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

The Physical Health Nurse Consultant: Perceptions and Experiences of Those Who Care for People with Mental Illness

Mental health carers are crucial in improving the physical health outcomes of people diagnosed with a mental illness (hereafter referred to as consumers). The long-term and multifaceted mental and physical health support carers provide to consumers can contribute to caregiver burden. Consequently, carers advocate for coordinated and integrated physical healthcare to improve the physical health outcomes of consumers and alleviate caregiver burden. The aim of this qualitative exploratory study is to explore carers' perceptions and experiences with the Physical Health Nurse Consultant role. Semi-structured interviews with nine carers nominated by consumers were conducted. Interviews were transcribed and reflexively thematically analysed. Three main themes were identified: (i) Therapeutic relationship s were a catalyst for health behaviour change; (ii) Overt and covert positive changes were observed by carer and (iii) Cares' involvement in integrated mental health and physical health care. Nine carers who were nominated by consumers to be involved in their physical healthcare planning, preferred to adopt a supporting role as this prevented or reduced caregiver burden. The findings support the adoption and continuation of the Physical Health Nurse Consultant role to facilitate positive physical health outcomes for consumers and a reduction in caregiving burden. The benefits of the Physical Health Nurse Consultant provide a compelling argument to embed the role in routine practice. Mental healthcare services should advocate for continued funding and career development for such positions to provide long term benefits for consumers and carers. Future research is required to explore carer and consumer involvement in co-producing future and localised iterations of the Physical Health Nurse Consultant role. This research should also measure the outputs and outcomes of co-production to clarify how the process worked in practice.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association of mental disorders with costs of somatic admissions in France

OBJECTIVES

Mentally ill patients have worse health outcomes when they suffer from somatic conditions compared to other patients. The objective of this study was to assess the association of mental illness with hospital inpatient costs for somatic reasons.

METHODS

All adult inpatient stays for somatic reasons in acute care hospitals between 2009 and 2013 were included using French exhaustive hospital discharge databases. Total inpatient costs were calculated from the all-payer perspective and compared in patients with and without a mental disorder. Only patients who had been admitted at least once for a mental disorder (either full-time or part-time) were considered to be mentally ill in this study. Generalized linear models with and without interaction terms studied the factors associated with hospital inpatient costs.

RESULTS

17,728,424 patients corresponding to 37,458,810 admissions were included. 1,163,972 patients (6.57%) were identified as having a mental illness. A previous full-time or part-time admission for a mental disorder significantly increased hospital inpatient costs (+32.64%, 95%CI=1.3243-1.3284). Interaction terms found an increased impact of mental disorders on costs in patients with low socio-economic status, as well as in men, patients aged between 45 and 60, and patients with a cardiovascular disease or diabetes.

CONCLUSION

Mentally ill patients have higher hospital costs than non-mentally ill patients. Improving curative and preventive treatments in those patients could improve their health and decrease the burden on healthcare systems.

Acceptability and feasibility of continuous glucose monitoring in people with diabetes: protocol for a mixed-methods systematic review of quantitative and qualitative evidence

BACKGROUND

Good glycaemic control is a crucial part of diabetes management. Traditional assessment methods, including HbA1c checks and self-monitoring of blood glucose, can be unreliable and inaccurate. Continuous glucose monitoring (CGM) offers a non-invasive and more detailed alternative. Availability of this technology is increasing worldwide. However, there is no current comprehensive evidence on the acceptability and feasibility of these devices. This is a protocol for a mixed-methods systematic review of qualitative and quantitative evidence about acceptability and feasibility of CGM in people with diabetes.

METHODS

We will search MEDLINE, Embase, CINAHL, and CENTRAL for qualitative and quantitative evidence about the feasibility and acceptability of CGM in all populations with diabetes (any type) using search terms for "continuous glucose monitoring" and "diabetes". We will not apply any study-type filters. Searches will be restricted to studies conducted in humans and those published from 2011 onwards. We will not restrict the search by language. Study selection and data extraction will be carried out by two reviewers independently using Rayyan and Eppi-Reviewer, respectively, with disagreements resolved by discussion. Data extraction will include key information about each study, as well as qualitative evidence in the form of participant quotes from primary studies and themes and subthemes based on the authors' analysis. Quantitative data relating to acceptability and feasibility including data loss, adherence, and quantitative ratings of acceptability will be extracted as means and standard deviations or n/N as appropriate. Qualitative evidence will be analysed using framework analysis informed by the Theoretical Framework of Acceptability. Where possible, quantitative evidence will be combined using random-effects meta-analysis; otherwise, a narrative synthesis will be performed. The most appropriate method for integrating qualitative and quantitative findings will be selected based on the data available.

DISCUSSION

Ongoing assessment of the acceptability of interventions has been identified as crucially important to scale-up and implementation. This review will provide new knowledge with the potential to inform a programme theory of CGM as well as future roll-out to potentially vulnerable populations, including those with severe mental illness.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021255141.

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.

Mental health consumers' perspectives of physical health interventions: An integrative review

Consumers of mental health services experience poor physical health compared to the general population, leading to long-term physical illness and premature death. Current research and policy activity prioritizes the physical health of consumers yet few of these recommendations have translated to practice. This implementation gap may be influenced by the paucity of literature exploring consumer perceptions and experiences with physical healthcare and treatment. As a result, little is understood about the views and attitudes of consumers towards interventions designed to improve their physical health. This integrative review aims to explore the literature regarding consumer perspectives of physical healthcare and, interventions to improve their physical health. A systematic search was undertaken using (i) CINAHL, (ii) MEDLINE, (iii) PsycINFO, (iv) Scopus, and (v) Google Scholar between September and December 2021. Sixty-one papers comprising 3828 consumer participants met the inclusion criteria. This review found that consumers provide invaluable insights into the barriers and enablers of physical healthcare and interventions. When consumers are authentically involved in physical healthcare evaluation, constructive and relevant recommendations to improve physical healthcare services, policy, and future research directions are produced. Consumer evaluation is the cornerstone required to successfully implement tailored physical health services.

Results of a Qualitative Study Aimed at Building a Programme to Reduce Cardiovascular Risk in People with Severe Mental Illness

People with severe mental illness (PSMI) have a shorter life expectancy and are more likely to have cardiovascular disease than the general population. Patients, carers, psychiatric professionals and primary care providers can all play a role in increasing PSMI physical health. The present qualitative exploratory study aimed to explore the views of these four populations as part of the multi-phase COPsyCAT project, whose objective is to build and test a cardiovascular risk prevention programme for PSMI. Overall, 107 people participated in the study's 16 focus groups, which were transcribed and analysed in a thematic analysis. With a view to building the health promotion programme, major themes identified in the corpus were translated into a list of needs as follows: communication, information, training and support. Results show that it is essential to improve communication between all the different stakeholders in mental health. The greatest challenge facing this programme will be to adapt it to the needs and expectations of PSMI while facilitating work between the various mental health stakeholders. Simple and inexpensive actions could be taken to improve the cardiovascular health of PSMI and will be experimented with during the programme's feasibility study which will start in September 2022.

Physical symptoms as psychiatric manifestations in medical spaces: A qualitative study

BACKGROUND

Mental health and physical health issues frequently co-occur, but the impact of the psychological wellbeing on the body's physical functioning remains poorly understood within medical spaces. Individuals living with psychiatric diagnoses in particular are at an increased risk for developing chronic health issues and may be especially disadvantaged by healthcare systems which treat the mind and body as separate entities.

METHODS

We used secondary analysis (SA) to analyze 30 semi-structured interviews of individuals living with a serious mental illness or reflecting on a family member living with a serious mental illness. We deliberately sampled participants who reflected on salient experiences with co-occurring physical and mental health symptoms. All participants were associated with the National Alliance on Mental Illness (NAMI), the nation's largest grassroots mental health organization. We coded interviews using qualitative thematic analysis with an interpretative phenomenological framework centered on participants' subjective experiences.

RESULTS

Our analyses uncovered physical health challenges which often occur in individuals living with a psychiatric illness, emphasizing the bidirectionality of mental and physical symptoms. We identified three overarching domains: (i) manifestations, in which participants reflected on how their body responded physically to mental states; (ii) medical management, in which they discussed challenging experiences seeking medical treatment for physical symptoms while living with a mental health condition; and (iii) disjointedness, in which they reflected on challenges in navigating poorly coordinated mental and physical healthcare systems.

DISCUSSION

Participants and their medical providers struggled to incorporate mental wellbeing and its impact on physical health into overall healthcare. Given common experiences with misdiagnoses, difficulties navigating health care, and significantly delayed treatment, medical spaces may be able to improve patient experiences and satisfaction by accounting for psychological influences on health outcomes.

CONCLUSION

Greater integration of physical and mental health care in medical spaces could improve health outcomes and reduce challenges for patients seeking treatment.

