Physical Health of People with Mental Illness: A Snapshot of Consumer Engagement in the Provision of Care in Primary Care

Abstract

Primary care is crucial to the health of people with mental illness. However, there is limited information on their reported engagement in this setting. This study surveyed 100 people with mental illness who had a general practitioner or a general practitioner and a case manager from a tertiary mental health service to determine their engagement level with their GP and what interventions they received to manage their health. Forty-four per cent had their psychotropic medications primarily prescribed by their GP, and 58% reported visiting their GP for physical health problems. Ninety-four point nine percent of participants aged 50 years and over had not received government age-recommended preventive health checks. Only 62% of participants reported being screened by their GP for psychotropic side effects. Primary care plays a crucial role in providing physical and mental health care, but service users report gaps in service. The findings suggest a need to support primary care professionals further to coordinate care across primary and secondary care settings.

Background

Mental and substance use disorders are responsible for 12% of the total disease burden in Australia, the fourth-highest group of diseases behind cancer (18%), cardiovascular diseases (14%) and musculoskeletal conditions (13%) (AIHW, 2019a). Globally, the disease burden due to mental illness is much more significant than reported because mental illness also contributes to physical illness (Cassioli et al., 2020).

People with mental illness are more likely than the general population to develop significant physical health conditions, including metabolic diseases, cardiovascular disease, cancer and respiratory diseases (Cassioli et al., 2020; Rotella et al., 2020). A report by the Australian Bureau of Statistics (ABS) for 2020–2022 showed that 8.4% of adults with a mental illness also reported having one or more physical illnesses (ABS, 2022). People with mental illness have excessive morbidity and a higher standardised mortality rate compared to the general population (de Mooij et al., 2019). Whilst some of this additional mortality is directly linked to mental illness (death through suicide and accidental death), there is also a substantial increase in mortality from physical health conditions (Schneider et al., 2019).

The increased morbidity from metabolic and cardiovascular diseases can partially be attributed to lifestyle choices, the side effects of psychotropic medications (Rotella et al., 2020; Smith et al., 2020), delayed treatment for these physical conditions and lack of timely preventive health checks (Jang et al., 2015; Lord et al., 2010). Systematic reviews of literature looking at receipt of preventive health care and medical screening for people with mental illness concluded that over 50% do not receive timely health checks (Lord et al., 2010; Mitchell et al., 2014). In Lord’s study, over half of the studies reported suboptimal preventive care was offered to people with mental illness for osteoporosis, breast cancer and cholesterol monitoring (Lord et al., 2010). Both studies recommended early preventive health checks and regular monitoring of physical health status (Lord et al., 2010; Mitchell et al., 2014). Recent studies have also identified that physical healthcare of people living with mental illness is far from optimal and have recommended that different innovative strategies that are person-centred need to be adopted for changes to occur (Tabvuma et al., 2022; Young et al., 2017). The review by Tabvuma et al. (2022) advocated for co-design approaches and collaborative care planning with consumers instead of solely relying on consumers to adhere to the recommended physical health screenings (Tabvuma et al., 2022). Moreover, to achieve these outcomes, the review suggested there needs to be a trustworthy, flexible, and knowledgeable healthcare professional to engage consumers and offer support (Tabvuma et al., 2022).

About 71% of mental health services in Australia are provided in the community (AIHW, 2019b). Primary care, particularly general practice, plays a crucial role in providing care to people with mental illness. Most of the services for people living with a mental illness are funded by Medicare - an Australian government-funded universal healthcare system that provides medical services to Australians (AIHW, 2019b). In Australia, a 2017–18 analysis of mental health services showed that general practitioners (GPs) provided a significant proportion of mental health services compared to other clinicians (three in 10 (31.1%) of all Medicare-subsidised mental health-specific services (AIHW, 2019b). For example, in 2017–2018, about 3.9 million (92.7%) of 4.2 million people who received a mental health-related prescription were prescribed by a GP (AIHW, 2019b). Collaboration between general practice and other primary care services providing care to people with mental illnesses is crucial to reducing the extra load of care for GPs and improving the physical health of people with mental illnesses (Jang et al., 2015).

Despite the increasing emphasis on ongoing and coordinated efforts by all stakeholders (general practice, case managers and people with mental illness) to ensure better care coordination for people with mental illness, there are still disparities in physical health care. An audit of the general practitioner involvement in Australian mental health services in 2015 showed that preventive health checks such as metabolic screening were not always completed even for individuals with a GP identified in their hospital medical records (Jang et al., 2015). In a recent literature review conducted by Fogarty et al. (2021) concerning the physical health of consumers with common mental health disorders in European primary care, only 19 studies were identified. This limited number of studies underscores the scarcity of research in this area and the growing significance of physical health research among individuals with mental health issues.

Notwithstanding the growing evidence showing a high prevalence of physical health problems and poor health outcomes for people with a mental illness and the disparities in care provision, there is limited empirical work seeking the opinion of people with mental illness regarding their care in primary care and what their engagement with primary care services means to them. de Bienassis et al. (2022) emphasise that consumers play a crucial role in shaping the standards by which mental healthcare quality is assessed. Consumers should have the authority to define what they consider desirable or undesirable in healthcare services and have the freedom to report on aspects such as accessibility, convenience, comfort, and timeliness of care from their lens. Furthermore, consumers are the ones best positioned to assess the extent to which they are heard, informed, engaged in decision-making, and respected. As a result, the assessment of consumer experiences, satisfaction, and outcomes, is an indispensable component of any quality improvement initiative in healthcare.

Our study provides a snapshot of participants’ reported engagement with their GP over a 12-month period.

Aim

This study assessed participants experiences with primary care and their perception of the care they receive in primary care. We hypothesised that the levels of physical health checks offered to participants who consulted their GP for their mental illness but also had a case manager through the tertiary mental health service would be higher than for participants who only consulted their GP. In the context of this study, a case manager refers to a mental health professional, other than a general practitioner who coordinated participants’ health services in the primary care.

Materials and methods

Design, participants and study setting

Participants recruited for this cross-sectional study were part of a larger cohort of participants enrolled in a study that examined the physical health outcomes of people with mental illness.

All participants in the main study were followed for 1 year, and data for this study were collected at the end of the 12 months (December 2020). All 170 participants were invited to participate in the survey, and 100 responded.

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement was used to guide the framework of this paper (Von Elm et al., 2020). The design incorporates background literature and rationale for the study, methods, presentation and discussion of the results (see Supplementary File 1).

Ethical considerations and data collection

Ethics approval was obtained from the University and the Health Service (ethics number HR61/2014) and (SMSH-14/12). For this study, participants initially gave written consent as part of the main study, which also included this interview. Prior to commencing the structured interview, their consent was reconfirmed verbally. Consenting participants were surveyed via telephone using structured questions developed for the purposes of the study. Data obtained during the phone survey was directly entered into Qualtrics^© online platform (Qualtrics, 2020).

Data collection tools

The survey questions were adapted from existing literature on Australian mandatory physical health checks (Department of Health, 2017), typical side effects of antipsychotic medication (Goldberg & Stahl, 2021) and general satisfaction questions with primary care (AIHW, 2021). Satisfaction questions had a scale of 1 = strongly disagree to 4 = strongly agree, and physical health checks required binary responses (yes = 1 and no = 0). Even though the questions were derived from prior studies, they demonstrated moderate to high reliability. Satisfaction with the practitioner (Cronbach’s α = 0.728); medication side-effects related to physical health checks (Kuder-Richardson (KR20) formula α = 0.851); other physical health checks (KR20, α = 0.476); age-specific screening tests for participants 50 years and older (KR20 α = 0.686).

Details of the questions asked, and the reliability rating are in Supplementary File 2.

Data analysis

The data acquired through the Qualtrics^© online platform (Qualtrics, 2020) was downloaded in Excel format and subsequently uploaded into SPSS for analysis. SPSS Statistics, Version 26 (IBM Corp, 2016) was used to summarise the participants’ traits and clinical characteristics.

Demographic variables were explored using frequencies, means, standard deviation and chi-square. An unadjusted analysis was used to check whether variables such as consultation type (physical health or mental health), primary care providers (GP and case manager), age, gender, and BMI influenced physical health checks by a GP. Where differences were demonstrated (at the p < 0.05 level) or if variables were deemed clinically relevant although not significant in the preliminary analysis, they were included in the final regression model. The odds of being screened for medication side effects (through interview, ECG, blood test, BMI, X-ray, etc.) were assessed using logistic regression analysis. Only models produced from adjustment variables have been presented.

Results

Participants profile

Out of 170 participants who had a GP, 100 (58.8%) agreed to complete the survey. Table 1 shows differences in the demographic and clinical variables of participants who consulted their GP for their mental health care and those who had a GP and a case manager from tertiary mental health service. Thirty-four participants were under the care of their GP following discharge from community specialist mental health services, and 66 had a GP and were still being case managed by community mental health services. There were no statistically significant differences between the two groups in all the variables that were assessed. On average, participants who consulted their GP were slightly older (Mean difference = −3.186), had stayed with their GP for longer (Mean difference = −1.143), and had presented to the emergency department (ED) more than once in the 12 months (26 vs. 39.5%). However, across both groups, most participants were satisfied with the care their GP provided (mean satisfaction in both groups was >3 out of 4).

Table 1. Demographic and clinical variables of participants who consulted their GP for mental health care compared to those who consulted their GP and had a case manager.

Characteristics	GP + CM (n = 66)	GP only (n = 34)	p Value
Age (years), mean (SD)	46.17 (12.19)	49.35 (11.27)	0.207
The period has been with their GP (years), mean (SD)	8.14 (6.702)	9.28 (7.08)	0.430
Gender, n (%)
Male	32 (48.5)	13 (38.2)	0.398
Female	34 (51.5)	21 (61.8)
ICD10 classification, n (%)
F00-F09 organic, including symptomatic, mental disorders	0 (0.0)	3 (8.8)	0.104
F10-F19 mental and behavioural disorders due to psychoactive substance	1 (1.5)	1 (2.9)
F20-F29 schizophrenia, schizotypal and delusional disorders	26 (40.0)	11 (32.4)
F30-F39 mood (affective) disorders	22 (33.9)	10 (29.4)
F40-F48 neurotic, stress-related and somatoform disorders	6 (9.2)	1 (2.9)
F50-F59 behavioural syndromes associated with physiological disturbances and physical factors	2 (1.9)	2 (2.9)
F60-F69 disorders of adult personality and behaviour	7 (10.8)	7 (20.6)
F99 mental disorder, not otherwise specified	1 (1.5)	1 (2.9)
BMI-WHO groupings, n (%)
Normal 18.5 − 24.9	14 (21.2)	4 (11.8)	0.429
Overweight to obese 25–>40	49 (74.2)	29 (85.3)
Underweight <18.4	3 (4.5)	1 (2.9)
Smoking status, n (%)
Yes	36 (54.5)	12 (35.3)	0.091
No	30 (45.5)	22 (64.7)
Reason for visiting a GP in the previous year, n (%)
Physical health	41 (62.1)	17 (50.0)	0.288
Physical and mental health issues	25 (37.9)	17 (50.0)
In the last year visited the emergency department, n (%)
Yes	26 (39.4)	16 (47.1)
No	40 (60.6)	18 (52.9)	0.524
Satisfaction with GP, mean (SD)	3.1 (.078)	3.2 (.060)	0.203
GP prescribes medications for their mental illness
Yes	25 (39.9)	19 (55.9)	0.667
No	41 (62.1)	15 (44.1)
In the last year, GP screened for medication side-effects
Yes	41 (62.1)	21 (61.8)	1.000
No	25 (37.9)	13 (38.2)

Key: GP: general practitioner; CM: case manager; significant p value assessed at 0.05.

A substantial proportion of study participants across both groups were females (55%), nearly half smoked cigarettes (48%), and the majority had a BMI >25 to 40 (78%), which is classified by World Health Organisation (WHO) as overweight to obese (WHO, 2020). The proportion of participants screened by their GP for medication side effects was generally low and did not significantly differ between the two groups (X² = 0.001, df (1), p = 1.000). In both groups, more than 60% of participants had a psychotic or an affective disorder, 44% had their psychotropic medications primarily prescribed by their GP, and 58% reported visiting their GP for physical health problems.

Participants experiences of Australian population age-recommended health checks and other checks

Participants aged 50 years and over were asked whether they had been offered or referred for a mammogram, Papanicolaou (PAP) smear, prostate-specific antigen (PSA) test, faecal occult blood test (FOBT), skin cancer screen, colonoscopy or blood-check for diabetes. These screening tests are population age-recommended health checks for this population demographic in Australia (Department of Health, 2017). Table 2 presents data specific to participants aged 50 years and over, regarding age-recommended population-based screening tests. Overall, the data shows that most participants (94.9%) had not undertaken a screen for any of the seven tests. Of the 59 participants, none had undertaken a colonoscopy, pap smear, or PSA check, and only one reported having a faecal occult blood test, and three had a diabetes screen and skin cancer checks. These are quite low in comparison to the national data from Australia for the period of 2021–2022, which shows higher participation rates in health screenings: 50% for breast cancer screening (AIHW, 2023b), 40.9% for the Faecal Occult Blood Test (FOBT)(AIHW, 2023a), and 68% for Pap smears (AIHW, 2023c).

Table 2. Proportion of participants offered age-recommended screening tests (n = 59) compared to national screening rates for similar timeframes.

Screening for >50 years (n = 59)	GP + CM (n = 43)	GP only (n = 16)		Australia age-recommended screening rates.
Test	n (%)	n (%)	p Value
Offered any of the tests
Yes	2 (4.7)	1 (6.3)	1.000
No	41 (95.3)	15 (93.8)
Mammogram (females n = 34)				50–74 yrs. − 2021–2022
Yes	1 (2.3)	1 (6.3)	0.472	50%
No	18 (97.7)	15 (93.8)
Pap smear (females n = 34)				25–74 yrs. 2018–2022
Yes	0 (0)	1 (6.3)	0.271	68%
No	18 (100)	15 (93.8)
PSA (males n = 25)				*
Yes	0 (0)	0 (0)	–
No	20 (100)	5 (100)
sColonoscopy
Yes	0 (0)	0 (0)	–
No	43 (100)	16 (100)
FOBT				50–74 yrs. − 2021–2022
Yes	1 (2.3)	0 (0)	1.000	40.9%
No	42 (97.7)	16 (100)
Skin cancer screening				*
Yes	2 (0)	1 (0)	–
No	43 (100)	16 (100)
Diabetes screening				*
Yes	2 (4.7)	1 (6.3)	1.000
No	41 (95.3)	15 (93.8)

Key: GP: general practitioner; CM: case manager; PAP: Papanicolaou smear; PSA: prostate-specific antigen test; FOBT: faecal occult blood test; *national data not available.

Significant p value assessed at 0.05.

Because of the small sample size (n = 43 vs. n = 16), it was not possible to run a regression analysis to assess the odds of being offered a population age-recommended health check between the two groups or with national data.

Participants’ experiences of screening for the side effects of psychotropics

An adjusted logistic regression model was used to explore the odds of having to undertake to screen for mental health medication side effects. Results are presented in Table 3 below. Overall, participants were more likely to be screened for medication side effects if they presented for physical health consultation, were males, and if they had previously referred the participant to the emergency department (ED). Participants who visited their GP for a physical and a mental health consultation had a reduced chance (OR = 0.068; 95% CI: 0.005 − 0.985, p = 0.049) of being screened for side effects compared to those who presented for a physical health consultation. Equally, female participants had a lesser chance (OR = 0.014; 95% CI: 0.000 − 0.792, p = 0.038) of being screened compared to male participants. On the contrary, participants were 12 times (p = 0.007) more likely to be screened for medication side effects if they had previously been referred to the emergency department. Also, there was a slightly increased chance that they would be screened for side effects if they were smokers (p = 0.049). Factors such as the clinician who primarily managed the consumer’s mental health care (GP only vs. GP and case manager), age and BMI did not have any impact on whether a participant was screened for side effects.

Table 3. Logistic regression analysis of factors that influence screening for medication side-effects (n = 100).

	B	SE.	Wald	df	Sig.	OR	95% Confidence interval for OR
							Lower	Upper
ED referrals: If referred by GP to ED in the previous year (ref cat = No)	4.814	1.793	7.210	1	0.007	12.32	3.670	41.395
Gender: (ref cat = male)	−4.267	2.058	4.299	1	0.038	0.014	0.000	0.792
Smoking status: (ref cat = No)	−2.925	1.484	3.883	1	0.049	0.054	0.003	0.985
Main provider: GP only or GP and a case manager (ref cat = GP only)	−2.176	1.335	2.658	1	0.103	0.113	0.008	1.552
Consultation type: Physical health care only/physical and mental health care (ref cat = physical only)	−2.688	1.363	3.886	1	0.049	0.068	0.005	0.985
BMI categories: Overweight to obese/normal wt. (ref cat = normal wt.)	2.698	1.563	2.979	1	0.084	14.85	0.694	31.779
Age	−0.052	0.054	0.904	1	0.342	0.950	0.854	1.056
Constant	4.231	4.108	1.061	1	0.303	68.81

Variable(s) entered on step 1 block 1 = If referred by GP the ED in the last year; gender; smoking status, visits GP + mental health services for treatment; Step 1 block 2 = reason for the GP visit, BMI_WHO Classification, age.

Key: ED: emergency department; GP: general practitioner; BMI: body mass index; wt.: weight; ref cat: reference category; B: intercept; SE: standard error; Wald: chi-square characteristics; df: degrees of freedom; sig: p value; OR: odds ratio.

Discussion

This study provides a snapshot of participants’ reported engagement with their GP over a 12-month period. All participants of this study engaged with primary care more that once during the 12 months. The results suggest that people with mental illness still engage with primary care for the management of their health. The findings show that most people with mental illness engage with their GP about their mental illness despite also consulting other mental health services.

Although general practice has a key role in the management of people with mental illness, the findings of this study suggest that several areas require strengthening to improve consumers care outcomes in this setting. Our study reveals that while individuals with mental illness do utilise primary care for health services, their preventive health checks and medical screenings remain lower compared to the general population. This finding echoes the results of Lord et al., 2010 and Tabvuma et al. (2022), that showed that people with a mental illness are less likely to complete preventive health checks (Lord et al., 2010; Tabvuma et al., 2022).

