Mental Health in Scotland: Improving the Physical Health and Well Being of those Experiencing Mental Illness

Background

Evidence Base

Research in Europe and the USA has shown that the mortality rate from physical illness for those with mental health problems is significantly higher than in the general population. Schizophrenia is generally acknowledged as a life shortening illness with sufferers dying on average 10 years earlier than the general population. Two thirds of this excess mortality is due to poor physical health. ^{1, 2, 3}

Equal Treatment: Closing the Gap (2006) ⁴ - a UK based study commissioned by the Disability Rights Commission ( DRC) in England and Wales - describes an analysis of 8 million health records in primary care. It confirms that for people with schizophrenia and bipolar disorder the rates of ischaemic heart disease, stroke, high blood pressure and diabetes are higher than in the general population, with diabetes 2 to 3 times more common than expected. Bowel cancer is 90% more likely in someone with schizophrenia and women with schizophrenia are 42% more likely than other women to get breast cancer.

They also found that people with major mental health problems are developing these illnesses at a younger age and are dying from them earlier with 5 year survival rates reduced by up to 16%.

These and other studies of General Practice based populations in the UK and abroad have shown that increased mortality rates from cardiovascular disease in people with severe mental illness is a robust finding even when smoking rates and deprivation are taken into account. ^{5, 6} Similarly, a clear link between depression and cardiovascular disease has been established. ^{7, 8} There may be a range of factors contributing to elevated levels of obesity and diabetes including medication and related weight gain. ^{9, 10, 11} These factors are likewise involved in the development of cardiovascular disease, the leading cause of excess mortality due to physical illness. Some causal factors are potentially amenable to change. These include lifestyle factors, in particular smoking (where rates among this care group are up to twice that of the general population), poor diet and lack of exercise. ^{12, 13, 14, 15}

People especially vulnerable to severe mental health problems include those who have suffered major trauma and adverse life events in childhood, such as physical and sexual abuse. A range of research has demonstrated that they have higher rates of some major physical conditions, of medically-unexplained symptoms, and of damaging lifestyle issues such as heavy smoking, obesity and substance use, largely due to attempts to self-medicate and block out disturbing post-traumatic stress symptoms. ^{16, 17}

As medications (such as anti-psychotics, mood stabilisers and antidepressants) used to treat mental illness can lead to a number of significant side effects ⁹ their impact and the need for their use should be regularly reviewed with service users. ¹⁸

Where the presence of cardiovascular disease or other physical illnesses have been established there is evidence that those with additional mental health problems are less likely to receive quality interventions which could improve outcomes. ^{4, 19} Clearly there are barriers to access which must be overcome.

Other common mental health problems are also associated with poorer than average physical health. Eating disorders are often associated with physical illness ²⁰. Dementia in the middle aged and elderly can be accompanied with poor physical health ²¹. Again, there is a higher incidence of cardiovascular disease with other physical conditions seen more commonly also. People with substance misuse disorders, especially if co-morbid with other mental health problems, will tend to have poorer than average physical health ²².

There are numerous recommendations as to what to include in a regular physical review for people with schizophrenia, ^{23, 24, 25} bipolar disorder, ^{26, 27} learning disability ^{28, 29} and dementia. ³⁰Annex A gives some practice examples of how services across Scotland are working to improve the physical health of people with mental illness.

Given this evidenced context it is important that the health needs of individuals with major mental health problems are responded to in a targeted way, with reasonable adjustments for disability status and with clearly communicated responsibilities. Where depression, severe life traumas and poor self esteem have contributed to intractably unhealthy lifestyles, it is important that services address the underlying issues. There is also a clear imperative for all health, social services, voluntary sector and other partners to promote general health and well being.

Other Considerations

In Primary Care the Quality and Outcomes Framework ( QOF) Mental Health indicators provide incentives for General Practices to offer regular reviews with, 'routine health promotion and prevention advice appropriate to age, gender and health status for people with a diagnosis of schizophrenia, bipolar disorder or other forms of psychosis'. (see Annex BGMS Contract for Primary Medical Services ). Though delivery is entirely voluntary, encouragingly, the uptake is high. Participating Practices have developed registers for psychosis, dementia and learning disabilities. In due course this should improve the care delivered to these individuals.

Additional attention is needed for people who may not absorb the public health and other initiatives targeted at the wider population through established mediums and approaches. ³¹ The shortcomings of such blanket approaches have been highlighted by the initial reports from the Keep Well, Anticipatory Care Initiative - Have a Heart Paisley³². Specific support for health behaviour change and service user involvement in the design of approaches to optimise physical health and wellbeing might help improve their relevance, uptake and outcome.

Consideration must be given to the importance of opportunistic brief health promotion and screening interventions, for example at routine GP or outpatient appointments. Social care providers are also ideally placed to contribute to the promotion of general health and wellbeing to service users. Unfortunately it is clear that even for those in contact with services opportunities are being missed.