Morbidity and Mortality in People with Severe Mental Conditions

Morbidity and Mortality in People with Severe Mental Conditions

Morbidity and Mortality in People with Serious Mental Illness National Association of State Mental Health Program Directors Medical Directors Council July 2006 Overview- THE PROBLEM Increased Morbidity and Mortality Associated with Serious Mental Illness (SMI) Increased Morbidity and Mortality Largely Due to Preventable Medical Conditions Metabolic Disorders, Cardiovascular Disease, Diabetes Mellitus High Prevalence of Modifiable Risk Factors (Obesity, Smoking) Epidemics within Epidemics (e.g., Diabetes, Obesity) Some Psychiatric Medications Contribute to Risk Established Monitoring and Treatment Guidelines to Lower Risk Are Underutilized in SMI Populations Overview - PROPOSED SOLUTIONS Prioritize the Public Health Problem Target Providers, Families and Clients Focus on Prevention and Wellness Track Morbidity and Mortality in Public Mental

Health Populations Implement Established Standards of Care Prevention, Screening and Treatment Improve Access to and Integration of Physical Health and Mental Health Care Why Should we be Concerned About Morbidity and Mortality? Recent data from several states have found that people with serious mental illness served by our public mental health systems die, on average, at least 25 years earlier that the general population. Recent Multi-State Study Mortality Data: Years of Potential Life Lost Year 1997 1998 1999 2000 AZ MO

OK 32.2 31.8 26.3 27.3 26.8 27.9 25.1 25.1 26.3 RI 24.9 TX UT VA (IP only) 28.5

28.8 29.3 29.3 26.9 15.5 14.0 13.5 Compared to the general population, persons with major mental illness typically lose more than 25 years of normal life span Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited]. Available from: URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm Ohio Study-1998-2002 Mean Years of Potential Life lost 20,018 persons discharged, 608 deaths Cause All Intentional self-harm (suicide) Assault (homicide) Accidents (unintentional injuries) Symptoms, signs, & abnormal clinical & laboratory findings, NEC Diabetes mellitus

Pneumonia & Influenza Diseases of heart Cerebrovascular diseases Malignant neoplasms (cancers) Chronic lower respiratory diseases M 31.8 41.4 42.3 39.5 32.8 F 32.5 42.7 35.8 43.1 35.0 N 32.0 41.7 41.6 40.4 33.4

25.8 29.4 27.7 20.7 24.3 18.6 37.2 25.0 26.6 32.8 26.9 24.1 30.2 28.3 27.3 25.5 25.3 21.1 Massachusetts Study: Deaths from Heart Disease by Age Group/DMH Enrollees with SMI Compared to Massachusetts 1998-2000 40 Rates per 100,000

35 2.2RR DMH MA 30 1.5RR 4.9RR 25 20 15 10 3.5 RR 5 0 25-34 35-44

45-54 55-64 Maine Study Results: Comparison of Health Disorders Between SMI & Non-SMI Groups 80 70 Percent Members 60 SMI (N=9224) Non-SMI (N=7352) 59.4 50 40 30 20 10 0 33.9 30

28.6 28.4 22.8 21.7 16.5 11.5 11.1 6.3 5.9 Ohio Study Leading Causes of Death Cause Diseases of heart Intentional self-harm (suicide) Accidents (unintentional injuries) Malignant neoplasms (cancers) Symptoms, signs, & abnormal clinical & laboratory findings, NEC

Chronic lower respiratory diseases Diabetes mellitus Pneumonia & Influenza Cerebrovascular diseases Assault (homicide) ICD-9 Codes 390-398, 402, 404, 410-429 E950-959 E800-869, E880-929 140-208 780-799 490-494, 496 250 480-487 430-434, 436-438 E960-969 ICD-10 Codes I00-09, I11, I13, I20-51 X60-84, Y87.0 V01-X59,

