- Email: [email protected]
Long way to go to close the mortality gap
Comment
acceptance of psychotic experiences. Although they state that the aim of the study was not to characterise a general population sample with psychotic experiences, but to compare individuals with poor and good outcomes of their psychotic experiences, the clinical relevance of their findings will depend, at least in part, on the transferability of characteristics and practices from one group to another. Research has highlighted the importance of understanding beliefs about anomalous experiences within the context of individuals’ spiritual beliefs,8,9 and shown that appraisal is not simply an in-the-moment assessment, but can develop over time through socially meaningful practices of cultivation, which in turn might shape phenomenology. Comprehensive understanding of these experiences is unlikely to be reached through the methods and measures of psychiatry alone and, therefore, future studies could fruitfully engage concepts and modes of inquiry indigenous to these groups8 and to the many other disciplines engaged in the study of human experience.10 Improved understanding of the relevance of spiritual context in the appraisal of psychotic experiences in nonclinical cohorts has the strong potential to enhance understanding of the importance of context in the ways individuals make sense of psychotic experiences more generally.
*Angela Woods, Sam Wilkinson Centre for Medical Humanities and Department of English Studies, University of Durham, Durham DH1 4SZ, UK (AW) and School of Philosophy, Psychology and Language Sciences, University of Edinburgh, Edinburgh, UK (SW) [email protected] We declare no competing interests. Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Alderson-Day B, Lima CF, Evans S, et al. Distinct processing of ambiguous speech in people with non-clinical auditory verbal hallucinations. Brain 2017; 140: 2475–89. 2 Kråkvik B, Larøi F, Kalhovde AM, et al. Prevalence of auditory verbal hallucinations in a general population: a group comparison study. Scand J Psychol 2015; 56: 508–15. 3 Johns LC, Kompus K, Connell M, et al. Auditory verbal hallucinations in persons with and without a need for care. Schizophr Bull 2014; 40 (suppl 4): S255–64. 4 Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a ‘need for care’. World Psychiatry 2016; 15: 41–52. 5 Peters E, Ward T, Jackson M, Woodruff P, Morgan C, McGuire P, Garety PA. Clinical relevance of appraisals of persistent psychotic experiences in people with and without need for care: and experimental study. Lancet Psychiatry 2017; 4: 927–36. 6 Fletcher PC, Frith CD. Perceiving is believing: a Bayesian approach to explaining the positive symptoms of schizophrenia. Nat Rev Neurosci 2008; 10: 48–58. 7 Ratcliffe M. Feelings of being: phenomenology, psychiatry and the sense of reality. Oxford: Oxford University Press, 2008: 324. 8 Luhrmann TM. When God talks back: understanding the American evangelical relationship with God. New York, NY: Vintage Books, 2012. 9 Powers AR, Kelley MS, Corlett PR. Varieties of voice-hearing: psychics and the psychosis continuum. Schizophr Bull 2017; 43: 84–98. 10 Woods A, Jones N, Bernini M, et al. Interdisciplinary approaches to the phenomenology of auditory verbal hallucinations. Schizophr Bull 2014; 40 (suppl 4): 246–54. 1
Voisin/Phanie/Science Photo Library
Long way to go to close the mortality gap
Published Online November 6, 2017 http://dx.doi.org/10.1016/ S2215-0366(17)30428-5 See Articles page 937
892
The premature mortality of people with mental disorders is well established, but achieving an understanding of this problem has proved difficult. Drawing on the remarkable Danish case register system, Erlangsen and colleagues1 report on the excess mortality of people with mental disorders in Denmark over a 20 year period, from 1995 to 2014. In their study, people with mental disorders were defined as all people who had been diagnosed with a mental disorder during psychiatric hospitalisation or outpatient treatment. The size of the sample (more than 6 million individuals who contributed more than 89 million person-years) and the use of sophisticated statistical methods enabled the investigators to assess differences between people with mental disorders and those without mental disorders in terms of specific causes of
mortality as well as changes in the causes of mortality over time. The investigators employed an innovative measure to compare mortality between the two groups, the number of excess life years lost, a metric that takes into account life expectancy at the age of diagnosis. They noted that mortality decreased in both those with and without mental disorders over the time period of the study but without any narrowing of the large mortality gap between the two groups. This study adds to results of other studies from around the world in documenting the continuing premature mortality in persons with mental disorders.2–4 The study was done in a country with an excellent and accessible public health-care system, suggesting that the availability of medical care is not, by itself, sufficient to prevent excess mortality. www.thelancet.com/psychiatry Vol 4 December 2017
