Reversing the downward spiral for people with severe mental illness through educational innovations
Authors: Marc de Hert, Johan Detraux
Journal: World Psychiatry (2017)

In two earlier papers on physical diseases in people with severe mental illness (SMI) which appeared in this journal1, 2, we indicated that the screening, assessment and management of physical health aspects in these patients were poor, even in developed countries. Although (young and adult) people with SMI are entitled to the same standards of care as the rest of the population3, Liu et al4 report now, half a decade later, that little to no progress has been made. Moreover, it seems that the mortality gap between these people and the general population is only increasing over time3, 5. Thus, despite numerous calls to take their physical health seriously, people with SMI still suffer excess morbidity and mortality from physical causes and receive inferior physical health care. It is a fact that the integration of physical and mental health care systems is still a long way from becoming a reality and that poor or absent liaison links limit the ability of most psychiatrists to focus beyond their own specialty. Moreover, in several countries, reforms in mental health, emphasizing on community care and ambulant therapies, have led to shorter and infrequent hospital admissions with less time available to deal with physical health problems. In their paper, Liu et al4 propose a multilevel model of interventions to reduce the excess mortality in people with SMI. This model assumes that an effective approach must comprehensively implement interventions or strategies that focus on the individual, the health system, and the community. Although we believe that the adoption of this model would contribute to a significant improvement in the physical and related mental health of people with SMI (despite that actions are not easy to realize at a system level, especially for developing countries)2, there is more than meets the eye. The physical health of people with SMI is an issue that should concern both primary and secondary care services. However, it seems that most psychiatrists and primary care providers or general practitioners are wandering on the road of the Cheshire cat. Like the conversation between Alice and the Cheshire cat in the famous novel Alice's Adventures in Wonderland, there still seems to be a lot of confusion and uncertainty. Before interventions or strategies can result in improved outcomes for people with SMI, it is important that both know which way they have to go. According to a 2014 report of the UK National Audit of Schizophrenia6, the monitoring of people with SMI for physical health problems falls well below agreed standards. Only about one fifth of people with schizophrenia had had their physical health properly monitored – following the clinical guidelines on schizophrenia of the UK National Institute for Health and Care Excellence (NICE) – by their general practitioner and, of those with documented evidence of risk factors, many were not receiving appropriate treatment. Recently, the NICE published a new set of quality standards which specifically address the problem of poor physical health in young and adult people with schizophrenia. This guideline requires for primary care providers to carry out monitoring of physical health risk factors for all service users with schizophrenia7, 8. To avoid a lack of clarity and consensus as to where the responsibility of primary caregivers and psychiatrists lies, it is specified that specialist mental health teams should assume lead responsibility for the first 12 months or until the service user's condition has stabilized, and that thereafter primary care providers should assume that responsibility, unless there are particular reasons for this remaining with secondary care. For example, people with SMI may be seen with greater frequency by mental health care providers than by their primary care providers, and may prefer to be monitored by the former. In any case, taking care of the physical health of people with SMI also requires supporting the rapid sharing of the results of routine physical health monitoring between primary and secondary care. However, more is needed than new recommendations and structural changes to reverse the negative, downward spiral for people with SMI. First, we think there is an urgent need to change the culture of both psychiatrists and primary care providers, who see the mental and physical health of their patients still as mutually exclusive responsibilities. Second, we have to provide them with more information on physical health problems commonly associated with SMI. Both can be accomplished through educational innovations3, 7, 8. On the one side, we should teach psychiatrists during their training that they have to ensure that persons with SMI receive appropriate treatment for physical health problems and that the monitoring of simple and modifiable health risk factors, such as weight and blood pressure, should be part of routine psychiatric care. Thus, they should learn not to overemphasize on mental health to the exclusion of physical health. Furthermore, they should improve their communication skills, avoid erroneous beliefs about the patients' capability to change their lifestyle, and adhere to treatment guidelines. The latter is particularly important. Besides mental illness-related factors, disparities in health care access and utilization, stigma and lifestyle factors, psychotropic medications can contribute to the emergence or aggravation of physical diseases3, 8-10. Higher dosages and polypharmacy seem to be associated with a greater effect on most physical diseases10. This is not as straightforward as it seems. An editorial in The Lancet drew attention to a "worrying" lack of training in physical health needs amongst psychiatrists and psychiatric nurses11. Therefore, doctors who pursue a career in psychiatry should be educated and trained to recognize physical illness and perform basic medical tasks. Moreover, knowledge about specific medication effects and greater attention to the possible impact of psychotropic medications on the physical health of people with SMI can aid psychiatrists in selecting appropriate treatment3, 10. The same is true for primary care providers. Some primary care professionals hold negative attitudes toward this vulnerable group, or wrongly attribute physical illness signs and symptoms to concurrent mental disorders, leading to underdiagnosis and mistreatment of the physical conditions. It seems that there still is a lack of awareness among these providers that people with SMI face a greater risk of developing physical illnesses, such as heart disease, obesity and diabetes3. Primary care providers may also not be knowledgeable about the health risks associated with psychotropic medications and the resulting health monitoring that is indicated for persons with SMI. They therefore should specifically be trained to identify and treat physical health problems in people with SMI3. It is clear that deficiencies in the care of those with SMI, due to cultural and educational factors and unclear roles and responsibilities of their providers, continue to leave many service users with SMI vulnerable to serious physical health issues, which may limit their recovery. We can change these aspects through educational innovations. Only then we can leave the road of Cheshire cat and will multilevel interventions or strategies, as those proposed by Liu et al4, result in improved outcomes for people with SMI. Marc De Hert, Johan Detraux KU Leuven - University Psychiatric Centre, Department of Neurosciences, Kortenberg, Belgium