Improving the physical health of long-stay psychiatric in-patients

A health promotion intervention to improve lifestyle choices and health outcomes in people with psychosis: a research programme including the IMPaCT RCT

Background

People with psychotic disorders have reduced life expectancy largely because of physical health problems, especially cardiovascular disease, that are complicated by the use of tobacco and cannabis.

Objectives

We set out to (1) chart lifestyle and substance use choices and the emergence of cardiometabolic risk from the earliest presentation with psychosis, (2) develop a pragmatic health promotion intervention integrated within the clinical teams to improve the lifestyle choices and health outcomes of people with psychosis and (3) evaluate the clinical effectiveness and cost-effectiveness of that health promotion intervention.

Design

We performed a longitudinal cohort study of people presenting with their first episode of psychosis in three mental health trusts and followed up participants for 1 year [work package 1, physical health and substance use measures in first episode of psychosis (PUMP)]. We used an iterative Delphi methodology to develop and refine a modular health promotion intervention, improving physical health and reducing substance use in psychosis (IMPaCT) therapy, which was to be delivered by the patient’s usual care co-ordinator and used motivational interviewing techniques and cognitive–behavioural therapy to improve health choices of people with psychosis (work package 2). We then conducted a multicentre, two-arm, parallel-cluster, randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of using the intervention with people with established psychosis (work package 3: IMPaCT randomised controlled trial) in five UK mental health trusts. The work took place between 2008 and 2014.

Participants

All people aged between 16 and 65 years within 6 months of their first presentation with a non-organic psychosis and who were proficient in English were eligible for inclusion in the PUMP study. Participants in the work package 2 training development were staff selected from a range of settings, working with psychosis. Participants in the phase 3 Delphi consensus and manual development comprised three expert groups of (1) therapists/researchers recruited from the local and national community, (2) clinicians and (3) service users, each of whom took part in two iterative review and feedback sessions. For work package 3, IMPaCT randomised controlled trial, care co-ordinators in participating community mental health teams who were permanently employed and had a minimum of four eligible patients (i.e. aged between 18 and 65 years with a diagnosis of a psychotic disorder) on their caseload were eligible to participate. In studies 1 and 3, patient participants were ineligible if they were pregnant or had a major illness that would have had an impact on their metabolic status or if they had a significant learning disability. All participants were included in the study only after giving written confirmed consent.

Main outcome measures

Cardiometabolic risk markers, including rates of obesity and central obesity, and levels of glycated haemoglobin (HbA1c) and lipids, were the main outcomes in work package 1 (PUMP), with descriptive data presented on substance use. Our primary outcome measure for the IMPaCT randomised controlled trial was the physical or mental health component Short Form questionnaire-36 items quality-of-life scores at 12 months.

Results

Obesity rates rose from 18% at first presentation with psychosis to 24% by 1 year, but cardiometabolic risk was not associated with baseline lifestyle and substance use choices. Patterns of increase in the levels of HbA1c over the year following first presentation showed variation by ethnic group. We recruited 104 care co-ordinators, of whom 52 (with 213 patients) were randomised to deliver IMPaCT therapy and 52 (with 193 patients) were randomised to deliver treatment as usual, in keeping with our power calculations. Of these 406 participants with established psychosis, 318 (78%) and 301 (74%) participants, respectively, attended the 12- and 15-month follow-ups. We found no significant effect of IMPaCT therapy compared with treatment as usual on the physical or mental health component Short Form questionnaire-36 items scores at either time point in an intention-to-treat analysis [physical health score (‘d’) –0.17 at 12 months and –0.09 at 15 months; mental health score (‘d’) 0.03 at 12 months and –0.05 at 15 months] or on costs. Nor did we find an effect on other cardiovascular risk indicators, including diabetes, except in the case of high-density lipoprotein cholesterol, which showed a trend for greater benefit with IMPaCT therapy than with treatment as usual (treatment effect 0.085, 95% confidence interval 0.007 to 0.16; p = 0.034).

Limitations

Follow-up in work package 1 was challenging, with 127 out of 293 participants attending; however, there was no difference in cardiometabolic measures or demographic factors at baseline between those who attended for follow-up and those who did not. In work package 3, the IMPaCT randomised controlled trial, care co-ordinators struggled to provide additional time to their patients that was devoted to the health promotion intervention on top of their usual clinical care contact with them.

Conclusions

Cardiometabolic risk is prominent even soon after first presentation with psychosis and increases over time. Lifestyle choices and substance use habits at first presentation do not predict those who will be most cardiometabolically compromised 1 year later. Training and supervising care co-ordinators to deliver a health promotion intervention to their own patients on top of routine care is not effective in the NHS for improving quality of life or reducing cardiometabolic risk.

