Impact of inequalities in health care on the mortality risk of individuals with severe mental illnesses

Abstract

It is well known that individuals with severe mental illnesses (SMI), such as bipolar disorder (BD), major depressive disorder (MDD), and schizophrenia, have a twofold to threefold-higher risk of mortality relative to the general population and a markedly reduced life expectancy (by 15 years on average). Although suicide is unquestionably an important factor, replicated evidence indicates that the main driver of excessive and premature mortality in this population is cardiovascular disease. The burden of cardiovascular disease is evident also in younger age groups, in which heart disease, alongside other physical illnesses, accounts for most of the excess mortality.A major success story in medicine and public health has been the progressive increase in life expectancy throughout the world. Unfortunately, individuals with SMI do not seem to be benefitting from this trend. Whereas overall mortality rates have decreased sharply, including from disparate conditions such as heart disease, cancer, and infectious diseases, this decline is less evident in the SMI population. For example, the incidence of myocardial infarction has decreased by almost 50% in the general population, but has barely changed in individuals with SMI.Several factors have been explored as possible mediators of cardiovascular disease and excess or premature mortality in SMI. These factors include, but are not limited to, metabolic and cardiac effects of medications (especially second-generation antipsychotics, antidepressants and mood stabilizers); poor health habits (e.g., smoking and alcohol abuse); and pathophysiological mechanisms intrinsic to the systemic manifestations of mental disorders.1,2 Nevertheless, inequalities in the access to health care and in the quality of its delivery, especially regarding detection and treatment of cardiovascular conditions and other physical problems in people with SMI, have been relatively less discussed.The evidence is as clear as it is damning. Health systems worldwide, including those in high-income countries, are failing to provide optimal, evidence-based, cost-effective interventions to this already vulnerable population. There is replicated evidence that individuals with SMI are less likely to have a regular source of primary medical care, even after accounting for possible confounders such as age, gender, race, education, income, and health insurance status. 3Neither psychiatrists nor general practitioners screen and monitor individuals with SMI appropriately for metabolic risk factors, despite recommendations from several agencies, such as the U.S. Food and Drug Administration, American Diabetes Association, and American Psychiatric Association. For example, the rates of baseline metabolic assessment in individuals taking second-generation antipsychotic range from 8 to 30%, and only 8.8% of these patients undergo metabolic monitoring as recommended. Individuals with SMI are less likely to be prescribed cardiovascular medications (e.g., antihypertensives, antihyperlipidemics) and to receive smoking c...

Bipolar depression: a major unsolved challenge

“…Life-expectancy with BD is reduced by 12-15 years (Chesney et al 2014). Factors associated with this decreased longevity include co-occurring substance abuse, smoking, and being overweight, unmarried, and having limited access to adequate medical care (Hjorthøj et al 2015;Brietzke et al 2017;Dickerson et al 2018). The decreased longevity may be particularly associated with depression (Dickerson et al 2018).…”

A qualitative study: health professionals’ perceptions toward psychiatric palliative care for people with serious mental illness

“…People with serious mental illness have a higher risk of mortality than the general population, and a reduced life expectancy of 10-25 years (Brietzke et al, 2017;World Health Organization, 2015). The Substance Abuse and Mental Health Administration (Substance Abuse and Mental Health Services Administration, 2016) defines serious mental illness (SMI) as "persons aged 18 or older who currently or at any time in the past year have had a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) of sufficient duration to meet diagnostic criteria specified within Diagnostic and Statistical Manual of Mental Disorders (DSM-V) that has resulted in serious functional impairment, which substantially interferes with or limits one or more major life activities" (Substance Abuse and Mental Health Services Administration, 2016) such as maintaining interpersonal relationships, activities of daily living, selfcare, employment and recreation.…”