Physical health care monitoring for people with serious mental illness

Promoting physical health among people with enduring mental illness: a qualitative study of healthcare providers' perspectives

BACKGROUND

People with enduring mental illness (EMI) have higher morbidity and mortality from chronic diseases than the general population, and this results in a significantly reduced relative life expectancy-accounted for primarily by physical illness. This gap may be partly influenced by the reduced likelihood of access to and uptake of regular physical health screening.

AIM

To establish Irish service providers' perspectives regarding the care of the physical health of people with EMI in an effort to inform future service developments aimed at improving the physical health of people with EMI.

DESIGN AND SETTING

Qualitative study of healthcare providers-general practitioners (GPs) and members of the community mental health teams-in Ireland.

PARTICIPANTS

GPs and mental health service providers.

METHODS

Qualitative semi-structured interviews were conducted with 34 service providers. Thematic analysis was undertaken.

RESULTS

Participants considered that the physical health of people with EMI is not currently regularly addressed by the patient's GP or the mental health team. Factors associated with this include patient compliance with attendance, time constraints in consultations to adequately support patient self-management, communication difficulties with the patient and between primary and secondary care, and lack of clarity as to whose responsibility it is to ensure physical health is monitored. In participants' view, a barrier to improvement is the present funding approach.

CONCLUSION

The evidence from this study has the potential to form the basis for innovation and change in service delivery for people with an EMI in Ireland and internationally, specifically in countries where it is not clear who has the overall responsibility to monitor the physical health of patients with EMI. This role requires time and regular contact, and both the organisation and the funding of the health system need to support it.

Reducing patient surge: community based social networks as first responders

A major challenge for health services worldwide is in providing adequate medical care during mass disasters. The ongoing COVID-19 pandemic highlights this difficulty. Patient surge, a consequence of most types of disasters that contribute to trauma experiences, is a primary factor in disrupting such care as it is composed of worried well persons and those experiencing psychosocial trauma that can severely disrupt and overwhelm effective acute hospital based health care. We review the literature and propose a potential solution framework to reduce such a surge that relies on exploiting community social networks as first responders. We utilize and integrate literature based evidence on patient surge, community disaster behaviors and community based informal social networks to examine reasons for patient surge to hospitals. We then propose that leveraging community based social networks as a potent deterrent for non-critically injured, especially those who have experienced psychosocial trauma or the worried well, from seeking hospital care during ongoing disasters. By emphasizing the social capital inherent in community based social networks, this perspective posits an alternative cost-effective means of reducing patient surge.

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.

HIV prevention advice for people with serious mental illness

BACKGROUND

People with serious mental illness have rates of Human Immuno-deficiency Virus (HIV) infection higher than expected in the general population for the same demographic area. Despite this elevated prevalence, UK national strategies around sexual health and HIV prevention do not state that people with serious mental illness are a high risk group. However, a significant proportion in this group are sexually active and engage in HIV-risk behaviours including having multiple sexual partners, infrequent use of condoms and trading sex for money or drugs. Therefore we propose the provision of HIV prevention advice could enhance the physical and social well being of this population.

OBJECTIVES

To assess the effects of HIV prevention advice in reducing morbidity, mortality and preserving the quality of life in people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (24 January 2012; 4 July 2016).

SELECTION CRITERIA

We planned to include all randomised controlled trials focusing on HIV prevention advice versus standard care or comparing HIV prevention advice with other more focused methods of delivering care or information for people with serious mental illness.

DATA COLLECTION AND ANALYSIS

Review authors (NW, AC, AA, GT) independently screened search results and did not identify any studies that fulfilled the review's criteria.

MAIN RESULTS

We did not identify any randomised studies that evaluated advice regarding HIV for people with serious mental illness. The excluded studies illustrate that randomisation of packages of care relevant to both people with serious mental illness and HIV risk are possible.

AUTHORS' CONCLUSIONS

Policy makers, clinicians, researchers and service users need to collaborate to produce guidance on how best to provide advice for people with serious mental illness in preventing the spread of HIV infection. It is entirely feasible that this could be within the context of a well-designed simple large randomised study.

