Morbidity and Mortality in Individuals with Serious Mental Illness
This is Marsha Snyder, faculty at the University of Illinois College of Nursing.
I am going to address some of the cultural considerations related to this topic. So let’s get started.
We have four learning objectives for this module
The first one is to realize that people with mental illness also have increased risk of physical illness
To identify the co-morbid diseases most likely to be seen in individuals with Serious Mental Illness (SMI)
We want to discuss some of the reasons for this increased risk
And lastly, examine the role of culture in the health disparities of persons with SMI
People with serious mental illness die younger. Why is this? There are several reasons for this
phenomenon. (1) Persons with serious mental illness enter into the healthcare system through the
mental health system where the tunnel vision by providers and the expertise and energy is focused on
the mental illness and its manifestations. Here physical illnesses are really attributed to the mental
illness presentation. (2) Physical illness is when undiagnosed and left untreated until the person actually
enters into the medical system become more complicated and severe and so you have a very
complicated problem by the time the individual comes into the physical or medical system.
And because of all these complications and lack of attention what we see are a number of comorbidities in this population
A large outpatient study examined Medicaid claims to determine prevalence, severity and co-morbidity
of chronic physical health problems in SMI
74% had at least 1 other illness
50% had 2 or more illnesses
33% had 3 or more illnesses
20% had 4 or more illnesses
So you can see the extent of the problem.
Morbidity and mortality in persons with serious mental illness
Some of the common co-morbidities that we see in this population include obesity, hypertension,
diabetes, COPD, hepatitis B and C (particularly in terms of some of the drug use), HIV, tuberculosis
because of the living conditions people are associated with, and lipid disorders.
Many of these problems are related to medication or to a sedentary lifestyle. And so as a result in terms
of mortality we see that persons with serious mental illness are more likely to die younger.
Statistics show that men die at 14.1 years and women 5.7 years sooner than the non-mentally ill
population.
Leading causes of death in this population are heart disease (in terms of, you have to look at the comorbidities), suicide and accidents
Some of the reasons for these co-morbidities relate to several factors and I kind of alluded to some of
these. Some of this is certainly is related to the psychotropic medications. Some of the newer
psychotropics, such as clozeril, zyprexia, and rispirdal, all have a high level of metabolic syndrome
propensity and so as a result, with these medications, you are going to see weight gain, obesity,
diabetes, hypertension, and dyslipidemia.
This is a population that is highly addicted to tobacco products. Especially persons in schizophrenia who
have a genetic link to nicotine; persons who smoke excessively are also dually addicted to other
substances and they probably use alcohol, cocaine, and marijuana excessively; and also persons with
schizophrenia just in terms of, again, another genetic link seem to suffer from diabetes more than other
groups and of course then you add on the psychotropic drugs, and it is a “reinforcer” for this other
problem.
And here are some more reasons for these co-morbidities. Due to low income and reliance on fast food
restaurants and cheap food, the nutrition is generally poor and filled with refined sugars and also this
sugar enhancement is further promoted by the use of alcohol.
Related to low energy this is a gang who lacks motivation, and have poor concentration, particularly
persons who suffer from schizophrenia, they don’t attend to their hygiene and as result they are at
higher risk for skin infections;
They’re inactive. These are couch potatoes. They tend to isolate themselves or have alienated
themselves from friends and family due to their psychosis and as a result they are less physically active.
As a result, all of these factors affect well being and health needs and these are not addressed by the
mental health system and it is not just by the very nature of mental illness but it is the overall health
care system that affects the outcomes in terms of these co-morbidities.
And here we are have asylum to homelessness. And this is what happened in the 1970s. We have the
social factors that we discussed earlier in terms of the last slide and in many ways that people with
mental illness are marginalized. In the 19th century until well into the 20th, people were really locked
away in these asylums and sometimes these places were not so bad because they had working farms.
They had working bakeries and kitchens and laundries and so there was a lot of physical activity actually
for people on the grounds of these asylums. And then people were moved out of the asylums into
nursing homes and (Single Room Occupancy) SROs and as a result many people preferred the street to
some of these substandard housing situations. And so today we have our “bag people” living on the
street and while deinstitutionalism was meant to integrate people into communities, it never really
actualized. Policy and funding has not met the need to support community reintegration, nor has
research and services adequately addressed the needs of this population. The advent of psychotropic
drugs made deinstitutionalization possible, but the issue now becomes many of the newer drugs are
actually causing more problems while actually getting people back on their feet and able to work and
lead productive lives in terms of recovery. We have had some movement right now with this program, it
is called “Money Follows the Person” and there is some hope that money will be moved into
communities and work with people in terms of their particular community areas as opposed to just
dumping it into, say, nursing homes or hospitals so we will see if that doesn’t make a difference. I am
hopeful.
