High congruence was found among the mortality of public mental health clients in eight states as indicated by multiple standardized measures of mortality. The higher risk of death among these clients compared with the general populations of their states using the AADRs and SMRs are consistent with conclusions of other research. Most importantly, the findings in this study show that results are similar in several states. In all eight states, public mental health clients have higher AADRs and higher relative risks of dying as shown by SMRs considering age and sex. Even though the magnitude of AADRs and SMRs vary by state and year, the results show strong similarities. CDC's National Vital Statistics Reports
) and work by other researchers show differences in mortality and leading causes of death among state populations and years. Some interstate differences in mortality measures reported in this article might be attributed partially to differences among state populations. Therefore, in this study, mortality statistics were calculated and compared between mental health clients in each state and the general populations within the state during the same year.
In addition, parallels between the public mental health clients in all eight states were found in the YPLL and mean age at time of death. Public mental health clients lost decades of potential life and died at younger ages than their cohorts nationwide for the years studied. YPLL as a mortality measure provides insight into the risk of premature death for public mental health clients. Clients with MMI diagnoses (schizophrenia, major depressive disorders, bipolar disorders, delusional and psychotic disorders, and attention deficit/hyperactivity disorders) died at younger ages on average than most clients with non-MMI diagnoses. The YPLL for clients with MMI diagnoses were higher than clients with non-MMI diagnoses in more than 81% of the comparisons made.
All eight states did not submit data for all years, which may influence the generalizations of our study findings. Future similar analyses with additional data will increase the generalizability of our findings. Regardless, a review of the findings in this study raises the issue of determining what can be done to lower the mortality rates and risk of early death for people with mental illness, especially people with the most serious diagnoses. Twenty years ago, McCarrick et al reported higher rates of chronic medical problems among people with chronic mental illness, and chronic illness is known to increase risk of death. They suggested in their conclusions that "psychiatrists need to be adept at caring for physical illness, and primary-care physicians need to acquire skills in caring for the mentally ill" (8
It was noted previously that clients in Virginia state psychiatric hospitals had a lower risk of death and longer lives than public mental health clients from the other seven states. These findings raise additional questions. Do differences in treatment and care exist between clients in hospital residences and clients residing and receiving treatment in communities? If so, the differences could influence mortality rates, life span, age at time of death, and subsequently YPLL. Are medical and other types of care for improving physical health provided to public mental health clients living in a hospital setting but not to clients in less-controlled environments? Although answering these questions directly is beyond the scope of this study, causes of death for public mental health clients and the health issues of people with mental illness suggest that treatment practices can be developed and used to help address the problem of premature death among people with mental illness.
Utah's data highlight that differences exist among states. The general population of Utah is younger than the population of most states in the United States; one third of Utah's general population was aged 17 years or younger, and one fourth was aged 18 to 34 years during the study years. According to the National Vital Statistics Reports,
accidents are generally the leading cause of death among people younger than 34 years (11
). The high proportion — almost 60% of Utah residents younger than 34 years — could have affected Utah's data in this study. Age distribution and lifestyle among Utah residents may also affect the lower incidence of cancer in the state. To explain the lower percentages of cancer among deceased adults who had been served by the Massachusetts Department of Mental Health, Dembling et al (3
) suggested that the development of cancer might be preempted by early death. A similar explanation could be applied to this study's data from multiple states, especially in view of the younger average ages at time of death for the public mental health clients.
Although the increased mortality rates found in this study are outcome results, health conditions and other factors related to people with mental illness have been described by other researchers and help explain these mortality findings; examples are cited in the following paragraphs. Most public mental health clients in all of the states died of natural causes and at younger ages than the general populations of their states. Leading causes of death for most public mental health clients were similar to those of individuals throughout the United States and in state general populations, especially heart disease, cancer, and cerebrovascular, respiratory, and lung diseases. People with mental illness have medical problems that lead to death, especially if they have inadequate medical treatment.
Researchers and clinicians continue to document comorbidity and medical treatment issues for individuals with mental illness. In 2004, researchers found that outpatient clients with serious mental illness were more likely to have comorbid medical conditions than the general population and have an increased risk for medical conditions, especially diabetes, lung disease, and liver conditions (7
). Researchers from Australia found that physical comorbidity in people with schizophrenia accounts for 60% of premature deaths not related to suicide in this population (6
). The prevalence of chronic bronchitis and emphysema was significantly higher among Maryland adult outpatients with serious mental illness than national comparison subjects (24
). In addition, it was also found that the prevalence of cardiovascular disease was higher among the Maryland adults with serious mental illness who had major depressive episodes, minor depression, and moderate mental health. Other researchers found that after a confirmed myocardial infarction, Medicare clients "with comorbid mental disorders were substantially less likely to undergo coronary revascularization procedures then those without mental disorders" (25
). In western Australia, psychiatric clients were found to have a higher fatality rate from cancer, even though they did not have a higher incidence rate of cancer (26
); the higher fatality rates were attributed to screening and treatment deficiencies. In Vermont, "the incidence of cancer for adults with serious mental illness is more than twice the incidence for the general population" (27
Researchers have studied the health risks of individuals with mental illness. Compared with other populations, people with mental illness have a higher prevalence of cardiovascular risk factors, including smoking, overweight and obesity, lack of moderate exercise, harmful levels of alcohol consumption, excessive salt intake, and poor diet (6
). Lack of emotional support and social networks, lower socioeconomic status, and substance abuse are described as risk factors that affect mortality in people with serious mental illness (29
According to the Harvard Mental Health Letter,
people with psychiatric disorders have higher rates of medical illnesses, but they often do not seek needed medical care (30
). Lifestyle, social consequences of mental illness, and difficulties in accessing health care are factors related to managing physical illness in those with mental illness (31
). Lifestyle factors include long-term use of antipsychotic medication and sexual practices. Social consequences of mental illness include poverty, unemployment, poor housing, stigma, and low self-esteem. Difficulties accessing health care include doctors' focus on mental illness and not physical health, erratic compliance with health screening and treatment, and poor communication.
Some mental health practitioners and heath care professionals are proposing ways to improve the physical health of individuals with mental illness, which could consequently help decrease mortality rates and rates of premature death. If primary care and mental health professionals pay attention to the physical ramifications of mental illness, the physical health of people with serious mental illness can be improved (32
). Improved intervention practices could include engaging clients in preventive care, diagnosis, and management of serious physical illnesses and additional training for mental and physical health professionals to encourage communication about patient care (33
). In Australia and Great Britain, health promotion programs and treatment improvements are being proposed for people with mental illness (33
). In the United States, advance-practice nurses and consumer peer providers are being added to Assertive Community Treatment Programs to address physical health problems among people with serious mental illness (36
The 1999 Surgeon General's report on mental health recognized "the inextricably intertwined relationship" between mental health and physical health (20
). Research to track mortality and primary care among mental health clients should be increased to provide information for additional action and treatment modification. More research about diagnosis-specific risk and evidence-based practices should be developed. Awareness among clients and providers of mental health services and primary care should be increased. Best evidence-based practices for the prevention and diagnosis of medical conditions among people with mental illness should be developed. Mental health clients should receive regular primary health care by a physician to monitor their physical health. Finally, the recommendation from the World Health Organization to integrate mental health care and primary health care should be followed (37
). At the least, mental health care and physical health care should be better linked within health care delivery systems.