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World Mental Day 2014 Living with

1 section V Time To Act

LIVING A HEALTHY LIFE WITH themselves but also by people around between 45 and 55%12,14,17. People with SCHIZOPHRENIA: PAVING THE them and even by health systems. schizophrenia have demonstrated lower ROAD TO RECOVERY People with severe mental disorders, levels of physical activity and physical fitness than the general population, M.T. Yasamy, A. Cross, E. McDaniell, S. Saxena including schizophrenia, experience disproportionately higher rates of which may be due to the limited ability mortality6, 7, often due to physical to be physically active, being overweight Background illnesses such as cardiovascular , or obese, higher smoking rates and side 18 metabolic diseases, and respiratory effects from anti-psychotic . People with schizophrenia can recover1,2. diseases8. The mortality gap results in The service users, their families, Impact of health and treatment a 10-25 year life expectancy reduction communities and the health and social systems in these patients4,5,9-11. For people with care providers need to recognize such Institutionalization commonly robs service schizophrenia, mortality rates are 2 to 2.5 a possibility and maintain realistic hope users of the space and the autonomy times higher than the general population 1, 3 required for being mobile and physically during treatment . However, for most of (9, 12). the affected population in the real world, active. Many institutions lack structured, especially those with poor psychosocial Physical health conditions balanced or individualised dietary support, this would be a lengthy and There is evidence to suggest that people regimes and people may gain weight strenuous journey. One extreme for with schizophrenia have higher prevalence and even become obese. Furthermore, people living with schizophrenia is rates of cardiovascular problems and many increase immediate and complete recovery; the obstetric complications (in women). appetite, and if not monitored regularly, other is enduring . The gray zone There is also good evidence that they may directly or indirectly contribute to in between embraces the majority of are more likely to become overweight, substantial metabolic changes, which affected people. develop , hyperlipidaemia, can lead to diabetes, hyperlipidaemia and hypertension19. Estimated prevalence We briefly review the different dental problems, impaired lung function, rates for diabetes and hypertension in requirements for a better outcome among osteoporosis, altered pain sensitivity, patients with schizophrenia are between people with schizophrenia, as well as and polydipsia or be 10 and 15% and between 19 and 58% how certain changes and interventions affected by some infectious diseases respectively14. can contribute to the healthy life that such as HIV, hepatitis and tuberculosis as is attainable for people living with compared with the general population13. The elevated physical health risks schizophrenia. A “healthy life” here Different factors contribute to premature associated with schizophrenia and refers to the WHO definition of health death. Fig. 1 summarises the association other severe mental illnesses indicate which comprises physical, mental and of different proposed factors contributing a stronger need for close and regular social health. Respecting the human to premature death among people with health monitoring. Paradoxically, people rights of people with schizophrenia is an schizophrenia and other severe mental with severe mental illness receive less overarching principle that needs to be disorders. medical care for their physical problems as recognized across all these interrelated compared with others20. Unhealthy life style and factors of risk aspects of health. Heavy smoking is about 2-6 times Being in good physical health is a crucial more prevalent among people with aspect for ; however, it is known that people living with Physical Health schizophrenia as compared with the general population, with prevalence schizophrenia and other severe mental Premature mortality rates between 50 and 80%14. Even as illnesses have a higher prevalence of physical diseases compared to An important phenomenon observed compared with people with other severe the general population21. Promoting among people with schizophrenia and mental illnesses, being a current smoker collaboration between mental and other severe mental disorders is poor is 2-3 times more common among people physical health is vital for improving care physical health and premature death. with schizophrenia15. Particularly high of people with severe mental illness. Such physical health disparities have rates of smoking are observed among The diagnosis of physical conditions is rightfully been stated as contravening patients hospitalised for psychiatric commonly overshadowed by a psychiatric international conventions for the ‘right to treatment16. diagnosis and delayed diagnosis makes health’4, 5. The physical health of people Patients with schizophrenia are often interventions less effective or even with severe mental illness is commonly at greater risk for being overweight or impossible22. ignored not only by the service users obese, with estimated prevalence rates 33 Mental and Social Health Problems Interventions of interactions between people with A common but harmful mistake is to schizophrenia and a socially In many countries efforts have begun identify people with schizophrenia simply and functionally biased towards the to better improve the physical health as a clinical diagnosis. The inappropriate population living with severe mental of people with schizophrenia, whilst term “schizophrenic” is commonly used disorder. People with schizophrenia die simultaneously encouraging the social by the public and even by some care earlier not because schizophrenia per and sector to provide better givers to refer to a person who is living se is fatal but rather because of the access to service for people with severe with schizophrenia. This term eclipses the discrimination and lack of access to good mental illness. Treatments should human and social nature of that individual, health services, regular monitoring for not be limited to pharmacotherapy. and renders them as purely a diagnosis. other risk factors for health and physical Non-pharmacological psychosocial People living with schizophrenia experience diseases, and poor family and social interventions are gaining an increasing discrimination and violations of their rights support. A disempowered person with importance and should be considered an both inside and outside institutions. In schizophrenia becomes incapable of self- adjunctive component of they face major problems care as well. management. Psychosocial interventions in the areas of education, employment, are also effective at preventing some and access to housing. As previously of the of antipsychotic mentioned, even access to health services The Way Forward . A meta-analysis has shown is more challenging. the enduring effects of a range of non- For decades, we have been rightfully People living with a severe mental pharmacological interventions at reducing advocating for “no health without mental disorder are also likely to suffer from other antipsychotic-induced weight gain, health”. This has been a popular slogan mental disorders such as and namely individual or group interventions, and is still valid. However, as coverage substance . Lifetime prevalence cognitive–behavioural and of services has escalated, of among those living with a nutritional counselling27. we have become more concerned about severe mental disorder is around 5% poor quality services worldwide. The which is much higher than that in the time has arrived to call for “no mental general population23, 24. Higher prevalence Discussion health without physical health” as well31. of substance use among people with Realizing this wish requires serious efforts The severity of disability in general schizophrenia along with some other from all stakeholders. reflects the interaction between features factors contributes to the higher reported of a person and features of the society. Our knowledge of mortality among violent activity among them and to their Disability and morbidity experienced people with severe mental illness and higher rates of victimization alike24. People by people living with schizophrenia are its correlates in low and middle income with severe mental illnesses, including not purely caused by . countries (LAMICs) is very limited. In a schizophrenia are also more likely to Similarly, poor physical health and 2007 review, 86% of such studies came be homeless, unemployed, or living in from industrialized countries32. In high 25,26 premature death are consequences . income countries is higher, better quality services are available and there is overall better monitoring of the institutions and a greater frequency of regular check-ups for physical health of people with mental illness. The situation is expected to be much worse in low and middle income countries where the resources are poor, the institutions are poorly managed and access to sound mental and physical care is limited. WHO has started fresh evidence reviews and is sharing information on these important issues. Many of WHO’s ongoing programmes also contribute to paving the way towards recovery of people with severe mental disorders including schizophrenia. WHO’s Mental Health Action Plan33, endorsed by the World Health Assembly in 2013 envisions and plans for all different aspects of services required to provide a healthy life for people living with mental disorders including

34 We are sharing two examples of services that integrate different aspects of There are a range of actions that could be health and are summarized in boxes 1 and 2. taken by different stakeholders; examples are summarized here: Box 1. The example of Fountain House28 People with schizophrenia: Exercising Fountain House, based in the US but with a global reach, has already developed an self-care and demanding their rights, initiative which is community based, recovery oriented and at the same time very including the right to comprehensive sensitive about the general well-being and physical health of the service users. health care. Participation in decision- making and implementation of Their reports point to a high level of success and satisfaction of the service users programmes on mental health. and to “reversing the trend” in this regard and “Bringing hope to ”. The programmes are comprehensive. They include wellness, education, employment Families: Supporting and empowering and housing. Their meticulous concern about the physical health of the service the family members of people with users is reflected across many of their reports of activities and achievements. The schizophrenia “Health ” of their Sidney Baer Centre is a good example of responding to Communities and civil : this commonly ignored need. Empowering the people with schizophrenia, removing stigma and discrimination, respecting their rights, facilitating inclusion in economic and 29, 30 Box 2. The chain free initiative in Mogadishu social activities, as well as including The “chain free initiative” in Somalia is an example of scaling up a community socially and culturally appropriate oriented service model in a poor resource country. WHO/EMRO started this . Meeting the low cost programme in Mogadishu and then expanded to similar contexts. families’ physical, social and mental The programme includes three phases: Phase 1. (Chain-free ) includes health needs. Working with local agencies removing the chains, and reforming the into a patient friendly and to explore employment or educational humane place with minimum restraints. Phase 2. (Chain-free ) organizing opportunities, based on the person’s mobile teams and home visits, removing the chains, providing family psycho- needs and skill level. education, and training family members on a realistic, recovery-oriented approach. Health sector: Taking certain measures Phase 3. (Chain-free environments) removing the “invisible chains” of stigma such as downsizing and ultimately and restrictions affecting the human rights of persons with mental illness, and terminating institutionalization. respecting the right to universal access to all opportunities with and for persons Also providing high quality physical with mental illness, empowering and supporting the service users and ex-service services and regular monitoring for risk users by mobilizing communities to provide them with job opportunities and factors and side effects of treatments, shelter. The programme, which followed a results-based management approach, tackling unhealthy life styles, as well as improved the situation in the psychiatric ward, and increased the number of identifying and treating common chronic those receiving services through home visits and outpatient visits. More and more physical conditions among people with ex-patients are now living and working in a community that is now more aware schizophrenia. Adoption of smoking about the right of people with severe mental illness. The teams at the same time cessation strategies for and with service started to improve the service users’ and provided them with treatment of users and promoting smoke free service physical conditions including TB. environments. Coordinating with the service users as well as social, education, housing, employment and other sectors. schizophrenia. The global plan emphasizes psychosocial interventions in addition to Social sector: Empowering and that persons with mental disorders pharmacotherapy and in terms of a better supporting people with schizophrenia should be able to access, without the risk focus on the health of service users in to obtain education, employment and of impoverishing themselves, essential its totality. The revision of mhGAP-IG is housing as well as coordinating with health and that enable underway and the updated version will be health and other sectors. them to achieve recovery and the highest published in 2015. The updated version attainable standard of health. WHO will provide us with guidelines that can promotes global actions using guidelines further assure that harm is reduced to that are not only based on evidence but its minimum and benefits are maximized also observe the human rights of service in terms of a holistic approach to service users, which is why obtaining recovery has users’ health. been observed as one of the favourable The Quality Rights Project of WHO and outcomes of access to services.33 its checklist provides a good opportunity The Mental Health Gap Action for monitoring the quality of services Programme of WHO 34 and its for people with mental illness including Intervention Guide 35 are examples of schizophrenia36. WHO’s new approach in emphasizing

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