BMJ - Association of Mental Illness & Poor Physical Health

[Guest guest]

http://bmj.com/cgi/content/full/322/7284/443?

BMJ 2001;322:443-444 ( 24 February )

Editorials

Physical health of people with severe mental illness

Can be improved if primary care and mental health professionals pay

attention to it.

Over 60 years ago the BMJ reported an association between mental illness and

poor physical health.1 Subsequent research, in many countries, has

consistently confirmed that psychiatric patients have high rates of physical

illness, much of which goes undetected. 2 3 Such investigations have led to

calls for health professionals to be more aware of these findings and for

better medical screening and treatment of psychiatric patients. So far there

is no evidence that this is happening, and the excess illness and mortality

continue unabated, with people being managed as psychiatric outpatients

being nearly twice as likely to die as the general population.4

People with schizophrenia are subjected to the long term effects of

antipsychotic medication and have high rates of substance misuse. Yet much

of their excess mortality is due to natural causes. They eat less well,

smoke more, and take less exercise than the general population.5 Smoking

related fatal disease is commoner than in the general population, as are

deaths which could have been avoided by medical treatment.6 Comparative

studies have, however, failed to compare patients with people from similar

social backgrounds, so it is not clear to what extent poverty, poor housing,

and unemployment are causal factors, rather than the direct effects of

mental illness.

Several factors prevent people with mental illness from receiving good

physical health care. People with schizophrenia are less likely than healthy

controls to report physical symptoms spontaneously.7 Some symptoms of the

consequences of schizophreniacognitive impairment, social isolation, and

suspicionmay contribute to patients not seeking care, or adhering to

treatment. When they do present themselves their lack of social skills and

the stigma of mental illness may also make it less likely that they receive

good care. In the United States a fragmented healthcare system, and

difficulties in accessing care, have exacerbated the problems.8

In most industrialised countries reform in mental health care has led to the

closure of long stay mental hospitals and the development of community

mental health teams. Such teams are expected to meet the whole range of

health and social needs. Hospital admissions are often short and infrequent,

and physical health care is not necessarily given priority. In Britain the

national service framework for mental health states that people with a

severe mental illness should have their physical needs assessed. However,

many mental health practitioners have little training in physical care.

Physical assessments of psychiatric inpatients by junior psychiatrists are

poor,9 and the monitoring of physical health and health education by

community mental health staff is generally unsatisfactory.10

Most patients with severe mental illness are in frequent contact with

primary care services, and for many this is their only contact with health

services. However, such contact does not necessarily ensure that they

receive good physical health care. The orientation of primary care is

reactive, and this does not fit well with patients who may be reluctant, or

unable, to seek help. Short consultation times make it difficult for doctors

to assess mental state and conduct a physical assessment, especially in

vague or suspicious patients. When patients are accompanied by mental health

staff more emphasis may be given to psychological and social issues. Doctors

who are inexperienced in, or uncomfortable with, mental health work may

resist intensifying their engagement with a patient by actively asking about

symptoms and performing a physical examination.

A study in the US has highlighted that structured physical assessments of

patients with schizophrenia are effective in revealing physical illness.7 In

the UK the NHS Executive has suggested that general practitioners should be

paid for showing that they have assessed the general physical health of

patients with severe mental illness and made any necessary interventions.11

For such schemes to be successful practices would need to identify their

patients with a severe mental illness and to have an effective and

acceptable screening mechanism. This should highlight physical symptoms and

unmet physical healthcare needs, such as cervical screening and dental care.

The lifestyle of patients with severe mental illness suggests a need for

health promotionwhich can be effective. For instance, group therapy is

effective in helping patients with schizophrenia stop smoking.12 But

progress in this is hampered by negative staff attitudes. Initiatives in

this area should be accompanied by research, so that the most effective

approaches can be identified and widely adopted.

The evidence suggests that it is possible to improve the physical health of

this vulnerable section of the population. Progress will, however, depend on

both mental health and primary care staff being aware of the problem and

being willing to find imaginative solutions which are acceptable and useful

to patients.

Phelan, consultant psychiatrist.

Department of Psychiatry, Charing Cross Hospital, London

W6 8RP

Stradins, mental health nurse.

