Dartmouth Study Uses Peer Support, Mobile Technology, and Social Media to Improve Fitness in Young Adults with Serious Mental Illness

A new Geisel School of Medicine study aims to stem the prevalence of obesity among young adults with serious mental illness through peer support, mobile technology, and popular social media.

Kelly Aschbrenner, PhD, an assistant professor of psychiatry at Geisel and of The Dartmouth Institute for Health Policy and Clinical Practice, received a four-year, $2 million National Institutes of Health (NIH) grant to study an intervention targeting cardiometabolic risk reduction in young adults with serious mental illness, including schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder. Researchers from two Dartmouth centers are collaborating with Aschbrenner: the Health Promotion Research Center at Dartmouth (HPRCD), a designated Prevention Research Center by the Centers for Disease Control and Prevention, led by Stephen Bartels, MD, a professor of psychiatry and the Herman O. West Professor of Geriatrics, and the Center for Technology and Behavioral Health led by Lisa Marsch, PhD, the Andrew G. Wallace Professor of Psychiatry.

Young adults living with serious mental illness experience disruption in nearly all aspects of their lives leading to devastating consequences, such as unhealthy behaviors resulting in higher rates of obesity, which can set up a trajectory toward poor health for the rest of their lives. Complicating matters, the side effects related to psychiatric medications also contribute to weight gain.

Even under the best of circumstances in the general population, it is difficult to keep people engaged in sustained lifestyle and weight loss behavior change. But for those living with serious mental illness there are additional challenges—poverty, limited access to safe and affordable options for physical activity, low motivation caused by mental health conditions, and lack of social support for exercise and healthy eating.  Behavioral interventions need to include frequent prompting, reminders, positive motivation, and self-monitoring to achieve sustained behavior changes, especially for this at-risk group.

“Our research with Drs. Stephen Bartels and Sarah Pratt from the HPRCD has shown that many people with serious mental illness benefit from intensive lifestyle interventions,” Aschbrenner says. “However, it is often difficult to sustain use of these programs in real world mental health settings. In this new study, we want to see if a technology-enhanced peer-to-peer support program involving a shorter period of in-person lifestyle training is effective in helping young adults with serious mental illness lose weight and improve their fitness, and if it helps them sustain lifestyle changes over time.”

John Nalslund (L), Kelley Ashbrenner (C), and Stephen Bartels.

In an earlier pilot project, Aschbrenner and John Naslund, a PhD candidate at The Dartmouth Institute and collaborator on the NIH study, along with Bartels, developed and successfully tested a group-based program called PeerFIT using peer group support and technology (wearable fitness trackers and Facebook™) to promote healthy lifestyles in adults living with serious mental illness.

As Naslund explains, the pilot revealed that adults with serious mental illness were interested and willing to interact on Facebook and to use this popular social media platform to share personal successes and challenges, and support each other towards making healthy lifestyle changes. Wearable devices, such as the fitness-tracking Fitbit were also highly promising for supporting healthy lifestyle changes in this group. “Fitbit was especially successful—daily use rates were around 85 percent,” he says. Though the study sample was small, the encouraging results suggested that use of these new mobile technologies, in context of a broader program, could help participants achieve their physical activity goals.

But young adults typically do not share the same motivations for weight loss as their middle-age counterparts. They are more likely to focus on appearances and the social aspects of health.  Also, people who are closer in age are more likely to share common interests and goals.

For this new study, Aschbrenner, Naslund and Bartels have adapted PeerFIT for younger adults, ages 18 to 35, with serious mental illness by incorporating community-based physical activity sessions and more interactive use of popular technologies. During the initial six months, PeerFIT participants will meet in person for twice weekly sessions focusing on weight management and fitness led by a lifestyle coach.  The in-person peer group sessions are enhanced by technology, including Fitbit, a private Facebook group, and motivational text messaging support. After six months, participants transition to technology-based lifestyle support with less frequent face-to-face group sessions. The ongoing Facebook group, moderated by the lifestyle coach, allows participants to stay connected to each other while also receiving support from the coach.

“I’m interested in how we can take technology we already know people are using and leveraging it to change the way they engage in health behaviors,” Naslund says. “We know from our own research that people with serious mental illness are highly active on social media.

“With Facebook, the intention is to bring people together around a shared goal to work together towards living a healthier lifestyle and to support each other—they may not know each other, but they know they share common challenges, such as living with a serious mental illness, and common goals to be more physically active and to eat healthier foods,” Naslund adds.

The PeerFIT program will be compared with a control condition involving basic education and use of activity trackers provided one-on-one.

“Many young adults with or without mental illness want to be involved in activities that are highly interactive, engaging, and participatory,” Aschbrenner says, “and PeerFIT will play an important role in appealing to their sense of being part of a community of like people who are trying to lose weight and increase their fitness, which is very different from what’s been done in the past where many lifestyle programs are didactic or involve one-on-one coaching.

“We are testing a model that we think would be desirable to young adults, and part of this is helping them to think about how lifestyle changes will help them feel and look better—maybe it will even help them get more satisfaction from their interpersonal social interactions,” she says. “Peer-to-peer support focuses on participants helping one another increase motivation to make healthier life choices, and overcoming the severe mental health symptoms that may get in the way of living a healthy lifestyle.”

Most people want to be fit, it’s a very normalizing thing to do these days, and because of the other complicating issues in the lives of young adults with serious mental illness, using popular technologies such as Fitbit and Facebook may be more normative to them, making them feel they as though they are engaged in the same things as their peers.

“What’s exciting about this project is that we are pushing the status quo in mental health wellness programs for young adults,” Aschbrenner says. “We know young adults are generally motivated less by the health consequences of being overweight and sedentary and more by the way it makes them look and feel, and wellness programs for persons with serious mental illness have yet to be designed with this age group in mind. One goal of our project is to help young adults think about how lifestyle changes will help them with their other life goals, like building positive relationships, going back to school or getting a job, and having fun—a big motivator for this age group.”