Inequalities in healthcare provision for
people with severe mental illness
David Lawrence1and Stephen Kisely2
There are many factors that contribute to the poor physical health of people with severe mental illness (SMI), including lifestyle factors and medication
side effects. However, there is increasing evidence that disparities in healthcare provision contribute to poor physical health outcomes. These
inequalities have been attributed to a combination of factors including systemic issues, such as the separation of mental health services from
other medical services, healthcare provider issues including the pervasive stigma associated with mental illness, and consequences of mental illness
and side effects of its treatment. A number of solutions have been proposed. To tackle systemic barriers to healthcare provision integrated care models
could be employed including co-location of physical and mental health services or the use of case managers or other staff to undertake a co-ordination
or liaison role between services. The health care sector could be targeted for programmes aimed at reducing the stigma of mental illness. The cognitive
deficits and other consequences of SMI could be addressed through the provision of healthcare skills training to people with SMI or by the use of peer
supporters. Population health and health promotion approaches could be developed and targeted at this population, by integrating health promotion
activities across domains of interest. To date there have only been small-scale trials to evaluate these ideas suggesting that a range of models may have
benefit. More work is needed to build the evidence base in this area.
Bipolar disorder, co-morbidity, health status, quality of care, schizophrenia, severe mental illness
The excess mortality associated with severe mental illness
(SMI) is well known and has long been documented
(Brown, 1997; Harris and Barraclough, 1998; Saha et al.,
2007). While much attention has been focused on suicide
and homicide which are associated with higher rate ratios,
the public health burden associated with major chronic dis-
eases is much higher in people with SMI. The majority of
excess deaths in this population are due to physical illnesses,
in particular cardiovascular disease, respiratory illness and
cancer (Kisely et al., 2005; Lawrence et al., 2001; Leucht
et al., 2007). Both incidence rates and mortality rates are ele-
vated for cardiovascular disease and respiratory illness, but
mortality is higher than expected based on incidence alone so
higher incidence of disease and worse outcomes both contrib-
ute to the excess mortality (Laursen et al., 2009; Lawrence
et al., 2001). For cancers there is little evidence of excess inci-
dence, but worse case fatality has been reported (Kisely et al.,
2008; Lawrence et al., 2000), suggesting that factors associ-
ated with diagnosis, progression and treatment of disease play
Although substance use, unhealthy lifestyles, and the side
effects of medications increase the risk of physical illness in
people with SMI, there is a growing body of evidence that
unequal healthcare provision also plays a role in this dispar-
ity. In some cases, unequal quality of healthcare provision
seemed to explain much of the subsequent excess mortality
(Druss et al., 2001a). Although the highest number of excess
deaths in schizophrenia is associated with cardiovascular dis-
ease, people with schizophrenia have low rates of surgical
interventions such as stenting and bypass grafting (Druss
et al., 2000; Kisely et al., 2007; Lawrence et al., 2003;
Laursen et al., 2009). People with psychosis are less likely to
receive cerebrovascular arteriography or warfarin following
stroke (Kisely et al., 2009). The quality of medical care con-
tributes to excess mortality in older people with mental dis-
orders after heart failure (Rathore et al., 2008). Diabetes
patients with mental health conditions are less likely to
receive standard levels of diabetes care (Desai et al., 2002;
Frayne et al., 2005; Nasrallah et al., 2006). People with
SMI are less likely to receive routine cancer screening
(Carney and Jones, 2006; Xiong et al., 2008). Schizophrenia
patients with appendicitis have been found to be more likely
1Centre for Developmental Health, Curtin Health Innovation Research
Institute, Telethon Institute for Child Health Research, Perth, Western
2The University of Queensland, Brisbane, Australia.
