Training practice nurses to care for people with severe mental illness

Cancer Risk Factors Among Adults with Serious Mental Illness

Veterans with serious mental illness (SMI) are at substantial risk for premature mortality. Engagement in primary care can mitigate these mortality risks. However, veterans with SMI often become disengaged from primary care. The US Department of Veterans Affairs (VA) measures and reports at VA facilities primary care engagement among enrolled veterans with SMI. This quarterly metric enables VA facilities to identify targets for quality improvement and track their progress. To inform quality improvement at our VA facility, we sought to identify promising practices for supporting engagement in primary care among veterans with SMI. We conducted semistructured telephone interviews from May 2019 through July 2019 with a purposeful sample of key informants at VA facilities with high levels of engagement in primary care among veterans with SMI. All interviews were recorded, summarized using a structured template, and summaries placed into a matrix. An interdisciplinary team reviewed and discussed matrices to identify and build consensus around findings. We interviewed 18 key informants from 11 VA facilities. The strategies used to engage veterans with SMI fell into 2 general categories: targeted outreach and routine practices. Targeted outreach included proactive, deliberate, systematic approaches for identifying and contacting veterans with SMI who are at risk of disengaging from care. In targeted outreach, veterans were identified and prioritized for outreach independent of any visits with mental health or other VA services. Routine practices included activities embedded in regular clinical workflows at the time of veterans' mental health visits, assessing, and connecting/reconnecting veterans with SMI into primary care. In addition, we identified extensive formal and informal ties between mental health and primary care that facilitated engaging veterans with SMI in primary care. VA facilities with high levels of primary care engagement among veterans with SMI used extensive engagement strategies, including a diverse array of targeted outreach and routine practices. Intentionally designed organizational structures and processes and facilitating extensive formal and informal ties between mental health and primary care teams supported these efforts. Additional organizational cultural factors were especially relevant to routine practice strategies. The practices we identified should be evaluated empirically for their effects on establishing and maintaining engagement in primary care among veterans with SMI.

Life expectancy in members of the general population has steadily improved in most countries since 1960. However, during the same period, the life expectancy of people with serious mental illness (SMI) has actually reduced. The majority of premature deaths result from natural causes, such as coronary heart disease. Obesity, a key risk factor for heart disease in this client group, might be caused both by unhealthy lifestyle behaviours and the side-effects of antipsychotic medication. Mental health nurses (MHN) nurses have an important role to play in improving the physical health of people with SMI. Evidence, however, suggests that they are often ambivalent about this role, and might perceive themselves as being inadequately trained and lacking in confidence. In this paper, we will argue that MHN need to re-evaluate their practice and recognize that the provision of physical health care is as important as other roles they occupy in relation to the care of people with SMI. We will also consider examples of best practice in physical health care, and discuss how these might be adopted by MHN and other professionals, in order to begin to improve services and to reduce health inequalities in this client group.

Serious mental illnesses (SMI), including psychotic, bipolar, and major depressive disorders, can lead to severe functional impairments, affecting work and social relationships. Individuals with SMI face complex health needs, including poor physical health and a high prevalence of chronic conditions. Yet health systems around the world struggle to meet these needs. Life expectancy among people with SMI is 15-20 years shorter than the general population, primarily due to somatic illnesses and increased all-cause mortality. This gap continues to widen, making excess mortality a critical indicator of healthcare quality and system performance. However, methodological variations in its calculation hinder robust international comparisons. Contributing factors to this mortality gap include adverse health behaviors, iatrogenic effects of antipsychotics, social and economic disadvantages, and inadequate physical healthcare. The longstanding separation between mental and somatic care exacerbates these issues, reducing access to preventive services and guideline-concordant care. To address these challenges, integrated care models tailored to the needs of people with SMI are essential. These models emphasize continuous, comprehensive and coordinated care to improve health outcomes and patient experience. Various approaches have emerged, such as primary care-based models or mental health-specialized settings incorporating primary care practitioners and case managers. However, evidence remains limited and consensus on the most suitable models is lacking. In response, the EUropean Mental and physical health Initiative for people with severe Mental Disorders (EU-MIND), funded by the 2024 European Partnership on Transforming Health and Care Systems, was developed as a collaboration between six countries: Denmark, Finland, France, Italy, Poland, and Sweden. The initiative aims to identify key considerations for implementing integrated care models for SMI and physical comorbidities in Europe, based on empirical evidence and expert consensus. This workshop will present EU-MIND's initial findings through three presentations: • Mortality trends: Longitudinal findings on the mortality of people with SMI across participating European countries, leveraging a standardized methodology for robust comparison and large-scale health claims datasets, will be presented. • Current evidence on integrated care models: A scoping literature review summarizing attributes and effectiveness of existing integrated care models for SMI and physical conditions, including a taxonomy of these models based on the SELFIE framework for multimorbidity care, will be analyzed. • Expert consensus on best-practice models: Findings from a Delphi study engaging service users, caregivers, care professionals, and policymakers to identify the most promising and acceptable integrated care models at the European level will be discussed. Each presentation will last 15 minutes, allowing time for discussion. Key messages • EU-MIND pioneers a rigorous multi-method approach (national datasets, scoping review, Delphi consensus) to generate robust evidence on physical health gaps in SMI. • EU-MIND promotes the implementation of stakeholder-accepted integrated care models, engaging patients, professionals, policymakers, and society.

