das: physical health in the in-patient mental health setting
DESCRIPTION
Wonca Working Party on Mental Health World mental Health Day presentation Dr Mrigendra Das (UK) Physical Health in the In-Patient Mental Health SettingTRANSCRIPT
Physical Health Care in the Mental Health In-Setting
Dr Mrigendra Das
Clinical Lead, Consultant Psychiatrist
Broadmoor High Secure Hospital
United Kingdom
This Talk
• Describes a group of Mentally disordered in patients
• The Physical health problems they experience• How these are managed.• Iatrogenic contributions- Atypical antipsychotics• Ways forward
Broadmoor High Secure Hospital
• One of 4 High Secure Hospitals in the UK.• Looks after the most highest risk mentally
disordered offenders.• Offending + Mental Disorder= Highest level of
risk.• All detained under the Mental Health Act.• Hospital, Not a Prison.
A view
Broadmoor Hospital
Broadmoor High Secure Hospital
• Principles of Care• Most on Hospital Orders• Some on Prison Transfer• Diagnosis: Schizophrenia - 70%• The rest: Personality Disorder (20%), Sex
Offending, Mood Disorder.• Average stay: 6 years
Broadmoor Hospital Demographics
• 241 patients• All men• 29 (12%) have diabetes• 24 (10%) have hypertension• 35 (15%) have asthma/COPD• 100% don’t smoke• 80% have a BMI above 30
QOF
• We use the same parameters as in the community• Some parameters are not appropriate• e.g. cervical smears• We don’t prescribe electronically • Administrative and organisation excluded
Broadmoor High Secure Hospital
[0 - 4] [5 - 16] [17 - 24] [25 - 34] [35 - 44] [45 - 54] [55 - 64] [65 - 74] [75 - 84] [85 - 89] [90+]
Age Sex Analysis 0 0 0 0 0 0 0 0 0 0 0
Males 0 0 21 67 82 51 16 3 0 0 0
Females 0 0 0 1 0 0 0 0 0 0 0
0
10
20
30
40
50
60
70
80
90
Care Pathway
• A 30 year old man with a history of treatment resistant schizophrenia.
• Admitted weight 60 kgs; no physical health concerns• Serious violence- admitted to High security• No response to numerous antipsychotics• Initiated on clozapine• Negative symptoms• Marginal response with clozapine
3 years on
• Weighing 120 kgs• Hyperlipidemia• Diabetic• Very high BMI• Sedentary life style• Unhealthy eating
• No longer a risk and ready for transfer out of Broadmoor
• What length of life though?
Our Interventions
• GP• Dietitics• Sports and Leisure• Occupational Therapy• Psychological Interventions• Pharmacy Interventions• Systems related• Specific Medical interventions• Unusual and innovative interventions
Historical Insight
• Diabetes is a disease which often shows itself in families in which insanity prevails’
• Henry Maudsley
• 1879 Pathology of the Mind, London, Macmillan Press
SMR = standardized mortality ratio (observed/expected deaths).
1. Harris et al. Br J Psychiatry. 1998;173:11.2. Osby et al. BMJ. 2000;321:483-484.
Increased mortality rates for medical disorders in mental illness
• 50% increased risk of death from medical causes in schizophrenia, and 20% shorter lifespan1 (1966-1995)
• Cardiovascular mortality in schizophrenia increased from 1976-1995, with greatest increase in SMRs (8.3 males/5.0 females) from 1991-19952 (Data from Sweden)
Source of medical risk in major mental disorders
• Related to mental disorder– Symptoms– Contributory risk for
diabetes?
• Health behaviours– Alcohol and substance
abuse– HIV and hepatitis C– Smoking– Inactivity– Poor nutrition
• Related to treatment– Neurologic effects– Weight gain– Diabetes– Dyslipidaemia– Hyperprolactinemia– CVD
• Related to system of care– Fragmentation– Poor access
Lambert TJR et al. MJA. 2003;178:S67-S70.
1. Allison DB et al. Am J Psychiatry. 1999;156(11):1686–1696; 2. Herran A et al. Schizophr Res. 2000;41(2):373–381; 3. Goff DC et al. J Clin Psychiatry 2005;66:183–94; 4. Davidson S et al. Aust N Z J Psychiatry. 2001;35(2):196–202.
Cardiovascular risk factors and schizophrenia
Non-modifiable risk factors
Modifiable risk factors
Gender Obesity1
Family history Smoking2
Personal history Diabetic control3
Age Hypertension4
Dyslipidaemia4
Metabolic syndrome – NCEP ATP III criteria
Metabolic syndrome defined as 3 of the following NCEP
ATP III criteria:
Central obesity Men > 102cmWomen > 88cm
Blood pressure ≥ 130/ ≥ 85mmHg
Triglycerides ≥ 1.69mmol/L
HDL cholesterol Men < 1.03mmol/LWomen < 1.29mmol/L
Fasting blood glucose ≥ 6.1mmol/L
NCEP Expert Panel. Circulation. 2002;106(25):3143–3421
Prevalance of Metabolic Syndrome (Yadav etal 2009)
Description n(%) Description n(%)
Metabolic syndrome 75(53) Atypical antipsychotics 66(47)
Caucasian 101(72) Clozapine 33 (25)
Black 23(16) Olanzapine 14(11)
Asian 8(6) Quetiapine 11(8)
Mixed Race 8(6) Risperidone 12(9)
Smoker 101 (72) Typical Antipsychotics 21(16)Schizophrenia spectrum 100(71) Typical and atypical Antipsych 10(7)
Personality Disorder 36(25) Mood Stabiliser 25(18)
Mood Disorder 2(1) Valproate 17(12)
Autistic Spectrum 2(1) Other antidepressant 8 (6)
Relative risk for diabetes and cardiovascular disease among patients with the Metabolic Syndrome (13 studies)*
00.5
11.5
22.5
33.5
44.5
5
Rel
ativ
e R
isk
1-Circulation, 2004;109:42-462-Circulation, 2003;108:414-4193-Diabetes Care 2005;28(2):385-904-Circulation 2004;110:1239-12445-JAMA 2002;289:2709-27166-Am J Card 2004;93(2):136-141
diabetes
7-Circulation 2003;107:391-3978-Arch Int Med 2004;164:1066-10769-Diabetes Care 2001;24:683-68910-Atheroschlerosis 2004; 173:309-31411-Circulation 2004;110:1245-125112-Diabetes Care 2003;26:3153-315913-EASD 2004
00.5
11.5
22.5
33.5
44.5
55.5
66.5
7
one two three four
Rel
ativ
e ri
skCHD risk increases with increasing number of metabolic syndrome risk factors (3 separate studies)
Sattar et al, Circulation. 2003;108:414–419Whyte et al, American Diabetes Association, 2001Adapted from Ridker, Circulation. 2003;107:393–339
Number of metabolic risk factors
Prevalence of metabolic syndrome according to BMI
“Overweight” = BMI 25-29.9; “obese” = BMI 30 (National Heart, Lung and Blood Institute, Obesity Guidelines); N=12,363; Data using NCEP ATP III definition for metabolic syndrome
0
10
20
30
40
50
60
70
Pre
vale
nce
(%
)
Healthy Overweight Obese Healthy Overweight Obese
Men Women
Park YW et al. Arch Intern Med. 2003;163:427–436
Visceral adiposity and drug-naïve schizophrenia
Not significantAge, gender,BMI and waist circumference
10 chronic patients, 10 controlsMeyer (Submitted)
Not significantAge, gender46 first-episode, drug-naïve patients in Nanjing, China, 46 controls
Zhang ZJ et al. (2004)3
Greater IAF in patientswith schizophrenia
Age, gender19 first-episode, drug-naïve patients in Dublin, 19 controls
Ryan MC et al. (2004)2
3x greater IAF in patientswith schizophrenia
Age, gender15 drug-naïve patients or drug-free for 6 weeks in Dublin, 15 controls
Thakore JH et al.(2002)1
Intra-abdominalfat (IAF) mass
Matching variablesNStudy
1Thakore JH et al. Int J Obes Relat Metab Disord. 2002;26(1):137–141; 2Ryan MC et al. Life Sci. 2004;74(16):1999–2008; 3Zhang ZJ, Yao ZJ, Liu W et al. Br J Psychiatry. 2004;184:58–62
Short-term mean change in weight with some antipsychotics
1Adapted from: Allison DB et al. Am J Psychiatry. 1999(Nov);156(11):1686–1696. 2Marder et al. Schizophr Res. 2003; 61:123–126; 3Jones et al. Presentation at ACNP. 1999
Estimated weight change at 10 weeks on ‘standard’ dose
Haloper
idol
Risper
idone
Olanza
pine
Cloza
pine
6
Wei
gh
t ch
ang
e (k
g) 5
4321
0
-1-2
-3
Place
bo
Fluphen
azin
e
Zipra
sidone
Chlorp
rom
azin
e
Thiorid
azin
e/
mes
oridaz
ine
13.2
Weig
ht ch
ang
e (lb)
11.08.86.64.42.20-2.2-4.4-6.6
Quetia
pine
Aripip
razo
le
Aripiprazole (4-6 week pooled data)2 and quetiapine (6-week data)2 added to analysis by Allison et al.
Abilify® [package insert]. Princeton NJ: Bristol-Myers Squibb and Rockville, Md: Otsuka America Pharmaceutical; 2005 ; Risperdal® [package insert]. Titiusville, NJ: Janssen Pharmaceutica Products, LP; 2003; Seroquel® [package insert]. Wilmington DE: AstraZeneca; 2004; Zyprexa® [package insert]. Indianapolis, Ind: Eli Lilly and Company; 2004.
