Randomised control trial of the effectiveness of an integrated psychosocial health promotion intervention aimed at improving health and reducing substance use in established psychosis (IMPaCT)

Gaughran, Fiona; Ståhl, Daniel; Ismail, Khalida; Greenwood, Kathryn; Atakan, Zerrin; Gardner-Sood, Poonam; Stubbs, Brendon; Hopkins, David; Patel, Anita; Lally, John; Lowe, Philippa; Arbuthnot, Maurice; Orr, Diana; Corlett, Sarah; Eberhard, Jonas; David, Anthony; Murray, Robin M.; Smith, Shubuladè

doi:10.1186/s12888-017-1571-0

“…Most evidence is restricted to adults with SMI and may underestimate the prevalence in other ages and diagnoses. For instance, a recent meta-analysis of 3,029 adolescents with a range of psychiatric diagnoses reported a 15% lifetime prevalence of sexually transmitted illnesses (95% CI = 3-50%) and that 40% engaged in risky behaviour at their last encounter (95 CI = 23-78%) 100 . Furthermore, these risky behaviours interacted with other lifestyle factors with recent alcohol use increasing the likelihood of unprotected sex (OR = 1.66, 95% CI = 1.09, 2.52) 100 .…”

Section: Health Behaviours and Mental Illness In Low And Middle Incommentioning

confidence: 99%

The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness

Firth

¹

,

Siddiqi

²

,

Koyanagi

³

et al. 2019

The Lancet Psychiatry

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Executive SummaryThe poor physical health of people with mental illness is a multi-faceted, transdiagnostic, and global problem. Physical health disparities are observed across the entire spectrum of mental illnesses, in low, middle-and high-income countries. This stems from both a heightened risk of physical diseases in people with mental illness, along with their reduced access to adequate healthcare. The high rates of physical comorbidities (and typically-poor clinical management of this) drastically reduces life expectancy, and also increases the personal, social and economic burden of illness across the lifespan.This Commission has brought together an international team of researchers, clinicians, and key stakeholders from various backgrounds and professionally / personally-relevant experience, in order to summarize advances in understanding on this topic, and present clear directions for health promotion, clinical care and future research. The breadth and multifactorial nature of physical health disparities across the range of mental health diagnoses poses an almost limitless number of potential considerations. Therefore, rather than attempting to cover all of the different possible combinations of physical-mental comorbidities individually, the aim of this Commission was to: (i) establish highlypertinent aspects of physical health-related morbidity and mortality which apply transdiagnostically, (ii) highlight the common modifiable factors driving these disparities, (iii) present actions and initiatives for health policy and clinical services to address these issues, and (iv) identify promising areas for future research towards discovering novel solutions. This was addressed across 5 different Parts of the Commission: Parts 1 and 2 determined the scope, priorities and key targets for physical health improvement across multiple mental illnesses. Parts 3, 4 and 5 discussed emerging strategies and produced recommendations for improving physical health outcomes in people with mental illness. Leaders and contributors for each Part are shown in the Appendix (pg.1) . Part 1: 'Its more than premature mortality'Part 1 identified almost 100 systematic reviews/meta-analyses examining the prevalence of physical comorbidities in mental illness. Around 70% of the meta-research focused on cardiometabolic diseases; consistently reporting that mental illnesses were associated with 1.4-to 2-fold increased risk for obesity, diabetes and cardiovascular diseases compared to the general population. Although mostly studied in 'severe mental illness' ('SMI', and particularly psychotic disorders), the prevalence of cardiometabolic diseases was similarly elevated across a broad range of other diagnoses, including substance use disorders (SUDs), and 'common mental disorders' ('CMDs', such as depression and anxiety). Part 2: Key modifiable factors in health behaviours and health servicesPart 2 built on the findings of Part 1 with a hierarchal evidence synthesis of modifiable risk factors for physical diseases in mental illness. The bu...

