Inequalities in healthcare provision for people with severe mental illness

Clubhouse Partnerships with Clinical Services: Current Status and Barriers to Integration

The Clubhouse model of psychosocial rehabilitation has supported the recovery of people with serious mental illness for over 75 years, but many of the roughly 350 Clubhouses are not well-integrated into the larger health care system, limiting their reach. This article examines Clubhouses' and psychiatric providers' interactions and experiences to understand the nature of and barriers to partnerships. The directors of Clubhouses affiliated with Clubhouse International were surveyed, examining their attitudes and practices around collaboration with psychiatric providers. To provide context, psychiatric providers were also surveyed regarding their understanding of and experiences with Clubhouses. Findings reveal broad support among both Clubhouse directors and psychiatrists for enhancing partnerships, despite current barriers, limited interactions, and the need for greater mutual understanding. Key considerations that emerged include the importance of maintaining the Clubhouse model's distinct non-clinical, community-based, and member-directed identity in any integration efforts.

Inclusion in the cancer patient pathway among cancer patients with and without pre-existing mental or substance use disorders: a nationwide register-based study

BACKGROUND

Cancer patients with a pre-existing mental disorder or substance use disorder (SUD) have a poorer prognosis compared to other cancer patients, with suboptimal routes to diagnosis and treatment as possible contributing factors. Shorter intervals from suspicion of cancer to start of cancer treatment have been observed following the implementation of Cancer Patient Pathways (CPP) in the Nordic countries, which may have led to a better prognosis. We aimed to investigate whether incident cancer patients with and without pre-existing mental disorder or SUD were equally likely to be included in a CPP. We also investigated the associations between pre-existing mental disorder or SUD and low primary care utilization, and cancers diagnosed post-emergency or close to death in non-CPP enrolees.

METHODS

This population-based registry study included incident cancer patients aged 21-79 between 2015 and 2018 (n = 65,328). Information on pre-existing mental disorders or SUD was gathered from national registries of primary and specialised health care, prescriptions, and disability diagnosis. Propensity score analyses using inverse probability weighting along with the McNemar test were performed to evaluate the risk of non-inclusion in any CPP for all cancers combined, lifestyle-related cancers combined, and the most common cancers individually.

RESULTS

Cancer patients with pre-existing mental disorder or SUD had an 8% (RR = 1.08; 95% Confidence Interval (CI) 1.03-1.13) higher risk of non-enrolment in a CPP. Patients with prior hospitalisation for mental disorder or SUD, and patients with pre-existing psychosis or depression were at particular risk of non-inclusion in a CPP compared to controls, especially for cancers that often present with symptoms late in the course of the disease, such as lung cancer. In line with this, patients with pre-existing mental disorder or SUD who were not referred to a CPP faced a 34% (RR = 1.34; 95% CI 1.18-1.53%) increased risk of unrecognised cancer close to death.

CONCLUSIONS

Cancer patients with pre-existing mental disorder or SUD have an increased risk of non-inclusion in a CPP. If not included in a CPP, they have an increased risk of having unrecognised cancer close to death. By addressing barriers to CPP-inclusion, and enhancing the quality of diagnostic and treatment services, healthcare systems could achieve better cancer outcomes for vulnerable patient groups.

Psychoeducation in the management of menopause symptoms for women living with a serious mental illness: a scoping review

IMPORTANCE AND OBJECTIVE

People living with a serious mental illness (SMI) may require additional management during the menopause transition and may have specific education needs regarding menopause. The aim of this scoping review was to assess the literature on psychoeducation programs that have been developed to address the menopause knowledge needs of people living with a mental illness.

METHODS

A scoping review of the literature was conducted in November 2024, focussing on psychoeducation programs for menopause developed for women living with a SMI using PsycINFO, Medline, Embase, and Google Scholar using the "Population, Concept, and Context" framework. The population considered was individuals with SMI, mental illness, bipolar disorder, schizophrenia, schizoaffective disorder, personality disorder, post-traumatic stress disorder, depression, anxiety disorders, obsessive-compulsive disorder, alcohol use, substance use, and eating disorders. Five studies were found that utilized psychoeducation in the context of cognitive behavior therapy delivered as a treatment of either depression or menopause symptoms. Participants in these studies included women living with depression or bipolar disorder. No studies were identified that delivered any psychoeducation intervention for the majority of conditions assessed. Population groups with no research included schizophrenia or schizoaffective disorder, personality disorder, post-traumatic stress disorder, anxiety disorders, obsessive-compulsive disorder, alcohol use, substance use, and eating disorders.

DISCUSSION AND CONCLUSION

More research is needed to further explore how people living with a mental illness may be best prepared for the menopause transition considering both menopause symptoms and psychiatric symptoms. The development and assessment of psychoeducation programs and materials addressing individual needs should be further considered for those living with a mental illness.

Physical Health and Health Behaviours of Australians with Psychosis

People living with psychosis live up to 20 years less compared to the general population. Cardiometabolic ill-health and barriers to health-related behaviour are significant contributors. This is a cross-sectional descriptive study of cardiometabolic health and health behaviours of consumers attending a public community mental health service in an Australian city. One hundred and fourteen consumers currently living with psychosis participated. Standard measures of cardiometabolic health, quality of life and, health-related behaviours were utilised. Data were analysed using descriptive statistics. The cohort reported higher fruit intake and physical activity, and lower excess alcohol use compared to previous studies. Health-related behaviours including smoking and vegetable intake were poorer than previously reported. Participants had low levels of cardiometabolic health (e.g. abnormal lipids). Physical and mental quality of life was also lower than for general populations. Improved efforts to address physical health for people with mental health conditions are urgently needed.

The impact of COVID-19 on participation in Australia's National Bowel Cancer Screening Program by people with severe mental illness: A national data linkage study

OBJECTIVE

The impact of COVID-19 on Australia's National Bowel Cancer Screening Program remains unclear, especially for individuals with severe mental illness. These individuals have historically participated in the National Bowel Cancer Screening Program at significantly lower rates than the general population. This study aimed to understand the impact of COVID-19 on participation in Australia's National Bowel Cancer Screening Program among individuals with severe mental illness.

METHODS

Cohort study using deidentified linked health and National Bowel Cancer Screening Program data. We compared participation in the National Bowel Cancer Screening Program between individuals with and without severe mental illness by examining rates of participation (returning an immunochemical faecal occult blood test), returning a valid immunochemical faecal occult blood test, receiving a positive immunochemical faecal occult blood test result and undergoing a follow-up colonoscopy before (25 January 2018-24 January 2020) and during (25 January 2020-31 July 2021) the COVID-19 pandemic.

RESULTS

Overall National Bowel Cancer Screening Program participation fell by 10.3% from pre-COVID to during COVID. Less than one-quarter (23.9%) of people with severe mental illness participated in the National Bowel Cancer Screening Program during the COVID-19 pandemic compared to 30.5% before. People with severe mental illness were less likely to return a valid immunochemical faecal occult blood test and more likely to return a positive immunochemical faecal occult blood test result both before and during the pandemic, compared to the general population. They were also significantly less likely to have a colonoscopy following positive immunochemical faecal occult blood test result (pre-COVID adjusted relative risk = 0.97, 95% confidence interval: 0.94-1.01, vs during COVID adjusted relative risk = 0.87, 95% CI: 0.82-0.91).

CONCLUSION

The pandemic significantly reduced the rate at which all Australians participated in the National Bowel Cancer Screening Program. Disparities between people with severe mental illness and the general population generally improved with the exception of follow-up colonoscopy after positive immunochemical faecal occult blood test result.

Exploring the Landscape of Intensive Outreach Services for Older Adults With Serious Mental Illness: A Scoping Review

Older adults living with mental illness, particularly those with serious mental illness (SMI), represent a vulnerable and underserved patient population. Deinstitutionalization laid the groundwork for intensive outreach services for this population, yet little attention was paid to the unique needs of older individuals with SMI. We conducted a scoping literature review to map the landscape of intensive outreach services developed for older adults living with SMI. We specifically focused on peer-reviewed literature. EMBASE, MEDLINE, PsycINFO and CINAHL databases were searched for pertinent literature between 1990 and 2023. Fourteen studies were selected for inclusion from 2,952 articles screened. Most studies were descriptive (N = 7). There were three randomized controlled trials (N = 3), three quasi-experimental studies (N = 3) and one (N = 1) pre-experimental study. All programs had a multidisciplinary component with a wide range of allied health clinicians. Six programs were adapted from the assertive community treatment model. Three programs included medical specialists. Only seven studies focused on examining treatment outcomes or efficacy, though there was notable variability in outcome measures analyzed. While intensive outreach services for older adults with SMI show promise, this scoping review highlights the paucity of research in this area. Future research rigorously evaluating models of care, with emphasis on fidelity, cost-effectiveness and patient outcomes, will be essential to inform service delivery to this population.

Strengthening the Delivery of Physical Healthcare for Adults Living With Serious Mental Illness - A Qualitative Description of Patient and Family Member Perspectives

BACKGROUND

Individuals with serious mental illness (SMI) have higher rates of comorbid physical health conditions, poorer associated health outcomes, and die on average 10-20 years earlier than the general population. This qualitative study aimed to explore the perspectives and experiences of adults living with SMI and family members with accessing physical healthcare within primary and mental health settings in Canada.

METHODS

We conducted a qualitative descriptive study using semi-structured interviews with 20 adults living with SMI and five focus groups with 18 family members between July 2023 and April 2024. After coding by two authors, thematic analysis was completed with the support of a data analysis team to identify overarching themes capturing participant experiences with accessing physical healthcare, care needs and preferences.

RESULTS

Four main themes emerged from participant narratives: (1) The centrality of mental health problems in the lives of people with SMI; (2) Challenges in accessing physical healthcare; (3) The role of families in supporting access to care; (4) Perceived health priorities and preferences. There was a high degree of congruence between the perspectives of individuals living with SMI and family members. Both participant groups described challenges accessing primary care settings, fragmented health services, and a desire for person-centred, whole-person health within mental health settings, with family member support where available.

CONCLUSIONS

Findings from this study highlight the need for advancing the integration of physical healthcare within mental health settings for adults living with SMI, who are less likely to engage with community-based primary care services. Enhanced access to physical healthcare could leverage multidisciplinary resources in these settings and partnerships with families. These findings can inform efforts to provide whole-person healthcare for individuals experiencing SMI.

