398 398..399 A Swedish national database study concluded that mortality risks were highest in those untreated with antipsychotics. 4 However, this conclusion maybe an oversimplification and we suggest ‘untreated’ here describes being poorly engaged, lacking care and support rather than simply ‘untreated with antipsychotics’; indeed, ‘treated with antipsychotics’ could be a proxy for well engaged, supported and receiving a range of inter- ventions comparable to those recommended by NICE. Another anomaly was the study’s reported average age of 36 years for its FEP subgroup, much older than usually reported.5 Thus the study may have missed substantial numbers of younger people, a particularly vulnerable group for antipsychotic-induced weight gain and metabolic disturbance, limiting its applicability to more typically aged FEP populations.6 Nevertheless the finding that lower mortality correlated with low and moderate antipsychotic dosing supports the importance of good prescribing. Our simple collective view in providing this editorial as general practitioner, nurse and psychiatrist together, is that health inequality could be reduced by healthcare systems collaboratively embracing a more preventive approach in relation to the physical health of this vulnerable group from the earliest opportunity. 1 Mitchell AJ, De Hert M. Promotion of physical health in persons with schizophrenia: can we prevent cardiometabolic problems before they begin? Acta Psychiatr Scand 2015; 132: 83–5. 2 Barnes TR. Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2011; 25: 567–620. 3 Dixon LB, Stroup ST. Medications for first-episode psychosis: making a good start. Am J Psychiatry 2015; 172: 209–11. 4 Tiihonen J, Mittendorfer-Rutz E, Torniainen M, Alexanderson K, Tanskanen A. Mortality and cumulative exposure to antipsychotics, antidepressants, and benzodiazepines in patients with schizophrenia: an observational follow-up study. Am J Psychiatry 7 Dec 2015 (doi: 10.1176/appi.ajp.2015.15050618). 5 Kirkbride JB, Fearon P, Morgan C, Dazzan P, Morgan K, Tarrant J, et al. Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings from the 3-center AeSOP study. Arch Gen Psychiatry 2006; 63: 250–8. 6 Correll CU, Manu P, Olshanskiy V, Napolitano B, Kane JM, Malhotra AK. Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. JAMA 2009; 302: 1765–73. David Shiers, MBChB, MRCGP, MRCP(UK), School of Psychological Sciences, University of Manchester, Manchester M13 9PL, UK. Email: david.shiers@ doctors.org.uk; Jonathan Campion, MBBS, MRCPsych, South London and Maudsley NHS Foundation Trust, and Faculty of Brain Sciences, University College London, London; Tim Bradshaw, RMN, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK doi: 10.1192/bjp.208.4.398a ‘Lethal discrimination’, ideology and social justice Perhaps the journal risks accusations of hyperbole by adopting the slogan of ‘lethal discrimination’ in relation to the shockingly high standardised mortality ratios (SMRs) of people with severe mental illness (SMI). Other serious illnesses (cancer, etc.) have high SMRs but to suggest that this is due to lethal discrimination would attract criticism. Taggart & Bailey1 are right to draw attention to the high SMRs in people with SMI. This is consistent with accepted tenets of moral philosophy, particularly liberal political philosophy. Central to this are principles that citizens enjoy maximum liberty (subject to respect for the liberty of others) and, second, that social arrangements permit social inequality only to the degree that this improves the well-being of the least advantaged.2 People with SMI are among the most disadvantaged. Table 1 of the editorial indicates that those with SMI in contact with services fare better in the USA than in the UK. This will not surprise those who have expressed dismay about developments in mental health services in the UK. 3 However, the important question is whether the way US mental health services are funded, commissioned and managed may be better. Psychiatrists need to remain open minded about what systems deliver best results, if we are to achieve our aims effectively.4 International comparisons are notoriously difficult to make. A host of health and social indicators however suggest worse outcomes in more unequal societies. Because the USA is a more unequal society, Table 1 is counterintuitive. Perhaps Table 1 is misleading. Taggart & Bailey do not tell us whether the US data include outcomes of individuals with SMI receiving care in prison. In the past 40 years the proportion of people with SMI who are compulsorily detained in the USA has remained the same. However, whereas 40 years ago 75% were in mental hospitals and 25% in penal institutions, now the proportions are 5% and 95% respectively.5 Table 1 will have validity only if the outcomes of imprisoned individuals with SMI are included. Should further research confirm US superiority, another issue might arise: does more restrictive treatment (in prison) achieve better outcomes? If so, psychiatrists will have to face deeply uncomfortable questions. Could it be that enhanced incarceration leads to lesser freedom but a lower SMR? Would lower a SMR be the effect of more intensive psychopharmacological treatment or is there less psychopharmacological intervention in prison and the higher UK SMR is due to more psychopharmacological treatment in the community? What kind of societies lead to best outcomes for people with SMI? Health outcomes do not depend only on healthcare. To participate constructively in debate and action aimed at reducing SMRs in those with SMI, psychiatrists need to become familiar with the complex issues addressed by political philosophy2 as well as public mental health. They also need to be aware that although they may master evidence and political ethical reasoning, social ideology will sometimes prevail as to what happens on the ground.6 Perhaps it is anxiety secondary to this that impelled invention of the concept of lethal discrimination in people with SMI. Declaration of interest G.I. is an NHS consultant psychiatrist, and Chairman and Director, London International Practice Ltd. 1 Taggart H, Bailey S. Ending lethal discrimination against people with serious mental illness. Br J Psychiatry 2015; 207: 469–70. 2 Ikkos G. Fairness, liberty and psychiatry. Int Psychiatry 2009; 6: 46–8. 3 St John-Smith P, McQueen D, Michael A, Ikkos G, Denman C, Maier M, et al. The trouble with NHS psychiatry in England. Psychiatr Bull 2009; 33: 219–25. 4 Ikkos G, Sugarman P, Bouras N. Mental health services commissioning and provision: lessons from the UK? Psychiatriki 2015; 26: 181–7. 5 Bark N. Prisoner mental health in the USA. Int Psychiatry 2014; 11: 53–5. 6 Bouras N, Ikkos G. Ideology and psychiatry. Psychiatriki 2013; 24: 17–27. George Ikkos, Consultant Psychiatrist in Liaison Psychiatry, Royal National Orthopaedic Hospital NHS Trust, Stanmore, Middlesex, UK. Email: george.ikkos@ nhs.net doi: 10.1192/bjp.208.4.399 399 Correspondence Downloaded from https://www.cambridge.org/core. 06 Apr 2021 at 02:20:36, subject to the Cambridge Core terms of use. https://www.cambridge.org/core