Social and economic disadvantage and lifestyle

Lifestyle, diet and antipsychotic medications have been implicated in cardiovascular morbidity in people living with SMI. ^{Reference Walker, McGee and Druss2} Adverse ‘social gradients’ for health, whereby people of lower social standing have poorer health, potentially mediated through chronic stress, ^{Reference Marmot, Allen, Goldblatt, Boyce, McNeish and Grady10} may also play a role for people with SMI. The association of social position or the gradient with health outcomes is not purely accounted for through traditional risk factors such as smoking, and these health-related behaviours in themselves may also follow strong social gradients. ^{Reference Marmot, Allen, Goldblatt, Boyce, McNeish and Grady10} The association of this with ethnicity and SMI needs further clarification and has been restricted by data limitations. For example, prediction models for 10-year risk of cardiovascular disease in people with SMI could not include ethnicity, due to this being inconsistently recorded in health records. ^{Reference Osborn, Hardoon, Omar, Holt, King and Larsen11}

Social and economic inequalities have also been implicated as a fundamental cause of cardiovascular health inequalities in some ethnic minority groups, although there is much heterogeneity. ^{Reference Nazroo, Jackson, Karlsen and Torres4} It is possible that there may be genetic interactions with environmental factors; however, to date there is no evidence to suggest that these are mediated solely by ethnic differences in genotype. ^{Reference Li, Canham, Vongpatanasin, Leonard, Auchus and Victor12} It is likely that there are complex associations between socioeconomic position and physical health and mortality for ethnic minorities living with SMI, which will vary according to context. The role of social and economic disadvantage will need to be central to any analyses.

Stigma and discrimination

People with SMI such as schizophrenia anticipate and experience stigma and discrimination in their everyday lives. ^{Reference Thornicroft, Brohan, Rose, Sartorius and Leese13} Discrimination also plays a role in the aetiology of psychosis in ‘visible’ ethnic minorities ^{Reference Bourque, van der Ven and Malla5} and affects the type and quality of healthcare received. For example, within mental health services, Black patients are more likely to experience complex pathways into care, with a greater likelihood of police involvement and compulsory detention, relative to White patients. ^{Reference Bhui, Stansfeld, Hull, Priebe, Mole and Feder14}

It is possible that the role of discrimination functions in multiple ways when related to the concept of double jeopardy. First, ‘doubly’ discriminated people may experience greater levels of chronic discrimination which are cumulatively more stressful and directly pathogenic for health. ^{Reference Grollman3} Second, such individuals may be more likely to experience structural discrimination which extends to the quality of physical healthcare received, especially if healthcare services are perceived as discriminatory ^{Reference Gilvarry, Walsh, Samele, Hutchinson, Mallett and Rabe-Hesketh15} or are inadequately culturally sensitive. Third, high levels of perceived discrimination may increase the risk of participation in ‘unhealthy’ behaviours and reduce ‘healthier’ behaviours. ^{Reference Pascoe and Smart Richman16}

Implications and recommendations

There appears to be some evidence indicating a double jeopardy for physical health for ethnic minorities living with SMI, supported through a handful of studies which have suggested that the prevalence of cardiovascular morbidity or mortality risk may be greater in people from an ethnic minority background with SMI, compared with referent populations. The evidence is sparse and mostly informed by non-epidemiological samples from psychiatric clinics, relating to populations from the USA. ^{Reference Carliner, Collins, Cabassa, McNallen, Joestl and Lewis-Fernández6,Reference Ward and Druss7}

With this in mind, we propose the following clinical, research and policy recommendations.

1. 1 Research based on representative samples, rather than convenience-based clinical samples is needed. ^{Reference Carliner, Collins, Cabassa, McNallen, Joestl and Lewis-Fernández6} There is very little data highlighting the prevalence of cardiovascular risk factors such as type 2 diabetes mellitus, ischaemic heart disease, obesity and tobacco use in ethnic minority people living with SMI. The use of routine electronic patient records may help to deal with gaps in the literature which could then be used to inform service provision, especially in ethnically diverse areas.

2. 2 For clinicians the possibility that physical health inequalities may be even worse in ethnic minority groups living with SMI is a concern. This may mean more proactive screening and management in ethnic minority groups with SMI, especially in groups already known to be at a higher risk of cardiovascular disease, which would render screening more cost-effective.

3. 3 It is unclear whether the experience of living with an SMI leads to additional disadvantage for ethnic minority people, for example in terms of equitable access to evidence-based treatments, or through an impact on help-seeking. Future research could investigate this. Qualitative methods may help to unpack the intersectionality of ethnicity and living with SMI (which may go beyond additive/multiplicative models of epidemiological ‘risk’). ^{Reference Grollman3} Such approaches could help to highlight barriers to accessing equitable care from the perspectives of patients and the role of perceived discrimination on health-related behaviours. ^{Reference Pascoe and Smart Richman16} In particular these approaches may highlight overt as well covert/structural forms of discrimination and the way in which this may impact on health-seeking behaviours and self-management.

4. 4 Shifts in policy which target the management of physical health comorbidities in people with SMI may potentially narrow treatment inequalities, ^{Reference Mathur, Hull, Boomla and Robson8} although evidence for this remains limited, especially with respect to ethnic minority groups. Research is needed to assess whether such approaches are of benefit.

5. 5 As there is evidence to support other forms of disadvantage in SMI populations, ^{Reference Carliner, Collins, Cabassa, McNallen, Joestl and Lewis-Fernández6} future research will need to consider the role of holding multiply disadvantaged identities, ^{Reference Grollman3} not just restricted to ethnicity and SMI, and the ways in which these may interact to lead to poorer health outcomes.

6. 6 Research based on electronic health records can only be as good as the data entered. Understanding these differences in health will require clinicians to ensure information on the health status of patients is adequately assessed and recorded. Policy makers should consider local incentives to improve the recording of key indicators such as self-ascribed ethnicity and measures for physical health, in ethnically diverse areas. This will help to inform service provision.