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Exercise Activates Memory Neural Networks In Older Adults

A study of cognitively healthy older adults showed that just one session of moderately intense exercise increased activation in the brain circuits associated with memory. The regions of the brain that were activated by exercise included the hippocampus, which shrinks with age and is associated with cognitive impairment, such as Alzheimer’s disease.

These findings were reported in “Semantic Memory Activation After Acute Exercise in Healthy Older Adults” by Junyeon Won, Alfonso J. Alfini, Lauren R. Weiss, Corey S. Michelson, Daniel D. Callow, Sushant M. Ranadive, Rodolphe J. Gentili, and J. Carson Smith. The researchers sought to determine how moderately intense aerobic exercise affected memory performance. A growing body of research suggests that regular participation in aerobic exercise is associated with enhanced cognitive function. However, less is known about the beneficial effects of acute exercise on semantic memory; semantic memory involves the capacity to recall words, concepts, or numbers. This study investigated brain activation during a semantic memory task after a single session of exercise in healthy older adults using functional magnetic resonance imaging (fMRI).

The study examined the mental performance of 32 physically active, right-handed older adults ages 55 to 85 years old. Potential participants were excluded if they reported a history of stroke, diabetes, high blood pressure, neurological disease, major psychiatric disturbance, substance abuse, or were taking psychoactive prescription medications. Participants were pre-screened using a structured interview questionnaire which included items pertaining to MRI safety to ensure they could participate in the MRI scan. Before the first MRI scan, participants completed a seven-day physical activity recall (PAR). PAR is a semi-structured interview that estimates an individual’s time spent in physical activity, strength, and flexibility activities for the seven days prior to the interview. The participants also completed the Mini-Mental State Examination (MMSE), a 30-point questionnaire used to screen for global cognitive impairment and dementia; their mean scores were 29.3 out of 30, indicating that the participants were cognitively normal. The participants then underwent two experimental visits on separate days. During each visit, the participants engaged in 30 minutes of rest or stationary cycling exercise immediately before performing a Famous and Non-Famous name discrimination task (FNT) during fMRI scanning. The fMRI task stimuli consisted of 30 names of easily recognizable prominent entertainers, politicians, or sports figures obtained from magazines, trivia books, and the Internet and 30 names of non-famous individuals chosen from a local phone book. For this task, the participants used a clicker to categorize the names as famous or not famous. The researchers assessed accuracy and response time.

The participants in both groups correctly categorized 92% of the non-famous names, and 88% (exercise group) to 89% (rest group) of the famous names. The response times were slightly faster among the exercise group than the rest group. However, the differences in accuracy and response times could have been due to chance.

The researchers found that the FNT comparison of exercise versus rest resulted in 13 regions showing significant semantic processing-related activation after exercise. The regions that showed significant activation included the frontal lobe, inferior temporal, middle temporal, and fusiform gyri. They concluded that the fMRI results provided evidence that a single session of aerobic exercise can influence semantic memory activation in several brain regions involved in semantic memory retrieval.

Based on their findings, the researchers concluded that greater brain activation following a single session of exercise suggests that exercise may increase neural processes underlying semantic memory activation in healthy older adults. These effects were localized to the known semantic memory network, and thus did not appear to reflect a general or widespread increase in brain blood flow.

The full text of “Semantic Memory Activation After Acute Exercise in Healthy Older Adults” was published April 25, 2019, by Journal of the International Neuropsychological Society. An abstract is available online at (accessed May 10, 2019).

For more information, contact: J. Carson. Smith, II, Associate Professor, Department of Kinesiology and Director of Kinesiology Undergraduate Honors Program, University of Maryland, 2351 SPH Building, College Park, Maryland 20742; 301-405-0344; Email:; Website:

Background & Purpose

Most individuals experience short-term sleep disturbances of one type or another, like difficulty falling asleep or staying asleep, at some point during their lifetime. These disruptions can result in decreased motivation, poor concentration, and overall reduced functioning in subsequent days. If experienced over a longer term, sleep dysfunctions can have profound impacts on a persons’ physical and mental health.*

Luckily, one easy intervention exists to combat sleep disturbances: physical activity (PA). In studies of the general population, increased PA levels demonstrated positive effects on sleep quality (e.g. sleep aspects like onset, duration, and next day impacts). Unfortunately, the same depth of studies on this interrelation for patients with serious mental illness (SMI) is lacking. This is especially problematic as individuals with SMI, when compared to the general population, experience poorer physical health and higher rates of sleep dysfunction.

Between 30-80% of individuals diagnosed with schizophrenia (SZ) experience sleep disturbances. Different sleep dysfunctions may be present throughout the course of their illness, and prevalence rates for individual disturbances vary from patient to patient. (For a more comprehensive, though not exhaustive, picture of sleep difficulties often experienced by individuals living with SZ, see Figure 1.)

Sleep dysfunction can have major implications for patient outcomes. Previous research has demonstrated correlations between positive/negative symptomology, poor cognitive functioning, difficulty with daily activities, poorer quality of life, and higher rates of obesity and cardiovascular disease and poor sleep quality. Many patients living with SZ are prescribed sleep medication or antipsychotics with sedative qualities to improve sleep. However, as patients often express treatment goals involving taking less medication, nonpharmacological interventions like increased PA may provide an alternative avenue to addressing sleep dysfunction in patients with SZ.

In a recent analysis, Raquel Costa and colleagues bolster this argument with findings from their investigation on the impact of and interrelation between improved PA and sleep quality for patients living with SZ. They reported their findings in “Sleep quality in patients with schizophrenia: The relevance of physical activity,” which was published in April 2018 in Mental Health & Physical Activity.


Burnout – measured in terms of emotional exhaustion, cynicism, and sense of professional efficacy – continues to be an issue among health care providers. Mental health providers are believed to be at a high risk for burnout due to the very nature of their jobs; they are often exposed to traumatic material and must withhold emotions and reactions while providing services. The Veterans Health Administration (VHA) is the largest single provider of mental health services, with a high percentage of the population they treat seeking services for posttraumatic stress disorder (PTSD).

There are many factors that may contribute to provider burnout at the VHA – a heavily monitored and highly public agency governed by bureaucratic and political oversight. Quality and performance of the agency is regulated by a vast number of administrative performance metrics alongside a myriad of rules and policies. On top of the sheer amount of evaluative metrics, care at the VHA must constantly live up to public scrutiny, as VHA performance is often reported to Congressional Oversight Committees and through national media outlets. Lastly, political pressure to provide specific diagnoses and treatment options to patients under their care may be a unique experience among providers at the VHA. Accessing benefits and treatment, or continuing treatment, is a major and highly-publicized concern amongst beneficiaries – and the pressure to conform to specific diagnoses or treatment against independent judgement may exist, as providers don’t want to be labeled “anti-veteran.”

A recently published article in Mental Health & Prevention, “Occupational burnout among PTSD specialty clinic providers in the Veterans Health Administration: Perceptions of bureaucratic and political oversight,” written by Hector A. Garcia, Justin K. Benzer, Elizabeth Haro, and Erin P. Finley, attempts to measure the impact of such pressures amongst VHA staff providing services through PTSD specialty clinic teams (PCTs). Specifically, the authors investigated the burnout risk and protective variables presented in Figure 1.


Background & Purpose

Unfortunately, for many individuals living with serious mental illness (SMI), presentation of their illness may include experienced lethargy, leaving them less active than their otherwise healthy peers. Additionally, some antidepressant and antipsychotic medications can place patients at a higher risk for metabolic disorder, which is associated with poorer physical health and comorbid physical health conditions like cardiovascular disease. Physical health problems can in turn depress patient mood, affect psychosocial functioning, and negatively impact other lifestyle outcomes. There is a plethora of research indicating that increased physical activity and changes to diet can positively impact patient quality of life (QoL). However, populations included in these studies have mostly been recruited from or treated in outpatient programs. Due to the limited population, findings may not be generalizable to patients living with SMI receiving treatment within an inpatient setting.

Recently, a program aimed at improving sedentary lifestyle and metabolic health was implemented amongst a patient population with SMI in an inpatient setting. This Multidisciplinary Lifestyle Enhancing Treatment For Inpatients With SMI (MULTI) demonstrated overall improvements in the physical health of patients over the long-term. If improving QoL for patients with SMI is one of mental health treatment’s key outcomes, professionals cannot ignore the benefits of physical activity and healthy lifestyle habits. However, more intangible factors of improved patient lifestyle – like psychosocial functioning and QoL – are also important, though less well-studied. Jeroen Deenik and colleagues examine the improvements in these factors amongst the MULTI participants in a secondary, cohort analysis of the program’s findings. Their study results were released in, “Improved psychosocial functioning and QoL in inpatients with severe mental illness receiving a multidisciplinary lifestyle enhancing treatment. The MULTI study II,” published in October 2018 in Mental Health & Physical Activity. In addition to investigating whether MULTI improved other lifestyle factors for inpatients with SMI, the authors also examine if physical health improvements have an amplifying effect on demonstrated positive outcomes.

Care for major depressive disorder (MDD) has come a long way. The mental health field continues to make new strides in the understanding of the underlying pathology and potential treatment for this condition. In this interview, Dr. Madhukar Trivedi provides an overview of the state of the science in 2019 related to treatment for MDD. He touches on depression biomarkers; measurement-based care; the prevalence of MDD and treatment-resistant MDD; early identification; and working towards remission.

Madhukar Trivedi, MD, is a PsychU Major Depressive Disorder Section Advisor. He is the Director of the Center for Depression Research & Clinical Care; and Betty Jo Hay Distinguished Chair in Mental Health & Julie K. Hersh Chair for Depression Research & Clinical Care at the UT Southwestern Medical Center.

A 12-month intervention program featuring integrated weight loss and mental health treatments reduced obesity and depression in program participants. For these individuals, body mass index (BMI) decreased from 36.7 to 35.9, compared to no change for those not on the program; and showed a decline in depression severity scores based on responses to a validated questionnaire from 1.5 to 1.1, compared with a change from 1.5 to 1.4 among those not on the program.

The 12-month intervention program integrated core components of two interventions for patients with both obesity and depression:

  • The Group Lifestyle Balance (GLB) program consisted of videos for self-study, which were previously demonstrated to be effective for weight loss and cardiometabolic risk reduction in primary care. The GLB program used a goal-based approach to promote modest (5%-10%) weight loss through healthy dietary changes with reductions of 500 to 1000 kilocalories per day and at least 150 minutes of moderate-intensity physical activity (eg, brisk walking) per week.
  • The Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) used problem-solving treatment with behavioral activation strategies, supplemented with as-needed stepwise increases in doses and number of antidepressant medications. The study intervention integrated these two independent programs a two-phased curriculum which included nine individual face-to-face sessions lasting 60 minutes each (four weekly, two biweekly, and then three monthly sessions), and 11 home-viewed GLB videos lasting 20 to 30 minutes each watched over a six-month period. The maintenance phase included monthly telephone sessions lasting 15 to 30 minutes each for six additional months

A health coach and dietitian delivered the intervention using input from a psychiatrist and primary care physician to determine the exact needs of each participant. Participants received self-care materials, including intervention handouts, a DVD set or an online access code for the GLB videos, a wireless activity tracker with replacement batteries, and written instructions for creating a account to track weight and dietary intake. A trained bachelor’s-level health coach delivered the intervention, and a supervising master’s-level registered dietitian oversaw fidelity assurance.

These findings were reported in “Effect of Integrated Behavioral Weight Loss Treatment and Problem-Solving Therapy on Body Mass Index and Depressive Symptoms Among Patients With Obesity and Depression; The RAINBOW Randomized Clinical Trial” by Jun Ma, M.D., Ph.D.; Lisa Goldman Rosas, Ph.D., MPH; Nan Lv, Ph.D.; et al. The researchers enrolled 409 participants with a BMI of 30 or greater, 9-item Patient Health Questionnaire (PHQ-9) scores of 10 or greater, and no serious comorbidities in the Research Aimed at Improving Both Mood and Weight (RAINBOW) program. The PHQ-9 is a 9-question instrument given to patients in a primary care setting to screen for the presence and severity of depression, with possible scores ranging from 0 (no depression) to 27 (severe depression); the eligibility cutoff at 10 or above indicated at least moderate depression. Participants were randomly assigned to the intervention program (204 participants), or a usual care control group (205 participants). Both groups received medical care from their personal medical professionals as usual, received information on routine services for obesity and depression at their clinic, and received wireless physical activity trackers. Intervention participants also received a 12-month intervention that integrated a Diabetes Prevention Program–based behavioral weight loss treatment with problem-solving therapy for depression and antidepressant medications, if warranted. All participants were again evaluated for obesity and depression following 6, 12, 18, and 24 months on their respective treatment programs, and followed the same assessment protocols as those used at baseline. The goal was to test whether an integrated collaborative care intervention would significantly improve both obesity and depression at 12 months, compared with usual care.

The integrated collaborative care intervention program synergistically combined two evidenced-based programs:

  • The Group Lifestyle Balance (GLB) program: a program adapted from the Diabetes Prevention Program, consisting of short videos for self-study, and focused on modest, 5%-10% weight loss via healthy dietary changes with reductions of 500 to 1000 calories per day, combined with at least 150 minutes of moderate-intensity physical activity per week.
  • The Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) program used problem-solving treatment with behavioral activation strategies as first-line, combined with antidepressant medications as needed.

Both the GLB and PEARLS programs are disseminated through trainings and certifications provided to physicians and non-physician practitioners in diverse disciplines nationwide. Reimbursement is possible through Medicare and private insurers for patients with qualifying conditions.

At six months, the between-group mean differences between the two groups were already statistically significant, which sustained through 12 months. At six months, the intervention group showed a mean BMI change of -0.6 (compared to no change for those not on the program), and the intervention group showed a mean depression score that was 0.3 lower than those not on the program.

The researchers concluded that a collaborative care intervention that includes concurrent weight loss treatment, problem-solving therapy, and as-needed antidepressant medications significantly improved weight loss and depressive symptoms at 12 months, compared with usual care. However, they caution that effect sizes were modest, and clinical importance is unknown.

The full text of “Effect of Integrated Behavioral Weight Loss Treatment and Problem-Solving Therapy on Body Mass Index and Depressive Symptoms Among Patients With Obesity and Depression; The RAINBOW Randomized Clinical Trial” was published March 5, 2019, by JAMA. An abstract is available online at (accessed March 20, 2019).

For more information, contact: Sharon Parmet, Director of Health Sciences and Research Communications, University of Illinois at Chicago, 1200 West Harrison Street, Chicago, Illinois 60607; 312-413-2695; Email:; Website:; or Jun Ma, M.D., Ph.D., FAHA, FABMR, Director, Center for Health Behavior Research, University of Illinois Institute for Health Research and Policy, 1747 West Roosevelt Rd, Room 586, MC 275, Chicago, Illinois 60608; 312-413-9831; Email:

A tobacco quit line program for low-income individuals was 7.9% more effective among Medicaid participants who received financial incentives for engaging with tobacco treatment. Paying financial incentives to low-income individuals participating in a smoking cessation program resulted in higher participation in quit line calls, and a higher likelihood of abstinence at a six-month follow-up. About 21.6% of those who received financial incentives were abstinent at the six-month follow-up, compared to 13.8% of those who did not receive incentives.

These findings were reported in “Paying Low-Income Smokers to Quit? The Cost-Effectiveness of Incentivizing Tobacco Quit Line Engagement for Medicaid Recipients Who Smoke” by Marlon P. Mundt, Timothy B. Baker, David L. Fraser, Stevens S. Smith, Megan E. Piper, and Michael C. Fiore of the University of Wisconsin School of Medicine and Public Health. The researchers recruited and paid 948 participants to take calls from a tobacco quit line counselor, with a biochemical test that verified tobacco abstinence at six months. An unpaid control group of 952 individuals was also used. The researchers then analyzed costs and effectiveness from a health-care systems perspective over a six-month follow-up, based on the incremental cost-effectiveness ratio (ICER), a statistic used in cost-effectiveness analysis to summarize the cost-effectiveness of a health care intervention. The goal was to determine the cost-effectiveness of an incentive-based stop-smoking intervention that paid Medicaid recipients who smoke to take calls from a tobacco quit line.

The researchers concluded that the use of financial incentives to engage with tobacco quit-line treatment was a cost-effective option to enhance smoking cessation rates for low-income smokers. The key findings were as follows:

  • The ICER of the financial incentives for tobacco treatment engagement was $2,316 per additional person who quit.
  • The study ICER of $2,316 compares favorably with the ICER other smoking treatments, such as varenicline combined with proactive telephone counseling. The ICER for varenicline plus telephone counseling has been estimated at $2,600 per additional smoker who quit.

The full text of “Paying Low-Income Smokers to Quit? The Cost-Effectiveness of Incentivizing Tobacco Quit Line Engagement for Medicaid Recipients Who Smoke” was published in the February 2019 issue of Value in Health. An abstract is available online at–Issue-2/Paying-Low-Income-Smokers-to-Quit–The-Cost-Effectiveness-of-Incentivizing-Tobacco-Quit-Line-Engagement-for-Medicaid-Recipients-Who-Smoke (accessed March 4, 2019).

For more information, contact: Marlon P. Mundt, Ph.D., Associate Professor, Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, 110 Delaplaine Court, Madison, Wisconsin 53715; 608-268-1419; Email:; or Betsy Lane, Chief Marketing and Communications Officer, International Society for Pharmacoeconomics and Outcomes Research, 505 Lawrence Square Boulevard South, Lawrenceville, New Jersey 08648; 609-586-4981,ext. 112; Fax: 609-586-4982; Email:

Background & Purpose

One of the barriers to helping individuals living with major depressive disorder (MDD) reach recovery is that depression often goes undiagnosed and untreated. A variety of symptoms associated with the illness may impact an individual’s participation in activities and within society, including lethargy (i.e. lack of energy) and anhedonia (i.e. lack of interest in activities that the individual used to enjoy). Additionally, experienced stigma related to mental health conditions may prevent individuals from seeking treatment on their own. Addressing these burdens is paramount to helping individuals reach recovery and improve their quality of life.

Available data suggests that increased physical activity may be associated with reduced risk of depression. It stands, therefore, that a measured lack of mobility may provide insight into individuals at risk, or insight into those who are experiencing depressive symptomology; low mobility measures may be able to serve as proxies for experienced lassitude or anhedonia. But measurement in mental health can be challenging. Often, outcomes or experiences are measured using patient self-report, which can produce inaccurate or incomplete data for analysis.

To overcome hurdles related to self-report data collection and to reach patients in their everyday environments, researchers are starting to investigate passive data collection methodology to measure mobility. This methodology relies on collecting data using existing applications or utilities available on a wearable or portable device, such as a smartphone. Smartphones are an apt choice for such collection, as they are a nearly ubiquitous technology for adults in the United States and may come with built-in utilities such as accelerometers or global positioning systems (GPS). For a researcher measuring mobility, these applications can provide captured data related to travel speed, travel distance, and physical movement throughout the day – provided the individual maintains contact with the charged device.

The use of smartphone mobility passive data collection in mental health research is only beginning. One looming question over this data’s utilization is, “Do these proxies really measure risk or experienced symptomology for MDD?” That’s precisely what Brenna Renn and colleagues set out to investigate in their recent article, “Smartphone-based passive assessment of mobility in depression: Challenges and opportunities,” which was published in April 2018 in Mental Health & Physical Activity.

On December 17, 2018, the U.S. Department of Health & Human Services (HHS) Pain Management Best Practices Inter-Agency Task Force (Task Force) released a draft report on pain management that recommended a biosocial, multi-modal, and multidisciplinary approach to chronic and acute pain management. Currently, inconsistencies and fragmentation of pain care limit best practices and consumer outcomes. The Task Force believes a coherent policy for pain management within health systems is needed to address challenges and gaps that affect special populations, and gaps stemming from stigma, education, and access to care. Multi-modal, non-opioid therapies are underutilized in the perioperative setting. Clinical policies tend to employ simple medication rules to treat the large population of consumers with multiple conditions causing chronic pain.

HHS released these recommendations in “Pain Management Best Practices Inter-Agency Task Force: Draft Report On Pain Management Best Practices: Updates, Gaps, Inconsistencies, & Recommendations.” The Comprehensive Addiction and Recovery Act (CARA) of 2016 led to the creation of the Pain Management Best Practices Inter-Agency Task Force (Task Force). The Task Force’s mission is to determine whether gaps in, or inconsistencies between, best practices for acute and chronic pain management exist, and to propose updates and recommendations to those best practices. The Task Force consists of 29 experts who have significant experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, and minority health. The HHS is also accepting public comments until April 1, 2019, before they submit the finalized report to Congress.

The researchers made the following high-level best-practice updates and recommendations. Details of these recommendations were further broken down in the report:

  1. Balanced pain management should be based on a biopsychosocial model of care. This approach systematically considers biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery.
  2. Provide individualized, patient-centered care. This is vital to addressing the public health pain crisis.
  3. Ensure better and safer opioid stewardship through risk assessment based on an individual’s medical, social, and family history to ensure safe and appropriate prescribing.
  4. Employ a multidisciplinary approach to chronic pain that focuses on the individual’s medical condition, co-morbidities, and various aspects of care including appropriate medications for the individual. This approach can include restorative movement therapies such as physical and occupational therapy, massage therapy, and aqua therapy; minimally invasive procedures that may be important for both forms of pain; complementary and integrative health such as acupuncture, yoga, tai chi, and mediation; and appropriate behavioral and psychological interventions such as teaching coping skills and providing cognitive behavioral therapy.
  5. Employ a multi-modal approach to acute pain in the surgical, injury, burn, and trauma setting. This approach combines pharmacologic and nonpharmacologic techniques may prevent development of chronic pain in those with severe or persistent pain.
  6. Provide perioperative surgical and acute pain guidelines to provide a framework for improved surgical experience and outcomes.
  7. Address drug shortages that might affect pain care.
  8. Improve health care coverage to provide better access to care, and larger variety of treatment types. This will provide a greater number of pain specialists and behavioral health clinicians to help guide and support appropriately trained primary care clinicians.
  9. Provide empathy and a non-judgmental approach to improve treatment and outcome to prevent stigma.
  10. Increase through societal awareness, provider education and training, and patient education regarding chronic and acute pain. This helps individuals understand choices and promotes therapeutic alliances between health care consumers and health care providers.
  11. Employ innovative solutions to pain management such as telemedicine, tele-mentoring, mobile apps for behavioral and psychological skills, newer medicines, and medical devices to assist with pain management.
  12. Encourage research to develop a better understanding of the mechanisms of pain, preventive measures, the use of innovative medical devices and medications to prevent the acute-to-chronic pain transition, and methods to improve outcomes of chronic pain conditions.
  13. Consider the unique issues related to pain management in special populations such as older adults, pregnant women, those with sickle cell disease, those with chronic pain relapse, racial and ethnic populations, and military personnel and veterans.

For more information, contact: Alicia Richmond Scott, Designated Federal Officer, Pain Management Best Practices Inter-Agency Task Force, U.S. Department of Health and Human Services, Office of the Assistant Secretary for Health, 200 Independence Avenue SW, Room 736E, Washington, District of Columbia 20201; 240-453-2816. Email:

Why any given experience should induce one person to adapt, while another is edged toward a maladaptive stress response that could ultimately lead to psychiatric illness, is not clearly understood. However, new insights are emerging.

In this webinar, Dr. Aida Mihajlovic and Dr. Greg Mattingly discuss how the influences of nature and nurture shape an individual’s response to stress, and what the field of mental health has learned about building resilience in individuals living with mental illness.

Aida Mihajlovic, MD, MS, is a Clinical Assistant Professor of Psychiatry at UIC; Member of the American Psychiatric Association Disaster Psychiatry Committee; Member of the GAP Committee on Political Violence & Terrorism; Fellow of the American College of Psychiatrists; Board Member at AASP; Council Member of the Illinois Psychiatric Society; and Chair of the Women’s Committee of the Illinois Psychiatric Society.

Greg Mattingly, MD, is an Associate Clinical Professor at Washington University School of Medicine; Principle Investigator of Clinical Trials at Midwest Research Group; Founding Partner at St. Charles Psychiatric Associates; Board Member at Headway House; Member of the Board of Directors at the American Professional Society of ADHD & Related Disorders; and Certified Evaluator for ADHD / Head Concussions for the National Football League.

On January 14, 2019, CVS Health (NYSE: CVS) announced a $100 million commitment to support community health initiatives over the next five years through the company’s “Building Healthier Communities” initiative. The initiative will be a joint effort between the company, its CVS Health Foundation, and the Aetna Foundation. CVS completed a $69 billion acquisition of Aetna in November 2018.

Exact amounts of program investments are yet to be determined. Senior Director of CVS Corporate Communications, Joe Goode, says that “funds will be disbursed across the key categories, and that our strategy is to identify programs, partners and solutions that drive the most meaningful impact at the local level.” Investments of the Building Healthier Communities program will include:

  1. Expansion of the CVS Health Project Program. This program provides health screenings to underserved populations which can help detect early risk factors for chronic conditions.
  2. Funding to support efforts of organizations that combat chronic conditions or diseases, like the American Cancer Society and the American Diabetes Association. For example, CVS is partnering with the American Heart Association to install blood pressure kiosks in highly-trafficked areas to decrease high blood pressure, which is a particular problem among women.
  3. Organizations fighting the opioid epidemic. For example, CVS is partnering with Easterseals to prevent and mitigate prescription drug abuse among our nation’s veterans.
  4. CVS’ “Be the First” youth tobacco prevention program, which includes e-cigarette education, healthy behaviors programming and national and local partnerships with organizations like Campaign for Tobacco-Free Kids, CATCH Global Foundation, CDC, and Truth Initiative.
  5. Continue to support community-based organizations that address public health. This includes support for the Healthiest Communities rankings that evaluates the health of nearly 3,000 communities nationwide and identifies the best approaches for improvement.
  6. Pledge at least $10 million in value of volunteer hours each year by CVS Health and Aetna employees to create healthier, more sustainable communities.

CVS Health is a health innovation company helping people on their path to better health. CVS operates more than 9,800 retail locations, and more than 1,100 walk-in medical clinics. CVS Caremark, the company’s pharmacy benefits manager, has approximately 94 million plan members, and the CVS dedicated senior pharmacy care business serves more than one million consumers per year.

Mr. Goode advised organizations interested in applying for funding or learning more about CVS Health’s corporate giving or community grant-making organizations to inquire at

For more information, contact: Joe Goode, Corporate Communications, CVS Caremark Corporation, One CVS Drive, Woonsocket, Rhode Island 02895; 401-770-9820; Email:; or Ethan Slavin, Communications Director, Aetna, 151 Farmington Avenue, Hartford, Connecticut 06156; 860-273-6095; Email:

On December 19, 2018, Optum announced that the federal Department of Veterans Affairs (VA) selected OptumServe to provide 12-month telephone lifestyle coaching (TLC) services in a pilot with the Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention. The services are for eligible veterans receiving care from the VA at 20 medical centers in Minnesota, Missouri, and Nebraska and their corresponding community-based outpatient clinics. The contract is structured as an indefinite delivery, indefinite quantity (IDIQ) contract with an initial 12-month contract term followed by four 12-month renewal options.

The request for proposals (RFP 36C24518R0176) was released on June 25, 2018, with proposals due by July 17, 2018. The VA did not report the number of proposals received or the names of unsuccessful bidders. The contract was awarded in September 2018. No minimum or maximum contract value has been announced.

The coaching is focused on helping veterans maintain a healthy diet, increase their physical activity, manage their weight and stress, stop smoking, and limit alcohol use. A qualified lifestyle coach will provide scheduled calls to veterans enrolled in the program. Participants will also be able to call the coaching lines outside of scheduled appointments. Veterans will be referred to the program via the VA “Patient Aligned Care Team” (PACT)/primary care, or extended PACT staff, who will enter a Computerized Patient Record System (CPRS) consultation request which shall be accessed by the contractor whose staff shall then call the veteran. The calls will take place at regular intervals, with greater frequency at the start of the service.

The VHA National Center for Health Promotion and Disease Prevention (NCP), in partnership with the VHA Office of Rural Health, is focused on decreasing risky health behaviors as an important strategy to reduce the large burden of chronic disease within the veteran population seen in the VHA health care system and improve overall health and well-being. The VA piloted the TLC service at 24 selected VA medical centers from 2011 through 2013. The pilot services were provided by Free & Clear under a contract awarded on June 29, 2011, valued at $4.5 million. The pilot offered veterans six different TLC programs: dietary change, physical activity, weight management, smoking cessation, stress management, and unhealthy alcohol use. Veterans could participate simultaneously in as many of the six as they desired. Each program offered 10 coaching sessions over a six-month period.

The pilot implementation and outcomes were analyzed in “Implementation Evaluation Of The Telephone Lifestyle Coaching (TLC) Program: Organizational Factors Associated With Successful Implementation” by Laura J. Damschroder, Caitlin M. Reardon, Nina Sperber, Claire H. Robinson, Jacqueline J. Fickel, and Eugene Z. Oddone. More than 9,000 veterans were referred to the TLC program operated by Free & Clear. Of those referred, 5,321 (57%) completed at least one coaching session and self-reported their lifestyle behaviors six months after enrollment. Among these veterans, 40% quit smoking and 25% lost more than 5% of their baseline weight. The goal of the study was to identify facility-based contextual factors that influenced implementation of the TLC program to inform future scale-up and implementation. The NCP determined that the services were effective for health behavior change across a variety of behaviors, including dietary change, physical activity, weight management, smoking cessation, stress management, and unhealthy alcohol use.

OptumServe provides health services and expertise to federal agencies. OptumServe partners with the Departments of Defense, Health and Human Services, Veterans Affairs and other organizations. OptumServe is part of Optum, an information and technology-enabled health services business, which is part of UnitedHealth Group.

The full text of “Implementation Evaluation Of The Telephone Lifestyle Coaching (TLC) Program: Organizational Factors Associated With Successful Implementation” was published in the June 2017 issue of Translational Behavioral Medicine. An abstract is available online at

For more information about the contract, contact: Aaron Albright, Director, External Communications, Optum, Inc., 11000 Optum Circle, Eden Prairie, Minnesota 55344; Email:; or Public Relations, U.S. Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, District of Columbia 20420; 202-461-7600; Email:

For more information about the study findings, contact: Laura J. Damschroder, Corresponding Author, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System (152), 2800 Plymouth Road, Building 16, Ann Arbor, Michigan 48105; Email:

On December 10, 2018, the Pennsylvania Department of Human Services (DHS) announced that all tobacco, e-cigarettes, and vapes had been banned at all six state behavioral health hospitals. This includes Clarks Summit State Hospital, Danville State Hospital, Norristown State Hospital, Torrance State Hospital, Warren State Hospital, and Wernersville State Hospital. The facilities instead offer smoking cessation programs, individualized support as needed, nicotine patches, and nicotine gum for residents. No information about funding for the program by the State are available.

The cessation initiative comes in response to a November 2017 summit to address the high prevalence of smoking among adults with behavioral health disorders in Pennsylvania. The goal of the summit was to find applicable solutions to reduce tobacco use among individuals with behavioral health conditions. Sixty-two participants from more than 40 organizations throughout Pennsylvania, and across the country, attended. During the summit, the participants agreed that 100% of State mental health treatment facilities and State substance abuse treatment facilities should be tobacco-free by 2020.

The full text of “Pennsylvania State Strategy Session for Tobacco-Free Recovery: Draft Action Plan” was published December 4, 2017 by the University of California, San Francisco Smoking Cessation Leadership Center (SCLC). A copy is available online at

For more information, contact: Colin Day, Press Secretary, Pennsylvania Department of Human Services, Post Office Box 2675, Harrisburg, Pennsylvania 17105-2675; 717-425-7606; Email:

About 70% of physicians who use electronic health records (EHRs) report health information technology (HIT) stress. HIT stress was defined as the presence of at least one of: poor/marginal time for documentation, moderately high/excessive time spent on the electronic health record (EHR) at home, and agreement that using an EHR adds to daily frustration.

These findings were reported in “Physician Stress And Burnout: The Impact Of Health Information Technology” by Rebekah L Gardner, Emily Cooper, Jacqueline Haskell, Daniel A. Harris, Sara Poplau, Philip J Kroth, and Mark Linzer. In 2017, the researchers analyzed the HIT survey conducted by the Rhode Island Department of Health (RIDOH) and its public reporting contractor, Healthcentric Advisors. The survey has been administered in the State since 2009 to all 4,197 participating physicians regarding their HIT use. The 2017 survey resulted in 1,792 responses. Questions about HIT use include EHR adoption; use of EHR functionality; electronic prescribing; health information exchange; and the effect of technology on work flow, care of the health care consumer, and job satisfaction. Burnout was measured using a single question from the survey, which asked participants to indicate their level of work enjoyment, including level of any burnout experienced. The goal was to determine how stress related to HIT use predicts burnout among physicians.

Additional findings include:

  • About 91% of respondents reported using an EHR; about 10.9% of these worked with a medical scribe.
  • About 82.9% of physicians that use EHRs access the system remotely. About 59.7% of these said they most often use remote access because they could not complete their work during regular business hours.
  • The specialties with the highest prevalence of HIT-related stress are: orthopedic surgery (86.5%), general internal medicine (86.0%), and family medicine (83.2%).
  • About 77.6% of emergency physicians report that EHRs add to the frustration of their day; it was the most commonly cited stress measure in almost every specialty, with the highest prevalence among emergency physicians.

About 27.2% of physicians who use EHRs reported one or more symptoms of burnout. Burnout is defined as a psychological syndrome in response to chronic interpersonal stressors on the job; responses may include an overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment. Physicians that report poor or marginal time for documentation had 2.8 times the odds of burnout symptoms compared to doctors without that pressure. Physicians that report moderately high/excessive time on EHRs at home had 1.9 times the odds of burnout symptoms compared to those with minimal or no use at home. Physicians that agree that EHRs add to their daily frustration had 2.4 times the odds of burnout than those who disagreed.

The researchers concluded that HIT-related stress is predictive of burnout symptoms. They recommend that health care organizations recognize HIT-specific factors associated with burnout to measure those factors in their workforce and use their findings to alleviate burnout among their physicians and staff.

The full text of “Physician Stress And Burnout: The Impact Of Health Information Technology” was published December 5, 2018 in the Journal of the American Medical Informatics Association. An abstract is available online at

PsychU reported on this topic in “Primary Care Doctors Spend More Than 50% Of Workday On Documenting In The EHR,” which published on December 4, 2017.

For more information, contact: Mollie Rappe, Ph.D., Life Sciences Writer, Brown University, South Street Landing, Floor 5, Box 1920, 350 Eddy Street, Providence, Rhode Island 02903; 401-863-1862; Email:

Background & Purpose

Young adulthood is a time of life with unique developmental characteristics, including assuming responsibility for one’s health and health care. It is also a time during which chronic mental health issues often emerge; past research has shown that 75% of major depressive disorders first occur by age 24 years, and young adults 18-24 years of age have the highest mental illness prevalence of any age group, with 6.4 million affected.

While the majority of young adults access and use health care (e.g., 59% of men and 81% of women age 18-26 years visited a doctor in the last 12 months), a significant proportion do not. This, in part, may be due to lack of access or the absence of symptoms requiring medical care.

However, many health risk behaviors (e.g., tobacco use, physical inactivity) often emerge in young adulthood, worsen over time, and are associated with greater risk for cancer and other chronic health conditions. It has been established that adults with mental health problems are more likely than those in the general population to have at least one medical or chronic health problem, but few studies have examined links between mental health issues, health risk behaviors, and health service use in young adults.

In a recent study entitled “Mental Health Problems and Cancer Risk Factors Among Young Adults,” Greta M. Massetti and colleagues analyzed Behavioral Risk Factor Surveillance System (BRFSS) data collected in 2014 to examine possible links between mental health problems and health status, including cancer risk factors and health service use, in 90,821 adults age 18-39.

On September 18, 2018, Cigna announced that it will be using Omada Health to expand its Diabetes Prevention Program (DPP), effective in January 2019. The new offering will provide Cigna beneficiaries with an expanded suite of personalized, user-friendly digital health tools to help prevent the onset of diabetes and other chronic diseases. DPP will be available at no charge to members of Cigna-administered national and regional employer health plans. Prior to this national launch, Cigna and Omada Health ran a series of pilot programs with several large employer clients.

The DPP is a digital lifestyle program that encourages behavior changes under the guidance of a personal health coach. Peer group support also offers encouragement to members. According to the Omada Health website, the program helps participants track weight, food, and activity to discover current habits and opportunities for change with the use of a digital app. This is done using a smart scale that syncs with the participant’s user account to track progress over time, a food tracking app that offers insight to eating habits, and user account synchronization to a phone or fitness device to track steps over time. A health coach helps participants through challenges; simple and fun weekly lessons help participants learn about – and manage – food, activity, sleep, and stress; and tips are provided by both the health coach and peers via the app based on participants’ habits and interactions. The app offers personal challenges to support progress, reminders at key moments (based on usage), and assigns a small support group to personalize the experience.

According to the 2016 Omada Diabetes Prevention Program Study (Full Year), these pilots demonstrated positive participant results in the form of average sustained weight loss of 3.5% to 5% of their body weight beyond one year; net medical cost savings of $424 to $972 over two years, compared to non-participants, equating a return on investment (ROI) between 1.5:1 to 2:1 for employers; and 83% of participants said they would recommend the program to a friend.

Omada Health is a digital intensive behavioral counseling program focused on reducing costly chronic disease in employer and health plan populations. The company received full recognition status of its DPP from the Centers for Disease Control and Prevention on May 30, 2018. As of May 30, more than 150,000 participants had enrolled in the DPP.

For more information, contact: Ellie Polack, Director, External Communications, Cigna Corporation, 3 Waterside Crossing, Windsor, Connecticut 6095; 860-902-4906; Email:; or Sean Duffy, Chief Executive Officer, Omada Health, 500 Sansome Street, Suite 200, San Francisco, California 94111; 888-987-8337

When health care executives discuss the overlap between behavioral health care, physical health care, and social services, the conversation is often to identify some condition that is equally important to all three disciplines. One condition that can be a large part of those strategies—and one that more specialty provider organizations need to start considering—is obesity.

Obesity is defined in adults as a body mass index (BMI) of 30 or higher; among youth, the definition is statistical and is based on comparison to a reference population. And earlier this year, we looked at how obesity is directly tied to life expectancy, after researchers estimated that 11.7% of the deaths among people ages 40 to 84 were due to complications of obesity and the CDC identified 14 different health conditions that are directly related to obesity, including clinical depression, anxiety, and other mental disorders (see Managing Obesity In Managing ‘Whole Person Health’ and Mental Health & Metabolic Wellness Series: Focus On Weight & Obesity).

How prevalent is this condition now? In 48 states, more than 25% of the adult population was obese as of 2017, according to research from Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF). The adult obesity rate was highest in West Virginia, at 38.1%, and lowest in the District of Columbia (23.8%) and Hawaii (23%). Adult obesity rates exceeded 30% in 29 states and met or exceeded 35% in seven states. Since 1988, adult obesity rose from an age-adjusted national average of 22.9% to the 2015-2016 national average of 39.6%.

On September 9, 2018, the U.S. Preventive Services Task Force (USPSTF) said intensive, multicomponent behavioral weight loss intervention for adults with a body mass index (BMI) of 30 or higher can lead to clinically significant reductions in BMI and reduce the incidence of type 2 diabetes among obese adults. After reviewing the evidence-base for behavior- based weight loss (80 trials), behavior-based weight loss maintenance (9 trials), pharmacotherapy-based weight loss (32 trials), and pharmacotherapy-based weight loss maintenance (3 trials), there were a couple key findings.

First, intensive, multicomponent behavioral interventions and behavior-based weight loss maintenance interventions are of moderate benefit. These interventions can lead to clinically significant improvements in weight status and reduce the incidence of type 2 diabetes among adults with obesity and elevated plasma glucose levels. Second, interventions that combined pharmacotherapy with behavioral interventions reported greater weight loss and weight loss maintenance over 12 to 18 months compared with behavioral interventions alone.

If you are a behavioral health specialty provider organization, the question is: Should you embed any of these approaches into your service models? To answer that question, consider the strong link between obesity and the complex consumer population. Some studies have found that 80% of consumers with diagnoses of schizophrenia, bipolar disorder or depression are overweight or obese. The rate of obesity among adults with I/DD is as high as 58.5%. Children and young adults with autism spectrum disorder (ASD) are twice as likely to be overweight and nearly five times as likely to be obese than those that aren’t. And a 2016 review of medical records from U.S. children with autism showed much higher rates for hypertension, high cholesterol and nonalcoholic fatty liver disease. And finally, obesity at age 50 is associated with increased risk for dementia.

And if you’re evaluating adding weight management as part of your care coordination programs, recent research provides some interesting food for thought. According to a 2017 study, online weight management tools and weekly peer coaching resulted in greater weight loss for people with serious mental illness than in person clinic visits—another reason to be thinking about how to incorporate virtual health in your care coordination models. What are the kind of approaches—with savings that cross over into physical health care and have big effects on a consumer’s total health care costs—that will get the attention of payers and health plans? One example is The Providence Center in Rhode Island, which uses InShape, a wellness program that provides “one-on-one physical fitness and mental health support for adults of all ages”. The program pairs clients with health mentors who are certified personal trainers and experienced case managers. Other pilot programs and studies have shown demonstrable results and led to new programing. An Arizona CMHC tested the Nutrition and Exercise for Wellness and Recovery (NEW-R) curriculum, which is an 8-week program designed to help consumers with serious mental illness lose weight by focusing on nutrition, physical activity, and behavior changes. The program was shown to help participants to manage their weight, and the curriculum is now available to other mental health provider organizations through the Center on Integrated Health Care & Self-Directed Recovery at the University of Illinois.

About 14% of adults in the United States have diabetes, and 4.3% of them are undiagnosed. About 8.5% of adults in the United States have been diagnosed with Type 2 diabetes, and 0.5% have been diagnosed with Type 1.

These findings were reported in two studies. The national prevalence of diabetes was reported in “Prevalence of Total, Diagnosed, and Undiagnosed Diabetes Among Adults: United States, 2013–2016” by Nicholas D. Mendola, M.P.H.; Te- Ching Chen, Ph.D.; Qiuping Gu, M.D., Ph.D.; Mark S. Eberhardt, Ph.D.; and Sharon Saydah, Ph.D.; with the National Center for Health Statistics. The study is based on data from the National Health and Nutrition Examination Survey (NHANES). The goal was to present the prevalence of total, diagnosed, and undiagnosed diabetes in U.S. adults in 2013 through 2016. The key findings were as follows:

  • The prevalence of total diabetes was 14.0%; the prevalence of diagnosed diabetes was 9.7%; and the prevalence of undiagnosed diabetes was 4.3% among U.S. adults.
  • The prevalence of total (diagnosed and undiagnosed) diabetes was 15.9% among men, and 12.2% among women.
  • The prevalence of total, diagnosed, and undiagnosed diabetes increased with age.
  • The prevalence of total, diagnosed, and undiagnosed diabetes was higher in Hispanic adults than in non-Hispanic white adults. The prevalence of total and diagnosed diabetes was higher among non-Hispanic black adults compared with non-Hispanic white adults.
  • The prevalence of total, diagnosed, and undiagnosed diabetes increased with increasing weight status category.

The national prevalence by type of diabetes was reported in “Prevalence of diagnosed type 1 and type 2 diabetes among U.S. adults in 2016 and 2017: population-based study” by Guifeng Xu, Buyun Liu, Yangbo Sun, Yang Du, Linda G Snetselaar, Frank B Hu, and Wei Bao. The study is based on data from the National Health Interview Survey (NHIS). The goal was to develop benchmark estimates on the national prevalence of diagnosed type 1 and type 2 diabetes. The key findings were as follows:

  • Among the 58,186 who responded to the NHIS in 2016 and 2017, 6,317 had been diagnosed with diabetes. The weighted population prevalence of diagnosed total diabetes was 9.7%, with 0.5% diagnosed with type 1 diabetes, and 8.5% diagnosed with type 2 diabetes.
  • Diagnosed type 1 diabetes was more prevalent among adults with lower education level. Diagnosed type 2 diabetes was more prevalent among older adults, men, and those with lower educational level, lower family income level, and higher body mass index (BMI).
  • Among the 6,317 diagnosed with diabetes, 5.6% were diagnosed with type 1 diabetes, and 91.2% were diagnosed with type 2 diabetes.

The full text of “Prevalence of diagnosed type 1 and type 2 diabetes among U.S. adults in 2016 and 2017: population based study” was published September 4, 2018, by British Medical Journal. A free abstract is available online at

For more information, contact:

  • National Center for Health Statistics, S. Centers for Disease Control and Prevention, 3311 Toledo Road, Hyattsville, Maryland 20782; 800-232-4636; Email:
  • Wei Bao, D., Ph.D., Assistant Professor, Department of Epidemiology, College of Public Health, University of Iowa, 145 N Riverside Drive, Room S431 CPHB, Iowa City, Iowa 52242; Email:

In 48 states, more than 25% of the adult population was obese as of 2017. The adult obesity rate was highest in West Virginia, at 38.1%, and lowest in the District of Columbia (23.8%) and Hawaii (23%). Adult obesity rates exceeded 30% in 29 states and met or exceeded 35% in seven states. Since 1988, adult obesity rose from an age-adjusted national average of 22.9% to the 2015-2016 national average of 39.6%. Obesity is defined in adults as a body mass index (BMI) of 30 or higher; among youth, the definition is statistical and is based on comparison to a reference population.

These findings were reported in “The State of Obesity 2018: Better Policies for a Healthier America” by Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF). The findings are based on an analysis of the federal National Health and Nutrition Examination Survey (NHANES) through 2016, and the Centers for Disease Control and Prevention’s (CDC’s) 2017 Behavioral Risk Factors Surveillance Survey (BRFSS).

Additional findings were as follows:

  • At least 20% of adults are obese in every state.
  • Obesity rates were highest in the South (32.4%) and Midwest (32.3%), followed by the Northeast (27.7%) and West (26.1%).
  • Women had a higher average obesity rate (41.1%) than men (37.9%).
  • Adult obesity rates vary by race and Among Blacks, about 46.8% are obese. Among Latinos, about 47.0% are obese. Among Whites, about 37.9% are obese. Among Asians, about 12.7% are obese.
  • As of 2016, obesity rates are nearly 60% higher among adults without a college education.
  • Generally, the more someone earns, the less likely they are to have obesity. During the 2011 to 2014 time-frame, about 6% of adults with incomes of 100% to 400% of the Federal Poverty Level (FPL) are obese. About 29.7% of adults with incomes exceeding 400% of the FPL are obese. The exception is the very poor, who had a 39.2% obesity rate.
  • As of 2016, adult obesity rates were 19% higher in rural regions than they were in metro areas.

The full text of “The State of Obesity 2018: Better Policies for a Healthier America” was published on September 12, 2018, by Trust for America’s Health. An abstract is available online at

For more information, contact: Information Office, Trust for America’s Health, 1730 M Street NW, Suite 900, Washington, District of Columbia 20036; 202-223-9870; Fax: 202-223-9871; Email:

On September 9, 2018, the U.S. Preventive Services Task Force (USPSTF) said intensive, multicomponent behavioral weight loss intervention for adults with a body mass index (BMI) of 30 or higher can lead to clinically significant reductions in BMI and reduce the incidence of type 2 diabetes among obese adults. Adults in the U.S. with a BMI of 30 or higher are considered “obese”.

The recommendations were issued in “Behavioral Weight Loss Interventions to Prevent Obesity-Related Health Problems, Death in Adults” by the USPSTF. The USPSTF reviewed the evidence on interventions (behavioral and pharmacotherapy) for weight loss or weight loss maintenance that can be provided in, or referred from, a primary care setting. Surgical weight loss interventions and non-surgical weight loss devices were not included in the review. The goal was to update the USPSTF 2012 recommendations on screening for obesity in adults.

The USPSTF reviewed the evidence-base for four types of interventions. The analysis did not identify the specific interventions used in the trials. The four types are: behavior-based weight loss (80 trials), behavior-based weight loss maintenance (9 trials), pharmacotherapy-based weight loss (32 trials), and pharmacotherapy-based weight loss maintenance (3 trials).

The intensive behavioral interventions used in the trials were designed to help participants achieve or maintain weight loss of 5% or more through a combination of dietary changes and increased physical activity. Most of the interventions lasted for 1 to 2 years, and the majority had at least 12 sessions in the first year. Most behavioral interventions focused on problem solving to identify barriers, self-monitoring of weight, peer support, and relapse prevention. The interventions also provided tools to support weight loss or weight loss maintenance, such as pedometers, food scales, or exercise videos. Some of the interventions were modeled on the Diabetes Prevention Program lifestyle intervention for use in a primary care or community setting.

The key findings were as follows:

  • Intensive, multicomponent behavioral interventions in adults with obesity are of moderate benefit. These interventions can lead to clinically significant improvements in weight status and reduce the incidence of type 2 diabetes among adults with obesity and elevated plasma glucose levels.
  • Behavior-based weight loss maintenance interventions are of moderate These interventions are associated with less weight gain after the cessation of weight loss interventions.
  • Potential harms are small to none for intensive, multicomponent behavioral interventions (including weight loss maintenance interventions) in adults with obesity.
  • Interventions that combined pharmacotherapy with behavioral interventions reported greater weight loss and weight loss maintenance over 12 to 18 months compared with behavioral interventions alone. However, the participants in these trials were required to meet selective inclusion criteria, such as adherence to taking medication, and meeting weight loss goals; and the trials had high attrition rates. It was unclear how well participants tolerated the medications, and whether the findings are applicable to the general primary care population. Data were lacking about maintenance of improvement after discontinuation of the medications.

USPSTF concluded with moderate certainty that offering (or referring) adults with obesity to intensive behavioral interventions or behavior-based weight loss maintenance interventions has a moderate net benefit. The recommendation encouraged primary care professionals to refer adults with a BMI of 30 or higher to behavior-based interventions.

The full text of “Behavioral Weight Loss Interventions to Prevent Obesity-Related Health Problems, Death in Adults” was published September 18, 2018, by JAMA. An abstract is available online at

For more information, contact: U.S. Preventive Services Task Force, 5600 Fishers Lane, Mail Stop 06E53A, Rockville, Maryland 20857; Email:

In this short interview, Robert Bransfield, MD, DLFAPA, provides an expert point of view on his research paper published in Neuropsychiatric Disease & Treatment in June 2017, “Suicide and Lyme and Associated Diseases.” Dr. Bransfield shares his insights regarding the correlation between Lyme Disease and psychiatric disorders. You can also read a summary of his original research on PsychU here.

On February 28, 2018, Health Partners Plans (HPP), a not-for-profit health plan in Pennsylvania, released a “call to action” report on positive outcomes resulting from a partnership with the Metropolitan Area Neighborhood Nutrition Alliance (MANNA). MANNA is a Philadelphia non-profit organization whose goal is to bring food to those in the area who have serious diseases. HPP implemented MANNA’s “Food as Medicine Model,” and as of February, had provided more than 530,000 medically tailored meals to its most chronically ill Medicaid and Medicare members with life-threatening illnesses such as diabetes, heart disease, malnutrition, and kidney failure. The program also offers medical nutrition therapy to these members.

Due to the overall success of the program, HPP recommends that health plans across the U.S. implement Food as Medicine. As of May 2017, HPP found the following program results:

  • 100% of those surveyed said the food provided met their medical needs.
  • 100% of those surveyed said that they were better prepared to make healthier food choices.
  • 97% of those surveyed said that they had health goals prior to the program, and that MANNA helped them meet their particular health goals.
  • Hemoglobin HbA1c results were strong: Of 742 members reporting, about 2% reported lower levels, and 59.4% reported steady levels, within six months after starting the program.
  • Medical costs showed improvements in the areas of hospital admissions (decreased 27.7%), emergency room visits (decreased 9%), primary care physician visits (decreased 15.9%), and specialist visits (decreased 7.1%).

The results of the effort are detailed in “Food as Medicine Model: A Framework for Improving Member Health Outcomes and Lowering Health Costs,” by Health Partners Plans. Since 2015, HPP tracked work done by the team during the program, and results reported by recipients who volunteered health data during their time on the program. The goal was to demonstrate the potential success of, and outcomes for those served by, the Food as Medicine Model. Information on program implementation is also available in the document.

