Lancet Commission to Tackle Health Inequalities in Mental Illness
Behaviors and lifestyle factors such as suboptimal eating habits, reduced adherence to medication regimens, and smoking increase the risk of physical illness.
The impact of mental illness on physical health has been documented since at least 1932, when statistician and epidemiologist Benjamin Malzberg published a study showing that compared with the general population, patients with mental illness died 10 to 14 years sooner, and compared with individuals of the same age, had mortality rates that were 3 to 6 times higher.1 Contemporary estimates show an even greater impact of mental illness on mortality, with some estimates suggesting that the lifespan of people with mental illness is reduced by up to 25 years, largely due to an excess risk of cardiovascular disease.2,3 Patients with serious mental illnesses are twice as likely to be obese, 2 to 3 times more likely to have metabolic syndrome, 3 times more likely to have diabetes,2 and 5 times more likely to have emphysema.4
Several factors that contribute to the excess burden of poor health in patients with mental illness have been identified. Behaviors and lifestyle factors that increase the risk of physical illness — such as suboptimal eating habits, reduced adherence to medication regimens, increased smoking, and risky sexual behaviors — are highly prevalent among people with mental illness.5 Medications used to treat psychiatric conditions can contribute to metabolic dysregulation.3 Additionally, some researchers have posited that the frequent comorbidity of metabolic disorders and serious mental illnesses may be due in part to shared genetic pathways leading to abnormal functioning in the immunometabolic and endocrine homeostasis systems.6 Genome-wide association studies and candidate gene studies have begun to identify the specific genetic variants that may be responsible for this connection.6 A growing body of evidence has demonstrated that systemic barriers are also at play, including the frequent absence of coordination between mental and physical health service settings, poor continuity of care, and uncertainty among clinicians about who is responsible for the physical health of patients treated for mental illness.7
In order to summarize recent advances, identify high priority areas, and present updated recommendations regarding physical health inequalities in patients with mental illness, an official Lancet Commission titled 'Improving Physical Health Outcomes in People with Mental Illness' will be launched at the 19th WPA World Congress of Psychiatry to be held in Lisbon, Portugal, in August 2019. The commission is composed of researchers, clinicians, and key stakeholders from a wide range of backgrounds and professional or personal experience in the topic. For more information on the Commission, Psychiatry Advisor interviewed its chair, Joseph Firth, PhD, research fellow at the NICM Health Research Institute at Western Sydney University in Sydney, Australia.
Psychiatry Advisor: What is the background on the formation of this Lancet Commission?
Dr Firth: Lancet Commissions are special taskforce-based documents that draw on the latest research and global expertise to produce novel solutions and recommendations for an emergent issue in medicine/healthcare, across 5 or 6 individual but related specific sections on a broader topic. One such topic is the drastic physical health inequalities experienced by people with mental illness, which is currently regarded as a human rights scandal.
The upcoming Commission on ‘Improving Physical Health Outcomes in People with Mental Illness' began in April 2018 after initially being proposed by myself, Prof Eoin Killackey (ORYGEN Centre of Excellence in Youth Mental Health, Melbourne), Prof Christoph Correll (Hofstra Northwell School of Medicine, New York), and Dr Brendon Stubbs (King's College London), with the guidance of the editors of The Lancet Psychiatry.
Since then, the researchers have brought together a team of more than 30 international experts across multiple fields of medicine including psychiatrists, psychologists, endocrinologists, primary care physicians, service users and carers, and allied health professionals. The process has begun with developing the scope and different sections of the Commission, which has resulted in identification of several key novel themes, such as:
- Aiming to determine physical health inequalities and their causes across multiple psychiatric conditions, including both common and severe mental illnesses;
- Building upon recent policy documents addressing premature mortality, to also examine the consequences of physical health comorbidities for quality of life, functioning, and psychosocial well-being from the very onset of illness;
- Creating implementation-focused recommendations to combat these inequalities across multiple health services and different settings; and
- Capitalizing on novel technologies and improving early intervention for physical health in psychiatry to prevent inequalities from arising in the next generation of psychiatric care.
The Commission in now in the process of synthesizing existing top-tier evidence for each of the topics addressed. Following this, the Commission aims to build from the existing evidence and fill in any crucial gaps in knowledge in order to produce evidence-based and practical recommendations for changes that can occur at the individual level, in psychiatric services, and for public health commissioning in order to improve physical health outcomes in people with mental illness. Throughout this process, the researchers will work closely with healthcare professionals across various disciples and settings (including those in low-income countries), service users, carers, and health economists to maximize the real-world applicability of the solutions presented. Where clear solutions are not currently available from the given evidence base, the Commission will produce key research questions to be addressed by the future studies required to determine the best path forward in these unknown areas.
Psychiatry Advisor: What should be the role of the psychiatrist in addressing the physical health issues that frequently accompany mental illness?
Psychiatric services all over the world are often underresourced and overstretched, making it difficult and impractical for future responsibilities to be piled upon existing staff. Thus, this Commission aims to explore novel and cost-effective methods for providing additional physical health support in psychiatric and primary care services through integration with allied healthcare professionals and through improving the accessibility of community-based and public health initiatives for people with mental illness. However, a dedicated section of the Commission will aim to provide the most recent, evidence-based advice for optimizing psychiatric prescribing for improving physical health outcomes.
- Malzberg B. Life tables for patients with mental disease.J Am Statistical Assoc. 1932;27(177):160-174.
- Scott D, Happell B. The high prevalence of poor physical health and unhealthy lifestyle behaviours in individuals with severe mental illness.Issues Mental Health Nurs. 2011;32(9):589-597.
- Penninx BWJH, Lange SMM. Metabolic syndrome in psychiatric patients: overview, mechanisms, and implications.Dialogues Clin Neurosci. 2018;20(1):63-73.
- Himelhoch S, Lehman A, Kreyenbuhl J, Daumit G, Brown C, Dixon L. prevalence of chronic obstructive pulmonary disease among those with serious mental illness.AJP. 2004;161(12):2317-2319.
- Cohen S, Rodriquez MS. Pathways linking affective disturbances and physical disorders.Health Psychol. 1995;14(5):374-380.
- Evans TS, Berkman N, Brown C, Gaynes B, Weber RP. Disparities within serious mental illness. Rockville, MD: Agency for Healthcare Research and Quality (US); 2016.
- Lawrence D, Kisely S. Inequalities in healthcare provision for people with severe mental illness.J Psychopharmacol. 2010;24(4_supplement):61-68.