Barriers to accessing SRH care

People with severe mental illness experience barriers to access as well as lower-quality care, which can result in poorer SRH outcomes.^{Reference Reilly, Olier, Planner, Doran, Reeves and Ashcroft1–Reference Edelman, Patel, Glasper and Bogen-Johnston5} The reasons for this may include patient factors such as vulnerability, illness-related behaviours, and comorbid substance use; staff factors such as a lack of routine enquiry of needs by mental health staff¹, knowledge and skills gaps in SRH and associated stigma; and service factors such as variable access to appropriate healthcare at times of acute illness. Given this complexity, standard service models can find it extremely challenging to prioritise and meet the SRH needs of patients; quality improvement and innovation is often required to meet these and other physical health needs for patients.

From a clinical perspective, mental illness-related behaviours can themselves result in increased SRH need (for example, because of sexual disinhibition in the context of mania), and untreated disease as well as the iatrogenic effects of psychotropic medications can affect sexual function, reproductive health and fertility. Rates of unintended and unwanted pregnancy have been found to be higher in women with severe mental illness,^{Reference Özcan, Aydin, Yalcin and Kasali15} and those with an unintended pregnancy that goes to term may be unable to care for their child, resulting in the subsequent removal from the mother. This can lead to a devastating cycle of trauma that, in turn, may increase risk of comorbid mental health problems.^{Reference Dagher, Bruckheim, Colpe, Edwards and White16} Barriers to accessing SRH services where a termination of pregnancy is desired may also affect current and future well-being. Relationship, sexual and reproductive difficulties can also precipitate or perpetuate mental health difficulties.^{Reference Apantaku-Olajide, Gibbons and Higgins17} This context highlights the necessity of enhancing the profile and priority of the SRH needs in patients with severe mental illness.

Our integrated care model

To the best of our knowledge, this is the first time that an SRH service has directly integrated into a women's PICU. The quality improvement approach, the enhancements to the skills of the PICU multidisciplinary team, and the new clinical protocol allowed for the implementation of a routine and proactive SRH assessment system, resulting in increased assessment and identification of unmet needs, as well as successful completion of interventions in a proportion of patients. However, given that 58.4% of PICU patients did not receive an SRH assessment, the true level of unmet need is likely to be much higher. Furthermore, progress to the SHRINE clinic and interventions were impeded by clinical factors, including fluctuating capacity to consent and relatively short length of stay on the ward. It is also important to note that limitations were placed on face-to-face clinical care because of the COVID-19 pandemic. This resulted in less SHRINE interventions being undertaken, likely leading to an underestimation of the level of SRH need as well as limited care. Of note, patients were not just offered support and follow-up within the framework of this project, but were also followed up post-discharge, in line with standards of good clinical care.

Before this project, clinicians were less likely to routinely explore SRH concerns with a patient unless there was a clear need, such as the disclosure of sexual assault. In these cases, conversations were often led by a doctor. The project enhanced the knowledge and consultation skills of the team in line with a new protocol, resulting in most SRH conversations being nurse-led in the early stages of the PICU admission. Nursing staff that received training felt more confident in initiating SRH conversations and were well placed to appropriately time the interventions by keeping each patient's clinical and risk status in mind.

The multidisciplinary team found that SRH assessments were best conducted several days or a couple of weeks into the PICU admission, allowing time for clinical improvement and engagement. An individualised approach was required, particularly where there were historical sexual health factors such as a history of sexual trauma, sexual disinhibition or delusions relating to SRH. In these circumstances, it was important to support and safeguard both patients and staff. All assessments and interventions were delivered with safeguarding and gender sensitivity uppermost in mind.

The positive outcomes provide reassurance that delivering nurse-led assessments is an acceptable model in this clinical environment. There were other indirect quality gains, such as that SRH assessments led to patients receiving a much wider review of health and social care needs, including endocrinology, menopause, incontinence, substance misuse, domestic violence and child health.

Capacity challenges and delivering personalised care

The mental health in-patient setting, and particularly the PICU, may not be the obvious clinical setting to provide SRH services, but on closer inspection, it provides a unique opportunity to support patients in accessing services where they might ordinarily feel stigmatised and marginalised.^{Reference Hughes, Mitchell, Gascoyne, Moe-Byrne, Edmondson and Coleman18} Feedback from the patient and carer surveys showed that offering SRH assessments was considered both acceptable and necessary in the PICU. This feedback also highlighted that patients were responsive to discussing SRH concerns with a member of clinical staff with whom they had a good rapport and trusting relationship. In a psychiatric setting, this is hardly surprising, given the known association between therapeutic alliance and good outcomes; however, it is notable because it is in the early stages of this care journey.

In any psychiatric setting, patient capacity may be lacking or fluctuant, and clinicians will consider the necessity of immediate treatment and whether it is in the patient's best interests. There was a constant focus on patients’ capacity to consent to SRH assessments and interventions throughout this project. General considerations when weighing up the appropriateness of interventions included the clinical need and urgency, treatability of the condition, invasiveness and reversibility of the procedure, a patient's capacity to consent and whether this is likely to change. Fundamental human rights (enshrined in the Human Rights Act 1998) should be prioritised, including right to private and family life (Article 8), right to life (Article 2), right to marry and start a family (Article 12) and protection from discrimination (Article 14).¹⁹ Relevant ethical principles in the context of good psychiatric care include proportionality, equity, individual liberty and autonomy.

Many psychiatric in-patients are likely to regain their capacity to consent to assessments or interventions within a small number of days or weeks, with treatment of their mental disorder. In the treatment of sexually transmitted diseases, it is likely to be clinically appropriate to wait until the patient's restoration in capacity. However, if the infection is not identified through routine screening, then the potential implications on the patient's fertility cannot be addressed, even later down the line. Considerations around capacity to consent and what is in the best interests of the patient should be individualised, intervention-specific and regularly reviewed.

Given the severity of mental illness presentations in the PICU setting, there would be an understandable concern that patients would be too unwell to engage and provide capacitous consent. However, 41.6% of the PICU admissions received an SRH assessment, of which 71.9% had unmet SRH needs; 69.6% of those initiated SHRINE interventions, of which 68.8% completed SHRINE interventions. These are large percentages indicative of considerable engagement.

The multidisciplinary team's view was that a psychiatric admission should be considered an opportunity to address a patient's mental and physical health, since they are inextricably linked. Over time, with repeated and proactive engagement, patients may learn to reframe their self-worth, mitigate risky behaviours and improve their expectations of healthcare. Patients may come to understand that healthcare, including SRH, is a right to which they, like all others, are entitled.

With these factors in mind, the authors advocate for SRH needs assessments to be offered in all mental health settings, with the emphasis on identifying potential needs that can be addressed as capacity recovers.

In conclusion, there is a paucity of research both in identifying the level of SRH need in patients with severe mental illness and in assessing their ability to engage with standard services. Routine and proactive nurse-led SRH assessments were successfully implemented in this PICU setting. In doing so, the prevalence of need was far higher than expected. This finding is likely to extend to the wider psychiatric in-patient population. In psychiatric in-patient settings and especially PICUs, issues such as capacity, risk and trauma are heightened, which inevitably raises the question of the appropriateness or necessity of delivering SRH care in this context.

Data gathered on staff, patient and carer attitudes identified that all groups deemed delivery of SRH care in this PICU setting to be acceptable and even a necessary part of holistic care. Data from questionnaires and focus groups highlighted the value of training, so that staff feel sufficiently resourced and empowered to lead an intervention, ensuring these are appropriately timed.

At the very least, the implementation of routine SRH assessment in a psychiatric setting provides an opportunity for staff to engage and educate patients. We have shown it can be done, and if it is possible in a PICU, then it should be replicable in other mental health settings. At most, it may result in life changing interventions, such as the timely treatment of infection, the initiation of contraception, family planning, identification of abuse or education on maintaining good SRH and healthy relationships.

Although stark health inequalities in those with mental disorders remain, there is hope that with dynamic, innovative and individualised patient care, the barriers and stigma that prevent access to high-quality treatment can be eroded, and greater parity achieved.