Individuals with mental illness have higher rates of physical co-morbidity and mortality than the general population. The association between mental illness and mortality from physical health conditions increases with the severity of the mental illness. Those with severe mental illness have a life expectancy approximately 25 years less than the general population.
Several factors contribute to this – lifestyle (e.g. smoking, poor diet and relative lack of exercise), relative lack of access to general practice and specialist care and the prescription of psychotropic medications, the side-effect profile of which often includes metabolic disturbances. This essentially represents risk factors for cardiovascular disease including weight gain, hypertension, hyperglycaemia and hypercholesterolemia. These metabolic risk factors and lifestyle issues are critical to screen for and intervene against.
A relevant factor is that patients primarily seen within mental health settings may be less likely to have their physical health care considered in their overall management plan.
There is now an increasing understanding and policy direction for holistic models of care addressing both mental and physical health. Mental health services need to structurally and culturally function to provide this care and as a psychiatric profession we must continue to take more responsibility for the physical wellbeing of our patients including promoting collaborative care with general practitioners.
The initial focus has been screening patients prescribed psychotropic medications, especially antipsychotic medication, for baseline weight, Body Mass Index (BMI), waist circumference and blood pressure. These should be monitored at least monthly to bi-monthly in the first six months and six monthly thereafter. Baseline fasting serum glucose, lipid levels and prolactin should be obtained and repeated at three months and then every six to twelve months thereafter. A baseline ECG for QTc interval repeated yearly is advisable.
This early monitoring is accompanied by education and early transition away from weight-inducing medication if possible. Increasingly, the focus is prevention including prescribing more metabolic friendly antipsychotic medications (e.g. aripiprazole, lurasidone) and avoiding more metabolically unfriendly medications (e.g. olanzapine, quetiapine). Medications such as risperidone and paliperidone sit in the middle.
Early intervention is increasingly recognised with the early prescription of metformin (500mg daily) to reduce the likelihood of, or offset, initial weight gain. Dietician and exercise physiology referrals can be very helpful.
Finally, increasingly, mental health services are embedding physical health nurses into the workforce who carry responsibility for ensuring the mental health service attends to screening and assists in connecting patients with general practitioners as part of their ongoing care.
Having general practitioners contracted to work within mental health services has also been another effective way to facilitate physical health measures for our mental health patients.
- Physical health is a critical but often overlooked issue for mental health patients
- Prescribed medications can contribute to metabolic disturbance
- Prevention, screening, early detection and early intervention are paramount, ideally in shared care with GPs.
Author competing interest – nil