Patients with Serious Mental Illness (SMI) have worse survival compared to cancer patients without SMI after controlling for delayed diagnosis. Decision-making capacity (DMC) may be impaired in both populations (cancer or SMI). DMC may be further impaired based on coupled vulnerability factors that challenge Shared Decision Making (SDM) for patients with cancer and SMI. Psychiatric consultations for DMC in hospitalized patients with cancer (n=97) were consecutively evaluated across a single institution cancer center. SMI data, demographic, and cancer-related variables were obtained from the medical record. Descriptive data were contrasted in patients with and without DMC and used for logistic regression modeling. Overall, 42% had DMC with no significant differences based on SMI (χ2 =2.60, p=0.11). Patients with SMI were younger, receiving anticancer treatment, and were less likely facing end of life issues. Age (OR 1.03, p=0.05) and no recent anticancer treatments (OR 0.34, p=0.02) were associated with decisional incapacity. At 3 months post discharge, almost two-thirds were dead with no difference based on SMI (χ2 =0.01, p=0.91). But End of Life (EOL) concerns were documented in 63% of non-SMI patients and only 36% of SMI patients (χ2 =5.63, p=0.02). Healthcare proxy (16%), four determinates of DMC (22%), and repeated psychiatric DCM assessments (35%) were documented with no differences based on SMI. SDM is not equitable for cancer patients with SMI. Advanced directives and a robust effort to provide value-congruent care for patient with SMI who develop cancer may lessen this health inequity for cancer patients with SMI.

Despite increasing attention to employment within the mental health sector, reports indicate that people with serious mental illness (SMI) continue to experience limited employment success in the province of Ontario, Canada. Research specifies that people with SMI who live in rural places are less likely than those living in urban centers to have access to satisfactory employment services or to become gainfully employed. The objective of this study was to examine access to employment from the perspectives of people with SMI, mental health and vocational service providers, and decision-makers, and to explore whether place influenced their access to work in northeastern Ontario. A qualitative case study using community-based participatory research methods was chosen to examine the experience of access to competitive employment in two northeastern Ontario communities. The cases selected for study were two geographic areas in northeastern Ontario which provided best-practice, mental health services to persons with SMI. Community-based site partners advertised and recruited participants, and a consumer advisory provided input on key stakeholders, questions, findings and the study action plan. The study findings were informed by individual and group interviews conducted with 46 individuals who resided in both rural and urban settings in the case communities, and feedback from 49 participants who attended town hall forums for presentation of study findings and development of an action plan. The qualitative data was supported by a secondary data source reporting on the employment outcomes of 4112 people with SMI who received disability income support and who resided in the case communities. Qualitative data were analyzed inductively, and categories and themes were developed. Findings were member checked with all informants and town hall participants in each case community. This article draws on the findings of a larger study and reports on the influence of place to the low employment success experienced by people with SMI who reside in the case communities; 91.3% of those receiving disability income support are unemployed, and rural residents experience higher levels of unemployment than those in urban places. Place was found to influence access to employment in five ways: by limited access to employment support services in rural places, and to recommended ratios in urban places; by the use of different models and practices that were inconsistent with best practices for people with SMI; by the lack of a plan for the implementation of employment services in the case communities; by limited use of the available, dedicated vocational resources for employment purposes; and by inadequate supports provided to persons with SMI who wish to enter the workforce. The results also underscore how people with SMI continue to be perceived negatively regarding their capacity for employment. Such stereotypical attitudes additionally contributed to employment marginalization of people with SMI from the workforce, especially in rural communities. The study highlights the influence of geography and human resources to the implementation of best practice employment services and supports for persons with SMI. Important policy implications include the need to consider place when implementing evidence-based practices in places where geography, distance and human health resources limit the communities' capacity to successfully do so. The study also underscores the need to build community capacity for supported employment, especially in rural places, in order to improve the participation of people with SMI in employment, and subsequently, to help shift the communities' thinking about their capacity for work.

