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General health checks for mental health clients

David Law
BSc CMHN RMN
Specialist Practitioner
Community Psychiatric Nurse
Riverside Community Mental Health Team
Riverside Resource Centre
Glasgow
E:david.law@glacomen.scot.nhs.uk

In Glasgow, community mental health services are empowered to provide a multidisciplinary and interagency approach to holistic care for people with mental health problems; however, it remains unknown to what level they provide a health and wellbeing screening service. Client-focused care is central to the Scottish Executive's healthcare policy that stresses the importance of clients' views in forming policy and service development.(1) The reduction of health inequalities and improving access to care and services for all sections of society is a priority for people with mental ill- health in Scotland. In the UK, the National Framework for Mental Health states that people with severe mental illness (SMI) should have their physical health needs assessed.(2) This is supported within the new General Medical Services (GMS) Contract, which includes a quality framework for which GP practices can qualify for additional income when they deliver a range of quality standards.(3) There are 41 points available on completion of the mental health indicator.
It is known that many factors contribute to the poor health of those suffering SMI, including high incidence of substance misuse, poor diet, smoking, irregular exercise and deprivation.(4,5) In a recent study it was found that clients with SMI appear to have an increased risk of death from circulatory and respiratory conditions, indicating that people who suffer from SMI appear to be at greater risk of experiencing poor general health and increased co-morbid medical illness.(6)
Newer "atypical" antipsychotic medication represents one advance in the management of SMI. However, some of these new agents may contribute to some unpleasant side-effects, such as excess weight, increases in cholesterol, triglyceride and glucose levels, as well as sexual dysfunction. These potential side-effects, as well as affecting concordance rates, may substantially increase the risk of developing other conditions such as diabetes and cardiovascular disease. This suggests that improving the physical health of our clients is extremely important. However, many mental health practitioners have little training in physical healthcare.(7) It has been suggested that physical assessments of psychiatric patients by psychiatrists are poor and the monitoring of physical health by community mental health staff is generally unsatisfactory.(8)
It was in response to these issues and guidelines that the clinic was established initially as a short-scale pilot study, which is designed to aid the clinician and client to assess and manage some of the following: weight gain, hyperprolactinaemia, sexual health, sedation, hyperlipidaemia and cardiovascular risk factors, extrapyramidal side-effects, postural hypertension, and altered glucose metabolism and hyperglycaemia.

Pilot project
The Health and Wellbeing pilot project was implemented in Riverside Resource Centre, located in the west of Glasgow, providing mental health services for a population of around 100,000 people.
The centre operates as a multidisciplinary team (MDT) and has 26 staff of various disciplines, including community psychiatric nurses (CPNs), occupational therapists, psychiatrists, psychologists and social workers. It has a caseload of approximately 1,200 clients, a third of whom suffer from severe and enduring forms of mental illness.
Following discussions with local stakeholders (clients, carers, GPs, the primary care trust, housing associations, colleges, and voluntary and statutory organisations) it was agreed that a steering group be formalised and that a pilot project would be implemented within the Riverside community mental health team (CMHT).
Awareness of the pilot was created by using posters, leaflets, word-of-mouth recommendation, and attendance at local meetings and by staff presentations to local support groups. Clients and carers were invited to complete a questionnaire, in which they outlined their general health concerns, their potential usage of the clinic facility and, if interested, availability details.
More than 120 clients completed and returned the questionnaire, 70 of whom were referred by clinical staff. A further 50 were currently attending other clinics within the resource centre such as the continuing care clinic and clozapine blood analysis clinic.
Of those expressing an interest, 35 were randomly selected to participate in the pilot project, all of whom were diagnosed as having a severe and enduring form of mental illness - 31 had schizophrenia and four had bipolar affective disorder.

Clinic sessions
The clinic sessions ran on a Monday using premises within the resource centre. Four staff provided the pilot service: three CPNs and one healthcare assistant. Two staff were trained to carry out venepuncture, and all staff were trained to use the health screening equipment, but only the CPNs administered the rating scales. A health and wellbeing assessment tool was developed for use within the clinic.
Each client was expected to participate in two one-hour sessions over a week. The first session was designed to deal with specific health issues and involved detailing each client's current lifestyle pattern. A physical health screening was conducted in which height, weight, waist measurement, blood pressure, pulse, BMI, temperature and body fat percentage were recorded, and blood samples were collected for analysis of cholesterol, glucose, triglycerides, lipids and full blood count.
General health and wellbeing issues were raised in the second session, such as diet, exercise, smoking and chemical substance misuse. Any positive changes to lifestyle behaviour were suggested and discussed.
On a long-term basis, these sessions would need to be repeated at 12-month intervals, or more frequently if required. In addition, medication management and concordance were assessed and discussed through the use of a series of rating scales, including the Liverpool University Neuroleptic Side-Effects Rating Scale (LUNSERS).(9) From the results of these, and in conjunction with outcomes from both sessions, further interventions might be necessary, and these would be discussed with other clinical staff involved with the client, such as the consultant psychiatrist, GP or primary care team.

Results
The 35 clients were therefore scheduled for 70 sessions during the pilot study. Of these clients, five (15%) failed to attend the scheduled sessions. The non-attendees consisted of two clients who failed to attend for either session and three clients who failed to attend session two. However, 30 clients (85%) attended for both sessions as planned.
Of the 35 clients selected, 22 (63%) were male and 13 (37%) female. Eight (23%) were aged under 40 years, 18 (51%) were aged between 40 and 49 years, and the remaining nine (26%) were aged 50 or above.
Of these clients, over half acknowledged that they had never had a review of their general health, and almost all agreed that they felt their general health could be better.
Sixteen clients (46%) were smokers, although only four of these expressed a desire to stop. Almost half also acknowledged that the use of alcohol or other substances was a factor for concern in their lifestyles.
Most cited a number of issues that they felt prevented them from being in better health. These included lack of time, willpower and funds and, in general, were consistent with the view expressed by the general population.
However, for these clients, the effects of mental illness are an additional contributory factor. A benefit of the approach used in this pilot is that the promotion of "good health" lifestyle choices is being provided by staff competent also to take account of the effects of both mental illness and related treatments, particularly with respect to medication compliance and side-effects.
In terms of anticipated benefits, clients were asked at the outset to specify issues on which they would welcome advice (see Table 1).

[[NIP24_table1_48]]

The issues raised by these clients confirm that, aside from mental health problems, the most common concerns related to weight, exercise and dietary issues. Given the prominence of these issues in the media, this is not unexpected, particularly as over half these clients had a BMI above 25, thereby classifying them as pre-obese, with a further third considered to be clinically obese.
It was also clear from the responses that most clients did not engage in any specific form of exercise other than activity related to domestic tasks or walking required by their general lifestyle arrangement.
The majority of the 16 smokers recognised this as a problem, but since only four of these clients had previously expressed the desire to stop, there is perhaps a concern that a tendency to smoke might prove to be more prevalent among clients of mental health services. In addition, the implications of alcohol consumption, stress and drug usage, although less evident as concerns, cannot be ignored.
It emerged that these clients were also using healthcare services other than those provided under the mental health umbrella. For example, five clients had consulted their GP up to six times in the previous year, eight had done so between seven and 12 times, and three more frequently.
In addition, over half of these clients had reason to attend an A&E department in the previous year and two thirds had seen nursing staff based within the CMHT.

Medication related issues
As expected, given the diagnoses of severe and enduring mental illness for all of these clients, they were all in receipt of most of the more common medications used in treatment, and most received a combination of medications, including those administered by intramuscular injection.
Almost half noted that their concordance was erratic and a third indicated that they experienced side-effects, to the extent that they complied reluctantly.
Given the potential consequences of poor medication compliance, ie, in terms of relapse, this is evidently of concern. A further consideration is the importance of monitoring side-effects in order to minimise them, or at least manage them effectively, to ensure that concordance is enhanced. The issue of medication management must therefore be viewed as key to improving the general health of these clients, in addition to their other mental healthcare needs.
In service planning terms, there are already substantial community psychiatric nursing resources allocated to the administration of depot medication by injection. Thus, the extent to which drug administration activity and a health and wellbeing service may overlap, and the possibility of their provision by use of a "one-stop service", dealing with both issues, may be considered.
 
Other client feedback
This was overwhelmingly positive, which is not surprising given that the expressions of interest outnumbered the places available by a factor of three.
From the postpilot questionnaire the following feedback was received:

  • 30 clients preferred individual rather than group sessions.
  • Seven clients were prepared to attend as many sessions as required.
  • 30 clients felt that the times offered were convenient.
  • 28 clients noted that the leaflet information provided was useful.

In the longer term, wider aspects of efficacy and impact on overall service provision may need to be looked at. However, this will require a larger sample than used in this pilot, as well as a research methodology designed to evaluate the specific health benefits that may be achieved, a major component that would feature in any future health and wellbeing service established as a consequence of this pilot project.

[[NIP24_cs1_50]]
 
Conclusion
There are benefits to the general health status of clients by offering a health and wellbeing service, as proved by the positive response to this pilot programme. However, there is no specific provision for health and wellbeing screening within existing mental health services in Glasgow, which constitutes an unmet need. Such a service could "bolt on" to existing provision, where clients currently have frequent contact with the mental health services and, as such, could make use of this service on a regular basis. Providing a health and wellbeing facility will enhance the overall scope of mental health services, not only providing direct benefits for clients, but also wider benefits for health services in general.

References

  1. Scottish Executive. National programme for improving mental health and well-being action plan 2003-2006. Edinburgh: HMSO; 2003.
  2. DH. A national service framework for mental health. London: DH; 1999.
  3. BMA. Investing in general practice: the new general medical services contract. London: BMA; 2003.
  4. Casey PA. Guide to psychiatry in primary care. 2nd ed. Guildford: Biddles; 1997.
  5. Kendrick T. Br J Psychiatry 1996;169:733-9.
  6. Taylor D, et al. The South London and Maudsley NHS Trust 2003 prescribing guidelines. 7th ed London: Martin Dunitz Taylor and Francis Group; 2003.
  7. Luckstead A, et al. Psychiatr Serv 2000;51:1544-8.
  8. Phelan M, et al. BMJ 2001; 322(7284):443-4.
  9. Day W, et al. Br J Psychiatry 1995;166:650-3.