Cancer rates and mortality in people with severe mental illness: Further evidence of lack of parity

Cancer inequalities experienced by people with disability: a systematic review

BACKGROUND

People with disability experience worse cancer outcomes than people without disability. One potential pathway is through low screening participation leading to delayed cancer diagnosis and late disease presentation.

OBJECTIVE

To summarise and evaluate evidence quantifying disability-related inequalities in (1) cancer mortality, (2) fatality among cancer patients; and for cervical, breast, colorectal and lung cancers: (3) screening participation and (4) stage at diagnosis.

METHODS

We searched MEDLINE, Embase, PsycInfo and Scopus up to November 2023 for studies that quantified disability-related inequalities in the four outcomes. Studies were evaluated using the Risk Of Bias In Non-randomized Studies - of Exposures tool.

RESULTS

We found 73 eligible articles globally. People with disability had higher cancer mortality compared to those without. This inequality was most pronounced among people with intellectual disability. Evidence showed substantially higher fatality among cancer patients with disability compared to those without consistently across disability groups and cancer types. Screening uptake for breast, cervical and colorectal cancers was consistently lower for people with various disability types in multiple countries. Evidence regarding inequalities in stage at diagnosis for people with disability was limited and inconsistent. The main methodological challenges for future research are: complexity in defining disability, underestimation of inequalities due to over-adjustment of mediating factors, under-representation of people with severe disability in data, and reporting inequalities on relative scales only.

CONCLUSIONS

Existing evidence reinforces the need for high-quality cancer inequality research for this population, and a multi-pronged, inclusive approach to prioritise people with disability in the whole cancer control pathway.

Five-year survival following a non-small-cell lung cancer diagnosis among Veterans Health Administration patients with schizophrenia and bipolar disorder

OBJECTIVE

Veterans with schizophrenia or bipolar disorder (SZ/BP) experience excess mortality due to several reasons, including cancer. We evaluated whether disparities exist in stage of non-small-cell lung cancer (NSCLC) diagnosis and survival between Veterans Health Administration (VHA) patients with and without SZ/BP.

METHOD

This retrospective evaluation used VHA data to identify patients newly diagnosed with NSCLC from 2005 to 2014. Bivariate analyses compared NSCLC stage at diagnosis by SZ/BP status. Kaplan-Meier and adjusted Cox proportional hazards regression analyses examined differences in survival by SZ/BP status. Meaningful differences were assessed using statistical significance, p < .01, and effect sizes of least 0.2 less/greater than 1.

RESULTS

The cohort included 64,269 VHA patients with newly diagnosed NSCLC. These included 1605 (2.5 %) patients with schizophrenia and 1099 (1.7 %) with bipolar disorder. Stage at diagnosis did not meaningfully differ between patients with and without SZ/BP. After adjusting for stage of diagnosis and other factors, schizophrenia, but not bipolar disorder, was associated with an increased risk of five-year all-cause mortality compared to no SZ/BP (schizophrenia: HR 1.22, 95 % CI 1.14-1.30; bipolar: HR 1.01, 95 % CI 0.94-1.10).

CONCLUSIONS

VHA patients diagnosed with NSCLC who had schizophrenia experienced greater mortality compared to those without SZ/BP, despite no meaningful differences between the two groups in stage of NSCLC at diagnosis. Further work to understand drivers of this difference (e.g., access to NSCLC treatment) and subsequent interventions are needed.

Colorectal cancer mortality in persons with severe mental illness: a scoping review with meta-analyses of observational studies

BACKGROUND AND PURPOSE

Persons with severe mental illnesses (SMIs) have reduced participation in colorectal cancer (CRC) screening programs, higher odds of advanced stage at diagnosis, and are less likely to receive adequate treatment than the general population. It remains unclear to what extent these factors impact CRC outcomes for persons with SMI. The aim of this scoping review was to describe and quantify CRC mortality for persons with SMI compared with the general population.

