Chapter 1. Breadth and Depth of Mortality and Morbidity
Publication: Health and Wellness in People Living with Serious Mental Illness
Serious mental illness (SMI) has a deep and broad impact on the physical health of many people. People with SMI frequently get sick and die about 20 years younger than same-age peers. We seek to describe the overall problem in this chapter. First, we begin with a brief “definition” of psychiatric disability. Next, we review research on the extent of mortality in this population. We then seek to make sense of varying morbidities by organ systems. SMI also undermines wellness, the next topic reviewed in the chapter. We end the chapter by summarizing the key issues as a foundation for the remainder of the book.
Who Are People With Psychiatric Diagnoses?
Many people experience a mental illness in their lifetime. In some cases, the illness becomes serious. Approximately one in five adults in the United States have symptoms that meet criteria for mental illness during their lifetime; 24% of those individuals experience SMI (National Institute of Mental Health 2019). Seriousness is defined by diagnosis, persistence, and disability. Several diagnoses in DSM-5 are typically viewed as serious—schizophrenia spectrum and other psychotic disorders, mood disorders (bipolar and depressive), and trauma- and stressor-related disorders—though diagnosis per se does not equal severity (American Psychiatric Association 2013). Schizophrenia, which is often viewed as the prototypical disorder, actually has a more benign course than that originally described by Emil Kraepelin in the early twentieth century and later incorporated into versions of DSM. A rough rule of thirds seems to emerge from long-time follow-up research on schizophrenia: about one-third of persons with the disorder seem to recover altogether, one-third are able to meet life goals with relatively low treatment demands (e.g., regular visits to a psychiatrist and corresponding medication), and one-third—those we typically think of—are seriously disabled by the recurring illness (Harding et al. 1987; Huber et al. 1975; Ogawa et al. 1987). Hence, it is the recurring and challenging nature of mental illness that makes it disabling. For example, anxiety disorders, considered less pernicious than schizophrenia, can be persistently disabling and thus serious. Let us consider these two concepts more thoroughly.
Serious Mental Illness
SMI is persistent; its effects tend to be chronic. For some people, the course of symptoms and dysfunctions may be unchanging. For others, especially those with mood disorders, symptoms may wax and wane. It is not clear from the criteria how long the illness must harm someone for it to be considered persistent. Persistence is best understood from the perspective of people with lived experience, and where they find themselves in their development. Young adults, for example, may find a course of mental illness lasting just a year to be persistent. Conversely, elders in their 60s might not consider a couple of months of schizophrenia recurring every 5 years or so to be chronic. Like most ideas in this book, chronicity and persistence are defined by the person.
Key to “seriousness” is disability: people are not able to achieve significant life goals because of the symptoms and dysfunctions of their mental illness. The standard for “significant life goal” is defined by culture: goals in one ethnic group may differ from those in another. Under Title XVI, the U.S. Social Security Administration defines disability in terms of work: “the inability to engage in any substantial gainful activity” (U.S. Code §§1381–1383f, Subchapter XVI, Chapter 7, Title 42). In addition to work, common life goals impeded by SMI include education, independent living, relationships, and health. Specific to this book, people with SMI are disabled in terms of health when their symptoms and dysfunctions undermine accomplishing these goals.
Co-occurring Disorders
The disabilities of people with the index psychiatric diagnoses summarized above—for example, schizophrenia spectrum and other psychotic disorders, mood disorders, and anxiety disorders—are worse when there are co-occurring disorders, especially those related to substance use disorder. Epidemiological research suggests that the lifetime prevalence of substance use disorders can be as high as 50% in persons with these index conditions (Kenneson et al. 2013). Co-occurring disorders may lead to greater rates of relapse, violence, incarceration, homelessness, and HIV infection; in Chapter 3 of this book, Gaba and colleagues more thoroughly unpack this issue in terms of health.
Illness Leading to Death
Co-occurring Physical Illness
People with psychiatric disabilities show inordinate rates of co-occurring physical illnesses that worsen disabilities or lead to death. As explored in more detail later in this chapter, they have a higher incidence and prevalence of cardiovascular and respiratory illness, gastrointestinal disorders, neurological disorders, cancer, blood-borne illnesses, and orthopedic illnesses, including those due to accident. As a result, people with SMI are hospitalized for physical health problems at much higher rates (Mai et al. 2011). They overutilize emergency rooms both for exacerbated chronic conditions and for relatively benign primary care evaluations (Kêdoté et al. 2008).
