Death rate from ischaemic heart disease in Western Australian psychiatric patients 1980-1998

Chronic somatic comorbidity and excess mortality due to natural causes in persons with schizophrenia or bipolar affective disorder

Background

Suicide and death by accidents in persons with schizophrenia and bipolar disorder are common, but excess mortality from natural death accounts for even more years of life lost. The impact of somatic comorbidity, however, often is not duly considered in analyses and explanations of excess mortality in patients with psychotic disorders.

Objective/Methods

This study investigates and evaluates the impact of 19 severe chronic diseases on excess mortality due to diseases and medical conditions (natural death) in individuals with psychotic disorders compared with the general population using a population-based cohort study in Denmark. Incidence/mortality rate ratios of admission/mortality were calculated using survival analysis.

Results

Cohort members with psychotic disorders had higher incidence rates of hospital contacts for almost all of the 19 disorders than the general population. The mortality rate ratio (MRR) of natural death was 7.10 (95% CI 6.45, 7.81) for schizophrenic men, decreasing to 4.64 (95% CI 4.21, 5.10) after adjustment for the somatic disorders. The same pattern existed in women and in both genders with bipolar disorder. Highest MRRs were observed for psychotic patients without hospital admissions with the investigated somatic disorders.

Conclusion

Chronic somatic diseases accounted for half of the excess mortality in patients with schizophrenia or bipolar disorder. Chronic disorders investigated in this paper seem to be under-treated or under-detected among such patients.

Advanced dental disease in people with severe mental illness: systematic review and meta-analysis

BACKGROUND

Psychiatric patients have increased comorbid physical illness. There is less information concerning dental disease in this population in spite of risk factors including diet and psychotropic side-effects (such as xerostomia). Aims To compare the oral health of people with severe mental illness with that of the general population.

METHOD

A systematic search for studies from the past 20 years was conducted using Medline, PsycINFO, Embase and article bibliographies. Papers were independently assessed. The primary outcome was total tooth loss (edentulousness), the end-stage of both untreated caries and periodontal disease. We also assessed dental decay through standardised measures: the mean number of decayed, missing and filled teeth (DMFT) or surfaces (DMFS). For studies lacking a control group we used controls of similar ages from a community survey within 10 years of the study.

RESULTS

We identified 21 papers of which 14 had sufficient data (n = 2784 psychiatric patients) and suitable controls (n = 31 084) for a random effects meta-analysis. People with severe mental illness had 3.4 times the odds of having lost all their teeth than the general community (95% CI 1.6-7.2). They also had significantly higher scores for DMFT (mean difference 6.2, 95% CI 0.6-11.8) and DMFS (mean difference 14.6, 95% CI 4.1-25.1). Fluoridated water reduced the gap in oral health between psychiatric patients and the general population.

CONCLUSIONS

Psychiatric patients have not shared in the improving oral health of the general population. Management should include oral health assessment using standard checklists that can be completed by non-dental personnel. Interventions include oral hygiene and management of xerostomia.

Poor clinical outcomes among pneumonia patients with schizophrenia

Despite the recent attention to patient safety and quality of care, no prior studies have addressed outcomes of hospitalization for pneumonia among patients with schizophrenia. This study investigated the extent to which clinical outcomes of pneumonia were different among patients with schizophrenia. This study used data from the Taiwan National Health Insurance Research Database. Of the total of 81,599 patients admitted with a principal diagnosis of pneumonia from 2002 to 2004, 949 had previously been admitted with a principal or secondary diagnosis of schizophrenia within the 2 years of their index pneumonia admission. We randomly selected 2847 pneumonia patients matched with the study group in terms of gender, age, year of admission, length of stay, and Charlson Comorbidity Index score as the comparison cohort. Conditional logistic regression models were used for analysis. Findings indicated a higher prevalence of adverse outcomes among patients with schizophrenia. Patients with schizophrenia were independently associated with a 1.81 times greater risk of intensive care unit admission (95% confidence interval [CI] = 1.37-2.40), a 1.37 times greater risk of acute respiratory failure (95% CI = 1.08-1.88), and a 1.34-fold greater risk of mechanical ventilation (95% CI = 1.04-1.92) after adjusting for characteristics of patients, physicians, hospitals, and potential clustering effects. Adjusted odds ratios were further evident among those treated in private hospitals and in regional/district hospitals. Significant barriers to prompt and appropriate medical care for pneumonia persist for patients with schizophrenia. Careful monitoring of physical health and proper integration between psychiatrists and physicians should be stressed to reduce poor clinical outcomes in this vulnerable population.

Quality of care for cardiovascular disease and diabetes amongst individuals with serious mental illness and those using antipsychotic medications

Individuals living with serious mental illness (SMI) experience excess mortality due to natural causes. Cardiovascular disease (CVD) and diabetes are twice as prevalent in SMI populations as in the general population, and this may be partly related to unhealthy lifestyle behaviors and the use of antipsychotic medications. This review examined comparative studies of quality of care in SMI and non-SMI populations, and studies investigating cardio-metabolic screening in patients prescribed antipsychotics. We identified that individuals with SMI are around 30% less likely than those without SMI to receive hospital care for CVD and diabetes complications, to receive blood glucose, lipid, and other diabetes tests, to undergo invasive procedures, and to be prescribed medications known to be effective in the treatment of CVD and diabetes. In addition, less than 30% of individuals with SMI may receive examinations for weight, blood glucose, and lipids, before or during treatment with antipsychotics. Evidence from studies within the U.S.' Veteran Affairs health care system indicates that the integration of physical and mental health services may be beneficial in reducing disparities in health care for individuals with SMI. Clear policies, which identify practitioner responsibilities for cardio-metabolic screening in patients receiving antipsychotic therapy must be disseminated.

Perceptions of mental health nurses and patients about health promotion in mental health care: a literature review

The aim of this review was to examine the perceptions of patients with mental disorders and mental health nurses of health promotion targeting physical activity and eating habits in mental health care. An electronic search strategy was conducted. Furthermore, references were searched by hand-searching the reference lists of the retrieved articles from the electronic databases. The literature on perceptions of health promotion and lifestyle interventions in mental health care principally consist of qualitative studies using interviews and focus groups. Positive perceptions of both mental health nurses and patients towards health promotion targeting physical activity and eating habits in mental health care were identified. Contrary, several barriers for integrating healthy lifestyles into the daily life of patients were described. Patients usually want to learn more about healthy lifestyles, but see the ability to change their physical health as beyond their control. In this sense, support from mental health nurses is considered as important. Despite the awareness of the importance of health promotion in mental health care, it appears that visions and attitudes towards the potential of health promotion are in need of change.

Aboriginal to non-Aboriginal differentials in 2-year outcomes following non-fatal first-ever acute MI persist after adjustment for comorbidity

BACKGROUND

We investigated the relationship between Aboriginality and 2-year cardiovascular disease outcomes in non-fatal first-ever myocardial infarction during 2000-04, with progressive adjustment of covariates, including comorbidities.

DESIGN

Historical cohort study.

METHODS

Person-linked hospital and mortality records were used to identify 28-day survivors of first-ever myocardial infarction in Western Australia during 2000-04 with 15-year lookback. The outcome measures were: (1) cardiovascular disease death; (2) recurrent admission for myocardial infarction; and (3) the composite of (1) and (2).

RESULTS

Compared with non-Aboriginal patients, Aboriginals were younger and more likely to live remotely. The proportions having 5-year histories of diabetes and chronic kidney disease were double and triple those of non-Aboriginals. When adjusting for demographic variables alone, the Aboriginal to non-Aboriginal hazard ratios for cardiovascular death or recurrent myocardial infarction were 3.6 (95% CI 2.5-5.3) in men and 4.5 (95% CI 2.8-7.3) in women. After adjustment for comorbidities, including diabetes, chronic kidney disease and heart failure, the hazard ratios decreased 36% and 47% to 2.3 (1.6-3.0) and 2.4 (1.5-4.0) in males and females, respectively.

CONCLUSIONS

The high prevalence of comorbidities in Aboriginal people, including diabetes, kidney disease, heart failure, and other risk factors contribute substantially to the disparity in post-myocardial infarction outcomes in Aboriginal people, reinforcing the importance of both primary prevention and comprehensive management of chronic conditions in this population. Aboriginality remains a significant independent risk factor for disease recurrence or mortality, even after adjusting for comorbidity, suggesting the need for society-level interventions addressing social disadvantage.

Feasibility of using routinely collected inpatient data to monitor quality and inform choice: a case study using the UK inflammatory bowel disease audit

OBJECTIVE

To assess the utility and cost of using routinely collected inpatient data for large-scale audit.

DESIGN

Comparison of audit data items collected nationally in a designed audit of inflammatory bowel disease (UK IBD audit) with routinely collected inpatient data; surveys of audit sites to compare costs.

SETTING

National Health Service hospitals across England, Wales and Northern Ireland that participated in the UK IBD audit.

PATIENTS

Patients in the UK IBD audit.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Percentage agreement between designed audit data items collected for the UK IBD audit and routine inpatient data items; costs of conducting the designed UK IBD audit and the routine data audit.

RESULTS

There were very high matching rates between the designed audit data and routine data for a small subset of basic important information collected in the UK IBD audit, including mortality; major surgery; dates of admission, surgery, discharge and death; principal diagnoses; and sociodemographic patient characteristics. There were lower matching rates for other items, including source of admission, primary reason for admission, most comorbidities, colonoscopy and sigmoidoscopy. Routine data did not cover most detailed information collected in the UK IBD audit. Using routine data was much less costly than collecting designed audit data.

CONCLUSION

Although valuable for large population-based studies, and less costly than designed data, routine inpatient data are not suitable for the evaluation of individual patient care within a designed audit.

Revascularisation and mortality rates following acute coronary syndromes in people with severe mental illness: comparative meta-analysis

BACKGROUND

High levels of comorbid physical illness and excess mortality rates have been previously documented in people with severe mental illness, but outcomes following myocardial infarction and other acute coronary syndromes are less clear.

AIMS

To examine inequalities in the provision of invasive coronary procedures (revascularisation, angiography, angioplasty and bypass grafting) and subsequent mortality in people with mental illness and in those with schizophrenia, compared with those without mental ill health.

METHOD

Systematic search and random effects meta-analysis were used according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies of mental health and cardiovascular procedures following cardiac events were eligible but we required a minimum of three independent studies to warrant pooling by procedure type. We searched Medline/PubMed and EMBASE abstract databases and ScienceDirect, Ingenta Select, SpringerLink and Online Wiley Library full text databases.

RESULTS

We identified 22 analyses of possible inequalities in coronary procedures in those with defined mental disorder, of which 10 also reported results in schizophrenia or related psychosis. All studies following acute coronary syndrome originated in the USA. The total sample size was 825 754 individuals. Those with mental disorders received 0.86 (relative risk, RR: 95% CI 0.80-0.92, P<0.0001) of comparable procedures with significantly lower receipt of coronary artery bypass graft (CABG; RR = 0.85, 95% CI 0.72-1.00), cardiac catheterisation (RR = 0.85, 95% CI 0.76-0.95) and percutaneous transluminal coronary angioplasty or percutaneous coronary intervention (PTCA/PCI; RR = 0.87, 95% CI 0.72-1.05). People with a diagnosis of schizophrenia received only 0.53 (95% CI 0.44-0.64, P<0.0001) of the usual procedure rate with significantly lower receipt of CABG (RR = 0.69, 95% CI 0.55-0.85) and PTCA/PCI (RR = 0.50, 95% CI 0.34-0.75). We identified 6 related studies examining mortality following cardiac events: for those with mental illness there was a 1.11 relative risk of mortality up to 1 year (95% CI 1.00-1.24, P = 0.05) but there was insufficient evidence to examine mortality rates in schizophrenia alone.

CONCLUSIONS

Following cardiac events, individuals with mental illness experience a 14% lower rate of invasive coronary interventions (47% in the case of schizophrenia) and they have an 11% increased mortality rate. Further work is required to explore whether these factors are causally linked and whether improvements in medical care might improve survival in those with mental ill health.

Improving medical student attitudes towards people with schizophrenia

OBJECTIVE

To develop and evaluate an intervention for final year medical students to reduce stigma against people with schizophrenia.

METHOD

A total of 87 students participated in a 3-h workshop that included both a contact component (a DVD of a young man with schizophrenia) and an experience of simulated auditory hallucinations. Attitudes to schizophrenia were evaluated using the Attitudes to Mental Illness Questionnaire (AMIQ), completed at the beginning and end of the workshop.

RESULTS

There was a significant improvement in mean AMIQ scores after participating in the workshop. Students with more negative attitudes before the workshop showed the most significant improvement, whilst there was little change for students who held more positive attitudes.

CONCLUSION

A workshop combining a DVD narrative by a young person with schizophrenia and simulated auditory hallucinations is an effective teaching tool to improve medical students' attitudes to people with schizophrenia.

Effectiveness and cost-effectiveness of lifestyle interventions on physical activity and eating habits in persons with severe mental disorders: a systematic review

BACKGROUND

There is a high prevalence of overweight and obesity in persons with severe mental disorders and this has serious implications on the short and long term health outcomes of these patients. The aim of this review was to evaluate the effectiveness of lifestyle interventions targeting physical activity and eating habits in persons with severe mental disorders. Special attention was given if any of the included studies in the review also examined the cost-effectiveness of these health promotion interventions.

METHODS

A systematic search through the electronic databases Medline, Web of Science, CINAHL and Cohrane Library was conducted, and by hand-searching the reference lists of the retrieved articles from the electronic databases. Studies were included if they examined effectiveness and/or cost-effectiveness of lifestyle interventions targeting physical activity and eating habits in persons with severe mental disorders, with primary outcome changes in Body Mass Index and body weight.

RESULTS

Fourteen studies met the inclusion criteria. Weight loss and Body Mass Index decrease were observed in intervention groups in 11 studies. The difference in weight change between intervention and control groups was statistically significant in nine studies. Differences in mean Body Mass Index between intervention and control groups were statistically significant in eight studies. Five studies reported improvements in quality of life and general health. In none of the studies cost-effectiveness of lifestyle interventions was examined.

CONCLUSION

Further research on both effectiveness and cost-effectiveness of lifestyle interventions targeting physical activity and eating habits in persons with severe mental disorders is required to assist in the development of new health promotion interventions in this population.

What can we do to reduce the burden of avoidable deaths in those with serious mental illness?

Individuals with schizophrenia have higher mortality rates compared to the general community. Apart from an increased risk of suicide, people with schizophrenia have an increased risk of death related to a wide range of comorbid physical conditions. There is evidence to suggest that much of this mortality is avoidable. The provision of assertive management of comorbid physical disorders has the potential to help close the differential mortality gap. While the primary data are robust, there is less empirical evidence to guide policy makers and service providers when dealing with these problems. Focused clinical programs aimed at reducing risk factors (e.g. smoking, obesity) and shared care between mental health teams and primary care providers can help reduce the burden of avoidable deaths. In light of recent evidence suggesting that the mortality gap has widened in recent decades, there is an urgent need to address the burden of avoidable deaths in those with serious mental illnesses.

Smoking and mental illness: a population study in South Australia

OBJECTIVE

To examine smoking prevalence and smoking behaviour among South Australians with a mental illness and compare findings to those with no mental illness.

METHOD

Data were collected in three cross-sectional representative population surveys of South Australians aged ≥15 years from 2005 to 2007. Merged data yielded a total sample size of 8417. The main outcome measures were: smoking prevalence, measures of tobacco dependence, awareness of the health effects of active and passive smoking, smoke-free homes and cars, awareness of health warnings, and use of cessation aids by two measures of mental illness status.

RESULTS

Overall 26.4% of the population with a general mental illness and 51.2% of the population with a severe mental illness smoked, compared to 18.7% of the population without a mental illness. People with a mental illness, particularly severe mental illness displayed higher measures of tobacco dependence. Smokers with a severe mental illness were less likely to have smoke-free homes (OR = 0.29, 95%CI 0.16-0.55). Television was an effective medium to present the health effects of smoking to all groups. Those with a general mental illness were more likely than those with no mental illness to have asked a general practitioner for advice to help them quit in the past year (OR = 2.02, 95%CI 1.07-3.84).

CONCLUSIONS

Whilst smokers with a mental illness are more dependent on their smoking; they are interested in quitting. There are a number of mainstream tobacco control strategies that could be further utilized (e.g. mass media and health professional referrals to the Quitline) to increase cessation among this disadvantaged group.

Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care

The lifespan of people with severe mental illness (SMI) is shorter compared to the general population. This excess mortality is mainly due to physical illness. We report prevalence rates of different physical illnesses as well as important individual lifestyle choices, side effects of psychotropic treatment and disparities in health care access, utilization and provision that contribute to these poor physical health outcomes. We searched MEDLINE (1966 - August 2010) combining the MeSH terms of schizophrenia, bipolar disorder and major depressive disorder with the different MeSH terms of general physical disease categories to select pertinent reviews and additional relevant studies through cross-referencing to identify prevalence figures and factors contributing to the excess morbidity and mortality rates. Nutritional and metabolic diseases, cardiovascular diseases, viral diseases, respiratory tract diseases, musculoskeletal diseases, sexual dysfunction, pregnancy complications, stomatognathic diseases, and possibly obesity-related cancers are, compared to the general population, more prevalent among people with SMI. It seems that lifestyle as well as treatment specific factors account for much of the increased risk for most of these physical diseases. Moreover, there is sufficient evidence that people with SMI are less likely to receive standard levels of care for most of these diseases. Lifestyle factors, relatively easy to measure, are barely considered for screening; baseline testing of numerous important physical parameters is insufficiently performed. Besides modifiable lifestyle factors and side effects of psychotropic medications, access to and quality of health care remains to be improved for individuals with SMI.

The high prevalence of poor physical health and unhealthy lifestyle behaviours in individuals with severe mental illness

Recent mental health care policy has addressed the need for health care professionals to consider the physical health of consumers. Mental health nurses are particularly well-placed for this role. To provide mental health nurses with practical information, this narrative review summarises evidence from recent research on the physical health of individuals with Serious Mental Illness (SMI). In those with SMI, the international prevalence of obesity, the metabolic syndrome, diabetes mellitus, symptoms of cardiovascular disease, and respiratory disease all exceed that of the general population by at least two times, and HIV prevalence may be increased by as much as eight times. This increased prevalence of chronic disease may be largely responsible for an increased risk of death of up to five times, resulting in as much as 30 years of potential life lost. Of particular concern, the recent evidence suggests that for physical health and increased mortality, the gap between individuals with SMI and the general population is worsening. Unhealthy lifestyle behaviours undoubtedly play a role in the development of poor physical health and chronic disease, and the present review indicates that low physical activity, poor diet, smoking, alcohol and substance abuse, and risky sexual behaviour are common in individuals with SMI. This narrative review demonstrates that the prevalence of poor physical health and health behaviours in people with SMI far exceed that observed in the general population, and reinforces the urgent need for mental health nurses to address physical health concerns in patients.

Physical health in schizophrenia: a challenge for antipsychotic therapy

In the management of schizophrenia, mental health outcomes are the principal focus of treatment. The objective is to control the psychotic symptoms while minimising negative features of the illness, to achieve an overall improvement in the societal functioning of patients. Physical health is also important because if it is compromised, many of the benefits of improved mental health will be offset. Compared with the general population, schizophrenia patients are at increased risk of weight gain, abdominal obesity, diabetes, metabolic syndrome, and cardiovascular disease. These physical health problems can contribute to the decreased quality of life, lowered self-esteem and reduced life expectancy commonly reported in schizophrenia. For these reasons there is a pressing need to improve both the monitoring and the management of physical health in patients with schizophrenia as a part of their overall care. A consensus for metabolic monitoring of patients receiving treatment with antipsychotic drugs is available. However, the practicing clinician requires guidance about management of physical health in routine clinical practice. This should include recommendations for measurements that have strong predictive value about physical health risks yet are easy to make, and about the use of medications that have the least effect on physical health parameters. This article will review the gravity of the physical health risks facing schizophrenia patients.

The epidemiology of excess mortality in people with mental illness

OBJECTIVE

to investigate the burden of excess mortality among people with mental illness in developed countries, how it is distributed, and whether it has changed over time.

METHOD

we conducted a systematic search of MEDLINE, restricting our attention to peer-reviewed studies and reviews published in English relating to mortality and mental illness. Because of the large number of studies that have been undertaken during the last 30 years, we have selected a representative cross-section of studies for inclusion in our review.

RESULTS

there is substantial excess mortality in people with mental illness for almost all psychiatric disorders and all main causes of death. Consistently elevated rates have been observed across settings and over time. The highest numbers of excess deaths are due to cardiovascular and respiratory diseases. With life expectancy increasing in the general population, the disparity in mortality outcomes for people with mental illness is increasing.

CONCLUSIONS

without the development of alternative approaches to promoting and treating the physical health of people with mental illness, it is possible that the disparity in mortality outcomes will persist.

Schizophrenia and cancer: in 2010 do we understand the connection?

OBJECTIVE

in recent years, there has been a plethora of cancer mortality and incidence data reported in schizophrenia. Despite this, there has been little focus on cancer in schizophrenia guidelines. Additionally, there have been suggestions that schizophrenia may provide inherent protection against cancer. The goal of this review is to establish, using recent data, the incidence and mortality rates for cancer in schizophrenia.

