Temelkova-Kurktschiev T, Stefanov T. Lifestyle and genetics in obesity and type 2 diabetes. Exp Clin Endocrinol Diabetes 2012; 120: 1–6. Molyneaux L, Constantino M, Yue D. Strong family history predicts a younger age of onset for subjects diagnosed with type 2 diabetes. Diabetes Obes Metab 2004; 6: 187–94. Tuomi T, Santoro N, Caprio S, Cai M, Weng J, Groop L. The many faces of diabetes: a disease with increasing heterogeneity. Lancet 2014; 383: 1084–94. Hasnain M, Vieweg WV, Hollett B. Weight gain and glucose dysregulation with second-generation antipsychotics and antidepressants: a review for primary care physicians. Postgrad Med 2012; 124: 154–67.
Maayan L, Correll CU. Weight gain and metabolic risks associated with antipsychotic medications in children and adolescents. J Child Adolesc Psychopharmacol 2011; 21: 517–35. Starrenburg FC, Bogers JP. How can antipsychotics cause diabetes mellitus? Insights based on receptor-binding proﬁles, humoral factors and transporter proteins. Eur Psychiatry 2009; 24: 164–70. Henderson DC, Vincenzi B, Andrea NV, Ulloa M, Copeland PM. Pathophysiological mechanisms of increased cardiometabolic risk in people with schizophrenia and other severe mental illnesses. Lancet Psychiatry 2015; 2: 452–64.
Parity begins at home Stigma goes hand in hand with mental illness. I have encountered it often over the years of living with a chronic depressive illness. At my ﬁrst committee meeting as a patient representative with a group of psychiatrists, I experienced a highbrow form of stigma. I had prepared thoroughly for the meeting and contributed to the discussions during the morning. After lunch, the psychiatrist sitting beside me turned and said in a patronising tone, ”You are very well read!” I suspected the unspoken end of the sentence was: “for a patient”. Language is a key tool in psychiatry; its capacity to have a negative or positive impact on lives should not be minimised. The quality of communication in oral and written form can facilitate respect, dignity, empathy, trust, and co-production, enabling an eﬀective collaborative relationship between the patient and the psychiatrist. Why is the phrase “a mental health problem” the one frequently chosen when referring to mental illness and mental health issues? We do not refer to physical illnesses and disorders in this way. ”I have Crohn’s disease” not ”I have a Crohn’s problem”; ”I have ovarian cancer” not ”I have a cancer problem”; ”I have a diabetes” not ”I have a diabetic problem”. In mental illness, people suﬀer a speciﬁc illness; they have lived with the experience of mental and emotional distress. They deal with mental health conditions, disabilities, and disorders. We are not people or patients with “a mental health problem”.1 This terminology needs to change if parity is to be achieved within the language used in health care. Parity involves partnership and co-production between the psychiatrist and the patient, a shared ethos and a shift in balance and perspective—ie, doing with, not doing to.2 It requires more commitment from the patient to own and be responsible for their part in the journey towards recovery from illness and building resilience. The www.thelancet.com/psychiatry Vol 2 December 2015
psychiatrist is an expert with knowledge and training, the patient is an expert by experience. The continuing advances in molecular biology and neuroscience will enhance understanding and allow for the development of new treatments.3 Evidence-based psychological and social interventions are also important treatment options and should be available for each patient, resulting in a more sustained recovery outcome. A robust professional identity enables doctors to take responsibility and leadership in psychiatry as a medical speciality and as an equal player in the spectrum of medical specialities. This boosts conﬁdence and could improve the recruitment and retention of doctors who choose psychiatry as their specialism.4 Recruitment, training, and retention are key lifelines in psychiatry; they need to be ﬁt for purpose. This includes a selection process based on character and attitude as well as grades. Requirements should include interpersonal qualities such as empathy and positivity, valuing collaborative working within a holistic model of care, and good communication skills. Experience of a quality psychiatric placement in the foundation years of training is necessary; often placements have only occurred in the last 2 years of medical school. It is also important that doctors in all specialities have more training in caring for patients with mental health disorders.5 The current developments in psychological medicine and working within multidisciplinary teams are evidencing consistency of care, sustainable outcomes, and parity at work.6 Delivering parity for mental health in the wider healthcare landscape involves: reducing stigma within the National Health Service; putting training, funding, and commissioning on a par with physical health services; addressing both the physical and mental health needs of patients; equal access to crisis care and waiting times for 1051
treatment; investment in research; and the Government putting in place policies that realise their promise of parity of esteem. The contribution that psychiatrists make to the health of the nation is often underestimated and undervalued. Kamaldeep Bhui comments “the profession of psychiatry requires the brightest and the best, the most ethical and the most progressive to continue a journey towards the most humane and hopeful ways to recovery, while also helping the wider population to better understand the mind and how to look after ourselves, our families and our communities”.7 Psychiatry demands exceptional doctors.8 The NHS will be faced increasingly with choices that will aﬀect its sustainability. This will bring challenges, opportunities, potential, ownership, and responsibilities. What is our engagement and commitment in this process of moving towards achieving parity, in which mental health is valued and resourced equally with physical health? Do we need to refresh our vision?
