Abstract
Psychiatry and general practice have both been criticized for failing to adequately manage physical comorbidity among mentally ill patients [1–3]. General pratitioners have been accused of failing to diagnose and treat physical health problems among the mentally ill [2], and psychiatrists have been accused of failing to assume responsibility for the holistic care of their patients [3, 4]. It can be argued that the lack of integrated medical treatment may be a factor in the increased morbidity and mortality observed among people with chronic mental illness [5–9].
Historically, the institutionalization of people with chronic and severe mental illness meant that the facility's medical and nursing staff had an unchallenged responsibility for both the physical and psychiatric health of their patients. In contrast, community-based care (in Australia at least) has been characterized by a fragmentation of service delivery. Patients are required to attend different practitioners, usually based at different sites, to meet their various health needs. This often requires a degree of organization beyond the capacity of many people with chronic mental illness, leading to an outcome whereby patients fail to ‘access preventative health services, and may not identify illness (or) seek appropriate treatment’ [10].
Poor detection of physical health problems among psychiatric patients is well documented. A recent Victorian study found that the prevalence of known risk factors for cardiovascular disease, HIV and hepatitis C was up to five times higher among clients of Area Mental Health Services (AMHS) than for the general community [11, 12]. Overseas studies report that between 26% and 93% of psychiatric patients had comorbid medical illnesses that were either not diagnosed or inadequately treated [13]. One study found that detection rates of physical illness among mentally ill patients was less than 50% [14].
This study aims to examine the attitudes and selfreported practices of case managers working at community mental health clinics regarding the physical health of their clients. It attempts to determine the systemic barriers facing mentally ill patients in receiving optimal care for physical conditions. It is also a subset of a larger project examining the physical health status of people with chronic mental illness [11, 12, 15].
Method
The research was conducted at four AMHSs in the North-western Health Care Network Mental Health Program in Melbourne, Australia. At the time of the study, approximately 1782 clients with chronic mental illness were receiving long-term case management across the four services. The majority of case-managed clients had a primary diagnosis of psychotic disorder, with a smaller proportion of mood and personality disorders. The target population for the current study were the case-managers of these clients. The four continuing care teams employed a total of 111 case managers. All case managers were invited to participate in the study.
A 20 item questionnaire survey was developed by the first (BH) and third (SD) authors to assess the attitudes and practices of case managers regarding the physical health of their clients. Five items requested demographic information and five items asked respondents about their attitudes regarding the physical health of their clients. The final 10 items asked respondents how often case managers enquired about clients’ health issues such as smoking, diet, blood pressure assessments, mammography and attendance at a GP. The questionnaire was administered to the case managers immediately before they participated in a focus group. Descriptive analyses and crosstabulations were performed on the survey data.
A focus group was conducted at each of the four clinics. The focus group schedule (Table 1) was derived from a literature review and clinical experiences of the research team. The sessions, lasting approximately 60 min, were audiotaped and transcribed. The transcripts were compared with hand-written notes taken through the session to enhance meaningful interpretation.
Focus group schedule, derived fr om a liter ature review and clinical e xperience
Results
Sample
Thirty-two case managers participated in the focus groups and 29 returned questionnaires. Two participants completed only the first part of the questionnaire. Therefore, results for the final 10 items are based on a sample of 27. The majority (72%) of case managers were female. The professional background of participants was nursing (41%), social work (24%), occupational therapy (14%), psychology (10%) and medicine (10%).
Questionnaire
The attitudes and behaviours of case managers toward the physical health of their patients varied considerably. While 38% agreed that ‘living with a mental illness is generally such a struggle that physical health is of lesser importance’, 60% disagreed with this statement. Over a third of case managers believed that physical health issues were secondary to mental health issues, however, at the same time almost all (90%) believed that they had a responsibility to optimize the physical health of their clients. Not only did they believe that this was their responsibility, but 86% also agreed or strongly agreed that case managers can make a significant difference in promoting client behaviours that will improve physical health. Case managers with a nursing background were more likely than case managers with a psychology background to believe that they had both a responsibility for the physical health of their clients and that they could make a difference.
Table 2 shows that case managers did not systematically review a broad range of health behaviours with their clients. While alcohol use, GP attendance, smoking and illicit drug use were commonly reviewed, preventive behaviours such as mammograms, Pap smears and blood pressure checks received far less attention.
Behaviours case managers enquire about patients†
Focus groups
Transcripts from the focus groups were entered into the NUDIST software package. Analysis of the qualitative data resulted in the identification of eight themes (see Table 3).
