Virtual Learning Collaborative Compared to Technical Assistance as a Strategy for Implementing Health Promotion in Routine Mental Health Settings: A Hybrid Type 3 Cluster Randomized Trial.

BACKGROUND: Despite widespread use of learning collaboratives, few randomized trials have evaluated their effectiveness as a strategy for implementing evidence based practices. This randomized trial evaluated the effectiveness of a virtual learning collaborative (VLC) in the implementation of a health promotion program for persons with serious mental illness (SMI) aimed at reducing cardiovascular risk reduction in routine mental health settings, compared to routine technical assistance (TA). METHODS: Fifty-five mental health provider organizations were recruited to participate in a Hybrid Type 3 cluster randomized implementation-effectiveness trial of the InSHAPE health promotion program for persons with SMI. Sites were stratified by size and randomized prior to implementation to an 18-month group-based VLC with monthly learning sessions or individual site TA with four scheduled conference calls over 18 months. Primary implementation and service outcomes were InSHAPE program fidelity, participation, and reach. Primary clinical outcomes were weight loss, cardiorespiratory fitness, and cardiovascular risk reduction (≥ 5% weight loss or > 50 m increase on the 6-Minute Walk Test). Program fidelity was assessed at 6, 12, and 24 months; program participation and participant-level outcomes were assessed at 3, 6, 9, and 12 months. RESULTS: VLC (N = 27) and TA (N = 28) sites were similar in organizational characteristics (all p > 0.05). At 12-month follow-up mean program fidelity score was higher in VLC compared to TA (90.5 vs. 79.1; p = 0.002), with over double the proportion with good fidelity (VLC = 73.9% vs. TA = 34.8%; p = 0.009). Over half of individuals in both VLC and TA achieved cardiovascular risk-reduction at 6-month follow-up (VLC: 51.0%; TA: 53.5%; p = 0.517) and at 12-month follow-up (62% VLC and TA; p = 0.912). At 12-month follow-up VLC compared to TA was associated with greater participation (VLC 69.5% vs. TA 56.4% attending at least 50% of sessions, p = 0.002); larger caseloads (VLC = 16 vs. TA = 11; p = 0.024); greater reach consisting of 45% greater number of participants receiving InSHAPE (VLC = 368 vs. TA = 253), and 58% greater number of participants achieving cardiovascular risk reduction (VLC = 150 vs. TA = 95). CONCLUSION: Virtual learning collaboratives compared to routine technical assistance as an implementation strategy for evidence-based health promotion promote greater intervention fidelity, greater levels of intervention participation, greater reach, and a greater number of participants achieving clinically significant risk reduction outcomes, while achieving similarly high levels of intervention effectiveness for participants who completed at least 6 months of the program.

Evaluation of cognitive restructuring for post-traumatic stress disorder in people with severe mental illness.

BACKGROUND: A cognitive-behavioural therapy (CBT) programme designed for post-traumatic stress disorder (PTSD) in people with severe mental illness, including breathing retraining, education and cognitive restructuring, was shown to be more effective than usual services. AIMS: To evaluate the incremental benefit of adding cognitive restructuring to the breathing retraining and education components of the CBT programme (trial registration: clinicaltrials.gov identifier: NCT00494650). METHOD: In all, 201 people with severe mental illness and PTSD were randomised to 12- to 16-session CBT or a 3-session brief treatment programme (breathing retraining and education). The primary outcome was PTSD symptom severity. Secondary outcomes were PTSD diagnosis, other symptoms, functioning and quality of life. RESULTS: There was greater improvement in PTSD symptoms and functioning in the CBT group than in the brief treatment group, with both groups improving on other outcomes and effects maintained 1-year post-treatment. CONCLUSIONS: Cognitive restructuring has a significant impact beyond breathing retraining and education in the CBT programme, reducing PTSD symptoms and improving functioning in people with severe mental illness.

Automated telehealth for managing psychiatric instability in people with serious mental illness.

