Morbidity and Mortality in people labeled with

1
Morbidity and Mortality in people labeled with
serious mental illness

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

2
Why Should we be Concerned About Morbidity and
Mortality?

• Recent data from several states have found that
  people with serious mental illness served by our
  public mental health systems die, on average, at
  least 25 years earlier that the general
  population.

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

• Compared to the general population, persons with
  major mental illness typically lose more than 25
  years of normal life span

• Colton CW, Manderscheid RW. Prev Chronic Dis
  serial online 2006 Apr date cited. Available
  from URLhttp//www.cdc.gov/pcd/issues/2006/apr/0
  5_0180.htm

4
Overview- THE PROBLEM

• Increased Morbidity and Mortality Associated with
  Serious Mental Illness (SMI)
• Increased Morbidity and Mortality Largely Due to
  Preventable Medical Conditions
• Metabolic Disorders, Cardiovascular Disease,
  Diabetes Mellitus
• High Prevalence of Modifiable Risk Factors
  (Obesity, Smoking)
• Epidemics within Epidemics (e.g., Diabetes,
  Obesity)
• Some Psychiatric Medications Contribute to Risk
• Established Monitoring and Treatment Guidelines
  to Lower Risk Are Underutilized in SMI Populations

5
Overview - PROPOSED SOLUTIONS

• Prioritize the Public Health Problem
• Target Providers, Families and Clients
• Focus on Prevention and Wellness
• Track Morbidity and Mortality in Public Mental
  Health Populations
• Implement Established Standards of Care
• Prevention, Screening and Treatment
• Improve Access to and Integration of Physical
  Health and Mental Health Care

6
Other solutions needed, that NASMHPD didnt
propose

• Seek wherever possible to use mental health
  treatments that do not shorten lives
• In other words, vastly reduce reliance on
  anti-psychotic medications
• Reform the way medical research is done
  information is distributed
• Prevention reduce trauma!

7
What are Adverse Childhood Experiences (ACEs)?

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

8
Number of Adverse Childhood Events resulted in
increases in

• Risk factors for disease, like smoking and
  obesity
• Actual diseases, such as heart disease, diabetes,
  others
• Substance abuse
• A wide variety of mental health problems,
  including depression and psychosis

9
(No Transcript)
10
Adoption of health-risk behaviors can include
not just behaviors independently adopted by
individuals, but also behaviors that are promoted
by mental health professionals, such as reliance
on neuroleptic medications.
11
Understanding parallel process

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

12
What are the Causes of Morbidity and Mortality in
People with Serious Mental Illness?

• While suicide and injury account for about 30-40
  of excess mortality, about 60 of premature
  deaths in persons with schizophrenia are due to
  natural causes
• Cardiovascular disease
• Diabetes
• Respiratory diseases
• Infectious diseases

13
Increased Mortality From Medical Causes in Mental
Illness

• Increased risk of death from medical causes in
  schizophrenia and 20 (10-15 yrs) shorter
  lifespan1
• Bipolar and unipolar affective disorders also
  associated with higher SMRs from medical causes2
• 1.9 males/2.1 females in bipolar disorder
• 1.5 males/1.6 females in unipolar disorder
• Cardiovascular mortality in schizophrenia
  increased from 1976-1995, with greatest increase
  in SMRs in men from 1991-19953

• SMR standardized mortality ratio
  (observed/expected deaths).
• Harris et al. Br J Psychiatry. 199817311.
  Newman SC, Bland RC. Can J Psych.
  199136239-245.
• 2. Osby et al. Arch Gen Psychiatry.
  200158844-850.
• 3. Osby et al. BMJ. 2000321483-484.

14
What portion of the risk of early death results
from the medications?

• One recent 17 year study of people with
  schizophrenia found the following death rates
  depending on the number of neuroleptic
  (antipsychotic) drugs taken
• Those on one drug 35
• Those on two drugs 44
• Those on 3 drugs 57
• Those on 0 drugs 20
• BRITISH JOURNAL OF P SYCHIATRY (2006), 188,
  122127
• Schizophrenia, neuroleptic medication and
  mortality
• MATTI JOUKAMAA, MARKKU HELIOVAARA, PAUL KNEKT,
• HELIO VAARA, ARPO AROMAA, RAIMO RAITASALO and
  VILLE LEHTINEN

15
Even Suicide Risk is Linked with Modern Treatment

• A major study showed that people diagnosed with
  schizophrenia are 20 times more likely to commit
  suicide in the modern era, than they were 100
  years ago
• The studys authors suggested
• One cause was more people spending more time
  outside hospitals
• The other cause was side effects of
  anti-psychotics, which can increase risk of
  suicide
• Study title Lifetime suicide rates in treated
  schizophrenia 18751924 and 19941998 cohorts
  compared

