The Holy Grail in medicine is prevention. Simply put, to avert an illness before it’s onset leads to a reduction in suffering and cost savings. Yet, prevention also refers to screening (e.g. BreastCheck), encouraging healthy lifestyle choices (e.g. Smoking Cessation Programmes), immunisations (e.g. polio) and the use of medicines to prevent the onset of illness (e.g. aspirin).
Robust evidence supports these strategies and has led to behaviours in the general population changing positively leading to longevity and greater years without disability secondary to illness. For instance, in Ireland over the past 30 years, our overall rates of death due to heart disease has fallen by almost 50% with great benefits coming from getting people to adopt a healthy lifestyle.
Sadly, the same is not true of our patients with serious mental illness (SMI). The standardized mortality ratios of those with SMI remain stubbornly high. In fact, a study in the United States in 2006 showed that that those with SMI died on average 25 years earlier than expected.
Why? The reasons are complex but can be roughly explained in terms of the patient and the physician. Patients present late in their illnesses and usually to A & E settings, whereas physicians though knowing of this risk of premature mortality do not take decisive action. Poor lifestyle choices taken by patients and the hopelessness of effecting change are usually cited for not doing more. Yet, studies are showing that simple interventions involving diet, exercise and smoking cessation can lead to beneficial changes in those with SMI.
Preventative Medical Care in Psychiatry brings together the principles of prevention, cardiovascular disease (CVD) and respiratory disorders, endocrine disorders, infectious diseases and oncological diseases in the Psychiatric population into a single text. It is written with the psychiatrist in mind. Each chapter starts with a case discussion followed by a clinical overview. Diagnostic, preventative and treatment guidelines follow thereafter, and the chapter ends usually with a ‘when to refer’. Most chapters contain a ‘special considerations section for psychiatric patients’, which usually highlights studies performed in specific patient groups. A book of this size cannot be comprehensive and so the chapters are short, though contain practical information on the key points of each topic. At times, the chapters contain similar preventative information as the some of topics, for example, obesity and dyslipidaemia, yet this is to be expected. Therefore, there is some repetition, yet the editors have been careful to keep this to a minimum.
However, I do have a few small issues with the book. The chapter on obesity cites evidence that diets might work. Perhaps, putting into the context that most people on diets do not lose weight would have been helpful. Medication is trotted out at some point in the CVD, Obesity and Endocrine chapters as a major issue in the development of illnesses leading to the conclusion that when appropriate it should be switched to a metabolically favourable agent. Yet, the accumulating evidence suggesting that some of the antipsychotics that result in weight gain may lead to a reduction in all cause mortality is either absent or given scan recognition. The emphasis should be that all patients with SMI need to be offered preventative strategies not just those on ‘obesogenic’ medications.
In conclusion, the information is accessible and erudite. The book is useful to all grades within psychiatry and should serve as a reminder to us as psychiatrists that we do have an active and meaningful role to play in the alleviation of illness and premature death in this already vulnerable population.
