This transcript has been edited for clarity.
In this podcast, 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.
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.
Although this resource focuses on antipsychotic treatment, its principles can be applied to other psychotropic medication used to treat long-term mental health disorders. The updated Lester resource is freely available on the Royal College of Psychiatrists London website and was discussed in an editorial in the British Journal of General Practice during November 2023.
The tool guides us, as health professionals, through the cardiometabolic assessment of a person living with severe mental illness. On reviewing that individual, we must discuss smoking history, health behavior and lifestyle changes, and body mass index; and, of course, we must remember to ethnically adjust the body mass index as appropriate. We need to look at blood pressure, glucose regulation, and blood lipids. This tool gives us red zones where appropriate person-centered interventions should be considered to improve that individual's physical health.
Green target zones are also suggested after interventions have been actioned. For example, if HbA1c is between 42 and 47 mmol/mol or 6% to 6.4%, that is the red zone for glucose regulation, and a referral to an evidence-based lifestyle program should be offered. If this is ineffective, we should consider and offer metformin, modified release. As always, the mantra with metformin is start low, go slow. The green target zone for glucose regulation is an HbA1c of less than 42 mmol/mol, or 6%, to prevent or delay the onset of type 2 diabetes.
Importantly, weight should be assessed weekly for the first 6 weeks of taking a new antipsychotic drug, as rapid early weight gain — for example, 3-4 kg within the first 4 weeks — predicts long-term weight gain and a higher risk for cardiometabolic disorders. Average weight gain with antipsychotic therapy is around 12 kg within the first 2 years of treatment.
As a rule of thumb, quetiapine is less likely to cause weight gain than olanzapine, and aripiprazole even less so. If there is rapid, early weight gain within 4 weeks of starting an antipsychotic medication or worsening of cardiometabolic indices, such as lipids, within the first 3 months, do consider discussion with your local mental health team.
UK-based risk assessment tools to consider using for people living with severe mental illness include QRISK3 for cardiovascular disease and QDiabetes for type 2 diabetes. Both of these tools do account for severe mental illness and the use of antipsychotic medication but were not specifically developed for these populations.
A UK-based severe mental illness–specific tool is called PRIMROSE for cardiovascular disease, specifically developed for adults living with severe mental illness. As always, risk scores always should be balanced alongside individual preference, concern, and expectations to inform rather than dictate clinical decisions.
Another useful UK-based tool is the Glasgow Antipsychotic Side-Effect Scale, or GASS questionnaire, which helps monitor side effects to antipsychotic medication. This can help inform treatment decisions for continuing, changing, or stopping antipsychotic medication. A call to action for us all in primary care: Don't just screen; intervene. We need to consider cardiometabolic disease prevention in people living with severe mental illness from point of diagnosis.
Medscape Family Medicine © 2024 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Kevin Fernando. Primary Care Tips: Improving Physical Health in Severe Mental Illness - Medscape - Jul 09, 2024.
Comments