Service learning experiences of doctor of physical therapy students with a severe mental illness population

INTRODUCTION

Physical therapists provide important services to improve physical health for the general population; however, physical therapy interventions are less utilized with underserved populations such as those with severe mental illness (SMI). The quality of services for these populations is impacted in part by negative provider attitudes and lack of preparation to work with the SMI population. This study examined the impact of structured educational field experience on the physical therapist's attitudes and knowledge about working with the SMI population. This will inform future educational practices to best prepare students to provide quality of healthcare to the population.

MATERIALS AND METHODS

Seven graduates of a doctor of physical therapy (DPT) program from a Mid-Atlantic University in the United States who participated in an SMI service-learning (SL) experience completed a semi-structured qualitative interview in 2016. Questions about how the experience impacted their current work were asked. Interviews were digitally recorded, transcribed, and examined using interpretive phenomenological analysis. Coding and investigator triangulation were conducted. All interviews reached thematic saturation.

RESULTS

The graduated DPT students reported attitudinal changes toward people with SMI through qualitative interviews. They reported an improvement in their skills, greater competence to work with the SMI population, and an increased focus in the use of person-centered services.

CONCLUSIONS

The results of this study suggest that DPT students gain an understanding of both the SMI population and themselves during SL. Using SL as part of the DPT educational curriculum can offer students and the opportunity to build confidence in working with the SMI population. SL can also improve their skills and attitudes toward the population, key areas that are identified as barriers to receiving quality physical healthcare among the SMI population.

Adult Vaccination Rates in the Mentally Ill Population: An Outpatient Improvement Project

Background: Adults who suffer with severe and persistent mental illness (SPMI) rarely access medical care to receive preventive vaccines. Aims: To increase the rate of vaccines among the SPMI population in an outpatient community mental health center (CMHC). Methods: A review of the literature identified a gap between the general population and SPMI clients in receiving preventive vaccinations. An initial mixed-method convenience survey of SPMI clients (n = 392) provided information on current vaccination status, demographics, beliefs, and interest in receiving vaccines. A vaccination program was developed to address identified barriers and increase vaccination rates. Postintervention data were collected through a mixed-method convenience survey of SPMI clients (n = 60) who participated in immunizations clinics to evaluate client satisfaction. A partnership between the health department and CMHC was developed to deliver vaccines in a nontraditional site. Vaccines administered included annual influenza; hepatitis A; hepatitis B; herpes zoster; measles, mumps, and rubella; pneumococcal; and tetanus, diphtheria, and pertussis (Tdap). Results: More than 1,000 vaccines were administered in the first 8 months, with a significant increase in vaccination rates over baseline for individual vaccines ranging from 18.75% to 83%. Postintervention survey results found a 95% satisfaction rate. Conclusions: Implementation of a vaccination program in a nontraditional site that facilitates access for SPMI clients can promote an overwhelming increase in the vaccination rates for this underserved population. Results suggest that the integration of mental health and CMHC services can have a profound positive effect on SPMI population health.

Physical Comorbidities are Independently Associated with Higher Rates of Psychiatric Readmission in a Chinese Han Population

BACKGROUND

In people with psychosis, physical comorbidities are highly widespread and leading contributors to the untimely death encountered. Readmission rates in psychiatric patients are very high. Somatic comorbidities could be one of the considerable risk factors for psychiatric rehospitalization. Nevertheless, much less is known about the relation between physical comorbidities and psychiatric readmission. We aimed to investigate the association between physical comorbidities and psychiatric readmission in Han Chinese patients with psychiatric disorders.

METHODS

We used administrative data for January 1, 2009 to December 31, 2018 from the headquarters of the Affiliated Brain Hospital of Guangzhou Medical University to identify adults with schizophrenia, unipolar depression or bipolar disorder discharged from hospital. Data were extracted on sociodemographic and clinical characteristics. The Charlson comorbidity index (CCI) was used to assess the existence of significant physical comorbidity. Cox proportional hazards regression estimated rehospitalization risk after discharge.

RESULTS

A total of 15,620 individuals were included in this study, with the mean age of 35.1 years (SD = 12.8), and readmission occurred for 23.6% of participants. Survival analysis showed that physical comorbidities were statistically and significantly associated with psychiatric readmission, even after the adjustment for the number of psychiatric comorbidities, other sociodemographic and clinical variables.

