Targeted intervention to improve monitoring of antipsychotic-induced weight gain and metabolic disturbance in first episode psychosis

Metabolic Monitoring for Adults Living with a Serious Mental Illness on a Second-Generation Antipsychotic Agent: A Scoping Review

Premature mortality in people living with a severe mental illness (SMI) is often attributed to multiple factors including the use of medicines such as antipsychotics. Second-generation antipsychotics (SGAs) are known to cause metabolic syndrome which can increase the risk of cardiovascular disease. Practice guidelines have recommended regular physical health monitoring, particularly of metabolic parameters, however, metabolic monitoring for people living with SMI using antipsychotics remains suboptimal. Therefore, highlighting the need for ongoing research. This scoping review aimed to provide an overview of current metabolic monitoring practices. We anticipate that this information will assist clinicians and policymakers and inform future research. The following databases were searched: MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), the Cochrane Database of Systemic Reviews (Wiley), APA PsycInfo (Ovid) and Scopus (Elsevier Science Publishers). The target group was adults (aged ≥ 18) diagnosed with SMI (including bipolar disorder, major depressive disorder and psychotic disorders) and taking SGAs. In total, 44 studies from 14 countries were retrieved. Our findings highlighted that most studies conducted in hospitals did not report on metabolic monitoring practices. Additionally, the roles and responsibilities of healthcare professionals in metabolic monitoring for SMI were infrequently described and parameters such as waist circumference and BMI were often poorly monitored. The scoping review highlights that no streamlined approach towards metabolic monitoring currently exists. There is a need to stipulate and define the roles and responsibilities of all health professionals involved in metabolic monitoring in SMI to optimise care for these individuals. Moreover, there is a need for ongoing research, particularly in the community setting, to promote increased accessibility to metabolic monitoring for SMI.

Community Pharmacists' Role in Reducing the Incidence of Cardiometabolic Adverse Drug Events in Schizophrenia: Insights from Mental Health Professionals

Background and Objectives: Schizophrenia, a debilitating mental illness, is often associated with significant physical health risks. Many second-generation antipsychotics increase the risk of metabolic syndrome and cardiovascular disease. Community pharmacists are highly accessible and could play a role in monitoring cardiometabolic adverse drug events in people with schizophrenia. However, it remains uncertain whether mental health professionals perceive this as valuable. This study aimed to explore the opinions of mental healthcare professionals regarding the role of community pharmacists in reducing the incidence of cardiometabolic adverse events in people with schizophrenia and their integration into a multidisciplinary mental health team. Materials and Methods: Qualitative semi-structured interviews were conducted with Australian psychiatrists, mental health nurses and mental health pharmacists. Transcription of the interviews underwent thematic analysis using an inductive approach. Results: Eleven mental healthcare professionals from metropolitan and regional areas across Australia were interviewed, leading to the identification of five overarching themes. These themes encompassed the following aspects: the benefits of community pharmacists' involvement in managing cardiometabolic adverse drug events in people with schizophrenia, improving communication pathways with community pharmacists, defining roles and responsibilities for monitoring cardiometabolic parameters and managing adverse cardiometabolic drug events, fostering collaboration between community pharmacists and mental health care professionals, and recognising the acceptance of community pharmacists' integration within a multidisciplinary team. Mental health professionals believed that community pharmacists could play a role in reducing the incidence of cardiometabolic adverse events in schizophrenia. However, they underscored the need for enhanced communication and collaboration pathways with other healthcare professionals, emphasised the importance of more comprehensive mental health first aid training, and identified potential barriers for community pharmacists such as remuneration, workload, and staff resources. Conclusions: Mental health professionals acknowledged the benefits of incorporating community pharmacists into multidisciplinary teams as a strategy to reduce the incidence of adverse events among individuals with schizophrenia. They recognise the competence of community pharmacists in monitoring cardiometabolic adverse events. However, these professionals have also highlighted specific perceived barriers to the complete integration of community pharmacists within these teams. Notably, there are concerns related to remuneration, staff resources, time constraints, acceptance by other healthcare professionals and patients, and the need for improved communication pathways. Addressing these barriers and providing targeted training could facilitate the valuable inclusion of community pharmacists in the comprehensive care of people with schizophrenia.

A retrospective database study on 2-year weight trajectories in first-episode psychosis

Introduction

It is critical to focus on individual weight profiles in line with efforts to tailor treatment, given the heterogeneous nature of the clinical population. This study aims to identify and describe possible two-year weight trajectories among patients accepted to the Early Psychosis Intervention Programme (EPIP) in Singapore.

Methods

De-identified data was extracted from EPIP's standing database for patients accepted from 2014 to 2018 with a schizophrenia spectrum disorder. Data collected at fixed time-points (baseline, 1-year, and 2-year) included anthropometric measures (height and weight), and sociodemographic (age, sex, highest education level, and vocational status) and clinical (duration of untreated psychosis, number of inpatient admissions, and scores on the Positive and Negative Syndrome Scale and Global Assessment of Functioning) information.

Results

A total of 391 complete data sets were included for main analyses. Those with missing weight data were more likely to be males, older at baseline, have a highest education level of tertiary and above at baseline, and have a longer duration of untreated psychosis. The weight change across two years resulted in the following membership breakdown: 151 (38.6%) in super high risk; 133 (34.0%) in high risk mitigated; 17 (4.3%) in at risk; 34 (8.8%) in delayed risk; and 56 (14.4%) in low risk.

Discussion

The lack of pharmacological, dietary, and physical activity data is a significant limitation in this study; however, the results reinforce the justification for future studies to prospectively capture and examine the influence of these data, with the aim of early detection and weight intervention for high risk groups.

Quality prescribing in early psychosis: key pharmacotherapy principles

OBJECTIVE

To present a practical, easy-to-implement clinical framework designed to support evidence-based quality prescribing for people with early psychosis.

METHOD

Identification and explanation of key principles relating to evidence-based pharmacotherapy for people with early psychosis. These were derived from the literature, practice guidelines and clinical experience.

RESULTS

Key principles include (1) medication choice informed by adverse effects; (2) metabolic monitoring at baseline and at regular intervals; (3) comprehensive and regular medication risk-benefit assessment and psychoeducation; (4) early consideration of long-acting injectable formulations (preferably driven by informed patient choice); (5) identification and treatment of comorbid mood disorders and (6) early consideration of clozapine when treatment refractory criteria are met.

CONCLUSIONS

Current prescribing practices do not align with the well-established evidence for quality pharmacotherapy in early psychosis. Adopting evidence-based prescribing practices for people with early psychosis will improve outcomes.

Systematic Quality Improvement and Metabolic Monitoring for Individuals Taking Antipsychotic Drugs

OBJECTIVE

The authors sought to increase the rate of cardiometabolic monitoring for patients receiving antipsychotic drugs in an academic outpatient psychiatric clinic serving people with serious mental illness.

METHODS

Using a prospective quasi-experimental, interrupted time-series design with data from the electronic health record (EHR), the authors determined metabolic monitoring rates before, during, and after implementation of prespecified quality improvement (QI) measures between August 2016 and July 2017. QI measures included a combination of provider, patient, and staff education; systematic barrier reduction; and an EHR-based reminder system.

RESULTS

After 1 year of QI implementation, the rate of metabolic monitoring had increased from 33% to 49% (p<0.01) for the primary outcome measure (hemoglobin A1C and lipid panel). This increased monitoring rate was sustained for 27 months beyond the end of the QI intervention. More than 75% of providers did not find the QI reminders burdensome.

CONCLUSIONS

Significant improvement in the rate of metabolic monitoring for people taking antipsychotic drugs can be achieved with little added burden on providers. Future research needs to assess the full range of patient, provider, and system barriers that prevent cardiometabolic monitoring for all individuals receiving antipsychotic drugs.

Minding metabolism: targeted interventions to improve cardio-metabolic monitoring across early and chronic psychosis

Background

Antipsychotics (APs) increase weight, metabolic syndrome, diabetes and cardiovascular disease. Guidelines recommend cardio-metabolic monitoring at initial assessment, at 3 months and then annually in people prescribed APs.

Aim

To determine the rates of cardio-metabolic monitoring in AP treated early and chronic psychosis and to assess the impact of targeted improvement strategies.

Methods

Medical records were reviewed in two cohorts of first-episode psychosis (FEP) patients before and after the implementation of a physical health parameter checklist and electronic laboratory order set. In a separate group of patients with chronic psychotic disorders, adherence to annual monitoring was assessed before and 3 months after an awareness-raising educational intervention.

Results

In FEP, fasting glucose (39% vs 67%, p=0.05), HbA1c (0% vs 24%, p=0.005) and prolactin (18% vs 67%, p=0.001) monitoring improved. There were no significant differences in weight (67% vs 67%, p=1.0), BMI (3% vs 10%, p=0.54), waist circumference (3% vs 0%, p=1.0), fasting lipids (61% vs 76% p=0.22) or ECG monitoring (67% vs 67%, p=1.0). Blood pressure (BP) (88% vs 57%, p=0.04) and heart rate (91% vs 65%, p=0.03) monitoring dis-improved. Diet (0%) and exercise (<15%) assessment was poor. In chronic psychotic disorders, BP monitoring improved (20% vs 41.4%, p=0.05), whereas weight (17.0% vs 34.1%, p=0.12), BMI (9.7% vs 12.1%, p=1.0), fasting glucose (17% vs 24.3%, p=0.58) and fasting lipids remained unchanged (17% vs 24.3%, p=0.58).

