Vital Signs

In SHAPE: Local pilot becomes national model

By Rosemary Lunardini

Photo by Jon Gilbert Fox

In SHAPE trainer Bethany Hesch, right, urges on Tracy Bleyler as she works out on a rowing machine. Bleyler is a participant in the In SHAPE program.

The most disadvantaged group in the U.S. in terms of life expectancy is not, as most people might expect, a racial minority. It is people with serious mental illnesses. Due to a host of associated health problems—including high rates of obesity, diabetes, cardiovascular disease, and breathing disorders—Americans with a serious mental illness have a life expectancy 15 to 30 years less than the rest of the population. But a program being studied and refined at Dartmouth now offers them hope for healthier, longer lives.

"This is the biggest health disparity in the U.S., and very few people know about it," says Dr. Stephen Bartels, a geriatric psychiatrist and director of the Dartmouth Centers for Health and Aging. The problem, he explains, "is that mental health is completely separated from regular health care. People [with serious mental illnesses] often don't get good primary care."

Alarming: A few years ago, Bartels became aware of a program that had been developed by Ken Jue, the director of Monadnock Family Services, a mental-health agency in Keene, N.H. Jue had noticed that an alarming number of the agency's patients were dying in their forties and fifties. Diabetes and heart disease, often due to obesity and smoking, were common factors in these early deaths, so Jue started an exercise and fitness program for his patients. He named it In SHAPE, which stands for Individualized Self Health Action Plan for Empowerment. Bartels was impressed by the program and offered Dartmouth expertise to study and possibly expand it.

In a pilot study of In SHAPE, participants showed a decrease in waist measurements and psychiatric symptoms (such as being withdrawn or apathetic), an increase in time spent exercising, and an improved diet.

In SHAPE works by pairing participants with a personal health mentor, someone who is trained in fitness and nutrition, as well as in "how to motivate people with mental-health challenges," Bartels says. "How do you motivate someone who is depressed and overweight? Who has a serious mental illness like schizophrenia or bipolar disorder? How do you motivate someone who has been smoking and eating bad food for years?"

The health mentors meet with patients weekly, working out with them (a free gym membership is included), showing them how to select and cook healthy food, and referring them to smoking-cessation programs. Health mentor Bethany Hesch says participants set their own goals. At first, most just want to lose weight, she says. Later, as their confidence grows, they set additional goals.

Prove: Bartels soon realized that a randomized trial was needed to really prove In SHAPE's effectiveness, so he secured grants from the National Institute of Mental Health and the Centers for Disease Control to set up and study programs in Concord, N.H., and Boston, Mass. The Concord study is complete, and it showed favorable results for the In SHAPE participants compared to subjects in a control group.

The next step, Bartels decided, was to establish In SHAPE at all of the community mental-health centers in New Hampshire; this required getting Medicaid to support some of the services related to the program. Bartels's plea to the state's commissioner of health and human services wasn't successful at first, but eventually he did get approval to extend In SHAPE throughout the state, as long as the initiative is cost-neutral. A grant from the National Institute of Mental Health is now funding an evaluation of In SHAPE's statewide implementation; the program is currently available in Lebanon, Keene, Concord, and Manchester and soon will be offered in every region.

"There's no other state rolling out a comprehensive wellness program like this," says Bartels. "Every single mental-health center could adopt this."

Vouchers: That's not just wishful thinking. His team recently put together a successful application to the state of New Hampshire for a $10-million grant from Medicaid. The funds will be used to study the effect of a range of services, including vouchers for In SHAPE and smoking-cessation programs, aimed at improving health and reducing early mortality in people with mental disorders.

"We started with a little pilot study in Keene, and now we're doing a grant across the state to help people not die early due to these terrible health disparities," Bartels says. "We believe it will be a model for the country."