Ealing, Hammersmith, Fulham Mental Health Trust, Gloucester House, London W6

8BS

Sue on, general practitioner.

lebone Health Centre, London NW1 5LT

--------------------------------------------------------------------------------

1. Philips RJ. Physical disorder in 164 consecutive admissions to a mental

hospital: the incidence and significance. BMJ 1934; 2: 363-366.

2. Koran LM, Sox HC, Marton KI, Moltzen S, Sox CH, Kraemer HC, et al.

Medical evaluation of psychiatric patients. 1. Results in a state mental

health system. Arch Gen Psychiatry 1989; 46: 733-740[Medline].

3. Makikyro T, Karvonen JT, Hakko H, Nieminen P, Joukamen M, Isohanni M, et

al. Comorbidity of hospital-treated psychiatric and physical disorders with

special reference to schizophrenia: a 28 year follow-up of the 1966 northern

Finland general population birth cohort. Public Health 1998; 112:

221-228[Medline].

4. EC, Barraclough B. Excess mortality of mental disorder. Br J

Psychiatry 1998; 173: 11-53[Abstract].

5. Brown S, Birtwistle J, Roe L, C. The unhealthy lifestyle of

people with schizophrenia. Psychol Med 1999; 29: 697-701[Medline].

6. Brown S, Inskip H, Barraclough B. Causes of the excess mortality of

schizophrenia. Br J Psychiatry 2000; 177: 212-217[Abstract/Full Text].

7. Jeste DV, Gladsjo JA, mer LA, Lacro JP. Medical comorbidity in

schizophrenia. Schizophrenia Bull 1996; 22: 413-427[Medline].

8. Goldman LS. Medical illness in patients with schizophrenia. J Clin Psych

1999; 60 (suppl 21): 10-15.

9. Rigby JC, Oswald AG. An evaluation of the performing and recording of

physical examinations by psychiatric trainees. Br J Psychiatry 1987; 150:

533-535[Abstract].

10. Gournay K. Setting clinical standards for care in schizophrenia. Nursing

Times 1996; 92: 36-37.

11. NHS Executive. Health Service Circular. London: NHSE, 1999 (HSC

1999/107).

12. Addington J, el-Guebaly N, W, Hodgins DC, Addington D. Smoking

cessation treatment for patients with schizophrenia. Am J Psychiatry 1998;

155: 974-976[Abstract/Full Text].

--------------------------------------------------------------------------------

© BMJ 2001

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Download to Citation Manager

Search Medline for articles by:

Phelan, M. || on, S.

Alert me when:

New articles cite this article

Collections under which this article appears:

Other Psychiatry

This article has been cited by other articles:

Gray, G. E (2002). Integrated medical care in a mental health clinic

improved quality of care and outcomes in serious mental disorders. Evid

Based Ment Health 5: 46-46 [Full text]

Osborn, D. P J (2001). The poor physical health of people with mental

illness. eWJM 175: 329-332 [Full text]

Barr, W., van de Hoef, P., Colls, I., Scheurer, R., McGrath, J., Whiteford,

H. (2001). Physical health of people with severe mental illness. BMJ 323:

231-231 [Full text]

Barr, W., van de Hoef, P., Colls, I., Scheurer, R., McGrath, J., Whiteford,

H. (2001). Physical health of people with severe mental illness. BMJ 323:

231-231 [Full text]

Rapid Responses:

Read all Rapid Responses

Influenza vaccinations for people with severe mental illness

Alan Cohen

bmj.com, 25 Feb 2001 [Full text]

The user and carer perspective-translating research findings into changing

practice

Judy Dean

bmj.com, 27 Feb 2001 [Full text]

Reducing physical morbidity in psychiatric patients

Byrne

bmj.com, 27 Feb 2001 [Full text]

Role of GPs in providing care for the people with psychotic disorders

McGrath

bmj.com, 28 Feb 2001 [Full text]

Identifying patients with severe mental health problems

Wally Barr

bmj.com, 1 Mar 2001 [Full text]

Physical Assessments for Psychiatric Patients an Area of Gross Neglect

Dan L. Stradford

bmj.com, 8 Apr 2002 [Full text]

Related letters in BMJ:

Physical health of people with severe mental illness

Wally Barr, Pamela van de Hoef, Ian Colls, Roman Scheurer, McGrath, and

Harvey Whiteford

BMJ 2001 323: 231. [Letter]

_________________________________________________________________

Get your FREE download of MSN Explorer at http://explorer.msn.com/intl.asp.

[Guest guest]

http://bmj.com/cgi/content/full/322/7284/443?

