Death rate from ischaemic heart disease in Western Australian psychiatric patients 1980-1998

The perspectives of hospital doctors about end-of-life care in people with mental illness: an observational pilot study

BACKGROUND

Negative attitudes towards people living with mental illness (PLWMI), defined here as mentalism, are a major contribution to health care inequity, which may extend into end-of-life care. There is a clear need for investigation of the attitudes of doctors towards PLWMI at the end of life as doctors may lead processes of care that contribute to this inequity.

AIMS

The aim of this pilot study is to examine the perspectives of hospital-based doctors regarding end-of-life care and medical decision-making in PLWMI.

METHODS

A survey was created to explore whether mentalism is present in the perspectives of hospital doctors regarding end-of-life care for PLWMI. The survey included demographic characteristics of participants and questions comprising statements and vignettes that required agree/disagree responses. Descriptive statistics were used to summarise responses, and chi-square tests examined associations with demographic variables.

RESULTS

The survey was commenced by 48 hospital-based doctors and completed by 45. Descriptive statistics indicated that mentalism is present in the attitudes of hospital doctors regarding end-of-life care of PWLMI, with 47 of 48 participants (98%) endorsing at least one mentalist response. One significant association found that psychiatrists and psychiatry trainees were less likely to endorse a stereotype response in one vignette.

CONCLUSIONS

This preliminary study addresses a gap within the literature on the potential contribution of mentalist attitudes in doctors to the poorer end-of-life care outcomes for PLWMI. The findings highlight the need for further study of this topic and suggest a role for targeted medical education in the pursuit of health care equality for PLWMI.

A Study of Hypertension and Related Biophysical and Health-related Lifestyle Behaviors in Patients Suffering from Schizophrenia

Background

Schizophrenia is a life-shortening disease. The standardized mortality ratio has been higher than that of the general population, and it has doubled what it was 3-4 decades ago. This rise is mostly attributed to the increased cardiovascular risk associated with high second-generation antipsychotic (SGA) use. Evidence from the first-generation antipsychotic (FGA) era shows a lower prevalence of hypertension (HTN) but data regarding SGAs is scarce.

Purpose

The purpose of the study was to assess the prevalence of HTN and related factors using standardized methodology in patients with schizophrenia on treatment with SGAs.

Methods

A cross-sectional study through convenient sampling was done. Blood pressure, anthropometry, physical activity, and health-related lifestyle factors were assessed using the standard World Health Organization (WHO) methodology of cardiovascular survey methods and the Global Physical Activity Questionnaire (GPAQ) version 2. The prevalence of HTN, obesity, inadequate physical activity, and other demographic and clinical correlates like antipsychotic use, duration of illness, and family history of non-communicable diseases (NCDs) were studied.

Results

The prevalence of HTN is 20.50%, and it increases with age. SGAs with the use of a single agent are the most common. In total, 45.50% of persons with schizophrenia have a positive family history of a NCD; 22.00% and 07.50% are current tobacco and alcohol users, respectively; and 70% have abdominal obesity, and 54% have generalized obesity. Waist circumference, obesity, and family history of NCDs are significant correlates of HTN. A family history of NCDs is the most significant predictor.

Conclusion

The prevalence of HTN is lower than that of the general population despite the high prevalence of SGA use, obesity, and inadequate physical activity.

Impact of the mental health reform in Israel on health care and mortality among people with severe mental illness

OBJECTIVE

Reports show disparities in the health care of people with severe mental illness (SMI). Yet, the moderating effect of mental health reforms on the health care disparities remain unexplored. The current study aimed to investigate the outcomes of the mental health reform in Israel on the use of health services among people with SMI.

METHOD

A case-control epidemiological study comparing the use of health services 3.5 years before and after the mental health reform for service users diagnosed with schizophrenia, schizoaffective disorder, and bipolar disorder. Data on health services included: blood cholesterol test (LDL), hemogalobin-A1C test, and visits to general practitioners (GPs) and specialists. Mortality was recorded.

RESULTS

Following the reform the number of visits to GPs was decreased among service users of the three SMI groups, as well as visits to specialists among service users with a schizoaffective or bipolar disorder. Following the reform service users of the three SMI groups showed no-change in the performance of LDL test. Complex findings were noted with regard to the performance of Hemoglobin-A1C test. Mortality rates were higher among service users with SMI and the relative risk were similar before and after the reform.

CONCLUSIONS

Users of the three SMI groups showed no benefits of the mental health reform in terms of use of health services. Improved health care can be attained by a closer collaboration between the primary physicians and community mental health services.

Schizophrenia as a risk factor for cardiovascular and metabolic health outcomes: a comparative risk assessment

AIMS

Cardiometabolic diseases are responsible for the majority of premature deaths in people with schizophrenia. This study aimed to quantify the fatal burden of ischaemic heart disease (IHD), stroke and diabetes attributable to schizophrenia.

METHODS

Comparative Risk Assessment methodology from the Global Burden of Disease (GBD) study was used to calculate attributable burden; pooled relative risks (RRs) for IHD, stroke and diabetes were estimated via meta-regression, which were combined with GBD schizophrenia prevalence estimates to calculate the deaths and years of life lost (YLLs) caused by these health outcomes that were attributable to schizophrenia. The proportion of explained all-cause fatal burden and corresponding unexplained burden was also calculated.

RESULTS

The pooled RRs for IHD, stroke and diabetes mortality were 2.36 [95% uncertainty interval (UI) 1.77 to 3.14], 1.86 (95% UI 1.36 to 2.54) and 4.08 (95% UI 3.80 to 4.38) respectively. Schizophrenia was responsible for around 50 000 deaths and almost 1.5 million YLLs globally in 2019 from these health outcomes combined. IHD, stroke and diabetes together explained around 13% of all deaths and almost 11% of all YLLs attributable to schizophrenia, resulting in 320 660 (95% UI 288 299 to 356 517) unexplained deaths and 12 258 690 (95% UI 10 925 426 to 13 713 646) unexplained YLLs.

CONCLUSIONS

Quantifying the physical disease burden attributable to schizophrenia provides a means of capturing the substantial excess mortality associated with this disorder within the GBD framework, contributing to an important evidence base for healthcare planning and practice.

A critical review of research into mental health consumers' perspectives on their physical health: Is there an absence of consumers in the design, conduct, analysis and reporting of this research?

We conducted a critical review, using systematic methods, of the literature examining mental health consumer perspectives on their physical and mental health in academic research published between 2005 and 2021. This review examined the inclusion, extent, type and centrality of consumer perspectives regarding their mental and physical health. The search produced 1,865 papers from which 116 met the inclusion criteria. Studies predominantly focused on consumers' individual experiences of their physical and mental health, including but not limited to their understandings and experiences of medication and associated risk factors. They also captured some social aspects of mental health consumers' physical health, including factors that impacted individual agency, stigma, and social and interpersonal factors. Structural factors affecting physical and mental health, such as accessibility of services and financial constraints, were also identified. The review revealed that in comparison to clinician perspectives, the direct representation of consumer perspectives was lacking. Similarly, while clinician and carer perspectives on structural factors were investigated, the consumer perspective in this area was missing. The review also found few genuine codesigned or coproduced research studies. To better identify and respond to the health needs as prioritized by consumers, this paper argues it is imperative that future studies prioritize codesigned and coproduced research. It is argued that a focus on "services as provided" rather than "services as received" has contributed to a lack of progress in addressing the life expectancy gap for consumers. It is recommended that journals, ethics committees and research policy organizations develop guidelines and standards to inform best practice in research on consumer perspectives and experience and to support the implementation of codesigned and/or coproduced approaches in future research. Respecting and including consumers as equal partners in the research process will lead to more meaningful insights to inform policy and practice and reduce the life expectancy gap for people living with mental health concerns.

Mortality, Revascularization, and Cardioprotective Pharmacotherapy After Acute Coronary Syndrome in Patients With Severe Mental Illness: A Systematic Review and Meta-analysis

BACKGROUND AND HYPOTHESIS

People with severe mental illness (SMI) may experience excess mortality and inequitable treatment following acute coronary syndrome (ACS). However, cardioprotective pharmacotherapy and SMI diagnoses other than schizophrenia are rarely examined in previous reviews. We hypothesized that SMI including bipolar disorder (BD) is associated with increased post-ACS mortality, decreased revascularization, and cardioprotective medication receipt relative to those without SMI.

STUDY DESIGN

We performed a meta-analysis to quantitatively synthesize estimates of post-ACS mortality, major adverse cardiac events (MACEs), and receipt of invasive coronary procedures and cardioprotective medications in patients with SMI, comprising schizophrenia, BD, and other nonaffective psychoses, relative to non-SMI counterparts. Subgroup analyses stratified by SMI subtypes (schizophrenia, BD), incident ACS status, and post-ACS time frame for outcome evaluation were conducted.

STUDY RESULTS

Twenty-two studies were included (n = 12 235 501, including 503 686 SMI patients). SMI was associated with increased overall (relative risk [RR] = 1.40 [95% confidence interval = 1.21-1.62]), 1-year (1.68 [1.42-1.98]), and 30-day (1.26 [1.05-1.51]) post-ACS mortality, lower receipt of revascularization (odds ratio = 0.57 [0.49-0.67]), and cardioprotective medications (RR = 0.89 [0.85-0.94]), but comparable rates of any/specific MACEs relative to non-SMI patients. Incident ACS status conferred further increase in post-ACS mortality. Schizophrenia was associated with heightened mortality irrespective of incident ACS status, while BD was linked to significantly elevated mortality only in incident ACS cohort. Both schizophrenia and BD patients had lower revascularization rates. Post-ACS mortality risk remained significantly increased with mild attenuation after adjusting for revascularization.

CONCLUSIONS

SMI is associated with increased post-ACS mortality and undertreatment. Effective multipronged interventions are urgently needed to reduce these physical health disparities.

Effects of antipsychotics on heart rate in treatment of schizophrenia: a systematic review and meta-analysis

BACKGROUND

Antipsychotics are the treatment of choice in the therapy of schizophrenia. These drugs can be associated with changes in heart rate, but this question has never been examined systematically.

OBJECTIVE

We aimed to analyse changes in heart rate during treatment with antipsychotics using the frequency of tachycardia and bradycardia events.

DESIGN

For this systematic review and meta-analysis, we included all randomized controlled trials for the acute treatment of schizophrenia comparing antipsychotics head-to-head or with placebo.

DATA SOURCES AND METHODS

We searched Embase, MEDLINE, PsycINFO, PubMed, BIOSIS, Cochrane Central Register of Controlled Trials (CENTRAL), WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (last search June 2021). Two authors independently selected studies and extracted data. We conducted pairwise meta-analyses using a random-effects model. Outcomes were tachycardia and bradycardia events.

RESULTS

We found 469 trials meeting the inclusion criteria. Seventy-seven studies with 16,907 participants provided data on tachycardia or bradycardia events. We found no significant differences between antipsychotics and placebo or between antipsychotics for bradycardia events based on sparse data. Antipsychotics had a higher risk for tachycardia events compared with placebo [N = 37, n = 7827, risk ratio (RR) = 1.83, 95% confidence interval (CI) = 1.40-2.41], with large differences between the individual substances (iloperidone RR = 14.05, chlorpromazine RR = 4.84, loxapine RR = 4.52, risperidone RR = 3.38, quetiapine RR = 2.64, paliperidone RR = 1.65). Some head-to-head comparisons were also significantly different: olanzapine versus haloperidol RR = 2.87, chlorpromazine versus thiothixene RR = 2.92, quetiapine versus lurasidone RR = 3.22, risperidone versus aripiprazole RR = 4.37, iloperidone versus ziprasidone RR = 4.65).

CONCLUSION

Many studies do not report data for cardiac outcomes, but the available evidence indicates that treatment with antipsychotics raises the risk for tachycardia. Therefore, especially patients with cardiac risk factors should be monitored closely during antipsychotic treatment.

REGISTRATION

PROSPERO: CRD42014014919.

Effects of exercise on mortality rates of individuals with severe mental illness

Persons with severe mental illness have a 10-to-20-year shorter life span than the general public. Excess morbidity and mortality in this patient population has been described as a major public health challenge worldwide. Despite robust extant literature on the role of exercise in reducing morbidity and mortality, especially from cardiovascular disease and diabetes (highly prevalent in this patient population), Very few clinical programs or clinical research projects currently exist to implement and study the effects of exercise on decreasing morbidity and mortality in this highly vulnerable patient population. Given the global lack of trained mental health providers, the need to integrate healthcare providers from different disciplines, such as nurses, physical therapists, occupational therapists, physician assistants, cannot be overstated. This mini-review will provide an historic perspective and current data supporting the need to establish exercise, and other Lifestyle Psychiatry interventions, as a key component of treatment for all patients with serious mental illness.

How to improve the physical health of people with severe mental illness? A multicentric randomized controlled trial on the efficacy of a lifestyle group intervention

Background

People with severe mental illnesses (SMI) have a mortality rate two times higher compared to the general population, with a decade of years of life lost. In this randomized controlled trial (RCT), we assessed in a sample of people with bipolar disorder, major depressive disorder, and schizophrenia spectrum disorder, the efficacy of an innovative psychosocial group intervention compared to a brief psychoeducational group intervention on patients’ body mass index (BMI), body weight, waist circumference, Framingham and HOMA-IR indexes.

Methods

This is a multicentric RCT with blinded outcome assessments carried out in six Italian university centers. After recruitment patients were randomized to receive a 6-month psychosocial intervention to improve patients’ physical health or a brief psychoeducational intervention. All recruited patients were assessed with standardized assessment instruments at baseline and after 6 months. Anthropometric parameters and blood samples have also been collected.

Results

Four-hundred and two patients with a diagnosis of bipolar disorder (43.3%), schizophrenia or other psychotic disorder (29.9%), or major depression (26.9%) were randomly allocated to the experimental (N = 206) or the control group (N = 195). After 6 months, patients from the experimental group reported a significant reduction in BMI (odds ratio [OR]: 1.93, 95% confidence intervals [CI]: 1.31–2.84; p < 0.001), body weight (OR = 4.78, 95% CI: 0.80–28.27, p < 0.05), and waist circumference (OR = 5.43, 95% CI: 1.45–20.30, p < 0.05). Participants with impaired cognitive and psychosocial functioning had a worse response to the intervention.

Conclusions

The experimental group intervention was effective in improving the physical health in SMI patients. Further studies are needed to evaluate the feasibility of this intervention in real-world settings.

Are Mental Health and Substance Use Disorders Risk Factors for Missed Acute Myocardial Infarction Diagnoses Among Chest Pain or Dyspnea Encounters in the Emergency Department?

STUDY OBJECTIVE

To assess if having a mental health and/or substance use disorder is associated with a missed acute myocardial infarction diagnosis in the emergency department (ED).

METHODS

This was a retrospective cohort analysis (2009 to 2017) of adult ED encounters at Kaiser Permanente Southern California. We used the validated symptom-disease pair analysis of diagnostic error methodological approach to "look back" and "look forward" and identify missed acute myocardial infarctions within 30 days of a treat-and-release ED visit. We use adjusted logistic regression to report the odds of missed acute myocardial infarction among patients with a history of mental health and/or substance use disorders.

RESULTS

The look-back analysis identified 44,473 acute myocardial infarction hospital encounters; 574 (1.3%) diagnoses were missed. The odds of missed diagnoses were higher in patients with mental health disorders (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.23 to 1.77) but not in those with substance abuse disorders (OR 1.22, 95% CI 0.91 to 1.62). The highest risk was observed in those with co-occurring disorders (OR 1.90, 95% CI 1.30 to 2.76). The look-forward analysis identified 325,088 chest pain/dyspnea ED encounters; 508 (0.2%) were missed acute myocardial infarctions. No significant associations of missed acute myocardial infarction were revealed in either group (mental health disorder: OR 0.92, 95% CI 0.71 to 1.18; substance use disorder: OR 1.22, 95% CI 0.80 to 1.85).

CONCLUSION

The look-back analysis identified patients with mental illness at increased risk of missed acute myocardial infarction diagnosis, with the highest risk observed in those with a history of comorbid substance abuse. Having substance use disorders alone did not increase this risk in either cohort. The look-forward analysis revealed challenges in prospectively identifying high-risk patients to target for improvement.

The impact of clinical and social factors on the physical health of people with severe mental illness: Results from an Italian multicentre study

Our manuscript aims to: 1) assess physical health in a sample of patients with severe mental disorders; and 2) identify the psychopathological and psychosocial characteristics associated with an increased likelihood of having a poor physical health. The study, funded by the Italian Ministry of Education, has been carried out in psychiatric outpatient units of six Italian University sites. All recruited patients have been assessed through standardized assessment instruments. Moreover, anthropometric parameters have been obtained at recruitment and a blood samples have been collected to assess cardiometabolic parameters. Four-hundred and two patients with a primary diagnosis of bipolar disorder (43.3%), schizophrenia or other psychotic disorder (29.9%), or major depression (26.9%) were recruited. Internalized stigma, psychosocial functioning, quality of life, psychiatric hospitalizations, depressive/anxiety and manic symptoms and cognition were those domains more strongly associated with poor metabolic parameters, including high body mass index, HOMA and Framingham indexes and waist circumference. There were no statistically significant differences among the three diagnostic groups. Our findings highlight the importance of perceived stigma and quality of life on patients' physical health. This should be taken into account when developing plans for reducing the mortality rate in patients with severe mental disorders.

Insomnia symptoms are associated with metabolic syndrome in patients with severe psychiatric disorders

OBJECTIVE

To examine the relationship between insomnia symptoms and metabolic syndrome in patients with severe psychiatric disorders.

METHODS

We conducted a cross-sectional study including 272 inpatients (mean age: 34.06 ± 11.52 years, 67.3% males) with severe psychiatric disorders consecutively admitted in Shantou University Mental Health Center Inpatient Department. All patients underwent a psychiatric evaluation. Insomnia symptoms were assessed by the Pittsburgh Sleep Quality Index (PSQI) and defined present if PSQI>7. The diagnosis of metabolic syndrome was defined using the new International Diabetes Federation definition based on clinical and laboratory evaluation.

RESULTS

Among the 272 patients, 94 (34.6%) presented insomnia symptoms. Overall, patients with insomnia symptoms had significantly higher percentage of metabolic syndrome (23.4% vs. 12.4%, p = 0.019) and hypertriglyceridemia (30.9% vs. 19.1%, p = 0.029), and marginally significantly higher levels of fasting insulin (58.75 ± 37.22 pmol/L vs. 51.72 ± 34.09 pmol/L, p = 0.050), homeostasis model assessment of insulin resistance (1.83 ± 1.31 vs. 1.62 ± 1.25, p = 0.055) and percentage of insulin resistance (55.3% vs. 44.4%, p = 0.086) compared to those without insomnia symptoms. Multiple logistic regressions showed that patients with insomnia symptoms had significantly higher odds for metabolic syndrome [odds ratio (OR) = 2.99, 95% confidence interval (CI) = 1.25-7.14], central obesity (OR = 3.02, 95% CI = 1.18-7.76), hypertriglyceridemia (OR = 2.46, 95% CI = 1.28-4.76) and marginally significantly higher odds for insulin resistance (OR = 1.68, 95% CI = 0.93-3.02) after controlling for potential confounders.

CONCLUSIONS

Within severely mentally ill patients, insomnia symptoms are associated with metabolic syndrome and insulin resistance. It appears that insomnia symptoms are independent clinical indicators of underlying metabolic syndrome in patients with severe psychiatric disorders.

Recent physical conditions and health service utilization in people with common mental disorders and severe mental illness in England: Comparative cross-sectional data from a nationally representative sample

Background.

Policies addressing the physical health of people with mental disorders have historically focused on those with severe mental illness (SMI), giving less prominence to the more prevalent common mental disorders (CMDs). Little is known about the comparative physical health outcomes of these patient groups. We aimed to first compare the: (a) number of past-year chronic physical conditions and (b) recent physical health service utilization between CMDs vs. SMI, and secondly compare these outcomes between people with CMDs vs. people without mental disorders.

Methods.

We analyzed cross-sectional data from the third Adult Psychiatric Morbidity Survey, a representative sample of the English population. We determined the presence of physical conditions and health service utilization by self-report and performed logistic regression models to examine associations of these outcomes between participant groups.

Results.

Past-year physical conditions were reported by the majority of participants (CMDs, n = 815, 62.1%; SMI = 27, 63.1%) with no variation in the adjusted odds of at least one physical condition between diagnoses (odds ratio [OR] = 0.96, 95% confidence intervals [CI] 0.42–1.98, p = 0.784). People with CMDs were significantly more likely to be recently hospitalized relative to with those with SMI (OR = 6.33, 95% CI 5.50–9.01, p < 0.05). Having a CMD was associated with significantly higher odds of past-year physical conditions and recent health service utilization (all p < 0.001) compared with the general population.

Conclusions.

People with CMDs experience excess physical health morbidities in a similar pattern to those found among people with SMI, while their somatic hospitalization rates are even more elevated. Findings highlight the importance of recalibrating existing public health strategies to bring equity to the physical health needs of this patient group.

A health promotion intervention to improve lifestyle choices and health outcomes in people with psychosis: a research programme including the IMPaCT RCT

Background

People with psychotic disorders have reduced life expectancy largely because of physical health problems, especially cardiovascular disease, that are complicated by the use of tobacco and cannabis.

Objectives

We set out to (1) chart lifestyle and substance use choices and the emergence of cardiometabolic risk from the earliest presentation with psychosis, (2) develop a pragmatic health promotion intervention integrated within the clinical teams to improve the lifestyle choices and health outcomes of people with psychosis and (3) evaluate the clinical effectiveness and cost-effectiveness of that health promotion intervention.

Design

We performed a longitudinal cohort study of people presenting with their first episode of psychosis in three mental health trusts and followed up participants for 1 year [work package 1, physical health and substance use measures in first episode of psychosis (PUMP)]. We used an iterative Delphi methodology to develop and refine a modular health promotion intervention, improving physical health and reducing substance use in psychosis (IMPaCT) therapy, which was to be delivered by the patient’s usual care co-ordinator and used motivational interviewing techniques and cognitive–behavioural therapy to improve health choices of people with psychosis (work package 2). We then conducted a multicentre, two-arm, parallel-cluster, randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of using the intervention with people with established psychosis (work package 3: IMPaCT randomised controlled trial) in five UK mental health trusts. The work took place between 2008 and 2014.

Participants

All people aged between 16 and 65 years within 6 months of their first presentation with a non-organic psychosis and who were proficient in English were eligible for inclusion in the PUMP study. Participants in the work package 2 training development were staff selected from a range of settings, working with psychosis. Participants in the phase 3 Delphi consensus and manual development comprised three expert groups of (1) therapists/researchers recruited from the local and national community, (2) clinicians and (3) service users, each of whom took part in two iterative review and feedback sessions. For work package 3, IMPaCT randomised controlled trial, care co-ordinators in participating community mental health teams who were permanently employed and had a minimum of four eligible patients (i.e. aged between 18 and 65 years with a diagnosis of a psychotic disorder) on their caseload were eligible to participate. In studies 1 and 3, patient participants were ineligible if they were pregnant or had a major illness that would have had an impact on their metabolic status or if they had a significant learning disability. All participants were included in the study only after giving written confirmed consent.

Main outcome measures

Cardiometabolic risk markers, including rates of obesity and central obesity, and levels of glycated haemoglobin (HbA1c) and lipids, were the main outcomes in work package 1 (PUMP), with descriptive data presented on substance use. Our primary outcome measure for the IMPaCT randomised controlled trial was the physical or mental health component Short Form questionnaire-36 items quality-of-life scores at 12 months.

Results

Obesity rates rose from 18% at first presentation with psychosis to 24% by 1 year, but cardiometabolic risk was not associated with baseline lifestyle and substance use choices. Patterns of increase in the levels of HbA1c over the year following first presentation showed variation by ethnic group. We recruited 104 care co-ordinators, of whom 52 (with 213 patients) were randomised to deliver IMPaCT therapy and 52 (with 193 patients) were randomised to deliver treatment as usual, in keeping with our power calculations. Of these 406 participants with established psychosis, 318 (78%) and 301 (74%) participants, respectively, attended the 12- and 15-month follow-ups. We found no significant effect of IMPaCT therapy compared with treatment as usual on the physical or mental health component Short Form questionnaire-36 items scores at either time point in an intention-to-treat analysis [physical health score (‘d’) –0.17 at 12 months and –0.09 at 15 months; mental health score (‘d’) 0.03 at 12 months and –0.05 at 15 months] or on costs. Nor did we find an effect on other cardiovascular risk indicators, including diabetes, except in the case of high-density lipoprotein cholesterol, which showed a trend for greater benefit with IMPaCT therapy than with treatment as usual (treatment effect 0.085, 95% confidence interval 0.007 to 0.16; p = 0.034).

Limitations

Follow-up in work package 1 was challenging, with 127 out of 293 participants attending; however, there was no difference in cardiometabolic measures or demographic factors at baseline between those who attended for follow-up and those who did not. In work package 3, the IMPaCT randomised controlled trial, care co-ordinators struggled to provide additional time to their patients that was devoted to the health promotion intervention on top of their usual clinical care contact with them.

Conclusions

Cardiometabolic risk is prominent even soon after first presentation with psychosis and increases over time. Lifestyle choices and substance use habits at first presentation do not predict those who will be most cardiometabolically compromised 1 year later. Training and supervising care co-ordinators to deliver a health promotion intervention to their own patients on top of routine care is not effective in the NHS for improving quality of life or reducing cardiometabolic risk.

Future work

Further work is needed to develop and evaluate effective, cost-effective and affordable ways of preventing the emergence of and reversing existing cardiometabolic risk indicators in people with psychosis.

