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International Journal of Nursing Studies 44 (2007) 457–466
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Serious mental illness and physical health problems:
A discussion paper
Debbie Robson!, Richard Gray
Health Services Research Department, King’s College London, Section of Psychiatric Nursing, Institute of Psychiatry,
De Crespigny Park, London SE5 8AF, UK
Received 1 April 2006; received in revised form 28 June 2006; accepted 13 July 2006
Abstract
People with serious mental illness have higher morbidity and mortality rates of chronic diseases than the general
population. This discussion paper explores the complex reasons for these disparities in health, such as limitations of
health services, the effects of having a serious mental illness, health behaviours and the effects of psychotropic
medication. Physical health can be enhanced by improved monitoring and lifestyle interventions initiated at the start of
treatment. There are opportunities for mental health nurses to play a significant role in improving both the physical and
mental health of people with serious mental illness.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Serious mental illness; Physical health; Health behaviours; Lifestyle; Antipsychotic medication
serious mental illness and adds to the debate about
the role of the mental health nurse in monitoring
physical health and promoting healthy lifestyles.
What is already known about the topic?
! People
with serious mental illness have increased
rates of physical illness compared with the general
population and have a reduced life expectancy.
Reasons for increased morbidity and mortality
include factors relating to having a mental illness,
the fragmentation of health care, health behaviours
such as smoking and physical inactivity and the
effects of psychotropic medication.
What this paper adds
! This
paper summarises and synthesises the current
literature on the physical health of people with
!Corresponding author.
E-mail addresses: [email protected] (D. Robson),
[email protected] (R. Gray).
1. Introduction
People with serious mental illness (SMI) have higher
morbidity and mortality rates of cardiovascular disease
than the general population, they also have higher than
expected rates of infectious diseases, non-insulin-dependant diabetes, respiratory diseases, some forms of
cancers (Dixon et al., 1999) and HIV infection
(Cournos et al., 2005). It has been estimated that the
life expectancy of people with schizophrenia is reduced
by 10 years (Newman and Bland, 1991). These high rates
of morbidity and mortality need to be considered within
the context of a global increase in the rates of chronic
diseases in high, middle and low-income countries.
Although the demands on the mental health nurses role
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2006.07.013
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are great, the size of the mental health-nursing workforce in relation to other disciplines means we are in a
strategic position to have a positive impact on both the
mental and physical well being of people with SMI.
This paper discusses the epidemiology of the morbidity and mortality of physical health problems that
impact on people with SMI, the possible reasons for
poor physical health in people with SMI and the
potential role of the mental health nurse in improving
the physical health of people with SMI. The databases
MEDLINE, CINAHL, PsychINFO were searched from
1980–2006 using the terms schizophrenia and/or psychosis and combined with physical and/or diabetes,
obesity, smoking*, diet, exercise, HIV, cancer, antipsychotics*. Papers by key authors in the field of physical
health and schizophrenia were also searched as well as
Department of Health websites in the UK, USA and
Australia for policy recommendations.
asthma (Sokal et al., 2004). These rates were all
significantly higher than those of the matched controls
from the general population. They also found that even
when smoking was controlled for as a confounder, both
people with schizophrenia and bi-polar disorder were
more likely to suffer from emphysema.
2.3. Cancers
Cardiovascular disease (CVD) currently causes
16.7 million, or 29.2% of all deaths globally. By 2010,
CVD will be the leading cause of death in developed
countries (WHO, 2003) and is rapidly becoming the
leading cause of death in the developing world (WHO,
2005). In addition to risk factors such as age, gender and
family history that can not be modified, CVD is also
associated a number of other risk factors including:
obesity, hypertension, smoking, diabetes, hyperlipedemia, lack of exercise and poor diet. These are all
conditions and health behaviours common in people
with SMI and can all be prevented or minimised (Harris
and Barrowclough, 1998, Brown et al., 2000). People
with SMI have rates of CVD 2–3 times higher than the
general population (Brown et al., 2000, Osby et al.,
2000) and a recent study suggested that women with
SMI have a higher risk of developing coronary heart
disease than men (Goff et al., 2005).
Cancer accounts for 7.1 million or 12.6% of global
deaths annually, with the number of new cases annually
estimated to rise from 10 to 20 million by 2020 (WHO,
2003). Tobacco use is the single-largest causative factor,
followed by poor diet and physical inactivity. Both
increased and decreased prevalence rates of different
types of cancer in people with schizophrenia have been
reported in the literature.
