Mind and body: physical health needs of individuals with mental illness in the 21st century

It is well recognized that individuals with severe mental illness show high rates of suicide and also various physical illnesses which contribute to reduced longevity1. This is a major public health challenge in the 21st century. Drugs and alcohol consumption and tobacco use further add to the increased rates of morbidity and mortality. The delays in help‐seeking, whether it is for physical illness or psychiatric illness, and the underdiagnosis due to stigma and other factors contribute further to this disparity. Liu et al2 provide a model based on a multi‐level approach at individual, health care systems and social determinant levels to cope with the excess mortality among mentally ill people. We believe that it is a relevant proposal in the framework of modern medicine.

At the individual level, although early recognition of physical comorbidity and early interventions are effective strategies to reduce mortality, it is also relevant to explore what people seek help for and where they seek it from. In fact, culture and explanatory models will guide people to the sources of help, especially those which are easily available and accessible3. Explanations of distress and symptoms (explanatory models) will vary across cultures and communities and also be related to educational and socio‐economic status.

Health care systems need to be geographically and emotionally available and accessible for people affected by mental illness, so that they can seek help early. Some of the physical comorbidity may not be recognized by clinicians and on occasion the responsibility for managing physical illness may be left to primary care physicians or specialists who in turn may not recognize mental illness or due to stigma may not intervene early enough. This might be due, in the West at least, to a somewhat rigid division between mental health and physical health services. For centuries, the mind‐body dualism attributable to Descartes’ dogma has affected clinical practice and has increased the dichotomy between psychiatric and physical health care services. This dualism may well have contributed to stigma against mental illness, the mentally ill and the psychiatric services4. Furthermore, if physicians are not very good at identifying psychiatric disorders or carrying out mental state examinations, psychiatrists are often not very good at identifying and managing physical illnesses either. When interventions have taken place in partnerships between services, physical health of patients with severe mental illness has been shown to improve1.

At a social level, explanatory models of disease do not only vary across cultures and communities. They may also differ between the patients, their families and their carers, who may interpret these experiences on the basis of physical or psychosocial factors. More industrialized societies are likely to have psychological, medical or social causative factors as explanations, whereas more traditional societies may hold supra‐natural and natural explanations3. In many cultures, mind and body are seen as in connection with each other, and patients may link their symptoms to both body and mind, thus making sense of their experiences in a holistic manner. Among Punjabi women in India and Pakistan, for example, the distress may be expressed in different parts of the body feeling hot and cold at the same time3. So, when they seek help from physicians who are not aware of these cultural differences, the clinician may miss the distress and underlying psychiatric disorders completely.

In 2013, in a report for the UK Mental Health Foundation5, we recommended an integration at multiple levels similar to Liu et al's model. One of the potential solutions might be to develop units based on medical liaison, such as consultation‐liaison psychiatry, where physicians work with psychiatrists to help early diagnosis and management6. Also, we believe that the multi‐level model proposed by Liu et al has major implications for training. Training health professionals is a critical first step to make them aware of various components of patient's health. Moreover, education on cultural factors that may influence physical and mental health is relevant. One option may well be teaching social sciences and medical humanities at early stages of training7, so that clinicians are aware of the impact of cultures on presentation and the interaction between mind and body.

Psycho‐educational programmes about physical health among mentally ill patients need to be widely explained and utilized, as they are known to be effective1. In addition to the general information about various risk factors, specific programmes must be developed for vulnerable groups and individuals. Also, screening at early stages of treatment may help to reduce physical complications, improving psychiatric outcomes1, 6. Integration with social care may help individuals with chronic mental illness so that all their needs are met in a single port of call.

Integrated care across primary and secondary care, across physical and mental health, and across social and health care means that training, recruitment and retention of workforce needs to be at the top of the political agenda, so that patients with severe mental illness get the best services they need, deserve and will utilize8. It is imperative that psychiatrists take the lead in identifying the physical health needs of persons with severe mental illness as well as in orienting the public mental health agenda to ensure that cultural norms and values are taken into account when developing and delivering integrated care at all levels. They must work with stakeholders, including service users and their families groups, to ensure that integrated care and services are sensitive to patients’ needs.

Dinesh Bhugra1, Antonio Ventriglio2
1President, World Psychiatric Association; Institute of Psychiatry, King's College London, London, UK; 2Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy