Clinical trial of wellness training: health promotion for severely mentally ill adults

Nurse-led physical health interventions for people with mental illness: an integrative review of international literature

BACKGROUND

People experiencing mental illness receive physical healthcare from nurses in a variety of settings including acute inpatient, secure extended care, forensic, and community services. While nurse-led clinical practice addressing sub-optimal consumer physical health is salient, a detailed understanding and description of the contribution by nurses to physical health interventions in people experiencing mental illness is not clearly articulated in the literature.

AIMS

The aim of this integrative review is to describe the state of knowledge on nurse-led physical health intervention for consumers, focusing on nursing roles, nursing assessment, and intervention settings.

METHODS

A systematic search of six databases using Medical Subject Headings from 2001 and 2022 inclusive was conducted. The Mixed Methods Appraisal Tool (MMAT) was utilised for quality appraisal.

RESULTS

Seventy-four studies were identified as "nurse-led". Interventions were most common among community settings (n = 34, 46%). Nurses performed varied roles, often concurrently, including the collection of 341 physical health outcomes, and multiple roles with 225 distinct nursing actions identified across the included studies. A nurse as lead author was common among the included studies (n = 46, 62%). However, nurses were not always recognised for their efforts or contributions in authorship.

CONCLUSIONS

There is potential gap in role recognition that should be considered when designing and reporting nurse-led physical health interventions.

Nurse-Led Physical Health Interventions for People with Mental Illness: A Scoping Review of International Literature

People with mental illness have a higher prevalence of co-occurring physical health conditions and poor health behaviors, leading a mortality gap of up to 16 years, compared with the general population. Nurses working in mental health settings play an important role in addressing factors influencing sub-optimal physical health. Therefore, this scoping review aimed to identify nurse-led physical health interventions and align interventions to eight recognized physical healthcare priority areas (i.e. Equally Well in Victoria Framework). A systematic search strategy was used to identify relevant literature. Data extraction included alignment to the Equally Well priority areas, research design, and indication of co-design (meaningful and collaborative involvement of consumers and significant others) and recovery-oriented practice (focusing on needs and goals of a consumer's recovery journey). All included papers (n = 74) were aligned to at least one of eight Equally Well priority areas. Papers were predominately quantitative (n = 64, 86%), with the remainder mixed methods (n = 9, 9%) or qualitative (n = 4, 5%). Most papers were aligned to improving metabolic health and support to quit smoking. One study focused on nurse-led intervention designed to reduce falls. Recovery-oriented practice was evident in six papers. No paper described evidence of co-design. A research gap was identified for nurse-led intervention to reduce falls and improve dental/oral care. Relative to mental healthcare policy, there is a need for future nurse-led physical health research to be co-designed and include recovery-oriented practice. Evaluation and description of future nurse-led physical interventions should seek to report perspectives of key stakeholders as these remain relatively unknown.

Health Education and Activity - Lessening The Inequalities in mental health (HEA - LTI mental health)

