WE STILL NEED TO BE BOTHERED ABOUT BILLY
The late Helen Lester, in her 2012 Royal College of General Practitioners (RCGP) Annual General Meeting James Mackenzie lecture ‘Being Bothered about Billy’, implored primary care physicians to make the proactive recognition and treatment of physical health conditions in people with severe mental illness (SMI) core business, particularly cardiometabolic comorbidity.
SMIs, including schizophrenia and bipolar disorder, affect around 3% of the population over the life course,1 and carry a shortened life expectancy of about 15 years.2 Early death is most often due to preventable conditions such as cardiovascular disease (CVD), diabetes, and obesity, which are multifactorial in nature.3 The extent of the physical comorbidity of SMI has led to calls for psychosis to be repositioned as a ‘multisystem disorder’, particularly since the consequences of the physical manifestations of SMI may outweigh those arising from the brain.4
The cardiometabolic comorbidity of SMI starts early (Figure 1). Whereas disturbances such as impaired glucose tolerance and diabetes, hypertension, and dyslipidaemia tend to emerge around middle age in the general population, in people with SMI they may be detectable from as early as the first presentation.4 This helps to explain why cardiovascular risk prediction tools developed primarily for the general population underestimate risk in young people with SMI.5,6 As a result, the benefits of preventative interventions for CVD, which represent the biggest area for potential life- saving changes according to the NHS Long Term Plan, too often do not reach people with SMI in time, and so the mortality gap continues to widen.7
Figure 1. Summary of contributing factors to early death from preventable physical conditions in people with severe mental illness
A key predictor of higher treatment costs of SMI is the presence of comorbid physical conditions, and over half of the total annual NHS costs for treating SMI is accounted by physical comorbidity.8 Addressing the health inequalities experienced by people with SMI is one of the five clinical areas of focus requiring accelerated improvement in the NHS Core20PLUS5 approach.
The majority of people with SMI require long- term support and management, and this is predominantly delivered by primary care, even for people on a secondary care caseload.
DON’T JUST SCREEN, INTERVENE!
The Lester positive cardiometabolic resource, first published in 2014, is an adaptation of a similar Australian resource.9 The Lester resource and its Australian sibling have been highly influential in many countries and have now been translated into seven languages. In the UK it paved the way for two physical health standards (screening and interventions) to be featured in the mandatory annual National Clinical Audit for Psychosis, to which all English Early Intervention in Psychosis services are required to contribute. Yearly audit reports show generally good adherence to these standards, though with some geographical variation.10 Annual reviews of people with SMI are a target within the Quality and Outcomes Framework, although the current requirement does not cover all the recommended items by the National Institute for Health and Care Excellence.11
THE LESTER RESOURCE 2023 UPDATE: WHAT’S NEW?
The assessment and management of cardiometabolic risk has changed as newer risk prediction tools and therapies have become available, and it was time to update the Lester resource.12 The changes to the 2023 update can be broadly summarised into three areas: refinements, amendments, and additions (Box 1).
| Area | Description |
|---|
| Refinements |
|
| Amendments |
Specifying ethnicity-specific cut-offs for body mass index and waist circumference Encouraging weekly weight checks after initiation of a new antipsychotic, since early weight gain is a strong predictor of longer-term physical morbidity Clarifying that risk prediction tools are likely to underestimate risk in young people with SMI
|
| Additions |
New recommendations on health behaviours, including advice on alcohol use and physical activity, which along with diet and smoking cessation (already prominent in the resource) represent key modifiable targets for intervention Where health behaviour modification is ineffective alone, the recommendation for metformin is strengthened. A modified-release preparation is licensed for the prevention of diabetes, particularly in ‘high-risk’ groups that include people with SMI
|
Box 1. Refinements, amendments, and additions to the Lester resource 202312
MULTIDISCIPLINARY WORKING TO ADDRESS A MULTIDIMENSIONAL PROBLEM
To return to Helen Lester’s plea for primary care physicians to make the cardiometabolic hea≠≠≠lth of people with psychotic disorders ‘core business’, we go one step further and implore that this must be everyone’s business, together. Improved communication and information sharing between primary care and secondary care mental health services, particularly at the local level, is critical for the Lester resource to fulfil its purpose. Primary care physicians must also be able to refer patients to secondary care metabolic, endocrine, or cardiovascular specialists according to local referral criteria, since evidence suggests that this does not occur as often as it should.13
Excellent examples of joined-up approaches between primary and secondary care have shown promise in improving physical outcomes in people with SMI; such approaches should be seen as the benchmark, and expanded and adapted based on the needs of local populations.14
Developing collaborative approaches to protect the cardiometabolic health of this vulnerable population must be a task for all.
Notes
Provenance
Freely submitted; not externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2023