However, we do have social factors currently, today, in the 21st century that are influencing risk for
medical problems and co-morbidity. The first one of course is homelessness. In a study of 10,340
persons in a public mental health system - 15% were homeless. 20% of these homeless people have
SMI, 25% have a disabling physical health condition, and 40% have substance use disorders. Social
factors as well as the mental illness itself influence the risk for deterioration in physical and mental
health. Many of the persons suffering from mental illness are homeless due to a number of reasons.
Which we talk about in terms of victimization and stigma, unemployment, poverty, incarceration and of
course when people are coming out of the prisons the supports are not there. They are not eligible,
mostly in terms of the men, for (Supplemental Security Income) SSI. They have a very big difficulty
finding employment and with the economy, this is doubly a problem. Social isolation and of course loss
of family and friends so that they have feelings of victimization and lack of sense of belonging and all of
this leads to deterioration in coping and problem solving ability, and subsequent loss of family support.
The Surgeon General’s Report:
Historical and current data about the health status of American populations confirm that there are
significant differences in prevalence and incidence of physical and mental health problems among
groups based on culture, color, income, and country of origin. Also noted are major differences in helpseeking patterns. And so this is the area that we are going to look at next.
Americas Underserved Populations: While there may be other groups that are underserved the larger
groups of African Americans, Hispanics, Native and Alaska Americans, and Asian/Pacific Americans
represent most groups. And so we are going to look at each of these groups according to the unique
perspectives.
African Americans: In terms of this particular population, African American and Black are used
interchangeably and refer to people of African descent. Statistics indicate that those AA who have a
mental disorder do not readily seek health care from either mental health or any health care provider
and they do so in lower rates than do while Americans. And I think that the slide speaks for itself. Only
16 percent of African Americans with a diagnosable mood disorder saw a mental health specialist, and
fewer than one-third consulted a health care provider of any kind. And so this is not a group that is
seeking health care in terms of mental health.
And the question is, “Why is this?”
Well, it has to do with health practices in terms of African Americans. They drop out of services at a
significantly higher rate than White populations; they use fewer treatment sessions for their mental
health problems than White populations; they enter mental health treatment services at a later stage in
the course of their illness than do White populations; and so if they are coming in through inpatient
units or through emergency rooms, they are already very seriously ill. They under-consume community
mental health services of all kinds; they over-consume inpatient psychiatric care in state hospitals at
twice the rate of corresponding White populations; they are more often misdiagnosed by mental health
practitioners than White populations; and they are more often diagnosed as having a severe mental
illness more often than Whites. And so the type of services they receive over time, differs from their
white counterparts.
When we look at Hispanic or Latino, Hispanic can be of any race. The term "Latino(s)," as used by
SAMHSA refers to all persons of Mexican, Puerto Rican, Cuban, or other Central and South American or
Spanish origin. The problem with this clumping is that each of these groups is different culturally and
they have different viewpoints and different health practices. Overall, the Latino population in the
United States is not homogenous, but is an extremely diverse group of nationalities of origin. We know
that there are include 13.4 million of Mexican origin, 2.4 million of Puerto Rican heritage, Cuban, 1.1
million, and 2.9 million from Central and South American countries.
And so, their cultural backgrounds are diverse, including Spanish, Aztec, Mayan, Incan, and Caribbean
cultures, and Native American, White, and African American racial/ethnic origins.
Despite their common language and link with Spanish culture, Latinos' diverse religious belief, folk,
family, and health beliefs and values as well as diverse linguistic idioms make them one of the most
culturally rich groups in America. And they are more likely to access care through primary care versus
any mental health care provider so actually primary care is a portal of entry for this population.
Asian Americans and their health practices: The terms Asian, Asian Americans, or Asian/Pacific Islander
is used when referring to this group the most diverse in terms of ethnic origin, cultural background,
immigration history, and acculturation to U.S. culture.
