The New York Times published an article yesterday (30-May-2018) titled “The Largest Health Disparity We Don’t Talk About” by Dhruv Khullar. The finding of several studies is that:

Americans with serious mental illnesses die 15 to 30 years younger than those without.

One of the studies referenced in the article is a 2006 paper on causes of death, mortality rates and years of potential life lost by Craig Colton and Ronald Manderscheid. This study looks at data across 8 different US states. While there are some interesting differences between states, some general patterns emerged. Consider the following histogram charts for the state of Texas from an analysis covering the years 1997 – 1999:

Leading causes of death in general populations (All) and public mental health clients (MH) nationwide and statewide in Texas, 1997 – 1999

One visible difference is a significantly higher percentage of suicides among mentally ill compared to healthy population (the white bars are much higher in the MH compared to the All cases). Similarly, there are relatively speaking more accidents, including motor vehicles, indicating perhaps impaired judgment or more risky behavior.

While those are hardly surprising, another clear result is that the leading causes of death – heart disease and cancer – are structurally similar across mentally ill and healthy people. As the NYT article puts it:

We may assume that people with mental health problems die of “unnatural causes” like suicide, overdoses and accidents, but they’re much more likely to die of the same things as everyone else: cancer, heart disease, stroke, diabetes and respiratory problems.

I was a bit surprised by this finding, because prior to seeing these statistics and thinking about it, I certainly shared the above assumption that mentally ill people die of different causes.

The finding that mentally ill people have drastically shorter life expectancy – 15 to 30 years less compared to mentally healthy people – is attributed to several factors, including struggles with homelessness, poverty and social isolation. They have higher rates of obesity, physical inactivity and tobacco use. Many don’t receive treatment, and for those who do, there is often a long delay. When these patients do make it into our clinics and hospitals, their troubled mind can distract doctors from an ailing heart or a budding cancer. The shortcomings of medical care for mentally ill patients are attributed to two related biases:

  • The first is therapeutic pessimism: “Clinicians, including mental health professionals, often hold gloomy views about whether patients with serious mental illness can get better. This can lead to a resigned passivity, meaning that certain tests and treatments aren’t offered or pursued.”
  • The second is a concept called diagnostic overshadowing, “by which patient’s physical symptoms are attributed to their mental illness. When doctors know a patient has depression, for example, they’re less likely to think her headache or abdominal pain portends a serious illness”.

There are many examples listed and further statistics from linked studies to indicate that such biases lead to less-than-ideal treatment (or lack thereof) for mentally ill patients. It points to a problem of separating behavioral health from regular healthcare and the need to better integrate the two fields. An earlier study reported higher rates of chronic medical problems among people with chronic mental illness, and chronic illness is known to increase risk of death. They suggested in their conclusions that “psychiatrists need to be adept at caring for physical illness, and primary-care physicians need to acquire skills in caring for the mentally ill”.

The author, Dr. Dhruv Khullar, sums it up this way:

After decades of fragmenting medicine into specialties and subspecialties, it’s perhaps not surprising that a siloed system often fails those in need of whole-person care. I still sometimes wonder if I had let my patient’s mental illness overshadow his physical needs. Did I overlook some subtle cue?

Our hope here at MedicalMime is that more systematic rehab EHR and practice management systems will help behavioral and mental health facilities converge in their practices and treatment approaches towards more mainstream healthcare systems and best practices. It starts with systematic tracking of patient data, treatment and outcomes, all hallmarks of any modern EHR system.

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