Gaps in health care for the somatic health of outpatients with severe mental illness

Treatment pearls: Management of physical healthcare needs in patients with mental illness

ABSTRACT

Clinicians caring for persons with mental illness should be aware of increased mortality, physical problems, and health disparities in this population. This article provides a brief overview of physical health problems in the context of mental illness as well as those related to psychotropic medications, and discusses strategies to manage treatment effectively.

Predictors of competitive employment in individuals with severe mental illness: results from an observational, cross-sectional study in Germany

Background

Employment is of great importance as it is associated with various positive effects. Individuals with severe mental illness (SMI) are often excluded from competitive employment. Current data on employment of individuals with mental illness are rare, and influencing factors are under-researched. The present study examines possible predictors of competitive employment among individuals with SMI.

Methods

This was a cross-sectional and multicentered study of 300 individuals with SMI aged 18 to 65 years. The following inclusion criteria were used: (I) diagnosis of schizophrenia, schizotypal and delusional disorders (ICD-10 F2x), or affective disorders (ICD-10 F3x), (II) duration of psychiatric illness ≥ 2 years, and (III) substantial impact of illness on social functioning. Participants were interviewed by trained staff using standardised instruments. The relationship between potential predictors (age, sex, education, marital status, living situation, migration background, psychosocial functioning, age at first mental problem, physical illness, work ability) and employment was analysed using a hierarchic binary logistic regression model.

Results

Only one-third (34%) of participants were competitively employed. Almost one-third were unemployed (30%), and 28% reported early retirement due to mental illness. Psychosocial functioning was positively associated with competitive employment (OR = 1.09, 95% CI: 1.05 – 1.13, p < 0.001); concurrent chronic physical illness was negatively associated with competitive employment (OR = 0.38, 95% CI: 0.21 – 0.71, p = 0.002).

Conclusions

Findings confirm a high risk of exclusion from competitive employment among individuals with SMI. Nonetheless, a substantial proportion of individuals are employed. Findings call for efforts to maintain or enhance workforce participation among individuals with SMI. A special focus should be placed on improving physical health and strengthening psychosocial functioning.

Trial registration

The study was registered in the German Clinical Trials Register (DRKS) under the registration number DRKS00015801 before the start of recruitment (Registration date: 21.02.2019).

Undiagnosed disease in decedents with and without schizophrenia: an autopsy-based case-control study

BACKGROUND

Individuals with schizophrenia (SCZ) suffer from higher morbidity and mortality than the general population. Some of this is due to concurrent somatic disease.

AIMS

To identify and compare the somatic comorbidities antemortem (AM) and postmortem (PM) in autopsied decedents with SCZ and with no mental illness (NMI), using the Charlson Comorbidity Index (CCI).

MATERIALS

A total of 106 autopsied decedents with SCZ and 156 decedents with NMI were included. AM diagnoses were sampled from Danish national health registers. PM diagnoses were included from forensic autopsies. Negative binomial regression models were used to test associations between age, sex, SCZ diagnosis, manner of death and the CCI score both AM and PM.

RESULTS

The CCI score increased significantly from AM to PM for both decedents with SCZ and NMI (SCZ, AM 0.669 vs PM 1.208, p = 0.008) (NMI, AM 0.519 vs PM 1.218, p = 0.000). Regression analysis showed that age was significantly associated with the CCI score both AM and PM (AM, OR 1.044 [1.029-1.060] p ≤ 0.001) (PM, OR 1.028 [1.015-1.041], p ≤ 0.001). A diagnosis of SCZ was correlated with the CCI score AM but not PM (AM, OR 1.880 [1.207-2.928], p = 0.005) (PM, OR 1.170 [0.828-1.654], p = 0.374).

CONCLUSION

The autopsies revealed undiagnosed diseases in both decedents with SCZ and NMI. The diseases were primarily of cardiovascular, pulmonary and gastrointestinal origin and may have contributed to premature mortality. Age was the only covariate significantly associated with the CCI score both AM and PM; the SCZ diagnosis was positively correlated to the CCI score before death.

