A Program Targeting Metabolic Risks in Patients with Mental Illness

1. A Program Targeting Metabolic Risks in Patients with Mental Illness Nicole Poellet, MS, PMHNP-BC; Judy Coucouvanis, MS, PMHNP-BC; Iva Grasso, RN, MSW; Jim Smith, RN; Robin Scott, RN; Julie Kuebler, MS, PMHNP-BC; and Charlene Lindahl, MA, RN Department of Psychiatry, University of Michigan, Ann Arbor, MI • Methods • Nursing staff in ambulatory psychiatry formed a committee in July 2010 with the objective of building an intervention aimed at reducing incidence and risk of metabolic syndrome in an outpatient psychiatric population. High importance was placed on feasibility for patients by limiting the time and financial commitment involved. Compared to previous studies, the group intervention was shortened, however direct care manager support was added. Specific content was modified as well to incorporate several psychotherapeutic modalities aimed at behavior change. • The Healthy Living, Mental Wellness Program: • Part I: • Patients participate in a 4-session group uses cognitive behavioral, self- management, and motivation interviewing techniques to motivate patients and learn basic skills for behavior change. • Session 1: Metabolic Risks & Management Strategies • Session 2: Diet & Nutrition Factors • Session 3: Staying Fit: The Role of Exercise • Session 4: Managing Stress • Part II: • At the end of the 4-session group, patients work together with staff guidance, to develop a goal for the next six months. Monthly phone follow up is provided by RN care managers who build on skills learned in group and offer problem solving support. • Nursing Roles: • Psychiatric RN: • Fifteen minute support contact (phone or in person) once a month • Therapeutic listening • Goal setting/self-management • Psychiatric Nurse Practitioner: • Facilitate group • Cognitive-Behavioral interventions • Motivational Interviewing • Self-Management • Didactic as indicated • Provide support to RN care managers • Nurse Manager: • Development of documentation templates • Procedure development • Systems facilitation • Results • Results are pending at this time. Outcomes to measure will include: • Patient self-monitoring for metabolic syndrome, • Behavior change in the area of the three primary modifiable risk factors (diet, exercise, stress management), and • Maintenance/improvement in clinical indicators of metabolic syndrome. • Overall patient satisfaction • Ability to access the program for majority of ambulatory psychiatric patients Purpose Patients with major mental illnesses have an average lifespan 25 to 30 years less than individuals in the general population. The primary cause of mortality in these cases is premature cardiovascular disease. Identified contributors to this risk include psychotropic medications, psychiatric symptoms, and access to care. The University of Michigan Department of Psychiatry observed high levels of metabolic morbidity in child and adult psychiatry clinics and identified this as a problem. A department wide committee was developed to increase consistent, standardized monitoring for metabolic risk factors in the outpatient clinics. In response to increased monitoring, nursing staff developed an intervention for patients who were identified as being at risk for developing diabetes and cardiovascular disease. This poster describes the Metabolic Wellness Program that resulted. Conclusions/Implications Individuals with psychiatric diagnoses are at significant risk of morbidity and mortality related to cardiovascular disease. While the exact cause remains unknown, interventions to address the primary risk factors for metabolic illness are warranted. This program aims to implement evidence based health behavior change interventions implemented by a nursing team to reduce risks of co-morbid medical illness for psychiatric patients. The pending outcomes will determine the feasibility of these interventions for this patient population and guide modifications for improved interventions in the future. Background Several research studies have tested interventions addressing modifiable risk factors of metabolic illness in mentally ill populations. The primary modifiable risk factors include diet, exercise, and stress management. All of the interventions demonstrated success, though often only moderate statistical significance or trends toward significance. Several studies compared a behavioral intervention to the addition of a medication, usually metformin, to assess differences in response. While both were effective, lifestyle changes resulted in greater improvements overall. While the literature reports success with lifestyle change interventions, there were several limitations regarding feasibility of implementation in a standard outpatient practice. Several studies had significant attrition, leading to questions about response bias (i.e., those who complete are also most likely to be successful with behavior change). This further leads to questions about the ability to keep patients engaged long enough to achieve behavior change in an outpatient practice. Length of the intervention was another significant factor. Research interventions took place over 12 -16 weeks, which is not practical in an outpatient clinical setting given limitations of insurance coverage for this type of service. References Allsion, D.B., Newcomer, J.W., Dunn, A.L., Blumenthal, J.A., Fabricatore, A.N., Daumit, G.L., Cope, M.B., Riley, W.T., Vreeland, B., Hibbeln, J.R., & Alpert, J.E. (2009). Obesity among those with mental disorders: A National Institute of Mental Health meeting report. American Journal of Preventive Medicine, 36, 341-350. Correll, C.U., Druss, B.G., Lombardo, I., O’Gorman, C., Harnett, J.P., Sanders, K.N., Alvir, J.M., & Cuffel, B.J. (2010). Findings of a U.S. national cardiometabolic screening program among 10,084 psychiatric outpatients. Psychiatric Services, 61, 892-898. Diabetes Prevention Program Research Group. (2009). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The New England Journal of Medicine, 346, 393-403. Fagiolini, A. & Goracci, A. (2009). The effects of undertreated chronic medical illness in patients with severe mental disorders. Journal of Clinical Psychiatry, 70, 22-29. Lindenmayer, J., Kahn, A., Wance, D., Maccabee, N., Kaushik, S., & Kaushik, S. (2009). Outcome of evaluation of a structured educational wellness program in patients with severe mental illness. Journal of Clinical Psychiatry, 70, 1385-1396. Lorig, K.R. & Holman, H.R. (2003). Self-management education: History, definition, outcomes, and mechanisms. Annals of Behavioral Medicine, 26, 1-7. Newcomer, J.W. (2007). Metabolic syndrome and mental illness. The American Journal of Managed Care, 13, S170-S177. Orchard, T.J., Temprosa, M., Goldberg, R., Haffner, S., Ratner, R., Marcovina, S., & Fowler, S. (2005). The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: The diabetes prevention program randomized trial. Annals of Internal Medicine, 142, 611-619. Vreeland, B., Minsky, S., Menza, M., Radler, D.R., Roemheld-Hamm, B., & Stern, R. (2003). A program for managing weight gain associated with atypical antipsychotics. Psychiatric Services, 54, 1155-1157. Weber, M., & Wyne, K. (2006). A cognitive/behavioral group intervention for weight loss in patients treated with atypical antipsychotics. Schizophrenia Research, 83, 95-101.