Attitudes to physical healthcare in severe mental illness; a patient and mental health clinician qualitative interview study

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Healthcare Professional Perspectives on the Impact of the Physical Health Nurse Consultant

Early mortality experienced by people living with mental health issues (hereon termed consumers) is largely preventable. Healthcare professionals perceive healthcare system inadequacies such as diagnostic overshadowing, stigma and fragmentation of physical and mental healthcare services can be resolved through effective integration approaches. Service- and individual-level integration approaches involve multidisciplinary teams collaborating and coordinating care to holistically meet consumers' physical and mental health needs. Evidence suggests appropriately trained healthcare professionals can deliver effective integrated treatment without financial or organisational restructuring. Specialist nursing positions such as Physical Health Nurse Consultants can support and integrate physical and mental health care. Consumers report the Physical Health Nurse Consultant as providing dedicated, integrated, coordinated and holistic mental and physical health care. This study aimed to explore the Physical Health Nurse Consultant role from the perspectives of healthcare professionals. A qualitative exploratory study design was used. Fourteen healthcare professionals participated in individual interviews or focus groups. Interview recordings were transcribed, and thematically analysed. Three themes were identified: (i) role functions, including integration of physical and mental health care, (ii) impact on consumer physical health outcomes and (iii) impact on service delivery. Healthcare professionals perceive the Physical Health Nurse Consultant effectively integrates physical and mental health care and subsequently support the continuation and embedding of the role in routine practice. Future research is required to explore healthcare professionals' experiences and perceptions of how these roles be translated to routine clinical practice. Examining the professional development requirements, service provider constraints and economic implication to achieve these outcomes also warrants attention.

Patient, supporter and primary healthcare professional perspectives on health risks in over 16s with attention deficit hyperactivity disorder (ADHD) in England: a national survey study

BACKGROUND

Current research suggests that people with attention deficit hyperactivity disorder (ADHD) are at higher risk of physical and mental health disorders. This study aimed to explore these health risks in ADHD from the perspectives of multiple stakeholders.

METHODS

This study forms part of the 'Managing young people with ADHD in Primary care (MAP) study'. A survey developed by the study team was distributed to over 16 year olds with ADHD, their supporters, primary healthcare professionals and health commissioners across England, via social media and through patient/clinical networks (September-October 2022). This survey contained two questions on health risks. Question one asked about views on health risks in ADHD (free text). Question two asked about advice given (options list and free text). Descriptive statistics summarised responses to questions one and two, and qualitative analysis (reflexive thematic analysis) was used to explore free text responses from question one.

RESULTS

782 participants responded to the MAP survey. Of these, 206 healthcare professionals, 157 people with ADHD and 88 supporters answered question one. The most mentioned perceived risks were substance misuse, sleep disorders, weight management and smoking. More people with ADHD reported disordered eating as a health risk (n = 32) than healthcare professionals (n = 5). Generated themes included perceived health risks, impact of living with ADHD, lack of adequate healthcare, and need for ADHD awareness. In respect to advice given (question two), based on responses from 258 professionals, 162 people with ADHD and 100 supporters, the most common advice discussed in consultation was mental health (n = 149, n = 50 and n = 17 respectively). High numbers of respondents reported not giving/receiving advice on wider health (n = 38, n = 88 and n = 61 respectively).

CONCLUSIONS

Findings demonstrate that respondents perceived a range of physical and mental health risks posed by ADHD. These related to difficulties with activities of daily living, as well as healthcare interactions and the impact of core features of ADHD (e.g. impulsivity, emotional dysregulation). These risks are not currently explicitly addressed in United Kingdom national guidance on ADHD. More work is needed to examine and address the broader health outcomes of people with ADHD.

Transmural collaborative care model for the review of antipsychotics: a feasibility study of a complex intervention

General practitioners (GPs) are often unaware of antipsychotic (AP)-induced cardiovascular risk (CVR) and therefore patients using atypical APs are not systematically monitored. We evaluated the feasibility of a complex intervention designed to review the use of APs and advise on CVR-lowering strategies in a transmural collaboration. A mixed methods prospective cohort study in three general practices in the Netherlands was conducted in 2021. The intervention comprised three steps: a digital information meeting, a multidisciplinary meeting, and a shared decision-making visit to the GP. We assessed patient recruitment and retention rates, advice given and adopted, and CVR with QRISK3 score and mental state with MHI-5 at baseline and three months post-intervention. GPs invited 57 of 146 eligible patients (39%), of whom 28 (19%) participated. The intervention was completed by 23 (82%) and follow-up by 18 participants (64%). At the multidisciplinary meeting, 22 (78%) patients were advised to change AP use. Other advice concerned medication (other than APs), lifestyle, monitoring, and psychotherapy. At 3-months post-intervention, 41% (28/68) of this advice was adopted. Our findings suggest that this complex intervention is feasible for evaluating health improvement in patients using AP in a trial.

