Reducing the morality gap in people with severe mental disorders

Article in review: Fiorillo, A., Luciano, M., Pompili, M. and Sartorious, N. (2019). Editorial: Reducing the Mortality Gap in People With Severe Mental Disorders: The Role of Lifestyle Psychosocial Interventions. Frontiers in Psychiatry, DOI: 10.3389/fpsyt.2019.00434

Summary

Compared to other non-communicable diseases, severe mental disorders like major depression, bipolar disorder and schizophrenia are associated with larger morbidity, poorer health and higher mortality rates. Emerging research suggests that interventions for this population group that target lifestyle behaviours can be effective. The authors of this research topic have grouped articles on relevant studies intended to present new research on and approach for reducing morbidity and mortality of people with severe mental disorders.

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A public health scandal

People with severe mental disorders on average die between 10 and 20 years earlier than the general population, with this gap increasing over time. Among people with severe mental disorders, only a small number of these premature deaths can be attributed to causes such as suicide, homicide or accident. The vast majority of premature deaths occur as a result of physical health problems, such a cardiovascular, respiratory or infectious disease, diabetes and cancers. The early mortality among people with severe mental disorders is described as a “public health scandal”.

The occurrence of the early death of people with severe mental disorders is attributed to intertwined and interrelated factors:

• Individual – the severity of symptoms, impulsivity, emotional deregulation, deficits in social and cognitive skills
• Lifestyle behaviours – including smoking, poor diet, sedentary behaviours, alcohol and drug abuse
• Social disadvantages – stigma, discriminating policies, unemployment, homelessness, limited family, social and community resources
• Healthcare disparities – poor quality of service provision, limited access to health information, reduced checkups, the negative attitudes of professionals to people with mental disorders

An increasing problem

The mortality gap for people with severe mental disorders is expected only to increase, in part due to an increased life expectancy across all populations, a result of medical advancements, and improved hygiene and food supply. A consequence of this improvement is an increased chance of physical disorders, particularly non-communicable ones. Industry changes are also involved, such as the over-division and over-specialisation of medical disciplines which fragments knowledge. Examples of this would be in situations where a psychiatrist might choose to deal only with people of certain ages (e.g. children, adolescents, the elderly) or with certain conditions (e.g. eating disorders or bipolar) or at certain stages of a disease (e.g. early intervention specialists).

There is also an increasing gap in knowledge within disciplines because of the refinement or extension of training, and the continuing lack of awareness about the need to be able to work effectively with people who have comorbidities.

Collaboration to improve care

Within the Global Action Plan for Prevention and Control of Non-Communicable Diseases, the World Health Organisation has outlined actions that should be undertaken to address the identified gaps in control of risk factors, the standard of primary health care and policy development. Addressing this gap effectively requires a multi-faced approach, undertaken through collaboration and consistency by health care providers and specialists. Policymakers and individual carers of people with severe mental disorders also play a part. Interventions for people with severe mental disorders should be operating at different levels, including the:

• Community and policy level – the creation of policies for health promotion, encouraging healthy behaviours and, and the provision of adequate care packages and services
• Health system organisational level – through the improvement of the assessment of health conditions, promotion of appropriate care strategies and guidelines for integrated mental and physical health services and care
• Individual clinical level – through the early management of physical illnesses in people with severe mental disorders, along with lifestyle and behavioural psychosocial interventions to promote health through weight loss, increased physical activity and less use of tobacco, alcohol and other drugs

Relevant research

The studies presented in this research topic looked at summarising the existing knowledge about the benefits offered by psychosocial interventions within the cohort. Studies to consider the specific needs of people with severe mental disorders have not been widely disseminated, and are typically done in much-localised populations, without consideration of wider implications and overall cost benefits of these treatments. The research undertaken within the topic included the:

• Effect of oral vs. long-acting injectable antipsychotics
• Relationship between smoking habit and vitamin D deficiency
• Presence of depressive symptoms in people who have had a stroke
• Relationship between unexplained physical medical symptoms and mental illness
• Lifestyle behaviours, mental health and suicide risks
• Benefits in reduction of cardiovascular risk for people with severe mental disorders
• Benefits of interventions to both reduce smoking and promote physical health as unique contributors
• Benefits of multiple changes to lifestyle and behaviours to improve health
• Role of carers and family in care

The authors close with the suggestion that future research must focus on an improved understanding of protective factors and the characteristics of interventions that possibly promote lifestyle and behavioural changes.