Shorter life spans for the mentally ill?

Stories such as this one ‘Mentally ill have reduced life expectancy, study finds’ http://www.bbc.co.uk/news/health-13414965 could make you believe that people who are mentally ill are all doomed to die early and much earlier than the so called normal population. This story quotes;

Those most affected were women with schizoaffective disorder - problems with mood or sometimes abnormal thoughts - whose average life expectancy was reduced by 17.5 years, and men with schizophrenia whose lives were shortened by about 14.6 years

If a true reflection of the situation it would indeed be tragic. The article is based on a study published on line and it’s results although interesting do not I feel give a good picture. The article ‘Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London’ can be found here http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0019590 and it finds:

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).

This study however only compares life expectancy with national norms which of itself seems reasonable however might not be.

I found a study done in America that compared similar matched populations from Massachusetts, one with and one without known severe mental health problems and this showed something rather different (http://ps.psychiatryonline.org/data/Journals/PSS/3521/1036.pdf). By comparing two populations from the same area they tried to account for the variation in age of death within the population. In this study they made several comparisons. The first and obvious one was between age of death, which is similar to the BBC’s claim that life expectancy goes down with severe mental health problems as it quotes:

The median age at death was 66 years for the DMH population (service users with severe mental health problems) and 76 for the non- DMH population (those without)

However they then went on to estimate the life years lost for both populations for each cause of death and compared them to each other. By matching the populations by cause of death they are trying to reduce the effect that any physical medical conditions, socioeconomic and environmental factors for the areas in the estimate to zero, however this is not possible but could reasonably be expected to be closer to the actual difference made.

Thus they report:

Table 3 summarizes differentials in years of potential life lost by underlying cause of death. Overall, the difference in means between decedents served by DMH and others was 8.8 years (t=65.5, df=1, p<.001).

Which means that the service users ie those with severe mental health problems died 8.8 years earlier than those without with mean age of death of 65.5 years and significant to 1% and can therefore be considered a good estimate of the actual difference in life expectancy between the populations. The 1^st article has this to say about the discrepancies

In a US study conducted by the Massachusetts Department of Mental Health from 1989 to 1994, service users with SMI were found to have lost 8.8 years of potential life (14.1 years for men and 5.7 for women) on average compared to the general population, a stronger impact for men and weaker impact for women compared to findings from our sample. However, SMI was not specifically defined in the Massachusetts study other than stating “evidence of serious dysfunction” as an inclusion criterion [1], which might explain the discrepancy

which I have to say us not entirely convincing since they make no attempt to estimate the effect of co-morbid conditions on life expectancy.

So why is that?

Well basically everyone knows that life expectancy is altered by what other conditions you may be suffering. For instance if you get a cancer your life expectancy plummits or heart disease, it stands to reason that it will go down. So when I see this study using the national averages I wonder whether the if it is that simple to say only the diagnostic criteria matter. National averages will include all people and therefore those that suffer from these conditions as well but the question then is does this subset of data contain a disproportionate number of people who suffer from these conditions because if it does then you could reasonably expect that the national average would be artificially high for this group and therefore not a good comparison however this article does not mention this either.

So does this group have an artificially larger proportion of people with secondary illness?

 If you look at this article http://www.kingsfund.org.uk/current_projects/mental_health_and_longterm_conditions/cost_of_comorbidity.html Mental health and long-term conditions: the cost of co-morbidity, you will see that they quote this:

the evidence suggests that at least 30 per cent of all people with a long-term condition also have a mental health problem (Cimpean and Drake 2011).

And if you look at Figure 1 the diagram clearly says 30% of the population of England have a long term condition and 30% of them have a mental health problem. Now 20% of the population have a mental health problem and 46% of them have a long-term condition. So the answer is yes it does a whole 16% extra percent, surely a good enough reason to suggest that this population would have a decreased life expectancy than the national norm.

Incidentaly the comments on the BBC suggest that the reason the mentally ill are dying young is because of poor health services

"These grim statistics tell a depressingly familiar story. It is completely unacceptable that people with a mental illness are effectively living in the 1930s in terms of life expectancy.

"Action must be taken; we cannot carry on tolerating the fact that people are dying from preventable illnesses, due to a health system which treats mental health patients as second class citizens."

The problem is I’m not sure how they are drawing these conclusions. The problem is I can’t tell whether people with mental heal issues are dying young purely because of failures with their physical health care or because they have two if not more long term health issues. I would dearly like to see the statistics that show that having two or more physical health conditions doesn’t result in the same shortening of life; that actually this isn’t happening with the same regularity for those diagnosed with a physical condition first or even more than one.

The fact remains that just because people with mental health issues die young of treatable conditions it doesn’t mean that we weren’t treated to the best possible care and sadly I see no evidence here to suggest otherwise. The sad fact is that I believe it is extremely difficult to get care for physical complaints once you have a mental health diagnosis however this evidence is not convincing me and I’m not in government.

Is there actually a problem with the health care provided?

Not that I necessarily agree with the estimates of how much earlier people are dying but there is definitely a problem and the simple fact is that it is not just about those with a pre existing mental health condition. If you read this http://www.kingsfund.org.uk/current_projects/mental_health_and_longterm_conditions/cost_of_comorbidity.html Mental health and long-term conditions: the cost of co-morbidity you will find that it focuses on the other side of the coin.

For example, one study found that while more than 90 per cent of people with depression alone were diagnosed in primary care, depression was detected in less than a quarter of cases among people who also had a long-term condition (Bridges and Goldberg 1985).More recent evidence confirms that the majority of cases of depression among people with physical illnesses go undetected and untreated (Cepoiu et al 2008; Katon 2003) page 13.

The health care system is failing everyone by not looking out for both the physical and the mental health needs of its patients and no extra care is being taken to look for and monitor for possible risk illnesses for either.