9.1. Introduction
People with bipolar disorder seem to be at increased risk of physical health problems, particularly from cardiovascular disease. Overall, 38% of people with bipolar disorder die from cardiovascular disease, about twice the expected standardised mortality rate, compared with 18% by suicide in a national sample from Sweden (Westman et al., 2013). The reasons for this are not entirely clear although lifestyle factors, weight gain and other adverse effects of antipsychotic and other medication, substance misuse including alcohol and tobacco, and reduced use of cardiovascular drugs (such as statins) may all play a role (Crump et al., 2013; Gomes et al., 2013; Kilbourne et al., 2007; Mitchell et al., 2009). Lithium can lead to renal impairment and the greatest risk of this can be cardiovascular disease although there is also evidence that it may reduce mortality other than from suicide (Angst et al., 2013).
9.2. Interventions to Promote Physical Activity and Healthy Eating
9.2.1. Introduction
For people with bipolar disorder, and people taking antipsychotics in particular, a combination of poor diet and nutrition, weight gain and lack of physical activity contribute to high rates of physical comorbidities such as type 2 diabetes and reduced life expectancy particularly from cardiovascular disease. Excluding suicide, all-cause mortality may be increased by 40 to 50% in people with bipolar disorder not taking antipsychotics when compared with the English general population, but increased by 70 to 80% in people with bipolar disorder taking antipsychotic medication (Murray-Thomas et al., 2012). Even higher rates have been reported for all cause and cardiac mortality (Laursen et al., 2013; Westman et al., 2013). The prevalence of metabolic syndrome is also increased by 70 to 80% with antipsychotic drug use in bipolar disorder (Vancampfort et al., 2013). There is increasing evidence that adverse effects associated with an increased risk of long-term health problems are prevalent with the use of antipsychotics (Newcomer et al., 2013). Additionally, cardiometabolic risks appear within weeks of commencing antipsychotics, particularly weight gain and hypertriglyceridaemia and later glucose dysregulation and hypercholesterolemia (Foley & Morley, 2011). Moreover weight gain and obesity further contribute to stigma and discrimination and may explain unplanned discontinuation of antipsychotic medication leading to relapse. Limited research has mainly been directed towards weight reduction rather than physical activity programmes, although in practice these approaches may overlap. Weight reduction should not be the only concern since poor nutrition may directly contribute to physical ill health. Moreover studies using actigraphs show that people with bipolar disorder often lead very sedentary lives (Janney et al., 2014).
9.2.2. Clinical evidence review
Review strategy
People with severe mental illness may be taking similar medications and experience similar physical health problems irrespective of diagnosis (for example, bipolar disorder or schizophrenia). For these reasons, the GDG wished to investigate ways to improve the physical health of bipolar disorder by considering a wide body of evidence about interventions for people with severe mental illness.
A review of behavioural interventions for this guideline was undertaken in conjunction with a NICE guideline being developed at the same time, Psychosis and Schizophrenia in Adults (NICE, 2014), which includes the full methods and results of those reviews. The studies included in these reviews included people with bipolar disorder (subgroup analyses were undertaken where possible) and the results are directly relevant to this guideline. Before making any recommendations, the GDG were presented with the evidence and draft recommendations made by the Psychosis and Schizophrenia in Adults GDG. The method of incorporation and adaptation (see section 3.7) was followed to ensure that the recommendations were appropriate for people with bipolar disorder. Further information about shared recommendations and the reason for incorporating or adapting each one can be found in the next section.
A review of pharmacological interventions for managing or preventing weight gain revealed only RCTs in people taking particular antipsychotic drugs for a range of indications or in the general population. The GDG did not believe that this evidence was informative and for this reason they are not reviewed further. Other interventions to modify risk factors for cardiovascular disease or other physical health problems were not considered as part of the scope of this guideline.
