28 March 2017

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Match: Living Well, Living Longer: Improving physical health outcomes for people living with serious mental illness
Hosted by Sydney Local Health District
Sydney, Australia

This article includes the discussions and presentations of participants in this event but does not necessarily reflect the views or policies of the Mental Health Commission of NSW.

Preventing mental health consumers from falling through the gaps

By Steph Nash

The need for more focus on improving the physical health of people who experience mental illness was the main concern at the Living Well, Living Longer match held as part of the 2017 IIMHL Exchange in Sydney.

In Australia, the life expectancy of people living with severe mental illness is 15-25 years less than the general population. Why? Approximately 75% of deaths for people living with severe mental illness are caused by cardiovascular and metabolic disease. 50% of people with psychosis have metabolic syndrome and 33% are at risk of a cardiovascular event. People with severe mental illness are more likely to smoke and due to a combination of their illness, lifestyle factors and medication side effects, develop chronic conditions, such as diabetes or cardiac complications. There are also known comorbidity links to the prolonged use of medications prescribed to treat psychotic illness.

However these physical health conditions are less likely to be identified or treated in people with severe mental illness, which means they may be missing out on primary care for treatable conditions, such as hypertension, diabetes and high cholesterol. This can result in early ageing, chronic illness and premature death.

Research suggests that a contributor to early death could be consumer reluctance to access medical care in response to stigma and systemic barriers to access. The Royal Australian and New Zealand College of Psychiatrists published a report in 2015 that concluded that there was overwhelming evidence to suggest that mental health consumers do not receive adequate responses when presenting with physical health concerns due to a focus on their mental illness.

“Studies have identified that people with serious mental illness routinely receive suboptimal care for established medical conditions and that these inequalities in access to treatments exist in some of the most critical areas of patient care, such as general medicine, cardiovascular, care for diabetes and cancer and postsurgical care,” the report states.

“The literature suggests that the attitudes of health-care staff in both primary and secondary care, as well as in specialist settings, inhibit help-seeking by people with mental illnesses and associated physical health needs.”

Life expectancy for people with enduring mental illness is much shorter than most of the population. A Western Australian study found that between 1985 and 2005, the gap in life expectancy for people with psychiatric disorders increased from 13.5 years to 15.9 years for men, and 10.4 years to 12 years for women. While countries in the developed world are benefiting from increased lifespans and are living well into their 80s and 90s, they are not seeing that longevity extend to consumers.

Professor Tim Lambert from the Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHIP) says the perception of mental health consumers in the health sector is like that of the old Hollywood science-fiction film, ‘Attack of the 50 Foot Woman’. In the 1958 movie, the protagonist is transformed into a giantess after an encounter with a UFO. In fear that she will cause havoc in the community, she is sedated and shackled.

“There’s a perception that mentally ill patients are all poor, so they won’t pay their bills, they won’t show up to appointments, and they’re rowdy and disturbing to others in the waiting room,” Lambert says.

“And all of these perceptions, of course, are occasionally true but in most cases not true at all.”

Lambert says that doctors and specialists are failing to see the big picture when it comes to the all-round health care of mentally ill consumers. In his experience, he has noticed that patients with physical health complaints are often referred to psychiatrists and misdiagnosed because practitioners are failing to see the connections between mental health and general physical health.

“The psychiatrist says to the patient, ’I’m a mental health specialist. You say you’ve got a pain in your chest – tell me about your anxiety?’” he says.

“But if the patient sees a cardiologist, you get an ECG straight away. So in one case, you might have a pain in your chest because you have coronary insufficiency, and in the other, it might be because you have an anxiety disorder.”

As the issue becomes more recognised, however, some organisations have begun working to stop mental health consumers from falling through the gaps by developing and implementing programs that provide an integrated response to improve the physical health outcomes of people with severe mental illness.

Integrating care

The Living Well, Living Longer (LWLL) program is Sydney Local Health District (LHD) integrated care program. Sydney LHD has approximately 2100 people living with severe mental illness who are care coordinated by community mental health teams. According to program manager, Cheryl Davenport, the aim of LWLL is to improve access to appropriate health services for mental health consumers through the development of innovative strategies.

 “There is increased focus on collaboration between services to improve the physical health outcomes of people with severe mental illness,” Davenport says.

“It’s about innovative ways of working together to ensure the physical health needs of the consumers are met.”

This program is not the first of its kind, with similar programs existing outside Australia. New Zealand’s Bay of Plenty District Health Board has initiatives to support and strengthen linkages between primary and secondary care. Some of their services include early intervention services with weight management support and personalised wellness programs. Also similar are the mental health programs implemented by the Swedish Association of Local Authorities and Regions (SALAR). This organisation works with employer organisation across Sweden to provide members with better conditions. SALAR’s current priority is to improve the physical health for people with severe mental illness and disabilities.

There are also other initiatives within Australia that are pushing for the integration of health services. Established in 2002, the WentWest primary health network is responsible for auditing and commissioning public and community health services in Western Sydney. Head of mental health services at WentWest, Bill Campos, says that the integration of services is crucial for mental health consumers and it’s a top priority.

“To be honest, integration is probably the most important function of the PHNs at the moment,” Campos said.

“We’re trying to commission services that not only allow the services to be delivered, but also the integration points. That involves technology which can allow consumers to have one referral process that’s seamless.”

GP collaborative care

Dr Michelle Crockett is a GP at Riverstone Family Medical Practice. Her practice, which has a partnership with WentWest, approaches the challenge in a very different way from most general practices. Crockett explains that her practice uses a team-based approach to help engage mental health consumers so she can keep track of their physical health.

“It’s about having more people involved and working in a more team-based model instead of the GP and patient model, which has been the traditional practice model. If the patient hasn’t turned up, they are followed up by our reception staff who will often alert the doctor,” Crockett says.

“The nurse will usually ring to see if the patient is alright and find out if they have cancelled, because otherwise that’s what happens – they cancel, nobody realises and then they fall through the cracks in the system.”

The results for her patients have been pleasing. Crockett says not only do her patients keep coming back but her staff appear to be benefiting from the team-based approach.

“I think the patients feel more supported. Relationships are really important in health care and particularly in mental health. Patients like to know that someone is always there for them,” Crockett says.

“Our own level of satisfaction goes up because we’re motivated by trying to help people. You just feel like you’re doing a better job and that you’re really making a difference. We’ve seen better outcomes for staff and patients, so it’s a win-win situation really.”

The LWLL program describes the integration of health care services as a collaborative process between consumers, mental health care coordinators, general practitioners, specialists and support workers. Care coordinators can help the client get to their nominated GP, who then conducts the client’s annual health check and refers them for screening at ccCHIP. At the ccCHIP clinic, clients consult with psychiatrists, cardiologists, endocrinologists, dentists, sleep experts and exercise physiologists and dieticians.

From there, the client’s GP and care coordinator are sent a well-rounded treatment plan for follow-up.  LWLL also provides the consumer with support from peer support workers with a lived experience of mental illness , who work alongside consumers to support engagement in their health and wellbeing.

Change takes time, but Davenport says the program is making significant impacts.

“We have seen significant increases over time in the number of consumers who visit and are having regular checks with a GP,” Davenport says.

“We do regular audits of all our 2000+ care coordinated clients, and what we’ve seen over time is an increase in the number of clients linked to the GP, the number of clients having regular health checks, and the number of clients being referred to ccCHIP for screening, detection and treatment planning.”

ccCHIP

One of the most innovative elements of the LWLL collaborative care process is ccCHIP, the Collaborative Centre for Cardiometabolic Health in Psychosis. The clinic is used to screen and detect chronic health conditions in mental health consumers. Davenport says the LWLL partnership with ccCHIP has been a huge success, as numbers of referrals increased from 2014 to December 2016.

“There have been changes in practice over time within mental health about how we address specific health needs. Part of that is better utilising the services provided at ccCHIP,” Davenport says.

“It’s a really innovative model and it brings together chronic care streams, lifestyle teams and oral health as well as mental health – it really is a massive improvement in the way that we can offer services to consumers.”

ccCHIP is almost a one-stop-shop for all  general health needs. Consumers liaise with a range of health professionals, including students, who Professor Lambert says have all been trained to maintain an encouraging, stigma-free environment that is comfortable for consumers.

 “We train all of our staff to be pleomorphic, broad and adaptable, and we narrow the workplace down to people who are really practicing what they learn,” Lambert says.

“I’m trying to get people to broaden their skill base and not have any preconceptions about what anything means. If you’ve got a problem, we need to fix that problem. And that problem may come from psychological, physical, psychiatric or just purely social means as the driver of all of this.” 

The lifestyle team

Research continues to show there are links between increased physical activity and mental health recovery. The Royal Australian and New Zealand College of Psychiatrists identifies that exercise may complement other treatments for mental illnesses and is a valuable adjunct to recovery. It can also assist with preventing relapse as well as in managing the side effects of some medications.

The LWLL program provides access to a lifestyle team which is comprised of accredited exercise physiologists and dieticians. Consumers can receive individual lifestyle coaching or participate in group activities, including educational workshops, cooking classes, supermarket tours and group exercise classes. Referrals to the lifestyle team have seen an increase in consumers attending for physical activity and dietary support.  The feedback from carers has been positive, with clients benefiting from increased energy, increased confidence and a reduction in the symptoms of psychosis, such as auditory hallucinations.

 Encouraging mental health consumers to eat right and exercise can be difficult, but accredited exercise physiologist Joel Penson says that with the right support and motivation, clients can motivate themselves to make a change.

“Self-determination theory stipulates that if you want someone to make a change, you can’t impose it on them. You need to let people have the autonomy to choose to do something. You need to build on their existing capacities, and get them to a point that they can continue through on their own,” Penson says.

“I can provide guidance to make sure it’s going to be safe and comfortable for them to come up with something that’s reasonable. They might not make three healthy meals every day, but we would encourage them to start with a couple of healthy meals, or to add veggies to some meals – same thing with physical activity. It might just be once a week that we can get them involved in a swimming program, but it’s more about working with them to take ownership of it.”

Peer support workers are integral to supporting consumers with their recovery, especially when it comes to motivation. The LWLL program has funding for four peer support workers to help consumers engage in activities for their health and wellbeing. Davenport says the response to peer support was overwhelmingly positive with 100% of survey respondents acknowledging that peer support workers had been able to help them identify their physical health goals.

“Peer support workers use their own lived experience to establish empathy. They also help with the facilitation of a social connection, which can help consumers embrace lifestyle changes,” Davenport says.

“Support workers also help to adapt medical recommendations to the needs of the consumer to help them meet their goals.”

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Last updated: 22 June 2017