Physical health comorbidity in the context of Severe Mental illness - PowerPoint Presentation

Slide1

Physical health comorbidity in the context of Severe Mental illness

Dr. Krishna Prasad M

Slide2

Background

People with severe mental illness die on average 10-20 years earlier than the general population

Mortality gap worldwide is widening

Majority of (around 80%) of deaths in people with SMI are due to preventable physical illnesses

Slide3

Background

Prevalence of most physical health conditions is higher and outcomes are poorer

Multi-morbidity is also more common - poorer physical health and quality of life

Neglect of the physical health needs of people with SMI by policymakers and healthcare services

Slide4

Reasons for the neglect

Professional: Competing issues – mental health, social

Illness: Cognitive deficits

Person: Less health care seeking

Research: RCTs exclude SMI

Slide5

Mortality in severe mental illness

Setting - patients

Mortality

Study

Schizophrenia patients from a rural community

SMR – 1.4 - 2.16

Bagewadi et al, 2016

IPSS follow up of 14 years (140 patients)

SMR of 2.3 and 4.5 in males and females

Dube et al, 1984

ISoS

analyses

SMRs of 1.9, 1.86, 1.88, and 3.02 in Madras, Agra, Chandigarh urban, and Chandigarh rural centers

Harrison et al, 2001

Mental hospital setting (nearly 45 % with SMI) – 26 year data

SMR - 0.356, higher in males

Shinde et al, 2014

Bipolar disorder

No data available separately

Slide6

Causes of mortality

Setting

Causes of mortality

Study

Rural population – south India (Schizophrenia)

Cardiovascular, respiratory – 50% of cases

Bagewadi et al, 2016

Hospital setting (45 % with SMI)

Cardiovascular (43.6%), respiratory (14.9%)

Shinde et al, 2014

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Metabolic syndrome in schizophrenia

Setting - patients

Pooled Prevalence

Community based studies

10.81 %

Hospital based

33.5 %

Drug naïve

11.86 %

Meta-analysis of 14 Indian studies

(Ganesh et al, 2016)

31.8% of the patients with schizophrenia in a south Indian rural population compared to 28.9% of general population controls were diagnosed to have Metabolic syndrome

(Rawat et al, 2018)

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Metabolic syndrome in bipolar disorder

40 % of treated bipolar patients of a north Indian hospital

(Grover et al, 2012)

Bipolar patients (55 %) > schizophrenia patients (34 %) > controls (6 %)

(Grover et al, 2013)

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Metabolic syndrome in bipolar disorder

6 months of follow-up the prevalence of Metabolic syndrome increased by 8% and 9.4% in the bipolar and the schizophrenia groups

(Malhotra et al, 2013)

Higher proportion of prevalence of Insulin Resistance in Bipolar drug naive cases vs. controls (26/55 vs. 2/25)

(Guha et al, 2014)

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Infectious diseases - STI

Patients

Sero

-positivity

Study

Newly admitted patients (n=948)

(71 % with SMI) - NIMHANS

HIV (2%), chlamydia (10%), Hepatitis B (3%), syphilis (3%)

(Carey et al, 2007)

Out-patients at CMC Vellore

HIV - 1.03% (national average – 0.7 %, local population – 1.8%)

(

Tharyan

et al, 2003)

Institutionalized patients with psychosis (n=100), Bareilly

Australia antigen - 11 %

Controls – 2 %

(

Chaudhury

et al, 1994)

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Service users at NIMHANS

Patients (SMI)

Dyslipidemia

Diabetes

Hypertension

Obesity

Inpatients (n=101)

13

6

4

14

Outpatients (n=50)

7

8

5

8

Day-care users (n=50)

13

7

7

13

Chronic inpatients

(n=36)

17

11

14

5

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Service users at NIMHANS

Patients with SMI

Nutritional deficiencies

Hypothyroidism

Hepatitis B

Tuberculosis

Cancer

Inpatients (n=101)

41- B12

17-anemia

6

-

-

-

Outpatients (n=50)

7- B12

3-anemia

2

-

-

1 – ca breast

Day-care users (n=50)

11-B12

4-D

3- anemia

13

-

1

2 – ovarian cysts

Chronic inpatients

(n=36)

4-B12

2-D

7- anemia

11

5

3

1-Ovary

2 men -Leukoplakia

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Special clinics

Metabolic clinic

visceral adiposity (n=150) - schizophrenia (37.5%), BPAD (34%)

insulin resistance was as high as 20% in antipsychotic naïve (n=44)

Addiction

82% had Alcohol dependence Syndrome, NDS – 75 %

General medical comorbidity

Psychiatric comorbidity

ADS

21.5%

18.1%

NDS

19.95%

21.29%

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Risk factors for metabolic syndrome

Schizophrenia

Female gender, Urban, married, age >35 years

BMI > 25, family history, high calorie diet, sedentary lifestyle

Antipsychotic exposure, second generation antipsychotic use

“continuous” treatment

IGF -1 deficit - might underlie insulin resistance

Bipolar disorder

Age, sex or current mood status not predictive in bipolar disorder

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Sexually transmitted infections

Engaging in risky sexual behavior (inpatients with SMI) – male, using tobacco and screening positive for either drug use or alcohol problems

(Chandra et al, 2003)

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Tobacco use in SMI

Schizophrenia – 33.64%, mood disorders -33.33% (any form - inpatients)

More than three fourths had markedly severe illness

Dependence – moderate to severe

80 to 90 % case records did not document diagnosis

(Amol, 2017, unpublished)

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Outcomes and economic impact

SMI patients score low on domains of health responsibility and nutrition habit

physical activity and stress management domain in BPAD group

no studies that directly measure the economic impact of physical illnesses

low functioning on GAF, poor quality of life

(Malhotra et al, 2016)

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Existing Interventions

Psychoeducation - importance of adaptive lifestyle

Physical activity – assessment & optimizing

Advise about aerobic physical exercises

Yoga Therapy

Diet Counselling

Optimization of antipsychotics

Metformin, topiramate

Referrals - Physicians, Endocrinologists, Gynecologists, Dentists

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Policy drivers

integrate mental health services into general health care services at all levels of care

Mental health Care Act of India ,2017

care within the existing health systems using a primary health care approach

National Mental Health Policy, 2014

health workers – common for NCD and mental health

National health policy, 2017

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Gaps – services, policy

No countrywide data available on prevalence

Screening may happen only during inpatient care

Mental hospitals - services for evaluation, treatment of physical illness are not available

Barriers

Lack of baseline data of prevalence of comorbidity

Cost is not known

No specific policy

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Research priorities

Prevalence and patterns of comorbidities in SMI need to be examined

Direct and Indirect costs of comorbidities in SMI also need to be studied

NMHS, 2016 – missed an opportunity to examine

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Key factors - experience

Poor access to services

Stigma and negative attitude towards the health of a mentally ill

Cost of treatment

Poor health literacy

Lack of employment opportunities

Poverty, low education, rural background

Slide23

Human rights – channels to work

Framework

Legislative

–MHCA, RPWD

Policy

- National Mental Health policy, National health policy 2017

Programs

- National Mental Health Programme

Bodies

Judiciary and Human Rights commissions

National Commission for Women

Mental health review boards and authorities

Mental Health establishments

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Investigating Mental and Physical Health ComorbiditySurvey in people with severe mental illness in South Asia

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Primary aim

To determine the prevalence of physical disorders and lifestyle health-risk behaviours in people with SMI in South Asia

This will inform stakeholders about lifestyle behaviors and healthcare needs in people with severe mental illness and highlight inequalities in healthcare practices

.

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Settings & population

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Inclusion and exclusion criteria

Inclusion criteria

Adults with a clinical diagnosis of severe mental illness

Able to provide informed consent

Exclusion criteria

Perceived lack of capacity or inability to complete study questionnaires

Slide28

Recruitment Of Participants

Random sampling

1200 out-patients and 300 in-patients will be recruited

Slide29

Measures

MINI version 6

WHO STEPs Version 3.2

PHQ 9

,

GAD 7,

EQ-5D-5L

Infectious diseases, Risk behaviours

BP, Weight, Height, Waist Circumference

HbA1C, LFT, Creatinine, Lipids, TFT, Hb

Slide30

Is it relevant to psychiatric rehabilitation?

Illness management – core component of a recovery framework

Medical comorbidities - within the scope of illness management

Collaborative and reciprocal exercise

Engaging patient and natural supporters

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Why in a Rehabilitation program?

Intrinsic skill building

Environmental supports

Motivational interviewing

Potential sustainability

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Challenges and Prospects

Responsibility for physical health in patients with SMI

Resources and cooperation (or lack of)

Professional competence (building)

Care boundaries (illness, professional, system)

Time for each patient and being persistent