Cynthia Scott is your average health-conscious 56-year-old. She watches what she eats, drinks lots of water and takes a multivitamin every morning. She goes for frequent walks and visits her doctor regularly for checkups, including cholesterol and diabetes screenings.
Scott also has schizoaffective bipolar disorder, a mental illness she keeps in check with a low dose of Zyprexa. If you were to ask Scott, she would say she is a healthy person overall. So she was shocked when the National Association of State Mental Health Program Directors (NASMHPD) published a study two years ago called Morbidity and Mortality in People with Serious Mental Illness. The report analyzed data from 16 states and found that, on average, people with severe mental illness die 25 years earlier than the general population. "Hearing that made me so sad," says Scott.
The findings were a bombshell for the rest of the mental-health community. "The study jarred the field," says Dr. Bob Glover, the executive director of NASMHPD. After the 2006 report came out, many mental-health agencies in the U.S. made it an immediate priority to figure out why their patients die sooner and how to improve their longevity. Says Glover: "Mental health has been late to the dance in terms of looking at the connections between mental health and physical health. It may be moot what you're doing for mental-health needs if people are dying so early from physical causes."
Indeed, the causes of physical illness and death among psychiatric patients are much the same as those in other groups — cigarette smoking, obesity, diabetes — and are treatable. The problem is that people with serious mental illness tend to be low on the socioeconomic totem pole and often don't get the best available health care. Frequently, their own doctors pay little heed to their patients' physical health. "Medical doctors think, 'Well, they're crazy,' so they don't take their concerns seriously," says Wendy Brennan, executive director of the National Alliance on Mental Illness (NAMI) in New York City. "Their very real physical symptoms are often dismissed."
One of the most common contributors to early death among mentally ill patients, for instance, is smoking. While about 22% of the general population smokes, more than 75% of people with severe mental illness are tobacco-dependent. According to Glover, a study conducted by NASMHPD after the publication of its mortality study found that 44% of all cigarettes in the United States are consumed by people with psychiatric histories. "I used to run state hospitals, and we'd use cigarettes as reinforcement — 'You did good; you get a cigarette,'" he says. "When people didn't do well, we took away their tobacco privileges. We were part of the problem." The agency is now working to make state mental hospitals smoke-free by 2011.
Obesity is another big risk factor. People with depression or bipolar disorder are about twice as likely to be obese as the general population; in people with schizophrenia, that likelihood is three times greater. This is in part because so many psychotropic medications cause weight gain. At many state hospitals, says Glover, "you'd see a woman be admitted at 120 lb. Three to six months later, she'd weigh 200."
Obesity-related illnesses, like diabetes, are so prevalent among the mentally ill that health officials call them an epidemic within an epidemic. For example, about 13% of schizophrenic adults in their 50s have received a diabetes diagnosis, compared with 8% of the general population of the same age. In October, the NASMHPD released another report, with recommendations for treating the particular problem of obesity, including giving those with severe mental illness better access to dietary consultations and promoting the prescription of low-weight-gain antipsychotics. The agency is currently working on creating a tool kit for federal health-care providers to better inform them on the issue.
At NAMI–New York City, after reading the 2006 mortality report, health workers held focus groups to assess their patients' health concerns. There were many — foremost among them, the simple desire to feel deserving of good health. "The most shocking thing was that people really wanted to be healthy but there was a disconnect," says program associate Katie Linn, who ran the focus groups. "A lot of it came down to self-worth — they didn't feel like they were worthy of taking care of themselves."
Based on the participants' responses, NAMI created a program called Six Weeks to Wellness, a weekly class that teaches everything from proper nutrition to controlling anxiety through yoga and meditation. "It's been wildly popular," says Linn. "It helps to say, 'Your health is important to us.' They've never heard that before."
For the NASMHPD, the next logical step is to educate the doctors who care for the mentally ill. This month, the agency will release guidelines for standardizing the medical tests, assessments and care given to mental-health patients in the public system. The recommendations include taking regular measurements of patients' height and weight, checking their glucose levels and carefully evaluating their medication history. Psychiatrists, likewise, are not exempt. According to Mental Heath America, based in Virginia, a recent survey of people with schizophrenia revealed that they rarely discussed physical health with their psychiatrists. So the organization is working on an initiative with the American Psychological Association to better educate mental-health specialists about the physical concerns facing patients with serious mental illness.
As for Cynthia Scott, over the past two years she has taken her health consciousness to a whole new level, regularly attending NAMI's yoga workshops in New York City. "I'm big on taking care of myself," she says.