It is widely acknowledged that individuals with serious mental illnesses (SMI) such as schizophrenia, bipolar disorder and severe depression have increased rates of mortality, due to poor physical health. As well as reducing quality of life and function and decreasing life expectancy, physical illness can worsen these mental illnesses. The reasons for this include lifestyle factors, medication side effects and social consequences of the illness. Therefore, it makes sense that clinicians place physical health monitoring high on their list of priorities for their most impaired patients.
Clear guidance on physical health monitoring in this population is plentiful:
- The Royal College of Psychiatrists Physical health in mental health guidance
- The NICE guidelines on Psychosis and schizophrenia and Bipolar disorder
- The Maudsley Prescribing Guidelines
It is also a popular subject for Psychiatry Trainee audits; this Elf recalls hearing one poster presentation judge at a conference recently remark: “not that old chestnut again, sigh”.
I was therefore surprised to discover from a recent Cochrane review (Physical health care monitoring for people with SMI), that there is a lack of evidence to support all of these well-intended efforts.
The Cochrane reviewers conducted a comprehensive search, using an appropriate screening strategy. Their inclusion criteria for participants were broad (age and diagnosis). They only considered randomised controlled trials (RCTs) comparing monitoring with standard care. Monitoring was defined as “any means of observation, supervision, keeping under review, measuring or testing at intervals”, and standard care as “care in which physical health monitoring is not specifically emphasised above and beyond care that that would be expected for people not suffering from SMI”. Different ways of delivering monitoring were considered. Outcomes of interest were also broad and included measures of physical and mental health, as well as functioning.
17 articles were selected and assessed for eligibility, but no studies met the inclusion criteria for this review. The main reason for excluding studies was that they did not focus on general physical health as a primary outcome. One study, looking at monitoring oral health is ongoing, and therefore could not be included.
The authors said that:
Care, and the time of people with serious mental illness, are too costly to waste on ideas that are not of proven benefit.
The authors of this Cochrane review argue that “what could be known, should be known”. By this they mean that clinicians have a duty to provide evidence for the benefit or harm that our interventions cause, and vulnerable patients have the right to have these interventions evaluated. They suggest an RCT whereby a patient’s care co-ordinator administers a physical health check-list (and presumable responds to any concerns raised, but this is not stated). This would be a low intensity intervention, delivered by the most appropriate person in terms of patient care. However, any results could be confounded by the fact that people in trials are very good at completing check-lists, but are less likely to do it in a real world setting.
This review focused on evidence obtained from RCTs, the gold-standard for evidence of intervention efficacy. This is not the only way to study the effect of an intervention, and is often not feasible over the longer time-frame that may be required to assess the benefit of physical monitoring in this population. A longitudinal study, such as a large cohort study might provide us with useful information about what works and what doesn’t. A brief search of the existing literature revealed very little research using any other study design.
The ethical basis for entering a patient into an RCT is a subject of debate and an alternative view considers the principle of clinical equipoise. This assumes that participation in a trial is only ethical if there is disagreement among clinical experts about the preferred treatment. Since expert consensus is that physical health monitoring is better than standard care for people with SMI, this goes beyond a mere hunch. The benefits of physical health monitoring for adults with SMI may not be established using clinical trials, but this Cochrane review is unlikely to drastically change the current recommendations. The authors have made an important point, and it is definitely something that requires discussion so that service users can make an informed decision about their care.
Tosh G, Clifton AV, Xia J, White MM. Physical health care monitoring for people with serious mental illness. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD008298. DOI: 10.1002/14651858.CD008298.pub3.
Physical health in mental health. Final report of scoping group. The Royal College of Psychiatrists, 2009.
Psychosis and schizophrenia in adults: treatment and management. NICE, CG178, 2014.
Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines in Psychiatry 11th Edition Published by Wiley-Blackwell.
Many thanks to BEST in mental health for their help searching the literature that fed into this blog.