• The physical reality of mental illness

    schizophrenia_235vOne of the persistent misunderstandings of mental illness was — unfortunately — perfectly expressed in a recent Slate Magazine article. Discussing the Oregon Medicaid Experiment, the headline writer stated that

    A new study suggests universal health care makes people happier but not healthier.

    Apparently the writer believes that ‘Health’ = ‘Physical Health,’ whereas ‘Mental Health’ = ‘Subjective Well-Being.’ This misunderstanding promotes views that physical illness is real and must be treated, whereas the mentally ill… well, they need to suck it up.

    It’s true that unlike mental illnesses, some physical illnesses kill you directly by stopping your breathing or your heart. But if you look at the data (for example, here or here) you find that the mentally ill die a lot earlier than those who do not have mental illnesses.

    The figure below is from a recent paper in the BMJ by David Lawrence, Kirsten Hancock, and Stephen Kisely. The horizontal axis in each graph is historical time, the vertical axis is life expectancy. The red dotted line is the average life expectancy of Western Australians from 1985 to 2005. The blue line is the life expectancy of mentally ill Western Australians.


    Lawrence et al found that, first, mental illness is associated with a substantial life expectancy loss and, second, this loss is increasing over time.

    the size of the gap in life expectancy for people with psychiatric disorders in Western Australia increased between 1985 and 2005, from 13.5 to 15.9 years for males and from 10.4 to 12.0 years for females.

    This is big: The mortality difference associated with having a mental illness is comparable to that associated with being a life-long smoker. The reason the gap is growing is that life expectancy is improving among the non-mentally ill but not much among the mentally ill.

    So mental illness isn’t just about happiness: Mental illness kills. Sometimes by suicide, of which mental illness is a principal cause. But most of the excess deaths among the mentally ill are caused by diseases such as cardiovascular disease or cancer.  In a sense, mental illness amplifies the risk or lethality of physical health problems. This occurs for many reasons.  Mentally ill people are more likely to develop tobacco, alcohol, and substance abuse addictions. Mentally ill people also experience high levels of stress from the loss of jobs, marriages, and families. Chronic diseases such as diabetes require intensive daily self-care routines and mental illness undermines a patient’s ability to carry these out.

    The causal story relating mental and physical illness is complex. Each may promote the other and both kinds of illness are promoted by stress and other social determinants of health.

    The essential point, however, is that it is a terrible mistake to equate “health” with “physical health.” The unity of the body and mind is not just new age rhetoric. It also points to the comprehensive physical suffering of the mentally ill.


    • This is a great post, but I think you are actually understating the *direct* link between mental illness and increased morbidity/mortality. I am not a doctor, I think that the disease of depression actually puts direct stress on the body than can be manifested in new physical illness or exacerbation of existing physically illness (and not just indirectly through reduced compliance with treatment).

      Anecdotally, when I started taking Wellbutrin, my chronic neck and bachaches suddenly improved dramatically. I think there is something to the “depression hurts” ad campaign.

      • L,
        I agree with you and thought about trying express a similar thought. People with long term severe mental illness always seem prematurely aged, and my intuition is that this is an effect of intense chronic stress. But I don’t know how to substantiate that intuition.

    • Also, mental illness might very well leave physical traces, but the technology doesn’t exist yet to spot it.

    • “Depression” is not a clinical term. Were rates of Major Depressive Episodes, Dysthmic Disorder, and/or Bipolar Depression decreased? It sounds as if “recipients’ reported rates of depression” was the metric, rather than a clinical diagnosis.

    • @Bill_Gardner I agree with you on Mental illness being just as serious as other illness.
      Do you relate this to the Oregon finding because you think that anti-depressants should be subsidized to the poor? This can be done apart from providing low deductible health programs.
      Or are you saying that the security of knowing that you are covered decreases depression?

      The solution that has the best combination of politically possible and efficient might be to subsidize the most bang for the bucks treatments like anti-depression medications, hypertension medications, diabetes treatments and provide very high deductible health insurance to the poor. This way we could add the best bang for the buck treatments overtime even while avoiding the claim of death panels.

    • Really interesting point about the mortality rate being comparible with a smoker. It is so sad how millions of people suffer in this way with mental illness.

    • I think you are generalizing in your interpretation of the headline by ignoring the data the headline is referring to. The data that were measured: blood pressure, cholesterol levels, glycated hemoglobin and depression rates. The study found blood pressure, cholesterol and glycated hemoglobin levels identical despite the fact that the medicaid recipients had lower depression rates.

      The study would seem to contradict your example: “Chronic diseases such as diabetes require intensive daily self-care routines and mental illness undermines a patient’s ability to carry these out.” The data indicated diabetes maintenance was unaffected by a decrease in depression; it should have decreased as well for that to be true.

      I agree with you 100% that mental health diseases are dangerous to those who suffer from them and are poorly understood and framed in our national conversation, but I’m not sure that was an ideal example.

      • Diabetes maintenance was unaffected by depression because few people in the study had both depression and diabetes. This is not because the two are unlinked but just because there were relatively few people with diabetes (or hypertension) in the enrolled population. Depression is a much more prevalent diagnosis.

        The NJEM article did not look at the experience of the subgroup with both depression and diabetes when they gained coverage. But future researchers could when the full data set is available.

    • I also don’t like the use of the term “happiness” to define mental well-being. Mentally healthy people can be sad, and mentally ill people can be happy. That’s not what mental health means.