The central place of psychiatry in health care worldwide

Three recent papers in the Acta Psychiatrica Scandinavica highlight an important dilemma that is shared by psychiatry and general health care (1–3). The evidence that psychiatric and somatic illnesses are intertwined and mutually influential is indisputable (4), and continues to grow in explanatory power. Yet, awareness of this reality remains low among health practitioners and their patients, as well as in planners and policymakers. So far, this dilemma has not been resolved, and its consequences are increasing rather than diminishing (1–3). There is continuing damage to those directly involved and the health and productivity of the community. International efforts and partnerships are needed to devise, evaluate and implement a range of solutions for people living with mental illnesses; for those living with severe mental illnesses as well as for those with the common mental illnesses. There is an urgent need for research and action on the somatic health and quality of life (QoL) of all those living with mental illnesses. The somatic health of people living with severe mental illnesses is identified as a significant moral and practical concern for the communities in which they live (5–7). Patients and family still describe the regular experience of stigma and discrimination in the community, treatment under conditions that offer little respect and dignity, and poor access to care for both mental and physical health problems. The problems for people living with common mental illnesses are also pressing. Depression, anxiety and somatisation are a significant burden in the general population and failure to recognise and manage these problems in general health care contributes to delayed recovery (8). Furthermore, mental and somatic illnesses cannot be regarded as distinct entities. They are interrelated, for example, by common aetiologies, and underlying somatic conditions can worsen psychiatric symptoms and vice versa (1, 4, 9). Recent analyses of the global burden of disease recognise the rising burden from the mental and behavioural disorders. The economic costs outstrip those associated in each case with diabetes, cardiovascular disease, respiratory disease and cancer (5). This is creating new challenges for primary health care, general hospital and medical care, social welfare and other systems, in addition to the specialist mental health services. Martin Prince and colleagues (4) note the ‘protean interactions between mental illnesses and other health conditions’. Mental illnesses increase risk for communicable and non-communicable diseases and injuries, and many somatic conditions increase the risk for mental illnesses. Comorbidity complicates access to care, diagnosis and treatment, and influences the course and outcome of illnesses (4), whether people present primarily with somatic or mental illnesses. This is true for people of all ages, including young people, among whom mental ill health is the main cause of poor health and the first onset of mental illness is most likely to occur. Yet the training, practice and policy related to mental health and mental ill-health generally remain alienated from mainstream health services and from public health. The legacy of this alienation includes continuing inequity for those living with mental illnesses.