David Lawrence, Centre for Developmental Health, Curtin Health
Innovation Research Institute, Telethon Institute for Child Health
Research, Perth, Western Australia
Journal of Psychopharmacology
24(11) Supplement 4. 61–68
! The Author(s) 2010
Reprints and permissions:
to present late, have more complications such as gangrene or
perforation of the appendix, and have worse outcomes from
surgery (Cooke et al., 2007). Patients with psychotic disorders
are less likely to receive medical treatments for arthritis
(Redelmeier et al., 1998). Mitchell et al. (2009), in a recent
meta-analysis of quality of medical care for people with co-
morbid mental illness, reported that the majority of studies
demonstrate significant inequalities in receipt or uptake of
medical care for people with SMI. McIntyre et al. (2007)
reviewed medical co-morbidity in bipolar disorder and
found that chronic health problems are very common in
patients with bipolar disorder, and tend to be under-recog-
nised and sub-optimally treated. Patients with SMI are more
likely to have physical co-morbidities, more likely to have
physical health problems that are not being treated, and
more physical co-morbidities are associated with worse
mental health (Dixon et al., 1999).
The aim of this review was to consider the evidence in
relation to healthcare provision for people with SMI, identify
gaps in knowledge and provide an overview of the field.
Owing to the large number of physical conditions indexed, the
lack of standardized keywords in the area of inequalities in
healthcare provision and the very large number of papers that
would need to be searched in a broad-based search strategy,
this is an overview rather than a systematic review. Papers
were initially selected by undertaking a search of Medline
(1966–December 2009). We identified papers relevant to
SMI by searching for ‘schizophrenia’, ‘psychotic disorders’,
‘mood disorders’, ‘affective disorders’ and ‘depressive disor-
der’. We then selected papers that overlapped with any of the
following search terms ‘health status’, ‘quality of health care’,
‘cardiovascular disease’, ‘neoplasms’, ‘stroke’ or ‘diabetes’.
We supplemented this search with reviews of the bibliogra-
phies of relevant articles. As most of the relevant papers
found related to describing the excess of physical health prob-
lems in people with SMI, we have focused on articles that
discuss levels and standards of healthcare provision, factors
influencing access and use of healthcare services and the small
number of trials that have investigated ways of improving
physical healthcare outcomes for people with SMI.
Healthcare provision for people with SMI
Barriers to effective healthcare provision for the mentally ill
can be split into system-level issues, provider issues and
patient-related factors (Druss, 2007; Lambert et al., 2003).
Systemic issues include the geographic, managerial and
resource separation of physical and mental healthcare facili-
ties, lack of clarity as to who takes responsibility for the phys-
ical health of patients with SMI, fragmentation of care across
providers, lack of integration between medicine and psychia-
try, lack of continuity of care, and under-resourcing of mental
healthcare that provides little opportunity for specialists to
focus on issues outside their core specialty (Druss, 2007). At
the provider level there are the effects of stigma, time and
resource constraints, and the possibility of regarding physical
complaints as psychosomatic symptoms (Leucht et al., 2007).
Patient-related factors include health risk factors and lifestyle
factors such as substance use, diet, lack of exercise and obe-
sity (Brown et al., 1999; Kendrick, 1996), side effects of med-
ications (Mitchell and Malone, 2006) and the effects of mental
illness including cognitive impairment, social isolation and
lack of family support, higher pain threshold or reduced sen-
sitivity to pain, suspiciousness or fear, self-neglect, lack of
motivation, socio-economic factors and difficulties in commu-
nicating health needs (Dworkin, 1994; Sokal et al., 2004).
It has been suggested that not only do patients with schizo-
phrenia have less access to medical care, and consume less
medical care, they are also less compliant with medical care
(Brugha et al., 1989; Hennekens, 2007). This lack of compli-
ance with follow-up care has been suggested as a reason why
patients with schizophrenia may be less likely to receive inva-
sive cardiac procedures (Shander, 2000). People with schizo-
phrenia also have higher rates of adverse events during
medical and surgical care (Daumit et al., 2006). More aggres-
sive or high-risk treatments such as more complex surgeries or
chemotherapy may be contra-indicated if the patient has mul-
tiple co-morbidities. There can also be ethical and consent
issues in undertaking high-risk procedures. Mateen et al.
(2008) undertook a small study of lung cancer care for
patients with schizophrenia. They described a small number
of cases where non-optimal cancer care was provided. In
some cases the patient declined chemotherapy treatment or
was considered unable to consent to it, while in others the
presence of co-morbid physical conditions was considered a
contra-indication for chemotherapy.