16
Schizophrenia Natural Causes of Death

• Higher standardized mortality rates than the
  general population from
• Diabetes 2.7x
• Cardiovascular disease 2.3x
• Respiratory disease 3.2x
• Infectious diseases 3.4x
• Cardiovascular disease associated with the
  largest number of deaths
• 2.3 X the largest cause of death in the general
  population

Osby U et al. Schizophr Res. 20004521-28.
17
Cardiovascular risk factors overview
The Framingham Study
BMI body mass index TC total cholesterol DM
diabetes mellitus HTN hypertension. Wilson
PWF et al. Circulation. 19989718371847.
18
Cardiovascular Disease (CVD) Risk Factors
Modifiable Risk Factors Estimated Prevalence and Relative Risk (RR) Estimated Prevalence and Relative Risk (RR) Estimated Prevalence and Relative Risk (RR) Estimated Prevalence and Relative Risk (RR)
Modifiable Risk Factors Schizophrenia Schizophrenia Bipolar Disorder Bipolar Disorder
Obesity 4555, 1.5-2X RR1 265
Smoking 5080, 2-3X RR2 556
Diabetes 1014, 2X RR3 107
Hypertension 184 155
Dyslipidemia Up to 5X RR8
1. Davidson S, et al. Aust N Z J Psychiatry.
200135196-202. 2. Allison DB, et al. J Clin
Psychiatry. 1999 60215-220. 3. Dixon L, et al.
J Nerv Ment Dis. 1999187496-502. 4. Herran A,
et al. Schizophr Res. 200041373-381. 5. MeElroy
SL, et al. J Clin Psychiatry. 200263207-213. 6.
Ucok A, et al. Psychiatry Clin Neurosci.
200458434-437. 7. Cassidy F, et al. Am J
Psychiatry. 19991561417-1420. 8. Allebeck.
Schizophr Bull. 199915(1)81-89.
19
BMI Distributions for General Population and
Those With Schizophrenia (1989)
30
Under-weight
Obese
Overweight
Acceptable
20
Percent
10
0
lt 18.5
18.5-20
20-22
22-24
24-26
26-28
28-30
30-32
32-34
gt 34
BMI Range
No schizophrenia Schizophrenia
Allison DB et al. J Clin Psychiatry.
199960215-220.
20
Mental Disorders and Smoking

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

George TP et al. Nicotine and tobacco use in
schizophrenia. In Meyer JM, Nasrallah HA, eds.
Medical Illness and Schizophrenia. American
Psychiatric Publishing, Inc. 2003 Ziedonis D,
Williams JM, Smelson D. Am J Med Sci.
2003(Oct)326(4)223-330
21
Increased smoking is also linked with at least
some anti-psychotic medications

• Older anti-psychotics are definitely associated
  with increased urge to smoke
• Evidence is mixed with newer atypical
  anti-psychotics

22
In 2001, it was estimated that people diagnosed
mentally ill were smoking 43 of all cigarettes
consumed in the US.The percentage has probably
gone up since then.
23
Hypothesized Reasons Why There May Be More Type 2
Diabetes in People With Schizophrenia

• Genetic link between schizophrenia and diabetes
• Impact of lifestyle
• Medication effect increasing insulin resistance
  by impacting insulin receptor or postreceptor
  function
• Drug effect on caloric intake or expenditure
  (obesity, activity)

24
How Does This Relate to What is Happening in the
General Population?

• There is an epidemic of obesity and diabetes,
  increasing risk of multiple medical conditions
  and cardiovascular disease.
• Obesity
• Diabetes
• Metabolic Syndrome
• Cardiovascular Disease

25
Diabetes and Obesity The Continuing Epidemic
Diabetes
Mean body weight
kg
Prevalence ()
Year
Mokdad et al. Diabetes Care. 2000231278. Mokdad
et al. JAMA. 19992821519. Mokdad et al. JAMA.
20012861195.
26
Diabetes and Gestational Diabetes Trends US
Adults, BRFSS 1990
Mokdad et al. Diabetes Care. 2000231278-1283.
27
Diabetes and Gestational Diabetes Trends US
Adults, BRFSS 1995
Mokdad et al. Diabetes Care. 2000231278-1283.
28
Diabetes and Gestational Diabetes Trends US
Adults, BRFSS 1999

Mokdad et al. Diabetes Care. 200124412.
29
Diabetes and Gestational Diabetes Trends US
Adults, BRFSS 2000
Mokdad et al. JAMA. 2001286(10).
30
Diabetes and Gestational Diabetes Trends US
Adults, Estimate for 2010

No Data Less than 4 4 to 6
Above 6 Above 10
www.diabetes.org.
31
Diabetes is a CVD Risk Equivalent to Previous
Myocardial Infarction
45.0
Equivalent MI Risk Levels
Fatal or nonfatal MI ()
20.2
18.6
3.5
No Prior MI Prior MI No Prior MI Prior MI
Nondiabetic Subjects Type 2 Diabetic Subjects
(n 1373) (n 1059)
Haffner SM et al. N Engl J Med. 1998339229-234.
32
Identification of the Metabolic Syndrome
3 Risk Factors Required for Diagnosis 3 Risk Factors Required for Diagnosis
Risk Factor Defining Level
Abdominal obesity Men Women Waist circumference gt40 in (gt102 cm) gt35 in (gt88 cm)
Triglycerides ?150 mg/dL (1.69mmol/L)
HDL cholesterol Men Women lt40 mg/dL (1.03mmol/L) lt50 mg/dL (1.29mmol/L)
Blood pressure ?130/85 mm Hg
Fasting blood glucose ?110 mg/dL (6.1mmol/L)
HDL high-density lipoprotein. NCEP III.
Circulation. 20021063143-3421.
33
CHD Risk Increases with Increasing Number of
Metabolic Syndrome Risk Factors
Sattar et al, Circulation, 2003108414-419 Whyte
et al, American Diabetes Association,
2001 Adapted from Ridker, Circulation
2003107393-397
34
Modifiable Risk Factors Affected by Psychotropics

• Overweight / Obesity
• Insulin resistance
• Diabetes/hyperglycaemia
• Dyslipidemia

Newcomer JW. CNS Drugs 200519(Supp 1)1.93.
35
1-Year Weight Gain Mean Change From Baseline
Weight
14
30
12
25
10
20
Change From Baseline Weight (kg)
8
15
Change From Baseline Weight (lb)
6
10
4
5
2
0
0
52
48
44
40
36
32
28
24
20
16
12
8
4
0
0
Weeks
Nemeroff CB. J Clin Psychiatry. 199758(suppl
10)45-49 Kinon BJ et al. J Clin Psychiatry.
20016292-100 Brecher M et al. American College
of Neuropsychopharmacology 2004. Poster 114
Brecher M et al. Neuropsychopharmacology.
200429(suppl 1)S109 Geodon package insert.
New York, NYPfizer Inc 2005. Risperdal
package insert. Titusville, NJ Janssen
Pharmaceutica Products, LP 2003 Abilify
package insert. Princeton NJ Bristol-Myers
Squibb Company and Rockville, Md Otsuka America
Pharmaceutical, Inc. 2005.
36
CATIE Trial Results Weight Gain Per Month
Treatment
Weight gain (lb) per month
OLZ
RIS
PER
QUET
ZIP
NEJM 2005 3531209-1223
37
Change in Weight From Baseline 58 Weeks After
Switch to Low Weight Gain Agent
58
27
19
49
53
45
40
36
32
23
14
10
6
5
0


-5
LS Mean Change (lb)

-10


-15
Plt0.05 Plt0.01 Plt0.0001
-20

-25
Switched from
Conventionals
Risperidone
Olanzapine
Weiden P et al. Presented APA 2004.
38
CATIE Results Metabolic Changes From Baseline
40.5
Cholesterol (mg/dL) Triglycerides (mg/dL)
21.2
9.4
9.2
6.6
1.3
-1.3
-2.4
-8.2
-16.5
PER
OLZ
RIS
QUET
ZIP
NEJM 2005 3531209-1223
39
CATIE Results Metabolic Changes From Baseline
13.7
Glucose (mg/dL) Glycosylated HB ()
7.5
6.6
5.4
2.9
0.4
0.11
0.0
0.07
0.04
PER
OLZ
RIS
QUET
ZIP
NEJM 2005 3531209-1223
40
American Diabetes Association, American
Psychiatric Association, American Association of
Clinical Endocrinologists, North American
Association for the Study of Obesity Consensus
Conference on Antipsychotic Drugs and Risk of
Obesity and Diabetes
Drug Weight Gain Diabetes Risk Dyslipidemia
clozapine
olanzapine
risperidone D D
quetiapine D D
aripiprazole /- - -
ziprasidone /- - -
increased effect - no effect D
discrepant results.
Diabetes Care 27596-601, 2004
41
ADA/APA/AACE/NAASO Consensus on Antipsychotic
Drugs and Obesity and Diabetes Monitoring
Protocol
Start 4 wks 8 wks 12 wk qtrly 12 mos. 5 yrs.
Personal/family Hx X X
Weight (BMI) X X X X X
Waist circumference X X
Blood pressure X X X
Fasting glucose X X X
Fasting lipid profile X X X
X

• More frequent assessments may be warranted based
  on clinical status

Diabetes Care. 27596-601, 2004
42
Problem SMI and Reduced Use of Medical Services

• Fewer routine preventive services (Druss 2002)
• Worse diabetes care (Desai 2002, Frayne 2006)
• Lower rates of cardiovascular procedures (Druss
  2000)

43
Access and Quality of Care

• SMI may be a health risk factor because of
• Patient factors, e.g. amotivation, fearfulness,
  homelessness, victimization/trauma, resources,
  advocacy, unemployment, incarceration, social
  instability, IV drug use, etc
• Provider factors Comfort level and attitude of
  healthcare providers, coordination between mental
  health and general health care, stigma,
• System factors Funding, fragmentation

44
Anti-psychotics may cause people to delay seeking
treatment for physical illness until its too late

• One of the first noted effects of anti-psychotic
  medications was to reduce responsiveness to
  aversive stimuli
• For example, rats given these drugs would quit
  taking action to avoid electric shock
• People may just tolerate things going wrong with
  their body, delaying treatment.

45
Goals Lower Risk for CVD

• Blood cholesterol
• 10 ? 30 ? in CHD (200-180)
• High blood pressure (gt 140 SBP or 90 DBP)
• 4-6 mm Hg ? 16 ? in CHD 42 ? in stroke
• Cigarette smoking cessation
• 50-70 ? in CHD
• Maintenance of ideal body weight (BMI 25)
• 35-55 ? in CHD
• Maintenance of active lifestyle (20-min walk
  daily)
• 35-55 ? in CHD

Hennekens CH. Circulation. 1998971095-1102.
46
Survival Following MyocardialInfarction

• 88,241 Medicare patients, 65 years of age and
  older, hospitalized for MI
• Mortality increased by
• 19 any mental disorder
• 34 schizophrenia
• Increased mortality explained by measures of
  quality of care

Druss BG et al. Arch Gen Psychiatry.
200158565-572.
47
Other treatment-induced morbidity

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

48
Anti-psychotics and brain damage

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

49
Overview - PROPOSED SOLUTIONS

• Prioritize the Public Health Problem
• Target Providers, Families and Clients
• Focus on Prevention and Wellness
• Track Morbidity and Mortality in Public Mental
  Health Populations
• Implement Established Standards of Care
• Prevention, Screening and Treatment
• Improve Access to and Integration of Physical
  Health and Mental Health Care

50
Recommendations LOCAL AGENCY / CLINICIAN

• BH providers shall provide quality medical care
  and mental health care
• Screen for general health with priority for high
  risk conditions
• Offer prevention and intervention especially for
  modifiable risk factors (obesity, abnormal
  glucose and lipid levels, high blood pressure,
  smoking, alcohol and drug use, etc.)
• Prescribers will screen, monitor and intervene
  for medication risk factors related to treatment
  of SMI (e.g. risk of metabolic syndrome with use
  of second generation anti-psychotics)
• Treatment per practice guidelines, e.g heart
  disease, diabetes, smoking cessation, use of
  novel anti-psychotics.

51
LOCAL AGENCY / CLINICIAN Recommendations

• 2. Care coordination Models
• Assure that there is a specific practitioner in
  the MH system who is identified as the
  responsible party for each persons medical
  health care needs being addressed and who assures
  coordination all services.
• Routine sharing of clinical information with
  other providers (primary and specialty healthcare
  providers as well as mental health providers
• Care integration where services are co-located

52
LOCAL AGENCY / CLINICIAN RECOMMENDATIONS

• 3. Support consumer wellness and empowerment
  to improve personal mental and physical
  well-being
• educate / share information to make healthy
  choices regarding nutrition, tobacco use,
  exercise, implications of psychotropic drugs
• teach /support wellness self-management skills
• teach /support decision making skills
• motivational interviewing techniques
• Implement a physical health Wellness approach
  that is consistent with Recovery principles,
  including supports for smoking cessation, good
  nutrition, physical activity and healthy weight.
• attend to cultural and language needs

53
Full NASMHPD report available at

• http//www.nasmhpd.org/publications.cfmtechpap
• Note you can access both the slideshow and a pdf
  file that has a written report, at this website.
  

54
Eliminating unnecessary treatment induced harm

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

55
How to reduce reliance on harmful medications

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

56
Parallel process reduce reliance on drug money
misinformation

• Most psychiatric research and continuing
  education is financed by drug companies
• Drug companies withhold information that hurts
  their profits
• Even when this threatens the lives of thousands
  of people
• Case example Eli Lilly Zyprexa

57
Awareness may be going up, but.

• Use of psychiatric medications, in particular
  anti-psychotics, continues to escalate
• Reaching way beyond those diagnosed with
  psychosis
• Reaching a younger and younger population
• In a few states where data is known, cases of
  infants (lt 12 months old) on anti-psychotics have
  been found

58
Finally

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