Mental illness can shorten lifespan by 20 years
SINGAPORE — Mr Matthew Gan’s late mother spent a large part of her life grappling with schizophrenia, a severe mental disorder which caused her to experience hallucinations and delusions.
Yet what killed her, when she was in her sixties, was sepsis, an infection of the blood due to complications arising from Type 2 diabetes, said Mr Gan, 62, a retiree.
She had kept her schizophrenia symptoms under control with treatment, but not physical health conditions such as hypertension and heart disease. Poorly controlled diabetes led to the amputation of both her lower limbs.
Today, premature deaths among people with mental disorders are still common even though medical care for physical illnesses and life expectancy have improved.
The average life expectancy of Singaporeans is about 82. But those with mental disorders die about 20 years earlier than the general population, said Adjunct Associate Professor Daniel Fung, chairman of the Medical Board at the Institute of Mental Health (IMH), at the Singapore Mental Health Conference 2017 last weekend.
The life expectancy of 891 IMH patients who died from 2015 to 2016 was 64.3, he said. The data is similar across the world, including developed countries.
This loss of years is twice as high compared to that of heavy smokers or Type 2 diabetics, whose lives have been estimated to be shorter by around 10 years, according to the United States’ Centres for Disease Control and Prevention and the 2010 Diabetes UK report, respectively.
Among those with mental disorders, individuals with schizophrenia usually fare the worst. A study, reported in the Jama Psychiatry journal in December 2015, on 1.1 million people with schizophrenia in the US estimated that this group lost as many as 28.5 years of life.
But early deaths occur even among those with anxiety disorders, not only those with serious mental disorders like schizophrenia and depression, said Adj Assoc Prof Fung.
While high-risk behaviours such as suicide are not uncommon among those with psychiatric conditions, Adj Assoc Prof Fung said physical ill health remains a pressing problem among these patients.
According to the 2010 Singapore Mental Health Study, more than half (50.6 per cent) the individuals with mental illness also have a chronic physical illness.
In the 2015 Jama Psychiatry report, more than eight in 10 of the premature deaths among those with schizophrenia were due to largely preventable conditions such as high blood pressure, high cholesterol, diabetes and heart disease.
Unhealthy lifestyle factors, such as poor diet, lack of exercise and high rates of cigarette smoking, contribute to many physical problems.
The stigma of mental illness means some patients are reluctant to seek treatment for their physical health conditions.
“Many of our patients say they don’t want to see the general physician because they feel they are treated differently (because of their condition). They also don’t want to seek medical care because they don’t want sensitive health information to be shared,” said Adj Assoc Prof Fung.
Getting patients to comply with their medical referrals is a challenge. For instance, only about a fifth of patients with schizophrenia seen at IMH’s Annual Review Clinic, who are referred to polyclinics, turn up for their medical appointments.
Among those who do, a significant proportion end up defaulting on treatments, said Adj Assoc Prof Fung.
IMH’s Annual Review Clinic is an outpatient service that reviews all patients with schizophrenia and delusional disorders annually.
Patients are assessed for psychiatric and physical co-morbidities, adherence to pharmacotherapy and side effects to medications.
They are also referred to healthcare services to manage their medical conditions.
There is also a tendency for healthcare practitioners to draw a line between mental and physical illnesses.
“The assumption today is that (mental illness) is a brain disorder. (The fact is), maybe, maybe not. Take stomach ulcers for instance. In the past, people used to think it’s just due to stress, alcohol (consumption). Now, it turns out that it’s due to the Helicobacter pylori bacteria. People didn’t use to think about infections (causing stomach ulcers),” said Adj Assoc Prof Fung.
Increasingly, research has shown a link between the two unlikely bedfellows. At the conference, clinical health psychologist Shen Biing-Jiun from Nanyang Technological University (NTU) shared clinical evidence on the connection between mental health and chronic diseases.
Studies have shown that depression independently predicted the onset of coronary heart disease among initially healthy individuals, as well as worse health outcomes among coronary heart disease patients, he said.
“The evidence is so strong that the American Heart Association issued a statement in 2014 recognising depression as a risk factor for poor prognosis (chances of getting better) among heart patients,” said Associate Professor Shen of the Psychology Programme at NTU’s School of Social Sciences. Emerging research has also found that depression appears to predict Type 2 diabetes and worse outcomes among diabetic patients, he added.
Psychological distress may cause disturbances in the body’s stress-response systems and immune system, causing higher chronic inflammation, which has been linked to medical conditions such as coronary heart disease, said Assoc Prof Shen.
“Also, excess psychological distress may lead to unhealthy behaviours. People who are depressed or anxious may engaged in unhealthy behaviours such as smoking, overeating or unhealthy diet, which would also lead to an increased disease risk,” he added.
Adj Assoc Prof Fung called for action to bridge the disconnect between mental and physical healthcare.
“Mental health, when taken apart from physical health, is not tenable … we can’t afford to have two separate systems,” he said.
For a start, doctors treating patients for mental health disorders could take a “whole person approach” and ask their patients questions about their physical health, taking appropriate action when needed, he said. Patients and caregivers should work closely with their doctors and healthcare team.
On its part, IMH has taken steps to address the physical health issues of some patients.
In 2014, IMH worked with the Singapore Healthcare Improvement Network (SHINe), spearheaded by the Ministry of Health, to improve diabetes management among patients.
The team developed a diabetes care plan, which includes an educational brochure for patients, and a rescue protocol for when a patient is hypoglycaemic (low blood sugar).
“When you talk about a medical illness like diabetes, you should not forget depression as well as other mental conditions that are linked to it, and vice versa.
“Whether as a primary care physician, a patient or caregiver, it is important to be aware (of the connection between physical and mental health) and to look out for these symptoms,” said Adj Assoc Prof Fung.