ABSTRACT
People with severe mental illness are 4.5 times more likely to die prematurely than the general UK population. We review the drivers of poorer physical health across mental health conditions and propose some practical approaches to addressing this in the clinic.
The problem
We live in interesting times but it is not a good time to be poor, with decades of worldwide falling life expectancy, particularly in the US and the UK,1 or to have severe mental illness (SMI), which is associated with premature mortality relative to the general population that has risen disproportionately over the past 30 years.2,3 Much of what we now know about why people with SMI live shorter, less healthy lives was known 3 decades ago.3,4 We knew about the increased risk of cardiovascular diseases, that our patients who smoked had chest diseases way before their contemporaries, and that they were more likely to become overweight, with a sedentary lifestyle and unhealthy diets.5 The 1990s brought selective serotonin reuptake inhibitors (SSRIs), of which only fluoxetine is weight-neutral, and second generation antipsychotics (SGAs), which were better tolerated than neuroleptics but added unwanted weight gain to the illness burden in SMI.6 In retrospect, psychiatry probably focused on the wrong aspects of these challenges. We spoke of metabolic syndrome7 rather than calling it out as the wrong choice of obesogenic medications in excessive doses; we took sociological concepts of stigma and thought discrimination was the main driver of the worst health outcomes in SMI.8 There is plenty of evidence that people with SMI have less access to, and receive less active treatments in (for example) cardiology9 and cancer,10 but this is only part of the story here. Other health service discrimination is more subtle: clinicians not bothering to ask SMI patients about smoking as ‘it's all they've got in their lives' – an example of ‘pity not parity’11 – and doctors' low expectations of people with mental disorders. This is paternalism in the absence of evidence: people with SMI (where smoking rates are >40%) are just as likely to want to quit as the 15% of the general population in England who still smoke.12 Smoking is an important issue to address with the adult SMI patient in front of you, but it should not be the first point of intervention as smoking is far more complex than a ‘lifestyle choice’.
The drivers of poorer physical health across mental health conditions
We need to think about Marmot's ‘causes of the causes'13 in relation to both physical health and risk factors for the mental disorder: inequalities affect everyone no matter where they sit on the health gradient. Reducing economic and other inequalities requires radical systems change.14 Related to inequalities, we see very high rates of adverse childhood experiences (ACEs) in people living with poorer mental health.15 As a society that says it values children, we can mitigate their poverty16 and support traumatised children earlier and better.17 It does not take a village to raise a child but just one trusted adult, especially in under-pressure families where parents have mental disorders and/or addictions: simple interventions can prevent a lifetime of mental distress and poorer physical health.18 The UK's ‘lost decade’ was the decade of austerity that began in 2010: alongside cuts to benefits, housing budgets, schools and other essential public services, the world leading Sure Start programme was dismantled.19 As we plan solutions, we must start with the reduction of inequalities, the mitigation of ACEs and systems to ameliorate chronic stressors in children (Fig 1). As clinicians, we need to use what we know (that for sicker, disadvantaged patients, lifestyle advice alone will not be adequate or useful) to engage people beyond our health services to reverse and mitigate the effects of poverty and inequality.
Poverty and inequality activating the seven drivers of premature mortality in mental disorders. Adapted with permission from Byrne 2023.3
The consequences and interactions of multiple disadvantage
Two important reflections arise from the seven drivers of poorer physical health in every mental disorder, with the single exception of eating disorders.3 First, we cannot ignore the ‘too difficult’ central box of poverty as this makes these more likely to occur and endure at a higher level. At an individual level, there are many things we can do to mitigate for poverty: this could include advocacy, signposting to debt advice and food banks, and/or travel allowances to attend clinics.16 Second, there are significant interactions between these seven secondary drivers (Fig 1). To give just one example, people who smoke and drink potentiate the behaviours and the health harms of each.20 On the right of Fig 1, each of alcohol misuse (no amount of alcohol is safe but weekly consumption over 14 units will impair mental and physical health) and obesogenic prescribing push weight upwards in people with SMI, compounding pre-existing sedentary behaviours and access to exercise. Poverty and cheaper ultra-processed foods21 seem the hardest challenges and will require national anti-obesity strategies, local action and more: see below. On the left of Fig 1, three drivers are the focus of every community mental health team – if the patient is fortunate to achieve referral, pass the threshold for inclusion and remain engaged with the team. Central to this is the essential skill for every clinician (physician, physician assistant, general practitioner, nurse, physiotherapist, dietitian, and more): motivational interviewing.22 Whether the immediate target is smoking, alcohol excess, risky behaviours (across the range of self-harm) or substances (stronger cannabis, novel psychoactive agents), clinicians should ask about the behaviour, link the activity to current symptoms and abnormal tests, and offer support. This is the essence of very brief advice (VBA) in smoking23 and intervention and brief advice (IBA) for problem drinkers,24 especially in the emergency department. You are the best placed person to advise and intervene. The patient's smoking cessation advisor will not understand pulmonary function tests, their alcohol counsellor will not consider a fibroscan to alert to potential liver damage in an overweight person who drinks too much. The final driver here might be opioid prescription in some patients. The UK has not yet emulated the opioid epidemic seen in the US,25 which started with overprescribing and was perpetuated by synthetic fentanyl, but the latter is now the illegal drug most frequently seized by the police in Europe.26 Pressure of space means one sentence to warn of opioid harms coming to Europe: opioids don't work in primary pain;27 they are frequently prescribed to fix social problems and/or alleviate anxiety and will increase housebound, sedentary behaviours–and ultimately mortality–in patients who are prescribed them.3
Don't just screen, intervene
Few physicians will read the details of this article. Poorer physical health in people with SMI and other mental disorders triggers the ‘can't someone else do it?’ response. For many reasons, when this is left to specialist mental health services, there is screening but little action from it. It is no-one's job when it is everyone's job: nurses (and mental health nurses rarely have in-depth physical health training), physician assistants, allied health professionals, other mental health service staff, primary care, dietitians, physiotherapists, pharmacists et al need to engage this neglected group with solutions. They will not do this without physician leadership, and this must include training and supervision to implement evidenced interventions. A recent review of risk factors and evidence28 urges ‘task shifting’, ie moving tasks from highly specialised to less specialised health workers. Every psychiatric admission and many community contacts begin with consideration of cardiometabolic risk factors, but the Lester adaptation29 merely starts a conversation on what to do. Right now, health checks in SMI across England are just that: checking but not intervening. High levels of evidence with treatment pathways are set out in experts' reviews3,28–31 and in bespoke textbooks.32,33 Even with increased scrutiny and significant resources, NHS England has not achieved 60% screening for all six areas of the Lester adaptation29 in SMI populations engaged with health services.34 We do not know what interventions result from screening, or their outcomes. What UK and other health services deliver currently is not working, and a major refocus at multiple levels is required (Table 1).
Seven ways to interrupt declining health and premature mortality in people with mental disorders
Early intervention: what does great practice look like?
Best practice starts with coproduction: patients developing care pathways with clinicians and others with a focus on access, the experience of those using the service, and outcomes. At a one-to-one level this is the essence of personalised medicine,3,30 and will promote more self-management as patients engage more and feel that they own their data (Table 1). We cannot manage multimorbidity while working in individual silos,28 and integrated care30 must become standard. We see this challenge in patients with both diabetes and psychosis. The diabetologist asks us to ‘manage the psychosis and we will then fix the diabetes', and those working in mental health services say something similar, but vice versa. In a better scenario, joint physician and psychiatrist assessments at first presentation will set out viable plans; multidisciplinary team meetings will be planned into the medium term; and family and local organisations will be involved as required to achieve a safety net. In parallel at a wider level, psychosis is now part of the National Diabetes Audit35 and regional differences and trends can be monitored. While we wait in hope for the resources for primary prevention, secondary prevention as early intervention (EI) continues: some disorders will present at advanced stages (psychosis in young people) but we can implement EI for the expected physical health risk factors and disease processes at an earlier stage (Fig 1). These yield individual benefits for every patient and their loved ones and also healthcare savings for other parts of the system. There are wider societal benefits to EI: the big three of quitting smoking, gentle exercise and cooking from ingredients3 are good for the planet as environmentally sustainable actions and they can prevent and/or delay dementia.36 Dementia itself is a sustainability issue and younger people care more about climate change than our generation, and may act towards increased health goals if they are framed using those concerns: air pollution in cities has become a major public health challenge, acting against physical and mental health.37
Obstacles outside our health services
‘We're doing everything we can’ is one of our great medical clichés. But in 2023 UK health services, we are doing it most of what is possible, and the outcomes of terrible physical health and excess preventable mortality are getting worse. One pressing example is healthy weight management (HWM). Clinicians may follow this article and other sources3,28,30–33 but see little progress and conclude that the problems lie outside the health service. Medicine's approach to HWM needs readjustment as the scientific findings change,39 and the old ways of finger wagging and fat shaming of patients need to be replaced by stepwise motivational interviewing.22 The UK public have been let down by its governments, with three decades of policies40 that have failed to prevent the rise of the UK as one of the most overweight countries in the world, with disproportionate rates of obesity in more deprived groups including children.41 Rather than hand wringing and blaming immutable social determinants, we can examine the commercial determinants of health,42 and in particular the unhealthy commodity industries (UCIs). What we eat has changed over recent decades with diets now including higher levels mass produced processed foods that are low in water (to last longer on our shelves) but are high in fat, sugars and salt, which are often washed down by sugar-sweetened beverages.42 We can see the power of the UCIs in marketing (especially to children), obfuscating the science, and lobbying and/or buying influence within governments.42 The supermarkets acquiesce with these UCIs not to meet consumer ‘demand’ but to maximise profits, and many disadvantaged communities have reduced access to cooking from ingredients. Henry Dimbleby, author of two abandoned UK government reports on sustainable healthy nutrition, has resigned in frustration that commercial determinants trumped the science.43 These new approaches to old problems are worth discussing with our patients too, and those discussions need to travel further still–to achieve a healthier, happier and more sustainable society.
Conclusions
People with SMI are 4.5 times more likely to die prematurely (defined as before aged 75) than the general UK population.2,3 When a problem is getting worse, we need to reframe (Fig 1) and refocus (Table 1) in all our clinical contacts. Taking a public health approach conforms to both the Lancet Psychiatry Commission on protecting the physical health of people with mental illness30 and a recent consensus review28 whose six-word central message bears repeating here: ‘prioritisation of prevention while strengthening treatment’. Treatment depends on engagement, itself a product of trust – something many consider another social determinant. SMI is a protected characteristic and within that group there are further exclusions based on ethnicity, LGBTQ+ and other exclusionary traits: homeless people, people who have come into contact with police and courts, prisoners, and migrants. Access and positive health service experiences if maximised will yield the best outcomes. The evidence base for prevention is established and growing.28,30,44 The win–win outcome is prevention of mental disorders, and their associated harms, mostly physical ill health, of those disorders. There are vested interests, UCIs and their fellow travellers,42 who will resist and have the resources to distort any public debate on ways forward. That will become the challenge as we define not just individual doctor-patient interactions, but the doctor-society relationship.
- © Royal College of Physicians 2023. All rights reserved.
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