May 23, 2023
Don’t just screen, intervene! Physical health care for people living with psychosis needed right from the start.
By Dr Scott Teasdale, Prof Jackie Curtis, Dr David Shiers
For people experiencing psychosis for the first time, the early treatment phase presents a critical opportunity to avoid a future blighted by poor physical health. The goals of the Healthy Active Lives consensus statement (HeAL) remain as pertinent today as they did when they were launched at the International Early Psychosis Association conference in Tokyo in 2014. This blog sets out the ongoing challenges.
Living 10-20 years less than others – a gap unjust
This stark life expectancy gap for people with psychosis is predominantly due to preventable physical health conditions such as cardiovascular disease and diabetes.1 Yet, over the last several decades the life expectancy of people with psychosis has largely remained the same, in contrast to the general population where it has steadily increased. This should not be occurring in 2023. Nor is this simply a moral argument. Health care costs increase by at least 45% when people with psychosis experience co-occurring physical health conditions. This equated to AUD $15 billion in one year (~1% Gross Domestic Product) being attributable to the physical health conditions of people with psychosis in Australia alone.2
Keeping the body in mind
If we want to improve the physical health of people living with psychosis, then we must consider wider ranging social determinants. This starts with basic human needs such as financial security, food and housing. This vulnerable population need education and support to reduce the use of tobacco and other substances, to access more nutritious food and a safe space to be physically active.
Challenging the inverse care law:
We need to promote inclusion and reduce the stigma and discrimination that continues to occur in society and within healthcare. And we need to provide access to quality holistic healthcare that is well integrated. For too long, mental health services and physical health services have worked in silos allowing the physical health of people with psychosis to fall through the cracks. Mental health services saw physical health as out of their scope of practice even though treatments being provided (particularly antipsychotic medications) were having dire consequences on cardiometabolic health. Access to quality care from General Practitioners has been complicated given capacity barriers, with mental health often overshadowing routine physical health checks in the limited time available, or the perception by General Practitioners that the treatment of people with severe mental illness was the role of mental health services. And access to additional specialist services such as dietitians and exercise professionals and oral healthcare can often be a bridge too far in terms of the wider health system.1
Don’t just screen – intervene! Right from the start.
There has been a shift to ensure cardiometabolic monitoring occurs within mental health services. But monitoring will not improve physical health, unless action follows. This should occur right from the start of illness and treatment, a particularly vulnerable phase for rapid accumulation of cardiometabolic risks.3 For example:
Best practice prescribing such as prescribing antipsychotic treatments with lower potential for metabolic change, being alert to and reviewing the treatment of those with rapid weight gain, and optimal use of other medications such as metformin is critical.4
Many mental health services are taking the step to include professions such as physical health nurses, dietitians, exercise professionals and tobacco cessation officers in their multidisciplinary teams to provide a holistic, person-centred approach and remove the access barrier. When provided early in the course of treatment, this approach has been shown to support healthier behaviours and reduce the progression of cardiometabolic risk factors.5
With service uptake, sustained engagement, navigation and access being critical challenges to implementation of physical health approaches in mental healthcare, the importance of peer worker roles, inclusion of carers and a transition to co-designed solutions is becoming realised.
What’s to be done?
As we have outlined above this remains a rights issue. Encouragingly, the last decade has seen early intervention in psychosis services increasingly recognise the importance of keeping the body and mind. There is now tangible emergence of new models of care, increasing research evidence of what works and greater policy interest. Nevertheless, there is still much to do. Poor physical health should not be the inevitable consequence of experiencing a psychosis.
If you would like to find out more about physical health care for people living with psychosis the iphYs group, concerned with physical health in young people experiencing psychosis (iphYs) meets every two years as a satellite event to IEPA’s biennial international conference.
You can also follow iphYs on Twitter @iphYs_YMH and follow the authors:
About the Authors
Dr Teasdale is funded through an Australian National Health and Medical Research Council Emerging Leader Fellowship and is a Senior Research Fellow at UNSW, Sydney. His research focus is on the physical health and wellbeing of people living with serious mental illness. He was the original mental health dietitian for the Keeping the Body in Mind lifestyle and life skills program that became routine clinical care for people of a mental health service in Sydney, Australia.
Prof Curtis is a psychiatrist and Executive Director of the Mindgardens Neuroscience Network. She is Conjoint Professor (UNSW, Sydney). She has a long-standing interest in the physical health of people living with psychosis. Her clinical research has had strong research translation implications, influencing clinical practice, health service delivery, policy and guidelines in mental health services locally, nationally and internationally. With Dr Shiers, she co-founded the international group concerned with physical health in young people experiencing psychosis (iphYs) in 2010 which she co-chairs.
Dr Shiers is a carer and former GP and joint lead on national EIP development programme. Sort of retired, David is an advocate for improving the physical health of people with psychosis, participated in developing related NICE guidelines and several ongoing NIHR research programmes. The highlight of David’s last ten years has been collaborating with Jackie, Scott and colleagues on initiatives like the Healthy Active Lives international consensus (HeAL 2014).
1. Firth J, Siddiqi N, Koyanagi A, et al. The Lancet Psychiatry Commission: a blueprint for protecting the physical health in people with mental illness. Lancet Psychiatry, 2019; 6(8): 675-712
2. Royal Australian and New Zealand College of Psychiatrists (RANZCP). The economic cost of serious mental illness and comorbidities in Australia and New Zealand. Melbourne: RANZCP; 2016.
3. Shiers D & Curtis J. Cardiometabolic health in young people with psychosis. Lancet Psychiatry, 2014; 1(7): 492-4.
4. World Health Organisation (WHO). Guidelines for the management of physical health conditions in adults with severe mental disorders. Geneva: WHO; 2018.
5. Curtis J, Watkins A, Rosenbaum S, et al. Evaluating an individualized lifestyle and life skills intervention to prevent antipsychotic-induced weight gain in first episode psychosis. Early Intervention in Psychiatry, 2016; 10(3):267-76.
Declaration Of Interests:
DS is an expert advisor to NICE Centre for Guidelines the views expressed are the authors and not those of NICE
The World Schizophrenia Day 2023 IEPA Project has been sponsored by H. Lundbeck A/S