Caring for the Whole Person: Integrated Health Care for Older Adults with Severe Mental Illness and Medical Comorbidity

Abstract

Schizophrenia is associated with a 20% shorter life span than for the general population 1 and high rates of chronic medical illnesses, including diabetes mellitus (DM), hypertension, heart disease, and emphysema. 2 Recent research suggests that premature mortality and excess physical disability in schizophrenia is associated with a variety of extrinsic risk factors that are potentially preventable, including unhealthy lifestyles, metabolic and neurological side effects of psychiatric medications, and poor health care. The aging of the population of persons with severe mental illness (SMI) further contributes to growing rates of medical comorbidity. The number of older adults with major psychiatric illness is predicted to more than double by 2030. 3 This paper provides an overview of selected research findings on the prevalence and causes of medical comorbidity in schizophrenia and other SMIs, current challenges to providing quality health care, and suggested directions for integrated models of care for the older person with a SMI. EARLY MORTALITY AND RESEARCH ON MEDICAL COMORBIDITY IN SMI Approximately 3% of American adults have SMI, including 1% with schizophrenia and 2% with depression or bipolar disorder that is refractory to treatment. 4 In older adults, the prevalence of schizophrenia and bipolar disorder decreases to approximately 0.5% and 0.2%, respectively, whereas the prevalence of major depression ranges from less than 1% to 5%. 5,6 The lower prevalence of schizophrenia in older persons is most likely due to remission of psychotic symptoms 7,8 for some individuals and premature mortality. Schizophrenia is associated with a 20% shorter life expectancy than for the general population. 1 The lives of men with schizophrenia are 10 years shorter than those of men without schizophrenia, whereas the lives of women with schizophrenia are about 9 years shorter than those of women without schizophrenia. 9‐12 Factors that contribute to premature death and poor outcomes for persons with schizophrenia and other SMIs include high prevalence of comorbid medical disorders, poor health behaviors, and inadequate health care. 10‐17 The research literature on medical comorbidity and health care for persons with SMI consists of studies specific to schizophrenia and studies that also include individuals with other psychotic-spectrum disorders, bipolar disorder, and treatment-refractory severe depression, collectively referred to as SMI. Throughout the following overview of medical comorbidity and health care, studies on the subgroup of persons with the diagnosis of schizophrenia and on the larger group of persons with SMI are included. Much of what is known about medical comorbidity and health care in persons with SMI has been derived from samples of young and middle-aged mentally ill persons. Hence, in the following overview of this topic, data on comorbidity and health care for the larger population, which includes younger and middle-aged persons, are included, in addition to the few studies specific to the older adult population (� 65), where available.