Results Summary

What was the research about?

People with serious mental illness like bipolar disorder or schizophrenia often don’t receive the physical health care they need. Community mental health centers can help people with serious mental illness manage their health and prevent later health problems.

In this study, the research team gave different kinds of health and wellness support to patients with serious mental illness. All patients in the study worked with wellness coaches. These coaches were staff at mental health centers who received special training. They taught patients skills to help them manage their health and health care. The team then compared two types of extra support:

  • Nurse-supported: Nurses helped patients get health care and improve their health and wellness. The nurses also advised the wellness coaches about working with the patients.
  • Self-directed: Patients got online or paper resources with information designed for them. Resources included worksheets and manuals to help them improve behaviors like eating healthy food and exercising.

What were the results?

The two types of extra support had about the same success in helping patients with serious mental illness. By the end of the study, patients in both groups reported increased

  • Involvement in their health care
  • Doctor visits
  • Quality of life
  • Satisfaction with their care

They were also more likely to get physical health care when they needed it. Patients reported that their mental health improved. At the same time, they viewed their physical health as being worse. Patients were no more or less likely to take their medicines for mental illness than before the study.

Who was in the study?

The study included 1,229 adults with serious mental illness from mental health centers in rural Pennsylvania. Of these, 90 percent were white, 8 percent were black, and 2 percent were another race. The average patient age was 43, and 63 percent were women. Patients had major depressive disorder (38 percent), bipolar disorder (27 percent), schizoaffective disorder (16 percent), schizophrenia (10 percent), or other mental illnesses (8 percent). All patients had Medicaid insurance.

What did the research team do?

The research team assigned 11 mental health centers by chance to one of the two programs offering extra support: nurse-supported or self-directed.

Patients filled out surveys at 6, 12, 18, and 24 months. The team also looked at patients’ Medicaid claims to track doctor visits and medicine use.

The research team developed the study with help from people with serious mental illness, clinicians, and others who work in mental health.

What were the limits of the study?

At the end of the study, the team didn’t have survey or claims data for 16 percent of patients. Results might have been different if the team had data for more patients. The study didn’t look at how well the extra support programs worked compared with usual mental health care. Most patients in this study were white and all lived in rural areas. Future research could test the two types of extra support with patients of other backgrounds.

How can people use the results?

Mental health centers can think about training staff as wellness coaches and letting patients choose the type of extra support that works best for them.

Final Research Report

View this project's final research report.

More About This Research

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.

Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:

  • Reviewers were concerned that the abstract overstated the inferences made from the study results, particularly because the highlighted results did not appear to come directly from the listed study objectives. The researchers responded that the analyses presented in the abstract were indeed all planned analyses, and that their results were robust enough to support the study conclusions. They did revise the abstract to include the primary aim results so that the Results section is better aligned with the study objectives.
  • Reviewers particularly noted the strong inferences made about the moderating effects of gender on treatment outcomes over time and criticized the analytic approach to testing these moderating effects. The researchers rebutted that their approach to testing for the moderating effect of gender was appropriate because they first wanted to determine whether actual differences over time between the two treatments were present but masked by gender differences in outcomes.
  • The reviewers were unclear about whether this cluster-randomized trial included 10 or 11 clinics, because both numbers were used. The researchers clarified the report to show that 11 clinics entered the trial, but that the two smallest clinics had similar enough characteristics that their data were combined.
  • Reviewers were concerned that the study did not adequately account for multiple outcomes when determining the sample size for the study. In addition, reviewers felt it was unclear whether the study had enough power to test the heterogeneity of treatment effects. The researchers explained that they used the best available historical effect sizes for the primary outcomes to calculate sample size, and clarified that the heterogeneity of treatment effects analyses should be considered exploratory because the study was not adequately powered for those analyses.
  • The reviewers commented on the significant loss-to-follow-up of participants between baseline and final outcome data collection, expressing concern because there were differences between completers and those who didn’t complete on some key measures. The researchers responded that they did not understand why completers differed from those who didn’t complete, but that they did account for it in their analyses.

The reviewers noted the significant and unexpected finding that patient-reported physical health status worsened over time and interpreted this as indication of the difficulty in improving health status within this population, even after improvement in mental health and patient activation. The researchers disagreed with this interpretation; they interpreted the worsening health status as a consequence of patients’ improved understanding and acknowledgement of their health brought about by their increased engagement in preventive and maintenance care. The researchers felt that longer periods of observation would demonstrate a gradual improvement in physical health as patient  engagement translated into better health behavior.

Conflict of Interest Disclosures

Project Information

James M. Schuster, MD, MBA
UPMC Center For High-Value Health Care
$1,776,586
10.25302/2.2019.CER.271
Optimizing Behavioral Health Homes by Focusing On Outcomes That Matter Most for Adults with Serious Mental Illness

Key Dates

December 2012
August 2018
2012
2018

Study Registration Information

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Last updated: December 28, 2021