You ask an important question with far ranging implications and complex solutions.

I think the best framework to use in approaching this question is a model developed for  the US Institute Medicine. In practical terms, it recommends four categories of care (Wellness Basics, Restorative Therapies, Symptom Relief, Over-care avoidance - these are not the names they use, but are ones that are much easier to grasp).

I think the best way to answer your question is to  restate it, "what is the best way to optimize physical health in each of the four categories of care, for someone with severe mental illness?". I think the restatement is important, because the answers in each category are different. Typically, activity is required in all categories at the same time. In addition, these approaches are best deployed within the context of a recovery model of evolutionary improvement and ever-increasing self-determination.

I'll assert the highest level answer in all four categories.

Wellness Basics. These include 1) Housing & Security, 2) Diet & Digestion, 3) Exercise & Sleep, 4) Calm Awareness, 5) Effective Self-Management, 6) Purpose & Meaning, 7) Social & Outer Engagement, 8) Belief, Hope & Self-Transcendence. There are hundreds of RCTs that support that doing the right things in these areas directly support both mental and physical health. For instance, housing is the absolute first thing that one must do to support the physical wellness of someone with severe mental illness. Without it, their life nearly always remains in shambles. Approaches to wellness in this category are normal disciplines of wellness for everyone and are fairly well understood, though not always within reach. The challenge here is that these approaches often requires self-determination and lifestyle changes, things that can be extremely hard for people with severe mental illness. But, the good news here is that most of these things do not require medical intervention and can often, with a little creativity, be found without huge expense.

Restorative Therapies. These are mental health interventions targeted at suspected root causes of mental health symptoms, divided into two groups: Biomedical and Psychosocial. The Biomedical ones are directly tied to both physical health and mental health. Things like Nutrient therapy, Pathogen therapy, Endocrine therapy, Food Allergy Therapy, detoxification therapy, etc. are all therapeutic responses to physical issues that are well-known to potentially cause mental health symptoms. Approaches to wellness in this category are squarely within the medical discipline. It demands - though it is rare in conventional psychiatry today - robust biomedical testing. This testing is one of the cornerstones of integrative psychiatry, which is producing recovery rates substantially higher than those from drug therapy alone (the best evidence of this is through extensive open-label trials with Nutrient Therapy). Dr. Michael First, editor of the DSM-5 laments that current psychiatry often jumps to symptom-based diagnoses and all but avoids step three of the differential diagnosis process (the step that looks for underlying causative issues).

Symptom Relief. Effort here is to relieve residual mental health symptoms that the first two categories don't address. Psychotropics are by far the most common option here, but there are others with a smaller, but non-trivial evidence base: herbs, very small current electro-stimulation devices (like tDCS, tACS, CES, etc.), sensory therapy, etc. This area is predominantly tangential to the issue of physical health, with one exception. Symptom relief to some degree is often a mandatory first step to achieve stabilization. It is only after some measure of stabilization that we can even begin to consider improving physical health through approaches in the first two categories of care.

Over-care avoidance. This is a huge challenge in psychiatry today. Ill-advised polypharmacy and off-label prescribing, prescribing at dosages over recommended levels, over prescribing of psychotropics to vulnerable populations (the elderly, veterans, foster children...) and probably the most detrimental - antipsychotic polypharmacy - have been known to substantially impact physical health negatively. These are well understood by the APA and they have campaigns to reel-in some of these, especially antipsychotic polypharmacy. This has a huge implication on physical health. Outcomes from overcare are stark: significantly increased chances of death and a far ranging list of serious side effects.

So, how do we ensure the physical health of people with severe mental illness? 1) Focus outside of the medical discipline on the most out-of-balance wellness basics to establish new healthier lifestyle choices, 2) through robust biomedical testing, search for and address any physical issues found that are commonly known to cause mental health issues, 3) do enough symptom relief to reach a measure of stability so that a focus on physical health can be begun, 4) be ever vigilant to avoid over-care and seek "minimal effective dosages", starting dosages small and ramping slowly, 5) deliver these wellness approaches within the context of a recovery model that maximizes self-determination and recognizes that recovery is an iterative, evolutionary process where setbacks are common.

To deliver the above in a coordinated way is extremely difficult today and, to be done well, requires a holistic approach to patient care. I think to make substantive progress, we need to adopt something similar to this 4-categories of care model and train case workers on its fundamentals and how they can help individuals map into available services in each area.

That sounds very productive, Miyuru - I especially like the awareness programmes, and that the data is shared.

The cohort of clients I work with (severe mental illness and complex needs (Australia)) are typically low income earners and most likely on welfare payments, which limits their choice for GPs to those who agree to bulk-bill. This means the GPs receive less money, and often see more clients as a result. Clients are given roughly 10-15 minutes per appointment, and their mental health issues or immediate problems (i.e. pain) take importance, and we're finding that without prompting GPs aren't asking other health-related questions. This is particularly worrying for our indigenous clients, who are more susceptible to chronic disease, where their GPs aren't conducting yearly 715 health checks. Clients can also bounce between GPs - usually whoever's available at the time. 

I'm trying to figure out a way to reduce the work on GPs, and whether that's engaging practice nurses

With diabetes, the government (through Medicare) gives you up to 8 sessions a year of group education sessions; they're generally run by a team of dietitians, exercise physiologists, and diabetes educators. But GPs aren't doing referrals, and people aren't asking GPs to do the referrals :(

We prevented or cured over 900 diseases in the animal kingdom with vitamin and mineral supplements. Food pellets provide perfect nutrition for animals. The problem is the food industry. As long as profits and not health is the goal the mentally ill, along with the rest of us will suffer. Proper nutrition for all is the key. The food industry will have to be regulated and prevented from distributing food that is hazardous to our health. Education will not help someone with only $1 to buy a processed food for lunch to eat better. We must provide everyone with healthy food and vitamins and minerals along with free housing and health care for free as a human right. Surely we deserve equal treatment with animals. PETA protects animals. Who protects us?          

You ask an important question with far ranging implications and complex solutions.

I think the best framework to use in approaching this question is a model developed for  the US Institute Medicine. In practical terms, it recommends four categories of care (Wellness Basics, Restorative Therapies, Symptom Relief, Over-care avoidance - these are not the names they use, but are ones that are much easier to grasp).

I think the best way to answer your question is to  restate it, "what is the best way to optimize physical health in each of the four categories of care, for someone with severe mental illness?". I think the restatement is important, because the answers in each category are different. Typically, activity is required in all categories at the same time. In addition, these approaches are best deployed within the context of a recovery model of evolutionary improvement and ever-increasing self-determination.

I'll assert the highest level answer in all four categories.

Wellness Basics. These include 1) Housing & Security, 2) Diet & Digestion, 3) Exercise & Sleep, 4) Calm Awareness, 5) Effective Self-Management, 6) Purpose & Meaning, 7) Social & Outer Engagement, 8) Belief, Hope & Self-Transcendence. There are hundreds of RCTs that support that doing the right things in these areas directly support both mental and physical health. For instance, housing is the absolute first thing that one must do to support the physical wellness of someone with severe mental illness. Without it, their life nearly always remains in shambles. Approaches to wellness in this category are normal disciplines of wellness for everyone and are fairly well understood, though not always within reach. The challenge here is that these approaches often requires self-determination and lifestyle changes, things that can be extremely hard for people with severe mental illness. But, the good news here is that most of these things do not require medical intervention and can often, with a little creativity, be found without huge expense.

Restorative Therapies. These are mental health interventions targeted at suspected root causes of mental health symptoms, divided into two groups: Biomedical and Psychosocial. The Biomedical ones are directly tied to both physical health and mental health. Things like Nutrient therapy, Pathogen therapy, Endocrine therapy, Food Allergy Therapy, detoxification therapy, etc. are all therapeutic responses to physical issues that are well-known to potentially cause mental health symptoms. Approaches to wellness in this category are squarely within the medical discipline. It demands - though it is rare in conventional psychiatry today - robust biomedical testing. This testing is one of the cornerstones of integrative psychiatry, which is producing recovery rates substantially higher than those from drug therapy alone (the best evidence of this is through extensive open-label trials with Nutrient Therapy). Dr. Michael First, editor of the DSM-5 laments that current psychiatry often jumps to symptom-based diagnoses and all but avoids step three of the differential diagnosis process (the step that looks for underlying causative issues).

Symptom Relief. Effort here is to relieve residual mental health symptoms that the first two categories don't address. Psychotropics are by far the most common option here, but there are others with a smaller, but non-trivial evidence base: herbs, very small current electro-stimulation devices (like tDCS, tACS, CES, etc.), sensory therapy, etc. This area is predominantly tangential to the issue of physical health, with one exception. Symptom relief to some degree is often a mandatory first step to achieve stabilization. It is only after some measure of stabilization that we can even begin to consider improving physical health through approaches in the first two categories of care.

Over-care avoidance. This is a huge challenge in psychiatry today. Ill-advised polypharmacy and off-label prescribing, prescribing at dosages over recommended levels, over prescribing of psychotropics to vulnerable populations (the elderly, veterans, foster children...) and probably the most detrimental - antipsychotic polypharmacy - have been known to substantially impact physical health negatively. These are well understood by the APA and they have campaigns to reel-in some of these, especially antipsychotic polypharmacy. This has a huge implication on physical health. Outcomes from overcare are stark: significantly increased chances of death and a far ranging list of serious side effects.

So, how do we ensure the physical health of people with severe mental illness? 1) Focus outside of the medical discipline on the most out-of-balance wellness basics to establish new healthier lifestyle choices, 2) through robust biomedical testing, search for and address any physical issues found that are commonly known to cause mental health issues, 3) do enough symptom relief to reach a measure of stability so that a focus on physical health can be begun, 4) be ever vigilant to avoid over-care and seek "minimal effective dosages", starting dosages small and ramping slowly, 5) deliver these wellness approaches within the context of a recovery model that maximizes self-determination and recognizes that recovery is an iterative, evolutionary process where setbacks are common.

To deliver the above in a coordinated way is extremely difficult today and, to be done well, requires a holistic approach to patient care. I think to make substantive progress, we need to adopt something similar to this 4-categories of care model and train case workers on its fundamentals and how they can help individuals map into available services in each area.

A major challenge is stigmatising attitudes of health providers who view patient complaints through a mental health dx and then failing to suggest dx investigations or monitoring for metabolic disorders and treating chronic illness. 

One interesting approach in Ontario is the recruitment and training of mental health peer support workers to provide education, outreach and ongoing support for people living with diabetes with terrific success.  

Here is a project description and a video explaining the approach:  http://www.opdi.org/training.phphttps://www.youtube.com/watch?v=y-ZTJQR-SHA

https://www.youtube.com/watch?v=y-ZTJQR-SHA

Hi Hannah, If you speak to any local Early Intervention for Psychosis team , they will have interventions in place to encourage physical exercise ( ie football groups etc) , review medications regularly  for weight gain and complete physical health checks etc.   They should be able to point you in the right direct with the large evidence base behind these interventions. Cost and transport to venues are huge barriers to physical exercise. 

Hoffer, (2012) discovered that most mental illness can be cured with basic nutrition and so can most physical illness. If we take Linus Pauling's Orthomolecular medical approach    and Abram Hoffer's approach we will have a mentally and physically healthy population. 

References

Hoffer, A. (2012) Dr. Abram Hoffer Aiming at recoveries for schizophrenia and symptoms of severe mental illness. Retrieved from https://isepp.wordpress.com/2012/01/09/dr-abram-hoffer-aiming-at-recoveries-for-schizophrenia-and-symptoms-of-severe-mental-illness/

This problem is five-fold.

First,  in  my opinion, the mental health stigma is greater among the medical and mental health providers than it is in the community because doctors and other medical providers only see people with psychiatric disorders when they are acutely symptomatic. Although well trained, the emotional toll of only seeing people at their worst can have a cumulative psychological effect. Many providers lose their ability to provide unbiased top quality services because emotionally, they expect their patients to fail, again.

Second, because of stigma, many valid physical health concerns are dismissed as psychosomatic simply because the primary diagnosis is a severe mental illness. I have seen this occur three separate times with a single patient in the ER. The patient was later diagnosed with Influenza (ER diagnosed it as Bulimia?), tachycardia induced by medication (ER diagnosed it as Anxiety) and a trans ischemic attack (Who knows what the ER was rationalizing on that one).

Third, like everyone, people diagnosed with severe mental  illness are interested in  bettering their own lives on  their own  terms. Helping peers develop a Wellness Recovery Action Plan (WRAP is an evidence-based practice) with a peer support specialist can improve all aspects of wellness in part because the person learns to identify what they feel like when they are well and then begins to identify when preferred strategies would be appropriately applied to their life in order to maintain or improve wellness.

It is difficult to break through amotivational symptoms caused by illness and compounded by certain medications. Having a daily action plan, like those created in the process of developing a WRAP, can improve outcomes--especially when developed with a Peer Support Specialist. Peers have more confidence in Peer Support Specialists than Doctors because they feel understood and not directed. When a peer support specialist explains what helped them to lose weight,  even while on Haldol, a person living with severe mental illness will be more likely to listen than simply getting educated instruction from a health professional who does not have lived experience with the effects of antipsychotics on weight gain and motivation. Woodhouse & Vincent (2006) discovered that Information provided by peers to peers is often seen to be more credible than that provided by mental health professionals. I would argue the same is true for the entire medical community simply because of the systematic mistreatment of peers by the system.

Fourth,  until we can connect with people who have severe mental illness in a way that empowers them to break through Learned Helplessness, not much we do by way of education or special programs will change the current situation. Peer Support Specialists can help break the barriers of Learned Helplessness.

Fifth, until the medical community begins to recognize that psychiatric medications cause more physical symptoms than effectively treating psychological ones,  we must acknowledge are fighting an uphill battle against the foundational training of the medical community.  Many physicians do not adequately understand the physiological impact of the medication they prescribe, blaming the patient for eating too much,  when many medications cause an increase in appetite. Many doctors blame the patient for not being motivated when in reality the very nature of the illness (which symptoms can often be compounded by prescribed medication) mistaking lack of motivation as a patient's disinterest rather than a symptom of the illness or side-effect of the medication.

I wrote about the unique nature of Peer Support Specialists with my colleague, Gerald Monk in  the article "Recovering a Life with Severe Mental Illness: Psychologists and Peer Support Specialists Working Together."  

Here is the other cited article: Woodhouse, A. and Vincent, A. (2006). Mental health delivery plan—development of peer specialist roles: A literature scoping exercise. Scottish Recovery Network and the Scottish Development Centre for Mental Health,Edinburg

Article Recovering a Life with Severe Mental Illness: Psychologists ...

Hi Sarah:

I am a health psychologist. I am 73 years old and I have never taken a prescribed medication.As far as physical health is concerned you may want to research orthomolecular medicine. As far as mental health is concerned you may want to research Abram Hoffer, MD. He used only nutrition, (niacin cures depression etc).

References

Hoffer, A. (2012) Dr. Abram Hoffer Aiming at recoveries for schizophrenia and symptoms of severe mental illness. Retrieved from https://isepp.wordpress.com/2012/01/09/dr-abram-hoffer-aiming-at-recoveries-for-schizophrenia-and-symptoms-of-severe-mental-illness/

 Orthomolecular Medicine: www.orthomed.org

 Thank you all so much for your input. It clearly is a tip-of-the-iceberg question, where there isn't a simple solution but many complex and deep issues. It really is a system overhaul, from education to available nutrition to affordable housing to access to healthcare providers.

I"m fascinated to keep learning more