INTRODUCTION
People with severe mental illness (SMI) face a future not only limited by stigmatising psychiatric illness, but also a life shortened by 15–20 years through physical comorbidities. Social and behavioural determinants help explain why many of these comorbidities cluster together. Moreover, the experience of multiple conditions, sometimes with conflicting management requirements and multiple healthcare providers, creates a disproportionate treatment burden accompanied by often poorer individual disease outcomes, a situation compounded by discriminatory health care.1
The late Professor Helen Lester called upon GP colleagues to make the care of people with SMI core business in her 2012 James Mackenzie Lecture, ‘Being Bothered about Billy’, to the Royal College of General Practitioners (RCGP) Annual General Meeting. Recognising the particular contribution of cardiovascular disease (CVD) and diabetes to reduced life expectancy, Professor Lester urged GPs to ‘Don’t just screen, intervene’ for cardiometabolic risks. This advice was seemingly unheeded when GP contract negotiators retired three key cardiometabolic indicators from the 2014/2015 Quality and Outcomes Framework (QOF),2 with the predictable detrimental impact of this decision.3 While CVD remains the commonest cause of a still widening mortality gap,4 this population also experiences elevated rates of other physical comorbidities compared with the general population.5 We will argue that tackling this health inequality should remain core business for GPs.
‘CLOSING THE MORBIDITY AND MORTALITY GAP’
Why this matters to primary care
In the UK, the lifetime prevalence of psychotic disorders such as schizophrenia and bipolar disorder are 0.72%6 and 1–2%7 respectively. A GP with an average list size can expect about one patient per year to present with a new psychotic illness, characterised by changes in perception, thinking, mood, and behaviour. Stigma and social isolation compound disrupted education and employment, and financial and accommodation uncertainties.
About 20% of individuals will fully recover following a single episode. However, most continue to experience psychological and social difficulties. Of these, about half achieve good levels of social functioning, while the remainder experience a more difficult course sometimes leading to severe disability; many develop poor physical health. This means that every general practice in the UK cares for substantial numbers of patients affected by SMI who have ongoing physical and mental health needs. GPs and primary care teams are ideally placed to build up relationships over time, and to proactively support these individuals and their families.
The widening mortality gap
While suicide rates are particularly high early in the course of psychosis, overall many more premature deaths arise from physical illnesses including CVD and smoking-related pulmonary disorders. Type 2 diabetes is 2–3 times more frequent, eventually affecting 10–15% of people with SMI.9 CVD is three times more frequent for those with schizophrenia and the single biggest cause of a still widening mortality gap which sees people with schizophrenia dying, on average, 11 years earlier than the general population.4,8 Unlike life expectancy trends which see the general population living longer, the average age of death of men and women with schizophrenia decreased between 1980 and 2010.8
Why do people with severe mental illness still die early?
Increased cardiometabolic risk is a major contributor to reduced life expectancy. This is partly due to adverse health risk behaviours such as poor diet, smoking, and inactivity, in addition to the impact of psychiatric illness and its treatment (for example, lack of self-care, poor concentration); this is all compounded by stigma and social disadvantage. Vulnerability to some of these risks may be present even before psychosis is diagnosed.
Smoking is a major contributor to the health inequality experienced by this population.10 Four decades of public health focus on preventing smoking-related diseases in the UK have witnessed smoking rates in the general population steadily fall from around 40–50% in 1974 to around 15% in 2017 alongside reduced daily cigarette consumption in those who do smoke. Yet for those with SMI, smoking rates are stuck at 40–50% and most smokers do so heavily.11 Given that quitting smoking is probably the single most effective way of improving the health of people with SMI, how this can be achieved will be considered in the section ‘What can be done’.
A study of 1150 people with SMI drawn from 64 practices across England found average consultation rates of three per year,12 barely higher than for the wider practice population; moreover, practice nurses were half as likely to see people with SMI as the wider practice population. Despite annual physical health checks for people with SMI being incentivised through the QOF since 2004, the 2012 National Audit of Schizophrenia for England and Wales reported that less than a third of >5000 patients had received a completed cardiometabolic risk assessment within the previous 12 months; even if assessed, many of those with identified risks received no intervention.13 This may reflect barriers to accessing routine health checks and poorly coordinated primary and mental healthcare services. Findings were echoed in a survey of 314 general practices in Scotland, revealing under-recognition and under-treatment of cardiovascular disease in people with schizophrenia.5 Thus the care of people with SMI is an example of the ‘inverse care law’,14 with those with most need of care being least likely to receive it.
