MA Department of Mental Health MA Department of Mental Health Healthy Changes InitiativeHealthy Changes Initiative

June 17, 2009June 17, 2009

Health and Wellness for Health and Wellness for Individuals with Serious Mental Individuals with Serious Mental

Illness; Challenges and Illness; Challenges and OpportunitiesOpportunities

Sally Reyering, M.D.Sally Reyering, M.D.Sally.reyering@state.ma.usSally.reyering@state.ma.us

AgendaAgenda

Project rationaleProject rationale– Mortality dataMortality data– SAMSHA and NASMHPD calls to actionSAMSHA and NASMHPD calls to action

Evidence base to support choice of three Evidence base to support choice of three target areas of initiative target areas of initiative

Outcome measures and evaluation toolsOutcome measures and evaluation tools

Interventions to achieve outcomesInterventions to achieve outcomes

Mortality CrisisMortality Crisis

Recent data from several states have found Recent data from several states have found thatthat people with serious mental illness people with serious mental illness served by our public mental health systems served by our public mental health systems die, on average, at least 25 years earlier that die, on average, at least 25 years earlier that the general populationthe general population..

US Life Expectancy 2008 = 78 yearsUS Life Expectancy 2008 = 78 years

Serious mental illness = 53 – 57 yearsSerious mental illness = 53 – 57 years– Comparable to Cameroon, Gabon, Democratic Comparable to Cameroon, Gabon, Democratic

Republic of CongoRepublic of Congo

Biggest lifespan disparity in U.S.Biggest lifespan disparity in U.S.

Morbidity and Mortality ~ CausesMorbidity and Mortality ~ Causes

While suicide and injury account for about While suicide and injury account for about 30-40% of excess mortality, about 60% of 30-40% of excess mortality, about 60% of premature deaths in persons with premature deaths in persons with schizophrenia are due to “natural causes”schizophrenia are due to “natural causes”

– Cardiovascular diseaseCardiovascular disease

– DiabetesDiabetes– Respiratory diseasesRespiratory diseases (including pneumonia (including pneumonia

and flu)and flu)

– Infectious diseases Infectious diseases (including HIV and Hep C)(including HIV and Hep C)

Premature Mortality by 25 yearsPremature Mortality by 25 years

Six major causes of death in U.SSix major causes of death in U.Sand increased relative risk in SMIand increased relative risk in SMI–Cardiovascular Disease Cardiovascular Disease 3.4 X3.4 X

–Cancer Cancer Maybe lower rates except lungMaybe lower rates except lung

–Stroke Stroke 2x in age < 502x in age < 50

–Respiratory disease Respiratory disease 5x5x

–Accidents Accidents higherhigher –Diabetes Diabetes 3.4x3.4x

Massachusetts Study: Deaths from Heart Massachusetts Study: Deaths from Heart Disease by Age Group/DMH Enrollees with Disease by Age Group/DMH Enrollees with

SMI Compared to Massachusetts 1998-2000SMI Compared to Massachusetts 1998-2000

0

5

10

15

20

25

30

35

40

25-34 35-44 45-54 55-64

Rat

es p

er 1

00,0

00

DMH

MA

High Rates of Chronic IllnessHigh Rates of Chronic Illness

70% SMI have a chronic health cond70% SMI have a chronic health cond

–Mostly pulmonary diseaseMostly pulmonary disease

50% have two or more 50% have two or more

42% severe enough to limit function42% severe enough to limit function

34% HPTN34% HPTN

Hep B rates increased 5x; Hep C 11xHep B rates increased 5x; Hep C 11x

Calls for ActionCalls for ActionSAMSHA:SAMSHA: – Increase the average life span of those with Increase the average life span of those with

mental illness by 10 years in 10 years.mental illness by 10 years in 10 years.

NASMHPDNASMHPD– 1313thth Technical Report Technical Report

CDC, Healthy People 2010CDC, Healthy People 2010

Health and Human Services; HealthierUSHealth and Human Services; HealthierUS

President’s New Freedom Commission President’s New Freedom Commission

Bazelon Center For Mental Health LawBazelon Center For Mental Health Law

Factors Associated with Premature Factors Associated with Premature DeathDeath

Reduced Use/Inefficient Use of Medical ServicesReduced Use/Inefficient Use of Medical Services

PovertyPoverty

Systemic Barriers to Ideal Health CareSystemic Barriers to Ideal Health Care– Healthcare systems and financingHealthcare systems and financing

Psychotropic medicationsPsychotropic medications

Individual health habitsIndividual health habits– SmokingSmoking– InactivityInactivity– Obesity/poor nutritionObesity/poor nutrition

Healthy Changes InitiativeHealthy Changes Initiative

TheThe Healthy Changes InitiativeHealthy Changes Initiative is designed to is designed to address the individual’s modifiable risk factors address the individual’s modifiable risk factors which result in chronic illness and early death in which result in chronic illness and early death in individuals with psychiatric disabilities.individuals with psychiatric disabilities.

