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Morbidity and Mortality in people labeled with serious mental illness A selection of slides from the National Association of State Mental Health Program.

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Presentation on theme: "Morbidity and Mortality in people labeled with serious mental illness A selection of slides from the National Association of State Mental Health Program."— Presentation transcript:

1 Morbidity and Mortality in people labeled with serious mental illness A selection of slides from the National Association of State Mental Health Program Directors (NASMHP) Medical Directors Council report, July 2006, along with commentary and additional slides by Ron Unger LCSW (also some graphics from the ACES study) Slides in blue are from the NASMHP report, slides in green are by Ron Unger LCSW

2 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.

3 Recent Multi-State Study Mortality Data: Years of Potential Life Lost 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

4 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

5 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

6 Other solutions needed, that Other solutions needed, that NASMHPD didnt propose Seek wherever possible to use mental health treatments that do not shorten lives Seek wherever possible to use mental health treatments that do not shorten lives –In other words, vastly reduce reliance on anti-psychotic medications Reform the way medical research is done & information is distributed Reform the way medical research is done & information is distributed Prevention: reduce trauma! Prevention: reduce trauma!

7 What are Adverse Childhood Experiences (ACEs)? Growing up (prior to age 18) in a household with: Growing up (prior to age 18) in a household with: –Recurrent physical abuse. –Recurrent emotional abuse. –Sexual abuse. –An alcohol or drug abuser. –An incarcerated household member. –Someone who is chronically depressed, suicidal, institutionalized or mentally ill. –Mother being treated violently. –One or no parents. –Emotional or physical neglect.

8 Number of Adverse Childhood Events resulted in increases in: Risk factors for disease, like smoking and obesity Risk factors for disease, like smoking and obesity Actual diseases, such as heart disease, diabetes, others Actual diseases, such as heart disease, diabetes, others Substance abuse Substance abuse A wide variety of mental health problems, including depression and psychosis A wide variety of mental health problems, including depression and psychosis

9

10 Adoption of health-risk behaviors can include not just behaviors independently adopted by individuals, but also behaviors that are promoted by mental health professionals, such as reliance on neuroleptic medications.

11 Understanding parallel process: People who are traumatized often respond by making choices that seem to improve things but really make things worse People who are traumatized often respond by making choices that seem to improve things but really make things worse People and systems responding to traumatized people themselves frequently become organized by trauma, People and systems responding to traumatized people themselves frequently become organized by trauma, –and soon are making choices that seem to improve things but really make things worse A holistic approach is needed, that focuses on the overall health of both individuals, and of the people and the systems that attempt to help A holistic approach is needed, that focuses on the overall health of both individuals, and of the people and the systems that attempt to help

12 What are the Causes of Morbidity and Mortality in People with Serious Mental Illness? While suicide and injury account for about 30- 40% of excess mortality, about 60% of premature deaths in persons with schizophrenia are due to natural causes –Cardiovascular disease –Diabetes –Respiratory diseases –Infectious diseases

13 SMR = standardized mortality ratio (observed/expected deaths). 1.Harris et al. Br J Psychiatry. 1998;173:11. Newman SC, Bland RC. Can J Psych. 1991;36:239-245. 2.Osby et al. Arch Gen Psychiatry. 2001;58:844-850. 3.Osby et al. BMJ. 2000;321:483-484. Increased Mortality From Medical Causes in Mental Illness Increased risk of death from medical causes in schizophrenia and 20% (10-15 yrs) shorter lifespan1 Bipolar and unipolar affective disorders also associated with higher SMRs from medical causes 2 –1.9 males/2.1 females in bipolar disorder –1.5 males/1.6 females in unipolar disorder Cardiovascular mortality in schizophrenia increased from 1976-1995, with greatest increase in SMRs in men from 1991-1995 3

14 What portion of the risk of early death results from the medications? One recent 17 year study of people with schizophrenia found the following death rates depending on the number of neuroleptic (antipsychotic) drugs taken: One recent 17 year study of people with schizophrenia found the following death rates depending on the number of neuroleptic (antipsychotic) drugs taken: Those on one drug: 35% Those on one drug: 35% Those on two drugs: 44% Those on two drugs: 44% Those on 3 drugs: 57% Those on 3 drugs: 57% Those on 0 drugs: 20% Those on 0 drugs: 20% BRITISH JOURNAL OF P SYCHIATRY (2006), 188, 122^127 Schizophrenia, neuroleptic medication and mortality MATTI JOUKAMAA, MARKKU HELIOVAARA, PAUL KNEKT, HELIO« VAARA, ARPO AROMAA, RAIMO RAITASALO and VILLE LEHTINEN

15 Even Suicide Risk is Linked with Modern Treatment A major study showed that people diagnosed with schizophrenia are 20 times more likely to commit suicide in the modern era, than they were 100 years ago A major study showed that people diagnosed with schizophrenia are 20 times more likely to commit suicide in the modern era, than they were 100 years ago –The studys authors suggested: One cause was more people spending more time outside hospitals One cause was more people spending more time outside hospitals The other cause was side effects of anti- psychotics, which can increase risk of suicide The other cause was side effects of anti- psychotics, which can increase risk of suicide Study title: Lifetime suicide rates in treated schizophrenia: 1875–1924 and 1994–1998 cohorts compared

16 Osby U et al. Schizophr Res. 2000;45:21-28. Schizophrenia: Natural Causes of Death Higher standardized mortality rates than the general population from: –Diabetes 2.7x –Cardiovascular disease2.3x –Respiratory disease3.2x –Infectious diseases 3.4x Cardiovascular disease associated with the largest number of deaths –2.3 X the largest cause of death in the general population

17 Cardiovascular risk factors – overview BMI = body mass index; TC = total cholesterol; DM = diabetes mellitus; HTN = hypertension. Wilson PWF et al. Circulation. 1998;97:1837–1847. 0 2 4 6 8 10 12 14 HTNDMSmokingBMI >27TC >220 Single Risk Factors Multiple Risk Factors Odds ratios Smoking + BMI 2 + TC >220 3 Smoking + BMI + TC >220 + DM 4 Smoking + BMI + TC >220 + DM + HTN 5 The Framingham Study

18 Cardiovascular Disease (CVD) Risk Factors Modifiable Risk Factors Estimated Prevalence and Relative Risk (RR) Schizophrenia Bipolar Disorder Obesity 45 – 55%, 1.5-2X RR 1 26% 5 Smoking 50 – 80%, 2-3X RR 2 55% 6 Diabetes 10 – 14%, 2X RR 3 10% 7 Hypertension 18% 4 15% 5 Dyslipidemia Up to 5X RR 8 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.

19 Allison DB et al. J Clin Psychiatry. 1999;60:215-220. Percent < 18.518.5-2020-2222-2424-2626-2828-3030-3232-34> 34 0 10 20 30 No schizophrenia Schizophrenia ObeseOverweightAcceptable Under- weight BMI Range BMI Distributions for General Population and Those With Schizophrenia (1989)

20 Mental Disorders and Smoking Higher prevalence (56-88% for patients with schizophrenia) of cigarette smoking (overall U.S. prevalence 25%) 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) More toxic exposure for patients who smoke (more cigarettes, larger portion consumed) Smoking is associated with increased insulin resistance Smoking is associated with increased insulin resistance Similar prevalence in bipolar disorder 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

21 Increased smoking is also linked with at least some anti-psychotic medications Older anti-psychotics are definitely associated with increased urge to smoke Older anti-psychotics are definitely associated with increased urge to smoke Evidence is mixed with newer atypical anti-psychotics Evidence is mixed with newer atypical anti-psychotics

22 In 2001, it was estimated that people diagnosed mentally ill were smoking 43% of all cigarettes consumed in the US. The percentage has probably gone up since then.

23 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)

24 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

25 Mokdad et al. Diabetes Care. 2000;23:1278. Mokdad et al. JAMA. 1999;282:1519. Mokdad et al. JAMA. 2001;286:1195. Prevalence (%) Diabetes Mean body weight kg Year Diabetes and Obesity: The Continuing Epidemic

26 No Data Less than 4% 4% to 6% Above 6% Mokdad et al. Diabetes Care. 2000;23:1278-1283. Diabetes and Gestational Diabetes Trends: US Adults, BRFSS 1990

27 Mokdad et al. Diabetes Care. 2000;23:1278-1283. Diabetes and Gestational Diabetes Trends: US Adults, BRFSS 1995 No Data Less than 4% 4% to 6% Above 6%

28 Mokdad et al. Diabetes Care. 2001;24:412. Diabetes and Gestational Diabetes Trends: US Adults, BRFSS 1999 No Data Less than 4% 4% to 6% Above 6%

29 Mokdad et al. JAMA. 2001;286(10). Diabetes and Gestational Diabetes Trends: US Adults, BRFSS 2000 No Data Less than 4% 4% to 6% Above 6%

30 www.diabetes.org. No Data Less than 4% 4% to 6% Above 6% Above 10% Diabetes and Gestational Diabetes Trends: US Adults, Estimate for 2010

31 Haffner SM et al. N Engl J Med. 1998;339:229-234. Fatal or nonfatal MI (%) 3.5% 18.6% 20.2% 45.0% Equivalent MI Risk Levels No Prior MIPrior MINo Prior MIPrior MI Nondiabetic SubjectsType 2 Diabetic Subjects (n = 1373)(n = 1059) Diabetes is a CVD Risk Equivalent to Previous Myocardial Infarction

32 Identification of the Metabolic Syndrome 3 Risk Factors Required for Diagnosis Risk Factor Defining Level Abdominal obesity Men Women Abdominal obesity Men Women Waist circumference >40 in (>102 cm) >35 in (>88 cm) Waist circumference >40 in (>102 cm) >35 in (>88 cm) Triglycerides Triglycerides 150 mg/dL (1.69mmol/L) 150 mg/dL (1.69mmol/L) HDL cholesterol Men Women HDL cholesterol Men Women <40 mg/dL (1.03mmol/L) <50 mg/dL (1.29mmol/L) <40 mg/dL (1.03mmol/L) <50 mg/dL (1.29mmol/L) Blood pressure Blood pressure 130/85 mm Hg 130/85 mm Hg Fasting blood glucose Fasting blood glucose 110 mg/dL (6.1mmol/L) 110 mg/dL (6.1mmol/L) HDL = high-density lipoprotein. NCEP III. Circulation. 2002;106:3143-3421.

33 CHD Risk Increases with Increasing Number of Metabolic Syndrome Risk Factors Sattar et al, Circulation, 2003;108:414-419 Whyte et al, American Diabetes Association, 2001 Adapted from Ridker, Circulation 2003;107:393-397

34 Modifiable Risk Factors Affected by Psychotropics Overweight / Obesity Insulin resistance Diabetes/hyperglycaemiaDyslipidemia Newcomer JW. CNS Drugs 2005;19(Supp 1):1.93.

35 1-Year Weight Gain: Mean Change From Baseline Weight Change From Baseline Weight (lb) Weeks Change From Baseline Weight (kg) 52 48 44 40363228242016128400 Olanzapine (12.5–17.5 mg) Olanzapine (all doses) Quetiapine Risperidone Ziprasidone Aripiprazole 0 5 10 15 20 25 30 0 2 4 6 8 10 12 14 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.

36 CATIE Trial Results: Weight Gain Per Month Treatment NEJM 2005 353:1209-1223 OLZRIS PER QUET ZIP Weight gain (lb) per month

37 Conventionals Olanzapine Risperidone -25 -20 -15 -10 -5 0 5 LS Mean Change (lb) 4953 58 454036 32 27 23 19 14 10 6 * *** ** *** *P<0.05 **P<0.01 ***P<0.0001 Switched from Weiden P et al. Presented APA 2004. Change in Weight From Baseline 58 Weeks After Switch to Low Weight Gain Agent

38 CATIE Results: Metabolic Changes From Baseline OLZRIS PER QUET ZIP 9.4 -8.2 1.3 -1.3 6.6 40.5 21.2 -2.4 9.2 - 16.5 Cholesterol (mg/dL) Triglycerides (mg/dL) NEJM 2005 353:1209-1223

39 CATIE Results: Metabolic Changes From Baseline NEJM 2005 353:1209-1223 Glucose (mg/dL) Glycosylated HB (%) 13.7 0.11 2.9 0.0 5.4 0.07 6.6 0.04 7.5 0.4 OLZRIS PER QUET ZIP

40 American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity: Consensus Conference on Antipsychotic Drugs and Risk of Obesity and Diabetes + = increased effect; - = no effect; D = discrepant results. Drug Weight Gain Diabetes Risk Dyslipidemia clozapine + + + ++ olanzapine ++ risperidone + + DD quetiapine DD aripiprazole+/--- ziprasidone+/--- Diabetes Care 27:596-601, 2004

41 ADA/APA/AACE/NAASO Consensus on Antipsychotic Drugs and Obesity and Diabetes: Monitoring Protocol * *More frequent assessments may be warranted based on clinical status Diabetes Care. 27:596-601, 2004Start 4 wks 8 wks 12 wk qtrly 12 mos. 5 yrs. Personal/family Hx XX Weight (BMI) XXXXX Waist circumference XX Blood pressure XXX Fasting glucose XXX Fasting lipid profile XXX X X

42 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)

43 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

44 Anti-psychotics may cause people to delay seeking treatment for physical illness until its too late One of the first noted effects of anti- psychotic medications was to reduce responsiveness to aversive stimuli One of the first noted effects of anti- psychotic medications was to reduce responsiveness to aversive stimuli –For example, rats given these drugs would quit taking action to avoid electric shock –People may just tolerate things going wrong with their body, delaying treatment….

45 Hennekens CH. Circulation. 1998;97:1095-1102. 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) Maintenance of ideal body weight (BMI = 25) –35%-55% in CHD Maintenance of active lifestyle (20-min walk daily) –35%-55% in CHD

46 Survival Following Myocardial Infarction 88,241 Medicare patients, 65 years of age and older, hospitalized for MI Mortality increased by –19%: any mental disorder –34%: schizophrenia Increased mortality explained by measures of quality of care Druss BG et al. Arch Gen Psychiatry. 2001;58:565-572.

47 Other treatment-induced morbidity Risk of increased relapse is associated with use of all types of psychiatric medications, versus psychosocial treatments Risk of increased relapse is associated with use of all types of psychiatric medications, versus psychosocial treatments –There is good evidence for the argument that medications initially reduce symptoms, but then interfere with emotional self-regulation in a way that increases long term mental and emotional problems –Recovery from schizophrenia is no better or is worse than it was in the pre-drug era While it is twice as good in parts of the world where much less medication is used. While it is twice as good in parts of the world where much less medication is used.

48 Anti-psychotics and brain damage Cause over 10% shrinkage of the brain in monkeys given doses comparable per body weight to doses given humans with schizophrenia Cause over 10% shrinkage of the brain in monkeys given doses comparable per body weight to doses given humans with schizophrenia –Usually, such shrinkage is associated with the illness Truth may be complex, maybe some shrinkage due to distress, some to the use of medications Truth may be complex, maybe some shrinkage due to distress, some to the use of medications Also cause some areas of the brain, that are associated with psychosis if they are too dominant, to expand Also cause some areas of the brain, that are associated with psychosis if they are too dominant, to expand

49 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

50 Recommendations LOCAL AGENCY / CLINICIAN 1. 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.

51 LOCAL AGENCY / CLINICIAN Recommendations 2. Care coordination Models l lAssure 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

52 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

53 Full NASMHPD report available at http://www.nasmhpd.org/publications.cfm#techpap http://www.nasmhpd.org/publications.cfm#techpap http://www.nasmhpd.org/publications.cfm#techpap –Note you can access both the slideshow and a pdf file that has a written report, at this website.

54 Eliminating unnecessary treatment induced harm: Reduce reliance on anti-psychotic (neuroleptic) medications Reduce reliance on anti-psychotic (neuroleptic) medications –A large number of studies show that at least a significant portion of diagnosed people could function well without anti-psychotic medications Those who recover the most are typically not using medications Those who recover the most are typically not using medications Many people think they need medications because they confuse withdrawal effects with their natural state off medications Many people think they need medications because they confuse withdrawal effects with their natural state off medications Providing good alternative care could increase the number of people able to function without medications Providing good alternative care could increase the number of people able to function without medications

55 How to reduce reliance on harmful medications: All newly diagnosed individuals should receive an initial trial of treatment without medication All newly diagnosed individuals should receive an initial trial of treatment without medication –Medications should be considered a backup, used as little as possible All those on medications should be offered assistance in attempting a transition to being on less medication or off medication All those on medications should be offered assistance in attempting a transition to being on less medication or off medication –Reducing medication reliance should be an ongoing goal

56 Parallel process: reduce reliance on drug money & misinformation Most psychiatric research and continuing education is financed by drug companies Most psychiatric research and continuing education is financed by drug companies Drug companies withhold information that hurts their profits Drug companies withhold information that hurts their profits –Even when this threatens the lives of thousands of people Case example: Eli Lilly & Zyprexa Case example: Eli Lilly & Zyprexa

57 Awareness may be going up, but…. Use of psychiatric medications, in particular anti-psychotics, continues to escalate Use of psychiatric medications, in particular anti-psychotics, continues to escalate –Reaching way beyond those diagnosed with psychosis –Reaching a younger and younger population In a few states where data is known, cases of infants (< 12 months old) on anti- psychotics have been found In a few states where data is known, cases of infants (< 12 months old) on anti- psychotics have been found

58 Finally Whenever trauma is prevented from occurring, we reduce the risk of a whole host of problems Whenever trauma is prevented from occurring, we reduce the risk of a whole host of problems Whenever trauma is effectively healed, we also break the chain that leads to these problems Whenever trauma is effectively healed, we also break the chain that leads to these problems


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