Longevity Gap Continues to Widen for Schizophrenia Patients

Pauline Anderson

September 21, 2017

Findings from a new systematic review point to a widening longevity gap between people with schizophrenia and the general population that began in the early 1970s.

The results of the review suggest that although many people enjoy an extended life span, owing to improved healthcare, those with schizophrenia do not.

Psychiatrists should look beyond psychotic symptoms and treat the mentally ill person as a whole, study author Dilip V. Jeste, MD, Distinguished Professor of Psychiatry and Neurosciences, University of California, San Diego, told Medscape Medical News.

Dr Dilip Jeste

"We should not be satisfied with just prescribing antipsychotics to people with schizophrenia; we have to look at their physical health."

The study was published online September 15 in Schizophrenia Research.

First Review of Mortality Trends

This study, said Dr Jeste, is the first systematic review of longitudinal trends in mortality in people with schizophrenia.

After a literature search, the researchers included eight longitudinal studies in the review. Two were initiated before 1970, and six after 1970. All studies investigated mortality in patients with schizophrenia or other psychotic disorders.

All of the included studies reported the standardized mortality ratio (SMR), a measure of the mortality rate in persons with schizophrenia compared to the general population. The data were adjusted for age and sex and for sufficiency of information to allow SMR calculation. They also reported data for more than one time point.

Half the studies examined outpatients, and the others focused on inpatients. Five of the studies included more than 1000 people with schizophrenia.

One study that represented 50% of the data for estimates before 1970 was from the United States; the other studies came from Western European countries. All studies used patient registries to identify and track the population.

Within each study, investigators calculated the annual rate of change in SMR. They also examined the overall mean SMRs before and after the early 1970s.

Overall, the studies showed an increasing gap in mortality rates between those with schizophrenia and the general population after the early 1970s.

During the course of the studies, the average rate of change of SMR was -1.6% per year (95% confidence interval [CI], -10.5 to 7.4) in the two pre-1970s studies, and an increase of 3.0% (95% CI, 0.1 - 6.0) in the six post-1970s studies.

The mean SMR was 2.2 in the pre-1970s studies and 3.0 in the post-1970s studies. This, said Dr Jeste, represents an increase of about 37%.

He explained that to arrive at this, the authors divided the change in the SMR (3.0 ─ 2.2 = 0.8] by the baseline SMR of 2.2 and computed that to the percentage ratio.

The life expectancy in the general population has increased steadily since 1900, owing initially to a drop in infant mortality and subsequently to lifestyle changes (eg, smoking cessation, improved diets) and scientific advances that led to an increase in survival of patients with cancer, heart disease, stroke, and other conditions, said Dr Jeste.

Growing Gap

In 1900, the life expectancy in the general population was 47 years; today it's 80 years, and by 2050, it's expected to be 90 years, he said.

That's not been the case for people with schizophrenia. Although they made some headway in terms of life expectancy during the 1950s with the advent of antipsychotic drugs, they lost ground with deinstitutionalization in the 1970s.

With the closing of hospital inpatient services and with few social supports and inadequate housing, many mentally ill patients became impoverished, with some becoming homeless or incarcerated in prisons.

Despite the Mental Health Parity Act, which mandates that health insurers provide the same level of benefits for mental health treatments and services that they do for medical/surgical care, companies "have ways of getting around that," said Dr Jeste.

"The big concern is that with further change in the healthcare system, many more people with mental illness will fall through the cracks and will be uninsured."

The widening longevity gap is not due to suicide. People with schizophrenia take their own life at a much higher rate than the general population, but the difference in mortality due to unnatural causes ― suicides and accidents ― has been stable over time.

"Schizophrenia is not just a serious mental illness, it's also a serious physical illness, in the sense that people with schizophrenia mostly die from physical illnesses such as heart disease, cancer, stroke, or COPD [chronic obstructive pulmonary disease]," said Dr Jeste.

They just die from these conditions earlier. "Things that usually kill people in their 70s and 80s and 90s kill people with schizophrenia in their 40s, 50s, and 60s."

Schizophrenia appears to predispose people to "rapid deterioration," said Dr Jeste, who is undertaking research on what he described as "accelerated biological aging" in patients with schizophrenia.

Inflammation at the cellular level, which underlies cancer, heart disease, and diabetes, could explain why schizophrenia affects the whole body and not just the mind, said Dr Jeste.

He noted that people with schizophrenia still face significant stigma. Although celebrities have come out acknowledging that they're being treated for depression, and even bipolar disorder has become more accepted, this is not the case with schizophrenia, he said.

It is likely that the new findings "reflect on persistent and pervasive stigma against mental illness and societal neglect of this vital yet vulnerable segment of the population, which continues to be disenfranchised," write the authors.

"Work is urgently warranted to help reduce stigma, improve healthy lifestyles...and tailor primary care services to that person with serious mental illnesses are not left behind in the longevity revolution."

A limitation of the review is that the number of studies that met inclusion criteria was low, especially before 1970. Another limitation was that data from the studies were presented in different ways and that the periods used to calculate SMRs varied. In addition, the results may not be generalizable to non-Western countries.

Dr Jeste reports no relevant financial relationships.

Schizophr Res. Published online September 15, 2017.

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