Who should provide primary healthcare for
There has long been concern as to whether psychiatrists
should provide primary healthcare assessments for people
with SMI, or whether people with SMI have access to, and
utilize appropriately, primary care physicians. McIntyre and
Romano (1977) reported that most psychiatrists acknowledge
the importance of physical examination of their patients, but
that few routinely undertake these assessments, either because
they believe the patient’s physical health is being assessed by
another physician or they do not feel competent to perform
such an examination. Psychiatrists often delegate the respon-
sibility for physical examination of their patients (Patterson,
1978). Not all psychiatrists keep up to date on the manage-
ment of chronic medical conditions (Cradock-O’Leary et al.,
At the same time, there are barriers to people with SMI
accessing primary care. Some primary care physicians see
patients with SMI as being disruptive to their practices or
feel uncomfortable treating them (Goodwin et al., 1979;
Karasu et al., 1980). The likeability of patients has also
been linked to the amount of attention they receive in primary
care (Gerbert, 1984; Hall et al., 1993). However, problems in
access to primary care are not the entire explanation. For
instance, in the Australian Study of Low Prevalence
Disorders, 81% of people with psychosis had been seen by
a general practitioner in the year prior to the survey
(Jablensky et al., 2000). It is possible that primary care
62Journal of Psychopharmacology 24(11)
physicians feel that they have insufficient time to provide both
physical and mental healthcare for patients with SMI, limit-
ing opportunities for health screening (Jaen et al., 1994). Both
primary care settings and psychiatric settings regularly fail to
diagnose physical illnesses in patients with mental illness
(Koranyi, 1979, 1982; Koran et al., 1989).
Because patients with SMI fare poorly in primary care,
there have been calls for psychiatrists to take primary respon-
sibility for the overall health of their patients (Lancet, 1979;
Lamb, 1989; Shore, 1996). However, these calls have had little
impact (Daumit et al., 2002). As the treating psychiatrist may
only see the patient infrequently, it has also been suggested
that this responsibility needs to be shared with the mental
healthcare team. Two consensus conferences have called on
mental healthcare providers to take responsibility for the
physical health of their patients (Fleischhacker et al., 2008;
Marder et al., 2004). As the burden of physical illness is so
high in this population the risk of over-servicing is considered
to be minimal even if patients are also seen in primary care,
and more frequent monitoring would increase the likelihood
of early detection of medical conditions. To address the con-
cern that mental healthcare professionals do not feel compe-
tent to take on this responsibility, these calls have been
accompanied by calls for better and more comprehensive
training in primary healthcare for mental health profes-
sionals. With appropriate medical support, psychiatrists
have been considered as appropriate treatment providers for
many physical conditions (Golomb et al., 2000). However, it
should be recognized that mental healthcare facilities in many
countries are under-resourced compared with other health-
care facilities, and that many mental healthcare providers
are already stretched in attempting to manage the mental
health of their patients (Sartorius, 2007a). It is unlikely that
calls such as these will be successful in improving the primary
healthcare of people with SMI unless they are accompanied
by investments and resourcing models that recognize the time
requirement associated with this expanded role, as well as
addressing the logistical and cultural barriers to their
This issue has been compounded by a long tradition of sep-
aration of mental healthcare facilities from general healthcare,
both in the physical location of facilities and in the resourcing
should seek the help of multiple care providers.
In recent years, some jurisdictions have issued guidelines
on healthcare for people with SMI that have included mini-
mum standards of physical healthcare. For instance, the
European Psychiatric Association has recently issued a posi-
tion statement on cardiovascular disease and diabetes man-
agement that sets out standards for monitoring body weight,
blood lipids, blood glucose and smoking status on a regular
basis (de Hert et al., 2009). Responsibility for coordinating
assessment and management is assigned to psychiatrists, ide-
ally as part of a shared care arrangement. The Spanish
Societies of Psychiatry and Biological Psychiatry call for
six-monthly monitoring of blood pressure, blood lipids,
blood glucose, height, weight, and medication reviews for
schizophrenia patients in outpatient treatment (Sa ´ iz Ruiz
et al., 2008).
