Challenges in mental health care

1. Challenges in mental health care School of Nursing and Midwifery

2. 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@uea.ac.uk w: http://eastanglia.academia.edu/RichardGray School of Nursing and Midwifery

3. “Look to your health; and if you have it, praise God, and value it…” IZAAK WALTON 1593-1683 School of Nursing and Midwifery

4. Why do research? School of Nursing and Midwifery

5. Why do research? • To enhance patients quality of life, health and experience of healthcare • IMPACT • Research without impact is pointless School of Nursing and Midwifery

6. School of Nursing and Midwifery

7. How much younger will you die if you have schizophrenia? School of Nursing and Midwifery

8. 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 School of Nursing and Midwifery 1. Arch Gen Psychiatry. 2007;64(10):1123-1131

9. What is the major cause of death for people with schizophrenia? School of Nursing and Midwifery

10. 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 School of Nursing and Midwifery 1. Arch Gen Psychiatry. 2007;64(10):1123-1131

11. What is the major cause of death for people with schizophrenia? School of Nursing and Midwifery

12. 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) School of Nursing and Midwifery 1. Robson D. and Gray R. (2006) Int J Nursing Studies 2. Arch Gen Psychiatry. 2007;64(10):1123-1131

13. Why is life expectancy getting worse? School of Nursing and Midwifery

14. It’s the nasty drugs we give them… School of Nursing and Midwifery

15. Mean change in weight with antipsychotics Estimated Weight Change at 10 Weeks on “Standard” Dose 6 5 4 † 3 Weight Change (Kg) 2 * 1 0 -1 -2 -3 Placebo Quetiapine Fluphenazine Aripiprazole Clozapine Ziprasidone Risperidone Chlorpromazine Olanzapine Haloperidol Thioridazine School of Nursing and Midwifery *4–6 week pooled data (Marder et al. Schizophr Res. 2003;1;61:123-36; †6-week data adapted from Jones et al. ACNP; 1999.Allison et al. Am J Psychiatry. 1999;156:1686-1696.

16. Medication is good for you… …If you have schizophrenia/bipolar illness (or depression) School of Nursing and Midwifery

17. Neuroprotection with olanzapine vs haloperidol School of Nursing and Midwifery

18. School of Nursing and Midwifery

19. 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? School of Nursing and Midwifery

20. 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 School of Nursing and Midwifery

21. 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 School of Nursing and Midwifery Eldridge et al (in prep) BMI and Obesity in Schizophrenia

22. Average BMI=30.0 School of Nursing and Midwifery

23. Prevalence of obesity in men (n=272) School of Nursing and Midwifery Eldridge et al (in prep) BMI and Obesity in Schizophrenia

24. Prevalence of obesity in women (n=225) School of Nursing and Midwifery Eldridge et al (in prep) BMI and Obesity in Schizophrenia

25. Why is obesity so prevalent in patients with SMI? School of Nursing and Midwifery

26. It’s the nasty drugs we give them (again)… School of Nursing and Midwifery

27. BMI category by psychotropic medication School of Nursing and Midwifery Eldridge et al (in prep) BMI and Obesity in Schizophrenia

28. BMI category by psychotropic medication Mean bmi; no medication=25, any medication=30, p<.05 School of Nursing and Midwifery Eldridge et al (in prep) BMI and Obesity in Schizophrenia

29. 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 School of Nursing and Midwifery Eldridge et al (in prep) BMI and Obesity in Schizophrenia

30. 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) School of Nursing and Midwifery Eldridge et al (in prep) BMI and Obesity in Schizophrenia

31. Prevalence of other lifestyle behaviours • 51% had an unhealthy diet • High in fat, <5 portions of fruit and veg a day, high in calories • 44% took no regular activity • 58% smoked • Many motivated to quit • >85% 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 School of Nursing and Midwifery

32. A quick word about sex School of Nursing and Midwifery

33. 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 School of Nursing and Midwifery

34. What do mental health nurses think about physical health? School of Nursing and Midwifery

35. 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 School of Nursing and Midwifery Robson D. (in prep) Survey of mental health nurses

36. 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 School of Nursing and Midwifery Robson D. (in prep) Survey of mental health nurses

37. How good are we at monitoring physical wellbeing? School of Nursing and Midwifery

38. Metabolic screening is below recommended levels % patients screened Fewer than 2 in 10 patients are screened for obesity School of Nursing and Midwifery Screening of 4 aspects of metabolic syndrome in the total national sample (n=1966)Barnes et al. Schizophr Bull 2007;33:1397-403.

39. Bells and whistles… The Wellbeing support programme School of Nursing and Midwifery

40. Addressing physical health: the WellBeing support programme School of Nursing and Midwifery

41. 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 School of Nursing and Midwifery

42. 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) School of Nursing and Midwifery 1. Smith S. (2007) International Journal of Clinical practice

43. 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 School of Nursing and Midwifery Eldridge et al (under review)

44. WellBeing in the hands of the NHS • Industry… ‘Wellbeing no longer fits with our strategy’ • Nurse advisors withdrawn from practice • The NHS… ‘it works let’s 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? School of Nursing and Midwifery Eldridge et al (under review)

45. 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 School of Nursing and Midwifery Eldridge et al (under review)

46. 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 hadn’t 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…” School of Nursing and Midwifery Eldridge et al (under review)

47. Outcomes of the programme • Enrolled 754 • Attended 1580 WellBeing sessions • Mean of 2.1 sessions (half the programme) • 159 completed the programme School of Nursing and Midwifery Eldridge et al (under review)

48. Effect on the cohort… None at all School of Nursing and Midwifery Eldridge et al (under review)

49. In those patients that completed the programme School of Nursing and Midwifery Eldridge et al (under review)

50. Sub-group analysis of Wellbeing completers N=159; 2=126.01; df=4; p<0.01 School of Nursing and Midwifery Eldridge et al (under review)