Researchers have consistently reported higher rates of
digestive and breast cancers in people with schizophrenia
(Schoos and Cohen, 2003) but the research on lung
cancer in people with schizophrenia is contradictory.
Brown et al. (2000) and Lichtermann et al. (2001) both
found mortality rates for lung cancer twice as high in
people with schizophrenia than in the general population. However, in two extensive cohort studies by
Mortenson (1989, 1994), rates of lung cancer were found
to be similar or lower than those seen in the general
population. Tentative hypotheses about the possible
reasons for the reduced rates of lung cancer and other
cancers in people with schizophrenia have been posited.
These include: death from other causes (such as CVD)
before reaching the expected age of death from lung
cancer (Casey and Hanson, 2003); an under diagnosis of
malignancies in this population and the theory that
antipsychotic medication has anti-tumour properties
(Cohen et al., 2002). The increased rates breast cancers
are thought to be associated with high levels of prolactin
caused by some antipsychotic medicines and inadequate
breast care (for example failure to undertake regular self
examination). Digestive cancers have been associated
with poor diet and high levels of alcohol consumption
(Casey and Hanson, 2003).
2.2. Respiratory disease
2.4. Diabetes
Up until 50 years ago respiratory diseases such as
pneumonia and tuberculosis accounted for the majority
of deaths amongst people with SMI who lived in
institutions (Brown, 1997). Respiratory diseases are still
more prevalent in people with SMI, which are thought
to be as a result of the high rates of smoking or passive
smoking. In a study of 200 out patients with schizophrenia or bi-polar disorder in America, 15% of those
with schizophrenia and 25% with bi-polar disorder had
chronic bronchitis and 16% of people with schizophrenia and 19% of people with bi-polar disorder had
Worldwide, at least 177 million people (2.8% of the
population) have diabetes. This number is expected to
rise to 370 million (4.4% of the population) by 2030
(WHO, 2003). The relationship between diabetes and
schizophrenia has been discussed and investigated more
than any other co-occurring mental and physical health
problem. Controversy exists about the prevalence and
aetiology of diabetes in people with SMI (Holt and
Peveler, 2005).
The association between schizophrenia and diabetes
was first observed in the 1800s by the famous British
2. Epidemiology
2.1. Cardiovascular disease
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Psychiatrist Henry Maudsley (1897 cited by Koren,
2004) who observed ‘‘diabetes is a disease which often
shows itself in families in which insanity prevails’’.
Increased rates of insulin resistance and glucose
dysregulation have also been observed in psychiatric
patients since the 1920s (Koren, 2004). Diabetes occurs
in approximately 15% of people with schizophrenia
(Holt and Peveler, 2005) compared with approximately
5% in the general population (Busche and Holt, 2004).
Diabetes is associated with a range of risk factors that
include: a family history, physical inactivity, poor diet,
smoking and the metabolic effects of antipsychotic
medication (Gough and Peveler, 2004).
Diabetes in the general population often goes
undiagnosed for many years. Estimates suggest that
the disease may go unrecognised for up to 12 years
(Department of Health (DH), 2001). The consequence
of delayed diagnosis results in prolonged exposure to
raised blood glucose and this can cause visual impairment and blindness, damage to kidneys, which may lead
to renal failure and nerve damage (DH, 2001).
2.5. Human immunodeficiency virus
Globally around 40 million people have been infected
with the Human Immunodeficiency Virus (HIV) (UNAIDS/WHO, 2005). The majority of prevalence studies
that have examined rates of HIV in people with SMI
were conducted in the USA and report prevalence rates
of between 3% and 7% (Sewell, 1996, Rosenberg et al.,
2001). Blank et al. (2002) observed that people with
schizophrenia were 1.8 times more likely to have a
diagnosis of HIV and patients with a mood disorder
were 3.8 times more likely to have a diagnosis of HIV
compared with the general population.
Contrary to prevailing clinical stereotypes, people
with SMI are sexually active. Although a smaller
proportion of people with SMI are sexually active
compared to the general population, those that are
sexually active are more likely to engage in high risk
behaviours that may lead to HIV, such as sex without a
condom and injecting drug use (Cournos et al., 2005).
Reasons for this include lack of knowledge about how
sexually transmitted diseases and HIV are transmitted
and prevented (Arrufo et al., 1990; Kalichman et al.,
1994), a susceptibility to coercion into unwanted sexual
activity, difficulties in establishing stable social and
sexual relationships, and comorbid alcohol and substance use (Coverdale and Turbott, 2000).
