People diagnosed with a mental illness tend to die 15 to 20 years earlier than those who do not have a mental illness. Many of these early deaths are from preventable physical illnesses like heart disease, cancer and respiratory disease (NHS England 2024). Parity of esteem has been a hot and important topic for over 10 years and is described as valuing mental health equally with physical health (Mitchel et al 2017; Hilton et al 2016; Sheikh 2022; NHS England 2024). Those who have a mental illness often experience diagnostic overshadowing (when their symptoms of physical illness are explained as mental illness when in fact there is a physical cause) and people can be wrongly turned away from receiving physical health support (Hallyburton 2022).
Previous blogs have highlighted that there is an elevated risk of several chronic physical conditions both at the point of diagnosis of a severe mental illness as well as 5 years after suggesting early intervention is vital to reduce the mortality gap. The elves have also presented population data showing that overall deaths are three times higher for people with diagnosis of bipolar disorder compared to the general population.
Respiratory disease has been highlighted as one of the main preventable physical illnesses, alongside cardiac health, that shorten the lives of people diagnosed with a mental illness (NHS Digital 2024; Office for Health Improvement and Disparities 2024).
Laguna-Muñoz et al., (2025) focus on people with bipolar disorder (BD) and their increased risk of early death and death caused by a respiratory issue. The inclusion criteria cover several respiratory illnesses, including asthma, chronic obstructive pulmonary disease (COPD), pneumonia, lung cancer and tuberculosis.
This elf isn’t just for Christmas. It’s time for ‘Equality, Lung health, and Fairness’ for those with mental illness! Nothing says ‘parity of esteem’ quite like being told your chest pain is just anxiety for the third time this month.
Respiratory disease has been highlighted as one of the main preventable physical illnesses, alongside cardiac health, that shorten the lives of people diagnosed with a mental illness.
Methods
Laguna-Muñoz et al., (2025) followed international guidelines for systematic reviews and registered their study in PROSPERO, which is the international systematic review registry. They searched major databases up to June 2023 for studies on over 18s with BD and common lung diseases like asthma, COPD, and pneumonia. Only observational studies with medical diagnoses were included. Two reviewers independently collected and analysed the data.
They assessed study quality, calculated how common these lung diseases were in people with BD, and compared them to control groups where possible. They also explored how factors like age, sex, location, and smoking affected the results, using statistical techniques like meta-analysis and meta-regression.
On review of the paper, the author used the right type of papers to obtain the results they were looking for, and the number of papers considered is vast, and there are no gaps that I could see while completing a review using the CASP critical appraisal tool. The authors considered the risk of bias well and also the quality of the studies, with most being rated ‘good’ or ‘fair’, which is great in terms of mental health research.
Results
Laguna-Muñoz et al., (2025) reviewed the link between bipolar disorder (BD) and common lung diseases like asthma, chronic obstructive pulmonary disease (COPD), pneumonia, lung cancer, and tuberculosis. They included 20 studies involving over 960,000 people with BD, with an average age of 54 years and nearly 45% being male.
Key Findings
This meta-analysis revealed that approximately 5.4% of individuals with bipolar disorder had some form of lung disease. More specifically:
- Risk of asthma was double that of the general population, identified in 4% of people with BD. This increased risk was particularly pronounced in hospital-based and retrospective studies, suggesting both healthcare settings and study design influence the observed outcomes.
- Risk of Chronic Obstructive Pulmonary Disease (COPD) was 1.7 times higher compared to the general population affecting 9.1% of people with BD diagnosis. Notably, prevalence varied by region: it was highest in the United States (15.7%) and Europe (11.9%), while much lower rates were found in the UK and Taiwan.
- Individuals with BD were almost three times more likely to develop pneumonia compared to the general population, affecting 2.8%.
- Lung cancer, while relatively rare, was found in 0.4% of people with BD. However, no statistically significant difference in risk was observed between those with and without BD.
- Only one study examined tuberculosis, which reported a 0.4% prevalence and over 7 times greater odds in people with BD than in the general population.
Factors influencing risk
Age and gender played a substantial role in modifying respiratory risk:
- Younger individuals with BD showed a higher likelihood of developing both asthma and COPD.
- Women with BD were found to be at greater risk of COPD than their male counterparts.
The nature of the studies themselves also affected the results:
- Higher risks were noted in hospital-based settings and in retrospective studies, which look back over time.
- Interestingly, studies conducted in the 1990s reported a higher COPD risk than more recent research, possibly reflecting historical smoking trends and shifts in public health behaviours.
Study quality varied, with half of the included research rated as “Good.” Most of the remaining studies were categorised as “Fair,” and only one study was considered “Poor” in quality. This variation underscores the importance of continued methodological rigour in future research.
9% of people with bipolar are affected by COPD, almost double the risk compared to the general population.
Conclusions
Laguna-Muñoz et al., (2025) show that people with a diagnosis of bipolar disorder (BD) are more likely to have lung issues like asthma, COPD, and pneumonia than the general population. Surprisingly, these problems show up younger and more often in women.
Smoking, limited healthcare access, and lifestyle factors play a big role. Think of it like this: BD doesn’t just affect wellbeing and the mind, it also makes the lungs vulnerable!
The takeaway? It’s time to breathe new life into healthcare for people with bipolar disorder, especially with early check-ups, better access to care, and using the making every contact count principle, alongside smoking cessation to reduce/stop the person smoking. As a registered mental health nurse and adult nurse, this only highlights to me again that mental and physical health go hand in hand!
It’s time to breathe new life into healthcare for people with bipolar disorder, especially with early check-ups.
Strengths and limitations
This study demonstrates considerable strengths due to its unprecedented scale and rigorous methodology. By examining data from almost one million individuals with bipolar disorder (BD) and over 35 million from the general population, it provides substantial statistical power and enhances the credibility of its conclusions. Importantly, it is the first meta-analytic review to comprehensively assess the prevalence and relative risk of major respiratory conditions among people with bipolar disorder.
The inclusion of studies from a range of countries, age groups, and healthcare settings means that the findings are widely applicable and not restricted to a particular demographic or system. By taking a broad view rather than concentrating on a single illness, the research offers a much fuller understanding of respiratory health risks in this population.
Moreover, the consistency of the results with existing evidence from other serious mental illnesses lends further weight to the findings (Public Health England 2018). The study also sheds light on the widespread issue of delayed diagnosis and inadequate treatment of respiratory conditions in people with BD. This is a key public health concern and emphasises the need for more integrated and proactive care models that bridge the gap between mental and physical healthcare, particularly within the NHS.
The first meta-analytic review to comprehensively assess the prevalence and relative risk of major respiratory conditions among people with BD.
Further research is needed to explore the impact of smoking status and the use of psychotropic medications on respiratory health in people with bipolar disorder. The current data do not provide sufficient detail to draw firm conclusions in this area.
This paper offers limited insight into how psychiatric medication might affect the respiratory system. For instance, recent findings by Winter et al. (2024) highlight early indicators that individuals with serious mental illness (SMI), particularly those of advanced age and those prescribed high doses of atypical antipsychotics, may be at elevated risk of respiratory failure. Although that study focused specifically on respiratory failure rather than broader respiratory disease, it does raise critical questions about the longer-term respiratory effects of antipsychotic use, questions that remain unanswered in the present meta-analysis.
This paper offers limited insight into how psychiatric medication might affect the respiratory system.
Notably, existing studies have not sufficiently discussed potential risk mitigation strategies for these vulnerable populations, such as routine screening for underlying conditions like COPD or the optimisation of respiratory care in those with pre-existing lung disease. This omission represents a missed opportunity for preventive intervention.
Another area of ambiguity lies in how smoking was recorded across studies. It is unclear whether the term ‘smoking’ includes vaping, an increasingly common practice among younger populations. This distinction is crucial, especially when assessing risks in younger individuals with bipolar disorder, and future studies would benefit from greater clarity in how tobacco and nicotine use are defined and measured.
It was unclear whether the term ‘smoking’ included vaping.
Implications for practice
The work of Laguna-Muñoz, et al. (2025) underscores the pressing need to improve how we collect and use data on prescribed medication and smoking status in people with bipolar disorder (BD). While NHS England’s Lester Tool, which is designed to help frontline staff make assessments of cardiac and metabolic health, includes questions about smoking habits and offers guidance on cessation, it lacks any meaningful assessment of respiratory health itself. Questions as simple as, “Can you run a short distance?” or “Can you speak in full sentences without becoming breathless?” are missing, yet they could offer valuable early warning signs of compromised lung function (RCGP/RCPsych 2023).
As mental health nurses, we might be the most consistent point of contact for individuals living with BD. That places us in a vital position to intervene early. We already understand that people with serious mental illness are more likely to experience poorer physical health, but this evidence shows just how much more vulnerable they are to lung disease. With this knowledge, assessing respiratory health should become a routine part of physical health checks, which should focus not just on treatment, but for prevention.
The findings from this meta-analysis bring to light several areas where practice across the UK must improve. Most urgently, respiratory screening should be incorporated into standard care pathways for individuals with BD, especially younger adults and women, who appear to be at greatest risk. Rather than waiting for symptoms to become serious or life-limiting, we should be identifying asthma, COPD, and other lung conditions early on.
The role of smoking cannot be overlooked. This paper highlights that there is an increased risk of smoking in people with BD. That makes smoking cessation not just an optional intervention, but a core component of any mental health care plan. The support provided must be realistic and responsive to the specific challenges this group faces, such as greater dependence, earlier onset of smoking, and social or environmental barriers to quitting.
To deliver this effectively, the NHS needs to adopt a more integrated approach to care, an NHS that treats physical and mental health as inherently connected. While cardiovascular risk in serious mental illness has rightly received attention in recent years, respiratory health must now be given equal priority.
Access to prevention and timely treatment remains an issue. Too often, people with BD experience delays in diagnosis, or symptoms are dismissed as side effects or anxiety. That’s why it’s so important for primary care and mental health services to work together more closely, making routine respiratory assessments a standard part of care, rather than something reactive.
There’s also a wider need for public awareness. Families, carers, and health professionals need to understand that BD doesn’t just affect mood; it significantly increases the risk of serious physical illnesses. Policymakers must invest in more joined up care, especially in underserved areas, where health inequalities tend to be even more severe.
Finally, we must prioritise early intervention. Young people with BD are developing lung conditions earlier than the general population, which could have lifelong consequences. Education and early support, which could be delivered through schools, early intervention teams and youth mental health services could make a real difference to long-term outcomes.
As an adult and mental health nurse, this research not only reminds me of the importance of physical and mental health care, but also the importance of people being listened to. In my clinical experience, I often saw people with mental illnesses judged for their life choices rather than accepted, understood and provided advice to move forward. People with mental illness must be listened to when reporting physical symptoms to truly achieve the long-term goal of party of esteem.
If someone is living with bipolar disorder, it’s not just their mental health we need to be concerned about but their lungs too. With more integrated, proactive care, we have a real opportunity not only to improve quality of life, but to prevent serious illness and save lives.
Five steps to prioritise and improve lung health for people with bipolar disorder.
Links
Primary paper
Laguna-Muñoz, D., Jiménez-Peinado, A., Jaén-Moreno, M. J., Camacho-Rodríguez, C., Del Pozo, G. I., Vieta, E., Caballero-Villarraso, J., Khan, M. I., Rico-Villademoros, F., & Sarramea, F. (2025). Respiratory disease in people with bipolar disorder: a systematic review and meta-analysis. Molecular psychiatry, 30(2), 777–785.
Other references
Hallyburton A. (2022). Diagnostic overshadowing: An evolutionary concept analysis on the misattribution of physical symptoms to pre-existing psychological illnesses. International journal of mental health nursing, 31(6), 1360–1372. https://doi.org/10.1111/inm.13034
Hilton C. Parity of esteem for mental and physical healthcare in England: a hundred years war? J R Soc Med. 2016 Apr;109(4):133-6. doi: 10.1177/0141076815616089.
Mitchell AJ, Hardy S, Shiers D. Parity of esteem: Addressing the inequalities between mental and physical healthcare. BJPsych Advances. 2017;23(3):196-205. doi:10.1192/apt.bp.114.014266
NHS England (2023) RightCare physical health and severe mental illness scenario Access: NHS England » RightCare physical health and severe mental illness scenario
NHS England (2024) 10 key actions: Improving the physical health of people living with severe mental illness. Access: NHS England » 10 key actions: Improving the physical health of people living with severe mental illness
NHS England (2024). Improving the physical health of people living with severe mental illness Access: NHS England » Improving the physical health of people living with severe mental illness
Office for Health Improvement and Disparities. (2024). Severe mental illness Access: Severe mental illness | Fingertips | Department of Health and Social Care
Public Health England. (2018). Severe mental illness (SMI) and physical health inequalities: briefing Access:https://www.gov.uk/government/publications/severe-mental-illness-smi-physical-health-inequalities/severe-mental-illness-and-physical-health-inequalities-briefing.
RCGP/RCPsych. (2023). Lester UK Adaptation | 2023 update Access: ncap-lester-tool-intervention-framework.pdf (Accessed on: May 2025)
Sheikh Y, Gakhar D, Asunramu MH, Low H, Yassin H, Muthukumar K. Achieving Parity of Esteem of Mental Healthcare in the UK. Eur Psychiatry. 2022 Sep 1;65(Suppl 1):S632. doi: 10.1192/j.eurpsy.2022.1620.
Winter, S., Kirkpatrick, T., Winckel, K., Honarparvar, F., Robinson, L., Tanzer, T., Smith, L., Warren, N., Siskind, D., & Ellender, C. M. (2024). Antipsychotic medications and risk of respiratory failure in the respiratory high dependency unit. BJPsych open, 10(6), e211. https://doi.org/10.1192/bjo.2024.773