Trial registration

Current Controlled Trials ISRCTN58667926.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

Association between attitudes of stigma toward mental illness and attitudes toward adoption of evidence-based practice within health care providers in Bahrain

The health care system is one of the key areas where people with mental illnesses could experience stigma. Clinicians can hold stigma attitudes during their interactions with patients with mental illness. To improve the quality of mental health services and primary care, evidence-based practices should be disseminated and implemented. In this study, we evaluated the attitudes of health care providers in Bahrain toward people with mental illness and adoption of evidence-based practice using the Opening Minds Stigma Scale for Healthcare Providers (OMS-HC) and Evidence-Based Practice Attitude Scale (EBPAS). We conducted a cross-sectional study across 12 primary health care centers and a psychiatric hospital (the country's main mental health care facility). A self-report questionnaire was distributed among all health care providers. A total of 547 health care providers participated, with 274 from mental health services and 273 from primary care services. Results of the OMS-HC indicated differences between both main groups and subgroups. Regression model analysis reported significant outcomes. There was no statistical difference found between both groups in EBPAS scores. A weak but statistically significant negative association was reported between both scales. Participants showed varying stigma attitudes across different working environments, with less stigma shown in mental health services than in primary care services. Providers who were more open to adopting evidence-based practices showed less stigma toward people with mental illness. Comparing our findings with previous research showed that health care providers in Bahrain hold more stigma attitudes than other groups studied. We hope that this study serves as an initial step toward future campaigns against the stigma of mental illness in Bahrain and across the region.

Variation in coronary angiography and revascularisation procedures in relation to psychological distress among patients admitted to hospital with myocardial infarction or angina

OBJECTIVE

Cardiac patients with psychological distress have a poorer prognosis than patients without distress; which may in part reflect differences in treatment. We quantified variation in coronary angiography and revascularisation procedures according to psychological distress among patients admitted with incident acute myocardial infarction (AMI) or angina.

METHODS

Questionnaire data (collected 2006-09) from 45 and Up Study participants were linked to hospitalisation and mortality data, to 30 June 2016. Among patients free from ischaemic heart disease at baseline and subsequently hospitalised with AMI or angina, Cox regression was used to model the association between distress (Kessler-10 scores: low [10-<12], mild [12-<16], moderate [16-<22] and high [22-50]) - assessed on the questionnaire - and coronary angiography and revascularisation procedures (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) within 30 days of admission, adjusting for personal characteristics, including physical functioning.

RESULTS

Proportions receiving angiography and PCI/CABG were 71.4% and 51.7% following AMI (n = 3749), and 61.3% and 31.3% for angina patients (n = 3772), respectively. Following AMI, age-sex-adjusted rates of PCI/CABG were lower with higher levels of distress (test for trend: p = .037), as were rates of angiography and PCI/CABG (p < .01) following admission with angina. After additional adjustment for personal characteristics, associations between distress and procedure rates attenuated substantively and were no longer significant, except that PCI/CABG rates remained lower among angina patients with high versus low distress (HR = 0.76, 95%CI: 0.59-0.99).

CONCLUSION

Distress-related variation in coronary procedures largely reflects differences in personal characteristics. Whether lower revascularisation rates among angina patients with high compared to low distress are clinically appropriate or represent under-treatment remains unclear.

Primary care management of cardiovascular risk for people with severe mental illnesses: the Primrose research programme including cluster RCT

Background

Effective interventions are needed to prevent cardiovascular disease (CVD) in people with severe mental illnesses (SMI) because their risk of CVD is higher than that of the general population.

Objectives

(1) Develop and validate risk models for predicting CVD events in people with SMI and evaluate their cost-effectiveness, (2) develop an intervention to reduce levels of cholesterol and CVD risk in SMI and (3) test the clinical effectiveness and cost-effectiveness of this new intervention in primary care.

Design

Mixed methods with patient and public involvement throughout. The mixed methods were (1) a prospective cohort and risk score validation study and cost-effectiveness modelling, (2) development work (focus groups, updated systematic review of interventions, primary care database studies investigating statin prescribing and effectiveness) and (3) cluster randomised controlled trial (RCT) assessing the clinical effectiveness and cost-effectiveness of a new practitioner-led intervention, and fidelity assessment of audio-recorded appointments.

Setting

General practices across England.

Participants

All studies included adults with SMI (schizophrenia, bipolar disorder or other non-organic psychosis). The RCT included adults with SMI and two or more CVD risk factors.

Interventions

The intervention consisted of 8–12 appointments with a practice nurse/health-care assistant over 6 months, involving collaborative behavioural approaches to CVD risk factors. The intervention was compared with routine practice with a general practitioner (GP).

Main outcome measures

The primary outcome for the risk score work was CVD events, in the cost-effectiveness modelling it was quality-adjusted life-years (QALYs) and in the RCT it was level of total cholesterol.

Data sources

Databases studies used The Health Improvement Network (THIN). Intervention development work included focus groups and systematic reviews. The RCT collected patient self-reported and routine NHS GP data. Intervention appointments were audio-recorded.

Results

Two CVD risk score models were developed and validated in 38,824 people with SMI in THIN: the Primrose lipid model requiring cholesterol levels, and the Primrose body mass index (BMI) model with no blood test. These models performed better than published Cox Framingham models. In health economic modelling, the Primrose BMI model was most cost-effective when used as an algorithm to drive statin prescriptions. Focus groups identified barriers to, and facilitators of, reducing CVD risk in SMI including patient engagement and motivation, staff confidence, involving supportive others, goal-setting and continuity of care. Findings were synthesised with evidence from updated systematic reviews to create the Primrose intervention and training programme. THIN cohort studies in 16,854 people with SMI demonstrated that statins effectively reduced levels of cholesterol, with similar effect sizes to those in general population studies over 12–24 months (mean decrease 1.2 mmol/l). Cluster RCT: 76 GP practices were randomised to the Primrose intervention (n = 38) or treatment as usual (TAU) (n = 38). The primary outcome (level of cholesterol) was analysed for 137 out of 155 participants in Primrose and 152 out of 172 in TAU. There was no difference in levels of cholesterol at 12 months [5.4 mmol/l Primrose vs. 5.5 mmol/l TAU; coefficient 0.03; 95% confidence interval (CI) –0.22 to 0.29], nor in secondary outcomes related to cardiometabolic parameters, well-being or medication adherence. Mean cholesterol levels decreased over 12 months in both arms (–0.22 mmol/l Primrose vs. –0.39 mmol/l TAU). There was a significant reduction in the cost of inpatient mental health attendances (–£799, 95% CI –£1480 to –£117) and total health-care costs (–£895, 95% CI –£1631 to –£160; p = 0.012) in the intervention group, but no significant difference in QALYs (–0.011, 95% CI –0.034 to 0.011). A total of 69% of patients attended two or more Primrose appointments. Audiotapes revealed moderate fidelity to intervention delivery (67.7%). Statin prescribing and adherence was rarely addressed.

Limitations

RCT participants and practices may not represent all UK practices. CVD care in the TAU arm may have been enhanced by trial procedures involving CVD risk screening and feedback.

Conclusions

SMI-specific CVD risk scores better predict new CVD if used to guide statin prescribing in SMI. Statins are effective in reducing levels of cholesterol in people with SMI in UK clinical practice. This primary care RCT evaluated an evidence-based practitioner-led intervention that was well attended by patients and intervention components were delivered. No superiority was shown for the new intervention over TAU for level of cholesterol, but cholesterol levels decreased over 12 months in both arms and the intervention showed fewer inpatient admissions. There was no difference in cholesterol levels between the intervention and TAU arms, which might reflect better than standard general practice care in TAU, heterogeneity in intervention delivery or suboptimal emphasis on statins.

Future work

The new risk score should be updated, deployed and tested in different settings and compared with the latest versions of CVD risk scores in different countries. Future research on CVD risk interventions should emphasise statin prescriptions more. The mechanism behind lower costs with the Primrose intervention needs exploring, including SMI-related training and offering frequent support to people with SMI in primary care.

Trial registration

Current Controlled Trials ISRCTN13762819.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 2. See the NIHR Journals Library website for further project information. Professor David Osborn is supported by the University College London Hospital NIHR Biomedical Research Centre and he was also in part supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Barts Health NHS Trust.

[Electrocardiographic and hemodynamic profile of patients with psychotic disorder]

INTRODUCTION

Cardiac mortality among patients diagnosed with mental disorders is higher compared to the general population. Some authors suggest that cardiovascular risk is related to intrinsic factors specific to psychiatric disease. Nevertheless, the interpretation of these results is limited by the concomitant prescription of antipsychotics which have a cardiovascular effect. Studies evaluating the hemodynamic and electrocardiographic profile of drug naïve or drug-free patients suffering from mental disorders remain few.

AIMS

The aims of this work were to study the electrocardiographic and hemodynamic profile of drug naïve or drug-free patients with mental disorders and to determine clinical and biological factors associated with any electrocardiographic abnormalities.

SUBJECTS AND METHODS

It was a descriptive and evaluative cross-sectional study. We enrolled drug naïve or drug-free patients for at least two months. All subjects were inpatients and had at admission clinical, biological and electrocardiographic evaluation.

RESULTS

Forty-four percent of the sample had asymptomatic electrocardiographic abnormalities. These subjects had lower serum thyroid hormone levels compared to healthy group (P=0.066). Hemodynamic profile showed that 12% of the population had orthostatic hypotension.

CONCLUSION

Electrocardiographic and hemodynamic abnormalities are common among drug-free or drug naïve patients diagnosed with psychotic disorders. The association of electrocardiographic abnormalities with low levels of thyroxin requires more investigation.

The Association of Pre-stroke Psychosis and Post-stroke Levels of Health, Resource Utilization, and Care Process: A Register-Based Study

Background: While approximately one percent of the global population is formally diagnosed with psychosis or schizophrenia, the actual number is expected to be significantly higher. These patients often consume more healthcare resources and have poorer somatic health. In this study, we analyze potential differences in health, resources, and care process between stroke patients with and without a previous diagnosis of psychosis or schizophrenia.

Methods: Ischemic stroke patients from seven regions in Sweden were identified via ICD-10 codes (I63.0-9) in regional administrative systems and the Swedish Stroke Register, and approximately 70% of all ischemic stroke cases in Sweden during 2008–2011 were included (n = 46,350). Relevant patient-level data from national registries were linked to enable multivariate regression analysis, including data on socioeconomics, mortality, municipality services, and filled prescriptions. History of psychosis or schizophrenia was defined via ICD-10 codes F20-29 (n = 389).

Results: Patient-reported functional outcomes at 3 months and 1 year were significantly lower in the psychosis subgroup, and stroke recurrence was higher. Patients with pre-stroke psychosis did not receive the same levels of reperfusion treatment as the non-psychosis group. Time at the stroke unit was the same, as were first-year levels of somatic care, but dispensation of antihypertensives was less common.

Conclusion: Our findings emphasize the importance of taking mental comorbidity into account during stroke treatment as well as when evaluating indicators for health, resources, and the care process, since mental comorbidity such as psychosis or schizophrenia may have a significant impact the year preceding and the year succeeding the stroke event.

Antipsychotics and cardiovascular risk: A case/non-case study

Severe mental disorders have been reported to be associated with an increased cardiovascular risk. To measure the potential risk excess as compared, not with the baseline cardiovascular risk for the general population, but with the cardiovascular risk associated with drug iatrogenia. 197 reported cases of cardiovascular adverse reaction to antipsychotic drugs as compared to the reported cases of this type of adverse reactions to drugs other than antipsychotics entered in the Spanish Pharmacovigilance System database (FEDRA) (1995-2018) in an observational case/non-case study. Risk estimates of association were reporting odds ratio (ROR), and, chi-square test (χ²). Overall disproportionality for the whole drug class was found [ROR 2.3 (95% CI 2.0-2.7)], χ² = 127.07]. When the two types of antipsychotics (typical and atypical) were analysed separately, we also found statistically significant disproportionality, and this disproportionality is similar between both groups, with disproportionality measures around 2.30, with the confidence intervals not including the 1. The disproportionality observed suggests a risk excess that might be greater than expected, which holds particularly true for torsade de pointes, sudden death and cardiac arrhythmias in patients treated with any of the two types of antipsychotics. There was no significant risk for ischaemic heart disease.

Using the capabilities approach to understand inequality in primary health-care services for people with severe mental illness

BACKGROUND

Epidemiological studies show disparities in the provision of physical health-care for people with severe mental illness. This observation includes countries with universal health insurance. However, there is limited in-depth data regarding the barriers preventing equality of physical health-care provision for this population. This study applied the capabilities approach to examine the interface between general practitioners and patients with severe mental illness. The capabilities approach provides a framework for health status which conceptualizes the internal and external factors relating to the available options (capabilities) and subsequent health outcomes (functioning).

METHODS

Semi-structured in-depth interviews were conducted with 10 general practitioners and 15 patients with severe mental illness, and then thematically analyzed.

RESULTS

We identified factors manifesting across three levels: personal, relational-societal, and organizational. At the personal level, the utilization of physical health services was impaired by the exacerbation of psychiatric symptoms. At the relational level, both patients and physicians described the importance of a long-term and trusting relationship, and provided examples demonstrating the implications of relational ruptures. Finally, two structural-level impediments were described by the physicians: the absence of continuous monitoring of patients with severe mental illness, and the shortfall in psychosocial interventions.

CONCLUSION

The capability approach facilitated the identification of barriers preventing equitable health-care provision for patients with severe mental illness. Based on our findings, we propose a number of practical suggestions to improve physical health-care for this population: 1. A proactive approach in monitoring patients' health status and utilization of services. 2. Acknowledgment of people with severe mental illness as a vulnerable population at risk, that need increased time for physician-patient consultations. 3. Training and support for general practitioners. 4. Increase collaboration between general practitioners and mental-health professionals. 5. Educational programs for health professionals to reduce prejudice against people with severe mental illness.

The effect of history of severe mental illness on mortality in colorectal cancer cases: a register-based cohort study

BACKGROUND

While the link between mental illness and cancer survival is well established, few studies have focused on colorectal cancer. We examined outcomes of colorectal cancer among persons with a history of severe mental illness (SMI).

MATERIAL AND METHODS

We identified patients with their first colorectal cancer diagnosis in 1990-2013 (n = 41,708) from the Finnish Cancer Registry, hospital admissions due to SMI preceding cancer diagnosis (n = 2382) from the Hospital Discharge Register and deaths from the Causes of Death statistics. Cox regression models were used to study the impact on SMI to mortality differences.

RESULTS

We found excess colorectal cancer mortality among persons with a history of psychosis and with substance use disorder. When controlling for age, comorbidity, stage at presentation and treatment, excess mortality risk among men with a history of psychosis was 1.72 (1.46-2.04) and women 1.37 (1.20-1.57). Among men with substance use disorder, the excess risk was 1.22 (1.09-1.37).

CONCLUSION

Understanding factors contributing to excess mortality among persons with a history of psychosis or substance use requires more detailed clinical studies and studies of care processes among these vulnerable patient groups. Collaboration between patients, mental health care and oncological teams is needed to improve outcomes of care.

Anti-stigma training for medical students: The Education Not Discrimination project

Background

Education Not Discrimination (END) is the component of the Time to Change programme intended to reduce mental health stigma among professionals and professional trainees.

Aims

To investigate the impact of the END anti-stigma programme on medical students immediately and after 6 months with regard to knowledge, attitudes, behaviour and empathy.

Method

A total of 1452 medical students participated in the study (intervention group n = 1066, control group n = 386).

Participants completed questionnaires at baseline, and at immediate and 6-month follow-up. Groups were compared for changes in stigma outcomes.

Results

All measures improved in both groups, particularly among students with less knowledge and more stigmatising attitudes and intended behaviour at baseline. At immediate follow-up the intervention group demonstrated significantly greater improvements in stigma-related knowledge and reductions in stigma-related attitudes and intended behaviour, relative to the control group. At 6 months' follow-up, however, only one attitude item remained significantly better.

Conclusions

Although the intervention produced short-term advantage there was little evidence for its persistent effect, suggesting a need for greater integration of ongoing measures to reduce stigma into the medical curriculum.

Physical health of patients in rehabilitation and recovery: a survey of case note records

Aims and Method

The aim of this survey was to determine details recorded about the physical health of patients in rehabilitation and recovery. All medical and nursing notes from January 1998 to March 2003 were reviewed. Case notes from 63 patients were studied.

Results

There was mention in less than 13 of the patients' notes (18%) of smoking, diet, exercise or prolactin levels; weight, blood pressure, electrocardiogram, erythrocyte sedimentation rate or lipids were mentioned in less than 20 (30%). A blood sugar test was performed in only 16 patients (25%) in the past year and 38 patients (59%) had a record of a test in the past 5 years. These results suggest that there is inadequate recording of the physical health parameters in patients in rehabilitation and recovery.

Clinical Implications

The physical healthcare of patients with schizophrenia is prioritised in the National Institute for Clinical Excellence (NICE) clinical guidelines, which specifically mention the monitoring of endocrine disorders such as diabetes and hyperprolactinaemia, cardiovascular risk factors, such as blood pressure and lipids, and lifestyle factors such as smoking. Routine recording of physical health indices should be mandatory and staff may need further training to enable them to do this.

Double disparities in the health care for people with schizophrenia of an ethnic-national minority

BACKGROUND

Studies have shown health care disparities among persons of minority status, including in countries with universal health care. Yet, a dearth of studies have addressed disparities resulting from the combined effect of two minority status groups: severe mental illness and ethnic-national sector filiation. This study aimed to compare the differential health care of Jewish- and Arab-Israelis with schizophrenia in a country with a universal health insurance.

METHOD

This study builds on a large case-control epidemiological sample (N = 50,499) of Jewish- (92.9%) and Arab-Israelis (7.1%) service users with (n = 16,833) and without schizophrenia (n = 33,666). Health services records were collected in the years 2000-2009. Diabetes and cardiovascular disease (CVD) served as sentinel diseases. We compared annual number of LDL tests and visits to specialists in the entire sample, Hemoglobin-A1C test among people diagnosed with diabetes, and cardiac surgical interventions for those diagnosed with CVD.

RESULTS

Service users with schizophrenia were less likely to meet identical indexes of care as their study counterparts: 95% of cholesterol tests (p < .001), and 92% visits to specialists (p < .001). These differences were greater among Arab- compared to Jewish-Israelis. Annual frequency of Hemoglobin-A1C test among people diagnosed with diabetes was lower (94%) in people with schizophrenia (p < 0.01), but no ethnic-national differences were identified. Among service users with CVD less surgical interventions were done in people with schizophrenia (70%) compared to their counterparts, with no ethnic-national disparities.

CONCLUSIONS

In Israel, service users with schizophrenia fail to receive equitable levels of medical and cardiac surgical care for CVD and regular laboratory tests for diabetes. Although disparities in some health indicators were enhanced among Arab-Israelis, schizophrenia was a greater source of disparities than ethnic-national filiation.

Health Care and Mortality among Persons with Severe Mental Illness

OBJECTIVE

Reports show disparities in the health care of persons with severe mental illness (SMI), including in countries with universal health insurance. However, the moderating effect on disparities of specific mental health legislation is yet to be studied. The study aimed to investigate equality of health care for people with SMI in a country with a national health insurance and a comprehensive rehabilitation law for persons with mental disabilities.

METHOD

A case-control epidemiological study compared health services (laboratory tests, visits to specialists, and medications) provided to users with and without a history of schizophrenia and bipolar disorder ( N = 52,131) and with regard to a subgroup of users with diabetes ( n = 16,280). In addition, we examined the mortality rates of the study population.

RESULTS

While service users with schizophrenia were somewhat less likely to meet the same indexes of care as controls, those with bipolar disorder did not differ from their counterparts. Yet, mortality risk among service users with schizophrenia and bipolar disorder was 2.4 and 1.7 times higher, respectively. Rates of services to persons with SMI and comorbid diabetes did not differ from their counterparts.

CONCLUSIONS

In Israel, a country with a national health insurance and a rehabilitation law for persons with mental disabilities, service users with bipolar disorder receive equitable levels of general health care. For users with schizophrenia, the disparities exist in some of the health care measures but to a smaller extent than in other countries with universal health insurance. In contrast, mortality rates are elevated in persons with SMI.

Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas

Excess mortality in persons with severe mental disorders (SMD) is a major public health challenge that warrants action. The number and scope of truly tested interventions in this area remain limited, and strategies for implementation and scaling up of programmes with a strong evidence base are scarce. Furthermore, the majority of available interventions focus on a single or an otherwise limited number of risk factors. Here we present a multilevel model highlighting risk factors for excess mortality in persons with SMD at the individual, health system and socio-environmental levels. Informed by that model, we describe a comprehensive framework that may be useful for designing, implementing and evaluating interventions and programmes to reduce excess mortality in persons with SMD. This framework includes individual-focused, health system-focused, and community level and policy-focused interventions. Incorporating lessons learned from the multilevel model of risk and the comprehensive intervention framework, we identify priorities for clinical practice, policy and research agendas.

The chasm of care: Where does the mental health nursing responsibility lie for the physical health care of people with severe mental illness?

The poor physical health of people with a severe mental illness is well documented and health professionals' attitudes, knowledge and skills are identified factors that impact on clients' access to care for their physical health needs. An evaluation was conducted to determine: (i) mental health nurses' attitudes and beliefs about providing physical health care; and, (ii) the effect that participant demographics may have on attitudes to providing physical health care. It was hypothesized that workplace culture would have the largest effect on attitudes. Nurses at three health services completed the "Mental health nurses' attitude towards the physical health care of people with severe and enduring mental illness survey" developed by Robson and Haddad (2012). The 28-item survey measured: nurses' attitudes, confidence, identified barriers to providing care and attitudes towards clients smoking cigarettes. The findings demonstrated that workplace culture did influence the level of physical health care provided to clients. However, at the individual level, nurses remain divided and uncertain where their responsibilities lie. Nursing leadership can have a significant impact on improving clients' physical health outcomes. Education is required to raise awareness of the need to reduce cigarette smoking in this client population.

Health care disparities among persons with comorbid schizophrenia and cardiovascular disease: a case-control epidemiological study

AIMS

Studies showed health care disparities among persons with comorbid schizophrenia and cardiovascular disease (CVD), including in countries with universal health care. However, the potential positive effect of specific mental health legislation has not been reported. This study aimed to investigate the health care of persons with comorbid schizophrenia and CVD in a country with both a national health insurance and a comprehensive rehabilitation law for persons with mental disabilities.

METHOD

This study builds on a large case-control epidemiological sample (N = 52 189) of service users. Within the sample we identified a sub-group of persons with CVD diagnoses (n = 8208) and compared service users with and without schizophrenia on drug utilisation, laboratory tests, visits to specialists and surgical interventions.

RESULTS

Service users with schizophrenia were less likely to meet similar indexes of care as their counterparts: 91% cholesterol tests (p < 0.001), 60% stress tests (p < 0.001), 93% visits to specialists (p = 0.001), 93% drug utilisation (p < 0.001) and 55% CVD surgical interventions (odds ratio 0.55, 95% confidence intervals 0.49-0.61).

CONCLUSIONS

In Israel, a country with a national health insurance and a rehabilitation law specific for persons with mental disabilities, service users with schizophrenia still fail to receive equitable levels of health care for CVD. However, the disparities appear to be smaller than in other countries with universal health insurance.

Metabolic syndrome in people with a psychotic illness: is cannabis protective?

BACKGROUND

Rates of the metabolic syndrome in people with psychotic illness are high. Emerging evidence suggests that cannabis use may have a positive impact on cardiometabolic risk factors in the general population, but little is known about its impact for people with psychotic illness. Our aim was to investigate whether the rate of the metabolic syndrome in people with psychotic illness was associated with frequency of cannabis use.

METHOD

The 2010 Australian psychosis survey used a two-phase design to randomly select a nationally representative sample of 1825 adults with psychotic illness for interview and physical assessment. This study is based on 1813 participants who provided data on cannabis use. Multiple logistic regression was used to model the influence of frequency of cannabis use on the metabolic syndrome, adjusting for potential covariates including antipsychotic medication use, smoking, alcohol use and cognitive function.

RESULTS

One-third (33.0%) of participants had used cannabis in the past year. The proportion of non-users, occasional users and frequent users with the metabolic syndrome was 63.0, 51.7 and 43.5%, respectively (p < 0.001). In unadjusted analyses, both occasional use and frequent cannabis use were associated with significantly lower odds of the metabolic syndrome. In the adjusted analyses, the association between the metabolic syndrome and frequent cannabis use remained significant [odds ratio = 0.56, 95% confidence interval (CI) 0.39-0.80], but not the association with occasional use (odds ratio = 0.75, 95% CI 0.49-1.13).

CONCLUSIONS

While cannabis use may be detrimental for mental health, these data suggest that it may also have a cardiometabolic protective effect. Further investigation is required to understand the mechanism underlying this paradoxical finding.

Approach bias modification in inpatient psychiatric smokers

Drug-related automatic approach tendencies contribute to the development and maintenance of addictive behavior. The present study investigated whether a nicotine-related approach bias can be modified in smokers undergoing inpatient psychiatric treatment by using a novel training variant of the nicotine Approach-Avoidance-Task (AAT). Additionally, we assessed whether the AAT-training would affect smoking behavior. Inpatient smokers were randomly assigned to either an AAT-training or a sham-training condition. In the AAT-training condition, smokers were indirectly instructed to make avoidance movements in response to nicotine-related pictures and to make approach movements in response to tooth-cleaning pictures. In the sham-training condition, no contingency between picture content und arm movements existed. Trainings were administered in four sessions, accompanied by a brief smoking-cessation intervention. Smoking-related self-report measures and automatic approach biases toward smoking cues were measured before and after training. Three months after training, daily nicotine consumption was obtained. A total of 205 participants were recruited, and data from 139 participants were considered in the final analysis. Prior to the trainings, smokers in both conditions exhibited a stronger approach bias for nicotine-related pictures than for tooth-cleaning pictures. After both trainings, this difference was no longer evident. Although reduced smoking behavior at posttest was observed after both trainings, only the AAT-training led to a larger reduction of nicotine consumption at a three-month follow-up. Our preliminary data partially support the conclusion that the AAT might be a feasible tool to reduce smoking in the long-term in psychiatric patients, albeit its effect on other smoking-related measures remains to be explored.

Excess Mortality in Patients with Severe Mental Disorders in 1996-2010 in Finland

Unselected population-based nationwide studies on the excess mortality of individuals with severe mental disorders are scarce with regard to several important causes of death. Using comprehensive register data, we set out to examine excess mortality and its trends among patients with severe mental disorders compared to the total population. Patients aged 25-74 and hospitalised with severe mental disorders in 1990-2010 in Finland were identified using the national hospital discharge register and linked individually to population register data on mortality and demographics. We studied mortality in the period 1996-2010 among patients with psychotic disorders, psychoactive substance use disorders, and mood disorders by several causes of death. In addition to all-cause mortality, we examined mortality amenable to health care interventions, ischaemic heart disease mortality, disease mortality, and alcohol-related mortality. Patients with severe mental disorders had a clearly higher mortality rate than the total population throughout the study period regardless of cause of death, with the exception of alcohol-related mortality among male patients with psychotic disorders without comorbidity with substance use disorders. The all-cause mortality rate ratio of patients with psychotic disorders compared to the total population was 3.48 (95% confidence interval 2.98-4.06) among men and 3.75 (95% CI 3.08-4.55) among women in the period 2008-10. The corresponding rate ratio of patients with psychoactive substance use disorders was 5.33 (95% CI 4.87-5.82) among men and 7.54 (95% CI 6.30-9.03) among women. Overall, the mortality of the total population and patients with severe mental disorders decreased between 1996 and 2010. However, the mortality rate ratio of patients with psychotic disorders and patients with psychoactive substance use disorders compared to the total population increased in general during the study period. Exceptions were alcohol-related mortality among patients with psychoactive substance use disorders and female patients with psychotic disorders, as well as amenable mortality among male patients with psychotic disorders. The mortality rate ratio of persons with mood disorders compared to the total population decreased. The markedly high mortality amenable to health care intervention among patients with severe mental disorders found in our study suggests indirectly that they may receive poorer quality somatic care. The results highlight the challenges in co-ordinating mental and somatic health services.

Effectiveness of Varenicline in Psychiatric Patients with Co-Morbid Polysubstance Dependence

Introduction: Individuals with substance use disorders (SUDs) and mental health disorders (MHDs) have greater prevalence of smoking and suffer greater tobacco-related morbidity and mortality. Varenicline is the latest FDA-approved smoking-cessation agent and few studies have investigated the use of varenicline in this difficult-to-treat population.

Aims: This study examines the smoking cessation outcomes and tolerability of varenicline when used to help quit smoking in 16 patients enroled in both psychiatric and substance abuse programme.

Methods: A retrospective chart review was conducted on 16 patient charts. Patient demographics, psychiatric disorder diagnoses, substance use history, dosing, side effects, number of cigarettes used pre/post varenicline use and the number of complete smoking cessation outcomes were tabulated.

Results: After varenicline intervention, 25% of those who completed treatment completely quit smoking. Thirty-one per cent were able to substantially cut back the amount that they smoked to one cigarette per day. The average reduction in cigarettes was 16 per day (64%), and all but one patient tolerated varenicline.

Conclusions: The authors observed reasonable clinical benefit when varenicline was used to help quit smoking in patients with comorbid SUDs and MHDs. Better-controlled future studies with larger sample sizes will help further determine clinical utility of varenicline in this difficult-to-treat nicotine-dependent population.

Why do psychiatric patients have higher cancer mortality rates when cancer incidence is the same or lower?

OBJECTIVE

Studies of overall cancer incidence and mortality in psychiatric patients have had mixed results. Some have reported lower than expected cancer incidence or mortality, while others have found no association or an increased risk depending on sample, psychiatric diagnosis, cancer site and methodology. Few studies have compared cancer incidence and mortality using the same population and methodology.

METHOD

A population-based record-linkage analysis to compare cancer incidence and mortality in psychiatric patients with that for the general Queensland population, using an historical cohort to calculate age- and sex-standardised rate ratios and hazard ratios. Mental health records were linked with cancer registrations and death records from 2002 to 2007.

RESULTS

There were 89,992 new cancer cases, of which 3349 occurred in people with mental illness. Cancer incidence was the same as the general population for most psychiatric disorders. Rates were actually lower for dementia (hazard ratio = 0.77; 95% confidence interval = [0.67, 0.88]) and schizophrenia (hazard ratio = 0.84; 95% confidence interval = [0.72, 0.98]). By contrast, mortality was increased in psychiatric patients (hazard ratio = 2.27; 95% confidence interval = [2.15, 2.39]) with elevated hazard ratios for all the main psychiatric diagnoses.

CONCLUSIONS

Lifestyle, such as alcohol or tobacco use, would not explain our findings that people with mental illness are no more likely than the general population to develop cancer but more likely to die of it. Other factors may be the difficulty in differentiating medically explained and unexplained symptoms, greater case fatality or inequity in access to specialist procedures. The study highlights the need for improved cancer screening, detection and intervention in this population.

Evaluating the clinical and cost effectiveness of a behaviour change intervention for lowering cardiovascular disease risk for people with severe mental illnesses in primary care (PRIMROSE study): study protocol for a cluster randomised controlled trial

Background

People with severe mental illnesses die up to 20 years earlier than the general population, with cardiovascular disease being the leading cause of death. National guidelines recommend that the physical care of people with severe mental illnesses should be the responsibility of primary care; however, little is known about effective interventions to lower cardiovascular disease risk in this population and setting. Following extensive peer review, funding was secured from the United Kingdom National Institute for Health Research (NIHR) to deliver the proposed study. The aim of the trial is to test the effectiveness of a behavioural intervention to lower cardiovascular disease risk in people with severe mental illnesses in United Kingdom General Practices.

Methods/Design

The study is a cluster randomised controlled trial in 70 GP practices for people with severe mental illnesses, aged 30 to 75 years old, with elevated cardiovascular disease risk factors. The trial will compare the effectiveness of a behavioural intervention designed to lower cardiovascular disease risk and delivered by a practice nurse or healthcare assistant, with standard care offered in General Practice. A total of 350 people will be recruited and followed up at 6 and 12 months. The primary outcome is total cholesterol level at the 12-month follow-up and secondary outcomes include blood pressure, body mass index, waist circumference, smoking status, quality of life, adherence to treatments and services and behavioural measures for diet, physical activity and alcohol use. An economic evaluation will be carried out to determine the cost effectiveness of the intervention compared with standard care.

Discussion

The results of this pragmatic trial will provide evidence on the clinical and cost effectiveness of the intervention on lowering total cholesterol and addressing multiple cardiovascular disease risk factors in people with severe mental illnesses in GP Practices.

Trial registration

Current Controlled Trials ISRCTN13762819. Date of Registration: 25 February 2013.

Date and Version Number: 27 August 2014 Version 5.

A retrospective study of medical comorbidities in psychogeriatric patients

BACKGROUND

This study contributes further research into the assessment and treatment of older psychiatric patients with medical comorbidities.

METHODS

A retrospective file audit was conducted at the acute inpatient psychogeriatric unit of St Vincent's Aged Mental Health Service, Melbourne, in order to determine the prevalence of certain medical comorbidities and the nature of medical interventions provided for psychogeriatric inpatients.

RESULTS

This study, investigating 165 admissions into an acute inpatient psychogeriatric unit, highlights that psychiatric and medical comorbidities are routine in this population: the vast majority (91.5%) of all inpatients had at least one medical comorbidity.

CONCLUSIONS

As the population ages, psychogeriatric wards are likely to see more of the oldest-olds, who are likely to have comorbid medical illnesses. Currently, appropriate detection, investigation, and management of these illnesses are often suboptimal and can affect quality of life, increase mortality, and complicate treatment. This paper adds to the literature about the need for integrating medical and psychiatric care to create a more comprehensive strategy for treating the older person with psychiatric illness.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study

PURPOSE

People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK.

METHODS

E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers.

RESULTS

In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)).

CONCLUSIONS

There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.

Promoting physical health in severe mental illness: patient and staff perspective

OBJECTIVE

To explore physical health problems and their causes in patients with severe mental illness, as well as possibilities for prevention and treatment from the patients' and staff's perspectives.

METHOD

We conducted six focus groups with patients and staff separately, from three out-patient clinics treating patients with schizophrenia or substance-use disorder comorbid to another psychiatric disorder. Focus groups were audio-recorded, transcribed verbatim and analysed using a template approach.

RESULTS

Paramount physical health problems are weight issues, cardiovascular diseases and poor physical shape. Main causes are lifestyle, the mental disorder and organisational issues. Patients and staff expressed similar opinions regarding physical health problems and their causes. Possibilities for prevention and treatment includes a case manager and binding communities with like-minded, as well as management support and implementation of physical health into daily psychiatric practice. Although patients and staff suggested different possibilities for prevention and treatment, they support one strategy: less fragmentation of the treatment system and cooperation between psychiatric and somatic healthcare.

CONCLUSION

To prevent and treat physical health problems in patients with severe mental illness, support in daily structure and lifestyle changes is needed. Management support is needed to change daily practice and implement routines regarding physical health.

A Surveillance System to Monitor Excess Mortality of People With Mental Illness in Canada

OBJECTIVE

Outcome measures are rarely available for surveillance and system performance monitoring for mental disorders and addictions. Our study aims to demonstrate the feasibility and face validity of routinely measuring the mortality gap in the Canadian context at the provincial and regional levels using the methods and data available to the Canadian Chronic Disease Surveillance System (CCDSS) of the Public Health Agency of Canada.

METHODS

We used longitudinal data from the Quebec Integrated Chronic Disease Surveillance System, which also provides aggregated data to the CCDSS. This includes data from the health insurance registry physician claims and the hospital discharge abstract for all mental disorder diagnoses (International Classification of Diseases [ICD]-9 290-319 or ICD-10 F00-F99). Patients were defined as having had received a mental disorder diagnosis at least once during the year. Life expectancy was measured using Chiang's method for abridged life tables, complemented by the Hsieh method for adjustment of the last age interval.

RESULTS

We found a lower life expectancy among psychiatric patients of 8 years for men and 5 years for women. For patients with schizophrenia, life expectancy was lowered by 12 years for men and 8 years for women. Cardiovascular disease and cancer were the most common causes of premature death. Findings were consistent across time and regions of the province. Lower estimates of the mortality gap, compared with literature, could be explained by the inclusion of primary care patients and methods.

CONCLUSIONS

Our study demonstrates the feasibility of using administrative data to measure the impact of current and future mental health plans in Canada provided the techniques can be replicated in other Canadian provinces.

Using Avoidable Admissions to Measure Quality of Care for Cardiometabolic and Other Physical Comorbidities of Psychiatric Disorders: A Population-Based, Record-Linkage Analysis

OBJECTIVE

Quality of care for comorbid physical disorders in psychiatric patients can be assessed by the number of avoidable admissions for ambulatory care sensitive (ACS) conditions. These are admissions for physical conditions that, with appropriate primary care, should not require inpatient treatment. Avoidable admissions for ACS conditions feature prominently in Australia's National Health Performance Framework and have been used to assess health care provision for marginalized groups, such as Indigenous patients or those of lower socioeconomic status. They have not been applied to people with mental illness.

METHODS

A population-based, record-linkage analysis was used to measure ACS admissions for physical disorder in psychiatric patients of state-based facilities in Queensland, Australia, during 5 years.

RESULTS

There were 77 435 males (48.0%) and 83 783 females (52%) (total n = 161 218). Among these, 13 219 psychiatric patients (8.2%) had at least 1 ACS admission, the most common being for diabetes (n = 6086) and angina (n = 2620). Age-standardized rates were double those of the general population. Within the psychiatric group, and after adjusting for confounders, those who had ever been psychiatric inpatients experienced the highest rates of ACS admissions, especially for diabetes.

CONCLUSIONS

In common with other marginalized groups, psychiatric patients have increased ACS admissions. Therefore, this measure could be used as an indicator of difficulties in access to appropriate primary care in Canada, given the availability of similar administrative data.

Scoping review of research in Australia on the co-occurrence of physical and serious mental illness and integrated care

The physical health of people with serious mental illness (SMI) has become a focal area of research. The aim of the present study was to ascertain the attention and distribution of research from within Australia on physical illness and SMI co-occurrence, and to identify gaps. A scoping review of peer-reviewed research literature from Australia, published between January 2000 and March 2014, was undertaken through an electronic literature search and coding of papers to chart trends. Four trends are highlighted: (i) an almost threefold increase in publications per year from 2000-2006 to 2007-2013; (ii) a steady release of literature reviews, especially from 2010; (iii) health-related behaviours, smoking, integrated-care programmes, and antipsychotic side-effects as the most common topics presented; and (iv) paucity of randomized, controlled trials on integrated-care models. Despite a marked increase in research attention to poorer physical health, there remains a large gap between research and the scale of the problem previously identified. More papers were descriptive or reviews, rather than evaluations of interventions. To foster more research, 12 research gaps are outlined. Addressing these gaps will facilitate the reduction of inequalities in physical health for people with SMI. Mental health nurses are well placed to lead multidisciplinary, consumer-informed research in this area.

Relative Risk of Acute Myocardial Infarction in People with Schizophrenia and Bipolar Disorder: A Population-Based Cohort Study

OBJECTIVE

Despite high mortality associated with serious mental illness, risk of acute myocardial infarction (AMI) remains unclear, especially for patients with bipolar disorder. The main objective was to investigate the relative risk of AMI associated with schizophrenia and bipolar disorders in a national sample.

METHOD

Using nationwide administrative data, an 11-year historic cohort study was assembled, comprised of cases aged 18 and above who had received a diagnosis of schizophrenia or bipolar disorder, compared to a random sample of all other adults excluding those with diagnoses of serious mental illness. Incident AMI as a primary diagnosis was ascertained. Hazard ratios stratified by age and gender were calculated and Cox regression models were used to adjust for other covariates.

RESULTS

A total of 70,225 people with schizophrenia or bipolar disorder and 207,592 people without serious mental illness were compared. Hazard ratios in men adjusted for age, income and urbanization were 1.15 (95% CI 1.01~1.32) for schizophrenia and 1.37 (1.08~1.73)for bipolar disorder, and in women, 1.85 (1.58~2.18) and 1.88(1.47~2.41) respectively. Further adjustment for treated hypertension, diabetes and hyperlipidaemia attenuated the hazard ratio for men with schizophrenia but not the other comparison groups. Hazard ratios were significantly stronger in women than men and were stronger in younger compared to older age groups for both disorders; however, gender modification was only significant in people with schizophrenia, and age modification only significant in people with bipolar disorder.

CONCLUSIONS

In this large national sample, schizophrenia and bipolar disorder were associated with raised risk of AMI in women and in the younger age groups although showed differences in potential confounding and modifying factors.

Exercise practices in individuals at clinical high risk of developing psychosis

AIM

Recent research suggests aerobic exercise has a positive impact on symptoms and cognition in psychosis. Because individuals with psychosis are at risk of weight gain and the resultant metabolic side-effects, developing effective exercise programmes is of interest. Furthermore, this may be a useful intervention for those who are at risk of developing psychosis, that is, those at clinical high risk (CHR). The aim of this initial exploratory project was to examine the role of exercise in participants at CHR for psychosis.

METHODS

A comprehensive questionnaire was developed to assess current physical activity involvement; exercise levels in terms of frequency, intensity and duration; and perceived fitness levels. Reported barriers to exercise and reasons for exercising were also considered. Eighty participants, 40 CHR and 40 healthy controls, were assessed with this questionnaire.

RESULTS

Overall, both groups were involved in a wide range of physical activity. Healthy controls reported higher levels of participation in indoor/outdoor activities and strength and/or flexibility training. They also exercised more frequently, more intensely and reported higher perceived fitness levels than CHR participants. Levels of exercise were unrelated to clinical symptoms and functioning in CHR participants. CHR youth reported more barriers to exercise and less positive reasons for exercising that were related to self-perception.

CONCLUSION

The results suggest that exercise should be investigated further in the CHR population as it may have treatment implications.

Under Construction: One State's Approach to Creating Health Homes for Individuals with Serious Mental Illness

Changes to the health care market associated with the Patient Protection and Affordable Care Act (ACA) are creating both need and opportunity for states, health plans, and providers to improve quality, outcomes, and satisfaction through better integration of traditionally separate health care delivery systems. Applications of the term "integrated care" vary widely and include, but are not limited to, the integration of care for Medicare-Medicaid dually enrolled beneficiaries, the integration of mental health and substance abuse (also known as behavioral health), and the integration of mental health and substance abuse with medical care, most commonly primary care. In this article, integrated care refers to well-coordinated physical health and behavioral health care. Medicaid Health Homes are emerging as a promising practice, with sixteen states having adopted the Health Home model through approved State Plan Amendments. This article describes one state's journey towards establishing Health Homes with a behavioral health focus. We discuss a partnership model between the relevant state organizations, the contracted providers, and the behavioral health managed care organization responsible for many of the supportive administrative functions. We highlight successes and operational challenges and offer recommendations for future Health Home development efforts.

Excess non-psychiatric hospitalizations among employees with mental disorders: a 10-year prospective study of the GAZEL cohort

OBJECTIVE

To examine whether non-psychiatric hospitalizations rates were higher in those with mental disorders.

METHOD

In a cohort of 15,811 employees, aged 35-50 years in 1989, mental disorder status was defined from 1989 to 2000. Hospitalizations for all-causes, myocardial infarction (MI), stroke, and cancer, were recorded yearly from 2001 to 2011. Negative binomial regression models were used to estimate hospitalization rates over the follow-up.

RESULTS

After controlling for baseline sociodemographic factors, health-related behaviors, self-rated health, and self-reported medical conditions, participants with a mental disorder had significantly higher rates of all-cause hospitalization [incidence rate ratio, IRR=1.20 (95%, 1.14-1.26)], as well as hospitalization due to MI [IRR=1.44 (95%, 1.12-1.85)]. For stroke, the IRR did not reach statistical significance [IRR=1.37 (95%, 0.95-1.99)] and there was no association with cancer [IRR=1.01 (95%, 0.86-1.19)]. A similar trend was observed when mental disorders groups were considered (no mental disorder, depressive disorder, mental disorders due to psychoactive substance use, other mental disorders, mixed mental disorders, and severe mental disorder).

CONCLUSION

In this prospective cohort of employees with stable employment as well as universal access to healthcare, we found participants with mental disorders to have higher rates of non-psychiatric hospitalizations.