Severe mental illness– time to see red (and act on it.)

After a long day in General Practice, it sometimes feels like I’ve spent the whole day putting out fires. But as we manage the constant barrage of urgent queries and same day appointment requests, the longer-term management of our patients is inevitably neglected. Prevention gets pushed to the bottom of the pile, continuity and holistic care become luxuries rather than imperatives and health inequalities widen. And this dangerous precedent is never more relevant than when it comes to the physical health of our patients with serious mental illness. 

Why does it matter?

Patients with severe mental illness (SMI) face a dual burden - not just from their psychiatric symptoms but also their significantly increased risk of physical health problems. This so called ‘physical health gap’ is accompanied by a reduced life expectancy of about 15 years, with adults living with serious mental illness having an almost five time increased risk of dying prematurely compared to those without. For these patients, about 2/3^rd of deaths and over half their total NHS costs are from preventable physical illnesses, rather than the mental illness itself. These statistics are shocking, for us and of course most importantly our patients. Furthermore, because serious mental illness frequently emerges in late adolescence, patients often start ‘accumulating’ cardiometabolic risks from a much younger age, whether due to their obesogenic medications, social disadvantage or unhealthy lifestyles. 

So how can we help? 

The Lester tool, just updated in 2023, aims to help us improve the cardiovascular health of our patients with serious mental illness. It brings together advice from different NICE guidelines  (CG185, CG178, CG155 and NG181) into one easy to use flow chart. It also provides thresholds above which we should act – the aptly named ‘red zone’ - and recommends specific interventions and treatments for anyone in this red zone, as well as targets to aim for. 

The consistent mantra of the resource ‘Don’t just screen – intervene’ is an important one. All too often we can find ourselves falling victim to therapeutic inertia and succumbing to the tick-box mentality. This resource is not just about identifying risk, but getting on and doing something to reduce it. It’s time we saw red, and acted on it. 

For me, my key take-homes from the guideline include:

• Risk assessment tools, even those like QRISK3 and QDiabetes that account for SMI, still often underestimate risk. SMI-specific tools, such as PRIMROSE can more accurately assess risk and are available online. 
• A pro-active approach is recommended to pre-diabetes. If, despite referral to a diabetes prevention programme, a patient remains at high risk, we can offer metformin MR to try and prevent or delay the onset of diabetes. This is particularly important for those with BMI >35. 
• BMI should be adjusted based on ethnicity. Our target BMI is <23 for patients from a Black, Asian or minority ethnic background, compared with <25 for Caucasian patients. This reflects the impact of differences in regional body fat distribution and body composition on cardiovascular risk. 
• Specific recommendations, e.g. on physical activity levels, alcohol and diet, provide tangible targets for support and intervention. Motivational interviewing is a key skill when it comes to behaviour change; more effective than ‘advice’, and something we can integrate even into short consultations. 
•  If someone DNA’s their review don’t just grab a cuppa and thank the stars you’re no longer running quite so behind… That’s clearly important, but if you can, try to actively follow them up and inform their care co-ordinator. That ‘DNA’ might just have been the most vulnerable patient booked in to see you all day. 

Of course, shared decision making and empowering our patients is the key to making any of this stick – our patient’s preferences and the barriers they face are just as important as any results or risk assessment tools. But as primary care clinicians, we remain the frontline advocates for our patients’, and we play a crucial role in reducing the ever widening ‘mortality gap’ faced by this uniquely vulnerable population. 

So as those of us in England breathe an inevitable sigh of relief as we come to the end of yet another year of QOF reviews, spare a thought for the key message of the Lester tool - ‘Don’t just screen, intervene’. This is about so much more than a tick-box exercise, with the opportunity to make a real difference to the lives and futures of our patients. And whilst we might not see the benefits today, tomorrow or even next week, it’s worth remembering the ancient Chinese proverb; “The best time to plant a tree was 20 years ago. The second best time is today.”