Using Motivational Techniques to Increase Levels of Physical Activity in Long Term Psychiatric Inpatient Wards

Study Overview
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Brief Summary
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The current research project aims at investigating whether it is possible to obtain an increase in physical activity among inpatients with schizophrenia spectrum disorders by the use of motivational interviewing and environmental interventions, and whether interventions will be associated with an increase in physical fitness and/or improvement in mental health. The Norwegian health care system operates with a catchment-area based organization, which make high levels of representability of patients possible. Patients will be recruited from intermediate-long term inpatient departments where patients typically have schizophrenia spectrum disorders and are admitted for longer periods. There are thus unique possibilities for coordinated efforts to motivate for and change dysfunctional habits.

Detailed Description
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The aim of the study is to investigate if motivational interviewing and environmental interventions may induce behavioral or clinical changes in intermediate-long term psychiatric in-patients with severe mental disorders. Specific research questions: Will levels of physical activity increase? Will self-esteem, life satisfaction or mental or physical health improve? Will it be possible to identify subgroups of patients with differentiated responses to the interventions? (i.e. for whom does it work?) The study aims at including the majority of patients at all wards and the interventions will be additions to the ordinary treatment routines. The design is thus observational. The project will not influence the natural flow of patients through the wards during the study period. The patient population will thus be in a state of continuous change throughout the project period and the individual treatment periods will show substantial variation between patients. The total study period at one site will be 15 months. Consecutive patients will be included during a 12 month period form study start. All consenting patients admitted during this period will be assessed according to protocol at admittance and discharge, at start of interventions and every 3 months. The study will start in the first department in the first quarter of 2013 and will end in the last department the second quarter of 2015. The main interventions will consist of change in the ward routines on several fields. The main organization of interventions will thus be according to wards and not according to individual patients as it will be difficult to direct the interventions to specific patients within the ward. As a consequence, once the interventions have started in a ward all subsequent patients admitted will necessarily receive interventions from day one of their admission into treatment. Hypotheses will be tested by comparing assessments obtained before start of interventions with assessments obtained after a period of active interventions. As start of interventions in a ward will be an irreversible event, only patients in treatment in the ward at start of interventions will be subjects to crossover studies. Some patients will complete their treatment periods either before or after start of interventions and thus not be able to be subject to individual crossover studies. Data from these patients will be pooled in a pre-intervention and a post-intervention group respectively. In the pre-intervention period all patients will receive individual treatment plans and make weekly plans of activity together with the staff. All patients are generally encouraged to physical training, and there are some common activities, but there is no specific focus on this. All wards have a dietary standard which include presence of fruit and raw vegetables between meals, pre-portioned dinner servings, restrictions on sugar-containing beverages and sweets and a general focus on a low-fat and high-fiber menu. Primary measures will be measures of physical activity and fitness, clinical-physical measures or results from laboratory tests. Procedure for informed consent and handling of data: At start of project and at every new admittance after this point of time all patients are informed about the project and asked to give informed consent to participation. A folder is created for each individual participant (ring-binder) containing overview over assessments with time-lines and place-holders for score sheets for baseline and follow-up assessments. An information/registration sheet with the participants' signature is added to this folder. Each unit will have a person responsible for data-collection. This person will supervise that assessments are done according to protocol, distribute registration and score sheets and collect sheets after assessments. The score sheets are added continuously to the individual folders. One person is responsible for collecting and gathering data from all units. At the clinical wards, the project information from individuals will be stored with the same security as ordinary charts and other patient information. The research data will be put into folders which will be kept locked in a room with restricted access within the hospital premises in a 24-h locked building. Folders are only accessed when adding data (new score sheets). One person supervises this and is in charge of this local folder-database. The contents of the score sheets are eventually punched into a central computer database with the necessary formal specifications and security measures. Assessments at baseline only: Diagnosis: The participants will be diagnosed with the Structural Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, version IV) for axis I disorders (SCID-I). General and psychosocial data: Data are collected about age and gender, ethnicity, education, occupation, housing and marital/civil status.

Official Title
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Using Motivational Techniques to Increase Levels of Physical Activity in Long Term Psychiatric Inpatient Wards

Conditions
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Schizophrenia, Bipolar Disorder, Inpatient Facility Diagnoses, Cardiovascular Risk Factor

Intervention / Treatment
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* Behavioral: Motivational interviewing and environmental interventions


