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Background: Patients with serious mental illness (SMI; e.g., psychotic disorders and major mood disorders) die earlier, have more medical illnesses, and receive worse medical care than those in the general population.."75 Patients with SMI are losing an astonishing number of years of life to preventable and treatable medical illnesses. The reasons for this mortality gap are numerous and interrelated and include patient-, provider-, and system-level factors. Solutions to the problem will require attention to all these areas, but provider responsibility and strategies aimed at the integration of medical and psychiatric care hold immediate promise for correcting the health and healthcare disparities faced by this vulnerable and neglected population. Viron and Stern Psychosomatics 51:6, November-December 2010 http://psy.psychiatryonline.org 463 References
Background: Patients with serious mental illness (SMI; e.g., psychotic disorders and major
mood disorders) die earlier, have more medical illnesses, and receive worse medical care than
those in the general population. Objective: The aims of this article are to review the data on
medical morbidity and mortality in those with SMI, to highlight the factors that lead to such disparities, and to discuss potential solutions to the problem. Method: The authors reviewed the
literature on medical morbidity and mortality in those with SMI. Results: Adults with SMI in the
United States die 25 years earlier than those in the general population; cardiovascular disease
is responsible for the majority of this excess mortality, accounting for roughly 50%– 60% of the
deaths due to medical illness. Patient, provider, and system-level factors interact to contribute to
poor health outcomes in people with SMI. Conclusion: Patients with SMI are losing many years
of life to preventable and treatable medical illnesses. Solutions to the problem will require attention to patient, provider, and system-level factors. (Psychosomatics 2010; 51:458 – 465)
“Recovery” from mental illness has become a guiding principle of current mental health policy and
practice.1 Patients with serious mental illness (SMI), for
example, psychotic disorders and major mood disorders,
also described as “severe,” “major,” or “severe and persistent” mental illness, face numerous obstacles on the
path to recovery. Although social stigma, medications with
limited effectiveness, and the inadequate availability and
funding of mental health services all interfere with optimal
treatment, sadly, these are only a few of the barriers to effective care. Those with SMI die earlier, have more medical
illnesses, and receive worse medical care than those in the
general population. They lose years of potential life, most
often secondary to medical illnesses; cardiovascular disease
(CVD) is an especially significant contributor. Poor outcomes
are linked with a host of patient, provider, and system factors,
as well as with the provision of substandard medical care.
True recovery is not possible if a patient is dying prematurely
from a preventable and/or treatable medical illness. Addressing this complex problem will require the effort of mental
health providers as well as system-wide integration of medical and mental health care. The aim of this article is to
review the elevated mortality and medical morbidity in those
with SMI, and illuminate the patient, provider, and system
factors that lead to such disparities, and discuss potential
solutions to the problem.
Mortality Associated with Serious Mental Illness
Compared with the general population, adults with
SMI in United States public systems of care are at a
greater risk of death, with deceased patients losing over 25
years of potential life.2 This mortality gap, based on data
from 1997 to 2000, is 10-to-15 years wider than it was in
Received December 3, 2009; revised January 12, 2010; accepted January
13, 2010. From the Dept. of Psychiatry, Massachusetts General Hospital,
Boston, MA. Send correspondence and reprint requests to Mark J. Viron,
M.D., Dept. of Psychiatry, Massachusetts General Hospital, 15 Parkman
St., WACC 812, Boston, MA 02114. e-mail: [email protected]
© 2010 The Academy of Psychosomatic Medicine
458 http://psy.psychiatryonline.org Psychosomatics 51:6, November-December 2010
the early 1990s.3 Similar inequities have been seen in
other developed countries; a Finnish register study of
66,881 patients with schizophrenia revealed a mortality
gap of 25 years in 1996 and 22.5 years in 2006.4
People with SMI are known to have an elevated risk
of death from suicide and injuries.5 These deaths account
for 30%– 40% of the excess deaths seen in people with
SMI, and the other 60%–70% of deaths are attributable to
medical illnesses.5 In fact, 87% of the years of potential
life lost are due to deaths from medical illnesses.6 CVD is
responsible for the majority of this excess mortality, accounting for some 50%– 60% of the deaths due to medical
illness.2,5,7
Medical Morbidity in Serious Mental Illness
Medical illnesses are highly prevalent in people with
mental illness. In fact, compared with those in the general
population, mentally ill individuals are more likely to develop medical illnesses, develop them at a younger age,
and die sooner from them; 50%–90% of people with SMI
have at least one chronic medical illness.8 Rates are even
higher in those with comorbid substance-use disorders.9 In
an age- and gender-matched sample of Medicaid enrollees
with and without SMI, patients with SMI had higher rates
of medical illnesses across all 12 disease categories examined, including CVD.10 Not surprisingly, individuals with
schizophrenia and bipolar disorder also had higher rates of
modifiable cardiovascular risk factors. Obesity, smoking,
diabetes, hypertension, and dyslipidemia occur at rates
1.5–5 times greater than the rates seen in the general
population.11 Metabolic syndrome (a clustering of obesity,
dyslipidemia, hypertension, and glucose dysregulation),
which confers a 2–3 times greater risk of coronary heart
disease (CHD), myocardial infarction (MI), and stroke, as
well as a relative risk of cardiovascular death of 3.55, is
found in those with schizophrenia and bipolar disorder at
a rate 2–3 times the rate seen in the general population.11,12 Potentially contributing to this problem is the use
of atypical antipsychotics, which, although having differential metabolic liabilities by agent, are known to cause
weight gain, glucose dysregulation, and lipid abnormalities.13
In 2006, the United Kingdom Disability Rights Commission commissioned an analysis of 8 million primarycare records from England and Wales, finding multiple
examples of health disadvantages faced by people with
mental illness;14 31% of people with both schizophrenia
and CHD were diagnosed with CHD before the age of 55
years, versus 18% of those in the general population.
Similar patterns of early diagnosis held true in schizophrenia for stroke, diabetes mellitus, and chronic obstructive
pulmonary disease (COPD).14 Whether these data reflect
earlier onset of medical illness in patients with SMI or
simply earlier detection is unclear.
When patients with serious mental illness develop
CVD, they tend to die sooner than patients with CVD
without mental illness. In a population-based cohort study
of 4.6 million people in Denmark (from 1994 to 2007), 5
years after their first contact with the healthcare system for
heart disease, 8.26% of those with SMI had died, versus
2.86% of those with CVD but without serious mental
illness.15
Factors That Contribute to Poor Health and Poor Health
Outcomes Numerous patient-, provider-, and systemlevel factors interact in multiple ways to contribute to the
poor health outcomes seen in people with SMI.
Patient-Level Factors
Mental illness may be an independent risk factor for
medical illness, via direct physiological effects or underlying genetic vulnerabilities. Almost 100 years ago, well
before the use of antipsychotic medication, glucose dysregulation was noted in patients with psychotic disorders.16,17 Recently, impaired fasting glucose tolerance was
found in drug-naive patients with their first episode of
schizophrenia.18 Also, depression is known to decrease
heart rate variability and to increase platelet adhesiveness;
each contributes to adverse cardiovascular consequences.19 Finally, some of the same genetic abnormalities associated with mental illness (such as a variant of the methylenetetrahydrofolate reductase gene that is found in
schizophrenia, major depression, and premature CVD)
have been found in medical illnesses.16
The symptoms of mental illness can adversely affect
a person’s general health. Fear and mistrust of healthcare
providers, disorganized thinking, cognitive impairment,
impaired insight into illness, and a lack of motivation can
make it difficult for a patient to describe or to recognize
physical symptoms and communicate these symptoms to
providers.16,20 –23 Symptoms of mental illness can also
make it difficult for a patient to access and to engage in
care when healthcare systems are complex and fragmented;24 adherence to treatment may also be impeded by
SMI.8,23
Viron and Stern
Psychosomatics 51:6, November-December 2010 http://psy.psychiatryonline.org 459
Patients with SMI tend to engage in unhealthy behaviors. They are less physically active,25,26 and they have
worse dietary habits.16,26 High rates of drug and alcohol
use have also been detected in those with SMI. In the
National Institute of Mental Health (NIMH) Epidemiologic Catchment Area (ECA) survey of 20,291 people,
having a mental illness conveyed a 2.3-times greater risk
of having an alcohol-use disorder and a 4.5-times greater
risk of having a non-alcohol substance-use disorder than
did not having a mental disorder.27 Of those people with
schizophrenia, 47% met criteria for a substance-use disorder (odds ratio [OR]: 4.6).27
Furthermore, those with SMI are more likely to live in
disadvantaged social circumstances, and people who live
in resource-poor conditions are known to experience
worse health.28,29 In the general U.S. population, for example, limited education is associated with increased mortality (477.6 deaths per 100, 000 in those with education
beyond high school versus 650.4 per 100, 000 in those
with less than a high school education);28 people with SMI
are less likely to complete high school.30 Also, rates of
unemployment are 3-to-5 times higher in this population;
poverty affects one-third to one-half, and up to one-fifth of
those with schizophrenia are, at some point, homeless.8
Finally, 25% of those with SMI report having been the
victim of a violent crime in the year preceding the survey.31 Such adverse social circumstances likely play a
significant role in the poor health experienced by people
with SMI.
