This article describes the implementation of an initiative to improve the physical health of clients with mental health problems.
Andrea Arnold, BSc Community Specialist Practitioner, BSc Psychology, RMN, is cluster leader and CPN; Paula Bevan is carers support worker; Elmari Bishop is senior social worker; James Isbell is STR (support time recovery) worker; Brian Jackson, RMN, is CPN; Rosalind Yin, BSc Community Specialist Practitioner, RMN, is CPN; all at Castle Point Community Mental Health Team, South Essex Partnership NHS Foundation Trust.
Arnold, A. et al (2008) Promoting healthy choices for mental health clients. This is an extended version of the article published in Nursing Times; 104: 16, 28-29.
This article describes the implementation of an initiative to improve the physical health of clients with mental health problems. Evidence suggests that people with mental ill-health are at greater risk of premature death than the general population. This project aimed to promote healthy choices and improve physical well-being, which also then impacts on clients’ mental health and self-esteem. The initiative addressed issues such as exercise, diet, medication, relationships, confidence building, return to work and blood glucose monitoring. It resulted in improvements in clients’ physical and mental well-being.
We are a multidisciplinary community mental health team (CMHT) working with adults aged 18–65 years. This encompasses the age range in which people are at their most productive, attempting to fulfil their goals and dreams.
Over seven years we developed five projects. The aim of these projects was to ensure that service users could make healthy choices. The projects were: an allotment; a coffee morning; a walking group; a healthy living group and blood glucose testing. They developed through partnership between CMHT practitioners, clients and carers and local government and business.
We had been aware for some time that clients were not achieving their aims or enjoying everyday life, and they did not feel included in society. They only had a limited choice of daily activities that were provided mostly by government sources. In addition, these did not offer choice because of their rigid structure, lack of imagination or simply because they were too daunting for clients. Furthermore, we found it unacceptable that physical health needs of people with mental health problems were not given sufficient care and attention (Department of Health, 2004a; 2004b).
Two reports from the Social Exclusion Unit highlighted the importance of promoting social inclusion for people with mental health problems and set out the government’s programme of action (SEU, 2004a; 2004b). The Disability Rights Commission also identified that people with mental health problems and learning disabilities have an increased risk of developing serious health conditions at a younger age and dying as much as 10 years earlier than the general population (DRC, 2006).
Data from ongoing research supported our knowledge about the local situation. Research indicates that service users, particularly those diagnosed with schizophrenia or bipolar disorder, have an increased risk of coronary heart disease, diabetes, infections, respiratory disease and obesity (Rethink, 2004). They are almost twice as likely to die from CHD as the general population and four times more likely to die from respiratory disease (Nocon, 2006; Cohen and Phelan, 2001; Brown et al, 2000). When researchers analysed the records of 1.7 million primary care patients, they found that people with schizophrenia or bipolar disorder were more than twice as likely to have diabetes than other patients, and also more likely to experience ischaemic heart disease, stroke, hypertension and epilepsy (DRC, 2006).
Physiologically, research has shown associations between depression/anxiety and cardiovascular and cerebro-vascular diseases, and also that too much stress weakens the immune system (Bunker et al, 2003; Kuper et al, 2002). From a behavioural perspective, depression can negatively affect a person’s nutritional choices, commitment to exercise, sexual practices, smoking and concordance with medication and appointments, and reduce self-esteem.
A person’s social class, gender, ethnicity, education, housing, supportive relationships, social and civic involvement and availability of work all have a bearing on their health status. People with mental health problems are among the most excluded and uninvolved in society. It is recognised that general health promotion programmes may widen these inequalities because more affluent people make more effective use of prevention advice and services (DH, 2004b). The white paper Choosing Healthstated: ‘Everyone deserves equal access to high-quality services and an equal opportunity to live their lives to the maximum of their potential’ (DH, 2004b). It added that not everyone has the same opportunities to present their case or make full use of services. It is therefore practitioners’ duty to ensure clients are able to make healthy choices, a view emphasised in the white paper Our Health, Our Care, Our Say (DH, 2006a).
