The document discusses a program called PIPS (Program for Integrative Psychiatry) implemented at Psychiatric Hospital "Sveti Ivan" in Croatia to address high rates of physical illness and mortality in patients with serious mental illness like schizophrenia and bipolar disorder. PIPS is a 3-step program that includes comprehensive physical exams, screening for risk factors, personalized treatment, and lifestyle change programs. The goals are to reduce mortality, provide integrated physical and mental health care, encourage rehabilitation, and improve quality of life for psychiatric patients managing chronic medical conditions.

1. assist. prof. Igor Filipčić, MD, PhD
Psychiatric Hospital „Sveti Ivan”
Zagreb, Croatia
Prevention of mortality
and morbidity in acute
and chronic psychiatric
patients
Program for integrative psychiatry

2. Overview
• Increased Morbidity and Mortality Associated with
Serious Mental Illness (SMI)
• Increased Morbidity and Mortality – data from Psychiatric
Hospital „Sv Ivan”
• Program for integrative psychiatry (PIPS) – in three steps
• Conclusion

4. In Serious Mental Illness (schizophrenia, depression, bipolar)
1. mortality is being 2 to 3 times higher compared to the general population
2. 60% of this excess mortality is due to physical illness (MI, CVI, embol.)
3. high risk of undetected somatic co-morbidity
4. incidence is much higher than in the normal population for
• cardiovascular diseases / infarct my. stroke/
• unrecognized cancer /lungs, colon/
• diabetes mellitus, metabolic syndrome
• respiratory diseases /COPD
5. psychiatric patients
• have still limited access to physical health care
• physical complaints at a late and more serious stage
Data from Oud et al 2009 BMC Family Practice
Crump et al. 2013 AM J Psychiatry
Leucht et al.2007 AP Scandinavica
Introduction

5. Potential factors for high rates of the co-morbid physical
illnesses in schizophrenic patients
environment
schizophre
nialifestyle
BEHAVIOR
• psychotic symptoms
• negative sy./ low energy
• cognitive disturbances
• reduced communication
• isolated
LIFESTYLE
• smoking
• using drugs
• alcohol
• poor diets/obesity
• not enough exercise
SYSTEM-RELATED FACTORS
• not covered by health
insurance
• less access to health care
• not adequate access to
medical treatment
• unemployment
TREATMENT
Antipsychotics
• side effects
• weight gain, diabetes
• increased prolactin level

6. Mortality and somatic morbidity in schizophrenic patients
Percentageofdeaths
50
40
20
10
0
30
Heart disease Cancer Cerebrovascular Chronic respiratory
Diabetes Influenza/pneumoniaAccidents Suicide
MO OK RI TX UT VA
*Average data from 1996–2000
Colton & Manderscheid 2006, Crump et al. 2013 AM J Psychiatry
Schizophrenic patients are at risk of under-diagnosis and under-treatment
• men with schizophrenia die 15 years earlier
• women die 12 years earlier
The leading causes of death in persons with schizophrenia are
ischemic heart disease and cancer

7. People with SMI have limited access to physical health care
N=8227
Schizophrenic patients use less
than general population
• general medical services
• coronary revascularization
• standard diabetes care
• antihypertensive medication
• lipid-lowering medication
 Risk factors
 smoking
 alcohol
 drugs/narcotics
 poor nutrition
 not exercise

8. We can improve the detection and treatment of comorbid
somatic illnesses in schizophrenic patients by.......
…taking more responsibility for the patient
…implementing systematic education
…improving parity in health care access and provision
…forging collaborations with other medical specialist
Fleischhacker WW et al. Comorbid Somatic Illness in Patients with Severe Mental Disorders: Clinical, Policy and Research Challenges
J Clin Psychiatry. 2008; 68:514-519

10. Somatic comorbidity in psychiatric patients - PH „Sveti Ivan”
hospitalizations from 2013 to August 2015
N=13 686
• schizophrenia 31%
• depression 28%
• bipolar 10%
78.9%
15.8%
5.7%
3.9% 3.9% 3.5%
Prevalence of cardiovascular diseases
hypertension
cardiomyopathy
atrial fibrillation
paroxysmal tachycardia
ishemic heart disease
sequelae of myocardial
infarction
39,3% of patients had
cardiovascular disease
personal data

11. Somatic comorbidity in psychiatric patients - PH „Sveti Ivan”
35,8% patients had
endocrine system
disease
41.80%
34.90%
25.70%
24.50%
4.00% 3.60%
Prevalence of endocrine system diseases
diabetes
hiperlipidemia
hypothyreosis
adiposity
anemia
struma

12. 0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
2012. 2013. 2014.
10.80%
18.30%
29.70%
16.70%
23.50%
34.50%
SCHIZOPHRENIA
endocrine system disease cardiovascular disease
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
2012. 2013. 2014.
19.70%
28.30%
37.90%
22.60%
32.10%
42.10%
DEPRESSION&BIPOLAR
endocrine system disease cardiovascular disease
Mortality: MI /CVI/embolis
64 patients - 8 patients (2013)
77 patients - 9 patients (2014)
69 patients - 9 patients (2015)*
Cancer:
4.9% (2013)
5.8% (2014)
6.3% (2015)
* 2015 . first 8 months
personal data

13. Prevalence and relative risks factors (RR) in schizophrenia
and depression /bipolar in PH „Sveti Ivan”compared to the
general population in Croatia
RR = relative risk
Risk factors schizophrenia
Prevalence RR
depression/ bipolar
Prevalence RR
Obesity 51.9% 2 36.3% 2
Smoking 72.2% 4 61.5% 3
DM 29.2% 2 33.4% 2
Hypertension 37.3% 3 49.7% 3
Dyslipidemia 55.4% 5 26.9% 3
personal data
2013-2015

14. Conducted In
 hospital
 daily hospital
 outpatient
 collaborating institutions
Program for integrative psychiatry
Team
 psychiatrists, psychotherapists
 nurses, occupational therapists
 psychologists, social workers, nutritionist
 internal medicine specialist, neurologist
Goals
 reduction of mortality
 comprehensive treatment
 rehabilitation
 early identification
 quality of life improvement
in psychiatric patient with
chronic somatic diseases

15. more responsibility for the patient in 3 steps
Program for integrative psychiatry
preventive programme
personalized pharmacotherapy &
psychotherapy
a. physical examinations
b. screening
 BMI, weight, waist blood pressure
 fasting glucose, HbA1C
 fasting lipids, HDL-cholesterol
 ECG
c. screening habits (smoke, drug abuse,
alcohol abuse, activity, fast food)
d. questionnaires, scales (PANS, CGI,QLSQ….)
1
2
a. pharmacotherapy strategies
• drugs selection & monitoring
• plasma concentration,
• side effects (metabolic,prolactin level)
• switch medications
b. psychotherapy strategies
 psychodynamic group therapy
 CBT
 multifamily therapy

16. 3
A. patients with major menthal health
problem
B. family – caregivers
Lifestyle changes with behavioural
treatments
overweight, obesity & diet training
smoking cessation / non-smoking tr.
physical activity training
metacognitive training
anti-suicidal programme
anti-stigma programme
adherence programme
wellbeing programme
education
C. Professionals
 psychiatrists
 GP
 others

18. www.pbsvi.hr

19. 380 employees
40 psychiatrists
9 teachers
125 nurses
700 patients
550 beds
150 daily hospital places