Medical comorbidities in patients with serious mental illness: a retrospective study of mental health patients attending an outpatient clinic in Qatar

Trends in CV mortality among patients with known mental and behavioral disorders in the US between 1999 and 2020

Introduction

Patients with mental disorders are at increased risk of cardiovascular events. We aimed to assess the cardiovascular mortality trends over the last two decades among patients with mental and behavioral co-morbidities in the US.

Methods

We performed a retrospective, observational study using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) Multiple Cause of Death dataset. We determined national trends in age-standardized mortality rates attributed to cardiovascular diseases in patients with and without mental and behavioral disorders, from 1999 to 2020, stratified by mental and behavioral disorders subtype [ICD10 codes F], age, gender, race, and place of residence.

Results

Among more than 18.7 million cardiovascular deaths in the United States (US), 13.5% [2.53 million] were patients with a concomitant mental and behavioral disorder. During the study period, among patients with mental and behavioral disorders, the age-adjusted mortality rate increased by 113.9% Vs a 44.8% decline in patients with no mental disorder (both p<0.05). In patients with mental and behavioral disorders, the age-adjusted mortality rate increased more significantly among patients whose mental and behavioral disorder was secondary to substance abuse (+532.6%, p<0.05) than among those with organic mental disorders, such as dementia or delirium (+6.2%, P- nonsignificant). Male patients (+163.6%) and residents of more rural areas (+128-162%) experienced a more prominent increase in age-adjusted cardiovascular mortality.

Discussion

While there was an overall reduction in cardiovascular mortality in the US in the past two decades, we demonstrated an overall increase in cardiovascular mortality among patients with mental disorders.

Mental Health Care Education and Training in Pharmacy Programs in Arabic-Speaking Countries

OBJECTIVE

This study aimed to assess how entry-level pharmacy programs in Arab countries prepare graduates to provide mental health care, specifically examining the didactic curricula and experiential training in psychiatry in bachelor and PharmD programs.

METHODS

An electronic survey was sent to all entry-level pharmacy programs in the 22 Arab countries asking to report on the 2021-2022 academic year. The survey assessed teaching and learning (eg, psychiatric diseases taught and extent of the coverage; contact hours dedicated to psychiatric therapeutics, pharmacology, and medicinal chemistry), experiential training in psychiatry and its challenges, and graduates' preparedness to provide mental health. A descriptive analysis of the data was undertaken, and data were reported for bachelor and PharmD programs separately.

RESULTS

Overall, 35 pharmacy programs completed the survey. All PharmD programs and 80% of bachelor programs covered psychiatric therapeutics, and most contact hours were dedicated to pharmacology, followed by psychiatric therapeutics and medicinal chemistry. Over half of the faculty considered that depression and anxiety disorders were covered sufficiently, and 56.2% of programs did not offer experiential training in psychiatry. Common challenges in psychiatry experiential training included a lack of sites and qualified preceptors. Overall, 26.4% of faculty positively rated graduates' preparedness to provide mental health care. Graduates who completed experiential training in psychiatry and PharmD graduates were rated higher.

CONCLUSION

Pharmaceutical education in Arab countries could be improved by enhancing the teaching and assessment of mental health topics and expanding psychiatry experiential training. Such changes would improve entry-level pharmacists' competencies in mental health care provision.

Physical and psychiatric comorbidities among patients with severe mental illness as seen in Uganda

While psychiatric and physical comorbidities in severe mental illness (SMI) have been associated with increased mortality and poor clinical outcomes, problem has received little attention in low- and middle-income countries (LMICs). This study established the prevalence of psychiatric (schizophrenia, bipolar affective disorder, and recurrent major depressive disorder) and physical (HIV/AIDS, syphilis, hypertension and obesity) comorbidities and associated factors among 1201 out-patients with SMI (schizophrenia, depression and bipolar affective disorder) attending care at two hospitals in Uganda. Participants completed an assessment battery including structured, standardised and locally translated instruments. SMIs were established using the MINI International Neuropsychiatric Interview version 7.2. We used logistic regression to determine the association between physical and psychiatric comorbidities and potential risk factors. Bipolar affective disorder was the most prevalent (66.4%) psychiatric diagnoses followed by schizophrenia (26.6%) and recurrent major depressive disorder (7.0%). Prevalence of psychiatric comorbidity was 9.1%, while physical disorder comorbidity was 42.6%. Specific comorbid physical disorders were hypertension (27.1%), obesity (13.8%), HIV/AIDS (8.2%) and syphilis (4.8%). Potentially modifiable factors independently significantly associated with psychiatric and physical comorbidities were: use of alcohol for both syphilis and hypertension comorbidities; and use of a mood stabilisers and khat in comorbidity with obesity. Only psychiatric comorbidity was positively associated with the negative outcomes of suicidality and risky sexual behaviour. The healthcare models for psychiatric care in LMICs such as Uganda should be optimised to address the high burden of psychiatric and physical comorbidities.

The effects of sustained COVID-19 emergency and restrictions on the mental health of subjects with serious mental illness: A prospective study

Few longitudinal studies have so far investigated the impact of sustained COVID-19 among people with pre-existing psychiatric disorders. We conducted a prospective study involving people with serious mental illness (n = 114) and healthy controls (n = 41) to assess changes in the Perceived Stress Scale, Generalized Anxiety Disorder Scale, Patient Health Questionnaire, and Specific Psychotic Experiences Questionnaire scores 18 months after the COVID-19 pandemic outset. Subjects underwent interviews with a mental health professional in April 2020 and at the end of the local third wave (October 2021). A significant increase in perceived stress was found in healthy controls, especially females. Psychiatric patients showed a significant worsening of anxiety symptoms compared to baseline records (t = -2.3, p = 0.036). Patients who rejected vaccination had significantly higher paranoia scores compared to those willing to get vaccinated (U = 649.5, z = -2.02, p = 0.04). These findings indicate that COVID-19's sustained emergency may cause enduring consequences on mental health, soliciting further investigations.

How psychosocial stress profile influences the subsequent occurrence of neuropsychiatric comorbidities: A longitudinal population-based cohort study

BACKGROUND

The role of psychosocial stressors in psychiatric disorders and executive dysfunction has been reported, separately. The literature has also suggested the involvement of social support and coping strategies in these relationships. However, there is a lack of research conducted to examine the relationships among multiple stressors and neuropsychiatric comorbidities while considering the presence of social support and coping strategies. This study aims to articulate the roles of multiple psychosocial stressors, social support, and coping strategies in the subsequent occurrence of neuropsychiatric comorbidities.

METHODS

Data analyzed were from the 6th data collection of a large-scale, longitudinal population-based cohort from Southwest Montreal in Canada. The cumulative effects of multiple stressors were separately examined by a composite score and latent profile analysis. Multinomial logistic regression models were used to test the relationship between cumulative stressors and neuropsychiatric comorbidities.

RESULTS

A total of 210 participants were included in the analyses. The LPA identified a 2-class model for psychosocial stressors (low and high) and executive function (executive dysfunction and no executive dysfunction), respectively. There were 11.8% of participants with neuropsychiatric comorbidities. Both the composite stress score (RR = 1.08, 95%CI = 1.01-1.15) and latent stress groups (RR = 3.65, 95%CI = 1.15-11.57) were associated with neuropsychiatric comorbidities after adjusting for social support and coping strategies. The risk of developing neuropsychiatric comorbidities decreased when the level of social support was high (P < 0.05).

CONCLUSIONS

Exposures to multiple stressors increased the risk of subsequent neuropsychiatric comorbidities, but the risk can be modified by a higher level of social support.

International perspective on integrated care models in child and adult mental health

The dearth of child and adolescent mental health services (CAMHS) is a global problem. Integrating CAMHS in primary care has been offered as a solution. We sampled integrated care perspectives from colleagues around the world. Our findings include various models of integrated care namely: the stepped care model in Australia; shared care in the United Kingdom (UK) and Spain; school-based collaborative care in Qatar, Singapore and the state of Texas in the US; collaborative care in Canada, Brazil, US, and Uruguay; coordinated care in the US; and, developing collaborative care models in low-resource settings, like Kenya and Micronesia. These findings provide insights into training initiatives necessary to build CAMHS workforce capacity using integrated care models, each with the ultimate goal of improving access to care. Despite variations and progress in implementing integrated care models internationally, common challenges exist: funding within complex healthcare systems, limited training mechanisms, and geopolitical/policy issues. Supportive healthcare policy, robust training initiatives, ongoing quality improvement and measurement of outcomes across programs would provide data-driven support for the expansion of integrated care and ensure its sustainability.

An Exploration of Smoking Patterns Among People with Serious Mental Illness Attending an Outpatient Clinic in Qatar

BACKGROUND

Studies have shown that tobacco use is exceptionally high in people affected with serious mental illness (SMI). Many countries worldwide have observed a decrease in the prevalence of tobacco smoking; however, the smoking rates among people with SMI have declined much less than in those without mental illness. To date, no nationally representative data have examined the smoking patterns or the sociocultural factors that influence smoking among SMI people in Qatar.

METHODS

A retrospective medical chart review was conducted to collect patient demographics, psychiatric and medical comorbidities, medications, the most recently documented smoking status and if on tobacco cessation treatment. A descriptive and inferential analysis of the data was performed.

RESULTS

Of 346 patients included in the cohort, 196 (56.6%) had their smoking status documented, of which 72 (36.7%) were "currently smoking." Significantly more males than females were "current smokers" (62.9% versus 15.0%, respectively, p < 0.001). Significantly more patients with psychotic disorders than those with any other SMI were "current smokers", and this difference was statistically significant (p = 0.006). Positive and significant associations with current smoking were found for the male gender, psychotic disorders, and high levels (≥6.2 mmol/L) of total cholesterol. Only 12 (16.7%) of current smokers were receiving smoking cessation treatment.

CONCLUSION

More than half of a sample of people with SMI attending outpatient psychiatric services in Qatar had documented smoking status. Still, only a few current smokers were on smoking cessation treatment. Efforts are needed to implement smoking cessation strategies in this population.

Evaluation of cardiovascular risk in adult psychiatric outpatients in Qatar using two risk assessment tools

Introduction: Individuals with serious mental illness (SMI) experience premature death, likely due to increased rates of obesity and cardiovascular disease (CVD). This study was conducted to estimate the CVD risk in a cohort of individuals with SMI receiving outpatient psychiatric services in Qatar and to assess contributory CVD risk factors.

Methods: This is a retrospective review of the electronic medical records of a cohort of outpatients with SMI attending a mental health clinic in Doha, Qatar. The CVD risk was estimated using two risk prediction tools: the American Heart Association and the American College of Cardiology (AHA/ACC) risk calculator and the World Health Organization/International Society of Hypertension (WHO/ISH) CVD risk prediction charts for the Eastern Mediterranean region. Descriptive and inferential statistics were used to analyze the demographic and clinical data. Data were analyzed using Statistical Package for the Social Sciences.

Results: Of the 346 eligible patients, 28% (n = 97) had obtainable data for the estimation of their CVD risk using both tools. Approximately one-third of the cohort (33%) were classified as high risk using the AHA/ACC risk calculator, and 13.3% were classified as intermediate to high risk using the WHO/ISH CVD risk prediction charts. Based on the AHA/ACC risk scores, among those with a high CVD risk, almost two-thirds had CVD modifiable risk factors (i.e., smoking, diabetes, dyslipidemia, and hypertension). No statistically significant difference in the CVD risk estimates was observed among individuals with a body mass index of more or lower than 30 kg/m² (p = 0.815).

Conclusion: Based on the AHA/ACC risk calculator, approximately one-third of the study cohort had high CVD risk estimates. The WHO/ISH CVD risk prediction charts appeared to underestimate CVD risk, particularly for those identified as high risk using the AHA/ACC risk calculator. A closer alliance between psychiatrists and primary healthcare professionals to control modifiable cardiovascular risk factors among patients with SMI is necessary.

Cardiovascular risk assessment for patients with serious mental illnesses: An internal review

Cardiovascular diseases (CVD) are the leading cause of excess premature mortality among patients with serious mental illness (SMI), mainly because of higher cardiovascular risk and metabolic syndrome compared to the general population.^1,2 A pertinent contributing factor is second-generation antipsychotics, which further negatively impact the cardiovascular risk burden, amounting to a significant clinical and public health challenge among patients with SMI.³ Qatar has a high metabolic syndrome prevalence of 26%, and the blood pressure of patients with SMI receiving antipsychotics is significantly higher.⁴ In 2019, the Pharmacy Department of Mental Health Services at Hamad Medical Corporation (HMC) in Doha, Qatar flagged four moderately and one mildly severe cases of adverse drug reaction secondary to antipsychotics. In response to above mentioned incidents, this quality improvement (QI) project was conducted in an acute inpatient male ward from November 2019 to June 2020 in the Psychiatry Hospital of Hamad Medical Corporation to implement a cardiovascular risk assessment for inpatients with SMI. The atherosclerotic cardiovascular disease (ASCVD) risk estimator was used to estimate the 10-year risk of CVD, and inpatients were categorized into low-risk ( < 5%), borderline risk (5%-7.4%), intermediate-risk (7.5%-19.9%), and high risk ( ≥ 20%).⁵ Patients with SMI above 40 years of age were included. Within 72 hours of admission, the admitting inpatient nurse filled a cardiovascular risk assessment (CVRA) questionnaire, including basic demographics, past and present cardiology and smoking history, laboratory test results such as lipid panel, and renal function tests. This study used an in-depth, semi-structured face-to-face interview as a primary data collection technique. An interview guide was developed to address the purpose. At the end of each assessment, the QI nurse approached the participants again to educate them about the cardiovascular risk result accordingly and explained the required referrals (Cardiology and/or Smoking Cessation). The QI team member calculated the cardiovascular risk by utilizing the ASCVD plus application to determine inpatient cardiovascular risk. Out of 26 inpatients with SMI who underwent CVRA, nine (35%) scored moderate to high risk, and were referred to Cardiology for further intervention. Among these nine patients, two (22%) were started on statin therapy, three (33%) started on aspirin, and the remaining four (44%) received lifestyle modifications advice and counseling. Ten (38%) were referred to a smoking cessation clinic for nicotine replacement therapy and counseling. Table 1 shows the clinical characteristics of patients included in this study. Three inpatient consultations to cardiology were rejected, which shows how health professionals underestimate and stigmatize effective interventions for patient with SMI. In case of comorbidities of two diseases, one of them is known overlooked and this is particularly true for mental illness.⁶ A cohort study on medical comorbidities in patients with SMIs in Qatar concluded that an evidence of individuals with SMI is less likely to receive standard levels of care for their medical comorbidities.⁷ Mental health training could help medical health professionals from other specialties improve their understanding on the impact of both psychotropic medications and mental illness in the physical health of people with SMI and address the fear and stigma. Communication improvement between professionals by meaningful discussion of objectives of referral with the patient and contacting the consultant referred to might improve coordination among the referring psychiatrist, physician referred to, and patient.⁸ Patients who scored high on (ASCVD) assessment and are asymptomatic might benefit from referral to primary health care centers for further assessment by a generalist from whom a referral to other specialty like cardiology might be more easily accepted. From the patients' perspective, physical health education, and most importantly, cardiovascular risk assessment are now significantly invested. All patients above 40 years old with SMI will undergo a CVRA. Besides, their assigned nurse will work jointly with allied health professionals to educate them about the importance of healthy lifestyle, including healthy diet and staying fit. Tailor-made recommendations will be established, taking into consideration the cardiovascular risk status and antipsychotic medications. Close participation with the clinical pharmacist and dietician will ensure constant psychoeducation about the metabolic side effects of antipsychotic medications. Physiotherapists will identify barriers, if any, for patients to participate in physical activities offered by the ward. Simultaneously, facilitators will include one-to-one contact with staff and work on increasing awareness of the positive impact of physical activity at the departmental level. Leadership involvement is crucial to ensure joint agreement with different specialties, particularly those based in other HMC facilities, such as cardiology and smoking cessation clinics, to accept referrals when required.

Individuals with Major Depressive Disorder Report High Scores of Insecure-Avoidant and Insecure-Anxious Attachment Styles, Dissociative Identity Symptoms, and Adult Traumatic Events

Objective: Individuals with major depressive disorder (MDD) report more issues in social interaction compared to the general population. Moreover, dimensions of dissociation are considered dysfunctional strategies to cope with adverse life events. In this regard, current symptoms of MDD could be associated with traumatic events that occurred in childhood and in adult life. Given this background, the aim of the present study was to explore the associations between attachment styles as a proxy of quality of social interaction, dimensions of dissociation, and childhood and adult traumatic life events among individuals with MDD. Method: A total of 300 individuals with MDD (mean age: 31.31 years; 58.7% female) took part in this study. They completed a series of questionnaires on sociodemographic information, attachment styles, dimensions of dissociation, and childhood and adult traumatic life events. Results: Prevalence rates for attachment styles were as follows: anxious/ambivalent attachment style—71.7%; avoidant/dependent attachment style—13%; secure/close attachment style—15.3%. Compared to the general population, the participants reported higher prevalence rates of insecure attachment styles. Current symptoms of dissociation were associated with adult but not childhood traumatic life events. An anxious attachment style was associated with higher scores of dissociation. Conclusion: Psychotherapeutic treatment of individuals with MDD should consider the individuals’ challenging attachment styles and their risk of dissociation. While it is important to consider both adult and childhood traumatic events, in this research, more recent trauma occurring in adulthood was associated with current symptoms of dissociation.

Serious mental illness, other mental health disorders, and outpatient health care as predictors of 30-day readmissions following medical hospitalization

OBJECTIVE

Prior research has not addressed whether both serious mental illness (SMI) and other mental health (OMH) disorders affect the likelihood of 30-day readmissions after medical hospitalizations, or whether post-discharge use of outpatient medical, mental health, and pharmacy services is associated with readmission likelihood.

METHODS

Using the Truven Health Analytics MarketScan® Medicaid Multi-State Database, we studied 43,817 Medicaid beneficiaries, age 18-64, following discharge from medical hospitalizations in 2011. Logistic regression models compared all-cause, 30-day readmissions among those with SMI, OMH, and no psychiatric diagnosis, and examined associations of 30-day outpatient service use with 30-day readmissions.

RESULTS

Thirty-day readmission rates were 15.9% (SMI), 13.8% (OMH), and 11.7% (no mental illness). In multivariable analysis, compared to patients without mental illness, odds of readmission were greater for those with SMI (aOR = 1.43, 95%CI:1.32-1.51) and OMH (aOR = 1.21, 95%CI:1.12-1.30), and lower among those using outpatient mental health services (aOR = 0.50, 95%CI: 0.44-0.56).

CONCLUSION

The adult Medicaid population disproportionately includes patients with SMI and OMH disorders, both of which were found to be associated with 30-day hospital readmissions. Receiving outpatient mental health services after hospital discharge may be protective against readmission following medical hospitalizations, suggesting the need for further research on these topics.

COVID-19 Vaccination: crucial roles and opportunities for the mental health professionals

Besides addressing the increased prevalence of psychiatric disorders, social challenges, and building community resilience during the crisis, mental health professionals (MHPs) are in a unique position to assist the vaccination drive against coronavirus disease-2019 (COVID-19) in various nations. Vaccination programs are adversely affected by misinformation, fake news and vaccine hesitancy fuelled by social media. MHPs can enable this vital public health strategy by prioritizing vaccination for individuals with severe mental illness (SMI) and substance use disorders, promote awareness and public education, debunk misinformation and integrate psychosocial care into the vaccination drives. In order to target the health inequity and discrimination faced by people with SMI coupled with their additional risks, the authors urge the global mental health fraternity to tailor these crucial roles with respect to COVID-19 vaccination based on the regional needs and contexts.

Prevalence and correlates of diagnosed and undiagnosed epilepsy and migraine headache among people with severe psychiatric disorders in Ethiopia

BACKGROUND

There is a paucity of research on the prevalence of diagnosed as well as undiagnosed neurological disorders with episodic manifestations such as epilepsy and migraine headaches in people with severe psychiatric disorders (SPD). To the best of our knowledge, this is the first study analyzing and comparing the prevalence of diagnosed and undiagnosed chronic neurological disorders with episodic manifestations including epilepsy and migraine headache in people with SPD.

METHOD

This quantitative cross-sectional survey was undertaken among 309 patients with SPD selected by a systematic random sampling technique. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was used to confirm SPD among the participants. The International Classification of Headache Disorders (ICHD-3) and International League Against Epilepsy (ILAE) were used to define migraine headache and epilepsy, respectively]. Risk factors for chronic neurologic disorders were explored by using logistic regression models.

RESULT

In this study, the prevalence of overall neurological disorders, epilepsy, and migraine headache among people with SPD were found to be 5.2% (95%CI 3.2-8.3), 1.6% (95%CI 0.7-3.9), and 3.9% (95%CI 2.2-6.7), respectively. We found that a considerably higher proportion of people with SPD had undiagnosed overall neurological disorder (87.5%; 14/16), epilepsy (60%; 3/5), as well as migraine headaches (100%; 12/12). On the other hand, in this study, 12.5%, 40%, and 0% of patients with overall neurologic disorder, epilepsy, and migraine headaches respectively were diagnosed by the professionals. Higher disability score (WHODAS score) was associated with increased odds of having neurological disorders compared with the lower WHODAS score [OR = 1.30 (95% CI 1.02-1.66)].

CONCLUSION

Whilst the prevalence estimates of neurological disorders with episodic manifestations including epilepsy and migraine headache was high among people with SPD, the vast majority of them remained undiagnosed. The diagnosis rates of those disorders were significantly low, perhaps surprisingly zero for migraine headache. High WHODAS score was associated with increased odds of having neurological disorders. Routine screening and management of epilepsy and migraine headache are imperative among people with SPD.

Acute Myocardial Infarction in Severe Mental Illness: Prevalence, Clinical Outcomes, and Process of Care in U.S. Hospitalizations

BACKGROUND

Severe mental illness (SMI) is associated with increased cardiovascular mortality. We sought to examine the prevalence, clinical outcomes, and management strategy of patients with SMI presenting with acute myocardial infarction (AMI).

METHODS

All AMI hospitalizations from the National Inpatient Sample were included, stratified by mental health status into 5 groups: no SMI, schizophrenia, other non-organic psychoses (ONOP), bipolar disorder, and major depression. Regression analyses were performed to assess the association (adjusted odds ratios [ORs], P ≤ 0.001 for all outcomes) between SMI subtypes and clinical outcomes.

RESULTS

Of 6,968,777 AMI hospitalizations between 2004 and 2014, 439,544 patients (6.5%) had an SMI diagnosis. Although patients with schizophrenia and ONOP experienced higher crude rates of in-hospital mortality and stroke compared with those without SMI, only schizophrenic patients were at increased odds of mortality (OR, 1.10; 95% confidence interval [CI], 1.04-1.16), whereas ONOP was the only group at increased odds of stroke (OR, 1.53; 95% CI, 1.42-1.65) after multivariate adjustment. Patients with ONOP were the only group associated with increased odds of in-hospital bleeding compared with those without SMI (OR, 1.11; 95% CI, 1.04-1.17). All those with SMI subtypes were less likely to receive coronary angiography and percutaneous coronary intervention, with the schizophrenia group being at least odds of either procedure (OR, 0.46; 95% CI, 0.45-0.48 and OR, 0.57; 95% CI, 0.55-0.59, respectively).

CONCLUSION

Schizophrenia and ONOP are the only SMI subtypes associated with adverse clinical outcomes after AMI. However, all patients with SMI were less likely to receive invasive management for AMI, with female gender and schizophrenia diagnosis being the strongest predictors of conservative management. A multidisciplinary approach between psychiatrists and cardiologists could improve the outcomes of this high-risk population.