Patients suffering from mental health illness have considerably more physical health disease burden than the rest of the population and are more likely to die 10 to 20 years younger compared with their peers. Diabetes, cardiovascular and respiratory disease have been recognised as contributing factors to premature death. Furthermore patients with severe mental illness undertake lower levels of physical activity. The aim of the project was therefore to address the inequalities in physical health that affect patients with mental health illness through designing and implementing a sustainable, transferable, patient-centred education and activity intervention. The objective of the project was to increase patient motivation to change behaviour as a result of physical health interventions by increasing patients' physical health understanding, motivation to change their physical health behaviour, motivation to do exercise and by reducing their anxiety. The method used was a prospective cohort study in four eighteen bed psychosis inpatient units. The units were across two large London hospitals in one Hospital Trust involving male and female inpatients with a range of mental health issues. The intervention was comprised of two components. The first component was a weekly 45 minute teaching group designed in collaboration with patients focusing on the key domains that affect the physical health of mental health patients. Four discussion domains (heart health, diabetes and weight, smoking and lung disease, cancer screening and substance misuse) were undertaken, with each cycle lasting four weeks. The second component was a weekly 45 minute exercise group ('normalisation activity') in collaboration with patients and the multidisciplinary team. The intervention was evaluated at the end of each cycle and four cycles in total took place. Weekly pre and post intervention measures were undertaken comprising of a self reported change in understanding, motivation to change physical health behaviours, confidence to change, anxiety and motivation to exercise. The result was a 26% improvement in self-reported understanding across the four domains following teaching. Furthermore patient anxiety reduced by on average 35%, self-reported motivation to change increased by 20%, motivation to do exercise by 26% and confidence to change by 16% as a result of the intervention. The authors conclude that a collaborative approach to education and activity between the Multidisciplinary Team (MDT) and service user results in sustained improvement in understanding of physical health, motivation to change behaviour and to do exercise. It also results in improved confidence and reduced anxiety.

Systematic Review of Integrated General Medical and Psychiatric Self-Management Interventions for Adults With Serious Mental Illness

OBJECTIVE

Adults with serious mental illness are disproportionately affected by general medical comorbidity, earlier onset of disease, and premature mortality. Integrated self-management interventions have been developed to address both general medical and psychiatric illnesses. This systematic review examined evidence about the effect of self-management interventions that target both general medical and psychiatric illnesses and evaluated the potential for implementation.

METHODS

Databases, including CINAHL, Cochrane Central, Ovid MEDLINE, PsycINFO, and Web of Science, were searched for articles published between 1946 and July 2015. Studies evaluating integrated general medical and psychiatric self-management interventions for adults with schizophrenia spectrum or mood disorders and general medical comorbidity were included.

RESULTS

Fifteen studies (nine randomized controlled trials and six pre-post designs) reported on nine interventions: automated telehealth, Health and Recovery Peer program, Helping Older People Experience Success, Integrated Illness Management and Recovery, Life Goals Collaborative Care, Living Well, Norlunga Chronic Disease Self-Management program, Paxton House, and Targeted Training in Illness Management. Most studies demonstrated feasibility, acceptability, and preliminary effectiveness; however, clinical effectiveness could not be established in most studies because of methodological limitations. Factors identified that may deter implementation included operating costs, impractical length, and workforce requirements.

CONCLUSIONS

Integrated general medical and psychiatric illness self-management interventions appear feasible and acceptable, with high potential for clinical effectiveness. However, implementation factors were rarely considered in intervention development, which may contribute to limited uptake and reach in real-world settings.

Dietary advice for people with schizophrenia

BACKGROUND

People with serious mental illness have consistently higher levels of mortality and morbidity than the general population. They have greater levels of cardiovascular disease, metabolic disease, diabetes, and respiratory illness. Although genetics may have a role in the physical health problems of these people, lifestyle and environmental factors such as smoking, obesity, poor diet, and low levels of physical activity play a prominent part.

OBJECTIVES

To review the effects of dietary advice for schizophrenia and schizophrenia-like psychosis.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (September 09, 2013 and February 24, 2016).

SELECTION CRITERIA

We planned to include all randomised clinical trials focusing on dietary advice versus standard care.

DATA COLLECTION AND ANALYSIS

The review authors (RP, KTP) independently screened search results but did not identify any studies that fulfilled the review's criteria.

MAIN RESULTS

We did not identify any studies that met our inclusion criteria.

AUTHORS' CONCLUSIONS

Dietary advice has been shown to improve the dietary intake of the general population. Research is needed to determine whether dietary advice can have a similar benefit in people with serious mental illness.