The physical functioning of people with SMI resembles that of people in the general population who are 10–20 years older (Chafetz et al. 2006). Individuals with SMI are vulnerable to early institutionalization in nursing homes (Bartels et al. 2004). They enter nursing homes several years earlier than do their non–mentally ill counterparts in the population. Medical problems exacerbate mental health conditions. Finally, people with SMI experience high levels of early death; on average, people with SMI have a 20% shorter life span than others in the general population (Newman and Bland 1991).
Mortality
Mortality rates due to physical illness among people with mental illness are catastrophic across the globe. A meta-analysis of studies from around the world showed that medical diseases account for almost 70% of deaths among people with mental illness (Walker et al. 2015). Large-scale epidemiological studies have documented this more fully within individual countries. A 17-year nationally representative epidemiology study in the United States revealed that the life span of people with SMI is shortened, on average, by 8.2 years compared with the general population; 95.4% of deaths could be attributed to physical illnesses (Druss et al. 2011). In the United Kingdom, the ratio between observed and expected death rates for people with SMI ranges from 2.2 to 3.2, with bipolar and mood disorders being the lowest and psychotic disorders being the highest (John et al. 2018). Those living with SMI in the United Kingdom were 2.2–3.2 times more likely to die compared with the general population. In Australia, the life expectancy gap between people with and without mental illness is estimated to be 14–16 years; physical diseases contributed to 80% of this excess mortality (Lawrence et al. 2013). Although relatively few national epidemiological studies on comorbidities of mental and physical disorders have been conducted in developing countries, a similar pattern has been observed. Researchers investigating the Chinese population in rural communities showed that depression and anxiety significantly increased mortality rates for persons with chronic obstructive pulmonary disease (COPD), with a 3.8- to 4.5-fold elevated risk of premature death (Lou et al. 2014).
Morbidities
People with SMI exhibit morbidities in each of the 12 organ systems. We summarize the research on this in Table 1–1. In this section, we review epidemiological data on differing morbidities, describing incidence or prevalence across specific diagnoses. We also examine how physical illnesses might occur as an iatrogenic effect of treatment.
| Organ system | Examples |
|---|---|
Integumentary, muscular, and skeletal systems | Integument |
Increased risk of skin infection in the presence of comorbid diabetes and obesity relative to those without diabetes and obesity (Mookhoek et al. 2010) | |
Link between clozapine use and benign skin neoplasms (Mookhoek et al. 2010) | |
Skeleton | |
Risk of decreased bone mineral density associated with antipsychotic use (Leucht et al. 2007) and diagnosis of depression (Cizza et al. 1996) | |
Greater likelihood (three times greater) of experiencing edentulousness and higher prevalence of tooth decay among people with psychiatric disability compared with people without psychiatric disability (Kisely et al. 2011) | |
Cardiovascular, nervous, and respiratory systems | Cardiovascular system Greater likelihood of experiencing cardiovascular disease and of dying compared with people without psychiatric disability (Leucht et al. 2007) |
Greater likelihood (two times greater) of having an elevated coronary heart disease score compared to people without psychiatric disability due to increased rates of smoking, cholesterol, diabetes mellitus, and hypertension (Osborn et al. 2006) | |
Greater likelihood (4.9 times greater) of sudden cardiac death among people with schizophrenia (Ruschena et al. 2003) | |
Association between depression and heart disease (Leucht et al. 2007) | |
Link between anxiety disorders, including panic disorder, and heart disease such as stroke, arrhythmia, cardiomyopathy, high blood pressure, and mitral valve prolapse (Kahn et al. 1990) | |
Nervous system | |
Link between epilepsy and schizophrenia (Qin et al. 2005) | |
Increased risk of obstructive sleep apnea due to weight gain as a side effect of antipsychotic medications (Winkelman 2001) | |
More frequent reports of migraines among people with serious mental illness, with greater likelihood of poorer health outcomes among individuals with both migraines and a mental health diagnosis compared with those reporting just one of those conditions (Jette et al. 2008) | |
Higher rates of Alzheimer’s disease among older adults with schizophrenia compared with estimates in the general population (Prohovnik et al. 1993) | |
Link between preceding diagnosis of depression or anxiety and Parkinson’s disease (Ishihara and Brayne 2006) | |
