Benjamin Druss MD, MPH
October 3, 2012

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We have known for 3 generations that people treated in the public MH sector die younger than the general population; this excess mortality is largely due to “natural” causes 1
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As advances have improved longevity of the general population, disparities appear to be growing over time.
2,3
1.
Journal of the American Statistical Association Mar 1932;27(177A):160-174. 2. BMJ. 2011 Sep 13;343:d5422 3. 3. Nord J
Psychiatry. 2012 Apr;66(2):97-106. Epub 2011 Aug 23
.

1
Year of Publication Excess Risk of Death
1970s 1.84
1980s
1990s
2.98
3.20
1. Saha et al Arch Gen Psychiatry. Oct 2007;64(10):1123-1131 http://www.qcmhr.uq.edu.au/epi/index_files/Page562.htm

What Are the Causes of Excess Morbidity and
Mortality in Mental Disorders?
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
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Persons with SMI on highest dose of antipsychotics have a 1/3 higher rate of CVD death than those on lower doses 1
In a national US sample, SES and health system factors each explained about ¼ of excess mortality.
3
Among veterans with schizophrenia, behavioral risks including obesity explain about 1/3 of excess mortality 2
1.
Arch Gen Psychiatry . 2007;64(2):242-24 2. Gen Hosp Psychiatry. 2009 31(6):555-6 3 Medical Care,
2011;49(6):599-60

1. Arch Gen Psychiatry. 2006 Jul;63(7):824-30
2. J Nerv Ment Dis 2003;191: 799
–805

What are the causes of obesity in mental disorders?

Side effects of medications, most notably newer
(second generation) antipsychotic medications. 1
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Diet and physical activity: Individuals with schizophrenia consume significantly greater amounts of sugar and fat and are less likely to engage in physical activity than the general population.
2
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Poverty: Mental illnesses are a risk for poverty which is in turn associated with excess rates of obesity. 3
1. Acta Psychiatr Scand. 2009100:3 –16. 2. Compr Psychiatry. 2012 3. Epidemiol Rev. 2007;29:29-48 .

What are the consequences of obesity in mental disorders?
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Reinforces stigma of mental illness 1
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Increases costs of care 2
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Decreased quality of life 3
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Poor health: diabetes, cardiovascular disease and ultimately, premature mortality 4
1. Am J Public Health. 2010 Jun;100(6):1019-28. 2. Gen Hosp Psychiatry. 2009 Jan-Feb;31(1):1-7.
N Engl J Med. 2006 Aug 24;355(8):763-78 2. 3. Obesity (Silver Spring). 2008 Apr;16(4):749-54.4
4 European Journal of Preventive Cardiology June 2008 vol. 15 no. 3 239-246

A Public Health Approach To Addressing Obesity and Premature Mortality in People with SMI
Primary Prevention Secondary Prevention
Tertiary Prevention
Populations with SMI
Risk Factors Cardiometabolic disease
Wellness programs
Environmental Policies
Medication choice
Screening Treatment

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Include persons with with SMI in broader public health campaigns and develop programs targeted at this population (e.g. SAMHSA Wellness Initiative).
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Track health indicators including mortality among people with SMI (e.g. NCQA’s new performance measures for people with SMI for HEDIS 2013).
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Promote effective clinical models that provide integrated medical care for people with SMI. (PBHCI program; Medicaid Medical Home demonstration projects)

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The problem of premature mortality in people with
SMI is a “crisis” that has existed for at least ¾ of a century.
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More recently, this problem has been compounded by high rates of obesity in people with SMI, which represents an epidemic within an epidemic.
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Policies addressing poor health and obesity in this population need to support a public health approach that supports both prevention and high quality medical treatment.