Physical health assessment for people with a severe mental illness

People with severe mental illness (SMI) have poorer physical health than the general population and die on average 15 to 20 years earlier than people without a mental health condition (HM Government and Department of Health (DH), 2011). This is mostly because of physical health problems that are not diagnosed or managed efficiently (HM Government and DH, 2011). Being in contact with a mental health service does not always mean that people with an SMI have a physical health assessment, have their physical health monitored or receive information, support and lifestyle interventions to improve their overall wellbeing. A group of organisations, including several royal colleges, have produced a report setting out actions to improve the physical health of these patients (Academy of Royal Medical Colleges et al, 2016).

Nurses from all fields have unparalleled opportunities to improve the physical health conditions of SMI patients, both in inpatient and community settings (HM Government and DH, 2011). To make these improvements and ensure parity of esteem between physical and mental health, all nurses must capitalise on every contact they have with people with SMI to improve early detection, evidence-based care and interventions.

Physical and mental health are inextricably linked and a holistic approach is needed to manage both. There is strong evidence to suggest that having a long-term mental health condition can be a significant risk factor for poor physical health and long-term physical health can have a detrimental impact on a person's mental health (HM Government and DH, 2011). Medically unexplained physical symptoms are often the basis of poor mental health and have been estimated to cost the NHS over £3 billion a year (Bermingham et al, 2010). Comorbid mental health problems and long-term conditions increase healthcare costs by 45% per person (Naylor et al, 2016). Key issues include increased respiratory diseases, diseases of the liver, cardiovascular disease and ischaemic heart disease. Physical health problems are also highly prevalent among people with eating disorders, personality disorders, drug and alcohol use disorders, or untreated depression or anxiety.

Risky health behaviours are common among people with SMI and include smoking, a poor diet and a sedentary lifestyle, which lead to obesity and hyperlipidaemia (Glasper, 2016). Yet, offers of timely access to physical health assessments and interventions are often inconsistent. People with SMI are also less likely to report accidents or injury and access medical care, leaving symptoms untreated. Individuals with serious mental illness are found to be less likely to engage with healthcare services despite increased risk factors associated with their illness.

Negative attitudes from health professionals, including ‘diagnostic overshadowing’, whereby physical symptoms are attributed to an individual's mental illness, and perceived stigma about mental conditions, often deter people from seeking health advice (Nash, 2014). People with SMI are at increased risk of asthma, obesity, diabetes, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), stroke and heart failure (Public Health England (PHE), 2018a). In addition, antipsychotic medication has been shown to increase food intake, impair glucose tolerance and alter people's level of physical activity (Lord et al, 2017). Approximately eight out of ten people prescribed olanzapine [for schizophrenia] develop significant weight gain (defined as an increase of 7% or more of their starting weight) (Haddad, 2017).

Contact with any health service should be an opportunity to improve both mental and physical health. Health professionals can make brief interventions or carry out a full physical health assessment as appropriate.

For nurses, this means a greater focus in education on improving assessments for these patients, more screening to identify physical health problems and the use of interventions to improve outcomes and reduce health inequalities and improve quality of life (Mental Health Taskforce, 2016). Barriers for staff delivering physical healthcare in SMI patients include a lack of knowledge and training in communication and negotiation skills and a lack of integrated services (McBain et al, 2018). The Five Year Forward View for Mental Health (Mental Health Taskforce, 2016) produced for NHS England, aimed to ensure that by 2020, 280 000 people living with SMI have their physical health needs met, expanding access to evidence-based detection, assessment and intervention and creating integrated mental and physical health services nationally by April 2021 (NHS England, 2019). However, there is a lack of understanding among healthcare providers about how to meet the complex needs of people with SMI (Ross et al, 2016). All health professionals have a part to play in delivering integrated care to manage the needs of this population group (Naylor et al, 2016).