How mental illness puts you at risk of chronic disease

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Jenny Bowman: I see research as a tool, a very powerful if you like, potential weapon. We want to be able to tell health services how they could make a difference, not just be saying, “You know, you really should be doing this.” We need to say, “How could you do this?” Research, I see, as a very powerful means of change, that’s what my research is.

Gretchen Miller: Hello there. You’re listening to Prevention Works, the podcast of The Australian Prevention Partnership Centre. Today, mental illness and chronic disease. I was shocked to discover the difference in life expectancy between people with mental illness and those in generally good mental health.

Jenny Bowman: To hear patients say, “I’d quit and I’d actually been stopped smoking for two years,” or the family member or the carer or someone who says, “Yeah. My son had stopped smoking.” Then, their mental health symptoms worsened, they sought care, they became an inpatient for some period of time. They started smoking again.

Gretchen Miller: I’m Gretchen Miller. I’m at the University of Newcastle in New South Wales, with Jenny Bowman, who’s Professor in the School of Psychology. She specialises in health psychology which examines the impact of our mental health, on our physical wellbeing. How much lower is that life expectancy?

Jenny Bowman: In Australia, it’s something between about 12 and 15 years shorter life expectancy for people with mental health conditions. It does vary a little by the type of mental health condition someone has and how severe a condition that is. It is a noticeable difference, across the spectrum, for all types of diagnoses of mental health condition. In some parts of the world, the difference is larger. The research suggests can be as great as a 30 year difference in life expectancy in other parts of the world.

Gretchen Miller: Fifteen years. You know, that’s the difference between living to 80 and living to 65, or living to 90 and living to 75. I’m wondering therefore how you came to study this, and we’ll get in a minute to, of course, what on earth we can do to improve the situation.

Jenny Bowman: I guess, for me, the way I came into studying this was through one specific risk behaviour for chronic disease in the general population, and that was smoking. I had an interest already as a research in smoking and in how we could help people who remained smokers in the general population quit. As I started to look more into which particular groups in the community were most at risk for still being smokers, people with a mental health condition were there, front and centre. I had not realised that the smoking prevalence among people with mental health conditions was something like three times what it is among people without.

Gretchen Miller: Three times.

Jenny Bowman: That’s right. Very, very different. Whereas we’ve seen the prevalence among the general population increasingly dropping over time, there a very positive story in general around smoking, that has not happened for people with mental health conditions. Not in Australia, not in the US, not in the UK. Everywhere across many countries, this was clearly a really vulnerable, high risk group for smoking. Smoking remains one of the biggest risk factors for chronic disease, many chronic diseases. Smoking contributes to morbidity, mortality across the board.

My way into the area was through smoking. Then, of course, we realised looking at some of the other major risk factors for chronic disease as well, so things like, which are behavioural, nutrition, our use of alcohol, our levels of physical activity, it also became clear while there was less information, that people with mental health conditions were also more vulnerable and likely to be at high risk for those factors as well. It became clear that we needed to broaden our focus from smoking, to some of those other behaviours.

Gretchen Miller: That makes sense. I’m just wondering why. I mean, in the general population, and it’s really hammered home to kids, right from primary school, and has been for some time. Smoking is a real issue. Why is it that mental health makes you so attracted to something like smoking, when it is … It’s a lot less prevalent in the general population?

Jenny Bowman: That’s an excellent question. There’s unfortunately, absolutely no simple answer. We do know it’s a very complex interaction of lots of factors. Some of it may well be, something to do with a biological, kind of underlying cause, so that for some mental health conditions particularly, there are changes in brain neurotransmitters, etc, that make it more likely that someone may become dependent on nicotine, which is the addictive substance, of course in tobacco, cigarettes. There are also many other factors at play. We think there are psychological factors at play as well.

Someone with a mental health condition for instance may have lower self-esteem, higher levels of anxiety or stress at particular periods of their life that lead them to adopt smoking, and that also mean that it’s harder for those folk to stop. Very importantly for us and for my work as well, I think there are some environmental and some health system reasons as well, that actually make it more likely someone with a mental health condition may take up smoking, but also be much less able to quit, even though they would want to.

Gretchen Miller: I guess it’s partly about self-medicating too.

Jenny Bowman: There’s a self-medication hypothesis, and I think that does have something to do with it. I actually think, sometimes that we use that as a little, bit of a, I think as a reason to look no further. We’re saying, well, the individual chooses to do to this as a way of dealing with some of their mental health symptoms or problems.

In fact, I would think that there are probably other even more important determinants and influences and some of those environmental things in particular. If someone with a mental health condition wants to stop smoking, it is harder, because the whole social circle, the places that they live in, and sadly until recently even the healthcare facilities that they use, were actually more likely to encourage smoking, than discourage smoking.

