Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697645516962.pdf (Australia)
The physical health of people living with mental illness Submission to the House Select Committee on Mental Health and Suicide Prevention Submission from: Professor Russell Roberts, National Project Director of the Equally Well Alliance Professor Mal Hopwood, Co-Chair of the Equally Well Alliance Dave Peters, Consumer Co-Chair of the Equally Well Alliance#1 ‘One of the starkest facts we must all face is that people with severe mental illness die on average 15–20 years earlier than other people in our communities.
Some have rightly described these as ‘stolen years’.

Yet the majority of these premature deaths are avoidable, if people receive the right care, in the right place, and at the right time.’ Professor Dame Sue Bailey President of the Academy of Medical Royal Colleges 1.

Introduction Equally Well in Australia is a multisector, multidisciplinary alliance to collectively address the issue of the poor physical health and high rate of premature deaths of people living with mental illness.
Its aim is to achieve equity in physical health outcomes for people living with mental illness and to support the implementation of the 48 actions in the Equally Well National Consensus Statement.1 A full description can be found in Roberts et al.2 and on our website https://www.equallywell.org.au/.
Over 90 organisations including consumer carer peaks, NGOs, PHNs, 15 professional associations and each government jurisdiction have formally committed to “making the physical health of people living with mental illness a priority at all levels: National, state/territory and regional”1 (p. 7).

Using a collective impact approach,2 a small backbone team (1.3 fte) supports and enables collaboration, coordination, facilitating communities of practice, hosting conferences, meetings and webinars.
Using these processes in addition to social media, it disseminates best practice information through continuous communication of the latest implementation initiatives, research and policy from across Australia and overseas.

#1Due to the broad-based membership of the Equally Well Alliance, and potential conflicts of interest, the views expressed in this submission do not purport to represent the views of all of the EWA Committee members, or the 90 organisational supporters of Equally Well.
P a g e | 1 Submission to the House Select Committee on Mental Health and Suicide Prevention Mental Health and Suicide PreventionSubmission 137 The physical health of people living with mental illness 2.

Background In 2011, 11,302 people with mental illness died prematurely of the top 10 causes of death.3 This equates to over 30 people a day.
Comprising 12.9% of the population, people accessing mental health-related MBS and PBS services constitute over half of all premature deaths in Australia due to physical health conditions.4 Figure 1: Annual number of deaths of persons (age: 15–74 years) accessing medical benefits scheme (MBS) and/or pharmaceutical benefits schedule (PBS) mental health-related services by cause of death5 (adapted from ABS, 2017).4 3.
Term of Reference – 1 Findings of previous strategic reviews The physical health of people living with mental illness was identified in the Productivity Commission Inquiry Report into Mental Health6 as a ‘priority reform’ and implementing the actions of the Equally Well National Consensus Statement was identified as a ‘start now’ reform.

This was underpinned by a recommendation that the National Mental Health Commission monitor and report on progress in this respect.
Recommendation 1 Equally Well strongly recommends the government supports and commits to the physical health recommendations and actions in the Productivity Commission Inquiry Report into Mental Health.

P a g e | 2 Submission to the House Select Committee on Mental Health and Suicide Prevention Mental Health and Suicide PreventionSubmission 137 The physical health of people living with mental illness 4.
Term of Reference – 2.1 Evidence-based approaches and international experience and directions There is extensive research3 and widespread commitment to this issue as a policy priority internationally and in Australia.

Research The evidence outlining the extent and seriousness of this problem is comprehensive and compelling.
Thousands of studies and scores of meta- and pooled analyses have highlighted the extent and nature of the poor health and premature death of people living with mental illness.7 Australia is a world leader in research and major data linkage studies in WA8 and NSW9, 10 and Australia wide4 have consistently demonstrated the poor health and life expectancy gap between people living with mental illness and the rest of the population.
Figure 2: Number of articles published on mortality and physical health of people living with mental illness.7 Policy International policy directions have been summarised in the:  World Health Organization.

Guidelines for the management of physical health conditions in adults with severe mental disorders11 2018 Global Ministerial Mental Health Summit.
Report and Declaration on Achieving Equality for Mental Health in the 21st Century12 (WHO) Multi-level intervention framework a multi-level intervention framework and priorities for clinical practice, policy and research agendas to reduce excess mortality in persons with severe mental disorders13 The Lancet Psychiatry Commission: Blueprint for protecting physical health in people with mental illness14 Healthy Active Lives (HeAL) Consensus Statement15 Royal Academy of Medical Colleges: Improving the physical health of adults with severe mental illness16 Equally Well New Zealand – The physical health of people with mental health conditions and/or addiction.17       In Australia, the physical health of people living with mental illness has been prioritised in the:       Fifth National Mental Health and Suicide Prevention Plan18 Equally Well National Consensus Statement1 Victorian Equally Well strategy for public mental health services19 RANZC: Keeping Mind and Body Together20 RANZCP: Guidelines and resources for pratice21 Joint Regional Planning for Integrated Mental Health and Suicide Prevention Services.
A Guide for Local Health Networks (LHNs) and Primary Health Networks (PHNs).22 P a g e | 3 Submission to the House Select Committee on Mental Health and Suicide Prevention Mental Health and Suicide PreventionSubmission 137 The physical health of people living with mental illness Evidence-based approaches to reducing the premature deaths and life expectancy gap Cancer-caused deaths as an exemplar Every year 6,063 people living with mental illness die prematurely of cancer (16 per day).
If people living with mental illness had the same cancer deaths rates as the rest of the Australian population, this number would drop to 656 premature cancer-caused deaths per annum (1.7 per day).