The role of prescribed medication is also important. Many antipsychotics increase appetite and can directly cause weight gain and insulin resistance, increasing the likelihood of developing diabetes and cardiovascular disease. Initiation of drug treatment is associated with a striking trajectory of weight gain of around 12 kg within 24 months of initial diagnosis (Figure 1).
Figure 1. Antipsychotic-induced weight gain in chronic and first-episode psychotic disorders. Used by permission of Dr Mario Álvarez-Jiménez.16
This degree of weight gain can be demoralising, adding further stigma to that of mental illness. For some patients, feeling ‘fattened and flattened’ by their medication may lead them to withdraw from care, thus entering a dismal cycle of relapsing psychosis and further treatment attempts. This is a particular concern given the high risk of suicide in the first 5 years of psychosis and underlines the difficult balance between adverse cardiometabolic effects against the consequences of having no treatment.
What can be done? ‘Don’t just screen, intervene’15
We wish to highlight some practical examples of how primary care can help address the mortality and treatment gap.
CVD AND DIABETES
High rates of CVD and diabetes in people with SMI are not only predictable but also potentially avoidable. Moreover, the best way to tackle physical comorbidity is through prevention and early intervention rather than waiting until something goes wrong. This forms the basis of the Lester resource (Table 1), tailored to respond proactively to cardiometabolic risk from the onset of psychosis and instigation of treatment. With its mantra ‘Don’t just screen, intervene’, the Lester resource resonates with the NHS vascular health check but targets the particular needs of this (often younger) high-risk population. It was adapted for UK use from an original Australian version in a process led by the late Helen Lester involving the RCGP and The Royal College of Psychiatrists (RCPsych), and endorsed by the National Institute for Health and Care Excellence (NICE) in 2014. Encouragingly, this international collaboration has led to six other countries developing their own adapted versions for use by clinicians in primary and secondary care.
Table 1. Lester resource monitoring schedule
The Lester resource stresses the importance of involving the person with SMI in discussions about the benefits and adverse effects of their antipsychotic medication. There are relatively small differences in efficacy but substantial differences in side effects. These vary according to individual drug response rather than an arbitrary classification into first-generation and second-generation drugs.17 There is a hierarchy of effect on weight gain and metabolic disturbances, with olanzapine and clozapine having greater impact than drugs such as aripiprazole and lurasidone. However, a large Finnish cohort study18 of people with schizophrenia found that olanzapine and clozapine were associated with the lowest overall mortality. The important message is that prescribing should be tailored to maximise benefits and minimise side effects for individual patients.
The Lester resource encourages a collaborative approach to care; its framework for identifying and treating abnormal CVD risk utilises a simple traffic-light system to support clinicians in providing a consistent approach across primary and secondary care services. Encouragingly, a large randomised controlled study in the US recently showed that an 18-month tailored care intervention drawing from care coordination and care management approaches could significantly reduce overall CVD risk in adults with SMI.22
SMOKING CESSATION
GPs and primary care nurses can ‘make every contact count’ in encouraging their patients with SMI to quit smoking. However, some myths have perpetuated this major cause of health inequality (Box 1).
Smoking helps people with mental disorders. No! Stopping smoking is as effective as antidepressants for treating mild-to-moderate depression. People with mental illness can’t or won’t stop smoking. No! Not only do they often want to stop smoking, but also with appropriate tailored support the SCIMITAR study (the largest trial of its kind) shows they can.19 Resources that can be offered to patients include the y-QUIT leaflet.20 Pharmacological smoking cessation interventions used in the general population do not help with these patients. No! prescribed treatments like nicotine replacement therapy, varenicline, and bupropion can be as effective and safe for people with SMI.21
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Box 1. Myths about smoking and severe mental illness
It is important to note that stopping smoking can affect the hepatic metabolism of drugs such as clozapine and olanzapine, causing drug levels to rise by up to 25% within a week and 50% within a month. Similar effects can occur with certain antidepressants and benzodiazepines. These effects can work in reverse for those patients who resume smoking. Therefore, prescribing should be carefully managed and coordinated when considering smoking cessation.
