A landmark report on comorbid medical and mental illness recommends that
people with serious mental illness (SMI) be designated as a distinct
health-disparities population under the federal government's initiative to
reduce disparities in health outcomes.
That was just one recommendation in the extensive report "Morbidity
and Mortality in People With Serious Mental Illness," released by the
National Association of State Mental Health Program Directors
The report documents striking evidence from state studies showing that
people with serious mental illness die on average 25 years earlier than the
general population and that about 60 percent of these premature deaths are
from natural causes such as cardiovascular and pulmonary disease.
On the basis of that evidence, the report urges that this population be
included in the federal Health Research and Services Administration's Health
Disparities Collaborative. That initiative is designed to reduce disparities
in health outcomes for poor, minority, and other underserved populations.
The report also recommends changes to national health surveillance
activities that would incorporate information about the health status of
people with serious mental illness. In particular, the report calls for
tracking of deaths and "key data elements" of morbidity in this
population across states.
Psychiatrist Benjamin Druss, M.D., a consultant on the report, said its
findings and recommendations are likely to be used as a model for other mental
health advocacy organizations.
"The issue of the poor physical health and health care for people
with serious mental illness has really come onto the clinical and policy radar
screen in the last one or two years," Druss told Psychiatric
News. "This report is really the first to explicitly address this
issue and certainly is the most comprehensive that has ever been written on
"The core message is derived from the President's New Freedom
Commission report, which began with the statement that mental health is
essential to overall health," Druss said. "The NASMHPD report is
addressing the corollary—that overall health is essential to mental
He added that the recommendation that people with SMI be designated as a
health disparities population is a recognition that the issue is one of
"The statistics on premature death were really the impetus,"
Druss said. "These patients are dying younger, and it's a very troubling
and unambiguous statistic. This issue is one of fairness in that a vulnerable
population is dying younger and that makes it extremely compelling."
The recommendation for new surveillance measures specific to this
population is also significant. "It calls for monitoring at the state
level of things like morbidity and mortality rates in this population,"
he said. "You cannot do anything about a problem you are not
Psychiatrist Dale Svendsen, M.D., medical director at the Ohio Department
of Mental Health and co-author of the NASMHPD report, told Psychiatric
News that the report grew out of an initial study of health outcomes for
people with serious mental illness in Massachusetts. The study found that
between 1998 and 2000, people aged 25 to 44 served by the department had a
cardiovascular mortality rate 6.6 times that of the general population.
That study led to a 16-state report and separate studies in Ohio and Maine
(see graph on page 5)
showing similar results.
"It was really a wake-up for all of us when we brought together a
group of state medical directors and became aware that people with serious
mental illness are dying 25 years earlier than the general population,"
Svendsen said. "Here in Ohio, we looked at people over a six-year period
who were discharged from our state hospital system. We had access to their
inpatient records and all of their diagnoses, and we also looked at death
records. We found that people who had been in our hospitals died at three
times the expected rate with a loss of life of 32 years. The major reason for
death was cardiovascular disease."
The NASMHPD report is unequivocal about the role of antipsychotic
medications in the development of metabolic syndrome among patients with
serious mental illness and especially about problems with polypharmacy. In
addition to specific recommendations for federal and state policymakers, the
report has four broad recommendations for clinicians and health systems:
The last item entails having a specific practitioner in the mental health
system who is responsible for ensuring that each person's needs for other
kinds of medical care are being addressed and that all services are
coordinated; and for ensuring that health-status assessment and planning are a
part of treatment planning and goal setting for every person with serious
Within each of those broad recommendations are extensive and detailed
recommendations, especially regarding screening for metabolic symptoms and
cardiovascular disease and counseling regarding lifestyle and behavior.
"Psychiatrists need to pay attention to weight, lipid levels, blood
pressure, and exercise in our patients with serious mental illness,"
Svendsen said. "The psychiatrist of the future is going to have to be
more of a general physician than in the past, and our training programs are
going to need to adapt."
"Morbidity and Mortality in People With Serious Mental
Illness" is posted at<http://www.nasmhpd.org/general_files/publications/med_directors_pubs/Technical%20Report%20on%20Morbidity%20and%20Mortaility%20-%20Final%2011-06.pdf>.
Information on the Health Research and Services Administration's Health
Disparities Collaborative is posted at<www.healthdisparities.net>.▪