From the Editor
Dying too young
Cardiovascular neglect of the mentally ill
The life span of the seriously mentally ill is even shorter than we had thought. Earlier studies showed a loss of 20% of the average life span or 15 to 16 years.1 Recent figures are alarmingly higher, however, and vary from state to state.
Virginia has the "best" mortality rate among the seriously mentally ill with a loss of "only" 13.5 years of potential life, according to the Center for Mental Health Services (CMHS) and the Centers for Disease Control and Prevention (CDC).2 Perhaps persons who suffer from schizophrenia should move to Virgina because the loss of potential life years in other states is much worse:
• Arizona: 31.8 years
• Texas: 29.3 years
• Missouri: 27.9 years
• Utah: 26.9 years
• Oklahoma: 26.3 years.
A recent Ohio study of mortality and medical illness found an average loss of 32 years of life among persons with schizophrenia.3
Why is the life span of mentally ill persons so short? Apart from their high rates of death from unnatural causes (suicide, homicide, and accidents), the most frequent killer is cardiovascular disease. High mortality rates are well-documented in schizophrenia from various ailments but especially heart disease.4 Bipolar disorder and major depression are also associated with high death rates from cardiovascular disease.5
The sad truth is that a “dual neglect” contributes to premature mortality of the seriously mentally ill: the system fails to provide ongoing basic primary healthcare, and patients neglect to seek or adhere to medical care.
Persons with serious mental illness often have risk factors associated with preventable causes of heart disease and stroke, including smoking, obesity, sedentary life styles, and poor nutrition. In addition, the metabolic syndrome—obesity, hypertension, hyperglycemia, and dyslipidemia—is highly associated with schizophrenia,6 bipolar disorder,7 and unipolar depression.8
Cardiovascular risk associated with metabolic syndrome requires ongoing medical follow-up, which many mentally ill patients do not receive. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) found shockingly low treatment rates for diabetes, hypertension, and hyperglycemia among outpatients with schizophrenia around the country.9
Let us mobilize to correct this shameful health disparity, one patient at a time. The message to mental health professionals is clear:
• In addition to controlling symptoms of psychosis, mania, depression, or anxiety, routinely screen patients for weight gain, hypertension, high fasting serum glucose, and elevated lipid levels.
• Refer overweight and obese patients to primary care providers, dietitians, and exercise counselors to reduce their cardiovascular risks.
Psychiatrists and nurse practitioners must address both mental and medical health needs when formulating assessments, treatment plans, and patient education. For practical recommendations on managing medical comorbidities, see “7-point checkup for stable schizophrenia outpatients,” by Britton Ashley Arey, MD, and Stephen R. Marder, MD. The public mental health system also could help the seriously mentally ill by integrating primary healthcare with mental healthcare in community settings across the nation. There are no excuses to do anything less.
1. Newman SC, Bland RC. Mortality in a cohort of patients with schizophrenia: a record linkage study. Can J Psychiatry 1991;36:239-45.
2. Cotton CW, Manderscheid RW. Congruencies in increased mortality rates years of potential life lost and causes of death among public mental health clients in eight states. Preventing Chronic Disease 2006;3:1-14.
3. Miller B, Paschall CB. Svendsen DP. Mortality and medical comorbidity among patients with serious mental illness. Psychiatr Serv 2006;57:1482-7.
4. Meyer JM, Nasrallah HA, eds. Medical illness and schizophrenia. American Psychiatric Publishing, Inc.: Washington DC; 2003.
5. Angst F, Stassen FF, Clayton PJ, Angst J. Mortality of patients with mood disorders: follow-up over 34-38 years. J Affect Disord 2002;68:167-81.
6. McEvoy JP, Meyer JM, Goff DC, et al. Prevalence of the metabolic syndrome in patients with schizophrenia: Baseline results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES III. Schizophr Res 2005;80:19-32.
7. Taylor V, MacQueen G. Associations between bipolar disorder and the metabolic syndrome: a review. J Clin Psychiatry 2006;67:1034-41.
8. Heiskamn TH, Niskanen LK, Hintikka JJ, et al. Metabolic syndrome and depression: a cross-sectional analysis. J Clin Psychiatry 2006;67:1422-7.
9. Nasrallah HA, Meyer JM, Goff DC, et al. Low rates of treatment for hypertension, dyslipidemia, and diabetes in schizophrenia: data from the CATIE schizophrenia trial sample at baseline. Schizophr Res 2006;80:15-22.