BACKGROUND: Serious mental illness (SMI) with psychiatric instability accounts for disproportionately high use of emergency room visits and hospitalizations. AIM: To evaluate the effectiveness of an automated telehealth intervention supported by nurse health care management for improving psychiatric illness management and reducing acute service use among individuals with SMI and psychiatric instability. METHODS: Thirty-eight individuals with SMI received the automated telehealth intervention for 6 months. Psychiatric symptoms, illness self-management, and self-reported service use (emergency room visits and hospital admissions) were collected at baseline, 3- and 6-months. Measures of quality of life, health indicators, and subjective health status were also collected. RESULTS: Participants demonstrated improvements in self-reported psychiatric symptoms and illness self-management skills, an 82% decrease in hospital admissions (from 76 to 14 hospitalizations, p < 0.001) and a 75% decrease in emergency room visits (from 63 to 16 visits, p < 0.001). Improvements were also observed in quality of life, severity of depressive symptoms, and mental health status. CONCLUSION: These highly promising findings support the use of an automated telehealth device monitored by a nurse care manager for people with SMI, and highlight the potential for cost savings through reductions in acute health care utilization.

Long-term outcomes of a randomized trial of integrated skills training and preventive healthcare for older adults with serious mental illness.

OBJECTIVE: This report describes 1-, 2-, and 3-year outcomes of a combined psychosocial skills training and preventive healthcare intervention (Helping Older People Experience Success [HOPES]) for older persons with serious mental illness. METHODS: A randomized controlled trial compared HOPES with treatment as usual (TAU) for 183 older adults (age ≥ 50 years [mean age: 60.2]) with serious mental illness (28% schizophrenia, 28% schizoaffective disorder, 20% bipolar disorder, 24% major depression) from two community mental health centers in Boston, Massachusetts, and one in Nashua, New Hampshire. HOPES comprised 12 months of weekly skills training classes, twice-monthly community practice trips, and monthly nurse preventive healthcare visits, followed by a 1-year maintenance phase of monthly sessions. Blinded evaluations of functioning, symptoms, and service use were conducted at baseline and at a 1-year (end of the intensive phase), 2-year (end of the maintenance phase), and 3-year (12 months after the intervention) follow-up. RESULTS: HOPES compared with TAU was associated with improved community living skills and functioning, greater self-efficacy, lower overall psychiatric and negative symptoms, greater acquisition of preventive healthcare (more frequent eye exams, visual acuity, hearing tests, mammograms, and Pap smears), and nearly twice the rate of completed advance directives. No differences were found for medical severity, number of medical conditions, subjective health status, or acute service use at the 3-year follow-up. CONCLUSION: Skills training and nurse facilitated preventive healthcare for older adults with serious mental illness was associated with sustained long-term improvement in functioning, symptoms, self-efficacy, preventive healthcare screening, and advance care planning.

The impact of skills training on cognitive functioning in older people with serious mental illness.

OBJECTIVES: Research on psychosocial interventions for people with serious mental illness (SMI) demonstrates that cognitive functioning is associated with psychosocial functioning. However, cognitive impairment is more pronounced and progressive in older adults with SMI and is associated with poorer functioning. Little is known about the long-term impact of psychosocial skills training on cognitive functioning in this rapidly growing group. DESIGN: We conducted post-hoc analyses on a previously reported randomized controlled trial to evaluate the relationship between cognitive and psychosocial functioning and the potential impact of psychosocial skills training on cognitive functioning over time. SETTING AND PARTICIPANTS: The current study was conducted using a community-dwelling sample of 183 people older than age 50 with SMI. INTERVENTION: Half of the study sample received a psychosocial skills training and health management program, Helping Older People Experience Success, and were compared with a treatment-as-usual group. MEASUREMENTS: Cognitive and psychosocial functioning were assessed at baseline and at 1-, 2-, and 3-year follow-ups. RESULTS: Psychosocial functioning was strongly related to cognitive functioning at baseline. Participation in the Helping Older People Experience Success program was not associated with greater improvements in overall cognitive functioning; however, exploratory analyses suggested a modest improvement in executive functioning. CONCLUSIONS: Given the lack of long-term data on interventions associated with sustaining or improving executive functioning in older adults with SMI, these exploratory findings suggest that future research is warranted to establish the potential benefit of psychosocial skills training as a component of treatment aimed at enhancing long-term psychosocial and cognitive functioning.

Factors associated with weight gain prevention in young adults with serious mental illness.

AIM: The purpose of this study was to examine factors associated with weight gain prevention among young adults with serious mental illness who participated in the Fit Forward randomized controlled trial evaluating lifestyle interventions adapted for this high-risk group. The aims were to: (1) examine baseline differences between participants that gained weight and those that lost or maintained weight at six and 12 months, and (2) evaluate whether changes in weight control strategies were associated with weight gain prevention at 6 and 12 months. METHODS: This study was a secondary analysis of the Fit Forward Study. Participants were young adults (age 18-35) with a serious mental illness and a body mass index in the overweight or obese range. Participants completed assessments at baseline and 6 and 12 months. t-Tests and chi-squared tests were used to examine baseline differences between those that gained weight and those that lost/maintained weight. Logistic regression was used to evaluate whether changes in weight control strategies were associated with weight gain prevention in the sample overall. RESULTS: Lower baseline BMI was significantly associated with weight gain prevention at six and 12 months. Greater increases in weight control strategies total score and psychological coping subscale were significantly associated with weight gain prevention at six and 12 months. CONCLUSIONS: Weight control strategies, particularly psychological coping tools that support positive thinking and reduce negative self-talk should be considered as core strategies in healthy lifestyle interventions aimed at preventing weight gain in young adults with serious mental illness.

Healthy choices, healthy changes: A randomized trial of incentives to promote healthy eating and exercise in people with schizophrenia and other serious mental illnesses.

INTRODUCTION: People with schizophrenia and other serious mental illnesses (SMI) represent a concerning health disparity population, with 10-30 fewer years of life compared to the general population, mainly from high rates of cardiovascular disease (CVD). Preventing CVD is possible with exercise and diet interventions, but only 50 % of participants in clinical trials achieve reduction in CVD risk. This study assessed whether cash incentives improved weight loss, cardiovascular endurance, and/or mortality risk when added to one of four healthy lifestyle programs (gym membership, Weight Watchers membership, the InSHAPE program, InSHAPE + Weight Watchers). METHODS: From 2012 to 2015, 1348 overweight or obese adults with SMI enrolled in a study using equipoise stratified randomization. Participants were randomly assigned to intervention, then to cash incentives, or not, for participation (gym and/or Weight Watchers), with baseline and quarterly assessments for 12 months. We examined effects of the interventions, key covariates, and incentives, using generalized linear models. RESULTS: Main effects of randomization to receive cash incentives was not significant for any outcome; whereas total amount of incentives was significantly associated with all three primary outcomes (weight loss, cardiovascular endurance, mortality risk), mainly for participants in the InSHAPE+WW group who received additional cash incentives. CONCLUSIONS: Incentives may be effective at preventing CVD and improving health outcomes for people with SMI, especially in the context of intensive support for healthy lifestyle behaviors. Policy changes are required to increase access to healthy lifestyle programming and more research is needed to establish the optimal amount of incentives for people with SMI. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02515981.

Sleep quality and its relationship to mental health, physical health and health behaviours among young adults with serious mental illness enrolled in a lifestyle intervention trial.

