Efficacy of behavioural interventions in managing atypical antipsychotic weight gain.

Atypical antipsychotic treatment is associated with weight gain and increased metabolic risk. This systematic literature review evaluates the current research on the effectiveness of behavioural interventions in treating and preventing atypical antipsychotic weight gain and reducing metabolic risk, describes characteristics of interventions implemented and discusses findings in the context of the RE-AIM framework. Sixteen studies were identified. When initiated at the start of treatment with an atypical antipsychotic agent, behavioural weight loss interventions decreased the amount of weight gain associated with atypical antipsychotic treatment. When behavioural interventions were initiated after the start of atypical antipsychotic treatment, these interventions were associated with weight loss. Mean weight losses across studies by treatment duration were 2.63 kg for 12- to 16-week interventions, 4.24 kg for 6-month interventions and 3.05 kg for 12- to 18-month interventions. Behavioural weight loss interventions were also found to improve insulin regulation and HbA1c. In addition to assessing efficacy, future studies should evaluate other components of the RE-AIM framework, including reach, adoption, implementation and maintenance. This information will be useful in determining what types of interventions are both effective and practical for delivery in health care or community mental health settings.

A pilot study evaluating a minimal contact telephone and mail weight management intervention for primary care patients.

OBJECTIVE: This study examined an 8-week telephone and mail weight management intervention for Veterans who are unable to attend frequent clinical visits. METHODS: A mail and phone based intervention was compared to a "usual care" intervention in a Hospital clinic. 26 participants (80% male; mean wt=246.2 lbs, BMI=34.7) completed the study. All participants received weight management counseling at weeks 1 and 8. Participants in the intervention group received phone calls and mailings during weeks 2-7. RESULTS: The intervention group lost more weight, although it was not statistically significant. Multivariate analyses showed stage of change was associated with weight loss and attendance. Treatment group and role limitations due to emotional problems were related to weight loss. The intervention group significantly increased their intake of fruits and vegetables. CONCLUSION: This pilot study suggests that minimal interventions may be a method to reach populations that do not have access to more intensive treatments for weight management.

Exercise and hypertension.

Epidemiologic studies have consistently revealed inverse associations between physical activity (or fitness) and hypertension. There are hypotensive benefits to exercise training found across a number of aerobic and progressive resistance training modalities. Optimal exercise prescriptions remain unclear, but hypotensive benefits have been noted for mild to vigorous ranges of exercise intensity, for as few as three exercise sessions per week and durations as short as 20 minutes. Hypertensive subjects appear to experience greater reductions than normotensive subjects. Exercise interventions may be safely and effectively used with mild to moderate as well as severe levels of hypertension. The incorporation of physical activity with other lifestyle interventions provides multiple benefits to hypertensive patients that extend beyond a reduction in blood pressure.

Health barriers to walking for exercise in elderly primary care.

Health status is acknowledged by nursing theory as a factor in the probability of health behavior changes. Yet few studies have addressed the health-related barriers encountered by chronically ill elderly patients in primary care clinics who are trying to increase their physical activity. This study used self- and interviewer-administered instruments to assess potential barriers to physical activity in a sample of 60- to 80-year-old patients entering a walking program. Pain, fatigue, and mobility and sensory impairments were prevalent and could be significant barriers to participation. The authors present specific suggestions for helping patients overcome these barriers.

Physical activity behavior change: issues in adoption and maintenance.

The many benefits of participation in regular moderate- or vigorous-intensity physical activity are well established, yet more than 60% of the population is sedentary or insufficiently active. Published studies have revealed that behavior modification and cognitive-behavior modification can be successfully used to assist patients, healthy adults, and youth in the adoption of physically active lifestyles. However, few studies with adults and youth have examined the maintenance of physical activity behavior beyond 6 months of adoption of this behavior. Maintenance of physical activity is critically important because ongoing participation in the behavior is necessary to sustain health benefits. Knowledge of effective intervention strategies for long-term maintenance of physical activity is at an early stage. The authors provide a summary of what is known about the maintenance of physical activity behavior in adults and youth and how physical activity behavior relates to other health behaviors such as smoking, as well as recommendations for research on physical activity behavior change and maintenance.

Prevention and Treatment of Hypertension Study (PATHS): effects of an alcohol treatment program on blood pressure.

OBJECTIVE: To determine whether blood pressure is reduced for at least 6 months with an intervention to lower alcohol intake in moderate to heavy drinkers with above optimal to slightly elevated diastolic blood pressure, and whether reduction of alcohol intake can be maintained for 2 years. DESIGN: A randomized controlled trial. METHODS: Six hundred forty-one outpatient veterans with an average intake of 3 or more alcoholic drinks per day in the 6 months before entry into the study and with diastolic blood pressure 80 to 99 mm Hg were randomly assigned to a cognitive-behavioral alcohol reduction intervention program or a control observation group for 15 to 24 months. The goal of the intervention was the lower of 2 or fewer drinks daily or a 50% reduction in intake. A subgroup with hypertension was defined as having a diastolic blood pressure of 90 to 99 mm Hg, or 80 to 99 mm Hg if recently taking medication for hypertension. RESULTS: Reduction in average weekly self-reported alcohol intake was significantly greater (P<.001) at every assessment from 3 to 24 months in the intervention group vs the control group: levels declined from 432 g/wk at baseline by 202 g/wk in the intervention group and from 445 g/wk by 78 g/wk in the control group in the first 6 months, with similar reductions after 24 months. The intervention group had a 1.2/0.7-mm Hg greater reduction in blood pressure than the control group (for each, P = .17 and P = .18) for the 6-month primary end point; for the hypertensive stratum the difference was 0.9/0.7 mm Hg (for each, P = .58 and P = .44). CONCLUSIONS: The 1.3 drinks per day average difference between changes in self-reported alcohol intake observed in this trial produced only small nonsignificant effects on blood pressure. The results from the Prevention and Treatment of Hypertension Study (PATHS) do not provide strong support for reducing alcohol consumption in nondependent moderate drinkers as a sole method for the prevention or treatment of hypertension.

Prospective evaluation of the effects of stress on exercise adherence in community-residing women.

The effects of stress on exercise behavior in community-residing women exercising on their own were assessed. Participants (N = 82) completed a background questionnaire and kept exercise diaries and Weekly Stress Inventories (P. J. Brantley, G. N. Jones, E. Boudreax, & S. L. Catz, 1997) for 8 consecutive weeks. During weeks with a high frequency of stressful events, participants exercised for less time and reported lower self-efficacy for meeting upcoming exercise goals. During weeks of high perceived stress, participants exercised significantly fewer days, omitted more planned exercise sessions, were less satisfied with their exercise, and had lower self-efficacy for meeting exercise goals. Findings suggest that perceptions of stressful events and cognitive reactions to missed exercise may play a significant role in mediating exercise behavior and support the view of exercise relapse as an ongoing process.

Nonpharmacologic approaches to therapy for hypertension.

OBJECTIVE: To provide an overview of nondrug therapeutic modalities for management of hypertension. METHODS: We review four strategies that involve lifestyle changes--weight reduction, moderation of sodium intake, physical activity, and moderation of alcohol consumption--that can potentially have a blood pressure-lowering effect. RESULTS: Several clinical trials have shown that a weight loss of 10 to 20% will significantly decrease blood pressure. An average of 1 to 2 mm Hg reduction in blood pressure may occur per kilogram of weight lost. Although sodium restriction has less effect on blood pressure than does weight reduction, a decrease in sodium intake to <100 mmol/day can yield a mean blood pressure reduction of 3 to 5 mm Hg systolic and 2 to 3 mm Hg diastolic. Exercise regimens have demonstrated convincing antihypertensive effects. In recent randomized studies, the average reduction in blood pressure ranged from 5 to 15 mm Hg for systolic measurements and 5 to 10 mm Hg for diastolic readings. Alcohol consumption has been shown to have one of the strongest associations with blood pressure among the potentially modifiable risk factors for hypertension. An average of 1 mm Hg decrease in blood pressure has been noted per one drink/day reduction in consumption. CONCLUSION: Lifestyle changes that can decrease blood pressure are important because they may not only eliminate the need for drug treatment but also decrease other cardiovascular risk factors.

Effects of group discussion and guided patient care experience on nurses' attitudes towards care of patients with AIDS.

Nurses with limited experience in caring for persons with AIDS (PWAs) were randomized into three groups receiving an educational session on universal precautions and (a) three group discussion sessions; (b) three sessions of caring for a PWA; or (c) assessment materials only. Both interventions were conducted by a nursing instructor experienced in care of PWAs and infectious diseases over a 3-4 week period. Measures included instruments for assessing prejudicial attitudes towards homosexual PWAs, self-ratings of infectious disease knowledge, ratings of perceived comfort and confidence in caring for PWAs, and a measure of willingness to provide care to PWAs. Results showed no significant change in willingness to provide care over time in any of the groups. Multiple regression exploring predictors of willingness to provide care found only the measure of AIDS prejudice to be an independent predictor of willingness to provide care to PWAs 6 months after completion of the intervention phase.

Assessment of sexual beliefs and information in aging couples with sexual dysfunction.

