Screening for cardiovascular risk in patients with severe mental illness in primary care: a comparison with patients with diabetes

Implementation of the healthy heart tool- an algorithm with potential cardiometabolic health benefits in persons with severe mental illness

BACKGROUND

Cardiometabolic diseases are the main causes of death in persons with severe mental illness (SMI), highlighting the need to improve management of cardiovascular risk factors in both primary and specialized health care. The "Healthy Heart Tool" aims at helping health care workers to identify persons at risk, and to initiate proper interventions. Here we investigate if the recommendations in the Healthy Heart Tool are followed one year after implementation and whether implementation of the tool improved cardiometabolic risk factors in SMI.

METHODS

Data from 270 individuals with SMI from six Norwegian hospitals were collected at baseline and at 12 months after implementation of the Healthy Heart Tool throughout the health care services. Changes from baseline to 12 months follow-up were analyzed using chi-square and independent t-tests, whereas implementation effects were analyzed using logistic general linear mixed models.

RESULTS

After implementing the Healthy Heart Tool, significantly more persons received dietary advice and/or salt restriction advice (75.5% vs. 84.8%, p = 0.035). After controlling for Body Mass Index (BMI) ≥ 30 and sex, there was an odds ratio (OR) of 8.9 (95% CI 1.42-55.77) for receiving dietary advice and/or advice on salt reduction. There was a significant reduction (p = 0.016) in numbers of participants with high levels of total serum cholesterol ≥ 5 mmol/ (54.4% vs. 46.3%).

CONCLUSIONS

Implementing the Healthy Heart Tool can increase awareness of cardiovascular risk factors in patients with SMI. The intervention increased the proportion of individuals who received dietary and salt reduction advice and decreased the proportion of individuals with high cholesterol levels. However, due to the small numbers, these results should be interpreted with caution. Nonetheless, the findings suggest that the Healthy Heart Tool may be an effective means for improving the management of cardiovascular risk factors in individuals with SMI in typical clinical settings.

TRIAL REGISTRATIONS

The trial was retrospectively registered in ClinicalTrials.gov 29.01.25, ID NCT06807242.

The impact of providing care for physical health in severe mental illness on informal carers: a qualitative study

BACKGROUND

People with severe mental illness (SMI) such as schizophrenia and bipolar disorder are at a substantially higher risk of premature death in that they die between 10 and 20 years earlier than the general population. Cardiovascular disease (CVD) and diabetes are the main potentially avoidable contributors to early death. Research that explores the experiences of people with SMI highlights their struggles in engaging with health professionals and accessing effective and timely interventions for physical health conditions. A consequence of such struggles to navigate and access physical healthcare results in many people with SMI relying heavily on support provided by informal carers (e.g., family members, close friends). Despite this, the experiences of informal carers, and the roles they undertake in relation to supporting the physical health and psychotropic medication use of people with SMI, remains under-researched.

AIMS

To explore the impacts of providing care for physical health in severe mental illness on informal carers.

METHOD

Thematic analysis of semi-structured interviews with eight informal carers of people with SMI in United Kingdom (UK) national health services.

RESULTS

Informal carers played an active part in the management of the patient's conditions and shared their illness experience. Involvement of informal carers was both emotional and practical and informal carers' own lives were affected in ways that were sometimes deeply profound. Informal carers were involved in both 'looking after' the patient from the perspective of doing practical tasks such as collecting dispensed medication from a community pharmacy (caring for) and managing feelings and emotions (caring about).

CONCLUSIONS

Providing care for the physical health of someone with SMI can be understood as having two dimensions - 'caring for' and 'caring about'. The findings suggest a bidirectional relationship between these two dimensions, and both have a cost for the informal carer. With appropriate support informal carers could be more actively involved at all stages of care without increasing their burden. This should be with an awareness that carers may minimise the information they share about their own needs and impacts of their role to spare the person they care and themselves any distress.

A scoping review of cardiovascular risk factor screening rates in general or family practice attendees living with severe mental ill-health

BACKGROUND

Primary care is essential to address the unmet physical health needs of people with severe mental ill-health. Continued poor cardiovascular health demands improved screening and preventive care. No previous reviews have examined primary care cardiovascular screening rates for people living with severe mental ill-health; termed in the literature "severe mental illness".

METHODS

A scoping review following Joanna Briggs Institute methodology was conducted. Cardiovascular risk factor screening rates in adults with severe mental ill-health were examined in general or family practices (as the main delivery sites of primary care). Literature published between 2001 and 2023 was searched using electronic databases including Medline, Embase, Web of Science, PsychINFO and CINAHL. Two reviewers independently screened titles and abstracts and conducted a full-text review. The term "severe mental illness" was applied as the term applied in the literature over the past decades. Study information, participant details and cardiovascular risk factor screening rates for people with 'severe mental illness' were extracted and synthesised.

RESULTS

Thirteen studies were included. Nine studies were from the United Kingdom and one each from Canada, Spain, New Zealand and the Netherlands. The general and/or family practice cardiovascular disease screening rates varied considerably across studies, ranging from 0 % to 75 % for people grouped within the term "severe mental illness". Lipids and blood pressure were the most screened risk factors.

