The Physical Care of People with Mental Health Problems

A Guide For Best Practice

Eve Collins, Mandy Drake, Maureen Deacon, Eve Collins, Mandy Drake, Maureen Deacon, SAGE Publications Ltd

• Publisher: SAGE Publications Ltd
• Year: 2013
• Print ISBN: 9780857029218, 9780857029201
• eBook ISBN: 9781446291023
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

This accessible, practical text provides mental health practitioners with the core knowledge and skills they need to be able to care effectively for the physical health of those who have been diagnosed with mental illness.

Linked closely to professional standards, and with a clear values- and evidence-base, the book aims to raise awareness of the physical health needs of individuals with mental health problems, outline the physical health assessment process and suggest health enhancing interventions for use in clinical practice. Consideration will be given to the following aspects of physical wellbeing;

- cardiovascular health

- diabetes

- sexual health

- respiratory health

- cancer

- wound care

- substance misuse

- infection control

- medicine management

Further chapters on legal and ethical issues explain the need to practise appropriately within the Mental Health Act and the Mental Capacity Act, while a linking theme throughout the book stresses the importance of health promotion.

Backed up by case examples and with a range of reflective exercises throughout, The Physical Care of People with Mental Health Problems is a key text for students and practitioners working in mental health services. It will also be useful reading for practice nurses, district nurses, midwives and all allied health practitioners.

1

THE PHYSICAL HEALTH NEEDS OF INDIVIDUALS WITH MENTAL HEALTH PROBLEMS – SETTING THE SCENE

MANDY DRAKE

Learning outcomes

By the end of this chapter you should be able to:

• Identify the main physical health conditions affecting individuals with mental health problems
• Explain the reasons for poor physical health among this client group
• Discuss the barriers to physical health improvement
• Provide an overview of the political agenda in relation to physical and mental health co-morbidity
• Debate the mental health practitioner’s role in physical health care

INTRODUCTION

There is growing awareness in clinical practice of what researchers have known for some time, which is that people who experience mental health problems are highly susceptible to physical ill health. This is particularly true of individuals who have a severe mental illness (SMI), such as schizophrenia or bipolar disorder, who are at a significantly increased risk of acquiring a range of physical health conditions (Northrop 2009; Waldrock 2009).

It is not just those with mental health problems who experience physical health conditions; indeed, poor physical health is a growing concern across society as a whole, but of the estimated 17.5 million of the UK population who were living with a chronic physical illness in 2005, the prevalence was much higher where there was a co-morbid mental health problem present (Department of Health 2005b).

While research has consistently shown the poorer physical health of individuals with mental health problems (Phelan et al. 2001), it has been just as consistent in highlighting the neglect of these (Roberts et al. 2007), a neglect some would speculate has contributed significantly to the premature deaths seen in those experiencing a mental health problem.

The shortened life expectancy of this group is a global problem that has been apparent for many years (Nash 2010a). While it could be argued that the heavy focus on suicide prevention in current UK mental health services is an attempt to reverse this, on its own this is ineffective as 60% of premature deaths are as a result of physical health conditions (Brown 1997).

The majority of studies investigating life expectancy have focused on individuals with SMI and early estimates suggested that the presence of a mental illness equated to 10 years of lost life (Newman and Bland 1991). A later study estimated that this had increased to 10–15 years (Richardson and Faulkner 2005), while the most recent suggestion is that people with SMI will die, on average, 25 years earlier than the general population (Parks et al. 2006; Tiihonen et al. 2009). Not only does this corroborate the findings of Saha et al. (2007) that people with SMI are dying at a younger age now than they were 30 years ago, but it is at odds with the majority of the world’s population who are enjoying increased longevity (Bradshaw and Pedley 2012).

As well as acknowledging the shocking statistics above, the Coalition government’s strategic vision for mental health (Department of Health 2011a) recognises the role poor physical health plays in this, adding that not only is life expectancy of this group vastly reduced, but during their lives individuals with mental health problems will experience far more physical ill health than the general population.

This chapter aims to provide an introduction to the topic of the physical health needs of individuals with mental health problems by presenting an overview of what is currently known. It starts by outlining the main physical health conditions that pose a particular risk to this group before asking why this is. It then discusses what is preventing the health of those with mental health problems from improving before taking a brief look at the UK government’s views through recent health policy and guidance. Finally, the role of the mental health practitioner is explored with suggestions from the literature about how this role could become pivotal in the much needed development of physical health care for this vulnerable client group.

