Mental Patients\' Physical Health Who Use Antipsychotic Medication

Antipsychotic Medication and the Physical Health Problems of the Patient With Mental Illness

More and more attention is now being given to the mental disorders especially in U.S. And due to this increase in attention an increase has also been noticed in the treatment of these mental health issues (Zuvekas, 2005). About 30% of the total U.S. population that is between the ages of 18-52 is being affected by mental health issues which make up a large part of the public health problem (Kessler et al., 2005; Narrow et al., 2002). The risk of morbidity and smaller life expectancy is very high in the patients who suffer from the mental health issues (Millar, 2008; Skodol, 2008). It has been observed from numerous researches that the chances of suffering from various health issues such as diabetes, cardiovascular disease and hypertension are a lot more for the patients suffering from schizophrenia (Millar, 2008; Sharif, 2008). 4 and 6 Also, the patients who have mental disabilities live a low quality life and the social and personal burden of their disease increases even more due to a lot of functional impairments (Cotter, 2007; Ostacher et al., 2008).

The main method of treating the mental illnesses is prescription medication. This treatment method is also being given a lot of importance with regards to managing the mental health issues. There are also a number of other mental conditions like mood disorders, bipolar disorder and dementia which are treated with the help of these antipsychotics (Glick et al., 2001; Katzung, 2007). Although there do exist some disagreements but generally the atypical antipsychotics are considered to have the same levels of effectiveness as the typical antipsychotics but the extrapyramidal side effects associated with them are far less (Duggan, 2005; Kapur and Remington, 2001; Stahl, 2002).

The cost of atypical antipsychotics can be as much as 4-10 times the cost of the typical antipsychotics. This fact raises the question regarding the cost-effectives of these particular drugs (Daumit et al., 2003; Martin et al., 2001). There are some people who have put forward the arguments regarding atypical antipsychotics that they help in reducing the universal expenses of schizophrenia as these drugs provide the patients with better social functioning and adherence along with fewer consultations and hospitalizations (Mark et al., 2002). With regards to the cost saving aspect of atypical antipsychotics, there are still a lot of controversies (Duggan, 2005).

With the increase in the rate of diagnosis of the mental health issues the use of antipsychotic medication to treat these conditions has risen as well. It was noted that as compared to 1991 in the year 2001 5.5 million more patients were given the prescription medication to treat the mental health issues. A large portion of this increased medication use from 1991 to 2001 can be attributed to the consumption of the atypical antipsychotic medications that was observed to have gone through an average annual increase of 44% in the new users. There are some factors which can be held responsible for this increase in the use of the atypical antipsychotic medications like the problems that these medications market themselves to be able to treat such as pervasive developmental disorder, obsessive-compulsive disorder, and depression (Fountoulakis et al., 2004).

With the increase in the popularity of these antipsychotic medications a very steep increase has been noticed in their expenditure as well (Zuvekas, 2005; Jano et al., 2007). It was calculated that about 2.1 million Americans were given the antipsychotic treatment which increased its expenditure from about $0.5 billion in 1996 to $3.1billion in 2001 (Zuvekas, 2005; Huskamp, 2005). From 1996 to 2001 there has been an average increase of 77% in the expenditures associated with the antipsychotic medications. In 2003 the total expenditures for the antipsychotic were about $2.82 billion and the atypical antipsychotic agents were responsible for 93% of this amount (Aparasu and Bhatara, 2006).

Focus question and rationale

The morbidity and mortality rates of the cardiovascular disease are a lot more for the people who suffer fromserious mental illness (SMI) as compared to the rest of the population. The SMI patients are also more prone to the non-insulin-dependent diabetes, some kinds of cancers (Dixon et al., 1999), infectious diseases, respiratory diseases and HIV infection (Cournos et al., 2005). According to an estimate the life expectancy of the people who suffer from schizophrenia gets reduced by about 10 years (Newman and Bland, 1991). With regards to the universal increase in the occurrence of the chronic diseases in the low, middle and high-income countries there is an immediate need for these high mortality and morbidity rates to be considered seriously.

The demand for nurses in the mental health field is very high. This high demand places us in a very positive position strategically speaking as; the nurses can play a very important role in the physical as well as mental well-being of the patients who suffer from SMI. For this reason the focus question in this study is going to be: Antipsychotic medication (Clozapine, Olanzapine and others) and the physical health problems such as cardiovascular diseases (CVD), weight gain, diabetes (type 2) and Obesity that are suffered by the patients who have mental illnesses.

Antipsychotics are the type of drugs which are prescribed very often to the people who suffer from intellectual disability. These drugs are usually given to the patients for many years and quite often they are prescribed for reasons other than what they are officially licensed for (i.e. not to treat the psychotic disorders but to rather ease the behavioral issues de Kuijper et al., 2010, Stolker et al., 2002, Tobi et al., 2005 and van SchrojensteinLantman-de Valk et al., 1995). An occurrence of 32.2% (n = 763) was found for the usage of antipsychotics in the population (N = 2373) which lived in the residential areas.

It was noted that majority of the people from among these 763 have been consuming the antipsychotics for many years. The people who had used these medications for less than a year made up 1% of the total population, the ones who used it for 1-5 years made up 12%, the ones using it for 5-10 made up 8% and about 78% of them had been taking these drugs for many years (de Kuijper et al., 2010).

