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What can be done to decrease early deaths in people with severe mental disorders?

Isaac, Mohan; Filipčić, Igor

doi: 10.1097/YCO.0000000000000537

Division of Psychiatry, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia

Correspondence to Mohan Isaac, Division of Psychiatry, Faculty of Health and Medical Sciences, The University of Western Australia, Level 7, T Block, Fremantle Hospital, Fremantle, WA 6160, Australia. E-mail:

It is well known that people with severe mental disorders on average die earlier than the general population. The difference in life expectancy between persons with severe mental disorders and the general population is 10–25 years. Numerous studies and meta-analyses have shown that this difference has not lessened over time. The urgent need to develop and implement meaningful initiatives and interventions to reduce early deaths in people with severe mental disorders has been repeatedly highlighted. In this issue of the Current Opinion in Psychiatry, there are several articles that review recent advances and developments in not only our understanding of various factors which contribute to early deaths in severe mental disorders, but also what can be done about them. Ashdown-Franks et al. [1] review the quantity and quality of the steadily increasing evidence of the efficacy of structured and supervised physical activity in improving multiple outcomes in many mental disorders, including schizophrenia and bipolar disorders. They make an appeal to make more concerted effort to prioritize physical activity as an established adjunctive treatment across mental health services.

Are serious mental illnesses ‘whole body’ and multisystem illnesses? Are serious mental illnesses associated with accelerated biological ageing? Could the mental illness itself, through accelerated ageing, be an independent risk factor for other illnesses and early death? These are questions which Bersani et al.[2] attempt to answer in their review of accelerated ageing in severe mental disorders. They critically look at the significance of various markers of biological ageing that have been examined in serious mental illnesses. Accelerated biological ageing may be present in people with serious mental illnesses and this may be a contributory factor in the increased co-occurrence of various age-related physical illnesses in them resulting in early death. However, lifestyle changes and appropriate pharmacological interventions may have the potential to decelerate the pace of biological ageing.

Although the complex link between smoking and schizophrenia has been studied for years, the reasons for the consistently high rates of smoking and nicotine dependence in schizophrenia are still poorly understood. Reviewing recent data on smoking and schizophrenia, Sagud [3] notes that despite worldwide efforts to reduce smoking rates and the consequent worldwide reduction in cigarette consumption, prevalence of smoking in people with schizophrenia continues to be high. Although there may be questionable beneficial effects of smoking in schizophrenia, the risks associated with smoking substantially outweigh any potential benefits. Several treatment strategies are proven to be effective and every effort must be made towards smoking cessation across all stages of the disease in schizophrenia.

Comorbidity of various chronic physical illnesses in people with schizophrenia is shown to affect schizophrenia treatment outcomes [4]. The relationship between chronic physical illnesses and schizophrenia is complex and the mechanisms of this association are yet to be understood fully. Studies have shown that the relationship is bidirectional at both pathophysiological and clinical levels. Health professionals involved in managing people with schizophrenia should constantly strive to raise awareness about the importance of identifying and managing physical health problems.

Laursen [5] observes that the higher mortality risk and early deaths in persons with severe mental disorders labelled schizophrenia compared to the general population was recognized as early as the early nineteen hundred, and this finding has been replicated countless times during the past many decades. Reviewing the most recent data on the causes of early death in schizophrenia, he has identified five sets of causes for natural deaths in schizophrenia namely: adverse effects of medications, suboptimal lifestyle, somatic comorbidity, suboptimal treatment of somatic disorders and accelerated ageing/genetic explanations. Although future research should attempt to disentangle the complex interplay between medication, lifestyle, comorbidity, somatic disorders and genetic effects, it is vital to continuously improve the access to physical healthcare for people with schizophrenia.

Sarnayi et al.[6] review the accumulating evidence for impaired glucose handling and energy metabolism and mitochondrial functioning in the brain emerging as important pathophysiological mechanism in schizophrenia. Therapeutic ketogenic diet shows promise to restore brain energy metabolism and synaptic communication. It is speculated that because of the impact of ketogenic diet on systemic metabolism, it may be possible to address the metabolic features and cardiovascular risk factors associated with schizophrenia by dietary intervention. Ketogenic diet's place in regular management of schizophrenia will have to wait until more research at preclinical levels as well as controlled clinical trials produce more robust evidence.

Comorbidity of mental and physical disorders has been identified as ‘the most important challenge’ to medicine of the 21st century [7]. In this issue, Mukherjee and Chaturvedi [8] review the factors related to the co-occurrence of depression and diabetes and their bidirectional association. As most of the significant number of persons with diabetes who suffer from depression or diabetes-related distress are not diagnosed or treated, authors highlight the need for routine screening of persons with diabetes for these conditions and their appropriate treatment. For better outcomes, collaborative, interdisciplinary care is recommended.

Anxiety disorders, such as generalized anxiety disorder and panic disorder, are estimated to be high in patients with various medical illnesses and conditions [9]. Conversely, various medical illnesses and conditions are highly prevalent in persons suffering from anxiety disorders. The complex relationship between personality disorders and physical comorbidities, hitherto not well recognized or studied, is reviewed by Dokucu and Cloninger [10]. There is a strong association between personality disorders and physical disorders in both cross-sectional and community-based studies. Longitudinal studies of persons diagnosed with a personality disorder who also have a physical disorder show that they deteriorate physically over a period. The authors have also explored the association of personality traits and temperament in the context of medical conditions.

Approximately 120 million people worldwide are affected by one type or another depressive disorder making depression the leading cause of burden and disability worldwide. In this issue, Halaris [11] reviews the theory of inflammation in depression – inflammation as a result of stress-induced immune system activation, causing neurotransmitter dysregulation and mediating depression in its various manifestations. Chris et al.[12] examine the current status as well as future directions of repetitive transcranial magnetic stimulation as an accepted treatment for major depressive disorder.

The specific realities of cancer patients and their families in large parts of the developing world would be very different from those of the resource rich developed countries. Murthy and Alexander [13] provide an overview of the progress in psycho-oncology in developing countries. Families are central to cancer care in developing countries.

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Conflicts of interest

There are no conflicts of interest.

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1. Ashdown-Franks G, Sabiston CM, Stubbs B. The evidence for physical activity in the management of major mental illnesses: a concise overview to inform busy clinicians’ practice and guide policy. Curr Opin Psychiatry 2019; 32:375–380.
2. Bersani FS, Mellon SH, Reus VI, Wolkowitz OM. Accelerated aging in serious mental disorders. Curr Opin Psychiatry 2019; 32:381–387.
3. Sagud M, Peles AM, Pivac N. Smoking in schizophrenia: recent findings about the old problem. Curr Opin Psychiatry 2019; 32:402–408.
4. Filipčić IS, Bajić Z, Filipčić I. Effects of chronic physical illness on treatment outcomes among patients with schizophrenia. Curr Opin Psychiatry 2019; 32:451–460.
5. Laursen TM. Causes of premature mortality in schizophrenia: a review of literature published in 2018. Curr Opin Psychiatry 2019; 32:388–393.
6. Sarnyai Z, Kraeuter A-K, Palmer CM. Ketogenic diet for schizophrenia: clinical implication. Curr Opin Psychiatry 2019; 32:394–401.
7. Sartorius N. Comorbidity of mental and physical: a key problem for medicine in the 21st century. Acta Psychiatr Scand 2018; 137:369–370.
8. Mukherjee N, Chaturvedi SK. Depressive symptoms and disorders in type 2 diabetes mellitus. Curr Opin Psychiatry 2019; 32:416–421.
9. Latas M, Latas DV, Stojaković MS. Anxiety disorders and medical illness comorbidity and treatment implications. Curr Opin Psychiatry 2019; 32:429–434.
10. Dokucu ME, Cloninger CR. Personality disorders and physical comorbidities: a complex relationship. Curr Opin Psychiatry 2019; 32:435–441.
11. Halaris A. Inflammation and depression but where does the inflammation come from? Curr Opin Psychiatry 2019; 32:422–428.
12. Baeken C, Brem A-K, Arns M, et al. Repetitive transcranial magnetic stimulation treatment for depressive disorders: current knowledge and future directions. Curr Opin Psychiatry 2019; 32:409–415.
13. Murthy RS, Alexander A. Progress in psycho-oncology with special reference to developing countries. Curr Opin Psychiatry 2019; 32:442–450.
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