Ohlsen_et_al_2005_service_development by BipolarLab.com

et al.

Journal of Psychiatric and Mental Health Nursing, 2005, 12, 614–619

Practice Development Editors: 1 Martin Ward 2 Ann Jackson

Submission address: 1

Cawston Manor, Aylsham Road, Cawston, Norwich, NR10 4JD, UK 2 RCN Institute, Radcliffe Infirmary, Woodstock Road, Oxford, OX2 6HE, UK

Developing a service to monitor and improve physical health in people with serious mental illness R. I. OHLSEN, MRCPsych

1,2

RGN, RMN, DipN

G. PEACOCK

RMN

& S. SMITH

2,4

MBBS

Clinical Research Nurse, Institute of Psychiatry, London, UK, South London and Maudsley NHS Trust, London, 3 4 UK, Nurse Advisor, Well-Being Support Programme, Institute of Psychiatry, London, UK Senior Clinical Lecturer and Honorary Consultant Psychiatrist, Institute of Psychiatry London, UK

Correspondence: Ruth Ohlsen Section of Neurochemical Imaging and Psychiatry Institute of Psychiatry De Crespigny Park London SE5 8AF UK E-mail: r.ohlsen@iop.kcl.ac.uk

OHLSEN R. I., PEACOCK G. & SMITH S. (2005) Journal of Psychiatric and Mental Health Nursing 12, 614–619 Developing a service to monitor and improve physical health in people with serious mental illness Developing effective models of identifying and managing physical health problems amongst mentally ill populations has become a more pressing issue in recent years as the prescription of Second Generation Antipsychotics (SGAs) has burgeoned. Some of the side effects commonly associated with SGAs such as weight gain and metabolic disorders have potentially devastating effects on health and well-being, increasing cardiovascular risk and the incidence of diabetes. The Well-Being Support Programme (WSP), a nurse-led service, was designed to provide a care delivery system whereby physical problems could be identified and appropriate treatment and monitoring initiated by prompt referral to suitable specialist services or general practitioners, forging strong links between primary and secondary care and ensuring that mentally ill patients with physical health problems were receiving holistic care packages. Other problems such as unhealthy lifestyles and obesity were managed by the Nurse Advisor running the programme. Interventions such as weight counselling and groups, and structured exercise programmes were beneficial in terms of encouraging healthier lifestyles, managing obesity and improving self-esteem. This paper describes the manner in which the service was set up and implemented, demonstrating an effective model for identifying and managing physical health problems in the mentally ill. Keywords: antipsychotic, communication, lifestyle, physical health, selfesteem Accepted for publication: 8 June 2005

614

Service to monitor and improve physical health

Introduction The physical health of people with serious mental illness is a relatively neglected area of clinical focus (Lambert et al. 2003). People with schizophrenia are more vulnerable to several physical conditions, such as non-insulin dependent diabetes mellitus (NIDDM) and cardiovascular disorders, and are more likely to suffer metabolic abnormalities (Ryan & Thakore 2002). While some elements of lifestyle such as poor diet, cigarette smoking, heavy alcohol use and sedentary lifestyle (Brown et al. 1999) are significantly detrimental to the health of some schizophrenic people, there is no doubt that schizophrenia per se appears to be a risk factor for poor physical health (Ryan & Thakore 2002, Thakore 2004). Antipsychotic-induced weight gain is a widespread and serious problem. The physical and psychological effects of being overweight are well known, and have been studied at length amongst the general population. Hypertension and other cardiovascular disorders, such as cerebro-vascular accidents (CVA) and myocardial infarction (MI), may arise as a consequence of antipsychotic treatment. The risk of developing NIDDM increases with the degree of overweight, but may also arise independently as a direct drug effect, irrespective of baseline weight or weight gained on antipsychotic medication (Henderson et al. 2000, Mir & Taylor 2001). Apart from the well-documented cases of EPSE, akathisia and tardive dyskinesia, other iatrogenic health problems affecting the mentally ill include hyperprolactinaemia, which affects sexual function and fertility. As well as being a significant cause of physical morbidity and mortality in mentally ill people, antipsychotic induced weight gain has been identified as a cause of non-adherence to treatment regimes and subsequent relapse (Nasrallah & Mulvihill 2001). There is a pressing need for the development of effective and widely applicable models of detecting and treating physical health problems and effecting positive lifestyle changes in this group. With this in mind, the Well-Being Support Programme, a project designed to assess and care for the physical health of mentally ill people in the community, was set up in several centres throughout the UK. Registered Mental Nurses (RMNs) were trained in the identification of physical health problems and detailed to run services in community mental health teams

(CMHTs). This paper will outline how the service was set up in the North-east Lambeth District of London, based in Brixton.

