My patient had struggled with bipolar disorder his entire life, and his illness dominated our years together. He had, in a fit of hopelessness, tried to take his life with a fistful of pills. He had, in an episode of mania, driven his car into a tree. But the reason I now held his death certificate — his sister and mother in tears by his bed — was more pedestrian: a ruptured plaque in his coronary artery. A heart attack.
Americans with depression, bipolar disorder or other serious mental illnesses die 15 to 30 years younger than those without mental illness — a disparity larger than for race, ethnicity, geography or socioeconomic status. It’s a gap, unlike many others, that has been growing, but it receives considerably less academic study or public attention. The extraordinary life expectancy gains of the past half-century have left these patients behind, with the result that Americans with serious mental illness live shorter lives than those in many of the world’s poorest countries.
National conversations about better mental health care tend to follow a mass shooting or the suicide of a celebrity. These discussions obscure a more rampant killer of millions of Americans with mental illness: chronic disease.
We may assume that people with mental health problems die of “unnatural causes” like suicide, overdoses and accidents, but they’re much more likely to die of the same things as everyone else: cancer, heart disease, stroke, diabetes and respiratory problems. Those with serious mental illness are more likely to struggle with homelessness, poverty and social isolation. They have higher rates of obesity, physical inactivity and tobacco use. Nearly half don’t receive treatment, and for those who do, there’s often a long delay.
For doctors, two related biases are probably at play. The first is therapeutic pessimism. Clinicians, including mental health professionals, often hold gloomy views about whether patients with serious mental illness can get better. This can lead to a resigned passivity, meaning that certain tests and treatments aren’t offered or pursued.
As Lisa Rosenbaum, a cardiologist at Brigham and Women’s Hospital in Boston, writes: “Many of us have internalized the directive to seek a test or procedure only if ‘there’s something you can do about it.’ For mentally ill patients with medical illness, however, this principle often justifies doing nothing.”
The second is a concept called diagnostic overshadowing, by which patients’ physical symptoms are attributed to their mental illness. When doctors know a patient has depression, for example, they’re less likely to think her headache or abdominal pain portends a serious illness.