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Cover of Interventions To Improve Cardiovascular Risk Factors in People With Serious Mental Illness

Interventions To Improve Cardiovascular Risk Factors in People With Serious Mental Illness

Comparative Effectiveness Reviews, No. 105

Investigators: Jennifer M Gierisch, PhD, MPH, Jason A Nieuwsma, PhD, Daniel W Bradford, MD, MPH, Christine M Wilder, MD, Monica C Mann-Wrobel, PhD, Amanda J McBroom, PhD, Liz Wing, MA, Michael D Musty, BA, Megan M Chobot, MSLS, Vic Hasselblad, PhD, and John W Williams, Jr, MD, MHSc.

Duke Evidence-based Practice Center
Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Apr.
Report No.: 13-EHC063-EF
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Structured Abstract


Individuals with serious mental illness (SMI) have excess mortality from cardiovascular disease (CVD) and high rates of CVD risk factors such as diabetes, obesity, and hyperlipidemia. We conducted a systematic review to evaluate interventions to improve CVD risk factors in adults with SMI.

Data Sources:

We searched PubMed®, Embase®, PsycINFO®, and the Cochrane Database of Systematic Reviews for English-language trials published since 1980 that evaluated patient-focused behavioral interventions, peer or family support interventions, pharmacological treatments, and multicondition lifestyle interventions, or their combination, that targeted weight control, glucose levels, lipid levels, or CVD risk profile among adults with SMI at elevated risk of CVD.

Review Methods:

Two investigators screened each abstract and full-text article for inclusion, abstracted data, and performed quality ratings, efficacy–effectiveness ratings, and evidence grading. Qualitative and quantitative methods, using random-effects models, were used to summarize results.


Of 35 eligible studies, most enrolled patients with schizophrenia who were prescribed antipsychotics. Most studies were designed to control weight (n=28); one study specifically addressed diabetes management, none targeted hyperlipidemia, and three were multicondition interventions. Most studies were efficacy trials comparing behavioral interventions with control; none evaluated peer and family support. There were few direct comparisons of active interventions; effects on overall CVD risk, physical functioning, or cardiovascular events were reported rarely.

Compared with controls, behavioral interventions (mean difference [MD] −3.13 kg; 95% CI, −4.21 to −2.05), metformin (MD −4.13 kg; CI, −6.58 to −1.68), the anticonvulsive medications topiramate and zonisamide (MD −5.11kg; CI, −9.48 to −0.74), and adjunctive or antipsychotic switching to aripiprazole improved weight control. However, aripiprazole switching may be associated with higher rates of treatment failure. Nizatidine did not improve any outcome. The evidence was insufficient for all other interventions and effects on glucose and lipid control.


Few studies have evaluated interventions to address one or more CVD risk factors in patients with SMI. Comparative effectiveness studies are needed to test multimodal strategies, agents known to be effective in non-SMI populations, and antipsychotic-management strategies.


Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10066-I, Prepared by: Duke Evidence-based Practice Center, Durham, NC

Suggested citation:

Gierisch JM, Nieuwsma JA, Bradford DW, Wilder CM, Mann-Wrobel MC, McBroom AJ, Wing L, Musty MD, Chobot MM, Hasselblad V, Williams JW Jr. Interventions To Improve Cardiovascular Risk Factors in People With Serious Mental Illness. Comparative Effectiveness Review No. 105. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I.) AHRQ Publication No. 13-EHC063-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

This report is based on research conducted by the Duke Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10066-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.


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