Tackling Premature Death in People with Schizophrenia

People diagnosed with schizophrenia die prematurely at an alarmingly high rate. A recent report from the United States, based on analyses of 75,000 deaths of people with schizophrenia, is the largest study to date on this topic. 1 Age-adjusted death rates among people diagnosed with schizophrenia were more than 3.5 times that of the general population. These results are highly consistent with previous reports from high as well as low and middle-income countries around the world. The findings have important implications because the main causes of premature death among people with schizophrenia are medical illnesses that are preventable and treatable.

Cardiovascular diseases (19,000 deaths), cancer (10,000), accidents (6,000), diabetes mellitus (3,000), and suicide (2,500) were the leading causes of death. Using the Years of Potential Life Lost (YPLL) metric, individuals who committed suicide lost the greatest average number of potential life years (38 years). However, because deaths due to cardiovascular disease were far more common and the average number of years lost for these individuals was also large (27 years), the overall burden of cardiovascular disease was much higher. The total YPLL for cardiovascular diseases was over 500,000 years compared to a little less than 100,000 for suicide.

Cigarette smoking is implicated in a huge proportion of these premature deaths. Most remarkable is the increased death rate from chronic obstructive pulmonary disease (COPD, including emphysema), which is 10 times higher in people with schizophrenia than in similarly aged people in the general population. Public health measures such as cigarette taxes; age restrictions on purchasing cigarettes; and smoking bans in workplaces, restaurants, and public places have contributed to a large decrease in the rate of smoking in the general population in the U.S. but have had little impact the high rate of smoking among people with schizophrenia. Continued efforts to promote policies that reduce smoking and to train mental health professionals to intervene are urgently needed. Because alcohol and drug abuse were also important causes of excess deaths, improved recognition of substance abuse and improved access to interventions to reduce associated harms are also needed.

Multiple other causes also contribute to the excessive death rate. People with serious mental illnesses such as schizophrenia receive poorer medical care than others. Medical problems are often not recognized. Stigma may lead health professionals and others not to pay enough attention to medical issues raised by people with schizophrenia. Cognitive or communication problems may mean that patients do not describe problems well. Even when medical problems are identified the optimal treatments are not provided.

The World Health Organization has promoted improved general medical care for people with mental illnesses in its Comprehensive Mental Health Action Plan and mental health GAP Action Programme (mhGAP). A WHO Information Sheet on this topic proposes the following three key actions:

  1. Create prevention, identification, assessment and treatment protocols for the general and mental health needs of people with severe mental illnesses.
  2. Integrate mental and physical health services to improve access to general medical care.
  3.  Work to reduce stigma and to end discrimination against people with severe mental illness.  

On a practical and immediate level, specialty mental health and primary care providers must pay close attention to both the behavioral and medical issues of their patients. Educators should emphasize this to trainees from the outset of professional training.

Reference

1. Olfson M, Tobias G, Huang C, et al. Premature mortality among adults with schizophrenia in the United States. JAMA Psychiatry 2015; 72: 1172-81. doi: 10.1001/jamapsychiatry.2015.1737