Poor physical health in mental health: Finding a way forward

Lambert et al.’s (2017) efforts to bring about consensus in the treatment, management and monitoring of the physical health of people with an enduring psychotic illness are laudable. One of their main strengths is the emphasis placed upon recommendation at the systems level in order to change practice, representing a way forward for psychiatry in Australia. Higher morbidity and mortality rates from all main causes of death when compared to the general population are now well known, and the Royal Australian and New Zealand College of Psychiatry (RANZCP, 2016) highlight the economic cost of poor physical health, suggesting that much needed primary health care and support to address these issues are decidedly low.

To provide consensus and reduce the risk of bias, Lambert et al. (2017) incorporated mental health consumer and carer expertise. We must always remember that consumers and carers themselves are experts in their own experience. A consumer and a carer panel were invited to rate one-third of the survey items – 117/416 items – but were not asked to contribute to items deemed to require clinical expertise. It is here that many people will have issues with the claim of consensus. For example, mental health consumers were not asked for their ‘expertise’ on medication side effects, which is astonishing as they are the ones directly experiencing them. In addition, as consumers rated all 117 items as important or essential in round 1, they were excluded from rating in the second and third rounds. Clinicians who rated items as essential or important in the first round were still able to participate in the second and third rounds. This methodology did not allow consumers and carers to rate any of the 14 new items that were added after the first round.

It also concerns me that for such an important document primarily aimed at clinicians, medication and treatment side effects are only given a cursory glance in the introductory descriptors of poor physical health in mental health consumers. This is despite overwhelming evidence that they are a major contributor alongside (rather than behind) smoking, substance abuse and cardiometabolic risk factors, such as sedentary behaviour and poor eating habits. Indeed, the College report (RANZCP, 2016) on the cost of comorbid physical and mental ill health in Australia and New Zealand dedicated an entire section to ‘Treatment of Psychosis and Side Effects’, and the College guidelines for managing schizophrenia and related disorders highlight the need to attend to adverse medication effects throughout their document (Galletly et al., 2016). The only inkling in the Introductory section of the paper that treatment factors may need to be considered was the brief mention of the ‘duration of antipsychotic therapy’ (Lambert et al., 2017). Yet, this is vague enough to allow for the consideration that the illness itself may be responsible for poor physical health rather than the medications used to treat it. The impact of medication side effects does appear much later in the paper in the Consensus Statement when discussing the rationale for screening and detection. It is also included for consideration when developing a management plan for people with enduring psychotic illness. Here emerges the difficulties psychiatrists face in balancing the mental and physical wellbeing of patients in their day-to-day work. This important point of the impact of psychiatric medications upon physical health, though, needs to be made much earlier in the piece so as not to downplay the responsibilities of clinicians and mental health services to their clients.

The impact of treatment on mental health is appreciated in the seminal paper by Basu and Meltzer (2006). The authors put forward the view that poor physical health is concordant with treatment modalities and medication change over time. This is explained through a comparison of pre- and post-atypical antipsychotic eras in the United States, where the authors examined trends in the prevalence of diabetes mellitus (DM) and general medical illness. The incidence of DM in people with a diagnosis of schizophrenia before the use of newer atypical antipsychotics (1979–1989) was similar to that of the general population. The increasing use of atypical antipsychotics (the 1990–1995 period and the 1996–2001 period) was strongly associated with an increasing prevalence of DM, ‘… creating the potential for cardiovascular disease and other consequences of DM, in patients with SCHZ [schizophrenia] as well as other types of patients who use these drugs on a chronic basis’ (Basu and Meltzer, 2006: 107). The example of DM here reinforces the need for an overall awareness of differing treatment approaches.

Finally, as the authors suggest, the mere development of guidelines does not ensure their use in clinical practice. Algorithms for use at the ground level in services can be helpful (Stanley and Laugharne, 2014), but the standardisation of all-inclusive guidelines and recommendations are needed to address the poor physical health of people experiencing psychotic illness. The Consensus Statement proposed by Lambert et al. (2017), although needing a little more balance, is a step in the right direction.