Common People Physical health, lifestyle and quality of life in persons with psychosis and their striving to be like everybody else

Abstract: Background: As psychosis is often a lifelong disorder, improved health-related quality of life (HRQoL) can be a relevant treatment goal. Persons with psychosis have significantly reduced physical health. Research has demonstrated a great excess of mortality due to cardiovascular diseases, as psychosis may lead to an inactive lifestyle and difficulties making healthy lifestyle choices. Metabolic side effects of second-generation antipsychotics are also common. Many are therefore affected by the metabolic syndrome. The overall situation calls for action by developing health promotion interventions suitable for this group. In recent years, there has been an increased interest in the physical health of persons with psychosis. However, efforts have not been optimally tailored to the needs of this group, and health care services have not done enough, despite being aware of the problem.Aim: The general aim of this thesis was to study HRQoL, and metabolic risk factors in persons with psychosis, and by a health promotion intervention and through the participants’ own perspective contribute to an improvement in lifestyle interventions.Methods: Study 1 had a cross-sectional cohort study design that was carried out in specialised psychiatric outpatient departments in Sweden. The patients (n=903) were diagnosed with a psychotic disorder and invited consecutively to participate. A prospective population-based study of public health in the south-east of Sweden (n=7238) served as reference group. Patients were assessed using psychiatric questionnaires, including the Global Assessment of Functioning (GAF). Health-related quality of life was assessed using the EQ5D, both for patients and the population. Several other health status outcomes relevant to the metabolic syndrome were measured, together with lifestyle habits and clinical characteristics. Study II, III and IV were based on a lifestyle intervention for persons with psychosis. Study II was a longitudinal intervention study with a matched reference sample. The purpose of the lifestyle intervention  was to promote a healthier lifestyle by combining theoretical education with physical activities. The intervention group consisted of 42 participants. A matching procedure was made in which two individuals per participant were matched (n=84) into a reference group. The reference sample was matched for sex, BMI class, and being of as similar an age as possible. Socio-demographics were collected and metabolic risk factors relevant to the metabolic syndrome were measured. Symptom severity was measured using Clinical Global Impression (CGI), and HRQoL was assessed using EQ5D. Measurements were made at baseline and at a one-year follow-up. In study III, a qualitative exploratory study was conducted in order to explore prerequisites for a healthy lifestyle. Data were collected through individual interviews (n=40), using a semi-structured interview guide with participants who had undergone the lifestyle intervention. Data were collected 6–7 months after the intervention had been completed. Conventional content analysis was used. Study IV was also based on these 40 interviews and aimed to describe how persons with psychosis perceive participation in a lifestyle intervention. A phenomenographic analysis approach was used.Results/conclusions: Persons with psychosis are at great additional risk of physical comorbidity. Almost half of the patients met the criteria for metabolic syndrome. In addition, persons with psychosis had significantly lower HRQoL in all dimensions in the EQ5D, except for the pain/discomfort dimension. The only risk factor included in the metabolic syndrome that was associated with lower HRQoL was elevated blood pressure. Raised LDL-cholesterol was also related to lower HRQoL, together with low GAF, older age, high BMI, and female gender. The intervention study demonstrated that HRQoL was significantly improved in the intervention group when comparing EQ-VAS at baseline and at the one-year follow-up. It can be concluded that our intervention was not powerful enough to influence the metabolic factors to any greater extent. The key prerequisite for a healthy lifestyle seemed to be a wish to take part in the society and a longing to live like everybody else. However, many became stuck in a constant state of planning instead of taking action towards achieving a healthy lifestyle. Support by health care professionals is therefore also a prerequisite for a healthy lifestyle. This support should target the transition from thought to action and facilitate the participants’ ability to mirror themselves against healthy people in society by introducing activities they perceive that “common people” do. The challenge for health care professionals is to find a moderate intervention level that does not underestimate or overestimate the person’s capacity. This can facilitate continued participation, and participants can thereby find new social contacts and achieve health benefits.