The physical co-morbidity and poor health behaviour of South-Verona patients with functional psychoses. A prevalence study and the design of a protocol of a health promotion randomised controlled study - PHYSICO

BACKGROUND Substantial evidence has been produced of an excess mortality and of a higher prevalence of physical comorbidity in mental patients as compared to the general population. (Harris et al., 1998; Amaddeo et al., 2007, Leucht et al., 2007a, Fleischhacker et al., 2008). These findings have been related to a number of risk factors, including patient’s scarce concern with personal health and well-being, medication side-effects, institutionalisation in possibly unsupportive and unhealthy environments, scarce compliance and stigma tending to disaffect health professionals, discriminating or inadequate medical care, smoking, alcohol, street drugs (Marder et al., 2004; Chafetz et al., 2005; Nasrallah et al., 2006; Sartorius, 2007; Vreeland, 2007; Likouras et al., 2008). Unfortunately, while scientific research has also addressed the assessment of strategies to increase knowledge about health, to change unhealthy behaviours and to promote health, the number of clinical trials and intervention studies is still scanty and their scientific strength is relatively modest. To our knowledge, no Italian study of this kind has been published to date and also the majority of international studies on co-morbidity were performed retrospectively on clinical registers rather than on subjects recruited ad hoc and directly investigated by the research staff. The underlying rationale of this of this PhD research project was to fill such potential gap by increasing the knowledge on physical co-morbidity, risk factors and poor health behaviour and promoting preventive actions in both the patients and the mental health staff of an Italian Psychiatric Service. OBJECTIVES This PhD dissertation aimed at reviewing the literature, giving an account of the preliminary selection of assessment instruments and describing the PHYSICO study protocol; it consists of two phases: to study the prevalence of physical co-morbidity and poor health behaviour in patients with severe mental disorders in contact with the South-Verona CPS (Phase 1); a randomised controlled trial on the efficacy health promotion strategies related to dietary habits and physical exercise within a controlled study (Phase 2). The dissertation specifically reports the implementation and the results of Phase 1 as seen from the perspective of a researcher directly involved in a clinical context. The general objective of the Phase 1 was investigating the prevalence of physical comorbidity, risk factors and poor health behaviour (especially related to diet and physical exercise) in people affected by functional psychoses in contact with the South-Verona Community Mental Health Service (CMHS). Specific objectives were: i. to investigate fruit and vegetable daily consumption; ii. to investigate physical exercise habits and iii. to compare the prevalence in these subjects with that of the general population. METHODS The review of the literature covers the period 1995-2010 and is divided into three sections covering mortality, physical co-morbidity and unhealthy lifestyles and risk factors. Developing the assessment package required a review of the instruments of common use to select those appropriate to the study rationale and to the areas of investigation, including: socio-demographic and clinical characteristics of subjects, use of services, health related quality of life, satisfaction, medication, health status and health behaviour. The design of the study protocol took also advantage of consulting national and international experts and implied the submission to the local Ethical Committee. Phase 1 had a cross-sectional design and included all patients with an ICD-10 diagnosis of affective and non-affective functional psychotic disorder in contact with the South-Verona CMHC. The assessment procedure consisted of a physical health examination, laboratory tests and an interview on socio-demographic data, physical health status, risk factors, lifestyles and quality of life. Two current methods were used to assess the cardiovascular risk in the sample: the Italian Cuore risk index (Ferrario et al., 2005, www.cuore.iss.it) and the diagnosis of the Metabolic Syndrome (MS) according to the ATP III definition (Grundy et al., 2004). All the required provisions to protect the confidentiality of data were applied. Multivariate statistical analyses were performed in order to describe the observed sample, to compare it with the general population, to explore the association between physical health status and lifestyle. RESULTS The Physico study has successfully completed Phase 1 thus confirming the feasibility of this type of research. The project has also witnessed an excellent cooperation of both the personnel and the patients of the South-Verona CPS: they appreciated assuming greater responsibility for physical, besides mental, health. One hundred and ninety-three subjects were included (i.e. provided written informed consent) and completed the assessment. Results showed that the diseases of the circulatory system, including hypertension and coronary heart disease took the lions' share. Nervous systems diseases including severe diseases like stroke or Alzheimer and less severe ailments like migraine followed. Metabolic diseases including diabetes and thyroid dysfunctions came as third, together with diseases of the musculoskeletal system/connective tissue. Almost half of our subjects for whom the Cuore index was calculated were at risk for cardiovascular disease, especially the majority of males of the age group 50-69yrs, among whom seven subjects were at high risk and where referred to the cardiologist. The MS occurred in less than one third of subjects in the sample, mainly males aged 50-69 yrs. Lifestyles (dietary habits, physical activity, smoking habits and alcohol consumption) were recorded and analysed according to the methodology proposed by the PASSI study report (Progressi delle Aziende Sanitarie per la Salute in Italia - 2008). The comparison with the data of the Veneto population showed that the patients in the PHYSICO sample present a higher percentage of overweight/obesity and of smoking habits and a lower percentage of adherence to WHO recommendations for diet and physical activity. A lower percentage of patients in our sample, as compared to the PASSI population, declared to consume alcohol, but a higher percentage resulted doing it according to the pattern defined as at risk. CONCLUSION To date, only little attention has been granted to physical comorbidity in mental patients; including the public programs like the 2006-2008 National Health Plan (Ministero della Salute, 2006), in which no mention is made of this topic. The underlying rationale of the whole PHYSICO Study is one of drawing from knowledge and best practice already available to provide a simple and easy-to-apply tool to support the staff of both community and institute-based mental health services. It offers physical health monitoring means and health-promotion interventions for mental patients, especially the severely ill and can be easily disseminated to mental health facilities and programs. PHYSICO presents some limits and has to face the fact that professional of different specialties have long been accustomed to work separately. However, PHYSICO Phase 1 has already shown that it is possible to improve collaboration and has collected good quality data on health parameters and health-related lifestyles. We look forward to replicating the study in multiple centres with increased confidence and to move forward to Phase 2.