Comment
The study by Erlangsen and colleagues also provides information about differences in causes of death in men and women with and without mental disorders. Among men with mental disorders, death from alcohol misuse, accidents, and suicide were the major contributors to the 10·2 excess years life lost. Among women with mental disorders, respiratory diseases were the leading cause of death contributing to the overall 7·3 years of excess years life lost, along with alcohol misuse, heart disease, and suicide. Over the last 5 years of the study period, more of the excess life years lost were due to natural than to unnatural causes for both men and women with mental disorders compared with the first 5 years, but the overall pattern of excess mortality remained the same. Looking at the absolute number of deaths, the largest numbers of deaths in individuals with mental disorders and those without mental disorders were due to heart disease and neoplasms, but there was a striking difference in age at death between the groups. For people in the general population without mental disorders, there was a sharp increase in death after the age of 80 years; however, for people with mental disorders, especially men, mortality occurred earlier and became more common steadily through middle age. Like other epidemiological studies of this kind, the investigation has some limitations. The lack of individual data relating to factors such as cigarette smoking, obesity, physical exercise, psychiatric symptom severity, and immune markers precluded determination of the role of these factors in mortality outcomes. Cigarette smoking is likely to be an important factor in view of the large number of years life lost due to respiratory illness, accounting for 20% of the excess years life lost among women and 8% among men with mental disorders. Additionally, smoking probably contributed to excess mortality from heart disease and some cancers. We know that people with mental disorders are much more likely to be smokers; previous studies, albeit with smaller samples sizes than in this Danish cohort, have reported a strong
www.thelancet.com/psychiatry Vol 4 December 2017
and independent effect of smoking on mortality in individuals with schizophrenia.5 What are the next steps in this important body of research? It would be informative to know more about the excess mortality in specific populations of people with mental disorders. By studying people with mental disorders as one group, it is hard to develop and prioritise actions for particular subgroups, for example, those with schizophrenia, eating disorders, or substance abuse, all of which might be assumed to have different patterns of premature mortality. Also important for the research agenda are studies that will better identify the proximate causes of early death in people with mental disorders (tobacco use being just one) and then help guide the development of interventions to address those causes that are modifiable. As noted in a recent report prepared in collaboration with the WHO,6 there is no one solution; achieving health equity for people with mental disorders will require actions at the level of the individual patient, the health system, and public policy. Faith Dickerson Stanley Research Program, Sheppard Pratt Health System, Baltimore MD 21204, USA [email protected] I declare no competing interests. 1
2 3 4 5 6
Erlangsen A, Kragh Andersen P, Toender A, Munk Laursen T, Nordentoft M, Canudas-Romo V. Cause-specific life years lost in people with mental disorders: a nationwide, register-based cohort study. Lancet Psychiatry 2017; published online Nov 6. http://dx.doi.org/10.1016/ S2215-0366(17)30429-7. Hayes JF, Marston L, Walters K, King MB, Osborn DPJ. Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000–2014. Br J Psychiatry 2017; 211: 175–81. Olfson M, Gerhard T, Huang C, Crystal S, Stroup TS. Premature mortality among adults with schizophrenia in the United States. JAMA Psychiatry 2015; 72: 1172–81. Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry 2015; 72: 334–41. Dickerson F, Origoni A, Schroeder J, et al. Mortality in schizophrenia and bipolar disorder: Clinical and serological predictors. Schizophrenia Res 2016; 170: 177–83. Liu NH, Daumit GL, Dua T, et al. Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas. World Psychiatry 2017; 16: 30–40.
893
acceptance of psychotic experiences. Although they state that the aim of the study was not to characterise a general population sample with psychotic experiences, but to compare individuals with poor and good outcomes of their psychotic experiences, the clinical relevance of their findings will depend, at least in part, on the transferability of characteristics and practices from one group to another. Research has highlighted the importance of understanding beliefs about anomalous experiences within the context of individuals’ spiritual beliefs,8,9 and shown that appraisal is not simply an in-the-moment assessment, but can develop over time through socially meaningful practices of cultivation, which in turn might shape phenomenology. Comprehensive understanding of these experiences is unlikely to be reached through the methods and measures of psychiatry alone and, therefore, future studies could fruitfully engage concepts and modes of inquiry indigenous to these groups8 and to the many other disciplines engaged in the study of human experience.10 Improved understanding of the relevance of spiritual context in the appraisal of psychotic experiences in nonclinical cohorts has the strong potential to enhance understanding of the importance of context in the ways individuals make sense of psychotic experiences more generally.
*Angela Woods, Sam Wilkinson Centre for Medical Humanities and Department of English Studies, University of Durham, Durham DH1 4SZ, UK (AW) and School of Philosophy, Psychology and Language Sciences, University of Edinburgh, Edinburgh, UK (SW) [email protected] We declare no competing interests. Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Alderson-Day B, Lima CF, Evans S, et al. Distinct processing of ambiguous speech in people with non-clinical auditory verbal hallucinations. Brain 2017; 140: 2475–89. 2 Kråkvik B, Larøi F, Kalhovde AM, et al. Prevalence of auditory verbal hallucinations in a general population: a group comparison study. Scand J Psychol 2015; 56: 508–15. 3 Johns LC, Kompus K, Connell M, et al. Auditory verbal hallucinations in persons with and without a need for care. Schizophr Bull 2014; 40 (suppl 4): S255–64. 4 Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a ‘need for care’. World Psychiatry 2016; 15: 41–52. 5 Peters E, Ward T, Jackson M, Woodruff P, Morgan C, McGuire P, Garety PA. Clinical relevance of appraisals of persistent psychotic experiences in people with and without need for care: and experimental study. Lancet Psychiatry 2017; 4: 927–36. 6 Fletcher PC, Frith CD. Perceiving is believing: a Bayesian approach to explaining the positive symptoms of schizophrenia. Nat Rev Neurosci 2008; 10: 48–58. 7 Ratcliffe M. Feelings of being: phenomenology, psychiatry and the sense of reality. Oxford: Oxford University Press, 2008: 324. 8 Luhrmann TM. When God talks back: understanding the American evangelical relationship with God. New York, NY: Vintage Books, 2012. 9 Powers AR, Kelley MS, Corlett PR. Varieties of voice-hearing: psychics and the psychosis continuum. Schizophr Bull 2017; 43: 84–98. 10 Woods A, Jones N, Bernini M, et al. Interdisciplinary approaches to the phenomenology of auditory verbal hallucinations. Schizophr Bull 2014; 40 (suppl 4): 246–54. 1
Voisin/Phanie/Science Photo Library
Long way to go to close the mortality gap
Published Online November 6, 2017 http://dx.doi.org/10.1016/ S2215-0366(17)30428-5 See Articles page 937
892
The premature mortality of people with mental disorders is well established, but achieving an understanding of this problem has proved difficult. Drawing on the remarkable Danish case register system, Erlangsen and colleagues1 report on the excess mortality of people with mental disorders in Denmark over a 20 year period, from 1995 to 2014. In their study, people with mental disorders were defined as all people who had been diagnosed with a mental disorder during psychiatric hospitalisation or outpatient treatment. The size of the sample (more than 6 million individuals who contributed more than 89 million person-years) and the use of sophisticated statistical methods enabled the investigators to assess differences between people with mental disorders and those without mental disorders in terms of specific causes of
mortality as well as changes in the causes of mortality over time. The investigators employed an innovative measure to compare mortality between the two groups, the number of excess life years lost, a metric that takes into account life expectancy at the age of diagnosis. They noted that mortality decreased in both those with and without mental disorders over the time period of the study but without any narrowing of the large mortality gap between the two groups. This study adds to results of other studies from around the world in documenting the continuing premature mortality in persons with mental disorders.2–4 The study was done in a country with an excellent and accessible public health-care system, suggesting that the availability of medical care is not, by itself, sufficient to prevent excess mortality. www.thelancet.com/psychiatry Vol 4 December 2017
