Improving the length as well as the quality of life


OPINION:MENTAL HEALTHCARE is different. A substantial proportion of us will have mental health problems at some point in our lives.

Current policy, based on the 2006 report A Vision for Change, aims to provide services “equitably and across all service user groups”. It calls for an orientation towards recovery and more social inclusion. I welcome this, but I am struck by how different policy is from general medical care, which is based on treating specific illnesses to improve outcome.

Perhaps these, more fundamental aims, have already been met in mental healthcare? Having spent almost 20 years as a clinician treating and researching severe mental illness I do not believe this is true. I find the difference disturbing.

If you have a heart attack or stroke and are too incapacitated to consent, you will receive medical care using the “best interests” principle. Many people with serious mental illness don’t believe that being admitted to hospital is in their best interest. However, there were 2,057 involuntary admissions in 2011 under the Mental Health Act 2001.

At least three-quarters of these were for treatment of two disorders: schizophrenia and bipolar disorder. What the figures reflect is that these two conditions are more common than generally appreciated (there are likely to be more than 50,000 people in Ireland affected).

Most treatment is actually provided in the community by teams including doctors, nurses, psychologists, social workers and occupational therapists. Involuntary admission is reserved for where this approach fails because a person’s judgment is impaired by illness. This could mean that you develop a complete conviction that others are involved in an international conspiracy to kill you or that you have uncontrolled mania causing you to behave recklessly.

This is likely to affect your decision-making, but admission under the Act is reserved for situations where “judgment of the person is so impaired that failure to admit would result in a serious deterioration in the condition, or immediate and serious harm to the person or others”. The average duration of admission, unclear to me from annual reports, is probably fewer than 21 days.

Similar legislation is present in other EU countries. With the implementation of the 2001 Act, Irish admission rates, average by European standards, have fallen by more than a third.

Representative of much of the debate about mental health is a piece in this paper (Irish Times, Friday July 6th) by Dr Pat Bracken, a consultant psychiatrist, arguing that this practice is too “paternalistic” and “at odds with” national policy. I couldn’t help wondering how this might sound if applied to acute medical care. Would one argue that the provision of care to incapacitated medical patients is too “paternalistic”? Unlikely.

He appears to argue for a person’s “right to define the nature of one’s own problems” even if judgment is impaired by illness. Do we expect patients suffering heart attacks or strokes to “define” their own problems? No. He questions the central role of the consultant in providing acute psychiatric care. We trust hospital consultants to manage acute medical problems.

Maybe serious mental illness is not medically important compared to cardiac disorders, strokes or cancer? Tragically, this is not so. People with schizophrenia have an average life expectancy 17 to 25 years shorter than the general population; for bipolar disorder the figure is 10 years. This is based on international data – Irish figures are not collated – but I doubt the picture is better here.

The facts and their potential consequences for thousands of people go unmentioned in the Irish mental health policy document. If these conditions were physical, with this information, wouldn’t health policy focus on improving the length, not just the quality, of life?

Perhaps psychiatry has nothing to offer? Dr Bracken echoes a prevalent view that effective medical treatments are unavailable and describes current treatments as “a mess” and “toxic”. This is wrong. Take schizophrenia; we know the condition is debilitating and 80 per cent of patients relapse within five years.

Treatment with medication is effective in reducing initial symptoms, but staying on medication, from early in the illness, reduces risk of relapse by more than 50 per cent.

This is similar in efficacy to treatments for diabetes, and better than current treatments for asthma and high blood pressure. Despite the evidence, medical nihilism has had a damning impact on investment in the development of new and better treatments compared to other medical areas. (Pre-empting criticism that as an academic psychiatrist my opinions are “corrupted” by the pharmaceutical industry, I don’t receive funding from industry for my work.)

Rather than helping people to live with serious mental illness, our focus could include improving life expectancy. People with serious mental illness die because of suicide, increased rates of accidental death, from heart disease and as a consequence of poor health related to smoking, low physical activity, poor nutrition and medication.

Can we improve life expectancy? Yes. One function of the Mental Health Act is to allow the management of immediate risk of suicide or serious accident. Patients who take antipsychotic medication live longer. Treating depression in schizophrenia with antidepressant medication reduces death by suicide.

Addressing lifestyle changes and reducing smoking rates is challenging but achievable. People with heart disease and schizophrenia die because of poor medical care. Across international studies, it has been shown that these patients receive fewer heart surgeries and are less likely to be prescribed heart medication than the rest of the population.

Mental healthcare policy is different, but it shouldn’t be. All patients should have access to the best medical care irrespective of whether their condition is physical or mental. The focus of this article has been on only one aspect of treatment. Regrettably provisions for psychological or social interventions are also neglected. Limited mental health resources are currently spread “equitably and across all service user groups”. Based on medical need and available medical interventions, people with serious mental illness may have the greatest claim.

Prof Aiden Corvin is a consultant psychiatrist at St James’s Hospital, Dublin, and professor of psychiatry at Trinity College Dublin

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