METHOD

we identified systematic reviews and meta-analyses and undertook a search using the Medical Subject Headings' entry terms schizophrenia and neoplasm.

RESULTS

incidence and mortality rates for cancer in schizophrenia are increased, compared with relevant general populations. Data are not uniformly reported and cohort ages tend to be young for expected cancer incidence. Despite the young cohort ages, the incidence of the major cancers-lung and breast-are substantially increased. Confounders are often not measured in the epidemiologic databases. When lung cancer is adjusted for smoking rates, there appears to be a lower risk of lung cancer than expected providing some basis to support an inherently reduced risk of cancer. There may also be a dissonance between incidence and mortality rates that suggest a prejudice against either diagnosis or treatment of these vulnerable patients.

CONCLUSION

a single definitive study of schizophrenia and cancer is unfeasible, and future research will lean heavily on systematic review and meta-analysis. Researchers should report cancer data to include age and follow-up data and cohort overlap. Cancer accounts for almost an equivalent mortality as cardiovascular disease.

Do deficits in cardiac care influence high mortality rates in schizophrenia? A systematic review and pooled analysis

We have previously documented inequalities in the quality of medical care provided to those with mental ill health but the implications for mortality are unclear. We aimed to test whether disparities in medical treatment of cardiovascular conditions, specifically receipt of medical procedures and receipt of prescribed medication, are linked with elevated rates of mortality in people with schizophrenia and severe mental illness. We undertook a systematic review of studies that examined medical procedures and a pooled analysis of prescribed medication in those with and without comorbid mental illness, focusing on those which recruited individuals with schizophrenia and measured mortality as an outcome. From 17 studies of treatment adequacy in cardiovascular conditions, eight examined cardiac procedures and nine examined adequacy of prescribed cardiac medication. Six of eight studies examining the adequacy of cardiac procedures found lower than average provision of medical care and two studies found no difference. Meta-analytic pooling of nine medication studies showed lower than average rates of prescribing evident for the following individual classes of medication; angiotensin converting enzyme inhibitors (n = 6, aOR = 0.779, 95% CI = 0.638-0.950, p = 0.0137), beta-blockers (n = 9, aOR = 0.844, 95% CI = 0.690-1.03, p = 0.1036) and statins (n = 5, aOR = 0.604, 95% CI = 0.408-0.89, p = 0.0117). No inequality was evident for aspirin (n = 7, aOR = 0.986, 95% CI = 0.7955-1.02, p = 0.382). Interestingly higher than expected prescribing was found for older non-statin cholesterol-lowering agents (n = 4, aOR = 1.55, 95% CI = 1.04-2.32, p = 0.0312). A search for outcomes in this sample revealed ten studies linking poor quality of care and possible effects on mortality in specialist settings. In half of the studies there was significantly higher mortality in those with mental ill health compared with controls but there was inadequate data to confirm a causative link. Nevertheless, indirect evidence supports the observation that deficits in quality of care are contributing to higher than expected mortality in those with severe mental illness (SMI) and schizophrenia. The quality of medical treatment provided to those with cardiac conditions and comorbid schizophrenia is often suboptimal and may be linked with avoidable excess mortality. Every effort should be made to deliver high-quality medical care to people with severe mental illness.

Mortality in schizophrenia: a measurable clinical endpoint

Over the last five years, large data sets on mortality in schizophrenia have been published which have established mortality as a measurable clinical endpoint. Four issues need clarification: whether mortality rates are declining, what the causes of death are, the effects antipsychotic treatments have on mortality and whether these data inform as to how mortality may be reduced in the future. A PubMed search was carried out to identify relevant publications. The search strategy was conducted as a review focusing predominantly on data since 2006. A large number of retrospective epidemiological and prospective studies have been published on mortality rates and causation in schizophrenia, predominantly from 2006-2009. Data suggest that the mortality gap with the general population increased from the 1970s but may have peaked in the mid-1990s. The main causes of mortality are suicide, cancer and cardiovascular disease, with evidence that cancer mortality rates are similar to cardiovascular mortality rates. Mortality causation is dependent upon age of the cohort, length of follow up and type of study. Antipsychotic treatments reduce mortality when compared with no treatment and atypical antipsychotics do not appear to increase cardiovascular mortality and morbidity compared with conventionals; further research is required for any definitive conclusion.

Inequalities in healthcare provision for people with severe mental illness

There are many factors that contribute to the poor physical health of people with severe mental illness (SMI), including lifestyle factors and medication side effects. However, there is increasing evidence that disparities in healthcare provision contribute to poor physical health outcomes. These inequalities have been attributed to a combination of factors including systemic issues, such as the separation of mental health services from other medical services, healthcare provider issues including the pervasive stigma associated with mental illness, and consequences of mental illness and side effects of its treatment. A number of solutions have been proposed. To tackle systemic barriers to healthcare provision integrated care models could be employed including co-location of physical and mental health services or the use of case managers or other staff to undertake a co-ordination or liaison role between services. The health care sector could be targeted for programmes aimed at reducing the stigma of mental illness. The cognitive deficits and other consequences of SMI could be addressed through the provision of healthcare skills training to people with SMI or by the use of peer supporters. Population health and health promotion approaches could be developed and targeted at this population, by integrating health promotion activities across domains of interest. To date there have only been small-scale trials to evaluate these ideas suggesting that a range of models may have benefit. More work is needed to build the evidence base in this area.

Motivation to quit smoking among hospitalised individuals with and without mental health disorders

BACKGROUND

Persons with mental health disorders (MHD) have higher rates of smoking and poorer cessation of smoking outcomes than those without MHD. A decreased level of motivation may partially explain lower cessation rates, but there is little information on motivation among inpatients with MHD.

OBJECTIVES

Primary aims were to compare (1) motivation to cease smoking among those hospitalised with MHD or non-MHD, (2) the proportion that attempted smoking cessation, and (3) use of aids to cessation. A secondary aim was to assess cessation up to six months post-discharge.

METHODS

Smokers were recruited at a tertiary hospital in Perth, Western Australia. Surveys were administered upon admission and at 5 and 14 days and 6 months post-discharge.

RESULTS

We recruited 64 MHD inpatients and 43 non-MHD inpatients. At baseline there were no significant differences between the groups on any measures of the five measures of motivation. Significantly more of the MHD sample attempted smoking cessation than those in the non-MHD sample (34 versus 13: chi(2)(1)=5.472, P=0.028). Nicotine replacement therapy (NRT) alone was used by 70% of those attempting to quit but was only provided as part of discharge medication to two people and few persons (<21%) in either group used NRT post-discharge. By 14 days, three (4.7%) of the MHD group and none (0%) of the non-MHD group reported abstinence, at 6-months one from each group reported continuous abstinence since discharge from hospital.

CONCLUSIONS

Motivation to cease smoking among inpatients with MHD was similar to those without MHD, as was use of NRT while hospitalised. The low provision of post-discharge NRT may contribute to the poor cessation of smoking outcomes and does not fulfil evidence based guidelines.

Mortality among psychiatric patients in Taiwan--results from a universal National Health Insurance programme

This study investigated 6-year follow-up mortality rates and cause of death for persons younger than 45 years old with a history of hospitalisation for major psychiatric disorders after the introduction of the National Health Insurance (NHI). Linkage data combining death certificates with Taiwan NHI research claims data were used. The study cohort was comprised all patients under the age of 45 years, who had been hospitalised for major psychiatric disorders in 1998. Patients aged <45 years undergoing an appendectomy were selected as a control group. Cox proportional hazard regressions were performed to compute the adjusted 6-year hazard ratios. For patients with schizophrenia, major depression, or bipolar disorder, the adjusted risks of dying during the follow-up period were significantly 4.614, 3.707 and 3.866, respectively, times higher than that for appendectomy patients. The adjusted hazard ratios of non-natural dying during the follow-up period were significantly 16.316, 14.626 and 8.481 times for female patients with schizophrenia, major depression, and bipolar disorder, respectively, as high as for female appendectomy patients. The continuing excess mortality among psychiatric patients, from both natural and unnatural causes, still remains even after implementation of a NHI.

Do users of mental health services lack access to general practitioner services?

OBJECTIVE

To compare rates of visits to a general practitioner between users and non-users of mental health services (MHS).

DESIGN, PARTICIPANTS AND SETTING

Population-based retrospective cohort study of 204 727 users and 294 076 matched non-users of MHS in Western Australia from 1 January 1990 to 30 June 2006, based on linked records of the use of MHS, hospital admissions, Medicare claims for GP and specialist services, electoral roll registration and deaths.

MAIN OUTCOME MEASURES

Adjusted rate ratios (ARRs) for the number of visits to GPs by users of MHS relative to non-users, and for different categories of mental disorders.

RESULTS

Relative to non-users of MHS, the ARR of visits to GPs by users of MHS was 1.622 (95% CI, 1.613-1.631) overall, and was elevated in each separate category of mental illness. ARRs were highest for alcohol/drug disorders, schizophrenia and affective psychoses (2.404, 1.834 and 1.798, respectively). The results were not changed by location (metropolitan, rural or remote addresses). However, the 4% of MHS users with no fixed address had a very low ARR of visits to GPs (0.058; 95% CI, 0.057-0.060).

CONCLUSIONS

Users of MHS visit GPs substantially more often than non-users, with the exception of those with no fixed address who seldom see a GP at all.

There is no health without mental health: are we educating Australian nurses to care for the health consumer of the 21st century?

One in five Australians has a diagnosable mental illness and the impact of the illness on the individual, their family, and the community is significant. Since comprehensive nursing was introduced in the 1980s there have been repeated concerns raised regarding the preparedness of graduates from Australian undergraduate nursing programs to care for people who have a mental illness. In 2009, despite a recent comprehensive national review of the mental health/illness content in pre-registration curricula, these concerns remain. The nursing profession must have a responsibility to the global community to ensure that registered nurses are educated to meet evolving health challenges and the needs of the health consumer in the 21st Century. The purpose of this paper is to highlight the prevalence and impact of mental illness on health care outcomes in all settings and to challenge the profession to acknowledge that mental health nursing content must be a core area of all undergraduate curricula. A nationally coordinated response to address the long standing identified deficits in the educational preparation of comprehensive nurses is now a priority to ensure that nurses remain a major stakeholder group in the delivery of health care and key health informants and decision makers within the global health care arena.

Preexisting comorbid psychiatric conditions and mortality in nonsurgical intensive care patients

PURPOSE

To examine the effects of preexisting comorbid psychiatric conditions on mortality in a large cohort of patients admitted to a nonsurgical intensive care unit.

METHODS

This retrospective cohort study involved 66,672 consecutive eligible nonsurgical patients admitted to intensive care units in 129 Veterans Health Administration hospitals during 2005 and 2006. Preexisting comorbid psychiatric conditions were identified by using diagnoses from outpatient encounters in the prior year for depression, anxiety, psychosis, bipolar disorders, and posttraumatic stress disorder. Generalized estimating equations were used to adjust the risks of in hospital and 30-day mortality for demographics, comorbid medical conditions, markers of severity, and abnormal findings on laboratory tests at admission.

RESULTS

Comorbid psychiatric conditions were identified in 28% (n = 18 698) of patients. Patients with preexisting comorbid psychiatric conditions had lower (P < .001) unadjusted in hospital mortality (7.3% vs 8.7%) and 30-day mortality (10.0% vs 12.8%) than did patients without such conditions. After demographics, comorbid medical conditions, and severity were adjusted for, risk of in-hospital mortality among patients with comorbid psychiatric conditions was somewhat higher (odds ratio, 1.07, 95% confidence interval, 1.01-1.14; P = .02), although differences in 30-day mortality (odds ratio, 1.01, 95% confidence interval, 0.94-1.08; P = .70) were no longer significant.

CONCLUSION

Preexisting comorbid psychiatric conditions are common among intensive care patients, but after comorbid medical conditions and severity were adjusted for, preexisting comorbid psychiatric conditions were not associated with a higher risk of 30-day mortality in a large national cohort of veterans.

Impact of a nurse-led intervention to improve screening for cardiovascular risk factors in people with severe mental illnesses. Phase-two cluster randomised feasibility trial of community mental health teams

Background

People with severe mental illnesses (SMI) are at increased risk of cardiovascular disease (CVD). Clinical guidelines recommend regular screening for CVD risk factors. We evaluated a nurse led intervention to improve screening rates across the primary-secondary care interface.

Methods

Six community mental health teams (CMHTs) were randomised to receive either the nurse led intervention plus education pack (n = 3) or education pack only (n = 3). Intervention (6 months): The nurse promoted CVD screening in primary care and then in CMHTs. Patients who remained unscreened were offered screening by the nurse. After the intervention participants with SMI were recruited from each CMHT to collect outcome data. Main outcome: Numbers screened during the six months, confirmed in General Practice notes.

Results

All six CMHTs approached agreed to randomisation. 121 people with SMI participated in outcome interviews during two waves of recruitment (intervention arm n = 59, control arm n = 62). Participants from both arms of the trial had similar demographic profiles and rates of previous CVD screening in the previous year, with less than 20% having been screened for each risk factor. After the trial, CVD screening had increased in both arms but participants from the intervention arm were significantly more likely to have received screening for blood pressure (96% vs 68%; adjusted Odds Ratio (OR) 13.6; 95% CI: 3.5-38.4), cholesterol (66.7% vs 26.9%, OR 6.1; 3.2-11.5), glucose (66.7% vs 36.5% OR 4.4; 2.7-7.1), BMI (92.5% vs 65.2% OR 6.5; 2.1-19.6), and smoking status (88.2% vs 57.8% OR 5.5; 3.2-9.5) and have a 10 year CVD risk score calculated (38.2% vs 10.9%) OR 5.2 1.8-15.3). Within the intervention arm approximately half the screening was performed in general practice and half by the trial nurse.

Conclusions

The nurse-led intervention was superior, resulting in an absolute increase of approximately 30% more people with SMI receiving screening for each CVD risk factor. The feasibility of the trial was confirmed in terms of CMHT recruitment and the intervention, but the response rate for outcome collection was disappointing; possibly a result of the cluster design. The trial was not large or long enough to detect changes in risk factors.

Trial Registration

International Standard Randomised Controlled Trial Registration Number (ISRCTRN) 58625025.