People living with mental illness have the same or lower incidence of cancer as the general population, yet mortality rates are much higher.23 Many cancers, if detected early, are completely curable.

Yet people living with mental illness have 9 times the cancer-caused death rate.
There are many reasons for this, such as stigma, discrimination, access to primary healthcare and ‘diagnostic overshadowing’.
All these result in the simple fact that people with mental illness do not receive equity of access to evidence-based physical health screening and treatment.24 The pattern of excessive cancer-caused death due to a lack of quality healthcare is replicated across most of the major chronic health conditions, such as respiratory disease, cardiovascular disease, diabetes and cerebrovascular disease and other chronic physical health conditions (see Figure 3).
Most early deaths are preventable A recent AIHW report cited 38% of Australian deaths due to chronic disease are avoidable.25 In New Zealand, a major study of cardiac disease in people living with severe mental illness found 69% of premature deaths were avoidable.26 Figure 3: Percentage of deaths due to major chronic physical health conditions (age: 15–74 years) – people with mental illness and the rest of the Australian population.
P a g e | 4 Submission to the House Select Committee on Mental Health and Suicide Prevention Mental Health and Suicide PreventionSubmission 137 The physical health of people living with mental illness Infectious diseases and vaccine preventable conditions Existing data indicate people living with mental illness have vaccination rates of less than half the general population27, 28 and high rate ratios (2.2 times) for vaccine preventable hospitalisations.10, 29 People with mental illness are more susceptible to infections during epidemics.
This may be related to confined living arrangements, lower levels of personal protection behaviours, and a lower awareness of risk.30 It could also be related to the increased difficulties of accessing timely medical services.

In addition, when and if services are accessed, treatment is more challenging due to increased complexity related to the co-existing mental health condition.
Further, once infectious diseases such as COVID-19 are contracted, the death rates of people living with serious mental illness are much higher.31, 32 Immediate public health action to provide people living with mental illness with outreach and screening for currency of vaccination status, including the flu vaccination, would lessen virus prevalence in the community, reduce the burden on public hospitals,10 save money and save lives.
Impact In Australia we have the existing infrastructure, workforce, screening and interventions to address major chronic physical health conditions.

However, much work needs to be done to enable people living with mental illness to achieve equity of access to these services.

Initiatives to improve the physical health of people living with mental illness could save thousands of Australian lives each year.
The impact of this on a range of economic, social, personal and familial issues affecting the welfare of Australians would be profound.

Every day 30 people living with mental illness die early due to chronic physical health conditions.

Most of these are preventable.

Access to basic screening and interventions would see this figure begin to reduce within months.
Recommendation 2 Processes must be urgently put in place to ensure people living with mental illness achieve equity of access to standard physical health screening, treatment and interventions.
Poor physical health is a major contributor to mental illness and suicidality Prevention and treatment of mental illness McNamara et al.33 in their ‘45 and up’ study (n=223,405) in NSW concluded that the “markedly elevated prevalence of high distress among older Aboriginal Australians appears largely attributable to greater physical morbidity and disability” (p. 145).

They found a similar result for non-Aboriginal Australians.
For the entire participant group they concluded: nearly all of the medical conditions examined were associated with an increased prevalence of high psychological distress as measured by the K10.
A collaborative research project in Europe found a dose-response relationship between poor physical health and depression consistent across 11 countries.34 Likewise, a meta-analysis of effective treatments for depression concluded that improving physical health and increasing physical activity should be a first line treatment choice for depression.35, 36 As such, increasing physical activity has been recognised as ‘step zero’ in the treatment of depression by the RANZCP.
Recommendation 3 Improving physical health is an evidence-based treatment strategy to improve mental health, and should be prioritised in all future treatment planning, policy and funding.
P a g e | 5 Submission to the House Select Committee on Mental Health and Suicide Prevention Mental Health and Suicide PreventionSubmission 137 The physical health of people living with mental illness Prevention of suicide There are numerous research studies linking poor physical health with increased suicide risk.37-39 Chronic pain, poor health and functional disability are all major predictors of suicidality.
Improving the physical health of people living with mental illness is a largely neglected, yet proven effective strategy to reduce suicide risk, particularly in older persons.40 Recommendation 4 Suicide prevention strategies should include improving physical health and reducing chronic pain.

P a g e | 6 Submission to the House Select Committee on Mental Health and Suicide Prevention Mental Health and Suicide PreventionSubmission 137 The physical health of people living with mental illness 5.
Term of Reference – 2.3 Roles, training and standards for the workforce Much of the reason for the early death and disparity in physical health status for people living with mental illness is due to the fact that the physical health of people living with mental illness is often seen as ‘the other’s business’.

Primary healthcare providers often expect the specialist mental health workforce to address physical health as part of a comprehensive and holistic approach to care.
On the other hand, the mental health workforce often expects the primary physical healthcare workforce to address this aspect of care.

As a result, far too frequently, the physical health of people living with mental illness falls is not addressed at all.

The solution to this is quality coordinated and integrated care.

The reality, however, is due to the complex governance and funding arrangements in the Australian mental health system,41 effective and consistent integrated care remains a challenge.
A practical and more achievable approach to address this challenge is for all to take responsibility to address the physical healthcare of people living with mental illness.

This should be reflected in professional roles, and standards for all healthcare professionals.
There are examples of how this has been applied to nursing, allied health5, 42, 43 and general practice.44 Recommendation 5 Ensuring quality physical healthcare for people living with mental illness should be included in the roles, training and standards of all health and allied health professionals who contribute to mental healthcare, including peer workers and general practice.
Recommendation 6 Much of the disparity in the health outcomes for people living with mental illness is related to difficulties navigating and accessing primary physical healthcare services.

Supporting access to physical healthcare could be a major role of the peer workforce.

Recommendation 7 Mechanisms to make access to physical health screening and treatment services affordable for people living with serious mental illness should be considered.
P a g e | 7 Submission to the House Select Committee on Mental Health and Suicide Prevention Mental Health and Suicide PreventionSubmission 137 The physical health of people living with mental illness Training The Productivity Commission Inquiry Report into Mental Health6 has provided a series of recommendations relating to training and workforce development to improve the physical health of people living with mental illness: Workers in mental health services should have access to relevant training on physical health including:  what the common physical health and substance use comorbidities are in people with  mental illness and how to screen for them effective prevention and lifestyle interventions to prevent and manage physical health and substance use problems the side effects of medication for mental illness and effectively managing them   where to refer people if physical healthcare cannot be provided in-house (Action 14.1).
Up-to-date and evidence-based guidelines and other resources would also be needed.

(pp 638-639 Similarly, The Fifth National Mental Health and Suicide Prevention Plan recommended the development and updating of resources and guidelines to support health services and health professionals to improve the physical health of people living with mental illness (Action 15).
Information for consumers and carers Carers make a significant voluntary contribution toward the support and care of people living with mental illness.

The Productivity Commission Inquiry Report into Mental Health6 recognised the need to equip and empower consumers and carers to be active partners in managing their physical health.
It recommended: Governments and service providers should develop and provide information and guidance for people with mental illness and their carers on managing their physical health, including the side effects of medication, and the different types of physical healthcare available to them (Action 14.1).(p.
640) Recommendation 8 The Productivity Commission actions (14.1 & 14.2) regarding the training of mental health workers, ensuring access to comprehensive guidelines and resources on key physical health risk for people living with mental illness, and the development of information and guidance resources for consumers and carers be adopted.
P a g e | 8 Submission to the House Select Committee on Mental Health and Suicide Prevention Mental Health and Suicide PreventionSubmission 137 The physical health of people living with mental illness 6.

Conclusion The causes and solutions to poor physical health and premature death are well-known and amenable to change.

Investing in solutions will return significant benefits.
A comprehensive review of the causes of early death is presented in a narrative literature review3 on physical health and mental illness.

The causes of premature death are complex, dynamic and interrelated.

However, the major causes include: 1.

A lack of physical health screening and treatment 2.

Relatively high rates of smoking 3.

Antipsychotic medication side-effects, including metabolic syndrome 4.

Lifestyle impacts such as poor diet and a low level of physical activity 5.
Stigma and discrimination 6.

Social economic status (i.e., unstable/unsuitable housing, unemployment etc.)

7.

Behaviours and conditions associated with the mental illness itself.

The first five of these factors are modifiable and proven effective, evidence-based interventions exist to address the first four of these factors.
“Being Equally Well” a major collaborative project between the Mitchell Institute and the Equally Well Alliance is developing a series of reform options with a strong focus on the primary health and chronic diseases sector to improve the physical health of people living with mental illness.45 Australia has the pre-existing resources and infrastructure to address and significantly improve the physical health of people living with mental illness.
The main reasons the disparity in physical health outcomes persist for people living with mental illness are related to stigma, ‘diagnostic overshadowing’46 and a lack of coordination between mental health and physical health focussed services.

People living with mental illness face disadvantages at every point of contact with the health system: screening, diagnosis, and treatment.

This disparity results in poor health and needless premature death.
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P a g e | 11 Submission to the House Select Committee on Mental Health and Suicide Prevention Mental Health and Suicide PreventionSubmission 137