Key Takeaways

From the Authors As published in the article
  1. Analysis of 195,180 US deaths (1999–2023) involving co-occurring obesity and psychiatric disorders showed a marked rise in age-adjusted mortality from 6.0 to 82.2 per million, followed by a decline to 66.6 per million in 2023.
  2. Substance use disorders accounted for the greatest mortality burden (age-adjusted mortality rate 29.8), with significant disparities observed among males (incidence rate ratio [IRR] 1.41), adults aged 65–74 years (IRR 8.34), and American Indian/Alaska Native populations, with higher rates in rural and Midwestern regions.
  3. Autoregressive integrated moving average (ARIMA) forecasting projects mortality increasing to 74.2 per million by 2030, highlighting the need for integrated strategies addressing obesity treatment, metabolic monitoring in psychiatric care, and targeted substance use interventions.
Extended Takeaways
  1. The sharpest acceleration after the prepandemic period occurred from 2018 to 2021 (APC 20.64%, P<.05), followed by a reversal from 2021 to 2023 (APC −9.35%, P<.05), suggesting clinicians should not interpret the recent decline as sustained improvement given the projected rebound in mortality.
  2. Within non-substance psychiatric categories, organic mental disorders carried a weighted mean AAMR of 2.21 (95% CI: 2.17 to 2.24), compared with 2.60 (95% CI: 2.56 to 2.64) for mood disorders and 1.00 (95% CI: 0.96 to 1.03) for schizophrenia spectrum disorders, indicating that metabolic risk surveillance should extend beyond traditionally emphasized psychotic illness.
  3. Major depressive disorder accounted for most of the mood-disorder burden, with a weighted mean AAMR of 1.95 (95% CI: 1.91 to 1.99) versus 0.68 (95% CI: 0.64 to 0.71) for bipolar disorder, so weight and cardiometabolic monitoring should not be reserved only for patients receiving antipsychotic treatment.
  4. Female mortality showed a slightly delayed pattern but the largest increase occurred between 2018 and 2021 (APC 20.87%, P<.05), exceeding the contemporaneous male increase of APC 18.66%, P<.05; psychiatrists should be alert to a potentially narrowing sex gap when obesity and psychiatric illness coexist.
  5. After adjustment, non-Hispanic decedents had more than twice the mortality rate of Hispanic decedents (IRR=2.66, 95% CI: 2.46–2.87, P<.001), while the South (IRR=0.92, 95% CI: 0.85–1.01, P=.078) and West (IRR =1.07, 95% CI: 0.97–1.17, P=.183) did not differ significantly from the Northeast, which argues for targeting interventions to ethnicity-related and Midwest-specific disparities rather than assuming uniformly elevated regional risk.
  6. State-level burden was highly concentrated, with the highest AAMRs in Vermont (216.7 per million), Wyoming (192.2), West Virginia (178.9), and North Dakota (178.8), even though the largest absolute death counts occurred in Texas (n =9,801), California (n=9,708), and New York (n =8,494); clinicians and health systems should distinguish rate hotspots from volume hotspots when planning services.
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