Somatic Care Research Articles

‘Working as a Real Nurse’: Nursing Students’ Experiences of a Clinical Education Ward in Psychiatric Care

Although the concept of clinical education wards has shown encouraging outcomes regarding nursing students’ satisfaction with clinical placements in somatic care, the existing research in a psychiatric context is sparse. This study aims to explore nursing students’ experience during clinical education at a psychiatric clinical education ward. A qualitive descriptive study with content analysis, using interviews with 16 bachelor’s degree nursing students was conducted. The results indicated that an enriched and adapted learning environment focusing on psychiatric nursing with peer learning supported independence and progression into the future nursing role.

Early Detection of Psychological Comorbidity in Patients Admitted to Dermatological and Internal Medicine Wards: A New Care Model for Psychosomatic Consultation Service

This article explains the development and implementation of a psychosomatic screening and consultation service for inpatient somatic care. Approximately one in six somatic inpatients has a mental disorder. It is estimated that only half of these cases are properly identified. Consequently, a large proportion of patients remains untreated. To address this gap in care, a psychosomatic early detection programme was developed by an interdisciplinary working group. This programme is based on the Patient Health Questionnaire-4 (PHQ-4), a psychometrically very well evaluated ultra-short screening questionnaire for the detection of depressive and anxiety disorders. For implementation in routine inpatient care, the PHQ-4 was programmed as a form in the electronic medical record and administered by nursing staff during the admission interview. If the PHQ-4 screening result indicates the presence of a mental comorbidity and the patient expresses a wish for assessment of this disorder, a psychosomatic consultation is automatically ordered. The PHQ-4 was implemented into the clinical routine in four internal medicine and three dermatology wards of the University Medical Center Hamburg-Eppendorf. Documentation of the early diagnosis in the electronic patient record is a minimally costly, less time-consuming and practicable method of providing patients with holistic care through rapid interdisciplinary referral. An evaluation of cost-effectiveness, clinical efficiency, and acceptance is still pending.

Poor family relationships in adolescence as a risk factor of in-patient somatic care across the life course: Findings from a 1953 cohort.

BackgroundPrior research has shown that poor family relations during upbringing have long-term detrimental effects on mental health. Few previous studies have, however, focused on somatic health outcomes and studies rarely cover the life span until retirement age. The aims of the current study were, firstly, to examine the association between poor family relationships in adolescence and in-patient somatic care across the life course whilst adjusting for confounders at baseline and concurrent psychiatric in-patient care; and secondly, to compare the risks of somatic and psychiatric in-patient care across the life course.MethodsProspective data from the Stockholm Birth Cohort study were used, with 2636 participants born in 1953 who were followed up until 2016. Information on family relationships was collected from the participants’ mothers in 1968. Annual information on in-patient somatic and psychiatric care was retrieved from official register data from 1969 to 2016.ResultsPoisson regressions showed that poor family relationships in adolescence were associated with an increased risk of in-patient somatic care in mid- and especially in late adulthood (ages 44–53 and 54–63 years), even when controlling for the co-occurrence of psychiatric illness and a range of childhood conditions. No statistically significant association was observed in early adulthood (ages 16–43 years), when controlling for confounders. These findings are in sharp contrast to the analyses of inpatient psychiatric care, according to which the association with poor family relations was strongest in early adulthood and thereafter attenuated across the life course.ConclusionPoor family relationships in adolescence are associated with an increased risk of severe consequences for somatic health lasting to late adulthood even when controlling for confounders including in-patient psychiatric care, emphasising the potentially important role of early interventions.

Bumpy road: implementing integrated psychiatric and somatic care in joint-specialty emergency departments: a mixed-method study using Normalization Process Theory

PurposeLife expectancy is 15–20 years shorter for individuals with than for people without mental illness. Assuming that undiagnosed and undertreated somatic conditions are significant causes, the Central Denmark Region set out to implement joint psychiatric and somatic emergency departments (EDs) to support integrated psychiatric/somatic care as an effort to prolong the lifetime of individuals with mental illness. Through the lens of Normalization Process Theory, the authors examine healthcare frontline staff’s perceptions of and work with the implementation of integrated psychiatric/somatic care in the first joint-specialty ED in Denmark.Design/methodology/approachA single-case mixed-methods study using Normalization Process Theory (NPT) as an analytic framework to evaluate implementation of psychiatric/somatic integrated care (IC) in a joint-specialty emergency department. Data were generated from observations, qualitative interviews and questionnaires distributed to the frontline staff.FindingsImplementation was characterized by a diffuse normalization leading to an adaption of the IC in a fuzzy alignment with existing practice. Especially, confusion among the staff regarding how somatic examination in the ED would ensure prolonged lifetime for people with mental illness was a barrier to sense-making and development of coherence among the staff. The staff questioned the accuracy of IC in the ED even though they recognized the need for better somatic care for individuals with mental illness.Practical implicationsThis study highlights that a focus on outcomes (prolonging lifetime for people with mental illness and reducing stigmatization) can be counterproductive. Replacing the outcome focus with an output focus, in terms of how to develop and implement psychiatric/somatic IC with the patient perspective at the center, would probably be more productive.Originality/valueIn 2020, the Danish Health Authorities published new whole-system recommendations for emergency medicine (EM) highlighting the need for intensifying integrated intra and interorganizational care including psychiatric/somatic IC (ref). Even though this study is not conclusive, it points to subjects that can help to identify resources needed to implement psychiatric/somatic IC and to pitfalls. The authors argue that the outcome focus, prolonging the lifetime for individuals with mental illness by identifying somatic illness, was counterproductive. In accordance with the recommendations of contemporary implementation studies, the authors recommend a shift in focus from outcome to output focus; how to develop and implement psychiatric/somatic IC.

Uncovering re-traumatization experiences of torture survivors in somatic health care: A qualitative systematic review.

Little research has focused on torture survivors’ re-traumatization experiences in health and hospital units that treat somatic diseases, though any medical procedure can re-traumatize survivors. This study’s purpose was to summarize qualitative research evidence on torture survivors’ somatic healthcare experiences and to identify “triggers” or “reminders” that can lead to re-traumatization. The study’s search strategies identified 6,326 citations and eight studies, comprising data from 290 participants, exploring encounters with healthcare providers from torture survivors’ perspectives, which were included in the present research. Dallam’s Healthcare Retraumatization Model was used as a framework for data extraction and analysis. Five main themes were elicited from the findings: (1) invisibility, silence, and mistrust; (2) healthcare providers’ attitudes and a lack of perceived quality in healthcare; (3) disempowerment; (4) avoidance; and (5) satisfaction and gratitude. An analysis of the study’s findings revealed that torture survivors do not receive adequate healthcare and may experience challenges during treatment that can result in re-traumatization. The findings of this literature review provide a basis for understanding the difficulties that survivors experience in receiving somatic healthcare, as well as an explanation of the re-traumatization process.

Covid-19 infectious disease is also a psychogeriatric disease

Severe forms of Covid-19 infectious disease often affect the frail elderly. They can induce inaugural psychiatric manifestations or aggravate the underlying psychiatric pathologies. Some of these pathologies persist after the acute episode and require specific management. Doctors and caregivers involved in the care of infected patients are themselves exposed to psychological and even psychiatric difficulties and are looking for collaborative help complementing actions in the somatic care sectors.

Stigma as a Barrier to Treatment for Former Residents of GDR Children's Homes - A Qualitative Study with Members of the "Betroffeneninitiative Missbrauch in DDR-Kinderheimen"

Exploratory study of stigma as a barrier to treatment with former GDR home children with traumatic experiences. Discussion of the topic "stigmatisation" within a self-help group for people with abuse experience in GDR children's homes using an interview guideline. Transcription and processing of the material based on the thematic analysis. The participants report stigmatisation in public, in the family and structurally. These experiences can be related to strong perceived barriers to treatment in somatic and psychosocial care. For the psychotherapeutical treatment of this group, it is important to consider perceived barriers to treatment and to give patients sufficient space to address traumatic experiences and their consequences.

Quality of treatment outcomes in alcohol- and substance-related disorders: an evaluation of inpatients from ten psychiatric hospitals

Alcohol and substance-related disorders (ICD 10 F1x.x) are among the most frequent diagnoses made in hospitalized patients requiring somatic and psychiatric care. In order to assess the success of treatment, it is important to establish and implement outcome indicators in practice. In 2016, global treatment indicators for admission and at discharge were collected at 10 Vitos clinics in Hesse (CGI and GAF). More than 10,000 patients with ICD10 F1x diagnoses were included in the evaluation. The evaluations show significant improvements of the clinical status as well as differences in treatment duration, remissions and gender differences. The study suggests that global indicators of outcome quality are useful in the assessment of treatment success of alcohol and substance-related disorders. Limitations of the study design, instruments and sample are critically reviewed.

Public attitudes and health law in conflict: somatic vs. mental care, role of next of kin, and the right to refuse treatment and information

BackgroundNorwegian law and regulations regarding patient autonomy and the use of coercion are in conflict with the Convention on the Rights of Persons with Disabilities (CRPD) and the Oviedo Convention on several points. A new law concerning the use of coercion in Norwegian health services has been proposed. In this study we wanted to investigate the attitudes of the Norwegian lay populace with regards to some of these points of conflict.MethodsAn electronic questionnaire with 9 propositions about patient autonomy, the use of coercion, the role of next of kin, and equality of rights and regulations across somatic and mental health care was completed by 1617 Norwegian adults (response rate 8.5%).ResultsA majority of respondents support the patient’s right to refuse treatment and information in serious illness, that previously expressed treatment preferences should be respected, that next of kin’s right to information and authority in clinical decision-making should be strengthened, and that this kind of legal regulations should be equal across somatic and mental health care.ConclusionsThe findings in this study suggest that the opinions of the Norwegian lay populace are in conflict with the national law on several points relating to patient autonomy, the role of next of kin and use of coercive measures, and different legal regulation of somatic vs. mental health care. The study suggests that the populace is more in line with the CRPD, which supports equal rights across somatic and mental health care, and the Oviedo Convention, which does not allow for the same degree of strong paternalism regarding coercive measures as the current Norwegian law. This can be taken to support the recently proposed legislation on the use and limitation of coercion in Norwegian health services.

Cultural dynamics and tensions when applying design thinking for improving health-care quality

Purpose The purpose of this paper is to contribute knowledge concerning the dynamics and potential cultural tensions that occur when applying user involvement and design thinking (DT) for improving quality in a health-care setting. Design/methodology/approach This paper is based on a case study following a quality improvement (QI) project in a medium-sized Swedish county council in the field of somatic care. The project involved eight health-care professionals, one designer, four patients and two relatives. A multiple data collection method over a period of ten months was used. It included individual interviews, e-mail correspondence and observations of workshops that covered the QI project. Findings The result shows tensions between QI work and the daily clinical work of the participants. These tensions primarily concern the conflict between fast and slow processes, the problem of moving between different fields of knowledge, being a resource for the individual clinic and the system and the participants’ expectations and assumptions about roles and responsibilities in a QI project. Furthermore, these findings could be interpreted as signs of a development culture in the health-care context. Practical implications There are several practical implications. Among others, the insights can inspire how to approach and contextualize the current concepts, roles and methods of DT and user involvement so that they can be more easily understood and integrated into the existing culture and way of working in the health-care sector. Originality/value This study provides a unique insight into a case, trying to uncover what actually is going on and perhaps, why certain things are not happening at all, when user involvement and design practices are applied for improving health-care quality.

The somatic care situation of people with mental illness.

Background and AimsPeople with mental illness have worse physical health and reduced life expectancy compared to the general population. Nevertheless, their medical care is often insufficient. The present study aimed to investigate the somatic status of people with mental illness with a focus on somatic diagnoses, metabolic risk factors, regular somatic care, and routine check‐ups.MethodsThis study used a 14‐item questionnaire to survey the somatic care situation of psychiatric university hospital patients. Main survey topics were psychiatric and somatic diagnoses, metabolic risk factors, regular somatic care, and routine check‐ups.ResultsFour‐hundred and thirty‐five people with mental illness (48.3% male, mean age 45.4 years) were included. More than three quarters of the participating people with mental illness had access to a general practitioner. People with affective and anxiety disorders reported significantly more contact with medical specialists for somatic diseases, but schizophrenic patients did not receive enough care. Not all people with mental illness and on psychiatric medication received regular somatic care. Somatic diseases increased with number of diagnoses, and the duration of the psychiatric illness was positively correlated with treatment motivation.ConclusionThe observed unmet medical needs in this study might reflect the lack of treatment motivation in people with mental illness, but could also represent their obstacles to access care as well as a suboptimal communication between the treating psychiatrist and the referring general practitioner. Increasing awareness of somatic diseases in psychiatric patients and easier access to somatic care have to be implemented in psychiatric clinical routine. The risk of stigmatization in somatic institutions and the lack of self‐care management in people with mental illness are complicating factors.