3. Reasons for poor physical health in people with SMI
There are a number of reasons why people with SMI
may experience physical health problems.
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3.1. Service-related factors
The physical health care needs of this population have
long been overlooked by workers in both primary and
secondary care (Gournay, 1996; Phelan et al., 2001). For
example, Brugha et al. (1989) found that in 145 people
with SMI at a psychiatric day care facility, 41% had
medical problems requiring care and 44% had unmet
needs. There are many reports in the literature about the
lack of assessment, monitoring and recording of the
physical health status of people with SMI. In a UK
study of physical health care monitoring in a primary
care setting, Burns and Cohen (1998) demonstrated that,
although the annual general practice consultation rate
was significantly higher than normal for people with
SMI the amount of data recorded was poor: 27% had
weight; 38% blood pressure and 2% had their cholesterol levels recorded. Monitoring of physical health is no
better in secondary mental health services. In a UK
study, Paton et al. (2004) reviewed the case notes of 606
inpatients with SMI to determine if weight, cholesterol
and triglycerides had been measured at any point in their
care. Only 18% (1 1 3) of the patients had their weight
recorded and 3.5% (21) had their lipids monitored
during their admission. In a study by Greening (2005) of
63 patients in a rehabilitation and recovery service, 16%
had their weight recorded, 16% had their smoking status
recorded and 24% had their blood pressure taken.
A lack of clarity about whose role it is to provide
health promotion, detect and manage physical problems
in people with SMI add to the service-related barriers to
promoting health. In the UK, guidelines published by
the National Institute for Clinical Excellence (NICE) for
the treatment of schizophrenia in secondary and
primary care (NICE, 2002) recommend that primary
care practitioners should provide routine physical
checks for people with schizophrenia, unless the person
does not want contact with or has no general practitioner (GP), in which case secondary mental health
services should provide these routine physical health
checks. The guidelines also state that people admitted to
psychiatric wards should have their physical health
routinely checked. In the USA, an expert panel have
published consensus recommendations for the monitoring of the physical health of patients with SMI (Marder
et al., 2004). They recommend that mental health care
providers carry out the necessary monitoring of physical
health as they believe that in addition to the physical
health checks carried out in primary care settings,
additional monitoring by mental health practitioners
will result in earlier detection of serious conditions.
Government policies in parts of Australia acknowledge
that the physical health of people with SMI should be
incorporated into case management (Victorian Mental
Health Services, 1995). Although clarification of roles
and responsibilities is welcome it is important to
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highlight that the physical health care of people with
SMI is the responsibility of primary and secondary care
practitioners as well as service users and their carers.
The most important thing is that each of these parties
knows who is responsible for doing what, when, where,
that this information is written down and all relevant
parties have a copy of the plan.
3.2. Illness-related factors
SMI may impact on people’s help-seeking behavior.
For example, it has been suggested that people with
schizophrenia are less likely to spontaneously report
physical symptoms (Jeste et al., 1996). They may also be
unaware of physical problems because of the cognitive
deficits associated with the schizophrenia (Phelan et al.,
2001), because of a high pain tolerance (Dworkin, 1994)
or due to a reduced pain sensitivity associated with
antipsychotic medication (Jeste et al., 1996). There are
also socio-economic consequences of suffering from a
mental health disorder, such as poverty, poor housing,
reduced social networks, lack of employment and
meaningful occupation opportunities, and social stigma,
all of which impact on the physical health and the
physical health behaviours of people with SMI.
3.3. Health behaviours of people with SMI
Commonly cited reasons for the increased morbidity
and mortality rates in people with SMI are their high
rates of smoking, poor diet, lack of exercise, co-morbid
substance use and unsafe sexual practices (Brown et al.,
1999, Lambert et al., 2003). These behaviours are often
referred in the literature as ‘‘lifestyle choices’’. Services
users may argue that these are not choices at all, but the
physical, psychological, social and environmental consequences of having a severe mental illness and the
treatments prescribed for them.
3.3.1. Smoking
Epidemiological studies that have established international prevalence rates of smoking in people with
schizophrenia and bi-polar disorder range from 58%
to 88%, up to three times higher than the general
population (Hughes et al., 1986; de Leon et al., 2002).
People with SMI tend to be heavier smokers, smoking
more than 25 cigarettes a day (Kelly and McCreadie,
2000). The reasons why people with SMI may have such
high rates of smoking are well researched and include
neurobiological, psychological, behavioural and social
factors making it extremely difficult to alter smoking
behaviour in this population.
An increase in dopamine through inhaling nicotine
has been shown to alleviate certain psychiatric symptoms (for example, negative symptoms, cognitive deficits
and antipsychotic side effects) and, therefore, smoking
can be seen as a means of self medication (Goff et al.,
1992; Dalek et al., 1998). Smoking may also improve the
attention and selective processing of information that is
normally impaired in people with schizophrenia (Alder
et al., 1998). Qualitative studies by Lawn et al. (2002)
and Luckstead et al. (2000) found that people with
schizophrenia smoke out of habit and routine, for
relaxation purposes, as a way of making social contact,
for pleasure and as a way of gaining control in their
lives. Smoking is ingrained in the culture of psychiatry.
Health professionals often doubt this client group’s
motivation to stop smoking and promote smoking by
using cigarettes to manage service users’ behaviour
(McNeill, 2001).
3.3.2. Physical activity
The World Health Organization (WHO) identifies
physical inactivity as one of the leading causes of death
in developed countries (WHO, 2003). People with SMI
have been shown to be less physically active than the
general population (Brown et al., 1999; McCreadie,
2003). Encouraging people to follow national recommended guidelines to improve their physical health
through activity is a major public health challenge.
People with SMI face additional challenges to lead a
more active lifestyle. The sedating effects of some
medications make it more difficult to be active.
Depression or the negative symptoms of schizophrenia
may make it difficult to get motivated. The financial cost
of joining a gym may be off-putting or the lack of
confidence to do so may also influence a person’s
decision to participate in exercise. However, the benefits
of exercise are well documented and can prevent, delay
the onset or help with the management of a number of
physical and mental health problems (DH, 2004).
3.3.3. Diet
In a survey of the dietary habits of 102 people with
SMI by McCreadie (2003) the average fruit and
vegetable intake for these people was 16 portions a
week, compared with recommended intake of 35 per
week (DH, 2004). The physical health consequences of a
poor diet include CVD, diabetes, obesity and some
cancers. Studies of people with SMI repeatedly show
that saturated fats from dietary intake of meat and dairy
products are associated with worse outcomes in schizophrenia (Peet, 2004). There is a particularly strong
association between sugar consumption and poorer
outcome in schizophrenia whereas consumption of fish
and sea food, particularly omega 3 fatty acids, has been
associated with better outcomes (Peet, 2004).
3.4. Treatment-related factors
Since the introduction of psychotropic medication
many people have been enabled to live productive lives
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in their own communities rather than spending long
periods of time in hospital. The beneficial effects of
atypical compared to typical antipsychotic medication
has led clinicians to prescribe these medications for
other disorders such as bi-polar and dementia (Jin et al.,
2004). However, we have known for many years that
antipsychotic medication has a deleterious impact on
physical health. For example, in the late 1950s, within a
year of its introduction, there were reports in the
literature that chlorpromazine was linked to hyperglycaemia, glycosuria and weight gain (Koran, 2004). With
the introduction of atypical antipsychotics in the early
1990s there has been heightened interest in the relationship between antipsychotic drugs and increased rates of
obesity, type 2 diabetes, CVD, hyperprolactineamia and
metabolic syndrome in people with SMI. Although the
observed increase in some of these disorders may be due
to the fact that there is much better medical surveillance
with these medicines.
3.4.1. Weight gain
Obesity is a global epidemic and related to an increase
of consumption of energy dense foods, nutrient poor
foods (i.e. high levels of sugar and saturated fats)
combined with reduced physical activity (WHO, 2003).
The impact of obesity on health can lead to a number of
disabling conditions such as increased blood pressure,
insulin resistance, respiratory difficulties, an increased
risk of diabetes, and an increased risk of heart disease
(WHO, 2003). There is contradictory evidence that
people with SMI have higher rates of obesity than
the general population (Wirshing and Meyer, 2003). The
literature seems to suggest that women with SMI are
more obese than men (Allison et al., 1999, McCreadie
et al., 2003). There is also evidence that people with SMI
have higher rates of upper body obesity (visceral fat),
which is more of a risk factor for developing CVD and
diabetes than overall body fat (Ryan and Thakore,
2001).
Both typical and atypical antipsychotic drugs have an
effect on dopaminergic, serotonergic, histaminergic,
cholinergic and adrenergic neurotransmitters, all of
which are associated with the aetiology of weight gain.
Clozapine and olanzapine are commonly associated with
weight gain compared with other antipsychotics and
may initially cause insulin sensitivity leading to hypoglyceamia and food cravings (Werneke et al., 2003). The
noticeable difference in body composition (a higher
waist to hip ratio and more visceral fat) between service
users with SMI and healthy controls has also been found
in people with schizophrenia who have never taken
antipsychotics (Thakore et al., 2002). Antipsychotics,
some mood stabalisers and antidepressants increase
appetite and make people thirsty. Fast food and
carbonated drinks that are high in saturated fats and
sugar are quick way of relieving these problems and an
461
affordable and easy option for people on a low income.
Weight gain added to schizophrenia or bi-polar disorder
increases the social stigma people have to endure and
increases the risk of people stopping their medication.
3.4.2. Diabetes and glucose intolerance
Typical antipsychotics, in particular the low potency
ones such as chlorpromazine may induce or make
existing diabetes worse (Newcomer et al., 2002). The
atypical antipsychotics clozapine and olanzapine are
associated with new onset or exacerbating type 2
diabetes, not just through their propensity to cause
greater weight gain than other newer agents but because
of their effects on glucose regulation (Newcomer et al.,
2002). There are also case reports linking respiridone
and quetiapine to impaired glucose intolerance, diabetes
and ketoacidosis (Taylor et al., 2005). Although the
research on the use of antipsychotics and its association
with diabetes is copious, some argue that the quality of
the research is methodologically weak and at this point
in time more controlled prospective studies are needed
before a definite causal link between antipsychotics and
diabetes is confirmed (Taylor et al., 2005, Holt and
Peveler, 2005).
Diabetic Ketoacidosis (DK), a potentially fatal
condition, may be the first obvious symptoms of type
2 diabetes. It is related to metabolic stress such as an
infection, trauma, myocardial infarction or stroke (Jin et
al., 2004). Mental health nurses need to be aware that
DK has a rapid onset (often o24 h) and symptoms
include polyuria, polydipsia, polyphagia, vomiting,
abdominal pain, dehydration, potentially leading to
coma and death (Expert Panel, 2004). Emergency
treatment includes rehydration, insulin therapy, electrolyte correction and treatment of the underlying condition.
3.4.3. Cardiovascular effects
Although the overall risk is very low, most drugs used
to treat mental illness are associated with ventricular
arrhythmia, ECG changes and even sudden cardiac
death (Taylor et al., 2005). In recent years there have
been concerns about the impact antipsychotic mediation
has on the corrected QT (QTc) interval prolongation
and sudden death, despite the fact that a whole range of
medicines including antibiotics can cause QTc prolongation (Taylor et al., 2005). The medicines that have been
associated with QTc prolongation are thioridazine and
sertindole, although it is important for mental health
nurses to be aware that any antipsychotic that is given
intravenously and in combination with other antipsychotics at high doses may cause these cardiac changes
(Taylor et al., 2005). Hypotension is a common side
effect of both typical and atypical antipsychotics and
tricylic antidepressants because of their blockade of a1
adrenergic receptors. It most frequently occurs with the
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use of low-potency drugs such as chlorpromazine and
clozapine, though does occur with other antipsychotics
in high doses (Taylor et al., 2005). Clozapine use has
also been linked to myocarditis (inflammation of the
heart muscle). This usually occurs within the first two
months of initiating treatment and symptoms including
tachycardia, fever, flu-like symptoms, fatigue and chest
pain (Killion et al., 1999).
Other conditions also need to be taken into account
when considering potential causes of sudden death in
people with SMI, such as co-morbidity of substance
abuse, acute exhaustive mania, where there is continuous manic psychomotor excitement, dehydration and
electrolyte imbalance (Gray, 2001).
Hyperlipedaemia (too much cholesterol and triglycerides in the blood) is one of the many risk factors for
CVD and influenced by health behaviours such as diet
and smoking. The higher the total cholesterol and lowdensity lipoprotein (LDL) cholesterol, the higher the
morbidity and the higher the level of high-density
lipoprotein (HDL) the lower the risk of heart attacks.
Both typical and atypical antipsychotics have been
shown to have an effect on triglyceride and cholesterol
levels with olanzapine and clozapine appearing to have
the most impact (Casey, 2004).
