Poor Physical Health Of People Research Articles

Making sense of self-care practices at the intersection of severe mental illness and physical health-An Australian study.

The poor physical health of people who experience severe mental illness (SMI) is an important public health issue that has been acknowledged, yet not properly addressed. People who live with SMI perform a myriad of complex tasks in order to take care of their physical health, while receiving unpredictable levels of support and assistance from health professionals. In this qualitative study, we aimed to uncover the kinds of work people with SMI do in order to look after their physical health. In a metropolitan area in Queensland, Australia, 32 people with lived experience of SMI participated in semi-structured, face-to-face interviews. Data were digitally recorded, transcribed verbatim and open coded. They were then themed using a constant comparative process. We found that people with SMI were engaged in a "rhythm of life with illness" that consisted of relatively short, acute and chaotic cycles of mental and physical illness, accompanied by much longer mental and physical illness recovery cycles. Participants engaged in three specific types of health-related work to manage these cycles: discovery work (and the associated role of the health professional); sense-making work to meaningfully interpret health and illness; and embedding work to become engaged self-managers of illness and producers of health. We discuss how varying levels of support from health professionals impact consumers' self-management of their physical and mental health; how health professionals influence consumers' experience of treatment burden; and implications for practice.

Shared decision making: People with severe mental illness experiences of involvement in the care of their physical health

Addressing the poor physical health of people with severe mental illness (SMI) occurs within a complex mix of individual requirements. People with SMI often have demanding health and illness management workloads, which they are required to perform on a daily basis. Most clinical studies lack information on how much people are affected by the side effects they experience and how to manage these problems. Mental health staff often consider that their primary target is to reduce psychotic symptoms rather than health promotion. Therefore, the objective of this qualitative study was to describe the current experience of people with SMI, with the view to exploring ways that they might be involved in managing their physical health. Thirty-two people with lived experience of mental illness within a defined geographic area in Queensland, Australia, participated in semi-structured face-to-face interviews. Data were digitally recorded, transcribed verbatim and analysed using qualitative content analysis. Four key areas in which people with SMI were able to be involved in their health were identified: care continuity within a fragmented care system; medication management; credibility and being mastered; and self-mastery and self-managing health. Shared decision making in mental health care can contribute to equality, control and recovery. Involving people with SMI in shared decision making will contribute positively to their overall health. However, substantial changes are required to shift the health system from a traditional “health professional as expert” approach to one with the patients in the centre.

The chasm of care: Where does the mental health nursing responsibility lie for the physical health care of people with severe mental illness?

The poor physical health of people with a severe mental illness is well documented and health professionals' attitudes, knowledge and skills are identified factors that impact on clients' access to care for their physical health needs. An evaluation was conducted to determine: (i) mental health nurses' attitudes and beliefs about providing physical health care; and, (ii) the effect that participant demographics may have on attitudes to providing physical health care. It was hypothesized that workplace culture would have the largest effect on attitudes. Nurses at three health services completed the "Mental health nurses' attitude towards the physical health care of people with severe and enduring mental illness survey" developed by Robson and Haddad (2012). The 28-item survey measured: nurses' attitudes, confidence, identified barriers to providing care and attitudes towards clients smoking cigarettes. The findings demonstrated that workplace culture did influence the level of physical health care provided to clients. However, at the individual level, nurses remain divided and uncertain where their responsibilities lie. Nursing leadership can have a significant impact on improving clients' physical health outcomes. Education is required to raise awareness of the need to reduce cigarette smoking in this client population.

Physical health and mental illness: listening to the voice of carers

Background: Shortened life expectancy of people with mental illness is now widely known and the focus of research and policy activity. To date, research has primarily reflected perspectives of health professionals with limited attention to the views and opinions of those most closely affected. The voice of carers is particularly minimal, despite policy stipulating carer participation is required for mental health services.Aim: To present views and opinions of carers regarding physical health of the people they care for.Methods: Qualitative exploratory. Two focus groups and one individual interview were conducted with 13 people identifying as carers of a person with mental illness. Research was conducted in the Australian Capital Territory. Data analysis was based on the thematic framework of Braun and Clarke.Results: Two main themes were interaction between physical and mental health; and, carers’ own physical and mental health. Participants described the impact of mental illness and its treatments on physical health, including their own.Conclusions: Carers are acknowledged as crucial for the delivery of high quality mental health services. Therefore they have an important role to play in addressing the poor physical health of people with mental illness. Hearing their views and opinions is essential.

