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Ending lethal discrimination against people with serious mental illness

  • Holly Taggart (a1) and Sue Bailey (a2)

Summary

Each year in England 33 000 people diagnosed with a serious mental illness (SMI) die from causes that could have been avoided. Our mental-health-specific Atlas of Variation is the first to demonstrate the extent to which these inequalities and inequities affect mortality nationally.

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Copyright

Corresponding author

Holly Taggart, Policy Unit, Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB, UK. Email: htaggart@rcpsych.ac.uk

Footnotes

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Declaration of interest

H.T. is author of the Atlas of Variation to which S.B. contributed the Foreword.

Footnotes

References

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1 Department of Health. No Health without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of all Ages. Department of Health, 2011.
2 Department of Health. Living Well for Longer. National Support for Local Action to Reduce Premature Avoidable Mortality. Department of Health, 2013.
3 Taggart, H. The CentreForum Atlas of Variation: Identifying Unwarranted Variation across Mental Health and Wellbeing Indicators. CentreForum, 2014.
4 Health & Social Care Information Centre. Dataset 1.5.i Excess under 75 mortality rate in adults with serious mental illness (formerly indicator 1.5). Health & Social Care Information Centre, 2015.
5 Lutterman, T, Ganju, V, Schacht, L, Shaw, R, Monihan, K, Bottger, R, et al. Sixteen State Study on Mental Health Performance Measures. DHHS Publication No. (SMA) 03-3835. Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003.
6 Organisation for Economic and Co-operative Development. Health at a Glance. OECD, 2013.
7 Thornicroft, G. Physical health disparities and mental illness. Br J Psychiatry 2011; 199: 441–2.
8 McManus, S, Meltzer, H, Campion, J. Cigarette smoking and mental health in England. Data from the Adult Psychiatric Morbidity Survey. National Centre for Social Research, 2010.
9 Green, H, McGinnity, A, Meltzer, H, Ford, T, Goodman, R. Mental health of children and young people Great Britain 2004. Office for National Statistics, 2004.
10 Royal College of Psychiatrists. Report of the National Audit of Schizophrenia (NAS) 2012. Healthcare Quality Improvement Partnership, 2012.
11 De Hert, M, Correll, CU, Bobes, J, Cetkovich-Bakmas, M, Cohen, D, Asai, I. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 2011; 10: 5277.
12 Thornicroft, G. Premature death among people with mental illness. BMJ 2013; 346: f2969.
13 Rethink Mental Illness. Lethal Discrimination. Rethink Mental Illness, 2013 (https://www.rethink.org/media/810988/Rethink%20Mental%20Illness%20-%-20Lethal%20Discrimination.pdf).
14 Wahlbeck, K, Westman, J, Nordentoft, M, Gissler, M, Munk Laursen, T. Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders. Br J Psychiatry 2011; 199: 453–8.
15 Harris, EC, Barraclough, B. Excess mortality of mental disorder. Br J Psychiatry 1998; 173: 1153.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Ending lethal discrimination against people with serious mental illness

  • Holly Taggart (a1) and Sue Bailey (a2)
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eLetters

Taggart, H, Bailey, S. Ending lethal discrimination against people with serious mental illness British Journal of Psychiatry (2015) 207:469-479

George Ikkos, Consultant Psychiatrist in Liaison Psychiatry, Royal National Orthopaedic Hospital NHS UK
07 December 2015

Perhaps the journal risks accusations of hyperbole by adopting the slogan of “lethal discrimination” in relation to the shockingly high Standardised Mortality Ratios (SMR) of the severely mentally ill (SMI). Other serious illnesses (Cancer etc.) have high SMR but to suggest this is due to “lethal discrimination” would attract criticism.



The authors are right to draw attention to the high SMR in SMI. This is consistent with accepted tenets of moral philosophy, particularly liberal political philosophy. Central to this are principles that citizens enjoy maximum liberty subject to respect for the liberty of others and, second, social arrangements permit social inequality only to the degree that this improves the wellbeing of the least advantaged (1). The SMI are amongst the most disadvantaged.

Table 1 of the editorial indicates those SMI in contact with services fare better in the US than the UK. This will not surprise those who have expressed dismay about developments in mental health services in the UK (2). However, the important question is whether the way US mental health services are funded, commissioned and managed may be better . Psychiatrists need to remain open minded about what systems deliver best results, if we are to achieve our aims effectively (3).

