More than 700 veterans attended the Washington DC VAMC’s Winterhaven Homeless Veterans Stand
Down in 2015, when this photo was taken. The VA has a number of initiatives to fight homelessness,
which a new study says contributes to high mortality rates in patients with schizophrenia.
VA photo by
Robert Turtil

SAN DIEGO — Since the 1970s, mortality rates have declined, extending average lifespan by almost a decade.

Patients with schizophrenia are outliers in living longer lives, however, with the mean standardized mortality ratio (SMR) actually increasing 37%, from 2.2 in studies prior to 1970 to 3.0 since then, according to a study in Schizophrenia Research.1

The research led by the VA San Diego Healthcare System and the University of California San Diego School of Medicine called for “urgent” changes in societal stigma, as well as healthcare and economic policy to assure that these patients benefit from increasing longevity trends.

Currently, schizophrenia patients have life expectancy 15 to 30 years shorter than the general population, where the average life expectancy in developed countries increased from 72 years in 1970 to 1975 to 80 years in 2005 to 2010, according to the United Nations.

“There has long been a longevity gap between persons with schizophrenia and the general population,” explained co-senior author Dilip Jeste, MD. “Much of it has been attributed to natural causes of death, such as cardiovascular disease, unhealthy lifestyles (persons with schizophrenia have a greater propensity to behaviors like smoking or eating poorly), inadequate access to health care and biological factors, such as accelerated cellular aging. A small proportion of individuals with schizophrenia die from suicides.”

Researchers reached their conclusions after analyzing all eight published longitudinal studies of mortality in schizophrenia meeting strict research criteria. Jeste, who practices at the San Diego VAMC, pointed out that the study was the first systemic review of longitudinal trends in mortality among persons with schizophrenia.
Within the VA, 4% of veterans in care have a diagnosis of schizophrenia.

In general, the studies demonstrated an increasing chasm in mortality rates between those diagnosed with schizophrenia and the general population from all causes after the early 1970s. Over the course of the studies, the SMR dropped an average of 1.6% a year in the two pre-1970s studies but increased 3% in the six post-1970s studies.

In fact, the mean SMR was 2.2 in the pre-1970s studies vs. 3.0 in the post-1970s studies, an increase of 37%.
“The reasons for the widening gap in longevity are not clear,” noted first author Ellen Lee, MD, a researchers at the San Diego VAMC and a research fellow at UC San Diego School of Medicine. The study team posited that schizophrenia mortality rates appeared to decrease from the mid-1950s to early 1970s because of development of antipsychotic drugs and deinstitutionalization of persons with serious mental illness. Longevity might have been affected, however, by the later widespread closure of mental health facilities, fragmentation of outpatient healthcare services and increasing homelessness and incarceration rates, they suggested.

“Clinicians need to know that schizophrenia is a serious physical illness as well as a mental illness,” Lee told U.S. Medicine. “The fact that patients with schizophrenia are not showing the same extension of life as people without this disorder should alert clinicians to look for ways to encourage their patients to keep connected with the VA healthcare system and to make lifestyle changes, like decreasing smoking or increasing exercise, that might help them live longer.”

Jeste urged “comprehensive and regular physical monitoring and care to prevent and treat chronic age-related medical conditions. They are more vulnerable, for example, to obesity and diabetes. Without that, he noted, 3.2 million Americans believed to have some form of schizophrenia are missing out on new scientific advances, lifestyle changes or healthcare improvements that are extending the lives of others.

Role of Homelessness

In the overall homeless population (estimated at 600,000), people with untreated psychiatric illnesses comprise one-third, or 200,000 people, according to the Coalition for the Homeless Mentally Ill. According to the U.S. Department of Housing and Urban Development (HUD), 39,471 veterans are homeless on any given night, and the National Coalition for Homeless Veterans says half of them have serious mental illness (SMI).

The study found that natural causes of death, often due to premature onset of serious medical diseases, were generally responsible for the increasing mortality gap in schizophrenia. While unnatural causes of death, such as suicides and accidents, have high SMRs, they account for 20% or less of death in schizophrenia. In addition, study authors pointed out, the mortality gap related to unnatural causes has remained stable over time.

A key issue might be that patients with SMI, especially those lacking stable housing, aren’t benefiting from comprehensive and regular physical monitoring by primary care services to prevent and treat chronic age-related medical conditions, the article stated. Another factor could be accelerated biological aging in schizophrenia, with researchers noting, “evidence of elevated inflammation and oxidative stress in persons with schizophrenia compared to healthy comparison subjects.”

While questions have been raised about adverse effects of chronic treatment with first- and second-generation antipsychotics, antipsychotic use in schizophrenia patients is associated with lower mortality, despite recognized metabolic and cardiovascular side effects, study authors maintained. They suggested that other factors, such as lifestyle habits, are likely to have a greater impact on mortality than drug therapies.

In explaining that view, the researchers proposed an analogy with longevity gaps in some ethnic minorities or lower-income groups. “One may draw a parallel between socially or economically disadvantaged segments of the general population and people with schizophrenia,” study authors wrote. “For instance, people in the bottom 1% of the income strata have a 10 to 15-year shorter life expectancy relative to the top 1% of the income strata. The individuals in the lowest socioeconomic strata face several challenges similar to those faced by people with schizophrenia, such as low level of education, poor diet, poverty, poor healthcare and high levels of stress.”

“Most strikingly, low-income earners have significantly improved life expectancies if they live in cities with highly educated and high-income populations and well-funded public services,” they added. “These effects may be a result of local influences such as public policies that improve health (e.g., bans on smoking in public places), availability of social services and positive health behaviors that may be ‘contagious’ between those with higher and lower incomes. Such findings may serve as guiding principles for reducing excess morbidity and mortality in schizophrenia.”

Community-based psychosocial interventions have been successful in improving outcomes for schizophrenia patients, according to the report, which cited a project in London in the 1980s-90s which provided community services after deinstitutionalization, including meals and housing along with social supports. That significantly improved psychopathology, including negative symptoms, and socialization, at five-year follow-up assessments.

“Such findings suggest a potential for improving prognosis and longevity in persons with chronic schizophrenia, by employing appropriate environmental and cultural interventions,” the researchers wrote.

“Over the past half-century, despite a growing body of empirical research on schizophrenia and the accompanied improvements in available treatments, the mortality gap between people with schizophrenia and the general population has widened, rather than narrowed,” study authors concluded. “It is likely that these findings reflect on persistent and pervasive stigma against mental illness and societal neglect of this vital yet vulnerable segment of the population, which continues to be disenfranchised. Accordingly, work is urgently warranted to help reduce stigma, improve healthy lifestyles in a disseminable way, and tailor primary care services so that persons with SMI are not left behind in the longevity revolution.”

1Lee EE, Liu J, Tu X, Palmer BW, Eyler LT, Jeste DV. A widening longevity gap
between people with schizophrenia and general population: A literature review and call for action. Schizophr Res. 2017 Sep 27. pii: S0920-9964(17)30542-X. doi: 10.1016/j.schres.2017.09.005. [Epub ahead of print] PubMed PMID: 28964652.