Y85-86 C00-C97 R00-99 M F N % 83 43 126 20.7 84 24 108 17.8 61 22 83 13.7 27 23 17 9 44 32 7.2

5.3 J40-J47 E10-14 J10-18 I60-69 17 11 12 6 14 7 4 4 31 18 16 10 5.1 3.0 2.6 1.6

X85-Y09, Y87.1 9 1 10 1.6 Ohio Study Standardized Mortality Ratios Cause All causes of death Intentional self-harm (suicide) Symptoms, signs, & abnormal clinical & laboratory findings, NEC Pneumonia & Influenza Chronic lower respiratory diseases Accidents (unintentional injuries) Diseases of heart Diabetes mellitus Assault (homicide) Cerebrovascular diseases Malignant neoplasms (cancers) P<0.001

Overall N SMR 608 3.2 108 12.6 32 9.7 16 31 83 126 18 10 10 44 6.6 5.5 3.8 3.4 3.4 1.7 1.5 0.9 What are the Causes of Morbidity and Mortality in People with Serious Mental Illness?

While suicide and injury account for about 3040% of excess mortality, about 60% of premature deaths in persons with schizophrenia are due to natural causes Cardiovascular disease Diabetes Respiratory diseases Infectious diseases Schizophrenia: Natural Causes of Death Higher standardized mortality rates than the general population from: Diabetes Cardiovascular disease Respiratory disease Infectious diseases

2.7x 2.3x 3.2x 3.4x Cardiovascular disease associated with the largest number of deaths 2.3 X the largest cause of death in the general population Osby U et al. Schizophr Res. 2000;45:21-28. Cardiovascular risk factors overview 14 The Framingham Study Multiple Risk Factors 12 Odds ratios 5 4

10 8 6 Single Risk Factors 3 4 2 2 0 BMI >27 Smoking TC >220 DM HTN Smoking + BMI Smoking Smoking + BMI + BMI + TC >220 + TC >220 + DM

Smoking + BMI + TC >220 + DM + HTN BMI = body mass index; TC = total cholesterol; DM = diabetes mellitus; HTN = hypertension. Wilson PWF et al. Circulation. 1998;97:18371847. Cardiovascular Disease (CVD) Risk Factors Modifiable Risk Factors Estimated Prevalence and Relative Risk (RR) Schizophrenia Bipolar Disorder Obesity 4555%, 1.5-2X RR1 26%5

Smoking 5080%, 2-3X RR2 55%6 Diabetes 1014%, 2X RR3 10%7 Hypertension 18%4 15%5 Dyslipidemia Up to 5X RR8 1. Davidson S, et al. Aust N Z J Psychiatry. 2001;35:196-202. 2. Allison DB, et al. J Clin Psychiatry. 1999; 60:215-220. 3. Dixon L, et al. J Nerv Ment Dis. 1999;187:496-502. 4. Herran A, et al. Schizophr Res. 2000;41:373-381. 5. MeElroy SL, et al. J Clin Psychiatry. 2002;63:207-213. 6. Ucok A, et al. Psychiatry Clin Neurosci. 2004;58:434-437. 7. Cassidy F, et al. Am J Psychiatry. 1999;156:1417-1420. 8. Allebeck. Schizophr Bull. 1999;15(1)81-89.

BMI Distributions for General Population and Those With Schizophrenia (1989) 30 Underweight Acceptable Overweight Obese Percent 20 10 0 < 18.5 18.5-20 20-22 22-24 24-26 26-28 28-30 30-32 32-34 > 34 BMI Range Allison DB et al. J Clin Psychiatry. 1999;60:215-220. No schizophrenia Schizophrenia

Mental Disorders and Smoking Higher prevalence (56-88% for patients with schizophrenia) of cigarette smoking (overall U.S. prevalence 25%) More toxic exposure for patients who smoke (more cigarettes, larger portion consumed) Smoking is associated with increased insulin resistance Similar prevalence in bipolar disorder George TP et al. Nicotine and tobacco use in schizophrenia. In: Meyer JM, Nasrallah HA, eds. Medical Illness and Schizophrenia. American Psychiatric Publishing, Inc. 2003; Ziedonis D, Williams JM, Smelson D. Am J Med Sci. 2003(Oct);326(4):223-330 Prevalence of Diagnosed Diabetes in General Population Versus Schizophrenic Population Diagnosed Diabetes, General Population Diagnosed Diabetes, Schizophrenic Patients 30

