Rhonda Wilson Warren Isaac

1. Nurse-led policy to practice: Integrating physical and mental health care to reduce metabolic syndrome (MetS) risk amongst mental health consumers. Rhonda Wilson Warren Isaac

2. Introduction • Mental Health nursing is increasingly integrating the physical &mental health care of consumers. • Concern has arisen about the poor physical health of mental health consumers who take atypical antipsychotic medication & the increased risk of developing metabolic syndrome (MetS). • Ethical issues relate to the administration of medications that result in harm to physical health. • Pilot project is a nurse-led metabolic syndromerisk reduction program in a rural communityand is underpinned by the NSW Health Guideline (2009) Physical Health Care of Mental Health Consumers.

3. Research Question • How do rural mental health service clients who take atypical antipsychotic medication respond to an 8 week nurse-led metabolic syndrome risk reduction program? • What changes in practice will need to occur to facilitate the integration of physical and mental health care delivery, especially with regard to the reduction of MetS risk? • What are the barriers and enablers for consumer in participating in this risk reduction program? • What are the barriers and enablers for clinical stakeholders to deliver arisk reduction program?

4. Purpose of the research • To facilitate the transaction of the NSW Health Guideline Physical Health Care of Mental Health Consumers (Document Number GL2009_007) into practice. • To evaluate a 8 week pilot nurse-led metabolic risk reduction program in a rural mental health service.

5. Guideline highlights • Physical health of MH consumers has been either superficial or neglected. • People with severe mental illness have poorer physical health & reduced life expectancy. • MH consumers have a right to equitable physical health care consistent with that provided for the general population. • MH consumers in NSW should receive a comprehensive physical assessment every 12 months & ongoing physical health monitoring every 6 months as a minimum standard. • Health services are now required to integrate physical & mental health care. • Nurses & medical officers have a scope of practice that includes Physical health assessment & monitoring.

6. Literature review • The side effects of 2nd gen atypical antipsychotic medications include: • weight gain (up to 300g/week) • diabetes • hyperlipidemia. • Metabolic syndrome has serious health &well being consequences . • Side effect need to be better understood so that the negative health and well-being problems can be reduced . • Medications taking: • induces obesity • which in turn produces increased leptin (reduced appetite satiation) &insulin resistance which leads to visceral fat accumulation • increased fat and triglyceride levels • insulin resistance • hypertension • = a cumulative burden of spiraling risk for diabetes, cardiac problems and poor body mechanics • Metforminshould be considered as an adjunctive pharmaocotherapyto the administration of atypical antipsychotics because it acts to prevent continued weight gain associated with the atypical antipsychotic, & has no serious adverse side effects

7. Monitoring guide • Monitored in the first 12 weeks for significant increase in triglycerides and weight gain so that earlier intervention can be implemented for people who exhibit gains . • Regular ongoing monitoring should include lifestyle activities; fasting glucose levels; lipid profiles; waist measure; blood pressure; weight and nutrition .

8. Nursing management • Physical health problems lend themselves to nursing management, primarily because the nurse is frequently responsible for the administration of the medication that is known to include side effects which can be treated by implementing a range of psychosocial and physical nursing interventions. • Nursing strategies include: • preventing illness • monitoring physical and mental health problems & wellness • promoting health where well-being is compromised • facilitating recovery.

9. Nursing intervention • Medication taking enhancement, and monitoring • Advocating for preventative medications such Metforminto be considered carefully as prophylaxis for weigh gain in polypharmacological profiles . • Education in regard to medication and their side effects, and the management of these side effects . • Education and support for clients in self monitoring their health, and promoting self care in regard to the development and maintenance of a healthy lifestyle . • Nutrition support inclusive of education, decision making about the selection of food, and weight management strategies • Physical activity assessment, education and promotion • Stress management and anxiety management using strategies such as mindfulness interventions • Physical and mental health screening and ongoing monitoring • Promotion of healthy community resources, collaborations and partnerships

10. Research design • Transactional evaluation research design (Guba & Lincoln, 1989) will be used where a recent NSW Health guideline will be mobilized into a rural practice setting. • A mixed methods study will yield descriptive statistics and qualitative data which will specifically address the research questions for the study, and will enable the effective evaluation of an 8 week nurse-led metabolic syndrome risk reduction program. • The program design has adopted the structure and best practice evidence which is outlined in the guideline.

11. Settings • Participants will be recruited from current medication taking clients within the Tablelands cluster of the HNEH Northern Region health service area. Program sessions will be held on the HNEH Armidale health campus, with some sessions held off campus to utilize specific resources such as suitable exercise space. Group program sessions will be held in group rooms in either the community health setting or the bed-based mental health unit (Clark Centre). The setting will be familiar to the participants as their usual mental health consultations take place in this setting also.

12. Research design • Transactional evaluation research design (Guba & Lincoln, 1989) will be used where a recent NSW Health guideline will be mobilized into a rural practice setting. A mixed methods study will yield descriptive statistics and qualitative data which will specifically address the research question for the study, and will enable the effective evaluation of an 8 week nurse-led metabolic syndrome risk reduction program. The program design has adopted the structure and best practice evidence which is outlined in the guideline.

