of grounded theory were used to categorize and interpret themes. Results: The results indicate that many current smokers interpret and frame perceptions of health risks from smoking in rel...