Issues in Mental Health Nursing, 35:114–121, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.842619

Cardiometabolic Health Nursing to Improve Health and Primary Care Access in Community Mental Health Consumers: Baseline Physical Health Outcomes from a Randomised Controlled Trial Brenda Happell, PhD, RN Central Queensland University, School of Nursing and Midwifery, Rockhampton, Australia

Robert Stanton, BHMSc Central Queensland University, Institute for Health and Social Science Research, Rockhampton, Australia

Wendy Hoey, RN Queensland Health, Rockhampton, Australia

David Scott, PhD University of Melbourse, NorthWest Academic Centre, Melbourne, Australia

People with serious mental illness (SMI) are more likely to have poorer health and poorer health behaviours, and therefore are at greater risk for cardiometabolic health comorbidities compared to those without SMI. Referral to a specialist cardiometabolic health care nurse may result in increased detection of poor cardiometabolic health in at-risk individuals. In this article, we present the results of the physical health measures of people with serious mental illness who have accessed a community mental health service in a regional centre and argue for the need for a multidisciplinary approach. Our data show the high prevalence of obesity, hypertension, low activity, smoking and nicotine dependence, alcohol misuse disorders, and poor diet among people with serious mental illness. The high prevalence of at-risk factors for poor cardiometabolic health in people with serious mental illness adds support for the role of a specialist cardiometabolic health care nurse in the detection and referral for multidisciplinary treatment to improve the physical health outcomes for people with serious mental illness.

Compared to the general population, persons with serious mental illness (SMI) are more likely to be overweight (Allison et al., 2009; Daumit et al., 2003), have low levels of physical activity (Callaghan, 2004; Happell, Platania-Phung, & Scott, 2011; Scheewe et al., 2012; Sylvia et al., 2012), have poor health behaviours, such as smoking and alcohol use (Compton, Address correspondence to Robert Stanton, CQUniversity, Institute for Health and Social Science Research, Building 18, Bruce Highway, Rockhampton 4702 Australia. E-mail: [email protected]

Daumit, & Druss, 2006; Grant, Hasin, Chou, Stinson, & Dawson, 2004; Lasser et al., 2000), and have a poor nutritional intake (McCreadie, 2003; Osborn, Nazareth, & King, 2007; SimonelliMu˜noz et al., 2012). Either as a consequence of, or in addition to the potential side effects of medication, people with SMI are considerably more likely to exhibit comorbid physical illness compared to those without mental illness (De Hert et al., 2011; Hardy & Thomas, 2012; Scott et al., 2012). This partly explains the two to threefold increase in mortality risk experienced in this population, with the most common cause of mortality being treatable physical illnesses such as cardiovascular disease (Brown, Kim, Mitchell & Inskip, 2010). Persons with SMI also are more likely to neglect their physical health care needs compared to people without SMI (Lawrence & Kisely, 2010; McCloughen & Foster, 2011; Park, Usher, & Foster, 2011). Coupled with the aforementioned poor lifestyle behaviours, the documented shorter lifespan of people with SMI is inevitable (Druss, Zhao, Von Esenwein, Morrato, & Marcus, 2011; Harris & Barraclough, 1998). However, investigations into the health care inequalities experienced by people with SMI suggest that when the quality and scope of health care of this group is equitable compared to people without SMI, both the physical and mental health of consumers improve (Druss et al., 2010), and the mortality rate reduces (Druss, Bradford, Rosenheck, Radford, & Krumholz, 2001). Mental health services are often the primary health care point of contact for people with SMI. Therefore mental health nurses (MHNs) are often at the front line of the provision of everyday

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care (Happell, Platania-Phung, Gray et al., 2011). Although mental health nurses are considerate of the need for the physical health care of people with SMI, factors such as lack of time, lack of resources, and priority of mental health treatment often precludes the treatment of physical health (Happell, Scott, Platania-Phung, & Nankivell, 2012). Thus, the resultant impact on unmet cardiometabolic health care needs—compounded by the effects of medications, lifestyle behaviours, and health care inequalities of people with SMI—is significant and there is an urgent need for intervention. In order to address the cardiometabolic health care needs of people with SMI, the role of a specialist cardiometabolic healthcare nurse (CHN) has been proposed (Brunero & Lamont, 2009). In general, this proposed role is well accepted by Australian MHNs who agree that creation of such a position would likely improve cardiometabolic care for consumers and reduce workloads of nursing staff without adverse consequences to the service or consumers (Happell et al., 2012). We recently commenced a 26-week randomised controlled trial (RCT) (ACTRN12612000801819) of a CHN in a regional communitybased mental health care service. The service receives some 85 new referrals per month and currently has more than 400 adult consumers enrolled in community mental health care. Baseline assessments by the CHN have concluded and the purpose of this preliminary report is to describe the physical health of participants randomised to the CHN intervention in our 26-week RCT. METHODS The protocol for this RCT has been previously described (Happell, Stanton, Hoey and Scott, 2013). Briefly, adult mental health care consumers of a regional hospital community mental health service in Queensland, Australia, were invited to participate in the study by their case manager or mental health nurse. Participants were randomised to either a CHN (intervention) or usual care (control group). Intervention group participants received access to the CHN with the primary purpose of identifying at-risk indicators of cardiometabolic health. Participants identified as at-risk were provided linkages to General Practitioners or other allied health professions as necessary, or provided health behaviour change advice. The CHN was responsible for follow-up on all appointments. Participants’ demographics and physical health parameters, including blood pressure and anthropometrics, were assessed by the CHN, and self-reported health behaviours, including physical activity, smoking status, nicotine dependence, alcohol use, and dietary habits, were recorded. Preliminary data reported here are shown as frequencies, means, and SD. Data were analysed using Statistical Package for the Social Sciences Version 19.0 (IBM Corp, New York, NY.) The project was approved by the service and university Ethics committees. Participants were informed that participation in the

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study was purely voluntary and whether or not they chose to be involved would not influence their treatment from the service. RESULTS Demographics To date, we have baseline data from 21 participants. More than half our participants are male (61.9%), two-thirds report their marital status as single (66.7%), and more than 80% report being on a pension. Fourteen percent of participants are of Aboriginal or Torres Strait Islander descent. The vast majority (85.7%) of participants have completed a Secondary School education with only one participant having achieved a lesser education level, one having attended Technical School or further education, and one having attended University. Blood Pressure Mean systolic blood pressure (SBP) for females was 127.5 ± 17.4 mmHg while mean diastolic (DBP) was 80.6 ± 8.2 mmHg. Mean SBP for males was 131.3 ± 15.4 mmHg while mean DBP was 85.6 ± 14.9 mmHg. Evidence of hypertension (SBP > 135 mmHg or DBP > 85 mmHg) was evident in 25.0% and 46.2% of females and males, respectively. Anthropometrics Mean body mass (BM) was 99.7.5 ± 20.1 kg and 98.9 ± 22.9 kg for females and males, respectively. Waist circumference was not measured in all participants; however, in females, all waist measurements were above the cut-off for at risk cardiometabolic health (88 cm). In male participants, 46.2% had a waist measurement above the cut-off for at risk cardiometabolic health (100 cm). Based on body mass index, 100% of the female and 69.2% of the male participants were classified as overweight (BMI 25.0–29.9 kg.m2 ) or obese (BMI > 30 kg.m2 ). Self-Reported Physical Activity Current physical activity was assessed using the Active Australia Survey. Scoring was based on standard algorithms. Data for walking and vigorous activity time were not normally distributed. Therefore data are reported as mean, median, and range (Table 1). The number of walking bouts performed by participants and the proportion of people reporting sufficient physical activity are reported in Tables 2 and 3, respectively. Smoking A significant proportion of participants report smoking, with 62.5% of female and 61.5% of males, respectively, reporting being current smokers. The average age of commencement of smoking for females was 14.4 ± 3.0 years and for males it was 14.9 ± 1.9 years. Former smokers commenced at a slightly later age of 15.5 ± 2.1 years for females and 17.5 ± 4.9 years for men. The average duration of smoking behaviour for former

