Addressing the disparity in physical health provision for people with schizophrenia: an important role for physiotherapists

People with schizophrenia often die decades before members of the general population [1], despite the fact that people with schizophrenia are reported to have up to twice as much contact with health services [2]. The reasons for this health disparity are complex and include genetic predisposition, use of antipsychotic medication and a range of modifiable risk factors around poor lifestyle choices [1]. A recent report published in the UK [3] stated that people with serious mental illnesses such as schizophrenia are at substantially higher risk of various physical comorbidities, many of which are avoidable. For example, people with schizophrenia have a 10-fold higher risk of death from respiratory disease, are twice as likely to develop diabetes, and two to three times as likely to develop coronary heart disease compared with the general population [3].

At present, there is great political pressure and momentum to reduce the profoundly increased morbidity and mortality seen in people with schizophrenia. However, the consideration of physiotherapy-led interventions to reduce this gap in clinical practice and, perhaps to a greater extent, in the academic literature has been limited until recently. This lack of consideration in the mainstream academic world is highlighted by a recent editorial in the British Journal of Psychiatry [4], where the authors provided an eloquent account of the need for physical activity to be integrated into routine care for people with mental illness (something that a select group of physiotherapists have been doing for many years); however, not once did the authors suggest that physiotherapists could lead this movement.

This is surprising for a number of reasons. First, in general healthcare settings, physiotherapists are established leaders in both clinical practice and research considering the delivery of physical activity in many of the common comorbidities that affect individuals with schizophrenia. This includes, but is not limited to, diabetes [5] and cardiovascular disease [6]. Second, a recent systematic review [7] of physiotherapy-based randomised controlled trials established that physical activity reduces psychiatric symptoms and psychological distress, and improves health-related quality of life in individuals with schizophrenia. Third, specialist mental health physiotherapists have the necessary clinical skills to lead in the delivery of physical activity programmes in clinical practice [8]. Fourth, specialist mental health physiotherapists are particularly well versed in identifying the common barriers and facilitators to physical activity in people with schizophrenia [9]. Finally, physiotherapists have been leading the promotion of physical health of people with mental illness, including physical activity, for many decades, and whilst it is clearly the role of all members of the multidisciplinary team to promote an active lifestyle, the leading role of physiotherapists should be acknowledged.

In order to increase capacity as evidence-based leaders in clinical practice, all physiotherapists and students require adequate training. However, worldwide, the unification of training in mental health among physiotherapists remains unclear, and specialising in mental health still appears to be unpopular [10]. There is an urgent need to understand the best way to train physiotherapists to enable them to engage fully with patients with mental illness, including schizophrenia. However, rather than limiting this to mental health specialists, it is recommended that all physiotherapists should be trained and equipped to work with people with mental illness. This is especially important when one considers that one in four people will experience mental illness at some point in their life [11]. Recently, a survey was undertaken of specialist mental health physiotherapists from the International Organisation of Physical Therapists in Mental Health (IOPTMH). The survey investigated members’ views on the most important areas for training to ensure that physiotherapists are best placed to be leaders in the care of people with schizophrenia. Over 150 physiotherapists from 31 countries completed the survey. Of these, 103 physiotherapists provided their opinions on the training requirements for all physiotherapists (including those working outside mental health services) in order to be leaders in clinical practice. From the responses, two common training themes arose: (1) the need for physiotherapist-specific evidence-based guidance in schizophrenia; and (2) the need to treat the side effects of schizophrenia. Within the first theme, 48% (50/103) of physiotherapists felt that training should focus specifically on the role of the physiotherapist in schizophrenia, and 26% (27/103) felt that there is a need for research updates on common outcome measures and interventions. Within the second theme, physiotherapists felt that training on overcoming the side effects of medication (15%, 15/103), metabolic syndrome (6%, 6/103) and the commonly seen physical comorbidities (10%, 10/103) would better equip physiotherapists in clinical practice.

We believe there is an urgent need to develop a sound evidence base for physiotherapy-led interventions through robust high-quality research in the care of people with mental illness, including people with schizophrenia. In addition, it is recommended that all physiotherapists should receive training and education in working with people with mental illness. Physiotherapists are ideally placed to lead clinical teams in addressing the physical health needs of individuals with schizophrenia [8]. With further training, physiotherapists will be optimally placed to help reduce the comorbidities of the disease and ultimately prevent premature mortality for individuals with schizophrenia. IOPTMH recognises the urgency of this and is committed to developing research and evidence-based training that can impact clinical practice and place physiotherapists as leaders in the field of physical health promotion [12].

Conflicts of interest: Four authors are board members of IOPTMH. However, this had no influence on the study at any stage. Davy Vancampfort is funded by the Research Foundation – Flanders (FWO-Vlaanderen).