Genes may load the gun but it is the environment that pulls the trigger

As well as genetic determinants, socioeconomic inequalities also increase the likelihood of mental disorder, exemplified by several-fold variation in incidence of psychosis between least and most deprived areas of England. ^{Reference Kirkbride, Jones, Ullrich and Coid2} Socioeconomic inequalities operating early in life are particularly important, given that most lifetime mental disorders, including psychosis, emerge in adolescence or early adulthood. Mental disorder is then associated with a range of further inequalities including health-risk behaviours, resulting in higher rates of physical illness and premature mortality as well as poorer educational and employment outcomes, stigma and discrimination. ^{Reference Campion, Bhugra, Bailey and Marmot3} Therefore, addressing inequalities can prevent mental disorder and early intervention for mental disorder across different aspects including physical health can prevent wide-ranging adverse outcomes.

Socioeconomic inequalities and poor life skills of people experiencing psychosis are associated with higher rates of health-risk behaviours that are further exacerbated by illness factors such as lack of motivation or adverse effects of medication on appetite or concentration. In particular, smoking is the largest UK cause of premature death including for people with mental disorder. ^{Reference Campion, Shiers, Britton, Gilbody and Bradshaw4} However those with psychosis are two to three times likelier to smoke than the general population, smoke more heavily and spend proportionately more income on cigarettes. ^{Reference Campion, Shiers, Britton, Gilbody and Bradshaw4} Other unhealthy lifestyle factors include greater alcohol and illicit drug use, poor diets and physical inactivity. ^{Reference Henderson, Vincenzi, Andrea, Ulloa and Copeland1} All increase risk for CVD and diabetes.

Antipsychotic drugs also affect cardiovascular risk directly, relevant to every prescriber's duty to minimise harm. ^{Reference Henderson, Vincenzi, Andrea, Ulloa and Copeland1} Any antipsychotic drug can cause weight gain and metabolic disturbance although this tendency varies between individual drugs. ^{Reference Henderson, Vincenzi, Andrea, Ulloa and Copeland1} These adverse effects can occur within weeks of commencing antipsychotics with 50% of individuals who are treatment-naive gaining over 7% of body weight within 1 year. ^{Reference Kahn, Fleischhacker, Boter, Davidson, Vergouwe and Keet5}

Minding the monitoring and intervention gap

As the UK's Chief Medical Officer highlighted, ^{Reference Davies6} only a minority with any mental disorder receive treatment, with even less coverage of interventions to address associated health-risk behaviour and physical illness. ^{Reference Campion, Bhugra, Bailey and Marmot3} For those with psychosis, improved understanding about the nature of early psychosis has translated into two decades of welcomed service reform although coverage by early intervention psychosis services has recently reduced despite their evidenced benefits. ^{Reference Davies6} However, the need for continuing reform is highlighted by the widening mortality gap reflecting systemic failure to provide and monitor appropriate coverage of evidence-based treatments for people with psychosis. This arises in part from underlying discriminatory attitudes at every level, further exacerbated by ‘diagnostic overshadowing’ and reduced likelihood of receiving treatments even when physical problems are recognised. ^{Reference Davies6}

The National Audit of Schizophrenia (NAS), examining the care of over 5000 people attending community mental health services from England and Wales, discovered inadequate physical health monitoring and lack of intervention for identified risk by secondary and primary care. ^{Reference Crawford, Jayakumar, Lemmey, Zalewska, Patel and Cooper7} The quality outcomes framework (QOF) encourages primary care to improve the physical health of people experiencing psychosis. This had previously relied on 11 pay-for-performance measures, although most incentivised screening rather than monitoring intervention coverage or outcomes. However, the 2014 QOF decision to retire weight, glucose and lipid measures may further widen health inequalities, notwithstanding evidence for systematic underrecognition and undertreatment of CVD by primary care of people experiencing schizophrenia even before these retirements. ^{Reference Smith, Langan, McLean, Guthrie and Mercer8} Thus, although the epidemic of obesity, diabetes and CVD is clearly predicted by antecedent risks evident from the onset of psychosis, few patients go on to receive appropriate monitoring or intervention, representing a breach of the right to health.

