Many people will be relieved that Congress did not repeal the Affordable Care Act. Whilst those of us with an interest in mental health have a cause to celebrate we cannot rest on our laurels because for many people with mental health conditions face a continuous struggle for access to health.
The current situation
People with severe mental disorders such as schizophrenia and bipolar disorder die 10 to 20 years earlier than the general population. There has been little progress in addressing this health disparity and we need new ways to tackle this inequality such as that proposed in a recent 2017 review published in World Psychiatry by a group of international opinion leaders.
Factors that need to be considered
The 2017 review in World Psychiatry reminds us that excess mortality in people with mental health conditions is not due to a single factor but due to many things that interact. It suggests that these include:
- individual factors
- Health system factors
- Non- medical factors such as the social determinants of health
At the level of the individual with a mental health problem lifestyle factors such as tobacco use, poor diet, lack of physical activity, substance misuse, sexual and other risk taking behaviors make a contribution to premature death.
When they looked at the systems level the authors suggested that poor leadership and an absence of policies, reduced access to health financing, poor co-ordination of services and poor access to care make a significant contribution to premature death.
The non-medical factors that they considered important in leading to premature death were discrimination in public policy that sometimes forgets to include mental health, limited coverage in health packages, higher levels of unemployment and poor housing, mental health stigma and discrimination in public attitudes.
Targets for change
Quite rightly, the authors of this review suggested that the approach to decrease the rate of premature mortality in those people with mental health problems has to be multi-level, so that each factor contributing to premature death can be tackled simultaneously in a holistic way in order to increase the chances of success.
We need to use the opportunity of the continuation of the Affordable Care Act to galvanize our efforts so that people with mental health conditions can have the same access to help that many people take for granted. We need attitudes towards mental health to change at individual and community level, we need activists who will fight for mental health at local and national government level and at International level.
There are many global initiatives specifically targeting an improvement in mental health outcomes using social, economic and medical interventions with the aim of improving on the current projections for global mortality and burden of disease by 2030. For instance, the Comprehensive Mental Health Action Plan 2013-2020 has set local, global and national targets for countries to meet including mental health promotion and prevention. Bringing together primary care, secondary care and community resources using a collaborative approach will go a long way towards improving the life expectancy of those with mental health conditions.
Public policy as a treatment intervention
We need to use policy change as a tool to deliver care packages. Public policy should also be considered as a treatment intervention in its own right because it has the power and potential to make change to people’s lives.
There has been a systematic failure of many health care systems in preventing, identifying and treating physical diseases in mental health conditions partly through a failure of recognition that a policy is a care package not just a tool. This is a new way of thinking that needs to be recognized by those who purchase and commission services.
There is a need to have combined mental and physical health guidelines to address both screening and treatment using a collaborative approach to care which delivers health promotion, reinforces the role of the individual and self-care and the need for research that is rooted in day to day clinical practice so that we can continue to apply those interventions that we know will work.
We can no longer continue to treat the statistics about poor outcomes in mental disorder as if that is all that can be expected. Every life matters, and that includes lives affected by mental ill health.
- Liu NH, Daumit GL, Dua T et al. Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas. World Psychiatry 2017; 16(1):30-40 http://www.wpanet.org/uploads/Publications/WPA_Journals/World_Psychiatry/Past_Issues/English/World_Psychiatry_February-2017.pdf
- Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLOS 2006; 3(11):2011-2030 doi:10,1371/journal.pmed.0030442
- World Health Organization. Comprehensive mental health action plan 2013-2020. Geneva: WHO 2013
- Ivbijaro GO. Excess mortality in severe mental disorder: the need for an integrated approach. World Psychiatry 2017; 16(1):48
Professor Gabriel Ivbijaro MBE JP MBBS FRCGP FWACPsych MMedSci MA IDFAPA
President WFMH (World Federation for Mental Health) & Chair The World Dignity Project
The Wood Street Medical Centre, 6 Linford Road, Walthamstow, London E17 3LA, UK
Tel: 020 8430 7715 Mobile: 07973 175955