Tuesday, September 18, 2012

Why Psychiatric Patients Die Younger

If you're reading this for the answer, you can stop now.  I don't know why psychiatric patients die younger than people who do not have psychiatric disorders.  I think that fact only applies to those with chronic psychiatric illnesses, not to someone who has had a single episode of depression or anxiety.  What qualifies as a chronic mental illness?  I'm not sure -- but certainly if you get on-going disability (SSDI) benefits because of your psychiatric disorder, or if you live with a careprovider and attend a long-term psychosocial rehabilitation program for years, or have resided in a state hospital for years.  

How much less time do psychiatric patients live?  The numbers vary from 8 years to 25 years, though I have hard time believing that the average lifespan of a psychiatric patient is only a little over 50.  I have had a few psychiatric patients who have died young, but none under age 50.

So, if we start from the premise that psychiatric patients die younger than people without chronic and persistent mental illnesses, then why?  I'll throw out some ideas.  None of them are the right answer because there is no right answer, just my thoughts on some possible contributing factors.

  • Poor coordination of care: psychiatric patients may be less likely to make appointments, coordinate their care, and may receive medical treatment of their conditions at a substandard rate. (Roy likes this one, I bet)
  • Psychiatric patients smoke cigarettes at rates that are higher than the general public.   
  • Psychiatric medications predispose people to weight gain and metabolic syndromes that may precipitate diabetes and heart disease.
  • Psychiatric patients have high co-morbidity with substance abuse disorders and substance abusers die young for many reasons.
  • Psychiatric patients have higher rates of suicide and suicide is common cause of death among young people.
  • People with psychiatric disorders may not be evaluated as carefully as people without such disorders when they present to a medical professional with problems.  The medical professionals may be too quick to attribute problems to anxiety or depression or psychiatric concerns.
  • Certain psychiatric conditions may predispose people to  behaviors that are not good for them.
  • Certain psychiatric conditions may predispose people to have less interest in investing energy in the caring for themselves or making lifestyle decisions that favor good health.
  • Chronic mental illness is associated with poverty and this is associated with obesity, and as well as a lower likelihood of investing in more expensive and healthier food choices, gym memberships, and a full range of medical care.
  • Patients with psychiatric disorders may have fewer close relationships and family members often cajole their relatives to take care of themselves, pursue medical care, and provide a reason to live.
Just my thoughts.  Tell me what I missed.


George Dawson, MD, DFAPA said...

Cardiovascular risk factors were summarized by Newcomer and Hennekens in a definitive opinion piece in the JAMA on the shortened life span: http://jama.jamanetwork.com/article.aspx?articleid=209157

I think that stigma is the unspoken risk factor. Many of the problems from substandard housing to less comprehensive treatments compared with medical or surgical patients is a direct result of stigma and how insurance companies have institutionalized stigma. Another obvious example is in addiction treatment where most people have no access to adequate detoxification. Insurance companies can learn a lot from AA - specifically that they should not refuse resources to people who want to recover.

Anonymous said...


Dinah said...

Dr. Dawson:
You say this as though insurance companies want patients to get better. They want to make money. Once a patient has a chronic illness, the insurance company is better off with them dead.

L said...

Dinah, have you ever had a patient who killed himself?

Dinah said...

L: No and I hope to keep it that way.

jesse said...

Psychiatric conditions interfere with the optimum social functioning of those that have them. On average, then, they will interfere with longevity as social functioning is related to it.

Sarebear said...

For the first time, this last week, I felt like a doctor treated me like I was "mental" . . . like what I said wasn't completely valid or valid at all.

I was quite agitated at the appointment, at an urgent care clinic, and I tried with everything I had to not be agitated, to keep everything in check.

Didn't work, couldn't do it, it wasn't enough. Perhaps my efforts kept it from being worse than it was . . .

But by the end of the appt., it was clear he was treating me as if my capacity to reason was lessened or gone. I don't ever want to be treated that way again . . . I can understand a certain degree of it given how agitated I was (I've never been that way in front of people, and not nearly like that even alone).

Anyway, I can see how going to the doc might become something someone like me might avoid or postpone for as long as possible, if they fear being treated that way. Which would, of course, negatively impact one's health I'd think.

I have almost no support system.

I have a variety of chronic conditions, and perhaps another one now (if it's psych med caused, my shrink said let's treat the side effect, cause the other choice would be dangerous, and I reluctantly agreed, but then again I don't see near as much wrong with the dangerous option as she does, which is why I'm following what she said, if reluctantly, cause my judgment sucks right now). So, coordination of care is an issue (although since Utah's Medcaid just forced an opti-in to the state's EHR on me, and the legislators are actively seeking to make it mandatory, with no opt-out, well, perhaps coordination of care will improve?)

The suicidal thing, check.

The exercise thing is an issue, because it bloody hurts to exercise (stupid leg pain). Still, last year I kept it up for five months, so I just need to push myself. Some days you just don't want to add extra pain on to the pile, however. If I had more friends, I'd have people to go walking with and stuff, so lack of social connections affects that too (but yeah, I can go by myself).

I'll haveta think about what else might affect this, but fear of unknown is a biggie for me, and that includes going anywhere new, seeing new doctors, getting new types of tests that I haven't done the procedures for before (MRI was a big one, and I'll never go in that thing head first, feet first was bad enough).

George Dawson, MD, DFAPA said...

"You say this as though insurance companies want patients to get better."


Certainly did not want to give that impression. I thought I was saying that insurance companies are responsible for institutionalizing stigma. The best example is grossly disproportionate resources for mental health and addiction such as lack of detox facilities and shifting the burden of care for severe mental illnesses (the people losing 25 years off their life span) to the state. More than a little ironic that many states are now paying these same managed acre companies to provide even more tightly rationed care.

Anonymous said...

It is really difficult to get a medical professional to take a psychiatric patient's concerns at face value. Near impossible.

My psychiatrist is great tho. She really wants me to have my eyes checked because I'm seeing odd things. She knows an ophthalmologist so she called his office to see about his availability and then his office called me to make an appt.

She knows how traumatic it is for me to go to drs considering some of the treatment I've received. So when she really wants me to see someone about my health, she tries to remove as many barriers as possible. She's my primary care dr as far as I'm concerned.

Anonymous said...

Psychiatry cannot cure mental illness so it aims to control it whether as a means of getting to the patient to behave in line with social expectations or whether as an attempt to alleviate suffering to whatever extent that is possible. Looking strictly as pysch drugs, although Dinah listed many other factors and they are not invalid, they confuse me. On the one hand, my doc does not want me to commit suicide. On the other, if I take those drugs and oh boy, I have taken a lot,I increase my odds for dying earlier. I have seen how some of my blood tests come back outside the normal range as a result of certain meds. Others can damage the kidneys and others can give you a heart attack if you are susceptible.My relative had cancer (not a psychiatric patient) and the chemo did him in way faster than the cancer would have. So psych drugs are powerful and like drugs used to try to treat other illnesses, they can kill you faster than if you had not been taking them provided you were not otherwise going to kill yourself or endanger your life if you were not on them.

Anonymous said...

It's pretty impressive that you haven't had a patient die under the age of 50 ,considering the number of people I know who have DIED under the age of 50,whether of cancer, heart attack, etc. Lost one friend to breast cancer at 41. Another to Lymphoma at 47. I know a bunch of people who died in their 30s and 40s of heart attacks. None were psychiatric patients, btw.My father died ,aged 51 of a sudden massive Heart attack, but 51 IS over 50.
as for hope that you will never lose a patient to suicide, I hope that is true, but bear in mind, it could happen to even the BEST of psychiatrist or other mental health professionals. Suicidal patients will often NOT tell psychiatrist if they are serious about ending their lives. Why would they ? Informing Dr. will result in hospitalization or other attempt to thwart suicide. IF someone truly wants to die, that person is unlikely to inform you of such. I think you have been more fortunate in this respect, than anything else. I don't know you and am not implying that you are not an excellent psychiatrist. Just that suicide cn be unavoidable in the face of severe depression,etc.

Anonymous said...

Psychiatric patients may very well die younger because when they present with medical complaints to physicians they are more likely to be dismissed than non-psychiatric patients.
I have had several near death experiences due to this reason.
It was "all in my head, anxiety, etc" until I had seizures and lost consciousness On an MAOI-after weeks of complaining of blurred vision and other symptoms.Even when I presented with the classic MAOI headache,I was told my my internist that it was "in my head."
I started having seizures within an hour of seeing him, and lost consciousness about 6 hours later, after a desperate call to my psychologist resulted in the response that it was all in my mind.
It was "all in my mind" Until I was unconscious. How all the Doctors scrambled to cover this up afterwards. I regret that I failed to report this to anyone.
Had my internist taken my Blood Pressure sitting and THEN STANDING, he would have known that I was suffering from severe Orthostatic HYPOTENSION. I had never eaten a single prohibited food. This is but one example of when it was "all in my mind."
is it any wonder psychiatric patients die younger, given the dismissal of M.D.s of even life threatening symptoms such as I experienced?

Anonymous said...

Response to George Dawson:

AA does not charge any fees. so of course they would not refuse "treatment" to anyone. Therefore, I do not understand your comparison between AA and insurance companies.
AA has no financial dis-incentive to deny help.
Insurance companies are all about profit.
Also, while I believe that in many respects AA/OA/NA etc are marvelous organizations whose only intent is to help people, my personal experience is that "turning over" my eating disorder ( in my case, in OA) to "Higher Power", praying, reviewing and admitting my character defects, etc did nothing to help me recover from my eating disorder. In the long term, the "abstinence; all or nothing model" HARMED ME.
I DID find a fantastic SUPPORT GROUP in OA. However, now that I have a fantastic Psychologist who specializes in C.B.T. I have to unlearn everything I was taught about the Addiction Model I was taught in OA , to learn that the concept of forbidden foods inevitably results in eventual binging due to deprivation,etc.
My wonderful C.B.T. therapist has taught me that I CAN eat cookies, chocolate etc in moderation following exposures to such foods in his company.
It was heavily stressed in OA that one should NOT trust therapists , that eating disorder therapists did not know what they were talking about.
Having said that, if someone can not access any other treatment, I would recommend 12 step groups as superior to NO CARE. I do know people who have benefited.
However, 12 steppers are NOT professionals,and I was taught much that is not ,as my C.B.T. therapist would say" Supported by Evidence."

Anonymous said...

Sigh. I arrived at emergency for physical ailment. Not a headache, flu or broken bone. I was taken seriously for five minutes until they called up the info in the medical record that indicates psych hospitalizations for psychosis related to bipolar. Suddenly, I had no other medical issues and it was all in my head. This was reinforced by putting me on a three day hold for being "psychotic". I could probably sue since I was not in any way psychotic but was suffering from a "real" medical condition which is chronic and will likely end my life earlier than if I did not have especially since I refuse treatment for it after that experience. Who wants to be an old person with an illness that no one cares about because the psych history trumps it all?
Suicide? I would not tell my shrink if I were intent on it. I wonder if you have former patients who have suicided and you don't realize.

Jane said...

I have had a similar experience to the anon who commented that even the psychologist told him it was all in his head. In my experience, a psychologist is very unlikely to refute a doctor who thinks the symptoms are all psychosomatic. If the doc says it's in your head, the psychologist will jump on board as well and start treating for something psychosomatic.

Anonymous said...

It would be interesting to know which chronic physical illnesses were associated with early mortality.

Here's a study for epilepsy (2-10 years, worst at diagnosis, improving over time):


And epilepsy often comes with depression, and anticonvulsants can be both physically harsh and depressing.

Anonymous said...

I'm a long time reader of the blog who agrees that having medical problems taken seriously once you've experienced psychiatric problems is extremely difficult. I first sought treatment for an anxiety disorder and depression in my early thirties and then later developed chronic pain in my mid-forties which still isn't being adequately addressed by my HMO; it's easier to code me with "somatization". I'm also a poor medication metabolizer--have considered cytochrome p450 testing--which many MDs can't seem to accept. I dread dealing with physicians because too frequently the implication is I'm responsible for my health problems; I know that's not true.

Joy said...

Dinah, you make the classic mistake of assuming that psychiatric patients don't live as long because their psychiatric illness causes them to DO things that are not good for their health. I think it's far more likely that psychiatric illness is, directly, bad for your health.

We know that stress, all on its own, is intrinsically bad for you: it messes up how your body self-regulates cortisol, blood sugar, etc. It's likely that psychiatric illness has direct metabolic effects in the same way. The Adverse Childhood Experiences study is a good example of this: the experience of trauma, ITSELF, somehow changes your brain and body in a way that predisposes you to lots of illnesses.

I think this is a fundamental distinction: it's not that psychiatric patients just need to take care of themselves better despite their psychiatric illness, it's that their psychiatric illness has direct physical effects that are unavoidable.

Anonymous said...

Many psychiatric medications are carcinogenic and used for a long time. It is well known that people who suffer from depression get cancer younger and more often, probably due to the drugs that they take for it. Here is an article on the carcinogenicity of various medications, which is another thing that should be taken into consideration when choosing a medication.


Noni Mausa said...

Let's try "poverty" as a major contributor.