Nurses' and patients' perceptions of physical health screening for patients with schizophrenia spectrum disorders: a qualitative study

BACKGROUND

Despite worldwide concern about the poor physical health of patients with schizophrenia spectrum disorders (SSD), physical health screening rates are low. This study reports nurses' and patients' experiences of physical health screening among people with SSD using the Finnish Health Improvement Profile (HIP-F) and their ideas for implementation improvements.

METHODS

A qualitative exploratory study design with five group interviews with nurses (n = 15) and individual interviews with patients with SSD (n = 8) who had experience using the HIP-F in psychiatric outpatient clinics. Inductive content analysis was conducted.

RESULTS

Two main categories were identified. First, the characteristics of the HIP-F were divided into the subcategories of comprehensive nature, facilitating engagement, interpretation and rating of some items and duration of screening. Second, suggestions for the implementation of physical health screening consisted of two subcategories: improvements in screening and ideas for practice. Physical health screening was felt to increase the discussion and awareness of physical health and supported health promotion. The HIP-F was found to be a structured, comprehensive screening tool that included several items that were not otherwise assessed in clinical practice. The HIP-F was also considered to facilitate engagement by promoting collaboration in an interactive way. Despite this, most of the nurses found the HIP-F to be arduous and too time consuming, while patients found the HIP-F easy to use. Nurses found some items unclear and infeasible, while patients found all items feasible. Based on the nurses' experiences, screening should be clear and easy to interpret, and condensation and revision of the HIP-F tool were suggested. The patients did not think that any improvements to the HIP-F were needed for implementation in clinical settings.

CONCLUSIONS

Patients with schizophrenia spectrum disorders are willing to participate in physical health screening. Physical health screening should be clear, easy to use and relatively quick. With this detailed knowledge of perceptions of screening, further research is needed to understand what factors affect the fidelity of implementing physical health screening in clinical mental health practice and to gain an overall understanding on how to improve such implementation.

Comparison of outcomes for patients with and without a serious mental illness presenting to hospital for chronic obstruction pulmonary disease: retrospective observational study using administrative data

BACKGROUND

There are few data on the profile of those with serious mental illness (SMI) admitted to hospital for physical health reasons.

AIMS

To compare outcomes for patients with and without an SMI admitted to hospital in England where the primary reason for admission was chronic obstructive pulmonary disease (COPD).

METHOD

This was a retrospective, observational analysis of the English Hospital Episodes Statistics data-set for the period from 1 April 2018 to 31 March 2019, for patients aged 18-74 years with COPD as the dominant reason for admission. Patient with an SMI (psychosis spectrum disorder, bipolar disorder) were identified.

RESULTS

Data were available for 54 578 patients, of whom 2096 (3.8%) had an SMI. Patients with an SMI were younger, more likely to be female and more likely to live in deprived areas than those without an SMI. The burden of comorbidity was similar between the two groups. After adjusting for covariates, SMI was associated with significantly greater risk of length of stay than the median (odds ratio 1.24, 95% CI 1.12-1.37, P ≤ 0.001) and with 30-day emergency readmission (odds ratio 1.51, 95% confidence interval 1.34-1.69, P ≤ 0.001) but not with in-hospital mortality.

CONCLUSION

Clinicians should be aware of the potential for poorer outcomes in patients with an SMI even when the SMI is not the primary reason for admission. Collaborative working across mental and physical healthcare provision may facilitate improved outcomes for people with SMI.

How is physical healthcare experienced by staff, service users, and carers in adult community mental health services in a south London mental health trust? A service evaluation

Background

Adults with a serious mental illness (SMI) are at greater risk of physical health morbidity and premature death than the general population, largely as a result of preventable physical health issues. Staff working in mental health services have a role to play in addressing these inequalities, but little is known about how they perceive their role and how this impacts on their practice. Understanding this better would enable services to improve their approach and support better health outcomes for SMI patients. A service evaluation was undertaken to investigate how physical healthcare is approached within adult community mental health teams (CMHTs) at a South London (UK) Mental Health Trust.

