Severe mental illness (SMI) includes schizophrenia, bipolar disorder and other psychoses. A study carried out in the UK (Hayes et al, 2017) found a mortality gap between people with SMI and the general population of up to 25 years. Evidence suggests that 75% of this excess mortality is caused by physical illness such as respiratory disease, diabetes and cardiovascular disease (Liu et al, 2017; Barber and Thornicroft, 2018). Factors which may have an impact on premature mortality in this group include economic disadvantage, unhelpful health behaviours (smoking, poor diet, lack of exercise), and difficulties accessing and adhering to medical treatments (Olfson et al, 2015). The antipsychotic medication sometimes used to treat SMI is also linked with premature mortality as it contributes to the development of cardiovascular disease, diabetes and obesity (Mitchell et al, 2013; Torniainen et al, 2015). People with SMI are often not given adequate treatment for major medical conditions which may increase their risk of premature mortality (Woodhead et al, 2016).
The mortality gap between people with SMI and the general population has not improved despite increased recognition of the importance of physical comorbidity (Mitchell et al, 2017). This may be due to the focus being on lifestyle factors alone, which will not increase the life expectancy of people with mental health problems (Marmot, 2010). Inadequate social relationships, poor housing, unemployment and despondency also have a major impact on physical health so need to be addressed (Marmot, 2010). Many other physical conditions are also prevalent in this group (such as sexually transmitted infections, obstetric complications, osteoporosis, dental problems), but the symptoms of these are often viewed by health professionals as part of the person's mental illness (Nash, 2013).
How a person is affected by mental illness
How a person is affected by their mental illness will have an impact on their behaviour, communication and ability to take on board information and advice. Understanding the symptoms will be helpful when consulting with people with SMI.
Psychosis
Psychosis is a symptom of mental illness rather than an illness itself (American Psychiatric Association, 2013). It alters the senses, so the affected person may not be able to distinguish between reality and their symptoms, and they may perceive or interpret things differently from those around them. The two main aspects of psychosis are hallucinations (auditory or visual) and delusions (belief maintained despite being contradicted by reality).
Schizophrenia
Schizophrenia is a psychotic disorder where the person has positive, negative and cognitive symptoms (American Psychiatric Association, 2013). The positive symptoms include hallucinations, delusions and thought disorder (thoughts and conversation appear illogical and lacking in sequence). The negative symptoms are an absence of behaviour that the person may have had. The person with schizophrenia may appear emotionally inexpressive and unresponsive, have poverty of speech, lack the desire for company, be unable to show or feel pleasure, and may have a lack of will, spontaneity, and initiative. Cognitive symptoms are common and include problems in concentration and task planning.
Bipolar disorder
Bipolar disorder is characterised by episodes of mania (elated mood) and depression (American Psychiatric Association, 2013). During a phase of mania, the person may feel euphoric and self-important, be full of energy and have new ideas and plans. People with bipolar disorder may talk quickly, become easily distracted, irritated or agitated, and may not sleep or eat. Individuals with bipolar disorder may engage in pleasurable behaviour with distressing consequences, such as spending large amounts of money or engaging in risky sexual encounters. During the depression phase the symptoms may include feeling sad and hopeless, empty or worthless, and guilty or despairing. People with bipolar disorder may lack energy, have difficulty concentrating and remembering things, lose interest and enjoyment in everyday activities and experience self-doubt. Problems with sleeping and waking up early, and suicidal thoughts may also be present. Symptoms of psychosis can be experienced during either phase.
The role of primary care
Authors of the National Institute for Health and Care Excellence (NICE) guidance for psychosis and schizophrenia (NICE, 2014a, checked March 2019) and bipolar disorder (2014b, checked October 2017 and amended February 2020) recommend that GPs and other primary health professionals in England should monitor the physical health of people with these conditions when responsibility for monitoring is transferred from secondary care, and then at least annually. Most of the elements recommended as part of the annual health check are tasks that are familiar to nurses and other health professionals working in primary care; these are described in Table 1. Parity of esteem means valuing mental health as much as physical health in order to close inequalities in mortality, morbidity or delivery of care (Mitchell et al, 2017). In order to achieve parity of esteem, the government placed a legal responsibility on health services to make reasonable adjustments to ensure that people with SMI are not disadvantaged compared with the general population in accessing healthcare (Equality Act 2010).
Table 1. Elements of a health check
| Measurements | Body mass index (BMI) and/or waist circumference, pulse rate and electrocardiography (ECG), blood pressure |
| Blood tests | Liver function, lipids, glucose and/or HbA1c. Also consider prolactin, urea, electrolytes and calcium, thyroid function, full blood count, B12 and folate, plasma levels (as appropriate, such as lithium) |
| Screening | Check cervical cytology has been carried out; give advice about self-examination (testicles, breasts); discuss dental hygiene and dental visits; recommend visit to opticians; check feet (for neglect, poorly fitting shoes); ask women about their menstrual cycle; ask if there are problems with urination; enquire about bowel habits and offer appropriate advice |
| Lifestyle | Ask about sleep issues (too much, too little) and provide appropriate advice; check smoking status and provide advice on reduction or cessation; offer advice regarding exercise, alcohol, fluid intake and diet; ask about caffeine intake and drug use; discuss safe sex and sexual satisfaction |
| Medication review | To monitor patients taking antipsychotics, use a side effect rating scale such as the Glasgow Antipsychotic Side-effect Scale (Waddell and Taylor, 2008), ask patients about all medication use |
| Care plan | Discuss a plan of care to prevent relapse (most patients who have a mental illness are seen only in a primary care setting, so it is important that the primary care team takes responsibility for discussing and documenting a care plan in their primary care record) |
| Flu vaccination | As patients have an increased possibility of cardiovascular disease, they should be considered as an at-risk group |
Reasonable adjustments in primary care
Inviting patients for a health check
People with SMI are not consistently made aware of their risk of increased cardiovascular risk and other physical conditions (Hardy et al, 2012; Hardy, 2013), which may influence their decision to attend a health check. Symptoms of their mental illness may affect their ability to remember the appointment or keep to time, and they may feel too anxious to come. Even otherwise healthy people are often not motivated to attend for a check-up because they may believe that they have a healthy lifestyle or are free from symptoms and do not have other chronic conditions (Burgess et al, 2015). A randomised controlled trial in England found that overall uptake of NHS health checks was only 14% following a standard invitation letter (McDermott et al, 2016). Box 1 provides some suggestions for making it easier for people with SMI to attend a health check.
Box 1.Making it easier for people with severe mental illness (SMI) to attend a health check
- Invite by letter giving date and time of appointment
- Use a prompt two days before to remind them of the appointment
- Avoid early mornings and times when the practice is busy
- Provide explanations about the purpose of the appointments
Norman and Conner (1993) carried out a study in a primary care centre in England which showed that letters offering patients an appointment with a specific date and time for a health check nearly doubled the attendance rate compared with letters containing an open invitation (70% vs 37%). An audit of people with SMI in one primary care practice showed a 70% attendance for their physical health check when they were invited by letter giving a date, time, place and name of practitioner (Hardy and Gray, 2012). The authors determined that offering a set time and date removed a complex step in the process for the person with SMI. Sending a prompting letter a few days before the appointment (consisting of a short paragraph, taking about 30 seconds to read, explaining the programme of care, and providing gentle encouragement) has increased attendance in the general population (Perron et al, 2010).
In addition to inviting patients by letter, people with SMI can also be telephoned or sent a text message. Randomised controlled trials in England on the subject of NHS Health Checks showed that nearly 14% more people attended an appointment when invited by telephone compared to those who received a letter (Gidlow et al, 2019) and endorsed text message reminders had a big impact on participation (Sallis et al, 2019). A systematic review of telephone prompting (McClean et al, 2016) only found one study specific to people with SMI (Reda et al, 2001). They observed no clear difference in attendance between those prompted by telephone one or two days before the appointment and those given a standard appointment management system. This may be because some people with SMI do not have access to a working phone. However, telephone prompts may be more successful now as owning a mobile phone has become standard. According to an international survey, 94% of people in advanced economies now own a mobile phone (Pew Research Center, 2019).
Some people with SMI will be in contact with the community mental health team (CMHT). If they are informed of the health check invitation, they may be able to encourage the patient to attend and might even come with them. National guidance states that it is the responsibility of the mental health team to ensure that patients under their care receive physical healthcare from primary care (NICE, 2014a). However, in practice, liaison between nurses working in primary care and nurses working in mental health services is poor. This is because there is generally no system of communication in place and it relies on individual nurses making extra effort to find out who they should contact.
Appointment set up
There is no published evidence to support how to make it easier for patients with SMI to attend for their health check but there are practical adjustments that can be attempted. Anecdotally, practice nurses have reported some success with adjusting the time and duration of the appointments.
Time of appointment
As some people with SMI may struggle to get up due their symptoms and medication side effects, it may be helpful to offer appointments later in the day. As this group of people may become agitated if they have to wait, and anxiety may be increased if the waiting room is full of people and is very noisy, it is worth considering how this best can be avoided in individual practices – although during the COVID-19 pandemic this is unlikely to be an issue.
Duration of appointment
People with SMI may struggle with lengthy appointments which provide too much information, but there is a risk of them not returning if all measures are not completed. Concise information and explanation about the benefits of coming back, coupled with the follow up appointment being given to them during the appointment may assist with this.
Support for behaviour change
Following a health check, people with SMI should be supported to change any identified unhealthy behaviour in order to reduce morbidity and mortality, as physical health checks alone do not improve health (Graham et al, 2014; White, 2015). Early physical health intervention and health promotion are the most important type of intervention for this group (Mitchell and De Hert, 2015). There is a perception among health professionals that helping people with SMI in making lifestyle changes would be difficult and that lifestyle interventions employed for the general population will not be effective for people with SMI (Hardy, 2015). However, studies have shown that patients with SMI can effectively work with health professionals to learn how to make lifestyle changes (Campion et al, 2005; Alvarez-Jimenez et al, 2008). In a research programme, Osborn et al (2019) demonstrated that primary care nurses and healthcare assistants can deliver cardiovascular disease risk-reducing interventions to people with SMI. They reported that the intervention was well attended (almost half of patients attending six or more appointments) and this resulted in fewer inpatient admissions. People referred to behaviour change groups, eg weight management, stop smoking, may still require support by the practice nurse to ensure attendance and engagement. A randomised controlled trial showed that structured group education alone is not clinically effective (Holt et al, 2018). The same behaviour change approaches used with the general population should be used with people with SMI (Box 2), but due their symptoms they may need more support. After assessing the person's understanding of healthy behaviour and their present behaviour (Box 3) and before giving advice, attention should be given to practical factors, for example have they got access to cooking facilities or are they able to shop? There are also special considerations with regard to smoking cessation which are described in Box 4.
Box 2.Behaviour change approachesIdentify the person's stage of readiness (see Box 3) and then consider the most suitable therapeutic interventionIf the person is in the precontemplation or contemplation stage, this should be acknowledged by listening, empathising and being curious about their reasonsIf the person is in preparation or action, it is appropriate to offer them support to help them change their behaviour. One behaviour should be tackled at a time
- Set a goal – what do they want to achieve?
- Plan the action – how are they going to achieve it? Provide instruction if applicable
- Record the action – to enable the monitoring of progress
- Review progress – to assess what is working and what can be improved
- Give positive feedback – praise or encourage behaviour change efforts
- Support with relapse – to assist them to get back on track
Adapted from Hardy, 2017
Box 3.Readiness to change
- Precontemplation – No, not me
- Contemplation – Well, maybe
- Preparation – OK, what do I do now?
- Action – OK, let's do this!
- Maintenance – it is possible!
Adapted from Prochaska et al, 1994
Box 4.Smoking cessation in severe mental illness
- As smoking increases the metabolism of some medications, including antidepressants, antipsychotics, benzodiazepines and opiates, the doses of these medications need to be reduced when smoking is reduced to prevent toxicity
- Further dose reductions may be required with continued cessation although original doses need to be reinstated if smoking is resumed
- Monitor the mental state of people following reduction/cessation. For those taking bupropion and varenicline, there should be a clearly negotiated plan of support that outlines actions to be taken in the event of change in psychiatric symptoms, especially in the first 2–3 weeks
- Monitor for smoking resumption since this is common and requires prompt dose increases of some medications
Adapted from Campion et al, 2014
Conclusion
Health professionals in primary care are responsible for carrying out physical health checks for people with SMI. Making reasonable adjustments will make it easier for this group to attend. Support to change behaviour needs to be provided to improve health and decrease the risk of early mortality.
KEY POINTS:
- People with severe mental illness (SMI) die up to 25 years earlier than the general population
- People with SMI are often not given adequate treatment for major medical conditions which may increase their risk of premature mortality
- Primary care health professionals should monitor the physical health of people with SMI
- Reasonable adjustments should be made to ensure that people with SMI are not disadvantaged compared with the general population in accessing healthcare
- The same behaviour change approaches used with the general population should be used with people with SMI, but they may need more support
CPD reflective practice:
- How are health checks for people with severe mental illness (SMI) organised in your practice?
- What support is provided by your practice team to assist people with SMI to change unhealthy behaviour?
- Is there anything that could be done differently in your practice to improve the physical health of people with SMI?