3.4.4. Metabolic syndrome
Abdominal obesity, hypertension, dyslipedemia, insulin resistance and glucose intolerance cluster together
to form the metabolic syndrome, also known as
Syndrome X and a diagnosis is made when 3 or more
of these conditions are present (Ryan and Thakore,
2001).There is evidence that the metabolic syndrome is
increased in people with schizophrenia and may provide
an explanation for the increased prevalence of diabetes
and CVD (Holt et al., 2004).
3.4.5. Eye health
Antipsychotic medication has been associated with
lens and corneal changes since the mid 1950s (Shahzad
et al., 2002). Isaac et al. (1991) reported that patients
receiving phenothiazines were four times more likely to
develop cataracts. A large cohort and nested case
control study by Ruigomez et al. (2000) using the
United Kingdom General Practice Database, found no
evidence of an overall increased risk of cataracts in
people-prescribed antipsychotics, though patients-prescribed chlorpromazine and prochloperazine did have a
significantly higher risk. There have been case reports
that quetiapine may cause cataracts, although a causal
link has not been demonstrated as these patients also
had co-occurring conditions such as diabetes and
hypertension and eye trauma (Marder et al., 2004).
Despite there not being a proven link, the company that
manufacture quetiapine recommend (in America) eye
examinations after initiation of treatment and at 6month intervals (Astra Zeneca, 2005).
3.4.6. Dental health
Antipsychotics, antidepressants and mood stabilizers
all cause xerostomia (a reduction in salivary flow). Lowpotency antipsychotics such as chlorpromazine cause
hyposalivation, as does the co-administration of anticholinergic medication. A reduction in salivary flow
changes the oral environment and leads to caries,
gingivitis and periodontal disease (Friedlander and
Marder 2002). In addition to the effects of medication,
poor dental health may also be related to poor diet,
smoking and poor oral hygiene (McCreadie et al., 2004).
3.4.7. Sexual effects
All antidepressants (especially the SSRIs), mood
stabilisers (particularly lithiuim and carbamazipine),
typical and atypical antipsychotics are known to cause
sexual problems. The adrenergic and anticholinergic
effects of antipsychotic medication affect sexual functioning and the blockade of dopamine receptors in the
tuberinfundibular pathway in the brain may result in
hyperprolactineamia (raised levels of the hormone
prolactin).
Raised prolactin levels can cause a decrease in
testosterone in men and a decrease in oestrogen in
women, leading to sexual dysfunction. Most studies
have shown that the older antipsychotics are associated
with up to a 10-fold increase in prolactin levels, which
usually occurs in the first week of treatment and will
remain high as long as the patient continues to take
medication. If treatment is stopped prolactin levels
return to normal within 2–3 weeks (Hummer and
Huber, 2004). The atypicals antipsychotics amisulpride
and risperidone have also been associated with increased
prolactin levels (Halbreich and Kahn, 2003). The
prevalence of hyperprolactinemia in females taking
risperidone may be as high as 88% compared with
47% in people taking typicals (Kinon et al., 2003). In
adolescents treated for childhood-onset schizophrenia 6
weeks of olanzapine treatment raised prolactin levels
beyond the upper limit of the normal range in 70% of
patients (Wudarsky et al., 1999).
There are numerous clinical effects of hyperprolactineamia seen in people with SMI who are taking
antipsychotic medication. Women experience amenorrhea, disturbed menstrual cycle and anovulation. Both
men and women experience galactorea (leaking milk
from the breasts), gynecomastia (painful and swollen
breasts) and sexual dysfunction (Dickson and Glazer,
1999, Halbreich and Kahn, 2003). There is contradictory
evidence that the reduction in oestrogen caused by
raised prolactin levels are associated with increased rates
of breast cancer (Halbreich et al., 1996) and osteoporosis (Halbreich and Palter 1996).