Cardiometabolic risk management requires not only effective monitoring but also careful antipsychotic selection and dosage, given their early adverse impact. However, the NAS reported widely varying prescribing practice including polypharmacy and prescribing of doses exceeding British National Formulary recommendations. ^{Reference Patel, Bishara, Jayakumar, Zalewska, Shiers and Crawford9}

The safest way to health

Although weight gain and metabolic disturbance can accelerate following antipsychotic initiation, ^{Reference Henderson, Vincenzi, Andrea, Ulloa and Copeland1,Reference Kahn, Fleischhacker, Boter, Davidson, Vergouwe and Keet5} these serious risks to health are often either ignored or even worsened by poorly prescribed drug treatments. ^{Reference Correll, Robinson, Schooler, Brunette, Marcy and Addington10} This represents a critical opportunity to intervene earlier and more effectively to minimise such risks.

Although antipsychotic medications are important, their use needs to balance benefits and harm particularly from associated cardiometabolic risk. In enabling patients to make informed choices from commencing treatment, this more balanced approach should include early universal access to evidence-based psychosocial interventions such as psychological therapies and family interventions; ^{Reference Morrison, Hutton, Shiers and Turkington11} and behavioural interventions and lifestyle approaches effective in reducing CVD risk. Evidence for addressing weight gain was sufficiently robust for Bartels to recently conclude ‘the greatest current barrier to increasing the life expectancy of persons with serious mental illness is no longer a knowledge gap – it is an implementation gap’. ^{Reference Bartels12} Indeed, emerging evidence suggests such interventions can be effective in the critical early phase of psychosis. ^{Reference Curtis, Watkins, Rosenbaum, Teasdale, Kalucy and Samaras13} Similarly, the continuing failure to address smoking, the single most important individual risk factor, is not about whether to act but how best to implement what is already known. ^{Reference Davies6}

The importance of such an integrated approach from the onset of illness and treatment can be summed up by Hippocrates (460–377 BC) ‘If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health’. ¹⁴

A matter of opportunity

Responding to these concerns, the NAS supported the Royal College of General Practitioners and the Royal College of Psychiatrists to codevelop the Lester Positive Cardiometabolic Health Resource encouraging collaborative and evidence-based approaches to protect cardiometabolic health using a simple assessment and intervention framework (see Appendix). ^{Reference Shiers, Rafi, Cooper and Holt15} Adapted for UK use from an original Australian resource in a process led by the late Professor Helen Lester, the Lester resource was recently updated and promoted by NHS England and Public Health England through the NHS Mental Health Commissioning Quality Innovation scheme (NHS CQUIN 2015/16, offering financial incentives to provider trusts), and NHS Improving Quality's Living Longer Lives Programme.

Two other Royal College of General Practitioners/Royal College of Psychiatrists coproduced and updated resources resonate with the Lester resource strap-line ‘Don't just screen, intervene’: ^{Reference Shiers, Rafi, Cooper and Holt15} Primary Care Guidance on Smoking and Mental Disorders and Early Intervention in Psychosis – Keeping the Body in Mind (Appendix). ^{Reference Campion, Shiers, Britton, Gilbody and Bradshaw4,Reference Shiers, Campion, Jones and Taylor16} These resources are reinforced by an international consensus entitled Healthy Active Lives (HeAL) asking health professionals and service providers to pay far greater attention to the cardiometabolic health of people experiencing psychosis for the first time. HeAL has attracted growing support since its 2013 launch by the Royal College of Psychiatrists in England and by New South Wales Health in Australia. ^{17,Reference Shiers and Curtis18} These four resources highlight tremendous opportunity …

A time for action

Addressing the inequalities experienced by people with psychosis is a defining challenge for modern psychiatric care. The nature and size of the morbidity/mortality gap for psychosis demands systematic prevention and early intervention through a population-based public health approach. This typically young population requires early, practical and positive support through careful prescribing, promoting and monitoring of physical health, and addressing health-risk behaviours. Nor is this simply a task for specialist services in the early treatment phase. Critically, primary care must be involved if early gains are to be consolidated. Local public health input is also vital to routinely monitor levels of both mental and physical unmet need, intervention coverage and outcomes, and coordinate upstream population approaches. ^{Reference Davies6,Reference Campion19} The shared commitment required is exemplified by the collaborative development of the resources detailed in the Appendix.

Recognising primary care's importance in tackling this health inequality, perhaps the last word should go to the late Helen Lester, Professor of Primary Care. In delivering the prestigious 2012 James McKenzie lecture ‘Bothering about Billy’, she called on her GP colleagues to act: ‘there are many things that cost little, that are based on simple observations not rocket science that we could introduce tomorrow … ’. Speaking out against the stigma that ‘seeps and creeps’ into clinical practice behind the health inequalities of patients with psychosis like Billy, she concluded ‘But above all, I think, if we examine our hearts, it boils down, quite simply, to being bothered about Billy’. ^{Reference Lester20}