Nutritional screening has been identified as an essential component of patient care (Scottish Executive 2003⁽¹⁾, BAPEN 2010⁽Reference BAPEN²⁾) Individuals with mental health illnesses have significantly higher rates of chronic diseases such as diabetes and coronary heart disease than the general population (Davidson et al. 2001⁽Reference Davidson, Judd, Jolley, Hocking, Thompson and Hyland³⁾, Prince et al. 2007⁽Reference Prince, Vikram, Maj, Maselko, Philips and Rahman⁴⁾, Isenring 2008⁽Reference Isenring⁵⁾), in addition to a higher prevalence of smoking, physical inactivity, overweight and obesity and high levels of alcohol and salt intake (Sharpe & Hills 1998⁽Reference Sharpe, Jenny-Kay and Andrew⁶⁾, Elmslie et al. 2000⁽Reference Elmslie, Silverstone, Mann, Williams and Romans⁷⁾, Davidson et al. 2001⁽Reference Davidson, Judd, Jolley, Hocking, Thompson and Hyland³⁾, Marder et al. 2004⁽Reference EMarder, Essock and Miller⁸⁾). Adverse health related risk factors for mental health patients include obesity, antipsychotic medication, smoking, drugs, alcohol, low social economic status, disordered eating, overall poor physical health, lack of employment and motivation (Thomas B 2007)⁽Reference EThomas⁹⁾. Nutritional screening has been promoted to help decrease rates of malnutrition. The Quality Improvement Scotland Standards for Food, Fluid and Nutritional Care in Hospitals (2003⁽¹⁾) state that all patients must be nutritional screened using a validated tool upon admission and on an ongoing basis. More recently ‘Realising Potential’ The Action Plan for Allied Health Professional's working in Mental Health (SG 2010)⁽¹⁰⁾ reiterates the importance of nutritional screening.

Nutritional screening is a key requirement of the QIS Food, Fluid and Nutritional Care Standards and in preparation for the 2009 review consideration was given to the use of the nationally recognised, validated screening tool, MUST (BAPEN 2003)⁽Reference EBAPEN¹¹⁾. Following a robust review of MUST, an exploratory project was undertaken in a High Secure Psychiatric Hospital in Scotland to audit the results of MUST used along side a local developed nutritional screening tool (State Hospital, Overweight, Underweight, Learning Disability (SHOULD) NST) which includes potential risk factors relating to malnutrition likely in long stay mental health patients.

Twenty four patients were nutritionally screened using both tools by one of the authors. The results were analysed and showed that MUST only identified two patients at nutritional risk in comparison to the local tool which identified 13 patients as being at nutritional risk. The 13 patients identified by SHOULD, included the 2 underweight patients identified by MUST and identified a further 11 who had a variety of nutritional risks including; Disordered Eating, Obesity (inc inappropriate nourishment) Physical health conditions requiring a therapeutic diet, Physical illness, disease or treatment, Dysphasia and/or were prescribed high doses of know weight inducing Antipsychotics.

Following this exploratory audit and careful consideration of the results, the hospital decided to undertake the validation of ‘SHOULD’ as a more appropriate tool for undertaking nutritional screening of long stay mental health patients. An extensive validation exercise has been undertaken and will be published in due course. ‘SHOULD’ is currently implemented across the hospital where the author's practice and an internal audit undertaken one year after implementation confirmed that it is indentifying patients at nutritional risk.