Pharmacist-led service for improving cardiometabolic risk and metabolic syndrome for people with severe mental illness

Individuals with severe mental illness (SMI), such as schizophrenia and bipolar affective disorder, have a higher risk of physical illness than those without SMI^[1]
. These physical illnesses exist within the general population, but the incidence and impact on morbidity and mortality in those with SMI is significantly greater, resulting in a 20% shorter life expectancy and a mortality rate that is two- to three-times higher than those without^{[2],[3],[4],[5],[6],[7],[8],[9],[10]}
. This gap exists in countries considered to have high standards of healthcare and can, in part, be accounted for by a higher relative risk (around one- to five-fold) for cardiometabolic risk factors and metabolic syndrome. For people with SMI, metabolic syndrome is one of the most prevalent risk factors for developing cardiovascular disease (CVD)^{[11],[12],[13,[14]}
.

Compared with the general population, people with SMI are at increased risk of obesity and are more likely to be smokers^{[15],[16],[17],[18]}
. Weight gain is a possible side effect of the antipsychotics that are used to control symptoms in SMI. The greatest weight gain can occur in the first few months of antipsychotic use and is more common with newer antipsychotics^{[19],[20],[21],[22]
,[23]}
. Antidepressants (e.g. mirtazapine) and mood stabilisers (e.g. lithium and valproate) are also associated with weight gain^[24]
. Consequently, lifestyle factors (e.g. poor diet, smoking and obesity) play a prominent part in physical ill health in SMI, with a genetic predisposition and medication-specific risk factors also playing a role^[25]
.

Data from the National Audit of Schizophrenia showed that people with SMI received low rates of screening for cardiometabolic risk and metabolic syndrome in the Leicestershire Partnership NHS Trust^[26]
. To tackle this health inequality, a pharmacist-led service was set up in April 2014. Shortly after, NHS England set national Commissioning for Quality and Innovation (CQUIN) targets for NHS Trusts, covering the aims that had initially been set by the Leicestershire Partnership NHS Trust, as well as the need to act on and implement clinically relevant interventions, such as smoking cessation advice. As a result, funding and resources were approved for the pharmacist-led service to run for five years in the Leicestershire Partnership NHS Trust.

Each person with SMI under the care of the trust’s inpatient services, early intervention and community mental health teams received the service, which involved:

1. Cardiometabolic/metabolic data screening from within the previous year was searched for and collected (i.e. HbA_1c, lipids, smoking status, illicit drug use, alcohol consumption, blood pressure, body mass index, diet and exercise), utilising both primary and secondary care health records to find this information;
2. The relevant lead care professional (e.g. nurse) was prompted for any information that was missing or not documented;
3. Reminders and follow-ups were sent to the patient and refusal documented;
4. Accuracy, clinical checking and QRISK (the nationally accepted algorithm for CVD risk assessment) was calculated.

The data were recorded on a bespoke centralised electronic database (the Leicestershire Physical Health Register database) and a completed profile was uploaded onto the patient electronic record. Healthcare professionals were directed to clinically relevant interventions, where appropriate, by the lead pharmacist.

The Leicestershire Partnership NHS Trust achieved the highest results in the country for each of the five years that the CQUIN ran. By the end of the five-year period, 100% of inpatients, 97% of those in early intervention in psychosis services and 88% of community mental health patients (who were on a care programme approach) received both screening and related interventions. This is an increase from 24% of patients who were being screened at the start of the service. This model of care has proved to be effective in improving both the rate of screening, and implementation of interventions for cardiometabolic risk and metabolic syndrome for individuals with SMI.

Several aspects were important to the success of this service, including dedicated resources (e.g. funding and staff), as well as the electronic database which produced blood forms populated with a patient’s details and the tests required. These forms, which can be used anywhere within Leicestershire, can be sent to the lead healthcare professional by email or can be printed off and either given to the patient at an appointment, or sent to the patient with a clinic appointment letter. Although the service was led by the pharmacy team, it was supported through multidisciplinary working. For example, a consultant psychiatrist was nominated by the medical director as a champion to support the implementation of the service, and regular communication with community psychiatric nurses facilitated blood tests and interventions.

There have also been advancements to the work within the mental health trust, including the formation of a multidisciplinary physical health strategy group.

Furthermore, my PhD is focused on the role of pharmacy in supporting physical health in those with SMI. As part of this, a literature review of the subject was completed — the findings of which were used to inform a research study^[27]
. In this study, semi-structured interviews were conducted with people who have SMI, carers of people with SMI and healthcare professionals (including doctors, nurses, dietitians, support workers and pharmacists) about their experiences and opinions on pharmacy providing care for physical health for people with SMI. These data are currently being analysed. For further details about the study, please see our webpage: https://www.leicspart.nhs.uk/about/research-and-development/cardiophitness-research-study/ and our most recent study newsletter: https://www.leicspart.nhs.uk/wp-content/uploads/2020/01/Study-Newsletter-January-2020.pdf.

Dolly Sud, senior specialist mental health pharmacist/Leicestershire Physical Health Register lead, Leicestershire Partnership NHS Trust, UK; PhD student, Aston University, UK; member of the College of Mental Health Pharmacy; member of Cochrane