– Physical InactivityPhysical Inactivity– Overweight/ObesityOverweight/Obesity– SmokingSmoking

“…the recovery paradigm of needed services has to include the concept of health promotion in treatment planning and service delivery to to persons with SMI.” persons with SMI.” Hutchinson et al, 2006Hutchinson et al, 2006

Lifestyle Changes Work in those Lifestyle Changes Work in those with Mental Illnesswith Mental Illness

Addiction RecoveryAddiction Recovery

Smoking CessationSmoking Cessation

Prevention and reversal of Prevention and reversal of antipsychotic induced weight gainantipsychotic induced weight gain

Development of healthy eating and Development of healthy eating and exercise habitsexercise habits

www.health.gov/paguidelineswww.health.gov/paguidelines

Physical ActivityPhysical Activity

Physical Activity: BenefitsPhysical Activity: Benefits

““The health benefits of physical activity are The health benefits of physical activity are generally independent of weight.” generally independent of weight.” PAGuidelinesPAGuidelines

Sedentary lifestyle is an independent risk for Sedentary lifestyle is an independent risk for cardiovascular deathcardiovascular death even in normal weight even in normal weight individualsindividuals. .

Moderate intensity exercise without dietary Moderate intensity exercise without dietary changes brings changes brings reduced incidence of metabolic reduced incidence of metabolic syndrome.syndrome.

Physical Activity: BenefitsPhysical Activity: Benefits

Strong evidenceStrong evidenceEarly deathEarly death

Coronary artery diseaseCoronary artery disease

StrokeStroke

High blood pressureHigh blood pressure

Adverse lipid profileAdverse lipid profile

Type II DiabetesType II Diabetes

Metabolic syndromeMetabolic syndrome

Colon CancerColon Cancer

Breast CancerBreast Cancer

Prevention of Wt Gain and to Prevention of Wt Gain and to achieve weight lossachieve weight loss

Bone health in kidsBone health in kids

Function in older adultsFunction in older adults

Moderate evidenceModerate evidenceHip fracture, falls, bone densityHip fracture, falls, bone density

Lung cancerLung cancer

Endometrial cancerEndometrial cancer

Maintaining wt lossMaintaining wt loss

Improved sleep qualityImproved sleep quality

Within weeksWithin weeksIncreased cardiorespiratory Increased cardiorespiratory

fitnessfitness

Increased muscular strengthIncreased muscular strength

Decreased blood pressureDecreased blood pressure

Decreased depressive Decreased depressive symptomssymptoms

Physical Activity Physical Activity Mental Health BenefitsMental Health Benefits

Strong evidenceStrong evidenceDepression reduced in Depression reduced in

adultsadults

Cognition improved in Cognition improved in older adultsolder adults

Other evidenceOther evidenceAnxiety improved Anxiety improved Self-esteemSelf-esteemOverall well-beingOverall well-being

Moderate evidenceModerate evidenceDepression reduced in Depression reduced in

children children

Amounts of ExerciseAmounts of Exercise

Inactive or sedentary <30 min/wk, <10min/qd

Health benefits accrue at 60 min/wk

Low level 90 min/wk. Even low levels lead to dramatic decr in risk of premature death

For substantial health benefits 150 min cumulative moderate intensity exercise a week.

Greater benefits accrue at higher levels

300 minutes for weight loss

Physical ActivityPhysical Activity

CDC CDC datadata

Gen Gen poppop

PovertPovertyy

SedenSeden..

36%36% 56%56%

Some Some activitactivityy

31%31% 23%23%

RegReg

activitactivityy

33%33% 21%21%

NHANESNHANES Gen Gen poppop

SMISMI

Seden.Seden. 17%17% 26%26%

DecrDecr

activityactivity

22%22% 49%49%

Special Considerations Special Considerations Physical Activity in indiv. with SMIPhysical Activity in indiv. with SMIInactive; start low, go slow.Inactive; start low, go slow.Fear of heart attack with sensation of incr. Fear of heart attack with sensation of incr. HR, R.HR, R.Lack of familiarity with the sensation of Lack of familiarity with the sensation of muscle soreness.muscle soreness.Traumatic bodily relationshipsTraumatic bodily relationshipsBalance issues on moving treadmills; med Balance issues on moving treadmills; med effectseffectsCold temperatures and destimulating envCold temperatures and destimulating env

DMH DataDMH Data

Physical Activity and Exercise Among Persons Newly Admitted June 1, 2007 through May 31, 2008

0.0%10.0%20.0%30.0%40.0%

New Admissions: 1203 Adult, 48 Adolescents

Pers

on E

xerc

ises

20

or

Mor

e M

inut

es, 3

or M

ore

Day

s a

Wee

k (a

s as

sess

ed

by O

T st

aff o

n ad

mis

sion

)

Adult units only

Adolescent units only

Physical Activity: OutcomesPhysical Activity: Outcomeshttp://www.healthypeople.gov/http://www.healthypeople.gov/

Decrease the number of sedentary individuals <30 Decrease the number of sedentary individuals <30 min/ week min/ week

Increase the number of individuals who engage in Increase the number of individuals who engage in physical activity > 60 min/ weekphysical activity > 60 min/ week. .

Increase the proportion of individuals who engage Increase the proportion of individuals who engage in physical activity >90 min/ week.in physical activity >90 min/ week.

Increase the proportion of adults who engage in Increase the proportion of adults who engage in moderate physical activity >150 min/ week or moderate physical activity >150 min/ week or vigorous activity for at least >75 min/ week.vigorous activity for at least >75 min/ week.

Evaluation ToolsEvaluation Tools

Interventions:Interventions:Physical ActivityPhysical Activity

Physical activity opportunities for each patientPhysical activity opportunities for each patient– Structured group formatStructured group format– Milieu changes such as stairs to cafeteria, walking to Milieu changes such as stairs to cafeteria, walking to

appts on campusappts on campus

Encouragement of walking in all sites. Encouragement of walking in all sites.

Enhance and document physical activity Enhance and document physical activity opportunities in vocational and residential settingsopportunities in vocational and residential settings

Motivational interventions to eliminate culture of Motivational interventions to eliminate culture of lethargylethargy

Interventions:Interventions:Physical ActivityPhysical Activity

Fitness equipment at every facility, esp aerobic Fitness equipment at every facility, esp aerobic (exercise bikes, elliptical)(exercise bikes, elliptical)– Staffed for pts and open for staff useStaffed for pts and open for staff use– Relationships with local health clubs for equip.Relationships with local health clubs for equip.

Access to fitness centers in the communityAccess to fitness centers in the community

EducationEducation– Links to obesity and cardiovascular illness and deathLinks to obesity and cardiovascular illness and death– Benefits/BarriersBenefits/Barriers– Types/Low cost optionsTypes/Low cost options– Getting started; Medical ClearanceGetting started; Medical Clearance– PostersPosters

Interventions:Interventions:Physical ActivityPhysical Activity

Sponsoring Events to promote Culture Change and Sponsoring Events to promote Culture Change and Maintain Focus Maintain Focus – Physical Activity Challenges, Workplace wellness Physical Activity Challenges, Workplace wellness

opportunities for employees opportunities for employees – NAMI WalkNAMI Walk

Peer CounselorsPeer Counselors– Peers with lived experience key component in change of Peers with lived experience key component in change of

culture; Social network inspires group change.culture; Social network inspires group change.– Increase opportunities for shared wellness opportunitiesIncrease opportunities for shared wellness opportunities– Include consumers on area Health and Wellness task Include consumers on area Health and Wellness task

forcesforces

Overweight and ObesityOverweight and Obesity

www.smallsteps.govwww.smallsteps.gov

Overweight and ObesityOverweight and Obesity

Definitions:Definitions:Healthy WeightHealthy Weight

Body Mass Index (BMI) 18-24.9Body Mass Index (BMI) 18-24.9

Overweight; Overweight; BMI 25-29.9BMI 25-29.9

ObesityObesityBMI 30-34.9BMI 30-34.9

Extreme obesityExtreme obesityBMI >35BMI >35

US populationUS population30% overweight30% overweight30% obesity30% obesity

Health RisksHealth RisksPremature deathDiabetes type IICardiovascular DiseaseDyslipidemiaHigh blood PressureOsteoarthritisStrokeSleep ApneaGall Bladder DiseaseAsthmaHirsutism /menstrual irregularitiesSocial isolationSurgical complicationsDepression

