Co-Morbid Psychiatric and Medical Disorders: Challenges and Strategies

Article excerpt

A very troubling health care disparity exists among persons with serious mental illness (SMI). Even among those receiving regular psychiatric care, many individuals experience co-occurring medical conditions that go unidentified and/or untreated, significantly shortening their life spans. About 15 years ago, it was established that 60 percent of individuals with mental illness develop serious medical co-morbidities that result in a lost life span of 15 to 20 years compared to the general population (Berren, Hill, Merkile, Gonzalez, & Santiago, 1994). Recently, even more alarming evidence indicates the risk for lost years of life has accelerated to 25 years earlier than the general population (Parks, Svendesen, Singer, Foti, & Mauer, 2006). Gill (2008) commented:

   What does it mean that the life expectancy of
   persons with serious mental illness in the
   United States is now shortening in the context
   of longer life expectancy among others in our
   society? It is evidence of the gravest form of
   disparity and discrimination. (p.7)

Rates of circulatory disease, metabolic conditions including diabetes, obesity, hyperlipidemia (elevation of lipids in the bloodstream), osteoporosis, chronic pulmonary disease, HIV-related illnesses, polydipsia (excessive thirst and water drinking), and epilepsy are found to be consistently elevated in individuals with psychiatric illness (Green, Canuso, Brenner, & Wojcik, 2003; Jeste, Gladsjo, Linamer, & Lacro, 1996; Lambert, Velakoulis, & Panelis, 2003). Among the most common medical co-morbidities is the set of disorders known as metabolic syndrome, which increases an individual's risk for diabetes mellitus and coronary heart disease (Kelly, Boggs, & Conley, 2007). These symptoms include abdominal obesity (increased waist circumference), elevated triglycerides, elevated high density lipoprotein cholesterol, hypertension, and elevated fasting glucose (Grundy et al., 2005, as cited in Kelly et al., 2007). This medical co-morbidity, in combination with the vast health care disparities and service fragmentation among the mental health and medical service delivery systems, are associated with increased barriers to goal attainment, significantly reduced quality of life, and early mortality.

Early Mortality due to High Co-morbidity of Medical Conditions

According to the National Association of State Mental Health Program Directors, a multi-state mortality study revealed that the average years of life lost for people with mental illness were 25.2 (range = 13.5--29.3 in different states) and the average age at death was 56.8 (range = 48.9--76.7; Parks et al., 2006). Among individuals with schizophrenia, suicide and injury accounted for 30-40% of early deaths, but 60 % of early mortality was due to so called "natural causes" including cardiovascular disease, diabetes, respiratory diseases, and infectious diseases. In this group, individuals die from cardiovascular disease at more than double the rate of the general population and about triple the rate for diabetes, respiratory diseases, and infectious diseases (Parks et al.).

Among the general population in the United States, approximately 22% of adults have the metabolic syndrome. In comparison, among people with SMI the prevalence rate of the metabolic syndrome ranges from 30% to 60%. In one large study, the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), 43% of the subjects enrolled had the metabolic syndrome, and of this group up to 83% received little or no treatment for this condition (Kelly et al., 2007). The authors report:

   The metabolic syndrome has been found to be
   an independent predictor of all-cause mortality.
   Although each of the individual components
   may be a risk factor for cardiovascular
   morbidity, the existence of several of these
   abnormalities together poses a risk that may be
   synergistic. …