Objective Cardiovascular disease is the leading cause of premature mortality in people with severe mental illness (SMI). Despite this, there lacks consensus regarding the most appropriate platform to monitor and treat cardiometabolic risk factors in this cohort. The current study aims to evaluate the effectiveness of tailored cardiometabolic healthcare in a private, GP-led clinic for people with SMI. Method A total of 63 adults with SMI were referred to a private GP-led cardiometabolic clinic from a neighbouring inner-city mental health service, where they received individualised cardiometabolic healthcare free-of-charge between 2014 and 2020. Paired t test was used to measure change in cardiometabolic data over the course of treatment. Chi-squared and Fisher's Exact tests were used to examine differences in demographic data and client engagement. Results Over a mean period of 9 months, there was a significant mean reduction of weight (2.1 kg), BMI (0.72 kg/m2) and waist circumference (6 cm). Engagement over a longer period was associated with stable accommodation and improved cardiometabolic outcomes. Conclusions Targeted referral for individualised cardiometabolic interventions can lead to clinically significant improvement in cardiometabolic outcomes, providing a cause for therapeutic optimism when approaching physical health in people with SMI.

Background: Integrating exercise professionals into mental health settings is a key strategy in addressing the physical health inequalities of people living with mental illness. Workforce culture surrounding physical health may impact the utilisation of exercise professionals across inpatient settings. Aims: To evaluate clinician perspectives regarding the implementation of an exercise professional at the mental health service in a large, urban hospital in Sydney, Australia. Methods: A qualitative study using semi-structured interviews with a purposive sample of mental health staff was conducted. Data were analysed using thematic analysis. Results: Fourteen mental health clinicians (approximately 35% of all eligible staff) participated in interviews. Three themes emerged regarding the role of the exercise professional; i) drivers and facilitators; ii) support from leadership; and iii) directions for future practice. Conclusions: An exercise professional within a mental health service was identified as an effective strategy in improving consumer health outcomes while increasing the knowledge and confidence of mental health clinicians regarding the provision of physical health care. Exercise professionals should be recognised as important members of the standard multidisciplinary mental health team for in patients being treated for mental illness.

