Re: The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers
We commend Lawrence et al’s article on excess mortality in people with mental disorders, which is timely in view of the release of findings from the Global Burden of Disease 2010 Study (GBD 2010). Mental and substance use disorders are estimated to be the leading cause of burden in the UK amongst persons aged 5 to 49 years. The majority of burden is explained by time spent in ill-health; only 5% is attributed to premature mortality, which may lead to the mis-interpretation of summary findings that mental disorders have little impact on death.
Despite the enormous effort that went into GBD 2010, there are important limitations. In GBD calculations each death must be attributed to a single cause. Vital records, from where most data was drawn, identify the condition most directly related to loss of life. For example, in the UK, this is ischaemic heart disease (IHD), lung cancer and stroke. Deaths where other disorders, such as mental disorders, contribute are largely overlooked and the implication of this is that premature mortality in those with mental disorders was likely to have been underestimated in GBD 2010. As such, the low mortality estimates attributed to mental disorders in GBD 2010 cannot be interpreted as providing grounds to allocate a low policy priority to, not only the psychological health, but also the physical health of people with mental illness.
A person with a severe mental disorder can expect to live 10 to 20 years less than a person without a mental disorder and the life expectancy gap is increasing[2,3]. In the UK adults with a severe mental disorder are three times more likely than the general population to die of IHD and up to 80% more likely to die of stroke. The relationship between mental disorders and increased deaths due to chronic disease is complex.
Major modifiable risk factors for chronic disease, such as smoking, poor diet and physical inactivity, are overrepresented, yet more tolerated, in people with mental disorders. This is despite the availability of programs to address modifiable risk factors, for instance smoking cessation. In addition to unhealthy behaviours, mental disorders are in their own right considered an independent risk factor for diseases such as CHD[6,7].
Inequalities in access to and use of health services are well documented in people with mental disorders. Physical health issues are overshadowed by the presence of mental disorders as health service providers may attribute symptoms of physical illness to the co-occurring mental disorder and associated medications. Evidence shows that those with mental disorders receive lower than average prescriptions for CVD and are less likely to receive usual procedures. In the same issue of the journal, the editor points out that the continuing life expectancy gap in persons with mental disorders is a clear example of discrimination and lack of parity between this portion of the population and the community in general.
Whilst summary measures of disease burden have been important in recognising the impact of impaired health as well as premature death, the limitations of a single metric mean these alone cannot provide the information needed to develop effective health policies. The Royal College of Psychiatrists has, for example, provided comprehensive information making the case for parity between mental and physical disorders in policy, commissioning and service delivery, including in responding to premature mortality (see http://www.rcpsych.ac.uk/files/pdfversion/OP88xx.pdf).
There are effective interventions for CVD and other chronic disease which will improve outcomes in people with mental disorders[9,10]. Public health agencies and service providers need to take a decisive approach to integrating mental and physical health care. Beyond broad promises to ‘address’ the issue, health providers require integrated models of care to a) provide usual treatments for physical health problems in those with mental disorders, and b) ensure programs for risky behaviours such as smoking are in place that target the mentally ill and socially excluded. Our group is currently conducting a systematic review of interventions in people with mental disorders to prevent premature mortality. Although many effective interventions exist, their relative merits and effect sizes need to be investigated. Integrated treatment programs may be the best approach to reducing the life expectancy gap reported by Lawrence et al, and these deserve further investigation so that decision-makers can integrate best knowledge into policy and service planning.
1. Murray CJL, Richards MA, Newton JN, Fenton KA, Anderson HR, Atkinson C, et al. UK health performance: findings of the Global Burden of Disease Study 2010. The Lancet 2013;381(9871):997-1020.
2. Lawrence D, Hancock KJ, Kisely S. The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers. Br. Med. J. 2013;346.
3. Thornicroft G. Premature death among people with mental illness: At best a failure to act on evidence; at worst a form of lethal discrimination. British Medicial Journal 2013;346.
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11. Watts C, Cairncross S. Should the GBD risk factor rankings be used to guide policy? The Lancet 2012;380(9859):2060-61.
Competing interests: No competing interests