It has been ‘known’ in the way that you know things deep down, when you don’t really consciously want to know them, that seriously mentally ill people, on average, die younger than those without mental illness.
But it was an ugly shock when the National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council published the “Morbidity and Mortality in People with Serious Mental Illness” study in October, 2006.
Wrote the council,
In fact, persons with serious mental illness (SMI) are now dying 25 years earlier than the general population. [italics mine]
First let’s address the terminology. The Agency for Health Care Research and Policy estimate that 1 in 4 U.S. adults suffer from a mental disorder in any given year, with 1 in 6 suffering from a serious mental illness.
A diagnosis for a serious mental illness, or SMI, requires meeting of the DSM criteria for the diagnosis, which includes persistence for the requisite length of time, and significant impairment in functioning as a result of the illness. Specific conditions can include Bipolar Disorder (BD), Schizophrenia, Major Depressive Disorder (MDD), Panic Disorder, Obsessive Compulsive Disorder (OCD) and Post Traumatic Stress Disorder (PTSD).
Then come the ugly facts.
The October, 2006 study found that
Schizophrenia, Bipolar Disorder and Major Depressive Disorder have all been associated with medical causes of death which are often 2 to 3 times that of the general population. [emphasis mine]
I’d like to add to that the results of a presentation given to the American Heart Association’s Scientific Sessions 2010, Chicago. The researchers shared their findings there from a 10-year follow-up study of 286,194 veterans who had been treated in VA medical centers.
After factoring out age, sex and common cardiovascular risk factors, the researchers found that those with PTSD had a 2.41 higher risk of death–from all causes–compared to other veterans. They added that PTSD is “an independent risk factor for cardiovascular disease”.
But to return to the original 2006 paper, what’s going on, and where could such numbers come from?
Well, let’s take a look at what “Morbidity and Mortality in People with Serious Mental Illness” found regarding Schizophrenia, which has significantly higher standardized mortality rates from the general population in a number of ‘natural causes of death’ areas:If you break down the numbers, you’ll find that Schizophrenics are:
2.7X more likely to die of diabetes
2.3X more likely to die of cardiovascular disease
3.2X more likely to die of respiratory disease, and
3.4X more likely to die of infectious disease
than the general population.
A more recent study, the 2009 “Premature Mortality from General Medical Illnesses Among Persons with Bipolar Disorder: A Review,” found that
Higher mortality from natural causes among patients with bipolar spectrum disorders ranged from 35% higher than a comparison group to twofold [that’s 200%] higher. The increased mortality rate is similar to the increased risk of mortality associated with smoking. [emphasis mine]
The authors provide a plethora of possibilities to explain the shocking statistics, and the reasons apply equally well to the findings regarding Schizophrenia.
But let’s start simple, and let’s start with a very important fact:The causes of illness and death among the SMI are virtually the same as for those in other parts of the population (obesity, diabetes, cigarettes), and are treatable.
The reasons for appalling rates of illness among the SMI are manifold, and bear addressing, but one of the more obvious ones is disturbingly simple: The Agency for Health Care Research and Policy ran a number of studies from 2007-2009 and found that
People with psychotic disorders [like schizophrenia] and bipolar disorder are 45 percent and 26 percent less likely, respectively, to have a primary care doctor than those without mental disorders.
It doesn’t explain everything–but it’s a pretty good place to start, I’d say.
The other risk factors are all ones shared between the psychiatric and non-psychiatric community–and ones that could be addressed, were there a will and a way.
Let’s take a look at some of the major reasons the SMI are at such high risk for early death.
Three of the major causes of preventable death are: Smoking, obesity, and diabetes.
Causes of Preventable Death
Smoking. This is a serious one. Smoking is the leading cause of preventable deathin the U.S. according to the U.S. Department of Health and Human Services. Yet smoking is prevalent among psychiatric communities.In a paper entitled “Smoking and Mental Illness: A Population-Based Prevalence Study,” Karen Lasser and her colleagues from Harvard determined that 41% of people with mental illness smoke, compared with 22.5% of those who have never been mentally ill. After some rather complicated statistical figuring, they estimated that people with mental illnesses may make up nearly 45% of the total tobacco market in America. Over a decade has passed since the publication of that paper–but I could not find significant improvements in the numbers of mentally ill who smoked. It is a serious health hazard, and an issue that needs addressing.
Obesity: As recently as March of this year, the journal Progress in Neuro-Psychopharmacology & Biological Psychiatry published a study indicating that people with BD or Schizophrenia were three times more likely to be obese than the general population. There were a number of factors for this, including:
- poor diet, and
- a more sedentary lifestyle–AND
For the kicker is that a significant amount of obesity was contributable to the very medications the patients take to help them with their disorders.Write the study’s authors:
Our results… suggest that overweight or obesity among patients with BD or schizophrenia could be attributed, rather than to a specific psychiatric diagnosis, to a chronic course of illness and the long-term use of psychotropic medication.
