Download Carrying out the physical health check

Physical Health in Mental Illness
Presenter name, position, trust
Date
Acknowledgements
We would like to thank:
• Dr Sheila Hardy, Education Fellow at UCLPartners, and author of these materials.
• The expert reference group, steering group and project team:
Michael Benson
Lead Nurse Education and Practice Development, Barnet, Enfield and Haringey Mental Health NHS Trust
Stephanie Bridger
Director of Nursing, North East London NHS Foundation Trust
Eileen Bryant
Primary Care Nurse Advisor, NHS England
Stephen Cook
Interim Deputy Director of Nursing and Clinical Governance, Barnet, Enfield and Haringey Mental Health NHS Trust
Dr Rhiannon England
CCG Mental Health GP Lead
Professor Peter Fonagy
Director, Integrated Mental Health Programme, UCLPartners
Kate Hall
Director of Education, UCLPartners
Gemma Houghton
Project Coordinator, UCLPartners
Dr Henrietta Hughes
Medical Director, North and East London, NHS England
Claire Johnston
Director of Nursing, Camden and Islington NHS Foundation Trust
Becky Kingsnorth
Programme Manager, Adult Mental Health, UCLPartners
Fatema Limbada
Project Coordinator, UCLPartners
Dr Anna Moore
Director, Integrated Mental Health Programme, UCLPartners
Dr Fiona Nolan
Deputy Director of Nursing, Camden and Islington NHS Foundation Trust
Gill Rogers
Londonwide LMCs
Antony Senner
Head of Development, Health Education North Central and East London
Dr Geraldine Strathdee
National Clinical Director, NHS England
Jonathan Warren
Director of Nursing, East London NHS Foundation Trust
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Introductions
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Aims and objectives of the training
The aim of this training is to address the physical health needs of
people with mental illness by training practice nurses to consider
these needs opportunistically and to deliver physical health checks
to this group in primary care.
The objectives of the training will be assist practice nurses to
provide patients who have mental illness with:
• A reduced risk of cardiovascular disease (CVD)
• A named contact in the practice who offers support for all areas
of care
• Assistance with smoking cessation, diet and exercise planning
• Prompt treatment for other physical ailments
• Treatment in line with people with physical long-term
conditions, therefore reducing stigma
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Learning objectives
Following this training you should:
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Understand the definition of mental illness
Know the signs and symptoms of mental illness
Be familiar with the epidemiology of mental illness
Be aware of the impact of mental illness on physical health,
particularly the increased risk of CVD
• Be confident in navigating and using the physical health in
severe mental illness website developed for practice nurses
• Be confident in carrying out a health check using the Health
Improvement Profile for Primary Care (HIP-PC) best practice
manual as a guide
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Revision: What is mental illness?
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Depression and anxiety
What can you remember about people with depression
and anxiety in primary care?
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Depression and anxiety
Physical symptoms
Depression
Anxiety
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Change in appetite
Change in bowel function
Dry mouth
Palpitations
Indigestion
Feel slowed down
Looks unkempt
Loss of libido
Amenorrhoea
Sleep disturbance
Headaches, giddiness, tight band round
chest and head, skin-picking, handwringing, general aches and pains
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Change in appetite
Change in bowel function
Dry mouth
Palpitations, tachycardia, chest pain
Nausea, vomiting, burping
Increased muscle tension and weakness,
tremor, and akathisia (restlessness)
Loss of libido
Increased menstrual flow
Sleep disturbance
Panting for air, tightness of the chest,
increased respirations, sweating, cold
clammy palms, sighing
Headache, pins and needles, giddiness
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Depression and anxiety
Psychological symptoms
Depression
Anxiety
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Thinking slow and difficult
Poor concentration
Preoccupation with morbid thoughts
(death/suicide) and/or physical
symptoms
Feel sad, low or flat
Fed up, indecisive
Indifference, denial or lack of
awareness of symptoms
Loss of interest in life
Speech; slow, monotonous,
monosyllabic answers. Incessant
negative talk
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Preoccupation with ill-health
Poor concentration
Feelings of helplessness
Fatigue
Bizarre thoughts
Wanting to run away from a feared
situation
Irritability and restlessness
Thoughts of insecurity and inferiority
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Schizophrenia
Lifetime prevalence is 0.4%
Peak of onset is around late adolescence and early adulthood
Positive symptoms (those that are
additional to normal for the person)
• Hallucinations
• Delusions
• Thought disorder
Negative symptoms (those that appear
to take away from what the person once
experienced)
• Poor motivation
• Social isolation
• Withdrawal
Cognitive symptoms
• Impaired attention and memory
• Difficulty forward planning and
problem solving
Affective or mood symptoms
• Signs of depression and/or anxiety
are common
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Bipolar disorder
Lifetime prevalence is 1%, but it is underdiagnosed
Peak of onset is between 15 and 19 years of age
Depression
Mania
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Feeling sad and hopeless
Lack of energy
Finding it difficult to concentrate and
remember things
Loss of interest and enjoyment in everyday
activities
Feelings of emptiness or worthlessness
Feelings of guilt and despair
Feeling pessimistic about everything
Self-doubt
Difficulty sleeping and waking up early
Suicidal thoughts
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Feeling extremely happy, elated or euphoric
Talking quickly
Feeling full of energy
Feeling self-important
Feeling full of great new ideas and having
important plans
Being easily distracted
Being easily irritated or agitated
Not sleeping
Not eating
Doing pleasurable things with disastrous
consequences, such as spending money they
haven’t got or engaging in unwise sexual
relationships
Other
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Psychosis – may have hallucinations (seeing, smelling or hearing things that aren't there)
Self-harm can be used as a distraction from mental pain and distress
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Effect of mental illness on physical
health and morbidity
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Life expectancy
Someone with a mental illness will die 12–19 years earlier
than the general population (Chang et al. 2011)
The main cause is due to a physical disease (rather than
suicide or accident; Colton and Manderscheid 2006)
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Physical illness
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Tuberculosis
Chronic obstructive pulmonary disease (COPD)
Sexually transmitted infections
Hepatitis B/C
Sexual dysfunction
Obstetric complications
Cancer
Dental problems
Cardiovascular disease
(De Hert et al. 2011)
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Tuberculosis
Higher prevalence of tuberculosis in people with
schizophrenia
Few studies only (Cavanaugh et al. 2012, Zeenreich et al.
1998, Fisher et al. 1996, Ohta et al. 1988, Baldwin 1979)
Inpatient settings
Is it due to the setting or the mental illness?
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Chronic obstructive pulmonary disease
Systematic review – COPD most prevalent disease in people
with mental illness (Oud and Meyboom-de Jong 2009).
Why?
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Smoking ↑
Health checks ↓
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Sexually transmitted infections
Prevalence of HIV positivity higher in schizophrenia population
(Leucht et al. 2007)
Risky sexual behaviour in people with mental illness, particularly mood
disorders (Carey et al. 2004)
People with a substance use disorder (and mental illness) more vulnerable
to HIV and STI in general (Cournos et al. 1994, Gray et al. 2002)
Why do you think this is?
• Poor decision-making about safe sex
• Increased likelihood of sex with someone who is injecting drugs
• Hypersexuality
• Neglecting to use a condom
• Vulnerability to coercion into sex
• Selling/swapping sex for cash or drugs
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Hepatitis B/C
More prevalent in people with schizophrenia compared to
the general population (Nakamura et al. 2004, Kalkan et al.
2005)
Further increase if substance abuse disorder is also present
(Rosenburg et al. 2005)
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Sexual dysfunction
Higher incidence in people with schizophrenia (Smith et al.
2002, McDonald et al. 2003)
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Antipsychotic are drugs associated with sexual
dysfunction as they can cause hyperprolactinaemia
(Kasperek-Zimowska et al. 2008)
Is this also due to cardiovascular disease?
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Obstetric complications
High incidence of obstetric complications in women with
schizophrenia (De Hert et al. 2011)
No definitive association between the use of antipsychotics
during pregnancy and an increased risk of birth defects or
other adverse outcomes (Trixler et al. 2005, Einarson and
Boskovic 2009)
What do you think is causing the obstetric complications?
• ↑ Smoking
• Use of drugs and alcohol
• Low socio-economic status
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Osteoporosis
High prevalence of osteoporosis in people with mental illness
(De Hert et al. 2011)
Why do you think this is? (Think about the causes of
osteoporosis and the symptoms of mental illness)
• Sedentary lifestyle
• Lack of exercise
• Smoking
• Alcohol and drug abuse
• Dietary and vitamin deficiencies
• Decreased exposure to sunshine (↓ vitamin D)
• Polydipsia inducing electrolyte imbalance
• Antipsychotic drugs increase prolactin levels
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Cancer
Patients with schizophrenia have decreased incidences of
certain cancers but are more likely to:
• Die prematurely from cancer than the general population
• Have metastases at diagnosis
They are less likely to:
• Get screened for cancer
• Receive specialised interventions
Why do you think they do not get screened?
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Poor dental status
The prevalence of caries, gingivitis and periodontal disease is
increased in people with mental illness
Why is this?
• Poor diet
• Neglecting oral hygiene
• Smoking
• Some antipsychotics, antidepressants and mood
stabilisers reduce saliva flow
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Cardiovascular disease
Risk factors that cannot be modified:
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Age
Gender
Ethnicity
Family history
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Cardiovascular disease
Modifiable risk factors for CVD are significantly increased in
people with mental illness
What are these?
• Smoking
• Poor diet
• Low levels of exercise
• Stress
• Diagnostic overshadowing
• Antipsychotic medication
• Poverty
• Alcohol
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Cardiovascular disease
Two meta-analyses of patients with SMI showed:
• Half were obese
• Two in five had hypertriglyceridaemia
• Two in five had hypertension
• One in three had metabolic syndrome, diabetes or
pre-diabetes
(Vancampfort et al. 2013, Mitchell et al. 2011)
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Tea break!
