Challenges for Policy Makers and Organizational Leaders: Addressing Trends in Mental Health Inequalities

Document Type: Perspective


Center for Health Policy and Ethics, School of Medicine, Creighton University, Omaha, Nebraska, USA


We typically think of acutely and chronically mentally ill patients as those who belong in psychiatric hospitals and the latter category of patients belonging in “regular” hospitals, but the intersection of physical and mental illness draws attention to important challenges for policy-makers and organizational leaders. This article illuminates some broad trends in the health status of people with mental illnesses, canvasses important features of inequalities suffered by people with mental illnesses, and suggests strategies for systemic reform. Most reform recommendations I offer are in the area of healthcare organization leadership and management. Other key reforms will likely be legislative, regulatory, and insurance-related. Social and cultural reforms in organizational practices and structures will also be critical.


Main Subjects

1. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet 2007; 370: 859–77. doi: 10.1016/s0140-6736(07)61238-0
2. Osborn DP. The poor physical health of people with mental illness. West J Med 2001;175: 329–32. doi: 10.1136/ewjm.175.5.329
3. Felker B, Yazel JJ, Short, D. Mortality and medical comorbidity among psychiatric patients: a review. Psychiatr Serv 1996; 47: 1356–63.
4. Goldman LS. Comorbid medical illness in psychiatric patients. Current Psychiatry Report 2000; 2: 256–63. doi: 10.1007/s11920-996-0019-x
5. Lyketsos CG, Dunn G, Kaminsky MJ, Breakey WR. Medical comorbidity in psychiatric inpatients: Relation to clinical outcomes and hospital length of stay. Psychosomatics 2002; 43: 24–30. doi: 10.1176/appi.psy.43.1.24  
6. Maricle R, Hoffman W, Bloom J, Faulkner L, Keepers G. The prevalence and significance of medical illness among chronically mentally-ill outpatients. Community Ment Health J 1987; 23: 81–90. doi: 10.1007/bf00757162
7. Pavalonis D, DeCarr M, Shutty M. Nursing roles for chronic pain management in the seriously mentally ill. J Am Psychiatr Nurses Assoc 1995; 1: 107–11. doi: 10.1177/107839039500100402
8. Farmer S. Medical problems of chronic patients in a community support program. Hosp Community Psychiatry 1987; 38: 745–9.
9. Appelbaum PS, Grisso T. The MacArthur Treatment Competence Study III: Abilities of patients to consent to psychiatric and medical treatments. Law Hum Behav 1995; 19: 149–74. doi: 10.1007/bf01499323
10. Candilis PJ, Foti ME, Holzer JC. End-of-life care and mental illness: A model for community psychiatry and beyond. Community Ment Health J 2004; 40: 3–16. doi: 10.1023/
11. Dembling BP, Chen DT, Vachon L. Life expectancy and causes of death in a population treated for serious mental illness. Psychiatr Serv 1999; 50: 1036–42.
12. Bonhoeffer K. Die psychosen im gefolge von akuten infektiouen allgemeiner krankungen und inneren erkrankungen. Handbach der Psychiatrie (Ed. Aschaffenburg GL). Deuticke: Leipzig, Germany; 1912.
13. Jeste DV, Gladsjo JA, Lindamer LA, Lacro JP. Medical comorbidity in schizophrenia. Schizophr Bull 1996; 22: 413–30. doi: 10.1093/schbul/22.3.413
14. Harris EC, Barraclough B. Excess mortality of mental disorder. Br J Psychiatry 1998; 173: 11–53. doi: 10.1192/bjp.173.1.11
15. Schulz R, Beach SR, Ives DG, Martire LM, Ariyo AA, Kop WJ. Association between depression and mortality in older adults: the Cardiovascular Health Study. Arch Intern Med 2000; 160: 1761–8. doi: 10.1001/archinte.160.12.1761
16. Liptzin B, Gottlieb GL, Summergrad P. The future of psychiatric services in general hospitals. Am J Psychiatry 2007; 164: 1468–72. doi: 10.1176/appi.ajp.2007.07030541  
17. Iglehart J. The Mental Health Maze and the Call for Transformation. N Engl J Med 2004; 350: 507–14. doi: 10.1056/nejmhpr032740
18. Druss BG, Rosenheck RA. Mental disorders and access to medical care in the United States. Am J Psychiatry 1988; 155: 1775–7.
19. Young JK, Foster DA. Cardiovascular procedures in patients with mental disorders. JAMA 2000; 283: 3198–9.
20. Druss BG, Bradford DW, Rosenheck RA, Radford MJ, Krumholz HM. Mental disorders and use of cardiovascular procedures after myocardial infarction. JAMA 2000; 283: 506–11. doi: 10.1001/jama.283.4.506
21. Kendrick T. Cardiovascular and respiratory risk factors and symptoms among general practice patients with long-term mental illness. Br J Psychiatry 1996; 169: 733–9. doi: 10.1192/bjp.169.6.733
22. Karasu TB, Waltzman SA, Lindermayer JP, Buckly PJ. The medical care of patients with psychiatric illness. Hosp Community Psychiatry 1980; 31: 463–72.
23. Rentmeester CA. Postcolonial Bioethics: A Lens for Considering the Historical Roots of Racial and Ethnic Inequalities in Mental Health. Camb Q Healthc Ethics 2012; 21: 366–74. doi: 10.1017/s0963180112000084
24. Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. Improving the Quality of Health Care for Mental and Substance Use Conditions. National Academies Press: Washington, DC; 2006.
25. Mitchell JB, Dickey B, Liptzin B, Sederer LI. Bringing psychiatric patients into the Medicare prospective payment system: Alternatives to DRGs. Am J Psychiatry 1987; 144: 610–5.
26. Rentmeester CA. Should a Good Healthcare Professional Be (at Least a Little) Callous? J Med Philos 2007; 32: 43–64. doi: 10.1080/03605310601152982
27. Rentmeester CA. Moral Damage to Healthcare Professionals and Trainees: Legalism and other Consequences for Patients and Colleagues. J Med Philos 2008; 33: 27–43. doi: 10.1093/jmp/jhm006
28. Bermudes RA, Keck PE, Welge JA. The prevalence of the metabolic syndrome in psychiatric inpatients with primary psychotic and mood disorders. Psychosomatics 2006; 47: 491–7. doi: 10.1176/appi.psy.47.6.491  
29. Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. Diabetes Care 2004; 27: 596–601. doi: 10.2337/diacare.27.2.596
30. Casey DE, Haupt DW, Newcomer JW, Henderson DC, Sernyak MJ, Davidson M, et al. Antipsychotic-induced weight gain and metabolic abnormalities: implications for increased mortality in patients with schizophrenia. J Clin Psychiatry 2004; 65: 4–18.
31. Marder SR, Essock SM, Miller AL, Buchanan RW, Casey DE, Davis JM, et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry 2004; 161: 1334–49.
32. Citrome L, Blonde L, Damatarca C. Metabolic Issues in Patients with Severe Mental Illness. South Med J 2005; 98: 714–9. doi: 10.1097/01.smj.0000167621.49292.11
33. Goldenberg D, Holland J, Schachter S. Palliative care in the chronically mentally ill. Handbook of psychiatry in palliative medicine. Oxford University Press: New York; 2000. pp. 91–6.
34. Summergrad P, Hackett TP. Alan Gregg and the rise of general hospital psychiatry. Gen Hosp Psychiatry 1987; 9: 439–45. doi: 10.1016/0163-8343(87)90054-5