The document discusses the suboptimal medical care provided to psychiatric patients, highlighting issues of health care inequality and the quality of medical procedures and monitoring. It presents evidence indicating high rates of co-morbidity and mortality among these patients, along with inadequate preventive health care screenings and medical treatments. Various studies underline the discrepancy in the quality of care between those with mental health conditions and the general population, calling for improved guidelines and implementation.

1. Alex J Mitchell see www.psycho-oncology.info Acknowledgements Oliver Lord Darren Malone Caroline Carney-Doebbling Nasser Abdelmawla Brett Thombs Roy Ziegelstein Jim Coyne Marc DeHert Davy Vancampfort Liaison faculty - Mar2011 Failing Medical Care of Psychiatric Patients Latest evidence on suboptimal medical care from physicians and psychiatrists

2. Contents Mental Health & Physical Health Mortality | Impairment | Co-morbidity Preventive Health Care Inequality Screening | prevention Medical Health Care Inequality Procedures | prescribing Physical and Metabolic Monitoring? Guidelines & responsibility Implications for Mortality

3. Quality of medical care In medical settings Quality of preventive care (mass screening) Quality of Psychiatric medical care Medication Prescribing in medical settings Procedures rate & Mortality

4. Physical Health Comorbidity / Mortality

5. Merikangas (2007) NCS-R (n=5962) : disability days

6. Days totally out of role per year Alonso (2010) WHO MH Survey n=62,971

7. How much physical co-morbidity is there in mental ill health?

8. Sokal 2004 J Nerv Ment Dis 192: 421– 427 NHANES - US Department of Health National Health and Nutrition Examination Survey , 1988 –1994

9. Gili et al (2011) 10,257 Primary care in Spain

10. Metabolic syndrome meta-analysis in schizophrenia (Mitchell, DeHert et al unpublished)

11. MetS in First episode Patients Saddichha S et al. Schizophr Res 2008;101:266-72.

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

13. Five-year Mortality rates 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

14. 2. Preventive Health Care Inequality Should vulnerable patients receive similar or enhanced care?

15. Annual physical health checks ( NSF for mental health/NICE guidance) Blood pressure & weight/BMI Lifestyle advice (smoking/diet/exercise/alcohol/drugs) Urine/glucose 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

16. Mass Screening activities Mammography Pap. Smear Lifestyle counselling Blood pressure Bowel cancer screening Prostate PSA Osteoporosis Hepatitis & HIV tests

17. USPST recommendations Screening mammography every 1-2 years starting at age 40 UK NSC (England) Age 50-70 every 3 years OR of 0.7 P<0.0001 Receipt of Mammograpy by mental illness (Mitchell, Lord currently unpublished)

18. 3. Medical Health Care Inequality Medical monitoring eg HBA1c Medical procedures eg CABG Medical prescribing eg Aspirin post MI

19. Frayne et al. Arch Intern Med . 2005 Diab care 313,586 Veteran Health Authority patients with diabetes 76,799 (25%) had mental health conditions (1999) Depression Anxiety Psychosis Mania Substance use disorder Personality disorder 0.8 1.0 1.2 1.4 1.6 No HbA test done 0.8 1.0 1.2 1.4 1.6 No LDL test done 0.8 1.0 1.2 1.4 1.6 No Eye examination done 0.8 1.0 1.2 1.4 1.6 No Monitoring 0.8 1.0 1.2 1.4 1.6 Poor glycemic control 0.8 1.0 1.2 1.4 1.6 Poor lipemic control Odds ratio for:

20. 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

21. 3b. Inequalities in Procedures CABG – Coronary artery bypass graft CC - Cardiac catheterization PTCA – Percutaneous transluminal coronary angioplasty PCI - Percutaneous coronary intervention

22. Lawrence et al

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

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

25. 3c. Medication Prescribing Inequalities Aspirin ACE Inhibitors Statin / non-statin B-Blockers HAART HRT Chemotherapy

26. OR =0.94 (0.90-0.96) OR =0.69 (0.57-0.83) OR =0.72 (0.51-1.00) SMI Schz Affective Inequality of Prescribed Meds ii Medication by Diagnosis

27. OR =0.77 (0.69-0.86) Inequality of Prescribed Meds ii Medication by ALL

28. OR =0.79 OR =0.99 ns OR =0.83 OR =0.84 ns Inequality of Prescribed Meds ii Medication by drug class

29. OR =0.94 ns OR =0.96

30. 4. Inequality in Physical Care in Psychiatry

31. 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.

32. Bobes et al (2010) n=1193, 229 psychiatrists

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

34. Rothbard et al Psychiatric Services 2009; 60(4); (n=588)

35. Rothbard et al Proportion of Missed Medical Conditions……

36. Solution?......is the solution in (more) guidelines?

37. Summary of Monitoring Protocol American Diabetes Association and the American Psychiatric Association (ADA/ APA/AACE/NAASO, 2004). Base line 4 wk 8 wk 12 wk Quart Ann 5 yr 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

39. Monitoring Guidelines Simplified Adapted from Cohn TA, Sernyak M. Metabolic monitoring for patients treated with antipsychotic medications. Can J Psychiatry 2006;51:492–501. US-Mount Sinai Australia US-ADA–APA Belgium UK Canada Guidelines Apply to Which Groups? Schizophr, FGA/SGA All patients, FGA/SGA All patients, SGA Schizophr, SGA Schizophr, FGA/SGA Schizophr Biochemical Screening Fasting plasma glucose (FPG) Yes Yes Yes Yes Yes Yes Random glucose (RG) Yes Yes HbA1c optional No Yes OGTT Yes Yes Lipids Yes Yes Yes Yes Yes Physical Examination Weight Yes Yes Yes Yes Yes Waist circumference Yes Yes Yes Yes Yes Height Yes Yes Yes Yes Yes Hip Yes Yes Blood pressure Yes Yes Yes Yes Clinical Interview Family history Yes Yes Yes Yes Yes Past Medical history Yes Yes Yes Yes Yes Ethnicity Yes Yes Yes Tobacco Yes Yes Diet/activity Yes Yes Yes Diabetes signs/symptoms Yes Yes Yes Yes Yes

40. HR= 0.42 (0.34-0.50) Initiating antipsychotics

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

42. Conclusions Co-morbidity and mortality is high Excess medical deaths > non-accidental deaths 4:1 Quality of medical care is below usual standard prescribing | procedures after MI Physical health monitoring is poor Guidelines accumulating but implementation lacking

43. 5. Extras - Implication for Mortality

46. Quality of Care Influencing=> Mortality? Druss et al 2000 113,653 Druss et al 2001 88,241 Jones et al 2005 3,368 Kisely et al 2007 13,626 Lawrence et al 2003 210,129 p Li et al 2007 39,839 * Petersen et al 2003 4,340 Plomondon et al 2007 14,194 ns Young et al 2000 354,195 u