Mental health and life expectancy – Expert Reaction

People with mental illness could experience a gap in life expectancy of around 20 years, a report in The Lancet has found.

The report – the result of an Australian-led task-force – found a broad range of mental illnesses are associated with a lifelong burden of obesity, diabetes and cardiovascular disease.

It makes a range of lifestyle and healthcare recommendations to combat the huge disparities, with the commission chairman labelling the current state of things a “human rights scandal”.

The SMC asked experts to comment on the study, which is available on Scimex for registered journalists along with a briefing from the Australian SMC. 

Professor Jim Mann, Director, Healthier Lives National Science Challenge and Professor at the Dunedin School of Medicine, University of Otago, comments:

“The finding that life expectancy in those with a mental illness may be reduced by 20 years when compared with the general population should be of enormous concern to Government, all agencies and individuals involved in the health care of those with mental illness and indeed all New Zealanders. Clinicians and epidemiologists have long known that those with mental illness are at increased risk of heart disease as well as obesity and diabetes but the novel and immensely important finding of the Commission’s Report published in The Lancet is the magnitude of the inequity in health outcomes and life expectancy.

“The Report has international implications but is of special relevance to New Zealand. Our rates of mental illness are high. There are marked disparities in non-communicable disease (NCD) outcomes among Māori and Pacific compared with those of European ethnicity in the population at large and the inequities may be expected to be equal or greater among individuals with mental illness in any groups already at higher risk of NCDs.

“An improved approach to the management of mental illness and enhancing and hopefully achieving equity in health outcomes are clearly stated Government priorities in health care. Current guidelines suggest that cardiovascular risk assessment (which includes screening for diabetes) should be carried out at a younger age in those with mental illness and others considered to be at high risk.

“However, the facilities available for lifestyle management (including dietary and physical activity advice and support) which is the cornerstone of preventive treatment along with smoking cessation are limited, if not non-existent, in most of New Zealand and supportive public health measures are equally lacking. These neglected components of personal and public health would seem to be good starting points for a national response to the alarming message of the Commission’s Report as well as demonstrating a commitment to reducing inequities in health outcomes more generally.”

No conflict of interest. 

Professor Jeremy Krebs, endocrinologist, Department of Medicine, University of Otago, Wellington, comments:

“The findings of the Commission reinforce the strong association between mental health disorders and obesity and type 2 diabetes. This is certainly seen in clinical practice in New Zealand.

“The literature suggests a two-way causal relationship, and the interaction with socio-economic circumstance is clear. It is pleasing to see that the importance of the effects of psychiatric medication on weight and metabolic health are recognised as a priority area, with calls to implement preventative interventions rather than wait for weight gain and diabetes to ensue. Whilst lifestyle programmes such as the Diabetes Prevention Programme have been shown to reduce the progression of pre-diabetes to diabetes in the general population, implementation of this has been limited in New Zealand and almost non-existent in populations with mental health disorders.

“I support the calls from the Commission to address this, and translational research is needed to find ways to enable implementation of this or similar lifestyle interventions in this very vulnerable group.”

No conflict of interest declared. 

Max Abbott, professor of psychology and public health, and co-director, National Institute for Public Health and Mental Health Research, AUT, comments:

“The report findings are not a surprise. Accumulating research from around the world indicates that people with mental health and addiction disorders have a much higher risk of physical illness and reduced life expectancy. Links with obesity, diabetes and cardiovascular disease are particularly strong. In the case of severe mental health disorders, life expectancy is reduced by 20 to 25 years. New Zealand is no exception and this was highlighted in a 2014 Te Pou report and the recent Government Inquiry into Mental Health and Addiction. The reasons for reduced life expectancy include high rates of smoking and other drug use, unhealthy diet, lack of physical activity and side effects of medication, particularly antipsychotics. Suicide rates are also higher. Lack of access to comprehensive physical and mental health services is another major factor. While largely omitted from the Lancet report, stigma and discrimination, poverty, unemployment, housing problems, social isolation and residence in high deprivation, obesogenic neighbourhoods are undoubtedly also important.

“These high rates of physical health morbidity and greatly reduced life expectancy are totally unacceptable. While this matter has received increased attention in recent years, measures to prevent and reduce these iniquities need to be massively amplified. It is essential that physical and mental health are given equal consideration from the time of first contact with health services. Hopefully the Lancet report will help mobilise global efforts to address this too-long neglected issue. The report reviews relevant research and outlines measures capable of significantly improving the physical health and wellbeing of people experiencing mental health disorders.

“This Government has committed to transforming mental health services in this country, supported by additional funding of almost $2 billion over the next four years. This provides a unique opportunity to address the need and massive challenge presented in this important and timely report. However, health service transformation and individual behaviour change, while essential, will be only partially successful if major economic, social and environmental health determinants are not also addressed. Other Government commitments, reflected in the recently announced Wellbeing Budget, are highly relevant. The Budget includes measures intended to reduce poverty and a range of social and health disparities.”

Conflict of interest: I am a long-standing board member of Waitemata DHB.

Dougal Sutherland, Clinical Psychologist, Victoria University of Wellington, comments:

“The phrase ‘there’s no health without mental health’ is starkly demonstrated in findings released today by a taskforce of international experts. The report from the Lancet Psychiatry Commission found people with mental health problems are up to twice as likely to suffer from obesity, diabetes, and cardiovascular disease and are at risk of dying 20 years earlier than those without a mental illness. The report’s authors note that despite the link between mental health and physical health having been known for decades little has been done to address the issue, a failure which the authors rightly refer to as ‘human rights scandal’.

“Drawing together research from the past two decades, the Commission’s report highlights key risk factors linking mental and physical health including higher rates of smoking, poor sleep, diet, and physical activity, and medication side-effects. The report also reveals that people with mental health problems are often not given access to physical healthcare that they need, due partly to bias and lack of training of healthcare professionals.

“The report gives support to the rationale behind the New Zealand Government’s recent Wellbeing Budget which recognised the relationship between social factors, such as poverty, and mental health. The Commission’s report may also help us understand why in New Zealand Māori and Pasifika people are over-represented in both negative mental and physical health statistics as these two areas are tightly intertwined.

“Addressing the health inequities suffered by those with mental health difficulties requires a revolution in the way healthcare services are delivered and how healthcare professionals are trained. We need to break down the artificial distinction between physical and mental health which currently underpins our hospitals and medical practices, a call which was recently made in He Ara Oranga, the report of the Government Inquiry into Mental Health and Addiction. Medical professions need to have a greater understanding of mental health, and mental health professionals need more training and education in the basics of physical health. The Lancet Psychiatry Commission also recommends clinicians and researchers use advances in digital health technologies to bridge the gap in the physical wellbeing of people with and without mental health problems.

“The lead authors of today’s study point out many of the physical illnesses suffered by those with mental health problems are preventable and as a society we must address this inequity to ‘not only add years to [the] life, but life to [the] years’ of those with mental illness.”

No conflict of interest. 

Professor Rod Jackson, cardiovascular disease epidemiologist, University of Auckland, comments:

Note: The research mentioned below is preliminary and not yet published. Rod was part of the expert advisory group that helped develop a cardiovascular disease risk assessment  consensus statement for the Ministry of Health, released last year.

“The findings of the Commission are in line with our review of the literature and local data in regard to the increased risk of cardiovascular disease (CVD) in people with mental illness. Chronic disease, particularly CVD, accounts for a substantial proportion of the reduced life expectancy in people with severe mental illness.

“Our preliminary analyses of a cohort of 400,000 New Zealand primary care patients shows that people with severe mental illness have a significantly increased risk of CVD even after adjusting for the standard CVD risk factors. As a result, CVD risk is a double blow for this vulnerable population group because they also have a higher prevalence of most of the standard CVD risk factors.

“As this population group typically has many health-related issues to cope with, in addition to their physical health, they certainly need extra support to help them reduce their CVD risk.”