A School of Medicine psychiatrist wrote in the Journal of the American Medical Association (JAMA) that although mortality from cardiovascular disease has declined in the United States over the past several decades, patients with severe psychiatric illness are not enjoying the benefits of that progress.
In a commentary in the Oct. 17 issue of JAMA, John W. Newcomer, M.D., professor of psychiatry and of medicine in the School of Medicine, of psychology in Arts & Sciences and medical director of the Center for Clinical Studies, reported that those with illnesses such as schizophrenia, bipolar disorder and major depression lose 25 to 30 years of life expectancy compared to the general population. And although suicide does claim the lives of many psychiatric patients, most of those premature deaths are due to cardiovascular disease.
“This is really a double hit,” Newcomer said. “Not only are these patients dealing with the serious burden that accompanies their psychiatric disorder, but they also have an increased risk and an increased burden from major medical conditions like diabetes, heart disease and stroke. Ultimately, it is the unrecognized risk factors and the underdiagnosed and undertreated conditions that significantly shorten the lifespan.”
Newcomer said several factors conspire to elevate risk, including reduced access to appropriate medical care. Major mental disorders significantly impair a person’s ability to work and learn, so patients tend to have lower incomes and poorer dietary habits, often relying on fast food. In addition, patients with serious psychiatric illnesses are much more likely to smoke — between 50 percent and 80 percent smoke cigarettes — and although the severely mentally ill make up only between 5 percent and 10 percent of the population, they consume a disproportionate amount of all cigarettes smoked in the United States. Many psychiatric medications also tend to contribute to weight gain, in part by making people less active and sometimes by stimulating appetite, and weight gain can be a prominent side effect of some antipsychotic drugs in particular.
But that’s not the whole story. Newcomer also reports that patients with severe mental illness are significantly less likely to receive therapies of proven benefit for problems with cholesterol, diabetes, hypertension or heart disease. Those who have survived a heart attack are less likely to receive appropriate medications, cardiac catheterization procedures or bypass surgery than heart-attack patients without mental illness.
Regarding preventive care, Newcomer cited data from a national study of 1,500 patients with chronic schizophrenia who participated in the National Institute of Mental Health-funded Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study. The CATIE study found that 88 percent of patients entering the study with high cholesterol did not take lipid-lowering drugs. Another 30 percent with diabetes at the start of the study received no anti-diabetes medications, and 62 percent of those with high blood pressure were not taking any antihypertensive medication.
Those with severe psychiatric illness also are less likely to be screened for high cholesterol, high blood pressure or diabetes, despite the evidence of increased risk in general and specific evidence that some antipsychotic drugs can have adverse effects on body weight, glucose metabolism and lipid levels.
A solution, Newcomer argued, will emerge only if psychiatrists and primary-care providers can work together.
“This requires coordination,” he said. “And coordination between psychiatric professionals and primary-care providers is not easy when they often are physically located in different places. There are transportation issues and scheduling issues. For healthy people, the need to make an extra appointment lowers the probability that it will actually happen, and research further indicates that when patients with severe mental disorders have to go across the hall, it reduces the probability they will get care. If they have to cross the street, the probability gets even lower. Without case managers and others working closely with these patients, in general those follow-ups won’t happen.”
Getting psychiatrists to change their routine is important. Newcomer said that to lower the risk of cardiovascular complications, psychiatrists may need to regularly weigh their patients, take blood pressure and screen appropriately for blood glucose, cholesterol and triglycerides.
“I think there’s some ‘low-hanging fruit’ here,” he said. “Just getting psychiatrists engaged in this type of general health monitoring should help. Most of these patients already are seeing a physician, and if that physician and medical team can screen for cardiovascular risk factors, we may be able to intervene and find ways to lower that risk significantly.”