Disparities in preventive health checks were also reported by participants aged 50 years and over. Of the seven health checks included in the survey (mammography, pap smear, PSA, diabetes screen, skin cancer screen, colonoscopy and faecal occult blood), all were below the Australian national average screening rates for these conditions (AIHW, 2017). In Australia, GPs provide the majority of Medicare-subsidised mental health-specific services (AIHW, 2019b), and in 2017–18, over 90% of mental health prescriptions were by GPs (AIHW, 2019b). These findings may indicate an overstretched primary care system. Also, it is plausible that there is an overreliance on either of the systems (mental health services or general practice) to complete consumer preventive health checks. An audit of general practice’s involvement in the care of people with mental illness showed that overall, GPs are less involved in the physical health care of consumers with mental illness, and especially those still engaged with tertiary mental health services. The reasons specified by this audit were that consumer whose care was coordinated by the case manager had higher levels of disability and socioeconomic disadvantage that reduced access to health care in general practice (Jang et al., 2015). Our study findings underscore the importance of collaborating with consumers on their physical health checks rather than solely focusing on national age-specific recommended health checks. There is a crucial need for primary care and mental health specialists to develop innovative methods of delivering physical healthcare to individuals with mental illnesses. These findings are consistent with other studies, which have shown that the transition of care for people with mental illnesses from hospitals to primary care is frequently suboptimal. To improve this, adopting shared decision-making strategies is essential (Tabvuma et al., 2022; Young et al., 2017).

The insights from this study and implications for policy and clinical practice should be interpreted in the context of the complexities of providing care to people with serious mental illnesses (Hardy et al., 2014). The need to engage with people with mental illness to obtain screening is critical and may require a specialist mental health professional who is in close contact with the person and family (Hardy et al., 2014). Recent reports from some Australian jurisdictions have mandated establishment of physical health nurses be integrated within mental health services (Department of Health NSW, 2017). Also, the referral process from primary care to secondary care or to another service for tests can be daunting for people with mental illness, or they may not have the money or ability to get to the services, and the referral may not eventuate (Hardy et al., 2014). Such referrals could be made more accessible by having mental health nurse practitioners located in primary care who could facilitate the screening of consumers and complement GP care (Hardy et al., 2014). This advanced practice role for nurses has been recommended in the recent sustainability report, which supports advanced practice roles for nurses in primary care to improve access to health care, particularly for consumers of mental health services (Department of Health, 2019). The effectiveness of nurses in monitoring the physical health of consumers and patients has been documented in both mental health jurisdictions and general primary care settings (Hardy & Thomas, 2012).

Study limitations

This study was carried out in Western Australia, and participants were recruited through a tertiary mental health service in Perth. The results may not be generalisable to other countries with different healthcare arrangements for people with mental illness. A small sample size meant that exploration of some of the aspects of the study, such as population-based health checks, was only descriptively presented. Our study offers a glimpse into consumers’ interpretation of their engagement with primary care and the services they receive. However, the results may be subject to social desirability and recall biases. Perhaps a larger sample size would provide more insight into participants’ experiences with primary care and particularly on age-recommended physical health checks.

Conclusion

This study shows that participants perceived primary care as important to managing their mental health. However, several measures need to be put in place to support physical health checks and implement strategies to reduce smoking in this group. Strengthening the current systems to improve the coordination of care between mental health services and general practice is needed to improve the physical health monitoring of people with mental illness. Larger studies are needed to better represent the consumer voice in primary care and to further test the role of advanced nurse practitioners before establishing new approaches to coordinate physical health care for people with mental illness.

Ethical approval

Ethical approval was obtained from the South Metropolitan Health Service Human Research Ethics Committee and the University Human Research Ethics Committee (ethics number HR61/2014) and (SMSH-14/12). Informed consent detailing anonymity, data storage arrangements and participants’ right to withdraw was obtained by integrating the participant information sheet at the beginning of the online survey. Participants who were not interested in completing the study had the option to withdraw before starting the survey questions.

Author contributions

DW and KH authors contributed to the design and oversight of the study. DW, KH and IN have contributed equally to the data analysis and manuscript write-up and have no conflicts of interest to declare.

Acknowledgement

The authors would like to acknowledge participants of this study for being involved in the study. The Western Australia Department of Health for funding this project and Jenny Tatoha for her help in conducting the interviews.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This project was supported by the Western Australian Department of Health under Targeted Research Funds 2013 (Round 3) (Wynaden et al., 2014).