Psychosis and the Mortality Gap

Did you know that people with a diagnosis of schizophrenia, bipolar or psychosis have a life expectancy lower than twenty years compared to the general population? This is a shocking statistic and more needs to be done to support the physical health needs of this group of people.

Last week I attended an event bringing together three teams of researchers whose studies all tested interventions to address the physical health needs of people with a diagnosis of schizophrenia, bipolar or other psychosis. All the studies presented had worked with service users to develop their physical health programme, as well as working with practitioners. They all tested them in pilots before running randomised control trials.

One had created a bespoke package delivered by new therapists using behaviour change techniques adapted from research on diabetes. The other two chose to embed their solution in routine care by asking practice nurses in GP surgeries or community psychiatric nurses in community mental health teams to deliver packages which encourage healthy eating and physical activity. The packages addressed risk factors such as smoking, weight gain, alcohol use, and low levels of physical activity. The National Institute for Clinical Excellence (NICE) guidelines for schizophrenia recommend just this, but do not state what approaches to use.1

“1.1.3 Physical health People with psychosis or schizophrenia, especially those taking antipsychotics, should be offered a combined eating and physical activity programme by their mental health care provider. [new 2014]”

People need both mental and physical health support to improve wellbeing and promote recovery. When given a chance people with a diagnosis of schizophrenia do sign up and take part in research on physical health. In addition all three studies had follow-up rates with over 80% retention, meaning people stayed with the study and engaged with the packages on offer to some degree.

However, unfortunately all three studies found no difference in outcome between the people receiving the new physical health intervention and those that did not.

In the Primrose Study, the team found both groups in the study improved on our primary outcome measure at 12 months. People did not see a decline in their health, but the purpose was to develop an intervention to recommend for use across the country, and we can’t do that yet.2

The IMPaCT trial similarly sought to find an effective intervention that would achieve better physical and mental health in people with psychosis, by improving lifestyle choices and reducing substance use. The team from this research study concluded:

“Training and supervising community care coordinators to use IMPaCT therapy in patients with psychosis is insufficient to significantly improve physical or mental health quality of life. The search for effective, pragmatic interventions deliverable in health care services continues”.3

The third group are currently writing finings up and they are not yet public.

After four years of development and data collection and the statisticians reveal the findings and detect no impact, it was a heart sink moment for all involved. However, there was energy to keep progressing this work until we get this right, as the impact on people’s lives is so great.

On reflection, I took away three things from the event:

  1. We need to look at the current studies and learn more from them, including pooling of data to look across these research populations to see if there are lessons we can learn on why these tested approaches did not achieve changes in the health and quality of life impacts hoped for. This includes service user feedback on the usefulness of the programmes regardless of short term outcomes.
  2. Reaching people early is vital and all first episode psychosis services have to work exceptionally hard to prevent lifestyle factors, poor activity levels and problems around physical health developing in the first case. That includes medication management as well as psychosocial programmes. Lack of investment in early intervention for psychosis services puts much of this at risk.
  3. We need to consider that the answer may not be programmes addressing physical health as a distinct “problem” but developing a different way of delivering services that address social isolation, discrimination and unemployment as priorities using person centred and asset based approaches to support recovery. Motivating changes in lifestyle and physical activity levels for what these can help you achieve, rather than what you lose as a result was recommended by one participant today.We welcome your thoughts on how to take research or clinical practice forward on addressing physical health alongside mental health issues. Please do contact us.
1 National Institute for Clinical Excellence (NICE) guidelines for Schizophrenia.
2 Full write up of the Primrose Study is available here.
3 Full write up of the IMPACT trial is available here.