The program originally targeted 200 HPP Medicaid diabetic members but grew to 1,900 members with a number of chronic conditions. Participating members receive 21 meals per week and nutrition counseling, with the goal of reducing Hemoglobin A1c. Services are provided for six weeks, with up to two renewals. Provided meals are tailored to the participant’s particular dietary needs, and may be low or high calorie, high in protein, low in salt, low in fat, or have limited carbohydrates to improve a participant’s health.

Despite the success of the program, it is not a standard benefit for Medicare or Medicaid. However, private Medicaid and Medicare plans have the ability to spend government funding on services outside direct medical care.

To qualify for the Food as Medicine Model, potential participants must be in active case management for one or more chronic conditions, demonstrate a willingness to change their behavior, demonstrate a willingness to make dietary changes to improve their medical condition, demonstrate willingness to work with their HPP care manager, and must be willing to understand how portion control plays a role in their health outcome.

The full text of “Health Partners Plans Publishes Results of Groundbreaking Food is Medicine Program in Call to Action” was published February 28, 2018 by Health Partners Plans.

The full text of “Food as Medicine Model: A Framework for Improving Member Health Outcomes and Lowering Health Costs” was published January 9, 2018 by Health Partners Plans.

For more information, contact: Monet Irving, Health Partners Plans, 901 Market Street, Suite 500, Philadelphia, Pennsylvania 19107; 267-385-3802; Email:; or Laura Payne, Senior Manager of Marketing & Events, The Metropolitan Area Neighborhood Nutrition Alliance (MANNA), 420 North Street, Philadelphia, Pennsylvania 19130; 215-496-2662; Email:

Wellness Interventions for Life’s Demands (WILD-5) Wellness Program is a unique, five-element mental wellness program focused on self-directed, daily interventions including physical exercise, mindfulness, sleep, improved social connectedness, and nutrition. The program utilizes a 5-item wellness survey called the HERO Wellness Scale, which includes measures for happiness, enthusiasm, resilience, and optimism.

The HERO Wellness Scale is available with permission of the developers Saundra Jain & Rakesh Jain.

Source: Jain, S., Jain, R., & Kumar, L.M. (2015). Wild 5 wellness: Impact of a fivepronged (exercise, mindfulness, sleep, social connectness & nutrition) 30-day wellness program on mood, mindfulness, sleep behavior, social connectedness, emotional eating, and mental wellness. Poster presented at the 28th annual US Psychiatric Congress Annual Meeting.

This questionnaire is provided for PsychU member’s screening and educational purposes only and is not to be used as a diagnostic tool.

In June 2018 we asked the PsychU Community, “Sleep disruption is a problem in many mental health patients. In your practice, what type of behavioral therapy intervention are you most likely to speak with your patients about?” More than 50 of you responded to this poll by email, Twitter, or through the Community Insights webpage on PsychU. More than half of the voters reported that the behavioral therapy they speak with their patients about most is sleep hygiene, with 69.09% (N=38) of the vote. Further results are detailed in Table 1 and Figure 1 below.

What does this mean for our Community? While most of our respondents were more likely to discuss sleep hygiene as a therapeutic intervention to address sleep disruption, there are definitely other alternative interventions in the field. It may be that most patients seen by our responders are helped by introducing good sleep hygiene pratices, or that sleep hygiene is the most self manageable intervention for patients. It could even be the case that sleep hygiene is the first level of intervention utilized by most of our members and therefore the most likely to be discussed with patients. Whatever the case, we encourage all PsychU Community members to learn more about the impact of sleep on their patients and the additional potential therapeutic interventions to share with those affected – particularly individuals with mental health conditions, as the evidence for the interplay between sleep and many mental illnesses is mounting.

For more on the importance of sleep for individuals with mental illness, check out these related resources from the PsychU Library:

As always, make sure to participate in PsychU polling each month (through your email, the @PsychUCommunity Twitter feed, or through our website) to make your voice heard. You can also browse results of our previous polls on the Community Insights page on

Background & Methodology

Individuals with serious mental illnesses (SMI) have reduced life expectancies compared to those without mental illness, due in part to higher rates of behavioral risk factors and preventable conditions that may be exacerbated by medication side effects. It is possible that disparities in access to screenings and preventive health services may contribute to negative outcomes. Although there is a wealth of research on this topic, the wide variation in settings, populations, and measurement strategies has made it difficult to compare screening rates among different groups.

In a recent article entitled “Preventive Service Use Among People With and Without Serious Mental Illnesses,” Bobbi Jo H. Yarborough and colleagues sought to determine if preventive care disparities exist for people with SMI, and if so, what factors may account for those disparities. They examined electronic health record (EHR) data from 2012-2013 from patients in two different care settings: Kaiser Permanente Northwest (KPNW), a private not-for-profit integrated health plan, and federally qualified health centers and safety-net community health clinics (CHCs).

Participants were 803,276 adult patients within the two settings who were included if they had one or more health care visits during the study time. They were categorized in terms of mental health diagnosis (i.e., schizophrenia spectrum disorders, bipolar disorders and affective psychoses, anxiety disorders, unipolar depression, or the reference group comprised of patients having none of the identified mental health diagnoses). The outcome of interest was the “care gap rate,” which was the proportion of preventive services (e.g., annual influenza vaccine, diabetes screening, tobacco status) for which a patient was eligible but had not received by the end of the study period.

In recent months we’ve written about the importance of good nutrition for improving consumer outcomes and lowering the cost of care. For example, adults who are food insecure have health insurance costs $1,863 higher than adults who have access to adequate nutrition and are 15.3 percentage points more likely to have a chronic illness (see What Does The Farm Bill Have To Do With Health Care?). And my colleague Sarah Threnhauser recently reported on President Trump’s proposed budget for fiscal year 2019, in which the spending for supplemental nutrition assistance program (SNAP, or as the program is commonly referred to, “food stamps”) could be cut (see The Collision Of Food Policy & Health Care Costs).

Then, there are the effects of malnutrition. Among consumers with chronic diseases, malnutrition costs $15.5 billion annually in additional health care spending per year. Addressing this malnutrition has proven results. The cost- effectiveness of nutrition interventions using oral nutritional supplements (ONS) has been documented in both the hospital and community settings—consumption of a high-protein ONS both during hospitalization and 90 days post discharge amounted to cost savings of 12.2%, and a cost-effectiveness ratio of $33,818. About 7.1% of all inpatient hospital stays during 2013 involved malnutrition as a primary or secondary diagnosis, or in about 1.95 million of the total 27.6 million non-maternal and non-neonatal inpatient hospital stays. Malnutrition accounted for nearly $42 billion, over 12% of the $346.1 billion aggregate hospital cost for non-maternal and non-neonatal stays that year.

On the other end of the nutrition equation are the high number of individuals who are overweight and obese, which can lead to chronic diseases and also add to the cost of health care. In 2008, medical costs due to obesity were $147 billion, and in 2012, the cost of diagnosed diabetes was $245 billion, including $176 billion in direct medical costs and $69 billion in decreased productivity. A study by the Urban Institute, The New York Academy of Medicine and Trust for America’s Health found that investing $10 per consumer in community-based programs to increase physical activity and improve nutrition could save $16 billion annually, with a return-on-investment of $5.60 for every $1 spent.

What are we seeing in the market response to this social need? Last month I saw one interesting example of meeting this need with the announcement of “The Ford Mobile Farm,” located on the campus of Cass Community Social Services on Detroit’s west side – “an indoor farming and educational program to provide Detroit-area residents and restaurants with fresh produce year-round.” The farm is funded using $250,000 from the Bill Ford Better World Challenge, a grant program funded by Ford Motor Company and Bill Ford.

If you take a look around the market, this approach to community nutrition isn’t common, but it exists. The AspenPointe Community Garden in Colorado Springs has been in operation since 2012; the Mental Health Center of Denver’s Farmers Market includes a 40,000 square foot urban farm, a therapeutic garden, an aquaponics greenhouse, and community gardening space; and Services for the UnderServed Urban Farms—which includes 40 growing spaces and eight community farms in four New York City boroughs—provides therapeutic horticulture, nutritional programming, and employment opportunities.

Which raises the question: where are nutrition programs in the planning (and budgets) of payers and health plans?

Last fall, the California Department of Health Care Services (DHCS) announced its three-year Medicaid Medically Tailored Meals Pilot Program after January 1, 2018. The pilot will involve Medi-Cal (California Medicaid) beneficiaries with selected chronic health conditions, in a test on the effect of an evidence-based, specialized nutrition program on the participants’ hospital readmissions related to their chronic health condition, admissions to long-term care facilities, and emergency room utilization related to complications of their chronic health condition.

And in Pennsylvania, the Philadelphia-based Health Partners Plan (HPP) implemented a healthy meal program—Food- as-Medicine—to address food-related social determinants of health for Medicaid and Medicare consumers, in tandem with the Metropolitan Area Neighborhood Nutrition Alliance (MANNA). HPP contracted MANNA to provide members 21 meals per week over six months in 2015, and as a result, reported a 27% reduction in hospital admissions, a 6.9% reduction in emergency department visits, a 15.9% reduction in provider organization visits, and a 7.9% reduction in specialist visits.

In 2016, Geisinger, another Pennsylvania-based health plan and health system, launched the Fresh Food Farmacy. The Farmacy provides adults with diabetes and their families with food, recipes and menus to prepare two healthy meals per day, five days a week. Additionally, adults participate in group classes for diabetes self-management for at least 15 hours. The program costs about $2,200 per consumer per year and has resulted in the cost of care dropping two-thirds and HbA1c levels have dropped more than two points among participants

In March, the Blue Cross Blue Shield Association (BCBSA) announced it had launched a new subsidiary to address social determinants of health, which includes plans to address nutrition “deserts,” or areas that have limited access to affordable and nutritious food (see Blue Cross Blue Shield Association Launches Institute To Address Social Determinants). And Humana’s Bold Goal initiative is a long-term strategy to address community-level social determinants of health, including nutrition; it is a population health strategy to help the communities it serves be 20% healthier by 2020.

As we see more research on the costs of bad nutrition and more demonstration of the ROI of investing in nutrition programs, we’ll likely see more investments by provider organizations, public agencies, and health plans in nutrition. What will these models look like? It’s too early to tell, but the answer to that question will be determined by what strategies work.

This summary was developed utilizing the full recorded presentation of this webinar. You can access the full sourcing, polling results, recording, or presentation slides here:

Sleep can be disrupted in all stages of bipolar disorder (BD), including within euthymic patients, it may be a predictor of relapse. There is growing evidence that sleep disruption can affect many aspects of a patient’s life, such as mood, quality of life, and mood episode recurrence. On June 5, 2018, Dr. Terence Ketter and Dr. Holly Swartz convened to discuss the current evidence about the interplay between sleep and BD and potential interventions aimed at improving sleep within the patient population living with BD. Speakers were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

Terence Ketter, M.D., is an Emeritus Professor of Psychiatry & Behavioral Sciences, and Founder & Founding Chief of the Bipolar Disorders Clinic at Stanford University. He received his medical degree from the University of Toronto. Dr. Ketter completed a medical internship and psychiatry residency at the University of California San Francisco.

Holly Swartz, M.D., is a Professor of Psychiatry at the University of Pittsburgh. She also serves as the Director of the Center for Advanced Psychotherapy and Medical Director of the Depression & Manic Depression Prevention Program. She received her medical degree from the Albert Einstein School of Medicine. Dr. Swartz completed a psychiatry residency at the Payne Whitney Clinic at the New York Hospital and her postdoctoral research at Cornell University Medical Center.

The objectives of this presentation were to:

  • Review when, and how, patients with BD experience sleep disturbance
  • Discuss how sleep disturbances affect mood and vice versa in patients living with BD
  • Discuss nonpharmacological interventions to improve sleep in patients living with BD

Dr. Ketter began the presentation with a background discussion on sleep disturbances within the patient population living with BD. He described sleep pathophysiology to webinar attendees, and walked the audience through the circadian period, which lasts approximately 24 hours. During the 24-hour circadian period, body temperature and hormones rise and fall to regular the sleep-wake cycle. Dr. Ketter began his description of the circadian period during resting times for the individual. He explained that sleep consists of alternating periods of rapid eye movement (REM) and non-REM sleep. During resting periods, individuals experience an initial increase in melatonin and an initial decrease in overall body temperature. As individuals begin to wake up after a night of rest, Dr. Ketter explained that cortisol, another hormone that helps to regulate the cycle, peaks. Finally, as individuals progress through their wakeful hours, individual body temperature rises and melatonin and cortisol levels dip.

In addition to hormone and temperature fluctuation, two additional regulators of the sleep cycle should be considered. First, Dr. Ketter posited, most individuals would have heard of the internal regulator, the so-called ‘biological clock.’ He stated that this ‘biological clock’ refers to the suprachiasmatic nucleus (SCN), small nuclei in the hypothalamus of the brain. In addition, external changes such as light intensity can help to synchronize or disrupt circadian rhythms.

He dove into this second aspect in more detail, stating that the light-dark cycle is a key regulator of the circadian clock. Dr. Ketter explained that as light hits the eye, it travels to the SCN. The SCN influences outputs into hormonal systems, impacting adrenocorticotropic and thyroid-stimulating hormones, the autonomic nervous system, melatonin, and body temperature – all which can impact the sleep-wake cycle. Because of this interaction, he described that sleep can be disrupted by artificial light, which can in-turn, greatly impact individuals. Research has shown that severely disrupted sleep cycles have been linked to poorer overall health, including increased risk of metabolic dysfunction, obesity, and certain cancers. Pertaining to the topic of this presentation, Dr. Ketter clarified that patients living with BD may have an increased sensitivity to light, which, as just discussed, can lead to poorer patient outcomes.

Dr. Ketter posed a question to frame the next portion of his presentation: “How can you tell if someone has a sleep disorder?” He succinctly stated, “You ask” in response. He discussed how insomnia and sleep disturbances can be assessed within clinical interviews, and that such interviews can help to explain the nature, history and severity of sleep disturbances. This could involve clinical evaluation or analyzing self-reported data from patients (e.g. screening tool data, at-home sleep logs, symptom checklists, etc.). To provide clinicians on the line with additional resources they could investigate, Dr. Ketter reviewed a few validated self-report instruments that could be used, including: the Insomnia Severity Index (ISI); Athens Insomnia Scale (AIS); Pittsburgh Sleep Quality Index (PSQI); Sleep Quality Index (SQI); Epworth Sleepiness Scale (ESS); and 12-Item General Health Questionnaire (GHQ-12). He provided additional detail on one of the more well-known screening tools within this list, the PSQI. Dr. Ketter explained that the PSQI has been a valuable tool to the field because it measures more than just onset, with measures that address subjective sleep quality, latency, duration, habitual sleep efficiency, disturbances, use of medication, and daytime dysfunction.

At this point, the moderator paused to ask the audience about their perspective on sleep assessments in a polling question. Results are depicted in Figure 1. In Dr. Ketter’s opinion, self-administered questionnaires are the most impactful. However, the audience was split in their perspectives.

Dr. Swartz commented that while each of these methods present pros and cons for the clinician and the individual providing the data, an important strategy is to systematically evaluate sleep in the patient population you serve.

Continuing the discussion, Dr. Ketter then described the impact of sleep disturbance specific to patients living with BD. He began by explaining that sleep can be altered in all phases of the disorder and for all age-levels living with BD. He described differences between individuals living with BD in comparison to their otherwise healthy peers. Dr. Ketter noted that it’s unsurprising that individuals experiencing depressive and manic stages of BD experience sleep disruptions like increased REM density and decreased latency to REM or sleep continuity. However, he stated that it was interesting to see these disturbances persist in individuals living with BD during the euthymia phase of illness. He mentioned that some clinicians view these persistent disturbances as residual depressive symptoms, whereas others may view them as individual sleep problems. Evening chronotypes (e.g. “night owls” or those who are late to bed and late to rise), he explained, is a measured characteristic of many individuals living with BD, when comparing data from self-report or wearable device measures.

To further illustrate his point, Dr. Ketter discussed findings from relevant literature. He began with differences between sleep alterations in individuals living with mania and those with bipolar depression. Those with mania, unsurprisingly, experience decreased sleep. Though, Dr. Ketter noted that it remains unknown whether sleeplessness is considered a prodromal symptom or cause of mania. He presented data from a 2008 study published in the American Journal of Psychiatry indicating that unmedicated patients experiencing mania demonstrated shortened sleep time, increased time awake in bed, shortened REM latency, and daytime motor hyperactivity. On the opposite end of the spectrum, patients living with BD, Dr. Ketter explained, experience more hypersomnia or severe insomnia. He discussed data from a 2016 study in the Nature & Science of Sleep demonstrating that upwards of 70% of patients living with BD may experience hypersomnia (17-78% range). Additionally, he stated, this hypersomnia may differ from individuals living with unipolar depression diagnoses, with individuals with BD experiencing more early morning awakenings, greater total REM density, and fatigue instead of true excessive daytime sleepiness.

Next, he produced findings published in the Journal of Affective Disorders in 2016, which demonstrate that even in patients who have reached the recovery phase of BD, when compared to healthy controls, report worse global scores on the PSQI, indicating worse overall sleep experience. This can include longer sleep latency and more daytime dysfunction, as well as increased sleep medication usage.

Finally, Dr. Ketter reviewed published associations between sleep disturbance among individuals living with BD and impacts to their daily life. These included: impaired quality of life; reduced likelihood of engaging in healthy behaviors; increased rates of relapse and mood episode recurrence; disrupted affect regulation; adversely affected cognitive function; continued impulsivity and risk taking; increased substance use; and increased risk of suicidal ideation and attempt.

Dr. Swartz then stepped in to cover the bidirectional relationship between sleep and mood, which she mentioned was both important and complicated. She stated that sleep loss in patients in the euthymic phase of BD is the most reported trigger of hypomanic or manic episodes, citing findings published in the British Journal of Psychiatry in 2017. Dr. Swartz indicated that this was particularly true for patients diagnosed with BD-I than for BD-II, and for women over men. She posited that the literature isn’t conclusive about whether this trigger is prodromal or causal in nature. In any event, she stated, having poor sleep is associated with worse outcomes for patients living with BD. She presented data from a 2016 study in the Journal of Affective Disorders measuring sleep quality and mood severity in recovered patients living with BD. Euthymic study participants deemed “good sleepers” (i.e. scoring ≤5 on the PSQI) scored better on residual depression and mood elevation measures when compared with “poor sleepers” (i.e. those scoring >5 on the PSQI).

Echoing a previous statement from Dr. Ketter, Dr. Swartz reminded attendees that sleep is part of the circadian system and that BD is associated with a sensitive or easily disrupted circadian system. First, she described abnormal melatonin levels within the patient population, which may present in decreases overall and delay in onset peak melatonin secretion (which is associated with a delay in sleep onset). Next, she discussed disruptions in cortisol secretion. In healthy controls cortisol secretion follows a diurnal pattern, whereas in patients living with BD experience a relative flattening of the curve. Dr. Swartz posited that the underlying etiologic process of BD is very closely tied to the systems that control the sleep-wake cycle, and that this could explain in some part the close connection between sleep disturbance and BD.

Dr. Swartz stated that many within the field of psychiatry will attempt to utilize pharmacotherapy to address these issues for patients living with BD who are experiencing insomnia. However, research indicates that some medications used in the treatment of insomnia may affect BD symptoms as well. She briefly discussed considerations for benzodiazepines, benzodiazepine receptor agonists, low-does sedating antidepressants, anticonvulsants, and atypical antipsychotics. Given these potential affects, the speakers turned the conversation toward nonpharmacologic or behavioral strategies and their efficacy for this patient population.

Research demonstrates evidence-based, psychological or behavioral strategies exist to address insomnia, though some strategies have not been tested specifically within the BD patient population. Dr. Swartz explained that at least one adjunctive psychological or behavioral treatment is recommended and these may vary. Some options may include: cognitive behavioral therapy for insomnia (CBT-I); paradoxical intention; stimulus control therapy; biofeedback therapy; sleep restriction; relaxation training; and multicomponent therapy. She mentioned that CBT-I was the only adjunctive treatment that had been tested for BD, and that later in the presentation she would cover this treatment in more depth.

Before moving on, the moderator asked the audience to participate in another polling question, “Have you used any of the following therapies to help improve sleep in your patients?” Results are presented in Figure 2.

While the results were being tabulated, Dr. Swartz stated that since she is a psychiatrist she does prescribe medications for sleep disturbance in BD. However, she stated that she often starts with behavioral interventions for the reasons just discussed during the presentation.

Dr. Ketter stated that he was more of a pharmacologist than a behaviorist. However, he also stated that there were definitely limitations to pharmacotherapy for the BD population. He also expressed surprise at the low level of participants choosing answer choice “A”, though he posited that many individuals would be captured within the “C” answer group.

Dr. Swartz agreed that pharmacotherapy was very important to treat BD, but when she really considers addressing sleep disturbance in her patients, that psychological or behavioral interventions are incredibly important. She continued her discussion of such approaches with a brief explanation of another intervention, interpersonal and social rhythm therapy (IPSRT) – an evidence-based intervention for BD. Her research, published in 2012 in Professional Psychology Research and Practice demonstrated that adjunctive IPSRT addressed social and environmental cues that can promote or disrupt circadian rhythm integrity and sleep-wake rhythms in patients living with BD, by focusing on three pillars: psychoeducation, social rhythm therapy, and interpersonal therapy. She reminded the audience that this was an intervention for BD intervention not a sleep specific one, and, as an adjunctive therapy, demonstrated efficaciousness for mood and helped to entrain circadian rhythms in patients with BD-II.

She delved further into IPSRT’s effectiveness, by providing IPSRT efficacy findings from available literature on the subject. First, a 2005 study in Archives of General Psychiatry, which included 175 individuals diagnosed with BD-I or manic-type schizoaffective disorder in the acute phase, assigned these individuals to IPSRT for two years. Patients were also given adjunctive mood stabilizing medication therapy as part of the study. Outcomes from this research demonstrate improved daily rhythm regularity in patients assigned to the IPSRT treatment group when compared to participants in the study assigned to a more somatic-focused intensive clinical management treatment. Adjunctive IPSRT, Dr. Swartz described, also delayed mood episode recurrence in the patient population in this study. Second, a 2018 report in the Journal of Clinical Psychiatry studying patients assigned to IPSRT treatment alongside either antipsychotic medication or placebo. The study showed patients with BD-II depression assigned to IPSRT sessions in combination with either an antipsychotic or placebo had decreased depression scores measured on the Hamilton Depression Rating Scale (HAM-D). Dr. Swartz noted that the findings from this study also indicate that patient preference for treatment modalities can have an impact upon patient outcomes as well.

As promised, Dr. Swartz returned to examine the efficacy of CBTI which was adapted for BD (CBTI-BD). The American College of Physicians recommends CBTI as a first-line insomnia treatment for adults, but how does it perform specific to individuals living with BD? She presented data from a 2015 study in the Journal of Consulting & Clinical Psychology demonstrating that for inter-episode adult patients living with insomnia and BD-I, treatment with CBTI-BD yielded greater improvement in insomnia scores than treatment with psychoeducation. The domains measured in the study included post-treatment and 6-month response and remission rates. However, results from the same study also specifically examined the impact of adjunctive CBTI-BD in relation to psychoeducation for patient in terms of hypomania / mania relapse rates and days in episode. These results demonstrated that CBTI-BD was effective in decreasing mood symptoms in patients with insomnia, though not as effective for either measure as psychoeducation.

Finally, Dr. Swartz pointed out that good sleep hygiene may help patients regulate their sleep. By eliminating certain habits and making the bedroom a more comfortable place, individuals can promote sleep quality. Some of these habits to curtail could include: noise in the bedroom; using an uncomfortable mattress; using alcohol as a sleep aid; exercising less than four hours prior to bedtime; reading, watching television, using a phone, or playing the radio in bed; having a work desk in the bedroom; and drinking caffeinated beverages or smoking cigarettes after 5:00pm. She stated that one of the most influential sleep hygiene tips is to keep a regular schedule and get out of bed each day at the same time. While sleep hygiene strategies can be helpful and easy to implement, Dr. Swartz cautioned participants that these strategies lack sufficient evidence to support their use as a single or adjunctive therapy for patients with insomnia.

The moderator asked the audience a final polling question to let them weigh in on the presentation topic, “Are you considering using any of the following therapies to improve patient sleep?” Results are presented in Figure 3.

Dr. Ketter expressed his interest in utilizing CBT with his patients for insomnia, and his wish that more individuals in his profession would consider including it in their strategies. Dr. Swartz mentioned that pharmacological interventions are certainly helpful for BD, but that clinicians should consider some other strategies to help address insomnia as well, like CBT-I or IPSRT.

The presenters wrapped the presentation with a summary of key discussion points:

  • Patients with BD have sleep disturbances in all illness stages, including recovery.
  • Sleep disturbances are triggers for mood changes in patients with BD.
  • Insomnia treatments can affect mood in patients with BD.
  • Adjunctive psychosocial and behavioral therapies can help improve sleep in patients with BD.

The webinar concluded with a question and answer session in which the following were asked:

Are there notable differences in sleep patterns between individuals living with BD versus individuals living with unipolar depression?

Dr. Ketter responded with the classic symptomology difference between the two disorders: individuals with BD experience hypersomnia while those with depression experience insomnia more frequently. However, he stated, that this doesn’t divide evenly among the groups and that sleep disturbance isn’t a practical diagnostic tool.

Dr. Swartz agreed and added that the groups can overlap. So information related to sleep disturbances should be considered in conjunction with other pieces of information, particularly during diagnosis.

How do timezone changes effect individuals with BD?

Dr. Swartz mentioned that timezone changes may leave individuals with BD at risk for mood destabilization, as it may cause disruption in the circadian clock. She mentioned a few strategies to combat this, including:

  • Being mindful in advance of the change, particularly for individuals not in the euthymic stage
  • Allowing time to adjust to a new timezone or preemptively adjusting over time to prepare
  • Adjusting inputs for the SCN within the new timezone (e.g. sun exposure, changing mealtimes)
  • Judicious use of pharmacotherapy so that patients do not experience exhaustion or trigger themselves

Is the use of sleep aid medication a potential method to prevent mania?

Dr. Swartz mentioned that the appropriate medications for BD are mood stabilizing medications. However, inadequate sleep is a risk factor for mood destabilization. Therefore, she stated again that judicious use of medication can be important to stop hypomania to progressing into a manic episode or to address prodromal symptoms to improve outcomes.

Could you please address the use of light therapy, or amber-lensed glasses, in the treatment of individuals living with BD?

Dr. Ketter mentioned that the use of light therapy for seasonal depression has been well established by the literature. There are some data, though the numbers in his opinion were not ‘impressive,’ that suggest the use of amber lenses to block blue light absorption. He stated that though the limited science and clinical data does support the use of amber lenses, he wasn’t convinced just yet.

Dr. Swartz agreed about the data regarding amber glasses, though she mentioned the results were interesting. She mentioned preliminary data from a study on the efficacy of bright light therapy adjunctively for bipolar depression, which suggests bright light therapy may be useful in treatment. Interestingly to her, the recommendations from this study were to use the light therapy in the early afternoon rather than in the morning (as previous literature supports for other disease states utilizing this therapy), to reduce the instance of inducing mania for patients.

How harmful could it be to good sleep hygiene to wake up at the same time each day during the work week but then sleep in over the weekend?

Dr. Ketter stated that he encounters this all the time in his patient population. He mentioned that it is very difficult to train individuals to continue their waking time during the weekend.

Dr. Swartz mentioned a study that indicated individuals could have short sleep during the week and then “catch up” over the weekend and maintain health outcomes. However, she stated that she did not believe this was a good approach for patients living with unstable BD. IPSRT studies have measured the impacts of sleep hygiene practices, and maintaining weekday schedule on the weekends has been shown to improve social rhythm regularity. Those studied who had more regular routines actually demonstrated higher outcomes in the study.


In May 2018 we asked the PsychU Community, “As a health care professional, what is your largest work-related stress?” More than 300 of you responded to this poll by email, twitter, or through the Community Insights webpage on PsychU. Results were definitive, with nearly half of the voters (48.83%, N=168) identifying workload as their largest work-related stress. Further results are detailed in Table 1 and Figure 1 below.

What does this mean for our Community? Burnout among health care staff is staggering, and can lead to poor quality of life for health care professionals, medical errors, staff turnover, and other detrimental outcomes for the health care system. While there are no one-size-fits-all answers to workplace stressors and burnout among health care professionals, there are a variety of strategies that can help to mitigate the problem.

If you’d like to learn more about burnout and health care professional stress, check out these additional resources on PsychU:

  1. Staff Is Your Biggest Investment & Your Greatest Asset – Unless They Burnout
  2. Focus On Wellness: Fighting Provider Burnout – Recognizing The Risk (Part 1 Of 2)
  3. Focus On Wellness: Fighting Provider Burnout – Finding The Balance (Part 2 Of 2)

As always, make sure to participate in PsychU polling each month (through your email, the @PsychUCommunity Twitter feed, or through our website) to make your voice heard. You can also browse results of our previous polls on the Community Insights page on

Key Messages

  • Burnout and career dissatisfaction among residents and fellow trainees has been evident for many years leading to the development of both personal and institutional interventions to prevent and promote wellness and resilience.

Employee assistance programs, or EAPs (82%), smoking cessation programs (77%), and health risk assessments (72%) are the most frequently implemented digital health programs offered by employers. By contrast, the three programs with the highest employee satisfaction are financial wellness programs (54%), gym access (53%), and EAPs (44%).

These findings were reported in “The State of Digital Health 2018 Report” by Castlight Health. The report is based on a Castlight Health analysis of a survey on how employers and employees interact with health and wellness programs. The survey was conducted by Employee Benefits News with nearly 350 U.S.-based large employers – and more than 1,000 employees – about engagement, satisfaction, and the return on investment of digital health tools. The goal was to determine what digital health solutions, and what categories of solutions, have the most impact on employee health.

In the survey, an EAP was defined as a voluntary, work-based emotional well-being program that offers free and confidential behavioral health assessments, short-term counseling, referrals to outside treatment professionals, and follow-up services to employees. Smoking cessation programs use planning and support to help those enrolled stop smoking. A health risk assessment is a questionnaire used to evaluate a person’s health risks and quality of life.

Additional findings of the survey include:

  • The top three health goals of employees are to lose weight (45%), save for retirement (30%), and sleep better (27%). Losing weight is the top goal of all age groups surveyed.
  • Reflecting the top goals of employees: if offered for free, employees are most likely to use digital programs for retirement savings (73%); and tools to improve nutrition, sleep better, and walk more (70% each).
  • The top three digital health programs that employees are willing to pay for are smoking cessation (67%), children’s health and obesity programs (64%), and planning a healthy pregnancy (62%).
  • The three digital health programs that are offered least often by employers are sleep improvement programs (27%), children’s health and obesity programs (32%), and health concierge (35%).

The researchers concluded that while employers offer robust digital solutions, the solutions offered do not align with employees’ top health goals. Because employees expect technology to be digital and tailored, employers are unlikely to be successful in earning employee satisfaction without addressing these top health goals. According to the survey, win-win digital programs for both employers and employees include those for weight loss, financial wellness, biometrics screenings, and health risk assessments.

The full text of “The State of Digital Health 2018 Report” was published in April 2018 by Castlight Health. A free copy is available online.

For more information, contact: Shannon Magill, Press Office, Castlight Health, 150 Spear Street, Suite 400, San Francisco, California 94105; 415-829-1500; Email:

Kim Lonergan, RN, MSN, Medical Science Liaison (MSL) for Otsuka Pharmaceutical Development & Commercialization, Inc. (OPDC), has served as a nurse for 40 years, 26 of which were spent in trauma / critical care medicine. For this interview, she sat down to share her unique inside perspective on one strategy that emergency health care professionals use for self-care – debriefing after a traumatic event – with colleague Jason Carter, PharmD, MSL for OPDC.

Check out the rest of the series here:

This summary was developed utilizing the full recorded presentation of this webinar, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at

On May 17, 2018, Dr. Madhukar Trivedi and Dr. Gaurava Agarwal conducted a webinar to discuss the concept of burnout among health care professionals. Madhukar Trivedi, MD, serves as the Director of the Center for Depression Research & Clinical Care, the Betty Jo Hay Distinguished Chair in Mental Health, and the Julie K. Hersh Chair in Depression Research and Clinical Care at UT Southwestern Medical Center in Dallas, Texas. Gaurava Agarwal, MD, is an Assistant Professor in the Department of Psychiatry and the Behavioral Sciences, Assistant Professor of the Department of Medical Education, the Director of Undergraduate Medical Student Education in Psychiatry, and the Director of Graduate Medical Education Wellness Programming at Northwestern University Feinberg School of Medicine. Both speakers were paid consultants to Otsuka Pharmaceutical Development & Commercialization, Inc.

This webinar had the following educational objectives:

  • Discuss the incidence and prevalence as well as define burnout and highlight some of the challenges with available data and definitions
  • Explore some of the biologic, social, and systems-related data pertaining to burnout
  • Review drivers of burnout as well as strategies to identify and address this challenge

Dr. Agarwal began the presentation by observing that burnout is a “hot topic” in the health care world at present. He stated that his work is with impaired health professionals who are often experiencing substance misuse or mental health difficulties. He explained that, in his experience, burnout is frequently a factor for these professionals. He then described how burnout has been technically defined for the purposes of research by Christina Maslach, focusing on the three core symptoms of 1) emotional depletion (e.g., feeling frustrated, tired of going to work, hard to deal with others at work), 2) detachment/cynicism (e.g., being less empathic with patients/others, detached from work, seeing patients as diagnoses/objects/sources of frustration), and 3) diminished sense of personal achievement (e.g., experiencing work as unrewarding, “going through the motions”).

He explained that none of those symptoms alone fully capture burnout and described it as more of a three-step process, in which growing demands lead a person to feel depleted. As a result, the person makes a rational decision to distance themselves, which may lead them to become cynical and dehumanize their patients. He said that those feelings eventually lead the person to feel ineffective.

Dr. Agarwal presented data on physician burnout from a study showing that approximately 54% of physicians were impacted in 2014, compared to approximately 45% in 2011. He also noted data indicating that there is variation in burnout rates among the different medical specialties, pointing to a 30% difference between the specialty with the lowest reported burnout rate (occupational medicine) and the highest (emergency medicine). He stated that this finding is important because there has been a debate about whether the cause of burnout is within the individual or the institution, and he observed that if the cause were merely individual, the 30% difference between specialties would be less likely. He stated that this has led him to believe that the institution plays a role in burnout.

He then discussed other health care professionals. He presented research findings that hospitals with high patient to nurse ratios have higher surgical mortality. He cited one study of 68,000 registered nurses in which 34% reported being burned out and noted that another survey found a nurse burnout rate of 63%. He stated that research with physician assistants (PAs) indicates that they also have a high rate of burnout associated with feelings of professional isolation. He also said that findings from the 2015 National Pharmacist Workforce Study show that 45% believed workload negatively impacted their mental health. He stated that, among health care professionals, burnout rates of between 30-50% are typical study findings.

Dr. Agarwal moved on to describe the professional (e.g., decreased quality of care and patient satisfaction, decreased productivity, and increased medical errors) and personal (e.g., substance use, depression, suicide) correlates of burnout, emphasizing that at present, there is not adequate research to suggest that burnout causes these outcomes. Nevertheless, he noted that these associated factors have attracted the attention of accrediting bodies. He emphasized that individual physicians should be alert to burnout and its correlates in themselves.

Unfortunately, on average, one physician kills themselves each day, and that physicians have the highest suicide rate among other professionals. Dr. Agarwal noted that, compared to the general population, male physicians have a suicide rate 1.4 times higher and, for female physicians, the rate is double. He said that people who have high detachment/depersonalization scores and depression have a nearly double rate of suicidal ideation. In terms of substance use, he cited findings that people with high emotional exhaustion were nearly twice as likely to experience alcohol dependence.

Lastly, Dr. Agarwal described professional-related correlates of burnout. Citing a study of 2,500 physicians, he said that every one percentage point increase in burnout was associated with a 30-50% increase in the likelihood that physicians would reduce their professional effort, which affects patients’ access to health care. He stated that medical errors are the third leading cause of death in America behind cancer and heart disease, and explained that this factor was initially what led to the focus on burnout. Research findings indicate that for every one-point increase in burnout, there is a 3-10% increase in likelihood of physicians reporting medical errors. Compared to physicians reporting low levels of emotional exhaustion, physicians who reported high levels of emotional exhaustion had a 10% higher likelihood of committing a major medical error in the past three months. Dr. Agarwal also provided a financial perspective, noting that the two-year rate of turnover among physician faculty who are burned out is double that of non-burned out faculty, and when one team- member leaves, risk of burnout increases for all other members of that team for the next 12 months, even if that person is replaced. He noted that the hard cost of replacing a physician is $100,000, with indirect costs of 2-3 times the person’s salary, making the total physician replacement cost range between $500,000 and $1,000,000. He then expressed the hope that those statistics would help make the business, moral, and personal case for addressing burnout.

The moderator then presented the audience with a polling question: Do you believe you have experienced burnout to some degree during your career? Results are provided in Figure 1.

The moderator then asked Dr. Trivedi to predict the results. He replied that most of the published literature and a survey of the faculty at his institution, burnout is often in the range of 40-50%. He stated that he thinks the rate has been increasing over the past 10-15 years. Dr. Trivedi then cited the study results showing an increase in burnout rates from 2011 to 2015.

Dr. Trivedi began his portion of the presentation by noting that burnout has gained much attention and has primarily been measured through assessment of the three dimensions Dr. Agarwal described. He added that there is an additional component of depression, anxiety, and substance abuse, for which health care professionals may be reluctant to seek treatment. He stated that in the past, people may not have paid enough attention to these additional factors when addressing or researching burnout. He acknowledged that burnout is also affected by institutional issues and personal issues, both of which must be addressed if those in the field hope to make a difference. He warned that if they are not addressed, burnout is deleterious to both health care professionals and patients.

He transitioned the discussion to an explanation of the association between stress and depression, beginning with an oft- replicated research finding that stressful experiences lead to depression in some but not in others. He said that one possible explanatory factor is the serotonin transporter gene 5-HTT, which has been found to moderate the influence of stress on depression. Specifically, compared to people homogenous for the long allele, individuals with one or two copies of the short allele exhibited higher rates of depression and suicidality in relation to stressful life events. He explained that this finding demonstrates gene-environment interaction whereby stress may lead to depression.

Next, Dr. Trivedi explained that genetic factors are not the only links between stress and depression; biological factors also have a role. He described how chronic stress changes the ability for the brain to adapt, resulting in some decreased connections and some increased connections, both within brain regions and between them. More specifically, chronic stress may lead to increases in catecholamines in the prefrontal cortex and affects the connectivity between that region and the amygdala and hippocampus. He explained that this creates an “upside-down circuit” in which output to other regions is reduced by “removing the brake” and allowing other brain regions to overreact. In the face of chronic stress, over activity in the amygdala results in heightened emotional reactivity. He stated that people who are burned out report that they do not have control over their work environment, leading to chronic stress.

The moderator then presented a second audience polling question: Do you have initiatives at your work setting that target burnout? Results are provided in Figure 2.

As results were being tabulated, the moderator asked Dr. Agarwal for this thoughts regarding the likely results. He cited a research study indicating that only about 18% of respondents felt like their organization was doing something about burnout. He said that places often start with individual interventions such as yoga, mindfulness, or providing food and water. He said that most have not examined burnout systemically or comprehensively to address the larger organizational factors. Dr. Agarwal noted that the audience response was consistent with the literature. He said that, at his organization, they are starting to think about how to develop a more comprehensive view of burnout.

Dr. Trivedi stated his belief that physicians are starting to recognize that they have a role in burnout prevention and that things must change. He cited a recent JAMA commentary highlighting that health care systems should have physicians in leadership positions and involve them in decision-making processes. He said that it seems that people have developed an understanding that burnout is not merely an individual issue, but one that is affected by both personal and institutional factors.

Dr. Agarwal continued the webinar by explaining that making thoughtful changes requires examination of some of the drivers of burnout versus engagement. He displayed a graphic highlighting several factors (i.e., workload and job demands, control and flexibility, work-life integration, social support and community at work, organizational culture and values, efficiency and resources, and meaning in work), which when optimal can lead to engagement and when non- optimal can contribute to burnout. He said that some people might assert that a simple solution is to “pay me more and make me work less.” However, he stated that it is important to broaden ideas of what drives burnout.

Then Dr. Agarwal described one theory in which certain things make people unhappy at work and are dissatisfying about a job, and other things are more satisfying, and they are not the same things. He said it is not only important to reduce things that are dissatisfying. To achieve joy and fulfilment at work, it is also necessary to be deliberate and mindful regarding the aspects of the job that are satisfying, such as meaning and values. He explained that when he reviews the drivers of burnout versus engagement with faculty, it is usually not workload that they bring up, but rather issues such as fairness (e.g., scheduling, favoritism). Dr. Agarwal emphasized that it is important to broaden the examination of factors that lead to engagement or burnout, as it may lead to creative or novel ways to tackle the issue.

He stated that it is important to take those seven drivers of burnout versus engagement and apply them to self, organization, and specialty. Dr. Agarwal said that there is no one-size-fits-all solution, requiring each factor to be applied to the four levels in which we all work: individual, work unit, organizational, and national. He then reviewed one of the drivers in particular: social support and community at work. He stated that many times, the interventions are more acceptable to people. He explained that the positive psychology and psychiatry literature have confirmed the notion that social support and community are one of the biggest drivers of happiness and satisfaction. At an individual level, personality traits, boundary setting, and prioritization of time with friends and family can all be targets for change. In terms of work unit factors, collegiality (e.g., celebrating together, lunches with time for friendly discussion), physical configuration of workspace, and team structure can all be examined. At the organizational level, focus can be given to breaking down silos and social gatherings to increase collegiality across the system. And at the national level, medical and specialty societies can devote attention to building support and community, as meeting colleagues from around the nation may help re-energize.

Dr. Trivedi continued the presentation by discussing work-life balance, with internal and external factors that have positive and negative inputs. He explained that negative inputs include stress, internal conflict, and time and energy demands. Positive inputs include psychosocial support, social and healthy activities, mentorship (which Dr. Trivedi described as underused in current practice), and intellectual stimulation. He explained that these positive inputs can build coping reserves and promote resilience, and in their absence, burnout is a possible outcome.

Next, Dr. Trivedi described building resilience in health care professionals. He explained that system-level changes will happen but take time, and in the meantime, there are other factors such as social networks (e.g., family and social support, leisure time, interests outside of work) that are more under the individual’s control. He emphasized self-care and discussed personal factors associated with resilience (e.g., humor, flexibility, being team-oriented, using professional boundaries). He mentioned that mindfulness, meditation, and physical activity have been associated with positive outcomes. He acknowledged that challenges remain, in that workload and time pressure will not go away, but he stated that the issue of not having a voice or control seems to be a particularly relevant factor that may reduce resilience.

Dr. Trivedi also discussed strategies for avoiding burnout, from the literature. These strategies include realistic recognition; exercise, sleep, and nutrition; creating supportive professional and personal relationships; setting boundaries; valuing and using time away from work, having a passion for one’s work, having hobbies outside of medicine, practicing mindfulness, and focusing on positive emotions such as gratitude. He stated that focusing on the strategies used to build resilience may be important for avoiding burnout. He emphasized that health care professionals are human and should not avoid being diagnosed and treated for depression and anxiety when necessary. He cited research indicating that treatment rates for physicians are significantly lower than in the general population, the rate for which is already low.

The webinar concluded with a question and answer period in which the following were asked:

Are there specific assessments that I can use with my staff members to measure their risk for burnout (e.g., compassion, satisfaction, compassion fatigue, secondary trauma)?

First, Dr. Agarwal distinguished between assessing risk for burnout versus determining whether a staff person is or is not burned out. He said he likes to use the Areas of Worklife Survey by Dr. Maslach, who developed the Burnout Inventory (designed to determine whether or not someone is burned out). He explained that the Areas of Worklife Survey focuses on the previously discussed drivers and helps people determine the biggest mismatch between what staff want and what the organization is providing. He stated that this may help determine risk factors such as fairness and rewards, and that once these factors are identified, rational interventions can be designed to address them. He added that tools that are free online are the Mini Z, which is a part of the AMA’s burnout initiative, is 9-10 questions, and is available on their website. He mentioned that it also includes questions regarding electronic health records and leadership, both factors associated with burnout.

Then Dr. Trivedi added that it is important to keep in mind that burnout is not a problem unique to physicians, and occurs with many other professional such as lawyers and veterinarians. He stated that similar mechanisms are active for these other professionals with regard to burnout.

There is emerging research on the development of resilience as a strategy to prevent or alleviate burnout. Can you speak a little more fully to that and how you may also be including this in your work?

Dr. Trivedi stated that there is increasing evidence that resilience can be developed, as well as biological evidence showing there are “resilience genes.” He described these as protective factors that might be genetic, environmental, cognitive, psychological. He acknowledged that not all factors can be changed, but that approaches such as mindfulness and exercise have been shown to improve brain function. He said that taking time off from a stressful situation is also related to resilience. He cited interventions from positive psychology and psychiatry to change cognitive appraisals of situations, which may, along with other components of resilience, alter brain plasticity. He said that research is just beginning to determine the effects of such interventions.

Do you have any suggestions or insight on how people can better understand this concept of burnout?

Dr. Agarwal said that he believes that it is helpful that burnout is not conceptualized as a mental illness, but rather a relationship that we as workers have with our jobs. He expressed concern than many conflate burnout with depression and focus on the emotional exhaustion aspect of burnout. He acknowledged that that aspect likely does have many similarities and overlap with depression (e.g., fatigue, lack of motivation). He said it is critical to remember the other aspects of burnout, especially detachment from work and patients, when thinking about the difference between burnout and depression. He stated that it is most likely a mistake to say that someone is or is not burned out, because it is a continuum. People with mild to moderate burnout can refresh after a long weekend or a vacation, whereas with depression the problem is much more pervasive and unlikely to remit after a short respite.

Then Dr. Trivedi stated that he does not think it is necessary to consider burnout a mental illness, and that there is reason to be clear about what we mean when we speak about burnout. He then said that if depression or anxiety represents a component of burnout for someone it should not be ignored.

What are some ways that a person individually can work with her organization to encourage them to adopt programming to address burnout, and also, are there some strategies that are more effective than others?

Dr. Agarwal stated that one of the things that he thinks is important is to speak an organization’s language to get leadership involved, especially if funding is necessary. He explained that this involves making a business case as to why addressing burnout is important. He stated that there is an article about the business case for physician wellbeing that provides a guide for how an organization transforms to make wellbeing a part of the culture. He also said that the American Psychiatric Association has released a “Burnout Kit” that can be used to help identify different interventions that an organization can be part of and support. He said that his experience with organizations is that they want a solution but have not figured out the “why,” so if they are approached with specific ideas that may work and have worked in other places, they respond better than if they are asked to take a huge risk. He said that using the literature and existing kits and materials when approaching organizations has been helpful, in his experience.

Dr. Trivedi added that he agreed and reiterated that there are several recent commentaries in journals that provide suggestions. He mentioned leadership and mentoring roles as possible strategies for increasing engagement and providing and accessing social support.

Then Dr. Agarwal suggested creating a practice of gratitude (e.g., thinking about two good things that happened that day and why) helps prevent a tilt toward negativity. He said that being deliberate in cultivating gratitude is, in his opinion, important. He also said that literature shows that it may be important to structure one’s time so that one is doing something enjoyable that brings meaning at least 20% of the day. He expressed concern that many have become passive in terms of allowing someone else to structure their schedule, stating that often people have more power than they think. He said that structuring one’s time in this fashion may involve turning down a promotion that involves more time in administrative tasks.

The moderator then asked each presenter to make a concluding statement. Dr. Trivedi stated that, after being asked to work on resilience and burnout by the president of his organization, he became more mindful about his freetime. He said that it can be done. Dr. Agarwal said he often hears that burnout is inevitable, and he disagrees. He said that self- defeating and negative attitudes about this issue can be problematic and dangerous for the field. He recommended recognizing and breaking down the previously discussed drivers, in terms of what can an individual control, what can be changed in the work unit, and what are the larger organizational issues. He said that it might not be possible for an individual to change administrative and electronic health systems, but one could be a part of that change.

Health care professionals involved in the care of patients with mental health issues, including physicians, nurses, social workers, and others, are under an escalating amount of stress. This stress stems from factors such as increased patient load, decreased time per patient, staffing shortages, and a host of other challenges often leads to a cycle of fatigue and potential burnout. In this webinar, speakers Madhukar Trivedi, MD, and Gaurava Agarwal, MD, discuss issues and have practical discussions on strategies to avoid burnout in pursuit of living and working well within the health care system.

Kentucky, Oklahoma, New Mexico, West Virginia, and Wyoming saw the probability of death between ages 20 and 55 years increase more than 10% between 1990 and 2016. This is in contrast to the nationwide 0.17% decline in deaths for this age range between 1990 and 2016.

These findings were presented in “The State of US Health, 1990-2016 Burden of Diseases, Injuries, and Risk Factors Among US States,” by The U.S. Burden of Disease Collaborators. The researchers analyzed published studies and available data sources to complete the Global Burden of Disease Study. The goal was to determine trends in the burden of diseases, injuries, and risk factors at the state level from 1990 to 2016. Additional findings for the 1990 to 2016 time period include:

  • The probability of death for those between ages 20 and 55 declined in 31 The decline was greatest in California, at 12.6 percentage points.
  • The highest life expectancy at birth was in Hawaii, at 81.3 years.
  • The lowest life expectancy at birth was in Mississippi, at 74.7 years.

The largest factors to affect life expectancy were tobacco consumption, high body-mass index (BMI), and alcohol and drug use. Higher than average tobacco consumption contributed to lower life expectancy in 32 states. High BMI prevalence contributed to lower life expectancy in 10 states. Higher than average prevalence of alcohol and drug use contributed to lower life expectancy in eight states.

The full text of “The State of US Health, 1990-2016 Burden of Diseases, Injuries, and Risk Factors Among US States” was published April 10, 2018 by the Journal of the American Medical Association. A free abstract is available online.

PsychU reported on this topic in “U.S. Life Expectancy Falls For The First Time This Century,” which published on January 19, 2017.

For more information, contact: Christopher J.L. Murray, M.D., D.P.hil., Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Avenue, Suite 600, Box 358210, Seattle, Washington 98121; 206-897-2815; Email:

For many managers in the health and human service field, the Farm Bill may feel outside the realm of relevant legislation. But, the far-reaching multi-year bill has important implications for low-income consumers, many of whom have complex health conditions. In addition to commodity subsidies, conservation, crop insurance, and trade, the legislation also authorizes the Supplemental Nutrition Assistance Program (SNAP), which provides access to food for low-income individuals and families.

While states administer SNAP and other nutrition assistance programs, the federal government is responsible for the actual payment of benefits and consequently sets the majority of rules related to eligibility and the amount of benefits received.

The relationship between nutrition and health has been demonstrated through long-standing research, and recent research on social determinants of health has tied the effects of poor nutrition to increased health care spending:

  1. Working-age adults with low food security are 3 percentage points more likely to have a chronic illness compared to adults with high food security. This is a 40% increase in prevalence.
  2. Food insecurity is associated with significantly higher use of the emergency department and inpatient stays.
  3. Seniors experiencing food insecurity need assistance with activities of daily living comparable to someone 14 years older.
  4. A study of over 16,000 individuals found that food insecure individuals had an extra $1,863 in health care expenses each year, an estimated extra $77.5 billion in health care expenses per year.
  5. A 2016 pilot program by Humana found that food insecure individuals have two additional unhealthy days per month resulting in more than $30 additional in health costs per month.

For these reasons, health and human service managers should be concerned with the proposals for nutrition assistance, particularly SNAP. SNAP is the largest of the nutrition assistance program serving 44.2 million individuals or 14% of the U.S. population in FY2016. By comparison the other two major nutrition programs, the Supplemental Foods Program for Women, Children, and Infants (WIC) and the National School Lunch Program, serve 7.7 million women and children and 21.1 million children free or reduced lunch, respectively. Unlike SNAP, WIC and the National School Lunch Program are not governed through the Farm Bill.