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TABLE 1 Descriptive Statistics (Minutes) for Walking and Vigorous Exercise Mean

Median

Walking (minutes) Men 135.4 60 Women 58.1 52.5 Total 105.9 60.0 Vigorous exercise (minutes) Men 16.2 0 Women 60 0 Total 32.9 0

Minimum

Maximum

0 0 0

600 240 600

0 0 0

120 480 480

smokers was 28.5 ± 29.0 years and 30 ± 1.4 years for females and males, respectively. Severity of nicotine dependence was assessed using the Revised Fagerstrom Tolerance Questionnaire. Analysis revealed a summed score of 30.2 ± 6.8 for females and a summed score of 34.9 ± 4.8 for males. Alcohol Use Analysis of the Audit-C Alcohol Misuse Questionnaire indicates that 11.1% of female participants and 30.8% of male participants identified as having hazardous drinking habits or active alcohol use disorders. Views of Physical Activity Participants’ level of agreement on the physical activity statements in the Active Australia Survey are shown in Table 4. The proportion of men and women in agreement with the physical activity statements in the Active Australia Survey are remarkably similar (81.5% versus 85.0%). Nutrition Nutrition data were assessed using three questions reporting vegetable intake, fruit intake, and saturated fat (SF) consumption. Females report a mean intake of 1.3 ± 1.2 servings of vegetables and 1.25 ± 1.0 servings of fruit daily. Males report a mean intake of 0.8 ± 0.9 servings of vegetables and 1.1 ± 1.5 servings of fruit daily. Thus, neither females nor males in our study meet the recommended daily intakes for vegetables or fruit. Twenty-five percent of females and 46.2% of males do not TABLE 2 Percentage of People Performing Walking

Men Women Total

Nil

1–2 sessions

3–4 sessions

5 or more sessions

7.7% 37.5% 19.0%

30.8% 25.0% 28.6%

23.1% 25.0% 23.8%

38.5% 12.5% 28.6%

TABLE 3 Percentage of People Achieving “Sufficient” Time during the Previous Week

Men Women Total

Sedentary

Insufficient

7.7% 37.5% 14.3%

53.8% 37.5% 52.4%

Sufficient∗ 38.5% 25% 33.3%

∗ Sufficient time is defined as 150 minutes/week, using the sum of walking and moderate and vigorous activity (multiplied by two).

attempt to limit their intake of SF as they do not worry about the issue. In contrast, 37.5% of females and 15.4% of males attempt to keep their SF intake to a minimum. The remainder report already having a low saturated fat intake, or report keeping saturated fat intake to a minimum by low fat food choices. DISCUSSION Demographics Our cohort is somewhat dissimilar to populations of Australian mental health consumers described elsewhere. Compared to recent Australian data (Australian Institute of Health and Welfare [AIHW], 2012) that reports that a higher proportion of females have a mental illness compared to males, more than half our participants are male (61.9%). A greater proportion of our participants are single compared to other Australian data (AIHW, 2012), however the proportion of our participants receiving government support payments is similar to that recently reported (AIHW, 2012). Our cohort contains a small (n = 3) but culturally significant population by including those of Aboriginal or Torres Strait Islander decent. To our knowledge there are no RCTs describing the impact of a CHN on the physical health of Aboriginal or Torres Strait Islander people. It should be noted, however, that this population experiences a higher rate of both mental illness and chronic illness compared to the general population (Parker, 2010), although the relationship of causation is not confirmed. As suggested by Parker (2010), the involvement of an Aboriginal Health Worker when working with Aboriginal clients may lead to culturally safe practice and improve the reliability of data. Blood Pressure A large proportion of participants in our study have hypertension. Findings are equivocal on this topic with some (Jerome et al., 2012; Nasrallah et al., 2006), but not all, (Davidson et al., 2001) studies reporting a higher prevalence of hypertension in people with SMI. Hypertension is a key modifiable risk factor for stroke and cardiovascular disease. Indeed, physical activity is considered a first line therapeutic intervention for hypertension, with recommendations for moderate to vigorous aerobic and resistance exercise being routinely indicated (Sharman & Stowasser, 2009). Given the high prevalence of hypertension in

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TABLE 4 Percentage of People Agreeing (Combined “Strongly Agree” and “Agree”) with Knowledge Statements Message 1

Message 2

Message 3

Message 4

Message 5

Men Women

92.3% 87.5%

84.6% 100.0%

61.5% 62.5%

76.9% 75.0%

93.2% 100.0%

Total

90.5%

90.5%

61.9%

76.2%

95.2%

Message 1: Taking the stairs at work or generally being more active for at least 30 minutes each day is enough to improve your health. Message 2: Half an hour of brisk walking on most days is enough to improve your health. Message 3: To improve your health, it is essential for you to do vigorous exercise for at least 20 minutes each time, three times a week. Message 4: Exercise doesn’t have to be done all at one time—blocks of 10 minutes are okay. Message 5: Moderate exercise that increases your heart rate slightly can improve your health.

our cohort and the relationship with metabolic syndrome and adverse cardiometabolic outcomes, management of hypertension should be a high priority for treating professionals. Anthropometrics Where measured, all female participants in the present study had both BMI and waist girths placing them at risk of cardiometabolic illness. In males, almost half had a BMI and almost two-thirds had a waist girth that placed them at risk of cardiometabolic illness. This is not dissimilar to other studies (Dickerson et al., 2006), which report that more females than males with SMI are obese and that a greater proportion of people with SMI are obese compared to the general populations (Compton et al., 2006; Lopresti & Drummond, 2013). Both BMI and waist girth are independent risk factors for cardiovascular disease and early mortality in the general population. Updated Clinical Practice Guidelines to combat this epidemic have recently been released in Australia (Department of Health and Aging, 2013). However, while they acknowledge the contribution SMI may have on the development of obesity, particularly the roles medications and lifestyle have in weight gain, these guidelines exclude specific recommendations for people with SMI. This is, perhaps, a result of the multifactorial nature of obesity generally and the complexity of comorbid obesity and SMI. Previous studies in Australia have demonstrated that referral to supported exercise programs (Fogarty & Happell, 2005) or to health professionals with dual qualifications in dietetics and exercise physiology may assist with weight management and improve quality of life of people with depression (Forsyth, Deane, & Williams, 2009). Furthermore, integrating exercise and physical activity into mental health care is a feasible and effective strategy to address the prevalence of obesity, cardiometabolic health, and symptoms associated with mental illness (Jerome et al., 2012; Richardson et al., 2005). The cost effectiveness, however, remains to be fully evaluated. Physical Activity Around 70% of participants in our study do not meet the current recommendations for 150 minutes of physical activ-

ity per week to maintain physical health. The lack of physical activity contrasts markedly with the general population where more than 50% achieve sufficient physical activity for health (Queensland Health, 2011). However our results are consistent with reports from both Australia (Mental Illness Fellowship of ˚ Australia, Inc., 2011) and internationally (Lassenius, Akerlind, Wiklund-Gustin, Arman, & Soderlund, 2012) which document the low level of physical activity undertaken by this vulnerable group. This finding is significant since one recent study demonstrated that the amount of self-reported physical activity, not aerobic fitness, was related to mental health (Lindwall, Ljung, Hadˇzibajramovi´c, & Jonsdottir, 2012). Support for physical activity interventions from health practitioners may be lacking. Coombes and colleagues (2013) reported that very few Australian General Practitioners (GPs) provide exercise and physical activity advice to patients during usual consultations, and referrals from GPs to Accredited Exercise Physiologists for exercise interventions for individuals with mental illness are minimal (Stanton, 2013). This is despite the demonstrated efficacy of such programs (Forsyth et al., 2009). In contrast, psychologists’ views are markedly different with more than 80% promoting physical activity as a therapeutic adjunct (Burton, Pakenham, & Brown, 2010). The views of people with SMI regarding physical activity using the Active Australia Survey (AAS) have not previously been reported. More than 90% of participants in the current study agree that 30 minutes of general activity or brisk walking is sufficient to improve health and that moderate exercise, which slightly elevates heart rate, may improve health. In addition, more than three-quarters agree that this may be undertaken in repeated efforts, while slightly more than half agree that vigorous exercise is important for health. Interestingly, the AAS does not differentiate between physical and mental health; thus, it is impossible to distinguish whether the responses pertain to physical or mental health. Nonetheless, these responses are in contrast to the level of activity undertaken by our cohort. It is apparent that the vast majority believe physical activity is important, yet most fail to achieve the minimum recommended amount for health. People with SMI report a number of barriers to physical activity engagement,

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including stigmatisation, low self-efficacy, and low fitness ability (McDevitt, Snyder, Miller, & Wilbur, 2006; Ussher, Stanbury, Cheeseman, & Faulkner, 2007). Thus there exists the opportunity to expand on our current knowledge and practices regarding the design and delivery of physical activity interventions for people with SMI. Smoking Status Previous data suggest that people with SMI smoke more than people without SMI (Access Economics, 2007; Compton et al., 2006). The overall prevalence of smoking in our sample is 61.9%, which is similar to that reported in a large national survey of Australians with psychosis (Morgan et al., 2012) and to a US national survey sample (Lasser et al., 2000); however other studies have reported prevalence rates up to 90% (Williams & Ziedonis, 2004). In comparison, data from the Australian Institute of Health and Welfare (AIHW, 2011) report that around 15% of the total Australia adult population are smokers. Smoking represents one of the substantial contributors to coronary artery disease in people with and without SMI. A recent meta analysis suggests that people with SMI who smoke are at significantly greater odds for the development of coronary heart disease compared to non-smokers with SMI (Qin, Chen, Lou, & Yu, 2012). Additionally, a number of studies (Cuijpers, Smit, Ten Have, & De Graaf, 2007; Pedersen & Von Soest, 2009) have demonstrated the association between smoking and an increase in symptoms of some mental illnesses, particularly anxiety disorders. Encouragingly, Australian data suggest that more than 85% of people with SMI who smoke want to quit, and that almost half of those surveyed are concerned about the physical health effects (Ashton, Rigby, & Galletly, 2013). Smoking cessation programs targeted specifically for people with SMI have previously shown to be effective, particularly when support is available, reporting cessation rates of between 10% and 30% (Baker et al., 2006; Morris et al., 2011). It would be expected that if sustained, smoking cessation may have a significant positive benefit on subsequent cardiometabolic health. Nicotine Dependence Nicotine dependence was assessed using the Revised Fagerstrom Tolerance Questionnaire (Tate & Schmitz, 1993). Analysis revealed a summed score of 30.2 ± 6.8 for females and a summed score of 34.9 ± 4.8 for males. Previous studies (Niu et al., 2000) have used a cut-off score of ≥ 28 to signify nicotine dependence. Using this cut-off, 87.5% of females, 100% of males, and 94.7% of our overall sample demonstrate nicotine dependence. The prevalence of nicotine dependence in our cohort supports the rationale for targeted interventions for smoking cessation programs in people with SMI to reduced cardiometabolic risk. Alcohol Use More than one in ten female participants, and almost one in three male participants, were identified as having hazardous