Comment
The study by Erlangsen and colleagues also provides information about differences in causes of death in men and women with and without mental disorders. Among men with mental disorders, death from alcohol misuse, accidents, and suicide were the major contributors to the 10·2 excess years life lost. Among women with mental disorders, respiratory diseases were the leading cause of death contributing to the overall 7·3 years of excess years life lost, along with alcohol misuse, heart disease, and suicide. Over the last 5 years of the study period, more of the excess life years lost were due to natural than to unnatural causes for both men and women with mental disorders compared with the first 5 years, but the overall pattern of excess mortality remained the same. Looking at the absolute number of deaths, the largest numbers of deaths in individuals with mental disorders and those without mental disorders were due to heart disease and neoplasms, but there was a striking difference in age at death between the groups. For people in the general population without mental disorders, there was a sharp increase in death after the age of 80 years; however, for people with mental disorders, especially men, mortality occurred earlier and became more common steadily through middle age. Like other epidemiological studies of this kind, the investigation has some limitations. The lack of individual data relating to factors such as cigarette smoking, obesity, physical exercise, psychiatric symptom severity, and immune markers precluded determination of the role of these factors in mortality outcomes. Cigarette smoking is likely to be an important factor in view of the large number of years life lost due to respiratory illness, accounting for 20% of the excess years life lost among women and 8% among men with mental disorders. Additionally, smoking probably contributed to excess mortality from heart disease and some cancers. We know that people with mental disorders are much more likely to be smokers; previous studies, albeit with smaller samples sizes than in this Danish cohort, have reported a strong
www.thelancet.com/psychiatry Vol 4 December 2017
and independent effect of smoking on mortality in individuals with schizophrenia.5 What are the next steps in this important body of research? It would be informative to know more about the excess mortality in specific populations of people with mental disorders. By studying people with mental disorders as one group, it is hard to develop and prioritise actions for particular subgroups, for example, those with schizophrenia, eating disorders, or substance abuse, all of which might be assumed to have different patterns of premature mortality. Also important for the research agenda are studies that will better identify the proximate causes of early death in people with mental disorders (tobacco use being just one) and then help guide the development of interventions to address those causes that are modifiable. As noted in a recent report prepared in collaboration with the WHO,6 there is no one solution; achieving health equity for people with mental disorders will require actions at the level of the individual patient, the health system, and public policy. Faith Dickerson Stanley Research Program, Sheppard Pratt Health System, Baltimore MD 21204, USA [email protected] I declare no competing interests. 1
2 3 4 5 6
Erlangsen A, Kragh Andersen P, Toender A, Munk Laursen T, Nordentoft M, Canudas-Romo V. Cause-specific life years lost in people with mental disorders: a nationwide, register-based cohort study. Lancet Psychiatry 2017; published online Nov 6. http://dx.doi.org/10.1016/ S2215-0366(17)30429-7. Hayes JF, Marston L, Walters K, King MB, Osborn DPJ. Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000–2014. Br J Psychiatry 2017; 211: 175–81. Olfson M, Gerhard T, Huang C, Crystal S, Stroup TS. Premature mortality among adults with schizophrenia in the United States. JAMA Psychiatry 2015; 72: 1172–81. Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry 2015; 72: 334–41. Dickerson F, Origoni A, Schroeder J, et al. Mortality in schizophrenia and bipolar disorder: Clinical and serological predictors. Schizophrenia Res 2016; 170: 177–83. Liu NH, Daumit GL, Dua T, et al. Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas. World Psychiatry 2017; 16: 30–40.
893