There are some neurological side effects that can affect the extrapyramidal system and are associated with the prolonged use of the antipsychotics and these side effects (Matson and Mahan, 2010 and Stone et al., 1989). Some of these extrapyramidal symptoms can include parkinsonism, tardive dyskinesia, and tardive akathisiaand this can result in distressful feelings as well as secondary morbidity like muscle weakness and aching. Some of the other side effects associated with the long-term usage of antipsychotics are the metabolic symptoms like glucose dysregulation, weight gain, dyslipidemia (Bhuvaneswar et al., 2009, McKee et al., 2005 and Newcomer, 2007).

Also, hormonal dysregulation especially with regards to the increase in the levels of lactotrophic hormone prolactin and ultimately a decrease in the levels of the sex hormones can take place as well with the usage of the antipsychotics. Decrease in the levels of the sex hormones can result in low bone density; disturb the metabolism of bone, loss of calcium bone as well as an increase in the occurrence of osteoporosis (Bhuvaneswar et al., 2009 and Misra et al., 2004).

The extent of side effects of different antipsychotics varies largely. The first thing to be taken into consideration here is that the kind of antipsychotic being used plays a very important role in the extent of side effects which can occur. The factors that are associated with and responsible for the side effects caused by the various antipsychotics are serotonin 5-hydroxytryptamine 2C (5-HT2C), dopamine D2 and D3 as well as histamine H1 receptor affinity, all of these factors are responsible for causing low tardive dyskinesia's risk (Fodstad et al., 2010 and Matson et al., 2010) whereas, the risk of metabolic dysregulation and weight gain is really high in comparison to the usual antipsychotics (Deng et al., 2010, McKee et al., 2005, Newcomer, 2007 and Reynolds and Kirk, 2010). Also, the antipsychotics particularly the atypical antipsychotics (risperidone, paliperidone, and amisulpiride) have a very obvious link with prolactin's higher levels (Bushe et al., 2008a and Holt and Peveler, 2011).

The usage of antipsychotics and the side effects associated with them differ from person to person. Genetics can also be a reason for this difference in the manner that different people react to these drugs (Lencz & Malhotra, 2009). For instance it has been seen through the studies that in the people suffering from schizophrenia a single nucleotide polymorphism (SNP) of the dopamine D2 receptor gene rs1800497 (presence of the A allele); ( Guzey et al., 2007 and Liou et al., 2006) and of the dopamine D3 receptor gene SNP rs6280 (also presence of the A allele); ( Al Hadithy et al., 2009, Rizos et al., 2009 and Woo et al., 2002) has been noticed to have a link to the increase in occurrence of tardive dyskinesia.

Furthermore, there is a higher risk of antipsychotic induced prolactin elevation in the people who are carriers of the rs1800497 (Taq1A) A-allele of the dopamine D2 receptor gene ( Calarge et al., 2009 and Lopez-Rodriguez et al., 2011). This is due to the lower D2 receptor density in the striatum. Also, there is a possibility that the risk of increase in weight might occur by taking the antipsychotics as its use is linked to the polymorphism of the X-linked 5-HT2C serotonin receptor promoter gene rs3813929 (i.e., the absence of the T. allele) which is associated with weight gain (Reynolds et al., 2005, Risselada et al., 2011 and Ryu et al., 2007). Lastly, a relationship has been found to be present among the tragenic 5-HT2C serotonin receptor gene SNP rs1414334C allele and the existence of the metabolic syndrome in mature patients who use the antipsychotic drugs (Mulder et al., 2007a and Mulder et al., 2007b).

Methodology

Searching, critically analyzing, and synthesizing the literature was an important skills for researcher in this study. There were huge amounts of literature and other information available on the topic. In fact the researcher found it hard to figure out where to start. It was very important to be systematic (orderly and rigorous/thorough) in this approach of searching pertinent literature. There was a need to consider search strategies and inclusion and exclusion criteria. Furthermore the researcher also had to list the databases that he has reviewed as well as the keywords employed.

An orderly and rigorous scientific method/approach was used in this systematic literature search to study the evidence present in the previous studies. After the review was conducted in the study the SYSTEMATIC SEARCH became SYSTEMATIC REVIEW. What this means is that all of the references have to be read completely (this was done by reading the abstracts of majority of the papers and later on going through the important articles completely). This method/approach has also been reported in the review as its part. The basic objectives of the systematic review are to create an unbiased and comprehensive search of the literature.

After the studies were found and reviewed and decisions were made regarding their exclusion and inclusion criteria the findings were then classified into themes. Experts were also consulted during the research to discuss the topic.

NOTE: a step-by-step description of the way that the publications were retrieved has been given in a written manner.

1.

Set-up a priori rules - the exclusion/inclusion criteria to be used for the elimination of bias. These were reported in a clear manner and the databases and keywords were used.

2.

Rationale/reasons were given for these rules i.e. The databases and keywords that were made use of were justified.

3.

A reference number and theme was given to every theme.

4.

There were stages in which the literature was searched - after the initial search new keywords had to be used that were discovered in the initial stage. The reasons for using these new keywords were mentioned in the prior rules mentioned above, this was done in the next stage in order to try and narrow/refine the search.

In this paper the epidemiology of mortality of the physical health issues and morbidity has been discussed with regards to the people who suffer from SMI and who have been using antipsychotic medication for longer periods, the probable reasons for the bad physical health of these people and the possible role played by the mental health nurses in making the physical health of the SMI patients better. A search was conducted of the PsychINFO, MEDLINE and CINAHL from the year 1980 to 2014 by using the terms such as schizophrenia and psychosis in combination with diabetes, exercise, HIV, smoking, antipsychotics and cancer. A search was conducted for the papers written by major authors in the physical health and schizophrenia field along with the Department of Health websites in USA, Australia as well as UK for searching the policy recommendations.