Primary themes indentified from focus groups
Physical health
Case managers believed that the physical health of people with mental illness was worse than the general population. Poor health status was attributed to a combination of medication side-effects, lifestyle choices, poverty and difficulty in accessing optimal health care – all factors intricately tied to the symptoms of mental illness itself. An increase in psychiatric symptoms was linked to a decrease in positive health behaviours and vice versa. For example, one respondent said: ‘A lot of clients will smoke and drink alcohol and use drugs depending on their mental state at the time’; while another observed that: ‘When their mental health improves they become more interested in their physical health and they become more motivated to look after themselves’.
Obesity
Obesity was identified as a significant issue and case managers expressed concern about the negative impact of weight gain on selfesteem and body image. There was a sense of fatality in that many considered weight gain to be an inevitable outcome related to the interaction between psychotropic medication, symptoms of schizophrenia and lifestyle. Medication was frequently identified as a causal factor in weight gain. One respondent reported: ‘When you weigh the client after they have been put on a different injection, you notice significant weight rises, usually with quite a number of people and that's five kilograms I'm talking about over a four month period’. Several respondents spoke about the powerlessness associated with severe weight gain: ‘Even the ones who do try and keep their weight down with activity often fail and I think that it does appear to have something to do with the medication. It's not just lack of motivation all the time and I think that that's very demoralizing for a lot of patients, just to feel they can't control it.’ Case managers reported that patients also believe significant weight gain is caused by medication and that ‘a lot of (patients) complain about it’.
Smoking
Case managers were aware of high rates of smoking among their patients and were concerned about the physical and financial costs. Smoking was identified as a key factor in the poverty of psychiatric patients and as a contributor to poor nutrition. As one respondent noted: ‘Most of their income… goes on cigarettes and drugs…they put food last on the list, which means that they end up buying a hamburger or a sausage roll or something like that’.
Initially, case managers appeared to be proactive regarding smoking cessation and there were reports that some patients had successfully quit with GP assistance. However, further discussion revealed that case managers believed that smoking cessation was difficult to achieve in this group and many comments indicated that they believed that smoking might actually be more acceptable in this population than in other groups. There appeared to be a widely held belief that smoking was one of the few pleasures in the lives of their patients. For example one respondent said: ‘They don't have much money and I guess that if they are smoking it's one of the few pleasures that they have’. Another stated that psychiatric patients are ‘different from the general population. They're bored (and) they don't have a lot of activities. Most of their friends smoke, you go to the drop-in club (and) clients will smoke.’
There was also a clearly held perception that smoking could alleviate some of the distress associated with mental illness. One case manager said: ‘Relief from sedation seems to be something that (patients) rely both on cigarettes and coffee for’. Smoking was also believed to reduce anxiety: ‘I've seen research that shows that people smoke to decrease the side-effects of medication. Smoking decreases their anxiety and alleviates boredom’. Another case manager reported observing this phenomena: ‘I've noticed that some of my clients who are far more disturbed will report that they vary their smoking. So there seems to be an anxiety management aspect to it as well.’
Concern was expressed that cigarettes were used for behavioural modification in the inpatient setting: ‘For example, on-the-ward nursing staff give out cigarettes to calm patients down and to reward them for good behaviour’. One respondent was adamant that case managers ‘should stop the collusion mental health services have in encouraging patients to smoke’. However, there was disagreement on this issue as other respondents believed that ‘when they are in hospital…clients are usually psychotic so it's not really a good idea to enter into an education program about the ills of smoking…that's the last thing they're interested in really, so it's probably more that it's not an appropriate time.’
Case management
Case managers believed that their core business was to assess and treat mental illness. Related issues such as finance, accommodation, family relationships and physical health were seen to be of secondary importance. The majority of case managers did not routinely look at issues related to physical health. The attitude was summed up by one respondent who said: ‘If something came to your attention because somebody was complaining about weight gain or looking really big or looking really unwell you can inquire about it but I wouldn't do it as a routine’. However, there were some notable exceptions to this attitude. For example one respondent reported that they ‘routinely ask people, or women, if they had breast examinations, mammograms, Pap smears, chest X-rays, all kinds of tests’. Consistent with the questionnaire findings, different attitudes were observed between nurses and psychologists in relation to physical health issues. A nurse commented: ‘I think most of us can possibly see some of the more common symptoms as an alert, like going to the toilet or something, you know, for a nurse that would mean UTI’. A case manager with a psychology background replied: ‘For a psychologist it [going to the toilet] would mean anxiety’.
The influence of professional training did not appear to be limited to case managers. There were also reports of inconsistency in how frequently medical staff look at issues of physical health. Focus group participants reported that GP trainees and medical officers were more vigilant in addressing issues of physical health than psychiatry trainees and psychiatrists.
Barriers to optimal physical health
A clear theme to emerge from discussion on the barriers to good physical health was the lack of service delivery integration. Although respondents considered physical health issues to be a shared responsibility between patient, case manager, GP and psychiatrist; none of the four study sites had a systematic process to ensure that the perception of shared responsibility coexisted with the reality of shared action. None of the sites had a systemic process to monitor and review physical health and individual staff members leading this process could not be identified.
