The Cost of Mental Illness: Side Effects

In developed countries, mental illness causes more disability than any other disease group, including cancer. In 2004, 25% of adult Americans reported having a mental illness in the previous year2. As a consequence, the cost of mental illness is astronomical; it was approximately $300 billion in 2002 in the US alone2, accounting for 6.2% of US healthcare spending. That amounts to about $1,000 a year for every American5. However, if that price is the prescription for mental illness, it’s got plenty of side effects, because the sum, while staggering, only represents a fraction of the actual cost of mental illness. The true tally is much higher and harder to calculate, and includes the toll of mental illness on society, the ill and their families.

Social side effects

Mental illness and resulting discrimination impair the abilities of the ill to participate in society, and rob communities of their contributions. The cost of the work hours and wages lost due to the absence of the ill is referred to as productivity loss. In the UK, depression results in productivity losses that are 23 times as great as the associated healthcare costs, and is the most important cause of absenteeism from the workplace4. Mental illness can also relegate the suffering to the outskirts of society, with severe consequences. In the US, 22% of the incarcerated and 1/3 of the adult homeless population are mentally ill5, and it is estimated that for every £1 of healthcare spending on those referred for addiction treatment in the UK, £3 is spent on them by the criminal justice system, and £10 by the victims of crime4. The mentally ill are also less likely to be hired or be rented to, and more likely to be falsely charged with a violent crime3.

mental illness
For reference: this is what $1 billion in $100 bills looks like.

This social segregation has insidious effects. Working is not just a means to an economic end; it also imparts self-esteem to the employee, and expands their social network4. The benefits of social inclusion are sorely needed by the mentally ill, and could aid in their treatment and recovery. Being ostracized may actually prolong illness or contribute to relapse by lowering self-worth, perpetuating the cause of unemployment and exclusion, and creating a terrible feedback loop.

Personal side effects

While the cost of mental illness to society is very dear, it pales in comparison to the price paid by the afflicted and their families. The mentally ill shoulder physical, emotional, and social burdens as a result of their illness. Serious mental illnesses, such as schizophrenia, cause poor personal care and lifestyle choices (e.g. a high fat diet), which can negatively affect overall health and self-esteem, and act as barrier to social acceptance. The seriously mentally ill smoke 44% of cigarettes used in the US5, and are more likely to be overweight; 40-60% of people with schizophrenia are overweight or obese, which in turn makes them more likely to suffer from diabetes and cardiovascular disease7.

Unfortunately, seeking help isn’t without its own consequences. The treatment for mental illness often includes medication that can have serious side effects. Antidepressants can cause gastrointestinal (e.g. nausea, vomiting) and neuropsychiatric (e.g. drowsiness and dizziness) issues, and negatively interact with other drugs8. Antipsychotics can contribute to weight gain, and those that do put the patient at a greater risk for type II diabetes. Some antipsychotics may also increase the risk of movement disorders, cataracts, and cardiac dysfunction, such as arrhythmias7. Depression and schizophrenia, as well as their respective treatments, are also associated with negative sexual effects, meaning they impair sexual function and satisfaction1.

Stigma and its corollaries, prejudice and discrimination, are pervasive issues for the mentally ill, and mental illnesses have become increasingly stigmatized over the past few decades. These interactions depend on an ‘us’ and ‘them’ mentality perpetuated by stereotypes, and a social, economic, or political power imbalance between the groups. With that dynamic in place, the mentally ill are subjected to both everyday and structural discrimination. Stigma can also be internalized by the ill, a phenomena called self-stigmatization. Stigma strains familial ties; 20% of respondents to a family survey reported lower self-esteem and tenser relationships with other family members as a result of stigma3. The impact of stigma is profound, and can cause the ill to shun treatment, in order to avoid the label of mental illness and its resulting social repercussions6.

The social backlash against mental illness is contingent in part on the idea that it is rare. It isn’t; it’s incredibly common. And while the burden of its symptoms and their treatment is unavoidable, the sting of stigma is not. Acceptance and understanding of mental illness can lighten the load. Mental illness will never be painless, but we might be able to make it a little less expensive.

References

1. Baldwin, D, & A Mayers. (2003). Sexual side-effects of antidepressant and anti-psychotic drugs. Advances in Psychiatric Treatment, 9:202-210.

2. CDC Mental Illness Surveillance. Centers for Disease Control and Prevention. 2 December 2013. Web. 27 April 2014. http://www.cdc.gov/mentalhealthsurveillance/faqs.html

3. Corrigan, PW. (1998). The impact of stigma on severe mental illness. Cognitive and Behavioral Practice, 5:201-222.

4. Knapp, M. (2003). Hidden costs of mental illness. British Journal of Psychiatry, 183:477-478.

5. Insel, TR. (2008). Assessing the economic costs of serious mental illness. American Journal of Psychiatry, 165(6):663-665.

6. Rüsch, N, MC Angermeyer, & PW Corrigan. (2005). Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. European Psychiatry, 20:529-539.

7. Üçok, A, & W Gaebel. (2008). Side effects of atypical antispychotics: a brief overview. World Psychiatry, 7(1):58-62.

