Efforts to reduce early mortality in persons with serious mental illness (SMI) have largely focused on providing integrated primary care in a health home. Yet medical care alone accounts for a disproportionately small contribution to reductions in early morality in comparison to improving self-management and health behaviors. Illness self-management training (SMT) in the general population has been shown to improve health outcomes and lower costs associated with chronic health conditions by teaching and coaching individuals on monitoring symptoms, self-administering treatments, and improving health behaviors. More recently, the use of technologies such as Automated Telehealth (AT) has been shown to improve outcomes and potentially prevent expensive emergency room and acute hospitalizations in the general population by daily prompting of self-management and remote monitoring by a nurse who can pre-emptively intervene, guided by disease management algorithms. To our knowledge, neither of these approaches has been empirically evaluated as an integrated component in a behavioral health home for persons with SMI. We propose an RCT of 300 persons with SMI and medical comorbidity to evaluate outcomes for n=100 in a Community Based Health Home alone (CBHH), compared to n=100 also receiving Self-Management Training (CBHH+SMT), and n=100 also receiving Automated Telehealth (CBHH+AT). We will test the following 3 hypotheses: Primary H1: CBHH+SMT and CBHH+AT compared to CBHH alone, will be associated with greater health self-management (measured by the Self Rated Abilities for Health Practices Scale) and (Exploratory E1) greater mental health self-management (measured by the Illness Management and Recovery Scale) at 4, 8, 12, and 24-months. Primary H2: CBHH+SMT and CBHH+AT compared to CBHH alone, will be associated with greater reduction in risk of early mortality (as measured by the Avoidable Mortality Risk Index) and (Exploratory E2) in psychiatric symptoms (BPRS) at 4, 8, 12, and 24 months. Primary H3: CBHH+SMT and CBHH+AT compared to CBHH alone, will be associated with less acute service use (emergency room visits and hospitalizations) and (Exploratory E3) less acute service use costs at 4, 8, 12, and 24-months. In order to differentiate CBHH+SMT and CBHH+AT if both are found to be effective, we will evaluate the persistence of primary outcomes from intervention endpoint (at 12 months) to the final follow-up (at 24 months) and will calculate the additional incremental costs of implementing and providing SMT and AT. We will also explore differences in subjective health (SF-12) and in individual cardiovascular risk factors (e.g., BMI, tobacco use, blood pressure, glucose, lipids), comparing CBHH+SMT, CBHH+AT, and CBHH alone. Finally, we will explore hypothesized mechanisms of action (potential mediators) for the Aim 2 primary outcome of reduced risk of early mortality (i.e., improvement in health self-management) and for the Aim 3 primary outcome of less acute service use (i.e., medication adherence and number of nurse preemptive interventions).

Public Health Relevance

The purpose of this study is to test if we can help people with serious mental illness to better self-manage their own health and reduce the risk of dying early or of being hospitalized. We will compare 3 approaches: 1) an integrated primary care 'health home'; 2) adding training in self-management; 3) adding the use of telehealth.

Agency
National Institute of Health (NIH)
Institute
National Institute of Mental Health (NIMH)
Type
Research Project (R01)
Project #
5R01MH104555-02
Application #
8902271
Study Section
Special Emphasis Panel (ZMH1)
Program Officer
Azrin, Susan
Project Start
2014-09-01
Project End
2019-07-31
Budget Start
2015-08-01
Budget End
2016-07-31
Support Year
2
Fiscal Year
2015
Total Cost
Indirect Cost
Name
Dartmouth College
Department
Psychiatry
Type
Schools of Medicine
DUNS #
041027822
City
Hanover
State
NH
Country
United States
Zip Code
Rippberger, Peter L; Emeny, Rebecca T; Mackenzie, Todd A et al. (2018) The association of sarcopenia, telomere length, and mortality: data from the NHANES 1999-2002. Eur J Clin Nutr 72:255-263
Bartels, Stephen J; DiMilia, Peter R; Fortuna, Karen L et al. (2018) Integrated Care for Older Adults with Serious Mental Illness and Medical Comorbidity: Evidence-Based Models and Future Research Directions. Psychiatr Clin North Am 41:153-164
Naslund, John A; Aschbrenner, Kelly A; Araya, Ricardo et al. (2017) Digital technology for treating and preventing mental disorders in low-income and middle-income countries: a narrative review of the literature. Lancet Psychiatry 4:486-500
Batsis, John A; Gill, Lydia E; Masutani, Rebecca K et al. (2017) Weight Loss Interventions in Older Adults with Obesity: A Systematic Review of Randomized Controlled Trials Since 2005. J Am Geriatr Soc 65:257-268
Whiteman, Karen L; Naslund, John A; DiNapoli, Elizabeth A et al. (2016) Systematic Review of Integrated General Medical and Psychiatric Self-Management Interventions for Adults With Serious Mental Illness. Psychiatr Serv 67:1213-1225
Naslund, J A; Aschbrenner, K A; Marsch, L A et al. (2016) The future of mental health care: peer-to-peer support and social media. Epidemiol Psychiatr Sci 25:113-22
Naslund, John A; Aschbrenner, Kelly A; Marsch, Lisa A et al. (2015) Crowdsourcing for conducting randomized trials of internet delivered interventions in people with serious mental illness: A systematic review. Contemp Clin Trials 44:77-88
Bartels, Stephen J; Gill, Lydia; Naslund, John A (2015) The Affordable Care Act, Accountable Care Organizations, and Mental Health Care for Older Adults: Implications and Opportunities. Harv Rev Psychiatry 23:304-19
Naslund, John A; Marsch, Lisa A; McHugo, Gregory J et al. (2015) Emerging mHealth and eHealth interventions for serious mental illness: a review of the literature. J Ment Health 24:321-32