REVIEW
The role of pharmacy in optimising physical health in individuals with severe mental illness
People with severe mental illness die about 10 – 20 years earlier than the general population , mainly due to physical health disease . Evidence about the role of pharmacy in optimising care in this vulnerable patient population is provided in this article
Dolly Sud BSc ( Hons ) PGDip PharmPrac PGDip PsychPharm Credentialed Member of the CMHP PhD Senior Mental Health Pharmacist , Leicestershire Partnership NHS Trust ; Postdoctoral Research Fellow , Aston University , UK
SCIENCE PHOTO LIBRARY
People with severe mental illness ( SMI ), defined here as bipolar affective disorder , schizophrenia , schizoaffective disorder and other non-organic psychotic disorders , are at a substantially higher risk of premature death , in that they die 10 – 20 years earlier than the general population . 1 , 2 SMI represents a leading cause of the global burden of disease with high morbidity rates and an estimated excess mortality of 1.5 – 3-times higher than the general population . 3 While unnatural causes , including suicide , homicide and accidents explain some of this reduced life expectancy , 4 it is now firmly established that physical health diseases account for the overwhelming majority of premature deaths . 5
Mortality gap and associated factors The mortality gap exists in countries considered to have high standards of healthcare 6 – 10 and there is also evidence that the mortality gap has increased over time . 11 , 12 This appears to indicate that individuals with SMI have not experienced the same benefits from developments in healthcare as the general population . 12 The premature and excess morbidity and mortality in people with SMI has ramifications not only for mental health and all health services but also for human rights and equity . A situation that has been labelled a scandal and in contravention of international conventions for the ‘ right to health ’. 13
Among physical health diseases , cardiovascular disease ( CVD ) and diabetes are the main potentially avoidable contributors to early death in people with SMI . 5 In a comprehensive meta-analysis of CVD risk in individuals with SMI , which included 3,211,768 patients and 113,383,368 controls , individuals with SMI had a statistically significant increased risk of coronary heart disease ( CHD ) compared to controls ; a 54 % higher risk in longitudinal studies and 51 % higher risk in cross-sectional studies . 14 Studies have reported that among patients diagnosed with diabetes , those with SMI have 50 % higher mortality 15 and an increased risk of complications requiring specialist treatment 16 compared to people without SMI . These findings are well substantiated by multiple meta-analyses and systematic reviews .
People with SMI have a higher relative risk ( 1 – 5-fold ) for modifiable cardiometabolic factors . The prevalence of hyperglycaemia , hypertension , dyslipidaemia and hyperlipidaemia in those with SMI has been reported to be
17 – 19
19 %, 33.2 %, approximately 48 % and 61 %, respectively . Public health data from the UK and the US suggest that around two-thirds of people with SMI are current smokers ,
20 , 21 approximately double that of the general population . Literature reviews indicate that people with SMI are 2 – 3-times more likely than the general population to be overweight or obese . 22 , 23 This might be related to a poor diet as reported in a systematic review and meta-analysis of 58 studies . 24
Furthermore , metabolic syndrome ( MetS ) is one of the most
25 , 26
prevalent risk factors for developing CVD in those with SMI . Thirty-seven per cent of those with chronic schizophrenia have MetS compared with 24 % in the general population . 27
The World Health Organization ( WHO ) considers the premature and excess morbidity and mortality in individuals with SMI a public health priority and it is included within the WHO ’ s Comprehensive Mental Health Action Plan . 28
A poor quality of care Worldwide studies demonstrate that it is now well established that people with SMI receive a poor quality of care for their physical health when compared to the general population , from health promotion and disease prevention and screening through to interventions . 29 – 32 Despite having twice as many contacts with healthcare services , individuals with SMI receive less physical health screening , fewer prescriptions and fewer procedures , 33 , 34 and lower rates of CVD diagnosis even though , as outlined earlier , the risk of these patients dying from CVD is higher . 33 , 35 , 36 Specific examples include lower rates of surgical procedures such as coronary artery bypass and revascularisation and fewer prescriptions for cardiovascular
34 , 36
medication . The mainstay of treatment for most people with SMI is
hospitalpharmacyeurope . com | Issue 101 | 21