Obesity and Mental IllnessObesity and Mental IllnessEpidemic in mentally illEpidemic in mentally ill

– Multiple studies show increased incidence of overwt. and Multiple studies show increased incidence of overwt. and obesity in schizophrenia, esp womenobesity in schizophrenia, esp women

– Majority recognize the wt problem, want to/have tried to weigh Majority recognize the wt problem, want to/have tried to weigh lessless

Certain 2Certain 2ndnd gen antipsychotics (SGA) can cause rapid gen antipsychotics (SGA) can cause rapid wt gain (7 -30% of body wt) from 1wt gain (7 -30% of body wt) from 1stst sev. months of sev. months of therapy up to a yr or longer.therapy up to a yr or longer.

– Significant wt increases coincided with clozapine introductionSignificant wt increases coincided with clozapine introduction– Wt gain ranked as top “bad thing” about taking meds in UK Wt gain ranked as top “bad thing” about taking meds in UK

surveysurvey

Lifestyle modifications preferred approachLifestyle modifications preferred approach

Common Elements of Weight Common Elements of Weight Reduction ProgramsReduction Programs

Goal Setting of Realistic short-term goalsGoal Setting of Realistic short-term goals

Strategies to increase physical activity and Strategies to increase physical activity and decrease sedentary behaviordecrease sedentary behavior

Nutritional focus teaching and demo of Nutritional focus teaching and demo of healthy eating habitshealthy eating habits

Self-monitoring of nutritional intake and Self-monitoring of nutritional intake and physical activitiesphysical activities

Measures/Evaluation ToolsMeasures/Evaluation Tools

Body Mass Index (BMI)Body Mass Index (BMI) Underweight = 18 DMH 1%Optimal 18.1 -24.9 DMH 23%Overweight 25- 29.9 DMH 30%Obese 30 -39.9 DMH 34%Extremely Obese > 40 DMH 9%

Abnormal BMI addressed on all treatment Abnormal BMI addressed on all treatment plansplansStages of change approachStages of change approachSmall steps approachSmall steps approach

Interventions:Interventions: Client Education Client Education

Client Education about Nutrition and Weight Client Education about Nutrition and Weight Management Management Nutrition label readingNutrition label readingMacronutrient information (protein, carbs, fats, fiber)Macronutrient information (protein, carbs, fats, fiber)Eating behaviors and physiology; Eating behaviors and physiology;

recognizing and responding to hunger, slow eating recognizing and responding to hunger, slow eating

Substitution of healthy foods for less healthy foods; Substitution of healthy foods for less healthy foods; emphasis on addition of healthy foods rather than deprivationemphasis on addition of healthy foods rather than deprivation

Portion sizePortion sizeHigh calorie drinksHigh calorie drinksGoal setting; one change at a time.Goal setting; one change at a time.Grocery shoppingGrocery shoppingFood preparationFood preparationFast food, restaurant eatingFast food, restaurant eating

Interventions: MilieuInterventions: Milieu

Vending machines and canteensVending machines and canteens– Provision of healthy alternatives Provision of healthy alternatives

WaterWater

Fresh fruitFresh fruit

Low fat dairy productsLow fat dairy products

Substitute juice for water at med dispensingSubstitute juice for water at med dispensing

Printed materials and posters at cafeteriaPrinted materials and posters at cafeteria

Inpatient take out foodInpatient take out food– Emphasis on discretionary income, financial aspects Emphasis on discretionary income, financial aspects

recommendedrecommended

Engage staff; “biggest loser” contestsEngage staff; “biggest loser” contests

TSH: sample size 164

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

% UW % Opt % OW % OB % EO

BMI score

&

9/1/2007

12/1/2007

3/1/2008

6/1/2008

9/1/2008

SmokingSmoking

Cigarette smoking is the single most Cigarette smoking is the single most preventable cause of morbidity and preventable cause of morbidity and premature death in US for past 30 years.premature death in US for past 30 years. CDCCDC

