Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level
As outlined in the first part of this bi-partite publication 1, individuals with severe mental illness (SMI) are at an increased risk for a large number of physical disorders that require clinical attention. People with SMI are entitled to the same standards of care as the rest of the population. However, rates of undiagnosed and untreated medical illnesses are higher in SMI individuals, compared to the general population. Despite the fact that the higher morbidity and mortality of physical illnesses in SMI patients are largely due to modifiable lifestyle risk factors 1, there is sufficient evidence that disparities not only in health care access and utilization, but also in health care provision, contribute to these poor physical health outcomes 2,3. According to one recent study, people with psychotic disorders, bipolar disorder, or major depressive disorder have greatly increased odds of reporting difficulties in accessing care (odds ratios, OR=2.5–7.0) 4. Although parity in access to and provision of health care should be conceived as a basic human right, a confluence of patient, provider, treatment and system factors has created a situation in which access to and quality of health care is problematic for individuals with SMI 5. Table 1 summarizes the barriers to the recognition and management of somatic illnesses in SMI patients. In many cases, the SMI patients’ only contact with the health service is through the mental health care team. Moreover, because of their SMI, these patients are less capable than other patients of interpreting physical signs, as well as solving their problems and caring for themselves, which places an increased responsibility on the part of mental care workers to be in the fore front for the physical health care of these patients 6. Two consensus conferences have called on mental health care providers to take responsibility for the physical health of their patients 7,8. However, despite data suggesting that the sensitization of psychiatrists to expand their tasks to include assessments of both mental and physical health in SMI patients can be improved by consensus guidelines 9, many psychiatrists still consider their primary or, even, sole function to provide clinical care in terms of psychiatric symptom control and are reluctant to monitor physical health 6. Although many barriers can be related to the patient and his/her illness, and/or to the clinician and his/her medical treatment, the reintegration of psychiatric care and general somatic services, with an ultimate goal of providing optimal services to this vulnerable patient population, seems to represent one of the most important challenges for psychiatric care today 7,10. However, this is only one part of the broader picture: 37% of 195 countries in the world do not even have a specified budget for mental health, and 25% of the countries (of the 101 countries that reported their mental health budget) spend less than 1% of their total health care budget on mental health 11. In some parts of the world, mental health resources are even poorer. In Africa and in the Western Pacific Regions, a mental health policy was found to be present in only half of the countries 12. Moreover, in developing as well as in developed countries, stigmatization, discrimination, erroneous beliefs and negative attitudes associated with SMI will have to be eliminated to achieve parity in health care access and provision. Due to differences between regions and countries (e.g., level of economic development, budgeting of health care, availability of mental health care personnel, etc.), the majority of actions should be adapted to the local needs and circumstances 7. The excess mortality rates in persons with SMI are largely due to modifiable health risk factors 1. Therefore, the monitoring and treatment of these factors should be a part of clinical routine care of the psychiatrist. Furthermore, to address the problem of suboptimal medical treatment for patients with SMI, changes need to be made in the health care system and delivery 48, wherein the psychiatrist, once again, can and should play a pivotal role. Physical health checks should focus on monitoring 49,50,51: - weight gain and obesity (body mass index, BMI; waist circumference, WC); - blood pressure; - dietary intake; - activity level and exercise; - use of tobacco and alcohol or other substances; - fasting blood levels of glucose; - fasting blood levels of lipids, especially triglycerides and high-density lipoprotein (HDL)-cholesterol; - prolactin levels (if indicated by reproductive system and/or sexual symptoms); - cardiovascular disease (CVD) risk and electrocardiographic (ECG) parameters; - dental health; - liver function tests, blood count, thyroid hormone, electrolytes (periodically, as indicated). Many of these physical health monitoring tests are simple, easy to perform and inexpensive 6,52,53,54, and therefore can/should be implemented in the health care systems of developed as well as developing countries. Moreover, even in developing countries, several of these simple and inexpensive measurements (e.g., body weight and blood pressure) can be routinely done by health workers other than doctors. Screening and assessment of physical health should begin with the patient's personal and family history, covering 40: diabetes mellitus (DM), hypertension, CVD (myocardial infarction or cerebrovascular accident, including age at onset), smoking, diet, physical activity. Secondly, as the individual components of the metabolic syndrome (MetS) (see 1) are critical in predicting the morbidity and mortality of CVD, DM, cancer and other related diseases, these, as well as some other non-metabolic parameters, should be checked at baseline and measured regularly thereafter 46,51. Concerning metabolic parameters, one should remember that drug-naïve, first-episode patients, as well as children and adolescents with psychotic disorders, are at higher risk for metabolic side effects of medications 55,56. Higher baseline values of weight and visceral fat distribution, as well as laboratory evidence of impaired glucose and lipid metabolism, have been, although not consistently, reported for these patients 57. Likewise, young drug-naïve patients of non-Caucasian ethnicity with a personal or family history of metabolic risk factors are more likely to develop metabolic side effects 57. Psychiatrists should, regardless of the medication prescribed, monitor and chart BMI and WC of every patient with SMI at every visit, and should encourage patients to monitor and chart their own weight 58. WC seems to be a more useful measurement than BMI. Prospective data in patients with impaired glucose tolerance revealed that central adiposity, having a strong correlation with insulin resistance 59, better predicted future type 2 DM than BMI 60. WC is also a stronger indicator than BMI for systolic blood pressure, HDL-cholesterol, or triglycerides 61, and has been proposed as the best single measure to identify individuals at high risk for CVD and the MetS 52. It is also a simple tool to assess the likelihood of insulin resistance: in one study, a WC <100 cm excluded insulin resistance in 98% of males and 94% of females 61. This assessment can easily be done with a simple and inexpensive waist tape measure. The International Diabetes Federation (IDF) definition (see 1) provides sex- and race-specific criteria for defining elevated WC to identify people with central obesity, thus adapting this criterion to make it also applicable to non-Caucasian populations. However, multiple studies found that WC is rarely measured 62,63,64. The other MetS criteria of blood pressure, fasting plasma glucose and fasting lipid profile should also be assessed, even if WC is normal. As the MetS components seem to cluster, the presence of one component often suggests the presence of the others. High blood pressure in SMI patients is often missed 65. As the cost for measuring blood pressure is low, and hypertension is a relevant CVD risk factor, blood pressure can/ought to be assessed routinely, even at every visit. Hypertension can be defined as a systolic blood pressure $130 mm Hg or a diastolic blood pressure $85 mm Hg 66. This diagnosis requires at least two separate, independent measurements that fall both within the range of hypertension 65. Individuals with a systolic blood pressure of 120 to 130 mm Hg or a diastolic blood pressure of 80 to 85 mm Hg should be considered as pre-hypertensive and require lifestyle modifications to prevent heart disease 67. A baseline measure of plasma glucose level should be collected for all patients before starting treatment 58. In patients starting antipsychotic (AP) treatment, finger prick tests should be carried out at baseline, 6 and 12 weeks to capture early cases of hyperglycemia and then, at minimum, yearly. Formal laboratory screening tests can then be carried out blood glucose measurement should be in the fasting because this is the most measurement for the of developing glucose However, this can problematic to In cases patients present it is to a blood glucose than to the to 6. plasma glucose or suggests the of plasma glucose levels between and values of are of and should also assessment and However, the of need to be excluded by at least one measurement of fasting plasma the is the of fasting plasma glucose measurements needs to be increased to a to assess the of the Likewise, if fasting plasma glucose levels are or values are the of needs to be excluded by at least one measurement of fasting plasma the measurement the this should to a with an or other primary health care for assessment the glucose levels the This is as a goal for treatment but not to in early have risk factors for DM history, BMI WC critical should have their fasting plasma glucose level or at the same as other patients starting medication 6 and but thereafter need to be checked more every are or more of their baseline weight should also have their fasting plasma glucose level or more for every 58. of high should be to and often develop within and and poor weight of and in to metabolic and The of a patient with on the of the (e.g., or patients only of poor or In type 2 DM, and have been for weeks to of which can be through laboratory tests, blood glucose level and a of or triglycerides and should also be assessed at baseline and at with assessments screening is in of values for total are for patients DM and for patients with lipoprotein values for patients and with DM are and 65. However, the cost and of availability of this assessment not make it as a routine measure in all and patients. The patient's individual CVD risk should be his/her presence or of DM, systolic blood pressure and total or the of total to with to local or risk measurements are simple and easily In the psychiatric it is often to an as as in other medical In less well developed countries, an be even more In these cases, a is to patients should be heart as family history of early in males and in personal history of a heart of medications or or if has an of simple the measurement of as a baseline that the monitoring of patients with SMI has to be as a baseline in to assess the health As a general that every patient should have an measurement to the of on the by a monitoring can be A baseline assessment is especially important in patients with clinical risk factors for with a family history of early personal history of a heart hypertension or at heart and to have a prolactin levels should be measured in all patients at prolactin levels should only be measured in sexual or reproductive system are these need to be and system prolactin level measurement include or in and/or and in that should prolactin measurement include and/or that with antipsychotic treatment or including or problems with or In these cases, prolactin should be measured every especially the of Although the clinician needs to be that laboratory between in most prolactin values are at for and for A measurement of prolactin levels is the presence of which is but to high prolactin levels as measured by many that the presence of to in as many as of all reported of In cases measured prolactin is reporting of prolactin of can