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'One patient told me she overheard a member of staff referring to her as "just a psychiatric case"'

Our health service must place a greater priority on the physical healthcare needs of people with mental illness, writes Dr Stephen McWilliams.

Dr Stephen McWilliams

PATIENTS SOMETIMES TELL me that, by virtue of their existing mental illness, they must work twice as hard to have their physical illnesses taken seriously by the health service.

In the waiting rooms of general hospitals, accident and emergency departments and outpatient clinics, they overhear themselves talked about primarily with reference to their anxiety, depression or psychosis, even when their reason for attending is purely physical.

One such patient told me she overheard a member of staff referring to her as “just a psychiatric case”. Another recalled being informed by a general nurse (in a private medical hospital), “we don’t do mental health here.” Such examples are not unusual.

These attitudes, where they exist, come at a cost

Psychiatric patients often feel marginalised in general medical settings. They receive less effective and often delayed care for their physical illnesses because such symptoms are frequently eclipsed by their psychiatric diagnosis.

My patients are not alone in experiencing this. The phenomenon – termed “diagnostic overshadowing” – has been highlighted as a real problem in the healthcare of individuals with psychiatric illness.

Diagnostic overshadowing is a major theme in a recent report by the Royal College of Psychiatrists in London entitled: “Whole person care: from rhetoric to reality – Achieving parity between mental and physical health.” In Ireland, the drive to reduce costs has seen funding for the treatment of psychiatric illness gradually shrink in comparison to that for physical illness.

This is despite the World Health Organisation (WHO) estimation that 350 million people worldwide have depression, making it the world’s leading cause of disability. Mental illness and physical illness are a long way from gaining parity of esteem. They simply are not seen as equally important. It is little wonder people with mental illness sometimes feel disenfranchised.

Separation of mental illness and physical illness is largely artificial

shutterstock_47818288 Source: Shutterstock/Alexander Raths

They often occur in the same people. A recent report by the UK think-tank QualityWatch examined 100 million hospital episodes annually over five years. They found that almost half of people with mental ill health have a concurrent physical condition. They are four times more likely to die of respiratory (lung) disease and 2.5 times more likely to die of cardiovascular disease.

QualityWatch also reported that people with serious mental illness die 10 to 17 years younger, which echoes a WHO assertion that individuals with schizophrenia die 10 to 25 years younger.

Suicide accounts for some of this, but physical illness is the main reason. For example, people with schizophrenia are six times more likely to smoke heavily, while approximately half are significantly overweight. Up to 15% have diabetes and 58% have elevated blood pressure.

Meeting medical needs

As a general rule, meeting the medical needs of any patient will reduce the amount of emergency care they need relative to planned care. People with mental illness have 10% fewer planned medical admissions than the general population, according to QualityWatch.

Instead they have three times more A&E attendances and almost five times more emergency admissions. Less than one in five of these emergency admissions among psychiatric patients are to address their mental health needs; most are for the potentially-preventable complications of common illnesses such as high blood pressure, heart disease, epilepsy and various infections.

Individuals with underlying mental illness are more likely to be admitted overnight and they generally remain longer in hospital.

Deaths that could be avoided

It is little wonder that the UK National Health Service has estimated that some 40,000 deaths might be avoided each year if individuals with serious mental illness were afforded the same amount of physical healthcare as the general population. The equivalent number of deaths annually based on Ireland’s population would be almost 3,000.

In the words of the WHO, the reduced life expectancy of individuals with serious mental illness is due to “a society socially and functionally biased towards the population living with severe mental disorder.”

They die earlier not because of their psychiatric illness per se, but “because of the discrimination and lack of access to good health services.” The WHO further asserts that stigma is the biggest barrier preventing people with severe mental illness from receiving effective care.

People with mental illness already get a raw deal

It behoves our health service (our Government and, indeed, society) to place a greater priority than it currently does on the physical healthcare needs of people with mental illness.

With various mental health campaigns, public and professional knowledge is improving. But perhaps influencing attitudes is the greater challenge.

Dr Stephen McWilliams is a consultant psychiatrist and author. He is clinical lead of the Psychosis Programme at Saint John of God Hospital, Stillorgan, Co Dublin. @McWilliamsMD

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Dr Stephen McWilliams

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