Let’s get physical: improving the medical care of people with severe mental illness

High rates of mortality associated with psychiatric disorders have been extensively reviewed and quantified (Harris 1998; Neeleman 2001). The mortality gap between observed and expected deaths among people with severe mental illness (psychosis) has not improved over time, despite increased recognition of the contribution of physical comorbidity (Dembling 1999; Saha 2007). A generation of psychiatrists has tried to address deaths from so-called unnatural causes (suicide), but deaths from natural causes (comorbid physical illness) have continued to rise and may account for as much as 80% of premature mortality in people with mental disorders (Harris 1998; Colton 2006; Parks 2006; Mitchell 2009a). Medical illness affects more than half of people with mental illness, particularly in high-risk groups such as older people, those with intellectual disability, cognitive impairment or substance misuse, those in long-stay institutions and the homeless (Alaja 1998; Fisher 2001). A large US study of homeless people with severe mental illness reported that 74% had medical needs, 44% of which were unmet (Desai 2005). In another US study, systematic examination of people with intellectual disability referred to psychiatric services revealed that 75% had undetected medical problems (Ryan 1997). Even if medical problems are identified, medical in-patients with mental illness appear to experience more post-operative complications and elevated mortality (Copeland 2008; Khaykin 2010). Yet it is the nature as well as the extent of comorbid physical illnesses that is concerning, with an excess of metabolic and cardiovascular problems (Mitchell 2006; Leucht 2007; Bresee 2010). The European METEOR study reported that 70% of patients receiving antipsychotics for schizophrenia had lipid disorders and 40% hypertension (De Hert 2008), and a more recent US study found that 90% of Medicaid recipients prescribed second-generation antipsychotics for schizophrenia had at least one major metabolic risk factor (Bell 2009). Mental health professionals have unwittingly increased the risk of medical conditions in their patients by recommending a variety of psychotropic drugs that contribute to cardiovascular disease, diabetes and endocrine disorders (Newcomer 2005). In people with unmedicated schizophrenia, metabolic syndrome is relatively uncommon, affecting only about 10% (Chiu 2010). Although the mechanisms underlying cardiometabolic complications are not entirely clear, weight gain and cholesterol increases are particular problems with antipsychotics (Rummel-Kluge 2010). A 3.8 kg gain is typical in drug-naive patients starting antipsychotic treatment (Tarricone 2010), but 12–15 kg is not uncommon. Given this background of high rates of medical comorbidity in people with mental ill heath but no clear method to manage the problem, we suggest that it is pertinent to focus on the following questions: