June 7, 2018 by Shekhar Saxena | The Lancet Public Health
Excess mortality among people with mental disorders: a public health priority
Premature and excess mortality among people with mental illness is an issue that has implications for not only mental health and overall health services but also for equity and human rights. It has been called a scandal that contravenes international conventions for the “right to health”.1 WHO considers excess morbidity and mortality among people with mental disorders as a high public health priority; these aspects are also included within WHO’s Comprehensive Mental Health Action Plan.2 In 2017, WHO led an initiative on this issue and published a multilevel model of risk factors that lead to excess morbidity and mortality among people with severe mental disorders, and a framework for interventions.3 While presenting options for policy and clinical practice, WHO also suggested an agenda for research. Within this context, the paper by Dzmitry Krupchanka and colleagues4 in The Lancet Public Health is very welcome.
Several key messages can be derived from this study. Perhaps the most important is that, in many countries, careful linkage of nationwide databases is possible and important evidence can be generated with this method. Other countries should make a serious effort to do the same, which will build a stronger case globally for the issue of premature and excess mortality in people with mental disorders. Although low and middle income countries have poor health information systems, data are particularly needed from these countries. The findings of this large cohort study4 go a long way towards affirming that people with mental disorders die up to three times as frequently as those in the general population and that people with a diagnosis of substance use disorders and schizophrenia are especially vulnerable. Although it is important to document excess mortality and to identify the cause of death, which this paper does, this is not enough. More information is needed about the exact comorbidities, their durations, their exact relation (causal or otherwise), and their contribution to disabilities and eventual mortality. More information is also needed on how the health system is failing to identify and respond to these causes early enough. This information will assist in formulating a plan for interventions at policy, health system, and clinical levels to reduce excess mortality. Of course, national and regional differences would exist on the causes and also on the interventions; these differences need to be identified for an effective response.
Excess morbidity and mortality, especially among people with severe mental disorders, has remained invisible for far too long. For example, the global burden of disease does not take into account this burden within the estimates for the burden of mental disorders. However, some initial analyses5 suggest that adequate consideration of the contribution of severe mental illness to mortality from associated causes increases the burden estimates substantially. Similarly, health-care systems remain unresponsive to the need for additional and proactive interventions to reduce the risk factors and to identify and treat physical diseases among people with mental disorders in a timely and effective manner. Vertically segregated health care for physical and mental health, including the existence of large custodial psychiatric hospitals is partly responsible for this issue. General health-care providers are also unskilled in and reluctant to identify and manage these concomitant comorbidities in people with mental disorders. The all-pervading stigma against people with mental disorders contributes to neglect of routine health checks and provision of necessary and timely health care. More research is needed into all these aspects but corrective actions can and should be taken now. Public health planners and health administrators can begin initiatives with the information and evidence that is already available. These initiatives include individual-focused interventions such as better mental health management, physical health treatment, and lifestyle and behaviour interventions; health system-focused interventions such as more effective service delivery; and community-level and policy-focused interventions such as more effective social support, stigma reduction interventions, and other health and social policy measures.3 The current focus on universal health coverage within the Sustainable Development Goals and in WHO’s proposed priorities6 can be effective in taking some of these steps in an integrated manner.
For more on the Sustainable Development Goals see https://sustainabledevelopment.un.org