CONCLUSIONS

Cardiovascular disease screening rates in primary care settings for adults living with severe mental ill-health varied considerably. Tailored and targeted cardiovascular risk screening will enable more comprehensive preventive care to improve heart health outcomes and address this urgent health inequity.

Evaluation and Treatment of Obesity and Its Comorbidities: 2022 Update of Clinical Practice Guidelines for Obesity by the Korean Society for the Study of Obesity

The goal of the 8th edition of the Clinical Practice Guidelines for Obesity is to help primary care physician provide safe, effective care to patients with obesity by offering evidence-based recommendations to improve the quality of treatment. The Committee for Clinical Practice Guidelines comprised individuals with multidisciplinary expertise in obesity management. A steering board of seven experts oversaw the entire project. Recommendations were developed as the answers to key questions formulated in patient/problem, intervention, comparison, outcomes (PICO) format. Guidelines underwent multi-level review and cross-checking and received endorsement from relevant scientific societies. This edition of the guidelines includes criteria for diagnosing obesity, abdominal obesity, and metabolic syndrome; evaluation of obesity and its complications; weight loss goals; and treatment options such as diet, exercise, behavioral therapy, pharmacotherapy, and bariatric and metabolic surgery for Korean people with obesity. Compared to the previous edition of the guidelines, the current edition includes five new topics to keep up with the constantly evolving field of obesity: diagnosis of obesity, obesity in women, obesity in patients with mental illness, weight maintenance after weight loss, and the use of information and communication technology-based interventions for obesity treatment. This edition of the guidelines features has improved organization, more clearly linking key questions in PICO format to recommendations and key references. We are confident that these new Clinical Practice Guidelines for Obesity will be a valuable resource for all healthcare professionals as they describe the most current and evidence-based treatment options for obesity in a well-organized format.

Experiences and views of carers regarding the physical health care of people with severe mental illness: An integrative thematic review of qualitative research

WHAT IS KNOWN ON THE SUBJECT?: People with severe mental illness (SMI) have high rates of physical illnesses, and carers are core partners in managing their physical health. Qualitative research on carers' views/experiences of physical health care is limited, and there is no published systematic review that synthesizes the current evidence. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Carers' views from seven articles were synthesised into nine themes and six subthemes describing their perceived facilitators, barriers and roles regarding the physical health care of people with SMI. Carers' voiced similar concerns to those previously identified by professionals and service users, particularly in relation to poor service access/responsiveness and communication difficulties with healthcare professionals. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses should be aware of the risk of diagnostic overshadowing and ensure they are both responsive and sensitive to carers concerns about the physical health of people with SMI. It is essential for mental health nurses to actively involve carers in managing physical health, especially in formulating physical healthcare plans and providing clear practical advice/information. ABSTRACT: Introduction People with severe mental illness (SMI) have high rates of physical illnesses. Informal carers are core partners in addressing these issues, however research on their views/experiences is limited and there is no systematic review published on the topic. Aim This integrative thematic review explored the experiences and views of carers on physical health care in SMI by synthesizing the existing qualitative research findings. Methods Six databases were searched from 2000 to 2021. Data were extracted and synthesised using thematic integrative analysis. The quality of included studies was assessed with the JBI Critical Appraisal Checklist. Results Five studies were included. Nine themes were identified conceptualising carers' perceived facilitators, barriers and roles regarding physical health care for people with SMI. Discussion Carers felt that receiving practical help and a specialised role for mental health nurses would facilitate better physical health care. Lack of coordination/communication and poor service access/responsiveness were common barriers, often compounded by diagnostic overshadowing. Carers are involved in promoting healthy lifestyles, monitoring physical health and supporting access to services. Implications for Practice Mental health nurses should ensure they are responsive to carers' concerns and proactively support them to promote the physical health of people with SMI.

The Health Improvement Profile for people with severe mental illness: Feasibility of a secondary analysis to make international comparisons

WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: Individuals with severe mental illness (SMI) have elevated risks for physical health problems and low screening rates. No previous studies have compared the physical health promotion needs of people with SMI using the same screening tool across different international settings. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: It appears feasible to use the HIP to profile and compare physical health-related risks in people with SMI across different international settings. The HIP tool identified significant differences in areas of risk across the four countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The HIP could be used to identify unique clusters of health promotion needs in different countries. Use of HIP health checks may support implementation of individualized interventions. ABSTRACT: Introduction To date, no studies have contrasted physical health profiles of people with severe mental illness (SMI) in different countries. Aim To evaluate feasibility of using the Health Improvement Profile (HIP) to compare and contrast physical health and health behaviours of people with SMI from four countries. Method An observational feasibility study using secondary analysis of pooled health state and lifestyle data. Physical health checks using modified versions of HIP were administered in four countries. Results Findings suggest feasibility of HIP screening to profile and compare physical health and health behaviours of people with SMI across international settings. High overall numbers of risk items (red flags) were identified in all but the Thailand sample. Despite some commonalities, there were important differences in health profiles across countries. Discussion This is the first study to demonstrate feasibility of the HIP to compare health risks in individuals with SMI across countries. Future multi-national HIP studies should recruit a fully powered stratified random sample of people with SMI that is representative of each setting. Implications for practice It appears feasible to utilize the HIP to identify specific areas of health risk in different countries, which may help to better focus nursing interventions and use of resources.

Cardiovascular risk screening of patients with serious mental illness or use of antipsychotics in family practice

Background

Patients with serious mental illness (SMI) and patients on antipsychotics (AP) have an elevated risk for cardiovascular diseases. In the Netherlands, the mental healthcare for these patients is increasingly taken care of by family practitioners (FP) as a result of a shift from secondary to primary care. Therefore, it is essential to increase our knowledge regarding the characteristics of this patient group and the (somatic) care provided by their FPs. The aim was to examine the rate of cardiovascular risk screening in patients with SMI or the use of AP in family practice.

Methods

We performed a retrospective cohort study of 151.238 patients listed in 24 family practices in the Netherlands.

From electronic medical records we extracted data concerning diagnoses, measurement values of CVR factors, medication and frequency of visits over a 2 year period. Primary outcome was the rate of patients who were screened for CVR factors. We compared three groups: patients with SMI/AP without diabetes or CVD (SMI/AP-only), patients with SMI/AP and diabetes mellitus (SMI/AP + DM), patients with SMI/AP and a history of cardiovascular disease (SMI/AP + CVD). We explored factors associated with adequate screening using multilevel logistic regression.

Results

We identified 1705 patients with SMI/AP, 834 with a SMI diagnosis, 1150 using AP. The screening rate for CVR in the SMI/AP-only group (n = 1383) was adequate in 8.5%. Screening was higher in the SMI/AP − +DM (n = 206, 68.4% adequate, OR 24.6 (95%CI, 17.3–35.1) and SMI/AP + CVD (n = 116, 26.7% adequate, OR 4.2 (95%CI, 2.7–6.6). A high frequency of visits, age, the use of AP and a diagnosis of COPD were associated with a higher screening rate. In addition we also examined differences between patients with SMI and patients using AP without SMI.

Conclusion

CVR screening in patients with SMI/AP is performed poorly in Dutch family practices. Acceptable screening rates were found only among SMI/AP patients with diabetes mellitus as comorbidity. The finding of a large group of AP users without a SMI diagnosis may indicate that FPs often prescribe AP off-label, lack information about the diagnosis, or use the wrong code.

BMI-NECK: A simple assessment of risk of obstructive sleep apnea in schizophrenia

INTRODUCTION

A high risk of obstructive sleep apnea (OSA) has been reported in patients with schizophrenia. However, existing screening questionnaires for OSA haven't been validated in this population and the impact of OSA on schizophrenia symptoms has rarely been studied. This study aimed to investigate the prevalence and impact of OSA in patients with schizophrenia and validate the existing OSA screening scales.

METHOD

Patients with schizophrenia consecutively admitted to hospital (n = 51) and patients with schizophrenia and obesity (n = 31) were compared to healthy controls (n = 51). Apnea risk was measured with STOP-BANG, NoSAS, No-Apnea, and the Berlin Questionnaire; psychiatric symptoms were measured with the PANSS and Calgary scales and B-CATS battery. Daytime sleepiness was measured with the Epworth sleepiness scale. OSA was diagnosed using the Embletta system.

RESULTS

OSA was found more frequently in obese schizophrenia patients than in those consecutively admitted to hospital (45% vs. 22%, p < 0.05). Significant differences between patients with and without OSA were found on the PANSS negative symptoms subscale, B-CATS digit symbol test, and in daytime sleepiness. None of the used screening scales showed satisfactory sensitivity and specificity. Obesity with coexisting neck circumference ≥41 cm in women or ≥43 cm in men (BMI-NECK model) predicted OSA in 57% of cases.

CONCLUSIONS

OSA should be screened in patients with schizophrenia as it has a negative influence on psychiatric symptoms and may contribute to the higher mortality of these patients. Assessment of BMI and neck circumference proves a good screening test in ambulatory contexts.

Is there an association between perceived social support and cardiovascular health behaviours in people with severe mental illnesses?

PURPOSE

People with severe mental illnesses (SMI) have an increased risk of cardiovascular disease (CVD). Research in the general population suggests that social support may protect against increased CVD morbidity and mortality; however, this may not apply to those with SMI. We aimed to explore the association between perceived social support and attendance at primary care nurse CVD risk reduction clinic appointments and CVD risk-reducing behaviours in an SMI population with elevated CVD risk factors.

METHODS

We used longitudinal and cross-sectional data from a randomised controlled trial on 326 adults with SMI recruited via 76 general practices in England. Multilevel regression analysis estimated the effect of perceived social support on attendance at CVD risk reduction clinic appointments over 6 months, and adherence to CVD medication, physical activity, diet, smoking and alcohol use at baseline, adjusted by age, sex, ethnicity, deprivation, psychiatric diagnosis and employment.

RESULTS

Perceived social support predicted greater appointment attendance in unadjusted (IRR = 1.005; 1.000-1.010; p = 0.05) but not adjusted analysis (IRR = 1.003; 0.998-1.009; p = 0.25). Perceived social support was associated with greater adherence to medication; for each 1% increase in social support, there was a 4.2% increase in medication adherence (OR = 1.042; 1.015-1.070; p = 0.002). No association was found between greater perceived social support and greater physical activity, lower sedentary behaviour, healthier diet, lower alcohol use or being a non-smoker.

CONCLUSIONS

Social support may be an important facilitator for CVD medication adherence and is potentially important for primary care appointment attendance; however, alternative strategies might be needed to help people with SMI engage in physical activity, healthier diets and to reduce their smoking and alcohol use.

Which clinical and biochemical predictors should be used to screen for diabetes in patients with serious mental illness receiving antipsychotic medication? A large observational study

OBJECTIVE

We aimed to investigate which clinical and metabolic tests offer optimal accuracy and acceptability to help diagnose diabetes among a large sample of people with serious mental illness in receipt of antipsychotic medication.

METHODS

A prospective observational study design of biochemical and clinical factors was used. Biochemical measures were fasting glucose, insulin and lipids, oral glucose tolerance testing (OGTT), hemoglobin A1c, and insulin resistance assessed with the homeostatic model (HOMA-IR) were determined in a consecutive cohort of 798 adult psychiatric inpatients receiving antipsychotics. Clinical variables were gender, age, global assessment of functioning (GAF), mental health clinicians' global impression (CGI), duration of severe mental illness, height, weight, BMI and waist/hip ratio. In addition, we calculated the risk using combined clinical predictors using the Leicester Practice Risk Score (LPRS) and the Topics Diabetes Risk Score (TDRS). Diabetes was defined by older criteria (impaired fasting glucose (IFG) or OGTT) as well as2010 criteria (IFG or OGTT or Glycated haemoglobin (HBA1c)) at conventional cut-offs.

RESULTS

Using the older criteria, 7.8% had diabetes (men: 6.3%; women: 10.3%). Using the new criteria, 10.2% had diabetes (men: 8.2%, women: 13.2%), representing a 30.7% increase (p = 0.02) in the prevalence of diabetes. Regarding biochemical predictors, conventional OGTT, IFG, and HbA1c thresholds used to identify newly defined diabetes missed 25%, 50% and 75% of people with diabetes, respectively. The conventional HBA1c cut-point of ≥6.5% (48 mmol/mol) missed 7 of 10 newly defined cases of diabetes while a cut-point of ≥5.7% improved sensitivity from 44.4% to up to 85%. Specific algorithm approaches offered reasonable accuracy. Unfortunately no single clinical factor was able to accurately rule-in a diagnosis of diabetes. Three clinical factors were able to rule-out diabetes with good accuracy namely: BMI, waist/hip ratio and height. A BMI < 30 had a 92% negative predictive value in ruling-out diabetes. Of those not diabetic, 20% had a BMI ≥ 30. However, for complete diagnosis a specific biochemical protocol is still necessary.

CONCLUSIONS

Patients with SMI maintained on antipsychotic medication cannot be reliably screened for diabetes using clinical variables alone. Accurate assessment requires a two-step algorithm consisting of HBA1c ≥5.7% followed by both FG and OGTT which does not require all patients to have OGTT and FG.

Comparative risk of new-onset diabetes following commencement of antipsychotics in New Zealand: a population-based clustered multiple baseline time series design

OBJECTIVE

Newer antipsychotics are increasingly prescribed off-label for non-psychotic ailments both in primary and secondary care settings, despite the purported risk of weight gain and development of type 2 diabetes mellitus. This study aims to determine any relationship between the development of clinically significant new-onset type 2 diabetes mellitus and novel antipsychotic use in New Zealand using hypnotic drugs as control.

DESIGN

A population-based clustered multiple baseline time series design.

SETTING

Routinely collected data from a complete national pharmaceutical database in New Zealand between 2005 and 2011.

PARTICIPANTS

Patients aged 40-60 years in the year 2006 who were ever dispensed antipsychotics (exposure groups-first-generation antipsychotics, second-generation antipsychotics and antipsychotics with low, medium and high risk for weight gain) or hypnotics (control group) between 2006 and 2011.

MAIN OUTCOME MEASURE

First ever metformin dispensed to patients in each study group between 2006 and 2011 as proxy for development of clinically significant type 2 diabetes mellitus, no longer amendable by lifestyle modifications.

RESULTS

Patients dispensed a second-generation antipsychotic had 1.49 times increased risk (95% CI 1.10 to 2.03, p=0.011) of subsequently commencing metformin. Patients dispensed an antipsychotic with high risk of weight gain also had a 2.41 times increased risk of commencing on metformin (95% CI 1.42 to 4.09, p=0.001).

CONCLUSIONS

Patients dispensed a second-generation antipsychotic and antipsychotics with high risk of weight gain appear to be at increased risk of being secondarily dispensed metformin. Caution should be taken with novel antipsychotic use for patients with increased baseline risk of type 2 diabetes mellitus.

