Physical Healthcare and Promotion in Mental Health Nursing

Stan Mutsatsa, Author

• Publisher: Learning Matters
• Year: 2015
• Print ISBN: 9781446268186, 9781446268179
• eBook ISBN: 9781473908840
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

It is essential for mental health nurses to understand the physical health needs of people with mental health disorders in order to provide holistic care. Yet these people often have their physical health needs unrecognised or poorly managed. This book is a practical and informative guide to the physical health care of people with mental health illnesses. It covers a range of health-promotion strategies, including exercise, diet and oral health, and assessment, intervention and skills for common physical disorders found in people with mental-health problems. It takes a recovery perspective and emphasises the importance of communication and collaborative care for adherence to healthy lifestyles.

Chapter 1 The determinants of poor physical health in people with mental health problems

NMC Standards for Pre-registration Nursing Education

This chapter will address the following competencies:

Domain 3: Nursing practice and decision-making

Generic standard for competence

Nurses must practise autonomously, compassionately, skilfully and safely, and must maintain dignity and promote health and wellbeing. They must assess and meet the full range of essential physical and mental health needs of people of all ages who come into their care. Where necessary they must be able to provide safe and effective immediate care to all people prior to accessing or referring to specialist services irrespective of their field of practice. All nurses must also meet more complex and coexisting needs for people in their own nursing field of practice, in any setting including hospital, community and at home. All practice should be informed by the best available evidence and comply with local and national guidelines. Decision-making must be shared with service users, carers and families and informed by critical analysis of a full range of possible interventions, including the use of up-to-date technology. All nurses must also understand how behaviour, culture, socioeconomic and other factors, in the care environment and its location, can affect health, illness, health outcomes and public health priorities and take this into account in planning and delivering care.

NMC Essential Skills Clusters

This chapter will address the following ESCs:

Cluster: Care, compassion and communication

1. As partners in the care process, people can trust a newly registered graduate nurse to provide collaborative care based on the highest standards, knowledge and competence.
2. People can trust the newly registered graduate nurse to engage in person-centred care empowering people to make choices about how their needs are met when they are unable to meet them for themselves.

Chapter aims

By the end of the chapter, you should be able to:

• understand the importance of physical health in people with mental health problems;
• describe factors that influence poor physical health in people with mental health problems and how these factors interrelate.

Introduction

There is growing awareness through research that people with mental health disorders disproportionately suffer from specific physical health ailments. In particular those with severe mental illness (SMI), such as schizophrenia, depression or bipolar disorder, are at increased risk of suffering from cardiovascular disease (CVD), diabetes, infections, respiratory disease, cancer, infectious diseases and greater levels of obesity. In many others, weight gain is a clear side effect of psychotropic medication, particularly second-generation antipsychotics. People with SMI are almost twice as likely to die from coronary heart disease compared to the general population and four times more likely to die from respiratory disease (Brown et al. 1999; Nocon et al. 2004). In their analysis of records of 1.7 million primary care patients, the Disability Commission (2005) estimate that people with schizophrenia or bipolar disorder are more than twice as likely to have diabetes as other patients. In addition, they are more likely to experience ischaemic heart disease, stroke, hypertension and epilepsy compared to to the general population. Despite evidence of high prevalence of cardiovascular risk factors in this population, there is evidence of undertreatment of these modifiable risk factors. In an influential study, Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), 88% of patients with dyslipidaemia, 62% of those with hypertension and 38% of those with diabetes did not receive treatment for these ailments (Nasrallah et al. 2006a). This finding is in line with a large prospective study that has confirmed that many of these physical health problems are already present at the time of illness presentation (de Hert et al. 2006). A higher percentage of people with mental health problems use cannabis and other drugs than the general population (Boydell et al. 2006).

Regular cannabis use in people with SMI leads to increased relapse and hospitalisation. Moreover, cannabis use is associated with poor adherence to treatment and longer duration of illness (Grech et al. 2005; Kirsch et al. 2008). Patients who take cannabis are at increased risk of deterioration in physical health that includes bronchitis and lung cancer. Its use is highly prevalent in the UK and results in a vulnerability to SMI. A review of cannabis use in people with psychosis noted a misuse of 22.5% (Green et al. 2005).

There is evidence that people with mental health problems are disadvantaged by health inequalities and factors pertaining to these are complex and likely to include poverty, lifestyle, access to health assessments and treatments, and side effects of antipsychotic and mood-stabilising medication (Phelan et al. 2001).

A number of studies comparing people with mental health problems to the general population found that the former are less likely to be offered a number of interventions that include blood pressure, cholesterol, and urine or weight checks. In addition, they are less likely to receive opportunistic advice on smoking cessation, alcohol, exercise or diet (Phelan et al. 2001). As a nurse, you need to address this deficit actively to improve patient care.

Available evidence also shows that those with mental health problems are likely to have their physical health needs unattended to, unnoticed, poorly managed or simply dismissed as a reflection of their mental state. This underestimation of the significance of physical health problems because of significant psychiatric symptoms is called diagnostic overshadowing.

We see diagnostic overshadowing when we observe the high proportion of people with SMI not receiving tests assessing metabolic risk factors even for simple issues like obesity and blood pressure (Buckley et al. 2005). At present, neither mental health professionals nor primary healthcare professionals carefully screen or monitor patients receiving antipsychotic medication for metabolic risk factors (Hasnain et al. 2010). As an example of this problem, the CATIE schizophrenia study found non-treatment rates for diabetes in this population to be as high as 45.3%, in spite of clear National Institute for Health and Care Excellence guidelines (Nasrallah et al. 2006a). Undiagnosed diabetes and screening rates for metabolic abnormalities in people with SMI remain low, and may lead to prolonged periods of poor glycaemic control. As a nurse, you should pay greater attention at individual and system level to these physical disorders as they have the potential to reduce life expectancy and worsen psychiatric stability and treatment adherence, as well as quality of life.