Barriers and Possible Solutions to Providing Physical Health Care in Mental Health Care: A Qualitative Study of Danish Key Informants' Perspectives

Provision of physical health care to people diagnosed with severe mental illness is widely reported as inadequate. This interview study explored perspectives of a group of key informants on current practices of providing physical health care within two mental health care settings in Denmark. Thematic analysis of their accounts provided insights into 1) barriers to the provision of physical health care in mental health settings, and 2) possible solutions to overcome existing barriers. Negative attitudes and limited specialist health care knowledge among mental health care professionals constituted serious barriers. To effectively address these barriers, mental health services need to be reoriented towards the prioritisation of physical health alongside mental health. This will require equipping mental health professionals with relevant knowledge and skills and organisational resources, to effectively work with people experiencing or at risk of physical comorbidities.

Metabolic Syndrome Screening in People With Severe Mental Illness: Results From Two Spanish Community Mental Health Centers

BACKGROUND: The excess of mortality in people with severe mental illness is due to unnatural causes such as accidents or suicides and natural causes such as metabolic syndrome. The presence of modifiable risk factors like tobacco consumption increases cardiovascular and metabolic risk. AIMS: The purpose of this study was to identify the prevalence of metabolic syndrome and other cardiovascular risk factors in people with severe mental illness. This study also aimed to identify the prevalence of patients receiving treatment for any metabolic syndrome risk factor. METHOD: A cross-sectional descriptive study was performed. A total of 125 participants from two community mental health centers in Spain were recruited. RESULTS: More than half of the participants (58.4%) were active smokers. The prevalence of metabolic syndrome was 60%. A total of 16.8% received previous treatment for hypertension, 17.6% for hypertriglyceridemia, and 11.2% for diabetes. No differences were found between centers (22.7% vs. 18.7%, p = .9). CONCLUSIONS: The findings underscore the importance of monitoring the physical health of patients on antipsychotic therapy. The identification and management of cardiovascular and metabolic risks factors is an essential part of nursing care for people with severe mental illness. Mental health nurses are ideally positioned to carry out this task by performing physical health screening, health education, and lifestyle interventions.

Physical Health Literacy and Health-related Behaviors in Patients with Psychosis

Objective

This study compared the levels of knowledge of physical illnesses and patterns of health behaviors between patients with psychosis and the general population.

Methods

A total of 712 participants were included in the study; 292 patients with a schizophrenia spectrum disorder and 420 healthy controls matched for age and gender. Questionnaires were administered to study participants to determine the level of knowledge of chronic physical illnesses such as cancer, hypertension, and diabetes mellitus and health-related behavior. Results from the two study groups were compared to identify differences in knowledge of physical illness and health-related behaviors.

Results

Compared with healthy controls, patients with psychosis were less likely to undergo regular medical check-ups and engage in exercise. Patients with psychosis had poorer knowledge of physical illnesses, and were more likely to smoke, be overweight, or have diabetes. Patients with psychosis were significantly less likely to acknowledge the importance of early detection of cancer and controlling hypertension and diabetes, independent of education and type of medical insurance. Patients who smoked were significantly less likely to agree with the statement on the relationship between smoking and physical illnesses. Patients not undergoing regular medical check-ups were significantly less likely to agree with statements concerning the need for cancer screening.

Conclusion

Patients with psychosis demonstrated lower levels of knowledge of physical illnesses and a lack of understanding of preventive behaviors. Low levels of knowledge were associated with poor health-related behaviors. Education of physical health should be provided to patients with psychosis.

Mental health care professionals' accounts of actions and responsibilities related to managing physical health among people with severe mental illness

BACKGROUND

Life expectancy of people with severe mental illness (SMI) is greatly shortened compared to the general population, and despite extensive research, this issue is unsolved. Although it is widely recognised that people with SMI need support from health care services to manage health related issues, profound health inequalities exist within provision of health care. The aim of this study was to examine how mental health care professionals accounted for their actions and responsibilities related to managing physical health issues among people with SMI.

METHODS

Three focus groups were conducted with 22 mental health care professionals, employed at three mental health care locations. Participants' situated accounts were subjected to discourse analysis.

RESULTS

Participants accounted for actions and responsibilities in three typical ways; 1) by positioning people with SMI as difficult to motivate and actively resisting intervention, 2) by positioning people with SMI as so impaired that intervention was futile, and 3) by arguing they are undertreated for physical conditions and might have physical illnesses that staff are not aware of because of prominent mental illness. These discursive strategies seemed to legitimise situations where participants described not responding to physical health issues, and to downplay potential trouble in situations where participants described not succeeding in facilitating lifestyle changes or promoting compliance to treatment of physical conditions.