Methods

This was a prospective, cross-sectional evaluation design. Interviews and focus groups were conducted with clinical staff, service users and carers (non-professional caregivers e.g., family or friends, of adults living with an SMI), to understand their experiences and to identify key barriers and facilitators to supporting physical healthcare support for adults with SMI. Thematic analysis was conducted to identify key themes which were classified into five main categories.

Results

50 participants took part in the study, 38 were clinical staff, eight were service users and four were carers. We found staff widely recognised the importance of supporting physical healthcare. However, there was variability in how staff approached physical healthcare in routine practice, and differences in how physical healthcare is experienced by service users and carers. Staff were keen to engage in changes to the way physical healthcare is delivered in CMHTs. However, they sought clearer guidance on their roles and responsibilities, and wanted to better understand the rationale for changes in community mental health practice, such as increased screening for physical healthcare. Service users and carers felt equally that the role of CMHTs in physical healthcare was unclear, which limited their ability to access it and understand the benefit for their overall care. Staff articulated gaps in leadership and training that impacted on their ability to implement the overall vision for physical healthcare within the Trust.

Conclusion

Mental health staff recognise the role they play in supporting the physical health of adults living with SMI. This evaluation provides insight into common barriers and facilitators faced by staff, service users and carers when providing or accessing physical healthcare within adult CMHTs. These findings indicate a more comprehensive and better articulated approach to physical healthcare in mental health Trusts is needed to ensure service users and their carers understand what support is available and how to access it and to equip staff to provide and sustain that care in routine practice.

Profile changes in admissions to a psychiatric hospitalisation unit over 15 years (2006-2021), considering the impact of the pandemic caused by SARS-CoV-2

The objective of this current work was to explore whether modification of the diagnostic criteria upon the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the impact of the COVID-19 pandemic had influenced the diagnostic and sociodemographic profiles of mental health admissions. For that purpose, we designed an observational, longitudinal, and retrospective study of the data recorded in the discharge reports of the Brief Hospitalization Unit at Castellon (Spain), between January 2006 and December 2021. The sample consisted of 7,037 participants, with a mean age of 42.1 years. The mean age of admissions, number of women, and presentation of affective disorders, addictions, and dementias all increased significantly during the DSM-5 period. Beyond diagnoses, the reduction in readmissions before the pandemic could be attributed to the use of long-acting injectable antipsychotics. In contrast, the pandemic did not change the percentage of readmissions or the volume of admissions. Also, during the pandemic period, the significant results obtained indicate that the average stay was reduced, affective disorders decreased, and addictions increased. Therefore, clinicians should consider these diagnostic and sociodemographic fluctuations when adapting clinical care, taking into account gender perspective, ageing of patients and increasing of dual and affective disorders.

Provision of HIV services to psychiatric inpatients in Botswana: Challenges and recommendations

Background

The high prevalence of HIV among psychiatric inpatients is well-documented, yet little is known about the provision of HIV services for these patients.

Aim

This qualitative study aimed to explore and understand healthcare providers' challenges with providing HIV services to psychiatric inpatients.

Setting

This study was conducted at the national psychiatric referral hospital in Botswana.

Methods

The authors conducted in-depth interviews with 25 healthcare providers serving HIV-positive psychiatric inpatients. Data analysis was performed using a thematic analysis approach.

Results

Healthcare providers reported challenges with transporting patients to access off-site HIV services, longer waiting periods for antiretroviral therapy (ART) initiation, patient confidentiality, fragmented services for treatment of comorbidities, and a lack of patient data integration between the national psychiatric referral hospital and other facilities such as the Infectious Diseases Care Clinic (IDCC) at the nearby district hospital. Providers' recommendations for addressing these challenges included the establishment of an IDCC at the national psychiatric referral hospital, connecting the psychiatric facility to the patient data management system to ensure integration of patient data, and provision of HIV-related in-service training to nurses.

Conclusion

Psychiatric healthcare providers advocated for on-site integration of care for psychiatric illness and HIV among inpatients to address the challenges of ART provision.

Contribution

The findings suggest the need to improve the provision of HIV services in the psychiatric hospitals in order to ensure better outcomes for this often-overlooked population. These findings are useful in improving clinical practice for HIV in psychiatric settings.

