Jane McCredie: Risky assumptions

WE have known for decades that people with mental illness are at greater risk of physical disease and premature mortality than the rest of the community.

But that knowledge has not always translated into effective action to combat the problem.

Psychiatrist Professor Graham Thornicroft, writing in the British Journal of Psychiatry in 2011, said that in high-income countries there was still a 20-year mortality gap for men with mental illness compared with those without mental illness, and a 15-year gap for women.

The reasons people with mental illness die earlier than their peers are complex, including a higher rate of some risk factors — such as smoking and poor diet — as well as the side effects of some psychiatric medications and an increased risk of suicide or accidental death.

But there is also a considerable body of evidence showing people with mental illness receive a lower standard of care when they experience physical illness than do other members of the community.

This was brought home to me last week in novelist Juliann Garey’s account of her experiences with various health care providers in the US.

Garey believes clinicians’ attitudes to her change once they look at her medical records and see that she is on medication for bipolar disorder.

Doctors become more reluctant to provide treatment, especially pharmacological treatment, she says, even for an unrelated condition.

She describes a visit to an ear, nose and throat specialist, for example, who apparently told her he was not comfortable prescribing anything for her acute ear infection, given everything else she was taking.

“If you met me, you’d never know I was mentally ill”, Garey writes. “In fact, I’ve gone through most of my adult life without anyone ever knowing — except when I’ve had to reveal it to a doctor. And that revelation changes everything. It wipes clean the rest of my resume, my education, my accomplishments, reduces me to a diagnosis.”

This is one patient’s account and her treating physicians might have a different perspective on the encounters she describes, but the problem she describes is real.

“… medical staff, guided by negative stereotypes, tend to systematically treat the physical illnesses of people with mental illness less thoroughly and less effectively”, Professor Thornicroft writes.

One study, for example, found mentally ill people with diabetes presenting to an emergency department with diabetic complications were less likely than their non-mentally ill counterparts to be admitted.

Diagnostic overshadowing can also lead clinicians to attribute a patient’s symptoms to their mental illness, as documented in this WHO account of a young British woman with schizophrenia whose brain tumour remained undiagnosed until after it had killed her.

We like to establish categories and we like to slot people into them. We do it with race, gender, sexuality and a host of other classifications to which we ascribe various supposedly shared qualities.

This can lead us to make unwarranted assumptions about individuals, such as “this person is fat, therefore they are lazy”.

It’s not hard to see how generalisations associated with people who have mental illnesses might affect the treatment they receive for unrelated conditions.

Assumptions that they perhaps take less care of their health, are likely to be less compliant with treatment or that they might be prone to imagining symptoms could all have a negative impact on the care people with a mental illness receive.

It may go against our natures to stop putting people into those convenient little boxes, but the bottom line is that no human being should ever be “reduced to a diagnosis”.


Jane McCredie is a Sydney-based science and medicine writer.