The aim of this elearning material is to explore some of the factors that contribute to physical health problems for people who have mental health problems. This will include a discussion of some of the unwanted consequences or side effects of pharmacological approaches such as weight gain and sexual dysfunction. In addition the use of drugs such as clozapine and other anti-psychotics and anti depressants can sometimes lead to fatal adverse drug reactions and a number of these are presented here. Furthermore, lifestyle factors (e.g. smoking) and factors associated with health services providers (e.g. diagnostic overshadowing) may also mean that mental health service users are more vulnerable to physical health problems which at times remain undiagnosed. Finally, social factors such as education and poverty as they relate to.
After engagement with these eLearning materials you will
Psychotropic medication, which is medication used to treat and manage mental health problems, can have a significant impact on the physical health of the person who takes them. This section will focus on some of the main physical effects caused by commonly used psychotropic medications including antipsychotics, antidepressants and mood stabilisers. The main physical effects covered include weight gain, metabolic syndrome and sexual dysfunction in addition to briefly considering some potentially fatal physical effects of these medications including:
Weight gain has been identified as being 2-3 times more prevalent in people with schizophrenia than in the general population (Hardy & Gray, 2011, DeHet et al, 2011). Weight gain is a significant side-effect associated with a number of psychotropic medications, particularly antipsychotic medication and lithium. It is important to remember that for some people with a mental health problem weight gain can be a problem that exists independent of the use of psychotropic medications as poor motivation and energy can impact on physical activity. No single mechanism has been identified to explain the cause of medication induced weight gain; rather it appears that a number of factors are involved including increased appetite, metabolic disturbances, sedation leading to reduced physical activity and excessive thirst which may be sated through the consumption of high calorie drinks. Weight gain is a problematic side-effect of psychotropic medications for a number of reasons. As discussed below, it is a significant contributing factor to the development of metabolic syndrome. Weight gain can also act as a barrier to physical activity and exercise which is an independent risk factor for cardiac disease but can also serve to exacerbate weight gain. In addition, weight gain has found to be a significant reason for people deciding to no longer take their medication, even if that medication has a therapeutic effect (McCloughen & Foster 2011). The Expert Consensus Group (2005) identified some key predictors for weight gain in those who take psychotropic drugs and in particular antipsychotic medications. They are:
Weight gain is modifiable therefore there are a number of interventions that might improve outcomes with regard to weight. Firstly, it is imperative that those starting and continuing on psychotropic medication should be regularly weighed and screened for weight gain, particularly rapid weight gain. It is acknowledged that it is far preferable to prevent initial weight gain as significant weight loss can be difficult to achieve. By screening for weight gain, it will be possible to implement changes at the first indication of a significant increase in weight. Interventions to reduce weight gain include:
Psychotropic medications, both typical and atypical antipsychotic medications in particular, have been associated with the development of metabolic syndrome in the person taking these medications. Metabolic syndrome is a cluster of several risk factors for heart disease (Nash, 2014) and its prevalence is over 40% in those diagnosed with schizophrenia occurring at rates which is two-threefold high than in the general population (McCloughen & Foster, 2011). Metabolic side-effects of psychotropic medication include:
A number of atypical antipsychotic medications including Olanzapine and Cloapine appear to cause particular problem as they contribute to weight gain, a worsening lipid profile and risk of type 2 diabetes. Diabetes occurs in approximately 15% of people diagnosed with schizophrenia compared to approximately 5% of the general population (Hardy & Gray, 2011; De Hert et al 2011) heightening the need for adequate screening and monitoring of blood glucose. Is it therefore recommended that blood glucose should be checked at least annually although more frequent assessments are frequired for those with significant risk factors (e.g. being overweight) (Hardy & Gray, 2011). Should diabetes be diagnosed, referral to the diabetes nurse for further education and treatment is advisable (Hardy & Gray, 2011).
