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Child Psychiatrist /Adult Psychiatrist

Improving Physical Health in Severe Mental Illness

I'm going to talk about improving the physical health of people living with severe mental illness such as schizophrenia, bipolar disorder, and severe depression.

Mental Illness

The association between mental illness and physical health is both fascinating and very, very important. The ancient Greek philosopher Plato famously said that the greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.

The unarguable and unavoidable truth is that there is a huge excess mortality among those living with severe mental illness. People living with severe mental illness die, on average, 15-20 years earlier than the general population. Most of this excess mortality, around 75%, is due to common physical comorbidities such as cardiovascular disease, respiratory disease, diabetes, and cancer, rather than suicide. If these conditions were diagnosed and managed at an earlier stage, outcomes could be improved.

Tragically, this mortality gap continues to widen, driven particularly by cardiovascular disease. Over the past 25 years, the incidence of cardiovascular disease has fallen in the general population, whereas it has not declined at all in people living with severe mental illness. Why is this the case?

Severe mental illness often presents in younger individuals and can lead to unhealthy lifestyles, social disadvantage, and the use of antipsychotic medication with adverse cardiometabolic effects. As such, risk factors for cardiometabolic disease appear much earlier in people living with severe mental illness than in the general population.

For example, by the age of 40 years, people with severe mental illness are three to four times more likely to have features of the metabolic syndrome compared with the general population. Type 2 diabetes is two to three times more frequent, eventually affecting 10%-15% of people living with severe mental illness. Cardiovascular disease is three times more frequent in those living with schizophrenia.

Although it is challenging to address the social determinants of health, such as income, education, unemployment, and housing, we as healthcare professionals can pay closer attention to cardiometabolic risk factor management in people living with severe mental illness from the point of diagnosis rather than waiting, as usual, until the middle ages.

This recalls another, more recent quote by Julian Tudor-Hart, a Welsh GP, who sadly died in 2018. He coined the famous inverse care law back in 1971. The availability of good medical or social care tends to vary inversely with the need of the population served. Perversely, those who need healthcare most, such as our patients living with severe mental illness, are least likely to be able to access it.

What can we do in primary care? We need to consider cardiometabolic disease prevention from point of diagnosis. The late UK professor Helen Lester, a GP and academic, encouraged us not to just screen but intervene. During 2012, she contributed toward the Positive Cardiometabolic Health Resource, an intervention framework for people experiencing psychosis and schizophrenia. This was recently updated during 2023. This resource gives recommendations relating to the monitoring of physical health in people experiencing psychosis and schizophrenia.

Note: This article originally appeared on Medscape.

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