Community Ment Health J (2010) 46:531–539 DOI 10.1007/s10597-009-9237-0
ORIGINAL PAPER
Cardiovascular Risk Assessment and Management in Mental Health Clients: Whose Role is it Anyway? Amanda J. Wheeler Æ Jeff Harrison Æ Priya Mohini Æ Jeshika Nardan Æ Amy Tsai Æ Eve Tsai
Received: 2 June 2009 / Accepted: 3 August 2009 / Published online: 18 August 2009 Springer Science+Business Media, LLC 2009
Abstract People with serious mental illness have higher rates of morbidity and mortality from cardiovascular disease. This study describes health practitioners’ views on their role and confidence assessing and managing cardiovascular risk. The key findings were of a widespread acknowledgement of the need to undertake systematic risk assessment and offer structured approaches to risk factor management. Barriers of client engagement, lack of good systems and poor information sharing between primary and secondary care providers were identified. Solutions discussed included a collaborative care model or the integration of physical health services, perhaps a general practitioner-led clinic, within the secondary care setting. Whilst there is a need to identify an optimal care model there is an even greater need to take some rather than no action. Keywords Mental illness Cardiovascular risk Risk reduction Qualitative methods
A. J. Wheeler (&) Clinical Research & Resource Centre, Mental Health and Addictions, Waitemata District Health Board, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand e-mail:
[email protected] J. Harrison Medicines Management Research Group, School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand P. Mohini J. Nardan A. Tsai E. Tsai School of Pharmacy, University of Auckland, Auckland, New Zealand
Introduction People with serious mental illness (SMI) have an increased risk of morbidity and mortality associated with a wide range of physical health problems (Dickey et al. 2002; Harris and Barraclough 1998; Jones et al. 2004; Kilbourne et al. 2004; Osby et al. 2001; Scott et al. 2006; Sokal et al. 2004; Weeke et al. 1987). This burden of physical illness amongst people with SMI is well described in the literature dating back more than 20 years. The literature describes a 1.6 times increase in all-cause mortality in schizophrenia, a doubling of the risk in bipolar disorder (Casey 2005) and in those with major depressive episodes, with standardised mortality ratios of 1.5 in men and 1.6 in women (Casey 2005). This increased mortality rate among people with schizophrenia results in up to 20% lower life-expectancy compared to the general population (Casey 2005; Hannerz et al. 2001; Newman and Bland 1991). The majority of this excess mortality is due to physical illness, including as infectious diseases, endocrine, circulatory, respiratory, digestive and genito-urinary system disorders (Harris and Barraclough 1998). The causes of physical health problems in mental health clients are complex and multifactorial, almost certainly involving the intersection of genetic, environmental, behavioural, socioeconomic and treatment-related risks. This may be further exacerbated by mental health clients’ poor access to or inadequate engagement with health care services and, in some cases, sub-optimal management of physical health conditions when clients also have a serious mental illness (de Lusignan et al. 2005; Dickerson et al. 2003; Druss and Rosenheck 1998; Goldberg et al. 2007; Jennex and Gardner 2008; Kreyenbuhl et al. 2008; Petersen et al. 2003; Rathore et al. 2008; Smith et al. 2007; Voruganti et al. 2007).
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There has recently been interest in the prevalence of the ‘metabolic syndrome’, a cluster of risk factors for the development of type II diabetes mellitus and/or cardiovascular disease (CVD) (Basu et al. 2004; Morriss and Mohammed 2005; Ryan and Thakore 2002; Tirupati and Chua 2007). This interest has largely been driven by concern over the potential that medicines prescribed to treat SMI (in particular second-generation antipsychotics), have to cause or worsen these risks. There is now an extensive body of evidence, particularly around people with schizophrenia and bipolar disorder, indicating that there is an increased prevalence of risk factors for cardiometabolic disorders (CVD and diabetes). These factors include raised blood pressure, obesity and central adiposity, dyslipidaemia, glucose intolerance and insulin resistance, smoking and physical inactivity (Davidson et al. 2001; Hennekens et al. 2005; Klumpers et al. 2004; Regenold et al. 2002). In order to address the excess burden of physical ill health on mental health clients it is necessary to both understand the causes, to consider what is amenable to change and to consider how this change might be brought about. Although the problems of access, poorly integrated care and lack of preventative primary care services are well known and described (Druss et al. 2002; Horvitz-Lennon et al. 2006), there has been relatively little published regarding effective strategies for improving the general medical care of people with comorbid physical and mental health problems and most interventions seem to have focussed on bringing medical care to psychiatric service rather than facilitating clients access to and engagement with primary care services (Druss and von Esenwein 2006). In this paper we describe a qualitative investigation of health practitioners’ views on their role in assessing and managing their clients’ cardiovascular risk profile. We also sought to explore the practitioners’ perceptions of barriers and solutions for the management of cardiovascular risk in people with mental illness.
