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Premature mortality in individuals with major mental illness
Dr Daniel Smith
“A failure of social policy and health promotion, illness prevention and care provision.”
BJPsych, June 2013.
Life expectancy at birth of people with mental disorders in the period of 2007–09 (N = 31,719).
Chang C-K, Hayes RD, Perera G, Broadbent MTM, et al. (2011) Life Expectancy at Birth for People with Serious Mental Illness and Other Major
Disorders from a Secondary Mental Health Care Case Register in London. PLoS ONE 6(5): e19590. doi:10.1371/journal.pone.0019590
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0019590
Total life expectancy among psychiatric patients and general population in Denmark, Finland and Sweden 1987–2006 at 15 years of age.
Wahlbeck K et al. BJP 2011;199:453-458
©2011 by The Royal College of Psychiatrists
Excluding intentional self-harm as a cause of death
Changes in cardiovascular disease standardised mortality ratios (SMRs) in 5-year periods of a
community cohort of 370 people followed over 25 years.
Brown S et al. BJP 2010;196:116-121
©2010 by The Royal College of Psychiatrists
Suicide, accidental and violent deaths
Iatrogenic effects of psychotropic
medication
Cardiovascular diseases and some
cancers
Poor access to healthcare, ‘diagnostic overshadowing’ and
under-treatment
Shared genetic/epigenetic factors in psychiatric and
medical morbidity
Premature mortality in
major mental illness
Arch Gen Psychiatry. 2011;68(10):1058-1064. doi:10.1001/archgenpsychiatry.2011.113
Figure Legend:
Nordentoft et al, 2011, Archives Gen Psychiatry
Arch Gen Psychiatry. 2011;68(10):1058-1064. doi:10.1001/archgenpsychiatry.2011.113
Figure Legend:
Nordentoft et al, 2011, Archives Gen Psychiatry
Dr David Shiers
Professor Helen Lester
0
20
40
60
80
100
120
<25 25-34 35-44 45-54 55-64
De
ath
Rat
e/1
00
0 p
op
ula
tio
n
MMI (all cause)
MMI (exc. suicide)
All Scotland
Life-span influences on premature mortality in schizophrenia and
bipolar disorder: data from the Glasgow Psychosis Cohort. (Langan Martin et al, submitted)
<25 25-34 35-44 45-54 55-64 All ages
All causes
(n=230) 38.3 [7.9-111.8] 8.3 [4.9-13.0] 4.1 [2.9-5.6] 2.7 [2.1-3.4] 2.1 [1.7-2.6] 2.7 [2.4-3.1]
All causes
excluding suicide
(n=196)
0 [1-47.1] 6.0 [3.2-10.2] 3.0 [2.0-4.3] 2.4 [1.8-3.1] 2.0 [1.6-2.4] 2.3 [2.0-2.7]
Cardiovascular
disease (n=34) 0 [0-6587.3] 9.6 [0.2-53.2] 1.8 [0.4-5.2] 1.1 [0.5-2.2] 1.4 [0.8-2.1] 1.4 [0.9-1.9]
Cerebrovascular
disease (n=8) 0 [0-6587] 0 [0-49.8] 1.6 [0.04-8.97] 1.7 [0.5-4.3] 0.7 [0.1-2.1] 1.1 [0.5-2.2]
Cancer (n=33) 0 [0-399.2] 4.8 [0.6-17.4] 0.9 [0.2-2.5] 0.5 [0.2-0.9] 0.5 [0.3-0.8] 0.6 [0.4-0.8]
Life-span influences on premature mortality in schizophrenia and
bipolar disorder: data from the Glasgow Psychosis Cohort. (Langan Martin et al, submitted)
Standardised Mortality Ratios (SMRs) and [95% CIs]
<25 25-34 35-44 45-54 55-64 All ages
All causes
(n=230) 38.3 [7.9-111.8] 8.3 [4.9-13.0] 4.1 [2.9-5.6] 2.7 [2.1-3.4] 2.1 [1.7-2.6] 2.7 [2.4-3.1]
All causes
excluding suicide
(n=196)
0 [1-47.1] 6.0 [3.2-10.2] 3.0 [2.0-4.3] 2.4 [1.8-3.1] 2.0 [1.6-2.4] 2.3 [2.0-2.7]
Cardiovascular
disease (n=34) 0 [0-6587.3] 9.6 [0.2-53.2] 1.8 [0.4-5.2] 1.1 [0.5-2.2] 1.4 [0.8-2.1] 1.4 [0.9-1.9]
Cerebrovascular
disease (n=8) 0 [0-6587] 0 [0-49.8] 1.6 [0.04-8.97] 1.7 [0.5-4.3] 0.7 [0.1-2.1] 1.1 [0.5-2.2]
Cancer (n=33) 0 [0-399.2] 4.8 [0.6-17.4] 0.9 [0.2-2.5] 0.5 [0.2-0.9] 0.5 [0.3-0.8] 0.6 [0.4-0.8]
Life-span influences on premature mortality in schizophrenia and
bipolar disorder: data from the Glasgow Psychosis Cohort. (Langan Martin et al, submitted)
Standardised Mortality Ratios (SMRs) and [95% CIs]
Multimorbidity and major mental illness in Scotland:
– Data from 314 general practices in Scotland (1.8 million people)
– Schizophrenia and related psychoses and bipolar disorder identified (n=12,504)
– 32 physical health conditions also identified
– Multimorbidity described by age, gender and socioeconomic deprivation
– Some prescribing information
Physical health comorbidities assessed:
Coronary heart
disease
Parkinson’s disease Peripheral vascular
disease
Viral hepatitis
Chronic kidney
disease
Multiple sclerosis Sinusitis Liver disease
Asthma Stroke Chronic obstructive
pulmonary disease
Psoriasis/eczema
Atrial fibrillation Blindness Bronchiectesis Irritable bowel
syndrome
Epilepsy Glaucoma Chrones disease Migraine
Cancer (any) Hearing loss Diverticulitis Dyspepsia
Thyroid disorders Hypertension Rheumatoid arthritis Constipation
Diabetes Heart failure Prostate disease Pain disorder
Schizophrenia is associated with excess multiple physical health comorbidities but low levels of recorded cardiovascular disease in primary care: cross-sectional study. (Smith et al, BMJ Open, April 2013)
• Very high rates of “pro-atherosclerotic” conditions, eg,
smoking (32.3% vs. 20.6% p=0.01) and Diabetes (8.4%
vs. 5.3% p=0.001)
• BUT:
– Coronary Heart Disease, Heart Failure, Peripheral Vascular Disease, Stroke
and TIA not more common in the bipolar group
– Bipolar group displayed significantly lower recorded rates of hypertension (OR
0.82, p=0.001) and atrial fibrillation (OR 0.68, p=0.02)
– Substantial treatment inequalities for those bipolar patients known to have
coronary heart disease and hypertension.
Conclusions:
1. Premature mortality and multiple physical health problems are
well recognised in schizophrenia and bipolar disorder
2. Psychiatry has a central role to play in tackling this health
inequality
3. Don’t just screen – intervene!
4. We need better integration across primary and secondary care
5. We need new (innovative) treatment approaches and service
delivery models, particularly for younger patients.
Thanks to:
Secondary care (PsyCIS) mortality audit:
Moira Connolly, John Park, Frances Paton, Daniel Martin, Julie Langan, Gary McLean
Plus all Glasgow consultants who regularly update PsyCIS data.
SPICE primary care data:
We thank the Chief Scientist Office of the Scottish Government Health Directorates (Applied
Research Programme Grant ARPG/07/1); the Scottish School of Primary Care, which part
supported SWM’s post and the development of the Applied Research Programme; and the
Primary Care Clinical Informatics Unit at the University of Aberdeen, which provided the data.
The views in this publication are not necessarily the views of the University of Aberdeen of
University of Glasgow, their agents, or employees. We thank Katie Wilde and Fiona Chaloner
of the University of Aberdeen, who did the initial data extraction and management.
The analysis of SPICE data was conducted as part of the Living Well
with Multimorbidity Programme (CSO Grant ARPG/07/1) with
Professor SW Mercer (Principal Investigator) and Professor Bruce
Guthrie (epidemiology lead).
Premature mortality in individuals with major mental illness
Dr Daniel Smith