Gretchen Miller: To say that a health facility might encourage you to smoke, what do you mean by that?

Jenny Bowman: That figure you started with, in terms of the difference in life expectancy is a very stunning fact, that really continues to inspire the research that we do. One of the other pieces of information that I came across very early, was that clinicians in mental health hospitals and facilities were telling us, as were patients and as were family members of patients, that patients could go into a mental health facility and to a hospital as non-smokers, and leave that facility as smokers. That completely dumbfounded me, in the sense that, not only were some health facilities sometimes not helping people’s health, but we were actually sending them home with probably the most significant health risk factor known. And they’d previously been free of that problem.

Gretchen Miller: How’s that happening?

Jenny Bowman: I hope it’s not happening anymore. Although, perhaps it is, but to a lesser degree. There was a rather unique kind of history and relationship I think between mental health care and smoking over the years and not just in Australia, but probably globally. Many people with mental health conditions smoke. In the past, quite a few mental health clinicians and staff in facilities also smoked, sometimes at higher rates than the rest of the community. Smoking became sometimes a bit of a clinical tool almost, so that patients and staff would sometimes smoke together to build rapport. Sometimes cigarettes were used almost as a reward system. Cigarettes were given out to reward good behaviour, taken away if there wasn’t good behaviour.

I’ve also seen some work in the past from other researchers, colleagues in the United States, who’ve looked into the role that actually tobacco companies played as well, in actually promoting the use of cigarettes to vulnerable groups like people with mental health conditions, and they were well aware that they were vulnerable populations of people in treatment facilities, etc, who were vulnerable to their messages as well. A complex history of the way smoking has kind of played a part in mental health care, that represented some of  the challenges to be overcome.

Gretchen Miller: That’s fascinating and strong stuff isn’t it. Confrontational stuff if you’re a researcher in this field.

Jenny Bowman: It is, and heartbreaking. To hear patients say, “I’d quit and I’d actually been stopped smoking for two years,” or the family member or the carer of someone who says, “Yeah, my son had stopped smoking,” then their mental health symptoms worsened, they sought care, they became an inpatient for some period of time, they started smoking again. That’s absolutely heartbreaking.

Gretchen Miller: You’ve just completed a four year study for the Prevention Centre on this. What was at the heart of that research?

Jenny Bowman: Okay. Our work really is premised on the fact that we think that healthcare services, or other settings, that are already in touch and providing care to people with mental health conditions, potentially represent a very good place to also provide people with some positive care, around some of those kind of lifestyle behaviours I guess. Things like smoking, diet, harmful use of alcohol, or not getting enough physical activity, or being sedentary.

Those are some of our key risk behaviours for chronic disease. Our work is really premised on saying, people with mental health conditions are already in touch with many kinds of health services and others services that provide them with care, but mostly care for their mental health conditions. There’s also the capacity that those services could be providing care for people’s physical health risk behaviours, those lifestyle behaviours as well.

Gretchen Miller: That’s really interesting. You know, I mean, we all kind of know, as just ordinary people in the world, that physical and mental health are connected. It appears that those two things are treated very separately by our health system.

Jenny Bowman:  It’s an acknowledged, very significant problem that there tends to be a siloed approach to treating mental health and physical problems. Many people have argued very strongly, that there needs to be greater integration and various models for integration have been tried.

For instance, saying that perhaps GPs could do more work around people’s mental health and wellbeing, mental health clinicians could also do some work as well around the physical. There’s an acknowledgement that we’re holistic beings and mental and physical health very much interact together. And yet, when people enter a healthcare service, or a system, we tend to treat just one or the other, rather than being able to do a combination.

Gretchen Miller: What did your study look at?

Jenny Bowman: We worked with a community mental health service. We wanted to look at the effect of making it one clinician’s dedicated role within that service, to be providing some brief care for people around their smoking, nutrition, etc. What we looked at with the Prevention Centre’s assistance, was offering an appointment with that specialist clinician to patients coming into the service, where the clinician would have a conversation with them, and if, for instance, they were a smoker and wanted to address their smoking, or if they were someone who were, perhaps, consuming inadequate fruit and veggies in their diet, then trying to help that person link in with existing services that could help them. Quitline, get healthy coaching services that NSW Health provides. It was an opportunity to assess people for those risk behaviours, provide them with brief advice and motivation perhaps, to think that yes, I could make an attempt to change this, and then to link them in with some services that could help them do that.

Gretchen Miller: What outcomes did you find from providing this? Was it a one-off appointment, or a series of appointments?

Jenny Bowman: We trialled a one-off appointment with a telephone follow-up phone call a couple of weeks later, to see if the patient had been able to make some progress, or needed some more support to do that. It was a one-off appointment essentially. The key outcome for us was really connecting people with those follow-up services. What we actually found was very positive, so that a significant number of mental health clients were receptive to the idea of this appointment.

Those people that we offered it to, most of them came along and attended an appointment and most people took up a referral to one of those services when offered. It actually reinforced what some of our earlier work had shown, that people with a mental health condition and clients in a community mental health service are actually wanting some help to change their behaviours and will actually take up offers of help, when it’s provided to them.

Gretchen Miller: That means most people want to change. Do you have statistics around that, what proportion of people want to change, and was that something that you are the first to measure, or is that already replicated in other studies that people do want to shift their behaviour?

Jenny Bowman:  I don’t think we’re the first to measure, but we are one of the first to measure it. There’s still been actually quite little research in the area. In the general population, we actually know that most people who are current smokers, want to change. People are not kind of saying, “I’m happy being a smoker. I don’t ever want to be a non-smoker.” It’s very similar. The proportion’s the same for people with a metal health condition. It’s something like 80 per cent of people would say, “Yes. I’d like to stop, and I’ve tried to stop.”

Gretchen Miller: I’m not sure how long ago you finished that study. Have you had the opportunity to measure, say, six months down the track whether the intervention had stuck, so to speak?

Jenny Bowman: That’s actually what we’re still doing now. We are just finalising our final six month kind of data collection and analysing that data now. There’s another study that we did earlier, a different study, but also looking at people’s smoking. That was when they were discharged from hospital, and then going home, and we offered those folks some support to quit smoking in the form of some telephone calls, to motivate etc, and also some nicotine replacement therapy.

In that particular study, we absolutely made a difference in the short term and the longer term, in terms of people’s attempting to quit, but in the longer term, still proved difficult to actually show a difference in actual quit rates and cessation rates. I think what we found was what others had found, that, in fact, people need perhaps more intensive help and longer kind of support.

Gretchen Miller: That leads us really to your next study, which is also for the Prevention Centre, which you’re just starting. What are you doing there?

Jenny Bowman: We are leaving the land of mental health services per se. We’ve worked in the government-funded health service setting. We’re going into community managed organisations, or non-government organisations I think they’ve been known more commonly in the past. These are organisations that provide a variety of care to people in the community who need support, so they may be people of low socio-economic status, people with a mental health condition, people living with some kind of a disability.

CMOs are playing an increasingly important role, in providing support to folk, and particularly providing support to people with mental health conditions. Again, we think there’s real opportunity here to broaden the kind of remit of those agencies to include more physical health in there as well. Some of them are already doing that. Some are not.

Gretchen Miller: Are we talking, when you say CMOs are we talking things like, the Smith Family, or Salvation Army, that kind of thing?

Jenny Bowman: Absolutely, those kinds of organisations, yes. The point of our new project with the Partnership Centre is really to work with all those organisations, find out what they’re currently already doing, work out together, with them, how they could do more in this space, and what they would need to help them do that.

Our work has been able to really build on the policies that exist. If they weren’t there as the groundwork, if we didn’t know that there were policies already in place, and what we were doing was helping to make those policies feasible and actually doable for clinicians in their everyday work, then we would have a much harder job.

Gretchen Miller: I’d like to kind of dive in a bit deeper now, into some of the detail of the picture we’re looking at here. I’d like to clarify first of all, what level of mental health issues we’re looking at. Are we talking about in-patient psychiatric, or are we talking about major depression, or anxiety, where you are the still essentially functional in the world. You’ve got a job, you’ve got a family, etc. What level of mental illness are we talking about, that will severely impact your life expectancy here?

Jenny Bowman: That’s a difficult question to answer, but a good question. We do know that it’s not confined to some of what are labelled traditionally the more severe mental health diagnoses. Schizophrenia, for instance, or as you’ve said, major depression or something like bipolar disorder. The evidence says that people with those kind of conditions are more impacted, their physical health is more likely to be really severely impacted.

The evidence also says really that, across the board, physical health, for people with any mental health condition, is likely to be poorer than for people without. It’s not confined to any particular end of the spectrum in terms of severity or any particular kind of diagnosis. Probably just more marked for some of those more acute or severe kind of diagnoses. Really, it’s an issue across the board for everybody.

Gretchen Miller: You’re with Prevention Works, from The Australian Prevention Partnership Centre. I’m Gretchen Miller, talking with Jenny Bowman. Now, most of us want to be more healthy. It’s not as easy as just wanting, as we know. Why do we struggle?

Jenny Bowman: Another really good question. I guess that’s one of the key questions that occupies the health psychology area generally. It is absolutely not enough to be motivated to change, to have the knowledge and the attitudes that might help you want to change. That’s not enough, it’s not enough to have the intent. A lot of our work is actually looking at, well ,what really then pushes people to action and what supports people in taking action? There are a lot of theories around that. They suggest that it’s a matter of some individual factors. Sometimes it is,  there’s a cue to action.

It might be for instance, that my neighbour over the fence tells me that they’ve just actually changed their diet, they’re feeling much better, or that they’ve actually stopped smoking for the first time in you know, 10 years. That kind of cue to action can sometimes be important for us, as individuals. Often times, there are external factors and again, I kind of come back to the environmental factors that are very important. In lecture classes, I often talk to my students and say, “Give some examples and say, I’d really like to ride my bike to Uni everyday. I’d like to do it. I feel like I should do it.

The thing that stops me, is that there aren’t good bike paths. I worry about riding on the road. I feel unsafe so I’m not going to do it. A fairly simple kind of environmental change there would make the world of difference to me engaging in that behaviour.” For many of us, I believe there are things, not just at an individual level, it’s not just individual motivation. You also need to be equipped with the means then to change, and be supported to do it.

What I need to know is, for instance, around smoking … What I need to know is, that the Quitline for instance exists, that there are people there I can talk to, who will help me tailor a quit program. I’ve never tried nicotine replacement therapy before. I don’t know how that works. I didn’t know I could get it for free, or at subsidised rates. When I’m informed and when I’m supported by the environment, I’m actually more likely to be able to make that decision and actually take the step towards action.

Gretchen Miller: When you’re mentally unwell, you’re really quite vulnerable to stress and pressure …

Jenny Bowman: Sure.

Gretchen Miller: … and alcohol and cigarettes particularly help mitigate that in the short term. Good eating, is a motivational thing, isn’t it?

Jenny Bowman: Absolutely. If life seems very difficult and you are trying to contend with a lot of things at that time, it might be that thinking about and planning ahead, doing some meal planning, getting to the shops and buying what you need to make a meal, etc, is just a little bit beyond you at that time.

Gretchen Miller: Now, of course, there’s a wider impact of all of this. That is the carers, the individual family members who often pick up the slack. Can you talk about their role in, say, helping somebody improve their lifestyle choices, or the pressure in fact that’s on carers to do everything. This may well be one more thing.

Jenny Bowman: Okay. Carers are certainly a very important part of the network of care for people with a mental health condition. That’s really well acknowledged. They are … I’m not sure they pick up the slack, or if they’re actually the main underpinnings of, in fact quite often the mental health care that happens in the community. They are absolutely trying to help people every day with not only their mental health symptoms, and managing their mental health, but absolutely, their physical health. They are often engaged in trying to encourage positive behaviour change.

Carers will often say for instance, “I’m very conscious. I try, and cook good healthy meals. I try and go for a walk with the person that I care for.” But they are in a very, very difficult position. They’ve got a lot on their plates already. It’s one more factor that they feel, I guess, they take on as a responsibility, but aren’t always feeling well equipped to do that. Sometimes carers are placed in a difficult position around behaviours like smoking, for instance, where they’d like to be encouraging the person they care for not to smoke, but they will often find themselves being the purchaser of cigarettes and the provider of cigarettes, say for their son, who is smoking at the moment.

I guess what our work has shown is that they are already trying to be engaged in helping people reduce those risk behaviours, but would like certainly themselves some more support to be doing that, and to be working more closely with mental health clinicians and services to do it in a more organised kind of fashion.

Gretchen Miller: You’ve worked extensively in … You’re currently an academic at university,  but you have had a wealth of research in the so-called real world. For example, you’ve managed drug and alcohol services. Not easy. You’re particularly solutions focused, this means.

Jenny Bowman: Yes. I am absolutely solutions focused. I guess my background experience – in some other roles in the past, in drug and alcohol services in a management role there – really helped give me a good consumer focused, focus I think, to my research. Seeing people, seeing carers, struggling kind of with those issues, and wanting support, and I could see that research was actually one way to provide that support.

Much as we absolutely need good clinicians, we need health psychologists, at that clinical end of the spectrum, I see research as a tool, a very powerful, if you like, potential weapon. We wanted to dispel some of the myths around these things. We wanted to be able to tell health services how they could make a difference, not just be saying, “You know, you really should be doing this.” We needed to say, “How could you do this?” Research, I see, as a very powerful means of change, that’s what my research is.

Gretchen Miller: Professor Jenny Bowman. Thank you so much for your time. It’s been fascinating.

Jenny Bowman: Thanks Gretchen. It’s been a pleasure to talk to you. You’re very welcome.

Gretchen Miller: Professor Jenny Bowman there with me, Gretchen Miller, and Prevention Works, the podcast of The Australian Prevention Partnership Centre. For a transcript, just head to our webpage and you’ll find plenty more of Australia’s top health experts there, talking chronic disease and how they’re fighting against it. See you next time.


Host: Gretchen Miller

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