Future work

Further work is needed to develop and evaluate effective, cost-effective and affordable ways of preventing the emergence of and reversing existing cardiometabolic risk indicators in people with psychosis.

Trial registration

Current Controlled Trials ISRCTN58667926.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

Monitoring and Treating Metabolic Abnormalities in Patients with Early Psychosis Initiated on Antipsychotic Medications

Antipsychotic medications carry an established lifetime risk of metabolic syndrome. This retrospective chart review evaluated feasibility of a metabolic monitoring clinical decision support tool (CDST) for weight, lipid, blood glucose, and blood pressure management of 163 clients in an early psychosis outpatient clinic over 2 years. Each parameter had at least 98 (60.1%) clients with a recorded value, the most being documented for weight with 112 (68.7%) clients. CDST adherence ranged from at least 54.3-100% for non-pharmacologic interventions (e.g. clinic counseling, referral to health program or primary care) and at least 33.3-100% for pharmacologic interventions (e.g. metformin). Though no baseline cardiometabolic abnormalities were identified, dyslipidemia and obesity were later found in 37 (22.7%) and 35 (21.5%) clients, respectively. Only 14 (8.6%) clients were prescribed medications for cardiometabolic abnormalities by psychiatrists in the clinic. Increasing focus on physical health is needed to better this population's long-term prognosis.

Physical health and health risk factors in a population of long-stay psychiatric patients

Aims and Method

To evaluate the physical health and health risk factors in long-stay psychiatric patients in a high secure psychiatric hospital. A cross-sectional survey of consenting patients was undertaken using a semi-structured questionnaire, a brief physical examination and review of patient case notes. A comparison was made with data collected on admission and held on the Special Hospitals' Case Register.

Results

Main findings were: a mean increase in weight since admission, in men of 10.62 kg and in women of 12.74 kg; high rates of smoking, obesity and large waist size; 54% of patients had one or more health problems.

Clinical Implications

The study's profile of the physical health of psychiatric in-patients indicates the need for health promotion initiatives in such hospitals and the need for primary care services.

Screening for incontinence in a secure psychiatric service for women

Incontinence is associated with mental illness and neuroleptic medications but diagnosis and treatment is often poor or non-existent. Problems of incontinence are compounded in secure psychiatric services for women by poor health, obesity, and a sedentary lifestyle. Addressing the physical health of this group necessitates a more accurate picture of the nature, incidence, and management of incontinence. A point-in-time survey of 108 women who agreed to be interviewed (93%) covered presence, frequency, and nature of incontinence, and information on management case note data was used to gather demographic and previous medical history, comparisons were made between patients with and without problems of incontinence. Findings indicate a problem of incontinence in 48% of women with a dominance of problems of stress and urge enuresis. Of modifiable factors that contribute to enuresis, the current study highlighted the contribution of obesity, smoking and clozapine medication. A further finding was the preference for managing rather than treating problems of incontinence. Actions to improve the detection and treatment of this problem are described.

Bone mineral density and general health of long-term residential psychiatric inpatients

OBJECTIVE

The aim of this study was to determine the rates of osteopenia and osteoporosis and other general health problems in a long-stay male psychiatric unit.

METHOD

All 15 patients underwent a semi-structured clinical interview and a full physical examination including calculation of Body Mass Index, central obesity (abdominal circumference) and blood pressure measurement. All patients had blood sampling examining FBC, U&E, LFTs, TFTs, PSA, prolactin, lipid profile and glucose. The rates of metabolic syndrome were calculated according to the International Diabetes Federation consensus worldwide definition. Bone mineral density was determined in the lumbar vertebrae and left hip by DEXA scanning.

RESULTS

The prevalence of osteopenia or osteoporosis was 46%, and bone mineral density was inversely correlated with serum prolactin levels (r = -0.595, p = 0.041) and chlorpromazine equivalence (r = -0.645, p = 0.017). The prevalence of obesity was 53%, while central obesity was present in 87% of patients. Metabolic Syndrome was present in 27% of patients.

CONCLUSIONS

More attention should be given to diagnosing and treating osteopenia and osteoporosis in patients on long-term antipsychotic agents and preventative measures should form part of any treatment regime in these individuals. Frequent input from dietitians should also be available for long-stay psychiatric inpatients to reduce the prevalence of obesity.

High prevalence of risk factors for physical illness in a long-stay psychiatric unit

Objective: The aim of this study was to determine the prevalence of risk factors for physical illness in a long stay psychiatric unit, where all care (both psychiatric and physical) is provided by the psychiatric team.

Method: All patients in the long-stay ward had a full physical examination including calculation of BMI. All patients had blood sampling including FBC, U&E, LFTs, TFTs, lipid profile (total cholesterol, triglycerides, HDL and LDL), glucose, HbA1c, and prolactin. ATP111 criteria were used to determine the presence of the metabolic syndrome.

Results: We found the mean number of comorbid medical diagnosis was 2.7. The prevalence of metabolic syndrome was 40.7% (44.4% of females and 24.1% of males). The prevalence of obesity was 51%, and 51% also had a total cholesterols in excess of 5.0mmol/l. Prolactin was elevated in two-thirds of female patients.

Conclusion: We conclude that the annual physical examination is of limited value in long-stay psychiatric unit. The high prevalence of physical illness and physical risk factors warrants primary care involvement in screening and treatment of long-stay psychiatric patients.

Prevalence of obesity and metabolic syndrome in a long-stay psychiatric unit

Objective:The aim of this study was to determine the prevalence of metabolic syndrome and obesity as defined by Body Mass Index (BMI) in a long-stay psychiatric unit where all care is provided by the psychiatric team.

Method:All residents in this long-stay unit were screened. Their BMI was calculated. Waist circumference and blood investigations were done. Ward records were used to determine those who had been previously diagnosed with hypertension and diabetes. The ATP 111 criteria were used to determine the prevalence of metabolic syndrome.

Results:We found a prevalence of 33% for BMI obesity and a prevalence of 66% for metabolic syndrome. These are higher than those of the general Irish middle aged population and the accepted estimate of a general psychiatric population. It is also higher than that of a previous published study on an Irish long-stay psychiatric ward population.

Conclusion:There is high prevalence of BMI obesity and metabolic syndrome in long-stay psychiatric residents. This has the potential to impact significantly on physical morbidity and mortality. People with severe and enduring mental illness should have access to primary care and other health services on the same basis as any other citizen.

Identification of nutritional risk by nursing staff in secure psychiatric settings: reliability and validity of St Andrew's Nutrition Screening Instrument

Nutrition screening is the first-line approach to addressing the nutritional needs of service users and has been recommended as best practice by several authoritative and regulatory bodies. A simple and comprehensive screening tool, the St Andrew's Nutrition Screening Instrument (SANSI), was developed for use in an inpatient secure psychiatric setting. The aim of this study was to test the screening tool for reliability and validity. This study identified SANSI as reliable and valid for use in secure psychiatric settings for adolescents and adults. This should give confidence to regulatory and commissioning organizations, that the nutritional risk for patients in an organization which serves a diverse mental health population is being correctly identified, raising staff awareness and allowing appropriate action to be planned.

The Use of the Wii Fit in Forensic Mental Health: Exercise for People at Risk of Obesity

Introduction:

Side effects of psychotropic medication often lead to rapid weight gain, having detrimental effects on forensic mental health patients' health, wellbeing, occupational performance and quality of life. Virtual reality technology could provide novel environments and motivating forums for exercise, which are otherwise unavailable to patients in such secure settings. This exploratory study aimed to evaluate the use of the Nintendo Wii Fit in changing engagement in physical activity for patients at risk of obesity at a secure hospital.

Method:

Two participants used a Wii Fit for 8 weeks in individual or group sessions. A mixed methods approach was taken, because participants' use of the Wii Fit was compared with their attitudes towards it (reported during interviews) and their daily physical activity levels (measured using an accelerometer). Researcher field notes were also used to gather contextual data.

Findings:

Participants played Wii Fit up to four times a week in sessions ranging from 7 to 127 minutes. When using the Wii Fit, participants increased their overall time spent actively moving their bodies in physical activity, as measured by the accelerometer. Using the Wii Fit also changed participants' attitudes towards exercise as they realised that it could be ‘fun’ and ‘challenging’, especially if staff members also participated.

Conclusion:

The Wii Fit encouraged patients to attempt physical activities and to learn about their bodily response to exercise. It provided a meaningful occupational intervention in a secure setting and demonstrated a potential use of the technology in mental health settings.

The physical health of residents of long-stay wards in Carlow/Kilkenny

OBJECTIVES

This audit is supported by regulations within the Mental Health Act 2001. It is in response to the Mental Health Commission Strategic Priority Number One, Quality Framework, 2002-2008 which aims to promote high standards of physical examination in the care of long-stay residents of psychiatric facilities. It is based on improved awareness of adverse effects of mental illness or its treatment on physical health. This awareness informs better practice.

