Progress towards parity: Improving the physical health of long-term psychiatric inpatients

People with severe mental illness (SMI) are amongst the most disadvantaged in our community. The inadequacy of the physical health care often provided for people living with SMI has been described as a form of ‘lethal discrimination’ (Rethink Mental Illness, 2013), leading to the ‘scandal of premature mortality’ (Thornicroft, 2011). The life-expectancy gap for people with mental illness compared to the general population in Australia is 15–20 years, a gap higher than that seen in Indigenous Australians.

Although research in this field over the past decade has increased, this has predominantly focused on describing physical health disparities in people with SMI. Only more recently have evaluations of interventions aimed at improving this disparity begun to appear. In an earlier of the ANZJP, Hjorth and colleagues (2014) report findings from a pragmatic 12-month intervention aimed at improving the physical health of clients with persistent and severe mental illness. Their results are encouraging. Participants were recruited from six long-stay psychiatric inpatient units in Denmark into a cluster-controlled trial. Three sites were randomly allocated to provide usual care, and three sites provided usual care in addition to the HELPS ‘active awareness’ intervention. The intervention was delivered by two experienced psychiatric nurses and included motivational interviewing in small focus groups for clients, as well as a brief individual session.

In a novel approach, the intervention also focused on staff behaviour, providing motivational interviewing and educational sessions on smoking, nutrition, physical activity and medication usage. Additionally, staff had the opportunity to gain support for their own smoking cessation. Staff and clients were encouraged to make changes in the ward environment to improve physical health outcomes. The main outcome measure was waist circumference and, interestingly, measures were also obtained from staff, although these data were not reported in the current paper.

At baseline, of the 85 participants, 69% were regular tobacco smokers and the majority of participants were overweight or obese, with central obesity. This is similar to a recent large Australian cohort in contact with mental health services where the prevalence of overweight and obesity was 75.5%, and 82.1% had central obesity (Galletly et al., 2012). At the 12-month follow-up the intervention group showed a small decrease in waist circumference (0.75 cm), whilst this increased in the control group (2.17 cm), highlighting the success of the intervention in preventing further deterioration of metabolic health among this cohort. This is encouraging given the high rates of existing obesity and the pragmatic nature of the intervention. The study did not involve intensive or specialized exercise or dietetic interventions, with lifestyle interventions delivered by mental health nurses following training. Future studies could examine whether additional benefits might accrue with more specialized and intensive lifestyle interventions.

For people experiencing SMI, preventing further weight gain, reducing smoking, improving nutrition and increasing physical activity should be standard clinical practice. There is increasingly robust evidence to demonstrate this is feasible and acceptable for people with established mental illness (Daumit et al., 2013). The Hjorth et al. study reinforces how difficult it is to reduce weight once it has become established and its success was in preventing further increases in weight, rather than in reduced weight or waist circumference. Preventive strategies can also be applied to key cardiovascular disease (CVD) risk factors during the early phase of psychosis. This is a time of potentially rapid and severe weight gain where prevention could alter the trajectory towards obesity and associated metabolic disturbances. This offers the prospect of preventing the seeding of poor physical health, with the potential to ultimately reduce the premature morbidity and mortality gap in people living with SMI.

This approach fits within the ethos of prevention and early intervention for psychosis that aims to reduce the duration of untreated psychosis thereby improving prognosis and quality of life, and minimizing the secondary consequences of untreated illness. We believe the evidence for extending this paradigm to include early intervention to avoid future negative physical health outcomes is strong. There is clear evidence that the trajectory of compromised physical health occurs rapidly, within the first 12 weeks of commencing antipsychotic medication (Alvarez-Jimenez et al., 2008; Correll et al., 2009; Pérez-Iglesias et al., 2014), with significant weight gain and disturbances in glucose and lipid metabolism, including in children and adolescents. These early disturbances predict future life-shortening CVD, obesity and diabetes. There is promising new evidence that structured, lifestyle interventions from the outset of treatment in first-episode psychosis youth can attenuate antipsychotic-induced weight gain, in contrast to treatment as usual (Curtis et al., 2014).

Highlighting global recognition of this issue, the iphYs (international physical health in youth stream) consortium was established in 2010 and has developed the Healthy Active Lives (HeAL) declaration (www.iphys.org.au) launched in June 2013. The HeAL declaration alerts consumers, clinicians, and policy makers to the physical health inequalities in young people experiencing psychosis and calls for ‘a world where young people experiencing psychosis have the same life expectancy and expectations of life as their peers who have not experienced psychosis’. Supporting the need for parity of physical health expectations, the HeAL declaration sets out 5-year targets and principles to prevent premature cardiometabolic disease and has been widely endorsed.

As demonstrated by Hjorth et al., improving the physical health of inpatients with mental illness is possible, and influencing staff attitudes is likely to play a significant role in facilitating change. The challenge is to ensure widespread dissemination and translation of such findings into practice, and adoption of the ambitious targets of the HeAL declaration. Such initiatives will set the scene for progress towards parity.

See Research by Hjorth et al., (2014) 48(9): 861–870