drinking habits or active alcohol use disorders. Despite suggestions that both tobacco and alcohol use are more prevalent among people with SMI compared to the general population (Degenhardt & Hall, 2001; Teesson, Slade, & Mills, 2009), our findings are similar to that reported for a general sample from the Australian population where 35.3% of males and 14.1% of females were reported to have lifetime alcohol abuse or dependence. However, our findings differ substantially from a large Australian sample of people with SMI (Morgan et al., 2012) where 58.3% of males and 38.9% of females were deemed to have lifetime alcohol abuse or dependence. These differences may be due to the sample size, sociodemographic variables, or the assessment instrument used. Alcohol misuse carries with it a number of adverse consequences for people with SMI, including medication interactions, symptom exacerbation, relapse, and social withdrawal (Healey, Peters, Kinderman, McCracken, & Morriss, 2009). Alcohol misuse is also linked to weight gain and poorer cardiometabolic health. Thus there is clearly a need for interventions. The current literature indicates that integrated treatments that combine substance abuse and mental illness interventions are more successful than addressing each issue separately (Drake, O’Neal, & Wallach, 2008; Mangrum, Spence, & Lopez, 2006). Nutrition Poor fruit and vegetable intake and a high intake of saturated fats are linked with poor health outcomes for the general population and can have a significant effect on both physical and mental health (World Federation for Mental Health [WFMH], 2010). Participants from the current study report similar dietary habits to those previously reported for people with SMI (Brown, Birtwistle, Roe, & Thompson, 1999; Kilbourne et al., 2007; Ryan, Collins, & Thakore, 2003; Wallace & Tennant, 1998). No participant in the current study reported meeting the Australian dietary guidelines for fruit and vegetable intake combined and almost one-third do not address their intake of saturated fat due to lack of concern of this issue. While disinterest may be a factor in poor nutritional habits for some people with SMI, there are a number of other possible reasons including lack of daily living skills, such as shopping, menu planning, and cooking. These deficits may contribute to choosing more easily obtainable, high sugar, high fat fast food, which is often energy dense and of low nutritional value. Lifestyle interventions that target poor nutrition in people with SMI must be cognisant of these skill deficits and provision of education alone may be insufficient to address the poor cardiometabolic health evident in this group. SUMMARY Participants in the current study exhibit poor cardiometabolic health with obesity, hypertension, low physical activity, substance misuse, and poor nutrition being highly prevalent. The cardiometabolic health nursing role appears effective in identifying these at-risk individuals independent of the treatment

CARDIOMETABOLIC HEALTH NURSING

of mental illness and should be considered in the integrated treatment model for people with SMI.

Clinical Implications The preliminary finding from our study underpins the need for a multidisciplinary approach, including pharmacological and behavioural strategies to address the physical heath disparity affecting people with a mental illness. Given the propensity for overweight or obesity in this population, there is a clear need for General Practitioners to assume an active role in cardiometabolic screening and treatment for people with a mental illness. The provision of, or referral to, physical activity programs, smoking cessation programs, or lifestyle interventions are essential in reducing the health care disparity observed in local mental health care consumers. Use of currently underutilised referral schemes to allied health professions including Accredited Exercise Physiologists and Dieticians, which have demonstrated effectiveness with mental health consumers, should be encouraged. We would strongly suggest all health care professionals consider the physical health of mental health consumers and advocate for equality in health care. Our current study demonstrates a high proportion of participants with unmet cardiometabolic health care needs. Therefore there is reason for the development and implementation of specialist cardiometabolic health care nurses to work in close collaboration with primary care providers and MHNs to facilitate the cardiometabolic health care of people with SMI. The adoption of this innovative role into the integrated care of people with serious mental illness will provide significant benefits by meeting the needs of physical health care provision. The cardiometabolic health care nursing role also will positively impact mental health nursing practice by reducing workloads on nurses, providing co-located and integrated care, reducing confusion regarding primary care responsibilities for providers, and reducing the time requirements for primary care by mental health nurses. While factors such as cost effectiveness remain to be confirmed, our initial data would support the effectiveness of the specialised role in identifying at-risk consumers. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. REFERENCES Access Economics. (2007). Smoking and mental illness: Costs. Canberra, Australia: SANE. Allison, D., Newcomer, J., Dunn, A., Blumenthal, J., Fabricatore, A., Daumit, G., . . . Hibbeln, J. (2009). Obesity among those with mental disorders: A National Institute of Mental Health meeting report. American Journal of Preventive Medicine, 36(4), 341–350. Ashton, M., Rigby, A., & Galletly, C. (2013). What do 1000 smokers with mental illness say about their tobacco use? Australian and New Zealand Journal of Psychiatry, 47(7), 631–636.

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