Inequalities in physical comorbidity: a longitudinal comparative cohort study of people with severe mental illness in the UK Smoking Cessation Intervention for severe Mental Ill Health Trial (SCIMITAR): a pilot randomised control trial of the clinical effectiveness and cost-effectiveness of a bespoke smoking cessation service. Next steps for meeting the needs of people with severe mental illness in low- and middle-income countries. Impact of socioeconomic deprivation on maternal perinatal mental illnesses presenting to UK general practice. Posttraumatic stress disorder, supported employment, and outcomes in people with severe mental illness. Randomized trial of social rehabilitation and integrated health care for older people with severe mental illness. Cognitive Behavioral HIV Risk Reduction in Those Receiving Psychiatric Treatment: A Clinical Trial Telephone-Delivered Physical Activity Intervention for Individuals With Serious Mental Illness Recognition of Co-Occurring Medical Conditions Among Patients With Serious Mental Illness Psychoeducation for Siblings of People with Severe Mental Illness Impact of a nurse-led intervention to improve screening for cardiovascular risk factors in people with severe mental illnesses. Phase-two cluster randomised feasibility trial of community mental health teams
Objectives Little is known about the prevalence of comorbidity rates in people with severe mental illness ( SMI ) in UK primary care . We calculated the prevalence of SMI by UK country , English region and deprivation quintile , antipsychotic and antidepressant medication prescription rates for people with SMI , and prevalence rates of common comorbidities in people with SMI compared with people without SMI . Design Retrospective cohort study from 2000 to 2012 . Setting 627 general practice s contributing to the Clinical Practice Research Data link , a UK primary care data base . Participants Each identified case ( 346 551 ) was matched for age , sex and general practice with 5 r and omly selected control cases ( 1 732 755 ) with no diagnosis of SMI in each yearly time point . Outcome measures Prevalence rates were calculated for 16 conditions . Results SMI rates were highest in Scotl and and in more deprived areas . Rates increased in Engl and , Wales and Northern Irel and over time , with the largest increase in Northern Irel and ( 0.48 % in 2000/2001 to 0.69 % in 2011/2012 ) . Annual prevalence rates of all conditions were higher in people with SMI compared with those without SMI . The discrepancy between the prevalence of those with and without SMI increased over time for most conditions . A greater increase in the mean number of additional conditions was observed in the SMI population over the study period ( 0.6 in 2000/2001 to 1.0 in 2011/2012 ) compared with those without SMI ( 0.5 in 2000/2001 to 0.6 in 2011/2012 ) . For both groups , most conditions were more prevalent in more deprived areas , whereas for the SMI group conditions such as hypothyroidism , chronic kidney disease and cancer were more prevalent in more affluent areas . Conclusions Our findings highlight the health inequalities faced by people with SMI . The provision of appropriate timely health prevention , promotion and monitoring activities to reduce these health inequalities are needed , especially in deprived areas BACKGROUND There is a high prevalence of smoking among people who experience severe mental ill health ( SMI ) . Helping people with disorders such as bipolar illness and schizophrenia to quit smoking would help improve their health , increase longevity and also reduce health inequalities . Around half of people with SMI who smoke express an interest in cutting down or quitting smoking . There is limited evidence that smoking cessation can be achieved for people with SMI . Those with SMI rarely access routine NHS smoking cessation services . This suggests the need to develop and evaluate a behavioural support and medication package tailored to the needs of people with SMI . OBJECTIVE The objective in this project was to conduct a pilot trial to establish acceptability of the intervention and to ensure the feasibility of recruitment , r and omisation and follow-up . We also sought preliminary estimates of effect size in order to design a fully powered trial of clinical effectiveness and cost-effectiveness . The pilot should inform a fully powered trial to compare the clinical effectiveness and cost-effectiveness of a bespoke smoking cessation ( BSC ) intervention with usual general practitioner ( GP ) care for people with SMI . DESIGN A pilot pragmatic two-arm individually r and omised controlled trial ( RCT ) . Simple r and omisation was used following a computer-generated r and om number sequence . Participants and practitioners were not blinded to allocation . SETTING Primary care and secondary care mental health services in Engl and . PARTICIPANTS Smokers aged > 18 years with a severe mental illness who would like to cut down or quit smoking . INTERVENTIONS A BSC intervention delivered by mental health specialists trained to deliver evidence -supported smoking cessation interventions compared with usual GP care . MAIN OUTCOME MEASURES The primary outcome was carbon monoxide-verified smoking cessation at 12 months . Smoking-related