Long-Term Outcomes of a Randomized Trial of Integrated Skills Training and Preventive Healthcare for Older Adults with Serious Mental Illness

Abstract

Objectives This report describes one, two, and three-year outcomes of a combined psychosocial skills training and preventive health care intervention (Helping Older People Experience Success – HOPES) for older persons with serious mental illness. Design A randomized controlled trial compared HOPES to treatment as usual (TAU) for n=183 older adults (age≥50) with serious mental illness (mean age=60.2; 28% schizophrenia, 28% schizoaffective disorder, 20% bipolar disorder, 24% major depression). Setting Two community mental health centers in Boston, MA and one in Nashua, NH. Intervention Twelve months of weekly skills training classes, twice-monthly community practice trips, and monthly nurse preventive health care visits, followed by a 1-year maintenance phase of monthly sessions. Measurements Blinded evaluations of functioning, symptoms, and service use were conducted at baseline, one-year (end of the intensive phase), two-year (end of the maintenance phase), and three-year (12 months after the intervention) follow-up. Results HOPES compared to TAU was associated with improved community living skills and functioning, greater self-efficacy, lower overall psychiatric and negative symptoms, greater acquisition of preventive health care (more frequent eye exams, visual acuity, hearing tests, mammograms, and PAP smears) and nearly twice the rate of completed advance directives. No differences were found for medical severity, number of medical conditions, subjective health status, or acute service use at 3-year follow-up. Conclusions Skills training and nurse facilitated preventive health care for older adults with serious mental illness was associated with sustained long-term improvement in functioning, symptoms, self-efficacy, preventive health care screening, and advance care planning.

Activating older adults with serious mental illness for collaborative primary care visits.

“…The final study group consisted of 17 patients and 6 participating providers. We achieved a completion rate of 74%, which is consistent with a prior study of an intervention similarly targeting older adults with serious mental illness and medical comorbidity (Bartels, Pratt, Mueser, Wolfe, et al, in press). …”

“…We selected persons age 50 and older due to the common presence of medical comorbidity in middle-aged and older adults with serious mental illness and the need for integrated health care targeting persons at high risk for early mortality and premature nursing home placement (Aschbrenner, Cai, Grabowski, Bartels, & Mor, 2011; Bartels, 2004; Bartels & Naslund, 2013; Bartels, Pratt, Mueser, Forester, et al, in press). Primary care providers were approached to participate in the pilot program including internists, family physicians, and nurse practitioners.…”

One size doesn’t fit all: A trial of individually tailored skills training.

“…First, there was no comparison group and the sample size was modest, suggesting that improvements in functioning could reflect “regression to the mean” or the natural course of SMI. However, participants were older adults with SMI whose eligibility for services required longstanding impairment in social and community functioning, which tend to be stable over time and resistant to change in the absence of focused rehabilitation (Mueser et al, 2010, Bartels et al, 2013). Second, it cannot be determined whether participation in the skills training or non-specific treatment factors (e.g., attention) contributed to the observed gains.…”

“…Given the importance of strengthening social networks in older people with SMI to improve management of chronic medical conditions and reduce premature nursing home placement, particular emphasis was placed on reconnecting and improving communication with family and friends. The effectiveness of HOPES was demonstrated in a randomized controlled trial with 183 people with SMI (mean age 60.1 years) in which participants assigned to HOPES improved significantly in social and independent living skills, community functioning, social functioning, negative symptoms, and receipt of preventive health care compared to those who received usual care at 12 and 24 months (Mueser et al, 2010), with effects maintained over 3 years (Bartels et al, 2013). …”

Characteristics and Service Use of Older Adults with Schizoaffective Disorder Versus Older Adults with Schizophrenia and Bipolar Disorder

“…20–23 The study consisted of a 12-month social skills training program conducted at three mental health centers in New Hampshire and Massachusetts. All measurements presented in this study were conducted at baseline, prior to treatment randomization.…”