The life expectancy gap between people with severe mental illness (SMI) and the general population persists and may even be widening. This study aimed to estimate contributions of specific causes of death to the gap. Age of death and primary cause of death were used to estimate life expectancy at birth for people with SMI from a large mental healthcare case register during 2007-2012. Using data for England and Wales in 2010, death rates in the SMI cohort for each primary cause of death category were replaced with gender- and age-specific norms for that cause. Life expectancy in SMI was then re-calculated and, thus, the contribution of that specific cause of death estimated. Natural causes accounted for 79.2% of lost life-years in women with SMI and 78.6% in men. Deaths from circulatory disorders accounted for more life-years lost in women than men (22.0% versus 17.4%, respectively), as did deaths from cancer (8.1% versus 0%), but the contribution from respiratory disorders was lower in women than men (13.7% versus 16.5%). For women, cancer contributed more in those with non-affective than affective disorders, while suicide, respiratory and digestive disorders contributed more in those with affective disorders. In men, respiratory disorders contributed more in non-affective disorders. Other contributions were similar between gender and affective/non-affective groups. Loss of life expectancy in people with SMI is accounted for by a broad range of causes of death, varying by gender and diagnosis. Interventions focused on multiple rather than individual causes of death should be prioritised accordingly.
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Everyone knows that older people are at greater risk of dying if infected with coronavirus. Some have even suggested that most people dying of the virus would have died this year or next year anyway because of their age and frailty. But this is not true. In fact, the typical person who dies because of the virus loses over a decade of life. This means that in the UK alone, with almost 50,000 deaths from the virus, half a million years of life have already been lost. Each death is awful, but so is each lost day, month and year; the tragedy is much worse than many people realised. And that is before we consider other lost lives and life among other casualties of coronavirus. In this blog, I briefly explore these issues.
And of course, the loss is not only that of the person who has died. If not for the coronavirus, bereaved families and friends would have had over ten more years with its victims. It is not just the loss of a loved one that hurts; it is the loss of all the time we could have spent with them, and their ongoing absence where and when there should have been presence. This ongoing loss can severely reduce the quality of life of those left behind.
We should also remember that those who die because of Covid-19 are not the only ones whose lives are shortened by the virus. While many people who are hospitalised return to normal function, some of those who survive are likely to have ongoing health issues as a result, particularly lung and kidney problems caused by complications of acute respiratory distress syndrome. These complications will reduce their quality of life, and may shorten their lives as well, resulting in additional lost years of life.
But we must also consider those who have not yet died, but will die sooner because of delayed consultation and diagnosis caused by the virus. Cancer screening programmes have been suspended, GPs are doing telephone consultations, and as already mentioned many people are delaying contacting their GPs because of concerns about the virus. This does not mean that these people will die soon, but they may die sooner than they would have if the pandemic had not occurred; yet more lost years of life. And they, of course, have families too.
The most important limitation in COVID-19 attributable death or excess death approaches, however, is that these approaches do not provide information on how many life years have been lost. Deaths at very old ages can be considered to result in fewer life years lost, when compared to deaths at very young ages. In fact, several policy responses (or non-responses) have been motivated with the argument that COVID-19 is mostly killing individuals who, even in the absence of COVID-19, would have had few life years remaining. However, comprehensive evaluation of the true mortality impact of COVID-19 has not been conducted.
We analyze the premature mortality impact of COVID-19 by calculating the amount of life-years lost across 81 countries covering over 1,279,866 deaths. We base our analysis on two large recently established and continuously growing databases4,5 and on two different methodological approaches, one based on COVID-19 attributable deaths, and, for selected countries, one based on estimated excess deaths comparing recent mortality levels to an estimated baseline. We are not able to solve the measurement limitations of either of these approaches, but the complementary nature of the two ways of measuring COVID-19 deaths makes these concerns explicit and allows us to evaluate the implications. This study is also limited to premature mortality only; a full health impact evaluation might consider for instance, the burden of disability associated with the disease6. This latter dimension requires thorough understanding of sequelae associated with COVID-19, for which data are limited at this point on a cross-country, comparable level. As such, we focus on premature mortality here.
Country death counts by age and gender due to COVID-19 come from the COVerAge-DB4; the analysis includes all countries with at least one COVID-19 related death in4 at the time of the study. Population data are drawn from the Human Mortality Database5 and the World Population Prospects7. Country life expectancies are from the life tables in the World Population Prospects for the period 2015-2020.
In total, 20,507,518 years of life have been lost to COVID-19 among the studied 81 countries, due to 1,279,866 deaths from the disease. The average years of life lost per death is 16 years. As countries are at different stages of the pandemic trajectory, this study is a snapshot of the impacts of COVID-19 on years of life lost (YLL) as of January 6, 2021 (a complete list of countries and their dates at measurement is in the Supplementary Information). In 35 of the countries in our sample, coverage of the data spans at least 9 months; in such cases, this suggests that the full impacts of the pandemic in 2020, or at least the first waves of the pandemic, are likely captured. For other countries still on an upwards incline of transmission rates or for which data is yet forthcoming for end of 2020, the YLL experienced are likely to further increase substantially in the next few months. We encourage context-based interpretation of the results presented here, especially when used for evaluation of the effectiveness of COVID-19 oriented policies.
It has also become apparent that there are gender disparities in the experience of COVID-1914; our study finds this to be true not only in mortality rates, but in absolute years of life lost as well. In the sample of countries for which death counts by gender are available, men have lost 44% more years than women. Two causes directly affect this disparity: (1) a higher average age-at-death of female COVID-19 deaths (71.3 for males, 75.9 for females), resulting in a relatively lower YLL per death (15.7 and 15.1 for males and females respectively); and (2) more male deaths than female deaths in absolute number (1.39 ratio of male to female deaths).
These results must be understood in the context of an as-of-yet ongoing pandemic and after the implementation of unprecedented policy measures. Existing estimates on the counterfactual of no policy response suggest much higher death tolls and, consequently, YLL. Our calculations based on the projections by8 yield a total impact several orders of magnitude higher, especially considering projections based on a complete absence of interventions (see Supplementary Information for details on projections). This is in line with further evidence of the life-saving impacts of lockdowns and social distancing measures15.
As noted earlier, our analysis is limited to premature mortality. A full health impact evaluation ought to consider the burden of disability associated with the disease.Indeed, YLL are often presented jointly with years lived with disability (YLD) in a measure known as disability-adjusted life year (DALY), constructed by adding YLD to YLL19. In order to compute YLD, though, we must have a thorough understanding of the sequela associated with the disease, as well their prevalence. Several sequelae have been linked to COVID-19 recently20,21 in China, but we still lack the full understanding of the extent that would be needed to compute reliable cross-national YLD measures at the scale of this article. We see collection of such measures as therefore of key importance in next steps in advancing our understanding of the magnitude of the COVID-19 effects on public health.
Some of our findings are consistent with dominant narratives of the COVID-19 impact, others suggest places where more nuanced policy-making can affect how the effects of COVID-19 might be spread among society. Our results confirm that the mortality impact of COVID-19 is large, not only in terms of numbers of death, but also in terms of years of life lost. While the majority of deaths are occurring at ages above 75, justifying policy responses aimed at protecting these vulnerable ages, our results on the age pattern call for heightened awareness of devising policies protecting also the young. The gender differential in years of life lost arises from two components: more men are dying from COVID-19, but men are also dying at younger ages with more potential life years lost than women. Holding the current age distribution of deaths constant, eliminating the gender differential in YLL would require on average a 34% reduction in male death counts; this suggests that gender-specific policies might be equally well justified as those based on age. 041b061a72