The incidence and prevalence of sexual dysfunction indicate that a large portion of the U.S. population will experience a sexual dysfunction, with older individuals being particularly at risk. Cognitive factors (e.g., attitudes, misinformation, beliefs) may contribute to the development of sexual dysfunction or influence response to treatments. The purpose of the current study was to evaluate the psychometric properties of a brief instrument designed to assess information and beliefs regarding sexual functioning in an aging population. Results indicate that the Sexual Beliefs and Information Questionnaire (SBIQ) had adequate test-retest reliability and is an internally consistent measure of sexual knowledge and beliefs. MOst individuals had adequate knowledge regarding sexual functioning as indicated by correct responses to most items; however, there were several items missed more often than expected. Exploratory factor analysis suggests an underlying five-factor structure of the SBIQ. Scores were not correlated with years of education, mood, or marital satisfaction. Scores on the SBIQ improved after a brief standardized educational intervention. The SBIQ is a simple and psychometrically sound measure of sexual knowledge and myths that can assist clinicians to identify and possibly rectify knowledge deficits.

Erectile dysfunction in men with chronic medical illness.

This study examined interrelationships of psychosocial variables found in a psychological evaluation for erectile disorder in 75 male veterans with chronic medical illness. Patients whose partners participated in the evaluation were compared with those whose partners were not involved, and agreement on measures between patients and partners was examined. Finally, a principal components analysis was performed to assess the primary dimensions underlying the variance in mental health and sexual functioning variables. Five factors were identified, accounting for 65.5% of the variance. Results of these analyses are discussed in order to obtain an understanding of the interrelationship between behavioral, psychological, and interpersonal variables in the onset and course of sexual dysfunction.

Stress, coping, and well-being among third-year medical students.

BACKGROUND: Medical school is recognized as a stressful environment that often exerts a negative effect on the academic performance, physical health, and psychological well-being of the student. METHOD: Stress, coping, depression, and somatic distress were examined among 69 third-year students completing a psychiatry clerkship in 1992-93 at the University of Mississippi School of Medicine. Stress was assessed using the Medical Education Hassles Scale-R. Coping was assessed using the Coping Strategies Inventory. Depression was assessed using the Center for Epidemiologic Studies-Depression Scale, and somatic distress was assessed using the Wahler Physical Symptoms Inventory. Statistical methods included correlational analysis and hierarchical regression. RESULTS: Clinical levels of depression were found in 16 (23%) of the students, and 39 (57%) endorsed high levels of somatic distress. Stress accounted for a large percentage of the distress variance (i.e., 29% to 50%). Coping efforts contributed significant variance to the prediction of distress above and beyond that accounted for by stress alone, especially in relation to depression. Coping efforts classified by Engagement strategies were associated with fever depressive symptoms, while coping efforts classified by Disengagement strategies were associated with higher levels of depressive symptoms. CONCLUSIONS: Because students who employed coping efforts characterized by Engagement strategies suffered from fewer depressive symptoms, the results suggest that training in these types of strategies may be a useful intervention to lessen the negative consequences of stress among medical students.

Prevention and Treatment of Hypertension Study (PATHS). Rationale and design.

Alcohol consumption has been recognized as an important correlate of blood pressure in many epidemiologic studies, but few interventional studies have been conducted to examine the effect of a reduction in alcohol intake on blood pressure. Because these studies have usually included few subjects and been of short duration, the National Heart, Lung, and Blood Institute (NHLBI), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the Veterans Affairs (VA) Cooperative Studies Program have initiated a randomized, controlled, multicenter trial to determine whether blood pressure and left ventricular mass are lowered over 6 months of alcohol moderation in non-dependent moderate to heavy drinkers (three or more drinks per day average but not alcohol dependent) with above-average normal (80 to 89 mm Hg) and mildly hypertensive (90 to 99 mm Hg) levels of diastolic blood pressure, and whether a reduction in alcohol intake can be maintained for 2 years. Eligible veterans are randomized to either an alcohol reduction intervention or a control observation group at seven clinical sites. The projected sample size is 580 participants. Alcohol intake is assessed by self-report using a retrospective diary (Chronological Drinking Record) and by various biochemical markers, including apolipoproteins, HDL cholesterol (and subfractions), and carbohydrate deficient transferrin, analyzed at a central laboratory. The alcohol intervention technique is a cognitive-behavioral program, the intensive phase of which consists of six counseling sessions over 3 months. Echocardiograms are obtained at baseline and 6 months after randomization. This trial has important implications for both the prevention and treatment of hypertension.

Endurance exercise in mild hypertension: effects on blood pressure and associated metabolic and quality of life variables.