Melissa’s case is an example of how a patient’s mental state can be overshadowed by the need to treat the underlying physical illness. In the next case study we see the effect of not paying enough attention to the physical health needs of people with SMI.

As the case study demonstrates, the quality of physical healthcare provided to people with SMI is usually suboptimal. In Jake’s case, if the nurse had asked further questions regarding his pain, it is likely that the nurse would have established that the pain was radiating around the umbilical region, that Jake had been vomiting and that his temperature was elevated. This extra information (symptoms of appendicitis) would have been very useful and provided sufficient reason for the healthcare team to take prompt action.

The nurse was quick to offer Jake PRN medication without further investigation; this is diagnostic overshadowing, which is a huge problem with negative health consequences for the patient. Jake was providing clear clues to the nurses that should have prompted further investigation: his irritability, late waking and refusal of food.

Attending to the physical health needs of people with SMI has been associated with multiple improvements in both mental and physical health, including improvement in self-esteem and well-being. Such multiple outcomes provide strong reasons for targeting support and treatment for people with SMI. In order to give this support, you need to understand the determinants of poor physical health in this client group.

This chapter starts by discussing the prevalence of long-term physical health problems in people with mental health problems in general and those with serious mental health problems in particular. It will then discuss specific factors that affect physical health problems in this population. Such factors can broadly be divided into lifestyle, treatment, biological, socio-economic and environmental factors. We will discuss lifestyle-related factors first.

Case study

Manesh is a 26-year-old man who suffers from bipolar disorder. He has had many previous admissions to hospital due to relapses in his condition. Periods of relapse coincide with heavy periods of cannabis use. During the winter months, he tends to suffer from a more severe and protracted form of chest infection. Coincidentally, he smokes more cannabis during the winter months.

Activity 1.1 Critical thinking

Melissa is a 46-year-old woman whose cancer was being treated with the medication interferon-alpha. After a few weeks of treatment, Melissa started to experience depressive symptoms and became suicidal. Her mood became so severe that one day she doused herself in oil and set herself alight. Fortunately, she survived.

What factors may have contributed to her low mood and how may these factors have been overlooked?

There are outline answers to all the activities at the end of the chapter.

Case study

Jake is a 23-year-old man who has been suffering from schizophrenia since he was 18 years old. He is currently in hospital but generally keeps to himself and spends a lot of his time listening to music. He is prescribed olanzapine, which he takes regularly. One morning, he approached his primary nurse complaining of abdominal pain and increased urinary output. The primary nurse thought Jake was suffering from indigestion and gave him a dose of antacid. At lunchtime, Jake refused to eat his food, stating that he was not hungry, and continued to refuse food for the rest of that day, stating a lack of appetite. This was unusual for Jake.

The following day, Jake woke up much earlier than usual and had to be reminded to wash. He was irritable, raising his voice whilst talking to another patient, which was unusual for him. The nurse who attended to him was concerned about his behaviour and therefore offered Jake an extra dose of medication to help him to calm down, which he agreed to. An hour later Jake’s physical condition deteriorated so dramatically that he was urgently transferred to a general hospital where he was diagnosed with a burst appendix.

Lifestyle-related factors

We generally accept the view that lifestyle factors interact with biological factors to produce susceptibility to an illness. A lifestyle is a way of living that reflects the attitudes and values of a person or constellation of habitual activities unique to a person. Connolly and Kelly (2005) have asserted that a variety of factors, such as genes, environment and socio-demographic status, influence lifestyle. They further assert that, in schizophrenia, the illness itself contributes to shaping lifestyle. For example, people with schizophrenia tend to be unemployed and therefore drift down the social scale. This downward drift is usually associated with poorer financial standing and poor health. This view is supported by early studies that examined the effects of lifestyle factors on the physical health of people with schizophrenia living in the community (Brown et al. 1999; McCreadie 2003). These two studies compared the lifestyle factors of people with schizophrenia with that of low-social-class cohorts from the general population. In both studies, people with schizophrenia made significantly poorer dietary choices, took less exercise and smoked more than the general population. Before you read further, please take part in the activity below.

Smoking has emerged as one of the most potent factors of poor health in people with mental health problems. In comparison to the general population, people suffering from mental illness are at least twice as likely to smoke cigarettes. Approximately 80% of those with schizophrenia smoke cigarettes (McNeil 2001). The case study of Owen shows the problem of smoking and its complications. Higher rates of smoking have been observed in people sufferi...

Table of contents

• Cover
• Half Title
• Publisher Note
• Title Page
• Copyright Page
• Contents
• Publisher Note
• Foreword
• Acknowledgements
• About the author
• Introduction
• Chapter 1 The determinants of poor physical health in people with mental health problems
• Chapter 2 The physical health assessment in mental health nursing
• Chapter 3 Physical health promotion, communication and the therapeutic alliance
• Chapter 4 The care and management of cardiovascular disorders
• Chapter 5 Metabolic syndrome and diabetes mellitus
• Chapter 6 Respiratory disorders
• Chapter 7 Substance misuse and physical health in mental health
• Chapter 8 Side effects of psychotropic drugs and their management
• Chapter 9 Diet, exercise and sleep in health promotion for mental health
• Glossary
• References
• Index