EBN Perspectives, Mental Health.

EBN Perspectives brings together key issues from the commentaries in one of our nursing topic themes. © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

This article forms part of an Evidence-Based Nursing (EBN) ‘Perspectives’ series in which commentaries related to a particular theme are summarised and discussed. In this article, commentaries on the topic of ‘mental health’ have been collated, drawn from EBN archives between 2017 and 2019. The evidence is arranged into key themes and the implications for practice and research are explored.

Key themes

Eighteen commentaries (see box 1) and three themes were identified:

The interface between mental and physical health needs.

Patient experience.

Innovations in treatment and management of mental health problems.

Study of electronic records from a South London psychiatric trust suggests that the increased mortality from physical illness linked to depression varies between ethnic groups (https://ebn.bmj.com/content/22/4/111.info).

Intimate partner violence, post-traumatic disorders and menopausal symptoms (https://ebn.bmj.com/content/22/3/90).

Evidence that active pain treatment improves sleep quality and quantity in people with depression and dementia (https://ebn.bmj.com/content/22/2/49).

Higher rates of depression among women living with coronary heart disease are associated with poorer treatment outcomes and prognosis (https://ebn.bmj.com/content/22/2/47).

Expanding midwifery’s role to improve perinatal mental healthcare access (https://ebn.bmj.com/content/22/3/72).

Young people with an intellectual disability experience poorer physical and mental health during the transition to adulthood (https://ebn.bmj.com/content/21/1/20).

Adults with intellectual disabilities experience shame that leads to psychological distress and mental illness that requires assessment and treatment (https://ebn.bmj.com/content/21/3/86).

Impact of stigma on the care of postpartum women with severe mental illness (https://ebn.bmj.com/content/22/3/81).

Stigma is a prominent barrier for parental disclosure of a child with a mental illness (https://ebn.bmj.com/content/21/1/17).

People who face the bereavement of a partner with dementia have poorer mental health than those whose partners are dying from other diseases (https://ebn.bmj.com/content/21/1/29).

Antidepressant discontinuation can be problematic for patients but relapse rates might be reduced with cognitive behavioural therapy or mindfulness-based cognitive therapy (https://ebn.bmj.com/content/22/4/112).

Risk of suicidal thinking in caregivers of people with dementia should be assessed and monitored by health professionals (https://ebn.bmj.com/content/21/3/73).

Self-management programme for people with dementia and their spouses demonstrates some benefits, but the model has limitations (https://ebn.bmj.com/content/20/1/26).

Telephone-based collaborative care is an effective approach for treating anxiety in primary care patients (https://ebn.bmj.com/content/21/1/28).

Anger treatment has a therapeutic effect on cardiac function and productive living (https://ebn.bmj.com/content/22/4/113).

Nurse-led cognitive behavioural group treatment intervention for insomnia successfully reduces daytime symptomatology (https://ebn.bmj.com/content/22/3/79).

When compared with comparator treatment, specialist interventions for anorexia nervosa are more effective in reducing weight-based symptoms, but not psychological symptoms (https://ebn.bmj.com/content/22/2/55).

The usage of coercive measures13 in psychiatric units and their potential counter-therapeutic impact on outcome (https://ebn.bmj.com/content/early/2019/07/11/ebnurs-2019-103125).

Implications for practice and future research

This collection of commentaries encompassed a range of issues pertinent to contemporary mental health nursing. Several studies addressed the complex interplay between physical and mental health conditions listed in theme 1. For example, the importance of considering mental health needs in perinatal care was highlighted in a systematic review by Viveiros (2019).1 One commentary by McKenzie2 described a study by Das-Munchi et al (2018) who examined electronic health records in a South London mental health trust, and identified significant differences in mortality for people with a diagnosis of depression from different ethnic groups. The study identified higher rates not only of suicide, but also of a range of physical health conditions, including diabetes and respiratory diseases. However, the findings need to be interpreted with care as these causal links are complex. Future research needs to focus on community-based studies to better understand the ethnic differences in mortality for people with depression.

Links between mental health and physical conditions were also addressed by Buckland (2018),3 who carried out a systematic literature review to explore depressive symptoms and coronary heart disease (CHD). Of the 20 papers reviewed, depression rates were found to be higher among women following the initial cardiac event, and although symptoms reduced over time, they remained higher than women without CHD. However, there were no papers that followed women up beyond 6 months, and there was a lack of consistency in patient-reported outcomes measures, which made comparisons difficult.

Women’s experience of menopausal symptoms (both physical and psychological) is impacted by a range of factors, one of which is their pre-existing mental health. Gibson (2019)4 undertook a cross-sectional survey of 2016 women aged 40–80 years about the impact of emotional and physical intimate partner violence (IPV). They found that women who had suffered IPV developed clinically significant post-traumatic stress disorder symptoms and experienced a greater intensity of menopausal symptoms, such as difficulty sleeping and vasomotor and vaginal symptoms. This paper forms part of the growing literature on the impact of trauma on well-being over time.

The connection between pain and mental well-being is well-established. A study by Blytt et al (2018)5 demonstrated a significant link between effective pain management and sleep quality and quantity for people with dementia. However, the findings may be constrained by the fact that participants on more than 1 g paracetamol a day were randomised to buprenorphine (a strong opioid), and there is a potential that the opioid itself contributed to better sleep rather than the fact that their pain was better controlled.

Common to these studies is the need for practitioners to recognise the link between psychosocial factors and the trajectories of other illnesses, recognising the links between pre-existing mental health conditions and the risk of developing chronic diseases, as well as understanding the mental health impact of living with poor physical health.

Theme 2 focuses on patients’ and carers’ experiences of mental health conditions and services. Two commentaries focused on people with intellectual disabilities (ID) and their experiences of mental health services and support. Transitions between services was the focus of a statistical analysis of census data by Young-Southward et al (2017),6 which compared health outcomes for young people with and without ID. Using data from the 2011 Scottish census, statistical analyses were applied to determine relationships between ID, general health, mental health and other factors. This was an important study in terms of quantifying disparities across a whole country’s population of the transition into adulthood. Higher rates of mental illness in the older group (19–24 years) suggested that greater attention could be given to screening young adults with ID for early signs of mental illness. The study also has implications for coordinating transitions between children and adult services.

Stigma was a key focus within this theme. Four papers explored stigma, three through the eyes of the service user and one from the perspective of nurses. A systematic review by Clapton et al (2017)7 reported that adults with ID experienced shame that contributed to psychological distress and mental health problems. The review demonstrated the importance of a proactive approach to screening for mental health issues, and the need to ensure that services for people with ID take into account the potential impact of stigmatisation, including social exclusion, labelling and subordination by others.

Orden et al’s (2018)8 paper carried out a questionnaire-based study of nurses examining attitudes towards pregnant women with existing severe mental illness (SMI). There was a positive correlation between prejudice towards women with SMI and their ability to provide adequate care for their infant. This led to nursing care being more paternalistic, which was associated with a reduction in interventions to promote parental autonomy and a perception that these women required input from mental health professionals. These findings augment previous research in this area, but also point to the need for future research to explore the subjective experiences of women with SMI as they make use of maternity services.

The issue of disclosure is a challenge for parents of children with mental illness; disclosure must be in the best interests of parents and the child. The experiences of parents of children with mental illness were the focus of a study by Eaton et al (2017),9 in which interviews and focus groups with parents were analysed using Giorgi’s thematic analysis. This study identified a tendency for parents to downplay the severity of illness to try and protect the child’s social status. It is vital for nurses to provide appropriate information and support for parents of children with mental illnesses to enable them to evaluate the relative harms and benefits of partial and full disclosure, as well as to provide support in the event of negative experiences.

The fourth paper to examine issues of stigmatisation was that by Ferlatte et al (2019)10. Although it is known that people who identify as lesbian, gay, bisexual, transgender and queer (LGBTQ+) have poorer mental health than their heterosexual peers, this study adds to existing literature through the qualitative exploration of GBTQ+ men’s day-to-day experiences through developing a captioned photograph series. Themes that emerged from the data were homophobia, accessing support services and of the importance of peer groups.

