Improving the physical health of long-term psychiatric inpatients

Improving physical health monitoring and interventions in a learning disabilities forensic psychiatric secure service

BACKGROUND

Patients in psychiatric inpatient settings are at increased risk of developing physical health complications due to the structure of inpatient wards, the metabolic side-effects of antipsychotic medications and socioeconomic factors. Robust physical health monitoring and interventions are paramount in reducing this health inequality.

OBJECTIVE

To improve the quality of physical health interventions in the ward environment and empower patients to follow healthy lifestyle guidance to reduce their risk of metabolic syndrome.

METHODS

Patient weight and waist circumference data were collected at baseline and weekly throughout the 8-week intervention period. A questionnaire was recorded from baseline to week-5 to assess patient understanding. Two Plan-Do-Study-Act (PDSA) cycles were completed: (1) Series of weekly psychoeducation sessions and group exercise and (2) Implementation of healthy living diaries.

RESULTS

Our data did not demonstrate any definitive impact upon the waist circumference and weight of participants. However, analysis of the questionnaires showed a consistent trend in knowledge improvement.

CONCLUSION

Whilst our aim of reducing patient weight and waist circumference was not realised, there was a significant impact on participant's knowledge, demonstrating a subjective benefit of our interventions. Our project also highlighted inconsistencies in physical health measurements and data collection, providing vital information for further quality improvement measures.

Motivational theory-based interventions on health of people with several mental illness: A systematic review and meta-analysis

Motivational theory-based interventions are known to be effective for increasing physical activity (PA) in the general population but their effects in people with severe mental illness are poorly understood. Therefore, we conducted a meta-analysis on the effect of these interventions on PA and cardiometabolic risk factors. A systematic search of randomized controlled trials through 6 databases was carried out from inception to March 2019. Analyses were conducted using random-effect models. Weighted mean difference (WMD) were used as effect size when outcomes had the same units, otherwise Hedge's g was used. Fourteen articles including 2128 participants were identified. Motivational theory-based interventions were effective in increasing PA (g = 0.27, 95%CI[0.03; 0.51], p = .003), reducing weight (WMD = -1.87 kg, 95%CI[-2.98; -0.76], p = .001), body mass index (WMD = -0.82 kg/m², 95%CI[-1.23; -0.41], p = .009), waist circumference (WMD = -1.91 cm, 95%CI[-3.63; -0.18], p = .03) and fasting glucose (g = -0.17, 95%CI[-0.34; -0.001], p = .04). Larger effect sizes were found in interventions based on only one theoretical model of motivation. In conclusion, interventions using motivational theories are effective to improve PA levels and the cardiometabolic health profile of people with severe mental illness. Systematic review registration: CRD42018104445.

Evaluation of a participatory approach to improve healthy eating and physical activity in a secure mental health setting

Purpose

The prevalence of obesity in secure mental health units is higher than in the general population, having a negative impact on the physical health and mental well-being of people with severe mental health illness (SMI). The purpose of this study was to describe the feasibility of a programme aimed to help people with SMI to eat healthily and be physically active.

Design/methodology/approach

A mixed-methods approach was used. A questionnaire administered to patients in both wards measured acceptability, demand, implementation and practicality of the project. Individual semi-structured interviews and focus groups were used to explore staff and patients’ perceptions of the project; as well as the barriers and enablers towards an effective implementation and participation in the project’s activities.

Findings

Patients were, overall, satisfied with the activities implemented. Successful activities were easy to implement, had staff actively engaged and did not require logistic or administrative planning beforehand. Barriers included unawareness around funding mechanisms of activities, staff capacity issues or lack of patients’ permission to leave the ward.

Originality/value

Few studies have assessed the feasibility of real-life interventions aimed to improve healthy eating and physical activity in secure mental health units. The results of this study can inform commissioners and providers of mental health services to design and implement new interventions and programmes.