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“…IMPaCT randomised controlled trial). Thi s section provides a summary of work published in Gaughran et al 175,176 and Heslin et al 177 Parts of this text have been reproduced from Gaughran et al 176 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.…”

Section: Discussionmentioning

confidence: 99%

“…We failed to identify differences in cardiometabolic risk in people with established psychosis who were prescribed antipsychotic medication of different types or in emergent cardiometabolic risk in FEP patients. 176 Despite the side effects, antipsychotic medication is important in optimising one's mental health so that one is well enough to take charge of one's physical health. In a large study of 66,881 patients with schizophrenia over a 10-year period, long-term treatment with antipsychotic medication was associated with lower mortality than receiving no antipsychotic medication.…”

Section: Discussionmentioning

confidence: 99%

“…IMPaCT therapy showed no significant effect on the physical or mental health components of the SF-36 scores compared with TAU at 12 or 15 months. 176 Sensitivity analyses, including missing data analyses, did not alter any conclusion 176 No effect was observed for cardiovascular risk indicators, except for HDL cholesterol, which showed greater improvement following IMPaCT therapy than following TAU (treatment effect 0.09, 95% CI 0.007 to 0.16; p = 0.034). The 22% of patients who received > 180 minutes of IMPaCT therapy in addition to usual care achieved a greater reduction in waist circumference (-4.2 cm, 95% CI -7.2 to -1.2 cm; p = 0.006) than did control patients.…”

Section: Key Findingsmentioning

confidence: 93%

“…The search for effective evidence-based approaches to reduce the excess cardiometabolic risk experienced by people with SMI is proving a challenge for many research groups, following the negative results in all recent large European RCTs on the topic, namely IMPaCT, STEPWISE, PRIMROSE, HIP and CHANGE. 176,186,[220][221][222] Although the interventions in all these studies were intuitively sensible and it was reasonable to believe that they should have been helpful, researchers are struggling to demonstrate evidence of additional effectiveness in the context of structured health-care systems. It may be that the effectiveness of more individualised long-term approaches to reverse cardiometabolic risk in this population needs to be evaluated, bearing in mind that reversing established cardiometabolic risk in the general population is also a challenge.…”

Section: Recommendations For Researchmentioning

confidence: 99%

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A health promotion intervention to improve lifestyle choices and health outcomes in people with psychosis: a research programme including the IMPaCT RCT

