Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2022 Jan 19.
Published in final edited form as: Perspect Psychol Sci. 2021 Jul 15;17(1):183–190. doi: 10.1177/1745691621990613

Social Processes Associated with Health and Health Behaviors Linked to Early Mortality in People with a Diagnosis of a Serious

Karen L Fortuna 1, Ashley Williams 2, George Mois 3, Kendra Jason 4, Cynthia L Bianco 1
PMCID: PMC8760359  NIHMSID: NIHMS1661550  PMID: 34264159

Abstract

Individuals with serious mental illness (SMI) experience a 10–25 year reduced life expectancy compared to the general population. Early mortality for people with SMI has mainly been attributed to unhealthy behaviors (e.g., poor diet, sedentary lifestyle), which has led to the development of health promotion and self-management interventions specifically for people with SMI to promote health behavior change. Yet, after decades of research, the mortality gap between those with SMI and the general population is increasing. To address this early mortality disparity for individuals with SMI, a new paradigm must be explored. This report presents Social Processes Impacting Early Mortality in People with SMI paradigm, highlighting the powerful role of social processes in shaping the health and health behaviors of people with SMI. This paradigm explores how loneliness, stigma (social and self), trauma, social exclusion, social isolation, and social norms are related to early mortality in people with SMI. The Social Processes Impacting Early Mortality in People with SMI paradigm is an important step in understanding, and potentially, addressing early mortality in people with SMI.

Keywords: Serious mental illness, health disparities, early mortality

Introduction

Individuals with serious mental illness (SMI) have a reduced life expectancy of approximately 10 to 25 years compared to the general population (DE Hert et al., 2011). SMI is defined as individuals with a diagnosis of schizophrenia spectrum disorder, bipolar disorder, and persistent major depressive disorder. All of which are marked by significant functional impairments that impact their ability to carry out basic functions in their daily lives due to mental health conditions such as steady employment, paying bills, etc.

Poor health behaviors related to diet and activity patterns is the most prominent contributor to preventable early mortality in the United States (McGinnis & Foege, 1993). Following this assertion the early mortality gap in people with SMI is due, in part, to unhealthy behaviors such as poor diet, sedentary lifestyle, alcohol consumption, and cigarette smoking (Firth, 2019; Liu et al., 2017; Mauer, 2006). These ideas led to the development of health promotion and self-management interventions designed for people SMI to promote health behavior change (Naslund et al.; Whiteman, Naslund, DiNapoli, Bruce, & Bartels, 2016) through addressing modifiable risk factors (Firth, 2019). Yet, after decades of research, the mortality gap between those with SMI and the general population is increasing (Walker, McGee, & Druss, 2015). To address this health disparity, a new paradigm must be explored. This report seeks to fill the critical knowledge gap connecting social processes, health behavior, and early mortality for those with SMI. Social processes are patterns of observable or repetitive patterns social contact and social interactions between individuals and groups (Bardis, 1979).

Limited knowledge exists on multiple, interconnected, and overlapping social processes on early mortality among people with SMI. The seminal study by McGinnis and Foege (1993) found the actual causes of death in the United States were predominately due to poor health behaviors in the general population. Historically, these findings have been generalized to people with SMI, yet people with SMI were excluded from the original study--thus limiting the external validity of these findings to people with SMI. Further, due to data limitations, McGinnis and Foege (1993) were unable to examine the effect of social processes such as the impact of trauma and loneliness on individuals’ mortality. Thus, generalizing these results to people with SMI may explain why interventions aimed at changing health behaviors have not addressed the early mortality gap.

We expand on existing models that aim to address early mortality in people with SMI through health behavior change (Firth, 2019 et al., 2019; (Liu et al., 2017) and present the powerful role of social processes in shaping health and health behavior in people with SMI. This model provides a way to delineate the associations between social processes and anticipate potential unexplored direct and mediated effects of health and health behavior in people with SMI as related to early mortality and provides a new paradigm to evaluate the role of the social processes on early mortality.