MEETING THE HOLISTIC CHALLENGE
This is not just about CVD, diabetes, and smoking. A survey of 314 general practices in Scotland revealed that, compared with the wider practice population, people with schizophrenia experience higher rates of a range of comorbidities, including a three-fold increase in Parkinson’s disease, constipation, and viral hepatitis.5 Smoking-related respiratory disease such as COPD is more common. Primary care is uniquely placed to respond to such diverse physical health needs through its strengths of holism and continuity.
We also highlight the frequently neglected subject of sexual health. GPs may be reluctant to discuss this or, if they do, limit this to an enquiry about the adverse effects of medication on sexual functioning. This population is vulnerable to risks including sexual exploitation and abuse, self-stigma and limited choice of partners, and lack of awareness of how to practise ‘safe sex’. All can lead to risky sexual behaviours, with serious consequences such as elevated rates of unplanned and hazardous pregnancies and sexually transmitted diseases (including potentially life-shortening blood-borne virus infections).23 GPs and primary care nurses are ideally placed to help and the message is simple: START THE CONVERSATION about sexually transmitted diseases and blood-borne virus infections, contraception, and family planning.
Finally, oral health is an important concern for this population. A systematic review found people with SMI were three times more likely to have total tooth loss, and decayed, missing, or filled teeth.24 Many of the same risk factors for CVD (for instance, smoking and poor nutrition) contribute to poor oral health. Furthermore, increased vulnerability through poor oral hygiene can result from low motivation and concentration from the psychiatric illness as well as medication side effects such as xerostomia. Poor oral health has serious consequences on self-esteem and quality of life, with one study reporting that a third of people with SMI felt their oral health had interfered with simple functions, such as eating and talking.25 Despite these concerns, dental care is often inaccessible and ineffective. The key message is that oral health is an essential component of holistic care and should be mentioned as part of the regular primary care review, with signposting to a community dentist.
CONCLUSIONS
People with SMI view primary care as the cornerstone of their health care. Box 2 offers practical tips for practices to improve access and care, reducing the impact of the inverse care law.14 Key is the need for continuity, which offers a unique understanding of the patient’s context and family, and which can improve outcomes for people with SMI.26 Primary care has an important role to play in support of carers. The primary care team plays a critical role in addressing the health inequalities experienced by people with SMI, and their carers, above achieving QOF targets. Box 3 provides additional resources.
Reach out to people with severe mental illness (SMI): be aware of the risk of relapse, ask about concordance with medication, ask about support. Ensure that details of carers are documented (and contact carers to enquire after their wellbeing). Flag notes so that receptionists can prioritise access to a GP (or other clinician) who knows the patient. Offer slightly longer appointments — whether this is by telephone, video, or face-to-face. If a patient is attending, offer waiting space outside the GP’s door to avoid busy waiting areas that can exacerbate stressful symptoms. At every contact, explore lifestyle factors (smoking, diet, activity, alcohol) and give advice; review whether physical examination or blood tests are needed; review medication — is the patient on a high-risk antipsychotic? Act on abnormal findings — on examination or blood tests.
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Box 2. Practical tips for supporting people with severe mental illness during the COVID-19 pandemic and afterwards
The last word should go to Helen Lester. Reflecting on the issue of stigma that ‘seeps and creeps’ into clinical practice behind the health inequalities of patients with psychosis like Billy, she concluded:
‘But above all, I think, if we examine our hearts, it boils down, quite simply, to being bothered about Billy.’
Acknowledgments
We are grateful to the late Helen Lester who first highlighted the need for making the care of people with SMI primary care’s core business. We thank Dr Mario Álvarez-Jiménez for his permission to reproduce data from CNS Drugs 2008; 22: 547–562.
Notes
Provenance
Freely submitted; externally peer reviewed.
Competing interests
David Shiers is an expert advisor to the National Institute for Health and Care Excellence (NICE) centre for guidelines and board member of the National Collaborating Centre for Mental Health (NCCMH); his views are personal and not those of NICE or the NCCMH.
- © British Journal of General Practice 2021
