People with severe mental illness die much earlier than others, often of physical comorbidities. What can – and needs to – be done to improve their physical health?
People with severe mental illness have poorer physical health, and are more vulnerable to the consequences of poor physical health, than the general population. This population also tends to die 15-25 years earlier; improving their physical health is high on the agenda – as shown by a report published in 2016 by the Royal College of Psychiatrists. However, mental healthcare providers face unique challenges in trying to achieve this. This article describes the latest policy recommendations, the challenges linked to their implementation, and how a London mental health trust is improving the physical health of its patients.
Citation: Nazarko L (2017) Improving the physical health of people with severe mental illness. Nursing Times [online]; 113: 8, 42-45.
Author: Linda Nazarko is nurse consultant in physical health care, West London Mental Health Trust.
- This article has been double-blind peer reviewed
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Despite advances in healthcare, many people experience both mental and physical health problems but do not receive the holistic, patient-centred care they need. In particular, people with severe mental illness (SMI) have poorer physical health than the general population. They also have shorter lives, a higher incidence of long-term conditions, more difficulties managing their health, and a reduced quality of life (Davies, 2013; Naylor et al, 2012).
Improving their physical health is a priority that was outlined last year in a report from the Royal College of Psychiatrists (RCPsych) (2016), Improving the Physical Health of Adults with Severe Mental Illness: Essential Actions. This article puts the report’s recommendations into context, exploring the difficulties of improving physical health in people with SMI and the work of a London mental health trust in moving towards that goal.
Severe mental illness
The RCPsych used three elements to define SMI in the report (RCPsych, 2016):
- Diagnosis: schizophrenia, bipolar disorder, or other psychotic disorder;
- Disability: the disorder causes significant disability;
- Duration: the disorder has lasted for a significant duration – usually at least two years.
People with SMI have worse physical health than the general population. Diabetes, for example, affects 7.4% of the general population but 15% of people with SMI (Health and Social Care Information Centre, 2015; Chwastiak et al, 2014; Becker and Hux, 2011). Half of all people with SMI have comorbid conditions and they die 15-25 years earlier than the general population (Davies, 2013; Rethink Mental Illness, 2013; Disability Rights Commission, 2006; Hennekens et al, 2005). The main causes of death among people with SMI are circulatory disease, diabetes and obesity. This has been described as ‘third-world mortality in a first-world country’ (Thornicroft, 2013).
A vicious circle
People with SMI often struggle to live independently and look after themselves. Not only are they at greater risk of developing health problems, but their condition also means that they are less well-equipped to respond to acute or sub-acute deteriorations and manage their physical health (Velligan et al, 2009).
People with mental health problems are two to three times more likely to smoke cigarettes, and find it more difficult to quit, than the general population (Tidey and Miller, 2015). They are also more likely to drink alcohol heavily (four units or more a day) and to use cannabis and other illegal drugs (Hartz et al, 2014).
People with SMI are often prescribed a class of drugs known as antipsychotics to control symptoms. All antipsychotics are associated with weight gain – some more than others (Leucht et al, 2009) – and this weight gain can compound cardiometabolic risk (Shiers et al, 2014; RCPsych, 2013).
As a consequence of the above, people with SMI can all too easily enter a vicious circle of treatment with antipsychotic drugs, weight gain, increased cardiometabolic risk, diabetes, obesity and worsening physical and mental health – potentially compounded by unhealthy lifestyle behaviours and difficulties managing their own health issues. Poorly managed physical health can lead to worsening mental health and worsening mental health can lead to a further deterioration in long-term conditions such as diabetes.
Working with people with mental health problems, and balancing the need for drugs to treat mental health symptoms against the negative effects these drugs can have presents unique challenges.
The struggles of care providers
Medical and nursing staff may struggle to look after the physical health of people with SMI. There is evidence to suggest that GPs and psychiatrists do not always effectively screen, recognise and treat physical conditions in people who have mental health problems (Rethink Mental Ilness, 2013; Ratcliffe et al, 2011).
Mental health nurses often deliver physical healthcare but they have variable levels of confidence and lack appropriate skills and training (Howard and Gamble, 2011). A study of 168 mental health nurses found that 71% were involved in delivering physical healthcare; however, 96% thought they needed more training (Nash, 2005). Robson and Haddad (2012) developed a measurement tool to assess attitudes to physical healthcare and found these attitudes to be positive among nurses, but also that nurses felt they needed training.
Mental health staff may also feel unsupported by their managers and the organisations they work for in their efforts to address physical health problems. There may be a lack of systems, processes and even equipment enabling staff to deliver certain aspects of care traditionally associated with acute care settings. Mental health wards may, for example, lack wound dressings, commodes, high-low beds, urinals and bedpans.
Anecdotal evidence suggests that mental health trusts have adopted various strategies to overcome these challenges. Some have set up physical healthcare departments or primary care centres – both typically employing GPs as well as nurses with a general nursing qualification, who may be nurse practitioners. In mental health units, nurses often provide care to inpatients who have physical healthcare needs (for example, wound dressing). Resources can be limited and staff may have to concentrate on those with the greatest needs. This can lead to inequity of access to care and reinforce the divide between physical and mental health. Some trusts have appointed a nurse consultant in physical health. However, one person on their own might struggle to train staff, set up new systems and processes, change the culture and move a whole organisation forward.
Key policy recommendations
There have been many literature reviews and reports on how to improve the physical health of people with SMI (Shiers et al, 2014; RCPsych, 2013). Last year’s RCPysch (2016) report involved all the royal colleges, including the Royal College of Nursing, as well as the Royal Pharmaceutical Society and Public Health England. It recognises that a strategic approach is needed and makes recommendations for:
- A national steering group;
- Royal colleges and societies;
- Regulatory bodies and inspectorates;
- Commissioners of healthcare services;
- Providers of healthcare services;
- Information technology (IT);
- Physical healthcare;
- Training of health professionals.
The first three recommendations are aimed at strategy level. A national steering group is to be created to monitor the implementation of the recommendations at national level. Each royal college or society is to appoint a lead clinician who will work with the steering group – in particular on setting standards for training. Regulators and inspectors are to align their objectives, and base their criteria, on the standards outlined in the report.
The fifth lists, among others, seven recommendations to mental health services (Table 1), while the seventh is about physical healthcare (Table 2), with some overlap between the two. They include various recommendations regarding the education and training of staff, aimed at ensuring that they are able to manage long-term physical conditions, recognise deterioration in their patients and take appropriate action.
The fifth, sixth and seventh sets of recommendations also tackle systems and processes, with recommendations such as:
- Having a physical healthcare strategy that is reviewed annually and approved by the board;
- Having, at board level, a lead clinician responsible for the implementation of the physical healthcare strategy;
- Having an appropriate IT infrastructure to help staff meet patients’ health needs and improve access to investigation results;
- Using a carers’ forum to facilitate the sharing of information about physical health with informal/family carers.
Fostering holistic care
The report makes it clear that organisations need to review their strategies and appoint, at senior level, a person who has the ability to drive change. They should ensure that the policies and procedures to make it happen are in place. The challenge is to transform the culture in mental health and ensure that staff at all levels combine physical and mental healthcare in a holistic approach – this involves educating staff.
It may involve re-examining the skill mix and, on some wards, introducing a mix of mental health nurses and general nurses. Any such changes will have to be made carefully, ensuring that all staff are trained to provide physical healthcare. Although nurse consultants and specialist nurses could ‘take over’ the physical healthcare of patients in mental health settings, this would only contribute to deskilling mental health nurses and would not help them develop holistic care skills. The role of nurse specialists, nurse consultants and senior nurses with specialist skills is to educate, support and guide staff, not meet patients’ physical healthcare needs.
Improvements at a London trust
West London Mental Health Trust (WLMHT) provides care and support to people with mental health problems in inpatient and community settings in West and North London – as well as Broadmoor Hospital in Berkshire. It provides care and treatment for around 62,570 people each year. In November 2015 the trust appointed me as a nurse consultant in physical healthcare – a newly created role. I carried out an analysis of staff training needs, and of the systems and processes required, to improve the care of patients’ physical health. These matched many of the recommendations outlined in the 2016 report (RCPsych, 2016).
The trust has reviewed its strategy, put systems and processes in place, and carried out audits. Student nurses on placements, healthcare assistants, registered nurses and medical staff now receive, on induction, training on how to address common physical health needs. Tables 1 and 2 give an overview of the work carried out to date by WLMHT against the report’s recommendations (the work is ongoing).
The trust’s three inpatient units are located next to acute general hospitals. Many psychiatric patients require electrocardiograms and blood tests before receiving treatment for their mental health problems. In the past, patients used to be escorted by a member of staff to the neighbouring acute general hospital for these tests. This was disruptive for patients – who were sufficiently unwell to be admitted – and time-consuming for staff. Patients often had to wait and this could be unsettling – patients occasionally declined tests because they did not want to leave the unit. Staff in the mental health units received in-house training to learn to record electrocardiograms, which is now done within their units – with less time and resources used and less anxiety for patients.
Thanks to a partnership with one of our local acute general trusts, mental health nurses now also receive venepuncture training. As the trust’s nurse consultant in physical healthcare, I deliver catheterisation training in exchange, and nurses from the acute general and mental health trusts are trained together. This means patients can now access treatment more quickly and without having to leave the unit. Mental health nurses spend less time escorting patients; and, as reported by some nurses, patients consider them more skilled.
At our mental health trust and in others, staff are working hard to address the physical health needs of people with SMI. This hard work will not only enable patients to receive the right care in the right place at the right time, but also reduce the pressure on acute services.
