Prevalence of chronic obstructive pulmonary disease among those with serious mental illness

"The Person Gets Lost in the Whole Process": Access to Physical Healthcare for Patients Hospitalized in a Psychiatric Hospital

Background and Purpose: Persons living with mental illnesses have unmet physical healthcare needs, leading to premature death. When they attempt to access physical health services, they are faced with numerous barriers that lead to delays in care. Although mental health nurses are identified as being essential actors in helping persons with mental illnesses navigate the complexities of the healthcare system, they also engage in conduct that further stigmatizes them. To complicate matters more, mental health nurses themselves face stigmatization when they help their patients living with mental illnesses access physical healthcare services. The aim of the study was to explore mental health nurses' experiences of associative stigma when accessing physical health services for their patients. Methods: To achieve this aim, we used an interpretive phenomenology methodology and a theoretical framework rooted in Erving Goffman's notion of associative stigma. Specifically, we conducted six interviews with mental health nurses working at an urban multisite psychiatric hospital to elicit accounts of their experiences of associative stigma when seeking physical healthcare for their patients and the meanings they make of these. Results: The results presented in this article illustrate some of the mechanisms by which stigmatization toward persons living with mental illnesses and mental health nurses cause delays in physical healthcare accessibility. Implications for Practice: In our discussion, we highlight the implications of these results for the practice of nurses and propose two structural solutions to improve access to physical healthcare and reduce stigmatizing experiences.

Nurses’ Perspectives on Smoking Policies, Safety and Cessation Support in Psychiatric Wards: A Cross-Sectional Survey

A high prevalence of smoking and low rates of smoking cessation interventions can be observed in psychiatric wards. A questionnaire-based, cross-sectional study was performed in five hospitals among 107 psychiatric ward nurses. The aim was to investigate nurses’ views on patients’ smoking practices and their influence on the safety of both the patients and medical personnel. In addition, we asked about the availability of smoking cessation support. Most of the respondents noticed the negative impacts of smoking on patients and medical personnel. Nearly a third of our respondents (29.0%) recalled smoking-related accidents in their facilities. In 45.2% of these accidents, a patient set someone else on fire. Around one fifth of nurses had rather permissive attitudes towards tobacco use in hospital wards. Significant associations were identified between respondents’ smoking status and their opinions on amending smoking policies and on unsupervised smoking. Regarding professional help available to smoking patients, 88.8% of participants reported that interventions to address smoking were available in their wards. Psychiatric hospitalisation can be an opportunity to offer tobacco treatment to patients with mental health conditions. To make use of this opportunity, smoke-free policies need to be put in place and hospital personnel, particularly nurses, should be trained and equipped with the knowledge and skills needed to assist in the smoking care of psychiatric ward patients.

Associations between self-reported respiratory symptoms and non-specific psychological distress following exposure to a prolonged landscape fire

We investigated the association between respiratory symptoms and psychological distress in the context of a prolonged smoke event, and evaluated whether smoke exposure, or pre-existing respiratory and mental health conditions, influenced the association. Three thousand ninety-six residents of a rural town heavily exposed to smoke from the 6-week Hazelwood coal mine fire, and 960 residents of a nearby unexposed town, completed Kessler's psychological distress questionnaire (K10) and a modified European Community Respiratory Health Survey. Logistic regression models evaluated associations between distress and respiratory symptoms, with interactions fitted to evaluate effect modification. Smoke exposed participants reported higher levels of distress than those unexposed, and participants reporting respiratory symptoms recorded higher levels of distress than participants without respiratory symptoms, irrespective of exposure. 5-unit increments in K10 scores were associated with 21%-48% increases in the odds of reporting respiratory symptoms. There were significant interactions with pre-existing asthma, chronic obstructive pulmonary disease and mental health conditions, but not with smoke exposure. Although participants with pre-existing conditions were more likely to report respiratory symptoms, increasing distress was most strongly associated with respiratory symptoms among those without pre-existing conditions. Communities exposed to landscape fire smoke could benefit from interventions to reduce both psychological and respiratory distress.

Tobacco Treatment Outcomes for Hospital Patients With and Without Mental Health Diagnoses

BACKGROUND

The prevalence of mental health conditions is higher in cigarette smokers than nonsmokers. However, those with diagnosed mental health disorders are understudied within general inpatient hospital settings. This study seeks to evaluate how having a mental health diagnosis influences response to a brief opt-out inpatient tobacco treatment intervention.

METHODS

Data included 4,153 admitted patients who completed a tobacco treatment visit. Post-discharge self-reported abstinence was obtained via response to an automated call 1-month after discharge. Mental health co-morbidities were assessed by reviewing electronic medical records. Logistic regression was used to assess associations between having a mental health diagnosis and patients' smoking history, interest in quitting smoking, and post-discharge abstinence.

RESULTS

Overall 34.1% of patients were diagnosed with mental health disorders, most commonly depression or substance use disorders. Patients with a diagnosed mental health disorder were more likely to report a history of long-term heavy smoking and were less likely to express an interesting in remaining abstinent from smoking after hospitalization. An intent-to-treat analysis using logistic regression analysis found lower rates of self-reported smoking abstinence in those with a mental health disorder compared to those without (9 vs. 13.2%, p < 0.001).

CONCLUSIONS

Patients with a history of mental health diagnoses, such as depression or substance use disorders, was associated with lower rates of smoking abstinence in patients after hospitalization. Hospital based opt-out smoking cessation programs have shown to be generally effective and efficient. However, certain subpopulations may require tailored intervention in order to improve treatment outcomes. Future research is needed to develop brief, effective tobacco treatment for hospital patients with comorbid mental health diagnoses.

Risk of COVID-19 diagnosis and death in patients with mental illness: a cohort study

AIMS

Patients with mental illness are vulnerable to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection because of behavioural changes associated with cognitive deterioration, especially without their caregivers. While studies have reported that SARS-CoV-2 infection risk and severe clinical outcomes are high among patients with mental illness, there is a lack of quantitative research supporting this claim. This study investigates if SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19)-related death are higher in patients with mental illness than among those without a mental disorder.

METHODS

A cohort study was conducted using the COVID-19 database of the National Health Insurance Service in South Korea. A total of 123 480 patients aged ⩾20 years who visited a hospital between 1 January 2020 and 30 May 2020 were analysed. Mental disorder diagnoses and types were determined based on 2019 medical records, and a multivariate logistic regression model was used to calculate the odds ratios (ORs) for SARS-CoV-2 infection and deaths.

RESULTS

The ORs for SARS-CoV-2 infection (OR 1.58; 95% CI 1.45-1.71) and COVID-19-related death (OR 2.18; 95% CI 1.57-3.04) were high among patients with mental illness. The OR of SARS-CoV-2 infection was higher among patients with severe mental illness (OR 2.60; 95% CI 2.21-3.06), dementia (OR 1.90; 95% CI 1.62-2.22) and substance use disorder (OR 4.98, 95% CI 3.60-6.88). The OR for COVID-19-related death was high among patients with severe mental illness (OR 3.53; 95% CI 1.82-6.83) and dementia (OR 2.12; 95% CI 1.39-3.22).

CONCLUSIONS

Patients with mental illness are at high risk for SARS-CoV-2 infection and COVID-19-related death. Behavioural changes associated with cognitive deterioration and long-term care facility residence increase SARS-CoV-2 infection risk, and severe medical conditions and delayed treatment increase the COVID-19-related mortality risk in patients with mental illness. Patients with mental illness are a priority target population for COVID-19 prevention and treatment, and it is important to plan prevention measures that address their needs.

Help Me Understand: Providing Palliative Care to Individuals With Serious Mental Illness

Individuals with serious mental illness (SMI) have shortened life expectancy with increased risk of developing comorbid medical illnesses. They might have difficulty accessing care and can be lost to follow-up due to complex socioeconomic factors, placing them at greater risk of dying from chronic or undiagnosed conditions. This, in combination with stigma associated with SMI, can result in lower quality end-of-life care. Interdisciplinary palliative care teams are in a unique position to lend assistance to those with SMI given their expertise in serious illness communication, values-based care, and psychosocial support. However, palliative care teams might be unfamiliar with the hallmark features of the various SMI diagnoses. Consequently, recognizing and managing exacerbations of SMI while delivering concurrent palliative or end-of-life care can feel challenging. The goal of this narrative review is to describe the benefits of providing palliative care to individuals with SMI with concrete suggestions for communication and use of recovery-oriented language in the treatment of individuals with SMI. The salient features of 3 SMI diagnoses-Bipolar Disorders, Major Depressive Disorder, and Schizophrenia-are outlined through case examples. Recommendations for working with individuals who have SMI and other life-limiting illness are provided, including strategies to effectively manage SMI exacerbations.

