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Article Excerpt
A very troubling health care disparity exists among persons with serious mental illness (SMI). Even among those receiving regular psychiatric care, many individuals experience co-occurring medical conditions that go unidentified and/or untreated, significantly shortening their life spans. About 15 years ago, it was established that 60 percent of individuals with mental illness develop serious medical co-morbidities that result in a lost life span of 15 to 20 years compared to the general population (Berren, Hill, Merkile, Gonzalez, & Santiago, 1994). Recently, even more alarming evidence indicates the risk for lost years of life has accelerated to 25 years earlier than the general population (Parks, Svendesen, Singer, Foti, & Mauer, 2006). Gill (2008) commented:
What does it mean that the life expectancy of persons with serious mental illness in the United States is now shortening in the context of longer life expectancy among others in our society? It is evidence of the gravest form of disparity and discrimination. (p.7)
Rates of circulatory disease, metabolic conditions including diabetes, obesity, hyperlipidemia (elevation of lipids in the bloodstream), osteoporosis, chronic pulmonary disease, HIV-related illnesses, polydipsia (excessive thirst and water drinking), and epilepsy are found to be consistently elevated in individuals with psychiatric illness (Green, Canuso, Brenner, & Wojcik, 2003; Jeste, Gladsjo, Linamer, & Lacro, 1996; Lambert, Velakoulis, & Panelis, 2003). Among the most common medical co-morbidities is the set of disorders known as metabolic syndrome, which increases an individual's risk for diabetes mellitus and coronary heart disease (Kelly, Boggs, & Conley, 2007). These symptoms include abdominal obesity (increased waist circumference), elevated triglycerides, elevated high density lipoprotein cholesterol, hypertension, and elevated fasting glucose (Grundy et al., 2005, as cited in Kelly et al., 2007). This medical co-morbidity, in combination with the vast health care disparities and service fragmentation among the mental health and medical service delivery systems, are associated with increased barriers to goal attainment, significantly reduced quality of life, and early mortality.
Early Mortality due to High Co-morbidity of Medical Conditions
According to the National Association of State Mental Health Program Directors, a multi-state mortality study revealed that the average years of life lost for people with mental illness were 25.2 (range = 13.5--29.3 in different states) and the average age at death was 56.8 (range = 48.9--76.7; Parks et al., 2006). Among individuals with schizophrenia, suicide and injury accounted for 30-40% of early deaths, but 60 % of early mortality was due to so called "natural causes" including cardiovascular disease, diabetes, respiratory diseases, and infectious diseases. In this group, individuals die from cardiovascular disease at more than double the rate of the general population and about triple the rate for diabetes, respiratory diseases, and infectious diseases (Parks et al.).
Among the general population in the United States, approximately 22% of adults have the metabolic syndrome. In comparison, among people with SMI the prevalence rate of the metabolic syndrome ranges from 30% to 60%. In one large study, the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), 43% of the subjects enrolled had the metabolic syndrome, and of this group up to 83% received little or no treatment for this condition (Kelly et al., 2007). The authors report:
The metabolic syndrome has been found to be an independent predictor of all-cause mortality. Although each of the individual components may be a risk factor for cardiovascular morbidity, the existence of several of these abnormalities together poses a risk that may be synergistic. (p. 460)
Potential Contributing Factors
There is a substantial body of research that has emerged documenting how psychotropic medications prescribed to ameliorate the symptoms of mental illness induce a number of serious adverse health issues including the metabolic syndrome, insulin resistance, diabetes, hyperglycemia, dyslipidemia (a condition of excessive levels of lipids or fats in the bloodstream), obesity, osteoporosis, and sexual dysfunction (Enger Weatherby, Reynolds, Glasser, & Walker, 2004; Joukamaa et al., 2006; Lieberman et al., 2005; Meltzer, 2005; Parks et al., 2006). Results of the CATIE study indicate that these effects are greater among those taking newer, "atypical" anti-psychotics. For example, those taking olanzapine were at an increased risk for abnormal glucose and lipid metabolism compared to those taking conventional antipsychotics (Lieberman et al.). In addition, the prolonged use of psychotropic medications also causes a range of oral complications and side effects including tooth decay, periodontal diseases, and xerostomia or "dry mouth" which leads to other complications such as gum disease (Barnes et al., 1988; Friedlander & Liberman, 1991; Velasco & Bullon, 1999). The link between oral health and general health, particularly cardiovascular functioning, has been well established and makes this of additional concern (Almomani, Brown, & Williams, 2006). For example, increased plaque on teeth is correlated with increased plaque on artery walls and thus heart disease and stroke (Almomani et al.).
The high incidence of medical comorbidity and increased rates of mortality among people with psychiatric disabilities is attributable in part to unhealthy, high risk behaviors. These behaviors include substance abuse, smoking, lack of exercise and poor diet (Brown, Birtwistle, Roe, & Thompson, 1999). Among individuals with mental illness, approximately half also have a substance use disorder. Substance use increases the likelihood that an individual will engage in risky behaviors including: intravenous drug use, needle sharing, and unprotected sex. These activities are implicated in elevated rates of HIV and other blood-borne viral infections (Corrigan, Mueser, Bond, Drake, & Solomon, 2008). An even greater percentage of people with mental illness are nicotine dependent. The reported rates of nicotine dependence range from 60-80% (Corrigan et al.; Parks et al., 2006). In addition to the high rates of use, people with mental illness are heavier smokers causing them to experience more toxic exposure than the average smoker (Parks et al.). Smoking is a known risk factor for cancer, chronic respiratory diseases, and cardiovascular disease. It is, in fact, a modifiable risk factor and there are a number of best practices available for helping persons with psychiatric disorders successfully discontinue smoking (NASMHPD, 2007).
The prevalence of being overweight and having a sedentary lifestyle is also increased among people living with a mental illness as compared to individuals without a mental illness. Lack of knowledge of correct dietary principles, lower self-efficacy, limited social support, and psychiatric symptoms all have an influence on health-related behavior (Leas & McCabe, 2007). According to Dickerson and colleagues (2006), 50% of women and 41% of men with psychiatric diagnoses studied are obese as compared to 27% and 20%, respectively, among a comparison group. The potential reasons for this increased obesity and poor diet are varied and include side effects of psychotropic medications (Allison et al., 1999; Elman, Borsook, & Lukas, 2006; Kane...
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