Psychiatric Mental Health Leadership at the Tipping Point

Currently the United States health care system is responding to the Patient Protection and Affordable Care Act (PPACA) and the vision it contains for health care transformation. Along with sweeping changes in service delivery and payment structures, health care reform has championed concepts such as patient-centered care, integrated care, and wellness. Although these are not new ideas, their adaptation, in both ideology and service design has been accelerated in the context for reform. Indeed they are reaching a tipping point; the point where ideas gain wide acceptance and become influential trends. Although psychiatric mental health (PMH) nurses have been active in wellness, patient-centered care, and integrated care, at the current time they seem to be situated peripheral to these national trends. Increased presence of PMH nurses will facilitate their contribution to the development of these concepts within service structures and interventions. To increase knowledge and appreciation of PMH nurses' practice and unique perspective on these issues, leaders are needed who will connect and effectively communicate PMH nursing efforts to the broader health care arena. This article outlines the events that created a context for these three concepts (patient-centered care, wellness, and integrated care), and I suggest why they have reached a tipping point and discuss the need for greater PMH nursing presence in the American national dialog and the role of nursing leaders in facilitating these connections.

A systematic review of self-management health care models for individuals with serious mental illnesses

OBJECTIVE

The general medical health of individuals with serious mental illnesses is compromised relative to those without serious mental illnesses. To address this health disparity, numerous integrated care strategies are being employed from the system level to the level of individual patients. However, self-management of health care, a strategy considered an integral aspect of typical care, has been infrequently included in interventions for this population. Despite reservations about the capacity of those with serious mental illnesses to self-manage health care, a subset of new interventions focused on general medical health in this population has tested whether models including self-management strategies have empirical support. To understand whether these models are supported, the authors reviewed the evidence for self-management models.

METHODS

This systematic review examined collaborative and integrated care models that include self-management components for individuals with serious mental illnesses.

RESULTS

Across the 14 studies identified in this review, promising evidence was found that individuals with serious mental health issues can collaborate with health professionals or be trained to self-manage their health and health care. The evidence supports the use of mental health peers or professional staff to implement health care interventions. However, the substantial heterogeneity in study design, types of training, and examined outcomes limited conclusions about the comparative effectiveness of existing studies.

CONCLUSIONS

This review found preliminary support that self-management interventions targeting the general medical health of those with serious mental illnesses are efficacious, but future work is needed to determine what elements of training or skills lead to the most salient changes.

Application of the Rasch model to measure five dimensions of wellness in community-dwelling older adults

BACKGROUND AND PURPOSE

Nurse researchers and practicing nurses need reliable and valid instruments to measure key clinical concepts. The purpose of this research was to develop an innovative method to measure dimensions of wellness among older adults.

METHOD

A sample of 5,604 community-dwelling older adults was drawn from members of the COLLAGE consortium. The Wellness Assessment Tool (WEL) of the COLLAGE assessment system provided the data used to create the scores. Application of the Rasch analysis and Masters' partial credit method resulted in logit values for each item within the five dimensions of wellness as well as logit values for each person in the sample.

RESULTS

The items fit the Rasch model, and the composite scores for each dimension demonstrated high reliability (1.00). The person reliability was low: social (.19), intellectual (.33), physical (.29), emotional (.20), and spiritual (.29). The small number of items within each dimension and the homogenous sample appear to have contributed to this low reliability.

CONCLUSION

Ongoing research using multidimensional tools to measure dimensions of wellness among older adults is needed to advance wellness science and wellness promotion in nursing practice.

Barriers to involvement in physical activities of persons with mental illness

Participating in physical activities could be essential for reducing the multiple risk factors for health problems that persons with severe mental illness (SMI) may suffer. However, people with SMI are significantly less active than the general population. To develop knowledge about factors related to the perceived barriers hindering this population's participation in physical activities and the benefits this participation would have, a study was conducted in Israel with 86 people with mental illness living in community mental health facilities prior to their participation in a health promotion program. A mixed method was implemented and included: a scale designed to measure participants' perceptions of the barriers to and benefits of involvement in physical activities; instruments focusing on bio-psycho-social factors that may affect the level of barriers experienced; and personal interviews. The findings revealed high ranking for accessibility barriers hindering the participation in physical activities. Bio-psycho-social factors stemming from the participants' mental health, such as level of depression, were correlated with higher ranking of accessibility barriers. Bio-psycho-social factors reflecting positive mental health and health, such as positive appraisal of body weight, were correlated with lower ranking of accessibility barriers. Other barriers may include organizational and broader systemic barriers in the mental health facilities where the participants reside. These findings illuminate the need to consider the unique challenges that persons with mental illness may face in any attempt to advance their involvement in physical activity.

Five dimensions of wellness and predictors of cognitive health protection in community-dwelling older adults: a historical COLLAGE cohort study

Wellness is associated with cognitive health protection; however, findings are limited because they only examine variable(s) within one dimension of wellness. This research examined the association between multiple dimensions of wellness and cognition among aging adults. The sample included 5,605 male and female community-dwelling adults 60 years and older. Four dimensions of wellness demonstrated a statistically significant higher mean difference in cognitively healthy older adults compared to cognitively impaired older adults, F(4, 5,595) = 47.57, p < .001. Emotional wellness demonstrated the strongest association with cognitive health, followed by physical and spiritual wellness, F(5, 5,372) = 50.35, p < .001. Future research is needed to examine the cognitive protective benefits of wellness using longitudinal, prospective designs that control for the potential temporal relationship between wellness and cognition.

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.

A systematic review of nurse physical healthcare for consumers utilizing mental health services

People with serious mental illness have higher rates of physical illness and are more likely to experience premature death than the general population. Nurse-led strategies to improve physical healthcare in mental healthcare services could potentially reduce these inequalities. However the extent of nurse involvement in physical healthcare (such as physical risk screening, health education and care co-ordination) in mental health settings is not known. A systematic review was conducted on nurse-led physical healthcare reported for consumers with serious mental illness (SMI) in mental health services, and their benefits. Electronic literature bases (CINAHL, Proquest, PsychINFO and Web of Science) were systematically searched, in conjunction with a manual search of literature reviews on physical healthcare in mental health services. Articles were included if they: (a) were published in the last 10 years; (b) were English language; (c) involved physical healthcare of adult consumers receiving mental healthcare services; and (d) reported nurse involvement in physical healthcare. Forty articles were included in the review. The distribution of types of care were: health education (47%), screening and/or monitoring (33.3%), care co-ordination and management (33.3%), lifestyle programme delivery (30.5%), follow-up actions to screening results (25%) and registers and data administration (5.5%). Overall, the evaluation of nurse-based physical healthcare is in early stages. Thus far, they appear to have positive implications for consumers with SMI.

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.

Evaluating interventions to improve somatic health in severe mental illness: a systematic review

OBJECTIVE

To present a systematic review of the evaluation of randomized interventions directed toward improving somatic health for patients with severe mental illness (SMI).

METHOD

A systematic search in PubMed, Embase, Cinahl, and PsycInfo was performed. The scope of the search was prospective studies for patients aged 18-70, published from January 2000 till June 2011. Randomized interventions directed toward improving somatic health for patients with SMI were selected. We excluded studies on elderly, children, and studies performed before 2000. Information on population, type of intervention, follow-up, outcome measures, and on authors' conclusions were drawn from the original articles.

RESULTS

Twenty-two original studies were included, presenting four types of interventions: health education (n = 9), exercise (n = 6), smoking cessation (n = 5), and changes in health care organization (n = 2). To evaluate the effect of these studies 93 different outcome measures were used in 16 categories.

CONCLUSION

Many interventions directed toward improving somatic health for patients with SMI have been started. These studies did not apply similar evaluations, and did not use uniform outcome measures of the effect of their interventions. Valuable comparisons on effectiveness are therefore almost impossible.