antipsychotic treatment, prolactin levels are most the of these levels is a of is the which has been associated with and The risk for cancer is less seems to be is that prolactin level that to should a treatment to a less prolactin antipsychotic (e.g., or, in patients, of the to out a should only be other for prolactin are excluded (e.g., by by thyroid hormone, and or if prolactin levels are and do not a to a risk or if are the of a Although considered by many as not health needs to be in the same as other physical health problems factors for a poor health (e.g., smoking, medication side and individual care needs should be assessed Physical screening and monitoring are well by patients and can be implemented in a of to general it is not to most patients to take part in the fasting blood and most are to and the of the Screening patients an monitoring 85 or risk chart is a than the more and guidelines recent both and have developed screening and monitoring guidelines these seem not to be routinely implemented in the clinical care of patients monitoring should be done at Physical health assessments should be on the and of the assessments compared with of treatment, it is important to measure weight to identify patients gain weight and screening of all patients on medication at baseline identify individuals and to early of changes in metabolic at the minimum, every guidelines screening and monitoring at baseline, 12 and patients gain at least of baseline body weight or are at increased risk for health outcomes (e.g., family history of DM or early personal history of or obesity, DM, the patient has central obesity, blood pressure mm plasma glucose or or DM plasma glucose or or triglycerides should be to primary care to these simple lifestyle or and/or to a risk medication can address these medical but not individuals with SMI are of the need to or do not the and to make lifestyle and other of the can and people with SMI to address their including smoking, and through the use of with SMI, as well as their family and should be and should to not need to be by a (e.g., a it require but should be by at the mental health and can be resources within the local service 6. should be and and treatment be to the individual needs of SMI patients dietary and physical activity in terms of weight gain in The on health, even with simple is A diet, physical activity and are the components of the and of modifiable risk However, if lifestyle do not including or be should be and as for the general and are well Moreover, to weight can be most evidence for to with or in Many patients with SMI do not the components of a It is that patients with have a higher in fat higher in in and poor in and Therefore, be should be to and even, as well as high high and poor as and The of as and and in a should be by Although patients well as their family and is patients need to that lifestyle changes should be people weight modifications will to their weight the likelihood of developing many are in fat and a weight in dietary can have has many that are of to SMI patients, including a in risk of DM and CVD, of triglycerides and in and in blood glucose and patients with type 2 However, that address weight management and physical activity have not a routine part of psychiatric care The can the individual with SMI in and that address the of health and which can medical in this population. as the and the for have been to be in people with SMI Table some of to the health of patients with Physical is one of the risk factors that can most easily be and in individuals with SMI People with are more than the general of these patients the health of a of at least physical activity According to the guidelines of the of and the physical activity between and a will provide weight and is in weight of physical activity a can be associated with weight Physical activity can metabolic health even in the of weight is evidence that physical activity with or is and in weight and risk profile in people with However, in patients are physical should be by to achieve weight if a patient for 1 are this is in terms of cardiovascular health, this will not in weight physical as be all these patients should be to in at least of activity least a on most of the 65. A of studies that patients, compared with the general population, have a higher of smoking, and high as well as of risk factors that make more vulnerable to to of individuals with SMI will and/or have a quality of because of a disease of is associated with a in the risk of heart disease and a in the risk of high cardiovascular Therefore, SMI patients should be to However, has important for the management of patients and of is associated with a risk of in patients levels can also found that the of patients with a plasma level increased to within the the despite Therefore, plasma levels be and made in if for at least Moreover, also the risk for In a study, an increased risk for DM that within of but was still 6 The increased risk seems to be by weight of to increased and excess Therefore, should consider (e.g., use of especially for tobacco is in patients with is evidence that people with SMI can Moreover, that in the general to be in SMI patients. The evidence also suggests that tobacco in SMI patients with psychiatric not mental although psychiatric often that a policy have a negative on the treatment this is not the Therefore, at a minimum, psychiatric should assess tobacco use in all patients, all tobacco to patients in developing a and and patients can be to a which can or other 65. blood pressure levels of less than are as smoking, weight and increased be sufficient to elevated blood pressure, although some patients are likely to require 65. guidelines the of best to the individual patient's needs health and should be to SMI patients, to their and treatment need to be to the individual needs of patients with and of mental should include dietary smoking, and side effects of and on the dietary control of and the of to the of a are to the side effects of some Psychiatrists should be made more of the of health Therefore, for in the of health risk factors as and of side