Serious mental illnesses, such as schizophrenia and bipolar disorder, have a profound impact on the lives of the people affected by them. About 1% of the Canadian population has schizophrenia and 1% suffers from bipolar disorder, according to the Canadian Mental Health Association. People with major mental illnesses also have higher rates of other acute and chronic diseases. It’s estimated people with major mental health illnesses die 25 years earlier, on average, compared to the general population. Much of this excess sickness and death is due to preventable conditions, especially cardiovascular disease, according to an analysis by the U.S. National Association of State Mental Health Program Directors.
Multiple factors—such as obesity, smoking, poor diet, substance misuse, physical inactivity, and some antipsychotic medications—are implicated in increasing the risk of cardiovascular problems in these populations. Despite their higher burden of illness, persons with serious mental disorders are less likely to be diagnosed or treated for the physical conditions they have, such as hypertension, dyslipidemia and diabetes.
What is the cause of this terrible health inequity? There are likely several factors at play, occurring at the levels of society, the health care system, the healthcare providers and the patients. At a societal level, people tend to marginalize and discriminate against people with serious mental illnesses. Research has shown that this stigma can lead to patients avoiding care.
The health care system also worsens health inequity, with health care divided into care for diseases of the body and care for diseases of the mind. Mental health professionals are rarely located in the same facility as primary care providers who could address the screening and treatment people with serious mental illnesses need for conditions like hypertension or diabetes. Effective communication between the providers of mental and physical health care is rare in Canada’s health care system. Evidence-based models of collaborative mental health care between primary care providers and psychiatrists are known to improve patient outcomes but are not widespread.
Beyond the issues with how our health system is set up, personal factors relating to both primary care providers and the patients themselves can pose barriers to care. Primary care providers may perceive caring for people who are considered medically complicated as a burden, and be overwhelmed by the competing demands of helping people with multiple issues. For patients, their mental illnesses can limit their motivation to seek or follow through on care or cause them to be fearful and mistrusting of the system and the providers in it. Patients with serious mental illnesses also tend to experience homelessness or unstable housing, poverty, and social isolation – all of which can interfere with their ability to find and stick to a family health provider.
While we cannot address all of the health system, societal or personal barriers that people with serious mental illnesses face, we can immediately begin to adjust our own behaviours and attitudes to be more inclusive towards people with serious mental illnesses. We encourage health providers to adopt what we call the “four Rs”. The first is recognition. At our community health centre, our staff do not focus simply on the presenting problem (a foot infection, for example), but rather look for the underlying issues as well (for example, poor housing or lack of access to transportation and healthy food ) and try to help the person deal with these issues. The second R is respect. It is vital to see patients as people, with talents, hopes, and fears, rather than seeing simply the mental illness. The third R is resources. We in primary care can’t do everything for everybody all the time. We need to know what supports for our patients with mental illness exist in our own community. We have realized that connections to housing, food, and meaningful interactions in the community are more important than medical supports for many people. The fourth R is relationships. We must work to build trusting relationships with patients and sustain them over time. This is probably the most powerful tool we have in our toolbox.