Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level

Improving the cardiometabolic health of people with psychosis: A protocol for a randomised controlled trial of the Physical Health Nurse Consultant service

BACKGROUND

Over 690,000 Australians experience psychosis annually, significantly impacting cardiometabolic illness and healthcare costs. Current models of care are fragmented and a critical implementation gap exists regarding the delivery of coordinated physical healthcare for Australians with psychosis.

OBJECTIVES

To describe a trial implementing a Physical Health Nurse Consultant (PHNC) role to coordinate physical health care in a community mental health setting.

DESIGN/METHODS

In this 24-month, 2-group randomised controlled trial, 160 adults with psychosis will be randomised to usual care, or to the PHNC in addition to usual care. Using the Positive Cardiometabolic Health treatment framework and working in collaborative partnerships with consumers (consumer-led co-design), the PHNC will provide care coordination including referral to appropriate programmes or services based on the treatment framework, with the consumer. Burden of Disease risk factors will be collected according to Australian Bureau of Statistics' National Health Survey guidelines. Consumer experience will be assessed using the 'Access', 'Acceptability' and 'Shared Decision Making' dimensions of the Patient Experiences in Primary Healthcare Survey. Cost-effectiveness will be modelled from Burden of Disease data using the Assessing Cost Effectiveness Prevention methodology.

RESULTS

Data collection of two years duration will commence in late 2018. Preliminary findings are expected in December 2019. Primary outcomes will be the effect of the PHNC role on physical healthcare in community-based adults with psychosis.

CONCLUSIONS

The PHNC is an innovative approach to physical health care for adults with psychosis which aims to meet the physical health needs of consumers by addressing barriers to physical health care.

Monitoring of somatic parameters at outpatient departments for mood and anxiety disorders

INTRODUCTION

Somatic complications account for the majority of the 13-30 years shortened life expectancy in psychiatric patients compared to the general population. The study aim was to assess to which extent patients visiting outpatient departments for mood and anxiety disorders were monitored for relevant somatic comorbidities and (adverse) effects of psychotropic drugs-more specifically a) metabolic parameters, b) lithium safety and c) ECGs-during their treatment.

METHODS

We performed a retrospective clinical records review and cross-sectional analysis to assess the extent of somatic monitoring at four outpatient departments for mood and anxiety disorders in The Netherlands. We consecutively recruited adult patients visiting a participating outpatient department between March and November 2014. The primary outcome was percentage of patients without monitoring measurements. Secondary outcomes were number of measurements per parameter per patient per year and time from start of treatment to first measurement.

RESULTS

We included 324 outpatients, of whom 60.2% were female. Most patients were treated for depressive disorders (39.8%), anxiety disorders (16.7%) or bipolar or related disorders (11.7%) and 198 patients (61.1%) used at least one psychotropic drug. For 186 patients (57.4%), no monitoring records were recorded (median treatment period 7.3 months, range 0-55.6). The median number of measurements per parameter per year since the start of outpatient treatment for patients with monitoring measurements was 0.31 (range 0.0-12.9). The median time to first monitoring measurement per parameter for patients with monitoring measurements was 3.8 months (range 0.0-50.7).

DISCUSSION

Somatic monitoring in outpatients with mood and anxiety disorders is not routine clinical practice. Monitoring practices need to be improved to prevent psychiatric outpatients from undetected somatic complications.

The relationship between lifestyle factors and clinical symptoms of bipolar disorder patients in a Chinese population

There is evidence that bipolar disorder (BD) patients with an unhealthy lifestyle have a worse course of illness. This study was designed to examine the extent to which lifestyle could influence the severity of clinical symptoms associated with BD. A total of 113 BD patients were recruited in this study. The lifestyle information including data on dietary patterns, physical activity, and sleep quality were collected using a self-rated questionnaire. The results showed that the consumption of whole grain, seafood, and dairy products were significantly negatively correlated with the 17-item Hamilton Rating Scale for Depression (HAMD-17) total score. The consumption of sugar, soft drinks, and alcohol as well as being a current smoker were positively correlated with the severity of clinical symptoms. Multiple linear regression and binary logistic regression analyses demonstrated an independent negative correlation between both whole grain and dairy product consumption with the HAMD-17 score. The results from the current study suggested that lifestyle factors, especially dietary patterns, might be associated with clinical symptoms of BD. The association between the consumption of specific foods and severity of depressive symptoms may offer some useful information and further understanding of the role of lifestyle factors in the development of BD.

What Is the Impact of Targeted Health Education for Mental Health Nurses in the Provision of Physical Health Care? An Integrated Literature Review

Individuals with a severe mental illness have a gap in life expectancy of up to 20 years in comparison to the general population. Nurses who work in mental health services have been identified as best placed to improve the physical health outcomes of individuals with mental illness. The literature identifies a lack of nursing knowledge related to physical health care and the presence of metabolic syndrome which is impeding nurses in providing essential physical health care to patients. An integrated literature review was carried out due to the dearth of research evidence pertaining to the impact of targeted education specifically with psychiatric/mental health nurses in the provision of physical healthcare. A search for literature included the following databases: CINAHL, Medline, PsycINFO, Embase and Web of Science revealed nine studies: seven quantitative, one qualitative and one mixed method. Qualitative synthesis has shed light on the value of targeted education on improving knowledge and skills in providing physical health care that can then be translated into clinical practice. Targeted education in physical healthcare grows psychiatric/mental health nurse's confidence and develops the skills necessary to enable them to screen and monitor and offer range of physical health interventions to individuals with severe mental illness. Accessible summary • The poor physical health outcomes and premature death of individuals with severe mental illness is of growing concern; a contributing factor is a lack of knowledge and confidence amongst psychiatric/mental health nurses to providing physical health screening and intervening in preventable diseases such as cardiovascular disease, stroke cancer, and type 2 diabetes mellitus. • An integrated literature review was used to ascertain if targeted education on physical health care can improve the knowledge base of psychiatric/mental health nurses within physical health care. • Nine studies were critically appraised, and the data reduced using a narrative synthesis that tells a story of the findings from these research studies. • The review found that targeted education with psychiatric/mental health nurses does result in a statistical increase in knowledge This review finds that nurses have not been regularly supported with physical health education to alter existing practices. This lack of knowledge within physical healthcare is hindering psychiatric/mental health nurses to fully engaging in physical health care activities in practice.

Physical comorbidity in schizophrenia & its correlates

The presence of common physical comorbidities, their demographic and clinical correlates and impact on functioning was assessed in 100 patients with schizophrenia. The patients had a mean age of 35.12±10.7 yr with mean duration of illness of 8.3±0.58 years. Seventy per cent were detected to have a comorbid physical condition. Common conditions included hypertension (21%), diabetes mellitus (15%) and anaemia (12%). Increasing age, being female, being married, longer duration of illness and longer duration of treatment were associated with higher risk of having a comorbid physical illness. Further studies need to be done with a large sample to confirm these findings.

Improving cardiovascular health and quality of life in people with severe mental illness: study protocol for a randomised controlled trial

Background

The estimated 300,000 adults in Australia with severe mental illness (SMI) have markedly reduced life expectancy compared to the general population, mainly due to physical health comorbidities. Cardiovascular disease (CVD) is the commonest cause of early death and people with SMI have high rates of most modifiable risk factors, with associated quality of life (QoL) reduction. High blood pressure, smoking, dyslipidaemia, diabetes and obesity are major modifiable CVD risk factors. Poor delivery of recommended monitoring and risk reduction is a national and international problem. Therefore, effective preventive interventions to safeguard and support physical health are urgently needed in this population.

Methods

This trial used a rigorous process, including extensive piloting, to develop an intervention that delivers recommended physical health care to reduce CVD risk and improve QoL for people with SMI. Components of this intervention are integrated using the Flinders Program of chronic condition management (CCM) which is a comprehensive psychosocial care planning approach that places the patient at the centre of their care, and focuses on building their self-management capacity within a collaborative approach, therefore providing a recovery-oriented framework. The primary project aim is to evaluate the effectiveness and health economics of the CCM intervention. The main outcome measures examine CVD risk and quality of life. The second aim is to identify essential components, enablers and barriers at patient, clinical and organisational levels for national, sustained implementation of recommended physical health care delivery to people with SMI. Participants will be recruited from a community-based public psychiatric service.

Discussion

This study constitutes the first large-scale trial, worldwide, using the Flinders Program with this population. By combining a standardised yet flexible motivational process with a targeted set of evidence-based interventions, the chief aim is to reduce CVD risk by 20%. If achieved, this will be a ground-breaking outcome, and the program will be subsequently translated nationwide and abroad. The trial will be of great interest to people with mental illness, family carers, mental health services, governments and primary care providers because the Flinders Program can be delivered in diverse settings by any clinical discipline and supervised peers.

Trial registration

Australian and New Zealand Clinical Trials Registry, ACTRN12617000474358. Registered on 31 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2748-7) contains supplementary material, which is available to authorized users.

Patient and health system factors associated with hospital readmission in older adults without cognitive impairment

OBJECTIVE

To study the factors associated with hospital readmission.

METHODS

Data used in this study came from a population-based survey of older adults without cognitive impairment. Cox regression was used to assess the factors associated with readmission within a 2-year follow-up period. According to Andersen's model of healthcare seeking behavior, study variables considered included predisposing, enabling and need factors at the individual and health system levels.

RESULTS

Of the 433 participants with an index hospitalization, 97% were discharged with a physical and 3% with a psychiatric disorder. During follow-up, 29% (128/433) were readmitted with a median time to readmission reaching 83 days. The risk of readmission was associated with the following: age, marital status, attraction index of the region of residence for psychiatric services, the presence of an anxio-depressive and other mental disorder, as well as a disorder of the musculoskeletal system. The presence of a physical and psychiatric comorbidity was also associated with readmission.

CONCLUSIONS

Post-discharge follow-up of vulnerable populations with a history of mental disorders and improved availability of psychiatric services in the community are associated with a reduced risk of readmission.

Cause-specific mortality in Finnish forensic psychiatric patients

PURPOSE

To analyze the causes of mortality among patients committed to compulsory forensic psychiatric hospital treatment in Finland during 1980-2009 by categorizing the causes of mortality into somatic diseases, suicides and other unnatural deaths.

MATERIALS AND METHODS

The causes of mortality were analyzed among 351 patients who died during the follow-up. Standardized mortality ratio (SMR) was calculated as the ratio of observed and expected number of deaths by using the subject-years methods with 95% confidence intervals, assuming a Poisson distribution. The expected number of deaths was calculated on the basis of sex-, age- and calendar-period-specific mortality rates for the Finnish population.

RESULTS

The vast majority (249/351) of deaths were due to a somatic disease with SMR of 2.6 (mean age at death 61 years). Fifty nine patients committed suicide with a SMR of 7.1 (mean age at death 40 years). Four patients were homicide victims (mean age at death 40 years) and 32 deaths were accidental (mean age at death 52 years). The combined homicides and accidental deaths resulted in a SMR of 1.7.

CONCLUSIONS

The results of this study point out that the high risk for suicide should receive attention when the hospital treatment and the outpatient care is being organized for forensic psychiatric patients. In addition, the risk of accidents should be evaluated and it should be assured that the patients receive proper somatic healthcare during the forensic psychiatric treatment and that it continues also in the outpatient setting.

Towards a comprehensive routine outcome monitoring program for people with psychotic disorders: The Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS)

BACKGROUND

Patients with psychotic disorders are at risk of developing mental health and social problems, and physical disorders. To monitor and treat these problems when indicated, an annual routine outcome monitoring program, Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS), was developed. This paper presents the background and content of PHAMOUS, implementation of PHAMOUS, characteristics of the patients screened in 2015, and the outcome of patients with three annual screenings between 2011 and 2015.

METHODS

PHAMOUS was implemented in four mental health institutions in the Northern Netherlands in 2006. During the PHAMOUS screening, patients are assessed on socio-demographics, psychiatric symptoms, medication, physical parameters, lifestyle, (psycho)social functioning and quality of life, using internationally validated instruments.

RESULTS

In 2015, 1955 patients with psychotic disorders were enrolled in the PHAMOUS screening. The majority (72%) was receiving mental healthcare for ten years or longer. A small group was hospitalized (10%) in the past year. Half of the patients were in symptomatic remission. Less than 10% had a paid job. More than half of the patients fulfilled the criteria for metabolic syndrome (54%). The subsample with three annual screenings from 2011 to 2015 (N = 1230) was stable, except the increasing prevalence of high glucose levels and satisfaction with social relationships (Cochran's Q = 16.33, p = .001 resp. Q = 14.79, p = .001).

CONCLUSION

The annual PHAMOUS screening enables to follow the mental, physical and social health problems of patients, which offers a good basis for shared-decision making with regard to updating the annual treatment plan, next to a wealth of data for scientific research.

Clozapine-related neutropenia, myocarditis and cardiomyopathy adverse event reports in Australia 1993-2014

RATIONALE

Clozapine is the gold-standard medicine for treating refractory schizophrenia but there are some notable serious adverse events (AE). We aimed to analyse reported rates of clozapine cardiac and haematological AEs in Australia.

METHODS

Using data from the Therapeutic Goods Administration, we examined all reported clozapine AEs (1993-2014) with a specific focus on neutropenia, myocarditis and cardiomyopathy. We related AEs to clozapine-dispensing data in Queensland, scaled up to Australia.

RESULTS

There were 8561 AEs reported: neutropenia (13.7%), myocarditis (9.3%) and cardiomyopathy (3.8%). Reported rates of myocarditis and cardiomyopathy increased after 1999 following a myocarditis case series from Sydney. Cardiomyopathy AE rates have remained stable since then but myocarditis AEs have increased steadily. Neutropenia was more common in women, while cardiomyopathy and myocarditis were more common in men. There were five, 13, and two reported deaths from neutropenia, myocarditis, and cardiomyopathy, respectively.

CONCLUSIONS

The rates of serious AEs (including deaths) are low and likely an underestimate of true rates and need to be considered by clinicians in balancing the risks and benefits. Continued education on the monitoring and treatment of these AEs for consumers, carers and health professionals is essential and reporting these to the relevant national reporting agency is crucial.

[The problem of multiple somatic and/or psychiatric pathology basic concepts and prevalence]

The literature of the last decades shows the growing interest to multiple pathologies in medicine including psychiatry and neurology. Multiple pathology is often determined as multimorbidity or comorbidity. Multiple pathology is a common phenomenon, which is the rule rather than the exception. In the medical care system, it is burden for the patient and for the physician in clinical, organizational and economic aspects. The review addresses all these issues in the aspect of terminology and prevalence.

Cardiovascular Safety of Psychiatric Agents: A Cautionary Tale

Psychiatric agents are among the most commonly prescribed medications. Despite the advent of newer generation agents, patients receiving them still experience cardiovascular (CV) side effects. However, these agents may have heterogeneous properties, calling for an individualized approach based on efficacy and also on the particular side effect profile of each specific agent. Proarrhythmic effects arising from drug-induced long-QT syndrome and consequent potentially life-threatening polymorphic ventricular arrhythmias in the form of torsade de pointes, the metabolic syndrome contributing to atherosclerosis and acute coronary syndromes, and drug-induced orthostatic hypotension raise major concerns. Of course, it is also crucial that fear of potential CV adverse effects does not deprive psychiatric patients of appropriate drug therapy. Modification of CV risk factors in psychiatric patients together with optimal management of their CV diseases and appropriate selection of psychotropic agents with greater efficacy and least CV toxicity are of paramount importance in mitigating CV risks and enhancing safety. Identifying patients at high risk of CV complications and close monitoring of all patients receiving these agents are crucial steps to prevent and manage such complications. All these issues are herein reviewed, relevant guidelines are discussed, and schemas are depicted that illustrate the interrelated connections among the psychotropic agents and their CV effects.