Provider-Level Factors
Certain attributes of medical care providers may interfere with delivery of optimal healthcare for those with
mental illness. Discriminatory beliefs, such as finding a
patient with mental illness to be “difficult and time-consuming,”32 and feeling a general uneasiness with such
patients are not uncommon32,33 and may stem from a
provider’s limited experience with this patient population.34 Having diminished expectations of mentally ill patients as collaborators in their care may lead to “therapeutic nihilism,”24 wherein patients are not provided with
enough information to help them make healthy lifestyle
changes (e.g., quitting smoking) out of concern that they
may be unwilling or unable to understand or adhere to
such recommendations.20
A phenomenon known as “diagnostic overshadowing,” where providers attribute a patient’s physical symptoms to his or her mental illness, rather than to a medical
illness, has the potential to interfere with the provision of
medical care.35 A survey of 300 family physicians who
were presented with hypothetical patient-care scenarios
demonstrated that physicians responded differently to patients with a mental-health history than they did to patients
without such a history (with respect to diagnostic considerations and testing); having a psychiatric history made
them less likely to think that a patient had a serious medical illness.36 Similar results were seen among nurses who
were given a hypothetical scenario (where a patient presented with chest pain and either a history of being on no
medication or on multiple psychiatric medications).37 The
nurses estimated that the probability the patient was having a myocardial infarction was 50.6% in those not taking
psychotropics versus 35% in those taking psychotropics.37
Diagnostic overshadowing, which may amount to a subtle
or unconscious form of discrimination, is often perceived
by patients with psychiatric illness. In a recent National
Alliance on Mental Illness (NAMI) survey of 250 people
with schizophrenia, 49% felt that doctors took their medical problems less seriously after discovering that they had
a psychiatric diagnosis.38
System-Level Factors
Elements of current healthcare systems, both national
and international, present abundant challenges (including
hindered access, lack of system integration, and the provision of poor-quality care) to patients with mental illness
in need of medical care, and, as a result, accessing medical
care is difficult for mentally ill patients.16,39,40 Problems
with healthcare access are often measured by using rates
of appendicitis with rupture (as a surrogate marker). Elevated rupture rates are seen in elderly and uninsured patients and in some minority groups. In a large Taiwanese
study, patients with schizophrenia had rates of appendicitis
with rupture that were 2.83 times higher than those in the
general population.41,42 Access to care is also limited by
being un- or under-insured, a situation in which many with
SMI find themselves.40 More proximal and procedural
barriers can also hinder healthcare access.34 In the U.K.
Disability Rights Commission investigation, many patients with mental illness reported difficulty navigating
cumbersome scheduling procedures and tolerating anxiety-inducing waiting-room milieus.14
Delivery of high-quality medical care for people with
SMI is also hindered by the systematic separation of mental and medical healthcare, which is seen at the federal,
Mental Illness and Healthcare
460 http://psy.psychiatryonline.org Psychosomatics 51:6, November-December 2010
state, and local levels. This separation leads to a fragmented system where cross-system coordination and collaboration are, at best, problematic and, at worst, disincentivized by lack of reimbursement.6,10 The role that
poorly integrated care may play in the poor health outcomes of patients with SMI may be suggested by the data
that shows an increase in mortality coinciding with the
years after deinstitutionalization in several countries,42
since, in a psychiatric hospital, prompt medical care may
be more readily available.
Poor Quality of Care
When patients with SMI obtain medical care, it tends
to be of lesser quality. In fact, such patients experience
disparities in care that fall under each of the three general
categories of poor quality care outlined by Chassin:43
“overuse,” “underuse,” and “misuse.”
Overuse of care refers to providing care in which the
risk outweighs the benefit. More broadly, it can be defined
as providing care that is inappropriate or excessive, given
the clinical situation,44 and frequent use of care can, when
risks trump benefits, be considered overuse. Patients with
SMI have high rates of emergency department (ED) use
for medical illness.45,46 In a randomly selected sample of
200 psychiatric outpatients with SMI, 37% had made one
or more visits to the ED for medical concerns in the past
year, versus 20% for those in the general population.46 A
report of ED use in Austin, Texas, found that 9 individuals
accounted for almost 2,700 ED visits from 2003 to 2008.47
Eight patients had substance-use disorders, and seven had
non–substance-related (but otherwise unspecified) psychiatric diagnoses.47 Although the evidence suggests increased usage of the ED for medical complaints by patients with SMI, the clinical appropriateness of emergency
care—and thus whether this use would constitute overuse—is difficult to assess without an analysis of the reasons for the individual ED visits.
Underuse of care involves failing to provide care in
situations where the benefit outweighs the risk. People
with SMI obtain fewer general preventive healthcare services,48 –50 and, in general, tend to receive medical care
sporadically and at later stages of their illness.45,51 In the
U.K., patients with SMI were less likely to be offered
smoking-cessation treatments, blood pressure monitoring,
and diet and exercise advice from their primary-care providers than were those without SMI.52 Even within psychiatry, where the cardio-metabolic risks associated with
various psychotropics medications, particularly atypical
antipsychotics, are well known, screening and monitoring
for these potential adverse consequences is infrequent. For
example, despite data showing that psychiatrists recognize
weight gain and other metabolic side effects as serious
concerns when using atypical antipsychotics,53 research
based on insurance database records revealed low rates of
guideline-recommended screening for abnormalities of serum glucose (23% of patients received baseline screening
and 38% annual screening) and lipids (8% of patients at
baseline screening and 23% of patients at annual screening).54
Poor rates of screening resulted in underdiagnosis of
medical illness, and likely contribute to the low rates of
treatment seen for these conditions in patients with SMI.
In the Clinical Antipsychotic Trials in Intervention Effectiveness (CATIE), the point-prevalence of treatment for
diabetes, hypertension, and dyslipidemia in individuals
with schizophrenia was 70%, 40%, and 10%, respectively.55 Similar rates of undertreatment were seen in a U.K.
sample of 1,966 patients treated in an assertive community-treatment program.56 Even with a known diagnosis of
diabetes, patients with SMI may not receive the same level
of standard-of-care monitoring. A study of 313,586 patients with diabetes cared for in the Veterans Health Administration (VHA) found that patients with SMI were at
greater risk for not receiving guideline-based periodic eye
examinations and monitoring of hemoglobin A1c and lowdensity lipoproteins.57 They were also more likely to have
had none of these parameters monitored during a 12-
month period.57
Disparities in the provision of medical care to patients
with SMI are also seen during medical hospitalizations. Of
88,241 Medicare patients over the age of 65 hospitalized
after an MI, the risk of mortality in the subsequent 12
months was 19% greater for patients with any mental
illness and 34% greater for patients with schizophrenia, as
compared with the non-mentally ill cohort.58 Furthermore,
the increased mortality was clustered among patients who
did not receive some or all of five well-established indicators of quality post-MI care: reperfusion therapies, betablockers, aspirin, angiotensin-converting enzyme (ACE)
inhibitors, and smoking-cessation treatments.58 Other
studies have also shown that post-MI cardiovascular procedures (such as cardiac catheterization, percutaneous
transluminal coronary angioplasty, and coronary artery
bypass graft surgery), are used in patients with SMI at
lower rates than they are in the general population.59,60
Viron and Stern
Psychosomatics 51:6, November-December 2010 http://psy.psychiatryonline.org 461
In a retrospective cohort study of 113,000 Medicare patients over the age of 65, twice as many patients (44%)
without a mental disorder received a cardiac catheterization after MI than did patients with schizophrenia (22%).59