The value of physical examination in mental health nursing

This article explores the use of a physical examination assignment in a mental health general nursing clinical placement course that addresses the poor physical health of people with mental illness and the barriers traditionally impeding health care provision for this population. A descriptive qualitative approach utilizes inductive content analysis to investigate 145 student survey responses. The assignment assists student nurses in understanding that physical and mental well-being are intrinsically linked. Students report increased comfort performing a physical examination on patients with mental illness post assignment. Students' initial bias towards this population was minimized post the clinical assignment. Poor physical health is common among people with mental health problems. Many view the provision of care as a major public health issue. Nurses are the front line caregivers of mental health service consumers and are well positioned to assess their physical needs. Their assessment may be the first step in recognizing health care issues in this population.

Consensus building to improve the physical health of people with severe mental illness: a qualitative outcome mapping study.

BackgroundThe poor physical health of people with severe mental illness (SMI) is often attributed to lifestyle, disease-related medication side effects and disparate provision of healthcare. The complexity and inexact nature of this issue prohibits the identification of a clear and concise causal pathway, which in turn leads to uncertainty and imprecision about the most appropriate action to address the problem. One proposed solution is to integrate care across multiple organisations and sectors through collaborative processes. The objective of this study was to identify collective pathways of action that were consensually developed and which could be initiated by clinicians to improve the physical health of people with severe mental illness.MethodsEighteen participants from a service catchment area in Australia were involved in a consensus-building workshop. This resulted in participants identifying and committing to a range of collaborative actions and processes to improve the physical health of people with severe mental illness. Consensus building was combined with an outcome mapping process, which has previously been used to facilitate health system integration. Data from the consensus-building workshop were thematically analysed and used to create an outcome map.ResultsParticipants identified that accessible, continuous, holistic, consumer-driven, recovery-oriented care was required if improved physical health of people with SMI were to be achieved. However, this all-encompassing care was dependant on a wide-ranging philosophical shift in two areas, namely societal stigma and the dominance of pharmacological approaches to care. Participants believed that this shift was contingent on the attitude and behaviours of healthcare professionals and would require an inclusive, networked approach to care delivery and maximal utilization of existing funding.ConclusionsRarely do multiple stakeholders from different sectors within the healthcare system have the opportunity to come together and create a collective vision for improving the health of a specific population in a defined area. We used a consensus building approach to generate solutions, actions and goal statements, which were then used to create a visual map that provided a purpose and signposts for action, thereby maximising the potential for cohesive action across sectors.

Consensus building and outcome mapping techniques can achieve an integrated roadmap for action to improve the physical health of people with severe mental illness

Introduction: The poor physical health of people with severe mental illness (SMI) is often attributed to lifestyle, disease-related medication side effects and disparate healthcare provision. The complex and inexact nature of this interaction between physical and mental health leads to uncertainty and imprecision about the most appropriate action required to address the problem. One proposed solution is to integrate care by using collaborative processes across multiple organisations. Theory / Methods: Consensus building was combined with an outcome mapping process, which has previously been used to facilitate health system integration. Eighteen participants from a service catchment area in Australia were involved in a consensus-building workshop. Data from the consensus-building workshop were thematically analysed and used to create an outcome map. Results: Participants identified that accessible, continuous, holistic, consumer-driven, recoveryoriented care was required if the physical health of people with SMI were to be achieved. However, this all-encompassing care was dependent on a wide-ranging philosophical shift in two areas, namely societal stigma and the dominance of pharmacological approaches to care. Discussion: No single organisation, team, disciplinary group or individual practitioner had the entire suite of knowledge and skills to deliver all components of the identified strategies. Therefore, networks and networking were essential, and integrated solutions that facilitated program and service coordination needed to be developed. In response, we created an outcome map to capture both the higher-level outcomes that participants were striving to achieve and the processes and actions that had been agreed by participant stakeholders. The outcome map visually represented both the socially defined meaning of the problem of the poor physical health of people with a severe mental illness and the multiple action pathways required. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116602– http://www.ijic.org/ Conclusions: We used a consensus building approach to generate solutions, actions and goal statements, which were then used to create a visual map that provided a purpose and signposts for action, thereby maximizing the potential for cohesive action across sectors. Lessons learned: Consensus-building workshops are practical and useful ways of developing pathways for action that include multiple sectors in integrated approaches to improving the physical health of people with SMI. Limitations: Although participants identified the need to work across sectors, important sectors such as law enforcement, housing and employment were not included in the consensus development process. However, including these sectors was beyond the scope of this project. A further limitation to this research is that the research was conducted in a defined geographical area and might therefore, not be transferable to other contexts. Future research: Including a broader range of stakeholders, including consumers and carers, should be considered in future research that is seeking to address complex issues. Further research is also required using identified implementation theories to facilitate the adoption of the action strategies identified in the outcome map into routine practice.

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.

Dying young: Excess morbidity and mortality in individuals with severe mental illness and what we should be doing about it

“We talk about people with mental illness, and people with diabetes, and smokers and the obese, and so on and so on. We’re talking about the same people – just with different labels.”– Health care professional [1, p. 6]Severe mental illness (SMI) most commonly refers to mental disorders with a psychotic component and significantly reduced functioning despite the presence of inherent differences in risk factors, etiologies, and treatments [1]. The most common disorders that fall under this term include schizophrenia and bipolar disorder [1]. Over a decade of research into the morbidity and mortality of individuals with SMI has consistently revealed mortality rates two to three times higher and a life expectancy of 25-30 years shorter compared to the general population [1-4]. Contrary to popular belief, the main causes of early death are not drug overdose or suicide, but rather, preventable illnesses such as cardiovascular disease, diabetes, and HIV/AIDS [1,3,5-7]. Incidence of other preventable conditions, such as obesity and respiratory disease, is also much higher among patients with SMI, and when present, is associated with a more severe course of mental illness and a reduced quality of life [3,8]. Such findings bring significant questions: what is the cause of this disparity in mortality/ morbidity? What can health care professionals do to help reduce this gap?A recent report by the Early Onset Illness and Mortality Working Group [1] outlines several factors that may contribute to poor physical health of people with SMI. Some factors, such as those related to the mental illness itself (e.g., cognitive impairment, a lack of communication skills, medication side-effects) and socioeconomic status (e.g., poverty, poor education) may be less amenable to modification, but should nevertheless be a target for action. Other contributing factors include behaviour and lifestyle (e.g., physical inactivity, obesity, tobacco smoking), and poor preventative medical care (e.g., disparity in quality of medical care), both of which are more easily modifiable with the assistance of medical care practitioners. Here we will summarize the factors responsible for poor physical health in SMI, specifically focusing on the mental illness itself, socioeconomic status, behaviour and lifestyle, health care system barriers, and insufficient preventative medical care. We will then propose future directions and ways in which medical students and current medical professionals can help reduce this gap.

Innovations aimed at improving the physical health of the seriously mentally ill: an integrative review

The aim of this paper is to report an integrative review of the literature that focused on innovations aimed at enhancing the physical health of people with serious mental illness. Despite the abundance of literature that highlights the relationship between serious mental illness and physical ill health, the provision of physical health care for the seriously mental ill remains a challenge. Many different strategies have been developed, which endeavour to address the poor physical health of people with serious mental illness. However, there is inadequate evidence to establish the success of these strategies. Integrative literature review. The review was conducted using an adapted version of Whittemore and Knafl's review method to critically appraise and evaluate the literature. Results. Three main themes derived for the types of intervention in the studies emerged from the review. These included assessment, health education/health promotion and multimodal interventions. Although there is some evidence to demonstrate that health assessments are effective in highlighting physical health problems, the evidence to support health education and multimodal interventions is far from conclusive. Further research is needed, in particular larger intervention and longitudinal studies, to help nurses decide on the best possible interventions that will improve the physical health of the seriously mentally ill. Whilst nurses' continued attempts to develop health-enhancing interventions are commendable, there needs to be a greater focus on conducting research to develop the evidence base to guide and support nurses in this area of their practice. Until robust and convincing evidence is available, policy relating to the advancement of the physical health of people with serious mental illness should be developed cautiously.