DISCUSSION AND CONCLUSION

Mental health care professionals need to increase their awareness of latent discriminating attitudes towards people with SMI. Such attitudes are suggested to reinforce barriers for people with SMI receiving physical health care.

Clozapine Patients at the Interface between Primary and Secondary Care

Patients receiving clozapine must undergo routine blood monitoring to screen for neutropenia, and to monitor for potential agranulocytosis. In Cork University Hospital, Cork, Ireland, clozapine is dispensed in the hospital pharmacy and the pharmacists are not aware of co-prescribed medicines, potentially impacting upon patient safety. The aim of this study was to examine the continuity of care of patients prescribed clozapine. A retrospective audit was conducted on patients attending the clozapine clinic at Cork University Hospital and assessed patients' (i) independent living, (ii) co-prescribed medicines and (iii) knowledge of their community pharmacists regarding co-prescribed clozapine. A list of prescribed medicines for each patient was obtained, and potential drug-drug interactions between these medicines and clozapine were examined using Lexicomp® and Stockley's Interaction checker. Secondary outcomes included patients' physical health characteristics, and a review of co-morbidities. Data were collected between the 29 May 2017 and 20 June 2017. Local ethics committee approval was granted. Patients were eligible for inclusion if they were receiving clozapine treatment as part of a registered programme, were aged 18 years or more, and had the capacity to provide written informed consent. Microsoft Excel was used for data analysis. Of 112 patients, (33% female; mean age (SD) 43.9 (11.3) years; 87.5% living independently/in the family home) 86.6% patients reported that they were taking other prescribed medicines from community pharmacies. The mean (SD) number of co-prescribed medicines in addition to clozapine was 4.8 (4) per patient. Two thirds of community pharmacists were unaware of co-prescribed clozapine. Interactions with clozapine were present in all but 3 patients on co-prescribed medicines (n = 97). Lexicomp® reported 2.9 drug-drug interactions/patient and Stockley's Interaction Checker reported 2.5 drug-drug interactions/patient. Secondary outcomes for patients included BMI, total cholesterol, and HbA1c levels, which were elevated in 75%, 54% and 17% respectively. Patients prescribed clozapine did not receive a seamless service, between primary and secondary care settings. Community pharmacists were not informed of clozapine, prescribed for their patients, in two thirds of cases. Patients in this study were exposed to clozapine-related drug-drug interactions and hence potential adverse effects. This study supports reports in the literature of substandard management of the physical health of this patient group. This study shows that there is an opportunity for pharmacists to develop active roles in the management of all clozapine-related effects, in addition to their traditional obligatory role in haematological monitoring. This study supports the need for a clinical pharmacist to review inpatients commencing on clozapine, monitor for drug-drug interactions and provide counselling.

Clozapine and concomitant medications: Assessing the completeness and accuracy of medication records for people prescribed clozapine under shared care arrangements

RATIONALE, AIM, AND OBJECTIVE

The objective of the study is to assess the completeness and accuracy of medication records held by stakeholders (secondary care, general practice, and community pharmacy) for clozapine consumers managed in a shared care programme.

METHODS

This was an exploratory, descriptive study examining secondary and primary care medication records in a large, urban, public mental health service setting in Queensland, Australia. Consumers (18-65 years old) prescribed clozapine under shared care management with capacity to consent were eligible (n = 55) to participate. Information from medication and dispensing records was used by a pharmacist to compile a best possible medication history for each consumer. Discrepancies were identified through reconciliation of stakeholder records with the history. Discrepancies were defined as an omission, addition, or administration discrepancy (difference in dose, frequency, or clozapine brand).

RESULTS

Thirty-five (63.6%) consumers consented for records to be reviewed. Overall, 32 (91.4%) consumers had at least 1 discrepancy in their records with a mean of 4.9 discrepancies per consumer. Of 172 discrepancies, 127 (73.8%) were omissions. Primarily, concomitant medicines were omitted in 19/35 (54%) of secondary care records while clozapine was omitted in 13/32 (40.6%) of community pharmacies records.