Several of the mood stabilizers, frequently taken by BD patients, are associated with weight gain. And of the second-generation antipsychotics, which many BD patients take and which the majority of Schizophrenics, several are associated with large weight gain, along with diabetes, which also puts the person at risk for cardiovascular disease.
Diabetes: Those with SMI have more chronic stress, which is correlated with increased cortisol levels, which increase insulin resistance, putting them on the diabetes path once again.
In a shocking statistic, it is now believed that around 1 in 5 among the mentally ill develop diabetes, fully double the rate in the general population.
Given its direct correlation with obesity, however, we shouldn’t really be that surprised. To make matters worse, it appears that their care suffers in relation to the non mentally ill, as well.
In a 2007 article, “Quality of Diabetes Care Among Adults With Serious Mental Illness,” the authors found that
Evidence of lower quality of diabetes care was found for persons with serious mental illness as reflected by their receipt of fewer recommended services and less education about diabetes, compared with those without serious mental illness.
Complications from diabetes are manifold, but, looking at the statistics above, it seems that the illness might very well be leading–directly or indirectly–to another over-inflated cause of death: heart disease, where the patients due from heart attacks or strokes.(picture from freedigitialphotos.net)
Additional Causes of Death
- Cardiovascular Disease: realized to the first three, it’s the same poor diet, lack of exercise and obesity that lead to diabetes that are also major risk factors for heart attacks and strokes, as well. But the risk factors keep increasing.
John W. Newcomer, M.D., professor of psychiatry, of psychology and of medicine and medical director of the Center for Clinical Studies at Washington University states the preventative care among the SMI is woefully lacking.
Analyzing the data of 1500 patients with chronic schizophrenia, he found that 88% of those with high cholesterol did not take lipid-lowering medications. 30 percent with diabetes at the start of the study received no anti-diabetes medications, and 62 percent of those with high blood pressure weren’t taking any antihypertensive medication.They were less likely to be screened for high cholesterol, high blood pressure or diabetes despite their known risk factors.
And in a truly quirky finding that has since been replicated, research indicated that SMI itself, specifically Depression, even without diabetes and obesity, could greatly increase one’s risk of heart disease.
Dr. William W. Eaton of the Johns Hopkins School of Hygiene and Public Health in Baltimore analyzed with his team 1,551 people in without heart disease, and discovered that those who were depressed were four times as likely to have a heart attack in the next 14 years.In fact, in the study, depression was a as great of a risk factor for heart disease as were elevated levels of blood cholesterol.A second study found followed 222 patients who had had heart attacks and found the following: Thoes who were depressed were four times as likely to die in the next six months as those who were not depressed.
Living alone and social deprivation are not uncommon with the SMI, and, in prior research, have been shown to lead to earlier mortality.*
SMI patients frequently have a ‘dual diagnosis,’ or also abuse alcohol or drugs.**
Psychiatric providers, with whom the patients may have more contact than the general health system, may fail to ask about and address medical problems, and other physicians may not address their needs. Wendy Brennan, executive director of the National Alliance on Mental Illness (NAMI) in New York City, says
Medical doctors think, ‘Well, they’re crazy,’ so they don’t take their concerns seriously. Their very real physical symptoms are often dismissed.***
These are entrenched problems, and it is difficult to deal with them–but it is not impossible.
Better health prevention and screening, better access to health care, more awareness of exercise and dietary needs, better education for physicians about spescific needs of the mentally ill–they’re all possible. You may have ideas–as do I; now all we need to do is write, campaign, petition, and otherwise work to enact them.
Because a society that–no matter how inadvertently–allows its mentally ill to die decades early, isn’t one that we can belong to, and still hold our heads high.
*See, for example, “Social Relationships and Mortality Risk: A Meta-analytic Review” (PLoS Med. 2010 July; 7(7): e1000316), or “Social network and activities in relation to mortality from cardiovascular diseases, cancer and other causes: a 12 year follow up of the study of men born in 1913 and 1923” (J Epidemiol Community Health. 1992 Apr;46(2):127-32.)
**Look at “Association of psychiatric illness and all-cause mortality in the National Department of Veterans Affairs Health Care System” (Psychosom Med. 2010 Oct;72(8):817-22. Epub 2010 Jul 16) for high rate of mortality caused by alcohol and drug abuse among veterans, and “Substance abuse and psychiatric co-morbidity as predictors of premature mortality in Swedish drug abusers: a prospective longitudinal study 1970-2006” (BMC Psychiatry. 2011 Jul 30;11:122) for a fascinating study in Sweden about the interplay of psychiatric siagnosis and substance abuse and its effect on early death.
***An interesting area for further study, there is research out there. See “Stigma toward the mentally ill in the general hospital: a qualitative study” (General Hospital Psychiatry 27(5):359-64; September 2005) and “Discrimination in health care against people with mental illness” (Int Rev Psychiatry. 2007 Apr;19(2):113-22.).
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Gurpegui M. Overweight and obesity in patients with bipolar disorder or schizophrenia compared with a non-psychiatric sample. Progress in Neuro-Psychopharmacology & Biological Psychiatry 2012; 37(1):169-75.
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