Objective To examine whether the socio‐medical needs and imprisonment risk among transitional care clients with serious mental illness (SMI) differ from other transitional care clients. Methods A retrospective cohort study was conducted of adults who entered the Formerly Incarcerated Transition (FIT) Program from 2018 to 2023 following a period of incarceration. At program entry, FIT clients were screened for socio‐medical needs and diagnoses, including those reflecting SMI. Imprisonment outcomes were assessed using administrative records. Cumulative imprisonment risk and relative risk of imprisonment were estimated comparing clients by SMI status. Results Among 759 clients, 78.1% were men, 53.6% were aged 31–50 years, 59.8% reported Black race, and 32.9% had SMI. Clients with SMI were significantly more likely to be female, aged ≤40 years, White race, recently without food, to have healthcare coverage, to be unhoused, and to be in need of housing assistance, disability benefits, or legal assistance. Cumulative imprisonment risk at 360 and 720 days for clients with SMI (0.14 and 0.21) was higher than for those without (0.08 and 0.11), p < 0.001. In a multivariable proportional hazards model, SMI was associated with increased risk of imprisonment (1.75, 95% CI: 1.18, 2.60). Conclusions Released persons with SMI have a particularly heavy burden of socio‐medical needs and high imprisonment rates in North Carolina (NC). Relevance to Clinical Practice Similar programs in other states should consider assessing outcomes among their clients with SMI. In NC, efforts are underway to facilitate greater care continuity upon re‐entry for people with SMI, including direct linkage to co‐located primary and psychiatric care.

Some of the most debilitating aspects of schizophrenia and other serious mental illnesses (SMI) are the impairments in social perception, motivation, and behavior that frequently accompany these conditions. These impairments may ultimately lead to chronic social disconnection (ie, social withdrawal, objective isolation, and perceived social isolation or loneliness), which may contribute to the poor cardiometabolic health and early mortality commonly observed in SMI. However, the psychological and neurobiological mechanisms underlying relationships between impairments in social perception and motivation and social isolation and loneliness in SMI remain incompletely understood. A narrative, selective review of studies on social withdrawal, isolation, loneliness, and health in SMI. We describe some of what is known and hypothesized about the psychological and neurobiological mechanisms of social disconnection in the general population, and how these mechanisms may contribute to social isolation and loneliness, and their consequences, in individuals with SMI. A synthesis of evolutionary and cognitive theories with the "social homeostasis" model of social isolation and loneliness represents one testable framework for understanding the dynamic cognitive and biological correlates, as well as the health consequences, of social disconnection in SMI. The development of such an understanding may provide the basis for novel approaches for preventing or treating both functional disability and poor physical health that diminish the quality and length of life for many individuals with these conditions.

