# Exercise as it relates to Disease/Is HARP an effective intervention for individuals with serious mental illnesses?
## Is HARP an effective intervention for individuals with serious mental illnesses?

Background to this research
Chronic conditions are ‘long lasting conditions with persistent effects’ (4) that impact on individuals’ quality of life. There are many different illnesses that are classified under chronic conditions however there is still the same level of needs that patients and their families experience despite these differences such as ‘altering their behaviour, to deal with the social and emotional impacts of symptoms, disabilities, approaching death, to take medicines and to interact with medical care’ (2).
People that suffer from serious mental illnesses have ‘elevated rates of comorbid medical conditions’ (1), they also struggle with effectively managing such conditions. To curve this growing issue, a program was developed. The program consisted of a six-session intervention, delivered by mental health professionals (1). The program aims to help patients become more effective in the management of their chronic diseases, 80 participants from two different clinics from their waiting rooms were recruited. Individuals with one or more chronic illness were prescribed to either the HARP program or the usual care program (1).
Chronic diseases are ‘long lasting and have persistent effects’ (5), and are ‘the leading cause of illness, disability and death in Australia’, there are many different illness and conditions that can be classified as chronic diseases (5). This rise in incidence has occurred with ‘changing lifestyles and an ageing population’ (5). Tackling chronic disease is important, as chronic diseases have social, economic and personal impacts (5). As chronic disease burden grows so does the need for effective treatment that is effective for multiple and complex chronic conditions. To achieve this, new treatments need to be developed and implemented that include ‘coordinated care and chronic disease management plans’ (5).
Where is the research from?
This research was conducted in the United States. The trial was conducted at a Community Mental Health Centre. The exact city/state has not been listed. The trial was conducted by multiple health professionals and professors. Benjamin G. Druss is a professor in the Department of Health Policy and Management, his work has included epidemiological studies, intervention trials, health policy and public health research (6). Kate Lorig is a professor at Stanford University and has been developing, evaluating and making available to the public self-management programs for people with chronic conditions (7). Both of these individuals have experience in many different mental health studies and their research has been published.
What kind of research was this?
This research is a peer lead pilot trial. It was a randomized trial with 80 participants, randomization occurred by using a computerized algorithm and patients were separated into the intervention group or into the usual care group. The Interviewers at the 6 month check in were blinded to the subject’s randomization group. As this was a pilot study the intervention designed was used to assess feasibility and effect sizes rather than to assess statistical significance on study outcomes (3). There are pros and cons to a pilot trial, cons include ‘not enough statistical power and not being able to inform decision making’ (8). Pro’s include finding the evidence needed in designing future trials, gaining information on adverse effects and adjustments on dose selections (8). There are also positives and negatives in conducting a randomized trial. Some positives include; the comparisons that the data provides, bias being minimised and statistical reliability (9). However, some negatives are the applicability and ethical limitations of the trial (9).
What did the research involve?
This study recruited 80 individuals from two separate locations. The target population for the trial was individuals over 18 years of age (3). Individuals were recruited that experienced serious mental illness ‘with or without comorbid additive disorders’ (3). This particular investigation was built on the ‘Chronic Disease Self-Management Program’ (3) which included ‘regular action planning and feedback, modelling of behaviours and problem-solving by participants, reinterpretation of symptoms and training in specific disease management techniques’ (3). Some changes were made in the HARP study such as the reading level to alter the ‘potential gaps in health literacy’ (3). A self-managed record was also added ‘to keep track of disease-specific self-management, medications, upcoming appointments, dietary intake and physical activity’ (3). The research involved questionnaires about disease management which included physical activity health services use and medication adherence (3). There are different ways that this information can be collected which was not stated, it can be collected by telephone, personal, postal and electronic (10). Each survey method has it’s own advantages and disadvantages, however in this investigation personal data would be recommended. Personal data allows for complex questions to be asked, visual aids and higher response rates. The disadvantages of this is that it is expensive, training is required to avoid bias, and it can be time inefficient depending on the number of meeting and participants (10). Physical activity questions were draw from the behavioural risk factor surveillance system. Medication adherence was assessed using a validated self-report measure of problems in adherence to medication (3). The behavioural risk factor surveillance system also has pros and cons. Some pros include the collection of data, no expertise is required to collect data and there is a nation and state data comparison (11). Cons of this system include the amount of time it takes for the data to be collected, interpreted and for policy implantation (11).
What were the basic results?