Healthcare Costs, School Performance, and Health-related Quality of Life in Adolescence Following Psychotic Experiences in Preadolescence: A Longitudinal Cohort Study.

Psychotic experiences (PEs) are common in the general population in preadolescence. The implications of PEs on socioeconomic outcomes, including educational attainment, are scarcely described. We aimed to estimate how preadolescent PEs were associated with later healthcare costs, school performance, and health-related quality of life (HRQoL) in adolescence. A total of 1607 preadolescents from the general population Copenhagen Child Cohort 2000 were assessed for PEs at age 11-12 years and followed up over 5 years using register-based data on mental and somatic healthcare costs, and school performance at age 16. Furthermore, HRQoL was assessed for a subsample of the children at age 16-17. We adjusted for perinatal and family sociodemographic adversities, prior parental mental illness and healthcare use, child IQ-estimate at age 11-12, and parent-rated general psychopathology of their child. PEs were associated with slightly poorer school performance. However, preadolescents with PEs more often reported HRQoL within the lowest 10th percentile (OR = 2.74 [95% CI 1.71-4.37]). Preadolescents who reported PEs had higher average total healthcare costs over the following 5 years. The costs for individuals with PEs were higher for mental healthcare services across primary to tertiary care, but not for somatic care. After adjustments, PEs remained independently associated with higher costs and poorer HRQoL, but not with poorer school performance. In conclusion, PEs are important in mental health screening of preadolescents and identify a group of young people with increased healthcare service-use throughout adolescence and who report poorer HRQoL in adolescence, over and above parent-rated general psychopathology of their child.

Severely increased generalized anxiety, but not COVID-19-related fear in individuals with mental illnesses: A population based cross-sectional study in Germany.

The COVID-19 pandemic affected individuals, governments, and health care centers all around the globe. Social isolation obligation, restricted working shifts, and curfews posed unprecedented challenges for the population. Social isolation, boredom, and financial problems have been shown to stress peoples' mental health in previous comparable pandemics and even in regular situations. Individuals with a mental illness may particularly be at risk due to an already instable mental health status. While research mainly focused on the pandemic's impact on somatic health care and risk group patients, psychological obstacles caused by legal restrictions and their impact on already mentally affected individuals have been discussed, but so far only scarcely been investigated in a large sample. For this study, 12,028 people completed an online-survey during that time in Germany, when the COVID-19 outbreak gained momentum with a surge in cases and death rates as well as a lockdown of the public life. Generalized anxiety (GAD-7), depression (PHQ-2), distress (distress thermometer) and COVID-19-specific items, especially COVID-19-related fear, were assessed in healthy individuals, patients suffering from mental illnesses, and in patients with chronic somatic diseases, known to be at risk for an unfavorable course of COVID-19. Results show that the COVID-19-pandemic significantly worsens psychometric scores throughout the population - individuals with already heightened levels, like people with mental illnesses now reach concerning levels. Surprisingly, even though generalized anxiety, depressive symptoms, and perceived distress are elevated in individuals with mental illness, these individuals seem to be less affected by explicit COVID-19-related fear, than the general population or individuals with chronic somatic diseases. This study thus objectively quantifies the psychological impact of COVID-19 in a large sample and provides evidence for not only the public, but also critically affected individuals with a mental illness.

Competency requirements for the assessment of patients with mental illness in somatic emergency care: A modified Delphi study from the nurses’ perspective

Patients suffering from mental illness are vulnerable, and they do not always have access to proper emergency care. The aim of this study was to identify competency requirements for the assessment of patients with mental illness by soliciting the views of emergency care nurses. A modified Delphi method comprising four rounds was used. Data were collected in Sweden between October 2018 and March 2019. The data were analyzed using content analysis and descriptive statistics. The panel of experts reached the highest level of consensus regarding basic medical knowledge: the capability to listen and show respect to the patient are essential competency requirements when assessing patients with mental illness in emergency care. Awareness of these competency requirements will enhance teaching and training of emergency care nurses.