Methods This study formed a final-year project for four Bachelor of Pharmacy students at the University of Auckland, New Zealand. Ethics approval was obtained from the University of Auckland Human Participants Ethics Committee (2006/ L/020). Study Participants and Data Collection Key informants were recruited by the study supervisors based on a purposive sampling framework to include representative viewpoints from a range of staff. Roles represented were: psychiatrists/psychiatric trainees, general
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practitioners, nurse specialists, mental health pharmacists, and consumer advisors. Key informants were contacted by e-mail and provided with a participant information sheet and consent form. The consent form was signed by the key informant at each face-to-face interview after discussion of the study purpose and data collection procedures. Semi-structured interviews were conducted with the use of a guide that had been developed by the researchers to elicit information that was not available in the published literature. This information fell into the following broad categories: reviewing the participants’ current knowledge of CVD risk assessment and management for people with a mental illness; exploring their perceptions and current practice; determining barriers to CVD risk assessment and management in this patient group; and interventions and solutions to address these barriers. The interview was structured around a standard set of questions with additional prompts. The first interview was conducted as a pilot with feedback provided by the key informant on the interview process. Each interview was audio-recorded and a second researcher was present to take written field notes. Audiorecordings were transcribed verbatim. Data Analysis Transcripts were analysed after all interviews had been conducted and the researchers confirmed that data saturation had been reached and no new issues emerged. The researchers reviewed the transcripts as a group, guidance was provided by a sociologist experienced in qualitative methodologies. A content analysis was undertaken to identify key themes and noting how these themes played out within and across participant responses (Davidson and Tolich 1999). The transcripts were read and re-read to identify key phrases that were coded as significant to the research topic. These codes were collated around categories that were collapsed into thematic material. These themes were further examined to identify the synergies and points of difference. All quotes reported in this paper were ‘tidied’ (deletion of ‘um’ and ‘ah’ and repeated words) by the authors to improve readability.
Results Nine interviews were conducted with key informants over 2 months in 2006. The characteristics of the key informants were as follows: six were male; five identified as New Zealand European, one Ma¯ori, one Asian, one Pacific Island, and one other European; six practiced in secondary care, one in primary care and two in both sectors. The key informants worked with adults in their current practice; the
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majority with clients from all cultures and two with culturally-specific health services and across a spectrum of mental disorders including schizophrenia, bipolar disorder, depression, anxiety disorders, personality disorders and substance-related disorders. Mental Health and Risk for Cardiovascular Disease The key informants believed that clients with a mental illness had increased CVD risk, but in particular, people of Polynesian descent (indigenous Ma¯ori and Pacific peoples) because of the prevalence of diabetes, dyslipidaemia, hypertension, obesity and smoking in this population. A number of participants expressed that CVD was only one of a number of physical health problems that increased morbidity and mortality in mental health clients. With respect to the relationship between CVD and mental illness most key informants felt this was complex. Two explanations for the association between mental illness and CVD were revealed. The first comprised of an older population with pre-existing CVD which predisposed them to mental disorders such as depression. The second consisted of a younger population who have a mental illness that predisposes them to CVD, as one participant explained: ‘‘I think there’s probably a relationship both ways and …I think certainly there’s an association between severe enduring mental illness and increased rates of severe physical illness including CVD and I guess that isn’t all due to lifestyle, high rates of smoking and obviously the side effects of antipsychotics…and I think there’s probably an association the other way too if you have got significant cardiovascular disease you’re probably at increased risk of certainly depression and probably a number of other disorders.’’ (7) Approximately half of the key informants concurred with both relationships, the other half only made reference to the latter group. A possible explanation for this diversity is that the health practitioners worked in different parts of the health sector (primary versus secondary care) and hence dealt with different clients on a day-to-day basis; most serious illness such as schizophrenia and bipolar disorder is managed in secondary care whilst depression and anxiety disorders are generally managed in primary care. Overall there was a consensus view that mental health clients had poor physical health. The secondary care practitioners described a need to be holistic in their approach to healthcare: ‘‘For a range of reasons mental health service users often have poor physical health and often mental health services focus on the mental health component so I actually think they need to take a broader approach. And my whole perspective on it is that we need to be holistic in the way we treat people…not treat them independently of their physical issues, we also can’t treat
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them independently of the social issues impacting on those people.’’ (2) Pharmacological Treatment of Mental Illness Concerns were frequently raised that second-generation antipsychotics increased CVD risk factors in mental health clients. Concern about the adverse effects of these drugs was high primarily because prescribing recommendations favoured the second generation agents, as one practitioner explained: ‘‘I think the focus when these drugs [secondgeneration antipsychotics] became available was a lot better in terms of tolerability and other adverse effects that affected mental state …and they reduced the burden of illness far more, so in terms of working in mental health we had better drugs so we wanted to use them. What emerged …as a consequence of using these drugs was that people were putting on a lot of weight and then subsequently we realised that they were having problems with diabetes.’’ (3) In a few instances practitioners acknowledged that despite less frequent use, first-generation antipsychotics can also cause cardiovascular problems. While most practitioners were aware of the adverse effects of second generation antipsychotics one primary care participant highlighted that this awareness may be limited to secondary care because this is where antipsychotic medication is managed: ‘‘If you’re talking about the new atypicals I suppose I’d have to be honest my knowledge isn’t there to know if there’s an increased risk. There may be, but I’m not aware of it. They tend to be initiated by specialist psychiatrists and I guess it would be thrown over to us for maintenance. One would hope, if there’s an issue, they will tell us what to look for.’’ (9) Mental Health Client Understanding of Cardiovascular Disease Risk Many key informants believed that mental health clients varied in their level of understanding and attitudes towards their cardiovascular risk as described by one participant: ‘‘Some people will know and will be keen to do something about it, some people will know and won’t be motivated to make changes and a lot of people will not know about cardiovascular risk factors.’’ (8) The reasons for clients’ lack of knowledge or concern about their cardiovascular risk were believed by most key informants to be due to a combination of factors including: the impact of the mental illness itself, their state of wellness, sociodemographics, life-style factors and self-esteem. Key informants believed that managing physical health overall and associated life-style was reflected in the emphasis placed on it during the interaction between practitioner and patient. Most participants felt that clients
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were aware that they were overweight, or smoking too much or not exercising enough but knowledge about this did not necessarily translate to understanding how this affected their risk of a cardiovascular event or motivate them to changing behaviour. One practitioner explained: ‘‘They’ve [SMI patients] got the knowledge but how do you change that—changing someone’s concern to make them concerned, people with poor self-esteem usually it’s hard to change any behaviour…and finally the thing around self-advocacy is that being able to know that you can make a change.’’ (4) Confidence and Current Practice in Cardiovascular Risk Assessment and Management The secondary care participants generally felt confident in mental health services’ ability to conduct cardiovascular risk assessment. However, the primary care practitioners believed that risk assessment by mental health practitioners was probably poor because this was outside their area of specialty. Mental health practitioners described that their current practice included conducting baseline assessments prior to initiation of pharmacological treatment (e.g. lifestyle factors, full blood count, lipid profile, blood glucose, electrocardiogram, body mass index, blood pressure and pulse measurements) and explained that they would refer patients to their GP if a risk assessment required subsequent intervention. The following quote typifies the confidence expressed by secondary care participants in assessing CVD risk: ‘‘I know about what you need to do for screening and then I know who to refer someone to if it appears that they have risk factors that need to be managed.’’ (8) In contrast, monitoring, management and follow-up of identified risks was described by all practitioners as outside the role of mental health services as exemplified by the following extract: ‘‘This should be managed by GPs who have expertise and know how to manage cardiovascular disease and I think we should, as best we can, normalise what happens to the rest of the public. If you go and see a dermatologist you don’t expect the dermatologist to manage your high blood pressure. You go and see a psychiatrist you shouldn’t expect them to manage your high blood pressure.’’ (3) However, in terms of responsibility for identifying and managing physical well-being, this was seen by most participants as a joint responsibility between primary and secondary care with liaison between practitioners a key factor: ‘‘No it’s a shared responsibility—the GPs need to know that their clients have a mental disorder and what their treatments are and what the risks are, and if they’ve got any concerns to contact us and vice versa. So it’s not about pushing it all on to the GP but if I identify somebody
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with a raised glucose or a dysfunctional lipid profile then I would refer them to their primary care provider to address that.’’ (4) ‘‘Yeah I would probably say it’s a joint responsibility seeing that patient and their GP. I think that’s what primary care is. It’s preventative medicine and we do it all the time…so there shouldn’t be any different or harder population to deal with because often people…don’t necessarily have the same insight you know but I think we’re probably the best place for that.’’ (9) In spite of reported confidence in being able to assess cardiovascular risk, secondary care participants reported that in general this was not done particularly well or routinely and was rather on an ad hoc basis. Mental health practitioners viewed that their primary role was to assess and manage mental health problems as summed up by the following quote: ‘‘We’re mental health people, we do mental health assessments okay. So cardiovascular risk is something that we pick up while we’re treating patients for mental health problems.’’ (5) Lack of expertise and ‘outside core business’ were not the only explanations for the inconsistency in physical health monitoring; in fact a key issue seemed to be the lack of any process or pathway to include CVD risk assessment in service delivery as expressed by one participant: ‘‘I don’t believe that we actually have an agreed strategy on how we respond to people’s physical health issues. It begins with the fact that there’s… no mandated recognition of the need to address physical health issues and as a result there’s no agreed protocol within mental health about how that might be done in terms of developing pathways of care within our DHB or with the GPs and PHOs.1 And so what is happening still continues in an ad-hoc way. Some doctors do it, some doctors don’t.’’ (2) All participants described that it was their usual practice to refer clients to programmes for management of life-style risks; smoking cessation, exercise and dietary advice. The exercise and healthy living programmes available for clients varied between mental health team-specific programmes, pharmaceutical company sponsored access to dieticians, to the use of the ‘Green Prescription’; a programme promoting affordable and accessible physical activity funded by Sport and Recreation New Zealand and the Pharmaceutical Management Agency (Elley et al. 2003; Handcock and Jenkins 2003). It was usual practice for secondary care practitioners to determine motivational status for smoking cessation and encourage the person to take the steps towards behavioural change. Most key 1
Primary Healthcare Organisations are national, government funded bodies responsible for providing essential primary healthcare services. They are intended to be multiprofessional organisations, including GPs, who deliver services appropriate to their health needs of their enrolled population.
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informants were aware of Quitline; a free telephone helpline with qualified advisors and subsidised nicotine replacement therapy (The Quit Group 2006). One participant felt that the mental health sector had become more proactive recently in suggesting smoking cessation programmes: ‘‘I think what’s happened now is we’re proactively asking patients if they wish to stop smoking whereas before we’d probably wait until the patient came to us.’’ (3) Despite availability of many programmes, utilisation of these was variable and participants felt that only a small number of clients participated: ‘‘…very small probably 6 to 10%.’’ (6) The same participant expressed that modifying lifestyle was a personal choice and as a result, there were limitations to practitioners influence on behaviour change: ‘‘What remains in our field of practice is the tension between the recovery model which is essentially people making decisions about their own life and ability and a right to intervene as people make these choices. There’s also our duty of care where we as health professionals can see issues but cannot directly intervene to impose a set of lifestyles on people and…how far you go to assisting people to meet those risks themselves.’’ (6) Another participant discussed the need to be innovative when encouraging life-style modifications: ‘‘…we know that we [clients] have weight issues but we also need help dealing with these health issues and so …rather than have the psychiatrist sitting there in the office and go, ‘‘Gee you’ve put on a lot of weight haven’t you? How about doing some exercise?’’ and offering nothing further; to offering a programme that you see people engage in, really positively as a demonstration that service users are aware of health risks that they may incur through the medications they take and in the illness they’ve got, and the weight that they gain. But we need to be more proactive in offering them opportunities in ways of which to deal with it.’’ (2) Barriers and Solutions Key informants were asked to identify perceptions of barriers to cardiovascular risk assessment and management for people with a mental illness and possible solutions to overcome these problems. These have been summarised in Table 1. One barrier in particular arose from practitioners acknowledged lack of expertise in secondary care alongside their desire to be holistic in their service delivery. This was expressed by mental health participants as a tension over their roles causing potential boundary issues: ‘‘We try to be holistic as a service, we try to be sometimes but we essentially focus on psychiatric, social and spiritual features. Treating the physical issues is managed by GPs and by other people so again we have boundary issues, we have a professional boundary issues, that is sometimes interesting to work your way through…Need to be clear about our
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roles which is difficult in mental health because mental health issues spill over into all areas of life so the risk is that you get so overly involved that we lose our mental health focus…’’ (6) Another important barrier raised by many participants’ focused on poor communication between the two health sectors. Communication issues occurred in both directions with examples of secondary care needing to inform general practitioners about the medication they were prescribing and any CVD risk assessments they had carried out as part of the referral process. Similarly, general practitioners needed to inform psychiatrists of CVD risk assessment results and interventions initiated to manage risk factors because psychiatrists need this knowledge to make informed treatment choices with psychotropic medication such as antipsychotics: ‘‘So there are some issues with information sharing and about who’s managing what and making sure that people have got some clarity.’’ (5)
Discussion This study explored the views and current practices of primary and secondary care practitioners in assessing and managing cardiovascular disease and its risk factors in people with mental illness. In addition, barriers to assessment and management in this client group were identified as well as interventions and possible solutions to address these barriers. Key informants supported the view reported in the literature that mental health clients commonly have poor physical health. In the local environment, participants particularly felt that those of Ma¯ori and Pacific Island background were at an even higher risk relative to their non-Ma¯ori counterparts in terms of CVD morbidity and mortality based on the higher prevalence of various cardiovascular risk factors including obesity, hypertension, dyslipidemia, diabetes and smoking in these ethnic groups. Participants were also aware of increased cardiovascular risk in people with a mental illness and the importance of risk assessment. The majority of the key informants believed that secondgeneration antipsychotics are associated with an increased incidence of adverse effects which in turn could negatively impact on cardiovascular risk. The opinions of the key informants regarding first-generation antipsychotics were varied as the participants had limited knowledge and experience with the older antipsychotics. This reflects current practice recommendations to use second-generation antipsychotics first-line in the treatment of psychotic disorders such as schizophrenia in New Zealand and internationally (National Collaborating Centre for Mental Health 2002; Royal Australian and New Zealand College
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Table 1 Perceived barriers and solutions for cardiovascular risk assessment and management in mental health clients Barriers
Solutions
Practitioners knowledge and skills
