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Your Mental Health

Higher death rate in mentally ill

Seriously mentally ill individuals have a much higher death rate than the general population.

On the surface, this may just seem like a probable consequence of having a serious mental illness. For example, much attention is paid to the increased suicide risk among those with major depression, schizophrenia or bipolar disorder.

Although this does contribute to the higher likelihood of death among the mentally ill, it is not the primary cause. In fact, those with psychiatric conditions are more likely to die from a lot of different causes than the general population – most notably from chronic physical illness such as heart and lung disease or cancer. There are 10 times as many deaths from these causes as there are from suicide among the mentally ill.

It has long been known that physical and psychiatric illness often go together. When one is present, it seems to worsen the other – in both directions. For example, depression is known to worsen outcomes in physical illness such as heart disease and at the same time, when physical illness begins, it tends to have an immediate effect to worsen symptoms of depression.

According to researchers in the field, the death rate for people with mental illness is about 70 percent higher than in the general population – and worse for those with schizophrenia. People with major mental illness often die up to 25 years earlier than their non-mentally ill peers.

In a review paper examining the scale of this problem, researchers learned that the highest death risk is among patients with severe mental illness and that 72 percent of the excess deaths occur in patients who have only ever attended general practice for their psychiatric care.

The problem of excess mortality is present in all clinical settings and has been around for centuries. All of this begs the question – why do we have so many unnecessary deaths among the mentally ill?

A few theories exist about the reasons for this problem. For one thing, many of the risk factors for chronic illness are preventable and involve lifestyle modification. Things like smoking, obesity, high blood pressure and cholesterol.

We know that some of these issues are particularly common among the mentally ill. For example, up to 80 percent of people with schizophrenia also smoke and some of the medications commonly used to treat this condition can cause significant weight gain. People with mental illness are more likely to smoke, drink and use drugs and less likely to exercise at recommended levels than the general population.

Perhaps individuals dealing with severe mental illness are missing out on opportunities to prevent or treat these issues when the rest of the population is not.

But lifestyle factors are not the only explanation. When it comes to cancer, the incidence of many forms is no higher than in the general population, but those with co-existing mental illness are more likely to die from their cancer.

Some other explanations for an increased death rate could include a lower compliance with treatment for chronic illness, issues with communication or an overlap between psychiatric and physical symptoms which could make it harder to diagnose chronic illness.

All of this simply points to the importance of educating health care providers in all settings about increased risks and ensuring regular health screening for patients dealing with mental illness. We could do a lot toward preventing as many as 33,000 unnecessary deaths each year in Canada.



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Exercise is good for your brain

Newsflash – physical exercise is good for you. Obviously, we all know this and have been given many reasons why lacing up the walking shoes or heading to the gym on a regular basis are beneficial activities.

In past columns I have even mentioned that exercise can also be great for reducing stress and improving mental health by getting those endorphins flowing. It has also been shown to improve memory and mental ability and was theorized to be useful in the maintenance of cognitive functioning as we get older.

Finally, a couple of new studies have shed a bit more light onto the specific ways in which physical exercise may protect our brains from deterioration and possibly even prevent the onset of dementia or Alzheimer’s disease.

Researchers at the University of Pittsburgh have published a couple of studies examining the effects of physical exercise on the brain. One study examined 299 cognitively normal adults with a mean age of 78. At baseline, the volunteers’ exercise levels were assessed based on the average number of blocks walked each week. Researchers then gave them MRI scans two or three years later, another high resolution MRI after nine years, and cognitive assessments at nine and 13 years after baseline.

During this time, 116 of the volunteers experienced mild cognitive impairment or dementia.

Study results found that the baseline weekly walking predicted gray matter volume at the nine year follow up – those with the most physical exercise had significantly higher gray matter volume than those who exercised less frequently.

In this study, walking six to nine miles a week was associated with the greatest gray matter volumes – associated with reduced risk of cognitive impairment or dementia. Walking more than that did not make a further difference.

Another study by the same group of researchers and published this year in February found even beginning a moderate exercise program late in life led to increased brain volumes and improved memory function.

A different group of researchers from Washington University examined the relationship between exercise and four known Alzheimer’s biomarkers in 69 normal adults aged 55 to 88.

Researchers analyzed exercise levels in volunteers over the last 10 years and found that those with the lowest amount of physical exercise had elevations in one biomarker associated with increased risk of Alzheimer’s disease (Pittsburgh Compound B binding). Those who exercised more frequently experienced lower levels of this as well as higher amyloid B42 (a protective biomarker).

All of these studies seem to associate physical exercise with brain health in older adulthood. More research is needed to better understand what it is about the exercise that provides the protective effect – some theories suggest aerobic exercise sends oxygen-rich blood into the brain, which is the organ that needs the most blood. This kind of exercise is also known to increase levels of a chemical called brain derived neurotrophic factor, which promotes growth of new brain cells and protect them from age-related damage.

Regardless, this information gives just a few more reasons why it is important to keep getting the recommended amount of exercise (30 minutes a day at least five days a week) to maintain optimal health throughout life.



Does bipolar disorder contribute to violence?

Are mentally ill people more likely to be violent? That is certainly the impression you could get from media reports, crime shows and the exaggerated stories of some. A typical horror story often begins with a ‘mentally unstable’ individual launching into a series of heinous violent crimes.

