Journal Reading

Supervisor : dr. Sabar P. Siregar, Sp. KJ

BACKGROUND
High caloric intake Increased appetite

Low Socioeconomic Status

Physical inactivity

Unhealthy diets Psychotropic medications

Schizophrenia Bipolar disorder Major depression 2-3x more risk

Impairement in memory & executive function Impede learning and adoption of new behaviours

DM Hypertension Dyslipidemia Certain Cancer

to determine the effectiveness of an 18-month tailored behavioral weightloss intervention in adults with serious mental illness.

STUDY Institutional review Johns Hopkins University and Sheppard Pratt Health System Independent data and safety monitoring Randomized Trial of Achieving Healthy Lifestyles in Psychiatric Rehabilitation (ACHIEVE)

SETTING AND STUDY POPULATION Outpatient psychiatric rehabilitation programs Obese adults (18 years of age) who attended 1 of 10 community psychiatric rehabilitation programs in central Maryland or their affiliated out-patient mental health clinics

We excluded persons with: a medical contraindication to weight loss, a cardiovascular event within the previous 6 months, an inability to walk, or an active alcohol-use or substance-use disorder

STUDY PERIODS
January 2009 to February 2011

Intervention
The intervention was composed of three contact types: group weight-management sessions, individual weight-management sessions, and group exercise sessions.

Control
The control group received standard nutrition and physical activity information at base-line.

Data collectors the rehabilitation programs

to determine study eligibility to perform follow-up assessments at 6, 12, and 18 months Measurements : Weight Height Blood pressure Waist circumference Fasting blood chemical levels were obtained at baseline and at 6 and 18 months.

Information on sociodemographic characteristics and medications were obtained from participant self-reports and program records. Psychiatric diagnoses were abstracted from program records.

Statistical Analysis

Done with intention-to-treat Primary Outcome : BMI changes Persentage of weight change Other weight-related outcomes included : - Percentage of weight change from baseline, - Percentage of participants at or below baseline weight, - Percentages of participants who lost at least 5% of their initial weight and those who lost at least 10%, - Change from baseline in body-mass index Chi-square test Sensitivity analysis

Figure 2.Mean Weight Change, According to Study Group.

As compared with the control group, the mean net weight loss in the intervention group increased progressively over the 18-month study period.

Table 2. Weight-Loss Outcomes at 6, 12, and 18 Months.

INTERVENTION PARTICIPATION
The median number of total attended sessions was 46 in the first 6 months and 31 in months 7 through 18. Attendance at the group exercise sessions contributed most to the total number of contacts.

ADVERSE EFFECT

3 death 8 cardiovascular events 13,0% of the participants reported a medical hospitalization 20,6% of the participants reported a psychiatric hospitalization

Control Group
Intervention Group

2 death 6 cardiovascular events 18,3% of the participants reported a medical hospitalization 14,8% of the participants reported a psychiatric hospitalization

 In overweight and obese adults with serious mental illness who were participating in psychiatric rehabilitation programs, a behavioral weight-loss intervention incorporating weightmanagement counseling and group exercise significantly reduced

participant weight over a period of 18 months.

Despite substantial challenges, persons with serious mental illness are able to lose weight with a tailored in-tervention.

Incorporating lifestyle interventions into rehabilitation programs or

placing such programs in other mental health settings would require financial and organizational resources.

STUDY STRENGTHS
Enrolled a diverse population of patients with serious mental illnesses from multiple community-based programs. Throughout the trial, we attained high follow-up rates for outcome data. The intervention was offered over a period of 18 months, in contrast to the short-term interventions in previous randomized trials of behavioral weight-loss interventions in this population.

STUDY WEAKNESS
Attendance at the intervention sessions and rehabilitation programs decreased. The trial was not designed or powered to determine the effects of weight reduction on cardiovascular risk factors in this population. The trial was not designed to influence the prescribing of medication. Efforts to provide healthy meal options were available to all participants in the rehabilitation programs.

Conclusion Over-weight and obese adults with serious mental illness

can make substantial lifestyle changes despite the myriad challenges they face.

Suggestion
Given the epidemic of obesity and weight-related disease among persons with serious mental illness, our findings support implementation of targeted behavioral weight-loss interventions in this high-risk population.

Journal ID

PICO

Valid

Important

Acceptable

CRITICAL APPRAISAL

Journal identity
The study come from : - Johns Hopkins University

Journal ID
PICO Valid

The Welch Center for Prevention, Epidemiology, and Clinical Research Johns Hopkins University, Division of General Internal Medicine and Department of Psychiatry Johns Hopkins University School of Medicine, Departments of Epidemiology Health Policy and Management, Mental Health, and Biostatistics Johns Hopkins Bloomberg School of Public Health

Important

- University of Maryland
Department of Veterans Affairs Capitol Health Care Network (VISN 5) Mental Illness, Education, and Clinical Research Center (R.W.G.), and Department of Psychiatry, University of Maryland School of Medicine (R.W.G.), Baltimore; Sheppard Pratt Health System (F.B.D.)

Acceptable

Journal ID
PICO

- Towson University
Department of Kinesiology, Towson University and Social and Scientific Systems (S.S.C.)

- University of California
Division of Preventive Medicine, Department of Family and Preventive Medicine, University of California, San Diego, La Jolla (C.A.M.A.)

Valid Important

- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena (D.R.Y.) - The National Center for Cardiovascular Research, Madrid (E.G.). Published on March 21th, 2013, at NEJM.org.

Acceptable

 Titles

Journal ID
PICO

A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness Positive:

Clearly shows that variables that were investigated Bold written with a capital letter at the beginning of the word There is no abbreviation Less than 12 words

Valid Important

Negative:
Acceptable

No location No time

Journal ID
PICO

Consist of 4 paragraphs Background Methods Results Conclusion > 250 words

Valid Important Acceptable

Journal ID
PICO

Positive:
Participant of study is clear, followed by the inclusion and exclusion criteria Intergroup interventions are clear Analysis tools mentioned clearly Measurable outcomes are clear Technique sampling is randomized
Valid Important

Negative:
Not blind

Acceptable

Journal ID
PICO

Positive Tables are presented in accordance with the international journal writing format (without the vertical and horizontal lines in a) with no serial number and table title and description of the contents of the table The values of the statistics written

Valid Important

Negative : Theres no interpretation of BMI

Acceptable

Journal ID
PICO

Positive There is a comparison test of previous research and theory There are disadvantages and advantages of the mentioned research results that have been achieved There is an emphasis if the results of the research will be applied There are suggestions for future research Negative : -

Valid Important Acceptable

PICO ANALYSIS
POPULATION

PICO

Adult patients with serious mental disorders excess body weight or obesity from 10 community rehabilitation program of outpatient psychiatry at central Maryland and affiliates

Valid Important

INTERVENTION
Behavioral weight loss through lifestyle in adult patients with serious mental disorders excess body weight or obesity

Acceptable

PICO
COMPARATION
Persentage of weight change at 6, 12, and 18 month between intervention group and control group.
Valid

OUTCOME
Important

A behavioral weight-loss intervention significantly reduced weight over a period of 18 months in overweight and obese adults with serious mental illness.

Acceptable

VALID EVIDENCE
QUESTIONS
Is the allocation of patients in the study randomized? Is patient observation done quite long and complete?

Valid

YES YES

Are all patients in the randomized, analyzed? Whether patients and physicians remain blind in doing therapy, apart from the therapy being tested?
Is the treatment and control groups equally?

YES NO

Important

YES

Acceptable

THE IMPORTANCE OF STUDY

WEIGHT LOSS FROM BASELINE AT 18 MONTHS FOLLOW UP WEIGHT LOSS

Important

Total (+) Intervention Control Total 88 70 158 (-) 49 72 121 137 142 279
Acceptable

EBM for RCT

RRR = -0.303 (95% CI: -0.605 to -0.058) Weight loss from baseline in the intervention group was 30.3% higher than the control group ARR = -0.149 (95% CI: -0.26 to -0.033) ARR = -0.149 means absolute advantage derived from behavioral interventions for weight loss is a 14.9% increase in the weight loss from baseline. NNT = -7 (-4 to -30) The number of patients who must be treated (for the duration of the study) in order to increase the weight loss from baseline in obese adult patients with mental disorders are 7 people All 95%CI does not include the number 1, indicating that the RRR, ARR, and NNT meaningful.

Important

Acceptable

Important
WEIGHT LOSS 5% FROM BASELINE AT 18 MONTHS FOLLOW UP

WEIGHT LOSS (+) Intervention Control 52 32 (-) 85 110 Total 137 142

Total

84

195

297
Acceptable

EBM for RCT

RRR = -0.684 (95% CI: -1.445 to -0.16) Weight loss in the intervention group by 5% from baseline was 68.4% higher than the control group ARR = -0.154 (95% CI: -0.258 to -0.046) ARR = -0.154 means absolute advantage derived from behavioral interventions for weight loss is a 15.4% increase in the weight loss of 5% from the baseline. NNT = -7 (-4 to -22) The number of patients who must be treated (for the duration of the study) in order to increase the 5% weight loss from baseline in obese adult patients with mental disorders are 7 people. All 95% CI does not include the number 1, indicating that the RRR, ARR, and NNT meaningful.

Important

Acceptable

APPLICABILITY OF TEST
QUESTIONS
Is there a difference in our patients when compared with that found in previous studies so that the results can not be applied to our patients? Whether such therapy may be applied to our patients? Does the patient have a potential beneficial or detrimental treatment or when the program implemented? NO

Acceptable

YES Profitable. Behavioral weight loss interventions can significantly reduce body weight over a period of 18 months in adults with overweight and obesity with serious mental DISORDER

CONCLUSION
1

Clinical study is valid

Clinical study is important Clinical study is applicable

Thank You