Physical health of individuals with psychosis - a mixed method study

People with psychosis have poorer physical health than the general population and this aspect of care delivery has largely been neglected. The IMPULSE trial (ISRCTN 11913964) investigated a psychosocial intervention prompting people with psychosis to discuss their physical health concerns with mental health clinicians. This mixed-method study explored a series of clinical meetings over 6 months to understand how physical health is discussed, what actions are taken, and if these translated into benefits for the participating individuals with psychosis. 221 individuals with psychosis were included, attending 847 clinical meetings over 6 months. Results show that, when prompted, most participants (54%) took up the opportunity to discuss their physical health at least once. These individuals were keen to make changes such as adopt healthy diet, stop smoking, lose weight, etc. Despite taking steps to achieve these goals, after 6 months no improvement was detected in subjective satisfaction with physical health, severity of physical health problems or satisfaction with services. Adopting healthier lifestyle behaviours is difficult even in motivated individuals. Future research is needed to determine innovative approaches to promote lifestyle change in individuals with psychosis.

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.

Metabolic syndrome and cardiovascular risk between clozapine and non-clozapine antipsychotic users with schizophrenia

INTRODUCTION

Clozapine use is associated with higher risks of metabolic side effects and cardiovascular diseases (CVD). Thus, this study aims to establish and compare the cardiometabolic profiles between non-clozapine antipsychotic and clozapine users with schizophrenia.

METHODS

Data from 88 non-clozapine and 166 clozapine users were extracted from existing databases - demographics, medications, smoking and medical histories, anthropometric parameters, serum lipid and fasting glucose levels. Prevalence of metabolic syndrome (MetS) was established using the AHA/NHLBI criteria. Cardiovascular risk profiles were established using the Framingham risk score (FRS).

RESULTS

The clozapine group had significantly higher proportions of diagnosed hypertension (10.8 % vs. 3.4 %, p = 0.041), diabetes mellitus (15.7 % vs. 3.4 %, p = 0.003) and dyslipidemia (36.7 % vs. 12.5 %, p < 0.001). However, the non-clozapine antipsychotic group had poorer anthropometric, serum lipids and glucose levels. The prevalence rates of MetS in the clozapine and non-clozapine antipsychotic groups were not statistically significant at 42.8 % and 43.2 %, respectively. As for CVD risk, the non-clozapine antipsychotic group had significantly higher FRS (6.59 % vs. 6.12 %, p = 0.001).

CONCLUSION

Although clozapine users had higher rates of diagnosed metabolic conditions, other cardiometabolic parameters appeared better compared to non-clozapine antipsychotic users, which could be due to greater awareness, earlier detection and treatment. Regardless of the type of antipsychotic used, metabolic abnormalities are prevalent in individuals with schizophrenia; physical healthcare should be prioritised alongside mental healthcare in this group.

Point-of-care diagnostic technology in paediatric ambulatory care: a qualitative interview study of English clinicians and stakeholders

Point-of-care (POC) tests have the potential to improve paediatric healthcare. However, both the development and evaluation of POC technology have almost solely been focused on adults. We aimed to explore frontline clinicians' and stakeholders' current experience of POC diagnostic technology in children in England; and to identify areas of unmet need.

DESIGN, SETTING AND PARTICIPANTS

Qualitative semistructured telephone interviews were carried out with purposively sampled participants from clinical paediatric ambulatory care and charity, industry and policymaking stakeholders. The interviews were audio-recorded, transcribed and analysed thematically.

RESULTS

We interviewed 19 clinicians and 8 stakeholders. The main perceived benefits of POC tests and technologies were that they aided early decision-making and could be convenient and empowering when used independently by patients and families. Clinicians and stakeholders wanted more POC tests to be available for use in clinical practice. Most recognised that play and reward are important components of successful POC tests for children. Clinicians wanted tests to give them answers, which would result in a change in their clinical management. Detecting acute serious illness, notably distinguishing viral and bacterial infection, was perceived to be an area where tests could add value. POC tests were thought to be particularly useful for children presenting atypically, where diagnosis was more challenging, such as those less able to communicate, and for rare serious diseases. Many participants felt they could be useful in managing chronic disease.