AIM: To characterize subjective sleep quality and examine its associations with mental health, physical health and health behaviours in a transdiagnostic sample of young adults with serious mental illness (SMI) enrolled in a lifestyle intervention trial. METHODS: Baseline data from a lifestyle intervention trial with young adults (ages 18-35 years) with SMI included the Pittsburgh Sleep Quality Index (PSQI), mental health, physical health and health behaviour outcomes. Descriptive statistics and multiple linear regression were used in analyses. RESULTS: Of 150 participants, 76% were categorized with poor sleep quality. Depressive symptoms were significantly associated with sleep quality (ß = .438, p < .001); however, no association was found with physical health and health behaviours. CONCLUSIONS: Young adults with SMI enrolled in lifestyle interventions may benefit from treatment that addresses sleep as part of a comprehensive approach to health promotion with attention to the role of depressive symptoms in sleep quality.

Group Lifestyle Intervention With Mobile Health for Young Adults With Serious Mental Illness: A Randomized Controlled Trial.

OBJECTIVE: Evidence-based lifestyle interventions tailored to young adults with serious mental illness are needed to reduce their cardiometabolic risk. This study evaluated the effectiveness of a group lifestyle intervention ("PeerFIT") enhanced with mobile health (mHealth) compared with one-on-one mHealth coaching (basic education supported by activity tracking [BEAT]) for young adults with serious mental illness who were overweight or obese. METHODS: Participants were young adults ages 18-35 years with serious mental illness and a body mass index ≥25 kg/m2, who were randomly assigned to PeerFIT or BEAT. Research staff collected data at baseline and at 6 and 12 months. Main outcomes were clinically significant changes from baseline in weight (≥5% weight loss), cardiorespiratory fitness (CRF; increase of >50 m on the 6-minute walk test), and cardiovascular disease (CVD) risk reduction (clinically significant weight loss or CRF improvement). RESULTS: Participants were 150 young adults with a mean ± SD body mass index of 37.1±7.4. Intent-to-treat analyses revealed no significant between-group difference for weight-loss, CRF, or CVD outcomes at 6 and 12 months. Participants in both conditions achieved clinically significant CVD risk reduction, weight loss, and CRF from baseline to 6 and 12 months, and all these improvements were statistically significant (p<0.01). CONCLUSION: The PeerFIT group lifestyle intervention was not superior to one-on-one mHealth coaching in achieving clinically significant changes in weight, CRF, and CVD risk reduction. Although both interventions improved outcomes, low-intensity mHealth coaching may be a more scalable approach for addressing modifiable cardiometabolic risk factors among young adults with serious mental illness.

Psychotic depression, posttraumatic stress disorder, and engagement in cognitive-behavioral therapy within an outpatient sample of adults with serious mental illness.

Depression with psychotic features afflicts a substantial number of people and has been characterized by significantly greater impairment, higher levels of dysfunctional beliefs, and poorer response to psychopharmacologic and psychosocial interventions than nonpsychotic depression. Those with psychotic depression also experience a host of co-occurring disorders, including posttraumatic stress disorder (PTSD), which is not surprising given the established relationships between trauma exposure and increased rates of psychosis and between PTSD and major depression. To date, there has been very limited research on the psychosocial treatment of psychotic depression; and even less is known about those who also suffer from PTSD. The purpose of this study was to better understand the rates and clinical correlates of psychotic depression in those with PTSD. Clinical and symptom characteristics of 20 individuals with psychotic depression and 46 with nonpsychotic depression, all with PTSD, were compared before receiving cognitive-behavioral therapy for PTSD treatment or treatment as usual. Patients with psychotic depression exhibited significantly higher levels of depression and anxiety, a weaker perceived therapeutic alliance with their case managers, more exposure to traumatic events, and more negative beliefs related to their traumatic experiences, as well as increased levels of maladaptive cognitions about themselves and the world, compared with participants without psychosis. Implications for cognitive-behavioral therapy treatment aimed at dysfunctional thinking for this population are discussed.

Neurocognition and social skill in older persons with schizophrenia and major mood disorders: An analysis of gender and diagnosis effects.

