A Systematic Review of Self-Management Health Care Models for Individuals With Serious Mental Illnesses
Abstract
Objective:
Methods:
Results:
Conclusions:
Top-down and bottom-up strategies
Integrating the patient into care
Methods
Search strategy
Data extraction, assessment of relevance, and data synthesis
Results
Study | Intervention description | Sample | Design | Self-management | Main health outcomes |
---|---|---|---|---|---|
Bartels et al., 2013 (30) | Nurses delivered 1 year of weekly skills training classes (clinic and classroom based) consisting of specific skills-building and role-playing sessions twice per day, bimonthly community practice trips, and monthly nurse visits. Postintervention monthly booster sessions (classroom based and in vivo) were launched to maintain skills for 1 year. | 183 participants: 90 in the intervention group and 93 in the wait-list control group; 169 completed the 1-year follow-up assessment; M±SD age=60.2±7.9; 42% male; 86% white; psychiatric conditions, schizophrenia, schizoaffective disorder, bipolar disorder, and major depressive disorder | RCT with 1-year intervention and 3 years of follow-up | The intervention group showed significant improvement (group main effect, d=.33) on the Revised Self-Efficacy Scale (perceived self-efficacy in social functioning and in managing symptoms). | Health status was assessed with the 36-item Short-Form Health Survey (SF-36) and the interview-based version of the Charlson Comorbidity Index. No significant difference was found between groups. Significantly more health screenings and preventive care occurred for the intervention group. |
Bartels et al., 2004 (29) | Hour-long group skills training (clinic and classroom based) twice a week for 1 year, co-led by a nurse case manager and a bachelor’s-level case worker; training and education on social skills (generally and with providers), health, medication, and illness self-management | 24 participants: 12 in the active control group and 12 in the intervention group; total sample: M±SD age=66.5±5.7; 29% male; 100% white; psychiatric conditions, schizophrenia, schizoaffective disorder, bipolar disorder, other psychotic disorders, and refractive depression | RCT pilot study with 1-year intervention, 2-year follow-up, and active control | Improved scores on functioning as measured by the Independent Living Skills Survey (d=.63) and on the health maintenance subscale (d=.45) | At 2-year follow-up, all 24 patients in the intervention had an assigned primary care physician, and all had had at least 1 physical examination. |
Chafetz et al., 2008 (28) | 1 year of individual classroom-based skills training provided by psychiatric nurses using a clinical manual and workbook. Goals are to promote skills in self-assessment, self-monitoring, and self-management of general medical health problems and health services. | 309 participants: 155 in the intervention group and 154 in the control group; M±SD age=38.2±10.1; 43% white; 24% African American; 8% Asian; 6% Hispanic; 20% other or mixed; 68% male; psychiatric conditions, depressive disorder, schizophrenia, bipolar, and other | RCT with assessment at baseline and 12 months | No significant improvements in health care efficacy were noted as measured by self-report. | In the intervention group, positive improvement over time was noted in perceived physical functioning (p=.02) and general health status as measured by the SF–36 (p<.006). |
Druss et al., 2010 (33) | Mental health peers delivered a manualized, classroom-based, 6-session intervention tailored to persons with serious mental illnesses and adapted from the Chronic Disease Self-Management Program. Training components include instruction on self-management, exercise and physical activity, pain and fatigue management, nutrition on a budget, medication management, and finding and accessing a physician. | 80 participants: 41 in the intervention group and 39 in the control group; 83% African American; 16% white, 1% other; M±SD age=47.8±10.1 in the intervention group and 48.4±10.1 in the control group; 30% male; psychiatric conditions, schizophrenia, bipolar disorder, major depression, and PTSD | RCT pilot study; participants attended a mean of 4.5 weekly groups; follow-up at 6 months | In a random-effects model, significant improvement was noted for the intervention group on the Patient Activation Measure (p=.03; 8% improvement for the intervention group and 6% decline for the control group); improvement (not significant) was also noted in medication adherence (14% improvement for the intervention group and 7% decline for the control group). | Significant improvement was noted in the proportion of the intervention group reporting one or more visit to a primary care provider (8% improvement for the intervention group and 17% decline for the control group; p=.04 for the group × time interaction). |
Druss et al., 2010 (32) | Nurses delivered a manualized care coordination protocol based on standardized approaches in care management literature. Services include psychoeducation about medical conditions, information about available community providers, development of action plans, planning for upcoming appointments, motivational interviewing, coaching, and accompaniment to doctors. | 407 participants: 205 in the intervention group and 202 in the control group; intervention group: M±SD age=47.0±8.1; 49% male; 77% African American; 2% Latino; control group: M±SD age=46.3±8.1; 55% male; 79% African American; 1% Latino; psychiatric conditions, schizophrenia, schizoaffective disorder, bipolar, PTSD, and depression | RCT, assessments at baseline and 12 months | None reported | At the 12-month follow-up, the intervention group had had significantly more preventive screenings and cardiovascular service use than the control group (based on chart reviews). The intervention group significantly improved in sustaining a primary care provider compared with the control group (from 50% to 71% of the group over the 12 months vs. from 48% to 52% p=.001). |