Conclusions

Targeted improvement strategies resulted in a significant improvement in a limited number of parameters in early and chronic psychotic disorders. Overall, monitoring remained suboptimal.

Physical health interventions for patients who have experienced a first episode of psychosis: a narrative review

Objectives:

Service users with severe psychiatric illnesses, such as schizophrenia, major depressive disorder and bipolar disorder, are more likely to suffer from ill health. There is evidence that lifestyle interventions, for example, exercise, dietary advice and smoking cessation programmes for service users with severe mental illness can be of health benefit. This review was carried out to identify the literature pertaining to physical health interventions for service users who have experienced a first-episode psychosis (FEP), to examine the nature of the interventions which were carried out and to assess these interventions in terms of feasibility and efficacy.

Methods:

A narrative review was conducted in August 2019 by searching ‘Pubmed’ and ‘Embase’ electronic databases. Studies investigating the effect a physical health intervention had on service users who had experienced a FEP were included in the review.

Results:

Fifteen studies met inclusion criteria: 12 quantitative studies and 3 qualitative. Exercise, dietary advice, smoking cessation and motivational coaching were some of the physical health interventions utilised in the identified studies. Positive effects were seen in terms of physical health markers wherever they were investigated, particularly when the intervention was delivered early. The impact on psychiatric symptoms and longer-term impacts on health were less frequently assessed.

Conclusions:

Physical health interventions have a positive impact on service users who have experienced a FEP. More research is warranted in this area in Ireland. These studies should include controls, have longer follow-up periods and should assess the impact on psychiatric health.

Evaluation of an exercise physiology service in a youth mental health service

Background

Individuals who experience serious mental health disorders are at an increased risk of physical illness co-morbidity and early intervention is crucial. Recommendations to embed an exercise physiologist service into a mental health service have not been fully evaluated.

Objectives

This study aimed to determine (i) demographics and clinical characteristics of the young people referred to exercise physiology, (ii) adherence to metabolic monitoring, (iii) baseline physical health and (iv) level of engagement after referral.

Methods

This is a naturalistic cohort study and included all young people referred to the exercise physiology service between 2015 and 2019 at Orygen, a specialist youth mental health service in the north-western region of Melbourne.

Results

During the study period of 45 months, 312 young people were referred to exercise physiology, and of those, 51.3% were male. The mean age was 19.8 years. In regard to primary diagnoses, 47.4% had a psychotic disorder and 33.7% an affective disorder. Baseline weight measurements were completed for 71.8% of young people. The proportion of young people who were classified as overweight or obese increased from 55.1% to 70.4% (p < 0.001). For those referred, 61.5% attended either an individual session or a group session. A total of 29.5% did not attend their appointment following referral.

Conclusions

As over half of young people had poor physical health at presentation, integrating an exercise physiology service into a youth mental health service is a novel and needed intervention. However, there still needs to be an emphasis on metabolic monitoring and engagement.

Interventions to Improve Metabolic Risk Screening Among Adult Patients Taking Antipsychotic Medication: A Systematic Review

OBJECTIVE

Antipsychotic use is associated with elevated cardiometabolic risk. Guidelines for metabolic risk screening of individuals taking antipsychotics have been issued, but with little uptake into clinical practice. This review systematically assessed interventions that address this guideline-to-practice gap and described their quality, improvement strategies, and effect on screening rates.

METHODS

Studies of interventions that addressed metabolic risk screening of adult patients taking antipsychotics, published from inception to July 2018, were selected from MEDLINE, Embase, PsycINFO, CINAHL, and Cochrane Reviews databases. Information was extracted on study characteristics; improvement strategies at the provider, patient, and system levels; and screening rates in the intervention and comparison groups.

RESULTS

The review included 30 complex interventions that used between one and nine unique improvement strategies. Social influence to shift provider and health organization culture to encourage metabolic risk screening was a common strategy, as were clinical prompts and monitoring tools to capture provider attention. Most studies were deemed at high risk of bias. Relative to comparison groups, the interventions were associated with an increase in median screening rates for glucose (28% to 65%), lipids (22% to 61%), weight (19% to 67%), and blood pressure (22% to 80%).

CONCLUSIONS

This knowledge synthesis points to shortcomings of current interventions to improve antipsychotic metabolic risk screening, both in quality and in outcomes. Findings may be used to inform the design of future programs. Additional interventions are needed to address the current guideline-to-practice gap, in which approximately one-third of patients are unscreened for metabolic risk.

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.

Interventions to increase access to or uptake of physical health screening in people with severe mental illness: a realist review

OBJECTIVES

To identify and evaluate interventions aimed at increasing uptake of, or access to, physical health screening by adults with severe mental illness; to examine why interventions might work.

DESIGN

Realist review.

SETTING

Primary, secondary and tertiary care.

RESULTS

A systematic search identified 1448 studies, of which 22 met the inclusion criteria. Studies were from Australia (n=3), Canada (n=1), Hong Kong (n=1), UK (n=11) and USA (n=6). The studies focused on breast cancer screening, infection preventive services and metabolic syndrome (MS) screening by targeting MS-related risk factors. The interventions could be divided into those focusing on (1) health service delivery changes (12 studies), using quality improvement, randomised controlled trial, cluster randomised feasibility trial, retrospective audit, cross-sectional study and satisfaction survey designs and (2) tests of tools designed to facilitate screening (10 studies) using consecutive case series, quality improvement, retrospective evaluation and pre-post audit study designs. All studies reported improved uptake of screening, or that patients had received screening they would not have had without the intervention. No estimation of overall effect size was possible due to heterogeneity in study design and quality. The following factors may contribute to intervention success: staff and stakeholder involvement in screening, staff flexibility when taking physical measurements (eg, using adapted equipment), strong links with primary care and having a pharmacist on the ward.

CONCLUSIONS

A range of interventions may be effective, but better quality research is needed to determine any effect size. Researchers should consider how interventions may work when designing and testing them in order to target better the specific needs of this population in the most appropriate setting. Behaviour-change interventions to reduce identified barriers of patient and health professional resistance to screening this population are required. Resource constraints, clarity over professional roles and better coordination with primary care need to be addressed.

Improving metabolic monitoring rate for young people aged 35 and younger taking antipsychotic medications to treat a psychosis: A literature review

Young people aged 35 and younger who are taking antipsychotic medications to treat a psychosis are a high risk for developing metabolic syndrome due to the adverse effects of the medications. This paper reports the finding of a review of literature to identify interventions to improve metabolic monitoring rates in this group. A review of 478 studies identified 15 articles which met the inclusion criteria. Five articles reported single-intervention studies and the remaining integrated two or more interventions to improve uptake level of metabolic monitoring. As metabolic syndrome can be detected early through metabolic monitoring in young people taking antipsychotics, early intervention is important to improve their physical health trajectory.

Utilization of the Behavior Change Wheel framework to develop a model to improve cardiometabolic screening for people with severe mental illness

BACKGROUND

Individuals with severe mental illness (e.g., schizophrenia, bipolar disorder) die 10-25 years earlier than the general population, primarily from premature cardiovascular disease (CVD). Contributing factors are complex, but include systemic-related factors of poorly integrated primary care and mental health services. Although evidence-based models exist for integrating mental health care into primary care settings, the evidence base for integrating medical care into specialty mental health settings is limited. Such models are referred to as "reverse" integration. In this paper, we describe the application of an implementation science framework in designing a model to improve CVD outcomes for individuals with severe mental illness (SMI) who receive services in a community mental health setting.

METHODS

Using principles from the theory of planned behavior, focus groups were conducted to understand stakeholder perspectives of barriers to CVD risk factor screening and treatment identify potential target behaviors. We then applied results to the overarching Behavior Change Wheel framework, a systematic and theory-driven approach that incorporates the COM-B model (capability, opportunity, motivation, and behavior), to build an intervention to improve CVD risk factor screening and treatment for people with SMI.

RESULTS

Following a stepped approach from the Behavior Change Wheel framework, a model to deliver primary preventive care for people that use community mental health settings as their de facto health home was developed. The CRANIUM (cardiometabolic risk assessment and treatment through a novel integration model for underserved populations with mental illness) model focuses on engaging community psychiatrists to expand their scope of practice to become responsible for CVD risk, with significant clinical decision support.

CONCLUSION

The CRANIUM model was designed by integrating behavioral change theory and implementation theory. CRANIUM is feasible to implement, is highly acceptable to, and targets provider behavior change, and is replicable and efficient for helping to integrate primary preventive care services in community mental health settings. CRANIUM can be scaled up to increase CVD preventive care delivery and ultimately improve health outcomes among people with SMI served within a public mental health care system.

A Randomized Controlled Trial of a Patient-Centered Approach to Improve Screening for the Metabolic Side Effects of Antipsychotic Medications

Adherence to recommendations for monitoring of metabolic side effects of antipsychotic medications has been historically low. This randomized controlled trial tested whether a computerized, patient-centered intervention that educated Veterans with serious mental illness about these side effects and encouraged them to advocate for receipt of monitoring would increase rates of monitoring compared to enhanced treatment as usual. The mean proportion of days adherent to monitoring guidelines over the 1-year study was similarly high and did not differ between the intervention (range 0.81-0.98) and comparison (range 0.76-0.96) groups. Many individuals in both groups had persistent abnormal metabolic parameter values despite high rates of monitoring, contact with medical providers, and receipt of cardiometabolic medications. Participants exposed to the intervention were interested in receiving personalized information about their cardiometabolic status, demonstrating the preliminary feasibility of brief interventions for enhancing involvement of individuals with serious mental illness in health care decision making.

