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Research · for Mental health organisations

The Mortality Gap Doesn’t Close at 65: Older People with Serious Mental Illness

Published 2026-10-16

People living with schizophrenia or bipolar disorder die, on average, 10 to 20 years earlier than the population around them, mostly from physical illnesses that can be prevented or treated[1]. Reaching 65 does not close that gap: in register and health-record data from Finland and Hong Kong, older people with schizophrenia died at roughly 2.7 to 4.4 times the rate of their peers[2][3].

Many people with a serious mental illness now live into their seventies, eighties and beyond, often after decades of contact with mental health services. Growing older brings them the same heart disease, diabetes, lung disease and memory problems as anyone else, but often earlier, more often and with less attention. This study brings together national registers, meta-analyses and official statistics from several countries to show what later life looks like for this group: how wide the mortality gap remains, what drives it, whether routine physical health care reaches older people, and what happens when care needs grow.

2.69times the expected death rate among people with schizophrenia aged over 65 in Finland, followed 1999–2008 (standardised mortality ratio)[2]
5.3 yearsof life lost, on top of the general population’s, by people with schizophrenia-spectrum disorders aged 65 and over in Hong Kong, 2005–2011[3]
55%of people aged 90 and over on England’s GP registers for serious mental illness had a full physical health check in the 12 months to June 2026, against 69% of those aged 70–74[4]

The mortality gap opens in mid-life and is still there after 65

Serious mental illness is not rare. The World Health Organization (WHO) estimates that about 1 in 300 people worldwide live with schizophrenia, rising to 1 in 206 adults aged 20 and over, and that people with schizophrenia die nine years earlier than the general population, often because of cardiovascular, metabolic and infectious diseases[5]. Studies that measure the gap in other ways find it larger. A 2017 meta-analysis of 11 studies covering up to 247,603 people put the average loss at 14.5 years of potential life, with an average life expectancy of 64.7 years, and found the loss had not lessened over time[6]. Among people admitted to psychiatric care in Denmark, Finland and Sweden in 2000–2006, life expectancy was about 15 years shorter for women and 20 years shorter for men than in the general population[7].

Across mental disorders more broadly, a review of 203 studies from 29 countries found people with mental disorders had 2.22 times the risk of death of comparison populations[8], and Danish registers covering 7.4 million people recorded 28.70 deaths per 1,000 person-years among people with a mental disorder diagnosis against 12.95 among people without one[9]. In England, the Office for Health Improvement and Disparities found that in 2018–2020 adults with serious mental illness were around 5 times more likely to die before 75 than adults without[10].

Far fewer studies look only at people who are already older, but those that do find the gap persists. Three examples, each measured differently, are set out below.

Where and whenWhoWhat was found
Finland, national registers, 1999–20089,461 people with schizophrenia or schizoaffective disorder aged over 65Deaths 2.69 times the number expected from general-population rates (standardised mortality ratio); 2.58 for natural causes[2]
Hong Kong, electronic health records, 2005–20112,665 people with schizophrenia-spectrum disorders aged 65 and over, and 18,298 matched people without4.39 times the hazard of death; 5.28 excess life-years lost, almost all from natural causes[3]
Prospective multicentre cohort, five-year follow-up564 older people with schizophrenia, bipolar disorder or major depression (mean age 67.9)29.4% of those with schizophrenia died within five years, against 18.4% of those with bipolar disorder or major depression; most of the difference was cardiovascular[11]

These figures are not directly comparable: one is a ratio against expected deaths, one a hazard ratio against matched peers, one a comparison between diagnoses. Together they show that the excess risk of death is still large decades after diagnosis. The Finnish study also found that older people who still needed psychiatric hospital treatment had a higher ratio (3.92) than those who did not (2.37), suggesting that people whose illness is still active in later life need closer attention[2].

Most of the gap is heart, lung and other physical illness

WHO says that the majority of premature deaths among people with severe mental disorders are due to physical health conditions, and that their physical health is commonly overlooked, including by health services[1]. England’s official estimate is that 2 out of 3 deaths among people with serious mental illness are from physical illnesses that can be prevented[10].

One of the largest studies of causes, covering 1,138,853 adults aged 20 to 64 with schizophrenia in the US Medicaid programme in 2001–2007, found death rates 3.7 times those of the general population. Cardiovascular disease was the leading cause of death, with a ratio of 3.6, and deaths from chronic obstructive pulmonary disease (9.9) and from influenza and pneumonia (7.0) were especially raised[12]. That study stops at 64, but the older-age studies point the same way: in Finland the most common causes of death among older people with schizophrenia matched those in the general population, only more frequent[2], and in Hong Kong natural causes accounted for almost all excess life-years lost after 65[3].

For bipolar disorder, a 2023 meta-analysis of 57 studies and 678,353 people found all-cause mortality 2.02 times that of the general population. Risks from respiratory (3.18), cardiovascular (1.76) and cerebrovascular (1.57) disease were all raised; cancer mortality was not (0.99). The risk of death by suicide was also much higher, at 11.69 times[13]. Unnatural deaths, including suicide and accidents, were also raised among older people with schizophrenia in Finland[2]. Suicide is not an inevitable part of any diagnosis, and treatment and support make a difference: the authors conclude that preventing suicide and promoting physical health should go together[13].

If you need support right now In the UK and Ireland, Samaritans are free to call on 116 123, day or night. Outside the UK and Ireland, findahelpline.com lists free, confidential helplines by country. If a life is at immediate risk, call 999 (or your local emergency number).

Routine physical health checks reach most older people in England, but fall back after the mid-seventies

Because so much of the gap is physical illness, WHO has issued guidance to help practitioners recognise and manage physical conditions in people with severe mental disorders[1]. England is one country that publishes national figures on routine checks, broken down by age. Each quarter, NHS England reports how many people on GP registers for serious mental illness received all six parts of an annual check: alcohol, blood glucose, blood lipids, blood pressure, body mass index and smoking. In the 12 months to the end of June 2026, 58.6% of the 489,754 people on the register had a full check[4].

The register is not only young people. By our count from the published tables, 102,695 people on it, about 21%, were aged 65 or over. Coverage actually rises with age into the early seventies, from 43% of people aged 20–24 to 69% at 70–74, then falls back: 64% at 80–84, 61% at 85–89 and 55% at 90 and over[4]. Among those aged 90 and over, 93% had their blood pressure checked, but only 74% had blood lipids checked and 77% had a smoking check recorded[4]. The data cannot say why. Some checks may matter less, or be declined, near the end of life; others may be missed because people are housebound, in care homes or harder to reach. Either way, the oldest people on the register are the least likely to have the full picture of their physical health recorded.

Share of people on GP serious mental illness registers who had a full physical health check, by age, England, 12 months to June 2026People on the GP register for serious mental illness in England who received all six elements of the annual physical health check in the 12 months to the end of June 2026: all ages 59%; aged 20-24 43%; 40-44 55%; 60-64 67%; 65-69 68%; 70-74 69%; 75-79 67%; 80-84 64%; 85-89 61%; 90 and over 55%.0%25%50%75%100%All ages59%Aged 20-2443%Aged 40-4455%Aged 60-6467%Aged 65-6968%Aged 70-7469%Aged 75-7967%Aged 80-8464%Aged 85-8961%Aged 90 and over55%
A full check means all six elements: alcohol, blood glucose, blood lipids, blood pressure, body mass index and smoking. Recorded in GP systems (GPES); people on the GP serious mental illness register. Source: NHS England, Physical Health Checks for People with Severe Mental Illness, Q1 2026-27, Table 2.

A check is only a start. Cancer screening shows a similar gap, even though, as one review notes, people with mental illness are more likely to die from cancer. A 2020 meta-analysis covering 4,717,839 people found that people with mental illness had lower odds of being screened for any cancer (odds ratio 0.76), breast cancer (0.65), cervical cancer (0.89) and prostate cancer (0.78), though not colorectal cancer; the authors highlight women with schizophrenia in particular[14]. An earlier review found the gap in mammography was widest for women with serious mental illness (odds ratio 0.54)[15]. These studies span all adult ages, and the evidence for people over 65 specifically is thin.

Dementia comes earlier, and so does moving into a care home

Schizophrenia is associated with a higher risk of dementia. In a Danish national register study of more than 2.8 million people aged 50 and over, including 20,683 people with schizophrenia, followed from 1995 to 2013, people with schizophrenia had 2.13 times the rate of all-cause dementia after accounting for age, sex and calendar period. The figure barely changed after adjusting for cardiovascular disease and diabetes (2.01) and fell somewhat after adjusting for substance use (1.71). The relative difference was largest below 65 (3.77)[16]. In absolute terms, 1.8% of people with schizophrenia had developed dementia by age 65, against 0.6% of people without; by 80, the figures were 7.4% and 5.8%[16]. This is an association from recorded diagnoses: it does not show that schizophrenia causes dementia, and memory problems may also be noticed and recorded differently in people already in contact with services.

Share of people who had developed dementia by age 65 and by age 80, with and without schizophrenia, DenmarkCumulative incidence of all-cause dementia in a Danish national register cohort of more than 2.8 million people aged 50 and over, followed 1995-2013. By age 65: 1.8% of people with schizophrenia and 0.6% of people without. By age 80: 7.4% and 5.8%.With schizophreniaWithout schizophrenia0%2%4%6%8%By age 651.8%0.6%By age 807.4%5.8%
Cumulative incidence proportions from national registers, recorded dementia diagnoses. Source: Ribe et al., JAMA Psychiatry 2015.

When care needs grow, people with serious mental illness tend to move into residential care sooner. Among 7,937 Medicaid beneficiaries aged 40 and over in New Hampshire, followed from 1996 to 2005, people with schizophrenia entered nursing homes at a median age of 65, against 80 for people with no mental illness. Between 40 and 64, their risk of nursing home admission was 3.90 times higher, after adjustment for other factors[17]. National US data for 2000–2008 also suggest that homes caring for a larger share of residents with serious mental illness had a weaker staffing skill mix and lower quality across most indicators studied[18]. Both studies are from the US; we did not find comparable published figures for most other countries. For care homes and dementia more broadly, see our study of dementia and care homes.

Older people with bipolar disorder are even less studied. An international expert task force described “a dearth of research and health efforts focused on older adults” with the condition; its report highlights medical comorbidity and cognitive impairment and decline as pressing questions[19].

What the evidence asks of us

The evidence points to a gap that is largely physical, largely preventable and still open in later life. That locates the problem in how health and care systems respond, not in the people living with these conditions. The figures suggest five priorities for services, commissioners and policymakers.

  • Treat physical health as core mental health care at every age. WHO’s 2018 guideline exists because the physical health of people with severe mental disorders is commonly overlooked[1]. Cardiovascular and respiratory disease drive most excess deaths in the studies above[11][12], and these are conditions that health services already know how to find and treat.
  • Keep checks going after 80. England’s data show full physical health checks falling from 69% at 70–74 to 55% at 90 and over[4]. Home visits and checks in care homes are one way services could close that gap.
  • Close the screening gap. People with mental illness are screened less often for breast, cervical and prostate cancer[14]; screening programmes can monitor uptake for this group and adjust how they invite and support people.
  • Plan for later life in mental health services. Only 29% of people with psychosis worldwide receive specialist mental health care[5]. Older people still experiencing relapses have a higher risk of death than those who did not need hospital treatment[2], and dementia comes earlier[16], so mental health, primary care and dementia services need to work together rather than hand people between them.
  • Collect and publish the data. England’s figures on premature death vary from 2.5 to more than 7 times the rate of people without serious mental illness between local areas[10], which shows the gap is not fixed. But that measure stops at 74, and few countries publish mortality, screening or care-home figures for older people with serious mental illness at all. Ageing populations need age-specific data to plan for this group. For dementia risk more generally, see our study of dementia risk factors.

Language: this piece says “older people” rather than “the elderly”, and “people with serious mental illness” or “people living with schizophrenia or bipolar disorder”, putting the person first, as most mental health organisations prefer. In the UK the same group is usually described as having “severe mental illness” (SMI), the term used in official English statistics.

Why we're publishing this

It is easy to treat a shorter life as simply part of having schizophrenia or bipolar disorder. The evidence says otherwise: most of the gap comes from heart, lung and metabolic disease that can be prevented, found early and treated. As more people with these conditions reach their seventies and eighties, the question is whether services built around younger adults will follow them into later life. We publish this so that mental health organisations, older people’s groups and the people they work with can make that case with the data in hand.

How to read this data

Most of the evidence comes from national registers and health records in Nordic countries, England, the US and Hong Kong, with few data from low- and middle-income countries. Studies use different measures: standardised mortality ratios compare deaths with the number expected from general-population rates; hazard ratios, rate ratios and relative risks compare people with and without the condition; odds ratios (used for screening) are not the same as risks. Figures from different countries and methods are not directly comparable and should not be read as a trend. Diagnoses come from hospital or GP records, so people who never received a diagnosis are missing, and the people in these studies may differ from everyone living with these conditions. England’s premature mortality measure covers ages 18 to 74 only and defines serious mental illness by contact with secondary mental health services[10]; its physical health check figures count people on GP registers[4]. Some large studies stop at 64, and evidence for older people with bipolar disorder in particular is thin. All associations here describe populations, not what will happen to any individual.

Use this data

Free to cite with attribution to Understanding Aging. Charities, carers' groups, campaigners and journalists are welcome to reuse these figures and charts. For the underlying figures as a spreadsheet, get in touch.

Suggested citation: Understanding Aging (2026). The Mortality Gap Doesn’t Close at 65: Older People with Serious Mental Illness. https://understandingaging.org/research/older-people-serious-mental-illness

Important: This article summarises published research and statistics for general information. It is not medical, care or financial advice and cannot be used to diagnose, treat or predict anything about an individual. If you have concerns about your own or someone else's memory or health, please speak to a GP or another qualified health professional.

Sources

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