Mental, neurological and substance use (MNS) conditions contribute significantly to global burden of disease, accounting for 10.4% of total all-cause disability adjusted life years (DALYs), and being the third leading cause worldwide1. The World Health Organization (WHO) has developed the mental health Gap Action Programme (mhGAP) to help close the treatment gap that exists in low- and middle-income countries (LMIC), through task-shifting care for MNS conditions to non-specialist health care ­providers2. The mhGAP Intervention Guide Version 2.0 (mhGAP-IG V2.0) includes evidence-based interventions for depression, psycho­ses, epilepsy, child and adolescent mental and behavioural dis­orders, dementia, substance use disorders, suicide and self-harm, and other disorders2. Training in the first version of mhGAP-IG demonstrated improvements in pre- and post-training knowledge testing, but with the need for ongoing supervision3, 4. Feedback collected by the WHO requested more experiential learning; a focus on building skills; easier access to training materials; shorter training of six days maximum with post-training supervision, and the addition of clinician competencies. This feedback has been incorporated into the updated mhGAP-IG V2.0 training package5, which for the first time includes core competencies. Competency-based education uses outcomes to inform curriculum and assessment, involving the consideration of knowledge, skills and attitudes needed to perform a task6, 7. For mhGAP-IG V2.0, these competencies tell us what non-specialist health care providers should be able to do in their clinical practice after training and supervision. Competency development in health education is often a multi-step process involving literature review, looking for repetitive themes or ideas, and review by key stakeholders, before incorporation into curriculum and assessment7. The evidence-based mhGAP-IG V2.0 identified key aspects of practice, supplemented by recent literature on competency development for non-specialist health care providers treating MNS conditions in LMIC. As a next step, core competencies were broadly identified. These included an attitude of respect and dignity towards those with an MNS condition, knowledge around identifying and managing priority MNS conditions, and accompanying skills to assess and deliver psychosocial (psychoeducation and basic supportive counselling skills) and pharmacological interventions. Additionally, mhGAP-IG V2.0 included the assessment and management of emergency presentations, performing follow-up, assessment and management of physical health, and referral and linkage to specialists and other sectors such as employment, education and social services. Each competency was then broken down to outline the exact tasks it requires, and standardized and mapped to each module of mhGAP-IG V2.0. A common theme in competency development is achieving stakeholder consensus7. Initially, we reviewed the draft competencies with our mhGAP expert team, reaching consensus on these and adding the skill of effective communication. The skills of self-care and reflection were raised, but deferred for coverage in supervision. The competencies were then distributed for broader stakeholder feedback, including thought-leaders, partner organizations, and field experts. Once complete, the competencies fed into curriculum development and instructional methods in the training package. Training to improve knowledge will be through group lectures and persons’ stories of lived experience. Training to develop skills will be through interactive methods, including videos and multiple role-plays across assessment, management and follow-up scenarios. Attitude will be developed through the use of persons’ stories, class discussion, and time for reflection and feed­back. Assessment can be defined as either formative, used to guide and motivate future learning, or summative, providing a potential barrier to practice if competency is not demonstrated8. In LMIC, summative assessment may exclude non-specialist health care providers who, with ongoing supervision, can improve their skills and treat large numbers of patients with MNS condi­tions, who would otherwise remain untreated. For this reason, the mhGAP-IG V2.0 assessment is only formative. Accordingly, instead of grading competency through traditional stages of novice through to expert7, a more pragmatic approach was taken to focus on areas of strength and areas for improvement. For ease and simplicity, all twelve mhGAP-IG V2.0 core competencies can be assessed using the same standardized form. The form outlines the exact tasks needed for each competency, is intuitive to use, suited to multiple settings, and can be kept by the trainee for future reference. Competencies should be assessed by methods that are tailored for their specific purpose, with sound psychometric properties, practicality and acceptability8. The multiple methods across mhGAP-IG V2.0 training enhance competency assessment. For knowledge assessment, multiple-choice questions show high reliability and easy administration8, and familiarity to LMIC. A bank of questions has been developed, utilizing techniques to improve validity. Skills can be assessed by using the multiple role-play scenar­ios available in the training package. These lack the formality and resource-intensiveness of observed structured clinical examinations, which have high reliability and validity in clinical skill assessment8, but share similarities, such as instructions on discrete clinical scenarios, timing, checklists for candidate demonstration, and capacity for multiple role-plays to improve reliability and cover various skills. Role-plays also have the advantage of established acceptability in LMIC training settings3, 4, and can utilize peer assessment to manage limited assessor availability8. Finally, attitudes can be assessed using multi-method and longitudinal formats8, involving role-plays, some multiple-choice questions, and direct observation throughout the training program and supervision. This variety of teaching and assessment methods ensures a truly blended training package that is more interactive and experiential. As competencies are a new addition to the mhGAP-IG training, principles of competency-based education for future trainers and supervisors are taught in the “training of trainers and supervisors” package5. The importance of ongoing supervision has not been overlooked, with inclusion of a participant logbook and multiple supervision options in the training package, to account for all resource settings5. The training package is now freely available online, to begin up-skilling the non-specialist health care workforce in LMIC5. Early feedback confirms usability of these resources. More rigorous field-testing may include improvements and retention seen on pre- and post-testing, and a review of validity and reliability, by correlating test results for participants, or between peer and trainer assessments. Such information will help future development of mhGAP-IG training material. Developing core competencies for the mhGAP-IG V2.0 training package clearly outlines what non-specialist health care providers should be able to do after the training, with ongoing supervision. Core competencies break down the individual steps needed to be able to assess and manage priority MNS conditions, providing a framework for training and assessment. These are supplemented by the WHO’s EQUIP: Ensuring Quality in Psychological Support, an initiative to develop and disseminate resources that support trained non-specialist health care providers to reach a standard of competency to be able to deliver manualized psychological interventions9. We hope that these materials will be valuable tools in the ongoing training of non-specialist health care providers in delivering care for MNS conditions.

