Introduction

Bipolar disorder is a serious mental illness. Worldwide estimates of the prevalence of bipolar disorder vary but in 2017 an estimated 46 million people in the world had bipolar disorder [1]. It is a leading cause of premature death and although early mortality in bipolar disorder is often associated with suicide, it is also due to an increased prevalence of serious physical health co-morbidities such as metabolic and cardiovascular diseases [2]. People with serious mental illness, to include bipolar disorder, die, on average, 25 years earlier than the general population and 60% of this early mortality is attributed to medical conditions [3].

Despite evidence of higher physical health comorbidities and excessive mortality (Smith et al. 2013) there is also evidence of a dearth of management strategies to address and meet the physical health needs of people with bipolar disorder [4]. Service providers must have knowledge, skills and attitudes required to develop and implement prevention, detection and treatment strategies essential in improving physical health care provision and prognosis [3].

To that end, it is suggested that mental health nurses are well placed to assess and monitor the physical health needs of their service users [5,6], to include bipolar disorder patients but where is the evidence to support this view? To date, no systematic review has been undertaken to evaluate the effectiveness of physical health assessment programmes for mental health nurses and the impact on knowledge, skills and attitude in providing for the physical health needs of patients with bipolar disorder.

Objective: To evaluate the effectiveness of physical health assessment programmes for mental health nurses and the impact on knowledge, skills and attitude in providing for the physical health needs of patients with bipolar disorder.

Research design: A systematic review guided by methodological procedures according to the Cochrane Handbook for Systematic Reviews of Interventions [Ref: Handbook].

Methods

Types of studies

We included Randomised Controlled Trials (RCTs).

Types of participants

Participants were mental health nurses caring for people with a clinical diagnosis of bipolar disorder. There was no restriction on gender, ethnicity or care setting. Participating nurses could be registered mental health nurses only or may have a dual qualification i.e., have trained and registered as a mental health and general nurse. Please note that in the context of this review, reflecting international literature, the terms, patient, service user, client, consumer or survivor may be used interchangeably.

Types of interventions

We included all physical health assessment programmes/ physical health assessment tools devised for or adapted for mental health nurses so that they could provide for the physical health needs of their patients with bipolar disorder. We included primary and secondary physical health assessment programmes. For the purpose of this review, we defined primary physical health assessment as the prevention of physical health co-morbidities in people with bipolar disorder and secondary prevention as the treatment of established physical health co-morbidities in people with bipolar disorder.

Comparator interventions

We planned to include the following comparators:

1. Treatment as usual also known as usual care;

2. No intervention.

Types of outcome measures

Outcomes measured in this review were aimed at the level of the mental health nurse:

Primary outcomes

1. Change in Knowledge pertaining to the physical health needs of people with bipolar disorder

2. Change in physical health monitoring skills. The physical health assessment domains outlined here were guided by the 2020 National Institute for Health and Care Excellence (NICE) [7] physical health monitoring guidelines for bipolar disorder and include the following:

• Weight or body mass index (BMI), diet, nutrition status and level of activity

• Cardiovascular status, including pulse and blood pressure

• Metabolic status inclusive of fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile

• Liver function

• Renal and thyroid function, and calcium levels for people taking long term lithium

3. Changes in attitude in terms of understanding the need to know and meet the physical health needs of people with bipolar disorder.

Secondary outcomes

1. Integration of physical health assessment / physical health tools into clinical practice and care planning.

Search methods for identification of studies

Search methods

We searched the below electronic databases on the date shown (6 dates: 06/11/20-10/12/20): Embase; Cochrane database; PubMed; Proquest; Scopus; Cinahl; Ovid MEDLINE; DART; Lenus. We did not place any restrictions on date published, language, or publication status. No start dates were defined, allowing the search to cover all years up to Nov/Dec 2020. Grey literature identified through these sources included theses identified through the DART-Europe E-theses portal and Lenus (Irish thesis portal). These grey sources were downloaded for screening as usual. The reference lists of identified papers and systematic reviews were examined, to identify further screening options. All identified papers were downloaded (either from the database or Google Scholar as needed) and titles were uploaded to Covidence. Details of the search undertaken for this review are presented in Table 1.

Data collection and analysis

Selection of studies

Two review authors, Fionnuala Jordan (FJ) and Siobhan Smyth (SS), independently screened all titles and abstracts identified through the literature searches to identify those that met the inclusion criteria. Full texts of studies identified as potentially relevant by at least one review author were retrieved. Two other review authors (FJ) and Brendan Power (BP) independently screened the full‐text studies for inclusion or exclusion. Disagreements were resolved by discussion, or, when necessary, we consulted a third review author (SS). Studies excluded at the full‐text stage were listed as excluded studies. Reasons for exclusion are presented in the ‘Characteristics of excluded studies’ table. The screening and selection processes are presented in the adapted PRISMA flowchart [8].

Data extraction and management

The review team designed a data extraction form, and had we included studies, we had planned that two members of the review team (FJ and SS), working independently, would extract data from eligible studies. Any disagreements would have been resolved by discussion, or, if necessary, a third review author (BP) was consulted. We had planned for one review author (FJ) to enter extracted data into Review Manager Software 5.4 [9], and for a second review author (SS) to check for accuracy and consistency against the data extraction sheets.

Assessment of risk of bias in included studies

Had we included studies we planned to assess risk of bias of the included studies using Cochrane’s tool for assessing risk of bias, as detailed in the Cochrane Handbook for Systematic Reviews of Interventions [10] and contained in RevMan 5.4 [9].

