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

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 insurancerelated. Social and cultural reforms in organizational practices and structures will also be critical.


Physical illness among people with mental illnesses
Globally, mental illnesses constitute about 14% of disease burden (1).Patients with mental illnesses have more physical illnesses than do patients without mental illnesses (2)(3)(4)(5)(6), and the breadth and severity of medical problems among patients with mental illnesses are not well known (7,8).Some populationbased evaluations of mentally ill people with physical illnesses suggest a lack of standardized assessments of needs, failure to address a plurality of competency standards, and contradictory findings are common methodological limitations to studying illness among members of this population (9,10).Medications for physical illnesses can have a range of psychiatric effects (5) and medications for mental illness can have a range of iatrogenic physical effects (2) that can generate medical comorbidity.

Inequalities: Challenges for policy makers and organizational leaders Health status, premature death
Risk of premature death is certainly one faced by people with mental illnesses, who have earlier mortality rates (3,11) than the general population.People with mental illnesses also suffer more preventable illness (3,12) than the general population.Risk of premature death is increased due to natural causes (2,3,13,14), and also to unnatural causes, such as accidents or suicide (2,15).Mental illnesses are also a leading cause of disability (16,17).

Less access to healthcare, lower quality healthcare
People with mental illness have restricted access to medical care (4,5).Important barriers to care include high costs of care and difficulty obtaining insurance (2,18).When they do get care, people with mental illness also receive inferior healthcare relative to members of the general population (2,3,(19)(20)(21)(22).Racial and ethnic inequalities in access to and quality of mental health care also persist (23).

Recommendations for systemic reform
The necessity for both physical and mental healthcare in an efficient, quality healthcare system is widely recognized (16,24).The importance of changing mental health policy such that emergency, outpatient, and inpatient mental health services are reimbursed at levels that allow for the sustainability and growth of such services is also widely recognized (16,25).Parity in mental health payments from insurers is obviously essential toward promoting health justice.Achieving parity will require cross-disciplinary commitment and collaboration.Table 1 below summarizes some of the critical areas that can contribute to improved policy and practice in mental healthcare.
Perhaps the broadest recommendation for systemic reform relates to a social and cultural shift we must make from seeing patients with mental illness in terms of their capacities to threaten themselves or others to seeing them in terms of their vulnerabilities.The current rise-to-the minimum, de facto standard of admitting patients for inpatient psychiatric care from emergency departments only when they are dangerous to themselves or others, sometimes known as the endangerment criterion, must quickly evolve to respond more capaciously to the needs of people with mental illnesses who are vulnerable and in trouble.It is easy to see here how the social and cultural shifts must work "hand-in-hand" with the reforms needed from insurance and organizational management structures.For example, reform evolution will require cultural and social support to end the persistent "bed crises"-the unavailability

Social and cultural
Implement transition from seeing patients with mental illness in terms of their capacities to threaten themselves or others to seeing them in terms of their vulnerabilities.
Implement transition from the endangerment criterion for admitting patients for inpatient psychiatric care to a standard that prioritizes the vulnerabilities and needs of people with mental illnesses.

Insurance
Implement requirements for payment parity in mental health and general health claims.
Eliminate "carve-outs" in health services coverage.

Healthcare organization leadership and management
Draw upon hospitals' and clinics' status as sites of major medical and surgical care to promote sustainable reimbursement rates for mental health services.
Partner with community-based mental health service providers to mitigate stigma, promote efficiency, and support care-continuity for people with mental illnesses.
Explore strategies for cultivating philanthropic sources of revenue to fill gaps in mental health service provision.
Recruit recovered patients, advocates, and professional caregivers for leadership roles in meeting with philanthropists to motivate responsive health promotions practices in communities.
Implement programs focusing on clinicians' practices of clinical moral perception (26,27) to help caregivers resist viewing patients with mental illness as"difficult" and to help caregivers maintain compassionate views toward patients.

Legislative and regulatory
Leverage public policy changes that respond to needs of the most vulnerable citizens.
Pursue closer monitoring of iatrogenic effects of medications that impact physical health of people with mental illnesses over the long term.
of infrastructure, space, staff, and resources to care for persons with mental illnesses in trouble-and appropriation of support to professional and nonprofessional caregivers of people with mental illnesses.Clinically, there are also important roles individual healthcare professionals can assume in improving physical and mental health services for patients with mental illness.Several experts call for closer monitoring of iatrogenic effects of antipsychotic medications, such as weight gain or elevated glucose and lipid levels, for example (28)(29)(30)(31)(32).Both clinically and ethically relevant is a reminder that the behaviours or symptoms of a person with mental illness "are not expressions of the patient's desire or right to be difficult but are rather driven by symptoms from which the patient suffers uncomfortably, even if those symptoms seem to be preferred or sought by the patient" (33).A critical insurance reform is elimination of "carve-outs," and hospitals and other healthcare organizations have important leadership roles in motivating this reform.Specifically, hospitals and clinics, for example, can draw upon their status as sites of major medical and surgical care to promote sustainable reimbursement rates for mental health services (16).Hospitals can also partner ( 16) with smaller community-based mental health service providers to mitigate stigma and promote efficiency and care-continuity for people with mental illnesses.Both hospitals and individual departments, say psychiatry, can explore strategies for cultivating philanthropic sources of revenue to respond to needs to fill gaps in mental health service provision (16).Professional caregivers, recovered patients, and advocates can all assume leadership roles in meeting with philanthropists to motivate cases for promoting responsive public health and health justice in communities.Finally, legislatures and regulators must leverage change by framing public policies (34) that prioritize and respond directly to the needs of some of our most vulnerable residents and neighbours.

Table 1 .
Key policy areas and reform recommendations