Sexual dysfunction has been reported as a side-effect of a number of psychotropic medications most notably antidepressant and antipsychotic medications. Treatment related sexual dysfunction with antidepressant medication is quite common; a review of relevant studies by Rothschild (2000) concluded that 40% of people taking antidepressants will experience some form of sexual dysfunction. It is important to note however that this may be an underestimate as those who take the medication can be too embarrassed to disclose the side-effect and healthcare workers may be reluctant to assess for it. It can be wide-ranging affecting both men and women and can include decreased libido, inability to get or sustain an erection, delayed orgasm, inability to reach orgasm, delayed ejaculation and priapism (Higgins et al 2010). As with weight gain, sexual dysfunction is also associated with negative attitudes about the medication (Apantaku-Olajide et al 2011) and a higher rate of non-concordance, even if the medication has had a therapeutic effect. The issue of medication induced sexual dysfunction is covered in more depth in the ‘Recovery’ unit and learners are therefore advised to consult this unit for further information.
Neuroleptic Malignant syndrome: Neuroleptic Malignant Syndrome (NMS) is a rare but life-threatening idiosyncratic reaction to antipsychotic medication. The incidence of NMS has been decreasing with the use of atypical medications as it is more often associated with typical antipsychotic medication. However, it is important to note that NMS can occur in response to any medication which impacts on Dopamine. It is more common in men (most likely due to the fact that they are likely to be prescribed higher amounts of antipsychotic medication) and while it can occur at any time while taking an antipsychotic, onset is usually within the first 2 weeks of taking the medication (REF). The clinical features of NMS include:
Treatment involves discontinuation of the offending agent and management of the symptoms as they arise.
Agranulocytosis: Agranulocytosis is a potentially life threatening adverse effect of Clozapine affecting approximately 1-2% of those who take it (Joint Formulary Committee, 2016). It is a lowering of the white blood cell count which requires regular monitoring to assess. It can be difficult to detect agranulocytosis and it is generally only detected when takers present with symptoms of infection. The clinical symptoms of agranulocytosis include:
Treatment of Clozapine induced agranulocytosis is to stop the offending agent immediately and generally treat symptomatically.
Serotonin Syndrome: Serotonin Syndrome (SS) is an adverse reaction to medications which increase serotonin and has similarities to Neuroleptic Malignant Syndrome (Healy, 2009). It is caused by an excess in serotonin which can occur in response to initiating or increasing antidepressant medication or can come about as a result of an overdose of antidepressant medication. It is most likely to occur within the first 24 hours of treatment but can occur at any time. Symptoms of SS include:
Treatment involves stopping the offending agent and managing symptoms as they arise.
Lithium Toxicity: Lithium, which is used primarily in the treatment and prophylaxis of bipolar disorder, has a narrow therapeutic margin below which the taker may experience no therapeutic effect but above which can cause lithium toxicity. Lithium toxicity can be fatal if not treated urgently. Signs of lithium toxicity include:
Treatment of lithium toxicity is to stop (or reduce) the offending agent (depending on the severity of toxicity) and to manage the symptoms as they arise e.g. correction of fluid and electrolyte imbalances. In severe toxicity, hospitalisation is warranted and haemodialysis many be required to ensure the rapid removal of excess lithium (Joint Formulary Committee, 2016).
Lifestyle refers to the way in which a person lives and can be influenced by a number of factors which can be broadly broken into physical, psychological and social elements. In this section we will consider a number of lifestyle issues that may negatively impacted on people who experience mental distress specifically smoking, diet and exercise. This section will also briefly consider some broad social factors that make people with mental health problems more prone to poorer physical health generally. In addition to service users experiencing high rates of physical ill health issues, their risk may be increased by a number of practitioner and service issues, these will also be presented.
According to Weir (2013) people with mental health problems are more likely to smoke. While smoking is a common habit, its prevalence has reduced worldwide as our knowledge of the negative effects it has on health increases. Preventing people from starting to smoke and helping people to quit smoking are key health policy concerns in many western countries. The consequences of smoking are well known internationally and are particularly worrying in people who have severe mental health problems who are already known to die earlier. As a reminder you can review the consequences of smoking at the National Cancer Institute’s website: What are some of the health problems caused by cigarette smoking?
It is also interesting to note that 80% of people who smoke live in low and middle income countries, a point that we will revisit later in this section (WHO 2015).
