Physical Health Inequities in People with Severe Mental Illness: Identifying Initiatives for Practice Change

People with severe mental illness have a higher prevalence of co-morbid physical diseases and a significantly reduced life expectancy when compared with people in the general population. This article explores the literature published between 2002 and 2012 in order to identify causes of poor physical health in those with severe mental illness and discusses interventions that may be implemented to enhance health outcomes for this group. The causes of poor physical health in those with severe mental illness are difficult to address. However, existing literature does identify some interventions that can potentially provide the basis for practice change.     

Physical health and well‐being: Experiences and perspectives of young adult mental health consumers

Compromised physical health and raised levels of morbidity and mortality are experienced by young people (16–24 years) with mental illness, and are compounded by psychotropic medication. How this group conceives and experiences physical health is not well understood. We investigated the meanings, beliefs, and endeavours of young people that impact their physical health understandings and behaviours. The present study formed the qualitative phase of a sequential mixed‐methods study, and incorporated semistructured interviews with 12 hospitalized young people. Qualitative content analysis was used to analyse data. Participants held a holistic ideal of physical health that they did not meet. Weight change, poor sleep, and limited exercise adversely impacted their lives and self‐image. Sedentary behaviour, reduced energy, and limited health literacy compromised effective management of physical health. Young people needed structure and support to assist them in addressing their physical health needs when amotivation overwhelmed their internal resources. Nurses are well placed to help young people increase their competency for health management. Individualized information and methods to promote good physical health are required for this group in jeopardy from physical morbidity and mortality.     

The Cardiometabolic Health Nurse: Physical Health Behaviour Outcomes from a Randomised Controlled Trial

To combat the increasingly poor physical health of people with serious mental illness, the position of a cardiometabolic health nurse has been proposed. We recently conducted a 26-week trial in a regional mental health service. This paper describes the background and rationale for the position, presents the outcomes on health behaviours and health behaviour knowledge and attitudes, and offers recommendations for the future direction of the role. We show that a cardiometabolic health nurse can improve the physical health behaviours in people with mental illness, however much needs to be done to further develop and implement the role.     

Evolving role of mental health nurses in the physical health care of people with serious mental health illness

Life expectancy in members of the general population has steadily improved in most countries since 1960. However, during the same period, the life expectancy of people with serious mental illness (SMI) has actually reduced. The majority of premature deaths result from natural causes, such as coronary heart disease. Obesity, a key risk factor for heart disease in this client group, might be caused both by unhealthy lifestyle behaviours and the side-effects of antipsychotic medication. Mental health nurses (MHN) nurses have an important role to play in improving the physical health of people with SMI. Evidence, however, suggests that they are often ambivalent about this role, and might perceive themselves as being inadequately trained and lacking in confidence. In this paper, we will argue that MHN need to re-evaluate their practice and recognize that the provision of physical health care is as important as other roles they occupy in relation to the care of people with SMI. We will also consider examples of best practice in physical health care, and discuss how these might be adopted by MHN and other professionals, in order to begin to improve services and to reduce health inequalities in this client group.     

Physical health and wellbeing of emerging and young adults with mental illness: an integrative review of international literature

Physical health in people with mental illness is often compromised. Chronic physical conditions and disease risk factors occur at higher rates than in the general population. Although substantial research exists regarding mental-physical comorbidities in middle to older-aged adults and mental illness consequential to childhood physical illness, research addressing physical health in young people/emerging adults of 16-24 years with primary mental illnesses is minimal. Health problems often track from youth to adulthood, indicating a need to better recognize and understand the overall health of young people with mental illness. This paper reports findings from an integrative review of published research investigating physical health of emerging/young adults with mental illness. A total of 18 research papers were systematically analysed. The review found that comorbid mental-physical illness/conditions were evident across a wide age span. Specific physical health problems, including pain, gastrointestinal, and respiratory disorders, were apparent in those 16 years to those in their mid-late 20s, and/or with first episode psychosis. Lifestyle risk factors for cardiometabolic disorders occurred with some frequency and originated prior to adulthood. These findings highlight the need for targeted health screening and illness prevention strategies for emerging/young adults with mental health problems and draws attention to the need for young people to be supported in their health-care behaviours.     

Medical co-morbidity risk factors and barriers to care for people with schizophrenia

The management of risk is a fundamental component of the work of mental health nurses and is most commonly associated with aggressive, violent and suicidal behaviours exhibited by those suffering from mental illness. However, people with severe mental illness are increasingly at risk of experiencing a number of related and complex health problems that include obesity, diabetes and cardiovascular disease. This group also has much higher rates of morbidity and mortality than that of the general population resulting in high social, economic and individual costs. Some of the barriers to receiving prompt and appropriate physical health care include lack of recognition by health professionals and the difficulties faced by consumers of mental health services in negotiating the health care system. Establishment of comprehensive (addressing both physical and mental health issues) programmes of care can address this need and offer additional opportunities for closer and more collaborative nurse-patient relationships. This paper explores risk factors for medical co-morbidity for people living with schizophrenia and suggests strategies that can facilitate better health outcomes.     

Cardiometabolic health nursing to improve health and primary care access in community mental health consumers: Protocol for a randomised controlled trial

Background

People with a serious mental illness are at significantly greater risk of poor cardiometabolic health with recent studies showing a greater than two-fold increase in the risk of obesity, infectious diseases, diabetes and cardiovascular disease. Contributing factors to this disparity include poorer health behaviours such as suboptimal physical activity, poor diet, smoking, alcohol and illicit drug misuse. In particular, the limited access to primary health care experienced by people with a serious mental illness has been highlighted. Persons with a serious mental illness are around 30% less likely than those without serious mental illness to receive health assessments, hospital admissions or procedures for cardiovascular disease and diabetes, and are less likely to undergo cancer screening or receive vaccinations. Studies show that mental health consumers may be more likely to use mental health services rather than primary care for contact with the health care system. However mental health nurses report several barriers to their capacity to provide cardiometabolic health care crucial for the treatment of people with a serious mental illness.

Objectives

To assess the impact of a specialist Cardiometabolic Health Nurse on the physical health care of community based mental health consumers.

Setting

Community mental health facility in a large regional centre in Central Queensland, Australia.

Design/methods

Community based mental health consumers will be randomised to receive either usual care, or consultations with a Cardiometabolic Health Nurse. The Cardiometabolic Health Nurse will be responsible for assessing the client and coordinating cardiometabolic health care as required. Post intervention review of health records will be performed with the primary outcome measure being self-reported physical health. Secondary outcomes include the utilisation of primary care services and changes in health behaviours. We hypothesise that the Cardiometabolic Health Nurse will increase the utilisation of health care services for mental health consumers.

Results

Data collection commenced in March 2013 and will conclude September 2013. Preliminary finding are expected in December 2013.     

Assessment of cardiovascular risk in an Italian psychiatric outpatient sample: A chart review of patients treated with second‐generation antipsychotics

Despite the call by the scientific community for a systematic monitoring of physical health in people with psychiatric illnesses, national and international audits have reported poor quality of cardiovascular risk assessments and management in this vulnerable population. Available evidence indicates that in people affected by mental illness, life expectancy is reduced by 10–20 years, mainly due to cardiovascular accidents and metabolic syndrome (MetS)‐related diseases. The primary aim of the present study was to evaluate the accuracy of cardiovascular risk monitoring in an outpatient sample of patients taking second‐generation antipsychotics. The sample consisted of 200 patients consecutively recruited from two community mental health centres. A clinical chart review was performed on the following laboratory tests: total cholesterol, high‐ and low‐density lipoprotein, serum triglycerides, fasting blood glucose, γ‐glutamyl transpeptidase. Blood pressure and waist circumference were measured. A complete cardiovascular risk assessment was available only in 60 patients out of 200 (33.3%). The only variable associated with laboratory tests for MetS was receiving three or more psychotropic medications, which increased fourfold the probability of metabolic screening. In the subsample of patients with full screening, the prevalence of MetS was 33.3%. Our findings suggest that mental health professionals working in community mental health services should incorporate a more systematic assessment of physical health in their practice, and intervene proactively to reduce the significant cardiovascular burden carried by people with several mental illness.     

Enabling healthy living: Experiences of people with severe mental illness in psychiatric outpatient services

It is well known that people with severe mental illness have a reduced life expectancy and a greater risk of being affected by preventable physical illnesses such as metabolic syndrome, cardiovascular disease and type 2 diabetes. There are still, however, only a few published studies focusing on what enables healthy living for this group. This study thus aimed to describe what enables healthy living among people with severe mental illness in psychiatric outpatient services. The data were collected in qualitative interviews (n = 16) and content analysis was used to analyze the data. The interviews resulted in an overall theme “Being regarded as a whole human being by self and others”, which showed the multidimensional nature of health and the issues that enable healthy living among people with severe mental illness. Three categories emerged: (i) everyday structure (ii), motivating life events and (iii) support from significant others. The results indicate that a person with severe mental illness needs to be encountered as a whole person if healthy living is to be enabled. Attaining healthy living requires collaboration between the providers of care, help and support. Health care organizations need to work together to develop and provide interventions to enable healthy living and to reduce poor physical health among people with severe mental illness.     

Serious mental illness and physical health problems: a discussion paper

People with serious mental illness have higher morbidity and mortality rates of chronic diseases than the general population. This discussion paper explores the complex reasons for these disparities in health, such as limitations of health services, the effects of having a serious mental illness, health behaviours and the effects of psychotropic medication. Physical health can be enhanced by improved monitoring and lifestyle interventions initiated at the start of treatment. There are opportunities for mental health nurses to play a significant role in improving both the physical and mental health of people with serious mental illness.     

Embedding a physical health nurse consultant within mental health services: Consumers’ perspectives

The life expectancy of people living with mental illness is significantly shorter than that of the rest of the population. Despite the profound impact of physical health issues on both quality of life and life expectancy, the perspectives of mental health consumers have yet to be thoroughly explored. Furthermore, research has focused far more on describing barriers than on identifying solutions. This paper reports on findings from a qualitative exploratory research study, with the aim to examine the potential role of a specialist nurse with advanced physical health‐care skills. Focus groups were conducted with 31 consumers. Data were analysed thematically. The concept of a role like this was supported; however, participants stressed: (i) the importance of integration between health professionals and various components of the health‐care system; and (ii) the need for culture change for nurses to work from a less medically‐dominated approach. Previous research literature suggests that a nursing position dedicated to physical health care and coordination might produce positive outcomes for mental health consumers. The findings from the current research project emphasize the need for consumers to be identified as key stakeholders in a solution‐focused approach to improved physical health care for mental health consumers.     

HIV prevention for people with serious mental illness: a survey of mental health workers’ attitudes,knowledge and practice

Aim. The aim of this survey was to investigate the attitudes, knowledge and reported practice (capabilities) of mental health workers concerning humanimmunodeficiency virus (HIV) and other sexually transmitted diseases in people with serious mental illness. Background. People with serious mental illness are at increased risk of HIV and other sexually transmitted infections. Mental health workers have a key role to play in promoting sexual health in this population, but it is unclear how they perceive their role in this work and whether they have the capabilities to deliver sexual health promotion. Design. Cross sectional survey. Methods. A questionnaire was devised and distributed to 650 mental health workers working in a London (UK) NHS mental health service. Results. A response rate of 44% was achieved. Overall, workers reported positive attitudes to sexual health promotion and were knowledgeable about risk behaviours and risk factors for HIV infection. Adherence to glove wearing was good. However, participants’ knowledge about HIV/AIDS in people with schizophrenia was poor and most reported they were not engaged in sexual health promotion activities with people with serious mental illness. Glove wearing was predicted by those who had drug and alcohol training and clinical experience and knowledge of risk factors was predicted by previous health promotion training. No other demographic factors predicted any of the other subscales. Conclusion. Mental health workers require training to provide skills for health promotion regarding sexual health and HIV in people with serious mental health problems. In addition, there needs to be more research on risk behaviours. Relevance to clinical practice. The development of effective interventions to reduce this behaviour.     

The high prevalence of poor physical health and unhealthy lifestyle behaviours in individuals with severe mental illness

Recent mental health care policy has addressed the need for health care professionals to consider the physical health of consumers. Mental health nurses are particularly well-placed for this role. To provide mental health nurses with practical information, this narrative review summarises evidence from recent research on the physical health of individuals with Serious Mental Illness (SMI). In those with SMI, the international prevalence of obesity, the metabolic syndrome, diabetes mellitus, symptoms of cardiovascular disease, and respiratory disease all exceed that of the general population by at least two times, and HIV prevalence may be increased by as much as eight times. This increased prevalence of chronic disease may be largely responsible for an increased risk of death of up to five times, resulting in as much as 30 years of potential life lost. Of particular concern, the recent evidence suggests that for physical health and increased mortality, the gap between individuals with SMI and the general population is worsening. Unhealthy lifestyle behaviours undoubtedly play a role in the development of poor physical health and chronic disease, and the present review indicates that low physical activity, poor diet, smoking, alcohol and substance abuse, and risky sexual behaviour are common in individuals with SMI. This narrative review demonstrates that the prevalence of poor physical health and health behaviours in people with SMI far exceed that observed in the general population, and reinforces the urgent need for mental health nurses to address physical health concerns in patients.     

Health behaviour interventions to improve physical health in individuals diagnosed with a mental illness: a systematic review

Individuals diagnosed with mental illness experience high rates of morbidity and mortality as a result of poor physical health and unhealthy lifestyle behaviours. The aim of this paper is to systematically review the literature on health behaviour interventions to improve the physical health of individuals diagnosed with a mental illness. A systematic search strategy was undertaken using four of the major electronic databases. Identified articles were screened for inclusion, included articles were coded, and data were extracted and critically reviewed. A total of 42 articles were identified for inclusion. The most commonly targeted physical health behaviour was weight management. The majority of studies reported improvements in health behaviours following interventions. The findings provide evidence for the positive effect of health behaviour interventions in improving the physical health of individuals diagnosed with a serious mental illness. A focus on health behaviour interventions within the mental health nursing profession might lead to improvements in health behaviours and general health in consumers of mental health services.     

Mental health and long-term conditions.1: Physical health

Poor diet, smoking, a lack of physical activity and excessive alcohol intake are just some of the factors that can contribute to a range of debilitating long-term conditions. Lifestyle risk factors can have a disproportionate impact on more vulnerable groups within society, such as people with mental health problems. In the first in a two-part series on mental health and long-term conditions, this article looks at the prevalence of physical illness among this service user group and how this affects mortality and morbidity. It also examines factors influencing physical health, and discusses the role nurses can play in screening for physical conditions in vulnerable groups.     

The Physical Health of Individuals Receiving Antipsychotic Medication: A Qualitative Inquiry on Experiences and Needs

Individuals with a mental illness are reported to have a reduced life expectancy and a greater risk of being affected by preventable physical illnesses such as cardiovascular disease and Type 2 diabetes. This inquiry sought to identify the physical health beliefs, experiences and needs of individuals with mental health problems in receipt of antipsychotic medication who live in the community. A qualitative inquiry was undertaken using three focus groups in a community mental health service in Ireland with 21 participants with mental health problems who were treated with antipsychotic medication. The participants were clear about the importance of good physical health as well as good mental health. They disliked the adverse effects of antipsychotic medication and experienced many barriers in accessing general practitioners/primary care services. They also preferred to receive health advice and self-management advice from the mental health services. The participants in this study were aware of the need to engage in health protective behaviours but were often overwhelmed by their comorbid health issues and the organizational and communication barriers in accessing their general practitioners.     

Clinical Supervision and the Well-Being of the Psychiatric Nurse

Recent mental health care policy has addressed the need for health care professionals to consider the physical health of consumers. Mental health nurses are particularly well-placed for this role. To provide mental health nurses with practical information, this narrative review summarises evidence from recent research on the physical health of individuals with Serious Mental Illness (SMI). In those with SMI, the international prevalence of obesity, the metabolic syndrome, diabetes mellitus, symptoms of cardiovascular disease, and respiratory disease all exceed that of the general population by at least two times, and HIV prevalence may be increased by as much as eight times. This increased prevalence of chronic disease may be largely responsible for an increased risk of death of up to five times, resulting in as much as 30 years of potential life lost. Of particular concern, the recent evidence suggests that for physical health and increased mortality, the gap between individuals with SMI and the general population is worsening. Unhealthy lifestyle behaviours undoubtedly play a role in the development of poor physical health and chronic disease, and the present review indicates that low physical activity, poor diet, smoking, alcohol and substance abuse, and risky sexual behaviour are common in individuals with SMI. This narrative review demonstrates that the prevalence of poor physical health and health behaviours in people with SMI far exceed that observed in the general population, and reinforces the urgent need for mental health nurses to address physical health concerns in patients.     

Providing physical health care for people accessing mental health services: Clinicians’ perceptions of their role

The prevalence of health risk behaviours and associated poor physical health is high in people with severe mental illness. Mental health service guidelines and policies stipulate that mental health services should address physical health of people who access services. This study reports results from a large, interdisciplinary, cross‐sectional study exploring mental health clinicians’ (n = 385) views of role legitimacy in physical health service provision. All disciplines reported that mental health clinicians have a role to play in addressing the physical health of consumers. Among mental health clinicians, psychiatrists and mental health nurses received higher endorsement than allied health clinicians in relation to the provision of physical health care, with primary care providers including general practitioners also ranking highly. As community mental health services routinely appoint allied health staff to case management roles, a challenge for services and a challenge for clinicians are to ensure that physical health and the effects of medication are monitored appropriately and systematically. Online and telephone support services received relatively lower endorsement. As the availability of nonface to face services increases, there is a need to explore their utility in this population and where appropriate promote their uptake.     

Role of the mental health nurse towards physical health care in serious mental illness: an integrative review of 10 years of UK literature

People with serious mental illness have significantly poorer physical health compared to the general population. Mental health nurses are in a prime position to help reduce unacceptable death in this population. A literature search was undertaken to identify the role of the mental health nurse in regards to physical health care, intervention, and attaining the necessary knowledge to address the physical health needs of people in the UK with serious mental illness. Of 254 papers identified, nine met the inclusion criteria. An integrative literature review found that mental health nurses are not routinely supported by physical health-care education and training, with many expressing role ambiguity. Inpatient setting correlated to a less positive role attitude; poor primary-secondary care interface communication compounded the problem of this vulnerable population having their physical health needs identified and met.