Increased risk of acute myocardial infarction after acute episode of schizophrenia: 6 year follow-up study

OBJECTIVE

The aim of the present study was to estimate the risk of acute myocardial infarction (AMI) among patients who received a first hospital diagnosis of schizophrenia during a 6 year follow-up period.

METHOD

Data from the Taiwan National Health Insurance Research Database were used. The study cohort consisted of 7353 patients who were hospitalized with a principal diagnosis of schizophrenia in 2000. The comparison cohort were 22 059 enrollees randomly selected matched with the study group in terms of gender and age. Each patient was tracked from their index hospitalization in 2000 until the end of 2006 to identify whether or not an AMI had occurred during the follow-up period. Cox proportional hazard regressions were performed to compute the adjusted 6 year survival rate, following adjustment for possible confounding variables.

RESULTS

A total of 130 patients suffered AMI during the 6 year follow-up period, including 30 from the study cohort (0.41% of the schizophrenia patients), and 100 (0.45%) from the comparison cohort. But after censoring those patients who died from non-AMI causes and adjusting for potential confounding factors, the risk of AMI occurrence during the 6 year follow-up period was 1.83-fold greater for schizophrenia patients (95% confidence interval 5 1.62-2.05) than for patients in the comparison cohort.

CONCLUSION

Schizophrenia patients had a higher risk of AMI compared to patients in the comparison cohort. The present study draws attention to the need for clinicians to more actively monitor and treat schizophrenia patients with well-recognized risk factors associated with AMI.

Treatment of ischaemic heart disease and stroke in individuals with psychosis under universal healthcare

BACKGROUND

Most data on the quality of vascular care for individuals with psychiatric conditions come from countries without universal healthcare.

AIMS

To investigate the treatment of people with psychosis admitted for ischaemic heart disease or stroke under universal healthcare.

METHOD

A population-based study of administrative data comparing Canadians with and without a history of schizophrenia or related psychosis (n = 65,039).

RESULTS

Of 49 248 admissions for ischaemic heart disease, 1285 had a history of psychosis. Despite a higher 1-year mortality, they were less likely to receive guideline-consistent treatment: e.g. coronary artery bypass grafting (adjusted odds ratio (OR) = 0.35, 95% CI 0.25-0.48), beta-blockers (adjusted OR = 0.82, 95% CI 0.71-0.95) and statins (adjusted OR = 0.51, 95% CI 0.41-0.63). Of 15 791 admissions for stroke, 594 had a history of psychosis. Despite higher 1-year mortality rates, they were less likely to receive cerebrovascular arteriography or warfarin.

CONCLUSIONS

People with a history of psychosis do not receive equitable levels of vascular care under universal healthcare.

European network for promoting the physical health of residents in psychiatric and social care facilities (HELPS): background, aims and methods

Background

People with mental disorders have a higher prevalence of physical illnesses and reduced life expectancy as compared with the general population. However, there is a lack of knowledge across Europe concerning interventions that aim at reducing somatic morbidity and excess mortality by promoting behaviour-based and/or environment-based interventions.

Methods and design

HELPS is an interdisciplinary European network that aims at (i) gathering relevant knowledge on physical illness in people with mental illness, (ii) identifying health promotion initiatives in European countries that meet country-specific needs, and (iii) at identifying best practice across Europe. Criteria for best practice will include evidence on the efficacy of physical health interventions and of their effectiveness in routine care, cost implications and feasibility for adaptation and implementation of interventions across different settings in Europe. HELPS will develop and implement a "physical health promotion toolkit". The toolkit will provide information to empower residents and staff to identify the most relevant risk factors in their specific context and to select the most appropriate action out of a range of defined health promoting interventions. The key methods are (a) stakeholder analysis, (b) international literature reviews, (c) Delphi rounds with experts from participating centres, and (d) focus groups with staff and residents of mental health care facilities.

Meanwhile a multi-disciplinary network consisting of 15 European countries has been established and took up the work. As one main result of the project they expect that a widespread use of the HELPS toolkit could have a significant positive effect on the physical health status of residents of mental health and social care facilities, as well as to hold resonance for community dwelling people with mental health problems.

Discussion

A general strategy on health promotion for people with mental disorders must take into account behavioural, environmental and iatrogenic health risks. A European health promotion toolkit needs to consider heterogeneity of mental disorders, the multitude of physical health problems, health-relevant behaviour, health-related attitudes, health-relevant living conditions, and resource levels in mental health and social care facilities.

Cardiovascular disease and diabetes in people with severe mental illness position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC)

People with severe mental illnesses, such as schizophrenia, depression or bipolar disorder, have worse physical health and reduced life expectancy compared to the general population. The excess cardiovascular mortality associated with schizophrenia and bipolar disorder is attributed in part to an increased risk of the modifiable coronary heart disease risk factors; obesity, smoking, diabetes, hypertension and dyslipidaemia. Antipsychotic medication and possibly other psychotropic medication like antidepressants can induce weight gain or worsen other metabolic cardiovascular risk factors. Patients may have limited access to general healthcare with less opportunity for cardiovascular risk screening and prevention than would be expected in a non-psychiatric population. The European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC) published this statement with the aim of improving the care of patients suffering from severe mental illness. The intention is to initiate cooperation and shared care between the different healthcare professionals and to increase the awareness of psychiatrists and primary care physicians caring for patients with severe mental illness to screen and treat cardiovascular risk factors and diabetes.

Smoking and mental illness: results from population surveys in Australia and the United States

BACKGROUND

Smoking has been associated with a range of mental disorders including schizophrenia, anxiety disorders and depression. People with mental illness have high rates of morbidity and mortality from smoking related illnesses such as cardiovascular disease, respiratory diseases and cancer. As many people who meet diagnostic criteria for mental disorders do not seek treatment for these conditions, we sought to investigate the relationship between mental illness and smoking in recent population-wide surveys.

METHODS

Survey data from the US National Comorbidity Survey-Replication conducted in 2001-2003, the 2007 Australian Survey of Mental Health and Wellbeing, and the 2007 US National Health Interview Survey were used to investigate the relationship between current smoking, ICD-10 mental disorders and non-specific psychological distress. Population weighted estimates of smoking rates by disorder, and mental disorder rates by smoking status were calculated.

RESULTS

In both the US and Australia, adults who met ICD-10 criteria for mental disorders in the 12 months prior to the survey smoked at almost twice the rate of adults without mental disorders. While approximately 20% of the adult population had 12-month mental disorders, among adult smokers approximately one-third had a 12-month mental disorder--31.7% in the US (95% CI: 29.5%-33.8%) and 32.4% in Australia (95% CI: 29.5%-35.3%). Female smokers had higher rates of mental disorders than male smokers, and younger smokers had considerably higher rates than older smokers. The majority of mentally ill smokers were not in contact with mental health services, but their rate of smoking was not different from that of mentally ill smokers who had accessed services for their mental health problem. Smokers with high levels of psychological distress smoked a higher average number of cigarettes per day.

CONCLUSION

Mental illness is associated with both higher rates of smoking and higher levels of smoking among smokers. Further, a significant proportion of smokers have mental illness. Strategies that address smoking in mental illness, and mental illness among smokers would seem to be important directions for tobacco control. As the majority of smokers with mental illness are not in contact with mental health services for their condition, strategies to address mental illness should be included as part of population health-based mental health and tobacco control efforts.

Smoking and mental illness: results from population surveys in Australia and the United States

BACKGROUND

Smoking has been associated with a range of mental disorders including schizophrenia, anxiety disorders and depression. People with mental illness have high rates of morbidity and mortality from smoking related illnesses such as cardiovascular disease, respiratory diseases and cancer. As many people who meet diagnostic criteria for mental disorders do not seek treatment for these conditions, we sought to investigate the relationship between mental illness and smoking in recent population-wide surveys.

METHODS

Survey data from the US National Comorbidity Survey-Replication conducted in 2001-2003, the 2007 Australian Survey of Mental Health and Wellbeing, and the 2007 US National Health Interview Survey were used to investigate the relationship between current smoking, ICD-10 mental disorders and non-specific psychological distress. Population weighted estimates of smoking rates by disorder, and mental disorder rates by smoking status were calculated.

RESULTS

In both the US and Australia, adults who met ICD-10 criteria for mental disorders in the 12 months prior to the survey smoked at almost twice the rate of adults without mental disorders. While approximately 20% of the adult population had 12-month mental disorders, among adult smokers approximately one-third had a 12-month mental disorder--31.7% in the US (95% CI: 29.5%-33.8%) and 32.4% in Australia (95% CI: 29.5%-35.3%). Female smokers had higher rates of mental disorders than male smokers, and younger smokers had considerably higher rates than older smokers. The majority of mentally ill smokers were not in contact with mental health services, but their rate of smoking was not different from that of mentally ill smokers who had accessed services for their mental health problem. Smokers with high levels of psychological distress smoked a higher average number of cigarettes per day.

CONCLUSION

Mental illness is associated with both higher rates of smoking and higher levels of smoking among smokers. Further, a significant proportion of smokers have mental illness. Strategies that address smoking in mental illness, and mental illness among smokers would seem to be important directions for tobacco control. As the majority of smokers with mental illness are not in contact with mental health services for their condition, strategies to address mental illness should be included as part of population health-based mental health and tobacco control efforts.

Prevalence and predictors of metabolic syndrome among patients attending an outpatient clozapine clinic in Australia

OBJECTIVE

This study aimed to determine the prevalence and predictors of metabolic syndrome in an outpatient clozapine clinic in Australia.

METHODS

Metabolic syndrome is a cluster of some of the most dangerous cardiovascular risk factors, and its high prevalence in people with mental illness has been demonstrated. Patients attending a clozapine clinic were screened for the following: age, gender, ethnicity, waist circumference, blood pressure, high-density lipoprotein level, low-density lipoprotein level, blood sugar levels, total cholesterol level, triglycerides level, weight, body mass index, insulin resistance level, length of time on clozapine, clozapine dose, smoking status, family history of diabetes and cardiovascular disease, and personal history of polycystic ovarian syndrome. All the variables that were found to be significantly associated with metabolic syndrome were entered into a multivariate logistic regression analysis.

RESULTS

Seventy-three patients were screened for metabolic syndrome using the International Diabetes Federation's (2007) definition. Forty-five (61.6%) patients met the criteria for the syndrome. Increased blood sugar level, high diastolic blood pressure, older age, increased waist circumference, raised triglycerides level, and higher body mass index emerged as significant predictors of metabolic syndrome in the sample.

CONCLUSIONS

This study adds further support for the systematic screening for metabolic syndrome in patients receiving clozapine. The need for intervention programs which screen for and address the modifiable risk factors of metabolic syndrome is discussed.

Quality of medical care for people with and without comorbid mental illness and substance misuse: systematic review of comparative studies

BACKGROUND

There has been long-standing concern about the quality of medical care offered to people with mental illness.

AIMS

To investigate whether the quality of medical care received by people with mental health conditions, including substance misuse, differs from the care received by people who have no comparable mental disorder.

METHOD

A systematic review of studies that examined the quality of medical care in those with and without mental illness was conducted using robust critical appraisal techniques.

RESULTS

Of 31 valid studies, 27 examined receipt of medical care in those with and without mental illness and 10 examined medical care in those with and without substance use disorder (or dual diagnosis). Nineteen of 27 and 10 of 10, respectively, suggested inferior quality of care in at least one domain. Twelve studies found no appreciable differences in care or failed to detect a difference in at least one key area. Several studies showed an increase in healthcare utilisation but without any increase in quality. Three studies found superior care for individuals with mental illness in specific subdomains. There was inadequate information concerning patient satisfaction and structural differences in healthcare delivery. There was also inadequate separation of delivery of care from uptake in care on which to base causal explanations.

CONCLUSIONS

Despite similar or more frequent medical contacts, there are often disparities in the physical healthcare delivered to those with psychiatric illness although the magnitude of this effect varies considerably.

Schizophrenia, "just the facts" 4. Clinical features and conceptualization

Although dementia praecox or schizophrenia has been considered a unique disease entity for the past century, its definitions and boundaries have continued to vary over this period. At any given time, the changing concept of schizophrenia has been influenced by available diagnostic tools and treatments, related conditions from which it most needs to be distinguished, extant knowledge and scientific paradigms. There is significant heterogeneity in the etiopathology, symptomatology, and course of schizophrenia. It is characterized by an admixture of positive, negative, cognitive, mood, and motor symptoms whose severity varies across patients and through the course of the illness. Positive symptoms usually first begin in adolescence or early adulthood, but are often preceded by varying degrees of negative and cognitive symptomatology. Schizophrenia tends to be a chronic and relapsing disorder with generally incomplete remissions, variable degrees of functional impairment and social disability, frequent comorbid substance abuse, and decreased longevity. Although schizophrenia may not represent a single disease with a unitary etiology or pathogenetic process, alternative approaches have thus far been unsuccessful in better defining this syndrome or its component entities. The symptomatologic, course, and etio-pathological heterogeneity can usefully be addressed by a dimensional approach to psychopathology, a clinical staging approach to illness course, and by elucidating endophenotypes and markers of illness progression, respectively. This will allow an approach to the deconstruction of schizophrenia into its multiple component parts and strategies to reconfigure these components in a more meaningful manner. Possible implications for DSM-V and ICD-11 definitions of schizophrenia are discussed.

Assessing motivation to quit smoking in people with mental illness: a review

BACKGROUND

People with mental health (MH) disorders smoke at higher rates, are more nicotine-dependent and suffer greater morbidity and mortality from smoking-related illnesses than the general population. Helping these people to quit smoking is a public health priority; however, many MH professionals assume that those with mental illness are not motivated to quit.

OBJECTIVES

To use predetermined criteria to identify, review critically and evaluate empirically all English language, peer-reviewed data on motivation to quit smoking in MH populations.

METHODS

A systematic search was conducted and key data on subject characteristics, measures of motivation and other variables abstracted. chi(2) analyses were used to compare motivation between MH and general populations, between in-patients and out-patients and between people with depression and people with psychotic disorders.

RESULTS

Evidence suggests that people with MH disorders are as motivated to quit smoking as the general population, although those with psychotic disorders may be less motivated than individuals with depression. Although readiness to cease smoking was assessed in 14 studies, only two evaluated motivation to quit smoking in in-patient populations.

CONCLUSIONS

People with MH disorders are motivated to quit smoking, although more research is needed looking at in-patient populations. The commonly held false belief that people with MH disorders are not motivated to cease smoking means that opportunities to encourage smoking cessation among this disenfranchised group are being missed.

Psychiatric comorbidity and mortality after acute myocardial infarction

BACKGROUND

Prior studies of the impact of psychiatric comorbidity on outcomes after acute myocardial infarction (AMI) have frequently relied on inpatient secondary diagnosis codes. This study compared associations between psychiatric comorbidity and AMI outcomes that were derived using secondary diagnosis codes and codes captured from prior outpatient encounters.

METHODS AND RESULTS

Retrospective cohort study analyzing 21 745 patients admitted in 2004 to 2006 to Veterans Health Administration hospitals with AMI using administrative data. Psychiatric comorbidity was identified using (1) secondary inpatient diagnosis codes from the index hospitalization and (2) diagnoses from prior outpatient encounters. Outcomes included 30- and 365-day mortality and the receipt of coronary revascularization within 30 days of admission. Generalized estimating equations and Cox proportional hazards were used to adjust mortality and receipt of revascularization for demographic and clinical variables. Psychiatric disorders were identified in 2285 (10%) patients from inpatient secondary diagnosis codes and 5225 (24%) patients from prior outpatient codes. Patients with psychiatric comorbidity had higher adjusted 30- and 365-day mortality, based on outpatient codes (odds ratios, 1.19 [95% CI, 1.09 to 1.30] and 1.12 [95% CI, 1.03 to 1.22], respectively), but similar mortality based on inpatient codes (odds ratios, 0.89 [95% CI, 0.69 to 1.01] and 0.93 [95% CI, 0.82 to 1.06], respectively). In contrast, patients with psychiatric comorbidity had lower receipt of coronary revascularization based on outpatient codes (hazard ratio, 0.92; [95% CI, 0.85 to 0.99], but similar receipt based on inpatient codes (hazard ratio, 1.00 [95% CI, 0.91 to 1.10]).

CONCLUSIONS

Inpatient secondary diagnosis codes identified fewer patients with psychiatric comorbidity than prior outpatient codes. Moreover, associations with AMI outcomes differed for the 2 approaches. These findings raise potential concerns about the validity and reliability of psychiatric inpatient secondary diagnosis in estimating the impact of psychiatric comorbidities on AMI outcomes and in developing risk-adjustment models.

Prevalence and risk of atopic disorders among schizophrenia patients: a nationwide population based study

OBJECTIVE

Although a body of evidence indicates a link between psychiatric illnesses and allergies, no one has investigated the association between schizophrenia and atopic disorders. The objective of this nationwide population-based study was to examine the prevalence and risk of atopic disorders (asthma, allergic rhinitis, urticaria, and atopic dermatitis) among schizophrenia patients.

METHOD

This study used data from the Taiwan National Health Insurance Research Database covering the years 2000 to 2002. A total of 44,187 patients diagnosed with schizophrenia in the year 2000 were included, together with 132,561 matched non-psychiatric controls. Follow up until the end of 2002 identified concurrent diagnoses of atopic disorders. Logistic regression analyses were performed after controlling for the covariates of socio-demographic characteristics.

RESULTS

Findings indicated high comorbidity, with 20.2% of schizophrenia patients (approximately one in five) experiencing concurrent atopic disorders. Moreover, schizophrenia in patients was independently associated with a 1.3-fold increased risk (95%CI=1.24-1.39) of concurrent asthma, after adjusting for socio-demographic characteristics. Yet the risk of diagnosed allergic rhinitis and urticaria was 23% (95%CI=0.74-0.81) and 26% (95%CI=0.72-0.77) lower, respectively, among schizophrenia patients compared to people without any psychiatric disease.

CONCLUSION

Data suggests an increased risk of asthma and decreased risk of allergic rhinitis and urticaria among schizophrenia patients. Future studies on the identification of common etiologic pathways for schizophrenia and asthma could be significant for developing innovative treatments that target both illnesses concurrently.

Five-year mortality of Finnish schizophrenia patients in the era of deinstitutionalization

BACKGROUND

Excess mortality among people with schizophrenia due to natural and unnatural causes, especially due to suicides, is a well-known fact. It has been suggested that deinstitutionalization increases suicide mortality but there are also contradictory results. We studied the changes in mortality and causes of death among schizophrenia sufferers during and after the years of deinstitutionalization process in Finland.

METHOD

The sample, identified from the Finnish hospital discharge register (FHDR), consisted of patients aged 15-65 and hospitalized for the first time due to schizophrenia. We focused on the 5-year follow-up from inclusion years 1980-1998 (N=23,959). Changes in 5-year follow-up mortality during the study period were explored for both genders and for different causes of death separately using multivariate logistic regression analyses.

RESULTS

During the study period 1,926 deaths occurred. Suicide was the major cause of death in both genders. A significant reduction in overall 5-year mortality was observed among persons hospitalized in 1995-1998 when compared to people hospitalized 1980-1984. In males a significant reduction was seen in all mortality (P=0.025) due to suicides (P=0.007) but not in the case of natural deaths. In females no significant changes in mortality were found.

CONCLUSIONS

Our study confirms a reduction in suicide mortality of male schizophrenia sufferers after the deinstitutionalization process. However the overall mortality is still very high and the attention needs to be focused on the general well-being of schizophrenia patients.

Executive cognitive function and cessation of smoking among older smokers

Evaluation of: Brega AG, Grigsby J, Kooken R, Hamman RF, Baxter J: The impact of executive cognitive functioning on rates of smoking cessation in the San Luis Valley Health and Aging Study. Age Ageing 37, 521–525 (2008). The prevalence of smoking among the elderly is lower than in the general population, but aging populations in many countries mean that smoking-related diseases will increase as a health burden in the future. Executive cognitive functioning (ECF) allows people to plan and regulate behavior in order to achieve future goals. Impaired ECF is prevalent in those aged over 65 years and may be a factor in continued smoking among the elderly. Initial studies suggest that current ECF predicts successful cessation of smoking. Among ever smokers, 74% of those with unimpaired ECF had successfully quit compared with 65% of those with some level of ECF impairment. However, a general measure of cognition did not predict cessation. These findings have implications for how cessation of smoking programs can be improved in order to help older smokers quit smoking by providing more social support as well as the removal of smoking cues.

Metabolic syndrome in people with schizophrenia: a review

Metabolic syndrome and other cardiovascular risk factors are highly prevalent in people with schizophrenia. Patients are at risk for premature mortality and overall have limited access to physical health care. In part these cardio-metabolic risk factors are attributable to unhealthy lifestyle, including poor diet and sedentary behaviour. But over recent years it has become apparent that antipsychotic agents can have a negative impact on some of the modifiable risk factors. The psychiatrist needs to be aware of the potential metabolic side effects of antipsychotic medication and to include them in the risk/benefit assessment when choosing a specific antipsychotic. He should also be responsible for the implementation of the necessary screening assessments and referral for treatment of any physical illness. Multidisciplinary assessment of psychiatric and medical conditions is needed. The somatic treatments offered to people with severe and enduring mental illness should be at par with general health care in the non-psychiatrically ill population.