8. Wilson, K, & P Mottram. (2004). A comparison of side effects of selective serotonin reuptake inhibitors and tricyclic antidepressants in older depressed patients: a meta-analysis. International Journal of Geriatric Psychiatry, 19:754-762.

Image source: http://www.moneybagsfull.com/2010/08/what-does-1-billion-dollars-in-cash.html

Pulmonary Embolism: A Special Request

Aliases: pulmonary embolism, PE, venous thromboembolism

Because this is a special, themeless post, I decided to cut to the chase and talk about what I imagine people really want to know when they’ve been diagnosed with pulmonary embolism (PE): what will my life be like now? Within the medical community, quality of life (QoL) is defined as the “patients’ recorded impact of disease and treatment on his/her physical, psychological and social functioning and wellbeing”4. While the biological impact of PE is relatively concrete and can be conveniently assessed statistically, the social and psychological effects are subjective and consequently much harder to measure.

The clinical component of QoL is relatively straightforward and, in this case, fairly positive. The recurrence and mortality rates after diagnosis are low. PE-related mortality is less than 2% during the typical 3-6 month anticoagulant/thrombolytics treatment period following a PE, and remains fairly steady (rising to 2.7%) over the course of 3.1 years. The risk of recurrent PE is higher: around 6% during the first 6 months after diagnosis, and rising to a cumulative recurrence rate of between 29.1-34.5% (depending on the study) over the following 10 years. When recurrent PE occurs, it has an estimated case fatality rate of between 10-45%. However, this is very likely an overestimate, because autopsies are rarely conducted when recurrent PE is suspected as the cause of death. More likely than recurrence are related complications, such as residual perfusion defects, which affect 31.4% of PE patients within the first 12 months after their diagnosis2.

The social and psychological effect of PE, its impact on the patient’s perception of their wellbeing, is much more varied1, but there are some fairly consistent trends. While overall QoL for PE patients is lower than healthy control groups, it is significantly higher across the board than patients suffering from chronic cardiovascular diseases, specifically chronic obstructive pulmonary disease (COPD) and congestive heart failure. PE’s long-term impact is similar to other acute cardiovascular disorders; the QoL for PE patients is roughly equal to that of acute myocardial infarction (aka heart attack) patients. Finally, the best news: it gets better. The further from the diagnosis, the higher PE patients rated their QoL4.

pulmonary embolism
It’s all relative.

Cause: PE is caused by material, usually a blood clot, lodging in one or more pulmonary arteries, blocking blood flow to lung tissue. These clots almost always travel to the lungs from the legs and are often the result of deep vein thrombosis (DVT), a condition where a blood clot forms in a vein deep in the body. While anyone can develop DVT and PE, several factors increase the likelihood of their occurrence. Surgery, especially hip and knee replacements, are a leading cause, because they may introduce tissue debris into the bloodstream, and require immobility both during and after the procedure. Other risk factors include a family history of blood clots, heart disease, or certain cancers, as well as prolonged immobility (e.g. bed rest), being overweight, pregnancy and smoking. Unfortunately, one bad turn can beget another; once a person has had one embolism he or she has a greater risk of having another3.

Consequence: The most common symptoms of PE are a sudden shortness of breath that gets worse with exertion, chest pain, reminiscent of a heart attack, that may increase with coughing, breathing deeply, or bending over, and coughing that may produce bloody sputum. Other symptoms include leg pain or swelling, clammy or discolored skin, rapid or irregular heartbeat, dizziness, and excessive sweating. However, the symptoms of PE are highly variable, and depend on the size of the clots (there are almost always more than one), how much of the lung is affected, and the how healthy the person was before the PE3.

Cure: Treatment is critical for pulmonary embolism; approximately 1/3 of untreated patients will die. Because PE can be difficult to diagnose, physicians generally use multiple approaches, including blood tests for clotting factors, and a variety of body scans (e.g. x-rays, CT scans, or an MRI). Once it has been identified, PE is treated by either breaking down the blood clot with anticoagulants (blood thinners) and thrombolytics (clot dissolvers) or removing the clot surgically, or both. In extreme cases, PE is treated with an implanted vein filter that prevents blood clots from reaching the heart and lungs3.

References

1. Hogg, K, M Kimpton, M Carrier, D Coyle, M Forgie, & P Wells. (2013). Estimating quality of life in acute venous thrombosis. Journal of the American Medical Association Internal Medicine, 173(12).

2. Meyer, G, B Planquette, & O Sanchez. (2008). Long-term outcome of pulmonary embolism. Current Opinion in Hematology, 15:499-503.

3. Pulmonary embolism. Mayo Clinic. 2 January 2014. Web. 11 April 2014. http://www.mayoclinic.org/diseases-conditions/pulmonary-embolism/basics/definition/con-20022849

4. van Es, J, PL den Exter, AA Kaptein, CD Andela, PMG Erkens, FA Klok, RA Douma, ICM Mos, DM Cohn, PW Kamphuisen, MV Huisman, & S Middeldorp. (2013). Quality of life after pulmonary embolism as assessed with SF-36 and PEmb-QoL. Thrombosis Research, 132:500-505.

Image source: http://integral-options.blogspot.com/2012/02/pierre-cote-relative-happiness-index.html