secondary outcomes were reduction of number of cigarettes smoked , Fagerstrom test of nicotine dependence and motivation to quit ( MTQ ) . Other secondary outcomes were Patient Health Question naire-9 items and Short Form Question naire-12 items to assess whether there were improvements or deterioration in mental health and quality of life . We also measured body mass index to assess whether or not smoking cessation was associated with weight gain . These were measured at 1 , 6 and 12 months post r and omisation . RESULTS The trial recruited 97 people aged 19 - 73 years who smoked between 5 and 60 cigarettes per day ( mean 25 cigarettes ) . Participants were recruited from four mental health trusts and 45 GP surgeries . Forty-six people were r and omised to the BSC intervention and 51 people were r and omised to usual GP care . The odds of quitting at 12 months was higher in the BSC intervention ( 36 % vs. 23 % ) but did not reach statistical significance ( odds ratio 2.9 ; 95 % confidence interval 0.8 % to 10.5 % ) . At 3 and 6 months there was no evidence of difference in self-reported smoking cessation . There was a non-significant reduction in the number of cigarettes smoked and nicotine dependence . MTQ and number of quit attempts all increased in the BSC group compared with usual care . There was no difference in terms of quality of life at any time point , but there was evidence of an increase in depression scores at 12 months for the BSC group . There were no serious adverse events thought likely to be related to the trial interventions . The pilot economic analysis demonstrated that it was feasible to carry out a full economic analysis . CONCLUSIONS It was possible to recruit people with SMI from primary and secondary care to a trial of a smoking cessation intervention based around behavioural support and medication . The overall direction of effect was a positive trend in relation to biochemically verified smoking cessation and it was feasible to obtain follow-up in a substantial proportion of participants . A definitive trial of a bespoke cessation intervention has been prioritised by the National Institute for Health Research ( NIHR ) and the SCIMITAR pilot trial forms a template for a fully powered RCT to examine clinical effectiveness and cost-effectiveness . TRIAL REGISTRATION Current Controlled Trials IS RCT N79497236 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment , Vol . 19 , No. 25 . See the NIHR Journals Library website for further project information The explicit inclusion of mental health within the Sustainable Development Goals is a welcome development , borne out of powerful advocacy using public health , economic and human rights arguments . As funding comes on line for scale-up of evidence -based mental health care by task-sharing with primary care , it is time to take stock about care for people affected by severe mental illness ( SMI ) . The existing evidence base for task shared care for SMI provides an imperative to get started , but is skewed towards relatively more affluent and urban population s in middle-income countries where specialist mental health professionals provide most of the care . R and omised , controlled trials and rigorous implementation research on task shared service models are underway which will go some way to improving underst and ing of the quality , safety , effectiveness and acceptability of more widely generalisable care for people with SMI . A sub-group of people with SMI have more complex and long-term needs for care , with a high risk of homelessness , imprisonment and human rights violations as family and social supports become overwhelmed . Case studies from non-governmental organisations provide examples of holistic approaches to rehabilitation , recovery and empowerment of people with SMI , but rigorous comparative studies are needed to identify the most efficient , effective and scalable approaches to care . Health system constraints are emerging as the over-riding barriers to successful task-sharing , highlighting a need to develop and evaluate chronic care models for people with SMI that succeed in reducing premature mortality , improving wellbeing and achieving better social outcomes . Addressing these evidence gaps is essential if task-sharing mental health care is going to deliver on its promise of promoting recovery for the full range of people affected by SMI BACKGROUND Although maternal perinatal mental illnesses commonly present to and are primarily treated in general practice , few population -based estimates of this burden exist , and the most affected socioeconomic groups of pregnant women remain unclear . AIM To provide estimates of maternal depression , anxiety and serious mental illness ( SMI ) in UK general practice and quantify impacts of socioeconomic deprivation . DESIGN AND SETTING Cross-sectional analysis of prospect ively recorded general practice records from a UK-wide data base . METHOD A pregnancy ending in live birth was r and omly selected for every woman of childbearing age , 1994 - 2009 . Prevalence and diagnostic overlap of mental illnesses were calculated using a combination of medical diagnoses and psychotropic drug prescriptions . Socioeconomic deprivation was assessed using multivariate logistic regression , adjusting