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Challenges in advancing mental and physical health of patients with serious mental illness

Despite recent significant advances in the pharmacotherapy of schizophrenia and bipolar disorder, challenges such as the simultaneous improvement of the physical health of these patients still remain to be taken into account and formally included into the overall therapeutic plan. This is reflective not only of issues relating to pharmacotherapy but also lifestyle related factors. Recently however there has been renewed emphasis on exploring and evaluating the complex relationships that may exist between schizophrenia, bipolar disorder and relevant metabolic parameters. As a result the previously ignored potential role of lifestyle factors has also been recognized (McCreadie et al., 2003). Important questions have been raised by this debate for which we need answers. Does management of physical health require as its precursor a degree of improvement in the mental state? Certainly psychiatrists and physicians should work as a functioning team with clear defined roles. This is essential should an issue of physical health be deemed a reason to need a change of medications. Any change for physical health reasons must take into account the efficacy of the medication in addition to any perceived crimes against metabolism. Is it easier to manage a metabolic condition or a chronic psychotic illness? We do not have all the answers but we must start by asking the questions. Over the last decade there have been a plethora of consensus statements, guidelines and instructions for clinicians (Expert Consensus Meeting, 2003; ADA, 2004; Lambert and Chapman, 2004). A simple criticism that could be levelled at many of these is that often they have been unreferenced documents that do not allow clinicians to explore fully for themselves how conclusions and recommendations have been derived. Hence for each potential area of concern this supplement contains an individual stand-alone paper containing the data attempting to address each issue. Clinicians thus can read and judge for themselves the validity and degree of certainty that may exist supporting the content of the consensus paper which is the last article of this supplement; this consensus paper explores both the postulated relationships between psychotic illness and metabolic outcomes and the monitoring that might be indicated for our patients in order to prevent or reduce morbidity and mortality. It is clear that schizophrenia patients do die more often than the general population from cardiovascular causes (Brown et al., 2000). What is less clear is the degree to which this risk may be present and active as part of the illness itself before needing to invoke other causes that include smoking, lifestyle issues and antipsychotics (Thakore et al., 2002; Ryan et al., 2003; Thakore 2005). Evidence has been accumulating that schizophrenia to some extent should be viewed as a physical illness in addition to a psychiatric one. The Canadian Diabetes Association in 2003 gave schizophrenia the status of an independent risk factor for diabetes (CDA 2003). Recently the inherent link between metabolic syndrome and schizophrenia has been debated with attention drawn to the need to distinguish between visceral fat and abdominal fat. (Thakore, 2005) It is also apparent that little data exist within treatment-naive groups of patients and importantly also from placebo cohorts that have entered clinical trials. Data from these groups might be helpful in separating out the effects of the illness and its lifestyle from those of treatments. Other issues surrounding data are also of importance: the need for data generated independently from pharmaceutical companies and awareness of the possibility of publication biases that do not allow publication of ‘negative’ studies (Lexchin et al., 2003). The areas of metabolic concern do significantly overlap and thus it is simplistic to view each topic alone. A possible approach is to view them in clusters and this explains the order of their inclusion in this supplement. One overarching finding has been the small amount of data derived from prospective randomized clinical trials involving any of the metabolic parameters (Bushe and