Title: Effectiveness of multiple risk behaviour interventions in people with severe mental illness
Funder: Department of Health and Social Care

Abstract: People with severe mental illness (SMI) die 10-20 years earlier than the general population and are 2-3 times more likely to experience long term conditions. NHS England state this is one of the greatest health inequalities in the UK. Health risk behaviours (smoking, physical inactivity, unhealthy diet, alcohol misuse, drug misuse) are associated with increased risk for developing long term conditions (such as cancer, respiratory diseases, cardiovascular diseases, and liver disease). In addition, these behaviours are strongly associated with premature mortality. For example, smoking is the leading preventable cause of death in the UK. The magnitude of risk to morbidity and mortality grows as the number of risk behaviours engaged in increases. People with SMI engage in multiple risk behaviours more frequently than the general population. Smoking prevalence is three times higher than in the general population, and 42% of all cigarettes are now consumed by smokers with a mental health problem. Alcohol misuse and illicit drug use are four times more likely in people with SMI. Unhealthy diet and physical inactivity are also more likely for example people with first episode psychosis on average increase their bodyweight by 7% in the first year after diagnosis.Reducing these health inequalities, the so called ‘mortality gap’ between people with SMI and the general population, is a key priority for the NHS. Risk behaviour interventions for people with SMI are recommended by NICE and their implementation in the NHS are prioritised both in NICE quality standards and recent NHS England reports. However, there are important implementation challenges and questions relating to the evidence. For example, reviews focusing on interventions aiming to change particular behaviours (e.g. smoking, diet) generally indicate evidence of small benefits. However, since most people with SMI engage in more than one risk behaviour this raises important questions regarding whether to target the reduction of multiple risk behaviours in parallel (e.g. target two or more behaviours simultaneously) or to target one behaviour at a time. However, lack of data to inform this decision leads to uncertainty and variation in practice both in terms of i) whether services should seek to reduce risk behaviours in parallel or separately and ii) what factors contribute to optimal intervention content, duration, and delivery of risk behaviour interventions to reduce barriers to uptake and engagement with these interventions for people with SMI (identified as a key challenge by NHS England and also a WHO working group). Therefore the aim of this review is to examine the effectiveness of multiple risk behaviour compared with single risk behaviour interventions, to identify active ingredients of these interventions, and to identify factors impacting on the acceptability of risk behaviour interventions in people with SMI. In order to meet this aim we propose the following objectives: a) estimate comparative effectiveness of multiple and single risk behaviour interventions using network meta-analyses compared with controls b) identify which behaviour change techniques are associated with greater effectiveness in risk behaviour interventions c) synthesise qualitative and quantitative data about the acceptability and feasibility of implementing risk behaviour interventions in order to increase uptake and engagement

Lay abstract: Background People with severe mental illness (SMI) are on average: • 2-4 times more likely to participate in unhealthy behaviours • 2-3 times more likely to have long term physical illnesses • live 10-20 years less Smoking, unhealthy diet, lack of exercise, and drinking too much alcohol are bad for our physical health. These behaviours make us more likely to develop physical illnesses like cancer, diabetes or heart disease. These behaviours also make us more likely to die early. Proposal aims Reducing physical health problems in people with SMI is a priority in the NHS. But there are a number of questions about how best to help people with SMI reduce their risk of physical health problems. We aim to answer the following questions: • Are interventions aiming to help people with SMI change their behaviours effective? • Is it better to change two or more unhealthy behaviours at the same time? Or is better to focus on changing one behaviour at a time? What aspects of the intervention are most effective in helping people with SMI change their behaviour? • Do people with SMI find these interventions helpful? What do people with SMI find unhelpful about these interventions? How could these interventions be improved? What we plan to do We plan to summarise all studies that have tried to answer these questions. We will use standard statistical techniques (network meta-analysis) to compare how effective multiple risk behaviour interventions are compared with single risk behaviour interventions. We'll also use standard narrative synthesis techniques to bring together the research on the experiences of people with SMI and staff on changing risk behaviours. How well the studies are done will also be taken into account in our conclusions. We will then use this information to help guide NHS services how they may help people with SMI to improve their physical health. We will also recommend what further research is needed. We will work in partnership with people with different skills and experiences in this area including: • service users with experience of SMI • professionals with expertise in providing mental and physical health care for people with SMI.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH