Physical health of people with severe mental disorders: leave no one behind
Authors: Shekhar Saxena, Mario Maj
Journal: World Psychiatry (2017)

The 2030 United Nations Agenda for Sustainable Development seeks to ensure that, over the next 15 years, countries make concerted efforts towards economic, social and environ-mental development that is sustainable and inclusive. In order to achieve the goal of universal health and well-being (Goal 3), an important target is "to reduce premature mortality from non-communicable diseases (NCD) through prevention and treatment and promote mental health and well-being"1. While this goal applies to all, there is a need for making special efforts to the populations that are vulnerable to be left behind. One such population is people with severe mental disorders (SMD). SMD and NCD are related in complex ways. The major modifiable risk factors for NCD, such as physical inactivity, unhealthy diet, tobacco use and harmful use of alcohol, are exacerbated by poor mental health. Mental illness is a risk factor for NCDs; its presence increases the chance that an individual will also suffer from one or more chronic illnesses. In addition, individuals with mental health conditions are less likely to seek help for NCDs, and symptoms may affect adherence to treatment as well as prognosis. The physical health of people with SMD is commonly ignored not only by themselves and people around them, but also by health systems, resulting in crucial physical health disparities and limited access to health services. This impacts the life expectancy of people with SMD. The facts are clear: people with severe mental disorders die, on average, 15 to 20 years earlier than others. These excess and early deaths are not primarily due to suicide, but to physical diseases that occur more frequently, are not prevented adequately, are not identified early enough and are not treated effectively. And this disparity is not confined to some regions and countries, but seems to be a global reality. This state of affairs is not in keeping with the spirit and letter of the Sustainable Development Goals. It should be unacceptable to any country or community. What is needed? While interventions, guidelines and programmes have been developed to address the risk factors for excess mortality in persons with SMD, they will not really make a difference until a variety of challenges to their implementation are tackled, including problems with culture and attitudes of the various stakeholders involved, resources and expertise available, engagement of patients in the programmes, accessibility and feasibility of the interventions, their cost-effectiveness, and the fidelity of their application. At the policy level, there is an obvious issue of prioritization. Reducing excess mortality in persons with SMD should become part of the broader health agenda. Top-level integration of various programmes (e.g., mental health and substance abuse, NCD, tobacco cessation, violence prevention, nutrition and physical exercise) should be set as a precedent for making strides in addressing complex, multifactorial health problems. Health programme managers should promote awareness of the problem amongst health care providers and equip them with training, support and supervision to deliver comprehensive care. Health care providers should be especially attuned not to overlook somatic concerns and to pay attention to the lifestyle behaviours of persons with SMD. At the very minimum, persons with SMD should have access to the same care offered to people with other health conditions, including the same basic health screenings as the general population (e.g., for cardiovascular risk and cancer). There are guidelines and tools available to assist general health care providers in the assessment and management of people with co-occurring physical and mental health conditions. An example of one such tool is the World Health Organization (WHO)'s mhGAP Intervention Guide for Mental and Neurological Disorders, the new version of which has been recently released2. The Guide presents algorithms for clinical decision-making including specific guidelines for assessment and management of co-occurring physical health conditions. On the other hand, research challenges in this area should not be ignored. Among them are the problems of the representativeness of the study samples; of the availability and reliability of the information about the occurrence of mental disorders, the causes of death and the presence of the various risk and protective factors in the samples studied; and the difficulties in clarifying the relative impact of the various categories of risk and protective factors and the way these factors interact with each other. Furthermore, the evidence concerning protective factors is in general much more limited than that regarding risk factors, and high-quality research from low-income countries is still very scarce. The role of new communication technologies and of peer support in this field is also understudied. A major further challenge is the assessment of the impact of policy and health system interventions, which may emerge only after many years. Most importantly, the effectiveness and cost-effectiveness of evidence-based interventions and programmes will have to be evaluated systematically in different settings. Barriers to their implementation at various levels will have to be identified, and ways to address them appropriately tested. Also, the current focus on cardiometabolic risk in people with SMD living in the community should not distract our attention from the scandal of premature mortality among the mentally ill who live in large asylums, and the millions of people with SMD who are currently detained in prisons worldwide (see also McKenna et al3 in this issue of the journal), who are particularly exposed to chronic diseases (including, especially in low-income countries, infectious diseases), poor nutrition, victimization, neglect, suicide and substance abuse. In the Forum of this issue of the journal, the available evidence on risk factors and effective interventions has been collated to present a multilevel risk model and associated intervention framework for excess mortality in people with SMD4. An important feature of the proposed framework is that it integrates individual-focused, health system-focused and policy-focused interventions. A group of commentators has been carefully selected to reflect the views of various categories of stakeholders: policy makers, researchers, health care providers and service users. We hope that this Forum will contribute to catalyze actions for implementing what we already know and also research to know more. To fulfill our commitment towards sustainable global development for all, urgent and concerted efforts are needed to reduce preventable premature mortality in this population. Shekhar Saxena1, Mario Maj2 1Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland; 2Department of Psychiatry, University of Naples SUN, Naples, Italy S. Saxena is a staff member of the WHO. All opinions expressed in this editorial rest with the authors and do not necessarily represent the decisions, policy or views of the WHO.