Model Overview and Assumptions

We delineate the many different forms of social processes into established categories of social processes, including (1) intrapersonal; (2) person-to-person; (3) person-to-group or group-to-person; and (4) group-to-group (Bardis, 1979). Intrapersonal represents the individual, person to person represents interactions between people, person to group or group to person represents institutions, and the group to group represents society at-large—the individual is at the center while the (1) intrapersonal; (2) person-to-person; (3) person-to-group or group-to-person; and (4) group-to-group have overlapping influence with one another (Bardis, 1979). The proposed model entitled, Social Processes Impacting Early Mortality in People with SMI, includes the impact of social processes on individuals’ biology, psychology, and health behaviors related to early mortality (see Figure 1).

Figure 1.

Figure 1.

Open in a new tab

A Multi-level Framework of the Social Processes Impacting Early Mortality in People with SMI

Social Processes Impacting Early Mortality in People with SMI

Intrapersonal (Individual)

The intrapersonal level refers to the interactions between the parts of the personality (i.e., the relationship between the self and others) (Bardis, 1979; Hopwood, Wright, Ansell, & Pincus, 2013). Compared to the general population, a person with SMI has a disposition towards higher levels of feelings of loneliness and intrapersonal self-stigma—both of which are independently associated with morbidity and early mortality (Ong, Rothstein, & Uchino, 2011; Tremeau, Antonius, Malaspina, Goff, & Javitt, 2016). Here, we discuss each in detail.

Loneliness.

People with SMI experience 2.3x higher rates of loneliness compared to the general population (Badcock et al., 2015; Stain et al., 2012). Loneliness is an emotional response of an individual, in which people believe their social connections are not aligned with their need for a sense of belonging (Ernst & Cacioppo, 1999). Loneliness is an often unrecognized dimension of health that has serious implications for cardiovascular health and mortality (Ong, Rothstein, & Uchino, 2011).

The connection between loneliness and disease is well established. Loneliness increases stress hormones (Adam, Hawkley, Kudielka, & Cacioppo, 2006), which are linked to increased cancer risk (Fox, Harper, Hyner, & Lyle, 1994), cardiovascular disease (Hawkley & Cacioppo, 2003; Tomaka, Thompson, & Palacios, 2006), stroke (Tomaka et al., 2006), affective disorders, drug or alcohol abuse, respiratory disease (Tomaka et al., 2006), sleep disorders (Cacioppo et al., 2002), diabetes, (Tomaka et al., 2006), late-life dementia (Wilson et al., 2007), arthritis (Tomaka et al., 2006), anxiety and depression (Heinrich & Gullone, 2006; Singh & Misra, 2009), suicide (Heinrich & Gullone, 2006; Stravynski & Boyer, 2001) — all of which are associated with mortality in adults (House, Landis, & Umberson, 1988). Among people with SMI, loneliness is associated with similar health effects compared to the general population (Sündermann, Onwumere, Kane, Morgan, & Kuipers, 2014; Trémeau, Antonius, Malaspina, Goff, & Javitt, 2016). For people with SMI, higher levels of loneliness encourage a decrease in engaging in healthy behaviors such as diet and exercise (Eglit, Palmer, Martin, Tu, & Jeste, 2018).

Person-to-Person

The person-to-person level refers to interactions among individuals. This includes an individual’s immediate space and the social norms that may directly impact daily life. Examples of person-to-person level influences on the individual includes friends, family, therapists/clinicians (Bardis, 1979). This level is composed of positive social influences (e.g., people that help monitor changes in an individual’s health and promote a healthy lifestyle), as well as negative influences (e.g., people that pressure individuals to engage high risk health behaviors such as illicit drug use or smoking). Compared to the general population, a person with SMI has a disposition towards higher levels of trauma and negative social norms, which is independently associated with morbidity and early mortality (Ong, Rothstein, & Uchino, 2011; Tremeau et al., 2016). We discuss each in detail below.

Trauma.

Prevalence rates of trauma are significantly higher in people with SMI than in the general population (Mauritz, Goossens, Draijer, & van Achterberg, 2013). The accumulation of traumatic events contributes to poor physical, emotional, and mental health (Campbell, Walker, & Egede, 2015; Felitti et al.). Adverse childhood experiences (ACEs) are an established risk factor for early mortality (Tremeau et al., 2016). Adverse experiences in childhood can be the result of dysfunctional household environments, as well as physical, emotional, and/or sexual abuse (Campbell et al., 2015; Felitti et al.). Negative events experienced in childhood influence health throughout the lifespan. For example, when individuals have had contact with multiple ACEs then they are at an increased risk for alcoholism, drug use and abuse, depression, suicidal ideation, smoking, and obesity (Tremeau et al., 2016)—these health risks combined, may result in disability and early mortality (Kelly-Irving et al., 2013).

Social norms.

Social norms are defined as the standards against which the appropriateness of a certain behavior is assessed (Bettenhausen & Murnighan, 1985; Emmons, Barbeau, Gutheil, Stryker, & Stoddard, 2007). Social norms have a powerful role on health behaviors. Positive relationships can contribute to a greater meaning in life, as well as encourage an individual to maintain a healthy lifestyle (Uchino, 2006). For example, social norms around smoking behaviors are a strong indicator on smoking cessation. However, the opposite is true as well, individuals with SMI find it difficult to quit smoking if smoking is an acceptable behavior in their current environment (Aschbrenner et al., 2017).

Person-to-Group or Group-to-Person

The person-to-group or group-to-person level includes the community and institutions in which the individual resides and interacts with others. Possible communities and/or institutions can be schools, neighbors, sports teams, group homes, tent cities, peer support groups, churches, health agencies, places of employment, or even virtual communities such as Facebook and Twitter. Both interpersonal levels and person-to-person levels influence the person-to-group or group-to-person level. For example, being involved in a peer support group could result in a stronger social support system—all of which may result in strong sense of belonging within a community or institution. Compared to the general population, people with SMI have a disposition towards a higher prevalence of perceived social exclusion and social isolation (Abiri, Oakley, Hitchcock, & Hall, 2016). Both of which are independently associated with morbidity (Liu et al., 2017) and early mortality (Holt-Lunstad, 2018).

Perceived social exclusion.

While feelings of loneliness occur when people believe their social connections are not aligned with their need for a sense of belonging (Ernst & Cacioppo, 1999), perceived social exclusion is the feeling that one does not belong (Wenger, Davies, Shahtahmasebi, & Scott, 1996). People with SMI experience significantly higher rates of perceived social exclusion than the general population (Badcock et al., 2015; Gardner et al., 2019; Richter & Hoffmann, 2019). Social relationships are paramount to human survival (Liu et al., 2017). Evolutionarily, social inclusion is necessary in order to secure food, water, shelter, safety—simply put, social inclusion is necessary for individual subsistence (Berstein, 2016). In modern society, social inclusion continues to be a component of both physical and mental health (Berstein, 2016). Social exclusion can lead to increased levels of inflammation, weight, and risk for hypertension (Liu et al., 2017)—all risk factors for early mortality (Holt-Lunstad, 2018).

Social isolation.

People with SMI experience higher rates of social isolation than the general population (Linz & Sturm, 2013), and this increases with age (Cummings & Kropf, 2011). Social isolation is a significant risk factor for all-cause mortality and mortality associated with cardiovascular disease in the general population (Liu et al., 2017). Social isolation can activate the hypothalamic-pituitary-adrenal axis and cause inflammation, which if left unresolved, may subsequently lead to deterioration of brain structures and functions (Liu et al., 2017). Neuroinflammation and pro-inflammatory biomarkers have been identified in adults with SMI (Liu et al., 2017). Disease and early mortality is attributed to biological and biochemical mechanisms such as oxidative stress, inflammation, and shortening of telomeres (Wolkowitz, 2018). Telomere length has been an established indicator of biological aging (Liu et al., 2017). Telomeres are DNA-protein complexes that cap the ends of chromosomes and protect them from damage. With each cell division, telomeres are shortened and eventually reach a critically short length resulting in replicative senescence (the cell is unable to divide) or the cell becomes genomically unstable.

Group-to-Group (Society)

The group-to-group level is the outer most level that encompasses the individual and the other levels. This is considered the society-at-large. It could be considered the most influential level because it can implicitly and explicitly impact an individual’s life, beliefs, values, and everyday practices. Group-to-group factors include cultural ideals, political ideologies, economical practices, and public policies (Berger, 2016). These factors impact people’s lives and shape the actions that others have towards them. Compared to the general population, a person with SMI has an increased disposition to experience stigma, discrimination, and prejudice (Corigan & Watson, 2002; Farrelly et al., 2014; Mashiach-Eizenberg et al., 2013; Nemec, Swarbrick, & Legere, 2015).

Stigma, discrimination, and prejudice.

People with SMI experience elevated rates of stigma, discrimination, and prejudice than the general population (Abiri et al., 2016; Ahmedani, 2011; Farrelly et al., 2014). Stigma can be categorized into three separate manifestations: intrapersonal, interpersonal, and structural (Knaack et al., 2017).

Intrapersonal self-stigma.

People with SMI experience higher rates of self-stigma than the general population reporting lower self-esteem, feelings of shame, and lower sense of meaning in life (Corrigan & Rao, 2012; Mashiach–Eizenberg, Hasson-Ohayon, Yanos, Lysaker, & Roe, 2013). Self-stigma is the belief that individuals possess the negative traits that society has labeled them with (Corrigan & Watson, 2002). Self-stigma can produce low self-esteem, which can make it difficult to seek healthcare (Knaack, Mantler, & Szeto, 2017). Yet, lack of healthcare only accounts for 10–15% of preventable mortality (McGinnis & Foege, 1993).

Intrapersonal self-stigma is also related to biological mechanisms leading to disease. Stigma can have detrimental effects on mental health and physical health of any individual (Seeman, 2019). Experiencing stigma can be a source of stress. Stress activates the HPA axis which invokes a pro-inflammatory response (Liu et al., 2017). Chronic stress in SMI can desensitize the immune-inflammation response, allowing for the less stressful stimuli needed to activate said response (Muller, 2018). As discussed previously, individuals with SMI show abnormalities of the immune-inflammation response pathway causing high levels of inflammation and contributing to early mortality.

For the group-to-group level, interpersonal and structural stigma can be viewed together as a type of discrimination and prejudice that is held by the general public. For example, people with SMI have been stereotyped as dangerous, incompetent, or weak. Therefore, people with SMI are often met with fear and antipathy, and this translates into others avoiding them and withholding employment, housing, and other forms of help (Corrigan & Watson, 2002). Structural stigma can also shape policies resulting in less resources, reduced care standards, and encourages organizational cultures (Knaack et al., 2017) to define SMI individuals by their illness (see Figure 2).

Figure 2.

Figure 2.

Open in a new tab

The Interconnected Relationships Across the Triad of Stigma Manifestations

The experience of discrimination by individuals with SMI can be described as any occurrence of unfair treatment due to a diagnosis of mental illness (Coffey, 2009; Farrelly et al., 2014). Discrimination can have tremendous implications for individuals’ ability to engage and participate in general activities of daily life. For example, experiencing discrimination can exacerbate feelings of discouragement to participate in activities such as work, education, engaging and developing relationships, and accessing healthcare resources (Thornicroft et al., 2009; Uçok et al., 2012). Experiencing discrimination furthermore impacts individuals overall reported health status. For example, individuals with SMI often report social withdrawal and poorer mental and physical health (Pascoe & Richman, 2009; Rose et al., 2011).