PATIENT OR PUBLIC CONTRIBUTION

The study team collaborated closely with community organizations and individuals with lived experience at every stage of this research. This included contributions to the funding proposal, the study protocol, participant recruitment, study materials, data analysis and preparing the manuscript. Individuals with lived experience and family members actively participated in management and project meetings for the duration of the study.

Understanding Implementation Fidelity of Physical Health Screening in Mental Health Nursing: A Mixed Methods Study

Physical health screening for patients with schizophrenia spectrum disorders is suboptimal despite patients' poor physical health and nurses' willingness to conduct assessments. However, this inadequate service provision is poorly understood. The purpose of this study was to describe nurses' adherence to conducting screening with the Finnish Health Improvement Profile and related factors. An explanatory, sequential two-phase mixed-methods design was used. A quantitative method was used to describe nurses' adherence and a qualitative approach to describe moderating factors. The data were collected and analyzed separately and later integrated into one dataset. Generally, screening was implemented as intended regarding content adherence despite very few nurses conducting the screening. Analysis identified four main themes related to adherence. Comprehensiveness of policy description included complexity and duration; strategies to facilitate implementation included fragmented information, instructions, nurses' fragmented work tasks, management and equipment; quality of delivery included preparedness and nurses' confidence and skills; and participant responsiveness included nurses' enthusiasm in screening, nurses' engagement in screening, patient willingness to participate, patient's refusal to participate, patient's cognitive capacity and collaborative screening. For successful screening, the utility and feasibility of the screening tool would need to be reevaluated after addressing some of the barriers identified as moderating factors.

Caregivers' experiences of being asked about adverse childhood experiences and receiving support from an integrated health and social care hub: a qualitative study

OBJECTIVES

Adverse childhood experiences (ACEs) are significant contributors to the burden of disease and remain a serious concern for the health and wellbeing of children in Australia. To address ACEs, we co-designed and implemented two integrated health and social care hubs (Child and Family Hubs [CFHs]). This study explores the experiences of caregivers who received care from the CFHs, including the way they were asked about ACEs and the services offered to address identified ACEs.

DESIGN

A qualitative study design was used. Using a semistructured interview guide, 29 in-depth interviews were conducted with caregivers of children who were experiencing a range of adversities, including maltreatment and household dysfunction, child neglect, parent mental illness, domestic violence, family conflict, community dysfunction, discrimination, poverty or financial hardship. A thematic analysis approach was used to analyse textual data. Triangulation of investigators and sources of data improved validation of the findings. NVivo (V.12) was used to organise, index and retrieve data.

SETTINGS

This study was conducted in two Child and Family Hubs (CFHs) in Australia-IPC Health, Wyndham Vale, Melbourne, and Marrickville Health Centre, Sydney, between May and October 2023.

PARTICIPANTS

Participants (n=29) were the caregivers of children living with adverse childhood experiences (ACEs).

RESULTS

Four themes were identified which reflected the caregivers' experiences of being asked about adversities and how they linked to the support and services both in the CFHs and outside the CFH. These themes were as follows: (i) trusting relationships are fundamental; (ii) expectations play a role in talking about adversities; (iii) barriers to open discussion of adversities and (iv) barriers to accessing services.

CONCLUSIONS

Consultations between caregivers and hub practitioners can effectively identify and address ACEs despite certain barriers. Establishing a trusting relationship where caregivers feel heard and supported is vital, highlighting the hub model's potential impact in Australia and similar contexts. Enhancing consultation duration, and service availability and accessibility may further improve caregivers' experiences in identifying and addressing adversity.

Severe Traumatic Brain Injury Outcomes in Patients with Premorbid Psychiatric Illness

OBJECTIVE

Individuals with psychiatric illnesses (PIs) have increased rates of traumatic brain injury (TBI). Nonetheless, the influence of underlying PI on TBI outcomes is poorly understood.

METHODS

We analyzed the medical records of 633 adult-severe TBI patients admitted to our institution between 2010 and 2021. We identified patients with premorbid PI (Psych (+) group, n = 129) and a subset with only a substance use disorder (SUD (+) group, n = 60) and compared them to patients without PI (Psych (-) group, n = 480). Outcome measures included discharge Glasgow Coma Scale (GCS), length of stay, in-hospital survival, and Glasgow Outcome Scale-Extended (GOS-E).

RESULTS

The Psych (+) group had increased in-hospital survival (69.8% vs. 55.0%, P = 0.003) and fewer patients with severe (3-8) discharge-GCS (28.7% vs. 46.0%, P < 0.001). The SUD (+) group had increased in-hospital survival (70.0% vs. 55.0%, P = 0.028) and fewer patients with severe discharge-GCS (28.3% vs. 46.0%, P = 0.009). However, the Psych (+) (21.0 vs. 10.0 days, P < 0.001) and SUD (+) (16.0 v. 10.0 days, P = 0.011) groups had longer length of stay. The Psych (+) group had a higher mean GOS-E at discharge (2.7 vs. 2.4, P = 0.004), 6-months (3.8 vs. 3.0, P = 0.006) and 1-year (3.4 vs. 2.3, P = 0.027). The SUD (+) group also had a higher mean GOS-E at discharge (2.8 vs. 2.4, P = 0.034), six months (3.8 vs. 3.0, P = 0.035), and one year (3.5 vs. 2.3, P = 0.008). Additionally, there were no significant differences in injury severity or computed tomography scan findings.

CONCLUSIONS

Individuals with PI and SUD appeared to have better outcomes but more complicated hospital stays following severe TBI. Future studies should investigate the mechanisms underlying these outcomes.

Gender disparities in extreme psychological distress at cancer diagnosis and patients access to psycho-oncological care

BACKGROUND

Cancer has adverse consequences for mental health, especially in women. Lack of awareness of services and stigma diminish access to psycho-oncology services.

AIMS

To assess psychological distress and willingness to engage in multidisciplinary psycho-oncological services among cancer patients.

METHODS

Cross-sectional survey of attitudes towards psycho-oncology services in 142 cancer patients.

RESULTS

Women experienced more extreme distress than men, with 46.4% of females and 17.8% of males reporting "extreme" distress. Under one third of cancer patients (30.3%) knew the meaning of 'psycho-oncology'; one quarter (25.6%) knew of the psycho-oncology service, and two thirds (67.2%) were unsure if referral would be beneficial. One fifth (21.0%) would be somewhat/extremely uncomfortable disclosing attending palliative care, compared to 17.9% for psychiatry, 14.4% for psychology, and 5.8% for cardiology. On multivariable analysis, pre-existing psychiatric/psychological difficulty was the only variable independently associated with belief that a psycho-oncology referral would be beneficial.

CONCLUSIONS

Limited awareness of psycho-oncology services exist despite high rates of extreme distress among women with cancer.. Given that women have higher levels of extreme distress, it would be prudent to offer them enhanced psycho-oncological care.

Respiratory disease in people with bipolar disorder: a systematic review and meta-analysis

People with bipolar disorder (BD) have an increased risk of premature mortality and the respiratory mortality rate is higher than those of the general population. To date, however, the evidence on respiratory disease in this population has not been meta-analyzed. We systematically review and meta-analyze the frequency of respiratory diseases in patients with BD and to compare prevalence and odds ratio (OR) with the general population. The systematic literature search was conducted in Pubmed, PsycINFO, Scielo and Scopus, with snowball search of reference and citation lists. Inclusion criteria were studies reporting diagnoses of respiratory diseases (asthma, chronic obstructive pulmonary disease (COPD), pneumonia, lung cancer and tuberculosis) in people with BD according to operationalized criteria and where possible, control group. Of the 2158 articles screened, 20 including 962,352 people with BD and 37,340,405 control group, met the inclusion criteria. In people with BD, the prevalence of COPD was 9.14% (95%CI: 6.61-12.5%), asthma 6.4% (95%CI: 4.56-8.91%), pneumonia 2.78% (95%CI: 2.51-3.08%) and lung cancer 0.44% (95%CI:0.23-0.84%). Compared to the general population, people with BD had significantly higher rates of COPD (OR: 1.73; 95% CI: 1.40-2.14), showing an increased rate in younger and female patients; asthma (OR: 1.91, 95% CI: 1.25-2.94), with a greater rate in younger patients; and pneumonia (OR: 2.82, 95% CI: 1.33-5.99). In the first meta-analysis on the topic, BD was associated with an increased risk of respiratory illness versus the general population. In COPD and asthma, young people and women are at particular risk. Prevention programs are urgently needed.

SARS-CoV-2 infection and COVID-19 outcomes across mental disorders and the role of sex: A register-based study from Catalonia

INTRODUCTION

This study investigated the risk of SARS-CoV-2 infection and severe COVID-19 outcomes among different mental health diagnoses and the role of sex in these associations.

METHODS

Using electronic records from Catalonia, we identified adults receiving mental health care from 2017-2019 with diagnoses of non-affective psychosis (NAP), bipolar disorder (BD), depressive disorder (DEP), stress-related disorders, neurotic/somatoform disorders (NSD), and substance misuse (SUB) (exposed). The outcomes assessed were SARS-CoV-2 infection, COVID-19 hospitalization, and COVID-19-related death, compared to matched individuals without these mental disorders (unexposed). Adjusted logistic regression analyses were conducted.

RESULTS

785,378 adults were included (70.3% < 65 years old; 57.1% women). Compared to unexposed, those with NAP, BD, DEP, and SUB had a lower risk of SARS-CoV-2 infection, while those with NSD had an increased risk. Infected individuals with DEP, NSD, and SUB had a lower risk of hospitalization but a higher risk of COVID-19-related death. Higher COVID-19-related death was also observed in individuals with NAP and BD. Sex-stratified analysis revealed that women with NSD were especially vulnerable to infection, and women with DEP and NSD had a higher risk of COVID-19-related death.

CONCLUSIONS

These findings emphasize the need for tailored public health strategies to reduce excess mortality risk among individuals with certain mental disorders, while accounting for sex differences.

Criminal Offending and Incarceration in United States Adults With Early Phase Psychosis and Comorbid Substance Use Disorder

AIM

Studies have shown that people experiencing early phase psychosis (EPP) are at increased risk for criminal conviction and incarceration. However, there is limited data looking at overall legal burden. To address these gaps in the literature, the goal of this study was to categorise criminal charges and convictions using the United States Federal Bureau of Investigation (FBI) uniform crime reporting (UCR) program, assess frequency of incarcerations, and describe the frequency of substance use disorder (SUD) diagnoses and its relationship to criminal offending and incarceration in a well categorised EPP population.