As the population ages, people admitted to inpatient mental health units are more likely to require equipment and services not readily available in these units. More could be done if funds were made available to provide rooms tailored to the needs of people with mobility and other health issues, increase the number of therapists, and provide equipment.
Furthermore, if we are to improve services, commissioners need to commission in innovative ways that reward providers for developing integrated care. Regulators need to develop an awareness of what good practice looks like in relation to physical healthcare in mental health services, and work out ways to measure it so that improvement can be promoted.
Many of the factors that affect physical health are modifiable. Monitoring physical health and offering lifestyle interventions should start at the same time as psychiatric treatment (Robson and Gray, 2007). Ensuring people with SMI have the best possible health requires input from primary care, mental health and acute general hospital services. The Willis report (2015) highlights the importance of nurses across all fields of practice offering integrated physical and mental healthcare.
In mental health settings, nurses can make a real difference to patients’ lives by identifying any physical health problems, monitoring physical health and promoting a healthy lifestyle (Department of Health and Public Health England, 2016; Robson and Gray, 2007). The challenge is to ensure that none of our citizens experiences ‘third-world mortality’. That goal has not yet been reached – despite the efforts made so far – but the strategic approach outlined in last year’s report (RCPsych, 2016) has the potential to make a real difference.
- People with severe mental illness (SMI) have poorer physical health and die earlier than the general population
- Severe mental illness affects the ability to self-manage long-term conditions
- Balancing the need for antipsychotics against their potential negative effects on physical health is a challenge
- Mental health settings need to revise their strategies to improve patients’ physical health
- Adequately training mental health staff is key to improve patients’ physical health
Becker T, Hux J (2011) Risk of acute complications of diabetes among people with schizophrenia in Ontario, Canada. Diabetes Care; 34: 2, 398-402.
Chwastiak LA et al (2014) The effect of serious mental illness on the risk of rehospitalization among patients with diabetes. Psychosomatics; 55: 2, 134-143.
Davies SC (2013) Annual Report of the Chief Medical Officer 2013. Public Mental Health Priorities: Investing in the Evidence. London: Department of Health.
Department of Health, Public Health England (2016) Improving the Physical Health of People with Mental Health Problems: Actions for Mental Health Nurses.
Disability Rights Commission (2006) Equal Treatment: Closing the Gap. London: DRC.
Hartz SM et al (2014) Comorbidity of severe psychotic disorders with measures of substance use. JAMA Psychiatry; 71: 3, 248-254.
Health and Social Care Information Centre (2015) National Diabetes Audit 2012-2013 Report 2: Complications and Mortality. Leeds: HSCIC.
Hennekens CH et al (2005) Schizophrenia and increased risks of cardiovascular disease. American Heart Journal; 150: 6, 1115-1121.
Howard L, Gamble C (2011) Supporting mental health nurses to address the physical health needs of people with serious mental illness in acute inpatient care settings. Journal of Psychiatric and Mental Health Nursing; 18: 2, 105-112.
Leucht S et al (2009) Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet; 373: 9657, 31-41.
Nash M (2005) Physical care skills: a training needs analysis of inpatient and community mental health nurses. Mental Health Practice; 9: 4, 20-23.
Naylor C et al (2012) Long-Term Conditions and Mental Health: The Cost of Co-Morbidities. London: The King’s Fund.
Ratcliffe T et al (2011) Physical healthcare for people with serious mental illness. Clinical Governance: An International Journal; 16: 1, 20-28.
Rethink Mental Illness (2013) Lethal Discrimination: Why People with Mental Illness Are Dying Needlessly and What Needs to Change. London: Rethink Mental Illness.
Robson D, Gray R (2007) Serious mental illness and physical health problems: a discussion paper. International Journal of Nursing Studies; 44: 3, 457-466.
Robson D, Haddad M (2012) Mental health nurses’ attitudes towards the physical health care of people with severe and enduring mental illness: the development of a measurement tool. International Journal of Nursing Studies; 49: 1, 72-83.
Royal College of Psychiatrists (2013) Improving Physical Healthcare for People with Mental Illness: What Can Be Done? London: RCPsych.
Royal College of Psychiatrists (2016) Improving the Physical Health of Adults with Severe Mental Illness: Essential Actions. London: RCPsych.
Shiers DE et al (2014) Positive Cardiometabolic Health Resource: An Intervention Framework for Patients with Psychosis and Schizophrenia. 2014 update. London: Royal College of Psychiatrists.
Thornicroft G (2013) Premature death among people with mental illness. British Medical Journal; 346: f2969.
Tidey JW, Miller ME (2015) Smoking cessation and reduction in people with chronic mental illness. British Medical Journal; 351: h4065.
Velligan DI et al (2009) Association between changes on the Negative Symptom Assessment scale (NSA-16) and measures of functional outcome in schizophrenia. Psychiatry Research; 169: 97-100.
Lord Willis (2015) Raising the Bar Shape of Caring: A Review of the Future Education and Training of Registered Nurses and Care Assistants. Health Education England, Leeds.