Excess mortality in severe mental disorder: the need for an integrated approach
Authors: Gabriel Ivbijaro
Journal: World Psychiatry (2017)

Liu et al's paper1 comes at a crucial and relevant time, because it coincides with a period of increased global efforts to raise interest and awareness in mental health issues so that appropriate treatments are made available to narrow the mental health gap. We need to ensure that up to date medical interventions are available to people with severe mental disorder in the same way that they are available to everybody else and, as a family doctor, I particularly welcome this. Although we know that people with severe mental disorder such as schizophrenia and bipolar disorder die 10 to 20 years earlier than the general population, there has been little progress in addressing this health disparity over time and there is an urgent need to narrow this gap. People often try to find linear answers to complex issues, but Liu et al's paper highlights that excess mortality is not due to a single factor. This means that we require novel approaches to this complex problem. Doing nothing is not an option. We can no longer continue to treat the statistics about poor outcomes in mental disorder as if it is all that can be expected. Every life matters and that of course includes lives affected by mental ill health. There has always been controversy about which elements of mental health promotion and lifestyle choices contribute to an improvement in mental health outcomes, including excess mortality. The research evidence provided in Liu et al's paper lends support for some health promotion activities, including smoking cessation and weight management. Furthermore, it is traditionally believed that substance use disorder has a significant impact on long-term physical and mental health outcomes in people with a diagnosis of mental disorder. Many interventions to address this particular comorbidity have been put forward and the paper notes the limited evidence base about the effectiveness of our current strategies. This is consistent with a recent review2, highlighting the need to direct resources at continuing research into the effective treatment of substance abuse in people with severe mental illness in order to reduce morbidity and mortality. The proposed framework supports current thinking about the need to deliver interventions for such complex problems through an integrated care pathway, recognizing that each component of that pathway is a care package. Some care packages will need to be delivered by the individual affected by ill health, some through social care interventions, some through primary care, and some through secondary care. Policy change is often seen as a tool to deliver care packages, but this should not be the case. Policies should be regarded as a care package in their own right. This new way of thinking needs to be recognized by those who purchase and commission services, so that they can change their own ways of working, especially as current commissioning practice has not made a significant impact on rates of excess mortality in people with severe mental disorder. The proposed multilevel intervention also highlights the need to have combined mental and physical health guidelines to address both screening and treatment, because for too long there has been an over-reliance on specialism and so called “silo working”, which has not delivered the desired health outcomes for people with severe mental disorder. It also reinforces the need for services to have an integrated approach to care which delivers health promotion and emphasizes the role of the individual and self-care, and the need for research that is aligned with practice so that we can continue to apply those interventions that we know will work. Innovative working and task shifting such as developing workforce roles for the management of long-term physical and mental health conditions is needed, because mental and physical health comorbidity significantly increases costs of care and use of health care resources3, 4. As a family doctor, mental health advocate and somebody who has previously been involved in commissioning health and mental health services, I find Liu et al's paper useful because it brings together much of the relevant evidence about what works into a single construct and provides a framework that makes the task of intervention less daunting. However, I would have liked to see more about the role that family interventions can play in addressing the excess mortality in people with severe mental disorder, especially as there is already strong evidence for the role of families in the prevention of relapse and re-hospitalization5. There has been a systematic failure of the health care system in preventing, identifying and treating physical diseases in mental health conditions, partly through a failure of recognition that a policy is a care package, not just a tool. Liu et al's paper represents a call for action to do something that is possible, and provides a comprehensive framework to make this happen. Gabriel Ivbijaro President, World Federation for Mental Health; Wood Street Medical Centre, Walthamstow, London, UK