PATIENTS/MATERIALS AND METHODS

We followed the JBI Manual for Evidence Synthesis and PRISMA guidelines in a systematic search of four databases from inception until April 29th, 2024. We included studies that provided CRC mortality estimates for adults with preexisting clinical diagnosis of SMI. We synthesized the results descriptively and pooled the data to estimate the magnitude of the associations.

RESULTS

Twenty-four original studies were identified with a total of 16.4 million persons. Most studies reported increased CRC mortality for persons with SMI compared with persons without SMI. The meta-analysis demonstrated a 25% increased CRC mortality for persons with SMI (e.g. pooled hazard ratio 1.25; 95% confidence interval 1.13 to 1.39; n = 13,178,161).

INTERPRETATION

The evidence points consistently to an increased CRC mortality for persons with SMI compared with persons without SMI. Furthermore, this evidence supports the idea that persons with SMI are a heterogenous population, and as such, any future initiatives to improve CRC outcomes for persons with SMI would warrant a tailored approach to potentiate individual resources, to mitigate stigma and structural discrimination.

Clinician Perspectives on Palliative Care for Older Adults With Serious Mental Illnesses: A Multisite Qualitative Study

OBJECTIVES

Approximately 5.5% of the population live with serious mental illnesses (SMI). Older adults with SMI experience a high burden of serious medical illnesses and disparities in advance care planning, symptom management, and caregiver support. The objectives of this study are to explore interdisciplinary clinician perspectives on the palliative care needs of older adults with SMI and serious medical illnesses.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study utilized thematic analysis of semi-structured interviews of interdisciplinary clinicians practicing palliative care, geriatrics, or geriatric/consultation-liaison psychiatry at four hospitals within an urban health system.

MEASUREMENTS

Themes related to care of older adults with serious mental illness and serious medical illness with respect to clinician experiences, challenges in care, and opportunities to improve care.

RESULTS

The authors interviewed 45 clinicians. Major themes identified were: (1) Current paradigms of palliative care do not meet the needs of patients with SMI; (2) Clinicians are motivated to care for this population but require more training and interdisciplinary practice; (3) There is a need for structural integration of psychiatric and palliative care services.

CONCLUSIONS

The study underscores the inadequacy of current palliative care models in meeting the unique needs of older adults with SMI. Models of integrated psychiatric and serious illness care and enhanced training are needed to improve the delivery of palliative care. Integrated care models and workforce development at the interface of serious illness care and psychiatric have the potential to improve outcomes for this vulnerable population.

Collaborative Approach to Cancer Care in Patients Who Have Co-Existing Severe Mental Illness With Psychotic Features

Severe and persistent mental illness with psychotic features as a comorbidity to a cancer diagnosis presents unique challenges to delivery of cancer care. Current literature suggests that there are poorer outcomes and higher mortality in patients with severe mental illness, partly explained by barriers to access of screening services and social vulnerability factors. However, cancer care is also delivered differently in patients with SMI, and often less aggressive care is offered. These healthcare disparities could be addressed in part by preparing for the ethical issues that can arise during the course of care. Cancer care staff may have limited experience and knowledge about treatment of psychiatric symptoms and may feel troubled in scenarios when patients lack capacity and become unwilling to participate in their care. Conversely, patients may benefit from early involvement of their mental health team for psychiatric optimization and contingency preparation. Specifically, preemptive planning between the cancer care team and the mental healthcare team can alleviate distress for the patient and healthcare teams alike. This is especially important when medical decision-making capacity can fluctuate during treatment. A person-centered, team-based approach to care delivery provides bidirectional empowerment. A process is proposed to enhance medical decision-making in patients with severe mental illness and cancer. It is imperative to acknowledge the disparities that exist in this patient population and create a process that will improve care and alleviate distress for the patient and the cancer care team.