‘‘They may not be aware, mental health staff Training and continuing education ‘‘For doctors the information is all there may not have the knowledge or skills.’’(8) but you know educating people is not just about giving people the ‘‘Psychiatrists have limited skill base in information, its actually about ensuring terms of CVD risks. I do have concerns that they apply the knowledge that they about these people because they are not have’’(8) experts in that field’’(3)
Communication issues between primary and secondary care
‘‘There’s quite a barrier between secondary Improved liaison between and primary care and its on both sides’’(3) practitioners ‘‘I probably don’t keep my GP colleagues informed as much as I should’’ (4) ‘‘I suppose a barrier is communication, good communication and liaison and probably clear delineation about who’s doing what.’’ (1)
Inadequate resources/time
‘‘There’s a process we’re getting where we can get access to blood results done by a diagnostic lab and the GPs so we’re not having to repeat’’(4)
‘‘GPs are very busy and see patients in 5-10 Mental health practitioners minutes supposedly addressing any CVD working collaboratively with problems. It takes me an hour to do the general practitioners within a initial assessment on a patient and that’s hospital or primary care setting got nothing to do with the cardiovascular problems’’ (5) ‘‘They may lack equipment, a scale or a tape measure’’(8)
Clients financial status
‘‘Our guys cant afford to go to a GP and pay Subsidy for primary care visits for treatment…so those problems go largely untreated’’ (4) ‘‘If you’re living on a benefit and most of your income goes to accommodation, its hard to manage going to a GP’’(3)
Addressing motivation and behaviour change
‘‘My thing is to have mental health working alongside GPs. They’ll be screening and identifying issues right from the start and that’ll be a seamless service….it’ll be together’’(4) ‘‘I would really like to have a physician working with us—attached to our service or this building, I would really like to see services integrated into our organisation’’(6) ‘‘The beauty of the primary partnership scheme is that there is funding so that these patients can avail themselves of assessments’’(9) ‘‘A large number of our patients would qualify in terms of deprivation index and then get heavily subsidised GP visits’’(8)
‘‘Barriers would be maintaining a motivation with people for the life-style changes the stuff that’s going to be really helpful in the long run but as you know its difficult changing peoples eating habits’’(1)
of Psychiatrists Clinical Practice Guidelines Team for Schizophrenia and Related Disorders 2005). There were numerous examples of life-style interventions and programmes currently available to clients, however, access to these initiatives varied greatly between mental health services and client participation was believed to be low overall. Disempowerment and paternalism were raised as problems for practitioners to be aware of when addressing lifestyle issues with clients, and focusing on improvement in well-being and proactively offering opportunities for clients to engage were suggested. Most commonly in healthcare the process of CVD risk assessment and management is closely interlinked, for both practical and continuity of care reasons, and undertaken by the same practitioner or service. During this study it became clear that specialist mental heath practitioners
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‘‘Better liaison could be meetings, it could be educational opportunities for GPs and psychiatrists to get together and discussing how to address these problems’’ (5)
believed that these two components could be carried out separately. They felt confident in their knowledge to undertake the assessment part of the process but not the management component, especially prescribing medication and monitoring its effectiveness. Primary care practitioners’ views differed. They believed that the entire process should be undertaken in primary care; reflecting their expertise in preventative health, that it fell outside a psychiatrist’s scope of practice, is already a core component of their practice and that people with a mental illness should not be managed differently to the rest of the population. Of concern was that whilst secondary care practitioners expressed confidence in risk assessment and described situations when they had completed assessments, it became clear that in fact this was carried out inconsistently and that formal risk assessment was rarely carried out in routine
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practice. There was a consensus view that mental health services were not effectively screening clients for CVD risk. Primarily this was because this was not seen as their area of expertise and that assessment and management of mental health issues was time consuming. Identifying who was actually taking responsibility for risk assessment and subsequent management and follow-up raised concerns about boundary issues and role confusion. There was diversity of opinion with some preferring that primary care took responsibility and others suggesting that in order for CVD outcomes to improve this should be a shared responsibility between the psychiatrist and the general practitioner. The collaborative model, however, required better communication and liaison between primary and secondary care than was currently in place if it was to work. Sharing of blood results and information about medicines were specific examples identified that were problematic. Another suggestion made to improve collaboration was to bring the two sets of expertise together, that is, to have a primary care practitioner working with a community mental health centre or hospital setting. These findings are supported by other work carried out in Melbourne and north London (Hyland et al. 2003; Wright et al. 2006). Hyland et al. (2003) surveyed mental health case managers and found that physical health interventions were offered inconsistently and preventative health measures such as blood pressure were neglected. The case managers believed that their core business was to assess and treat mental illness. They considered that physical health issues were a shared responsibility but they identified a clear lack of service delivery integration; there was no systematic process of how this shared responsibility might become reality. The north London study similarly found that CVD risk assessment was not carried out routinely by psychiatric staff (Wright et al. 2006). As with our study, general practitioners felt that this was their role in people with SMI but lack of experience with CVD-related side effects of antipsychotics was raised as an obstacle. Interestingly, in contrast to the key informants in our study, most psychiatric professionals also believed it was the responsibility of primary care and that if they took responsibility it would blur professional roles. However, Wright et al. (2006) also found that a number of mental health staff were keen to include risk assessment in their practice. This was also the preferred model of service users because they felt more able to engage with mental health staff. Numerous barriers were identified by the current study and particular emphasis was placed on the inadequate liaison between primary and secondary health care. Patients are referred back and forth between the sectors and there was confusion amongst the practitioners as to followup procedures, resulting in the breakdown of a client’s
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continuity of care. Another important barrier the key informants alluded to was the financial constraints faced by many clients, creating an obstacle in accessing primary care services. It was evident that the key informants found it easy to identify the barriers as they saw them everyday in the workplace. Proposing solutions, however, was a lot harder since most of the key informants did not feel they were involved in the development phase of initiatives within their services. The views expressed by the north London professionals concurred with our study suggesting improved collaboration between primary and secondary care and that one person needed to take overall responsibility to ensure adequate screening (Wright et al. 2006). They also identified that improved communication especially about CVD risk results back to secondary care was important. The UK study went further and possible models were introduced for discussion. Many participants felt that the best solution was to have a service led by one person liaising between primary and secondary care. The model proposed was led by a specialist nurse (a physical health nurse attached to community mental health to bridge the gap between primary and secondary care). The financial barrier expressed in our study reflects the current funding situation in New Zealand where most people are required to contribute some form of co-payment for primary care visits whereas secondary care is free for clients. The mental health practitioners felt that people with SMI were commonly on a government benefit and would find it difficult to prioritise payment for primary care visits from this limited income. Exploring service users’ views on how and where they would prefer to access physical health care is an important area for future research. This study using in-depth questioning has explored the opinions of a wide-range of experts who have first hand knowledge of cardiovascular risk assessment and management in people with mental illness. Whilst the interview is a powerful tool for extracting data and allows the researcher to establish rapport and explore deeper into areas of interest it is important to recognise the limitations of using this methodology. Firstly, participant selection can be difficult because of people’s different views and backgrounds. Another disadvantage lies in the difficulty in analysing the information and the generalisability of the findings to a larger population. The data is also susceptible to researcher bias (Binnendijk 1996; Carroll et al. 2004). The key informants were selected by the academic supervisors because they were knowledgeable and experts in their respective fields and to reflect the diversity of ethnicity, years of experience and professional role and recruited from predominantly one area of Auckland. Purposive selection of the participants was necessary to ensure the people recruited were individuals who will make the
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most contribution to the study whilst providing a breadth of viewpoints and experience. The results of the study therefore may not be generalisable to other services and settings. In conclusion, our findings highlight inadequacies in the assessment and management of cardiovascular risk in people with a mental illness. The lack of an overarching plan with systematic processes to address the physical health needs and the poor liaison between the two different healthcare sectors were reflected most strongly. This is a complex problem and further research is needed to better understand how different models of care, involving both primary and secondary care, might better meet the needs of this client group. At the same time there is an urgent need to address those, largely unidentified and unmanaged, mental health clients with increased cardiometabolic risk factors. Acknowledgments Thanks to all those who participated in the key informant interviews. We would also like to thank Tamasailau SualiiSauni for her input regarding the qualitative analysis and reviewing the presentation of results. Thanks also to Teresa Timo for transcribing assistance, the administration staff at the School of Pharmacy and the library staff at The University of Auckland for their support, knowledge and advice. Declaration of Interests: No author received any financial compensation for the completion of this manuscript. No author is financially involved with any organisation that may benefit financially by this manuscript.
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