METHODS

A sample of 309 adults experiencing EPP were enrolled in a specialty care clinic. The research team expanded upon prior work and collected data from three public databases to identify legal burden in this population.

RESULTS

Almost 50% (n = 155) of subjects had a history of a criminal charge, 34% (n = 104) of subjects had a history of criminal conviction, and 40% (n = 123) of subjects had at least one incarceration event. The most common typology of criminal offence were crimes against society. Lastly, a dual diagnosis was statistically associated with incarcerations (χ2 = 10.152, p < 0.0011), crimes against society (χ2 = 13.172, p < 0.0002), and crimes against persons (χ2 = 9.136, p < 0.0023).

CONCLUSIONS

These data highlight the high legal burden people experiencing EPP face and the need for future work to examine the risks incarceration places on this population. This work also shows the need for specialty care clinics managing EPP to be proficient in treating a dual diagnosis or the need to partner with an appropriate clinic.

Clinical factors for all-cause mortality in people with schizophrenia: A retrospective cohort study between 2013 and 2021

BACKGROUND

Schizophrenia is a severe mental illness associated with significantly elevated mortality rates. However, factors related to the mortality risk among people with schizophrenia in low and middle-income countries remain to be examined. This study aims to explore the clinical factors for all-cause mortality in people with schizophrenia.

METHODS

We conducted a 9-year retrospective cohort study on people with schizophrenia in Guangzhou, China. Cox proportional hazards regression analysis and competing risk analysis was used to identify clinical factors associated with all-cause mortality and specific-cause mortality. A propensity score matching method was performed to minimize the impact of confounding factors.

RESULTS

The overall age-standardized mortality rate in people with schizophrenia between 2013 and 2021 was 1606.04 per 100,000 person-years. We found that medical expenses not covered by medical insurance (adjusted hazard ratio [aHR]: 2.49 [95 % CI: 2.21-2.82]), relatively-stable (aHR: 1.18 [95 % CI: 1.01-1.38]) and unstable illness (aHR: 2.65 [95 % CI: 1.90-3.68]), history of non-continuous treatment (aHR: 1.35 [95 % CI: 1.25-1.46]), and no treatment history (aHR: 1.41 [95 % CI: 1.29-1.55]) were associated with a higher risk of all-cause mortality. Frequent hospital stays (once: aHR: 0.46 [95 % CI: 0.42-0.50], more than once: aHR: 0.23 [95 % CI: 0.21-0.26]) and a family history of mental disorders (aHR: 0.50 [95 % CI: 0.40-0.64]) were associated with a lower risk of mortality.

CONCLUSION

We identified clinical factors associated with all-cause mortality. Targeted interventions should be developed to reduce the mortality risk in people with schizophrenia.

Place of death and healthcare utilisation at the end of life among individuals with mental and behavioural disorders as underlying cause of death: population-level multiple-register study

BACKGROUND

Understanding the place of death for individuals with mental and behavioural disorders (MBDs) is essential for identifying disparities in healthcare access and outcomes, as well as addressing broader health inequities within this population.

AIMS

To examine the place of death among individuals in Sweden with the underlying cause of death reported as a MBD and compare variations between diagnostic groups, as well as explore associations between place of death and individual, sociodemographic and clinical factors.

METHOD

This population-level analysis used death certificate data (gender, age, underlying cause of death and place of death) recorded between 2013 and 2019 and other national register data. MBD group differences were compared using chi-square tests (χ2) and multinominal logistic regressions explored variations in place of death.

RESULTS

The final sample consisted of 2875 individuals. Our regression model revealed that individuals with MBDs other than intellectual disabilities were less likely to die in hospitals (odds ratio 0.60-0.134 [95% CI = 0.014-0.651]) or care homes (odds ratio 0.11-0.97 [95% CI = 0.003-0.355]) than at home. Substance use disorders were the most common underlying cause of death (61.3%). This group consisted predominantly of men (78.8%, χ2, P < 0.001), and tended to be younger (χ2, P < 0.001).

CONCLUSIONS

Individuals with intellectual and developmental disabilities are more likely to die in hospitals or care homes than at home. Those with MBDs, particularly substance use disorders, face a high risk of premature death, highlighting gaps in healthcare and palliative care provision for these populations.

The short-, medium-, and long-term prevalence of physical health comorbidities in first-episode psychosis: a systematic review and meta-analysis protocol

Background

Individuals with first-episode psychosis (FEP) face an increased risk of physical comorbidities, notably cardiovascular diseases, metabolic disorders, respiratory disorders, and certain types of cancer. Previous reviews report pooled physical health prevalence from chronic psychosis and FEP groups. By contrast, this review will focus on antipsychotic-naïve FEP cohorts and incorporate data from observational longitudinal studies and antipsychotic intervention studies to understand the progression of physical health comorbidities from the onset to later stages of psychosis. This review aims to examine the short-, medium-, and long-term period prevalence of these comorbidities in FEP and variations related to demographic factors.

Methods

Using the PRISMA and MOOSE guidelines, Medline, Embase, PsycINFO, and CINAHL+, as well as Clinical Trials gov.uk, OpenGrey, WHO International Clinical Trials Registry Platform, Current Controlled Trials, United States National Institute of Health Trials Registry, and the Irish Health Repository, will be searched from inception. Longitudinal studies and antipsychotic intervention studies monitoring health outcomes in antipsychotic naïve FEP individuals will be eligible for inclusion. Two reviewers will independently screen titles, abstracts, and full-text articles. Risk of bias will be assessed using the Joanna Briggs Institute Critical Appraisal Checklist. A meta-analysis of the short-, medium-, and long-term prevalence of cardiovascular, metabolic, cancer, and respiratory outcomes and a narrative synthesis will be conducted. Where feasible, a meta-regression on the impact of demographic variables will be conducted. Potential limitations include the risk of diagnostic heterogeneity across studies and possible underreporting of certain comorbidities.

Conclusions

This systematic review will clarify the progression of physical health comorbidities in FEP, informing early intervention strategies and policies. Subsequent findings will be submitted to a leading journal, supplemented by a recovery education module and a lay summary for wider dissemination.

Registration

The study was registered in PROSPERO, the International Prospective Register of Systematic Reviews ( CRD42023431072; 17/06/2023).

The Challenging Problems of Cancer and Serious Mental Illness

PURPOSE OF REVIEW: Patients with Serious Mental Illness (SMI) are reported to be at higher risk for somatic disorders (e.g. cardiovascular and metabolic diseases) and higher mortality, compared to the general population, because of the consequences of SMI including psychotropic medication side effects, sedentary and unhealthy lifestyle, difficult access to physical health care. The aim of this review was to examine the current evidence regarding oncology, focusing on the problem of cancer among patients with SMI. RECENT FINDINGS: Compared to the general population, individuals with SMI showed a lower rate of screening for cancer, suboptimal standard cancer treatment, delayed treatment, and higher mortality from cancer. Several factors, including those related to the patient, the health-care system, and the social context, are involved in these negative outcomes. It is therefore necessary to raise awareness and alert clinicians in oncology settings to the challenging problem of cancer among patients with SMI, a marginalized and vulnerable segment of the population that can be at risk for not receiving proper cancer prevention and care. Evidence supports the mandatory need for an interdisciplinary approach involving psychiatry and mental health services.

All-cause mortality risk in long-acting injectable versus oral antipsychotics in schizophrenia: a systematic review and meta-analysis

Patients with schizophrenia receiving antipsychotic treatment present lower mortality rates than those who do not. However, the non-adherence rate is high, which can be partially addressed using long-acting injectable (LAI) antipsychotics. The impact of LAI treatments on all-cause mortality compared to oral antipsychotics remains unclear. To fill that gap, a random effects meta-analysis was conducted to analyze the odds ratio (OR) of all-cause, suicidal, and non-suicidal mortality among patients taking LAI antipsychotics compared to oral antipsychotics (PROSPERO:CRD42023391352). Individual and pooled LAI antipsychotics were analyzed against pooled oral antipsychotics. Sensitivity analyses were performed for study design, setting, and industry sponsorship. Meta-regressions were conducted for gender, age, antipsychotic dose, and race. Seventeen articles, total sample 12,042 patients (N = 5795 oral, N = 6247 LAI) were included. Lower risk of all-cause mortality for patients receiving LAI antipsychotics vs receiving oral antipsychotics was found (OR = 0.79; 95%CI = 0.66-0.95). Statistical significance was maintained when only studies comparing the same LAI and oral antipsychotic were included (OR = 0.79; 95%CI = 0.66-0.95; p = <0.01), as well as for non-suicidal mortality (OR = 0.77: 95%CI = 0.63-0.94; p = 0.01), but not for suicidal mortality (OR = 0.86; 95%CI = 0.59-1.26; p = 0.44). Mortality reduction was more pronounced for LAI antipsychotics in first-episode psychosis (FEP) (OR = 0.79; 95%CI = 0.66-0.96) compared to chronic psychosis. No individual LAI reported statistically significant differences against all pooled oral antipsychotics. LAI antipsychotics are associated with a lower risk of all-cause and non-suicidal mortality in individuals with schizophrenia compared to oral antipsychotics. Better adherence to the medication and health services may explain this difference. Whenever possible, the use of LAIs should be considered from the FEP.

Psychological Distress, Antipsychotic Medications and Cardiovascular Risk Factors Among Patients With Schizophrenia

AIMS

This study aims to assess the correlation between antipsychotic drug use, psychological distress and cardiovascular risk factors among patients with schizophrenia.

METHODS

A cross-sectional correlational design was used to obtain data from 143 patients with schizophrenia who were conveniently selected. Data were collected by assessing selected cardiovascular risk indicators blood pressure (BP), random blood sugar (RBS), body mass index (BMI), waist-to-height ratio (WtHR) and waist circumference (WC). A self-administered questionnaire was used to collect sociodemographic data, clinical history and the 18-item Psychological Stress Index for patients with schizophrenia.

RESULTS

The use of antipsychotics was associated with increased cardiovascular risk factors including BP, BMI and WtHR. Atypical antipsychotic medications were associated with weight gain and obesity which increase the risk of diabetes and cardiovascular diseases. Age was significantly correlated with systolic BP (r = 0.31), diastolic BP (r = 0.30) and RBS (r = 0.26). Furthermore, significant correlations were found between the duration of diagnosis with systolic (r = 0.26) and diastolic (r = 0.21) BP. None of the correlations between stress and the other study variables were significant.

