Real life issues & answers: the mental health patient

Professor Richard Byng (GPwSI mental health and Professor in Primary Care Research, University of Plymouth)

What are the clinical issues?
Patients with mental health issues and cardiovascular disease provide long-term challenges to healthcare professionals that demands a careful, individualised approach. These are complex diseases with diagnostic categories that are very unscientific which, in turn, cause problems when trying to treat these patients effectively. People with psychosis have a reduced lifespan between 15-20 years when compared with the general population, primarily from cardiovascular disease.

What are the implications and answers?
Professor Byng said that the most important issue for healthcare professionals to focus on when managing patients with these complex issues is to consider the individual and their symptoms, rather than management guidelines.
SHERPA (Sharing Evidence Routine for Person-centred Action) is a new tool to help clinical decision-making in patients with complex multimorbidity (Jack E et al. Lancet 2018). It has a simple, three-step consultation framework to help clinicians provide holistic bio-psycho-social care. The technique focuses on identifying the key bio-psycho-social issues being experienced by the patient (i.e. low mood, chest pain, weight gain etc) and then working out how these issues are causally linked. The final step is to support patients with their their individual goals and providing practical interventions to the most important challenges they have identified.
This approach may mean that some cardiovascular issues are not tacked immediately as the patient starts to address some of their issues that are giving them most concern. However, tackling issues such as mood swing, loneliness and depression will improve the chances of managing cardiovascular issues in the future.

Key points to make best practice everyday practice
Professor Byng described a number of key points that are valuable in caring for patients with mental health and cardiovascular issues:

  • Understand the individual’s complex bio-psycho-social whole – develop an understanding of how key issues are linked causally
  • Be fascinated by this most challenging of intellectual endeavours and try to feel confident about being uncertain. Realise that we do not have to (and cannot) ‘fix’ everything
  • Listen to your patients, and do not be scared about helping them learn something new too – you should both have transformed your views by the end of the consultation
  • Work together and prioritise the goals they care about – whether social, emotional or biological. Medical support should be subservient to individuals’ goals in life
  • Build your treatment plan around their goals based on your knowledge of evidence and their understanding of their life – remember that small differences in effect sizes between different medications may be dwarfed by evidence from them informing you of what might work
  • Use coaching or motivational interviewing to support individuals