Lisanne E. M. Koomen
Marte Z. van der Horst
Jeroen Deenik
Wiepke Cahn1,6†- 1Department of Psychiatry, UMC Utrecht, Utrecht, Netherlands
- 2Lister, Utrecht, Netherlands
- 3GGnet, Warnsveld, Netherlands
- 4GGz Centraal, Amersfoort, Netherlands
- 5School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
- 6Altrecht, Utrecht, Netherlands
Although supported housing facilities (SHF) appear to be an ideal setting for supporting people with severe mental illness (SMI) to obtain a healthier lifestyle, little is known about the effects of lifestyle interventions in SHF and the factors contributing to successful implementation. We performed a systematic review and meta-analysis to assess the effect of lifestyle interventions on mental and physical health in people with SMI in SHF, and reviewed which intervention factors contribute to successful implementation. A meta-analysis using a random effects model was undertaken. Discussions were reviewed to identify factors that foster successful implementation. Of 7401 identified studies, 9 RCTs (n = 1260) were included for the systematic review and 8 (n = 1187) for the meta-analysis. Improvements in weight (n = 3), BMI (n = 1), 6-Min Walk Test (n = 1) and metabolic criteria (n = 2) were seen. In the meta-analysis we only found a small effect for a decrease in waist circumference. Reviewing factors involved with the implementation showed that the most successfully implemented interventions were multidisciplinary and integrated into standard care. In conclusion, we found limited evidence for the effectiveness of lifestyle interventions on physical health for those living in SHF. To reliably examine the effects on mental and physical health, more studies with high involvement of staff and participants are needed.
Introduction
People with severe mental illness (SMI) often suffer from long lasting psychiatric symptoms and experience difficulties in rehabilitation. Despite current treatment options, two-thirds of patients experience long-term psychiatric symptoms that cause difficulties in day-to-day life (1–3) resulting in a lower quality of life (1). In addition, people with SMI have a 10–25 years lower life expectancy compared to the general population (4–8). The decreased life expectancy is largely due to a higher prevalence of cardiometabolic diseases (5, 7), which is mainly caused by the use of psychotropic drugs and an unhealthy lifestyle (i.e., smoking, dietary risks, and sedentary lifestyle) (4, 6, 9, 10). A meta-analysis (11) showed that in people with SMI, 50–65% were obese, 18–23% had hyperglycemia, 36% hypertriglyceridemia, 39% hypertension, and 39% low high-density lipoproteins (HDL) cholesterol. The prevalence of metabolic syndrome (MetS) was 33% and there was an increased risk of 58% on MetS compared to the general population.
Lifestyle interventions, such as promoting physical activity habits, healthy eating, and smoking cessation, can improve this impaired mental and physical health in people with SMI (12–18). Lifestyle interventions can reduce psychotic and mood symptoms, stimulate social functioning, increase quality of life, and there is early evidence that they can lower the need for psychotropic drugs (14, 15, 18, 19). Moreover, increased physical activity is associated with a decrease in all-cause mortality (20) and can reduce cardiometabolic risk factors (21).
However, in day-to-day practice, it is difficult for people with SMI to adopt and maintain a healthy lifestyle. Studies show that adherence to lifestyle interventions is low and high numbers of dropouts are reported (22–24). People with SMI experience several barriers, such as anxiety and negative symptoms, a lack of social support, knowledge, and money (25). Studies conducted in inpatient (26) and outpatient (27) settings show that there are also barriers at the staff and the organizational level that hamper successful implementation of lifestyle interventions. These barriers are a lack of time, understanding of the intervention, knowledge, and financial resources. The type of psychiatric and rehabilitation care people with SMI receive may have specific barriers and opportunities for lifestyle interventions. A significant number of people with SMI are living in supported housing facilities (SHF) and receive support in their rehabilitation and daily life. Despite the intensive and broad care that is provided, so far little attention has been paid to achieving and maintaining a healthy lifestyle. Nevertheless, SHF could be an ideal setting to support people with SMI in adopting a healthier lifestyle as people are living in their own environment and have less acute problems compared to people in inpatient care, but are guided in a more intensive way compared to an outpatient setting. Additionally, the mental health professionals in SHF are in close contact and work in a semi-intensive way with the people living in SHF and can therefore be of great value in overcoming the barriers (28).
