Managing physical health in mental health populations.

People with serious mental illness (SMI) have greatly increasing morbidity and mortality from physical illness than the general population. This results in a 25 to 30 year shorter life expectancy with cardiovascular disease being the leading cause of death 1 . It has been suggested that current policy, services and health promotion actions are ineffective in targeting physical illness in this population. Vulnerabilities for Physical Health Difficulties Excess mortality seen in the psychiatric population reflects multiple vulnerabilities and risk factors including poverty, unemployment, being single and marginalised have been reported. Lifestyle risks include a poor diet, increasing smoking and substance abuse rates and lower levels of exercise 2 . Although there may be a genetic predisposition to develop metabolic abnormalities in schizophrenia, the impact of negative symptoms of illness such as difficulties in concentration and memory and a lack of motivation is also significant 3 . This is compounded by the finding that people with mental illness have inadequate access to good quality physical healthcare and that they receive poorer treatment for physical disorders (‘diagnostic overshadowing’) than the general population 4 . The potential of antipsychotic medications to cause significant weight gain and other metabolic side effects leaves this population at high risk of physical illness. Targeting Physical Health The chief risk factors for mortality are lipid abnormalities, diabetes, high blood pressure, smoking, physical inactivity, obesity and stress 5 . A recent review found that the top modifiable risk factors for premature mortality could be lowered in patients with schizophrenia 5 . The dilemma for health care services lies in the differing focus between physical and mental health providers, and the finding that those with mental health problems do not attend to their physical health. There are clear benefits to monitoring and managing risk factors for physical illness. It is argued that patients with serious mental illness are less capable than other patients of interpreting physical signs of ill health, suggesting the need for an increased role for either primary or secondary care to monitor the physical health needs of these patients 4 . NICE guidelines acknowledge the risk of increased physical morbidity and mortality in individuals with schizophrenia and recommends routine monitoring of these risks. They advise that health promotion advice be offered on smoking, alcohol, drug use and exercise 3 . The guidelines further state that individuals taking atypical antipsychotic medication should be offered a comprehensive package of care that addresses clinical, emotional and social needs. In bipolar disorder, the British Association for Psychopharmacology has produced guidelines that emphasise the medical need to assume responsibility for physical examinations to advise patients to maintain normal levels of exercise and moderate calorie intake 3 . “The 2009 Schizophrenia PORT Psychosocial Treatment Recommendations and Summary Statements” recommend a three month psychosocial treatment for weight loss management in those who are overweight or obese 6 . This intervention should include psychoeducation focused on nutritional counselling, calorie expenditure and portion control; behavioural self management including motivational enhancement; goal setting; regular weigh-ins; self-monitoring of daily food and activity levels; and dietary and physical activity modifications 1,7 . Furthermore, where psychiatric patients have or are at risk of metabolic syndrome, weight-neutral psychotropic medications are recommended. Clinical Research The guidelines currently advise psychiatrists to routinely evaluate the risk factors associated with metabolic syndrome. The few interventions that exist combine elements of health screening, education and promotion with behavioural initiatives; however, the empirical evidence to support these is weak. Lifestyle programmes have been described as a cost-effective way of providing education about lifestyle changes to improve physical health and mental well-being, however, the use of exercise programmes with patients as an adjunct therapy in clinical practice remains limited. More importantly, the question of how these strategies might be disseminated and implemented across diverse clinical settings and patient populations has not been addressed. The Future In order to address the physical needs of those with serious mental illness there should be a greater focus on physical health assessment and health promotion within the multidisciplinary team. This approach will need to primarily address patient engagement and sustained motivation but should also include a major support role for carers as well as primary and secondary health care workers and incorporate health service and health promotion initiatives specific to this population and their needs. The current evidence is that while most patients will accept entry into an appropriate programme, engagement with the intervention is not sustained 2 . Yet, in light of the significant risks to physical health it is incumbent on all health professionals, perhaps even our ethical and moral responsibility, to find a way of encouraging people with mental illness to participate in and to complete physical health interventions. The role of motivational interviewing may be central to success in this population and such initiatives will likely need to build in components to address self esteem and confidence as an initial step towards engagement. As with most illness and health initiatives, prevention may be more beneficial than cure. The research to date illustrates the increased morbidity and earlier mortality of people with mental illness 1 . A number of modifiable risk factors have been identified, some similar to those in the general population and some illness specific and complicated by the metabolic side effects of medication 1 . Managing physical health poses a significant challenge to frontline mental health staff and providers. The current guidelines do not give specific recommendations on evidence based physical health interventions nor do they address how interventions should be tailored to meet the specific needs of these populations who in addition to facing the motivational challenges of healthy individuals, they often struggle with negative symptoms of their illness. Further research and evaluation in this area is urgently needed to enable the development and delivery of a multidisciplinary and evidence-based intervention for patients and families that focuses on prevention and screening as well as management. The longer term human and health care saving could be immense. M McCormack, P Connolly, E Lawlor, M Clarke, A Lane The Physical Health and Wellbeing Group, St. John of God Hospital, Stillorgan, Co Dublin Email: [email protected] AcknowledgementsThe Physical Health and Wellbeing Group St John of God Hospital supported by a St John of God Research Grant. References1. The cardiovascular health of young people with severe mental illness: addressing an epidemic within an epidemic.The Psychiatrist 2012, 375-3782. Collins E, Tranter S, Irvine F. The physical health of the seriously mentally ill: an overview of the literature. JPsychiatr Mental Health Nurs. 2011 Oct 183. Citrome L, Yeomans D. Do guidelines for severe mental illness promote physical health and well-being? JPsychopharmacol. 2005 Nov: 19:102-94. Thornicroft G. Physical health disparities and mental illness: the scandal of premature mortality. Br J Psychiatry.2011 Dec; 199:441-2.5. Wildgust HJ, Beary M. Are there modifiable risk factors which will reduce the excess mortality in schizophrenia? JPsychopharmacol. 2011 Nov; 24:37-50.6. Dixon L, Dickerson F, Bellack, A, Bennett M, Dickinson D, Goldberg R, et al. The 2009 Schizophrenia PORTPsychosocial Treatment Recommendations and Summary Statements. SchizophrBull. 2010 Jan; 36:48-70. Epub 2009 Dec 2.7. Millar H. Management of physical health in schizophrenia: a stepping stone to treatment success. EurNeuropsychopharmacol. 2008 May; 18 Suppl 2: S121-8. Managing Physical Health in Mental Health Populations1