Prejudicial attitudes towards individuals with SMI can be described as any preconceived or incorrect attitude towards someone whom has received a diagnosis of mental illness (Stuart, 2016; Stuart et al., 2014). Prejudicial attitudes towards people with SMI can have significant implications for social acceptance across the intrapersonal, person-to-person, person-to-group or group-to-person, and group-to-group level of interactions. Prejudicial attitudes such as patronizing rhetoric, dehumanizing language, and condescending tone of voice are often accompanied by discriminatory actions towards individuals with SMI (Nemec et al., 2015). As the result of prejudicial attitudes, individuals with SMI may be prevented from accessing and receiving proper health services, experience worsening health conditions, result in feelings of rejection and fear, and perceived a diminished pursuit of opportunities for one’s life (Corrigan & Watson, 2002; Link, Struening, Rahav, Phelan, & Nuttbrock, 1997; Link, 1987)

Conclusion

The influences of social processes are relevant to everyone, but the consequential significance of social processes’ impact on the health, health behaviors, and lifespan of people with SMI has yet to be adequately explored. In this report, our goal was to develop a new paradigm for addressing early mortality in people with SMI that can augment existing paradigms (i.e., the Lancet Psychiatry Commission’s Blueprint for Protecting Physical Health in People with Mental Illness [Firth, 2019 et al., 2019]; A Multilevel model of Risk for Excess Mortality in Persons with Severe Mental Disorders (Liu et al., 2017). The Social Processes Impacting Early Mortality in People with SMI may advance basic, behavioral and social sciences research on under researched social processes. By doing so, we may further our understanding of fundamental patterns and interactions between environmental, behavioral, cultural, neurobiological, or biopsychosocial mechanisms on health and health behavior that are relevant to early mortality in people with SMI--potentially leading to next discovery in early mortality prevention, diagnosis, and/or treatment in people with SMI for the first time in history.

We first consider social processes, at the (1) intrapersonal; (2) person-to-person; (3) person-to-group or group-to-person; and (4) group-to-group levels, that people with SMI are embedded, and examine how these multiple and overlapping social processes influence, and are influenced by, each other. Our approach indicates that basic human social needs may be mechanisms of action on health behavior change (proximal), health (proximal), and early mortality in people with SMI (distal).

Human beings are complex and require interventions that address multiple dimensions of health simultaneously—not sole modifiable health behaviors. The majority of interventions have a single focus—either a medical, psychiatric, or social (Whiteman et al., 2016). Combined (1) intrapersonal; (2) person-to-person; (3) person-to-group or group-to-person; and (4) group-to-group level interventions can promote the development and maintenance of social processes that promote inclusion, acceptance, and sense of belonging (Fortuna, Brooks, Umucu, Walker, & Chow, 2019). Whole health interventions can more likely counteract the biological and psychological impact of loneliness, self-stigma, negative social norms, interpersonal trauma, social exclusion, social isolation, and societal stigma, discrimination, and prejudice.

Social processes have a powerful role in shaping health and health behaviors of people with SMI. To date, limited knowledge exists on the effect of social processes on early mortality among people with SMI. Thus, the state of the science is limited by data that examines associations between social processes and health and health behaviors of people with SMI, not causality in the context of social processes, SMI and health. As such, there is a need to explore mechanistic effects of social dimensions of health on early mortality in fully powered longitudinal studies. Subpopulation analysis can examine differences by SMI diagnosis (i.e., defined as individuals with a diagnosis of schizophrenia spectrum disorder, bipolar disorder, and persistent major depressive disorder) to examine the validity of this model transdiagnostically. The Social Processes Impacting Early Mortality in People with SMI model may offer guidance in beginning to examine the casual effects of social processes and lead to greater understanding of individual and interconnected factors that impact early mortality in people with SMI.