Metabolic Side Effects in Patients Using Atypical Antipsychotic Medications During Hospitalization

The current research evaluated metabolic side effects in inpatients (N = 271) using atypical antipsychotic medications in a psychiatric hospital in Turkey between June and December 2016. Data were collected via an information form created after reviewing the literature at the time of patients' hospitalization and discharge. According to the analysis, 73.8% of patients stated they experienced side effects from antipsychotic medications and 20.7% of patients experienced weight gain. A statistical difference was detected among body mass index, waist circumference, diastolic blood pressure, and heart rate during patient hospitalization and discharge. Patients using atypical anti-psychotic medications gained weight, had increased cardiovascular risk, and experienced adverse effects on their physical health during hospitalization. Mental health nurses should inform patients of medication effects and possible side effects, monitor side effects, and teach patients how to manage metabolic side effects. [Journal of Psychosocial Nursing and Mental Health Services, 56(4), 28-37.].

An Investigation of Cardiovascular Risks in a Group of Children and Adolescents Who Use Atypical Antipsychotics

This study was conducted to identify the metabolic parameters and body measurements associated with cardiovascular risks in a group of children and adolescents who as part of inpatient treatment received atypical antipsychotics at a psychiatric hospital in Turkey. Body mass indexes (BMIs), waist circumferences (WCs), diastolic blood pressures (DBPs), systolic blood pressures (SBPs) and heart rates (HRs) of the patients were evaluated during hospitalization and at discharge. A statistically significant difference was found among the mean BMIs, WCs, DBPs and HRs of the patients at the stages of their hospitalization and discharge (p < 0.05). On the basis of the study findings, it is recommended that mental health nurses evaluate these risk factors in children and adolescents and provide education on this subject to the patients and their families.

Improving physical health of patients with severe mental disorders: a critical review of lifestyle psychosocial interventions

INTRODUCTION

People with severe mental disorders have a mortality rate that is more than two times higher than the general population, with at least a decade of potential years of life lost. People with mental disorders have a significantly higher risk of obesity, hyperglycemia and metabolic syndrome, which are related to modifiable risk factors, such as heavy smoking, poor physical activities, and inappropriate unhealthy diet, which can be improved through lifestyle changes. Areas covered: Lifestyle behaviours are amenable to change through the adoption of specific psychosocial interventions, and several approaches have been promoted. In the present review, the authors aim to: 1) critically analyze studies involving multimodal lifestyle interventions; 2) discuss the way forward to integrate these interventions in clinical routine care. Expert commentary: The psychoeducational approaches developed for the improvement of healthy lifestyle behaviours differ for several aspects: 1) the format (individual vs. group); 2) the setting (outpatient vs. inpatient vs. home-based); 3) the professional characteristics of the staff running the intervention (psychiatrists or nurses or dietitians or psychologists); 4) the active ingredients of the intervention (education only or inclusion of motivational interview or of problem solving); 5) the duration of treatment (ranging from 3 months to 2 years).

The value of counting WHO-defined cardiovascular risk factors for death and disability in a national sample of adults with psychosis

OBJECTIVE

This study explored the prevalence and associations of eight WHO-defined CVD risk factors for death and disability in people with psychosis.

METHOD

The study included 1156 people aged 18-64years, diagnosed with psychosis. The 2009 World Health Organisation (WHO) Global Health Risks Report was used as a framework to determine the prevalence and number of eight key risk factors for cardiovascular disease (CVD) in men and women with psychosis. Differences in the number and type of risk factors by age and gender were investigated. Multi-predictor analysis was performed to identify associations between demographic factors, psychiatric diagnosis and accumulative CVD risk factors.

RESULTS

Women had fewer CVD risk factors than men. The number of risk factors significantly decreased in association with single marital status, current employment and significantly increased with earning a higher income. People aged 35-49years and 50-64years had an average of 4 risk factors (SD 1.38 and 1.30); people aged 18-34years had an average of 3 risk factors (SD 1.30). Mean risk factors were higher in the middle age and older age groups (35-49years and 50-64years) compared with the younger age group (18-34years) (p<0.0001). Overweight/obesity, hypertension, high blood glucose/diabetes and high cholesterol were significantly more prevalent in older men and women.

CONCLUSION

People with psychosis have a high prevalence of individual and aggregate CVD risks. These were more common in men and rose with age, implying the necessity of close clinical monitoring. The most common risk factors should be targeted by lifestyle interventions.

The chasm of care: Where does the mental health nursing responsibility lie for the physical health care of people with severe mental illness?

The poor physical health of people with a severe mental illness is well documented and health professionals' attitudes, knowledge and skills are identified factors that impact on clients' access to care for their physical health needs. An evaluation was conducted to determine: (i) mental health nurses' attitudes and beliefs about providing physical health care; and, (ii) the effect that participant demographics may have on attitudes to providing physical health care. It was hypothesized that workplace culture would have the largest effect on attitudes. Nurses at three health services completed the "Mental health nurses' attitude towards the physical health care of people with severe and enduring mental illness survey" developed by Robson and Haddad (2012). The 28-item survey measured: nurses' attitudes, confidence, identified barriers to providing care and attitudes towards clients smoking cigarettes. The findings demonstrated that workplace culture did influence the level of physical health care provided to clients. However, at the individual level, nurses remain divided and uncertain where their responsibilities lie. Nursing leadership can have a significant impact on improving clients' physical health outcomes. Education is required to raise awareness of the need to reduce cigarette smoking in this client population.

