No mental health without physical health – a call to arms

This volume includes two invited editorials on the important topic of comorbid physical health in those with serious mental illness (Docherty et al. in press; Suetani et al. in press). This field of research has matured substantially over the last two decades, thanks to the hard work of many researchers, who have compiled a solid and consistent body of observational epidemiology. Patients with serious mental disorders (such as schizophrenia) have a shorter life expectancy (Saha et al. 2007; Walker et al. 2015). Those with serious mental disorders such as schizophrenia are more likely to die from suicide, but are also more likely to die from respiratory and cardiometabolic related conditions (Olfson et al. 2015). The medications we use to treat mental disorder are associated with increased mortality estimates (Correll et al. 2015). When our patients develop comorbid physical disorders, they are less likely to receive optimal health care (Lawrence et al. 2013).

In addition to the substantial body of research based on primary data, regular editorials have been appearing on this topic (Mitchell & De Hert, 2015; Stewart, 2015; Suetani et al. 2015). This volume of Epidemiology and Psychiatric Sciences contributes to the rise in this metric. What does it say about a field when the ratio of editorials to primary papers increases? It suggests that a particular topic is important. It might also suggest that some type of response from the field is required. The message from the two linked editorials is clear. We need to shift focus into developing better interventions to reduce the burden of physical disorder comorbidity, and we need to invest in health services research and implementation science. We need to ensure that effective treatments are used routinely and become engrained into everyday practice.

There is a danger that sincere and diligent researchers will invest time and research dollars in telling us results that we already know. This is a well-recognized issue for the field of epidemiology – it is called ‘circular epidemiology’ (Kuller, 1999). Kuller describes how a field of research can ‘freeze’ and fail to evolve into applied clinical and service-level interventions. Normally, this type of scientific ‘arrested development’ is not associated with particularly adverse outcomes. However, when the focus of the circular epidemiology is mortality, then the matter becomes more pressing.

Both editorials outline what type of interventions work, and what type of research is needed now. The authors have hard-won experience in this tough area of research. It involves patient-related factors, clinical services and policy factors, and whole-of-society issues. Mindful of how hard it is to shift behaviour in the general population (e.g. smoking, exercise, diet), we need to have a realistic appreciate of what is feasible in the short term. Because it would not be ethical to withhold proven and safe interventions from those with serious mental illnesses, interventions related to reducing adverse physical health outcomes may be better suited to comparative effectiveness studies (e.g. Is proven treatment X cheaper/quicker/more acceptable than proven treatment Y?). And because we know how hard it is roll out these treatments in under-funded services, perhaps we need more investment in interventions that target implementation and service-level reform (e.g. the Recovery After Initial Schizophrenia Episode [RAISE] study, which examined patient and service-level outcomes in cluster-randomised, non-University clinical settings (Correll et al. 2014; Kane et al. 2015b ; Kane et al. 2015a )).

If we do nothing, then we can predict that we will see a further widening of the life expectancy gap between the general population (who are benefitting from public health interventions and better clinical care) v. that of people with severe mental disorder. The widely used mantra of ‘no health without mental health’ needs to be complemented with a commitment to ‘no mental health without physical health’ (Editorial, 2011).