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IIR 09-083 – HSR&D Study

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IIR 09-083
Web-Based Delivery of MOVE! to Veterans With Serious Mental Illness
Alexander Stehle Young MD MSHS
VA Greater Los Angeles Healthcare System, West Los Angeles, CA
West Los Angeles, CA
Funding Period: September 2010 - June 2015

BACKGROUND/RATIONALE:
People with serious mental illness (SMI) are at high risk for obesity and related medical problems, and die 10 to 20 years prematurely, most commonly from cardiovascular disease. The VA has deployed a "MOVE! Weight Management Program" nationally. Since individuals with SMI usually have cognitive deficits, specialized psychoeducational interventions are needed. Specialized, in-person weight management interventions have been developed and are recommended in treatment guidelines for individuals with SMI. These programs result in weight loss when delivered in efficacy trials done with motivated patients who are paid to receive the intervention. In usual practice, these interventions are rarely provided, patient enrollment and retention are low, and effectiveness has been inconsistent. Interventions require substantial clinician time and frequent clinic visits for patients. We studied whether these barriers could be addressed using computerized provision of diet and exercise education and decision support, combined with motivation and support from peer coaches.

OBJECTIVE(S):
This project had three key objectives: 1) develop a comprehensive web-based system that delivers MOVE! using design features that meet the needs of individuals with SMI; 2) complete a randomized, controlled trial to evaluate the effectiveness, in veterans with SMI, of web-based MOVE! compared with in-person MOVE! and a control group; and 3) characterize, from the patient's perspective, the strengths, weaknesses, and barriers to the use of in-person and web-based MOVE!.

METHODS:
This was a randomized, controlled, comparative effectiveness study. Inclusion criteria included a DSM-IV diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, recurrent major depressive disorder with psychosis, or post-traumatic stress disorder; age 18 and over; receipt of an antipsychotic medication for at least 3 months; a BMI of 30 or higher (obese) or a BMI of 28 and self-reported weight gain of at least 10 pounds in the last 3 months; medical clearance to participate by a VA physician; and some control over diet. Exclusion criteria included a history of bariatric surgery; pregnant and nursing mothers; a diagnosis of dementia; current participation in weight loss groups; or psychiatric hospitalization during the month prior to enrollment.

Patients were randomized to 1) web-based weight management with peer coaching, 2) in-person clinician-led weight services, or 3) treatment as usual. Web-based weight management included 30 modules plus weekly telephonic peer coaching. The web-based system could be accessed from clinic kiosks, or anywhere there was internet access. It provided simultaneous audio and text-based education, video, pedometer tracking, goal setting, homework, diet plans, and quizzes. Coaching was delivered by individuals with lived experience with mental illness, was phone-based, and utilized motivational interviewing principles. In-person weight management included 24 sessions and had the same curriculum as the online program. These two active interventions were available for six months following enrollment. Research assessments occurred at 0, 3, 6, 9, and 12 months. The efficacy of the intervention was assessed at 6 months, when all the main outcomes were assessed and semi-structured interviews were conducted to understand barriers and facilitators to those outcomes. The maintenance of outcomes from the intervention was assessed at the 9- and 12-month brief assessments.

FINDINGS/RESULTS:
276 patients with SMI and who were overweight or obese were enrolled from a Veterans Affairs medical center. Enrolled participants included 94% males (n=259). The average age of participants was 54 years (SD=9.4) with a range of 23 to 77. The participants were 48% Black (n=131), 37% Caucasian (n=103) and other races. 65% (n=180) had a high school diploma and/or some college education, and the remainder had less education. At baseline, 232 participants (84%) were obese (BMI > 30). The 6 month retention rate was 84% (232/276) and the 12 month retention rate was 81% (223/276).

Between baseline and 6 months (intervention period), for those participants who were obese and, if randomized to an intervention, started at least one session/module, there was a time by group effect (F = 4.3, p = .01). The web-based with peer coaching group had weight loss averaging 6 pounds (t = 3.3; p < .01). No change was seen in care as usual (p = .91) or in-person services (p = .77). No effect was seen in non-obese patients (BMI < 30).

Between 6 and 12 months (maintenance period), for those participants who were obese and, if randomized to an intervention , started at least one session/module, there was an effect of time with all three groups losing a significant amount of weight (F = 23.2, p < .01), but no time by group effect. The web-based with peer coaching group had weight loss averaging 2 pounds (p < .01). The in-person group had weight loss averaging 2 pounds (p < .05). The care as usual group had weight loss averaging 4 pounds (p < .01). No effect was seen in non-obese patients (BMI < 30).

In terms of retention in the intervention, there was no difference in the percent of patients (33-34%) who completed 50% of the sessions/modules, but there was a significant difference in how many completed 100% of the intervention. 22% of patients completed the web-based program compared to 0% completing all in-person groups (chi-sq = 20; p < .001). The web-based system was well-received by patients. Patients reacted very positively to the peers, who provided motivation and social connection. Patients who failed to engage with either the web-based or in-person program did not feel losing weight was a priority.