BMJ 2001;322:443-444 ( 24 February )

Editorials

Physical health of people with severe mental illness

Can be improved if primary care and mental health professionals pay

attention to it.

Over 60 years ago the BMJ reported an association between mental illness and

poor physical health.1 Subsequent research, in many countries, has

consistently confirmed that psychiatric patients have high rates of physical

illness, much of which goes undetected. 2 3 Such investigations have led to

calls for health professionals to be more aware of these findings and for

better medical screening and treatment of psychiatric patients. So far there

is no evidence that this is happening, and the excess illness and mortality

continue unabated, with people being managed as psychiatric outpatients

being nearly twice as likely to die as the general population.4

People with schizophrenia are subjected to the long term effects of

antipsychotic medication and have high rates of substance misuse. Yet much

of their excess mortality is due to natural causes. They eat less well,

smoke more, and take less exercise than the general population.5 Smoking

related fatal disease is commoner than in the general population, as are

deaths which could have been avoided by medical treatment.6 Comparative

studies have, however, failed to compare patients with people from similar

social backgrounds, so it is not clear to what extent poverty, poor housing,

and unemployment are causal factors, rather than the direct effects of

mental illness.

Several factors prevent people with mental illness from receiving good

physical health care. People with schizophrenia are less likely than healthy

controls to report physical symptoms spontaneously.7 Some symptoms of the

consequences of schizophreniacognitive impairment, social isolation, and

suspicionmay contribute to patients not seeking care, or adhering to

treatment. When they do present themselves their lack of social skills and

the stigma of mental illness may also make it less likely that they receive

good care. In the United States a fragmented healthcare system, and

difficulties in accessing care, have exacerbated the problems.8

In most industrialised countries reform in mental health care has led to the

closure of long stay mental hospitals and the development of community

mental health teams. Such teams are expected to meet the whole range of

health and social needs. Hospital admissions are often short and infrequent,

and physical health care is not necessarily given priority. In Britain the

national service framework for mental health states that people with a

severe mental illness should have their physical needs assessed. However,

many mental health practitioners have little training in physical care.

Physical assessments of psychiatric inpatients by junior psychiatrists are

poor,9 and the monitoring of physical health and health education by

community mental health staff is generally unsatisfactory.10

Most patients with severe mental illness are in frequent contact with

primary care services, and for many this is their only contact with health

services. However, such contact does not necessarily ensure that they

receive good physical health care. The orientation of primary care is

reactive, and this does not fit well with patients who may be reluctant, or

unable, to seek help. Short consultation times make it difficult for doctors

to assess mental state and conduct a physical assessment, especially in

vague or suspicious patients. When patients are accompanied by mental health

staff more emphasis may be given to psychological and social issues. Doctors

who are inexperienced in, or uncomfortable with, mental health work may

resist intensifying their engagement with a patient by actively asking about

symptoms and performing a physical examination.

A study in the US has highlighted that structured physical assessments of

patients with schizophrenia are effective in revealing physical illness.7 In

the UK the NHS Executive has suggested that general practitioners should be

paid for showing that they have assessed the general physical health of

patients with severe mental illness and made any necessary interventions.11

For such schemes to be successful practices would need to identify their

patients with a severe mental illness and to have an effective and

acceptable screening mechanism. This should highlight physical symptoms and

unmet physical healthcare needs, such as cervical screening and dental care.

The lifestyle of patients with severe mental illness suggests a need for

health promotionwhich can be effective. For instance, group therapy is

effective in helping patients with schizophrenia stop smoking.12 But

progress in this is hampered by negative staff attitudes. Initiatives in

this area should be accompanied by research, so that the most effective

approaches can be identified and widely adopted.

The evidence suggests that it is possible to improve the physical health of

this vulnerable section of the population. Progress will, however, depend on

both mental health and primary care staff being aware of the problem and

being willing to find imaginative solutions which are acceptable and useful

to patients.

Phelan, consultant psychiatrist.

Department of Psychiatry, Charing Cross Hospital, London

W6 8RP

Stradins, mental health nurse.

Ealing, Hammersmith, Fulham Mental Health Trust, Gloucester House, London W6

8BS

Sue on, general practitioner.

lebone Health Centre, London NW1 5LT

--------------------------------------------------------------------------------

1. Philips RJ. Physical disorder in 164 consecutive admissions to a mental

hospital: the incidence and significance. BMJ 1934; 2: 363-366.

2. Koran LM, Sox HC, Marton KI, Moltzen S, Sox CH, Kraemer HC, et al.

Medical evaluation of psychiatric patients. 1. Results in a state mental

health system. Arch Gen Psychiatry 1989; 46: 733-740[Medline].

3. Makikyro T, Karvonen JT, Hakko H, Nieminen P, Joukamen M, Isohanni M, et

al. Comorbidity of hospital-treated psychiatric and physical disorders with

special reference to schizophrenia: a 28 year follow-up of the 1966 northern

Finland general population birth cohort. Public Health 1998; 112:

221-228[Medline].

4. EC, Barraclough B. Excess mortality of mental disorder. Br J

Psychiatry 1998; 173: 11-53[Abstract].

5. Brown S, Birtwistle J, Roe L, C. The unhealthy lifestyle of

people with schizophrenia. Psychol Med 1999; 29: 697-701[Medline].

6. Brown S, Inskip H, Barraclough B. Causes of the excess mortality of

schizophrenia. Br J Psychiatry 2000; 177: 212-217[Abstract/Full Text].

7. Jeste DV, Gladsjo JA, mer LA, Lacro JP. Medical comorbidity in

schizophrenia. Schizophrenia Bull 1996; 22: 413-427[Medline].

8. Goldman LS. Medical illness in patients with schizophrenia. J Clin Psych

1999; 60 (suppl 21): 10-15.

9. Rigby JC, Oswald AG. An evaluation of the performing and recording of

physical examinations by psychiatric trainees. Br J Psychiatry 1987; 150:

533-535[Abstract].

10. Gournay K. Setting clinical standards for care in schizophrenia. Nursing

Times 1996; 92: 36-37.

11. NHS Executive. Health Service Circular. London: NHSE, 1999 (HSC

1999/107).

12. Addington J, el-Guebaly N, W, Hodgins DC, Addington D. Smoking

cessation treatment for patients with schizophrenia. Am J Psychiatry 1998;

155: 974-976[Abstract/Full Text].

--------------------------------------------------------------------------------

© BMJ 2001

PDF of this article

Email this article to a friend

Respond to this article

Read responses to this article

Related letters in BMJ

PubMed citation

Related articles in PubMed

Download to Citation Manager

Search Medline for articles by:

Phelan, M. || on, S.

Alert me when:

New articles cite this article

Collections under which this article appears:

Other Psychiatry

This article has been cited by other articles:

Gray, G. E (2002). Integrated medical care in a mental health clinic

improved quality of care and outcomes in serious mental disorders. Evid

Based Ment Health 5: 46-46 [Full text]

Osborn, D. P J (2001). The poor physical health of people with mental

illness. eWJM 175: 329-332 [Full text]

Barr, W., van de Hoef, P., Colls, I., Scheurer, R., McGrath, J., Whiteford,

H. (2001). Physical health of people with severe mental illness. BMJ 323:

231-231 [Full text]

Barr, W., van de Hoef, P., Colls, I., Scheurer, R., McGrath, J., Whiteford,

H. (2001). Physical health of people with severe mental illness. BMJ 323:

231-231 [Full text]

Rapid Responses:

Read all Rapid Responses

Influenza vaccinations for people with severe mental illness

Alan Cohen

bmj.com, 25 Feb 2001 [Full text]

The user and carer perspective-translating research findings into changing

practice

Judy Dean

bmj.com, 27 Feb 2001 [Full text]

Reducing physical morbidity in psychiatric patients

Byrne

bmj.com, 27 Feb 2001 [Full text]

Role of GPs in providing care for the people with psychotic disorders

McGrath

bmj.com, 28 Feb 2001 [Full text]

Identifying patients with severe mental health problems

Wally Barr

bmj.com, 1 Mar 2001 [Full text]

Physical Assessments for Psychiatric Patients an Area of Gross Neglect

Dan L. Stradford

bmj.com, 8 Apr 2002 [Full text]

Related letters in BMJ:

Physical health of people with severe mental illness

Wally Barr, Pamela van de Hoef, Ian Colls, Roman Scheurer, McGrath, and

Harvey Whiteford

BMJ 2001 323: 231. [Letter]

_________________________________________________________________

Get your FREE download of MSN Explorer at http://explorer.msn.com/intl.asp.

