Lesson 7 - Physical Health and Mental Health
1. Introduction
Mental health does not exist separately from physical health. The two are closely interconnected, and changes in one can have a significant effect on the other.
For people working in mental health services, this is particularly important. Someone who appears more tired, withdrawn, irritable or confused may be experiencing a deterioration in their mental health, but they may also be physically unwell. Equally, depression, anxiety, psychosis and other mental health difficulties can make it harder for someone to look after their physical health, attend appointments, eat well, exercise, take medication consistently or communicate physical symptoms.
People with severe mental illness experience particularly significant physical health inequalities. NHS England reports that people living with severe mental illness have a life expectancy approximately 15–20 years shorter than the general population, with much of this difference resulting from preventable physical illness.
For a case worker, the aim is not to become a doctor or nurse. Your role is to notice, ask, support and escalate. Because you may have more frequent or informal contact with a person than their medical team, you may be the first professional to notice that something has changed.
This lesson will therefore focus on recognising the relationship between physical and mental health, identifying common areas of concern, supporting people to access appropriate healthcare and understanding when physical symptoms require prompt clinical assessment.
2. Learning Outcomes
By the end of this lesson, learners should be able to:
Explain the two-way relationship between physical health and mental health.
Recognise common physical health problems and risk factors affecting people with mental health conditions.
Understand how mental illness and psychiatric medication can influence physical health.
Recognise how physical illness can present as, worsen or be mistaken for mental health difficulties.
Support people to engage with physical healthcare and make achievable improvements to their health.
Identify physical health concerns that should be escalated to a clinician or emergency service.
3. The Lecture
3.1 Mental and Physical Health Are Not Separate
One of the most useful habits you can develop in mental health work is to stop thinking of "mental health" and "physical health" as two completely separate systems.
Consider someone experiencing depression. They may sleep poorly, stop exercising, eat irregularly, smoke more and struggle to attend GP appointments. Over time, those changes may worsen their physical health. Poor physical health can then contribute to fatigue, reduced mobility, pain and social isolation, which may make their depression worse.
The relationship can therefore become circular:
Mental health difficulties → reduced self-care or physiological effects → poorer physical health → reduced functioning and wellbeing → worsening mental health
The reverse can happen too.
A person who develops chronic pain may stop working and become socially isolated. Someone diagnosed with cancer may understandably experience anxiety or depression. Thyroid disease can produce symptoms that resemble psychiatric illness. Infection or dehydration can cause confusion. Sleep apnoea can produce fatigue, poor concentration and irritability.
The important lesson is therefore simple:
A change in someone's behaviour or mental state should not automatically be assumed to be caused by their psychiatric condition.
3.2 Why Physical Health Can Be Worse in People with Mental Illness
There is no single explanation for poorer physical health among people with mental illness. Usually, several factors interact.
The effects of mental illness itself
Mental illness can make ordinary health-related tasks considerably more difficult.
A severely depressed person may understand perfectly well that they should make a GP appointment, but may lack the motivation or energy to do so. Someone experiencing paranoia may be frightened of attending a clinic. A person with severe anxiety may repeatedly cancel blood tests because they are afraid of needles. Someone with significant executive-functioning difficulties may intend to attend appointments but repeatedly forget them.
This distinction matters.
The person may not lack knowledge. They may need practical support to turn intention into action.
Lifestyle and social factors
People experiencing mental illness may also be more likely to encounter circumstances that adversely affect physical health. These can include poor diet, low levels of physical activity, smoking, harmful alcohol use, substance misuse, financial difficulties, unstable housing and social isolation.
These should never simply be dismissed as "bad lifestyle choices".
For example, telling someone experiencing severe depression that they should exercise five times a week is unlikely to be helpful if they are currently struggling to shower or leave their bedroom. A better intervention may be helping them establish a ten-minute daily walk and gradually building from there.
Good case work starts from where the person currently is, rather than where we think they should be.
Medication
Some psychiatric medications can affect physical health.
Depending on the medication, potential effects may include changes in appetite or weight, blood pressure, pulse, glucose regulation, cholesterol, sexual functioning, movement, sedation or other physical symptoms.