Psychotherapists' perspective on the treatment of patients with somatic symptom disorders

ObjectiveGuidelines recommend psychotherapy in addition to primary care for patients with moderate to severe somatic symptom disorders. While general practitioners' experiences have been well studied, psychotherapists' experiences with this patient group and the explanatory models psychotherapists use in psychotherapy are unknown. MethodsSemi-structured qualitative interviews were conducted between April and July 2018 with 20 German licensed outpatient psychotherapists with either a medical or a psychological background, using the label “somatoform disorders”. Interviews were analyzed applying thematic analysis. ResultsPsychotherapists experienced management of affected patients as challenging and partly frustrating, mainly due to the difficult diagnostic process and the “somatic fixation” of some patients. Diagnostic labelling was considered a delicate issue, with some psychotherapists using the term “somatoform”, while others preferred either “functional” or vague descriptions like “psychosomatic”. The explanatory process was deemed essential for treatment, as was the adaptation of explanations to both a patient's biography and language. As main explanatory factors, psychotherapists referred to generic vulnerability factors, previous somatic illness and health care system influences. ConclusionsExplanatory models used in psychotherapy are patient-centred, processual and constitute a major component of the psychotherapeutic process. However, this process might be impeded if patients are confronted with different diagnostic labels and explanatory models during their pathways through care.

Cardiovascular risk screening of patients with serious mental illness or use of antipsychotics in family practice

BackgroundPatients with serious mental illness (SMI) and patients on antipsychotics (AP) have an elevated risk for cardiovascular diseases. In the Netherlands, the mental healthcare for these patients is increasingly taken care of by family practitioners (FP) as a result of a shift from secondary to primary care. Therefore, it is essential to increase our knowledge regarding the characteristics of this patient group and the (somatic) care provided by their FPs. The aim was to examine the rate of cardiovascular risk screening in patients with SMI or the use of AP in family practice.MethodsWe performed a retrospective cohort study of 151.238 patients listed in 24 family practices in the Netherlands.From electronic medical records we extracted data concerning diagnoses, measurement values of CVR factors, medication and frequency of visits over a 2 year period. Primary outcome was the rate of patients who were screened for CVR factors. We compared three groups: patients with SMI/AP without diabetes or CVD (SMI/AP-only), patients with SMI/AP and diabetes mellitus (SMI/AP + DM), patients with SMI/AP and a history of cardiovascular disease (SMI/AP + CVD). We explored factors associated with adequate screening using multilevel logistic regression.ResultsWe identified 1705 patients with SMI/AP, 834 with a SMI diagnosis, 1150 using AP. The screening rate for CVR in the SMI/AP-only group (n = 1383) was adequate in 8.5%. Screening was higher in the SMI/AP − +DM (n = 206, 68.4% adequate, OR 24.6 (95%CI, 17.3–35.1) and SMI/AP + CVD (n = 116, 26.7% adequate, OR 4.2 (95%CI, 2.7–6.6). A high frequency of visits, age, the use of AP and a diagnosis of COPD were associated with a higher screening rate. In addition we also examined differences between patients with SMI and patients using AP without SMI.ConclusionCVR screening in patients with SMI/AP is performed poorly in Dutch family practices. Acceptable screening rates were found only among SMI/AP patients with diabetes mellitus as comorbidity. The finding of a large group of AP users without a SMI diagnosis may indicate that FPs often prescribe AP off-label, lack information about the diagnosis, or use the wrong code.

Comparison of Anxiety and Depression Scores in Patients with Oral Lichen Planus and Normal Individuals

