Case managers’ attitudes to the physical health of their patients

Brendan Hyland, Fiona Judd, Sandra Davidson, Damien Jolley, Barbara Hocking

Objective:

To examine the attitudes and practices of case managers working in AreaMental Health Services (AMHS) towards the physical health of people with chronic mentalillness.

Method:

Case managers at four AMHS in Melbourne participated in focus groups andcompleted a survey questionnaire.

Results:

Case managers generally believed that mental illness, psychotropic medicationand lifestyle factors contributed to the poor physical health status of their patients. Althoughmany case managers attempted interventions aimed at improving physical health, there wasinconsistency regarding the areas targeted. Preventive health measures were oftenneglected. Overall, there was a sense of pessimism around whether improved physical healthwas possible for people with chronic mental illness.

Conclusions:

Lack of coordination among health professionals and the health system maycontribute to the poor general health of people with mental illness. Patients often havedifficulty accessing general practitioners and the culture within the AMHS can excludeconsiderations of physical health. Case management should include aspects addressing thephysical health issues of AMHS clients.

Key words:

and attitude, case manager, chronic mental illness, physical health,

Australian and New Zealand Journal of Psychiatry 2003; 37:710–714

prevention.

Psychiatry and general practice have both been criti-cized for failing to adequately manage physical comorbid-ity among mentally ill patients [1–3]. General pratitioners

have been accused of failing to diagnose and treat phys-ical health problems among the mentally ill [2], andpsychiatrists have been accused of failing to assumeresponsibility for the holistic care of their patients [3,4].It can be argued that the lack of integrated medicaltreatment may be a factor in the increased morbidity andmortality observed among people with chronic mentalillness [5–9].

Historically, the institutionalization of people withchronic and severe mental illness meant that the facil-ity’s medical and nursing staff had an unchallengedresponsibility for both the physical and psychiatrichealth of their patients. In contrast, community-basedcare (in Australia at least) has been characterized by afragmentation of service delivery. Patients are requiredto attend different practitioners, usually based at differ-ent sites, to meet their various health needs. This oftenrequires a degree of organization beyond the capacity of

Brendan Hyland, Psychiatrist (Correspondence)

Centre for Rural Mental Health, Bendigo Health Care Group, Bendigo,Victoria, Australia. Email: b.hyland@bigpond.com.au

Fiona Judd, Professor

Centre for Rural Mental Health, School of Psychiatry, Psychology andPsychological Medicine, Monash University, Melbourne, Australia

Sandra Davidson, Research Fellow

Department of General Practice, Monash University, Melbourne,Australia

Damien Jolley, Director

Biostatistics and Epidemiology Unit, School of Health Sciences, DeakinUniversity, Melbourne, Australia

Barbara Hocking, Executive Director

SANE Australia

Received 18 June 2002; revised 27 November 2002; accepted 3 August2003.

B. HYLAND, F. JUDD, S. DAVIDSON, J. JOLLEY, B. HOCKING 711

many people with chronic mental illness, leading to anoutcome whereby patients fail to ‘access preventativehealth services, and may not identify illness (or) seekappropriate treatment’ [10].

Poor detection of physical health problems amongpsychiatric patients is well documented. A recent Vic-torian study found that the prevalence of known riskfactors for cardiovascular disease, HIV and hepatitis Cwas up to five times higher among clients of AreaMental Health Services (AMHS) than for the generalcommunity [11,12]. Overseas studies report that between26% and 93% of psychiatric patients had comorbidmedical illnesses that were either not diagnosed orinadequately treated [13]. One study found that detec-tion rates of physical illness among mentally ill patientswas less than 50% [14].

This study aims to examine the attitudes and self-reported practices of case managers working at commu-nity mental health clinics regarding the physical healthof their clients. It attempts to determine the systemicbarriers facing mentally ill patients in receiving optimalcare for physical conditions. It is also a subset of a largerproject examining the physical health status of peoplewith chronic mental illness [11,12,15].

Method

The research was conducted at four AMHSs in the North-westernHealth Care Network Mental Health Program in Melbourne, Australia.At the time of the study, approximately 1782 clients with chronicmental illness were receiving long-term case management across thefour services. The majority of case-managed clients had a primarydiagnosis of psychotic disorder, with a smaller proportion of mood andpersonality disorders. The target population for the current study werethe case-managers of these clients. The four continuing care teamsemployed a total of 111 case managers. All case managers were invitedto participate in the study.

A 20 item questionnaire survey was developed by the first (BH) andthird (SD) authors to assess the attitudes and practices of case man-agers regarding the physical health of their clients. Five itemsrequested demographic information and five items asked respondentsabout their attitudes regarding the physical health of their clients. Thefinal 10 items asked respondents how often case managers enquiredabout clients’ health issues such as smoking, diet, blood pressureassessments, mammography and attendance at a GP. The questionnairewas administered to the case managers immediately before theyparticipated in a focus group. Descriptive analyses and cross-tabulations were performed on the survey data.

A focus group was conducted at each of the four clinics. The focusgroup schedule (Table 1) was derived from a literature review andclinical experiences of the research team. The sessions, lasting approx-imately 60 min, were audiotaped and transcribed. The transcripts werecompared with hand-written notes taken through the session toenhance meaningful interpretation.

Results

Sample

Thirty-two case managers participated in the focus groups and 29returned questionnaires. Two participants completed only the first partof the questionnaire. Therefore, results for the final 10 items are basedon a sample of 27. The majority (72%) of case managers were female.The professional background of participants was nursing (41%), socialwork (24%), occupational therapy (14%), psychology (10%) andmedicine (10%).

Questionnaire

The attitudes and behaviours of case managers toward the physicalhealth of their patients varied considerably. While 38% agreed that‘living with a mental illness is generally such a struggle that physicalhealth is of lesser importance’, 60% disagreed with this statement. Overa third of case managers believed that physical health issues weresecondary to mental health issues, however, at the same time almost all(90%) believed that they had a responsibility to optimize the physicalhealth of their clients. Not only did they believe that this was theirresponsibility, but 86% also agreed or strongly agreed that casemanagers can make a significant difference in promoting clientbehaviours that will improve physical health. Case managers witha nursing background were more likely than case managers with apsychology background to believe that they had both a responsibilityfor the physical health of their clients and that they could make adifference.

Table 2 shows that case managers did not systematically review abroad range of health behaviours with their clients. While alcohol use,GP attendance, smoking and illicit drug use were commonly reviewed,preventive behaviours such as mammograms, Pap smears and bloodpressure checks received far less attention.

Focus groups

Transcripts from the focus groups were entered into the NUDISTsoftware package. Analysis of the qualitative data resulted in the iden-tification of eight themes (see Table 3).

Physical health

Case managers believed that the physical health of people withmental illness was worse than the general population. Poor healthstatus was attributed to a combination of medication side-effects, life-style choices, poverty and difficulty in accessing optimal healthcare – all factors intricately tied to the symptoms of mental illnessitself. An increase in psychiatric symptoms was linked to a decreasein positive health behaviours and

vice versa

. For example, onerespondent said: ‘A lot of clients will smoke and drink alcohol and usedrugs depending on their mental state at the time’; while anotherobserved that: ‘When their mental health improves they become moreinterested in their physical health and they become more motivated tolook after themselves’.

712 CASE MANAGERS’ ATTITUDES TO PHYSICAL HEALTH

Obesity

Obesity was identified as a significant issue and case managersexpressed concern about the negative impact of weight gain on self-esteem and body image. There was a sense of fatality in that manyconsidered weight gain to be an inevitable outcome related to the inter-action between psychotropic medication, symptoms of schizophreniaand lifestyle. Medication was frequently identified as a causal factor inweight gain. One respondent reported: ‘When you weigh the client afterthey have been put on a different injection, you notice significantweight rises, usually with quite a number of people and that’s five

kilograms I’m talking about over a four month period’. Severalrespondents spoke about the powerlessness associated with severeweight gain: ‘Even the ones who do try and keep their weight downwith activity often fail and I think that it does appear to have somethingto do with the medication. It’s not just lack of motivation all the timeand I think that that’s very demoralizing for a lot of patients, just to feelthey can’t control it.’ Case managers reported that patients also believesignificant weight gain is caused by medication and that

‘a lot of(patients) complain about it’

.

Smoking

Case managers were aware of high rates of smoking among theirpatients and were concerned about the physical and financial costs.Smoking was identified as a key factor in the poverty of psychiatricpatients and as a contributor to poor nutrition. As one respondent noted:‘Most of their income . . . goes on cigarettes and drugs . . . they putfood last on the list, which means that they end up buying a hamburgeror a sausage roll or something like that’.

Initially, case managers appeared to be proactive regarding smokingcessation and there were reports that some patients had successfullyquit with GP assistance. However, further discussion revealed that casemanagers believed that smoking cessation was difficult to achieve inthis group and many comments indicated that they believed thatsmoking might actually be more acceptable in this population than inother groups. There appeared to be a widely held belief that smoking

Table 1. Focus group schedule, derived from a literature review and clinical experience

What do you think of the physical health of your clients?

Who has primary responsibility for monitoring the physical health of your clients?

What do you think your role is in the physical health of your clients?

What are the barriers to good health for people living with chronic mental illness?

What strategies would improve the physical health of people with chronic mental illness?

Table 2. Behaviours case managers enquire about patients

†

Do you enquire about? With all or most patients(%)

With some or few patients(%)

With very few or no patients(%)

Smoking 74 15 11Diet 56 33 11Exercise 59 41 0Safe sex 26 56 19Illicit drug use 73 19 8Mammography

‡

19 48 33Pap smears

‡

30 41 30Blood pressure 11 44 44Alcohol 78 22 0GP attendance 78 19 4

†

Total may exceed 100% due to rounding;

‡

enquired about with female clients only.

Table 3. Primary themes indentified from focus groups

Physical healthLifestyleSmokingCase managementObesityPrimary careMedicationHealth improvement

B. HYLAND, F. JUDD, S. DAVIDSON, J. JOLLEY, B. HOCKING 713

was one of the few pleasures in the lives of their patients. For exampleone respondent said: ‘They don’t have much money and I guess that ifthey are smoking it’s one of the few pleasures that they have’. Anotherstated that psychiatric patients are ‘different from the general popula-tion. They’re bored (and) they don’t have a lot of activities. Most oftheir friends smoke, you go to the drop-in club (and) clients willsmoke.’

There was also a clearly held perception that smoking could allevi-ate some of the distress associated with mental illness. One casemanager said: ‘Relief from sedation seems to be something that(patients) rely both on cigarettes and coffee for’. Smoking was alsobelieved to reduce anxiety: ‘I’ve seen research that shows that peoplesmoke to decrease the side-effects of medication. Smoking decreasestheir anxiety and alleviates boredom’. Another case manager reportedobserving this phenomena: ‘I’ve noticed that some of my clients whoare far more disturbed will report that they vary their smoking.

So thereseems to be an anxiety management aspect to it as well.’

Concern was expressed that cigarettes were used for behaviouralmodification in the inpatient setting: ‘For example, on-the-wardnursing staff give out cigarettes to calm patients down and to rewardthem for good behaviour’. One respondent was adamant that casemanagers ‘should stop the collusion mental health services have inencouraging patients to smoke’. However, there was disagreement onthis issue as other respondents believed that ‘when they are inhospital . . . clients are usually psychotic so it’s not really a good ideato enter into an education program about the ills of smoking . . . that’sthe last thing they’re interested in really, so it’s probably more that it’snot an appropriate time.’

Case management

Case managers believed that their core business was to assess andtreat mental illness. Related issues such as finance, accommodation,family relationships and physical health were seen to be of secondaryimportance. The majority of case managers did not routinely look atissues related to physical health. The attitude was summed up by onerespondent who said: ‘If something came to your attention becausesomebody was complaining about weight gain or looking really big orlooking really unwell you can inquire about it but I wouldn’t do it as aroutine’. However, there were some notable exceptions to this attitude.For example one respondent reported that they ‘routinely ask people, orwomen, if they had breast examinations, mammograms, Pap smears,chest X-rays, all kinds of tests’. Consistent with the questionnairefindings, different attitudes were observed between nurses and psy-chologists in relation to physical health issues. A nurse commented:‘I think most of us can possibly see some of the more common symp-toms as an alert, like going to the toilet or something, you know, for anurse that would mean UTI’. A case manager with a psychology back-ground replied: ‘For a psychologist it [going to the toilet] would meananxiety’.

The influence of professional training did not appear to be limited tocase managers. There were also reports of inconsistency in how fre-quently medical staff look at issues of physical health. Focus groupparticipants reported that GP trainees and medical officers were morevigilant in addressing issues of physical health than psychiatry traineesand psychiatrists.

Barriers to optimal physical health

A clear theme to emerge from discussion on the barriers to goodphysical health was the lack of service delivery integration. Althoughrespondents considered physical health issues to be a shared responsi-bility between patient, case manager, GP and psychiatrist; none of thefour study sites had a systematic process to ensure that the perceptionof shared responsibility coexisted with the reality of shared action.None of the sites had a systemic process to monitor and review physicalhealth and individual staff members leading this process could not beidentified.

