People with severe mental illness also have reduced life expectancy and diminished physical health. A review of research highlights how general nurses can better support this patient group
Severe mental illness is associated with reduced life expectancy and poor physical health. Early detection and intervention increases the likelihood of improved health and social outcomes, but people experiencing their first episode of psychosis often experience delays in accessing treatment. This article summarises a review of studies funded by the National Institute for Health Research that investigates support for people with severe mental illness, and highlights how nurses working in acute, primary care and community settings can improve patients’ access to effective support and care.
Citation: Young N (2018) How nurses can improve care for people with severe mental illness. Nursing Times [online]; 114: 9, 34-36.
Author: Norman Young is nurse consultant for first-episode psychosis at Cardiff and Vale University Health Board and senior associate lecturer in mental health nursing at Cardiff University.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)
People with severe mental illness (SMI) have a lower life expectancy and are in poorer physical health than the general population. Earlier this year, the National Institute for Health Research (NIHR) published Forward Thinking, a review on support for people with SMI, drawing together 30 published studies and 19 ongoing projects. This article explains the nature and impact of SMI, and explores how nurses outside mental health settings can help detect it early and improve the physical care of patients who have SMI.
The NIHR is a UK research funding body, which focuses on the needs of patients and the public. Periodically it undertakes themed reviews of research it has funded to share the findings with a broader audience.
A themed review draws together all the NIHR-funded work in a specific area. The studies are selected by an advisory group comprising topic experts, service users and carers, and led by a lead author and chair. The advisory group helps the chair judge the impact of the research, put together the review and promote its dissemination.
In Forward Thinking, the advisory group was composed of 19 people, of whom six were nurses and authors of several of the studies included in the review. The review was built around four themes:
- Supporting early detection and intervention;
- Crisis care: location, settings and practice;
- Stabilising and managing physical and mental health;
- Supporting recovery, self-management and engagement.
This article focuses on the two areas that have the most relevance to nurses working outside mental health: early detection and intervention, and managing physical health.
What is severe mental illness?
While SMI encompasses a range of diagnoses, most research papers included in the NIHR review looked at psychotic disorders in particular. The review explains that SMI is generally accepted to be mental illness that:
- Includes a diagnosis of schizophrenia, bipolar disorder or other psychotic disorders;
- Results in significant disability in terms of day-to-day functioning;
- Has lasted for a significant duration, usually at least two years.
It further explains that people with a psychotic disorder may experience:
- Paranoid or persecutory delusions;
- Difficulties in thinking and concentrating, thought disorder, lack of emotional expression, and be withdrawn and unmotivated.
Prevalence and risk factors
About 80% of first-episode psychosis occurs by the age of 24 (Jones, 2013) and just under 1% of the general population has a psychotic illness, of whom a third meet the criteria for SMI (McManus et al, 2016; Ruggeri et al, 2000). If the criteria are broadened to include non-psychotic disorders, the number of people with SMI is estimated to be 4 per 1,000 (Ruggeri et al, 2000).
Several risk factors are associated with the development of psychosis, including:
- Genetic make-up;
- Adverse childhood/adolescent events;
- Living in a city;
- Recreational drug use – in particular amphetamine, cocaine, cannabis and ketamine (Howes and Murray, 2014).
Outcomes and treatment
While much less common than diabetes or depression – prevalence of which are 6.7% and 9.1%, respectively (NHS Digital, 2017) – SMI is associated with significant disability and adverse outcomes. These include:
- Lower life expectancy, losing 8-17.5 years of life due to suicide, and poor physical health (Chang et al, 2011);
- Being a victim of crime (Maniglio, 2009);
- Having a significantly lower rate of employment (Marwaha et al, 2007).
The annual cost of SMI to the NHS and social care is estimated to be £36,000 per patient (at 2011 prices), a figure that excludes the costs linked to caring and unemployment (Andrew et al, 2012; Schizophrenia Commission, 2012). However, a range of treatments and interventions are effective for SMI (Box 1) and, if delivered early, these can improve health and social outcomes (Tsiachristas et al, 2016; National Institute for Health and Care Excellence, 2014). On average, 58% of people who have psychosis reach remission and 38% achieve significant social, occupational or educational functioning (Lally et al, 2017).
Box 1. Psychosis: treatment and interventions
Family intervention is a structured therapy which involves the patient and the family or carers meeting for 10 sessions over three months to a year. It aims to reduce the risk of relapse and improve family members mental health and wellbeing. The early sessions involve increasing knowledge about the condition by sharing the personal experience of symptoms. The family members are coached in how to manage stress, approach problematic symptoms, communicate more effectively and use problem solving skills. Between sessions participants engage in homework to rehearse and consolidate knowledge and skills.
Improved knowledge about the condition alongside peer support can reduce carer burden. A carers’ support programme comprises a series of group meetings over three to six months where specific topics related to the condition and personal wellbeing are discussed. The peer support allows the carers rather than professionals to provide practical and personal insights into how problems can be overcome.
Employment, education or vocational interventions
Gaining employment can greatly reduce the risk of relapse, improve self-esteem and social participation. For people looking to return to work individual placement and support (IPS) should be offered. When referred for IPS the person will receive intensive support in identifying employment goals, rapid job searching for competitive jobs, and thereafter in work support for the employer and the employee to retain the person in employment. If the person is not work ready, then support in vocational activities or enrolling in education should be offered.
The review draws attention to the importance of early detection of, and intervention for, the first episode of psychosis. Early detection of psychosis helps because it:
- Reduces the risk of suicide;
- Improves outcomes;
- Can change the course of psychosis.
Early treatment is associated with recovery, leading to increased chances of employment and social participation (Tsiachristas et al, 2016).
This knowledge has led to a significant investment in dedicated ‘early intervention in psychosis’ services across the UK (Welsh government, 2016; Department of Health, 2014; Marshall et al, 2005).
Warning signs and symptoms of psychosis include changes in mood, thinking, perception, socialising and intellectual performance; these changes can then be followed by frank symptoms of psychosis (Perez et al, 2015; NICE, 2014). If nurses suspect psychosis, they need to refer the person for specialist assessment without delay (Box 2). Nurses working in emergency, primary and mental health care are the health professionals most likely to see young people presenting with their first psychotic episode.
Box 2. Psychosis: when to refer
Refer without delay to a specialist mental health service or an early intervention for psychosis team any person who is distressed, has a decline in their social functioning and has any one of the following:
- Unusual or bizarre thoughts, not in keeping with their culture
- Unwarranted suspicious thoughts about people
- Hallucinations – for example, hearing voices or unusual perceptions
- Other symptoms suggestive of psychosis
- A first-degree relative with schizophrenia or psychosis
The NIHR has funded four studies exploring the reasons for delays in accessing care and the effectiveness of interventions used to reduce these delays. The studies shed light on how early intervention in psychosis teams are the best at reaching and treating young people with psychosis, and show that targeted awareness campaigns can improve early identification and access to care. For example, a study in Birmingham tracked patients’ routes to treatment to ascertain where delays occurred. It found the main contribution to delays came from community mental health teams, followed by individuals not seeking help (Birchwood et al, 2013). It appears that community mental health teams were quick to discharge young people who did not attend appointments. Further, generic teams were less skilled at recognising symptoms and not youth-focused, unlike early intervention services.
These findings spurred the research team to conduct another study to investigate whether a public awareness campaign, combined with access points around Birmingham, would help young people to obtain rapid help (Connor et al, 2016). The intervention reduced the average duration of untreated psychosis from 71 to 39 days – there was no change in the control group. This was a proof-of-concept study, so a larger trial is required to determine whether the effects were real or down to chance. It is also important to understand the cost implications of such interventions.
Researchers in Cambridge explored issues of clinical and cost effectiveness in a cluster randomised controlled trial using an education intervention targeted at GPs (Perez et al, 2015). The intervention comprised an information card (explaining how to recognise psychosis and what to do), an hour-long training session with a follow-up session one year later, and intensive liaison with mental health services. The controls received the information card only.
The researchers found that the intervention was clinically effective – it did improve the identification of people with psychosis and facilitate prompt access to services – as well as cost effective. There were limitations, including the fact that GP practices in areas of socioeconomic deprivation were more likely to choose not to enter the study – and it is in those areas that psychosis is more prevalent.
Maintaining good physical health
People with SMI are more likely to die prematurely of preventable diseases such as diabetes, cardiovascular disease and stroke than the general population. The increased risk of these diseases in people with SMI is attributed to the mental health condition, the effects of treatment, and the attitudes and skills of health practitioners; for example, mental health nurses may overlook signs of physical illness because they focus on the person’s mental health (Hoang et al, 2013; Jones et al, 2008). One example is smoking: people with SMI are more likely to smoke and more likely to find it harder to stop, but just as likely to want to quit as any other smoker. Despite this, they are far less likely to be offered support for quitting (Royal College of Physicians and Royal College of Psychiatrists, 2013).
The NIHR review highlights a pilot study of an intervention aimed at increasing smoking cessation rates in people with SMI (Peckham et al, 2015). The researchers compared a bespoke smoking cessation service with usual GP care in a randomised sample of 97 community patients. At follow-up 12 months later, the bespoke smoking cessation service participants were almost three times more likely to have stopped smoking than those receiving usual care. Although this did not reach statistical significance, the intervention was shown to be feasible and a move in the right direction, which has led the researchers to begin a larger randomised controlled trial.
Implications for practice
Early detection and intervention is key in preventing SMI in young people. Several of the studies in the NIHR review demonstrate that simple, targeted information can improve the detection of first-episode psychosis. Reminder cards, prompts and guidance on access to specialist advice can help nurses to identify warning signs of psychosis, reduce delays in referrals and, thereby, improve outcomes for people with psychosis.
Regarding the physical health of people with SMI, the NIHR review emphasises the importance of nurses recognising personal or unconscious biases so they do not miss signs of degrading physical condition. For example, nurses need to be wary of attributing physical symptoms to the mental health problem or of neglecting to offer routine screening or health promotion interventions. People with SMI may also need help from nurses to successfully undergo a health promotion intervention.
- Severe mental illness in the broad sense is estimated to affect four in 1,000 people, many of whom have psychosis
- About 80% of first-episode psychosis occurs by the age of 24
- Early detection and intervention can change the course of psychosis
- Warning signs of psychosis include changes in mood, thinking, perception, socialising and intellectual performance
- The physical health needs of people with severe mental illness are too often neglected
Andrew A et al (2012) Effective Interventions in Schizophrenia: The Economic Case.
Birchwood M et al (2013) Reducing duration of untreated psychosis: care pathways to early intervention in psychosis services. British Journal of Psychiatry; 203: 1, 58-64.
Chang CK et al (2011) Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London. PLoS One; 6: 5, e19590.
Connor C et al (2016) Don’t turn your back on the symptoms of psychosis: the results of a proof-of-principle, quasi-experimental intervention to reduce duration of untreated psychosis. BMC Psychiatry; 16: 127.
Department of Health (2014) Achieving Better Access to Mental Health Services by 2020.
Hoang U et al (2013) Avoidable mortality in people with schizophrenia or bipolar disorder in England. Acta Psychiatrica Scandinavia; 127: 3, 195-201.
Howes OD, Murray RM (2014) Schizophrenia: an integrated sociodevelopmental-cognitive model. Lancet; 383: 9929, 1677-1687.
Jones PB (2013) Adult mental health disorders and their age at onset. British Journal of Psychiatry; 202, s5-s10.
Jones S et al (2008) ‘Diagnostic overshadowing’: worse physical health care for people with mental illness. Acta Psychiatrica Scandinavia; 118: 3, 169-171.
Lally J et al (2017) Remission and recovery from first-episode psychosis in adults: systematic review and meta-analysis of long-term outcome studies. British Journal of Psychiatry; 211: 6, 350-358.
Maniglio R (2009) Severe mental illness and criminal victimization: a systematic review. Acta Psychiatrica Scandinavia; 119: 3, 180-191.
Marshall M et al (2005) Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Archives of General Psychiatry; 62: 9, 975-983.
Marwaha S et al (2007) Rates and correlates of employment in people with schizophrenia in the UK, France and Germany. British Journal of Psychiatry; 191, 30-37.
McManus S et al (2016) Mental Health and Wellbeing in England: Adult Psychiatric Morbidity Survey 2014.
National Institute for Health and Care Excellence (2014) Psychosis and Schizophrenia in Adults: Prevention and Management.
National Institute for Health Research (2018) Forward Thinking: NIHR Research on Support for People with Severe Mental Illness.
Peckham E et al (2015) Smoking Cessation Intervention for severe Mental Ill Health Trial (SCIMITAR): a pilot randomised control trial of the clinical effectiveness and cost-effectiveness of a bespoke smoking cessation service. Health Technology Assessment; 19: 25, 1-148.
Perez J et al (2015) Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial. Lancet Psychiatry; 2: 11, 984-993.
Royal College of Physicians, Royal College of Psychiatrists (2013) Smoking and Mental Health.
Ruggeri M et al (2000) Definition and prevalence of severe and persistent mental illness. British Journal of Psychiatry; 177, 149-155.
Schizophrenia Commission (2012) The Abandoned Illness.
Tsiachristas A et al (2016) Economic impact of early intervention in psychosis services: results from a longitudinal retrospective controlled study in England. BMJ Open; 6: 10, e012611.
Welsh Government (2016) Together for Mental Health – Delivery Plan: 2016-19.