Analysis of the data was conducted using the ‘SAS MIXED procedure for continuous variables and PROC GENMOD for binary and ordinal variables’ (3). ‘The model assessed the outcome as a function of the randomization group, time since randomization and group time interaction’ (3). Out of the 80 subjects that were recruited for the study 41 for given the HARP intervention and 39 were given usual care (3). At the end of the six months ‘patient activation was clinically and statistically higher in the HARP intervention than the usual care group 52.0+/-10.1 intervention vs. 44.9+/-9.6 control, p=0.01) 7.7% improvement in the intervention vs. 5.7% decline in the usual care’ (3).
What conclusions can we take from this research?
The Health and Recovery Peer Program implemented changes which showed promise in the previous results in improving a range of ‘self-management and health outcome measure, including significant improvements in patient activation and greater likelihood of using primary care medical services’ (3). Further investigation is required into the program as the most disadvantaged groups recruited had the highest success rates. As this was a pilot study, further testing should be used with a ‘broader range of outcome measures’ (3). The use of ongoing resources are required to maintain ‘long-term outcomes and to support sustainable healthcare-community collaborations’ (12).
Practical advice
Future community health interventions in relation to mental health should aim to improve health and ‘achieve large-scale social outcomes through initiatives that address mental health, structural and social inequities’ (12). It is important to implement a coordinated model of care as many individuals suffer from one or more chronic conditions (13). The HARP program showed promising results however as it was a pilot trial more evidence and further studies are required. The socioeconomic status of participants also needs to be acknowledged due to the evidence relating to the link between status and the results gathered.
References
1. Druss B, Zhao L, von Esenwein S, Bona J, Fricks L, Jenkins-Tucker S et al. The Health and Recovery Peer (HARP) Program: A peer-led intervention to improve medical self-management for persons with serious mental illness. Schizophrenia Research. 2010;118(1-3):264-270. 2. Wagner E. Care for chronic diseases The efficacy of coordinated and patient centred care is established, but now is the time to test its effectiveness. theBMJ. 2002;. 3. Druss B, Zhao L, Essenwein S, Bona J, Fricks L, Jenkins-Tucker S et al. The Health and Recovery Peer (HARP) Program: A Peer-Led Intervention to Improve Medical Self-Management for Persons with Serious Mental Illness [Internet]. NCBI. 2010 [cited 3 September 2020]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856811/ 4. Chronic disease Overview - Australian Institute of Health and Welfare [Internet]. Australian Institute of Health and Welfare. 2019 [cited 8 September 2020]. Available from: https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/chronic-disease/overview 5. Chronic Disease - Australia's Biggest Health Challenge. Australia's Health 2014. 14th ed. Canberra: Australian Institute of Health and Welfare; 2014. 6. Rollins School of Public Health [Internet]. Sph.emory.edu. [cited 9 September 2020]. Available from: https://www.sph.emory.edu/faculty/profile/index.php?FID=58 7. K. Lorig | Evidence Based Leadership Council [Internet]. Eblcprograms.org. 2020 [cited 10 September 2020]. Available from: http://www.eblcprograms.org/about-us/eblc-directors/k.lorig-bio/ 8. Tobey R. The Pros and Cons of Using Pilot Studies in the Clinical Research Process | ClinSmart [Internet]. ClinSmart. 2020 [cited 12 September 2020]. Available from: https://www.clinsmart.com/blog/pilot-study-clinical-research-pros-and-cons-5af32 9. Yartsev A. Advantages and disadvantages of randomised control study design | Deranged Physiology [Internet]. Derangedphysiology.com. 2017 [cited 14 September 2020]. Available from: https://derangedphysiology.com/main/cicm-primary-exam/required-reading/research-methods-and-statistics/Chapter%202.0.2/advantages-and-disadvantages-randomised-control-study-design 10. Jones T, Baxter M, Khanduja V. A quick guide to survey research. The Annals of The Royal College of Surgeons of England. 2013;95(1):5-7. 11. Mokdad A. The Behavioral Risk Factors Surveillance System: Past, Present, and Future. Annual Review of Public Health. 2009;30(1):43-54. 12. Castillo E, Ijadi-Maghsoodi R, Shadravan S, Moore E, Mensah M, Docherty M et al. Community Interventions to Promote Mental Health and Social Equity. Current Psychiatry Reports. 2019;21(5). 13. Department of Health | Best-practice examples of chronic disease management in Australia [Internet]. Www1.health.gov.au. 2017 [cited 16 September 2020]. Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/health-care-homes-best-practice