The average benefit for SNAP is $125.40 per individual per month. In general, to qualify for SNAP an individual or family must have gross income below 130% of the federal poverty level and net income below 100% of the FPL. At the individual state level the number of beneficiaries, the average benefit, and spending vary significantly. For example, between 2014 and 2016, Nevada saw a 15% increase in the number of participating beneficiaries while Kentucky saw a 20% decrease. As an entitlement program, SNAP is fully funded each year by the federal government, and while the state administers the program, there is little leeway in setting eligibility requirements compared to a program like Medicaid. Therefore, differences in benefits and populations across states can be attributed to the state population, the demographic mix of that population, and how the local economy is fairing.

While the SNAP program has been somewhat stable for the past years, there may be changes afoot. The Farm Bill is set to expire in September 2018, and the House Agriculture Committee recently passed the bill out of committee with major changes to SNAP. What exactly do the changes include? Mainly, the proposal would expand the current SNAP work requirements. Under the current program, only able-bodied adults ages 18 to 49 without dependents are required to work 20 hours a week and report those hours every six months. In the new proposal, all able-bodied adults ages 18 to 59 without children under age six must demonstrate they are working 20 hours a week on a monthly basis, increasing to 25 hours in 2026. Additionally, the bill creates a duplicative enrollment database that will allow states to ensure individuals are not receiving SNAP benefits in multiple states. While the bill imposes more work requirements, it does simplify the housing deduction for homeless individuals, continue to increase access to fruits and vegetables, and mandate transitional benefits for individuals that are leaving SNAP.

Why does this matter? The nutrition/ health care spending link is an important one for the field—particularly as the use of value- based reimbursement increases and provider organizations are increasingly responsible for consumer health care spending. If the new SNAP regulations pass, The Center on Budget and Policy Priorities estimates that the new work requirements will result in one million households and nearly two million individuals losing their SNAP benefits. As a result, this population may be at-risk for poor health-related outcomes. Provider organizations should be prepared to help fill in the gap and connect individuals to other local and private nutrition assistance programs.

And the issue of adequate funding of social support programs is not limited to nutrition. Access to adequate housing, the ability to meet basic needs, transportation, a solid social support group, and an individual’s environment all have an impact on their health. For more on this topic, check out these resources in the PsychU Library:

  1. It Gets Down To The Dollars
  2. Health Care Spending Vs. Social Service Spending
  3. The Social Service Factor In The Health Care Value Equation
  4. The Health Care/Social Service Seesaw
  5. Poverty Really Does Matter When It Comes To Health Care Spending
  6. State Spending On TANF Benefits – By Both Dollars & Programs – Varies Widely
  7. Payers Approaches To Addressing Social Determinants Vary
  8. Paying For Social Services ‘Value’ Requires Measuring Cost Impact
  9. Addressing Social Determinants—The Measurement Challenge
  10. Social Determinants Today, Social Determinants Tomorrow

 “Burnout” continues to make headlines when it comes to the American workforce. A quick search of recent news shows reporting on burnout among entrepreneurs, pilots, freelancers, and more – including the pervasive problem of burnout in health care settings.

While burnout isn’t exactly a diagnostic term, it is generally defined as long-term exhaustion and diminished interest in work, and the symptoms of burnout are similar to those of clinical depression. Beyond the headlines, how pervasive is burnout in health and human services? A 2015 study from the Mayo Clinic found that half of physicians have at least one sign of burnout; and the 2017 edition of the Medscape Physician Lifestyle Survey found that 59% of emergency physicians, 56% of obstetricians, and 55% of family and internal physicians, suffer from higher levels of burnout.

It’s not just a physician issue—caregivers, social workers, home care workers, nursing home care workers all experience burnout (see Over Half Of Organizations Providing Wraparound Services Have Staff Turnover Above 25%). Leadership and management are also experiencing the stress of change. Provider organizations are facing new performance expectations that they are often structurally incapable of meeting in their current state; this requires executives to lead the way in building a new strategy for sustainability (see The Executive Body Is Business Relevant and How “Fit” Is Your Executive Athlete?). Turnover rates for chief executive officers (CEO) at hospitals average 18% and reach as high as 30% in some states.

A recent discussion paper at the National Academy of Medicine notes that the effects of burnout aren’t limited to just the individual staff member, but the repercussions extent to affect service quality, safety, consumer satisfaction, and staff turnover costs. The cost of turnover among registered nurses is estimated at 1.2 times their $88,000 salary; the costs to replace one physician could be as high as $1 million.

The bigger management question is: Can leaders do anything about stress and, if so, what should they do? According to a report from NEJM Catalyst, the answer is yes, leaders can play a large role in shaping employee productivity, noting that “employees don’t tend to leave organizations, they leave their managers.” It’s clear that this is an issue facing just about every organization in the field—96% of survey respondents said burnout is a problem in their organization. Burnout is exacerbated by issues that can be addressed by managers—issues such as workload, work/life balance, and workplace culture.

The drivers of workplace stress also vary by position. For example, physician burnout is driven more by “work/life balance, cognitive dissonance, and clerical work,” while burnout among nurses driven by “compassion fatigue, moral distress, and work environment issues such as psychological safety and hostility.”

For more on addressing this, I reached out to former Chief Executive Officer for The Pavilion at Williamsburg Place, Shirley Repta, Ph.D., who noted the importance of staff empowerment to off-set the high stress and burnout in health care settings. She explained:

In the current environment, the emphasis on outcomes continues to grow. As leaders, we can become focused on the outcome and not the underlying variables that drive the results. Provider organizations should work to make sure that all staff understand what the measures are, how their work impacts the results, and finally, elicit their ideas on how we can make adjustments to improve those outcomes. Keeping the conversations focused on consumer safety and quality also reinforces what we are here to do. I have found this to improve satisfaction, as staff feel empowered to do the right thing always.

Dr. Repta also noted that sometimes addressing burnout and stress can be more effective when handled on a program-by- program, or unit-by-unit basis. Issues affecting units and teams may vary throughout the organization, depending on roles and responsibilities and specific performance goals. This means there is no “one-size-fits-all” solution that will work throughout your organization, and it may be more beneficial to give managers and program directors the freedom to work with their teams to address performance and productivity. She noted:

Another significant initiative available is developing unit-specific programming. The process involves sitting down with the staff in each unit and identifying the issues related to performance. This process should be repeated every three months to evaluate staff and unit effectiveness and make adjustments that would improve the programming. This allows for and improves staff engagement, empowerment, and investment in the programming.

On April 1, 2018, Medicare started covering a performance-based diabetes prevention program. The program is a structured behavioral intervention with the goal of preventing progression to type 2 diabetes in beneficiaries with an indication of prediabetes. The goal is that the participants will implement lifestyle changes and achieve at least 5% weight loss, which will reduce their risk of developing type 2 diabetes.

The clinical intervention for the Medicare Diabetes Prevention Program (MDPP) consists of a minimum of 16 intensive “core” sessions of a Centers for Disease Control and Prevention (CDC) approved curriculum furnished over six months in a group- based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. After the completing the core sessions, less intensive follow-up meetings furnished monthly help ensure that the participants maintain healthy behaviors. The total MDPP service period lasts for two years, consisting of one year of core and core maintenance sessions followed by up to one year of ongoing maintenance sessions. To maintain eligibility for ongoing maintenance sessions, the MDPP beneficiaries must obtain 5% weight loss.

The MDPP uses a performance-based payment structure that ties payment to performance goals based on attendance and weight loss. The MDPP is covered by Medicare Part B; beneficiaries enrolled in a Part C Medicare Advantage plan are also eligible for MDPP if their Medicare Advantage plan has contracted with an MDPP enrolled supplier.

The Part B fee-for-service reimbursement methodology gives beneficiary weight loss greater value than attendance because weight loss is a key indicator of reducing the risk of type 2 diabetes. Provider organizations will receive payment for beneficiaries who attend at least two out of three monthly sessions within a core or ongoing maintenance interval, given other payment requirements are satisfied.

Medicare Diabetes Prevention Program Performance-Based Payment Structure, Benchmarks With & Without Weight Loss & Corresponding Payments

Performance Goal Performance Payment Per Beneficiary (with the required minimum weight loss) Performance Payment Per Beneficiary (without the required minimum weight loss)
1st core session attended $25 $25
4 total core sessions attended $50 $50
9 total core sessions attended $90 $90
2 sessions attended in first core maintenance session interval (months 7-9 of the MDPP core services period) $60 (the required minimum weight loss from baseline must be achieved or maintained during the core or ongoing maintenance) $15
2 sessions attended in second core maintenance session interval (months 10-12 of the MDPP core services period) $60 (the required minimum weight loss from baseline must be achieved or maintained during the core or ongoing maintenance) $15
5% weight loss achieved $160 $0
9% weight loss achieved $25 $0
2 sessions attended in ongoing maintenance session interval (4 consecutive 3-month intervals over months 13-24 of the MDPP ongoing services period) $50 (the required minimum weight loss from baseline must be achieved or maintained during the core or ongoing maintenance) $0 (attendance requirements must be met, and minimum weight loss must be maintained during an ongoing maintenance session)
Total performance payment $670 $195

MDPP services are furnished in community and health care settings by coaches, such as trained community health workers or health professionals. To bill for MDPP services, MDPP provider organizations must have received MDPP Interim Preliminary Recognition from CMS by February 28, 2018, or after that date must receive recognition from the Centers for Disease Control and Prevention (CDC) 2018 Diabetes Prevention Recognition Program in order to enroll in Medicare as an MDPP supplier. Any organization that received MDPP Interim Preliminary Recognition will automatically qualify as having CDC Preliminary Recognition. Organizations that have MDPP Interim Preliminary Recognition will not have to take any action to apply for CDC Preliminary Recognition and should receive notification of their transitioned DPRP recognition status from the CDC on or after March 1, 2018. After March 1, organizations that apply for Medicare enrollment as an MDPP supplier should use their notification from CDC of achievement of CDC Preliminary Recognition for their MDPP enrollment application. The CDC will maintain a registry of recognized MDPP provider organizations.

In November 2017, the Centers for Medicare & Medicaid Services (CMS) finalized MDPP polices related to the set of MDPP services, including beneficiary eligibility criteria, the MDPP payment structure, and supplier enrollment requirements and compliance standards aimed to enhance program integrity. This information is published in the Calendar Year 2018 Physician Fee Schedule (PFS) final rule, published in November 2016. The final details were issued in the CY 2018 PFS final rule, and include the Healthcare Common Procedure Coding System (HCPCS) G-codes that MDPP suppliers will use to submit claims for payment when all the requirements for billing the codes have been met.

MDPP suppliers may only furnish the MDPP services to eligible beneficiaries. Eligibility is limited to beneficiaries enrolled in either Medicare Part B or Part C who have a Body Mass Index (BMI) of at least 25 (23 if self-identified as Asian) on the date of the first core session and have at least one clinical indicator of prediabetes, but no previous diagnosis of diabetes (except for gestational diabetes). The clinical indicators include a hemoglobin A1c test with a value between 5.7% and 6.4%, or a fasting plasma glucose of 110-125 mg/dL, or a 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test).

The CDC MDPP Registry is posted online.

For more information, contact: Help Desk, Medicare Diabetes Prevention Program, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 877-906-4940; Email:

Humana Medicare members who report experiencing severe loneliness have per member health care costs about $300 higher than costs for the average Medicare member. According to a member survey, about 9% of Humana Medicare members experience severe loneliness, and an additional 29% have some loneliness each month. Those who were severely lonely reported having up to 34.5 combined mentally and physically unhealthy days per month, about three times higher than the average Medicare member. Those who reported some loneliness had twice as many unhealthy days per month than the average member. A single unhealthy day, whether due to mental health problems or physical health problems, raises per-member per- month (PMPM) medical costs by $15.64.

Humana reported these findings in its 2018 Bold Goal Progress Report. The Bold Goal, which launched in 2015, is a business and health strategy to improve the health of communities by 20% by 2020. The Bold Goal communities are those where Humana has a large presence, in terms of corporate offices or member enrollments. The goal is to create evidence-based, scalable, and financially sustainable solutions with community partners and physician practices. The Bold Goal targets priority conditions and social determinants of health, inside and outside clinical settings.

For this initiative, Humana defines social determinants of health as “conditions in the places where people live, learn, work and play (that) affect a wide range of health risks and outcomes.” These conditions can include food insecurity, loneliness, stress, poor education, low-income, or lack of transportation.

Humana is tracking the Bold Goal progress via the Centers for Disease Control and Prevention (CDC) population health tool, Healthy Days. The tool measures both mentally and physically “Unhealthy Days” over a 30-day period; the maximum score is 60 Unhealthy Days. The Healthy Days tool helps demonstrate the link between improved health, positive business results, and social impact. The Healthy Days tool associated with $15.64 increase in PMPM medical costs. The tool also shows a correlation to both social determinants of health and chronic conditions. Healthy Days is correlated with disease progression among Humana members diagnosed with diabetes, congestive heart failure and/or chronic obstructive pulmonary disease (COPD).

The progress report presented results for initiatives focused on food insecurity, loneliness, and employee stress. The report also presents findings for each Bold Goal site.

Food insecurity is linked to twice as many unhealthy days. In a primary care screening pilot in Florida, about 46% of Humana members screened positive for food insecurity. Within that group, 86% accepted a referral to meet with an on-site Feeding South Florida representative; 94% subsequently accepted an emergency food box. To further test the findings, Humana has launched a 12-month randomized control trial with the same primary care partners and Feeding America. Humana seeks to show that addressing food insecurity in a primary-care setting can have a positive impact on health, clinical outcomes, and business metrics. Additionally, Humana partnered with Feeding America to develop a physician-facing food insecurity toolkit for physicians participating in the pilot to implement into their clinical workflows. The trial results will be released in 2019.

Loneliness and social isolation are correlated with up to three times as many unhealthy days. For this initiative, Humana surveyed its Medicare members to ask them about risk factors for loneliness. More than 10,000 responded to the initial survey: 62% were not lonely, 29% were somewhat lonely, and 9% were severely lonely. About 16.4% of those who engaged in Humana member assistance services, and 5,679 members responded to a pre- and post-survey about their loneliness before and after participating in member assistance services. Using the survey data, Humana developed a predictive model using the UCLA Loneliness Scale. It is now used throughout Humana’s business lines.

The employee stress findings are specific to Humana employees in the targeted Bold Goal communities. For this initiative, Humana implemented a number of employee engagement strategies. Over the past five years, Humana employees have improved their Healthy Days by 18%, which translates to 1.8 million more Healthy Days than they would have otherwise experienced. Employees with high levels of belonging had six times fewer mentally Unhealthy Days. Those with high well-being perceived three times less stress; they missed three times fewer work days; and they were less likely to look for another job.

Humana has increased the number of Bold Goal communities from seven to 12 metro areas, and four of its original seven Bold Goal communities demonstrated improved Healthy Days in their senior populations in 2017. Other communities saw slight Healthy Days improvements in Humana members living with chronic obstructive pulmonary disease (COPD), diabetes and depression. Of the original seven Bold Goal communities, Humana Medicare members in Knoxville, Tennessee; Baton Rouge and New Orleans, Louisiana; and San Antonio, Texas all had improved Healthy Days as well as improved clinical outcomes.

Louisville, Kentucky; and Tampa Bay and Broward County, Florida saw increases in Unhealthy Days, but also experienced slight improvements in clinical outcomes and in Healthy Days in Humana seniors living with conditions such as COPD, diabetes and depression. Knoxville, Tennessee saw a 5.4% improvement in Healthy Days due to strong community outreach efforts that improved clinical outcomes in diabetes.

The full text of “Bold Goal: 2017 Progress Report” was published in March 2018 by Humana. A free copy is available online.

PsychU reported on the Bold Goal strategies in “Humana Partners With CleanSlate Centers To Provide Outpatient Addiction Treatment Services In 8 States,” which published on November 30, 2017.

For more information, contact: Alex Kepnes, Corporate Media Relations, Humana, 321 W Main Street, Louisville, Kentucky 40202; 502-580-2990; Email:; or Mark Mathis, National Public Relations, Humana, 550 W Adams Street, Chicago, Illinois 60661; 312-441-5010; Email:

Background & Purpose

Mindfulness-based therapies (MBTs) have emerged as promising, low-cost, nonpharmacological treatments for stress- management and reduction of symptoms of mental illness, including depression, and results from numerous published studies and reviews suggest that this type of intervention is effective. However, most published studies that report primarily statistically significant results for these MBTs have had very low statistical power, raising the specter of reporting biases.

Reporting biases occur when significant or “positive” research outcomes are more likely to be published than nonsignificant or “negative” findings. Types of reporting biases include:

  1. Study Publication Bias – studies with positive, significant findings are more likely to be published than those with negative, nonsignificant findings
  2. Selective Outcome Reporting Bias – specific positive, significant outcomes are more likely to be reported and published than negative or nonsignificant outcomes
  3. Selective Analysis Reporting Bias – multiple methods are used to analyze data but are only reported if findings are positive and significant
  4. Other Bias – nonsignificant primary findings are framed as less important when results are published

Past meta-analyses of MBT have often used nonoptimal methods to detect reporting biases, such as those that require very large numbers of included trials to achieve accuracy. In a recent study entitled “Reporting of Positive Results in Randomized Controlled Trials of Mindfulness-Based Mental Health Interventions,” Stephanie Coronado-Montoya and colleagues set out to clarify understanding of the results reported in studies of MBTs by assessing the potential influence of reporting biases on the number of positive, published trials.

In this interview, Roger McIntyre, MD, FRCPC, Professor of Psychiatry & Pharmacology at the University of Toronto, Head of the Mood Disorders Psychopharmacology Unit at University Health Network, and Executive Director of the Brain & Cognition Discovery Foundation, discusses mechanisms of mood disorders, such as major depression and bipolar, and recent findings regarding the role that inflammation and disturbances in metabolism may play in the symptomology experienced by patients with mood disorders.

Dr. McIntyre also discusses the bidirectional relationship between the brain and gut, and results from a growing body of research surrounding diversity within the microbiome / microbiota and potential gut biome interplay in mental illness. Lastly, he touches on the possible therapeutic nature of manipulating aspects of the gut biome in order to produce improvement in psychopathology measures such as stress, anxiety, and depression.

In this two part series, Pamela Arenella, MD, Director of Residency Training & Vice Chair for Education, University of New Mexico School of Medicine, explores the importance of wellness in fighting burnout syndrome for health care professionals.

In this presentation, Part 2 of the series, Dr. Aranella discusses the changes that may be necessary to fight provider burnout, including the state of research related to wellness interventions for providers.

You can watch Part 2 of the series, “Focus On Wellness: Fighting Provider Burnout – Recognizing The Risk (Part 1 Of 2)” here:

In this two part series, Pamela Arenella, MD, Director of Residency Training & Vice Chair for Education, University of New Mexico School of Medicine, explores the importance of wellness in fighting burnout syndrome for health care professionals.

In this presentation, Part 1 of the series, Dr. Aranella discusses burnout syndrome symptoms and the prevalence of burnout for medical students, residents, and practicing health care professionals.

You can watch Part 2 of the series, “Focus On Wellness: Fighting Provider Burnout – Finding The Balance (Part 2 Of 2)” here:

During this follow up interview, Saundra Jain, MA, PsyD, LPC, further discusses the importance of including wellness alongside symptom reduction in treatment outcomes for patients with mental illness, as a follow up to her co-presented January 23, 2018 webinar entitled “The Power Of Mental Wellness: Wellness In Psychiatry.” She also touches on the importance of utilizing tools to measure patient wellness outcomes and the importance of encouraging mental health awareness in the community.

You can watch the full recorded video presentation, and download the slides from this webinar at

In this webinar, experts Roger McIntyre, MD, FRCPC, Professor of Psychiatry & Pharmacology at the University of Toronto, Head of the Mood Disorders Psychopharmacology Unit University Health Network, and Executive Director of the Brain & Cognition Discovery Foundation; and David Scheiderer, MD, MBA, DFAPA, Director of Education at Integrative Psychiatry, Inc review the association between dysfunction of gut microbiota-brain axis and mental health disorders. They also discuss when, how, and in whom gut strategies for the evaluation and treatment of psychiatric illness may be appropriate.

Life expectancy in the U.S. is going down due to alcoholism, opioid addiction, and suicide according to a recent report using data from the National Vital Statistics System Mortality file (see U.S. Life Expectancy Falls For The First Time This Century, Between 2000 & 2015 U.S. Life Expectancy Rose, But At A Slower Rate Than Expected Due To Opioid Overdose Deaths and U.S. Adult Suicide Attempts Rise Over Past Decade). But a recent story last week highlights another confounding factor in this disturbing trend—the U.S. obesity rate.

How is obesity tied to life expectancy? Researchers estimated that 11.7% of the deaths among people ages 40 to 84 were due to complications of obesity (see Rise In Obesity Rate Impedes Improvement In U.S. Mortality Rate). The statistics are startling—the percentage of United States adults aged 40 to 79 who had been obese at some point in their lives increased from 39.8% in 1988, to 52.0% in 2011. Ten times more children and teens are obese today than 40 years ago, marking a 1,027% increase in the children and teens classified as obese; 46 states have an obesity rate greater than 25%.

Beyond the effect on mortality, obesity is a driver of preventable health care costs. The CDC recognizes 14 different health conditions that are directly related to obesity, including clinical depression, anxiety, and other mental disorders. Many of these— such as heart disease, diabetes, and stroke—are well-known chronic diseases with significant overlap with mental health issues, and cause of death. Some studies estimate that obesity is responsible for 21% of U.S. health care costs and others place it at $150 billion in direct costs.

As the field moves to integrated care coordination models (like medical homes and health homes) and to more proactive population health management, the question is: what is being done to address the obesity issue? There are a few emerging guidelines and models for addressing the obesity in the care coordination initiatives, including a “ask, advise, and refer” approach; multidisciplinary collaboration between primary care physicians and other trained health professionals; and measurement of “signs and symptoms that affect the human movement system including aerobic fitness deficit, lower extremity joint pain and strength deficit, gait dysfunction and motor control deficit.

But what does this looks like on the ground? We recently spoke with Senior Associate George Braunstein, and former executive director for the Fairfax-Falls Church Community Services Board, who described his experience at a community mental health center integrating nutrition and physical health into their programs:

In my previous work, we had multiple approaches. We made sure that everyone had access to primary care and an annual physical for one. Also, our physicians and nurses were expected to do preventive interventions with early signs of diabetes, smoking, and obesity. This included nutritional counseling. Those interventions were sometimes inconsistent. And, all programs for all disabilities had regular trips to gyms for exercise-some of our staff were actually trained as trainers. And finally, all residential programs (we served hundreds in these programs every day) were required to serve balanced meals and to teach people about adequate nutrition.

We also reached out to Senior Associate Darryl Donlin, and former Vice President of Network Operations at New Directions Behavioral Health, who explained some of the obstacles between health plans and managed behavioral health care organizations (MBHO) that keep them developing closer knit medical and behavioral integration for such health issues as obesity.

Both the health plan and MBHO clearly understand how interpersonal issues may play a contributing role in obesity, however, there are important dynamics at play that may prevent such a collaboration across both organizations. On one hand, from a quality of care perspective, it makes logical sense for both parties to combine forces and develop clinical and contractual pathways to ensure individuals with obesity are getting their health issues addressed holistically by medical and mental health specialists. On the other hand, there are some relationships between both organizations where the business models of both organizations do not align and prevent this from happening.

For example, the MBHO’s contract with the health plan may only include services for members with a behavioral health diagnosis only. Therefore the MBHO will not get paid for those members with Obesity or another type of primary medical diagnosis. A potential solution around this issue is the development of an integrated care program that can benchmark the historic costs of this patient population and then determine the amount of savings to share (if any) with the MBHO based on the behavioral health service level intensity of the care collaboration. The ultimate goal to achieve is a reduction in the total cost of care through such a partnership. The only way to accomplish this is for both organizations to not only agree philosophically about the importance of holistic care integration, but to also back it up with a clear business model aligning incentives to ensure optimal outcomes for individuals with obesity.

For more, check out these resources in the PsychU Library:

  1. Life Expectancy As Our Key Performance Indicator
  2. The Collision Of Food Policy & Health Care Costs
  3. Stress & Health (& Health Care Spending)
  4. Is Loneliness The Overlooked Social Determinant?
  5. Rise In Obesity Rate Impedes Improvement In U.S. Mortality Rate
  6. 21% Of Unemployed Adults Unable To Work Due To Depression, Anxiety, Or Emotional Problems
  7. Lifestyle Changes Are Effective For Preventing Dementia

During this follow up interview, Rakesh Jain, MD, MPH, further discusses wellness and mindfulness for patients with mental illness, as a follow up to his co-presented January 23, 2018 webinar entitled “The Power Of Mental Wellness: Wellness In Psychiatry.” He also touches on the importance of mental health awareness in the larger scale community to support patients and their caregivers.

You can watch the full recorded video presentation, and download the slides from this webinar at

Key Messages

  • Suicide is a major and potentially preventable public health concern. It is the result of an interaction between known and unknown contributors, deterrents, and acute triggers.
  • Studies have demonstrated that increases in suicidality can be attributed to infections and associated proinflammatory cytokines, inflammatory-mediated metabolic changes, and quinolinic acid and glutamate changes that affect the neural circuitry.
  • Research has suggested that there is a strong association between inflammation, brain inflammation, elevated cytokine levels, and suicide. Lyme and Associated Diseases (LAD) causes immune-mediated effects by activating proinflammatory cytokines, specifically TNF-α, IL-1β, and IL-6 which are cytokines that have been found to be associated with suicide.

Mental Health America (MHA), a leading nationwide nonprofit organization dedicated to promoting the mental wellness of all Americans, has released its latest report “The 2018 State of Mental Health in America.” To learn more about the report, PsychU interviewed Paul Gionfriddo, President & Chief Executive of MHA, who shares highlights of the report regarding mental health access, prevalence, and related trends seen across the nation and within individual states.

Last month, Twitter and news reports were abuzz with President Trump’s plans for the supplemental nutrition assistance program (SNAP, or as the program is commonly referred to “food stamps”). The president’s proposed budget for fiscal year 2019 cuts program spending and radically alters how the program functions. According to the Center on Budget Policy & Priorities, the proposal would cut the program by 30% ($213 billion) and over four million people would lose SNAP benefits over the next decade.

SNAP serves an estimated 42 million people annually—about 80% of the 50 million people eligible for benefits. The average per- person SNAP benefit across the United States is $129 per month, or $1,548 over a 12-month period. The part of the proposal that really got everyone talking is the plan to provide a government-purchased, non-perishable food box to households, rather than allowing beneficiaries to purchase their own food from the grocery store. This proposal has been called everything from a way to “micro-manage the food consumption of low-income Americans” to “a Blue-Apron type program.”

SNAP isn’t only important when it comes to providing food security for Americans—it also has an impact on health care costs. About one third of consumers with chronic conditions have trouble paying for food, medications, or both. And people who have consistent access to food have health care costs about 45% lower than people who are food insecure. Recent study showed a direct link between SNAP and health care costs—the study reported that low-income adults enrolled in SNAP had estimated annual health care expenditures about $1,409 lower than low-income adults not enrolled in SNAP. Participation in SNAP has also been shown to reduce hospitalization, prevent nursing home stays, and limit the number of days consumers stay in hospitals and nursing homes among seniors.

In the background are rising rates of obesity in U.S. children—35% children were overweight in 2016, up from 29% in 1999, and studies have shown that adult SNAP recipients showed greater rates of obesity. The high rates of obesity are estimated to cost between $147 to $210 billion a year in obesity-related medical illnesses.

In addition, in 2017 we’ve seen the emergence of the concept of “nutritional psychiatry” that explores the relationship between dietary patterns and risk of mental health disorders. Some of the related research publications last year have brought the discussion to a new level.

As Senior Associate Annie Medina noted:

Nutrition plays a critical role in managing chronic conditions. Understanding proper nutrition and having the means to access healthy food options can prevent disease, promote overall health and wellness, and improve health outcomes. Health plans and payers are increasingly addressing the nutrition issue. For example, in 2016 the Pennsylvania-based Geisinger Health System launched Fresh Food Farmacy initiative to provide fresh, healthy food to health care service consumers with diabetes. And New York City health officials are adopting a UnitedHealthcare program to make eating healthier less cost-prohibitive.

With a payer and health plan focus on value—and the emerging interest in social determinants of health—what happens with nutrition and food security may get more attention in the months and years ahead. Will President Trump’s plans to remake SNAP come to fruition? The changes are subject to congressional approval. We know that last year, congress ignored the president’s proposed cuts to the SNAP program—and that this year, congress also needs to renew the farm bill (80% of spending in the farm bill is for nutrition assistance). The only thing left to do now is wait and see. But reductions to SNAP could result in more consumers dealing with food insecurity, pushing more of the responsibility for these types of social support into the health care system.

The decline in the United States mortality rate has been slowed by a rise in deaths due to complications related to obesity, defined as a body mass index (BMI) of 30 or higher. Between 1988 and 2011, the percentage of United States adults aged 40 to 79 who had been obese at some point in their lives increased from 39.8% in 1988 to 52.0% in 2011. The increase in the number who had been obese is estimated to have reduced United States life expectancy at age 40 by 0.9 years in 2011.

These findings were reported in “The Role Of Obesity In Exceptionally Slow US Mortality Improvement” by Samuel H. Preston, Yana C. Vierboom, and Andrew Stokes. The researchers analyzed data from the National Health and Nutrition Examination Survey (NHANES) III pertaining to the period 1988–1994 and data from the NHANES for the period 1999–2011. NHANES is a nationally representative survey of the noninstitutionalized U.S. population and includes a questionnaire as well as clinical and laboratory components. The goal was to determine whether rising BMI in the U.S. has had a negative effect on the country’s mortality rate.

For this report, the researchers measured mortality trends for six BMI categories recommended by the World Health Organizations. The categories include: less than 18.5 (which is considered underweight); 18.5 to 24.9 (which is considered a normal BMI range); 25 to 29.9 (which is considered overweight); 30 to 34.9 and 35 to 39.9 (which are considered obese); and 40 or higher (which is considered very obese). The mean BMI was 25. The researchers estimated the effect of maximum BMI across three NHANES cohorts: 1988 to 1994; 1999 to 2004; and 2005 to 2010.

Additional findings of the study include:

  • Between 1988-1994 and 2005-2010, the maximum BMI units above the 25.0 BMI mean rose from 5.00 to 6.93. Average maximum BMI in the 1988 to 1994 cohort was 30.00; in the 1999 to 2004 cohort it was 31.25; and in the 2005 to 2010 cohort, it was 13.93.
  • Without controlling for changes in BMI, age-specific death rates fell by 1.81% per year.
  • After controlling for changes in BMI, age-specific death rates fell by 2.35% per year.

The researchers calculated that if age-specific death rates had fallen at the BMI-uncontrolled rate of 1.81% per year, life expectancy at age 40 would have increased from 37.6 more years in 1988 to 41.4 more years in 2011. However, if age-specific death rates had fallen at the BMI-controlled rate of 2.35% per year, life expectancy at age 20 in 2011 would have risen to 42.3 more years. The researchers concluded that rising BMI reduced gains in life expectancy at age 40.

After controlling for age, sex, race, smoking status, and educational attainment, but without controlling for BMI, the death rate fell by 0.90% per year between 1988 and 2011. After controlling for BMI, the death rate fell by 1.47% per year, a difference of 0.57 percentage points.

Using the difference in mortality rates, researchers calculated the number of excess deaths due to complications of obesity in 2011. That year, there were 2.5 million deaths at any age, with nearly 1.6 million among people ages 40 to 84. The researchers estimated that 11.7% of the deaths among people ages 40 to 84 were due to complications of obesity, for a total of 186,000 excess deaths. These excess deaths attributable to rising obesity rates represented 7.4% of the total deaths in the United States in 2011.

The full text of “The Role Of Obesity In Exceptionally Slow US Mortality Improvement” was published January 16, 2018, by Proceedings of the National Academy of Sciences. A free abstract is available online.

PsychU reported on mortality rate trends in “U.S. Death Rates Increase Due To Suicide, Drug Overdoses & Alzheimer’s,” which published on June 21, 2016.

For more information, contact:

  • Samuel H. Preston, Ph.D., Professor of Sociology, Department of Sociology and Population Studies Center, University of Pennsylvania, 289 McNeil Building, Philadelphia, Pennsylvania 19104; 215-746-5396; Email:;
  • Andrew Stokes, Assistant Professor of Global Health, School of Public Health, Boston University, 715 Albany Street, Boston, Massachusetts 02118; 617-414-1276; Email:

In 2015 suicide was the 10th leading cause of death in the U.S., claiming the lives of an estimated 44,193 people,and it takes a toll on victims, their families, and the community. Behavioral health professionals from all disciplines work tirelessly to understand and prevent such tragedies. During this webinar, hear about one community’s experience in suicide prevention from Chelsey Patriss, BA, Executive Director of The Community Health Network of North Central Massachusetts, an organization committed to reducing negative health outcomes, such as suicide, by addressing the social determinants of health through the collaborative effort of community partners. Ms. Patriss and Moderator Rachel Self, MS, PhD, Senior Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc. (OPDC), offer insight into what communities can do to identify and address social factors that may be related to suicide.

If you or someone you know is in crisis, please contact the Suicide Prevention Hotline / Lifeline at 1-800-273-TALK (8255), or text the Crisis Text Line at 741-741.

1Drapeau, C. W., & McIntosh, J. L. (2016). USA suicide 2015: Official final data. Washington, DC: American Association of Suicidology. Retrieved December 2017 from

Approximately 23.5% of Baltimore residents live in areas that lack access to healthy and affordable food, affecting 146,000 of the city’s 621,000 residents. These areas are called healthy food priority areas and are defined as areas with a lower than average number of food stores, and median income at or below 185% of the federal poverty level. Also, less than 30% of residents own a car, and supermarkets are more than a quarter of a mile from resident homes. In previous years, healthy food priority areas were referred to as “food deserts.” Compared to 2015, an estimated 5,000 fewer residents live in a healthy food priority area due to a new supermarket opening.

Children are the most likely age group to live in a healthy food priority area (28.3%) followed by seniors at 24.3%. Black residents are the most likely of any racial or ethnic group to live in a healthy food priority area (31.5%). In comparison, only 8.9% of white residents and 11.4% of Hispanic residents live in a healthy food priority area.

The findings were reported in “Baltimore City’s Food Environment: 2018 Report” published by Johns Hopkins Center For A Livable Future based within the Department of Environmental Health and Engineering at the Bloomberg School of Public Health. The report presents the findings of a geospatial analysis of the city to determine healthy food priority areas. A healthy food priority area designation (HFAI) is a tool, adapted from the Nutrition Environment Measures Survey (NEMS-S) to score healthy food availability. Data was collected from surveys of 761 food stores using the HFAI tool that categorizes food choice and healthy options, including participation in Federal Nutrition programs, including U.S. Department of Agriculture Supplemental Nutrition Assistance Program (SNAP) and Women, Infants and Children (WIC).

Additional findings were as follows:

  • Over 75% of retail food stores evaluated accept SNAP and 18% accept WIC.
  • HFAI scores range from 0 to 28.5, with higher scores indicating a greater presence of healthy for policy and programmatic activities foods. Supermarkets offered the highest HFAI score at 23.5 to 28.5; small groceries score range was 0 to 23.5; convenience stores scored 0 to 18; and public markets with scores of between 5 and 20.
  • Healthy food priority areas had 103 small grocery or corner stores and six convenience stores. In areas not designated as healthy food priority areas there were 422 small grocery or corner stores and 177 convenience stores.

The full text of “23.5% Of Baltimore Residents Still Lack Access to Healthy, Affordable Food” was published January 2018 by Johns Hopkins Center for a Livable Future. A free abstract is available online.

For more information, contact: Angela Evatt, Chief, Health Information Exchange, Maryland Health Care Commission, 4160 Patterson Avenue, Baltimore, Maryland 21215; 410-764-3574; Fax: 410-358-1236; Email:

Background & Purpose

For individuals with mental illness, families can be a source of support as well as stress, and for family members, caregiving relationships can be both rewarding and distressing. Research has shown that familial caregivers report more psychiatric and health symptoms and lower quality of life when compared with non-caregivers. Several aspects of caregiving can contribute to experienced stress, including the need for vigilance, lack of control, and secondary strain on other domains of life functioning, necessitating effective coping strategies to maintain successful relationships and well- being.

Mindfulness, defined as an awareness developed by intentional and nonjudgmental focusing of attention on what the individual is experiencing in the present moment, has been linked with positive physical and mental health outcomes in both clinical and nonclinical populations. In addition, mindfulness is associated with increased relationship satisfaction and ability to respond constructively to relationship stress. Findings from early-stage research show that MBIs may result in positive effects for caregivers of individuals with chronic conditions. As a result, mindfulness-based interventions (MBIs) represent a promising avenue of inquiry. However, there is a dearth of high-quality evidence demonstrating that MBIs can result in significant improvements in outcomes for familial caregivers.

In a recent article entitled “Effectiveness and Usability of a Web-Based Mindfulness Intervention for Families Living with Mental Illness,” Sigrid Stjernswärd and Lars Hansson describe the results of a randomized controlled trial designed to evaluate a brief, web-based MBI for families of individuals with mental illness.

A couple weeks ago I found myself in a great conversation about the future of value-based payments—a future that my colleagues and I agreed would involve social determinants of health (SDH) in some shape or form. Our main takeaway from that talk was that the key to assigning risk of SDH and measurable value to social support services to address them is standardized models and methods—but that presupposes that everyone is on the same page about what constitutes a SDH.

Generally, when health care executives discuss SDH, the conversation is focused on the widely-recognized categories of employment and economic stability, housing, nutrition, and neighborhood context (see Tending To The Social Determinants Of Health – Or Not). And, watching the effect these determinants have on cost has become a big part of executive strategic planning (see Social Risk & The ‘Value’ Of Health Care). But there is another category that is starting to gain more attention—socialization and loneliness.

Earlier this month, the United Kingdom grabbed a lot of attention when the Prime Minister appointed a “Minister Of Loneliness.” This new position will lead a government coalition to develop new policies designed to combat loneliness in the elderly, caregivers, people who have lost loved ones, and the population in general. Why has the U.K. taken such a dramatic step?

Loneliness is a growing problem across the developed world – and one that has serious health consequences.

According to an article in Scientific American, people with no one to discuss important matters has tripled, 28% of older adults live alone, and one third over the age of 45 report feeling lonely. While social media has helped to stem the tide of loneliness for some people, particularly younger generations, studies have shown that a high use of social media can actually increase perceived social isolation.

Isolated individuals who report frequent feelings of loneliness suffer higher rates of morbidity, mortality, infection, depression, and cognitive decline. A survey done by AARP found that 55% of respondents who were in poor health reported being lonely, compared to 24% of respondents who were in good health and 25% of respondents who were in excellent health. As former Surgeon General Vice Admiral Vivek H. Murthy noted in a recent article “Loneliness and weak social connections are associated with a reduction in lifespan similar to that caused by smoking 15 cigarettes a day and even greater than that associated with obesity”.

And the costs for this isolation are just beginning to be recognized—Medicare spends an additional $1,608 a year for each older person who has limited social connections for an estimated $6.7 billion in added spending.

So, is “loneliness” the next big SDH? Considering that research is beginning to reveal that social connections can have larger effects on health than many existing SDH, I think it’s only a matter of time before “social health”—focused on “social activities, social well-being, social network quality, interpersonal communication, social support, and social role participation and satisfaction” —becomes a big part of this conversation.

Key Messages

  • Major depressive disorder (MDD) and bipolar disorder (BD) are associated with high rates of medical and psychological comorbidities as well as functional impairment.
  • Exercise appears to be a promising adjunctive treatment for mood disorders and comorbid conditions.

This summary was developed utilizing the full recorded presentation of this webinar, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at

On January 23, 2018, Dr. Rakesh Jain and Dr. Saundra Jain conducted a webinar to discuss the neurobiology and clinical implications of wellness interventions. Rakesh Jain, MD, MPH, is a Clinical Professor in the Department of Psychiatry at the Texas Tech Health Sciences School of Medicine in Midland, Texas. Saundra Jain, MA, PsyD, LPC, is an Adjunct Clinical Affiliate for the University of Texas School of Nursing in Austin, Texas. The speakers were paid consultants to Otsuka Pharmaceutical Development & Commercialization, Inc.

The presentation had the following educational objectives:

  • Examine the neurobiology of wellness interventions and appreciating the associated clinical implications
  • Review data from a 30-day prescriptive wellness program
  • Discuss wellness strategies focusing on the importance of accountability

Dr. R. Jain began the presentation by discussing factors that define wellness. He said that some products (e.g., teeth whitening products, eyelash extensions) are sold under the banner of “wellness products,” but in psychiatry, a more rigorous definition of wellness is required. He then offered a 60-year-old definition of “health” from the World Health Organization (WHO): “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” He suggested the term applies to mental as well as physical health. He stated that as a medical resident, he was trained to stamp out mental illness, but he emphasized that wellness is also worthy of address.

He presented a depiction of traditional treatment goals as being symptom reduction plus improved functionality leading to improved outcomes. He then suggested that the formula would be more complete if wellness were included among the components leading to those improved outcomes. He stated his belief that the measurement and assessment of wellness is equally important to addressing symptoms and improving functionality.

Next he introduced a description of his and Dr. S. Jain’s work, the Wellness Interventions for Life’s Demands (WILD-5) Wellness program. This program involves five interventions: exercise, mindfulness, sleep, social connectedness, and nutrition. He stated that they have studied the program seven or eight times and planned to present their data from work with psychiatrically ill patients. He pointed the audience to the WILD-5 Wellness Workbook as a resource for work with their own patients. He stated that the five interventions were chosen because the data for each is persuasive, even when used as monotherapies or as adjuncts to other forms of therapy.

Dr. R. Jain then presented data for each component, beginning with exercise. He stated that research indicates that physical inactivity is linked to not only reduced quality of life, early mortality, and a variety of physical conditions, but mental health conditions as well. He pointed out that obesity and metabolic syndrome are not uncommon among individuals receiving psychiatric care.

He presented research findings from a study of 16 overweight young adults (20-42 years of age) who were offered supervised exercise, a combination of aerobic and weight training. Findings included magnetic resonance imaging (MRI) data showing an increase in gray matter density as well as improved connectivity among brain regions associated with depression, suggesting improved brain functionality. He emphasized that these were not trivial changes.

Dr. R. Jain presented additional findings from the study, highlighting decreases in body mass index (BMI); increases in high-density lipoprotein cholesterol (HDL-C); increases in gray matter density in the hippocampus, insular cortex, and cerebellum; and altered serum brain-derived neurotrophic factor (BDNF). He said that the take-home point was that exercise is an important component in helping patients deal with not only mental illness, but also in driving them toward mental wellness.

Transitioning to a discussion of mindfulness, Dr. R. Jain first acknowledged his initial skepticism about it before incorporating it into practice approximately 10 years ago. He stated that now the research results are clear and the neurobiological effects of mindfulness are well-established. He presented a definition of mindfulness from Dr. Jon Kabat-Zinn: ““Paying attention, on purpose, in the present moment, non-judgmentally.” He explained that many have the misconception that mindfulness is “emptying your mind” or only thinking about one thing without being distracted.

He stated that research results point to mindfulness as a neurobiological intervention of the first order. He summarized results from one study focused on abnormalities in brain connectivity in stressed individuals, which found “excessive connections” between the dorsal anterior cingulate cortex (dACC) and the amygdala, which are associated with both anxiety and major depression. He also presented findings from a study of mindfulness meditation training, showing both clinical improvements and also decreased connectivity between the ACC and the amygdala, which he described as normalization of that brain activity. Based on these findings, he said that it is highly illogical to think of mindfulness as only a psychological distraction technique, as there is abundant evidence to show that it also reduces symptoms and improves wellness.

Dr. R. Jain addressed the role of sleep in wellness. He pointed to research showing that insomnia is strongly associated with a wide variety of disorders, including anxiety and depression. He stated that insomnia has also been linked with reductions in hippocampal and prefrontal cortex volume, as well as increased activity during sleep in the thalamus and generally in the amygdala. He stated that it was no wonder that patients with insomnia experience increased incidence of pain, depression, anxiety, and lower levels of wellness.

He then moved on to a discussion of the neurobiology of social connectedness. He stated that feeling isolated is as much of a problem, neurobiologically speaking, as physical pain, depression, and anxiety. He emphasized that social isolation could be elevated as a priority for treatment, as several research studies have found that the number and quality of social connections are associated with reduced risk of depression relapse as well as higher levels of mental wellness. He described it as a dose-dependent association.

Dr. R. Jain discussed the neurobiological findings for nutrition. He pointed to research results showing that frequent consumption of red meat is associated with reduced brain volume, while those who adhere to the Mediterranean diet have greater brain volume. Further, in elderly adults, adherence to the Mediterranean diet, as well as reduced meat intake and increased fish intake, are associated with significantly greater cortical thickness than that observed in individuals with a more “Western” diet of high levels of red meat consumption. He explained that depression and anxiety have repeatedly been linked to cortical thinning in the dorsolateral prefrontal cortex and the hippocampus. He summarized by saying that eating the wrong things can contribute to neurological damage, but the proper diet may contribute to increased brain volume, which can in turn contribute to wellness.

He went on to explain that there are protective, neutral, and deleterious associations between brain health and certain foods. He presented a summary of a meta-analysis of over 300 studies and said the data are clear with regard to sweetened beverages and red processed meats having deleterious effects. However, consumption of whole grains, fruits and vegetables, and fish can have protective associations with brain structure, which can be connected with functionality.

Dr. R. Jain described that he and Dr. S. Jain developed the WILD-5 intervention for their own patients, and as time went on, conducted seven or eight studies to assess its impacts. Before discussing the results of his own work, he offered a disclaimer, stating that they are not claiming that there is any “perfect program.” The disclaimer further stated: “The supporters of this educational content do not have vested interests in specific educational tools or resources and do not necessarily promote or condone the use of any one resource over another. Healthcare professionals should use their own medical judgment in deciding whether a tool or resource is right for their practice. Individuals should always seek advice from their treating doctor or other qualified professional before undertaking or considering a specific strategy.”

He then presented the specific recommendations of the 30-day WILD-5 program for each of the five interventions: 1) mindfulness exercises for eight minutes or more per day, 2) implement pro-sleep hygiene practices daily, 3) log daily food intake daily, 4) text or call a family member or friend daily, and 5) 30-minutes of moderate intensity exercise 6 out of 7 days per week. He commented that the expectations are not “overwhelming.”

In terms of the sleep intervention, Dr. R. Jain explained that they asked patients to implement four out of the following six pro-sleep practices: 1) avoid electronic activities (including e-readers) 90 minutes before bedtime, 2) avoid napping during the day, 3) eliminate ambient light in the bedroom (e.g., light from clock radios, cell phones, and windows) and/or use blackout shades or a night mask to block out excess light, 4) take a warm relaxing bath or shower before bedtime, 5) establish and stick to a regular bedtime each night, including weekends, and 6) avoid caffeinated drinks after 12:00pm.

Dr. R. Jain emphasized the importance of tracking and accountability. He stated that they asked their patients to document activities in tracking logs and urged colleagues considering such interventions to do the same with their own patients.

He then presented results from two studies, one with patients who had psychiatric disorders, and the other with chronic pain patients. He noted that findings of these studies have been presented at an international congress and stated that they have also conducted a replication study. Assessment measures included the Patient Health Questionnaire 9 (PHQ-9), and in pre-post intervention analysis, patients in both the mental health group and the pain group reported a 43% improvement in depression symptoms, a finding that was also statistically significant. The study also used the Generalized Anxiety Disorder 7-item scale (GAD-7) to assess anxiety, and results showed a 40% reduction in symptoms after the 30-day intervention for the mental health group and a 39% decrease in symptoms for the pain group.

Dr. R. Jain stated that sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI), and results showed a 29% improvement in scores after the intervention in both the mental health and pain groups. Wellness was assessed using the five-item World Health Organization Well-being Index (WHO-5), and results showed a 60% post-intervention improvement in the mental health group and a 57% improvement in the pain group. He recommended the use of the WHO-5 as a free, not-under-copyright form for assessing wellness. In light of the findings, Dr. R. Jain advocated for the consideration of wellness interventions as an adjunct to more traditional forms of treatment.

Taking over the presentation, Dr. S. Jain introduced of “wellness deficit disorder,” which she acknowledged as not being a recognized disorder at this time, then questioned whether perhaps it should be. She explained that they came up with the disorder after observing that treated patients exhibited improvements in symptoms and functionality, but when a scale was used to measure their wellness, scores were low even when symptoms had improved. She said that she also observed this pattern in friends and colleagues.

Dr. S. Jain explained that the current DSM-5 has over 350 different identified disorders, and said they are not necessarily advocating for the inclusion of Wellness Deficit Disorder in the next update. Rather, she stated that the aim is to emphasize that while measuring symptoms and functionality is still important for clinicians, perhaps consideration should be given to routine and specific measurement of wellness. She also recommended including wellness in treatment planning. She showed a slide of all the different DSM-5 categories and asked where Wellness Deficit Disorder could be included in the clinical conversation.

She stated that they did not want their own personal observations to skew their idea of wellness. Therefore, they conducted an anonymous online survey to measure happiness, enthusiasm, resilience, and optimism (“HERO elements”). She said they wanted to include positive psychology elements in addition to the categories of intervention previously described by Dr. R. Jain, and so they collected survey responses from 757 individuals from across the United States as well as some from Canada.

Dr. S. Jain stated her belief that there would not be much debate that the HERO traits from positive psychology are important and asked if it is possible to strengthen those traits. She displayed a picture of the online survey, which included questions regarding the four HERO elements, as well as an item that asked participants to rate their overall mental wellness. She asked the audience to consider how they would rate themselves on the 10-point Likert scale for each of the five items.

Next, Dr. S. Jain presented findings from the survey, which asked people to rate themselves on each item over the last seven days. With regard to happiness, with higher numbers equaling more happiness, respondents without a mental health condition rated themselves 6.5 out of 10 on average, while those with a mental health condition rated themselves an average of 4.9. She noted this finding and stated that there is work to be done.

Dr. S. Jain presented findings for the other items. For the enthusiasm item, those without mental health conditions rated their enthusiasm an average of 5.9, while those with mental health conditions rated themselves an average of 4.6. In terms of resilience (which she described as the ability to deal with adversity and trauma exposure), respondents without mental health conditions gave themselves an average rating of 7.2, while those with mental health conditions rated themselves an average of 5.9. For optimism, those without mental health conditions rated themselves an average of 6.5, while those with mental health conditions rated their optimism an average of 5.0. In terms of the final question about overall mental wellness, those without mental health conditions rated themselves an average of 7.4, while those with mental health conditions rated their optimism an average of 5.5.

She questioned if, based on the data she presented, Wellness Deficit Disorder should enter into our clinical thinking, conversations, treatment plans, and strategies. She then stated that they would present more data to help the audience make an informed decision.

Dr. S. Jain began with the topic of the neurobiology of positive emotions, though she acknowledged that traditionally clinicians have been trained to focus more on negative emotions. She stated that the HERO elements are considered positive emotions, and the brain regions associated with such emotions include the ventral striatum, the amygdala, the hippocampus, and the orbital prefrontal cortex. She noted that these regions are also associated with negative emotions. She also listed the neurotransmitters involved in positive emotional processing, including dopamine, GABA (gamma-aminobutyric acid), opiate receptors, endogenous opiates, and endogenous endocannabinoids. She pointed out that the neurobiology of and neurotransmitters associated with positive emotions is well-established.

She discussed whether there is evidence of wellness interventions having an impact on resilience. She stated that wellness interventions will not change genes, but they may have an impact on epigenetics by improving functioning of genes. She explained that wellness interventions such as the ones previously discussed promote resilience in the brain through epigenetic mechanisms.

Dr. S. Jain then summarized research findings on optimism, which have shown that higher levels of optimism are linked with improved physical and psychological well-being, including reduced risk for future cardiovascular disorders compared with those who are pessimists. She showed brain imagery from a study showing that those higher in dispositional optimism had higher levels of gray matter volume (specifically, in a cluster that mainly included areas in the left thalamus/left pulvinar, which extended to the left parahippocampal gyrus). She also pointed to findings showing that individuals with higher levels of optimism have lower activation of amygdala when viewing negative stimuli and higher activation of ACC when viewing positive stimuli.