Gaughran

¹

,

Ståhl

²

,

Patel

³

et al. 2020

Programme Grants Appl Res

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Background People with psychotic disorders have reduced life expectancy largely because of physical health problems, especially cardiovascular disease, that are complicated by the use of tobacco and cannabis. Objectives We set out to (1) chart lifestyle and substance use choices and the emergence of cardiometabolic risk from the earliest presentation with psychosis, (2) develop a pragmatic health promotion intervention integrated within the clinical teams to improve the lifestyle choices and health outcomes of people with psychosis and (3) evaluate the clinical effectiveness and cost-effectiveness of that health promotion intervention. Design We performed a longitudinal cohort study of people presenting with their first episode of psychosis in three mental health trusts and followed up participants for 1 year [work package 1, physical health and substance use measures in first episode of psychosis (PUMP)]. We used an iterative Delphi methodology to develop and refine a modular health promotion intervention, improving physical health and reducing substance use in psychosis (IMPaCT) therapy, which was to be delivered by the patient’s usual care co-ordinator and used motivational interviewing techniques and cognitive–behavioural therapy to improve health choices of people with psychosis (work package 2). We then conducted a multicentre, two-arm, parallel-cluster, randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of using the intervention with people with established psychosis (work package 3: IMPaCT randomised controlled trial) in five UK mental health trusts. The work took place between 2008 and 2014. Participants All people aged between 16 and 65 years within 6 months of their first presentation with a non-organic psychosis and who were proficient in English were eligible for inclusion in the PUMP study. Participants in the work package 2 training development were staff selected from a range of settings, working with psychosis. Participants in the phase 3 Delphi consensus and manual development comprised three expert groups of (1) therapists/researchers recruited from the local and national community, (2) clinicians and (3) service users, each of whom took part in two iterative review and feedback sessions. For work package 3, IMPaCT randomised controlled trial, care co-ordinators in participating community mental health teams who were permanently employed and had a minimum of four eligible patients (i.e. aged between 18 and 65 years with a diagnosis of a psychotic disorder) on their caseload were eligible to participate. In studies 1 and 3, patient participants were ineligible if they were pregnant or had a major illness that would have had an impact on their metabolic status or if they had a significant learning disability. All participants were included in the study only after giving written confirmed consent. Main outcome measures Cardiometabolic risk markers, including rates of obesity and central obesity, and levels of glycated haemoglobin (HbA1c) and lipids, were the main outcomes in work package 1 (PUMP), with descriptive data presented on substance use. Our primary outcome measure for the IMPaCT randomised controlled trial was the physical or mental health component Short Form questionnaire-36 items quality-of-life scores at 12 months. Results Obesity rates rose from 18% at first presentation with psychosis to 24% by 1 year, but cardiometabolic risk was not associated with baseline lifestyle and substance use choices. Patterns of increase in the levels of HbA1c over the year following first presentation showed variation by ethnic group. We recruited 104 care co-ordinators, of whom 52 (with 213 patients) were randomised to deliver IMPaCT therapy and 52 (with 193 patients) were randomised to deliver treatment as usual, in keeping with our power calculations. Of these 406 participants with established psychosis, 318 (78%) and 301 (74%) participants, respectively, attended the 12- and 15-month follow-ups. We found no significant effect of IMPaCT therapy compared with treatment as usual on the physical or mental health component Short Form questionnaire-36 items scores at either time point in an intention-to-treat analysis [physical health score (‘d’) –0.17 at 12 months and –0.09 at 15 months; mental health score (‘d’) 0.03 at 12 months and –0.05 at 15 months] or on costs. Nor did we find an effect on other cardiovascular risk indicators, including diabetes, except in the case of high-density lipoprotein cholesterol, which showed a trend for greater benefit with IMPaCT therapy than with treatment as usual (treatment effect 0.085, 95% confidence interval 0.007 to 0.16; p = 0.034). Limitations Follow-up in work package 1 was challenging, with 127 out of 293 participants attending; however, there was no difference in cardiometabolic measures or demographic factors at baseline between those who attended for follow-up and those who did not. In work package 3, the IMPaCT randomised controlled trial, care co-ordinators struggled to provide additional time to their patients that was devoted to the health promotion intervention on top of their usual clinical care contact with them. Conclusions Cardiometabolic risk is prominent even soon after first presentation with psychosis and increases over time. Lifestyle choices and substance use habits at first presentation do not predict those who will be most cardiometabolically compromised 1 year later. Training and supervising care co-ordinators to deliver a health promotion intervention to their own patients on top of routine care is not effective in the NHS for improving quality of life or reducing cardiometabolic risk. Future work Further work is needed to develop and evaluate effective, cost-effective and affordable ways of preventing the emergence of and reversing existing cardiometabolic risk indicators in people with psychosis. Trial registration Current Controlled Trials ISRCTN58667926. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

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Psychosocial interventions for people with both severe mental illness and substance misuse

Hunt

¹

,

Siegfried

²

,

Morley

³

et al. 2019

Cochrane Database of Systematic Reviews

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Randomised control trial of the effectiveness of an integrated psychosocial health promotion intervention aimed at improving health and reducing substance use in established psychosis (IMPaCT)

Cited by 32 publications

References 46 publications

The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness

The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness

A health promotion intervention to improve lifestyle choices and health outcomes in people with psychosis: a research programme including the IMPaCT RCT

Psychosocial interventions for people with both severe mental illness and substance misuse

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