IMPACT:
On-line weight management with peer supports can provide educational content and decision support that is tailored to individuals, convenient, and patient-centered. In those individuals who are obese, this on-line program was shown to be superior to both in-person clinician-led groups and usual care. Integration of peers and technology into care was well received. An internet-based system that helps Veterans lose weight in combination with phone-based peer support could be feasible to disseminate broadly at VA sites, including medical centers and community-based outpatient clinics serving rural and urban areas. The informatics system could be disseminated nationally for use by kiosk or internet. Web-based delivery can substantially enhance access to services that help veterans improve their diet and activity, lead to lower weight, and thereby reduce morbidity and premature death due to obesity. While this system is designed for a population with mental illness, it is quite possible that this system could also be effective in other populations that can have cognitive deficits, low literacy, or limited computer experience.

PUBLICATIONS:

Journal Articles

  1. Bennett LL, Cohen AN, Young AS. Factors Associated With Weight Intervention Participation Among People With Serious Mental Illness. The Journal of nervous and mental disease. 2018 Nov 1; 206(11):896-899.
  2. Muralidharan A, Niv N, Brown CH, Olmos-Ochoa TT, Fang LJ, Cohen AN, Kreyenbuhl J, Oberman RS, Goldberg RW, Young AS. Impact of Online Weight Management With Peer Coaching on Physical Activity Levels of Adults With Serious Mental Illness. Psychiatric services (Washington, D.C.). 2018 Oct 1; 69(10):1062-1068.
  3. Young AS, Cohen AN, Goldberg R, Hellemann G, Kreyenbuhl J, Niv N, Nowlin-Finch N, Oberman R, Whelan F. Improving Weight in People with Serious Mental Illness: The Effectiveness of Computerized Services with Peer Coaches. Journal of general internal medicine. 2017 Apr 1; 32(Suppl 1):48-55.
  4. Cohen AN, Golden JF, Young AS. Peer wellness coaches for adults with mental illness. Psychiatric services (Washington, D.C.). 2014 Jan 1; 65(1):129-30.
Center Products

  1. Young AS. Live from the Meeting: Peer Coaching and Web-based Interventions to Help Veterans with Serious Mental Illness Better Manage Their Weight [Podcast]. HSR&D; 2018 Jun 26. Available from: https://www.hsrd.research.va.gov/news/podcasts/listen.cfm?ID=35&Title=Peer.
VA Cyberseminars

  1. Young A. Improving Weight in Veterans with Serious Mental Illness: A Randomized Controlled Trial of Computerized Weight Services with Peer Coaches. VIReC Clinical Informatics Seminar [Cyberseminar]. HSR&D. 2016 Apr 19.
Conference Presentations

  1. Young AS, Cohen AN. Using consumer-facing kiosks and conjoint analysis to elicit mental health treatment preferences. Paper presented at: National Institute of Mental Health National Conference on Mental Health Services Research; 2016 Aug 2; Bethesda, MD.
  2. Young AS, Cohen AN, Goldberg R, Kreyenbuhl J, Whelan F. Improving Weight in People with Serious Mental Illness: The Effectiveness of Computerized Weight Services with Peer Coaches. Paper presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2016 Apr 1; Washington, DC.
  3. Young AS, Cohen AN, Goldberg R, Kreyenbuhl J, Whelan F. Improving Weight in Patients with Serious Mental Illness: A Randomized Controlled Trial of Computerized Weight Services with Peer Coaches. Paper presented at: American Medical Informatics Association Annual Symposium; 2015 Nov 18; San Francisco, CA.
  4. Young AS, Cohen AN, Goldberg R, Kreyenbuhl J, Hellemann G, Whelan F. Improving Weight in Veterans with Serious Mental Illness: A Randomized Controlled Trial of Computerized Weight Services with Peer Coaches. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  5. Young AS, Cohen AN, Goldberg R, Kreyenbuhl J, Hellemann G, Whelan F. The Effectiveness of Computerized Weight Management with Peer Supports for People with Mental Illness. Paper presented at: Society for Medical Decision Making Annual Meeting; 2014 Oct 21; Miami, FL.
  6. Young AS. Web-Based Delivery of MOVE! to Veterans with Mental Illness (WebMOVE!). Paper presented at: VA Mental Health Showcase; 2014 May 13; Washington, DC.
  7. Young AS, Cohen AN, Goldberg RW, Kreyenbuhl JA, Hellemann G, Nowlin FN. eWellness: Online Weight Management with Peer Supports for People with Serious Mental Illness. Paper presented at: National Institute of Mental Health Annual Conference; 2014 Apr 25; Bethesda, MD.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational, Treatment - Comparative Effectiveness
Keywords: Obesity, Outcomes - Patient, Physical Activity, Self-Care, Serious Mental Illness, Severe mental illness, Telemedicine
MeSH Terms: none