The Case for Severe Mental Illness as a Disparities Category

Health services researchers have long recognized that people with severe mental illness have higher rates of morbidity and mortality than the general population (2). A recent meta-analysis found that people with mental disorders have an all-cause mortality relative risk of 2.22 compared with the general population, with a median of 10 years of potential life lost (3). Furthermore, a severe mental illness diagnosis is associated with health care of lower quality and higher cost (4).

These profound trends, at least in part, stem from discrimination, exclusion, widespread stigma, and criminalization of individuals with mental illness (5). The consequences are profound in an individual’s personal and professional life, and they negatively influence experiences in both general medical and mental health settings. As a result, people with mental illness are reluctant to seek help, they are subject to “diagnostic overshadowing” that leads to underdiagnosis of comorbid medical illnesses, and they receive unequal treatment compared with the general population (6).

As such, people with severe mental illness fit within the U.S. Department of Health and Human Services (DHHS) definition of a health disparity category: a subpopulation with “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage” (7). Furthermore, in its report on recommendations for the framework and format of Healthy People 2020, the DHHS Secretary’s Advisory Committee on National Health Promotion and Disease Prevention states, “Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, mental health, cognitive, sensory, or physical disability, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion” (7). In contrast, the National Institute on Minority Health and Health Disparities (NIMHD) and the National Quality Strategy do not formally recognize people with severe mental illness as a disparities group.

Addressing health disparities is a key focus of the DHHS aim to achieve better care, healthy people and communities, and affordable care (8). The Minority Health and Health Disparities Research and Education Act of 2000 authorized the Director of NIMHD, in consultation with the director of the Agency for Healthcare Research and Quality (AHRQ), to define health disparity populations (9). For example, in December 2016 the Director of NIMHD announced the formal designation of sexual and gender minorities as a health disparity population for research purposes for the National Institutes of Health, building on extensive research documenting such disparities (9).

Although designation as a health disparity population does not necessarily result in an immediate allocation of resources, it can bring greater national attention and important implications. For example, AHRQ releases its National Healthcare Quality and Disparities Report each year (10). Designation of people with severe mental illness as a disparities group would signify inclusion in these annual national reports and help advance research on this population. Disparities designation puts pressure on organizations and agencies to develop quality measures for use in value-based payment models, to incentivize the development and application of evidence-based practices, and to expand resources for research to better understand the factors that result in unequal care.

Consideration of a new disparities category must take into account important counterarguments. First, there is already a scarcity of resources to adequately address the needs of all groups who experience worse health care because of disparities. Second, people with severe mental illness make up approximately 4%−6% of the total population, which is relatively small compared with other disparities groups. Finally, the category of severe mental illness differs from traditional designations in that it is partially defined by a group of diagnoses rather than by demographic characteristics.

Nevertheless, we believe that there is an urgent need to better understand and address the unique contributors to stigma and discrimination toward people with severe mental illness, who have disproportionately high needs, poor outcomes, and costly care (11).

Designating severe mental illness as a disparities category would have important implications for health policy and quality measurement, health services research, and clinical practice.

At this transitional moment in national mental health reform, we must devise strategies to encourage dissemination of effective, research-proven interventions currently available and expand the research base to develop new ones. We believe that the population with severe mental illness represents one of society’s most vulnerable and marginalized groups with disproportionately high needs and poor outcomes. Ethical priorities compel policy makers, payers, providers, and health services researchers to maintain special focus on populations most at risk. Officially designating severe mental illness as a disparities category is a key step to enhance advocacy to influence policy solutions, practice innovations, and political will.