effects of and on is patients with SMI need and to make use of dental are by dental care The should for do not patients and are to take care of this vulnerable population. the for of dental care should be Formal for the dental and of mental illness and medication side effects can be or to be associated with should not be for SMI patients with heart a personal history of a family history of at an early age if both or syndrome (see of and of are in patients with treatment, the SMI patient should be related to elevated as of and or patients are medications to be associated with prolactin these baseline should be at every starting the medication or the is sexual is management include the to a or sexual function by as or a should be considered prolactin is even a elevated level for more than or to a medication should be a has the of the and levels are or the patient has of a other than then to an is psychiatrists should also be that even to can be the of a as a 58. there are more data on the of on and development, the clinician will to in a of individual clinical the of the is and should be made on a The and be for patient on an individual In the use of medication is indicated risk to the to this medication is by the of untreated or psychiatric illness in the require treatment should the and of with their if it is that treatment should be the will be of in this important on and should also be as part of routine mental health care Many psychiatrists are reluctant to despite the presence of physical health 6. should be to and/or medication a SMI patient of weight of or or other effects (e.g., side The should, consider the psychiatric and physical of the patient and the of both is to a to or prevent the (e.g., or to weight gain in patients DM or severe physical illness has been the SMI patient should be to services, including and to the health are at two levels of system level and health care and individual level patients, the with SMI as a health population. is still a of of the physical health and health care access problems for people with Therefore, and health care first have to identify and people with SMI as a health before the problem can be Psychiatrists can play an important in this of by the with policy and budget the health care and local should be implemented to physical health in persons with SMI and to encourage of the the health care In to mental health care also need to be in and measuring CVD health and other (e.g., health in SMI should be to primary care access to and care of physical health of the SMI population. and health care should access to and care of physical health of the SMI to and treatment of general health care have to to the physical health care needs of the SMI population. and is a and major access for people with It the of the health services and people with SMI to or to treatment and personal contact with persons with SMI can be to and should be and be implemented to access to health the between physical and mental health care and a policy of and mental and physical health care for persons with The reintegration of psychiatric care and general somatic services, with an ultimate goal of providing optimal services to this vulnerable patient population, seems to represent the most important for psychiatric care today for these service and provide for the health assessment and service In developing countries this to be or responsibility for the physical health of the SMI there is a provision of general somatic health care services for SMI patients, the should responsibility for the somatic health of his/her patients. has to a on the as SMI patients not the problem is or not be of physical monitoring and have been the patient's personal and family history at baseline to identify patients and to early of changes in critical patients with a personal or family history of obesity, high blood pressure, DM, heart disease or cerebrovascular accident, or with high or values on metabolic with risk of effects should be of the health of SMI patients should include monitoring of blood pressure, fasting plasma fasting lipids, smoking, physical diet, and sexual health, as well as effects of the an monitoring or risk chart the patient's This is a and better than the more and guidelines to monitor the physical health of the SMI weight gain of glucose or other effects consider to medications with risk higher to risk medications has been to cardiovascular and risk factors but needs to be done in a and monitoring to the primary care and services, including and that people with SMI have been to be at risk of developing CVD and/or DM be People with SMI have CVD and/or DM should be in primary stronger with these medical and other health care and physical care of patients with SMI has the of their physical health care outcomes should to develop at the of primary care SMI patients, to and erroneous as well as the of the psychiatrist, to better monitor and physical illness in SMI patients. care should be include of services a primary health care to mental health services, with between primary care and mental health is in the physical health of with having one service on a or to between services and the care for the a of health workers including medical as well as psychiatrists lifestyle modifications and treatment for SMI patients. and should be and to the SMI population. to encourage and the patient's to medical and personal and individual responsibility in patients with SMI, to make for and their individual (e.g., the and to people with SMI to more of their a range of and health including patient and likelihood of primary care medical services The of these in Table health care systems the world on local will contribute to a in the medical and related psychiatric health of patients with The improved physical health outcomes in SMI patients will both patients and This will and and physical health care that and patients with physical illnesses on the presence and effects of psychiatric changes in the monitoring and management of physical disorders that do not have to be can make a in this and patient The of this is part of the and has been by the the of and