InSHAPE New Hampshire: Promoting Mental Health Wellness, Saving Lives

People with severe and relentless mental illness such as schizophrenia and bipolar disorder also bear a greater physical burden; they are at increased risk for obesity and chronic diseases including diabetes, hypertension, cardiovascular disease, and nicotine dependence. Serious mental illness is an important risk factor for morbidity and mortality; these patients die an average of 25 years earlier than the average individual due to higher rates of medical illness than can lead to premature mortality.

These gloomy statistics inspired Ken Jue, MSW, CEO of Monadnock Family Services in Keene, New Hampshire to start the In SHAPE program. "What we're trying to do is prevent premature death of persons with serious mental illness," says Jue.

Research shows that people with schizophrenia and other psychotic and mood disorders who exercise three times a week for approximately 4 months lose weight, gain cardiovascular fitness, and experience less depression and fewer psychiatric symptoms. But few programs exist to help people with SMI maintain healthier lifestyles; for example, fewer than 20% of people with schizophrenia engage in regular exercise, and approximately 40% are completely inactive. In SHAPE is one of the few wellness and prevention program for individuals with SMI that seeks to fill this void.

In SHAPE seeks to improve physical health and quality of life, reduce the risk of preventable diseases, and enhance life expectancy of individuals with SMI. Each participant is teamed up with a trained health mentor to create a Self Health Action Plan for Empowerment (SHAPE) that includes physical activity, healthy eating goals, and attention to medical needs. The program enrolls adults in community wellness activities such as exercise, dance classes, weight loss programs, and smoking cessation activities.

Until 2002, Jue continued to attend a number of funerals of his patients that seemed far too young to be dying. He often looked at his patients' photographs and noticed that they all looked youthful and active at one time in their lives. Jue started researching information about co-morbid medical illnesses among people with SMI and also interviewed Monadnock staff about patients' medical conditions. Staff members confirmed that many of their patients had died prematurely or had a number of other chronic health conditions exacerbated by their lifestyle choices and their mental illness. Jue knew something had to be done to help this unique population, and so he outlined key program elements that he would want to see in a program that helped people with SMI improve their physical health.

Instead of relying on formal referrals from mental health providers, Monadnock encouraged voluntary participation and began to form partnerships with hospitals and organizations that would provide exercise, nutrition, and general health services. These partnerships were critical to In SHAPE's success. The local hospital provided smoking cessation programs, while a large non-profit medical clinic provided primary care services to participants without a medical home at no charge to the patient. The local YMCA and a dance and fitness center also offered up their services to encourage creative forms of physical activity. Graduates from Keene State College Department of Health and Fitness were hired to serve as health mentors. They did not receive formal mental health training so that they would not be influenced to think about and treat the participants as "ill" or "sick" patients.

Participants were not only given the chance to be educated on leading a healthy lifestyle, but they were also given the opportunity to meet other people with similar challenges and to feel included in the community. Fitness assessments were repeated every three months to track progress, and there were regular celebrations during which participants received recognition for their efforts and incentive prizes.

A pilot study was launched with the commencement of the In SHAPE program to gauge participants' progress in improving their overall health. While Jue only expected 40 people to enroll in the program, he was surprised to see that 65 people had signed up, and more wanted to join but couldn't due to limited funding. Three months after beginning the program, participants exhibited increased exercise capacity and flexibility, enhanced readiness to change, and improved mental well-being; weight loss was variable across participants. Anecdotal evidence suggests that participants seemed to have greater confidence in social situations, reduction in their waist circumference and blood pressure, and an overall reduction in their depressive symptoms. While
In SHAPE does not promote exercise as a replacement for pharmacotherapy, preliminary results suggest that the exercise and increased health awareness help patients better cope with their mental illness.

Currently, the In SHAPE program is active in New Hampshire, Massachusetts, and Maine. Jue and his team at Monadnock have strengthened In SHAPE by developing new programs that help address challenges that come with varying populations with SMI. For example, Parents as Teachers is a new initiative developed for mothers with mental illness on Medicaid. Through home visits, mothers are taught on how to grow and develop relationships with their children with greater continuity and less disruption as a result of their mental illness. While the program presents its own challenges for the mothers involved, most participants are deeply committed to the one-year program and strive to make significant changes for themselves and their families.

Jue encourages other associations to support wellness and build partnerships with their local healthcare clinics and organizations with a few caveats:

>> Do not underestimate the insight of people with mental illness: Patients with SMI are likely to readily acknowledge the need to make lifestyle changes to improve their health.
>> Emphasize local inclusion: Involving people with SMI in community activities and exercise centers will ultimately improve their quality of life and reduce local stigma.
>> Seek community partnerships: Programs don't need to have their own exercise centers or nutrition staff; they should leverage use of community resources by creating mutually beneficial partnerships.
>> Employ a patient centered approach: Encouraging participants to set their own goals will increase the likelihood that goals will be achieved. Participants should understand that they have responsibility for and control of their health.
>> Do not "medicalize" the program: Orient the program as an activity to promote the participant's health and wellness, not as a response to his or her mental illness or medical comorbidities.

Funding for the In SHAPE program initially came from the New Hampshire Endowment for Health. The Robert Wood Johnson Foundation also provided monies for program expansion and a pilot study to test the effectiveness of the program. Enrolled patients also pay a $5 monthly membership fee to access exercise facilities and classes offered by In SHAPE partners. Recently, the state of New Hampshire agreed to reimburse the In SHAPE program under the state's Medicaid program.