Introduction
The global burden of disease due to mental disorders continues to rise, especially in low- and middle-income countries (LMIC). In addition to causing a large proportion of morbidity, mental disorders – especially severe mental disorders (SMD) – are linked with poorer health outcomes and increased mortality. SMD are defined as a group of conditions that include moderate to severe depression, bipolar disorder, and schizophrenia and other psychotic disorders. People with SMD have a two to three times higher average mortality compared to the general population, which translates to a 10–20 year reduction in life expectancy. While people with SMD do have higher rates of death due to unnatural causes (accidents, homicide, or suicide) than the general population, the majority of deaths amongst people with SMD are attributable to physical health conditions, both non-communicable and communicable. Furthermore, people with SMD are more likely to engage in lifestyle behaviours that constitute risk factors for non-communicable diseases (NCDs) such as tobacco consumption, physical inactivity and consuming unhealthy diets.
Most studies reporting the excess mortality in people with SMD are from high income countries. The situation may be much worse in LMIC where the resources are inadequate, the institutions are not well managed and access to quality mental health care and physical care is limited.
Equitable access to comprehensive health services remains out of reach for the majority of people with SMD. Unfortunately, people with SMD often lack access to health services or receive poor quality care, including promotion and prevention, screening, and treatment. It is crucial to address the disparities in health care access and provision for people with SMD. Following the principle of non-discrimination and universal health coverage as elaborated in target 3.4 of the United Nations Sustainable Development Goals (“By 2030, reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote of mental health and well-being”), people with SMD should be offered at least the same level of treatment for physical health conditions and their risk factors as the general population.
The WHO Comprehensive Mental Health Action Plan (2013–2020) outlines a vision where people living with mental disorders are able to exercise the full range of human rights and to access high quality, culturally-appropriate health and social care in a timely way to promote recovery. In service of this vision and as part of WHO’s Mental Health Gap Action Programme (mhGAP), these Guidelines on the management of physical health conditions in adults with severe mental disorders will provide up-to-date, evidence-based recommendations to support the scale-up of care for physical health conditions and their risk factors affecting people living with SMD globally.
Accordingly, the objective of these guidelines is:
To improve the management of physical health conditions in adults with SMD and support the reduction of individual health behaviours constituting risk factors for these illnesses, with the aim of decreasing morbidity and premature mortality amongst people with SMD.
Existing WHO guidelines for the general population are relevant to the physical health conditions that increase the morbidity and mortality for people with SMD. For example, the Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-Resource Settings Geneva, WHO, 2010 provides guidelines and recommendations for tobacco cessation, weight management, cardiovascular disease prevention including diabetes management and prevention of complications, treatment and prevention of chronic respiratory diseases in the general population. Other WHO guidelines for infectious disease are also relevant such as the Consolidated guidelines on HIV prevention, diagnosis, treatment, and care for key populations. WHO, 2016 update and Guidelines for treatment of drug-susceptible tuberculosis and patient care, 2017 update. WHO, 2017.
Guideline Development Methods
The process of development of these guidelines followed the WHO handbook for guideline development and involved: (1) recruitment of the Guideline Development Group (GDG); (2) declaration of interest by GDG members and peer reviewers; (3) scoping review to formulate questions and select outcomes (4) identification, appraisal and synthesis of available evidence; (5) formulation of recommendations with inputs from a wide range of stakeholders; and (6) preparation of documents and plans for dissemination.
The GDG, an international group of experts, provided input into the scope of the guideline and assisted the steering group in developing the key questions. A total of one background question and seven PICO (Population, Intervention, Comparison, and Outcome) questions were developed.
To address the PICO questions, a series of searches for systematic reviews was conducted and GRADE evidence profiles prepared. During a meeting at WHO headquarters in Geneva, 9 – 10 May 2018, the GDG discussed the evidence, sought clarifications, and interpreted the findings in order to develop recommendations. The GDG considered the relevance of the recommendations for people with SMD including the balance of benefit and harm of each intervention; values and preferences of people with SMD; costs and resource use; and other relevant practical issues for providers in LMIC.