Goldberg et al., 2013 (34) | In vivo and classroom-based, abridged version of the peer-delivered Living Well intervention (13 weekly sessions, each 60–75 minutes) with a focus on self-management, action planning, peer feedback and support, modeling, problem solving, and specific disease management techniques and use of skills for lifestyle, sleep, medication, addictive behaviors, and coordination of general medical and psychiatric services. Peer facilitators tracked progress between sessions. | 63 participants: 32 in the intervention group and 31 in the control group; M±SD age=49.5±9.1; 29% white; 67% African American; 4% mixed race; 48% male; psychiatric conditions, schizophrenia spectrum disorder and bipolar disorder with psychotic features | RCT pilot study; 13-week intervention with 2-month follow-up assessment | Postintervention, the Living Well group had significantly higher mean scores than the control group on the Lorig Self-Management Efficacy Scale (d=.65) and the Patient Activation Measure. At follow-up, the Living Well group had significantly higher mean scores than the control group (d=.66, p=.018) on the internal locus of control subscale of the Multidimensional Health Locus of Control. | The Living Well group used emergency rooms less frequently (31% at baseline and 11% at follow-up) than the control group (27% at baseline and 28% at follow-up) (between-group difference not significant). |
Katon et al., 2010 (25) | A clinic-based, 12-month intervention by a nurse working alongside physicians, who visit patients every 2–3 weeks to provide collaborative care management, help manage depression, improve hemoglobin A1C levels, blood pressure, and lipid control. Nurses provide support and used “motivational and encouraging coaching” to help patients solve problems and set goals for medication adherence and self-care. | 214 participants: 106 in the intervention group and 108 in the control group; intervention group: 52% male, 25% nonwhite or Hispanic, M±SD age=57.4±10.5; control group: 44% male, 22% nonwhite or Hispanic, M±SD age=56.3±12.1; psychiatric condition, depression only | RCT; single-blind design (research assistants unaware of intervention status); 12-month intervention with follow-up at 6 and 12 months | None reported | No difference between intervention and control groups in diet and exercise. Intervention patients were more likely to have 1 or more adjustments of insulin (p=.006) or antihypertensive medications (p<.001) and improvement in hemoglobin A1C, low-density lipoprotein cholesterol, and systolic blood pressure. |
Kelly et al., 2014 (27) | A 6-month, clinic-based and in vivo individualized, manualized intervention led by peers and with four components: assessment and care planning, coordinated linkages and referrals, consumer education, and self-advocacy. Consumers are taught to navigate the health care system through coaching, role-play, modeling, and fading to allow consumer self-sufficiency. | 23 participants: 12 in the intervention group and 11 in the control group; M±SD age=46.78±8.45; 57% male; 26% white; 35% African American; 13% Latino; 26% mixed race or other; psychiatric conditions, any serious mental illness | RCT pilot study; baseline and 6 month follow-up assessments | Outcomes were measured with the Health Care Efficacy Scale. No significant changes were detected either within or between groups. | The intervention group significantly reduced pain compared with the control group (d=.91), and patients changed their orientation to care seeking to a primary care provider (83% in the intervention group vs. 44% in the control group) rather than the emergency department (none in the intervention group vs. 56% in the control group). The intervention group reported fewer health problems posttreatment (trend-level significance). |
Kilbourne et al., 2008 (23) | Classroom-based intervention over 6 months that includes a self-management component, delivered over 4 weekly 2-hour sessions, about the importance of managing health conditions and psychoeducation about management of bipolar disorder; a care management component with nurse liaisons; and a guideline implementation component, delivered in 2 1-hour sessions, for improving medical care | 58 participants: 27 in the intervention group and 31 in the control group; M±SD age=55.3±8.4; 91% male; 90% white; 10% African American; psychiatric condition, bipolar disorder | RCT pilot study, 6-month intervention; follow-up at 3 and 6 months | At 6 months, mean change in the Lorig Self-Management Efficacy Scale score was higher for the intervention group than for the control group (not significant). | At 6 months, the intervention group was less likely than the control group to report problems accessing medical care (7% vs. 23%; not significant) At 6 months, the control group had a significant decline in general medical health as measured by the SF-36 (p=.04). |