13. Particpants • A limited number of up to 20 mental health consumer participants will be recruited to the pilot program. Case managers/ care coordinators and clinicians will be invited to refer their clients who meet the inclusion criteria to register for the program. • Mental health consumer participants will be asked to participate in an 8 week program. The program is designed to cover a range of topics and activities and will require a 3 hour per week commitment by each participant. In addition participants will be asked to undertake a daily exercise & well being program which will be planned for their individual and unsupervised use.

14. Inclusion & exclusion criteria Inclusion criteria: • Currently taking one of four atypical antipsychotics • Able to commit to completing the 8 week program. • Adult participants 18-65 years. • Resident of HNEH Tablelands Cluster and able to participate in the program which will be based in Armidale (2350) NSW. • Current client of Armidale Mental Health Team, HNEH. • Able to provide signed consent to participate in the program (either themselves or by guardian). • The pilot study will be limited to 20 participants in the 8 week program. Exclusion criteria: • Clients who are not currently taking any of the inclusion medications. • Children and young people under the age of 18 years.

15. Methods & procedures • A mixed methods evaluation research design yielding descriptive statistics and qualitative data will be analyzed and will enable the effective evaluation of the intervention program. Twenty atypical antipsychotic medication takers will be invited to participate in the program. Regular integrated physical and mental health assessment and monitoring of intervention participants will take place. The program is designed to enhance the general health and well being of the participants, and a range of evidence-based nursing interventions will be implemented including nutritional, physical/lifestyle and psychosocial interventions. Physical health monitoring will target the high risk collection of MetS problems.

16. Program consultaitons • Pre program management stakeholder consultation • Pre program Armidale & Tableland Cluster based stakeholder orientation to program

17. Program Overview • Week One • TopicIntroduction to improving physical health and the reduction of risk factors while taking antipsychotic medications. Swap it! • Aim Orientation to an integrated physical wellbeing lifestyle program. Motivate and engage participants ready to embark on change in regard to improving physical health while taking prescribed antipsychotic medications, following obtaining the informed consent of up to 20 voluntary participants. • Week Two • TopicMedication: Understanding how it works, its side effects & how your community pharmacist can help you towards good health and well being. • Aim To help participants to consult with local community pharmacists, to improve regular medication taking and to ensure that participants are well informed about the medications they take. To position participants to take charge of their medication taking and their related well-being. • Week Three • TopicMake over – Swap over • Aim To initiate and/or support healthy behavior changes which assist participants to feel better, think better and do better in general. Building the self care skills required to achieve well-being. • Week Four • TopicEat better – feel better – live better • Aim Improve general nutrition and promote a balanced diet which will reduce the diet related risk factors for Metabolic Syndrome (a focus on diabetes prevention, cardiac risk reduction and nutrition which promotes healthy brain chemistry). • Week Five • TopicHealthy hearts • Aim To improve cardiac health and reduce cardiac risk factors • Week six • TopicFit for life • Aim Improve or enhance functional fitness for everyday living. • Week seven • TopicLife coaching – meaning making and value-adding. • Aim Making meaning in life – setting and achieving realistic personal goals for wellness. • Week Eight • TopicEvaluation - How do you feel now? Any changes in outlook, ability, fitness? • Aim Wrap up – bringing it all together – holistic physical and mental health self care

18. Ethical implications

20. Limitations • We acknowledge that an inflated service request may follow the initiation of a new risk reduction program which combines a mental health and physical health intervention. A spike in physical health service interventions would represent an under servicing of a vulnerable population over a long period of time, and it is inevitable that a transitional ‘catch-up’ phase will be needed for mental health consumers where physical co-morbidity is detected. A need for the program undoubtedly exists based on literature evidence in regard to the extent of the health problems the program will seek to address, but there is also a NSW health guideline directive that mental health consumers be provided with this basic level for service provision, so despite an anticipated influx of service requests, the program should be developed to better address the baseline physical and mental health needs of a vulnerable rural population. • There will be a limit of 20 participants in the pilot program. If following analysis of the data, a finding supports the notion of developing an ongoing intervention program, or modifying the program, a second phase of the program will be developed and funding sort to support to development of the initiative further. • This is likely to be the case where the caseloads are high and where service availability is less accessible, such as in rural communities.

21. Conclusion • The research will examine some important practice-based research questions and the results of this research will inform how mental health services can adequately respond to a recent NSW Health guideline for practice. In particular this research will add to the evidence base about the promotion of physical health care for mental health consumers. The findings from this research will have important clinical outcomes for a vulnerable population and will especially inform the planning of health service delivery to rural consumers. • There are recognized risk reduction strategies that address metabolic syndrome specifically and the promotion physical health and well being more generally for people with mental illness. There is now sufficient evidence to support initiatives to move to reduce metabolic syndrome risks and this is the focus to the current research. This paper has outlined an overview for a pilot research project aimed at translating current NSW Health policy, into rural mental health service practice.

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23. acknowledgements