April 2004
Occasional Paper No. 5
‘Our Physical Health…Who Cares?’
by Alex Handiside, Analyst (Service User Projects)
Mental Health Commission
One of the objectives of the National Health Strategy is to “improve the health status of people with
severe mental illness”.1 This objective identifies an inequality in health status and a need for
improvement. Lee et al’s study of the physical health of Dunedin service users concluded that the
“physical health needs in the [serious mental illness] community are not being met”.2
This paper is intended to provoke and inform debate rather than define a policy position. Mental
health service users and alcohol and other drug (AOD) service users are included together unless
otherwise specified. Differences between inpatient and community populations are specified.
International research suggests service users die at 2.5 to 4.3 times the rate of the general
population,3 even when suicide has been factored out. Male service users can expect to live 14
years less than the general male population. Female service users can expect to live almost 6 years
less than the general female population.4 These rates stretch across ethnicity, diagnosis, nationality
and gender.5 It is useful to compare these life expectancy figures with those of other subpopulations
in New Zealand. For example, a Māori male can expect to live to 65 years of age, a male Pākehā to
75.7 years of age,6 and a male service user to 61.7 years of age.7
There is no longer debate that service users have poorer physical health than the general
population.8 Harris and Barraclough reference 152 published articles that support this notion.9 In
fact, 13 years earlier, Tsuang had posed the question, “Do we need any more studies?”10
This paper examines selected literature and attempts to answer the following questions:



In what areas do service users have worse mortality (death) and morbidity (disease) rates
than the general population?
Why are service users more physically unwell and dying younger than the general
population?
What are possible solutions to these problems?
1. THE FACTS
Lawrence et al, and Singh and Cohen (an Australian and a British study respectively) identified a
myriad of areas where service users have worse physical health than the general population. 11
These key areas are:



Heart disease deaths: Service users have a death rate 2.2 times that of the general
population.12
Cancer (all sites) deaths: Service users have a death rate 1.5 times that of the general
population.13
Influenza deaths: Service users have a death rate 5 times that of the general population.14


Diabetes deaths: Service users have a death rate 3 times that of the general population.15
Respiratory illness deaths: Service users have a death rate 2.8 to 4 times that of the general
population.16
Service user morbidity rates are also higher than the rates in the general population. Singh and
Cohen state that 45 percent of service users have a concurrent physical illness, and that those
illnesses are mainly cardiovascular, respiratory, diabetes and medicine related.17
2. WHY ARE SERVICE USERS SICKER AND DYING YOUNGER?
There are several possible reasons why service users are sicker and dying younger than the general
population:
A. exposure to risk factors
B. the lack of a clear, national statement of responsibilities for service users’ physical health care
C. discrimination
D. iatrogenic illness (harm caused by medical intervention.)
A. Exposure to risk factors
For the purposes of this paper a risk factor is considered a behaviour or an exposure to behaviours
or environments that may cause harm. The key risk factors discussed in this paper are poverty and
smoking.
Poverty
“Mental disorders [sic] are over represented in the lower social strata,”18 often due to the labour
market discrimination experienced by service users, truncated education, and truncated career paths.
The relationship between cost and access to health care services is well documented and needs no
explaining here. (Most mental health shared care pilots in New Zealand operate to lessen this barrier
for mental health services in primary care.19 New Zealand’s primary care funding formula also allows
for lower co payments from disadvantaged groups.)
The relationship between poverty and physical illness is also well documented. Poverty too often
means a lack of access to services, poor quality housing, unintentional injury, addiction, and poor
nutrition. However, it would be naïve to believe all service users’ physical ill health is caused by
poverty.
First, some of us are not poor. Miech et al discovered that “different mental health problems are
differently related to social status”.20 In addition, the effects of iatrogenic illness, discrimination and a
lack of systemic responsibility, as will be discussed, indicate the cause of physical ill health in service
users is not as simple as poverty alone.
Smoking
Smoking is a significant risk factor for service users. It contributes to the “big three” of heart disease,
cancer and respiratory disease. Service users smoke far more than the general population and
across most diagnoses.21 Smoking is also related to deprivation or low socioeconomic status.
However, McNeill has stated that smoking is associated with mental illness even after controlling for
socio-demographic factors.22 It appears that the inpatient environment, both past and current, may
be a contributing factor to high levels of service user smoking. As the author is aware, “If you weren’t
a smoker when you went in [to hospital], you were when you came out”.23
2
In New Zealand’s inpatient past, service users were rewarded or “paid” with a daily quota of
cigarettes.
Cigarettes are used as prizes during organised games in some supported
accommodation. In the current inpatient environment, the room that is warmest and friendliest, a
gathering point, is the smoking room, a fact that helps foster addiction.
Nicotine’s purported self-medicating aspects (particularly for those with schizophrenia and
depression) are still being debated. McNeill considers research in this area is still exploratory.24
Lawn et al’s major qualitative study of service users and smoking offers some useful perspectives:25
“The main barriers to their [subjects] quitting were existential, ie, to do with their sense of despair,
their lack of hope for a recovery … Causes and consequences must be interpreted through
multiple lenses.”
B. Lack of clear responsibility for service users’ physical health care
Responsibility for service users’ physical health care is not clearly defined between primary care
services, community mental health teams, community AOD services and inpatient facilities.
The literature is generally in agreement that clarifying the roles and responsibilities of health care
professionals is important. Clear responsibilities are considered important to avoid gaps in access
and service provision and to improve and monitor the quality of service provision. Brown et al
states, “responsibility for medical treatment should be explicitly allocated”.26 Pritchard and Hughes
states that shared understanding of responsibilities is “far and away the most important factor”27.
Bathgate et al, a New Zealand study, states the importance of the interrelationship between physical
and mental health, and places general practitioners (GPs) and primary care services in the position
of key responsibility. The study goes on to suggest that, amongst other things, shortcomings in
primary care are caused by a lack of a clear relationship between GPs and community mental health
teams.28
It probably fair to say that New Zealand mental health policy, in general, is playing a “catch up” game
in primary care; for example the mental health guidelines for primary health organisations have not
yet been written. In addition, only three words relating to mental health (let alone the physical health
needs of mental health service users) appear in Establishment Service Specifications for Essential
Primary Health Care Services Provided by Primary Health Organisations.29. The result is a lack of
clear responsibilities. As was discovered in Otago, this confusion contributes to the poor physical
health status for service users.30
It is important to note that a few District Health Boards (DHBs) have stated their intentions to improve
the physical health status of their service user populations. Counties Manukau DHB, for example,
aims to have 99 percent of people with significant mental illness engaged with appropriate primary
care or specialist services by 2005.31 In addition, Otago DHB’s GP Link programme specifically
targets the physical health of service users, as does Wellington’s Newtown Union Health Centre.
The Union Health Centre, for example, runs yearly full physical exams of the service users in its
population, including lipid function.
In New Zealand, responsibilities for the physical health needs of AOD consumers are more explicitly
stated, perhaps because of a longer acknowledgement of the causal relationship between types of
AOD use and physical ill health. Of note is the Ministry of Health AOD DHB toolkit, which stresses
the importance of intersectoral collaboration between primary care and specialist services.32 Another
Ministry publication, Guidelines for Recognising, Assessing, and Treating Alcohol and Cannabis
Abuse in Primary Care, states the physical health needs of AOD consumers that can, and should be,
3
met in primary care.33 This is reiterated in the Ministry’s Opiod Substitution Treatment New Zealand
Practice Guidelines.34
C. Discrimination: “Plainly speaking, the patients are unattractive”35
In 2001 in the United Kingdom, the British Medical Association, the Royal College of Physicians and
the Royal College of Psychiatrists combined to examine mental health discrimination within the
medical profession. They found that “research to date suggests that doctors at large share the
public’s overall stereotypical images of people with mental illness”.36 Discrimination by medical
professionals affects service users’ level of and access to care:
“I went to my GP with a breast lump – he said ‘come back if it gets bigger’ I insisted on a referral
to a breast specialist. My GP sent a referral stating ‘over anxious patient, had nervous
breakdown at 16 yrs’ (20 years ago!) Consequently I was greeted by the specialist with ‘You’re a
bit of a worrier aren’t you?’ Because of this reference in my hospital notes when I became
seriously ill with a lung clot they dismissed me as a hypochondriac for weeks until I became very
sick.”37 (Service user)
This quotation is not to suggest that all doctors practice in a discriminatory fashion. However, in an
audit of his own practice, Tony Kendrick, a leading GP researcher in this area, discovered a lack of
effort by doctors to deal with physical ailments in mental health service users.38 Further studies
indicate that service users are not offered blood pressure, cholesterol, urine and weight checks or
health promotion at the same frequency as the general population.39
“They don’t really care if you smoke, just as long as you take your medication.”40 (Service user)
Curiously, Davidson et al, in an Australian study, found that mental health service users visited the
GP at least as often as the general population, but their risks for serious physical disease were still
much higher.41 This prompted the question: “Are people with mental illness receiving the same
services as other people when they visit a health professional?”42 The study went on to suggest that
physicians favour those who have more chance of making lifestyle changes and ignore those most at
risk.43 Lee et al’s Dunedin study also found high GP use, “but [service users] still have poorer
physical health, again suggesting that their health needs are not being met”.44
It follows that a recurring issue in qualitative research has been service users’ perception that doctors
do not take them seriously, “that physical symptoms are wrongly believed to be figments of our
imagination”.45 Friedli and Dardis identified that a “key issue is the perceived attitudes and
awareness of primary care staff”.46
(In this context it is interesting to note that service users are revascularised  less and suffer more
medical misadventure than the rest of the population.47)
D. Iatrogenic illness (harm caused by medical intervention)
Most mental health pharmaceuticals have side effects. Some are life threatening and sudden; others
more minor. It is beyond the scope of this paper to list the contraindicators and side effects of all
mental health pharmaceuticals. However, central to the discussion of iatrogenic illness is the
relationship between medications and obesity ― obesity being a key risk factor for heart disease,
hypertension and diabetes.
Wallace and Tennant discovered that 71 percent of their sample were overweight or obese, a
percentage that “is likely to become worse”.48 (52 percent of the general New Zealand population are
4
obese or overweight.49) They go on to say “neuroleptic and psychotropic drugs play a significant role
in the undesirable weight gain in the mental health population”.50
Davidson et al state that as more people are prescribed newer atypical anti-psychotics weight gain
may increase, as weight gain with some atypical medication has been significant.51 Research
examining the relationship between newer atypical anti-psychotics and diabetes indicates that
irrespective of obesity, drug-related chemical reactions may disturb glucose levels.52 Edgar has
stated “Over 2% of the general New Zealand population may be exposed to this [atypical] risk factor.
The role of anti-psychotic medications in Type II diabetes in general, or for Maori psychiatric patients
[sic] has not been investigated in New Zealand.”53
The interrelationship between iatrogenic obesity and mental health provides a clear example of the
interwoven nature of mental and physical health:
“Carl is worried about weight and is on a permanent diet. At Christmas we took lots of pictures. I
took them in to show him. He didn’t want see them. He said “Mum, I used to be good
looking…look at me now”.54
In addition to obesity, tardive dyskinesia (TD) must be mentioned in any discussion of physical
iatragenic illness.55 Large doses of older anti-psychotics, such as Haloperidol, and related
permanent paralysis are comparatively rare in today’s clinical environment. However, temporary TD
related to medications remains common, including symptoms of jaw lock, twitching and restricted
movement. The negative effects TD has on a person’s ability to initiate recovery cannot be
underestimated — this again indicates the interwoven relationship of mental and physical health.
The dental health of mental health service users is also of concern. An article in the Journal of the
Canadian Dental Association documents the possible effects of mental health medication on dental
health.56 Oral side effects included xerostomia (dry mouth) decay, candida, or perelech (fissures).
(Although not considered a directly physical illness, addiction to prescription medications particularly
benzodiazapine and possibly some serotonin re-uptake inhibiting medications, needs mention in light
of indirect physical illness such as weight loss, sleeplessness and lowered immunity.)
3. ALCOHOL AND OTHER DRUG (AOD) CONSUMERS
AOD consumers, in addition to the experiences mentioned above, have a distinct context for poor
physical health. Within the spectrum of AOD consumers there are again many specific physical
health needs. One example is the physical health needs of members of the intravenous (IV) drug
community.
New Zealand’s needle exchanges are a mechanism to minimise physical disease for AOD
consumers. As the New Zealand Health Strategy notes: “Of particular concern is the risk to public
health from the transmission of blood-borne viruses through the sharing of needles and syringes.57
Paradoxically, however, under current legislation, clean or used needles being stored or transported
for exchange can be used as a legal means by which the police can search homes and people. This
threat of criminality provides a perverse incentive to recycle needles. It is estimated that 70 percent
of New Zealand’s IV drug users have Hepatitis C.58 It has been claimed that the health care cost of
one New Zealander with HIV/AIDS will pay for the needle exchange network for one year.59
The Boston School of Public Health national survey affirmed that AOD consumers experienced
discrimination in access and quality of appropriate health care.60 The Royal College of Psychiatrists,
in their Changing Minds discrimination campaign, identified that services can and do discriminate
against AOD consumers.61 (For example, in New Zealand, anecdotal evidence suggests some
5
pharmacists can be reluctant participants in opiod substitution programmes, based on discriminatory
attitudes to AOD consumers).
It is noted that in the Ministry of Health’s Opiod Substitution Treatment New Zealand Practice
Guidelines, pharmacists and GPs are expected to provide certain levels of physical health care.
4. A NOTE OF CAUTION…
An analysis of risk factors in population groups needs to be read with care. Decades of Disparity (an
investigation of ethnic inequalities in physical health status) was used by some people to promote the
view that Māori and Pacific peoples were to blame for their own poor health,62 a “blaming the victim”
view. A similar interpretation is also possible of this paper. The authors of Decades of Disparity
published a rejoinder article in the Dominion Post to correct the more naïve interpretations of their
work. The article included this metaphor:63
“Third class passengers on the Titanic were twice as likely to die as first-class passengers. Were
poor people so stupid that they forgot to pack their wetsuits? Or were the parents of the people
on the Titanic so neglectful that they failed to teach their children to swim? Obviously, these are
ridiculous explanations. The reasons were structural. There were only enough life jackets for the
first class passengers, and the poor were locked in — preventing them using lifeboats.”
