Improving physical health monitoring in psychiatry – change we need?

Gonzalez et al ¹ highlight the very important issue of routine blood testing of patients on antipsychotics, which currently is under-monitored in a psychiatric setting, particularly so in out-patients. However, the audit was conducted between 2004 and 2005, and it might not represent the current practice in UK. But physical health monitoring of patients with mental health problems still remains unsatisfactory. Some studies in 1986 and 2004 reported recording of physical examination carried out on admission by psychiatric trainees to be ‘uniformly poor’ to ‘variable’. ² The age-adjusted annual death rates from all causes among individuals with a psychiatric diagnosis is two to four times higher than in the general population. ³ This makes it even more pertinent for us to take extra measures in order to provide the best care for our patients.

In 2009, we completed an audit with colleagues at North Derbyshire Mental Health Services NHS Trust. The results illustrated that physical examination on admission to an in-patient unit increased from 67 to 83% by the end of the audit cycle. The reasons for not examining patients varied from ‘transferred from medical ward’ to ‘team to review tomorrow’. We encouraged the consultant-led teams to take more responsibility in ensuring that a complete physical examination (including investigations such as baseline bloods and electrocardiograms) is done for every patient admitted to the unit, and also recommended quick and easy access to physical health equipment, especially out of hours.

While I appreciate the emphasis of the Royal College of Psychiatrists on increasing the awareness of physical illnesses in our client group and the importance of their detection, I believe actions speak louder than words. Our underperformance in this area is due to problems at multiple levels. Training in psychiatry has become completely detached from medicine. We need to increase psychiatric trainees' exposure to medicine by incorporating physical examination in the MRCPsych curriculum nationally and possibly offering a compulsory rotation in medicine during core training. We also need to change the ethos within psychiatric teams (in-patient and community based) by encouraging psychiatric nurses to also improve their medical skills.

It can be quite tricky in out-patients to address physical health problems while also managing mental health issues. Like other services, why can't we have a dedicated nurse at the out-patient clinic who records blood pressure, measures height, weight, hip and waist circumference, and does all the routine blood tests for every patient, before they go in to see the doctor?