CONCLUSION

Our results suggest that somatic comorbidities are related with higher rates of psychiatric readmission. Hence, to treat psychosis more effectively and to reduce rehospitalization, it is crucial to treat physical comorbidities promptly and adequately. It is absolutely necessary to bring somatic comorbidities to the forefront of psychiatric treatment and research.

Understanding Engagement with a Physical Health Service: A Qualitative Study of Patients with Severe Mental Illness

OBJECTIVE

Individuals with severe mental illness (SMI) are disproportionally affected by medical comorbidities, resulting in poor physical health and premature death. Despite this, care for chronic medical conditions is suboptimal, and there is limited research that explores this phenomenon from the patient's perspective. The aim of this study was to identify barriers and facilitators of engagement with a physical health service experienced by individuals with SMI.

METHODS

Adults with SMI were recruited from a large psychiatric hospital and offered referral to a physical health service focused on the prevention and treatment of obesity and diabetes. Interviews were conducted at referral, 3, and 6 months. Data from 56 interviews of 24 participants were analyzed using the framework method to identify factors influencing engagement.

RESULTS

Barriers to engagement were identified at individual, medical program, and health system levels. Factors influencing the individual experience included difficulty in care coordination, affective symptomatology, and ability to bond with providers. Factors at the program level included difficulty adjusting to the clinic environment and the inability to achieve treatment goals. Factors at the system level included challenges in attending multiple appointments in a fragmented health system, lack of social support, and financial constraints.

CONCLUSIONS

This qualitative study suggests that traditional models of medical care for chronic conditions pose challenges for many individuals with SMI and contribute to health disparities. Adaptation of medical care to populations with SMI and close collaboration between medical and mental health services are necessary to improve medical care and, subsequently, health outcomes.

Physical Healthcare of People with Serious Mental Illness: A Cross-Sectional Study of Nurses' Involvement, Views, and Current Practices

Background: Based on the poor physical health and unhealthy lifestyle behaviors, people with serious mental illness (SMI) have a high risk for long-term disorders such as diabetes, cardiovascular and respiratory diseases. Aims: This study examined nurses' current practices and views regarding the physical health of people with SMI. Methods: Cross-sectional study was conducted among nurses working in acute wards in large mental health hospital in Istanbul, Turkey. Convenience sample of 184 nurses agreed to participate in the study. Data collection was based on the self-reported responses. Descriptive statistics and comparison tests were used to describe the sample's characteristics and identify associations amongst the participants' characteristics. Findings: The results showed that nurses considered the patients' physical health important, particularly female nurses. Monitoring blood pressure, assessing physical health status at admission, and helping self-care needs were common practices. Believing in the importance of physical health was correlated with high knowledge and self-confidence levels in delivery of physical healthcare. Discussion: These findings are useful for implementing integrated nursing care in acute psychiatric care and improving patients' mental and physical well-being.

Impact of mental illness on care for somatic comorbidities in France: a nation-wide hospital-based observational study

AIMS.

People with a mental illness have a shorter lifespan and higher rates of somatic illnesses than the general population. They also face multiple barriers which interfere with access to healthcare. Our objective was to assess the effect of mental illness on the timeliness and optimality of access to healthcare for somatic reasons by comparing indicators reflecting the quality of prior somatic care in hospitalised patients.

METHODS.

An observational nation-wide study was carried out using exhaustive national hospital discharge databases for the years 2009-2013. All adult inpatient stays for somatic reasons in acute care hospitals were included with the exception of obstetrics and day admissions. Admissions with coding errors were excluded. Patients with a mental illness were identified by their admissions for a psychiatric reason and/or contacts with psychiatric hospitals. The quality of prior somatic care was assessed using the number of admissions, admissions through the emergency room (ER), avoidable hospitalisations, high-severity hospitalisations, mean length of stay (LOS) and in-hospital death. Generalised linear models studied the factors associated with poor quality of primary care.

RESULTS.

A total of 17 620 770 patients were included, and 6.58% had been admitted at least once for a mental illness, corresponding to 8.96% of hospital admissions. Mentally ill patients were more often hospitalised (+41% compared with non-mentally patients) and for a longer LOS (+16%). They also had more high-severity hospitalisations (+77%), were more often admitted to the ER (+113%) and had more avoidable hospitalisations (+50%). After adjusting for other covariates, regression models found that suffering from a mental illness was significantly associated with a worse state for each indicator of the quality of care except in-hospital death.

CONCLUSION.

Inadequate primary care of mentally ill patients leads to more serious conditions upon admission to hospital and avoidable hospitalisations. It is, therefore, necessary to improve primary care and prevention for those patients.