We were compelled to provide a service that met clients’ needs, even if it meant modifying our own practice. We took into account key policy documents such as the National Service Framework for Mental Health (DH, 1999) and a report on this NSF five years on (DH, 2004a). Our flexibility enabled us to address issues on a more personal basis, expecting more of ourselves and our clients, who rose to every challenge we set them and challenged us in return. This contradicts the common belief that there is a lack of interest (Sherr, 1998).
In the early stages our aim was to develop a more socially inclusive service. Changing people’s behaviour is a complex process (NICE, 2007; Bandura, 1997). Therefore developments had to evolve gradually and be the result of true collaboration.
Physical and mental health
Physical health and mental health influence each other and their relationship can also affect the onset, course and outcome of each. It is also known that good physical health is a positive attribute, influencing the outcome of both physical and mental well-being, with clients having a sense of control, optimism and meaning, protecting both mental and physical health. These complex interactions suggest that a problem in one area of a person’s life affects all other areas and overall health and well-being.
It is said that health may refer to a state of fitness and ability, or to a reservoir of personal resources that can be called on when needed (Naidoo and Wills, 1997). It is possible to use this to encourage a small improvement in one area knowing that there will be a positive impact in others, which gradually provides raised self-esteem or a kind of ‘hardiness’ to help people in future situations. Our objective throughout was to ensure that any goals were meaningful to clients, by embracing holistic concepts of health such as emotional well-being, spiritual, environmental, physical and social factors.
Since they have a mental health problem, many of our clients see themselves as ‘sick’ and this affects their perception of themselves and directs their level of involvement in their community.
We aimed to build the concept of having a ‘health problem’, rather than perceiving oneself as ‘ill’, to encourage a state of ‘wellness’. The intention is that clients are less likely to react to life situations in a negative way.
We started the original part of the initiative – the allotment – seven years ago. Since then it has evolved by addressing physical and mental health issues, with additional projects running concurrently. Each part addresses one major issue. Examples of this include: exercise (walking group and allotment); diet (healthy living group); and relationships and education (coffee mornings). However, just as the issues they address are complex, so too are the ways these projects interact with each other. Ultimately, they address much more than one issue and support each other. Positive achievements have been recorded in all areas, such as improved self-esteem, improvement in self-care, confidence building, returning to work, going to the gym and becoming active in local issues.
The allotment and gardening group
The allotment/gardening group has been running over the last seven years, provided free of charge by our local council, and using equipment donated by local people and businesses. Clients have used this plot to grow fruit and vegetables, starting with potatoes and now venturing into Chinese leaves and pak choi. These are all cooked and eaten by service users who now run the group. Clients participate as much or as little as they are able, forming steady working relationships, getting exercise, education, a surplus of good food and the satisfaction of watching seeds grow and flourish.
Coffee morning and depot clinic
The coffee morning was the next project to develop. A survey of clients receiving a depot injection revealed they wanted a more informal setting where they could meet socially. Hence, the coffee morning was set up, and is held at the same time and place as the depot clinic. This is a social group led by service users, encouraging friendships, support and education.
The group has a regular membership, with clients attending even when they are not due for an injection. It is also an opportunity to gather information privately, through the LUNSERS (Liverpool University Neuroleptic Side-Effect Rating Scale) questionnaires (Day et al, 1995). Our consultant psychiatrists also hold their outpatient clinics on the same morning and are frequently able to talk informally with clients in the kitchen while making coffee.
It is also an excellent opportunity to ensure nursing students can participate fully and acquire the appropriate attitude to service-user care.
Glaser (1994) advocated that ownership and acknowledgment of ideas, with open communication, is necessary to develop a team. This staff empowerment significantly increased job satisfaction. For example, this evolving relationship with clients and carers resulted in a morning session on medication. Our head pharmacist devoted a whole morning to answering client queries about medication, previously answered by practitioners, with a large turnout from both service users and carers. If we can help clients understand how to make changes in their lives, however small, it shows that control can be slowly regained and gradually confidence grows.
Healthy living group
This service provides facilities for weighing and blood glucose testing, as well as education about diet, goal setting and other issues. This has now been running for three years. Its successes include ‘bargain-hunting’ service users teaching us how to spot the healthier options, good deals and splitting ‘buy one get one free’ offers to make a small income go further.
Clients avidly read newspapers and bring in articles about food and they search the internet at the local library. They meet up after the group and go for coffee, with some women teaching a man in the group how to cook.
Another positive initiative was when Sainsbury’s provided a store guide and a home economist, who took the group on a tour around the store with taste-testing of ‘something different’.
The walking group was set up following comments from clients in the allotment group. After seeing the local ramblers’ society out on a walk, they said they would like to do the same but lacked confidence.
We started this with the agreement that ultimately clients would join the Ramblers. All members were bought a pedometer to encourage their understanding of taking 10,000 steps. Some service users who attended the healthy living and coffee morning groups decided they would also like to get more exercise and this proved an excellent opportunity to draw attention to the fact that exercise is a potential mood-enhancer, as well as being beneficial for fitness and weight control.
Testing blood glucose levels
Our latest project testing blood glucose levels was a direct result of the research on schizophrenia and incidence of diabetes. The World Health Organization (2003) predicted that by 2030 the number of adults with diabetes will have almost doubled worldwide, from 177 million in 2000 to 370 million. Jonsson (2002) stated that throughout the world there are substantial numbers of people with undiagnosed diabetes and impaired glucose tolerance. Therefore it is reasonable to assume that within this cohort there is a significant group of individuals with psychiatric illness. Diabetes is often asymptomatic and even if symptoms are present they are rarely unique and obvious enough to lead to an early diagnosis. This is a potentially significant risk factor for a group which is less likely to report side-effects or attend their GP surgery.
There is a complex interaction between type 2 diabetes and schizophrenia. There is a suggestion that schizophrenia itself might be an additional risk factor for diabetes, as may antipsychotic drugs used to treat schizophrenia (Dinan et al, 2004).
It is suggested that the prevalence of type 2 diabetes is higher in patients with schizophrenia compared with the general population. Although many factors, including genetic and lifestyle issues, contribute to this association, there has been a recent surge in interest in the subject because of the possible link between the use of atypical drugs and the development of diabetes. Samele (2004) suggested that the inequalities cannot be explained by mental health problems alone. The increased prevalence of type 2 diabetes among people with schizophrenia has implications for the delivery of care by psychiatrists, as well as for diabetologists and GPs.
We took all these factors into account, as well as the chief nursing officer’s recommendations (DH, 2006a).
In view of our close links with primary care colleagues, we decided, after some additional training, to expand our existing interventions and set up the latest project on blood glucose testing. We initially ran a pilot of 34 service users noting their sex, weight, height, BMI, contents of last meal and time eaten, time and date of test and the reading. In addition, a note was made of any action taken, for example, whether clients were advised to visit their GP or given dietary advice about eating breakfast.
We have received encouraging feedback with a plethora of anecdotal evidence. Examples range from service users whose glucose levels were high and who were advised to visit their GP, to another who had irregular readings, became hypomanic and was then sectioned under the Mental Health Act 1983. After involving the local diabetes specialist nurse and changing medication this client has been stable and without admission since. Another client whose glucose reading was high was asked to visit his GP. There was no problem with his glucose levels but he had an undiagnosed thyroid problem.
