“The seriously mentally ill die, on average, 25 years earlier than the general population…”

(exploring the source of a statistic)

Are you familiar with this oft-quoted statistic: “people with serious mental illness served by the public mental health system die, on average, 25 years earlier than the general population”?  You see it everywhere – for example in TIME magazine, USA Today, and throughout the mental health blogosphere.

It comes from this 2006 report on mortality and morbidity in the seriously mentally ill population published by the National Association of State Mental Health Program Directors [NASMHPD].  The report also contains several other [less frequently quoted but no less powerful] statistics.  Consider:

• suicide accounts for 30% of excess mortality [in the population suffering from “serious mental illness”], but 60% of premature deaths are due to other causes such as cardiovascular and pulmonary disease, obesity, and smoking – causes which are in some ways preventable.
• people diagnosed with schizophrenia are 2.7X more likely to die of diabetes than the general population; 2.3X more likely to die of cardiovascular disease, 3.2X more likely to die of respiratory disease, and 3.4X more likely to die of infectious disease.  All of these causes of death are exacerbated by the following risk factors – obesity, smoking, diabetes, hypertension, and dyslipidemia [high blood cholesterol] – which are, again, significantly more prevalent amongst this population.

These are shocking things for science to say, surely a kind of gauntlet thrown at the feet of this population and those who serve/support/love them.

What causes this shocking mortality/morbidity problem, and what can be done?

Are you thinking what I’m thinking?

In light of all that we’ve recently learned about psychotropic medications, antipsychotics in particular (causing brain shrinkage, diabetes, obesity, heart disease, et al): does the NASMHPD report have the guts to honestly own up to the fact that most of the abovementioned risk factors can often be traced back directly to the psychotropic medications so glibly prescribed to this population?  Actually, they do a pretty good job, acknowledging all of the following:

Residence in group care facilities and homeless shelters (exposure to TB [tuberculosis] and other infectious diseases as well as less opportunity to modify individual nutritional practices)… symptoms associated with serious mental illness [such as] feelings of hopelessness and powerlessness, learned helplessness…

Psychotropic medications may mask symptoms of medical illness and contribute to symptoms of medical illness and cause metabolic syndrome… [and] polypharmacy [is] identified as a risk factor for sudden death.

(from the 2006 NASMPHD report on mortality in the mental health population)

 

Seeing such promising signs – a willingness to acknowledge these usually unspoken-of risk/causative factors – I eagerly turned to the “Policy Recommendations” section…

Only to be severely disappointed.  Nothing addresses the risk factors listed above.  NOTHING.

[alright – they did briefly mention a tool used in New York State hospitals to insure folks weren’t prescribed 3 or more antipsychotic medications at the same time but that was just a subordinate clause in a very long sentence buried near the bottom of page 47… and I feel that’s just a tad inadequate, don’t you?]

Here’s what they do instead:

 

Policy Recommendations?  Change the language, of course…

The “Policy Recommendations for Providers and Clinicians” section starts out with some powerful and exciting language: mentally ill people must be assisted in finding “hope for tomorrow” and to “understand the hopeful message of recovery.”  They must be “enabled to engage as equal partners in care and treatment” and “empowered.”

But what is really meant is that the language must be changed so that these things are implied, while treatment remains largely the same.  Here is how NASMHPD recommends achieving a “partnership with the people we serve:”

Agree on a Treatment Plan

“Adherence” is the goal because it implies sticking to a collaboratively developed plan, as opposed to the more directive term “compliance.”  Six specific actions can increase the likelihood of adherence: keep the regimen simple, write out treatment details, give specifics about the expected benefits of treatment and the timetable, prepare the patient for side effects and optional courses of action, discuss obstacles to moving forward with the regimen, and get patient feedback.

(from the 2006 NASMHPD report)

So “partnership” between providers and “consumers” is to be achieved by a mere change of language (from “compliance” to “adherence”), which no longer implies the directive (ie use of force), power flowing from provider to patient.  Never mind that involuntary commitment and treatment of the mentally ill is as frequent a practice as ever, and that a patient’s supposed mental competence/ability to provide informed consent is often judged solely on the basis of the patient’s willingness to “adhere” to whatever lucrative treatment the doctor prescribes (take for example the strange case of Paul Henri Thomas, who was competent as long as he said “yes” to expensive ECT treatments, but was immediately “incompetent” upon refusing treatment).

What’s more, from the NASMHPD’s above use of the terms “regimen” and “side effects,” it’s clear they’re mainly talking abouttreatment centered on medication.

So in an almost incomprehensibly illogical turn of events, the NASMHPD first acknowledges that psychotropics and polypharmacy are causative factors for the increased mortality rate of the seriously mentally ill population, and then strongly emphasizes in the policy recommendations section the importance of compliance with/adherence to medication regimes!

What’s the big deal?

Ok. So the NASMHPD put out a lousy report in 2006 that, while acknowledging the mortality rate for the mentally ill population, failed to make good policy recommendations addressing its own listed causative/risk factors… so what?

What it boils down to is there’s a reason this statistic is quoted so often (a reason apart from its shocking nature).  The NASMHPD report forms the very foundation of some of the most important nationwide “official” mental health initiatives — and what I mean by that are SAMHSA [Substance Abuse and Mental Health Services Administration] and DHHS-funded [Department of Health and Human Services] initiatives.  These initiatives are meant to address the issue of mortality of the seriously mentally ill population; but they’re also taking their cues from the fatally flawed “Policy Recommendations” section… and that’s not a good thing.  In fact, it’s the most self-defeating setup imaginable.

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