Effective social interactions necessary for getting affiliative and instrumental needs met require the smooth integration of social skills, including verbal, non-verbal, and paralinguistic behaviors. Schizophrenia is characterized by prominent impairments in social and role functioning, and research on younger individuals with the illness has shown that social skills deficits are both common and distinguish the disease from other psychiatric disorders. However, less research has focused on diagnostic differences and correlates of social skills in older persons with schizophrenia. To address this question, we examined diagnostic and gender differences in social skills in a community-dwelling sample of 183 people older than age 50 with severe mental illness, and the relationships between social skills and neurocognitive functioning, symptoms, and social contact.Individuals with schizophrenia had worse social skills than those with bipolar disorder or major depression, with people with schizoaffective disorder in between. Social contact and cognitive functioning, especially executive functions and verbal fluency, were strongly predictive of social skills in people with schizophrenia and schizoaffective disorder, but not those with mood disorder. Other than blunted affect, symptoms were not predictive of social skills in either the schizophrenia spectrum or the mood disorder group. Older age was associated with worse social skills in both groups, whereas female gender was related to better skills in the mood disorder group, but not the schizophrenia group. The findings suggest that poor social skills, which are related to the cognitive impairment associated with the illness, are a fundamental feature of schizophrenia that persists from the onset of the illness into older age.

Implementation of the thinking skills for work program in a psychosocial clubhouse.

OBJECTIVE: Cognitive remediation programs aimed at improving role functioning have been implemented in a variety of different mental health treatment settings, but not in psychosocial clubhouses. This study sought to determine the feasibility and preliminary outcomes of providing a cognitive remediation program (the Thinking Skills for Work program), developed and previously implemented in supported employment programs at mental health agencies, in a psychosocial club-house. METHODS: Twenty-three members with a history of difficulties getting or keeping jobs, who were participating in a supported employment program at a psychosocial clubhouse, were enrolled in the Thinking Skills for Work program. A neurocognitive battery was administered at baseline and 3 months later after completion of the computer cognitive training component of the program. Hours of competitive work were tracked for the 2 years before enrollment and 2 years following enrollment. Other work-related activities (school, volunteer) were also tracked for 2 years following enrollment. RESULTS: Twenty-one members (91%) completed 6 or more computer cognitive training sessions. Participants demonstrated significant improvements on neurocognitive measures of processing speed, verbal learning and memory, and executive functions. Sixty percent of the members obtained a competitive job during the 2-year follow-up, and 74% were involved in some type of work-related activity. Participants worked significantly more competitive hours over the 2 years after joining the Thinking Skills for Work program than before. CONCLUSIONS: The findings support the feasibility and promise of implementing the Thinking Skills for Work program in the context of supported employment provided at psychosocial clubhouses.

Work, recovery, and comorbidity in schizophrenia: a randomized controlled trial of cognitive remediation.

Employment is central to the concept of recovery in severe mental illness. However, common comorbid conditions present significant obstacles to consumers seeking employment and benefiting from vocational rehabilitation. We review research on the effects of three common comorbid conditions on work and response to vocational rehabilitation, including cognitive impairment, substance abuse, and medical conditions, followed by research on vocational rehabilitation. We then present the results of a randomized controlled trial evaluating the effects of adding cognitive remediation to a vocational rehabilitation program compared with vocational rehabilitation alone in 34 consumers with severe mental illness. Consumers who received both cognitive remediation and vocational rehabilitation demonstrated significantly greater improvements on a cognitive battery over 3 months than those who received vocational rehabilitation alone and had better work outcomes over the 2-year follow-up period. Substance abuse was associated with worse employment outcomes, but did not interact with treatment group, whereas medical comorbidity was not related to work outcomes. More research is warranted to evaluate the interactions between substance abuse and medical comorbidity with vocational rehabilitation and cognitive remediation.

HIV and hepatitis C knowledge among individuals with serious mental illness.

