The Lancet Psychiatry Commission: A blueprint for protecting physical health in people with mental illness

The poor physical health of people with mental illness is a multi-faceted, transdiagnostic, and global problem

The Lancet Psychiatry Commission: A blueprint for protecting physical health in people with mental illness has been compiled by a team of 42 researchers, clinicians, and stakeholders from a wide range of relevant backgrounds and professional and personal experience from many different countries.

The team has reviewed key research and new resources and guidelines from international health bodies to provide clear directions for health policy, clinical services, and future research to protect the physical health of people with mental illness.

The scope, priorities, and key targets for improving physical health across multiple mental illnesses are described in Parts 1 and 2 of the report. Emerging strategies and present recommendations for improving physical health outcomes in people with mental illness are presented in Parts 3, 4 and 5. The full report is available online.¹

Increased risk of obesity, diabetes, and cardiovascular disease

Poor physical health leads to premature mortality, poor psychiatric outcomes, disability, and impaired quality of life

Physical health disparities for people with mental illness is the title of Part 1 of the report. The leader of this part described the team’s methodical assessment of almost 100 systematic reviews and meta-analyses on the prevalence of physical comorbidities in mental illness. Around 70% of these analyses focused on cardiometabolic diseases.

The review demonstrated that people with severe mental illnesses, substance use disorders, and common mental disorders, such as depression and anxiety, are up to twice as likely to be obese and have diabetes and cardiovascular disease compared to the general population.

It was further noted that people with mental illness also have an increased risk for infectious and respiratory diseases, including tuberculosis.

Increased risk of multimorbidity in low- and middle-income countries (LMIC)

Studies of physical health among people with mental illness from LMIC were highlighted by the leader of Part 2 of the report.

LMIC comprise 84% of the global population and contribute over 75% of the global mental illness burden; but, research findings from high-income countries cannot necessarily be extrapolated to them because, for instance:

• treatment in LMIC is often suboptimal
• first-generation antipsychotics, which carry less cardiometabolic risk, are commonly prescribed
• knowledge about health hazards differ and are associated with risky health behaviors

The cross-sectional World Health Survey (WHS) of 2002–2004 of 70 LMIC countries (involving around 250,000 people, over 18 years²) revealed that the prevalence of multimorbidity among people with subclinical psychosis and psychosis was two and four times higher than for healthy controls, respectively; and multimorbidity was most evident in younger age groups.²

Analysis of the data of 190,593 individuals from 43 LMIC, recruited via the WHS, subsequently demonstrated a pooled odds ratio for multimorbidity and depression of 3.26.³

Key risk factors

Six well-known risk factors contribute to the increased cardiometabolic morbidity

Part 2 of the Commission’s report — Key modifiable factors in health-related behaviors and health services — was developed from the findings of Part 1.

The leader of Part 2 highlighted that the following six risk factors for cardiometabolic morbidity are increased across a broad range of mental illness diagnoses in low-, middle-, and high-income countries:

• tobacco and excessive alcohol consumption
• sedentary behavior and a lack of physical activity
• poor sleep and diet

Other risk factors contributing to poor cardiometabolic health include the use of second-generation antipsychotics and the poor provision of physical healthcare services for people with mental illness, such as screening for cancer.

Strategies to reduce physical health disparities

Improved prescribing practices can lower the risk of cardiometabolic side effects

Parts 3, 4 and 5 of the report titled Interplay between psychiatric medications and physical health, Multidisciplinary approaches to multimorbidity, and Innovations in integrating physical and mental health care provide comprehensive updates of the literature in these areas and highlight the gaps.

The leader of Part 3 explained that psychiatric medications are the mainstay of treatment for mental illness; but they cause many adverse events (AEs), and that it is incumbent on psychiatric prescribers to monitor and manage AEs. He also emphasized the importance of ensuring the patient is an informed partner and the decision maker.

Provision of a gym and an endocrinologist at the psychiatric clinic can help improve physical health outcomes

The leader of Part 4 of the report noted the need for additional resourcing for people with mental illness and highlighted:

• the collaborative care principles of the Diabetes Prevention Program,⁴ which are highly effective in improving the physical health of people with mental illness
• the importance of changing the provision of care culture and targeting staff to ensure lifestyle interventions, and physical health care are integrated into the care program, for instance embedding an endocrinologist and providing a gym at the clinic