The setting: London borough of Lambeth Lambeth is the largest inner city borough in London. It measures approximately 7 miles north to South and 2 1/2 miles east to west. The population of Lambeth is around 260 000, 34% of which are from ethnic minorities. Over 130 languages are spoken in Lambeth, after English the most commonly spoken are Yoruba and Portuguese. North-east Lambeth stretches from East Brixton to West Camberwell. It is one of the most deprived areas of the country, with high rates of crime and mental illness.

Aims and objectives The primary aims of this service were: • To assess the levels of physical health in a seriously mentally ill population, and to identify any physical health problems in individuals and in this group as a whole. • To maintain adherence to antipsychotic medication. We placed a particular emphasis on those physical health problems that were likely to impact on compliance and thus result in deterioration in mental health and global functioning because of cessation of medication. We accepted that certain medications might improve psychotic symptoms, global functioning and quality of life but cause side-effects such as weight gain and sexual dysfunction. We hypothesized that these side effects could be managed with the aid of a replicable programme reliant on intelligent nursing intervention rather than additional pharmacological treatment. • To encourage positive lifestyle changes directed towards health promotion such as weight loss, exercise and smoking cessation within a dedicated, structured programme. • To forge links with other community caregiving and support agencies. • To develop and strengthen links between primary and secondary care. • To support, advise and educate carers. • To do all the above in a specific, systematic manner.

615

R. I. Ohlsen et al.

616

Methods

Referrals

The nurse advisor (NA) set up the service in an unfamiliar CMHT. As well as familiarizing himself with local procedures and protocols the nurse advisor needed to develop awareness of the clinical and managerial infrastructure in order to maximize appropriate input and ensure the smooth running of the service. From the earliest stages, it was essential for the nurse advisor to meet as many key people likely to form an integral part of the day-to-day running of the programme as possible. The NA met with senior management staff so that the WSP could be publicized, and any of their concerns about the programme raised and discussed. An informal presentation of the aims and objectives of the WSP followed by an open question and answer session was effective in allaying concerns and opening and establishing channels of communication. Practitioners likely to provide clinical input and advice were informed of and consulted about the WSP from the very first stages of the setting-up process. To inform best practice and establish efficient and consistent liaison protocol, the NA formulated ‘joint working agreements’ (JWAs) between the working group, and other services such as dietetics, diabetology, pharmacy, smoking cessation, pathology and with the local Primary Care Trust (PCT) that were likely to be allied to the WSP through referral and cross referral. The JWAs outlined working relationships, operational procedures and protocols. Negotiating a standardized JWA with the PCT proved untenable owing to the vast number of general practitioner (GP) practices within the catchment area and the wide variability in their preferred modes of referral from the WSP. Open communication and good relations were established and maintained with the PCT, as those patients enrolled onto the WSP who were found to have physical health problems often required ongoing monitoring by the GP or specialist intervention accessible only by referral through the GP. It is important to clarify throughout that the role of the NA was to identify patients with physical health problems and refer them on to the appropriate agency, not to actually do the physical health care themselves. Many of the patients in this service did not have regular contact with their GP and therefore the NA helped to establish these links.

The referral process needed several revisions before a successful model was identified. Initially, the nurse advisor designed a referral form which we estimated would have taken between 5–10 min for the care co-ordinator (CC) to complete. This approach proved unsuccessful as most staff found written referrals time consuming and preferred to refer patients verbally. This enabled the NA and CC to exchange relevant information, and for the NA to access any relevant information pertaining to current clinical condition and risk factors on the Trust’s computerized patient database. Procedures were adopted to facilitate the patient’s attendance at the appointment, such as a phone call from the CC to the patient on the day of the NA appointment, or arranging appointments on the same day. This not only dramatically increased the flow of referrals but facilitated attendance at consultations. Generally, once the initial assessment had taken place, and a rapport had been established, future attendance was less of a problem. Referrals were accepted from care co-ordinators, consultant psychiatrists and junior doctors within the North-east Lambeth sector. Patients that wanted to self refer were asked to contact their CC who could discuss the referral with the NA.