The Challenging Problems of Cancer and Serious Mental Illness

PURPOSE OF REVIEW: Patients with Serious Mental Illness (SMI) are reported to be at higher risk for somatic disorders (e.g. cardiovascular and metabolic diseases) and higher mortality, compared to the general population, because of the consequences of SMI including psychotropic medication side effects, sedentary and unhealthy lifestyle, difficult access to physical health care. The aim of this review was to examine the current evidence regarding oncology, focusing on the problem of cancer among patients with SMI. RECENT FINDINGS: Compared to the general population, individuals with SMI showed a lower rate of screening for cancer, suboptimal standard cancer treatment, delayed treatment, and higher mortality from cancer. Several factors, including those related to the patient, the health-care system, and the social context, are involved in these negative outcomes. It is therefore necessary to raise awareness and alert clinicians in oncology settings to the challenging problem of cancer among patients with SMI, a marginalized and vulnerable segment of the population that can be at risk for not receiving proper cancer prevention and care. Evidence supports the mandatory need for an interdisciplinary approach involving psychiatry and mental health services.

Elevated mortality risks associated with late diagnosis of cancer in individuals with psychiatric disorders?

INTRODUCTION

Considering the elevated cancer mortality in individuals with psychiatric conditions, possibly associated with late diagnosis, this study investigated cancer screening participation rates among patients under the care of four Trieste community mental health centers (CMHCs).

METHODS

We conducted a retrospective cohort study on 1252 individuals with psychiatric disorders, retrieving their electronic health records up to December 2019. The study assessed participation rates in breast, cervical, and colorectal cancer screening programs. We explored differences in demographic and clinical characteristics of participants versus non-participants in screening programs.

RESULTS

Patients with psychiatric conditions had lower screening participation rates compared to the general population of Trieste. The rates for breast and cervical cancers were approximately one-third lower, whereas the rate for colorectal cancer was halved. Psychiatric diagnosis influenced participation in breast cancer screening, with patients having anxiety disorders more likely to participate than those suffering from schizophrenia or disorders of adult personality and behavior. Age, nationality, marital status, employment status, and living situation all affected adherence to cervical cancer screening. Individuals who participated more frequently were in the 35-54 age range, of Italian nationality, employed, and had a family of their own. Conversely, non-participants were more likely to be widowed or unmarried. Finally, among patients eligible for colorectal cancer screening, those who participated were more likely to have a family of their own and have a diagnosis of affective or anxiety disorders, while those who did not adhere to the programs were more commonly widowed and had a higher frequency of diagnosis of schizophrenia or disorders of adult personality and behavior.

CONCLUSIONS

Mental health services should focus on increasing patients' participation in cancer screening programs in order to improve their physical health and reduce mortality. This intervention could contribute to promoting equitable access to preventative care and to bridging the gap between mental health and general medical services.

Disparities in cancer care in individuals with severe mental illness: A narrative review

Individuals with severe mental illness (SMI) have higher mortality rates from cancer than individuals without SMI. The aim of this paper is to highlight these disparities in cancer care in individuals with SMI and suggest potential solutions. We conducted a narrative review of published papers, focusing on mortality, incidence, behavioral and provider risk factors, screening, diagnosis, treatment, and palliative care among individuals with SMI and cancer. The literature does not provide a clear consensus on whether a difference in cancer incidence exists among individuals with SMI compared to the general population. However, it is evident that individuals with SMI have higher mortality from cancer. Factors such as increased cancer related risk behavior, mental health stigma, and difficulty accessing cancer care contribute to this mortality difference. The literature also indicates lower screening rates, delayed and improper diagnosis and treatment, as well as inadequate clinical trial enrollment in individuals with SMI. While the literature is inconclusive regarding disparities in palliative care, we outline key concepts to provide the best possible end of life care to this population. We also summarize strategies to address disparities at the screening, diagnostic, and treatment levels and describe general strategic approaches to improve cancer care in individuals with SMI. We highlight patient-related, physician-related, and healthcare/systems-related factors leading to disparities in cancer care in individuals with SMI. Future research must examine the effectiveness of proposed solutions to guide evidence-based practices.