Modeling Health Disparities and Outcomes in Disenfranchised Populations

The Health Disparities and Outcomes (HDO) model originally created to explain the complexity of obtaining healthcare in rural settings has been revised and updated using emerging theoretical models of adversity and inequity and two decades of empirical work by the authors. With a strong orientation to explaining population-based health inequities, the HDO is applied to individuals with Serious Mental Illness (SMI), to explain their high rates of morbidity and mortality compared to the general population. Individual-, community-, and system-level factors that reflect an understanding of life-long risk, accrued hazards associated with multiple and intersecting disadvantages, and difficulty obtaining healthcare that meets accepted standards are described. The revised HDO can be applied to populations with disproportionate health challenges to identify multi-level factors that affect illness trajectory and overall health outcomes.

Using the capabilities approach to understand inequality in primary health-care services for people with severe mental illness

BACKGROUND

Epidemiological studies show disparities in the provision of physical health-care for people with severe mental illness. This observation includes countries with universal health insurance. However, there is limited in-depth data regarding the barriers preventing equality of physical health-care provision for this population. This study applied the capabilities approach to examine the interface between general practitioners and patients with severe mental illness. The capabilities approach provides a framework for health status which conceptualizes the internal and external factors relating to the available options (capabilities) and subsequent health outcomes (functioning).

METHODS

Semi-structured in-depth interviews were conducted with 10 general practitioners and 15 patients with severe mental illness, and then thematically analyzed.

RESULTS

We identified factors manifesting across three levels: personal, relational-societal, and organizational. At the personal level, the utilization of physical health services was impaired by the exacerbation of psychiatric symptoms. At the relational level, both patients and physicians described the importance of a long-term and trusting relationship, and provided examples demonstrating the implications of relational ruptures. Finally, two structural-level impediments were described by the physicians: the absence of continuous monitoring of patients with severe mental illness, and the shortfall in psychosocial interventions.

CONCLUSION

The capability approach facilitated the identification of barriers preventing equitable health-care provision for patients with severe mental illness. Based on our findings, we propose a number of practical suggestions to improve physical health-care for this population: 1. A proactive approach in monitoring patients' health status and utilization of services. 2. Acknowledgment of people with severe mental illness as a vulnerable population at risk, that need increased time for physician-patient consultations. 3. Training and support for general practitioners. 4. Increase collaboration between general practitioners and mental-health professionals. 5. Educational programs for health professionals to reduce prejudice against people with severe mental illness.

Monitoring of somatic parameters at outpatient departments for mood and anxiety disorders

INTRODUCTION

Somatic complications account for the majority of the 13-30 years shortened life expectancy in psychiatric patients compared to the general population. The study aim was to assess to which extent patients visiting outpatient departments for mood and anxiety disorders were monitored for relevant somatic comorbidities and (adverse) effects of psychotropic drugs-more specifically a) metabolic parameters, b) lithium safety and c) ECGs-during their treatment.

METHODS

We performed a retrospective clinical records review and cross-sectional analysis to assess the extent of somatic monitoring at four outpatient departments for mood and anxiety disorders in The Netherlands. We consecutively recruited adult patients visiting a participating outpatient department between March and November 2014. The primary outcome was percentage of patients without monitoring measurements. Secondary outcomes were number of measurements per parameter per patient per year and time from start of treatment to first measurement.

RESULTS

We included 324 outpatients, of whom 60.2% were female. Most patients were treated for depressive disorders (39.8%), anxiety disorders (16.7%) or bipolar or related disorders (11.7%) and 198 patients (61.1%) used at least one psychotropic drug. For 186 patients (57.4%), no monitoring records were recorded (median treatment period 7.3 months, range 0-55.6). The median number of measurements per parameter per year since the start of outpatient treatment for patients with monitoring measurements was 0.31 (range 0.0-12.9). The median time to first monitoring measurement per parameter for patients with monitoring measurements was 3.8 months (range 0.0-50.7).

DISCUSSION

Somatic monitoring in outpatients with mood and anxiety disorders is not routine clinical practice. Monitoring practices need to be improved to prevent psychiatric outpatients from undetected somatic complications.

A Qualitative Study on Primary Care Integration into an Asian Immigrant-specific Behavioural Health Setting in the United States

Introduction

Integrating primary care and behavioural health services improves access to services and health outcomes among individuals with serious mental illness. Integrated care is particularly promising for racial and ethnic minority individuals given higher rates of chronic illnesses and poorer access to and quality of care compared to Whites. However, little is known about integrated care implementation in non-White populations. The aim of this study is to identify facilitators and barriers to successful implementation of primary care-behavioural health integration in a multilingual behavioural healthcare setting.

Methods

Seven focus groups and five semi-structured interviews were conducted with 41 patients and 5 providers participating in integrated care in a community mental health clinic in California serving Asian immigrants.

Results

Themes generated from constant comparative analysis suggest limited system-level preconditions and cross-organisational dynamics challenged integrated care. At the same time, changing organisational culture and practice, improving patient-provider and provider-provider communication, and increasing patient involvement enhanced clinical outcomes and facilitated successful implementation.

Discussion and conclusions

Findings highlight the importance of patient involvement, peer services and interdisciplinary communication to successfully implement integrated care in the face of linguistic and operational challenges in settings serving multilingual and multicultural patients.

Comorbidity of chronic somatic diseases in patients with psychotic disorders and their influence on 4-year outcomes of integrated care treatment (ACCESS II study)

BACKGROUND

People with psychotic disorders fulfilling criteria of a severe and persistent mental illness (SPMI) display a high risk of somatic comorbidity (SC).

METHODS

ACCESS II is a prospective, long-term study examining the effectiveness of Integrated Care for people with psychotic disorders fulfilling SPMI criteria. Chronic comorbid somatic disorders were systematically assessed according to ICD-10-GM criteria. Patients treated for ≥4years in ACCESS were categorized as early psychosis (treatment: ≤2years) or non-early psychosis (treatment: >2years) patients.

RESULTS

Of 187 patients treated in ACCESS for ≥4years (mean age=41.8years, males=44.4%), 145 (77.5%) had SC, (mean=2.1±2.1). Overall, 55 different diseases from 15 different ICD-10-GM disease areas were identified. Prevalence of ≥1 SC (p=0.09) and specific types of SC (p=0.08-1.00) did not differ between early and non-early psychosis patients, but non-early psychosis patients had a higher mean number of SC (2.3±2.2 vs. 1.3±1.3, p=0.002). SC patients had higher rates of comorbid mental disorders (93% vs. 81%, p=0.002), specifically posttraumatic stress disorder (23% vs. 7%, p=0.002), and suicide attempts (43% vs. 19%, p<0.001). At the 4-year endpoint, both patients with and without comorbidity displayed major improvements in psychopathology, severity of illness, functioning, quality of life and satisfaction with care.

CONCLUSIONS

SC is frequent in patients with severe psychotic disorders, even in the early psychosis phase. The magnitude of the problem underlines the need for regular screening, comprehensive assessment, preventive pharmacotherapy, and targeted SC management.

Evaluation of a general practitioner-led cardiometabolic clinic: Physical health profile and treatment outcomes for clients on clozapine

The present study is a review of a cardiometabolic clinic for consumers taking clozapine. This clinic was recently established and co-located with the clozapine clinic at a regional hospital in New South Wales, Australia, to enhance engagement and improve the physical health outcomes of consumers taking antipsychotic medication. A descriptive analysis of clients' (n = 73) information collected during routine care for the first 6 months of the clinic's operation, from January 2016 to July 2016, was conducted. First-visit data were analysed to establish a client profile, consisting of weight, height, blood pressure, pulse, a range of blood measurements, smoking status, alcohol consumption, and eating and exercise habits. Data collected for clients who had three or more visits with the general practitioner (n = 40) were analysed separately for outcomes. Two case studies are used to depict the service received and client profile. At the first appointment, the majority of clients had metabolic syndrome that was mostly left untreated; many of these clients were commenced on metformin. The outcomes are positive, and show that the majority of clients lost weight (82.5%) and had a reduction in body mass index (84.6%); nearly half (44.4%) had a reduction in waist circumference. The majority of clients self-reported increased physical activity (72.5%, n = 29) and positive dietary changes (77.5%, n = 31) since their first appointment. The model trialled by the cardiometabolic clinic integrated a specialist mental health and primary care service, and demonstrates success in engaging clients with severe mental illness in physical health care. Co-location is conceptualized as critical for positive patient outcomes and high levels of engagement.

