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Cited by 46Schizophrenia research and treatmentPsychiatric care and mental health servicesCardiac Health and Mental Health

Physical health and severe mental illness: If we don't do something about it, who will?

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Gray, Richard, Hardy, Sheila, Anderson, Kathryn Hoehn·2009·International Journal of Mental Health Nursing
DOI 10.1111/j.1447-0349.2009.00640.x
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Abstract

If you are a mental health nurse working in clinical practice, chances are that you have done or will do a risk assessment sometime today. As practitioners, we worry, quite rightly, about patients with severe mental illnesses, such as schizophrenia, committing suicide. We use risk assessment tools to try and predict patients who are at particularly high risk and then plan appropriate intervention. When our patients do kill themselves, we will often hold an inquiry to determine whether the treating team did everything they could have done to prevent the tragedy occurring. It will come as no surprise then that patients with severe mental illness (SMI) have a dramatically reduced life expectancy compared to the general population. In the USA, adults with severe mental illness die 25 years younger than other Americans (NAMI 2007). What might come as a surprise is that most patients with SMI die from cardiovascular disease (CVD) or from a sequelae of metabolic complications, not suicide, and that life expectancy for patients with SMI is actually decreasing (Fontaine et al. 2001). One of us vividly remembers caring for a patient who died suddenly in his 50s from CVD; he was overweight, had a terrible diet, smoked, and drank. After his death, there was no inquiry, no questions were asked about the care and treatment the health-care team looking after him provided. This is perhaps the real tragedy of 21st century mental health care. We can imagine no other area of medicine where the life expectancy of a patient population getting worse would be anything other than a scandal. At a public debate about physical health and SMI at the (world famous) Maudsley Hospital in 2003, the debate was not about what we can do to improve physical health and increase life expectancy; instead it was about whether primary or secondary care was responsible. Ultimately, responsibility for the physical health care of people with SMI does lie (in most countries) with primary care, but all nurses have a duty to promote health (Hardy 2009). Why then do our patients die? Patients with SMI may have an inherent vulnerability to CVD and other comorbities (Chwastiak et al. 2006; Lawrence et al. 2003); lifestyle risk factors (obesity, smoking, lack of exercise, and a poor diet) are also prevalent (Robson & Gray 2007). Even some of the medications we prescribe increase the risk of cardiometabolic diseases; for example, by causing weight gain, hyperglycemia, dyslipidemia, and hypertension (Allison & Casey 2001; Newcomer 2007). While CVD is the big killer, other physical comorbidities, including respiratory disease, some cancers, and sexually-transmitted infections are also prevalent (Robson & Gray, 2007; Gray et al. 2002). Other common, but overlooked comorbidities include poor eye and dental health, as well as influences from alcohol and drug misuse. Addressing and improving these aspects of health is also important to reverse this increasing trend of early death in our patients with SMI. System issues created by completely different care sites for physical and mental health care create disconnections among providers that limit the continuity of care. Internationally, there have been a number of impressive examples where mental health nurses have demonstrated that they can have a positive impact on the physical health of patients with SMI. A well-being support programme run by nurses reduced cardiovascular risk factors in patients with SMI (Smith et al. 2007). A number of other authors have shown the potential of weight management programmes for patients with SMI (Lowe et al. 2008). A critique of these programmes is that they are complex with a specific focus (often weight gain) delivered in secondary care by specially-trained nurses. As a consequence, only a minority of patients will receive intervention. In the UK, there are approximately half a million patients with SMI; in the USA, there are approximately 13 million. In our clinical experience, every single one of these patients is likely to benefit from physical health intervention. In order to reach every patient, we need to think about simple intervention that can be offered to the many and not the few. We are sure that many of you are thinking that although this is a major health issue for our patients, the idea of offering every patient with SMI a well-being intervention is absurd. We would argue that with determination, we (by which we mean nurses) can achieve the goal of a physical health intervention for all patients with SMI. After all, if every patient can have a suicide risk assessment why can't they have a physical health risk assessment? This model of a simple physical health risk assessment that can be offered to large numbers of patients has been adopted by White et al. (2009) who describe the health improvement profile (HIP). The HIP is a sex-specific, 28-item physical health risk assessment tool that is completed annually by nurses working either in primary or secondary care m

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  • Long-term antipsychotic use and adverse lifestyle choices (e.g. obesity, smoking, poor diet, illicit drug use, and physical inactivity) are implicated in increased risk of cardiovascular events in these populations.

    “Long-term antipsychotic use and adverse lifestyle choices (e.g. obesity, smoking, poor diet, illicit drug use, and physical inactivity) are implicated in increased risk of cardiovascular events in these populations [3], [19], [20], [22], [31]–[33]”

    From Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London (2011) · cites this paper as [20]

    In “Why then do our patients die?” (page not provided), Gray identifies obesity, smoking, lack of exercise and poor diet as prevalent lifestyle risks in people with severe mental illness, and says some prescribed medications increase cardiometabolic disease risk. The passage does not specify long-term antipsychotic use or link illicit drug use to cardiovascular events; it mentions drug misuse only as another influence on health. (LLM, conf=0.85)

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  • Physical health risk assessments and assertive intervention by primary and secondary medical services have been proposed and have resulted in improvements.

    “Physical health risk assessments and assertive intervention by primary and secondary medical services have been proposed and have resulted in improvements [20], [43].”

    From Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London (2011) · cites this paper as [20]

    The body text (page unavailable) proposes physical health risk assessment and coordinated intervention by primary and secondary care nurses. It also reports reduced cardiovascular risk factors after a nurse-run well-being programme, but does not show that the proposed risk assessment or coordinated primary-and-secondary-care approach had produced improvements. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • Despite healthcare improvements, there has been little evidence of benefit on life expectancy in people with SMI.

    “Despite healthcare improvements, there has been little evidence of benefit on life expectancy in people with SMI [1], [20], [21]”

    From Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London (2011) · cites this paper as [20]

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1 of the 13 references couldn’t be matched to a known paper.

Research works printed but not linked: 2

  1. Hardy, S. (2008). Integrating Models for care in mental illness. Practice Nurse, 36 (3), 38-40.
  2. Lowe, T. & Lubos, L. (2008). Effectiveness of weight manage- ment interventions for people with serious mental illness who receive treatment with atypical antipsychotic medica- tion. Journal of Psychiatric and Mental Health Nursing, 15, 857-863.

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Authors
Gray, R., Hardy, S., & Anderson, K. H.
Affiliations
  • University of East Anglia (GB)
  • Florida International University (US)
ORCID
Venue
International Journal of Mental Health Nursing
Publisher
Wiley
Published
2009-09-03
Volume
18
Issue
5
Pages
299-300
ISSN
  • 1445-8330 (ISSN-L)
  • 1447-0349
DOI
10.1111/j.1447-0349.2009.00640.x
OpenAlex
W1585345743
Cited by
46
References
13
Citations by year
2026: 1 · 2024: 3 · 2022: 2 · 2020: 3 · 2019: 3 · 2018: 3 · 2017: 4 · 2016: 2 · 2015: 5 · 2014: 2 · 2013: 2 · 2012: 4
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • International Journal of Mental Health Nursing (publishedVersion)
  • PubMed (publishedVersion)
  • UEA Digital Repository (University of East Anglia) (acceptedVersion)
  • UWE Research Repository (UWE Bristol) (submittedVersion, cc-by)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
  • Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
Keywords
severe mental illness, physical health, cardiovascular disease, life expectancy, comorbidities, lifestyle risk factors, cardiometabolic medications, primary care, psychiatric nursing, health promotion, suicide risk assessment, metabolic complications, obesity, mental health policy, health disparities
MeSH terms
Mental Disorders, Cardiovascular Diseases, Health Promotion, Humans, Life Expectancy, Nursing Assessment, Psychiatric Nursing, Comorbidity, Risk Assessment, Nurse's Role

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