The 15-year life expectancy gap between people with severe mental illness (SMI) and the general population is shocking, but well-established (Chan et al., 2023), and we must do more to understand and change this.
Elves have written on the topic many times, with a lot of previous research looking at cardiovascular disease, so it was interesting to read this elf blog on respiratory diseases in people with bipolar disorder earlier this summer (Snowden, 2025). Respiratory illnesses include things like COPD, pneumonia and lung cancer, and while they are recognised as a major cause of death for people with SMI, there is less research on this compared to other causes, and respiratory health features less prominently in health policy, beyond stop smoking campaigns.
Today we’re looking at a systematic review of respiratory disease mortality in people with SMI, a broader category including schizophrenia spectrum disorders, bipolar disorder, and severe depression (Laguna-Muñoz et al., 2025).
This review builds on previous work by the same authors on respiratory mortality for people with bipolar disorder, covered in the blog mentioned above (Laguna-Muñoz and colleagues are really churning out the papers!). It includes some interesting findings about specific respiratory conditions, and some suggestions for how we might try to address poor respiratory health.
Groundhog Day: another Elf blog on the mortality gap. When will the 15-year mortality gap for people with severe mental illness be eradicated?
Methods
The authors carried out a systematic review and meta-analysis, which means they looked at all the previous studies on the topic and then combined the results of these to come up with an overall conclusion about the mortality from respiratory disease in people with SMI.
They only included certain types of studies (cohort studies), which followed people up over time, compared people with SMI to people from the general population, and reported data that could be combined in a meta-analysis. Systematic reviews follow quite strict criteria on how they should be carried out, and here the authors followed standard procedures – PRISMA, MOOSE and PROSPERO (Jiminez et al., 2024; Page et al., 2021; Stroup et al., 2000).
The main outcome of interest was overall respiratory disease-related mortality, but the authors also looked at disease-specific mortality (e.g. asthma, pneumonia, lung cancer).
Results
Study findings
- The authors included 83 studies with a total of 4,837,720 people with SMI, who were compared to 785,538,236 people from the general population. Big numbers!
- 57 studies looked at people with schizophrenia spectrum disorders, 21 with bipolar disorder, 20 with major depressive disorder, and 10 with mixed severe mental illness.
- 49% of the people studied were male, and the average age was 58 years old.
- Data on ethnicity was not reported well enough in the included studies for the authors to analyse this.
- The authors assessed the quality of the studies included. Most of the studies were rated as ‘good’ on the Newcastle-Ottawa scale (94%), which assesses research quality.
Main outcomes
- The main result showed people with SMI have double the risk of respiratory mortality compared to the general population.
- Overall, the risk ratio for respiratory mortality in people with SMI was 2.28 compared to the general population, with a 95% CI of 2.02 to 2.56.
Results by mental health diagnosis
- The authors separated people into groups with each diagnosis and compared this to the general population. This shows that people with schizophrenia spectrum disorders had the highest risk, and people with depression had a lower risk (but still significantly higher than the general population)
- People with schizophrenia spectrum disorder had a risk 2.6 times higher
- People with bipolar disorder had a risk 1.9 times higher
- People with mixed severe mental illness had a risk 1.9 times higher
- People with major depressive disorder had a risk 1.7 times higher
- They also looked at some sub-groups and showed that the risk was even higher in younger people, males, and smokers.
Results by respiratory diagnosis
The authors looked at specific respiratory illnesses – this is particularly interesting, but for some of these sections there are smaller numbers of studies included.
- They found higher mortality rates from asthma, COPD, infections, pneumonia, and COVID-19 in people with SMI compared to the general population.
- They found the highest rates for tuberculosis, but this was only based on two studies and only for people diagnosed with schizophrenia.
- Lung cancer mortality rates were similar or slightly lower for people with SMI compared to the general population. The authors make an interesting (and sad) comment, that people may not live long enough to develop / be diagnosed with lung cancer.
Although lung cancer rates were similar in people with severe mental illness (SMI) and those without, the authors note that it might be that people with SMI do not live long enough to be diagnosed with lung cancer.
Conclusions
Respiratory disease mortality is twice as high in people with SMI compared to the general population. This was shown across a range of different respiratory conditions, and a range of mental health diagnoses.
The authors made the following suggestions:
Programmes for smoking cessation, lung cancer screening, vaccination against respiratory infections, and pulmonary health monitoring in people with severe mental illness should be developed and implemented to address the unmet health needs of this population.
I’m glad I didn’t have to read all 83 papers – thanks to the authors for summarising the literature which found that people with severe mental illness were more than twice as likely to die from respiratory illness than those without.
Strengths and limitations
Overall I think this is a good study, combining information from lots of other studies, and including information on a large number of people (5 million people with SMI and 785 million people from the general population). As with any research there are some limitations, and I’ve mentioned these below.
The authors only included specific types of studies, which means that they will have excluded information from other types of research (e.g. cross-sectional studies). However, this does mean they were able to combine the results to produce summary statistics, and the quality of the studies that were included is pretty high.
The results are presented as risk ratios, which compare rates between groups, but this doesn’t tell us the absolute risk difference (i.e. the overall number of deaths). This would be helpful for public health planning as even a small increase in the ratio for a common condition (e.g. asthma) would lead to a large number of excess deaths (Köhler-Forsberg et al., 2025).
There was no involvement of people with lived experience of SMI, which could have helped the authors to interpret their results.
The study didn’t include information on ethnicity as this was not reported well enough in the original studies. This causes a blind spot in our understanding, and highlights the lack of reporting in other studies.
Almost all of the studies (82/83) were from ‘very high income’ countries on Human Development Index, so the results might not be generalisable to other countries. And the authors only looked at studies published in English.
And finally, a number of the authors have quite a lot of industry links – I don’t think this necessarily affected the outcome of the study, but it is worth acknowledging.
A helpful and important study, but sadly there is still a blind spot when it comes to the relationship between respiratory-related mortality and severe mental illness in diverse ethnic cultures.
Implications for practice
The authors highlight the importance of supporting people to stop smoking, monitoring respiratory health, and vaccination for respiratory illness (this is an access to healthcare issue). The recent elf blog on their previous paper highlights some important ideas for how we might do some of this (Snowden, 2025), and the Maudsley Physical Health Guidelines have some advice on specific respiratory conditions (Taylor et al., 2020).
At the moment respiratory health is not prominent in UK guidance for monitoring physical health in people with SMI, beyond reviewing smoking status, and so improving this guidance could be a place to start (NHS England, 2025).
A public mental health approach?
The risks of developing respiratory disease build up over someone’s whole life and are affected by the conditions that they grow up and live in. Smoking status is impacted by a range of factors including mental illness and poverty – it’s not a simple individual decision and these factors combine to increase risks. Access to healthcare, and breathing clean healthy air are important, but how many people with mental illness end up living in overcrowded homes in polluted neighbourhoods? These issues can’t just be addressed at an ‘individual’ level and need wider action on public mental health.
Action on the social determinants of health, alongside well-funded mental health and public health systems are essential to tackle the factors driving respiratory mortality for people with SMI, and integration with primary care is important too. Unfortunately these are all areas facing significant challenges and tight budgets, and the UK government’s 10 Year Health Plan doesn’t do enough to build the services needed to deliver change (UK Government, 2025).
As members of the mental health community, we can advocate for wider systems change, as well as helping each other with the specific challenges individuals face.
Always more areas to research?
- Research to work out how best to monitor respiratory conditions in people with SMI is important, to suggest practices alongside stop smoking campaigns. Should people with SMI who smoke be offered chest X-rays? Should respiratory function be checked in annual health reviews? If so, would this change outcomes? These would be helpful questions to answer!
- The absence of data on ethnicity and lack of studies in medium and low income countries needs to be addressed to ensure the respiratory health of all people with SMI.
- This review didn’t look at the impact of psychiatric medications on respiratory health, and current research on this is limited (Winter et al., 2024). We do know that having good mental health is key for physical health, and medication can reduce overall mortality, but it’s important we fully understand any adverse effects (Firth et al., 2019).
Smoking status is impacted by a range of factors including mental illness and poverty. These cannot be addressed at an individual level and need a public health approach.
Statement of interests
No conflicting interests to declare.
Links
Primary paper
Laguna-Muñoz D, Pata MP, Jiménez-Peinado A, et al (2025). Mortality from respiratory diseases in individuals with severe mental illness: a large-scale systematic review and meta-analysis of pooled and specific diagnoses. The Lancet Psychiatry 12, 768–779. [PubMed abstract]
Other references
Chan JKN, Correll CU, Wong CSM, et al (2023). Life expectancy and years of potential life lost in people with mental disorders: a systematic review and meta-analysis. eClinicalMedicine 65, 102294.
Firth J, Siddiqi N, Koyanagi A, et al (2019). The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. Lancet Psychiatry 6, 675–712. [PubMed abstract]
Jimenez A, Jaen Moreno MJ, Sarramea Crespo F, et al (2024). Mortality from Respiratory Diseases in Severe Mental Illness: A Meta-Analysis and Systematic Review. PROSPERO. Last accessed 17 Oct 2025.
Köhler-Forsberg O, Plana-Ripoll O, Bak Fuglsang NF. (2025). Respiratory diseases in individuals with severe mental illness. Lancet Psychiatry 12, 725–726. [PubMed abstract]
NHS England (2025). Improving the physical health of people living with severe mental illness. Last accessed 02 Oct 2025.
Page MJ, McKenzie JE, Bossuyt PM, et al (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372, n71.
Snowden J. Increased risk of respiratory disease in bipolar means it’s time to breathe new life into physical healthcare. The Mental Elf, 01 Jul 2025.
Stroup DF, Berlin JA, Morton SC, et al (2000). Meta-analysis of observational studies in epidemiology: a proposal for reporting. JAMA 283(15), 2008-12. [PubMed abstract]
Taylor D, Gaughran F, Pillinger T. (2020). The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry. Wiley-Blackwell.
UK Government (2025). Fit for the Future: 10 Year Health Plan for England. Last accessed 02 Oct 2025.
Winter S, Lee KR, Fung E, et al (2024). The association between respiratory failure and psychotropic medications: A systematic review. Journal of Psychiatric Research 180, 121–130.