Other issues about literature searches

Non-peer reviewed sources (Grey Literature): There are various other information sources which aren't always peer reviewed like the government departments, local councils, community groups and health and welfare agencies. It was very important to take into consideration the possible values of such type of literature that also has monographs and reports which are published by the universities, government departments as well as the non-government organizations. For this study, most of the references cited were taken from the peer-reviewed sources like the scientific journal articles

Primary and Secondary research. Primary research publications report research undertaken by the authors (original work).This kind of report helps in explaining the methodology as well as the study rationale. Complete reference list, detailed results as well as the discussion/interpretation results are also given by this kind report. Furthermore, it also gives significant amount of detail which makes it possible for the other researchers to be able to duplicate the research. Usually particular areas, newspaper and magazine articles, textbook chapters as well as other kinds of media like films are reviewed in the secondary research publications. In this study the primary as well as secondary research was made use of in order to facilitate the research.

Conclusion

There are a number of things that have to be kept in mind while preparing a review. First of all the reviews were used in such a manner that it could be associated with our research problem as well as bring to light the relationship that we think it has with the already present data. We studied the problem mentioned in research in the light of the already present theory as, the chances of a research playing a substantial role in the future researches decreases a lot in case of no theory.

Secondly, the literature review was tried to be made in such a manner that it would be substantial as well as logical. We had to make the decision regarding choosing from among various ways in order to form and present our review. The significant thing to do here is to decide upon one method and to start using it. If there does occur a need the researcher had the option of changing the approach later on with regards to more reflection and information. This method is far more suitable and productive than getting overwhelmed by the thought of so many choices.

Thirdly, themes were developed in the research which proved to be very helpful in our varying perceptions of the work done by others. This can help the author in identifying the areas and aspects that we want to focus upon in a clearer and better manner.

Last and probably the most important point is that we presented our review in such a manner that it doesn't merely seem to be a presentation of the material which is available rather it gives a very detailed critique of the material. In the review, the methodologies which were used by others have been discussed in great detail along with the context in which they used the research as well as the assumptions made by using those methodologies. Details of the search strategy have been illustrated in the section below titled, "Strengths and limitations of this extended literature review."

Chapters

A General Background on antipsychotic medication

For the long-term and acute treatment of schizophrenia, antipsychotics are the vital elements. (Kane and Marder,, 1993; Kane and McGlashan, 1995). In 1050s, the first generation which is also referred to as 'typical' was introduced. Even though the treatment was being given to this first generation of antipsychotics, a large amount of these patients did not show frequent improvement. Moreover, the association of these drugs is mostly done with important side effects which also include the symptoms of pyramidal that are the uncontrolled movement which might exist in the patients of schizophrenia after a long period of treatment of the medication of antipsychotic. The tardive dyskinesia due to is high yearly rates are significantly a symptom of extrapyramidal that should be worried about (Correll and Schenk, 2008).

In 1989, Olanzapine and Clozapine were re-introduced which marked the start of the second generation of antipsychotics 'atypical' (Pickar et al., 1994; Pickar and Hsiao, 1995). This expanded the effects of therapeutic that occurs in the patients who do not respond properly to the treatment and also has low side effects risks. However, the association of Clozapine with serious agranulocytosis has made it in appropriate to be a first line drug. The success of Clozapine motivated enough to make more antipsychotics thus resulting in more drugs of second generation like olanzapine and risperidone (Pickar, 1995).

Pharmacologically, the first generation drugs are different from the second generation drugs legally in having more affinities for neuro-receptos like serotonin and low affinity for dopamine-2 receptor and also in their capability of modulating behaviors and functions of glutamate receptor mediated (Kinon and Lieberman, 1996). The new antipsychotics also have low symptoms of extrapyramidal of tardive dyskinesia. They also do not share agranulocytosis which is the risk of clozapine (Adkins et al., 2011).

The antipsychotics of second generation are associated with different side effects of metabolism like weight gain, elevated glucose level and dyslipidemia (Leucht et al., 2009; Meyer et al., 2009). It also has some medical outcomes like vascular disease, diabetes, coronary artery disease and hypertension (Henderson and Doraiswany, 2008). A cautious treatment and monitoring of antagonistic effects of metabolism are required. Moreover, the mentioned side effects are the main elements which are fundamentally substantial and portraying the therapy of antipsychotic (Bellack, 2006).

The capability of minimizing the side effects of metabolism by corresponding patients individually to concentration of optimal drug before the treatment is considered to be of great value clinically. The factors that are genetically important are mostly likely to explain a part of separate differences in the side effects of metabolism. Serotonin receptors are being suggested by many studies (Gunes et al., 2009).

Serotonergic system is included in the management of the control of satiety and behavior of feeding in the system of central nervous while the serotonin receptors are explained in the areas of central-nervous system in the balance of the energy (Banes and Sharp, 1999).

Moreover, olanzapine includes greater affinity for the receptors and they are speculated to activate the gain of weight most importantly with the help of 5 hydroxytryptamine receptor (Meltzer, 2005).H1 antagonism and Histamine receptor have been implicated as well (Matsui-Sakata et al., 2005). However, the continuous evidence that implicates any individual candidate polymorphism or gene has not been common (Malhotra et al., 2004).

Clozapine provides a lot of benefits and rarely originates any side effects that prove to be fatal or serious and due to this particular reason, clozapine is required only when either the person cannot be helped with any treatment of when every treatment has failed to work on him. In order for the patient to get this drug, the patients, pharmacists and doctors have to agree and cautiously follow all the requirements related to the registry program of the patient (Barrett et al., 2008). The requirements are only applied in the U.S. And the person based in any other country has to consult the pharmacist or doctor according to the regulations of the country. The medication of this drug can also create a severe problem of immune system known as agranulocytosis which results in the decrease of the white blood cells. So in order to ensure that the patient has plenty of white blood cells, a blood test needs to be taken before the medication of clozapine. Regular blood testing during the course of the treatment is also recommended (Barrett et al., 2008).

In high doses, serious seizures can be caused by Clozapine and the patient must inform their doctor in case he had any seizures. Some activities like driving and other similar activities must be avoided by the patient during medication because sudden fainting can be fatal even like swimming or operating large machines. Clozapine can also cause myocarditis, and the patient should get immediate treatment in case of swelling of legs or ankles, chest pain, rapid or difficult breathing and weakness. During the treatment, the risk of such effects is much higher. Other than that, blood pressure can also be dropped that can cause dizziness and create difficulties for the patient to stand up properly. In this case, the patient needs to stand up very slowly. Dizziness is likely to happen when the patient is taking a dose of benzodiazepine like diazepam, lorazepam and clonazepam or if his clozapine dose has been increased (Beninger, 2006).

If the medication of clozapine is being used by older people along with dementia, then the risks might increase and cause side effects that can prove to be fatal like pneumonia, irregular or fast heartbeat stroke etc. so clozapine is not recommended for people with dementia. For such patients, they fist need to discuss the risks of medications with their doctor so that no fatal risks take place (WebMD, 2014). A lot of other side effects can occur which lessen with the increased dependency of the drug. Such effects include constipation, weight gain, vision problems, shaking, headache, dizziness, drowsiness and drooling. The patient should directly contact their doctor in case these side effects become severe. The prevention of constipation requires a fiber diet, increase in the intake of water and a lot of exercise to keep the muscles active. A laxative is required to be used in case constipation occurs with the intake of medication, with consultation of the patient's doctor. The doctors in this case who assign the medication keep in mind all the problems of the patients and judge that he/she will have more benefits from the drug than side effects and a lot of people using the drug do not experience any severe side effect (Kapur et al., 2005).

Clozapine however can rise up the level of blood sugar and cause the diabetes to worsen which can also cause a diabetic coma. The patient needs to inform their doctor right away in case of high blood sugar symptoms which include increased urination and thirst. In case if the patient has diabetes already then the doctor has to adjust the medication so that no sever side effect occurs. Apart from that, the medication can also cause high cholesterol and weight gain which increases the risk of heart diseases. In case of seizures, tremors, infection and twitching, the patients need to inform the doctor immediately. Neuroleptic malignant syndrome is a condition that can be caused by the medication which requires immediate medical help if the symptoms like dark urine, fast or irregular heartbeat, confusion, tiredness; sweating, pain, fever etc. are felt. An allergic reaction to the medication is not likely to happen but medical help is required immediately for this. The symptoms might include trouble in berating, severe dizziness, swelling and itching, rash etc. (Li et al., 2004).

Epidemology

Cardiovascular disease

Cardiovascular disease (CVD) accounts for 29.2% of deaths across the world; or claims an average of 16.7 million lives annually. A recent survey showed it was the leading cause of death in developing countries (WHO, 2003); while it also seems to fast becoming the same in the developing world as well (WHO, 2005). Risk factors for CVD include age, gender, family history, obesity, smoking, hypertension, hyperlipidemia, poor diet and lack of exercise. These behaviors and health conditions are in evidence with people who have SMI; and each is either preventable or can be minimized (Harris and Barrowclough, 1998, Brown et al., 2000). It bears noting that the occurrence of SMI often results in CVD at rates of 2 to 3 times greater than in the general population (Brown et al., 2000, Osby et al., 2000). As well, one study purports women who suffer from SMI have a higher risk as well of contracting coronary heart disease than their male counterparts (Goff et al., 2005).

Respiratory disease

Respiratory diseases including tuberculosis and pneumonia were the main precipitator of deaths in people that had SMI and also lived in institutions - as recently as fifty years ago (Brown, 1997). Even now, respiratory disease is more common in people who have SMI; but the cause is traced to higher smoking rates including second-hand smoke. One study also found that of 200 schizophrenic and bipolar patients in the U.S.; 15% of the former and 25% of the latter had chronic bronchitis; and 16% of the former and 19% of the latter had asthma (Sokal et al., 2004). The matched controls for the general population indicated significantly lower rates; a fact that was true even when smoking as a cofounder was controlled. As well, there was also evidence that these same populations have a propensity for emphysema.

