Authors' reply

We thank Dr Kripalani for his interest in our editorial and we share his aspiration to improve the physical health of people who use mental health services. We would like to respond to some of the issues he has raised and note the following.

We believe our editorial demonstrated that this continuing health inequality represents a systems failure of primary care, secondary care and public health to coordinate to prevent premature mortality through implementation of evidence-based interventions. Our proposed systems solution was reflected in a recent editorial by Mitchell & De Hert ‘ … there is much more we can do to help promote physical health in our patients with schizophrenia. We should be doing this early, at first contact by proactively attempting to minimise the accrual of cardiometabolic risk factors. In the long-term, this will prove a more effective strategy than responding only once the complication is established’. ¹

Our editorial highlighted the importance of evidence-based interventions that include antipsychotics. Our call for careful antipsychotic prescribing, well-balanced with psychological interventions and promotion of physical health, resonates with views of others, including major guidelines, particularly in the critical early treatment phase of psychosis:

1. • National Institute for Health and Care Excellence (NICE) guidelines (www.nice.org.uk/guidance/cg178) explicitly recommend that people experiencing first-episode psychosis (FEP) should access an early intervention service and be offered a range of evidence-based interventions that include pharmacological, psychological and physical health-promoting approaches.

2. • NICE recently endorsed the Lester UK Adaptation of the Positive Cardiometabolic Health Resource supporting systematic monitoring of those receiving antipsychotics (www.rcpsych.ac.uk/quality/NAS/resources).

3. • The British Association of Psychopharmacologists recommend specific prescribing considerations for treatment-naive individuals with FEP; for example antipsychotic choice based on relative side-effect liability, patient preference, low-dose initiation and titration within British National Formulary range, systematic side-effects monitoring following initiation, etc. ²

4. • Dixon & Stroup recently highlighted, ‘Because medication experiences for individuals at the beginning of treatment may have a lasting impact on their attitudes toward medication and course of illness, this is a critical time to optimise prescribing.’ ³

A Swedish national database study concluded that mortality risks were highest in those untreated with antipsychotics. ⁴ However, this conclusion maybe an oversimplification and we suggest ‘untreated’ here describes being poorly engaged, lacking care and support rather than simply ‘untreated with antipsychotics’; indeed, ‘treated with antipsychotics’ could be a proxy for well engaged, supported and receiving a range of interventions comparable to those recommended by NICE. Another anomaly was the study's reported average age of 36 years for its FEP subgroup, much older than usually reported. ⁵ Thus the study may have missed substantial numbers of younger people, a particularly vulnerable group for antipsychotic-induced weight gain and metabolic disturbance, limiting its applicability to more typically aged FEP populations. ⁶ Nevertheless the finding that lower mortality correlated with low and moderate antipsychotic dosing supports the importance of good prescribing.

Our simple collective view in providing this editorial as general practitioner, nurse and psychiatrist together, is that health inequality could be reduced by healthcare systems collaboratively embracing a more preventive approach in relation to the physical health of this vulnerable group from the earliest opportunity.