In contrast to the perception of shared responsibility were reports by focus group members that patients were encouraged to have their physical health problems addressed by external GPs. Medical staff would occasionally perform physical examinations if the patient had obvious physical problems and could not, or would not, consult a GP. However, generally few medical staff in the AMHS performed physical examinations. The lack of physical examinations was attributed to resources, both facilities and time: ‘(Doctors) look at them but they can't follow through…because they don't have the facilities and I think it's time too. I mean they haven't got time to do more extensive medical assessment and treatments.’ At the clinics where the study took place, medication for physical health problems was not generally paid for by the service. Case managers perceived this practice as a sign that the community mental health clinics did not see physical health as a core responsibility. The lack of clinical autonomy to address physical health issues seems to engender a sense of futility. As one respondent said: ‘If you identify something, well we can't prescribe physical medication anyway because we can't pay for them’.
Lack of integration within the AMHS foreshadowed a similar issue for the wider health care sector. Weak relationships between the AMHS and other medical personnel such as GPs and the hospital system was seen as a barrier to patients accessing holistic care. To some degree this is also exacerbated by patient preference. At some clinics there was regular communication between case managers and their patients’ GPs, usually in the form of written information on current management issues and treatment. However, case managers reported that in order to maintain their privacy some patients refuse permission for staff to communicate with the GP.
Another perceived barrier was the attitude of clients themselves and a tendency to ignore their own physical health. This was attributed to self-esteem issues including a sense of hopelessness, a lack of autonomy and the compounding factor of ‘doctor fatigue’, that is, clients’ frequent contact with the medical profession in the mental health system. It was also noted that people with chronic mental illness often lack the ability to negotiate the health system. One respondent said: ‘One of the skills that you need to be able to go along to a GP and say, “Hey this is what is wrong with me” and I don't think that the client has got those assertiveness skills’. It was also reported that people with chronic mental illness ‘tend not to be able to wait in line like other people. There's restlessness and a lot of frustration and intolerance that prevents them from being able to hang around too long. There is a big expectation that people do that [wait around] nowadays in hospitals.’ Participants also expressed concerns about the ability of GPs to understand the special needs of people with mental illness.
Discussion
This study examines some of the systemic and cultural factors that may contribute to the poor physical health status of people with chronic mental illness. While the exact causes behind high morbidity and mortality rates among this population are complex and multifactorial, it appears that the pervading attitudes and processes within the mental health system do little to improve the problem.
Although both case managers and government policy on mental health services [10] acknowledge that the physical health of psychiatric patients is within the realm of case management, there does not appear to be any process to incorporate it into practice. Assessment and management of physical conditions seems to be provided in an ad hoc manner based on the discretion of the case manager and medical staff. The lack of systematic processes is likely to contribute to the inconsistency regarding which areas case managers inquired into. Although it was encouraging to find that the majority of case managers asked about common risk factors such as smoking, alcohol intake and diet, it was of concern that relatively few regularly inquired about safe sexual practice, exercise, mammography and Pap smears.
Less than three-quarters of case managers inquired as to whether their patients attended a GP. Given that key principles of case management is to link patients with appropriate services, one would expect case managers to be more proactive in encouraging integration of primary health care. Consumer consultants have pointed out that liaison between case managers and GPs may undermine patients’ autonomy in managing their health. Consultation between health professionals and consumer groups would be useful to explore solutions.
Patients who wish to consult a GP often report difficulty finding one. Many GPs have difficulty assessing and treating people with mental illness [2]. At the same time, those doctors trained to treat people with chronic mental illness seem disinclined to treat physical conditions [1]. Few medical staff in community mental health clinics performed physical examinations. Case managers perceived discouragement to address physical health as most clinics do not pay for medication to treat of physical health problems. However, the attitudes and practices of medical staff and case managers may differ.
Although the sample was small, we suggest that the lack of systematic processes in AMHS regarding physical health may contribute to the high prevalence of risk factors for poor physical health among people with chronic mental illness. We therefore propose that: (i) case managers receive additional training on physical health problems of people with chronic mental illness; (ii) that mental health services ensure clients have a GP and attend to ongoing and preventative primary care; (iii) as part of the initial assessment and individual service plan, there is a detailed section for physical health risk factors such as smoking, illicit drug use, alcohol abuse, obesity, etc.; (iv) medical staff in AMHS include physical assessment as part of routine management conducted either by themselves or by a GP; (v) the Royal Australian and New Zealand College of Psychiatrists consider producing a statement on practice regarding attending to the physical health of people with chronic mental illness; and (vi) patients at high-risk for cardiovascular and respiratory disease are systematically referred to appropriate health professionals.