Oral health education (advice and training) for people with serious mental illness

BACKGROUND

People with serious mental illness not only experience an erosion of functioning in day-to-day life over a protracted period of time, but evidence also suggests that they have a greater risk of experiencing oral disease and greater oral treatment needs than the general population. Poor oral hygiene has been linked to coronary heart disease, diabetes, and respiratory disease and impacts on quality of life, affecting everyday functioning such as eating, comfort, appearance, social acceptance, and self esteem. Oral health, however, is often not seen as a priority in people suffering with serious mental illness.

OBJECTIVES

To review the effects of oral health education (advice and training) with or without monitoring for people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (5 November 2015), which is based on regular searches of MEDLINE, EMBASE, CINAHL, BIOSIS, AMED, PubMed, PsycINFO, and clinical trials registries. There are no language, date, document type, or publication status limitations for inclusion of records in the register.

SELECTION CRITERIA

All randomised clinical trials focusing on oral health education (advice and training) with or without monitoring for people with serious mental illness.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.

MAIN RESULTS

We included three randomised controlled trials (RCTs) involving 1358 participants. None of the studies provided useable data for the key outcomes of not having seen a dentist in the past year, not brushing teeth twice a day, chronic pain, clinically important adverse events, and service use. Data for leaving the study early and change in plaque index scores were provided. Oral health education compared with standard careWhen 'oral health education' was compared with 'standard care', there was no clear difference between the groups for numbers leaving the study early (1 RCT, n = 50, RR 1.67, 95% CI 0.45 to 6.24, moderate-quality evidence), while for dental state: no clinically important change in plaque index, an effect was found. Although this was statistically significant and favoured the intervention group, it is unclear if it was clinically important (1 RCT, n = 40, MD - 0.50 95% CI - 0.62 to - 0.38, very low quality evidence).These limited data may have implications regarding improvement in oral hygiene. Motivational interview + oral health education compared with oral health educationSimilarly, when 'motivational interview + oral health education' was compared with 'oral health education', there was no clear difference for the outcome of leaving the study early (1 RCT, n = 60 RR 3.00, 95% CI 0.33 to 27.23, moderate-quality evidence), while for dental state: no clinically important change in plaque index, an effect favouring the intervention group was found (1 RCT, n = 56, MD - 0.60 95% CI - 1.02 to - 0.18 very low-quality evidence). These limited, clinically opaque data may or may not have implications regarding improvement in oral hygiene. Monitoring compared with no monitoringFor this comparison, only data for leaving the study early were available. We found a difference in numbers leaving early, favouring the 'no monitoring' group (1 RCT, n = 1682, RR 1.07, 95% CI 1.00 to 1.14, moderate-quality evidence). However, these data are problematic. The control denominator is implied and not clear, and follow-up did not depend only on individual participants, but also on professional caregivers and organisations - the latter changing frequently resulting in poor follow-up, but not a good reflection of the acceptability of the monitoring to patients. For this comparison, no data were available for 'no clinically important change in plaque index'.

AUTHORS' CONCLUSIONS

We found no evidence from trials that oral health advice helps people with serious mental illness in terms of clinically meaningful outcomes. It makes sense to follow guidelines and recommendations such as those put forward by the British Society for Disability and Oral Health working group until better evidence is generated. Pioneering trialists have shown that evaluative studies relevant to oral health advice for people with serious mental illness are possible.

Lifestyle and Behavioral Interventions to Reduce the Risk of Metabolic Syndrome in Community-Dwelling Adults With Serious Mental Illness: Implications for Nursing Practice

Adults with mental illness are at increased risk of being diagnosed with metabolic syndrome and consequently cardiovascular disease, diabetes, and stroke. The current article explores community-based interventions to decrease the risk of metabolic syndrome by changing health behaviors among adults with serious mental illness (SMI). Ovid Medline, PsycINFO, and CINAHL were searched for nonpharmacological studies of behavioral or lifestyle interventions addressing risk of metabolic syndrome among adults with SMI. Thirteen studies, seven with statistically significant results, were included in the review. Despite the well-known risks of metabolic syndrome, the majority of available studies had small samples with insufficient power. There was little consistency in methods or outcome measures. Studies that were client-directed and involved peer and staff support appeared most useful in changing health behaviors and improving quality of life. Further research is needed to guide nursing practice in implementing effective methods to reduce the risk of metabolic syndrome in community-dwelling adults with SMI.