A depressed relative has been on SSDI since the mid-80s, and has lived with family till recently, making him poor but not destitute or homeless. I have no idea what he will do now that his mother has gone to a nursing home. His income is about $8,400 a year, and no-one's likely to increase it.

Frankly, living on that sort of minimal income would depress anyone except Pippi Longstockings.

There are services out there, after a fashion, but getting to them is confusing. Also, because of his depression he judges social services ahead of time as hostile or disinterested, and may spend days or weeks avoiding calling anyone. He had a broken tooth for a couple of months before he approached anyone. Forward planning is not something he does -- he sleeps 50-65% of the time. Now that he will be on his own, I can't guess what will happen.

The puzzle is not why he might die sooner -- it's why anyone would think he would not.

Jane said...

@ the poster with a relative on SSI. Honestly, he is probably not prejudging social services. I am on disability, and they usually are very restrictive about who they help and are hostile towards people on public assistance. This is why you hear about family members who will abandon disabled relatives because social services would not get involved unless they did that. A lot of programs geared towards disabled people are very restrictive and pick and choose who they help. They can say he is not needy enough and has family helping him so he does not qualify for services. Even if your relative wanted to get a job, and requested help, they could turn him down by saying he is too depressed to work and so he does not qualify for that assistance.

Public assistance programs, in my experience, are not that good and they can be very rude to people with mental health issues.

Personally, social services tried to tell me that I would not be able to work, support myself, or be anything besides too mentally ill to care for myself. I was told I would have to rely on my family to care for me. I have since lived on my own for five years now, obtained a BA, and done this all without the help of social programs. In fact, I did it at their discouragement.

Corinna West said...

I met Steve at the Partnership with Patients conference this weekend. You can read the actual morbidity and mortality report here: http://www.dsamh.utah.gov/docs/mortality-morbidity_nasmhpd.pdf

It's 80 pages, but Overall it's actually a "good news" story. report, saying that small increases in wellness make improvements mortality risks.

The report also says, on page 7: "However, with time and experience the second generation antipsychotic medications have become more highly associated with weight gain, diabetes, dyslipidemia, insulin resistance and the metabolic syndrome and the superiority of clinical response (except for clozapine) has been questioned. Other psychotropic medications that are associated with weight gain may also be of concern."

The excess mortality was only a 12 year different before the so called second generation meds came on line.

This is because those meds increase the rate of heart attack 9 to 18 fold. 10.1093/eurheartj/ehr368

care provider said...

I am commenting a couple of months late, but was listening to "My Three Shrinks" and heard the topic come up. I'm not sure what is being done about this issue in other places but I can tell you what they are doing in AZ.
In Maricopa County someone in a position to do something read the research about life span. In the SMI population here, the average life span is 27 yrs less. Starting on the summer of 2011, the clinics that serve the adult SMI population did a pilot study using health risk assessments to evaluate things like already diagnosed illness, the results of the annual labs like cholesterol and fasting glucose, and utilization of specific medical/preventative care over the prior year. They also asked about personal support system. The clinics are now doing these risk assessments annually on every adult deemed Seriously Mentally Ill.
I'm sure there are stats but I haven't seen specifics. They determined that the risk factors that they could address were:
lifestyle issues such as level of exercise, nutrition, smoking cessation, and coordination of primary care with the mental health providers. It is standard to request records from PCP's and include the lab results from the annual fasting labs drawn at clinics.
The issue of lack of primary medical care was a big one. This summer the county integrated health system opened up primary care offices in a few of the clinics with plans to eventually open an office in each. There are primary care providers in each one on certain days. They can see the clients who are treated there for psych for anything medical, from urgent care to full PCP services. As they grow, some of the clients will utilize them as their main PCP.It enables what they have referred to as "one stop shopping". Barriers such as transportation and ability to show up at scheduled appts are reduced. If someone comes in for their psych care and they don't feel well, or have an elevated blood pressure or glucose, it is standard practice to walk them to see the nurse practitioner.
There is also at least one group of clinics that has a pharmacy liason at the clinics every day. They can order their meds through the pharmacy, medical meds included, and have them delivered to them at home.
They also hired Health and Wellness coaches and have exercise groups, nutrition groups, and smoking cessation assistance. There is space for exercise, a Wii fit for fun exercise. A group went on a hike in one of the many hiking areas this past weekend.
It will be interesting in the long term to see what kinds of changes will be seen in the risk assessments in the coming years.
This is a medicaid funded program, and somehow it wasn't cut when a lot of other stuff was.
As someone involved with the clients in direct care, it is nice to see someone doing something useful about it.