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:

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 NASMHPD didn’t propose
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
Prevention: reduce trauma!

7. What are Adverse Childhood Experiences (ACEs)?
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
Actual diseases, such as heart disease, diabetes, others
Substance abuse
A wide variety of mental health problems, including depression and psychosis

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 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

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. 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 causes2
1.9 males/2.1 females in bipolar disorder
1.5 males/1.6 females in unipolar disorder
Cardiovascular mortality in schizophrenia increased from , with greatest increase in SMRs in men from
SMR = standardized mortality ratio (observed/expected deaths).
Harris et al. Br J Psychiatry. 1998;173:11. Newman SC, Bland RC. Can J Psych. 1991;36:
2. Osby et al. Arch Gen Psychiatry. 2001;58:
3. Osby et al. BMJ. 2000;321:

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:
Those on one drug: 35%
Those on two drugs: 44%
Those on 3 drugs: 57%
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
The study’s authors suggested:
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
Study title: Lifetime suicide rates in treated schizophrenia: 1875–1924 and 1994–1998 cohorts compared

16. Schizophrenia: Natural Causes of Death
Higher standardized mortality rates than the general population from:
Diabetes x
Cardiovascular disease 2.3x
Respiratory disease 3.2x
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
Osby U et al. Schizophr Res. 2000;45:21-28.

17. Cardiovascular risk factors – overview
The Framingham Study 2 4 6 8 10 12 14
HTN DM
Smoking
BMI >27
TC >220
Single Risk Factors
Multiple Risk Factors
Odds ratios
Smoking + BMI
+ TC >220 3
+ DM
+ DM + HTN 5
This slide illustrates the cumulative effect of risk factors and illustrates that risk factors are more than additive; the total risk is higher than just the sum of the individual risk factors.
Monitoring of a USA population cohort in the town of Framingham, Massachusetts, USA, for the period of 12 years led to the identification of the major CVD risk factors, including high blood pressure, high total blood cholesterol, smoking, obesity and diabetes. Odds ratio for each of these risk factors alone ranges from around 1.2 to 2.2. When more than one factor is present, odds ratios are increased by more than an additive rate, so that all five (BMI>27, smoking, high total cholesterol, diabetes and hypertension) led to an approximate 7-fold increased risk compared to any one risk factor alone.
1. Wilson PWF, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. May 1998;97:1837–1847
BMI = body mass index; TC = total cholesterol; DM = diabetes mellitus; HTN = hypertension.
Wilson PWF et al. Circulation. 1998;97:1837–1847.

18. Cardiovascular Disease (CVD) Risk Factors
Modifiable Risk Factors
Estimated Prevalence and Relative Risk (RR)
Schizophrenia
Bipolar Disorder
Obesity
45–55%, 1.5-2X RR1
26%5
Smoking
50–80%, 2-3X RR2
55%6
Diabetes
10–14%, 2X RR3
10%7
Hypertension
≥18%4
15%5
Dyslipidemia
Up to 5X RR8
Key Points:
There is growing evidence that patients with major mental disorders (on this slide, schizophrenia is shown as an example) have a higher prevalence of key cardiovascular risk factors; this may explain the observation of higher rates of cardiovascular disease in mental health populations
1. Davidson S, et al. Aust N Z J Psychiatry. 2001;35: Allison DB, et al. J Clin Psychiatry. 1999; 60: Dixon L, et al. J Nerv Ment Dis. 1999;187: Herran A, et al. Schizophr Res. 2000;41: MeElroy SL, et al. J Clin Psychiatry. 2002;63: Ucok A, et al. Psychiatry Clin Neurosci. 2004;58: Cassidy F, et al. Am J Psychiatry. 1999;156: Allebeck. Schizophr Bull. 1999;15(1)81-89.

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

20. 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
Medical Illness and Schizophrenia (62106) by Jonathan M. Meyer (Editor), Henry A. Nasrallah (Editor)
Paperback: 256 pages ; Dimensions (in inches): 0.50 x 9.00 x 6.00
Publisher: Amer Psychiatric Pr; 1st edition (May 2003)
ISBN:
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):

21. Increased smoking is also linked with at least some anti-psychotic medications
Older anti-psychotics are definitely associated with increased urge to smoke
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)
Slide 53: Current Treatment Paradigm
The current treatment paradigm for type 2 diabetes consists of a stepwise approach with diet followed by a single oral agent, a second oral agent, and eventually insulin. Data from NHANES III indicate that the majority of patients with type 2 diabetes are poorly controlled by this approach.
Failure of monotherapy results from the progressive nature of the disease and because a single drug does not address the defects in insulin secretion, hepatic glucose production, and peripheral insulin resistance that characterize type 2 diabetes.
Furthermore, by waiting for failure before changing therapy, glucose toxicity may develop before the therapy is adjusted and impair the treatment response.
Harris MI, Eastman RC, Cowie CC, et al. Racial and ethnic differences in glycemic control of adults with type 2 diabetes. Diabetes Care. 1999;22:
Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, Diabetes Care. 1998;21:

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. Diabetes and Obesity: The Continuing Epidemic
Mean body weight
Prevalence (%) kg
The Behavioral Risk Factor Surveillance System (BRFSS) is a cross-sectional random-digit telephone survey conducted by the CDC and state health departments. In 2000, 184,450 adults (age 18 years and older) were surveyed.
According to the BRFSS data, the prevalence of diabetes increased by 49% in the period from 1990 through 2000, from 4.9%-7.3%. During the same period, the average self-reported weight increased from kg. The prevalence of obesity (BMI >30 kg/m2, calculated from self-reported weight and height) increased from 12% in 1991 to 19.8% in 2000.
BMI is one of the strongest predictors of diabetes. In a national sample of adults, every 1-kg increase in measured weight was associated with a 4.5% increase in risk for diabetes. According to analyses from BRFSS, in which weight was self-reported, every 1-kg increase in average weight is associated with a 9% increase in the prevalence of diabetes.
Both diabetes and obesity are preventable through improved diet and increased physical activity.
Despite proven benefits of weight loss and previous appeals to physicians to become more involved in weight counseling, only 43% of obese adults were advised to lose weight during regular checkups.
In 2000, most BRFSS participants (74%) were trying to lose or maintain weight. However, only 17.5% of those were following the recommendations to eat fewer calories and increase physical activity.
The prevalence of obesity and diabetes has been increasing over the past decade despite calls to action. Weight loss, increased activity, and healthy eating can prevent onset of diabetes, but seem to be difficult to achieve in general population. More aggressive public education or alternative approaches are needed to stem the epidemic of diabetes.
Mokdad AH, Ford ES, Bowman BA, et al. Diabetes trends in the U.S.: Diabetes Care. 2000;23:
Mokdad AH, Serdula MK, Dietz WH, et al. The spread of the obesity epidemic in the United States, JAMA. 1999;282:
Mokdad AH, Bowman BA, Ford ES, et al. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001;286:
Prevalence of obesity, increased by 61% since
More than 50% of US adults are overweight
Only 43% of obese persons advised to lose weight during checkups
BMI and weight gain major risk factors for diabetes
Year
Mokdad et al. Diabetes Care. 2000;23:1278.
Mokdad et al. JAMA. 1999;282:1519.
Mokdad et al. JAMA. 2001;286:1195.

26. Diabetes and Gestational Diabetes Trends: US Adults, BRFSS 1990
The next few slides show graphically how dramatically the incidence of diabetes has risen over the last decade.
These can be flipped through rather rapidly to show the changing of the map over the 10-year period.
This is 1990—the majority of the country reported rates below 6%.
In these slides, white areas are states that did not report data to the BRFSS.
Light blue is rate less than 4%--11 states
Medium blue is 4 to 6%--looks like about half the country
Red is above 6%; which in 1990 is 4 states only
Data are from the CDC and the Behavioral Risk Factors Surveillance System
No Data Less than 4% % to 6% Above 6%
Mokdad et al. Diabetes Care. 2000;23:

27. Diabetes and Gestational Diabetes Trends:
US Adults, BRFSS 1995
Only two years later,
12 states reported rates above 6% and only 5 states reported rates less than 4%.
No Data Less than 4% % to 6% Above 6%
Mokdad et al. Diabetes Care. 2000;23:

28. Diabetes and Gestational Diabetes Trends:
US Adults, BRFSS 1999
In 1999, the entire country is above 4%, with increasing numbers of states reporting rates above 5%, and, finally…
No Data Less than 4% % to 6% Above 6%
Mokdad et al. Diabetes Care. 2001;24:412.

29. Diabetes and Gestational Diabetes Trends:
US Adults, BRFSS 2000
In 2000, the last year that figures are available from the CDC, as you can see, nearly the entire country is red.
And predictions are not good. As you can see on the next slide…
No Data Less than 4% % to 6% Above 6%
Mokdad et al. JAMA. 2001;286(10).