for calendar period and pregnancy history . RESULTS Among 116 457 women , 5.1 % presented with antenatal depression and 13.3 % with postnatal depression . Equivalent figures for anxiety were 2.6 % and 3.7 % and for SMI 1/1000 and 2/1000 women . Socioeconomic deprivation increased the risk of all mental illnesses , although this was more marked in older women . Those age 35 - 45 years in the most deprived group had 2.63 times the odds of antenatal depression ( 95 % confidence interval [ CI ] = 2.22 to 3.13 ) compared with the least deprived ; in women aged 15 - 25 years the increased odds associated with deprivation was more modest ( odds ratio = 1.35 , 95 % CI = 1.07 to 1.70 ) . Similar patterns were found for anxiety and SMI . CONCLUSION Strong socioeconomic inequalities in perinatal mental illness persist with increasing maternal age . Targeting detection and effective interventions to high-risk women may reduce inequity and avoid substantial psychiatric morbidity OBJECTIVE To evaluate whether posttraumatic stress disorder ( PTSD ) is related to outcomes in persons with severe mental illness ( SMI ) participating in a study of vocational rehabilitation programs . BACKGROUND PTSD is a common comorbid disorder in people with SMI , but it is unknown whether PTSD interferes with the ability to benefit from rehabilitation programs such as supported employment . METHODS The relationships between PTSD and symptoms , health , quality of life , and work outcomes was examined in 176 clients with SMI participating in a 2-year r and omized controlled trial of three vocational rehabilitation programs : supported employment based on the Individual Placement and Support model , a psychosocial rehabilitation program based on transitional employment , and st and ard services .  RESULTS The overall rate of current PTSD in the sample was 16 percent . Compared with clients without PTSD , clients with PTSD had more severe psychiatric symptoms , worse reported health , lower self-esteem , and lower subjective quality of life . Clients with PTSD who participated in the Individual Placement and Support model ( the most effective vocational model of the three studied ) also had worse employment outcomes over the 2-year study period than clients without PTSD , with lower rates of competitive work , fewer hours worked , and fewer wages earned . Employment outcomes did not differ between clients with PTSD versus without PTSD in the other two vocational rehabilitation approaches . CONCLUSION The findings suggest that PTSD may contribute to worse work outcomes in clients participating in supported employment programs . Effective treatment of these clients with PTSD may improve their ability to benefit from supported employment OBJECTIVE The Helping Older People Experience Success ( HOPES ) program was developed to improve psychosocial functioning and reduce long-term medical burden in older people with severe mental illness ( SMI ) living in the community . HOPES includes 1 year of intensive skills training and health management , followed by a 1-year maintenance phase . METHOD To evaluate effects of HOPES on social skills and psychosocial functioning , we conducted a r and omized controlled trial with 183 older adults with SMI ( 58 % schizophrenia spectrum ) age 50 and older at 3 sites who were assigned to HOPES or treatment as usual with blinded follow-up assessment s at baseline and 1- and 2-year follow-up . RESULTS Retention in the HOPES program was high ( 80 % ) . Intent-to-treat analyses showed significant improvements for older adults assigned to HOPES compared to treatment as usual in performance measures of social skill , psychosocial and community functioning , negative symptoms , and self-efficacy , with effect sizes in the moderate ( .37-.63 ) range . Exploratory analyses indicated that men improved more than women in the HOPES program , whereas benefit from the program was not related to psychiatric diagnosis , age , or baseline levels of cognitive functioning , psychosocial functioning , or social skill . CONCLUSIONS The results support the feasibility of engaging older adults with SMI in the HOPES program , an intensive psychiatric rehabilitation intervention that incorporates skills training and medical case management , and improves psychosocial functioning in this population . Further research is needed to better underst and gender differences in benefit from the HOPES program Among severely mentally ill ( SMI ) substance abusers , HIV rates are elevated and HIV risk reduction interventions have been shown to be less effective . An enhanced cognitive behavioral HIV risk reduction intervention ( E-CB ) for SMI was compared to a health promotion condition ( HPC ) in 222 psychiatric out patients at 6 months postintervention . Compared to females , males in the E-CB improved on intention to practice safer sex and in condom use skills and in unprotected vaginal sex , but did not differ in HIV knowledge , perceived susceptibility , anxiety , condom attitudes , safer sex self-efficacy , unprotected vaginal sex acts , or sex partners . Across intervention groups , there were improvements in all areas except self-efficacy and number of partners . Risk reduction among SMI may be facilitated by increasing awareness of health related behaviors and HIV-targeted content . However , meaningful changes in critical risk reduction skills and intentions may require a more focused intervention and may vary by gender BACKGROUND : Obesity is prevalent in individuals with serious mental illness ( SMI ) . OBJECTIVE : The purpose of this study is to examine the feasibility of a telephone-delivered physical activity ( PA ) intervention for out patients with serious mental illness to maintain PA and to explore the preliminary efficacy of the intervention on health status . DESIGN : This study used a r and omized experimental design . The treatment group received pedometers and eight weekly phone calls ; the control group received written information regarding PA . Descriptive statistics were used to analyze data collected at baseline and 8 weeks . RESULTS : Twenty-two subjects with SMI ( mean age = 44.09 ± 7.6 years ; 54.5 % were male ) were recruited and 16 subjects completed the study in 8 weeks .  PA ( z = −2.37 , p = .02 ) increased in the treatment group ( n = 8) whereas the control group ( n = 8) maintained baseline PA level ( z = −1.61 , p = .11 ) . Health outcomes were not changed ( ps > .05 ) . CONCLUSION : Telephone-delivered intervention is feasible and has the potential to improve PA  in individuals with SMI We determined whether patients with serious mental illness ( SMI ) were less likely than non-SMI to self-report having a medical condition that was recorded in their medical record . We included all patients from the VA National Psychosis Registry diagnosed with SMI and a r and om sample of non-SMI patients in fiscal year 1999 who completed the Large Health Survey of Veteran Enrollees ( N = 35,837 ) . Among patients with diagnoses for any of 11 conditions recorded in administrative data , we evaluated whether patients reported having that same condition in the survey , using multivariable logistic regression and generalized estimating equations . Among patients diagnosed with a given condition , those with SMI were less likely to report being told by providers that they had seven of the 11 conditions examined : heart disease ( OR = 0.68 , p < 0.001 ) , arthritis ( OR = 0.79 , p < 0.001 ) , cancer ( OR = 0.69 , p < 0.001 ) , diabetes ( OR = 0.79 , p < 0.001 ) , back pain ( OR = 0.81 , p < 0.001 ) , congestive heart failure ( OR = 0.71 , p < 0.001 ) , and hypertension ( OR = 0.77 , p < 0.001 ) . Patients with SMI were less aware of co-occurring medical conditions Background Many people with severe mental illness ( SMI ) have siblings . Siblings are often both natural agents to promote service users ’ recovery and vulnerable to mental ill health due to the negative impact of psychosis within the family . Despite a wealth of research evidence supporting the effectiveness of psychoeducation for service users with SMI and their family members , in reducing relapse and promoting compliance with treatment , siblings remain relatively invisible in clinical service setting s as well as in research studies . If psychoeducational interventions target siblings and improve siblings ' knowledge , coping with caring and overall wellbeing , they could potentially provide a cost-effective option for supporting siblings with result ing benefits for service users ' outcomes . Objectives To assess the effectiveness of psychoeducation compared with usual care or any other intervention in promoting wellbeing and reducing distress of siblings of people affected by SMI . The secondary objective was , if possible , to determine which type of psychoeducation is most effective . Search methods We search ed the Cochrane Schizophrenia Group Trials Register and screened the reference lists of relevant reports and review s ( 12th November 2013 ) . We contacted trial authors for unpublished and specific data on siblings ' outcomes . Selection criteria All relevant r and omised controlled trials focusing on psychoeducational interventions targeting siblings of all ages ( on their own or amongst other family members including service users ) of individuals with SMI , using any means and formats of delivery , i.e. individual ( family ) , groups , computer-based . Data collection and analysis Two review authors independently screened the abstract s and extracted data and two other authors independently checked the screening and extraction process . We contacted authors of trials to ascertain siblings ' participation in the trials and seek sibling-specific data in those studies where siblings ' data were grouped together with other participants ' ( most commonly other family members'/carers ' ) outcomes . We calculated the risk difference ( RD ) , its 95 % confidence interval ( CI ) on an intention-to-treat basis . We presented continuous data using the mean difference statistic ( MD ) and 95 % CIs . We assessed risk of bias for the included study and rated quality of evidence using Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) . Main results We found 14 studies that included siblings amongst other family members in receipt of psychoeducational interventions . However , we were only able to include one small trial with relevant and available data ( n = 9 siblings out of n = 84 family member/carer- participants ) comparing psychoeducational intervention with st and ard care in a