CONCLUSION

Screening of antipsychotic side effects is needed in the early phases, and attention must be paid to the cardiovascular risk in patients with schizophrenia, particularly BP, glucose level and BMI. In addition, clinicians should be informed of this evidence to set guidelines for regular monitoring of metabolic parameters.

REPORTING METHOD

STROBE guidelines were followed in this study.

PATIENT OR PUBLIC CONTRIBUTION

Actively involving patients in data collection, this study ensured that their voices were heard and their experiences were central to informing the research findings. In addition, involving patients in the study would enhance the relevance and applicability of the study's conclusions to real-world contexts, promoting patient-centered care and improved health outcomes for patients with schizophrenia.

Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates

Cardiovascular disease (CVD) is a leading cause of premature mortality among patients with severe mental illness (SMI). Effective care delivery models are needed to address this mortality gap. This study examines the impact of an enhanced primary care (PC) program that specializes in the treatment of patients with SMI, called Medicine in Psychiatry Service-Primary Care (MIPS-PC). Using multipayer claims data in Western New York from January 1, 2016 to December 31, 2021, patients with SMI and CVD were identified using International Classification of Diseases, Tenth Revision codes. National Provider Identification numbers of MIPS-PC providers were then used to identify those patients who were treated by MIPS-PC during the period. These MIPS-PC-treated patients were compared against a cohort of one-to-one propensity score matched contemporaneous comparison group (ie, patients receiving PC from providers unaffiliated with MIPS-PC). A difference-in-difference approach was used to identify the treatment effects of MIPS-PC on all-cause emergency department (ED) visits and hospitalization rates. The MIPS-PC group was associated with a downtrend in the acute care utilization rates over a 3-year period following the index date (ie, date of first MIPS-PC or other PC provider encounter), specifically a lower hospitalization rate in the first year since the index date (25%; P < 0.001). ED visit rate reduction was significant in the third-year period (18%; P = 0.021). In summary, MIPS-PC treatment is associated with a decreasing trend in acute care utilization. Prospective studies are needed to validate this effect of enhanced PC in patients with SMI and CVD.

The effectiveness of peer support on the recovery and empowerment of people with schizophrenia: A systematic review and meta-analysis

BACKGROUND

People with schizophrenia have a shorter life span and high mortality and morbidity rates. Peer support is an important strategy that can improve outcomes for people with schizophrenia. Peer support involves people with a lived experience of recovery who help and support others experiencing mental health problems.

AIMS

The main aim of this systematic literature review was to examine the effectiveness of peer support on the recovery and empowerment outcomes of service users with schizophrenia disorders. The objectives were to contribute to evidence-based practice and promote peer support interventions in mental health services.

DATA SOURCES

We searched for randomised controlled trials (RCTs) on peer support in MEDLINE, CINAHL, AMED, Academic Search Premier, PubMed, PsycArticles, PsycINFO, Cochrane, and Psychology and Behavioural Sciences Collection. We identified additional trials from the citations of previous studies.

METHODS

We assessed the trials' methodological quality and biases using the risk of bias (RoB) and grading of recommendations, assessment, development, and evaluation (GRADE) tools. We performed a meta-analysis in the RevMan application and extracted data from the clinical trials using narrative synthesis. This systematic review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) procedures.

RESULTS

A total of 17 trials with 5974 participants were included in this review. The most common peer support was peer-led self-management interventions. The RE model (SMD = 0.29, 95 % CI = 0.13 to 0.45, p-value = 0.0004) shows that peer support interventions significantly improved the recovery outcome compared to standard care provided to service users with schizophrenia. The RE model (SMD = 0.22, 95 % CI = 0.11 to 0.33, p-value = 0.0001) also shows that peer support interventions significantly empowered service users with schizophrenia. However, the positive effects were small. A sub-group analysis found moderate effects on the recovery outcome among the emerging peer support interventions. The quality of the evidence was moderate.

CONCLUSIONS

Peer support interventions effectively improved the recovery and empowerment outcomes. Current clinical trials indicate that peer support is an essential psychosocial intervention in improving empowerment and recovery in service users with schizophrenia.

Quality indicators for schizophrenia care: A scoping review

Measuring quality of care is a critical first step towards improving the healthcare contributing to persistent poor outcomes experienced by many people living with schizophrenia. This scoping review aims to identify and characterize indicators for measuring the quality of care for people living with schizophrenia. We searched 6 academic databases, 4 grey literature databases, and 23 organization websites for documents containing quality indicators developed for or applied in a population with schizophrenia-spectrum disorders. We identified 119 unique documents, yielding 390 distinct quality indicators. Most measures were process indicators (68 %; n = 267) commonly reflecting safety (30 %; n = 118) and effectiveness (35 %; n = 136) domains of quality of care. Quality indicators included measures of primarily mental healthcare (77 %; n = 299), as well as physical healthcare (23 %; n = 91). Indicators reflected aspects of care related to service delivery, pharmacotherapy, assessments, resources and policies, psychological interventions, social and other interventions. Indicator development was notable for a lack of well-described validation and selection processes. Gaps in indicator availability for comorbid substance use, reproductive health, and healthcare equity were also identified. Results reflect a growing recognition of the importance of quality measurement in this population but highlight the need for prioritization of indicators to guide future quality measurement and improvement.

Transitional Care Support for Medicaid-Insured Patients With Serious Mental Illness: Protocol for a Type I Hybrid Effectiveness-Implementation Stepped-Wedge Cluster Randomized Controlled Trial

BACKGROUND

People diagnosed with a co-occurring serious mental illness (SMI; ie, major depressive disorder, bipolar disorder, or schizophrenia) but hospitalized for a nonpsychiatric condition experience higher rates of readmissions and other adverse outcomes, in part due to poorly coordinated care transitions. Current hospital-to-home transitional care programs lack a focus on the integrated social, medical, and mental health needs of these patients. The Thrive clinical pathway provides transitional care support for patients insured by Medicaid with multiple chronic conditions by focusing on posthospitalization medical concerns and the social determinants of health. This study seeks to evaluate an adapted version of Thrive that also meets the needs of patients with co-occurring SMI discharged from a nonpsychiatric hospitalization.

OBJECTIVE

This study aimed to (1) engage staff and community advisors in participatory implementation processes to adapt the Thrive clinical pathway for all Medicaid-insured patients, including those with SMI; (2) examine utilization outcomes (ie, Thrive referral, readmission, emergency department [ED], primary, and specialty care visits) for Medicaid-insured individuals with and without SMI who receive Thrive compared with usual care; and (3) evaluate the acceptability, appropriateness, feasibility, and cost-benefit of an adapted Thrive clinical pathway that is tailored for Medicaid-insured patients with co-occurring SMI.

METHODS

This study will use a prospective, type I hybrid effectiveness-implementation, stepped-wedge, cluster randomized controlled trial design. We will randomize the initiation of Thrive referrals at the unit level. Data collection will occur over 24 months. Inclusion criteria for Thrive referral include individuals who (1) are Medicaid insured, dually enrolled in Medicaid and Medicare, or Medicaid eligible; (2) reside in Philadelphia; (3) are admitted for a medical diagnosis for over 24 hours at the study hospital; (4) are planned for discharge to home; (5) agree to receive home care services; and (6) are aged ≥18 years. Primary analyses will use a mixed-effects negative binomial regression model to evaluate readmission and ED utilization, comparing those with and without SMI who receive Thrive to those with and without SMI who receive usual care. Using a convergent parallel mixed methods design, analyses will be conducted simultaneously for the survey and interview data of patients, clinicians, and health care system leaders. The cost of Thrive will be calculated from budget monitoring data for the research budget, the cost of staff time, and average Medicaid facility fee payments.

RESULTS

This research project was funded in October 2023. Data collection will occur from April 2024 through December 2025. Results are anticipated to be published in 2025-2027.

CONCLUSIONS

We anticipate that patients with and without co-occurring SMI will benefit from the adapted Thrive clinical pathway. We also anticipate the adapted version of Thrive to be deemed feasible, acceptable, and appropriate by patients, clinicians, and health system leaders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06203509; https://clinicaltrials.gov/ct2/show/NCT06203509.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64575.

Development and Evaluation of the "Eating More Consciously" Module of a Lifestyle Intervention Program to Prevent Medication-Induced Weight Gain in Psychiatric Patients: A One-Arm Pilot Study

Objective

Overweight and obesity are health issues that are increasing worldwide. Patients with severe mental illness are particularly vulnerable for various reasons, including the intake of weight gain-associated drugs. In this pilot study, we targeted eating behavior as a predictor for medication-induced weight gain and developed a module of a prevention program ("Eating More Consciously") to be evaluated by psychiatric inpatients.

Methods

Thirty-three patients participated in a behaviorally oriented group therapy program with 2 modules of 120 minutes each and weekly follow-up measurements over 4 weeks. Measures included weight, laboratory parameters, the German versions of the Three-Factor Eating Questionnaire (Fragebogen Essverhalten; FEV) and the Food Craving Inventory (FCI) as well as a questionnaire on the implementation of the strategies in everyday life.

Results

Thirty-three participants completed both modules and felt that they had benefited from the module "Eating More Consciously". Fragebogen Essverhalten domain "cognitive restraint" scores increased significantly throughout the study (P = .039), and the FCI sum score decreased significantly (P = .003).

Conclusion

We propose that the "Eating More Consciously" module is a promising approach to behavioral intervention in weight management in patients with severe mental illness. Prospective randomized controlled studies with a larger sample and a longer follow-up are needed.

Racial Disparities in Time to Huntington Disease Diagnosis in North America: An ENROLL-HD Analysis

Background and Objectives

There are well-documented racial and ethnic disparities in access to neurologic care and disease-specific outcomes. Although contemporary clinical and neurogenetic understanding of Huntington disease (HD) is thanks to a decades-long study of a Venezuelan cohort, there are a limited number of studies that have evaluated racial and ethnic disparities in HD. The goal of this study was to evaluate disparities in time from symptom onset to time of diagnosis of HD.

Methods

Using the ENROLL-HD periodic data set 5 (PDS5), we performed sequential multivariate linear regressions to evaluate sociodemographic factors associated with disparities in time to diagnosis (TTD) for gene-positive individuals (CAG repeats 36+) in the North America region. Sensitivity analyses included imputed multivariate regression analysis of individuals with a total motor score (TMS) of 10 or higher and those with 40+ CAG repeats. We also used descriptive statistics to present TTD data in other ENROLL-HD participating regions.

Results

Among 4717 gene-positive participants in the North American region, 89.5% identified as White, 3.4% as Hispanic or Latino, and 2.3% as African American/Black. The average TTD in the group was 3.78. When adjusting for clinical and sociodemographic variables, Black participants were diagnosed with HD 1 year later than White participants (p < 0.05). Additional factors associated with a later diagnosis included psychiatric symptoms as initial HD symptom, unemployment during baseline ENROLL visit, and higher educational attainment. Sensitivity analysis of gene-positive (36+ CAG) participants with a TMS of 10 or higher and of those with 40+ CAG repeats yielded similar findings.

Discussion

Across multiple statistical models, Black ENROLL-HD participants were diagnosed with HD 1 year later than White participants. Clinical factors suggesting a delay in HD diagnosis included psychiatric symptoms at disease onset and a negative family history of HD. Unemployment during baseline visit and higher educational attainment were sociodemographic factors suggestive of a later diagnosis. Additional multicenter qualitative and quantitative studies are needed to better understand reasons for delays in HD diagnosis among Black individuals, and the role of social and structural determinants of health in obtaining a timely HD diagnosis.

Experiences of receiving a medical consultation - an interview study among hospitalized psychiatric patients

PURPOSE

People with mental illness often experience more physical health problems, compared to the general population. Therefore, we conducted medical consultations to hospitalized psychiatric patients. The purpose of our study was to investigate experiences of medical consultations from a patient perspective.

MATERIALS AND METHODS

We conducted 17 qualitative, semi-structured interviews with hospitalized psychiatric patients who received a medical consultation in the period of February to May 2023. The interviews were analyzed using Braun and Clarke's thematic analysis.

RESULTS

Patients perceived the medical consultation as important in bridging the gap between psychiatric and somatic treatment. The consultation created a sense of security, with patients emphasizing the importance of acknowledgment by the medical doctor. However, some patients were affected by their state of mind and their psychiatric treatment, resulting in memory impairment, which prevented fully utilization of the medical consultation. The support from psychiatric staff proved crucial for patients in initiating somatic interventions.The results are presented in the two overarching themes: (1) Experiences of a medical consultation in a psychiatric setting and (2) communication and support as influential factors for benefits of the medical consultation.

CONCLUSION

Our interview study reveals that hospitalized psychiatric patients experience a medical consultation as an important initiative. The relationship between the patient and the medical doctor, the patient's state of mind, and the support of the psychiatric staff play significant roles. Incorporating these factors in the medical consultation enables a beneficial outcome that can improve the health of people with mental illness.

A feasibility study of a participatory designed program for preventing cardiovascular disease in mentally vulnerable patients

AIM

To test the feasibility of a participatory design intervention aimed at reducing the risk of cardio-vascular disease among patients suffering from alcohol use disorder (AUD) or severe mental illness (SMI).

METHODS

The intervention was developed by patients from the Community Mental Health Center and the Alcohol Treatment Facility in Odense, Denmark, and consisted of eight modules (health interviews, screening and treatment, introduction, diet/alcohol, physical activity, smoking, health app, and sleep problems). The intervention was tested using pre- and post-measurements of selected variables, patients' intervention attendance, and interviews and dialogue workshops at the end of the study.

RESULTS

A total of 21 out of 42 eligible patients from the Alcohol Treatment Facility and two out of 443 eligible patients from the Community Mental Health Center accepted participation in the study. The two patients from the Community Mental Health Center were not included in the analyses due to General Data Protection Regulation (GDPR). All patients accepted being screened for risk factors at inclusion, and the majority enrolled in at least one of the subsequent modules. The study indicated that the patients followed recommendations from their GPs.

CONCLUSIONS

There is a great need for focus on cardio-vascular disease in patients with SMI and those with AUD. Results indicate that the intervention is feasible for patients with AUD, but due to inclusion of too few patients with SMI, nothing can be concluded for this patient group. Patients and staff in the Alcohol Treatment Facility agreed that the intervention has future perspectives.

Mental illness and COVID-19 vaccination: a multinational investigation of observational & register-based data

Individuals with mental illness are at higher risk of severe COVID-19 outcomes. However, previous studies on the uptake of COVID-19 vaccination in this population have reported conflicting results. Using data from seven cohort studies (N = 325,298) included in the multinational COVIDMENT consortium, and the Swedish registers (N = 8,080,234), this study investigates the association between mental illness (defined using self-report measures, clinical diagnosis and prescription data) and COVID-19 vaccination uptake. Results from the COVIDMENT cohort studies were pooled using meta-analyses, the majority of which showed no significant association between mental illness and vaccination uptake. In the Swedish register study population, we observed a very small reduction in the uptake of both the first and second dose of a COVID-19 vaccine among individuals with vs. without mental illness; the reduction was however greater among those not using psychiatric medication. Here we show that uptake of the COVID-19 vaccine is generally high among individuals both with and without mental illness, however the lower levels of vaccination uptake observed among subgroups of individuals with unmedicated mental illness warrants further attention.

Interventions targeting patients with co-occuring severe mental illness and substance use (dual diagnosis) in general practice settings - a scoping review of the literature

BACKGROUND

People with dual diagnosis die prematurely compared to the general population, and general practice might serve as a setting in the healthcare system to mend this gap in health inequity. However, little is known about which interventions that have been tested in this setting.

AIM

To scope the literature on interventions targeting patients with dual diagnosis in a general practice setting, the outcomes used, and the findings.

DESIGN AND SETTING

A scoping review of patients with dual diagnosis in general practice.

METHODS

From a predeveloped search string, we used PubMed (Medline), PsychInfo, and Embase to identify scientific articles on interventions. Studies were excluded if they did not evaluate an intervention, if patients were under 18 years of age, and if not published in English. Duplicates were removed and all articles were initially screened by title and abstract and subsequent fulltext were read by two authors. Conflicts were discussed within the author group. A summative synthesis of the findings was performed to present the results.

RESULTS

Seven articles were included in the analysis. Most studies investigated integrated care models between behavioural treatment and primary care, and a single study investigated the delivery of Cognitive Behavioral treatment (CBT). Outcomes were changes in mental illness scores and substance or alcohol use, treatment utilization, and implementation of the intervention in question. No studies revealed significant outcomes for patients with dual diagnosis.

CONCLUSION

Few intervention studies targeting patients with dual diagnosis exist in general practice. This calls for further investigation of the possibilities of implementing interventions targeting this patient group in general practice.

Mind the gap: an administrative data analysis of dental treatment outcomes and severe mental illness

BACKGROUND

Oral health of people with severe mental illness (SMI) remains an important public health issue, despite evidence pointing suboptimal dental health outcomes in this population.

AIMS

We test the hypotheses that individuals with SMI have lower contact with dental services and higher levels of fillings and extractions. We also examine effect modification by age-group.

METHODS

We used linked administrative data from general practitioner (GP), hospital and dental records to examine dental service use and treatments (extractions, fillings, crowns and x-rays) among the Northern Ireland hospital population between January 2015 and November 2019 (N = 798,564).

RESULTS

After adjusting for available socio-demographic characteristics, analysis indicated lower levels of dental service use (OR = 0.80, 95% CI = 0.77, 0.84), including lower likelihood of fillings (OR = 0.81, 0.77, 0.84) and x-rays (OR = 0.77, 0.74, 0.81), but higher levels of extractions (OR = 1.23, 1.18, 1.29) among patients with SMI. We also found effect modification by age-group, with older individuals with SMI less likely to have each of the four dental treatments.

CONCLUSIONS

We suggest that in the general area of physical healthcare for people with SMI, oral healthcare is neglected. There is a need for improved understanding of the barriers to routine care and treatment, and development of psychoeducational interventions.

Characteristics of quality improvement interventions to improve physical healthcare in mental health settings: a scoping review protocol

INTRODUCTION

Mental health concerns globally impact millions of people, resulting in significant financial impact and adverse health outcomes. People living with mental health concerns are at higher risk of developing physical health issues, which can lead to a shortened life expectancy. Barriers to physical healthcare, such as limited service capacity, low help seeking and stigma, contribute to health disadvantage. Quality improvement (QI) interventions can address these challenges by addressing staff-level and service-level factors to improve the focus on physical healthcare in mental health settings. The aim of this scoping review is to describe studies of QI interventions to improve physical healthcare in mental health settings.

METHODS AND ANALYSIS

The proposed scoping review will be conducted in accordance with guidance for scoping reviews from the Joanna Briggs Institute Manual and in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. A systematic review search for peer-reviewed and published articles will be conducted across eight databases: PubMed, MEDLINE (Ovid), Web of Science, CINAHL (EBSCOhost), ProQuest Central, PsycINFO (Ovid), Scopus and Embase (Elsevier). Two independent reviewers will screen the titles, abstracts and full text using Covidence. Any disagreement will be resolved through discussion or with a third reviewer. Data collection will be facilitated using Microsoft Excel. The details of included studies will be extracted by two authors independently.

ETHICS AND DISSEMINATION

No ethical approval is required for the scoping review. The results of this review will be presented at conferences and published in a peer-reviewed scientific journal. This review will also inform the development of a QI strategy to influence mental health staff practices in the provision of physical healthcare in Australian mental health settings.

Impact of the mental health reform in Israel on health care and mortality among people with severe mental illness

OBJECTIVE

Reports show disparities in the health care of people with severe mental illness (SMI). Yet, the moderating effect of mental health reforms on the health care disparities remain unexplored. The current study aimed to investigate the outcomes of the mental health reform in Israel on the use of health services among people with SMI.

METHOD

A case-control epidemiological study comparing the use of health services 3.5 years before and after the mental health reform for service users diagnosed with schizophrenia, schizoaffective disorder, and bipolar disorder. Data on health services included: blood cholesterol test (LDL), hemogalobin-A1C test, and visits to general practitioners (GPs) and specialists. Mortality was recorded.

RESULTS

Following the reform the number of visits to GPs was decreased among service users of the three SMI groups, as well as visits to specialists among service users with a schizoaffective or bipolar disorder. Following the reform service users of the three SMI groups showed no-change in the performance of LDL test. Complex findings were noted with regard to the performance of Hemoglobin-A1C test. Mortality rates were higher among service users with SMI and the relative risk were similar before and after the reform.

CONCLUSIONS

Users of the three SMI groups showed no benefits of the mental health reform in terms of use of health services. Improved health care can be attained by a closer collaboration between the primary physicians and community mental health services.

Factors that influence participation in physical activity for people with bipolar disorder: a synthesis of qualitative evidence

BACKGROUND

Mental health problems contribute significantly to the overall disease burden worldwide and are major causes of disability, suicide, and ischaemic heart disease. People with bipolar disorder report lower levels of physical activity than the general population, and are at greater risk of chronic health conditions including cardiovascular disease and obesity. These contribute to poor health outcomes. Physical activity has the potential to improve quality of life and physical and mental well-being.

OBJECTIVES

To identify the factors that influence participation in physical activity for people diagnosed with bipolar disorder from the perspectives of service users, carers, service providers, and practitioners to help inform the design and implementation of interventions that promote physical activity.

SEARCH METHODS

We searched MEDLINE, PsycINFO, and eight other databases to March 2021. We also contacted experts in the field, searched the grey literature, and carried out reference checking and citation searching to identify additional studies. There were no language restrictions.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that focused on the experiences and attitudes of service users, carers, service providers, and healthcare professionals towards physical activity for bipolar disorder.

DATA COLLECTION AND ANALYSIS

We extracted data using a data extraction form designed for this review. We assessed methodological limitations using a list of predefined questions. We used the "best fit" framework synthesis based on a revised version of the Health Belief Model to analyse and present the evidence. We assessed methodological limitations using the CASP Qualitative Checklist. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) guidance to assess our confidence in each finding. We examined each finding to identify factors to inform the practice of health and care professionals and the design and development of physical activity interventions for people with bipolar disorder.

MAIN RESULTS

We included 12 studies involving a total of 592 participants (422 participants who contributed qualitative data to an online survey, 170 participants in qualitative research studies). Most studies explored the views and experiences of physical activity of people with experience of bipolar disorder. A number of studies also reported on personal experiences of physical activity components of lifestyle interventions. One study included views from family carers and clinicians. The majority of studies were from high-income countries, with only one study conducted in a middle-income country. Most participants were described as stable and had been living with a diagnosis of bipolar disorder for a number of years. We downgraded our confidence in several of the findings from high confidence to moderate or low confidence, as some findings were based on only small amounts of data, and the findings were based on studies from only a few countries, questioning the relevance of these findings to other settings. We also had very few perspectives of family members, other carers, or health professionals supporting people with bipolar disorder. The studies did not include any findings from service providers about their perspectives on supporting this aspect of care. There were a number of factors that limited people's ability to undertake physical activity. Shame and stigma about one's physical appearance and mental health diagnosis were discussed. Some people felt their sporting skills/competencies had been lost when they left school. Those who had been able to maintain exercise through the transition into adulthood appeared to be more likely to include physical activity in their regular routine. Physical health limits and comorbid health conditions limited activity. This included bipolar medication, being overweight, smoking, alcohol use, poor diet and sleep, and these barriers were linked to negative coping skills. Practical problems included affordability, accessibility, transport links, and the weather. Workplace or health schemes that offered discounts were viewed positively. The lack of opportunity for exercise within inpatient mental health settings was a problem. Facilitating factors included being psychologically stable and ready to adopt new lifestyle behaviours. There were positive benefits of being active outdoors and connecting with nature. Achieving balance, rhythm, and routine helped to support mood management. Fitting physical activity into a regular routine despite fluctuating mood or motivation appeared to be beneficial if practised at the right intensity and pace. Over- or under-exercising could be counterproductive and accelerate depressive or manic moods. Physical activity also helped to provide a structure to people's daily routines and could lead to other positive lifestyle benefits. Monitoring physical or other activities could be an effective way to identify potential triggers or early warning signs. Technology was helpful for some. People who had researched bipolar disorder and had developed a better understanding of the condition showed greater confidence in managing their care or providing care to others. Social support from friends/family or health professionals was an enabling factor, as was finding the right type of exercise, which for many people was walking. Other benefits included making social connections, weight loss, improved quality of life, and better mood regulation. Few people had been told of the benefits of physical activity. Better education and training of health professionals could support a more holistic approach to physical and mental well-being. Involving mental health professionals in the multidisciplinary delivery of physical activity interventions could be beneficial and improve care. Clear guidelines could help people to initiate and incorporate lifestyle changes.

AUTHORS' CONCLUSIONS

There is very little research focusing on factors that influence participation in physical activity in bipolar disorder. The studies we identified suggest that men and women with bipolar disorder face a range of obstacles and challenges to being active. The evidence also suggests that there are effective ways to promote managed physical activity. The research highlighted the important role that health and care settings, and professionals, can play in assessing individuals' physical health needs and how healthy lifestyles may be promoted. Based on these findings, we have provided a summary of key elements to consider for developing physical activity interventions for bipolar disorder.

Professional identity and representations of advanced practice nurses specialising in psychiatry and mental health: A national study

Advanced practice nurses constitute a new professional group within the French health care system. Advanced practice nurses specialise in one of five disciplines including Psychiatry/Mental-Health. This specific discipline is strongly marked by stigmatising representations by healthcare users and other health professionals (including other advanced practice nurses), whose consequences have a deleterious effect. The aim was to highlight all advanced practice nurses representation of Psychiatry/Mental-Health advanced practice nurses. An observational descriptive survey, based on an anonymous online questionnaire was conducted in April 2022 among qualified and student advanced practice nurses from the five specialist disciplines. Overall, 356 advanced practice nurses completed the survey questionnaire. No significant difference in stigmatising representations of Psychiatry/Mental-Health advanced practice nurses versus other advanced practice nurses was observed. Only 3.3% of other advanced practice nurses thought that Psychiatry/Mental-Health advanced practice nurses are often 'strange'. Psychiatry/Mental-Health advanced practice nurses and other advanced practice nurses appeared to have similar representations of the professional roles of advanced practice nurses in general and of advanced practice nurses APN specifically. Unlike other professionals in the psychiatric field (e.g. medical interns, nurses), very little stigmatisation of Psychiatry/Mental-Health advanced practice nurses by their colleagues (i.e. other advanced practice nurses) was observed. This could be partly due to the fact that advanced practice nurses professional identity appeared to be built collectively around the concept of advanced practice. Advanced practice nurses constitute a professional group that is fully involved in contemporary transformations in care and organisational innovation. The very low level of stigmatisation of Psychiatry/Mental-Health advanced practice nurses by other advanced practice nurses in our study suggests that these new healthcare actors could play a crucial role in the improvement of professional health practices, particularly in terms of improved coordination between psychiatric-care and physical-care.

Association between initial clozapine titration and pneumonia risk among patients with schizophrenia in a Korean tertiary hospital

Pneumonia is a significant adverse drug reaction (ADR) associated with clozapine, characterized by high mortality and potential linkage with other inflammatory responses. Despite the critical nature, research regarding the development of pneumonia during initial clozapine titration remains limited. This retrospective study included 1408 Korean inpatients with schizophrenia spectrum disorders. Data were collected from January 2000 to January 2023. Pneumonia developed in 3.5 % of patients within 8 weeks of clozapine initiation. Patients who developed pneumonia were taking a greater number and higher dose of antipsychotics at baseline (2.14 vs. 1.58, p < 0.001; 25.64 vs. 19.34, p = 0.012). The average onset occurred 17.24 days after initiation, on an average dose of 151.28 mg/day. Titration was either paused or slowed in most of these patients, with no reported fatalities. The types of pneumonia included aspiration pneumonia, mycoplasma pneumonia, bronchopneumonia, and COVID-19 pneumonia. Myocarditis, drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, and urinary tract infections were also identified. Logistic regression analysis revealed that a greater number of concomitant antipsychotics (odds ratio [OR] = 1.59, p = 0.027) and concomitant benzodiazepine use (OR = 2.33, p = 0.005) at baseline were associated with an increased risk of pneumonia. Overall, pneumonia development during clozapine titration is linked with other inflammatory ADRs, suggesting a shared immunological mechanism. Close monitoring is recommended, especially for patients taking multiple antipsychotics and benzodiazepines. Further studies involving repeated measures of clozapine concentrations at trough and steady state, along with a more detailed description of pneumonia types, are warranted.

Barriers and Facilitators to Breast Cancer Screening for Women With Severe Mental Illness

BACKGROUND

Women with severe mental illness (SMI) are diagnosed with breast cancer at later stages, with greater mortality rates than the general population. Although breast cancer screening is an acknowledged strategy for early breast cancer detection, women with SMI are 32% to 50% less likely to have regular mammography screenings, yet the specific factors related to the disparity in this population have not been determined.

AIM

The purpose of this study was to identify the barriers and facilitators toward breast cancer screening in women diagnosed with SMI.

METHOD

In collaboration with a community-based mental health services agency, women aged 40 and older, diagnosed with SMI, and treated at that agency, were identified and asked if they were willing to participate. Fifteen women agreed to be interviewed. An interpretive descriptive approach was utilized to analyze the qualitative data.

RESULTS

The themes elicited included barriers and facilitators to screening. Barriers found were: Psychiatric Symptoms, Fear, Distrust in the Health care System, and Not my Priority. Among the facilitators were Support, Good Health care Experiences, Make it Easy, Integrated Care, and Self-Care.

CONCLUSION

Unique to this study was the understanding by participants that physical health needed to be integrated into their mental health care services through direct support and education, primarily because the process of recovery from mental illness itself entailed the increasing ability for self-care, encompassing a focus on both mental and physical health needs and preventive care.

The perspectives of hospital doctors about end-of-life care in people with mental illness: an observational pilot study

BACKGROUND

Negative attitudes towards people living with mental illness (PLWMI), defined here as mentalism, are a major contribution to health care inequity, which may extend into end-of-life care. There is a clear need for investigation of the attitudes of doctors towards PLWMI at the end of life as doctors may lead processes of care that contribute to this inequity.

AIMS

The aim of this pilot study is to examine the perspectives of hospital-based doctors regarding end-of-life care and medical decision-making in PLWMI.

METHODS

A survey was created to explore whether mentalism is present in the perspectives of hospital doctors regarding end-of-life care for PLWMI. The survey included demographic characteristics of participants and questions comprising statements and vignettes that required agree/disagree responses. Descriptive statistics were used to summarise responses, and chi-square tests examined associations with demographic variables.

RESULTS

The survey was commenced by 48 hospital-based doctors and completed by 45. Descriptive statistics indicated that mentalism is present in the attitudes of hospital doctors regarding end-of-life care of PWLMI, with 47 of 48 participants (98%) endorsing at least one mentalist response. One significant association found that psychiatrists and psychiatry trainees were less likely to endorse a stereotype response in one vignette.

