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

Equity of access for delivery of care

Among people with mental health problems there are those for whom special considerations may apply. Specific examples are set out below.

Age - Younger

Young people can be difficult to engage in health care or influence with health promotion. Creativity may be required in meeting their particular needs.

Services delivering early intervention for psychosis must be particularly vigilant when recommending drug treatments with the potential for "metabolic" side effects such as weight gain and glucose irregularities. Full discussion of potential side effects and frequent monitoring from the outset, coupled with appropriate action if side effects emerge - which might include a recovery based discussion about treatment options - are necessary to prevent an insidious slide into obesity and poor physical health at a young age and for the longer term.

Age - Older

Those in the over 65 population are more prone to falls, confusion regarding medication regimes, nutritional neglect and co-morbid physical health problems. In addition, they may have fewer (or older) carers and they may experience physical, cognitive or sensory barriers to health care. The introduction of registers for dementia and associated reviews in General Practice is a positive development.

Social care, health and voluntary sector services may need to contribute more to the enabling of older people with mental health problems such as schizophrenia, bipolar disorder, depression and dementia to access regular health and wellbeing input.

Learning Disabilities

For people with a learning disability, having a mental illness can add to the health inequalities gap. Factors include lack of self-reporting of symptoms and barriers to access such as physical, cognitive and overt discrimination. People with learning disabilities have a different pattern of health need and a broader pattern of leading causes of death. They have a higher prevalence of schizophrenia and can develop dementia at an earlier age. ⁴²

Targeted work should take account of the specific needs of this group and the individuals within it, including the needs of the carers. This is best done in consultation with specialist learning disabilities services or in keeping with arrangements in place under the GMS Local Enhanced Services, (see Annex BGMS Contract for Primary Medical Services) . A number of organisations have websites which offer guidance. ^{29, 43}

Autism spectrum disorders ( ASD)

People with ASD are more vulnerable to mental health problems, and depression, anxiety, obsessive compulsive disorders and other psychiatric conditions are not uncommon particularly among adolescents and adults with ASD. However, people with ASD may also have difficulty in communicating unrelated physical and mental health needs.

Black and minority ethnic groups

For some in this population there is an even higher risk of diabetes and other physical problems.

There is a need therefore to ensure that the delivery of care reflects particular considerations. These considerations will include cultural, gender and other relevant aspects.

There may also be stigma issues for some associated with mental ill health, culturally different distinctions between mental and physical health, language barriers and problems with evidence bases and monitoring systems not accounting for race.

Disability

Where an individual has a suspected or established physical sensory or communication disability, steps must be taken to ensure that their needs are clarified and responded to appropriately.

Action is required to remove or overcome physical barriers. Sensory and communication impairment must not be allowed to contribute to further health inequality. Awareness raising, providing information in appropriate formats and wider availability of staff competent in British Sign Language, and providing communication, including Augmentative and Alternative Communication support ( AAC) should help improve wider health care to these individuals. ⁴⁴

Inpatients

Individuals admitted to psychiatric inpatient care have a review of their physical health which should include health promotion advice. People who are inpatients for more than a year should be offered an appropriate annual review of their health promotion, prevention and physical care needs. This is in addition to any specific requirements associated with their treatment or co-morbid illnesses.

Medication Treatment

Extra monitoring is required for those whose treatment includes medication at high dosage or with special monitoring requirements (e.g. Clozapine). This may involve extra contacts with general practice or acute services when ECGs (electrocardiograms) or extra blood tests are required. Monitoring for side effects and advice about the effects of nicotine, caffeine and illicit drugs on medication effectiveness is the responsibility of prescribers.

Sexual Health

Contraceptive needs, pre pregnancy counseling and safe prescribing in pregnancy requires consideration in addition to education about the risks of sexually transmitted diseases.

Sexual dysfunction can be directly attributed to some medications and when problematic can lead to some people deciding to stop their treatment with associated risks to their mental health.

Anyone recommending or prescribing drug treatments with the potential for causing sexual dysfunction should ask about the presence of this or other side effects and consider the need to organise a review of an individual's prolactin levels with appropriate follow up.

People who experienced childhood sexual abuse trauma

Survivors of childhood sexual abuse are a group at above-average risk for both physical and mental ill health. Survivors of childhood sexual abuse are found among sufferers of all types of mental illness and mental health problems, including severe and enduring conditions. They are also vulnerable to unhealthy lifestyles. For instance many have used alcohol, tobacco, food, and both legal and illicit drugs to self-medicate, to block out disturbing memories, nightmares and flashbacks. Sexual violence itself damages health. Severe loss of self-esteem undermines people's motivation to care about their physical health. Many with poor mental health will also have suffered side effects of medication. Often, survivors of sexual abuse fear medical checks, especially in sexual and reproductive health and in dental care, because of their intrusive past experiences.

Before this particularly vulnerable group can be motivated to adopt healthier lifestyles and undertake preventive health checks, they need supportive and understanding services, to help them address their trauma issues. The appropriate training of staff to inquire sensitively where appropriate about an abuse history, must therefore be encouraged.

People in residential care

The Care Commission regulates a wide range of services providing care and treatment for people with mental illness, dementia and learning disabilities. There is a legal obligation on care providers to make provision for the health and welfare of service users.

People in prison

The prison population has high rates of mental illness and requires access to the same range of healthcare and health improvement initiatives.