Skip to main content
×
×
Home

Improving physical health monitoring for out-patients on antipsychotic medication

  • Carlos Gonzalez (a1), Niyaz Ahammed (a2) and Robert Fisher (a3)
Abstract
Aims and method

Mental illness is associated with increased physical morbidity. We aimed to assess and improve the routine blood testing of prescribed antipsychotics in out-patients from a busy London inner city area. Audit findings were presented locally to prescribers, together with educational suggestions to improve physical health assessment.

Results

Initially, the numbers monitored were low in the overall number of 126 patients included in the first audit. Following the intervention, this improved significantly in the second audit (of 106 patients).

Clinical implications

A simple one-page monitoring prompt and an educational intervention could significantly increase the adherence to routine blood-testing guidelines. Better physical screening may help reduce physical morbidity and mortality, and improve the quality of life of individuals with mental illness.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Improving physical health monitoring for out-patients on antipsychotic medication
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Improving physical health monitoring for out-patients on antipsychotic medication
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Improving physical health monitoring for out-patients on antipsychotic medication
      Available formats
      ×
Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Robert Fisher (robert.fisher@eastlondon.nhs.uk)
Footnotes
Hide All

Declaration of interest

None.

Footnotes
References
Hide All
1 Cohn, TA, Sernyak, MJ. Metabolic monitoring for patients treated with antipsychotic medications. Can J Psychiatry 2006; 51: 492501.
2 Marder, SR, Essock, SM, Miller, AL, Buchanan, RW, Casey, DE, Davis, JM, et al. Physical health monitoring of people with schizophrenia. Am J Psychiatry 2004; 161: 1334–49.
3 Brown, S. Excess mortality of schizophrenia. A meta-analysis. Br J Psychiatry 1997; 171: 502–8.
4 Expert Group. ‘Schizophrenia and Diabetes 2003’ Expert Consensus Meeting, Dublin, 3–4 October 2003: consensus summary. Br J Psychiatry 2004; 184: s1124.
5 Tarrant, CJ. Blood glucose testing for adults prescribed atypical antipsychotics in primary and secondary care. Psychiatr Bull 2006; 30: 286–8.
6 Feeney, L, Mooney, M. Atypical antipsychotic monitoring in the Kilkenny Mental Health Services. Ir J Psych Med 2005; 22: 101–2.
7 Barnes, TR, Paton, C, Cavanagh, MR, Hancock, E, Taylor, DM. A UK audit of screening for the metabolic side effects of antipsychotics in community patients. Schizophr Bull 2007; 33: 1397–403.
8 American Diabetes Association. Screening for type 2 diabetes. Diabetes Care 2004; 27: s114.
9 Taylor, D, Paton, C, Kerwin, R. The Maudsley 2003 Prescribing Guidelines (7th edn). Martin Dunitz, 2003.
10 Taylor, D, Paton, C, Kerwin, R. The Maudsley Prescribing Guidelines 2005–2006 (8th edn). Taylor & Francis Group, 2005.
11 Fisher, R. Monitoring of antipsychotic prescriptions in an inner city district of London [in German]. Nervenarzt 2006; 77 (suppl 3): s140.
12 National Institute for Clinical Excellence. Schizophrenia: Full National Clinic Guidelines on Core Interventions in Primary and Secondary Care. Royal College of Psychiatrists & The British Psychological Society, 2003.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
  • URL: /core/journals/bjpsych-bulletin
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×
Type Description Title
PDF
Supplementary materials

Gonzalez et al. supplementary material
Supplementary Material

 PDF (85 KB)
85 KB
UNKNOWN
Supplementary materials

Gonzalez et al. supplementary material
Supplementary Material

 Unknown (473 bytes)
473 bytes

Metrics

Full text views

Total number of HTML views: 1
Total number of PDF views: 1 *
Loading metrics...

Abstract views

Total abstract views: 14 *
Loading metrics...

* Views captured on Cambridge Core between 2nd January 2018 - 21st July 2018. This data will be updated every 24 hours.

Improving physical health monitoring for out-patients on antipsychotic medication

  • Carlos Gonzalez (a1), Niyaz Ahammed (a2) and Robert Fisher (a3)
Submit a response

eLetters

Can making physical healthcare policies more readable improve healthcare standards?

Waqqas A Khokhar, Specialty Registrar
23 August 2010

Gonzalaz et al 1 have pointed out an interesting omission in the formof poor physical healthcare monitoring in routine psychiatric practice andthere is evidence from various local and national audits 2, 3 that it is not restricted to just the outpatient settings. The authors have also rightly picked up on key barriers to the implementation of physical healthcare monitoring in psychiatric settings namely unclear responsibilities, competing demands on limited resources and liability issues. We believe that, for a start, this can be addressed by having readable, succinct and unambiguous physical healthcare policies.

Tosh et al 4 examined the physical health care policy documents of the three mental healthcare Trusts in the north sector of the East Midlands Strategic Healthcare Authority (UK) in detail. We found significant disparities between the policies in terms of size, readability, external references and reading cost. All the policies incorporated vague language in their directives and none could be read swiftly. It is only fair to make a reasonable observation here that if a policy cannot be accessed or is unfocussed or vague, then it will be ignored.

Multiple layers of guidance and variation between deaneries, trusts and teams also complicate the situation. This leads to confusion and lackof confidence between team members as to which policy to follow. The result is a huge wastage of money from duplication and undermining of the ability of the policy to deliver its objectives.

A collaborative effort at the national level could produce a simple, clear and succinct policy for physical health care of people with serious mental illness. We believe that the Royal College of Psychiatrists is in aunique position to take a lead on this very important aspect of patient health and well being. There are already themes emerging from research that it is an area which is very important to the patients, carers and their families alike 5. A clear national policy statement from the Royal College of Psychiatrists should dispel current confusion, policy fatigue and waste.

References:

1.Gonzalez C, Ahammed N, Fisher R. Improving physical health monitoring for outpatients on antipsychotic medication. The Psychiatrist 2010; 34: 91-94.

2.Abbasi Y. Improving physical health monitoring in psychiatry - change we need? The Psychiatrist 2010; 34: 210 - 211.

3.Barnes TR, Paton C, Cavanagh MR, Hancock E, Taylor DM. A UK audit of screening for the metabolic side effects of antipsychotics in communitypatients. Schizophr Bull 2007; 33: 1397-403.

4.Tosh G, Clifton A, Adams CE. Physical health care policies in mental health trusts in the North East Midlands (UK). Mental Health Review Journal 2010; 15: 15-20.

5.McCrae J. Physical health concerns of the patient, the family and the carers. European Psychiatry 2010; 25 supplement 2: 34-36.

Declaration of interest:

None.
... More

Conflict of interest: None Declared

Write a reply

Physical health monitoring for out-patients with severe mental illness � is everybody�s business

Kamini Vasudev, Consultant Psychiatrist (locum)
08 March 2010

Gonzalez et al (1) highlight the positive impact of their intervention in secondary care health service on physical health monitoring of out-patients on antipsychotic medication.

There is increasing recognition of the role that general practitioners (GPs) can play in the physical and mental health care of patients with mental illness(2,3). The quality and outcomes framework (QOF) of the General Medical Services contract, rewards GP practices for maintaining register of people with schizophrenia, bipolar disorder and other psychoses and providing them annual health check and routine health promotion and prevention advice(4).

The recent National Institute for Health and Clinical Excellence (NICE) guidelines on Schizophrenia (5) recommend that ‘GPs and other primary healthcare professionals should monitor the physical health of people with schizophrenia at least once a year…….A copy of the results should be sent to the care coordinator and/or psychiatrist, and put in thesecondary care notes.’ Regarding monitoring of physical health in secondary care, NICE recommends ‘As part of the CPA, healthcare professionals in secondary care should ensure that the regular physical health checks mentioned above are being carried out in primary care.’

We would like to share our experience of improving the standard of physical health care of individuals with severe mental illness in an Earlyinterventions in Psychosis (EIP) service through both ‘in-house’ training and improved liaison with primary care health service.

The initial audit to examine what percentage of individuals under thecare of EIP service had undergone any physical health check in the previous year revealed an alarming figure of about 20% in December 2008. This figure improved to 58% over the next 6 months following the interventions described below.

An in-house half-day workshop was organised for the multidisciplinarystaff of the EIP team to recognise the need for physical health monitoringin our patient group and to address their resistance to physical investigations, supporting them in booking appointments and attending their GP surgeries. It was decided that physical health would be a mandatory component of the care plan review (which happens 6 weeks into the service and then 6 monthly), and the care coordinators and the psychiatrist would jointly take responsibility for sending letters out tothe GPs requesting physical health checks and following the outcome.

An e-mail discussion was started with the mental health leads among primary care health services in the region. The template out-patient letters were sent out and feedback sought. A number of amendments were suggested in order to make the whole process simple, robust, and less timeconsuming for the GPs. It was agreed that for every patient under the careof EIP service, a letter would be sent to the primary health care service within a fortnight of acceptance to the EIP service and then annually, requesting a physical health check. Subsequently, the patient would be encouraged to book an appointment with the practice nurse for a physical health check and another double appointment with the GP the following weekto discuss the results. This would give an opportunity to the GPs to provide appropriate advice and complete QOF checks and would also prompt the GPs to send a copy of the results to the EIP service.

Discussions were also held with the mental health leads of primary healthcare services to decide the physical health parameters that needed monitoring. These included BP, body mass index (BMI), ECG, blood sugar and lipids (fasting if possible), full blood count, urea and serum electrolytes, liver function tests, thyroid function test and prolactin, as recommended by the Maudsley prescribing guidelines 2007, depending on the psychotropic agent prescribed.

The vulnerability of people with severe mental illness makes it imperative that health providers offer them every opportunity to adopt healthy lifestyles and access health services.

References

1.Gonzalez C, Ahammed N, Fisher R. Improving physical health monitoring for out-patients on antipsychotic medication. The Psychiatrist 2010; 34: 91-94.

2.Shiers D, Jones PB, Field S. Early intervention in psychosis: keeping the body in mind. Br J Gen Pract 2009; 59(563): 395-6.

3.Oud MJ, Schuling J, Slooff CJ et al. Care for patients with severemental illness: the general practitioner’s role perspective. BMC Fam Pract2009; 10: 29.

4.BMA and NHS Employers Quality and outcomes framework guidance for GMS contract 2009/10. British Medical Association and NHS Employers. www.nhsemployers.org

5.National Institute for Health and Clinical Excellence. CG 82 Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care (update). Clinical Guidelines,London, NICE 2009.

Declaration of interest : nil
... More

Conflict of interest: None Declared

Write a reply

Improving physical health monitoring in psychiatry- Change we need?

Yasir Abbasi, ST 5
02 March 2010

Dear Editor,

Gonzalez et al(1) highlight the very important issue of routine blood testing of patients on antipsychotics, which currently is under-monitored in a psychiatric setting particularly so in outpatients. However, the audit was conducted between 2004 and 2005, and it might not represent the current practice in UK. But physical health monitoring of patients with mental health problems still remains unsatisfactory. Some studies in 1986 & 2004 reported that recording of physical examination carried out on admission by psychiatric trainees to be ‘uniformly poor’ to ‘variable’.(2) The age adjusted annual death rates from all causes among individuals with a psychiatric diagnosis is 2-4 times higher than in general population.(3) This makes it even more pertinent for us to take extra measures in order to provide the best care for our patients.

In 2009, we completed an audit with my colleagues at North DerbyshireMental Health Services NHS Trust. The results illustrated that physical examination on admission to an inpatient unit increased from 67% to 83% bythe end of the audit cycle. The reasons for not examining patients varied from “transferred from medical ward” to “team to review tomorrow.”We encouraged the consultant led teams to take more responsibility in ensuring a complete physical examination (including investigations such asbaseline bloods, ECG) are done for every patient admitted to the unit and also recommended quick and easy access to physical health equipment, especially out of hours.

Whereas, I can appreciate the emphasis of the Royal College of Psychiatrists in increasing the awareness of physical illnesses in our client group and the importance in detecting them, but I believe actions speak louder than words. The reasons for our under performance in this area are due to problems at multiple levels. Training in psychiatry has become completely detached from medicine. We need to increase psychiatric trainees’ exposure to medicine by incorporating physical examination in the MRCPsych curriculam nationally and possibly offering a compulsory rotation in medicine during their core training. We also need to change the ethos within the psychiatric teams (inpatient and community based) by encouraging psychiatric nurses to also improve their medical skills.

It can be quite tricky in outpatients to address physical health problems while also managing mental health issues.Like other services, why can’t we have a dedicated nurse at the outpatientclinic who records the blood pressure, measures the height, weight, hip and waist circumference and does all the routine blood tests for every patient, before they go in to see the doctor?

References:

1) Gonzalez C, Ahammed N, Fisher R. Improving physical health monitoring for out-patients on antipsychotic medication. Psychiatr Bull 2010; 34: 91- 94.

2) Garden, G. Physical examination in psychiatric practice. Adv Psychiatr Treat 2005; 11: 142-149.

3) Harris E C, Barraclough B. (1998) Excess mortality of mental disorder. Br J Psychiatry 1998; 173: 11-53
... More

Conflict of interest: None Declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *