**2. Epidemiological studies**

Results of most research on the physical health of people with mental health illness suggest the morbidity and the mortality from certain physical disease is high in these populations. Patients with schizophrenia are a medically vulnerable population due to underdiagnosed medical problems, and minimal or not utilization of primary care services. Not only there is increased medical morbidity among these patients, there is also increased mortality.

Medical comorbidity in patients with bipolar disorder, is associated with an intensification of bipolar depressive symptoms and other indices of bipolar severity, as well as premature mortality. Somatic health issues remain underrecognized and suboptimally treated.

### **2.1 Mortality**

An increasing number of studies have found higher rates of mortality in schizophrenia patients due to natural causes (Mortensen & Juel, 1993; Ruschena et al, 1998). Such increased rates of mortality due to natural causes highlight the failure to detect and manage physical health conditions in this group. In meta-analysis deaths due to natural causes accounted for

Dyslipidemia and Mental Illness 351

their psychiatric illness; 80% had physical illnesses requiring treatment, and 4% had

Research indicates that 25% to 80% of patients with schizophrenia and other mental illness have a serious medical comorbidity, yet less than half of these medical conditions are

A number of reasons exist to explain the poor detection of physical health problems in patient with mental illness. Some patients are unaware of any physical health problems, usually a consequence of cognitive deficits associated with their mental illness (Goldman, 1999). Often there is a reluctance to seek medical help and when it sought patient with mental health find it difficult to describe their problems to a medical practitioner, or present with atypical medical symptoms. Patient with schizophrenia have been shown to have a high tolerance for pain and subsequently are less likely to report this symptom (Dworkin, 1994). Another complexity concerns the effects of psychiatric illness on perceived physical health. For example, depression can lead to an increase in perceived physical symptoms and

The management of medical conditions is a complex and problematic issue, arising largely because of the separation of medical and psychiatric health care services. The stigma of mental illness is one obvious barrier preventing psychiatric patients from receiving adequate physical health care, as some physicians may be uncomfortable in working with this patient. Another concern is managing physical conditions where patients that have an increased prevalence with psychiatric illness and where there is a general lack of treatment compliance. The challenging task of managing physical illness with this patient requires skill, patience and experience as patients often present late with complications. (Table 1)

Lack of understanding of benefits of preventive services by health care workers

Table 1. Barriers to health care for patients with mental illness. Adapted from Goldman.

In recent years, there is a growing concern about physical illness in patients with mental illnesses, specifically the risk of cardiovascular disease. Those patients are more likely to be overweight, to smoke, to have hypertension, hyperglycemia or diabetes, and dyslipidemia

precancerous conditions or illnesses (Hall et al, 1981).

**3. Causes of poor physical health in mental illness** 

diagnosed (Cradock-O'Leary et al, 2002).

worsening of subjective health outcomes.

System-Related Barriers

Patients–Barriers Poverty

Non compliance

**3.1 Lifestyle risk factors** 

(Table 2).

 Lack of insurance coverage Lack of access to health care

 Pour communication skills Denials of illness Related

Stigmatization by health care providers

Lack of integration of medical and mental health systems

59% of the excess mortality in schizophrenia (Brown, 1997). Respiratory and cardiovascular diseases are the most common causes of natural death. The standard mortality ratio (SMR) for respiratory disease was 226 (95%CI, 209-244) and for cardiovascular disease 110 (95%CI, 105-115) (Brown, 1997). However, another study found an SMR of 1.78 for men and 0.86 for women with schizophrenia for ischemic heart disease (Lawrence et al, 2003). Analysis of standardized mortality ratios for deaths from natural causes showed an increased risk of death in patients with a wide range of psychiatric conditions, including substance misuse, schizophrenia, bipolar disorder and unipolar depression. The Standardized mortality ratios (SMR) showed that in schizophrenia it is 1.57 for all cause mortality, and cardiovascular and cancer deaths accounted for the largest number of deaths with SMRs of 1.04 and 1.00 respectively (Harris & Barraclough, 1998). Depression confers a 24% increased risk of dying within the next 6 years (Wulsin, 2000). A study published through the Centers for Disease Control and Prevention (CDC) compared the mortality of public mental health patients in 8 states with the mortality of the states' general population, for 1997 through 2000. In all the study states, mental health had a higher risk of death than the general population and died at much younger ages compared with their cohorts. In all states studied, cardiac disease was found to be the leading cause of death in mentally ill patients. And this population had lost decades of potential years of life, with average exceeding 25 years (Colton & Manderscheid, 2006).

Another indicator of the medical care is avoidable mortality. These indicators are calculated by selecting the number of avoidable causes of death considered amenable to health care (Rustein et al, 1976). A follow-up study of 30045 psychiatric in-patients born between 1912- 1970 was conducted to specifically address avoidable mortality. The standardized rate ratios (SRR) for male patients with schizophrenia are 3.74 (95%CI, 2.38-5.89) and 3.99 (95%CI, 2.47- 6.44) for females (Ringback Weitoft et al, 1998).