She also discussed the association between happiness and inflammation. Findings from a past study showed that those with lower perceived happiness have higher levels of interferon-alpha (an inflammatory cytokine) compared to those with higher perceived happiness. She noted that an additional finding of the study was that touching and warm or positive emotion induced by the touch of a loved one reduced levels of interferon-alpha.

Dr. S. Jain stated that people can make changes in individual characteristics and behaviors that may promote wellness. These things include the HERO elements, wellness practices including physical exercise, social connectedness, and humor. She concluded that portion of the presentation by offering three points: 1) wellness has a neurobiological and anti-inflammatory footprint, 2) lower levels of wellness have a negative neurobiological imprint and the reverse is equally true, and 3) wellness traits can be improved via wellness practices and exercises.

She noted the existence of illness markers and asked the audience to also consider markers of wellness. Presenting the results of a study showing pre-post intervention changes in the HERO elements (as measured by their five-item Likert scale measure) following the 30-day WILD-5 intervention, Dr. S. Jain described how self-reported happiness increased by 30%, enthusiasm increased by 51%, resilience increased by 63%, and optimism increased by 45%. She pointed to the findings as evidence that markers of wellness can be changed with interventions. She stated that using specific practices to change such markers is an empowering possibility for both clinicians and patient.

Dr. S. Jain concluded the presentation with three summary points: 1) integrated interventions that address specific areas of wellness (such as exercise, mindfulness, sleep, social connectedness, nutrition, and attention to HERO elements) may be of benefit in some clinical situations, 2) measurement-based and tracking tools may be used to incorporate wellness interventions into clinical practice in order to add the elements of accountability and tracking, and 3) the combination of exercise, mindfulness, sleep, social connectedness, and nutrition provides an intervention that may improve wellness on the basis of a 30-day pilot program. She noted that the workbook and other resources are available on their website that is referenced in the slides.

The webinar concluded with a question and answer period in which the following were asked:

Can you speak to program adherence, and is it difficult to keep patients engaged?

Dr. R. Jain said that he believes adherence is a challenge in any branch of medicine, but particularly in psychiatry. He acknowledged challenges with adherence in the WILD-5 intervention, but also shared lessons learned regarding skills that could be used to improve adherence. He noted that telling patients to do something does not work as well as telling them why those things could help them. He said that many patients assume that the only goal of the psychiatrist is to reduce symptoms and may not know that addressing not only psychopharmacology and psychotherapy needs, but also wellness issues, is the way to do that well. He stated that, after psychoeducation, the single greatest strategy to increase adherence is tracking and monitoring. He said the way to do that is to give the patient a yes-no checklist of some kind so they can log what they have done. It allows the individual to look back on the previous seven days or more and get feedback and coaching from the clinician. He estimated adherence for the intervention to be in the 50-60% range depending on the intervention. He stated that despite any adherence issues, the results of the intervention remain impressive.

Additionally, Dr. S. Jain stated that another way to improve adherence was to engage patients in their own measurement. On a weekly basis, they asked patients to complete the HERO wellness scale so that they could see areas that were improving and areas that required more focus. She advocated for actively involving the patient not only in the interventions but also the measurement of progress.

Would a clinic be overwhelmed with the extra work in order to use a program like WILD-5 Wellness?

Dr. S. Jain acknowledged that time is a limited resource and can be a barrier. However, she stated that WILD-5 does not present a significant drain on their clinic resources. She said that they hoped to ease the burden on colleagues by creating the WILD-5 workbook so that other clinicians do not have to reinvent the wheel. She invited anyone who uses the workbook and runs into a barrier to reach out to her or Dr. R. Jain with questions or feedback. She stated her belief that the time it takes to engage patients in wellness interventions is worth it.

Then Dr. R. Jain invited the audience to use slides from the presentation to show to patients in order to start them thinking. He stated that the goal of life is not to live without mental challenges, and having a life full of the HERO elements is a life well lived. He emphasized that individuals with higher levels of the HERO elements do better psychiatrically and who seem to get a more beneficial augmentative effect to psychopharmacological and other treatments. He said that interventions that can help change the structure of the brain in such a beneficial way should be embraced.

Data from a 30-day prescriptive wellness program supports the clinical repercussions of neglecting a targeted wellness strategy in the care of patients with mental health issues. In this webinar, speakers Rakesh Jain, MD, MPH, Clinical Professor in the Department of Psychiatry at Texas Tech Health Sciences School of Medicine and Saundra Jain, MA, PsyD, LPC, Adjunct Clinical Affiliate for the University of Texas School of Nursing, examine the neurobiology of wellness interventions and highlight potential clinical implications. The strategies discussed during this program emphasize not only the importance of educating patients on the concept of wellness, but also on the critical need for ensuring accountability in any wellness approach.

Hear more from Rakesh Jain, MD, MPH & Saundra Jain, MA, PsyD, LPC, as they provide additional context for wellness and mindfulness in these follow-up interviews:

Key Messages

  • There has been no national study that has evaluated the rates of burnout among US physicians compared to US workers in other fields
  • Burnout was measured using what is widely seen as the gold standard tool for measuring burnout, the, 22-item Maslach Burnout Inventory (MBI) questionnaire
  • A total of 26.7% physicians who received an invitation completed the survey
  • Almost half of the physicians surveyed experiences at least 1 symptom of burnout with the highest rates of burnout being reported by physicians in the front line of care
  • Results also demonstrated that burnout is more common in physicians compared to other US workers

During this presentation, Steven Chen, PharmD, FASHP, FNAP, provided a brief overview of the role hypertension may play in outcomes in mental health. Key discussion points included:

  • Prevalence and significance of hypertension
  • Relationship between hypertension and mental illness
  • Tools and guidelines for patients with hypertension
  • Nonpharmacologic treatments that may benefit patients with hypertension

This full live presentation, and others like it, are available for free for PsychU Members. To learn more or schedule a live program for your organization, please visit

Background & Purpose

Individuals with mental disorders often experience sleep difficulties, but traditionally, these have been considered symptoms of the illnesses. As a result, interventions for sleep may be given low priority. There is an alternative hypothesis, however: sleep may be a significant contributing factor in the development and escalation of symptoms of mental illness. However, few studies have been adequately designed to evaluate a potential causal path.

In a recent study entitled “The Effects of Improving Sleep on Mental Health (OASIS): A Randomized Controlled Trial with Mediation Analysis,” Daniel Freeman and colleagues conducted a single-blind, randomized controlled trial to evaluate whether treating insomnia in college students was associated with reductions in symptoms of psychosis, among other mental health issues, compared with usual care.

Opioid-related hospital stays have more than doubled over a ten-year period in small metropolitan areas, increasing by 121.6%. Between 2005 and 2014, the rate of inpatient stays in small metropolitan areas increased from 89.6 per 100,000 residents to 198.5 per 100,000 residents. This increase was larger than increases in large metropolitan areas, medium-sized metropolitan areas, and rural areas.

In the analysis, the metropolitan area definitions are as follows:

  • Large metropolitan area: counties of metropolitan areas with 1 million or more residents. Examples include New York County, New York; Los Angeles County, California; and Dallas County, Texas.
  • Medium-size metropolitan areas: counties in metropolitan areas of 250,000– 999,999 residents. Examples include Utah County, Utah (containing Provo); Summit County, Ohio (containing Akron); and Albany County, New York (containing Albany).
  • Small metropolitan areas: counties in metropolitan areas of 50,000 up to 249,999 residents. Examples include Adams County, Pennsylvania (containing Gettysburg); Knox County, Ohio (containing Mount Vernon); and Parker County, Texas (containing Aledo).
  • Rural areas: non-metropolitan areas of any population. Examples include Schuyler County, New York (containing Watkins Glen); Mendocino County, California (containing Ukiah); and Wapello County, Iowa (containing Ottumwa).

These findings were presented in “Patient Residence Characteristics of Opioid-Related Inpatient Stays and Emergency Department visits Nationally ad by State, 2014” by Audrey J. Weiss, Ph.D., Molly K. Bailey, Lauren O’Malley, Marguerite L. Barrett, M.S., Anne Elixhauser, Ph.D., and Claudia A. Steiner, M.D., M.P.H. The researchers used data from the Healthcare Cost and Utilization Project (HCUP), Claritas demographic profiles, and related studies. The goal was to show opioid-related hospital use by state and select patient subgroups. Inpatient stay data was available for 46 of the 51 states (including the District of Columbia). States excluded from the study were Alabama, Alaska, Idaho, Mississippi, and New Hampshire (because of the lack of data availability at the time analyses were done).

The study also found:

  • In rural areas, opioid-related hospital stays increased by 99.1%. Between 2005 and 2014, the rate of inpatient stays in rural areas increased from 102.5 per 100,000 residents to 204.0 per 100,000 residents.
  • In medium-sized metropolitan areas, opioid-related hospital stays increased by 67.0%. Between 2005 and 2014, the rate of inpatient stays in rural areas increased from 126.0 per 100,000 residents to 210.4 per 100,000 residents.
  • In large metropolitan areas, opioid-related hospital stays increased by 33.8%. Between 2005 and 2014, the rate of inpatient stays in rural areas increased from 307.3 per 100,000 residents to 464.1 per 100,000 residents.

PsychU reported on opioid-related hospital stays in “Opioid-Related Hospitalizations Among Women Up 75% From 2005 To 2014, Men’s Hospitalizations Rise 55%,” which published on July 21, 2017.

For more information, contact: Alison Hunt, Media Contact, Office of Communications, Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, Maryland 20857; 301-427-120544; Email:

This summary was developed utilizing the full recorded presentation of this webinar, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at

On November 7, 2017, Drs. Christoph Correl and John Newcomer conducted a webinar which revisited various strategies for early intervention (EI) in psychotic syndromes while focusing on strategies to improve metabolic risk. Christoph Correll, MD, is a Professor of Psychiatry at Hofstra Northwell School of Medicine in New York, NY, and Medical Director of the Recognition and Prevention (RAP) program at the Zucker Hillside Hospital. John Newcomer, MD, is a Professor of Integrated Medical Science at the Charles E. Schmidt College of Medicine at Florida Atlantic University (FAU) in Boca Raton, Florida. Both speakers are paid consultants to Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of this webinar were to:

  • Provide an overview of the potential importance of early intervention in psychosis
  • Discuss possible metabolic effects of treatment
  • Review challenges and barriers to implementing screening
  • Explore integrated care approaches in overcoming such barriers
  • Examine primary prevention and intervention for cardiometabolic disease

Dr. Correll began the presentation with a brief overview of the development of schizophrenia. He explained that schizophrenia is a neurodevelopmental disorder with a strong genetic input, but that there is still an environmental or “chance” component during brain development. Early infection or trauma to a fetus or traumatic events during childhood may affect gene expression and increase predisposition for future psychosis. Dr. Correll explained that there is at least one subtype of schizophrenia with a strong neurodevelopmental trajectory characterized by motor abnormalities and developmental delays in early childhood, as well as psychosocial abnormalities and inhibitions. He then described a “pruning process” in the brain during adolescence that may be overactive in individuals who go on to develop schizophrenia. He added that social isolation, stress, and marijuana use and abuse may also prime the brain for the emergence of schizophrenia.

Dr. Correll described the course of schizophrenia, beginning with functional impairment; moving into experience of negative symptoms; and culminating in the emergence of attenuated positive symptoms that may subsequently lead to a first episode of psychosis. Dr. Correll stated that some patients have persistent negative symptoms, while others have undulating courses of positive and negative symptoms. He also explained that, currently, the only effective known treatment for psychosis involves reducing dopamine tone.

Dr. Newcomer then discussed the importance of early intervention, stating that several lines of evidence indicate that the longer psychosis remains untreated, the worse outcomes may be. He noted that there is also evidence of cognitive decline as well as possibly related progressive reductions in gray matter during the early course of the illness. He cited these patterns as rationale for the need to intervene as early as possible to potentially alter the long-term course of the condition.

Dr. Newcomer noted that there are challenges to successful intervention, including that current treatments are limited by their efficacy and potential side effects, including with the newer atypical antipsychotic medications. He also stated that there is some research suggesting that antipsychotic medications may contribute to adverse structural brain changes. He acknowledged that there are still questions about whether the benefits of early intervention can be sustained with long-term treatment.

Next, Dr. Newcomer described an example of an early intervention program: the 2012 revised version of the Incident Response Improvement Program (IRIS) in the United Kingdom, which involved multiple elements:

  • Access to early detection
  • Patient assessment
  • Individual and family engagement
  • Individual interventions such as cognitive behavioral therapy and antipsychotic medication
  • Support of appropriate social, educational, and vocational roles
  • Family interventions
  • Monitoring and modification of physical health risks

Dr. Newcomer explained that, while promising, the IRIS intervention was not formally structured as a study. He then encouraged Dr. Correll to discuss some of the findings from early intervention research funded by the National Institute of Mental Health.

Dr. Correll presented results from the Recovery After an Initial Schizophrenia Episode (RAISE) study, a cluster randomized study (i.e., individual patients were not randomized, but treatment sites were) to determine whether it was possible to change the trajectory of schizophrenia. The study was implemented in real-world mental health clinics to increase the external generalizability of the findings. Dr. Correll added that the National Institute of Mental Health (NIMH) specified that the intervention had to be carried out under the current reimbursement structure to facilitate dissemination and implementation throughout the United States after the study’s completion.

Dr. Correll explained that the RAISE study enrolled 404 outpatients who were 15 to 40 years of age, had been diagnosed with a schizophrenia spectrum disorder, and had received fewer than six months of antipsychotic treatment during their first episode of psychosis. Participants were randomized to receive the NAVIGATE intervention or treatment as usual (i.e., “community care”). Treatment follow-up was two years, though the study is ongoing, and the primary outcome was defined as quality of life, which Dr. Correll described as a confluence of symptoms and side effects, functionality, and recovery-based outcomes.

Dr. Correll then described the NAVIGATE intervention in more detail. The four components of this intervention were:

  • Psychopharmacology – with the aid of a measurement-based tool: a computerized system accessed via a secure web-based platform that used relevant inputs (e.g., patient health information, responses to questionnaires, adherence) to develop algorithms to enhance clinical decision-making
  • Individual resiliency training – a strengths-based (rather than deficit-focused) individual psychotherapy, applied with the hope of giving patients a positive therapy experience that increased motivation to excel
  • Family psychoeducation – to align patient and family member understanding of the illness and its treatment, with the understanding that social connection and support is important for outcomes
  • Supported employment and education – to help patients “get back on track” and into a productive life situation as rapidly as possible

Dr. Correll described some of the demographics of the sample, noting that participants were, on average, about 23 years of age, with approximately 80% having been previously hospitalized. With regard to role functioning, he described that the sample had, on average, not more than seven weeks of antipsychotic treatment, and less than a third of patients were in school or working.

In terms of findings, Dr. Correll presented results demonstrating that the NAVIGATE intervention was superior in terms of improvements in the outcome (i.e. quality of life) when compared to treatment as usual; however, he noted that the effect size was small. Therefore, he explained, investigators examined factors that might improve or attenuate the treatment effects and found that duration of untreated psychosis (DUP) was a significant moderator of quality of life and scores on the Positive and Negative Syndrome Scale (PANSS). Specifically, across the 34 treatment sites in 21 states, the median DUP was approximately 18 months. Patients who experienced DUP for longer than 18 months did not show differences in outcome depending on which intervention they received, but those who experienced DUP for a shorter period showed steeper improvement when they received the NAVIGATE intervention. Individuals with shorter DUP also demonstrated greater engagement and better attendance at school and work.

Dr. Correll explained the role of antipsychotic medication in early intervention. He cited research showing that first-episode patients respond to lower doses of antipsychotic medication and may be more sensitive to issues with side neuromotor and metabolic effects, and he mentioned that the care provided through the NAVIGATE intervention may have been more consistent with that guideline than community care. Dr. Correll acknowledged that clinicians in the NAVIGATE sites had done extensive community outreach and may have recruited patients who were more difficult to treat but who also had greater room for improvement. He stated that these differences were accounted for during analyses.

With respect to other early intervention programs, Dr. Correll described a recently completed meta-analysis summarizing 10 programs, including RAISE but also programs in the United Kingdom and other countries, and showing that early intervention programs tended to result in better outcomes when compared to treatment as usual, with a smaller effect size for symptom reduction but larger effect sizes for achieving remission, recovery, and prevention of rehospitalization. Dr. Correll explained that the treatments lasted between 6-24 months, and findings showed that the interventions were effective during that time. He then stated that three of the studies in the meta-analysis have presented follow-up data after the intervention ended, and findings show that when the intervention supports are removed, patients who were doing better tended to “catch up with the illness.” Based on those findings, Dr. Correll suggested that the critical period for intervention may be longer than two years and recommended that the field attempt to develop methods to determine which patients require an extended period of intervention and which may successfully “graduate” earlier. He then offered a reminder that interventions affect the body as well as the brain, and sometimes there may be adverse cardiovascular and metabolic effects from treatments.

Dr. Newcomer stated that some findings, including from the IRIS study, show that relatively low cost interventions may have positive effects. Dr. Correll agreed and stated that the effective interventions fall under the label of “coordinated specialty care,” and what required funding was allowing the various members of the treatment team to be reimbursed for talking to each other and have team meetings that included the patients. He then emphasized the importance of coordination of not just mental health care but also physical care.

Dr. Newcomer transitioned the presentation to the topic of metabolic wellness, starting by acknowledging that, while there may be a critical period for early intervention to improve mental health symptoms, there may be a period where cardiovascular and metabolic health should be attended to, prior to any cumulative effects which may be difficult to reverse. He presented data showing mortality rates from cardiovascular causes such as myocardial infarction and stroke, and pointed out that preventive interventions have reduced this mortality rate around the globe. However, individuals with severe mental illnesses such as schizophrenia have a threefold higher risk of death from any cause, including cardiovascular issues. He noted that the findings show that the risk of death for individuals with severe mental illness are dropping but are not yet commensurate with rates within the general population.

Dr. Newcomer stated that the emerging thesis for why individuals with schizophrenia and other severe mental illnesses are more at risk for death from cardiovascular causes is not necessarily mysterious: several well-established and described modifiable risk factors (e.g., obesity, diabetes, hypertension, metabolic syndrome, smoking), reduced access to and utilization of health care, reduced adherence to therapies, poverty, and possibly a psychiatric disease-related risk related to genetic risk factors linked to mental illness.

Dr. Correll continued the presentation by presenting data from a meta-analysis on the prevalence of metabolic syndrome in individuals with schizophrenia, which showed that the condition is more likely to be experienced by those with a chronic condition treated with antipsychotic medication compared with unmedicated and first-episode patients. Dr. Correll stated that the findings suggest that accumulation of risk factors throughout the duration of the illness and/or treatment seem more likely to account for the increased risk than genetic underpinnings.

Dr. Newcomer agreed and noted that the data also suggest that in the early stages of schizophrenia, metabolic issues may not yet be a concern, but there may be opportunities for interventions to prevent the development of metabolic syndrome. He then presented data showing that individuals with severe mental illness are less likely to be screened or treated for conditions such as hyperlipidemia and hypertension, less likely to receive procedures like angioplasty and drug therapies of proven benefit such as beta-blockers, and more likely to experience premature mortality following a myocardial infarction.

To bolster the evidence, Dr. Newcomer presented data from Medicaid programs in California, Missouri, and Oregon from 2002-2005 before, during, and after a consensus panel from the American Psychiatric Association (APA), the American Diabetes Association (ADA), and other groups recommended increased metabolic and cardiovascular screening for individuals taking antipsychotic medications. These recommendations resulted in warnings on labels for antipsychotic medication recommending additional screening. Nevertheless, the results from the multistate, multiyear study, as well as other studies Dr. Newcomer completed, showed that screening rates for glucose and lipids did not increase after these recommendations and warnings were issued.

Dr. Correll presented information from past studies regarding factors that may explain the overall poor adherence to monitoring guidelines for individuals being treated with psychotropic medications. These factors included:

  • Patient characteristics (e.g., less likely to seek care, less likely to adhere to prescribed treatments, and difficulty communicating symptoms)
  • Primary care clinician behaviors (e.g., time constraints, potential skill-deficits to treat this particular population)
  • Psychiatrist behaviors (e.g., time constraints, may not believe physical health is under their purview, may not have adequate knowledge of physical medicine, are generally in shortage)
  • Complex medical systems that are difficult to navigate

Dr. Newcomer next discussed two examples of system-level interventions. The first took place in a 6,000-patient community mental health center setting in St. Louis and involved using “standard approaches” to work with all the clinicians to increase the rate of glucose testing. Dr. Newcomer stated that the pre-intervention rate of testing was approximately 40%, which he described as close to the national average, and the target rate was set at 70%. Clinicians received prompts as to whether individual patients had been tested that year (provided via a note and order slip on the front of each chart), as well as monthly feedback regarding clinicians’ progress toward the target rate. Dr. Newcomer displayed a table that showed how the rate of testing improved to above 70% within a few months of initiating the intervention. He then explained that after approximately a year and additional feedback, the rate of glucose testing was above 90%.

Dr. Newcomer next presented data gathered from a 10-year retrospective study that examined delivery of team-based integrated care within a primary care setting, in comparison to traditional practice. He summarized the findings by noting that integrated team-based care resulted in increases in quality indicators and lowered health care utilization in terms of emergency visits and hospitalizations. He concluded by stating that in both community mental health settings and primary care settings, there are interventions that successfully increase rates of screening.

Dr. Correll added that there were related findings in the RAISE study, where patients in the coordinated specialty care group gained less weight, had lower body mass indexes, and experienced fewer side effects, despite taking antipsychotic medications for longer periods than those who received treatment as usual. Dr. Correll attributed this benefit to NAVIGATE patients having received guideline-adherent care.

Dr. Correll summarized action steps for managing cardiometabolic risk for patients with mental illness, beginning with baseline screening (e.g., weight, waist circumference, fasting glucose, hemoglobin A1C, lipids) to understand metabolic risk upon initiation of antipsychotic treatment, and continuing with ongoing monitoring consistent with APA and ADA guidelines, which should be more frequent for patients who are at higher risk. He noted that weight may be a good benchmark, but some metabolic effects can take place without weight gain, so weight is not fully adequate for monitoring purposes. Dr. Correll also recommended beginning with lower risk medications, providing healthy lifestyle education and intervention for those who are already overweight, and treatment of emergent risk factors.

Dr. Correll continued by explaining that there are secondary and tertiary tiers of intervention for patients experiencing cardiometabolic disease, involving continuing the interventions described in the primary management tier but adding coordination with specialty teams (e.g., diabetes medical team) and switching to lower risk antipsychotic medications as appropriate.

Dr. Newcomer presented a closing slide from a study that showed the effects of interventions to reduce coronary heart disease risk, explaining that clinicians do not have to solve all metabolic problems for patients to achieve large reductions in 10-year coronary disease event risk. He pointed out that small decreases in blood pressure and weight, among other factors, result in such risk reductions. Smoking cessation and maintenance of a healthy lifestyle result in even larger reductions, he pointed out.

Dr. Correll asked Dr. Newcomer: “In your clinical experience, and also looking at the data, what are the main contributors to cardiovascular mortality in patients with schizophrenia, and what have been the most effective strategies for addressing cardiovascular illness in this population?”

Dr. Newcomer answered that there are five interrelated but statistically independent key modifiable risk factors for cardiovascular disease: overweight and obesity, hypertension, dyslipidemia, hyperglycemia, and smoking. He stipulated that some of those risk factors also involve risk behaviors, but they are modifiable compared to genetic risk factors. He added that there is strong evidence that intervention, whether behavioral or pharmacotherapy, results in reductions in long-term risks. Dr. Newcomer then acknowledged that for individuals with severe mental illness, engaging in such a process of addressing risk factors may be more challenging, but he cited research demonstrating that such efforts can still result in reduction in cardiovascular risk if interventions are tailored to the specific patient population.

The presentation concluded with a question and answer period in which the following were asked:

Can you speak to ways of integrating early intervention strategies into clinical care?

Dr. Correll stated that first we need to have a low threshold for people to enter services, citing the findings regarding worse outcomes associated with longer DUP in the RAISE study. He asserted that trying to educate the public regarding mental illness and “attracting them into assessments which are low threshold” is important. He explained that coordinated specialty care, where different treatment providers communicate with each other, even via an email or a phone call if reimbursement is not yet possible, is important so that providers do not work in silos. He reminded the audience of the four components of the NAVIGATE intervention, stating that it’s not just pharmacology or therapy, but also family psychoeducation as well as supported employment and education. He explained that these components can be tailored in intensity for individual patients, but that early intervention can be successful with a team approach.

Are there ways to use service utilization and outcome data to monitor progress or measure adherence to metabolic monitoring and management?

Dr. Newcomer began by reminding the audience of the chart he showed showing increases in glucose testing rates at a large community mental health center, explaining that those increases were achieved using the precise strategy mentioned in the question: taking available data regarding current screening rates for specific clinicians and offering that feedback to the clinicians. He continued by saying that at a larger system level, for example at a state Medicaid level, seeing the claims data offers information regarding whether interventions to increase screening are working or not. He concluded by emphasizing the importance of using data to determine whether interventions are actually making a difference in the desired outcomes.

Dr. Correll added that the social pressure for clinicians, in terms of knowing where they are compared to others, may also help to increase screening rates. He asked Dr. Newcomer if that hypothesis was correct.

Dr. Newcomer then explained that, in the studies he had conducted, investigators did not embarrass anyone by showing clinicians each other’s screening rates, but doctors were able to see their individual ranking on a list of physicians and know whether they were above or below the target screening rate. He stated that although clinicians were only aware of their own metrics and knew that colleagues were not privy to that information, there is an internal drive among clinicians to improve performance.

What nonpharmacologic and metabolic treatment options are there for patients who have already been living with schizophrenia?

Dr. Newcomer discussed a study funded by the National Institutes of Health that was a good example of a lifestyle intervention that targeted activity level, diet, and other factors specific to people with mental illness. He stated that the study isn’t the only recipe for success, but those kinds of tailored interventions, taking behavioral interventions already proven to work in the general population and adjusting them in relevant ways for individuals with mental illness, would be the fastest way to implement evidence-based nonpharmacologic interventions for individuals with schizophrenia.

Dr. Correll then stated that, in his clinical experience, it’s not always the easiest thing to motivate patients with negative symptoms who are taking high metabolic risk agents that increase appetite. He reiterated that monitoring is important, and self-weighing for patients might be helpful, as well as doing some interventions as a group. Dr. Newcomer agreed that both patients and doctors should receive feedback, but he also asserted that in some cases, a coach or other member of the team may need to be added, though he cited reimbursement difficulties with that option. Dr. Newcomer continued by saying that at an administrative level, it must be asked “how much does this cost” in terms of quality of life, morbidity and mortality, and in the financial sense if heart disease and diabetes are not prevented.

Increasingly, schizophrenia is considered a medical psychiatric disease. There is evidence that metabolic changes occur within the first episode of psychosis, and within the first few weeks of initiating antipsychotic treatment. There are treatment options available that can address these dangers and they need to be implemented as early as possible in the course of schizophrenia. Early Intervention (EI) programs are aimed at early detection of the disease, prevention of conversion to manifested psychosis, and phase-specific treatment to reduce the development of chronic disabilities. During this webinar, Christoph Correll, MD, and John Newcomer, MD, revisit the various strategies for EI in psychotic syndromes while focusing on strategies to intervene early in the process to improve metabolic risk.

Key Messages

  • Cognitive insight has a biological/anatomical basis that can be visualized with imaging technology such as Positron Emission Tomography (PET).
  • The authors used PET to study the extent to which there are anatomical/metabolic differences between psychotic patients with low versus high cognitive insight.
  • The group with low cognitive insight had reduced metabolism in posterior brain regions (occipito- temporo-insulo-parietal) and increased metabolism anterior structures (orbito-frontal) regions.

During this presentation, Charles Nguyen, MD, provided a brief overview of the obesity epidemic and how obesity may be a contributing factor to other serious medical conditions, including the potential ramifications for individuals with mental illness. Key discussion points included:

• Prevalence and demographic breakdown of the obesity epidemic
• The cycle of craving and obesity
• Serious systemic health problems for which obesity increases risk
• Link between earlier mortality for individuals with mental illness and obesity

This full live presentation, and others like it, are available for free for PsychU Members. To learn more or schedule a live program for your organization, please visit

During this presentation, Sloan Manning, MD, provided a brief overview of the global epidemic of diabetes mellitus and the disease’s impact on patients with comorbid mental illness. Key discussion points included:

• Prevalence of diabetes mellitus
• Bidirectional relationship between type 1 and type 2 diabetes across the mood disorder spectrum
• Metabolic monitoring standards for patients with mental illness
• Treatments strategies, including individualized pharmacologic treatment, though no specific drug compounds are discussed

This full live presentation, and others like it, are available for free for PsychU Members. To learn more or schedule a live program for your organization, please visit

During this presentation, Sloan Manning, MD, provided a brief overview of the role lipids may play in outcomes in mental health. Key discussion points included:

  • Interplay of lipids and metabolic syndrome
  • The role lipids and obesity may play in antidepressant medication response
  • Guidelines for dyslipidemia management
  • Strategies for improving lipid levels

This full live presentation, and others like it, are available for free for PsychU Members. To learn more or schedule a live program for your organization, please visit

Key Messages

  • This review explored potential mechanisms linking circadian and sleep abnormalities in schizophrenia and psychosis, with a particular focus on dopaminergic pathways.
  • Sleep disruption and circadian rhythm disturbance may induce elevated dopamine activity in the brain, increasing susceptibility to psychosis. At the same time, elevated dopamine levels can induce sleep disturbance, potentially creating a positive feedback loop in which dopamine disturbance and sleep disturbance reinforce each other.
  • Evidence of abnormal melatonin regulation in individuals with schizophrenia suggests a lack of normal homeostatic control may also contribute to this loop.
  • Sleep and circadian abnormalities in schizophrenia were suggested to be influenced by genetic factors.

Healthier lifestyles are associated with declining prevalence of cognitive impairment and dementia. Furthermore, specific lifestyle changes are effective for preventing dementia, including increasing education in early life, increasing physical activity and social engagement, reducing smoking, treating hypertension, diabetes, and hearing impairment.

These findings were reported in “Dementia Prevention, Intervention, And Care” by Gill Livingston, Andrew Sommerlad, Vasiliki Orgeta, Sergi G. Costafreda, and colleagues, and published in The Lancet. Dementia was defined as a decline from a previously attained cognitive level that affects activities of daily living or social functioning. The authors calculated a population attributable fraction (PAF), defined as “the percentage reduction in new cases over a given time if a particular risk factor were completely eliminated.” They calculated a combined PAF for known modifiable risk factors for dementia, including hypertension, obesity, hearing loss, smoking, depression, physical inactivity, social isolation, and diabetes.

Other lifestyle changes that were found to be protective against diabetes included antihypertensive drugs, hormone-replacement therapy medications, a “Mediterranean diet”, cognitively stimulating activities, exercise and physical activity interventions, and social engagement. Globally, 47 million people live with dementia and the annual global cost of dementia is estimated to be $818 billion (U.S. dollars).

The authors recommended that advances in technology could help monitor the lifestyles of people with dementia, and to help them “live in safe, stimulating, and functionally enabling environments, and support and assist carers and professionals in improving quality of care.” Examples of technologies that can provide this help include:

Diagnosis and assessment

  1. Computerised diagnostic assessment: neuropsychological assessments and video-conferenced examinations
  2. Detecting progression: wearable sensors to detect changes in gait or activities of daily living
  3. Virtual reality: assessment of activities of daily living, such as meal preparation


  1. Environmental sensors: detection of changes in movement, such as falls; sensors to detect and intervene in the environment – e.g., heat or gas, satellite tracking devices, or remote viewing camera
  2. Physiological sensors: devices measuring pulse, blood pressure, oxygen saturation, blood glucose, or sleep; or so-called smart garments with sensors that send biometric data

Assistive technology

  1. Cognitive aids: reminder systems—eg, medication management; activities of daily living prompting—eg, a tool that prompts user through handwashing; cognitive training
  2. Activities of daily living assistance: robots to help with eating, washing, and mobility
  3. Safety: electrical outlet shut-off devices, hands-free taps, and water temperature sensors
  4. Combination: robot to assist with care and monitor physiological or environmental changes and send information to carer

Therapeutic technology

  1. Communication: support reminiscence-based communication between people with dementia and their carers or chat groups
  2. Companionship: robotic animals
  3. Activity: technology to deliver music, messages, images, and video tailored to an individual’s interests

Carer-supportive technology

  1. Telemedicine: video-conferencing with professionals
  2. Online information: virtual assistance for managing challenges or web-based tools to support carer decision making
  3. Peer support: carer online or phone support groups

The full text of “Dementia Prevention, Intervention, And Care” was published July 19, 2017, by The Lancet.

For more information, contact: Gill Livingston, M.D., Professor, Division of Psychiatry, The Institutional Research Information System, 149 Tottenham Court Road, 6th Floor, Maple House, London, W1T 7NF; England; 020 7679 9435; Email:

Key Messages

  • A review of currently available literature indicated that patients with bipolar disorder (BD) may benefit from psychosocial interventions that adopt a multimodal strategy that goes beyond treatment adherence to promote a healthy lifestyle and behavior changes in terms of physical activity and dietary habits. These interventions may result in improved longterm management of BD, improved quality of life (QOL), and improvement in functional outcomes.
  • Multiple steps may be required to challenge and change maladaptive patterns of behavior, including the use of techniques to help patients make healthy lifestyle changes, boost their readiness for change, and educate them about the risks associated with their maladaptive behaviors and lifestyle.
  • There is a need for future randomized trials of interventions that examine the effectiveness of interventions that target dietary lifestyle, physical activity, and realistic goal setting.

It’s been almost 20 years since the first results from the Adverse Childhood Experiences Study (ACE) were published. If you aren’t familiar with it, the ACE study is long-term study of over 17,000 participants that explores the effects of childhood maltreatment on later health and wellbeing. The study has found that certain experiences are major risk factors for certain illnesses, death, and poor quality of life.

I was reminded of the ACE study as I read some recent coverage of Alzheimer’s disease. The short summary – stress and stressful experiences increases the risk of developing Alzheimer’s disease. On a related note, there was a lot of press in the past two weeks about a study published in the Lancet in July “Dementia Prevention, Intervention, and Care”. According to the study, about one third of dementia cases are attributable to preventable risk factors – including lack of education, high blood pressure, obesity, diabetes, hearing loss in mid-life, smoking, lack of physical exercise, social isolation, and depression.

And Alzheimer’s disease and dementia isn’t the only area where we see the effects of stressors – violence, poverty, abuse – on health status:

These findings are in keeping with the emerging research findings in epigenetics – the effect of what a person does and what happens to that person on their genetic makeup. Research shows that people who are frequently exposed to traumatic episodes have changes in how their brain functions and their genetic make-up.

What surprises me is both how strong the evidence is and how little we see service development focused on these issues. But there is not a lot out there yet.

From reimbursement perspective, there is limited coverage of programs that are more “preventative” in nature. There is limited coverage by the Centers for Medicare and Medicaid Services (CMS) for preventive cardiac rehabilitation programs and a recent preventive diabetes program. And there are some pay-for-success and pilot measures in the works.

The good news is that there is a continuing focus on integrated approaches to coordinating health, mental health, and social service needs. These represent new opportunities for specialty provider organizations to create innovative partnerships with payers and health plans – developments that we will be covering in the months ahead.

Evidence suggests that cognitive training, blood pressure management for people with hypertension, and increased physical activity may prevent cognitive decline and dementia. This statement was issued in a report on the current state of evidence on interventions for preventing or slowing cognitive decline and dementia; the report was sponsored by the National Institute on Aging.

The evidence base indicates that the following interventions have encouraging evidence of positive effects:

  • Cognitive training: programs aimed at enhancing reasoning and problem solving, memory, and speed of processing – to delay or slow age-related cognitive decline. Such structured training exercises may or may not be computer-based, but the evidence base does not suggest that computer-based “brain training” game applications offer the same beneficial long-term cognitive effects.
  • Blood pressure management for people with hypertension: management may prevent, delay, or slow clinical Alzheimer’s-type dementia.
  • Increased physical activity: activity which may delay or slow age-related cognitive decline.

The report, “Preventing Cognitive Decline and Dementia: A Way Forward” was issued by the Committee on Preventing Dementia and Cognitive Impairment at the National Academies of Sciences, Engineering, and Medicine (NAS). The committee examined the current state of evidence on interventions for preventing or slowing cognitive decline and dementia, and analyzed the outcomes of randomized controlled trials with the goal of making recommendations regarding prevention.

The scope of the committee’s review did not address the effectiveness of interventions to slow the rate of decline in those already diagnosed with dementia. However, the review gave special attention to interventions targeting stroke risk factors because they may contribute to clinical Alzheimer’s-type dementia (CATD) and conditions that coexist with CATD. The committee also did not study the potential of public health policies to prevent cognitive decline and dementia.

The evidence for the impact of cognitive training was primarily from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial, which included both cognitive training and social engagement in a group setting. This randomized controlled trial (RCT) provided the strongest and most comprehensive design to assess the effect of cognitive training on cognitive performance for older adults with normal cognition. The results presented moderate-strength evidence at two years (and low-strength evidence at 5 and 10 years) that cognitive training can improve cognitive function in the domain trained. However, improved function rarely transferred to other domains that were not trained. The evidence base suggested that training to improve processing speed was also associated with improvements in instrumental activities of daily living (IADLs), which include medication management, meal preparation, shopping, and managing finances. However, longer-term studies were rated as low strength of evidence.

The evidence base of RCTs on computer-based “brain training” applications lacked follow-up periods long enough to enable assessment of impacts on long-term outcomes such as age-related cognitive decline. As a result, no evidence indicates that the beneficial long-term cognitive effects suggested by the ACTIVE trial also apply to computer-based “brain training” applications.  Further, the suite of cognitive training interventions in the ACTIVE trial differ substantially from those available through commercial computer-based “brain training” applications. The effects of computer-based “brain training” applications appear to have short-term effects that apply only to the specific cognitive task that is rehearsed.

Overall, the committee determined that despite an array of advances in understanding cognitive decline and dementia, the available evidence on interventions derived from randomized controlled trials – considered the gold standard of evidence – remains relatively limited and has significant shortcomings.  Based on the totality of available evidence, however, the committee concluded that the three classes of interventions can be described as supported by encouraging but inconclusive evidence. The committee suggested that the National Institutes of Health and health care professionals could carefully cue the public about the potential benefits. However, the committee said the evidence base was insufficient to support a public health campaign to urge people to use cognitive training, manage their blood pressure, and increase physical activity as preventive measures,

The full text of “Preventing Cognitive Decline and Dementia: A Way Forward” was published June 22, 2017, by National Academies Press.

For more information, contact: Jennifer Walsh, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine, 2101 Constitution Ave NW, Washington, District of Columbia 20418-0007; 202-334-2183; Fax: 202-334-1412; Email:

When compared against young women in previous generations since 1965, the well-being of young women (ages 30 to 34) in the Millennial generation has declined in terms of four key measures: poverty, maternal mortality rates, suicide rates, and incarceration rates. The decline spanned the Baby Boom generation born from 1946 to 1964, Generation X born from 1965 to 1981, and the Millennial generation born from 1982 to 2002 (this generation is also referred to Generation Y and the Echo Boom).

Comparison Of Young Women’s Well-Being Across Three Generational Cohorts In The United States, Selected Indicators, Plus Overall Well-Being Index Score
Point Of Comparison Baby Boom  Gen X  Millennial 
Poverty (percent of all women in the U.S. ages 30 to 34 in the cohort)




Maternal Mortality Rates (deaths due to pregnancy complications per 100,000 births in the cohort to women ages 25 to 34)




Suicide Rates (deaths per 100,000 women in the cohort ages 25 to 34)




Incarceration rates (per 100,000 in the cohort ages 18 and older)




Overall index score for all indicators (includes others not shown) compared to previous generation (with previous generation at a baseline of 100)




Percent Change In Well-Being Baseline From Prior Generation




Young women of the Millennial generation experienced a 1% decline in overall well-being compared with women of Generation X. Women of Generation X experienced a 2% gain in well-being relative to women of the Baby Boom generation. Women of the Baby Boom generation experienced a 66% gain in overall well-being relative to women of the World War II generation. Additional information about the declines included the following:

  • Poverty rates for women ages 30 to 34 increased by five percentage points between Generation X and the Millennial generation. In Generation X, about 12% of women ages 30 to 34 lived in poverty. In the Millennial generation, about 17% of women age 30 to 34 live in poverty.
  • Maternal mortality rates among women ages 25 to 34 (due to complications of pregnancy and childbirth or complications during the six weeks post-delivery) have increased for each generation, from the Baby Boom (at 7.5 per 100,000 births), to Generation X (at 9.2 per 100,000 births), to the Millennials (at 19.2 per 100,000 births).
  • Suicide rates among women ages 25 to 34 have increased by 43% in a single generation, from 4.4 per 100,000 women in Generation X to 6.3 per 100,000 for women in the Millennial generation.
  • Incarceration rates for women 18 and older have increased by a factor of 10 between the World War II generation, at 8.9 per 100,000 women in the population and the Millennial generation, at 88.8 per 100,000 women in the population.

These findings were reported in “Losing Ground: Young Women’s Well Being Across Generations in the United States” by Beth Jaroz and Mark Mather of the Population Reference Bureau. The report is based on an analysis of 14 indicators of well-being in terms of social, economic, and health. The researchers compared outcomes for each generation of young women up to age 34 with outcomes for the previous generations. The researchers calculated an overall index score for each generation.

Overall, the index score declines indicate that well-being for women in the Millennial generation is lower than previous generations, although the Millennial generation had improvements on some of the 14 measures in the index. Additional findings were as follows:

  • The teen birth rate in 2015 was lower among the Millennial generation ages 15 to 19 than previous generations, at 22 births per 1,000 in 2015, down from 60 births per 1,000 females in 1990. Further, the birth rate among women ages 20 to 24 fell by 33%, from 116 per 1,000 in 1990 to 77 per 1,000 in 2015.
  • The share of young women ages 25 to 34 who are smoking has dropped significantly, from 43.7% of women in the World War II generation to 32.0% of the Baby Boom generation, to 22.3% of Generation X, to 17.5% of the Millennials.
  • The female homicide rate for women ages 25 to 34 has fallen in each generation since the Baby Boom, from 6.4 homicides per 100,000 women in the population for the Baby Boom generation, to 4.3 per 100,000 for Generation X, to 3.3 for the Millennial generation.
  • Educational attainment is higher for Millennial generation than previous generations. The female high school dropout rate has fallen over time, and a greater share of Millennial women have a bachelor’s degree than in previous generations.

Long-standing gender gaps in earnings and in business ownership persist, but have narrowed from one generation to the next.

  • The percent of businesses owned by women of any age has increased from 4.6% in the World War II generation, to 26.1% in the Baby Boom generation, to 27.2% among Generation X, to 35.8% among Millennials.
  • However, women ages 25 to 34 still earn less than men in nearly every occupation and at every education level; the ratio of young women’s median earnings to men’s has increased from 65% in the World War II generation, to 75.1% in the Baby Boom generation, to 82.4% in Generation X, to 89.6% among Millennials. In most occupations, women need to complete a higher level of education than men to achieve equivalent earnings.
  • The percentage of women working in high paying science, technology, engineering, and mathematics (STEM) fields has declined from about 25% of all STEM workers in Generation X to 20% for Millennials.

The full text of “Losing Ground: Young Women’s Well Being Across Generations in the United States” Population Bulletin 72, no. 1 (2017) was published in June 2017.

For more information, contact: Peter Goldstein, Vice President, Communications and Marketing, Population Reference Bureau, 1875 Connecticut Avenue NW, Suite 520, Washington, District of Columbia 20009; 800-877-9881; Fax: 202-328-3937; Email:

Mood disorders, disrupted sleep, and living with a solo caregiver are the most significant non-autism-related risk factors for hospitalization due to behavioral health crisis among youth with autism. Hospitalization risk factors related to autism include greater severity of autism symptoms, and the degree of adaptive daily life functioning.

These findings were reported in “Predictors of Inpatient Psychiatric Hospitalization for Children and Adolescents with Autism Spectrum Disorder” by Giulia Righi, Jill Benevides, Carla Mazefsky, Matthew Siegel, Stephen Sheinkopf, and Eric Morrow, for the Autism and Developmental Disabilities Inpatient Research Collaborative. The researchers analyzed data from two large prospective, naturalistic studies: the Autism Inpatient Collection (AIC) and the Rhode Island Consortium for Autism Treatment and Research (RI-CART). The AIC is a phenotyping and genotyping study carried out in six academically affiliated specialized inpatient psychiatry units in six states for youth with autism and other developmental disorders. RI-CART is a patient registry established in 2013; it includes about 1,500 prospectively recruited individuals with autism and their families living in Rhode Island and nearby areas of Connecticut and Massachusetts. The researchers analyzed AIC records of 218 youth ages 4 to 20 who were hospitalized, and compared them with 255 age- and gender-matched members of RI-CART who were not hospitalized. The goal was to isolate risk factors that were independently and significantly associated with the risk of hospitalization. In total there were 18 points of comparison.

The strongest predictor was the presence of a mood disorder, which was associated with a seven-fold increase in the odds of hospitalization. The presence of sleep problems was the second strongest risk, more than doubling the odds. A high score on a standardized scale of autism symptom severity raised the odds a little bit, though still significantly. Meanwhile, having a high score on a standardized scale of “adaptive functioning,” or basic life and coping skills, slightly but significantly lowered the odds of hospitalization. Finally, children and teens in households with married caregivers had only 0.4 times the odds of needing hospital care compared with comparable youth living with only one adult caregiver.

Additional findings about the relationship between relevant factors and likelihood of psychiatric hospitalization were as follows:

  • Three factors were linked to higher risk of psychiatric hospitalization. The odds were 7.0 times higher for youth with mood disorders, and 2.4 times higher for youth with sleep problems. The odds of hospitalization were 1.1 times higher for youth with greater social difficulties as indicated by their social affect severity scores.
  • Four factors were linked to a lower risk of psychiatric hospitalization. The odds were 0.9 for youth with higher adaptive behavior composite scores. The odds were 0.7 for youth with co-occurring intellectual disability. The odds were 0.4 for youth whose primary family caregiver was married. The odds were 0.5 for youth who were primarily non-verbal.

The researchers concluded that their findings emphasize the utility of thorough assessment and treatment of mood and sleep conditions to decrease the likelihood of requiring psychiatric hospitalization. The findings highlight the need to consider the child’s functioning in the context of family resources and needs during assessment and treatment, and the need to provide adequate supports to caregivers, especially single caregivers. They cautioned that because the study measured associations of risk factors with hospitalization, it was not possible to prove that the risk factors caused the hospital visits.

The full text of “Predictors of Inpatient Psychiatric Hospitalization for Children and Adolescents with Autism Spectrum Disorder” was published on May 23, 2017, by Journal of Autism and Developmental Disorders.

For more information, contact: Giulia Righi, Ph.D., Corresponding Author, Rhode Island Consortium for Autism Research & Treatment, 1011 Veterans Memorial Parkway, Bradley Hospital, East Providence, Rhode Island 02915; 401-432-1200; Fax: 401-432-1607; Email:; Website:; or David Orenstein, Writer for Life Sciences, News Office, Brown University, Providence, Rhode Island 02912; 401-863-1862; Email:; Website:

Key Messages

  • An association between tobacco smoking and schizophrenia has been consistently described in the literature.
  • This meta-analysis showed a 5-fold increased rate of current smoking in patients with schizophrenia compared with the general population, and a 3-fold increased rate of ever-smoking.
  • Results showed that the increase in current smoking was greater with schizophrenia than with other mental illnesses.
  • Based on epidemiological data, the authors proposed a 3-step approach to identify candidate genes to explain the increased risk of ever-daily smoking with schizophrenia.
  • The authors concluded that both schizophrenia and nicotine dependence exhibit high heritability, and evidence suggests a shared genetic vulnerability between schizophrenia and ever-daily smoking.

This summary was developed utilizing the full recorded presentation of this webinar, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at connecting-science-clinical-practice-inflammation-part-2/.

On June 15, 2017, an expert in the field of psychiatry presented a webinar on practical interventions with anti- inflammatory effects to improve mental health, building on an initial webinar that addressed the scientific foundation for understanding the role of inflammation in mental illness (the archived presentation is available here: approaches-psychiatry-part-1-2/). Rakesh Jain, MD, MPH, is an Associate Clinical Professor in the Department of Psychiatry at the Texas Tech University School of Medicine. He is a compensated contractor of Otsuka Pharmaceutical Development & Commercialization, Inc. The moderator and discussant for this presentation was Dr. Rachel Self, MS, PhD, Senior Medical Science Liaison at Otsuka Pharmaceutical Companies.

The objectives of this webinar were to:

  • Review underlying mechanisms of inflammation and understand how they may affect physical and mental health
  • Discuss nonpharmacological interventions that may have anti-inflammatory effects
  • Explore practical approaches for implementing nonpharmacological interventions

Dr. Jain opened this discussion on the role of inflammation in physical and mental health by describing immunity from an evolutionary perspective. He explained that in the hunter-gatherer period, when mortality rates were high, the primary stressors were acute in nature: predators, pathogens, and conflicts with other humans. Therefore, immunity was primarily driven towards fighting infection and wound healing. In the modern period, when mortality rates are low, the stressors tend to be chronic: physical illness, along with environmental and psychosocial stress. As a result, immunity is geared toward high rates of inflammation and autoimmune conditions that affect the brain and body.

Next, Dr. Jain explained neurological processes associated with inflammation. Tryptophan is converted to serotonin, a neurotransmitter that plays a role in a variety of functions, including modulation of mood. When inflammation is present, tryptophan may instead be converted to kynurenine, which in the continuing presence of inflammation may in turn metabolize to become quinolinic acid, an excitotoxin. However, anti-inflammatory cytokines may modulate tryptophan metabolism, converting kynurenine into kyurenic acid, which is not excitotoxic. Dr. Jain stipulated that unchecked inflammation that leads to excessive excitotoxicity can result in neuropathological and neurobehavioral sequelae, which may manifest as mental illness.

Dr. Jain elaborated on how the inflammatory process affects the brain. Stress causes the sympathetic nervous system to stimulate the bone marrow to increase production of monocytes which, upon coming into contact with injured tissue and bacteria, activate additional inflammatory signaling pathways. This action stimulates the release of more pro- inflammatory cytokines that may affect the brain’s metabolism of amino acids like tryptophan and may also activate microglia, which in turn produce excessive cytokines. He summarized by explaining that psychosocial stress can activate immune responses within the body and cause peripheral inflammation, and the greater the inflammatory response, the more likely a person is to develop depression in the months that follow.

Dr. Jain stated that even chronic mild inflammation can have lasting effects on the body and brain, citing research showing that chronic inflammation is associated with physical illnesses (e.g., cardiovascular disease, cancer, and diabetes) and mental illnesses (e.g., post-traumatic stress disorder, bipolar disorder, and major depressive disorder). He reviewed additional research that revealed that patients with major depressive disorder (MDD) had significantly elevated levels of interleukin 6 (IL-6), a cytokine that plays an important role in brain-body functioning, and tumor necrosis factor alpha (TNF-α), which he emphasized is relevant the development of mental illness via its association with inflammation. He described another study showing that severity of depression symptoms is associated with increased concentration of IL-6 and lower levels of brain neurotrophic development factor (BNDF), both markers of inflammation.

Dr. Jain then invited Dr. Self to comment. Dr. Self noted that the understanding of the evolution of the human immune system from fighting pathogens to an interaction with psychosocial stressors has resulted in a paradigm shift within the field of psychiatry, away from a focus on “the neck up” and toward a focus on the entire body and the effect of psychosocial stressors, including their bidirectional association with peripheral inflammation.

She then asked Dr. Jain for his thoughts on the following question: Is a person with chronic inflammation truly not a well person? Can it be that simple? Dr. Jain stated that the paradigm shift Dr. Self identified within psychiatry is also taking place within other medical disciplines, based on the understanding that chronic inflammation carries significant consequences, and psychosocial stressors represent a danger to immunity and overall health.

Dr. Self shifted the discussion to non-pharmacological interventions to address inflammation. Dr. Jain began by stipulating that pharmacological interventions play an important role in treatment, but holistic approaches also play a significant role. He focused on strategies in five areas that are well-researched as model and adjunct therapies to improve wellness and positively impact inflammation and overall mental health: socialization, exercise, mindfulness, sleep, and nutrition. Dr. Self observed that although these strategies may seem straightforward, each one requires effort and attention.

She asked Dr. Jain: Do you ever get pushback from patients who prefer a traditional, pharmacological type of treatment rather than focusing on the time and effort that it takes to focus on other components of wellness? Dr. Jain stated that often, the issue is the way the provider educates the patient regarding these aspects of wellness. He stated that patients might not know there are options in addition to pharmacological treatments if their providers don’t offer them information on how the strategies can be helpful, and that offering the nonpharmacological intervention and then tracking it along with other types of treatment is an approach often welcomed by patients.

Dr. Jain proceeded to offer information on the scientific underpinnings of nonpharmacological, anti-inflammatory wellness and lifestyle interventions, beginning with exercise. He described several mechanisms through which exercise affects inflammation, specifically through adipose cells (increasing angiogenesis and blood flow, decreasing hypoxia and vasoconstriction), immune cells (decreasing toll-like receptors and inflammatory monocytes, increasing regulatory T- cells), endothelial cells (decreased adhesion molecules, increased cell regeneration), and muscle cells (increased IL-6, but as a result, there is also an increase in anti-inflammatory cytokines and a decrease in other proinflammatory cytokines). He stated that exercise should be considered a broad-spectrum intervention that promotes neuroprotective gene expression and helps maintain health tissue. Specifically, exercise activates an enzyme that helps convert kynurenine to kynurenic acid (as opposed to quinolinic acid), a positive development if the intention is to reduce the inflammatory load. He described research results for patients with major depressive disorder already being treated with an SSRI, who were prescribed varying doses of exercise as an add-on intervention. Findings showed that higher intensity, frequent exercise (4-6 times a week) was more likely to result in remission of symptoms than lower intensity, less frequent exercise.

Dr. Self then asked the audience its first polling question. True or False: All mechanisms that contribute to possible anti- inflammatory effects of exercise training depend on weight loss.

Dr. Self asked Dr. Jain to comment on the concept of “FID (frequency, intensity, duration) to be fit” and the importance of individuals finding a type of exercise they enjoy and are willing to maintain. Dr. Jain acknowledged that in his clinic, they use this mantra with their patients, where they suggest a frequency of at least five times per week, at a relatively high intensity (during which the rate of respiration is high enough to prevent the person from talking in complete sentences). He acknowledged that while weight loss is helpful, it is not necessary to receive the positive anti- inflammatory effects of exercise.

Dr. Jain turned the conversation to mindfulness, for which he received formal training to enable him to offer it to his patients. He cited research showing that mindfulness-based stress reduction training significantly reduced cortisol production in response to the introduction of a psychosocial stressor when compared to the effect of a general health enhancement program. He stated that he advises other providers not to think of this type of intervention as just being for the mind, given its potential to reduce peripheral inflammation.

Next, Dr. Jain addressed the impact of abnormal or reduced sleep on inflammation, describing sleep deficiency as a “national epidemic.” He explained that, in the endocrinology field, sleep deficiency has been found to lead to inflammation, increased oxidative distress, impaired glucose tolerance, and insulin resistance, all of which contribute to the development of Type 2 diabetes. Delving deeper into the association between sleep and inflammatory markers, he reviewed the data from a meta-analysis of 72 studies showing that sleep deficiency is linked with increasing circulating inflammatory markers, specifically IL-6 and C-reactive protein (CRP). He also reviewed a study of American troops returning from deployment. Troops who experienced restorative sleep showed significant decreases in their CRP levels compared to those whose sleep habits did not change; the restorative sleep group also experienced reduction in fatigue and depressive symptoms, and increases in their emotional well-being and social and physical functioning.

Dr. Jain then discussed socialization and its relation to inflammation. He introduced the subject by reviewing the results of research showing that social isolation in childhood leads in adulthood to decreases in educational attainment and social class, and increases in psychological distress, body mass index (BMI), and CRP. He also presented results from a study of adults with a history of cancer, showing that a lower number of social ties was associated with high levels of inflammation (measured by CRP).

Dr. Jain then reviewed the final nonpharmacological area of intervention: nutrition. He explained that 60 years of research has shown that certain foods are known to be protective against inflammation (e.g., whole grains, fruits and vegetables, fish), while some are pro-inflammation (e.g., sweetened beverages, red processed meat). He also described the MIND diet (Mediterranean-DASH Intervention for Neurodegenerative Delay, combining the Mediterranean diet and the Dietary Approaches to Stop Hypertension—DASH—diet), involving increased consumption of green leafy vegetables, fish, nuts, and whole grains, moderate consumption of oil and dairy products, and very limited consumption of red meat and sweets/pastries, which has been associated with a reduction in cognitive decline in aging patients.

Dr. Jain invited Dr. Self to comment on the data on the five nonpharmacological areas for anti-inflammatory intervention. She noted that with regard to sleep, recent research has shown that alternating sleep schedules (e.g., swing shifts) is deleterious enough to have effects comparable to carcinogens, and that the data on social isolation in childhood also showed that it is associated with increased nicotine use. She then asked Dr. Jain about the potential interactive effects of using multiple types of nonpharmacological interventions in combinations.

Dr. Jain stated that approximately seven years ago, he and his colleagues decided that the research evidence on anti- inflammatory interventions was strong enough that it was time to implement the strategies systematically with patients. He presented the data from a pilot study of 36 adults (half of whom had been diagnosed with a mental illness) who used strategies in all of the five previously described areas for 30 days. Patients in both groups demonstrated statistically significant reductions from baseline in self-reported anxiety and depression symptoms, and an increase in overall well- being. He noted that his clinic has now completed four replications of this study. He considers the interventions fundamental, broad-spectrum strategies that work well with or without medication.

Based on his clinical experience and research, Dr. Jain reviewed practical approaches to implementing these nonpharmacological anti-inflammatory interventions in each of the five areas: exercise (30 minutes of moderate activity 6 days/week for 30 days, starting slow in the context of physical limitations or injury), mindfulness (engage in mindfulness activities at least 8 minutes per day for 30 days), social connectedness (text or call a family member or friend each day for 30 days), nutrition (keep a daily dietary log for 30 days, given that research shows that logging nutrition leads to improved eating habits), and sleep (implement pro-sleep hygiene practices for 30 days). He explained providers are more likely to gain compliance from patients if they are prescriptive in their recommendations, encouraging, consistent in promoting daily practice of wellness, and offering supportive resources (e.g., his clinic recommended an app with mindfulness exercises). He also encouraged being a “gentle coach” as opposed to being frustrated in the face of noncompliance, and engaging in frequent check-ins with patients when possible. Dr. Self agreed that high expectations often lead to higher achievement in terms of engaging in these interventions.

Dr. Self introduced the final polling question: How likely are you to implement these strategies into your clinical practice?

 She then asked Dr. Jain if there were certain interventions or areas that he found more challenging when trying to incorporate them into his discussions with patients. He stated that all were a bit challenging, and that it is important for providers to choose the right time to open the conversation, given that patients are often quite ill and depressed during initial visits. He also emphasized the importance of true provider buy-in, acknowledging that there is no “wellness-deficit disorder” in the diagnostic manual, which may lead to more tentativeness. He asserted that it is empowering for providers to be able to provide more than just medication, knowing there is solid research support showing the benefits.

Dr. Self provided a summary of points from the presentation:

  • Inflammation may have lasting effects on physical and mental health
  • Exercise, mindfulness, sleep, nutrition, and social connectedness have been demonstrated to influence inflammatory responses
  • Nonpharmacological interventions, including those aimed at encouraging exercise and mindfulness and optimizing sleep, nutrition, and socialization, may positively affect both physical and mental health

The presentation concluded with time for one audience question.

Would it be straightforward to just use an immunosuppressive agent to improve mental health across patients?

Dr. Self noted as she posted the question that there have been studies showing that not every patient needs anti- inflammatory treatment, and medications meant to treat inflammation have at times had detrimental effects for certain patients.

Dr. Jain agreed and said the field is not at a point where it can recommend an anti-inflammatory medication intervention to specifically target mental health, because not every patient benefits, and some could be harmed. He emphasized that the same is not true for all the nonpharmacological interventions discussed in the presentation, as there is no evidence that improving sleep, exercise, nutrition, mindfulness, and social connectedness is detrimental in any way. He stated that it makes sense from an evolutionary perspective, and that the post-industrial lifestyle has pulled people away from these naturally healthy lifestyle practices.

In this second webinar in the inflammation series, Rakesh Jain, MD, MPH along with moderator and discussant, Rachel Self, MS, PhD, discuss nonpharmacologic anti-inflammatory strategies to build on the science discussed during Part 1 of the series. They provide practical interventions that can be instituted in the clinic setting, such as exercise, mindfulness, sleep hygiene, social connectedness, and optimized nutrition that suggest anti-inflammatory effects and improve mood and overall wellbeing.

Hear more from Rakesh Jain, MD, MPH, as he responds to additional questions from attendees in this follow-up Q&A:

In Part 1 of the inflammation series, Dr. McIntyre discusses the concept of inflammation metastasizing to the brain and how physical markers for inflammation play a role in mental health disorders. He discusses the immune and metabolic mechanisms associated with cognitive and mood disorders, which was presented in the context of disease modelling, as well as novel approaches. If you missed Part 1 of the inflammation series, you can review the archived presentation on PsychU at:

The Wellness Recovery Action Plan – known as WRAP – celebrated its 20th birthday in March 2017! What do we know about this nationally-recognized self-help program for people with mental illness? During this interview we hear from Mary Ellen Copeland, PhD, who explains how people with mental illness can benefit from this unique program to achieve wellness. Dr. Copeland is an author and mental health advocate, as well as the Founder of the Copeland Center for Wellness and Recovery; she earned her Doctor of Philosophy degree from Union Institute & University in Cincinnati, OH.

Recharge, a new Maryland health company run by doctors of physical therapy, combines physical therapy, CrossFit, and mindfulness training for better overall physical and mental health. The organization was designed on a proactive, rather than reactive foundation, in response to national numbers on obesity, opioid addiction, and depression.

While the three activities are often available separately, the founders realized that the three in combination would make a powerful wellness tool for communities. Each Recharge community member receives a complimentary 20-minute in-person session to discuss goals, motivations, fitness levels, and to develop a unique plan for success. Other “health hub” offerings include:

  • Physiotherapy – evidence-based treatments for aches, pains, and/or musculoskeletal injury
  • Mindfulness – Strategies to reduce stress, improve focus, and take control thoughts; offered both as a part of fitness classes, and as individual sessions
  • HoCo CrossFit – led by doctors of physical therapy to reduce the risk of injury and improve results, specializing in movement and fitness

This was reported by PRNewswire on May 23, 2017.

Contact Information: Recharge, 5136 Dorsey Hall Drive, Ellicott City, MD 21042; 443-583-7093; Email:; Website:

Chestnut Global Partners has released their 2017 Employee Assistance Program (EAP) and Wellness Trends and Analysis Report. The report is an analysis of what is happening in the fields of Employee Assistance, Organizational health, and Workplace Productivity, based on analysis of company EAP service usage.

Among other things, the report lists four trends in the EAP market:

  1. EAP requests due to anxiety are rising;
  2. The top three industry needs are increased utilization rates, improved collaboration and coordination of care, and measurable outcomes that improve the perceived value of EAP;
  3. Procurement is now more involved in EAP purchasing decisions than ever; and
  4. EAP return on investment analysis are being geared towards high-ranking management.

This was reported by PRWeb on April 12, 2017.

Contact Information: Chestnut Global Partners, 1003 Martin Luther King Drive, Bloomington, IL 61701; 309-820-3604; Website:

In 2016, the top three reasons employees in North America accessed services through their company’s employee assistance program (EAP) were marital/relationship problems (16.4% of EAP users), stress (16.2%), and anxiety (14.4%). Since 2014, the rate of EAP visits for the top two categories has remained steady, but the rate of EAP visits for anxiety has increased by 29%. EAP services for anxiety are for individuals who report more specific and serious physical and emotional symptoms of stress.

These are data published in “2017 EAP & Wellness Trends & Analysis Report” published by Chestnut Global Partners (CGP) in which CGP reported its EAP utilization statistics. During the study time period, CGP provided EAP services in North America, as well as to companies with staff located in Latin America, Asia-Pacific, Europe/Russia, and Africa. The report focuses on EAP utilization trends, industry needs identified by a CGP survey of EAPs, procurement trends, and return on investment (ROI). Additional findings included the following:

  • EAP utilization rates: During 2016, 6,5% of employees covered by a CPG EAP in North America used the services. In 2016, the average number of counseling sessions per person was 2.9, up 15% over the previous year. International utilization averaged 3.8%, down from 4.3% in 2014. Across continents, utilization averaged 6.1% for Latin America; 4.4% for Asia-Pacific; 2.2% for Europe/Russia; and 1.8% for Africa.
  • The top 10 concerns for an EAP visit in North America were marital problems (16.4%), stress (16.2%), anxiety (14.4%), depression (11.6%), child behavior (10.2%), occupational (7.1%), legal (6%), grief (5.3%), extended family (3.7%), and substance abuse (3.0%). Occupational concerns include job dissatisfaction due to organizational change and increased workloads.
  • The top 10 concerns for an international EAP visit were marital/ relationship (18.3%), stress (9.5%), child behavior (8.9%), legal (8.8%), anxiety (8.2%), depression (6.2%), work stress (3.5%), extended family (3.2%), grief (2.8%), and behavior/conduct (2.1%).

The report also covered some environmental issues of interest to organizations that offer EAP service lines. One challenge reported was the conflict between encouraging utilization and low capitation rates because low capitation rates do not reward the EAP for engaging with employees to ensure that those with difficulties are identified promptly and offered services.  Another challenge was the lack of consistency in determining consumer needs—more than 75% of EAP provider organizations do not use a validated screening tool to evaluate the employee’s concerns, and instead rely on collecting the information during an intake call lasting less than 10 minutes.

In addition, EAP procurement is changing. CGP reported that, over the past several years, fewer EAP purchasing decisions have been made by human resources and benefit teams – and have shifted to organizational procurement teams. The emerging procurement model assumes that all EAP services and service provider organizations are equivalent. Because procurement teams are incentivized to select the lowest-cost bids, the competition is on price, rather than identifying an EAP partner that is a good fit for the organization. Further, most procurement teams have little experience with employee benefit services and less experience with work/life services.

PsychU reported on this topic in “EAP Services Linked To 46% Reduction In Absenteeism,” which published on August 8, 2016.

For more information, contact: Todd Donalson, MA, LCPC, Director of Training and Consultation, Chestnut Global Partners, 1003 Martin Luther King Drive, Bloomington, Illinois 61701; 309-820-3619; Email:

In an effort to further assist and benefit our country’s combat veterans, the U.S. Department of Veteran Affairs (VA) has created the Center for Compassionate Innovation (CCI) to explore therapies that may improve and enhance veterans’ physical and mental well-being. The Center will primarily focus on those veterans for whom conventional treatment is ineffective.

To further this objective, the VA is  accepting proposals ( for innovative treatments to be added to their health care system of benefits for suicide prevention, traumatic brain injury, post-traumatic stress disorder, and chronic pain.

This was reported by Veterans Affairs Office on April 18, 2017.

Contact Information: U.S. Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420; 202-461-7600; Email:; Website:

What is the role of diet, exercise, or sleep for patients with bipolar disorder?

A healthy diet, exercise, and good sleep habits are all essential for optimal physical and mental health. Bipolar disorder is not an exception for these variables to have an effect.1,2 Epidemiological and treatment studies have reported that diets high in omega-3 fatty acids (contained in fish) are associated with lower prevalence rates of mood disorders, including bipolar disorder.3 Despite this, findings regarding the use of omega-3 fatty acids in the treatment of bipolar disorder are not conclusive.4The role of exercise in bipolar disorder has been reported in the literature, suggesting that routine exercise may improve the outcome in patients suffering from the condition.5 A number of studies have shown that sleep is impaired in patients with bipolar disorder. Studies have also suggested that poor sleep habits may impact symptom burden in those suffering from the condition.1


  1. Gold AK, Sylvia LG. Nat Sci Sleep. 2016;8:207-14.
  2. Bauer IE, et al. J Psychiatr Res. 2016;74:1-7.
  3. Parker G, et al. Am J Psychiatry. 2006;163(6):969-78.
  4. Turnbull T, et al. Arch Psychiatr Nurs. 2008;22(5):305-11.
  5. Melo MC, et al. J Affect Disord. 2016;198:32-8.

Music is known to produce in individuals feelings that range from happiness to melancholy. But can music be used as medicine to improve brain health in individuals? During this podcast Linda Maguire, MHS, MA-CBN, BMus, a cognitive and behavioral neuroscientist and internationally renowned professional musician, describes her cutting edge approach of using music as therapy for Alzheimer’s patients and others with brain disorders.

Ms. Maguire and her colleagues (Patricia B. Wanschura, Margorie M. Battaglia, Stefanie N. Howell, and Jane M. Flinn) conducted a study that showed an active singing program significantly improved cognitive abilities in individuals with dementia. You may read about the study in a letter to the editor published by the Journal of American Geriatrics Society on April 20, 2015. The letter is entitled “Participation in Active Singing Leads to Cognitive Improvements in Individuals with Dementia” and can be found at (Accessed February 2017)

Although a majority (60%) of Americans age 90 and older describe themselves as in good, very good, or excellent health, 73% have one or more chronic health condition. On average, they took about 6.2 different medications. Most have difficulty with one or more instrumental activities of daily living (IADLs), such as preparing food, performing light housework or managing money. About half have difficulty with activities of daily living (ADLs) such as bathing, eating, dressing, using the toilet, getting out of bed or a chair, or walking around their home. About one-third have cognitive impairment.

These findings were reported in “Health and Functional Status of Adults Aged 90 Years in the United States” by Michelle C. Odden, Ph.D.; William Jen Hoe Koh, Ph.D.; Alice M. Arnold, Ph.D.; et al. The researchers analyzed the cognitive function and mental and physical health of 1,889 people aged 90 years who participated in the Cardiovascular Health Study (CHS), which began in 1989. The CHS is a federally funded observational community-based study of risk factors for cardiovascular disease in people 65 years and older. Of the original 5,888 CHS participants, 2062 (35.0%) survived to 90 years as of July 16, 2015. There were 1889 (91.6% of those surviving) participants with available measures, and of these, 65.5% were women.

For this report, the researchers described the health and functional status of participants at age 90 years. The group included 1,237 women and 652 men. Additional findings were as follows:

  • 59% of women and 62% of men reported being in good or better health, and about 77% of women and men reported absence of depressive symptoms.
  • 75% of women and 58% of men reported difficulty walking half a mile, and 60% of women and 42% of men reported difficulty walking 10 steps.
  • 25% of women and 39% of men reported no IADL limitations; about 25% of women and 20% of men reported having four, five, or six IADL limitations.
  • 47% of women and 62% of men reported no ADL limitations; about 20% of women and 9% of men reported having four, five, or six ADL limitations.

About 73% of the group had one or more chronic diseases, at 72% of women and 74% of men. Across specific conditions tracked by the study, the prevalence rates for the group, and by gender were as follows:

  • 49% of the group had cardiovascular disease, at 47% of women and 52% of men.
  • 21% of the group had heart failure, at 21% of women and 21% of men.
  • 11% of the group had stroke, at 12% of women and 9% of men.
  • 13% of the group had diabetes, at 13% of women and 13% of men.
  • 15% of the group had cancer, at 12% of women and 19% of men.
  • 16% of the group had chronic obstructive pulmonary disease, at 17% of women and 15% of men.
  • 26% of the group had dementia, at 29% of women and 21% of men.

The full text of “Health and Functional Status of Adults Aged 90 Years in the United States” was published March 20, 2017 in JAMA Internal Medicine.

For more information, contact: Michelle C. Odden, Ph.D., Oregon State University, 2520 SW Campus Way, 141B Milam Hall, Corvallis, Oregon 541-737-3184; Email: 

Independent Health has created a program to help Medicare Advantage members stay motivated to maintain good health. The new point-based FitWorks program offers rewards for physical health upkeep and online interaction challenges.

Each 100 points earned results in a $50 gift card to TOPS Friendly Markets, a neighborhood supermarket with locations throughout New York State, Vermont, northern Pennsylvania, and even a Massachusetts store. FitWorks challenges include completing wellness visits, preventative services, and vision exams; joining a fitness program; and participating in Independent Health’s online services.

Independent health is a Buffalo-based, not-for-profit health plan with a goal to provide innovative health-related products and services for affordable access to quality health care.

This was reported by The Buffalo News on March 7, 2017.

Contact Information: Independent Health, 511 Farber Lakes Drive, Buffalo, New York 14221; 716-631-3001; Website:

About 45% of people at age 80 will have cognitive impairment that limits their financial decisionmaking in some way. About 30% will have a mild cognitive impairment (MCI), which limits some aspects of their financial decisionmaking and capacity, and an additional 15% of people at age 80 will have dementia, which greatly limits their financial capacity, in terms of their ability to pay bills and manage their accounts. Of those with a cognitive impairment limiting financial decisionmaking, some will have sufficient capacity to manage some financial tasks. However, even with capacity to manage some tasks, these individuals will be at higher risk of making financial mistakes, being victimized by fraud, or victimized by a caregiver with control over their finances.

These findings were reported in “Cognitive Aging and the Capacity to Manage Money,” by Anek Belbase, a research fellow, and Geoffrey T. Sanzenbacher, an economist, with the Center for Retirement Research at Boston College. The brief is the third in a series on the topic of cognitive impairment and financial decisionmaking. For this brief the researchers conducted a literature review to assess how cognitive aging between age 70 and 90 affects the capacity to manage money.

Financial capacity includes relatively simple activities such as bill paying and handling cash transactions; more complicated activities such as balancing an account and asset and account management; and activities requiring judgment, such as assessing the potential return or risk of an investment. Performing financial tasks requires knowledge; making financial judgments requires a mix of knowledge, memory, attention, and information processing. Research indicates that for those experiencing normal cognitive aging knowledge remains intact into the 70s and 80s. However, memory, attention, and information processing start declining as early as the 30s.

As a result, that individuals experiencing normal aging are more likely to develop deficits in their financial judgment than in their ability to carry out financial tasks. Individuals experiencing normal aging who lacked knowledge about how to perform specific financial management tasks were vulnerable to making serious errors in performing the tasks. Retirees with normal cognitive aging could need assistance if they are financial novices – most likely due to the death or disability of a spouse who handled the household’s finances.

About 95% of older adults who have normal cognitive aging at age 80, but not cognitive impairment, can continue to manage their finances, pay bills, enter contracts, and exercise good financial judgment to protect their interests. However, only 82% of those with mild cognitive impairment and only 20% of those with dementia are able to perform tasks requiring financial judgment to manage their finances.

Mild cognitive impairment or dementia renders older adults more vulnerable, but in different ways. The brief emphasized that several studies have found that people with mild cognitive impairment and those with dementia continue to feel confident about handling financial matters. Their self-confidence, intact knowledge of financial procedures, and impaired financial judgment make people with mild cognitive impairment more susceptible to fraud. People with moderate to severe dementia are often unable to carry out financial transactions. They are at greater risk of financial abuse by a caregiver, rather than fraud.

The researchers noted that multiple gaps currently exist between institutions in the public and private sectors that prevent timely assessment of financial capacity. The lack of coordination creates obstacles to timely determinations of whom should assume fiduciary responsibility for an incapacitated person. However, financial advisers can better pinpoint levels of financial capacity using a variety of performance assessments to determine how capable clients are of managing their finances.

The full text of “Cognitive Aging and the Capacity to Manage Money” was published in January 2017 by the Center for Retirement Research.

For more information, contact: Amy Grzybowski, Media Contact, Center for Retirement Research at Boston College, 258 Hammond Street & Boston College, Chestnut Hill, Massachusetts 02467; 617-552-1762; Email:; Website:

Alliance Healthcare Foundation (AHF) has awarded Mission Support Grant awards (MSGs) to nonprofit, San Diego and Imperial County organizations that are dedicated to advancing resident health and wellness. This is the eighth year that AHF has issued MSGs.

The goal of the MSG program is to support advances in health and wellness. Grants are awarded to nonprofits in San Diego and Imperial Counties who serve what is thought of as the most vulnerable of the countys’ populations: the poor, uninsured and underinsured, children, and the homeless.

San Diego County MSG recipients include:

  1. Access Youth Academy,
  2. Angels Foster Family Agency,
  3. Bastyr University,
  4. Community Health Improvement Partners,
  5. ElderHelp of San Diego,
  6. Environmental Health Coalition,
  7. Just In Time For Foster Youth,
  8. Monarch School Project,
  9. Multicultural Health Foundation,
  10. Neighborhood House Association,
  11. North County Lifeline, Inc.,
  12. Olivewood Gardens,
  13. Project New Village,
  14. Reality Changers,
  15. San Diego Hunger Coalition,
  16. Somali Family Service of San Diego,
  17. UCSD Student Run Free Clinic,
  18. Voices for Children, and
  19. Chula Vista Community Collaborative.

Imperial County MSG recipients include:

  1. Boys and Girls Clubs of Imperial Valley,
  2. Imperial Valley Food Bank,
  3. Comite Civico del Valle,
  4. Cancer Resource Center of the Desert,
  5. Court Appointed Special Advocates of Imperial County,
  6. Clinicas de Salud del Pueblo, and
  7. Neighborhood House of Calexico, Inc.

Alliance Healthcare Foundation works to advance health and wellness for the most vulnerable— the poor, uninsured and underinsured, children and the homeless in San Diego and Imperial Counties.

This was reported by prweb on March 6, 2017.

Contact Information: Alliance Healthcare Foundation, 5060 Shoreham Place, Suite 350, San Diego, CA 92122; 858-678-0974; Email:; Website:

According to the National Committee for Quality Assurance (NCQA), “[s]moking and tobacco use are the largest causes of preventable disease and death in the United States.”i In an effort to decrease this, each state and the District of Columbia have established state “quitlines” to provide telephonic counseling for smoking and tobacco use cessation to individuals. These services are particularly relevant for individuals with mental illness, as this population experiences higher smoking and tobacco use rates, higher related-illness rates, and more difficulty quitting smoking than the general population. Quitlines do not treat and typically do not assess for mental health conditions (MHCs); however, given the additional challenges that individuals with mental illness experience with cessation, implementing a brief mental health questionnaire could help identify those that may benefit from additional support or counseling services in order to combat barriers to cessation success. But is this type of intervention really helpful when trying to predict the behavior of individuals accessing cessation quitlines?

A recent study, “Smokers with Self-Reported Mental Health Conditions: A Case for Screening in the Context of Tobacco Cessation Services,” published July 2016 in PLOS ONE, says, “Yes.”  As part of the study design, a brief mental health assessment was included in the intake procedures at the California Smokers’ Helpline (CSH) – the longest running quitline in the United States – and administered by trained counselors to consenting adult smokers calling the CSH from June 2012 to September 2015. A randomized sub-set consisting of 9% of 125,261 individuals who participated in the mental health questionnaire were assessed for service utilization and quitting behaviors seven months after enrollment in order to test whether self-reported MHCs could predict the following treatment engagement measures, as described in Table 1.

Table 1: Measuring Treatment Engagement
Service Utilization Quitting Behavior
  • Total number of counseling sessions
  • Quit Attempts: quitting for at least 24 hours
  • Prolonged Abstinence: not smoking for at least 180 days at the time of evaluation
Table 1 developed by PsychU. Data source: Tedeschi, G.J., Cummins, S.E., Anderson, C.M., Anthenelli, R.M., Zhuang, Y., & Zhu, S. (2016, July). Smokers with self-reported mental health conditions: A case for screening in the context of tobacco cessation services. PLOS ONE, 11(7): e0159127. Retrieved from:

Though counseling protocol dictated the same number of therapy sessions regardless of MHC self-report, overall findings of the analysis demonstrated that smokers with MHCs were more likely to participate in additional counseling sessions. The authors attribute this to possible increased receptivity to counselors’ follow up appointment scheduling. Individuals with MHCs were also more likely to use pharmacotherapy as part of their cessation attempt. Interestingly, though they received a greater number of counseling services, an inverse relationship between additional counseling sessions and probability of prolonged abstinence was observed for individuals self-reporting MHC. While all participants quit attempt rates were high, individuals reporting >1 MHC were less likely to engage in a 24-hour quit attempt than their peers. Finally, the probably of relapse was greater for participants with one or more MHCs than their peers reporting no MHC, and those reporting >1 MHC having the highest rate of relapse.

Over the course of the study, CSH-trained counselors administered the brief MHC assessment at the time of intake to 125,261 individuals, using a computer-assisted telephone interview (CATI) system which embedded MHC assessment questions after physical health questions in the standard intake interview. MHC assessment design was intended to be short, based upon self-report, and included the following questions:

  • Do you have any mental health conditions such as anxiety disorder?
    • Depression disorder?
    • Bipolar disorder?
    • Schizophrenia?
    • Alcohol / drug use?
  • (If yes to any of the above) Has a doctor or other health care professional told you that you have a mental health condition?

At baseline, 52.2% of smokers reported at least one MHC. Breakdowns of self-reported MHC are presented in Table 2.

Table 2: Rates Of Self-Reported MHC At Baseline
Depression 38.4%
Anxiety Disorder 35.1%
Bipolar Disorder 17.1%
Drug / Alcohol Abuse 11.8%
Schizophrenia 8.1%
Table 2 developed by PsychU. Data source: Tedeschi, G.J., Cummins, S.E., Anderson, C.M., Anthenelli, R.M., Zhuang, Y., & Zhu, S. (2016, July). Smokers with self-reported mental health conditions: A case for screening in the context of tobacco cessation services. PLOS ONE, 11(7): e0159127. Retrieved from:

Overlap between reported MHCs was high, with depression being the most likely reported MHC to occur in conjunction with another MHC. Among those who self-reported an MHC:

  • 5% reported one MHC
  • 6% reported two MHCs
  • 0% reported three MHCs
  • 2% reported four or more MHCs

Though MHC self-report may not be as accurate as a clinical diagnosis, it does allow staff at state quitlines to quickly assess for possible MHCs, which can provide an additional point of reference for predictive data used to create treatment approaches for individuals utilizing state smoking quitlines.

Once admitted, individuals accessing the CSH received standard treatment, based upon established protocols, including an initial session where individuals plan for a quit date and four follow-up calls at critical impasses based upon the individual’s predicted probability of relapse.

To evaluate the predictions for individuals with mental health conditions, approximately 9% of study participants were randomly selected from January 2013 to February 2015 to participate in a seven-month post enrollment evaluation interview.

Participants were segmented into three groups for the purpose of the study’s analysis, based upon responses to the brief MHC assessment:

  • Group One: No MHCs (47.8% of the population)
  • Group Two: One (1) MHC (18.5% of the population)
  • Group Three: Greater than one (>1) MHC (33.7% of the population)

Smokers in group two (those with 1 MHC) and group three (those with >1 MHC) were more likely than their peers in group one (those with no MHC) to receive at least one counseling session and to participate in additional counseling sessions.). Of the individuals selected who participated in a post assessment, quit rates across all groups were high, with at least 70% attempting a 24-hour quit, though those in group three were less likely to make a quit attempt than their peers. When examining relapse rates, those in group three had the highest rate (33.7%), followed by those in group two (28.6%), and finally those in group one (21.8%).

Given the prevalence of tobacco use behaviors for individuals with MHCs and their additional difficulty quitting, the analysis provided by Tedeschi et al. indicates that even a simple self-report-based mental health assessment can be a good predictor of success with cessation programs. By identifying individuals who may have more difficulty quitting, state quitlines can tailor counseling services to their callers in a more effective way, thereby increasing positive outcomes.

The full text of “Smokers with Self-Reported Mental Health Conditions: A Case for Screening in the Context of Tobacco Cessation Services” was published in July 2016 by PLOS ONE; a copy was accessed on February 22, 2017.

iNational Committee On Quality Assurance (NCQA). (n.d.) Medical assistance with smoking and tobacco use cessation. Retrieved October 24, 2016.

While it has been shown that primary care-based quality improvement (QI) programs for depression are effective at combatting racial and ethnic disparities in quality and access for mental health care for minority and impoverished communities, they are still not widely implemented. To combat the social determinants of health and homelessness in under-resourced communities that perpetuate this disparity, approaches like community-based participatory research (CBPR) are recommended.i A 2013 research study, “Community-Partnered Cluster-Randomized Comparative Effectiveness Trial Of Community Engagement & Planning Or Resources For Services To Address Depression Disparities,” conducted by Kenneth B. Wells and colleagues through Community Partners In Care (CPIC), examined the effects of one such CBPR approach in two under-resourced areas in Los Angeles, California. CPIC implemented two separate approaches with the goal of improving QI interventions for depression:

  • Community Engagement and Planning (CEP), consisting of a coalition of community-based agencies working together to improve programs for depression
  • Resources for Services (RS), a technical assistance model based on “train-the-trainer”, offered through webinars and on-site at primary care locations to assist individual agencies with their quality improvement programs.

Both categories of intervention (RS and CEP) used a depression QI toolkit which included a manual and pocket cards on assessment and medication management, a case management manual, a brochure and video to support patient education, individual and group manuals on cognitive behavioral therapy (CBT), a lay health worker manual, and team support tools. Under the CEP intervention, administrators within the community were invited to participate in bi-weekly meetings, co-led by community and academic council members, over the course of five months in order to collaboratively build a plan for implementation and training, and to develop a network of services for consumers. Additionally, CEP councils were given a workbook tailored to their planned implementation, which allowed for corrections throughout the implementation timeline, as needed. Under RS, agencies received training to implement the QI toolkit. The authors of the study found CEP, as compared to RS and outreach to individual programs, to be more effective at implementing depression QI programs and producing positive outcomes. Not only did the authors of the study demonstrate that CEP was more effective at increasing the participation of staff in depression training, they also determined CEP had a greater effect on participant outcomes: increasing mental health quality of life, reducing risk of homelessness, and improving physical activity.

A follow-up study, “The Impact Of Community Engagement On Health, Social, & Utilization Outcomes In Depressed, Impoverished Populations: Secondary Findings From A Randomized Trial”, published in the 2016 May-June issue of the Journal of the American Board of Family Medicine, sought to demonstrate, using the same data resulting from the original methodology, whether the original research results held true under two new models. While the first study evaluated the measures against each other, the new models aimed to consider how the results specifically applied to impoverished people. Model One examined whether results differed between participants with incomes below the federal poverty level (FPL) (“poor”) and their peers (“non-poor”). Model Two examined the poor population in three mutually-exclusive sub-populations that were identified by community leaders involved in CPIC, including:

  1. Justice Involved: those individuals who had been arrested or on probation in the 6-months prior to baseline assessments
  2. Homeless, But Not Justice Involved: those individuals who were homeless or had greater than or equal to two risk factors for homelessness, and not meeting criteria for the “justice involved” subgroup
  3. Other Poor: those individuals that were below the FPL, but not meeting criteria for either of the “justice involved” or “homeless, but not justice involved” subgroups.

Outcome measures for the study were split into primary and secondary measures which are described in Table 1. Measure outcomes were self-reported at the 6- and 12-month markers.

Table 1: Primary & Secondary Outcome Measures
Primary Measures Secondary Measures
  • Percentage Of Individuals With Poor Mental Health Quality Of Life: Measured on the 12-Item Short Form Health Survey Mental Health Composite
  • Reduction Of Depression Symptoms: Measured on the Patient Health Questionnaire 8 (PHQ-8)
  • Mental Wellness
  • Physical Health
  • Homelessness/Risk For Homelessness: Defined as no place to stay for greater than or equal to two nights, eviction from a primary residence, financial crisis, or food insecurity in the past 6 months
  • Financial Worry Hindering Seeking Treatment For Emotional Problems
  • Total Number Of Life Difficulties: Measured on 15 life events such as, no place to stay, witness of violence, death of loved one, reduced work hours, loss of health insurance, etc.
  • Use Of Health Services Over A 6-Month Period: Including:
    • Nights spent in a behavioral health hospital
    • Mental health specialty outpatient visits where advice about mental health or medication was given
    • Counseling visits
    • Use of outpatient substance abuse services
    • Stays in residential treatment programs for substance abuse problems
    • Use of outpatient primary care or public health clinics
    • Number of visits in the informal sector where emotional problems or depression help were received
    • Total number of outpatient contacts for depression
Table 1 developed by PsychU. Source: Lam, C.A., Sherbourne, C., Tang, L., Belin, T.R., Williams, P., Young-Brinn, A., Miranda, J., Wells, K.B. (2016), The impact of community engagement on health, social, and utilization outcomes in depressed, impoverished populations: Secondary findings from a randomized trial. Journal of the American Board of Family Medicine, (29)3: 325-338. Retrieved from

Under Model One, Lam and colleagues found that primary outcomes from the original research study did not hold true; that is, in the low-income group, participants of QI programs under CEP and RS did not differ in mental health–related quality of life and the 8-item Patient Health Questionnaire. However, secondary outcomes related to mental wellness and physical activity were comparable between the two studies. Specifically, the authors found that under CEP, individuals in the poor cohort had:

  • Improved mental wellness at 6-months
  • Suggested evidence of improved physical health at 12-months
  • Reduced financial worry hindering seeking treatment
  • No difference in the percentage of hospitalization or outpatient visits
  • Suggested reduction of the total number of mental health specialty visits at 6-months
  • Increased primary care visitations at 12-months
  • Suggested increase in average depression specific visits within community settings

Outcome effects for specific sub-populations under Model Two were middling to mixed; the authors found no significant effects on primary outcomes and variable or suggestive evidence of improved secondary outcomes under CEP versus RS for some sub-populations in some measures. Secondary measure effects suggested by sub-population are presented in Table 2.

Table 2: Secondary Measure Effects Demonstrated Under Model 2 For Poor Sub-Populations
Justice Involved Homeless, But Not Justice Involved Other Poor
  • Suggested reduction in homelessness risk and life difficulties at 6-months
  • Suggested reduction in specialty visitations for medication and counseling at 6-months
  • Reduction in arrests or probation at 6-months
  • Improved physical health at 12-months
  • Improved mental wellness at 6-months
  • Increased use of community services
Table 2 developed by PsychU. Source: Lam, C.A., Sherbourne, C., Tang, L., Belin, T.R., Williams, P., Young-Brinn, A., Miranda, J., Wells, K.B. (2016), The impact of community engagement on health, social, and utilization outcomes in depressed, impoverished populations: Secondary findings from a randomized trial. Journal of the American Board of Family Medicine, (29)3: 325-338. Retrieved from

Additional findings for both models related to the final secondary measure, use of health services over a 6-month period, are presented in their entirety within the research article.

Lam et al., believe their findings provide supplementary support for the CPIC findings in regards to the poor and poor sub-populations, in that CEP is a more effective QI program that addresses disparities experienced in impoverished and under-resourced communities. Their findings have a number of limitations, including the geographic location of the study participants; sample sizes, particularly in regards to the poor sub-populations; missing data on why participants were involved in the justice system, the chronicity of their homelessness, or the severity of their medical illnesses; and measures were self-reported by study participants. Despite its limitations, the study demonstrated improvements in both health and social indicators for participants, and positive outcomes, regardless of magnitude.

Study Outcome Detail

Specific outcomes at the 6- and 12-month markers versus the baseline for Model One and Model Two are presented in Tables 3 and 4, respectively. Both RS and CEP demonstrated improvements in outcomes in almost all areas for all populations; however, the significance of the differences, as discussed above, vary.

Table 3: 6- & 12-Month Outcome Measures Versus Baseline, By Intervention, By Poor / Non-Poor
  Non-Poor (N = 268) Poor (N = 750)
Poor MHRQOL (%) – Reduced Percentage = Positive Outcome
Baseline 55.2 52.5
6-Month 51.4 37.0 51.6 46.5
12-Month 45.3 42.4 52.2 45.7
PHQ-8 Score (Mean) – Reduced Average = Positive Outcome
Baseline 14.7 15.1
6-Month 12.1 11.8 13.1 12.7
12-Month 10.9 10.9 12.4 12.1
Mental Wellness (%) – Increased Percentage = Positive Outcome
Baseline 39.3 39.8
6-Month 40.1 49.0 31.6 44.6
12-Month 54.7 51.0 44.8 48.2
Physical Health (%) – Increased Percentage = Positive Outcome
Baseline 77.7 73.0
6-Month 78.1 80.2 73.5 76.4
12-Month 78.0 77.4 69.6 78.4
Homelessness / Risk Of Homelessness (%) – Reduced Percentage = Positive Outcome
Baseline 50.7 55.3
6-Month 38.1 27.9 40.3 30.3
12-Month 25.7 31.0 33.8 35.7
Financial Worry (%) – Reduced Percentage = Positive Outcome
Baseline No Baseline Measurements Taken
6-Month 29.5 32.2 33.0 29.6
12-Month 28.7 30.1 32.6 24.0
Life Difficulties (Mean) – Reduced Average = Positive Outcome
Baseline 4.2 4.0
6-Month 3.0 2.7 3.0 2.7
12-Month 2.6 2.4 2.8 2.6
Table 3 developed by PsychU. Source: Lam, C.A., Sherbourne, C., Tang, L., Belin, T.R., Williams, P., Young-Brinn, A., Miranda, J., Wells, K.B. (2016), The impact of community engagement on health, social, and utilization outcomes in depressed, impoverished populations: Secondary findings from a randomized trial. Journal of the American Board of Family Medicine, (29)3: 325-338. Retrieved from


Table 4: 6- & 12-Month Outcome Measures Versus Baseline, By Intervention, By Poor Sub-Population
  Justice Involved
(N = 158)
Homeless, But Not Justice Involved
(N = 298)
Other Poor
(N = 294)
Poor MHRQOL (%) – Reduced Percentage = Positive Outcome
Baseline 48.8 54.6 52.3
6-Month 50.1 38.0 55.6 49.4 47.9 47.6
12-Month 50.6 40.9 55.3 48.1 50.2 45.8
PHQ-8 Score (Mean) – Reduced Average = Positive Outcome
Baseline 15.2 15.4 14.6
6-Month 13.0 13.0 13.7 12.8 12.5 12.5
12-Month 11.8 11.5 12.7 12.1 12.5 12.6
Mental Wellness (%) – Increased Percentage = Positive Outcome
Baseline 43.5 35.7 42.3
6-Month 31.0 50.8 33.4 40.3 29.6 45.7
12-Month 51.8 58.4 40.1 48.9 46.1 43.0
Physical Health (%) – Increased Percentage = Positive Outcome
Baseline 74.5 73.3 71.9
6-Month 74.2 79.8 73.5 74.0 72.9 76.8
12-Month 73.9 81.8 66.5 78.3 70.9 77.0
Homelessness / Risk Of Homelessness (%) – Reduced Percentage = Positive Outcome
Baseline No Baseline Measurements Taken For Sub-Populations
6-Month 41.9 20.6 55.1 46.1 24.5 17.9
12-Month 32.2 36.7 45.2 48.0 23.1 21.7
Financial Worry (%) – Reduced Percentage = Positive Outcome
Baseline No Baseline Measurements Taken
6-Month 34.9 32.9 35.7 30.7 29.0 27.5
12-Month 30.8 26.4 37.3 23.3 28.3 23.7
Life Difficulties (Mean) – Reduced Average = Positive Outcome
Baseline 5.9 5.0 2.0
6-Month 2.9 1.9 3.3 3.3 2.6 2.6
12-Month 2.5 2.6 3.0 2.7 2.7 2.5
Table 4 developed by PsychU. Source: Lam, C.A., Sherbourne, C., Tang, L., Belin, T.R., Williams, P., Young-Brinn, A., Miranda, J., Wells, K.B. (2016), The impact of community engagement on health, social, and utilization outcomes in depressed, impoverished populations: Secondary findings from a randomized trial. Journal of the American Board of Family Medicine, (29)3: 325-338. Retrieved from


The CPIC study had significant implications, including that there no demonstrated significant differences in the use of antidepressants and health care counseling between RS and CEP; that treatment exposure alone cannot account for outcome differences between RS and CEP; and that the development of a collaborative network across health care and other community-based services for QI program implementation under CEP provides added benefits that are not applicable for RS. Lam et al.’s study provides additional evidence that CEP demonstrates similar effects for the depressed poor, with suggestive evidence of positive secondary outcomes when examining poor sub-populations (particularly the justice involved).

The full text of the original study, “Community-Partnered Cluster-Randomized Comparative Effectiveness Trial Of Community Engagement & Planning Or Resources For Services To Address Depression Disparities” was published in May 2013 by Journal of General Internal Medicine; a copy was accessed on February 22, 2017.

The full text of “The Impact Of Community Engagement On Health, Social, & Utilization Outcomes In Depressed, Impoverished Populations: Secondary Findings From A Randomized Trial” was published in the May-June 2016 issue of the Journal Of The American Board Of Family Medicine; a copy was accessed on February 22, 2017.

i Wells, K.B., Jones, L., Chung, B., Dixon, E.L., Tang, L., Gilmore, J., Sherbourne, C., Ngo, V.K., Ong, M.K., Stockdale, S., Ramos, E., Belin, T.R., & Miranda, J. (2013). Community-partnered cluster-randomized comparative effectiveness trial of community engagement and planning or resources for services to address depression disparities. Journal of General Internal Medicine (28)10, 1268-1278.

Adults age 80 and older who used information and communication technology (ICT) to connect with friends and families had higher psychological well-being than non-users. ICT includes electronic devices and systems with micro-processors such as cell phones, e-mail, and smart device applications. Compared to non-users, adults 80 and older who used ICT to connect socially with friends and family or to learn new information reported greater higher life satisfaction, less loneliness, higher goal attainment, better subjective health, and fewer functional limitations.

These findings were reported in “Information and Communication Technology Use Is Related to Higher Well-Being Among the Oldest-Old,” by Tamara Sims, Andrew E. Reed, and Dawn C. Carr. The researchers surveyed 445 adults ages 80 and older about their “technology use and well-being.” The 15-minute survey took place via telephone and online. The participants reported their frequency of ICT use, motivations for ICT use, and their psychological and physical well-being. The researchers sought to determine if those using ICT to facilitate social connections had higher well being scores than those using ICT to learn new information.

Key findings were as follows:

  • The participants used ICT more to connect with friends and family than to learn information.
  • Overall, ICT use predicted higher well-being outcomes whether the person used ICT for social or informational purposes.
  • Using more devices/apps was associated with motivation to use ICT to help connect to loved ones and to learn new information.
  • However, motivations to use ICT for social reasons was linked to slightly higher psychological well-being scores. Motivation to use ICT for information purposes was not linked to higher psychological well being.

The researchers concluded that older adults aged 80-plus who use ICT experience improvements in different facets of well-being depending on whether they do so for social or informational purposes. They noted that the results underscore the need to align older adults’ motivational goals with the ways older adults use ICT in order to maximize potential benefits of technology. Future research on ICT with adults over age 80 should continue this approach, assessing both motivations for ICT use (e.g., social and informational) and multiple aspects of well-being.

The full text of “Information and Communication Technology Use Is Related to Higher Well-Being Among the Oldest-Old” was published on October 4, 2016, by Journal of Gerontology: Psychological Sciences.

For more information, contact: Tamara Sims, Ph.D., Stanford Center on Longevity, Stanford University, 365 Lasuen Street, Littlefield Center, Room 349, Stanford, California 94305-6053; 650-736-9083; Email:; Website:

This summary was developed utilizing the full recorded presentation of this webinar, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at

Robert McIntyre, MD, FRCPC, presented information on the effects of inflammation and metabolic disturbances on mood disorders during a PsychU live webinar held on February 14, 2017. Dr. McIntyre is a Professor of Psychiatry and Pharmacology at the University of Toronto, and Head of the Mood Disorder Psychopharmacology Unit at the University Health Network, Toronto, Canada. He is a paid consultant for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of the presentation were to:

  • Describe the importance of cognitive symptoms as psychiatric targets
  • Review immune and metabolic systems associated with cognitive deficits and mood disorders
  • Discuss innovative approaches that may target these symptoms

Dr. McIntyre began with the statement that there is no cure or disease modification available for depression, schizophrenia, bipolar disorder, or other related disorders. There are psychosocial and pharmacologic treatment options that can reduce symptoms and improve outcomes for patients, but, he stated too few people benefit from modification, cure, or recovery from these diseases. Therefore he focused his presentation on understanding the effector systems, in this case inflammation and metabolic changes that metastasize to the brain, causing cognitive dysfunction. Cognitive symptoms such as memory dysfunction, decreased processing speed, and difficulties with executive function and attention are common across different types of mental health conditions (e.g., major depressive disorder, schizophrenia, Alzheimer’s disease) and scientists from National Institutes of Health have identified this domain as a priority therapeutic target.

Citing a study that examined cognitive dysfunction in people with diabetes mellitus, Dr. McIntyre noted that although diabetes is an insulin-glucose homeostatic disturbance it greatly affects the brain’s cognitive abilities, similar to the symptoms seen in adults with mood disorders. He also called attention to a study conducted in his clinical practice that looked at body mass index (BMI) as a significant moderating factor for cognitive function, in which they found that people with higher BMI were more likely to have cognitive impairments.

The moderator asked Dr. McIntyre, “Do we know how mood disorders and metabolic disorders are related? Do they have the same underlying cause?” Dr. McIntyre said yes, that they typically begin with the social determinants of health (e.g., economics, housing dislocation, exposure to high-crime areas). Next he explained there are substrates that are common in the two conditions, like disturbances in the hypothalamic-pituitary-adrenal system, at the molecular level. He continued by explaining the association between metabolic and neuropsychological phenotypes, implicating inflammation, metabolism, oxidative stress, and behaviors such as consumption of high empty calorie food. These may lead to sustained disturbances in glucose-insulin homeostasis, along with inflammation, which leave the brain vulnerable to harm. He continued with a chart showing how adipose tissue increases inflammation, caused by peptides called adipokines produced by the adipose sites. People who have mood disorders and are overweight are more likely to exhibit elevated C-reactive peptides and pro-inflammatory cytokines interleukin-1 or 6 in their peripheral blood stream. Dr. McIntyre observed that inflammation is a cause, consequence, and concurrent condition in people with mood disorders; and obesity can be the cause, consequence, and concurrent condition of people with inflammatory disorders. He postulated that inflammation, when gone awry, leaves a person at risk for obesity, diabetes, and mood disorders.

Dr. McIntyre presented another study wherein he and colleagues observed that exposure to early childhood adversity (e.g., physical or sexual abuse) increased the risk of cardiovascular disease, obesity, diabetes, and other metabolic syndromes. He said this is similar to what he’s seen in general population studies. This prompts him to ask every patient, without exception, about histories of early trauma. He then counsels them about the possible risk factors of cardiovascular disease, being overweight, and obesity. He believes that sustained activation of the stress response leaves these individuals at risk for obesity, diabetes, major depression, and bipolar disorder.

The moderator asked, “Do we have any idea how this occurs? Are there any specific pathways involved that you can talk about?” Dr. McIntyre replied that the stress response system is abnormal in people who’ve been exposed to chronic, uncontrollable, pathological stressors like physical and sexual abuse. The stress system is in interplay with the innate immune-inflammatory system and regulatory systems such as for endocrine-based systems; eventually the effector system becomes abnormal. People who come to Dr. McIntyre’s clinic have depressive symptoms, obesity, and metabolic changes that are brought about by psychosocial events.

Next Dr. McIntyre explained hippocampal volume changes in people with diabetes or major depression. The longer the duration of depression, and the longer an individual has diabetes, the more hippocampal volume is reduced. He also pointed out that people with schizophrenia, autism, bipolar disorder, and depression experience alterations in brain connectivity as shown in diffusion tensor imaging, as do people with diabetes and obesity. In his clinical experience, these patients can’t focus, can’t regulate their moods, and are impulsive, which is evidence of the presence of brain-connectivity abnormalities. His next slide focused on the mechanisms of neuro-inflammation – in the form of activated microglia that release pro-inflammatory cytokines in the brain — which increase when individuals have major depression, bipolar disorder, schizophrenia, and trauma-based disorders such as post-traumatic stress disorder (PTSD). In addition, pro-inflammatory markers can cause fatigue as seen in people with a common cold, metabolic diseases, and mood disorders. In light of this information, Dr. McIntyre believes someone with a brain-based illness should be treated for somatic morbidities in addition to mental health problems.

The next part of the presentation focused on metabolic or inflammation-based treatments for people with conditions such as depression or bipolar disorder. Dr. McIntyre believes that an anti-inflammatory approach can work against depression. He gave the example of people with metabolic conditions who are more likely to be depressed than people without metabolic conditions. When people with dyslipidemia take statins – which have an anti-inflammatory and antioxidant effect – they are less likely to be depressed than people who do not take statins for dyslipidemia. Dr. McIntyre doesn’t think doctors should measure people’s inflammatory proteins as a way to inform or stratify treatment because there isn’t enough evidence for a baseline marker to support it, although it is a promising approach. He also discussed the possibility of inoculations for depression involving gut biome or gut biota, which are known to be relevant to disease and health in humans. People with schizophrenia or other mood disorders have shown improved symptoms when given an antibiotic. He continued by saying there are other approaches to anti-inflammation including getting a good night’s sleep because it normalizes circadian rhythm, a nutritional diet, and exercise, especially a combination of aerobic exercise and resistance training, which has proven to be anti-depressant and pro-cognitive. Dr. McIntyre reminded the audience about the important role of social determinants of health as it affects an individual’s metabolism and level of inflammation. For example, air pollution, exposure to high calorie food, high crime environments, and high unemployment are all linked to pro-inflammatory outcomes. He suggests that a multisystem approach to target social, biological, and individual factors is needed.

Dr. McIntyre believes that when treating someone for mental disorders, professionals need to counsel the individual about risk factors for metabolic diseases like cardiovascular disease. He said, “…treat the patient not only from the neck up, but the neck down” to help them achieve mental and physical wellness.

The question and answer session included these questions from the audience. The presenter’s responses are shown below.

  • Considering the relationship between adverse childhood events and physical, emotional, and social disorders, including inflammation, it would seem that primary prevention starts well before adulthood. What are your thoughts on that?

Dr. McIntyre indicated that you can look even further upstream. In utero exposure to infections like herpes, cytomegalovirus, or toxoplasmosis increases the risk that the individual or offspring will have a mood or psychotic condition, autism, or a learning disorder. This speaks to the importance of antepartum care. He also spoke about sugary drinks consumed by children, which when consumed in excess can cause obesity but can also cause trauma to the brain.

  • The information you’ve presented today makes the negative impact on metabolics from anti-psychotic therapy all the more concerning. Can you share your thoughts on this?

Dr. McIntyre referred to the Florida Medicaid Treatment guidelines, which contain very clear statements about the deleterious effects of obesity and diabetes on brain health and how people with mental disorders are disproportionately affected by these (metabolic) conditions. He believes we should prioritize and use psychotropic medications that do not have the liability of weight gain and other metabolic effects.

  • Could you just briefly share any thoughts that you have on the role of epigenetics on any of the systems you discussed?

Dr. McIntyre explained that epigenetics refers to the modification of genetic transcription on the basis of environmental exposure. As an example, people who have been exposed to trauma are also exposed to a change in their biological milieu that alters the way the genes are transcribed. There are efforts to look at novel ways of treating depression and cognitive impairment through epigenetics. One way is to restrict calorie intake, which reduces inflammatory transcription. Dr. McIntyre also believes that sleep and the normal circadian rhythm, as well as aerobic exercise, can target the epigenetic systems.

During this webinar, Dr. Roger S. McIntyre, Professor of Psychiatry and Pharmacology (University of Toronto), Head of the Mood Disorders Psychopharmacology Unit (University Health Network), and Executive Director of the Brain and Cognition Discovery Foundation, discusses the effect of inflammation and metabolic disturbances on mood disorders. Additionally, he discusses how innovative treatment approaches that target metabolic disturbances may have a positive impact on mental health.

Humana has released the Goal Guru app for employers to improve employee activity levels and increase overall well-being. The app gathers data from multiple users and their wireless devices to let employees interact with others through competitions, challenges, and wellness-goal tracking. The app also provides 24/7 access to a digital coach and custom news feeds. The overall goal for the software is to create a healthier workforce to increase employee engagement and productivity, and offer companies insight into overall health care costs.

Humana is a Kentucky-based health insurance company with a goal of helping members live healthy, active, and rewarding lives.

This was reported by Business Wire on November 22, 2016.

Contact Information: Humana Inc., 500 West Main Street, Louisville, KY 40202; 502-883-6266; Website:

Life expectancy declined for the total U.S. population between 2014 and 2015, falling from 79.9 years to 79.8 years, according to the National Center for Health Statistics (NCHS) and the Centers for Disease Control and Prevention (CDC). It’s the first time U.S. life expectancy has decreased since 1999, which was around the same time that the HIV/AIDS health crisis began to subside.

The NCHS study assessed overall life expectancy in two ways: from birth and age-adjusted from 65 years. The death rate for the latter increased among non-Hispanic white males, non-Hispanic white females, and non-Hispanic black males. However, age-adjusted life expectancy for the entire U.S. population stayed the same from 2014-2015.

Life expectancy

Source: NHCS/CDC

The top 10 causes of death in 2015 stayed the same as the previous year, with heart disease still the leading source of U.S. fatalities. Among those 10, cancer was the only cause to drop in rate of incidence from 2014. The overall rate went up in the other nine categories. Causes of death related to cognitive and behavioral health issues included Alzheimer’s disease (number six), and suicide (number 10).

These findings were reported in “Mortality in the United States, 2015,” a report conducted by Jiaquan Xu, M.D., Sherry L. Murphy, B.S., Kenneth D. Kochanek, M.A., and Elizabeth Arias, Ph.D., all with the NCHS’s Division of Vital Statistics.

For more information, contact:

  • Elizabeth Arias, Ph.D., Health Scientist, National Center for Health Statistics, National Center for Health Statistics, 3311 Toledo Road, Hyattsville, Maryland 20782; 301-458-4727; Email:; Website:
  • National Center for Health Statistics, U.S. Centers for Disease Control and Prevention, 3311 Toledo Road, Hyattsville, Maryland 20782; 800-232-4636; Email:; Website:

Face-to-face cognitive behavioral therapy (CBT) has been used for decades as a way to effectively treat depression, and web-based CBT is now being incorporated into treatment strategies. Consumers and providers alike are accepting of web-based interventions for depression and many studies have been performed to document the outcomes. A team of researchers from the Netherlands wanted to expand on the successes of web-based CBT by developing and testing a highly-structured and integrated blended CBT (bCBT) protocol for depressed patients in specialized mental health care. Their report “Development and initial evaluation of blended cognitive behavioural treatment for major depression in routine specialized mental health care” by Lisa C. Kooistra, et al. was published by Internet Interventions in January 2016. It details the development of a highly-structured blended CBT strategy that provides one face-to-face session and one online session per week for ten weeks, instead of the usual once a week face-to-face session for 20 weeks. Development of bCBT relied on evidence-based information provided by health care experts, and consumers with depression.

Patients were eligible to participate in bCBT if they were 18 years old, had a diagnosis of depressive disorder, spoke Dutch fluently, and had access to the internet at home via a computer. Patients were excluded if they were already receiving psychotherapy. Of the nine patients eligible to participate in bCBT, one chose face-to-face CBT instead of bCBT because of a malfunctioning computer at home, and another had financial problems and therefore could not travel to the clinic for face-to-face sessions. Seven patients began the program and five finished most of the treatments; two did not finish all sessions (one patient experienced full remission with antidepressants and the other received a new diagnosis of attention deficit disorder).

The bCBT treatment protocol was designed with the help of 18 Dutch health experts during two four-hour group discussions; and with the assistance of three patients in the final phase of face-to-face CBT for depression. Table 1 briefly summarizes the principles for guiding development given by health experts, and feedback from consumers.

Table 1: Guiding Health Expert Principals & Consumer Feedback On bCBT Treatment Protocol
Health Expert Guiding Principals Consumer Feedback
  • Establish a therapeutic relationship with patients face-to-face and explain the web-based environment in order to motivate their use of bCBT
  • Provide face-to-face sessions and online sessions in equal measure (50/50 ratio)
  • Focus face-to-face sessions on adapting the treatment content to the individual patient
  • Structure treatment under a fixed sequence of modules, instead of tailored online content, to ensure delivery to the full CBT protocol
  • Include optional, open-ended session evaluation questions during online sessions, encouraging patients to comment on the session and promoting reflective thinking on homework exercises’ meaning and impact
  • Send email reminders in order to encourage patients to access the online platform and engage in treatment
  • Provide feedback after each online session to monitor and motivate patients between sessions
  • Concern over the amount of homework was expressed
  • A preference for having access to only one session at a time in the web-based treatment system, instead of all sessions at once, was expressed
  • Importance of at least one face-to-face session on a weekly basis was expressed
Table 1 developed by PsychU. Source: Development and initial evaluation of blended cognitive behavioural treatment for major depression in routine specialized mental health care. Kooistra, Lisa C. et al. Internet Interventions, Volume 4, 61–71. Accessed December 2016 at

Clinicians used patient electronic health records to gain information on DSM-IV-TR diagnoses and use of anti-depression medication; in addition clinicians used a variety of assessment tools (see Table 2) to corroborate patients’ self-reported information.

Table 2: Assessment Tools Used To Corroborate Patient Self-Report
Assessment Name Measures
Inventory Of Depressive Symptoms Tool Assesses the severity of patients’ depressive symptoms
Beck Anxiety Inventory Measures patient anxiety levels
EuroQol Questionnaire Measures health-related quality of life
Table 2 developed by PsychU. Source: Development and initial evaluation of blended cognitive behavioural treatment for major depression in routine specialized mental health care. Kooistra, Lisa C. et al.  Internet Interventions, Volume 4, 61–71. Accessed December 2016 at

Before entering the program patients evaluated whether bCBT was credible and could met their expectations by using a six-item credibility/expectancy questionnaire (CEQ); after finishing bCBT they rated usability with the 10-item System Usability Scale; and post-treatment satisfaction with bCBT was measured with the Client Satisfaction Questionnaire-8 (CSQ-8).

In addition, participants completed an on-line questionnaire to report their demographics and establish baseline information on their depressive symptoms; and they received a demonstration of the web-based CBT application before beginning the program. Face-to-face CBT took place at the clinic and web-based therapy was delivered via computer to the patients’ homes. When treatment was complete patients were asked to complete an online questionnaire to self-assess their outcomes.

Participants reported improvements in depression, health-related quality of life, and anxiety as a result of the treatment; they rated the system usability above average, and were overall very satisfied with bCBT.


The small scale of the study makes findings questionable for generalization to other populations; however the goal of the study was to test the feasibility and acceptance of blended cognitive behavioral therapy. The authors report success on this endeavor because they identified a willingness of all parties to partake in bCBT. Adherence by patients to bCBT sessions was above average and researchers noted some patients did not need the full number of face-to-face sessions. Their interpretation of this finding was that bCBT has the potential to shorten treatment duration compared to the standard 16 to 20 weeks needed in face-to- face CBT. In addition, while patient self-reported expectations were neutral before treatment, most reported positive attitudes post-treatment. The authors concluded that blended CBT can be a valuable treatment option for patients with severe depression in an outpatient specialty mental health setting.

The full text of “Development and initial evaluation of blended cognitive behavioural treatment for major depression in routine specialized mental health care” was published online by Internet Interventions on January 27, 2016. A copy was accessed December 21, 2016.

A recent study found that many mental health professionals experience elevated levels of stress and anxiety in relation to their role in managing suicidal behaviors; their distress was found to be associated with the emotional exhaustion component of burnout. Further, measures showed that adverse responses were higher for outpatient mental health professionals than inpatient workers; higher for those who had received generic training in suicide prevention; and higher for those who had experienced a workplace related client suicide. These study findings were published Psychology, Community & Health’s, “Mental Health Workers’ Views About Their Suicide Prevention Role,” by Virginia Ross, Anoop Sankaranarayanan, Terry J. Lewin, and Mick Hunter. The goal of the study was to describe and evaluate the effects on mental health workers of their ongoing role in managing suicidal behaviors and to identify the thoughts and feelings associated with their role in suicide prevention.

Invitations to participate were sent to 500 mental health professionals in New South Wales, Australia. Invited mental health professionals who elected to participate in the study provided demographic and work-related information and completed assessments through an online survey administration software, including: a locally-devised questionnaire investigating the effects on mental health workers of working with client suicidality and their attitudes toward this role; and two standardized scales – the Maslach Burnout Inventory – Human Services Survey (MBI-HSS) and the state version of the State-Trait Anxiety Inventory (STAI-S). A summary of each of the assessments is provided in Table 1.

Table 1: Summary Of The Locally-Devised Questionnaire, Maslach Burnout Inventory – Human Services Survey (MBI-HSS), & State-Trait Anxiety Inventory (STAI-S)
Locally-Devised Questionnaire MBI-HSS STAI-S
Assessed views of mental health workers about their role in suicide prevention

Used 19 Likert-Scale style questions covering five topic areas:

  • Predictability and preventability of suicide
  • Responsibility for preventing suicide
  • Role in managing suicidality
  • Stress or anxiety experienced while working with suicidal clients
  • Training received on suicide and prevention

Also asked supplemental open-ended questions if they had experienced a client suicide.

Comprised of 222 questions related to three aspects of burnout

Aspects investigated included:

  • Emotional exhaustion
  • Depersonalization (includes impersonal, uncaring responses to recipients of services)
  • Personal accomplishment (sense of competence and achievement at work)
Comprised of 20 items

To contextualized the responses on this assessment, individuals were asked to recall a recent event of managing client suicidality and to write their responses based upon that event.

Table 1 developed by PsychU. Source: Psychology, Community & Health, 2016, Vol. 5(1), 1–15, doi:10.5964/pch.v5i1.174. Accessed December 2016 at

The participants of the study were 135 mental health workers from a variety of workplaces and professional disciplines. Of the 135 participants:

  • 1 individual did not respond to demographic questions (but completed the survey on anxiety and burnout)
  • 89 (66%) were women and 45 (33%) were men
  • 83 (62%) worked in an outpatient setting and 51 (38%) in an inpatient setting
  • 95 (70%) indicated they had experienced a client suicide
  • 68 (50%) indicated they had experienced a connection with suicide in their personal lives
  • 96 (71%) had attended a training program on suicide prevention, while 38 (28%) had not
  • Age ranged from 21 to 64 years
  • Years worked in a mental health field ranged from 0.66 years to 45 years (mean of 14.11 years)
  • A majority (95 individuals; 70%) indicated they were not made aware of increased risk of client suicide in their mental health workplace in a job advertisement or during the job interview or training
  • Of the 40 individuals (30%) who were made aware of increased risk of client suicide in their mental health workplace, only 14 learned about the risk during training; for the remainder the risk was implicit or inferred
  • A majority (97 individuals; 72%) indicated they had not received any information or formal training about how to manage their own distresses or concerns following a client suicide

In the development of a new questionnaire to assess the views of mental health workers about their role in suicide prevention seven of the 19 questions were dropped from the questionnaire because some items were redundant, resulting in the selection of one version of the originally comprised sub-questions that could be expressed as a single question. The 12 item questionnaire that was retained covered three main areas: preventability beliefs (beliefs about suicide being always and/or permanently preventable); associated distress (stress/anxiety about managing suicidal behavior); and the prevention role (covering views about personal roles and responsibilities in preventing suicidal behaviors).


The researchers of the study cite several limitations to the study and developed questionnaire, including: lack of psychometric validation of the study; small sample size; and that the responses for the study came for individuals already working in the mental health field in a particular region of the world.

Considering the results, training for mental health workers should not solely focus on the burden of responsibility on mental health works to prevent suicide but also focus on personal self-care and stress management of the workers. Redesigning suicide prevention training programs would allow for the trainings to be more effective and in turn improve the well-being of mental health workers. The researchers of the study suggest that future research using their developed questionnaire should be conducted to better understand why some subcategories fair better emotionally when dealing with client suicide than others.

The full text of “Mental Health Workers Views About Their Suicide Prevention Role” was published online March 24, 2016 by Psychology, Community & Health. A copy is available online and was last accessed December 21, 2016.

Prescribed exercise and internet-based cognitive behavioral therapy (iCBT) each reduced depression severity over 12 months for 84% of adults with mild to moderate depression. A study compared depression severity scores after 12 weeks of prescribed supervised group exercise, 12 weeks of iCBT sessions, or usual care by a physician. The comparison assessed change in depression scores on the Montgomery–Åsberg Depression Rating Scale (MADRS) at three months after treatment and again at 12 months. At 12 months, scores for the exercise group had dropped by 11.4 points, scores for the iCBT group had dropped by 12.1 points, and scores for the usual care group had dropped by 9.7 points.

Pre-Post Depression MADRS Scores For Exercise, iCBT & Treatment As Usual Groups
Assessment Average MADRS score Physical Exercise iCBT Treatment As Usual
Baseline 22.2 21.9 20.8
Interim (3 months) 11.3 11.2 13.9
End-point (12 months) 10.8 9.8 11.1

These findings were reported in “Exercise and internet-based cognitive–behavioural therapy for depression: multicentre randomised controlled trial with 12-month follow-up” by Mats Hallgren, Björg Helgadóttir, Matthew P. Herring, Zangin Zeebari, Nils Lindefors, Viktor Kaldo, Agneta Öjehagen, and Yvonne Forsell. The researchers conducted the study with 945 adults with mild to moderate depression aged 18 to 71 years who were recruited from primary healthcare centers located throughout Sweden. The participants were randomly assigned one of three 12-week interventions: supervised group exercise, clinician-supported ICBT or usual care by a physician. The average MADRS score at baseline ranged from 7 to 19 indicating mild depression or from 20 to 34 indicating moderate depression.


The 316 people assigned to the exercise group were then assigned to one of three sub-groups: light exercise (yoga/ stretching classes), moderate exercise (an intermediate aerobics class) and vigorous exercise (a higher-intensity aerobics/ bodyweight strength training class). The 60-minute sessions led by certified personal trainers took place three times a week at a fitness center. The participants’ adherence to the assigned exercise program was monitored through weekly meetings with a trainer or physiotherapist, and was verified by the participants’ membership card activity. Data was also collected from wearable fitness devices that tracked the participants’ pulse rates. The participants completed an average of 12 of the 36 recommended sessions.


The 317 people assigned to the iCBT group accessed the sessions through a secure website operated through a county council. The program was created by qualified, accredited clinical psychologists with 1.5 years of CBT education and training. The participants worked through modules of a text-based self-help manual (plus a few images and sound clips) posted online at the website. Before starting the iCBT sessions, the participants completed online forms to identify specific mental health concerns and work-related problems; this information was used to customize the 13 modules assigned. The first modules addressed depressive symptoms, such as inactivity and avoidance behaviors. The remaining modules targeted the issues identified by each participant, such as comorbid symptoms often seen in depression, such as worry, panic attacks, social anxiety, stress, insomnia and pain. Other person-specific modules focused on problems related to the workplace and motivated the participant to return to work or find a new job. Participation was monitored via log ins and completion of each task in the module. In total, the participants sent 18 messages to their assigned therapist via a secure online messaging system, received 17 messages, and accessed 7.8 online modules out of an expected 13.

Usual Care

The 312 people assigned to the usual care group received standard treatment for depression administered by their primary care physicians. For most in this group, usual care consisted of a 45 to 60 minute CBT intervention delivered by an accredited psychologist or counselor. During the 12 weeks, the participants made an average of 8.2 visits to their general medical professional. Outside the primary care setting, about 22% reported visiting a psychiatrist, psychologist, or psychotherapist, and making an average of 3.3 visits. Another 10% reported visiting a counselor, and making an average of 2.9 visits. About 27% of people in the usual care group reported receiving no formal psychological treatment.

The researchers found that MADRS scores for 84% of the participants were significantly lower at the 12 month follow-up. Depression severity reduced significantly in all three treatment groups. On average, the participants’ depression severity declined from about 20, or moderate depression at baseline to about 10, or mild depression after 12 months. The researchers concluded that the long-term treatment effects suggested that prescribed exercise and clinician-supported ICBT should be considered for the treatment of mild to moderate depression in adults.

The full text of “Exercise and internet-based cognitive–behavioural therapy for depression: multicentre randomised controlled trial with 12-month follow-up” was published in the November 2016 issue of British Journal of Psychiatry.

PsychU reported on this topic in “CBT May Help Improve Outcomes For Consumers With Insomnia & Chronic Pain,” which published on October 25, 2016.

PsychU also reported on this topic in “American College Of Physicians Recommends CBT—In-Person Or Internet-Based—As First-Line Treatment For Insomnia,” which published on September 16, 2016.

For more information, contact: Mats Hallgren, Ph.D., Department of Public Health Sciences, K9, Karolinska Institute, Tomtebodavägen 18a, Widerströmska Huset, Stockholm, 171 77; Sweden; Email:; Website:

I am always on the lookout for new opportunities for provider organizations to serve complex consumers. And just such a new opportunity surfaced this past month – the expansion of Medicare coverage for diabetes prevention effective January 1, 2018.

What is included in the Medicare coverage of diabetes prevention? The Medicare Diabetes Prevention Program (MDPP) model is a 12-month intervention provided by trained community health workers or health professionals in community and health care settings. For the first six months, the benefit covers at least 16 weekly, hour-long sessions. For the second six months, the benefit covers at least six monthly maintenance sessions. The goal of the program is to prevent the onset of type 2 diabetes among Medicare beneficiaries diagnosed with pre-diabetes by providing a structured behavioral change intervention to be covered as an additional preventive service with no Medicare cost sharing. The reimbursement structure for the MDPP has not yet been finalized, but CMS has reported that they plan to tie provider organization payments for MDPP services to the number of Diabetes Prevention Program sessions attended and the achievement and maintenance of minimum weight loss.

The new model was based on a pilot of a program developed by the YMCA. The YMCA received an $11 million CMS Health Care Innovation Award for two program components: hiring and training lifestyle coaches to deliver the program’s curricula and implementing the MDPP among eligible participants. The MDPP curriculum was delivered over a 10 to 12 month period in groups of eight to 15 participants – followed by eight monthly maintenance sessions (see “Certification of Medicare Diabetes Prevention Program” from the Centers for Medicare & Medicaid Services). The curriculum includes 16 sessions that cover topics related to diet, exercise, and healthy lifestyle changes. The results showed a drop in costs by $2,650 per person – a cost reduction greater than the cost of the services (see “Evaluation of the Health Care Innovation Awards: Community Resource Planning, Prevention, & Monitoring, Annual Report 2015″ from RTI International).

What makes this a great opportunity? To paraphrase Robert Gabbay, M.D., Chief Medical Officer at Joslin Diabetes Center – It opens the door to a world where “lifestyle interventions” are reimbursable treatments. As we’ve seen before, Medicare can be a trend setter among payers when it comes to new care delivery and financing models. One great example is the push to value-based payment (see Medicare Bets Big On Pay-For-Value) and accountable care organizations (see Medicare ACOs – A Blueprint For P4P For All Payers?). As Medicare explores new ways to incorporate wellness initiatives into the reimbursable service delivery continuum, we can expect other payers to follow suit (see Medicare’s Path To Incorporating Social Determinants Into Value-Based Payment).

For specialty provider organizations, this is an opportunity to provide their current consumers with a new and much needed service – and more. The link between diabetes and depression is clear, as is the high prevalence of diabetes in consumers with schizophrenia. And, beyond those consumers, the market is large. An estimated 29.1 million people, or 9.3% of the U.S. population has diabetes. The estimated cost of diabetes treatment is $322 billion per year, with one of every three dollars being spent by Medicare (see “The Staggering Costs Of Diabetes In America” from the American Diabetes Association). It is also an opportunity to build a prototype for the new model of wellness programs, focused and tied to performance, that we are likely to see again soon.

In response to in-house social support activities at some New Hampshire schools, the state’s Office of Student Wellness is using $20 million in Project Advancing Wellness and Resilience in Education (AWARE) Grants from the Office of Substance Abuse and Mental Health Services Administration (SAMHSA). These funds were included in the President and Vice President’s Now Is the Time plan to increase access to mental health services and improve school safety. The funds will be administered to six school districts including Berlin, Concord, Franklin, Laconia, Rochester, and SAU #7 in Pittsburg.

Due to student’s increasing social needs, school districts in New Hampshire’s prevalent low-income neighborhoods started setting up in-house social needs support programs including food pantries, meal programs, mental health check-ups, support for kids with drug-addicted parents, trauma programs, and clothing provisions in order to help kids succeed academically. These programs put strain on facility space and monetary budgets, necessitating additional funding to keep the programs running.

The Office of Student Wellness, created by the New Hampshire Department of Education, committed to the development of the whole child in collaboration with communities, school districts, and individuals to improve community health and success.

Project AWARE is a SAMHSA grant program created under the President and Vice President’s Now Is the Time plan to improve behavioral health awareness among school-age youth and their communities. The program launched in September 2015.

This was reported by New Hampshire Public Radio on May 31, 2016.

Contact Information: Terry Stafford, Program Assistant, Office of Student Wellness,  New Hampshire Department of Education, 101 Pleasant Street, Concord, NH 03301; 603-271-3720; Email:; Website:

Contact Information: Kathryn McKinnon, Project AWARE Coordinator, U.S. Department of Health and Human Services, Office of Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857; 877-726-4727; Email:; Website:

A new report released by the Substance Abuse and Mental Health Services Administration – U.S. Department Of Health & Human Services Health Resources and Service Administration (SAMHSA-HRSA) Center For Integrated Health Solutions provides helpful information for health care professionals who provide services to elderly individuals, especially those with behavioral conditions. “Growing Older: Providing Integrated Care For An Aging Population” begins with statistics on the exponentially growing elderly population in the U.S., including that one in five older Americans have a mental health or substance use disorder (SUD). The authors note several ways that the geriatric population differs from the general population, including that they:

  • Are prone to complex health conditions
  • Receive multiple medications
  • Encounter health disparities (e.g. transportation, nutrition, housing)
  • Are frail and therefore at risk for falls or injury
  • Experience loss of loved ones, functioning, and independence
  • Are vulnerable to elder abuse
  • Are exposed to behavioral health stigma and discrimination

Older adults may present with physical, behavioral and cognitive symptoms that can be interpreted differently than for younger patients. According to the report, like the general population, most elderly individuals receive services for behavioral health needs in primary care settings, therefore the authors recommend an integrated approach to care and outline strategies to accomplish it. Possible strategies for effective integrated care for this population, according to the authors, would include:

  • Striving for effective interpersonal communication by including caregivers in care planning and using easy to understand terminology when speaking with patients and caregivers.
  • Developing and relying on a multidisciplinary team-based approach, utilizing external professionals if needed to address the medical, behavioral, social, and environmental needs of the patient.
  • Screening for depression, anxiety, substance abuse, chronic pain, and risks of falls, as well as accounting for gender differences in prevalence (e.g. women being more likely to be depressed, men being more likely to misuse substances).
  • Understanding the difference between depression, delirium, and dementia in order to make accurate diagnoses.
  • Including all types of stakeholders in care planning and coordination (e.g. both paid and unpaid caregivers, pharmacists, and other professionals to assist with continuity of care).
  • Knowing which interventions are appropriate for symptoms of stress, loss, trauma, and mental health disorders and being careful not to overprescribe antipsychotics for people with cognitive impairments.
  • Using culturally competent and adaptive approaches to treat older individuals, which may include help navigating technology commonly used in an office setting and altering physical space to include wider doorways, exam rooms with space for caregivers, and handrails.
  • Assisting older patients with understanding their health plan benefits and training staff to coordinate their benefits for maximum effectiveness.
  • Continually monitoring patient and caregiver satisfaction and making training available to staff to follow identified best practices.
  • Incorporating a monitoring system for incidents common with older patients, e.g. injuries, infections, and adverse reactions to multiple medications.
  • Maintaining complete electronic health records, which are essential to providing quality care to all patients.
  • Enlarging buttons on touchpad technologies or font sizes of printed material.

To round out the report, the authors provide web links to many informative resources that can be used by health care professionals and the community to assist older populations. Of particular interest to providers may be the list of evidence-based integrated care practices for older adults, and brief screens for primary care providers. The screens available in the report included:

  • Depression Screen – Patient Health Questionnaire (PHQ-9)
  • Anxiety Screen – Generalized Anxiety Disorder 7-Item Scale (GAD-7)
  • Cognitive Measure For Dementia – The Mini-Cog
  • Cognitive Impairment Screen – Montreal Cognitive Assessment (MoCA)
  • Dementia Functional Assessment – Functional Activities Questionnaire (FAQ)
  • Delirium Assessment Tool – The Confusion Assessment Methods Diagnostic Algorithm (The CAM)
  • Brief Alcohol Screen – Alcohol Use Disorders Identification Test (AUDIT-C)
  • Opioid Abuse/Chronic Pain Medication Abuse Screen – The Opioid Risk Tool (ORT)

A copy of “Growing Older: Providing Integrated Care For An Aging Population” was accessed November 2016 and is available online courtesy of SAMHSA-HRSA.

Key Messages

  • Sleep disturbance is commonly observed in patients with bipolar disorder (BD), during mood episodes and when they experience residual symptoms between episodes.
  • Compared with healthy individuals, recovered patients with BD demonstrated poorer sleep quality, including longer sleep latency, greater use of sleep medication, and greater daytime dysfunction. Among recovered patients, poor sleep was significantly associated with residual depressive and mood elevation symptoms, and recovered patients who were poor sleepers experienced earlier mood episode recurrence compared with good sleepers.
  • Interventions aimed at improving sleep may help delay or prevent mood episode recurrence in patients with BD.

Key Messages

  • Patients with bipolar disorder (BD) commonly experience sleep disturbances, which are negatively associated with treatment outcomes, throughout all stages of the illness.
  • Sleep disturbances in patients with BD result from disruptions in circadian systems and sleep-wake homeostasis processes.
  • Sleep-related biomarkers of manic and depressive episodes include a reduction in rapid eye movement (REM) latency and sleep continuity and an increase in REM density. Additionally, increased time in bed and reduced sleep efficiency are markers of euthymia.
  • Novel treatments for improving sleep disturbances in patients with BD are needed.

This summary was developed utilizing the full recorded presentation of this webinar, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at

On November 17, 2016 during a live PsychU webinar, Arthur C. Evans, Jr., PhD, the Commissioner of Philadelphia’s Department of Behavioral Health & Intellectual disAbility Services (DBHIDS), and Paul Block, PhD, the Vice President of Consulting for OPEN MINDS, presented their insights into the importance of social determinants of population health.

The objectives of the webinar were to:

  • Explore the connection between social determinants of health and the well-being of a population
  • Understand why social determinants of health should be addressed, especially for people with behavioral health needs
  • Understand what can be done to lessen the impact of adverse social conditions on a population’s health from the public health perspective

The overall presentation focused on why income, housing, and employment are important to an individual’s well-being, the challenges that social determinants present to population health management, insights into what health care providers can do to address social determinants in their service delivery strategy, and the successful interventions that the City of Philadelphia, Pennsylvania has put into place to address these challenges in order to improve the health status of individuals in their care.

The presenters began the conversation by discussing the challenges to keeping populations healthy that the U.S. health system currently faces. Dr. Evans began by saying the current system of care is focused more on illness as opposed to preventive health, which tends to be intensified in the behavioral health setting by the fact that resources are often allocated towards serving individuals in a reactive way. He went on to cite the dual-natured challenge for health care providers, namely, to continue to address behavioral health crises when they occur but to also proactively focus resources toward behavioral and physical health prevention and wellness efforts. Drs. Evans and Block both discussed financing models as a perpetuating factor in the lack of early intervention and prevention efforts, as payers are not always responsible for financing interventions for these determinants and available funding does not typically allow providers the flexibility to provide care in more proactive ways.

Dr. Evans continued by explaining the connection between social determinants of health and the well-being of a population. He began with a discussion of the factors that influence health status, and then compared a traditional treatment model with a recovery-oriented system of care. Dr. Evans stated that the current model is characterized by the mentality that outcomes are measured by “fixing” individuals as they come in for treatment, and can be problematic because it: constrains provider thinking about why individuals may be coming for care; develops treatment options that only address issues conventionally related to health care; and limits treatment to only individuals who actively seek help. In contrast, the recovery-oriented system views an individual within the context of their lives and environment, in order to develop treatment that addresses all factors that may be influencing an individual’s well-being.

The first polling question of the presentation was focused on respondents’ perception of the most important social determinants:

What do you think is the most important social determinant of health in the area where you live and work?

  1. Economic stability (33%)
  2. Education (3%)
  3. Social and community acceptance (6%)
  4. Access to health care and health literacy (17%)
  5. Safe community, access to health foods, and sufficient housing (41%)

Drs. Evans and Block expounded that all answers were valid, and that the goal is to expand providers’ ways of thinking to include a discussion of social determinants and their impacts on health outcomes. Dr. Evans mentioned, in particular, that stabilizing housing can have a large impact on outcomes.

Dr. Evans continued by discussing health disparities with significant economic impacts on the health care system. He mentioned that even though aggregate data may show positive outcomes, health care providers need to investigate their disaggregated data for additional trends and insights. He provided an example from his own work in Philadelphia: when investigating aggregate data for penetration (service access) Philadelphia’s outcomes appeared quite good, but when looking at disaggregated data they could tell that these positive outcomes did not hold true for Asians and African Americans. Dr. Evans mentioned that for Philadelphia the service access measure has sweeping consequences, not only for individuals’ access, but for the health care system as a whole, as individuals with untreated mental health and substance use issues cause significant cost to the system.

Dr. Block discussed the difference that better management of social factors can have on health outcomes. He stated that the behavioral health population is particularly impacted by social determinants of health, and due to this, tend to demonstrate poorer health outcomes, are less likely to receive adequate care, and may face stigma when they seek care. He continued by stating that individuals with mental health issues tend to cost the health care system more than individuals without mental health issues, and this may lead to a hesitancy to move more funding toward preventative measures outside of mental health care treatment. Dr. Evans agreed and added that untreated behavioral health conditions also contribute to increased spending on physical health care.

Dr. Block demonstrated that only 5% of Medicaid enrollees account for more than 50% of total expenditures, raising a critical question for the health care system – why are these individuals so expensive to care for? He pointed to behavioral health conditions and social determinants as key answers to this question. He discussed the idea that social determinants are more complicated than just focusing on poverty, and presented the Graham Center’s Social Deprivation Index (SDI) as one way to predict health outcomes for individuals based on a more comprehensive set of social determinants.

The second polling question of the presentation attempted to assess respondents understanding of U.S. spend on social services, which a majority of participants answered correctly:

In the United States, for every $1.00 spent on health care, how much is spent on social services?

  1. $2.00 (10%)
  2. $1.50 (4%)
  3. $1.00 (1%)
  4. $0.75 (4%)
  5. $0.50 (81%)

Dr. Block discussed that according to a World Health Organization study, even though the United States spends more than all other countries on health care alone, the United States is only 13th in ranking when you consider health care with social services, indicating a potential mistaken priority in spending.

Dr. Evans then presented the change that the City of Philadelphia, Pennsylvania, has been implementing in order to address population health, keys to the transition included:

  • Moving from a traditional model to a recovery-based model
  • Providing public education and training
  • Focusing on prevention and early intervention
  • Involving and engaging the community
  • Developing cross-system collaboration
  • Providing evidence-based services
  • Developing innovative ways to provide treatment
  • Integrating behavioral health care and intellectual disability services into a comprehensive system

Dr. Evans discussed looking at broad interventions that they can implement or improve in order to affect public health. A few examples of social determinants being leveraged to improve the health of Philadelphia’s population were discussed, including: tackling stigma and social understanding of mental health issues; employment; housing; and community capacity. He walked through a specific example, improving permanent supportive housing for individuals with serious mental illness: Philadelphia takes a systems approach to addressing homelessness, where the City provides targeted outreach for individuals with the longest histories of homelessness, places qualifying individuals with specialized residential substance abuse treatment programs for individuals experiencing long-term homelessness, and referring individuals with chronic street homelessness to safe havens or shelters (serving 554 individuals in 2015 alone). Dr. Evans presented compelling cost outcomes experienced by the City of Philadelphia after homelessness interventions were implemented. For individuals involved in the Safe Haven program alone, this resulted in an average cost reduction from the $112 average cost per day experienced during the implementation of the program to $18 average cost per day one year after lease-up.

Dr. Evans described the evidence that provider organizations should look for to know that their population management approach is working, including looking at both high-level macro data and subset data on specific measures.

Dr. Evans concluded his case study by discussing the “rethinking” needed to address population health management. He focused on 7 competencies:

  • Working At The Community- & Group-Level: Most practitioners are trained to work with specific individuals. However in population health management, interventions need to be more group-, neighborhood-, or community-wide.
  • Working Upstream: Right now practitioners serve a more passive role, where they wait for individuals to come to them. When thinking about population health management, practitioners need to work on intervening at the earliest moment.
  • Trying A Broad Set Of Strategies: The primary way that most practitioners deal with behavioral health treatment is through psychotherapy, medication, and possibly case management. When thinking about population health management, practitioners need to address additional factors (social determinants) with new strategies outside of a traditional health care realm.
  • Working With Non-Diagnosed Populations: Going beyond only those who have been diagnosed to address health for all populations – even those who are currently healthy.
  • Delivering Health Promotion Interventions: Health is not just the absence of illness, it’s more than this. If practitioners can help individuals who are healthy stay healthy, and to work on wellness, they can help reduce the likelihood they develop a condition needing treatment.
  • Working In Community & Other Non-Clinical Settings: Getting out of the treatment black box – working in various and creative community settings to provide the community with information to help them be healthy and well, and to get services when needed.
  • Developing Health Activation Approaches & Empowering Others: Educating in order for individuals to take more ownership of their health and wellness.

The question and answer session included these two questions from the audience. The presenters’ responses are summarized below.

  • What experiences have you had in moving funds, or in other words, how are these services being paid for?
    Dr. Evans explained that Philadelphia has created a single-payer behavioral health care system where all of the public sector dollars (including Medicaid) flow through his office. This has allowed them to redistribute funding that is saved (with state approval) to other programs. In addition, the ACA has reduced the reliance on grant dollars for the uninsured population – which could be reutilized for upstream public health strategies.
  • Vocational support for behavioral health clients is perceived in many settings as a paraprofessional activity, instead of a clinical one, what are your experiences in framing these supports as clinical supports?
    Dr. Block indicated that integration may increase collaboration to make sure that these activities are supported not just by paraprofessionals, but also by all the stakeholders in a population’s overall health.

People with chronic pain conditions and insomnia who received cognitive behavioral therapy (CBT) that targeted their beliefs about pain and sleep quality reported experiencing less insomnia and lower pain levels. More than 200 people with chronic pain and comorbid insomnia improvement participated in a study testing a new specialized 10-item questionnaire called the Pain-Related Beliefs and Attitudes about Sleep (PBAS) scale. They completed the PBAS and other validated measures of pain interference, insomnia severity, and cognitive-behavioral processes before and after completing a CBT intervention focused on dysfunctional thinking about insomnia and pain. The participants’ post intervention PBAS scores were significantly lower, and their scores on the other measures also showed improvement.

These findings were reported in “Development of the Pain-Related Beliefs and Attitudes about Sleep (PBAS) Scale for the Assessment and Treatment of Insomnia Comorbid with Chronic Pain” by Esther F. Afolalu, MSc; Corran Moore, BSc; Fatanah Ramlee, MHSc; Claire E. Goodchild, Ph.D.; and Nicole K.Y. Tang, DPhil. The researchers sought to evaluate the psychometric and functional properties of the PBAS. The PBAS scale is intended for use by people with long-term pain issues plus insomnia. The PBAS questions measure the individual’s beliefs about sleep and pain, and the individual’s quality of sleep.

The researchers tested the PBAS psychometric properties, test-retest reliability, sensitivity to treatment, and generalizability with four groups of people with chronic pain and co-morbid insomnia. The PBAS total score was positively correlated with scores from the Insomnia Severity Index (ISI) scale, Dysfunctional Beliefs and Attitudes about Sleep (DBAS) scale, and the Anxiety and Preoccupation about Sleep Questionnaire (APSQ).

The responses indicated that those who believed they would not be able to sleep as a result of pain were more likely to have insomnia, which exacerbated their pre-existing pain. The PBAS was able to predict the participant’s level of insomnia and the degree of pain.

The dual-focus CBT intervention was able to reduce the participants’ negative thoughts about pain and sleep that were perpetuating their insomnia. With better sleep, their pain problems were significantly reduced. The researchers concluded that the PBAS can accurately monitor the effect of CBT on an individuals’ negative thoughts about sleep quality and pain.

The full text of “Development of the Pain-Related Beliefs and Attitudes about Sleep (PBAS) Scale for the Assessment and Treatment of Insomnia Comorbid with Chronic Pain:” was published in September 2016 by Journal of Clinical Sleep Medicine.

PsychU reported on this topic in “American College Of Physicians Recommends CBT—In-Person Or Internet-Based—As First-Line Treatment For Insomnia,” which published on September 16, 2016.

For more information, contact: Nicole Tang, D.Phil, C.Psychol, Associate Professor, Department of Psychology, University of Warwick, University Road, Room H110, Coventry, CV4 7AL; United Kingdom; 024 761 50556; Email:; Website: or Ester Afolalu, Corresponding Author, Department of Psychology, University of Warwick, University Road, Room H144, Coventry, CV4 7AL; United Kingdom; 024 765 23158; Email:; Website: or or Luke Walton, International Press Officer, Executive Office, University of Warwick, University Road, Coventry, CV4 8UW; United Kingdom; 02476 150 868; Email:; Website:

Key Messages

  • The increasing prevalence and comorbidity of metabolic syndrome (MetS) and mental health disorders (MHDs) has raised interest in potential underlying mechanisms.
  • The relationship between MetS and MHDs is thought to be bidirectional. In addition to environmental and lifestyle factors, shared mechanisms such as chronic inflammation, disruption of neuroregulatory pathways, and hypothalamic−pituitary−adrenal (HPA) axis dysregulation may underlie these syndromes. Further, inflammation caused by maternal obesity/MetS may ultimately increase the risk of MHDs and MetS in offspring.
  • The authors recommended treating individuals with comorbid MetS and MHD using an integrated approach to target aspects of both conditions. The need to develop strategies to prevent maternal transfer of increased risk for these syndromes was also emphasized.

The American College of Physicians (ACP) recommends cognitive behavioral therapy (CBT) as first-line treatment for insomnia for adults, whether the CBT is delivered in-person or via an Internet-based program. For adults who try CBT for insomnia but whose insomnia continues, the ACP recommends that clinical professionals use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy.

CBT for insomnia consists of a combination of treatments that include cognitive therapy around sleep; behavioral interventions, such as sleep restriction and stimulus control; and education, such as sleep hygiene. The treatments involved in CBT for insomnia can be performed in primary care. Delivery methods for CBT for insomnia include as individual or group therapy, telephone- or Web-based modules, or self-help books.

The guidelines were reported in “Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians” by Amir Qaseem, M.D., Ph.D., MHA; Devan Kansagara, M.D., MCR; Mary Ann Forciea, M.D.; Molly Cooke, M.D.; Thomas D. Denberg, M.D., Ph.D., for the Clinical Guidelines Committee of the American College of Physicians. The guideline was developed to present the evidence and provide clinical recommendations on managing chronic insomnia disorder in adults. The guideline is based on a systematic review of randomized, controlled trials published in English from 2004 through September 2015. The outcomes evaluated included global outcomes assessed by questionnaires, patient-reported sleep outcomes, and harms.

The guideline grades the evidence and recommendations by using the ACP grading system, which is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Most studies focused on in-person CBT for insomnia; however, the data suggest that other delivery methods are also effective.

The recommendation of CBT as first-line treatment received a strong recommendation, and was supported by a moderate-quality evidence base. The evidence base was insufficient to show the harms associated with behavioral interventions. Additional findings were as follows:

  • Moderate-quality evidence showed that CBT improved global outcomes in the general population, including increased remission and treatment response.
  • Moderate-quality evidence showed that CBT also improved sleep outcomes in the general population, including reduced sleep onset latency and wake after sleep onset and improved sleep efficiency and sleep quality.
  • Low- to moderate-quality evidence showed that CBT also improved global and sleep outcomes in older adults, reduced sleep onset latency, and improved sleep efficiency.
  • Moderate-quality evidence showed that CBT reduced wake after sleep onset in older adults.
  • The recommendation for shared decision-making if CBT is unsuccessful received a weak recommendation; it was supported by a low-quality evidence base.

The benefits of pharmacologic treatment include improved sleep outcomes, such as sleep onset latency and total sleep time, and in some cases improved global outcomes in the general population and in older adults. Most studies have examined newer medications, whereas commonly used older and generic medications have not been studied. The evidence is insufficient to evaluate the balance of the benefits and harms of long-term use of pharmacologic treatments in adults with chronic insomnia disorder. The FDA has approved pharmacologic therapy for short-term use (about a month). The FDA recommends further evaluation if insomnia does not remit within 7 to 10 days of treatment.

Evidence on harms was limited from randomized controlled trials that met the inclusion criteria for the review, which mostly reported on study withdrawals. However, observational studies have shown that hypnotic drugs may be associated with infrequent but serious adverse effects, such as dementia, serious injury, and fractures. In addition, FDA labels warn of daytime impairment, “sleep driving,” behavioral abnormalities, and worsening depression. The FDA suggests dosages lower than those used in many of the included studies, especially for older adults. There was insufficient evidence overall on the comparative effectiveness and safety of the various drug treatments.

The full text of “Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians” was published July 19, 2016, in Annals of Internal Medicine.

PsychU reported on online insomnia therapies in “Computer-Based Psychotherapy Reduced Chronic Insomnia Among Veterans With Substance Use Disorders,” which published on January 25, 2016.

For more information, contact: Angela Collom, Media Relations Manager, American College of Physicians, 190 North Independence Mall West, Philadelphia, Pennsylvania 19106-1572; 215-351-2653; Email:

Approximately 25% of non-institutionalized adults age 18 and older, in the civilian population are diagnosed with multiple chronic physical health conditions (MCC). They have been diagnosed with two or more of the following 10 conditions: arthritis, asthma, cancer, chronic obstructive pulmonary disease (COPD), coronary heart disease, diabetes, hepatitis, hypertension, stroke, or weak or failing kidneys. The prevalence of MCC with the 10 conditions varies across the states – from 19.0% in Colorado to 38.2% in Kentucky. Regional prevalence was lowest in the Pacific states, at 21.4% and highest in the East South Central region, at 34.5%. Prevalence rates are highest among older adults.

These findings were reported in “State and Regional Prevalence of Diagnosed Multiple Chronic Conditions among Adults Aged ≥18 Years — United States, 2014” by Brian W. Ward, Ph.D., and Lindsey I. Black, MPH, of the National Center for Health Statistics at the federal Centers for Disease Control and Prevention (CDC). The researchers analyzed responses to the National Health Insurance Survey (NHIS), a multistage health survey of the U.S. civilian, noninstitutionalized population conducted continuously throughout the year. Data on chronic conditions were collected in the NHIS Sample Adult Core questionnaire. The sample included responses from 36,697 adults. Those who reported a diagnosis of two or more of the following selected conditions were categorized as having MCC: arthritis, asthma, cancer, chronic obstructive pulmonary disease (COPD), coronary heart disease, diabetes, hepatitis, hypertension, stroke, or weak or failing kidneys. The NHIS included half of the 20 conditions that the federal Department of Health and Human Services (HHS) has identified for inclusion in studies of MCC; no mental health or addictive conditions were included in the survey or this analysis.

Additional findings were as follows:

  • Ten states had higher than average MCC prevalence: Kentucky at 38.2%, Alabama at 35.8%, West Virginia at 34.6%, Mississippi at 34.2%, Montana at 33.2%, New Mexico at 32.9%, Maine at 30.9%, Michigan at 30.3%, Ohio at 29.6%, and Pennsylvania at 29.6%.
  • Six states had lower than average MCC prevalence: Colorado at 19.0%, Alaska at 19.6%, California at 20.1%, Wyoming at 20.3%, Minnesota at 20.4%, and New York at 21.3%. It was also below average in the District of Columbia, at 19.2%.
  • By age group, about 7.3% of adults ages 18 to 44 had MCC, about 32.1% among adults ages 45 to 64, and 61.6% among adults age 65 and older. In regions where prevalence of MCC was higher than the national average (East North Central and East South Central), the prevalence of MCC for each age group was also higher than the national average in each respective age group.

The researchers noted that the MCC prevalence estimates for the non-institutionalized, civilian population are conservative and for several reasons may be understated. The NHIS asked about a limited set of conditions, and not at all about behavioral health conditions.  Further, the NHIS only asked about physician-diagnosed chronic conditions. Because adults in institutional long-term care settings are excluded from the NHIS sample design, the MCC prevalence estimates cannot be generalized to the entire United States population. The MCC prevalence estimates by state also do not account for differences in age distributions among the states and the District of Columbia.

For more information, contact: Brian W. Ward, Ph.D., Health Statistician, Division of Health Interview Statistics, National Center for Health Statistics, 3311 Toledo Road, Room 2217, Hyattsville, Maryland 20782-2064; 301-458-4568; Email:; Website:; or Lindsey I. Black, Division of Health Interview Statistics, National Center for Health Statistics, 3311 Toledo Road, Room 2217, Hyattsville, Maryland 20782-2064; 301-458-4548; Email:; Website:

Absenteeism was 46% lower among people who participated in employee assistance program (EAP) services. During the 30-day period before using EAP services, the participants missed an average of 12.2 hours of work. During the 90 days after participating in EAP services, the participants missed an average of 6.5 hours of work in 30 days.

These findings were reported in “EAPs Can and DO Achieve Positive Workplace Outcomes” by Chestnut Global Partners, LLC. The researchers analyzed outcomes of 13,400 EAP users (only employees, not their family members or dependents) who had been assessed with the Workplace Outcome Suite (WOS) both before and after EAP use. The data was analyzed by examining changes in average WOS scores 90 days after EAP services were rendered.

The WOS is a validated consumer outcomes survey administered before starting and after completing EAP services. The survey collects outcome data for absenteeism, presenteeism, work engagement, life satisfaction, and workplace distress. The goal is to measure the effectiveness of the EAP intervention in terms of improved work performance. The three-minute WOS pre-test is administered by trained intake counselors, usually over the phone. It can also be completed by the employee while waiting for a first visit with an EAP counselor or clinical professional. The data set includes responses from employees who were assessed using a 5-item version of WOS, a 9-item version, or a 25-item version. Because different versions were used for the Work Absenteeism scale, responses to the 9-item and the 25-item surveys were pooled. Absenteeism was defined as missing either complete work days, or partial days, such as when the employee came in late or left work early.

Findings about EAP performance on the other four work domains were as follows:

  • Work presenteeism dropped by 26.7%, from 3.3 hours during the 30 days before EAP services down to 2.4 hours after EAP services. Presenteeism was defined as distraction at work due to the problem addressed by the EAP services.
  • Work engagement improved by 7.1%, from a score of 3.2 to a score of 3.4. The WOS uses a Likert scale of 1 (strongly disagree) to 5 (strongly agree) to measure agreement with the statement: I am often eager to get to the work site to start the day. Work engagement is defined as the extent to which the employee is invested in or passionate about his or her job.
  • Work distress declined by 12.8%, from a score of 2.2 to a score of 1.9. The WOS measures agreement with the statement: I dread going in to work. Work distress is defined as the degree of anxiety or stress at work.
  • Life satisfaction increased by 21.9%, from 3/0 to 3.6. The WOS measures agreement with the statement: So far, my life seems to be going very well. Life satisfaction is defined as one’s general sensee of well-being.

The full text of “EAPs Can and DO Achieve Positive Workplace Outcomes” was published in June 2016 by Chestnut Global Partners and the Employee Assistance Professionals Association.

PsychU reported on WOS research findings in “Employee Assistance Programs Reduce Absenteeism & Presenteeism,” which published on May 25, 2016.

