Recent news from the NIMH (National Institute of Mental Health) suggests a call for more attention paid to data culled from co-morbidity and mortality studies in both the United States and Sweden (Director's Blog, 3/29/13) to address the alarming life-expectancy rates among those with severe mental illnesses. It goes without saying these two countries have vastly different reverences for and interpretation of good health however (!) these studies both showed increased co-morbidity and mortality rates among those with severe mental illness when compared with the general population. The schizophrenic patients that were the focus of the study in Sweden even saw health care providers more often than the general population, a trend in opposition with what is going on in the U.S., where access to care for those with a severe mental illness is ponderously out of reach. In Sweden, the problem was not with access to treatment but early detection; when detected too late, ischemic heart disease, pulmonary disease and cancers reduced life years in schizophrenic women by 12, men by 15 (Crump et al). Numbers in the U.S., where individuals included in studies have the societal advantage of accessing our notoriously inaccessible mental health care system, are equally macabre, with 8.2 years average years less lived by those with any severe mental illness diagnosis (Druss et al). I'm reading Bad Souls: Madness and Responsibility in Modern Greece (Duke 2012), by Elizabeth Anne Davis right now, who's discerning look at Greece's psychiatric reformation considers 'responsibilities' as they shape the clinical and broader therapeutic encounters between patients and psychiatric staff. These 'responsibilities' employ clinician expertise to diagnose (my use here) deceptive and performantive measures taken by patients that give form to the clinical encounter. Compliance with treatment programs and an interest in self-help are some of the identifiers of a 'responsible' patient and while mental illness itself can impede both of these characteristics, they nevertheless persist as cultural accessories to moral patienthood. These characteristics may also play a role in the lived years reduction among the severely mentally ill. The patients involved in the Swedish study on co-morbidity and mortality, despite the safety net that is universal healthcare, lived significantly shorter lives than the general population because of late detection of non-communicable (arguably 'life style') diseases. In Davis' modern Greece, as in the U.S., patients are held accountable for maintaining treatment, even though in these socio-political spaces health care is not as accessible as it should or could be. Responsibility is emphasized as a means to not only well-being but perhaps even greater care exercised by clinicians (who deal often with unruly patients and/or are held in positions as 'gate-keepers' to care). With Obamacare looming near, can we argue our numbers in co-mortality and co-morbidity studies relating mental health with life years will improve because of access or will early-detection plague us too as a silent precipitator of premature death? With the U.S. psychiatric reform era decades behind us, and a more universal health care system in the near future, are we in a position to learn from both Greece and Sweden in changing these numbers for the better? In what ways will patient responsibility interact with healthcare access to decrease these co-morbidity and mortality rates? In Sweden, early detection certainly remains stubbornly elusive for the mentally ill so we may remain hesitant to see greater access to health care in the US as an agent of longer lives lived. Despite the increased access to healthcare on the horizon, the Swedish study shows us access alone is not enough.
References:
Crump, C., et al.
2013 Comorbidities and Mortality in Persons with Schizophrenia: a Swedish national cohort study. American Journal of Psychiatry 170 (3): 324-33.
Davis, E.A.
2012 Bad Souls: Madness and Responsibility in Modern Greece. Durham: Duke.
Druss, B.G., et al.
2011 Understanding Excess Mortality in Persons with Mental Illness: 17-Year Follow up of a Nationally Representative US Survey. Medical Care 49 (6): 599-602.
Thomas Insel
2013 Director's Blog Schizophrenia as a Health Disparity, 3/29.
