Critical Reflection

Assessment 2 Example 2

The ‘Equally Well’ campaign – is it enough?

The Equally Well campaign aims to improve the physical health and wellbeing of Australians living with mental illness through a commitment to six key principles and numerous subsidiary actions, with a particular focus on equity of access to healthcare (National Mental Health Commission (NMHC), 2016). While Equally Well is to be commended for the breadth of its ambition in tackling these challenges, an equivalent level of commitment to addressing the social determinants of health, and to shifting entrenched societal attitudes to persons living with mental illness, will be required if long term improvements are to be achieved.

Australian and international studies have repeatedly shown that people living with mental illness have poorer physical health than the general population (NMHC, 2016). Life expectancy is up to 30% less for people living with mental illness, with the majority of premature deaths relating to illnesses such as cancer, diabetes, respiratory and cardiovascular disease (NMHC, 2016). Many of these diseases are of a chronic nature and adversely impact quality of life for many years prior to death (NMHC, 2016). A higher rate of disease implicates a higher need for quality healthcare, but in practice people living with mental illness are significantly less likely than the general population to access the care they require (NHMC, 2016).

A well-educated person with strong social support, comfortable housing and no financial pressures will often postpone seeking help for health problems due to fear around diagnosis or unwillingness to prioritise their own health (Byrne, 2008). For this socially advantaged person, a “high degree of persistence, tenacity and confidence” will nonetheless be required to obtain high quality care for complex conditions (The Royal Australian and New Zealand College of Psychiatrists (RANZCP), 2015, p. 14). For a person living with mental illness, these barriers are even more challenging and are further compounded by a range of additional factors.

A person living with mental illness is less likely to have an existing relationship with a regular doctor and more likely to lack trust in the medical system, often as a result of past trauma (Corscadden et al., 2019). Their mental illness may impair their ability to recognise symptoms of disease and their motivation to seek advice (Lerbaek et al., 2021). When the person attends an appointment, aspects of their mental illness such as anxiety and agitation may heighten the challenge of dealing with long waiting periods, a stressful physical environment and disrespectful staff attitudes (Gedik et al., 2020).

Diagnostic overshadowing, whereby the clinician overlooks or dismisses physical health concerns by misattributing them to mental illness, presents a further impediment for the person with mental illness, and is considered a significant contributing factor to 35% of people living with mental illness having an undiagnosed physical health issue (Geiss et al., 2017; Lerbaek et al., 2021). Clinician bias is a significant contributor to diagnostic overshadowing, with many clinicians dismissive of the person’s insight into their own condition (Lerbaek et al., 2021).

The consequences of this attitudinal bias are apparent throughout diagnosis, treatment and ongoing support. Standard health screening is less likely to be provided to a person with mental illness, and even if a diagnosis is made, the same level of treatment, referral and ongoing support may not be offered (Roberts, 2019). This failure to listen and respond appropriately to a person living with mental illness breeds a “culture of hopelessness and low expectations” and further inhibits the willingness of those persons to report their symptoms (RANZCP, 2015, p. 5). As a result, physical health worsens, opportunities for early intervention are lost, disease becomes chronic, care needs become more complex, clinicians have their negative biases reinforced through encountering serious physical health conditions in advanced stages that have not been adequately addressed, disadvantage in access to healthcare is further entrenched, and thus the cycle continues.

Diagnostic overshadowing has also been attributed to the tendency of practitioners to focus only on their own area of specialty, itself arguably a product of the distinction between mental and physical health which permeates the healthcare system (Lerbaek et al., 2021; Roberts, 2019). At the primary care level, some general practitioners will actively avoid dealing with patients living with mental illness, or conversely will focus exclusively on addressing mental health issues (Nankivell et al., 2013). In emergency departments, the complexity of presentations attributable to multiple causes, time pressures and clinicians’ fear of dysregulated patient behaviours can further exacerbate this problem (Geiss et al., 2017). Geiss et al. (2017) illustrate this by reference to presentation of a patient with elevated temperature, high heart rate and agitation, which would generally be interpreted as delirium suggestive of an underlying infection. Notwithstanding the high mortality rate associated with this presentation, where a person has been diagnosed as having a psychiatric disorder the same symptoms are likely to be attributed to mental illness, increasing the potential for further clinical decline.

While Equally Well recognises the need to promote standardised physical assessments and monitoring for people with mental illness, this must be combined with a shift in clinician mindset in order to be effective (NHMC, 2016). Such reform will be difficult to achieve while undergraduate medical degrees continue to treat mental health as a peripheral issue, and while clinicians continue to view people living with mental illness as a separate category of person, warranting a lesser degree of care and respect (Gedik et al., 2020).

A person’s health is closely linked to the social and environmental conditions of their life, in particular their socioeconomic, housing, employment and educational status (Australian Institute of Health & Welfare (AIHW), 2020). In addition to directly impacting health, these social determinants have an indirect effect due to their influence on behavioural and biomedical risk factors (AIHW, 2020). As a result, social determinants “interact with and amplify other barriers” to accessing quality healthcare, exacerbating the burden of disease (Nankivell et al., 2013, p. 446).

Adverse life circumstances have been shown to have long term effects on behavioural and psychological pathways, and to trigger epigenetic changes, elevating the risk of mental and physical health disorders (Roberts, 2019). People with mental illness are more likely to experience poverty, unemployment, housing problems and lack of social support and, conversely, people experiencing adverse social circumstances are more likely to experience mental illness (Roberts, 2019). A person living in poverty is more likely to suffer poor nutrition due to limited access to healthy foods, low levels of education and employment, inadequate housing, violence and trauma, and in turn poor nutrition increases the likelihood of obesity, cardiovascular disease and type 2 diabetes (Roberts, 2019).

For a person living in poverty with a serious mental illness, higher healthcare needs do not equate to higher access to care (Corscadden et al., 2019). Financial pressures impact the person’s ability to pay medical fees, fund treatments and travel to appointments (Corscadden et al., 2019). The person may lack the resources to make online appointments, and for those experiencing homelessness the lack of a fixed address or Medicare card can add a further layer of complexity. People living with homelessness, long-term unemployment and poverty are less likely to have good health literacy, and less likely to enjoy social support networks which might otherwise facilitate overcoming these barriers (Corscadden et al., 2019).

Prior experience of stigma with respect to their mental health or socioeconomic status may further inhibit a person’s willingness to engage with the health system (Happell et al., 2018). Social exclusion harms self-esteem, and it is difficult for a person who is marginalised to have faith in their society (Schout et al., 2011). Yet latent distrust in the system is too often cemented by the marginalised person’s experience of diagnostic overshadowing and substandard care when they do seek to engage with healthcare providers.

While Equally Well includes acknowledgement of the relevance of social determinants of health to equity of healthcare access, without a parallel detailed commitment specific to addressing underlying social inequities and promoting healthy living environments on a societal scale, the success of the Equally Well initiatives is likely to be curtailed (NHMC, 2016). For example, there is strong evidence that prioritising housing, together with clinical and psychological support, has a lasting positive impact on a person’s health and wellbeing (AIHW, 2020). Unless Equally Well can be matched by a similar commitment to evidence-based practice in housing policy, the uphill battle to effect positive change in health outcomes will likely continue.

A shift away from a purely biomedical approach focused on pharmacological treatments, towards interventions which encompass lifestyle changes such as nutrition and exercise, is recognised by Equally Well as another critical aspect of improving the physical health of people living with mental illness (NHMC, 2016). There is a misplaced perception amongst clinicians that people living with mental illness are disinterested in lifestyle changes (Happell et al., 2012). A person is less likely to be offered the same information about lifestyle options as a person without mental illness, despite the likelihood that their need for lifestyle guidance is greater (Lerbaek et al., 2021). This unwillingness to acknowledge the capabilities of a person living with mental illness further exacerbates the tendency to view their challenges through a purely biomedical lens rather than as a product of their broader social context (Schout & de Jong, 2017). The tendency to blame an individual for their lifestyle choices overlooks that social determinants are generally not a matter of choice, and again highlights the need for significant attitudinal shift to accompany the specifics of Equally Well.

The importance of providing lifestyle prescriptions to persons living with mental illness is heightened by the iatrogenic effects of many medications for psychiatric disorders (Schout & de Jong, 2017). In particular, common antipsychotic medications are known to cause adverse metabolic effects, yet persons already at higher risk of metabolic disease as a result of the social determinants of health are still prescribed these treatments with no regard to boarder health consequences (RANZCP, 2015).

Evidence is growing that nutrition plays a key role in mental health, particularly with respect to the link with chronic inflammation and the potential of healthy diets to modify some potential side effects of psychiatric medications (Teasdale et al., 2020). While research has focused primarily on interactions with depression and anxiety, early indications are that nutritional interventions may also be beneficial in treatment of disorders involving psychosis (Teasdale et al., 2020). While the biological pathways that mediate these interactions are not fully understood, there is sufficient evidence to support guidance on dietary improvement being included as a standard aspect of psychiatric care, as recognised by Equally Well (NHMC, 2016). Of equivalent importance is prescribing physical exercise, which has been demonstrated to assist with emotional dysregulation, psychomotor agitation, anxiety and depression (NHMC, 2016; Tomasi et al., 2019).

For lifestyle guidance offered to people living with mental illness to be effective, it is essential to tailor the support to address the specific challenges (such as socioeconomic disadvantage) which are likely to make adherence to dietary and exercise interventions more difficult. Facilitating participation in mainstream physical health activities may be a means of linking people living with mental illness with the broader community and helping address social isolation. Where lifestyle interventions can be integrated with development of a sense of community and connection, there will likely be greater potential for successful long term change.

Equally Well is an ambitious and necessary step towards improving the physical health and wellbeing of people living with mental illness in Australia. However, to achieve its outcomes it must be combined with a parallel commitment to addressing the upstream systemic issues affecting entrenched social determinants of health. Moreover, this must be accompanied by a societal shift in attitudes towards persons with mental illness: a shift away from negative assumptions and disrespectful attitudes towards a greater recognition of shared commonalities, and a willingness to embrace community with no ‘us and them’.

References

Adan, R., van der Beek, E., Buitelaar, J., Cryan, J., Hebebrand, J., & Higgs, S. et al. (2019). Nutritional psychiatry: towards improving mental health by what you eat. European Neuropsychopharmacology, 29(12), 1321-1332. https://doi.org/10.1016/j.euroneuro.2019.10.011

Australian Institute of Health & Welfare. (2020). Australia's health 2020: data insights. Canberra: AIHW.

Byrne, S. (2008). Healthcare Avoidance. Holistic Nursing Practice, 22(5), 280-292. https://doi.org/10.1097/01.hnp.0000334921.31433.c6

Corscadden, L., Callander, E., & Topp, S. (2019). Disparities in access to healthcare in Australia for people with mental health conditions. Australian Health Review, 43(6), 619. https://doi.org/10.1071/ah17259

Ewart, S., Bocking, J., Happell, B., Platania-Phung, C., & Stanton, R. (2016). Mental health consumer experiences and strategies when seeking physical healthcare. Global Qualitative Nursing Research, 3, 233339361663167. https://doi.org/10.1177/2333393616631679

Gedik, M., Partlak Günüşen, N., & Çelik Ince, S. (2020). Experiences of individuals with severe mental illnesses about physical health services: a qualitative study. Archives of Psychiatric Nursing, 34(4), 237-243. https://doi.org/10.1016/j.apnu.2020.04.004

Geiss, M., Chamberlain, J., Weaver, T., McCormick, C., Raufer, A., & Scoggins, L. et al. (2017). Diagnostic overshadowing of the psychiatric population in the emergency department: physiological factors identified for an early warning system. Journal of the American Psychiatric Nurses Association, 24(4), 327-331. https://doi.org/10.1177/1078390317728775

Happell, B., Platania-Phung, C., Bocking, J., Ewart, S., Scholz, B., & Stanton, R. (2018). Consumers at the centre: interprofessional solutions for meeting mental health consumers’ physical health needs. Journal of Interprofessional Care, 33(2), 226-234. https://doi.org/10.1080/13561820.2018.1516201

Happell, B., Scott, D., & Platania-Phung, C. (2012). Perceptions of barriers to physical healthcare for people with serious mental illness: a review of the international literature. Issues in Mental Health Nursing, 33(11), 752-761. https://doi.org/10.3109/01612840.2012.708099

Lerbaek, B., McCloughen, A., Lauritsen, M., Aagaard, J., Nordgaard, J., & Jørgensen, R. (2020). Barriers and possible solutions to providing physical healthcare in mental healthcare: a qualitative study of Danish key informants’ perspectives. Issues in Mental Health Nursing, 42(5), 463-472. https://doi.org/10.1080/01612840.2020.1823537

Nankivell, J., Platania-Phung, C., Happell, B., & Scott, D. (2013). Access to physical healthcare for people with serious mental illness: a nursing perspective and a human rights perspective – common ground? Issues in Mental Health Nursing, 34(6), 442-450. https://doi.org/10.3109/01612840.2012.754974

National Mental Health Commission. (2016). Equally Well Consensus Statement: Improving the physical health and wellbeing of people living with mental illness in Australia. Sydney: NHMC.

Roberts, R. (2019). The physical health of people living with mental illness: a narrative literature review. Charles Sturt University. https://www.equallywell.org.au/wp-content/uploads/2019/06/Literature-review-EquallyWell.pdf

Schout, G., & de Jong, G. (2017). Nursing and the emergence of egoless care: a discussion on social engineering in mental health. Issues in Mental Health Nursing, 39(2), 159-165. https://doi.org/10.1080/01612840.2017.1387626

Schout, G., de Jong, G., & Zeelen, J. (2011). Beyond care avoidance and care paralysis: theorizing public mental healthcare. Sociology, 45(4), 665-681. https://doi.org/10.1177/0038038511406591

Teasdale, S., Mörkl, S., & Müller-Stierlin, A. (2020). Nutritional psychiatry in the treatment of psychotic disorders: current hypotheses and research challenges. Brain, Behavior, & Immunity - Health, 5, 100070. https://doi.org/10.1016/j.bbih.2020.100070

The 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. RANZCP. https://www.ranzcp.org/files/resources/reports/keeping-body-and-mind-together.aspx

Tomasi, D., Gates, S., & Reyns, E. (2019). Positive patient response to a structured exercise program delivered in inpatient psychiatry. Global Advances in Health And Medicine, 8, 216495611984865. https://doi.org/10.1177/2164956119848657

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