Breaking down barriers to good physical health
By Dr. Steve Kisely and Leslie Anne Campbell
Autumn 2010, Volume 14 No 1
Physical and mental illnesses are closely related. Mental health problems can increase the risk of developing diabetes, heart disease and stroke. Depression, for example, is not only a serious chronic illness; it is also a major risk factor for heart disease and cancer. At the same time, strong evidence indicates that mental health is important in coping with stressors and maintaining good physical health and healthy lifestyle practices.
These inter-relationships can have fatal consequences. Mortality risk is more than 70 per cent higher in people with mental illness than the general population, even after adjusting for demographics such as socio-economic status. Excess risk of mortality from chronic physical disorders, including cardiovascular disease, cancer and chronic lung disease, is 10 times that of suicide, yet it receives far less attention. A meta-analysis of mortality in schizophrenia by Saha and colleagues, published in the Archives of General Psychiatry in 2007, identified 36 studies drawn from 19 different countries. It found increases for all causes of death apart from cerebrovascular disease. Unexpectedly, the review also found that the differential mortality gap associated with schizophrenia was increasing. These data suggest that people with mental illness have not shared in the improved health of the general community.
Although lifestyle factors such as obesity and alcohol or tobacco use are often suggested as an explanation for increased mortality among individuals with psychosis, they are unlikely to be the sole explanation. Hamer and colleagues in the Archives of Internal Medicine in 2008 found that all-cause mortality remained high, even after adjusting for behavioural risk factors such as smoking, physical activity and body mass index. In the case of cancer, our paper published in 2008 in the Canadian Journal of Psychiatry found that mortality rates for some cancers were 65 per cent higher for people with mental illness than for the general population, even though incidence rates were similar. It is unlikely that lifestyle explains this finding, as otherwise, incidence should better reflect the increased mortality.
Prescribed medication can also predispose to physical illness through mechanisms such as weight gain. The largest group of medications associated with weight gain are those used for psychiatric conditions and include the most commonly used antipsychotic agents and mood stabilizers and several antidepressants.
Another explanation for increased mortality might be that physical illnesses go unrecognized among people with severe mental illness. Reasons might include the tendency for people with psychosis to be less likely to report a medical complaint and to have more difficulty interpreting physical symptoms or distinguishing them from symptoms of their mental illness. These individuals may also be less able to problem-solve and care for themselves.
A 2007 article in Family Practice by Roberts and colleagues reported that even when physical health problems are diagnosed, people with mental illness are less likely to receive adequate treatment for their physical health problems. This is despite the fact that physician consultation rates are higher among people with severe mental illness. For instance, Hippisley-Cox, among others, reported that people with mental illness are less likely to have a physical examination or to be assessed and treated for hyperlipidemia (abnormally high level of lipids, especially cholesterol). They are also less likely to be screened for cancer. Our preliminary data suggest that delays in initial presentation lead to more advanced cancer at diagnosis.
Management of physical health in secondary health services may be no better. Of particular concern is that people with severe mental illness such as schizophrenia are less likely to receive common medical or surgical interventions. In the Canadian Medical Association Journal in 2007, we found that people with mental illness and circulatory disease were less likely to receive specialist interventions such as cardiac catheterisations and coronary artery bypass grafting than the general population, despite their significantly higher mortality rates. Last year, we reported in the British Journal of Psychiatry that people with mental illness were also less likely to receive appropriate medications on discharge following heart attack.
All these data suggest that even when people with psychiatric conditions have their comorbid physical illness detected by the health system, they are not afforded the same level of active treatment as the general community. This may reflect practical difficulties in engaging these individuals in complex health systems, including a lack of co-ordination between mental health services and the general health sector. Shander, writing in JAMA 10 years ago, suggested that physicians are reluctant to offer some procedures because of the ensuing psychological stress, concerns about capacity or adherence with post-operative care or the presence of contra-indications such as smoking. Daumit and colleagues, in a 2005 paper in the Archives of General Psychiatry, also suggested that people with mental illness may be at higher risk of developing complications following medical or surgical interventions or have poorer outcomes post-operatively.
These explanations are less applicable to the prescription of medications known to reduce morbidity and mortality. Contra-indications to specialized interventions, such as smoking or problems with informed consent, are less relevant to the prescription of vascular drugs such as ACE inhibitors, beta blockers or statins. The concern is, therefore, that appropriate treatments are not offered because of the stigma of mental disorders in general medical settings. For instance, Goodwin’s 1979 article in JAMA suggested that some primary care physicians may see people with severe mental illness as being disruptive to their practices or may feel uncomfortable treating them. In a 2009 BMC Family Practice article, Fleury and colleagues reported that lack of expertise also contributed to the reluctance of general practitioners to take on patients with serious mental illness. With a shift toward community care of people with serious mental illness comes the need for improved education of primary care practitioners.
Dr. Steve Kisely is director of Health LinQ at the University of Queensland in Australia and an adjunct professor in the Department of Psychiatry and the Department of Community Health and Epidemiology at Dalhousie University in Halifax, Nova Scotia. Leslie Anne Campbell is a lecturer in these departments and a research co-ordinator with Capital Health in Halifax.
Fast facts about physical health and mental illness
Compared to the general population, people with severe mental illness are:
- 2.5 times more likely to die from cardiovascular disease
- more than twice as often overweight or obese
- more likely to develop type 2 diabetes
- less physically active
- more likely to smoke, and smoke heavily
- 3.5 times more likely to have liver disease and cirrhosis
Source: Activate: Mind and Body
Risk factors for the development of depression in physical illness
- past history of psychiatric disorder
- illnesses or treatments affecting central nervous system
- chronic painful, disabling or disfiguring illness hindering self-care
- life-threatening illness
- major and unpleasant treatments
- lack of social support
- sense of loss associated with serious medical illness
- effects on body image, self-esteem, sense of identity
- impaired capacity to work and maintain relationships
Source: Siobhan MacHale, “Managing depression in physical illness,” Advances in Psychiatric Treatment, 2002.
Chronic disease management in Ontario
Improving chronic disease prevention and management (CDPM) is a priority in Ontario’s health care agenda. The Canadian Mental Health Association – Ontario division, in partnership with other organizations, is working to define the place of mental illness and mental health within the CDPM framework. To read about policy and research related to CDPM, visit CMHA Ontario’s website and read the public policy paper, “Chronic Disease Prevention and Management.”
The Ontario Chronic Disease Prevention Alliance has developed messages for use by individuals, groups and organizations to promote action on chronic disease prevention. The messages address five chronic disease risk factors: high-risk alcohol consumption, physical inactivity, poor mental health, tobacco use exposure and unhealthy eating.