Introduction: Oral lichen planus (OLP) is a common chronic inflammatory, psycho-mucocutaneous disease affecting about 1%–4% of the general population associated with psychoneuroendocrine and psychoimmunological comorbidities. Lichen planus although it is not an infectious disease, its cause is unknown, it is classified as an autoimmune disorder that may be precipitated or exacerbated by psychosocial stress. The Hospital Anxiety and Depression Scale (HADS) was originally developed to indicate the possible presence of anxiety and depressive states in the setting of a medical outpatient clinic and was found to perform well in assessing the anxiety disorders and depression in both somatic, psychiatric and primary care patients and in the general population. Aims: The aim of this study is to evaluate the levels of psychological status and the impact of treatment on psychological status in OLP individuals and compare it with normal individuals. Materials and Methods: Forty OLP patients along with the same number of age- and gender-matched healthy controls were included in the study. HADS questionnaire was administered to all 40 OLP (start of therapy) and 40 non-OLP individuals. In the OLP Group (40 participants): 20 were given “active” intervention with Cyclosporine Oral Solution (Group A), 20 were given “placebo” intervention (Group P). HADS questionnaire was given to all the twenty participants of Group A and all twenty participants of Group P at the end of therapy. The questionnaire consisted of 14 questions; 7 questions pertaining to anxiety and 7 pertaining to depression. Results: High level of anxiety (47.5%) and depression (85%) was observed in participants with OLP as compared to non-OLP (0%). After the active intervention, 14 participants were relieved of anxiety as compared to 8. Comparison of the prevalence of depression in OLP individuals before and after getting “active” intervention revealed that on getting active intervention the depression present in all 20; 1 (10%) mild and 9 (90%) frank came down to 1 (10%), and 4 (40%) mild. Five (50%) participants were completely relieved of depression. Conclusion: Lichen planus is to some extent a psychosomatic or somatopsychic disease or both. The present study results matches with the majority of the studies, showing a positive association between anxiety and depression levels in OLP patients, suggesting counseling along with traditional treatment can be effective in reducing the size of the lesions. Oral healthcare providers should pay attention to the emotional state of their patients. Emotional factors are important as evidenced by higher frequency of psychiatric symptoms, poor quality of life, higher level of anxiety, and neuroendocrine and immune dysregulations. Counseling may help in ameliorating symptoms, improving quality of life, and enhancing recovery.

Prise en charge des comorbidités cardio-vasculaires chez les jeunes patients souffrant d’une psychose débutante : état des lieux et perspectives thérapeutiques

Patients with psychiatric disorders have a decrease in their life expectancy. Excess mortality of patients with schizophrenia was demonstrated by a meta-analysis in the late 1990s and has not decreased for the past 30years. A recent meta-analysis including nearly 250,000 patients with schizophrenia found an average decrease in life expectancy of 14.5years (CI95: 11,2–17,8), more important for men than for women: 15.9 (CI95: 13,8–18,0) vs 13.6 (CI95: 11,4–15,8). A closer look at the somatic comorbidities, including metabolic syndrome, and investigation of causes of death of these patients highlighted already well-known factors, namely late diagnosis and insufficient treatment of physical diseases, side effects of antipsychotics, unhealthy lifestyle (poor diet, smoking, excessive alcohol consumption and lack of exercise), and higher risk of suicide and accident. Concerning ultra-high risk (UHR) patients, a 2016 meta-analysis of 47 studies evaluated the cardiovascular risk factors. They reported a higher prevalence of smoking in UHR (odds ratio 2,3) and a lower level of physical activity associated with a normal BMI (Body Mass Index) compared to the control population. A meta-analysis about patients with a first episode of psychosis (FEP) found reduced total and LDL cholesterol levels and an increased triglyceride level compared to the control population. One study found alteration of the fasting plasmatic levels of glucose and insulin, as well as insulin resistance in FEP patients, compared to controls albeit the HbA1c level was not significantly different. A meta-analysis reported a prevalence of metabolic syndrome of 10 % in FEP or drug naïve patients versus 35 % and 20 % in treated and untreated patients with chronic schizophrenia respectively. Somatic comorbidities usually appear during the first two years of the disease. Some interventions have proven their efficacy in reducing the occurrence of metabolic syndrome and other cardiovascular risk factors. For instance, metformin, a treatment for type 2 diabetes that is allowed from the age of 10, has shown benefits in children and adolescents receiving second-generation antipsychotics in a recent meta-analysis, with a mean weight loss of 3.23kg (IC95 % −5.59 −0.86) after 16 weeks. Dietary-hygienic interventions are also effective in reducing cardiovascular risk. Other interventions such as omega-3 supplementation, vitamin D, N-acetylcysteine, and fasting have not proven to be effective. Comprehensive care programs have been developed to promote somatic care in psychiatric patients, such as the Canadian HeAL (Healthy Active Lives) program. These programs are more effective when proposed from the beginning of the disease and the introduction of antipsychotics. In this review, because there is no French recommendation, we translate a tool for the prescription of metformin and the Canadian recommendations from the HeAL program. Generalization of these programs to all young psychotic patients could improve their life expectancy and reduce the overall mortality. Prevention of cardiovascular risk factors and cardio-metabolic monitoring of treatments must be part of the standard of care in early psychosis. These programs aim at providing patients with the quality of somatic and mental care they are entitled to. This requires the involvement of all stakeholders, including patients and their families but also psychiatrists and other caregivers.