Antipsychotic medication is particularly important because some antipsychotics can contribute to weight gain and cardiometabolic problems. NICE therefore recommends systematic physical-health monitoring for people receiving antipsychotic treatment.
The case worker is not expected to interpret laboratory results or decide whether medication should be changed. However, you should recognise that physical-health monitoring may be an important part of someone's treatment and encourage them to attend requested reviews and investigations.
3.3 The Risk of Diagnostic Overshadowing
One of the most important concepts in this lesson is diagnostic overshadowing.
Diagnostic overshadowing occurs when physical symptoms are incorrectly attributed to someone's mental illness, resulting in physical disease being overlooked or inadequately investigated. NHS England specifically identifies diagnostic overshadowing as one contributor to physical illness being underdiagnosed and undertreated in people living with severe mental illness.
Imagine that someone with a long history of anxiety repeatedly reports palpitations.
It would be easy to think:
"He has anxiety. These are probably panic attacks."
They might be.
But palpitations can also have physical causes.
Similarly, tiredness in someone with depression may be part of their depression, but it could also relate to anaemia, thyroid disease, sleep apnoea, infection, medication or another medical problem.
The presence of a psychiatric diagnosis does not protect someone from developing physical illness.
A useful question
When you notice a change, ask yourself:
"If this person did not have a mental health diagnosis, would I still think this symptom deserved medical attention?"
If the answer is yes, their psychiatric diagnosis should not prevent appropriate physical assessment.
3.4 Physical Illness Can Look Like Mental Illness
Another reason physical health matters is that some physical illnesses can produce psychiatric or behavioural symptoms.
For example, someone who becomes confused and agitated may initially appear psychiatrically unwell. However, particularly when the change is sudden, physical causes need to be considered.
Possible contributors can include:
infection
dehydration
low blood sugar
medication effects
alcohol or drug use
head injury
neurological illness
endocrine disorders
severe sleep deprivation.
The speed of change is particularly important.
A gradual deterioration over several months may suggest one pattern of illness. Someone becoming markedly confused, disorientated or behaviourally different over a few hours requires a different level of concern.
Clinical example
You visit a person you have supported for several months. They have schizophrenia but are normally calm, organised and able to hold a clear conversation.
Today they seem confused. They repeatedly ask what day it is, appear unusually sleepy and have difficulty following the conversation.
It would be unsafe simply to document:
"Mental state appears worse today."
The change may have nothing to do with their schizophrenia.
A significant and unexplained alteration in consciousness, orientation or cognition should prompt urgent clinical assessment.
3.5 The Physical Health Areas Case Workers Should Think About
Case workers do not need to perform a complete medical assessment during every contact. Instead, develop the habit of noticing several broad areas of physical wellbeing.
Weight, Diet and Metabolic Health
Changes in weight can be clinically important.
Some people gain significant weight after starting certain psychiatric medications. Others lose weight because of depression, anxiety, eating difficulties, substance use, financial problems or physical illness.
Rather than focusing only on appearance or numbers on a scale, explore change.
Has the person's weight changed noticeably? Are their clothes becoming much looser or tighter? Are they eating regular meals? Has their appetite changed? Are financial difficulties affecting access to food?
Avoid judgemental language.
A conversation about weight should be about health and wellbeing, not appearance.
Physical Activity
Regular movement can benefit both physical and mental health, but recommendations need to be realistic.
For someone who is relatively well, joining a gym or taking part in organised sport might be achievable. For someone recovering from severe depression, walking to the end of the road may represent meaningful progress.
Think in terms of increasing movement from the person's current baseline.
Ask:
"How active are you at the moment?"
rather than:
"Do you exercise enough?"
The first invites discussion. The second can sound like criticism.
Sleep
Sleep sits directly at the intersection between physical and mental health.
Poor sleep can worsen concentration, mood, anxiety, irritability and emotional regulation. Conversely, depression, anxiety, mania, psychosis, ADHD, trauma and substance use can all disturb sleep.
Physical disorders can also interfere with sleep.
If someone describes severe snoring, choking or gasping during sleep, repeated waking, restless legs or profound daytime sleepiness despite apparently sleeping for many hours, a physical cause may need assessment.
Again, the case worker does not diagnose the problem. Your job is to recognise that further assessment may be appropriate.
Smoking
Smoking remains an important physical-health issue in mental health populations.
A useful approach is to remain curious rather than judgemental.
Instead of repeatedly telling someone that smoking is unhealthy, ask whether they have ever considered reducing or stopping, what smoking does for them, what has made stopping difficult previously and whether they would like support.
Remember that nicotine dependence is an addiction, not simply a lack of motivation.
Alcohol and Drugs
Alcohol and recreational drugs can affect both physical and mental health and may interact with prescribed medication.
Ask about them routinely and without moral judgement.
People are considerably more likely to disclose substance use when they believe the professional is trying to understand rather than punish them.
If use appears harmful, escalating or associated with significant risk, this should be discussed with the appropriate clinician.
Oral Health
Dental health is sometimes forgotten in mental health care.
Depression can reduce motivation for brushing teeth or attending dental appointments. Some medications can cause dry mouth. Diet, smoking, alcohol and substance use may further affect oral health.
Persistent dental pain, swelling, difficulty eating or signs of infection should not simply be tolerated because someone has other more obvious mental health problems.
Helping someone register with a dentist or attend an appointment may be a very meaningful case-work intervention.
Sexual and Reproductive Health
Mental health care should not ignore sexual health.
Depending on the person's circumstances, this may include contraception, pregnancy, sexually transmitted infections, sexual functioning, medication-related sexual side effects and vulnerability to exploitation.
These conversations require sensitivity, privacy and awareness of professional boundaries.
You do not need to ask intrusive questions without reason. However, neither should important health concerns be avoided simply because they feel uncomfortable to discuss.
3.6 Severe Mental Illness and Annual Physical Health Checks
People with severe mental illness require particular attention to physical health.
In England, NHS guidance identifies six core components of the annual physical health check for people with severe mental illness:
Core physical health checkWhy it mattersBlood pressureHelps identify hypertension and cardiovascular riskBody mass index (BMI)Helps monitor weight and metabolic riskBlood glucose or HbA1cHelps identify diabetes or impaired glucose regulationLipid profileAssesses cholesterol and cardiovascular riskSmoking statusIdentifies an important modifiable health riskAlcohol consumptionIdentifies potentially harmful alcohol use
A more comprehensive review may also consider physical activity, diet, cardiovascular risk, liver health, vaccinations, cancer screening, oral health, sexual and reproductive health, substance use and medication monitoring.
What does this mean for a case worker?
You are unlikely to be responsible for carrying out these investigations unless you have received specific training and this falls within your role.
You may, however, discover that someone has repeatedly missed their physical health check.
That is where case work becomes important.
Rather than simply recording:
"Patient declined physical health review."
find out what actually happened.
Perhaps they did not understand why the blood tests were needed. Perhaps they are frightened of needles. Perhaps appointments are always offered early in the morning when medication makes them very sedated. Perhaps they cannot afford transport. Perhaps they become overwhelmed by telephone booking systems.
Once you understand the barrier, you may be able to help remove it.
3.7 "Don't Just Screen – Intervene"
NHS England uses an important principle in its guidance on physical health and severe mental illness:
"Don't just screen, intervene."
This principle applies very well to case work.
Recording that someone smokes 30 cigarettes per day achieves very little by itself.
Recording that someone has gained significant weight is not an intervention.
Discovering that someone has not seen a dentist for six years does not improve their oral health.
The next question should be:
"What happens now?"
Perhaps the person needs support to make a GP appointment. Perhaps they would like smoking-cessation support. Perhaps a clinician needs to review medication. Perhaps they need help registering with a dentist.
Case workers can often bridge the gap between identifying a problem and something actually being done about it.
3.8 Supporting Healthy Behaviour Without Becoming the "Health Police"
There is a danger that conversations about physical health become repetitive instructions:
"You need to lose weight."
"You need to exercise."
"You need to stop smoking."
"You need to eat better."
Most people already know these things.
A more useful approach is collaborative.
Instead of asking:
"Why aren't you exercising?"
try:
"What makes it difficult to be active at the moment?"
Instead of:
"You need to eat more healthily."
try:
"What are meals looking like for you at the moment?"
Instead of:
"You really need to stop smoking."
try:
"Have you ever thought about cutting down or stopping?"
The difference is important.
Your job is not to control someone's behaviour. It is to help them understand their options, identify barriers and make achievable changes if they want to do so.
3.9 Making Goals Small Enough to Succeed
Mental health difficulties can make large goals overwhelming.
Imagine someone with depression who spends almost the entire day indoors.
A goal of:
"Exercise for 30 minutes five times per week"
may sound sensible but be completely unrealistic.
A first goal might instead be:
"Walk outside for ten minutes on Monday, Wednesday and Friday."
If that becomes manageable, the goal can gradually increase.
This is the principle of graded change.
Small successful changes can build confidence. Repeated failure against unrealistic targets can do the opposite.
3.10 Barriers to Accessing Physical Healthcare
Sometimes the most useful thing a case worker can do is identify why healthcare is not being accessed.
Consider this example.
Case example: David
David is 48 and has schizophrenia. His GP practice has invited him for an annual physical health check several times, but he has not attended.
It would be easy to describe David as "non-compliant".
During a conversation, however, you discover that his antipsychotic medication makes him very sleepy in the morning. His GP repeatedly offers appointments at 8:30 am. David also becomes anxious on crowded buses and does not have money for taxis.
The problem suddenly looks very different.
The case worker might help David request an afternoon appointment, explore transport options, arrange reminders or, where appropriate, help him communicate his difficulties to the practice.
NHS England specifically encourages proactive engagement and reasonable adjustments to improve access to physical-health checks for people with severe mental illness.
Good case work often involves solving apparently small practical problems that have significant clinical consequences.
3.11 Medication and Physical Health: Staying Within Your Role
People may ask case workers questions such as:
"Is this medication making me gain weight?"
"Can these tablets cause headaches?"
"I feel much better. Can I stop taking them?"
It is important to stay within your professional role.
You can listen, document concerns and ensure that relevant information reaches the prescriber or another appropriate clinician.
You should not independently advise someone to stop, start or alter prescribed medication unless medication advice specifically falls within your professional scope and you are authorised to do so.
A useful response might be:
"That sounds like something we should make sure your prescriber knows about. Let's work out the best way of getting it reviewed."
This validates the concern without giving medical advice beyond your competence.
3.12 Recognising When Something May Be Urgent
Most physical-health issues encountered in routine case work are not emergencies. However, case workers must be able to recognise situations where delay could be dangerous.
Seek urgent clinical or emergency assistance in accordance with your service procedures if someone develops concerning symptoms such as:
severe difficulty breathing
significant chest pain
sudden collapse or loss of consciousness
signs suggestive of a stroke, such as sudden facial weakness, arm weakness or speech disturbance
a seizure, particularly if new or prolonged
severe bleeding
severe allergic reaction
significant head injury
sudden severe confusion
suspected overdose or poisoning
rapidly worsening physical illness
any other presentation in which the person appears seriously medically unwell.
You are not expected to diagnose the cause before seeking help.
That point is crucial.
If someone appears seriously unwell, the question is not:
"Can I work out what this is?"
It is:
"What is the safest way to get this person assessed?"
Follow local emergency procedures and escalate appropriately.
4. Clinical Perspective
Think "What Has Changed?"
Knowing the person is often one of the case worker's greatest advantages.
You may not know whether a pulse rate is clinically significant or how to interpret a blood result, but you may know that this person normally walks quickly, speaks clearly and remembers appointments.
Today they are breathless walking across the room, struggling to concentrate and appear unusually drowsy.
That change from baseline is clinically valuable information.
When escalating concerns, describe what you have actually observed:
"She is normally able to walk from her flat to the office without difficulty. Today she had to stop twice because she was breathless."
This is much more useful than:
"She didn't seem well."
Avoid Diagnostic Overshadowing
Never assume that a new physical complaint is "just anxiety", "part of the psychosis" or "attention seeking".
Mental illness and physical illness can occur simultaneously.
A psychiatric diagnosis should broaden your awareness of vulnerability, not narrow your thinking.
Ask About Basic Needs
When someone's mental health deteriorates, simple questions can reveal important problems.
Have they eaten today?
Are they drinking enough?
Have they slept?
Have they been taking their medication as prescribed?
Are they in pain?
Have they fallen or injured themselves?
Are they using more alcohol or drugs?
