Call for action to address premature mortality due to physical illness in individuals with severe mental disorders

Abstract

The study conducted by Tapio Paljärvi et al., titled “Cardiovascular mortality in bipolar disorder: population-based cohort study,” sheds crucial light on the alarming rates of cardiovascular disease mortality among individuals with bipolar disorder.¹ The findings underscore a significant excess in mortality due to various cardiovascular causes, including coronary artery disease, cardiomyopathy, and hypertensive heart disease. This issue is part of a larger problem for people with severe mental illnesses (SMI), such as schizophrenia, bipolar disorders, and major depressive disorders. Individuals with SMI die up to 15 years earlier than the general population, and around 70% of this mortality gap is due to physical disorders.² Increased risk of physical disorders in those with mental disorders is due to reduced access to adequate physical health monitoring, care and prevention,^3-5 increased risk of adverse health behaviors⁶ such as sedentary behavior, poor diet, and smoking, comorbid substance abuse, and side effects of psychiatric medications.⁷

Despite the availability of clinical practice guidelines and evidence-based interventions aimed at reducing excess mortality rates due to physical comorbidities in persons with SMI, the problem still persists. There is a crucial need to better understand how to implement clinical practice guidelines and evidence-based interventions successfully in the real world. Individuals with comorbid mental and physical disorders face specific challenges in service organization, requiring complex treatment and intense resource utilization.⁸ The management of multimorbidity is recognized to be complex, with a high treatment burden in terms of understanding and self-managing the conditions, attending multiple appointments, and managing complex drug regimens.⁹ Evidence suggests that a key part of the problem is the lack of integration of care across service settings. There is major fragmentation in how care is coordinated between family doctors and hospitals, between physical and mental health care, and across health and social care. As proposed by Tapio Paljärvi et al.¹ and other authors,¹⁰ person-centered and integrated care models are a critical step to support effective implementation approaches to translate evidence into practice.

However, despite local and innovative experiences in several countries, the large-scale implementation of integrated care models faces numerous barriers and conservatisms. These obstacles hinder progress and maintain the status quo, perpetuating major health inequalities in individuals with SMI. A call for action in Europe, similar to initiatives already established in the United States,¹¹ is necessary. Currently, there are two main types of integrated care models: those based in primary care and those based in specialty mental health care. These models appear to address different populations—with the former primarily targeting common mental disorders such as anxiety and mild or moderate depression, while the latter focuses on individuals with SMI. This distribution results from the current organization of our healthcare system. Individuals with SMI often do not access primary care services as readily as those with anxiety and mild depression, who have better access to primary care. Both models improve the quality of care including prevention, physical screening, and follow-up. However, improvements in clinical outcomes are less evident, likely due to the unrealistic expectation of rapidly modifying outcomes when health is influenced by long-lasting determinants acting over many years. The absence of impact on outcomes should not undermine these initiatives; they represent an initial attempt at addressing the issue and remind us that integrated care must imperatively consider all determinants of health. This underscores the need for a comprehensive approach that includes social drivers of health.¹²

We propose a five-step approach to break this deadlock.

First, filling the knowledge gap at the European level: conducting transnational analyses of nationwide databases to better understand all-cause and cause-specific mortality, as reported in the work of Paljärvi et al.,¹ but also healthcare utilization patterns and their impact on the health outcomes of people with severe mental disorders. This includes addressing the lack of analysis on longitudinal healthcare utilization patterns, utilizing multidimensional trajectory analysis¹³ that combines physical and mental care, to learn from each other's successes and failures.

Second, conducting an updated review of all the integrated care models, including their components, settings, and types of evidence available, based on the literature and local experiences. Special attention should be paid to new technologies and the sustainability/environmental impact of the integrated care models.¹⁴ This second step aims to identify the key ingredients for achieving maximum effect within each model and determine the best organization in the context of a constrained healthcare workforce.¹⁵

Third, addressing political challenges that go beyond efficacy and mere reorganization. This involves questioning the roles, positions, and powers of the organizations and actors involved. For example, in France, the presence of nurse practitioners and lay workers is not always accepted by physicians, and the role of community care is not widely recognized by all stakeholders. The question of whether integrated care models should be based on primary care and/or specialty mental health care can also be a significant source of tension. A European consensus from a Delphi panel—including patients, caregivers, healthcare professionals, and policymakers—about which integrated care models are most acceptable and promising is essential. The involvement of users is indispensable at this stage to ensure that the chosen solutions meet their needs.

Fourth, achieving this consensus should lead to addressing the financing of key elements crucial for the success of these new models, such as prevention, addressing social drivers of health, the critical role of coordination, developing robust information systems, and community support, and so on. This includes societal knowledge, attitudes, practices, willingness to pay, and the financial impact of implementing an integrated care model. These findings will inform key stakeholders that European citizens are aware of the issue of excess mortality and injustice faced by patients with SMI and that scaling up integrated models across Europe is both feasible and likely to have public support.

Finally, research should also provide insights into the practicality and sustainability of the integrated model of care in real-world settings, following recommendations for transforming mental health implementation research to produce more actionable evidence to narrow the mental health implementation gap.¹⁶

Through this comprehensive approach, we can pave the way for more effective, person-centered care for individuals with comorbid SMI and physical disorders. The collaboration of patients, healthcare professionals, policymakers, and citizens across Europe will be critical in achieving this goal.

None.

The authors declare no conflict of interest.