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Untangling the messiness of mental illness is key to tackling inequalities

Ask an expert how we should deal with inequalities in severe mental illness and most often they will say: it’s complicated. It impacts on - and is impacted by - myriad social, physiological and psychological factors that give rise to a uniquely challenging set of problems.

The building blocks of good health are what, in his 2010 report Fair society, healthy lives, Professor Sir Michael Marmot called ‘social determinants’. They include good housing, stable employment, reliable income and access to education. These are all precarious for those living with severe mental illness.

Dr Gordana Milavić, consultant child and adolescent psychiatrist and President Elect of the Royal Society of Medicine’s Psychiatry Section, said: “Poverty is a huge factor in this causation chain.

“What is not clear is how direct the influence is or how circuitous it is.”

The past two decades have seen an exponential rise in conversations and initiatives to destigmatise mental illness. Yet, while society has become increasingly accommodating of mild and moderate mental ill health, there is less understanding of severe conditions such as psychosis or bipolar.

Concurrently, there has been an explosion in the number of people trying to access services. Waiting times for Child and Adolescent Mental Health Services (CAMHS), for example, are up to 12 months. COVID-19 pandemic restrictions were associated with an increase in probable mental disorder in young people and children and, with so much distress, it is increasingly hard to make decisions about who has the highest level of need.

Child and adolescent psychiatrist Dr Jacqueline Phillips Owen, of the Royal Society of Medicine’s Psychiatry Section, said: “Since the pandemic, there are so many children and young people presenting with suicidal ideation or who are self-harming, that it's really difficult to prioritise who needs care first.”

Part of the problem, some suggest, is that we often talk about mental illness as a single condition, ignoring the huge variations that exist. The impact is particularly acute at the severe end of the spectrum. Simon Kitchen, Chief Executive of the charity Bipolar UK, said: “It's been quite helpful to engage people in a conversation about mental health, but living with bipolar is totally different from being a little bit sad.

“There's a lack of awareness of manic or hypomanic symptoms, especially when people are quite high but they're functioning.

“If it's not treated right, people experience quite a long cognitive, physical and mental decline over their lives.”

Most people living with bipolar are undiagnosed and 60 per cent don’t get any treatment at all. Those who have a diagnosis waited on average nine-and-a-half years to receive it. This makes existing in society, let alone thriving, an extreme challenge. While some achieve good careers, others lose or leave their jobs after experiencing a manic or depressive episode and end up on long-term benefits.

Bipolar UK published in March 2022 its report Hidden in plain sight, which details the lived experiences of those living with bipolar. The most common triggers for relapse included lack of sleep and self-care, and major life changes such as a new job, getting married or moving house. In seeking to avoid circumstances that may trigger their illness, it is easy to see how some people get left behind.

Credit: Bipolar UK

The exclusion of people living with severe mental illness is not a new phenomenon. Long before it became a 21st-century buzz phrase, Dr Anthony Fry of the Royal Society of Medicine’s Psychiatry Section was advocating for ‘safe spaces’ for people with psychosis. His 1987 book Safe Space: How to Survive in a Threatening World drew on his experiences treating patients at Guy’s Hospital. In it, he championed day hospitals so that severely mentally ill people could be discharged earlier and receive day care in the community. He said: “Social exclusion is a secondary and enduring loss of being psychotic.

“The mentality of ‘out of sight, out of mind’ is not good for patients and it’s not good for society.”

Mental illness – especially at the severe end – is debilitating enough on its own but its impact on physical health is often underestimated.

People with severe mental illnesses die 15-20 years earlier than those without, according to the NHS Long Term Plan. They are at higher risk of poor physical health, including obesity, asthma, diabetes, chronic lung disease and heart disease. They use urgent and emergency services more and are twice as likely to smoke, with the highest rates among people with psychosis or bipolar.

This is recognised by patients, too. When asked by Bipolar UK what they wanted more frequent access to, more people with the condition said a personal trainer than they did a psychiatrist.

The NHS is attempting to address the issue by increasing routine physical health checks for those with severe mental illness, to allow for earlier intervention.

Physical and mental health are too often played off against each other in a zero-sum game – in which, for one side to ‘win’, the other must lose. The evidence very clearly does not support that. Likewise, it is crucial to view the mental health spectrum with the same complexity and respect for difference as we do physical health. It is in everybody’s interests, not least those who are living with poor health for longer or dying earlier than they should, that we recognise and address this.

The Royal Society of Medicine has launched a major multi-year programme to tackle health inequalities, opening with a flagship conference on 11 January 2023, in partnership with NHS England and NHS Improvement.

This is the third in a series of features in support of the RSM’s Tackling Inequalities programme. Each examines health inequalities through the lens of a different RSM section. This article focused on severe mental illness and the Psychiatry Section. Thank you to all contributors.

You can join the conversation on social media using the hashtag #tacklinginequalities. If you have a suggestion for a future feature or wish to contribute, please email

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