Physical health policies and metabolic screening in mental health care systems of sub-Saharan African countries: a systematic review

Mental and substance use disorders are the leading cause of years lived with disability in sub-Saharan Africa (SSA), accounting for almost 20% of all disability-associated burden [1]. The burden is estimated to increase even further [2]. The consequences of this rising burden will be devastating and will be worsened by secondary physical health co-morbidities people with mental and substance use disorders are confronted with [3‐5]. Combined mental and physical health problems will have in particular large consequences for women as in SSA women are mostly generating the family income. They mostly rely for this on labor-demanding jobs in the informal sector with no job security or compensation for lost income. Maintaining physical health is therefore crucial for their livelihoods and the society as a whole.

To date, a mental health policy has been relatively low on the priority list in most of SSA countries [6]. In most countries still less than 1% of the health budget is spent on mental health [7]. As a result mental health services are poorly resourced and treatment rates for people with mental disorders remain low, with treatment gaps over 90% [8]. Pharmacotherapy, and in particular antipsychotic medication use, is also the mainstay of therapy programs in SSA [6], but has important cardio-metabolic risk factors [9, 10]. The metabolic risk associated with antipsychotics has led to the development of several International treatment guidelines for routine metabolic screening and monitoring in patients taking antipsychotic medication [11, 12]. The extent and frequency of screening is debatable, but there is global consensus that baseline metabolic screening should worldwide form part of the standard package of care for all patients with a regular prescription of any antipsychotic [13]. Several years ago reports of routine metabolic screening practices in large cohorts of patients from high-income countries (USA, UK, Australia, Canada and Spain) have shown that metabolic testing was not optimal despite widespread dissemination of the guidelines and a high level of awareness of the metabolic risks associated with antipsychotic medication use among psychiatrists [14]. Recent reports show that progress has been made [15], albeit inconsistently [16] in these high-income countries. To date, metabolic screening rates in people under antipsychotic treatment in middle-to-low-income countries have however not been explored systematically.

The aim of the current systematic review is twofold. First, we explored whether or not within the current mental health plans of SSA countries a physical health component or policy has been included. Second, we systematically investigated the routine metabolic screening rates for people with severe mental illness in SSA countries.

The current systematic review shows that in those SSA countries that have a mental health plan (n = 33, 70%) only 6 were found to make reference to a physical health component or policy. Only the South-African mental health plan stated that a routine screening and treatment of physical illness should be implemented in all consultations for people with mental illness. Our review findings clearly indicate that although physical health concerns are becoming acknowledged as an important focus in the multidisciplinary management of severe mental health problems [24], a clear physical health policy is yet to be embraced in mental health care systems of most SSA countries. The lack of priority given to physical health concerns is also mirrored in the limited number of studies exploring the metabolic screening rates in the management of mental health problems. Only 2 South-African studies assessed the metabolic screening rates. In both studies, routine screening was unacceptably low with less than one percent adequately screened for waist circumference, a modifiable metabolic syndrome risk factor for type 2 diabetes mellitus and cardiovascular disease [25]. This is surprising as waist circumference is very easy to measure and inexpensive.

Hence, there is a clear need to re-orient the current mental health care systems in SSA and focus more on the physical health needs of people with mental illness. An important environmental reason is the lack of integrated mental and medical services locally and the poorly developed community-based psychiatric services resulting in an overreliance on institutional care [26]. Closer integration of primary care and mental health in SSA countries is needed. Many mental health providers do not ask about medical issues or test for them because of lack of consideration of this health care aspect, lack of time or lack of resources directly available to them. For example, in the study of Ludwick and Oosthuizen [22] 90% of the mental health providers believe that patients with psychiatric disorders are not being discriminated against and that they are being monitored as regularly as or even more than the rest of the clinical population. The prejudice may therefore not be conscious, but on an unconscious level, which makes it even more complex to address [22]. Lack of knowledge is also exemplified in the observation that only 10% of mental health providers are aware of the fact that people with severe mental illness die earlier than the general population [22].

Therefore, first of all, there is a clear need to increase awareness of the importance physical health needs of patients with severe mental illness among mental health providers in SSA. Continued medical education (CMEs which is a common practice in SSA) [6] should be used to inform these mental health care providers on the importance of assessing physical health risks in people with mental illness. Mental health care providers in low-and-middle-income countries need to be informed that their roles extend beyond taking care of the mental health of their patients and assume responsibility for the physical health of their patients as well. Policy makers should be made aware that investment in CME and in screening for physical health risks could optimize mental and physical health improvements. However, effective monitoring of metabolic risks is not sufficient on its own, as appropriate treatment is also mandatory [27].

Secondly, governmental and non-governmental agencies in the region will do well to increase public health awareness of the increased physical health risks of people with severe mental illness.

For example, the increased physical health needs should be integrated into the existing Information, Education and Communication (IEC especially on mental health and lifestyle diseases) public health awareness programs of the World Health Organization [28]. Targeted and regular messages should be developed in order to make these campaigns affordable in SSA countries. At a minimum, the physical health risks and the benefits of regular physical health screening should be properly outlined. Action is urgently needed. While the worldwide disability-associated burden and premature mortality due to type 2 diabetes mellitus and cardiovascular diseases are projected to increase by 2020, the largest increases in deaths are predicted for SSA countries [29]. SSA is experiencing the most rapid urbanization worldwide which may be contributing to more sedentary behaviours and a rising prevalence of non-communicable diseases [30]. Against this background, people with severe mental illness in SSA, especially those under antipsychotic treatment, are at particularly high risk. Without adequate screening the increasing risks will, in all likelihood, go undetected in the overwhelming majority of patients with severe mental illness. We advocate that all psychiatric services in SSA, even the lowest-resourced one should assess at a minimum the body mass index and waist circumference at initiation of pharmacotherapy and afterwards at regular intervals. Optimal monitoring should also include assessments of fasting glucose, lipids, cholesterol, and blood pressure.

Future research should explore whether complying with the minimum and optimal standards and, if needed, treatment will reduce the risk for future type 2 diabetes and cardiovascular diseases, YLD and consequently disability-associated burden. In order to justify the inclusion of more costly fasting blood screening as a routine component, cost-benefit analysis are required in order to determine and quantify the financial implications of diverting resources or investing funds into such initiatives. Such economic rationales must aim to include cost-savings associated with prevention in the context of the treatment of physical health comorbidities and ideally potential benefits regarding preventing future episodes of poor mental health. Finally, future research in SSA on behavioral health should incorporate the mental health and physical health of people with mental illness rather than the current trend of focusing research solely on one or the other.

In conclusion, the current data shows that in SSA the physical health risks is largely ignored in the current mental health policies in most SSA countries. Policy makers and existing work force should be informed about the importance of considering physical health needs in the multidisciplinary treatment of people with mental health problems.