Psychosocial Services for Individuals With Serious Mental Illness/Severe Emotional Disturbance: Clinical Practice Guideline Toolkit

This article presents a short, easy-to-use guideline for clinicians working with people with serious mental illness, particularly those with schizophrenia, schizoaffective disorder, delusional disorders, other psychotic disorders, or depression with significant impact on functioning, and may be of use for those working with individuals with bipolar disorder. This guideline is not meant to supplant the more detailed, excellent clinical practice guidelines that have been developed and published. Rather, the charts and explanation presented here are designed as a step-by-step tool that clinicians can use to ensure they are following the most appropriate course of action and providing the best psychosocial rehabilitation services possible for persons with these disorders. Program managers can use this tool to evaluate the processes used in their system to ensure that appropriate services are offered for the individuals in their care. This guideline is also not meant as a substitute for comprehensive training in the practice of assessment and treatment for individuals with serious mental illness. Very little detail is provided about the disorders, appropriate assessments, and interventions because clinicians providing services to people with these disorders should have received the specialized training necessary to appropriately deliver the services needed by these individuals.

Understanding experiences of and preferences for service user and carer involvement in physical health care discussions within mental health care planning

BACKGROUND

People with severe mental illness suffer more physical comorbidity than the general population, which can require a tailored approach to physical health care discussions within mental health care planning. Although evidence pertaining to service user and carer involvement in mental health care planning is accumulating, current understanding of how physical health is prioritised within this framework is limited. Understanding stakeholder experiences of physical health discussions within mental health care planning, and the key domains that underpin this phenomena is essential to improve quality of care. Our study aimed to explore service user, carer and professional experiences of and preferences for service user and carer involvement in physical health discussions within mental health care planning, and develop a conceptual framework of effective user-led involvement in this aspect of service provision.

METHODS

Six focus groups and four telephone interviews were carried out with twelve service users, nine carers, three service users with a dual service user and carer role, and ten mental health professionals recruited from one mental health Trust in the United Kingdom. Data was analysed utilising a thematic approach, analysed separately for each stakeholder group, and combined to aid comparisons.

RESULTS

No service users or carers recalled being explicitly involved in physical health discussions within mental health care planning. Six prerequisites for effective service user and carer involvement in physical care planning were identified. Three themes confirmed general mental health care planning requirements: tailoring a collaborative working relationship, maintaining a trusting relationship with a professional, and having access to and being able to edit a living document. Three themes were novel to feeling involved in physical health care planning discussions: valuing physical health equally with mental health; experiencing coordination of care between physical-mental health professionals, and having a physical health discussion that is personalised.

CONCLUSIONS

High quality physical health care discussions within the care planning process demands action at multiple levels. A conceptual framework is presented which provides an evidence-based foundation for service level improvement. Further work is necessary to develop a new patient reported outcome measure to enable meaningful quantification of health care quality and patient experience.

The role of boundary spanners in delivering collaborative care: a process evaluation

Background

On average, people with schizophrenia and psychosis die 13–30 years sooner than the general population (World Psychiatry 10 (1):52–77, 2011). Mental and physical health care is often provided by different organisations, different practitioners and in different settings which makes collaborative care difficult. Research is needed to understand and map the impact of new collaborative ways of working at the primary/secondary care interface (PloS One 7 (5); e36468). The evaluation presented in this paper was designed to explore the potential of a Community and Physical Health Co-ordinator role (CPHC) (CPHCs were previously Care Co-ordinators within the Community Mental Health Team, Community in the title CPHC refers to Community Mental Health) and Multi-Disciplinary Team (MDT) meetings across primary and community care, with the aim of improving collaboration of mental and physical health care for service users with Severe Mental Illness (SMI).

Methods

Data collection took place across five general practices (GPs) and a Community Mental Health Team (CMHT) in the Northwest of England, as part of a process evaluation. Semi-structured interviews were conducted with a purposive sample of GP staff (n= 18) and CMHT staff (n=4), a focus group with CMHT staff (n=8) and a survey completed by 13 CMHT staff, alongside cardiovascular risk data and MDT actions. Framework analysis was used to manage and interpret data.

Results

The results from the evaluation demonstrate that a CPHC role and MDT meetings are effective mechanisms for improving the collaboration and co-ordination of physical health care for SMI service users. The findings highlight the importance of embedding and supporting the CPHC role, with an emphasis on protected time and continuing professional roles and integrating multiple perspectives through MDT meetings. Considering the importance of physical health care for SMI service users and the complex environment, these are important findings for practitioners, researchers and policy makers in the field of primary care and mental health.

Conclusion

There is an increasing focus on integration and collaborative working to ensure the delivery of quality care across the whole patient pathway, with a growing need for professionals to work together across service and professional boundaries. The introduction of a two pronged approach to collaboration has shown some important improvements in the management of physical health care for service users with SMI.