Cancer characteristics in patients with schizophrenia: a 25-year retrospective analysis

Schizophrenia is associated with higher cancer-related mortality, perhaps due to delayed diagnosis and limited access to treatment. The study aimed to compare patients diagnosed with cancer with and without schizophrenia to determine whether these groups differ in terms of oncological variables and survival outcomes. This was a retrospective, observational cohort study that included 30.990 patients diagnosed with cancer between 1997 and 2021. We performed univariate and bivariate analyses for the sociodemographic and clinical variables, and constructed Kaplan-Meier survival curves and used the log-rank test to perform the comparisons. All variables were compared for each cancer type. One hundred and sixty-two (0.52 %) patients had a confirmed diagnosis of schizophrenia (ICD-9 criteria). The mean age at diagnosis was significantly lower in the schizophrenia group. A significantly higher proportion of the schizophrenia group was diagnosed with cancer through the emergency department and a lower percentage through scheduled appointments. A smaller percentage of patients in the schizophrenia group received radical treatment for cancer. The mortality rate was higher in the schizophrenia group and median survival was lower. These findings suggest that cancer patients with schizophrenia have worse outcomes than patients without schizophrenia in terms of oncological variables and survival.

Delirium risk and mortality in people with pre-existing severe mental illness: a retrospective cohort study using linked datasets in England

BACKGROUND

Delirium is a severe neuropsychiatric syndrome caused by physical illness, associated with high mortality. Understanding risk factors for delirium is key to targeting prevention and screening. Whether severe mental illness (SMI) predisposes people to delirium is not known. We aimed to establish whether pre-existing SMI diagnosis is associated with higher risk of delirium diagnosis and mortality following delirium diagnosis.

METHODS

A retrospective cohort and nested case-control study using linked primary and secondary healthcare databases from 2000-2017. We identified people diagnosed with SMI, matched to non-SMI comparators. We compared incidence of delirium diagnoses between people with SMI diagnoses and comparators, and between SMI subtypes; schizophrenia, bipolar disorder and 'other psychosis'. We compared 30-day mortality following a hospitalisation involving delirium between people with SMI diagnoses and comparators, and between SMI subtypes.

RESULTS

We identified 20 566 people with SMI diagnoses, matched to 71 374 comparators. Risk of delirium diagnosis was higher for all SMI subtypes, with a higher risk conferred by SMI in the under 65-year group, (aHR:7.65, 95% CI 5.45-10.7, ⩾65-year group: aHR:3.35, 95% CI 2.77-4.05). Compared to people without SMI, people with an SMI diagnosis overall had no difference in 30-day mortality following a hospitalisation involving delirium (OR:0.66, 95% CI 0.38-1.14).

CONCLUSIONS

We found an association between SMI and delirium diagnoses. People with SMI may be more vulnerable to delirium when in hospital than people without SMI. There are limitations to using electronic healthcare records and further prospective study is needed to confirm these findings.

Sex and gender differences in cancer in individuals with severe mental disorders

PURPOSE OF REVIEW

Although cancer incidence is similar between individuals with severe mental disorders (SMD) and the general population (GP), survival rates are lower, particularly in those with schizophrenia. While the scientific and medical communities acknowledge sex differences in cancer mechanisms, including risk factors and cancer types, less is known about sex and gender disparities in incidence, mortality, and care pathways among those with SMD. This review aims to explore these differences in cancer among individuals with SMD.

RECENT FINDINGS

Current evidence on sex and gender differences in cancer care for SMD is limited. It is unclear how these factors affect cancer incidence and mortality in the SMD population, and if they correspond to those in the GP. The literature frequently omits detailed information on sex-based differences in SMD-related cancer rates, complicating conclusive analysis. Moreover, people with SMD experience significant challenges in accessing cancer screenings compared to the GP, and findings on sex and gender disparities in this context remain inconclusive.

SUMMARY

This review emphasizes that while significant sex and gender-based differences in cancer mechanisms, incidence, and survival exist within the GP, they have not been fully integrated into clinical practice. It underscores the need of addressing these differences in cancer incidence, outcomes, mortality, and care pathways to enhance treatment for individuals with SMD.

Shaping research for people living with co-existing mental and physical health conditions: A research priority setting initiative from the United Kingdom

INTRODUCTION

Those with severe and enduring mental ill health are at greater risk of long-term physical health conditions and have a reduced life expectancy as a result. Multiple factors compound this health inequality, and the need for setting research priorities in this area is highlighted with physical and mental healthcare services being separate, and limited multimorbidity research.

METHODS

The aim of this exercise was to work in partnership with healthcare professionals and carers, family, friends and individuals with lived experience of both mental and physical health conditions, to set research priorities to help people with mental health conditions to look after their physical health. The exercise was guided by the James Lind Alliance approach. For this, a steering group was set up, two surveys were completed and a final priority workshop was conducted.

RESULTS

This priority setting exercise guided by people's needs and lived experience has produced a set of well-defined research topics. Initially, 555 research questions were suggested in the first survey, which were refined to 54 questions for the second survey. A priority setting workshop was then conducted to get the final 10 priorities.

CONCLUSIONS

Taking these topics forward to improve services and treatment for both mental and physical ill health may in turn improve physical health and lessen the reduced life expectancy of those living with mental ill health.

PATIENT OR PUBLIC CONTRIBUTION

This work was completed in collaboration with people who have lived experience of mental ill health and physical health conditions, as well as carers, family and friends. Their contribution has been significant for this work from piloting surveys, amending language used and educating the researchers and contributing to this paper. The initial work was completed with a steering group and continued with surveys and workshops.

The causal relationship between severe mental illness and risk of lung carcinoma

Observational studies have suggested a link between severe mental illness (SMI) and risk of lung carcinoma (LC); however, causality has not been established. In this study, we conducted a two-sample, two-step Mendelian randomization (MR) investigation to uncover the etiological influence of SMI on LC risk and quantify the mediating effects of known modifiable risk factors. We obtained summary-level datasets for schizophrenia, major depressive disorder (MDD), and bipolar disorder (BD) from the Psychiatric Genomics Consortium (PGC). Data on single nucleotide polymorphisms (SNPs) associated with lung carcinoma (LC) were sourced from a recent large meta-analysis by McKay et al. We employed two-sample MR and two-step MR utilizing the inverse variance weighted method for causal estimation. Sensitivity tests were conducted to validate causal relationships. In two-sample MR, we identified schizophrenia as a risk factor for LC (OR = 1.06, 95% CI 1.02-1.11, P = 3.48E-03), while MDD (OR = 1.18, 95% CI 0.98-1.42, P = .07) and BD (OR = 1.07, 95% CI 0.99-1.15, P = .09) showed no significant association with LC. In the two-step MR, smoking accounted for 24.66% of the schizophrenia-LC risk association, and alcohol consumption explained 7.59% of the effect. Schizophrenia is a risk factor for lung carcinoma, and smoking and alcohol consumption are the mediating factors in this causal relationship. LC screening should be emphasized in individuals with schizophrenia, particularly in those who smoke and consume alcohol regularly.

The Emergence of a Psychotic Disorder With a Diagnosis of Breast Cancer Metastasized to the Brain: A Case Report

It is known that psychotic patients have a reduced ability to evaluate reality and self-care. However, no case has been reported in which a breast lump was misdiagnosed as an insect bite and neglected, and a diagnosis of psychotic disorder led to metastatic breast cancer. A 44-year-old woman diagnosed with invasive breast cancer with brain metastasis became unresponsive with little reaction to verbal communication as a result of successive life-threatening events. After her presentation to the emergency department, she was diagnosed with metastatic breast cancer as a result of detailed examinations. The patient, who did not have any psychiatric illness or alcohol or drug addiction in her medical history, was so insensitive to herself and her environment that she could not notice the large mass in her breast and the bad odors coming from her. According to these findings, the patient was suspected to have a psychotic disorder accompanied by substupor, and olanzapine 2.5 mg/day was administered. If the diagnosis of psychotic disorder is not recognized and treated, the highly visible breast lump may be misperceived and cancer treatment may be delayed, thus the cancer may progress. Early recognition and treatment of mental disorders affect the mortality and morbidity of patients.

Physical health disparities and severe mental illness: A longitudinal comparative cohort study using hospital data in Northern Ireland

BACKGROUND

People with severe mental illness (SMI) die prematurely, mostly due to preventable causes.

OBJECTIVE

To examine multimorbidity and mortality in people living with SMI using linked administrative datasets.

METHOD

Analysis of linked electronically captured routine hospital administrative data from Northern Ireland (2010-2021). We derived sex-specific age-standardised rates for seven chronic life-limiting physical conditions (chronic kidney disease, malignant neoplasms, diabetes mellitus, chronic obstructive pulmonary disease, chronic heart failure, myocardial infarction, and stroke) and used logistic regression to examine the relationship between SMI, socio-demographic indicators, and comorbid conditions; survival models quantified the relationship between all-cause mortality and SMI.

RESULTS

Analysis was based on 929,412 hospital patients aged 20 years and above, of whom 10,965 (1.3%) recorded a diagnosis of SMI. Higher likelihoods of an SMI diagnosis were associated with living in socially deprived circumstances, urbanicity. SMI patients were more likely to have more comorbid physical conditions than non-SMI patients, and younger at referral to hospital for each condition, than non-SMI patients. Finally, in fully adjusted models, SMI patients had a twofold excess all-cause mortality.

CONCLUSION

Multiple morbidities associated with SMI can drive excess mortality. While SMI patients are younger at referral to treatment for these life-limiting conditions, their relatively premature death suggests that these conditions are also quite advanced. There is a need for a more aggressive approach to improving the physical health of this population.

Experiences of Everyday Life among Individuals with Co-Existence of Serious Mental Illness and Cancer-A Qualitative Systematic Literature Review

Daily life with severe mental health (SMI) and cancer comorbidity entails multiple challenges. The study aims to explore everyday life experiences among individuals with SMI and cancer comorbidity from the perspectives of patients, significant others, and involved healthcare professionals. The study is registered in PROSPERO (CRD42021259604). A qualitative systematic review was conducted through searches in the databases MEDLINE, CINAHL, PsychInfo, and Web of Sciences (last search 14 February 2023). Inclusion criteria were empirical qualitative research studies investigating experiences of healthcare and everyday life among persons living with SMI and who were subsequently diagnosed with cancer from the perspective of the individuals themselves, their significant others, and healthcare professionals involved in their care. Exclusion criteria: Literature reviews, quantitative studies, intervention studies, quantitative parts of mix-methods studies, non-English languages, persons <18 years, dementia/learning disabilities, diagnosed with anxiety/depression as a consequence of cancer. Seven articles, published between January 2011 and February 2023, were included and analysed through a thematic analysis. The PRISMA 2020 checklist guided the study. The results were presented in four themes: 'Navigating between different worlds and logics', 'Decision-making capacity depending on the assessor', 'Cancer must give way to severe mental illness or vice versa', and 'Significant others as a safety net'. Research about the everyday lives of persons with SMI and cancer comorbidities from patients' and relatives' perspectives is lacking and thus called for.

Breast cancer risks following antipsychotic use in women with bipolar disorder versus schizophrenia: A territory-wide nested case-control study spanning two decades

Accrued epidemiologic data largely support an association of antipsychotic use with breast cancer in women with schizophrenia. No studies have specifically investigated such risks in women with bipolar disorder. This study aims to examine the association between antipsychotics and breast cancer in women with bipolar disorder and compare it against schizophrenia. We conducted a nested case-control study using a territory-wide public healthcare database in Hong Kong examining women aged ≥18 years with bipolar disorder or schizophrenia. Using incidence density sampling, women with a breast cancer diagnosis were matched by up to 10 control participants. In total, 672 case participants (109 with bipolar disorder) and 6,450 control participants (931 with bipolar disorder) were included. Results show a significant association of first-generation antipsychotics with breast cancer in both women with schizophrenia [adjusted odds ratio (aOR) 1.49, 95% confidence interval (CI) 1.17-1.90] or bipolar disorder (aOR 1.80, 95% CI 1.11-2.93). Second-generation antipsychotics was associated with breast cancer only in women with bipolar disorder (aOR 2.49, 95% CI 1.29-4.79), with no significant association found in women with schizophrenia (aOR 1.10, 95% CI 0.88-1.36). In conclusion, further research on breast cancer risks is warranted for women with bipolar disorder on antipsychotics.

Breast Cancer Care Pathways for Women with Preexisting Severe Mental Disorders: Evidence of Disparities in France?

The excess cancer mortality in persons with severe mental illness (SMI) has been well documented, and research suggests that it may be influenced by care-related factors. Our objective was to assess breast cancer care pathways in women with SMI in France, using an exhaustive population-based data-linkage study with a matched case-control design. The cases were 1346 women with incident breast cancer in 2013/2014 and preexisting SMI who were matched with three controls without SMI presenting similar demographics, initial breast cancer type, and year of incidence. We compared cancer care pathways and their quality for cases and controls, using a consensual set of indicators covering diagnosis, treatment, follow-up, and mortality (until 2017). After adjusting for covariates, cases had lower odds to undergo the main diagnostic tests, lumpectomy, adjuvant chemotherapy, and radiotherapy, as well as hormone therapy, but higher odds for mastectomy. Suboptimal quality in cancer pathways was observed for both groups, but to a higher extent for cases, especially for not receiving timely care after diagnosis and post-treatment follow-up. Breast cancer mortality, considering competing risks of deaths, was significantly elevated in women with SMI. These findings highlight disparities in cancer care pathways for individuals with SMI, as well as specific aspects of the care continuum which could benefit from targeted actions to reach equity of outcomes.

Mortality in Schizophrenia-Spectrum Disorders: Recent Advances in Understanding and Management

Schizophrenia is a life-shortening disease and life expectancy in patients may be 15-20 years shorter than in the general population, with increasing longevity gap over time. Premature mortality in schizophrenia-spectrum disorders is mainly due to preventable natural causes, such as cardio-vascular disease, infections, respiratory tract diseases and cancer, alongside suicide, homicide and accidents. There is a complex interplay of factors that act synergistically and cause physical morbidity to patients and subsequent mortality. Smoking, alcohol/substance abuse and sedentary life style, alongside disease-related factors, such as metabolic abnormalities and accelerating aging contribute to physical morbidity. Moreover, the symptomatology of psychosis and stigma may limit patients' access to quality medical care. Interventions to promote physical health in those patients should be multifaceted, and should target all patient-related modifiable factors, but also should address service-related healthcare disparities. Long-term antipsychotic use (including clozapine and long-acting injectables) is associated with substantially decreased all-cause mortality, including suicide and cardiovascular mortality, in patients with schizophrenia despite the well-known cardiometabolic adverse effects of second-generation agents. Integrated care may involve co-location of physical and mental health services, liaison services, shared protocols and information sharing systems, and has emerged as a way to address the physical health needs of those patients. Interventions to address mortality in schizophrenia and related syndromes should take place as early as possible in the course of the patients' treatment, and could be an integral component of care delivered by specialized early intervention services.