New research from the Institute of Psychiatry, Psychology & Neuroscience, supported by the Population Mental Health Consortium and ESRC Centre for Society and Mental Health, has found that social exclusion in South London is a potentially contributing factor in premature death in people with severe mental illness, and may be evident in people as young as 15 years old.
Previous research has shown that social exclusion in the general population can determine health outcomes, leading to poorer mental health as well as higher rates of mortality. However, the relationship between social exclusion and mortality in severe mental illness has up until now been under-researched.
Published today in Psychological Medicine, the large cohort study led by Professor Jayati Das-Munshi, found strong associations between adverse social conditions and earlier deaths in people with severe mental health conditions. This is significant as people with severe mental health conditions die on average 15 to 20-years earlier than the general population. Based on these findings, the authors suggest that socially-focussed interventions could be explored as a potential approach to improve survival in those with severe mental illness.
The study included 8,098 people in South London with schizophrenia-spectrum and bipolar affective disorders (known as severe mental illnesses) and 581,209 people living in the same four boroughs of South London, but with no recorded contact with secondary mental health services.
The team used three linked datasets followed up over nearly six years, including ethically approved electronic health records from the South London and Maudsley NHS Foundation Trust, one of Europe's largest mental health service providers. Using Clinical Record Interactive Search (CRIS), the team were able to link data from individuals with schizophrenia-spectrum or bipolar affective disorders anonymously to their census data which they used to measure social exclusion. These records were also linked to information on deaths.
Social exclusion was defined as an "enforced lack of participation in key social, cultural and political activities". Census data was used to measure markers of social exclusion including data on marriage and partnerships, exclusion from employment and higher education, as well as housing stability and wealth.
Social exclusion in severe mental illness
People with severe mental illness are more likely to experience social exclusion, potentially due to stigma and discrimination. The study found that indicators of social exclusion were higher in the severe mental illness group than those without severe mental illness across all ages.
Dr Lukasz Cybulski, second author on the paper, said: "While social exclusion data is not often collected in health records, by using data linkage we were able to anonymously link the health records of those diagnosed with severe mental illness to their census data, to understand levels of social exclusion. We were then able to connect this data with the Office for National Statistics death certificate information, to record mortality. Data linkage is a useful tool that allows us to investigate issues that are not necessarily well documented by health services, like social inequalities."
Reduced life expectancy
This study found that mortality was higher overall in the severe mental illness group than those without severe mental illness, and that this was linked to social exclusion. Even in the youngest age group, encompassing those aged 15 to 44 years, social exclusion was linked with excess mortality: an association which was not observed in those without severe mental illness.
In particular, the team found that never being married or in a civil partnership was a strong contributing factor in early death in the younger group. They speculate that further research should therefore be conducted into whether close personal relationships play an important role in minimising suicides, which will be explored in future work.
This study is particularly important given the high levels of stigma and discrimination experienced by people with severe mental illness. Social exclusion is a complex issue, which can be experienced across multiple areas of life. Our findings suggest that socially focussed interventions which may mitigate against social exclusion, such as peer-support or employment interventions, should be explored in further research. Such approaches may play an important role, when it comes to preventing early deaths in people with severe mental health conditions like psychosis and bipolar disorders."
Professor Jayati Das-Munshi, lead author on the paper, Professor of Social & Psychiatric Epidemiology at the Institute of Psychiatry, Psychology & Neuroscience at King's College London