OBJECTIVE: The present study examines knowledge of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) among individuals with serious mental illness. METHODS: Two hundred and thirty-six people answered questions regarding their knowledge of HIV and HCV. RESULTS: The total correct score for the set of HIV items (79%) was significantly higher than the total correct score for the set of HCV items (70%). Although the majority of demographic variables were not significantly associated with knowledge, individuals who had been previously screened for HIV answered significantly more HIV and HCV questions accurately. CONCLUSIONS: These results indicate that there is a specific gap in knowledge about HCV among individuals with serious mental illness, suggesting the need for intervention development to increase disease-related knowledge.

Incentivizing healthy lifestyle behaviors to reduce cardiovascular risk in people with serious mental illness: An equipoise randomized controlled trial of the wellness incentives program.

BACKGROUND: Medicaid recipients with serious mental illness die 25-30 years earlier than people in the general population due to health conditions that are modifiable through lifestyle changes. Cardiovascular diseases from excess weight, smoking, and sedentary lifestyle contribute substantially to this life expectancy disparity. The current study evaluated the impact of incentives on participation in weight management programming (for overweight and obese adults) and smoking cessation treatment (for regular smokers). METHODS: Participants were Medicaid recipients with disabling mental illness receiving services at any one of 10 community mental health centers across New Hampshire. Using an equipoise stratified randomized design, n = 1348 were enrolled and assigned to one of four weight management programs (Healthy Choices Healthy Changes: HCHC) and n = 661 were enrolled and assigned to one of three smoking cessation interventions (Breathe Well Live Well: BWLW). Following assignment to an intervention, participants were randomized to receive financial incentives (to attend weight management programs, or to achieve abstinence from smoking) or not. Data were collected at baseline and every 3 months for 12 months. DISCUSSION: New Hampshire's HCHC and BWLW programs were designed to address serious and preventable health disparities by providing incentivized health promotion programs to overweight/obese and/or tobacco-smoking Medicaid beneficiaries with mental illness. This study was an unprecedented opportunity to evaluate an innovative statewide implementation of incentivized health promotion targeting the most at-risk and costly beneficiaries. If proven effective, this program has the potential to serve as a national model for widespread implementation.

A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness.

A cognitive-behavioral therapy (CBT) program for posttraumatic stress disorder (PTSD) was developed to address its high prevalence in persons with severe mental illness receiving treatment at community mental health centers. CBT was compared with treatment as usual (TAU) in a randomized controlled trial with 108 clients with PTSD and either major mood disorder (85%) or schizophrenia or schizoaffective disorder (15%), of whom 25% also had borderline personality disorder. Eighty-one percent of clients assigned to CBT participated in the program. Intent-to-treat analyses showed that CBT clients improved significantly more than did clients in TAU at blinded posttreatment and 3- and 6-month follow-up assessments in PTSD symptoms, other symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD, and case manager working alliance. The effects of CBT on PTSD were strongest in clients with severe PTSD. Homework completion in CBT predicted greater reductions in symptoms. Changes in trauma-related beliefs in CBT mediated improvements in PTSD. The findings suggest that clients with severe mental illness and PTSD can benefit from CBT, despite severe symptoms, suicidal thinking, psychosis, and vulnerability to hospitalizations.

A randomized controlled trial of cognitive remediation among inpatients with persistent mental illness.

