[NYAPRS Enews] 'Physical Health and Well-Being for People with Mental Illnesses'

[Harvey Rosenthal]

NYAPRS Note: The following comes to us courtesy of Peggy Swarbrick.

 

In It Together: Physical Health and Well-Being for People with Mental Illness 

By Sharon Lawn Australia and New Zealand Journal of Psychiatry 2012 46: 14

 

Department of Psychiatry, Flinders University, Adelaide, Australia (Flinders Human Behaviour and Health Research Unit, The Margaret Tobin Centre (Room 4T306), Flinders University PO Box 2100, Adelaide SA 5001, Australia Email: sharon.lawn at flinders.edu.au).

 

In mental health and physical health care settings, we have largely ignored mentally ill peoples' physical health problems, arguing that they have other priorities, that they won't be motivated, that someone else is responsible, or that the situation is hopeless anyway. As workers, we can spend lifetimes telling people what they should be doing and then won­der why they don't follow our good advice. We sometimes don't even expect to wonder; which is part of the problem. 

Why is physical health important for people with mental illness? The statistics are stark. We know that almost half of all cigarettes smoked in Australia, the US and the UK are smoked by people with mental illness (Access Economics, 2007; Lasser et al., 2000; McManus et al., 2010). Those with more severe mental illness die on average 25 years sooner than they should (Manderscheid et al., 2008). We also know that they have two to three times the mortality and morbid­ity from all the major chronic health conditions (Coghlan et al., 2001). For example, cardiovascular disease is their leading cause of death for people with mental illness (Kilbourne et al., 2007; Osborne et al., 2007). Diabetes in the third leading cause of death for people with schizophrenia, after sui­cide and epilepsy (Chue and Cheung, 2006). 

 

It has become so insidious in this group that some experts suggest it be officially recognised as an inde­pendent risk factor for diabetes in its own right (Dursun et al., 2005). Cancer rates occur similarly across the whole population. However, mortality rates are significantly higher in people with mental illness (40% higher in males and 20% higher in females), most likely due to insuffi­cient early detection, treatment and care; too little, too late (Lawrence et al., 2000). Metabolic syndrome has reached epidemic proportions, and is expected rather than the exception for people with long-term mental ill­ness (De Hert et al., 2009). And finally, people with schizophrenia have a 10-fold increased death rate from res­piratory disease, with smoking as the main cause (Joukamaa et al., 2001). What makes these statistics even more concerning is that many people with mental illness have more than one of these health problems. We already know a lot about the problem. We have spent a lot of time measur­ing it. It is time for action.

So, why don't people just do what they are told and what they know is good for them? The simple answer is that most of us are not very good at doing this (Vermeire et al., 2001). There are likely to be particular rea­sons why many people with mental ill­ness struggle with their physical health. We know that they can live very sed­entary lives. They are particularly likely to smoke and to eat fewer serves of fruit and vegetables than is recom­mended for good health. 

 

Add to this the side effects of psychiatric medications, and problems with mem­ory, planning, motivation and initiating tasks, in addition to stigma (Lambert and Newcomer, 2009; Muir-Cochrane, 2006), and it becomes obvious that maintaining good physical health, let alone good mental health, is hard work. If you are sleeping 14 or 16 hours a day, every day, because of sedation from medications or because there is little to get up for, of course there will be negative consequences for health. If you are too paranoid or anxious to get on a bus or go to a major supermarket to buy groceries and you're living on takeaways at the local deli, of course your diet is going to be poor. This is not true for every­one but is clearly so for some people, particularly many people with lower prevalence psychiatric disorders. Many people with mental illness are running a marathon every day, just in their minds, let alone what we expect them to do to be fit and well. It is hard work. It can be exhausting. 

To make the journey even more difficult, there are many barriers to people with mental illness receiving adequate care for their physical health at every point in our health system. We have highly fragmented systems of care; we don't talk to each other very well, we palm off responsibility to each other, or we 'forget' about the whole picture of the person's journey when they leave our office (Lawn et al., 2009). 

 

And many people with mental illness have had bad experiences in mental and physical healthcare sys­tems, so of course they're going to be tentative about seeking help. This is obvious, yet we continue in our failure to recognise this. When people lapse in medication use, they are labelled non-compliant. When they forget their medication and then, 2 or 3 days down the track, they are becoming unwell and have crossed that line already, they weren't non-compliant-they just had a problem with not having anyone there to help. 