““No other health intervention makes such a No other health intervention makes such a difference.”difference.” Schroeder SA Schroeder SA

““We cannot in good conscience ignore a We cannot in good conscience ignore a substance and practice that is the leading substance and practice that is the leading cause of morbidity and mortality in our cause of morbidity and mortality in our patients.” patients.” (NASMHPD)(NASMHPD)

Nicotine Dependence among Nicotine Dependence among Seriously Mentally Ill (SMI)Seriously Mentally Ill (SMI)

75% of SMI are tobacco 75% of SMI are tobacco dependent (22% gen pop)dependent (22% gen pop)– 85% in schizophrenia85% in schizophrenia

60 - 95% of people with addiction 60 - 95% of people with addiction disorders smokedisorders smoke44% of all US cigarette 44% of all US cigarette consumption by those with mental consumption by those with mental illness/substance abuse (SA) illness/substance abuse (SA) disorderdisorder

Nicotine Dependence among Nicotine Dependence among Seriously Mentally IllSeriously Mentally Ill

27% of consumer income went to 27% of consumer income went to cigarettes.cigarettes.

22% of consumers reported that they 22% of consumers reported that they started smoking in a psychiatric setting.started smoking in a psychiatric setting.– Metro Suburban Area Survey, Mary Ellen Foti, M.D., 1999-2000Metro Suburban Area Survey, Mary Ellen Foti, M.D., 1999-2000

40% of staff smoke versus 22% in the 40% of staff smoke versus 22% in the general population. general population. NASMHPDNASMHPD

DMH Inpatient Smoking DataDMH Inpatient Smoking Data55% smokers55% smokers in 12/07 to 45.6% 3/09 in 12/07 to 45.6% 3/09

53% have moderate to high levels of nicotine addiction where full 53% have moderate to high levels of nicotine addiction where full access to smoking is limitedaccess to smoking is limited

54% in the “precontemplation stage”54% in the “precontemplation stage”

29% contemplating a change29% contemplating a change

3% in preparation to quit3% in preparation to quit

3% in action phase3% in action phase

10% in maintenance of past successful quit attempts.10% in maintenance of past successful quit attempts.

93% of smokers were advised to quit smoking93% of smokers were advised to quit smoking

OutcomesOutcomes

Decrease number of smokers in every setting.Decrease number of smokers in every setting.

Increase the number of smokers advancing toward Increase the number of smokers advancing toward quitting as measured by stage of changequitting as measured by stage of change

Precontemplation Contemplation PreparationPrecontemplation Contemplation Preparation

Action MaintenanceAction Maintenance

Increase the number of smokers who have been Increase the number of smokers who have been given advise to quit.given advise to quit.

Increase the number of patients who have smoking Increase the number of patients who have smoking cessation interventions addressed on the treatment cessation interventions addressed on the treatment plan.plan.

Clinical and Educational Clinical and Educational InterventionsInterventions

Living and Learning: Tobacco and YouLiving and Learning: Tobacco and You group treatment group treatment manualmanualhttp://ubhc.umdnj.edu/nav/LearningAboutHealthyLiving.pdf

Motivational enhancement approachMotivational enhancement approachCO monitors, discretionary income toolsCO monitors, discretionary income tools

Educational events in all settingsEducational events in all settings Training Tobacco Treatment SpecialistsTraining Tobacco Treatment SpecialistsPharmacotherapyPharmacotherapy

Substitutes for social aspects of smokingSubstitutes for social aspects of smoking wellness walkswellness walksgroup physical activitiesgroup physical activitiesPrecede cigarette lighting on breaks with a walkPrecede cigarette lighting on breaks with a walk

Employee groupsEmployee groups

Preliminary ResultsPreliminary Results

55% smokers55% smokers in 12/07 in 12/07

45.6% 3/0945.6% 3/09

Plans to role out as a Learning Plans to role out as a Learning Collaborative to measure Collaborative to measure effectiveness of various interventionseffectiveness of various interventions(Institute of Healthcare Improvement)(Institute of Healthcare Improvement)

National Wellness SummitNational Wellness SummitWellness PledgeWellness Pledge

We Envision:We Envision: a future in which people with mental illnesses pursue optimal health, happiness, recovery, and a full and satisfying life in the community via access to a range of effective services, supports, and resources.  

We pledge:We pledge: to promote wellness for people with mental illnesses by taking action to prevent and reduce early mortality by 10 years over the next 10 year time period.