Why serious mental illness should be designated a health disparity and the paradox of ethnicity
Authors: Stephen J Bartels, Peter DiMilia
Journal: The Lancet Psychiatry (2017)

The global tragedy of excess mortality among people with serious mental disorders transcends geography, different systems of health care, and different approaches to health-care financing. Authors of a meta-analysis1Walker ER McGee RE Druss BG Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis.JAMA Psychiatry. 2015; 72: 334-341Crossref PubMed Scopus (1490) Google Scholar identified 203 studies representing 29 countries across six continents, finding a 2·2-times greater risk of mortality and an average of 10 years of potential life loss for people with serious mental illness compared with the general population. Contrary to expectations, the greatest cause of excess and early mortality is not suicide, but a high proportion of chronic health conditions, including cardiovascular disease, respiratory disorders, diabetes, tobacco-related illness, and obesity.2Liu NH Daumit GL Dua T et al.Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas.World Psychiatry. 2017; 16: 30-40Crossref PubMed Scopus (339) Google Scholar Given the multinational finding of excess and early mortality, should people with serious mental illnesses be considered a distinct health disparity population with unique risk factors and susceptibilities? Or is serious mental illness similar to other health conditions for which disparities are driven by increased risk associated with ethnicity or socioeconomic status? A study by Jayati Das-Munshi and colleagues3Das-Munshi J Chang CK Dutta R et al.Ethnicity and excess mortality in severe mental illness: a cohort study.Lancet Psychiatry. 2017; (published online March 16.)http://dx.doi.org/10.1016/S2215-0366(17)30097-4PubMed Google Scholar in The Lancet Psychiatry provides intriguing findings that challenge common assumptions about key drivers of health disparities in special populations. The authors did a cohort study of 25 871 individuals with schizophrenia-spectrum or bipolar disorder in the UK comparing mortality rates between five ethnic subgroups (white British, black Caribbean, black African, south Asian, and Irish adults with these serious mental illnesses [SMI]) using age-standardised and sex-standardised mortality ratios. This study's findings substantiated a greater than double risk of mortality for individuals with serious mental illnesses compared with that of the general population, with significantly higher risk because of both natural (respiratory disease, cardiovascular disease, and neoplasms, among others) and unnatural (suicide, accidents, and assaults, among others) causes of mortality—irrespective of ethnicity. Adjusted hazard ratios indicated that ethnic minority groups with SMI (black Caribbean, black African, and south Asian) experienced an overall lower rate of mortality by at least 27% than did the white British group with SMI. These differences by ethnicity included adjustments for various covariates, consisting of sex, diagnosis, marital status, comorbid alcohol or substance misuse, and an index of area-level deprivation, taking into account income, employment, health education, housing, environment, and crime. This UK study replicates similar findings by Olfson and colleagues4Olfson M Gerhard T Huang C Crystal S Stroup TS Premature mortality among adults with schizophrenia in the United States.JAMA Psychiatry. 2015; 72: 1172-1181Crossref PubMed Scopus (597) Google Scholar in the USA. What explains the paradoxical finding of a reduced risk of excess mortality for ethnic minorities with SMI compared with white British people with SMI? Das-Munshi and colleagues concede that the reported magnitude of reduced risk could be inflated because of different base rates of mortality by ethnicity. However, this replication of findings also reported in the USA lends support to the notion that social factors experienced by ethnic minorities might act to buffer the effect of risks associated with serious mental illnesses. For example, greater group affiliation and social support associated with migrant communities than with the general population might reduce risk factors such as alcohol use and social isolation while also promoting protective social norms.3Das-Munshi J Chang CK Dutta R et al.Ethnicity and excess mortality in severe mental illness: a cohort study.Lancet Psychiatry. 2017; (published online March 16.)http://dx.doi.org/10.1016/S2215-0366(17)30097-4PubMed Google Scholar Migrant groups with serious mental illness might have greater resilience than might the general population, potentially counteracting the ill effects of common risk factors.3Das-Munshi J Chang CK Dutta R et al.Ethnicity and excess mortality in severe mental illness: a cohort study.Lancet Psychiatry. 