For more information, contact: Chestnut Global Partners, LLC, 1003 Martin Luther King Drive, Bloomington, Illinois 61701; 800-433-7916; Email:; Website:; or Charles Epstein, Media Contact, Chestnut Global Partners, LLC, 1003 Martin Luther King Drive, Bloomington, Illinois 61701; Email:; Website:

On July 6, 2016, Providence Health & Services and St. Joseph Health merged and announced that they were creating an initiative to promote mental health care improvements. Providence St. Joseph Health invested $100 million to fund the Institute for Mental Health and Wellness, which will identify and advance innovative solutions in mental health. Fund distributions will be made through a formalized grant process and be available internally to Providence St. Joseph Health entities as well as other organizations within the communities it serves. Non-profit Providence St. Joseph Health is a health and social services system that is the parent organization for more than 100,000 caregivers in Alaska, California, Montana, New Mexico, Oregon, Texas, and Washington.

To launch the Institute, Providence St. Joseph Health and a soon-to-be convened expert advisory panel chaired by Maureen Bisognano, will collaborate with national and local organizations with expertise addressing mental health. The fund will support research and startup operations for mental health awareness, diagnosis and treatment. Members of the expert advisory panel will provide strategic guidance on the distribution of funds.

Providence St. Joseph Health was formed by the merger of the Sisters of St. Joseph of Orange, located in Irvine, California and the Sisters of Providence, located in Seattle, Washington. The merger was announced in March 2016, and was slated to close in May. The organizations believe the merger creates the third-largest non-profit health system in the United States, behind Kaiser Permanente and Ascension Health. Providence’s system included 34 hospitals, and the merged organization has 50. Annual revenue is projected to increase from $14 billion to $20 billion.

For more information, contact:

  • Colleen Wadden, Director, External Communications, System Office Communication, Providence Health & Services, 4515 Martin Luther King Jr Way S, Suite 200, Seattle, Washington 98108; 206-979-1620; Email:; Website:
  • Susan Solomon, Media Contact, Joseph Health, 3345 Michelson Drive, Suite 100, Irvine, California 92612; 949-381-4770; Email:; Website:; or Nisha Morris, Media Contact, St. Joseph Health, 3345 Michelson Drive, Suite 100, Irvine, California 92612; 949-381-4782; Email:; Website:


This tool is designed to help patients recognize and manage symptoms of schizophrenia. Patients can use it as practical support for wellness, as a daily guide, and to turn to during times of difficulty. This workbook also includes instructions for the patients’ families, caregivers, or loved ones to help guide them on how best to help the patients when their symptoms make it difficult to care for themselves. Also available in Spanish.


This tool is designed to help patients focus on their MDD. Patients can use it as practical support for wellness, as a daily guide, and to turn to during times of difficulty. This workbook also includes support information for patients’ families, caregivers, and loved ones. Also available in Spanish.

This summary was developed utilizing the full recorded presentation of this webinar, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at

During a live PsychU webinar on August 4, 2016, Deborah Adler, Senior Vice President for Optum’s Network Strategy Department in Minneapolis, Minnesota, and Maurice Lelii, Director of Outpatient & Managed Care for Gracepoint in Tampa, Florida, provided their insight on paying for value in mental health services. The speakers were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of the webinar were to:

  • Understand why models of reimbursement are moving from volume- to value-based
  • Understand the role of payers in value-based purchasing and what tools payers offer to providers to meet quality goals
  • Understand the responsibilities of providers in value-based delivery and what providers are doing to meet the expectations of payers and consumers.

Mr. Lelii started the webinar by discussing how change is necessary to improve the value of care, and providers should continually look for better ways to deliver quality care for the best price – hence the shift from the traditional pay-for-volume model. He mentioned high rates of uninsured people, high health care costs, low levels of consumer satisfaction, limited access to care, and increasing employer cost and tax burden from health care has provided much of the impetus for change.

Ms. Adler began the presentation by discussing the impact of the Patient Protection and Affordable Care Act (ACA) on improving value. She described how the ACA has changed health care organization, delivery, and funding in the United States, including three key ACA supports:

  • Testing new models of health care delivery
  • Shifting from a reimbursement system based on the volume of services provided to one based on the value of care
  • Investing in resources for system-wide improvement.

Mr. Lelii discussed the changes required by the shift towards value-based reimbursement for consumers and provider organizations. He stated that every stakeholder has changing responsibilities and involvement in the evolving health care process brought about by a strong focus on wellness: consumers have increased cost sharing and more requirements for engagement in their treatment, while for provider organizations, there is a strategic re-engineering in the value chain exemplified by more access to care through innovative programs like telehealth, integrating medical and behavioral health care, and mobile health.

Ms. Adler offered her views on changes affecting professionals and health plans as a result of pay-for-value models. For example, the new norm for professionals requires participation in population health management and standardization of care, as well as significant pressure to achieve quality outcomes. For health plans, these changes are bringing about downward pressure on rates, increased competition from other health plans, backward integration, gain-sharing reimbursement arrangements with providers, smaller subsidies and more stringent ratings for private health exchanges, Medicaid, and Medicare populations.

Ms. Adler continued by reviewing the role of payers in value-based purchasing from Optum’s managed care organization (MCO) perspective. She defined value-based purchasing as any purchasing practice aimed at improving the value of health care services, where value is a function of both quality and cost. Ms. Adler believes plans should implement programs that will lead to higher quality care and better health (e.g. consumer information campaigns) and the use of financial incentives / cost sharing to encourage the selection of health care organizations and providers that are able to document their high-quality of care. She also stated that quality standards should be incorporated into contracts with health plans or care systems.

Ms. Adler discussed how Optum uses certain tools to drive quality and cost savings, including:

  • Pay-For-Performance Shared Savings Contracts With Qualified Facilities & Outpatient Providers: Metrics on inpatient and outpatient services such as Healthcare Effectiveness Data and Information Set (HEDIS) measures and wellness assessments are regularly collected from providers, as are case-mix adjusted per episode costs and utilization measures. Results include lower readmission rates and improved follow-up after hospitalization.
  • Medication Assisted Therapy for Substance Use Disorders: Readmission rates and per episode costs are tracked for providers of these services; resulting in reduced readmissions and an increase in people living in the community.
  • Accountable Care Organizations (ACOs) & Medical-Behavioral Integration In Health Homes: Metrics from a variety of services are collected from the providers (e.g. care coordination, care transition, referral management, health promotion, individual support, family/caregiver support). Implementation of these services has strengthened patient engagement with primary care providers and improved assistance to patients with needed social services.

Ms. Adler stated that Optum’s appointment reminder program is one of the tools they have found most effective in helping patients adhere to their appointments. In addition, the Achievements in Clinical Excellence Program, or ACE, guides and rewards providers for delivering services more effectively and efficiently by:

  • Gathering unbiased, risk-adjusted data that is benchmarked against regional clinicians and facilities
  • Pinpointing and eliminating variations in practice patterns that drive costs and create poor outcomes
  • Assigning specific tier designations and incentivize providers and facilities to achieve and maintain high performance

Other tools for consumers include efforts in transparency for members, the “Bridge on Discharge” program, and peer coaches. Optum has developed a 24-item outpatient member assessment tool that they have put on their website. Ms. Adler pointed out there are limited national assessment tools available to behavioral health professionals.

Mr. Lelii then discussed the responsibility of providers in value-based delivery. He gave an overview of Gracepoint (formerly Mental Health Care Inc.), which is a private, non-profit behavioral health care organization founded in 1949 by the Tampa Junior League. Gracepoint annually provides services to more than 21,000 individuals (2015) in Hillsborough County, and employs 600 staff members. Aside from routine services provided to clients there are a number of special services offered such as central intake, a children’s crisis stabilization unit, family infant wellness, a 60-bed adult crisis stabilization unit, intensive case management, and a community action team.

Gracepoint recently began offering value-added services to their clients, including a partnership with a federally qualified health center (FQHC) and a full-time primary care physician. A full-time pharmacy, laboratory, and telehealth services are available in-house. His advice on success as a value-based program included implementing a strong network, facilities, and accredited clinical team to provide
full continuum of care services.

Both presenters provided their insight into the anticipated changes in the market in the next five years: Ms. Adler said that the Centers for Medicare and Medicare Services (CMS) will be instrumental in defining future requirements. She also believes that ACOs will take a greater role in pay for value. Mr. Lelii believes the industry itself will drive changes in the future. He mentioned that providers and payers need to work together to provide effective, necessary care.

The question and answer session included these five questions from the audience. The presenters’ responses are summarized below.

  • What quality measures does Gracepoint use?
    Mr. Lelii stated that Gracepoint uses readmissions rates, HEDIS, length-of-stay (LOS), satisfaction surveys, case management, and inpatient utilization measures.
  • What data should a practice have to be prepared and readily available to be a strong partner with health plans?
    Ms. Adler said they receive proposals from providers that indicate how they track outcomes, quality measures, inpatient residential data, and HEDIS scores. She recommended that health plans and providers share data.
  • What are the different payment models that are being used in behavioral health?
    Mr. Lelii stated his preference for a blend of both capitation and fee-for-service.
  • What is the difference between pay-for-performance and pay-for-value?
    Ms. Adler said that clarity is needed when using these terms: pay-for-value is based on improvement in member outcomes; pay-for-performance is based on improving processes like coordinating care.
  • How is risk adjustment measured at Gracepoint?
    Mr. Lelii explained that they calculate risk adjustment using severity of illness, age, gender, and other factors, such as if the client is under a public health system.

Key Messages

  • The subset of the population affected by serious mental health encounters a disproportionate burden from cardiovascular (CV) disease.
  • Key elements of diet, exercise, behavioral therapy, the use of multicomponent, longer-duration programs, personalization, more frequent contact, and trained treatment providers, have been associated with improved outcomes of lifestyle interventions for CV risk in the general population, but have not always been incorporated into such interventions targeting patients with serious mental illness (SMI).
  • Tailoring existing lifestyle interventions to people with SMI will require innovative solutions to barriers such as low socioeconomic status, difficulties accessing care, psychiatric symptoms, cognitive impairment, and medication side effects.

To help police officers develop emotional resilience needed to withstand the trauma of mass casualty events, the National Alliance on Mental Illness (NAMI) recommends that police departments adopt officer wellness programs and trauma-education programs. Police commanders should assign an official representative on mental health issues and form a work group to recommend officer wellness programs and education. Police officers involved in a traumatic event, such as a mass casualty, may have widely varied, but normal, reactions, and that those normal reactions can still be upsetting and unexpected for officers. By implementing best practices for officer mental health and wellness programs and procedures, police departments can protect first responders in the early moments of critical events and over the long-term aftermath of traumatic events.

The work group should include command staff, supervisors, union leadership, mental health providers affiliated with the agency, and mental health providers from the broader community. The workgroup should network with mental health providers and assess what sort of wellness education officers need; and should recommend ongoing officer wellness programs and any policy changes needed related to access and use of psychological services following a critical incident.

These recommendations were reported in “Preparing For The Unimaginable; How Chiefs Can Safeguard Officer Mental Health Before And After Mass Casualty Events” by Laura Usher, Stefanie Friedhoff, Major Sam Cochran, and Anand Pandya, M.D. The report was written by researchers NAMI for the Office of Community Oriented Policing Services, U.S. Department of Justice. The guide has three sections and eight chapters. Section one is focused on understanding trauma and resiliency. Section two is focused on preparing for a mass casualty event in terms of enhancing resilience, planning incidence responses, and managing a mass casualty event and its aftermath in the short and long-term. The guide also includes handouts with officer’s personal stories that serve as examples of the various types of trauma that affect police officers.

Additional recommendations were as follows:

  • Officer mental wellness programs should be developed during incidence response planning in partnership with other first-responder organizations and community leaders. Plans can also be developed at the regional or statewide level.
  • To ensure that officer mental wellness remains a priority, police departments should implement policies around psychological services and programs to support officer wellness.
  • Policies could include creating a mental health manager role, supporting an ongoing officer wellness workgroup, offering officer wellness education and training, and providing regular interaction with mental health professionals.

For more information, contact: Lauren Gleason, Director, Public Relations & Media Communications & Public Affairs, National Alliance on Mental Illness, 3803 North Fairfax Drive, Arlington, Virginia 22203; 703-516-7230; Fax: 703-516-7238; Email:; Website:

At a ribbon cutting ceremony on April 29, 2016, the Army Wellness Center (AWC) officially opened at Joint Base San Antonio-Fort Sam Houston. AWCs are a U.S. Army Medical Command initiative overseen by the Army Public Health Center and are located all over the U.S. and Europe.

The Army Wellness Center (AWC) mission is prevention, and its approach is holistic, meaning providers look at physical, psychological, and social traits when providing service. The individual gets a Health Assessment to analyze their current health status and ability to increase physical activity. They then receive a custom-designed exercise program to achieve the goals. Participants get education in sleep habits, resiliency, lifestyle changes, tobacco-free living, and preventing chronic disease. Biofeedback training is provided to address psychological stressors – to help individuals build resilience and develop positive coping strategies. If a soldier transfers, their records transfer electronically and they can pick up the program where they left off at their previous station.

This was reported by Texas Public Radio on April 28, 2016.

Contact Information: JBSA-Fort Sam Houston Public Affairs, 2080 Wilson Road, JBSA-Fort Sam Houston, Texas 78234-5004; 210-808-7554; Email:; Website:

Under new federal rules for employer sponsored voluntary wellness programs, employers can offer participating employees discounts on health plan costs of up to 30% as an incentive for participation. If the discounts are higher, then the wellness program will not be considered a voluntary program and may violate the Americans with Disabilities Act (ADA). Employer-sponsored wellness programs generally provide health promotion and disease prevention activities as part of an employer-sponsored group health plan or separately as a benefit of employment. Many of these programs ask employees to answer questions on a health risk assessment (HRA) and/or undergo biometric screenings for health risk factors, such as high blood pressure or cholesterol. Some wellness programs provide educational health-related information or programs that may include nutrition classes, weight loss and smoking cessation programs, on-site exercise facilities, and/or coaching to help employees meet health goals.

The ADA places limits on disability-related inquiries and medical examinations related to wellness programs, regardless of how the information obtained is ultimately used. The limit on incentives applies to any wellness program that requires employees to answer disability-related questions or undergo medical examinations. In this context, incentives includes both financial and in-kind incentives, such as reductions in insurance premiums, cash, time-off awards, prizes, and other items of value, as well as “trinket” gifts.

The new rules for corporate wellness programs were released by the Equal Employment Opportunity Commission (EEOC) on May 16, 2016. The final rules address how employer-sponsored wellness programs work with existing anti-discrimination laws, including the ADA and the Genetic Information Nondiscrimination Act (GINA). The ADA and GINA prohibit employers from using information about their employees’ health conditions and that of the employees’ other family members, including spouses, unless the information is collected under a voluntary wellness program. The ADA requires employers to make all wellness programs, even those that do not obtain medical information, available to all employees, to provide adjustments or modifications to employees with disabilities, and to keep all medical information confidential.

Before the final rule was issued the EEOC’s ADA regulations permitted employers to make inquiries and conduct medical examinations that are part of a voluntary health program but did not define the term “voluntary” or explain what constitutes a “health program.” The previous regulations also did not clarify whether the ADA allowed employers to offer incentives to encourage employees to participate in such programs. The ADA regulates certain aspects of wellness programs not regulated by the Health Insurance Portability and Accountability Act (HIPAA) or the Patient Protection and Affordable Care Act (PPACA), which governs wellness programs that are part of a group health plan.

In issuing this final rule, EEOC sought to provide consistency with HIPAA and the Affordable Care Act rules on wellness program incentives, while also ensuring that incentives would not be so high as to become coercive and render participation in the program involuntary. HIPAA and the PPACA allow wellness programs that are part of an employer-sponsored group health plan to offer incentives for “health-contingent” wellness programs. These programs offer rewards to employees who perform activities, such as walking 10,000 steps a day, or who achieve certain health outcome, such as lowering their blood pressure. These wellness programs can also impose penalties if participants do not perform an activity or fail to achieve a particular outcome. However, the HIPAA regulations do not impose any incentive limits on “participatory” programs, and as long as participatory wellness programs are available to all similarly situated individuals and incentives are made available regardless of a health factor or their answers on an HRA, such programs do not violate HIPAA and the PPACA.

PsychU reported on this topic in “Feds Issue Proposed Rules On Wellness Programs & Compliance With The Americans With Disabilities Act,” which published on May 22, 2015.

For more information, contact: Office of Communications, Equal Employment Opportunity Commission, 10 South Howard Street, Baltimore, Maryland 21201; 202-663-4191; Email:; Website:

Vanderbilt University Medical Center (VUMC) is partnering with Verily (formerly Google Life Sciences) to launch a pilot for the federal Precision Medicine Initiative (PMI) Cohort Program. The goal of the PMI Cohort Program is to collect genetic data from a large group of volunteers to test methods of matching individuals, based on their specific genetic characteristics, to tailored treatments or prevention strategies for a wide variety of chronic illnesses.

On February 25, 2016, the National Institute of Health (NIH) awarded Vanderbilt University a grant to lead the Direct Volunteers Pilot Studies under the PMI Cohort Program. As part of the Direct Volunteers Pilot Studies, VUMC will create and optimize a prototype informational website to engage a diverse array of potential volunteers, and develop an interface for obtaining consent and basic enrollment and health information that is efficient, effective, and secure. VUMC will roll out a pilot program that will seek to enroll 79,000 volunteers by the end of December 2016. The Direct Volunteers Pilot Studies research team also includes the University of Michigan and the Broad Institute of MIT and Harvard.

President Obama announced the PMI on January 20, 2015. The federal budget for fiscal year 2016 allocated $130 million to NIH to build a national, large-scale research participant group, called a cohort; and $70 million was allocated to the National Cancer Institute to lead efforts in cancer genomics as part of PMI for Oncology. The PMI Cohort Program will seek to extend precision medicine to all diseases by building a national research cohort of one million or more U.S. volunteers. These volunteers will allow researchers to track their genetic characteristics, which will help expand approaches to precision medicine for conditions such as diabetes, heart disease, Alzheimer’s, obesity, and mental illnesses like depression, bipolar disorder, and schizophrenia, as well as rare diseases. Importantly, the cohort will focus not just on disease. The cohort will also focus on ways to increase an individual’s chances of remaining healthy throughout life.

In preparation for the PMI Cohort Program, in March 2015, the NIH formed a workgroup to develop a plan for creating and managing a large research cohort. On September 17, 2015, the workgroup submitted its report, “The Precision Medicine Initiative Cohort Program – Building A Research Foundation For 21st Century Medicine,” and a framework for the PMI Cohort Program. NIH Director Francis Collins, M.D., accepted the framework outlined in the report, and began moving to build the infrastructure. The NIH anticipates that volunteers can begin enrolling during 2016.

The objective of Direct Volunteers Pilot Studies is to create a prototype set of technologies and experiments that give researchers a way to collect data and create durable relationships to keep this large group of volunteers engaged with the project over time. The research team will establish and test innovative methods and technologies for enabling robust participant engagement, as well as user-friendly data collection. Later during 2016, the NIH plans to award cooperative agreements for the full implementation phase. This will include establishment of a Coordinating Center to oversee Direct Volunteer recruitment, and Healthcare Provider Organizations to enroll more participants, and a Biobank capable of storing and managing blood, urine and saliva samples for analysis.

For more information, contact:

  • Precision Medicine Initiative Cohort Program, National Institutes of Health, 9000 Rockville Pike, Bethesda, Maryland 20892; 301-496-4000; Email:; Website:
  • Craig Boerner, Media Contact, Vanderbilt Health, 3401 West End Avenue, Suite 290, Nashville, Tennessee 37203; 615-322-4747; Email: craig.boerner@Vanderbilt.Edu; Website:; or John Howser, Assistant Vice Chancellor, Medical Center News and Communications, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, Tennessee 37232; 615-322-4747; Email:; Website:

This summary was developed utilizing the full recorded presentation of this webinar, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at

Two noted professionals presented a live PsychU webinar on June 8, 2016 to discuss managing metabolic wellness in individuals with mental illness. Christoph Correll, MD, is a professor of Psychiatry at Hofstra Northwell School of Medicine and Medical Director of the Recognition and Prevention program at Zucker Hillside Hospital, also in New York. Sloan Manning, MD, is the Medical Director at Novant Health PrimeCare in Greensboro/Winston-Salem, Adjunct Associate Professor at the University of North Carolina School of Medicine, and consulting staff member of the Moses Cone Health System in Greensboro, North Carolina. The speakers were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives for the webinar were to:

  • Highlight the importance of wellness in individuals with schizophrenia
  • Discuss the guidelines available to maintain wellness in patients with schizophrenia
  • Understand the importance of monitoring and treating cardiometabolic risk factors
  • Explore successful wellness programs for those with schizophrenia and serious mental illness.

Results of the first polling question indicated a range of care provision for individuals with co-morbid cardiometabolic illness:

In your experience, what percentage of patients with serious mental illness have been diagnosed with a comorbid cardiometabolic illness?

  1. 10% or less (2%)
  2. 11% to 25% (6%)
  3. 26% to 50% (47%)
  4. 51% to 75% (32%)
  5. Greater than 75% (11%)

The presenters discussed the challenges that schizophrenia can pose to physical and mental wellness, including: preventable risks of morbidity and mortality of schizophrenia (smoking, obesity, hypertension, diabetes, dyslipidemia) which exceed that of the general population; as well as how these issues can be caused by treatments (e.g. side effects of medicine). Metabolic syndrome is very prevalent in people with schizophrenia, as high as 50% of those affected also have metabolic conditions. Wellness management is essential for patients with schizophrenia, it can benefit patients with symptom reduction, knowledge about lifestyle issues, and weight loss, to name a few. The presenters stressed the importance of involving different providers, and the patient and their caregivers themselves, in wellness management and keeping the patient informed, interested, and at the center of the program. However, some barriers to successful wellness management were acknowledged, such as cognitive limitations, sedation, unstable mental state, and weight gain. The presenters engaged in a discussion of the various risk factors that potentially impact a patient’s overall health, including disease, lifestyle, genetics, and diet. They also noted how difficult it can be to untangle the relative contributions of these factors and suggested that a more useful conceptualization was modifiable and unmodifiable risk factors.

The next polling question focused on assessment for metabolic monitoring guidelines:

In your experience how many patients with serious mental illness are assessed according to metabolic monitoring guidelines in clinical practices?

  1. Less than 10% of patients (20%)
  2. 11% to 25% of patients (38%)
  3. 26% to 50% of patients (29%)
  4. Greater than 50% of patients (13%)

Drs. Correll and Manning interjected that regular metabolic monitoring is essential for this population. The Drs. addressed the lack of success in managing metabolic wellness in the mentally ill, despite the well-established knowledge of instance of co-morbidity. They then presented American Diabetes Association (ADA) / American Psychiatric Association (APA) guidelines for baseline assessments (for body mass index (BMI), waist circumference, blood pressure, and indicators for diabetes and high cholesterol) and demonstrated poor adherence to monitoring the guidelines. They agreed that the best practice for treating schizophrenia should include regular baseline evaluations every three months, with re-measuring if and when medications are switched.

Another study was cited which showed significant lack of pharmacologic interventions for hypertension, diabetes, and dyslipidemia in people with chronic schizophrenia; followed by a study on the effect of interventions to reduce coronary heart disease risk in people taking antipsychotics — smoking cessation was shown to have the largest effect, followed by active lifestyle, and maintaining a healthy weight. The Drs. also provided information on hypertension treatment from the Eighth Joint National Committee, Type 2 diabetes treatment for non-pregnant adults from the ADA, and treatment considerations by the National Lipid Association’s guidelines.

The question and answer session included these questions from the audience. The presenters’ responses are summarized below.

  • How can psychiatrists and physical health specialists best interact with one another?
    Dr. Manning stated that behavioral medicine providers should orchestrate and oversee a co-located model. When behavioral health and physical health “live together” it helps increase collaboration for care. In addition, he said, practitioners need to become advocates for practical policies and payment arrangements that allow integration and actual improvements in the quality of care received by consumers. Dr. Correll added that practitioners can also help patients by giving them resources and education.
  • How can barriers to optimal and proactive monitoring be overcome?
    Dr. Manning wondered if it was possible for a psychiatrist to include lab draw stations and have lab monitoring and ordering slips in an electronic record. He asked Dr. Correll how psychiatrists typically order baseline laboratories (through referral, nearby lab).
    Dr. Correll described a two-step process: first that these considerations and baseline labs need to be on psychiatrists’ minds as a quality indicator of their care and health indicator for their patient; secondly there needs to be a common process that individuals go through to get these baseline measurements to ensure they are given the assessments/labs. He mentioned that usually in mental health clinics, the labs would be ordered, but having slips or electronic health record reminders for monitoring would increase the likelihood of adherence to monitoring. Dr. Manning mentioned that the Healthcare Effectiveness Data and Information Set (HEDIS) guidelines still do not take into account the risk of severe mental illness and cardiovascular comorbidity.
  • How do we best motivate patients to participate in wellness programs?
    Dr. Manning stated that this is an ongoing conversation, but motivational interviewing helps them focus on addressing a patient’s own ambivalence. Introducing new information to patients can help motivate and self-actualize, but it has to be an “every time conversation.” Dr. Correll mentioned that finding the “carrot” for the patient, is an important step for the process – the question should be, “What could motivate them toward more participation?” He stated that self-monitoring methods are helpful as they allow the patient to see their real-time progress, which can be a motivation factor.

Metabolic wellness is an extremely important consideration in treating patients with schizophrenia, who have an increased incidence of cardiometabolic risk factors. In this webinar, Christoph Correll, MD and Sloan Manning, MD, discuss the importance of wellness for individuals with schizophrenia, review available guidelines, address the importance of monitoring and treating cardiometabolic risk factors, and explore successful wellness programs for patients with schizophrenia and serious mental illness.

Hear more from Christoph Correll, MD, and Sloan Manning, MD, as they respond to additional questions from attendees in this follow-up Q&A:

The federal Department of Housing and Urban Development (HUD) is planning to launch a pilot program to test a promising housing and services model for low-income adults age 65 and older, focused on helping these adults remain in their homes and avoid or delay the need for nursing home care. The demonstration, “Supportive Services Demonstration for Elderly Households in HUD-Assisted Multifamily Housing,” will offer three-year grants to eligible owners of HUD-assisted senior housing developments to cover the cost of a full-time enhanced service coordinator and a part-time wellness nurse. HUD released a notice of funding availability in January 2016, responses are due by April 18, 2016.

The demonstration is based on the Support and Services at Home (SASH) demonstration in Vermont. The model provides supportive living services to older adults in their homes.

The demonstration will be independently evaluated to determine the impact of the enhanced supportive services model on aging in place in HUD-assisted senior developments in terms of the following outcomes:

  • Avoiding early transitions to institutional care
  • Preventing unnecessary emergency room visits and hospitalizations for residents in HUD-assisted senior developments

The HUD Notice Of Funding Availability for “Supportive Services Demonstration for Elderly Households in HUD-Assisted Multifamily Housing” will provide up to $15 million in grants to subsidize supportive services. HUD seeks to test the effectiveness of Section 202 housing as a platform for improving access to home and community-based supportive services that are designed to promote general well-being, and improved health outcomes for older adults.

The new demonstration will take place in elderly restricted HUD assisted independent housing developments. Residents of the selected housing developments will be enrolled in a random assignment study. The supportive service subsidy will cover all reasonable cost related to the provision of a full-time enhanced service coordinator and part-time preventive health nurse as well as allocate a nominal amount towards eligible services expenses for the residents.

For more information, contact: Brian Sullivan, Public Affairs Supervisor, Office of Press Relations, U.S. Department of Housing and Urban Development, 451 7th Street, S.W., Room 10134, Washington, District of Columbia 20410; 202-708-0685, ext. 7527; Email:; Website:

CSC has launched a full-service chronic care management system that offers a technology-based approach for providers that are looking for technology to enable them to participate in the care management program developed by the Centers for Medicare and Medicaid Services last year. The offering from CSC is based on a similar service that the company launched in the United Kingdom last year; the Falls Church, Va.-based CSC named Reliance ACO as the first adopter of the system here.

The program enables providers to select from an array of services that can facilitate participation in the federal CCM program, including a patient outreach center; implementation of patient-centered care plans; care transition management; electronic collaboration and transmission of clinical documents, asynchronous communication and time tracking; dedicated medical assistants for each practice; behavioral engagement coaching; patient education; wellness training; community health; seamless integration and interoperability with EMRs; and enhanced mobile engagement with exception-based management.

This was reported by HealthData on April 4, 2016.

Contact Information: Rich Adamonis, Media Contact, CSC, 3170 Fairview Park Drive Falls Church, VA 22042; E-mail: ; Website:

On March 31, 2016, the U.S. Preventive Services Task Force posted a final research plan on behavioral and pharmacotherapy weight loss interventions to prevent obesity-related morbidity and mortality in adults. The draft research plan for this topic was posted for public comment from December 10, 2015 to January 13, 2016. The Task Force reviewed all of the comments that were submitted and took them into consideration as it finalized the research plan. To view the final research plan, please go to

This was reported by Agency for Healthcare Research and Quality on March 31, 2016.

Contact Information: U.S. Preventative Services Task Force, 5600 Fishers Lane, Mail Stop 06E53A, Rockville, Maryland 20857; 202-572-2044; Email:; Website:

A major new study funded by the Employee Assistance Research Foundation (EARF) has confirmed the effectiveness of Employee Assistance Programs (EAPs) to help employees address personal and work-related concerns which can negatively affect job performance. The study was conducted by Drs. Melissa Richmond and Ana P. Nunes of the OMNI Institute in Denver, CO and Dr. Fred Pampel, of the University of Colorado Boulder in partnership with the Colorado State Employee Assistance Program (C-SEAP). To demonstrate the value of EAPs, the researchers recruited a large survey population from Colorado state employees, included validated and objective measurement tools, and used a quasi-experimental design in which two groups (employee EAP users and non-users) were carefully matched and compared. The study findings indicate that employees receiving EAP services showed improved work functioning (reduced absenteeism and presenteeism) significantly more than a well-matched comparison group of employees not receiving EAP services.

This was reported by Business Wire on April 26, 2016.

Contact Information: Bob McLean, Media Contact, Employee Assistance Research Foundation, Post Office Box 3146, Norfolk, Virginia 23514-3146; 703-416-0060; Email:; Website:

Earlier this month, my colleague Athena Mandros discussed the relationship between education level and the management of chronic conditions – and the importance of consumer engagement to improving health outcomes (see Less Consumer Education Demands More Consumer Engagement). As we move into a more value-based market, there is an increased focus on consumer engagement – studies show that consumers who are engaged or “activated” in their care have lower health care costs and better outcomes. Health Affairs reports that consumers who are the least engaged have health costs averaging between eight percent and 21% higher than consumers who are highly engaged in their care (see “Health Policy Briefs: Patient Engagement” from Health Affairs). And countless other studies have demonstrated that consumer engagement strategies can result in better medication adherence (see “Nurse’s Notes: Patient engagement reduces harm related to medications” from Missoulian); reduced utilization of the emergency department (see “A New Twist on Emergency Department Utilization – An Innovative ED Outreach Program Using C&BI to Improve Population Health” from Healthcare Information and Management Systems Society); and lower readmission rates (see “Four Ways Hospitals Can Reduce Patient Readmissions” from Gallup).

Value-based care demands that payers and provider organizations think more holistically about care delivery – and a big part of that equation is consumer engagement. To discuss this idea in more detail, I spoke with OPEN MINDS senior associate Sharon Hicks. She noted that the transition to a new model of financing and service delivery means that provider organizations need to consider a new way of thinking about consumer relationships as our system evolves:

When it comes to value-based contracting, the biggest cultural change for provider organizations is taking a step back and thinking about care delivery on a holistic scale. We are used to earning revenue by providing a direct service to an individual consumer, so we think about our role in terms of individual transactions. Value-based payments make us take a step back and think about the health of our population as a whole. Under a value-based arrangement, it may be better for a provider organization’s bottom line to keep people out of the office. Initiatives like text message check-ins, email reminders, and telephone support are designed to help people to function in their real life – rather than only thinking about their care when they’re in the provider organization office. It’s about transitioning from being reactive to consumer needs, to being proactive. That’s a huge psychological change for provider organizations. At the heart of it, there is a goal of moving both the person receiving care and the person providing care into this idea of a holistic and wellness-focused approach to care.

We used to think about patient engagement in terms of how often a person shows up for service, but if we’re not in a transaction-based economy, then patient engagement is something much broader and bigger. It means engaging a consumer to be active in their own care and their own health and well being. Without that engagement, you still have the risk of someone being disconnected from the care environment. And being disconnected results in things like a consumer going to an ER when they don’t feel well because they have no relationship with their primary care doctor, and they don’t know who to call, or how to get a hold of someone to help after hours. The engagement component is really what the entire holistic model is dependent on. If a consumer is engaged as part of a care team, then they are thinking about their role and responsibilities as part of that team when they have a need – as opposed to thinking about themselves as a lone entity who is getting services from all these disconnected care providers.

We have to find a way to get people engaged. That engagement has to transcend just a call introduction from a care coordinator. That’s not engagement and that’s not population focused. Patient engagement in a holistic, population-focused model is about understanding the consumer and their issues and being able to anticipate their needs based on the data and knowledge that you have gathered from across the system.

What does this type of consumer engagement look like? Patient education, shared decisionmaking, more time with health care providers in office to answer questions, remote monitoring technologies, increased tech-enabled communication, consumer wellness incentives – these are all tactics that provider organizations are working with at the consumer level. And at the structural level, patient-centered medical homes, health homes, accountable care organizations (ACOs), and other care coordination models that focus on a holistic, population-focused approach to care are incentivizing increased engagement through value-based contracting.

After receiving services from an employee assistance program (EAP), employees had improved work functioning, in terms of reduced absenteeism and presenteeism, compared to a matched group of employees who did not seek or receive EAP services. Absenteeism among the EAP group dropped from a mean of 15.2 hours away from work due to a personal or work problem during the past 30 days to 10.7 hours. Among the comparison group, absenteeism increased from 13 hours during the past 30 days to 16.9 hours. Presenteeism was measured as a score based on five items assessing impact of personal/work problems on productivity.  Among the EAP group, presenteeism scores dropped from an average of 2.9 to 2.3. Among the comparison group, presenteeism scores dropped from 2.8 to 2.5.

These findings were reported in “The Impact of Employee Assistance Services on Workplace Outcomes: Results of a Prospective, Quasi-Experimental Study” by Melissa K. Richmond; Fred C. Pampel; Randi C. Wood; and Ana P. Nunes. The researchers recruited a large survey population from Colorado state employees and compared outcomes of a matched group of 156 EAP users to 188 non-EAP users. The goal was to determine the effect of EAP services on absenteeism (absent from work for part or all of a workday) and presenteeism (unproductive, but at work), and workplace distress. The researchers also sought to determine if outcomes differed as a function of baseline workplace outcomes, depression, anxiety, and hazardous alcohol use. The study participants from various departments were enrolled in three waves over a 10-month period between October 1, 2013, and July 31, 2014.

  • The researchers noted that the severity of issues did not influence program impact: EAP improved absenteeism and presenteeism equally well for individuals with varying levels of baseline productivity and alcohol use.
  • Workplace distress outcomes were not significantly different for the EAP and comparison groups. For the EAP group, workplace distress scores averaged 2.7 at baseline, and dropped to 2.4 at follow-up. For the comparison group, workplace distress scores dropped from 2.7 at baseline to 2.5 at follow-up.

The researchers said that their research design was rigorous enough to contribute to the evidence-base for EAPs. Because the findings demonstrated that EAP services are associated with improvements in worker productivity the researchers concluded that the findings support the business value of EAPs and suggest that workplace programs designed to provide individualized support to employees are a good investment for employers.

The full text of “The Impact of Employee Assistance Services on Workplace Outcomes: Results of a Prospective, Quasi-Experimental Study” was published in Journal of Occupational Health Psychology.

PsychU reported on this topic in “One-Fifth Of Private Health Plans Offer Employee Assistance Programs,” which published on April 23, 2015.

For more information, contact:

  • Melissa K. Richmond, PhD, Director of Research and Evaluation, OMNI Institute, 899 Logan Street, Suite 600, Denver, Colorado 80203. Email:; Website:
  • Bernie McCann, Ph.D., Development Consultant, Employee Assistance Research Foundation, 2001 Jefferson Davis Highway, Suite 100, Arlington, Virgnia 22202; Email:; Website:; or Bob McLean, Executive Officer, Employee Assistance Research Foundation, 2001 Jefferson Davis Highway, Suite 100, Arlington, Virgnia 22202; 703-416-0060; Email:; Website:

Key Messages

  • According to reports in the literature, ~40% of patients with a serious mental illness meet the National Cholesterol Education Panel-Adult Treatment Panel III guidelines for metabolic syndrome, and while a pharmacogenetics risk for metabolic syndrome has been suggested, poor diet and unhealthy lifestyle choices may also contribute.
  • In this study, patients with schizophrenia or bipolar disorder had higher rates of metabolic syndrome than matched subjects from the National Health and Nutrition Examination Survey (NHANES) 1999-2000 (hereafter referred to as the general population). No dietary or lifestyle differences were found between study patients with and without metabolic syndrome.

This summary was developed utilizing the full recorded presentation of this webinar, which is available on PsychU for all members free of charge. For full sourcing or polling results, please access the recording or the presentation slides at

On April 13, 2016, Ralph Aquila, MD, Medical Director of the Fountain House in NYC; and Robert Davis, MD, Medical Director of Family Services of Western Pennsylvania in Pittsburgh, PA provided their insight during a live PsychU webinar to discuss the complex definition of recovery and how they handle recovery in their practices. The speakers were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives for the webinar were to:

  • Discuss the evolving definition of recovery in mental illness, including schizophrenia
  • Understand the components of recovery in mental illness, and factors associated with them
  • Explore current recovery models in mental illness

Dr. Aquila noted the definition of recovery can vary but it is possible for all patients with mental illness to experience recovery. He pointed out that recovery is not the same as a cure; people with serious mental illness (SMI), such as schizophrenia, will likely have the condition for a lifetime but it is possible to have symptom remission and independent psychosocial functioning. He also stated that he often relies on each patient’s idea of recovery and he helps them to achieve it; what drives recovery is hope and expectations for better outcomes.

Continuing, the presentation focused on the components of recovery and the presenters provided an in-depth discussion of the multiple elements that are considered essential for recovery. For example, one of the most important aspects of recovery is for the consumer to take responsibility for his or her care by following and engaging in treatment plans. Other components include peer support, patient empowerment, and the fact that recovery is not a linear progression; consumers will experience success and setbacks. The presenters next focused on recovery for people with schizophrenia and what can be done to enhance the chances of recovery.

The issue of how to incorporate recovery into a treatment plan was discussed by the presenters who suggested that a wider range of referrals be utilized, such as peer support; additionally better reimbursement for psychiatric rehabilitation and other interventions would provide improved access to other opportunities for treatment. More training in residency programs regarding recovery from mental illness was on the “wish list” as well.

Dr. Aquila gave an overview of the Clubhouse Model at Fountain House, which provides a range of support programs for people with mental illness (social, health, education, employment). Members of the clubhouse all contribute in running the facility which builds confidence in the members and helps them to transition into the community. The Fountain House offers a robust transitional employment program for its members who are paid the prevailing wage by employers in the community.

Dr. Davis described the operation of Family Services of Western PA which caters to consumers with severe and persistent mental illness who want to regain a valued role in the community. The consumers receive help with new housing environments, education, volunteering or working, and gaining social skills needed in the community.

The question and answer session included these five questions from the audience. The presenters’ responses are summarized below.

  • How or what means are available to get inpatient facilities involved in recovery?
    Dr. Davis stated that helping the referral process, addressing medication and treatment adherence, and involving direct referrals to peer supports, supportive employment can help. Dr. Aquila agreed and added that the longer a patient is stable the better – this includes all types of supports. Communication channels need to be in place, as well as funding for rehabilitative programming.
  • How do you integrate wellness with recovery?
    Dr. Aquila stated that his clinic has been fully integrated since the year 2000. There was an understanding of need to look at medical comorbidities, but as a psychiatrist you need the support of primary care to be addressing all the needs of the patient. We also do a wellness unit within Fountain House to educate the patients themselves on nutrition, exercise, and wellness. Dr. Davis mentioned that his organization partners with a Federally Qualified Health Center (FQHC) and provide consultative care to primary care physicians, to help empower primary care, with the exception of referring out for more intensive psychiatric needs.
  • In your specific programs, do all members have to have housing to be involved or eligible for the program?
    Dr. Davis stated that housing is not a requirement, but this clinic tries to help individuals access stable housing since it has such a great effect on recovery outcomes. Dr. Aquila added that homelessness is a devastating event for any individual; for individuals with SMI homelessness becomes a real barrier to recovery and wellness.
  • For the Clubhouse Model, can you discuss the staffing model of the medical clinic?
    Dr. Aquila explained that the medical clinic is not within the Clubhouse – it is a distance away. Fountain House’s belief is that when individuals are within the Clubhouse, they are focused on strengths and life supports; The clinic is two floors: the first floor is for primary care, which is staffed with a primary care physician, registered nurse; the second floor is more for psychiatric services, and is staffed with psychiatrists who see individuals with serious mental illness exclusively. A Fountain House representative typically comes along with a member to their appointments at the medical clinic to help explain treatment options being presented among other items.
  • How do you handle patients whose decisions may not align with your recommended guidance for recovery?
    Dr. Davis stated that no one agrees 100%, but that they try to address the patient’s goals; for patients who can’t develop goals they work with the individual to develop therapeutic alignments and programming and hopefully something will click with the individual from those items. Developing rapport is a large part of this. Dr. Aquila emphasized that relationships are everything; even with individuals who are not doing well they are able to let their contacts know that they need additional supports to help guide them.

On February 22, 2016, the iThrive Initiative formed by the D.N. Batten Foundation and Centerstone Research Institute released a request for proposals (RFP) seeking project plans for electronic games that strengthen adolescent emotional well-being and empathy. Up to five projects may be selected to share $150,000 in financial support for further development. In addition to financial awards, iThrive will provide additional support resources including subject matter experts, detailed information on how to  apply empathy in games, how to measure empathy, a diverse network of adolescent playtesters, testing of the slices and mods, and important partnerships with leading academics in gaming and positive psychology.

The RFP provided examples of the three qualities “empathy games” tend to have: strong narrative, character interactions, and mechanics that change based on the player’s behavior. It noted that in the ideal context for character interactions, the characters work together to achieve a common goal, or the player has the ability to view the situation from more than one character’s point of view.

Game developers can propose new games or modifications for existing games. Proposals are due by April 22, 2016, and the iThrive Initiative anticipates making preliminary selections in May 2016; during June 2016, the selected game developers will present more details about their proposals during pitch meetings. The final selections will be announced in July 2016. Maximum funding for a game or app is $75,000. iThrive will provide clarifications and comments to developers whose proposals are not selected for this funding round so that they are prepared to participate future iThrive RFPs. Game developers worldwide can participate.

The iThrive Initiative is a charitable effort to facilitate the development of digital games and applications that promote emotional well-being among adolescents. iThrive seeks to foster a cooperative ecosystem bringing together game developers, subject matter experts, investors and donors, educators, researchers, youth, and youth organizations. Funding for iThrive has been provided by the D.N. Batten Foundation. iThrive founder Dorothy Batten said, “The unlimited interactive and creative environments found in digital games provide a unique opportunity to encourage adolescents to explore aspects of themselves. They can practice playing roles they may not have the opportunity or courage to do in their real lives, step into the shoes of others, develop new perspectives, find solutions to problems, and learn more effective ways of communicating and interacting with others.”

Centerstone Research Institute (CRI) is a non-profit organization is the research affiliate of Centerstone, a large non-profit community mental health provider organization. CRI provides research, analytics and evaluation services that help bridge the gap between the scientific discovery of effective treatments and the implementation of these treatments into standard clinical practice.

For more information, contact: Heidi McDonald, Creative Director, iThrive Initiative, Centerstone Research Institute, 44 Vantage Way, Suite 280, Nashville, Tennessee 37228; 615-463-6240; Email:; Website:

People diagnosed with serious mental illness (SMI) and other health risks related to metabolic disorder who participated in an integrated health care program called BE Well operated by a community mental health center (CMHC) were able to reduce their risk of developing metabolic disorder by losing weight, controlling blood sugar, reducing blood pressure, and reducing smoking. Six months after entering the BE Well program, the participants lost an average of 6.9 pounds. Among those who were at clinical risk of diabetes when they entered the program experienced an average reduction of 5% in their blood glucose levels, which reduced their risk to pre-diabetes.

These findings were reported in “Integrated Healthcare in a Community-Based Mental Health Center: A Longitudinal Study of Metabolic Risk Reduction” by John W. Putz, Ph.D.; Hillel E. Sapir, BA; Jonathan T. Macy, Ph.D.; Tovah E. Lieberman, MPH; Sarah E. Forster, BS; Michael Reece, Ph.D.; Kathryn A. Mathes, Ph.D.; Maren Sheese, MSW; J. Matthew Andry, M.D.; and Kathy A. Frasure, MSN. The researchers analyzed outcomes of the BE Well program developed by Centerstone, a large non-profit behavioral health provider organization. The BE Well program provides integrated physical and mental health care services at the CMHC site. For the two-year study, the researchers analyzed physical health data from a sample of 169 adults who participated in the BE Well program operated from January 2010 through August 2012 by an outpatient CMHC clinic located in south-central Indiana.

The BE Well program served individuals diagnosed with both SMI and at least one of five indicators of metabolic disease risk, including hypertension, obesity, diabetes, dyslipidemia, and/or tobacco use. The program’s clinical staff employed a licensed clinical social worker (the project director), a physician specializing in metabolic diseases, a family nurse-practitioner, two nurse care managers, a peer-support specialist/certified recovery specialist, a part-time wellness coach, and an office professional. Program evaluation services were provided by a co-located doctoral-level principal investigator, masters-level program evaluator, two research associates, and research technician interns.

When they were accepted into the program, each participant received a comprehensive physical health assessment from the physician or nurse-practitioner, was assigned a medical case manager, and was offered enrollment in individual and group wellness programming related to specific health risks, such as diabetes support, weight-loss support, tobacco cessation, physical activity instruction, stress management, chronic disease self-management, and/or peer-support. Measurements of physiological vital indicators were collected at baseline and then at least every six months, and blood- based markers were collected at baseline and again every six months.

Additional findings about the six-month outcomes were as follows:

  • Of the 93 overweight or obese participants, 67.7% lost weight, with the average weight loss of 6.9 pounds) and their glycated hemoglobin was reduced by 0.50%. Of those who lost weight, nearly one-third lost at least 5% of their baseline body weight, and more than 9% lost at least 10%.
  • For the 16 participants with high cholesterol, total cholesterol levels remained about the same, but their high-density lipoprotein increased and their low-density lipoprotein decreased.
  • For the participants who initially had high blood pressure, both systolic and diastolic blood pressure readings decreased.
  • Among the 52% who smoked at baseline, daily cigarette use declined by about 5 to 6 cigarettes each day. About 16% of smokers at baseline reported smoking zero cigarettes per day at the six-month follow-up.

The researchers concluded that the results indicate that provision of collaborative care integrated health services was associated with improvements in multiple markers of metabolic disease risk. They said the findings highlight the role of social work practitioners in improving the health status of persons living with SMI.

The full text of “Integrated Healthcare in a Community-Based Mental Health Center: A Longitudinal Study of Metabolic Risk Reduction” was published in January 2016 by Journal of Social Service Research.

For more information, contact: John W. Putz, Ph.D., Operations Manager, Research and Evaluation, Centerstone Research Institute, 44 Vantage Way, Suite 280, Nashville, Tennessee 37228; Website:

Apple has released a preview for the new version of iOS, 9.3, which will feature updates across a number of Apple’s own apps, including Health. Part of the update to Health will be a new slider menu that allows users to find third party apps to help them track certain metrics in Health. These slider menus will be available for a number of categories including weight, workouts, and sleep. When a user goes into the weight section, they will see suggestions to download apps like Calorie Counter, Lose It!, Health Mate, Mayo Clinic, and iHealth MyVitals. The Health app will also show the user their move, exercise, and stand data as well as their goals from the Apple Watch. The Apple Notes app also has a new health-related feature. In iOS 9.3 users will be able to store private information in Notes with a fingerprint or password protected lock on the data.

This was reported by mobihealth news on January 12, 2016.

Contact Information: Apple Incorporated, 1 Infinite Loop, Cupertino, California 95014; 408-974-2042; E-mail:; Website:

The University of Pittsburgh Medical Center (UPMC) and UPMC Health Plan have been selected as a Platinum winner of the 2015 Best Employers for Healthy Lifestyles awards by the National Business Group on Health (NBGH) for the sixth time since 2009. UPMC Health Plan and UPMC (combined as a joint entry) was one of 26 companies in the nation to earn the Platinum award, which recognizes outstanding programs that promote healthy work environments and encourage workers to live healthier lifestyles. UPMC and UPMC Health Plan were selected by NBGH for “exemplary workplace well-being initiatives” that are offered through their UPMC MyHealth program, which is designed to maintain and advance the health, productivity, and quality of life of employees while reducing their incidence of health risks and the cost of those risks to their employer. The primary goal of the Best Employers for Healthy Lifestyles awards is to encourage all employers to take action and respond to the urgent need to improve their employees’ health.

This was reported by PR Newswire on June 17, 2015.

Contact Information: Gina Pferdehirt, Director, Public Relations & Community Relations, UPMC Health Plan, U.S. Steel Tower, 600 Grant Street, Pittsburgh, PA 15219; 412-454-4953; E-mail:; Website:

Whitemarsh Behavioral Health Care in Lafayette Hill announced the recent addition of Rebecca Rogers, M.A., R.D., and L.D.N. As a registered dietitian with over 10 years of experience in nutrition and wellness, Rogers will provide a wide range of nutrition therapy services to Montgomery County residents. Rogers is a graduate of Drexel University and holds her B.A. in Nutrition and an M.A. in Counseling Psychology from Arcadia University.

Whitemarsh Behavioral Health Care was established as a family practice in Montgomery County, PA in 1976. Since then, WHBC has been providing quality mental health services in Montgomery County PA to individuals of all ages, couples, and families for well over 30 years. Their team of diverse, well trained therapists and psychologists are equipped to assess and treat a large variety of mental health disorders and provide interactive, dynamic relationship management.

This was reported by Digital Journal on December 24, 2015.

Contact Information: Emma Nash, Public Relations Manager, Whitemarsh Behavioral Health Care, 600 Germantown Pike, Lafayette Hill, Pennsylvania 19444; 610-825-4450; E-mail:; Website:

With the longer careers of current “knowledge worker” executives (see How “Fit” Is Your Executive Athlete?), what do executives do to prepare? Answering the question of executive athlete performance was the focus of Carmella Sebastian, M.D. in her plenary session, “Leaders As Executive Athletes: Training To Take Your Performance To The Next Level”, today at the 2015 OPEN MINDS Executive Leadership Retreat.

To sustain high executive performance in the face of ever-increasing pressure and rapid change requires personal executive resilience that is not just mental but also encompasses physical and psychological dimensions. Jim Loehr and Tony Schwartz, in their Harvard Business Review article, “The Making of a Corporate Athlete”, described this as the executive performance pyramid – the physical, emotional, mental, and spiritual energy and capacity for the executive.

There has been much coverage of the negative health effects of sitting too much – “Sitting Disease: Moving Your Way to a Healthier Heart” from US News and “Even With Low BMI, Sitting Linked to Fatty Liver Disease” from Medscape.  And coverage of the impact of stress on executive health is frequent – “BMW chief’s collapse highlights executive stress” from Financial Times and “Executive Stress: Leaders Under Pressure” from The Chartered Management Institute. Dr. Sebastian presented the compelling data on the importance of these domains to executive performance – and the challenges to executive health. She stressed the need for executives to “train” like a physical athlete, in order to align their energy (physical, emotional, mental and spiritual). In particular, the concept of periodization – alternating specific times of stress and specific times of rest to promote recovery and, with recovery, growth in the capacity to work and endure stress.