Percent of population 25 20 15 10 5 0 Schizophrenic: 50-59 y General: 50-59 y Harris et al. Diabetes Care. 1998; 21:518. Mukherjee et al. Compr Psychiatry. 1996; 37(1):68-73. 60-69 y 60-74 y 70-74 y 75+ y Hypothesized Reasons Why There May Be More Type 2 Diabetes in People With Schizophrenia Genetic link between schizophrenia and diabetes

Impact of lifestyle Medication effect increasing insulin resistance by impacting insulin receptor or postreceptor function Drug effect on caloric intake or expenditure (obesity, activity) How Does This Relate to What is Happening in the General Population? There is an epidemic of obesity and diabetes, increasing risk of multiple medical conditions and cardiovascular disease. Obesity Diabetes Metabolic Syndrome Cardiovascular Disease 7.5 7.0 6.5 6.0 5.5

5.0 4.5 4.0 1990 Diabetes Mean body weight 78 77 76 75 74 73 72 1992 Mokdad et al. Diabetes Care. 2000;23:1278. Mokdad et al. JAMA. 1999;282:1519. Mokdad et al. JAMA. 2001;286:1195. 1994 1996 Year 1998

2000 kg Prevalence (%) Diabetes and Obesity: The Continuing Epidemic Obesity Trends* Among US Adults BRFSS, 1991, 1996, 2003 (*BMI 30, or about 30 lbs overweight for 54 person) 1991 1996 2003 No Data <10% 10%-14% 15%-19% 20%-24%

25% Behavioral Risk Factor Surveillance System, CDC. Diabetes and Gestational Diabetes Trends: US Adults, BRFSS 1990 No Data Less than 4% Mokdad et al. Diabetes Care. 2000;23:1278-1283. 4% to 6% Above 6% Diabetes and Gestational Diabetes Trends: US Adults, BRFSS 1995 No Data Less than 4% 4% to 6%

Mokdad et al. Diabetes Care. 2000;23:1278-1283. Above 6% Diabetes and Gestational Diabetes Trends: US Adults, BRFSS 2000 No Data Mokdad et al. JAMA. 2001;286(10). Less than 4% 4% to 6% Above 6% Diabetes and Gestational Diabetes Trends: US Adults, Estimate for 2010 No Data www.diabetes.org. Less than 4%

4% to 6% Above 6% Above 10% US Diabetes Prevalence by Ethnic Group Men and Women, Age 45-74 Years % with diabetes 50 40 30 20 10 0 European Cuban American Japanese African Mexican AmericanAmerican American

Harris et al. Diabetes. 1987;36:523. Flegal et al. Diabetes Care. 1991;14(suppl 3):628. Knowler et al. Diabetes Care. 1993;16(suppl 1):216. Fujimoto et al. Diabetes Res Clin Pract. 1991;13:119. Fujimoto et al. Diabetes. 1987;36:721. Puerto Rican Pima Natural History of Type 2 Diabetes Obesity IGT Diabetes Uncontrolled Hyperglycemia PostMeal Glucose Fasting Glucose Plasma

Glucose 126 (mg/dL) Relative -Cell Function 100 (%) Insulin Resistance Insulin Level -20 -10 0 10 20 30 Years of Diabetes IGT = impaired glucose tolerance. Adapted from: International Diabetes Center (IDC). Available at: www.parknicollet.com/diabetes/disease/diagnosing.cfm. Accessed March 26, 2006. Prevalence of Diabetic Tissue Damage at Diagnosis of Type 2 Diabetes Urine Albumin 4%

Absent Reflexes 8% Absent Foot Pulses 12% Cardiovascular 17% Retinopathy 18% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% Prevalence