Development of integrated mental health care: critical workforce competencies

In integrated care, a person will have his or her medical and behavioral health needs addressed within one health care system. Support for integrated models has grown with the increasing awareness of how the medical comorbidities of individuals with serious mental illness contribute to their morbidity and mortality, the prevalence of mental health problems in the general population, and the mental health issues among those with chronic medical problems. The enactment of effective integrated care will demand developing clinicians who are trained to work with mental health needs at various levels of intensity, who are capable of addressing complex comorbidities, and who operate from a person-centered approach to care. In this light we argue that given their unique skill set and clinical training, Psychiatric-Mental Health Advanced Practice Nurses could play a critical role in integrated care and present policy recommendations which support the development of the Psychiatric-Mental Health Advanced Practice Nurses role in such models.

Effect of psychosocial interventions on social functioning in depression and schizophrenia: meta-analysis

BACKGROUND

Psychosocial interventions may contribute to reducing the burden of mental disorders in low- and middle-income (LAMI) countries by improving social functioning, but the evidence has not been systematically reviewed.

AIMS

Systematic review and meta-analysis of the effect of psychosocial interventions on social functioning in people with depression and schizophrenia in LAMI countries.

METHOD

Studies were identified through database searching up to March 2011. Randomised controlled trials were included if they compared the intervention group with a control group receiving placebo or treatment as usual. Random effects meta-analyses were performed separately for depressive disorders and schizophrenia and for each intervention type.

RESULTS

Of the studies that met the inclusion criteria (n = 24), 21 had sufficient data to include in the meta-analysis. Eleven depression trials showed good evidence for a moderate positive effect of psychosocial interventions on social functioning (standardised mean difference (SMD) = 0.46, 95% CI 0.24-0.69, n = 4009) and ten schizophrenia trials showed a large positive effect on social functioning (SMD = 0.84, 95% CI 0.49-1.19, n = 1671), although seven of these trials were of low quality. Excluding these did not substantially affect the size or direction of effect, although the precision of the estimate was substantially reduced (SMD = 0.89, 95% CI 0.05-1.72, n = 863).

CONCLUSIONS

Psychosocial interventions delivered in out-patient and primary care settings are effective at improving social functioning in people with depression and should be incorporated into efforts to scale up services. For schizophrenia there is an absence of evidence from high-quality trials and the generalisabilty of the findings is limited by the over-representation of trials conducted in populations of hospital patients in China. More high-quality trials of psychosocial interventions for schizophrenia delivered in out-patient settings are needed.

Engagement in Activities and Occupations by People Who Have Experienced Psychosis: A Metasynthesis of Lived Experience

Purpose:

The purpose of this study was to answer the question ‘How do people who have experienced psychosis describe their engagement in activities of daily living and occupations?’

Procedures:

A qualitative metasynthesis was undertaken on nine studies (encompassing 73 participants) published in occupational therapy literature. Only studies that had used individual qualitative interviews were included to highlight lived experience on a personal level. The quality of the evidence was assessed across all studies and found to be generally high.

Findings:

Four overarching themes across the nine studies were identified: my emotions and identity; my own health and wellbeing; my relationships with family, friends and community; and my activities and occupations. The overarching themes are not intended to be considered categorically, as they all influence and interact with each other.

Conclusion and relevance:

There is considerable synchronicity between the experiences of people who have experienced psychosis and the values of the profession. A client's meaningful engagement in activities and occupation is evidence towards how therapists provide authentic, respectful and effective support to these clients, in a manner that meets their needs as individuals.

Interventions for the metabolic syndrome in schizophrenia: a review

The metabolic syndrome (MetS) is an increasingly prevalent condition in people with schizophrenia. It remains highly prevalent in the general population in developed countries, but recently health promotion campaigns and greater awareness of the high associated mortality rates have resulted in improvements in the rates of cardiovascular risk factors. This is not the case for people with schizophrenia who continue to have more than twice the rates of MetS and significantly higher mortality rates than the general population. Various behavioural and pharmacological interventions have been used to improve conditions that are linked to MetS, mainly smoking and obesity. This review aims to provide an update of the latest knowledge about the behavioural, pharmacological and other interventions that might help to combat this life-threatening problem in people with schizophrenia.

