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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 2 Introductions 3 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 4 Learning objectives Following this training you should: • • • • 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 5 Revision: What is mental illness? 6 Depression and anxiety What can you remember about people with depression and anxiety in primary care? 7 Depression and anxiety Physical symptoms Depression Anxiety • • • • • • • • • • • • • • • • • 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 • • • • • 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 8 Depression and anxiety Psychological symptoms Depression Anxiety • • • • • • • • • • • • • • 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 • • 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 9 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 10 Bipolar disorder Lifetime prevalence is 1%, but it is underdiagnosed Peak of onset is between 15 and 19 years of age Depression Mania • • • • • • • • • • • • • • • 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 • • • • • 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 • • 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 11 Effect of mental illness on physical health and morbidity 12 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) 13 Physical illness • • • • • • • • • 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) 14 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? 15 Chronic obstructive pulmonary disease Systematic review – COPD most prevalent disease in people with mental illness (Oud and Meyboom-de Jong 2009). Why? • • Smoking ↑ Health checks ↓ 16 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 17 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) 18 Sexual dysfunction Higher incidence in people with schizophrenia (Smith et al. 2002, McDonald et al. 2003) • • Antipsychotic are drugs associated with sexual dysfunction as they can cause hyperprolactinaemia (Kasperek-Zimowska et al. 2008) Is this also due to cardiovascular disease? 19 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 20 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 21 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? 22 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 23 Cardiovascular disease Risk factors that cannot be modified: • • • • Age Gender Ethnicity Family history 24 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 25 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) 26 Tea break! 27 Carrying out a physical health check 28 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? 29 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/ 30 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 31 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 32 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 33 Carrying out the health check using the HIP-PC Measurements • • • • • Body Mass Index Waist circumference Pulse rate (ECG) Blood pressure Temperature 34 Carrying out the health check using the HIP-PC Blood tests • • • • • • • • • • Liver function tests Lipids Glucose/HbA1c Prolactin Urea, electrolytes and calcium Thyroid function test Full blood count B12 and Folate Lithium Vitamin D 35 Carrying out the health check using the HIP-PC Screening • • • • • • • • • • Cervical cytology Prostate and testicular examination Teeth Eyes Feet Breasts (women) Breasts (men) Menstrual cycle Urine Bowels 36 Carrying out the health check using the HIP-PC Lifestyle • • • • • • • • • • Sleep Smoking Exercise Alcohol intake Diet Fluid intake Caffeine intake Safe sex Sexual satisfaction Cannabis 37 Carrying out the health check using the HIP-PC Medication review • • • • Antidepressants Antipsychotics Mood stabilisers Other drugs (e.g. for physical conditions) 38 Carrying out the health check using the HIP-PC Additional factors • • Care plan Flu vaccination 39 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 40 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? 41 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 42 If the patient did not attend 1. Send a second invitation letter 2. Telephone the patient, carer or CMHW as appropriate 43 References Baldwin J. (1979). Schizophrenia and physical disease. Psychological Medicine 9 (4): 611-618. 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. 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(2009) Use and safety of antipsychotic drugs during pregnancy. Journal of Psychiatric Practice 15 (3): 183-192. Fisher I, Bienskii A, Fedorova I. (1996) Experience in using serological tests in detecting tuberculosis in patients with severe mental pathology. Problemy Tuberkuleza 1: 19-20. Gray R, Brewin E, Noak J, Wyke-Joseph J and Sonik B. (2002) A review of the literature on HIV infection and schizophrenia: Implications for research, policy and clinical practice. Journal of Psychiatric and Mental Health Nursing 9 (4): 405-409. Kalkan A, Ozdarendeli A, Bulut Y, Saral Y, Ozden M, Keleştimur N and Toraman ZA. (2005) Prevalence and genotypic distribution of hepatitis GB-C ⁄HG and TT viruses in blood donors, mentally retarded children and four groups of patients in eastern Anatolia, Turkey. Japanese Journal of Infectious Diseases 58 (4): 222-227. 44 References Kasperek-Zimowska B, Brodniak WA and Sarol-Kulka A. (2008) Sexual disorders in schizophrenia – overview of research literature. 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