Cancers

The number of global cancer deaths annually is 7.1 million; or 12.6% of worldwide loss of life. Additionally, the estimated rise in new cases each year is expected to jump from ten to twenty million by 2020 (WHO, 2003). Use of tobacco is the single largest causative factor. Physical inactivity and poor diet are also sources. Meanwhile, the literature reveals increases and decreases of frequency in schizophrenics depending on the type of cancer. For example, the research reveals consistently higher rates of both breast and digestive cancer in those who suffer from schizophrenia (Schoos and Cohen, 2003). However, research on this same population when studying lung cancer is inconclusive if not contradictory. Lichtermann et al. (2001) and Brown et al. (2000) each reported double mortality rates for the schizophrenic population vs. The general population. Conversely, two large-scale cohort studies conducted by Mortenson (1989, 1994) reported lung cancer rates in schizophrenics to be similar or even lower than that of the general population. It has been hypothesized that the reason for this is this segment of the population may die from other causes before advancing to an age that is common for lung cancer (Casey and Hanson, 2003). Too, there appears to be under diagnosing of malignancies in the schizophrenic population; perhaps because the anti-psychotic medicine taken by these patients has unaccounted for anti-tumor properties (Cohen et al., 2002). Breast cancer rates have been hypothesized to be connected to the presence of higher levels of prolactin in some atypical antipsychotic pharmaceuticals; leading the user to forgo regular breast self-examination. Finally, digestive cancers are linked to greater levels of alcohol consumption as well as poor diet (Casey and Hanson, 2003).

Diabetes

Conservatively speaking, an estimated 177 million people globally suffer from diabetes (2.8% of the world populace). Unfortunately, the incidence is expected to rise to 370 million by 2030 (or 4.4% of the global population) (WHO, 2003).Diabetes and schizophrenia as co-occurring ailments has garnered the greatest amount of investigation; and remains controversial regarding the etiology and prevalence in people suffering from SMI (Holt and Peveler, 2005). Psychiatrist Henry Maudsley was first to observe the association of the two factors (1897, cited by Koren, 2004); stating that diabetes was a disease that seems more prevalent in families with insanity. The physiology of this might be traces to insulin resistance and/or glucose dysregulation; both observed since the 1920s in psychiatric patients (Koren, 2004). Statistically, diabetes occurs in 15% of the schizophrenic population (Holt and Peveler, 2005) and only 5% of the general population (Busche and Holt, 2004). Risk factors for the disease include family history, poor diet, smoking, physical inactivity and the metabolic effects of anti-psychotic medication (Gough and Peveler, 2004).

In the general population it is not uncommon for diabetes to go undiagnosed for years; perhaps as many as 12 (Department of Health (DH), 2001). Delayed diagnosis can have devastating consequences due to prolonged blood glucose increases. Visual impairment and blindness, renal failure, and never and kidney damage are among them (DH, 2001).

Human immunodeficiency virus

Currently there are 40 million people infected with the Human Immunodeficiency Virus (HIV) around the world (UNAIDS / WHO, 2005). HIV studies of rates in people with SMI in the United States reveals prevalence rates of between 3% and 7% (Sewell, 1996, Rosenberg et al., 2001). This group was 1.8 times more likely to be diagnosed with HIV; and persons having mood disorders were 3.8 times more likely to have HIV than people in the general population (Blank et al. 2002). People with SMI are less sexually active than the general population; and they are also more likely to engage in high risk behaviors that result in HIV. For example, studies show they are less likely to use condoms; and do more drug injecting than the general population (Cournos et al., 2005). This is probably due to a lack of information about how HIV and sexually transmitted diseases occur and/or can be prevented (Arrufo et al., 1990; Kalichman et al., 1994). As well, the SMI person is more susceptible to sexual coercion due to their difficulty in establishing wholesome social and sexual relationships; as well as the comorbidity of substance and alcohol abuse Coverdale and Turbott, 2000).

Reasons that people with SMI have poor physical health

Service related factors

The health care needs of the SMI population have generally been overlooked in both primary and secondary care forums (Gournay, 1996; Phelan et al., 2001). Statistics from multiple studies are grim. One research group reported that in a single psychiatric day care facility; of the 145 patients with SMI a full 41% had medical problems and 44% had unmet needs (Brugha et al. 1989). Moreover, the literature is replete with similar reports of unfulfilled monitoring, recording - or for that matter, even minimal assessment - of the health status of SMI patients. Burns and Cohen (1998) reported that the physical health care monitoring of patients in primary care settings revealed a lack of recorded statistics; only 27% had weight, 2% had cholesterol and 38% had blood pressure recordings. Findings from secondary health services fared no better according to a study by Paton et al. (2004). Here the case notes of 606 inpatients were reviewed and an abysmal 18% had weight recordings, and 3.5% had their lipids recording upon admission. Still another study by Greening (2005) only reconfirms this inexplicable oversight of basic medical services; noting that of 63 patients in a rehabilitation facility only 16% had their smoking status recorded; 24% had blood pressure recordings and a final 16% had their weight noted for the record.

The excuse is there seems to be a lack of clarity as to whose responsibility it is to address the physical health problems of the SMI population; which exacerbates service-related barriers. In the United Kingdom, the National Institute for Clinical Excellence (NICE) published guidelines addressing this. They recommend primary care practitioners provide routine physical checkups for the schizophrenic population. In cases where the patient has no primary care physician (general practitioner or GP) then it should fall to the secondary mental health services to provide routine physical health examinations. Too, persons who are admitted to psychiatric wards should naturally have routine physical checkups. In the United States, consensus recommendations were published regarding the monitoring of the physical health of schizophrenic patients (Marder et al., 2004). Mental health care providers are expected to carry out routine physical health monitoring; and where patients have had the good fortune to be checked up by a primary care physician - then this allows for double the chance of early detection of serious physical problems. In Australia, government policies are in place that automatically requires the incorporation of SMI patient case management (Victorian Mental Health Services, 1995). While there is value in clarifying the responsibilities for the physical health care of schizophrenic persons; both primary and secondary care practitioners should claim this role. Ultimately, the most important point is that everyone is aware of their responsibilities and has a copy of a collaboratively developed plan.