However, an individual’s personal responsibility for their own health must be acknowledged in any
discussion of clinical and structural responsibilities. How much responsibility for physical health care
can be expected of services? How much of physical health care is an individual responsibility? The
answer is not simple. An individual must have the ability to improve their physical health: This ability
needs:




a person’s ability to access appropriate services and promotion
physicians and services who are aware of their role in improving and maintaining a person’s
good physical health
physicians who are aware of the dangers of iatrogenic illnesses
no inadvertent discrimination from physicians and services.
5. SOLUTIONS FOR NEW ZEALAND/AOTEAROA
Facing up
In New Zealand, the issue of service users’ and AOD consumers’ physical health appears not to
have registered with most policy-makers or researchers, despite improving service users’ physical
health being an objective in the New Zealand Health Strategy.64 The theme the 2004 World Mental
Health Day is “The Relationship between Physical and Mental Health”.
Acknowledgement
There are District Health Boards and services trying to improve the physical health of service users.
They need to be supported, celebrated and discussed.
Identify responsibilities
The mental health sector, the AOD sector and the primary care sector must assign and clarify
responsibility for service users’ physical health. An opportunity to address this lies with the PHO
Service Development Guidelines for Mental Health being prepared for the Ministry of Health.
In the United Kingdom, the National Service Framework for Mental Health makes explicit
recommendations that the responsibility for monitoring and managing the physical health of those
6
with “severe [sic] mental illness” lies with primary care services.65 As a result, 90 percent of British
GPs accept responsibility for the physical health care of service users.66 In addition, the Mental
Health Policy Implementation Guide for Community Mental Health Teams explicitly states the
physical health services that community mental health teams are to provide. 67 For example, all
community mental health teams are expected to have “every patient” registered with a GP.68 (It
should be noted the “fully funded” primary care sector in the United Kingdom is different to New
Zealand’s, and that the strategies mentioned above are in addition to fully funded access.)
In addition, recent Australian research calls for “the Royal Australian and New Zealand College of
Psychiatrists to consider producing a statement on practice regarding attending to the physical health
of people with chronic [sic] mental illness”.69
Resource
If the primary care sector is expected to be the location for the improvement in physical health status,
then that sector’s organisations must be given the resources they need to do so. Lee et al
recommend, “There is potential [in New Zealand] for improvement through adequately funded
primary health care designed specifically to meet the needs of this group”.70 The United Kingdom
primary care sector was allocated bonuses for screening and testing service users. Service users
have glucose tests, blood pressure checks and free influenza vaccinations. Physical Health of the
Severe and Enduring Mentally Ill: a training pack for GP educators71 and software for linking records
is freely available to aid links with secondary and tertiary care. These examples should be carefully
considered for use in New Zealand. Given the rates of influenza deaths are five times the general
population, free flu injections should be considered for the service user population.
High co-payments function as an access barrier for some service users. The funding formula for
disadvantaged groups in primary care needs to include those people with experience of mental
illness. As has been shown, service users people are suffering even worse physical health than
other eligible groups.
Research
Research on the physical health of New Zealand service users is needed. Australia and the United
Kingdom, in particular, have invested resources to find local evidence from which to develop and
fine-tune policy and practice. In New Zealand there is a lack of data, with Lee et al and Fergusen et
al the only studies available.72 (It should be noted, however, that the large mental health in primary
care MAGPIE study intends to include the physical health of service users in their study.) In
particular, research around service users’ relationship with primary care and issues of discrimination
is needed.
Provider ‘self reflection’
Most individuals working in primary care or mental health are aware of the possibilities of their own
discriminatory behaviour. If providers are to achieve the outcomes they are seeking, pausing to
examine the motivators of their clinical practice may reveal the opportunity to eliminate unconsidered
discriminatory practice.
Different solutions for different people
Different solutions will be needed for different subpopulations of mental health service users and
AOD consumers. For example, solutions taking into account the difference between the Western
medical model and the Māori Whare Tapa Wha model.
Compare Ferguson’s statement, “The notional division of mind and body runs like a fault line through
our medical training and through our entire Western world view” 73 with Durie’s four pillars or Whare
Tapa Wha framework, in which physical, mental, spiritual and whānau are required to stand together
to create health.74
7
In addition, Lee et al make mention of the age-specific nature of some illness among Dunedin service
users and suggest “different strategies” to achieve health gain.75
Targeted health promotion
Studies such as those of Lawrence et al, Seymour, and Friedlis and Dardis have suggested that a
lack of targeted physical health promotion is a major problem for service users. 76 They argue that
generic health promotion has failed service users with regard to smoking and weight control. Service
users in the United Kingdom have also identified the need for targeted physical health promotion.77
“While the general information is good and we all know about it, sometimes it’s really difficult to
relate it to you because of your specific needs and it’s hard to see how to manage that.”78
(Service user)
Despite a “dearth of information” on the subject,79 Australia’s SANE, for example, has produced antismoking health promotion resources that target service users: “The issues are different, the
pressures are different”.80 Lee et al recommend this targeted approach for New Zealand. 81
In the Ministry of Health’s recently published Building on Strengths: a new approach to promoting
mental health in New Zealand Aotearoa targeted approaches for physical health are absent.
