No true health without mental health

In 1954 the first director of the World Health Organization said ‘without mental health there can be no true physical health’. Mental illness is the largest single cause of disability in the UK and increases the risk of developing physical illness. Physical health problems increase our risk of developing mental illness. A person's mental health profoundly impacts how they interact with healthcare staff (and how staff interact with them), how well they can engage with treatment and their overall outcomes. In this issue of Future Healthcare Journal, we hope to illustrate the complexity and opportunity that lies across this messy but fascinating interface.

Siloed thinking and splitting between mental and physical health percolates through all aspects of our health and social care system, from government policy to commissioning and the organisational split between mental and physical health providers. Despite repeated calls for better integration, only slow progress has been made. The mind–body dichotomy is an oversimplistic and unhelpful model for the delivery of patient care. The complexity and multi-morbidity that physicians see in practice, combined with social disadvantage and the impact of austerity means our traditional medical models may be reaching their limits; persistent physical symptoms are not always helped by more scans and tests. Taking only a narrow biomedical approach sets future services up to fail.

While steps have been taken to increase mental health ‘awareness’, people with severe mental illness such as bipolar disorder, schizophrenia, and personality disorder still experience significant stigma in general hospitals and other health care settings. ‘Equality of access’ and ‘parity of esteem’ are phrases used by politicians and service providers but in reality we remain far from this. Psychiatric liaison services in acute hospitals have expanded rapidly since 2014 but remain patchy and often only commissioned to look after general hospital inpatients. Many areas lack services funded to work with medical and surgical outpatients. Chronic lack of resources, and over-demand for community mental health services have led to increasing numbers of people presenting to emergency departments in acute mental health crisis. Liaison psychiatry teams are increasingly drawn into providing crisis care, rather than working as intended with patients with complex physical and mental health needs. A cornerstone of the NHS Long Term Plan and the move to integrated care systems is ‘triple integration’: primary and specialist care, physical and mental health services, and health with social care. We are now in a unique position to address some of these challenges.

Our first paper, by the clinical director of the Royal College of Psychiatrists' Public Mental Health Implementation Centre, highlights the shocking excess mortality of people with severe mental illness, who are 4.5 times more likely to die prematurely than the general population, and sets the broader public health context for this special issue; as Byrne says ‘it is not a good time to be poor... or to have a severe mental illness’.¹ Physicians frequently see the downstream effects of diabetes, smoking and obesity in people with mental illness, and the paper suggests practical steps to overcome some of these inequalities.

Patients with severe mental illness risk being wrongly labelled as ‘not engaging’, ‘difficult’ and sometimes ‘unlikeable’. There then develops a malignant cycle as staff disengage, reinforcing therapeutic nihilism. This is a key driver of severe health inequality for people who are street homeless, often the most disadvantaged in terms of complex mental, physical and social unmet needs. An understanding of the impact of adverse childhood experience and a trauma-informed care approach can help a homeless person to engage with the medical care being offered. Albert et al² illustrate how every contact in any setting can make small but important changes.

It's a good thing we have a growing older population and a testament to advances in medicine. There is a fine line between pathologising normal human emotions and diagnosing a ‘treatable’ mental illness. How do you disentangle the profound losses of health, loved ones and social role experienced by many older people from depression? Crowther and Ninan explore the familiar case of a depressed older person and show how fundamental and commonly used frameworks such as Comprehensive Geriatric Assessment, already widely implemented in the NHS, can enhance assessment and treatment.³

Cancer will affect many of us during our lifetimes. Recent advances in treatment bring better survival. But the impact of uncertainty, waiting for diagnosis and treatment, managing gruelling therapies and their direct or indirect impacts on mental health, or navigating the complexities of being a cancer ‘survivor’ requires psychological and psychiatric support. Jointly commissioned provision is increasing, but Fernando et al make a strong argument for integration beyond clinical services.⁴ The closer that psychiatric and physical health services work together, even in terms of physical co-location and day to day integration, the better the outcomes for our patients.

There is a focus on mental illness in cities with their associated inequalities and socioeconomic deprivation, but rural areas are left behind too. In the UK some of our most poorly served patients live in rural or coastal towns. Interventions and services designed and tested in urban areas need to be adapted and commissioned differently. Munoz advocates for more appreciation of third sector and community organisations, which are often the backbone of mental health services and other care provision in rural care economies.⁵

Staff working in the NHS, whether in medicine or psychiatry are seeing a level of demand, acuity and complexity that has not occurred before, all in the context of a post-COVID increase in staff turnover and sickness, mostly due to stress and mental health problems. Staff from all professional backgrounds can feel hopeless and helpless caring for someone with combined physical and mental illness. In our final article, Shields et al describe how even senior clinicians can improve their ‘power skills’, helpful with burnout, compassion fatigue and when managing particularly unwell patients.⁶

In this issue we highlight the profound interaction between physical and mental health. We took a broad perspective and have barely touched the surface; we could have covered so many more topics. The articles demonstrate both the fascinating complexity and the huge potential benefits for patients, services and ourselves as clinicians when we begin to take a more integrated approach.

Elizabeth Sampson
Consultant liaison psychiatrist, East London NHS Foundation
Trust, London, UK and honorary professor, Centre for Psychiatry
and Mental Health, Queen Mary's University of London, and
Faculty of Brain Sciences, University College London, London UK

Kevin Fox
Consultant cardiologist, Imperial College Healthcare NHS Trust,
London, UK and NHS Orkney, Orkney, UK