Feasibility and Acceptability of a Student-Led Lifestyle (Diet and Exercise) Intervention Within a Residential Rehabilitation Setting for People With Severe Mental Illness, GO HEART (Group Occupation, Health, Exercise And Rehabilitation Treatment)

PURPOSE

People with severe mental illness (SMI) experience poor physical health and premature mortality, contributed significantly by modifiable lifestyle risk factors such as poor nutrition, low cardiorespiratory fitness, and physical inactivity. Lifestyle interventions can reduce cardiometabolic risk and confer a range of other positive mental and physical health benefits. We assessed the feasibility, acceptability, safety, and preliminary effectiveness of a lifestyle (combined dietary and exercise) intervention lead by senior exercise and dietetics students in a residential mental health rehabilitation setting.

DESIGN

Single arm, prospective study evaluating outcomes pre and post a 10-week dietary and exercise intervention.

METHOD

People with SMI from three residential rehabilitation units participated in a mixed aerobic and resistance training exercise intervention three times per week that was combined with a dietary intervention (six individual and group sessions). Primary outcome considerations were feasibility (recruitment, retention, and participation rates), acceptability, and adverse events. Secondary outcomes were preliminary effectiveness; (functional exercise capacity, volume of exercise, and metabolic markers), psychiatric symptoms, quality of life, and attitudes to exercise.

RESULTS

Forty-two participants were recruited (92% primary diagnosis of schizophrenia). Intervention feasibility was supported by high levels of recruitment (68%), retention (77%), and participation (70% exercise, 65% diet sessions); and the absence of serious adverse events. Significant improvements in functional exercise capacity, volume of exercise, general psychiatric symptoms, and negative psychotic symptoms occurred. Anthropometric and metabolic blood markers did not change. While the intervention was acceptable to participants, motivation for and perceived value of exercise reduced over 10 weeks.

CONCLUSIONS

A brief pragmatic student-led lifestyle intervention integrated into usual mental health care was feasible, acceptable, safe, and scalable across two additional mental health residential rehabilitation sites, and resulted in physical and mental health improvements. Increased frequency of dietary sessions and length of dietary intervention may improve metabolic outcomes in the future. People with SMI living in residential rehabilitation units should have access to lifestyle programs to address modifiable lifestyle risk factors. While this brief intervention was feasible and acceptable, this study highlights some of the challenges associated with maintaining motivation for healthy lifestyles for people with SMI. Longer term investigation of real-world lifestyle interventions is warranted, together with additional interventions that may support people with SMI to sustain motivation to address lifestyle factors.

CLINICAL TRIAL REGISTRATION

The trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), Unique Identifier: ACTRN 12618000478213, http://www.anzctr.org.au Universal trial number (UTN)-U1111-1211-4009.

Metabolic risk in patients participating in residential rehabilitation programs: how are we doing?

OBJECTIVES

To examine the prevalence of metabolic syndrome and its association with clinical, demographic and lifestyle factors in patients with mental illness participating in residential rehabilitation.

METHODS

A physical health audit of all consumers ( n = 364) in publicly funded residential rehabilitation programs in Queensland was carried out in late 2016. Data collection focused on clinical, demographic and lifestyle factors associated with physical health.

RESULTS

Central obesity was identified in 80% of males and 89% of females and half of the patients (49.4%) met criteria for metabolic syndrome (MetS). The prevalence of MetS in Indigenous patients (66.1%) was 20% higher than the rate found in non-Indigenous patients (46.1%). Smoking, substance abuse, gender, Indigenous background, length of stay and rarely eating fruit and vegetables were individually associated with MetS.

CONCLUSIONS

The prevalence of MetS in this cohort is almost double that of the general population, while the rate in Indigenous patients is among the highest reported for those with mental illness. Rehabilitation staff are encouraged to engage more fully in the monitoring of physical health status, sharing this information with consumers and primary care providers, and encouraging consumers to play a greater role in managing their physical health.

Effect of a 30-Month Health-Promoting Program on the Prevalence of Cardiovascular Risk Factors in Patients With First Episode Schizophrenia

BACKGROUND

Lifestyle interventions aimed at reducing cardiovascular risk factors in patients with first-episode schizophrenia (FES) have shown modest efficacy, probably owing to a short observation period and the presumption of linear trajectories of cardiovascular risk factors.

STUDY QUESTION

How prevalent are abnormal cardiovascular values in patients with FES and how do cardiovascular risk factors develop during a 30-month program?

STUDY DESIGN

A 30-month naturalistic longitudinal study of 136 consecutively referred patients with FES from 2 outpatient clinics. The health-promoting program consisted of individual guidance, group sessions, and normal treatment and care.

MEASURES AND OUTCOMES

The prevalence of abnormal cardiovascular risk factors (body mass index, waist circumference (WC), body fat percentage, systolic and diastolic blood pressure, pulse, total cholesterol, high- and low-density lipoproteins, triglycerides, mean glucose, and visceral adiposity index) was estimated at index. The cardiovascular risk factor trajectories were analyzed with longitudinal mixed-effect models.

RESULTS

The patient with FES showed elevated cardiovascular risk factors at index. Thus, 56.8% of the patients were overweight in different grades and 50.4% had increased WC. A total of 81.8% had high level of body fat and hypertension prevalence with only 20% with normal blood pressure. Important changes during the intervention period were that the risk factors weight and WC were increasing the first 581 and 646 days, after which they decreased. Almost all cardiovascular risk factors worsened initially, improving after 1-2 years.

CONCLUSIONS

Patients with FES show increases in cardiovascular risk factors at index. Short observation periods and the presumption of linear trajectories may indicate that the effect of health-promoting programs is ineffective, as the effects are curvilinear and improvements appear only after 1 year. The implication clinically is the importance of a long intervention period regarding lifestyle modifications to ascertain improvement among patients with FES.

Tackling obesity in mental health secure units: a mixed method synthesis of available evidence

BACKGROUND

The prevalence and incidence of obesity are high in people with severe mental illness (SMI). In England, around 6000 people with SMI access care from secure mental health units. There is currently no specific guidance on how to reduce the risk of obesity-related morbidity and mortality in this population.

AIMS

To identify international evidence that addresses the issue of obesity in mental health secure units.

METHOD

A mixed method review of evidence (published 2000-2015) was carried out to assess obesity prevalence, intervention and policy change, as well as barriers to change.

RESULTS

Evidence from 22 mainly small, non-comparator studies (reported in 21 papers) using a range of methods was reviewed. Dietary, physical activity and cultural interventions being implemented within secure units to address the problem of obesity showed some promising outcomes for physical health and health education. These were facilitated by adequate organisational resources, staff training and motivated staff. Holistic interventions that included a social and/or competitive element were more likely to be taken up. Involving patients in decision-making mediated the tension between facilitating behaviour change and imposing control. Barriers to successful outcomes included patient movement in and out of units, severity of mental health condition and resistance to change by patients and staff.

CONCLUSIONS

Despite the promising outcomes reported, further assessment is needed of the feasibility, acceptability and effectiveness of interventions and policies targeting the obesogenic environment, using robust research methods.

DECLARATION OF INTEREST

None.

Reducing the Risk of Type 2 Diabetes in Nonselected Outpatients With Schizophrenia: A 30-Month Program

BACKGROUND

Type 2 diabetes is 2- to 3-fold more common in patients with schizophrenia than in the general population. A lifestyle with a focus on diet, exercise, and medication is required to prevent complications from type 2 diabetes, but patients with schizophrenia frequently have trouble maintaining such a lifestyle because of factors related to their illness, such as cognitive disturbances, negative and positive symptoms, and side effects of psychotropic medications.

OBJECTIVE

To measure and reduce risk factors for type 2 diabetes in patients with schizophrenia and examine characteristics associated with positive outcomes.

METHODS

This study, which was conducted in clinics treating both newly diagnosed and long-term (LT) patients with schizophrenia, evaluated the effects of a 30-month naturalistic intervention on improvement in the physical health of patients treated for schizophrenia and reduction in their risk factors for type 2 diabetes. The clinical intervention incorporated individual guidance, group sessions, and treatment as usual.

RESULTS

Patients newly diagnosed with schizophrenia were found to have high consumption of soft drinks and low physical activity at their index evaluation. At follow-up, the physical profile of these patients had worsened, with increased weight, waist circumferences, visceral adiposity index (P=0.030), and glycosylated hemoglobin (HbA1c; P=0.010). Average HbA1c values increased in newly diagnosed male patients by 0.24 mmol/l (P=0.007). At follow-up, LT patients improved with regard to their consumption of soft drinks (P=0.001) and fast food (P=0.009). The LT patients also reduced their weight and waist circumferences and became more physically active. No changes in HbA1c values were found in the LT patients during the intervention period.

CONCLUSION

The study found that positive outcomes were associated with female sex and a longer duration of illness. Negative outcomes with worsening of risk factors were associated with being newly diagnosed with schizophrenia and male sex. It was possible to produce improvements in some risk factors through individual health-oriented lifestyle interventions, especially in LT patients.

Reducing the Risk of Cardiovascular Diseases in Non-selected Outpatients With Schizophrenia: A 30-Month Program Conducted in a Real-life Setting

BACKGROUND

The most common cause of premature death in people with schizophrenia is cardiovascular disease, partially explained by an unhealthy lifestyle, smoking, poor diet and sedentary behavior. We aimed to reduce cardiovascular risk factors.

METHOD

Naturalistic follow-up study with 54 long-term-treated non-selected outpatients with schizophrenia. The 30-month program consisted of individual guidance, group sessions and normal treatment and care offered in our clinic.

RESULTS

On average, the participating women reduced their waist circumference by 11.4cm (P=0.037), whereas the participating men increased their waist circumference by 3.3cm (P=0.590). Patients' consumption of fast food was reduced from 1.2 to 0.8 times/week (P=0.016), just as their consumption of soft drinks was reduced from 0.7 to 0.1l/day (P=0.006). Their consumption of coffee increased from 1.6 to 2.5 cups/day (P=0.086). The time women spent on light physical activity increased from 134 to 469min/week (P=0.055). The number of daily cigarettes smoked was reduced by 25.7% for all smokers.

CONCLUSIONS

Our program showed that it is possible for women but not for men to reduce their risk factors for developing cardiovascular disease. The program is manageable in most outpatient clinics and can be performed by nursing staff interested in physical health with support from and in cooperation with medical doctors, psychiatrist and leaders/managers.

Changing the obesogenic environment to improve cardiometabolic health in residential patients with a severe mental illness: cluster randomised controlled trial

BackgroundFor patients with severe mental illness (SMI) in residential facilities, adopting a healthy lifestyle is hampered by the obesity promoting (obesogenic) environment.AimsTo determine the effectiveness of a 12-month lifestyle intervention addressing the obesogenic environment with respect to diet and physical activity to improve waist circumference and cardiometabolic risk factors v. care as usual (Dutch Trial Registry: NTR2720).MethodIn a multisite cluster randomised controlled pragmatic trial, 29 care teams were randomised into 15 intervention (365 patients) and 14 control teams (371 patients). Intervention staff were trained to improve the obesogenic environment.ResultsWaist circumference decreased 1.51 cm (95% CI -2.99 to -0.04) in the intervention v. control group after 3 months and metabolic syndrome z-score decreased 0.22 s.d. (95% CI -0.38 to -0.06). After 12 months, the decrease in waist circumference was no longer statistically significantly different (-1.28 cm, 95% CI -2.79 to 0.23, P=0.097).ConclusionsTargeting the obesogenic environment of residential patients with SMI has the potential to facilitate reduction of abdominal adiposity and cardiometabolic risk, but maintaining initial reductions over the longer term remains challenging.

Changes in antipsychotics and other psychotropic drugs during a 30-month lifestyle intervention among outpatients with schizophrenia

BACKGROUND

Patients with schizophrenia have high risk of early death from diabetes and cardiovascular diseases, partly because of poor lifestyle and partly because of long-lasting exposure to antipsychotic treatment.

AIMS

To investigate the influence of a lifestyle intervention program on changes in psychotropic medication in a non-selected cohort of patients with schizophrenia.

METHODS

Observational study of outpatients in the Central Denmark Region during a 30-month lifestyle program.

RESULTS

One hundred and thirty-six patients were enrolled and 130 were available for analysis. Median follow-up time was 15.9 months (range 1-31 months). Nineteen patients (15%) were not treated with antipsychotic drugs during the study period. 54% of the 111 patients exposed to antipsychotics were subject to monotherapy at index and at follow-up. The median defined daily dose (DDD) of antipsychotics was 1.33 at index (interquartile range (IQR) 0.67-2.00) and 1.07 at follow-up (IQR 0.40-1.50). 52% of the patients experienced a decrease in DDD during the study period (median change 0.33; IQR 1.00-0.43). There were no significant differences between the patients with decreased, stable or increased DDD with regard to age, sex, follow-up time and time since diagnosis. The number of prescriptions was significantly higher in the patients who decreased their DDD and the proportion of antipsychotic depot formulation was higher in those who increased their DDD.

CONCLUSIONS

Most patients decreased or stabilized their total dose of antipsychotic medication during the study period. Many patients were subject to antipsychotic polypharmacy. The extent of participation in the lifestyle intervention program did not correlate with the changes in dosing of antipsychotic medication.

Improving quality of life and physical health in patients with schizophrenia: A 30-month program carried out in a real-life setting

BACKGROUND

Patients with schizophrenia experience low quality of life (QoL) and poor physical health, which is explained, in part, by unhealthy lifestyle, tobacco smoking, poor diet and sedentary behavior.

AIM

To measure QoL and physical health in patients with schizophrenia and to quantify associations between QoL and physical health.

METHODS

This was a naturalistic longitudinal 30-month follow-up study including individual guidance, group sessions and treatment as usual.

RESULTS

We included 190 patients. QoL was low among newly diagnosed patients. Higher body mass index was significantly associated with lower QoL. Newly diagnosed male patients showed lower QoL compared with females. Newly diagnosed patients experienced worsened health during the study period. In contrast, long-term schizophrenic patients started with worse physical health but improved with regard to weight, waist circumferences, intake of fast food and soft drinks, and light physical activity level. Newly diagnosed patients improved their QoL ( p = .056), and the psychological domain improved by 8.0 points ( p = .003). The number of interventions was positively associated with QoL.

CONCLUSION

Patients with schizophrenia presented with low QoL and elevated risk factors for poor physical health. The intervention added onto 'treatment as usual' improved some risk factors for poor physical health among long-term patients. The number of interventions had an elevating effect on QoL in patients.

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 physical health of Indigenous and non-Indigenous patients participating in residential rehabilitation programs: a comparison study

OBJECTIVE

To examine the differences in the physical health of Indigenous and non-Indigenous patients with severe mental illness (SMI) undergoing psychiatric rehabilitation.

METHODS

An audit of the physical health of patients ( n = 361) in all publicly funded residential rehabilitation programs in Queensland was carried out in late 2014. Data collection focused on clinical and lifestyle factors associated with physical health.

RESULTS

The prevalence of smoking, substance use and type 2 diabetes in Indigenous patients was significantly higher than rates found in non-Indigenous patients. Metabolic syndrome was also significantly higher in indigenous patients, with 66% of Indigenous patients compared to 46% of non-Indigenous patients meeting criteria for metabolic syndrome.

CONCLUSIONS

Patients with SMI in residential rehabilitation programs have poor physical health. Our findings underscore the need for clinicians to develop and evaluate interventions aimed at improving the metabolic profile of those with SMI in residential rehabilitation programs. Historical factors and cultural traditions need to be considered when designing lifestyle interventions for Indigenous patients.

Solving a weighty problem: systematic review and meta-analysis of nutrition interventions in severe mental illness

BACKGROUND

Nutrition interventions would appear fundamental for weight management and cardiometabolic risk reduction in people experiencing severe mental illness (SMI). Comprehensive evaluation of nutrition interventions is lacking.

AIMS

To subject randomised controlled trials of nutrition interventions in people with SMI to systematic review and meta-analysis, and to measure anthropometric and biochemical parameters and nutritional intake.

METHOD

An electronic database search identified trials with nutrition intervention components. Trials were pooled for meta-analysis. Meta-regression analyses were performed on anthropometric moderators.

RESULTS

Interventions led to significant weight loss (19 studies), reduced body mass index (17 studies), decreased waist circumference (10 studies) and lower blood glucose levels (5 studies). Dietitian-led interventions (6 studies) and studies delivered at antipsychotic initiation (4 studies) had larger effect sizes.

CONCLUSIONS

Evidence supports nutrition interventions as standard care in preventing and treating weight gain among people experiencing SMI.

Reducing cardiovascular risk factors in non-selected outpatients with schizophrenia

OBJECTIVES

Cardiovascular diseases are the most common causes of premature death in patients with schizophrenia. We aimed at reducing cardiovascular risk factors in non-selected outpatients with schizophrenia using methods proven effective in short-term trials. Furthermore, we examined whether any baseline characteristics were associated with positive outcomes.

METHODS

All outpatients treated for schizophrenia at two Danish hospitals were included in this 1-year follow-up study. The patients were offered health interventions both individually and in groups. Weight, waist circumference, blood glucose and lipids and information on smoking and alcohol were obtained.

RESULTS

On average, small significant increases in body mass index (BMI) and waist circumferences were observed while small non-significant improvements in other cardiovascular risk factors were seen. Patients with high baseline BMI and patients with duration of treated illness beyond 2 years had significantly better intervention outcomes.

CONCLUSION

Our results show that it was difficult to improve physical health in a group of non-selected patients with schizophrenia as part of routine care. The patients were not easily motivated to participate in the interventions, and it was difficult to monitor the recommended metabolic risk measures in the patient group. Future research should focus on simple strategies in health promotion that can be integrated into routine care.

Reducing cardiovascular risk factors in non-selected outpatients with schizophrenia

OBJECTIVES

Cardiovascular diseases are the most common causes of premature death in patients with schizophrenia. We aimed at reducing cardiovascular risk factors in non-selected outpatients with schizophrenia using methods proven effective in short-term trials. Furthermore, we examined whether any baseline characteristics were associated with positive outcomes.

METHODS

All outpatients treated for schizophrenia at two Danish hospitals were included in this 1-year follow-up study. The patients were offered health interventions both individually and in groups. Weight, waist circumference, blood glucose, serum lipids, and information on smoking and alcohol were obtained.

RESULTS

On average, small significant increases in body mass index (BMI) and waist circumferences were observed while small non-significant improvements in other cardiovascular risk factors were seen. Patients with high baseline BMI and patients with duration of treated illness beyond 2 years had significantly better intervention outcomes.

CONCLUSIONS

Our results show that it was difficult to improve physical health in a group of non-selected patients with schizophrenia as part of routine care. The patients were not easily motivated to participate in the interventions, and it was difficult to monitor the recommended metabolic risk measures in the patient group. Future research should focus on simple strategies in health promotion that can be integrated into routine care.

Self management interventions for type 2 diabetes in adult people with severe mental illness

BACKGROUND

People with severe mental illness are twice as likely to develop type 2 diabetes as those without severe mental illness. Treatment guidelines for type 2 diabetes recommend that structured education should be integrated into routine care and should be offered to all. However, for people with severe mental illness, physical health may be a low priority, and motivation to change may be limited. These additional challenges mean that the findings reported in previous systematic reviews of diabetes self management interventions may not be generalised to those with severe mental illness, and that tailored approaches to effective diabetes education may be required for this population.

OBJECTIVES

To assess the effects of diabetes self management interventions specifically tailored for people with type 2 diabetes and severe mental illness.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, EMBASE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the International Clinical Trials Registry Platform (ICTRP) Search Portal, ClinicalTrials.gov and grey literature. The date of the last search of all databases was 07 March 2016.