Big data for bipolar disorder

The delivery of psychiatric care is changing with a new emphasis on integrated care, preventative measures, population health, and the biological basis of disease. Fundamental to this transformation are big data and advances in the ability to analyze these data. The impact of big data on the routine treatment of bipolar disorder today and in the near future is discussed, with examples that relate to health policy, the discovery of new associations, and the study of rare events. The primary sources of big data today are electronic medical records (EMR), claims, and registry data from providers and payers. In the near future, data created by patients from active monitoring, passive monitoring of Internet and smartphone activities, and from sensors may be integrated with the EMR. Diverse data sources from outside of medicine, such as government financial data, will be linked for research. Over the long term, genetic and imaging data will be integrated with the EMR, and there will be more emphasis on predictive models. Many technical challenges remain when analyzing big data that relates to size, heterogeneity, complexity, and unstructured text data in the EMR. Human judgement and subject matter expertise are critical parts of big data analysis, and the active participation of psychiatrists is needed throughout the analytical process.

BMI independently relates to glycaemia in patients with severe enduring mental illness (SMI)

BACKGROUND

People with severe mental illness (SMI) have higher rates of diabetes than the general population.

AIMS

To assess the type-2 diabetes screening rates in primary care and the relation between body mass index (BMI) and dysglycaemia for patients on the SMI register in the Cheshire region of the United Kingdom.

METHODS

The setting was 24 general practices in Central and Eastern Cheshire, United Kingdom. Subjects were identified through a semianonymized search of GP registers.

RESULTS

About 451 of the 787 SMI patients were screened for dysglycaemia and dyslipidaemia. Fasting glucose was in the impaired fasting glycaemia range (6.1-6.9 mmol/l) in 6.5%, and indicative of type-2 diabetes (≥7.0 mmol/l) in 17.3%. There was a positive univariate relation between BMI and fasting glucose (normalized β = 0.26, p < 0.001). In multivariate models, adjusting for age, gender, smoking and blood pressure, each unit increase in BMI [OR = 1.07 (1.01, 1.13); p = 0.031] and triglycerides [OR = 1.28 (1.06, 1.55); p = 0.009] were independently associated with an increased risk of having type-2 diabetes.

CONCLUSION

Increasing BMI relates to dysglycaemia in patients with severe enduring mental illness (SMI). All patients with SMI whether or not receiving neuroleptic treatment should undergo routine monitoring of weight and metabolic parameters.

Preparing non-government organization workers to conduct health checks for people with serious mental illness in regional Australia

WHAT IS KNOWN ON THE SUBJECT?: People diagnosed with schizophrenia or bipolar disorder have a life expectancy 10-15 years less than the general population. In rural and remote Australia, there is a shortage of health care professionals to provide physical health care for people living with a serious mental illness (SMI). A large proportion of the care for people living with a SMI is provided by non-government organizations (NGOs), often employing workers without formal qualifications. There has been minimal research regarding the experiences of NGO workers who have been trained to complete health checks to help people living with SMI to access primary care services. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study to examine the experiences of preparing NGO workers to use the health improvement profile (HIP) to support the physical health of people with SMI. It builds on previous studies that examined the use of the HIP by trained/qualified staff. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study highlights that NGO employees may have an important role in helping people with a SMI to address their physical health. Engaging lay workers to use the HIP increases their awareness of the importance of providing good physical health care for people with SMI. The use of a tool, such as the HIP, prepares NGO workers to support the physical health needs and enables them to describe meaningful improvements in the health of people with a SMI.

ABSTRACT

Background The life expectancy of people living with a serious mental illness (SMI) is up to 10-15 years less than the general population. They experience difficulties in accessing timely and appropriate physical health care. People with SMI living in regional Australia experience additional barriers to accessing services. This is in part due to the difficulties associated with recruiting and retaining health professionals in regional Australia. Aim To explore the regional non-government organization (NGO) workforce views of using a physical health care check list - the health improvement profile (HIP) - with people with a SMI. Gain insights into the workers' experiences of using the HIP. Understand which aspects of the HIP workers perceived as being most and least helpful. Learn how the HIP and the training program could be modified to better support its application in regional Australia. Method A focus group using a semi-structured interview was conducted with seven NGO employees who had been trained to use the HIP and subsequently used the HIP in their everyday work with patients. A mental health nurse (MHN) and a Psychology graduate working for the University of South Australia Department of Rural Health conducted the focus group. Results Using thematic analysis, the focus group discussion generated four main themes: taking control; accessing services; guiding my conversation; and working with others. The overall meta-theme was that lay workers can work effectively to address physical health problems in SMI patients. Conclusion Our observations highlight the important role lay workers in regional Australia have in helping people with SMI to address their physical health needs. They have an opportunity to extend their role in parts of the world where it is difficult to recruit MHNs.