Non-pharmacological interventions for smoking in persons with schizophrenia spectrum disorders - A systematic review

INTRODUCTION

The rates and intensity of tobacco use are higher in persons with schizophrenia spectrum disorders (PwS) compared to the general population, contributing to increased morbidity and mortality. We aimed to systematically review randomised control trials (RCTs) that used non-pharmacological interventions to reduce or cease tobacco use in PwS.

METHODS

We searched PubMed, EBSCO, ProQuest and PsycINFO for RCTs, published between January 2004 and December 2019, which included adult PwS. Studies providing self-reported or biochemically measured reduction of tobacco use and cessation after a minimum follow-up period of 6 months were included. We used the Cochrane Risk of Bias (ROB) tool for assessing the quality of selected studies.

RESULTS

Of the six included trials, two compared non-pharmacological interventions alone while four compared combinations with pharmacological interventions with routine care. The non-pharmacological interventions varied widely. Continuous abstinence and seven days point-prevalence abstinence (7 PPA) were reported in 2 and 4 studies respectively, with one study assessing both. All six trials measured reduction in the number of cigarettes smoked, but only two trials reported significant reductions in intervention groups. No worsening of psychiatric symptoms was reported.

CONCLUSIONS

Two trials were rated as "low risk", and 4 trials as "some concerns" on the ROB tool. Heterogeneity among trials precluded meta-analysis. Abstinence was significantly higher among groups who were given combination interventions, and intervention groups in studies showed significantly greater or a trend towards reduction in the number of cigarettes smoked than controls. No specific method of non-pharmacological management was conclusively favoured.

IMPLICATIONS

Reduction in cigarettes smoked seemed to significantly favour or show non-significant trends favouring intervention groups over controls, while abstinence was significantly higher among groups in studies that used specific combination interventions. Combinations of pharmacological and non-pharmacological treatment were better than non-pharmacological interventions used in isolation, for facilitating abstinence and reduction in cigarettes smoked. Specific interventions such as home visits and contingent reinforcement merit further study. Trials included in this study were conducted in high-income and upper-middle-income countries. Thus, the application of these interventions to low and middle-income countries (LAMICs) needs to be further studied.

Economic and humanistic burden associated with noncommunicable diseases among adults with depression and anxiety in the United States

Aims: This study estimated the economic and humanistic burden associated with chronic non-communicable diseases (NCCDs) among adults with comorbid major depressive and/or any anxiety disorders (MDD and/or AAD).Materials and methods: A retrospective analysis was conducted using the Medical Expenditure Panel Survey data (2010-2015). The analytic cohort included adults (≥18 years) with MDD only (C1), AAD only (C2), or both (C3). The presence of either of 6 NCCDs (cardiovascular diseases [CVD], pulmonary disorders [PD], pain, high cholesterol, diabetes, and obesity) were assessed. Study outcomes included healthcare costs, activity limitations, and quality of life. Multivariate regressions were conducted in each of the 3 cohorts to evaluate the association between the presence of NCCDs and outcomes.Results: The analytic sample included 9,160,465 patients: C1 (4,391,738), C2 (3,648,436), C3 (1,120,292). Pain (59%) was the most common condition, followed by CVD (55%), high cholesterol (50%), obesity (42%), PD (17%), and diabetes (14%). Mean annual healthcare costs were the greatest for C3 ($14,317), followed by C1 ($10,490) and C2 ($7,906). For C1, CVD was associated with the highest increment in annual costs ($3,966) followed by pain ($3,617). For C2, diabetes was associated with the highest incremental annual costs ($4,281) followed by PD ($2,997). For C3, cost trends were similar to those seen in C2. NCCDs resulted in a significant decrease in physical quality of life across all cohorts. Pain was associated with a significantly higher likelihood of self-reported physical, social, cognitive, and activity limitations compared to those without pain.Conclusions: 60% of patients with MDD and/or AAD had at least one additional NCCD, which significantly increased the economic and humanistic burden. These findings are important for payers and clinicians in making treatment decisions. These results underscore the need for development of multi-pronged interventions which aim to improve quality of life and reduce activity limitations among patients with mental health disorders and NCCDs.

Paramedic performance when managing patients experiencing mental health issues - Exploring paramedics' Presentation of Self

INTRODUCTION

Mental health is a growing global concern with a significant rise in patients calling emergency services to respond to their needs. Paramedics in the UK are increasingly being asked to respond to this increase in demand.

AIM

This study explores how paramedics perform in practice when managing patients experiencing mental health issues.

METHODS

Qualitative observation over 240 h and interviews involving 21 paramedics and 20 patients with mental illness.

RESULTS

Using Goffman's seminal text Presentation of Self to frame the analysis the findings of this study reveal that paramedics '"perform" on two stages: front stage and back stage. Their coping mechanisms, in the metaphorical sense, include props such as uniform and scripts filled with humour, stereotyping and nostalgia to aid in their management of this specialist patient group.

CONCLUSIONS

Paramedics feel frustrated and unsupported when dealing with patients experiencing mental health issues. This study identifies the coping mechanisms paramedics use to manage this patient group but questions the longevity of these mechanisms and therefore recommends additional support for paramedics with further supportive education around mental health.

Increased risk of smoking-related illnesses in schizophrenia patients: A nationwide cohort study

BACKGROUND

Schizophrenia patients smoke at three times the rate of the general population, and are more susceptible to smoking-related illnesses. The goal of the current study was to evaluate the cumulative probability of chronic obstructive pulmonary disease (COPD) and ischemic heart disease (IHD) following first documentation of smoking among schizophrenia patients as compared to smoking healthy controls.

METHODS

A nationally representative cohort study was designed to assess the odds and cumulative probability of COPD and IHD among individuals with schizophrenia (n = 10,502) and a matched-sample of smoking healthy controls (n = 10,502). Hierarchical logistic regressions and Kaplan-Meier regression models were used to compare odds and cumulative probabilities across the two groups.

RESULTS

After adjusting for clinical and demographic factors, smoking schizophrenia patients had a higher probability of receiving a diagnosis of COPD than smoking healthy controls (OR 2.14, 95%CI 1.51-3.01, p < 0.001). The probability of having COPD increased more rapidly in smoking schizophrenia patients, yet the opposite trajectory prevailed for IHD, showing a decreased cumulative probability in smoking schizophrenia patients compared to smoking healthy controls.

DISCUSSION

Schizophrenia has a unique contribution to the facilitation of COPD, which extends beyond the effect of smoking, or other clinical and demographic risk factors. Differential smoking patterns could potentially account for this effect. The differential pattern of IHD should be subjected to further research, as our results might indicate that schizophrenia patients are underdiagnosed with IHD, and may be even less diagnosed as a function of time and chronicity.

Cigarette Smoking and Quitting-Related Factors Among US Adult Health Center Patients with Serious Mental Illness

INTRODUCTION

US adults with serious mental illness (SMI), compared to those without SMI, have a higher prevalence of smoking, which contributes to a shorter life expectancy. This study compared current smoking and quitting-related characteristics of low-income US adults with and without SMI who received healthcare at federally funded health centers.

METHODS

Using cross-sectional data from adults ≥ 18 years old in the nationally representative 2014 Health Center Patient Survey (n = 5592), we compared the prevalence of ever and current smoking among adults with and without SMI and calculated quit ratios as the percentage of ever smokers who have quit smoking. We examined the association between SMI and receiving advice to quit, making quit attempts, and having plans to quit in the next 30 days using multivariable logistic regression.

RESULTS

A total of 1376 (23%) of participants had SMI. Ever smoking prevalence was 68% in adults with SMI and 41% in adults without SMI, and current smoking prevalence was 48% and 22%, respectively. The quit ratio was 30% and 46% among participants with and without SMI, respectively. Compared to smokers without SMI, more smokers with SMI reported receiving advice to quit in the past 12 months (aOR 2.47, 95% CI 1.20-5.07). Smokers with and without SMI did not differ significantly in their odds of having made a past-12-month quit attempt or plans to quit.

CONCLUSIONS

Smokers with SMI seen in federally funded health centers were just as likely to have made a quit attempt and to have plans to quit as smokers without SMI. Despite a higher likelihood of receiving clinician advice to quit, the lower quit ratio in this population suggests that advice alone is unlikely to be sufficient. These results underscore the need for augmented strategies to promote smoking cessation and reduce the excess burden of tobacco-related disease in patients with SMI.

Comparative Effectiveness of Proactive Tobacco Treatment among Smokers with and without Chronic Lower Respiratory Disease

RATIONALE

Adults with chronic lower respiratory disease differ in their barriers to smoking cessation but also suffer from tobacco-related health concerns, which may motivate quit attempts. Few studies have examined differences in tobacco treatment response between smokers with and without chronic lower respiratory disease.

OBJECTIVE

We examined the effectiveness of a proactive outreach program for cessation among smokers with and without chronic lower respiratory disease.

METHODS

Subgroup analysis of the Veterans Victory over Tobacco Study, a pragmatic randomized controlled trial that demonstrated the effectiveness of proactive outreach and the choice of tobacco treatments compared with usual care. Smokers identified via the electronic medical record were proactively offered phone-based counseling and care coordination to receive medication from their Veterans Affairs providers or in-person care. We compared the response among those with and without an International Classification of Diseases, 9th Revision diagnosis of a chronic lower respiratory disease (chronic obstructive pulmonary disease, chronic bronchitis, emphysema, asthma). We used stratification by propensity scores to adjust for imbalanced covariates between groups with and without chronic lower respiratory disease within each treatment arm, using complete case analysis accounting for the stratified sampling by site.

RESULTS

The study participants were predominantly older, white, male smokers. Overall, 19.6% had chronic lower respiratory disease. A total of 3,307 had outcome data with the following assignments to the intervention: proactive care: n = 1,272 without chronic lower respiratory disease, n = 301 with chronic lower respiratory disease; usual care: n = 1,387 without chronic lower respiratory disease, n = 347 with chronic lower respiratory disease. A total of 1,888 had both complete baseline and outcome data and were included in the primary analysis. In unadjusted analyses (n = 3,307), among individuals with chronic lower respiratory disease, 13.1% in the proactive group reported 6-month prolonged abstinence compared with 8.7% of those in the usual care group (odds ratio, 1.57; 95% confidence interval, 0.93-2.65). Among individuals without chronic lower respiratory disease, 13.1% quit in the proactive group compared with 11.0% in the usual care group (odds ratio, 1.22; 95% confidence interval, 0.95-1.55). In adjusted analyses (n = 1,888), the association between treatment arm and quit rate varied by the presence of chronic lower respiratory disease, with a stronger association between allocation to the proactive group and quit rate among those with chronic lower respiratory disease (odds ratio, 3.45; 95% confidence interval, 1.59-7.47) than those without chronic lower respiratory disease (odds ratio, 1.34; 95% confidence interval, 0.95-1.88; P for interaction with chronic lower respiratory disease = 0.03).

CONCLUSIONS

Smokers with chronic lower respiratory disease may be more likely to respond to a proactive outreach intervention for tobacco cessation treatment than those without chronic lower respiratory disease. Clinical trial registered with www.clinicaltrials.gov (NCT 00608426).

Clinical Characteristics of Obstructive Sleep Apnea in Psychiatric Disease

Patients with serious psychiatric diseases (major depressive disorder (MDD), bipolar disorder (BD), and schizophrenia and psychotic disorder) often complain about sleepiness during the day, fatigue, low energy, concentration problems, and insomnia; unfortunately, many of these symptoms are also frequent in patients with Obstructive Sleep Apnea (OSA). However, existing data about the clinical appearance of OSA in Psychiatric Disease are generally missing. The aim of our study was a detailed and focused evaluation of OSA in Psychiatric Disease, in terms of symptoms, comorbidities, clinical characteristics, daytime respiratory function, and overnight polysomnography data. We examined 110 patients (56 males and 54 females) with stable Psychiatric Disease (Group A: 66 with MDD, Group B: 34 with BD, and Group C: 10 with schizophrenia). At baseline, each patient answered the STOP-Bang Questionnaire, Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), and Hospital Anxiety and Depression Scale (HADS) and underwent clinical examination, oximetry, spirometry, and overnight polysomnography. Body Mass Index (BMI), neck, waist, and hip circumferences, and arterial blood pressure values were also measured. The mean age of the whole population was 55.1 ± 10.6 years. The three groups had no statistically significant difference in age, BMI, hip circumference, and systolic and diastolic arterial blood pressure. Class II and III obesity with BMI > 35 kg/m² was observed in 36 subjects (32.14%). A moderate main effect of psychiatric disease was observed in neck (p = 0.044, η² = 0.064) and waist circumference (p = 0.021, η² = 0.078), with the depression group showing the lowest values, and in pulmonary function (Forced Vital Capacity (FVC, %), p = 0.013, η² = 0.084), with the psychotic group showing the lowest values. Intermediate to high risk of OSA was present in 87.37% of participants, according to the STOP-Bang Questionnaire (≥3 positive answers), and 70.87% responded positively for feeling tired or sleepy during the day. An Apnea-Hypopnea Index (AHI) ≥ 15 events per hour of sleep was recorded in 72.48% of our patients. AHI was associated positively with male sex, schizophrenia, neck, and waist circumferences, STOP-Bang and ESS scores, and negatively with respiratory function. A large main effect of psychiatric medications was observed in waist circumference (p = 0.046, η² = 0.151), FVC (%) (p = 0.027, η² = 0.165), and in time spend with SaO₂ < 90% (p = 0.006, η² = 0.211). Our study yielded that patients with Psychiatric Disease are at risk of OSA, especially men suffering from schizophrenia and psychotic disorders that complain about sleepiness and have central obesity and disturbed respiratory function. Screening for OSA is mandatory in this medical population, as psychiatric patients have significantly poorer physical health than the general population and the coexistence of the two diseases can further negatively impact several health outcomes.

Implementation of a Quit Smoking Programme in Community Adult Mental Health Services-A Qualitative Study

Little is known about the experiences of people with severe mental health difficulties in smoking cessation interventions. This study aimed to review the implementation of a smoking cessation programme across 16 community mental health day services. The aim was to establish the experience from both service user and facilitator perspectives and refine implementation for future groups. In-depth interviews were conducted with 20 service users and four focus groups held with 17 facilitators. Thematic analysis was used to analyse the data for emergent themes in relation to key enablers and barriers to implementation. Data from service users and facilitators revealed that implementation was enabled by an open and engaged recruitment approach; the resourcefulness of facilitators; programme materials and group-based format; combining the cessation programme with other and broader health initiatives; and participants' motivations, including health and money. Barriers included the structure of the service; the lack of a joined-up approach across the health services; literacy issues and the serial/logical process assumed by the programme. Barriers perceived as more specific to those with mental health difficulties included the use of smoking as a coping mechanism, lack of alternative activities/structure and lack of consistent determination. The tobacco free policy, implemented shortly before the programme, interestingly emerged as both a barrier and an enabler. In conclusion, although this group-based cessation programme in community mental health settings was well-received overall, a number of key barriers persist. A joined-up approach which addresses the culture of smoking in mental health settings, inconsistencies in smoking policies, and provides consistent cessation support, is needed. Care needs to be taken with the timing as overall it may not be helpful to introduce a new smoking cessation programme at the same time as a tobacco free policy.

Schizophrenia and Nicotine Dependence: What Psychopharmacological Treatment Options are Available for the Duo Perturbationes?

Nicotine dependence has progressively become a foremost community health interest in both the developed and developing nations due to the economic burden and health-related problems. Smoking was significantly higher among patients with schizophrenia in comparison to the general population. Nicotine dependence is not only associated with public stress, but among patients with schizophrenia, smoking brings major challenges to the management. Nicotine may diminish the therapeutic efficacy of the bioavailability of the psychopharmacological agents in-vivo. These duo perturbations, i.e. two clinical conditions co-existed may prevent psychotic symptoms remission among patients suffering from schizophrenia who smoke at the same time. The aim of this review was to highlight the role of pharmacological treatment options and strategies for patients with nicotine dependence in schizophrenia with emphasis on the underlying neurobiological process. The role of nicotine replacement therapy, i.e. norepinephrine-dopamine reuptake inhibition (NDRI) e.g. bupropion and selective partial agonist of α4β2 and full α7-nicotinic acetylcholine receptor e.g. varenicline was deliberated. An ideal choice of drug targets for patients with schizophrenia with nicotine dependence is pivotal to foster a better therapeutic alliance.

Increased risk of chronic obstructive pulmonary disease in patients with bipolar disorder: A population-based study

BACKGROUND

We conducted this nationwide study to examine the prevalence and incidence of chronic obstructive pulmonary disease (COPD) among patients with bipolar disorder in Taiwan.

METHODS

We used a random sample of 766,427 subjects who were aged ≥18 years in 2005. Patients with at least one primary diagnosis of bipolar disorder were identified. Study participants with one primary or secondary diagnosis of COPD for either ambulatory or inpatient care were also identified. We compared the prevalence of COPD in patients with bipolar disorder and the general population in 2005. In addition, we further investigated this cohort from 2006 to 2010 to detect incident cases of COPD in patients with bipolar disorder compared with the general population. The factors associated with COPD among patients with bipolar disorder were also analyzed.

RESULTS

The prevalence of COPD in patients with bipolar disorder was higher than in the general population in 2005 (5.68% vs. 2.88%, odds ratio 2.03; 95% confidence interval, 1.53-2.67). The average annual incidence of COPD in patients with bipolar disorder was also higher than in the general population (2.03% vs. 1.03%, risk ratio 1.94; 95% confidence interval, 1.65-2.29) from 2006 to 2010.

LIMITATIONS

Some risk factors for COPD such as substance use, obesity, or lifestyle pattern were not available in this study.

CONCLUSIONS

Patients with bipolar disorder had a higher prevalence and incidence of COPD compared with the general population. Higher prevalence of COPD among bipolar patients was associated with increased age, males, hypertension, and second-generation antidepressant use.

Stroke survivors with severe mental illness: Are they at-risk for increased non-psychiatric hospitalizations?

BACKGROUND

This study examined outcomes for two groups of stroke survivors treated in Veteran Health Administration (VHA) hospitals, those with a severe mental illness (SMI) and those without prior psychiatric diagnoses, to examine risk of non-psychiatric medical hospitalizations over five years after initial stroke.

METHODS

This retrospective cohort study included 523 veterans who survived an initial stroke hospitalization in a VHA medical center during fiscal year 2003. The survivors were followed using administrative data documenting inpatient stroke treatment, patient demographics, disease comorbidities, and VHA hospital admissions. Multivariate Poisson regression was used to examine the relationship between patients with and without SMI diagnosis preceding the stroke and their experience with non-psychiatric medical hospitalizations after the stroke.

RESULTS

The study included 100 patients with SMI and 423 without SMI. Unadjusted means for pre-stroke non-psychiatric hospitalizations were higher (p = 0.0004) among SMI patients (1.47 ± 0.51) compared to those without SMI (1.00 ± 1.33), a difference which persisted through the first year post-stroke (SMI: 2.33 ± 2.46; No SMI: 1.74 ± 1.86; p = 0.0004). Number of non-psychiatric hospitalizations were not significantly different between the two groups after adjustment for patient sociodemographic, comorbidity, length of stay and inpatient stroke treatment characteristics. Antithrombotic medications significantly lowered risk (OR = 0.61; 95% CI: 0.49-0.73) for stroke-related readmission within 30 days of discharge.

CONCLUSIONS

No significant differences in medical hospitalizations were present after adjusting for comorbid and sociodemographic characteristics between SMI and non-SMI stroke patients in the five-year follow-up. However, unadjusted results continue to draw attention to disparities, with SMI patients experiencing more non-psychiatric hospitalizations both prior to and up to one year after their initial stroke. Additionally, stroke survivors discharged on antithrombotic medications were at lower risk of re-admission within 30 days suggesting the VHA should continue to focus on effective stroke management irrespective of SMI.

To what extent are psychiatrists aware of the comorbid somatic illnesses of their patients with serious mental illnesses? - a cross-sectional secondary data analysis

Background

Somatic comorbidities are a serious problem in patients with severe mental illnesses. These comorbidities often remain undiagnosed for a long time. In Germany, physicians are not allowed to access patients’ health insurance data and do not have routine access to documentation from other providers of health care. Against this background, the objective of this article was to investigate psychiatrists’ knowledge of relevant somatic comorbidities in their patients with severe mental illnesses.

Methods

Cross-sectional secondary data analysis was performed using primary data from a prospective study evaluating a model of integrated care of patients with serious mental illnesses. The primary data were linked with claims data from health insurers. Patients’ diagnoses were derived on the basis of the ICD-10 and the Anatomical Therapeutic Chemical (ATC) classification system. Diabetes, hypertension, coronary artery disease (CAD), hyperlipidaemia, glaucoma, osteoporosis, polyarthritis and chronic obstructive pulmonary disease (COPD) were selected for evaluation. We compared the number of diagnoses reported in the psychiatrists’ clinical report forms with those in the health insurance data.

Results

The study evaluated records from 1,195 patients with severe mental illnesses. The frequency of documentation of hypertension ranged from 21% in claims data to 4% in psychiatrists’ documentation, for COPD from 12 to 0%, respectively, and for diabetes from 7 to 2%, respectively. The percentage of diagnoses deduced from claims data but not documented by psychiatrists ranged from 68% for diabetes and 83% for hypertension, to 90% for CAD to 98% for COPD.

Conclusions

The majority of psychiatrists participating in the integrated care programme were insufficiently aware of the somatic comorbidities of their patients. We support allowing physicians to access patients’ entire medical records to increase their knowledge of patients’ medical histories and, consequently, to increase the safety and quality of care.

Risk excess of mortality and use of antipsychotics: a case-noncase study

Severe mental disorders are associated with an increased mortality risk and the use of antipsychotic drugs may be one of the causes. In this study, we addressed the potential association of the reported mortality among patients on antipsychotics compared to other drugs from a pharmacovigilance database with the aim of evaluating the drug-induced mortality risk. A database containing 189 441 entries of suspected adverse reactions reported from 1 January 1995 to 31 December 2012 was explored for fatal outcomes. Potential disproportionality was estimated using the reporting odds ratio, proportional reporting ratio, and the χ-test. Two-hundred fatal outcomes were reported in patients on antipsychotics, which indicated the occurrence of disproportionality for this pharmacological class compared with any other drugs. When data were analysed by antipsychotic subclass, disproportionality was found only for atypical but not for typical antipsychotics. When individually analysed by active substances and routes, only a few substances were found to show disproportionality. The disproportionality encountered in this study compared with the mortality associated with other drugs suggests that the active substances under study may be associated with a mortality risk higher than what is assumed currently. Also, it suggests that atypical antipsychotics are likely to have a mortality risk higher than the risk of typical antipsychotics. The disproportionality found for zuclopentixol, in both oral and depot formulations, can be considered to be a drug surveillance signal.

Smoking, Mental Illness, and Public Health

Tobacco use remains the leading preventable cause of death worldwide. In particular, people with mental illness are disproportionately affected with high smoking prevalence; they account for more than 200,000 of the 520,000 tobacco-attributable deaths in the United States annually and die on average 25 years prematurely. Our review aims to provide an update on smoking in the mentally ill. We review the determinants of tobacco use among smokers with mental illness, presented with regard to the public health HAVE framework of “the host” (e.g., tobacco user characteristics), the “agent” (e.g., nicotine product characteristics), the “vector” (e.g., tobacco industry), and the “environment” (e.g., smoking policies). Furthermore, we identify the significant health harms incurred and opportunities for prevention and intervention within a health care systems and larger health policy perspective. A comprehensive effort is warranted to achieve equity toward the 2025 Healthy People goal of reducing US adult tobacco use to 12%, with attention to all subgroups, including smokers with mental illness.

Predictors of Pharmacotherapy for Tobacco Use Among Veterans Admitted for COPD: The Role of Disparities and Tobacco Control Processes

BACKGROUND

Many smokers admitted for chronic obstructive pulmonary disease (COPD) are not given smoking cessation medications at discharge. The reasons behind this are unclear, and may reflect an interplay of patient characteristics, health disparities, and the receipt of inpatient tobacco control processes.

OBJECTIVES

We aimed to assess potential disparities in treatment for tobacco use following discharge for COPD, examined in the context of inpatient tobacco control processes.

PARTICIPANTS

Smokers aged ≥ 40 years, admitted for treatment of a COPD exacerbation within the VA Veterans Integrated Service Network 20, identified using ICD-9 discharge codes and admission diagnoses from 2005-2012.

MAIN MEASURES

The outcome was any tobacco cessation medication dispensed within 48 hours of discharge. We assessed potential predictors administratively up to 1 year prior to admission. We created the final logistic regression model using manual model building, clustered by site. Variables with p < 0.2 in biviariate models were considered for inclusion in the final model.

RESULTS

We identified 1511 subjects. 16.9 % were dispensed a medication at discharge. In the adjusted model, several predictors were associated with decreased odds of receiving medications: older age (OR per year older 0.96, 95 % CI 0.95-0.98), black race (OR 0.34, 95 % CI 0.12-0.97), higher comorbidity score (OR 0.89, 95 % CI 0.82-0.96), history of psychosis (OR 0.40, 95 % CI 0.31-0.52), hypertension (OR 0.75, 95 % CI 0.62-0.90), and treatment with steroids in the past year (OR 0.80, 95 % CI 0.70-0.90). Inpatient tobacco control processes were associated with increased odds of receiving medications: documented brief counseling at discharge (OR 3.08, 95 % CI 2.02-4.68) and receipt of smoking cessation medications while inpatient (OR 5.95, 95 % CI 3.19-11.10).

CONCLUSIONS

Few patients were treated with tobacco cessation medications at discharge. We found evidence for disparities in treatment, but also potentially beneficial effects of inpatient tobacco control measures. Further focus should be on using novel processes of care to improve provision of medications and decrease the observed disparities.

Physical Functional Capacity and C-Reactive Protein in Schizophrenia

INTRODUCTION

Schizophrenia is a severe, debilitating mental disorder that affects both the physical health and the functional capacity of patients, causing great impairment throughout the life course. Although physical and cognitive impairments may represent different expressions of a single systemic inflammatory process, little is known about the relationship between motor function and schizophrenia.

OBJECTIVE

To evaluate physical functional capacity in patients with schizophrenia and ascertain whether it correlates with markers of inflammation, disease severity, and pharmacotherapy.

METHODS

Cross-sectional study using a convenience sampling strategy. Forty patients with stable schizophrenia, undergoing treatment, were recruited from the Outpatient Program of Hospital de Clínicas de Porto Alegre, University Hospital linked to Public Health System. Physical functional capacity was assessed by the 6-min walk test (6MWT), and inflammatory markers were measured by C-reactive protein (CRP) and Von Willebrand factor.

RESULTS

Mean functional capacity and clinical variables differed among patients and Brazilian population regarding heart rate (p = 0.004), diastolic (p = 0.001) and systolic (p < 0.001) blood pressure, respiratory rate (p < 0.001), CRP (p = 0.015), Borg Scale of Perceived Exertion scores (BSPE) (p < 0.001), and 6MWT both in men (p < 0.001) and women (p = 0.024). Additionally, 6MWT and dyspnea in BSPE were positively associated with CRP (r = -0.369, p = 0.019) and (r = -0.376, p = 0.017) and (r = 0.354, p = 0.025 and r = 0.535, p < 0.001, respectively).

CONCLUSION

The present study detected significant association between measures of functional impairment and markers of inflammation, especially elevated CRP in a group of stable outpatients with DSM-IV and ICD10 diagnosis of schizophrenia. Possible explanations for the associations could be linked to continued use of antipsychotics, although underlying neuroinflammatory mechanisms directly related to illness (schizophrenia) could not be ruled out. The findings of this study expand evidences of neuroinflammation to systemic inflammation in schizophrenia linking it to alterations of physical functional capacity and point to the need of additional studies exploring general inflammation and novel therapeutic interventions.

Expanding Cessation Pharmacotherapy Via Videoconference Educational Outreach to Prescribers

INTRODUCTION

Smoking cessation pharmacotherapy is underutilized by people with mental illnesses, who smoke at high rates and die prematurely of smoking-related diseases. Educational outreach can improve prescribing, but distances impede widespread use of this practice. Little research has assessed whether videoconference can effectively deliver educational outreach. We conducted a randomized, controlled trial of in-person versus videoconference educational outreach for smoking cessation pharmacotherapy across a state mental health system.

METHODS

We randomly assigned clinics to receive in-person or videoconference educational outreach with audit and feedback for cessation pharmacotherapy. Prescribers completed brief questionnaires before and after the intervention. With segmented regression analysis of interrupted time series, we evaluated prescribing trends in Medicaid pharmacy claims for nicotine replacement therapy (NRT) and varenicline, with interaction terms for the effect of intervention type (in-person vs. videoconference).

RESULTS

With interaction terms in the model, filled NRT prescriptions increased after the intervention compared to before (p < .01). The pattern of fills after the intervention were different at centers receiving in-person compared to videoconference educational outreach (p < .02) without clearly favoring one over the other. Additionally, filled varenicline prescriptions increased after the intervention compared to before (p = .04), but type of intervention delivery did not influence varenicline fills. Prescriber satisfaction with the educational intervention was high and prescriber attitudes became more positive in both groups.

CONCLUSION

This study suggests that single session educational outreach with audit and feedback can increase cessation pharmacotherapy utilization, and that videoconference delivery could be an effective, scalable approach to improve workforce capacity in systems serving mentally ill smokers.

Lung function and respiratory diseases in people with psychosis: population-based study

BACKGROUND

There is little information on lung function and respiratory diseases in people with psychosis.

AIMS

To compare the respiratory health of people with psychosis with that of the general population.

METHOD

In a nationally representative sample of 8028 adult Finns, lung function was measured by spirometry. Information on respiratory diseases and symptoms was collected. Smoking was quantified with serum cotinine levels. Psychotic disorders were diagnosed utilising the Structured Clinical Interview for DSM-IV (SCID-I) and medical records.

RESULTS

Participants with schizophrenia and other non-affective psychoses had significantly lower lung function values compared with the general population, and the association remained significant for schizophrenia after adjustment for smoking and other potential confounders. Schizophrenia was associated with increased odds of pneumonia (odds ratio (OR) = 4.9), chronic obstructive pulmonary disease (COPD, OR = 4.2) and chronic bronchitis (OR = 3.8); and with high cotinine levels.

CONCLUSIONS

Schizophrenia is associated with impaired lung function and increased risk for pneumonia, COPD and chronic bronchitis.

Smoking Cessation in Individuals With Serious Mental Illness: A Randomized Controlled Trial of Two Psychosocial Interventions

OBJECTIVE

Smoking among individuals with serious mental illness is a critical public health problem. Although guidelines recommend bupropion for these smokers, many do not want to use medications for smoking cessation, express ambivalence about identifying a "quit date," and do not have access to behavioral smoking cessation services integrated with mental health care.

METHODS

Individuals with serious mental illness who smoked 10 or more cigarettes per day (N = 178) were randomized to either a multifaceted behavioral group intervention or a supportive group intervention, both of which were integrated within outpatient mental health services at three VA medical centers. Participants attended twice-weekly meetings for 12 weeks, provided information on their smoking at each meeting, and completed baseline and post-treatment assessments conducted by an assessor who was blind to condition. Primary outcomes collected at post-treatment included 1-week abstinence, number of cigarettes smoked per day during the last week, and number of quit attempts during the treatment period. Outcomes examined for a subset of participants who attended at least one intervention meeting (n = 152) included smoking abstinence for 1-, 2-, and 4-week blocks during the treatment period. Analyses conducted on those participants who attended three or more intervention meetings (n = 127) included time to 50% reduction in the number of cigarettes smoked and time to first quit attempt.

RESULTS

Sixteen participants achieved abstinence (11.8%), smoking quantity was significantly reduced (baseline M = 15.2, SD = 9.8 to post-treatment M = 7.5, SD = 7.7, p <.0001), and most reported making a quit attempt (n = 88, 72.7%). There were no differences by study condition on any abstinence or reduction outcomes. Significant reductions in number of cigarettes smoked generally took place within the first two weeks; however, these reductions did not often translate into abstinence.

CONCLUSIONS

Many participants reduced their smoking and sampled quitting during the study. Implementing smoking cessation services in mental health treatment settings is feasible and, if delivered in line with best practices, either a behavioral or a supportive approach can be helpful. Future research should examine ways to facilitate the transition from reduction to abstinence. This study was part of a clinical trial registered as NCT #00960375 at www.clinicaltrials.gov.

Factors influencing implementation of smoking cessation treatment within community mental health centers

OBJECTIVE

Consumers with serious mental illness smoke more and are at higher risk for smoking-related illness. We examined provider and consumer factors influencing the implementation of the evidence-based "5 A's" (ask, advise, assess, assist, arrange) in six community mental health centers in greater Baltimore.

METHODS

Data collected as part of a larger study examining the effectiveness of delivery of the 5 A's at patient visits. First, we examined responses to a survey administered to 49 clinicians on barriers and attitudes toward delivering the 5 A's. Second, we used multilevel models to examine variance between patients (n = 228), patient factors, and variance between their psychiatrists (n = 28) in the delivery of the 5 A's (and first 3 A's).

RESULTS

The most strongly endorsed barrier was perceived lack of patient interest in smoking cessation. Psychiatrists and patients both accounted for significant variance in the delivery of the 5 A's and 3 A's. Patient "readiness to change" predicted delivery of the full 5 A's, while smoking severity predicted delivery of the first 3 A's.

