Self-Management Interventions May Help Improve Mental, Physical Health

Stacey Kaltman, M.D., was developing a program to help Latino immigrants manage stress and depression when she realized there might be a way to offer even more support to patients dealing with comorbid conditions.

“Latinos, especially immigrants, are vulnerable to depression, but also diabetes,” she told Psychiatric News. “But many of the patients I interviewed were being treated for their diabetes separately, which did not seem optimal, especially as many interventions, like exercise, are beneficial for both disorders.”

Kaltman, an associate professor of psychiatry at Georgetown University Medical Center, decided she could adapt her depression intervention to target diabetes as well.

Her approach involved counseling patients using psychotherapy techniques such as behavioral activation to get them engaged and interested in making lifestyle changes, in a way that would work best for them.

“The counselor focuses on what patients want to do and has them come up with their own goals for how to improve,” she explained.

She recently led a pilot study to test this intervention in 18 Latino patients and found that patients who participated in the program experienced drops in blood sugar levels and depressive symptoms.

Kaltman is one of a growing number of clinicians working to create patient-centered programs that co-manage psychiatric and general medical conditions, building on more established self-management interventions.

Stephen Bartels, M.D., a professor of psychiatry and community and family medicine at Dartmouth’s Geisel School of Medicine, is working with colleagues at Dartmouth to develop a trio of integrated interventions for older adults with mental illness.

“People with serious mental illness are living longer, so we are seeing an increasing number of older adults coping with these disorders in their 50s and 60s, which is the same time that other big medical problems like diabetes, hypertension, and COPD begin to show up,” he told Psychiatric News.

His programs include Integrated Illness Management and Recovery (I-IMR), which promotes individual goal development, healthy lifestyle practices, and improved awareness of comorbidities; Helping Older People Experience Success (HOPES), which emphasizes psychosocial skills training to better manage medical problems; and an automated telehealth intervention that aims to let people manage their conditions from home.

Each program offers something a little different, which Bartels said he believes is valuable given that the integrated self-management movement is still nascent and topics such as feasibility, scalability, and acceptability need to be addressed.

Bartels and his colleagues recently conducted a systematic review of integrated self-management programs, which was published June 15 in Psychiatric Services in Advance.

The team identified 15 interventions in total (including HOPES, I-IMR, and automated telehealth). Most studies demonstrated feasibility, acceptability, and preliminary effectiveness, with patients experiencing improvements in self-management skills and clinical outcomes such as lower blood pressure and less use of acute health services. However, because the review included studies that were small in sample size or had other methodological limitations, it was difficult to determine which might offer the greatest benefits for patients. (Bartels noted that his group is part of a larger clinical study actively recruiting patients with comorbid mental and physical health problems from the Boston area to compare the effectiveness of the I-IMR approach with the automated telehealth option.)

“The other issue that current interventions haven’t really addressed is how easy they can be rolled out to the greater population,” Bartels said. He pointed out that many of the small trials that showed success employed intense, individualized therapy sessions, which would be difficult to implement at national levels.

“How much can we augment these interventions through technology, for example, or health workers who aren’t specialists?” he continued. “Scalability will be a significant obstacle that researchers should factor in to study design.”

Kaltman believes her intervention should be fairly easy to implement: although it involves individualized sessions, the program was designed to be run in clinics with few resources.

However, she has been thinking about potential strategies to help patients sustain their improvements, as her pilot study only monitored the patients for three months. “One idea was to have program graduates who did really well lead group sessions that patients could attend once they finished their individual therapy,” she said.

First, however, Kaltman hopes to secure funding to carry out a randomized, controlled trial so she can determine just how much better this integrated approach is compared with standard care practices.

Bartels’ meta-analysis was funded by the Health Promotion Research Center at Dartmouth, with additional support from the Centers for Disease Control and Prevention and National Institute of Mental Health. Kaltman’s pilot study was supported by the National Institute of Mental Health. ■