These questions are simple, but the answers can significantly change what needs to happen next.
Do Not Interpret Tests You Are Not Qualified to Interpret
If someone shows you abnormal blood-test results, do not feel pressured into explaining their medical significance if that falls outside your competence.
Help them obtain appropriate clinical advice.
Knowing the boundaries of your role is a professional strength.
Do Not Make Every Problem About Lifestyle
When someone has gained weight while taking medication, simply telling them to eat less can be dismissive.
When someone sleeps all day, telling them to "develop a routine" may miss medication-related sedation or physical illness.
When someone repeatedly misses appointments, labelling them "unmotivated" may miss anxiety, cognitive difficulties, poverty or transport problems.
Always ask:
"What might be making this difficult?"
before deciding that the answer is lack of motivation.
Escalate Changes That Do Not Make Sense
One of the safest principles for newly qualified practitioners is this:
If someone's presentation has changed significantly and you cannot explain why, seek clinical advice.
You do not need certainty before escalating.
Your responsibility is to recognise that something may require assessment.
5. Summary
Physical and mental health are deeply interconnected. Mental illness can increase vulnerability to physical-health problems, while physical illness can cause or worsen psychiatric symptoms.
People with severe mental illness experience substantial physical-health inequalities, making proactive attention to physical wellbeing an essential part of good mental healthcare. Annual physical-health monitoring is therefore an important component of care for people with severe mental illness.
For case workers, good practice does not mean becoming a medical practitioner. It means developing a broad awareness of physical wellbeing and recognising meaningful change.
Remember the four key actions:
NOTICE → ASK → SUPPORT → ESCALATE
Notice changes in someone's physical health or functioning.
Ask sensitively about what has changed and what barriers they are experiencing.
Support the person to access appropriate healthcare and make realistic improvements where possible.
Escalate concerns when symptoms require clinical assessment or fall outside your competence.
Perhaps most importantly, never allow someone's mental health diagnosis to prevent you from taking their physical symptoms seriously.
6. Further Reading
NHS England – Improving the Physical Health of People Living with Severe Mental Illness
This is particularly relevant to case workers because it considers not only physical-health monitoring but also engagement, reasonable adjustments, health inequalities and supporting people to access follow-up interventions. NHS England identifies six core elements of the annual SMI physical health check and recommends broader comprehensive assessment where appropriate.
NHS England – 10 Key Actions: Improving the Physical Health of People Living with Severe Mental Illness
A useful practical overview emphasising health inequalities, proactive outreach, comprehensive health checks, reasonable adjustments and the principle of "don't just screen, intervene".
NICE CG178 – Psychosis and Schizophrenia in Adults: Prevention and Management
Includes recommendations relating to physical-health monitoring and the metabolic effects of antipsychotic treatment.
NICE NG238 – Cardiovascular Disease: Risk Assessment and Reduction, Including Lipid Modification
Useful background reading regarding cardiovascular risk assessment, including consideration of severe mental illness as an important clinical factor.
7. Knowledge Check
Question 1
A person with a history of anxiety reports new episodes of palpitations. What is the most appropriate approach?
A. Assume they are panic attacks because the person has anxiety
B. Tell the person to practise breathing exercises
C. Recognise that physical causes may also need to be considered and seek appropriate clinical assessment
D. Advise the person to stop their psychiatric medication
Correct answer: C
A history of anxiety should not result in new physical symptoms automatically being attributed to anxiety. Appropriate medical assessment may be necessary.
A is incorrect because this risks diagnostic overshadowing.
B is incorrect because breathing exercises may sometimes help anxiety but should not substitute for assessment of unexplained physical symptoms.
D is incorrect because a case worker should not independently advise someone to discontinue prescribed medication.
Question 2
Which best describes diagnostic overshadowing?
A. A person refusing to discuss their mental health
B. Physical symptoms being incorrectly attributed to a person's mental illness
C. Two psychiatric diagnoses occurring together
D. Medication causing physical side effects
Correct answer: B
Diagnostic overshadowing occurs when physical-health problems are overlooked or inadequately investigated because symptoms are attributed to an existing psychiatric condition.
A, C and D are incorrect because they describe different clinical situations.
Question 3
Which of the following is one of the six core elements of an annual physical health check for people with severe mental illness?
A. MRI brain scan
B. Chest X-ray
C. Blood pressure
D. ECG in every person
Correct answer: C
Blood pressure is one of the core components alongside BMI, blood glucose/HbA1c, lipid profile, smoking status and alcohol consumption.
The other investigations may be clinically indicated in particular circumstances but are not universal components of the core annual SMI physical health check.
Question 4
A person with severe depression currently leaves their home only once per week. Which is likely to be the most useful initial physical-activity goal?
A. Attend the gym five days per week
B. Run five kilometres every morning
C. Agree a small, achievable increase in walking from their current level
D. Explain that exercise is entirely their responsibility
Correct answer: C
Behaviour change is more likely to succeed when goals are realistic and graded from the person's current level of functioning.
A and B are likely to be unrealistic and may reinforce a sense of failure.
D is incorrect because case workers can play an important role in supporting achievable health-related change.
Question 5
A person taking antipsychotic medication tells you they have gained considerable weight and asks whether they should stop their medication. What should you do?
A. Tell them to stop immediately
B. Tell them the weight gain is irrelevant
C. Acknowledge the concern and arrange for it to be discussed with the appropriate clinician or prescriber
D. Recommend that they halve the dose
Correct answer: C
Potential medication side effects should be taken seriously and communicated to the appropriate clinician.
A and D are incorrect because case workers should not independently alter prescribed treatment.
B is incorrect because weight gain may have important implications for physical health and treatment adherence.
Question 6
You visit someone with schizophrenia whom you know well. They are normally alert and organised but today are suddenly confused and very drowsy. What should you do?
A. Assume their schizophrenia has deteriorated
B. Wait until your next scheduled visit
C. Recognise the significant change from baseline and arrange urgent clinical assessment
D. Ask them to sleep and review them next week
Correct answer: C
Sudden confusion and altered consciousness can indicate significant physical illness and require urgent assessment.
A is particularly unsafe because it demonstrates diagnostic overshadowing.
B and D could result in a serious physical condition going untreated.
Question 7
A person has repeatedly failed to attend their GP for a physical health check. What is the best first response?
A. Record that they are non-compliant
B. Discharge them from case work
C. Explore why they are finding it difficult to attend
D. Tell them they must attend next time
Correct answer: C
Repeated non-attendance often has an underlying reason. Anxiety, sedation, transport difficulties, cognitive problems, financial difficulties or misunderstanding may all contribute.
A labels the behaviour without understanding it.
B is unlikely to address the underlying problem.
D may communicate the importance of attendance but does nothing to identify or resolve the barrier.
Question 8
Which statement best describes the case worker's role in physical healthcare?
A. Diagnosing common physical illnesses
B. Interpreting blood tests independently
C. Noticing concerns, supporting healthcare engagement and escalating appropriately
D. Adjusting medication when side effects occur
Correct answer: C
The case worker's role is generally to notice, ask, support and escalate.
A, B and D would usually fall outside the case worker's competence and professional role.
Question 9
Which is the best way to discuss smoking with someone receiving mental health support?
A. "You know smoking is bad for you, so you need to stop."
B. "Why haven't you stopped smoking yet?"
C. "Have you ever thought about cutting down or stopping, and would you like any support with that?"
D. Avoid discussing smoking because it is unrelated to mental health
Correct answer: C
A collaborative, non-judgemental approach is more likely to encourage an honest discussion and engagement with support.
A and B risk sounding critical or judgemental.
D is incorrect because smoking is an important physical-health issue and physical health forms part of holistic mental healthcare.
Question 10
Which principle should guide a case worker when they encounter a physical-health problem they do not understand?
A. Try to diagnose it before contacting anyone
B. Ignore it unless the person specifically requests medical help
C. Search online and recommend the most likely treatment
D. Recognise the limits of their competence and seek appropriate clinical advice or escalation
Correct answer: D
Case workers are not expected to know the diagnosis behind every physical symptom. Safe practice involves recognising potential concerns, working within professional boundaries and escalating appropriately.
A may delay appropriate assessment.
B risks overlooking significant illness.
C risks giving inappropriate medical advice outside the case worker's competence.
The safest principle is:
You do not need to know what is wrong to recognise that someone may need medical assessment.
