Serious mental illness (SMI) is generally considered to be bipolar and schizophrenia: the two or the three forms of psychosis that Kraepilin separated a century ago (the other is delusional disorder). The delineation between bipolar and schizophrenia is quite difficult and requires time, which is a reason that clinicians tend to talk about psychosis until the illness course is clear. This has been criticized, particularly by Richard Bentall.

If the 19th Century concept of schizophrenia is to be abandoned, what will replace it in the 21st Century? Some have argued that categorical classifications can be replaced by dimensional conceptions, with patients rated on a series of different continua. For example, patients can be rated according to the severity of their positive symptoms, negative symptoms and formal thought disorder. This approach squares well with recent epidemiological data that show that subclinical psychotic phenomena are surprisingly common in the general population.

Another approach advocated by the present author is to abandon the pretence that the complexity of psychiatric problems will be adequately captured by any simple method of classification, and instead try to explain the actual complaints (symptoms) experienced by psychiatric patients. On this account, once we have successfully explained why people have hallucinations, delusions, thought disorders and so on, there will be no such schizophrenia left over to explain.

I’d disagree with Bentall, but let us consider if SMI itself is a disorder? Does it shorten life?

Well, it does, and this is getting — apparently worse.

Background

Bipolar disorder and schizophrenia are associated with increased mortality relative to the general population. There is an international emphasis on decreasing this excess mortality.

Aims

To determine whether the mortality gap between individuals with bipolar disorder and schizophrenia and the general population has decreased.

Method

A nationally representative cohort study using primary care electronic health records from 2000 to 2014, comparing all patients diagnosed with bipolar disorder or schizophrenia and the general population. The primary outcome was all-cause mortality.

Results

Individuals with bipolar disorder and schizophrenia had elevated mortality (adjusted hazard ratio (HR) = 1.79, 95% CI 1.67–1.88 and 2.08, 95% CI 1.98–2.19 respectively). Adjusted HRs for bipolar disorder increased by 0.14/year (95% CI 0.10–0.19) from 2006 to 2014. The adjusted HRs for schizophrenia increased gradually from 2004 to 2010 (0.11/year, 95% CI 0.04–0.17) and rapidly after 2010 (0.34/year, 95% CI 0.18–0.49).

Conclusions

The mortality gap between individuals with bipolar disorder and schizophrenia, and the general population is widening.

Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000–2014
Joseph F. Hayes, Louise Marston, Kate Walters, Michael B. King, David P. J. Osborn
The British Journal of Psychiatry Jul 2017, bjp.bp.117.202606; DOI: 10.1192/bjp.bp.117.202606

But is it? The mortality rate for bipolar and Schizophrenia is, from the data shown, decreasing. However, it is decreasing more slowly than the general UK population. This leads to an increased Hazard Ratio. Either the illness is toxic — and there is some evidence that people with psychosis have insulin resistance before they are diagnosed — confirmed with insulin clamp studies, but there is a marked increase in suicide in the seriously mentally ill.

So yes, SMI is important, and there is an increased relative hazard risk for mortality among those who suffer from this. We can debate the divisions. But we cannot call these phenomena normal, or the illness a myth.