There have been, and probably always will be, some marked inequalities when it comes to healthcare. Some 20 years ago, for example, women from the west of Ireland with breast cancer were largely unable to access radiotherapy, while for those in the east of the country, radiotherapy after surgery was a regular component of treatment. This geographic inequity has since been addressed with the implementation of a national cancer strategy.
But one of the starkest examples of inequity, and one that in my opinion has received shockingly little attention until now, is the huge difference in longevity between people with serious mental illness and the rest of the population. People with severe depression, bipolar disorder and psychotic disorders such as schizophrenia generally die 10-25 years earlier than the general population. The majority of these premature deaths are due to physical health conditions.
According to the World Health Organization (WHO), access to comprehensive health services remain out of reach for the majority of people with severe mental disorders. Recognising this inequity, the organisation has released, for the first time, evidence-based guidelines on the management of physical conditions in adults with severe mental disorders.
Huge price
While the pharmacological treatment of diseases such as schizophrenia has developed significantly in recent years – offering relative stability and autonomy in the lives of patients – modern antipsychotic medication comes with a huge price. Drugs such as clozapine (an atypical antipsychotic) are associated with significant weight gain which triggers diabetes and heart disease, with premature death the result for some.
While weight gain, high blood sugar, diabetes, and raised cholesterol were a feature of older treatment, the metabolic effects of the newer medications are more marked. But patients with severe mental illness die prematurely from other physical illnesses too, such as chronic obstructive pulmonary disease, HIV infection, hepatitis C and tuberculosis.
Like a lot of WHO documents, the latest is admirably aspirational but short on practical specifics. However NICE (National Institute for Health and Care Excellence) guidelines from the UK advise doctors that before prescribing antipsychotic medication, they must record the person’s weight, waist circumference, pulse and blood pressure, cholesterol levels, diet and level of physical activity. The exact intervals between remeasuring these variables is clearly set out.
Obese
And the guideline advises doctors to, “Identify people with psychosis or schizophrenia who have high blood pressure, have abnormal lipid levels, are obese, are at risk of diabetes or are physically inactive at the earliest opportunity.”
Earlier this year, signatories of the UK’s Charter for Equal Health said tha they will work towards winning back the 17 years of life that people with long-term mental health conditions lose on average. “These are the stolen years of life,” says the charter. “And for too many, this means living for many years in pain and with reduced quality of life. We want to win back these stolen years and make sure people with mental health conditions have longer and healthier lives.”
The charter commits mental health providers to conducting yearly physical health checks for people with mental health conditions and securing access to evidence based treatments. Primary care and public health services should identify people at risk of physical ill health and should intervene early, while commissioners should collect and publish routine data on physical health inequalities to drive improvements, it advises.
‘Scary to contemplate’
Philippa Lowe, chair of the charity Rethink Mental Illness, who has a son with schizophrenia, welcomed the commitment to monitor physical health alongside mental health from the moment of initial diagnosis. And in a comment that will resonate with patients and relatives of those with severe mental illness here, she said: "The best medication for my son's mental health, which has changed his life so positively, has been the worst for his weight. He now weighs twice what he should, and the consequences for his health and life expectancy are scary to contemplate."
The time has come to address this terrible inequity in Ireland.