CONCLUSIONS

This exploratory study found that clinicians and stakeholders supported the use of diagnostic POC technology in paediatric ambulatory care settings in England. Some existing tests are not fit for purpose and could be refined. Industry should be encouraged to develop new child-friendly tests tackling areas of unmet need, guided by the preferred characteristics of those working on the ground.

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.

Recognition and management of depression in early psychosis

AIMS AND METHOD

Depression in first-episode psychosis (FEP) is highly prevalent and associated with poor outcomes; it has become increasingly recognised and adopted in national and international guidelines for psychosis. Using a 26-item questionnaire, this study aimed to explore if this shift has led to greater recognition among UK psychiatrists, and more effective management of depression in FEP.

RESULTS

Of the 297 respondents, 54.4% observed depression occurring in chronic psychosis, with the least number of respondents (17.7%) identifying depression occurring frequently during FEP. Although there was reasonable agreement in the use of antidepressants as a first-line treatment for depression (70% prescribing antidepressants), there was uncertainty around assessing depression and delineating from psychosis symptoms, and particularly negative symptoms.

CLINICAL IMPLICATIONS

Evidence-based treatments for comorbid depression in psychosis will lead to clearer national guidelines, allowing for optimal management of depression in early psychosis, potentially leading to improved outcomes for these individuals.

The Complex Interplay Between Physical Activity and Recovery Styles in Patients With Severe Mental Disorders in a Real-World Multicentric Study

Compared with the general population, people with severe mental disorders have significantly worse physical health and a higher mortality rate, which is partially due to the adoption of unhealthy lifestyle behaviors, such as heavy smoking, use of alcohol or illicit drugs, unbalanced diet, and physical inactivity. These unhealthy behaviors may also play a significant role in the personal and functional recovery of patients with severe mental disorders, although this relationship has been rarely investigated in methodologically robust studies. In this paper, we aim to: a) describe the levels of physical activity and recovery style in a sample of patients with severe mental disorders; b) identify the clinical, social, and illness-related factors that predict the likelihood of patients performing physical activity. The global sample consists of 401 patients, with a main psychiatric diagnosis of bipolar disorder (43.4%, N = 174), psychosis spectrum disorder (29.7%; N = 119), or major depression (26.9%; N = 118). 29.4% (N = 119) of patients reported performing physical activity regularly, most frequently walking (52.1%, N = 62), going to the gym (21.8%, N = 26), and running (10.9%, N = 13). Only 15 patients (3.7%) performed at least 75 min of vigorous physical activity per week. 46.8% of patients adopted sealing over as a recovery style and 37.9% used a mixed style toward integration. Recovery style is influenced by gender (p < 0.05) and age (p < 0.05). The probability to practice regular physical activity is higher in patients with metabolic syndrome (Odds Ratio - OR: 2.1; Confidence Interval - CI 95%: 1.2-3.5; p < 0.050), and significantly lower in those with higher levels of anxiety/depressive symptoms (OR: 0.877; CI 95%: 0.771-0.998; p < 0.01). Globally, patients with severe mental disorders report low levels of physical activities, which are associated with poor recovery styles. Psychoeducational interventions aimed at increasing patients' motivation to adopt healthy lifestyle behaviors and modifying recovery styles may improve the physical health of people with severe mental disorders thus reducing the mortality rates.

"Modifying" or "Retreating"- Self-management of physical health among a group of people with schizophrenia. An ethnographic study from Denmark

The aim of this ethnographic study was to explore how a group of nine Danish people with schizophrenia managed physical health issues as they naturally occurred in everyday life. Qualitative methods were used to generate of data. Thematic analysis led to the description of two typical strategies used by participants to manage debilitating physical health issues in everyday life. Modifying everyday life to manage discomfort was a strategy employed to manage potential or actual discomfort associated with ongoing poor physical health, while retreating from everyday life to recover was a strategy used by participants who experienced recurring discrete episodes of poor physical health characterized by fast deterioration. Both management strategies were inexpedient as they failed to produce any positive progress in terms of the participants regaining health. The social context of participants' everyday life was characterized by a lack of interactions with others about their prevailing and ongoing physical health issues. Repeated use of these inexpedient strategies to manage physical health caused potential worsening rather than improvements to physical health. There is a need for future research that explores aspects of beneficial management of physical health issues among people with severe mental illness. Relevant foci of such research include enhancing self-management of physical health, active help-seeking behaviours, and opportunities to engage in interactions with others about physical health issues.