The challenge for surgical patients with serious mental illness (SMI) has been previously highlighted in this journal with significantly worse surgical outcomes being shown across a range of measures compared with the overall surgical population.1, 2 While the reasons for this are multifactorial, the input of health professionals is certainly a critical aspect in determining the clinical outcomes and experiences of patients with mental illness. Although their primary role is to provide care, health professionals have been shown to hold negative attitudes and to frequently adopt words and labels that are stigmatizing towards individuals with SMI.3, 4 This has been demonstrated among general practitioners, psychiatrists, clinical psychologists, physicians, nursing staff, pharmacists and medical students.4-8 There is little evidence within the surgical context and, specifically on the current knowledge, attitudes and behaviours of surgeons in treating patients with co-morbid SMI. In the 1970s and 1980s, surgeons were shown to be less interested in dealing with patients with psychological problems compared with physicians, and largely felt it was not their responsibility.9-11 A more recent study, albeit still some 15 years old, suggests there has been a heightened awareness regarding mental health among surgeons12 but the evidence still remains limited with further investigation into this area warranted. To gain a better understanding of how surgeons currently interact with this unique patient group, a web-based survey of Australian consultant surgeons who were members of the ANZ Society of Cardiac and Thoracic Surgeons or General Surgeons Australia was conducted between November 2017 and February 2018. Out of 850 surgeons invited, only 87 completed the 33-question survey providing a 10% response rate. Certainly, the lack of response in itself may reflect a general level of disinterest from surgeons regarding the treatment of patients with SMI. Despite the low response rate, which is an obvious limitation of this study, some interesting insights were gained that are worthwhile highlighting for further consideration. In terms of knowledge, the responding surgeons demonstrated they were aware of the challenges faced by patients with SMI. They reasonably estimated the percentage of their patients with SMI and recognized these patients as likely to have higher mortality and longer stays in hospital compared with the general population. The responding surgeons also had comparable attitudes with other health professionals based on their mean Mental Illness: Clinician Attitudes scores and did not demonstrate high levels of stigma towards patients with SMI.4, 5, 13 Although these results may have been somewhat biased by those surgeons with more positive attitudes or greater interest in the topic participating in the survey. While the preoperative management of SMI for surgical patients should arguably be the same as other medical co-morbidities, little is known about how surgeons routinely handle this unique patient group. In terms of behaviours, the majority of responding surgeons (74%) reported they did not normally ask their patients about their mental health status in the preoperative setting. A range of reasons were provided including lack of time, it being inappropriate and the patients disliking it, which are in line with previous findings.12 Interestingly, those surgeons who reported routinely asking their patients about their mental health during preoperative consultations (26%) were found to have significantly lower stigmatizing attitudes compared with those surgeons who did not. This indicates there may be a level of stigma impacting on the behaviour of some surgeons. Further to this, the responding surgeons also reported they felt less confident about how to manage patients with SMI compared with other medical co-morbidities, such as diabetes, obesity or high blood pressure. This highlights that it may not be that they do not care, that perhaps surgeons do not know what to do when it comes to managing this complex group of patients. Certainly it was worrying that one-third of the responding surgeons reported they had declined to operate on a patient due to concerns about their mental health status. Although limited conclusions can be made from these findings, in the absence of very little other information, the insights gained are nonetheless helpful in highlighting there is considerable opportunity to enhance the way surgeons manage patients with SMI, particularly in the preoperative setting. Whether surgeons care about taking a more proactive approach to manage this unique patient group remains to be determined. Ethics approval was obtained for this study from the Royal Prince Alfred Ethics Review Committee (X17-0282).

Feasibility and Acceptability of a Collaborative Lung Cancer Screening Educational Intervention Tailored for Individuals With Serious Mental Illness.

Prevalence of diagnosed ocular disease in veterans with serious mental illness.

Serious Mental Illness in USa Nursing Homes: Differences and Similarities Between Nursing Homes with Higher Versus Lower Proportions of Patients with Serious Mental Illness

Adopting and maintaining physical activity behaviour in people with severe mental illness: The importance of autonomous motivation

Objective-Persons with severe mental illness have higher rates of chronic general medical illness compared with the general population.Similarly, compared with the general population, incarcerated persons have higher rates of chronic medical illness; however, there is little information about the synergy between severe mental illness and incarceration and the general medical problems of consumers.To address this gap in the literature this study addresses the following question: are consumers with a history of incarceration at greater risk of general medical problems compared with consumers without such a history?Methods-Administrative data were used to compare the medical problems of 3,690 persons with severe mental illness with a history of incarceration and 2,042 persons with severe mental illness with no such history.Results-Consumers with a history of incarceration were more likely than those with no such history to have infectious, blood, and skin diseases and a history of injury.Furthermore, when analyses controlled for gender, race, age, and substance use disorders, consumers with an incarceration history were 40% more likely to have any general medical problem and 30% more likely to have multiple medical problems.Conclusions-The findings presented here call for better communication among local public health and mental health providers and jails and better integration of primary care and behavioral health care among community mental health providers.Also, research on evidence-based interventions designed to divert persons with severe mental illness from the criminal justice system and facilitate community reentry for persons with severe mental illness who are released from jails and prisons should be accelerated.

Physical Function Assessment of Older Veterans With Serious Mental Illness