METHOD

Physical examination proforma and case notes of all long-stay residents in wards in Carlow and Kilkenny were assessed over a six month period to examine the quality of physical examination. Following departmental meetings and literature review, standards of care as recommended by the Royal College of Psychiatrists in Occasional Paper 67 and Irish statutory documents were agreed to be the appropriate benchmark.

RESULTS

Areas of strength were the examination of 'routine' systems (> 92%), ie. cardiovascular, respiratory, alimentary, central nervous, genitourinary and the frequency of clinical review by treating psychiatric team. Areas needing improvement were eye (8%) and ear (3%) examinations, measurements of weight (58%), height (1.6%), body mass index (1.6%), waist circumference (0%), investigating for prostatic specific antigen (50%), discussion of results of physical examination and investigations with the residents (both 0%) and referral to BreastCheck (36%).

CONCLUSION

A new physical examination form has been created for long-stay residents to correct these deficiencies and a new departmental policy document setting out a standard of practice consistent with recommended practice and general statutory requirements has been put into place.

The incidence and associated risk factors for sudden unexplained death in psychiatric in-patients in England and Wales

Clinical characteristics and risk factors associated with sudden unexplained death (SUD) in the psychiatric population are unclear. Psychiatric in-patients (England, Wales) who met criteria for SUD were identified (1 March 1999-31 December 2005). Cases were matched with controls (in-patients alive on the day a SUD occurred). Data were collected via questionnaires. Some 283 cases of SUD were identified (41 annually), with a rate of 2.33/10,000 mental health admissions (in England). Electrocardiograms were not routine, cardiopulmonary resuscitation equipment was sometimes unavailable, attempts to resuscitate patients were carried out on one-half of all patients and post mortems/inquiries were not routine. Restraint and seclusion were uncommon. Risk factors included: benzodiazepines (odds ratio (OR): 1.83); ≥ 2 antipsychotics (OR: 2.35); promazine (OR: 4.02); diazepam (OR: 1.71); clozapine (OR: 2.10); cardiovascular disease (OR: 2.00); respiratory disease (OR: 1.98); diagnosis of dementia (OR: 2.08). Venlafaxine and a diagnosis of affective disorder were associated with reduced ORs (OR: 0.42; OR: 0.65). SUD is relatively rare, although it is more common in older patients and males. Prevention measures may include safer prescribing of antipsychotics and improved physical health care. The contribution of restraint or seclusion to SUD in individual cases is unclear. A uniform definition of SUD may help to identify contributing factors.

There is no health without mental health: are we educating Australian nurses to care for the health consumer of the 21st century?

One in five Australians has a diagnosable mental illness and the impact of the illness on the individual, their family, and the community is significant. Since comprehensive nursing was introduced in the 1980s there have been repeated concerns raised regarding the preparedness of graduates from Australian undergraduate nursing programs to care for people who have a mental illness. In 2009, despite a recent comprehensive national review of the mental health/illness content in pre-registration curricula, these concerns remain. The nursing profession must have a responsibility to the global community to ensure that registered nurses are educated to meet evolving health challenges and the needs of the health consumer in the 21st Century. The purpose of this paper is to highlight the prevalence and impact of mental illness on health care outcomes in all settings and to challenge the profession to acknowledge that mental health nursing content must be a core area of all undergraduate curricula. A nationally coordinated response to address the long standing identified deficits in the educational preparation of comprehensive nurses is now a priority to ensure that nurses remain a major stakeholder group in the delivery of health care and key health informants and decision makers within the global health care arena.

Who should swing the stethoscope? An audit of baseline physical examination and blood monitoring on new patients accepted by an early intervention in psychosis team

AIM

It has been established that patients with severe mental illness are at increased risk of physical illness and that physical health screening should be performed when an individual experiences a first episode of psychosis. The aim of the audit was to examine how physical health screening was achieved in the real world of an early intervention in psychosis (EIP) service in Scotland. Of particular interest was considering if primary or secondary care were more effective in providing specific physical health assessment for those presenting to the service.

METHODS

A case note audit was performed.

RESULTS

The audit shows that physical examination and blood tests were being completed in the majority of service users under the care of the Esteem service. However, an unacceptably high number were not undergoing sufficient initial screening for metabolic syndrome or having baseline monitoring prior to commencing antipsychotic medication.

CONCLUSIONS

Our results suggest that relying on primary care to provide physical health screening was not an effective approach in a population experiencing first-episode psychosis. Having a psychiatrist motivated to perform physical health screening within the EIP team may help to improve the uptake of physical health screening. Strategies to improve physical health screening in EIP services are discussed.