Mental Health Professionals in Princeton Nj by nfb18092

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									Morbidity and Mortality in
   people labeled with
 “serious mental illness”
       A selection of slides from the National
    Association of State Mental Health Program
  Directors (NASMHP) Medical Directors Council
  report, July 2006, along with commentary and
 additional slides by Ron Unger LCSW (also some
          graphics from the ACES study)

   Slides in blue are from the NASMHP report,
     slides in green are by Ron Unger LCSW
Why Should we be Concerned About
     Morbidity and Mortality?

Recent data from several states have
found that people with serious mental
illness served by our public mental
health systems die, on average, at least
25 years earlier that the general
population.
 Recent Multi-State Study Mortality Data:
      Years of Potential Life Lost
  Year        AZ       MO        OK        RI       TX        UT     VA (IP
                                                                      only)
  1997                 26.3     25.1                28.5
  1998                 27.3     25.1                28.8     29.3      15.5
  1999       32.2      26.8     26.3                29.3     26.9      14.0
  2000       31.8      27.9               24.9                         13.5


    Compared to the general population, persons
    with major mental illness typically lose more
    than 25 years of normal life span

Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date
cited]. Available from: URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm
        Overview- THE PROBLEM
Increased Morbidity and Mortality Associated with
Serious Mental Illness (SMI)

Increased Morbidity and Mortality Largely Due to
Preventable Medical Conditions
     Metabolic Disorders, Cardiovascular Disease, Diabetes Mellitus
     High Prevalence of Modifiable Risk Factors (Obesity, Smoking)
     Epidemics within Epidemics (e.g., Diabetes, Obesity)

Some Psychiatric Medications Contribute to Risk

Established Monitoring and Treatment Guidelines to
Lower Risk Are Underutilized in SMI Populations
Overview - PROPOSED SOLUTIONS

Prioritize the Public Health Problem
    Target Providers, Families and Clients
    Focus on Prevention and Wellness


Track Morbidity and Mortality in Public Mental
Health Populations

Implement Established Standards of Care
    Prevention, Screening and Treatment

Improve Access to and Integration of Physical
Health and Mental Health Care
    Other solutions needed, that
     NASMHPD didn’t propose
 Seekwherever possible to use
 mental health treatments that do not
 shorten lives
  – In other words, vastly reduce reliance
    on anti-psychotic medications
 Reform  the way medical research is
  done & information is distributed
 Prevention: reduce trauma!
     What are Adverse Childhood
       Experiences (ACEs)?
   Growing up (prior to age 18) in a
    household with:
    – Recurrent physical abuse.
    – Recurrent emotional abuse.
    – Sexual abuse.
    – An alcohol or drug abuser.
    – An incarcerated household member.
    – Someone who is chronically depressed,
      suicidal, institutionalized or mentally ill.
    – Mother being treated violently.
    – One or no parents.
    – Emotional or physical neglect.
  Number of Adverse Childhood
  Events resulted in increases in:
 Risk factors for disease, like smoking
  and obesity
 Actual diseases, such as heart
  disease, diabetes, others
 Substance abuse

 A wide variety of mental health
  problems, including depression and
  psychosis
“Adoption of
health-risk
behaviors” can
include not just
behaviors
independently
adopted by
individuals, but
also behaviors
that are promoted
by mental health
professionals,
such as reliance
on neuroleptic
medications.
Understanding parallel process:
 People who are traumatized often respond
  by making choices that seem to improve
  things but really make things worse
 People and systems responding to
  traumatized people themselves frequently
  become organized by trauma,
    – and soon are making choices that seem to
      improve things but really make things worse
   A holistic approach is needed, that focuses
    on the overall health of both individuals,
    and of the people and the systems that
    attempt to help
What are the Causes of Morbidity and
Mortality in People with Serious
Mental Illness?
 While suicide and injury account for about 30-
 40% of excess mortality, about 60% of
 premature deaths in persons with schizophrenia
 are due to “natural causes”
 –   Cardiovascular disease
 –   Diabetes
 –   Respiratory diseases
 –   Infectious diseases
  Increased Mortality From Medical
       Causes in Mental Illness
 Increased risk of death from medical causes in
 schizophrenia and 20% (10-15 yrs) shorter lifespan1
 Bipolar and unipolar affective disorders also
 associated with higher SMRs from medical causes2
   – 1.9 males/2.1 females in bipolar disorder
   – 1.5 males/1.6 females in unipolar disorder
 Cardiovascular mortality in schizophrenia increased
 from 1976-1995, with greatest increase in SMRs in
 men from 1991-19953

SMR = standardized mortality ratio (observed/expected deaths).
1. Harris et al. Br J Psychiatry. 1998;173:11. Newman SC,
   Bland RC. Can J Psych. 1991;36:239-245.
2. Osby et al. Arch Gen Psychiatry. 2001;58:844-850.
3. Osby et al. BMJ. 2000;321:483-484.
     What portion of the risk of early
        death results from the
             medications?
 One recent 17 year study of people with
  “schizophrenia” found the following death
  rates depending on the number of
  neuroleptic (antipsychotic) drugs taken:
 Those on one drug: 35%
 Those on two drugs: 44%
 Those on 3 drugs: 57%
 Those on 0 drugs: 20%
   BRITISH JOURNAL OF P SYCHIATRY (2006), 188, 122^127
   Schizophrenia, neuroleptic medication and mortality
   MATTI JOUKAMAA, MARKKU HELIOVAARA, PAUL KNEKT,
   HELIO« VAARA, ARPO AROMAA, RAIMO RAITASALO and VILLE LEHTINEN
    Even Suicide Risk is Linked with
          Modern Treatment
   A major study showed that people
    diagnosed with schizophrenia are 20
    times more likely to commit suicide in the
    modern era, than they were 100 years
    ago
     – The study’s authors suggested:
            One cause was more people spending more
             time outside hospitals
            The other cause was side effects of anti-
             psychotics, which can increase risk of suicide
   Study title: Lifetime suicide rates in treated schizophrenia: 1875–1924 and 1994–1998 cohorts

    compared
                     Schizophrenia:
                 Natural Causes of Death

     Higher standardized mortality rates than the general
     population from:
      –   Diabetes                            2.7x
      –   Cardiovascular disease              2.3x
      –   Respiratory disease                 3.2x
      –   Infectious diseases                 3.4x


     Cardiovascular disease associated with the largest
     number of deaths
      – 2.3 X the largest cause of death in the general population



Osby U et al. Schizophr Res. 2000;45:21-28.
                Cardiovascular risk factors –
                         overview
                                  The Framingham Study                                        5
         14

         12                                               Multiple Risk
                                                            Factors
  Odds ratios




         10                                                                         4

                8

                6         Single Risk Factors                             3
                4                                              2
                2

                0
                    BMI >27 Smoking TC >220 DM      HTN      Smoking   Smoking Smoking        Smoking
                                                              + BMI      + BMI     + BMI        + BMI
                                                                       + TC >220 + TC >220    + TC >220
                                                                                   + DM      + DM + HTN
BMI = body mass index; TC = total cholesterol; DM = diabetes mellitus; HTN = hypertension.
Wilson PWF et al. Circulation. 1998;97:1837–1847.
        Cardiovascular Disease (CVD) Risk
                     Factors

      Modifiable Risk                      Estimated Prevalence and Relative Risk (RR)
         Factors                            Schizophrenia                           Bipolar Disorder
                                                 45–55%, 1.5-2X
            Obesity                                                                                26%5
                                                      RR1
           Smoking                            50–80%, 2-3X RR2                                     55%6
           Diabetes                             10–14%, 2X RR3                                     10%7
       Hypertension                                      ≥18%4                                     15%5
        Dyslipidemia                               Up to 5X RR8
1. Davidson S, et al. Aust N Z J Psychiatry. 2001;35:196-202. 2. Allison DB, et al. J Clin Psychiatry. 1999; 60:215-220. 3.
Dixon L, et al. J Nerv Ment Dis. 1999;187:496-502. 4. Herran A, et al. Schizophr Res. 2000;41:373-381. 5. MeElroy SL, et
al. J Clin Psychiatry. 2002;63:207-213. 6. Ucok A, et al. Psychiatry Clin Neurosci. 2004;58:434-437. 7. Cassidy F, et al.
Am J Psychiatry. 1999;156:1417-1420. 8. Allebeck. Schizophr Bull. 1999;15(1)81-89.
  BMI Distributions for General Population
   and Those With Schizophrenia (1989)
            30
                 Under-            Acceptable               Overweight      Obese
                 weight


            20




            10




             0
                 < 18.5 18.5-20 20-22 22-24 24-26 26-28 28-30 30-32 32-34 > 34
                                                        BMI Range
                                                                         No schizophrenia
Allison DB et al. J Clin Psychiatry. 1999;60:215-220.
                                                                         Schizophrenia
 Mental Disorders and Smoking
• Higher prevalence (56-88% for patients
    with schizophrenia) of cigarette smoking
    (overall U.S. prevalence 25%)
• More toxic exposure for patients who
    smoke (more cigarettes, larger portion
    consumed)
• Smoking is associated with increased
    insulin resistance
• Similar prevalence in bipolar disorder
George TP et al. Nicotine and tobacco use in schizophrenia. In: Meyer JM, Nasrallah
HA, eds. Medical Illness and Schizophrenia. American Psychiatric Publishing, Inc. 2003;
Ziedonis D, Williams JM, Smelson D. Am J Med Sci. 2003(Oct);326(4):223-330
 Increased smoking is also linked
 with at least some anti-psychotic
            medications
 Older anti-psychotics are definitely
  associated with increased urge to
  smoke
 Evidence is mixed with newer
  “atypical” anti-psychotics
 In 2001, it was estimated that
people diagnosed “mentally ill”
    were smoking 43% of all
cigarettes consumed in the US.

The percentage has probably
    gone up since then.
Hypothesized Reasons Why There
 May Be More Type 2 Diabetes in
   People With Schizophrenia
Genetic link between schizophrenia and
diabetes
Impact of lifestyle
Medication effect increasing insulin
resistance by impacting insulin receptor
or postreceptor function
Drug effect on caloric intake or
expenditure (obesity, activity)
  How Does This Relate to What is
Happening in the General Population?

There is an “epidemic” of obesity and diabetes,
increasing risk of multiple medical conditions
and cardiovascular disease.
 –   Obesity
 –   Diabetes
 –   Metabolic Syndrome
 –   Cardiovascular Disease
                                     Diabetes and Obesity:
                                    The Continuing Epidemic
                                                    Diabetes
                                                    Mean body weight
                                    7.5                                   78
                   Prevalence (%)



                                    7.0                                   77
                                    6.5                                   76




                                                                               kg
                                    6.0
                                                                          75
                                    5.5
                                                                          74
                                    5.0
                                    4.5                                   73
                                    4.0                                   72
                                      1990   1992   1994 1996   1998   2000
                                                       Year
Mokdad et al. Diabetes Care. 2000;23:1278.
Mokdad et al. JAMA. 1999;282:1519.
Mokdad et al. JAMA. 2001;286:1195.
    Diabetes and Gestational Diabetes Trends:
    US Adults, BRFSS 1990




                    No Data          Less than 4%   4% to 6%   Above 6%

Mokdad et al. Diabetes Care. 2000;23:1278-1283.
    Diabetes and Gestational Diabetes Trends:
             US Adults, BRFSS 1995




               No Data      Less than 4%      4% to 6%   Above 6%


Mokdad et al. Diabetes Care. 2000;23:1278-1283.
      Diabetes and Gestational Diabetes Trends:
               US Adults, BRFSS 1999




                     No Data          Less than 4%   4% to 6%   Above 6%

Mokdad et al. Diabetes Care. 2001;24:412.
      Diabetes and Gestational Diabetes Trends:
               US Adults, BRFSS 2000




                     No Data        Less than 4%   4% to 6%   Above 6%

Mokdad et al. JAMA. 2001;286(10).
  Diabetes and Gestational Diabetes Trends:
        US Adults, Estimate for 2010




          No Data   Less than 4%   4% to 6%   Above 6%   Above 10%


www.diabetes.org.
   Diabetes is a CVD Risk Equivalent to
      Previous Myocardial Infarction
                      50
                                                                                              45.0%

                      40
   Fatal or nonfatal MI (%)




                                                        Equivalent MI Risk Levels
                      30

                                                                           20.2%
                      20                                18.6%


                      10
                                     3.5%

                              0
                                  No Prior MI           Prior MI         No Prior MI          Prior MI
                                        Nondiabetic Subjects                Type 2 Diabetic Subjects
                                             (n = 1373)                            (n = 1059)

Haffner SM et al. N Engl J Med. 1998;339:229-234.
Identification of the Metabolic Syndrome

                              ≥3 Risk Factors Required for Diagnosis
                                Risk Factor            Defining Level
                          Abdominal obesity           Waist circumference
                            Men                         >40 in (>102 cm)
                            Women                        >35 in (>88 cm)
                                                         150 mg/dL
                          Triglycerides
                                                       (1.69mmol/L)

                          HDL cholesterol
                                                            <40 mg/dL
                            Men
                                                   (1.03mmol/L)      <50
                            Women
                                                     mg/dL (1.29mmol/L)
                         Blood pressure                 130/85 mm Hg
                                                          110 mg/dL
                         Fasting blood glucose
HDL = high-density lipoprotein.                         (6.1mmol/L)
NCEP III. Circulation. 2002;106:3143-3421.
           CHD Risk Increases with Increasing
           Number of Metabolic Syndrome Risk
                        Factors
                  7
                6.5
                  6
                5.5
                  5
Relative Risk




                4.5
                  4
                3.5
                  3
                2.5
                  2
                1.5
                  1
                0.5
                  0
                      one            two            three   four
Sattar et al, Circulation, 2003;108:414-419
Whyte et al, American Diabetes Association, 2001
Adapted from Ridker, Circulation 2003;107:393-397
Modifiable Risk Factors Affected
       by Psychotropics
   Overweight / Obesity
   Insulin resistance
   Diabetes/hyperglycaemia
   Dyslipidemia




Newcomer JW. CNS Drugs 2005;19(Supp 1):1.93.
               1-Year Weight Gain:
         Mean Change From Baseline Weight
         Change From Baseline Weight (kg)




                                            14




                                                                                                                            Change From Baseline Weight (lb)
                                                        Olanzapine (12.5–17.5 mg)                                      30
                                                        Olanzapine (all doses)
                                            12          Quetiapine                                                     25
                                                        Risperidone
                                            10          Ziprasidone
                                                                                                                       20
                                                        Aripiprazole
                                            8
                                                                                                                       15
                                            6
                                                                                                                       10
                                            4

                                            2                                                                          5

                                            0                                                                          0
                                                0   4   8    12   16   20   24      28   32   36   40   44   48   52
                                                                              Weeks

Nemeroff CB. J Clin Psychiatry. 1997;58(suppl 10):45-49; Kinon BJ et al. J Clin Psychiatry. 2001;62:92-100; Brecher M et
al. American College of Neuropsychopharmacology; 2004. Poster 114; Brecher M et al. Neuropsychopharmacology.
2004;29(suppl 1):S109; Geodon® [package insert]. New York, NY:Pfizer Inc; 2005. Risperdal® [package insert]. Titusville,
NJ: Janssen Pharmaceutica Products, LP; 2003; Abilify® [package insert]. Princeton NJ: Bristol-Myers Squibb Company
and Rockville, Md: Otsuka America Pharmaceutical, Inc.; 2005.
                                         CATIE Trial Results:
                                         Weight Gain Per Month
                              2
                                              Treatment
 Weight gain (lb) per month




                              1




                              0




                                   OLZ       QUET   RIS   PER    ZIP
                              -1


NEJM 2005 353:1209-1223
  Change in Weight From Baseline
58 Weeks After Switch to Low Weight
            Gain Agent
                                 6     10 14    19 23 27 32 36 40 45      49 53 58
                            5
     LS Mean Change (lb)




                            0
                                  *
                            -5   ***
                                                           **
                           -10

                                                          ***                        **
                           -15
                                     *P<0.05
                                   **P<0.01
                           -20
                                  ***P<0.0001
                                                                                ***
                           -25                       Switched from
                                       Conventionals      Risperidone   Olanzapine

Weiden P et al. Presented APA 2004.
                      CATIE Results:
    Metabolic Changes From Baseline
              40.5
                                           Cholesterol (mg/dL)
                                           Triglycerides
                                           (mg/dL)
                            21.2


        9.4                                                9.2
                      6.6
                                                   1.3


                                   -1.3 -2.4

                                                                 -8.2

                                                                         -
                                                                        16.5
        OLZ               QUET       RIS                 PER            ZIP
NEJM 2005 353:1209-1223
                      CATIE Results:
     Metabolic Changes From Baseline
14    13.7
                                           Glucose (mg/dL)
12                                         Glycosylated HB (%)

10

                      7.5
8
                                   6.6
                                                  5.4
6


4                                                                2.9


2            0.4                                                       0.11
                            0.04         0.07            0.0
0
       OLZ            QUET         RIS             PER           ZIP


NEJM 2005 353:1209-1223
        American Diabetes Association, American Psychiatric Association,
        American Association of Clinical Endocrinologists, North American
                     Association for the Study of Obesity:
     Consensus Conference on Antipsychotic Drugs and
              Risk of Obesity and Diabetes
       Drug                      Weight Gain   Diabetes Risk     Dyslipidemia

       clozapine                 +++           +                 +
       olanzapine                +++           +                 +
       risperidone               ++            D                 D
       quetiapine                ++            D                 D
       aripiprazole              +/-           -                 -
       ziprasidone               +/-           -                 -

                          + = increased effect; - = no effect; D = discrepant results.

Diabetes Care 27:596-601, 2004
    ADA/APA/AACE/NAASO Consensus on
     Antipsychotic Drugs and Obesity and
        Diabetes: Monitoring Protocol*

                        Start 4 wks 8 wks 12 wk   qtrly   12 mos. 5 yrs.

Personal/family Hx       X                                  X
Weight (BMI)             X     X     X      X        X
Waist                    X                                  X
circumference
Blood pressure           X                  X               X
Fasting glucose          X                  X               X
Fasting lipid profile    X                  X                X      X
*More frequent assessments may be warranted based on
clinical status       Diabetes Care. 27:596-601, 2004
              Problem:
SMI and Reduced Use of Medical Services

  Fewer routine preventive services (Druss
  2002)
  Worse diabetes care (Desai 2002, Frayne
  2006)
  Lower rates of cardiovascular procedures
  (Druss 2000)
   Access and Quality of Care

SMI may be a health risk factor because of:

– Patient factors, e.g.: amotivation, fearfulness,
  homelessness, victimization/trauma, resources,
  advocacy, unemployment, incarceration, social
  instability, IV drug use, etc
– Provider factors: Comfort level and attitude of
  healthcare providers, coordination between mental
  health and general health care, stigma,
– System factors: Funding, fragmentation
Anti-psychotics may cause people
  to delay seeking treatment for
 physical illness until it’s too late
 Oneof the first noted effects of anti-
 psychotic medications was to reduce
 responsiveness to aversive stimuli
 – For example, rats given these drugs
   would quit taking action to avoid electric
   shock
 – People may just tolerate things going
   wrong with their body, delaying
   treatment….
      Goals: Lower Risk for CVD
    Blood cholesterol
     – 10%  = 30%  in CHD (200-180)
    High blood pressure (> 140 SBP or 90 DBP)
     – 4-6 mm Hg  = 16%  in CHD; 42%  in stroke
    Cigarette smoking cessation
     – 50%-70%  in CHD
    Maintenance of ideal body weight (BMI = 25)
     – 35%-55%  in CHD
    Maintenance of active lifestyle (20-min walk daily)
     – 35%-55%  in CHD




Hennekens CH. Circulation. 1998;97:1095-1102.
   Survival Following Myocardial
             Infarction
     88,241 Medicare patients, 65 years of
     age and older, hospitalized for MI
     Mortality increased by
      – 19%: any mental disorder
      – 34%: schizophrenia
     Increased mortality explained by
     measures of quality of care



Druss BG et al. Arch Gen Psychiatry. 2001;58:565-572.
Other treatment-induced morbidity
   Risk of increased relapse is associated
    with use of all types of psychiatric
    medications, versus psychosocial
    treatments
    – There is good evidence for the argument that
      medications initially reduce symptoms, but
      then interfere with emotional self-regulation in
      a way that increases long term mental and
      emotional problems
    – Recovery from “schizophrenia” is no better or
      is worse than it was in the pre-drug era
             it is twice as good in parts of the world where
        While
        much less medication is used.
Anti-psychotics and brain damage
   Cause over 10% shrinkage of the brain in
    monkeys given doses comparable per
    body weight to doses given humans with
    “schizophrenia”
    – Usually, such shrinkage is associated with “the
      illness”
        Truth may be complex, maybe some shrinkage due
        to distress, some to the use of medications
   Also cause some areas of the brain, that
    are associated with psychosis if they are
    too dominant, to expand
Overview - PROPOSED SOLUTIONS

Prioritize the Public Health Problem
    Target Providers, Families and Clients
    Focus on Prevention and Wellness
Track Morbidity and Mortality in Public
Mental Health Populations

Implement Established Standards of Care
    Prevention, Screening and Treatment

Improve Access to and Integration of
Physical Health and Mental Health Care
              Recommendations
           LOCAL AGENCY / CLINICIAN

1. BH providers shall provide quality medical care and
   mental health care
        Screen for general health with priority for high risk conditions

        Offer prevention and intervention especially for modifiable risk
        factors (obesity, abnormal glucose and lipid levels, high blood
        pressure, smoking, alcohol and drug use, etc.)

        Prescribers will screen, monitor and intervene for medication risk
        factors related to treatment of SMI (e.g. risk of metabolic
        syndrome with use of second generation anti-psychotics)

        Treatment per practice guidelines, e.g heart disease, diabetes,
        smoking cessation, use of novel anti-psychotics.
         LOCAL AGENCY / CLINICIAN
             Recommendations
2. Care coordination Models

     l   Assure that there is a specific practitioner in the MH system
         who is identified as the responsible party for each person’s
         medical health care needs being addressed and who
         assures coordination all services.


         Routine sharing of clinical information with other
         providers (primary and specialty healthcare
         providers as well as mental health providers

         Care integration where services are co-located
       LOCAL AGENCY / CLINICIAN
          RECOMMENDATIONS
3. Support consumer wellness and empowerment to improve
    personal mental and physical well-being

        educate / share information to make healthy choices
        regarding nutrition, tobacco use, exercise, implications of
        psychotropic drugs
        teach /support wellness self-management skills
        teach /support decision making skills
        motivational interviewing techniques
        Implement a physical health Wellness approach that is
        consistent with Recovery principles, including supports for
        smoking cessation, good nutrition, physical activity and healthy
        weight.
        attend to cultural and language needs
    Full NASMHPD report available
    at
   http://www.nasmhpd.org/publications.cfm#techpap

    – Note you can access both the slideshow and a pdf file that has
      a written report, at this website.
Eliminating unnecessary treatment
          induced harm:
   Reduce reliance on anti-psychotic
    (neuroleptic) medications
    – A large number of studies show that at least a
      significant portion of diagnosed people could
      function well without anti-psychotic
      medications
        Those  who recover the most are typically not using
         medications
        Many people think they need medications because
         they confuse withdrawal effects with their “natural
         state” off medications
        Providing good alternative care could increase the
         number of people able to function without
         medications
How to reduce reliance on harmful
          medications:
 Allnewly diagnosed individuals
  should receive an initial trial of
  treatment without medication
  – Medications should be considered a
    backup, used as little as possible
 Allthose on medications should be
  offered assistance in attempting a
  transition to being on less medication
  or off medication
  – Reducing medication reliance should be
    an ongoing goal
 Parallel process: reduce reliance
 on drug money & misinformation
 Most  psychiatric research and
  continuing education is financed by
  drug companies
 Drug companies withhold information
  that hurts their profits
  – Even when this threatens the lives of
    thousands of people
     Case   example: Eli Lilly & Zyprexa
   Awareness may be going up,
             but….
 Use of psychiatric medications, in
 particular anti-psychotics, continues
 to escalate
  – Reaching way beyond those diagnosed
    with psychosis
  – Reaching a younger and younger
    population
     In   a few states where data is known, cases
        of infants (< 12 months old) on anti-
        psychotics have been found
              Finally
 Whenever  trauma is prevented from
 occurring, we reduce the risk of a
 whole host of problems

 Whenever  trauma is effectively
 healed, we also break the chain that
 leads to these problems

								
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