THE pandemic and lockdowns have focused minds on the mental health of the nation, with a strong focus on what is happening with the young. But the difficulties faced by those with a severe mental illness (SMI) have been long in the making, with stigma affecting them whether they are at the start or the end of their lives.

Stigma permeates all aspects of life, so while there has been a lot of focus on combatting it within some aspects of society, the destructive power within the medical community has not had the same attention.

Such problems can be present from both mental health staff and those medics treating someone with a physical complaint who they know also has a mental health diagnosis, leading to what is called “diagnostic overshadowing.” This is when a patient has a diagnosis, for example depression and there is a tendency for any other health problems to be attributed to that condition.

Mental health staff can often dismiss physical problems blaming the symptoms instead on the mental health diagnosis or as part of the patient’s “behaviour.” For example, a common issue has been psychiatrists and mental health nurses who have diagnosed a patient with an eating disorder but have overlooked the autism diagnosis and traits putting it all down to the eating disorder diagnosis.

On the other side, medics who see a patient with a physical complaint may be far too quick in dismissing symptoms or attributing them to the mental illness a patient may have, rather than going the extra mile to determine why these symptoms are present.

Just a small selection of real-life cases shows the extent of the problem.

• There was a lump on this patient’s leg and they were in excruciating pain. The doctor mentioned the borderline personality disorder diagnosis the patient had and dismissed the leg pain as “probably nothing.” The leg was broken.
• When a patient who has multiple disabilities including a condition that causes problems with her eyes, had “hydrops” where the cornea can split, the doctor asked, what she “had been doing to herself.”
• Another patent had considerable back pain, but this was put down by medics to anxiety/PTSD. It was only when she was reluctantly given an MRI that a giant fibroid was discovered requiring major surgery, a consequence of which has been arthritis. The pain still gets dismissed by mental health professionals.
• A patient was in hospital with Covid and found that the staff were far more interested in her lithium levels than her oxygen, which went as low as 60. When she shared her concerns with nurses, she was told she was being difficult.
• A doctor examined the breast of a patient who was complaining of pain and noted she had experienced depression in the past. So, as the doctor couldn’t feel a lump, she put it down to anxiety and depression and only sent her for a scan to “put her mind at ease.” This patient had aggressive breast cancer.

If serious physical health problems are missed because they are attributed to mental health problems, or they are not taken seriously, such as with the patient with aggressive breast cancer, this can ultimately lead to an erosion of trust with the person not attending health services at all. For someone with SMI and seriously ill, this could result in a lack of access to potentially lifesaving or life-lengthening treatments and trials.

This might be an explanation as to why research has found that if someone with an SMI has cancer they are more likely to die of it than someone without an SMI (Irwin et al, 2014). But there are multiple factors at play that explain why those with an SMI die younger than their peers.

If we join the dots between problems patients face in dealing with and accessing mental health and general health, then we add them to the prevalence of chronic diseases and disabilities with poor access to services and a lack of power, then finally, throw in societal issues such as housing problems, isolation and poverty, then the life expectancy for those with an SMI, with men dying just over a decade earlier and women dying 7.3 years earlier, can start to make sense.

These inequalities are deeply rooted but are not inevitable, says a key report from the Centre for Mental Health’s Commission for Equality in Mental Health (mstar.link/SMI-report).

They say to break the “triple barrier of unequal determinants, access and outcomes” communities need to be empowered. Along with this transparency and accountability in services is required to help foster improvements and change. There needs to be commitment to these changes, because “change is possible and there has never been a better or more important time to commit to mental health equality.”

To help bring about such change in the medical environment can be seen in the work from Liaison Psychiatrists. They are medics that can help bridge the gap between psychiatric and physical health services, however, external problems have meant they have had constraints on what they can and can’t do.

Emeritus Professor of Liaison Psychiatry Allan House said: “In the UK, liaison psychiatry services have developed to improve care for people who are receiving hospital treatment for physical illness and they should be ideally placed to help with the challenges of palliative and end-of-life care in people with mental health problems.

“But they face huge pressures to prioritise making a rapid response to acute problems, which limits their ability to provide care in longer-term more complex cases. This situation has been made worse by increasing demand coupled with reduction in resources in community and mental health services — problems that have followed from austerity policies and been made worse in the pandemic."

The article “Lean in, don’t step back: the views and experiences of patients and carers with severe mental illness and incurable physical conditions on palliative and end of life care” from J Jerwood, G Ward, D Phimister, N Holliday and J Coad stressed the lifelong nature of the problems those with an SMI face, right up to their final weeks and days:

“Patients and carers experienced poor care throughout their journey from diagnosis to death. Their accounts were sadly characterised by feeling abandoned, unheard, ignored and feared by clinical staff and services throughout the healthcare system.”

In this article it details just how few patients with an SMI get a hospice bed compared to those without such a diagnosis. Those patients without a bed are left to fend for themselves in the community or spend their last days in hospital. The few that do get a hospice place can often face stigma in the form of negative attitudes from staff.

“The problems in palliative and end of life care for those with an SMI are not helped by the dearth of evidence in relation to understanding the palliative needs of people with an SMI,” says PhD fellow and palliative care nurse, Marianne Tinkler. “This research is imperative so future care delivery can be designed to both recognise and respond to those needs.”

Tinkler hopes her research and a greater focus on the needs of this client group will make a difference to people with an SMI and their outcomes through influencing better access to palliative care so that people with an SMI can have the same level of care as anyone else.

“Future policy and practice will benefit from a better understanding of the needs and development of future service models of care that are timely with barriers such as stigma not preventing access.”

For now, it must be priority to involve the wider community in decision-making about care. Funding must meet these needs, with liaison psychiatrists able to fulfil their roles. Training staff is also important — ensuring that patients and their family and friends are equal partners in their treatment. This is all required to lessen the chances of inequality and stigma influencing care right up until death.

Ruth F. Hunt is a freelance journalist and author.