[Guest guest]

http://bmj.com/cgi/content/full/322/7284/443?

BMJ 2001;322:443-444 ( 24 February )

Editorials

Physical health of people with severe mental illness

Can be improved if primary care and mental health professionals pay

attention to it.

Over 60 years ago the BMJ reported an association between mental illness and

poor physical health.1 Subsequent research, in many countries, has

consistently confirmed that psychiatric patients have high rates of physical

illness, much of which goes undetected. 2 3 Such investigations have led to

calls for health professionals to be more aware of these findings and for

better medical screening and treatment of psychiatric patients. So far there

is no evidence that this is happening, and the excess illness and mortality

continue unabated, with people being managed as psychiatric outpatients

being nearly twice as likely to die as the general population.4

People with schizophrenia are subjected to the long term effects of

antipsychotic medication and have high rates of substance misuse. Yet much

of their excess mortality is due to natural causes. They eat less well,

smoke more, and take less exercise than the general population.5 Smoking

related fatal disease is commoner than in the general population, as are

deaths which could have been avoided by medical treatment.6 Comparative

studies have, however, failed to compare patients with people from similar

social backgrounds, so it is not clear to what extent poverty, poor housing,

and unemployment are causal factors, rather than the direct effects of

mental illness.

Several factors prevent people with mental illness from receiving good

physical health care. People with schizophrenia are less likely than healthy

controls to report physical symptoms spontaneously.7 Some symptoms of the

consequences of schizophreniacognitive impairment, social isolation, and

suspicionmay contribute to patients not seeking care, or adhering to

treatment. When they do present themselves their lack of social skills and

the stigma of mental illness may also make it less likely that they receive

good care. In the United States a fragmented healthcare system, and

difficulties in accessing care, have exacerbated the problems.8

In most industrialised countries reform in mental health care has led to the

closure of long stay mental hospitals and the development of community

mental health teams. Such teams are expected to meet the whole range of

health and social needs. Hospital admissions are often short and infrequent,

and physical health care is not necessarily given priority. In Britain the

national service framework for mental health states that people with a

severe mental illness should have their physical needs assessed. However,

many mental health practitioners have little training in physical care.

Physical assessments of psychiatric inpatients by junior psychiatrists are

poor,9 and the monitoring of physical health and health education by

community mental health staff is generally unsatisfactory.10

Most patients with severe mental illness are in frequent contact with

primary care services, and for many this is their only contact with health

services. However, such contact does not necessarily ensure that they

receive good physical health care. The orientation of primary care is

reactive, and this does not fit well with patients who may be reluctant, or

unable, to seek help. Short consultation times make it difficult for doctors

to assess mental state and conduct a physical assessment, especially in

vague or suspicious patients. When patients are accompanied by mental health

staff more emphasis may be given to psychological and social issues. Doctors

who are inexperienced in, or uncomfortable with, mental health work may

resist intensifying their engagement with a patient by actively asking about

symptoms and performing a physical examination.

A study in the US has highlighted that structured physical assessments of

patients with schizophrenia are effective in revealing physical illness.7 In

the UK the NHS Executive has suggested that general practitioners should be

paid for showing that they have assessed the general physical health of

patients with severe mental illness and made any necessary interventions.11

For such schemes to be successful practices would need to identify their

patients with a severe mental illness and to have an effective and

acceptable screening mechanism. This should highlight physical symptoms and

unmet physical healthcare needs, such as cervical screening and dental care.

The lifestyle of patients with severe mental illness suggests a need for

health promotionwhich can be effective. For instance, group therapy is

effective in helping patients with schizophrenia stop smoking.12 But

progress in this is hampered by negative staff attitudes. Initiatives in

this area should be accompanied by research, so that the most effective

approaches can be identified and widely adopted.

The evidence suggests that it is possible to improve the physical health of

this vulnerable section of the population. Progress will, however, depend on

both mental health and primary care staff being aware of the problem and

being willing to find imaginative solutions which are acceptable and useful

to patients.

Phelan, consultant psychiatrist.

Department of Psychiatry, Charing Cross Hospital, London

W6 8RP

Stradins, mental health nurse.

Ealing, Hammersmith, Fulham Mental Health Trust, Gloucester House, London W6

8BS

Sue on, general practitioner.

lebone Health Centre, London NW1 5LT

--------------------------------------------------------------------------------

1. Philips RJ. Physical disorder in 164 consecutive admissions to a mental

hospital: the incidence and significance. BMJ 1934; 2: 363-366.

2. Koran LM, Sox HC, Marton KI, Moltzen S, Sox CH, Kraemer HC, et al.

Medical evaluation of psychiatric patients. 1. Results in a state mental

health system. Arch Gen Psychiatry 1989; 46: 733-740[Medline].

3. Makikyro T, Karvonen JT, Hakko H, Nieminen P, Joukamen M, Isohanni M, et

al. Comorbidity of hospital-treated psychiatric and physical disorders with

special reference to schizophrenia: a 28 year follow-up of the 1966 northern

Finland general population birth cohort. Public Health 1998; 112:

221-228[Medline].

4. EC, Barraclough B. Excess mortality of mental disorder. Br J

Psychiatry 1998; 173: 11-53[Abstract].

5. Brown S, Birtwistle J, Roe L, C. The unhealthy lifestyle of

people with schizophrenia. Psychol Med 1999; 29: 697-701[Medline].

6. Brown S, Inskip H, Barraclough B. Causes of the excess mortality of

schizophrenia. Br J Psychiatry 2000; 177: 212-217[Abstract/Full Text].

7. Jeste DV, Gladsjo JA, mer LA, Lacro JP. Medical comorbidity in

schizophrenia. Schizophrenia Bull 1996; 22: 413-427[Medline].

8. Goldman LS. Medical illness in patients with schizophrenia. J Clin Psych

1999; 60 (suppl 21): 10-15.

9. Rigby JC, Oswald AG. An evaluation of the performing and recording of

physical examinations by psychiatric trainees. Br J Psychiatry 1987; 150:

533-535[Abstract].

10. Gournay K. Setting clinical standards for care in schizophrenia. Nursing

Times 1996; 92: 36-37.

11. NHS Executive. Health Service Circular. London: NHSE, 1999 (HSC

1999/107).

12. Addington J, el-Guebaly N, W, Hodgins DC, Addington D. Smoking

cessation treatment for patients with schizophrenia. Am J Psychiatry 1998;

155: 974-976[Abstract/Full Text].

--------------------------------------------------------------------------------

© BMJ 2001

PDF of this article

Email this article to a friend

Respond to this article

Read responses to this article

Related letters in BMJ

PubMed citation

Related articles in PubMed

Download to Citation Manager

Search Medline for articles by:

Phelan, M. || on, S.

Alert me when:

New articles cite this article

Collections under which this article appears:

Other Psychiatry

This article has been cited by other articles:

Gray, G. E (2002). Integrated medical care in a mental health clinic

improved quality of care and outcomes in serious mental disorders. Evid

Based Ment Health 5: 46-46 [Full text]

Osborn, D. P J (2001). The poor physical health of people with mental

illness. eWJM 175: 329-332 [Full text]

Barr, W., van de Hoef, P., Colls, I., Scheurer, R., McGrath, J., Whiteford,

H. (2001). Physical health of people with severe mental illness. BMJ 323:

231-231 [Full text]

Barr, W., van de Hoef, P., Colls, I., Scheurer, R., McGrath, J., Whiteford,

H. (2001). Physical health of people with severe mental illness. BMJ 323:

231-231 [Full text]

Rapid Responses:

Read all Rapid Responses

Influenza vaccinations for people with severe mental illness

Alan Cohen

bmj.com, 25 Feb 2001 [Full text]

The user and carer perspective-translating research findings into changing

practice

Judy Dean

bmj.com, 27 Feb 2001 [Full text]

Reducing physical morbidity in psychiatric patients

Byrne

bmj.com, 27 Feb 2001 [Full text]

Role of GPs in providing care for the people with psychotic disorders

McGrath

bmj.com, 28 Feb 2001 [Full text]

Identifying patients with severe mental health problems

Wally Barr

bmj.com, 1 Mar 2001 [Full text]

Physical Assessments for Psychiatric Patients an Area of Gross Neglect

Dan L. Stradford

bmj.com, 8 Apr 2002 [Full text]

Related letters in BMJ:

Physical health of people with severe mental illness

Wally Barr, Pamela van de Hoef, Ian Colls, Roman Scheurer, McGrath, and

Harvey Whiteford

BMJ 2001 323: 231. [Letter]

_________________________________________________________________

Get your FREE download of MSN Explorer at http://explorer.msn.com/intl.asp.

[Guest guest]

http://bmj.com/cgi/content/full/322/7284/443?

BMJ 2001;322:443-444 ( 24 February )

Editorials

Physical health of people with severe mental illness

Can be improved if primary care and mental health professionals pay

attention to it.

Over 60 years ago the BMJ reported an association between mental illness and

poor physical health.1 Subsequent research, in many countries, has

consistently confirmed that psychiatric patients have high rates of physical

illness, much of which goes undetected. 2 3 Such investigations have led to

calls for health professionals to be more aware of these findings and for

better medical screening and treatment of psychiatric patients. So far there

is no evidence that this is happening, and the excess illness and mortality

continue unabated, with people being managed as psychiatric outpatients

being nearly twice as likely to die as the general population.4

People with schizophrenia are subjected to the long term effects of

antipsychotic medication and have high rates of substance misuse. Yet much

of their excess mortality is due to natural causes. They eat less well,

smoke more, and take less exercise than the general population.5 Smoking

related fatal disease is commoner than in the general population, as are

deaths which could have been avoided by medical treatment.6 Comparative

studies have, however, failed to compare patients with people from similar

social backgrounds, so it is not clear to what extent poverty, poor housing,

and unemployment are causal factors, rather than the direct effects of

mental illness.

Several factors prevent people with mental illness from receiving good

physical health care. People with schizophrenia are less likely than healthy

controls to report physical symptoms spontaneously.7 Some symptoms of the

consequences of schizophreniacognitive impairment, social isolation, and

suspicionmay contribute to patients not seeking care, or adhering to

treatment. When they do present themselves their lack of social skills and

the stigma of mental illness may also make it less likely that they receive

good care. In the United States a fragmented healthcare system, and

difficulties in accessing care, have exacerbated the problems.8

In most industrialised countries reform in mental health care has led to the

closure of long stay mental hospitals and the development of community

mental health teams. Such teams are expected to meet the whole range of

health and social needs. Hospital admissions are often short and infrequent,

and physical health care is not necessarily given priority. In Britain the

national service framework for mental health states that people with a

severe mental illness should have their physical needs assessed. However,

many mental health practitioners have little training in physical care.

Physical assessments of psychiatric inpatients by junior psychiatrists are

poor,9 and the monitoring of physical health and health education by

community mental health staff is generally unsatisfactory.10

Most patients with severe mental illness are in frequent contact with

primary care services, and for many this is their only contact with health

services. However, such contact does not necessarily ensure that they

receive good physical health care. The orientation of primary care is

reactive, and this does not fit well with patients who may be reluctant, or

unable, to seek help. Short consultation times make it difficult for doctors

to assess mental state and conduct a physical assessment, especially in

vague or suspicious patients. When patients are accompanied by mental health

staff more emphasis may be given to psychological and social issues. Doctors

who are inexperienced in, or uncomfortable with, mental health work may

resist intensifying their engagement with a patient by actively asking about

symptoms and performing a physical examination.

A study in the US has highlighted that structured physical assessments of

patients with schizophrenia are effective in revealing physical illness.7 In

the UK the NHS Executive has suggested that general practitioners should be

paid for showing that they have assessed the general physical health of

patients with severe mental illness and made any necessary interventions.11

For such schemes to be successful practices would need to identify their

patients with a severe mental illness and to have an effective and

acceptable screening mechanism. This should highlight physical symptoms and

unmet physical healthcare needs, such as cervical screening and dental care.

The lifestyle of patients with severe mental illness suggests a need for

health promotionwhich can be effective. For instance, group therapy is

effective in helping patients with schizophrenia stop smoking.12 But

progress in this is hampered by negative staff attitudes. Initiatives in

this area should be accompanied by research, so that the most effective

approaches can be identified and widely adopted.

The evidence suggests that it is possible to improve the physical health of

this vulnerable section of the population. Progress will, however, depend on

both mental health and primary care staff being aware of the problem and

being willing to find imaginative solutions which are acceptable and useful

to patients.

Phelan, consultant psychiatrist.

Department of Psychiatry, Charing Cross Hospital, London

W6 8RP

Stradins, mental health nurse.

Ealing, Hammersmith, Fulham Mental Health Trust, Gloucester House, London W6

8BS

Sue on, general practitioner.

lebone Health Centre, London NW1 5LT

--------------------------------------------------------------------------------

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