Although these kinds of stories chill our blood on a hot day, they do not actually represent the facts. I have mentioned in past columns that the mentally ill are in reality more likely to be the victims of violent crime than the perpetrators.

One study out of Sweden sought to definitively answer this issue when it comes to individuals with bipolar disorder – one of the illnesses characterized by shifts in mood states between the lows of depression and the reckless, agitated highs of mania. Some feel this condition is likely to contribute to violence.

In this study, researchers gathered comprehensive, population-wide data by analyzing hospital discharge records between 1973 and 2004. They compared the data of 3,743 individuals diagnosed with bipolar disorder on at least two occasions with over 37,000 unaffected people from the general population and just over 4,000 unaffected full siblings.

Information was cross-referenced against a database of convictions for violent crimes in that country. The prevalence of violent crime was 8.4 percent for patients, 3.5 percent for the population controls and 6.2 percent for siblings. When adjusted for relevant demographic factors, the odds ratio for patients was 2.3 compared with the population and 1.6 compared with siblings.

The interesting part of this study is that patients who did not have co-existing substance abuse also did not have a significantly increased likelihood of violence. When the data was analyzed while only comparing those with substance abuse to the controls, the odds ratios were much higher – 6.4 compared to the population and 2.8 compared to siblings.

Similarly, when the population and sibling control groups were analyzed based on their own substance abuse, the rates of violent crime were much higher – 33 percent for the general population and 42 percent for the sibling group.

So – although bipolar disorder does involve the manic mood state with impulsive behaviours, recklessness and feelings of agitation, the real danger for increased violence is associated with substance abuse rather than the mood state itself.

That said, substance abuse is much more common among individuals with bipolar disorder than it is in the general public.

Substance abuse screening and assessment is an important part of the ongoing treatment of anyone with a psychiatric problem. Many people try to self-medicate with drugs or alcohol and these can do a lot of harm – making symptoms of the disorder worse and can even increase the likelihood of violence in some patients. When there is a substance abuse issue co-existing with a mental illness, it is critical to deal with both issues.





Workplace mental health in the spotlight

I have written about mental health in the workplace in the past and highlighted the importance for employers to realize that mental health problems affect people in all areas of life including the workplace.

Mental illness hits companies hard every year in terms of lost productivity and disability days and now more than ever it is also costing employers in legal settlements. According to a report by the Mental Health Commission of Canada (MHCC), financial rewards for damages caused by mental injury at work increased 700 percent in recent years.

More than ever before, employers must now face their responsibilities when it comes to providing psychologically safe workplaces.

In our modern world, the workplace can be filled with pressure and excessive stress – not to mention our tendencies today to never really leave work as we bring it with us on our mobile devices everywhere we go.

All of this can lead to common mental health issues including depression, anxiety and burnout, which are increasingly being characterized as mental injury in legal settings. According to the MHCC report, Canadian courts are increasingly intolerant of workplace factors that threaten the psychological safety of employees and the courts are ordering management to change habits while imposing financial punishments for failing to do so.

An even more recent report released by the Conference Board of Canada surveyed more than 1,000 Canadian employees and found 44 percent say they have coped with a mental health problem such as extreme stress, depression, substance abuse or schizophrenia.

Twelve percent said they were currently experiencing a mental health issue and another 32 percent said they had dealt with this in the past.

These numbers are surprisingly high and definitely point to the need for employer awareness of mental health issues and how to prevent them in the workplace.

Another interesting point in this report was the extent to which managers and employees see things differently. Almost half of all managers had no training in dealing with workplace mental health issues but four fifths said they felt equipped to do so. This compared with only 30 percent of employees who agreed their management were prepared to deal with mental health issues and many feared disclosing their problems may jeopardize employment security or success.

There are a few ways in which employers can help ensure a safe and mentally healthy workplace. First, it would go a long way toward eliminating stigma if management were encouraged to openly discuss the importance of mental health – this would help employees feel more comfortable admitting if they are having difficulty.

Providing education to all management and employees about the dangers of excessive stress and the nature of some common mental illnesses would also be very helpful.

Employers can review disability claims to raise their awareness of mental health within their own companies and can then review their return to work policies, education programs and workplace attitudes about mental health.

When individuals are off work with a psychiatric disability, it is unrealistic to require them to return to work full time and 100 percent better. Often a graduated return to work is necessary to help them regain their confidence and overcome anxiety.

Finally, employers should consider implementing assistance programs for employees experiencing mental illness. These measures can help to make the workplace more productive and more compassionate.

If companies placed a true priority on mental health in the workplace, we could vastly reduce the amount of lost productivity and personal distress caused by workplace mental health issues.



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About the author...

Paul Latimer has over 25 years experience in clinical practice, research and administration. After obtaining his medical degree from Queen's University in Kingston, Ontario, he did psychiatric training at Queen's, Oxford and Temple Universities. After his residency he did a doctorate in medical science at McMaster University where he was also a Medical Research Council of Canada Scholar. Since 1983 he has been practicing psychiatry in Kelowna, BC where he has held many administrative positions and has done numerous clinical trials. He has published many scientific papers and one book on the psychophysiology of the functional bowel disorders. He is an avid photographer, skier and outdoorsman.



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The views expressed are strictly those of the author and not necessarily those of Castanet. Castanet presents its columns "as is" and does not warrant the contents.


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