assist. prof. Igor Filipčić, MD, PhD Psychiatric Hospital „Sveti Ivan”

Zagreb, Croatia

Prevention of mortality and morbidity in acute and chronic psychiatric

patients

Program for integrative psychiatry

Overview

• Increased Morbidity and Mortality Associated with Serious Mental Illness (SMI)

• Increased Morbidity and Mortality – data from Psychiatric Hospital „Sv Ivan”

• Program for integrative psychiatry (PIPS) – in three steps

• Conclusion

In Serious Mental Illness (schizophrenia, depression, bipolar)

1. mortality is being 2 to 3 times higher compared to the general population

2. 60% of this excess mortality is due to physical illness (MI, CVI, embol.)

3. high risk of undetected somatic co-morbidity

4. incidence is much higher than in the normal population for

• cardiovascular diseases / infarct my. stroke/

• unrecognized cancer /lungs, colon/

• diabetes mellitus, metabolic syndrome

• respiratory diseases /COPD

5. psychiatric patients

• have still limited access to physical health care

• physical complaints at a late and more serious stage Data from Oud et al 2009 BMC Family Practice

Crump et al. 2013 AM J PsychiatryLeucht et al.2007 AP Scandinavica

Introduction

Potential factors for high rates of the co-morbid physical illnesses in schizophrenic patients

environment

schizophrenialifestyle

BEHAVIOR• psychotic symptoms• negative sy./ low energy• cognitive disturbances• reduced communication• isolated

LIFESTYLE• smoking• using drugs• alcohol• poor diets/obesity• not enough exercise

SYSTEM-RELATED FACTORS• not covered by health

insurance• less access to health care• not adequate access to

medical treatment• unemployment

TREATMENTAntipsychotics• side effects• weight gain, diabetes• increased prolactin level

Mortality and somatic morbidity in schizophrenic patients

Per

cent

age

of d

eath

s50

40

20

10

0

30

Heart disease Cancer Cerebrovascular Chronic respiratory

Diabetes Influenza/pneumoniaAccidents Suicide

MO OK RI TX UT VA

*Average data from 1996–2000Colton & Manderscheid 2006, Crump et al. 2013 AM J Psychiatry

Schizophrenic patients are at risk of under-diagnosis and under-treatment

• men with schizophrenia die 15 years earlier• women die 12 years earlier

The leading causes of death in persons with schizophrenia are ischemic heart disease and cancer

People with SMI have limited access to physical health care

N=8227

Schizophrenic patients use less than

general population• general medical services

• coronary revascularization

• standard diabetes care

• antihypertensive medication

• lipid-lowering medication

Risk factors smoking alcohol drugs/narcotics poor nutrition not exercise

We can improve the detection and treatment of comorbid

somatic illnesses in schizophrenic patients by.......

…taking more responsibility for the patient

…implementing systematic education

…improving parity in health care access and provision

…forging collaborations with other medical specialist

Fleischhacker WW et al. Comorbid Somatic Illness in Patients with Severe Mental Disorders: Clinical, Policy and Research ChallengesJ Clin Psychiatry. 2008; 68:514-519

Somatic comorbidity in psychiatric patients - PH „Sveti Ivan”

hospitalizations from 2013 to August 2015 N=13 686• schizophrenia 31% • depression 28%• bipolar 10%

78.9%

15.8%

5.7%

3.9% 3.9% 3.5%

Prevalence of cardiovascular diseases

hypertension cardiomyopathy atrial fibrillation paroxysmal tachycardiaishemic heart diseasesequelae of myocardial in-farction39,3% of patients had

cardiovascular disease

personal data

Somatic comorbidity in psychiatric patients - PH „Sveti Ivan”

35,8% patients had endocrine system disease

41.80%

34.90%

25.70%

24.50%4.00% 3.60%

Prevalence of endocrine system diseases

diabetes

hiperlipidemia

hypothyreosis

adiposity

anemia

struma

2012. 2013. 2014.0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%

10.80%

18.30%

29.70%

16.70%

23.50%

34.50%

Schizophrenia

endocrine system disease cardiovascular disease

2012. 2013. 2014.0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%

19.70%

28.30%

37.90%

22.60%

32.10%

42.10%

Depression&BIPOLAR

endocrine system disease cardiovascular disease

Mortality: MI /CVI/embolis64 patients - 8 patients (2013) 77 patients - 9 patients (2014)69 patients - 9 patients (2015)*

Cancer:4.9% (2013)5.8% (2014) 6.3% (2015)

* 2015 . first 8 months

personal data

Prevalence and relative risks factors (RR) in schizophrenia and depression /bipolar in PH „Sveti Ivan”compared to the

general population in Croatia

RR = relative risk

Risk factors schizophreniaPrevalence RR

depression/ bipolarPrevalence RR

Obesity 51.9% 2 36.3% 2

Smoking 72.2% 4 61.5% 3

DM 29.2% 2 33.4% 2

Hypertension 37.3% 3 49.7% 3

Dyslipidemia 55.4% 5 26.9% 3

personal data

2013-2015

Conducted In hospital daily hospital outpatient collaborating institutions

Program for integrative psychiatry

Team psychiatrists, psychotherapists nurses, occupational therapists psychologists, social workers, nutritionist internal medicine specialist, neurologist

Goals reduction of mortality

comprehensive treatment

rehabilitation

early identification

quality of life improvement

in psychiatric patient with

chronic somatic diseases

more responsibility for the patient in 3 steps

Program for integrative psychiatry

preventive programme

personalized pharmacotherapy & psychotherapy

a. physical examinations

b. screening BMI, weight, waist blood pressure fasting glucose, HbA1C fasting lipids, HDL-cholesterol ECG

c. screening habits (smoke, drug abuse, alcohol abuse, activity, fast food)

d. questionnaires, scales (PANS, CGI,QLSQ….)

12

a. pharmacotherapy strategies

• drugs selection & monitoring

• plasma concentration,

• side effects (metabolic,prolactin level)

• switch medications

b. psychotherapy strategies psychodynamic group therapy CBT multifamily therapy

3

A. patients with major menthal health problem

B. family – caregivers

Lifestyle changes with behavioural treatments

overweight, obesity & diet training

smoking cessation / non-smoking tr.

physical activity training

metacognitive training

anti-suicidal programme

anti-stigma programme

adherence programme

wellbeing programme

education C. Professionals psychiatrists GP others

www.pbsvi.hr

380 employees40 psychiatrists9 teachers125 nurses

700 patients550 beds150 daily hospital places