Kilbourne et al., 2013 (24) | A 12-month, clinic- and classroom-based intervention run by a health specialist with the following components: life goals collaborative care (weekly 2-hour group sessions on the chronic care model enhanced by social cognitive theory to focus on health behavior change), care management (specialist tracked symptoms and medical needs), clinical registry tracking (information given to providers about patients’ cardiovascular disease risk factors), and guideline support (shared treatment guidelines with providers) | 118 participants: 58 in the intervention group and 60 in enhanced usual care; M±SD age=52.8±9.9; 83% male, 5% nonwhite; psychiatric conditions, bipolar I and II disorder | RCT; follow-up at 6, 12, and 24 months | None reported | At 24 months, the intervention group had reduced systolic blood pressure (borderline significance, d=–.20) and significantly reduced diastolic blood pressure (d=–.24). After post-hoc Bonferroni adjustment, these findings were not statistically significant. No significant differences were found between groups on low- or high-density lipoprotein cholesterol and body mass index. |
Study | Intervention description | Sample | Design | Self-management | Main health outcomes |
---|---|---|---|---|---|
Chiverton et al., 2007 (31) | Classroom-based intervention featuring psychiatric nurses with case management experience delivered in 16 training sessions that address client assessment, education, and support in major areas of wellness and diabetes self-management. Patients are taught about lifestyle; stress management; proper medication usage; use of a glucometer; skin, foot and eye care; and community resources. | 74 participants; mean age=46; 32% male; 58% white; 34% African American, 8% unidentified; psychiatric conditions, substance use disorders, episodic mood disorder, schizophrenia, and personality disorders | Pre-post pilot, within-subjects comparison over 16 total sessions (duration not specified) | None reported | Mean health risk status, measured with the Gordon Personal Health Analysis, improved significantly from baseline to program completion (p<.001). The hemoglobin A1C level declined significantly after the program (p<.05). |
Lawn et al., 2007 (22) | The 6-month study used 2 generic approaches to self-management support: all received the Flinders clinician-administered care planning approach, which provides self-management support, linkage to resources, and active management of patient-provider relations; and 17 received the Stanford model, a peer-led, 6-week education course that teaches self-management (3 attended only the Stanford groups). | 38 participants; 55% female (mean age=46); 45% male (mean age=39); psychiatric conditions, schizophrenia, schizoaffective disorder, bipolar disorder, anxiety, major depression, personality disorders, and PTSD | Pre-post pilot, within-subjects comparison over 6 months | Patients’ Partners in Health (PIH) scores showed significant change on all self-management parameters (knowledge, lifestyle choices, and managing the impact of their condition). At 6 months, a significant relationship was noted between the PIH knowledge subscale and the SF-12 physical functioning subscale. | No significant change was noted in the SF-12 physical summary scores. A case note audit showed that no patients required hospitalization during the study period, and patients had fewer hospital admissions 12 months after study participation compared with 12 months before (not significant). |
Lorig et al., 2014 (26) | Peer-led, classroom-based, 6-session trainings over 6 months that focus on self-management education and chronic disease management and feature weekly action planning and feedback on progress toward self-management and problem solving | 139 participants; M±SD age=48.2±11.0; 24% African American; 27% male; psychiatric conditions, depression, bipolar disorder, schizophrenia, and schizoaffective disorder | Pre-post, within-subjects comparison over 6 months | None reported | At 6 months, 8 of 10 health indicators (for example, fatigue, quality of life, health distress, bad physical health days, and bad mental health days) and health behaviors (communication with a physician and adherence to medical care) improved significantly. None of the 4 medical utilization measures changed significantly. |
Sajatovic et al., 2011 (35) | Nurse and peer-led training in illness management adapted to the primary care setting for persons with serious mental illnesses and diabetes, which includes 2 phases: 12 weekly group sessions lasting 60–90 minutes and 4 weekly telephone follow-up sessions | 12 participants; median age=49.5; all had type 2 diabetes; psychiatric conditions, DSM-IV diagnosis of serious mental illness (schizophrenia or schizoaffective disorder, bipolar disorder, and major depressive disorder) | Pre-post pilot, within-subjects comparison over 16 weeks | None reported | At week 16, hemoglobin A1c had improved at clinically significant levels for 8 participants (67%, mean=.83±.74), 1 participant maintained controlled diabetes, and 3 had slightly increased hemoglobin A1c. Weight loss was insignificant, but significant improvement was noted in dietary behaviors. |
Sample composition
Self-management
Medical and behavioral outcomes
Health care services
Intervention setting
Discussion
Conclusions
Acknowledgments and disclosures
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