‘Problematising’ Australian policy representations in responses to the physical health of people with mental health disorders

Australia, like other jurisdictions, is recognising the poorer physical health of people with mental health disorders. This paper explores policy responses to this issue through discourse analysis of 22 Australian Federal and State government policy documents published in 2006–2011. The paper utilises Bacchi's ‘what's the problem represented to be?‘ approach to explore policy solutions in relation to the representation of the issue, enabling identification of issues which are not problematised and policy solutions that have not been considered. The poor physical health of people with mental health disorders is attributed in policy to poor lifestyle habits and limited access to monitoring of physical health care. Three policy solutions are offered: collaborative care delivery involving greater use of fee‐for‐service primary care to manage physical health; the monitoring of physical health status by mental health teams; and the promotion of lifestyle change. These solutions fail to address ongoing issues with collaboration between specialist mental health and primary care services. Reliance upon fee‐for‐service primary mental health care may, in fact, reduce rather than increase access to services. The strategies are discussed in light of neoliberal ideals of governance and personhood which are underpinned by informed consumer choice and personal responsibility for health.

Letter – Lessons learnt from a pilot bicycle program with community mental health service consumers

Physical activity improves mental health. Building on previous work promoting cycling in the general community, we trialled an innovative cycling program for mental health service consumers in the former Sydney South West Area Health Service. The poor physical health of people with a mental illness is well documented. Increasing consumer?s physical health is difficult and the literature surrounding the issue is limited. One study found that outside activity significantly improves self esteem and mood.

Review: A systematic review of hypothalamic-pituitary-adrenal axis function in schizophrenia: implications for mortality

There is convincing evidence that environmental stress plays a significant role in modifying both mental and physical health. The biological mechanisms linking stress to ill health are not fully understood, but significant evidence points to a central role of the stress axes; the hypothalamic–pituitary–adrenal (HPA) axis and the sympathetic nervous system. Together these two systems link the brain and the body and are crucial in maintaining homeostasis as well as improving an organism’s survival chances in the face of environmental challenge. There is evidence of altered HPA axis function in people with a range of mental disorders, and this may in part explain the poor physical health of people with psychotic, mood and anxiety disorders. This paper systematically reviews HPA axis function in people with schizophrenia and relates this to the pattern of physical health seen in this disease. In summary, the evidence suggests people with schizophrenia can experience both hyper- and hypo-function of the HPA axis. It is likely that this contributes to the pattern of poor physical health and premature mortality suffered by people with schizophrenia, in particular the high rates of cardiovascular and metabolic disturbance.

Inequalities in healthcare provision for people with severe mental illness.

There are many factors that contribute to the poor physical health of people with severe mental illness (SMI), including lifestyle factors and medication side effects. However, there is increasing evidence that disparities in healthcare provision contribute to poor physical health outcomes. These inequalities have been attributed to a combination of factors including systemic issues, such as the separation of mental health services from other medical services, healthcare provider issues including the pervasive stigma associated with mental illness, and consequences of mental illness and side effects of its treatment. A number of solutions have been proposed. To tackle systemic barriers to healthcare provision integrated care models could be employed including co-location of physical and mental health services or the use of case managers or other staff to undertake a co-ordination or liaison role between services. The health care sector could be targeted for programmes aimed at reducing the stigma of mental illness. The cognitive deficits and other consequences of SMI could be addressed through the provision of healthcare skills training to people with SMI or by the use of peer supporters. Population health and health promotion approaches could be developed and targeted at this population, by integrating health promotion activities across domains of interest. To date there have only been small-scale trials to evaluate these ideas suggesting that a range of models may have benefit. More work is needed to build the evidence base in this area.

Behavioural interventions to reduce the risk of physical illness in persons living with mental illness

It is beyond dispute that people living with mental illness suffer a disproportionate disease burden when compared with people in the general population. This review considers the efficacy and effectiveness of lifestyle behavioural interventions at service delivery level as a strategy to reduce the risk factors that contribute to somatic disease comorbidity. As many factors contribute to the very poor physical health of people living with mental illness and as there are no 'quick fix' remedies, strategies to improve physical health need to be sustainable on a system-wide basis. Most studies of behavioural interventions at best report modest success during the period of the intervention. However, even limited success can significantly reduce the likelihood of physical comorbidities developing. Unfortunately, the evidence suggests that any gains during the intervention are mostly lost over time. The implication is that interventions need to be sustainable over the long-term. When planning behavioural interventions, consideration ought to be given to extending them over a period of years not weeks or months. Approaches that include additional on-going support beyond the intervention period itself promote a greater likelihood of maintaining the improved physical health of the target population.