Do mental health consumers want to improve their long-term disease risk behaviours? A survey of over 2000 psychiatric inpatients

Policies and clinical guidelines acknowledge the role mental health services have in addressing the physical health of individuals with a mental illness; however, little research has explored interest in reducing health risk behaviours or the acceptability of receiving support to reduce such risks among psychiatric inpatients. This study estimated the prevalence of four long-term disease risk behaviours (tobacco smoking, hazardous alcohol consumption, inadequate fruit and/or vegetable consumption, and inadequate physical activity); patient interest in reducing these risks; and acceptability of being provided care to do so during a psychiatric inpatient stay. A cross-sectional survey was undertaken with 2075 inpatients from four inpatient psychiatric facilities in one health district in Australia (October 2012-April 2014). Prevalence of risk behaviours ranged from 50.2% (inadequate physical activity) to 94.8% (inadequate fruit and/or vegetable consumption). The majority of respondents (88.4%) had more than one risk behaviour, and most were seriously considering improving their risk behaviours (47.6% to 65.3%). The majority (80.4%) agreed that it would be acceptable to be provided support and advice to change such behaviours during their psychiatric inpatient stay. Some diagnoses were associated with smoking and hazardous alcohol consumption, interest in reducing alcohol consumption and increasing fruit and/or vegetable consumption, and acceptability of receiving advice and support. The findings reinforce the need and opportunity for psychiatric inpatient facilities to address the long-term disease risk behaviours of their patients.

Enhancing metabolic monitoring for children and adolescents using second-generation antipsychotics

The prevalence of children and adolescents using second-generation antipsychotics (SGAs) has increased significantly in recent years. In this population, SGAs are used to treat mood and behavioural disorders although considered 'off-label' or not approved for these indications. Metabolic monitoring is the systematic physical health assessment of antipsychotic users utilized to detect cardiovascular and endocrine side effects and prevent adverse events such as weight gain, hyperglycaemia, hyperlipidemia, and arrhythmias. This practice ensures safe and efficacious SGA use among children and adolescents. Despite widely available, evidence-based metabolic monitoring guidelines, rates of monitoring continue to be suboptimal; this exposes children to the unnecessary risk of developing poor cardiovascular health and long-term disease. In this discursive paper, existing approaches to metabolic monitoring as well as challenges to implementing monitoring guidelines in practice are explored. The strengths and weaknesses of providing metabolic monitoring across outpatient psychiatry, primary care, and collaborative community settings are discussed. We suggest that there is no one-size-fits-all solution to improving metabolic monitoring care for children and adolescents using SGA in all settings. However, we advocate for a pragmatic global approach to enhance safety of children and adolescents taking SGAs through collaboration among healthcare disciplines with a focus on integrating nurses as champions of metabolic monitoring.

Prevalence of underweight in patients with schizophrenia: A meta-analysis

AIMS

Although the relationship between body mass index and all-cause mortality is U-shaped, underweight has received comparatively less attention than obesity. There is only limited evidence to date regarding underweight among patients with schizophrenia. This is the first meta-analysis to address the prevalence of underweight in these patients.

METHODS

We conducted database searches (PubMed, PsycINFO) to identify studies examining underweight in patients with schizophrenia. In total, 17 studies (18 groups) with 45,474 patients were included; data were extracted independently by two authors. A meta-analysis was performed to calculate the pooled prevalence of underweight in patients.

RESULTS

The pooled prevalence of underweight was 6.2% (95% CI=4.5-8.6) for the 18 groups, which included 45,474 patients with schizophrenia. The heterogeneity was I²=98.9% (95% Cl=98.7-99.1%). Four studies with 4 groups, consisting of 30,014 individuals, focused on Japanese inpatients with schizophrenia. The pooled prevalence of underweight among inpatients in these 4 groups was 17.6% (95% CI=15.5-20.0). Fourteen studies were conducted with non-Japanese inpatients and included 14 groups of 15,460 patients with schizophrenia. The pooled prevalence of underweight in non-Japanese inpatients was 4.6% (95% CI=3.9-5.4). The proportion of underweight in the 18 groups significantly varied between Japanese inpatients and other patients.

CONCLUSIONS

The results indicated that Japanese inpatients with schizophrenia have a high proportion of underweight. Future research should focus on evaluating interventions that target underweight.

The opinions of Turkish mental health nurses on physical health care for individuals with mental illness: A qualitative study

WHAT IS KNOWN ON THE SUBJECT

Individuals with mental illness have significantly higher mortality and morbidity than the general population due to physical illnesses. Mental health nurses play a key role in providing care for common physical problems and protecting and promoting healthy lifestyles. Little is known from previous studies in the international literature about the attitudes, behaviours and thoughts of mental health nurses on providing physical health care.

WHAT THIS PAPER ADDS TO THE EXISTING KNOWLEDGE

Mental health nurses mostly focus on the existing physical health problems of individuals with mental illness. However, mental health nurses do not include practices of disease prevention and physical health promotion for individuals with mental illness. The desire to see positive changes in individuals with mental illness, receiving positive feedback, feeling useful and happy, and feeling satisfied with their profession motivate mental health nurses in terms of providing physical health care.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

The knowledge and skill required of mental health nurses to provide physical health care need to be increased. Institutions should employ expert nurses who are able to guide mental health nurses to provide physical health care. It is important to provide adequate physical infrastructure and human resources to provide better physical health care in mental health services.

ABSTRACT

Background Mental health nurses play an important role in improving the physical health of individuals with mental illnesses. However, there are limited studies of their attitudes and practices about physical health. Therefore, there is a need for qualitative studies to clarify the issue.

AIM

The aim of this study was to determine mental health nurses' opinions about physical health care for individuals with mental illness.

METHODS

This study was carried out in Turkey. A qualitative descriptive approach was taken in the study. The sample consisted of twelve mental health nurses selected by purposeful sampling. In-depth interviews were conducted using a semi-structured interview format. A thematic analysis was used to evaluate the interviews.

RESULTS

Four main themes were determined. (1) The barriers to physical healthcare theme included barriers related to patients, illness and treatment, barriers related to patients' caregivers, barriers related to health professionals and barriers related to the healthcare system. (2) The physical healthcare practices theme included common physical health problems and current nursing practices. (3) Motivators theme included the desire to see positive changes in a patient, receiving positive feedback, feeling useful and happy, having a sense of conscience and feeling satisfied with their profession. (4) The needs for better physical healthcare theme included the nurses' recommendations for better physical health care.

CONCLUSION

Mental health nurses believe that the physical health care provided to individuals with mental illness is not adequate. Many barriers to providing care for physical health, such as having psychiatric symptoms that are not seen as a priority by patients and health personnel, were determined.

IMPLICATIONS FOR PRACTICE

Mental health nurses should integrate physical healthcare practices into their routine care. In addition, mental health nurses' knowledge and skills about physical health care should be improved.

Frequency and Nature of Medication Errors and Adverse Drug Events in Mental Health Hospitals: a Systematic Review

INTRODUCTION

Little is known about the frequency and nature of medication errors (MEs) and adverse drug events (ADEs) that occur in mental health hospitals.

OBJECTIVES

This systematic review aims to provide an up-to-date and critical appraisal of the epidemiology and nature of MEs and ADEs in this setting.

METHOD

Ten electronic databases were searched, including MEDLINE, Embase, CINAHL, International Pharmaceutical Abstracts, PsycINFO, Scopus, British Nursing Index, ASSIA, Web of Science, and Cochrane Database of Systematic Reviews (1999 to October 2016). Studies that examined the rate of MEs or ADEs in mental health hospitals were included, and quality appraisal of the included studies was conducted.

RESULT

In total, 20 studies were identified. The rate of MEs ranged from 10.6 to 17.5 per 1000 patient-days (n = 2) and of ADEs from 10.0 to 42.0 per 1000 patient-days (n = 2) with 13.0-17.3% of ADEs found to be preventable. ADEs were rated as clinically significant (66.0-71.0%), serious (28.0-31.0%), or life threatening (1.4-2.0%). Prescribing errors occurred in 4.5-6.3% of newly written or omitted prescription items (n = 3); dispensing errors occurred in 4.6% of opportunities for error (n = 1) and in 8.8% of patients (n = 1); and medication administration errors occurred in 3.3-48.0% of opportunities for error (n = 5). MEs and ADEs were frequently associated with psychotropics, with atypical antipsychotic drugs commonly involved. Variability in study setting and data collection methods limited direct comparisons between studies.

CONCLUSION

Medication errors occur frequently in mental health hospitals and are associated with risk of patient harm. Effective interventions are needed to target these events and improve patient safety.

Monitoring of physical health in services for young people at ultra-high risk of psychosis

AIM

People with schizophrenia have poor physical health and high rates of premature mortality. Risk factors for later cardiovascular disease are present from an early stage, and recording of these factors is recommended in first-episode services. However, it is unclear whether cardiometabolic risk factors are monitored prior to first-episode psychosis.

METHODS

A retrospective analysis was conducted on case notes of individuals accepted into a specialized early detection service for young people at ultra-high risk for psychosis. Notes were assessed to determine whether the following physical health measures were recorded: height, weight, body mass index, blood pressure, blood glucose and lipids, physical activity levels, smoking status, substance use and alcohol intake.

RESULTS

Forty individuals were deemed at ultra-high risk for psychosis and accepted into the service. The two measures reported most frequently were whether a person used substances (82.5%) or alcohol (72.5%), but more specific details were not commonly reported. A minority of case files contained information on height (2.5%), weight (7.5%), body mass index (5%), blood glucose (2.5%), smoking status (15%) and physical activity (7.5%). Six case files had no measure of physical health.

CONCLUSIONS

Physical health and unhealthy lifestyle factors were not assessed routinely in the specialized service. Clear monitoring guidelines should be developed to establish routine assessment of common metabolic risk factors present in this population.

Residents Perceive Limited Education on Family Planning and Contraception for Patients with Severe and Persistent Mental Illness

OBJECTIVE

The primary goal of this study was to assess perceived adequacy of training by residents from multiple specialties on contraceptive prescribing and family planning for patients with severe and persistent mental illness (SPMI). Secondary goals included the following: (1) explore resident knowledge, attitudes, and behavior towards patients with SPMI and (2) identify barriers to meeting the reproductive health needs of patients with SPMI.

METHODS

The target population was 44,237 residents from four medical specialties. Participants were from a stratified, self-selected sample. Program coordinators were asked to forward a survey link to residents. Consenting residents were provided access to a questionnaire via a secure, web-based application (REDCap). The survey assessed resident education on the reproductive health needs of patients with SPMI and included demographics (age, gender, year of residency, and specialty), perceived adequacy of training, knowledge, and attitudes, and barriers regarding contraception and family planning. Responses were summarized with frequency and compared by medical specialty.

RESULTS

A total of 768 residents consented: 49% female, 20% male, and 31% did not indicate their gender; 19% were first year residents, 21% second year residents, 21% third year residents, 8% fourth year residents, and 30% did not indicate their year of training. By specialty, 30.6% of residents were from family medicine programs (n = 235), 10.8% were from internal medicine programs (n = 83), 18.1% were from OBGYN programs (n = 139), and 10.4% were from psychiatry programs (n = 80); 231 (30.1%) did not indicate specialty. Regarding training, 60% of residents disagreed or strongly disagreed that they had proper training on prescribing contraceptives for patients with SPMI (363 of 599). Sixty two percent of residents disagreed or strongly disagreed that they had proper training about family planning for patients with SPMI (368/599). Over 83% of residents surveyed (405/486) would prescribe contraception for patients with SPMI if they had adequate training.

CONCLUSIONS

Results indicate the need for curricular change on the reproductive health needs of patients with SPMI.

Access to specialist palliative care services by people with severe and persistent mental illness: A retrospective cohort study

Compared to the general population, people with pre-existing serious and persistent mental illness (SPMI) have higher rates of physical illness and die at an earlier age, raising questions about their palliative and end-of-life care needs when they are diagnosed with an incurable physical illness. In the present study, we explored access to specialist palliative care services within one New Zealand health district. Routinely-collected, de-identified patient information on a cohort of people diagnosed with SPMI, and receiving specialist palliative care services from the Capital and Coast District Health Board (CCDHB), was compared to the general population from the same health district. People with SPMI are 3.5 times less likely to receive specialist palliative services compared to the general population from the Capital and Coast District Health Board. The proportion of people identifying as Māori is 1.2 times higher in the SPMI cohort than the general CCDHB population. The SPMI cohort experiences a higher level of deprivation compared to the general population in the CCDHB. The present study confirms that those diagnosed with an SPMI are less likely to use specialist palliative care services at the end of life. Research using a national dataset is needed to determine whether the study findings are applicable to the national population.

Elucidating the diagnostic odyssey of 22q11.2 deletion syndrome

Clinical molecular testing has been available for 22q11.2 deletion syndrome (22q11.2DS) for over two decades yet under-recognition and diagnostic delays are common. To characterize the "diagnostic odyssey" in 22q11.2DS we studied 202 well-characterized unrelated adults, none ascertained through an affected relative. We used a regression model to identify clinical and demographic factors associated with length of time to molecular diagnosis. Kaplan-Meier analysis compared time to diagnosis for the molecular testing era (since 1994) and earlier birth cohorts. The results showed that the median time to molecular diagnosis of the 22q11.2 deletion was 4.7 (range 0-20.7) years. Palatal and cardiac anomalies, but not developmental delay/intellectual disability, were associated with a shorter time to molecular diagnosis. Non-European ethnicity was associated with longer time to diagnosis. Inclusion of a cohort from another 22q11.2DS center increased power to observe a significantly earlier diagnosis for patients born in the molecular testing era. Nonetheless, only a minority were diagnosed in the first year of life. On average, patients were seen in seven (range 2-15) different clinical specialty areas prior to molecular diagnosis. The findings indicate that even for those born in the molecular testing era, individuals with 22q11.2DS and their families face a diagnostic odyssey that is often prolonged, particularly in the absence of typical physical congenital features or for those of non-European ancestry. The results support educational efforts to improve clinical recognition and testing, and ultimately newborn screening as a means of maximizing early detection that would provide the best opportunity to optimize outcomes.

Cardiometabolic comorbidities and life expectancy in people on medication for schizophrenia in Australia

OBJECTIVE

This study aimed to assess the risks of people on medication for schizophrenia developing different components of the metabolic syndrome and their life expectancy, through reference to a representative population of Australians without schizophrenia.

METHOD

Pharmacy payment-claim records from the Pharmaceutical Benefits Scheme were analyzed based on a representative 10% sample of Medicare numbers supplied by the Department of Human Services. Records were analyzed based on the date of supply of the prescription and the dataset included year of death information. Two major analyses were conducted for 9,533 people on medication for schizophrenia and a 1:1 sex/age matched control, followed for up to 7 years. Patient life expectancy was estimated by performing a Kaplan Meier survival analysis.

RESULTS

People on medication for schizophrenia compared to controls were 1.91-times (95% CI = 1.66-2.21) and 1.28-times (95% CI = 1.15-1.43) more likely to start treatment for diabetes and hyperlipidemia, respectively, but were no more likely to start treatment for hypertension (hazard ratio = 0.87; 95% CI = 0.78-0.97). Overall, people on medication for schizophrenia were 1.32-times more likely to start treatment for one of these three comorbidities. Median life expectancy was assessed as 80 years for people on medication for schizophrenia, and 91 years for controls.

CONCLUSIONS

The results for this study confirm in a large representative Australian sample of people on medication for schizophrenia, an excess risk of components of the metabolic syndrome and early death.

Comorbidity of chronic somatic diseases in patients with psychotic disorders and their influence on 4-year outcomes of integrated care treatment (ACCESS II study)

BACKGROUND

People with psychotic disorders fulfilling criteria of a severe and persistent mental illness (SPMI) display a high risk of somatic comorbidity (SC).

METHODS

ACCESS II is a prospective, long-term study examining the effectiveness of Integrated Care for people with psychotic disorders fulfilling SPMI criteria. Chronic comorbid somatic disorders were systematically assessed according to ICD-10-GM criteria. Patients treated for ≥4years in ACCESS were categorized as early psychosis (treatment: ≤2years) or non-early psychosis (treatment: >2years) patients.

RESULTS

Of 187 patients treated in ACCESS for ≥4years (mean age=41.8years, males=44.4%), 145 (77.5%) had SC, (mean=2.1±2.1). Overall, 55 different diseases from 15 different ICD-10-GM disease areas were identified. Prevalence of ≥1 SC (p=0.09) and specific types of SC (p=0.08-1.00) did not differ between early and non-early psychosis patients, but non-early psychosis patients had a higher mean number of SC (2.3±2.2 vs. 1.3±1.3, p=0.002). SC patients had higher rates of comorbid mental disorders (93% vs. 81%, p=0.002), specifically posttraumatic stress disorder (23% vs. 7%, p=0.002), and suicide attempts (43% vs. 19%, p<0.001). At the 4-year endpoint, both patients with and without comorbidity displayed major improvements in psychopathology, severity of illness, functioning, quality of life and satisfaction with care.

CONCLUSIONS

SC is frequent in patients with severe psychotic disorders, even in the early psychosis phase. The magnitude of the problem underlines the need for regular screening, comprehensive assessment, preventive pharmacotherapy, and targeted SC management.

Excess mortality in people with mental illness: findings from a Northern Italy psychiatric case register

PURPOSE

People with mental disorders show mortality rates up to 22.2 times higher than that of the general population. In spite of progressive increase in life expectancy observed in the general population, the mortality gap of people suffering from mental health problems has gradually widened. The aim of this paper was to study mortality rates in people suffering from mental illness in a cohort of people (16,981 subjects) in the local mental health register of the province of Modena during the decade 2006-2015.

METHODS

Standardized Mortality Ratios (SMRs) were calculated to compare the mortality of people with mental disorders to the mortality of people living in the province of Modena and the excess of mortality was studied in relation to the following variables: gender, age group, diagnosis and causes of death. In addition, Poisson regression analysis was performed to study the association between patient characteristics and mortality.

RESULTS

An overall excess mortality of 80% was found in subjects under the care of mental health services as compared to the reference population (SMR = 1.8, 95% CI 1.7-1.9). Subjects in the 15-44 year group presented the highest SMR (9.2, 95% CI 6.9-11.4). The most prevalent cause of death was cancer (28.1% of deaths). At the Poisson regression, the diagnosis "Substance abuse and dependence" showed the highest relative risk (RR) (4.00). Moreover, being male, single, unemployed and with a lower qualification was associated with higher RRs.

CONCLUSIONS

Our study confirms that subjects with mental illness have higher SMR. Noteworthy, the overall higher risk of mortality was observed in the younger age group.

Assessing the reliability of the short form 12 (SF-12) health survey in adults with mental health conditions: a report from the wellness incentive and navigation (WIN) study

Background

Although Short Form (SF)-12 × 2® has been extensively studied and used as a valid measure of health-related quality of life in a variety of population groups, no systematic studies have described the reliability of the measure in patients with behavioral conditions or serious mental illness (SMI).

Methods and results

We assessed the internal consistency, split-half reliability and annual test-retest correlations in a sample of 1587 participants with either a combination of physical and behavioral conditions or SMI. The Mosier’s alpha was 0.70 for the Physical Composite Scale (PCS) and 0.69 for the Mental Health Composite Scale (MCS), indicating good internal consistency. We observed strong correlations between physical functioning, physical role and body pain scales (r = 0.55–0.56), and between social functioning, emotional role, and mental health (r = 0.53–0.58). We calculated split-half reliabilities to be 0.74 for physical functioning, 0.75 for physical role, 0.73 for emotional role and 0.65 for mental health respectively. We assessed the annual test-retest correlation using intraclass correlation (ICC) and found an ICC of 0.61 for PCS and 0.57 for MCS composite scores, adjusting for age, sex, race/ethnicity, and CRG. We found no decline in the correlations between baseline and the following study years until year 3.

Conclusions

Our results encourage using SF-12v2® to assess health-related quality of life in the Medicaid population with combined physical and behavioral conditions or similar cohorts.

Trial registration

The WIN study was registered with clinicaltrials.gov on April 22, 2015. Trial registration number: NCT02440906. Retrospectively registered.

Impact of a nurse practitioner role on metabolic monitoring completion and referrals for consumers admitted to the intensive care area of an acute inpatient psychiatric unit

Mental illness increases a person's risk of physical health issues, including cardiovascular disease, leading to premature morbidity and mortality. Screening for cardiovascular disease through metabolic monitoring is recommended to aid in early detection. The aim of the present study was to ascertain whether consumers admitted to an inpatient mental health unit receive routine metabolic monitoring, and to explore the contribution of a nurse practitioner to metabolic monitoring and the actioning of abnormal results. The present study used a retrospective mirror image cohort method to look at clinical consumer files for two separate 6-month periods before and after a nurse practitioner role commenced. Metabolic monitoring variables were computed as completion frequencies and percentages. Univariate analyses were computed to describe differences among metabolic monitoring variables. A total of 497 consumers were admitted to the mental health inpatient unit's intensive care area across the two 6-month data-collection periods. Prior to the nurse practitioner role, only 2% of consumers had their body mass index (BMI) risk calculated; less than 1% had their waist circumference measured, and no abnormal results were referred to a general practitioner (GP). After the nurse practitioner role commenced, BMI risk was calculated for 67% of consumers, waist circumference recorded for 68%, and referrals for abnormal results were forwarded to 37 consumers' GPs. A nurse practitioner on the inpatient mental health unit has allowed for a considerable increase in the metabolic screening of admitted consumers resulting in a number of referrals being forwarded to consumers' GPs to be acted upon.

The pharmacological management of metabolic syndrome

INTRODUCTION

The metabolic syndrome includes a constellation of several well-established risk factors, which need to be aggressively treated in order to prevent overt type 2 diabetes and cardiovascular disease. While recent guidelines for the treatment of individual components of the metabolic syndrome focus on cardiovascular benefits as resulted from clinical trials, specific recent recommendations on the pharmacological management of metabolic syndrome are lacking. The objective of present paper was to review the therapeutic options for metabolic syndrome and its components, the available evidence related to their cardiovascular benefits, and to evaluate the extent to which they should influence the guidelines for clinical practice. Areas covered: A Medline literature search was performed to identify clinical trials and meta-analyses related to the therapy of dyslipidemia, arterial hypertension, glucose metabolism and obesity published in the past decade. Expert commentary: Our recommendation for first-line pharmacological are statins for dyslipidemia, renin-angiotensin-aldosteron system inhibitors for arterial hypertension, metformin or sodium/glucose cotransporter 2 inhibitors or glucagon-like peptide 1 receptor agonists (GLP-1RAs) for glucose intolerance, and the GLP-1RA liraglutide for achieving body weight and waist circumference reduction.

Offer and Use of Smoking-Cessation Support by Depression/Anxiety Status: A Cross-Sectional Survey

Introduction: Higher levels of anxiety and depression have been found to be associated with greater difficulty in stopping smoking. This raises the question as to whether mood disturbance may be associated with exposure to, and use of, quitting support.

Aims: This study examined whether General Practitioner (GP) advice and/or offer of support, or stop-smoking service use differed between smokers reporting or not reporting depression/anxiety.

Methods: Data came from the Smoking Toolkit Study. Participants were 1,162 English adults who reported currently smoking or having stopped within the past 12 months, aged 40+ years, surveyed between April and September 2012. Anxiety/depression was assessed by the mood disturbance item of the EuroQol five dimensions questionnaire (EQ-5D). This was compared to recall of GP quit advice and/or support, and stop-smoking aid use adjusting for age, gender, and social grade.

Results/Findings: Smokers reporting depression/anxiety were more likely to recall being offered advice and support to stop smoking by their GP (OR = 1.50, 95% C.I. = 1.05–2.13). However, there were no significant differences in use of stop-smoking aids during the past year.

Conclusions: Smokers reporting depression/anxiety are more likely to be offered stop-smoking support by their GPs, but this does not appear to translate into stop-smoking aid use, despite high motivation to quit. Given higher nicotine dependence in this group, mental health specific support may need to be offered, and more needs to be done to make this offer of aid attractive.

Somatic Care with a Psychotic Disorder. Lower Somatic Health Care Utilization of Patients with a Psychotic Disorder Compared to Other Patient Groups and to Controls Without a Psychiatric Diagnosis

Patients with non-affective psychotic disorders (NAPD) face higher risk of somatic problems and early natural death compared to the general population. Therefore, treatment guidelines for schizophrenia and psychosis stress the importance of monitoring somatic risk factors. This study examined somatic Health Care utilization (HCu) of patients with NAPD compared to non-psychiatric controls and patients with depression, anxiety or bipolar disorders using a large Health Insurance database. Results show lower specialist somatic HCu of patients with NAPD compared to matched controls and also lower percentages for prescribed somatic medication and general practitioner consultations for patients aged ≥60 years and after longer illness duration.

Access to primary and specialized somatic health care for persons with severe mental illness: a qualitative study of perceived barriers and facilitators in Swedish health care

BACKGROUND

Persons with severe mental illness (e.g. schizophrenia, bipolar disorder) have a high prevalence of somatic conditions compared to the general population. Mortality data in the Nordic countries reveal that these persons die 15-20 years earlier than the general population. Some factors explaining this high prevalence may be related to the individuals in question; others arise from the health care system's difficulty in offering somatic health care to these patient groups. The aim of the present study was therefore to explore the experiences and views of patients, relatives and clinicians regarding individual and organizational factors which facilitate or hinder access to somatic health care for persons with severe mental illness.

METHODS

Flexible qualitative design. Data was collected by means of semi-structured individual interviews with patients with severe mental illness, relatives and clinicians representing primary and specialized health care. In all, 50 participants participated.

RESULTS

The main barrier to accessing somatic care is the gap between the organization of the health care system and the patients' individual health care needs. This is observed at both individual and organizational level. The health care system seems unable to support patients with severe mental illness and their psychiatric-somatic comorbidity. The main facilitators are the links between severe mental illness patients and medical departments. These links take the form of functions (i.e. systems which ensure that patients receive regular reminders), or persons (i.e. professional contacts who facilitate patients' access the health care).

CONCLUSIONS

Health care services for patients with severe mental illness need reorganization. Organizational structures and systems that facilitate cooperation between different departments must be put in place, along with training for health care professionals about somatic disease among psychiatric patients. The links between individual and organizational levels could be strengthened by introducing professional contacts, such as liaison physicians and case managers. This is also important to reduce stress and responsibility among relatives.

Preventive Service Use Among People With and Without Serious Mental Illnesses

INTRODUCTION

People with serious mental illnesses experience excess morbidity and premature mortality resulting from preventable conditions. The goal was to examine disparities in preventive care that might account for poor health outcomes.

METHODS

In this retrospective cohort study, adults (N=803,276) served by Kaiser Permanente Northwest and federally qualified health centers/safety-net community health clinics were categorized into five groups: schizophrenia spectrum disorders, bipolar disorders/affective psychoses, anxiety disorders, nonpsychotic unipolar depression, and reference groups with no evidence of these specific mental illnesses. The primary outcome was overall preventive care-gap rate, the proportion of incomplete preventive services for which each patient was eligible in 2012-2013. Secondary analyses examined Kaiser Permanente Northwest data from 2002 to 2013. Data were analyzed in 2015.

RESULTS

Controlling for patient characteristics and health services use, Kaiser Permanente Northwest mean care-gap rates were significantly lower for bipolar disorders/affective psychoses (mean=18.6, p<0.001) and depression groups (mean=18.6, p<0.001) compared with the reference group. Schizophrenia (mean=19.4, p=0.236) and anxiety groups (mean=19.9, p=0.060) did not differ from the reference group (mean=20.3). In community health clinics, schizophrenia (mean=34.1, p<0.001), bipolar/affective psychosis (mean=35.7, p<0.001), anxiety (mean=38.5, p<0.001), and depression groups (mean=36.3, p<0.001) had significantly lower care-gap rates than those in the reference group (mean=40.0). Secondary analyses of diabetes and dyslipidemia screening trends in Kaiser Permanente Northwest showed diagnostic groups consistently had fewer care gaps than patients in the reference group.

CONCLUSIONS

In vastly different settings, individuals with serious mental illnesses received preventive services at equal or better rates than the general population.

A Randomized Controlled Trial on the Efficacy of a Psychosocial Behavioral Intervention to Improve the Lifestyle of Patients With Severe Mental Disorders: Study Protocol

Patients with severe mental disorders die on average 20 years prior to the general population. This mortality gap is mainly due to the higher prevalence of physical diseases and the adoption of unhealthy lifestyle behaviors.The LIFESTYLE trial aims to evaluate the efficacy of a new psychosocial group intervention (including psychoeducational, motivational, and problem-solving techniques) focused on healthy lifestyle behavior compared to a brief educational group intervention in a community sample of patients with severe mental disorders. The trial is a national-funded, multicentric, randomized controlled trial with blinded outcome assessments, which is carried out in six outpatient units of the Universities of Campania "Luigi Vanvitelli" in Naples, Bari, Genova, L'Aquila, Pisa, and Rome-Tor Vergata. All patients are assessed at the following time points: baseline (T0); 2 months post-randomization (T1); 4 months post-randomization (T2); 6 months post-randomization (T3); 12 months post-randomization (T4); and 24 months post-randomization (T5). T1 and T2 assessments include only anthropometric tests. The BMI, a reliable and feasible anthropometric parameter, has been selected as primary outcome. In particular, the mean value of BMI at 6 months from baseline (T3) will be evaluated through a Generalized Estimated Equation model. The work hypothesis is that the LIFESTYLE psychosocial group intervention will be more effective than the brief educational group intervention in reducing the BMI. We expect a mean difference between the two groups of at least one point (and standard deviation of two points) at BMI. Secondary outcomes are: the improvement in dietary patterns, in smoking habits, in sleeping habits, physical activity, personal and social functioning, severity of physical comorbidities, and adherence to medications. The expected sample size consists of 420 patients (70 patients for each of the six participating centers), and they are allocated with a 1:1 ratio randomization, stratified according to center, age, gender, and educational level. Heavy smoking, sedentary behavior, and unhealthy diet pattern are very frequent and are associated with a reduced life expectancy and higher levels of physical comorbidities in people with severe mental disorders. New interventions are needed and we hope that the LIFESTYLE protocol will help to fill this gap.

TRIAL REGISTRATION NUMBER

2015C7374S.

Investigating the Agreement Between Cardiovascular Disease Risk Calculators Among People Diagnosed With Schizophrenia

Background: People diagnosed with schizophrenia have a much reduced life expectancy compared to the general population, and a more than doubled risk of dying from cardiovascular disease (CVD). Existing CVD risk calculators can be used to detect people with an elevated predicted risk of CVD to inform interventions to reduce risk. Aims: This study aimed to compare four different risk calculators for 10-year predicted CVD risk in a sample of people with schizophrenia. Methods: Thirty participants with a diagnosis of schizophrenia spectrum disorders living within Greater Manchester, United Kingdom took part. Ten-year predicted cardiovascular risk scores were calculated using four different models: QRISK3, Framingham, PRIMROSE BMI, and PRIMROSE lipid. Risk estimates and classified risk categories were compared. Results: QRISK3 identified 11 (39%) as having >10% risk of a CV event within 10 years, 4 (14%) of whom exceeded 20%. The Framingham model identified 4 (14%) as exceeding 10%, none of whom exceeded 20%. PRIMROSE risk calculators identified no participants as having >10% risk of a CV event within 10 years. Pairwise concordance correlation coefficients between types of model ranged 0.22-0.77. Mean (± SD) age was 40 (± 10) years but QRISK3's mean "Heart age" was 58 (± 14) years. Conclusion: Risk calculators generate differing predicted CVD risk scores for patients with schizophrenia. Using one risk calculator might yield different recommended monitoring and treatment plans compared to another. Clinicians should therefore take into account other patient-related factors, such as patients' preferences and other underlying physical conditions when making treatment decisions.

Three Approaches to Understanding and Classifying Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental Health’s Research Domain Criteria (RDoC)

The diagnosis of mental disorder initially appears relatively straightforward: Patients present with symptoms or visible signs of illness; health professionals make diagnoses based primarily on these symptoms and signs; and they prescribe medication, psychotherapy, or both, accordingly. However, despite a dramatic expansion of knowledge about mental disorders during the past half century, understanding of their components and processes remains rudimentary. We provide histories and descriptions of three systems with different purposes relevant to understanding and classifying mental disorder. Two major diagnostic manuals—the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders—provide classification systems relevant to public health, clinical diagnosis, service provision, and specific research applications, the former internationally and the latter primarily for the United States. In contrast, the National Institute of Mental Health’s Research Domain Criteria provides a framework that emphasizes integration of basic behavioral and neuroscience research to deepen the understanding of mental disorder. We identify four key issues that present challenges to understanding and classifying mental disorder: etiology, including the multiple causality of mental disorder; whether the relevant phenomena are discrete categories or dimensions; thresholds, which set the boundaries between disorder and nondisorder; and comorbidity, the fact that individuals with mental illness often meet diagnostic requirements for multiple conditions. We discuss how the three systems’ approaches to these key issues correspond or diverge as a result of their different histories, purposes, and constituencies. Although the systems have varying degrees of overlap and distinguishing features, they share the goal of reducing the burden of suffering due to mental disorder.

Depression and pain: primary data and meta-analysis among 237 952 people across 47 low- and middle-income countries

BACKGROUND

Depression and pain are leading causes of global disability. However, there is a paucity of multinational population data assessing the association between depression and pain, particularly among low- and middle-income countries (LMICs) where both are common. Therefore, we investigated this association across 47 LMICs.

METHODS

Community-based data on 273 952 individuals from 47 LMICs were analysed. Multivariable logistic and linear regression analyses were performed to assess the association between the International Classification of Diseases, 10th Revision depression/depression subtypes (over the past 12 months) and pain in the previous 30 days based on self-reported data. Country-wide meta-analysis adjusting for age and sex was also conducted.

RESULTS

The prevalence of severe pain was 8.0, 28.2, 20.2, and 34.0% for no depression, subsyndromal depression, brief depressive episode, and depressive episode, respectively. Logistic regression adjusted for socio-demographic variables, anxiety and chronic medical conditions (arthritis, diabetes, angina, asthma) demonstrated that compared with no depression, subsyndromal depression, brief depressive episode, and depressive episode were associated with a 2.16 [95% confidence interval (CI) 1.83-2.55], 1.45 (95% CI 1.22-1.73), and 2.11 (95% CI 1.87-2.39) increase in odds of severe pain, respectively. Similar results were obtained when a continuous pain scale was used as the outcome. Depression was significantly associated with severe pain in 44/47 countries with a pooled odds ratio of 3.93 (95% CI 3.54-4.37).

CONCLUSION

Depression and severe pain are highly comorbid across LMICs, independent of anxiety and chronic medical conditions. Whether depression treatment or pain management in patients with comorbid pain and depression leads to better clinical outcome is an area for future research.

Underweight and hypoalbuminemia as risk indicators for mortality among psychiatric patients with medical comorbidities

AIM

Medical comorbidities are a major cause of death among patients with mental illness. The purpose of this study was to clarify the risk factors for mortality among psychiatric patients with medical comorbidities.

METHODS

We retrospectively reviewed the clinical files of patients transferred to Tokyo Metropolitan Matsuzawa Hospital from a psychiatric hospital to treat medical comorbidities during the 3-year period from January 2014 to December 2016. We analyzed the clinical differences between the expired and alive patients.

RESULTS

Of the 287 patients included, 29 (10.1%) had expired at the time of hospital discharge, while 258 (89.9%) were living. A multivariable analysis to determine the prognostic factors related to mortality from medical comorbidities showed that body mass index <18.5 had the highest odds ratio among the predictive factors (5.1; 95% confidence interval, 1.5-17.1; P < 0.05), followed by a serum albumin level < 3.0 mg/dL (3.0; 95% confidence interval, 1.1-8.1; P < 0.05).

CONCLUSION

We found that underweight and hypoalbuminemia were risk factors for mortality among psychiatric patients with medical comorbidities. Physicians at psychiatric hospitals should consider transferring patients with medical comorbidities to a general medical hospital in the presence of underweight and/or hypoalbuminemia.

Mental health nursing students' views on their readiness to address the physical health needs of service users on registration

There is substantial evidence that people (service users) living with a serious mental illness experience poorer physical health than the general population and die prematurely from life-threatening illnesses. Mental health nurses are best placed to address the physical health needs of service users but evidence points to numerous challenges, including a deficit in their proficiency to meet these needs. Nurse education and mental health services are being reshaped to better equip nurses with the skill set to meet the care needs of service users. The aim of the present study was to gain an in-depth insight into final-year mental health nursing students' views (MHNS) of their preparation to address the physical health needs of service users. Using a qualitative exploratory approach, the views of final-year MHNS learning experiences of physical care were explored through a focus group and in-depth interviews. The focus group generated broad issues, which were then explored in semistructured, individual interviews. The transcribed audio-taped data were analysed using a framework approach to identify the emerging key themes. The themes identified were the comprehensiveness of physical care content, delivery and method of teaching, exposure to physical care in practice, and confidence to address physical health needs. The findings of the present study indicate that there is a need to enhance both the theoretical and practical components of preregistration education for MHNS on physical care.

Moving Towards Wellness: Physical activity practices, perspectives, and preferences of users of outpatient mental health service

OBJECTIVE

This study assessed the beliefs, barriers and preferences for physical activity (PA) among users of outpatient mental health (MH) services. Outpatient discussions with MH providers were also evaluated.

METHOD

Between September-December 2014, patient advisors approached adult and family members in an academic MH clinic's waiting room on high volume patient visit days during peak clinic hours; 83% participated in the survey. Analyses were restricted to MH services users (n=295).

RESULTS

Fully 84% of respondents reported a link between PA and their mood or anxiety level and 85% wanted to be more active. Less than half currently met US PA guidelines (≥150min/week). Most (52%) reported their mood limited their involvement in PA. Only 37% reported their MH providers regularly discussed PA with them. Beliefs about the benefits of physical activity (p<0.0001), mood limiting their ability to be physically active (p=0.03), and wanting to be more physically active (p=0.02) were significant predictors of PA (min/week) in the multivariate linear regression model.

CONCLUSIONS

Most MH outpatients may need and want assistance in increasing PA. Patient-centered research could inform the development of PA programs in MH settings.

Unresolved Issues for Utilization of Atypical Antipsychotics in Schizophrenia: Antipsychotic Polypharmacy and Metabolic Syndrome

Atypical antipsychotics (AAP) are the prevailing form of schizophrenia treatment today due to their low side effects and superior efficacy. Nevertheless, some issues still need to be addressed. First, there are still a large number of patients with treatment-resistant schizophrenia (TRS), which has led to a growing trend to resort to AAP polypharmacy with few side effects. Most clinical treatment guidelines recommend clozapine monotherapy in TRS, but around one third of schizophrenic patients fail to respond to clozapine. For these patients, with clozapine-resistant schizophrenia AAP polypharmacy is a common strategy with a continually growing evidence base. Second, AAP generally have great risks for developing metabolic syndrome, such as weight gain, abnormality in glucose, and lipid metabolism. These metabolic side effects have become huge stumbling blocks in today's schizophrenia treatment that aims to improve patients' quality of life as well as symptoms. The exact reasons why this particular syndrome occurs in patients treated with AAP is as yet unclear though factors such as interaction of AAP with neurotransmitter receptors, genetic pholymorphisms, type of AAPs, length of AAP use, and life style of schizophrenic patients that may contribute to its development. The present article aimed to review the evidence underlying these key issues and provide the most reasonable interpretations to expand the overall scope of antipsychotics usage.

Double disparities in the health care for people with schizophrenia of an ethnic-national minority

BACKGROUND

Studies have shown health care disparities among persons of minority status, including in countries with universal health care. Yet, a dearth of studies have addressed disparities resulting from the combined effect of two minority status groups: severe mental illness and ethnic-national sector filiation. This study aimed to compare the differential health care of Jewish- and Arab-Israelis with schizophrenia in a country with a universal health insurance.

METHOD

This study builds on a large case-control epidemiological sample (N = 50,499) of Jewish- (92.9%) and Arab-Israelis (7.1%) service users with (n = 16,833) and without schizophrenia (n = 33,666). Health services records were collected in the years 2000-2009. Diabetes and cardiovascular disease (CVD) served as sentinel diseases. We compared annual number of LDL tests and visits to specialists in the entire sample, Hemoglobin-A1C test among people diagnosed with diabetes, and cardiac surgical interventions for those diagnosed with CVD.

RESULTS

Service users with schizophrenia were less likely to meet identical indexes of care as their study counterparts: 95% of cholesterol tests (p < .001), and 92% visits to specialists (p < .001). These differences were greater among Arab- compared to Jewish-Israelis. Annual frequency of Hemoglobin-A1C test among people diagnosed with diabetes was lower (94%) in people with schizophrenia (p < 0.01), but no ethnic-national differences were identified. Among service users with CVD less surgical interventions were done in people with schizophrenia (70%) compared to their counterparts, with no ethnic-national disparities.

CONCLUSIONS

In Israel, service users with schizophrenia fail to receive equitable levels of medical and cardiac surgical care for CVD and regular laboratory tests for diabetes. Although disparities in some health indicators were enhanced among Arab-Israelis, schizophrenia was a greater source of disparities than ethnic-national filiation.

Appraisal of primary health care services in Federal Capital Territory, Abuja, Nigeria: how committed are the health workers?

Introduction

The primary health care model was declared as the appropriate strategy for ensuring health-for-all. However up till date, very few studies have assessed the services provided by primary health centres in terms of its basic components. This study aimed to appraise health services provided and to estimate the commitment of the health workers in selected primary health care centres within Abuja Nigeria.

Methods

A cross sectional study was utilized to obtain information from 642 health workers across 6 area councils of the Federal Capital Territory, Nigeria. Data collection was performed using pre-tested, structured, interviewer-administered questionnaires and data were analyzed at 95% level of significance using SPSS version 17.0.

Results

Our study participants were largely females (58.6%), Christians (63.2%) and aged 30-39 years (40.0%). Health services offered in centres were adequate in all components of PHC except for mental health (23.7%) and care of the elderly (43.0%). Conduct of home visits was least practiced by health workers (83.8%) compared to the use of patient appointments (96.4%) and conducting staff outreach activities (94.9%). Commitment was three times more likely when service was related to health promotion and education (OR = 2.52; CI = 1.23-5.18); nutrition education (OR = 3.13; CI = 1.13-8.68).

Conclusion

Health workers in primary health centres of the federal capital territory still provide sub-optimal services with respect to mental health and care of elderly. Concerted efforts and unrelenting political will to strengthen mental and geriatric health components are recommended.

Health behavior models for informing digital technology interventions for individuals with mental illness

OBJECTIVE

Theoretical models offer valuable insights for designing effective and sustainable behavioral health interventions, yet the application of theory for informing digital technology interventions for people with mental illness has received limited attention. We offer a perspective on the importance of applying behavior theories and models to developing digital technology interventions for addressing mental and physical health concerns among people with mental illness.

METHOD

In this commentary, we summarize prominent theories of human behavior, highlight key theoretical constructs, and identify opportunities to inform digital health interventions for people with mental illness. We consider limitations with existing theories and models, and examine recent theoretical advances that can specifically guide development of digital technology interventions.

RESULTS

Established behavioral frameworks including health belief model, theory of planned behavior, transtheoretical model, and social cognitive theory consist of important and overlapping constructs that can inform digital health interventions for people with mental illness. As digital technologies continue to evolve and enable longitudinal data collection, real-time behavior monitoring, and adaptive features tailored to users' changing needs over time, there are new opportunities to broaden our understanding of health behaviors and mechanisms of behavior change. Recent advances include dynamic models of behavior, persuasive system design, the behavioral intervention technology model, and behavioral models for just-in-time adaptive interventions.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Behavior theories offer advantages for guiding use of digital technologies. Future researchers must explore how theoretical models can effectively advance efforts to develop, evaluate, and disseminate digital health interventions targeting individuals with mental illness. (PsycINFO Database Record

Physical Health and Drug Safety in Individuals with Schizophrenia

BACKGROUND

While antipsychotic medications are the mainstay of therapy for individuals with schizophrenia and psychotic disorders, their use is associated with adverse effects on physical health that require the attention and care of prescribers.

METHODS

We used the ADAPTE process to adapt existing guideline recommendations from the National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the dosing of antipsychotics and antipsychotic polypharmacy, screening for adverse effects of antipsychotics, and management of metabolic and extrapyramidal side effects to the Canadian context.

RESULTS

Prescribers are encouraged to use the lowest effective dose and to avoid the routine use of multiple antipsychotics. Scheduled monitoring of body mass index, waist circumference, blood pressure, glucose, lipids, prolactin, electrocardiograms, and extrapyramidal symptoms is recommended. Lifestyle interventions are recommended to mitigate antipsychotic-induced weight gain. Prescribers should follow Canadian guidelines on the treatment of obesity, dyslipidemia, and diabetes. Recommendations on antipsychotic drug choice are made for users particularly concerned about extrapyramidal symptoms.

CONCLUSION

Careful monitoring and attention by prescribers may mitigate adverse effects associated with antipsychotic medications.