VA patients with serious mental illnesses (SMI- e.g., schizophrenia, bipolar disorder) die an average of 13-18 years earlier compared to the general U.S. population, mostly from cardiovascular disease(CVD). Increased risk of CVD and related risk factors in persons with SMI is attributed to patient, provider, and system-level barriers. Collaborative Care Models (CCMs) can address these barriers by providing proactive care for patients through self-management education, coordination of services, and ongoing follow-up with patients and communications with providers. Life Goals Collaborative Care (LG-CC) is a CCM-based intervention developed to address physical health and CVD risk in patients with bipolar disorder, but has not been tested in a broader SMI patient population.
The goal of this randomized controlled trial (SMI Life Goals) is to determine whether LG-CC compared to usual care improves physical and mental health outcomes in 12 months among patients with SMI.
Patients diagnosed with SMI and at least one CVD risk factor receiving care at a VA mental health clinic were randomized to LG-CC or usual care. LG-CC included five self-management sessions covering mental health symptom management reinforced through healthy behavior change; care coordination and health monitoring via a registry, and provider feedback. The primary hypothesis is, within 12 months, patients randomized to receive LG-CC compared to those randomized to receive usual care will have improved physical health-related quality of life (VR-12) scores from baseline to 12 months later. Our secondary hypotheses are that compared to those enrolled in UC, patients in the LG-CC group will have reductions in CVD risk factors or psychiatric symptoms.
Out of 304 enrolled, 139 were randomized to LG-CC and 145 to UC. Among patients completing baseline assessments (N=284); the mean age was 55.2 (SD=10.9; range 28-75 years), 15.6% were women, the majority (62%) were diagnosed with depression, and the majority (63%) were diagnosed with hypertension or were overweight (BMI mean+SD=33.3+6.3). Baseline VR-12 physical health component score was below population norms (50.0+SD=10) at 33.4+11.0. Intent-to-treat analysis (N=246, thsoe completing 12-month assessments) revealed that compared to those in usual care, patients randomized to LG-CC had increased VR-12 physical health scores (coefficient=3.21;p=.01). No significant differences were found for secondary CVD risk factor outcomes excpet for reduced cholesterol (LDL) levels (coefficient-8.8, P=.04).
Patients with chronic mental disorders and cardiovascular disease risk who received a collaborative care intervention tailored to their mental health conditions had overall improved physical health-related quality of life. Findings from this RCT will inform ongoing VA transformational initiatives around behavioral health integration and preventive care implementation for Veterans with SMI and inform VA transformational initiatives including the Blueprint for Excellence goal of improving access to integrated mental and physical health treatment.
- Kilbourne AM, Bramlet M, Barbaresso MM, Nord KM, Goodrich DE, Lai Z, Post EP, Almirall D, Verchinina L, Duffy SA, Bauer MS. SMI life goals: description of a randomized trial of a collaborative care model to improve outcomes for persons with serious mental illness. Contemporary clinical trials. 2014 Sep 1; 39(1):74-85.
- Waxmonsky J, Kilbourne AM, Goodrich DE, Nord KM, Lai Z, Laird C, Clogston J, Kim HM, Miller C, Bauer MS. Enhanced fidelity to treatment for bipolar disorder: results from a randomized controlled implementation trial. Psychiatric services (Washington, D.C.). 2014 Jan 1; 65(1):81-90.
- O'Donnell AN, Williams M, Kilbourne AM. Overcoming roadblocks: current and emerging reimbursement strategies for integrated mental health services in primary care. Journal of general internal medicine. 2013 Dec 1; 28(12):1667-72.
- Goodrich DE, Kilbourne AM, Nord KM, Bauer MS. Mental health collaborative care and its role in primary care settings. Current psychiatry reports. 2013 Aug 1; 15(8):383.
- Kilbourne AM, Goodrich DE, Lai Z, Post EP, Schumacher K, Nord KM, Bramlet M, Chermack S, Bialy D, Bauer MS. Randomized controlled trial to assess reduction of cardiovascular disease risk in patients with bipolar disorder: the Self-Management Addressing Heart Risk Trial (SMAHRT). The Journal of clinical psychiatry. 2013 Jul 1; 74(7):e655-62.
- Young AS, Armstrong N, Cohen AN, Hellemann G, Reist C. Validating a Brief Measure of Mental Health Recovery. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2013 Nov 4; Boston, MA.
- Young AS, Cohen AN, Hamilton A, Glover DL, Whelan F. Implementing Evidence-Based Quality Improvement to Improve Outcomes at Mental Health Clinics. Paper presented at: AcademyHealth Annual Research Meeting; 2013 Jun 25; Baltimore, MD.
- Kilbourne AM. Multisite Randomized Controlled Trial of Life Goals Collaborative Care to Reduce CVD Risk in Patients with Serious Mental Illness. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD.
Cardiovascular Disease, Mental, Cognitive and Behavioral Disorders, Health Systems
Treatment - Comparative Effectiveness, Treatment - Efficacy/Effectiveness Clinical Trial
Bipolar Disorder, Care Coordination, Comparative Effectiveness, Depression, Outcomes - Patient, Risk Factors, Schizophrenia, Serious Mental Illness