However, the document does mention that mental health promotion - by definition - includes physical
health and wellbeing.82 (And it does stress the importance of the interconnected relationship
between physical, spiritual, mental and environmental health.83) Building on Strengths also promotes
a ‘real world’ interdependence for health promotion in New Zealand. Targeted health promotion for
the physical health of service users needs to fit this context.
Indeed targeted health promotion is not an isolated exercise. For example, clinicians need to
personally acknowledge the importance and dangers of iatrogenic obesity. Medication levels,
resources from pharmaceutical companies, such as the “Bite for Life” club, and tighter relationships
with consumer initiatives such as the Weight Awareness Club in Dunedin are all possible solutions.
Moreover, given the extent of obesity and its dangers for physical and mental health, more
progressive solutions such as hiring exercise trainers, and financial reward for clinicians who help
keep weight gain to minimum, are not as implausible as they once were.
AND THE FUTURE?
I see a future in which service users have the same rates of morbidity and mortality as the general
population; policy-makers make a strong statement conveying clear responsibilities for adequately
resourced, able, health professionals; health professionals who do not accept discrimination in their
workplace.
In the future, when I go to the doctor, I will be able to access health care information about quitting
smoking and losing weight that is specific to my needs as a service user.
To put it simply, in the future I’ll be an old man with many grandchildren.
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
Ministry of Health. 2000. New Zealand Health Strategy. Wellington: Ministry of Health, at p 11.
J Lee, et al. 2000. The physical health of people with serious mental illness in Dunedin. Unpublished,
Otago School of Medicine, at p 4 (mental health service users only).
D Lawrence, et al. 2001. Preventable Physical Illness in People with Mental Illness. Perth: University of
Western Australia, p xi; C Harris, B Baraclough. 1998. Excess mortality of mental disorder. British
Journal of Psychiatry 173: 11–53, at p 39;
S Davidson, et al. 2000. The general health status of people with mental illness. Australian Psychiatry
8(1): 31–5, at p 31.
B Debling, et al. 1999. Life expectancy and causes of death in a population treated for serious medical
illness. Psychiatric Services 50: 1036–42, at p 1036.
A Sims. 1987. Why the excess mortality from psychiatric illness? British Medical Journal 294: 986-7, at p
987.
S Ajwani, et al. 2003. Decades of Disparity: ethnic mortality trends in New Zealand 1980-1999, at pp 223., Ministry of Health, Wellington
The figure for service users was estimated from overseas data.
A Sims. 1987. Why the excess mortality from psychiatric illness? British Medical Journal 294: 986-7, at p
987.
C Harris, B Barraclough. 1998. Excess mortality of mental disorder. British Journal of Psychiatry 173:
11–53.
M Tsuang. 1985. Mortality studies in psychiatry: should they proceed or stop? Archive of General
Psychiatry 42: 98–103.
D Lawrence, et al. 2001. Preventable Physical Illness in People with Mental Illness. Perth: University of
Western Australia; A Singh, S Cohen. 2001. A General Practitioners Guide to Managing Severe Mental
Illness. London: Sainsbury Centre.
D Lawrence, et al. 2001. Preventable Physical Illness in People with Mental Illness. Perth: University of
Western Australia, at p xi.
Ibid.
Ibid.
Ibid.
Ibid; A Singh, S Cohen. 2001. A General Practitioners Guide to Managing Severe Mental Illness.
London: Sainsbury Centre, at p 5; L Seymour. 2003. Not All in the Mind: the physical health of mental
health service users. London, at p 9.
A Singh, S Cohen. 2001. A General Practitioners Guide to Managing Severe Mental Illness. London:
Sainsbury Centre, at p 5.
R Miech, et.al. 1999. Low socioeconomic status and mental disorders: a longitudinal study. American
Journal of Sociology 104(4): 1096–131, at p 1096.
K Nelson, et al. Evaluation of Mental Health/Shared Care Services, 2003, Health
Research Council, Auckland
R Miech, et.al. 1999. Low socioeconomic status and mental disorders: a longitudinal study. American
Journal of Sociology 104(4): 1096–131, at p 1125.
A McNeill. 2001. Smoking and Mental Health: a review of the literature. London, at p 4; S Lawrie. 1995.
Cigarette smoking in psychiatric inpatients. Journal of the Royal Society of Medicine 88, at p 59; K Lasser,
et al. Smoking and mental illness. Journal of American Medical Association 284(20), 2606-2610 at p
2606.
McNeill, ibid, at p 13.
Ibid.
Ibid, at p 17.
S Lawn, R Pols, J Barber. 2002. Smoking and quitting: a qualitative study with community living patients.