Integrated care in German mental health services as benefit for relatives--a qualitative study

BACKGROUND

As mental health services undergo the process of deinstitutionalization, this is resulting in a higher burden of care for relatives. Evidence suggests that interventions for carers have a beneficial impact on their psychological health. A reduction of responsibility for relatives is linked with a significantly improved outcome for the severely mentally ill. The aim of the study was to explore the relatives' experiences with severely mentally ill patients in different integrated care service providers.

METHODS

Semi-structured focus groups and interviews were conducted with 24 relatives of patients receiving community based integrated care for severe mental illness. The collected data was transcribed and evaluated using qualitative content analysis. A deductive-inductive approach was used in generating thematic categories.

RESULTS

Four main categories were found related to the structural aspects of the integrated care services and for the experiences of the relatives within these services. Relatives reported that the services offered significant relief and substantial support in daily life. In addition, relatives felt a reduced burden of carer responsibility and therefore that they were provided with more protection and stability. This resulted in a sense of encouragement and not feeling left alone to face challenges.

CONCLUSION

Relatives are a critical resource for patients suffering from mental health problems and benefit from formal structures and interventions to support them in carer role. An important need is to ensure continuity of care for patients and the bridging of gaps concerning information and support needs for relatives when providing integrated mental health services in the community.

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.

Preparing family physicians for the care of patients with severe and persistent mental illness: Examples from two U.S. residency programs

Individuals with severe and persistent mental illness have increased morbidity and mortality and significant barriers to accessing health care. Although primary care providers deliver most health care for this population, residency training programs generally lack specialized training in this area. This article describes the approaches of two family medicine residency programs in addressing this educational gap. Each program collaborated with external organizations to create service models that would enhance patient access, while immersing residents in the care of patients with severe and persistent mental illness. Residents educated in these programs gain experience with an underserved population, practice advanced skills in managing complex medical and psychiatric illness, and increase knowledge from collaborative work in unique care settings. Further implementation of programs like these, and rigorous study of such programs, could have significant benefits for family medicine education and the care of patients with severe and persistent mental illness.

Practical recommendations for improvement of the physical health care of patients with severe mental illness

OBJECTIVE

Health care for the physical health of patients with severe mental illness (SMI) needs to be improved. Therefore, we aimed to develop policy recommendations to improve this physical health care in the Netherlands based on consensus (general agreement) between the major stakeholders.

METHOD

A modified Delphi was used to explore barriers and subsequently establish policy recommendations with all key stakeholders. Consensus was sought between patients with SMI, their family carers, general practitioners, and mental healthcare professionals--all experts in the everyday practice of health care.

RESULTS

Consensus was reached on policy recommendations regarding (i) improvements in collaboration between healthcare professionals, (ii) the need for professional education on the specific medical risks of patients with SMI, and (iii) the distinguished responsibilities of general practitioners on the one hand and mental healthcare professionals on the other hand in taking care of patients' physical health.

CONCLUSION

This article provides a range of policy recommendations that could lead to considerable improvements in the physical health of SMI patients.

Poor monitoring of physical health in patients referred to a mood disorders service

BACKGROUND

Severe mental illness is associated with significantly increased morbidity and mortality, most commonly from cardiovascular disease. Much of the risk is explicable by potentially modifiable factors such as diabetes and dyslipidaemia, and regular screening of patients with severe mental illness is recommended. Screening and intervention for physical illness among people with schizophrenia is often suboptimal, but little is known about monitoring physical health in patients with affective (mood and anxiety) disorders.

METHOD

Electronic and paper records were examined for evidence of monitoring of cardiovascular disease risk factors in the 12 months prior to assessment in patients attending a tertiary referral specialist service for affective disorders over a period of 39 months. The number of contacts with healthcare services was calculated for each patient to provide an estimate of the opportunities for monitoring.

RESULTS

Notes for 113 patients were examined. The mean number of contacts with outpatient services in the 12 months before assessment was 6.9 (standard deviation 7.7). Documented evidence of physical-health monitoring was seen in only 29 patients: monitoring was more commonly undertaken in patients with recurrent unipolar depression and in those who had undergone recent inpatient treatment. Contacts that could have allowed monitoring of physical health were common.

DISCUSSION

Although most patients had multiple contacts with health services in the 12-month period before their assessment in the service, there was little evidence of use of primary-prevention measures to reduce the risks of diabetes and cardiovascular disease in this vulnerable population.