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Dartmouth Research Aims to Reduce Cardiovascular Risk for People with Mental Illness

Only a few years ago, the thought of joining a fitness club was too frightening for Tara See to consider.

“My anxiety level had reached a point where I barely left my house,” says Tara, who was suffering from the effects of post-traumatic stress disorder (PTSD) from childhood trauma and depression, and poor physical health. “When I had my own children, the anxiety became worse. It got to the point where I couldn’t go to the store to get groceries; my husband had to do everything.”

Making Healthy Changes

With treatments and counseling from her community mental health center care team, and support from the Healthy Choices, Healthy Changes program, Tara successfully joined a gym and changed her eating habits. She’s lost 75 pounds over the past year, and now feels fit and strong. “When you are too self-conscious to even leave your house, you have no life,” says Tara. “I know it’s hard, but I tell people, just do it and don’t look back.”

Mike Goodwin underwent a similar transformation after participating in the Healthy Choices, Healthy Changes program. “It’s been a great experience,” says Mike, who has been diagnosed with bi-polar disorder and PTSD. “I’m happy to have a gym membership; I love to work out. I used to have problems with anger and went to anger management counseling, but I don’t have to anymore. I can take out my frustration on my weights and it chills me out.”

Having a gym membership and participating in the Breathe Well, Live Well program also helped him quit smoking. “I was a long-time smoker and I’d tried to quit before, cold turkey, but it didn’t work. I didn’t think I could do it, but I wanted to try,” says Mike, who hasn’t smoked now for almost two years. “I think the keys were good treatment and support from my caseworker and my family, and being able to do these programs.”

Testing Wellness Incentives

Through their participation in Healthy Choices, Healthy Changes and Breathe Well, Live Well, Tara and Mike are part of a statewide research effort testing whether providing mentoring and financial incentives—supporting exercise, improved nutrition, and smoking cessation—can help clients of the New Hampshire Community Mental Health Center system improve their cardiovascular health.

The project, called the NH Medicaid Wellness Incentives Program (NH WIP), was funded by the Centers for Medicare and Medicaid Services, and coordinated through a partnership between the Bureau of Behavioral Health and investigators affiliated with the Health Promotion Research Center at Dartmouth (HPRCD). Part of the Geisel School of Medicine, the HPRCD has received funding from the Centers for Disease Control (CDC) to conduct long-term follow-up evaluations of WIP project participants.

Anna M. Adachi-Mejia, PhD
Anna M. Adachi-Mejia, PhD

“We’re one of only 26 academic research institutions nationwide designated a Prevention Research Center by the CDC,” explains Anna Adachi-Mejia, PhD, deputy director of the HPRCD.  “The CDC and Prevention Research Center network work together to test and apply approaches that can improve the nation’s health. At Dartmouth, our primary goal is to measurably decrease cardiovascular risk factors in our region by addressing two of the CDC’s top public health priorities that they refer to as Winnable Battles—obesity and smoking.”

Reducing Cardiovascular Risk

No group has more to gain from reducing their cardiovascular risk than those who suffer from serious mental illness. “I refer to it as the most under-recognized health disparity in the nation,” says Steve Bartels, MD, MS, a professor of psychiatry and of community and family medicine at Dartmouth’s Geisel School of Medicine, who directs and is the co-principal investigator of the HPRCD.

Steve Bartels, MD, MS
Steve Bartels, MD, MS

People with serious mental illness die about 25 years earlier than the rest of the population, largely due to cardiovascular disease, Bartels says. That’s why he and his Dartmouth colleagues have been working for a number of years with the CDC and public health partners to test interventions that can make a difference in this high-risk population.

That work began about 15 years ago with the evaluation of InSHAPE, a wellness program for people with mental illness that was created by Ken Jue at a community mental health center in Keene, NH, after he noticed that many of his patients were dying from heart attacks in their mid-50s.  The innovative program, which combined individual health coaching with community engagement, would eventually be expanded to include the state’s 10 community mental health centers.

“What we found in the two randomized trials that we did, the first funded by the CDC and the second funded by the National Institute of Mental Health (NIH), was that InSHAPE was associated with a reduction in cardiovascular risk in half of the individuals who participated—that was astonishing,” says Bartels, who followed that up with a NIH-funded implementation study in NH and found similar results.

Building on InShape’s Success

Sarah I. Pratt, PhD
Sarah I. Pratt, PhD

The NH Medicaid WIP project builds upon and benefits from the infrastructure established by the InSHAPE program, says Sarah Pratt, PhD, co-principal investigator on HPRCD’s core research project. “It’s giving us an opportunity to collect long-term, follow-up outcomes data (on 1,365 people who were overweight or obese and 1,400 smokers), which is very rare in this field,” she says.

In a randomized study, the WIP project will determine if using incentives like fitness trainers, gym memberships, Weight Watchers memberships, and smoking cessation programs can help people who are Medicaid beneficiaries and have mental health challenges make measurable health improvements.

“We’re still in the process of evaluating all of our data, so the overall results aren’t available yet,” says Pratt. “But it looks very promising—we’re seeing a lot of great success stories, where people like Tara and Mike have literally turned their lives around.”

Treating the Whole Patient

The next step, says Bartels, is to figure out how evidence-based health promotion interventions like InSHAPE can be implemented in mental health organizations, even though they haven’t been part of their core services or funding. He’s just secured another grant to study this in 48 mental health organizations across the country.

“Our challenge is to find out how we can change these organizations—to not only focus on symptom resolution for people with psychiatric symptoms but also wellness as a central part of their mission,” he says.