Improving management of schizophrenia and severe mental illnesses in general practice
Submitting InstitutionUniversity College London
Unit of AssessmentPublic Health, Health Services and Primary Care
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
Our research has led to major changes in the management of people with
severe mental illness (SMI) in general practice. Our findings that people
with schizophrenia are at greater risk of cardiovascular diseases informed
NICE guidance in the UK and international guidelines. The Department of
Health's strategy on Mental Health was influenced by our work on the
interface between physical and mental health. Recommendations in the NICE
guidance have now been taken up by the NHS Quality Outcomes Framework
(QoF) in England and Scotland. General practitioners are specifically
required to monitor BMI (Body Mass Index), blood pressure, and glucose and
serum lipids levels in all registered patients with SMI.
UCL has led internationally on research on the care offered to people
with severe mental illnesses (i.e. schizophrenia and bipolar illnesses) in
general practice. Little was known about the primary care management of
this population prior to us initiating research work on this topic in the
1990s. Professor Irwin Nazareth and colleagues (Department of Primary Care
& Population Health) found that although people with schizophrenia
were frequent attenders, their management was unstructured with little
attention given to their physical health, compared to the care offered to
people with other chronic diseases. We found that one in three people with
schizophrenia were exclusively managed by their general practitioners with
no contact with a psychiatrist. Moreover, most people with schizophrenia
were willing to have their physical and psychological health needs managed
by their general practitioners . Early evidence from an
exploratory controlled evaluation suggested beneficial trends from
structured health care delivered in primary care . Since then,
we have led on a programme of MRC-funded research to identify and reduce
cardiovascular disease (CVD) in NHS patients with severe mental disorders.
Our research demonstrated high relative rates of cardiovascular mortality
in people with severe mental illnesses when compared to people without
these disorders. There was a threefold risk of cardiovascular deaths in
people with schizophrenia between the age of 18-50, and twice the risk in
people aged 50-75 .
Further research on this topic found an excess rate of abnormal lipids
(especially low levels of HDL), smoking and diabetes in people with severe
mental illnesses in general practice compared with healthy controls .
The significantly lower level of HDL in people with schizophrenia was a
novel finding and had never been previously reported. This work also
revealed that poor diets and low levels of physical activity were common
in this group of people and were worthy targets for interventions .
Our research additionally demonstrated that people with mental disorders
were willing to participate in CVD screening in primary care 
and the importance of this finding was highlighted in a Lancet editorial
(vol 367; 1469-71).
We then published a systematic review regarding lipids, diabetes and
hypertension levels as well as qualitative and quantitative findings to
facilitate the design of a new nurse-led intervention for cardiovascular
screening in SMI . This led to a successful phase II trial of
the intervention  subsequently highlighted as a promising
development for clinical services in a Lancet editorial in 2011 (Lancet
Our ongoing research, funded by the Department of Health and NIHR,
explores inequalities in cancer and CVD screening in people with mental
illnesses and intellectual disabilities. We are also investigating the
contribution of antipsychotic medication to cardiovascular risk in these
people. Furthermore, we are developing and testing CVD risk prediction
models for people with SMI, and refining and evaluating a an intervention
delivered over a period of one year within a cluster trial based in
primary care settings.
References to the research
 Nazareth I, King M, Davies S. Care of schizophrenia in general
practice: the general practitioner and the patient. British Journal of
General Practice. 1995 July; 45(396):343-347. http://europepmc.org/articles/PMC1239294
 Osborn DPJ, King M, Nazareth I. Participation in screening for
cardiovascular risk by people with schizophrenia or similar mental
illnesses - a cross sectional study in general practice. BMJ. 2003 May
 Osborn DPJ, Nazareth I, King M. Risk for coronary heart disease in
people with severe mental illness: a cross sectional comparative study in
primary care. British Journal of Psychiatry. 2006 Mar;188:271-7. http://dx.doi.org/10.1192/bjp.bp.104.008060
 Osborn DPJ, Levy G, Nazareth I, Petersen I, Islam A, King M. Relative
risk of cardiovascular and cancer mortality in people with severe mental
illness from the United Kingdom's general practice research database.
Archives of General Psychiatry. 2007 Feb;64(2):242-9. http://dx.doi.org/10.1001/archpsyc.64.2.242
 Osborn DPJ, King MB, Nazareth I. Physical activity, dietary habits
and coronary heart disease risk factor knowledge amongst people with
severe mental illness. A cross sectional comparative study in primary
care. Social Psychiatry and Psychiatric Epidemiology. 2007
 Osborn DPJ, Wright CA, Levy G, King MB, Deo R, Nazareth I. Relative
risk of diabetes, dyslipidaemia, hypertension and the metabolic syndrome
in people with severe mental illnesses. Systematic review and
metaanalysis. BMC Psychiatry. 2008 Sep 25;8:84. http://dx.doi.org/10.1186/1471-244X-8-84
 Osborn DPJ, Nazareth I, Wright CA, King MB. Impact of a nurse-led
intervention to improve screening for cardiovascular risk factors in
people with severe mental illnesses. Phase-two cluster randomised
feasibility trial of community mental health teams. BMC Health Services
Research. 2010 Mar 10;10:61. http://dx.doi.org/10.1186/1472-6963-10-61
MRC Brain Sciences Initiative. Primary prevention of cardiovascular
diseases with Severe Mental Illnesses: development and feasibility of
complex intervention in primary and secondary care. £228,000
NIHR Programme Grant - Prediction and management of cardiovascular risk
for people with severe mental illnesses. A research programme and trial in
primary care. PRIMROSE. £2.03 million.
Details of the impact
Impact on NICE Guidelines
Our evidence regarding CVD was used by NICE in the 2009 update of their
schizophrenia guideline (CG 082). This recommends that annual physical
review of these patients should focus on cardiovascular risk factors
including blood pressure, cholesterol, HDL cholesterol, smoking and
diabetes. The guideline cites five of our papers as the reason for
focussing on CVD risk factors in annual reviews for people with
schizophrenia in national mental health policy. Nazareth was on the expert
advisory panel of the NICE Schizophrenia guideline group [a].
Impact on European Guidelines
Our work was cited as the research evidence justifying a position
statement by the European Psychiatric Association (EPA), supported by the
European Association for the Study of Diabetes (EASD) and the European
Society of Cardiology (ESC) in 2009. Their statement was designed to
improve the care of patients suffering from severe mental illness. They
cite two of our papers as the rationale for focusing on CVD risk screening
in people with SMI. The statement refers in detail to our systematic
review regarding the relative incidence of CVD risk factors in SMI, as
well as our research demonstrating excess CVD mortality in young people
with SMI [b].
The position statement from the EPA has had further impact both in the UK
and Australia. The EPA position document is referenced as the rationale
for specific algorithms to help mental health professionals to deal with
cardiovascular risk factors in people with SMI [c]. In turn the
Australian guidelines have recently been adapted and endorsed by the Royal
College of General Practitioners, Royal College of Psychiatrists, Royal
College of Nursing, Royal College of Physicians, HQIP, Rethink Mental
Illness and Diabetes UK to provide guidance in line with the SMI QoF (see
below) and NICE guidance, which largely originates from the research done
at UCL [d]. These guidelines have been sent to every GP and
psychiatrist in the UK.
Impact on Psychopharmacology guidance:
The British Association of Psychopharmacologists produces evidence-based
guidelines for international and national prescribing in mental health,
aimed at all psychiatrists and other clinicians who prescribe in mental
health. Their schizophrenia consensus guidelines cite two of our papers
(Osborn, 2006; Osborn 2008) in making their recommendations regarding
prescribing antipsychotics and screening for CVD risk factors for people
with SMI who have been prescribed antipsychotic medications [e].
Impact on Department of Health Policy:
The Department of Health published a new mental health strategy in 2011
titled "No health without mental health". It made a number of
recommendations regarding the interface between physical and mental
health. This included six main objectives, including "that more people
with mental health problems will have good physical health". Osborn was
invited to present our research findings to specific workshops run by the
DH to formulate this strategy [f].
Once published, the policy was developed into a guide for general
practitioners by the Centre for Mental Health, in alliance with seven key
national mental health organisations. These third sector organisations
(outside the NHS) such as RETHINK cite our mortality work as one of the
reasons why general practitioners should focus on CVD screening for people
with mental disorders [g].
Impact on the Quality Outcomes Framework:
In 2011, our influence on NICE guidelines led to changes in the national
GP contract, through the Quality Outcomes Framework (QoF) for people with
severe mental illnesses [h]. GPs are now remunerated for ensuring
that people with SMI have had specific cardiovascular risk factors
measured within the last 15 months. The QoF documents explicitly state
that their recommendations are in line with the NICE schizophrenia
guidelines regarding CVD screening and hence include screening for BMI,
cholesterol, blood pressure and diabetes screening in the outcomes
framework for SMI (see above). Our research has thus directly impacted on
the day to day care provided for people with severe mental illnesses in
general practices across England through NICE and into QoF.
Impact elsewhere in the UK
Further, the two most cited of our research papers on this topic were
used by the Scottish QoF in 2008, recommending that Scottish GPs included
these cardiovascular measurements in their annual assessments [i].
These important changes within the NHS are thus leading to a reduction in
the inequalities of care that occur in people with schizophrenia and
severe mental illnesses.
Sources to corroborate the impact
[a] National Institute for Health and Clinical Excellence (2009)
Schizophrenia: core interventions in the treatment and management of
schizophrenia in adults in primary and secondary care. NICE clinical
guideline 82. http://www.nice.org.uk/CG082.
See pages 7, 15, 21, 22, 26.
[b] De Hert M, Dekker JM, Wood D, Kahl KG, Holt RI, Möller HJ.
Cardiovascular disease and diabetes in people with severe mental illness
position statement from the European Psychiatric Association (EPA),
supported by the European Association for the Study of Diabetes (EASD) and
the European Society of Cardiology (ESC). Eur Psychiatry. 2009
See page 413.
[c] Australian guidelines: Curtis J, Newall H, Samaras K. HETI 2011.
Don't just screen. http://www.heti.nsw.gov.au/cmalgorithm
See reference to [b] on page 2.
[d] Guidelines from the Royal Colleges:
[e] Barnes TR; Schizophrenia Consensus Group of British Association for
Psychopharmacology. Evidence-based guidelines for the pharmacological
treatment of schizophrenia: recommendations from the British Association
for Psychopharmacology. J Psychopharmacol. 2011 May;25(5):567-620. http://dx.doi.org/10.1177/0269881110391123.
See references to  and  on page 581.
[f] Department of Health (2011). No Health without Mental Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123766"
[g] The Centre for Mental Health. No health without mental health. A
guide for general practitioners. http://www.centreformentalhealth.org.uk/pdfs/Web_Mental%20Health%20Strategic%20Partnership%20GPs.pdf"
See reference to  on page 3.
[h] NHS Employers. (2011) The Quality and Outcomes Framework. 2011-12 http://www.nhsemployers.org/SiteCollectionDocuments/QOFguidanceGMScontract_2011_12_FL%2013042011.pdf"
Based on [a]
[i] The Scottish Government (2008). Improving the physical health of
people experiencing Mental illness in Scotland. http://www.scotland.gov.uk/Publications/2008/11/28152218/0
References to  and  on page 34