Improving Health and Health Care for Persons With Serious Mental Illness: Title and subTitle BreakThe Window for US Federal Policy Change

In 1928, Benjamin Malzberg, a young epidemiologist in New York State's Division of Mental Hygiene, began a groundbreaking study examining causes of mortality in New York State's mental hospitals. During the ensuing 3 years, Malzberg reviewed every death that occurred throughout the state's psychiatric hospital system; his findings were both surprising and troubling. Patients in these hospitals died an average of 15 years younger than the general population of New York State.¹ Malzberg speculated that these excess deaths were likely due to a complex combination of factors:

Mental diseases are often the direct consequences of physical processes, as in general paralysis. It is also true, however, that the mental condition is in itself an important factor in the morbidity and mortality of patients with mental disease. There are also indirect results consequent upon bad personal attitudes toward health, such as the marked indifference of dementia praecox patients to the need of exercise.^1p160

In subsequent decades, these findings were confirmed and extended across a variety of settings. By 1996, more than 60 studies had found that standardized mortality rates across a range of serious mental illnesses including schizophrenia, bipolar disorder, and major depression were 2 to 3 times greater than those in the general population, with the majority of excess deaths due to medical illnesses rather than “unnatural” causes such as suicide.² Other studies identified a growing list of risk factors contributing to this excess morbidity and mortality, including unhealthy lifestyles (smoking, poor diet, lack of exercise), poor quality of medical care, poverty, biological mechanisms including dysregulation of the hypothalamic-pituitary-adrenal axis, and adverse metabolic consequences of psychotropic medications.³

Despite the public health implications of these findings, the issue of excess morbidity and mortality among patients with serious mental illness remained a clinical and policy orphan throughout the 20th century. Mental health clinicians largely focused on providing mental health services, and other health care practitioners paid scant attention to the population of individuals with serious mental illness. As new health technologies and public health innovations improved longevity in the general public, persons with serious mental illness lagged behind, and the mortality gap for this population widened still further.⁴

The problem of excess morbidity and mortality among persons with serious mental illness moved into the mainstream of mental health policy with the release of a 2006 study reporting that public mental health sector patients across 8 states died, on average, approximately 25 years earlier than age- and sex-adjusted populations from the same states.⁵ This finding became the centerpiece of a report by the National Association of State Mental Health Program Directors that called for coordinated efforts to reduce premature morbidity and mortality in persons with serious mental disorders.⁶ Since the release of that report, mental health advocates, clinicians, and consumer groups have rallied around this statistic to place the issue of morbidity and mortality among persons with serious mental illness squarely on the mental health policy agenda.

The recent policy interest in morbidity and mortality in persons with serious mental illnesses, coupled with current efforts to reform the US health care system, have created what Kingdon⁷ called a “policy window”: a critical but short-lived opportunity for policy action. Making effective use of that window, however, will require concerted efforts both within and outside of the formal health care system.

Health and health care for patients with mental health problems cannot be improved without addressing problems of access and fragmentation in the broader health system, particularly in the safety net settings where most persons with serious mental illness receive their medical care. Several features of current health care reform efforts hold promise for improving health care in this population. The proposed expansion of Medicaid will likely help reduce financial barriers to accessing medical care among persons with serious mental illness, a large proportion of whom are poor and uninsured. The medical home movement, which is seeking to develop a financing and organizational structure to support primary care, has considerable potential to improve care for persons with serious mental illness both in primary care and specialty settings. In an important new pilot initiative, the Substance Abuse and Mental Health Services Administration (SAMHSA) recently funded 13 community mental health centers across the country to develop co-located medical homes for their patients via partnerships with community medical groups.

While integration with broader health care reform initiatives is critical for improving care for mental disorders, these efforts need to be balanced with attention to the unique challenges faced by mental health patients. Despite the documented gap in quality of health and health care for persons with serious mental disorders, such patients are not currently designated as a health disparities population by the federal government. Such a designation would require that states and federal agencies track vital health statistics separately for this population and would also make them eligible for technical assistance and grant opportunities.⁸

Improving medical care is likely to be necessary, but not sufficient, to reduce the mortality gap for mental health care patients. In the general population, it has been estimated that only 10% of premature mortality is explained by health care, with the majority of excess mortality explained by health behaviors and social/environmental circumstances.⁹ Similarly, reducing the mortality gap in persons with serious mental illness will require addressing adverse health behaviors in their social and environmental contexts.

Reducing smoking rates in this population will require not only access to clinical treatments such as smoking cessation counseling but also environmental interventions such as smoke-free inpatient hospitals, group homes, and outpatient clinics. Efforts to improve diet and physical activity will need to recognize that persons with serious mental illnesses typically live in built environments that limit access to healthy food and exercise. Both smoking and obesity have been found to be “contagious” within social networks and may become self-perpetuating within mental health patient communities. These network effects can also be harnessed to improve health behaviors, as mental health patient peer networks begin to include physical wellness as part of their broader efforts to promote mental health recovery.

New public health initiatives such as the Centers for Disease Control and Prevention's Communities Putting Prevention to Work are seeking to improve health behaviors and outcomes across entire communities and geographic regions. For such population-based efforts to succeed, they will need to include a focus on subgroups, including those with serious mental illness, who have disproportionately high rates of adverse health behaviors.

In September of 2007, the SAMHSA unveiled a goal to reduce the 25-year mortality gap for mental health patients by 10 years within 10 years—the “10 by 10” campaign.¹⁰ A broad coalition of clinicians, consumer groups, researchers, and state and federal agencies signed that pledge. Reviewing the long history and complex determinants of this problem provides a sobering reminder of how challenging it will be to attain this goal. However, the current groundswell of interest in addressing this problem, coupled with efforts to reform the US health care system, suggest a once-in-a-century opportunity to begin to reverse that disparity and to improve the health and well-being of one of the United States' most vulnerable populations.