Improvements in Somatic Complaints Among Individuals With Serious Mental Illness Receiving Treatment in a Psychiatric Hospital

OBJECTIVE

Individuals with serious mental illness (SMI) experience significant comorbid somatic complaints. Little is known about response to integrated inpatient care that addresses psychiatric and general medical needs among individuals with SMI.

METHODS

Latent growth curve analyses were used to model somatic symptom trajectories across adult inpatients with SMI (n = 989). The Patient Health Questionnaire-15 (PHQ-15) was administered at admission, every 14 days, and at discharge.

RESULTS

Patients evidenced substantial reduction in somatization from admission (mean [standard deviation] = 9.0 [5.2]) to discharge (mean [standard deviation] = 5.2 [4.4]), with large effects (d = 0.83, 95% confidence interval = 0.76-0.90). Results indicate nonlinear improvement in somatic symptoms for 8 weeks of treatment, with greatest symptom reduction occurring during the first weeks of treatment with continued, albeit slowed, improvement until discharge. Initial PHQ-15 scores were lower among men and those who reported regular exercise in the 30 days preceding this hospitalization. In addition, presence of an anxiety disorder or personality disorder at admission; history of trauma, a gastrointestinal disorder, or major medical illness (within the past 3 months); and significant sleep disturbance independently contribute to higher PHQ-15 scores at admission. A substance use disorder and sleep disturbance were associated with greater immediate symptom reduction.

CONCLUSIONS

Somatic complaints can be managed in the context of inpatient psychiatric care integrated with 24-hour nursing and internal medicine specialists. Addressing psychiatric impairments, improving sleep, and ensuring abstinence from drugs and alcohol are associated with significant improvement in somatic complaints.

Primary care consultation rates among people with and without severe mental illness: a UK cohort study using the Clinical Practice Research Datalink

OBJECTIVES

Little is known about service utilisation by patients with severe mental illness (SMI) in UK primary care. We examined their consultation rate patterns and whether they were impacted by the introduction of the Quality and Outcomes Framework (QOF), in 2004.

DESIGN

Retrospective cohort study using individual patient data collected from 2000 to 2012.

SETTING

627 general practices contributing to the Clinical Practice Research Datalink, a large UK primary care database.

PARTICIPANTS

SMI cases (346,551) matched to 5 individuals without SMI (1,732,755) on age, gender and general practice.

OUTCOME MEASURES

Consultation rates were calculated for both groups, across 3 types: face-to-face (primary outcome), telephone and other (not only consultations but including administrative tasks). Poisson regression analyses were used to identify predictors of consultation rates and calculate adjusted consultation rates. Interrupted time-series analysis was used to quantify the effect of the QOF.

RESULTS

Over the study period, face-to-face consultations in primary care remained relatively stable in the matched control group (between 4.5 and 4.9 per annum) but increased for people with SMI (8.8-10.9). Women and older patients consulted more frequently in the SMI and the matched control groups, across all 3 consultation types. Following the introduction of the QOF, there was an increase in the annual trend of face-to-face consultation for people with SMI (average increase of 0.19 consultations per patient per year, 95% CI 0.02 to 0.36), which was not observed for the control group (estimates across groups statistically different, p=0.022).

CONCLUSIONS

The introduction of the QOF was associated with increases in the frequency of monitoring and in the average number of reported comorbidities for patients with SMI. This suggests that the QOF scheme successfully incentivised practices to improve their monitoring of the mental and physical health of this group of patients.

Lowering Cardiovascular Disease Risk for People with Severe Mental Illnesses in Primary Care: A Focus Group Study

Background

People with severe mental illnesses die early from cardiovascular disease. Evidence is lacking regarding effective primary care based interventions to tackle this problem.

Aim

To identify current procedures for, barriers to, and facilitators of the delivery of primary care based interventions for lowering cardiovascular risk for people with severe mental illnesses.

Method

75 GPs, practice nurses, service users, community mental health staff and carers in UK GP practice or community mental health settings were interviewed in 14 focus groups which were audio-recorded, transcribed and analysed using Framework Analysis.

Results

Five barriers to delivering primary care based interventions for lowering cardiovascular risk in people with severe mental illnesses were identified by the groups: negative perceptions of people with severe mental illnesses amongst some health professionals, difficulties accessing GP and community-based services, difficulties in managing a healthy lifestyle, not attending appointments, and a lack of awareness of increased cardiovascular risk in people with severe mental illnesses by some health professionals. Identified facilitators included involving supportive others, improving patient engagement with services, continuity of care, providing positive feedback in consultations and goal setting.

Conclusion

We identified a range of factors which can be incorporated in to the design, delivery and evaluation of services to reduce cardiovascular risk for people with severe mental illnesses in primary care. The next step is determining the clinical and cost effectiveness of primary care based interventions for lowering cardiovascular risk in people with severe mental illnesses, and evaluating the most important components of such interventions.

Diabetes mellitus and severe mental illness: mechanisms and clinical implications

The prevalence of diabetes mellitus is twofold to threefold higher in people with severe mental illness (SMI) than in the general population, with diabetes mellitus affecting ∼12% of people receiving antipsychotics. The consequences of diabetes mellitus are more severe and frequent in people with SMI than in those without these conditions, with increased rates of microvascular and macrovascular complications, acute metabolic dysregulation and deaths related to diabetes mellitus. Multiple complex mechanisms underlie the association between diabetes mellitus and SMI; these mechanisms include genetic, environmental and disease-specific factors, and treatment-specific factors. Although antipsychotics are the mainstay of treatment in SMI, a causative link, albeit of uncertain magnitude, seems to exist between antipsychotics and diabetes mellitus. The principles of managing diabetes mellitus in people with SMI are similar to those for the general population and should follow currently established treatment algorithms. Lifestyle interventions are needed to reduce incident diabetes mellitus. In addition, improved uptake of opportunities to screen for this disease will reduce the high prevalence of undiagnosed diabetes mellitus. Currently, people with SMI receive poorer treatment for diabetes mellitus than the general population. Thus, health-care professionals in primary care, diabetes mellitus services and mental health teams have a responsibility to ensure that patients with SMI are not disadvantaged.

Training mental health nurses to assess the physical health needs of mental health service users: a pre- and post-test analysis

PURPOSE

The aim of this project was to develop, deliver, and evaluate a brief evidenced-based education package to enhance physical health literacy in mental health nurses.

DESIGN AND METHODS

Pre- and post-test survey of knowledge of physical health in serious mental illness, satisfaction with the workshop, and applicability to practice.

FINDINGS

Participants were motivated to attend and complete the questions. There was statistically significant knowledge gain immediately post workshop and participants described satisfaction with the content and a willingness to apply learning from the session to their practice.

PRACTICE IMPLICATIONS

If such workshops are provided as a collaborative and relatively inexpensive way of education, they can contribute to building the capacity of mental health nurses to be literate in physical health interventions.

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

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

Serious mental illness and the role of primary care

Policies and guidelines from across the international community are attempting to galvanise action to address the unacceptably high morbidity and mortality rates amongst people with a serious mental illness (SMI). Primary care has a pivotal role to play in translating policy into evidence based practice in conjunction with other providers of health care services. This paper explores the current and potential of role of primary care providers in delivering health care to people with SMI. A review of research in the following key areas of primary health care provision is provided: access, screening and preventative care, routine monitoring and follow-up, diagnosis and delivery of treatments in accordance with guidelines and delivery of interventions. There is undoubtedly a need for further research to establish the effectiveness of primary care interventions and the organisation of services. Equally, understanding how primary care services can deliver high quality care and promoting effective working at the interface with other services must be priorities.

Diagnosis and treatment of sleep apnoea in women with schizophrenia

BACKGROUND

Obstructive sleep apnoea (OSA) is often overlooked in the context of schizophrenia because its hallmark, daytime sleepiness, is so easily attributable to antipsychotic drugs. This is a special problem for women.

AIMS

To underscore the importance of diagnosing and treating OSA in women with schizophrenia.

METHODS

A review of the recent literature (search terms: Obstructive Sleep Apnoea; Schizophrenia; Women (or Gender); Obesity; Antipsychotics; Continuous Positive Airway Pressure (CPAP)) as it applies to a composite case vignette taken from the files of a specialty clinic that treats women with psychosis.

RESULTS

The rate of OSA in women who are both obese and postmenopausal is very similar to that of men. Family history, smoking, and the use of tobacco, alcohol and of antipsychotic medication increase the risk. Despite reluctance, patients with schizophrenia generally agree to undergo sleep studies. Compliance with CPAP is difficult, but can be aided by the physician and is, on the whole, relatively high in women. CPAP improves sleep parameters and may also improve cardiometabolic and cognitive indices, although this still needs to be more fully researched.

CONCLUSION

Schizophrenia and untreated OSA are both associated with high mortality rates in women as well as men.

Cardiovascular health literacy and treatment adherence in persons with serious mental illness

Persons with serious mental illnesses have shorter life spans than the general population, and their earlier death is often related to cardiovascular disease. This study examined health literacy and cardiovascular medication adherence in a sample of 98 participants with serious mental illness. Sixty-two percent of the participants had adequate health literacy as measured by the Test of Functional Health Literacy in Adults. The association between health literacy and medication adherence was not significant after controlling for education. There was a significant association between health literacy and education level, health literacy and site, and health literacy and the sodium intake subscale of the Hill-Bone adherence scale.

Diabetes: increasing the knowledge base of mental health nurses

Physical health assessment for people with a serious mental illness (SMI) has been a neglected issue, with all the evidence showing that mental health nurses (MHNs) and associated practitioners need to develop such skills. The University of Huddersfield and South West Yorkshire Partnership Foundation Trust collaborated in a Physical Skills Project with the aim of facilitating knowledge and skills for MHNs. The development of the education and training workshop is presented. The results of a pre- and post-test evaluation of diabetes, evaluation of the workshop and, finally, implications for practice with regard to transferable knowledge and skill, are discussed.