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
- Graham Thornicroft, professor of community psychiatry
- 1Health Service and Population Research Department, King’s College London, Institute of Psychiatry, London SE5 8AF, UK
The findings of a linked paper by Lawrence and colleagues (doi:10.1136/bmj.f2539) raise disturbing questions about our disregard for the duration and value of the lives of people with mental illness.1 It has been clear for more than 50 years that people with the more disabling forms of mental illness do not live as long as those without mental illness.2 This finding has been repeatedly reported across decades and continents.3 4 Evidence from low and middle income countries is sparse,5 6 despite poignant accounts from colleagues in such countries of people with severe mental illness being abandoned in forests or deserts when families can no longer cope. Lawrence and colleagues’ research covers new ground by focusing on reduced life expectancy among people with a broader range of mental illnesses, rather than those with severe conditions only. However, their results support the accumulating evidence that inequalities between those with and without mental illness are not improving.
For the past 20 years, the mortality gap among people with mental illnesses (around 15 years for women and 20 years for men) has not been closing in Australia or Scandinavia—two of the most affluent parts of the world with among the most accessible health systems.1 7 We are coming to understand that this excess mortality is not the result of higher suicide rates, but rather a combination of socioeconomic, healthcare, and clinical risk factors.8
What are the implications of these sobering findings? Three things are clear. Firstly, the time for descriptive research alone is over. We now need evidence based interventions that can reduce excess mortality. Such interventions may include smoking reduction or cessation in people with mental illness, or specific lifestyle programmes that seek to modify risk factors for cardiovascular, respiratory, and malignant diseases.9
Secondly, because of the sheer scale of the problem, it needs to be placed high on the public health priority list. Here there are signs of progress. In the United Kingdom, the Health and Social Care Act 2012 included a commitment to “parity of esteem” between mental and physical health, and as a consequence the NHS Mandate of 2012 requires the NHS to tackle disparities between mental and physical healthcare. Internationally, the World Health Organization Mental Health Action Plan, to be presented to the World Health Assembly in late May 2013, states as its overall goal: “To promote mental wellbeing, prevent mental disorders, and reduce the mortality and disability for persons with mental disorders.”10 Another vital opportunity arises as David Cameron (UK), Ellen Johnson Sirleaf (Liberia), and Susilo Bambang Yudhoyono (Indonesia) co-chair the high level panel on the post 2015 development agenda, to set the targets to follow the millennium development goals. This panel must fully include the interests of people with mental illness within its global vision.
Thirdly, this huge loss of life among people with mental illness needs to be recognised as a human rights disgrace. Despite the “right to health” having become law in 126 countries worldwide (through their ratification of the United Nations Convention on the Rights of Persons with Disabilities),11 it has not been implemented into effective action. Measurable progress has now been made in treatment coverage for people with major global communicable diseases, such as HIV. However, there are no internationally agreed standards to measure how many people with mental illnesses need treatment; how many are treated; how effective treatments are; and what the mental and physical outcomes of treatment, undertreatment, or no treatment are. This last point is no exaggeration: the world mental health surveys showed that in some countries the prevalence of treatment for severe mental illness is as low as 2%.12 We continue to disregard the physical health needs of people with mental illness and act as if they are of less worth than others.13 We now know that these forms of discrimination can have lethal consequences.
Cite this as: BMJ 2013;346:f2969
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.
Provenance and peer review: Commissioned; not externally peer reviewed.