Premature death among people with mental illnessBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2969 (Published 21 May 2013) Cite this as: BMJ 2013;346:f2969
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In his editorial reviewing premature deaths in people with a mental illness, Graham Thornicroft blamed a combination of socioeconomic, healthcare, and clinical risk factors, and charactarised the scandal as a human rights disgraces. (1)
A 2010 ICM survey carried out on behalf of Mencap showed that more than a third of doctors and nurses think the NHS discriminates against patients with a learning disability, and approaching half of doctors (including 61% of GPs) considered they receive lower standards of healthcare (2)
The recent Confidential Inquiry into premature deaths of people with a learning disability, recommended by the 2008 Michael Inquiry, established that the deaths of 38% of people with a learning disability were amenable to change by good-quality healthcare, as compared to only 9% of a comparator group comprising people without a learning disability (3). The risk of someone with a learning disability dying as a result of inadequate medical care is over four times that of the rest of the population.
The most important insight into the Government's response to the Michael Inquiry, Valuing people now, lies in a foreword conspicuously signed by six Secretaries of State (4). This Executive display of ownership underlined the authority behind a conviction echoed throughout a report in which the term human rights was used fifty four times - that for people with a learning disability to enjoy the same opportunities as everyone else means using a human rights based approach.
The 2012 report on research led by Professor Marmot into social determinants of health in Europe, confirmed that the circumstances in which people are born, grow, live, work, and age, influence health, and noted that the empowerment of society essential to improving health requires recognising individual’s fundamental human rights. (5)
The editors of the first edition of the textbook Mental health and human rights consider that the disciplines of human rights and mental heath converge as fields of research and practice that intersect in multiple and complex ways (6). Within its 662 pages are chronicled the multiplicity, diversity and cruelty of abuses perpetrated against people with a mental illness. The scale of the historically cumulative crime committed against people with a mental illness globally may dwarf that of any other group (7).
Professor Thornicroft endorsed article 25 of the Convention on the Rights of Persons with Disabilities, which is mainly restricted to the proscribing discrimination in healthcare (8). However, the most authoritative right to the highest attainable standard of physical and mental health - Article 12 of the International Covenant on Economic, Social and Cultural Rights (9), as comprehensively defined by the 65 paragraph explication of health-specific rights known as General Comment 14 - also proscribes discrimination, applies to everyone, and has been ratified by more than four in every five countries (10).
During the GMC’s consultation over the current edition of Tomorrow’s Doctors, Doctors for Human Rights cited Valuing people now when urging that medical students receive human rights education. The reward was the stipulation, that graduates “recognise the rights and the equal value of all people and how opportunities for some people may be restricted by others’ perceptions". However, abolishing discrimination, albeit unconscious, against marginalised groups requires the profession observe human rights values in everyday medical practice - which means formal human rights education.
1. Thornicroft G. Premature death among people with mental illness. BMJ 2013;346:f2969 (21 May)
2. Perceptions of the care and treatment of people with a learning disability in the NHS according to health professionals in England, Wales and Northern Ireland. Mencap. ICM Poll. June. 2010.
3. Heslop P, Blair P, Fleming P et al. Confidential Inquiry into premature deaths of people with learning disabilities. p92. Norah Fry Research Centre. 2012. http://www.bris.ac.uk/cipold/fullfinalreport.pdf
4. Valuing people now: a new three-year strategy for people with learning disabilities (initial edition). p2. Department of Health. 19th January 2009. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.g...
5. Marmot M, Allen J, Bell R, et al. WHO European review of social determinants of health and
the health divide. Lancet 2012; 380:1013
6. Dudley M, Silove D, Gale F. Mental Health and Human Rights: Vision, Praxis and Courage. p1. Oxford University Press. 2012.
7. Hall P. Book Reviews. BJPsych, 2013; 202: 387
8. United Nations. Convention on the Rights of Persons with disabilities. UN. 2006
9. United Nations. International Covenant on Economic Social and Cultural Rights. Geneva: UN, 1976 http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx
10. United Nations. The right to the highest attainable standard of health. Geneva: UN, 2000. (General comment No 14.) http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En
Competing interests: I have specialised in physical healthcare for people with a learning disability in hospitals, the community, and a hospice over 46 years. I played a role in the development of the UN General Comment 14 of the International Covenant on Economic, Social and Cultural Rights.
One of the reasons for those with a diagnosis of mental illness still languishing in the long grass of indifference, ignorance and worse is because of the time-expired practice of dividing life and living into mental and physical domains in the first place. How is it possible to change ones mind, thinking or behaviour without there being an associated change in physical state? Further, the mind is embodied, not just embrained and changes in mind-state influence our entire physical body; similarly, changes in bodily state, or organ-system elements of it, influence our thinking and emotional state.
Unless and until we move on from Descartes and abandon the notion of our physicality being separate from, or differently originating our mentality, we will continue to stigmatise and discriminate against those who are some of the most physically distressed, disordered and diseased in our various nations.
Dr Chris Manning MRCGP
Competing interests: No competing interests
As Thornicroft suggests, investing in smoking cessation interventions may be a key method to help reduce the premature mortality associated with mental illness. The report entitled 'Smoking and mental health', issued by two royal colleges earlier this year(1) highlights that this is a significant public health issue that requires action from clinicians across the healthcare system. It has been suggested that false assumptions from healthcare staff that smoking cessation may exacerbate mental illness or that traditional cessation strategies are unlikely to work in this group, are potential barriers to implementing these services(2). We must, therefore, ensure that all health professionals recognise that smoking cessation is both an important and achievable goal for these patients.
1. Royal College of Physicians, Royal College of Psychiatrists. Smoking and mental health. London: RCP 2013.
2. The Lancet. Smoke alarm: mental illness and tobacco. Lancet
Competing interests: No competing interests