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Issues for those with a mental illness

One in two Australians have experienced an episode of mental illness and one in five currently have symptoms. Depression, trauma and anxiety are the most common. Other conditions like schizophrenia and bipolar are less common. All conditions can lead to complexities in the treatment regime for all health professionals.

This information is aimed to address some of the complexities for those caring for a patient with an existing mental illness who also requires palliative care.

Likely Common Issues for those with a mental illness

Co-morbidities often exist in patients with a mental illness which can sometimes cause or exacerbate psychiatric conditions. [1] Those with both physical and psychiatric pathologies will sometimes slip through the net between the two specialties. [2]

People with a mental illness have high mortality rates and reduced life expectancy, dying from ten to fifteen years earlier than the general population. [3] Sometimes though their physical complaints are put down to their mental illness, and in some cases delays in diagnosis and treatment are because their treating doctors are not always focusing on physical conditions. [4] Mortality from heart disease, diseases of the respiratory system and of the digestive system are markedly increased in schizophrenia. [5]

In other cases those with a mental illness don’t seek health care or access health screening in a timely manner, or don’t report early symptoms. [5] It has also been suggested that in some instances (such as schizophrenia) the pain that would ordinarily bring most people to seek medical attention is either muted or highly tolerated. In cases where help is not sought early enough, palliative care can be the patients’ first encounter with health professionals. [6]

Many patients will have challenging behaviours that may make them unwelcome in health services and may decrease the quality of care they receive. [7] Other issues such as illicit drug use or alcoholism may also impact health seeking behavior, and cause lack of trust in those provider professional support. [5] Patients with a serious mental illness may have difficulty keeping appointments, and may be dependent on unreliable caregivers. [8] A barrier to care may be the fact that patients cannot access care without money or transport. Health professionals working together (such as palliative care, mental health and allied health professionals) can facilitate case conferences or family conferences to help address and problem solve some of these issues.

Conversations around death and dying may not be facilitated with people who have a mental illness, for fear of provoking a negative reaction, resulting in little or no support in psychological or spiritual care. [9] This group of people is highly vulnerable, and approaches to care should look at partnership models between mental health and palliative care services. Palliative care or other generalist health care providers frequently do not understand the degree to which symptoms of mental illness influence the behaviors and decisions of the patient. [5] Often professional support is inaccessible if the person is physically ill and can no longer travel independently.

The risk of complicated bereavement appears to be no different than that of those without a mental illness, but may cause further burden in addition to the problems that they already live with.

Decision making

Psychiatric advanced directives are used in some areas to allow patients to consent to or refuse future mental health treatment in the event of an incapacitating psychiatric crisis. [10] This is similar to when an Advance Directive is used for end-of-life decision making. However, they are never completed well or very often by those with a mental illness, and if they are made, may or may not be recognized or adhered to. Important conversations in relation to decision-making at the end of life are not always held with the patient but with the family instead. However, one US study, through the use of hypothetical case studies found that mental health consumers were able to participate in advance care planning in relation to complex and potentially distressing situations that may arise. The authors recommend that, because those with serious mental illness die at a younger age than the general population, it is important to begin discussions about advance directives early, such as in outpatient clinics. [1]

Resources

• The Mental health Foundation (UK) has a Mental health and Palliative Care Project that included a Mental health and palliative care literature review. 2008.
• The American Psychiatric Association: The core principles for end-of-life care position statement. 2001.

General mental illness resources

• SANE Australia has information and resources on a range of mental health problems and issues that may help
• The beyondblue website has a lot of information and resources on depression
• The MyDr website has information on: Mental illness facts and figures
• Mental Health in Multicultural Australia provides national leadership in building greater awareness of mental health and suicide prevention amongst Australians from culturally and linguistically diverse (CALD) backgrounds
• HealthInsite has information for consumers on caring for someone with a mental illness
• The Australian Indigenous HealthInfoNet has the following resources:
  • A review of the social and emotional wellbeing of Indigenous Australian peoples
  • Health Promotion resources including suicide prevention, coping with grief and loss, tackling anxiety and depression

Related CareSearch Pages

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Prisoners

Free Full Text Articles

• McGrath P, Holewa H. Mental health and palliative care: exploring the ideological interface. Int J Psychosoc Rehabil. 2004;9(1):107-19.
• Campbell LA, Kisely SR. Advance treatment directives for people with severe mental illness. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD005963.
• Foti ME, Bartels SJ, Van Citters AD, Merriman MP, Fletcher KE. End-of-life treatment preferences of persons with serious mental illness. Psychiatr Serv. 2005 May;56(5):585-91.
• Woods A, Willison K, Kington C, Gavin A. Palliative care for people with severe persistent mental illness: a review of the literature. Can J Psychiatry. 2008;53(11):725-36.
• Macias C, Jones D, Harvey J, Barreira P, Harding C, Rodican C. Bereavement in the context of serious mental illness. Psychiatr Serv. 2004 Apr;55(4):421-6.

References

1. Foti ME, Bartels SJ, Van Citters AD, Merriman MP, Fletcher KE. End-of-life treatment preferences of persons with serious mental illness. Psychiatr Serv. 2005 May;56(5):585-91.
2. Ellison N. Mental health and palliative care literature review. London: Mental Health Foundation; 2008.
3. McGrath P, Holewa H. Mental health and palliative care: exploring the ideological interface. Int Psychosoc Rehabil. 2004;9(1):107-19.
4. Hahm HC, Segal SP. Failure to seek health care among the mentally ill. Am J Orthopsychiatry. 2005 Jan;75(1):54-62.
5. Baker A. Palliative and end-of-life care in the serious and persistently mentally ill population. J Am Psychiatr Nurses Assoc. 2005 Oct;11(5):298-303.
6. Goldenberg D, Holland J, Schachter S. Palliative care in the chronically mentally ill. In: Chochinov HM, Breitbart W, editors. Handbook of psychiatry in palliative medicine. New York: Oxford University Press; 2000. p. 91-96.
7. Felker B, Yazel JJ, Short D. Mortality and medical co-morbidity among psychiatric patients: a review. Psychiatr Serv. 1996 Dec;47(12):1356-63.
8. McConnell SD, Inderbitzin LB, Pollard WE. Primary health care in the CMHC: a role for the nurse practitioner. Hosp Community Psychiatry. 1992 Jul;43(7):724-7.
9. Tate FB, Longo DA. Death and dying: implications for inpatient, psychiatric care. Palliat Support Care. 2005 Sep;3(3):239-43.
10. Swanson J, Swartz M, Elbogen E, Van Dorn R, Ferron J, Wagner R, et al. Facilitated psychiatric advance directives: a randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness. Am J Psychiatry. 2006 Nov;163(11):1943-51.

Last updated 28 February 2011*