Physical health in severe mental illness

Billy is 39 and has a longstanding diagnosis of schizophrenia. He recently came for his annual review with our practice nurse for the first time in years. His mental health was the best it had been in ages, which is probably why she’d been able to persuade him to attend. A few days later, his blood results landed in my inbox – HbA1c in the 90s, total cholesterol 8.4, QRISK through the roof. I called and text messaged him a few times, and asked our receptionists to do the same over the coming days, but there was no response, and we had no details of carers or relatives to contact. These results bothered me, but I wondered what else I could, or should, do?

People living with severe mental illness face one of the greatest health equality gaps in the UK. Their life expectancy is 15–20 years shorter than that of the general population, and this is largely due to preventable physical illness, particularly cardiovascular disease (NHS England, 2024; Improving physical healthcare for people living with SMI in primary care).

In this article, we review the important role of primary care in improving the health and life expectancy of people living with severe mental illness.

This article was updated in March 2025.

What is severe mental illness?

Severe mental illness (SMI) affects around 3% of the population (BJGP 2023;73:488). SMI refers to any mental illness that is debilitating enough to have a significant long-term impact on the person’s ability to engage in functional or occupational activities (Public Health England, 2018; SMI and physical health inequalities).

This is a broad definition which includes conditions such as schizophrenia and other psychotic disorders, bipolar disorder, and other significant mental health conditions such as recurrent major depression.

Why does this topic matter?

Adults living with SMI have an almost 5x increased risk of dying prematurely compared with those living without SMI, and premature deaths of people living with SMI are increasing (NHS England, 2024 Improving the physical health of people living with severe mental illness). People living with SMI also have:

6.6x increased risk of respiratory disease.
6.5x increased risk of liver disease.
4.1x increased risk of cardiovascular disease.
2.3x increased risk of cancer.
And are 3x times more likely to lose their natural teeth.
SMI is also associated with an increased likelihood of fragility fractures and underdiagnosis of osteoporosis (BJGP 2024; 74:e861).

Factors that contribute to the increased mortality rate include (BJGP 2021;71:373, European Heart Journal 2024; 12:987, NHS England, 2024):

Higher rates of chronic disease	Patients with SMI have a 2–4-fold increase in the rates of diabetes, hypertension, dyslipidemia and metabolic syndrome compared with the general population. There is also an increased prevalence of having multiple comorbid conditions.
Unhealthy lifestyle	Around 50% of deaths in people living with SMI are attributable to smoking. Rates in the general population have significantly decreased from 40–50% in 1974 to around 15% in 2017, but remain at around 40–50% in people with SMI, many of whom are heavy smokers. Other unhealthy lifestyle behaviours such as poor diet, inactivity and drug and alcohol misuse all contribute to the increased risk of physical illnesses such as cardiovascular disease and diabetes. The best single modifiable candidate for increasing the life expectancy of people living with schizophrenia is smoking, and for people living with bipolar disorder is sedentary behaviour.
Medication	Antipsychotics and mood stabilisers increase life expectancy in people with SMI, most likely due to both improved mental health and regular access to healthcare interventions from medication monitoring. However, medication can also have side-effects that have a negative impact on physical health, with increased risk of weight gain, diabetes and increased lipids. The average weight gain in the first two years after initiation of antipsychotic treatment is 12kg! We may also be less likely to prescribe the correct cardiovascular drugs in patients with SMI. Following myocardial infarction, patients with SMI are less likely to receive treatments such as aspirin, beta-blockers, statins or ACE inhibitors.
Difficulties accessing treatment	Annual health checks: despite these being incentivised through QOF from 2004 to 2025, it’s estimated that less than a third of patients with SMI receive annual CVD screening, and many of those who are assessed receive no intervention for their identified risk factors. Cancer: the incidence of most cancers is similar among people with and without SMI, but adults with SMI are 2.1 times more likely to die from cancer under the age of 75. This may be due to reduced uptake of cancer screening, delayed diagnosis or lack of adherence to treatment (Public Health England, 2021; SMI: inequalities in cancer screening update).
Social disadvantage	Social deprivation has been associated with poor quality of care, poor control of cholesterol and blood sugar, and worse outcomes in patients with heart disease.
Genetic factors	Even after adjustment for lifestyle and medication effects, patients with schizophrenia (but not with bipolar disorder) may be genetically predisposed to cardiometabolic disease.
Increased risk of death by suicide	Suicide risk in people with SMI is high following acute psychotic episodes. It peaks during psychiatric hospital admission and shortly after discharge (Public Health England, 2018).

