The physical health of individuals with serious mental illness Josephine Bardi (RMN), MSc Public Health candidate Twitter @JoBardi01

“The problem of physical health in individuals with severe mental illness remains a global public health concern” (World Psychiatric Association, 2009, p.1).

Individuals with severe mental illness (SMI) particularly those with schizophrenia, schizoaffective disorder and bipolar disorder are vulnerable to poorer physical health which results in higher rates of mortality and morbidity when compared to the general population. They die an average 20 years younger than the general population due to side effects of psychotropic medication such as lifestyle choices and lack of adequate information.

Side effects of psychotropic medications

Individuals with SMI suffer from metabolic issues including; weight gain, diabetes and cardiovascular diseases due to the side effects from long-term use of psychotropic medications. The clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) sponsored by the National Institute of Mental Health revealed that antipsychotic medications help to improve quality of life (QoL) for individuals with SMI. However adverse effects of antipsychotic medications, over sedation and extrapyramidal reactions are key factors for poor physical health amongst the chosen population. For instance, individuals can gain weight 5-6kg during the first two months of starting antipsychotic medications like Clozapine and Olanzapine and, their weight continues to increase past the first year. Nonetheless, without antipsychotic medications most people with SMI might suffer serious and disabling symptoms such as: hallucinations, delusions, impaired cognitive and social functioning.

Obesity and cardiovascular diseases

A body mass index (BMI) ≥ 25 is considered obese. Individuals with SMI are predisposed to being overweight due to adverse effects of psychotropic medications, higher percentage of body fat which leads to obesity from lack of physical activity.

Diabetes

177 million people (2.8% of the population) in the world were diagnosed with diabetes and expected to rise to 370 million (4.4% of the population) by 2030. Diabetes is increasing in the UK with 24,000 people dying yearly. Universal screening for diabetes rarely occur in individuals with SMI even though they suffer type 2 diabetes mortality outcomes are three times higher than the general population.

Risky Sexual Behaviour

Individuals with SMI are often unaware of their HIV status and they are unlikely to seek voluntary testing. They are exposed to increased risk of infection due to high-risk behaviours from substance misuse through sharing of needles. Additionally, they have disproportionately higher rates of sexually transmitted infections and diseases (STIs and STDs). They are unable to effectively communicate safer sex with partners, have poor interpersonal and assertiveness skills which may result in lack of social support and lower sexual risk-reduction. They may also reside in areas with high rates of STDs, STIs and HIV and experience higher rates of readmission, which hinders long term relationship.

Smoking

Higher rates of smoking are the major cause of excess mortality in people with SMI. They are reported to be heavier smokers as a result of increase levels of nicotine dependence with daily smoking consumption averaging at 65% compared to roughly 21% in the overall population.

Poor dietary intake

NICE (2006) guidelines suggest a healthy BMI of between 18.5-24.9 and a referral to a dietician where the BMI is dramatically higher or lower than the recommended range. It seems though, that regardless of the continuous awareness campaign strategies, individuals with SMI are yet to fall into the category of people who are aware of the importance of healthy eating. Along with the central nervous system, medications such olanzapine and clozapine are linked to food craving, binge eating, weight gain and hypertriglyceridemia.

Physical activity

Individuals with SMI are less likely to participate in physical activities. Unquestionably, consistent physical activity decreases the risk of long-term physical illnesses and stimulates the release of acetylcholine which calms individuals, improves cerebral blood flow, muscle relaxation and body temperature. However these are not often discussed during assessments.

Respiratory diseases – Tuberculosis

TB in individuals with SMI seems largely related to those who share injections during drug use and live in overcrowded houses with infected persons. The NHS provides mobile Tuberculosis (TB) screening units where individuals receive chest x-ray to determine their TB status. Similar to above listed physical health illness, individuals with SMI have higher mortality rate as they are not aware of the risk of exposure, screening and treatment options.

Considering the magnitude of the identified physical health illnesses, it will come as no surprise then that physical health problems in individuals with SMI account for higher mortality rates when compared with mental health problems.

What is the role of the mental health nurse (MHN) in monitoring the physical health of individuals with serious mental illnesses?

Since the 1950s psychiatry has transformed radically from MHNs providing support for individuals asylums to gradually becoming qualified professionals identified worldwide as providers of key functions much the same as a century ago but, holistically through assessment of physical, mental, social and spiritual needs of service users. During the second half of 2009 there were changes in the funding and allocation of resources between primary and secondary health services in the United Kingdom. Consequently the DH (2009) focused more on the physical health of individuals with SMI with a corresponding shift towards the role of the MHN yet, MHNs are reported to lack the skills to effectively monitor the physical health of individuals with SMI. It is worth stressing that most mental health nurses are trained in the basics of anatomy and physiology so, arguably, they are not entirely to blame for their lack of physical health skills as this may be solely attributed to the difference in training syllabus between MHNs and other branches of nursing.

Neglecting this aspect of care impacts on the individuals with SMI with a mortality rate of 4,008 deaths per 100,000 compared to 1,122 deaths per 100,000 which is 3.6 times higher than the general population. For this reason, it is paramount that holistic and comprehensive assessment is carried out in collaboration with individuals with SMI so that needs can be identified, goals set and interventions implemented. However, several studies have found irregularities in the competencies of MHNs in the assessment and recording of physical health results. The upshot being poorer physical health outcomes due to poor assessments experienced by the individuals with SMI even when they are able to access physical health care.

Josephine Bardi is currently completing her MSc in Public Health at the University of East London

References

De Hert, M., Correll, C.U., Bobes, J., Cetkovich-Bakmas, M., Cohen, D., Asai, I., Detraux, J., Gautam, S., Möller, H., Ndetei, D.M., Newcomer, J.W., Uwakwe, R. and Leucht, S. (2011) Physical illness in patients with severe mental disorders. 1. Prevalence, impact of medications and disparities in health care. World Psychiatry, 10 (1), p.52-77 EBSCOhost: MEDLINE [Online]. Available at: http://search.ebsco.com [Accessed: 28 November 2012].

Department of Health (2006b) Choosing Health: Supporting the physical needs of people with severe mental illness – commissioning framework [Online]. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4138212 [Accessed: 18 November 2012].

Lieberman, J. A., Stroup, S., and McEvoy, J. P. et al. Clinical antipsychotic trials of intervention effectiveness (CATIE) investigators (2005) Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. The New England Journal of Medicine, 353 (12), p.1209-1223.

Nash, M. (2010) Assessing nurses’ propositional knowledge of physical health. Mental Health Practice, 14 (2), p. 20-23.

Ratcliffe, T., Dabin, S. and Barker, P. (2011) Physical healthcare for people with serious mental illness: Clinical governance: An International Journal 16 (1), p. 20-28.

Robson, D. and Haddad, M. (2012) Mental health nurses’ attitudes towards the physical health care of people with severe and enduring mental illness: The development of a measurement tool. International Journal of Nursing Studies, 49 (1), p. 72-83 EBSCOhost: MEDLINE [Online]. Available at: http://search.ebsco.com [Accessed: 29 November 2012].

The Health and Social Care Information Centre (2012) Mortality rate in sufferers of serious mental illness three times as high as in the general population [Online]. HSCIC. Available at: https://catalogue.ic.nhs.uk/publications/mental-health/services/ment-heal-bull-mhmds-anua-retu-2011-12/Publication%20Report.pdf [Accessed: 12 December 2012].

World Psychiatric Association (2009) Physical health care in persons with severe mental illness: a public health and ethical priority. World Psychiatry 8 (1), p. 43-44.

 

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