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Effective care for patients with mental health conditions

Anne Dyson
RMN
Community Psychiatric Nurse
Sheffield Health and Social Care NHS Foundation Trust

Imelda Murphy
RMN BSc MSc
Psychosocial Interventions Nurse Senior Practitioner
Sheffield Health and Social Care NHS Foundation Trust

The physical health needs of people with mental health problems have not always been at the forefront of community nursing interventions. However, practice nurses can play a key role

In recent years the physical health of people with serious mental health problems has developed into an area of concern for both the patient and for practitioners responsible for managing their care, including primary care trusts (PCTs) and secondary mental health services. Research has shown that mental ill health has a significant effect on an individual's physical wellbeing:

  • People with a serious mental illness are three times more likely to die prematurely from natural causes than the general public.1
  • While smoking is the greatest single cause of illness and premature death in the UK, the incidence of smoking is three to four times higher in those with a serious mental illness than in the general public.2
  • Diabetes is two to three times higher in people with schizophrenia and in those with bipolar disorder than the general public.3
  • Cardiovascular disease (CVD) is the leading natural cause of death in patients with schizophrenia.4
  • People with a serious mental illness experience a three-fold increase in coronary heart disease (CHD) mortality at age 18-49 with a two-fold increase between the ages of 50-75.5
  • Death rates in those with a serious mental illness from stroke were 2.5 times greater in those younger than 50 years and almost twice as high in 50-75 year olds.6

Reasons for increased risk of mortality in CVD patients with mental health problems include avoidance of contact with the GP, lack of awareness regarding physical health problems, alcohol and substance misuse, smoking, inactivity, poor nutrition, weight gain and diabetes hyperprolactinaemia.7

The National Institute for Health and Clinical Excellence (NICE) guidelines for schizophrenia suggest that GPs and other primary health workers should regularly monitor the physical health of people suffering from the condition.8 Similarly, the guidelines for bipolar disorder state that patients who initially present with the condition should be assessed for smoking status, alcohol use, height and weight, blood pressure and full bloods, followed by an annual physical health review including glucose, weight, smoking status and alcohol use. Cholesterol levels should be taken for people over the age of 40 even if there is no indication of risk.8

In 2008, an audit undertaken within a Sheffield community mental health team (CMHT) looked at practitioners' awareness of their patients' physical health. The results identified a clear lack of knowledge in this area.

The key recommendations from the audit are centred around engaging primary care providers in annual physical health reviews, and improving the way in which information is sought for patients. Secondary mental health services should develop systems for those patients who are not accessing their GP practice to ensure an annual health review takes place. Secondary mental health services should be developing physical health education/packages to improve patient's physical health.

A second audit in 2009 concentrated on the number of patients who attended their GP practice for an annual physical health review with the aim of improving the physical wellbeing of patients within the CMHT.

Methodology
The audit identified 81 patients within the team. Data were collected by sending an information sheet to GP practices requesting a copy of the patient's current prescription, blood pressure, weight, body mass index (BMI), alcohol consumption, smoking, relevant blood tests including blood glucose and cholesterol. From 81 patients identified there was a 75% return (61 forms).

Findings
Of the 61 returned forms, 41 had annual health review. Of those 20 patients who did not have a yearly health review, only 10 were accessing their GP and 10 had been seen within six months.

The results identified no difference between males and females attending for annual health checks. Results did not show any differences in the number of patients from ethnic minorities.

The quality of the annual health review showed a limited number of patients receiving an annual physical health review and forms were often incomplete. A total of 60.7% had their blood pressure taken, 40% had been weighed, 25% had a blood glucose and cholesterol check, 39.3% gave information on smoking and 16.4% on alcohol intake.

Discussion
Of a total of 25 practices, 19 gave a 100% response. Some practices raised concerns around confidentiality and information sharing. There was no real difference between ethnic minority groups or genders for having a yearly health review, which means that any work around such reviews does not have to focus on a target population but rather on service users with a serious mental health problem.

Of the returned form, two-thirds of patients had received an annual health review. The quality of the forms returned highlighted concerns about the quality of information captured.

It was noted that 60% of people had their blood pressure monitored; however, there was little information regarding the alcohol and smoking status of patients. An understanding of this is vital for the management of overall physical health for those with serious mental health problems due to their vulnerability to CVD and diabetes. Only a quarter of patients had a glucose and cholesterol check.

These results raised questions as to why all patients have not had an annual health review and the quality of such reviews undertaken. When considering answering these questions we need to bear in mind the ability/confidence of patients to engage with their GP practices.
 
Patients may not feel confident in providing information regarding alcohol and smoking if they feel that they are going to be encouraged to give these up, as they are often part of the individual's coping strategies. Patients may decline routine blood tests due to lack of information around the importance of these. Anecdotal information from patients suggests that they feel their mental health issues override their physical health needs.

[[Box 1 mental]]

As part of the overall care of patients with serious mental health problems there is a responsibility to ensure they receive an annual physical health check. The initial responsibility for this lies with GP practices under the guidelines of the Quality and Outcomes Framework (QOF). The NICE guidelines go on to say that the secondary health service also has to be actively involved in ensuring patients have an annual physical health review.

A summary of the results of the audit is as follows:

  • Not all patients are receiving annual physical health reviews.
  • The quality of the annual health check is limited.
  • Secondary mental health services assume that annual health reviews have been completed by GP practices.
  • GP practices and secondary mental health services need to work collaboratively to ensure all patients with serious mental problems receive annual physical health checks.

Conclusion
It is clear that patients with serious mental health problems are at higher risk of certain conditions. Their lifestyle and treatments are a huge contributing factor. There is increasing concern about how these health risks can be reduced, how health problems should be managed, and how we should work towards preventing them through regular health reviews and promoting positive wellbeing. Legislation makes it clear that responsibility for achieving the best possible health for people with a serious mental health problem lies with the whole team, across both primary and secondary care.

What this audit has demonstrated is that most GP practices are willing to engage with secondary care in providing information regarding patients' physical health. The number of patients receiving an annual health review is not as high as it should be and the quality of reviews is not capturing the information necessary to improve the patient's physical health.

Work needs to focus on the collaboration between primary and secondary care as to the way we address the physical health of those people with mental health problems. The role of the practice nurse is fundamental to the implementation of this process and through communication between the practice nurse and community psychiatric nurse the health of this group of patients can be significantly improved.

References
Harris EC, Barraclough B. Excess mortality of mental disorder. Br J Psychiatry 1998;173:11-53.
Jeste D, Gladsjo J, Lindamer L, Lacro J. Comorbidity in schizophrenia. Schizophrenia Bulletin 1996;22(3):414-30.
Bushe C, Holt R. Prevalence of diabetes and impaired glucose tolerance in patients with schizophrenia. Br J Psychiatry 2004;184(Suppl 47):S67-71.
Brown. Causes of excess mortality in schizophrenia. Br J Psych 2000;177:212-17.
Osborn D, Levy G, Nazareth I, Petersen I, Islam A, King M. Relative risk of cardiovascular and cancer mortality in people with severe mental illness from United Kingdom's General Practice Research Database. Arch Gen Psychiatry 2007;64:242-9. 
Lambert TJ, Velakoulis D, Pantelis C. Medical co morbidity in schizophrenia. Med J Aust 2003;5;178(Suppl):S67-70.
National Institute for Health and Clinical Excellence (NICE). Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. Clinical Guideline 1. London: NICE; 2002.
NICE. Bipolar disorder: The Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and Secondary Care. Guideline 1. London: NICE; 2006.

Resources
British Heart Foundation
W: www.bhf.org.uk

Rethink
W: www.rethink.org