Critical Reflection

Assignment 2 – "Critical Reflection"

There is a clear link between mental illness and poor physical health outcomes, leading to premature death and a lower quality of life for people with a mental illness (Productivity Commission, 2020). In Australia, four out of every five persons with a mental illness will have co-morbid physical health issues. Compared to the general population, people with a mental illness encompass approximately one-third of all avoidable deaths, are two times more likely to have cardiovascular disease, respiratory disease, metabolic syndrome, and five times more likely to smoke (National Mental Health Commission, 2016). Furthermore, the economic cost of physical health care for people with a mental illness is estimated to be 0.9%GDP in Australia, or $15billion per year (National Mental Health Commission, 2016). Despite being sicker than the general population, people with a severe mental illness, such as schizophrenia, access healthcare services much less, contributing to overall poor health outcomes (Royal Australian and New Zealand College of Psychiatrists, 2015).

As a means of addressing this health inequity, the National Mental Health Commission developed the "Equally Well" consensus, which aims to bridge the gaps in health disparity between mental health and physical health. It attempts to do this by the introduction of 48 actions that are aimed at developing person-centred, effective, equitable and coordinated healthcare (Productivity Commission, 2020). These actions aimed at mental health providers and GP’s, attempt to address a complex issue that is multifactorial through several suggested interventions.

Equally well works on the premise that people with a mental illness suffer the consequences of health inequity. In Australia, all residents have access to Medicare which enables equal access to healthcare regardless of any variables in their presentation or circumstance, this is defined as health equality (Botero et al., 2013). However, equity in health refers to providing tailored healthcare to individuals (Botero et al., 2013); for example, despite having Medicare provisions, people may not have transport to get to the health care that they require. This inequity in healthcare extends to many vulnerable populations across the country, including people with a severe mental illness.

The cause of inequity in mental health concerning poor physical health outcomes is complex and multifactorial and extends further than a simplistic view of lack of access to appropriate services; whilst access to services is valid, the complexities extend much further than this. Moreover, it is essential to note that not all mental illness are created equal. There is a greater health inequity for those with a serious mental illness or SMI, illnesses such as schizophrenia, major depression, and bipolar affective disorder (Young et al., 2017), compared to those with lower acuity illnesses such as mild to moderate depression and anxiety. This is due to several factors, but one worthwhile pointing out is the nature of these illnesses; all of them have aa affective or negative symptom component, which predominantly affects energy and motivation, causing people to be withdrawn and isolative (Gyllensten et al., 2020; Royal Australian and New Zealand College of Psychiatrists, 2015). This leads to poorer health outcomes because they are less likely to engage in initial treatment and ongoing follow up. Additionally, for someone with a severe mental illness, comprehending healthcare advice may be extremely difficult when experiencing auditory hallucinations, intrusive thoughts, or other cognitive deficits (De Hert et al., 2011). These diagnostic features of severe mental illnesses already set a footing for poor physical health outcomes.

Sickel et al. (2019) outline the impact of stigma, including self-stigma and other internal negative self-talk such as poor self-esteem, as a factor in help-seeking behaviours that can prevent someone with mental health issues from seeking assistance for their physical health. Moreover, when people with a severe mental illness do present for physical health issues, the focus remains on their mental health issues despite their presenting problem, or their physical health symptoms are attributed to part of their mental health presentation; this is termed "diagnostic overshadowing" (Berry et al., 2020; Royal Australian and New Zealand College of Psychiatrists, 2015) and is another barrier that contributes to the healthcare inequity for people with a severe mental illness.

There are also environmental conditions that affect the physical health of people with a serious mental illness, such as poor housing or homelessness, institutionalisation, limited income, and limited socialisation directly impact health (Collins et al., 2013). Collins et al. (2013) suggest that contributing factors to poor physical health in people with a serious mental illness are threefold: lifestyle factors, environmental factors, and illness-related factors. These factors play a role in preventing someone with a serious mental illness seek initial and ongoing treatment for physical health issues.

Additionally, people with a serious mental illness are often treated with medications with side effects that affect their physical health, people prescribed antipsychotic medications are at higher risk of developing metabolic syndrome as a result of side effects of these medications. Metabolic syndrome is a cluster of symptoms such as increases in weight, BMI, blood glucose levels, lipids and triglycerides, and hypertension (Berry et al., 2020). This risk is twofold; the medications used to treat the severe mental illness can lead to adverse physical health effects, leading to medication non-adherence, creating a two times burden on the patient and healthcare system. Additionally, fear of relapse and an increase in psychotic symptoms can lead to reluctance to change medications instead of a treatment that has fewer physical health effects (Berry et al., 2020).