When making a strong recommendation, the GDG was confident that the desirable effects of the intervention outweigh any undesirable effects. When the GDG was uncertain about the balance between the desirable and undesirable effects, the GDG issued a conditional recommendation. Strong recommendations imply that most individuals would want the intervention and should receive it while conditional recommendations imply that different choices may be appropriate for individual people and they may require assistance at arriving at management decisions. The GDG members reached an unanimous agreement on all the recommendations and ratings.
Summary of Recommendations
Tobacco cessation
In the context of tobacco cessation programmes:
Recommendation 1
In people with severe mental disorders, combined pharmacological and non-pharmacological interventions may be considered in accordance with the WHO training package (Strengthening health systems for treating tobacco dependence in primary care. Building capacity for tobacco control: training package). (Strength of recommendation: Conditional; quality of evidence: Very low).
Recommendation 2
In people with severe mental disorders, a directive and supportive behavioural intervention programme may be considered and should be tailored to the needs of the population. (Strength of recommendation: Conditional; quality of evidence: Very low).
Recommendation 3
In people with severe mental disorders, varenicline, bupropion and nicotine replacement therapy may be considered for tobacco cessation. (Strength of recommendation: Conditional; quality of evidence: Very low).
Best Practice Statement
Prescribers should take into account potential interactions between buproprion and varenicline with psychotropic medications as well as possible contra-indications.
Weight management
Recommendation 1
Behavioural lifestyle (healthy diet, physical activity) interventions should be considered in all people with severe mental disorders who are overweight or obese or at risk of becoming overweight or obese in accordance with WHO’s Package of Essential Noncommunicable Disease Interventions (WHO PEN) for primary care in low-resource settings (2010). These interventions should be appropriate and tailored to the needs of this population. (Strength of recommendation: Strong; Quality of evidence: Very low).
Recommendation 2
For people with severe mental disorders who are overweight or obese, and where lifestyle interventions and/or switching psychotropic medication do not appear successful, adjunctive metformin may be considered. This should be considered under close clinical supervision and monitoring.
(Strength of recommendation: Conditional; Quality of evidence: Low).
Best Practice Statements
For people with severe mental disorders who are overweight or obese or at risk of becoming overweight or obese, initiating a psychotropic medication with lower propensity for weight gain should be considered, taking into account clinical benefits and potential adverse effects.
For people with severe mental disorders who are overweight or obese, switching to a psychotropic medication with a lower propensity for weight gain may be considered, taking into account clinical benefits and potential adverse effects.
Substance use disorders
Recommendation 1
For people with severe mental disorders and comorbid substance use disorders (drug and/or alcohol), interventions should be considered in accordance with the WHO mhGAP guidelines.
(Strength of recommendation: Conditional; Quality of the evidence: Low).
Recommendation 2
Non-pharmacological interventions (e.g. motivational interviewing) may be considered and tailored to the needs of people with severe mental disorders and substance use disorders
(Strength of recommendation: Conditional; Quality of the evidence: Very low).
Best Practice Statement
Prescribers should take into account the potential for drug-drug interactions between medicines used for treatment of substance use disorders and severe mental disorders.
Cardiovascular disease and cardiovascular risk
Recommendation 1
For people with severe mental disorders and pre-existing cardiovascular disease, or with cardiovascular risk factors (e.g. high blood pressure or high cholesterol), pharmacological and non-pharmacological interventions may be considered in accordance with the WHO Package of Essential Noncommunicable Disease Interventions (WHO PEN) for primary care in low-resource settings (2010) for lowering cardiovascular risk and management of cardiovascular disease.
(Strength of recommendation: Strong; Quality of evidence: High to moderate for different interventions).
Recommendation 2
For people with severe mental disorders and pre-existing cardiovascular disease, the following is recommended:
- a)
Behavioural lifestyle (healthy diet, physical activity) interventions may be considered. These interventions should be appropriate and tailored to the needs of this population. (Strength of recommendation: Conditional; Quality of evidence: Very low).
- b)
Collaborative care i.e. a multi-professional approach to patient care with a structured management plan, scheduled patient follow-up, and enhanced inter-professional communication, may be considered for cardiovascular disease management. (Strength of recommendation: Conditional; Quality of evidence: Very low).
Recommendation 3
For people with severe mental disorders and cardiovascular risk factors, behavioural lifestyle (healthy diet, physical activity) interventions may be considered. These interventions should be appropriate and tailored to the needs of this population. (Strength of recommendation: Conditional; Quality of evidence: Very low).
Best Practice Statements
For people with severe mental disorders and pre-existing cardiovascular disease:
Initiating a psychotropic medication with lower propensity for cardiovascular risk is a strategy that should be considered, taking into account clinical benefits and potential adverse effects.
Switching to a psychotropic medication with lower propensity for cardiovascular risk may be considered, taking into account clinical benefits and potential adverse effects.
For people with severe mental disorders and pre-existing cardiovascular disease or cardiovascular risk factors:
Prescribers should be aware of potential interactions between prescribed medicines for cardiovascular disease and prescribed psychotropic medications, which may affect cardiovascular risk. Cardiovascular outcomes and risk factors should be monitored and dose adjustment of cardiovascular medicines may be required.
Diabetes mellitus
Recommendation 1
For people with severe mental disorders and diabetes mellitus, interventions in accordance with the WHO Package of Essential Non-communicable (PEN) Disease Interventions for Primary Health Care in Low-Resource Settings should be considered for diabetes management.
(Strength of recommendation: Strong; Quality of evidence: Low).
Recommendation 2
Behavioural lifestyle interventions should be considered for all people with severe mental disorders and diabetes mellitus. These interventions should be appropriate and tailored to the needs of this population.
(Strength of recommendation: Strong; Quality of evidence: Very low).
Recommendation 3
In people with depression and comorbid diabetes mellitus, cognitive behaviour therapy for treatment of depression may be considered. (Strength of recommendation: Conditional; Quality of evidence: Very low).
Best Practice Statements
For people with severe mental disorders and diabetes mellitus:
Initiating an anti-psychotic medication with lower propensity for producing hyperglycaemia should be considered, taking into account clinical benefits and potential adverse effects.
Switching to an anti-psychotic medication with lower propensity for producing hyperglycaemia is a strategy that may be considered, taking into account clinical benefits and potential adverse effects.
Prescribers should be aware of potential interactions between prescribed medicines for diabetes mellitus and prescribed psychotropic medicines, which may affect glycaemic control.
Glycaemic control should be monitored and dose adjustment of medicines may be required.
HIV/AIDS
Recommendation 1
For people with severe mental disorders and HIV/AIDS, antiretroviral drugs should be considered in accordance with the WHO Updated recommendations on first-line and second-line antiretroviral regimens. (Strength of the recommendation: Strong; Quality of the evidence: Moderate)
Recommendation 2
Additional psychosocial support for treatment adherence should be provided to people with HIV and severe mental disorders in accordance with the WHO consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. (Strength of the recommendation: Strong; Quality of the evidence: Moderate)
Best Practice Statement
For people with severe mental disorders and HIV/AIDS, prescribers should take into account the potential for drug-drug interactions between antiretroviral drugs and psychotropic medicines.
Other infectious diseases (Tuberculosis, Hepatitis B/C)
Recommendation 1
For people with severe mental disorders and TB, pharmacological management should be considered in accordance with the WHO guidelines for the treatment of drug-susceptible tuberculosis and patient care and the WHO treatment guidelines for drug-resistant tuberculosis.
(Strength of the recommendation: Strong; Quality of the evidence: Low).
Recommendation 2
For people with severe mental disorders and TB, non-pharmacological (social, psychological) management should be considered in accordance with the WHO guidelines for the treatment of drug-susceptible tuberculosis and patient care and the WHO treatment guidelines for drug-resistant tuberculosis.
(Strength of the recommendation: Strong; Quality of the evidence: Low).
Recommendation 3
For people with severe mental disorders and hepatitis B, treatment should be considered in accordance with the WHO guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection.
(Strength of the recommendation: Strong; Quality of the evidence: Low).
Recommendation 4
For people with severe mental disorders and hepatitis C, treatment should be considered in accordance with the WHO guidelines for the screening care and treatment of persons with chronic hepatitis C infection.
(Strength of the recommendation: Strong; Quality of the evidence: Low).
Best Practice Statement
For people with severe mental disorders and TB and/or Hepatitis B/, prescribers should take into account the potential for drug-drug interactions between TB medicines, medicines for hepatitis B and C with psychotropic medicines.
