(July 27, 2017) Serious mental illness is known to shorten average life expectancy by at least a decade and up to 25 years, but a major new study of first-episode psychosis reports far worse statistics for young adults experiencing a first psychotic episode (FEP).
In the 12 months following a psychosis diagnosis, an analysis by Michael Schoenbaum and colleagues found that death rates for individuals aged 16-30 were 24 times greater than for individuals in the same age group in the general population, even under the most conservative assumptions. Compared with the general population of all ages, the mortality rate following first-episode psychosis was 89 times higher.
Given the youth of the cohort, this means some individuals die 50 years or more than would be expected. Only individuals over 70 years old in the general population have overall mortality rates approaching those of young psychosis patients.
The authors blamed the phenomenon on the relatively slow adoption and limited implementation of early intervention practices in the United States. The specific causes of early death were outside the scope of the study, but co-morbid medical conditions like diabetes and suicide are the primary causes of early mortality in serious mental illness overall.
Undertreated, Overlikely to Die
To develop their report, the researchers analyzed federal data for a cohort of 1,357 individuals in the 16-30 age group who received a first diagnosis of psychosis in 2008-2009. They included only commercially insured patients (i.e., patients who had not qualified for public insurance) to avoid including individuals who previously had experienced psychosis.
The death rate in the youngest age group (16-20) was close to 10 times mortality in the general population of the same age: 531 deaths per 100,000 individuals compared with 66 deaths per 100,000. However, mortality in the oldest segment of the cohort was vastly more disproportionate: 5,263 deaths per 100,000 persons compared with 97 per 100,000 in the general population.
A common theme in the study population was under-treatment. The authors found participation in the key outpatient services in FEP programs to be low: 61% of the study population filled no prescriptions for psychotropic medications in the year following their diagnosis, and 41% received no psychotherapy. Only 13% received family therapy, a core element of FEP treatment.
In the same period of time, nearly two out of three individuals in the study cohort experienced at least one hospitalization or emergency department visit, suggesting that the lack of appropriate outpatient care led to higher rates of acute care, according to the authors. Those who received the least outpatient treatment and relied most heavily on hospital services (inpatient or emergency department) were most likely to die.
"Taken together, these findings provide a strong rationale for initiatives to improve early identification and integrated treatment for psychotic disorders in US treatment settings," the authors said.
RAISE and Similar Initiatives
In fact, FEP programs experienced a huge boost in the United States at roughly the same time this cohort was diagnosed. In 2008, the National Institute of Mental Health (NIMH) launched the RAISE Recovery After an Initial Schizophrenia Episode project, a large-scale research initiative to test a model of integrated care for teenagers and young adults experiencing a first psychotic episode.
The NIMH fast-tracked the project, and its results were released in 2015. Participants were found more likely to still be in treatment after two years than non-participants; more likely to be working or going to school; experiencing greater improvement in quality of life and significantly fewer symptoms; and doing so while on a lower dosage of antipsychotic medications. Subsequent study also reported the model to be more cost effective than the typical standard of care.
Since the findings were released, the number of FEP treatment programs in the United States has mushroomed from a handful to more than 100. Congress has allocated funds to develop early intervention programs for psychosis every fiscal year since 2014, and 32 states have announced plans to initiate or expand early treatment programs for FEP.
These measures may ultimately improve the numbers reported in the Schoenbaum study. Meanwhile, the majority of young Americans experiencing early psychosis live where FEP models are not accessible, and the United States continues to lag behind other Western democracies in treating FEP swiftly and comprehensively.
Doris A. Fuller
Chief of Research and Public Affairs
References:
- Schoenbaum, M. et al. (July 2017). Twelve-month health care use and mortality in commercially insured young people with incident psychosis in the United States. Schizophrenia Bulletin.
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