Physical health in schizophrenia

People with schizophrenia are at higher than average risk of physical ill health and die earlier than the general population from natural causes. The fatal conditions include cardiovascular, respiratory and metabolic disorders. [Harris EC, Barraclough B. Excess mortality of mental disorder. "Br J Psychiatry" 1998; 173: 11-53.] Although death by suicide in schizophrenia has received much needed attention, death from cardiovascular disease is far more common, accounting for up to 75 percent of deaths. [Hennekens CH, et al. Schizophrenia and increased risks of cardiovascular disease. "Am Heart J" 2005; 150(6): 1,115-21.] The causes of physical health problems include factors associated with mental illness and its treatment, poverty, poor housing, higher rates of smoking, poor diet and lack of exercise. [Phelan M, et al. Physical health of people with severe mental illness. BMJ 2001; 322: 443-44.] [Brown S, et al. The unhealthy lifestyle of people with schizophrenia. Psychol Med 1999; 29: 697-701.] [McCreadie R. Diet, smoking and cardiovascular risk in people with schizophrenia. Br J Psychiatry 2003; 183: 534-39.]

Despite the high rates of physical health problems, mental health service users report that health care workers overlook their physical health needs [Friedli L, Dardis C. Not all in the mind: Mental health service user perspectives on physical health. "J Mental Health Promotion" 2002; 1:36-46.] . Service users would like mental health practitioners to do more for their physical health. Rethink [Rethink. Just one per cent. Kingston-Upon-Thames: Rethink; 2003. Available from: http://www.rethink.org/.] interviewed 2,998 mental health service users, over half of whom lived with a diagnosed severe mental illness. Nearly one third said regular physical health checks were in their top three priorities for improving services. Mental health practitioners may feel unable to provide physical health input. Also there may be a feeling that people with mental health problems will not be interested in physical health education and support. In fact, much health promotion is simple and well received by service users. One review showed that people with schizophrenia benefited from a variety of behavioural interventions and achieved weight loss and lifestyle change. [Bushe C, et al. The role of lifestyle interventions and weight management in schizophrenia. J Psychopharmacol 2005; 19(6 Suppl): 28-35.]

Another study found little evidence to support one intervention over another [Richardson CR, et al. Integrating physical activity into mental health services for persons with serious mental illness. Psychiatr Serv 2005; 56: 324-31.] , but argued that moderately strenuous exercise was important.

Many guidelines reflect the need to incorporate physical health care into mental health provision, including NICE [(Clinical guideline 1. Schizophrenia) http://www.nice.org.uk/guidance/topic/behaviouraland the Maudsley Prescribing Guidelines (see resources)] in the UK. In primary care, the prodigy website provides practical and accessible advice. [ [http://www.prodigy.nhs.uk/schizophrenia CKS: Schizophrenia ] ]

However, a review of international guidelines for physical wellbeing in SMI has found that recommendations are variable. [Citrome L, Yeomans D. Do guidelines for severe mental illness promote physical health and well-being? J Psychopharmacol 2005; 19(6 Suppl): 102-9.] UK guidelines failed to address the specifics of physical health monitoring and lifestyle intervention, while US guidelines were more descriptive. Field studies suggested that all guidelines were inadequately implemented in practice.

The DoH in the UK has recommended wide-ranging action to enable the general population to choose healthier lifestyles in the "Choosing Health" white paper. [(Choosing health: making healthy choices easier. 2004)http://www.dh.gov.uk/PublicationsAndStatistics/Publications/fs/en ]

In the UK the National Health Service (NHS) is deeply split along physical/mental lines. Instead of treating whole people, services tend to treat parts of people separately.

One barrier to improving the physical health of people using mental health services is the sense within mental health services that this is someone else’s job; for example, the primary care team. Certainly primary teams should play the major role in physical care, but mental health services should be prepared to offer physical health assessment, promotion and support. Mental health trusts may resist using their budgets for physical health care because they see this as the role of primary care. Fortunately the chief nursing officer disagrees and recommends that all mental health nurses should attain the skills required to improve the physical wellbeing of people with mental health problems. [(From values to action: the chief nursing officer’s review of mental health nursing. 2006.) http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4133839&chk=RJV7mg]

The commissioning framework to support the physical health needs of people with severe mental illness recommends a holistic approach with interagency collaboration. [(Choosing health: supporting the physical needs of people with severe mental illness – commissioning framework. 2006.) http://www.dh.gov.uk/PublicationsAndStatistics/Publications/fs/en]

Nurses are seen as the key professional group leading wellbeing services in schizophrenia. However a range of professionals and voluntary groups can help. People with schizophrenia are motivated and able to change their lifestyles and improve their health. The outcome should be healthier and longer lives.

References