Nicotine the active ingredient contained in cigarettes is highly addictive and this is one of the key reasons that smoking is so difficult to give up. You can read more about how cigarettes exert their effects here.
You can look at the list in more detail at this link. Looking at the list we can see a couple of reasons (self-medication and stress relief) that might make smoking more attractive to people who may experience mental distress. Schroeder and Morris (2010) summarise some of the research that attempts to explain why people with mental health problems are more vulnerable to smoking. Many of these arguments are associated with neurobiological factors that make it difficult for people with schizophrenia, for example, to quit smoking once they have started. Other neurobiological and genetic theories suggest that nicotine might normalize deficits in sensory processing, attention, cognition and mood which are common symptoms of mental distress. In addition there are also suggestions that smoking reduces the impact of medication related side effects as it also decreases blood levels of medications used to treat mental illness. A common misconception is that smoking helps relieve stress and is somehow therapeutic, however, the Mental Health Foundation challenge this belief. When they ask the question ‘does smoking improve mental health?’ by state:
Although many people with mental health problems say that they smoke to reduce their symptoms, they usually start smoking before their problems begin. Heavy smoking does not necessarily lead to fewer symptoms of mental health problems in the long term. Any short term benefits that smoking seems to have are outweighed by the higher rates of smoking-related physical health problems, such as lung cancer, that are common in people with mental health problems.
In addition, Schroeder and Morris (2010) also suggest that the tobacco industry has targeted people with mental health problems and encouraged their smoking through manipulating some of the reasons that they smoke such as for stress relief and self-medication.
Other myths and misconceptions also exist which perpetuate the relationship between smoking and mental distress and are described by Prochaska (2011). She suggests that it is believed that people with mental illness do not want to give up smoking; that people with mental illness cannot give up smoking; that when people with mental illness try to give up smoking, it interferes with their recovery; and that giving up smoking is not a priority for people with mental illness. In the past, there was a strong smoking culture within psychiatry and cigarettes were often used as part of operant conditioning programmes. In addition, withdrawing smoking privileges was also used to ‘punish’ or ‘change’ unwanted behaviour. While these practices are not seen anymore, smoking continues to have a strong relationship with the mental health services and strategies to help people with mental health problems have not been seen as a priority. As health promotion is a key activity for mental health nurses and other mental health professionals, it is imperative that mental health service users are aware of the consequences of smoking and are supported in their attempts to stop.
ASH – Action on smoking and health is a worldwide organisation dedicated to educating the public about the dangers of smoking, campaigning for tighter education controls and encouraging people to stop smoking. Their website can be viewed here.
You can read more about smoking and mental health at the following website.
Mental Health Reform in the United Kingdom have also produced a resource about smoking and mental health which can be accessed here.
According to Citrome and Vreeland (2009) obesity is one of the most common physical health problems in mental health. The National Obesity Observatory (2011) suggests that both obesity and common mental health problems account for a significant proportion of the global burden of disease. Two recent reviews suggest that a "complex interplay" of neurobiological, psychological, and socioeconomic factors contribute to the dangerous association between obesity and mental illness. (register free to read the full article). Taylor et al (2012a) also states that people with mental health issues have a two- to three-times higher risk of obesity highlighting this as a significant problem. You can read a report about obesity and mental illness from the Canadian Obesity Network which refers to Dr Taylor’s work here.
While the benefits of exercise on our mental health is well documented (Walsh 2011) it may be difficult to motivate people to participate in exercise programmes (for example, the thought of going out for a walk may put many people off when they are finding it hard to even get out of bed!). Other factors such as impulsivity, poor decision making skills, poorer coping mechanisms and lack of education about diet and exercise make maintaining a healthy weight difficult for people with mental health problems. As with smoking, mental health nurses and other mental health professionals are in a position to equip service users with the knowledge and skills to help them be aware of the impact of diet and exercise on their physical health.
Some useful information for using exercise to manage mental health is available here.
Some useful information about diet and mental health is available here.
The factors that have been discussed so far can be described as being on a personal level for people with mental health problems and relate to individual choices that may be influenced by a range of factors. Other social factors may influence mental health service users physical health which are summarised by Nash (2014) in the table below. These factors are often interrelated and may lead to material disadvantage, poorer housing, lower educational attainment etc. (Nash 2014).
|Social class and mental illness||People from the lower social classes are more likely to have poorer mental health and co-morbid physical health problems. In addition, they are more likely to smoke, have poorer diets, consume more alcohol and more likely to misuse drugs. In addition stress is more common in this group which also affects physical health.|
|Poverty||There is a strong relationship between mental illness and poverty. People with mental health problems are also more likely to be unemployed.|
|Social inclusion and social exclusion||People with mental health problems may be socially excluded. This means that they are vulnerable to poorer social and health networks which may worsen access to health care and worsen mental health. Poverty and social exclusion may also lead to poorer mental health (Payne 2011)|
There is some evidence in the research that people with a diagnosis of mental illness are less likely to be given treatments considered best practice for a physical health problem, when compared to a similar cohort of people without a diagnosis of mental illness. In one study researchers found a significant number of people with mental health problems and co-morbid diagnosed physical health problems were going untreated. In this study, 38% (n=46) of people with a diagnosis of diabetes had no record of medication being prescribed, 36% (n=76) of people with dyslipidaemia and 52% (n=60) of people with hypertension went untreated (Barnes et al., 2007)
Access and read the following articles to explore some of the inequalities identified.
|Barnes et al (2007)||A UK audit of screening for the metabolic side effects of antipsychotics in community patients.|
|Druss et al (2000)||Mental disorders and use of cardiovascular procedures after myocardial infarction|
|Druss et al (2001)||Quality of medical care and excess mortality in older patients with mental disorders|
|Frayne et al (2005)||Disparities in diabetes care: Impact of mental illness|
In this section two factors that negatively impact on physical health for mental health service users will be explored; Lack of practitioner skills and competence and diagnostic overshadowing.
Research suggests that a considerable barrier to service users having their physical health concerns taken seriously is the attitude and knowledge of health-care providers. Research indicates that mental health practitioners lack knowledge of physical ill health and best practice guidelines on physical health. In addition, many lack the assessment and screening skills necessary to monitor physical health of service users, and consequently do not routinely screen for physical health problem, or provide information and education to service users on physical health. Documentation of physical health problems have also been found to be poor, which leads to compromised care.
Access the following document and explore the inequalities experience by people with who experience mental distress. Disability Rights Commission. (2006). Equal treatment: Closing the gap. A formal investigation into physical and health inequalities experienced by people with learning disabilities and/or mental health problems. Disability Rights Commission, Stratford upon Avon, UK.
Watch the following YouTube video where Professor Richard Grey talks about Improving the physical health of patients with severe mental illness: a programme of re-search.
Diagnostic overshadowing refers to the tendency for practitioners to attitudes symptoms of physical health problems to the persons underlying mental health problem, leading to an under-diagnosis of the presence of a co-morbid physical the presence of co-morbid physical illness. Diagnostic overshadowing is a form of discrimination and is a judgement bias that can have significant consequences for the service user.
The 2013 report ‘Lethal discrimination’ found that “many health professionals are failing to take people with mental illness seriously when they raise concerns about their physical health” (Rethink Mental Illness, 2013:1). Access and Read the report here.
Consider if the following 2 scenarios are a form of diagnostic overshadowing:
Shari has a past history of anxiety and panic disorders, when she complains of an unusual sensation in her chest, with gastric symptoms the practitioner advises her to take the meditation she has been prescribed and practice the relaxation techniques she taught her.
Novack tells her practitioner that he is constantly thirsty and passing urine much more frequently than normal. The practitioner reassures him that there is nothing wrong as it is related to his drinking water to ease his dry mouth, a side effect of his medication.
Read the following article about diagnostic overshadowing: Nash, M. (2013). Diagnostic overshadowing: A potential barrier to physical health care for mental health service users. Mental Health Practice, 17(4), 22-26.
It is evident that people living with a serious mental health problem in particular have a greater morbidity and mortality rate than those without a mental health problem. This unit has identified some of the issues that contribute to this increased morbidity and mortality rate. However limited screening for physical health problems and poor access to appropriate physical healthcare can have a negative impact on the outcome of these physical complications. It is critical therefore that integration of physical and mental health care is required to improve service delivery for people living with a mental health problem.
Apantaku-Olajide T., Gisbbons P. & Higgins A. (2011) Drug-induced sexual dysfunction and mental health patients’ attitude to psychotropic medication. Sexual and Relationship Therapy 26(2), 145-155.
Barnes, T.R., Paton, C., Cavanagh, M.R., Hancock, E., & Taylor, D.M. (2007). A UK audit of screening for the metabolic side effects of antipsychotics in community patients. Schizophrenia Bulletin 33, 1397–1403.
Citrome, L. & Vreeland, B. (2009) Obesity and mental illness, in J. Thakore and B.E. Leonard (eds) Metabolic Effects od Psychotropic Drugs: Modern Trends in Pharmacopsychiatry. Besel: Karger.
DeHert, M. et al. (2011) Physical illness in patients with severe mental disorders. Prevalence, impact of medication and disparities in health care. World Psychiatry 10, 52-77.
Druss, B., Bradford, D.W., Rosenheck, R.A., Radford, M.J., & Krumholz, H.M. (2000). Mental disorders and use of cardiovascular procedures after myocardial infarction. Journal of the American Medical Association 283(4), 506-511.
Druss, B., Bradford, D.W., Rosenheck, R.A., Radford, M.J., & Krumholz, H.M. (2001). Quality of medical care and excess mortality in older patients with mental disorders. Archives of General Psychiatry 58(6), 565-572.
Frayne, S.M., Halanych, J.H., Miller, D.R., Wang, F., Lin, H., Pogach, L., et al. (2005). Disparities in diabetes care: Impact of mental illness. Archives of Internal Medicine 165(22), 2631-2638.
Hardy, S. & Gray, R. (2011) Primary Care Physical Health Checks for people with Severe Mental Illness (SMI) – Best Practice Guide. NHS Northamptonshire/University of East Anglia: Northamptonshire.
Healy, D. (2009) Psychiatric Drugs Explained. 5th ed. Elsevier: Edinburgh.
Higgins, A., Nash, M., & Lynch, A.M. (2010) Antidepressant-associated sexual dysfunction: impact, effects, and treatment. Drug, Healthcare and Patient Safety 2, 141-150.
Joint Formulary Committee (2016) British National Formulary Group and Pharmaceutical Press: London.
McCloughen, A. & Foster, K. (2011) Weight gain associated with taking psychotropic medication: An integrative review. International Journal of Mental Health Nursing 20, 202-222.
Nash M. (2014) Physical Health and Wellbeing in Mental Health Nursing: Clinical Skills for Practice. McGraw-Hill Education, London.
Prochaska J. (2011) Smoking and Mental Illness — Breaking the Link. New England Journal of Medicine 365 (3), 196 – 198.
Rothschild, A. (2000) Sexual side effects of antidepressants. Journal of Clinical Psychiatry, 61 Suppl 11, 28-36.
Schroeder S. & Morris C. (2010) Confronting a neglected epidemic: tobacco cessation for persons with mental illnesses and substance abuse problems. Annual Review of Public Health 31, 297 – 314.
Taylor V., McIntyre R., Remington G., Levitan R., Stonehocker B. and Sharma A. (2012a) Beyond pharmacotherapy: understanding the links between obesity and chronic mental illness. Canadian Journal of Psychiatry 57(1), 5 – 12.
Taylor V., Stonehocker B., Steele M., and Sharma A. (2012b) An overview of treatments for obesity in a population with mental illness. Canadian Journal of Psychiatry 57 (1), 13 – 20.
Walsh R. (2011) Lifestyle and mental health. American Psychologist 66 (7), 579 – 592.
Weir K. (2013) Smoking and mental illness. Available at http://www.apa.org/monitor/2013/06/smoking.aspx, accessed on 14th February 2016.
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