People living with mental illness die on average 20 years earlier than the general population (Roberts, 2019). For every person living with mental illness who dies early of suicide, nine die early due to heart disease, respiratory disease or cancer. Every day, 20 Australians with mental illness die prematurely due to physical illnesses (Roberts, 2019). Suicide is shocking and tragic, and it is right to address suicide as a priority. However, every premature death is tragic and has a devastating impact on family and social networks. Early deaths due to a physical health condition are usually preceded by years or decades of poor health, disability and functional impairment. A large proportion of the premature deaths of people living with mental illness are due to physical illnesses such as heart disease, respiratory disease and diabetes (ABS, 2017). At least 40 per cent of the early deaths are preventable (AIHW, 2019). However, due to a variety of reasons such as stigma, discrimination, and limited access to quality health care, the gap in life expectancy persists and, in fact, appears to be growing (Walker, McGee, & Druss, 2015).
The Australian Psychological Society (APS) has formally committed to the Equally Well National Consensus Statement and to making the physical health of people living with mental illness a priority. This article highlights the key role psychologists can take in the domains of smoking cessation, nutrition, alcohol use, physical activity, advocacy and coordination of care to improve the physical health of people living with mental illness. In addition to having behavioural-change expertise and motivational techniques, psychologists are uniquely placed to help and support clients to access quality physical health care.
The physical health of people living with mental illness is a priority of the Fifth National Mental Health and Suicide Prevention Plan. It is also the focus of the National Consensus Statement, Equally Well: Improving the physical health and wellbeing of people living with mental illness in Australia (National Mental Health Commission, 2016). The APS was an active member of the expert advisory committee that guided and supported the development of the National Consensus Statement and is a foundational signatory to Equally Well, committing to “making the physical health of people living with mental illness a priority at all levels: National, state/territory and regional” (p. 7; equallywell.org.au).
Diagnostic overshadowing
Almost 80 per cent of people living with mental illness also have a mortality-related physical illness, and 55 per cent have two or more comorbid conditions (AIHW, 2012). Thus, the probability is high that psychologists’ clients will have a mortality-related physical health condition. When people living with mental illness see their general practitioner (GP), their mental health condition can mask and distract attention away from coexisting physical illnesses. This is a phenomenon known as ‘diagnostic overshadowing’ and it results in many chronic but treatable physical health conditions going undiagnosed and untreated. Therefore, when a psychologist conducts an initial assessment, in addition to assessing suicidality, they should also consider risks of premature death due to chronic physical health conditions. A psychologist should always inquire if the person has seen a GP in the past six to 12 months and had a comprehensive physical health examination. If they have not, it should become a priority.
The role of practising psychologists
With Equally Well’s focus on improving physical health, many psychologists may question the relevance to their work in mental health. Psychologists can play an important role in reducing the risk and impact of chronic physical health conditions in their clients. Existing evidence-based frameworks to guide the provision of preventive care for modifiable behavioural health risks used in other clinical settings, such as the ‘5As’ approach (ask, assess, advise, assist and arrange) recommended for use in Australian general practice, could also inform a systematic approach to care provision by psychologists. Some domains where psychologists should consider interventions are the key health-risk behaviours such as smoking, nutrition, alcohol misuse and physical activity (SNAP) (RACGP, 2015). There is also strong and growing evidence that improved physical health significantly reduces psychological distress and mental illness (Fässberg et al., 2016).
Smoking cessation
Smoking is a significant contributor to the risk of heart disease, respiratory disease, cancer and many other physical illnesses. The higher prevalence of smoking among people living with mental illness is reflected in greater smoking-related harm. The infographic opposite shows that although people living with mental illness made up 12.9 per cent of the population accessing Medicare Benefits Schedule (MBS) or Pharmaceutical Benefits Scheme (PBS) funded services, they comprised 59 per cent of the premature deaths due to trachea, bronchus and lung cancer and lower respiratory disease (ABS, 2017).
A recent study found that only 80 per cent of mental health-care professionals ask about smoking, only 45 per cent advised clients to quit and only one-third referred to Quitline or offered cessation assistance (Sharma, Meurk, Bell, Ford, & Gartner, 2017). Psychologists are uniquely qualified to advise, refer and implement smoking cessation programs. For every two people a psychologist helps quit smoking, they will save one from a premature cancer-caused death. Despite the fact that most psychologists believe people living with mental illness are not interested in quitting, motivation to quit is about the same as the general population (Ashton, Miller, Bowden, & Bertossa, 2010).
Psychologists are well-placed to deliver evidence-based smoking cessation interventions within the context of usual treatment. The most effective way to quit smoking is a combination of behavioural interventions and pharmacotherapy (for more see InPsych, October 2017). Even a brief intervention may trigger a quit attempt and result in cessation, especially if it includes referral to evidence-based help. At a minimum:
1. Ask all clients: “Do you smoke (tobacco or anything else)?”
2. Advise: Seek permission to give advice about smoking and how it might be interacting with the presenting condition: “Stopping smoking improves mental health and wellbeing.”
3. Assist: Make an enthusiastic offer of help and provide self-help material, advice regarding pharmacotherapy and offer referral to Quitline or a stop smoking specialist.
Nutrition
Nutrition has a major effect on mental and physical health. Healthy nutrition is important to minimise the risk of diabetes, cardiovascular diseases and other lifestyle diseases. It is also important for cognitive function. People with a serious mental illness tend to have poorer nutrition than the general population and their diet typically comprises fewer fruit and vegetables and is higher in fat and lower in fibre, than overall population rates.
Weight gain is a key contributor to the poor health of people living with mental illness. Weight gain is most significant in the first 12 weeks after the start of some antipsychotic medications and is associated with weight gain of up to 16 kg (Pérez-Iglesias et al., 2014). Research indicates that once this weight gain has occurred it is extremely difficult to reverse without surgery (Rosenbaum, 2019). Thus, early intervention is critical.
A Cochrane review (Pearsall, Praveen, Pelosi, & Geddes, 2016) found that while dietary advice was frequently offered by health professionals, this advice is not evidence-based. Working collaboratively with dietitians has been shown to improve intervention effectiveness, and psychologists are key to addressing the challenges such as reduced motivation, lack of attendance at appointments and sendentary behaviour.
Alcohol
Alcohol misuse has been found to be the condition associated with the highest elevated risk of premature mortality, and individuals with coexisting mental health and addiction have poorer health outcomes than people living with mental illness alone (Erlangsen et al., 2017).
Alcohol use disorder (AUD) is a common presentation in clinical practice. Twelve-month DSM-5 prevalence rates are similar to mood and anxiety disorders, at 17.6 per cent for men and 10.4 per cent for women (Grant et al., 2015). There is strong evidence that psychological treatments are effective (for more information see InPsych October 2017) but a delay of 18 years is likely to occur before diagnosis and treatment (Chapman, Slade, Hunt, & Teesson, 2015).
Psychologists have an especially important role to play in substance use treatment given their frequent work in primary healthcare with clients and family members. Further, the importance of routinely screening and assessing substance use and other addictive behaviours has been highlighted; using diagnostic criteria and screening tools such as the AUDIT (Alcohol Use Disorders Identification Test), DUDIT (Drug Use Disorders Identification Test) and DAST (Drug Abuse Screening Test), often freely available online. When problematic use is identified, information collected to describe use should include quantity, frequency, duration, route of administration, and patterns of use.
Physical activity
On average, the physical activity levels of people living with mental illness are much lower than the total population. The goal of physical activity is to improve cardiovascular fitness and overall health. Reviews of the effectiveness of interventions in increasing physical activity have shown variable results. While some reviews have shown programs to be effective, they have also found many programs to be ineffective (De Rosa et al., 2017) and it appears that motivation and ongoing participation appear to be crucial elements for program effectiveness or failure. The expertise of psychologists in behavioural activation and motivational techniques is vital. These can be applied in individual therapy and also to group programs delivered alongside other health professionals such as exercise physiologists and nurses.