Sometimes this service highlights that a simple change of eating pattern or diet is required, such as one client who was eating a lot at night and advised not to do so. Since this initiative he has lost two stone in weight. Another service user (who had side-effects) was advised to return to his GP, who changed his diabetes medication which worked better with his other medications. Another client’s blood sugar levels were low; she was encouraged to visit her GP and eat more regularly. This helped her energy levels and also the absorption, digestion and metabolism of medication to the extent that she has now returned to full-time work. Another has found a continued interest in the gym, returned to work and is discharged, confident to manage his own mental health. In addition to these examples, a further five members of the pilot group are now going to the gym, taking more care of themselves physically and, as a result, their self-esteem is increasing. For one service user it was the impetus to make sure they maintained regular badminton sessions.
Some 20% of the pilot group is now attending the healthy living group. The majority of tests highlighted that clients were not eating properly. As a result of the group they have now learnt more about their own bodies and related health issues, for example, how missing breakfast can affect performance. Furthermore, clients have experienced a difference in their daily lives, which has encouraged them to take the initiative and continue to explore diet more fully.
This holistic view of care provision includes service users taking responsibility for their own recovery with support. Direct payments (see www.dh.gov.uk) have enabled set programmes of care to be successful by either enabling freedom of choice for service users on a yearly basis or as a ‘one-off’ payment to encourage a newly established socialisation programme.
For example, during conversation at the allotment and coffee morning, some male clients found they had a mutual interest in football. We were able to assist one client with a direct payment for a season ticket for Canvey Island Football Club. He found that his confidence, initially encouraged by staff, started to grow by going out with others. He then found the courage to watch Canvey and Southend United play on his own when the others could not attend. Indeed, after 28 years he has taken lessons and started driving again. This is a major achievement for a man who, a few years ago, wanted to stay in hospital because he was too anxious to leave and did not feel safe.
Other successes include people returning to work, learning to read and write, taking up formal study and reading poetry in public. Increased self-confidence has resulted in clients attending breast screening and healthy men/women clinics. Clients have also made use of the exercise on prescription scheme. One of our aims is to make use of public ventures as this promotes social inclusion. Two service users have gone through the ‘Condition Management Programme’ jointly funded and run by the Job Centres. Although the CMHT instigated the healthy living group, coffee mornings and allotment projects, the whole initiative has only gone from strength to strength through service-user involvement and mutual encouragement. These are now led or co-led by clients.
Disseminating our work
We have presented this initiative at both health and social services venues and have liaised with other community teams and inpatient wards. The trust has now taken up the well-being programme from our team and the findings are being disseminated within other CMHTs, with the proviso that service users should determine the emphasis given to each development.
We are now testing blood glucose levels and BMIs in all clients and ensuring the LUNSERS questionnaire initiative is maintained.
We have plans to develop non-medical prescribing within the team (we have one prescriber currently), continue staff CBT training and establish a spirituality group (the lead for this is already in place). In addition, we are considering staff involvement in a ‘hearing voices’/CBT initiative with our psychologist.
Data produced from each of our current projects shows a significant improvement in concordance as service users have a more accepting attitude towards the need for medication. Data from the blood glucose testing is the most revealing. It has enabled stronger links between the CMHT and primary care, especially GPs, who have embraced our initiatives.
Furthermore, clients have become less dependent on CMHT practitioners and more included in their own community by, for example: joining a gym (and actually going); going dancing with others; making a film; having the courage to be discharged from the service and stay discharged; returning to or starting work (voluntary or paid); having medication reduced and/or taking control of it for the first time. Most changes are not substantial and to some may seem insignificant but when added up they represent a sizeable change in attitude and behaviour.
As Griffiths (1988) pointed out, when speaking about the introduction of community care and the necessity of joint working: ‘The problems of community care provision are so complex there will never be only one solution. The real task is to start a process of evolutionary change, and then to maintain or increase its momentum as new problems arise. To achieve this, politicians and professionals alike need to turn their attention away from petty conflicts and strive to share a clear understanding of the specific needs and the overall nature of the community care challenge.’
