This is a lecture from the friday Open Meeting series, Leicester Partnership Trust, Leicester. Delivered jan15, 2010.

1. Quality Of Medical Care for Patients With
Mental Illness -
Do Our Patients Get A Raw Deal?
Alex Mitchell
Oliver Lord
Acknowledgements
Darren Malone
Caroline Carney-Doebbling
Nasser Abdelmawla
Brett Thombs
Roy Ziegelstein Open meeting Jan 2010
Open meeting Jan 2010

2. Contents
1. Mental Health & Physical Health
Comorbidity & Mortality
2. Preventive Health Care Inequality
Screening & prevention
3. Medical Health Care Inequality
Procedures & prescribing
4. Implications for mortality
Linking poor quality of care with mortality
5. Who is Monitoring?
Guidelines & responsibility
6. Can inequalities be Improved?
Interventions

3. 1. Physical Health Comorbidity / Mortality

4. Comorbid Physical Diagnoses in Elderly Depressed
Patients
80
70
60
50
40
30
20
10
0
One Tw o Three+ None
Proctor EK, et al (2003) American Journal of Geriatric Psychiatry;11:329-
38.

5. 40
P hysical C omorbidity in S chiz ophrenia and D epression
35
30
Schizophrenia
Depression
25
NHANES
20
15
10 Sokal 2004
J Nerv Ment Dis 192:
421– 427
5
0
Angina
Ulcer
Heart condition
Any cancer
Asthma
Diabetes
Chronic bronchitis
Stroke
Emphysema
Myocardial infarction
Hypertension
Rheumatoid arthritis
Osteoarthritis
Coronary heart
Weak/failing kidneys
Congestive heart
Liver problems
disease
failure
NHANES - US Department of Health National Health and Nutrition Examination Survey , 1988 –1994

6. Maine Study Results:
Comparison of Health Disorders Between SMI & Non-SMI Groups
of Health Disorders Between
80
SMI (N=9224)
70
59.4 Non-SMI (N=7352)
60
P e rc e n t M e m b e rs
50
40 33.9
30 28.6 28.4
30 22.8 21.7
20 16.5
11.5 11.1
10 6.3 5.9
0
Sk Ga Ob CO In Hy De D C He Pn L iv
el e st r es P D f ect pe nt a iab e an c ar t eu e
tal o-I it y iou rt e lD tes er D is mo r Di
-C nte /D y s D nsi o iso ea n se
on
ne sti sl i
pid ise n rd e se ia/ In f ase
cti nal ase rs l ue
nz
ve a
Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited]. Available from:
from:
URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm

7. Lawrence & Coghlan N S W Public Health Bull 2002; 13(7): 155–158 n=240,000

8. Mortality and Depression - IHD
Psychosomatic Med (2004) Barth et al

9. Schizophrenia – all cause mortality
>
>
>
>
Saha (2007) AGP
Pooled estimate=2.50
(95% CI=2.18-2.83)

10. Five-year Mortality rates
30 People with schizophrenia 28%
People without schizophrenia
25
22%
20 19%
15
12%
10 9%
8%
5
0
CHD Diabetes Stroke
Hippisley-Cox J et al (2006) A comparison of survival rates for people with mental health
problems and the remaining population with specific conditions.
Disability Rights Commission. Equal treatment: closing the gap, July 2006
Slide credit: Dr Alan Farmer, Worcestershire Mental Health Partnership NHS Trust

11. Mortality & Mental illness: Caveat
Has the mortality gap been reducing?
Has modern medication improved the situation?

12. Mortality Trends

13. Mortality Trends

14. Effect of Medication
Varies according to
Schizophrenia
Dementia
Depression

18. Smoller et al (2010) Ann Int Med
SSRI associated with increased all-cause mortality
HR 1.32 95% CI, 1.10-1.59
SSRI associated with increased stroke
HR 1.45, 95% CI, 1.08-1.97
TCA associated with increased risk of all-cause mortality
HR,1.67 [95% CI, 1.33-2.09

19. Mental Illness => High Medical Morbidity & Mortality
Therefore do we?
i Improve preventive screening
ii Enhance quality of routine medical care
iii Ensure adequate physical health medication
iv Help with treatment adherence (NICE)
v Monitor physical health issues

20. 2. Preventive Health Care Inequality

21. Screening activities
Mammography => use as an example (over)
Pap. Smear
Vaccinations
Lifestyle counselling
Blood pressure
Bowel cancer screening
Breast examination
PSA
Osteoporosis
Hepatitis & HIV

22. Mammography
USPSTF recommendations
Screening mammography with or without clinical breast exam (CBE) every
1-2 years starting at age 40
Insufficient evidence for or against CBE alone
UK NSC (England)
Age 50-70 every 3 years

23. Mammography and Depression
Over 40 years
Druss (2008)US n= OR of not having mammogram
OR 1.22 (95% CI 1.18-1.26).
This difference was even greater if the depression was untreated
adj.OR 1.32 ( 1.22- 1.42).
Those being treated in secondary care were more likely to have not had
a mammogram than those treated in primary care
adjusted OR 1.22(95% CI 1.03-1.44).
Pirraglia (2004) US n=3302
Those who screened positive for depression were less likely to have a
mammogram in the subsequent year adj. OR 0.84 (95% CI 0.73-0.97).
Stecker et trend to increased use in Depression vs Hypertensive controls
Green and Pope, US 2000, n=589
showed increased rates of mammography
Over 65 year olds
2 US studies showing no difference n=3864
Over 50 year olds
Canadian study showed no difference, n =1,868
European study showed no difference, n = 15,380

24. Mammography and any mental disorder
Werenke (2006) UK n= 533,340
no difference for mental health service users
but those on enhanced care were less likely to attend (OR 0.4 95% CI 0.29-
0.55).
more than 2 admissions to a mental health hospital were less likely to attend
for mammography
(OR 0.65, 95% CI, 0.49-0.85).
Carney and Jones (2006) US n= 191356,
5 year study period:
high risk OR 0.38 (95% CI 0.33-0.43),
moderate risk 0.62 (95% CI 0.59-0.66).
last 2 years:
low risk 0.95(95% CI 0.92-.99),
moderate risk OR 0.71 (95% CI 0.66-0.75),
high risk OR 0.63 (95% CI 0.53-0.75).
Lasser (2003) US n=526 no difference for mammography in last 2 years
Steiner (1998) US n=64 no difference
Iezzoni (2001) US n=11399 a trend to reduced use of mammography (SMI)
in the last 2 yrs OR 0.6 (95% CI 0.4 – 1.1)

25. Mammography and Schizophrenia
Chochinov (2009) Canada n=110,240
In comparison to the general population (without schizophrenia)
(n=108,792), women with schizophrenia (n=1448)
OR 0.64 of mammography in the selected two year period.
Carney and Jones (2006) n=191,356
No difference over five years
less likely in the last two years
OR 0.31 (95% CI 0.12-0.83).
Werenke (2006) UK n= 533,340
Those with a diagnosis of psychosis were the least likely to attend for
mammography
OR 0.33 (95% CI 0.18-0.61)
Lindamer (2003) US n=116
(Convenience sample) in last 2 years
68% of women with psychotic disorder
98% of respondents to advertisement
Druss (2002) US
less likely to have had a mammogram in last 2 years (for women aged 50-69
years) adjusted
OR 0.78(95% CI 0.67-0.91).

26. 3. Medical Health Care Inequality
Medical monitoring eg HBA1c
Medical procedures eg CABG
Medical prescribing eg Insulin

27. Quality of Care MI vs No MI
27 examined receipt of medical care in
those with and without mental illness
19/27 showed deficits in care
10 examined medical care in those with
and without substance use disorder
(or dual-diagnosis
10/10 showed deficits in care

28. Relevant Primary Data Studies
26 studies
1 study 2 studies 10 studies 9 studies 4 studies
Studies examining Cancer Studies examining Studies examining Studies examining Studies examining
Care HIV Care Diabetes Care Cardiovascular care General Medical Care
Goodwin JS et al. 2004 Palepu A et al. 2006. J Sub Abuse Desai M et al. 2002 Druss B et al 2000. Redelmeier D et al. 1998 N Eng J
JAGS 52; 106-111. Treat. In Press * Am J Psych. 159;1584-90 * JAMA 283; 506-511 * Med. 338; 1516-1520
Bogart et al 2006 AIDS Patient Lin EH et al. 2004 Diabetes Care Young J et al 2000. Desai M et al. 2002 J Gen Intern
Care & STDs 20(3) 175-182 27(9):2154-60. JAMA 28, 3198-9 * Med.17; 556-560 *
Dixon L 2004. Psychiatric Druss BD et al. 2001. Arch Gen Cradock-O’Leary,et al 2002.
services. 55;892-900 ª psych. 58; 565-572 * Psychia Serv 53;874-8 *
Jones L et al. 2004. Medical Desai MM, et a; 2002. Dickerson F et al 2003
care.42;1167-1175 JNMD 190(1), 51-53 * Psychiatric Serv 41; 560-570.
Frayne S et al. 2006.Arch Int Lawrence D et al 2003.
med. 165;2631-2638 Br J Psych 182;31-36.
Krein et al 2006 Psychia Serv Petersen LA et al 2003
57:1016–1021 Health Serv Res 38; 41-63.
Sullivan et al. 2006 Psychiatr Jones L et al. 2005. Psychosom
Serv 57:1126–1131 Med 67; 568-76.
Weiss AP. et al 2006 Wang P et al. 2005.
* Studies reporting substance Psychiatr Serv 57(8):1145-1152 Hypertension. 46; 273-279
abuse and/or mental illness
Kreyenbuhl J et al 2006 Hippisley-Cox et al. 2007 Heart
JNMD 194:404–410 ª 93:1256–1262
a Studies reporting on the same
data set
Goldberg RW et al. 2007
Psychiatr Serv 58:536–543 ª

29. Quality of Medical Treatment i Procedures

31. Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction
Any Mental illness
HR = 0.86 (0.80-0.92)

32. Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction
Schizophrenia
HR = 0.53 (0.44 – 0.64)

33. Quality of Medical Treatment i Medication

34. Inequality of Prescribed Meds ii Medication by Diagnosis
OR =0.92 OR =0.68 OR =0.72
SMI Schz Affective

35. Inequality of Prescribed Meds ii Medication by Drug
OR =0.99
OR =0.79
ns
OR =0.83 OR =0.84
ns

36. Quality of Medical Treatment ii Medication by Drug
OR =0.94 OR =0.96
ns

37. 4. Implication for Mortality

40. 5. Who Is Monitoring Physical Issues?
Medical Colleagues
Mental health
Primary care

41. Disparities in care: impact of mental illness on diabetes
management
Depression
Anxiety
Psychosis
Mania
Substance
use disorder
Personality
disorder
0.8 1.0 1.2 1.4 1.6 0.8 1.0 1.2 1.4 1.6 0.8 1.0 1.2 1.4 1.6 0.8 1.0 1.2 1.4 1.6 0.8 1.0 1.2 1.4 1.6 0.8 1.0 1.2 1.4 1.6
No HbA test No LDL test No Eye No Poor Poor
Odds ratio for: done done examination Monitoring glycemic lipemic
done control control
313,586 Veteran Health Authority patients with diabetes
76,799 (25%) had mental health conditions (1999)
Frayne et al. Arch Intern Med. 2005;165:2631-2638

42. Monitoring patients DURING treatment with an atypical
Buckley PF et al Schizophrenia Research 79 (2005) 281– 288

43. Frequency of baseline assessment PRIOR to
initiating treatment with an atypical
Buckley PF et al Schizophrenia Research 79 (2005) 281– 288

44. Summary of Monitoring Protocol
Base
4 wk 8 wk 12 wk Quart Ann 5 yr
line
Personal/fam. Hist. X X
Weight (BMI) X X X X X
Waist circum. X X
Blood press. X X X
Fasting plasma
glucose
X X X
Fasting lipid profile X X X
American Diabetes Association and the American Psychiatric Association (ADA/ APA/AACE/NAASO, 2004).

45. Annual physical health checks
(NSF for mental health/NICE guidance)
Blood pressure & weight/BMI
Lifestyle advice (smoking/diet/exercise/alcohol/drugs)
Urine/blood test to exclude diabetes
Cholesterol check
Medication side effect monitoring
(Include thyroid function & creatinine if on lithium)
Encourage screening in appropriate groups (cervical
smears/mammography/hepatitis/HIV/high prolactin)
Offer flu vaccination and contraceptive advice

46. N=6000 pre-guideline
N=18,000 post guideline

47. Screening for metabolic side effects in AO clients
Review of 1966 case records from 53 teams, Barnes et al (2007)
% with recorded Documented Documented
measurement over diagnosis treatment
last 12 months
Blood pressure 26% Hypertension 6% 48%
Measure of 17%
obesity
Blood glucose 28% Diabetes 6% 62%
Plasma lipids 22% Dyslipidaemia 37%
6%
All of the above 11%
Slide credit: Dr Alan Farmer, Worcestershire Mental Health Partnership NHS Trust

48. Physical Screening of Psychiatric Patients
57.6% of inpatients receive a comprehensive physical examination
(Hodgson R, Adeyemo O. Physical examination performed by psychiatrists. International Journal of Psychiatry in Clinical
Practice 2004;8:57-60.)
No dental health target achieved in 428 people with Schizophrenia
McCreadie RG, et al The dental health of people with schizophrenia. Acta Psychiatrica Scandinavica 2004;110:306-10)
On screening at admission: 34% of older people had unrecognized
medical disorders (Woo BKR, et al. Unrecognized medical disorders in older psychiatric inpatients in a senior
behavioral health unit in a university hospital. Journal of Geriatric Psychiatry and Neurology 2003;16:121-5)
On screening at admission: 29% had physical disorder (80%
previously known 20% new diagnoses). These were contributory
to diagnosis in 5.5% (Koran LM, et al Medical disorders among patients admitted to a public-sector
psychiatric inpatient unit. Psychiatric Services 2002;53:1623-5.

49. 6. Can inequalities be Improved?

50. NICE Schizophrenia guidelines
“The higher physical morbidity and mortality of service
users with schizophrenia should be considered in all
assessments.
“Whilst this would normally be expected to be the role
of primary care services, secondary care services
should nevertheless monitor these matters where
they believe a service user may have little regular
contact with primary care.”
NICE 2002

52. Longitudinal f/u and monitoring Pr Pr Pr Pr Pr/Ps Pr/B/Ps Pr/Ps Pr/B/Ps B2/Ps Ps/B2
Extended B/P/S interventions B1 B1 B B B B B2 B2 B2 B2
2nd level or higher meds Pr Ps Ps Ps Ps Ps Ps Ps Ps Ps
Brief B/P/S interventions Pr/B1 Pr/B1 Pr/B1 Pr/B1 B1/Pr B/Pr B/Ps B/Ps B/Ps B/Ps
Initial Medications Pr Pr Pr Pr/Ps Pr/Ps Ps/Pr Ps Ps/Pr Ps Ps
Interventions
Diagnosis/Comprehensive Pr Pr Pr Pr/B1 B1/Pr B1//Pr B/Ps B/Ps B/Ps Ps
P/S assessment
Counseling/Psychoeducation Pr Pr Pr Pr/B1 B1//Pr B1/Pr B/Ps B B B
Recognition/Limited P/S assessment Pr Pr Pr Pr Pr Pr Pr Pr Pr Pr
Primary Care For GMC Pr Pr Pr Pr Pr Pr Pr* Pr* Pr* Pr*
Substance Use Problems
Depressive Disorders
Panic Disorder
Severe Personality Disorder
Somatization
Social, Specific Phobias
Other - Anxiety Disorders e.g.
Substance Abuse
Bipolar Disorder
Substance Dependence
Schizophrenia
Pr Primary Care Provider
* = in specialty setting
B1 - Behavioral health
B Specialist in PCP setting
B2 - Behavorial Health
specialist in specialty
Ps setting
Psychiatrist
Note - did not include child (e.g. ADHD) Conditions/Populations
geriatric (eg. dementia)

53. No Physical Health Without Mental Health
Awareness of the link between physical and
mental health
Liaison Mental Health Services
Engaging Patients and Carers
Re-organisation, Quality & Commissioning
Training and Education

54. Conclusions
Co-morbidity and mortality is high
Excess medical deaths > non-accidental deaths in MI
Medication influences morbidity & mortality
Quality of medical care is below usual standard
Physical health monitoring is poor
Guidelines accumulating but implementation lacking