Overview

• Examine the relationship between mental health and physical health, and identify common physical health issues that affect people with a mental illness.
• Why this is a critical issue: physical health optimization is essential to overall wellbeing, and nurses have a central role in assessment, treatment, and prevention of physical health problems in people with mental illness.
• Key concern: physical health issues are often overlooked when a person has a mental illness; partnerships and collaboration are key to improving both physical and mental health.
• A large share of premature mortality in people with mental illness is from preventable physical health conditions rather than suicide.
  • Approximately rac{4}{5} (i.e., 80%) of premature deaths are linked to preventable physical illnesses.
• Premature mortality in this population is supported by multiple risk factors beyond psychiatric symptoms, including medication effects, lifestyle factors, and social determinants of health.

Why physical health matters in mental health

• People living with mental illness have much poorer physical health outcomes than the general population.
• There is a life expectancy gap of in excess of 20 years for some types of mental illness.
• The misconception that most premature deaths are due to suicide is incorrect; the vast majority relate to preventable physical health conditions.
• Numerous factors contribute to high physical morbidity: psychotropic medications can cause weight gain and endocrine changes; symptoms such as negative symptoms of schizophrenia can lead to withdrawal, isolation, and sedentary behavior; poverty, smoking, alcohol/drug use, homelessness, unemployment, dental disease, sleep disorders, and poor diet all contribute to risk.
• People with serious mental illness (e.g., schizophrenia) have greater susceptibility to chronic illness risk factors in addition to social determinants of health.
• World Health Organization (WHO) defines mental health as a state of wellbeing where individuals realize their potential, cope with daily stresses, work productively, and contribute to their community; it also recognizes a universal right to health, including control over one’s health and body and access to health protection that allows everyone to attain the highest possible health level.
  • Key WHO concepts: wellbeing, potential realization, coping with life stresses, productive work, community contribution, and the right to health for all.

World Health Organization definitions and core rights

• WHO describes mental health as a state of wellbeing allowing realization of potential, coping with normal stresses, productive work, and community contribution.
• WHO acknowledges a universal right to health, including:
  • Right to control one’s health and body without interference.
  • Right to a health protection system that offers equal opportunity to achieve the highest attainable health level.

Historical context and professional role

• Historically, physical healthcare for people with mental illness has been neglected.
• In Australia, mental health commissions call for better addressing the physical health of mental health consumers.
• Nurses are well-placed to lead in ensuring physical health needs are considered from the initial assessment through the mental health journey.
• Holistic nursing practice should incorporate physical healthcare by keeping the body in mind (i.e., holistic consideration of both physical and mental health).

Issue Prevalence (Victoria, Australia)

• Data and statements summarized from the State of Victoria, Department of Health and Human Services (March 2019) within the Issue Prevalence sections.
• Key takeaway: there is a recognized prevalence of physical health neglect and gaps in integrated care when serving people with mental illness.

Physical health neglect in the mental health system

• Comorbidity with serious mental illness (SMI) and physical illness often leads to gaps between physical and mental healthcare services.
• The health system is frequently divided into physical vs. mental health services with limited integration.
• Clinicians in mental health settings may focus on mental illness symptoms, sometimes at the expense of other health issues (diagnostic overshadowing).
• Physical health symptoms are often not noticed or not addressed even when reported by patients.
• Barriers within mental health care include:
  • Some nurses and other staff may not view addressing physical health as part of their duty of care, or lack confidence in performing physical assessments.
  • In the wider health system there is often a lack of confidence in working with people who have mental illness.
  • Physical health services and allied health services may be financially inaccessible for this population.
• These barriers contribute to care challenges for people with complex chronic comorbid conditions (e.g., schizophrenia + diabetes).
• Access and availability are not the only barriers; higher physical illness burden also leads to shorter life expectancy and worsens the mental illness. Comorbidities can limit workforce participation and increase poverty/welfare dependence.
• Despite higher morbidity, people with SMI access health services less than the general population, which compounds health inequities.
• The burden on families, friends, and carers increases as they take on expanded roles in managing both mental and physical health needs.

When psychiatric symptoms are not a mental illness

• Some symptoms (confusion, vision problems, behavior changes) may indicate organic diagnoses (brain tumors, infections, dehydration).
• Correct assessment requires comprehensive history-taking and corroboration from relatives.
• In the first episode of psychosis, MRI or CT brain imaging should be conducted to rule out organic causes (e.g., tumors).

Metabolic syndrome: definition and risk

• Metabolic syndrome is a cluster of abnormal clinical and metabolic findings that increase the risk of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD), as well as CVD mortality.
• Key abnormal findings include:
  • Visceral adiposity
  • Insulin resistance
  • Increased blood pressure
  • Elevated triglycerides
  • Low HDL cholesterol
• Complications involve cardiovascular, hepatic, endocrine, and central nervous systems.
• Meeting the criteria for metabolic syndrome increases risk: ext{risk}{T2DM} o 5 imes ext{ baseline risk} over the next 5-10 years and ext{risk}{CVD} o 2 imes ext{ baseline risk} over the same period.
• Therefore, proactive intervention is required when metabolic syndrome risk factors are present.

Metabolic syndrome in people with SMI

• People with SMI have higher rates of obesity and abdominal obesity than the general population, even early in illness and with or without antipsychotic medication.
• Obesity in SMI is linked to lifestyle factors (poor diet, physical inactivity) and psychiatric symptoms (sedation, amotivation, disorganization) that worsen lifestyle factors.
• Medication effects on appetite and intake contribute to weight gain.
• Weight gain is a well-established side effect of antipsychotic medications, most pronounced at treatment onset and often continuing with prolonged treatment.
  • Clozapine and olanzapine are associated with the greatest weight gain; quetiapine, risperidone, and paliperidone with moderate gain; aripiprazole, asenapine, and ziprasidone with less gain.
  • All antipsychotics have been associated with significant weight gain upon initiation if no interventions are implemented.

Screening for metabolic health

• Screening for metabolic syndrome is essential to identify risk factors for CVD and T2DM and to enable early treatment.
• Screening is within the nursing scope of practice and should be an essential activity.
• Metabolic screening involves:
  • Waist circumference (best indicator of metabolic health)
  • Blood pressure
  • Height and weight
  • Body mass index (BMI)
  • Fasting lipids and fasting glucose
• Recommended frequency: every three months, with more frequent checks when starting a new medication or if health concerns exist.
• There is also a related metabolic monitoring tool used in practice.

Cardiovascular disease (CVD) in SMI

• CVD refers to diseases of the heart and blood vessels; coronary heart disease and cerebrovascular disease are the primary components.
• Major risk factors include: smoking, obesity, hypertension, dyslipidaemia, and T2DM.
• Other contributing factors: genetics, unhealthy diet, physical inactivity, and low socioeconomic status.
• CVD is the leading cause of death in people with SMI, with prevalence roughly twice that of the general population; in younger people with SMI, rates are about three times higher than matched controls.
• People with SMI have higher rates of modifiable risk factors (overweight/obesity, T2DM, hypertension, dyslipidaemia, smoking).

Gaps in CVD care for people with SMI

• Despite high CVD mortality, people with SMI receive less of many specialized interventions (e.g., cardiovascular medications).
• They are not adequately screened or treated for dyslipidaemia and hypertension; depression is also an independent risk factor for worse outcomes in coronary heart disease.
• People with SMI have lower rates of procedures such as stenting and coronary artery bypass grafting, contributing to excess mortality after heart failure.
• Barriers include reduced health-seeking behavior during acute cardiovascular events and potential under-treatment.
• Medication-related mechanisms contribute to CVD risk: antipsychotics may cause weight gain and metabolic changes, and some may directly affect insulin resistance (T2DM antagonism). Higher antipsychotic doses predict greater mortality risk from CVD and stroke.
• Many medications (including most antipsychotics and some antidepressants) are associated with QTc prolongation, increasing the risk of torsades de pointes, ventricular fibrillation, and sudden cardiac death.

Management of cardiometabolic health

• Screening alone is not enough; active intervention is required after problems are identified.
• Lifestyle interventions are central to cardiometabolic management.
• Nurses are well positioned to advise, encourage, and implement lifestyle changes focused on tobacco cessation, physical activity, and healthy nutrition.
• Even small lifestyle changes can have substantial benefits for people with SMI.
• Key reference: Elder et al. (2017).

Sexual health in mental health care

• Sexuality and sexual health are important components of health and wellbeing.
• Sexuality encompasses more than physical sex activity; it includes gender identity, values, and beliefs.
• Contrary to some beliefs, most people with SMI are interested in sex at levels similar to the general population.
• High-risk sexual behaviors are more common in people with SMI, including unprotected sex, multiple partners, involvement in sex work, and illicit drug use; higher rates of HIV and hepatitis C have been found among people with SMI.
• Social and interpersonal impairments associated with SMI can limit stable sexual relationships; gender differences exist (e.g., men may have poorer social outcomes; women may have chaotic sexual patterns and higher rates of non-consensual sex).
• Australian studies indicate women with SMI have lower use of effective contraception and higher rates of unplanned pregnancies.
• Mental health nurses may be reluctant to discuss sexual health; to enable comfort and confidence, nurses should identify personal barriers and increase knowledge about sexual health issues.
• Common issues affecting sexuality/sexual health include sexually transmitted infections, body image, gender identity, physiological changes, medications, and stigma.

Medication and sexual health

• Many psychotropic medications cause sexual dysfunction (low libido, delayed ejaculation, anorgasmia, erectile dysfunction).
• Medication-induced sexual dysfunction can affect relationships, medication adherence, and quality of life.
• Discussions of sexual health are often avoided by health professionals, leading to underestimation of prevalence and poorer treatment adherence among people with SMI.

Sexual health screening

• Health screening includes preventive testing for breast, prostate, cervical health, and sexually transmitted infections.
• Mental health nurses can play a pivotal role in screening, especially when access to services is challenging.
• Nurses may refer directly to screening services or provide health assessments themselves; they can also educate on safe sex practices (e.g., correct condom use).
• Screening services are generally offered by public health services (breast, prostate, cervical screening).
• Given vulnerability around sexual health, it is essential that nurses include sexual health screening as part of holistic care.
• Nurses should reflect on personal attitudes or beliefs that may create barriers to thorough sexual health assessment.

Equally Well framework in Victoria

• Equally Well in Victoria provides a physical health framework for specialist mental health services.
• This framework guides integration of physical health care within mental health services to reduce the health disparities experienced by people with SMI.

Review and synthesis

• People with SMI have markedly higher morbidity and mortality across most chronic health conditions.
• Specific health assessments highlighted in this lecture include: sexual health, oral health, sleep, metabolic syndrome, cardiovascular disease, diabetes, and respiratory disease.
• A full physical assessment, including routine health screening, remains an essential element of holistic mental healthcare.

References (notable sources cited in the material)

• Elder, R., Evans, K. & Nizette, D. (2017). Psychiatric and Mental Health Nursing (4th ed.). Elsevier: Australia.
• Galletly et al. (2012). Cardiometabolic risk factors in people with psychotic disorders: The second Australian national survey of psychosis. Australian and New Zealand Journal of Psychiatry; 46: 753-761.
• Hauck, Y., Nguyen, T., Frayne, J., Garefalakis, M., & Rock, D. (2014). Sexual and reproductive health trends among women with enduring mental illness: A survey of Western Australian community mental health services. Health Care for Women International; 36: 499-510.
• State of Victoria, Department of Health and Human Services (2019). Equally Well in Victoria: Physical health framework for specialist mental health services.
• World Health Organization (WHO) (2008). The right to health fact sheet no. 31. Geneva: WHO. Available: www.who.int/hhr/activities/RighttoHealth_factsheet31.pdf
• Additional references cited within the material (Elder et al., 2017) and related studies on metabolic and cardiometabolic health in SMI.