Measurement of Metabolic Monitoring in Youth and Adult Medicaid Recipients Prescribed Antipsychotics

BACKGROUND

Individuals being treated with first- and second-generation antipsychotics (FGAs and SGAs) are at risk for a variety of adverse cardiometabolic effects. Although consensus guidelines that recommend metabolic monitoring for patients receiving SGAs have been in place since 2004, the rate of monitoring remains low, especially in the pediatric population.

OBJECTIVES

To (a) examine differences in rates of laboratory monitoring for glucose and lipids for adults and youth prescribed FGAs and SGAs; (b) look at factors associated with the likelihood of metabolic testing; and (c) describe cohort effects that may have had an impact on the rates of laboratory testing. 

METHODS

This is a retrospective study examining the rates of glucose and lipid testing for 3 separate cohorts of Medicaid recipients who were prescribed antipsychotics during 3 measurement periods-2008, 2010, and 2012-using paid Medicaid pharmacy and laboratory claims data. The sample included adults aged 18 years and older and children aged 17 years and younger. For each measurement period, we identified the rate of metabolic monitoring and the demographic characteristics for each individual, including race, age, and gender. The proportion of laboratory monitoring was assessed using chi square tests for each of the outcomes. Logistic regression models for each time point were used to determine the characteristics of individuals who were more likely to receive monitoring.

RESULTS

The proportion of individuals receiving glucose and lipid tests increased for both age groups across all measurement periods. For individuals aged 18 years and over, glucose monitoring increased from 56.6%-72.6%. Testing for lipids remained constant, ranging from 38.3%-41.2% for each of the 3 measurement periods. During the first measurement period, in 2008, females were 41% and 15% more likely to receive glucose and lipid laboratory monitoring, respectively, compared with males. Females continued to be more likely to receive glucose monitoring during the measurement periods in 2010 and 2012, although there was no significant difference between females and males for lipid monitoring during these time periods. Individuals aged 17 years and younger were 59%-68% less likely to receive glucose monitoring than adults (aged ≥ 18 years) for all time points. Across all measurement periods, individuals aged ≤ 17 years were also 44%-58% less likely to receive lipid monitoring compared with adults (aged ≥ 18 years). While there was no significant difference between Caucasians and non-Caucasians in the first measurement period, Caucasians were about 30% less likely to receive glucose monitoring and about 50% less likely to receive lipid monitoring during the measurement periods covering 2010 and 2012.  

CONCLUSIONS

Metabolic monitoring in adults improved substantially over the time periods studied; however, rates remained suboptimal, especially in the pediatric population. This finding suggests that interventions to increase metabolic monitoring in adults and children using FGAs and SGAs are necessary.

Use of an electronic metabolic monitoring form in a mental health service - a retrospective file audit

BACKGROUND

People with severe mental illness have poorer physical health, experience disparities in physical health care, and lead significantly shorter lives, compared to the general population. Routine metabolic monitoring is proposed as a method of identifying risk factors for metabolic abnormalities. Efforts to date suggest routine metabolic monitoring is both incomplete and ad-hoc, however. This present study reports on the recent implementation of a routine metabolic monitoring form at a mental health service in regional Australia.

METHODS

A retrospective file audit was undertaken on 721 consumers with electronic health records at the mental health service. Descriptive statistics were used to report the frequency of use of the metabolic monitoring form and the range of metabolic parameters that had been recorded.

RESULTS

Consumers had an average age of 41.4 years (SD = 14.6), over half were male (58.4%), and the most common psychiatric diagnosis was schizophrenia (42.3%). The metabolic monitoring forms of 36% of consumers contained data. Measurements were most commonly recorded for weight (87.4% of forms), height (85.4%), blood pressure (83.5%), and body mass index (73.6%). Data were less frequently recorded for lipids (cholesterol, 56.3%; low density lipoprotein, 48.7%; high density lipoprotein, 51.7%; triglycerides, 55.2%), liver function (alanine aminotransferase, 66.3%; aspartate aminotransferase, 65.5%; gamma-glutamyl transpeptidase, 64.8%), renal function (urea, 66.3%; creatinine, 65.9%), fasting blood glucose (60.2%), and waist circumference (54.4%).

CONCLUSIONS

The metabolic monitoring forms in consumer electronic health records are not utilised in a manner that maximises their potential. The extent of the missing data suggests that the metabolic health of most consumers may not have been adequately monitored. Addressing the possible reasons for the low completion rate has the potential to improve the provision of physical health care for people with mental illness.

A collaborative approach to improve the assessment of physical health in adult consumers with schizophrenia in Queensland mental health services

OBJECTIVE

The objective of this study was to apply a quality improvement collaborative to increase the number of physical health assessments conducted with consumers diagnosed with schizophrenia in adult community mental health services across Queensland.

