Objectives
Persons with serious mental illnesses (SMI) have elevated rates of comorbid medical conditions, but may also face challenges in effectively managing those conditions.
Methods
The study team developed and pilot-tested the Health and Recovery Program (HARP), an adaptation of the Chronic Disease Self-Management Program (CDSMP) for mental health consumers. A manualized, six-session intervention, delivered by mental health peer leaders, helps participants become more effective managers of their chronic illnesses. A pilot trial randomized 80 consumers with one or more chronic medical illness to either the HARP program or usual care.
Results
At six month follow-up, participants in the HARP program had a significantly greater improvement in patient activation than those in usual care (7.7% relative improvement vs. 5.7% decline, p = 0.03 for group ∗ time interaction), and in rates of having one or more primary care visit (68.4% vs. 51.9% with one or more visit, p = 0.046 for group ∗ time interaction). Intervention advantages were observed for physical health related quality of life (HRQOL), physical activity, medication adherence, and, and though not statistically significant, had similar effect sizes as those seen for the CDSMP in general medical populations. Improvements in HRQOL were largest among medically and socially vulnerable subpopulations.
Conclusions
This peer-led, medical self-management program was feasible and showed promise for improving a range of health outcomes among mental health consumers with chronic medical comorbidities. The HARP intervention may provide a vehicle for the mental health peer workforce to actively engage in efforts to reduce morbidity and mortality among mental health consumers.
Persons with serious mental illness (SMI) are at elevated risk for a host of chronic medical conditions, (Jeste et al., 1996, Goldman, 2000, Dickey et al., 2002, Jones et al., 2004, Sokal et al., 2004, Carney et al., 2006, Carney & Jones, 2006, Leucht et al., 2007 and Meyer & Nasrallah, 2009). At the same time, they also face a series of barriers to effectively manage those illnesses. Physical inactivity (Brown et al., 1999 and Daumit et al., 2005), poor diet, (McCreadie et al., 1998) problems with adherence to somatic medications (Kreyenbuhl et al., 2008), and limited health literacy (Dickerson et al., 2005 and Dickerson et al., 2009) may both increase the incidence of illness and raise challenges to managing those conditions after they have developed.
Within the general medical literature, there is a growing recognition of the value of interventions that improve patient self-management of chronic medical conditions (Monninkhof et al., 2003, Chodosh et al., 2005 and Effing et al., 2007). These programs work to improve an individual's ability to manage his or her illness and health behaviors and act as an effective patient (Hibbard et al., 2004).
Peer specialists make up one of the most rapidly growing segments of the mental health workforce in the US. These peers are trained to work in a variety of different settings to promote mental health recovery and wellbeing (Davidson et al., 1999, Davidson et al., 2006 and Cook, 2005). Amidst growing concern in the mental health consumer community about elevated morbidity and premature mortality (Parks and Svedsen, 2006), mental health consumer leaders are increasingly calling for efforts to incorporate physical health and wellness into existing consumer recovery programs (Fricks, 2009). However there are currently no evidence-based interventions available to do so.
This study adapted an established medical disease self-management program to be delivered by, and to, mental health consumers. This manuscript describes the development of the program and results of a pilot study designed to assess its feasibility and potential to improve self-management and health outcomes.
A total of 80 subjects were randomized to either the HARP intervention (n = 41) or usual care (n = 39). Among those completing baseline assessments, 65 (81.2%) completed the 6-month follow-up. ( Fig. 1). Participants in the intervention group attended a mean of 4.75 (SD = 4.07) and a median of 5 sessions.
Full-size image (32 K)
Fig. 1.
Study flow chart.
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3.1. Baseline characteristics
The mean age of the population was 48; a majority (82.5%) were African American and most were poor (mean annual income $7704 ($2520, $12,306). A total of 20% of participants were uninsured, with the majority having Medicaid and/or Medicare. The most common primary mental diagnoses were bipolar disorder (32.5%), schizophrenia (28.8%), major depression (26.3%) and PTSD (11.3%). The most common medical comorbidities were hypertension (62.5%), arthritis (48.8%), asthma (22.5%), and heart disease (22.5%) (Table 1).
Table 1.
Baseline characteristics.
Variable HARP (n = 41) Usual care (n = 39) p value
Race
African American 30 (73.2%) 36 (92.3%) 0.07
White 10 (24.4%) 3 (7.7%)
Other 1 (2.4%) 0 (0%)
Gender 0.58
Female 27 (65.9%) 29 (74.4%)
Male 14 (34.1%) 10 (25.6%)
Age 47.8 +/− 10.1 48.4 +/− 10.1 0.92
Insurance 0.62
No Insurance 9 (22.0%) 7 (17.9%)
Medicare/Medicaid 30 (73.2%) 29 (74.4%)
Private Insurance 2 (4.9%) 2 (5.1%)
Annual income $10,620 (4560-14,400) $7476 (2400-9444) 0.20
Mental Diagnosis
Schizophrenia 11 (26.8%) 12 (30.8%) 0.60
Bipolar Disorder 14 (34.1%) 12 (30.8%) 0.70
Major Depression 9 (22.0%) 12 (30.8%) 0.31
PTSD 7 (17.1%) 2 (5.1%) 0.11
Medical Comorbidity
Hypertension 25 (60.9%) 25 (64.1%) 0.57
Arthritis 23 (56.1%) 16 (41.0%) 0.26
Asthma 10 (24.4%) 8 (20.5%) 0.82
Heart Disease 10 (24.4%) 8 (20.5%) 0.77