The effects of a ten week endurance exercise training programme on blood pressure and associated metabolic and quality of life variables were examined in 28 unmedicated mildly hypertensive men (21-54 years of age). At baseline, BP averaged 138.8/94.8 mmHg, body mass index averaged 27.9 and percentage body fat averaged 29%. The average reduction in BP of 11.4/9.8 mmHg (P = 0.0001) was accompanied by decreases in plasma renin activity of 1.82 ng/ml/h (P = 0.001) and in total plasma catecholamines of 77.9 pg/ml (P = 0.05). Percentage body fat decreased 1.3% (P = 0.02) and work capacity increased 1.2 METS (P = 0.002). There were no significant changes in body weight or plasma lipids, cortisol, insulin or urinary electrolyte excretion. Changes in SBP were correlated significantly with change in plasma renin activity (r = 0.38, P = 0.05). Favourable changes were also observed in mood (P = 0.04) and in one measure of type A behaviour (P = 0.04). None of the participants sustained an injury. We conclude that reduction of BP with endurance exercise training in these mildly hypertensive men was primarily associated with reduced plasma renin activity and did not adversely affect quality of life.

Development of a measure of willingness to provide nursing care to AIDS patients.

The Nursing Willingness Questionnaire (NWQ) was developed to measure nurses' willingness to perform specific direct care activities for an adult male patient with acquired immunodeficiency syndrome (AIDS). Measures of internal consistency and one-week test-retest stability indicated excellent reliability. NWQ scale scores correlated significantly with a measure of fear of contracting AIDS via interpersonal and medical contacts but not with fear of contagion through risky sexual behavior. In principle components analysis, all items loaded on one factor. These psychometric studies suggest the NWQ is a reliable and valid instrument for evaluating a construct of current concern to nursing administrators and educators.

Exercise in behavioral medicine.

Research on the preventive and rehabilitative applications of exercise and literature on exercise adherence from the past 10 years are briefly reviewed. Although there is now substantial evidence that a low level of physical activity is associated with decreased life expectancy for both men and women and contributes independently to the development of many prevalent chronic diseases, most adults and children lead sedentary lives. Recent intervention studies suggest exercise adherence can be improved in a variety of populations. Researchers in the next decade should continue to elaborate the population- and disease-specific effects of physical activity and exercise and give priority to the problem of exercise adherence, which limits the effectiveness of exercise interventions and remains a significant challenge to behavioral medicine.

Controlled trial of aerobic exercise in hypertension.

To determine the antihypertensive efficacy of aerobic exercise training in mild essential hypertension, a prospective randomized controlled trial was conducted comparing an aerobic exercise regimen to a placebo exercise regimen, with a crossover replication of the aerobic regimen in the placebo exercise group. The study took place in an outpatient research clinic in a university-affiliated Veterans Administration medical center. Twenty-seven men with untreated diastolic blood pressure (DBP) of 90-104 mm Hg were randomized to the two exercise regimens. Ten patients completed the aerobic regimen. Nine patients completed the control regimen, seven of whom subsequently entered and completed the aerobic regimen. The aerobic regimen consisted of walking, jogging, stationary bicycling, or any combination of these activities for 30 minutes, four times a week, at 65-80% maximal heart rate. The control regimen consisted of slow calisthenics and stretching for the same duration and frequency but maintaining less than 60% maximal heart rate. DBP decreased 9.6 +/- 4.7 mm Hg in the aerobic exercise group but increased 0.8 +/- 6.2 mm Hg in the placebo control exercise group (p = 0.02). Systolic blood pressure (SBP) decreased 6.4 +/- 9.1 mm Hg in the aerobic group and increased 0.9 +/- 9.7 mm Hg in the control group (p = 0.11). Subsequently, seven of the nine controls entered a treatment crossover and completed the aerobic regimen with significant reductions in both DBP (-6.1 +/- 3.2 mm Hg, p less than 0.01) and SBP (-8.1 +/- 5.7 mm Hg, p less than 0.01). BP changes were not associated with any significant changes in weight, body fat, urinary electrolytes, or resting heart rate. This randomized controlled trial provides evidence for the independent BP lowering effect of aerobic exercise in unmedicated mildly hypertensive men.

Increasing ICU staff handwashing: effects of education and group feedback.

This study provides an evaluation of the effectiveness of methods to increase handwashing (HW) by nurses working in an intensive care unit. After baseline observations, two interventions were implemented in sequence: three series of classes conducted by the infection control nurse (ICN); and feedback to staff about handwashing errors on the previous day. Staff were aware that handwashing was being observed throughout the study. The educational intervention produced an immediate increase in HW that was followed by a decline to baseline rates over four weeks. Feedback produced an improvement to 97% compliance that was sustained until completion of the study. Improvement in HW compliance following specified critical procedures was also observed following interventions.