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Intervention Summary

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Team Solutions (TS) and Solutions for Wellness (SFW)

Team Solutions (TS) and Solutions for Wellness (SFW) are complementary psychoeducational interventions for adults with a serious mental illness. TS teaches life and illness management skills, while SFW focuses on physical health and wellness. Together, they address many of the modifiable risk factors for medical morbidity, mortality, and relapse that are prevalent in this population. These risk factors include obesity, diabetes, high cholesterol, hypertension, and physical inactivity--all of which may be induced or exacerbated by medications used to treat mental illness--as well as substance use and lack of effective illness management skills. The interventions can be used in numerous treatment settings (e.g., inpatient, residential, outpatient, private office) and in a variety of session formats (e.g., group, individual, family, family group). With the underlying philosophy that overall health and wellness are important to mental health and recovery, these interventions apply a whole-person treatment approach that includes the mind, body, and spirit.

TS emphasizes knowledge that can help participants understand their illness and how to manage it. Clients learn about the disease state, diagnosis and treatment planning, medications, and the effects of stress on mental illness. TS materials include 10 workbooks that are used in 123 sessions of approximately 1 hour each. SFW emphasizes eating healthy foods and getting physical activity as well as maintaining a healthy lifestyle through improvements in tobacco use, sleep, stress, and access to health care. SFW aims to facilitate improvements in, for example, weight, blood pressure, and cholesterol. Materials include 2 workbooks implemented in 39 sessions of approximately 1 hour each.

TS and SFW can be implemented together (either sequentially or concurrently) or separately as independent, stand-alone interventions. Implementers may use all the workbooks or a selection of them and may use them in any order, as determined by the needs of their clients. Each session follows a structured, nine-step progression that incorporates a variety of educational, motivational, and cognitive behavioral techniques including personalized practice options. Depending on how TS and SFW are used, appropriate facilitators may include peer mentors, paraprofessionals, and individuals with undergraduate and graduate degrees.

The studies reviewed for this summary include implementations of TS only, SFW only, and both TS and SFW. The majority of outcomes reviewed reflect physical health factors that may be affected by medications deemed necessary as part of the treatment protocol.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: February 2012
1: Weight and body mass index (BMI)
2: Knowledge and attitudes related to mental and physical health
3: Blood pressure
4: Metabolic markers
Outcome Categories No outcome categories are applicable.
Ages 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities Asian
Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Inpatient
Outpatient
Other community settings
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History TS and SFW have been implemented since 1997. Outside the United States, the interventions have been used in Australia, Austria, Canada, Czech Republic, Denmark, Finland, France, Germany, Ireland, Israel, Italy, Japan, the Netherlands, Norway, Spain, Sweden, Taiwan, and the United Kingdom.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: Yes
Adaptations TS and SFW materials have been adapted, and in some cases translated, for use in Austria, Canada, Czech Republic, Denmark, Finland, France, Germany, Ireland, Israel, Italy, Japan, the Netherlands, Norway, Spain, Sweden, and Taiwan.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: February 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Littrell, K. H., Hilligoss, N. M., Kirshner, C. D., Petty, R. G., & Johnson, C. G. (2003). The effects of an educational intervention on antipsychotic-induced weight gain. Journal of Nursing Scholarship, 35(3), 237-241.  Pub Med icon

Study 2

Vreeland, B., Minsky, S., Yanos, P. T., Menza, M., Gara, M., Kim, E., et al. (2006). Efficacy of the Team Solutions program for educating patients about illness management and treatment. Psychiatric Services, 57(6), 822-828.  Pub Med icon

Study 3

Lindenmayer, J. P., Khan, A., Wance, D., Maccabee, N., Kaushik, S., & Kaushik, S. (2009). Outcome evaluation of a structured educational wellness program in patients with severe mental illness. Journal of Clinical Psychiatry, 70(10), 1385-1396.  Pub Med icon

Study 4

Vreeland, B., Minsky, S., Gara, M. A., & Toto, A. M. (2010). Solutions for Wellness: Results of a manualized psychoeducational program for adults with psychiatric disorders. American Journal of Psychiatric Rehabilitation, 13(1), 55-72.

Supplementary Materials

Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. (2006). Improving the quality of healthcare for mental and substance use conditions: Quality Chasm Series. Washington, DC: National Academies Press.

Parks, J., & Radke, A. Q. (2008). Obesity reduction and prevention strategies for individuals with serious mental illness. Alexandria, VA: National Association of State Mental Health Program Directors.

Porsdal, V., Beal, C., Kleivenes, O. K., Martisen, E. W., Lindstrom, E., Nilsson, H., et al. (2010). The Scandinavian Solutions for Wellness study--A two-arm observational study on the effectiveness of lifestyle intervention on subjective well-being and weight among persons with psychiatric disorders. BMC Psychiatry, 10(42), 1-13.  Pub Med icon

Outcomes

Outcome 1: Weight and body mass index (BMI)
Description of Measures Weight (in pounds) was assessed using either a mechanical or a balance scale. In each study, nursing staff measured weight repeatedly, using a standardized method each time (e.g., weights were measured on the same scale and at the same time of day without shoes, heavy clothing, or items in pockets). Height (in inches) was measured at baseline with the scales' attached stadiometer. BMI, an indicator of body fat, was calculated from a person's weight and height.
Key Findings In one study, patients with schizophrenia or schizoaffective disorder were randomly assigned to either an intervention group receiving weekly 1-hour SFW classes for 4 months or a comparison group receiving usual care. Usual care consisted of regular check-ups, which included a measurement of vital signs and weight as well as a discussion about the patient's medication and treatment progress. Weight and BMI were assessed using measurements taken at baseline and at 4 and 6 months after baseline. Results of this study included the following:

  • Intervention group participants did not have a significant change in weight from baseline to the 4-month assessment (increase of 0.81 pounds) or from baseline to the 6-month assessment (decrease of 0.06 pounds). Comparison group participants had a significant increase in weight from baseline to the 4-month assessment (7.17 pounds; p < .0001) and from baseline to the 6-month assessment (9.57 pounds; p = .0001). The differences between the two groups were significant from baseline to 4 months (p = .005) and from baseline to 6 months (p = .0007).
  • Intervention group participants did not have a significant change in BMI from baseline to the 4-month assessment (increase of 0.13) or from baseline to the 6-month assessment (increase of 0.01). Comparison group participants had a significant increase in BMI from baseline to the 4-month assessment (1.01; p < .0001) and from baseline to the 6-month assessment (1.37; p = .0002). No analysis of the differences in BMI between the two groups was reported.
In a 48-week study conducted in a psychiatric inpatient hospital, patients with schizophrenia, schizoaffective disorder, or bipolar disorder concurrently received TS and SFW. Each of three 16-week segments of the study included 12 weeks of group sessions focusing on specific TS and SFW workbooks. Workbooks were discussed in two daily 50-minute group sessions. Across the three study segments, two SFW workbooks and nine TS workbooks were taught. Weight and BMI were assessed using measurements taken at baseline, the midpoint of the study, and the end of the study. Among participants with weight data for all three study segments, there was a significant decrease in weight over time (4.88 pounds; p = .035) and a significant decrease in BMI over time, both for these participants overall (p = .045) and for those with a baseline BMI of 30 or higher (p = .024).

In another study, conducted at two locations of the same behavioral health organization, patients with severe mental illness receiving partial hospitalization services participated in SFW at one site or usual care at the other site. For 10 weeks, SFW participants attended five groups per week that covered both SFW workbooks. Usual care included wellness and recovery-oriented activities such as psychoeducational groups addressing tobacco, nutrition, physical activity, and symptom management, as well as recovery groups. Differences between the two groups were found from baseline to the 10-week assessment, with intervention group participants having a decrease in weight (3.2 pounds) and BMI (0.49) and those in the comparison group having a slight increase in weight (0.6 pounds; p = .007) and BMI (0.12; p = .006).
Studies Measuring Outcome Study 1, Study 3, Study 4
Study Designs Experimental, Quasi-experimental, Preexperimental
Quality of Research Rating 2.5 (0.0-4.0 scale)
Outcome 2: Knowledge and attitudes related to mental and physical health
Description of Measures Knowledge of mental and physical health was assessed using the following self-report instruments developed for the studies:

  • Knowledge About Schizophrenia Questionnaire (KASQ), a 25-item measure of general knowledge about schizophrenia. Scores range from 0 to 25, with higher scores indicating greater knowledge.
  • Team Solutions Comprehensive Knowledge Assessment Scale (TSCKAS), which was derived from knowledge assessments of individual TS workbooks. Scores range from 0 to 18, with higher scores indicating greater knowledge.
  • Team Solutions Individual Workbook Knowledge Assessment scales. A separate scale was used to assess knowledge of each of the six workbooks used in the study, with higher scores indicating greater knowledge:
    • Understanding Your Illness
    • Recovering From Schizophrenia
    • Understanding Your Treatment
    • Getting the Best Results From Your Medication
    • Helping Yourself Prevent Relapse
    • Avoiding Crisis Situations
  • Knowledge Assessment Scales (KASs), 30-item scales containing yes/no, multiple choice, and true/false questions, with higher scores indicating greater knowledge. A separate scale was used to assess knowledge of each of the 11 TS and SFW workbooks used in the study:
    • Medication Education: Coping With Symptoms
    • Discharge Preparation: Avoiding Crisis Situations
    • Symptom Recognition and Management: Relapse Prevention
    • Nutrition/Healthy Lifestyles
    • You and Your Treatment Team
    • Understanding Your Treatment
    • Schizophrenia: Understanding Your Symptoms (I and II)
    • Fitness and Exercise
    • Discharge Preparation: Recovering From Mental Illness
    • Medication Education: Getting the Best Results From Your Medicine
  • Solutions for Wellness Comprehensive Knowledge Assessment, which consists of 25 items derived from knowledge assessments of each SFW session. Scores range from 0 to 25, with higher scores indicating greater knowledge.
Attitudes about mental and physical health were assessed using the 17-item Health Survey, a self-report instrument developed for one of the studies. The Health Survey assesses attitudes and intentions related to making healthier lifestyle choices. Respondents answered each item using a Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree), with a higher score indicating healthier attitudes and intentions.
Key Findings One study recruited patients with schizophrenia or schizoaffective disorder from three day-treatment programs. Following randomization, all participants continued to receive their program's services (usual care), with the intervention group additionally participating in four 1-hour TS groups per week for 24 weeks that covered six TS workbooks in all. Usual care included involvement in prevocational work assignments, goal-oriented recreational groups, social skills training, and psychoeducational groups. Data were collected at baseline and at 8 and 24 weeks after baseline. For both the KASQ and the TSCKAS, scores increased for the intervention group and decreased for the comparison group over time (p < .05). For the TS Individual Workbook Knowledge Assessment scales, administered to the intervention group only, scores increased from baseline to the 24-week assessment (p < .01 for Getting the Best Results From Your Medication and p < .001 for all other scales).

In a 48-week study conducted in a psychiatric inpatient hospital, patients with schizophrenia, schizoaffective disorder, or bipolar disorder concurrently received TS and SFW. Each of three 16-week segments of the study included 2 weeks for a baseline knowledge assessment, 12 weeks of group sessions focusing on specific TS and SFW workbooks, and 2 weeks for a follow-up knowledge assessment. Workbooks were discussed in two daily 50-minute group sessions. Across the three study segments, two SFW workbooks and nine TS workbooks were taught. From the baseline to the follow-up knowledge assessments, participants had an increase in knowledge using the KASs in 7 of the 11 workbooks (p < .001 for all findings):