The physical health of the seriously mentally ill: an overview of the literature

Despite the wealth of literature which attests to the relationship between serious mental illness (SMI) and physical ill health, the provision of optimum physical health care for mental health service users remains a challenge. In England the Department of Health has identified the evident health inequalities for people with SMI as a priority area for health improvement, publishing numerous policy directives aimed at addressing these inequalities. However, this is a highly complex process and little is known about why the rhetoric of holistic health care has proved unattainable thus far. In this paper we present an informed commentary of the contemporary literature with the aim of offering a more comprehensive understanding of the health inequalities faced by people with SMI. We searched relevant databases for publications related to: the causes of poor physical health among the mentally ill, strategies to address these health needs and the impact which professional education, culture and services structure has on this facet of service delivery. This enabled us to identify potential strategies that can be adopted by health care practitioners wishing to improve the health of this vulnerable group, and by educationalists to advance professionals' knowledge of this important and ostensibly neglected area.

Innovations aimed at improving the physical health of the seriously mentally ill: an integrative review

AIMS AND OBJECTIVES

The aim of this paper is to report an integrative review of the literature that focused on innovations aimed at enhancing the physical health of people with serious mental illness.

BACKGROUND

Despite the abundance of literature that highlights the relationship between serious mental illness and physical ill health, the provision of physical health care for the seriously mental ill remains a challenge. Many different strategies have been developed, which endeavour to address the poor physical health of people with serious mental illness. However, there is inadequate evidence to establish the success of these strategies.

DESIGN

Integrative literature review.

METHOD

The review was conducted using an adapted version of Whittemore and Knafl's review method to critically appraise and evaluate the literature. Results.  Three main themes derived for the types of intervention in the studies emerged from the review. These included assessment, health education/health promotion and multimodal interventions.

CONCLUSION

Although there is some evidence to demonstrate that health assessments are effective in highlighting physical health problems, the evidence to support health education and multimodal interventions is far from conclusive. Further research is needed, in particular larger intervention and longitudinal studies, to help nurses decide on the best possible interventions that will improve the physical health of the seriously mentally ill.

RELEVANCE TO CLINICAL PRACTICE

Whilst nurses' continued attempts to develop health-enhancing interventions are commendable, there needs to be a greater focus on conducting research to develop the evidence base to guide and support nurses in this area of their practice. Until robust and convincing evidence is available, policy relating to the advancement of the physical health of people with serious mental illness should be developed cautiously.

Differences in substance-related risk behavior between dual and triple diagnosed severely mentally ill adults

OBJECTIVES: The purpose of this study was to determine if differences exist between adults with dual and triple diagnoses with regard to substance-related risk behaviors. METHODS: This secondary analysis was a cross-sectional study. There were 252 subjects with dual and triple diagnoses recruited from residential crisis programs in San Francisco. Using descriptive and logistic regression analyses, subjects in the two groups were compared with regard to demographic data, types of substances, and routes of administration used in the previous 30 days to determine risk for exposure and/or transmission of HIV/HCV. RESULTS: When compared to the dual diagnosis group, subjects with triple diagnoses were four times more likely to have engaged in IDU (p=.001) and 2.6 times more likely to use amphetamines (p=.05). They also reported using more types of substances over the lifetime (p<.0001). But with regard to other risk behaviors such as alcohol use to intoxication and cocaine/crack use, there were no significant differences. CONCLUSION: Though many substance-related risk behaviors occurred in both groups, adults with triple diagnoses were more likely to engage in IDU, amphetamine use, and to use more types of substances over the lifetime. This information has the potential to inform interventions that might prevent/reduce substance-related risk in this population.