Health inequalities

Despite the known preventable risk factors, people living with SMI often receive poorer physical healthcare compared with the general population. This can occur because (European Heart Journal 2024; 12:987):

There may be stigma and discrimination around mental illness, even from health professionals.
There may be ‘diagnostic overshadowing’, where mental health symptoms are more prominent than the co-occurring physical disease. As a result, clinicians may overlook or downplay physical symptoms in patients with SMI.
Lack of communication and coordinated working practices can lead to fragmentation of care across different specialties, creating gaps between mental health, primary care and secondary care physicians.

What can we do in primary care?

The high rates of CVD and diabetes in people with SMI are potentially avoidable. Prevention and early intervention are likely to be more effective than waiting for the patient to develop significant illness.

NICE and NHS England have both produced guidance about this:

NICE (2014, CG178 and 2014 (updated 2023), CG185) asks us to maintain a register and monitor the physical health of patients with psychosis, schizophrenia and bipolar disorder. This should take place at transfer from secondary care and then at least annually. While not specified by NICE, this is likely to be good practice for all patients who meet the broader definition of SMI.
NICE (2018, QS167) also emphasises the importance of an annual physical health check in people from black, Asian and other minority ethnic groups with SMI, who have an increased risk of CVD and diabetes.
NHS England (2024) specifies ‘core’ elements of a physical health check in people with SMI, and also lists more comprehensive ‘additional’ checks that may be commissioned locally.

We have summarised NICE and NHS England guidance below:

Core elements of the SMI health check	Weight or BMI. Waist circumference. Pulse and BP. Fasting glucose or HbA1c. Lipid profile. In bipolar disorder, we are advised to check LFTs, as well as U&E, TFT and calcium for those on long-term lithium. Alcohol and any other drug use. Smoking status.
What else should we consider?	Cardiovascular risk assessment (including QRISK). Personal and family history of CVD and diabetes. Medication review (check adherence to prescribed treatments and consider the need for monitoring, e.g. lithium levels, U&Es, LFTs, prolactin, ECG if indicated (see our articles on Antipsychotics and Lithium safety for more information, and our section below on review of long-term antipsychotic medication). Review diet and physical activity. Assessment for movement disorders in those taking antipsychotics.
Wider aspects of health (may be commissioned in a more comprehensive health check)	Support to access national immunisation and screening programmes, including cancer screening. Sexual and reproductive health assessment and advice (including contraception and screening for blood-borne viruses where appropriate) (see ‘Holistic health needs’ in the table below). Oral health advice and signposting to local dental services. Open questions to identify social or economic factors that may affect the person’s physical or mental health, such as isolation, housing problems or unemployment.

Offering effective and comprehensive care is likely to involve the wider primary care team, including practice nurses and clinical pharmacists. There is also current research and a systematic review being undertaken into the role of the community pharmacist in supporting people living with SMI (BMJ Open 2020;10:e038270).

Adjustments to healthcare to improve access

NHS England (2024) also highlights that people with SMI may have a history of trauma, which may include emotional, physical and/or sexual trauma, plus a range of other adverse life experiences. These can influence how the individual experiences their physical health, the health check and their ability to make lifestyle changes.

It is also important to offer care that addresses health inequalities. This includes the health inequalities experienced by people living with SMI, but should also consider the cumulative impact of SMI in people with other health disadvantages. This might include those from ethnically or culturally diverse communities; older adults; young people; those with a learning disability or neurodivergence such as autism; and LGBTQ+ individuals, all of which may contribute to especially poor experiences of care and outcomes.

All health interventions offered should be trauma-informed and include reasonable adjustments to support people with SMI to access healthcare. This might include:

Tailored communications and proactive ways of inviting people for an annual SMI physical health check, including letters, texts, phone calls or even home visits. Some people with SMI may avoid health services because of a lack of trust, and it may take time and require many attempts to make contact through multiple channels of communication.
Providing clear information on why someone has been invited for an annual SMI physical health check, and what will happen at the appointment and afterwards.
Explaining that reasonable adjustments can be made, agreeing with the individual what might be helpful and documenting this on the medical record.
Offering a longer appointment or one at the start/end of the day to avoid needing to sit in a busy waiting room, or if medication side-effects make early appointments difficult to attend.
Offering quieter places to sit if the waiting room is busy.
Encouraging the individual to bring a carer, family member or trusted friend to appointments.
Explaining how the person will be supported to implement suggested actions.
Where possible, providing continuity of the professional providing the health check and any follow-up.
Offering support to carers when needed.

Other changes that may improve outcomes for people with SMI could include:

Commissioning local enhanced or dedicated services to deliver a comprehensive annual physical health check.
Outreach services to support people with difficulty accessing healthcare, e.g. offering health checks at home or in a community hub.

What next?

Support should not end with the physical health check. We need to act on any abnormal findings. Guidance from the Lester Positive Cardiometabolic Health Resource (Royal College of Psychiatrists, 2023) emphasises:

DON’T JUST SCREEN, INTERVENE!

(We know this is difficult! A qualitative study found that GPs often see this complex primary prevention work as unachievable in the current workforce crisis, not to mention the erratic engagement and need for prioritisation of mental health and existing physical health needs that often arise when caring for this group (BJGP Open 2024; 8:2). But, where we can do it, it’s extremely valuable.)

The Lester approach involves actively responding to each risk factor in line with NICE’s recommendations for the general population in each area (hypertension, lipids, etc.). It also emphasises that care should be person-centred, tailoring discussion to the needs of the person to enable shared decision-making. The resource is designed for ‘people experiencing psychosis and schizophrenia,’ which is a narrower definition of SMI than we give earlier in this article. However, given that it encourages us to modify risk factors in line with NICE, it’s likely that we can apply it to anyone with SMI.

The following table gives some pointers on how to intervene effectively (BJGP 2021;71:373).

Smoking	Smoking prevalence in SMI is triple the general population, and smoking cessation is the single most effective way these individuals can improve their health. It doesn’t just improve physical health. Stopping smoking is as effective as antidepressants for treating mild-to-moderate depression. Many people with SMI want to quit smoking, and the SCIMITAR trial demonstrated that they can. Patients randomised to usual support and advice achieved a quit rate similar to the general population at 12 months, and those receiving adaptations for SMI (such as home visits) achieved an even better quit rate (Lancet Psychiatry 2019; 6:379). Efficacy and safety data for nicotine replacement therapy – varenicline and bupropion – suggests that they are effective and safe when used in SMI. E-cigarettes are also effective for supporting smoking cessation and are less harmful than cigarettes (BJGP 2023;73:251). Stopping smoking can affect how the body metabolises many psychotropic drugs, including most antipsychotics and some antidepressants (BJGP 2023;73:251). This means that prescribing during smoking cessation needs to be carefully coordinated (and that we need to be wary that drug levels can fall if smoking is resumed) – but it also represents a potential ‘double win’ for patients because they may need lower drug doses once they quit. For the following drugs, it is recommended that we consider a 25% dose reduction in the first week of stopping smoking to prevent toxicity (BJGP 2023;73:251; liaise with psychiatry as appropriate!): Escitalopram. Tricyclic antidepressants. Olanzapine. Haloperidol. Clozapine. Fluphenazine. Diazepam.
Diet and activity	Perhaps even more important than educating people with SMI about lifestyle (although we should definitely do this!) is helping them to address key social determinants. These might include lack of access to recreation and physical activity, a lack of cooking skills, a limited budget for food and increased alcohol intake. Social prescribers may be able to support us in this. People with SMI can experience rapid weight gain when starting antipsychotic medications, but this is not an inevitable side-effect and tailored support can help prevent obesity. Dietitian-led interventions have the greatest impact on weight gain if offered as soon as antipsychotics are initiated (NHS England, 2024). Weekly weight checks are recommended after initiation of a new antipsychotic because early weight gain is a strong predictor of long-term morbidity.
Abnormal results (e.g. hypertension, lipids, HbA1c)	Help people with SMI and their carers to understand their physical health risks, the benefits of screening and the plan for feeding back results. Remember that people with SMI will probably derive MORE benefit from modifying these risk factors than others. For example, hypertensive people with SMI have triple the risk of dying from hypertension-related disease if left untreated compared with hypertensive people without SMI. Where appropriate, refer patients with SMI and difficult-to-manage cardiometabolic risk (using metabolic, endocrine or cardiology clinic). Data shows that this happens less often than it should.
Metformin	Where health behaviour modification alone is not adequate, the Lester resource recommends metformin to prevent progression from prediabetes to diabetes, in line with NICE’s recommendations for the general population. See our article Prediabetes for more on using metformin in this context.
Holistic health needs	CVD isn’t the only condition to consider. Compared with the wider practice population, people with schizophrenia experience higher rates of a range of comorbidities, including a 3-fold increase in Parkinson’s disease. As well as medications in SMI potentially affecting sexual function , understanding of ‘safe sex’ can be poor, and this population can be at increased risk of sexual exploitation and abuse. Thinking and talking about sex, family planning and infections – including bloodborne viruses – is important. Poor oral health is very common in people with SMI, and can significantly impact on self-esteem and quality of life: signpost to a community dentist if needed.
Regular review of antipsychotic medication	Long-term antipsychotic use is associated with an increased risk of obesity, diabetes and cardiovascular disease. Regular medication review is therefore essential to support deprescribing when clinically appropriate. However, a BJGP study found that long-term antipsychotic use in primary care is rising, although fewer than half of prescriptions were issued to patients on the SMI register. This suggests a growing use of antipsychotics for unlicensed and/or non-psychotic conditions. Increasing numbers of patients are managed in primary care without psychiatrist review, but many GPs lack the confidence to adjust or discontinue these drugs without specialist input. As a result, opportunities for cardiometabolic monitoring and deprescribing may be missed, posing significant risks to patients (BJGP 2024; 75:e68).

Cardiovascular risk calculators in SMI

Following guidance on modifying cardiovascular risk often involves calculating QRISK. But how applicable is QRISK in SMI?

QRISK2 does not account for SMI, and may underestimate CVD risk in this population.
QRISK3 does account for SMI, and NICE recommends we use it. However, the Lester resource reminds us that it is not a tool developed specifically for this group.

The Lester resource points out that SMI-specific tools for CVD risk in adults do exist, including PRIMROSE. However, it also reminds us that any risk score should be used as part of a holistic assessment that accounts for individual factors, including patient preference, and be used to inform rather than dictate clinical decisions.

Did incentivising screening in SMI through QOF actually work?

As mentioned earlier in this article, despite annual health checks for people with SMI being previously incentivised through QOF, less than a third of people with SMI actually receive annual CVD screening. It’s therefore tempting to say that the answer to whether incentivisation works in this context is a resounding ’no’! However, a cohort study used UK primary care data to look at the effect of removing from QOF, and then reintroducing, the individual measures of BMI, cholesterol and alcohol consumption in people with SMI between 2011 and 2020 (BJGP 2024;74:e449). There were interesting results; a significant and almost immediate change in uptake was found in all three of the measures when they were removed from, and again after they were added back to, the QOF list. In 2025, the incentive was removed from QOF. Will this lead to a decrease in care for this already marginalised group?

	Physical health in severe mental illness SMI is a longstanding mental health illness that has a significant impact on function. People with SMI have significantly higher rates of mortality associated with preventable physical health conditions. In primary care, we should SCREEN for risk factors and INTERVENE to modify them. Many patients with SMI want to stop smoking and can often successfully quit with support. Psychotropic drug doses often need downward dose adjustment after smoking cessation due to altered metabolism. We can improve engagement by making practical adjustments, helping patients and their carers understand health screening, and working with the CMHT if needed.
	Does your practice have an SMI register? Could you audit how effectively you are screening and intervening for CVD risk in this group? How is your area doing? Have a look at Fingertips PHE – severe mental illness
	Useful resources: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) YouTube – Being Bothered About Billy (Professor Helen Lester’s 2012 lecture to the RCGP)

Physical health in severe mental illness