Furthermore, mental health medications also have high potential to cause other side effects, known as extrapyramidal side effects that present similar to Parkinson's symptoms and include involuntary muscle movements and spasms, muscle stiffness, tremors and restlessness, which further impairs the ability to engage effectively in physical health interventions, limits mobility, and perpetuates ongoing stigma and feelings of judgement (Firth et al., 2019). All of these medication effects can prevent someone with a serious mental illness from seeking further healthcare treatment for several reasons, such as fear of additional side effects and fear of judgement from side effects; additionally, these medication effects already lay the grounds for poorer physical health outcomes (Firth et al., 2019).

Lastly, health literacy plays a role in seeking adequate physical health. Health literacy refers to the innate ability to navigate the health care system, including locating, comprehending and conveying health information, seeking appropriate care, and making critical, up-to-date healthcare choices (Keleher & Hagger, 2007). The inequity is that health literacy is assumed for all Australians this is not considered in delivering advice and treatment options, leading to poor treatment adherence and preventing further engagement in treatment (Keleher & Hagger, 2007).

Furthermore, modifiable lifestyle factors are also a risk factor for poor physical health and precipitant for poor physical health outcomes in people with mental illness, these include sedentary lifestyle, smoking, poor diet and nutrition, alcohol and illicit substance misuse, and dysregulated sleep patterns (Berry et al., 2020; Gyllensten et al., 2020). The aetiology of these factors needs to be understood to put in place successful interventions. These causes can include intergenerational and childhood trauma, learnt behaviours, lack of education, low income and poverty, unemployment, and social exclusion (National Mental Health Commission, 2016). All of these lead to poorer physical health outcomes and increased financial strain, which reinforces the cycle of poverty and disadvantage (Productivity Commission, 2020).

Nevertheless, people with a serious mental illness still require physical health interventions, more so than the general population. So, the question remains, how do we achieve this? The "equally well" campaign attempts to address this question through suggested interventions and actions each health service can make to reduce the risk of physical health issues and promote more positive outcomes (National Mental Health Commission, 2016).

Modifiable lifestyle factors are primarily targeted in physical health interventions and considered to be first-line interventions for improving physical health issues for people with a serious mental illness (Firth et al., 2019), these lifestyle interventions include smoking cessation interventions, building physical activity by improving fitness and improving quality of diet (Firth et al., 2019). There have been several interventions in the past that have attempted to tackle this and improve the physical health of the overall population. It is widely recognised that early intervention during the first episode or prodromal stage of severe mental illness is core in developing healthy lifestyle changes (Royal Australian and New Zealand College of Psychiatrists, 2015).

The Royal Australian and New Zealand College of Psychiatrists (2015) report that referral for physical activity interventions such as diet and exercise coaching should be incorporated into routine screening and first phase interventions with regular evaluations and ongoing monitoring. Improving the physical health competency of mental health professionals is also addressed as pertinent to improve physical health outcomes for people with a severe mental illness (Young et al., 2017). Nevertheless, multidisciplinary approaches to physical activity coaching have been proven efficacious as a collaborative approach that empowers the individual and builds self-management of physical health, including mentoring, ongoing support, education, and collaborative, interactive activities (Royal Australian and New Zealand College of Psychiatrists, 2015; Watkins et al., 2020). Nutritional coaching is also an important factor; one that has been efficacious is ongoing coaching and diet support that includes shopping, budgeting, meal planning and cooking skills (Watkins et al., 2020).

There are times when additional medications are warranted to prevent further decline in physical health. The introduction of anti-hyperglycaemic agents, antihypertensive agents, and statins are often required to avoid further health deterioration and the introduction of other pharmacological interventions to assist with weight loss such as metformin (De Hert et al., 2011). Furthermore, pharmacological interventions can assist in side effect management, such as anticholinergic medications to reduce extrapyramidal side effects, or medications to assist in smoking cessation such as "Champix", or medicine to assist with substance abstinence such as methadone, or benzodiazepines to assist with alcohol withdrawal (Firth et al., 2019). Certainly, these pharmacological interventions play a role in treating the symptoms of physical health issues for people with a mental illness, however, early intervention and treating the underlying cause through nutrition, diet and exercise interventions provide better patient outcomes (Firth et al., 2019).

Moreover, the effects of building health literacy, improving nutrition and exercise support lead to flow-on effects that link to barriers of health inequality. Participation in physical health interventions and subsequent health benefits such as weight loss is linked to improved self-esteem, improved mood, increased feelings of hope for a positive future, and improved energy and motivation (Watkins et al., 2020).

Addressing the health inequity for people with a severe mental illness is a complex issue that requires a multidisciplinary and multifaceted approach. Whilst there have been some great initiates across the country to address this health gap, the problem remains, and interventions predominantly do not occur or occur at sub-optimal levels. Indeed, building-specific program interventions into health policies and providing adequate training and resources to health care services is vital in bridging the barriers that contribute to the gap in health. The Equally Well Campaign is a great starting point for health services in raising awareness and competence in assessing, responding, and providing a holistic model of care to patients with mental health and physical health issues.

References

Berry, A., Drake, R. J., & Yung, A. R. (2020). Examining healthcare professionals' beliefs and actions regarding the physical health of people with schizophrenia. BMC health services research, 20(1), 771-771. https://doi.org/10.1186/s12913-020-05654-z

Botero, A. M. C., Valencia, M. M. A., & Jaime, C. F. (2013). Social and health equity and equality: The need for a scientific framework. 7, 10-17.

Collins, E., Drake, M., & Deacon, M. (2013). The Physical Care of People with Mental Health Problems : A Guide For Best Practice. SAGE Publications. http://ebookcentral.proquest.com/lib/scu/detail.action?docID=4714347

De Hert, M., Cohen, D., Bobes, J., Cetkovich-Bakmas, M., Leucht, S., Ndetei, D. M., Newcomer, J. W., Uwakwe, R., Asai, I., Moeller, H.-J., Gautam, S., Detraux, J., & Correll, C. U. (2011). Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry, 10(2), 138-151. https://doi.org/10.1002/j.2051-5545.2011.tb00036.x

Firth, J., Siddiqi, N., Koyanagi, A., Siskind, D., Rosenbaum, S., Galletly, C., Allan, S., Caneo, C., Carney, R., Carvalho, A., Chatterton, M., Correll, C., Curtis, J., Gaughran, F., Heald, A., Hoare, E., Jackson, S., Kisely, S., Lovell, K., & Stubbs, B. (2019). The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. The Lancet Psychiatry, 6, 675-712. https://doi.org/10.1016/S2215-0366(19)30132-4

Gyllensten, A. L., Ovesson, M. N., Hedlund, L., Ambrus, L., & Tornberg, Å. (2020). To increase physical activity in sedentary patients with affective - or schizophrenia spectrum disorders - a clinical study of adjuvant physical therapy in mental health. Nordic journal of psychiatry, 74(1), 73-82. https://doi.org/10.1080/08039488.2019.1669706

Keleher, H., & Hagger, V. (2007). Health Literacy in Primary Health Care. Australian Journal of Primary Health - AUST J PRIM HEALTH, 13. https://doi.org/10.1071/PY07020

National Mental Health Commission. (2016). Equally Well Consensus Statement: Improving the physical health and well being of people living with mental illness in Australia. NMHC. https://www.equallywell.org.au/wp-content/uploads/2018/12/Equally-Well-National-Consensus-Booklet-47537.pdf

Productivity Commission. (2020). Mental Health: Inquiry Report. A. Government. https://www.pc.gov.au/inquiries/completed/mental-health/report/mental-health.pdf

Royal Australian and New Zealand College of Psychiatrists. (2015). Keeping Body and Mind Together: Improving the physical health and life expectancy of people with serious mental illness.

Sickel, A. E., Seacat, J. D., & Nabors, N. A. (2019). Mental health stigma: Impact on mental health treatment attitudes and physical health. Journal of health psychology, 24(5), 586-599. https://doi.org/10.1177/1359105316681430

Watkins, A., Denney‐Wilson, E., Curtis, J., Teasdale, S., Rosenbaum, S., Ward, P. B., & Stein‐Parbury, J. (2020). Keeping the body in mind: A qualitative analysis of the experiences of people experiencing first‐episode psychosis participating in a lifestyle intervention programme. International journal of mental health nursing, 29(2), 278-289. https://doi.org/10.1111/inm.12683

Young, S. J., Praskova, A., Hayward, N., & Patterson, S. (2017). Attending to physical health in mental health services in Australia: a qualitative study of service users’ experiences and expectations. Health and Social Care in the Community, 25(2), 602-611. https://doi.org/10.1111/hsc.12349