Cancer and serious mental illness--patient, caregiver and professional perspectives: study protocol

AIM

To explore the experience of serious mental illness and cancer from the perspective of patients, significant others and healthcare professionals involved in their care.

BACKGROUND

Serious mental illness is associated with poorer cancer outcomes. Those suffering from this comorbidity receive fewer specialist interventions and die earlier than the general population. Prior qualitative research in this area has comprised of a single study focussing on healthcare professionals and there is little evidence regarding the experiences of patients and caregivers.

DESIGN

A qualitative exploration using approximately 36 semi-structured interviews.

METHODS

Semi-structured digitally recorded interviews conducted with: adults living with serious mental illness and diagnosed with cancer; those providing them with informal support and care; and healthcare professionals. Questions will focus on the experience of having cancer and serious mental illness or caring for someone with this comorbidity, experiences of healthcare and priorities for patients and carers. Framework analysis will be used. Research Ethics Committee and Trust Research & Development approval was obtained. A steering group comprising six people with experience of either cancer or mental illness provided feedback and ratified the patient information sheets and interview schedules.

DISCUSSION

There is a paucity of research addressing stakeholder perspectives on the experience of cancer and of cancer services for people with serious mental illness. Dissemination of findings will inform practice relating to the care of an often neglected population, informing better support for their significant others and the professionals involved in their care.

Increasing the health literacy of learning disability and mental health nurses in physical care skills: a pre and post-test evaluation of a workshop on diabetes care

This paper presents the pre- and post-test results of the outcomes of a workshop designed to increase learning disability and mental health nurses' knowledge and skill to undertake interventions for service users at risk of, or with a diagnosis of, type 2 diabetes. Health literacy is also discussed as a way of explaining why such nurses may lack expertise in physical health care. Findings from the workshop show that learning disability and mental health nurses have the motivation to increase their health literacy (skills and knowledge) in diabetes care. The potential of such workshops, and how organisations looking forward to the future can build health literacy, is discussed.

Health outcomes and cost of care among older adults with schizophrenia: a 10-year study using medical records across the continuum of care

OBJECTIVES

The population of older patients with schizophrenia is increasing. This study describes health outcomes, utilization, and costs over 10 years in a sample of older patients with schizophrenia compared with older patients without schizophrenia.

METHODS

An observational cohort study of 31,588 older adults (mean age: 70.44 years) receiving care from an urban public health system, including a community mental health center, during 1999-2008. Of these, 1,635 (5.2%) were diagnosed with schizophrenia and 757 (2.4%) had this diagnosis confirmed in the community mental health center. Patients' electronic medical records were merged with Medicare claims, Medicaid claims, the Minimum Dataset, and the Outcome and Assessment Information Set. Information on medication use was not available.

MEASUREMENTS

Rates of comorbid conditions, healthcare utilization, costs, and mortality.

RESULTS

Patients with schizophrenia had significantly higher rates of congestive heart failure (45.05% versus 38.84%), chronic obstructive pulmonary disease (52.71% versus 41.41%), and hypothyroidism (36.72% versus 26.73%) than the patients without schizophrenia (p <0.001). They had significantly lower rates of cancer (30.78% versus 43.18%) and significantly higher rates of dementia (64.46% versus 32.13%). The patients with schizophrenia had significantly higher mortality risk (hazard ratio: 1.25, 95% confidence interval: 1.07-1.47) than the patients without schizophrenia. They also had significantly higher rates of healthcare utilization. The mean costs for Medicare and Medicaid were significantly higher for the patients with schizophrenia than for the patients without schizophrenia.

CONCLUSIONS

The management of older adult patients with schizophrenia is creating a serious burden for our healthcare system, requiring the development of integrated models of healthcare.

Exercise therapy in adults with serious mental illness: a systematic review and meta-analysis

BACKGROUND

Individuals with serious mental illness are at a higher risk of physical ill health. Mortality rates are at least twice those of the general population with higher levels of cardiovascular disease, metabolic disease, diabetes, and respiratory illness. Although genetics may have a role in the physical health problems of these patients, lifestyle and environmental factors such as levels of smoking, obesity, poor diet, and low levels of physical activity also play a prominent part.

METHODS

We conducted a systematic review and meta-analysis of randomised controlled trials comparing the effect of exercise interventions on individuals with serious mental illness.Searches were made in Ovid MEDLINE, Embase, CINAHL, PsycINFO, Biological Abstracts on Ovid, and The Cochrane Library (January 2009, repeated January 2013) through to February 2013.

RESULTS

Eight RCTs were identified in the systematic search. Six compared exercise versus usual care. One study assessed the effect of a cycling programme versus muscle strengthening and toning exercises. The final study compared the effect of adding specific exercise advice and motivational skills to a simple walking programme. The review found that exercise improved levels of exercise activity (n = 13, standard mean difference [SMD] 1.81, CI 0.44 to 3.18, p = 0.01). No beneficial effect was found on negative (n = 84, SMD = -0.54, CI -1.79 to 0.71, p = 0.40) or positive symptoms of schizophrenia (n = 84, SMD = -1.66, CI -3.78 to 0.45, p = 0.12). No change was found on body mass index compared with usual care (n = 151, SMD = -0.24, CI -0.56 to 0.08, p = 0.14), or body weight (n = 77, SMD = 0.13, CI -0.32 to 0.58, p = 0.57). No beneficial effect was found on anxiety and depressive symptoms (n = 94, SMD = -0.26, CI -0.91 to 0.39, p = 0.43), or quality of life in respect of physical and mental domains.

CONCLUSIONS

This systematic review showed that exercise therapies can lead to a modest increase in levels of exercise activity but overall there was no noticeable change for symptoms of mental health, body mass index, and body weight.

General physical health advice for people with serious mental illness

BACKGROUND

There is currently much focus on provision of general physical health advice to people with serious mental illness and there has been increasing pressure for services to take responsibility for providing this.

OBJECTIVES

To review the effects of general physical healthcare advice for people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (last update search October 2012) which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO and registries of Clinical Trials. There is no language, date, document type, or publication status limitations for inclusion of records in the register.

SELECTION CRITERIA

All randomised clinical trials focusing on general physical health advice for people with serious mental illness..

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.

MAIN RESULTS

Seven studies are now included in this review. For the comparison of physical healthcare advice versus standard care we identified six studies (total n = 964) of limited quality. For measures of quality of life one trial found no difference (n = 54, 1 RCT, MD Lehman scale 0.20, CI -0.47 to 0.87, very low quality of evidence) but another two did for the Quality of Life Medical Outcomes Scale - mental component (n = 487, 2 RCTs, MD 3.70, CI 1.76 to 5.64). There was no difference between groups for the outcome of death (n = 487, 2 RCTs, RR 0.98, CI 0.27 to 3.56, low quality of evidence). For service use two studies presented favourable results for health advice, uptake of ill-health prevention services was significantly greater in the advice group (n = 363, 1 RCT, MD 36.90, CI 33.07 to 40.73) and service use: one or more primary care visit was significantly higher in the advice group (n = 80, 1 RCT, RR 1.77, CI 1.09 to 2.85). Economic data were equivocal. Attrition was large (> 30%) but similar for both groups (n = 964, 6 RCTs, RR 1.11, CI 0.92 to 1.35). Comparisons of one type of physical healthcare advice with another were grossly underpowered and equivocal.

AUTHORS' CONCLUSIONS

General physical health could lead to people with serious mental illness accessing more health services which, in turn, could mean they see longer-term benefits such as reduced mortality or morbidity. On the other hand, it is possible clinicians are expending much effort, time and financial resources on giving ineffective advice. The main results in this review are based on low or very low quality data. There is some limited and poor quality evidence that the provision of general physical healthcare advice can improve health-related quality of life in the mental component but not the physical component, but this evidence is based on data from one study only. This is an important area for good research reporting outcome of interest to carers and people with serious illnesses as well as researchers and fundholders.

Enhanced physical health screening for people with severe mental illness in Hong Kong: results from a one-year prospective case series study

BACKGROUND

People with severe mental illness have significantly poorer physical health compared to the general population; previous health screening studies conducted outside Asian countries have demonstrated the potential in addressing this issue. This case series aimed to explore the effects and utility of integrating an enhanced physical health screening programme for community dwelling patients with severe mental illness into routine clinical practice in Hong Kong.