OBJECTIVE: This study evaluated the feasibility and efficacy of a cognitive remediation program in improving cognitive and work functioning for intermediate- to long-stay psychiatric inpatients. METHODS: Eighty-five inpatients with predominantly DSM-IV-defined schizophrenia were randomly assigned to cognitive remediation or to a control condition. The cognitive remediation program consisted of 24 hours of computerized practice over a 12-week period and a weekly discussion group to facilitate transfer of cognitive skills to daily activities. A computer control group received similar hours of staff and computer exposure without cognitive training exercises. A comprehensive neuropsychological battery was administered at baseline and posttreatment. Symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS) at baseline, midtreatment (six weeks), and posttreatment (12 weeks) and at six- and 12-month follow-ups. Work functioning was tracked during a 12-month follow-up period. RESULTS: The average number of 45-minute sessions completed was 23. Patients in the cognitive remediation group demonstrated significantly greater improvements over three months than the control group in the composite measure of overall cognitive functioning, psychomotor speed, and verbal learning. In addition, patients who received cognitive remediation worked more weeks than the control group over the 12-month follow-up period. Patients in both groups showed significant and comparable improvements over the follow-up period on the positive, activation, and depression subscales of the PANSS. CONCLUSIONS: Cognitive remediation was a feasible treatment for this group of inpatients and more effective at improving cognitive functioning than a computer control intervention. Longer-term follow-up indicated that cognitive remediation was associated with better work outcomes, suggesting benefits in psychosocial functioning.

Neuropsychological predictors of response to cognitive behavioral therapy for posttraumatic stress disorder in persons with severe mental illness.

This study examined whether cognitive functioning was related to treatment outcomes in persons with severe mental illness who received a cognitive behavioral therapy (CBT) program for co-occurring posttraumatic stress disorder (PTSD). The study sample was drawn from a larger controlled trial of 108 persons with severe mental illness and PTSD comparing the effects of CBT with treatment as usual on PTSD and related outcomes, with assessments conducted at baseline, post-treatment, and 3- and 6-month follow-ups. Among the 54 persons in CBT, 49 were administered a neuropsychological battery at baseline and 40 were exposed to the CBT program. Statistical analyses of these 40 participants were conducted to evaluate whether cognitive functioning was related to participation in the CBT program, completion of homework assignments, and improvements in PTSD, and other outcomes. Cognitive functioning was not related to participation in CBT or completion of homework. Lower cognitive functioning predicted less learning of information about PTSD at post-treatment and follow-up, but not less clinical benefit from CBT in PTSD diagnosis or symptoms, other symptoms, or health. The results suggest that cognitive impairment does not attenuate response to the CBT for PTSD program in persons with severe mental illness. Clinical Trials.gov Identifier: NCT00053690.

Randomized Trial of Interventions for Smoking Cessation Among Medicaid Beneficiaries With Mental Illness.

OBJECTIVE: Medicaid beneficiaries with severe mental illnesses are a financially disadvantaged group with high rates of smoking and poor cessation outcomes. This study examined whether abstinence-contingent monetary incentives improved outcomes when added to cessation treatments at community mental health centers: prescriber visit for pharmacotherapy only (PV only), prescriber visit and facilitated quitline (PV+Q), and prescriber visit and telephone cognitive-behavioral therapy (PV+CBT). METHODS: During 2012-2015, a total of 1,468 adult, daily smoking Medicaid beneficiaries with mental illnesses received Web-based motivational tobacco education. Eligible participants who wanted cessation treatment (N=661) were randomly assigned to treatment with or without abstinence-contingent incentives for four weeks after a quit attempt and assessed for biologically verified abstinence at three, six, nine, and 12 months. To examine intervention effect on abstinence over time, logistic generalized linear models estimated with generalized estimating equations were used, with missing observations imputed as smoking. RESULTS: Participants included smokers with schizophrenia disorders (N=148), bipolar disorder (N=150), major depressive disorder (N=158), and anxiety and other disorders (N=205). There was no significant effect of intervention (PV only, PV+Q, and PV+CBT). However, participants who received monetary incentives were more likely to be abstinent from smoking over time (adjusted odds ratio [AOR]=1.77, p=.009). Post hoc comparisons indicated greater abstinence at 12 months in PV+Q with incentives than in PV+Q without incentives (14% versus 4% abstinent, AOR=3.94, p=.014). Treatment participation and cessation outcomes did not differ significantly between diagnostic groups. CONCLUSIONS: Abstinence-contingent incentives improved cessation outcomes among financially disadvantaged smokers with mental illness receiving tobacco treatment at community mental health centers.