Why we need to do more to tackle cardiometabolic risk in patients with Serious Mental Illness

People with serious mental illness are at significantly increased risk of cardiovascular and metabolic diseases and it is up to us as healthcare professionals to step in to minimise these risks: Don’t just screen – intervene

Serious Mental Illness (SMI) affects 5% of our population.¹ Approximately one in a hundred of the population will experience a psychotic episode at some point in their lives with 80% experiencing their first episode between the ages of 15 and 30. SMI encompasses patients who suffer from schizophrenia, bipolar disorder and schizoaffective disorder. SMI means a life lived with hallucinations, delusions, mania or depression. It can affect personal relationships, employment and contribute to social isolation. If that isn’t enough, the life expectancy of people with SMI in Britain has not improved in the past 60 years.² Inequalities in health care for people with mental illness, together with a lack of specific resources directed at this vulnerable group, has meant that their physical health needs have not been met in the same way as for the general population. People with serious mental illness are dying preventable deaths.

SEVERE MENTAL ILLNESS AND PHYSICAL ILL-HEALTH

People with SMI have a significantly shortened life-span compared with the general population. Although suicide accounts for a third of these premature deaths, physical ill-health is responsible for reducing life expectancy, with cardiovascular disease being the main cause of death. Men and women with schizophrenia die approximately 20 years and 16 years earlier, respectively, compared with the general population.³

So what causes this increased risk of morbidity and mortality from cardiovascular disease in this population?

• Altered glucose metabolism in people with early psychosis⁴
• Increased visceral fat in people with early psychosis⁴
• Specific and rapid metabolic disturbances with antipsychotic medication (aripiprazole, olanzapine, quetiapine and risperidone) including:
  • rapid weight gain leading to obesity³
  • increases in glucose, total cholesterol and triglyceride levels³
  • decreased high density lipoprotein cholesterol³
  • 10-15% increased risk of developing type 2 diabetes⁵
  • increased incidence of myocardial infarction in young people with psychosis⁶
• The rate of heavy smoking amongst people with SMI is estimated at six times higher than the general population⁵
• Lifestyle factors, including unemployment, poor nutrition and a lack of exercise, social disadvantage and exclusion³

ACCESS TO SERVICES

For people with SMI, access to health services can be limited. The Report of the National Audit of Schizophrenia suggests that 31% of people with SMI are only seen in primary care and the experience varies considerably. Although this at-risk group of patients can present frequently in general practice, a lack of knowledge, experience or interest in mental health issues among the primary care team, with the obvious exception of the Community Psychiatric Team, results in a limited service at best. Poor or little monitoring of medication and assessment of physical health is a significant issue, with up to 70% of people with type 2 diabetes being undiagnosed.⁶ Focusing on other priorities in our target-driven world, together with a lack of suitable resources for intervention, these high risk individuals are being denied appropriate care and the opportunity to improve the outcomes of their poor health.⁶

THE INTERVENTION FRAMEWORK

The Lester UK adaptation of the Positive Cardiometabolic Health Resource 2014 is a framework that has been developed, and recently updated, to aid health professionals identify the risks of cardiovascular disease and type 2 diabetes in patients with psychosis who take antipsychotic medication.⁷ (Figure 1) It has been developed by the Royal College of Psychiatrists Centre for Quality Improvement, the Royal College of General Practitioners Clinical Innovation and Research Centre and the Royal College of Nursing as part of the National Audit on Schizophrenia. In addition to being a tool to identify cardiometabolic risks, the purpose of the framework is to provide guidance for intervention and treatment, alongside NICE guidance, to reduce those risks and improve the health outcomes for this vulnerable group. The key message is ‘Don’t just screen – Intervene’.⁷ It supports both NHS England’s commitment to reduce premature mortality in people with severe mental illness and the implementation of the 2014-15 physical health Commissioning for Quality and Innovation (CQUIN).^1,8

The framework sets standards for the monitoring of patients on antipsychotic medication, with examination at initiation and at least once after 3 months. Baseline examination should include:

• Personal and family history
• Assessment of lifestyle
• Weight
• Waist measurement
• Blood pressure
• Blood tests for fasting glucose, HbA1c and lipid profile

Weekly weight measurement is recommended for the first 6 weeks of taking antipsychotic medication. Early rapid weight gain is a predictor of severe long-term obesity and therefore early detection of weight gain is vital. Further assessment is recommended 12 weeks after commencement of medication to determine any deterioration, with the baseline examination repeated annually (Table 1).

INTERVENTION

Following cardiometabolic assessment, the framework recommends specific intervention based on risk. As a result, such intervention is designed to promote a greater collaboration between the psychiatric team, the patient and the general practitioner in terms of monitoring the health of a person on antipsychotic medication. Figure 1 highlights distinct areas which require intervention should a patient’s results fall into the ‘red zone’ through identification of smoking, obesity, hypertension, altered blood glucose or lipid profile or dietary and lifestyle risks. For example, specifically structured interventions, targeting physical activity and nutrition, may be required initially before further investigation.

Should improvements not be apparent after 3 months of interventions with changes to diet and exercise, then more specific action is recommended through primary care to target hypertension, lipid lowering and treatment of those at risk of diabetes in line with NICE guidance.^9-11 In addition, the framework suggests that those patients who are at high risk of developing diabetes could be offered a trial of off-label metformin, if appropriate, together with an intensive lifestyle programme.⁷

SMOKING

The Report of the National Audit of Schizophrenia sees tackling smoking as an absolute priority for those with SMI.⁶ The Lester UK Adaptation framework suggests a variety of interventions to help people achieve this from individual support through to intensive group support, with referral to smoking cessation services as necessary. In addition, use of pharmacotherapy, if not contraindicated with antipsychotic medication, may be especially beneficial when combined with cognitive behaviour therapy or group behavioural support. One of Public Health England’s goals is to provide greater access for people with SMI to smoking cessation programmes. The suggestion is that people with SMI are less likely to access mainstream services for smoking and that referral to specialist services may be more appropriate.¹²

MEDICATION MANAGEMENT

Along with monitoring physical health, the framework also provides guidance for the management of antipsychotic and mood stabiliser medications. The recommendation is that the GP and psychiatrist work together with the patient in making decisions about commencing, continuing or changing medication. It is vital to determine potential side-effects of medication, the likelihood of such medication contributing to the detriment of physical health and the risks of disturbing the equilibrium in the patient’s mental health when considering changing antipsychotics. Review of medication is essential if the patient displays rapid weight gain after initiation of an antipsychotic or if there is a sudden detrimental change in lipids, glucose or blood pressure within the first 3 months. Although it is recommended that the psychiatrist takes responsibility for monitoring physical health alongside monitoring medication, shared care arrangements with the GP may enable transfer of physical healthcare to primary care.

PRACTICE NURSE ROLE

A considerable part of the practice nurse’s role is to help patients modify their lifestyle in an attempt to reduce their risks of heart disease and diabetes. But what experience do most practice nurses have with regards to managing patients with psychosis? And do we recognise when people with SMI are most receptive to making such significant life changes?

The Rethink Mental Illness publication ‘Lethal Discrimination’ suggests that people with mental health problems have the same desire to stop smoking as anyone else.¹³ Barriers that may deter staff from supporting these patients include the attitudes of health professionals themselves and fixed service targets for achieving non-smoking status. Even when someone stops smoking, the risk of people with SMI starting again is significantly increased with any relapse of their condition. We know more than two thirds of people in psychiatric units smoke, half of them heavily. As a consequence, this increases the chances of those non-smokers who are admitted or re-admitted taking up the habit or starting to smoke again.¹⁴ NICE certainly recommends that people with SMI who are accessing secondary care services should receive more intensive and tailored support with smoking cessation. Shouldn’t that also happen in primary care? In reality, how many of us have that experience and, to be frank, are allowed to give such dedicated time? Indeed, many practices delegate the responsibility of smoking cessation to the healthcare assistants, who may have very limited experience with people with psychosis. Rethink Mental Illness recommends that smoking cessation service staff should have mental health training to be able to support these patients appropriately. In addition, patients who use tobacco as part of their cannabis habit may also need more specialised support from the community drugs and alcohol teams.

If you look at the Quality and Outcomes Framework (QOF) for 2014-15 in England, it is only the documentation of smoking and alcohol status with an annual blood pressure recording for people with schizophrenia, bipolar affective disorder and other psychoses that is incentivised.¹⁵ There is a recommendation, however, for a physical health review for those with SMI ‘over the age of 40’ as QOF acknowledges the increased risk of metabolic syndrome but this is based on a GP’s clinical judgment. With current workload in primary care, even with all the will in the world, are these unrewarded recommendations at risk of being overlooked? Practices are certainly up against it. And although the targets in Scotland and Wales incorporate measurements of BMI and HbA1c, with screening for lipids in Scotland as well, they are only directed for those aged 40 years or over and therefore younger patients, who are equally at risk, have been excluded.^16,17 We have a tough job to convince our budget holders that this intervention needs priority for all patients with SMI within our practice population.

It is acknowledged that people with SMI do not access services and respond to campaigns in the same way as the general public. Forging greater links with mental health teams would make absolute sense in order to address these issues and prevent physical health care needs falling between primary and secondary care. Finding out what local resources and projects are available and how to access them would clearly be of benefit to patients. Any intervention needs to be supportive, appropriate and individualised to the needs of patients with SMI taking into account their lifestyle and support networks.