  • Medication Education: Coping With Symptoms
  • Discharge Preparation: Avoiding Crisis Situations
  • Symptom Recognition and Management: Relapse Prevention
  • Nutrition/Healthy Lifestyles
  • You and Your Treatment Team
  • Schizophrenia: Understanding Your Symptoms (I)
  • Fitness and Exercise
In another study, conducted at two locations of the same behavioral health organization, patients with severe mental illness receiving partial hospitalization services participated in SFW at one site or usual care at the other site. For 10 weeks, SFW participants attended five groups per week that covered both SFW workbooks. Usual care included wellness and recovery-oriented activities such as psychoeducational groups addressing tobacco, nutrition, physical activity, and symptom management, as well as recovery groups. Differences between the two groups were found from baseline to the 10-week assessment, with scores on the SFW Comprehensive Knowledge Assessment increasing for the intervention group (6.1 points) and decreasing for the comparison group (0.02 points, p < .001), a finding associated with a large effect size (Cohen's d = 1.3). Likewise, intervention group participants had a significant increase in scores on the Health Survey relative to comparison group participants (p < .001), a finding associated with a large effect size (Cohen's d = 0.89).
Studies Measuring Outcome Study 2, Study 3, Study 4
Study Designs Experimental, Quasi-experimental, Preexperimental
Quality of Research Rating 2.3 (0.0-4.0 scale)
Outcome 3: Blood pressure
Description of Measures Blood pressure was assessed using either an automatic digital blood pressure monitor or a stethoscope and sphygmomanometer. In each study, blood pressure was measured repeatedly by nursing staff at the same time of day each time.
Key Findings In a 48-week study conducted in a psychiatric inpatient hospital, patients with schizophrenia, schizoaffective disorder, or bipolar disorder concurrently received TS and SFW. Each of three 16-week segments of the study included 12 weeks of group sessions focusing on specific TS and SFW workbooks. Workbooks were discussed in two daily 50-minute group sessions. Across the three study segments, two SFW workbooks and nine TS workbooks were taught. Blood pressure was assessed at baseline, the midpoint of the study, and the end of the study. From baseline to the end of the study, the percent of participants with high blood pressure (at least 140 mmHg systolic or 90 mmHg diastolic) significantly decreased from 50.18% to 42.55% (p < .001).

In another study, conducted at two locations of the same behavioral health organization, patients with severe mental illness receiving partial hospitalization services participated in SFW at one site or usual care at the other site. For 10 weeks, SFW participants attended five groups per week that covered both SFW workbooks. Usual care included wellness and recovery-oriented activities such as psychoeducational groups addressing tobacco, nutrition, physical activity, and symptom management, as well as recovery groups. Blood pressure was assessed for the intervention group only. From baseline to the 10-week assessment, intervention group participants had significant improvements in systolic blood pressure (125.0 mmHg to 118.1 mmHg; p = .006) and diastolic blood pressure (78.3 mmHg to 74.8 mmHg; p = .024).
Studies Measuring Outcome Study 3, Study 4
Study Designs Quasi-experimental, Preexperimental
Quality of Research Rating 2.7 (0.0-4.0 scale)
Outcome 4: Metabolic markers
Description of Measures Metabolic markers were assessed through tests of fasting blood samples. Blood samples were taken to perform a complete blood cell count and comprehensive metabolic panel, which measured glucose, HbA1c (which shows the average amount of sugar in the blood over 3 months), total cholesterol, total triglycerides, high-density lipoprotein (HDL), and low-density lipoprotein (LDL). Metabolic syndrome--the name for a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and type 2 diabetes--was defined according to World Health Organization (WHO) criteria and was identified using metabolic blood levels.
Key Findings In a 48-week study conducted in a psychiatric inpatient hospital, patients with schizophrenia, schizoaffective disorder, or bipolar disorder concurrently received TS and SFW. Each of three 16-week segments of the study included 12 weeks of group sessions focusing on specific TS and SFW workbooks. Workbooks were discussed in two daily 50-minute group sessions. Across the three study segments, two SFW workbooks and nine TS workbooks were taught. Metabolic markers were assessed at baseline, the midpoint of the study, and the end of the study. From baseline to the end of the study, reductions occurred in glucose levels (p < .05) and triglyceride levels (p < .05), as well as in the percentage of participants meeting the criteria for metabolic syndrome (25.5% to 19.6%; p = .027). No significant changes were observed for levels of HbA1c, total cholesterol, HDL, or LDL.
Studies Measuring Outcome Study 3
Study Designs Preexperimental
Quality of Research Rating 3.0 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult) 61% Male
39% Female
74% White
26% Black or African American
Study 2 26-55 (Adult)
55+ (Older adult)
55% Female
45% Male
55% White
32% Black or African American
9% Hispanic or Latino
4% Race/ethnicity unspecified
Study 3 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
83% Male
17% Female
65% Black or African American
22% Hispanic or Latino
8% White
3% Asian
2% Race/ethnicity unspecified
Study 4 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
54% Female
46% Male
60% Black or African American
26% White
8% Hispanic or Latino
6% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Weight and body mass index (BMI) 3.0 3.0 1.5 1.8 2.0 3.5 2.5
2: Knowledge and attitudes related to mental and physical health 2.0 2.3 1.5 2.0 2.3 3.5 2.3
3: Blood pressure 3.8 3.8 1.5 1.8 2.0 3.5 2.7
4: Metabolic markers 4.0 4.0 2.0 2.0 2.0 4.0 3.0

Study Strengths

The KASQ knowledge measure and all the measures used to assess physical health have strong psychometric properties. The TS and SFW interventions are manualized, and facilitators underwent training prior to implementation. Three of the four studies reviewed included a comparison group and employed an experimental or quasi-experimental design that helped control for some confounding variables. All studies used an intent-to-treat analysis, and one study additionally used multiple imputations for missing data. Sound analytical principles were used across all studies.

Study Weaknesses

With the exception of the KASQ, the instruments used to measure knowledge lack strong psychometric properties. Minimal effort was made in the studies to measure implementation fidelity. Researchers did not document any comparison between study completers and those who dropped out of the study or did not participate in all assessments. Some confounding variables, including medication history and receipt of additional psychoeducational services, were not adequately addressed in three of the studies.

Readiness for Dissemination
Review Date: February 2012

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Team Solutions and Solutions for Wellness Web site, http://www.treatmentteam.com

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.5 2.9 3.4 3.3

Dissemination Strengths

The implementation guide is comprehensive and provides clear guidance on the structure of each session. It is also easy to access and use. Client workbooks and supplemental materials provide a balance of information and engaging tools and exercises. The training materials are clear and easy to access, and they include helpful video clips and presentations that are appropriately targeted to practitioners. Technical assistance and program support are available from the developer and affiliated organizations and are accessible through a toll-free number. The facilitator checklist, pre- and posttest assessments of participant knowledge, and data trackers are provided to support quality assurance, as are detailed instructions for their use.

Dissemination Weaknesses

Limited guidance is available on how new sites can determine which organizational staff members are best suited for each role and how the interventions fit in with existing programs. No opportunities are offered for advanced training or interaction among organizations using the interventions. Tools to measure overall treatment fidelity are limited to the self-report facilitator's checklist, which may not be sufficient to ensure fidelity to the model.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Team Solutions Workbooks 1-10 (includes implementation guide) Free Yes
Solutions for Wellness Workbooks 1 and 2 (includes implementation guide) Free Yes
1-hour to full-day training online (e.g., video, live broadcast) Free No
Technical assistance and program support by phone and email Free No
Contact Information

To learn more about implementation or research, contact:
The Lilly Answer Center, Lilly USA, LLC
(800) 545-5979

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):