Severe mental illness robs years from people's lives

From the San Francisco Chronicle:

Barbara Redfield shudders when she thinks of the last time she saw her brother. He had been treated throughout his life for paranoid schizophrenia and developed multiple forms of cancer that went undetected until his final days.

"There was this scrawny - looked like he was in his 80s - man on his deathbed with bruises up and down his arms because they had him tied to the bed because he didn't want a catheter," said the San Francisco woman. "It was just horrible, and he died the next day."

Her brother, Sherwood Roberts Jr., was 53.

People diagnosed with severe mental illnesses, such as schizophrenia, major depression and bipolar disorder, die much earlier than the general population. Studies show they die as much as 25 to 30 years sooner, with an average life expectancy of about 54 years.

Research has shown that while suicides and accidents account for up to 40 percent of premature deaths, 60 percent of early mortality in people with schizophrenia, for example, is because of medical conditions such as cardiovascular, pulmonary and infectious diseases.

Most people with mental illnesses are dying for the same reasons as the rest of the population - they're just developing illnesses at an earlier age and dying a lot sooner.

Clearly, the behaviors of some mentally ill people put them at greater risk. They have higher rates of smoking, drug and alcohol abuse and unsafe sexual practices. People with these conditions also more likely to be homeless, unemployed, poor and socially isolated - all factors that would lead to poorer health.

But people diagnosed with schizophrenia, bipolar and major depressive disorders are associated with natural medical causes of death, such as cardiovascular disease, that are two to three times the rate of the general population.

"It's easier to understand why someone on the street will die a lot sooner. But a lot of people are living with families and with really great care, and they are still at risk of dying earlier," said Dr. Margot Kushel, associate professor of medicine at UCSF, who is based at San Francisco General Hospital and researches health issues of the homeless.

In the case of Redfield's brother, he was not homeless and had family members monitoring his care when he was institutionalized. Roberts did not take illegal drugs or have a weight problem. He had a healthy diet, although he would occasionally get strange ideas about certain foods being poisonous.

But he was a large man who was prone to raging outbursts that frightened the hospital staff. Roberts kept complaining that his heart was "busted" but refused to undergo medical testing.

Redfield suspected her brother was physically ill and had talked to the staff at the site where he was living, but his paranoia and hostility made intervention difficult. "He had been complaining about physical ailments for a while," she said of her younger brother, an athletic and popular Southern California boy until his first psychotic break at 17. "For a while, he also believed his teeth had been drilled on by dentists who came in the middle of the night. That was one of his delusions."

People with serious mental illnesses also are rarely treated for physical illnesses because so many have limited access to primary care screenings or treatment. For example, 88 percent of people with schizophrenia who had high cholesterol weren't getting treatment, according to a 2006 study published in the journal Schizophrenia Research.

Many of the mentally ill also are chronically homeless, making them more likely to adopt unhealthful behaviors - from drug use to poor nutrition - as well as increasing their chances of being victims of violent crime.

Smoking rates are two to three times that of the general population, in part because nicotine apparently has a calming effect on psychiatric symptoms, especially among people with schizophrenia. Research indicates that nicotine may normalize some deficits in the central nervous system, causing hallucinations to subside, while enhancing memory and the ability to process information.

Even in a city like San Francisco, which has a large, visible population of people with severe mental illnesses, public health officials do not track or know how many seriously ill people live here.

San Francisco's population of seriously mentally ill may be as high as 5 percent, according to Dr. Bob Cabaj, medical director for San Francisco Community Behavioral Health Services. In contrast, he said, in many communities that do not have the influx of people from other areas, such as a small city in the Midwest, the seriously mentally ill typically account for just 1 to 2 percent of the population.

Among the chronically homeless, the percentage of people with serious mental illnesses is estimated between 50 and 80 percent. The city's last homeless tally, taken in January 2009, found 6,514 homeless people living in San Francisco.

One of them used to be 37-year-old Antonio Morgan (pictured), who was diagnosed with paranoid schizophrenia at 23. When Morgan moved to San Francisco in 1997, he was homeless and lived in shelters.

"Even when you do have the money to eat, there's no grocery store," he said of life on the streets. "We self-medicate with tobacco and stuff. There's nowhere to go to get an apple, or if you do, you go to Whole Foods and it costs $2. A bag of chips that will fill you up costs 99 cents."

It took a stint in jail, during which he was offered help through a case-management program for homeless people with mental health problems, for him to be able to get his issues under control through medication and holistic approaches such as meditation, the Chinese physical and mental practice of qigong and religious studies.

But Morgan experienced one of the most common side effects of the newer psychiatric medications: severe weight gain, which can put patients at higher risk of heart disease and other health problems. "At times I was taking more than one psychiatric medication and that's what blew me up like a Ball Park Frank," he said.

He quickly ballooned to 275 pounds from his normal weight of about 185 pounds and was on the verge of having diabetes and high blood pressure. "Then I said I've got to do something. I started going on walks and doing all this physical activity," he said, explaining how playing basketball three times a week has helped him lose more than 35 pounds.

Morgan, who lives in a Tenderloin hotel, has winnowed his medications down to the minimum he needs to keep his psychiatric symptoms at bay.

One of Morgan's frustrations is the lack of coordination between his physical and mental health providers. "I wish they could put them all in one person or have them communicate," he said.

A key hurdle in treating psychiatric patients is coordinating care between medical and psychiatric providers. Firewalls between patients' mental health and physical health records and lack of communication between providers can often impede care.

"In San Francisco, we actually do a pretty good job of trying to provide integrated care," said Dr. Mason Turner, chief of psychiatry at Kaiser Permanente in San Francisco. "The city itself has a lot of very good mental health resources, and we really try to work with patients."

The San Francisco Public Health Department has made efforts to place behavioral health specialists in medical clinics to coordinate care.

"There's a big push within the health department to expand integration of medical and mental health care," said Dr. Joshua Bamberger, medical director of the Housing and Urban Health unit of the Public Health Department. "We will be even better in the future."