The final paper in this theme highlighted the link between depression and being a partner of a person with advanced dementia. By linking primary care records, Shah et al (2016)11 analysed the rates of depression and use of psychotropic medication in relation to whether that person had a partner with dementia. The use of palliative care by the person with dementia was also identified. Rates of depression diagnoses of partners were higher in the year before the death of their partners, compared with partners of people with other life-limiting conditions. This study indicated a need for future research to explore the experience of complex grief for partners of people with dementia.

The papers in theme 3 explored current evidence around innovations and intervention for mental health conditions. The issue of discontinuing antidepressants is a concern for many mental health practitioners as it may lead to unacceptable side effects and relapse of depression. A systematic review by Maund et al (2019)12 suggested that cognitive behavioural therapy (CBT) or mindfulness-based cognitive therapy may reduce relapse rates, although the meaningful analysis of the identified literature was hampered by the heterogeneity of studies. Future research needs to adopt more robust outcome measures and comparable, standardised longitudinal studies. Further, this area could be enhanced by additional studies into the best ways to help patients to stay well after they stop antidepressant treatment.

One area of concern within acute mental health services is the use of coercion and restraint. Ebrahimi (2019)4 evaluated the effectiveness of an intervention (REsTrain YOURSELF) on reducing the levels of physical restraint in mental health settings, identifying the potential for such interventions to enhance staff confidence at identifying alternative and less harmful ways of maintaining patient and staff safety. Their study provided important support for adopting a patient-centred approach and challenging coercive13 practices and identified a need for future robust research on a range of outcome measures for acute mental health interventions.

Two papers considered concerns around interventions to support people with dementia and their partners. Joling et al (2018)14 conducted a longitudinal study of caregivers of people with dementia. Findings showed high rates of anxiety and depression. Suicidal thinking was identified in 4.7% of the sample of 192. Although the generalisability of this study may be limited, findings suggest that an important facet of caring for caregivers is thinking ahead and routinely assessing the risk of suicidality in this group of people. The issue of supporting couples facing dementia was also explored by Laakonen et al (2016),15 whose study identified challenges in assessing the effectiveness of group-based self-management for people with dementia and their partners.

Perhaps, surprisingly, there was only one identified paper evaluating the effectiveness of technology-based interventions in mental healthcare. Rollman et al (2017)16 evaluated a telephone-based stepped collaborative care approach for people with a generalised anxiety and/or panic disorder. There is a need for robust feasibility studies to appraise the potential value of such interventions in the real world to ensure uptake and sustainability of services.

Three papers consider the effectiveness of CBT interventions. Chronic stress and anger are known to increase the risk of cardiovascular problems in later life. A randomised controlled trial by McIntyre et al (2019)17demonstrated a link between people in receipt of a CBT 12-week anger management intervention, and cardiovascular health, demonstrating a reduction in overall anger and stress compared with the control (wait list) group. Although this study is small, it lends strength to the holistic health benefits of promoting positive mental well-being for people with chronic mental health problems. The second paper by Sandlund (2018)18 identified a reduction in daytime symptomology for people with insomnia undergoing a nurse-led CBT clinic. Although blinding in this trial was not possible, the work was strengthened through the use of patient-centred quality of life measures rather than solely concentrating on the quantity of sleep.

The third paper to study CBT was a literature review of interventions for anorexia nervosa by Murray et al (2018),19 comparing the effectiveness of CBT, family therapy and pharmacological management. Unfortunately, although results showed that specialist interventions can lead to weight gain, there was no significant improvement in mental well-being when compared with control groups. The paper highlighted the importance of considering indicators beyond weight-based outcomes when adopting a patient-centred approach to the care of people with eating disorders.

This collection of commentaries relating to recent research in the area of mental health provides a summary of evidence that can be used in nursing practice, ensuring the continuing provision of evidence-based, patient-centred mental healthcare practice in a variety of contexts. Across all commentaries in this collection, it is notable that there are multiple challenges in designing robust, ethical research in mental health. The limited applicability of the systematic review conclusions points to the need for robust, patient-centred outcome measures, and there is a need for research into service user experiences and well-designed evaluations of complex interventions to establish causal links. Nonetheless, this collection provides an overview of current directions in mental health research pertaining to nursing practice, education and research.