• The lives of the neglected mentally ill: Solitary, poor, nasty, brutish and therefore short

    In the NEJM, Lisa Rosenbaum writes about the shortened lives of the mentally ill. She takes her fellow physicians to task for neglecting these patients by allowing them to refuse needed medical care. It’s an important essay — go read it. I want to add, though, that doctors aren’t the only ones who are failing to provide adequate care.

    She begins with the much shorter life expectancy of the severely mentally ill.

    In 1932, Benjamin Malzberg, a New York epidemiologist, published a study showing that people with mental illness died, on average, 14 to 18 years earlier than otherwise similar people in the general population. This mortality gap persists today and may even have widened: a 2006 U.S. study suggested that it ranged from 13 to 30 years. Indeed, the gap persists worldwide, mostly owing to medical conditions, such as cancer and cardiovascular disease, rather than “unnatural” causes, such as accidents and suicide.

    Rosenbaum points out that one reason why the mentally ill die early is that sometimes they refuse treatment when they need it. Physicians can, in her view, be complicit in these deaths. Physicians often have the legal power to override these refusals and treat the patients, but they do not pursue this course. This is a complex issue that Rosenbaum discusses with great sensitivity.

    Of course, medical neglect isn’t the only reason that the mentally ill die young. As Rosenbaum notes, there are several other causes.

    Certain behaviors that are more common among people with serious mental illness, such as smoking, substance abuse, and physical inactivity, heighten the risk for chronic diseases. Treatment of such diseases depends on adherence to medications and behavior changes, which may be more difficult for patients with severe mental illness. The impaired insight resulting from some forms of mental illness can compromise adherence, as can low health literacy and poverty, which disproportionately affect this population. Finally, common medications that may be critical for psychiatric stabilization often cause obesity and diabetes, thereby contributing to the cardiovascular disease burden.

    There are still more causes of the mortality gap. Mental illnesses are primarily diseases of the brain. But they also disrupt sleep and endocrine function, harming the rest of the body.

    Moreover, having a mental illness is extraordinarily stressful. The severely mentally ill may be haunted by imaginary threats, but too many also face real ones. Many are poor, unemployed, homeless, or exposed to violence. Many are solitary or in conflict with their families. You have likely never had a day in the kind of isolation that many of these people experience throughout the year.

    Prolonged exposure to any of these stress factors increases the body’s vulnerability to disease. Severe stress also ages the body. Epel and her colleagues describe one mechanism whereby chronic stress compromises health.

    Numerous studies demonstrate links between chronic stress and indices of poor health, including risk factors for cardiovascular disease and poorer immune function. Nevertheless, the exact mechanisms of how stress gets “under the skin” remain elusive. We investigated the hypothesis that stress impacts health by modulating the rate of cellular aging. Here we provide evidence that psychological stress— both perceived stress and chronicity of stress—is significantly associated with higher oxidative stress, lower telomerase activity, and shorter telomere length, which are known determinants of cell senescence and longevity, in peripheral blood mononuclear cells from healthy premenopausal women. Women with the highest levels of perceived stress have telomeres shorter on average by the equivalent of at least one decade of additional aging compared to low stress women. These findings have implications for understanding how, at the cellular level, stress may promote earlier onset of age-related diseases.

    In brief: too many of the mentally ill have lives that are solitary, poor, nasty, brutish and therefore short.

    It’s possible that more assertive psychiatric treatment would allow some of the severely mentally ill to maintain lives that would be less exposed to stress. But even with the best current treatments, many patients would still have limited ability to function in mainstream settings. Many would also have difficulty making sufficient income to afford minimally decent food, clothing, and shelter. Families can sometimes provide shelter and care for the severely ill, but this can be a crushing burden, and many patients lack this option.

    The alternative to living rough on the streets is subsidized housing, with staff who can keep patients safe, healthy, and connected to mental health and substance abuse treatment. These services are expensive. We have to be willing to either pay the taxes or provide the charity needed to supply safe shelters, halfway houses, substance abuse treatment, and supportive staff. We have to allow facilities that provide care and shelter to locate in our neighbourhoods. It’s not just on the doctors to provide the services that the severely mentally need to live. It’s also on us.

    @Bill_Gardner

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