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Carrying out a physical health check
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Who is responsible for the physical health of
people with severe mental illness?
Who do you think is responsible?
What does NICE say?
What does QOF say?
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Tools to help you look after the physical health
of people with mental illness
A website has been created specifically for practice nurses. It has
a best practice manual – the Health Improvement Profile for
Primary Care (HIP-PC) and other useful tools.
These can all be downloaded free:
http://physicalsmi.webeden.co.uk/
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Preparing to carry out health checks for people
with severe mental illness
1. Identify one or two practice nurses to be responsible for
carrying out the health checks
2. Ensure the practice nurse receives appropriate training to
feel confident in carrying out the health checks (you are
here!)
3. Check your SMI register for accuracy
4. If your employer supports you setting up clinics – work
out how you are going to do this
5. Identify your community mental health worker (CMHW)
linked with the practice
6. Prepare your template
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Inviting the patient
1. Inform the CMHW of the invitation (if they have one)
2. Send out the invitation letter 10–14 days before the
appointment
3. Consider telephoning the patient the day before the
appointment to remind them
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Carrying out the physical health check
1. Explain to the patient why they have been invited
2. Use the HIP-PC manual to guide you
3. There are a number of tools on the website (letters, care
plans, scales) which you may find useful
4. Provide your patient with any relevant leaflets (available
from the website)
5. If the patient needs any follow-up appointments, arrange
these and explain why
6. Request their permission to share results with the CMHW
where appropriate
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Carrying out the health check using the HIP-PC
Measurements
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Body Mass Index
Waist circumference
Pulse rate (ECG)
Blood pressure
Temperature
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Carrying out the health check using the HIP-PC
Blood tests
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Liver function tests
Lipids
Glucose/HbA1c
Prolactin
Urea, electrolytes and calcium
Thyroid function test
Full blood count
B12 and Folate
Lithium
Vitamin D
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Carrying out the health check using the HIP-PC
Screening
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Cervical cytology
Prostate and testicular examination
Teeth
Eyes
Feet
Breasts (women)
Breasts (men)
Menstrual cycle
Urine
Bowels
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Carrying out the health check using the HIP-PC
Lifestyle
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Sleep
Smoking
Exercise
Alcohol intake
Diet
Fluid intake
Caffeine intake
Safe sex
Sexual satisfaction
Cannabis
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Carrying out the health check using the HIP-PC
Medication review
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Antidepressants
Antipsychotics
Mood stabilisers
Other drugs (e.g. for physical conditions)
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Carrying out the health check using the HIP-PC
Additional factors
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Care plan
Flu vaccination
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Group work
You will receive a scenario question to answer.
• Use the HIP-PC to help you
• Also think about how you would organise health checks in
your own area of practice
Give feedback to the whole group
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Scenarios
Scenario 1
What antipsychotic medications are commonly associated with diabetes?
How do you think diabetes can be prevented in patients with mental illness?
Scenario 2
Why do you think patients with mental illness are more likely to have a raised blood cholesterol level and
what information can you exchange with them?
What methods could you use to motivate a patient with mental illness to become more active?
Scenario 3
Which drugs are associated with QT interval prolongation?
What factors should you take into consideration if a patient’s pulse is 114?
What action would you take?
Scenario 4
How would you bring up the subject of testicular self-examination with a 24-year-old patient with mental
illness?
A female patient with bipolar disorder tells you the last time she was high she had unprotected sex. What
action will you take?
Scenario 5
Would drinking 3 cups of coffee, 2 cups of tea and 2 cans of cola during one day be an excessive intake of
caffeine?
What advice would you offer?
How would you react if a patient with mental illness admitted to taking cannabis?
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After the health check
1. Inform the patient of the results from blood tests
2. If appropriate, inform the patient’s CMHW of the results
3. Check the patient has attended for follow-up
appointments
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If the patient did not attend
1. Send a second invitation letter
2. Telephone the patient, carer or CMHW as appropriate
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References
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Carey M, Carey K, Maisto S, Gordon C, Schroder K and Vanable PA. (2004) Reducing HIV-risk behavior among adults receiving outpatient
psychiatric treatment: Results from a randomized controlled trial. Journal of Consulting and Clinical Psychology 72 (2): 252-268.
Cavanaugh JS, Powell K, Renwick OJ, Davis KL, Hilliard A, Benjamin C, et al. (2012) An outbreak of tuberculosis among adults with mental
illness. American Journal of Psychiatry 169 (6): 569-575.
Chang CK, Hayes RD, Perera G, Broadbent MT, Fernandes AC, Lee WE, et al. (2011) Life expectancy at birth for people with serious mental
illness and other major disorders from a secondary mental health care case register in London. PLoS ONE 6 (5): e19590.
Colton CW and Manderscheid RW. (2006) Congruencies in increased mortality rates, years of potential life lost, and causes of death
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