Family involvement to support cardiovascular self-management care for people with severe mental illness: a systematic review.

BACKGROUND: Family members play a pivotal role in supporting cardiovascular self-management-based care of community-living adults with severe mental illness (SMI). However, little is known about what strategies caregivers employ as part of their caring roles. AIM: This paper aims to explore what caregiving strategies work (or not), why and how by collating and synthesising existing evidence on this issue. METHODS: A systematic search of peer-reviewed qualitative and mixed-method studies published between 2000 and 2019 was employed. This comprehensive process generated only nine papers for subsequent meta-synthesis of qualitative data. RESULTS: Findings suggested that caregivers have a complex yet comprehensive role to play in initiating and perpetuating self-management-based cardiovascular care. The elements of recovery such as promoting hope, normality, autonomy and identity were flagged as critical underpinning factors that motivated the person with SMI to adopt a healthy lifestyle. However, it was evident that caregivers needed to walk alongside the person, at times, to help them reach their maximum potential in sustaining improved self-management behaviours. CONCLUSION: Caregivers sit in a favourable bridging position between healthcare systems and community-living individuals with SMI, to support their cardiovascular health. However, this powerful but invisible 'workforce' clearly needs further support involving finance, skill-development and acknowledgement.

Why Do People with Severe Mental Illness Have Poor Cardiovascular Health?-The Need for Implementing a Recovery-Based Self-Management Approach.

People with severe mental illness (SMI) die significantly earlier than their well counterparts, mainly due to preventable chronic conditions such as cardiovascular disease (CVD). Based on the existing research, this perspective paper summarises the key contributors to CVD in people with SMI to better target the areas that require more attention to reduce, and ultimately resolve this health inequity. We discuss five broad factors that, according to current international evidence, are believed to be implicated in the development and maintenance of CVD in people with SMI: (1) bio-psychological and lifestyle-related factors; (2) socio-environmental factors; (3) health system-related factors; (4) service culture and practice-related factors; and (5) research-related gaps on how to improve the cardiovascular health of those with SMI. This perspective paper identifies that CVD in people with SMI is a multi-faceted problem involving a range of risk factors. Furthermore, existing chronic care or clinical recovery models alone are insufficient to address this complex problem, and none of these models have identified the significant roles that family caregivers play in improving a person's self-management behaviours. A new framework is proposed to resolve this complex health issue that warrants a collaborative approach within and between different health and social care sectors.

Recovery college as a transition space in the journey towards recovery: An Australian qualitative study.

Recovery colleges are formal learning programs that aim to support people with a lived experience of mental illness. In this study, we aimed to explore the experiences of participants in a pilot recovery college that opened in Adelaide, South Australia, in 2016. A qualitative exploratory study was conducted involving interviews with learners (n = 8) and focus groups with lived experience facilitators (course facilitators with a lived experience of mental illness, n = 5), Clinician facilitators (mental health service staff facilitators, n = 4), and care coordinators (staff providing case management support, n = 5). Three main themes (hope, identity, and the recovery college as a transition space) and two subthemes (recovery college experience and outcomes) were identified. The results showed that the recovery college provided a transition space for shifting learners' identities from patient to student, facilitated by the experiences and outcomes of the recovery college, providing hope for the future. This study highlights the importance of providing mentally healthy and non-stigmatizing learning environments to promote and cement recovery for people with a lived experience of mental illness.

Outcomes of telephone-delivered low-intensity cognitive behaviour therapy (LiCBT) to community dwelling Australians with a recent hospital admission due to depression or anxiety: MindStep™.

BACKGROUND: In 2006, the British government launched 'Improving Access to Psychological Therapies' (IAPT), a low intensity cognitive behaviour therapy intervention (LiCBT) designed to manage people with symptoms of anxiety and depression in the community. The evidence of the effectiveness of IAPT has been demonstrated in multiple studies from the UK, USA, Australia and other countries. MindStep™ is the first adaptation of IAPT in Australia, delivered completely by telephone, targeting people with a recent history of a hospital admission for mental illnesses within the private health system. This paper reports on the outcome of the first 17 months of MindStep™ implemented across Australia from March 2016. METHODS: This prospective observational study investigated the MindStep™ program in a cohort of clients with a recent hospitalisation for mental illnesses. The study used quantitative methods to compare pre-post treatment clinical measures (N = 680) using Patient Health Questionnaire (PHQ-9) and the Generalised Anxiety Disorder (GAD-7). This study also included in-depth interviews with participants (N = 14) and coaches (N = 4) to determine the feasibility and acceptability of the program. RESULTS: Of the 867 clients referred to MindStep™, 757 had initial assessments by phone making an enrolment rate of 87.3%. Following assessment, 680 commenced treatment and of them, 427 (62.7%) completed treatment. According to 'per-protocol' analysis (N = 427), there was a large effect size for post-treatment PHQ-9 (d = 1.03) and GAD-7 (d = 0.99) scores; reliable recovery rate was 62% (95% CI: 57-68%). For intent-to-treat analysis using multiple imputation (N = 680), effect sizes were also large for pre-post treatment change: PHQ-9 (d = 0.78) and GAD-7 (d = 0.76). The reliable recovery rate was 49% (95% CI: 45-54%). Qualitative findings supported these claims where participants were positive about MindStep™ and found the telephone delivery and use of mental health coaches highly acceptable. CONCLUSIONS: MindStep™ has demonstrated encouraging outcomes that suggest LiCBT can be successfully delivered to people with a history of hospital admissions for anxiety and depressive disorders and achieve target recovery rates of > 50%. Other promising evaluation findings indicate the MindStep™ option is acceptable, feasible and safe within the stepped models of mental health care delivery in Australia.

Improving cardiovascular health and quality of life in people with severe mental illness: study protocol for a randomised controlled trial.

BACKGROUND: The estimated 300,000 adults in Australia with severe mental illness (SMI) have markedly reduced life expectancy compared to the general population, mainly due to physical health comorbidities. Cardiovascular disease (CVD) is the commonest cause of early death and people with SMI have high rates of most modifiable risk factors, with associated quality of life (QoL) reduction. High blood pressure, smoking, dyslipidaemia, diabetes and obesity are major modifiable CVD risk factors. Poor delivery of recommended monitoring and risk reduction is a national and international problem. Therefore, effective preventive interventions to safeguard and support physical health are urgently needed in this population. METHODS: This trial used a rigorous process, including extensive piloting, to develop an intervention that delivers recommended physical health care to reduce CVD risk and improve QoL for people with SMI. Components of this intervention are integrated using the Flinders Program of chronic condition management (CCM) which is a comprehensive psychosocial care planning approach that places the patient at the centre of their care, and focuses on building their self-management capacity within a collaborative approach, therefore providing a recovery-oriented framework. The primary project aim is to evaluate the effectiveness and health economics of the CCM intervention. The main outcome measures examine CVD risk and quality of life. The second aim is to identify essential components, enablers and barriers at patient, clinical and organisational levels for national, sustained implementation of recommended physical health care delivery to people with SMI. Participants will be recruited from a community-based public psychiatric service. DISCUSSION: This study constitutes the first large-scale trial, worldwide, using the Flinders Program with this population. By combining a standardised yet flexible motivational process with a targeted set of evidence-based interventions, the chief aim is to reduce CVD risk by 20%. If achieved, this will be a ground-breaking outcome, and the program will be subsequently translated nationwide and abroad. The trial will be of great interest to people with mental illness, family carers, mental health services, governments and primary care providers because the Flinders Program can be delivered in diverse settings by any clinical discipline and supervised peers. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12617000474358 . Registered on 31 March 2017.

Hidden care: Revelations of a case-note audit of physical health care in a community mental health service.

People with severe mental illness (SMI) are widely reported to be at an increased risk of morbidity and premature death due to physical health conditions. Mental health nurses are ideally placed to address physical and mental health comorbidity as part of their day-to-day practice. This study involved an audit of hardcopy and electronic clinical case-notes of a random sample of 100 people with SMI case managed by community mental health service in metropolitan South Australia, to determine how well physical health conditions and risk factors, screening, and follow-up are recorded within their service records. Every contact between 1 July 2015 and 30 June 2016 was read. One-way ANOVA, Scheffe's test, and Fisher's exact test determined any significant associations across audit variables, which included gender, age, income, living arrangement, diagnosis, lifestyle factors, recording of physical health measures, and carer status. A focus on physical health care was evident from everyday case-note records; however, because this information was 'buried' within the plethora of entries and not brought to the fore with other key information about the person's psychiatric needs, it remained difficult to gain a full picture of potential gaps in physical health care for this population. Under-reporting, gaps and inconsistencies in the systematic recording of physical health information for this population are likely to undermine the quality of care they receive from mental health services, the ability of mental health service providers to respond in a timely way to their physical healthcare needs, and their communication with other healthcare providers.

Do Males and Females Conceptualise Work and Social Impairment Differently Following Treatment for Different Mental Health Problems?

The Work and Social Adjustment Scale (WSAS) is used by psychiatric nurses for screening and evaluating patients' treatment outcomes for a variety of mental health problems. This study investigated longitudinal and gender measurement invariance of WSAS using structural equation modeling within a help-seeking problem gambling sample (n=445), and an intervention program for depression and anxiety sample (n=444). The concept of functional impairment was defined by all WSAS items in males and females at pre- and post-treatment assessments. These findings confirm that the WSAS is a robust and efficacious instrument for evaluating treatment outcomes in two differing populations.

Children's physical activity levels during organised sports practices.

OBJECTIVES: This study measured the physical activity levels of children during practice sessions of four popular organised sports in Australia. DESIGN: Cross-sectional observational design. METHODS: Participants comprised children from four local organised sports clubs in suburban Adelaide, South Australia. The sports examined were Australian Rules Football (AFL), girls' netball, boys' soccer and girls' soccer. Each participant wore a waist-mounted GT3X or GT3X+Actigraph accelerometer in either one or two of the practice sessions. RESULTS: Participants typically spent 40-50% of each sport practice session in moderate to vigorous physical activity (MVPA). Participants in the boys' soccer teams spent significantly greater time in MVPA (mean=47% of practice time, 95% CI=37%, 57%) than participants in the girls' netball teams (mean=40%, 95% CI=30%, 50%), participants in the girls' soccer teams (mean=38%, 95% CI=28%, 48%) and participants in the boys' AFL teams (mean=40%, 95% CI=36%, 44%). The practice sessions contributed approximately half of the 60min of MVPA per day recommended by physical activity guidelines for children and young people. CONCLUSIONS: The results suggested that organised sports provide a supportive environment for physical activity accrual; however, one practice session is insufficient for children to reach the amount of MVPA recommended in daily physical activity guidelines.

Adapting, Pilot Testing and Evaluating the Kick.it App to Support Smoking Cessation for Smokers with Severe Mental Illness: A Study Protocol.

(1) Background: While the prevalence of tobacco smoking in the general population has declined, it remains exceptionally high for smokers with severe mental illness (SMI), despite significant public health measures. This project aims to adapt, pilot test and evaluate a novel e-health smoking cessation intervention to assist relapse prevention and encourage sustained smoking cessation for young adults (aged 18⁻29 years) with SMI. (2) Methods: Using co-design principles, the researchers will adapt the Kick.it smartphone App in collaboration with a small sample of current and ex-smokers with SMI. In-depth interviews with smokers with SMI who have attempted to quit in the past 12 months and ex-smokers (i.e., those having not smoked in the past seven days) will explore their perceptions of smoking cessation support options that have been of value to them. Focus group participants will then give their feedback on the existing Kick.it App and any adaptations needed. The adapted App will then be pilot-tested with a small sample of young adult smokers with SMI interested in attempting to cut down or quit smoking, measuring utility, feasibility, acceptability, and preliminary outcomes in supporting their quit efforts. (3) Conclusions: This pilot work will inform a larger definitive trial. Dependent on recruitment success, the project may extend to also include smokers with SMI who are aged 30 years or more.

Managing chronic conditions care across primary care and hospital systems: lessons from an Australian Hospital Avoidance Risk Program using the Flinders Chronic Condition Management Program.

