Mortality Research & Consulting

Mortality of Severely Mentally Ill Outpatients in Texas, 2006-2008

SM Day, RJ Reynolds

An extensive body of research has documented that people with serious mental illness are at increased risk of mortality in comparison to the general population. This has been found to be true for seriously mentally ill (SMI) in-patients as well as for out-patients.

One of the more comprehensive of these studies looked at the mortality of public mental health clients in 16 states for periods between 1997 and 2000, varying by state.1 The study found that the SMI in each of these states were at greater risk of mortality than the general population in every year. The standardized mortality ratio (SMR) estimates from this study ranged from 1.2 to 4.9, with the state of Texas routinely having among the highest mortality for hospitalized SMI. The most frequent causes of death for the patients in Texas were external causes (mainly accidents and suicides) followed by heart disease and cancer. Since the focus in that article was on identifying the similarities and differences in the 16 states, little effort was made to explain the frequency of these causes of death or the overall increased in mortality in Texas.1

Two follow-up studies in the State of Texas looked at the mortality of the SMI at Public Mental Health outpatient clinics.2,3 One found that among the nearly 250,000 patients studied, external causes of death were the most frequent, inclusive of motor vehicle accidents, accidental overdoses, suicides, and homicides.2 The SMR for external causes declined throughout the study period, being 6.93 (95% CI 6.20-7.72) in 2006, 5.28 (95% CI 4.80-5.81) in 2007, and 4.82 (4.43-5.23) in 2008.2 After external causes, the next most frequent causes of death were diseases of the digestive, respiratory, and circulatory systems, with SMRs between 2.5 and 3.0 in these categories over the three years.2 A more refined look within these categories suggested that diseases and conditions related to substance abuse were the primary drivers of these SMRs. In the category of external causes these included intentional and accidental overdoses, and chronic diseases potentially associated with substance abuse included liver failure and respiratory diseases.2

The second article examined mortality of SMI in Texas in 38 of the Local Mental Health Authorities, or LMHAs.3 The LMHAs serve conglomerations of Texas counties and provide services to the SMI in those counties through outpatient clinics. The practical implication of this is that the treatment methods and models are controlled and funded by these administrative bodies, which in turn receive their funding from the state, creating a somewhat homogeneous treatment environment across the counties covered by a single LMHA. When analyzed at this level, it was found that while point estimates of age adjusted death rates (AADRs) for the SMI were greater than those of the general populations in all 38 LMHAs, in only 4 of them were these differences statistically significant.3 However, the significantly different AADRs were either in the LMHAs with the largest patient population sizes or among the most extreme point estimates, suggesting that statistical power may have been too low in the other AADRs to detect significant departures from the general population rates. It should be noted also that 32 of the 38 LMHAs saw reductions in the point estimates of the AADR over the 2006 to 2008 period. So though mortality rates for SMI outpatients may have been greater than for the general population, they did improve in most of the state during that period.3 A tabulation of the causes of death for the SMI patients confirmed that in nearly all the LMHAs the most frequent were external causes.3

The in-depth analyses in these studies (Colton and Manderscheid 2006; Reynolds et al. 2013; and Reynolds et al. 2012) show that external causes of death are the most frequent for SMI outpatients in Texas. In particular, substance abuse, inclusive of illegal drugs, prescription drugs, alcohol and tobacco seem to play a central role. The recommendations of these papers are that the primary healthcare, mental health, and substance abuse systems need better integration and coordination to simultaneously treat medical and behavioral risk factors of mortality. Unless or until that occurs, mortality for SMI patients in Texas and elsewhere will likely remain high.


  1. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis 2006;3(2):A42.
  2. Reynolds RJ, Becker EA, Shafer AB. Causes of Death and Comparative Mortality in Texas Public Mental Health Clients, 2006-2008. Ment Health Clin. 2013;3(1):52.
  3. Reynolds RJ, Shafer AB, Becker EA. Mortality of public mental health clients treated at the Local Mental Health Authorities of Texas. Texas Public Health Journal 2012;64(2).


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