CONCLUSIONS

There is a critical need for creative and collaborative solutions, policies, and clinician training to address actual and perceived obstacles to the delivery of evidence-based smoking cessation treatment in the mental health care setting.

Metabolic syndrome and lung function in schizophrenia: a pilot study

This pilot study aimed to explore relationships between metabolic and lung functions in patients with schizophrenia. Eighty patients with schizophrenia (55 ♂; 36.8±10.0 years) underwent a spirometry, were screened for metabolic syndrome (MetS), performed a 6-min walk test (6MWT), and completed the International Physical Activity Questionnaire and the Psychosis evaluation tool for common use by caregivers. Patients with MetS (according to the International Diabetes Federation criteria) (n=28; 35%) had a reduced predicted forced expiratory volume for 1 second (77.4±13.2% versus 87.3±12.1%) and predicted forced vital capacity (75.3±11.1% versus 85.4±11.4%). Significantly more patients with MetS were diagnosed with restrictive lung dysfunction (RLD) (according to the Global Initiative for Chronic Obstructive Lung Disease criteria) (13 versus 8). Schizophrenia patients with RLD (n=21; 26.2%) had a significantly larger waist circumference (90.7±12.5 versus 105.6±14.7 cm), were less physically active (653.6±777.9 versus 1517.9±1248.7 metabolic equivalent min/week) and walked less on the 6MWT (502.6±92.3 versus 612.4±101.2 m) than patients without RLD. The present data suggest that in patients with schizophrenia RLD might be associated with metabolic dysfunctions. Further prospective analyses are required to elucidate the complex interrelationships between lung and metabolic functions in patients with schizophrenia.

School sport participation during adolescence and mental health in early adulthood

PURPOSE

This longitudinal study examined the association between participation in school sport during adolescence and mental health in early adulthood.

METHODS

Adolescents (n = 853) reported participation in school sport in each grade throughout the 5 years of secondary school. In early adulthood, participants reported depressive symptoms, level of stress, and self-rated mental health.

RESULTS

Involvement in school sport during adolescence was a statistically significant predictor of lower depression symptoms, lower perceived stress, and higher self-rated mental health in young adulthood.

CONCLUSIONS

School sport participation may protect against poor mental health in early adulthood. Policies to increase school sport participation may be warranted as part of public health strategies to promote mental health.

Tobacco use treatment in primary care patients with psychiatric illness

The prevalence of smoking is higher in patients with psychiatric illness compared with the general population. Smoking causes chronic illnesses, which lead to premature mortality in those with psychiatric illness, is associated with greater burden of psychiatric symptoms, and contributes to the social isolation experienced by individuals with psychiatric disorders. Most patients with a psychiatric illness present initially to primary care rather than specialty care settings, and some patients receive care exclusively in the primary care setting. Therefore, family physicians and other primary care clinicians have an important role in the recognition and treatment of tobacco use disorders in patients with psychiatric illnesses. In this article we review common myths associated with smoking and psychiatric illness, techniques for implementing evidence-based tobacco use treatments, the evidence base for tobacco use treatment for patients with specific psychiatric diagnoses, and factors to consider when treating tobacco use disorders in patients with psychiatric illness.

Clearing the air: Chronic respiratory illnesses and smoking cessation in the adult psychiatric population

Objective: To review current practice guidelines in the treatment of asthma and chronic obstructive pulmonary disease (COPD), review therapeutic options for smoking cessation, and apply current evidence to management of these conditions in the psychiatric population.

Background: Chronic respiratory illnesses and nicotine dependence are frequently encountered conditions in the psychiatric population. Psychiatric illness itself may contribute to or be affected by these conditions; medication therapy may additionally be linked to alterations in mental status. However, it is well established that when left untreated or improperly managed, chronic respiratory illness and tobacco use can negatively affect patients' quality of life and lead to increased healthcare utilization.

Methods: Current practice guidelines, literature reviews, and primary data pertaining to management of patients with asthma, COPD, and nicotine dependence were examined. Additional data regarding patients with psychiatric illness was reviewed and commented upon.

Conclusions: Management of this particular population can pose significant clinical challenges. Regardless of what factors may contribute to the disease states and their treatment, it is important for clinicians to identify and take steps to manage both respiratory and psychiatric concerns as they are able. Identification, evidence-based treatment with appropriate medication therapy, and continuing patient education should be used together to help improve patient outcomes.

High rates of obstructive sleep apnea symptoms among patients with schizophrenia

BACKGROUND

Patients with schizophrenia have high rates of obesity and cardiovascular morbidity, which are strongly associated with obstructive sleep apnea (OSA). The prevalence and risk factors for OSA are not well studied in patients with schizophrenia.

OBJECTIVE

The purpose of this study was to evaluate the frequency of OSA symptoms in a sample of outpatients with schizophrenia.

METHODS

This cross-sectional study was a secondary analysis of data generated from an insomnia study that evaluated 175 outpatients with schizophrenia or schizoaffective disorder in a single, large urban community mental health center. Results of scales evaluating insomnia were used to complete the STOP questionnaire, which is a screening tool for OSA validated in surgical populations. Appropriate statistical analysis was done to compare participants across groups.

RESULTS

Patients were classified into high risk for OSA (STOP ≥ 2) (57.7%), and low risk for OSA (STOP score < 2) (42.3%). We also identified patients with a known diagnosis of OSA (14.9%). Patients with diagnosed OSA had significantly higher STOP scores (mean 2.7 vs. 1.6 [t = 6.3; p < 0.001]). Only 23.8% of patients in the high-risk group were diagnosed with OSA. Body mass index was significantly higher in the diagnosed group (F[2,169] = 25; p < 0.001) as was diabetes (χ2 [2, N = 175] = 35, p < 0.001).

CONCLUSION

A large number of outpatients with severe mental illness are at high risk for OSA. The STOP questionnaire is easy to use and appears to have a very high clinical utility to detect OSA. Based on our findings, further studies are warranted to validate the tool in patients with severe mental illness.

Associations between expiratory spirometry parameters and limitations in daily life activities in patients with schizophrenia

OBJECTIVE

This cross-sectional study considered whether variability in respiratory functioning could explain the variability in walking ability of individuals with schizophrenia taking into account variability in body mass index (BMI), lifestyle factors, psychiatric symptoms, antipsychotic medication use and muscular fitness.

METHOD

Eighty patients with schizophrenia and 40 age-, gender- and BMI-matched controls underwent a spirometry and the 6-min walk test (6 MWT) and completed the International Physical Activity Questionnaire. Patients were additionally screened for psychiatric symptoms.

RESULTS

Compared to health controls, patients with schizophrenia achieved a lower distance on the 6 MWT (583.6 ± 109.7 m versus 710.6 ± 108.4 m, P<.001) and had a lower forced vital capacity (3.7 ± 1.1 L versus 4.3 ± 0.9 L, P<.001) and forced expiratory volume in 1 s (FEV1) (3.0 ± 1.0 L versus 3.6 ± 0.7 L, P<.001). In multiple regression analysis, 68.1% of the variance in walking distance was explained by FEV1, BMI, muscular fitness and total energy expenditure.

CONCLUSION

The respiratory health of patients with schizophrenia should be of concern for clinicians. In addition, future research interventions should seek to investigate the impact of an impaired respiratory health upon individuals with schizophrenia.

Physical comorbidity and its relevance on mortality in schizophrenia: a naturalistic 12-year follow-up in general hospital admissions