Avoidable complications of appropriate care, or
healthcare misuses, are also more common in patients
with SMI. In an analysis of all medical and surgical
discharges from acute-care hospitals in Maryland from
2001–2002, Daumit and colleagues61 found higher rates
of in-hospital adverse events when comparing 1,746
patients with schizophrenia with 732,158 without
schizophrenia. Specifically, patients with schizophrenia
had higher rates of infections from medical care (OR:
2.49), postoperative respiratory failure (OR: 2.08),
postoperative deep venous thrombosis or pulmonary
embolism (OR: 1.96), and postoperative sepsis (OR:
2.29).61 Similarly, Kudoh and colleagues62 found elevated postoperative rates of ileus and delirium in patients with schizophrenia, as opposed to those in the
general population. Finally, when patients with schizophrenia experienced these adverse events, they also experienced worse outcomes from these events when compared with other patients. The 2006 study by Daumit
and coworkers61 found that postoperative respiratory
failure or sepsis resulted in twice the rate of intensive
care unit (ICU) admissions and death in patients with
schizophrenia versus controls with the same complications.
SOLUTIONS: A CALL TO ACTION
The health and healthcare disparities faced by those with
mental illness have been well documented. Urgent and
transformative action will need to be taken to achieve the
elimination of these disparities. As with any complex
problem with multiple causes, eliminating disparities will
require action on many fronts. This section will focus on
opportunities for beneficial change at the provider and
healthcare-system levels.
Provider Responsibilities
Mental health care providers can challenge lowered
expectations— both their own and those of their patients—
with respect to their patients’ medical care.10 Despite the
fact that the overwhelming majority of people with SMI
believe that their overall health affects their recovery from
mental illness, only 52% of 250 people with schizophrenia
surveyed expected that their psychiatrist would focus on
their overall mental and physical health.39 Furthermore,
the fact that 55% of 74 patients recently surveyed at an
Irish community mental health clinic were unaware of the
metabolic side effects of atypical antipsychotics63 suggests
that health-education efforts may need to be increased.
Providers should educate patients, as well as their families
and caregivers, about pertinent general-health topics to
enable patients to make informed decisions about their
health and healthcare and to establish them as true partners
in their care.
Providers need to focus on prevention. Screening
for medical illness and modifiable risk factors for cardiovascular disease is of paramount importance because, although effective treatments exist, undiagnosed
illness and undetected risk factors will not receive clinical attention. Although consensus guidelines64 exist for
the cardio-metabolic monitoring of patients on atypical
antipsychotics, the evidence that patients with SMI tend
to have higher rates of metabolic disturbances irrespective of use of atypical antipsychotics has led some to
make the well-reasoned argument that greater emphasis
should be placed on screening all individuals with
SMI.49 The disturbing paradox remains that patients
with SMI are screened and monitored for cardio-metabolic problems less often than those in the general
population, although they represent a group that would
likely benefit from earlier and more intensive screening
and monitoring. Because patients with SMI are mostly
or often only in regular contact with their mental-health
providers,65 until better systems are in place to ensure
regular access to general-medical services, mentalhealth providers need to take responsibility for monitoring common general-health parameters and advocate
for access to timely and appropriate medical services.49
Improved disease-prevention efforts can take the
form of increasing rates of offering smoking-cessation,
diet, and exercise counseling. A cross-sectional analysis
of data from the National Ambulatory Medical Care
Survey from 1992 and 1996 found that in 1,600 office
visits of patients with mental illness who were documented smokers, psychiatrists offered smoking-cessation counseling at 12% of the visits, and diet and exercise counseling at 6% and 4% of visits, respectively.66
Although, more recently, psychiatrists may be spending
more time counseling patients on diet, exercise, and
lifestyle issues,12 creative solutions need to be developed to ensure that the majority of psychiatric patients
Mental Illness and Healthcare
462 http://psy.psychiatryonline.org Psychosomatics 51:6, November-December 2010
receive such information. Although not routinely offered smoking-cessation counseling, patients are interested in quitting. A survey of 60 patients with schizophrenia revealed that 40% were motivated to stop