Social Science and Medicine 54: 93–104, at p 101.
B Brown, H Inskip, B Barraclough. 2000. Causes of excess mortality in schizophrenia. British Journal of
Psychiatry 177: 212–7, at p 217.
Pritchard P, Hughes J. 1995. Shared Care: the future imperative. London, at p.17.
Ministry of Health. 2002. Establishment Service Specifications for Essential Primary Health Care Services
Provided by PHOs. Wellington: Ministry of Health, at p 3.
9
30
J Lee, et al. 2000. The Physical Health of People with Serious Mental Illness in Dunedin. Unpublished,
Otago School of Medicine, at p 4 (mental health service users only).
31 Counties Manukau District Health Board. 2002 Draft Annual Plan 2002/03. Counties Manukau District
Health Board, at p 10.
32 Ministry of Health. 2001. New Zealand Health Strategy: DHB toolkit: minimising alcohol and other drug
harm. Wellington: Ministry of Health, at p 18.
33 Ministry of Health. 1999. Guidelines for Recognising, Assessing, and Treating Alcohol and Cannabis
Abuse in Primary Care. Wellington: Ministry of Health.
34 Ministry of Health. 2003. Opiod Substitution Treatment New Zealand Practice Guidelines. Wellington:
Ministry of Health, at pp 17, 33.
35 F Bunce, et al. Medical illness in psychiatric patients: barriers to diagnosis and treatment. Southern
Medical Journal 75(8): 941–2, at p 941.
36 Royal College of Psychiatrists, British Medical Association, Royal College of Physicians 2001. Mental
Illness: stigmatisation and discrimination within the medical profession, London, at p18.
37 J Read, S Baker. 1996. Not Just Sticks ands Stones: a survey of the stigma, taboos and discrimination
experienced by people with mental health problems, London, The Mental Health Charity, at p 20.
38 T Kendrick. 1996. Cardiovascular and respiratory risk factors and symptoms among general practice
patients with long-term mental illness. British Journal of Psychiatry 169: 733–9, at p 739.
39 S Davidson, et al. 2000. The general health status of people with mental illness. Australian Psychiatry
8(1): 31–5. L Seymour. 2003. Not All in the Mind: the physical health of mental health service users.
London, at p 9.
40 Seymour, ibid, at p 25.
41 S Davidson, et al. 2000. The general health status of people with mental illness. Australian Psychiatry
8(1): 31–5.
42 Ibid, at p 34.
43 Ibid; J Lee, et al. 2000. The physical health of people with serious mental illness in Dunedin.
Unpublished, Otago School of Medicine, at p 8.
44 Lee, ibid, at p 38.
45 L Seymour. 2003. Not All in the Mind: the physical health of mental health service users. London, at p
26.
46 L Friedli, C Dardis. 2002. Not all in the mind: mental health service user perspectives on physical health.
Journal of Health Mental Health Promotion 1(1): 36–46.

Revascular surgery is a type of heart surgery.
47 D Lawrence, et al. 2001. Preventable Physical Illness in People with Mental Illness. Perth: University of
Western Australia, at p 90.
48 B Wallace, C Tennant. 1998. Nutrition and obesity in the chronically mentally ill. Australian and New
Zealand Journal of Psychiatry 32: 82–5, at p 83.
49 Ministry of Health, DHB Tool Kit to Reduce Obesity (2001) pg 6.
50 B Wallace, C Tennant. 1998. Nutrition and obesity in the chronically mentally ill. Australian and New
Zealand Journal of Psychiatry 32: 82–5, pg.85
51 S Davidson, et al. 2000. The general health status of people with mental illness. Australian Psychiatry
8(1): 31–5, at p 34.
52
DB Allison, et al. “Anti-psychotic –induced weight gain: a comprehensive research
synthesis”. The American Journal of Psychiatry 1999 156 (11):1686-96, in P Edgar.
“Anti-psychotic medications and diabetes”, Schizophrenia Research New Zealand
Newsletter 2003 at p 4.
53 P Edgar. “Anti-psychotic medications and diabetes”, Schizophrenia Research New Zealand
Newsletter 2003 at p 7.
54 J Dean, et al. “Mum, I used to be good looking…look at me now”: The physical needs of adults with mental
health problems: the perspectives of users, carers, and front line staff. International Journal of Mental
Health Promotion 1(3): 16–24, at p 21.
55 Tardive dyskinesia is a neurological disorder characterised by involuntary muscular contraction..
56
D Clark. Dental care for the patient with bipolar disorder. in Journal of the Canadian
Dental Association Vol 69(1) pp 20-24 at 20.
57 Ministry of Health. 2000. New Zealand Health Strategy. Wellington: Ministry of Health, at p 15.
58 I Shearin. 2003. Outcomes of methadone maintenance from client perspective. A presentation at the
Cutting Edge AOD Conference, New Zealand, August.