Schizophrenia is a major psychotic disorder with significant comorbidity and mortality. Patients with schizophrenia are said to suffer more type-2 diabetes mellitus (T2DM) and diabetogenic complications. However, there is little consistent evidence that comorbidity with physical diseases leads to excess mortality in schizophrenic patients. Consequently, we investigated whether the burden of physical comorbidity and its relevance on hospital mortality differed between patients with and without schizophrenia in a 12-year follow-up in general hospital admissions. During 1 January 2000 and 31 June 2012, 1418 adult patients with schizophrenia were admitted to three General Manchester NHS Hospitals. All comorbid diseases with a prevalemce ≥1% were compared with those of 14,180 age- and gender-matched hospital controls. Risk factors, i.e. comorbid diseases that were predictors for general hospital mortality were identified using multivariate logistic regression analyses. Compared with controls, schizophrenic patients had a higher proportion of emergency admissions (69.8 vs. 43.0%), an extended average length of stay at index hospitalization (8.1 vs. 3.4 days), a higher number of hospital admissions (11.5 vs. 6.3), a shorter length of survival (1895 vs. 2161 days), and a nearly twofold increased mortality rate (18.0 vs. 9.7%). Schizophrenic patients suffered more depression, T2DM, alcohol abuse, asthma, COPD, and twenty-three more diseases, many of them diabetic-related complications or other environmentally influenced conditions. In contrast, hypertension, cataract, angina, and hyperlipidaemia were less prevalent in the schizophrenia population compared to the control population. In deceased schizophrenic patients, T2DM was the most frequently recorded comorbidity, contributing to 31.4% of hospital deaths (only 14.4% of schizophrenic patients with comorbid T2DM survived the study period). Further predictors of general hospital mortality in schizophrenia were found to be alcoholic liver disease (OR = 10.3), parkinsonism (OR = 5.0), T1DM (OR = 3.8), non-specific renal failure (OR = 3.5), ischaemic stroke (OR = 3.3), pneumonia (OR = 3.0), iron-deficiency anaemia (OR = 2.8), COPD (OR = 2.8), and bronchitis (OR = 2.6). There were no significant differences in their impact on hospital mortality compared to control subjects with the same diseases except parkinsonism which was associated with higher mortality in the schizophrenia population compared with the control population. The prevalence of parkinsonism was significantly elevated in the 255 deceased schizophrenic patients (5.5 %) than in those 1,163 surviving the study period (0.8 %, OR = 5.0) and deceased schizophrenic patients had significantly more suffered extrapyramidal symptoms than deceased control subjects (5.5 vs. 1.5 %). Therefore patients with schizophrenia have a higher burden of physical comorbidity that is associated with a worse outcome in a 12-year follow-up of mortality in general hospitals compared with hospital controls. However, schizophrenic patients die of the same physical diseases as their peers without schizophrenia. The most relevant physical risk factors of general hospital mortality are T2DM, COPD and infectious respiratory complications, iron-deficiency anaemia, T1DM, unspecific renal failure, ischaemic stroke, and alcoholic liver disease. Additionally, parkinsonism is a major risk factor for general hospital mortality in schizophrenia. Thus, optimal monitoring and management of acute T2DM and COPD with its infectious respiratory complications, as well as the accurate detection and management of iron-deficiency anaemia, of diabetic-related long-term micro- and macrovascular complications, of alcoholic liver disease, and of extrapyramidal symptoms are of utmost relevance in schizophrenia.

Psychological distress and quality of life in older persons: relative contributions of fixed and modifiable risk factors

BACKGROUND

With a rapidly ageing population and increasing life expectancy, programs directed at improving the mental health and quality of life (QOL) of older persons are extremely important. This issue may be particularly relevant in the aged-care residential sector, where very high rates of depression and poor QOL are evident. This study aims to investigate the fixed and modifiable risk factors of psychological distress and QOL in a cohort of Australians aged 60 and over living in residential and community settings.

METHODS

The study examined the relationship between demographic, health and lifestyle factors and the outcome variables of self-reported QOL and psychological distress (K10 scores) based on data from 626 Australians aged 60 and over from the 45 and Up Study dataset. Univariate and multivariate regression analyses (performed on a subset of 496) examined risk factors related to psychological distress and QOL adjusting for age and residential status.

RESULTS

Significant psychological distress was experienced by 15% of the residential sample and 7% of the community sample and in multivariate analyses was predicted by older age, more functional limitations, more time spent sleeping and lower levels of social support (accounting for 18% of the variance). Poorer QOL was predicted by more functional limitations and greater levels of psychological distress. Together these variables accounted for 35% of the variance in QOL ratings.

CONCLUSIONS

While psychological distress was more common in residential settings, programs targeting modifiable risk factors have the potential to improve QOL and reduce psychological distress in older persons living in both residential and community settings. In particular, promoting health and mobility, optimising sleep-wake cycles and increasing social support may reduce levels of psychological distress and improve QOL.

A behavioral weight-loss intervention in persons with serious mental illness

BACKGROUND

Overweight and obesity are epidemic among persons with serious mental illness, yet weight-loss trials systematically exclude this vulnerable population. Lifestyle interventions require adaptation in this group because psychiatric symptoms and cognitive impairment are highly prevalent. Our objective was to determine the effectiveness of an 18-month tailored behavioral weight-loss intervention in adults with serious mental illness.

METHODS

We recruited overweight or obese adults from 10 community psychiatric rehabilitation outpatient programs and randomly assigned them to an intervention or a control group. Participants in the intervention group received tailored group and individual weight-management sessions and group exercise sessions. Weight change was assessed at 6, 12, and 18 months.

RESULTS

Of 291 participants who underwent randomization, 58.1% had schizophrenia or a schizoaffective disorder, 22.0% had bipolar disorder, and 12.0% had major depression. At baseline, the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 36.3, and the mean weight was 102.7 kg (225.9 lb). Data on weight at 18 months were obtained from 279 participants. Weight loss in the intervention group increased progressively over the 18-month study period and differed significantly from the control group at each follow-up visit. At 18 months, the mean between-group difference in weight (change in intervention group minus change in control group) was -3.2 kg (-7.0 lb, P=0.002); 37.8% of the participants in the intervention group lost 5% or more of their initial weight, as compared with 22.7% of those in the control group (P=0.009). There were no significant between-group differences in adverse events.

CONCLUSIONS

A behavioral weight-loss intervention significantly reduced weight over a period of 18 months in overweight and obese adults with serious mental illness. Given the epidemic of obesity and weight-related disease among persons with serious mental illness, our findings support implementation of targeted behavioral weight-loss interventions in this high-risk population. (Funded by the National Institute of Mental Health; ACHIEVE ClinicalTrials.gov number, NCT00902694.).

Increased prevalence of chronic physical health disorders in Australians with diagnosed mental illness

OBJECTIVE

To compare chronic physical health disorder prevalence amongst Australian adults with and without mental illness.

METHOD

Total n=1,716 participants (58% female) with a mean age of 52 ± 13 years (range: 18 to 89 years) completed an online survey of Australian adults in 2010. Outcome measures including prevalence of chronic physical conditions and self-reported body mass index (BMI) in n=387 (23%) with a self-reported mental illness diagnosis were compared to respondents without mental illness.

RESULTS

A significantly higher proportion of participants with mental illness were obese (BMI ≥ 30; 31 vs 24%, p=0.005). Adjusted odds ratios (OR) for coronary heart disease, diabetes, chronic bronchitis or emphysema, asthma, irritable bowel syndrome, and food allergies or intolerances (OR range: 1.54-3.19) demonstrated that chronic physical disorders were significantly more common in participants with a mental illness.

CONCLUSION

Australian adults with a diagnosis for mental illness have a significantly increased likelihood of demonstrating chronic physical health disorders compared to persons without mental illness.

IMPLICATIONS

Health professionals must be alert to the increased likelihood of comorbid chronic physical disorders in persons with a mental illness and should consider the adoption of holistic approaches when treating those with either a mental or physical illness.

Serious mental illness and acute hospital readmission in diabetic patients

Patients with serious mental illness (SMI), particularly those with other chronic illnesses, may be vulnerable to unplanned hospital readmission. The authors hypothesized that SMI would be associated with increased 30-day hospital readmission in a cohort of adult patients with comorbid diabetes admitted to a tertiary care facility from 2005 to 2009. SMI was defined by International Classification of Diseases, Ninth Revision, discharge diagnosis codes for schizophrenia, schizoaffective, bipolar, manic, or major depressive disorders, or other psychosis. The primary outcome was 30-day readmission to the index hospital. Among 26 878 eligible admissions, the prevalence of SMI was 6% and the incidence of 30-day hospital admission was 16%. Among patients aged <35 years, SMI was significantly associated with decreased odds of 30-day hospital readmission (odds ratio [OR] = 0.39; 95% confidence interval [CI] = 0.17, 0.91). However, among patients ≥35 years, SMI was not significantly associated with 30-day hospital readmission (OR = 1.11; 95% CI = 0.86, 1.42). SMI may not be associated with increased odds of 30-day hospital readmission in this population.

A Review of Varenicline's Efficacy and Tolerability in Smoking Cessation Studies in Subjects with Schizophrenia

Schizophrenia is a severe psychiatric disorder affecting 1% of the world's population. Nicotine addiction is one of the most important health concerns for patients with schizophrenia. An extensive body of evidence points to a high prevalence rate of comorbid nicotine addiction in people with schizophrenia (70-90%), which contributes to significant cardiovascular and cancer risks in this vulnerable population. Therefore, effective smoking cessation strategies could play a major role in preventing significant morbidity and mortality in this population. Two of the most common pharmacological approaches to smoking cessation, bupropion and nicotine replacement therapy (NRT), have been used in psychiatric patients to reduce their smoking. In 2006, varenicline, a partial agonist of α4β2 acetylcholine receptor, was approved for smoking cessation by the FDA. This drug not only has the beneficial effects on withdrawal symptoms, but also reduces craving and rewarding effects of smoking. While varenicline has been shown to be an effective, safe medication for the general population, its efficacy and safety for subjects with schizophrenia is less well characterized. A number of case studies have prompted FDA warnings about the potential exacerbation of psychiatric symptoms. However, other case studies and pilot studies have shown varenicline to be a safe and effective treatment for smoking cessation in subjects with schizophrenia. Varenicline has the potential to reduce smoking in subjects with schizophrenia, however, clinicians should carefully monitor patients receiving varenicline for potential exacerbation of psychiatric symptoms.

The impact of mental illness on potentially preventable hospitalisations: a population-based cohort study

BACKGROUND

Emerging evidence indicates an association between mental illness and poor quality of physical health care. To test this, we compared mental health clients (MHCs) with non-MHCs on potentially preventable hospitalisations (PPHs) as an indicator of the quality of primary care received.

METHODS

Population-based retrospective cohort study of 139,208 MHCs and 294,180 matched non-MHCs in Western Australia from 1990 to 2006, using linked data from electoral roll registrations, mental health registry (MHR) records, hospital inpatient discharges and deaths. We used the electoral roll data as the sampling frame for both cohorts to enhance internal validity of the study, and the MHR to separate MHCs from non-MHCs. Rates of PPHs (overall and by PPH category and medical condition) were compared between MHCs, category of mental disorders and non-MHCs. Multivariate negative binomial regression analyses adjusted for socio-demographic factors, case mix and the year at the start of follow up due to dynamic nature of study cohorts.

RESULTS

PPHs accounted for more than 10% of all hospital admissions in MHCs, with diabetes and its complications, adverse drug events (ADEs), chronic obstructive pulmonary disease (COPD), convulsions and epilepsy, and congestive heart failure being the most common causes. Compared with non-MHCs, MHCs with any mental disorders were more likely to experience a PPH than non-MHCs (overall adjusted rate ratio (ARR) 2.06, 95% confidence interval (CI) 2.03-2.09). ARRs of PPHs were highest for convulsions and epilepsy, nutritional deficiencies, COPD and ADEs. The ARR of a PPH was highest in MHCs with alcohol/drug disorders, affective psychoses, other psychoses and schizophrenia.

CONCLUSIONS

MHCs have a significantly higher rate of PPHs than non-MHCs. Improving primary and secondary prevention is warranted in MHCs, especially at the primary care level, despite there may be different thresholds for admission in people with established physical disease that is influenced by whether or not they have comorbid mental illness.

What does recovery from schizophrenia mean? Perceptions of medical students and trainee psychiatrists

BACKGROUND

The attitudes of medical professionals towards recovery from schizophrenia are key in defining the therapeutic encounter and may change as they move through their medical career.

METHOD

A qualitative methodology was used based on three focus groups of medical students and trainee psychiatrists in Hong Kong. Both held pessimistic attitudes towards recovery in schizophrenia. Four major categories and one central theme emerged, with little difference between students and doctors. The four categories were: (1) recovery is defined by the cessation of medication and the resumption of normal psychosocial functioning; (2) formal recovery requires medical confirmation plus the patient's admission of illness; (3) recovery should be discussed, but largely in terms of the contribution of drug compliance; and (4) participants recognized that stigma was an impediment to recovery while holding attitudes that were as unaccepting towards people with schizophrenia as lay people's.

CONCLUSIONS

Traditional medical education over-emphasizes symptomatic recovery and ignores the need for a more flexible construction of the concept. Professional knowledge must incorporate both quantitative and qualitative data and inculcate humanitarian concern through active contact with users, and acceptance of the legitimacy of their expert experience. Medical education should seek effective ways to change entrenched negative attitudes in students about schizophrenia and the possibility of recovery. Further large-scale research should be carried out to establish attitudes of medical professionals towards recovery from schizophrenia and how this changes during typical career trajectories. This information could then be used to devise effective means within medical education to combat stigma and change attitudes.

Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care

The lifespan of people with severe mental illness (SMI) is shorter compared to the general population. This excess mortality is mainly due to physical illness. We report prevalence rates of different physical illnesses as well as important individual lifestyle choices, side effects of psychotropic treatment and disparities in health care access, utilization and provision that contribute to these poor physical health outcomes. We searched MEDLINE (1966 - August 2010) combining the MeSH terms of schizophrenia, bipolar disorder and major depressive disorder with the different MeSH terms of general physical disease categories to select pertinent reviews and additional relevant studies through cross-referencing to identify prevalence figures and factors contributing to the excess morbidity and mortality rates. Nutritional and metabolic diseases, cardiovascular diseases, viral diseases, respiratory tract diseases, musculoskeletal diseases, sexual dysfunction, pregnancy complications, stomatognathic diseases, and possibly obesity-related cancers are, compared to the general population, more prevalent among people with SMI. It seems that lifestyle as well as treatment specific factors account for much of the increased risk for most of these physical diseases. Moreover, there is sufficient evidence that people with SMI are less likely to receive standard levels of care for most of these diseases. Lifestyle factors, relatively easy to measure, are barely considered for screening; baseline testing of numerous important physical parameters is insufficiently performed. Besides modifiable lifestyle factors and side effects of psychotropic medications, access to and quality of health care remains to be improved for individuals with SMI.

The high prevalence of poor physical health and unhealthy lifestyle behaviours in individuals with severe mental illness

Recent mental health care policy has addressed the need for health care professionals to consider the physical health of consumers. Mental health nurses are particularly well-placed for this role. To provide mental health nurses with practical information, this narrative review summarises evidence from recent research on the physical health of individuals with Serious Mental Illness (SMI). In those with SMI, the international prevalence of obesity, the metabolic syndrome, diabetes mellitus, symptoms of cardiovascular disease, and respiratory disease all exceed that of the general population by at least two times, and HIV prevalence may be increased by as much as eight times. This increased prevalence of chronic disease may be largely responsible for an increased risk of death of up to five times, resulting in as much as 30 years of potential life lost. Of particular concern, the recent evidence suggests that for physical health and increased mortality, the gap between individuals with SMI and the general population is worsening. Unhealthy lifestyle behaviours undoubtedly play a role in the development of poor physical health and chronic disease, and the present review indicates that low physical activity, poor diet, smoking, alcohol and substance abuse, and risky sexual behaviour are common in individuals with SMI. This narrative review demonstrates that the prevalence of poor physical health and health behaviours in people with SMI far exceed that observed in the general population, and reinforces the urgent need for mental health nurses to address physical health concerns in patients.

Physical disease in schizophrenia: a population-based analysis in Spain

Background

Physical disease remains a challenge in patients with schizophrenia. Our objective was to determine the epidemiological characteristics and burden of physical disease in hospitalized patients with schizophrenia.

Methods

We analyzed the 2004 Spanish National Hospital Discharge Registry, identified records coded for schizophrenia (295.xx) and characterized the physical diseases using the ICD-9 system and the Charlson Index. We also calculated standardized mortality ratios (SMRs) versus the general population adjusted by age and calendar time.

Results

A total of 16, 776 cases (mean age: 43 years, 65% males) were considered for analysis. Overall, 61% of cases had at least one ICD-9 physical code and 32% had more than one ICD-9 code. The Charlson index indicated that 20% of cases had a physical disease of known clinical impact and prognostic significance. Physical disease appeared early in life (50% of cases were 15-31 years of age) and increased rapidly in incidence with age. Thus, for patients aged 53 years or more, 84% had at least one physical ICD-9 code. Apart from substance abuse and addiction, the most prevalent diseases were endocrine (16%), circulatory (15%), respiratory (15%), injury-poisoning (11%), and digestive (10%). There were gender-related differences in disease burden and type of disease. In-hospital mortality significantly correlated with age, the Charlson Index and several ICD-9 groups of physical disease. Physical disease was associated with an overall 3.6-fold increase in SMRs compared with the general population.

Conclusions

This study provides the first nationally representative estimate of the prevalence and characteristics of physical disease in hospitalized patients with schizophrenia in Spain. Our results indicate that schizophrenia is associated with a substantial burden of physical comorbidities; that these comorbidities appear early in life; and that they have a substantial impact on mortality. This information raises concerns about the consequences and causes of physical disorders in patients with schizophrenia. Additionally, it will help to guide the design and implementation of preventive and therapeutic programs from the viewpoint of clinical care and in terms of health-care service planning.