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Respiratory Disease in Mental Illness

Dr Vincent MakConsultant Physician in Respiratory Integrated CareImperial College Healthcare and Central London Community Healthcare NHS TrustNHS England (London) Respiratory Clinical Leadership GroupClinical Director Outer NW London Integrated care Programme

LondonJune 2014

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...’

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

Severe Emphysema

COPD – an umbrella term covering the “irreversible” aspect of chronic bronchitis, emphysema and asthma

Emphysema

Airwayobstruction

Chronic severe asthma

Chronicbronchitis

COPD(shaded area)

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 ….’

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%∼

COPD and smoking

Fletcher and Peto British Medical Journal 1977

Value Framework

Health OutcomesPatient definedbundle of care

CostValue=

Health Outcomes Cost of delivering

Outcomes

Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

COPD ‘Value’ PyramidWhat 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

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

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?

Does tobacco smoking matter in people with mental illnesses?

‘Increased smoking is responsible formost of the excess mortality of peoplewith 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 ….

Smoking prevalence & tobacco dependence in people with mental illnesses

%

Adults21% smokers

9% heavy smokers

Inpatientswith 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 …

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.

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

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

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

YES

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

Can people with mental illnesses stop smoking?

2011YESSame treatments for tobacco dependence work as

for anyone elseTreatment does NOT worsen mental state

Do people with mental illnesses get evidence-based quit smoking interventions?

2009 London data Lisa McNally, Smoke Free Minds

NO

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 …

Quit smoking as treatmentSharing 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

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

Cannabis and Lung DamageBritish 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’.

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,. 2011European Respiratory Society Congress, Amsterdam

38:776s

Cannabis smokingEmphysema & bullae under 50

47 year old man20 pack-years20 joint-years

Severe (upper lobe) bullous emphysema

Radiology reporting:‘Does this patient smoke cannabis?

‘Appearance consistent with ‘cannabis lung’’

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

Comparing a ‘joint’ with a cigarette

CO (ppm) >20Heavy smokerShisha 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

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

Mental Health Services

Respiratory& GP

Services

Drug Dependency

Services

Stop Smoking Services

Addressing unmet needs:

working across ‘silos’