METHOD

This study utilises a consecutive prospective case series design. The serious mental illness Health Improvement Profile (HIP) was used as a screening tool at baseline and repeated at 12 months follow-up.

RESULTS

A total of 148 community-based patients with severe mental illness completed the study. At one year follow-up analysis showed a significant improvement in self-reported levels of exercise and a reduction in the numbers of patients prescribed medications for diabetes However, mean waist circumference increased at follow-up. In addition to the statistically significant results some general trends were observed, including: a lack of deterioration in most areas of cardiovascular risk; a reduction in medicines prescribed for physical health problems; and general improvements in health behaviours over the 12 month period.

CONCLUSIONS

The findings demonstrate that using the HIP is feasible and acceptable in Hong Kong. The results of the enhanced physical health-screening programme are promising, but require further testing using a randomised controlled trial design in order to more confidently attribute the improvements in well-being and health behaviours to the HIP.

TRIAL REGISTRATION

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN12582470.

Understanding the problems developing a healthy living programme in patients with serious mental illness: a qualitative study

BACKGROUND

People with serious mental illness are at an increased risk of physical ill health. Mortality rates are around twice those of the general population with higher levels of cardiovascular disease, metabolic disease, diabetes, and respiratory illness. Although genetics may have a role in the physical health problems of these patients, lifestyle and environmental factors such as smoking, obesity, poor diet, and low levels of physical activity play a prominent part.

METHODS

A qualitative grounded theory approach was used to understand the problems experienced by these individuals when asked to attend a healthy living programme. Three main areas were explored: the influence of potential barriers, health problems, and general attitudes towards healthy living.

RESULTS

Thirteen patients were interviewed during the study. Many did not recall receiving an initial invitation letter to the programme. Several believed that there was no necessity to attend as they had already had recent routine health checks by their general practitioner. The patients' current level of mental and physical health was important with symptoms such as depression, anxiety or arthritis affecting interest in the programme. Patients described that they found smoking enjoyable or calming in its effect. Dietary intake was determined by taste or gaining pleasure in eating certain types of food. Several lessons were learnt during this research that may aid future research and practice. Participation seemed to be better if the approach was first made by the patient's own community keyworker. This contact may have provided a greater opportunity to explain the purpose and importance of the programme. Alternative appointments should be considered when certain patients are in better physical and mental health. Healthy living programmes need to be flexible and adaptive to individual patient needs. Assistance from their community worker may help engagement. Simple measures may improve participation and reduce potential barriers.

CONCLUSION

These findings highlighted some of the problems encountered by patients when attempting to participate in a healthy living programme. These results may be useful when implementing future healthy living interventions for patients with serious mental disorders.

Community adherence to schizophrenia treatment and safety monitoring guidelines

The 2003 Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations and the Mount Sinai Conference Safety Monitoring recommendations generated guidelines for pharmacological treatment of schizophrenia and monitoring of antipsychotic side effects. This study examined rate of recommendation adherence and impact of adherence on outcomes of outpatients with schizophrenia or schizoaffective disorder in community mental health centers. Clinical practice was assessed as conformant, nonconformant, or not applicable. Treatment practices were conformant for antipsychotic dose (83%); use of antiparkinsonian (97%), antidepressant (100%), and antianxiety agents (90%) but not clozapine for residual positive symptoms (31%); and monitoring weight gain (48%), glucose dysregulation (53%), hyperlipidemia (34%), or extrapyramidal symptoms (11%). Community mental health center treatment practices were largely conformant with the 2003 Schizophrenia PORT treatment recommendations. There is less evidence that patients who receive treatment in the community are adequately monitored for antipsychotic side effects per the Mount Sinai recommendations.

Primary care-based educational interventions to decrease risk factors for metabolic syndrome for adults with major psychotic and/or affective disorders: a systematic review

BACKGROUND

Individuals with major psychotic and/or affective disorders are at increased risk for developing metabolic syndrome due to lifestyle- and treatment-related factors. Numerous pharmacological and non-pharmacological interventions have been tested in inpatient and outpatient mental health settings to decrease these risk factors. This review focuses on primary care-based non-pharmacological (educational or behavioral) interventions to decrease metabolic syndrome risk factors in adults with major psychotic and/or affective disorders.

METHODS

The authors conducted database searches of PsychINFO, MEDLINE and the Cochrane Database of Systematic Reviews, as well as manual searches and gray literature searches to identify included studies.

RESULTS

The authors were unable to identify any studies meeting a priori inclusion criteria because there were no primary care-based studies.

CONCLUSIONS

This review was unable to demonstrate effectiveness of educational interventions in primary care. Interventions to decrease metabolic syndrome risk have been demonstrated to be effective in mental health and other outpatient settings. The prevalence of mental illness in primary care settings warrants similar interventions to improve health outcomes for this population.

Comorbidity profile and healthcare utilization in elderly patients with serious mental illnesses

OBJECTIVES

Patients with serious mental illness are living longer. Yet, there remain few studies that focus on healthcare utilization and its relationship with comorbidities in these elderly mentally ill patients.

DESIGN

Comparative study. Information on demographics, comorbidities, and healthcare utilization was taken from an electronic medical record system.

SETTING

Wishard Health Services senior care and community mental health clinics.

PARTICIPANTS

Patients age 65 years and older-255 patients with serious mental illness (schizophrenia, major recurrent depression, and bipolar illness) attending a mental health clinic and a representative sample of 533 nondemented patients without serious mental illness attending primary care clinics.

RESULTS

Patients having serious mental illness had significantly higher rates of medical emergency department visits (p = 0.0027) and significantly longer lengths of medical hospitalizations (p <0.0001) than did the primary care control group. The frequency of medical comorbidities such as diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, thyroid disease, and cancer was not significantly different between the groups. Hypertension was lower in the mentally ill group (p <0.0001). Reported falls (p <0.0001), diagnoses of substance abuse (p = 0.02), and alcoholism (p = 0.0016) were higher in the seriously mentally ill. The differences in healthcare utilization between the groups remained significant after adjusting for comorbidity levels, lifestyle factors, and attending primary care.

CONCLUSIONS

Our findings of higher rates of emergency care, longer hospitalizations, and increased frequency of falls, substance abuse, and alcoholism suggest that seriously mentally ill older adults remain a vulnerable population requiring an integrated model of healthcare.

Examining the cost effectiveness of interventions to promote the physical health of people with mental health problems: a systematic review

BACKGROUND

Recently attention has begun to focus not only on assessing the effectiveness of interventions to tackle mental health problems, but also on measures to prevent physical co-morbidity. Individuals with mental health problems are at significantly increased risk of chronic physical health problems, such as cardiovascular disease or diabetes, as well as reduced life expectancy. The excess costs of co-morbid physical and mental health problems are substantial. Potentially, measures to reduce the risk of co-morbid physical health problems may represent excellent value for money.

METHODS

To conduct a systematic review to determine what is known about economic evaluations of actions to promote better physical health in individuals identified as having a clinically diagnosed mental disorder, but no physical co-morbidity. Systematic searches of databases were supplemented by hand searches of relevant journals and websites.

RESULTS

Of 1970 studies originally assessed, 11 met our inclusion criteria. In addition, five protocols for other studies were also identified. Studies looked at exercise programmes, nutritional advice, smoking, alcohol and drug cessation, and reducing the risk of blood borne infectious diseases such as HIV/AIDS and hepatitis. All of the lifestyle and smoking cessation studies focused on people with depression and anxiety disorders. Substance abuse and infectious disease prevention studies focused on people with psychoses and bipolar disorder.

CONCLUSIONS

There is a very small, albeit growing, literature on the cost effectiveness of interventions to promote the physical health of people with mental health problems. Most studies suggest that value for money actions in specific contexts and settings are available. Given that the success or failure of health promoting interventions can be very context specific, more studies are needed in more settings, focused on different population groups with different mental health problems and reporting intermediate and long term outcomes. There is a need to better distinguish between resource use and costs in a transparent manner, including impacts outside of the health care system. Issues such as programme fidelity, uptake and adherence should also be accounted for in economic analysis. The role of behavioural psychological techniques to influence health behaviours might also be considered.

An oral health intervention for people with serious mental illness (Three Shires Early Intervention Dental Trial): study protocol for a randomised controlled trial

Background

Oral health is an important part of general physical health and is essential for self-esteem, self-confidence and overall quality of life. There is a well-established link between mental illness and poor oral health. Oral health problems are not generally well recognized by mental health professionals and many patients experience barriers to treatment.

Methods/Design

This is the protocol for a pragmatic cluster randomised trial that has been designed to fit within standard care. Dental awareness training for care co-ordinators plus a dental checklist for service users in addition to standard care will be compared with standard care alone for people with mental illness. The checklist consists of questions about service users’ current oral health routine and condition. Ten Early Intervention in Psychosis (EIP) teams in Nottinghamshire, Derbyshire and Lincolnshire will be cluster randomised (five to intervention and five to standard care) in blocks accounting for location and size of caseload. The oral health of the service users will be monitored for one year after randomisation.

Trial registration

Current Controlled Trials ISRCTN63382258.

The serious mental illness health improvement profile [HIP]: study protocol for a cluster randomised controlled trial

Background

The serious mental illness Health Improvement Profile [HIP] is a brief pragmatic tool, which enables mental health nurses to work together with patients to screen physical health and take evidence-based action when variables are identified to be at risk. Piloting has demonstrated clinical utility and acceptability.

Methods/Design

A single blind parallel group cluster randomised controlled trial with secondary economic analysis and process observation. Unit of randomisation: mental health nurses [MHNs] working in adult community mental health teams across two NHS Trusts. Subjects: Patients over 18 years with a diagnosis of schizophrenia, schizoaffective or bipolar disorder on the caseload of participating MHNs. Primary objective: To determine the effects of the HIP programme on patients' physical wellbeing assessed by the physical component score of the Medical Outcome Study (MOS) 36 Item Short Form Health Survey version 2 [SF-36v2]. Secondary objectives: To determine the effects of the HIP programme on: cost effectiveness, mental wellbeing, cardiovascular risk, physical health care attitudes and knowledge of MHNs and to determine the acceptability of the HIP Programme in the NHS. Consented nurses (and patients) will be randomised to receive the HIP Programme or treatment as usual. Outcomes will be measured at baseline and 12 months with a process observation after 12 months to include evaluation of patients' and professionals' experience and observation of any effect on care plans and primary-secondary care interface communication. Outcomes will be analysed on an intention-to-treat (ITT) basis.

Discussion

The results of the trial and process observation will provide information about the effectiveness of the HIP Programme in supporting MHNs to address physical comorbidity in serious mental illness. Given the current unacceptable prevalence of physical comorbidity and mortality in the serious mental illness population, it is hoped the HIP trial will provide a timely contribution to evidence on organisation and delivery of care for patients, clinicians and policy makers.

Trial Registration

ISRCTN: ISRCTN41137900

A well-being support program for patients with severe mental illness: a service evaluation

BACKGROUND

The risk of cardiovascular disease is increased in patients with severe mental illness (SMI) dramatically reducing life expectancy.

METHOD

A real world pragmatic service evaluation of a Well-Being Support Program (WSP) was conducted. This was a four-session package delivered over a one-year period by mental health practitioners that had received additional training in providing physical health assessment and intervention. Patients' physical health was screened and appropriate one-to-one and group intervention was offered.

RESULTS

212 mental health practitioners were trained in the WSP and 782 patients were enrolled on the program. The majority of our sample was overweight or obese; 66% had a Body Mass Index (BMI) >25. Lifestyle risk factors for cardiovascular disease (CVD) were common and the patients had low self esteem. The average number of formally recorded well-being sessions attended was 2.10. Just under a quarter of those patients enrolled in the program completed. The only cardiovascular risk factor that significantly altered in patients that completed the program was BMI. The qualitative feedback about the program was largely positive.

CONCLUSIONS

The need to intervene to enhance the physical health of people with SMI is beyond doubt. Maintaining patient engagement in a physical health improvement program is challenging. Regular comprehensive physical health monitoring is necessary to establish the benefit of intervention and increase life expectancy and well-being in this population.