Summary of findings
Several studies suggested that behavioural interventions to promote physical activity and healthy eating may be efficacious in reducing body weight, and these effects may be maintained in the short term. Because no longer-term data were available, effects after 6 months are not known. In addition, there is evidence that an intervention that combines a behavioural approach to promoting both physical activity and healthy eating can improve quality of life when measured at the end of treatment. However, the longer-term benefits are not known. Interventions that aimed to promote physical activity alone were not found to be any more efficacious than control in reducing weight. Additionally there was no evidence of an increase in quality of life at the end of treatment. Limited evidence suggests that a yoga intervention may be more efficacious than aerobic physical activity in improving quality of life in the short term. There is no evidence that outcomes for people with bipolar disorder differ from outcomes for people with other severe mental illness.
No studies assessing the cost effectiveness of behavioural interventions to promote physical health in people with bipolar disorder were identified. The systematic review identified one study (Winterbourne et al., 2013) reporting that a behavioural intervention involving psychoeducation, nutritional and/or exercise counselling was cost effective in people with first episode psychosis, but the analysis was judged to be partially applicable to this guideline review and to have potentially serious methodological limitations (such as lack of robust long-term clinical evidence).
contains the original recommendations from Psychosis and Schizophrenia in Adults (NICE, 2014) in column 1 and the associated review question(s) and evidence base in column 2. The adapted/incorporated recommendations are shown in column 3 and reasons for doing so are provided in column 4.
Recommendations incorporated or adapted from another NICE guideline.
9.3. Linking Evidence to Recommendations
9.3.1. Relative value placed on the outcomes considered
The GDG agreed that the main aims of a physical health and/or healthy eating intervention should be to improve health, reduce weight and improve quality of life (Sattelmair et al., 2011; Tuomilehto et al., 2011). The GDG also considered the importance of engaging the service user in the intervention. Therefore, the GDG decided to focus on the following, which were considered to be critical:
physical health
BMI/weight
levels of physical activity
service use
primary care engagement (for example, GP visits)
quality of life
user satisfaction (validated measures only).
9.3.2. Trade-off between clinical benefits and harms
A wealth of research in the general population supports the importance of being physically active and having a healthy, balanced diet. For people with bipolar disorder, interventions that aim to both increase physical activity and to improve healthy eating may be efficacious for multiple outcomes. The GDG considered this evidence of clinical benefit to be of particular importance in a population with greatly increased risk of mortality.
There was no appropriate evidence to judge the benefits versus the potential harms of pharmacological interventions for managing weight gain, and therefore the GDG decided not to make any recommendations at this stage.
9.3.3. Trade-off between net health benefits and resource use
The health economic evidence on interventions to promote physical health was limited to one UK study. Despite the study’s limitations, the results provide evidence that non-pharmacological interventions that include psychoeducation, nutritional and/or exercise counselling may comprise a cost-effective strategy for the prevention of weight gain in the short term in people with serious mental illness. The positive economic finding supports the GDG’s view that these interventions are not only of important clinical benefit but also are likely to be cost effective within the NICE decision-making context.
9.3.4. Quality of the evidence
The evidence ranged from very low quality to high quality across interventions. For the combined physical health and healthy eating intervention, evidence was of better quality and rated from low to moderate quality across critical outcomes. Reasons for downgrading included risk of bias, inconsistency (although the direction of effect was consistent across studies) and, for some outcomes, imprecision.
9.3.5. Other considerations
The review of behavioural interventions to promote healthy eating (without a physical activity component) did not identify any studies meeting the inclusion criteria. A behavioural intervention to increase physical activity and healthy eating may be efficacious in reducing weight and improving quality of life in adults with serious mental illness. The GDG considered the possibility of cross-referring to existing guidance in this area for the general population. However, people with severe mental illness are at a high risk of morbidity and mortality because of physical complications such as diabetes, obesity, cardiovascular disease and other related illness. Therefore, the GDG decided it was important to generate recommendations specifically for this population and felt the available evidence assisted in informing these recommendations. They did, however, see the benefit of making specific reference to NICE guidance on obesity and prevention of diabetes and cardiovascular disease.
Evidence suggests that long periods of mild physical activity, for example walking, may be more efficacious than shorter periods of moderate to vigorous exercise in improving insulin action and plasma lipids for people who are sedentary. The GDG purposefully decided to use the terms ‘physical activity’ and ‘healthy eating’ (rather than the potentially stigmatising words ‘exercise’ and ‘diet’) in order to take this evidence into consideration and promote a long-term lifestyle change rather than a short-term ‘fix’ to reduce weight (Duvivier et al., 2013).
The GDG went beyond the evidence of clinical benefit to consider other important issues that can affect the physical health of an adult with severe mental illness. These issues relate to when physical health problems should be assessed, how they should be monitored and who should be responsible for both physical and mental health. The GDG considered and discussed the important role of primary care in monitoring physical health (especially current diabetes and cardiovascular disease) and that this should be made explicit in the care plan. The GDG believed that these issues were of equal importance to the service user’s health as the interventions themselves.
9.4. Recommendations
9.4.1. Clinical practice recommendations
Monitoring physical health in primary care
- 9.4.1.1.
Develop and use practice case registers to monitor the physical and mental health of people with bipolar disorder in primary care56.
- 9.4.1.2.
Monitor the physical health of people with bipolar disorder when responsibility for monitoring is transferred from secondary care, and then at least annually. The health check should be comprehensive, including all the checks recommended in recommendation 9.4.1.3 and focusing on physical health problems such as cardiovascular disease, diabetes, obesity and respiratory disease. A copy of the results should be sent to the care coordinator and psychiatrist, and put in the secondary care records57.
- 9.4.1.3.
Ensure that the physical health check for people with bipolar disorder, performed at least annually, includes:
weight or BMI, diet, nutritional status and level of physical activity
cardiovascular status, including pulse and blood pressure
metabolic status, including fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile
liver function
renal and thyroid function, and calcium levels, for people taking longterm lithium.
- 9.4.1.4.
Identify people with bipolar disorder who have hypertension, have abnormal lipid levels, are obese or at risk of obesity, have diabetes or are at risk of diabetes (as indicated by abnormal blood glucose levels), or are physically inactive, at the earliest opportunity. Follow NICE guidance on hypertension, lipid modification, prevention of cardiovascular disease, obesity, physical activity and preventing type 2 diabetes58.
- 9.4.1.5.
Offer treatment to people with bipolar disorder who have diabetes and/or cardiovascular disease in primary care in line with the NICE clinical guidelines on type 1 diabetes, type 2 diabetes, type 2 diabetes – newer agents and lipid modification59.
Monitoring physical health in secondary care
- 9.4.1.6.
Healthcare professionals in secondary care should ensure, as part of the care programme approach, that people with bipolar disorder receive physical healthcare from primary care as described in recommendations 9.4.1.1-9.4.1.5 after responsibility for monitoring has been transferred from secondary care60.
- 9.4.1.7.
People with bipolar disorder, especially those taking antipsychotics and long-term medication, should be offered a combined healthy eating and physical activity programme by their mental healthcare provider61.
- 9.4.1.8.
If a person has rapid or excessive weight gain, abnormal lipid levels or problems with blood glucose management, take into account the effects of medication, mental state, other physical health and lifestyle factors in the development of these problems and offer interventions in line with the NICE guidance on obesity, lipid modification or preventing type 2 diabetes62.
- 9.4.1.9.
Routinely monitor weight and cardiovascular and metabolic indicators of morbidity in people with bipolar disorder. These should be audited in the annual team report63.
- 9.4.1.10.
Trusts should ensure that they take account of relevant guidelines on the monitoring and treatment of cardiovascular and metabolic disease in people with bipolar disorder through board-level performance indicators64.