The one point that really made me think – there is a big range of people, activities, and situations that drain our energy as executives. Her point was that no matter the reason we expend our personal energy, that energy is gone and needs to be replaced. And that “reason” can be productive or not – the new strategy, the proposal deadline, the poor-performing team, a negative staff member, troubling personal relationships, and financial problems are but a few. As I thought about this concept, I also thought about how often we in the health and human service field talk about “recovery” of the consumers we serve, but we rarely focus on the concept in the context of our executive teams. It is apparent that we need to do more of the latter to make sure we have the energy for the former.

In 2014, about 16.8% of all adults in the United States smoked cigarettes, but among adults with disabilities or functional limitations, the prevalence was elevated to 21.9%. Comparatively, among adults without disabilities or functional limitations, smoking prevalence was 16.1%. The smoking prevalence rate was also higher than the nationwide average among several other demographic groups: adults age 25 and older with a General Education Development certificate (43.0%); American Indian/Alaskan Natives (29.2%); multiracial adults (27.9%); lesbian, gay, or bisexual adults (23.9%); people living in the Midwest (20.7%); and adults ages 25 to 44 (20%).

These findings were reported in “Current Cigarette Smoking Among Adults — United States, 2005–2014” by Ahmed Jamal, MBBS; David M. Homa, Ph.D.; Erin O’Connor, MS; Stephen D. Babb, MPH; Ralph S. Caraballo, Ph.D.; Tushar Singh, Ph.D.; S. Sean Hu, DrPH; and Brian A. King, Ph.D. The researchers analyzed smoking prevalence data from the 2014 National Health Interview Survey (NHIS) for adults aged 18 and older. People responding to the NHIS are considered as disabled if they report having selected impairments including vision, hearing, cognition, and movement. Limitations in performing activities of daily living defined based on response to the question, “Because of a physical, mental, or emotional problem, does [person] need the help of other persons with personal care needs, such as eating, bathing, dressing, or getting around inside this home?” Limitations in performing instrumental activities of daily living were defined based on response to the question, “Because of a physical, mental, or emotional problem, does [person] need the help of other persons in handling routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?” Any disability/limitation was defined as a “yes” response pertaining to at least one of the disabilities/limitations listed (i.e., vision, hearing, cognition, movement, activities of daily living, or instrumental activities of daily living).

The analysis reported trends in smoking prevalence between 2005 and 2014. Over the decade, the prevalence has declined from 20.9% in 2005 to the current 16.8% in 2014. The number of smokers each year declined from 45.1 million people in 2005 to 40.0 million people in 2014. The number of daily smokers also declined, from 36.4 million (80.8% of all smokers) in 2005, to 30.7 million (76.8%), in 2014. In both years, about 22% of adults were former cigarette smokers.

In 2014, smoking status varied by source of health insurance, with the highest rates among people insured by Medicaid-only (29.1%; about 5.5 million people) and people who were uninsured (27.9%; about 8.8 million people). Smoking prevalence was lower among people insured by private health insurance (12.9%; about 19.6 million people) and people insured by Medicare-only (12.5%; about 2.3 million people). Among those covered by Medicaid only, prevalence were higher among adults aged 25–44 years (35.6%) and those aged 45–64 years (29.7%) than among those aged 18–24 years (18.2%) (Figure 2).

The full text of “Current Cigarette Smoking Among Adults — United States, 2005–2014” was published in the November 13, 2015 issue of the Morbidity and Mortality Weekly Report. The full issue of the Morbidity and Mortality Weekly Report is maintained online at (accessed December 10, 2015).

For more information, contact: Media Relations, Centers for Disease Control & Prevention, 1600 Clifton Road, Atlanta, Georgia 30333; 404-639-3286; Fax: 404-639-7394; E-mail:; Website:

Key Messages

  • Metabolic abnormalities are common among patients with schizophrenia. Alterations in certain metabolic traits may be associated with different subgroups of patients and may reflect particular pathophysiological processes taking place.
  • Multiple regression analyses were used to investigate possible relationships between baseline Positive and Negative Syndrome Scale (PANSS) scores and changes in metabolic traits of patients with chronic schizophrenia. Several significant correlations were identified:
    • Body mass index (BMI) was negatively correlated with total PANSS score (estimate –0.05; standard error [SE] 0.01; p < 0.001), and with scores for positive (estimate –0.08; SE 0.04; p = 0.037) and negative syndromes (estimate –0.10; SE 0.02; p < 0.001) and general psychopathology (estimate –0.07; SE 0.02; p = 0.003).
    • Triglyceride (TG) levels were negatively correlated with total PANSS score (estimate –0.60; SE 0.22; p = 0.007) and negative syndrome score (estimate
      –1.74; SE 0.46; p < 0.001).
    • High-density lipoprotein cholesterol (HDLC) was positively associated with negative syndrome score (estimate 0.21; SE 0.07; p = 0.004).
  • Patients with severe negative symptoms of schizophrenia may have a distinct lipid pathophysiology associated with altered levels of TG and HDLC. More research may help to determine whether a different treatment approach could benefit these patients.

The Los Angeles County Department of Mental Health (LACDMH) and Tarzana Treatment Centers, Inc. (TTC) have launched a groundbreaking initiative that allows behavioral health clinicians and primary care physicians to safely and securely share vital, authorized client and patient data in real time – often at co-located facilities – to treat the mind and body. The program is a component of the county’s Health Neighborhoods project, which recognizes that multi-agency change models are most effective at improving population-level health and wellness outcomes.

In this new integrated care initiative, behavioral health clinicians at LACDMH’s San Fernando Mental Health Center (SFMHC) will have access to electronic health record (EHR) data about TTC’s clients’ co-occurring physical health conditions and medications. Likewise, TTC will receive EHR data from SFMHC. According to data from the Substance Abuse and Mental Health Services Administration (SAMHSA), as many as 70% of patients with severe mental illnesses served by the public mental system have co-morbid medical conditions such as heart disease, diabetes, asthma and COPD. Behavioral health clinicians are an integral part of “whole person” care, and need access to complete information to make informed treatment decisions.

In addition, primary care clinicians will have access to authorized EHR-based behavioral health and addiction treatment information, providing a more complete view of the person’s overall health status.

“By breaking down the silos that exist between mental health, physical health and addiction treatment services, we can reach our goal of improving the full health and well-being of our residents,” said Robin C. Kay, Ph.D., chief deputy director for the Los Angeles County Department of Mental Health.

All data is exchanged electronically between TTC and LACDMH in a protected manner in a standard CCD (Continuity of Care Document). However, the system also allows for inclusion of a patient narrative, giving clinicians the ability to communicate even more context than the structured data communicated in the CCD.

The data exchange and integration is facilitated by the Netsmart CareConnect care coordination solution, and includes the ability for the providers to do in-depth referrals for improved continuity of care, conduct ongoing treatment monitoring, and receive emergency alerts for situations such as a failure to take prescribed medications.

“Netsmart is excited to partner with the Los Angeles County Department of Mental Health and Tarzana to enable holistic health and wellness by effective data sharing and transition of care among all providers,” said Netsmart CEO Mike Valentine. “This care coordination initiative is designed to improve outcomes, reduce health-related costs and more deeply engage consumers.”

Both LACDMH and TTC have long-utilized Netsmart’s myAvatar CareRecord (electronic health record). Netsmart is also LACDHMH’s technology partner for IBHIS, the county’s comprehensive behavioral health clinical, administrative and financial information system.

TTC is offering primary care services at the SFMHC twice weekly to enable real-time treatment of mind and body. In addition, 24/7 referrals have been enabled from SFMHC to other services, including TTC’s substance use disorder treatment services. TTC operates seven primary care clinics which are also linked to SFMHC via CareConnect.

“You can’t properly address someone’s mental health if they’re not physically well,” explained Albert Senella, CEO and President of Tarzana Treatment Centers. “Likewise, mental health is directly linked to effectively managing physical wellness.”

The integrated care program is made possible by a Primary and Behavioral Health Care Integration (PBHCI) grant from SAMHSA. The objective of the PBHCI grant is to enhance the consumer experience of care (including quality, access, and reliability) while reducing/controlling the per capital cost of care. Results – including symptoms reduction, patient engagement rates, and costs of care – are being tracked in the Netsmart CareRecord and will be reported to SAMHSA twice a year.


The Los Angeles County Department of Mental Health is the largest county-operated mental health department in the United States, directly operating programs in more than 85 sites, and providing services via contract programs and DMH staff at approximately 300 sites many of which are co-located with other County departments, schools, courts and other organizations. Each year, the County contracts with more than 1,000 organizations and individual practitioners to provide a variety of mental health-related services.

On average, more than 250,000 County residents of all ages are served every year. The Department’s mission — enriching lives through partnership to strengthen our community’s capacity to support recovery and resiliency – is accomplished by working with stakeholders and community partners to provide clinically competent, culturally sensitive and linguistically appropriate mental health services to clients in the least restrictive setting.

About Tarzana Treatment Centers, Inc.

Tarzana Treatment Centers, Inc. is a full-service behavioral healthcare organization that provides high quality, cost-effective substance abuse and mental health treatment to adults and youth. We are a non-profit, community-based organization that operates a psychiatric hospital, residential and outpatient alcohol and drug treatment centers and family medical clinics. All facilities are licensed and certified by the State of California and the County of Los Angeles and are accredited by the Joint Commission. Since 1972, we have provided a comprehensive continuum of healthcare services.

About Netsmart

Netsmart is healthcare’s largest post-acute electronic health record (EHR) provider, and is committed to helping health and human services providers deliver coordinated, integrated, outcomes-based services and care. Netsmart serves more than 20,000 clients across all 50 states, resulting in approximately 450,000 users of its software and technology solutions. Netsmart clients include mental health and addiction services agencies, health homes, psychiatric hospitals, private and group mental health practices, public health departments, social services and child and family services agencies, managed care organizations, and vital records offices.

Netsmart’s CareFabric, a framework of innovative clinical and business solutions and services, supports integrated, coordinated delivery of health services across the spectrum of care.

Netsmart’s HIT Value Model, a vendor-agnostic planning and measurement system, provides a path for health and human services organizations to evaluate where on the healthcare IT spectrum they should focus their efforts, the value associated with that strategic decision and a comparison with peer organizations nationwide.

This was reported by Netsmart on September 15, 2015.

Contact Information: Kevin Allen, Senior Writer/Editor, Netsmart Technologies, 4950 College Boulevard, Overland Park, KS 66211; 913-226-5887; E-mail:; Website:

Key Messages

  • Inflammation has been implicated in the etiology of major depressive disorder (MDD).
  • Article evaluates rates of elevated inflammation among individuals with MDD.
  • This analysis highlights the prevalence of inflammation seen in patients with MDD and the links to significant metabolic burden such as metabolic syndrome (MetS).
  • Presence of inflammation may be a distinct subtype of MDD, warranting a targeted treatment approach.

Adults who had long-term low physical activity levels over 25 years and who watched four or more hours of television per day were twice as likely at mid-life to have worse cognitive function than people who exercised more and watched less television. For those who had low physical activity and watched more television, executive function and processing speed at mid-life were both impaired, indicating that higher levels of physical activity and a less sedentary lifestyle in early adulthood may have a preventive effect on cognitive aging.

These findings were reported in “Early Adult Patterns of Physical Activity and Television Watching and Mid-Life Cognitive Function” by Tina Hoang, MSPH; Kristine Yaffe, M.D.; and colleagues. The findings were presented in a session at the 2015 Alzheimer’s Association International Conference. The authors analyzed the association of long-term patterns of low physical activity and high television viewing among 3,247 adults over 25 years with cognitive function. The study participants were between age 18 and 30 when they enrolled between 1985 and 1986 in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Over the 25-year study, their physical activity levels and television viewing habits were assessed at least three times. Low physical activity was defined engaging activities that burned less than 300 calories in a 50-minute session, three times per week or less. High television viewing was defined as watching more than four hours per day. At the end of the 25-year study, the researchers assessed cognitive function in terms of memory, executive function, and processing speed using the Digit Symbol Substitution Test (DSST), Stroop Interference Score, and Rey Auditory Verbal Learning Test (RAVLT), respectively Additional findings are as follows:

  • 17% of participants reported long-term low physical activity patterns; they were more than 1.5 times more likely to have low cognitive function than people who were more active.
  • 11% of participants reported high television viewing patterns; they were from 1.34 to 1.61 times more likely to have low cognitive function than people who watched less television.
  • 3% of participants reported both long-term low physical activity and high television viewing patterns; they were twice as likely to have poor cognitive function than people who were less sedentary.

The researchers concluded that a sedentary lifestyle in early and mid-adulthood raises the risk of poor cognitive function and later development of Alzheimer’s disease and other dementias. They said increasing physical activity levels and reducing sedentary behaviors beginning in early adulthood may have a significant public health impact by supporting healthy cognitive aging.

The 2015 AAIC session abstracts are posted online at (accessed August 20, 2015).

More information about the CARDIA study can be viewed online at (accessed August 20, 2015).

For more information, contact:

  • Tina Hoang, MSPH, Northern California Institute for Research and Education, The Veterns Health Research Institute, 4150 Clement Street, 151NC, San Francisco, California 94121-1545; 415-750-6954; Fax: 415-750-9358; E-mail:; Website:
  • Alzheimer’s Association, 255 North Michigan Avenue, Floor 17, Chicago, Illinois 60601-7633; 800-272-3900; E-mail:; Website:

On May 6, 2015, Sinfonía HealthCare Corporation announced that its subsidiary divisions SinfoníaRx and Sinfonía Family Services of Louisiana were launching a health and wellness program for employees of the New Orleans Public Belt Railroad (NOPBRR) in Louisiana. The contract was signed on May 1, 2015; the initial term runs through April 30, 2016, followed by up to five one-year extension terms. Sinfonía will receive a fixed rate payment of $800 per month to cover services provided for up to 200 NOPBRR employees during the month.

The program is designed to improve NOPBRR workplace morale, employee quality of life, optimize treatment of chronic illness, and ensure medication safety. Under the contract, Sinfonía Family Services of Louisiana will provide educational seminars and counseling services. SinfoníaRx will provide pharmacists who will provide body mass index screenings, blood pressure screenings, glucose screenings, medication therapy reviews, on-site vaccinations, and smoking cessation education and counseling.

On October 20, 2014, Sinfonía Family Services announced expansion plans in Louisiana and Maine. On November 19, 2014, the State of Louisiana certified Sinfonía Family Services of Louisiana to provide community-based mental health services at its Jefferson Parish location. The organization is certified to provide community psychiatric support and treatment, crisis intervention, outpatient therapy, and psychosocial rehabilitation services for adults and children. Sinfonía plans to provide community-based services in Jefferson Parish, New Orleans, and Lafayette. On December 4, Sinfonía announced it had acquired Quality Life Counseling, LLC in New Orleans; it provides outpatient counseling services to children, adults, families and couples in the New Orleans area.

Sinfonía HealthCare Corporation was founded in January 2013 by Fletcher McCusker, who was formerly chief executive officer with Providence Service Corporation. Initially, the company focused on home health care services. In July 2014, Sinfonía launched a behavioral health division called Sinfonía Family Services designed to provide integrated mental health, pharmacy, and primary care services. The company currently provides services to over 7.5 million covered patient lives.

For more information, contact: Sandy Mellor, Director of Community Relations, Sinfonia HealthCare Corporation, 1 East Toole, Tucson, Arizona 85701; 520-545-1102; E-mail:; Website:

Humana Inc. announced a partnership with the American Diabetes Association (ADA) to develop a consumer-centric diabetes curriculum and delivery model with the goal of helping slow the progression of diabetes through engaging educational information based on the organization’s standards of medical care. The goal of the collaboration is to use an adaptable and engaging evidence-based curriculum to help people with diabetes manage and live well with the disease. A core component of the delivery model will be community-based engagement that extends beyond the workshop in the form of support groups, digital tools, and peer-to-peer service to provide accessible support, education, and information for people with diabetes and their family members. Individuals with diabetes will also assist in the co-creation of the program to ensure it is relevant and practical at an individual level. It will be for both those who are newly diagnosed and also for those individuals who have long-standing diabetes.

This was reported by Business Wire on June 17, 2015.

Contact Information: Alex Kepnes, Corporate Media Relations, Humana Inc., 500 West Main Street, Louisville, KY 40202; (502) 580-2990; E-mail:; Website:

Employers have increased the financial incentives they offer workers to participate in wellness programs to a record $693 per employee average in 2015, up 16% over the $594 in incentives in 2014, and $430 in incentives in 2010. Of the 79% of employers who offer health improvement programs, companies that have more than 20,000 employees spent the most, averaging $878 per employee compared to $717 in 2014. Companies that had 5,000-20,000 employers spent $661 per employee in 2015, up from $493 in 2014.

The results were reported in the 2015 National Business Group on Health/Fidelity Investments’ Annual Employer-Sponsored Health & Well-being Survey, the latest in a series Fidelity and NBGH have conducted since 2009 to analyze the growth and design of corporate health improvement programs.

The three most popular incentive-based health improvement programs identified in the survey were biometric screenings (72% of employers plan to offer this program), health risk assessments (70%), and physical activity programs (54%). Only six percent of employers planned to use disincentives for not taking a health risk assessment, while five percent planned disincentives for not participating in biometric screening. No company planned disincentives for failure to participate in physical activity programs.

A copy of the 2015 National Business Group on Health/Fidelity Investments’ Annual Employer-Sponsored Health & Well-being Survey is available to NBGH members at (accessed April 15, 2015).

PsychU reported on this topic in “EEOC Alleges Employer-Sponsored Wellness Programs Violate ADA,” which published on March 9, 2015.

For more information, contact:

  • Ed Emerman, Media Contact for National Business Group on Health, 20 F Street NW, Suite 200, Washington, District of Columbia, 20001-6700; 609-275-5162; E-mail:; Website:
  • National Business Group on Health, 20 F Street NW, Suite 200, Washington, District of Columbia, 20001-6700; 202-558-3000; Fax: 202-628-9244; E-mail:; Website:

About 83% of health plans sold through the state and federally facilitated health insurance marketplaces fail to cover smoking cessation medications with no cost sharing or prior authorization needed, as required by the Patient Protection and Affordable Care Act (PPACA). The PPACA requires health plans to cover, without cost to the member or prior authorization, screening for tobacco use and for those who use tobacco products, at least two cessation attempts per year. Each covered cessation attempt must include at least four counseling sessions of at least 10 minutes and 90 days of treatment with tobacco cessation medications approved by the Food and Drug Administration (FDA). Only 17% of plan issuers were in full compliance.

The FDA has approved seven medications for smoking cessation. Three are available over-the-counter: nicotine gum, patches, and lozenges.

In five states—Arkansas, Hawaii, Mississippi, South Dakota and Vermont—none of the plan issuers listed all the tobacco cessation medications on their formularies. In 21 states, at least half of issuers listed all seven medications on their formularies. The single plan for West Virginia covered all seven medications.

These findings were reported in “State Health Insurance Marketplace Plans: New Opportunities to Help Smokers Quit” by researchers with the American Lung Association. For this report, between January 15 and February 11, 2015, the authors reviewed publicly posted marketplace plan pharmacy formularies to see which tobacco cessation medications were listed, and to gather information about cost sharing and prior authorization requirements. They assessed whether there was a direct link to each formulary provided on the marketplace website as a proxy for determining how easily consumers shopping for plans could find this information. The American Lung Association was unable to track coverage of the required tobacco cessation counseling because public links are not available to the documents that would note the coverage.

Additional findings were as follows:

  • Of the 252 issuers selling plans through the federal marketplace, 101 (40.1%) list all seven medications as covered on their formularies. Only 44 (17.5%) listed all seven tobacco cessation medications and indicated that none had cost-sharing.
  • Of the 96 issuers selling plans in state-run marketplaces, 43 (44.8%) listed all seven tobacco cessation medications as covered on formularies. Only 19 (19.8%) listed all seven tobacco cessation medications and indicated that none had cost-sharing.
  • Of the 348 issuers, 10.1% required prior authorization. The medications most commonly requiring prior authorization were nicotine inhalers and nicotine nasal spray.
  • In total, across the federal and state marketplaces, 60 of the 348 issuers (17.2%) listed all seven tobacco cessation medications and indicated that none had cost-sharing or prior authorization.

The authors noted that often the tobacco cessation medications were listed on tiered formularies, which did not clearly indicate that there were no cost sharing requirements for this specific class of medications. Prescription medications for tobacco cessation were listed on formularies more frequently than over-the-counter medications.

The full text of “State Health Insurance Marketplace Plans: New Opportunities to Help Smokers Quit” was published March 31, 2015 by the American Lung Association. A copy can be downloaded at

For more information, contact: American Lung Association, 55 W. Wacker Drive, Suite 1150, Chicago, Illinois 60601; 312-801-7628; E-mail:; or Allison MacMunn, National Director, Media Relations, American Lung Association, 55 W. Wacker Drive, Suite 1150, Chicago, Illinois 60601; 312-801-7628; E-mail:

The California Department of Public Health (CDPH) released a health advisory and state health officer’s report centered on the dangers of e-cigarettes. Former state health officer and director of the CDPH, Ron Chapman, MD, MPH said e-cigarettes threaten to erode 25 years of progress in tobacco cessation in California. Not only has the state’s tobacco control efforts resulted in the saving of 1 million lives and $134 billion in healthcare costs, he said, but California also has the second lowest adult smoking rate in the U.S. State data show that the use of e-cigarettes among teen and young adults is escalating, and the concern among state officials is that many users are unaware that they pose some of the same risks as traditional tobacco products.

According to state officials, despite the fact that e-cigarettes contain a solution called “e-juice” or “e-liquid” that releases a toxic nicotine-containing aerosol when heated up by the battery-operated devices, common misconceptions are that they contain harmless water vapor, will help smokers quit, and have FDA-approved ingredients. According to Chapman, e-liquids and the aerosol they emit have been found to contain at least 10 chemicals—including benzene, formaldehyde, lead, nickel and nicotine—on California’s list of chemicals known to cause cancer, birth defects and other reproductive harm. Chapman said the availability of e-cigarettes is growing in California, with the number of stores selling them increasing fivefold from 2011 through 2013. The CDPH is still in early stages of planning what’s to come in the remainder of its e-cigarette campaign.

This was reported by Addiction Professional on February 25, 2015.

Contact Information: Anita Gore, Deputy Director, Office of Public Affairs, California Department of Public Health, PO Box 997377, MS 0500, Sacramento, CA 95899; 440-7143; E-mail:; Website:

Key Messages

  • In patients with major depressive disorder (MDD), symptoms such as fatigue, sleep problems, and cognitive dysfunction often remain after remission of other core depressive symptoms.
  • Residual symptoms may hinder patients’ functional recovery and contribute to relapse.
  • Based on the findings presented in this review, the author advised that clinicians consider treating residual symptoms as target symptoms from baseline and making use of clinically practical screening instruments to monitor these target symptoms throughout treatment.

On April 16, 2015, the U.S. Equal Employment Opportunity Commission (EEOC) released a Notice of Proposed Rulemaking (NPRM) describing how Title I of the Americans with Disabilities Act (ADA) applies to employer wellness programs that are part of group health plans. The goal of the proposed rule is to protect against discrimination based on disability. The proposed rule provides guidance to both employers and employees about how wellness programs offered as part of an employer’s group health plan can comply with the ADA, but also be consistent with provisions governing wellness programs in the Health Insurance Portability and Accountability Act (HIPAA), as amended by the Patient Protection and Affordable Care Act (PPACA).

The programs addressed in the proposed rule are workplace wellness programs intended to encourage healthier lifestyles or prevent disease. These programs sometimes use health risk assessments and biometric screenings to determine an employee’s health risk factors, such as body weight and cholesterol, blood glucose, and blood pressure levels. Some of these programs offer financial and other incentives for employees who participate or achieve certain health outcomes.

The EEOC worked with the Departments of Labor, Health and Human Services, and Treasury to develop the proposed rule to align the ADA requirements that employer medical inquiries and exams be voluntary and HIPAA provision allowing incentives to encourage participation in wellness programs. Comments on the proposed rule will be accepted through June 19, 2015. Additional details are as follows:

  • The ADA limits the circumstances in which employers may ask employees about their health or require them to undergo medical examinations. The ADA does allow such inquiries and exams if they are voluntary and part of an employee health program.
  • The proposed rule requires that if an employee health program seeks information about employee health or medical examinations, the program must be reasonably likely to promote health or prevent disease. Employees may not be required to participate in a wellness program, and they may not be denied health coverage or disciplined if they refuse to participate.
  • Under the ADA companies may offer incentives of up to 30% of the total cost of employee-only coverage in connection with wellness programs. These programs can include medical examinations or questions about employees’ health (such as questions on a health risk assessment).
  • However, to comply with HIPAA, medical information collected as a part of a wellness program may be disclosed to employers only in aggregate form that does not reveal the employee’s identity, and must be kept confidential in accordance with ADA requirements. Additionally, employers may not subject employees to interference with their ADA rights, threats, intimidation, or coercion for refusing to participate in a wellness program or for failing to achieve certain health outcomes. Individuals with disabilities must be provided with reasonable accommodations that allow them to participate in wellness programs and to earn whatever incentive an employer offers.

OPEN MINDS last reported on this topic in “EEOC Alleges Employer-Sponsored Wellness Programs Violate ADA,” which published on March 9, 2015.

For more information, contact: Office of Communications, U.S. Equal Employment Opportunity Commission, 10 South Howard Street, Baltimore, Maryland 21201; 202-663-4191; E-mail:; Website:

Cardinal Innovations Healthcare Solutions launched a smoking cessation campaign called “Kick It” on January 5 to help people with mental illnesses and substance use disorders quit smoking. Cardinal Innovations partnered with QuitlineNC, which provides free cessation services to any North Carolina resident who needs help quitting tobacco use. QuitlineNC offers a free 24-hour hotline to support people who are trying to quit and links them to quit coaches to talk them through kicking the habit. QuitlineNC has a 40 percent success rate of helping people to quit smoking. Cardinal Innovations’ smoking cessation campaign encourages individuals who want to quit smoking to try QuitlineNC. The campaign includes search engine marketing and web pages about the effect smoking has on various mental illness diagnoses.

This was reported by Cardinal Innovations Healthcare Solutions on January 7, 2015.

Contact Information: Craig Hummel, M.D., Chief Medical Officer, Cardinal Innovations Healthcare Solutions, 4855 Milestone Avenue, Kannapolis, NC 28081; 704-939-7700; Website:

In 2011-2012, an estimated 40% of state and federal prisoners and local jail inmates reported having a current chronic medical condition, while 50% reported having a chronic medical condition at some time in the past. High blood pressure was the most common condition reported by both prisoners (30%) and jail inmates (26%), while the majority of prisoners (74%) and jail inmates (62%) were overweight, obese, or morbidly obese.

These findings were reported in “Medical Problems of State and Federal Prisoners and Jail Inmates, 2011–12” by Marcus Berzofsky, Dr. P.H., and Jennifer Unangst of RTI International, with Laura M. Maruschak, a statistician with the federal Bureau of Justice Statistics (BJS). The report uses data were from the 2011–12 National Inmate Survey, and presents the prevalence of medical problems among state and federal prisoners and jail inmates, describing health care services and treatment received by prisoners and jail inmates with health problems, including doctor’s visits, use of prescription medication, and other types of treatment. Additional finding included:

  1. Twenty-one percent of prisoners and 14% of jail inmates reported ever having tuberculosis, hepatitis B or C, or other STDs (excluding HIV or AIDS).
  2. About 66% of prisoners and 40% of jail inmates with a current chronic condition reported taking prescription medication.
  3. More than half of prisoners (56%) and jail inmates (51%) said that they were either very satisfied or somewhat satisfied with the health care services received since admission.

For more information, contact: Kara McCarthy, Public Affairs Specialist, Office of Justice Programs, U.S. Department of Justice, 810 Seventh Street NW, Washington, District of Columbia 20531; 202-307-1241; E-mail:; Website: or Charles W. Wagner, Media Contact, Office of Justice Programs, U.S. Department of Justice, 810 Seventh Street NW, Washington, District of Columbia 20531; 202-532-0037; E-mail:; Website:

The Blue Cross and Blue Shield (BCBS) Government-wide Service Benefit Plan, also known as the Federal Employee Program (FEP), partnered with AbilTo, Inc., the nation’s largest remote behavioral change therapy company, to offer certain federal employees access to innovative programs that empower FEP members to live healthier lives. AbilTo behavioral change therapies are delivered via phone and video consulting programs to people who are experiencing significant medical events to help them make lifestyle changes. FEP will now be able to offer AbilTo’s Cardiac, Diabetes, Momentum (postpartum), Renew (pain management) and General Depression programs to participating members of the FEP Program in Washington and Alaska, in its initial phase. Delivered by phone or secure video link, AbilTo’s programs have delivered results including a 50-65 percent reduction in the rate of depression (average) among graduates of all programs. These programs focus on coordinating patient care to keep chronic conditions in check, and have been shown to reduce unnecessary emergency room visits, hospital admissions and readmissions, and other costly medical interventions.

This was reported by PR Newswire on February 11, 2015.

Contact Information: Eric Lail, Media Contact, Blue Cross Blue Shield, 1310 G Street, N.W., Washington, DC 20005; 202-626-8625; E-mail:; Website:

About one-fifth of U.S. health plans offer an employee assistance program (EAP). In a survey of 389 private health plans, 72 plans reported that they had 200 insurance products that included an EAP. The 389 health plans reported that they had a total 939 insurance products.

Of the 72 health plans offering an EAP, 88% offered an EAP operated by a subsidiary and 12% offered an outside vendor’s EAP. About 57% of health plans offering an EAP required that purchasers pay additional fees rather than including the EAP without charge in standard packages.

These findings were reported in “Employee Assistance Programs in Private Health Plans: What Do They Offer?” by Elizabeth Merrick, Ph.D., M.S.W.; Dominic Hodgkin, Ph.D.; Constance Horgan, Sc.D.; and Amity Quinn, M.A. They analyzed data from a 2010 survey of 389 private health plans in 60 markets. The plans reported on behavioral health services in 939 insurance products.

The analysis included 200 products (from 72 plans) reporting EAPs. Additional findings are as follows:

  • 36% of health plans recommended that enrollees use the EAP before accessing behavioral health benefits.
  • 4% of health plans required that enrollees use the EAP before accessing behavioral health benefits.
  • 45% of health plans with EAPs covered clinical assessment.
  • Nearly all EAPs covered both in-person and telephone counseling.
  • EAPs limited the number of visits either annually, or per-problem. All products reporting per-year limits reported a limit of eight-sessions. Of products with per-problem limits, 78% had a five-session limit, and the remainder had a six-session limit.

The full text of “Employee Assistance Programs in Private Health Plans: What Do They Offer” was published in the March 2015 by Psychiatric Services.

For more information, contact: Elizabeth Merrick, Ph.D., Senior Scientist, Brandeis University, 415 South Street, Waltham, Massachusetts 02453; 781-736-3917; E-mail:; Website:; or Michele Hutcheon, Senior Department Coordinator, Brandeis University, 415 South Street, Waltham, Massachusetts 02454-9110; 781-736-3979; E-mail:; Website:

On January 12, 2015, Chestnut Global Partners (CGP) announced it had developed a Return On Investment (ROI) Calculator tool that enables employee assistance programs (EAPs) to show customers the internal rate of return and net present value of their EAP. The EAP ROI Calculator variables can be tailored to each company’s demographics, covered employees, industry, occupation, region, and utilization rates. The ROI estimates are based on baseline data derived from published studies and research, or for greater accuracy, the baseline data can be customized with actual client data. The calculator complements CGP’s Workplace Outcome Suite, a tool used by over 400 EAPs worldwide to measure the effects of their employee assistance and health coaching programs.

The ROI Calculator assesses the financial impact of the following factors:

  • Reduced productivity losses due to lower employee presenteeism and absenteeism rates
  • Reduced employee out-of-pocket expenses associated with visits to benefits-based provider organizations
  • Reduction in workplace accidents caused by employee distraction
  • Reduced costs associated with turnover (voluntary or involuntary due to performance issues), including replacement, relocation, retraining, and disability costs
  • Reduced medical costs of comorbid health conditions associated with stress

CGP’s Workplace Outcome Suite is a psychometrically tested and validated instrument designed to assess EAP effectiveness. On February 12, 2015, CGP released pooled results reported by 20 different EAPs that surveyed over 8,000 employees engaged with EAP services over a three-month period. The “Workplace Outcome Suite (WOS) 2014 Pooled WOS Results” reported findings in five key areas, as follows:

  • 55% reduction in work absenteeism—Average hours missed dropped by 55%, from 5.3 hours before EAP services to 2.38 hours 90-days after EAP services
  • 27% reduction in work presenteeism—Measured on a five-point Likert Scale ranging from strongly disagree to strongly agree to assess the degree to which employees feel that their personal problems interfered with concentrating at work. Before receiving EAP services, the average response across all employees surveyed was 3.28. The average score for this measure of presenteeism dropped to 2.39 in the 90 days after receiving EAP services.
  • 6.2% increase in work engagement—Measured on a five-point Likert Scale ranging from strongly disagree to strongly agree to assess the degree to which employees report they are eager to “get to the work site to start the day.” Before receiving EAP services, the average score was 3.23; 90 days after receiving EAP services, the average score increased to 3.43.
  • 13.6% reduction in workplace distress—Measured on a five-point Likert Scale ranging from strongly disagree to strongly agree to assess the degree to which employees report they dread going into work. Before receiving EAP services, the average score was 2.21; 90 days after receiving EAP services, the average score dropped to 1.91.
  • 22.6% improvement in life satisfaction—Measured on a five-point Likert Scale ranging from strongly disagree to strongly agree to assess the degree to which employees feel that their lives are “going very well.” Before receiving EAP services, the average score was 2.97; 90 days after receiving EAP services, the average score increased to 3.64.

Chestnut Global Partners (CGP) is a behavioral health organization based in Bloomington, Illinois that offers a full range of culturally aware employee assistance and related workplace services. CGP combines EAP with wellness, disability, high risk maternity, employee safety, and compliance management programs, designed to promote employee well-being, improve performance and reduce absenteeism. The CGP EAP ROI Calculator is available directly through web access and includes telephone support from CGP’s EAP and research analytics consultants. CGP anticipates finalizing pricing for the EAP ROI Calculator during March 2015. The WOS is free; copies can be downloaded at

For more information, contact: Matt Mollenhauer, Vice President, Chestnut Global Partners, 1003 Martin Luther King Drive, Bloomington, Illinois 61701; 800-433-7916; E-mail:; Website:

On November 1, 2014, Aetna Resources for Living began its fourth consecutive contract to provide an employee assistance program (EAP) for the City of Los Angeles Department of Water and Power (LADWP). The contract is valued at $1.3 million; it runs through October 31, 2017.

The LADWP released the request for proposals (RFP 20771) on July 31, 2014. The RFP sought bids for EAP services for 9,800 eligible employees, including: short-term individual counseling; Department of Transportation (DOT) substance abuse professional (SAP) evaluations; trauma/critical incident response; and management consulting. By the August 19, 2014 deadline, LADWP had received proposals from Health and Human Resource Center, Inc., which does business as Aetna Resources for Living; Optum; and MHN.

The contract with Aetna Resources for Living was authorized on October 21, 2014. LADWP will pay a per employee per month (PEPM) payment of $3.57. The rate includes eight voluntary counseling and assistance sessions, mandatory referrals, DOT/SAP evaluations, trauma/critical incident response, and training and education.

Health and Human Resource Center, Inc./Aetna was the incumbent to the contract. Its first contract with LADWP was awarded in 2005. In its proposal, Aetna noted that it has over 16 million EAP covered members, with 948,000 members in California alone through contracts with 20 cities and counties. Aetna’s legacy EAP Company, Horizon, has more than three decades of experience in the EAP market. Horizon became part of Aetna in 2009.

For more information, contact:

  • Peggy Wagner, President, Aetna Resources for Living, 10260 Meanley Drive, San Diego, California 92131; 619-610-3964; E-mail:; Website:
  • Erin Lawrence, Utility Buyer, Los Angeles Department of Water and Power, 111 North Hope Street, Room 538, Los Angeles, California 90012; 213-367-2586; E-mail:; Website:

Key Messages

  • Individuals with serious mental illness (SMI) are at increased risk of metabolic disturbances, and existing lifestyle modification programs have reported modest results.
  • This study assessed the impact of STRIDE, a comprehensive lifestyle intervention for individuals taking antipsychotic medications, on outcomes such as body weight, blood glucose, and hospitalization rates, as compared to usual care.
  • The findings of this study suggest that it is possible for individuals with SMI taking antipsychotic medications to lose significant weight and improve fasting glucose levels through a comprehensive, tailored weight loss and lifestyle change program.

Since August 2014, the federal Equal Employment Opportunity Commission (EEOC) has sued three employers alleging that their employer-sponsored wellness programs discriminate against individuals with disabilities. The three employers are Orion Energy; Flambeau, Inc.; and Honeywell International. Each of the employers used financial incentives to reward participation in the wellness program; to penalize non-participation; and in some cases, required biometric testing and health risk assessments of spouses covered by the employer health plan. The EEOC said the design of the wellness programs violated the Americans with Disabilities Act (ADA) by imposing a non-participation financial penalty so significant as to make participation mandatory, and those that required biometric testing of spouses violated the Genetic Information Nondiscrimination Act (GINA). The EEOC lawsuits are ongoing.

The Patient Protection and Affordable Care Act of 2010 (PPACA) allows employers to give employees up to a 30% discount on premiums for their health insurance benefits if the employee participates in wellness programs to maintain healthy weight or reduce high cholesterol levels. However, the PPACA also set the following requirements on wellness programs:

  • The programs cannot discriminate. Employers must make the programs available to all employees and must provide a reasonable alternative if an employee cannot complete the program’s standard requirements.
  • The programs must be designed to promote health. The financial reward must be linked to health promotion activities, not better job performance.
  • All employees should have a chance to participate annually. Participation could include only a questionnaire completed by the employees about themselves and their family medical history, or could include a basic health screening of vital signs, such as weight, temperature, blood pressure, or could also include lab tests for cholesterol levels or diabetes. The information is to be used as a baseline.

The EEOC activity and its effect on employee wellness programs were the topic of a January 29, 2015 hearing by the U.S. Senate Committee on Health, Education, Labor & Pensions (HELP). The HELP Committee Chairman, Senator Lamar Alexander (R-Tennessee) said the EEOC legal actions against employer-sponsored wellness programs may discourage employers from using a tool authorized in the Patient Protection and Affordable Care Act of 2010 (PPACA) to lower employee health care costs. The majority of employers offer some sort of wellness program—94% of employers with over 200 workers and 63% of smaller employers.

In May 2014, the EEOC said it was developing guidance for employers regarding wellness programs and the ADA and GINA, but as of February 20, 2015, the guidance had not yet been released. However, an EEOC spokesperson said the Commission is scrutinizing employer-sponsored employee wellness programs in light of the ADA and GINA, as well as employers’ use of financial incentives. The specifics of the three lawsuits are as follows:

  • Orion Energy—On August 20, 2014, the EEOC sued Orion Energy because its wellness program imposed penalties that were so steep as to make the program involuntary. An employee was required to submit to medical exams and disability-related inquires that were not job-related. The employee declined to participate. Orion shifted responsibility for the entire health insurance premium to the employee. The employee protested, and was fired for objecting to the exams and inquiries. The EEOC said the program was not voluntary because the penalty for non-participation was shifting 100% of the health insurance premium cost to the employee, or possibly termination.
  • Flambeau, Inc.—On October 1, 2014, the EEOC sued Flambeau, Inc. because its wellness program required employees to submit to biometric testing and a health risk assessment. Failure to participate could result in cancellation of medical insurance or an unspecified “disciplinary action” and responsibility for the entire health insurance premium. Employees who completed the biometric testing and health risk assessment paid only 25% of the premium cost. The EEOC said the biometric testing requirement and health risk assessment constituted “disability-related inquiries and medical examinations” that were not job related, as defined in the ADA.
  • Honeywell International—On October 27, 2014, the EEOC sued Honeywell International seeking to stop Honeywell from imposing surcharges on employees who refuse to submit to biometric testing as part of its wellness program. The EEOC said the testing violates the ADA and GINA. Honeywell’s employee wellness program requires employees, and spouses of employees with family coverage to under go biometric screening and a blood draw. The employees and their spouses would be screened for blood pressure, cholesterol, glucose, height, weight, and waist circumference. They would also be checked for nicotine or cotinine. If an employee or the employee’s spouse does not take the biometric test, the employee can be penalized up to a total of $4,000 via a loss of $1,500 in health savings account (HSA) contributions from Honeywell; a $500 surcharge applied to the employee’s medical plan costs; and a $1,000 “tobacco surcharge” for choosing to not go through biometric testing, even if for reasons other than smoking; and another $1,000 “tobacco surcharge” for the spouse’s non-participation in biometric testing, even if for reasons other than smoking. The EEOC said the biometric testing violates the ADA because it is not job-related or consistent with business necessity. Medical testing that is not job-related or consistent with business necessity does not violate the ADA if it is voluntary. In this case, the EEOC claimed that the testing was not voluntary due to the penalties imposed for nonparticipation. The EEOC said the requirements violated GINA by requiring employees’ spouses to undergo medical testing to prevent the employee from being penalized. The EEOC claimed that Honeywell is offering an inducement to employees to acquire genetic information in violation of GINA.

For more information, contact:

  • Office of Communications, Equal Employment Opportunity Commission, 1801 L Street, N.W., Washington, District of Columbia 20507; 800-669-4000; E-mail:; Website:; or Office of Communications, Equal Employment Opportunity Commission, 1801 L Street, N.W., Washington, District of Columbia 20507; 202-663-4191; E-mail:; Website:
  • Margaret Atkinson, Press Secretary, Senate Health, Education, Labor and Pensions Committee, 428 Dirksen, Washington, District of Columbia 20510; 202-224-5375; E-mail:; Website:

On February 2, 2015, The Gerontological Society of America recommended strategies for increasing Alzheimer’s detection rates by including brief cognitive impairment assessments in primary care Medicare Annual Wellness Visits (AWV). The rationale for focusing on the AWV is that the visits are available to all older Americans insured by the Medicare Part B program, and that due to the age-associated nature of dementia-related disorders, the Medicare population is most likely to benefit from increased detection of cognitive impairment and earlier diagnosis of dementia.

The Gerontological Society of America’s Workgroup on Cognitive Impairment Detection and Earlier Diagnosis report outlines a way to increase the use of cognitive asssessment in the Medicare AWV. The outline includes four steps, as follows:

  1. The primary care professional asks if the patient is experiencing memory problems or cognitive problems and observes the patient during the visit to identify clinical signs or symptoms.
  2. For symptomatic patients, the primary care profesisonal uses an evidence-based assessment tool to detect cognitive impairment.
  3. For patients with cognitive impairment the primary care professional rules out reversible causes, and conducts or refers the patient for a full diagnostic evaluation.
  4. Upon making a diagnosis, the primary care professional or specialist develops a care plan and refers the patient and family to community resources and clinical trials.

The goal of the four-step process is to give the patient and family earlier access to diagnosis and care planning in the event that the cognitive impairment is not reversible. Primary care professionals should document the results of the assessment process in the patient’s medical record. The specific assessment tool used and the patient’s score should be documented. If cognitive impairment is not assessed during the Medicare AWV, the primary care professional should note why.

For more information, contact: Todd Kluss, Communications Manager, The Gerontological Society of America, 1220 L Street NW, Suite 901, Washington, District of Columbia 20005; 202-587-2839; E-mail:; Website:

On January 20, 2015, Magellan Healthcare, Inc. started a contract valued at up to $71 million to provide an employee assistance program (EAP) and work/life program services for the U.S. Department of Health and Human Services (HHS), Federal Occupational Health Service. The five-year contract runs through January 19, 2020.

The Federal Occupational Health Service (FOH) released the request for proposals (RFP 13-233-SOL-00185) on June 21, 2013, and proposals were due by August 7, 2013. The FOH sought a single contractor to provide the EAP services and the work/life program services. For the 2007 procurement cycle, the services were split. Magellan was awarded the EAP contract on a cost-plus-fixed-fee basis. LifeCare was awarded the work/life program contract on a firm-fixed price basis. Magellan has provided EAP services for FOH since 2000. The awards notice was posted on January 20, 2015, and did not report the names of other bidders or  mention how many proposals were submitted.

The EAP and work/life services under this new contract will be provided for departments, agencies, and other organizational components with the Federal Government when they enter into inter-agency agreements with FOH. EAP and work/life services are to be provided for agency employees and their family members worldwide. In the procurement, FOH said it had approximately 475 inter-agency agreements with various government departments and independent agencies.

The EAP portion of the contract includes in-person, telephonic, and online consultation and problem solving for a wide range of personal, wellness, and work/life concerns. The contractor shall provide educational and motivational activities; referral, monitoring, and follow-up services; behavioral health consultation and coaching; short-term problem-focused counseling for employees and specified family members; crisis intervention; and management consultation and support.

The work/life portion of the contract includes services for work and life events, including adoption, becoming a parent, newborn care, child care, elder care, college and technical schools, relocation, career development, financial planning, legal assistance, convenience services, retirement planning, and other services for adults with disabilities and illnesses. Services shall be accessible 24 hours a day, 7 days a week, 365 days a year, and include a 24-hour service center, and interactive, web-based resources.

The contract is structured as an indefinite delivery, indefinite quantity (IDIQ) type, with a minimum annual value of $1,000. IDIQ contracts provide for an indefinite quantity of services to be provided at a fixed cost for a fixed period of time. The federal government uses IDIQ contracts when it is not possible to determine, above a specified minimum, the precise quantities of supplies or services that the government will require during the contract period. For the FOH EAP and work/life services contract, the number of covered lives will vary with the number of inter-agency agreements  to use the FOH contractor.

For more information, contact:

  • Laura Schuntermann, Vice President of Marketing, Magellan Health, 55 Nod Road, Avon, Connecticut 06001; 860-507-1922; E-mail:; Website:
  • Federal Occupational Health Service, U.S. Department of Health and Human Services, 7475 Wisconsin Avenue, Suite 700, Bethesda, Maryland 20814; 301-492-5410; Website: and

Bettie Hartley, Contact Point for RFP 13-233-SOL-00185, U.S. Department of Health and Human Services, 12501 Ardennes Avenue, Suite 400, Rockville, Maryland 20857; 301-443-7848; E-mail:; Website:

One Feather Consulting, a provider of employee assistance (EAP) and disease management services to Native Nations and the Indian gaming industry, announced in January a community wide substance abuse condition management program for the Seneca Nation of Indians. One Feather will provide the Seneca Nation of Indians community with access to its telephonic assessment, coaching, support, and referral while proactively engaging “at-risk” members. The Senecas Strong/One Feather program will provide a 24 hour/365 day hotline for confidential assessment and short term coaching, as well as referral to on-territory and off-territory care, outpatient counseling, and related services. The program will incorporate a validated outcomes tool to provide individualized substance abuse condition management for all participants.

One Feather Consulting is a majority Native American owned company with its administrative office based from the sovereign territory of the Seneca Nation of Indians in New York, and the Seneca Strong Program focuses on substance use prevention and the healing of social, psychological and intergenerational traumas of the Seneca community. The Seneca Nation of Indians has a population of over 8,000 enrolled members.

This was reported by PR Web on January 20, 2015.

Contact Information: Rodney Haring, PhD, Founder, One Feather Consulting, 12190 Brant Reservation Road, Irving, NY 14081; (716) 549-2911; E-mail:; Website:

During this presentation, Sloan Manning, MD, provided a brief overview metabolic issues and wellness considerations in schizophrenia. Key points included:

  • Life expectancy is substantially shorter for patients with schizophrenia compared to the general population. (Laursen, 2011)
  • People with severe mental illness are more likely to be overweight, to smoke, and to have diabetes, hypertension, and dyslipidemia compared with the general population. In particular, patients with schizophrenia, with an increased risk of comorbidities, have poorer access to, and quality of, physical health care. (De Hert, 2009).
  • Barriers to engaging people with severe mental illness or schizophrenia to an intervention largely relate to illness, symptoms, and treatment. (Roberts, 2011)
  • Programs to improve physical healthcare in psychiatric patients are heterogeneous and include physicians dually trained in psychiatry and physical medicine, on-site-medical consultation at a mental healthcare center, collaborative care models that provide context and structure for regular communication between physical and mental healthcare teams, nurse case managers who facilitate access to care, aid in decision making, and educate, and facilitated referral models in which the psychiatric care team helps patients link to a primary care team through referral efforts. Each of these models aims in distinct ways to reduce barriers to physical care by connecting disconnected psychiatric and physical care services. (Morden, et al., 2009)

In 2014, about 87% of  employers in the United States offered behavioral health benefits in their employee health plans, and 74% of employers offered an employee assistance program (EAP). The percentage of employers offering mental health and addiction treatment coverage has increased by five percentage points since 2010 when 82% of employers covered mental health services. Since 2010, the percentage of employers offering an EAP has remained essentially flat, at 75% in 2010 and 74% in 2014.

These findings were reported in the “2014 Employee Benefits” by the Society for Human Resource Management (SHRM). The researchers surveyed SHRM members listed in the membership database as human resource professionals. The researchers excluded SHRM members who were students, located internationally, had no email address on file, or who had participated in a SHRM survey or poll in the last six months. The survey frame included 275,000 human resource professionals; the researchers selected a random sample of 4,000 for the survey. In February 2014, approximately 3,876 emails were successfully delivered to the respondents and 510 HR professionals responded within the three-week response window, yielding a response rate of 13%. The survey asked about the types of employee benefits offered by the members’ employers and about the employers to add or to stop offering specific types of employee benefits, such as health coverage, preventive and wellness benefits, retirement savings and planning, financial and compensation benefits, leave benefits, family friendly benefits, flexible working benefits, employee programs and services, professional and career development, housing and relocation benefits, and business travel benefits.

Additional findings about health coverage benefits were as follows:

  • Overall, 28% of the responses said the amount of employer-sponsored benefits increased during the last year; 63% said benefits remained the same; and 9% said benefits decreased.
  • About 98% of organizations offer some type of health care coverage to their full time employees.
  • Over the past five years, there was an increase in the percentage of employers offering coverage for mental health care, contraception, vision, and bariatric and laser vision surgery.
  • More employers offered health savings accounts (HSA), the prevalence increased from 33% in 2010 to 45% in 2014. More employers make HSA contributions on behalf of employees; the prevalence increased from 15% in 2010 to 32% in 2014.
  • Fewer offer retiree health care coverage; the prevalence has declined from 25% in 2010 to 18% in 2014.
  • More, but still very few, offer coverage for gender reassignment surgery; the prevalence increased from 2% in 2010 to 7% in 2014.
  • Fewer offer long-term care insurance; the prevalence declined from 31% in 2010 to 24% in 2014.

SHRM is a large membership organization for human resource management professionals. It has more than 275,000 members in over 160 countries.

The full text of “2014 Employee Benefits: An Overview of Employee Benefits Offerings in the U.S.” was released in June 2014. A free copy be viewed online at (accessed January 8, 2015).

For more information, contact: Society for Human Resource Management, 1800 Duke Street, Alexandria, Virginia 22314; 703-548-3440; Fax: 703-535-6490; E-mail:; Website:

During this recorded presentation, Rebecca Roma, MD, discussed Assertive Community Treatment in schizophrenia, including the definition of ACT, hurdles of ACT, measurement of its efficacy, and the importance of wellness management in this population. Key points included:

  • ACT is a comprehensive community-based model for delivering treatment, support, and rehabilitation services to individuals with severe mental illness
  • Compared with patients receiving standard community care, those receiving ACT are less likely to be admitted to the hospital, spent less time in the hospital, more likely to be living independently, less likely to be unemployed, less likely to be homeless, more likely to remain in contact with services (Marshall, 2000)
  • Patients with major mental illness have a 25-30-year shorter life span due primarily to premature cardiovascular disease, with seems to be related to an increased incidence of smoking, obesity, hypertension, diabetes, and dyslipidemia (Gibson, 2011)
  • Successful lifestyle intervention programs tend to be at 3-months long, combined education- and activity-based approaches, and incorporate both nutritional improvement and physical exercise (SAMHSA-HRSA Center for Integrated Health Solutions, 2012)