Draft Key Questions
Disposition of Comments Report
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Individuals with serious mental illness (SMI) have excess mortality from cardiovascular disease (CVD) and high rates of CVD risk factors such as diabetes, obesity, and hyperlipidemia. We conducted a systematic review to evaluate interventions to improve CVD risk factors in adults with SMI.
We searched PubMed®, Embase®, PsycINFO®, and the Cochrane Database of Systematic Reviews for English-language trials published since 1980 that evaluated patient-focused behavioral interventions, peer or family support interventions, pharmacological treatments, and multicondition lifestyle interventions, or their combination, that targeted weight control, glucose levels, lipid levels, or CVD risk profile among adults with SMI at elevated risk of CVD.
Two investigators screened each abstract and full-text article for inclusion, abstracted data, and performed quality ratings, efficacy–effectiveness ratings, and evidence grading. Qualitative and quantitative methods, using random-effects models, were used to summarize results.
Of 35 eligible studies, most enrolled patients with schizophrenia who were prescribed antipsychotics. Most studies were designed to control weight (n=28); one study specifically addressed diabetes management, none targeted hyperlipidemia, and three were multicondition interventions. Most studies were efficacy trials comparing behavioral interventions with control; none evaluated peer and family support. There were few direct comparisons of active interventions; effects on overall CVD risk, physical functioning, or cardiovascular events were reported rarely.
Compared with controls, behavioral interventions (mean difference [MD] ?3.13 kg; 95% CI, ?4.21 to ?2.05), metformin (MD ?4.13 kg; CI, ?6.58 to ?1.68), the anticonvulsive medications topiramate and zonisamide (MD ?5.11kg; CI, ?9.48 to ?0.74), and adjunctive or antipsychotic switching to aripiprazole improved weight control. However, aripiprazole switching may be associated with higher rates of treatment failure. Nizatidine did not improve any outcome. The evidence was insufficient for all other interventions and effects on glucose and lipid control.
Few studies have evaluated interventions to address one or more CVD risk factors in patients with SMI. Comparative effectiveness studies are needed to test multimodal strategies, agents known to be effective in non-SMI populations, and antipsychotic-management strategies.