Higher prevalence of hypoalgesia, or decreased sensitivity to pain, experienced in people with schizophrenia (reported in 37%–91% of schizophrenia patients) (Singh et al. 2006) | |
Respiratory system | |
Increased risk of chronic obstructive pulmonary disease and asthma among people with schizophrenia compared with the general population (Partti et al. 2015) | |
Potential genetic link between asthma and bipolar disorder (Wu et al. 2019) | |
Increased risk of pneumonia among people with bipolar disorder with antipsychotic use compared with people with bipolar disorder not receiving antipsychotics (Yang et al. 2013) | |
Digestive, reproductive, and urinary systems | Digestive system |
Increased prevalence of irritable bowel syndrome in schizophrenia and major depression compared with rates in the general population (Garakani et al. 2003) | |
Increased prevalence of celiac disease in individuals with schizophrenia and their relatives (Eaton et al. 2006) | |
Reproductive system | |
Increased prevalence of sexual dysfunction in individuals with schizophrenia compared with the general population (Meyer and Nasrallah 2009) | |
Association between medication-induced prolactin elevation and sexual dysfunction in schizophrenia (Knegtering et al. 2008) | |
Higher prevalence of amenorrhea in women using antipsychotic medication compared with those not using antipsychotic medication (Bargiota et al. 2013) | |
Urinary system | |
Increased lifetime prevalence of chronic kidney disease (linked with cardiovascular disease and death) in individuals with bipolar disorder partially mediated by chronic lithium and/or anticonvulsant use (Kessing et al. 2015) | |
Endocrine, immune, and lymphatic systems | Endocrine system |
Increased lifetime risk for affective disorder in individuals with hypothyroid disorder (Thomsen et al. 2005) | |
Immune system | |
Higher prevalence of autoimmune disease in individuals presenting with onset of schizophrenia compared with matched control subjects (Eaton et al. 2006) |
Integumentary, Muscular, and Skeletal Systems
These body systems constitute the foundations of human anatomy and include skin, hair, nails, bones, cartilage, teeth, ligaments, and muscles. Conditions involving these body systems can severely interrupt functioning as well as appearance of individuals who experience them. Links between comorbid conditions of the integumentary and skeletal systems and SMI, as well as possible etiology and impacts, are delineated below. (Of note, we were unable to find a connection between SMI and musculature.)
Integumentary System
An investigation by Mookhoek et al. (2010) noted increased risk of skin infection for individuals with SMI and comorbid diabetes (risk of diabetes in people with SMI is explored more later in this chapter) and in patients experiencing obesity. Pharmacological treatment of SMI could prove an added risk factor for developing integumentary conditions among individuals with SMI. In a study of 108 participants enrolled in psychiatric outpatient services in Hong Kong, the 51 participants prescribed lithium, typically for bipolar disorder, were significantly more likely than the 57 prescribed other psychotropic medications to develop skin conditions (P = 0.025); there was no significant difference between the two groups in terms of rate of cutaneous conditions before commencing medication. Cutaneous conditions reported included psoriasis, acne, maculopapular eruption, folliculitis, and seborrheic dermatitis (Chan et al. 2000). A possible link between use of clozapine and benign skin neoplasms has been reported, though the nature of this relationship is, as of yet, undetermined (Mookhoek et al. 2010).
Skeletal System
Long-term psychopharmacological treatment of SMI, specifically through the use of typical antipsychotics, may have an impact on bone mineral density (BMD) and thus increase risk for skeletal system damage such as osteoporosis, fractures, and sprains (Leucht et al. 2007). The relationship is often attributed in research to increased levels of prolactin caused by antipsychotic use and its effect on the dopamine2 receptors in the hypothalamic-pituitary axis. This can lead to hypogonadism in both men and women, resulting in decreased levels of testosterone and estrogen, respectively. Estrogen deficiency has been linked to decreased BMD and osteoporosis in women and men, and testosterone deficiency to profound osteopenia in men, though the latter has been less studied than estrogen deficiency in women. There is also evidence of a link between depression and osteoporosis, but the nature of this link is not clearly elucidated yet in the literature; the positive association between depression and osteoporosis is believed to involve hypercortisolism that leads to decreased bone formation, hypogonadism, and increased levels of interleukin-6 (Cizza et al. 1996).