The sentiments are still extremely relevant today, with Appleby (2007) suggesting that to extend reforms implemented in mental health care, familiar barriers must be broken down. Only then can a new way of thinking about and delivering care be achieved. Practitioners do not have to do this alone, as service users and those who care for them – who are normally accustomed to following professionals – can take the lead in their own recovery.
This is a formidable resource for any CMHT to have on its side.
- This project was a finalist in the mental health category of the NT Awards 2007. To enter the 2008 awards, go to www.nursingtimesawards.co.uk.
Appleby, L. (2007) Breaking Down Barriers. Clinical Case for Change: Report by Louis Appleby, National Director for Mental Health. www.dh.gov.uk
Bandura, A. (1997) Self-efficacy: The Exercise of Control. New York, NY: Freeman.
Brown, S. et al (2000) Causes of the excess mortality of schizophrenia. British Journal of Psychiatry; 177: 212.
Bunker, S.J. et al (2003) “Stress” and coronary heart disease: psychosocial risk factors. National Heart Foundation of Australia position statement update. Medical Journal of Australia; 178: 272–276.
Cohen, A., Phelan, M. (2001) The physical health of patients with mental illness: a neglected area. Mental Health Promotion Update; 2: 15–16.
Day, J.C. et al (1995) A self-rating scale for measuring neuroleptic side-effects. Validation in a group of schizophrenic patients. British Journal of Psychiatry; 166: 5, 650-653.
Department of Health (2006a) Our Health, Our Care, Our Say. www.dh.gov.uk
Department of Health (2006b) From Values to Action: The Chief Nursing Officer’s Review of Mental Health Nursing. www.dh.gov.uk
Department of Health (2004a) National Service Framework for Mental Health: Five Years On. www.dh.gov.uk
Department of Health (2004b) Choosing Health: Making Healthy Choices Easier. www.dh.gov.uk
Department of Health (1999) National Service Framework for Mental Health. www.dh.gov.uk
Dinan, T. et al (2004) Schizophrenia and Diabetes 2003. Expert Consensus Meeting. British Journal of Psychiatry; 184: suppl. 47, 112–114.
Disability Rights Commission (2006) Equal Treatment: Closing the Gap. A Formal Investigation into Physical Health Inequalities Experienced by People with Learning Disabilities and/or Mental Health Problems. London: DRC.
Glaser, S. (1994) Teamwork and communication: a three year case study of change. Management Communication Quarterly; 7: 3, 282-296.
Griffiths, R. (1988) Community Care: Agenda for Action. London: HMSO.
Jonsson, B. (2002) Revealing the cost of type 2 diabetes in Europe. Diabetologia; 45: S5-12.
Kuper, H. et al (2002) A systematic review of prospective cohort studies of psychosocial factors in the aetiology and prognosis of coronary heart disease. Seminars in Vascular Medicine; 2: 267–314.
Naidoo, J., Wills, J. (1997) Health Promotion, Foundations for Practice. London: Bailliere Tindall.
NICE (2007) Behaviour Change at Population, Community and Individual Levels. www.nice.org.uk
Nocon, A. (2006) Background Evidence for the DRC’s Formal Investigation into Health Inequalities Experienced by People with Learning Difficulties or Mental Health Problems. www.leeds.ac.uk
Rethink (2004) Only the Best: Information about Mood Stabiliser and Antipsychotic Medication. www.mentalhealthshop.org
Samele, C. (2004) Factors leading to poor physical health in people with psychosis. Epidemiologiae Psichiatria Sociale; 13: 141-145.
Sherr, L. (1998) Health promotion and mental illness – an overview. Psychology, Health and Medicine; 3: 1, 5-18.
Social Exclusion Unit (2004a) Mental Health and Social Exclusion. cabinetoffice.gov.uk
Social Exclusion Unit (2004b) Action on Mental Health: A Guide to Promoting Social Inclusion. cabinetoffice.gov.uk
World Health Organization (2003) Diet, Nutrition and the Prevention of Chronic Diseases, WHO Technical Report Series, 916. Geneva: WHO.