Recovery from psychosis : physical health, antipsychotic medication and the daily dilemmas for mental health nurses

This paper considers some of the dilemmas experienced by Mental Health Nurses everyday when faced with the seemingly conflicting relationships that exist between recovery, antipsychotics and the physical health of people experiencing psychosis. We examine the role of antipsychotics in the process of recovery from psychosis and argue that Mental Health Nursing’s laudable shift away from the medical model towards the concept of self-defined personal recovery should not result in overlooking the importance of physical health and medication management. Mental Health Nurses have a responsibility to help services users make an informed choice about treatment; this exchange of information should be based on the best available evidence rather than philosophical values or personal opinion

Poster 23: What do Mental Health Nurses think and feel when the service user becomes their student nurse: Is it really ok not to be ok?

Background: Increasing numbers of higher education students declare pre-existing mental health conditions that require support and reasonable adjustments under the Equality Act 2010 (Hubble and Bolton, 2021)). Research with mental health student nurses [MHSN]who have been mental health service users highlights the collective responsibility of programme and practice providers to remove barriers to disclosure and learning for these students (Ramluggan et al, 2020). Mental health nurse practice assessors [MHPAs] may not be adequately prepared to support the needs of this cohort, and we cannot rely on clinical supervision to address this need (Masamha et al, 2022). Aims: To apply an action learning approach to collectively reflect on and learn from student cases where the SMHN has a pre-existing mental health condition and has used services within the practice provider organisation where they are due to be placed.Methods: An email of concern about one student case illustrated the need to focus on practice support for SMHNs - ‘we wonder if there is a conflict of interest with this student attending practice”. The MHPA had nursed the MHSN during a past episode of care, and other members of the placement team had knowledge of their care and opinions about their fitness for practice. We implemented a new collective group meeting process to open dialogue with MHPAs about student cases using a supportive and psychologically safe action learning cycle process. We learned the importance of taking time to explore the fears expressed by the MHPAs and their team and worked to reframe their emotions before they were able to discuss and agree reasonable adjustments for the individual student and negotiate a learning plan with them. Results: A reflection on a specific case enabled our team to consider the needs of MHPAs, alongside student learning needs through a collective action learning cycle approach.Conclusions: Further formal research is required to address the ‘elephant in the room’ of self-perpetuating stigma for MHNSs with pre-existing mental health conditions and use of services that may fuel discrimination in practice, considering the question ‘is it really OK, not to be OK?

Is adherence therapy an effective adjunct treatment for patients with schizophrenia spectrum disorders? A systematic review and meta-analysis

Background Poor adherence to medication in schizophrenia spectrum disorders leads to inadequate symptom control. Adherence therapy (AT) is an intervention that seeks to reduce patients’ psychiatric symptoms by enhancing treatment adherence. We aimed to systematically review the trial evidence of the effectiveness of AT on improving clinical outcomes in these patients. Method Systematic review and meta-analysis of published RCTs. We included studies testing AT as an adjunct intervention against treatment as usual or a comparator intervention in the general adult psychiatric population. The primary outcome of interest was improvement in psychiatric symptoms. Results We included six studies testing AT in schizophrenia spectrum disorders published since 2006. A meta-analysis showed AT significantly reduced psychiatric symptoms compared to usual treatment over a follow-up period of less than 1 year. We found no significant effects of AT on patients’ adherence and adherence attitudes. Conclusions AT is an effective adjunctive treatment for people with schizophrenia spectrum disorders

Nurse-Facilitated Health Checks for Persons With Severe Mental Illness: A Cluster-Randomized Controlled Trial

Objective: This study tested the effectiveness of a nurse-delivered health check with the Health Improvement Profile (HIP), which takes approximately 1.5 hours to complete and code, for persons with severe mental illness. Methods: A single-blind, cluster-randomized controlled trial was conducted in England to test whether health checks improved the general medical well-being of persons with severe mental illness at 12-month follow-up. Results: Sixty nurses were randomly assigned to the HIP group or the treatment-as-usual group. From their case lists, 173 patients agreed to participate. HIP group nurses completed health checks for 38 of their 90 patients (42%) at baseline and 22 (24%) at follow-up. No significant between-group differences were noted in patients’ general medical well-being at follow-up. Conclusions: Nurses who had volunteered for a clinical trial administered health checks only to a minority of participating patients, suggesting that it may not be feasible to undertake such lengthy structured health checks in routine practice

The heart healthy lenoir project-an intervention to reduce disparities in hypertension control: study protocol

Background Racial disparities in blood pressure control are well established; however the impact of low health literacy (LHL) on blood pressure has garnered less attention. Office based interventions that are created with iterative patient, practice and community stakeholder input and are rolled out incrementally, may help address these disparities in hypertension control. This paper describes our study protocol. Methods/design Using a community based participatory research (CBPR) approach, we designed and implemented a cohort study that includes both a practice level and patient level intervention to enhance the care and support of patients with hypertension in primary care practices in a rural region of eastern North Carolina. The study is divided into a formative phase and an ongoing 2.5 year implementation phase. Our main care enhancement activities include the integration of a community health coach, using home blood pressure monitoring in clinical decision making, standardizing care delivery processes, and working to improve medication adherence. Main outcomes include overall blood pressure change, the differential change in blood pressure by race (African American vs. White) and health literacy level (low vs. higher health literacy). Discussion Using a community based participatory approach in primary care practice settings has helped to engage patients and practice staff and providers in the research effort and in making practice changes to support hypertension care. Practices have engaged at varying levels, but progress has been made in implementing and iteratively improving upon the interventions to date