Risk of falls and subsequent fractures is also increased among individuals with mental illness because of several factors. In addition to the potential for decreased BMD associated with certain types of psychiatric medications, as described above, several classes of medications are related to incidences of falls and fractures: antidepressants, sedatives, and hypnotics are specifically linked to fall risk among adults (Leipzig et al. 1999). In a case-control study by Liu et al. (1998), researchers investigated the link between use of differing classes of antidepressants and risk of hip fracture among elderly men and women in the hospital. The odds ratio (OR) of hip fracture among those taking tertiary tricyclic antidepressants was 1.5; among those taking selective serotonin reuptake inhibitors, the OR was 2.4 (Liu et al. 1998).
An area often treated as distinct entirely from physical or mental health is dental health. Aside from the obvious impacts dental disease can have on one’s daily functioning (e.g., eating, appearance, speech), evidence repeatedly indicates that dental disease increases individuals’ risk of systemic illnesses such as diabetes mellitus and cardiovascular disease, and makes it more likely that those comorbidities will result in death (Nazir 2017). This is especially important when considering the health and wellness of individuals with SMI. A meta-analysis looking at dental disease among people with SMI indicated that those with SMI were more than three times as likely as people without SMI to experience edentulousness (toothlessness), and the prevalence of dental caries (tooth decay) was significantly higher among people with SMI compared with people without SMI. These differences in dental health may be linked to less frequent access to and use of preventive dental care such as cleanings and treatments (Kisely et al. 2011).
There is an increased risk of unintentional injury among those with SMI (Wan et al. 2006). Wan and colleagues (2006) examined medical records of individuals admitted to a trauma center in San Francisco for unintentional injury; the rate of admission due to injury for those with SMI was twice as high as the rate for those without SMI, and the rate of repeated injuries (injury recidivism) for individuals with SMI was 4.5 times the rate for individuals without SMI. These findings indicate not only that mental illness may be an independent risk factor for hospitalization due to unintentional injury such as falls and accidents at home, but also that the risk of injury could complicate and/or exacerbate other comorbid conditions.
Cardiovascular, Nervous, and Respiratory Systems
Cardiovascular System
People with SMI are more likely to experience cardiovascular disease and are more likely to die due to heart disease than people without SMI. Several factors may contribute to this increased risk, including increased exposure to cardiac risk factors (e.g., smoking, obesity, diabetes mellitus), antipsychotic side effects, systemic barriers, stigma, and social barriers (Leucht et al. 2007). In a cross-sectional study by Osborn et al. (2006), people with SMI were two times more likely to have coronary heart disease compared with participants without SMI. Risk factors in the SMI group in this study included increased smoking rates, cholesterol risk factors, diabetes mellitus diagnosis, and hypertension risk (Osborn et al. 2006). Furthermore, varying treatments for SMI, including antipsychotic medications, can lead to significant weight gain. Increased adiposity, like that which can be caused or exacerbated by antipsychotic treatment, is often linked to increased risk of type 2 diabetes and cardiovascular disease. Insulin insensitivity that can result from increased adiposity is also associated with cardiovascular risk factors such as hypertension, increased likelihood of blood clots, and increases in blood low-density lipoprotein levels. There is also a demonstrated link between schizophrenia and sudden cardiac death; risk of sudden cardiac death in people with schizophrenia is 4.9 times the risk in the general population (Ruschena et al. 2003). Other risk factors contributing toward sudden cardiac death among people with schizophrenia include increased use of substances such as alcohol and cocaine.
Depression alone can be an independent risk factor for heart disease; for those with depression and comorbid heart disease, increased risk of morbidity and mortality has been found. Studies indicate that increased platelet reactivity among individuals with depression may be linked to changes in serotonin binding mechanisms at the platelet level (Schins et al. 2003) as well as changes in endothelial cells, which make up the lining of blood vessels. Anxiety and panic disorders have also been noted to increase risk of heart diseases such as stroke, arrhythmia, cardiomyopathy, hypertension, and mitral valve prolapse (Kahn et al. 1990). Additionally, there is a potential link between heart rate variability, mental illness, and heart disease; normal levels of heart rate variability are an indicator of balanced sympathetic and parasympathetic input from the nervous system to the cardiovascular system. Decreased heart rate variability, which is a risk factor for heart disease, has been observed in people with depression, anger/hostility, panic, and anxiety (Kemp and Quintana 2013).
Nervous System
The relationship between mental illness and neurological disorders is complicated. Many mental health conditions have neurological symptoms, psychiatric medications may have neurological side effects such as dyskinesia, and neurological disorders can have symptoms that mimic mental health symptoms (e.g., affective disruptions experienced by people with multiple sclerosis). The subtleties of the complex relationship between neurological diagnoses and SMI are beyond the scope of this text. However, we discuss below some of the connections and comorbidities among mental illness and acute neurological disorders, neurodegenerative conditions, and an important neurological symptom experienced by many individuals with SMI.
A number of studies indicate a relationship, though not clearly delineated, between epilepsy (temporal lobe epilepsy specifically) and schizophrenia or psychosis. A study including about 2.1 million people confirmed this relationship and identified a link between family history of epilepsy and increased risk of schizophrenia; the etiology of this connection is not well understood, but it may be indicative of genetic association between the two (Qin et al. 2005).
Use of psychiatric medications can often lead to weight gain, an often-mentioned risk factor for several comorbidities and systemic health conditions. Obesity is a primary risk factor in the development of sleep apnea, characterized by repeated obstruction of the upper airway during sleep. People with schizophrenia are at particular risk because of the significant causal relationship between antipsychotic use and weight gain; individuals with schizophrenia were more likely than individuals with other mental health diagnoses to present with obstructive sleep apnea (Winkelman 2001).
A robust study utilizing the data from the 2002 Canadian Community Health Survey—Mental Health and Well-Being identified a significant positive association between a mental health diagnosis and chronic migraines. Particularly important to note, the study also measured health outcomes, including quality of life, 2-week disability, restriction of activity, and mental health care utilization. Individuals who reported both migraines and a mental health diagnosis were more likely to have poorer health outcomes, compared with those who reported just one of those conditions, indicating that the combination of both illnesses has a significant impact on broader health and functioning (Jette et al. 2008).
There are also links between SMI and neurodegenerative diseases, though the connections are not clearly understood. For example, a study by Prohovnik et al. (1993) identified a high number of Alzheimer’s disease diagnoses among patients living with schizophrenia, especially in significantly older adults (≥ 90 years old), among whom prevalence rates reach about 50%. The authors speculated that this increased prevalence may have been due to the cognitive side effects of long-term antipsychotic use, though further research is necessary to explore the relationship (Prohovnik et al. 1993). Additionally, a 2006 study by Ishihara and Brayne identified a link between prevalence of mental illness—specifically depression and anxiety—and subsequent diagnosis of Parkinson’s disease. Again, the cause of this relationship has not yet been identified, but researchers supposed that it might be related to depletion of neurotransmitters involved in both mental illness and Parkinson’s disease (Ishihara and Brayne 2006).
Finally, an important feature of note is altered pain perception among individuals with schizophrenia. There is an extensive amount of literature that indicates decreased sensations of pain (hypoalgesia) among individuals with schizophrenia. A review of the literature indicated that from 37% to 91% of people with schizophrenia experience reduced levels of pain (Singh et al. 2006). The cause of the hypoalgesia is not well understood. Hypoalgesia may contribute to morbidity and mortality in other areas of health and wellness. If, for example, people with schizophrenia are not aware of or responsive to pain or discomfort, or do not report pain or discomfort to health care providers, proper diagnosis and treatment of comorbid health conditions may be impeded.
Respiratory System
The respiratory system is responsible for the exchange of oxygen and carbon dioxide between the air and the human body. The primary organs of the respiratory system are the lungs. Swelling or inflammation of the airways in the lungs can lead to various respiratory diseases, such as asthma, COPD, or pneumonia.
According to the few existing studies, SMI may be associated with an increased risk of COPD and asthma. The most important cause of COPD is smoking, which is highly prevalent in individuals with SMI. In a recent study, individuals with schizophrenia and other nonaffective psychoses had significantly lower lung function values when compared with the general population, and the association remained significant for schizophrenia after adjustment for smoking and other potential confounders. Schizophrenia was associated with increased odds of pneumonia, COPD, and chronic bronchitis (Partti et al. 2015).
Studies on the genetic linkages between respiratory diseases and SMI are limited. In a Swedish population-based cohort study, children with hospitalizations for asthma during adolescence (11–15 years) had increased rates for bipolar disorder and schizophrenia spectrum disorders. Researchers also found an association between both maternal and paternal asthma and bipolar disorder, suggesting that there is potentially a shared genetic vulnerability between the two (Wu et al. 2019).
Similar to the effect of antipsychotics in the development of diabetes, antipsychotics have also been shown to increase risk for pneumonia. Current use of atypical antipsychotics in individuals with schizophrenia—clozapine in particular—is associated with a dose-dependent increased risk for pneumonia. The possible mechanisms for drug-induced pneumonia remain speculative. Histamine H1 receptor antagonism by clozapine and olanzapine (inducing sedation) and muscarinic M1 receptor antagonism (resulting in dryness of the mouth, esophageal dilatation, and hypomotility) may be involved, as well as an additive sedating effect by carbamazepine or valproic acid (Yang et al. 2013).
Depression is associated with a 43% increased risk of asthma (Gao et al. 2015). Wamboldt and colleagues (2000) found evidence supporting a genetic linkage between asthma and depression. They assessed the prevalence of atopic disease and depressive symptomatology in Finnish twin pairs and found a within-person correlation between atopic and depressive symptoms; using a best-fit model, they estimated that 64% of this association was due to shared familial vulnerability, mainly genetic factors (Wamboldt et al. 2000).
Digestive, Reproductive, and Urinary Systems
Digestive System
Although diseases of the digestive system in people with SMI are relatively understudied, irritable bowel syndrome (IBS) and celiac disease have received significant attention in individuals with SMI. The prevalence of IBS in schizophrenia was reported to be 19% (Garakani et al. 2003). Individuals with major depression have a higher prevalence, at 29%, although no significant associations were found between bipolar disorder and IBS. Additionally, Eaton et al. (2006) found that individuals with schizophrenia and their relatives tend to have higher-than-expected prevalence of celiac disease (0.05 vs. 0.01 in comparison groups). Research into celiac disease and schizophrenia has found support for shared genetic susceptibility. Highly significant differences in allele frequencies were observed in the intron of MYO9B between individuals with schizophrenia and healthy control subjects, providing preliminary evidence for a correlation between celiac disease and schizophrenia (Jungerius et al. 2008).
Reproductive System
Prevalence of sexual dysfunction varies but has been historically reported to affect 50%–75% of individuals with schizophrenia, a rate significantly higher than that reported in the general population (Meyer and Nasrallah 2009). Effects of psychotropic medications vary considerably, but these medications are thought to most directly induce this effect via their impact on the dopaminergic, serotonergic, cholinergic, adrenergic, and/or histaminergic systems. Of particular concern are elevated prolactin levels, or hyperprolactinemia, which may be largely a downstream effect of dopamine antagonism. Prolactin-elevating antipsychotic drugs are associated with abnormalities in libido, erectile function, and menstruation. Knegtering et al. (2008) reported that medication-induced hyperprolactinemia accounted for 40% of all sexual dysfunction present in a sample of individuals with schizophrenia.
Psychotropic medication has also been associated with reproductive hormone abnormalities in women, and this has implications for fertility in individuals with SMI. According to a review by Bargiota et al. (2013), the prevalence of menstrual abnormalities ranges from 15% to 97% in women using antipsychotic agents. Given that hyperprolactinemia may mediate the production of abnormally low levels of estrogen or no estrogen, manifesting in abnormal menstruation, and given the clinical significance of low estrogen in cardiovascular disease and osteoporosis, research regarding best prescribing practices for long-term antipsychotic regimens is critical (Leucht et al. 2007).
Urinary System
Bipolar disorder has been associated with an increased lifetime prevalence of chronic kidney disease (CKD), though this relationship appears to be partially mediated by long-term use of lithium and/or anticonvulsants (Kessing et al. 2015). An analysis comparing a random sample of patients from the Clinical Practice Research Datalink Registry with patients with SMI who had first psychiatric contact between 1994 and 2012 revealed an increased likelihood of CKD (defined as glomerular filtration rate of < 60 mL/min/1.732 m2 for ≥ 3 months or confirmed renal replacement therapy) among those with SMI (Kessing et al. 2015). Those with SMI with no history of lithium use were 1.5 times more likely to develop CKD than the general population, and those with a history of lithium use were 6.5 times more likely, indicating the extent to which lithium use may mediate the strong correlation between CKD and SMI. Because CKD is independently and strongly associated with cardiovascular disease and mortality, relevant systemic disorders (i.e., hypothyroid-related kidney dysfunction) versus environmental factors (i.e., medication use) need to be captured with more specificity. The prevalence of other diseases of the urinary system, such as urological disease, systemic lupus erythematosus, and polycystic kidney disease, was not significantly different between SMI and No SMI groups.
Endocrine and Immune Systems
Endocrine System
In a British registry study following individuals with schizophrenia between 1981 and 1994, standard mortality ratio for diabetes-related death and all endocrine disease–related death was 9.96 and 11.66, respectively. Abnormalities in circulating thyroid hormones are related to glucose homeostasis and, by extension, the development of diabetes. Using population-level data obtained by linking three Danish registers—the Danish National Hospital Register, the Danish Psychiatric Central Research Register, and the Danish Register of Causes of Death—Thomsen et al. (2005) found that individuals hospitalized for hypothyroidism were significantly more likely to have a future psychiatric hospitalization for an affective disorder than were individuals hospitalized for either osteoarthritis or nontoxic goiter.
Immune System
In a population-based, retrospective case-control study conducted by linking the Danish National Patient Registry with the Danish Psychiatric Registry, Eaton et al. (2006) reported an association between the prevalence of autoimmune disease in individuals presenting with onset of schizophrenia (first contact with psychiatric care) compared with matched control subjects. History of thyrotoxicosis, intestinal malabsorption, acquired hemolytic anemia, interstitial cystitis, and Sjögren’s syndrome was significantly more prevalent in individuals presenting with onset of schizophrenia compared with matched controls. Prevalence of these autoimmune disorders in patients’ parents compared with parents of matched controls was significantly higher, lending some credence to the suggestion that heritability of predisposition to autoimmune diseases may exert a predisposition to physical disease that may confer significantly greater risk for the development of schizophrenia throughout the life span.
Considerations for Psychiatric Providers
To begin conceptualizing the risks of complex comorbidities and psychiatric providers’ role in reducing morbidity and mortality, consider the case of Charlotte.
Charlotte is an African American woman living in the rural United States who, 10 years ago, was diagnosed with schizoaffective disorder, which has been treated with antipsychotics for many years, contributing to her obesity. She has also developed type 2 diabetes mellitus. Charlotte lives in an apartment with her partner, works at the local library, and sees a provider at the clinic every 3 months for monitoring of her mental health. Unfortunately, she experiences an injury to her foot in an accident at home; however, because of neuropathy secondary to her diabetes, she is unable to feel the extent of this injury and does not seek proper treatment quickly. She does not complete regular foot checks as recommended by her doctor because of her challenges with planning and executive functioning related to her SMI, and she is geographically quite far from her primary care doctor. By the time Charlotte mentions the wound on her foot to her psychiatrist several months later, she is already at risk for complications such as local infection, irreversible tissue damage, septicemia, amputation, and death.
In treating someone like Charlotte, psychiatric providers should remain mindful of the potential health complications related to her mental illness. Communication and collaboration with patients and their physical health care providers are key to closely monitoring health risks and complications. In addition, understanding the links between mental health diagnosis and physical health conditions, delineated in this chapter, is crucial. Not only may her risk for additional health conditions increase because of genetic linkage to mental illness, psychiatric medication, and lifestyle factors, the functional limitations due to her mental illness may pose an additional challenge in managing physical health conditions. Because not all primary care and specialty health care providers are well versed in providing accessible, welcoming care to patients with SMI, psychiatric providers may consider collaborating to ensure the patients’ specific health care needs are met and appropriate accommodations are considered. In Charlotte’s case, these accommodations may include making a referral to occupational therapy to increase adherence to and efficacy of foot checks and wound care; inviting significant others who will provide support to Charlotte to attend follow-up appointments and to help her perform self-care; providing care instructions and appointment reminders in alternative formats that are more adaptive to her needs; speaking with Charlotte about peer navigator/community health worker or care management services; recommending that Charlotte obtain wound care supplies through the mail to reduce the likelihood that she will run out; and the like.
Another consideration in the morbidity and mortality of people with SMI is the impact a patient’s mental health diagnosis may have on the quality of treatment he or she receives from other providers. Health service disparities among people with SMI exist in both primary and specialized medicine for various reasons, explored in greater detail in Chapter 4 of this book. While some of the barriers to high-quality treatment may be related to systemic issues and diminished engagement and adherence in care, there are also considerations to be made about the providers and potential bias in treating people with SMI. Indeed, some primary care providers find patients with mental illness to be disruptive or challenging to engage, feel uncomfortable providing services, and may be less likely to recommend more advanced or intensive treatments (Lawrence and Kisely 2010). As such, psychiatric providers should remain ever mindful of the lifelong impact of diagnosis on each patient, especially within the health care system.
These, and other, considerations and potential solutions are unpacked in later chapters of this book, particularly in Chapters 7–13. However, in short, by establishing an alliance with Charlotte as a trusted psychiatric provider who acknowledges how her physical and mental health are connected, one may be able to help her manage, arrest, improve, or even prevent her comorbid physical health conditions and reduce mortality. Although fragmentation of physical and mental health care can make it particularly challenging to address comorbid physical health conditions, psychiatrists are well positioned to have crucial conversations with patients and other providers to ensure high-quality care to the patient as a whole person.
The Impact on Wellness
Absence of illness does not make for quality of life per se. The Centers for Disease Control and Prevention (CDC) and the National Institutes of Health in the United States, as well as the World Health Organization on the international stage, have added wellness and well-being as essential domains to a total definition of health. Steinberg (2007), from the CDC, described wellness as an active process of decisions and choices in pursuit of a healthy and fulfilling life. It is a dynamic process leading to physical, mental, and social well-being, and not merely the absence of disease or infirmity.
A position paper from the Boston University Center of Psychiatric Rehabilitation (2019) outlined eight dimensions of wellness specific to the person with SMI:
1.
Emotional—coping with life and developing satisfying relationships
2.
Environmental—finding stimulating settings that promote well-being
3.
Financial—achieving satisfaction with income and entitlements
4.
Intellectual—finding enjoyable ways to expand one’s knowledge and understanding
5.
Occupational—finding satisfaction with one’s employment
6.
Physical—engaging in activities that promote healthy foods, exercise, and sleep
7.
Social—having a sense of connectedness and a satisfactory support system
8.
Spiritual—meeting one’s sense of purpose and finding meaning in life
As is evident from this list, wellness is more than what happens in the organ systems. It also implies the overall impact on a person’s sense of well-being (however that person defines well-being). All the chapters in this book consider wellness and well-being where appropriate.
Key Points
•
Morbidity and mortality are clear concerns for the life and well-being of people with serious mental illness (SMI). Almost every organ system in the body seems to be impacted by mental illnesses.
•
SMI is defined by impact on functioning (disability), developmental considerations, and persistence/chronicity of symptoms.
•
The life expectancy gap for individuals with SMI compared with those without SMI ranges from 8.2 to 16 years.
•
Both having a SMI and taking psychiatric medications can increase risk for integumentary and skeletal systems, including skin sensitivities, decreased bone density, edentulousness, and unintentional injury.
•
People with SMI have high rates of cardiovascular disease related to increased exposure to risk factors as well as physiological changes to the cardiac structures.
•
Psychiatric medications may contribute to some comorbid neurological conditions, though there is also indication of genetic and physiological links between mental health and neurological diseases.
•
Rates of chronic obstructive pulmonary disease and other respiratory diseases among those with SMI are significantly higher than in the general population and contribute to the premature mortality of people with SMI.
•
Research indicates a relation between digestive conditions (such as irritable bowel disease and celiac disease) and mental health diagnosis.
•
Sexual and reproductive dysfunction and chronic kidney disease affect a disproportionate amount of people with SMI, with the increased prevalence often attributed to use of psychotropic medications.
•
Endocrine disease, including diabetes, contributes to around 1 in 10 deaths of people with schizophrenia.
•
Symptoms of comorbid mental illness and physical conditions often exacerbate one another, perhaps because of genetic linkage, exposure to risk factors, psychiatric medications, and related functional limitations.
•
Providers who diagnose and prescribe medications for the psychiatric care of people with SMI should remain mindful of health risks and disparities to help their patients manage comorbidities, reduce risk and harm, and access health care providers who are competent and considerate in working with individuals with mental illness.
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Health and Wellness in People Living with Serious Mental Illness
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Published in print: 3 March 2021
Published online: 5 December 2024
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