Innovative programmes are available in some areas of the country such as the Worcestershire Health and Care NHS Trust ‘SHAPE’ – Supporting Health And Promoting Exercise – project for young people with psychosis.¹⁸ The project is a structured, intensive intervention programme for young people who access mental health services to target their physical health needs over a 3 month period with follow up over a year. The aim of the project is to provide a variety of interventions that not only improve the physical health of young people with psychosis now but also ultimately enable them to make future lifestyle choices to reduce their risks of premature death.

CONCLUSION

Clearly the poor cardiometabolic health of people with SMI is responsible for significant morbidity and premature mortality. It is acknowledged that people with psychosis, schizophrenia and bipolar disorder have ‘slipped through the net’ with regards to improvements in cardiovascular disease and diabetes compared with the general population. Primary care, in collaboration with mental health services, needs not only to identify those at risk but provide adequate and specific intervention to improve the long-term health of our patients with SMI. The very nature of severe mental illness may mean progress might be one step forward, two steps back. But the evidence is clear – without identification of cardiometabolic risks and without intervention people with SMI will continue to die preventable deaths.

REFERENCES

1. NHS England. Everyone Counts: Planning for Patients 2014/15 - 2018/19. December 2013 http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf

2. NHS England. NHS England pledge to help patients with serious mental illness, 2014 http://www.england.nhs.uk/2014/01/20/mental-illness/

3. Shiers D, Holt R, Lester H et al. Fact file 13: Protecting the cardiometabolic health of people with severe mental illness. Diabetes Update 2013: Winter. http://www.diabetes.org.uk/upload/Professionals/Publications/Winter%202012/FactFile-Winter2012.pdf

4. Bailey S, Gerada C, Lester H, Shiers D. The cardiovascular health of young people with severe mental illness: addressing an epidemic within an epidemic. The Psychiatrist 2012;36:375-378.

5. Gordon E, Hulatt I, Shiers D. Protecting hearts and minds. Mental Health Practice 2012;16:20-21. http://rcnpublishing.com/doi/abs/10.7748/mhp2012.12.16.4.20.c9467

6. The Schizophrenia Commission. The abandoned illness: a report from the Schizophrenia Commission. London: Rethink Mental Illness; 2012 http://www.rethink.org/media/514093/TSC_main_report_14_nov.pdf

7. Shiers D E, Rafi I, Cooper S J, et al. Positive Cardiometabolic Health Resource: an intervention framework for patients with psychosis and schizophrenia. Royal College of Psychiatrists, London. 2014 update Available at: http://www.rcpsych.ac.uk/pdf/Lester%20update%202014%20FINAL2.pdf

8. NHS England. Commissioning for Quality and Innovation (CQUIN): 2014/15 guidance. February 2014 Available at:

http://www.england.nhs.uk/wp-content/uploads/2014/02/sc-cquin-guid.pdf

9. NICE. Hypertension: Clinical management of

primary hypertension in adults. NICE CG127 August 2011 http://www.nice.org.uk/guidance/cg127

10. NICE. Type 2 diabetes: The management of type 2 diabetes. NICE CG87. May 2009 modified March 2014

http://www.nice.org.uk/guidance/cg87

11. NICE. Lipid modification: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. NICE CG67. May 2008 modified March 2010 http://www.nice.org.uk/guidance/cg67

12. NHS England. Factsheet: Smoking cessation for people with a serious mental illness (SMI). February 2014. http://www.england.nhs.uk/wp-content/uploads/2014/03/sm-ft-7-4.pdf

13. Rethink Mental Illness. Lethal Discrimination, September 2013. http://www.rethink.org/media/810988/Rethink Mental Illness - Lethal Discrimination.pdf

14. NICE Smoking cessation in secondary care: acute, maternity and mental health services. NICE PH48. November 2013 Available at: http://www.nice.org.uk/Guidance/PH48

15. NHS England. 2014/15 General Medical Services (GMS) contract quality and outcomes framework (QOF). Guidance for GMS contract 2014/15. Gateway reference 01264.

16. Scottish Government. Quality and Outcomes Framework guidance for NHS boards and GP Practices. GMS contract 2014/15.

17. Quality And Outcomes Framework Guidance for the GMS Contract Wales 2014/15 June 2014

18. The Health Foundation. Worcestershire Health and Care NHS Trust: Supporting Health And Promoting Exercise (Shape) programme for young people with psychosis. http://www.health.org.uk/areas-of-work/programmes/shine-2014/related-projects/worcestershire-health-and-care-nhs-trust/