community care setting , over a duration of 21 months . There was insufficient evidence to determine the effects of psychoeducational interventions compared with st and ard care on ' siblings ' quality of life ' ( n = 9 , MD score 3.80 95 % CI -0.26 to 7.86 , low quality of evidence ) , coping with ( family ) burden ( n = 9 , MD -8.80 95 % CI -15.22 to -2.34 , low quality of evidence ) . No sibling left the study early by one year ( n = 9 , RD 0.00 CI -0.34 to 0.34 , low quality of evidence ) . Low quality and insufficient evidence meant we were unable to determine the effects of psychoeducational interventions compared with st and ard care on service users ' global mental state ( n = 9 , MD -0.60 CI -3.54 to 2.38 , low quality of evidence ) , their frequency of re-hospitalisation ( n = 9 , MD -0.70 CI -2.46 to 1.06 , low quality of evidence ) or duration of inpatient stay ( n = 9 , MD -2.60 CI -6.34 to 1.14 , low quality of evidence ) , whether their siblings received psychoeducation or not . No study data were available to address the other primary outcomes : ' siblings ' psychosocial wellbeing ' , ' siblings ' distress ' and adverse effects . Authors ' conclusions Most studies evaluating psychoeducational interventions recruited siblings along with other family members . However , the proportion of siblings in these studies was low and outcomes for siblings were not reported independently from those of other types of family members . Indeed , only data from one study with nine siblings were available for the review . The limited study data we obtained provides no clear good quality evidence to indicate psychoeducation is beneficial for siblings ' wellbeing or for clinical outcomes of people affected by SMI . More r and omised studies are justified and needed to underst and the role of psychoeducation in addressing siblings ' needs for information and support Background People with severe mental illnesses ( SMI ) are at increased risk of cardiovascular disease ( CVD ) . Clinical guidelines recommend regular screening for CVD risk factors . We evaluated a nurse led intervention to improve screening rates across the primary - secondary care interface . Methods Six community mental health teams ( CMHTs ) were r and omised to receive either the nurse led intervention plus education pack ( n = 3 ) or education pack only ( n = 3 ) . Intervention ( 6 months ) : The nurse promoted CVD screening in primary care and then in CMHTs . Patients who remained unscreened were offered screening by the nurse . After the intervention participants with SMI were recruited from each CMHT to collect outcome data . Main outcome : Numbers screened during the six months , confirmed in General Practice notes . Results All six CMHTs approached agreed to r and omisation . 121 people with SMI participated in outcome interviews during two waves of recruitment ( intervention arm n = 59 , control arm n = 62 ) . Participants from both arms of the trial had similar demographic profiles and rates of previous CVD screening in the previous year , with less than 20 % having been screened for each risk factor . After the trial , CVD screening had increased in both arms but participants from the intervention arm were significantly more likely to have received screening for blood pressure ( 96 % vs 68 % ; adjusted Odds Ratio ( OR ) 13.6 ; 95 % CI : 3.5 - 38.4 ) , cholesterol ( 66.7 % vs 26.9 % , OR 6.1 ; 3.2 - 11.5 ) , glucose ( 66.7 % vs 36.5 % OR 4.4 ; 2.7 - 7.1 ) , BMI ( 92.5 % vs 65.2 % OR 6.5 ; 2.1 - 19.6 ) , and smoking status ( 88.2 % vs 57.8 % OR 5.5 ; 3.2 - 9.5 ) and have a 10 year CVD risk score calculated ( 38.2 % vs 10.9 % ) OR 5.2 1.8 - 15.3 ) . Within the intervention arm approximately half the screening was performed in general practice and half by the trial nurse . Conclusions The nurse-led intervention was superior , result ing in an absolute increase of approximately 30 % more people with SMI receiving screening for each CVD risk factor . The feasibility of the trial was confirmed in terms of CMHT recruitment and the intervention , but the response rate for outcome collection was disappointing ; possibly a result of the cluster design . The trial was not large or long enough to detect changes in risk factors . Trial Registration International St and ard R and omised Controlled Trial Registration Number ( IS RCT RN ) 58625025
Discussion The proposed core outcome set will provide clear guidance about what outcomes should be measured , as a minimum , in trials of interventions for people with coexisting type-2 diabetes and SMI , and improve future synthesis of trial evidence in this area .
Background People with diabetes and comorbid severe mental illness ( SMI ) form a growing population at risk of increased mortality and morbidity compared to those with diabetes or SMI alone .
There is increasing interest in interventions that target diabetes in SMI in order to help to improve physical health and reduce the associated health inequalities .
However , there is a lack of consensus about which outcomes are important for this comorbid population , with trials differing in their focus on physical and mental health .
A core outcome set , which includes outcomes across both conditions that are relevant to patients and other key stakeholders , is needed .