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3.4.8. Neuroleptic malignant syndrome
Neuroleptic malignant syndrome (NMS) is a rare
though potentially fatal consequence of all antipsychotic
drugs or any drugs that block dopamine D2 receptors in
the brain. Reported incidence and mortality rates
with the use of typical drugs are 0.2–1% (Doran,
2003; Taylor et al., 2005). There are case reports of
NMS occurring with the use of atypicals but this is less
common than with the older drugs. NMS usually
occurs when people are taking drugs within the
therapeutic range, though studies suggest that people
are more likely to experience it if they take high
doses or the drugs are rapidly titrated (Taylor et al.,
2005). Some studies suggest that greater risk is
posed if the patient is catatonic, is exhausted and
dehydrated or has a previous history of NMS (Taylor
et al., 2005). Signs include hyperthermia and profuse
sweating, fluctuating blood pressure and tachycardia,
muscle rigidity, coarse tremor, confusion, mutism
and stupor leading to coma and death if not
treated. Blood tests reveal elevated creatine kinase,
leucocytosis and altered liver function (Taylor et al.,
2005). If NMS is suspected liaison with medical
colleagues is essential and antipsychotics must be
withdrawn and vital signs closely monitored until a
diagnosis can be confirmed. Moderate to severe cases
will need to be referred to an emergency unit where
dopamine agonists and muscle relaxants may be
prescribed. Patients usually recover in one to two weeks
and antipsychotic medication can be restarted with
very close monitoring of physical and biochemical
parameters (Taylor et al., 2005).
4. The monitoring of the physical health of people with
SMI
There is no consensus about the type and frequency of
physical health assessment and monitoring in people
with SMI, although a number of guidelines exist that
may inform practice (Marder et al., 2004; NICE, 2002).
Generally poor levels of knowledge and skills about
physical health monitoring in the workforce may
contribute to the poor physical health of people with
SMI. For example, in a survey of 640 practice nurses in
the UK (Gray et al., 1999), 61% were involved in
delivering mental health care in primary care settings
and 70% reported that they had received no formal
mental health training. Conversely, in a training needs
analysis of 168 qualified mental health nurses 45% had
no formal training in physical health care, although 96%
said they would be willing to attend physical health
training Nash (2005).
Based on our review of the literature essential routine
monitoring should include weight, body mass index
(BMI) and waist circumference, blood pressure, lipid
463
profiles, screening for insulin resistance and diabetes,
dental checks and eye health checks. It is not necessarily
the mental health nurses role to carry out these
checks, and local protocols should be in place to
guide the practitioner. However, the mental health
nurse has a role of ensuring these are carried out at
the onset of treatment and regularly throughout
treatment. It is also important that the service user
and their families/carers understand why these checks
are being done and the significance and meaning of
any results. Nurses can also systematically and proactively enquire about the quality of people’s dietary
intake, level of physical activity, smoking behaviour and
sexual health.
4.1. Lifestyle advice and interventions for improving the
health behaviours of people with SMI
Education on the management of weight through
healthy eating and exercise and how to minimise the
use of substances such as tobacco should be integrated
into routine care and should begin when the service
user first comes into contact with mental health
services. Most mental health services have access to
dieticians, physiotherapists and smoking cessation specialists. Mental health nurses could actively collaborate
with these professionals to design specialist health
promotion programmes for people with SMI. There
tends to be pessimism about changing health behaviours
such as stopping smoking or weight management in
people with SMI. There is emerging evidence that people
with SMI can stop smoking, loose weight and be more
physically active if interventions and lifestyle programmes are tailored to overcome the neurological,
cognitive, behavioural and social deficits associated with
SMI. Smoking cessation programmes specifically designed for people with schizophrenia that include
nicotine replacement therapy (NRT) or buproprion,
cognitive behavioural and motivational interviewing
produce quit rates of 12–18% after 6 months (Addington et al., 1998; George et al., 2000, Weiner et al., 2001;
George et al., 2002), similar to quit rates in the general
population who receive intensive behavioural support
and NRT (West et al., 2000). Weight management
programmes have been shown to help patients lose
weight. In a nurse-led study by Veerland et al. (2003) a
12-week programme that incorporated nutritional education, exercise, motivational counselling, cognitive and
behavioural interventions, clients lost 2.7 kg in weight
compared to a matched control group who put on
weight. However, interventions do not have to be
lengthy and complex. A study by Wirshing et al.
(2006) demonstrated knowledge about nutrition and
healthy lifestyles was significantly improved following a
single 30 min education programme for in patients with
schizophrenia.
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5. Conclusion
The causes of poor physical health in people with a
severe mental illness are complex and interactive. Whilst
adverse effects of medication have a significant impact,
health behaviours of people with SMI and the lack of
training health professionals receive have a part to play.
Mental health nurses have an opportunity to improve
the physical and mental health of people with SMI
through systematic monitoring and collaborative health
promotion interventions initiated at the onset of
people’s illness. Poor physical health in people with
SMI does not have to be inevitable.
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