The importance of the physical health needs of people with psychotic disorders

There is increased appreciation and associated concern regarding the importance of physical wellbeing in people living with psychotic disorders. In this population, the mortality and morbidity gaps persist with standardised mortality ratios of 2.6 or higher, and a reduction in life expectancy of 20% compared to the rest of the community. In the face of urgent calls to address this disparity (Suetani et al., 2016), it is timely that the latest edition of the Royal Australian and New Zealand College of Psychiatry (RANZCP) Clinical Practice Guidelines (CPGs) for schizophrenia and related disorders (Galletly et al., 2016) has devoted an entire section on management of physical health. The revised CPGs emphasise the importance of lifestyle interventions to target cardiometabolic risk factors, as well as linking regular physical health monitoring with appropriate and effective treatments.

Although people living with psychotic disorders continue to experience a disproportionate burden of physical illness, there has been some progress in lifestyle modification research in the last decade. Data from the second Australian National Survey of Psychosis have defined the magnitude of the problem (Galletly et al., 2012). Most people living with psychotic disorders are overweight or obese, and have an inactive lifestyle. Almost half of them are hypertensive, and two-thirds smoke cigarettes. This is in the context of striking a difficult balance between utilising sufficient anti-psychotic medication to maintain good mental health, while acknowledging that it may also be contributing to the physical health problems in our patients. Local interventional studies like the Bondi Keeping the Body in Mind programme (Curtis et al., 2016) have demonstrated beneficial outcomes. Initiatives such as the establishment of the Healthy Active Lives (HeAL) consensus statement in 2013 (available at: www.iphys.org.au) and the publication of the RANZCP report Keeping Body and Mind Together last year have had some impact in clinical practice as well.

As the CPGs foreground the importance of physical wellbeing of our patients, the key task for services is to implement effective interventions. Is there now enough research evidence to ‘Just Do It’? Don’t we already have sufficient knowledge to improve the physical health of people with psychotic disorders? Shouldn’t there be a binational implementation of lifestyle modification interventions? Despite some progress, challenges and barriers remain. For example, there is lack of clinical governance and accountability for the physical health of people with psychotic disorders. Is it the job of psychiatrists, general practitioners or physicians to prescribe statins and antihypertensive medication, and monitor clinical response? Additionally, implementation of lifestyle interventions with demonstrated efficacy in research trials may not readily translate to clinical settings. For instant, the CHANGE trial, one of the largest (n = 428), longest (12 months), and most comprehensive lifestyle modification studies for people with psychotic disorders, was recently published (Speyer et al., 2016). This pragmatic randomised control trial consisted of a manual-based intervention targeting physical inactivity, unhealthy diet, and smoking that was individualised and specifically targeted according to each participant. Despite high retention (86.0%), there were no differences in primary outcome (the 10-year risk of cardiovascular disease) nor secondary outcomes, including cardio-respiratory fitness, waist circumference, and physical activity level. Furthermore, additional exploratory outcomes including body mass index, smoking status, and psychotic symptoms scales showed no statistical differences either.

While it is encouraging that some physical health interventions have been effective in those at the early stages of illness, those with severe and persistent psychotic disorders warrant more attention. Most intervention studies in psychiatry have shown that benefits demonstrated during the intervention disappear once the increased level of support is withdrawn (i.e. ‘treatment as usual’ results in ‘outcomes as usual’). A challenge for clinicians, researchers and policy makers is to establish and evaluate programmes that benefit those with persistent illness over the long term. For any lifestyle intervention to be truly meaningful, benefits need to be sustainable. Furthermore, lifestyle interventions alone are unlikely to benefit most individuals. Given the complex interaction between physical health and mental health, addressing the social determinants of health such as unemployment, unstable housing, stigma and social exclusion which challenge this patient population is likely to be necessary in order to make a meaningful difference.

Changing the lives of people with psychotic disorders will require a societal and cultural shift supported by robust research evidence, and political leadership with appropriately financed research and service provision. Only then will solutions start to bridge the gaps in morbidity and mortality. The increased recognition of the physical comorbidities in the CPGs represents an essential step towards achieving health equity in our patients, and highlights our collective professional responsibility in achieving this goal.