 

Is it any wonder then, when we have systems that think one way, but which are disconnected with the person's needs, that people with mental illness have difficulty with their physical health? In such systems, every­one just does what they can and the problems continue unabated. Workers may blame the person with mental ill­ness, saying he or she wasn't moti­vated. Workers variously opt out, blame others, or abrogate responsibil­ity and accountability to others. A defeatist view prevails. Everyone pays, but particularly people with mental ill­ness. If we waited for people to be 'ready' for change, then many clients of mental health services would not get any service. We have to find ways to help people now. People with mental illness are very concerned about their physical health. Many people may feel they just can't succeed or are scared of becoming unwell (Siru et al., 2009). Change is scary. 

Another obvious issue for those of us who live with someone with schizo­phrenia is that the best laid plans for 'change' or 'motivation' or 'action' can be like shifting sand (Lawn et al., 2010). Each day is a different country, and next week can feel like a world away. It is not a case of, 'I am motivated and I will stay motivated for the next 3 weeks or 6 months'. Yet, we expect people to follow our textbook version of diet and exercise regimes, and we usually expect them to do it alone! 

Health policy, physical health care and the behaviour change goals implicit within them have become increasingly an industry. At the heart of these processes is health literacy and assumptions about how it will improve engagement by the person in his or her own health care (Nutbeam, 2000). Looking closely, the assump­tion is that the person needs to know more, that he or she has problems engaging with services, and greater health literacy on his or her part will solve these problems, that it is a 'criti­cal empowerment strategy'. This all sounds worthwhile and of course knowing as much as you can about your health conditions and how to manage them so that you can prevent further complications, react and respond for best effect, learn to tailor actions and solve new problems as they arise is clearly important (Lorig, 1993). This is so long as systems of care and the broader social circum­stances in which people live their lives are also addressed so that we do not create barriers for them like the ones mentioned already. 

 

We build services and structures and expect people to turn up and follow our rules and crite­ria, often without thinking how we can fit with their needs. So, when a person in his forties with schizophre­nia goes to the emergency depart­ment (ED) because he is experiencing chest pains and knows that something is wrong with his heart, and the ED staff ask him, 'How is your schizo­phrenia?', and he sits there for several hours but never sees any specialist except a psychiatric registrar, and he is discharged only to drop dead on his lawn the next day-did he have a problem with engagement or health literacy? No, he didn't. What he had a problem with was the service engag­ing with him and asking him about his physical health. Services also need to change. People do engage if condi­tions are created for them to do so. You see, people are more than a string of symptoms to be managed with medications, information and behavioural adjustments. They have complex life histories that impact on their health behaviour in spite of knowing what is 'good for them'. Within the service provider-driven interpretation of health care, denial, non-compliance and lack of insight are deemed as problems to be assertively addressed with education and treat­ment. Maybe many people with men­tal illness are just doing what they can to take back some control within a process that may be perceived to be out of control or controlling. 


Our beliefs, thoughts, and how we feel about ourselves also affect how we see ourselves and take action to look after our health (Bandura, 1977). One pertinent example of this complexity is the issue of smoking and mental illness. It typifies the multitude of absurdities that we have built up over decades about how, within systems of care, we fundamentally treat people with mental illness (Lawn, 2004, 2008). In the absence of effective support, people do what they can, as the following two comments demonstrate: 

 

(Mark - schizophrenia) 

The first time when I had no money and I couldn't get credit at the deli, I used to go around the streets looking for butts ... looking for butts ... I don't know where or who they came from but I'd unroll them and join them all up again into one. (pause) It was just a smoke wasn't it? When you can't have a smoke you just go around knocking on people's doors ask­ing for smokes ... and they'd say, 'Who are you and what do you want?' Some just used to swear at me and push the door in my face, bang the door. It was just a smoke. (pause) I would have done anything for one at the time. 

(Joan - bipolar) 

When I'm more agitated it's like I can't do things but I also can't not do anything. Having a cigarette fits right in that gap. 

 

If we are to address physical health for people with mental illness, we need to first believe that it is worth­while, that it is possible, and also that it is a priority alongside effective treat­ment for mental illness, not secondary to it. The following statement was made over a decade ago by a psychia­trist with influence (Lawn, 2004): 

Poor devils, they haven't got much left for them with schizophrenia. If they want to smoke, let them.

 

I showed this quote to a large group of psychiatrists in 2010 and the major­ity of them were appalled by it. However, one psychiatrist asked me what was wrong with it. So I asked him if he would say something like this to his patients, to which he quickly said 'No, of course not'. So I asked him why he wouldn't say this to his patients, to which he gave no response. 

 

A related argument that is often applied to people with mental illness is that smoking is 'one of their few pleasures' or 'their only pleasure'. This is another example of giving up hope and the biggest tragedy is when people with mental illness use this argument themselves. One recent example comes from a small group of consumers backed by a social action lobby group who wrote a submission to NSW Health protesting about its smoke-free policies. Their main argu­ment was that smoking was their only pleasure. But, why is smoking their only pleasure, and how the hell did it get this bad that it is perceived as their only pleasure? Surely, it is bad enough that we have systems of care that implicitly hold this view (and sometimes explicitly). Is this good enough and what are we all going to do about it? Answering these ques­tions would seem to be getting closer to a better sense of social justice and support for health and well-being for people with mental illness. 

 

So why do we need to find more effective ways to address physical health for people with mental illness? Because these are our family members, neighbours and friends and we're in this together. There is 'no health with­out mental health' but there is also 'no mental health without physical health' (Tiihonen, 2011). We are all affected, either directly because they are our family or indirectly because, as work­ers, we lose skills, or never develop them in the first place when we ignore these issues. Yet, many workers will tell you the best memories of their working lives are the times that they have truly been 'in it together' with their clients, learning together through a real human exchange. It is often the skill development and the impact that doesn't get measured. 

 

Two examples of services using peer workers demonstrate how it is possible to step out of our service comfort zone to learn together. The first was a hospital avoidance / early discharge peer-led support service in Adelaide. Peers were getting in the door and working with people when other workers were not. The person listened to the peers and trusted them because peers understood the barri­ers to mental and physical health first hand. They helped people find strate­gies for becoming and staying well (Lawn et al., 2007a). 

 

The second example is a study that tested a model of chronic condition self-management support with people with mental illness (Lawn et al., 2007b). Again, peers showed how the simple act of working alongside peo­ple can make all the difference. People were motivated to look after their physical health; they just needed rele­vant support to do so. Consumer-identified problems lessened, they achieved their goals, their quality of life improved and their hospital admis­sions disappeared. Workers found out things about their clients and understood them better simply by asking people what they knew already about their health conditions, what they did well, what they found diffi­cult, what they saw as 'the problem'. Peers reported improved health and well-being too, and GPs became more confident and skilled in their roles. 

 

In conclusion, how we take the steps with people is the most impor­tant thing. There are important system improvements that we can make to create a real difference and we now have the potential with more funding in the sector to do this. Services like the team at the Mental Illness Fellowship of Victoria, are demonstrating the strong leadership and commitment that are needed if we are to address the physi­cal health of people with mental illness. But they cannot do it alone. They need other services, particularly mental health services, to respect what they do and to work with them, together with the person. Workers across sys­tems need to believe that they can make a difference. They need to care. They need support, training and practi­cal tools that help them to work with their clients and each other, together. This requires resources to build more effective communication systems, and that give services the necessary time to support people adequately-not in the short term, but also along the journey-in order to make a real impact across the whole spectrum of physical and mental health support experiences for people with mental ill­ness. For people with mental illness to feel safe, valued, respected, listened to, and not judged, services need to work together with them and with each other. We are, after all, in it together. 

 

Funding 

I wish to acknowledge and thank Frank and Patricia Woodcock for their gener­ous sponsorship of the Annual Bruce Woodcock Memorial Lecture. 

Acknowledgements 

I wish to thank Elizabeth Crowther (CEO) and all the wonderful staff at the Mental Illness Fellowship Victoria. I also wish to thank Michael Nanai for permission to use his artwork. The full lecture can be heard on the Mental Illness Fellowship of Victoria website at: http://www.mifellowship.org/? q=content/physical-health-wellbeing. 

 

References 

Access Economics (2007) Smoking and mental illness: costs. Report by Access Economics Pty Ltd for SANE Australia. Available at: http://www.sane.org/images/ stories/information/research/0712_info_ smokecosts.pdf (accessed 30 June 2011). 

Bandura A (1977) Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall Inc. 

Chue P and Cheung R (2006) Minimising the risk of diabetes in patients with schizophrenia and bipolar disorder. International Journal of Psychiatry Clinics 10: 105-116. 

