Fascinating article from the NIMH implicitly linking  health disparities  to not only access and lack of insurance but  under-detection  (aka, missed diagnosis)  of  chronic medical conditions  in people  with  severe mental illness.   Recent studies in this country,  show people with serious mental illness are not only more likely to develop chronic medical conditions, aka, non-communicable diseases, but die 8-27 year earlier  than those in the general population.  The Swedish study below  suggests  under-detection of non-communicable diseases, such as heart disease, cancer and lung diseases,  in patients with schizophrenia as a reason for  mental illness disparities.

In  adults,  the leading causes of mortality (death)  are chronic medical conditions–heart dx, obesity, diabetes, pulmonary dx.    These conditions are more common in people with mental illness but less often diagnosed (detected by providers).   Why?

 In patients with schizophrenia,  the  Swedish study found only  about 25% of deaths from heart disease were diagnosed or detected prior to death.  In other words, 75% of   schizophrenic patients with heart disease  died from heart attacks  that was not detected  (diagnosed) prior to death.   Despite  Sweden’s  universal health coverage, where mental health patients have access  with frequent visits,   under-detection or possible  missed diagnoses were  contributing causes of death for people with schizophrenia.

This should make us pause,  under-detection, (I say missed diagnoses)  may  represent gaps in provider education.  As providers, we  are in dire need of training  in  screening and treating mental illness, especially in children, as well as,  understanding cultural norms in the context of  mental illness.  In other words, many in this system lack cultural competence.

Surprisingly, many  providers still harbor stigmatizing views of mental illness.     My  own  poignant  reminder  that a  perceived diagnosis of mental illness  or stress freed  providers to dismiss  the many elephants pointing to alternative diagnoses resulting in  “missed”  diagnosis.

Shoved into the world of mental illness
With psychiatrists who prescribe meds,
More meds and even more meds to treat the side effects
Of meds.
Are mental illness patients getting  quality medical care?
This is worthy of further research
Medications almost killed me!

As physicians  we need better communication and cultural skills.  Yes, we are trained to heal.   However, lack of cultural and linguistic competence  remain barriers to good  health care;  creating  breathing grounds for stereotypes and stigmas.   This leads to  “missed” diagnosis, misdiagnosis or under-detection).

{Food For Thought #1: In the US, health disparities  are largely  determined  by poverty and ethnicity.   I believe  mandating training in culture as part of continuing medical education  may lead to better communication with patients,  and decreased morbidity nd mortality of patients with chronic medical illnesses.   Many have co-existing mental illness which is emphasized at the expensive of  missing common treatable medical conditions.}

The findings of the Swedish study are surprising in the gravity and urgency to  help  people with mental illness,  who  we  know are dying not only from suicide or homicide but  also from missed diagnosis of  treatable medical conditions.    Many were under the care of providers.   That’s bad!  Here the science is  far ahead of the practice.  This is  Failure to Listen  in healthcare and it is systemic!. 

 {Food for Thought 2:    Did you know over 70% of children receive treatment for mental illness through schools ( usually as part of their IEP),  many without   specific diagnosis?     This means our children’s mental illnesses  are not  treated by anyone with the expertise to diagnosis or treat  mental illness.    Health, which include mental health,  can be a barrier to learning!   How can a child focus if depressed or sleep-deprived?

Food for Thought 3:  On the battlefield ,  did you know many  in our military are  defending this country and its people through the use of  antidepressants and/or narcotics?    Yes, we are drugging our soldiers so they can go onto to the battlefield.   Fighting wars on the outside battling  physical and mental pain inside… they deserve the BEST  healthcare.   Are they getting it? }

Often complaints by patients with mental illness, especially schizophrenia and other severe mental illness,  are not given equal attention and many are framed in the context of mental illness partly because of communication.

One can easily see why patients with severe mental illness  would die  up to 25 years younger from treatable medical condition  compared to the general population.

In the interest of fairness, most providers are competent and dedicated  groups of people who do  great jobs. Unfortunately, it only takes a couple of severely incompetent ones to open another world of medicine where patients are victims.  I apologize for the ranting.

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Enjoy the article —  with link to full article at the end.

Schizophrenia as a Health Disparity (NIMH)

By Thomas Insel on March 29, 2013

…….a new report on co-morbidity and mortality in persons with schizophrenia in Sweden.1 What Dr. Braunwald was thinking about was the Swedish universal health care system and population registries, making Sweden the ideal setting for epidemiology, the study of patterns and determinants of disease in populations. For a disorder like schizophrenia, virtually every affected person is identified and the predictive value (accuracy) of diagnosis is over 94 percent. Unlike in this country, there are few barriers to care based on insurance, access, or geography.

Which is why you should look at these new data on mortality. Crump and colleagues followed a Swedish national cohort of over 6 million adults between 2003 and 2009 to detect mortality and illness based on the results of every outpatient or inpatient visit nationwide. Among the 8,277 people with schizophrenia, men died 15 years earlier and women died 13 years earlier than the rest of the population. This early mortality was not due to suicide, but to cardiovascular disease, cancer, and pulmonary disease. The adjusted hazard ratio (increased risk) for mortality from ischemic heart disease in women with schizophrenia was a stunning 3.3—in other words, women with schizophrenia have over 3 times the risk of dying from heart disease compared with women in the general population—and for men with schizophrenia it was 2.2. Importantly, heart disease and cancer were not more common in people with schizophrenia, but mortality from these diseases was increased markedly.

These numbers might not be so surprising in the United States, where recent studies report early mortality in people with serious mental illness ranging from 8 years2 to 27 years.3 But in a country with a far more effective health care system, one might have expected much better health outcomes. In fact, in the Swedish study, people with schizophrenia were seen nearly twice as often for medical care as the general population. Yet even with these extra visits, heart disease and cancer went undetected: only 26.3 percent of people with schizophrenia who died of heart disease and 73.9 percent who died of cancer had been diagnosed previously. Another surprise—treatment with antipsychotic medications, which might have been considered a risk factor for cardiovascular disease, actually lowered the risk. The highest risk was among those not treated with antipsychotic medication.

What’s the lesson for the United States? The authors end this new report with this reflection: “Underdetection of important causes of mortality in schizophrenia patients in Sweden, despite universal health care, raises the question of whether it may be an even larger problem in countries without universal health care.” Indeed. While we are hopeful that the implementation of mental health parity and new, integrative care approaches such as medical homes will close the gap on early mortality and under-treated co-morbid conditions in the United States, the Swedish data suggest this may not be so easy……For the full article click on the following  link:

http://www.nimh.nih.gov/about/director/2013/schizophrenia-as-a-health-disparity.shtml

Other views of Culture:

How Doctors Die – – Popular blog  and   touching post by Dr. Ken Murrayy

For the Elderly, Medical Procedures to Avoid     http://newoldage.blogs.nytimes.com/2013/02/28/for-the-elderly-lists-of-tests-to-avoid/