In addition to mitigating the health risks for people living with mental illness, there is a strong and emerging body of research indicating the beneficial effects of exercise on mental health. Systematic reviews and meta-analyses have concluded that physical activity significantly improves mental health and should be considered a first-line therapeutic strategy for treatment of depression (Vancampfort, Stubbs, Ward, Teasdale, & Rosenbaum, 2015).
Medication
The side-effects of antipsychotic medication are well-documented. “People living with mental illness have a much higher risk of developing metabolic syndrome... Steps should be taken to limit the side-effects such as obesity, cardiovascular disease and diabetes” (National Mental Health Commission, 2016). It is not uncommon for people living with mental illness to gain 40 kg in the 36 months after starting antipsychotic medication (Maylea & Daya, 2019). The health, mental health and functional effects of this rapid and dramatic weight gain are profound.
Thus, psychologists should ask about medications including when clients began taking them. Early intervention to prevent and reduce the weight gain side-effects of antipsychotic medication is vital to reducing psychological distress and mortality-related consequences.
Social participation
Social disadvantage, social participation and workforce participation are all strongly related to an increased risk of early death for people living with mental illness. Recent reviews have revealed the profound influence of social isolation and loneliness on mental health (White et al., 2019). While people living with mental illness have 2.5 times the rate of premature death, for those also of low SES and not in the workforce this rate increases to three and six times that of the total population (Roberts, 2019). Low levels of social and work participation are both a cause and symptom of poor mental health and poor physical health. This underscores the importance of setting social engagement and community participation goals and working with clients to help them achieve these goals. Strong social support networks are key correlates of mental health (White et al., 2019; see infographic).
Agency and human rights
If you are not doing human rights, you are not doing mental health! This includes fully informed consent, active participation in recovery planning, equity of access to services, and shared decision making (Maylea & Daya, 2019). Client autonomy and personal agency need to be at the heart of both clinical practice and policy responses to address this problem. Wherever possible, clients should drive decisions related to the management of their illness. Evidence suggests that building the capacity of clients to actively manage their own health and their interaction with the health system can be a powerful way to overcome the fragmentation of the health system (RANZCP, 2015). People living with mental illness are often not informed in full about the side-effects of antipsychotic medications. Anecdotes of being told “you might put on a bit of weight” are common. The reality is a high risk of extreme weight gain. Engaging in honest discussions with clients on the side-effects of interventions opens opportunities for psychologists to advocate on their clients’ behalf with other professionals who partner in our clients’ care.
Helping clients navigate the system
People living with mental illness experience several significant barriers to accessing physical health care. These include cost, availability of services and stigma. While people living with mental illness and their carers view their physical health as important, these concerns are frequently dismissed by health providers (Happell & Ewart, 2016). Physical health treatment rates for people living with mental illness are much lower than those for people with a physical condition alone (RANZCP, 2015). When people living with mental illness do access care they often suffer from diagnostic overshadowing and discrimination. Due to past experiences of poor interpersonal treatment and discrimination, many people living with mental illness find arranging and attending medical appointments daunting.
As respected health professionals who have established a trusting relationship with their clients, psychologists can play a key role in helping to ensure their clients receive quality physical health care. For many people living with mental illness, securing a comprehensive physical examination and related physical health care may be the most impactful psychological intervention a psychologist makes. Improving physical health has a significant positive effect on mental health (Fässberg et al., 2016) and should be a goal of integrated mental health care.
Integrated care
Psychologists have a unique set of assessment, diagnostic and therapeutic skills. These skills are invaluable in facilitating multidisciplinary support for their clients. Depending on the client’s profile and recovery plan, this might include their GP, dietitian, occupational therapist, exercise physiologist and social worker. Further, recovery planning can include the client’s family, friends, peers and supporters and how they partner in ensuring access and provision of physical health care. Working in an integrative and multidisciplinary fashion can reduce the barriers inherent in the fragmented Australian health system. Psychologists’ expertise in behaviour modification, behavioural activation, social engagement and motivational methods adds a key element to the effectiveness of the care provided by GPs, nurses and allied health professionals.
The first author can be contacted at [email protected]