How Mental Illness Kills

On average, people with severe mental illness will die sooner than those suffering from either

HIV

or

diabetes

, at least in the developed world. Maybe the prior of those two is most apt as a comparison: a condition that enables other killers, a disease that (eventually) stops the door for death. When it comes to mental health, there’s suicide of course—with rates of successful attempts touching

10 to 13 percent

for schizophrenia and

15 percent

for clinical depression—but that’s just the start of it.

Even beyond endemic personal health neglect (which is severe), mental illness is like a prison of self-destructive behavior. Smoking, alcoholism, and drug addiction are generally known to be much more common in patients with severe mental illness, but a new study out in JAMA Psychiatry__ outlines the full extent in the largest ever accounting of alcohol, tobacco, and drug abuse in patients with mental health disorders.

The larger question behind the study is this: how do psychiatric patients die? Like HIV/AIDS, a patient doesn’t die of depression, but one of many things enabled by it. The statistics tell us that people with mental illness are dying young—up to 25 years earlier than the general population—but finding the specific cause isn’t as simple as it might seem.

“[Mentally ill patients] don't die from drug overdoses or commit suicide—the kinds of things you might suspect in severe psychiatric illness,” said Sarah M. Hartz, the study’s lead author. “They die from heart disease and cancer, problems caused by chronic alcohol and tobacco use.”

The study looked at about 20,000 people, split down the middle between a healthy control population and people suffering from schizophrenia, bipolar disorder, schizoaffective disorders, and/or major depression. Probably the most striking numbers have to do with smoking: over 75 percent of patients with major mental illness smoke cigarettes, compared to 33 percent in the general population.

Continuing on down the line, 50 percent of the mental illness pool smoked pot, compared to 18 percent in the general population, while 50 percent of the mental illness group used other illicit drugs, compared to 12 percent in the control group. Binge drinking: 30 percent vs. eight percent.

Smoking cigarettes and drug/alcohol abuse are already taken as the default in treating psychiatric illness, rather than the exception. I’ve encountered it first-hand as a patient—the baffled look of a doctor encountering a non-smoker—and Hartz noted, “I take care of a lot of patients with severe mental illness, many of whom are sick enough that they are on disability, and it's always surprising when I encounter a patient who doesn't smoke or hasn't used drugs or had alcohol problems."

If it's not suicide or drug overdoses doing the killing in psychiatric patients after all, how does that change the way we see severe mental illness? For one thing, it jerks this sort of disease back into the world of everyday misery. Society is excellent at sealing off the deep end, so to speak. Because this kind of illness is behavioral and has to do with the very ways in which we experience the world, it becomes easy to put the brakes on empathy. The study suggests that psychiatric patients are mostly dying in normal ways, albeit in hyperdrive: living life fast but miserable.

Hartz et al’s study also suggests that anti-smoking and other public health campaigns have effectively bounced off the mentally ill, perhaps in part because doctors are looking past these behaviors. “Some studies have shown that although we psychiatrists know that smoking, drinking, and substance use are major problems among the mentally ill, we often don't ask our patients about those things," Hartz says. "We can do better."

@everydayelk