Elsevier

The Lancet Psychiatry

Volume 2, Issue 8, August 2015, Pages 726-742
The Lancet Psychiatry

Review
Mental health starts with physical health: current status and future directions of non-pharmacological interventions to improve physical health in first-episode psychosis

https://doi.org/10.1016/S2215-0366(15)00213-8Get rights and content

Summary

People with psychotic disorders have reduced life expectancy compared with the general population. This difference is primarily due to increased prevalence of cardiovascular disease associated with antipsychotic drugs and with modifiable risk factors, including weight gain, low exercise, poor diet, and high prevalence of cigarette smoking. We review non-pharmacological interventions for physical health behaviour in patients with chronic and first-episode psychosis. Our findings suggest that weight loss and attenuation of weight gain are achievable but limited and might not persist beyond the end of an intervention. Evidence for smoking cessation interventions is scarce. The case for early intervention to prevent deterioration of physical health is strong. We propose a framework for development of interventions, which addresses three main factors largely absent in previous research: (1) examination of aetiological factors related to poor physical health, (2) theory-driven interventions that target aetiological factors, and (3) assessment of feasibility.

Introduction

Much evidence supports that living with and receiving treatment for a psychotic disorder are associated with substantial physical health deterioration.1, 2, 3, 4 People with schizophrenia have two to three times the risk of premature death compared with the general population, and this risk has increased over the past three decades.5 The risk equates to 10–25 years of life lost for people diagnosed with schizophrenia.6 Although treatment with antipsychotic medications and inequalities of access and quality of management in health-care treatment worldwide are implicated in this increased risk,2, 7 it can also be attributed to modifiable risk factors for cardiovascular disease, such as smoking, substance use, poor diet, insufficient physical activity, and overweight and obesity.8 Interest in non-pharmacological interventions to reduce the risk of early death for people with psychosis has increased in recent years.

Several systematic reviews and meta-analyses have already assessed non-pharmacological interventions for smoking cessation or reduction,9 exercise, diet, and weight loss in individuals with severe mental illness.10, 11, 12, 13, 14, 15 However, very little research in this topic has been undertaken in patients with a first episode of psychosis. This is surprising, because significant weight gain usually occurs in the first few months after initial treatment.16 Early intervention for smoking is particularly pertinent, because smoking cessation before the age of 30 years reduces long-term health risks to levels similar to those in non-smokers.17

Our narrative Review synthesises findings on physical health interventions in populations with severe mental illness based on the limited research reported in patients with first-episode psychosis, which have largely focused on weight gain or smoking cessation. We briefly summarise the present evidence for physical health interventions, pointing to limitations that might be addressed through a proposed framework to guide development of interventions. Because development of interventions has rarely been driven by theory, with little attention paid to mechanisms of action for behaviour change, our proposed framework for early interventions to achieve many changes in behaviour around physical health is based on an empirically tested theory of motivation and behaviour change.

Section snippets

Current status of non-pharmacological interventions

The increased risk of cardiovascular disease due to overweight or obesity means that studies of interventions to improve physical health have focused primarily on how exercise and diet interventions can lead to weight loss or attenuate weight gain. Five studies12, 13, 14, 15, 18 in our Review included patients with chronic and first episodes of psychosis, and these suggest that weight loss is achievable but that the magnitude of actual loss is small, roughly 2–4% of initial bodyweight.12, 13

Diet, exercise, and smoking

To date, evidence from two randomised trials34, 21 and one controlled trial26 in patients with first-episode psychosis suggests that prevention of weight gain is an achievable outcome, but the effects are not maintained.40 Alvarez-Jimenez and colleagues21 and Curtis and colleagues26 showed that a multicomponent intervention that addressed diet and exercise resulted in less weight gain for participants who received the intervention than controls. Lovell and colleagues34 reported the results of a

A framework for development of interventions

Previous studies of interventions to improve physical health outcomes have faced challenges, including non-clinically significant weight loss, limited evidence for maintenance of weight loss, and insufficient evidence for smoking-cessation interventions. Although early intervention for physical health problems in patients with a first episode of psychosis is likely to result in improved physical and mental health outcomes, further research into long-term outcomes is needed. To address the

Conclusion

Interventions for weight loss and smoking cessation have primarily been investigated in individuals experiencing chronic forms of psychosis. It is promising to see physical health interventions being used for individuals with a first episode of psychosis, but significant research in this topic is lacking. To date, findings from intervention studies with individuals experiencing continuing psychotic illness show that weight loss is achievable—but minimal—and not sufficient to reduce

Search strategy and selection criteria

We searched Medline, Scopus, PsycINFO, and CINAHL using the terms “psychosis”, “schizophrenia”, “severe mental illness”, “serious mental illness” with “physical health”, “weight”, “diet”, “exercise”, “smoking”, “tobacco”, “nicotine”, and “intervention”, “trial”, “therapy”, and “treatment”. We included results from trials in human beings published in English language journals. Relevant references for weight loss or attenuation of weight gain and smoking cessation cited in recent meta-analyses

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