Disclosures: Daumit reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
June 12, 2020
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Comprehensive intervention reduces CV risk in adults with mental illness

Disclosures: Daumit reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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An intervention that integrated behavioral counseling, care management and care coordination for patients with serious mental illness significantly reduced overall CV risk, researchers reported.

“We found that the intervention resulted in a significant decrease in the estimated 10-year risk of a cardiovascular disease event measured by the global Framingham Risk Score of almost 13%,” Gail L. Daumit, MD, MHS, Samsung Professor of Medicine at Johns Hopkins University School of Medicine and director of Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness, told Healio. “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.”

Framingham Risk Score among patients with mental illness at baseline and at 18 months.

Mental illness and CVD

In the IDEAL trial published in JAMA Network Open, researchers analyzed data from 269 patients (mean age, 49 years; 48% men) who attended outpatient psychiatric rehabilitation programs and clinics and had dyslipidemia (n = 175), hypertension (n = 142), diabetes (n = 93), overweight/obesity (n = 242) and/or were current tobacco smokers (n = 138).

Gail L. Daumit

“Persons with serious mental illness like schizophrenia, bipolar disorder and major depressive disorder have a very high rate of cardiovascular disease mortality, over twice that of the overall population,” Daumit said in an interview. “This is in the U.S. and internationally. This is a large disparity and a health equity issue.”

Patients were assigned the intervention (n = 132; mean age, 49 years; 47% men) or control (n = 137; mean age, 49 years; 48% men).

The intervention included CVD risk reduction behavioral counseling with a health coach and nurse that was individually tailored to the patient. Physicians collaborated with the health coach and nurse regarding risk factor management, in addition to discussing with the mental health staff how to help the patient attain health goals. Physical activity classes and diet consultation were also offered to the patients.

Patients assigned the control were exposed to the environmental changes without individual-level intervention.

The primary outcome was a change in CV event risk from baseline to 18 months according to the global Framingham Risk Score. At 18 months, 95.2% patients had complete measures to calculate the global Framingham Risk Score.

Of the patients in the trial, 59.1% had schizophrenia or schizoaffective disorder, 14.1% had major depressive disorder and 24.9% had bipolar disorder.

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At baseline, patients assigned the intervention had a global Framingham Risk Score of 11.5% compared with 12.7% in the control group. At 18 months, this score was 9.9% in the intervention group vs. 12.3% in the control group.

Compared with the control group, the intervention group had a net percentage reduction of 12.7% for the 10-year global Framingham Risk Score (95% CI, 2.5-22.9; P = .02). This corresponds to a number needed to treat of 66 and an absolute risk reduction of 1.5%.

“There are already behavioral health homes funded through the U.S. Affordable Care Act Medicaid Health Home Waiver in 17 states and D.C.,” Daumit told Healio. “Health homes have a nurse as part of the program. There is a preexisting structure with reimbursement. These health homes or similar programs integrating physical health and mental health could be a way to implement the intervention tested in this trial.”

Future research

Even with positive results, more research is needed in this area.

“We still need to study how to best scale-up this intervention into community settings,” Daumit said in an interview. “The intervention was intense because it’s hard to change lifestyle behaviors like tobacco smoking. What kind and how much of training and support would community mental health programs need to implement this intervention with high quality? These are important research questions for next steps.”

For more information:

Gail L. Daumit, MD, MHS, can be reached at gdaumit@jhmi.edu.