Illness related factors

It should not be surprising to learn that persons who suffer from SMI may be challenged with regard to help-seeking behavior. They are generally less likely to spontaneously report physical symptoms (Jeste et al., 1996). As well, their cognitive deficiencies may result in a general unawareness of physical problems (Phelan et al., 2001); have high pain tolerances (Dworkin, 1994); reduced pain sensitivity associated with anti-psychotic medication (Jesteetal., 1996). Socio-economic consequences are also common in people with mental health disorders. Poor housing, reduced social networks, unemployment, a lack of occupational opportunities, social stigma and poverty are all confounding factors to the physical health and behavior of the schizophrenic person.

There are a number of concerns that are faced by the families and care givers of the people who suffer from SMI. For instance they believe that the people who have SMI have needs that are different from the general population and therefore it is important to alter their health care in the light of their particular needs. There is a continuous struggle that the SMI patients experience with regards to the society and the stress that they feel as a result of wanting to be part of the society. The extent of help or assistance that is asked for by the people with SMI also differs according to the level of their disease and for this reason it is important to come up with programs that are designed by keeping in mind the stage of disease (Hasselt et al., 2013).

However, Verhaeghe et al. (2013) in his study found an improvement in the body weight, WC, BMI as well as the fat mass in the individuals who had care givers or families that were better aware and educated about their condition. These improvements were also seen in the people suffering from SMI and who had competed the interventions designed for them. The results of this particular study clearly state that with proper lifestyle counseling programs that are made a part of the treatment for people with MD, the risks of the occurrence of serious somatic diseases such as type 2 diabetes and CVD can be reduced (Verhaeghe et al., 2013).

Health behaviors of People with SMI

The most commonly recognized causes for increased morbidity and mortality in the SMI population is smoking and substance abuse, physical inactivity, poor diet and unsafe sexual practices (Brown et al., 1999, Lambert et al., 2003). While the literature refers to these behaviors as 'lifestyle choices'; health care professionals claim these are not choices at all; but rather consequences of mental illness - and, unfortunately, of the treatments which have been prescribed for them. Let us consider these in greater depth.

Smoking

According to research; and a plethora of epidemiological studies; the international prevalence of smoking rates in persons with bi-polar disorder and schizophrenia range anywhere from 58% to 88%. This is as much as three times higher than their general population counterparts (Hughes et al., 1986; de Leon et al., 2002). Studies also show SMI sufferers are inclined to be heavier smokers; going through as many as 25 cigarettes daily (or more than a pack a day) (Kelly and McCreadie, 2000). Research shows the reasons for this are psychological, neurobiological, behavioral and social; a combination that makes it highly challenging to reduce or alter smoking behavior in schizophrenics. When a person smokes a cigarette, he or she experiences an increase in dopamine through the inhalation process of nicotine. This, in fact, tends to alleviate certain psychiatric symptoms such as anti-psychotic side effects and cognitive deficits. The result is smoking is a form of self-medication (Goff et al., 1992; Dalek et al., 1998). Another seeming advantage of smoking for the schizophrenic patient is that it tends to improve the attention and selective information processing functions otherwise normally impaired in this population (Alder et al., 1998). Further qualitative studies conducted by Luckstead et al. (2000) and Lawn et al. (2002) revealed that the SMI individual often smokes simply out of routine or habit; but that it also is valuable for relaxation, is a form of providing social contact and is pleasurable; while giving them a sense of control in an otherwise disorderly life. There seems to be little authenticity in claims of the SMI patients motivation to cease smoking (McNeill, 2001).

Physical inactivity

The prestigious World Health Organization (WHO) claims physical inactivity is a leading cause of death in developed countries (WHO, 2003). Research shows that the SMI sufferer is less physically active than the general population (Brown et al., 1999; McCreadie, 2003). It is a major challenge to health professionals everywhere to engage people in following nationally recommended guidelines for physical activity; a fact that is even truer with the SMI patient because one of the side effects of medications is its sedating effect. Additionally, depression is a symptom of schizophrenia as well; and motivation is even more challenging; and the costs of joining a health club are often out of the reach of this segment of the population - or they may simply lack the confidence to pursue this option. Yet, there is a wealth of evidence to support the benefits of exercise for physical and mental health (DH, 2004).

Diet

A survey conducted on the dietary habits of an SMI population of 102 persons revealed an intake of fruit and vegetable portions to be 16; while the recommended amount is 35 (McCreadie, 2003; DH, 2004). The consequences of a poor diet on one's physical health resonate through a series of problems including obesity, cancers, diabetes and CVD. . Related studies show that people with SMI have higher evidence of saturated fats from their dietary intake of meat and dairy products; and these factors are actually associated with worse outcomes in schizophrenia (Peet, 2004). At the same time, sugar consumption is linked to poorer outcomes in schizophrenia and consumption of fish and sea food, particularly omega reveals better outcomes (Peet, 2004).

Treatment related factors

There is no argument that the introduction of psychotropic medication has improved the lives of persons with SMI; enabling them to lead more productive lives in their own homes and communities; versus the previous experience of long hospital stays. These benefits have spilled over into application for other mental disorders including dementia and bi-polar disorder (Jin et al., 2004). However, atypical antipsychotic medications are not a total panacea; and have a decidedly deleterious effect on physical health. As far back as 1950 there was a report of chlorpromazine was linked to hyperglycaemia, glycosuria and weight gain (Koran, 2004). When atypical antipsychotics were introduced in 1990 the research pursued concerns of a relationship between these medications and a host of ailments including increased rates of obesity, type 2 diabetes, CVD, hyperprolactineamia and metabolic syndrome in people with SMI. One note of interest regarding this is the incidence increase may actually be the result of improved medical surveillance and may have nothing at all to do with the medicine.

Weight gain

One of the most challenging global epidemics of developed countries is obesity. The increase of consumption of nutrient poor and energy dense foods containing high levels of saturated fats and sugar are deadly; particularly when combined with physical inactivity (WHO, 2003). Obesity is linked to a number of disabling conditions including blood pressure increases, respiratory difficulties, increased risk of heart disease and diabetes and insulin resistance (WHO, 2003). The evidence regarding incidence of obesity in the SMI population is contrary (Wirshing and Meyer, 2003). Some studies indicate more women than men are obese in this group (Allison et al., 1999, McCreadie et al., 2003); and there is indications of higher rates of upper body obesity (visceral fat) in the SMI population as well; creating a greater risk factor for diabetes, CVD and body fat (Ryan and Thakore, 2001).

Other research findings include the realization that typical and atypical antipsychotic drugs effect dopaminergic, serotonergic, histaminergic, cholinergic and adrenergic neurotransmitters. Each of these is connected to the etiology of gaining weight; while olanzapine and clozapine are connected to weight gain when compared with other antipsychotics. They may also causeinsulin sensitivity resulting in hypoglyceamia and food cravings (Werneke et al., 2003). Studies have also revealed there is a recognizable divergence in body composition between healthy control subjects and SMI individuals; as well as those with schizophrenia who have never been exposed to atypical antipsychotics (Thakore et al., 2002). It is well-known that anti-psychotic drugs, antidepressants and mood stabilizers increase the desire for food and drink. Often, the SMI patient will turn to fast food restaurants where the carbonated drinks and substance of the menu items is high in saturated fats and sugar; and provide a quick relief for this problem - as well as being an affordable option for this group that is often on a limited income. The result may be increased weight which exacerbates their social standing; further making them a target for social exclusion.

Diabetes and glucose intolerance

Chlorpromazine and other typical atypical antipsychotics with low potency have the added side effect of inducing or exacerbating diabetes (Newcomer et al., 2002).Clozapine, olanzapine and other atypical antipsychotics cause type 2 diabetes to become more problematic. This is due in part to the associated weight gain from their use as well as their effects on glucose regulation (Newcomer et al., 2002).Respiridone and quetiapine have also been linked to glucose intolerance, ketoacidosis and diabetes (Taylor et al., 2005). It would not be disingenuous to state that there is a plethora of research on the subject of atypical antipsychotics and diabetes; yet an argument can be made that the research is methodologically weak - rendering the findings suspect confirmed (Taylor et al., 2005, Holt and Peveler, 2005).

In the case of Diabetic Ketoacidosis (DK) it is a condition that is potentially fatal but may be the first warning sign of the presence of type 2 diabetes. DK is related to metabolic stress; typical in cases of trauma, infection, stroke or myocardial infarction (Jin et al., 2004). It is essential that mental health nurses are versed in the symptoms of Diabetic Ketoacidosis. It is especially challenging because it has a rapid onset (with as little as a 24-hour time frame) and the symptoms are varied but may include everything from dehydration to vomiting, abdominal pain to polyuria, polydipsia and polyphagia; all of which could result in coma or death (ExpertPanel, 2004). Emergency responses should include insulin therapy, electrolyte correction, rehydration and treatment of any and all other underlying or obvious conditions.

Cardiovascular effects

Unlike other problems caused by medications to treat mental illness; associated risks for cardiovascular effects is lower. However, they have been known to be connected to changes in an ECG, sudden cardiac death and ventricular arrhythmia (Taylor et al., 2005). Recently there have been concerns voiced regarding the effects of atypical antipsychotic medication on the corrected QT (QTc) interval prolongation and sudden death. The challenge here is that everything from antibiotics to a host of other medications have also been found to cause causeQTc prolongation (Taylor et al., 2005).Thioridazine and sertindole are two of the drugs that have been lined to QTc prolongation; and mental health nurses must be cognizant of the fact that intravenous anti-psychotic medications - when combined with other atypical antipsychotic drugs - can lead to cardiac changes (Taylor et al., 2005).

Another common side effect of tricyclic antidepressants and typical and atypical antipsychotics is hypo tension. The reason is these medications block adrenergic receptions; with more frequent occurrences in the low-potency drugs such as clozapine and chlorpromazine or high doses of atypical antipsychotics (Taylor et al., 2005). Clozapine has also been associated with myocarditis or inflammation of the heart muscle; occurring most often in the first two months of treatment initiation. Symptoms include fever, fatigue, chest pai, tachycardia, and flu-like problems (Killion et al., 1999). There are a broad number of other conditions that must be considered as potential for causing sudden death in SMI patients. Some of the more obvious include the co-morbidity of substance abuse, continuous manic or exhaustive mania, dehydration, psychomotor excitement and even the seemingly innocuous electrolyte imbalance (Gray, 2001).

An unhealthy diet and smoking are two health behaviors that can lead to CVD or hyperlipedaemia; which is the presence of too much cholesterol and triglycerides in the blood. Morbidity levels are higher when there is the presence of a higher total cholesterol and low density lipoprotein (LDL) cholesterol. Conversely, a lower risk of heart attacks is associated with higher levels of high-density lipoprotein (HDL). Typical and atypical antipsychotics have been revealed through research to effect cholesterol and triglyceride levels; clozapine and olanzapine are both considered to have the greatest impact (Casey, 2004).

Metabolic syndrome

The metabolic syndrome is the cluster of insulin resistance, glucose intolerance, hypertension, abdominal obesity, and dyslipidemia. This has also been named Syndrome X; its diagnosis results from the presence of 3 or more of these conditions (Ryan and Thakore, 2001). Again, research shows that this syndrome is more common in people with schizophrenia; and may additionally explain their increased prevalence of CVD and diabetes (Holt et al., 2004).

Eye Health

Finally research dating back to the 1950s shows that antipsychotic medications impact corneal and lens changes (Shahzad et al., 2002). One study found that phenothiazines intake increased the likelihood of cataract development four times over the general population (Isaac et al., 1991). In 2002, a group of researchers used the United Kingdome General Practice Database to conduct a large cohort and nested case control study (Ruigomez et al.). Their results were that no evidence existed to an overall increase in cataract risks for persons taking atypical antipsychotic drugs; except in the instance of prochloperazine and chlorpromazine; where there was indications of a significant higher risk. Additionally, research does that quetiapine may also cause cataracts; but no definitive link has been established despite case reports. Instead these patients show co-occurring conditions that include hypertension, eye trauma and diabetes (Marder et al., 2004). To be on the safe side; the manufacturer of quetiapine has taken to recommending eye examinations for patients after treatment initiation and in six-month intervals afterwards (Astra Zeneca, 2005). This caution is only utilized in the United States; and researchers remind us there has been established link even now.

Dental health

Xerostomia is a disease in which the production of saliva slows down in the mouth and this is caused by the usage of mood stabilizers, atypical antipsychotics and antidepressants. Hyposalivation is caused by the low potency antipsychotics like chlorpromazine as well as with the co-administration of anticholinergic medication. When the salivary flow reduces number of mouth related diseases occur such as periodontal disease as well as gingivitis (Friedlander and Marder 2002). Along with the side effect of medication there are also a number of other reasons because of which the dental health can become poor such as poor diet, bad oral hygiene and smoking (McCreadie et al., 2004).

Sexual effects

Sexual problems have been known to arise with the usage of all the atypical and typical antipsychotics, mood stabilisers (especially lithiuim and carbamazipine), and antidepressants (particularly the SSRIs). The sexual functioning is affected by the anticholinergic and adrenergic effects of the antipsychotic drugs, these also result in blockading the dopamine receptors in the tuberinfundibular pathway present in brain as a result of which hyperprolactineamia (increase levels of prolactin hormone) takes place.

The testosterone levels in men and the estrogen levels in the women can decrease as a result of the increase in the prolactin levels which leads to the sexual dysfunction. It has been observed through a number of studies that the prolactin levels increase by approximately 10 fold with the consumption of the older antipsychotics and this increase occur in the 1st week of treatment and these levels tend to remain high as long as the medication is continuously taken by the patient. Once the medication is stopped it takes about 2-3 weeks for the prolactin levels to return to normality (Hummer and Huber, 2004).

A relation has been found between the atypical antipsychotics i.e. risperidone and amisulpride and the increase in the levels of prolactin (Halbreich and Kahn, 2003). Females who take risperidone can have hyperprolactinemia as high as 88% in comparison to the people who take typicals and have hyperprolactinemia of 47% (Kinon et al., 2003). In the adolescents who were being treated for the childhood-onset schizophreniait was noted that in approximately 70% of the patientsthe prolactin levels went beyond the upper limit of the normal range after only six weeks of olanzapine treatment (Wudarsky et al., 1999).

People who suffer from SMI and take the antipsychotic medication have been noted to have a lot of clinical effectsof hyperprolactineamia. In case of women the side effects include amenorrhea, anovulation and troubled menstrual cycle. Galactorea (milk leakage from breasts), sexual dysfunction and gynecomastia (swollen and painful breasts) are experienced by women as well as men (Dickson and Glazer, 1999, Halbreich and Kahn, 2003). Some contradictory evidence is present regarding the reduced estrogen level because of the increase in the prolactin levels and its link with the increased risk of osteoporosis (Halbreich and Palter 1996) and breast cancer (Halbreich et al., 1996)

Neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is not a very common but quite dangerous side effect of almost all of the antipsychotic drugs and any other medication which blocks the dopamine D2 receptors present in brain. The reported mortality and incidence rates associated with the usage of typical drugs are about 0.2-1% (Doran, 2003; Taylor et al., 2005).Some cases have been reported in which the occurrence of NMS has been noted due to the usage of atypical however, these cases are not as common as they are in case of the older drugs. It is mostly when the drugs being taken by the people lie in the therapeutic range that NMS takes place. However, it has been seen through studies that the chances of people experiencing NMS increases in cases when the drug is taken in higher doses or when the concentration of drug is changed and increased suddenly (Taylor et al., 2005).