Personalised care in severe mental illness – there's no need to wait

Progress in Neurology and Psychiatry November/December 2016 www.progressnp.com 4 Repeated promises over several decades from leading academics in imaging and genetics1–3 that biologically personalised treatments were close and would be available in ‘a few years’ have not translated into routine clinical practice. Expansive claims are still made by some, though most contemporary views are more realistic about the likely contribution of such approaches in the near future.4 Such ‘biological’ approaches have substantially and importantly improved our knowledge and understanding of mental health disorders and should be recognised as having done so. It is disappointing, however, that these advances in understanding have not led to significant advances in routine clinical practice or outcomes. Similar promises are now being made for ‘big data’ generated by electronic records systems and its ability to identify characteristics that will transform healthcare.5,6 Smart-phone technology is also being strongly promoted as the cornerstone of a ‘new era’ of healthcare, as demonstrated by a bewildering variety of apps now available.7 It is early days and some are already urging caution in interpreting the results of studies using metadata for methodological reasons.8 While there is no doubt there will be significant gains, the largely unfulfilled previous claims of the imaging specialists and geneticists would suggest we should not expect miracles. During this prolonged period of ultimately unfulfilled claims from different disciplines, high quality evidence has steadily accumulated that does support personalised care, albeit in a different way. Numerous randomised controlled trials (RCTs) and systematic reviews have been reported that strongly support the use of specific interventions for people with specific deficits. While we may not be able to put our patients in a scanner or run a blood test to select a specially designed medication, we can sit and discuss with them a raft of evidence-based interventions that should improve well-being and functioning. This more holistic view of individualised treatment could include many elements, encompassing both whole service approaches and individual interventions targeted at specific difficulties faced by those with severe mental illness (SMI). Below we outline a few examples but the list is by no means exhaustive. We have known for many years that patients with psychosis have poor physical health and die much younger than the general population, even after allowing for suicide. One recent study9 estimated a reduction of 18.7 years and 16.3 years in men and women with schizophrenia, respectively – a shocking health inequality. The causes for this are complex, but we have the evidence-based interventions to ameliorate or even eliminate some. Smoking cessation therapy has strong evidence in mental health services10 and can significantly reduce morbidity and mortality while conferring other benefits such as reduced financial pressures and improved selfesteem. However, we know that many patients under our care are not offered it, or are not assertively assisted to take it up. We also know that metabolic syndrome causes significant morbidity and reduces functioning and that intervening early with lifestyle support and a mindful choice of antipsychotic can minimise the damage.11 Again, we do not always do this, despite the literature clearly supporting individualised choice of medication in psychosis that takes into account side-effect profiles, efficacy, and patient characteristics.12 This evidence extends to the preferential use of long-acting injections (LAI) in those who have had repeated episodes of illness,13 another area where there is substantial variation in practice in UK psychiatry. The evidence base for individualised placement and support is unquestionable now, with numerous RCTs and systematic reviews14 showing meaningful benefit in terms of return to functionality and employment. Contingency management is an approach in which reductions in substance misuse or improved adherence to medication may be rewarded by money or vouchers. It remains controversial and little used. This appears to be a missed opportunity given that recent empirical data, such as those from the FIAT study,15 show clear evidence of benefit. The availability of talking therapies for people with SMI remains patchy and inadequate, with local investments in increased availability frequently appearing to be swallowed up by less unwell and more vocal groups in primary care, backed by national drivers and targets. Family therapy is a good example of a treatment that has strong evidence dating back over Personalised care in severe mental illness – there’s no need to wait