Coming to grips with early death

Early death is a very existential, yet often unstated fear of persons who receive public mental healthcare. For more than a decade, we have known that public mental health clients die, on average, 25 years prematurely, yet from the same causes as do other people.¹ This totally unacceptable situation has generated considerable effort, particularly by peers and by SAMHSA, to develop and implement programs that promote and maintain personal wellness.

Evolution of research on early death

The decade-old research left many essential questions unanswered. For example, what causes early death in public mental health clients? Also, how do public mental health clients compare with other people who have the same demographics, but who do not have mental illnesses? And what happens to those with mental illness who receive no care? Without further information to begin answering these questions, progress in addressing early mortality tragically will be stymied.

In the intervening decade, additional research has been done to begin unraveling the answers to each of these important questions.² This more-refined work has helped guide some important current research just reported in General Hospital Psychiatry.³ Here, I would like to review the key findings from this latest research.

First, a little background is necessary. The work reported 10 years ago examined the population of persons receiving care through state-operated mental health systems. Persons receiving inpatient and ambulatory care were included. No contrast group of community residents was available, either for those with or without mental illness. Further, in the original research, all persons served by public mental health systems were included. Although two levels of disability were considered, no effort was made to differentiate people according to their specific diagnoses. Finally, some important key variables that could influence age of early death, such as lifestyle factors, e.g. smoking, were not available.

The new study addresses most of these issues: The sample examined was nationally representative of the community household population. It included people with and without mental illnesses, as well as people receiving and not receiving mental healthcare. Specific diagnoses were obtained for persons with major depressive episode, generalized anxiety disorder, panic attack, and any of these (hereafter collectively called depression/anxiety). Data also were obtained on sociodemographic factors, mediators between mental illness and death (i.e., socioeconomic factors, behaviors, and comorbid chronic diseases), and use of mental health services. Initial data were collected in 1999, and follow-up data to assess age of death were collected in 2011.

Key findings from the new study

The new study offers several very significant findings:

> First, and most important, receipt of mental health services reduces the risk of early death. Persons in the community with depression/anxiety die on average almost 8 years younger than persons without these conditions. However, receipt of mental health services by those with depression/anxiety eliminates this disparity in age of death.

> Second, the mediators between mental illness and death help explain the risk of early death. These mediators are socioeconomic factors (education and income), behaviors (smoking, exercise, and body mass), and comorbid chronic diseases. When these factors are not considered, the relative risk of death is 1.6 for those with depression/anxiety; when they are considered, the relative risk is about 1.0, the same as for other people.

>Third, behaviors and comorbid chronic diseases are more potent mediators of early death than are socioeconomic factors. Each of the former increases the relative risk of early death from 1.3 to 1.6 for persons with depression/anxiety, while the latter only increases the risk from 1.5 to 1.6.

> Fourth, early death of persons in the community with depression/anxiety is a large national problem. Nationally, about 3.5% of all mortality can be attributed to depression/anxiety. This represents almost 88 thousand deaths per year.

Recommended actions

This new study offers us much hope for the future. Our understanding has definitely been advanced. We can reduce the risk of early death for those with depression/anxiety by altering the mediators between mental illness and death, as well as through the provision of mental health services. To save lives, an urgent need exists to put these findings into practice as soon as possible.

This new study also points clearly to the need for ongoing national monitoring of early death for all persons with any mental illness or substance use condition. Specific illnesses must be assessed, we must know what the mediators are, and we must know their relative potency. We also must know whether we are making progress from year-to-year in reducing the disparity in length of life. An urgent need exists to develop and implement such a national monitoring system in the near term.

References

1 Colton CW and Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis 2006;3:A42.

2 Druss BG, Zhao L, Von Esenwein S, Morrato, EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17 year follow up of a nationally representative US survey. Med Care 2011;49:599-604.

3 Pratt LA, Druss, BG, Manderscheid, RW, and Walker, ER. Excess mortality due to depression and anxiety in the United States: results from a nationally representative survey. Gen Hosp Psych 2015;12:003.