Editorial

An important paper (1) in this month's journal draws attention again to what the authors call ‘poor health behaviour’ in patients with all major psychiatric diagnoses, especially schizophrenia and depression. I prefer the terms ‘physical health’ and ‘lifestyle’, but no matter. The findings are not surprising, but are discouraging. Health behaviour of 363 psychiatric in-patients with various diagnoses, including schizophrenia, affective illness and neurotic disorders was compared with that of a sample of 7200 persons of the German general population. More patients smoked and abused drugs and alcohol. Their diet was unhealthy and BMI was increased in those with schizophrenia. An intriguing finding was that patients with depression were more physically active than members of the general population – I wish the authors had speculated a little bit more as to why this might be. These findings add to the already considerable literature on physical health and severe mental illness, although most of the work has focussed on schizophrenia. People with schizophrenia, both men and women, die on average 10 years earlier than members of the general population. Suicide is the most notable cause, but is now believed to account for only about 5% of deaths (2). Natural causes predominate, especially cardiovascular and respiratory disease. Other conditions more common in schizophrenia include eye cataracts, diabetes and possibly the metabolic syndrome; their dental health is poor (3). The main putative factors that contribute to the poor physical health of people with schizophrenia include the illness itself, lifestyle and medication. With regard to the illness, two recent studies from Dublin, Ireland found that first episode patients had greater visceral obesity (4) and impaired fasting glucose levels (5) than healthy volunteers. With regard to lifestyle, a previous study on diet (6) found that compared with the general population, fewer individuals with schizophrenia consumed acceptable levels of fruit, vegetables, milk, potatoes and pulses. The recommended daily intake of fruit and vegetables is five portions; people with schizophrenia were consuming only 16 portions per week (6). With regard to medication, antipsychotics are implicated in obesity and sexual dysfunction, especially erectile dysfunction which is common in people with schizophrenia (7). As the authors of the paper in this month's journal point out and discuss there are probably complex neurobiological, psychosocial and treatment related factors important in the relationship between severe mental illness and physical health. Whatever the reason, this and previous papers have shown that our patients with severe mental illness, especially schizophrenia, are amongst the most vulnerable and disadvantaged in our community. What to do about it is another matter. Interventions to help people with schizophrenia stop smoking have not produced impressive results (8). The first double-blind study of bupropion, a noradrenaline- and dopamine-reuptake inhibitor, for smoking cessation in people with schizophrenia found the drug to be modestly effective for smoking cessation, without worsening the symptoms of schizophrenia (9). The first randomized controlled trial of a dietary intervention in people with schizophrenia (10) found that, when given free fruit and vegetables for 6 months, patients consumed markedly more fruit and vegetables than control (treatment-as-usual) patients. However, 12 months after the intervention, consumption had fallen back to pretreatment levels. It can be hard to involve people with severe mental illness in programmes designed to improve their physical health. For example, although 179 men were approached to take part in the first double blind study of sildenafil in men with schizophrenia and erectile dysfunction, only 24 consented to enter the study (11). Who should be responsible for monitoring the physical health of people with severe mental illness? In the UK, an authoritative body, the National Institute for Health and Clinical Excellence, is in no doubt that ‘secondary services should undertake regular and full assessment on the mental and physical health’ of people with schizophrenia (12). This may be so, but tackling satisfactorily the causes of poor physical health in people with severe mental illness still appears to be a long way off. To finish on an historical note. Although I would certainly not advocate a return to the ‘good old (paternalistic) days’, things were very different 40 years ago, when I entered psychiatry. Most people with severe mental illness, especially schizophrenia, spent much of their adult lives in a psychiatric hospital. There, their access to cigarettes was controlled; there was little or no alcohol or drug misuse; hospital food, though ‘stodgy’, was more nutritious; there were many opportunities to work (industrial therapy, the farm, domestic and clerical work); and ample opportunity to meet people of the opposite sex. Nowadays people with severe mental illness have choices; their lifestyle is not imposed upon them. So the question today is: how far should ‘professionals’ impose their view of a satisfactory lifestyle on patients?

The poor physical health of people with mental illness.

Results of most research on the physical health of people with mental illness suggests the morbidity and the mortality from certain physical conditions is high in people with long-term mental illnesses. In this review, I examine the physical health of psychiatric patients, especially those with schizophrenia or depression and some possible explanations for any inequities in their health status. I also discuss the health care that psychiatric patients receive, both in terms of recognition of physical illness and subsequent intervention, with particular reference to cardiovascular disease. Finally, I review potential barriers to effective care and methods for overcoming these.