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Somatic health in patients with severe mental illness 

The Norwegian Healthcare Investigation Board received a report about a woman in her 70s who likely died of a heart attack. She had a known psychotic disorder. It was two days from when emergency services were contacted due to symptoms of acute heart disease until her admission to the hospital. She was admitted to the emergency psychiatric care unit. Blood tests at admission indicated signs of heart disease. She was examined by a cardiologist, who recommended her continued stay in psychiatric care. Two days later, she was found on the floor in cardiac arrest. Resuscitation attempts were unsuccessful, and she was declared dead an hour later. 

In the report to the Norwegian Healthcare Investigation Board, questions were raised regarding why the patient was not admitted to the cardiology department or transferred there. The notifier believes that the patient did not receive the necessary treatment and monitoring for acute heart disease. It is perceived that the psychiatric disorder influenced the decisions made. 

We have chosen to refer to the patient as Inger. Her story contrasts with expectations of what should happen when emergency services are contacted with acute chest pains. Her story is not unique. The Norwegian Healthcare Investigation Board has received several notifications regarding somatic health care for patients with mental disorders. We have also heard from various professional communities and advocacy groups about other cases similar to Inger's. 

Cardiovascular disease is the leading cause of death among people with serious mental health conditions. They tend to receive less healthcare and live significantly shorter lives than the general population. The difference in life expectancy is mostly due to physical illnesses, not suicide or direct outcomes of their mental health issues. For example, there are about 10,000 people with schizophrenia in Norway, and this group alone loses between 150,000 and 200,000 years of life combined. It is important to actively work to reduce the loss of life years. 

In our investigation, we attempt to understand why the situation unfolded as it did for Inger. Why did it make sense for the health and care services staff to act as they did? We start Inger's story with her daughter's emergency call to the Emergency Medical Communication Center (AMK). We base our analysis on what the AMK operators knew and could have known when making their decisions. Furthermore, we investigated what happened during Inger's hospital admission. In conclusion, we examine Inger's history before she became acutely ill and the opportunities that existed to prevent the acute event. We have explored how knowledge about somatic comorbidity in patients with severe mental illness can be better utilized. 

Key Messages in the Report 

  • Mental illness can overshadow physical illness. Attention can be diverted away from symptoms that may be time-critical, leading to these symptoms not being detected. Consequently, both acute and long-term care of patients can fail. Healthcare personnel possess knowledge about the higher rate of somatic morbidity in patients with severe mental illness, but practical measures to address this issue need to be implemented, at both the individual and systemic levels. It must be ensured that the healthcare service takes symptoms of physical illness seriously when they occur. 
  • The greatest opportunity to reduce the loss of life years and improve quality of life lies in prevention before the onset of disease. 
  • There is a risk that patients in great need of help may be left without follow-up if they refuse healthcare. The opportunities for engaging in motivational and relationship-building work appear to be utilized to varying degrees. It is important to have clear expectations regarding the legal requirements for attempting voluntary measures. 
  • Prioritizing patients in acute situations is challenging. The methods and approaches have limitations when dealing with concurrent mental and somatic disorders. 
  • We find that the understanding of the legislation on the use of coercion in somatic illness is weak. In acute situations, this can lead to a risk of inadequate and delayed healthcare. It is important to clarify what options exist within the legislation. 
  • Upon hospital admission, the conditions for treatment in somatics and mental health care are vastly different. It is crucial for the safe and comprehensive care of patients that there is good cooperation, an understanding of each other's prerequisites, and effective consultation and liaison services between these services. 

This report is relevant for everyone in the health and care services, politicians, health authorities, and health education programs. However, the content is specifically targeted at personnel in municipal and specialist health services who come into contact with patients with severe mental illnesses. The report is also relevant in the context of construction and organizational projects affecting mental health care and somatic departments in hospitals. 

The translation from Norwegian to English is based in AI. Ukom has reviewed, edited and quality assured the translation.