PEOPLE WITH MENTAL illness often feel marginalised in society. This is hardly a scoop, except that sometimes the reasons are surprising.

For example, it’s not unusual for my own patients to tell me that their underlying psychiatric diagnoses make it a challenge to have their physical illnesses taken seriously in general medical settings, outpatient clinics, emergency departments and so forth.

In medical waiting rooms, they might overhear themselves talked about by staff primarily with reference to their anxiety or depression or bipolar disorder or schizophrenia or whatever, even when their reason for attending is purely physical. They say they must then work twice as hard to avoid their physical symptoms being under-investigated or even dismissed.

Overshadowing

This phenomenon is called “diagnostic overshadowing”, where a health professional – despite their best intentions – assumes that someone’s physical symptoms are part of their psychiatric illness rather than a separate physical health concern. The problem is widespread and can affect people with a psychiatric diagnosis, intellectual disability and neurodivergence such as autism.

And there’s unfortunately nothing new about it. It’s part of a much broader societal picture where the health of individuals with underlying psychiatric illnesses is not seen to be as important.

As far back as 2013, the Royal College of Psychiatrists in London expressed its concern in a report entitled “Whole person care: from rhetoric to reality – Achieving parity between mental and physical health”. In Ireland, the drive to reduce costs has seen funding for psychiatric care gradually shrink in comparison to that for the treatment of physical illness.

At present, around 5.6% of Ireland’s health budget is allocated to mental health, falling far short of the 10% recommended by the Sláintecare policy and the 12% guideline of the World Health Organization. Yet, psychiatric illness is common, debilitating and sometimes fatal. Depression alone is estimated by the WHO to affect some 300 million people worldwide, making it the world’s leading cause of disability.

The care shortfalls

But the paltry mental health budget is only half the problem. People with underlying psychiatric illnesses don’t even get their fair share of timely, effective healthcare for their physical illnesses. This leads to poorer outcomes. A 2019 report by Dr Susan Finnerty, Inspector of Mental Health Services (at the time) with the Mental Health Commission, highlighted the unmet physical healthcare needs of many people with severe mental illness. Similarly, a report by the UK think-tank QualityWatch examined 100 million hospital episodes annually over five years. It turns out almost half of people with mental ill health have a concurrent physical condition, and such individuals are four and 2.5 times more likely to die of respiratory (lung) disease and cardiovascular disease respectively.

QualityWatch found that people with serious mental illness die 10–17 years younger than the general population, which may be conservative given that the equivalent WHO figure is 10–20 years. This gap is widening year-on-year. In an updated 2023 report, the UK Department of Health estimated that around 40,000 people with severe mental illness die prematurely (before the age of 75) each year. The equivalent annual number of premature deaths based on Ireland’s population would be over 3,100. If those Irish deaths were because of a jumbo jet crash every two months, society might take more notice.

Suicide accounts for some of the difference, but physical illness is the main reason, partly due to increased risk factors. For example, people with schizophrenia are six times more likely to smoke heavily, while half are significantly overweight, up to 15% have diabetes and 58% have high blood pressure. Some studies have found that mortality from Covid-19 during the pandemic was four times higher among individuals with severe mental illness compared to those without.

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As a rule, prevention is better than cure. Meeting the planned medical needs of any patient will reduce the proportion of emergency care they need. According to QualityWatch, people with mental illness have 10% fewer planned medical admissions than the general population. Instead, they have three times more emergency department attendances and almost five times more emergency admissions. Fewer than one in five of these emergency admissions are to address their mental health needs; most are for the potentially preventable complications of common illnesses such as hypertension, heart disease, epilepsy and various infections. When the admissions occur, individuals with underlying mental illness generally remain longer in the hospital.

Imagine the pressure that could be taken out of our under-resourced, understaffed, overcrowded emergency departments if people with mental illness had earlier access to – and better uptake of – routine and preventative physical healthcare in the first place. Think of the human element. Wouldn’t patients be so much better off?

Unfortunately, in the words of the WHO, the reduced life expectancy of individuals with serious mental illness is due to “a society socially and functionally biased towards the population living with severe mental disorder”. They die earlier not because of their psychiatric illness per se, but “because of the discrimination and lack of access to good health services”. According to the WHO, stigma is the biggest barrier.

The overall amount of money available is less important than where it is spent. Indeed, investing the physical healthcare needs of people with underlying mental illness is likely to be cost effective. Detecting and actively managing any illness is less expensive than too little treatment too late. Early intervention is key and the responsibility for this is broad; it lies collaboratively with psychiatry, general practice, other medical and surgical specialties, and the emergency department. It’s also heavily dependent on the priorities of the HSE, the Department of Health and, indeed, society at large. With various mental health campaigns, public and professional knowledge is improving. But influencing attitudes is harder work.

Dr Stephen McWilliams is an author, a consultant psychiatrist at St John of God Hospital, Stillorgan, Co Dublin, a Clinical Associate Professor at the School of Medicine, University College Dublin, and an Honorary Clinical Senior Lecturer at RCSI University of Medicine and Health Sciences. @McWilliamsMD

• Samaritans 116 123 or email jo@samaritans.org
• Text About It — text HELLO to 50808 (mental health issues)
• Aware 1800 80 48 48 (depression, anxiety)
• Pieta House 1800 247 247 or text HELP to 51444 – (suicide, self-harm)
• Teen-Line Ireland 1800 833 634 (for ages 13 to 19)
• Childline 1800 66 66 66 (for under 18s)