Issue 31 / 19 August 2013

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.

5 thoughts on “Jane McCredie: Risky assumptions

  1. Alex Wood says:

    As a largely retired urological doctor, who has interfaced greatlly with mental illness people, the discrimination mentioned  about physical diagnosis in mentally ill patients has been evident.  Alas, we are not all good doctors who put through our minds that possibly there could be a second (or more) problem co-incident in one patient.  This is even more evident in treating mentally ill patients, which seems to indicate prejudice or lazy intellectual process, that we all need to guard against. Such people as those mentally ill need our protection more than others at times, rather than being too superficially judged.

  2. Hasina says:

    To have some respect for a “Psychiatrist” some psychiatric diagonistic and treatment processes need careful analysis. Antipsychotic drug being prescribed by the professional too often without proper diagnosis. DSM for metal health have listed all sorts of disorders  based on simply statistics (?). Perhaps they would like to include breathing disorder to be listed in there!  A case like Stephen’s father is very common.

  3. University of Tasmania says:

    Psychiatry has long been criticized for its ethical abuses and their ability to ultimately cancel all other medical investigations, we all know how many psychiatric patients get a second opinion. There are too many cases including those of anti-NMDA encephalitis that are being misdiagnosed.

  4. Michele Meltzer says:

        The problem of a poorer standard of treatment and diagnostic overshadowing exists for medical patients who also have a mental illness, but is even more exaggerated for medical patients who also have a physical or intellectual disability. In this case, not only does one hear “active medical treatment is not indicated in the … err … light of your other  problems”,  but behind closed doors, one also hears doctors privately expressing the opinion that they would be doing everyone a favour if they allowed a passive euthanasia to occur.

       As well as being a doctor working in the public mental health system, I am also the parent of a happy, sociable and active young woman with a significant physical disability. Her quality of life is excellent, yet I have often had to assertively argue the case for her active medical treatment with my medical colleagues. I find this distressing, and  I can only imagine how much more difficult it would be to argue this case without the benefits of good English and a good education.

  5. Stephen Kilkeary says:

    I recall when my father, who was a WW2 veteran and a TPI, living with the quite demonstrable symptoms of PTSD but categorised by Veterans’ Affairs, even after they conceded in 1984 that he had never showed any such symptoms, as if he was living with paranoid schizophrenia. That misdiagnosis led to my father being treated exclusively with antipsychotics and which effectively condemned him to a living hell. The final insult, I guess, was that when an x-ray showed a tumour on my father’s lung during a routine hospital stay in 1991, his treating doctors at the repatriation hospital in question took no action. It was only several months later, when the cancer showed itself through overt symptoms that my father’s local medical officer made a referral back to the same hospital that had chosen to ignore the cancer. By that stage, the tumour had grown close to my father’s aorta, making surgery impossible. Chemotherapy too, yielded null positive results. My father died in July 1992. Having gained access to his Veterans’ Affairs files from the 1950s to the 1990s, what I see from my father’s treating health professionals is persistent contempt for him, the belief that he was beyond care and not worth the bother. Working as I have done myself in mental health for the past 30 years, I can say that how my father was so shamefully neglected by those charged to uphold his care is regrettably a common phenomenon…


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