References

  1. Adam E, Hawkley L, Kudielka B, & Cacioppo J (2006). Day-to-day dynamics of experience—cortisol associations in a population-based sample of older adults. Proc Natl Acad Sci 103, 17058–17063. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Aschbrenner K, Naslund J, Gill L, Bartels S, O'Malley J, & Brunette M (2017). Preferences for smoking cessation support from family and friends among adults with serious mental illness. Psychiatric Quarterly, 88(4), 701–710. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Bardis P (1979). Social Interaction and Social Processes Social Science, 54(3), 147–167. [Google Scholar]
  4. Berger K (2016). Invitation to the life span. New York: NY, Worth [Google Scholar]
  5. Berstein MJ (2016). Research in social psychology: Consequences of short- and long-term social exclusion. In Riva P & Eck J (Eds.), Social exclusion: Psychological approaches ot understanding and reducing its impact (pp. 51–72). Cham, Switzerland: Springer; International. [Google Scholar]
  6. Bettenhausen K, & Murnighan J (1985). The emergence of norms in competitive decisionmaking groups.. Administrative Science Quarterly, 30(350–372). [Google Scholar]
  7. Cacioppo J, Hawkley L, Berntson G, Ernst J, Gibbs A, Stickgold R, & Hobson J (2002). Lonely days invade the night: Social modulation of sleep efficiency. Psychol. Sci, 13, 385–388. [DOI] [PubMed] [Google Scholar]
  8. Campbell J, Walker R, & Egede L (2015). Associations between adverse childhood experiences, high-risk behaviors, and morbidity in adulthood. American Journal of Preventative Medicine, 50(3), 344–352. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Corrigan P, & Watson A (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry, 1(1), 16–20. [PMC free article] [PubMed] [Google Scholar]
  10. DE Hert M, Correll C, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I, … Leucht S (2011). Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry, 10(1), 52–77. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Emmons K, Barbeau E, Gutheil C, Stryker J, & Stoddard A (2007). Social influences, social context, and health behaviors among working-class, multi-ethnic adults. Health, Educucation, and Behavior, 34(2), 315–334. [DOI] [PubMed] [Google Scholar]
  12. Ernst J, & Cacioppo J (1999). Lonely hearts: Psychological perspectives on loneliness. Applied & Preventive Psychology, 81, 1–22. [Google Scholar]
  13. Felitti V, Anda R, Nordenberg D, Williamson D, Spitz A, Edwards V, … Marks J (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study. American Journal of Preventative Medicine, 14(4), 245–258. [DOI] [PubMed] [Google Scholar]
  14. Firth J et al. (2019). The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. Lancet Psychiatry, 6(8), 675–712. [DOI] [PubMed] [Google Scholar]
  15. Fortuna K, Brooks J, Umucu E, Walker R, & Chow P (2019). Peer Support: a Human Factor to Enhance Engagement in Digital Health Behavior Change Interventions. Journal of Technology in Behavioral Science, 4(2), 152–161. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Fox C, Harper A, Hyner G, & Lyle R (1994). Loneliness, emotional repression, marital quality, and major life events in women who develop breast cancer. J. Commun. Health, 19, 467–482. [DOI] [PubMed] [Google Scholar]
  17. Hawkley L, & Cacioppo J (2003). Loneliness and pathways to disease. Brain Behav Immun, 1, S98–105. [DOI] [PubMed] [Google Scholar]
  18. Heinrich L, & Gullone E (2006). The clinical significance of loneliness: a literature review. Clin Psychol Rev(26). [DOI] [PubMed] [Google Scholar]
  19. Holt-Lunstad J (2018). Why Social Relationships Are Important for Physical Health: A Systems Approach to Understanding and Modifying Risk and Protection. Annu Rev Psychol, 69, 437–458. doi: 10.1146/annurev-psych-122216-011902 [DOI] [PubMed] [Google Scholar]
  20. Hopwood C, Wright A, Ansell E, & Pincus A (2013). The interpersonal core of personality pathology. Journal of personality disorders, 27(3), 270–295. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. House J, Landis K, & Umberson D (1988). Social relationships and health. Science, 241, 540–545. [DOI] [PubMed] [Google Scholar]