Coghlan R, Lawrence D, Holman CDJ, et al. (2001) Duty of care: physical health in people with mental illness. Technical Report. Perth: Centre for Health Services Research, School of Population Health, University of Western Australia. 

De Hert M, Schreurs V, Vancampfort D, et al. (2009) Metabolic syndrome in people with schizophrenia: a review. World Psychiatry 8: 15-22. 

Dursun S, Dinan T, Bushe C, et al. (2005) Challenges in advancing mental and physical health of patients with serious mental illness. Journal of Psychopharmacology 19: 3-5. 

Joukamaa M, Heliovaara M, Knekt P, et al (2001) Mental disorders and cause-specific mortality. British Journal of Psychiatry 179: 498-502. 

Kilbourne A, Brar J, Drayer R, et al. (2007) Cardiovascular disease and metabolic risk factors in male patients with schiz­ophrenia, schizoaffective disorder, and bipolar disorder. Psychosomatics 48: 412-417. 

Lambert TJR and Newcomer JW (2009) Are the cardiometabolic complica­tions of schizophrenia still neglected? Barriers to care. Medical Journal of Australia 190(4): S39-S42. 

Lasser K, Boyd JW, Woolhandler S, et al. (2000) Smoking and mental ill­ness: a population-based prevalence study. Journal of the American Medical Association 284: 2606-2610. 

Lawn SJ (2004) Systemic barriers to quit­ting smoking among institutionalised public mental health service popula­tions: a comparison of two Australian sites. International Journal of Social Psychiatry 50: 204-215. 

Lawn S (2008) Tobacco control policies, social inequality and mental health populations: time for a comprehensive treatment response. Australian and New Zealand Journal of Psychiatry 42: 353-356. 

Lawn S, Smith A and Hunter K (2007a) Mental health peer support for hos­pital avoidance and early discharge: an Australian example of consumer driven and operated service. Journal of Mental Health 17(5): 498-508. 

Lawn S, Battersby MW, Pols RG, et al. (2007b) The mental health expert patient: findings from a pilot study of a generic chronic condition self-management program for people with mental illness. International Journal of Social Psychiatry 58: 63-74. 

Lawn S, Battersby MW, Lindner H, et al. (2009) What skills do primary health care professionals need to provide effec­tive self management support?: seek­ing consumer perspectives. Australian Journal of Primary Health 15: 37-44. 

Lawn S, Walsh J and Barbara A (2010) The Bond We Share: Experiences of Caring for a Person with Mental and Physical Health Conditions. A resource for mental health services, primary health care, edu­cators and carers. Adelaide: FHBHRU, Flinders University. 

Lawrence D, Holman C, Jablensky A, et al. (2000) Excess cancer mortal­ity in Western Australian psychiatric patients due to higher case fatality rates. Acta Psychiatrica Scandinavica 101: 382-388. 

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McManus S, Meltzer H and Campion J (2010) Cigarette smoking and men­tal health in England: data from the adult psychiatric morbidity survey 2007. Melbourne: National Centre for Social Research (NatCan). Available at: http://www.natcen.ac.uk/study/ cigarette-smoking--mental-health (accessed 30 June 2011). 

Manderscheid R, Druss B and Freeman E (2008) Data to manage the mortality crisis. International Journal of Mental Health 37(2): 49-68. 

Muir-Cochrane E (2006) Medical co-mor­bidity risk factors and barriers to care for people with schizophrenia. Journal of Psychiatric Mental Health Nursing 13: 447-452. 

Nutbeam D (2000) Health literacy as a public healthy goal: a challenge for con­temporary health education and com­munication strategies into the 21st century. Health Promotion International 15(3): 259-267. 

Osborn D, Levy G, Nazareth I, et al. (2007) Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom's General Practice Research Database. Archives of General Psychiatry 2007; 64: 242-249. 

Siru R, Hulse G and Tait R (2009) Assessing motivation to quit smoking in people with mental illness: a review. Addiction 104(5): 719-733. 

Tiihonen J, Lönnqvist J, Wahlbeck K, et al. (2011) No mental health with­out physical health. The Lancet 377 (9766) 611. 

Vermeire E, Hearnshaw H, van Royen P, et al. (2001) Patient adherence to treatment: three decades of research: a comprehensive review. Journal of Clinical Pharmacy and Therapeutics 26(5): 331-342.

 

 

http://anp.sagepub.com/content/46/1/14.full.pdf

 

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