Objectives Cardiovascular disease is the leading cause of premature death in patients with mental illness. Metabolic syndrome is a cluster of co-occurring cardiovascular risk factors, seen in high frequency in severe mental illness. Despite ease of diagnosis, monitoring is often poor across psychiatric populations. This report details a quality improvement initiative undertaken on an inpatient psychiatric ward to improve rates of metabolic monitoring. Methods Four key interventions were developed: (1) A nurse-led intervention, where nurses were upskilled in performing metabolic monitoring, (2) Education was provided to all staff, (3) Introduction of a suite of interventions to improve metabolic risk and (4) Ongoing consumer involvement. A pre–post intervention study design was used to measure effectiveness, with an audit of metabolic monitoring rates performed 12 months after the intervention began. Results Rates of weight and height monitoring both increased from 46.0% to 69.5% (p=0.0185) and body mass index (BMI) recordings increased from 33% to 63% (p=0.0031). Rates of waist circumference monitoring increased from 44.2% to 65.2% (p=0.0498). Blood pressure (BP) measurements increased from 88.5% to 100% (p=0.0188). Lipid monitoring rates improved from 23% to 69.5% (p=0.001). Rates of glucose monitoring increased from 74% to 82.5% (p=0.8256), although this was not statistically significant. Conclusions We found that metabolic monitoring improved following these simple interventions, with a statistically significant increase in measurement rates of weight, BP, height, lipids, BMI and waist circumference (p<0.05). Overall monitoring of glucose also improved, although not to significant levels. The intervention was acceptable to both patients and staff.

Major Depressive Disorder (MDD) is a leading cause of the Global Burden of Disease. Cognitive Behavioural Therapy (CBT) is an effective treatment for MDD, but access can be impaired due to numerous barriers. Internet-delivered CBT (iCBT) can be utilised to overcome treatment barriers and is an effective treatment for depression, but has never been compared to bibliotherapy. This Randomised Controlled Trial (RCT) included participants meeting diagnostic criteria for MDD (n = 270) being randomised to either: iCBT (n = 61), a CBT self-help book (bCBT) (n = 77), a meditation self-help book (bMED) (n = 64) or wait-list control (WLC) (n = 68). The primary outcome was the Patient Health Questionnaire 9-item scale (PHQ-9) at 12-weeks (post-treatment). All three active interventions were significantly more effective than WLC in reducing depression at post-treatment, but there were no significant differences between the groups. All three interventions led to large within-group reductions in PHQ-9 scores at post-treatment (g = 0.88–1.69), which were maintained at 3-month follow-up, although there was some evidence of relapse in the bMED group (within-group g [post to follow-up] = 0.09–1.04). Self-help based interventions could be beneficial in treating depression, however vigilance needs to be applied when selecting from the range of materials available. Replication of this study with a larger sample is required.

Biological advances, including a larger than expected heritability (Gunderson et al., 2011), raise questions as to whether the person with borderline personality disorder can reasonably be held responsible for, or realistically change, their behaviour. The theoretical debate over whether we are ‘merely victims of neuronal circumstances’ took centre stage with an elegant series of experiments. Those studies suggested that electrical activity in the brain occurred before the person became aware of their intention to act, to move their fingers, and the question arose as to whether we do have free will. Considerable debate followed (Vincent, 2013). Various writers note the complex, intersecting and overlapping domains of the brain, the body and the environment. That is, the brain, although necessary, was not sufficient to account for all the physiological and psychological properties that make each of us a unique person. They note in particular the difficulty for a neurone-alone system to adequately explain the feeling of being ashamed, of being able to forgive or to receive and accept praise. Nor does an electrical model allow for thoughtless, automatic and habitual actions or, because a person has an urge, or image or idea, they will necessarily act rather than resist the impulse. Investigative techniques will undoubtedly improve and continue to define a biological difference in people with borderline personality disorder. However it is unclear whether this will be sufficient to convince, for example, a court that such findings are responsible for their behaviour. There will be a need to demonstrate in what way any specific difference may have affected the mental capacities to inform intent. Further, in order to excuse responsibility, it must be argued that each person with those findings will behave similarly on each occasion without a capacity to do otherwise. Rather than resisting, biological advances should be welcomed. If neuroscience confirms clinical experience, we are on safer ground, the corollary being that discrepancies should stimulate further enquiry. Secondly, it has been suggested that all forms of therapy are successful to the degree that they have found a way to tap into processes that build and modify neuronal structures within the brain. Thirdly, the likely scenario is that the person with borderline personality disorder can have both neurocognitive differences and be responsible and able to change (Little and Little, 2010).