Oyster Care: An Innovative Palliative Approach towards SPMI Patients.

Oyster Care is the result of the search by caregivers in Flanders, Belgium, to develop quality care for patients with a Severe and Persistent Mental Illness (SPMI). This article offers a conceptual analysis of the Oyster Care model, based on experiences, analysis, and reflection of the authors, and on several examples. The starting point of the development of this new care model is the complex and difficult context of the care for SPMI patients. Their needs and suffering are very challenging on account of a wide variety of causes. At the same time they are in danger of being neglected by the care system. Paradoxically, the development and implementation of psychosocial rehabilitation in Belgian mental health care puts the care for these patients under pressure. In practice, they are often exposed to over- or under-treatment. Another aspect that has influenced the search for more qualitative care in cases of severe psychological suffering in general and palliative approaches in particular is the background of the legal regulation of euthanasia in Belgium. Oyster Care is an innovative form of the palliative approach and philosophy, tailored to the specific target group of SPMI patients. The caregivers create an “exoskeleton” or “shell” in which SPMI patients can “come to life”: they are mainly dependent on the “external structure” they receive in order to function, rather than on the “internal structure” of their abilities. It is a dynamic approach that responds to the needs, possibilities and pace of each patient: within this safety, people can fold back or take new steps. Oyster Care is also a holistic care approach, based on four pillars: physical care adequately responding to the somatic impairments of these patients; psychological care changing the scope of therapy by focusing on mental comfort and wellbeing; social care providing a structure of daily activities and contacts; existential care enhancing the experience of life as valuable and meaningful. The wellbeing of patients is paramount and requires a range of interventions, such as a highly personal approach, a flexible dealing with rules, a great dose of creativity in everyday life, extensive expertise in somatic care, and specific attention to existential needs and the search for meaning. The development of this care model in a number of care units in Flanders increases the wellbeing of the patients and creates a significant positive dynamic among caregivers. However, more research and resources are needed to further develop and integrate this model.

Effect of Sit-to-Stand Exercises Combined With Protein-Rich Oral Supplementation in Older Persons: The Older Person's Exercise and Nutrition Study

ObjectivesNursing home (NH) residents are often undernourished and physically inactive, which contributes to sarcopenia and frailty. The Older Person's Exercise and Nutrition Study aimed to investigate the effects of sit-to-stand exercises (STS) integrated into daily care, combined with a protein-rich oral nutritional supplement (ONS), on physical function, nutritional status, body composition, health-related quality of life, and resource use. DesignResidents in 8 NHs were randomized by NH units into an intervention group (IG) or a control group (CG) (n = 60/group). The IG was a combination of STS (4 times/day) and ONS (2 bottles/day providing 600 kcal and 36 g protein) for 12 weeks. Setting and ParticipantsThe participants resided in NH units (dementia and somatic care), were ≥75 years of age, and able to rise from a seated position. MethodsThe 30-second Chair Stand Test was the primary outcome. Secondary outcomes were balance, walking speed, dependence in activities of daily living, nutritional status and body composition, health-related quality of life, and resource use. ResultsAltogether, 102 residents (age 86 ± 5 years, 62% female) completed the study. No improvement in the physical function assessments was observed in the IG, whereas body weight increased significantly (2.05 ± 3.5 kg, P = .013) vs the CG. Twenty-one (of 52) participants with high adherence to the intervention (ie, at least 40% compliance to the combined intervention) increased their fat free mass (2.12 kg (0.13, 4.26 interquartile range), P = .007 vs CG). Logistic regression analyses indicated that the odds ratio for maintained/improved 30-second Chair Stand Test was 3.5 (confidence interval 1.1, 10.9, P = .034) among the participants with high adherence compared with the CG. Conclusions/ImplicationsTwelve-week intervention of daily STS combined with ONS in NH residents did not improve physical function, but increased body weight. Subgroup analyses indicated that high adherence to the combined intervention was associated with maintained or improved physical function and a gain of fat free mass.