There are many factors that contribute to the poor physical health of people with severe mental illness (SMI), including lifestyle factors and medication side effects. However, there is increasing evidence that disparities in healthcare provision contribute to poor physical health outcomes. These inequalities have been attributed to a combination of factors including systemic issues, such as the separation of mental health services from other medical services, healthcare provider issues including the pervasive stigma associated with mental illness, and consequences of mental illness and side effects of its treatment. A number of solutions have been proposed. To tackle systemic barriers to healthcare provision integrated care models could be employed including co-location of physical and mental health services or the use of case managers or other staff to undertake a co-ordination or liaison role between services. The health care sector could be targeted for programmes aimed at reducing the stigma of mental illness. The cognitive deficits and other consequences of SMI could be addressed through the provision of healthcare skills training to people with SMI or by the use of peer supporters. Population health and health promotion approaches could be developed and targeted at this population, by integrating health promotion activities across domains of interest. To date there have only been small-scale trials to evaluate these ideas suggesting that a range of models may have benefit. More work is needed to build the evidence base in this area.

T he excess mortality of people with mental illness has been known for many years. In 1841, William Farr 1 reported to the Royal Statistical Society on mortality within the major asylums and licensed houses of the period in England. He estimated, using life-table methods, the mortality rate in the best facility to be about 3 times that of the general population, and mortality in other facilities to be several times higher again. The report inspired the British parliament to require regular compilation of statistics within all asylums, and established mortality rate as a measure of the quality of care provided. The high mortality was attributed to infectious diseases and the poor conditions within the asylums, such as lack of exercise and warmth, poor diet, and lack of medical care. During subsequent years, mortality in people with mental illness has been the subject of hundreds of studies. In the most comprehensive meta-analyses to date, Harris and Barraclough 2,3 identified 152 reports on all-cause mortality and 249 on suicide. They found that all mental disorders were associated with an increased risk of premature death. Overall

People with mental illness in Nova Scotia have increased mortality from cancer, which cannot always be explained by increased incidence. Possible explanations for further study include delays in detection or initial presentation leading to more advanced staging at diagnosis, and difficulties in communication or access to health care.