Clinical management
Severe Mental Illness associated with increased likelihood of fragility fractures and osteoporosis under-diagnosis
A UK cohort study examined the association between Severe Mental Illness (SMI) and diagnosis of osteoporosis (OP) and fragility fracture (FF) in people aged ≥50years.
SMI increased the risk of FF across all ages.
In men, diagnosis of SMI increased the likelihood of OP diagnosis, mainly amongst the youngest (50-54y:HR=2.12;95%CI 1.61-2.79) and oldest (85-99y:HR=2.15;95%CI 1.05-4.37). In women, SMI increased the risk of OP diagnosis only in those aged 50-54y (HR=1.16;95%CI 1.01-1.34).
More people with SMI had records of a FF than of an OP diagnosis, suggesting potential under-diagnosis of OP (In men with SMI, FF:OP=2.10, vs 1.89 in men without SMI. The women with SMI, FF:OP=1.56 vs.1.11 in women without SMI).
Suggested WiseGP actions:
Share these findings with staff performing annual reviews for people with SMI, to help ensure risk factors such as poor diet and lack of weight-bearing exercise are addressed.
Could your GP registrar audit patients with SMI with a history of FF, to identify those who have had no diagnosis of osteoporosis that might benefit from a review?
Read more about the research informing this GEM below:
Don’t just screen, intervene, to improve the physical health of people with severe mental illness
People with severe mental illness (SMI) are three times more likely to die prematurely than the general population. Three-quarters of deaths arise from physical illnesses, the biggest cause being cardiovascular disease. A more proactive approach is needed to address cardiometabolic risks.
Encourage smoking cessation, promote healthier lifestyles, treat hypertension, dyslipidaemia and diabetes and improve access to care (see linked tool below).
Support safe prescribing alongside lifestyle changes.
If someone experiences rapid weight gain or marked glucose/ lipid disturbance after starting an antipsychotic medication, facilitate urgent psychiatric review to consider stopping/ changing their medication.
Smoking cessation can reduce the hepatic metabolism of some drugs, so coordinated care is needed to consider whether antipsychotic/antidepressant/benzodiazepine doses need reducing when someone stops smoking.
Suggested WiseGP actions:
Consider if you could improve access to primary care for your patients with SMI? Is there a system to flag notes so that receptionists prioritise access to a GP who knows the patient? Could you offer longer less pressured appointments (eg. end of surgery)? Is there somewhere quieter the patient could wait to see you?
Consider a practice teaching session highlighting ways to ensure safe prescribing of antipsychotics, coordinated with secondary care.
Consider if your practice social prescriber could offer further support to families and informal care-givers of people with SMI.
Find out more about these recommendations here:
Oral health for people experiencing severe mental ill health
People experiencing severe mental ill health (including people with lived experience of psychosis, schizophrenia, severe depression and bipolar disorder) experience inequalities in oral health, with high rates of tooth decay, gum disease and tooth loss.
Effective whole-person care and collaborative working is needed to reduce the risk of poor oral health. Within general practice, all physical health reviews for people experiencing severe mental ill health should include an enquiry about oral health and signposting to a dental service for those not attending regular check-ups.
Suggested WiseGP actions:
Create/edit an EMIS template for physical health reviews in people experiencing severe mental ill health, to include prompts for clinicians to enquire about oral health and signpost to dental services as appropriate.
Discuss oral health problems in a practice teaching session, including the overlapping roles of GPs and dentists and how collaborative working could be improved.
Read the oral health consensus statement informing this GEM below:
Improving care for people with severe mental illness and a lung condition
Qualitative interviews were conducted with people with a diagnosis of severe mental illness (SMI) and comorbid asthma or chronic obstructive pulmonary disease (COPD).
Participants described isolation due to their mental health condition and breathing problems, leading them to become increasingly housebound and struggle to access care. Some clinicians used jargon and often didn’t consider the dual impact of their comorbid conditions on their health and wellbeing.
Participants found it helpful to have regular contact with the same clinician, whilst social prescribing was reported to help reduce the impact of socioeconomic issues on their health.
Suggested WiseGP Actions
Discuss the links between long-term conditions (LTCs) and comorbid mental health conditions at a practice teaching session and ensure clinicians delivering LTC reviews have the skills and confidence to offer initial advice and support to people with comorbid mental health problems.
Consider offering patients with SMI and comorbid asthma/ COPD an appointment with the social prescriber when they attend for their annual review.
Participants in this study didn’t use online or written materials to support the management of their LTCs. Reflect on whether your practice is supportive of people with LTCs and poor health literacy?
Is the health literacy of your patients considered when arranging LTC reviews/when developing personalised action plans as an outcome of their review?
Find out more about the research informing these recommendations here:
