Vince mak - respiratory and mental health
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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’