Despite the evidence from meta-analyses on the effect of lifestyle interventions for people with SMI, no meta-analytic evidence exists for this effect in people with SMI living in SHF. This evidence would be valuable as the setting of SHF may present specific opportunities and barriers to lifestyle interventions for people with SMI and this evidence is needed to design and implement the most suitable lifestyle interventions and improve mental and physical health in this particular group and setting.
This study aimed to systematically evaluate lifestyle interventions for people with SMI in SHF to investigate which lifestyle interventions are effective in improving mental and physical health. Furthermore, we reviewed the discussions and the author’s recommendations to study which intervention factors contribute most to successful implementation and positive outcome of lifestyle interventions in this specific setting.
Methods
We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines to ensure the quality of this systematic review and meta-analysis (29).
Search strategy
The search was performed by two independent researchers (LK and MH). The databases Pubmed, Cochrane Database, PsychINFO, and Embase were systematically searched for randomized controlled trials from inception until July 2021. Combinations of the following (MeSH) terms were used: “exercise,” “lifestyle intervention,” “healthy lifestyle,” “sport*,” “physical activity,” “exercise therapy,” “diet,” “weight loss,” “stop smoking,” “quit smoking,” “smoking cessation,” “schizophrenia,” “psychosis,” “bipolar disorder,” “SMI,” “serious mental illness,” “severe mental illness.” SHF was not included in the search, but was a selection criterion in the full-text screening of the articles, so that no relevant articles were missed. The search results were limited to studies published in English or Dutch. There was no limit to date of publication. In Embase, conference papers from 2018, 2019 and 2020 were included in the search. Reference lists of relevant articles were manually examined. All manuscripts were imported into EndNote X7 software and duplicates were removed. Abstracts and titles were screened and relevant articles were retrieved for full text review.
Inclusion criteria
Studies were included if the following criteria were met: (a) the paper reported a randomized controlled trial with a lifestyle intervention (any intervention that aims to improve lifestyle habits as physical activity, dietary habits, and sleeping pattern and/or smoking); (b) participants were diagnosed with SMI (defined as a psychiatric disorder classified by the DSM-5 that causes serious limitations in psychosocial functioning for a duration of ≥2 years) and at least 50% were living in SHF, to try to ensure that the lifestyle intervention was specifically targeted and designed for this particular group of patients, and (c) the paper was published in a peer-reviewed journal or conference book. Any comparator (e.g., treatment as usual, active comparator) and all outcomes on mental and physical health will be included.
Full text articles were reviewed by two independent researchers (LK and MH). In case of disagreement of inclusion, a third researcher was consulted to reach consensus.
Data extraction
We extracted the following information from each study: authors, publication year, number of participants included in the intervention and control group, type of intervention, diagnoses of participants, living situation of participants, participant characteristics, and results. The majority of studies included participants who lived independently as well as in SHF. In these cases, the authors were emailed and requested for the data of the participants that lived in SHF, so that this specific data could be used for the analyses. If this data was not available, the number of participants living in SHF was used in the meta-analysis.
Quality assessment
Two independent researchers (LK and MH) assessed the quality of the studies using the Cochrane Risk of Bias Tool (30). The risk of bias was assessed as “low,” “some,” or “high” (31). If study protocols were available, these were also screened for quality assessment.
Strategy for meta-analyses
Meta-analysis was performed if at least three studies reported on the outcome measure. Comprehensive Meta-Analysis software was used. The random-effects model was used to analyze the data to account for the heterogeneity in study populations. For each individual study, Hedges’ g was calculated for each outcome measure in the meta-analysis. We calculated Hedges’ g in every treatment arm using the mean difference in change scores (end of treatment minus baseline) and standard deviations (SD) or pre- and post-means (± SD). We calculated all effect sizes to check for errors. Effect sizes with p < 0.05 were considered statistically significant. Hedges’ g’s of 0.20 were considered a small effect, 0.50 a medium effect, and over 0.80 a large effect (32). In addition, we performed sensitivity analyses on follow-up period, type of intervention (sports, psychoeducation), and sample size to examine sources of heterogeneity.
Factors related to successful implementation
We reviewed the discussions and the author’s recommendations of each included paper to study which intervention factors contribute most to successful implementation and positive outcome of lifestyle interventions.
Results
Search results
A flow diagram of the literature search is displayed in Figure 1. 7401 articles were screened on title and abstract and 332 studies were retrieved for full text review. 9 articles fulfilled the inclusion criteria and were used in the analyses.
Figure 1. PRISMA flow chart.
Study quality
The results of the quality assessment are listed in Table 1. All studies scored ‘high concerns’ on deviations from the intended interventions and effect of assignment to intervention, since the instructors and participants were not blinded from the assigned intervention. We therefore chose to exclude this criterion from the quality assessment. In three studies (33–35) there were ‘high concerns’ of bias, as bias may have occurred due to missing outcome data or deviations from the intended intervention due to the study context. The study of Gyllensten and Forsberg (34) failed to implement the intervention, mainly due to staffing issues, and only 5% of the participants participated in the intervention. As a result, no reliable estimate can be made of the effectiveness of the intervention and it was decided to only include this study in the review on factors associated with successful implementation.
Table 1. Overview of the outcomes of the Cochrane Risk of Bias Tool (31).
Study and participant characteristics
Study and participant characteristics are depicted in Table 2. Eight studies (28, 33, 35–40) with a total number of 1187 participants examined the effect of lifestyle interventions on mental and/or physical health in people living in SHF. Forsberg et al. reported the effect of their lifestyle intervention in the same population in two different papers, one focusing on the effect on mental health (33) and one on physical health (28). Five studies (28, 33, 36–38), with a total number of 583 participants, only included participants living in SHF. The following types of interventions were implemented: psychoeducation on healthy lifestyle (n = 6) (28, 33, 36–38, 40), group sport sessions (n = 5) (28, 33, 37, 39, 40), meetings with an individual health coach or nurse (n = 1) (40), group sessions with behavioral techniques (n = 1) (36), and changing the environment into a more health and less obesogenic environment (n = 1) (35). The control conditions consisted of: care as usual (n = 4) (35–37, 39), in which in the study of Cabassa et al. control participants were also offered health promotion groups, waiting list condition (n = 1) (38), psychoeducation on nutrition, physical activity, and health (unrelated to weight) (n = 1) (40), or an aesthetic study circle (n = 2) (28, 33). The intensity of the interventions varied, with frequencies of group classes or sports sessions ranging from one (37), to two (28, 33, 38, 39), to three times a week (36, 40).
Table 2. Overview of study and participant characteristics.
Effect of lifestyle interventions on mental health and quality of life
Literature review
The effect of lifestyle interventions on mental health and quality of life was examined by three studies (28, 37, 39). Forsberg et al. (33) found an increase of 6.4 on the global assessment of functioning (GAF) score in the intervention group and Marzolini et al. (39) found a significant improvement on the mental health inventory for the intervention group, but both studies did not find between group differences. No significant effect on the other outcome parameters regarding mental health and social functioning was found.
Meta-analysis
Various non-comparable outcome measures were used for measuring psychiatric symptoms and social functioning and therefore this data could not be used in the meta-analysis. Two studies (33, 37) examined the effect of lifestyle interventions on quality of life and found no significant a significant effect.
Physical health outcomes of lifestyle interventions
Literature review
Five studies (28, 35, 37, 39, 40) with a total of 516 participants examined the effect of lifestyle intervention on Body Mass Index (BMI). One study (37) found a significant decrease in BMI. The effect of lifestyle interventions on weight loss was studied in six studies (28, 36–40), of which three studies (37, 38, 40) found a significant decrease. No significant change in waist circumference was observed in any of the five studies (28, 35, 37, 39, 40). None of the studies found a significant change in blood pressure, total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, or HbA1C. Two (28, 35) of the three (28, 35, 36) studies that examined metabolic criteria did, however, find a significant decrease in metabolic criteria (glucose level, HDL level, triglyceride level, blood pressure and waist circumference). Lastly, two studies (36, 39) with a total number of 325 participants examined the effect on physical fitness using the 6 min Walking Test (6MWT) and in the study of Marzolini et al. (39) a superior effect over controls was found.
Meta-analysis
The meta-analysis showed a small significant reduction in waist circumference (Figure 2). On the outcomes BMI, weight, systolic blood pressure, triglycerides, HDL cholesterol and metabolic criteria no significant effect was found (Table 3).
Figure 2. Meta analysis on the effect of a lifestyle intervention on waist circumference. Hedge’s g<0 favors control and Hedge’s g>0 favors intervention.
Table 3. Overview of results of the meta-analyses.
Lifestyle habits
One study (37) examined the effect of a lifestyle intervention on self-reported physical activity (International Physical Activity Questionnaire) and eating habits, but found no significant change in both outcomes. Forsberg et al. (28) observed no change in smoking habits after a lifestyle intervention.
Sensitivity analysis
In the sensitivity analyses on follow-up duration, intervention type, and sample size, the findings were robust (see Supplementary Information).
Factors associated with successful implementation
Eight studies (28, 33–37, 39, 40) discussed the implementation of their intervention and/or reflected on barriers and facilitators of successful implementation. In the study of Gyllensten et al. (34) and the study of Cabassa et al. (36) [presented in a separate article (41)] a qualitative analysis was done to study implementation factors. In the other studies implementation factors were evaluated in the discussion of their study. Six studies described the attendance rate of the participants, these rates are depicted in Table 2.
Half of the studies discussed factors associated with staff. Looijmans et al. (35) and Cabassa et al. (36) observed large variations between implementation of the intervention between the different teams and Looijmans et al. (35) argued that the attitude of staff played an important role. Implementation was complicated if there were conflicts in role definitions, insufficient experience with motivating people for obtaining a healthy lifestyle, and conflicting lifestyle behaviors of the mental health care workers themselves. Other barriers were staff turnover (36), lack of time (34, 35) and lack of knowledge (34). Therefore, Gyllensten et al. (34) argued that designated lifestyle nurses/coaches can be useful for teams for successful implementation of a lifestyle intervention because they can support other team members and act as a source of information.
Moreover, social support and supervised group exercise were reported as important elements for success in overcoming the barriers people with SMI experience from being physically active. Group exercise with involvement of staff, family, or peers, and a devoted coach were reported as being helpful in overcoming the barriers of motivational challenges in three studies (33, 36, 39). Participants found involvement of staff and competition with staff encouraging and experienced social support (33, 34, 39).
In addition, Looijmans et al. (35) discussed that psychoeducation on healthy lifestyle should be combined with exercise for a positive impact on physical health outcomes. Gyllensten et al. (34) argued that a successful lifestyle intervention should not be too complex, as technical difficulties in implementing their computer exercise games were perceived as a major barrier that resulted in very low adherence.
Daumit et al. (40) and Verhaeghe et al. (37) recommended to implement lifestyle interventions into the regular psychiatric rehabilitation program. Daumit et al. (40) argued that this could decrease barriers and increase attendance for participants, as they already often attend the psychiatric rehabilitation center.
Discussion
This systematic review and meta-analysis examined the effect of lifestyle interventions on mental and physical health in people with SMI living in SHF. We found weak evidence for the effectiveness of lifestyle interventions in SHF on mental and physical health. A meta-analysis on mental health outcomes was not possible due to the limited number of studies and non-comparable outcome measures. More studies were performed examining physical outcome measures. Although studies reported significant improvement of weight (n = 3), BMI (n = 1), 6MWT (n = 1) and metabolic criteria (n = 2), the meta-analysis only showed a statistically significant reduction in waist circumference, with small effect size (Hedges g < 0.20). Reviewing factors involved with the implementation of lifestyle interventions showed that most successfully implemented interventions were multidisciplinary and integrated into standard care.
Our results are in contrast with previous systematic reviews that included patients from various clinical trials and hospital settings. These systematic reviews concluded that lifestyle interventions are effective in improving mental health and quality of life in people with schizophrenia and major depression (13, 15, 18). This discrepancy may be due to the to the different participant population (general SMI population vs. people with SMI living in SHF) and low number and relatively low quality of the studies included in the current analysis. Compared to a hospital setting, staffing levels are lower in SHF and implementation in the living environment may be (even) more difficult, as evidenced by the low attendance rates in most of the included studies (5 to 72%). There is often not a structured day program in which healthy lifestyle components can be implemented, as is common in hospital settings. In addition, there is less guidance for individual clients to motivate them to engage in healthy lifestyle activities compared to inpatient settings. Moreover, compared to outpatient settings, patients often face more difficulties in mental health and social functioning and may experience more barriers to participating in lifestyle interventions.
In our meta-analysis, we found that lifestyle interventions only significantly decreased waist circumference and found no difference for other physical outcome measures. Previous meta-analyses have shown conflicting effects of lifestyle interventions on physical health outcomes in people with SMI in the general community (12, 21, 42). Speyer et al. (42) found no significant difference in weight after lifestyle interventions, while Vancampfort et al. (12) found a decrease in weight, waist circumference and BMI (although the latter was only due to individual lifestyle advice and not to exercise interventions).
Studies that discussed factors associated with successful implementation of lifestyle interventions (28, 33–37, 39, 40) mainly mentioned factors related to staff (e.g., own lifestyle, attitude, conflicts in role definition and other tasks), social support, adequate supervision, knowledge of both staff and patients (i.e., psycho-education) and the importance of achievable goal setting and a multidisciplinary, integrated, and multi-component approach as essential factors. This is in line with previous research on implementation barriers and facilitators in inpatients (26) and outpatients [Hassan et al., (27)], and recent recommendations on implementation of lifestyle interventions (18, 21). To successfully and sustainably implement lifestyle interventions for people with SMI living in SHF, we emphasize the importance of a multidisciplinary, highly integrated, and multi-component approach with high support of staff, peers and family, and integration into daily rehabilitation care, so that adherence improves and dropout rates decrease.
Strengths and limitations
The greatest strength of this study is that it provides an up-to-date and extensive overview of the literature on the outcomes of lifestyle interventions in people with SMI living in SHF and provides a review of factors associated with successful implementation of lifestyle interventions. Previous meta-analyses (12–15, 21, 42) did review the literature on lifestyle interventions for people with SMI, but did not specifically address people living in SHF. However, studies conducted in this setting may provide new insights and be of special interest, as it may present a unique opportunity for the implementation of lifestyle interventions, given the semi-intensive guidance in the direct environment of patients and the close contact with mental health professionals. By thoroughly reviewing the factors associated with successful implementation of different lifestyle interventions, we contribute to the literature on implementation science of lifestyle interventions in clinical practice (43, 44). This is important as evidence on this topic is limited and essential for implementing effective and sustainable lifestyle interventions. Another strength is that the participants in the included studies are diagnosed with a broad range of psychiatric diagnoses and do well represent the “real-world” SMI population.
This study also has some limitations. First, three of the nine included studies also included participants not living in SHF. We requested data from the authors to analyze only the participants living in SHF, but only Looijmans et al. (35) responded. To correct for this potential bias in the analysis, we included only the number of participants living in SHF. Second, the methodological quality of three studies was rated as high concern of bias, mostly because of missing outcome data. The study by Gyllensten et al. (34) was also excluded from the quantitative analyses, because the intervention was hardly carried out due to personnel problems. As a result, the effectiveness of the study could not be reliably estimated. Third, the study of Daumit et al. (40) did not report p-values for systolic and diastolic blood pressure, total cholesterol, HDL cholesterol, triglycerides, and waist circumference. Therefore, we used a p-value of 0.049 for these outcome measures as confidence intervals were small. Fourth, a wide range of lifestyle interventions was included in the analysis which could have led to high heterogeneity in the analysis, we therefore conducted a sensitivity analysis in which results were similar. Fifth, four of the studies had low study samples (N < 50), which might have led to underestimation of the results because these studies were underpowered. Finally, it is important to note that the protocol of this study has not been registered prospectively.
Future research
Previous research on the effect of lifestyle interventions on mental health has shown promising results (18) and future research should be performed in this specific setting of people with SMI living in SHF, as we could now only identify three studies examining this effect. Furthermore, future studies should focus more on the role of SHF staff, as high involvement could provide an opportunity to improve attendance and dropout rates. They can play an important role in overcoming barriers such as lack of motivation due to negative symptoms, anxiety, and lack of social support, as they are an important part of the daily living environment and can motivate patients, provide social support and facilitate a supportive environment for making healthy choices (45). In addition, only two studies examined the effect of lifestyle interventions on cardiorespiratory fitness (36, 39). Physical health outcomes as cardiorespiratory fitness may be more relevant for future lifestyle studies in people with SMI since there are direct dose-response relations between cardiorespiratory fitness and all-cause mortality (46) and associations between improvement of cardiorespiratory fitness and improvements in mental health (47).
In conclusion, we found limited evidence for the effectiveness of lifestyle interventions in SHF on physical health, but could only base this on the outcomes of nine studies. To reliably examine the effects on mental and physical health more studies with high involvement of staff and participants are needed.
Data availability statement
The original contributions presented in this study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.
Author contributions
LK: study design, retrieving, processing and analyzing data, and drafting the manuscript. MH: study design, supporting retrieving, processing and analyzing data, and supporting drafting of the manuscript. JD and WC: study design, supporting analyzing data, and drafting of the manuscript. All authors critically revised the manuscript and approved the final version.
Acknowledgments
We would like to thank Janna de Boer for her helpful insights and Anne Looijmans for making the data of her study available to us.
Conflict of interest
LK was employed by Lister. MH was employed by GGnet. JD was employed by GGz Centraal. WC was employed by Altrecht.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2022.966029/full#supplementary-material
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Keywords: lifestyle medicine, severe mental illness, physical activity, healthy eating, implementation, systematic review, meta-analysis
Citation: Koomen LEM, van der Horst MZ, Deenik J and Cahn W (2022) Lifestyle interventions for people with a severe mental illness living in supported housing: A systematic review and meta-analysis. Front. Psychiatry 13:966029. doi: 10.3389/fpsyt.2022.966029
Received: 10 June 2022; Accepted: 05 October 2022;
Published: 28 October 2022.
Edited by:
Jed Boardman, King’s College London, United KingdomReviewed by:
Brynmor Lloyd-Evans, University College London, United KingdomScott Stumbo, Kaiser Permanente Center for Health Research, United States
Copyright © 2022 Koomen, van der Horst, Deenik and Cahn. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Lisanne E. M. Koomen, l.e.m.koomen-2@umcutrecht.nl
†These authors have contributed equally to this work and share last authorship