  22. Kelly-Irving M, Lepage B, Dedieu D, Bartley M, Blane D, Grosclaude P, & Delpierre C (2013). Adverse childhood experiences and premature all-cause mortality. European Journal of Epidemology, 28(9), 721–734. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Knaack S, Mantler E, & Szeto A (2017). Mental illness-related stigma in healthcare. Healthcare Management Forum, 30(2), 111–116. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Liu N, Daumit G, Dua T, Aquila R, Charlson F, Cuijpers P, … Saxena S (2017). Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas. World psychiatry: official journal of the World Psychiatric Association (WPA), 16(1), 30–40. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Mauer B (2006). Morbity and mortality in people with serious mental illness. Retrieved from Alexandria, VA: https://www.nasmhpd.org/sites/default/files/MortalityandMorbidityFinalReport8.18.08.pdf [Google Scholar]
  26. Mauritz M, Goossens P, Draijer N, & van Achterberg T (2013). Prevalence of interpersonal trauma exposure and trauma-related disorders in severe mental illness. European journal of psychotraumatology, 4(10). [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. McGinnis J, & Foege W (1993). Actual causes of death in the United States. JAMA, 270(18), 2207–2212. [PubMed] [Google Scholar]
  28. Muller N (2018). Inflammation in Schizophrenia: Pathogenetic Aspects and Therapeutic Considerations. Schizophr Bull, 44(5), 973–982. doi: 10.1093/schbul/sby024 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Naslund J, Whiteman K, McHugo G, Aschbrenner K, Marsch L, & Bartels S (2017). Lifestyle interventions for weight loss among overweight and obese adults with serious mental illness: A systematic review and meta-analysis. General Hospital Psychiatry, 47, 83–102. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Ong A, Rothstein J, & Uchino B (2011). Loneliness accentuates age differences in cardiovascular responses to social evaluative threat. Psychology and Aging, 27(1). [DOI] [PubMed] [Google Scholar]
  31. Seeman MV (2019). Schizophrenia Mortality: Barriers to Progress. Psychiatr Q. doi: 10.1007/s11126-019-09645-0 [DOI] [PubMed] [Google Scholar]
  32. Singh A, & Misra N (2009). Loneliness, depression and sociability in old age. Industrial psychiatry journal, 18(1), 51–55. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Stravynski A, & Boyer R (2001). Loneliness in relation to suicide ideation and parasuicide: a population-wide study. Suicide Life Threat Behav, 31(1), 32–40. [DOI] [PubMed] [Google Scholar]
  34. Sündermann O, Onwumere J, Kane F, Morgan C, & Kuipers E (2014). Social networks and support in first-episode psychosis: exploring the role of loneliness and anxiety. Soc Psychiatry Psychiatr Epidemiol, 49(3), 359–366. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Tomaka J, Thompson S, & Palacios R (2006). The relation of social isolation, loneliness, and social support to disease outcomes among the elderly. Journal of Aging and Mental Health 18(3), 359–384. [DOI] [PubMed] [Google Scholar]
  36. Tremeau F, Antonius D, Malaspina D, Goff D, & Javitt D (2016). Loneliness in schizophrenia and its possible correlates. An exploratory study. Psychiatry Research, 246(211–217). [DOI] [PubMed] [Google Scholar]
  37. Trémeau F, Antonius D, Malaspina D, Goff D, & Javitt D (2016). Loneliness in schizophrenia and its possible correlates. An exploratory study.. Psychiatry Res, 246, 211–217. [DOI] [PubMed] [Google Scholar]
  38. Uchino B (2006). Social support and health: A review of physiological processes potentially underlying links to disease outcomes. Journal of Behavioral Medicine, 29(4), 377–387. [DOI] [PubMed] [Google Scholar]
  39. Walker E, McGee R, & Druss B (2015). Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry, 72(4), 334–341. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Wenger G, Davies R, Shahtahmasebi S, & Scott A (1996). Social isolation and loneliness in old age: review and model refinement. Ageing Soc, 16(03), 333–358. [Google Scholar]
  41. Whiteman K, Naslund J, DiNapoli E, Bruce M, & Bartels S (2016). Systematic Review of Integrated General Medical and Psychiatric Self-Management Interventions for Adults With Serious Mental Illness. Psychiatric Services 67(11), 1213–1255. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Wilson R, Krueger KSA, Schneider J, Kelly J, Barnes L, … Bennett D (2007). Loneliness and Risk of Alzheimer Disease. Archives of General Psychiatry, 64(2). [DOI] [PubMed] [Google Scholar]
  43. Wolkowitz OM (2018). Accelerated biological aging in serious mental disorders. World psychiatry: official journal of the World Psychiatric Association (WPA), 17(2), 144–145. doi: 10.1002/wps.20546 [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES