Public Health Hotline

“People with serious mental illness (SMI) die, on average, 25 years earlier than the general population.”¹ That's the attention-grabbing first sentence of a report entitled “Morbidity and Mortality in People with Serious Mental Illness,” published in October 2006 by the National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. It is one of the largest health disparities in the country. The report received national attention.

An earlier study showing this large health disparity had been published by the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration (SAMHSA),² and was based on mortality data reported by 16 states from 1997–2000. As an example, for the year 2000, the Years of Potential Life Lost reported in 4 of those states (Arizona, Missouri, Rhode Island, and Virginia) averaged 24.5 years. Additional studies in other states, including Massachusetts, Ohio, and Maine confirmed similar findings.¹ As the average life expectancy in the United States in the year 2000 was 77 years, and people with severe mental illness were dying on average at about age 52, the disparity was significant.

These findings were so noteworthy that the popular literature picked up the story, with articles appearing in USA Today³ and Time Magazine.⁴

After the report was released, the State of Hawai‘i Department of Health (DOH), Adult Mental Health Division (AMHD), conducted an internal study to compare the mortality data of Hawai‘i's population of individuals with severe mental illness who were receiving services from AMHD to the national data published by NASMHPD. The AMHD Performance Improvement Office and the Quality Review Committee examined data reported to AMHD about the deaths of consumers receiving services in Fiscal Year 2006 (FY 2006), covering the period from July 1, 2005 to June 30, 2006.⁵ The goal was to identify any patterns, opportunities for improvement, and opportunities for improved collaboration with medical providers.

During FY 2006, there were 103 deaths reported among the 12,569 individuals served by AMHD. Hawai‘i's population was 1,275,194, and there were 9,330 deaths reported for the state. The average age of death for the 103 AMHD consumers who died that year was 52.8 years. That year, according to Health Trends in Hawai‘i,⁶ the average life expectancy in Hawai‘i was 80 years. For Hawai‘i, the average Years of Potential Life Lost (YPLL) in FY 2006 was 27.2 years, slightly higher than the national average (the calculation of YPLL is the sum of (life expectancy - age at death) of those who died, divided by the number of deceased individuals). Additionally, the number of deaths per 1,000 population in Hawai‘i for FY 2006 was obtained from the Department of Health Office of Health Statistics Monitoring (OHSM), and compared to the number of deaths per 1,000 population of consumers served by AMHD, to give a death rate by age. The ages of each death in Hawai‘i for FY 2006 was not obtained, but the number of deaths for 4 adult age groups was available (age groups 18–34, 35–44, 45–64, and >65); see Table 1. The death rates for each of the age groups among adults in Hawai‘i compared to those of AMHD consumers shows a significantly increased death rate for each age group in the AMHD population.

Table 1.

AMHD Deaths per 1,000 by Age Group (Source: DOH OHSM Vital Statistics & AMHD Performance Improvement Office data on file)

Age group	Hawai‘i OHSM Vital Statistics			AMHD
	Hawai‘i Deaths	Hawai‘i 2000 census population	Hawai‘i Deaths / 1000 population	AMHD Deaths	AMHD consumer population	AMHD Deaths / 1000 population
18 to 34	209	254,568	.82	11	2,513	4.38
35–44	299	191,177	1.56	14	2,610	5.36
45–64	1767	277,940	6.36	58	4,134	14.03
>65	2437	160,601	15.17	20	878	22.78

In FY 2006, AMHD was able to obtain the death certificate or autopsy results for 40 of the 103 individuals receiving services who died that year. In cases in which autopsy results or a death certificate were not available, the underlying cause of death was classified by AMHD Performance Improvement Office based on the report submitted by the provider of services to the consumer. The causes of death for the 40 consumers for whom AMHD received information are shown in Table 2.

Table 2.

Cause of Death, AMHD, FY 2006 (Source: AMHD Performance Improvement Office data on file)

Cause of Death	Autopsy/Death Certificate Received	Autopsy/Death Certificate not Received	Total
	N	N
Accidental Death	7	6	13
Medical Death	21	41	62
Suicide	5	4	9
Unknown Cause	7	12	19
Totals	40	63	103

Of the 21 Medical Deaths for which AMHD was able to obtain autopsy results or a death certificate, cardiovascular disease was identified as the cause in 76% of the cases (Table 3).

Table 3.

Medical Causes of Death, AMHD, FY 2006, per autopsy or death certificate received (Source: AMHD Performance Improvement Office data on file)

Cause of Death	Number of Deaths	Percentage of deaths in AMHD population due to medical causes
Cardiovascular Disease/Cardiac Arrest	16	76%
Pulmonary Disease	1	5%
Carcinoma	1	5%
Infectious Disease	1	5%
Alcohol Dependence	1	5%
Undetermined	1	5%

According to the Centers for Disease Control,⁷ Cardiovascular Disease is the cause of approximately 25% of the deaths in the United States. The AMHD data shows that cardiovascular disease or cardiac arrest was the cause of 40% (16 of 40) of AMHD consumer deaths in which an autopsy or death certificate was received. This rate is 60% higher rate than the national average.