smoking.67 Smoking cessation can dramatically decrease the risk of CVD, and even modest weight reductions can have great health benefits.26 Furthermore,
identification of modifiable risk factors for CVD (such
as hypertension, dyslipidemia, and diabetes) is the first
step in getting patients treatment for these conditions—
treatment that greatly decreases the risk of CHD and
stroke.68
Systems of Care
From a healthcare-systems perspective, the integration of medical and mental healthcare remains a pressing
priority, and it holds great potential for closing the mortality gap. Greater integration of clinical services between
medical and mental healthcare is touted by the Institute of
Medicine as a central strategy for improving the quality of
care for people with mental illness.69 At its most basic, the
integration of clinical care involves increasing communication and collaboration between psychiatric and generalhealth providers.20 To be successful, clinical integration
needs to be supported (although not necessarily preceded)
by organizational integration, which provides functional
and formal linkages between services, and financial integration, which allows for a reimbursement structure that
supports integrated care activities.70
The VHA provides one model for care-integration
(with its co-located medical and mental health services,
shared electronic medical records, focus on national care
standards, and ongoing quality-of-care monitoring).71 Several studies have demonstrated reduced healthcare disparities within the VHA system. Rates of cardiac catheterization after MI are only marginally lower in patients with
SMI than they are in those without SMI (41% versus
43%), and, of four post-MI quality-of-care measures (use
of beta-blockers, ACE-I, ASA, and reperfusion therapies),
only the use of beta-blockers is lower in patients with
SMI.71 Furthermore, instead of the 25 years of potential
life lost seen in patients with SMI cared for in U.S. public
systems of care, the average VHA patient with SMI loses
13.8 years of potential life.72
Other successful models of integration exist, ranging from cross-specialty training of healthcare professionals to consultation, enhanced referral, and collaborative-care models.6,24 Druss and colleagues73 tested a
co-located collaborative-care model in which 59 VHA
patients with mental illness were randomized to receive
primary medical care through an integrated-care initiative within the mental health department, and 61 were
randomized to “usual care” in a VHA general-medicine
clinic for medical care. The integrated-care group, in a
manner that echoes the proposed “mental health home”
model of Smith and Sederer,74 had on-site primary care
provided by a family physician and nurse-practitioner;
case managers (who coordinated preventive medical
care, patient education, and collaboration among mental-health and general-health providers); and a flexible
approach to appointment scheduling (extended appointments, consecutive same-day medical and mental-health
visits) to allow for optimal delivery of services.73
Whereas merely having a formalized referral system in
place for the “usual care” group led to increased utilization of medical services by the patients over the next
year, the integrated-care group was significantly more
likely to have attended a primary-care visit, received
preventive health services, and scored better on a validated self-report measure of general health.73 Those in
the integrated model were also less likely to have utilized emergency medical services.73 Although total
healthcare costs were not different between the groups,
this model of integrated care appeared to be a successful
and cost-effective way to improve medical care for
patients with mental illness.
CONCLUSION
In a 2008 paper based on a consensus conference addressing medical illness in SMI, Fleischhacker and associates75 concluded that “[S]omatic health. . .is too often neglected, thus contributing to an egregious health
disparity. The reintegration of psychiatry and medicine. . .represents the most important challenge for psychiatry today, requiring urgent and comprehensive action. . .”75 Patients with SMI are losing an astonishing
number of years of life to preventable and treatable
medical illnesses. The reasons for this mortality gap are
numerous and interrelated and include patient-, provider-, and system-level factors. Solutions to the problem
will require attention to all these areas, but provider
responsibility and strategies aimed at the integration of
medical and psychiatric care hold immediate promise
for correcting the health and healthcare disparities faced
by this vulnerable and neglected population.
Viron and Stern
Psychosomatics 51:6, November-December 2010 http://psy.psychiatryonline.org 463
References
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