OVERVIEW

Chronic mental illness refers to conditions with persistently debilitating psychiatric symptoms and severely impaired function. Individuals with chronic mental illness suffer from symptoms that may interfere with their ability to perform activities of daily living (ADLs) and to participate in work, school, and interpersonal relationships. At times in their lives, these individuals often require significant care from family and from mental health care providers.

The limitations caused by schizophrenia, severe mood disorders, and some personality disorders (such as schizotypal, schizoid, or borderline) may lead to chronically disabling symptoms. Severe substance abuse is commonly co-morbid among individuals with chronic mental illness, and may, by itself, lead to chronic impairment. This chapter will focus on chronic mental illness associated with schizophrenia. We will review the history of the community mental health care system in the United States, review the most common medical co-morbidities in this population, and discuss the assessment and treatment of patients with chronic mental illness.

EPIDEMIOLOGY AND MANIFESTATIONS

The prevalence of schizophrenia is 1%; the condition affects equal numbers of men and women. However, the rates vary by region, with higher rates among the urban poor (probably because of the movement of these patients toward urban areas where treatment is more available than it is in rural settings). The course of schizophrenia is variable; about 10% of patients who are diagnosed with schizophrenia become completely asymptomatic, about 20% remain severely disabled, and the remainder will have a fluctuating course.¹ Maintenance of antipsychotic medications after the first episode of illness appears to decrease rates of relapse.² Among patients with schizophrenia, about 10% commit suicide and 50% attempt it.³

Direct and indirect costs of schizophrenia in the United States have been estimated at more than $62 billion in 2002, with over $22 billion accounting for direct health care.⁴ Examples of non–health care costs include living expenses, lost productivity due to unemployment or early death from suicide, the cost for families to provide care, and costs for law enforcement and homeless shelters.

An individual’s ability to function depends on how symptoms impinge on his or her life. For example, auditory hallucinations, delusions, and paranoia may interfere with work and relationships as the patient incorporates co-workers or significant others into the delusional beliefs. Disorganized thought, language, and behavior may impair the patient’s ability to live independently, to participate in employment and social situations, or to access medical and psychiatric care on his or her own. Among some patients, agitation is a component of the disorganization that could potentially lead to dangerous situations for the patient or caregivers. Finally, negative symptoms of schizophrenia (including apathy, flattening of affect, poverty of thought and speech, social isolation, and neglect of hygiene) can also interfere with a patient’s ability to participate in daily activities and can alienate those around him or her.³

THE STIGMA OF CHRONIC MENTAL ILLNESS

The individual who suffers from a chronic mental illness, such as schizophrenia, not only has to cope with the symptomatic aspects of his or her illness, but also suffers from the additional burden of being stigmatized by those around him or her (Figure 64-1). Goffman⁵ has defined stigma as “an attitude that is deeply discrediting” and describes that the stigma of mental illness is based on the belief that suffering from mental illness represents “a blemish on individual character.” Norman Sartorius,⁶ the former director of the Department of Mental Health and Substance Abuse at the World Health Organization, and others have focused on stigma as the major obstacle world-wide to quality care and to improved quality of life for those with mental illness. Stigma leads to discrimination of individuals with mental illness; they become viewed as second-class citizens who are different, separate, or ostracized from society. Discrimination is manifest in many ways, including outright poor treatment by others, avoidance of care by those with mental illness (and their families), and a comparative lack of resources allocated to research and to clinical programs. Some attempts to mitigate the negative effects of stigma (such as educational programs) have been made, but stigma still remains a central issue for those with chronic mental illness.

Figure 64-1 Individuals with chronic mental illness are at risk for homelessness.