CONCLUSIONS

This preliminary study addresses a gap within the literature on the potential contribution of mentalist attitudes in doctors to the poorer end-of-life care outcomes for PLWMI. The findings highlight the need for further study of this topic and suggest a role for targeted medical education in the pursuit of health care equality for PLWMI.

Distributions of recorded pain in mental health records: a natural language processing based study

OBJECTIVE

The objective of this study is to determine demographic and diagnostic distributions of physical pain recorded in clinical notes of a mental health electronic health records database by using natural language processing and examine the overlap in recorded physical pain between primary and secondary care.

DESIGN, SETTING AND PARTICIPANTS

The data were extracted from an anonymised version of the electronic health records of a large secondary mental healthcare provider serving a catchment of 1.3 million residents in south London. These included patients under active referral, aged 18+ at the index date of 1 July 2018 and having at least one clinical document (≥30 characters) between 1 July 2017 and 1 July 2019. This cohort was compared with linked primary care records from one of the four local government areas.

OUTCOME

The primary outcome of interest was the presence of recorded physical pain within the clinical notes of the patients, not including psychological or metaphorical pain.

RESULTS

A total of 27 211 patients were retrieved. Of these, 52% (14,202) had narrative text containing relevant mentions of physical pain. Older patients (OR 1.17, 95% CI 1.15 to 1.19), females (OR 1.42, 95% CI 1.35 to 1.49), Asians (OR 1.30, 95% CI 1.16 to 1.45) or black (OR 1.49, 95% CI 1.40 to 1.59) ethnicities, living in deprived neighbourhoods (OR 1.64, 95% CI 1.55 to 1.73) showed higher odds of recorded pain. Patients with severe mental illnesses were found to be less likely to report pain (OR 0.43, 95% CI 0.41 to 0.46, p<0.001). 17% of the cohort from secondary care also had records from primary care.

CONCLUSION

The findings of this study show sociodemographic and diagnostic differences in recorded pain. Specifically, lower documentation across certain groups indicates the need for better screening protocols and training on recognising varied pain presentations. Additionally, targeting improved detection of pain for minority and disadvantaged groups by care providers can promote health equity.

Comorbid physical health burden of serious mental health disorders in 32 European countries

BACKGROUND

Mental health disorders (MHDs) are associated with physical health disparities, but underlying excess risk and health burden have not yet been comprehensively assessed.

OBJECTIVE

To assess the burden of comorbid physical health conditions (PHCs) across serious MHDs in Europe.

METHODS

We estimated the relative prevalence risk of PHCs associated with alcohol use disorders (AUD), bipolar disorder (BD), depressive disorders (DD) and schizophrenia (SZ) across working-age populations of 32 European countries in 2019 based on a targeted literature review. Excess physical health burden was modelled using population-attributable fractions and country-level prevalence data.

FINDINGS

We screened 10 960 studies, of which 41 were deemed eligible, with a total sample size of over 18 million persons. Relative prevalence of PHCs was reported in 54%, 20%, 15%, 5% and 7% of studies, respectively, for SZ, DD, BD, AUD or mixed. Significant relative risk estimates ranged from 1.44 to 3.66 for BD, from 1.43 to 2.21 for DD, from 0.81 to 1.97 for SZ and 3.31 for AUD. Excess physical health burden ranged between 27% and 67% of the total, corresponding to 84 million (AUD), 67 million (BD), 66 million (DD) and 5 million (SZ) PHC diagnoses in Europe. A 1% reduction in excess risk assuming causal inference could result in two million fewer PHCs across investigated MHDs.

CONCLUSIONS

This is the first comprehensive study of the physical health burden of serious MHDs in Europe. The methods allow for updates, refinement and extension to other MHDs or geographical areas.

CLINICAL IMPLICATIONS

The results indicate potential population health benefits achievable through more integrated mental and physical healthcare and prevention approaches.

Hearing Loss in Older People With Schizophrenia: Audiologic Characteristics and Association With Psychosocial Functioning

OBJECTIVE

The severity and impact of hearing deficits among adults with schizophrenia spectrum disorders may become increasingly relevant with advancing age. This study evaluated hearing ability and associated psychosocial functioning among older adults aged 50-70.

DESIGN

Cross-sectional analysis.

SETTING

Four outpatient psychiatry clinics in New York City.

PARTICIPANTS

Individuals aged 50-70 years with diagnoses of schizophrenia or schizoaffective disorder.

MEASUREMENTS

Unaided pure tone air conduction audiometry conducted using a portable audiometry system determined the pure tone average (PTA) hearing threshold across four frequencies: 500, 1k, 2k, and 4k Hz. Better ear PTA defined the hearing threshold. Audiometry data retrieved from the U.S. National Health and Nutrition Examination Survey aided interpretation of sample hearing loss rates. Standard measures evaluated psychiatric symptoms, perceived impact of hearing impairment, loneliness, and quality of life.

RESULTS

Among audiometry completers (N = 40), 35% (n = 14) demonstrated subclinical hearing loss (16-25 dB) and 35% (n = 14) had mild or worse hearing loss (≥26 dB). Rates were higher than expected based on age-based population data. Those who perceived hearing handicap rated it moderate (12.2%) or severe (7.3%); those who perceived tinnitus rated the impact as mild to moderate (12.2%) or catastrophic (2.4%). Neither psychiatric symptoms nor interviewer-rated quality of life was associated with hearing ability. Greater loneliness was significantly correlated with worse audiologic performance (r = 0.475, p <0.01) and greater perceived hearing handicap (r = 0.480, p <0.01).

CONCLUSION

Identifying the need for hearing loss treatment among aging adults with schizophrenia spectrum disorders is important given the potential implications for social functioning, cognitive, and mental health.

Factors to Improve Reverse Integration: A Mixed Method Embedded Design Study

Individuals with serious mental illness face inequity in receiving primary care services. The Substance Abuse and Mental Health Services Administration (SAMHSA) granted funds to Certified Community Behavioral Health Clinics (CCBHC) to integrate primary care and behavioral health specialties to increase access to care. This mixed method study aimed to measure the SAMHSA-defined levels of reverse integration at a CCBHC at one point in time. Providers and patients provided feedback through semi-structured interviews. Qualitative data was investigated for themes, while the quantitative data was run through inferential analysis with the Kruskal Wallis H test. Clinically meaningful results showed people using primary care at the integrated clinic were more satisfied and were more apt to continue seeing their current providers than those receiving non-integrated care. The CCBHC achieved level 4 integration; factors investigated confirmed proximity alone does not necessitate integration without effective communication and implementation of practice changes.

Psychiatric disorders and the cancer diagnostic process in general practice: a combined questionnaire and register study exploring the patients' experiences in Denmark

OBJECTIVE

Patients with psychiatric disorders are at risk of experiencing suboptimal cancer diagnostics and treatment. This study investigates how this patient group perceives the cancer diagnostic process in general practice.

DESIGN

Cross-sectional study using questionnaire and register data.

SETTING

General practice in Denmark.

SUBJECTS

Patients diagnosed with cancer in late 2016 completed a questionnaire about their experiences with their general practitioner (GP) in the cancer diagnostic process (n = 3411). Information on pre-existing psychiatric disorders was obtained from register data on psychiatric hospital contacts and primary care treated psychiatric disorders through psychotropic medications. Logistic regression was used to analyse the association between psychiatric disorders and the patients' experiences.

MAIN OUTCOME MEASURES

Patients' experiences, including cancer worry, feeling being taken seriously, and the perceived time between booking an appointment and the first GP consultation.[Box: see text].

RESULTS

A total of 13% of patients had an indication of a psychiatric disorder. This group more often perceived the time interval as too short between the first booking of a consultation and the first GP consultation. Patients with primary care treated psychiatric disorders were more likely to worry about cancer at the first presentation and to share this concern with their GP compared with patients without psychiatric disorders. We observed no statistically significant association between patients with psychiatric disorders and perceiving the waiting time to referral from general practice, being taken seriously, trust in the GP's abilities, and the patients' knowledge of the process following the GP referral.

CONCLUSION

The patients' experiences with the cancer diagnostic process in general practice did not vary largely between patients with and without psychiatric disorders. Worrying about cancer may be a particular concern for patients with primary care treated psychiatric disorders.

Management of antipsychotics in primary care: Insights from healthcare professionals and policy makers in the United Kingdom

INTRODUCTION

Antipsychotic medication is increasingly prescribed to patients with serious mental illness. Patients with serious mental illness often have cardiovascular and metabolic comorbidities, and antipsychotics independently increase the risk of cardiometabolic disease. Despite this, many patients prescribed antipsychotics are discharged to primary care without planned psychiatric review. We explore perceptions of healthcare professionals and managers/directors of policy regarding reasons for increasing prevalence and management of antipsychotics in primary care.

METHODS

Qualitative study using semi-structured interviews with 11 general practitioners (GPs), 8 psychiatrists, and 11 managers/directors of policy in the United Kingdom. Data was analysed using thematic analysis.

RESULTS

Respondents reported competency gaps that impaired ability to manage patients prescribed antipsychotic medications, arising from inadequate postgraduate training and professional development. GPs lacked confidence to manage antipsychotic medications alone; psychiatrists lacked skills to address cardiometabolic risks and did not perceive this as their role. Communication barriers, lack of integrated care records, limited psychology provision, lowered expectation towards patients with serious mental illness by professionals, and pressure to discharge from hospital resulted in patients in primary care becoming 'trapped' on antipsychotics, inhibiting opportunities to deprescribe. Organisational and contractual barriers between services exacerbate this risk, with socioeconomic deprivation and lack of access to non-pharmacological interventions driving overprescribing. Professionals voiced fears of censure if a catastrophic event occurred after stopping an antipsychotic. Facilitators to overcome these barriers were suggested.

CONCLUSIONS

People prescribed antipsychotics experience a fragmented health system and suboptimal care. Several interventions could be taken to improve care for this population, but inadequate availability of non-pharmacological interventions and socioeconomic factors increasing mental distress need policy change to improve outcomes. The role of professionals' fear of medicolegal or regulatory censure inhibiting antipsychotic deprescribing was a new finding in this study.

General practice pharmacist-led antipsychotic physical health monitoring: a prospective intervention scoping study

BACKGROUND

People with severe mental health illness die prematurely, often due to preventable cardiometabolic disease, which can be exacerbated by antipsychotic medicines that are effective for treating mental illness. Literature demonstrates that physical health monitoring, as recommended in guidelines, for people receiving antipsychotics is substandard. Therefore, we aimed to scope the potential of a general practice clinical pharmacist (GPCP)-led multidisciplinary intervention optimising adherence to cardiometabolic monitoring guidelines and delivering polypharmacy reviews.

METHOD

Prospective intervention scoping study in three urban general practices; one usual care, two intervention. Patients 18-65 years old prescribed oral antipsychotics were identified from records, and invited for cardiometabolic monitoring and GPCP medication review, from January to December 2022. Interventions and onward referrals were recorded and collated. Anonymised pre- and post-review data were analysed, and actions were graded for clinical importance.

RESULTS

In total 1.5% (210/14,159) of patients aged 18-65 years met inclusion criteria; usual care practice (n = 58); and intervention practices (n = 152). From baseline, the usual care practice achieved an absolute 7% increase in the cardiometabolic monitoring care bundle (glucose/glycosylated haemoglobin, lipids, blood pressure plus body mass index) versus 19-58% in the intervention practices. Two-thirds (92/152) of patients participated in medication reviews, requiring pharmacological and/or non-pharmacological clinical actions. The majority of actions were graded as moderate importance. Seven percentage of patients were identified as new pre-diabetic/diabetic and 6% were at high risk of cardiovascular disease requiring statin initiation.

CONCLUSION

A pharmacist-led multidisciplinary general practice-based approach may be effective at optimising cardiometabolic monitoring; identifying and treating diabetic and cardiovascular risk factors.

An integrated primary care service to reduce cardiovascular disease risk in people with severe mental illness: Primrose-A - thematic analysis of its acceptability, feasibility, and implementation

BACKGROUND

Cardiovascular disease among patients with severe mental illness in England is a major preventable contributor to premature mortality. To address this, a nurse and peer-coach delivered service (Primrose-A) was implemented in three London general practices from 2019 (implementation continued during COVID-19). This study aimed to conduct interviews with patient and staff to determine the acceptability of, and experiences with, Primrose-A.

METHODS

Semi-structured audio-recorded interviews with eight patients who had received Primrose-A, and 3 nurses, 1 GP, and 1 peer-coach who had delivered Primrose-A in three London-based GP surgeries were conducted. Reflexive thematic analysis was used to identify themes from the transcribed interviews.

FINDINGS

Overall, Primrose-A was viewed positively by patients and staff, with participants describing success in improving patients' mental health, isolation, motivation, and physical health. Therapeutic relationships between staff and patients, and long regular appointments were important facilitators of patient engagement and acceptance of the intervention. Several barriers to the implementation of Primrose-A were identified, including training, administrative and communication issues, burden of time and resources, and COVID-19.

CONCLUSIONS

Intervention acceptability could be enhanced by providing longer-term continuity of care paired with more peer-coaching sessions to build positive relationships and facilitate sustained health behaviour change. Future implementation of Primrose-A or similar interventions should consider: (1) training sufficiency (covering physical and mental health, including addiction), (2) adequate staffing to deliver the intervention, (3) facilitation of clear communication pathways between staff, and (4) supporting administrative processes.

Profiles of Emergency Department Users with Psychiatric Disorders Related to Barriers to Outpatient Care

Emergency department (ED) overcrowding is a growing problem worldwide. High ED users have been historically targeted to reduce ED overcrowding and associated high costs. Patients with psychiatric disorders, including substance-related disorders (SRDs), are among the largest contributors to high ED use. Since EDs are meant for urgent cases, they are not an appropriate setting for treating recurrent patients or replacing outpatient care. Identifying ED user profiles in terms of perceived barriers to care, service use, and sociodemographic and clinical characteristics is crucial to reduce ED use and unmet needs. Data were extracted from medical records and a survey was conducted among 299 ED patients from 2021 to 2022 in large Quebec networks. Cluster algorithms and comparison tests identified three profiles. Profile 1 had the most patients without barriers to care, with case managers, and received the best primary care. Profile 2 reported moderate barriers to care and low primary care use, best quality of life, and more serious psychiatric disorders. Profile 3 had the most barriers to care, high ED users, and lower service satisfaction and perceived mental/health conditions. Our findings and recommendations inform decision-makers on evidence-based strategies to address the unmet needs of these vulnerable populations.

The moderating effect of mental health and health insurance ownership on the relationships between physical multimorbidity and healthcare utilisation and catastrophic health expenditure in India

BACKGROUND

The current demographic transition has resulted in the growth of the older population in India, a population group which has a higher chance of being affected by multimorbidity and its subsequent healthcare and economic consequences. However, little attention has been paid to the dual effect of mental health conditions and physical multimorbidity in India. The present study, therefore, aimed to analyse the moderating effects of mental health and health insurance ownership in the association between physical multimorbidity and healthcare utilisation and catastrophic health expenditure (CHE).

METHODS

We analysed the Longitudinal Aging Study in India, wave 1 (2017-2018). We determined physical multimorbidity by assessing the number of physical conditions. We built multivariable logistic regression models to determine the moderating effect of mental health and health insurance ownership in the association between the number of physical conditions and healthcare utilisation and CHE. Wald tests were used to evaluate if the estimated effects differ across groups defined by the moderating variables.

RESULTS

Overall, around one-quarter of adults aged 45 and above had physical multimorbidity, one-third had a mental health condition and 20.5% owned health insurance. Irrespective of having a mental condition and health insurance, physical multimorbidity was associated with increased utilisation of healthcare and CHE. Having an additional mental condition strengthened the adverse effect of physical multimorbidity on increased inpatient service use and experience of CHE. Having health insurance, on the other hand, attenuated the effect of experiencing CHE, indicating a protective effect.

CONCLUSIONS

The coexistence of mental health conditions in people with physical multimorbidity increases the demands of healthcare service utilisation and can lead to CHE. The findings point to the need for multidisciplinary interventions for individuals with physical multimorbidity, ensuring their mental health needs are also addressed. Our results urge enhancing health insurance schemes for individuals with mental and physical multimorbidity.

Estimating Changes in Weight and Metabolic Parameters Before and After Treatment With Cariprazine: A Retrospective Study of Electronic Health Records

PURPOSE

Weight gain and associated negative cardiometabolic effects can occur as a result of mental illness or treatment with second-generation antipsychotics (SGAs), leading to increased rates of morbidity and mortality. In this analysis, we evaluated the effect of the SGA cariprazine on weight and metabolic parameters in a real-world, retrospective, observational dataset.

METHODS

Electronic health records from the Optum Humedica database (October 1, 2014-December 31, 2020) were analyzed during the 12-month period before starting cariprazine (baseline) and for up to 12 months following cariprazine initiation; approved and off-label indications were included. Body weight trajectories were estimated in the overall patient cohort and at 3-, 6-, and 12-month timepoints (primary objective). Changes in hemoglobin A1c (HbA1c), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides were also evaluated (secondary objectives). Percentages of patients with clinically relevant shifts in body weight, total cholesterol, and fasting triglycerides were also determined. Discontinuation rates for metabolic regulating medications were calculated. Average predicted values were estimated by linear mixed-effects regression models.

FINDINGS

A total of 2,301 patients were included; average duration of follow-up was 133.7 days. Average predicted weight change for patients during the cariprazine overall follow-up period was +2.4 kg, with predicted weight changes of +0.8 kg (n = 811), +1.1 kg (n = 350), and +1.4 kg (n = 107) at months 3, 6, and 12, respectively. Overall, the majority of patients did not experience clinically significant (≥7%) weight gain (82.8%) or loss (90.5%) after starting cariprazine. Average predicted HbA1c levels (n = 189) increased during baseline (0.15%/year) and decreased during cariprazine treatment (-0.2%/year). Average predicted triglyceride levels (n = 257) increased during baseline (15.0 mg/dL/year) and decreased during cariprazine treatment (-0.7 mg/dL/year). Predicted LDL (n = 247) and HDL (n = 255) values decreased during baseline (-7.3 and -1.1 mg/dL/year, respectively); during cariprazine treatment, LDL increased by 5.6 mg/dL/year and HDL decreased by -0.6 mg/dL/year. During follow-up, most patients did not shift from normal/borderline to high total cholesterol (<240 to ≥240 mg/dL; 522 [90.2%]) or fasting triglyceride (<200 to ≥200 mg/dL; 143 [88.8%] patients) levels; shifts from high to normal/borderline levels occurred in 44 (61.1%) patients for total cholesterol and 38 (57.6%) patients for fasting triglycerides. After starting cariprazine, the discontinuation rate per 100 patient-years was 60.4 for antihyperglycemic medication and 87.4 for hyperlipidemia medication.

IMPLICATIONS

These real-world results support short-term clinical trial findings describing a neutral weight and metabolic profile associated with cariprazine treatment and they expand the dataset to include long-term follow-up.

A Systematic Review on the Association between Schizophrenia and Bipolar Disorder with Chronic Obstructive Pulmonary Disease

A systematic review aimed to investigate the association between schizophrenia and bipolar disorder and chronic obstructive pulmonary disease (COPD), its prevalence and incidence, potential factors associated with its occurrence and its impact on mortality among these patients. We performed the literature search in PubMed, Scopus and PsycInfo from inception to February 2022 and identified 19 studies: ten cross-sectional, 5 that included cross-sectional and longitudinal analyses, and 4 retrospective cohort studies. The reported prevalence of COPD ranged from 2.6% to 52.7% in patients with schizophrenia and between 3.0% and 12.9% in patients with bipolar disorder. Two studies reported an annual incidence of COPD of 2.21 cases/100 person-years in patients with schizophrenia and 2.03 cases/100 person-years in patients with bipolar disorder. Among the risk factors evaluated in three studies, only advanced age was consistently associated with the presence/occurrence of COPD in patients with schizophrenia and bipolar disorder; the role of tobacco consumption was not investigated in those three studies. According to two studies, the likelihood of mortality from COPD showed an over 3-fold increase in patients with schizophrenia and a 2-fold increase in those with bipolar disorder compared to the overall population; COPD was also associated with increased inpatient mortality. Available data indicate that COPD in patients with schizophrenia and bipolar disorder is a major public health problem. National and international health organizations should strive to specifically address this issue by creating awareness about this health problem and developing specific programs for screening and early intervention aimed to reduce the burden of COPD in these populations.