2017; (published online March 16.)http://dx.doi.org/10.1016/S2215-0366(17)30097-4PubMed Google Scholar Whatever the cause, these findings contribute to the body of research underscoring the importance of behavioural and social determinants of health. Estimates suggest that only 10% of health and longevity is associated with health care, by contrast with health behaviours that are responsible for 40% and environmental factors for 30%.5Health AffairsHealth policy brief: the relative contribution of multiple determinants to health outcomes.http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_123.pdfDate: Aug 21, 2014Google Scholar As recommended by a WHO statement, health coaching interventions promoting tobacco cessation, healthy diet, and physical activity should be among the core services provided to people with serious mental illnesses.2Liu NH Daumit GL Dua T et al.Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas.World Psychiatry. 2017; 16: 30-40Crossref PubMed Scopus (339) Google Scholar, 6Bartels SJ Can behavioral health organizations change health behaviors? The STRIDE study and lifestyle interventions for obesity in serious mental illness.Am J Psychiatry. 2015; 172: 9-11Crossref PubMed Scopus (33) Google Scholar Other highly promising approaches include integrated physical and mental health self-management,7Whiteman KL Naslund JA DiNapoli EA Bruce ML Bartels SJ Systematic review of integrated general medical and psychiatric self-management interventions for adults with serious mental illness.Psychiatr Serv. 2016; 67: 1213-1225Crossref PubMed Scopus (47) Google Scholar peer support interventions,8Aschbrenner KA Naslund JA Shevenell M Mueser KT Bartels SJ Feasibility of behavioral weight loss treatment enhanced with peer support and mobile health technology for individuals with serious mental illness.Psychiatr Q. 2016; 87: 401-415Crossref PubMed Scopus (38) Google Scholar and use of technology, including mobile health and social media.9Naslund JA Marsch LA McHugo GJ Bartels SJ Emerging mHealth and eHealth interventions for serious mental illness: a review of the literature.J Ment Health. 2015; 24: 321-332Crossref PubMed Scopus (196) Google Scholar Future research should also consider the role of resilience and potential protective factors associated with different ethnicities to develop a better understanding than at present of modifiable risk factors and levers for change. Why does it matter that serious mental illness should be designated a health disparity population in its own right? First, as suggested by the findings of this study, some of the factors that drive the early mortality health disparity experienced by people with serious mental illnesses clearly diverge from conventional factors associated with race, ethnicity, and socioeconomic status. Having a serious mental illness substantially increases the risk of early mortality compared with other low socioeconomic groups without mental illness, and being from an ethnic minority might paradoxically decrease risk. Second, qualifying as a health disparity group will facilitate prioritisation for national and global public health initiatives and greater inclusion in research than not qualifying as a health disparity group. Finally, designating serious mental illness as a health disparity group will help to overcome the related stigma and enable mental illness to be recognised as a high-risk health condition for development of physical illness and risk of earlier mortality. We do not need another decade of replication studies to document the obvious. People with serious mental illnesses are among the most vulnerable and least recognised health disparity groups and should be widely supported as an international priority for prevention, health promotion research, and public health initiatives promoting social inclusion and health equity.10Suetani S Whiteford HA McGrath JJ An urgent call to address the deadly consequences of serious mental disorders.JAMA Psychiatry. 2015; 72: 1166-1167Crossref PubMed Scopus (29) Google Scholar We declare no competing interests. Ethnicity and excess mortality in severe mental illness: a cohort studyPeople with severe mental illness have excess mortality relative to the general population irrespective of ethnicity. Among those with severe mental illness, some ethnic minorities have lower mortality than the white British group, for which the reasons deserve further investigation. Full-Text PDF Open AccessTowards a mental health inequity auditStephen Bartels and Peter DiMilia1 presented a compelling argument in the Lancet Psychiatry for the consideration of serious mental illness as a health disparity. Recent evidence2 in support of this change suggests that the greatest cause of excess morbidity and early mortality in people with serious mental illness compared with the general population is not suicide but common chronic health conditions, such as cardiovascular disease, respiratory disorders, diabetes, and tobacco-associated illness. Full-Text PDF