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Inpatients at the psychiatric departments of Oslo University Hospital or at the Skjelfoss Psychiatric center DSM-IV diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder, psychotic disorder not otherwise specified (NOS), bipolar I disorder or bipolar disorder NOS and/or current use of antipsychotic medication Informed consent to participation Exclusion Criteria: Pronounced cognitive deficit (IQ < 70) Severe brain damage BMI<17.5 Inability to speak Scandinavian or English Inability to give informed consent.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Intervention/Treatment |
| --- |
|Behavioral: Motivational interviewing and environmental interventions|Revision of ward routines towards facilitating physical activity in patients and motivational work by staff Education of staff with certified MI-expert organized as an intensive course and follow-up guidance. The first course held shortly before start of interventions, the rest arranged within a month Training equipment Motivational Interviewing (MI) techniques applied by staff Weekly treatment plans including physical activity which may consist of any continuous physical exercise.|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change from Baseline Level of Physical Activity at 6 months | Level of physical activity is assessed by the product of the answers to the questions of frequency (range1-5), intensity (range 1-3) and duration (range 1-4) of physical activity in the Health Survey of Northern Trondelag (HUNT) questionnaire, creating a physical activity index (PA-index). A higher score indicates higher levels of activity. Total range for the PA-index is 3-60. | At baseline and at 6 months follow-up | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change from Baseline Level of Self-esteem at 6 months | Self-esteem is assessed by the Rosenberg Self-Esteem Scale. It is a ten-item Likert-type scale with items answered on a four-point scale-from strongly agree to strongly disagree. Range is 10-40.Higher values represent a better outcome. | At baseline and at 6 months follow-up | 
| Change from Baseline Level of Motivation at 6 months | Measures for motivation: Four visual analog scales (VAS), with range 1-10 for assessing motivation for change; self-efficacy, perceived importance, perceived obstacles/difficulty for achieving change and readiness for change. Higher values represent higher motivation. | At baseline and at 6 months follow-up | 
| Change from Baseline BMI at 6 months | Weight and height will be combined to report BMI in kg/m^2 | At baseline and at 6 months follow-up | 
| Change from Baseline Life Satisfaction at 6 months | Life satisfaction is assessed by the question for life satisfaction (HUNT3 questionnaire). The range is 1-7, lower scores represent higher satisfaction. | At baseline and at 6 months follow-up | 
| Change from Baseline Level of Psychotic Symptoms at 6 months | The level of psychotic symptoms will be measured with The Positive and Negative Symptom Scale (PANSS), using the subscores for positive (range 7-49), negative (range 7-49) and general symptoms (range 16-112). Higher values represent a worse outcome | At baseline and at 6 months follow-up | 
| Change from Baseline Level of Global Symptoms (GAF-S) at 6 months | Global symptoms and psychosocial functioning are measured by the Global Assessment of Functioning Scale (GAF), the scores are split into scales of symptoms (GAF-S) and functioning (GAF-F) to improve psychometric properties. The range is from 0 (worst) to 100 (best). | At baseline and at 6 months follow-up | 
| Change from Baseline Level of Depressive Symptoms at 6 months | Depressive symptoms with the Montgomery Asberg Depression Rating Scale (MADRS). Range 0-60. Higher values represent a worse outcome. | At baseline and at 6 months follow-up | 
| Change from Baseline Level of Apathy at 6 months | Apathy is measured with the abridged 12-item (items 1,2,4,5,6,7,9,10,14,16,17,18) of the clinical version of the Apathy Evaluation Scale (AES-C-Apathy). Range 12-48. Higher values represent a worse outcome. | At baseline and at 6 months follow-up | 
| Change from Baseline Waist Circumference at 6 months | Waist circumference is measured with a horizontal tape measurement from the top of the right iliac crest. Measures in cm. | At baseline and at 6 months follow-up | 
| Change from Baseline Blood Pressure at 6 months | Systolic and diastolic blood pressure in mmHg. | At baseline and at 6 months follow-up | 
| Change from Baseline Blood Glucose in serum at 6 months | Glucose in serum, mmol/L | At baseline and at 6 months follow-up | 
| Change from Baseline HbA1C at 6 months | Glycosylated Hemoglobin (HbA1C) in full blood, % | At baseline and at 6 months follow-up | 
| Change from Baseline Insulin at 6 months | Insulin in serum, pmol/L | At baseline and at 6 months follow-up | 
| Change from Baseline Total Cholesterol at 6 months | Total Cholesterol in serum, mmol/L | At baseline and at 6 months follow-up | 
| Change from Baseline Triglycerides at 6 months | Triglycerides in serum, mmol/L | At baseline and at 6 months follow-up | 
| Change from Baseline HDL-cholesterol at 6 months | High Density Lipoprotein Cholesterol (HDL-cholesterol) in serum, mmol/L | At baseline and at 6 months follow-up | 
| Change from Baseline LDL-cholesterol at 6 months | Low Density Lipoprotein (LDL-cholesterol) in serum, mmol/L | At baseline and at 6 months follow-up | 
| Change from Baseline CRP at 6 months | C-Reactive Protein (CRP) in serum, mg/L | At baseline and at 6 months follow-up | 
| Change from Baseline Vitamin D at 6 months | Vitamin D total (Vit DTOT) in serum, nmol/L | At baseline and at 6 months follow-up | 
| Change from Baseline Level of Psychosocial Functioning (GAF-F) at 6 months | Global symptoms and psychosocial functioning are measured by the Global Assessment of Functioning Scale (GAF), the scores are split into scales of symptoms (GAF-S) and functioning (GAF-F) to improve psychometric properties. Range from 0 (worst) to 100 (best). | At baseline and at 6 months follow-up |