Novel Intervention Cuts Cardiovascular Risk in Severe Mental Illness

Megan Brooks

June 18, 2020

A comprehensive intervention embedded in routine outpatient specialty mental health care can significantly reduce overall cardiovascular risk in adults with serious mental illness (SMI), results of a randomized controlled trial show.

The 18-month intervention led to a significant decrease of nearly 13% in the estimated 10-year risk of a cardiovascular disease (CVD) event measured by the global Framingham risk score (FRS).

"This is an important finding because studies of care coordination interventions have not been able to show cardiovascular risk or risk factor reduction previously even though programs to incorporate physical health into community mental health settings are proliferating," Gail Daumit, MD, director of the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness, Baltimore, Maryland, told Medscape Medical News.

"This study really is the first to show cardiovascular risk can be meaningfully decreased with this kind of intervention in community mental health settings," said Daumit. 

The study was published online June 12 in JAMA Network Open.  

Health Equity Issue

Individuals with schizophrenia, bipolar disorder and other SMI die from CVD at a rate twice that of the general population.

"This is a large disparity and a health equity issue," said Daumit.

Patients with SMI often have multiple co-occurring CVD risk factors such as tobacco smoking and diabetes. However, they often need health programs tailored to their individual needs as they may have persistent psychiatric symptoms, executive function impairment, and socioeconomic barriers to attaining healthy lifestyles, Daumit explained.

The investigators tested the effectiveness of a multifaceted CVD risk reduction intervention delivered to adults with SMI at four community mental health centers in Maryland. 

They enrolled 269 participants (mean age, 48.8 years; 48% men). More than half (59%) had schizophrenia or schizoaffective disorder, 25% had bipolar disorder, and 14% had major depressive disorder; 132 were randomly allocated to the CVD risk reduction intervention and 137 to a control group.

The intervention incorporated individual behavioral counseling, care coordination, and care management with a health coach and a nurse. Both the intervention and control groups were offered physical activity classes and advice on healthy meal options.

Compared with the control group, rates of tobacco smoking were statistically significantly reduced in the intervention group, with a trend toward reduction in blood pressure and lipids.

At 18 months, average global FRS — which estimates an individual's 10-year probability of a CVD event — fell from 11.5% at baseline to 9.9% in the intervention arm, and from 12.7% to 12.3% in the control group.

Compared with the control group, the intervention group saw a 12.7% relative reduction in FRS at 18 months (95% confidence interval, 2.5% - 22.9%; P = .02).

"The level of cardiovascular risk reduction in this trial corresponds to a number needed to treat of 66, which is in range with trials of antihypertensive therapy and primary prevention with statins," the investigators write.

A Holistic Approach to Care

Reached for comment, Sadiya Khan, MD, assistant professor of medicine (cardiology) and preventive medicine (epidemiology) at Northwestern University Feinberg School of Medicine in Chicago, Illinois, said the findings demonstrate the benefit of counseling in primary CVD prevention in a "disadvantaged and vulnerable population."

Khan, who was not involved with the research, noted that adults with SMI often face additional challenges in accessing primary cardiovascular preventive care, including access to health insurance and medical services as well as the ability to maintain follow-up and continuity with additional providers.

"In addition to patient-specific factors, physician-specific factors may include bias and discrimination against patients with SMI that may contribute to lower rates of uptake of preventive therapies," said Khan.

Also weighing in for Medscape Medical News, Sabina Lim, MD, MPH, professor of psychiatry, Icahn School of Medicine at Mount Sinai in New York City, noted that CV risk is "one of the greatest physical health concerns that psychiatrists have for patients with SMI."

At Mount Sinai, "on a day to day basis, our psychiatrists routinely monitor and educate our patients on all of their physical health conditions, including those conditions that increase CV risk," said Lim, vice president and chief of strategy for behavioral health for the Mount Sinai Health System.

"For many patients with SMI, their psychiatric provider is the de facto primary provider who oversees all of their care, and often the only healthcare provider that they will consistently see.

"We believe it is critical to have a comprehensive, whole health approach to our patients — their mental and physical health needs are all interconnected and we should have active roles in helping our patients address all of these," said Lim, who was not associated with the study.

Beyond Risk Reduction

Lim said one of the most notable aspects of the study, "which perhaps could be part of the reason for the success of the intervention, is that the interventions were done within the mental health community centers and the psychiatric providers seem to be very much involved. This to me was really a significant takeaway."

One note of caution, said Lim, is the wide range of diagnoses within the study population. 

"It's important to consider the possibility that health education and care coordination methods and modes of delivery and content may need to be customized for people with different diagnoses," said Lim.

"The way you work with, motivate, and develop trust with a patient with schizophrenia is significantly different from how this would be done with someone with major depression, or for someone with a primary substance use disorder," she added.

Lim also cautioned that this is not an easy intervention to scale and sustain, unless there are existing care coordinators/care managers that can reorganize and focus their work to these kinds of interventions.

"And, as the authors noted, although there was reduced risk, risk is still different than actual real-time clinical improvements. At some point, you do need to see demonstrable, real-time clinical improvements, and not just an estimated risk reduction," said Lim.

She noted that Mount Sinai ran a similar 2-year, nonresearch pilot for patients with SMI and significant medical comorbidities such as diabetes and hypertension, where the key intervention was intensive, highly specialized care coordination, with significant involvement of mental health providers.

The main measures were primarily utilization and adherence measures, and the team looked for improvements across the whole population, not at the individual patient level. Improvements at the population level were seen, Lim said, with reductions in medical emergency department visits and greater adherence to hemoglobin A1c testing, for example.

This study was supported by the National Heart, Lung, and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Diseases. Daumit, Khan, and Lim have disclosed no relevant financial relationships.

JAMA Netw Open. Published online June 12, 2020. Full text

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