Issue Date: Online Exclusive
Mortality among our peers: Better, but not well
by Ron Manderscheid, PhD, Executive Director, NACBHDD
As we pause to honor recovery month (September) and Wellness Week (September 17-23), we must also forge ahead to assess our progress in combating premature mortality among public mental health peers.
What changes have actually occurred since the release of our April 2006 study in Preventing Chronic Disease which shows that public mental health peers die, on average, more than 25 years younger than other Americans?
On one hand, these dramatic and unsettling findings have had a very profound effect in mobilizing our field; on the other, they also appear to have had much less effect in several critical contexts. Here, we want to explore this paradox.
First, as a reflection of an extremely urgent public health problem, these findings have had a dramatic effect on our advocacy, on our efforts to transform services, and on our efforts to promote wellness in the mental health field.
By 2007, the Center for Mental Health Services (CMHS) at SAMHSA had initiated a highly visible 10 by 10 Campaign to reduce the 25 year disparity by 10 years within a 10 year period. This campaign has been supported strongly and persistently across the field by peers, providers, researchers, and program managers.
Now, slightly more than half a decade later, we must ask: Has the disparity in mortality actually been reduced?
Because a major factor in the premature mortality of peers is the absence of needed primary care, service transformation efforts have accelerated rapidly toward full integration of behavioral health and primary care; these efforts have been memorialized in the Affordable Care Act of 2010, and in major program initiatives of SAMHSA and HRSA.
Health homes that bring together mental health, substance use, and primary care services are being planned and implemented. As we race toward the initiation of the state Health Insurance Exchanges and the expansion of the Medicaid Program in 2014, we can fully expect the movement toward health homes to accelerate even more dramatically.
Now, we must ask: How many peers actually access and use these primary care services today? What health effects do they achieve?
Efforts to promote wellness also have exploded across the field. Numerous, local, peer-led projects are underway to define wellness regimens for self and others.
Also, many websites operated by peers, researchers, and by the 10 by 10 Campaign itself offer advice on weight control, smoking cessation, and lifestyle improvement. In a broad sense, these undertakings lend veracity to consumers’ self-efforts to recover and to retake control of their own lives.
Now, we must ask: How many peers actually engage in these wellness regimens? What health effects do they achieve?
Each of these developments should be great cause for rejoicing: As a field, we are making dramatic progress. Yet, clearly, much, much more also remains to be done.
As early as 2007, participants in a major meeting on recovery hosted by CMHS/SAMHSA called for the collection of annual data on mortality of public mental health peers, as well as much better data collection to understand the relationship across the life cycle between mental illness conditions and other chronic illnesses, such as heart disease and diabetes.
The very recent announcement by Secretary Sebelius of the Million Hearts Initiative holds great promise in this regard. As a result of this Initiative, we expect extensive collaboration between SAMHSA and CDC around data collection on mortality of peers and targeted program development of community and person-level interventions to reduce mortality rates significantly.
The Million Hearts Initiative will target major lifestyle factors, such as smoking, food consumption, exercise, and other key behaviors that affect one’s health. The Initiative has the potential to provide a great boost to wellness efforts already underway.
It is also very clear that second-generation antipsychotic medications play a major role in leading to the metabolic syndrome, which, in turn, is a major risk factor for the chronic illnesses, such as heart disease and diabetes.
Yet, to this day, we do not have an evidence-based practice that requires wellness counseling and monitoring when a psychiatrist or other physician prescribes one of these second-generation medications. We must develop this important practice and implement it broadly.
Related research also is needed urgently to define more clearly the different metabolic effects of the different second-generation antipsychotic medications. These drugs are not equal in their side effects, and we must understand the differences.
Recently, a National Institute of Child Health and Human Development (NICHD) panel successfully advocated for FDA to require a box-label warning on the drug olanzapine because of its serious metabolic effects in teenagers.
However, unfortunately, this is only an isolated incident rather than a systematic process. We must undertake the necessary advocacy so that the research we need is conducted and applied appropriately.
Finally, let me make just a brief comment about disease prevention and health promotion.
Although it is obvious that preventing disease is much preferable in both a personal and a fiscal sense to chronic disease, we have not actually behaved as if this is true.
Hence, we have expended little effort to understand how to delay the onset of chronic illnesses, such as heart disease, among peers, and we have expended almost no effort to understand the salutary effects of promoting positive mental health and wellbeing.
Included here are hope and the promise of recovery. These are areas of great future promise. We must advocate strongly so that this work will begin very soon.
Nearly six years has elapsed since the release of our original research on mortality. Yet, to use Richard Frank and Sherry Glied’s conclusion about mental health policy, overall, the efforts of our field to address this urgent public health problem are “better, but not well”.
We must continue to make essential improvements rather than rest on our laurels. The actual lives of peers we know and love depend upon our efforts.