For example, Asian Americans comprise at least 31 ethnic groups. Yet, Asian and Pacific Islanders are
often misunderstood and thought to be a homogeneous ethnic group. Unfortunately, failure to make
distinctions among the diverse ethnic, cultural, and language groups comprising Asian and Pacific
Islanders, and tendencies to generalize about their economic, social, and political circumstances, can
lead to faulty conclusions about individuals and their mental health needs. And Asian Americans tend to
seek more culturally congruent care. They like to seek care from providers who are also Asian or Asian
oriented service agencies.
And the last group that we are going to look at is the Native Americans: In the United States, the terms
Native American, Indian, and American Indian are commonly used and have been considered
interchangeable when referring to aboriginal people of the continental United States, i.e., American
Indians, Eskimos, and Aleuts. In the Surgeon General’s document, Native American also includes the
natives of Hawaii. Suicide rates are higher than anywhere in the nation with the higher uninsured
residing within this population. And the real problem here is that little research has been done with this
group, so really the nature and extent of their use of mental health services or health practices related
to mental health, we don’t have the information. So, again, trying to meet their needs becomes a very
huge challenge. And so lack of understanding leads to stigma and the stigma associated with mental
illness keeps person who are mentally ill disempowered and affords them mistrusting of health services
and providers. Feelings of anxiety and fear prevent these persons from accessing services if they were
even available. It is one thing to make the services available but you have to get the people to the
services. And reduction in stigma is certainly a place to begin that work.
And so, what can we do? Well, cultural awareness is a start. As providers we must attend to cultural
issues whether associated with ethnicity or with responses of a particular group. To be effective we
must be in touch with our own cultural values and guard against imposing these values on others.
Accepting persons with mental illness on their terms and viewing their illness and struggles from their
perspective will enable us to provide more effective patient care.
The Surgeon General identifies four possible reasons why health care professionals may not consider
culture as an important factor in the life of their patients: (This is the Surgeon General’s Report on
Mental Illness)
The first one is insufficient knowledge that results in an inability to recognize cultural differences.
Second is self protection and denial leading to the attitude that differences are insignificant; fear of the
unknown.
The third one is feelings of pressure due to time constraints in their own lives and jobs.
And the belief that cultural competence refers only to race, rather than to a whole range of differences
that relate to diversity presentations. And I was at a conference and they talked about how we get into
that “I’m cultural aware. I accept all people.” And the issue is that all people are not the same and so
this idea of accepting everyone as all the same and we need to identify the differences and understand
those differences and then incorporate those in terms of meeting the needs of that population. But the
first thing, of course, is self-awarness.
And finally the Surgeons General’s Report outlines three major goals in an effort to reduce health care
disparities: The first is to decrease social, geographic and financial barriers. Poverty is a big problem.
Improve access to services, bring the services closer to the individual and certainly integrated health
care is one way to do that. Whether it is bringing medical care to people who have mental illness as we
do at Thresholds, we bring the primary care into a mental health service provider or bringing mental
health services into primary care clinics. Making it much more of a one-stop shopping kind of thing. And
better understanding of cultural competence. Think of it as something that is in process, that you are
never truly culturally competent. It is kind of like Maslow’s hierarchy of needs. You never really get there
to actualization. It is always something that you are striving for and so that is what we need to think
about cultural competence. The more we know, the more we know we don’t know and we have to keep
learning more.
So how do we provide culturally sensitive care? Well, what we do know is that health services are more
effective when they are provided within the most relevant and meaningful cultural, gender-sensitive,
and age-appropriate context for the people who are being served. Therefore: ask about preferences,
demonstrate respect and empathy, integrate mental health and primary care health care services,
empower consumer for their own decision making and participation in self-care management, and plan
for realistic and appropriate outcomes with continuous dialog with consumers.
To summarize:
People dealing with mental illness also have other serious health issues and concerns.
Healthcare providers need compassion and vigilance when working with this population.
We need, as providers, to screen for health risks and do this frequently.
Assure comprehensive, quality care so that it includes both physical and mental health.
Integrate care wherever possible and lastly provide culturally competent care
So where do you fit in?
Now it is time for you to examine your personal learning goals. You need to ask the questions (this is
self-reflection) how will I integrate mental health and physical needs in the care that I provide clients?
How can I become more culturally competent? How can I ask about preferences?
Do I demonstrate respect and empathy? In my interactions with consumers, do I empower them and
plan for appropriate outcomes always with their goals in mind? So now, it is your turn for self-reflection.