What about the rest of me?

by Janet Meagher AM

Despite unprecedented investment in Australia’s mental health system in recent years and the establishment of the National Mental Health Commission to help drive a stronger, more coherent and equitable, response to mental health, it is becoming apparent that many people who use our system are struggling more than was previously acknowledged. The largely under-recognised burden of physical disease is rapidly testing our ability to improve quality of life and recovery outcomes for people who live with mental health issues.

People with a mental illness have a life expectancy that is from 10 to 32 years less than the general population. That statistic will surprise a lot of people. Similarly, the death rate for people with a mental illness is two-and-a-half times greater than for the general population – and the disparity is not attributable to suicide rates.

Mental health consumers are at higher risk of chronic physical health conditions such as diabetes, heart disease, and obesity, and have much higher mortality rates from all main causes compared to the general population. This is due primarily to the effects of mental illness and its medications. However, reduced access to healthcare including timely screening, assessment and treatment, also has an impact.

For people living with mental illness, poor health does not happen in isolation from the effects of the prescribed medications, the person’s genetic makeup and the more sedentary lifestyle to which mental illness contributes. People living with mental illness have a 30% higher chance of dying from cancer compared to the general population, yet the occurrence of cancer is statistically similar to that of the general population. Death rates are higher because access to screening and treatment comes too late in the trajectory of the cancer.

Regrettably, a higher risk of premature death is not confined to those with ongoing mental illness – depression is now known also to increase the risk of death from heart disease.

These health disparities are greater for people living with a psychotic disorder as well as for Aboriginal and Torres Strait Islander Australians (see Pat Dudgeon and Tom Calma’s article). People with illnesses such as bipolar disorder or schizophrenia have cardiac problems, metabolic or endocrine disorders (diabetes and obesity) at much higher rates than the rest of the community. For these two groups, cardiovascular disease and mental illness have been found to be the two leading drivers for their unacceptable burden of disease.

The national survey of psychotic illness exposed the extent of physical health problems for people in this group:

  • Diabetes rates at over three times those found in the general population.
  • One third carrying the risk of a cardiovascular event within five years.
  • Half affected by metabolic syndrome, which is associated with an increased risk of cardiovascular disease and diabetes as a side effect of prescribed antipsychotic medications.

Most Australians are not aware that treatment with prescribed psychiatric medications can seriously affect physical health and longevity. Where antipsychotic medications and treatments increase risks, prescribers need to ensure they respond appropriately in particular with:

  • Routine reviews of medication regimes.
  • Use of psychosocial/ talking therapies as alternatives to pharmaceuticals alone.
  • Screening for known risk elements.
  • Avoiding polypharmacy (multiple medications) whenever possible.

As professionals, planners, funders, service users and advocates, we must ask ourselves, how did we omit this for so long, and what can we do about it?

We know from one study that while nearly 90% of people living with psychosis had visited a general practitioner (GP) in the past year, two‑thirds reported they did not have a general health check or a cardiovascularrelated health check during the visit. It is estimated that only one in five people with a mental illness has a mental health treatment plan from their GP and that those plans usually do not refer to physical health checks or improving physical health.

The persistent and significantly higher levels of cardiovascular disease for people with persistent mental illness indicates a lack of understanding of how to implement interventions and service protocols to reduce risks, such as motivating individuals and introducing and encouraging selfmanagement programs that target weight, blood glucose, lipid control and physical activity.

Barriers to coordinated management
Evidence suggests that there are significant barriers to effective, coordinated management of co-existing physical and mental health conditions, including:

  • People with a mental illness being treated solely for symptoms of mental illness.
  • Poor recognition of the relationship between mental health and physical health.
  • Primary healthcare professionals’ lowconfidence or discriminatory response to whole-person care when working with people who have a mental illness.
  • Mental health workers’ unwilling or slow response to medical health issues.
  • Concerns of people with a mental illness about using the services from transport and access to discrimination.

In its first-ever national report card on mental health and suicide prevention, the National Mental Health Commission (NMHC) found that the low levels of physical health monitoring of people with mental illness made it difficult to know how best to increase that monitoring and close the gap on life expectancy for people with complex and demanding health needs.

Nevertheless, the Commission made several recommendations regarding further research into the metabolic side effects of psychiatric medications, as well as improved primary care service protocols more actively to address the physical health needs of people experiencing mental illness, with particular reference to the disproportionate prevalence of cardiovascular disease among people with mental illness.

Encouragingly, a national summit held May 24, 2013, discussed how to address increased mortality in the mental health consumer population. The May Summit Communiqué reported that:
The Summit agreed to a new national commitment to reversing the trend of people with a serious mental illness dying early and experiencing disproportionately adverse health outcomes with this to be based on the following principles:

  • People with severe mental illness should have the same expectations of a rich and contributing life as the general population. This includes having good mental health, physical health and wellbeing as well as the same access to timely and quality healthcare and the other supports and services critical to a contributing life.
  • To achieve these improvements, there is a need for the active engagement of all relevant portfolios across governments, noting the importance of a rehabilitation and recovery framework.
  • Any action to reverse this trend must be informed by the experience and knowledge of individuals living with mental illness and also that of their families and carers.
  • Improving the physical health of people with severe mental illness requires the active engagement and participation of all levels of healthcare and across all specialities particularly with regard to primary healthcare.

To progress action, it was agreed that immediate attention would be given to developing a series of commitments across jurisdictions, with further detail on implementation including targeted outcomes to be provided in due course.

Where does this leave us?
We must continue to support action on more effective service delivery for dealing with the unacceptable levels of morbidity and mortality linked to poor physical health among people affected by mental illness. This work is urgent. Acknowledging that it will take time we must, in accelerating our responses, ensure that our approaches are consistent, based on sound consumer empowerment and health promotion principles, and are tailored to meet the real needs of mental health consumers and those who support their efforts to get health equity and an all-round better deal.

With government interest and policy development and planning approaches underway, it is timely that we address the largely unspoken dynamic that underpins much of the historic oversight in this area of mental health – that people experiencing mental illness are still primarily defined by their mental illness, as needy and to be managed, rather than seen as a whole person with potential and a right to have a healthy, worthwhile contributing life.

It is time we shone some light on attitudes in clinical practice and challenge the shroud that a psychiatric diagnosis brings to other symptoms and markers.

How often do medical people pass off physical symptoms as psychosomatic? Why do not we undertake routine cardiovascular and metabolic investigations in mental health practice? Do we listen and observe, do we offer or refer to appropriate screening and health promotion services?

We can, and must, do better. Better practice is driven as much by progressive attitudes as by clinical protocols. Mental health consumers can tell the difference, and are much more likely to work in partnership with services that acknowledge their broader health needs in meaningful ways.

Unless we seriously reflect on how much we perpetuate the life expectancy gap for people with mental illness, we will never close it.

Janet Meagher AM is a former National Mental Health Commissioner, mental health consumer activist and advocate for over 30 years

This article is reproduced with the permission of Janet Meagher and MHAustralia.