Cardiovascular Screening of People With Severe Mental Illness in England: Views of Service Users and Providers

Surveys were distributed to 453 primary care staff and 391 staff of CMHTs (Table 1). Responses were received by 143 (31%) primary care staff and 166 (42%) CMHT staff. Among the primary care staff, 106 (74%) were general practitioners and 36 (25%) were practice nurses. Their mean±SD age was 47.1±8.8 years (range 27–71), and they had been in practice for 12.8±9.7 years; 52 (36%) were men, 84 (59%) were women, and data about gender were unavailable for seven (5%).

Among the CMHT staff, 49 (30%) were community psychiatric nurses, 41 (25%) were social workers, 32 (19%) were psychiatrists (consultants and trainees), nine (5%) were occupational therapists, nine (5%) were psychologists, 12 (7%) were team managers or leaders, and 13 (8%) were other staff. Their mean age was 41.9±10.04 (range 25–63), and they had been in practice for 22.3±22.9 years; 64 (39%) were men, 99 (60%) were women, and data about gender were unavailable for three (2%).

Completed questionnaires were returned by 227 service users, but the number distributed to service users could not be ascertained reliably. Demographic and other characteristics of the respondents are shown in Table 1.

This survey of primary care staff, mental health staff, and service users with severe mental illness showed that all three groups placed value on cardiovascular health checks for people with severe mental illness. This finding replicated previous research demonstrating service users' high commitment to attending a cardiovascular disease screen (15).

We found that CMHT staff reported more frequent discussion of risk factors for cardiovascular disease with service users than did primary care staff, but that primary care staff assessed risks of cardiovascular disease more routinely. High proportions of primary care and CMHT staff reported routine provision of lifestyle advice.

Although these findings appear encouraging, evidence from the United Kingdom, the United States, and Australia reveals suboptimal screening coverage for this patient group. Gaps in screening persist despite widespread awareness among stakeholders of its importance and recommendations for its use in evidence-based guidelines (12,35,36). In our survey, more than one-third of service users had not discussed their risk of cardiovascular disease with a professional, and their estimates of the provision of cardiovascular risk reduction interventions fell short of staff estimates. This finding points to the importance of understanding supply-side and demand-side barriers to integrated mental health care in England in order to identify acceptable means of addressing them (37).

Agreement about the respective roles and responsibilities of primary and specialty mental health care staff is an important determinant of willingness to supply or utilize a service, primarily because it confirms acceptability. For staff it reduces replications, omissions, and professional disputes, and for psychiatric patients it identifies the least stigmatizing model (38). This survey showed general agreement that screening and reduction of risk of cardiovascular disease should be provided as part of primary care, in contradiction of previous qualitative research showing that patients favored a CMHT setting (34). Provision of these services by primary care staff appeared to be the norm in this sample, but respondents' views about obstacles to uptake suggested explanations for the evident gaps in coverage. The barriers identified also indicate where further research is needed to identify incentives for achieving reduction of cardiovascular disease risk within a shared-care model.

Service users in this survey displayed a marked mismatch between their level of interest in screening for risk factors for cardiovascular disease and their preparedness to engage in interventions to reduce risk. Difficulty adopting healthy behaviors despite good intentions is a public health challenge for the wider population (39,40), but mass marketing material to promote healthy choices (41) may not be suitable for people with severe mental illness. Evidence suggests that educational programs for these patients should incorporate repetition and individual or group discussions with a key worker to reinforce messages about the likely benefits of risk reduction interventions (11). Such strategies would be deliverable through the Care Programme Approach, as discussed below.

In this sample, individuals' readiness to change modifiable cardiovascular risk was governed by factors such as travel, time, and an aversion to structured interventions. Their preference for receiving screening at generic primary care screening clinics rather than at clinics specifically targeted toward psychiatric patients highlighted the value they placed on minimizing stigma. Further qualitative research would help investigate specific factors that contribute to the apparent reluctance among individuals with severe mental illness to participate in risk reduction work. Factors to explore, which are likely to vary among ethnic groups, include the appropriateness of the format and language used in current interventions; the adequacy of incentives; self-perceptions of risk (42); and expectations about the pace of behavior change. The results of this research could be used to adapt interventions found to be successful in the general population to the needs of people with severe mental illness, just as adaptations are made for any other subgroup at risk of cardiovascular disease (43). Intervention studies, including trials of the contingency management approach (44), would quantify the impact of incentives on outcomes such as service uptake and cardiovascular health.

Incentives are also important when considering supply-side barriers to implementation, particularly if guidelines confer additional workload on primary care staff or CMHTs (12). Although in England, the Quality and Outcomes Framework already contains financial incentives to address most aspects of screening for risk of cardiovascular disease (24), the opportunity exists to expand screening in the future by adding lipid checks and addressing risk factors such as smoking and obesity. Our findings indicated that specialty mental health care staff may be willing to assist in providing screening and motivating service users to attend screening and adopt lifestyle changes. As noted, 70% of CMHT staff wanted more involvement in the general medical health of these patients.

CMHT staff also held more optimistic views than primary care staff about service users' engagement in risk reduction. Under existing Care Programme Approach arrangements, CMHT staff in regular contact with clients are well placed to review the monitoring information provided by primary care providers and encourage patients to address risk factors. Approaches might include motivational enhancement (45) and exercise groups promoting social connectedness (46). The advantages of such work include reduction of cardiovascular risk, increased social engagement, enhanced social capital, reduced stigma, improved mental health, and better social functioning.

Finally, clinical audit has been shown to improve screening provision for psychiatric patients by facilitating organizational change (47). The detailed approach of audit, with its emphasis on what is feasible locally, allows for local views to be factored into service provision, and practice suggests that it may be an acceptable way for local teams to adopt NICE clinical guidelines on mental health (48).

The study had strengths and limitations. The main strengths of the study were the random selection of primary care practices and CMHTs and the anonymous nature of the responses, which enhanced disclosure of the views of relevant stakeholders in rural and urban areas. It addressed current practice and preferred models of care, including a realistic consideration of the components of any screening and risk reduction program, and the providers best suited to offer them. It has direct relevance to implementation of current policy.

Response rates of between 31% and 42% for staff were to be expected for a survey of this kind, but the method did not allow for determination of a response rate among service users because the number of surveys that were distributed could not be tallied. A response bias is possible—for example, among service users motivated to improve health care services, staff who recognized a need to improve in this area, or staff concerned that service changes might increase workload. Respondents may also have been influenced by a desire for social acceptability, leading them to overestimate the degrees of preparedness to provide or engage in screening and risk reduction activities. These biases could limit generalizability. Although the results reported here are related to the NICE schizophrenia and bipolar guidelines, respondents included service users who had diagnoses of schizoaffective, depressive, and anxiety disorders. The data did not include objective measures of the severity of mental illness or of cardiovascular risk.

These results suggest that in England risk of cardiovascular disease among individuals with severe mental illness is managed mainly in primary care but that coverage is incomplete. The views of staff and service users indicated broad support for this service arrangement. However, the barriers to uptake they perceived indicated how such gaps might be addressed. For example, service users' attitudes suggested that research into incentive structures for persons with severe mental illness within different ethnic groups could be used to help design services that are more likely to achieve screening and risk reduction targets. Staff attitudes indicated that there may be capacity for psychiatric professionals to support primary health teams in this work as part of the Care Programme Approach.

This research was supported by Medical Research Council trial platform grant G0301032. The authors thank all staff and service users who took part in the research, the CMHT staff who helped with service user recruitment, and the National Health Service mental health trusts and primary care trusts for their agreement to participate. [A complete list of participating trusts is available in an online appendix to this report at ps.psychiatryonline.org.] They also thank Elaine Wong, R.G.N., who coordinated distribution of service user questionnaires, at clinics and by CMHT staff, and who coded survey responses.

The authors report no competing interests.