Abstract
Patients with mental illness have an increased risk of cardiovascular morbidity. The health dialogue developed in Sweden is a pedagogical tool for individualizing lifestyle advice, which is used in specific age groups to improve living habits and decrease mortality, but has not been tested. specifically for patients with mental illness. Patients & gt; Included were 18-year-olds seeking primary care for symptoms related to mental illness and diagnosed with depression, sleep disorders, stress, and anxiety. A nurse-led health dialogue was conducted, focusing on lifestyle habits, anthropometric measurements, and blood samples, leading to personalized advice on the person’s risk profile. All 64 participants had lifestyle areas with a higher level of risk. Approximately 20% had high levels of fasting glucose, blood pressure, or cholesterol, and more than 40% had the highest level of risk in the waist-hip ratio. 30% were overweight or physically inactive. The results suggest the need for a larger cohort study with long-term follow-up, to establish potentially positive effects on well-being and decreased cardiovascular risk in mentally ill patients.
Clinical Trial Registry: The study was registered at ClinicalTrials. To see also : Shawn Mendes postpones world tour to ‘take care of my mental health’.gov on January 6, 2022, registration number NCT05181254.
Introduction
Both patients with severe mental illness such as bipolarity or schizophrenia and patients with depression and anxiety have a higher risk of cardiovascular morbidity and mortality compared to the rest of the population, partly related to an increased risk of obesity. and diabetes1,2,3. Patients with mental illness in Sweden are managed at different levels, depending on the severity of the illness. Read also : The mental and physical health of infection preventionists suffered in the pandemic. Depression, anxiety, stress, or sleep disorders are common conditions that take care of primary care, while patients with the most severe psychiatric diagnosis are treated in psychiatric clinics. It is of great importance to identify high-risk patients early in order to prevent and treat high blood pressure, diabetes, hypercholesterolemia and obesity and to reduce the risk of metabolic and cardiovascular complications4.
General practitioners experience that patients with mental illness care less about lifestyle or preventative measures5. Meanwhile, patients want to be encouraged by health care to change their habits towards a healthier lifestyle6. Positive life changes and a functioning social network can contribute to a faster recovery from mental illness7. There are good examples of lifestyle interventions with physical activity and diet in primary health care for this group of patients, with significant improvements in stress, anxiety, and depression8,9. There are also indications that individualized programs provide better effects on cardiovascular health and risk factors compared to general lifestyle screening in the population10. Directed health conversations can reduce the risk of developing type 2 diabetes mellitus and cardiovascular disease11. To individualize lifestyle advice in primary care, the health dialogue developed by Swedish (Fig. 1, Appendix A) can be used as a pedagogical tool to visualize the risk score that each habit has on the risk of lifestyle-related illnesses.
Example of “Health Curve”, previously published by Ref.10.
The health assessment results in a visual color scale (Health Curve) showing a risk assessment of green to yellow, orange, and red (Fig. 1, Appendix A) to be used during health counseling. . It is based on both blood samples such as blood lipids, anthropometric measurements, and a web-based questionnaire with detailed questions on dietary habits, physical activity, inheritance, smoking, alcohol, stress, and mental illness10,12. The questionnaire should be completed prior to the scheduled health conversation as well as fasting blood test.
In a population cohort of 35-year-olds, with an intervention consisting of a health survey based on health dialogue, participants reported improvements in various lifestyle habits such as less smoking, lower fat intake, and increased physical activity13. A subsequent study showed that health dialogue is a prognostic tool for assessing the risk of developing diabetes, cardiovascular disease, and cancer14. A more recent study with long-term follow-up showed even reduced mortality after a health dialogue15.
However, the Health Dialogue is not specifically aimed at patients with mental illness, despite a potentially higher expected benefit from the intervention of this group with an increased risk of metabolic and cardiovascular complications. There are no previous studies on the effect of a systematic approach to Health Dialogue in patients with mental illness in primary care.
The main objective of this first part of the HEAD-MIP project is to make a basic description of the patient population included in the project in a primary health care center.
Methods
Patients
Patients & gt; 18-year-olds seeking a primary care center for symptoms of mental illness and a GP diagnosed with depression, anxiety, sleep disorders or stress were offered participation in the study at the same time as initiated the usual treatment (psychotherapy and / or medication). At first, patients filled out a questionnaire about lifestyle habits before the Health Dialogue at the health center. They were also designated for fasting blood sampling, blood pressure measurement, and BMI. A nurse with special training in health dialogue received the patient and offered personalized advice based on the patient’s unique conditions and the risk profile of the health dialogue, such as smoking cessation help, Swedish version of the activity physics with prescription (S-PaP). ), contact a dietitian or physiotherapist. Continued contact with a psychologist or physician was planned if necessary. Patient recruitment was done opportunistically (inclusion after a visit to a mental illness physician or psychologist) and chronologically from the start of the project in February 2020.
Primary outcome measure
Assessment of the risk profile in the Health Dialogue, self-reported responses on lifestyle (smoking, alcohol consumption, physical activity) and metabolic markers (blood sugar, lipids, BMI, blood pressure, waist-hip ratio) of the Curve of Health. See the article : Minister Magarik announces leadership changes at Department of Health and Human Services – State of Delaware News.
Data analysis and statistics
Reference data were analyzed with descriptive statistics. Group comparisons were analyzed with the Student’s t test and the χ2 test. A value p & lt; 0.05 was considered significant. SPSS version 27 (IBM Corporation®) was used for all statistical analyzes.
Ethics approval
This study was conducted in accordance with the principles of the Helsinki Declaration. Approval was granted by the Swedish Ethics Review Authority, reference number 2019-04990.
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Results
A total of 64 patients were included in the study. All patients had at least one psychiatric diagnosis, 27 patients (42%) had two diagnoses, and 8 (12.5%) even had a third psychiatric diagnosis. Initially there were 24 (37.5%) patients diagnosed with depression, 19 (29.7%) diagnosed with anxiety disorder, 22 (34.4%) diagnosed with stress-related disorder (burnout) and 23 (35.9%) diagnosed with sleep disorder. Seven patients (11%) were already at baseline diagnosed with hypertension, 3 (4.7%) with diabetes, 1 (1.6%) with cardiovascular disease, and 3 (4.7%) with hyperlipidemia.
Twenty-one percent of patients had abnormal fasting glucose values or high blood pressure and nearly thirty percent had high cholesterol levels. Twenty-three percent were very inactive and even three-quarters of patients were overweight or obese. Other features are shown in Table 1.
Risk levels were measured from the health dialogue form reports, and the results are shown in Table 2. Nearly 43% of participants had the highest risk level (4 / red) for RCE and high risk levels (3 / orange). or 4 / red) in the area of physical inactivity lifestyle.
No participants had the lowest level (1 / green) in all measured domains. Forty-nine of the 64 individuals (76.6%) had a high risk of at least 2 (yellow, orange, or red) for three or more lifestyle areas (Fig. 2).
Number of areas with a risk level of 2 (yellow) or higher, (only areas to be treated with lifestyle improvement).
More than half of the participants (54%) had the highest level of risk (3 / orange or 4 / red) in at least one of the lifestyle areas studied (Table 3).
Almost a quarter of women (23.4%) and men (23.5%) had the highest level (4) of physical inactivity with less than 500 kcal / week. Obesity (BMI ≥ 30 kg / m2) was found in 31% of women and 41% of men. There was a slightly higher proportion of overweight (BMI of 25 to 29.9 kg / m2) among men with 47% compared to 40% of women. The distribution of WHR is shown in Figure 3, which shows that half of men and 40% of women had the highest level of WHR.
Proportion of women and men at low, medium low, medium high and high risk with respect to WHR.
Comparison analyzes of groups (χ2 test and Student’s t test) of higher-risk individuals (defined as level 2 or higher in at least 2 lifestyle areas) with lower-risk individuals showed no differences in which relates to sex (p = 0.30) or age (p = 0.72).
Discussion
Main results
In this first part of the HEAD-MIP project we have made a basic description of the participants, adult patients seeking primary care for mental illness. All participants in our study reported at least one modifiable lifestyle area with an increased risk of cardiovascular disease or diabetes. WHR and physical inactivity showed high levels of risk in 43% of the patients studied. Other known risk factors such as high blood pressure, serum cholesterol, and elevated fasting blood glucose were also found in several participants, even in those without previously known chronic disease.
Comparison with other studies
Our results are comparable to the results of a screening project using the same method, carried out at the same time among people aged 40 in the general population of southern Sweden, with 411 participants included16. In our study, 88% of men and 71% of women were overweight or obese compared to 71% and 56%, respectively, of the examined population of people over 40 years of age. Compared with the general population aged 40 years, HEAD-MIP participants showed an even higher proportion of high blood pressure (21% women, 29% men versus 2% women, 13% men), abnormal values of fasting glucose (21). % women, 46% men versus 9% women, 21% men) or physical inactivity (23% women, 24% men versus 13% women, 10% men). Cohorts may not be fully comparable, as the population in the present study was larger (mean age 51.9 years) and all participants were included in the study due to psychiatric diagnoses. However, self-reported data in the screening project of 40-year-old individuals showed that 41% of women and 34% of men had felt depressed and about half of the participants had trouble sleeping during sleep. last year. Many of the participants in our study in the HEAD-MIP study were physically inactive. We believe that a targeted intervention focused on improving lifestyle in the group of patients with psychiatric illnesses could be even more cost-effective, as it has been shown that positive lifestyle changes such as improving diet and increased physical activity increases rates of remission of non-psychotic mental illness17, 18.
In the elderly, it has been shown that lifestyle habits such as smoking or low levels of physical activity can indicate mental illness such as depression19. Accumulation of various bad habits, smoking, high alcohol consumption, inactivity and poor diet, increases the risk of depression. Psychological well-being has also been shown to be influenced by lifestyle habits, with a higher degree of psychological well-being among those on a healthy diet, being physically active, and not smoking20.
Despite the small sample size of this study, it confirms the hypothesis that this group of patients needs closer attention with respect to lifestyle areas that may affect psychiatric well-being and increase the risk of developing diabetes. or cardiovascular disease. Detection of patients at higher risk allows targeted interventions to improve mental well-being but also reduce cardiovascular risk and complications. We could show that more than 20% had high blood glucose, cholesterol, blood pressure or various altered measures. Even if some of the participants had previously been diagnosed with diabetes, hyperlipemia, or hypertension, the health dialogue helped uncover impaired laboratory results even in other participants without previously known chronic disease.
The results indicate that health dialogues may be an effective method for detecting high blood glucose and blood pressure in patients with mental illness. Early detection allows for follow-up combined with treatment through lifestyle interventions and if necessary, even with medication, to prevent or at least postpone both a diagnosis of chronic disease and subsequent complications.
As far as we know, the use of a health dialogue has not been previously studied in a cohort of mentally ill patients. In the second part of the HEAD-MIP study we aim to evaluate the effect of Health Dialogue on the lifestyle habits of patients with mental illness.
Strengths and limitations
The study cohort is limited to a small sample size of patients recruited in a primary care center, therefore with little generalization. A larger cohort with greater sociodemographic representation and several primary health care centers is expected. The screening project with 40-year-olds using the same method in the same context of primary care showed good viability to the general population as well as profitability. An important limitation of our study is that we were unable to study the inclusion rate, due to the recruitment method. Several caregivers (doctors, nurses, and a psychologist) included patients opportunistically after initial contact at the primary care center for psychiatric illness. However, we believe that the inclusion method could have included a higher rate than invitation letter screening in this group of patients, a strong point of the study is therefore the opportunistic inclusion of the patient, with patients being recommended a lifestyle assessment by the caregiver, minimizing the risk of inclusion bias. Serious mental illness was not an exclusion criterion. However, patients with severe mental illness are not usually managed in primary care in Sweden and therefore none were included in this study. Therefore, our results are not transferable to this group of patients, and this is a limitation of the study. Another limitation of the study is the lack of data on the socioeconomic status of participants. Socioeconomic status is associated with a higher prevalence of tobacco, physical inactivity and poor nutrition21. Increased financial stress can also be associated with increased rates of mental illness. Even if the patients were in the same health care unit, that is, the socioeconomic status is expected to be approximately the same in n group level, there could have been individual socioeconomic differences.
Several participants in our study had an increase in fasting blood pressure and blood glucose levels. Even if these substitute measures may indicate a possible development of chronic diseases such as high blood pressure or diabetes, the diagnosis needs several valid repeated values. Another limitation is the lack of data on medications with possible side effects such as weight gain such as antipsychotics or some antidepressants. Patients with pre-existing conditions such as diabetes or hypertension diagnosed prior to inclusion in the present study were likely to have received qualified lifestyle counseling from health care personnel at the time of diagnosis. Due to the limited number of patients in the present study, no subgroup analysis was performed. Future studies should take this aspect into account.
Conclusion
Health dialogues in primary care patients with mental illness showed that all participants had at least one lifestyle area with a higher level of risk of developing diabetes or cardiovascular disease. In addition, most participants were obese, physically inactive, or both. We suggest that this group of patients should receive more care and argue that a larger cohort with long-term follow-up is highly motivated.
Data availability
The data sets used and / or analyzed during the current study available by the corresponding author upon reasonable request.
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Lingfors, H., Persson, L. G., Lindstrom, K., Bengtsson, C. & amp; Lissner, L. Effects of a global health and risk assessment tool for the prevention of ischemic heart disease in an individual health dialogue compared to a community health strategy only result from the health promotion program Live for life. Previous Med. 48, 20–24. https://doi.org/10.1016/j.ypmed.2008.10.009 (2009).
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