THE PHYSICAL HEALTH NEEDS OF INDIVIDUALS WITH MENTAL HEALTH PROBLEMS

CARDIOVASCULAR DISEASE

Cardiovascular disease (CVD) is a collective term for coronary heart disease (CHD), stroke and peripheral vascular disease (Daniels 2002) and there is much evidence to suggest that individuals with mental health problems, particularly those with schizophrenia, are two to three times more likely to experience this than the general population (Brown et al. 2000; Osby et al. 2000).

Of these conditions it is CHD that is the biggest threat to the population’s health, as this is now considered the leading cause of death worldwide (Aboderin et al. 2002). However, where one half of all deaths in the population are as a result of CHD, in individuals with SMI it is estimated to be two-thirds (Hennekens et al. 2005), indicating a very significant risk for this group.

METABOLIC SYNDROME

Metabolic syndrome is closely related to CHD in that it encompasses a number of risk factors for heart disease, such as increased blood pressure and obesity, and as such individuals with metabolic syndrome are at an increased risk of developing CHD (Nash 2010a). In addition, though, metabolic syndrome consists of impaired glucose tolerance, insulin resistance and type 2 diabetes (World Health Organization 1999).

While metabolic syndrome as a whole is two to three times more common in individuals with a severe mental illness (McEvoy et al. 2005), it is type 2 diabetes that has received most attention. In particular the relationship between schizophrenia and diabetes has been widely investigated; perhaps more so than any other co-morbid physical and mental health condition (Holt and Peveler 2006). This may be due to the controversy that exists in relation to the part that psychopharmacology may play in contributing to diabetes in this client group, but also as there is no agreement on how prevalent it is.

Robson and Gray (2009) suggest that type 2 diabetes occurs in approximately 15% of people with schizophrenia compared to 5% of the general population, indicating a threefold increased risk. McIntyre et al. (2007), however, propose this could be as high as four to five times that of the general population, increasing the risk even further. Despite the focus of the research being on those with schizophrenia, Robson and Gray (2009) suggest that the risk may actually be higher for individuals with bipolar disorder, but this is still unknown.

Where only 30% of the population with type 2 diabetes are diagnosed under the age of 55, it is 41% for individuals with schizophrenia and co-morbid diabetes, indicating that they develop diabetes at a younger age (Nash 2010a). Furthermore, only 9% of the general population with diabetes have died compared to 23% with SMI, demonstrating that not only do individuals with mental health problems develop diabetes more, and at an earlier age, but that they have a significantly poorer prognosis (Nash 2010a).

RESPIRATORY DISORDERS

During the years of institutionalised mental health care, respiratory diseases such as pneumonia were the major causes of death among its inhabitants (Brown 1997). While this is no longer the case, respiratory disorders among individuals with mental health problems are still high, with asthma, chronic bronchitis and emphysema being more prevalent among this group than the general population (Saha et al. 2007).

Although the exact prevalence of respiratory conditions in individuals with mental problems remains unknown, a US study found that 9% of people with SMI had asthma, 8% emphysema, 20% chronic bronchitis and 23% chronic obstructive pulmonary disease (Himelhoch et al. 2004). The latter, when compared against the 5% prevalence rate in the general population (Himelhoch et al. 2004), demonstrates a markedly increased risk, giving credence to Brown et al.’s (2000) estimate that individuals with mental health problems are four times more likely not only to experience chronic respiratory diseases but to die from them. Once again, the high risk that respiratory disorders present to both the morbidity and mortality of those with mental health problems is very apparent.

CANCER

Cancer presents a more confusing picture with current knowledge being mixed, if not contradictory. The consensus seems to be that there are some forms of cancer that are present more often than expected in individuals with mental health problems (Hippisley-Cox et al. 2007) but, on the whole, rates are similar or even slightly less than those in the general population (Mortensen 1994).

Breast cancer is generally accepted as posing a risk to women with SMI, with one study identifying a 42% increased risk in women with schizophrenia when compared to the general population (Hippisley-Cox et al. 2007). The same study also identified an extremely worrying 90% increased risk of bowel cancer among people with SMI, which the Disability Rights Commission (2007) confirmed in their estimation that individuals with schizophrenia had twice the risk of developing bowel cancer than the general population.

Rates of lung cancer are where most of the current contradiction lies, with Hippisley-Cox et al.’s (2007) study finding a 46% decreased risk in individuals with SMI, suggesting that there may actually be a protective link between the two conditions. Two earlier studies, however, found rates of lung cancer to be twice as high in people with schizophrenia (Brown et al. 2000; Lichtermann et al. 2001), although these were a measurement of mortality, not morbidity.

While the rates of lung cancer may in fact be lower among those with SMI, it may be the case that for those who contract it the death rate is much higher, raising the question of what happens during the progression of this disease that has such a negative impact on the outcome of those with SMI. Before moving on, take some time to think about Action Learning Point 1.1.

Action Learning Point 1.1

Think about the physical health of the clients you work with:

• Which of the conditions outlined do you come across?
• Are these conditions clearly identified in the care plan?
• Do you see physical care carried out?

WHY DO INDIVIDUALS WITH MENTAL HEALTH PROBLEMS HAVE SUCH POOR PHYSICAL HEALTH?

The reasons for the poor physical health of those with mental health problems are complex and varied and the general agreement is that it is a number of interlinking factors that present as a risk. These factors can be separated into health behaviours and treatment.

HEALTH BEHAVIOURS

Many of the conditions outlined are considered to be preventable through lifestyle management but there is widespread opinion that unfortunately individuals with mental health problems expose themselves to adverse lifestyle choices (Wand and Murray 2008). Such choices primarily include high rates of smoking, poor diet and lack of exercise, but co-morbid substance misuse and unsafe sexual practices can be considered among these (Lambert et al. 2003; McCreadie 2003).

Most of us know that the choices we make inevitably impact on our health and we would agree that there is a sense of individual responsibility around these choices. Applying the same level of responsibility to those with mental health problems may not, however, be fair as not all of the above behaviours are choices. Indeed, Robson and Gray (2009) argue that such behaviours may in fact be more accurately seen as the physical, psychological and environmental consequences of having a mental health problem and the treatments that are prescribed for this, and ask that professionals reconsider the use of the term lifestyle choices.

Smoking

Tobacco is the single largest causative factor for lung cancer and respiratory disease and is a contributory factor in both diabetes and cardiovascular disease (Gough and Peveler 2004; Robson and Gray 2007; Nash 2010a). The prevalence of smoking among individuals with mental health problems is known to be high, with estimates of up to 80% in those with SMI (McCreadie 2003), which is three times that of the general population (De Leon et al. 2002). In addition, individuals with SMI are heavier smokers, smoking on average in excess of 23 cigarettes a day (Kelly and McCreadie 2000).

While the negative impact of smoking is clearly outlined, there are also positives, in particular the reduction of psychiatric symptoms through the interaction of nicotine and dopamine (Robson and Gray 2007). Smoking is also ingrained in the very culture of mental health, adding to the challenge of reducing this behaviour.

Diet

The physical health consequences of poor diet include CHD, type 2 diabetes and some forms of cancer, as well as obesity, which in itself presents a risk factor for the conditions discussed (McCreadie 2003; Gough and Peveler 2004; Robson and Gray 2009). Brown et al. (1999) found a diet that is high in fat and low in fibre to be most characteristic of individuals with mental health problems, while McCreadie (2003) found a low intake of fruit and vegetables. In both studies excess weight gain was evident with 86% of women and 70% of men in McCreadie’s study being overweight. Similar results were found in a Spanish study where the dietary habits of individuals with mental health problems identified unhealthy foods leading to weight gain (Simonelli-Munoz et al. 2012). Whereas these studies all suggest a diet that is different in content to the general population, this was not the finding of Strassnig et al. (2003), whose American study reported little difference in content but a significant increase in calorie consumption, suggesting that it was the latter that resulted in the observed obesity. It seems, then, that it is both the type and amount of food consumed within the diet of this client group that present a risk and it is both that should therefore be the target of any proposed change.

Exercise

A lack of exercise is a health risk across all of society and in 2003 the World Health Organization (WHO) identified this as one of the leading causes of death in developed countries (WHO 2003a). Not only is a low level of exercise a significant factor in the development of CHD, but it is a contributory factor for diabetes and some forms of cancer (Gough and Peveler 2004; Robson and Gray 2009). Despite the low levels of physical activity across society as a whole, people with mental health problems have been found to have even lower levels of activity, with barriers to increasing this being reported as fatigue, poor confidence and a range of psychiatric symptoms (Ussher et al. 2007).

TREATMENT

Whether the treatments provided for mental health conditions contribute to the development of physical health conditions is a controversial topic, with psychotropic medication being at the centre of this. The link between antipsychotic medication and diabetes has been...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• About the editors and contributors
• Acknowledgements
• 1. The physical health needs of individuals with mental health problems – setting the scene
• 2. Physical health assessment in mental health practice
• 3. Understanding metabolic syndrome in mental health practice
• 4. Cardiovascular health in mental health practice
• 5. Respiratory health in mental health practice
• 6. Oncology in mental health practice
• 7. The physical effects of commonly misused substances on people with mental health problems
• 8. Sexual health in mental health practice
• 9. Wound care in mental health practice
• 10. Prescribing in mental health practice – the balancing act
• 11. Promoting physical wellbeing
• 12. Infection prevention and control in mental health practice
• 13. Legal and ethical matters
• Glossary
• References
• Index