Inclusion criteria

• • • • •

Patients suffering from severe mental illness (schizophrenia, bipolar or schizo-affective disorder). Aged 18–65. Currently receiving treatment with antipsychotic medication. Able to give informed consent. Mental Health to be stable enough to participate in the programme.

Intervention Once referrals had been received, patients were given an appointment for initial baseline assessment and screening. This included: • Blood pressure and Pulse. • Weight, Height, Body Mass index (BMI). • Current medication and medication history. • Demographic details, family history, medical and psychiatric history.

Service to monitor and improve physical health

•

Dietary assessment and diet classification (diets were classified and allocated to one of three categories, either ‘healthy’, ‘average’ or ‘unhealthy’ according to content. Factors such as fat, fruit and vegetable intake, sugar, fizzy drink, ‘junk’ food and alcohol intake, as well as how often meals were eaten). • Questionnaire about attitudes towards medication and weight gain. • The Liverpool University Neuroleptic Sideeffect Rating Scale (LUNSERS). Where problems were highlighted on this scale, the patients were rated more intensively using other instruments for example, the Sexual Dysfunction Scale (Smith et al. 2002), and asked about the specific problem in more depth. • Self-esteem assessment. • Cigarette, alcohol and illicit drug use rates. • Patients with dietary issues given food diary to complete prior to next appointment. • Arrangement of follow – up appointment (usually 2 weeks). Following this appointment, a standardized pro forma letter was sent to the responsible medical officer (RMO) and CC detailing the above information and follow-up plans. All patients were offered a further consultation at which the results of their tests and further therapeutic involvement with the WSP would be discussed. Patients were either offered individual sessions with the NA, where dietary advice and monitoring would take place on a regular basis, or they were invited to attend the weight management group (held weekly), and/or the exercise group (held weekly). Some patients opted to have individual sessions as well as attend one or both of the groups. Where physical health problems were detected during investigations, the patient’s GP would be informed as soon as possible. With the exception of smoking cessation services, referrals to secondary/tertiary specialist services could only be accessed via the GP, so informing the GP of the need for further investigation or referral was essential. Consultation 2: • All physical measurements repeated. • Food diary discussed and dietary goal planning initiated. • Blood investigations: urea and electrolytes (U and Es), liver function tests (LFTs), thyroid function tests (TFTs), glucose, cholesterol,

full blood count (FBC), prolactin, drug plasma levels. • Programme planning discussed, and available options within the programme offered: weight management group (WMG), physical activity groups (PAG), continued individual consultations. • Next consultation date set. All results/information set to RMO and CC. • If needed, refer onto appropriate specialist (e.g. Diabetologist). All abnormal blood investigation/physical measurements were brought to the immediate attention of the RMO and/or GP. All information taken was documented at the time and entered into a secure computerized database for the purpose of the audit.

Weight management group This group was run by the NA and a co-facilitator. For purposes of continuity, the group was held at the same venue (room at the local day centre) and the same time each week. The group provided a forum for peer support and informal education on basic nutrition, diet advice, weight management techniques and issues relating to antipsychotic induced weight gain. The group always started with a ‘weigh in’; participants were offered the option of keeping their weight confidential but were encouraged to share progress. Feedback from the group participants showed that the process of being weighed regularly in a group setting was a powerful motivator to weight loss. A variety of different activities such as quizzes, group discussion, food demonstrations, personal goal setting and education sessions were planned by the NA before group sessions.

Physical activity groups One group followed on from the WMG, partly for the clients’ convenience and to capitalize on motivation engendered in the WMG. Activities were planned ahead by the group and included 10 pin bowling, badminton, exercise walks, swimming and boating. Additional groups included swimming, and attendance at a local gymnasium on other days. The charitable grant funding the service allocated a budget for exercise and expenses incurred from any activities.

617

R. I. Ohlsen et al.

Management issues

Results

No. of patients

Low self esteem Low-medium Medium Medium-high

0 Baseline

Endpoint

Figure 1 Changes in patients’ self-esteem after two or more consultations (n = 79)

40 unhealthy diet average diet healthy diet

Initial assessment of the first 134 patients showed higher rates of obesity, overweight and smoking than for the mainstream population. Eighty-seven per cent of patients were overweight (n = 95) (BMI > 25), and 63% were obese (BMI > 30). Fiftyfour per cent of overweight patients have lost weight during the programme, and 10% of patients assessed had pre-existing non-insulin dependent diabetes mellitus (NIDDM). An additional 2% were diagnosed during the programme, and 37% of patients seen were hypertensive according to British Heart Foundation guidelines (BP > 140/85). When asked, 11% of patients admitted to using illicit drugs; mainly cannabis although it is likely that many more use illicit drugs but did not report it. Twenty-nine per cent of patients had abnormally high prolactin levels (defined as >550 nmol/L for men and > 650 nmol/L for women). Sixty-seven per cent of patients described themselves as having lower than average self-esteem at baseline, but after only two consultations, this figure had dropped to 17.5% (See Fig. 1). There was a similar improvement noted in the quality of dietary input after two consultations, 60% having had ‘unhealthy’ diets at baseline, and only 25% after two consultations (See Fig. 2). 618

No. of patients

Co-working within the team: The NA’s role was strictly defined both legally and clinically in terms of job description and aims and objectives. This precluded any involvement with matters or clients not directly within the remit of the WSP. Some potentially difficult situations arose when the nurse advisor was asked to take blood from or administer medication to patients who had not been referred to the WSP. Boundaries separating the role of the NA and the CPN needed to be clearly defined at the outset and maintained there after. Effective and open lines of communication ensured that information about the client’s condition, particularly concerns about their presenting mental health could be passed on promptly therefore enabling any necessary treatment or planning to occur immediately. It is possible that this prompt communication of any problems or change in clinical condition may have averted admission to hospital in several cases.

0 0

0.5

1 Baseline

1.5

2.5

Endpoint

Figure 2 Changes in patients’ diet after two or more consultations (n = 79)

Discussion and conclusions Preliminary results suggest that the programme has been beneficial in terms of effecting positive lifestyle changes, particularly in relation to improving the quality of diet and in improving self-esteem. The majority of patients seen lost weight, and attended either a weight management group or a physical activity group, services that had not been previously accessible. Patients were on a variety of antipsychotic medications, and many were also taking mood stabilizers and/or antidepressants. Weight loss and participation in group activities was not affected by medication, and very few patients switched medication during the programme. Although the initial setting-up process was time consuming and involved a significant amount of non-clinical work such as liaison and networking, one nurse was able to run the programme smoothly

Service to monitor and improve physical health

and efficiently. Embedding a service such as this within an existing team ensured that the referral process ran smoothly, and that good communication between the NA and members of the multidisciplinary team was maintained. Services such as this, which have clearly benefited patients and improved general physical health, could be set up and incorporated into routine clinical practice. The cost of employing extra personnel to manage these services may well be offset by the putative short, medium and long-term economic benefits afforded by preventing the development of physical co-morbidity such as cardiovascular disease, obesity and diabetes in this vulnerable population.

Acknowledgments The WSP was funded by a charitable grant from Eli Lilly. RI Ohlsen has received honoraria from AstraZeneca, BMS Otsuka, Eli Lilly, Janssen Cilag and Sanofi-Aventis. S Smith has received honoraria and educational support from AstraZeneca, BMS, Eli Lilly, Janssen-Cilag, Novartis and Sanofi-Aventis.

References Brown S., Birtwhistle J., Roe L. & Thompson C. (1999) The unhealthy lifestyle of people with schizophrenia. Psychological Medicine 29, 697–701. Henderson D.C., Caligero E., Gray C., Nasrallah R.A., Hayden D.L., Schoenfeld D.A. & Goff D.C. (2000) Clozapine, diabetes mellitus, weight gain and lipid abnormalities: a five-tear naturalistic study. American Journal of Psychiatry 157, 975–981. Lambert T.J.R., Velakoulis D. & Pantelis C. (2003) Medical co-morbidity in schizophrenia. Medical Journal of Australia 178 (Suppl. 5), S67–S70. Mir S. & Taylor D.M. (2001) Antipsychotics and hyperglycaemia. International Clinical Psychopharmacology 16, 63–73. Nasrallah H.A. & Mulvihill T. (2001) Iatrogenic disorders associated with conventional vs atypical antipsychotics. Annals of Clinical Psychiatry 13, 215–237. Ryan M. & Thakore J. (2002) Physical consequences of schizophrenia and its treatment. The metabolic syndrome. Life Sciences 71, 239–257. Smith S.M., O’Keane V. & Murray R. (2002) Sexual dysfunction in patients taking conventional antipsychotic medication. British Journal of Psychiatry 181, 49–55. Thakore J. (2004) Metabolic disturbance in first episode schizophrenia. British Journal of Psychiatry Supplement 47, S76–S79.

619