Barriers, facilitators, and effective interventions for lowering cardiovascular disease risk in people with severe mental illnesses: evidence from a systematic review and focus group study

Abstract

BackgroundPeople with severe mental illnesses die early from cardiovascular disease (CVD). They have increased CVD risk factors, yet are less likely to receive appropriate treatments. Little is known about effective interventions to reduce CVD risk in severe mental illness. This study aimed to consolidate the best available evidence on lowering CVD risk in severe mental illness in primary care. Methods75 participants took part in 14 focus groups. Participants included people with severe mental illness, general practitioners, practice nurses, community mental health staff, and carers. Staff were asked to identify the training, resources, and systems required to lower CVD risk in severe mental illness, while access to services, motivation, and capability to lower CVD risk were explored with people with severe mental illness. Effective interventions were identified through a systematic review. We searched the Cochrane Library for systematic reviews of randomised controlled trials (RCTs) and the Cochrane Schizophrenia and Cochrane Depression, Anxiety and Neurosis Group Trial Registers between 1966 and 2014 for additional RCTs. Search terms were (schizophrenia, severe mental illness, bipolar, mania, manic, hypomani*, psychos*, psychotic, rapid cycling, schizoaffective) AND (physical, cardio*, metabolic, weight, tobacco, smok, medical, alcohol, nutrition, diet, health, diabet*, blood pressure, hypertension, cholesterol, statin). Non-English language papers were excluded. Data from included studies were extracted with a template to record methodological and substantive characteristics. FindingsFocus groups identified five barriers: negative perceptions of severe mental illnesses, difficulties accessing services, difficulties managing a healthy lifestyle, not attending appointments, and lack of awareness of CVD risk. Five facilitators included social support, improving patient engagement, continuity of care, positive feedback, and goal setting. 15 systematic reviews and 28 additional RCTs were included. Effective pharmacological and behavioural interventions to manage weight and promote smoking cessation or reduction were identified. There was minimal evidence of effective interventions to reduce alcohol use and blood glucose and no evidence for interventions targeting cholesterol, hypertension, or diabetes. InterpretationCVD risk attributable to weight and smoking can be reduced in severe mental illness; other risk factors must currently be managed as for other populations. However we identified factors that can be incorporated in the design, delivery, and evaluation of services to reduce CVD risk for people with severe mental illness in primary care. New interventions should address these barriers and harness facilitating factors to reduce CVD risk in this population. FundingThis work was funded as part of a National Institute for Health Research Programme grant for applied research (ref RP-PG-0609-10156).