SELECTION CRITERIA

Randomised controlled trials of diabetes self management interventions for people with type 2 diabetes and severe mental illness.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts and full-text articles, extracted data and conducted the risk of bias assessment. We used a taxonomy of behaviour change techniques and the framework for behaviour change theory to describe the theoretical basis of the interventions and active ingredients. We used the GRADE method (Grades of Recommendation, Assessment, Development and Evaluation Working Group) to assess trials for overall quality of evidence.

MAIN RESULTS

We included one randomised controlled trial involving 64 participants with schizophrenia or schizoaffective disorder. The average age of participants was 54 years; participants had been living with type 2 diabetes for on average nine years, and with their psychiatric diagnosis since they were on average 28 years of age. Investigators evaluated the 24-week Diabetes Awareness and Rehabilitation Training (DART) programme in comparison with usual care plus information (UCI). Follow-up after trial completion was six months. Risk of bias was mostly unclear but was high for selective reporting. Trial authors did not report on diabetes-related complications, all-cause mortality, adverse events, health-related quality of life nor socioeconomic effects. Twelve months of data on self care behaviours as measured by total energy expenditure showed a mean of 2148 kcal for DART and 1496 kcal for UCI (52 participants; very low-quality evidence), indicating no substantial improvement. The intervention did not have a substantial effect on glycosylated haemoglobin A1c (HbA1c) at 6 or 12 months of follow-up (12-month HbA1c data 7.9% for DART vs 6.9% for UCI; 52 participants; very low-quality evidence). Researchers noted small improvements in body mass index immediately after the intervention was provided and at six months, along with improved weight post intervention. Diabetes knowledge and self efficacy improved immediately following receipt of the intervention, and knowledge also at six months. The intervention did not improve blood pressure.

AUTHORS' CONCLUSIONS

Evidence is insufficient to show whether type 2 diabetes self management interventions for people with severe mental illness are effective in improving outcomes. Researchers must conduct additional trials to establish efficacy, and to identify the active ingredients in these interventions and the people most likely to benefit from them.

Quality of life and clinical characteristics in a nonselected sample of patients with schizophrenia

BACKGROUND

Patients with schizophrenia experience low quality of life (QOL).

AIMS

To examine QOL in these patients and the relation between QOL and illness duration, adjusted daily doses (ADDs) of antipsychotics, body mass index (BMI), waist circumference and smoking.

METHODS

In this naturalistic, cross-sectional study, 82 patients were interviewed about smoking habits. Patients completed a QOL questionnaire (World Health Organization Quality of Life-Bref) consisting of physical, psychological, social and environmental domains and had height, weight and waist circumference measured. The characteristics and QOL were correlated using multiple regression analysis.

RESULTS

QOL was significantly lower in the patients than in the general population (p < .01). In first-ever diagnosed patients, QOL was associated with BMI (regression coefficient (RC): physical -0.73, psychological -1.44 and environmental -0.55; all p < .05), ADD (RC: physical 3.71, psychological 4.37 and environmental 2.94; all p < .10) and smoking (RC: physical -0.69; p < .01). In the long-term ill patients, QOL was associated with BMI (RC: physical -1.19 and psychological -1.28; all p < .05) and illness duration (RC: physical 1.38; p < .05).

CONCLUSION

Patients experienced low QOL. Lower QOL was associated with high BMI, low ADD and smoking in first-ever diagnosed patients and with high BMI and short illness duration in long-term ill patients.

Improving documentation of physical health investigations in an adolescent mental health inpatient unit

Physical health investigations, such as blood tests, ECGs, and appropriate radiological tests, are essential in the assessment and management of many patients in inpatient mental health settings. This project took place in a 12-bed adolescent mental health unit in Swindon, UK, where on average at least two-thirds of patients have a diagnosed eating disorder. Multidisciplinary ward rounds provide an appropriate setting for discussion and documentation of physical investigations. Over a two-week period, 22 electronic ward round entries were audited for any documentation of five common investigations - blood tests, ECG, MRI head, DEXA, and ovarian ultrasound. Blood tests were documented in 2/22 (9.1%), ECG, MRI head, DEXA, and ovarian ultrasound were documented in 0/22 (0%). Modifications were made to an electronic ward round template, to include headings for each of these investigations, with free-text boxes as well as drop-down boxes for the radiological tests. Following this, re-audit of 22 ward round entries over a two-week period showed documentation had hugely improved - blood tests were documented in 21/22 (95.5%), with ECG, MRI head, DEXA, and pelvis US all documented in 22/22 (100%). A further audit a month later showed these results were largely sustained. In conclusion, use of a simple, structured ward round template can hugely improve documentation of important physical investigations within mental health settings.

Intervention to promote physical health in staff within mental health facilities and the impact on patients' physical health

BACKGROUND

Patients with severe mental illnesses have an increased physical morbidity and premature mortality on account of somatic diseases. Patients with mental illness are nursed and cared for by the staff, who may acts as role models for the patients.

AIMS

The study tested the efficacy of an intervention programme for improving physical health in staff working in long-term psychiatric treatment facilities. Furthermore, the paper measured the association between staff's changes in physical health and the patients' changes in physical health.

METHODS

The study was a cluster randomized controlled 12-month intervention study, and the intervention was active awareness on physical health.

RESULTS

In the intervention group the staff reduced their waist circumference by 2.3 cm (95% CI: 0.3-4.4) when controlling for gender, age and cigarette consumption. In the control group, the staff changed their waist circumference by - 2.1 cm (95% CI: - 5.6-1.5). The staff in the intervention group experienced a significant reduction in diastolic blood pressure of - 5.9 mmHg (95% CI: - 9.5 to - 2.3, p = 0.009). The study indicated an association between the staff average change in each facility and the individual patient's changes in health parameters (body mass index, total body fat and quality of life).

CONCLUSION

The staff in the intervention group showed a significant reduction of waist circumference, while staff in the control group showed a non-significant increase. Furthermore, a significant reduction in the diastolic blood pressure was seen. Indications that staff acted as positive role models for the patients' physical health were seen.

The gap between available knowledge and its use in clinical psychiatry

OBJECTIVE

The time span between knowledge becoming available and its integration into daily clinical routine is lengthy. This phenomenon is explored in this study.

METHOD

We used the outcomes of our activities for investigating and strengthening the research-based activities to improve physical health in the routines of clinical psychiatric wards as examples for our analyses.

RESULTS

The time span between new knowledge becoming available and its implementation into general clinical treatment is very long. However, a shortening of this time span is seen through active leadership backup and clinical research experience among psychiatrists and staff in the wards. In particular, the involvement of medical students interested in clinical research activities seems to have a positive impact.

CONCLUSION

Academia needs to be re-implemented into clinical psychiatry. Staff with research experience is needed in all professions to increase evidence-based practice. Leaders must take responsibility for implementing new knowledge into the routines of the department and must support staff in these activities on a daily basis.

Reducing psychotropic pharmacotherapy in patients with severe mental illness: a cluster-randomized controlled intervention study

BACKGROUND

Many patients with mental illness receive psychotropic medicine in high dosages and from more than one drug. One of the consequences of this practice is obesity, which is a contributing factor to increased physical morbidity and premature death.

METHODS

Our study was a cluster-randomized intervention study involving 6 facilities and 174 patients diagnosed with severe mental illnesses (73% schizophrenia). The intervention period was 12 months and consisted of teaching sessions with the staff and evaluating the patients' intake of psychotropic medication. At index, 44% met criteria for obesity and 76% met criteria for overweight. Waist circumferences were 108 cm for men and 108 cm for women. Olanzapine, clozapine and quetiapine were the most common prescribed antipsychotics. Mean values of daily doses of antipsychotic were 2.5.

RESULTS

The intervention showed no significant differences between the intervention and control group regarding psychotropic treatment. At follow up, independent of intervention, patients receiving antipsychotic polypharmacy had a larger waist circumference compared with patients receiving antipsychotic monotherapy of 9.8 cm (1.5-18.1) (p = 0.028).

DISCUSSION AND CONCLUSION

We found both a high prevalence of obesity and that the patients received treatment with antipsychotic polypharmaceutics in high dosages. Active awareness did not change practice and we must think of other ways to restrict treatment with psychotropics in this group of patients.