Clinically significant (7%) weight gain during antipsychotic treatment
Inci
den
ce (
%)
0
5
10
15
20
25
30
35
0
5
10
15
20
25
30
35
0
5
10
15
20
25
30
35
0
5
10
15
20
25
30
35
Place
bo
Aripip
razo
le
Place
bo
Risper
idone
Place
bo
Quetia
pine
Place
bo
Olanza
pine
Data from package inserts (USA). Data obtained from different short-term (4-8 week) clinical studies.
Aripiprazole vs olanzapine: mean weight change (26 week study)
Baseline: aripiprazole = 80.8±1.85 kg; olanzapine = 80.4±1.84 kg (OC analysis)McQuade RD, et al, J Clin Psychiatry 2004;65(Suppl 18):47–56.
-4
-2
0
2
4
6
0 5 10 15 20 25 30
Weeks
Mea
n w
eig
ht
chan
ge
(kg
)
5.6kg*
* **
* * * * * * **
Aripiprazole
Olanzapine
P ≤ 0.02 significantly greater than aripiprazole. N=274.
Prevalence of diabetes or IGT in schizophrenia
—Current: 10.8%
Lifetime: 14.9%
Self-report of diabetes
Field study: uncontrolled SCZ sample from 2 states (n=719)
—5.1%Self-report of diabetes
vs NHANES III (n=18 825)
—11.1%Paid claim for diabetes
Medicaid sample SCZ sample (n=6066)
—12.5%Paid claim for diabetes
Medicare sample of SCZ adults (n=14,182)2Dixon et al (2000)
<.0215.4% vs 0%IFG (110 and 125 mg/dL)
First episode, drug-naive inpatients with SCZ vs age-, BMI-, and health habit-matched non-DM controls (n=52)
1Ryan et al (2003)
P Value
Rate of DM or IGT
Diabetes AssessmentSample (N)Study
IGT=impaired glucose tolerance; IFG=impaired fasting glucose; SCZ=schizophrenia; DM=diabetes mellitus
1. Ryan MC. et al. Am J Psychiatry. 2003;160:284-289; 2. Dixon L. et al. Schizophr Bull. 2000;26:903–912.
Diabetes, hyperglycaemia and diabetic ketoacidosis: case reports
*Into widespread useDKA = diabetic ketoacidosis
1. Koller E et al. Am J Med 2001;111:716–723; 2. Koller E et al. Pharmacotherapy 2003;23:735–744 ; 3. Koller E et al. Pharmacotherapy 2002;22:841–852; 4. Koller E. et al. J Clin Psychiatry 2004;65:857–863.
Year of introduction
New cases
Exacerbations
DKA
Deaths
Clozapine1 1990* 242 54 80 25
Olanzapine3 1996 188 44 80 15
Quetiapine4 1998 34 8 21 11
Risperidone2 1993 78 46 26 4
Antipsychotic therapy and differential risk for hyperlipidaemia*
*Adjusted for age, sex, duration of follow-up, use of -blocker, -blockers, corticosteroid, thiazide diuretic, lithium, valproate, oral contraceptives containing norgesterol. N = 18,309.
Koro et al. Arch Gen Psychiatry. 2002;59:1021.
Versusconventionalantipsychotic
agents
Versusconventionalantipsychotic
agents
Versusno exposure
Versusno exposure
Od
ds
of
hyp
erli
pid
emia
Olanzapine users Risperidone users
P0.001
P0.001
0
1
2
3
4
5
6
7
8
9
10
HOMA insulin resistance in treated patients with schizophrenia
0
1
2
3
4
5
6
Controls Typical Risperidone Olanzapine Clozapine
HOMA = homeostasis model assessment
Newcomer JW et al., Arch Gen Psychiatry, 2002;59:337–345.
P < 0.05
P = 0.06
HO
MA
in
suli
n r
esis
tan
ce
ADA consensus on antipsychotic drugs and obesity and diabetes
+ = increased effect; - = no effect; D = discrepant results.
*Newer drugs with limited long-term data. Precise risk estimates not ≤ available. †Not available in the UK
Drug Weight Gain Diabetes Risk Dyslipidaemia
clozapine + + + + +
olanzapine + + + + +
risperidone + + D D
quetiapine + + D D
aripiprazole* +/- - -
ziprasidone*† +/- - -
American Diabetes Association. Diabetes Care. 2004;27(2):596–601
The CATIE Trial
• Clinical Antipsychotic trial for Intervention Effectiveness
• Showed that whilst Olanzapine was marginally better in terms of discontinuation:
• Perphanazine equally effective.• Risperidone well tolerated• Clozapine better than others.
Conclusions
• Majority of long stay psychiatric in patients suffer from schizophrenia
• And they inevitably are treated with antipsychotics• Patients with schizophrenia have more physical co-
morbidity• Life style factors also contribute to cardiovascular risk• Are we making this worse by prescription of some of
the new generation antipsychotics?