No mental health without physical health

Abstract

Mental disorders are now recognised as some of the leading causes of disease burden globally but, to appreciate their full impact on individuals and societies, we must consider their role in early mortality. Although statistics consistently show a large difference in lifespan between people with and without a mental disorder, identification of the underlying causes of this difference, both biological and social, is an ongoing challenge. In this issue of The Lancet Psychiatry, Rory O’Connor and colleagues present the Gone Too Soon framework, which was developed in a global collaboration between academics, policy makers, clinicians, and experts with lived and living experience, organised by the charity, MQ Mental Health Research. Using a roadmapping approach, they synthesised input from all stakeholders involved in the study to identify 12 overarching risk factors and mechanisms driving premature mortality for people with mental illness. They also formulated several specific solutions on which the mental health community can take action. The authors highlight the importance of considering multimorbidities, including those from alcohol and drug misuse, which contribute significantly to the physical ill health that causes premature death in people with mental disorders. The COVID-19 pandemic showed the disproportionate risks that people with mental disorders face with regard to maintaining physical health, with several studies showing not only increased risk of infection, but also more severe outcomes, including death. Exacerbating this inequality, initial policies restricted access to COVID-19 vaccines for people with mental illness, and the efficacy of the vaccines for people with substance use disorders was questioned. Caige Huang and colleagues, using a matched case-control study design, provide reassuring evidence of the effectiveness of two COVID-19 vaccines for preventing infection and hospitalisation for people with a diagnosed substance use disorder during the spread of the SARS-CoV-2 omicron variant in Hong Kong. Analysing data on multiple doses, including boosters, of BNT162b2 and CoronaVac vaccines, they found significant reductions in COVID-19 hospitalisations, with a clear dose–response relationship. These findings add important evidence for policy makers to prioritise people with substance use disorders for future COVID-19 vaccine booster shots. One of the greatest contributors to premature mortality in people with mental illness is opioid use. Opioid agonist treatment (OAT) is a highly effective harm reduction method for reducing the risk of opioid overdoses, but is still underused in many countries. In a systematic review and meta-analysis, Louisa Degenhardt and colleagues compare the two most common OATs—methadone and buprenorphine—with regard to treatment retention and adherence. Importantly, they included long periods of treatment and several mental and physical health outcomes. While the authors found positive evidence for better retention in methadone than sublingual buprenorphine treatment, the key message is that comparative evidence on the most appropriate OAT for many important clinical outcomes is woefully inadequate. At the global level, the Gone Too Soon framework emphasises the need to design suitable and specific intervention strategies and resources for low-income and middle-income countries, and not simply to transfer practices from high-income countries. In a Health Policy paper, Gregory Farber and colleagues detail an effort by global funders and publishers of mental health research to develop and implement a common set of mental health outcome measures to be included in all future mental health research (alongside other measures that investigators choose to use). The goal of this effort is to improve consistency in research and reporting with the longer-term goal to aid evidence synthesis. A key challenge of implementing a common set of data elements is ensuring that these measures work similarly across multiple cultural contexts. The Gone Too Soon framework discussed by O’Connor and colleagues, and supported by findings throughout this issue, remind us that, while global efforts to reduce mortality and morbidity from infections and chronic non-communicable diseases have been very successful, there has been little change in premature mortality associated with mental disorders. For many physical comorbidities, evidence-based treatments exist: the challenge is to ensure that these are made available to people living with mental illness, wherever they are.