Premature mortality in individuals with major mental illness

Dr Daniel Smith

“A failure of social policy and health promotion, illness prevention and care provision.”

BJPsych, June 2013.

Life expectancy at birth of people with mental disorders in the period of 2007–09 (N = 31,719).

Chang C-K, Hayes RD, Perera G, Broadbent MTM, et al. (2011) Life Expectancy at Birth for People with Serious Mental Illness and Other Major

Disorders from a Secondary Mental Health Care Case Register in London. PLoS ONE 6(5): e19590. doi:10.1371/journal.pone.0019590

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0019590

Total life expectancy among psychiatric patients and general population in Denmark, Finland and Sweden 1987–2006 at 15 years of age.

Wahlbeck K et al. BJP 2011;199:453-458

©2011 by The Royal College of Psychiatrists

Excluding intentional self-harm as a cause of death

Changes in cardiovascular disease standardised mortality ratios (SMRs) in 5-year periods of a

community cohort of 370 people followed over 25 years.

Brown S et al. BJP 2010;196:116-121

©2010 by The Royal College of Psychiatrists

Suicide, accidental and violent deaths

Iatrogenic effects of psychotropic

medication

Cardiovascular diseases and some

cancers

Poor access to healthcare, ‘diagnostic overshadowing’ and

under-treatment

Shared genetic/epigenetic factors in psychiatric and

medical morbidity

Premature mortality in

major mental illness

Arch Gen Psychiatry. 2011;68(10):1058-1064. doi:10.1001/archgenpsychiatry.2011.113

Figure Legend:

Nordentoft et al, 2011, Archives Gen Psychiatry

Arch Gen Psychiatry. 2011;68(10):1058-1064. doi:10.1001/archgenpsychiatry.2011.113

Figure Legend:

Nordentoft et al, 2011, Archives Gen Psychiatry

Dr David Shiers

Professor Helen Lester

0

20

40

60

80

100

120

<25 25-34 35-44 45-54 55-64

De

ath

Rat

e/1

00

0 p

op

ula

tio

n

MMI (all cause)

MMI (exc. suicide)

All Scotland

Life-span influences on premature mortality in schizophrenia and

bipolar disorder: data from the Glasgow Psychosis Cohort. (Langan Martin et al, submitted)

<25 25-34 35-44 45-54 55-64 All ages

All causes

(n=230) 38.3 [7.9-111.8] 8.3 [4.9-13.0] 4.1 [2.9-5.6] 2.7 [2.1-3.4] 2.1 [1.7-2.6] 2.7 [2.4-3.1]

All causes

excluding suicide

(n=196)

0 [1-47.1] 6.0 [3.2-10.2] 3.0 [2.0-4.3] 2.4 [1.8-3.1] 2.0 [1.6-2.4] 2.3 [2.0-2.7]

Cardiovascular

disease (n=34) 0 [0-6587.3] 9.6 [0.2-53.2] 1.8 [0.4-5.2] 1.1 [0.5-2.2] 1.4 [0.8-2.1] 1.4 [0.9-1.9]

Cerebrovascular

disease (n=8) 0 [0-6587] 0 [0-49.8] 1.6 [0.04-8.97] 1.7 [0.5-4.3] 0.7 [0.1-2.1] 1.1 [0.5-2.2]

Cancer (n=33) 0 [0-399.2] 4.8 [0.6-17.4] 0.9 [0.2-2.5] 0.5 [0.2-0.9] 0.5 [0.3-0.8] 0.6 [0.4-0.8]

Life-span influences on premature mortality in schizophrenia and

bipolar disorder: data from the Glasgow Psychosis Cohort. (Langan Martin et al, submitted)

Standardised Mortality Ratios (SMRs) and [95% CIs]

<25 25-34 35-44 45-54 55-64 All ages

All causes

(n=230) 38.3 [7.9-111.8] 8.3 [4.9-13.0] 4.1 [2.9-5.6] 2.7 [2.1-3.4] 2.1 [1.7-2.6] 2.7 [2.4-3.1]

All causes

excluding suicide

(n=196)

0 [1-47.1] 6.0 [3.2-10.2] 3.0 [2.0-4.3] 2.4 [1.8-3.1] 2.0 [1.6-2.4] 2.3 [2.0-2.7]

Cardiovascular

disease (n=34) 0 [0-6587.3] 9.6 [0.2-53.2] 1.8 [0.4-5.2] 1.1 [0.5-2.2] 1.4 [0.8-2.1] 1.4 [0.9-1.9]

Cerebrovascular

disease (n=8) 0 [0-6587] 0 [0-49.8] 1.6 [0.04-8.97] 1.7 [0.5-4.3] 0.7 [0.1-2.1] 1.1 [0.5-2.2]

Cancer (n=33) 0 [0-399.2] 4.8 [0.6-17.4] 0.9 [0.2-2.5] 0.5 [0.2-0.9] 0.5 [0.3-0.8] 0.6 [0.4-0.8]

Life-span influences on premature mortality in schizophrenia and

bipolar disorder: data from the Glasgow Psychosis Cohort. (Langan Martin et al, submitted)

Standardised Mortality Ratios (SMRs) and [95% CIs]

Multimorbidity and major mental illness in Scotland:

– Data from 314 general practices in Scotland (1.8 million people)

– Schizophrenia and related psychoses and bipolar disorder identified (n=12,504)

– 32 physical health conditions also identified

– Multimorbidity described by age, gender and socioeconomic deprivation

– Some prescribing information

Physical health comorbidities assessed:

Coronary heart

disease

Parkinson’s disease Peripheral vascular

disease

Viral hepatitis

Chronic kidney

disease

Multiple sclerosis Sinusitis Liver disease

Asthma Stroke Chronic obstructive

pulmonary disease

Psoriasis/eczema

Atrial fibrillation Blindness Bronchiectesis Irritable bowel

syndrome

Epilepsy Glaucoma Chrones disease Migraine

Cancer (any) Hearing loss Diverticulitis Dyspepsia

Thyroid disorders Hypertension Rheumatoid arthritis Constipation

Diabetes Heart failure Prostate disease Pain disorder

Schizophrenia is associated with excess multiple physical health comorbidities but low levels of recorded cardiovascular disease in primary care: cross-sectional study. (Smith et al, BMJ Open, April 2013)

• Very high rates of “pro-atherosclerotic” conditions, eg,

smoking (32.3% vs. 20.6% p=0.01) and Diabetes (8.4%

vs. 5.3% p=0.001)

• BUT:

– Coronary Heart Disease, Heart Failure, Peripheral Vascular Disease, Stroke

and TIA not more common in the bipolar group

– Bipolar group displayed significantly lower recorded rates of hypertension (OR

0.82, p=0.001) and atrial fibrillation (OR 0.68, p=0.02)

– Substantial treatment inequalities for those bipolar patients known to have

coronary heart disease and hypertension.

Conclusions:

1. Premature mortality and multiple physical health problems are

well recognised in schizophrenia and bipolar disorder

2. Psychiatry has a central role to play in tackling this health

inequality

3. Don’t just screen – intervene!

4. We need better integration across primary and secondary care

5. We need new (innovative) treatment approaches and service

delivery models, particularly for younger patients.

Thanks to:

Secondary care (PsyCIS) mortality audit:

Moira Connolly, John Park, Frances Paton, Daniel Martin, Julie Langan, Gary McLean

Plus all Glasgow consultants who regularly update PsyCIS data.

SPICE primary care data:

We thank the Chief Scientist Office of the Scottish Government Health Directorates (Applied

Research Programme Grant ARPG/07/1); the Scottish School of Primary Care, which part

supported SWM’s post and the development of the Applied Research Programme; and the

Primary Care Clinical Informatics Unit at the University of Aberdeen, which provided the data.

The views in this publication are not necessarily the views of the University of Aberdeen of

University of Glasgow, their agents, or employees. We thank Katie Wilde and Fiona Chaloner

of the University of Aberdeen, who did the initial data extraction and management.

The analysis of SPICE data was conducted as part of the Living Well

with Multimorbidity Programme (CSO Grant ARPG/07/1) with

Professor SW Mercer (Principal Investigator) and Professor Bruce

Guthrie (epidemiology lead).

Premature mortality in individuals with major mental illness

Dr Daniel Smith