International comparisons are notoriously difficult to make. A host of health and social indicators however suggest worse outcomes in more unequal societies. Because the US is a more unequal society, Table 1 is counterintuitive. Perhaps Table 1 is misleading. Taggart and Bailey don't tell us whether the US data include outcomes of those SMI receiving care in prison. In the last forty years the proportion of people with SMI who are compulsorily detained in the US has remained the same. However, whereas forty years ago 75% were in mental hospitals and 25% in penal institutions, now the proportions are 5% and 95% respectively (4). Table 1 will have validity only if the outcomes of imprisoned SMI are included.

Should further research confirm US superiority, another issue might arise: does more restrictive treatment (in prison) achieve better outcomes? If so, psychiatrists will have to face deeply uncomfortable questions. Could it be that enhanced incarceration leads to lesser freedom but lower SMR? Would lower SMR be the effect of more intensive psychopharmacological treatment or is there less psychopharmacological intervention in prison and the higher UK SMR is due to more psychopharmacological treatment in the community? What kind of societies lead to best outcomes for the SMI?

Health outcomes do not depend only on healthcare. In order to participate constructively in debate and action aimed at reducing SMR in SMI psychiatrists need to become familiar with the complex issues addressed by political philosophy (1) as well as public mental health. They also need to be aware that though they may master evidence and political ethical reasoning, social ideology will sometimes prevail as to what happens on the ground (5). Perhaps it is anxiety secondary to this that impelled invention of the concept of “lethal discrimination” in SMI.

References

(1)Ikkos, G., Fairness, Liberty and Psychiatry, International Psychiatry (2009) 6: 46-48.

(2) St. John-Smith, P., McQueen, D., et. al. The trouble with NHS psychiatry in England, Psychiatric Bulletin (2009) 33:219-225.

(3)Ikkos, G., Sugarman, P., Bouras, N, Mental Health Services Commissioning and Provision: Lessons from the UK? Psychiatriki (2015) 26:181-187

(4) Bark, N. Prisoner mental health in the USA International Psychiatry (2014) 11:53-55

(5)Bouras, N., Ikkos, G. Ideology and Psychiatry, Psychiatriki (2013) 24:17-27

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Conflict of interest: 1: NHS Consultant Psychiatrist 2: Chairman and Director London International Practice Ltd

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Excess under 75 mortality rate in adults with a SMI: data update

Holly Taggart, Policy Analyst, Royal College of Psychiatrists
01 December 2015

On 19 November 2015, the Health and Social Care Information Centre published a further iteration of data on the excess under 75 mortality rate in adults with a serious mental illness (SMI) to cover the period between 2013 and 2014. This letter serves as an update to the 2012/13 data cited in the corresponding editorial.

The standardised mortality ratio (SMR) across England is now 3.52, an increase of 1.4% from the previous year. The pattern of excess mortality across different age groups remains the same, with those aged between 30-34 years continuing to have the greatest risk of premature mortality. The SMR for women is now 3.44, a 0.9% increase compared to the previous year, and the SMR for men is 3.58, a 1.7% increase.

One major difference is the regional variation in the excess mortality rate, which is more susceptible to change year on year. The Wirral now has the highest rate of excess mortality for people in contact with secondary mental health services in England with a SMR of 5.88, compared to the previous year where Hartlepool had a SMR of 5.64. In fact, within one year Hartlepool has seen the greatest reduction of excess mortality, from 5.64 times more likely to die prematurely (2012/13) to 3.38 times more likely to die prematurely (2013/14), a 40% reduction. Cheshire East has seen the greatest deterioration with an increase in SMR of 1.38. The Isle of Wight continues to have the lowest risk of excess death, but even this region has increased SMR by 3%. The fold difference between the best and worst areas in England is now 4.34, a 7.2% increase from last year.

For disease specific causes of death, the risk of dying from liver disease is still the most likely cause of excess death in people with a SMI, compared to respiratory disease, cardiovascular disease or cancer. The latest data shows a 1.7% increase in deaths through liver disease, the first increase since 2011. Conversely, the risk of dying from respiratory disease has continuously risen since data collections began but this is the first year where a 0.4% reduction has been observed. There has also been a marginal increase of 0.1% in mortality through cardiovascular disease. Cancer is still the least likely cause of premature mortality in people with a SMI when compared to the other diseases listed above and has seen the greatest yearly increase of 2.7%.

Overall, the data shows the gap between the observed number of deaths in people with a SMI and the expected number of deaths in the general population continues to widen year on year.

Reference

Health & Social Care Information Centre. Dataset 1.5.i Excess under 75 mortality rate in adults with serious mental illness (formerly indicator 1.5). Health & Social Care Information Centre, 2015

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Conflict of interest: Holly Taggart is author of the editorial, 'Ending lethal discrimination against people with serious mental illnesses',

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