In contrast to the perception of shared responsibility were reportsby focus group members that patients were encouraged to have theirphysical health problems addressed by external GPs. Medical staffwould occasionally perform physical examinations if the patient hadobvious physical problems and could not, or would not, consult a GP.However, generally few medical staff in the AMHS performed phys-ical examinations. The lack of physical examinations was attributedto resources, both facilities and time: ‘(Doctors) look at them but theycan’t follow through . . . because they don’t have the facilities and Ithink it’s time too. I mean they haven’t got time to do more extensivemedical assessment and treatments.’ At the clinics where the studytook place, medication for physical health problems was not gener-ally paid for by the service. Case managers perceived this practice asa sign that the community mental health clinics did not see physicalhealth as a core responsibility. The lack of clinical autonomy toaddress physical health issues seems to engender a sense of futility.As one respondent said: ‘If you identify something, well we can’tprescribe physical medication anyway because we can’t pay forthem’.

Lack of integration within the AMHS foreshadowed a similar issuefor the wider health care sector. Weak relationships between theAMHS and other medical personnel such as GPs and the hospitalsystem was seen as a barrier to patients accessing holistic care. Tosome degree this is also exacerbated by patient preference. At someclinics there was regular communication between case managers andtheir patients’ GPs, usually in the form of written information oncurrent management issues and treatment. However, case managersreported that in order to maintain their privacy some patients refusepermission for staff to communicate with the GP.

Another perceived barrier was the attitude of clients themselvesand a tendency to ignore their own physical health. This was attrib-uted to self-esteem issues including a sense of hopelessness, a lack ofautonomy and the compounding factor of ‘doctor fatigue’, that is,clients’ frequent contact with the medical profession in the mentalhealth system. It was also noted that people with chronic mentalillness often lack the ability to negotiate the health system. Onerespondent said: ‘One of the skills that you need to be able to goalong to a GP and say, “Hey this is what is wrong with me” and Idon’t think that the client has got those assertiveness skills’. It wasalso reported that people with chronic mental illness ‘tend not to beable to wait in line like other people. There’s restlessness and a lot offrustration and intolerance that prevents them from being able tohang around too long.

There is a big expectation that people do that[wait around] nowadays in hospitals.’

Participants also expressedconcerns about the ability of GPs to understand the special needs ofpeople with mental illness.

714 CASE MANAGERS’ ATTITUDES TO PHYSICAL HEALTH

Discussion

This study examines some of the systemic and cul-tural factors that may contribute to the poor physicalhealth status of people with chronic mental illness.While the exact causes behind high morbidity andmortality rates among this population are complex andmultifactorial, it appears that the pervading attitudesand processes within the mental health system do littleto improve the problem.

Although both case managers and government policyon mental health services [10] acknowledge that thephysical health of psychiatric patients is within the realmof case management, there does not appear to be anyprocess to incorporate it into practice. Assessment andmanagement of physical conditions seems to be pro-vided in an

ad hoc

manner based on the discretion of thecase manager and medical staff. The lack of systematicprocesses is likely to contribute to the inconsistencyregarding which areas case managers inquired into.Although it was encouraging to find that the majority ofcase managers asked about common risk factors such assmoking, alcohol intake and diet, it was of concern thatrelatively few regularly inquired about safe sexual prac-tice, exercise, mammography and Pap smears.

Less than three-quarters of case managers inquired asto whether their patients attended a GP. Given that keyprinciples of case management is to link patients withappropriate services, one would expect case managers tobe more proactive in encouraging integration of primaryhealth care. Consumer consultants have pointed out thatliaison between case managers and GPs may underminepatients’ autonomy in managing their health. Consulta-tion between health professionals and consumer groupswould be useful to explore solutions.

Patients who wish to consult a GP often report diffi-culty finding one. Many GPs have difficulty assessingand treating people with mental illness [2]. At the sametime, those doctors trained to treat people with chronicmental illness seem disinclined to treat physical condi-tions [1]. Few medical staff in community mental healthclinics performed physical examinations. Case managersperceived discouragement to address physical health asmost clinics do not pay for medication to treat of physi-cal health problems. However, the attitudes and practicesof medical staff and case managers may differ.

Although the sample was small, we suggest that thelack of systematic processes in AMHS regarding physi-cal health may contribute to the high prevalence of riskfactors for poor physical health among people withchronic mental illness. We therefore propose that: (i)case managers receive additional training on physicalhealth problems of people with chronic mental illness;

(ii) that mental health services ensure clients have a GPand attend to ongoing and preventative primary care;(iii) as part of the initial assessment and individualservice plan, there is a detailed section for physicalhealth risk factors such as smoking, illicit drug use,alcohol abuse, obesity, etc.; (iv) medical staff in AMHSinclude physical assessment as part of routine manage-ment conducted either by themselves or by a GP; (v) theRoyal Australian and New Zealand College of Psy-chiatrists consider producing a statement on practiceregarding attending to the physical health of people withchronic mental illness; and (vi) patients at high-risk forcardiovascular and respiratory disease are systematicallyreferred to appropriate health professionals.

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