Untimely Deaths in People with Schizophrenia

October 28, 2015

Young and middle-aged people with schizophrenia are 3.5 times more likely to die in a given year than similarly aged people in the general population, a study from Mark Olfson, MD, of Columbia Psychiatry has found.

The study examined the causes of death among 1 million people with schizophrenia in the United States from 2001 to 2007 and “is a reminder of how we are failing to meet the needs of people with schizophrenia,” write the authors of an editorial in JAMA Psychiatry.

Dr. Olfson spoke with us about the results of the study:

Q: It was known that adults with schizophrenia die sooner than general population; what are you trying to learn in this study?

A: Although it has been known for many years that people with schizophrenia have an exceptionally short life expectancy, previous studies have been too small to describe in much detail the specific diseases that drive premature mortality in schizophrenia.  We sought to improve our understanding of these mortality patterns to inform priorities for the medical management of adults with schizophrenia.

Q: What are the biggest causes of death for people with schizophrenia, and how does that differ from the general population?

A: We found that between the ages of 20 and 64, adults with schizophrenia die at a rate that is over three and one half times greater than the rate of adults of this age in the general population. The mortality gap in the new study is somewhat larger than the gap that has been reported in previous research, showing that recent advances in medical treatment have not closed the mortality gap.

Heart disease, which accounted for approximately one-quarter of deaths of people with schizophrenia, was the most common cause of death. The rate of death from emphysema and bronchitis was nearly 10 times greater among people with schizophrenia than among those in the general population.  Among common types of cancer, lung cancer accounted for the largest number of deaths and the greatest excess in deaths in relation to the general population.

Q: One thing you mention in the paper is that even though you found that people with schizophrenia are less likely to die from homicide, they are 3½ times more likely to die from a legal intervention.

A: These are the first findings that I am aware of on this issue, and I think they merit further research. Most of the discussion concerning guns and serious mental illness has focused on restricting access to firearms.  The finding that adults with schizophrenia are at increased risk for being killed by law enforcement underscores the importance of training these officials in rapid mental health assessments and non-lethal interventions.

The current study unfortunately does not provide any information about the circumstances of these deadly encounters. I imagine that it can be exceedingly difficult to interpret the meaning of some behaviors of people with schizophrenia who are in an agitated or disorganized state.

Q: Some of the biggest disparities seem connected to diseases caused by smoking.

A: We found extraordinarily high rates of mortality among people with schizophrenia for two conditions closely related to smoking: chronic obstructive pulmonary disease (COPD) and influenza/pneumonia. We know that people with schizophrenia not only smoke at a higher rate than the general population but they also smoke more than smokers in the general population.

But my impression is that this issue has not been a leading priority for many mental health professionals. In practice, screening for smoking and initiating smoking cessation treatment are still uncommon. It is also not widely appreciated that some of the standard treatments for smoking cessation, including varenicline and bupriopion, have demonstrated efficacy in schizophrenia.

Q: Do people with schizophrenia die from these diseases more often because the diseases are more common, or because they are not adequately treated?

A: This study doesn’t address those important issues. However, drawing on prior work, we know that both things are true. Ben Druss has done some elegant studies showing that people with schizophrenia who present to the emergency department with a heart attack are only about half as likely as their counterparts without schizophrenia to receive a cardiac catheterization.

Problems exist at several levels from having increased risk factors for cardiovascular and pulmonary disease such as high rates of obesity and smoking to delays in treatment seeking, less aggressive management, and poor adherence with recommended treatments. So there’s lots of work to be done all across the board to improve the medical care of adults with schizophrenia.

 

Q: What should clinicians and patients take away from this study?

A: Much more needs to be done to improve the general medical health of adults with schizophrenia. As a society, we cannot ignore their pressing medical needs.

The new results strongly suggest that high priority should be given to combatting cardiovascular and respiratory disease in schizophrenia. This means aggressively monitoring weight, blood pressure, serum glucose, and cholesterol; emphasizing smoking cessation interventions that work; stressing the importance of exercise and diet; and, whenever possible, selecting antipsychotic medications that are associated with less weight gain and lipid metabolism abnormalities.

Q: In just the past several months, you’ve published a NEJM study on the use of mental health services in youth and a study about theuse of antipsychotics among seniors. What’s driving you to ask these questions?

A: Much of what we know works isn’t consistently applied in practice. I am interested in defining the extent to which knowledge gained from medical research makes its way into community practice to the populations in greatest need. Because I am a psychiatrist, I am especially interested in examining the quality and outcomes associated with community mental health care.