In this assignment the author will critically analyse the health inequalities that are evident for people with a diagnosis of a severe mental illness. He will particularly focus on the inequalities that exist in relation to the prevalence, identification and management of the physical health aspects for this set of complex conditions.
In the course of the assignment he will critically evaluate these health inequalities from an international, a national United Kingdom and a more local Scottish perspective.
In doing so he will critically examine a selection of health promotion approaches which underpin the physical healthcare of people with severe mental illness. He will also systematically evaluate the effectiveness of some of the differing approaches which contribute to the management of these conditions and the enhancement of the health and social wellbeing of mental illness sufferers across the world.
In order to analyse the health inequalities the author will first define some of the key terms that he will refer to throughout the assignment.
Health was defined by the World Health Organisation (WHO) (1948) as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.Though this is a useful and accurate definition, some would consider it idealistic and non-realistic. Using the WHO definition classifies 70-95% of people as unhealthy.
However Davis (2009) declared the added importance of the wider definition of health stating “There is a biomedical component to health, but it exists in a setting that includes biological, personal, relational, social, and political factors”
Looking at health in a little more detail the determinants of health are defined by the WHO (2010) as
“Many factors combine together to affect the health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment. To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact.”
The determinants of health include:
the social and economic environment,
the physical environment, and
The person’s individual characteristics and behaviours.
Alternatively European Union public health information system (2009) define determinants of health as
“Many, often interacting factors that determine a person’s health or disease state. These include
Socio-economic factors: education, occupation, employment, poverty and income distribution;
Environment: social support, airborne particulate matter and working conditions;
Health behaviours: smoking, alcohol use, drug use, food consumption, physical activity and breastfeeding; and
Biological and personal factors: overweight and blood pressure.”
WHO (2010) declared that Health inequalities can be defined as differences in health status or in the distribution of health determinants between different population groups. For example, differences in mobility between elderly people and younger populations or differences in mortality rates between people from different social classes. It is important to distinguish between inequality in health and inequity. Some health inequalities are attributable to biological variations or free choice and others are attributable to the external environment and conditions mainly outside the control of the individuals concerned.
Whereas Samuel (2000) describes health inequalities in a more simple fashion as “unjust or unfair differences in health determinants or outcomes within or between defined populations”.
Severe Mental Illness
The Rethink operational definition of severe mental illness (2008) is when people:
Are diagnosed as suffering primarily from a mental illness, typically schizophrenia or a severe affective (mood) disorder.
Suffer substantial disability as a result of their illness, such as inability to care for themselves independently, sustain relationships or work
Are currently displaying florid symptoms or are suffering from a chronic enduring condition.
Have suffered recurring crises leading to frequent hospital admissions or interventions and/or place a significant burden on their informal carers.
Occasion significant risk to their own health or safety or to that of others.
The Ottawa charter for health promotion WHO(1986) defines Health promotion as “the process of enabling people to increase control over and improve their health” They describe it as not just the responsibility of the health sector and that it goes beyond healthy lifestyles to well being.
Health promotion has been defined by the World Health Organization’s (2005) Bangkok Charter for Health Promotion in a Globalized World as “the process of enabling people to increase control over their health and its determinants, and thereby improve their health”
The United Nations Convention on the Rights of Persons with Disabilities (2006) claim that “persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination. States should take all appropriate measures to ensure access to health services with the same range, quality and standard as provided to other persons.”
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A UK based study by the Disability Right Commission (2006) Equal treatment: Closing the gap described an analysis of 8 million health records. It confirmed that people with severe mental illness have rates of cardiovascular and diabetes problems that are 2-3 times more common than would be expected in the general public. Bowel cancer is 90% more common in males with schizophrenia and women are 42% more likely to get breast cancer.
The author will now go on to explore the phenomenon where many thousands of people with severe mental illness are at high risk of dying early with physical health problems. He sees this as a significant health inequality across the world and will examine some of the health promotion activities that have been attempted to reduce this inequality.
Appendix 1 gives an analysis of the search criteria and the database results that he used in order to critically examine this topic.
Evidence of Health Inequalities
United States of America
Miller et al (2006) in a well conducted and robust clinical study in the USA examined the mortality and medical morbidity of 20,018 patients admitted to psychiatric services with a diagnosis of psychosis in Ohio between 1998 and 2002. It identified that 21 percent of cases died from heart disease and 7 percent from a cancer related disease and 3 percent from diabetes related disorders. They cited the possible causes of these problems as medication induced weight gain, poor personal hygiene, reduced physical activity, and increased prevalence of smoking, increased substance misuse and a reduced social support network. In the study they were also able to report that deaths in this client group were three times higher than expected in the general USA population (with Heart disease being the main cause) and the average age of death at 47.7 years was 32 years younger than the general population figures. They acknowledged in their report the need to better integrate the delivery of both mental and physical healthcare by collaborating with all stakeholders to improve the quality of life outcomes for this population. They do not however go on to explain how they would take this agenda forward.
These international findings are also supported by statements from the Australian National Mental Health consumer and carer forum (2010) who state that the appalling health and early mortality of people with persistent mental illness is unacceptable.
These comments from a national user and carer forum are not defined from one particular study but from a body of research and audit from across Australia focussing on outcomes of a series of studies. The national voice and recommendations from a major player in Australian healthcare with a focus on the needs of the patient rather than services is as significant in the authors’ eyes as a single robust study.
They add that these issues are having a significant impact on the person’s wellbeing and is also contributing to their social exclusion. They add to the argument by stating that these causes are iatrogenic (occurring as a result of the disorder or its treatment ) They go on to add the other areas that are common in this group and that can add to the impact being poverty, neglect, discrimination, smoking, substance misuse and poor dietary habits. They add that the screening for these conditions occurs less often in patients with mental illness hence they are less likely to be treated. The Australian report adds that the life expectancy of this client group is 25 years less than the general population. An interesting fact that they add though is that their evidence suggests that the client group do not have higher than average rates of disease like cancer and heart disease but they die from the disease 2 to 3 times more often than the general public. They suggest again like the USA report that this is due to patients not receiving appropriate preventative screening and treatment for these illnesses. They go on to state that psychiatrists, GPs and other prescribers of psychotropic medication have a responsibility to monitor the effects of medication on a persons physical state as well as its impact on their mental wellbeing. They go on to recommend a series of actions for the future which include
State and territory governments undertake to educate all stakeholders on “Physical Health Impacts of Mental Health Problems and Disorders”
They enable appropriate screening, assessment and physical health checks for all persons with identified mental illness, including attention to dental health
The Australian Government takes leadership on these issues by requiring all identified mental health funding to be accountable for physical health maintenance
All mental health programs and policy areas report on physical health screening, assessment and monitoring for all mental health consumers in receipt of services
Given the nature of mental illness, service providers need to innovate and respond creatively to address the physical health impacts of mental health disorders and their treatment
Doctors take responsibility, when prescribing medications for people with mental health issues, to treat them holistically and monitor their physical health changes and needs.
Likewise in the United Kingdom Cormac (2009) in a Royal College of Psychiatrists paper cites several papers which indicate a higher incidence of physical health problems in people with severe mental illness. Phelen et al (2001) stated that people with mental disorder have a higher risk of poor health and premature mortality and a meta-analysis of 27 studies almost 10 years ago by Harris and Barraclough (1998) showed a standardised mortality ratio of at least 1.5 for this group of patients however it varied with the severity and type of disorder.
Patients with schizophrenia had increased mortality ratios of almost 3-4 times that of the general public with deaths mainly caused by cardiovascular and endocrine type disorders. These findings were reported by Brown et al (2000), Osby et al (2000 and Enger et al (2004). More recent findings in the UK has been the high escalation of the risk of developing metabolic syndrome for schizophrenics which has been found to be 2-4 times higher than the general public, finding borne out in the study by Saari et al(2005) and Thakore (2005). Joukamaa et al (2006) added some additional evidence to suggest that the risk of sudden death in patients with schizophrenia increases with the addition of each different psychotropic medication that is prescribed.
Likewise the Department of Health (2010) in the Our health and Wellbeing report suggest that looking beyond neighborhoods and deprivation, certain groups have poorer health and some are uniquely disadvantaged because of a combination of their circumstances. For example: People with schizophrenia: A total of 0.4% of the population experience psychosis each year. A recent UK study found that, of those living with schizophrenia in the community, men experienced 20.5 years lower life expectancy and women 16.4 years lower life expectancy than the general population. The largest single cause of this inequality is an increased rate of smoking, more than three times that of the general population.
