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Physical health and mental illness: a silent scandal.

I think it was about 10 years ago now, I remember I received a phone call from a colleague of mine. He was worried; a patient he was looking after had died. My first thought: was it suicide? If it was, there would be an inquiry. It wasn’t; the patient had died of ‘natural causes’, of colon cancer. She was just 54 years old. In patients with schizophrenia, this form of cancer is much more common than it is in the general population (Hippisley-Cox et al. 2007), but no one knew she had cancer; not her general practitioner, not her community nurse. It troubles me deeply that this lady died alone and probably in considerable pain. If anyone, perhaps someone who saw her regularly and knew her well, had asked her about any changes in her bowel habits, might she have talked about being constipated, having diarrhoea, or bleeding? Maybe, and maybe something could have been done. In the 20 years that I have been a mental health nurse, the life expectancy of patients with schizophrenia has lessened probably by about 10 years. Read though the papers in this special issue and they all make this same point. Can you imagine any other area of medicine where falling life expectancy would be anything other than a scandal? A couple of months ago, a survey was published that showed cancer survival rates to be worse in the UK than most of the rest of Europe. The media response was of disgust and outrage: ‘Our Cancer Shame’, the red top headline. Research is published that shows patients with schizophrenia can expect to die 20 years younger than you or I; the silence is deafening. Who is to blame? Listen to the chattering middle class of mental health nursing and they will tell you that it is the nasty pills and injections we give patents that make them fat and cause diabetes; an appealing fable, but one that is apocryphal, or at least highly inaccurate. Yes, cardiovascular disease (CVD) is the major cause of death in patients with schizophrenia, and yes, weight gain is a side-effect of some, but by no means all, antipsychotic drugs. The problem is that every other modifiable risk factor for CVD – poor diet, lack of exercise, smoking, drinking alcohol – is also much more prevalent in patients with schizophrenia than in the general population. Take smoking as an example, eight out of 10 patients with schizophrenia smoke. In fact, last year an incredible 44% of all the cigarettes consumed were by people with schizophrenia. To reduce the CVD risk in schizophrenia patients, we need to tackle these. When the question about whether antipsychotic medication is life extending or shortening, the striking and counterintuitive truth seems to be that patients that stick with treatment live longer than those who don’t (Tiihonen et al. 2009). One of the other major factors associated with patients’ worsening mental health is deinstitutionalization. It might not fit comfortably with our current fad for recovery-orientated working, but one of the unintended consequences of the closure of our asylums is that patients don’t live as long (Wahlbeck et al. 2011). As a mental health nurse, I have a deep sense of shame at the state of the physical health of the people we serve. To my mind, our branch of nursing has never really been at ease with itself; I have always felt that we don’t really know what we are supposed to be doing. Are we therapists or custodians, prescribers, or social workers? Is physical health really our problem at all? I think the work of the mental health nurse is quite straightforward. Our job is to promote health and enable the people we care for to lead full and productive lives. To return to the patient with colorectal cancer, I think we should have spotted it, we should have been thinking about her physical and mental health. Mental health nursing is about doing what needs to be done, not what we are interested in doing. The poor physical health of our patients is a silent scandal and something needs to be done. I hope you find the papers in this special issue informative and stimulating.