Improving physical health in severe mental illness 1 Dr Sheila Hardy, Education Fellow, UCLPartners and Honorary Senior Lecturer, UCL 15.10.14
Life expectancy Danish study using the entire population: Life-expectancy was 18.7 years shorter for men with schizophrenia and 16.3 years for women (Laursen 2011). The main cause is due to a physical disease (Colton and Manderscheid 2006) o Suicide -13% o Natural causes -80% Mortality gap is equal to diabetes, heart disease and cancer. 2
Physical illness Tuberculosis Chronic obstructive pulmonary disease (COPD) Sexually transmitted infections Hepatitis B/C Sexual dysfunction Obstetric complications Osteoporosis Cancer Dental problems Cardiovascular disease (De Hert et al. 2011) 3
Cardiovascular disease Two meta-analyses of patients with SMI showed: Half were obese Two in five had hypertriglyceridemia Two in five had hypertension One in three had metabolic syndrome, diabetes or pre-diabetes (Vancomfort et al. 2013, Mitchell et al. 2011) 4
Risk factors and care inequalities Modifiable risk factors for CVD are significantly increased in people with mental illness What are these? Smoking Poor diet Low levels of exercise Stress Diagnostic overshadowing Antipsychotic medication Poverty Alcohol 5
Risk factors and care inequalities People with schizophrenia are less likely to have: Monitoring of their physical health Physical examination Prompt diagnosis for a physical problem Intervention to help change unhealthy behaviour (e.g. smoking) Screening for cancer (e.g. mammography) Surgical intervention (e.g. following an MI) 6
Monitoring - secondary care 100 80 60 40 20 0 Percentage of people with schizophrenia monitored (n=5091) Smoking BMI Glucose Lipids Blood pressure All five Royal College of Psychiatrists. (2012) Report of the National Audit of Schizophrenia (NAS). 7
Monitoring - primary care (pre payment incentive) Hardy et al. (2013a) Journal of Mental Health. 8
Monitoring - primary care (post payment incentive) Diabetes Tested Diabetes % tested Severe mental illness Tested Severe mental illness %Tested Chi 2 Statistic P value Blood Pressure 2,298,767 96.1% 355,834 84.1% Chi² = 205712 p <.001 BMI 2,329,552 97.5% 335,652 79.4% Chi² = 691072 p<.001 Cholesterol 2,378,115 98.4% 218,539 71.7% Chi² = 262020 p <.001 HBA1c or glucose 2,363,485 94.9% 197,494 64.8% Chi² = 495257 p <.001 Mitchell and Hardy. (2013) Psychiatric Services. 9
More than monitoring needed Prevention Appropriate medication, lifestyle Early intervention (sooner is better) Support to encourage healthy life styles Suitable advice Groups functional skills, exercise, diet, stop smoking linked to third sector Good communication between services to ensure prompt treatment 10
Preventative activities People with SMI do not usually carry out preventative activities (behaviours which will help avoid physical health problems) These include: All the lifestyle behaviours. Activities such as oral hygiene and foot care, self-examination of breasts and testicles. Attending for regular screening (e.g. dentist, optician, cervical screening, breast screening, bowel screening). Adhering to treatment. What can you do? Encourage and support people with SMI to engage in these activities. 11
How do we do it? inpatient wards Ask yourself: Is there access to outside space and time for exercise? Is the food offered nutritious and appetising? Are people discouraged to smoke? Is there a programme of activity which includes relaxation? Are people with SMI taught to deal with stress and social problems? Can people sleep well (e.g. noise, temperature, comfy bed)? Are people taught how to continue with a healthy lifestyle once they have been discharged? 12
How do we do it? in the community Is promoting a healthy lifestyle in people with mental health problems seen as part of the role of the community mental health nurse, GP, practice nurse, carer, support worker? Are there identified groups within the trust and/or community (e.g. healthy eating, stop smoking, fitness, relaxation) or other organisations (e.g. MIND, local gym) where staff can refer people to for extra support? 13
How do we do it? Everyone involved in care: Taking responsibility Acting as a good role model Understanding what healthy behaviour is Recognising and working with different levels of motivation Supporting the patient to reach their own set goals 14
Training Primary Care 38% of practice nurses would like training to carry out physical health checks for people with SMI (Hardy 2014). Secondary care Over 80% of mental health nurses reported they would like training for the management of diabetes, cardiovascular health, and nutrition. Sixty-nine percent would like education about smoking and 67% reproductive health (Robson et al 2012). What training is available? Very little Module 3 of a 10 module practice nurse package (95% will apply learning to practice, 5% unsure) 15
Monitoring - primary care (post training) Hardy et al. (2013b) International Journal of Social Psychiatry. 16
Offering lifestyle advice following training Hardy et al. (2013b) International Journal of Social Psychiatry. 17
Tools to help nurses Primary Care A website has been created specifically for practice nurses. It has a best practice manual the Health Improvement Profile for Primary Care (HIP-PC) and other useful tools. These can all be downloaded free: http://physicalsmi.webeden.co.uk/ Secondary Care Health Improvement Profile available on request from website above 18
The HIP-PC Primary Care Physical Health Checks for people with Severe Mental Illness (SMI) Best Practice Guide FOURTH EDITION The Health Improvement Profile for Primary Care (HIP-PC) 19
The HIP 20
References Colton CW and Manderscheid RW. (2006) Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease 3 (2): A42. De Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I, et al. (2011) Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 10 (1): 52-77. Hardy S. (2014) Mental health and wellbeing survey: A snapshot of practice nurses views regarding responsibility and training. http://uclpstorneuuat.blob.core.windows.net/cmsassets/mental%20health%20and%20wellbeing%20survey%2020%20jan%202014.pdf Hardy S, Hinks P and Gray R. (2013a) Screening for cardiovascular risk in patients with severe mental illness in primary care: a comparison with patients with diabetes. Journal of Mental Health. 22 (1) 42-50. Hardy S, Hinks P and Gray R. (2013b) Does training practice nurses to carry out physical health checks for people with severe mental illness increase the level of screening for cardiovascular risk? International Journal of Social Psychiatry. Apr 22. [Epub ahead of print] Laursen T. (2011) Life expectancy among persons with schizophrenia or bipolar affective disorder. Schizophrenia Research. 131 (1-3) 101-104. Mitchell AJ, Vancampfort D, Sweers K, van Winkel R, Yu W and De Hert M. (2011) Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders: A systematic review and meta-analysis. Schizophrenia Bulletin 39 (2): 306-318. Robson D, Haddad M, Gray R and Gourney K. (2012) Mental health nursing and physical health care: A cross-sectional study of nurses attitudes, practice, and perceived training needs for the physical health care of people with severe mental illness. International Journal of Mental Health Nursing 22 409 417. Royal College of Psychiatrists. (2012) Report of the National Audit of Schizophrenia (NAS) 2012. London: Healthcare Quality Improvement Partnership. 21 Vancampfort D, Vansteelandt K, Correll CU, Mitchell AJ, De Herdt A, Sienaert P, et al. (2013) Metabolic syndrome and metabolic abnormalities in bipolar disorders: A meta-analysis of prevalence rates and moderators. American Journal of Psychiatry 170: 265-274.
For more information please contact: Sheila.hardy@uclpartners.com www.uclpartners.com @uclpartners 22