1
Respiratory Disease in
Mental Illness
Dr Vincent Mak
Consultant Physician in Respiratory Integrated Care
Imperial Colleg...
Why does respiratory disease
matter in people with mental
illnesses?
‘People with mental health problems
… die on average ...
Outcomes for people with mental
illness and COPD
Population 5 year COPD mortality
Schizophrenia 28%
Bipolar disease 19%
Ag...
Severe Emphysema
COPD – an umbrella term covering the
“irreversible” aspect of chronic
bronchitis, emphysema and asthma
Emphysema
Airway
ob...
Do we diagnose COPD in
people with mental illnesses?
• ‘Spirometry done less often in
people with mental illness
• Less li...
Diagnosed COPD prevalence in people
with serious mental illness (SMI)
Himelhoch S, Lehman A, Kreyenbuhl J et al. Am J Psyc...
COPD and smoking
Fletcher and Peto British Medical Journal 1977
Value Framework
Health
Outcomes
Patient defined
bundle of care
CostValue
=
Health Outcomes
Cost of delivering
Outcomes
Por...
COPD ‘Value’ Pyramid
What we know…. Cost/QALY
Triple Therapy
£35,000-
£187,000/QALY
Long term Oxygen
£16000/QALY
LABA
£8,0...
What is high value COPD care in
Psychiatric Settings?
• Look for COPD in smokers
• Ask about breathlessness - requires act...
Undiagnosed
Need respiratory assessment, chest X-ray & spirometry
By:
? GP
? ward team
? liaison physician
Diagnosed COPD
...
Does tobacco smoking matter in
people with mental illnesses?
‘Increased smoking is responsible for
most of the excess mort...
Smoking prevalence & tobacco dependence
in people with mental illnesses
%
Adults
21% smokers
9% heavy
smokers
Inpatients
w...
Randomised
Clinical Trial
~6000 people
with airway obstruction
over ~15 years
Effect of Smoking Cessation Intervention on
...
Value of smoking cessation
interventions in COPD
Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH Thorax...
Changing how we think about smoking
Tobacco addiction
Sick smokers are admitted to hospitals - acute and psychiatric
Evide...
Do people with mental illnesses want to
stop smoking?
Clearing the Air. King’s Fund 2006
70% of smokers
want to stop
>50% ...
So what should we be doing for
smokers with COPD?
‘Offer nicotine replacement therapy,
varenicline or bupropion (unless
co...
Can people with mental illnesses stop
smoking?
2011
Same treatments for tobacco dependence work as
for anyone else
Treatme...
Do people with mental illnesses get evidence-
based quit smoking interventions?
2009 London data Lisa McNally, Smoke Free ...
Beliefs…(Barriers)
(Mental) health professionals attitudes to
smoking
‘Some practitioners expressed doubt about the
value ...
Quit smoking as treatment
Sharing respiratory learning
Healthcare Professionals need to believe (from evidence)
that it is...
Cannabis smoking and
respiratory health
Is it common? Yes
Does it matter?
‘32% of population believe that smoking cannabis...
Cannabis and Lung Damage
British Lung Foundation Reports
2002
2012
www.blf.org.uk/Page/Special-Reports
…there is evidence ...
Cannabis smoking & respiratory
disease
 1 in 3 tobacco smokers in a hospital
population also smoke cannabis*
 all groups...
Cannabis smoking
Emphysema & bullae under 50
47 year old man
20 pack-years
20 joint-years
Severe (upper lobe)
bullous emph...
Cannabis smoking and lung cancer
Tunisia, Morocco & Algeria*
Odds Ratio for lung cancer if cannabis user >2
New Zealand** ...
Comparing a ‘joint’ with a cigarette
CO (ppm) >20
Heavy smoker
Shisha smoker
Cannabis
smoker
1 pack-year
‘20 cigarettes/da...
Virtual Ward Rounds –
Ealing Forensic Service
• Bi-monthly meeting – Multi-disciplinary
• Consultant psychiatrist, respira...
Mental
Health
Services
Respiratory
& GP
Services
Drug Dependency Services Stop Smoking Services
Addressing unmet needs:
wo...
Vince mak - respiratory and mental health
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Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning


Tuesday 24 June 2014: 15 Hatfields, Chadwick Court, London

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Vince mak - respiratory and mental health

  1. 1. 1 Respiratory Disease in Mental Illness Dr Vincent Mak Consultant Physician in Respiratory Integrated Care Imperial College Healthcare and Central London Community Healthcare NHS Trust NHS England (London) Respiratory Clinical Leadership Group Clinical Director Outer NW London Integrated care Programme London June 2014
  2. 2. Why does respiratory disease matter in people with mental illnesses? ‘People with mental health problems … die on average 16-25 years sooner than the general population. … have higher rates of respiratory, cardiovascular & infectious disease...’
  3. 3. Outcomes for people with mental illness and COPD Population 5 year COPD mortality Schizophrenia 28% Bipolar disease 19% Age adjusted population 12% Five year mortality for respiratory disease much higher in people with mental illness At least 1 in 4 deaths in people with mental illnesses due to respiratory disease Hippisley-Cox J et al . Health outcomes for patients with serious mental health problems: 2nd report to the DRC 2006 Joukamaa et al British Journal of Psychiatry 2006:188;122-127, Jones D et al Psychiatric Services 2004;55:1250-1257 www.rcpsych.ac.uk/pdf/No%20Health%20-%20%20the%20evidence_%20revised%20May%2010.pdf
  4. 4. Severe Emphysema
  5. 5. COPD – an umbrella term covering the “irreversible” aspect of chronic bronchitis, emphysema and asthma Emphysema Airway obstruction Chronic severe asthma Chronic bronchitis COPD (shaded area)
  6. 6. Do we diagnose COPD in people with mental illnesses? • ‘Spirometry done less often in people with mental illness • Less likely to have diagnosis based on spirometry ….’
  7. 7. Diagnosed COPD prevalence in people with serious mental illness (SMI) Himelhoch S, Lehman A, Kreyenbuhl J et al. Am J Psychiatry 2004;161:2317-2319 0 200 out-patients with SMI • 60% current smokers (mean age 44) • 23% COPD prevalence (self-reported) • Only 36% reported having COPD treatment 147 Medicaid patients with SMI • 31% COPD prevalence; 50% as co-morbidity • Annual costs for SMI and COPD were 4 x higher • 45% (5/11) deaths due to respiratory disease Jones DR, Macias C, Barreira PJ et al Psychiatric Services 2004;55:1250-1257 Average England QOF prevalence for COPD = ∼1%
  8. 8. COPD and smoking Fletcher and Peto British Medical Journal 1977
  9. 9. Value Framework Health Outcomes Patient defined bundle of care CostValue = Health Outcomes Cost of delivering Outcomes Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483
  10. 10. COPD ‘Value’ Pyramid What we know…. Cost/QALY Triple Therapy £35,000- £187,000/QALY Long term Oxygen £16000/QALY LABA £8,000/QALY Tiotropium £7,000/QALY Pulmonary Rehabilitation £2,000-8,000/QALY Stop Smoking Support with pharmacotherapy £2,000/QALY Flu vaccination £1,000/QALY in “at risk” population
  11. 11. What is high value COPD care in Psychiatric Settings? • Look for COPD in smokers • Ask about breathlessness - requires action • Is it breathlessness with or without respiratory failure?  Need oximeter Timely diagnosis and evidence-based treatment
  12. 12. Undiagnosed Need respiratory assessment, chest X-ray & spirometry By: ? GP ? ward team ? liaison physician Diagnosed COPD  Quit smoking interventions as treatment  Access to pulmonary rehabilitation? What is high value COPD care in Psychiatric Settings?
  13. 13. Does tobacco smoking matter in people with mental illnesses? ‘Increased smoking is responsible for most of the excess mortality of people with severe mental health problems. Adults with mental health problems …. smoke 42%* of all tobacco in England. *not including mental health settings, prisons, homeless or temp housing ….
  14. 14. Smoking prevalence & tobacco dependence in people with mental illnesses % Adults 21% smokers 9% heavy smokers Inpatients with serious mental illness People living with mental illnesses O’Brien et al 2002, Farrell et al 2001 (>20 cigarettes/day) 50% of smokers heavy smokers 30% of smokers heavy smokers High prevalence of severe tobacco dependence Very high smoking prevalence Just like in COPD …
  15. 15. Randomised Clinical Trial ~6000 people with airway obstruction over ~15 years Effect of Smoking Cessation Intervention on Mortality in COPD Anthonisen NR, Skeans MA , Wise RA; Manfreda J, Kanner RE & Connett JE for the Lung Health Study Research Group* Ann Intern Med. 2005;142:233-239.
  16. 16. Value of smoking cessation interventions in COPD Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH Thorax 2010: 65:711-718 1 year abstinence % QALY £ Usual care 1.4 Minimal counselling 2.6 14,735 Intensive counselling 6 7,149 Intensive counselling + pharmacotherapy 12.3 2,092
  17. 17. Changing how we think about smoking Tobacco addiction Sick smokers are admitted to hospitals - acute and psychiatric Evidence based quit smoking treatment is the most important treatment for sick smokers: Behaviour change support and quit smoking medication ‘Smoking kills, stopping works’ Sir Richard Peto 2012
  18. 18. Do people with mental illnesses want to stop smoking? Clearing the Air. King’s Fund 2006 70% of smokers want to stop >50% of smokers with mental illness also want to stop
  19. 19. So what should we be doing for smokers with COPD? ‘Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates… to all people with COPD who still smoke at every opportunity.’ NICE 2010
  20. 20. Can people with mental illnesses stop smoking? 2011 Same treatments for tobacco dependence work as for anyone else Treatment does NOT worsen mental state
  21. 21. Do people with mental illnesses get evidence- based quit smoking interventions? 2009 London data Lisa McNally, Smoke Free Minds
  22. 22. Beliefs…(Barriers) (Mental) health professionals attitudes to smoking ‘Some practitioners expressed doubt about the value of smoking cessation advice for people with mental health conditions’. Physical health professionals attitudes to psychiatry & people with mental illnesses …
  23. 23. Quit smoking as treatment Sharing respiratory learning Healthcare Professionals need to believe (from evidence) that it is their role & responsibility … to refer to quit smoking services and … to do quit smoking work themselves Needs leadership and incentives Make it easy to provide Right care • Brief interventions • Knowledge of quit smoking services & referral • Behaviour change skills • Prescribing knowledge • Medications available • Feedback on outcomes
  24. 24. Cannabis smoking and respiratory health Is it common? Yes Does it matter? ‘32% of population believe that smoking cannabis does not harm your health’ British Lung Foundation 2012
  25. 25. Cannabis and Lung Damage British Lung Foundation Reports 2002 2012 www.blf.org.uk/Page/Special-Reports …there is evidence that the risk of airway obstruction increases with the number of joint- years…, and of an increased risk of COPD from smoking cannabis with tobacco regularly’.
  26. 26. Cannabis smoking & respiratory disease  1 in 3 tobacco smokers in a hospital population also smoke cannabis*  all groups in society  have to ask not volunteered….  History of tobacco and cannabis smoking  Younger people with severe COPD  Young people with pneumothorax  Younger people with lung cancer *LJ Restrick, EV Cumbus, O Thomas, M Stern,. 2011 European Respiratory Society Congress, Amsterdam 38:776s
  27. 27. Cannabis smoking Emphysema & bullae under 50 47 year old man 20 pack-years 20 joint-years Severe (upper lobe) bullous emphysema Radiology reporting: ‘Does this patient smoke cannabis? ‘Appearance consistent with ‘cannabis lung’’
  28. 28. Cannabis smoking and lung cancer Tunisia, Morocco & Algeria* Odds Ratio for lung cancer if cannabis user >2 New Zealand** 79 cases lung cancer in under-55s Risk of lung cancer increased: 8% for each joint-year cannabis smoking 7% for each pack-year cigarette smoking >5 x Relative Risk with >10 joint-years cannabis ‘5% of lung cancer in those aged <55 years may be attributable to cannabis smoking.’ *Berthiller et al J Thoracic Oncology 2008 **Aldington et al ERJ 2008:31;280-286 ‘Stronger evidence than ever before that smoking cannabis is linked to lung cancer’. The impact of cannabis on your lungs. British Lung Foundation 2012
  29. 29. Comparing a ‘joint’ with a cigarette CO (ppm) >20 Heavy smoker Shisha smoker Cannabis smoker 1 pack-year ‘20 cigarettes/day for 1 year’ 1 joint-year ‘one joint/day for 1 year’ 0.4g cannabis cf 1g tobacco ?equivalence No filter Shorter butt Higher temperature Deeper inspiration Breath-hold & Valsalva 5 x tar deposition 3 x carbon monoxide levels
  30. 30. Virtual Ward Rounds – Ealing Forensic Service • Bi-monthly meeting – Multi-disciplinary • Consultant psychiatrist, respiratory physician, physical health nurse, mental health nurse, pharmacist, GP, smoking cessation team • Review of respiratory problems of inpatients • Targetting those who are heavy smokers and who already use respiratory medications • High prevalence of ?diagnosis (asthma or COPD) • High prevalence of ?Obstructive Sleep Apnoea • Patients rarely get adequate review from existing secondary care services
  31. 31. Mental Health Services Respiratory & GP Services Drug Dependency Services Stop Smoking Services Addressing unmet needs: working across ‘silos’

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