METHOD

Sixteen adult mental health service organisations voluntarily took part in the statewide collaborative initiative to increase the number of physical health assessments completed on persons with a diagnosis of schizophrenia spectrum disorders managed through the community mental health service.

RESULTS

Improvement in the physical health assessment clinical indicator was demonstrated across the state over a 3-year period with an increase in the number of physical health assessments recorded from 12% to 58%.

CONCLUSIONS

Significant improvements were made over a 3-year period by all mental health services involved in the collaborative, supporting the application of a quality improvement methodology to drive change across mental health services.

Interventions to Address Medical Conditions and Health-Risk Behaviors Among Persons With Serious Mental Illness: A Comprehensive Review

People with serious mental illness (SMI) have mortality rates 2 to 3 times higher than the overall US population, largely due to cardiovascular disease. The prevalence of cardiovascular risk factors such as obesity and diabetes mellitus and other conditions, such as HIV/AIDS, is heightened in this group. Based on the recommendations of a National Institute of Mental Health stakeholder meeting, we conducted a comprehensive review examining the strength of the evidence surrounding interventions to address major medical conditions and health-risk behaviors among persons with SMI. Peer-reviewed studies were identified using 4 major research databases. Randomized controlled trials and observational studies testing interventions to address medical conditions and risk behaviors among persons with schizophrenia and bipolar disorder between January 2000 and June 2014 were included. Information was abstracted from each study by 2 trained reviewers, who also rated study quality using a standard tool. Following individual study review, the quality of the evidence (high, medium, low) and the effectiveness of various interventions were synthesized. 108 studies were included. The majority of studies examined interventions to address overweight/obesity (n = 80). The strength of the evidence was high for 4 interventions: metformin and behavioral interventions had beneficial effects on weight loss; and bupropion and varenicline reduced tobacco smoking. The strength of the evidence was low for most other interventions reviewed. Future studies should test long-term interventions to cardiovascular risk factors and health-risk behaviors. In addition, future research should study implementation strategies to effectively translate efficacious interventions into real-world settings.

Screening for Metabolic Syndrome in Mental Health Consumers Using an Electronic Metabolic Monitoring Form

Metabolic syndrome is more prevalent in people with serious mental illness, compared to the general population. The main purpose of this study was to determine the extent electronic metabolic monitoring forms were being completed in a regional mental health service and the extent to which diagnoses of metabolic syndrome could be made using the data available. A retrospective file audit of 721 electronic mental health consumer records was undertaken. Metabolic monitoring data were recorded for 261 (36%) consumers, of which 57 (21.8%) met the clinical criteria for metabolic syndrome, 61 (23.4%) did not meet clinical criteria, and diagnoses could not be made for 143 (54.8%) consumers due to missing data. The limited use of electronic health records may inhibit the detection of risk factors for the diagnosis of metabolic syndrome.

Scoping review of research in Australia on the co-occurrence of physical and serious mental illness and integrated care

The physical health of people with serious mental illness (SMI) has become a focal area of research. The aim of the present study was to ascertain the attention and distribution of research from within Australia on physical illness and SMI co-occurrence, and to identify gaps. A scoping review of peer-reviewed research literature from Australia, published between January 2000 and March 2014, was undertaken through an electronic literature search and coding of papers to chart trends. Four trends are highlighted: (i) an almost threefold increase in publications per year from 2000-2006 to 2007-2013; (ii) a steady release of literature reviews, especially from 2010; (iii) health-related behaviours, smoking, integrated-care programmes, and antipsychotic side-effects as the most common topics presented; and (iv) paucity of randomized, controlled trials on integrated-care models. Despite a marked increase in research attention to poorer physical health, there remains a large gap between research and the scale of the problem previously identified. More papers were descriptive or reviews, rather than evaluations of interventions. To foster more research, 12 research gaps are outlined. Addressing these gaps will facilitate the reduction of inequalities in physical health for people with SMI. Mental health nurses are well placed to lead multidisciplinary, consumer-informed research in this area.

Prescription practices in the treatment of first-episode schizophrenia spectrum disorders: data from the national RAISE-ETP study

OBJECTIVE

Treatment guidelines suggest distinctive medication strategies for first-episode and multiepisode patients with schizophrenia. To assess the extent to which community clinicians adjust their usual treatment regimens for first-episode patients, the authors examined prescription patterns and factors associated with prescription choice in a national cohort of early-phase patients.

METHOD

Prescription data at study entry were obtained from 404 participants in the Recovery After an Initial Schizophrenia Episode Project's Early Treatment Program (RAISE-ETP), a nationwide multisite effectiveness study for patients with first-episode schizophrenia spectrum disorders. Treatment with antipsychotics did not exceed 6 months at study entry.

RESULTS

The authors identified 159 patients (39.4% of the sample) who might benefit from changes in their psychotropic prescriptions. Of these, 8.8% received prescriptions for recommended antipsychotics at higher than recommended dosages; 32.1% received prescriptions for olanzapine (often at high dosages), 23.3% for more than one antipsychotic, 36.5% for an antipsychotic and also an antidepressant without a clear indication, 10.1% for psychotropic medications without an antipsychotic, and 1.2% for stimulants. Multivariate analysis showed evidence for sex, age, and insurance status effects on prescription practices. Racial and ethnic effects consistent with effects reported in previous studies of multiepisode patients were found in univariate analyses. Despite some regional variations in prescription practices, no region consistently had different practices from the others. Diagnosis had limited and inconsistent effects.

CONCLUSIONS

Besides prescriber education, policy makers may need to consider not only patient factors but also service delivery factors in efforts to improve prescription practices for first-episode schizophrenia patients.

Applying the World Health Organization Mental Health Action Plan to evaluate policy on addressing co-occurrence of physical and mental illnesses in Australia

Objectives The aim of the present study was to document Australian policies on the physical health of people with mental illness and evaluate the capacity of policy to support health needs. Methods A search of state and federal policies on mental and physical illness was conducted, as well as detailed analysis of policy content and the relationships between policies, by applying the World Health Organization Mental Health Action Plan 2013–2020 as an evaluative framework. Results National policy attention to the physical health of people with mental illness has grown, but there is little interconnection at the national and state levels. State policies across the country are inconsistent, and there is little evidence of consistent policy implementation. Conclusions A coherent national health policy framework on addressing co-occurring physical and mental illnesses that includes healthcare system reforms and ensuring the interconnectedness of other relevant services should be prioritised. What is known about the topic? People with mental illness have a lower life expectancy and poorer physical health than people who do not have a mental illness. Government policy is critical to reducing inequalities in physical health and increasing longevity. What does this paper add? Evaluating policy developments against the World Health Organization’s Mental Health Action Plan 2013–2020, this review identified a lack of cohesive national-level policy on how to improve the physical health of people with mental illness. Although there are some state-based policies regarding strategies for better prevention and management of the physical health of people with mental illness, evidence of policy implementation is either scarce or inconsistent. The capacity of current policy to translate into reforms that increase the physical and overall health of people suffering mental health difficulties seems very limited. What are the implications for practitioners? This paper outlines major policy gaps and an overall need for a national-level policy. National-level leadership on integrated health care is required, with monitoring to ensure health care reforms are genuinely informed by consumer and clinician views and are effective.

Metabolic changes in first-episode early-onset schizophrenia with second-generation antipsychotics

AIM

Individuals with a diagnosis of schizophrenia have a reduced life expectancy compared with the general population and cardiovascular disease is the major contributor to this early mortality. The use of second-generation antipsychotic (SGA) medications is associated with significant weight gain and metabolic side effects; however, there is limited knowledge in certain diagnostic groups, specifically early-onset schizophrenia (EOS). This study aimed to investigate the metabolic side effects of SGAs, specifically olanzapine, risperidone and quetiapine, in a cohort of drug-naïve children and adolescents with first-episode EOS.

METHOD

Body mass index (BMI), serum cholesterol and triglycerides were measured at baseline and a median of 7 months of follow up in drug-naïve children and adolescents with EOS.

RESULTS

A total of 49 children and adolescents received a diagnosis of first-episode EOS and we had complete follow-up data for 74% (N = 36). A significant increase in BMI, serum triglycerides and cholesterol was observed in the unselected cohort after commencement of SGAs. One-third of children and adolescents had abnormal serum triglycerides and cholesterol; however, a dose-response was not demonstrated. Olanzapine and quetiapine had a greater increase in serum triglycerides.

CONCLUSIONS

In addition to highlighting the need for routine screening for metabolic side effects in EOS, interventions to prevent and treat obesity and the metabolic syndrome are indicated.

Medication monitoring in a nurse-led respiratory outpatient clinic: pragmatic randomised trial of the West Wales Adverse Drug Reaction Profile

Objective

To assess the clinical effect of medication monitoring using the West Wales Adverse Drug Reaction (ADR) Profile for Respiratory Medicine.

Design

Single-site parallel-arm pragmatic trial using stratified randomisation.

Setting

Nurse-led respiratory outpatient clinic in general hospital in South Wales.

Participants

54 patients with chronic respiratory disease receiving bronchodilators, corticosteroids or leukotriene receptor antagonists.

Intervention

Following initial observation of usual nursing care, we allocated participants at random to receive at follow up: either the West Wales ADR Profile for Respiratory Medicine in addition to usual care (‘intervention arm’ with 26 participants); or usual care alone (‘control arm’ with 28 participants).

Main Outcome Measures

Problems reported and actions taken.

Results

We followed up all randomised participants, and analysed data in accordance with treatment allocated. The increase in numbers of problems per participant identified at follow up was significantly higher in the intervention arm, where the median increase was 20.5 [inter-quartile range (IQR) 13–26], while that in the control arm was −1 [−3 to +2] [Mann-Whitney U test: z = 6.28, p<0.001]. The increase in numbers of actions per participant taken at follow up was also significantly higher in the intervention arm, where the median increase was 2.5 [1]–[4] while that in the control arm was 0 [−1.75 to +1] [Mann-Whitney U test: z = 4.40, p<0.001].

Conclusion

When added to usual nursing care, the West Wales ADR Profile identified more problems and prompted more nursing actions. Our ADR Profile warrants further investigation as a strategy to optimise medication management.

Trial Registration

Controlled-trials.com ISRCTN10386209

Medication monitoring for people with dementia in care homes: the feasibility and clinical impact of nurse-led monitoring

OBJECTIVES

People with dementia are susceptible to adverse effects of medicines. However, they are not always closely monitored. We explored (1) feasibility and (2) clinical impact of nurse-led medication monitoring.

DESIGN

Feasibility "before-and-after" intervention study.

SETTING

Three care homes in Wales.

PARTICIPANTS

Eleven service users diagnosed with dementia, taking at least one antipsychotic, antidepressant, or antiepileptic medicine.

INTERVENTION

West Wales Adverse Drug Reaction (ADR) Profile for Mental Health Medicines.

OUTCOME MEASURES

(1) Feasibility: recruitment, retention, and implementation. (2) Clinical impact: previously undocumented problems identified and ameliorated, as recorded in participants' records before and after introduction of the profile, and one month later.

RESULTS

Nurses recruited and retained 11 of 29 eligible service users. The profile took 20-25 minutes to implement, caused no harm, and supplemented usual care. Initially, the profile identified previously undocumented problems for all participants (mean 12.7 (SD 4.7)). One month later, some problems had been ameliorated (mean 4.9 (3.6)). Clinical gains included new prescriptions to manage pain (2 participants), psoriasis (1), Parkinsonian symptoms (1), rash (1), dose reduction of benzodiazepines (1), new care plans for oral hygiene, skin problems, and constipation.

CONCLUSIONS

Participants benefited from structured nurse-led medication monitoring. Clinical trials of our ADR Profile are feasible and necessary.

Attenuated psychosis syndrome: don't jump the gun

Attenuated psychosis syndrome (APS) was introduced in DSM-5 as a condition for further study. A number of concerns have been raised regarding APS, including its validity as a clinical entity, issues relating to stigma, the potential that it is an unnecessary diagnosis of what might be a self-limiting phase of attenuated psychotic symptoms, and treatment implications of the diagnosis. The current paper presents a number of conceptual and practical issues that should be addressed in deciding whether APS should be accepted as an official diagnosis in subsequent editions of DSM. These include the problem of transferring the established validity of 'at-risk' criteria to APS given some non-trivial differences between the criteria sets, the relationship between attenuated psychotic symptoms and other presenting non-psychotic disorders, the difficulties of operationalising the subthreshold or 'attenuated' concept in standard clinical practice, and the likelihood of the diagnosis leading to overprescription of antipsychotic medication for this group of patients.

Psychotropic drug prescribing in an Australian specialist child and adolescent eating disorder service: a retrospective study

BACKGROUND

To describe the rates, indications, and adverse effects of psychotropic drug prescription in a specialist tertiary hospital child and adolescent eating disorder service.

METHODS

Retrospective case note study of all active eating disorder patients (N = 115) over the period of treatment from referral to time of study (M = 2 years), covering patient demographics, clinical characteristics, drug prescriptions, indications, and adverse effects.

RESULTS

Psychotropic drugs were prescribed in 45% of cases, most commonly antidepressants (41%), followed by anxiolytics (29%) and antipsychotics (22%), with 8% initiated before referral to the specialist eating disorder program. Common indications were depressed mood, agitation, anxiety, and insomnia. Patient clinical severity and complexity was associated with prescribing. Adverse effects, mostly minor, were recorded in 23% of antidepressant prescriptions, 39% of antipsychotic prescriptions, and 13% of anxiolytic prescriptions. Second generation antipsychotic prescription was associated with subsequent new onset binge eating, in this preliminary observational study. Self-harm by overdose of psychotropics occurred in 11% of patients prescribed medication.

CONCLUSIONS

Psychotropic medications were frequently prescribed to adolescent eating disorder patients to treat distressing symptoms. Prospective randomised controlled trials to clarify efficacy and safety are needed. Given the difficulties of conducting clinical trials in this population, services are encouraged to monitor and audit medication safety and efficacy in everyday practice, and to report their findings.