Dagogo-Jack et al. Arch Int Med. 1997;157:1802-1817. Identification of the Metabolic Syndrome 3 Risk Factors Required for Diagnosis Risk Factor Abdominal obesity Men Women Triglycerides HDL cholesterol Men Women Blood pressure Fasting blood glucose HDL = high-density lipoprotein. NCEP III. Circulation. 2002;106:3143-3421. Defining Level Waist circumference >40 in (>102 cm) >35 in (>88 cm) 150 mg/dL (1.69mmol/L) <40 mg/dL (1.03mmol/L)

<50 mg/dL (1.29mmol/L) 130/85 mm Hg 110 mg/dL (6.1mmol/ L) Relative Risk CHD Risk Increases with Increasing Number of Metabolic Syndrome Risk Factors 7 6.5 6 5.5 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 one

two Sattar et al, Circulation, 2003;108:414-419 Whyte et al, American Diabetes Association, 2001 Adapted from Ridker, Circulation 2003;107:393-397 three four Modifiable Risk Factors Affected by Psychotropics Overweight / Obesity Insulin resistance Diabetes/hyperglycaemia Dyslipidemia Newcomer JW. CNS Drugs 2005;19(Supp 1):1.93. 14 30 Olanzapine (12.517.5 mg) Olanzapine (all doses) Quetiapine

Risperidone Ziprasidone Aripiprazole 12 10 8 25 20 15 6 10 4 2 5 0 0 0 4

8 12 16 20 24 28 32 36 40 44 48 52 Change From Baseline Weight (lb)

Change From Baseline Weight (kg) 1-Year Weight Gain: Mean Change From Baseline Weight Weeks Nemeroff CB. J Clin Psychiatry. 1997;58(suppl 10):45-49; Kinon BJ et al. J Clin Psychiatry. 2001;62:92-100; Brecher M et al. American College of Neuropsychopharmacology; 2004. Poster 114; Brecher M et al. Neuropsychopharmacology. 2004;29(suppl 1):S109; Geodon [package insert]. New York, NY:Pfizer Inc; 2005. Risperdal [package insert]. Titusville, NJ: Janssen Pharmaceutica Products, LP; 2003; Abilify [package insert]. Princeton NJ: Bristol-Myers Squibb Company and Rockville, Md: Otsuka America Pharmaceutical, Inc.; 2005. CATIE Trial Results: Weight gain (lb) per month 2 Weight Gain Per Month Treatment 1 0 OLZ -1

NEJM 2005 353:1209-1223 QUET RIS PER ZIP Change in Weight From Baseline 58 Weeks After Switch to Low Weight Gain Agent 6 10 14 19 23 27 32 36 40 45 49 53 58 LS Mean Change (lb) 5 0

* -5 *** ** -10 *** -15 -20 -25 *P<0.05 **P<0.01 ***P<0.0001 Switched from Conventionals Risperidone Weiden P et al. Presented APA 2004. **

*** Olanzapine ADA/APA/AACE/NAASO Consensus on Antipsychotic Drugs and Obesity and Diabetes: Monitoring Protocol* Start 4 wks 8 wks 12 wk qtrly 12 mos. 5 yrs. Personal/family Hx X X Weight (BMI) X Waist circumference X

Blood pressure X X X Fasting glucose X X X Fasting lipid profile X X X X

X X X X *More frequent assessments may be warranted based on clinical status Diabetes Care. 27:596-601, 2004 X Problem: SMI and Reduced Use of Medical Services Fewer routine preventive services (Druss 2002) Worse diabetes care (Desai 2002, Frayne 2006) Lower rates of cardiovascular procedures (Druss 2000) Access and Quality of Care SMI may be a health risk factor because of: Patient factors, e.g.: amotivation, fearfulness, homelessness, victimization/trauma, resources, advocacy, unemployment, incarceration, social

instability, IV drug use, etc Provider factors: Comfort level and attitude of healthcare providers, coordination between mental health and general health care, stigma, System factors: Funding, fragmentation Goals: Lower Risk for CVD Blood cholesterol 10% = 30% in CHD (200-180) High blood pressure (> 140 SBP or 90 DBP) 4-6 mm Hg = 16% in CHD; 42% in stroke Cigarette smoking cessation 50%-70% in CHD Maintenance of ideal body weight (BMI = 25) 35%-55% in CHD Maintenance of active lifestyle (20-min walk daily) 35%-55% in CHD Hennekens CH. Circulation. 1998;97:1095-1102. Why Should we be Concerned About Morbidity and Mortality? Recent data from several states have found that people with serious mental illness served by our public mental health systems die, on average, at least 25 years earlier that the general

population. Overview - PROPOSED SOLUTIONS Prioritize the Public Health Problem Target Providers, Families and Clients Focus on Prevention and Wellness Track Morbidity and Mortality in Public Mental Health Populations Implement Established Standards of Care Prevention, Screening and Treatment Improve Access to and Integration of Physical Health and Mental Health Care Recommendations NATIONAL LEVEL 1. Seek federal designation of people with SMI as a distinct at-risk health disparities population. Establish co-ordinated mental health and general health care as a national healthcare priority. 2. Establish a committee at the federal level to recommend

changes to national surveillance activities that will incorporate information about health status in the population with SMI. Consider representation from SAMHSA, Medicaid , the Centers for Disease Control and Prevention, state MH authorities / NASMHPD, and experts This may include the IOM project and other national surveys. Recommendations NATIONAL LEVEL 3. Share information widely about physical health risks in persons with SMI to encourage awareness and advocacy. Educate the health care community. Encourage consumers and family members to advocate for wellness approaches as part of recovery. Recommendations STATE LEVEL 1. Seek state designation of people with SMI as BOTH an at-risk and a health disparities

population. 2. Establish co-ordinated mental health and general health care as a state healthcare priority. 3. Education and advocacy policy makers funders providers individuals, family, community Recommendations STATE LEVEL 4. Require, regulate and lead Behavioral Health provider systems to screen, assess and treat both mental health and general health care issues. Provide for staffing time record keeping reimbursement

linkage with physical healthcare providers 5. Funding 6. Promote co-ordinated and integrated mental health and physical health care for persons with SMI. See 11th NASMHPD Technical Paper: Integrating Mental Health and Primary Care. Recommendations LOCAL AGENCY / CLINICIAN 1. BH providers shall provide quality medical care and mental health care Screen for general health with priority for high risk conditions Offer prevention and intervention especially for modifiable risk factors (obesity, abnormal glucose and lipid levels, high blood pressure, smoking, alcohol and drug use, etc.) Prescribers will screen, monitor and intervene for medication risk factors related to treatment of SMI (e.g. risk of metabolic syndrome with use of second generation anti-psychotics) Treatment per practice guidelines, e.g heart disease, diabetes,

smoking cessation, use of novel anti-psychotics. LOCAL AGENCY / CLINICIAN Recommendations 2. Care coordination Models l Assure that there is a specific practitioner in the MH system who is identified as the responsible party for each persons medical health care needs being addressed and who assures coordination all services. Routine sharing of clinical information with other providers (primary and specialty healthcare providers as well as mental health providers Care integration where services are co-located LOCAL AGENCY / CLINICIAN RECOMMENDATIONS 3. Support consumer wellness and empowerment to improve personal mental and physical well-being educate / share information to make healthy choices regarding nutrition, tobacco use, exercise, implications of psychotropic drugs teach /support wellness self-management skills teach /support decision making skills motivational interviewing techniques

Implement a physical health Wellness approach that is consistent with Recovery principles, including supports for smoking cessation, good nutrition, physical activity and healthy weight. attend to cultural and language needs Overview - PROPOSED SOLUTIONS Prioritize the Public Health Problem Target Providers, Families and Clients Focus on Prevention and Wellness Track Morbidity and Mortality in Public Mental Health Populations Implement Established Standards of Care Prevention, Screening and Treatment Improve Access to and Integration of Physical Health and Mental Health Care Full report available at http://www.nasmhpd.org/publications.cfm#techpap

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