While being diagnosed with a serious mental health condition like schizophrenia can have devastating consequences for patients, many don’t realise how much their physical health may suffer too.
The life expectancy for people with schizophrenia is around 10 – 25 years less than the general population. They also have two to three times the risk of premature death, and this risk has increased over the past three decades.
“The difference is mainly due to lifestyle factors like weight gain, low exercise, poor diet and the high prevalence of cigarette smoking,” explains Jesse Gates, a PhD student in the University of Melbourne’s School of Psychological Sciences, who recently published a paper on the subject in the prestigious Lancet Psychiatry journal.
While there are a range of reasons psychosis patients are typically less healthy than the general population, anti-psychotic medications play a major role. A common side effect is weight gain.
“So patients find themselves in a position where they learn they have a debilitating illness that impacts on their thinking and ability to relate to others, and at the same time often start gaining large amounts of weight” explains Mr Gates.
“When people already have a fragile sense of self and impaired social function, significant weight-gain is likely to lead to a dangerous downward spiral that is challenging to recover from.”
The solution, he argues, is to intervene early when psychosis is first detected, usually between the ages of 15 – 25.
“It is much easier to prevent weight gain in the first place, than to try and lose it retrospectively,” he says. “So early intervention is really important.”
Moreover, supporting patients’ physical health is likely to improve their psychological health.
“Anecdotal evidence suggests physically active patients have improved mental health outcomes,” he explains.
“Prevention is better than cure, and treating physical and mental health holistically will probably result in a better recovery for the patient, and reduce the overall burden to clinicians over time.”
Co-author Associate Professor Mario Alvarez, who is based at Orygen, the National Centre of Excellence in Youth Mental Health, agrees.
“There’s no such thing as good mental health if there’s no good physical health,” he says.
“We believe specialised mental health services need to look after the young person as a whole. For example, we think it is completely unacceptable that, after receiving a year of anti-psychotic medication, young people will put on 15 – 20 kg. They should have the same physical health as their peers.”
Various studies have shown conventional weight loss programs, where patients receive diet and exercise education, tend not to work long-term for psychosis patients. While there may be some short-term weight loss, over time patients tend to revert to their original weight, or put even more on.
Mr Gates says these programs have tended to ignore proven theories of behaviour change.
“Straightforward education doesn’t affect long-term behavioural change,” he explains. “Instead we need to allow people to be self-driven.”
Self-determination theory, he explains, provides a well-researched theory of behaviour change and motivation. When people are extrinsically motivated, for example to lose weight for an event, the behaviour change is unlikely to persist.
However, when people are intrinsically motivated, for example to lose weight to improve their health, the changes are much more likely to last. People are more likely to be intrinsically motivated when they feel autonomous, competent and related.
There is a need to counter widely-held beliefs among mental health practitioners that physical health support is not their responsibility, nor something they are trained to manage.
“Mental health and physical health should be not be treated as separate constructs, but rather as inextricably linked, and there is a need for training for mental health practitioners so they can also address physical health concerns,” says Mr Gates.
“Interventions that emphasise social support and focus on healthy living are likely to be effective, when done so in a manner that supports individual autonomy and competence” he says.
Associate Professor Alvarez says the problem is structural, and Australia’s healthcare system is too disjointed.
“Ideally, we should have a much more multidisciplinary approach,” he explains.
“We should integrate mental health experts, exercise physiologists, dieticians and GPs, so we can offer a one-stop-shop for young people’s health needs. We can’t keep expecting them to go from service to service.
“Headspace and specialised youth-mental health services are important step towards this model of care, but more progress need to be made regarding the integration of appropriate and coordinated mental and physical health care ”
Many physical health interventions can be straightforward for mental health practitioners to enact, Mr Gates argues.
“They might simply involve taking time to listen to the client’s concerns about physical health, responding empathically, and genuinely being involved in the therapeutic endeavor,” he says.
“Preventative interventions are easy enough to deliver,” agrees Associate Professor Alvarez. “From the medical perspective, clinicians should be monitoring patients’ metabolic functions and adjusting their medications accordingly.
“The other side is supporting good diet choices – very basic interventions like focusing on low sugar diets and offering accessible, affordable advice are important. Exercise is important from a wellbeing perspective, but not particularly effective when it comes to weight loss.”
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