Mental health and how it affects employment and commercial relationships has come increasingly under the spotlight recently. And maybe not before time.
Somatic (that is, physical) illnesses tend to engender sympathy and understanding. But illnesses of the psyche are somehow in a class of their own – and not in a good way. They run contrary to popular perceptions of what is ‘good’; that is, health, fun and success – the sort of things one shares with friends via social media. Diagnoses like anxiety and depression, on the other hand, imply weakness and failure. Bipolar disorder and schizophrenia are difficult for almost anyone to get their head round.
Yet the reality is that mental illnesses are medical conditions just like any other, except that they don’t manifest themselves via pain or any of the physical symptoms of somatic diseases – which is another barrier to understanding by non-sufferers. But they are nonetheless real and that they affect social and occupational functioning means they can have a significant impact on people’s lives. Mental illnesses – and their implications – need to be better understood.
It is the lack of physical manifestations coupled with the lack of objective tests that confirm a diagnosis and attest to severity that make mental health underwriting difficult compared with other medical conditions. Diagnosis to a large degree relies on just a physician’s interpretation of history and symptoms – and most of the latter are reported by the patient rather than seen by the doctor. The same applies to severity.
There is a close association between mental health and environment too: life at home, work, relationships with friends and colleagues, lifestyle (including drinking and use of drugs) contribute to the development of mental illnesses and influence their course. Some of those factors can be constants with no way out, with all that implies for prognosis. On the other hand changes in the individual’s environment can have a beneficial or a deleterious effect on a mental health issue; the course of a mental health problem can be very variable.
This variability and lack of objective testing mean that underwriters have a challenge in getting a firm grip on the nature of the individual case risk. There are no laboratory or other investigation reports by which to confirm a diagnosis and gauge the illness’s severity, only the physician’s opinion and subjective reports on response to treatment and control of symptoms.
The same problems arise in researching the mortality and morbidity implications in order to determine appropriate underwriting guidelines. Mortality data do exist – though morbidity statistics are, as ever, an enormous challenge – but cohort studies generally yield no information about that classic variability of course: risk rates compared with a ‘normal’ population calculated after x years of follow-up mask a whole host of events in the interim: improvement, deterioration, changes in or cessation of treatment, relapses and environmental changes, even episodes of self-harm maybe. And neither, generally, they do they give any clue to any factors that led to the development of the illness in the first place.
Notwithstanding the challenges, SelectX has been reviewing mental illness risks as part of maintaining and updating its RiskApps on-line underwriting manual. Some headline findings after scrutiny of nearly 50 journal articles are:
- Mental health problems tend to be chronic in nature. Some, especially those occurring in response to a set of abnormal environmental circumstances such as bereavement or divorce may be ‘one-offs’, but serious depressive illnesses for example often need to be regarded as life-long issues.
- In terms of mortality risks, younger lives merit higher percentage ratings than do older ones; this pattern is typical of physical illnesses too.
- Rates of extra mortality tend to fall gradually with the passage of time.
- A history of attempted suicide implies a serious extra risk, particularly so if by violent means, such as jumping, hanging, drowning or use of a firearm; those methods signify a real intent to end life.
We also found that the causes of excess mortality are not what one might think. While rates of ‘unnatural deaths’ (accident, suicide, etc) are far higher than expected, the bulk of the excess deaths are due to somatic and not psychiatric illnesses. And it became clear too that diagnosis is not everything. Certain subsidiary features, such as social and economic environment, the existence of support networks – especially via family – and co-existing alcohol or substance abuse problems count for a lot.
In the absence of adverse environmental features, many mental illnesses give rise to very little extra mortality. Anxiety and mild depression are generally very trivial risks. Moderately severe depression need not be rateable, even though therapy may be continuing. Severe depression, bipolar disorder and schizophrenia are indeed more significant risks but, even so, levels of excess mortality are not as high as one might think.
In order to deal with mental health risks fairly underwriters need to explore the facets of individual cases and to ensure they have sufficient information to work with. Quick pigeon-holing and a glance at the guideline in an underwriting manual are not good enough.
This article first appeared in Cover: www.covermagazine.co.uk.