Two review authors (SS and FJ) planned to assess risk of bias independently for each study. We planned to resolve any disagreements through consultation with a third review author (BP). For all included study designs, the review team had planned to base our assessment of risk of bias on the following seven domains [10].

• Random sequence generation

• Allocation concealment

• Blinding of participants and personnel

• Blinding of outcome assessment

• Incomplete outcome data

• Selective outcome reporting

• Other bias

The review team had planned to judge each potential source of bias as having low, high or unclear risk, and to provide a supporting quotation from the study report together with a justification for our judgement in the ‘Risk of bias’ table. We planned to summarise risk of bias judgements across different studies for each of the domains listed. If information on risk of bias related to unpublished data or correspondence with a study author, we would have noted this in the ‘Risk of bias’ table. We planned to judge each additional source of bias as having high, low, or unclear risk, and to provide a supporting quotation from the study report together with a justification for our judgement in the ‘Risk of bias’ table.

Measures of treatment effect

Dichotomous data

We planned to express results for dichotomous outcome measures using risk ratios (RRs) and associated 95% confidence intervals (CIs) in reflecting the uncertainty of the point estimate of effects [10].

Continuous data

For continuous outcome measures, we had planned to calculate mean differences (MDs) and standard deviations (SDs) with corresponding 95% CIs. We planned to use standardised mean differences (SMDs) with 95% CIs to combine outcomes from trials that measure the same outcome using different scales [10].

Dealing with missing data

For studies with missing data, we planned to contact the corresponding study authors to try to obtain additional information. We planned to record missing and unclear data for each included study. We also aimed to perform all analyses using an intention‐ to‐treat approach, that is, we planned to analyse all participants and their outcomes within the groups to which they were allocated, regardless of whether they received the intervention or not [10].

Assessment of heterogeneity

We planned to evaluate heterogeneity by visually inspecting point effect estimates and confidence intervals in forest plots, and by using Tau², the Chi² test, and the I² statistic as outlined in the Cochrane Handbook for Systematic Reviews of Interventions [11]. We planned to interpret the I² statistic as follows: 0% to 40% might not be important; 30% to 60% may represent moderate heterogeneity; 50% to 90% may represent substantial heterogeneity; 75% to 100% represents considerable heterogeneity [10].

Assessment of reporting biases

Had we 10 or more studies included in the review, we had planned to produce a funnel plot to investigate publication bias through visual inspection of asymmetry [10]. If asymmetry was evident, we planned to perform a statistical test for funnel plot asymmetry as proposed by Egger and Rücker [12].

Data synthesis

We planned to use RevMan 5.4 to conduct statistical analysis [9]. When reasonable to assume that studies were homogeneous, that is, examining the same intervention in similar populations using the same methods, we planned to use a fixed‐effect metaanalysis to combine data. If there was clinical heterogeneity (due to variations in participants, interventions, comparators or outcomes), we planned to use random effects meta-analysis to produce an overall summary if it were reasonable to assume that an average treatment effect across the included studies was clinically meaningful. If we did not perform a meta-analysis, alternatively we planned to present a narrative synthesis.

Subgroup analysis and investigation of heterogeneity

Had we included studies, planned subgroup analysis was as follows: Mental health nurses with no general nurse training versus nurses with a dual qualification. i.e., nurses with both a mental health nurse and a concurrent general nurse qualification.

Sensitivity analysis

Had we included studies, we planned to repeat the analyses to include only high quality studies. For the purpose of this review, we would have classified studies judged as ‘low risk of bias’ for sequence generation and allocation concealment as high quality studies.

Results

Description of studies

Results of the search

After the removal of duplicates (n=4), we assessed the titles and abstracts of 96 studies. We excluded 92 studies at the title and abstract stage. We reviewed the full text of four studies. None of the full text studies assessed met the inclusion criteria. All of the full text studies were excluded for the same reason i.e., the outcomes measured were patient outcomes only. See Figure 1, PRISMA flowchart and the ‘Characteristics of excluded studies’ table in Table 2 [13-16].

As none of the studies screened met the inclusion criteria for the review it was not necessary to undertake a risk of bias assessment nor was it possible to evaluate the effectiveness of physical health assessment programmes/ physical health assessment tools for mental health nurses in enabling them to provide for the primary and secondary physical health needs of people with bipolar disorder.

Discussion

This review sought to review the evidence to support the effectiveness of physical health assessment training programmes/ physical health assessment tools for mental health nurses enabling them to provide for the physical health needs of people with bipolar disorder. We were interested in knowing how physical health assessment training programmes impacted on knowledge, skills and attitudes of the mental health nurse participants. Disappointingly, we did not find any studies that met the inclusion criteria of the review.

Authors’ conclusions

Implications for practice

The research literature suggests that lower levels of physical health associated with mental illness are due to inadequate quality of care [6]. Mental health nurses are well placed to play a key part in the prevention and treatment of physical health co-morbidities and consequently improving the standards of physical health care provision for their patients. Yet, we found no evidence to inform the effectiveness of physical health assessment training programmes for mental health nurses in terms of the impact it has on their knowledge, skills and attitudes.

Implications for research

There is a need to design and evaluate physical health assessment training programmes for mental health nurses and to evaluate the effectiveness of those programmes employing RCT methodology. There is a need to measure the impact of physical health training programmes at the level of nurse participants.

Acknowledgement

The authors thanks the Research Committee at the School of Nursing and Midwifery, National Univeristy of Ireland, Galway for the financial support to undertake this research.

Conflict of Interest

The authors declare that there is no conflict of interest.

References

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