Physical health care in persons with severe mental illness: a public health and ethical priority

The issue of protection and promotion of physical health in persons with severe mental illness is emerging as one of great public health and ethical relevance worldwide. If we are really concerned about the quality of life of our patients with severe mental disorders and with the protection of their civil rights, we cannot ignore that physical health is a crucial dimension of quality of life in these persons, and that the access to a physical health care of the same quality as that available to the rest of the population is a basic right of these persons as human beings and as citizens.

As reviewed by De Hert et al in this issue 1, there is now an extensive research evidence that: a) the prevalence of many physical diseases is higher in persons with severe mental illness than in the general population 2; b) the gap between these persons and the rest of the population concerning the prevalence of some of these diseases (notably, type 2 diabetes mellitus) has been increasing in the past few decades 3; c) the co-existence of one or more physical diseases has a significant impact on many quality of life and psychopathological variables in persons with severe mental illness 4; d) mortality due to physical diseases is higher in persons with severe mental illness than in the general population 5, and the gap concerning mortality due to some diseases (in particular, ischaemic heart disease) has been increasing in recent decades 6; e) the access to physical health care of persons with severe mental illness is reduced compared to the general population 6; f) the quality of physical health care received by persons with severe mental illness is poorer than the general population: recent data about mortality due to post-operative respiratory failure (adjusted odds ratio, OR=8.85) and post-operative sepsis (adjusted OR=7.14) in persons with schizophrenia are striking in this respect 7.

In order to address this situation, several lines of action can be identified. Raising awareness of the problem among mental health professionals, primary care practitioners, patients and their families is obviously a first priority. The available research information about the increased morbidity and mortality due to physical diseases in people with severe mental disorders should be much better disseminated.

Education and training of mental health professionals and primary care providers is one more essential step. Mental health professionals should be trained to perform at least basic medical tasks. They should be educated about the importance of recognizing physical illness in people with severe mental disorders. They should be encouraged to familiarize themselves with the most common reasons for underdiagnosis or misdiagnosis of physical illness in their patients 8. On the other hand, primary care providers should overcome their reluctance to treat persons with severe mental illness. They should learn effective ways to interact and communicate with these persons: it is not so much an issue of knowledge and skills; it is mostly an issue of attitudes.

Another essential step is the development of an appropriate integration between mental health and physical health care. There is some debate in the literature about who should monitor physical health in people with severe mental illness. What really matters, however, is that there is always somebody who cares: every patient should have a professional who is identified as responsible for his/her physical health care. On the other hand, mental health services should be able to provide at least a standard routine assessment of their patients, in order to identify or suspect the presence of physical health problems. Currently available guidelines about the choice of antipsychotic medication in the individual patient and the management of patients receiving antipsychotics should be known and applied by all mental health services. Mental health professionals should encourage patients to monitor and chart their own weight and should sensitize patients and their caregivers to the health risk associated with excess weight. Dietary and exercise programs should be an essential part of what mental health services provide.

Finally, further research in this area is badly needed. Physical illnesses should not be always regarded as confounding variables in studies dealing with severe mental disorders. They should be studied by specific research protocols, so that the interaction between mental disorders and the various physical diseases – in men as well as in women; in young people as well as in the elderly; in inpatients as well as in outpatients – can be better understood. This could also facilitate the development of closer working relationships between physical and mental health professionals.

The WPA will implement during this triennium an international programme on the protection and promotion of physical health in persons with severe mental illness, in collaboration with other international and national medical associations and with some organizations of users and families. One of the components of the project will be the development of an educational module to be used in training of residents in psychiatry, dealing with physical diseases and access to health care services in persons with schizophrenia.

The promotion of physical health care in people with severe mental illness is today a key issue in our field. If we do not regard it as a priority, we will not be able to state convincingly that a better quality of life and the protection of the civil rights of our patients is really what we strive toward.