Are we reaching parity of esteem?

Jayati Das MunshiDr Jayati Das-Munshi is a Clinician Scientist and Honorary Consultant Psychiatrist based at the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King’s College London. In this piece she writes about a study in which electronic health records uncover inequalities in mind and body when it comes to severe mental health problems and diabetes.

Parity of esteem’ is the idea that mental health should be as much of a priority as physical health, but the ambition seems a long way off. People with severe mental health problems experience a 15 to 20 year reduction in life expectancy, and this is mostly due to preventable physical causes. The amount that life expectancy is shortened has been likened to having cancer. This is tragic.

Conditions like type 2 diabetes might play an important role. Previous research has shown that people living with psychosis are much more likely to have type 2 diabetes . But this association in ethnically diverse populations is much less understood.

Nationally representative surveys tell us type 2 diabetes is already more prevalent in Indian, Pakistani, Bangladeshi, Black Caribbean and Black African people in England, compared to White British people.  Outside of the United States, there have been very few studies which examine how much the link between severe mental health problems and type 2 diabetes changes in ethnically diverse populations. Most previous work has relied on small hospital samples, which tend to focus on individuals with more pronounced psychiatric symptoms.

We examined the prevalence of type 2 diabetes in people with severe mental health problems (conditions such as schizophrenia and bipolar affective disorder), using over half a million primary care UK electronic health records, in a cross-sectional survey study design. A well-defined part of London (boroughs of Lambeth, Tower Hamlets, Newham, Hackney & City), notable for its ethnic diversity, provided electronic health records from 98% of the area’s general practices.

As the majority of the UK is registered to primary care, our study had better coverage of the general population than previous studies where investigators focused on hospital populations.

Our analyses revealed some stark findings. Type 2 diabetes is rare in young populations (18-34 years) but we found young people with severe mental health problems were between four and ten times more likely to have type 2 diabetes than people in the same age group in the general population. All ethnic groups living with severe mental health problems faced an increased risk - including White British people. The prevalence of type 2 diabetes was highest in Bangladeshi people with severe mental health problems, but was also elevated in Indian, Pakistani, Black African and Black Caribbean groups.

When we focused on the over 55s living with severe mental health problems, we found 63% of Bangladeshi people, 48% of Pakistani people and 40% of Indian people also had diabetes. Around a third of Black Caribbean people (36%) and Black African people (27%) with severe mental health problems had a diabetes diagnosis. Irish and White British people with severe mental health problems, over the age of 55 saw roughly a fifth living with type 2 diabetes. This is considerably higher than the national prevalence which ranges from 8-16% in the over 55s.  Antipsychotic prescriptions are often suggested as the culprit for the association of severe mental health problems and type 2 diabetes. Our analyses adjusted for antipsychotic use and we found that they were not. You can see full details of our study here.

These findings have important implications for clinical care. Although the case for screening for diabetes in the whole population is controversial, there is a more specific issue around screening and clinical management of type 2 diabetes in people with severe mental illnesses. Our findings suggest that we should be alert to the possibility of type 2 diabetes in people with severe mental illness, even in those as young as 18 years old, and not just in people prescribed antipsychotic medications. Type 2 diabetes can affect everyone with severe mental health problems, irrespective of ethnic background.

The NHS had encouraged GPs to screen those with severe mental health problems for type 2 diabetes as part of their Quality and Outcomes Framework drive. In 2013, this was inexplicably dropped. This may have been short-sighted, as a sizeable proportion of people with severe mental health problems may have diabetes. The prevalence of diabetes in some ethnic minority groups with severe mental health problems is even higher. So failing to detect diabetes in routine health checks could amplify two forms of inequality - mental health’s lack of parity with physical health, and the unequal health outcomes of minority ethnic groups.

Views expressed are my own.

Paper details  

1 Das-Munshi, J., Ashworth, M., Dewey, M. E., Gaughran, F., Hull, S., Morgan, C., Nazroo, J., Petersen, I., Schofield, P., Stewart, R., Thornicroft, G. and Prince, M. J. (2017), Type 2 diabetes mellitus in people with severe mental illness: inequalities by ethnicity and age. Cross-sectional analysis of 588 408 records from the UK. Diabet. Med.. doi:10.1111/dme.13298