CONCLUSIONS

Discrepancies were highly prevalent in the shared care medication records of clozapine consumers of this service. Where there is incomplete and inaccurate medication information, there is a risk of suboptimal clinical decision making, increasing the likelihood of adverse drug events. This study demonstrates a need for improved documentation and timely access to accurate and complete medication records for shared care stakeholders. Expanding the pharmacist's role in this setting could improve medication accuracy in documentation and related communication.

To what extent are psychiatrists aware of the comorbid somatic illnesses of their patients with serious mental illnesses? - a cross-sectional secondary data analysis

Background

Somatic comorbidities are a serious problem in patients with severe mental illnesses. These comorbidities often remain undiagnosed for a long time. In Germany, physicians are not allowed to access patients’ health insurance data and do not have routine access to documentation from other providers of health care. Against this background, the objective of this article was to investigate psychiatrists’ knowledge of relevant somatic comorbidities in their patients with severe mental illnesses.

Methods

Cross-sectional secondary data analysis was performed using primary data from a prospective study evaluating a model of integrated care of patients with serious mental illnesses. The primary data were linked with claims data from health insurers. Patients’ diagnoses were derived on the basis of the ICD-10 and the Anatomical Therapeutic Chemical (ATC) classification system. Diabetes, hypertension, coronary artery disease (CAD), hyperlipidaemia, glaucoma, osteoporosis, polyarthritis and chronic obstructive pulmonary disease (COPD) were selected for evaluation. We compared the number of diagnoses reported in the psychiatrists’ clinical report forms with those in the health insurance data.

Results

The study evaluated records from 1,195 patients with severe mental illnesses. The frequency of documentation of hypertension ranged from 21% in claims data to 4% in psychiatrists’ documentation, for COPD from 12 to 0%, respectively, and for diabetes from 7 to 2%, respectively. The percentage of diagnoses deduced from claims data but not documented by psychiatrists ranged from 68% for diabetes and 83% for hypertension, to 90% for CAD to 98% for COPD.

Conclusions

The majority of psychiatrists participating in the integrated care programme were insufficiently aware of the somatic comorbidities of their patients. We support allowing physicians to access patients’ entire medical records to increase their knowledge of patients’ medical histories and, consequently, to increase the safety and quality of care.

Assessment of a Chronic Disease Self-Management Program to Increase Physical Activity of Adults With Severe Mental Illness

Individuals with severe mental illness (SMI) experience excessive co-morbidities and early mortality. Self-management programs have the potential to increase physical activity levels of individuals with SMI and reduce the incidence of co-morbidities. The purpose of this quality improvement project was to assess a chronic disease self-management program (CDSMP) to increase physical activity of adults with SMI measured by daily steps tracked with a pedometer. Results of data analysis indicated no statistically significant difference in steps across the six-week program. However, findings suggested that individuals with SMI are capable of using a pedometer and tracking steps on a daily basis.

Mental health first aid training needs of Australian community pharmacists

BACKGROUND

Pharmacists are highly accessible health care professionals and have regular interactions with consumers that suffer acute mental illness. Though pharmacists are trained in psychopharmacology, they lack formal mental health intervention skills. A solution to address this gap is to up-skill pharmacists in mental health first aid (MHFA).

OBJECTIVES

The purpose of this study was to establish the mental health first aid training needs for Australian rural pharmacists in the community setting. In addition, barriers to pharmacists providing MHFA support were ascertained.

METHODS

This study was conducted in two parts. First, semi-structured interviews were conducted with eight rural community pharmacists to ascertain enablers and barriers to MHFA training. Second, an online survey was conducted to assess the attitudes of pharmacists to MHFA and their training requirements. Data from the interviews were thematically analyzed.

RESULTS

Six major themes were identified including evolving role of the pharmacist, importance of relationships, complexity of mental health, need for training in MHFA, low confidence and barriers to assisting in acute mental illness. Pharmacists were accepting of the need for MHFA, but expressed concern over their lack of training, time and resources. The survey results also supported these findings.

CONCLUSIONS

Pharmacists supported MHFA training, but expressed difficulties in balancing professional and business responsibilities. Given that pharmacists are accessible and regularly exposed to mental health, MHFA training should be a core component of pharmacists' training and their primary health care role. Further research is needed to evaluate the benefits of such training in terms of the consumers' mental health outcomes.

Creating a 'reverse' integrated primary and mental healthcare clinic for those with serious mental illness

Individuals with serious mental illness (SMI) are more likely to experience preventable medical health issues, such as diabetes, hyperlipidemia, obesity, and cardiovascular disease, than the general population. To further compound this issue, these individuals are less likely to seek preventative medical care. These factors result in higher usage of expensive emergency care, lower quality of care, and lower life expectancy. This manuscript presents literature that examines the health disparities this population experiences, and barriers to accessing primary care. Through the identification of these barriers, we recommend that the field of family medicine work in collaboration with the field of mental health to implement 'reverse' integrated care (RIC) systems, and provide primary care services in the mental health settings. By embedding primary care practitioners in mental health settings, where individuals with SMI are more likely to present for treatment, this population may receive treatment for somatic care by experts. This not only would improve the quality of care received by patients, but would also remove the burden of managing complex somatic care from providers trained in mental health. The rationale for this RIC system, as well as training and policy reforms, are discussed.

Cardiovascular health promotion and consumers with mental illness in Australia

People with serious mental illness (SMI) have increased risk of cardiovascular disease and premature death, yet research on nurse-provided health promotion in mental health services remains under-developed. This paper informs efforts to improve the nursing role in physical health of consumers with SMI by establishing what nurse perceptions and background influence their care. Members of the Australian College of Mental Health Nursing were invited to participate in an online survey on their views on physical health care in mental health services. Survey questions included: (a) nurse-consumer collaboration in preventative care and (b) sub-sections of the Robson and Haddad Physical Health Attitude Scale to measure nurse perceived barriers to encouraging lifestyle change of consumers with SMI and frequency of nurse physical healthcare practices. Structural equation modelling was applied to investigate antecedents to physical health care, as well as relationships between antecedents. A national sample of 643 nurses reported regular engagement in health promotion (e.g. advice on diet). There was statistical support for a model depicting perceived consumer-nurse collaboration as a dual-determinant of nurse perceived barriers and self-reported health promotion to consumers with SMI. Perceived barriers to consumer lifestyle change did not predict health promotion. The effects of nurse-consumer collaboration were significant, but small. Perceived consumer-nurse collaboration in preventative care may positively influence the amount of health promotion by nurses in mental health. Perceived barriers to consumer adherence with a healthy lifestyle did not have an impact on nurse-delivered health promotion.

Is somatic health screening in patients with severe mental illness of added value?

PURPOSE

To evaluate the added value of somatic screening for patients with severe mental illness over regular care.

DESIGN AND METHODS

We compared the information on somatic health problems collected by screening with the general practitioner (GP) files (n = 118).

FINDINGS

The mean number of somatic health problems detected with somatic health screening was significantly higher than those noted in GP records (p < .01).

PRACTICE IMPLICATIONS

Somatic health screening is an addition to the care provided by the GP. Advanced mental health nurses can play a key role in somatic health screening and initiating further cooperation and communication of GP and mental health care.

Improvement of care for the physical health of patients with severe mental illness: a qualitative study assessing the view of patients and families

Background

Patients with severe mental illness (SMI) experience more physical comorbidity than the general population. Multiple factors, including inadequate seeking of healthcare and health care related factors such as lack of collaboration, underlie this undesirable situation. To improve this situation, the logistics of physical health care for patients with SMI need to be changed. We asked both patients and their families about their views on the current organization of care, and how this care could be improved.

Methods

Group and individual interviews were conducted with patients and family of patients to explore their needs and preferences concerning the care for the physical health of patients with SMI, and to explore the shortcomings they had experienced. Using thematic analysis, responses were firstly divided into common topics, after which these topics were grouped into themes.

Results

Three major themes for the improvement of the physical care of patients with SMI were found. Firstly, the reduced ability of patients with SMI to survey their own physical health interests requires health care that is tailored to these needs. Secondly, the lack of collaboration amongst mental health care professionals and general practitioners (GPs) hinders optimal care. Thirdly, concerns were expressed regarding the implementation of monitoring and supporting a healthy lifestyle. Patients with SMI welcome this implementation, but the logistics of providing this care can be improved.

Conclusions

An optimal approach for caring for the physical health of patients with SMI requires a professional approach, which is different to the routine care provided to the general public. This approach can and should be accomplished within the usual organizational structure. However, this requires tailoring of the health care to the needs of patients with SMI, as well as structural collaboration between mental health care professionals and GPs.