Wednesday, May 18, 2011

Improving the Physical Health of People With Serious Mental Illness

Mental Health Blog Party Badge

Today is the Mental Health Blog Party sponsored by the American Psychological Association as part of Mental Health Month. A widely neglected part of mental health treatment is encouraging and maintaining good physical health. This is extremely difficult when some of the major drugs prescribed for serious mental illnesses (such as schizophrenia and bipolar disorder) produce substantial weight gain. The "second generation" or atypical antipsychotics can cause obesity and hence diabetes, hypertension, cardiovascular problems, high cholesterol, and stroke.

Yesterday the BBC posted this headline:
Mentally ill have reduced life expectancy, study finds

By Dominic Hughes Health correspondent, BBC News

People suffering from serious mental illnesses like schizophrenia or bipolar disorder can have a life expectancy 10 to 15 years lower than the UK average.

Researchers tracked the lives of more than 30,000 patients through the use of electronic medical records.

They found that many were dying early from heart attack, stroke and cancer rather than suicide or violence.

Mental health groups say vulnerable people need to be offered better care to prevent premature deaths.

. . .

"We need to improve the general health of people suffering from mental disorders by making sure they have access to healthcare of the same standard, quality and range as other people, and by developing effective screening programmes."
The BBC article referred to a paper that was published today in PLoS ONE (Chang et al., 2011). The authors reviewed the electronic database of a major mental health care provider (the South London and Maudsley NHS Foundation Trust). The results were alarming (but not new, unfortunately):
A total of 31,719 eligible people, aged 15 years or older, with SMI [serious mental illness] were analyzed. Among them, 1,370 died during 2007–09. Compared to national figures, all disorders were associated with substantially lower life expectancy: 8.0 to 14.6 life years lost for men and 9.8 to 17.5 life years lost for women. Highest reductions were found for men with schizophrenia (14.6 years lost) and women with schizoaffective disorders (17.5 years lost).

click on image for a larger view

Figure 1 (Chang et al., 2011). Annual mortality risk (%) by age groups and diagnoses of mental illness, compared to England and Wales population in 2008.

The figure above illustrates the 2008 population of England and Wales in the red bars for five different age group: 15-29, 30-44, 45-59, 60-74, and 75+. Those with substance use disorders are shown in maroon, schizoaffective disorder in green, bipolar disorder in purple, schizophrenia in aqua, and depression/recurrent depression in light brown.

Mortality risk is increased for all psychiatric diagnoses, and is especially evident in the middle three age groups. Life expectancies were estimated using these data, and the results
confirmed substantially shortened life expectancies at birth for all serious mental disorder groups investigated compared to national norms. Largest reductions were found for men with schizophrenia, women with schizoaffective disorders, and both men and women with substance use disorders.

Why might this be? The authors do not speculate beyond stating that the "underlying causes may be multiple." Certainly, one can imagine that medication-induced weight gain [and increased levels of smoking] among the SMI contributes to lowered life expectancies.

To counteract these dismal statistics, a regular part of mental health treatment should include programs that promote better physical health. Smoking cessation and nutritionists and structured exercise classes in addition to standard psychiatric care and substance abuse treatment.

A six month intervention pilot study in Maryland enrolled 63 overweight participants at psychiatric rehabilitation day programs (Daumit et al., 2010):
Results: ... In total, 52 (82%) completed the study; others were discharged from psychiatric centers before completion of the study. Average attendance across all weight management sessions was 70% (87% on days participants attended the center) and 59% for physical activity classes (74% on days participants attended the center). From a baseline mean of 210.9lbs (s.d. 43.9), average weight loss for 52 participants was 4.5lb (s.d. 12.8) (P<0.014). On average, participants lost 1.9% of body weight. Mean waist circumference change was 3.1cm (s.d. 5.6). Participants on average increased the distance on the 6-minute walk test by 8%.

Conclusion: This pilot study documents the feasibility and preliminary efficacy of a behavioral weight-loss intervention in adults with serious mental illness who were attendees at psychiatric rehabilitation centers...
Although a 2% loss of body weight may not seem like much, it's better than a 10% weight gain over the same time period. The medical profession is obligated to provide the means for improved physical health in persons with serious mental illnesses. When physical health is potentially compromised by psychiatric treatments such as atypical antipsychotics, action to improve the situation is even more urgent.


Chang, C., Hayes, R., Perera, G., Broadbent, M., Fernandes, A., Lee, W., Hotopf, M., & Stewart, R. (2011). Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London PLoS ONE, 6 (5) DOI: 10.1371/journal.pone.0019590

Daumit, G., Dalcin, A., Jerome, G., Young, D., Charleston, J., Crum, R., Anthony, C., Hayes, J., McCarron, P., Khaykin, E., & Appel, L. (2010). A behavioral weight-loss intervention for persons with serious mental illness in psychiatric rehabilitation centers International Journal of Obesity DOI: 10.1038/ijo.2010.224

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At May 20, 2011 11:01 PM, Blogger Bec said...

This is a great post! I completely agree that physical health is so often neglected. It doesn't help that a lot of doctors write-off physical symptoms as psychosomatic and refuse to investigate them in a way they would with a non-MI patient.

I'm glad I found your blog. I've had a quick look around and I will certainly be coming back for more!

At May 22, 2011 8:39 AM, Anonymous Anonymous said...

The same drugs that are needed to control the psychiatric symptoms end up killing the patient prematurely. And that's the way it is. Life ain't fair. I didn't realize how many years were taken away from life expectancy. That's the shocker here.

At May 24, 2011 10:44 AM, Anonymous Emmy said...

What about the effects of exercise? I doubt it would put much of a dent in schizophrenia. But here's how I understand the benefits of cardiovascular exercise: when animals are physically active, it signals to the body that energy (food) is available, and that cells can be regenerated. When an animal lies around (or is a couch potato), it signals to the body that resources are scarce, and energy for cell regeneration is low - so cells die and the animal ages. So long as energy is available, the cells keep regenerating (good for the brain, I imagine) and people stay young and healthy longer. I'd think with the combination of endorphins and such, this would be a benefit to mental health. Too bad people, especially those who are depressed, have a hard time getting motivated. I'd say skip the gym and try trail running, since the mental benefits of being outside are also proving themselves to be helpful.

At May 27, 2011 3:30 PM, Anonymous Mare said...

Another possible reason for reduced life expectancy may be poor self-care. Adequate self-care can be impaired in so many ways when one has a mental illness. I have trouble with depression and speak from long personal experience. Good social supports could go a long way to aleviating self-care deficits, but are often unavailable.


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