THE COMMUNITY MENTAL HEALTH CARE SYSTEM

The way that our society views chronic mental illness and supports its treatment has changed dramatically in the United States over the past 200 years. The earliest public mental hospitals were built in the late 1700s as locations to house and care for the mentally ill.⁷ By 1903, 144,000 people were housed in public mental hospitals in the United States, and by 1955, this number had grown to 559,000.⁸

However, it was in the 1950s when newly created antipsychotic medications led to significant changes in psychiatric treatment that care could more easily be provided to chronically mentally ill patients in the community. New commitment laws and legal proceedings that restricted involuntary commitment and that endorsed patients’ rights to access care in the least restrictive setting led to more dramatic changes in hospitalization practices.⁹ In addition, there was a growing belief that treatment in the community would be more humane, and that hospitalization may actually contribute to the withdrawal and apathy associated with chronic mental illness.^3,8 All of these factors contributed to a period of deinstitutionalization in which thousands of patients were released from mental hospitals in order to live and receive treatment in the community. In 1998, there were just over 57,000 people in psychiatric hospitals in the United States, a decrease of nearly 90% as compared to 1955.⁸

In the context of these changes, the federal Community Mental Health Centers Act of 1964 contributed to widespread changes in the availability of resources. Additional financial resources for patients included Supplementary Security Income (SSI), Social Security Disability Insurance (SSDI), and Medicare and Medicaid health insurance programs. One novel community program already in place before this period of deinstitutionalization was led by Erich Lindemann, and was based on a theory of broad community intervention to understand life crises, with the identification of families at risk, and the strengthening of community resources using a range of professionals (e.g., doctors, clergymen, and educators) to prevent morbidity and to promote healthier coping strategies.¹⁰ Lindemann played an important role in the creation of the community mental health system in Boston and encouraged a public health approach to illness prevention, in addition to the treatment available at the community mental health centers. However, some critics have argued that deinstitutionalization was not accompanied by adequate financial and community resources to provide the additional care that patients needed once they left the hospital environment.

One unfortunate effect of inadequate housing and access to treatment has been high rates of homelessness among the chronically mentally ill.⁸ Homeless adults have about 30 times the prevalence of schizophrenia or mania compared to matched housed samples; about one-fourth of the homeless population report a history of psychiatric hospitalization.¹¹ In addition, the prevalence of schizophrenia is three times higher in jails than it is in the general population.¹² These psychiatrically ill patients become institutionalized through the criminal justice system,¹³ which does not provide the best opportunity or environment for treatment. Some studies have demonstrated slightly increased rates of violence among patients with schizophrenia as compared to those in the general population.^14,15 The increased risk of violence is thought to be related to delusional symptoms (e.g., paranoid beliefs that lead a patient to feel the need for retaliation against a person or group responsible for his or her symptoms) and substance abuse, but this has been debated, largely due to the stigmatizing effects of these data. There is some evidence that clozapine treatment may be associated with lower rates of violence and fewer arrests among patients with schizophrenia^16,17; this finding warrants further study. Finally, there is evidence to suggest that patients with chronic mental illness suffer from significant medical co-morbidities and that their symptoms may limit them from gaining access to the appropriate medical care in the community.

MEDICAL CO-MORBIDITY

Compelling evidence reveals that individuals with chronic mental illness have higher rates of medical morbidity and mortality when compared with those in the general population. Patients with schizophrenia have a life expectancy of 57 years for men and 65 years for women, which is nearly 20% shorter than the life expectancy of people without mental illness.¹⁸ The Massachusetts Department of Mental Health review of client deaths in 2000 revealed a mortality rate for patients with severe mental illness that was three times higher than it was in the age-matched comparison group.¹⁹ Cardiovascular disease was the most significant contributor to the increase in deaths, followed by respiratory illnesses. The difference in mortality rate between the two populations was most notable for individuals in the 25- to 44-year-old age-group. In this age-group, cardiac deaths were more than sixfold higher than were age-matched comparison samples.^19,20

Review of baseline data from the recent Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study also confirmed that patients with schizophrenia have a high prevalence of the metabolic syndrome,^21,22 which is a known risk factor for cardiovascular disease. Factors such as poor diet, a sedentary lifestyle, and lower rates of compliance with medication may also play a role in the elevated rates of physical morbidity and mortality in the chronic mentally ill population.