Mortality Gap Widening for the Mentally Ill

Fran Lowry

September 14, 2011

September 14, 2011 — The mortality gap between people with schizophrenia and bipolar disorder and the general population continues to widen in the United Kingdom, despite efforts by the government and health professionals to improve mental healthcare, according to a new study.

The findings highlight the challenge faced by the UK government's recent mental health strategy, which has stated clearly that "fewer people with mental health problems will die prematurely," write Uy Hoang, MD, from the Department of Public Health, University of Oxford, United Kingdom, and colleagues.

"We do welcome the government's new policies, but in light of what our results are showing, making good on these policies is going to be a real challenge for them," Dr. Hoang told Medscape Medical News.

The study was published online September 13 in the British Medical Journal.

"No Health Without Mental Health"

The UK's National Health Service recently released a new mental health strategy with the theme "no health without mental health," which stresses better integration between primary care and secondary care, more appropriate screening for physical illness among mentally ill patients, and more appropriate follow-up for patients with psychiatric disorders recently discharged from hospital.

People with schizophrenia or bipolar disorder have higher mortality rates than the general population, as a result of both natural and unnatural causes, including suicide. Recent studies suggest that the rate of suicide has been stabilizing among people with mental disorders, but mortality trends in this population in the United Kingdom were unknown.

In this study, Dr. Hoang and colleagues from King's College London, United Kingdom, sought to assess the current status of mortality in people with serious mental illness vs the general population.

The researchers analyzed records for all people in England discharged from inpatient care with a diagnosis of schizophrenia or bipolar disorder and compared their mortality with that of the general population from 1999 to 2006.

They followed up a cohort of patients for each year and compared their mortality risk with that of the general population for that particular year.

The researchers found a significant increase over time in the mortality gap between patients with mental illness and the general population.

For people discharged with schizophrenia in 1999, the excess risk was 1.6 times that of the general population (95% confidence interval [CI], 1.5 - 1.8), but by 2006, it was twice the rate, at 2.2 (95% CI, 2.0 - 2.4; P < .001 for trend).

The trend was similar for bipolar disorder. The ratios were 1.3 (95% CI, 1.1 - 1.6) in 1999 and 1.9 (95% CI, 1.6 - 2.2) in 2006 (P = .06 for trend).

"By 2006, the excess risk in these groups had risk to twice the rate of the general population, whereas prior to that it had only been 1.6 times the risk, so it increased by almost 40%," Dr. Hoang said.

Most of the deaths were a result of natural causes, especially cardiovascular disease and respiratory disease.

"These are things that we know have well-proven preventative measures that actually do work," Dr. Hoang said.

"We want a call to action on the part of government and clinicians," he concluded. "Inpatient care is a critical period during which clinicians can identify people at risk for physical illness. They can then offer appropriate treatments and follow-up."

Study a "Resounding Call to Arms"

In an accompanying editorial, Brian J. Miller, MD, from Georgia Health Sciences University, Augusta, points out that the well-documented association between serious mental illness and increased premature death from unnatural and natural causes is an important public health problem.

For example, in England in 2004 to 2005, indirect costs of schizophrenia were estimated at about $7.6 billion; in 2002 in the United States, indirect costs of death from suicide alone in patients with schizophrenia was estimated at $1.1 billion, he writes.

"However, an important unresolved question is whether this 'mortality gap' between people with and without serious mental illness is increasing over time," Dr. Miller writes. The study by Hoang and colleagues take on this important question.

The potential for confounding, heterogeneity between studies, and the potential lack of applicability to other cohorts, however, make any study of changes in mortality over time "inherently complex," he points out. Using standardized mortality ratios for death within 1 year of psychiatric inpatient care, the new study provides additional evidence that the so-called mortality gap is increasing. About 75% of deaths were from natural causes, primarily circulatory and respiratory disease.

"But perhaps the most striking finding was that the absolute risk of death within a year of inpatient care was about 1.5%," Dr. Miller writes. "The United Kingdom's national mental health strategy states that 'fewer people with mental health problems die prematurely' compared with the general population."

Given that circulatory and respiratory diseases were leading causes of death, the study suggests that inpatient psychiatric care "provides a critical window during which risk factors for mortality, particularly cardiorespiratory disease, can be recognised and modified in these patients," Dr. Miller notes. "Thus, systematic efforts to screen and treat modifiable risk factors for mortality in psychiatric inpatients will be crucial to the success of this strategy."

Even when recognized, patients with serious mental illness are less likely to receive standard care for most diseases, he notes. "How can services be reorganised to ensure better, more timely, delivery of comprehensive services for psychiatric inpatients?"

Targeted interventions that might be implemented during hospital admission include developing and implementing evidence-based guidelines for metabolic screening and treatment for patients taking antipsychotics, smoking cessation interventions, and pneumonia and influenza vaccination programs.

Dr. Miller concludes that this study "serves as a resounding call to arms that inpatient psychiatric hospital admission provides a critical window to help tackle the increasing mortality gap in patients with serious mental illness and an essential step towards achieving the UK's national mental health strategy."

Dr. Hoang has disclosed no relevant financial relationships. Dr. Miller reports that he is employed by the Georgia Health Sciences University Department of Psychiatry and is a recipient of the US National Institutes of Health Clinical Loan Repayment Program; that his research has been supported by grants from the Georgia Health Sciences University Intramural Scientist Training Program, Brain and Behavior and Immunotherapy Discovery Institutes, the University of Oulu (Finland), the Thule Institute of the University of Oulu, Oy H Lundbeck Ab, and the American Psychiatric Institute for Research and Education/Janssen Resident Psychiatric Research Scholars Program; that he has received consultancy fees for surveys from Medefied Europe and Plaza Research on behalf of Genentech/Roche, and payment for grand rounds lectures from the Maryland Psychiatric Research Center, the Texas A & M University, and Scott and White Hospital Department of Psychiatry; and has received travel/accommodations/meeting expenses from the Emory University/Pfizer psychiatry residents' symposium award, the International Congress on Schizophrenia Research young investigator award, the American Psychiatric Association research colloquium for junior investigators and chief resident executive leadership program, the Society of Biological Psychiatry travel scholarship, the National Institute of Mental Health New Clinical Drug Evaluation Unit new investigator award, and the American College of Psychiatrists Laughlin fellowship. He has also received payment for a survey from e-Rewards Medical Market Research and a cash award from the Georgia Psychiatric Physicians Association.

BMJ. Published online September 13, 2011. Abstract, Editorial

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