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

Abstract

Background: The poor physical health of people with mental illness is a multifaceted, transdiagnostic, and global problem. People with mental illness have an increased risk of physical disease, as well as reduced access to adequate health care. As a result, physical health disparities are observed across the entire spectrum of mental illnesses in low-income, middle-income, and high-income countries. The high rate of physical comorbidity, which often has poor clinical management, drastically reduces life expectancy for people with mental illness, and also increases the personal, social, and economic burden of mental illness across the lifespan. This Commission summarises advances in understanding on the topic of physical health in people with mental illness, and presents clear directions for health promotion, clinical care, and future research. The wide range and multifactorial nature of physical health disparities across the range of mental health diagnoses generate a vast number of potential considerations. Therefore, rather than attempting to discuss all possible combinations of physical and mental comorbidities individually, the aims of this Commission are to: (1) establish highly pertinent aspects of physical healthrelated morbidity and mortality that have transdiagnostic applications; (2) highlight the common modifiable factors that drive disparities in physical health; (3) present actions and initiatives for health policy and clinical services to address these issues; and (4) identify promising areas for future research that could identify novel solutions. These aims are addressed across the five parts of the Commission: in Parts 1 and 2 we describe the scope, priorities, and key targets for physical health improvement across multiple mental illnesses; in Parts 3, 4, and 5, we highlight emerging strategies and present recommendations for improving physical health outcomes in people with mental illness. Part 1: Physical health disparities for people with mental illness: Part 1 summarises the findings of almost 100 systematic reviews and meta-analyses on the prevalence of physical comorbidities among people with mental illness. Around 70% of the meta-research focuses on cardiometabolic diseases, and consistently reports that mental illnesses are associated with a risk of obesity, diabetes, and cardiovascular diseases that is 1·4–2·0 times higher than in the general population. Although cardiometabolic diseases have mostly been studied in patients with severe mental illness (particularly psychotic disorders), the prevalence of cardiometabolic disease is also increased in individuals with a broad range of other diagnoses, including substance use disorders and socalled common mental disorders (such as depression and anxiety). Part 2: Key modifiable factors in health-related behaviours and health services: Part 2 presents a hierarchical model of evidence synthesis to evaluate modifiable risk factors for physical diseases in mental illness. Most top-tier evidence has identified that smoking, excessive alcohol consumption, sleep disturbance, physical inactivity, and dietary risks are increased for a broad range of diagnoses, across various economic settings, and from illness onset. Additionally, parts 1 and 2 identify a scarcity of meta-research on the prevalence or risk factors of infectious diseases and physical multimorbidity in mental illness. We also highlight that increased attention on these areas will be particularly important in addressing the physical and mental comorbidities observed in low-income and middle-income settings. Part 3: Interplay between psychiatric medications and physical health: Part 3 examines the interactions between psychotropic medications and physical health across a range of conditions. Antipsychotics remain the best evidence-based treatments for psychotic disorders and reduce mortality rates compared with no treatment, but they have adverse effects on many aspects of physical health. Although drugs for depression have a less immediate effect on cardiometabolic health than drugs for psychosis per individual, drugs for depression are prescribed much more commonly, and the number of prescriptions is increasing over time. Therefore, further research is required to establish the population burden of the cardiometabolic side-effects of drugs for depression, particularly from long-term use. Part 3 also discusses emerging pharmacological strategies for attenuating and managing physical health risks, and provides recommendations for improving prescribing practices. Part 4: Multidisciplinary approaches to multimorbidity: Part 4 discusses multidisciplinary lifestyle interventions in mental health care. The Diabetes Prevention Program (DPP) is an example of a gold-standard lifestyle intervention that has broadly been successful in the general population. However, people with mental illness rarely have access to programmes based on the principles of the DPP, through either primary care or secondary care services. Based on the findings of largescale clinical trials, we propose that future lifestyle interventions in mental health care must adopt the core principles of the DPP by partnering with appropriately trained physical health professionals, and by providing sufficient access to supervised exercise services. Prevention is a key focus of the DPP. Similarly, lifestyle interventions for people with mental illness should be available pre-emptively to protect metabolic health from the point of the first presentation of illness. Priorities for future initiatives and research include translating the principles of the DPP into interventions for people with mental illness across primary care, secondary services, and low-income and middle-income settings, and using implementation science and cost-effectiveness evaluations to develop a business case for integrating DPP-based interventions as the standard of care in mental health care. Part 5: Innovations in integrating physical and mental health care: Part 5 focuses on the availability, content, and context of physical health care for people with mental illness. We summarise valuable new resources and guidelines from national and international health bodies that aim to address inequalities in both public health and clinical settings. National health strategies urgently need to give greater consideration to individuals with mental illness, who are often left behind from population gains in public health. The development of integrated care models for efficient management of physical and mental multimorbidity is an important step forwards, particularly in low-income and middle-income settings where health inequalities for people with mental illness are greatest. Similarly, taking a syndemic approach to the interaction between physical and mental comorbidities might improve the implementation of customised health interventions for a specific location or social setting. Continuing advances in digital health technologies also present new opportunities for addressing health inequalities on a global scale, although realising this potential will be dependent on further rigorous research. The Commission concludes with a discussion on the accountabilities and responsibilities of governments, health commissioners, health providers, and research funding bodies in implementing the recommendations of this Commission and protecting the physical health of people with mental illness.