59 Manager, Palmerston North Needle Exchange, Personal Communication.
10
60
National Policy Panel. 2003. Ending Discrimination against People with Alcohol and Drug Problems.
Boston: Boston School of Public Health, Boston University, at p 1.
61 Royal College of Psychiatrists. 2003. Drugs and Alcohol: whose problem is it anyway? London, at p 2.
62 S Ajwani, et al. 2003. Decades of Disparity: ethnic mortality trends in New Zealand 1980-1999,
Wellington: Ministry of Health
63 Blakey T. Robson B. 2003. Gaps: who’s to blame? Dominion Post, 1 August.
64 Ministry of Health. 2000. New Zealand Health Strategy. Wellington: Ministry of Health.
65 A Cohen, M Hove. 2001. Physical Health of the Severe and Enduring Mentally Ill: a training pack for GP
educators. London, at p 1.
66 In T Kendrick. 1996. Cardiovascular and respiratory risk factors and symptoms among general practice
patients with long-term mental illness. British Journal of Psychiatry 169: 733–9, at p 739.
67 Department of Health. 2000. Mental Health Policy Implementation Guide: community mental health
teams. London: Department of Health.
68 Ibid, at p 11.
69
B. Hyland et al. Case managers attitudes to the physical health of their patients, in Australian and New
Zealand Journal of Psychiatry, Vol. 37 (6) pp 710-714, at p 714.
70 J Lee, et al. 2000. The physical health of people with serious mental illness in Dunedin. Unpublished,
Otago School of Medicine, at p 4.
71 A Cohen, M Hove. 2001. Physical Health of the Severe and Enduring Mentally Ill: a GP guide. London:
Sainsbury Centre for Mental Health.
72 J Lee, et al. 2000. The physical health of people with serious mental illness in Dunedin. Unpublished,
Otago School of Medicine;
73
71
75
76
77
78
79
80
81
82
83
W Ferguson. 2003. Primary care can fill mental health void. New Zealand GP 20 August.
M Durie. 1994 Whaiora: Maori Health Development. Auckland: Oxford University Press
J Lee, et al. 2000. The physical health of people with serious mental illness in Dunedin. Unpublished,
Otago School of Medicine, at p 6.
D Lawrence, et al. 2001. Preventable Physical Illness in People with Mental Illness. Perth: University of
Western Australia; L Seymour. 2003. Not All in the Mind: the physical health of mental health service
users, London, at p 10; L Friedli, C Dardis. 2002. Not all in the mind: mental health service user
perspectives on physical health. Journal of Health Mental Health Promotion 1(1): 36–46.
Seymour, ibid, at p 10; Friedli and Dardis, ibid, at p 45.
Friedli and Dardis, ibid, at p 41.
J Dean, et al. “Mum, I used to be good looking … look at me now”: the physical needs of adults with
mental health problems: the perspectives of users, carers, and front line staff. International Journal of
Mental Health Promotion 1(3): 16–24, at p 16.
SANE. 2002. SmokeFree Kit (Manual for Mental Health Worker). Australia: SANE.
J Lee, et al. 2000. The physical health of people with serious mental illness in Dunedin. Unpublished,
Otago School of Medicine, at p 30.
Ministry of Health. 2003. Building on Strengths: a new approach to promoting mental health in New
Zealand/Aotearoa. Wellington: Ministry of Health, at p 20.
Ibid, at p 18.
References
Ajwani S, et al. 2003. Decades of Disparity: ethnic mortality trends in New Zealand 1980-1999, Wellington,
Ministry of Health
Allison, P et al. “Anti-psychotic –induced weight gain: a comprehensive research
synthesis”. The American Journal of Psychiatry 1999 156 (11):1686-96, in P Edgar.
“Anti-psychotic medications and diabetes”, Schizophrenia Research New Zealand
Newsletter 2003
Bathgate B, et al. 2001. The views of Otago and rural general practitioners on mental health services. New
Zealand Medical Journal 22 June: 289–91.
Blakely T, Robson, B 2003. Gaps: who’s to blame? Dominion Post, 1 August.
Brown B, H Inskip, B Barraclough. 2000. Causes of excess mortality in schizophrenia. British Journal of
Psychiatry 177: 212–7.
11
Bunce F, et al. 1982 Medical illness in psychiatric patients: barriers to diagnosis and treatment. Southern
Medical Journal 75(8): 941–2.
Clark D. Dental care for the patient with bipolar disorder. in Journal of the Canadian
Dental Association Vol 69(1) pp 20-24
Cohen A, Hove M. 2001. Physical Health of the Severe and Enduring Mentally Ill: a GP guide. London,
Sainsbury Centre for Mental Health.
Cohen A, Hove M. 2001. Physical Health of the Severe and Enduring Mentally Ill: a training pack for GP
educators. London: Sainsbury Centre for Mental Health.
Counties Manukau District Health Board. 2002 Draft Annual Plan 2002/03. Counties Manukau District Health
Board.