## **2.2 Morbidity**

A study list some of the common physical conditions found in people with psychosis. These include diabetes, hyperlipidemia, cardiovascular disease, obesity, malignant neoplasms, HIV/AIDS, hepatitis, osteoporosis, hyperprolactinemia, irritable bowel syndrome and helicobacter pylori infection (Lambert et al, 2003). The prevalence of physical illness in medically screened chronic psychiatric samples has been variously reported to be 12-53% (Lyketsos et al, 2002). Another study estimate that 35% of psychiatric patients have undiagnosed physical disorder (Felker et al, 1996).Some studies have attempted to establish whether medical comorbidity exacerbates patient' psychiatric condition (Bartsch et al, 1998).

Not only do patients with mental illness die of natural causes at high rate, when medical conditions occur, these patients are much more likely to underdiagnosed and undertreated. Several studies have shown that the detection rate of physical illness among patient with mental illness is very poor. A study estimated that 45% of patients in California's public mental-health system had physical disease and, of these, 47% were undetected by the treating physician (Koran, 1989). Another study of psychiatric clinic patients revealed remarkably similar findings: 43% of patients had physical illnesses and, of these, 48% had not been diagnosed by the referring doctor, non-psychiatrist physicians had missed 33% and psychiatrists had missed 50% (Koranyi, 1979). Hall et al found that 46% of patients admitted to a research ward had an unrecognized physical illness that either caused or exacerbated

59% of the excess mortality in schizophrenia (Brown, 1997). Respiratory and cardiovascular diseases are the most common causes of natural death. The standard mortality ratio (SMR) for respiratory disease was 226 (95%CI, 209-244) and for cardiovascular disease 110 (95%CI, 105-115) (Brown, 1997). However, another study found an SMR of 1.78 for men and 0.86 for women with schizophrenia for ischemic heart disease (Lawrence et al, 2003). Analysis of standardized mortality ratios for deaths from natural causes showed an increased risk of death in patients with a wide range of psychiatric conditions, including substance misuse, schizophrenia, bipolar disorder and unipolar depression. The Standardized mortality ratios (SMR) showed that in schizophrenia it is 1.57 for all cause mortality, and cardiovascular and cancer deaths accounted for the largest number of deaths with SMRs of 1.04 and 1.00 respectively (Harris & Barraclough, 1998). Depression confers a 24% increased risk of dying within the next 6 years (Wulsin, 2000). A study published through the Centers for Disease Control and Prevention (CDC) compared the mortality of public mental health patients in 8 states with the mortality of the states' general population, for 1997 through 2000. In all the study states, mental health had a higher risk of death than the general population and died at much younger ages compared with their cohorts. In all states studied, cardiac disease was found to be the leading cause of death in mentally ill patients. And this population had lost decades of potential years of life, with average exceeding 25 years (Colton & Manderscheid,

Another indicator of the medical care is avoidable mortality. These indicators are calculated by selecting the number of avoidable causes of death considered amenable to health care (Rustein et al, 1976). A follow-up study of 30045 psychiatric in-patients born between 1912- 1970 was conducted to specifically address avoidable mortality. The standardized rate ratios (SRR) for male patients with schizophrenia are 3.74 (95%CI, 2.38-5.89) and 3.99 (95%CI, 2.47-

A study list some of the common physical conditions found in people with psychosis. These include diabetes, hyperlipidemia, cardiovascular disease, obesity, malignant neoplasms, HIV/AIDS, hepatitis, osteoporosis, hyperprolactinemia, irritable bowel syndrome and helicobacter pylori infection (Lambert et al, 2003). The prevalence of physical illness in medically screened chronic psychiatric samples has been variously reported to be 12-53% (Lyketsos et al, 2002). Another study estimate that 35% of psychiatric patients have undiagnosed physical disorder (Felker et al, 1996).Some studies have attempted to establish whether medical comorbidity exacerbates patient' psychiatric

Not only do patients with mental illness die of natural causes at high rate, when medical conditions occur, these patients are much more likely to underdiagnosed and undertreated. Several studies have shown that the detection rate of physical illness among patient with mental illness is very poor. A study estimated that 45% of patients in California's public mental-health system had physical disease and, of these, 47% were undetected by the treating physician (Koran, 1989). Another study of psychiatric clinic patients revealed remarkably similar findings: 43% of patients had physical illnesses and, of these, 48% had not been diagnosed by the referring doctor, non-psychiatrist physicians had missed 33% and psychiatrists had missed 50% (Koranyi, 1979). Hall et al found that 46% of patients admitted to a research ward had an unrecognized physical illness that either caused or exacerbated

2006).

**2.2 Morbidity** 

condition (Bartsch et al, 1998).

6.44) for females (Ringback Weitoft et al, 1998).

their psychiatric illness; 80% had physical illnesses requiring treatment, and 4% had precancerous conditions or illnesses (Hall et al, 1981).

Research indicates that 25% to 80% of patients with schizophrenia and other mental illness have a serious medical comorbidity, yet less than half of these medical conditions are diagnosed (Cradock-O'Leary et al, 2002).
