Life expectancy for people with severe mental illness (SMI), such as schizophrenia is reduced by at least 20% compared with the general population [1
]. The major cause of death in this population is cardiovascular disease (CVD) [3
]. Just having a SMI may increase the risk of CVD but this inherent vulnerability is compounded by lifestyle factors that include a high fat and high calorie diet, lack of exercise, smoking and substance use [5
]. Weight gain and other side effects of antipsychotic medications used to treat SMI further add to the cardiovascular burden [8
]. Recognizing and managing risk factors for CVD and other physical co-morbidities is an important unmet need in the SMI population [9
]. Despite frequent contact with primary care services, physical health is rarely monitored [10
] an observation that may be explained by diagnostic overshadowing (where presenting symptoms are put down to the mental illness). SMI patients are generally in regular contact with community mental health workers who may be better placed to both monitor and promote physical wellbeing [13
]. There is evidence that that mental health workers consider the physical health of their patients an important part of their role [14
A Cochrane review [15
] of physical health monitoring for patients with SMI concluded that there was no evidence from RCTs to support current practice. Physical health screening programs for SMI patients in secondary care have been described by Millar [16
] and Shuel et al [17
]. In both, high rates of obesity and other CVD risk factors were observed and a high degree of patient appreciation for the programs was reported. Several exploratory evaluations of physical health interventions designed or adapted to be delivered in secondary care have been described [18
]. For example, Ball et al [18
] compared a "Weight Watchers" program in 11 schizophrenia and 11 matched control patients but did not observe significant weight loss as a result of the intervention. A service evaluation by Pendlebury et al [19
] reported a mean reduction in weight of just over 6 kg in a sample of 93 SMI patients attending a mean of 42 behavioral weight management clinic sessions.
The Wellbeing Support Program (WSP) described by Ohlsen et al [20
] is perhaps the most important described in the literature (because of the number of service providers in the UK that have gone on to adopt the program). The WSP is a nurse led screening service that aimed to:
• Identify physical health problems,
• Promote treatment adherence,
• Encourage positive lifestyle change,
• Strengthen links between primary and secondary care
• Provide support and advice to carers
• Direct patients to appropriate primary and secondary care services.
The service was facilitated by a team of nurse advisors who provided Well-Being support as an adjunct to routine care. Program development, support for the nurse advisors and subsequent evaluation was supported by the pharmaceutical company Eli-Lilly who manufacture an antipsychotic medciation used to treat schizophrenia.
Delivered over a two year period the WSP is a five-step program with a minimum of six face-to-face sessions with a nurse wellbeing worker:
• Step 1: SMI patients are invited to participate and enrolled on the WSP register
• Step 2: the first face-to-face well-being session where physical health (blood pressure, pulse, weight and height), lifestyle factors (diet, physical activity, smoking status) are measured.
• Step 3: results (from session 1) are fed back to patients at a second face-to-face session. Blood tests (random blood glucose, thyroid function, liver function, serum prolactin, lipid screen) are performed during this meeting
• Step 4: patients are referred by the practitioner to one or more of the following: a weight management or physical activity group, primary care or specialist doctor for additional physical health care, or medication review by prescribing clinician
Weight management groups are held weekly; patients are weighed and there is an opportunity to access support information and advice.
Physical activity groups were also held weekly. Activities including, bowling, badminton, walking and swimming were organized by the nurse.
• Step 5: follow-up face-to-face session(s) to evaluate the program and complete follow-up measures (as in step 1 and 2).
Patient progression through and adherence to the key elements of the five stages of the program was carefully monitored by the nurse advisors managers. Treatment and training manuals and fidelity measures for the WSP have not (to date) been published.
Smith et al.
] addressed the question of whether the Well-Being Support Program (WSP) provided in a secondary care setting was effective in modifying lifestyle factors such as diet, lack of exercise and cigarette smoking. Outcomes of the service were positive and encouraging. Of the 966 patients enrolled, 80% completed the program, and there were significant improvements in physical activity, smoking and diet [13
]. It might be argued that rather than advocating the rolling out the program Well-Being Support should be subject to a randomized controlled trial. Whilst there is considerable merit to this argument many service providers were convinced that the evidence from the service evaluation was sufficient to warrent adoption. Although we know anecdotally that many secondary mental health services in the UK have adopted the WSP actual numbers have not been published. As Tosh et al [15
] note there has been considerable financial investment by service provider in enhancing the physical health of SMI patients with minimal evidence establishing effectiveness or cost effectiveness of any intervention or programme.
The Kent and Medway National Health Service (NHS) and Social Care Partnership Trust, is a typical secondary mental health service provider to a population of 1.6 million in the South East of England. At any given point there are approximately 25,000 open cases and around 4,000 members of staff employed in the Trust. Prior to implementing the WSP, there was minimal physical health care provided to patients that used the service. There was considerable debate within clinical teams, management groups and the executive team about how to address the physical health needs of patients using Trust services. Despite the lack of evidence from clinical trials practitioners that had attended presentations about the WSP were keen advocates of the program. Support from clinicians and subsequent endorsement by the Department of Health convinced the Trust to implement the program.
For pragmatic (not scientific) reasons a number of adaptations to the WSP were made by the Trust prior to implementation:
• Mental health practitioners in routine practice (not Nurse advisors) would deliver the program
• Patients would be offered four and not six face to face Well-Being sessions
• The length of the program would be reduced from two to one year
• MHPs receive three days training to deliver the program by a Nurse Advisor who had worked on the Smith et al [21
• MHPs would deliver the program directly to patients on their caseload
• Adherence to each of the five steps of the program would not be monitored
Adoption and implementation of the WSP represented a considerable financial investment by the Trust. We argue that it is important to determine if, when rolled out in a real world service, patients engage and benefit from the program.
The primary aim of this investigation was to determine the proportion of patients that completed the WSP.
In addition, the project reviewed the effect of the WSP on a range of cardiovascular risk factors:
• Smoking status
• Alcohol use
• Substance use
• Physical activity
Additionally we conducted as series of in depth fact-to-face interviews with six WSP practitioners to help us better understand the strengths and weaknesses of the program and consider how it might be developed in the future.