Davidson S, et al. 2000. The general health status of people with mental illness. Australian Psychiatry 8(1):
31–5.
Dean J, et al. “Mum, I used to be good looking … look at me now”: the physical needs of adults with mental
health problems: the perspectives of users, carers, and front line staff. International Journal of Mental
Health Promotion 1(3): 16–24.
Debling B, et al. 1999. Life expectancy and causes of death in a population treated for serious medical illness.
Psychiatric Services 50: 1036–42.
Department of Health. 2000. Mental Health Policy Implementation Guide: community mental health teams.
London: Department of Health.
Edgar P. “Anti-psychotic medications and diabetes”, Schizophrenia Research New Zealand
Newsletter 2003
Ferguson W. 2003. Primary care can fill mental health void. New Zealand GP 20 August, pg 5
Friedli L, Dardis C. 2002. Not all in the mind: mental health service user perspectives on physical health.
Journal of Health Mental Health Promotion 1(1): 36–46.
Harris C, Barraclough B. 1998. Excess mortality of mental disorder. British Journal of Psychiatry 173: 11–53.
Hyland B. et al. Case managers attitudes to the physical health of their patients, in Australian and New Zealand
Journal of Psychiatry, Vol. 37 (6) pp 710-714,
Kendrick T. 1996. Cardiovascular and respiratory risk factors and symptoms among general practice patients
with long-term mental illness. British Journal of Psychiatry 169: 733–9.
Lasser K, et al. Smoking and mental illness. Journal of American Medical Association 284(20):
Pp2606-2610
Lawn S, Pols R, Barber J. 2002. Smoking and quitting: a qualitative study with community living patients.
Social Science and Medicine 54: 93–104.
Lawrence D, et al. 2001. Preventable Physical Illness in People with Mental Illness. Perth: University of
Western Australia.
Lawrie S. 1995. Cigarette smoking in psychiatric inpatients. Journal of the Royal Society of Medicine 88: p 59
Lee J, et al. 2000. The physical health of people with serious mental illness in Dunedin. Unpublished, Otago
School of Medicine.
McNeill A. 2001. Smoking and Mental Health: a review of the literature. London:
Manager, Palmerston North Needle Exchange, Personal Communication.
Miech R, et.al. 1999. Low socioeconomic status and mental disorders: a longitudinal study. American Journal
of Sociology 104(4): 1096–131.
Ministry of Health. 1999. Guidelines for Recognising, Assessing, and Treating Alcohol and Cannabis Abuse in
Primary Care. Wellington: Ministry of Health.
Ministry of Health. 2000. New Zealand Health Strategy. Wellington: Ministry of Health.
Ministry of Health. 2001. New Zealand Health Strategy: DHB toolkit: minimising alcohol and other drug harm.
Wellington: Ministry of Health.
Ministry of Health. 2002. Establishment Service Specifications for Essential Primary Health Care Services
Provided by Primary Health Organisations. Wellington: Ministry of Health.
12
Ministry of Health. 2003. Building on Strengths: a new approach to promoting mental health in New
Zealand/Aotearoa. Wellington: Ministry of Health.
Ministry of Health. 2003. Opiod Substitution Treatment New Zealand Practice Guidelines. Wellington: Ministry
of Health.
National Policy Panel. 2003. Ending Discrimination against People with Alcohol and Drug Problems. Boston:
Boston School of Public Health, Boston University.
Nelson K. et al. Evaluation of Mental Health/Shared Care Services, 2003, Health
Research Council, Auckland
Pritchard P, Hughes J. 1995. Shared Care: the future imperative. London:
Read J, Baker S. 1996. Not Just Sticks ands Stones: a survey of the stigma, taboos and discrimination
experienced by people with mental health problems. London, The Mental Health Charity.
Royal College of Psychiatrists. 2003. Drugs and Alcohol: whose problem is it anyway? London
Royal College of Psychiatrists, British Medical Association, Royal College of Physicians of London. 2001.
Mental Illness: stigmatisation and discrimination within the medical profession. London
SANE. 2002. SmokeFree Kit (Manual for Mental Health Worker). Australia: SANE.
Seymour L. 2003. Not All in the Mind: the physical health of mental health service users. London, Mentality
Shearin I. 2003. Outcomes of methadone maintenance from client perspective. A presentation at the Cutting
Edge AOD Conference, New Zealand, August.
Sims A. 1987. Why the excess mortality from psychiatric illness? British Medical Journal 294: 986-7.
Singh A, Cohen S. 2001. A General Practitioners Guide to Managing Severe Mental Illness. London:
Sainsbury Centre.
Tsuang M. 1985. Mortality studies in psychiatry: should they proceed or stop? Archive of General Psychiatry
42: 98–103.
Wallace B, Tennant C. 1998. Nutrition and obesity in the chronically mentally ill. Australian and New Zealand
Journal of Psychiatry 32: 82–5.
13