There is no simple resolution to this disparity. As in much of behavioral health, multiple factors are involved. The NASMHPD Morbidity and Mortality report stated, after factoring out the role of suicide in decreased life expectancy, “people with serious mental disorders are dying from similar causes as found in the general population and their standardized mortality rates are higher than those of the general public”.

These increased death rates among those with severe mental illness are thought to be associated with general modifiable risk factors as well as some that are specifically associated with psychiatric conditions. The general modifiable factors associated with a higher rate of death in consumers with severe mental illness include:

• Smoking

• Alcohol and drug use

• Poor nutrition and obesity

• Lack of exercise

• Unsafe sexual practices

• Homelessness

• Poverty/unemployment

• Victimization/trauma

• Incarceration

• Lack of access to medical and social services

The increased risk factors more specifically associated with mental illness include:

• Impaired reality testing

• Disorganized thought processes

• Paranoia

• Impaired communication skills

• Impulsive behavior

The significance of the phenomenon of increased mortality of individuals with severe mental illness is intuitive as well as supported by data. Our public health challenge is to make a meaningful impact on the problem! DOH and AMHD have implemented a number of initiatives and programs designed to improve the quality and quantity of life for those we serve.

Director of Health Loretta J. Fuddy has created a Department of Health Strategic Plan, FY 2011–2014,⁸ which includes “The Five Foundations for Healthy Generations,” serving as guiding principles at the DOH for planning and providing services for a healthier Hawai‘i. The Foundations include:

• Foundation 1: Health Equity

  • Goal: “Eliminate disparities and improve the health of all groups throughout Hawai‘i”

  • Objective 1-1: “Ensure integration of behavioral health with primary care.”

• Foundation 2: Health Promotion and Disease Prevention

  • Goal: “Attain lifelong quality health free from preventable disease, avoidable disability, and premature death”

  • Objective 2-2: “Increase promotion of healthy choices and behaviors.”

With the Foundations for Healthy Generations, the DOH has established as a priority the coordination of planning and programs to achieve the long term goal of eliminating disparities and improving the health of all groups in Hawai‘i.

DOH has applied for a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), called the Primary Behavioral Health Care Integration Grant, the main objective of which is to develop and implement a health home within state operated Community Mental Health Centers (CMHCs). These health homes will provide integrated primary care and behavioral health services to adults with severe and persistent mental illness. The grant proposal is for primary care providers to be deployed into a CMHC to create a health home in the same place where consumers receive their mental health services.

The AMHD CMHC system, which is comprised of a statewide network of centers providing outpatient services to those with severe and persistent mental illness, offers many programs to improve wellness and decrease morbidity. CMHC patients are routinely monitored for height, weight, Body Mass Index, blood sugar and cholesterol levels, blood pressure, heart rate, and lifestyle habits. Health services provided through the centers include smoking cessation programs, nutrition and exercise counseling, and wellness programs. Case managers and nursing staff at the CMHCs provide liaison services with primary care providers. At the rehabilitation programs provided at the CMHCs, known as Clubhouses, wellness supports and services (including exercise classes, healthy meal planning, and health education) were provided to 631 consumers in 2011. Smoking cessation programs are now being implemented.

The Hawai‘i State Hospital (HSH) has a Medical Services Unit which is staffed by two full time internists and one advanced practice registered nurse. Patients at the HSH receive primary and specialty care services, along with immunizations, vaccinations, tuberculosis testing, nutritional counseling, exercise programs, and screening and monitoring for common medical conditions. Prior to discharge, each patient receives referral and linkage to both physical and mental health providers through collaboration with the patient's health plans and community providers.

In addition to the State's efforts, every health care professional in Hawai‘i may participate in reaching the public health goal of eliminating the disparity in life span for those with severe mental illness. The 2006 NASMHPD report described a number of recommendations for community providers. They include:

• Adopt as a practice policy that mental health and physical healthcare should be integrated.

• Implement care coordination between mental health and physical health providers.

• Help consumers of healthcare services understand that improved health is possible, so as to enable their engagement as partners in care and treatment.

• Support wellness and empowerment in persons served, to improve health choices and mental and physical well-being.

• Ensure the provision of quality, evidence-based physical and mental health care.

• Ask about smoking status and offer smoking cessation counseling.

• Implement standards of care for prevention, screening and treatment of lifestyle related conditions.

The significant decrease in the life expectancy of those individuals in Hawai‘i who have severe and persistent mental illness compared to the general population is striking. It is consistent with the trend in the rest of the country. The causes of this disparity are significantly related modifiable lifestyle factors. The systems, providers, and consumers of healthcare services, working together, can make a significant impact to improve this disparity. Abraham Lincoln said, “… in the end it is not the years in your life that count; it's the life in your years.” With our commitment to include health and wellbeing as an integral part of every level of health care, both the quantity and quality of life can be improved for our consumers.

Conflict of Interest

The author reports no conflict of interest.