Serious Mental Illness and Weight Management Interventions

To the Editor: Persons with serious mental illness are more likely than persons in the general population to be overweight, leading to increased risk of cardiovascular disease and premature mortality (1). Losing weight is especially challenging for this group, who face multiple barriers because of functional impairment, social isolation, and fragmentation of general medical and mental health care (1). In the August issue, Goldberg and colleagues (2) reported findings from a randomized controlled trial of a weight management program for veterans with serious mental illness initiated by the Veterans Health Administration (VHA). This study, which essentially yielded negative findings, nonetheless represents a growing and long overdue body of research focused on weight management interventions for persons with serious mental illness.

Goldberg and colleagues suggested a number of opportunities and challenges in implementing weight management interventions for persons with serious mental illness. They were able to take advantage of the VHA MOVE! national weight management program, notably by implementing an adapted version for persons with serious mental illness. Recent national data suggested that VHA patients who completed at least eight MOVE! sessions were more likely than those not completing eight sessions to achieve weight loss >5% after one year (25% versus 14%), suggesting the importance of maintaining engagement in the program.

As one of the largest U.S. employers of psychologists, medical trainees, and peer specialists, the VHA has pioneered the integration of behavioral interventions and the colocation of general medical care within mental health programs. As a result, VHA patients with serious mental illness have not experienced the substantial gaps in quality of general medical care and the early mortality seen among non-VHA populations with serious mental illness (3).

Nonetheless, patients with serious mental illness face unique barriers to engaging in weight management programs. In the study by Goldberg and colleagues, many participants depended on others for shopping and cooking, and most had at least one co-occurring general medical condition, notably arthritis and joint pain (51%) or diabetes (30%). Outside VHA, persons with serious mental illness face the additional challenge of accessing medical services, especially because the mental health system is their de facto source of care. Recent interventions—such as Project Achieve (4), which that resulted in significant weight loss (>5%) for persons with serious mental illness—have integrated healthy food options and physical activity for patients at outpatient mental health facilities (1). Emerging community-based initiatives, notably in Genesee County, Michigan (5), have addressed system- and community-level barriers to weight management, primarily through colocation of general medical and mental health providers and implementation of programs that involve community reintegration opportunities through local gyms and nutrition classes. One of the Genesee County weight management programs (InShape) was associated with >5% weight loss in a predominantly African-American population engaged in the program for at least a year.

Ultimately, for weight management interventions to be successful for persons with serious mental illness, they must be included as part of the existing system of care and be integrated within existing community resources.