In recognition of the metabolic effects of antipsychotic
medications, both the US and the UK have guidelines
for the monitoring of metabolic risk factors in schizophrenia
patients on antipsychotic medications (National Institute for
Clinical Excellence, 2002; American Diabetes Association,
American Psychiatric Association, American Association of
Clinical Endocrinologists and North American Association
for the Study of Obesity, 2004). Where applied these guide-
lines may be cost-effective, as screening costs are more than
offset by savings in chronic disease management and care
(Bruggeman et al., 2008). However, while these guidelines
are helpful in setting expectations for standards of care, com-
pliance is often low (Citrome and Yeomans, 2005; Haupt
et al., 2009), and health of people with SMI may not have
improved (Mackin et al., 2007). Work is required to develop
and fund systems that allow these standards of care to be
routinely applied. To date, the development of standards
has mainly been in response to the metabolic effects of anti-
psychotics, and focus on these risk factors. More general
guidelines for physical healthcare of people with SMI, regard-
less of medication, remain to be developed.
Integrated care trials
To address the systemic separation of mental healthcare and
physical healthcare, a range of integrated care models have
been proposed (Vreeland, 2007). These include co-location
of services, having staff from one service visit another on a
regular basis, or appointing case managers to liase between
services and co-ordinate the overall care for the patient.
Some small-scale trials have been conducted which show
benefits associated with various types of integrated care
models. Griswold et al. (2005, 2008) found that nurse case
managers were effective in increasing the percentage of
patients with SMI who were successfully linked to primary
care services. A randomized trial of an integrated care model
within a Veterans Administration mental health clinic found a
significant improvement in overall health status after 1 year,
and increased likelihood of patients receiving a range of pre-
ventive health measures (Druss et al., 2001b).
Shared care with primary care physicians is another
approach that has several advantages. These include accessi-
bility, reduction in stigma, and potential for long-term conti-
nuity of care, and integration with management of medical
problems. In the United States, the use of care managers for
liaison with primary care physicians was associated with sig-
nificant improvements in the quality and outcomes of primary
care (Druss et al., 2010a). The Consultation and Liaison in
Primary Care Psychiatry (CLIPP) project in Victoria,
Australia (Meadows, 1998) provides a protocol to support
primary care physicians in managing people with SMI as
they reintegrate into the community. This includes a manage-
ment plan with support to the primary care physician after
the transfer. Involvement of the primary care physician is
encouraged early with an increasing degree of shared care
in transition towards discharge. The development of ‘super-
clinics’ affords the opportunity to develop ‘one stop shops’
that increase the opportunity and capacity to promote access,
early intervention with respect to mental and physical health-
care while also enabling engagement with specialized medical
Lawrence and Kisely63
services (Crompton et al., 2010). Larger-scale and longer-term
trials are required to determine whether these models of care
can improve morbidity and mortality of people with SMI.
Addressing patient-level factors
People with SMI may be naturally disadvantaged in their
ability to maintain good physical health and attend to their
physical health needs due to the range of patient-level factors
that commonly accompany SMI including cognitive impair-
ment, social isolation and lack of family support, self-neglect,
lack of motivation and socio-economic factors. Countering
these factors may help to address the inequality in health
outcomes for people with SMI. It is widely recognized that
additional investments and infrastructures are entirely appro-
priate to compensate for physical disabilities to allow people
with disabilities to participate more fully in life. Steps that
actively redress the negative consequences of mental illness
may also be appropriate for people with SMI.
There is an extensive literature relating adverse socio-
economic factors to poor health outcomes in the general
population (Marmot and Wilkinson, 2006). Socio-economic
disadvantage is more common in people with SMI, and
(Muntaner et al., 2004; Saraceno et al., 2005). Socio-economic
disadvantage is associated with unhealthy lifestyles and
reduced access to healthcare. While these factors would be
expected to have an impact on the physical health of people
with SMI, they do not fully explain the differential in health
outcomes between people with SMI and the general popula-
tion. Studies that have adjusted for socio-economic status still
find significantly worse morbidity and mortality for people
with SMI (Kisely et al., 2007, 2009).
The cognitive impairment associated with schizophrenia
has been estimated as a reduction of around one standard
deviation of IQ across a range of domains (Fioravanti
et al., 2005), and often persists after remission of other symp-
toms (Szo ¨ ke et al., 2008). Impairment may be particularly
severe in the area of social cognition (van Os and Kapur,
2009) which affects the ability to understand and interact
with our surroundings which may impair the ability to distin-
guish between health promotional and advertising messages,
and to understand and prioritize various sources of health
information or misinformation.
Folsom (2009) suggested that one possible approach to
addressing the sequelae of SMI is to provide healthcare
skills training for patients. This approach aims to develop
skills in accessing and understanding health information
and the healthcare system. There have been a couple of
specific trials of this type of approach. McKibben et al.
(2006) trialled a skills training intervention aimed at older
schizophrenia patients with diabetes which achieved a
significant reduction in weight gain at 6 months. Wu et al.
(2008) undertook a lifestyle intervention aimed at reducing
antipsychotic-induced weight gain, which achieved significant
benefits at 12 weeks. Further trials are needed to assess
longer-term benefits and applicability of the approach to
broader health needs than just weight control.
Another approach to this problem has been the use of peer
supporters. In this model, former patients provide support
of theirmental illness
services which may take the form of peer-led training, facili-
tation of access to or liaison with healthcare providers, or the
provision of support services such as case management
(Davidson et al., 2006). Peer support is more established in
areas such as addiction and cancer, and is a relatively recent
innovation in mental healthcare. As yet there is little evidence
base to support long-term benefits because of the lack of trials
in the area (Kemp et al., 2009), although a trial of a peer-
support service in Western Australia has shown initial prom-
ising results (Bates et al., 2008). In addition, Druss et al.
(2010b) have reported the results of a trial of a peer-led med-
ical self-management program, in which mental health peer
leaders deliver a six-session programme. After 6 months there
was a significantly elevated rate of access to primary care.
The stigma of mental illness pervades all aspects of society,
including the healthcare system. Severe mental illness too
often robs people of the characteristics that otherwise we
find most endearing. If there is one sector of society that
should be able to recognize that the behaviours that are oth-
erwise seen as signs of a difficult or negative person are actu-
ally symptoms of illness, it would be expected to be the
healthcare sector. Sartorius (2007b) has suggested that, as
part of the overall goal of reducing the stigma of mental ill-
ness, the healthcare sector should be particularly targeted.
As noted previously, one issue in the reduced access to
primary care for people with SMI is the way that some
practitioners regard people with SMI as being difficult or dis-
ruptive, attributing abnormal behaviour as an individual
characteristic rather than one of the symptoms of an illness.
Sartorius (2007b) has suggested that a campaign to reduce
stigma and discrimination within the healthcare sector
should be a high priority in efforts to reduce the stigma asso-
ciated with mental illness in the population at large.
Population healthcare and health promotion
Population health programmes have been credited with
improvements in health risk factor profiles and improved
life expectancy in developed countries. Common chronic dis-
eases such as cardiovascular disease, cancers and diabetes
have been major targets for these strategies which combine
a range of legislative and promotional approaches to reduce
exposure to known health risk factors. Probably the biggest
success in this regard is the reduction in smoking rates, but
major programmes have also been developed to address other
substance misuse including alcohol, diet and exercise, and
As inpatient treatment for psychiatric illness has been
reduced and community-based care has become the norm in
most Western countries, preventive healthcare measures are
becoming more important for improving the health of people
with SMI (Salokangas, 2007). The need to integrate general
medical and mental healthcare and to treat the person rather
than specific diseases has been recognized for some time.
However, population health has been significantly slower to
respond to this trend, with most population health initiatives
targeted at single diseases or risk factors. Agencies taking
64 Journal of Psychopharmacology 24(11)
responsibility for population health initiatives are often orga-
nized around specific diseases, such as heart disease, diabetes
or cancer, with mental illness seen as a separate group.
Population-health-based groups that address major chronic
diseases are reluctant to view people with mental illness as
an important target group. There is evidence that people with
SMI can quit smoking, become more physically active and
improve their diets but programmes should be tailored to
address the neurological, cognitive, behavioural and social
deficits associated with SMI (Addington et al., 1998;
Robson and Gray, 2007).
Despite the high rate of smoking in people with SMI
(de Leon and Diaz, 2005), it is rare to see population-
health-based anti-smoking measures targeted at people with
SMI. Where mental illness is identified as an important
target in smoking cessation, the suggested strategies are
almost always service-based, such as smoke-free units, with
often disappointing long-term results (Lawn and Pols, 2005;
Prochaska et al., 2006). For instance, of 100 patients admitted
to a smoke-free psychiatric unit, all resumed smoking within
about 5 weeks of discharge. The median time from discharge
to first cigarette was 5minutes, and the range was a few
seconds to 36 days (Prochaska et al., 2006). While some
have argued that the entire population, including people
with SMI, respond to general smoking-cessation programmes
(Chapman, 2007), the persistent high rate of smoking in this
group would suggest these programmes are not equally effec-
tive in this group. People with SMI could well benefit from
targeted messages, as there are specific issues around smoking
in people with SMI that need to be addressed. The interac-
tions between nicotine and anti-psychotics and anti-depres-
sive medications mean that people with SMI may need to
have their medications or doses adjusted when quitting smok-
ing, and the possibility that nicotine withdrawal symptoms
can be mistaken for symptoms of mental illness are specific
areas where people with SMI could benefit from targeted
information (Ziedonis et al., 2008). Some of the general
anti-smoking messages are also less relevant in this group.
For instance, campaigns around the idea that an early smok-
ing-related death may mean you will not be around to see
your children and loved ones as they grow older may be
less relevant for people who do not have children or who
are estranged from their families, demographic groups over-
represented among people with SMI (Compton et al., 2006).
Similarly the attempt to stigmatise smoking behaviour
(Chapman and Freeman, 2008) may have less of an impact
on a population already facing the stigma of mental illness,
and a strategy that may be effective in those without mental
illness may cause harm to those with SMI (Bayer and
People with SMI have higher rates of mortality and reduced
life expectancy, with deaths from common physical illnesses
such as cardiovascular disease, cancers and respiratory ill-
nesses representing the largest number of excess deaths.
There is a range of contributing factors that may be respon-
sible for this excess mortality, and while we do not know how
much these various factors contribute to the overall excess
mortality, inequalities in healthcare access and delivery have
been repeatedly documented and are likely to be a contribut-
ing cause. These inequalities can be attributed to a combina-
tion of factors including systemic issues, such as the common
separation of mental health services from other medical
services, healthcare provider issues including the pervasive
stigma associated with mental illness, and consequences of
mental illness and side effects of its treatment.
Fleishhacker et al. (2008) have suggested that parity in
healthcare for people with mental illness should be regarded
as a basic human right. This raises the question of whether we
would regard equality in health as meaning equality in access
to healthcare, equality in the use of healthcare, use of health-
care in proportion to need or equality in health outcomes.
A human rights argument could be made that people with a
higher burden of physical illness, such as people with SMI,
should be entitled to higher use of healthcare given the higher
level of health need.
There have been some small-scale trials examining ways to
address these issues which have shown promise (Druss and
von Esenwein, 2006), however there is a need to build the
evidence base on which to formulate programmes to address
the inequities in healthcare provision in this population. To
build this evidence base, it is important to include a trial and
evaluation component in policy and programme changes, to
determine which strategies are effective and aid in their refine-
ment. With the increasing availability of administrative data
in electronic form, evaluations can be carried out at minimal
cost using record linkage methodologies.
The complex and multifactorial nature of the problems
underlying the inequalities in healthcare provision for
people with SMI will require multifaceted solutions. It is unli-
kely that any one of the initiatives mentioned above will com-
pletely resolve the problem. The growing literature in the field
including some trials suggests that there is building momen-
tum to address health inequalities in people with SMI. The
health system has long been better at treating people with
single problems. While recognizing that treating multiple
health problems concurrently is more difficult, it may well
be the case that this approach would have substantial bene-
fits including possible long-term cost savings, as treating the
physical health problems of people with SMI may improve
their mental health as well as their physical health and vice
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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