Study Examines Causes of Premature Death of Individuals Diagnosed w Schizophrenia

NYAPRS Note: Some powerful findings from a study published a year ago pointing to diabetes, cancer and suicide among the reasons for the extraordinarily high rates of early death among individuals diagnosed with schizophrenia. The authors link the causes with smoking, limited physical activity, obesity, elevated serum glucose level, hypertension, and dyslipidemia as well as economic disadvantage and ‘negative health behaviors.’ One must include the impact of psychiatric medications in some instances.
Please note that “the mortality rate was higher for men than women, increased with age, and was higher for those of white race/ethnicity than for other racial/ethnic groups.”

The study ends with a very strong endorsement of the integration of behavioral and primary care, a linchpin of New York’s DSRIP initiative.

Urgent Care: Schizophrenia Patients Dying Prematurely, But Why?
By Debra Hughes, MS MPR January 22, 2016

Nonelderly adults with schizophrenia are 3.5 times more likely to die than adults in the general population.1,2 Each individual, on average, loses 28.5 years of life.1

Yet, more than 85% of these deaths are from natural causes, primarily cardiovascular disease, cancer, and diabetes mellitus.1

The questions are: “Why?” and “What can be done”?

One reason is that adults with schizophrenia are “less likely than their age-matched peers to receive adequate treatment for major medical conditions,” Mark Olfson, MD, MPH, and colleagues write in JAMA Psychiatry,2 thus compounding the risk of premature mortality.

“Many factors, including economic disadvantage, negative health behaviors, and difficulties accessing and adhering to medical treatments, are thought to contribute to premature mortality,” Dr. Olfson, of the Department of Psychiatry and New York State Psychiatric Institute, College of Physicians and Surgeons, Columbia University, New York, NY, and coauthors state. “Smoking, limited physical activity, obesity, elevated serum glucose level, hypertension, and dyslipidemia are all significantly more common in schizophrenia than in the general population.”

To characterize key sources of excess mortality among adults with schizophrenia, the investigators conducted a national examination of the Medicaid program, “the largest payer of health services for persons with schizophrenia in the United States.”

They identified 1,138,853 individuals in the schizophrenia cohort and 74,003 deaths, 65,553 of which had a known cause.

What they found was “a more comprehensive picture than was previously available of the gap in mortality, highlighting the need for more effective strategies to improve the medical care of this patient population.”

Increased risk of mortality “was particularly elevated for COPD, influenza and pneumonia, diabetes mellitus, cardiovascular disease, and suicide,” they write. “Among all causes of death, suicide was associated with the highest mean years of potential life lost per death,” Olfson et al note.

The mortality rate was higher for men than women, increased with age, and was higher for those of white race/ethnicity than for other racial/ethnic groups.

“In absolute terms, the leading identified causes of death were cardiovascular disease, cancer, and accidents,” they wrote. By age group, unnatural (vs. natural) deaths were highest among those 20 to 34 years of age, which was attributed to accidents and suicide, while natural deaths from cardiovascular disease were highest in those 35 to 54 and 55 to 64 years of age.

These patterns can guide clinicians managing patients with schizophrenia. Olfson et al suggest the following:

In an accompanying editorial in JAMA Psychiatry,1 Shuichi Suetani, MBChB and colleagues note that the Olfson et al research “is a reminder of how we are failing to meet the needs of people with schizophrenia.” They call on governments “to ensure priority is given to physical and mental health care of those with severe mental disorders” to prevent “a further widening of the life expectancy gap between the general population, whose life expectancy continues to rise, and that of people with severe mental disorders.”

Severe mental illness can also elevate risk for type 2 diabetes mellitus. For this reason, “the American Diabetes Association recommends annual diabetes screening for patients treated with antipsychotic medications, and public health administrators have targeted this population for improved health screening,” Christina Mangurian, MD, of the Department of Psychiatry at the University of California, San Francisco, CA, and colleagues note in JAMA.3

However, due to limitations in public health records, “to our knowledge, no studies have examined screening rates in this highest-risk population of adults with severe mental illnesses,” such as schizophrenia and bipolar disorder. To investigate the prevalence of diabetes screening, they used data from a California healthcare system that included publicly insured adults with severe mental illnesses treated with antipsychotic medications; also assessed were characteristics predictive of screening.

They found that of 50,915 study subjects, 15,315, or 30.1%, received diabetes-specific screening, while 15,832 (31.1%) received no form of glucose screening over the course of a year.

“The strongest correlate of diabetes-specific screening was having at least 1 outpatient primary care visit during the period examined,” in addition to mental health services, Mangurian et al report. The adjusted prevalence ratio was 1.80 (95% CI: 1.62–2.00; P<0.001).

“This observation supports the value of burgeoning efforts to integrate behavioral health and primary care,” they write. “Growing evidence supports the value of screening for diabetes mellitus in higher-risk populations….”

They call for studies “to explore barriers to screening in this vulnerable population.”

1. Suetani S, Whiteford HA, McGrath JJ. An urgent call to address the deadly consequences of serious mental disorders. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2015.1981. Published online October 28, 2015.

2. Olfson M, Gerhard T, Huang C, Crystal S, Stroup TS. Premature mortality among adults with schizophrenia in the United States. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2015.1737. Published online October 28, 2015.

3. Mangurian C, Newcomer JW, Vittinghoff E. Diabetes screening among underserved adults with severe mental illness who take antipsychotic medications. JAMA Intern Med. doi:10.1001/jamainternmed.2015.6098. Published online November 9, 2015.