Metabolic dysregulation of the lysophospholipid/autotaxin axis in the chromosome 9p21 gene SNP rs10757274

Background - Common chromosome 9p21 SNPs increase coronary heart disease (CHD) risk, independent of 'traditional lipid risk factors'. However, lipids comprise large numbers of structurally related molecules not measured in traditional risk measurements, and many have inflammatory bioactivities. Here we applied lipidomic and genomic approaches to three model systems, to characterize lipid metabolic changes in common Chr9p21 SNPs which confer ~30% elevated CHD risk associated with altered expression of ANRIL, a long ncRNA. Methods - Untargeted and targeted lipidomics was applied to plasma from Northwick Park Heart Study II (NPHSII) homozygotes for AA or GG in rs10757274, followed by correlation and network analysis. To identify candidate genes, transcriptomic data from shRNA downregulation of ANRIL in HEK293 cells was mined. Transcriptional data from vascular smooth muscle cells differentiated from iPSCs of individuals with/without Chr9p21 risk, non-risk alleles, and corresponding knockout isogenic lines were next examined. Last, an in-silico analysis of miRNAs was conducted to identify how ANRIL might control lysoPL/lysoPA genes. Results - Elevated risk GG correlated with reduced lysophosphospholipids (lysoPLs), lysophosphatidic acids (lysoPA) and autotaxin (ATX). Five other risk SNPs did not show this phenotype. LysoPL-lysoPA interconversion was uncoupled from ATX in GG plasma, suggesting metabolic dysregulation. Significantly altered expression of several lysoPL/lysoPA metabolising enzymes was found in HEK cells lacking ANRIL. In the VSMC dataset, the presence of risk alleles associated with altered expression of several lysoPL/lysoPA enzymes. Deletion of the risk locus reversed expression of several lysoPL/lysoPA genes to non-risk haplotype levels. Genes that were altered across both cell datasets were DGKA, MBOAT2, PLPP1 and LPL. The in-silico analysis identified four ANRIL-regulated miRNAs that control lysoPL genes as miR-186-3p, miR-34a-3p, miR-122-5p, miR-34a-5p. Conclusions - A Chr9p21 risk SNP associates with complex alterations in immune-bioactive phospholipids and their metabolism. Lipid metabolites and genomic pathways associated with CHD pathogenesis in Chr9p21 and ANRIL-associated disease are demonstrated

Neuropsychiatric manifestations and sleep disturbances with dolutegravir-based antiretroviral therapy versus standard of care in children and adolescents: a secondary analysis of the ODYSSEY trial

BACKGROUND: Cohort studies in adults with HIV showed that dolutegravir was associated with neuropsychiatric adverse events and sleep problems, yet data are scarce in children and adolescents. We aimed to evaluate neuropsychiatric manifestations in children and adolescents treated with dolutegravir-based treatment versus alternative antiretroviral therapy. METHODS: This is a secondary analysis of ODYSSEY, an open-label, multicentre, randomised, non-inferiority trial, in which adolescents and children initiating first-line or second-line antiretroviral therapy were randomly assigned 1:1 to dolutegravir-based treatment or standard-of-care treatment. We assessed neuropsychiatric adverse events (reported by clinicians) and responses to the mood and sleep questionnaires (reported by the participant or their carer) in both groups. We compared the proportions of patients with neuropsychiatric adverse events (neurological, psychiatric, and total), time to first neuropsychiatric adverse event, and participant-reported responses to questionnaires capturing issues with mood, suicidal thoughts, and sleep problems. FINDINGS: Between Sept 20, 2016, and June 22, 2018, 707 participants were enrolled, of whom 345 (49%) were female and 362 (51%) were male, and 623 (88%) were Black-African. Of 707 participants, 350 (50%) were randomly assigned to dolutegravir-based antiretroviral therapy and 357 (50%) to non-dolutegravir-based standard-of-care. 311 (44%) of 707 participants started first-line antiretroviral therapy (ODYSSEY-A; 145 [92%] of 157 participants had efavirenz-based therapy in the standard-of-care group), and 396 (56%) of 707 started second-line therapy (ODYSSEY-B; 195 [98%] of 200 had protease inhibitor-based therapy in the standard-of-care group). During follow-up (median 142 weeks, IQR 124–159), 23 participants had 31 neuropsychiatric adverse events (15 in the dolutegravir group and eight in the standard-of-care group; difference in proportion of participants with ≥1 event p=0·13). 11 participants had one or more neurological events (six and five; p=0·74) and 14 participants had one or more psychiatric events (ten and four; p=0·097). Among 14 participants with psychiatric events, eight participants in the dolutegravir group and four in standard-of-care group had suicidal ideation or behaviour. More participants in the dolutegravir group than the standard-of-care group reported symptoms of self-harm (eight vs one; p=0·025), life not worth living (17 vs five; p=0·0091), or suicidal thoughts (13 vs none; p=0·0006) at one or more follow-up visits. Most reports were transient. There were no differences by treatment group in low mood or feeling sad, problems concentrating, feeling worried or feeling angry or aggressive, sleep problems, or sleep quality. INTERPRETATION: The numbers of neuropsychiatric adverse events and reported neuropsychiatric symptoms were low. However, numerically more participants had psychiatric events and reported suicidality ideation in the dolutegravir group than the standard-of-care group. These differences should be interpreted with caution in an open-label trial. Clinicians and policy makers should consider including suicidality screening of children or adolescents receiving dolutegravir