Massachusetts Department of Mental Health 
Healthy Changes Initiative

Sally Reyering, M.D., FAPA.
Sally.reyering@state.ma.us
NASMHPD Research Institute
4/14/09
Integrated Health Care:
Physical and Behavioral Health Services and Systems
Agenda
•	Project rationale
–	Mortality data
–	SAMSHA and NASMHPD calls to action

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

•	Outcome measures and evaluation tools

•	Interventions to achieve outcomes

Mortality Crisis
•	Recent data from several states have found that people with serious mental illness served by our public mental health systems die, on average, at least 25 years earlier that the general population. 
•	US Life Expectancy 2008  = 78 years
•	Serious mental illness = 53 – 57 years
–	Comparable to Cameroon, Gabon, Democratic Republic of Congo
•	Biggest lifespan disparity in U.S. 

Morbidity and Mortality ~ Causes
While suicide and injury account for about 30-40% of excess mortality, about 60% of premature deaths in persons with schizophrenia are due to “natural causes”
–	Cardiovascular disease
–	Diabetes
–	Respiratory diseases (including pneumonia and flu)
–	Infectious diseases (including HIV and Hep C)
Premature Mortality by 25 years

•	Six major causes of death in U.S
	and increased relative risk in SMI
–	Cardiovascular Disease 3.4 X
–	Cancer Maybe lower rates except lung
–	Stroke 2x in age < 50
–	Respiratory disease 5x
–	Accidents higher 
–	Diabetes 3.4x
Massachusetts Study: Deaths from Heart Disease by Age Group/DMH Enrollees with SMI Compared to Massachusetts 1998-2000
High Rates of Chronic Illness
•	70% SMI have a chronic health cond
–	Mostly pulmonary disease
•	 50% have two or more 
•	42% severe enough to limit function
•	34% HPTN
•	Hep B rates increased 5x; Hep C 11x

Calls for Action
•	SAMSHA: 
–	Increase the average life span of those with mental illness by 10 years in 10 years.
•	NASMHPD
–	13th Technical Report
•	CDC, Healthy People 2010
•	Health and Human Services; HealthierUS
•	President’s New Freedom Commission 
•	Bazelon Center For Mental Health Law

Factors Associated with Premature Death
•	Reduced Use/Inefficient Use of Medical Services

•	Poverty

•	Systemic Barriers to Ideal Health Care
–	Healthcare systems and financing

•	Psychotropic medications

•	Individual health habits
–	Smoking
–	Inactivity
–	Obesity/poor nutrition

Individual Risk Factors Associated with Early Death
•	Smoking
•	High blood pressure
•	High cholesterol
•	Diet and obesity
•	Inactivity
•	Diabetes
•	Accidents
Healthy Changes Initiative
•	The Healthy Changes Initiative is designed to address the individual’s modifiable risk factors which result in chronic illness and early death in individuals with psychiatric disabilities. 

–	Physical Inactivity
–	Overweight/Obesity
–	Smoking

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

Healthy Changes Initiative
•	Choosing
•	Healthy
•	Activities
•	Nutrition
•	Getting
•	Exercise
•	Smoking Cessation
Lifestyle Changes Work in those with Mental Illness

•	Addiction Recovery
•	Smoking Cessation
•	Prevention and reversal of antipsychotic induced weight gain
•	Development of healthy eating and exercise habits
Physical Activity

www.health.gov/paguidelines
Physical Activity:  Benefits
•	“The health benefits of physical activity are generally independent of weight.”  PAGuidelines

•	Sedentary lifestyle is an independent risk for cardiovascular death even in normal weight individuals. 
 
•	Moderate intensity exercise without dietary changes brings reduced incidence of metabolic syndrome.

Physical Activity:  Benefits
•	Strong evidence
Early death
Coronary artery disease
Stroke
High blood pressure
Adverse lipid profile
Type II Diabetes
Metabolic syndrome
Colon Cancer
Breast Cancer
Prevention of Wt Gain and to achieve weight loss
Bone health in kids
Function in older adults

•	Moderate evidence
Hip fracture, falls, bone density
Lung cancer
Endometrial cancer
Maintaining wt loss
Improved sleep quality

•	Within weeks
Increased cardiorespiratory fitness
Increased muscular strength
Decreased blood pressure
Decreased depressive symptoms

Physical Activity  
Mental Health Benefits
•	Strong evidence
Depression reduced in adults

Cognition improved in older adults

•	Other evidence
Anxiety improved 
Self-esteem
Overall well-being

•	Moderate evidence
Depression reduced in children 

Amounts 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 Activity

Special Considerations 
Physical Activity SMI
•	Inactive; start low, go slow.
•	Fear of heart attack with sensation of incr. HR, R.
•	Lack of familiarity with the sensation of muscle soreness.
•	Traumatic bodily relationships
•	Balance issues on moving treadmills; med effects
•	Cold temperatures and destimulating env
DMH Data
Physical Activity: Outcomes
http://www.healthypeople.gov/
•	Decrease the number of sedentary individuals <30 min/ week  

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

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

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

•	Engaged in physical activity for 
( ) 10 -19 minutes.
( ) 20 - 29 minutes
( ) 30 or more minutes

•	Level of above physical activity:
	( ) Light
	( )  Moderate
	( )  Vigorous
Barriers/limitations to physical activity

Interventions:
Physical Activity
•	Physical activity opportunities for each patient
–	Structured group format
–	Milieu changes such as stairs to cafeteria, walking to appts on campus

•	Encouragement of walking in all sites. 

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

•	Motivational interventions to eliminate culture of lethargy

Interventions:
Physical Activity
•	Fitness equipment at every facility, esp aerobic (exercise bikes, elliptical)
–	Staffed for pts and open for staff use
–	Relationships with local health clubs for equip.
•	Access to fitness centers in the community
•	Education
–	Links to obesity and cardiovascular illness and death
–	Benefits/Barriers
–	Types/Low cost options
–	Getting started; Medical Clearance
–	Posters

Interventions:
Physical Activity
•	Sponsoring Events to promote Culture Change and Maintain Focus 
–	Physical Activity Challenges, Workplace wellness opportunities for employees 
–	NAMI Walk
•	Peer Counselors
–	Peers with lived experience key component in change of culture; Social network inspires group change.
–	Increase opportunities for shared wellness opportunities
–	Include consumers on area Health and Wellness task forces

Overweight and Obesity

www.smallsteps.gov
Overweight and Obesity
•	Definitions:
Healthy Weight
•	Body Mass Index (BMI) 18-24.9
Overweight;  
•	BMI 25-29.9
Obesity
•	BMI 30-34.9
Extreme obesity
•	BMI >35

•	US population
30% overweight
30% obesity

Health Risks
Premature death
Diabetes type II
Cardiovascular Disease
Dyslipidemia
High blood Pressure
Osteoarthritis
Stroke
Sleep Apnea
Gall Bladder Disease
Asthma
Hirsutism /menstrual irregularities
Social isolation
Surgical complications
Depression
Obesity and Mental Illness
•	Epidemic in mentally ill
–	Multiple studies show increased incidence of overwt. and obesity in schizophrenia, esp women
–	Majority recognize the wt problem, want to/have tried to weigh less
•	Certain 2nd gen antipsychotics (SGA) can cause rapid wt gain (7 -30% of body wt) from 1st sev. months of therapy up to a yr or longer.
–	Significant wt increases coincided with clozapine introduction
–	Wt gain ranked as top “bad thing” about taking meds in UK survey
•	Lifestyle modifications preferred approach

Common Elements of Weight Reduction Programs
•	Goal Setting of Realistic short-term goals
•	Strategies to increase physical activity and decrease sedentary behavior
•	Nutritional focus  teaching and demo of healthy eating habits
•	Self-monitoring of nutritional intake and physical activities

Measures/Evaluation Tools
•	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 plans
Stages of change approach
Small steps approach
Interventions:
 Client Education
•	Client Education about Nutrition and Weight Management 
Nutrition label reading
Macronutrient information (protein, carbs, fats, fiber)
Eating behaviors and physiology; 
recognizing and responding to hunger, slow eating 
Substitution of healthy foods for less healthy foods; 
emphasis on addition of healthy foods rather than deprivation
Portion size
High calorie drinks
Goal setting; one change at a time.
Grocery shopping
Food preparation
Fast food, restaurant eating

Interventions: Milieu
•	Vending machines and canteens
–	Provision of healthy alternatives 
•	Water
•	Fresh fruit
•	Low fat dairy products
•	Substitute juice for water at med dispensing
•	Printed materials and posters at cafeteria
•	Inpatient take out food
–	Emphasis on discretionary income, financial aspects recommended
•	Engage staff; “biggest loser” contests

Smoking

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

•	“No other health intervention makes such a difference.” Schroeder SA 
 	
•	“We cannot in good conscience ignore a substance and practice that is the leading cause of morbidity and mortality in our patients.” (NASMHPD)
	
Nicotine Dependence among Seriously Mentally Ill (SMI)
•	75% of SMI are tobacco dependent (22% gen pop)
–	85% in schizophrenia
•	60 - 95% of people with addiction disorders smoke
•	44% of all US cigarette consumption by those with mental illness/substance abuse (SA) disorder

Nicotine Dependence among Seriously Mentally Ill

•	27% of consumer income went to cigarettes.

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

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

DMH Inpatient Smoking Data
•	55% smokers  in 12/07 to 45.6% 3/09   

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

•	54% in the “precontemplation stage”

•	29% contemplating a change

•	3% in preparation to quit

•	3% in action phase

•	10% in maintenance of past successful quit attempts.

•	93% of smokers were advised to quit smoking
 
Outcomes
•	Decrease number of smokers in every setting.
•	Increase the number of smokers advancing toward quitting as measured by stage of change
Precontemplation  Contemplation  Preparation
Action  Maintenance
•	Increase the number of smokers who have been given advise to quit.
•	Increase the number of patients who have smoking cessation interventions addressed on the treatment plan.
Clinical and Educational Interventions
•	Living and Learning: Tobacco and You group treatment manual
http://ubhc.umdnj.edu/nav/LearningAboutHealthyLiving.pdf
•	Motivational enhancement approach
	CO monitors, discretionary income tools
•	Educational events in all settings 
•	Training Tobacco Treatment Specialists
•	Pharmacotherapy
•	Substitutes for social aspects of smoking 
	wellness walks
	group physical activities
	Precede cigarette lighting on breaks with a walk
•	Employee groups

Preliminary Results
•	55% smokers  in 12/07 

•	45.6% 3/09

•	Plans to role out as a Learning Collaborative to measure effectiveness of various interventions
	(Institute of Healthcare Improvement)
  National Wellness Summit
Wellness Pledge
•	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: 
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.