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 assess the effects of general physical health advice as a means of reducing morbidity, mortality and improving or maintaining quality of life in people with serious mental illness.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (November 2009) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO.

SELECTION CRITERIA

All randomised clinical trials focusing on general physical health advice.

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 mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.

MAIN RESULTS

For the comparison of physical healthcare advice versus standard care we identified five studies (total n = 884) of limited quality. For measures of quality of life one trial found no difference (n = 54, 1 RCT, MD Lehman scale 0.00 CI -0.67 to 0.67) but another did (n = 407, 1 RCT, MD Quality of Life Medical Outcomes Scale - mental component 3.7 CI 1.7 to 5.6). There was no difference between groups for the outcome of death (n = 407, 1 RCT, RR 1.3 CI 0.3 to 6.0), for the outcome of uptake of ill-health prevention services, one study found percentages significantly greater in the advice group (n = 363, 1 RCT, MD 36.9 CI 33.1 to 40.7). Economic data were equivocal. Attrition was large (> 30%) but similar for both groups (n = 884, 5 RCTs, RR 1.18 CI 0.97 to 1.43). 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 expenditure on giving ineffective advice. 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.

Exploring the impact of race on mental health service utilization among african americans and whites with severe mental illness

BACKGROUND

Disparities among African Americans and Whites with severe mental illness have been identified in numerous studies. Yet it remains unknown if disparities are associated with race or other vulnerabilities common to this population.

OBJECTIVES

This study used the Behavioral Model for Vulnerable Populations to examine mental health service utilization among 155 African Americans and Whites with severe mental illness for 12 months after discharge from a residential crisis program.

DESIGN

This cross-sectional study was a secondary analysis of data from a randomized trial.

RESULTS

Race did not emerge as a significant predictor of mental health service utilization. Factors associated with frequency of service use were diagnosis, age, drug use, gender, health benefit status, and enrollment in an outpatient mental health program.

CONCLUSION

It is possible that the geographic location of the study, equal access to services, and equal rates of substance use between racial groups explain the lack of racial differences found in this sample.

Packages of care for schizophrenia in low- and middle-income countries

In the third in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Jair Mari and colleagues discuss the treatment of schizophrenia.

Eligibility, recruitment, and retention of African Americans with severe mental illness in community research

Data that addresses severely mentally ill (SMI) African Americans (AAs) likelihood to participate in clinical research is limited. This study's purpose was to determine if differences exist between races regarding eligibility, recruitment, and retention in a community-based clinical trial. The sample included 293 participants. Data sources included clinical records and interviews. Logistic regression was used for analysis. AAs were as likely to participate and to complete followup interviews as Whites. In contrast to studies about non-mentally ill AAs, AAs with SMI appeared to be as willing to consent to and to remain in clinical research studies as Whites.

Behavioural interventions to reduce the risk of physical illness in persons living with mental illness

PURPOSE OF REVIEW

It is beyond dispute that people living with mental illness suffer a disproportionate disease burden when compared with people in the general population. This review considers the efficacy and effectiveness of lifestyle behavioural interventions at service delivery level as a strategy to reduce the risk factors that contribute to somatic disease comorbidity. As many factors contribute to the very poor physical health of people living with mental illness and as there are no 'quick fix' remedies, strategies to improve physical health need to be sustainable on a system-wide basis.

RECENT FINDINGS

Most studies of behavioural interventions at best report modest success during the period of the intervention. However, even limited success can significantly reduce the likelihood of physical comorbidities developing. Unfortunately, the evidence suggests that any gains during the intervention are mostly lost over time. The implication is that interventions need to be sustainable over the long-term.

SUMMARY

When planning behavioural interventions, consideration ought to be given to extending them over a period of years not weeks or months. Approaches that include additional on-going support beyond the intervention period itself promote a greater likelihood of maintaining the improved physical health of the target population.