Veryan Richards Royal College of Psychiatrists’ Service Users and Carers Fora, Royal College of Psychiatrists, London E1 8BB, UK [email protected]
I declare no competing interests. 1 2 3
5 6 7 8
Richards V. Respect and dignity through the use of language. Mental Health Today (Hove); 2013, July/August: 7. Public Health Wales,. Achieving prudent healthcare in NHS Wales. Cardiﬀ: Public Health Wales, 2014. Cooper D, Limet N, McClung I, Lawrie SM. Towards clinically useful neuroimaging in psychiatric practice. Br J Psychiatry 2013; 203: 242–44. Curtis-Barton MT, Eagles JM. Factors that discourage medical students from pursuing a career in psychiatry. The Psychiatrist 2011; 35: 425–29. Greenaway D.Securing the future of excellent patient care. London: Shape of Training (GMC), 2013. Sharpe M. Psychological medicine and the future of psychiatry. Br J Psychiatry 2014; 204: 91–92. Bhui K. From the Editor’s desk. Translational research in psychiatry Br J Psychiatry 2014; 205: 421–22. The Lancet. Bipolar disorder: at the extremes. Lancet, 2013; 381: 1597.
Mental health and wellbeing in the Sustainable Development Goals
Li Muzi/Xinhua Press/Corbis
Sustainable development cannot be achieved without the inclusion of mental health as a key global priority.1,2 Until recently the international community had not mobilised the necessary attention, eﬀorts, and resources for people with mental illness and disability, despite the knowledge that the economic cost of mental disorders is more than 4% of GDP worldwide,3 depression is a leading cause of disability,4 and more than 800 000 deaths by suicide occur every year,5 many of which are preventable. 2015 is historic because two UN global frameworks have included mental health and wellbeing and disability: the UN Sendai Framework for Disaster Risk Reduction 2015–306 and the 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs).7 The 2030 Agenda for Sustainable Development and SDGs7 were adopted at the 70th Session of the UN General Assembly on Sept 25–27, 2015. The 2030 Agenda and the SDGs build on the lessons learned and the gaps identiﬁed in implementation of the Millennium Development Goals (MDGs), as well as identifying newly emerging development challenges. Whereas the Millennium Declaration and MDGs did not make reference to mental 1052
health and disability in any of the goals, targets, and indicators, the Agenda and the SDGs have included mental health and disability in several paragraphs. The vision of the 2030 Agenda is of “…a world with equitable and universal access to quality education at all levels, to health care and social protection, where physical, mental and social wellbeing are assured.” Under the Goal 3 (“ensure healthy lives and promote wellbeing for all at all ages”), target 3.4 is to “reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and wellbeing”, and target 3.5 is to “strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol”. Furthermore, Goals 4, 8, 10, and 11 include speciﬁc references to inclusion of people with disabilities, essential for protection and promotion of the rights of people with mental, intellectual, and psychosocial disabilities who have been among the most ostracised. The diplomatic, technical, and practical importance of the SDGs is that the goals will guide global, regional, and national eﬀorts over the next 15 years in both www.thelancet.com/psychiatry Vol 2 December 2015