Challenges in mental health care

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Challenges in mental health care
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Physical health and severe mental illness time
for action

• Richard Gray RN PhD
• Adjunct Professor of Mental Health Nursing
• NUI Galway, Ireland
• e richard.gray_at_uea.ac.uk
• w http//eastanglia.academia.edu/RichardGray

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Look to your health and if you have it, praise
God, and value it

• IZAAK WALTON 1593-1683

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Why do research?
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Why do research?

• To enhance patients quality of life, health and
  experience of healthcare
• IMPACT
• Research without impact is pointless

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How much younger will you die if you have
schizophrenia?
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Life expectancy in patients with SMI

• Life expectancy in the UK at birth
• 81.5 year for girls
• 77.2 years for boys
• Newman and Bland (1991) estimated a 20 reduction
  in life expectancy in a cohort of 3,623 in Canada
• Systematic review of population based studies (1)
  
• SMR of 2.50 (95 confidence interval, 2.18-2.43)
• 20-25 years of lost life
• Early 60s for women
• Late 50s for men

SMR in epidemiology is the ratio of observed
deaths to expected deaths. SMR is quoted as a
ratio. 1.0 means the number of observed deaths
equals the number of expected cases. If higher
than 1.0, then there is a higher number of deaths
than is expected
1. Arch Gen Psychiatry. 200764(10)1123-1131
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What is the major cause of death for people with
schizophrenia?
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Suicide

• 4 in 10 attempt suicide
• 1 in 10 will commit suicide
• SMR for Suicide in SMI is (12.86) (1)
• More than 60 of premature deaths are not
  directly related to suicide

1. Arch Gen Psychiatry. 200764(10)1123-1131
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What is the major cause of death for people with
schizophrenia?
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Physical health of patients with SMI

• The biggest killer is cardio-vascular disease
  (CVD) (1)
• Most of the major causes-of death categories were
  found to be elevated in people with schizophrenia
  (2)
• The SMRs for all-cause mortality have increased
  during recent decades (2)
• Most psychiatric patients have a co-morbid
  medical illness (2)
• Many illnesses go undiagnosed (2)
• Patient group do not volunteer complaints readily
  (2)

1. Robson D. and Gray R. (2006) Int J Nursing
Studies 2. Arch Gen Psychiatry.
200764(10)1123-1131
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Why is life expectancy getting worse?
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Its the nasty drugs we give them
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Mean change in weight with antipsychotics
Estimated Weight Change at 10 Weeks on Standard
Dose
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5
4

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Weight Change (Kg)
2

1
0
-1
-2
-3
Placebo
Quetiapine
Fluphenazine
Aripiprazole
Clozapine
Ziprasidone
Risperidone
Chlorpromazine
Olanzapine
Haloperidol
Thioridazine
46 week pooled data (Marder et al. Schizophr
Res. 2003161123-36 6-week data adapted from
Jones et al. ACNP 1999. Allison et al. Am J
Psychiatry. 19991561686-1696.
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Medication is good for you

• If you have schizophrenia/bipolar illness (or
  depression)

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Neuroprotection with olanzapine vs haloperidol
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Why is life expectancy getting worse?

• Cardiovascular disease is caused by obesity
• I observe (in practice) that people with SMI are
  overweight!
• What is the prevalence of obesity in patients
  with SMI?

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Body mass index and prevalence of obesity in a
English cohort of patients with severe mental
illness Running header BMI and Obesity in
Schizophrenia Donna Eldridge (1), Nicky Dawber
(1), Louise Swift (2), Richard Gray (2) 1. Kent
and Medway NHS Social Care Partnership Trust 2.
University of East Anglia, Norwich, NR4 7TJ
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BMI and obesity in SMI

• Prospective
• Conducted in a mental health service in Kent,
  England
• Serves a population of 1.6 million
• Health checks performed by a mental health nurse
  who had had three days physical health training
• Demographic information, prescribed medication,
  lifestyle factors, weight, height, laboratory
  tests
• Recruited 497 patients

Eldridge et al (in prep) BMI and Obesity in
Schizophrenia
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Average BMI30.0
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Prevalence of obesity in men (n272)
Eldridge et al (in prep) BMI and Obesity in
Schizophrenia
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Prevalence of obesity in women (n225)
Eldridge et al (in prep) BMI and Obesity in
Schizophrenia
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Why is obesity so prevalent in patients with SMI?
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Its the nasty drugs we give them (again)
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BMI category by psychotropic medication
Eldridge et al (in prep) BMI and Obesity in
Schizophrenia
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BMI category by psychotropic medication
Mean bmi no medication25, any medication30,
plt.05
Eldridge et al (in prep) BMI and Obesity in
Schizophrenia
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What factors predict obesity?

• Multivariate analysis
• Final model had four factors that explained 17
  of the variance
• Prescribed antipsychotic medication
• Did not smoke cigarettes
• Poor quality diet
• Where they lived (patients less likely to be
  obese if they were homeless or in hospital)
• i.e. Patients with the lowest BMI were not taking
  medication, smoking cigarettes, homeless, but
  eating a healthy diet

Eldridge et al (in prep) BMI and Obesity in
Schizophrenia
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What factors predict obesity?

• Multivariate analysis
• Final model had four factors that explained 17
  of the variance
• Prescribed antipsychotic medication
• Did not smoke cigarettes
• Poor quality diet
• Where they lived (patients less likely to be
  obese if the were homeless or in hospital)

Eldridge et al (in prep) BMI and Obesity in
Schizophrenia
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Prevalence of other lifestyle behaviours

• 51 had an unhealthy diet
• High in fat, lt5 portions of fruit and veg a day,
  high in calories
• 44 took no regular activity
• 58 smoked
• Many motivated to quit
• gt85 reported in other epidemiological studies
• In 2003, 26 of British adults aged 16 smoked
  cigarettes, (28 of men and 24 of women)
  compared with 45 in 1974.
• The majority claimed that they did not drink
  alcohol or use illicit drugs
• Big issue about the accuracy of reporting

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A quick word about sex
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What are we going to do about?

• Options
• SEP (somebody else's problem - primary care)
• Create a new service
• Enhance the practice of secondary care mental
  health workers

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What do mental health nurses think about physical
health?
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What are nurses views about physical health?

• Survey of 600 Nurses in the South London and
  Maudsley NHS Trust
• 99 thought that promoting good physical health
  was part of their role
• 84 thought that mental health nurses need to
  take responsibility for the physical health care
  of clients with serious mental illnesses

Robson D. (in prep) Survey of mental health nurses
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Physical health survey

• 78 feel that their current workload is a barrier
  to promoting physical health
• Evidence of lack of knowledge and skills
• Want more training on
• Giving nutritional advice (78)
• Helping clients stop smoking (68)
• 74 thought mental health nurses should be more
  skilled at managing patients with diabetes
• These barriers can be addressed through
• Opportunity cost (or what do you not do)
• Training
• Clinical leadership

Robson D. (in prep) Survey of mental health nurses
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How good are we at monitoring physical wellbeing?
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Metabolic screening is below recommended levels
patients screened
Fewer than 2 in 10 patients are screened for
obesity
Screening of 4 aspects of metabolic syndrome in
the total national sample (n1966)Barnes et al.
Schizophr Bull 2007331397-403.
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Bells and whistles

• The Wellbeing support programme

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Addressing physical health the WellBeing support
programme
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The WellBeing support programme

• Two year programme
• Six formal sessions with a nurse advisor
• Nurse advisors trained by physical health experts
• Performance managed
• Funded by industry
• An add on to routine care

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Wellbeing support

• Step 1 Generating a register of SMI patients and
  inviting them to participate in the WSP
• Step 2 First face-to-face Well-Being Session
  where physical health (blood pressure, pulse,
  weight and height) lifestyle factors (diet,
  physical activity, smoking status) and
  antipsychotic side effects (LUNSERS Day et al
  1995) were measured
• Step 3 Results of measures taken in session 1
  were fed back to patients at a second
  face-to-face session. Blood tests (random blood
  glucose, thyroid function, liver function, serum
  prolactin, lipid screen) were performed during
  this meeting
• Step 4 Patients were referred by the
  practitioner to one or more of the following a
  weight management or physical activity group
  primary care or specialist doctor for additional
  physical health care medication review by
  prescribing clinician
• Step 5 Two follow-up face-to-face sessions to
  evaluate programme and complete follow-up
  measures (as in step 1 and 2)

1. Smith S. (2007) International Journal of
Clinical practice
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The WellBeing support programme

• 966 patients enrolled across seven demonstration
  sites
• 80 completed the programme
• Significant improvements in
• Physical activity
• Smoking
• Diet
• No change in patients BMI
• Maintenance of BMI reported as a positive outcome
• Programme recommended by English DH

Eldridge et al (under review)
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WellBeing in the hands of the NHS

• Industry Wellbeing no longer fits with our
  strategy
• Nurse advisors withdrawn from practice
• The NHS it works lets change it
• One year (not two year) programme
• Four (not six) formal sessions with mental health
  practitioner
• Practitioners attend a three day training course
  facilitated by a WellBeing nurse advisor
• Part of routine care (not an add on service)
• Does it still benefit patients?

Eldridge et al (under review)
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WellBeing in Kent

• Started in 2006
• Evaluation undertaken at the end of 2008
• 212 practitioners had attended training
• 754 patients enrolled on the programme
• Baseline and one year follow-up data on
• Cardiovascular risk factors
• Laboratory tests (glucose, lipids)
• Medication
• Face-to-face interviews with practitioners

Eldridge et al (under review)
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Wellbeing in Kent making a difference

• Making a difference was an emergent theme from
  practitioner interviews
• it has flagged up a massive deficit within out
  clients with some having not had physical
  interventions for a number years. A lady I
  assessed hadnt had a smear for 20 year!
• I have welcomed the programme as it recognises
  the need to provide health promotion activity to
  a client group where this can be overlooked,
  falling between services of secondary and primary
  care
• I am pleased about running the group and working
  with others getting the project off the ground
  has been really enjoyable
• In fact we are cooking a healthy fry up this
  week! (i.e. Grilling not frying, including lots
  of veg and fresh fruit)
• high blood sugar, hypertension, obesity,
  polypharmacy and sexual health problems all of
  which I have been able to refer to appropriate
  services.
• I have discovered a number of serious
  conditions including hypertension, raised
  cholesterol and recently two inpatients have been
  diagnosed with diabetes

Eldridge et al (under review)
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Outcomes of the programme

• Enrolled 754
• Attended 1580 WellBeing sessions
• Mean of 2.1 sessions (half the programme)
• 159 completed the programme

Eldridge et al (under review)
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Effect on the cohort

• None at all

Eldridge et al (under review)
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In those patients that completed the programme
Eldridge et al (under review)
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Sub-group analysis of Wellbeing completers
N159 ?2126.01 df4 plt0.01
Eldridge et al (under review)
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Adherence, adherence, adherence
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Learning

• Keep it simple
• Set standards that can be performance managed
• Competence of practitioners

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A different model the Health Improvement Profile
(HIP)

• Keep it simple stupid!

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The process of developing the HIP
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The Health Improvement Profile (HIP)
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The Health Improvement Profile (HIP)1

• A RISK ASSESSMENT tool for physical health
• Nurses can be trained to be competent in using
  the HIP is three hours
• The physical health of all patients can be
  profiled
• A HIP for every patient once a year
• Enables nudges nurses to plan care/make
  appropriate referrals
• Guides nurses to evidence based interventions
• Bridges communication between primary and
  secondary care

1. White J. et al (2009) Journal of Psychiatric
and Mental Health Nursing
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The HIP process
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HIP case series1

• 31 patients with schizophrenia
• Nurses in routine care trained to use the HIP
• 189 physical health issues
• 6.1 per patient
• Individualised (evidence based) care and
  treatment was planned based on individual
  profiles
• 28 interventions were used
• Providing advice, promoting health behaviour
  change, performing an ECG, referral to
  professional colleague

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The Health Improvement Profile

• Ongoing research
• Northampton (Shelia Hardy)
• Nurse practitioners using the HIP to review and
  jointly plan care for all patients on the Trust
  SMI register
• Scotland, Edinburgh (Hugh Masters)
• Qualitative study of patients experiences of
  physical health care
• Scotland, Lanarkshire (Francis Schule)
• HIP 100 case series

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Just finished developing the eHIP
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Impact

• 10 NHS Trusts in the UK are using the HIP/eHIP

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Key points

• Life expectancy is getting worse not better
• We need to turn the tide
• We CAN make a difference
• Keep it simple and stick with it!
• TIME FOR ACTION

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Physical health and severe mental illness time
for action

• Richard Gray RN PhD
• Adjunct Professor of Mental Health Nursing
• NUI Galway, Ireland
• e richard.gray_at_uea.ac.uk
• w http//eastanglia.academia.edu/RichardGray