Moreover the NHS in Scotland (2008) in their report “Improving the physical health and wellbeing of those experiencing mental illness” again cite evidence from studies across the world that the physical health of patients with severe mental illness is compromised. They state that “research in Europe and the USA has shown that mortality rates from physical illness for those with mental illness is significantly higher than the general population. Schizophrenia is generally acknowledged as a life shortening illness with sufferers dying on average 10 years earlier than the general population. Two thirds of this excess mortality is due to poor physical health.” They also identified that this group are developing these illnesses at a younger age and are dying from them earlier with 5 year survival rates reduced by up to 16%.
NHS Scotland (2008) also refers to the aspects of stigma and discrimination. They state that “Legislation requires that all Agencies dealing with the public remove discrimination and promote equality, yet a “See Me”(2006) survey reports that some people with mental health problems still feel stigmatised. The Highland Users Group ( 2008) have found that when it comes to their physical health needs they can be subject to unequal access to services and can feel stigmatised and discriminated against when they try to access general health care services. They feel their physical health concerns are too often put down to their mental health problem, especially if their symptoms are medically unexplained. Frayne et al (2005) suggest that research has confirmed that they do not always receive the same medical treatments as the rest of the public and consequently their health outcomes can be worse.”
Additionally the Scottish Government (2008) in the “equally well” report highlights Mental Illness and Mental wellbeing as important factors in the argument. They state that
“Mental illness and mental wellbeing are specific priorities for the Task Force. People with mental illness are more likely to die earlier from suicide, or illnesses such as cardiovascular disease (CVD) and tend to have generally poorer health through conditions such as diabetes.
Mental wellbeing is associated with good mental health, but is not necessarily the same as absence of mental illness. Much of the Task Force’s work is based on the importance of factors such as resilience, hopefulness and optimism that create mental wellbeing and quality of life. These allow people to deal effectively with life’s problems and normal stresses, to make the most of their abilities and the opportunities available and to play a positive part in their community.
People whose wellbeing is good are more likely to look after their own health. However, depression is closely associated with poor physical health, for example increasing significantly the risks of CVD.
The author concludes from the overriding evidence across the world that those suffering from a severe mental illness have much poorer physical health which causes them to have a shorter life expectancy. These conditions are identified as mostly cardiovascular and metabolic type problems. There is evidence that this client group has unequal access to health services and feel stigmatised and discriminated against.
Health Promotion Models and Interventions
Naidoo and Wills (2000) identify 5 approaches to health promotion.
Medical or preventative approaches which target the whole population and are aimed at reducing premature deaths and avoidable diseases.
Behavioural Change approaches view health as the property of the individual and encourages them to adopt healthy behaviours that are regarded as key to improving health.
Educational approaches are strongly linked to heath education and seek to provide knowledge, information and develop skills so that people can make informed choices about their health behaviour.
Empowerment approaches are bottom up approaches which encourage communities to identify their needs, develop skills and make appropriate life changes.
Social change approaches is a top down approach which targets specific groups and populations and defined by a belief that socio-economic circumstances determine health status in individuals. Its focus is usually at policy or environmental levels.
The author will now explore some of the interventions used across the world within the models/approaches above.
In the United Kingdom Phelan et al (2004) introduced a physical health check tool to support the monitoring and management of physical health issues with patients with severe mental illness. This would be seen in the above model as a medical or preventative approach which aims to assess need in a target population and then develop an agreed action plan with the patient on how they are going to address the defined health needs. The assessment is completed on a 12 monthly basis and is designed to supplement normal medical care and review. The results showed that 50% of clients had a diagnosed physical illness with 78.3% saying they had one or more physical symptoms. 65% of patients agreed to one or more of the actions available which included getting advice about smoking cessation, diet and starting regular exercise. The outcomes have seen an increase in the quality of the assessment and recording of the physical needs of the patients as well as a huge jump in the activities being care planned within a structured care programme approach care plan. The study compared the group with a neighbouring community mental health team and demonstrated that the use of the structured assessment and care planning tools significantly improved the quality of information recorded. The failings in the report highlight that although the staff were able to assess and plan care there was as yet no evidence that this approach had improved the health outcomes of patients and the life expectancy of them. When we relate this to the models above we identify that the medical and organisational policy approaches are easier to do and measure compared to the change behaviour that is required by the individuals concerned. The author suggests that further longer term studies are required to evaluate the long term health impact of this approach to the organisation of physical healthcare management.
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Likewise the Department of health (2006) in their commissioning framework document choosing health give examples of case studies which reflect some of the health promotion interventions across the UK. In one study a selection of clients from across a city were involved in a physical health consultation with a senior nurse. This assessment took place in their own home as there had been a previous reluctance to attend clinics for this purpose. Once the health issues were identified in an assessment patients were selected for inclusion in 2 healthy working groups. One focussed on healthy living and was attended by 15 patients whilst the other had a focus on physical activity, was based in the local sports centre and had an attendance rate of about 20 patients per week. A voluntary walking group was also available. There were very positive outcomes from the study which included the following
57% reduction in alcohol consumption
Only a 1% DNA rate at activities
32% reduction in smoking
50% increase in activity levels
95% improvement in patient self esteem
These significant health improvements for patients can only contribute to improving their life expectancy.
The author believes that the above interventions fall into a number of the approaches to health promotion identified by Naidoo and Wills (2000) for the following reasons.
Medical and preventative- These interventions are targeted at a particular sector of the population in order to prevent the formation of disease in an identified vulnerable group. The initial screening selects those that go forward for health promotion activity. This is a top down expert led approach to target interventions at a vulnerable client group reducing costs in the long term and improving outcomes.
Behaviour change- information, support and improvements in access to health, social, lifestyle and sports facilities has encouraged people to make informed choices to adopt more healthy behaviours. The evidence in the outcomes has shown that people have made real improvements in their health by taking responsibility (even though in some cases it was supported initially by staff) and changing their lifestyle significantly.
Health education- the specific classes and education provided by staff supported the individuals to make informed choices about their health and the behaviours that they were adopting to support it.
Empowerment – in this area the nurses were being seen as catalysts of change or facilitators in order to support individuals. The fact that local sports and leisure facilities was involved was evidence of a social inclusion aspect of the service where it was seen to be normal to engage with local facilities and not in specialist hospitals or clinics.
Social change approaches- the targeting of this client group in a top down approach by clinicians in many ways is evidence of this approach across the uk.
Likewise in the United Kingdom another approach which identifies this social change approach is the mental health component of the general practitioners contract and the quality and outcomes framework that they work to.
British Medical Association (2009) states in their advice on interventions to General practitioners that Patients with serious mental health problems are at considerably increased risk of physical ill-health than the general population. It is therefore good practice for a member of the practice team to review each patient’s physical health on an annual basis. Health promotion and health prevention advice is particularly important for people with serious mental illness however there is good evidence that they are much less likely than other members of the general population to be offered, for example, blood pressure checks and cholesterol checks if they have concurrent coronary heart disease, and cervical screening.
They feel the importance of this by identifying a number of targets in mental health two of which relate to physical health and are detailed below.
MH 8. The practice can produce a register of people with schizophrenia, bipolar disorder and other psychoses
MH 9. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. In the review there should be evidence that the patient has been offered routine health promotion and prevention advice appropriate to their age, gender and health status.
They also recommend that a review of physical health will therefore normally include:
1. An enquiry about smoking, alcohol and drug use
2. A blood pressure check
3. A cholesterol check where clinically indicated
4. Measurement of body mass index (BMI)
5. A check for the development of diabetes
6. Cervical screening where appropriate
7. An enquiry about cough, sputum, and wheeze.
Reports on the two targets have seen achievements in the high 90% range across the country hence showing evidence of improvement in screening.
This approach in primary care is commendable but there are a number of patients who still find it difficult to engage and access services. This client group require additional support to access services and NHS Quality Improvement Scotland (2007) felt it was an important enough matter to include it in their Mental Health Integrated Care Pathway standards. The GP targets which only include the offer of health assessment are enhanced further and include a recording of the completion of an assessment and actions relating to the outcome which include health promotion, communication with interested parties and evidence that action has been taken on the findings. The author agrees with NHS QIS that it was necessary to take this top down social change approach in order to bring about change which will enhance the health promotion of this complex client group.
Standard 13: A general physical health assessment and management of the findings are recorded.
13a The care record shows that physical health needs are assessed at least annually using the following features:
â€¢ the completion of a physical health assessment
â€¢ the provision of health promotion advice, and
â€¢ service users receiving medication should have side-effects and physical health assessed and managed according to the appropriate algorithm for that medication.
13b The care record shows information on the management of physical health needs, including:
â€¢ information on who is responsible for the physical health assessment (primary care or specialist services)
â€¢ evidence that results have been shared
â€¢ evidence that results have been acted upon, and
â€¢ evidence that information and/or advice on promoting a healthy lifestyle has been provided.
Marder et al (2004) make a number of recommendations in their paper in the American journal of psychiatry regarding the monitoring and appropriate prescribing of antipsychotic medications. They suggest that the key is to identify the risk factors for each individual patient and tailor the prescribing according to their presentation and the potential adverse side effects of a number of the medications available. They present evidence of side effects of diabetes and cardiovascular issues and suggest that appropriate prescribing will reduce the risks or developing or exacerbating these conditions in patients with schizophrenia. This is borne out also in the NHS QIS (2007) standards above in Scotland where they recommend that “service users receiving medication should have side-effects and physical health assessed and managed according to the appropriate algorithm for that medication” NHS boards have been asked to develop prescribing algorithms and audit tools that will guide clinicians in assessing the physical health needs and using this information to make informed choices on the best medications for patients which have reduced risks associated with their physical health. These systems are currently under development across Scotland but can in the future only improve the outcomes in the physical health management of patients with schizophrenia.
The author in this assignment has demonstrated some of the health inequalities that are evident for people who suffer from severe mental illness from across the world. Some of the inequalities are a product of the diagnosis itself where patients often have symptoms that cause them to have reduced motivation to help themselves in many situations. Often this patient group also comes with a lower socio economic deprivation with a poor employment and education history which again provides barriers to their self management in respect to their physical health.
Recent advances in the treatments available for psychoses which have physical health related side effects and the introduction of the disability human rights legislation which stipulates the requirement of equal access for all has further highlighted some of the health inequalities that exist for this complex patient group.
The needs identification and health promotion interventions that the author has looked at separate themselves into key areas.
This client group requires support to access to services and all of the interventions identified this need and had both support to access, structured recall systems and the facilitation of services close to patient’s home as their key themes.
Assessment of physical health needs and the prescribing of the most appropriate psychotropic medication for their mental illness requires to be structured and coordinated in an improved fashion. Structured physical health assessments frameworks and prescribing guidelines associated with physical health symptoms appeared to be the best way of coordinating this process for this patient group.
A mixture of a social change and educational approach is a model that appears to mix well with the review of mental health nursing in Scotland and across the world with mental health services now promoting a more patient inclusive and community involvement role. This allows nurses in particular to facilitate ownership of these health problems and use their teaching skills to teach patients how to change their lifestyles and effectively manage the physical health difficulties that they have. Nurses will engage with local leisure and sports facilities to make support available in a more normal rather than institutional fashion.
The author in completing this assignment has been able to explore different aspects of this problem that exists in Scotland and compare the Scottish approaches with what is happening in other areas. He has found a very similar pattern of difficulties and also some similar solutions although they seem to be at different levels of implementation. He noticed the American studies focussed a lot on the prescribing issues and getting appropriate prescribing correct. He felt this was probably due to the costs and charging policies associated with the American system and possible litigation if there are side effects of prescribed medications which go on to cause disease where risks are known and identified. He felt this is becoming more apparent in the UK now but the study in America was several years ago.
The approaches used were similar but there seemed to be a more coordinated approach to the assessment and monitoring of patients in the UK. The author felt that this was due to the NHS role in the coordination of care across the country where the USA has many different health economies and is focussed on a charging and insurance type policy.
Mental health nurses should continue work in a patient focussed way encouraging patients to take individual ownership of their needs and promote healthy living.
The services in Scotland should coordinate themselves to ensure a physical health check is commissioned; takes place and the appropriate actions are followed through. Patients should be supported to access primary care services to enable this screening to take place.
Medication algorithms should be developed and audited to ensure that prescribed medications are appropriate to the health profiles of patients and that medication for psychiatric reasons does no harm in relation to the patient’s physical health.
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