Objective The study aimed to determine the impact of the Flinders Chronic Condition Management Program for chronic condition self-management care planning and how to improve its use with Bendigo Health's Hospital Admission Risk Program (HARP). Methods A retrospective analysis of hospital admission data collected by Bendigo Health from July 2012 to September 2013 was undertaken. Length of stay during admission and total contacts post-discharge by hospital staff for 253 patients with 644 admissions were considered as outcome variables. For statistical modelling we used the generalised linear model. Results The combination of the HARP and Flinders Program was able to achieve significant reductions in hospital admissions and non-significant reduction in emergency department presentations and length of stay. The generalised linear model predicted that vulnerable patient groups such as those with heart disease (P=0.037) and complex needs (P<0.001) received more post-discharge contacts by HARP staff than those suffering from diabetes, renal conditions and psychosocial needs when they lived alone. Similarly, respiratory (P<0.001), heart disease (P=0.015) and complex needs (P=0.050) patients had more contacts, with an increased number of episodes than those suffering from diabetes, renal conditions and psychosocial needs. Conclusion The Flinders Program appeared to have significant positive impacts on HARP patients that could be more effective if high-risk groups, such as respiratory patients with no carers and respiratory and heart disease patients aged 0-65, had received more targeted care. What is known about the topic? Chronic conditions are common causes of premature death and disability in Australia. Besides mental and physical impacts at the individual level, chronic conditions are strongly linked to high costs and health service utilisation. Hospital avoidance programs such as HARP can better manage chronic conditions through a greater focus on coordination and integration of care across primary care and hospital systems. In support of HARP, self-management interventions such as the Flinders Program aim to help individuals better manage their medical treatment and cope with the impact of the condition on their physical and mental wellbeing and thus reduce health services utilisation. What does this paper add? This paper sheds light on which patients might be more or less likely to benefit from the combination of the HARP and Flinders Program, with regard to their impact on reductions in hospital admissions, emergency department presentations and length of stay. This study also sheds light on how the Flinders Program could be better targeted towards and implemented among high-need and high-cost patients to lessen chronic disease burden on Australia's health system. What are the implications for practitioners? Programs targeting vulnerable populations and applying evidence-based chronic condition management and self-management support achieve significant reductions in potentially avoidable hospitalisation and emergency department presentation rates, though sex, type of chronic condition and living situation appear to matter. Benefits might also accrue from the combination of contextual factors (such as the Flinders Program, supportive service management, clinical champions in the team) that work synergistically.

Support workers can develop the skills to work with complexity in community aged care: An Australian study of training provided across aged care community services.

Enhancing support workers' (SW) role is timely given increasing demands on human and financial health care resources. This article presents outcomes of a program, delivered to 140 participants from five community aged care providers in Australia, designed to enhance knowledge, skills, and confidence of community aged care SWs, building their practical skills in understanding, recognizing, and responding to complexity. Evaluation training modules on communication, complexity, behavior change, and chronic condition self-management support involved pre/post surveys with SWs and their supervisors. SWs reported greater awareness, skills, and confidence in working with complexity, reinforcing the value of their existing practices and skills. Coordinators reported greater appreciation of SWs' skills, and greater awareness of gaps in SWs' support and supervision needs. Educators, policy makers, and services should account for these contributions, given growing fiscal restraint and focus on reablement and consumer-directed care.

Type of unit and population served matters when implementing a smoke-free policy in mental health settings: Perceptions of unit managers across England.

BACKGROUND: Globally, smoking remains a significant issue for mental health populations. Many mental health trusts in England are facing challenges of implementing the National Institute for Health and Care Excellence guidance according to which all mental health settings, no matter the type, should be entirely smoke-free and provide comprehensive smoking cessation support. AIM: The aim of this paper was to determine if unit type and unit manager smoking status influence mental health smoke-free policy implementation. METHOD: This paper reports on the secondary analysis of data from a cross-sectional survey of 147 mental health inpatient settings in England, in 2010. The original study's main aim was to understand unit managers' perceived reasons for success or failure of smoke-free policy. RESULTS: Unit managers (n = 131) held a positive stance towards supporting smoke-free policy and most perceived that the policy was successful. Non-smoker unit managers were more likely to adopt complete bans than smoker unit managers, whereas smoker unit managers were more likely than non-smoker unit managers to think that stopping smoking aggravated patients' mental illness. Smoking rates for staff and patients remain high, as perceived by unit managers, regardless of unit type. Proportion of units offering nicotine replacement therapy and peer support to patients was significantly higher in locked units compared to semi-locked or residential rehabilitation. Applied strategies significantly vary by type of unit, whereas unit managers' knowledge, attitude and practices vary by their smoking status. DISCUSSION: There are nuanced differences in how smoke-free policy is enacted which vary by unit type. These variations recognise the differing contexts of care provision in different types of units serving different patient groups. Addressing staff smoking rates, promoting consistency of staff response to patients' smoking and providing staff education and support continue to be key strategies to successful smoke-free policy. CONCLUSIONS: Our results demonstrate the importance of taking into account the type of unit and acuity of patients when enacting smoke-free policy and addressing staff smoking.