30. Diabetes and Gestational Diabetes Trends:
US Adults, Estimate for 2010
By 2010, more than 10% of the US population will have diabetes.
No Data Less than 4% % to 6% Above 6% Above 10%

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

32. Identification of the Metabolic Syndrome
≥3 Risk Factors Required for Diagnosis
Risk Factor
Defining Level
Abdominal obesity Men Women
Waist circumference >40 in (>102 cm) >35 in (>88 cm)
Triglycerides
150 mg/dL (1.69mmol/L)
HDL cholesterol Men Women
<40 mg/dL (1.03mmol/L) <50 mg/dL (1.29mmol/L)
Blood pressure
130/85 mm Hg
Fasting blood glucose
110 mg/dL (6.1mmol/L)
Identification of the Metabolic Syndrome
This slide presents the ATPIII Adult Treatment Panel definition of the metabolic syndrome. Three or more of the criteria listed are required for a diagnosis of metabolic syndrome.
References National Cholesterol Education Program (NCEP) III. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. Circulation. 2002;106:
HDL = high-density lipoprotein.
NCEP III. Circulation. 2002;106:

33. CHD Risk Increases with Increasing Number of Metabolic Syndrome Risk Factors
Chd = coronary heart disease
Sattar et al, Circulation, 2003;108:
Whyte et al, American Diabetes Association, 2001
Adapted from Ridker, Circulation 2003;107:

34. Modifiable Risk Factors Affected by Psychotropics
Overweight / Obesity
Insulin resistance
Diabetes/hyperglycaemia
Dyslipidemia
Overweight and obesity are known to increase the risk for diabetes, cardiovascular disease (e.g., coronary heart disease [CHD] and cerebrovascular disease), hypertension, and certain cancers.1
In addition, they are associated with abnormal metabolic changes such as insulin resistance and dyslipidaemia, which are themselves risk factors for cardiovascular disease (CVD) and diabetes.
1. NIH/NHLBI guidelines. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. NIH Publication No National Institutes of Health. September 1998.
Newcomer JW. CNS Drugs 2005;19(Supp 1):1.93.

35. 1-Year Weight Gain: Mean Change From Baseline Weight14 30
Olanzapine (12.5–17.5 mg)
Olanzapine (all doses)
Quetiapine
Risperidone
Ziprasidone
Aripiprazole 12 25 10 20
Change From Baseline Weight (kg) 8 15
Change From Baseline Weight (lb) 6 10 4 5 2
1-Year Weight Gain: Mean Change From Baseline Weight
For the most part antipsychotics are not used as short-term therapies. They are used as chronic therapies, principally for psychotic disorders and bipolar disorders. This graph depicts 1-year data for mean changes from baseline weight in long-term clinical trials. This data represents the largest data sets available in this area. Kilograms are on the left and the corresponding pounds are on the right of the graph. Note at the bottom of the slide that the drugs ziprasidone and aripiprazole, which produced relatively minimal short-term weight gain, produced about the same amount of weight gain long term, or an ~1-kg mean weight gain at 52 weeks. Risperidone produced an ~2.5-kg increase and quetiapine produced a 3.6-kg weight gain over ~1 year. There are 2 lines for olanzapine; the first is pooling together all doses of olanzapine, from 2.5 mg up to 17.5 mg, from the pooled clinical trial data sets, resulting in a mean increase in weight at 1 year of about 6 kg or about 13 lb. For most antipsychotic therapy 2.5 mg of olanzapine is not used. In other analyses of this data the mean increase exceeded 22 lb, or more than 10 kg at 52 weeks. This is a clinically important increase in terms of physiologic effects.
References Nemeroff CB. Dosing the antipsychotic medication olanzipine. J Clin Psychiatry. 1997;58(suppl 10):45-49; Kinon BJ, Basson BR, Gilmore JA, Tollefson GD. Long-term olanzapine treatment: weight change and weight-related health factors in schizophrenia. J Clin Psychiatry. 2001;62:92-100; Brecher M, Zukin S, Leong R, Osterling-Koskinen L, Jones M. Long-term weight change with quetiapine treatment in schizophrenia: a comprehensive data review. Neuropsychopharmacology. 2004;29(suppl 1):S109; Brecher M, Zukin S, Leong R, Osterling-Koskinen L, Jones M. Long-term weight change with quetiapine treatment in schizophrenia: a comprehensive data review. Presented at: San Juan, Puerto Rico: Annual meeting of the American College of Neuropsychopharmacology. December 12-16,2004. Poster 114; Geodon® [package insert]. New York, NY:Pfizer Inc; 2005. 4 8 12 16 20 24 28 32 36 40 44 48 52
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; Poster 114; Brecher M et al. Neuropsychopharmacology. 2004;29(suppl 1):S109; Geodon® [package insert]. New York, NY:Pfizer Inc; 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
Weight gain (lb) per month
OLZ
QUET
RIS
PER
ZIP
NEJM :

37. Weiden P et al. Presented APA 2004.
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 5 *
LS Mean Change (lb) -5
*** **
-10
*** **
-15
*P<0.05
**P<0.01
***P<0.0001
-20
***
-25
Switched from
Conventionals
Risperidone
Olanzapine
Weiden P et al. Presented APA 2004.

38. CATIE Results: Metabolic Changes From Baseline
40.5
Cholesterol (mg/dL)
Triglycerides (mg/dL)
21.2
9.4
9.2
6.6
1.3
-1.3
-2.4
-8.2
-16.5
OLZ
QUET
RIS
PER
ZIP
NEJM :

39. CATIE Results: Metabolic Changes From Baseline
13.7
Glucose (mg/dL)
Glycosylated HB (%)
7.5
6.6
5.4
2.9
0.4
0.11
0.04
0.07
0.0
OLZ
QUET
RIS
PER
ZIP
NEJM :

40. clozapine + + + + olanzapine risperidone + + D quetiapine aripiprazole
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
Drug
Weight Gain
Diabetes Risk
Dyslipidemia
clozapine
+ + + +
olanzapine
risperidone
+ + D
quetiapine
aripiprazole
+/- -
ziprasidone
+ = increased effect; - = no effect; D = discrepant results.
Diabetes Care 27: , 2004

41. *More frequent assessments may be warranted based on clinical status
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
Weight (BMI)
Waist circumference
Blood pressure
Fasting glucose
Fasting lipid profile X
*More frequent assessments may be warranted based on clinical status
Diabetes Care. 27: , 2004

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
How stigma actually increases with medical model explanations

44. Anti-psychotics may cause people to delay seeking treatment for physical illness until it’s too late
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. Goals: Lower Risk for CVD
Blood cholesterol
10%  = 30%  in CHD ( )
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)
Hennekens CH. Circulation. 1998;97:

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:

47. Other treatment-induced morbidity
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.

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”
Usually, such shrinkage is associated with “the illness”
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

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
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.
Have effective linkages with community resources (including access to healthcare and engage families and other collateral service providers in understanding how to support consumers in maintaining their healthy choices)
Screen for co-morbid conditions (obesity, diabetes, high blood pressure)
Routinely assess treatment outcomes (physical as well as mental health)
Routinely share clinical information with other providers (primary and specialty healthcare providers as well as mental health providers)
Practice evidence-based care coordination (coordinate care of the whole person)
Assure health status assessment and planning are a part of treatment planning and goal setting for every person with SMI, throughout the system.
Adopt the U.S. Public Health Service guidelines for prevention and intervention in regard to modifiable risk factors—assure at least the same standard of care as that available to the general population.
Prescribers should be accountable for screening to assure adequate treatment of medical risk factors such as metabolic syndrome and its consequences to the same extent that they are for Extra-Pyramidal Symptoms and Tardive Dyskinesia.
Adopt consistent use of a metabolic screening and monitoring tool.
Implement standards of care for prevention, screening and treatment in the context of better access to health care. Use guidelines for prevention and intervention to assure there is consistent monitoring of individuals receiving psychotropic medications as a part of medication evaluation and follow up services in outpatient mental health settings as well as inpatient settings.
Using the monitoring tools recommended above, assure consistent diabetes screening for all individuals actively being served by the public mental health system.Assure priority for those receiving second generation antipsychotic medications and/or high risk ethnic populations.

51. LOCAL AGENCY / CLINICIAN Recommendations
2. Care coordination Models
Assure that there is a specific practitioner in the MH system who is identified as the responsible party for each person’s 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
Have effective linkages with community resources (including access to healthcare and engage families and other collateral service providers in understanding how to support consumers in maintaining their healthy choices)
Screen for co-morbid conditions (obesity, diabetes, high blood pressure)
Routinely assess treatment outcomes (physical as well as mental health)
Routinely share clinical information with other providers (primary and specialty healthcare providers as well as mental health providers)
Practice evidence-based care coordination (coordinate care of the whole person)

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
Utilize the system transformation recommendations from the New Freedom Commission, Institute of Medicine and SAMHSA to achieve a more person-centered mental health system. Specifically, implement the following selected recommendations, as identified in the IOM report, and modified to address the morbidity and mortality issues:
Direct care providers should:
Support consumer decision making and treatment preferences (regarding physical health as well as mental health, giving information to make healthy choices on weight, implications of psychotropic drugs, education about the effects of smoking, obesity and lack of exercise)
Use illness self-management practices ( expand opportunities for individuals to practice and develop decision making skills in regard to physical as well as mental health)
Develop approaches to support exercise, good nutrition, and weight within the context of each person’s unique interests and history.
Motivational interviewing techniques will be useful as a part of staging and framing the change process.

53. Full NASMHPD report available at
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
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
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

55. How to reduce reliance on harmful medications:
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
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
Drug companies withhold information that hurts their profits
Even when this threatens the lives of thousands of people
Case example: Eli Lilly & Zyprexa

57. Awareness may be going up, but….
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

58. Finally
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