Alex J Mitchell see www.psycho-oncology.info

AcknowledgementsOliver LordDarren MaloneCaroline Carney-DoebblingNasser AbdelmawlaBrett ThombsRoy ZiegelsteinJim CoyneMarc DeHertDavy Vancampfort Liaison faculty - Mar2011

Failing Medical Care of Psychiatric Patients Latest evidence on suboptimal medical care from physicians and psychiatrists

Contents1. Mental Health & Physical Health

Mortality | Impairment | Co-morbidity

2. Preventive Health Care InequalityScreening | prevention

3. Medical Health Care InequalityProcedures | prescribing

4. Physical and Metabolic Monitoring?Guidelines & responsibility

5. Implications for Mortality

Quality of medical careIn medical settings

Quality of preventive care(mass screening)

Quality of Psychiatric medical care

Medication Prescribing in medical settings

Procedures rate & Mortality

1. Physical Health Comorbidity / Mortality

Merikangas (2007) NCS-R (n=5962) : disability days

34.4

42.9 42.7

33.8

39.3

41.239.8

30.6

36.6

9

14.315.2

3.9

7.3

17.3

7.7

1.92.5

5.1

2.6 2.2 1.8 1.7 1.4 10.3 0.1

0

5

10

15

20

25

30

35

40

45

50

Depression Panic disorder PTSD Specific phobia Social phobia Bipolar disorder GAD Alcohol abuse Drug abuse

Yearly DOR

Unique

PAR%

Days totally out of role per yearAlonso (2010) WHO MH Survey n=62,971

How much physical co-morbidity is there in mental ill health?

Physical Comorbidity in Schizophrenia and Depression

0

5

10

15

20

25

30

35

40H

yper

tens

ion

Chr

onic

bro

nchi

tis

Ast

hma

Dia

bete

s

Ulc

er

Rhe

umat

oid

arth

ritis

Hea

rt c

ondi

tion

Ost

eoar

thrit

is

Any

can

cer

Stro

ke

Emph

ysem

a

Live

r pro

blem

s

Wea

k/fa

iling

kid

neys

Con

gest

ive

hear

tfa

ilure

Myo

card

ial i

nfar

ctio

n

Ang

ina

Cor

onar

y he

art

dise

ase

SchizophreniaDepressionNHANES

Sokal 2004 J Nerv Ment Dis 192:

421– 427

NHANES - US Department of Health National Health and Nutrition Examination Survey , 1988 –1994

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Card

iova

scul

ar d

iseas

eFu

nctio

nal s

omat

ic sy

ndro

mes

Osteoa

rticu

lar di

sord

ers

Neu

rolo

gical

dise

ases

Derm

atol

ogica

l dise

ases

Endo

crin

e dis

orde

rsRe

spira

tory

dise

ases

Dige

stive

dise

ases

: Ulce

r

Urin

ary

tract

dise

ase:

Ren

al lit

hias

is

Any m

edic

al di

sord

er

First Episode MDD (n=6090)

Recurrent Episode MDD (n=4167)

Gili et al (2011) 10,257 Primary care in Spain

Proportion meta-analysis plot [random effects]

0.0 0.2 0.4 0.6 0.8 1.0

combined 0.3227 (0.2882, 0.3581)

Saddicha et al (2007) [Females] 0.0333 (0.0008, 0.1722)

Padmavati et al (2010) 0.0392 (0.0048, 0.1346)

De Hert et al (2008) 0.0556 (0.0207, 0.1170)

Saddichha et al (2008) [ATPIII-A] 0.0909 (0.0424, 0.1656)

Baptista et al (2010) [Females] 0.1039 (0.0459, 0.1945)

De Hert et al (2010) [Sertindole] 0.1327 (0.0726, 0.2162)

Rezaei et al (2009) [Males] 0.1435 (0.1003, 0.1965)

Saddichha et al (2008) [IDF] 0.1818 (0.1115, 0.2720)

Kurt et al (2007) 0.1892 (0.1462, 0.2385)

Bernardo et al (2009) 0.1926 (0.1577, 0.2316)

Saari et al (2005) 0.1935 (0.0745, 0.3747)

Bai et al (2009) [Risperidone] 0.1942 (0.1463, 0.2498)

L’Italien (2007) [Aripiprazole] 0.1985 (0.1524, 0.2515)

De Hert et al (2010) [Risperidone] 0.2095 (0.1362, 0.2999)

Boke et al (2008) [Males] 0.2241 (0.1645, 0.2934)

Meyer et al (2009) [Black/Hispanic] [Olanzapine] 0.2273 (0.1331, 0.3470)

Bai et al (2009) [Olanzapine] 0.2447 (0.1619, 0.3442)

Kaya et al (2009) [Females] 0.2500 (0.1212, 0.4220)

Rejas et al (2007) [Females][ATPIII-A] 0.2559 (0.2200, 0.2943)

Rejas et al (2007) [Males][ATP III-A] 0.2561 (0.2273, 0.2866)

L’Italien (2007) [Placebo] 0.2581 (0.1912, 0.3344)

Baptista et al (2010) [Males] 0.2614 (0.1981, 0.3328)

Yazici et al (2010) [Males] 0.2766 (0.2047, 0.3582)

L’Italien (2007) [Aripiprazole Active] 0.2789 (0.2344, 0.3270)

Bai et al (2009) [Clozapine] 0.2857 (0.2284, 0.3486)

van Winkel et al (2008) [Schizophrenia] 0.2883 (0.2490, 0.3300)

Meyer et al (2009) [White][Aripiprazole] 0.2895 (0.1911, 0.4049)

Meyer et al (2009) [Black/Hispanic][Aripiprazole] 0.3239 (0.2176, 0.4455)

Hagg et al (2006) [Males] 0.3277 (0.2591, 0.4021)

Meyer et al (2009) [White][Olanzapine] 0.3297 (0.2347, 0.4361)

Kaya et al (2009) [Males] 0.3333 (0.2076, 0.4792)

McEvoy et al (2005) [Males] 0.3602 (0.3184, 0.4037)

Suvisaari et al (2007) [Schizophrenia] 0.3684 (0.2181, 0.5401)

Srisurapanont et al (2007) 0.3684 (0.2181, 0.5401)

Vuksan-Cusa et al (2010) 0.3710 (0.2516, 0.5031)

Hagg et al (2006) [Females] 0.3804 (0.2812, 0.4876)

Shi et al (2009) 0.3887 (0.3727, 0.4050)

Yazici et al (2010) [Females] 0.3933 (0.3210, 0.4691)

L’Italien (2007) [Olanzapine] 0.4155 (0.3650, 0.4674)

Brunero et al (2009) [Females][IDF] 0.4286 (0.2446, 0.6282)

Ramos-Rios et al (2010) 0.4561 (0.3799, 0.5339)

Maslow et al (2010) 0.4585 (0.3889, 0.5294)

Rezaei et al (2009) [Females] 0.4698 (0.3876, 0.5532)

Correll et al (2008) [Males][ATP III-A] 0.4815 (0.3434, 0.6216)

Correll et al (2008) [Males] 0.4815 (0.3434, 0.6216)

McEvoy et al (2005) [Females] 0.5140 (0.4383, 0.5892)

Correll et al (2010) (fasting cohort) 0.5166 (0.4829, 0.5503)

Steylen et al (2009) [Males] 0.5217 (0.3695, 0.6711)

Correll et al (2008) [Females][ATPIII-A] 0.5614 (0.4236, 0.6926)

Correll et al (2008) [Females] 0.5614 (0.4236, 0.6926)

Brunero et al (2009) [ATP] 0.5753 (0.4541, 0.6903)

Boke et al (2008) [Females] 0.6140 (0.4757, 0.7400)

Kato et al (2004) 0.6250 (0.4735, 0.7605)

Brunero et al (2009) [Males][IDF] 0.7333 (0.5806, 0.8540)

Steylen et al (2009) [Females] 0.8750 (0.6165, 0.9845)

proportion (95% confidence interval)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0 5 10 15 20 25

Schizophrenia & Related Psychoses

Schizophrenia Alone

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Clozapine(N=14)

Olanzapine(N=16)

Risperidone(N=18)

Aripiprazole(N=4)

Sertindole (n=4) Unmedicated(N=9)

Metabolic syndrome meta-analysis in schizophrenia (Mitchell, DeHert et al unpublished)

MetS in First episode Patients

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

Mets by ATP IIIA Mets by IDF BP (>130/85) HDL (M<40mg/dl, F<50

mg/dl)

TGL (>150mg/dl)

Glucose (>100mg/dl)

ATP IIIA Waist(M>102, F>88)

Saddichha S et al. Schizophr Res 2008;101:266-72.

Lawrence & Coghlan N S W Public Health Bull 2002; 13(7): 155–158 n=240,000

Five-year Mortality rates28%

19%

22%

12%

9%8%

0

5

10

15

20

25

30

CHD Diabetes Stroke

People with schizophrenia

People without schizophrenia

Hippisley-Cox J et al (2006) A comparison of survival rates for people with mental health problems and the remaining population with specific conditions.Disability Rights Commission. Equal treatment: closing the gap, July 2006

Slide credit: Dr Alan Farmer, Worcestershire Mental Health Partnership NHS Trust

2. Preventive Health Care Inequality

Should vulnerable patients receive similar or enhanced care?

Annual physical health checks(NSF for mental health/NICE guidance)

Blood pressure & weight/BMI

Lifestyle advice (smoking/diet/exercise/alcohol/drugs)

Urine/glucose test to exclude diabetes

Cholesterol check

Medication side effect monitoring(Include thyroid function & creatinine if on lithium)

Encourage screening in appropriate groups (cervical smears/mammography/hepatitis/HIV/high prolactin)

Offer flu vaccination and contraceptive advice

Mass Screening activitiesMammography

Pap. Smear

Lifestyle counselling

Blood pressure

Bowel cancer screening

Prostate PSA

Osteoporosis

Hepatitis & HIV tests

USPST recommendationsScreening mammography every 1-2 years starting at age 40

UK NSC (England)Age 50-70 every 3 years

OR of 0.7P<0.0001

Summary meta-analysis plot [random effects]

0.001 0.01 0.1 0.2 0.5 1 2 5

combined 0.709 (0.642, 0.784)

Lindamer et al (2003) 0.040 (0.002, 0.250)

Schwartz et al (2003) 0.310 (0.100, 0.960)

Werneke et al. (2006) [psychosis] 0.330 (0.180, 0.610)

Carney & Jones (2006) [high severity] 0.340 (0.280, 0.420)

Lasser et al (2003) 0.350 (0.240, 0.510)

Carney & Jones (2006) 0.380 (0.330, 0.430)

Werneke et al. (2006) [any] 0.400 (0.290, 0.550)

Carney & Jones (2006) [medium severity] 0.470 (0.330, 0.670)

Ludman et al (2010) 0.490 (0.310, 0.760)

Druss et al (2002) 0.520 (0.340, 0.790)

Carney & Jones (2006) [high severity] 0.560 (0.260, 1.210)

Carney & Jones (2006) [low severity] 0.590 (0.450, 0.780)

Iezzoni et al (2001) 0.600 (0.400, 1.100)

Leiferman et al (2006) 0.610 (0.350, 1.060)

Carney & Jones (2006) 0.620 (0.590, 0.660)

Carney & Jones (2006) [medium severity] 0.630 (0.570, 0.690)

Chochinov et al (2009) 0.640 (0.580, 0.710)

masterton et al (2010) 0.670 (0.420, 1.075)

Thorpe et al (2006) 0.680 (0.340, 1.370)

masterton et al (2010) 0.685 (0.448, 1.040)

Druss et al (2002) 0.780 (0.670, 0.910)

Patten et al (2009) 0.800 (0.400, 1.600)

Druss et al (2008) [specialist] 0.820 (0.690, 0.970)

Druss et al (2008) 0.820 (0.790, 0.847)

Pirraglia et al (2004) 0.840 (0.730, 0.970)

Stecker et al (2007) 0.867 (0.662, 1.130)

Werneke et al. (2006) [any] 0.910 (0.800, 1.040)

Carney & Jones (2006) [low severity] 0.930 (0.890, 0.970)

Carney & Jones (2006) 0.980 (0.950, 1.010)

Peytremann- Bridevaux et al (2008) 1.000 (0.800, 1.200)

Pirraglia et al (2004) 1.010 (0.860, 1.180)

Druss et al (2008) [primary care] 1.350 (1.160, 1.610)

Green and Pope (2000) 1.370 (1.040, 1.810)

Schwartz et al (2003) 2.790 (0.730, 1.720)

odds ratio (95% confidence interval)

Receipt of Mammograpy by mental illness(Mitchell, Lord currently unpublished)

3. Medical Health Care Inequality

Medical monitoring eg HBA1c

Medical procedures eg CABG

Medical prescribing eg Aspirin post MI

Frayne et al. Arch Intern Med. 2005 Diab care

313,586 Veteran Health Authority patients with diabetes76,799 (25%) had mental health conditions (1999)

Depression

Anxiety

Psychosis

Mania

Substance use disorder

Personality disorder

0.8 1.0 1.2 1.4 1.6

No HbA test done

0.8 1.0 1.2 1.4 1.6

No LDL test done

0.8 1.0 1.2 1.4 1.6

No Eye examination

done

0.8 1.0 1.2 1.4 1.6

No Monitoring

0.8 1.0 1.2 1.4 1.6

Poor glycemic control

0.8 1.0 1.2 1.4 1.6

Poor lipemic control

Odds ratio for:

Quality of Care - MI vs No MI

27 examined receipt of medical care in those with and without mental illness

19/27 showed deficits in care

10 examined medical care in those with and without substance use disorder (or dual-diagnosis

10/10 showed deficits in care

3b. Inequalities in Procedures

CABG – Coronary artery bypass graftCC - Cardiac catheterizationPTCA – Percutaneous transluminal coronary angioplastyPCI - Percutaneous coronary intervention

Lawrence et al

Any Mental illnessHR = 0.86 (0.80-0.92)

Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction

SchizophreniaHR = 0.53 (0.44 – 0.64)

Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction

3c. Medication Prescribing Inequalities

AspirinACE InhibitorsStatin / non-statinB-BlockersHAARTHRTChemotherapy

OR =0.94 (0.90-0.96) OR =0.69 (0.57-0.83) OR =0.72 (0.51-1.00)

SMI Schz Affective

Inequality of Prescribed Meds ii Medication by Diagnosis

OR =0.77 (0.69-0.86)

Inequality of Prescribed Meds ii Medication by ALL

OR =0.79 OR =0.99ns

OR =0.83 OR =0.84ns

Inequality of Prescribed Meds ii Medication by drug class

OR =0.94ns

OR =0.96

4. Inequality in Physical Care in Psychiatry

Physical Screening of Psychiatric Patients57.6% of inpatients receive a comprehensive physical

examination (Hodgson R, Adeyemo O. Physical examination performed by psychiatrists. International Journal of Psychiatry in Clinical Practice 2004;8:57-60.)

No dental health target achieved in 428 people with Schizophrenia McCreadie RG, et al The dental health of people with schizophrenia. Acta Psychiatrica Scandinavica 2004;110:306-10)

On screening at admission: 34% of older people had unrecognized medical disorders (Woo BKR, et al. Unrecognized medical disorders in older psychiatric inpatients in a senior behavioral health unit in a university hospital. Journal of Geriatric Psychiatry and Neurology 2003;16:121-5)

On screening at admission: 29% had physical disorder (80% previously known 20% new diagnoses). These were contributory to diagnosis in 5.5% (Koran LM, et al Medical disorders among patients admitted to a public-sector psychiatric inpatient unit. Psychiatric Services 2002;53:1623-5.

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0

Syphilis test

Ophthalmologist visit

HIV test

HBV-HCV test

Dentist visit / check-up

Respiratory exam including auscultation

Prolactin test

Electrocardiogram

Familiar physical health history

Physical exam

Sexual functioning history

Urine test

Haemogram

Basal creatinine

Blood pressure

Liver function tests

Bobes et al (2010) n=1193, 229 psychiatrists

Screening for metabolic side effects in AO clientsReview of 1966 case records from 53 teams, Barnes et al

(2007)

% with recorded measurement over last 12 months

Documented diagnosis

Documented treatment

Blood pressure

26% Hypertension 6%

48%

Measure of obesity

17%

Blood glucose 28% Diabetes 6% 62%

Plasma lipids 22% Dyslipidaemia 6%

37%

All of the above

11%

Slide credit: Dr Alan Farmer, Worcestershire Mental Health Partnership NHS Trust

0.138

0.108

0.025

0.005

0.080

0.015

0.175 0.179 0.177 0.175

0.256

0.219

0.037

0.071

0.153

0.1700.177

0.204

0.000

0.050

0.100

0.150

0.200

0.250

0.300

High glucoselevels

Hepatitis C High totalcholesterol

levels

High triglyceridelevels

HIV Hepatitis B

Clinician detected

Lab detected

missed

Rothbard et al Psychiatric Services 2009; 60(4); (n=588)

0.213

0.398

0.861

0.970

0.688

0.931

0.000

0.100

0.200

0.300

0.400

0.500

0.600

0.700

0.800

0.900

1.000

High glucoselevels

Hepatitis C High totalcholesterol

levels

High triglyceridelevels

HIV Hepatitis B

Rothbard et al Proportion of Missed Medical Conditions……

Solution?......is the solution in (more) guidelines?

Summary of Monitoring Protocol

Base line 4 wk 8 wk 12

wkQuar

t Ann 5 yr

Personal/fam. Hist. X XWeight (BMI) X X X X XWaist circum. X XBlood press. X X XFasting plasma glucose X X XFasting lipid profile X X X

American Diabetes Association and the American Psychiatric Association (ADA/ APA/AACE/NAASO, 2004).

Monitoring Guidelines Simplified

Adapted from Cohn TA, Sernyak M. Metabolic monitoring for patients treated with antipsychotic medications. Can J Psychiatry 2006;51:492–501.

 

US-Mount Sinai Australia

US-ADA–APA Belgium UK Canada

Guidelines Apply to Which Groups?

Schizophr, FGA/SGA

All patients, FGA/SGA

All patients, 

SGASchizophr, 

SGASchizophr, FGA/SGA Schizophr

Biochemical Screening            

Fasting plasma glucose (FPG) Yes Yes Yes Yes Yes Yes

Random glucose (RG)   Yes     Yes  

HbA1c optional     No Yes  

OGTT       Yes   Yes

Lipids Yes Yes Yes Yes   Yes

Physical Examination            

Weight Yes Yes Yes Yes   Yes

Waist circumference Yes Yes Yes Yes   Yes

Height Yes Yes Yes Yes   Yes

Hip   Yes Yes      

Blood pressure   Yes Yes Yes   Yes

Clinical Interview            

Family history Yes Yes Yes Yes   Yes

Past Medical history Yes Yes Yes Yes   Yes

Ethnicity Yes Yes   Yes    

Tobacco       Yes   Yes

Diet/activity   Yes   Yes   Yes

Diabetes signs/symptoms Yes   Yes Yes Yes Yes

Proportion meta-analysis plot [random effects]

0.0 0.2 0.4 0.6 0.8 1.0

combined 0.42 (0.34, 0.50)

Gul et al (2006) baseline 0.10 (0.04, 0.21)

Batscha et al (2010) 0.11 (0.01, 0.33)

Morrato et al (2009) baseline 0.13 (0.12, 0.13)

Mackin et al (2007) 0.13 (0.07, 0.22)

Holt et al (2009) outpatients 0.14 (0.06, 0.27)

Haupt et al (2009) preguideline: baseline 0.17 (0.16, 0.18)

Holt et al (2009) inpatients 0.18 (0.09, 0.31)

Morrato et al (2008) 0.19 (0.19, 0.19)

Moeller et al (2011) 0.23 (0.21, 0.25)

Morrato et al (2009) 0.23 (0.22, 0.24)

Gonzalez et al (2010) first audit: baseline 0.25 (0.17, 0.33)

Morrato et al (2010) prewarning 0.27 (0.27, 0.27)

Barnes et al (2008) (baseline) 0.28 (0.26, 0.30)

Shi et al (2009) 0.29 (0.28, 0.31)

Nguyen et al (2009) 0.34 (0.25, 0.45)

Taylor et al (2004) 0.41 (0.37, 0.45)

Boilson & Hamilton (2003) 0.50 (0.35, 0.65)

Crabb et al (2009) 0.56 (0.45, 0.66)

Hsu et al (2008) 0.57 (0.55, 0.59)

Batscha et al (2010) 0.58 (0.28, 0.85)

Jennex et al (2008) 0.59 (0.48, 0.68)

Organ et al (2010) 0.60 (0.56, 0.64)

Motsinger et al (2006)_All 0.63 (0.57, 0.69)

Copeland et al (2010) 0.64 (0.64, 0.65)

Kilbourne et al (2007) 0.69 (0.63, 0.74)

Bobes et al (2010) (baseline) 0.71 (0.68, 0.73)

Mangurian et al (2010) 0.71 (0.57, 0.83)

Voruganti et al (2007) 0.78 (0.75, 0.80)

Tarrant et al (2006) 0.82 (0.69, 0.91)

Gumber et al (2010) (baseline) 0.92 (0.84, 0.96)

proportion (95% confidence interval)

HR= 0.42 (0.34-0.50)Initiating antipsychotics

N=6000 pre-guidelineN=18,000 post guideline

ConclusionsCo-morbidity and mortality is high

Excess medical deaths > non-accidental deaths 4:1

Quality of medical care is below usual standard prescribing | procedures after MI

Physical health monitoring is poor

Guidelines accumulating but implementation lacking

5. Extras - Implication for Mortality

Quality of Care Influencing=> Mortality?Druss et al 2000 113,653Druss et al 2001 88,241Jones et al 2005 3,368Kisely et al 2007 13,626Lawrence et al 2003 210,129pLi et al 2007 39,839*Petersen et al 2003 4,340Plomondon et al 2007 14,194nsYoung et al 2000 354,195u