Cancer mortality among psychiatric patients treated in a community-based system of care: a 25-year case register study

Inequalities in cancer screening participation between adults with and without severe mental illness: results from a cross-sectional analysis of primary care data on English Screening Programmes

BACKGROUND

People with severe mental illness (SMI) are 2.5 times more likely to die prematurely from cancer in England. Lower participation in screening may be a contributing factor.

METHODS

Clinical Practice Research Datalink data for 1.71 million, 1.34 million and 2.50 million adults were assessed (using multivariate logistic regression) for possible associations between SMI and participation in bowel, breast and cervical screening, respectively.

RESULTS

Screening participation was lower among adults with SMI, than without, for bowel (42.11% vs. 58.89%), breast (48.33% vs. 60.44%) and cervical screening (64.15% vs. 69.72%; all p < 0.001). Participation was lowest in those with schizophrenia (bowel, breast, cervical: 33.50%, 42.02%, 54.88%), then other psychoses (41.97%, 45.57%, 61.98%), then bipolar disorder (49.94%, 54.35%, 69.69%; all p-values < 0.001, except cervical screening in bipolar disorder; p-value > 0.05). Participation was lowest among people with SMI who live in the most deprived quintile of areas (bowel, breast, cervical: 36.17%, 40.23%, 61.47%), or are of a Black ethnicity (34.68%, 38.68%, 64.80%). Higher levels of deprivation and diversity, associated with SMI, did not explain the lower participation in screening.

CONCLUSIONS

In England, participation in cancer screening is low among people with SMI. Support should be targeted to ethnically diverse and socioeconomically deprived areas, where SMI prevalence is greatest.

Gastrointestinal and liver disease in patients with schizophrenia: A narrative review

Schizophrenia is a severe mental illness which can have a devastating impact on an individual's quality of life. Comorbidities are high amongst patients and life expectancy is approximately 15 years less than the general population. Despite the well-known increased mortality, little is known about the impact of gastrointestinal and liver disease on patients with schizophrenia. We aimed to review the literature and to make recommendations regarding future care. Literature searches were performed on PubMed to identify studies related to gastrointestinal and liver disease in patients with schizophrenia. High rates of chronic liver disease were reported, with Non-Alcoholic Fatty Liver Disease being of particular concern; antipsychotics and metabolic syndrome were contributing factors. Rates of acute liver failure were low but have been associated with antipsychotic use and paracetamol overdose. Coeliac disease has historically been linked to schizophrenia; however, recent research suggests that a causal link is yet to be proven. Evidence is emerging regarding the relationships between schizophrenia and peptic ulcer disease, inflammatory bowel disease and irritable bowel syndrome; clinical vigilance regarding these conditions should be high. Patients with schizophrenia poorly engage with bowel cancer screening programmes, leading to late diagnosis and increased mortality. Clozapine induced constipation is a significant issue for many patients and requires close monitoring. There is a significant burden of gastrointestinal and liver disease amongst patients with schizophrenia. Better levels of support from all members of the medical team are essential to ensure that appropriate, timely care is provided.

Mood disorder and cancer onset: evidence from a population-based sample of Australian women

OBJECTIVE

The role of mood disorders in cancer onset is unclear. The aim of this study was to investigate the association between mood disorder and incident cancer in a population-based sample of women.

METHODS

Data were derived from women aged 28-94 years participating in the Geelong Osteoporosis Study. Mood disorder was identified via Clinical Interview (SCID-I/NP). Cancer data was obtained following linkage with the Victorian Cancer Registry. Demographic and lifestyle factors were self-reported. Nested case-control and retrospective study designs were utilized.

RESULTS

In the case-control study (n=807), mood disorder was documented for 18 of the 75 (9.3%) cancer cases and among 288 controls (24.0% vs. 39.3%, p = 0.009). Prior exposure to mood disorder was associated with reduced cancer incidence (OR 0.49, 95%CI 0.28-0.84); this was sustained following adjustment for confounders (ORadj 0.52, 95%CI 0.30-0.90). In the retrospective cohort study (n=655), among 154 women with a history of mood disorder at baseline, 13 (8.5%) developed incident cancer during follow-up, whereas among 501 women with no history of mood disorder, 54 (10.8%) developed incident cancer. Exposure to mood disorder was not associated with incident cancer over the follow-up period (HR 0.58, 95%CI 0.31-1.08, p = 0.09).

CONCLUSION

Mood disorder was associated with reduced odds of cancer onset. However, this finding was not supported in the retrospective cohort study. Larger studies able to investigate specific cancers and mood disorders as well as underlying mechanisms in both men and women are warranted.

The effect of a severe psychiatric illness on colorectal cancer treatment and survival: A population-based retrospective cohort study

OBJECTIVES

To identify inequalities in cancer survival rates for patients with a history of severe psychiatric illness (SPI) compared to those with no history of mental illness and explore differences in the provision of recommended cancer treatment as a potential explanation.

DESIGN

Population-based retrospective cohort study using linked cancer registry and administrative data at ICES.

SETTING

The universal healthcare system in Ontario, Canada.

PARTICIPANTS

Colorectal cancer (CRC) patients diagnosed between April 1st, 2007 and December 31st, 2012. SPI history (schizophrenia, schizoaffective disorders, other psychotic disorders, bipolar disorders or major depressive disorders) was determined using hospitalization, emergency department, and psychiatrist visit data and categorized as 'no history of mental illness, 'outpatient SPI history', and 'inpatient SPI history'.

MAIN OUTCOME MEASURES

Cancer-specific survival, non-receipt of surgical resection, and non-receipt of adjuvant chemotherapy or radiation.

RESULTS

24,507 CRC patients were included; 482 (2.0%) had an outpatient SPI history and 258 (1.0%) had an inpatient SPI history. Individuals with an SPI history had significantly lower survival rates and were significantly less likely to receive guideline recommended treatment than CRC patients with no history of mental illness. The adjusted HR for cancer-specific death was 1.69 times higher for individuals with an inpatient SPI (95% CI 1.36-2.09) and 1.24 times higher for individuals with an outpatient SPI history (95% CI 1.04-1.48). Stage II and III CRC patients with an inpatient SPI history were 2.15 times less likely (95% CI 1.07-4.33) to receive potentially curative surgical resection and 2.07 times less likely (95% CI 1.72-2.50) to receive adjuvant radiation or chemotherapy. These findings were consistent across multiple sensitivity analyses.

CONCLUSIONS

Individuals with an SPI history experience inequalities in colorectal cancer care and survival within a universal healthcare system. Increasing advocacy and the availability of resources to support individuals with an SPI within the cancer system are warranted to reduce the potential for unnecessary harm.

Mortality of site-specific cancer in patients with schizophrenia: a systematic review and meta-analysis

BACKGROUND

Numerous studies have reported contradicting results on the relationship between cancer mortality and schizophrenia. Our aim is to quantify the mortality rate of common site-specific cancers among patients with schizophrenia and to synthesize the available research evidence.

METHODS

We performed a systemic search of the PubMed, EMBASE and Web of Science databases. Studies reporting the mortality rate of different cancer in patients with schizophrenia were included. A random-effects model was applied to calculate the pooled relative risks (RRs) with 95% confidence intervals (95%CIs).

RESULTS

Seven studies consisting of 1,162,971 participants with schizophrenia were included in this meta-analysis. Data regarding mortality risk of breast, colon, lung and prostate cancer among schizophrenia patients were subjected to quantitative analysis. Pooled results showed significant increases in mortality risk of breast cancer (RR = 1.97, 95%CI 1.38-2.83), lung cancer (RR = 1.93, 95%CI 1.46-2.54) and colon cancer (RR = 1.69, 95%CI 1.60-1.80) in patients with schizophrenia compared with those in the general population or control group. The mortality risk of prostate cancer increased in male patients, although no significant difference was detected (RR = 1.58, 95% CI 0.79-3.15). Increased risks of mortality from lung and colon cancer were observed in female patients (RR = 2.49, 95%CI 2.40-2.59 and RR = 2.42, 95%CI 1.39-4.22, respectively) and elevated risks of mortality from lung and colon cancer in male patients (RR = 2.40, 95%CI 2.30-2.50 and RR = 1.90, 95%CI 1.71-2.11, respectively) were detected.

CONCLUSIONS

Individuals with schizophrenia have a significantly high risk of mortality from breast, colon, and lung cancer.

Stage at diagnosis and survival in patients with cancer and a pre-existing mental illness: a meta-analysis

INTRODUCTION

Individuals with a pre-existing mental illness, especially those experiencing reduced social, occupational and functional capacity, are at risk for cancer care disparities. However, uncertainty surrounding the effect of a mental illness on cancer outcomes exists.

METHODS

We conducted a systematic review and meta-analysis of observational studies using MEDLINE and PubMed from 1 January 2005 to 1 November 2018. Two reviewers evaluated citations for inclusion. Advanced stage was defined as regional, metastatic or according to a classification system. Cancer survival was defined as time survived from cancer diagnosis. Pooled ORs and HRs were presented. The Newcastle-Ottawa bias risk assessment scale was used. Random-effects models used the Mantel-Haenszel approach and the generic inverse variance method. Heterogeneity assessment was performed using I².

RESULTS

2381 citations were identified; 28 studies were included and 24 contributed to the meta-analysis. Many demonstrated methodological flaws, limiting interpretation and contributing to significant heterogeneity. Data source selection, definitions of a mental illness, outcomes and their measurement, and overadjustment for causal pathway variables influenced effect sizes. Pooled analyses suggested individuals with a pre-existing mental disorder have a higher odds of advanced stage cancer at diagnosis and are at risk of worse cancer survival. Individuals with more severe mental illness, such as schizophrenia, are at a greater risk for cancer disparities.

DISCUSSION

This review identified critical gaps in research investigating cancer stage at diagnosis and survival for individuals with pre-existing mental illness. High-quality research is necessary to support quality improvement for the care of psychiatric patients and their families during and following a cancer diagnosis.

The impact of psychiatric utilisation prior to cancer diagnosis on survival of solid organ malignancies

BACKGROUND

Among patients with cancer, prior research suggests that patients with mental illness may have reduced survival. The objective was to assess the impact of psychiatric utilisation (PU) prior to cancer diagnosis on survival outcomes.

METHODS

All residents of Ontario diagnosed with one of the top 10 malignancies (1997-2014) were included. The primary exposure was psychiatric utilisation gradient (PUG) score in 5 years prior to cancer: 0: none, 1: outpatient, 2: emergency department, 3: hospital admission. A multivariable, cause-specific hazard model was used to assess the effect of PUG score on cancer-specific mortality (CSM), and a Cox proportional hazard model for effect on all-cause mortality (ACM).

RESULTS

A toal of 676,125 patients were included: 359,465 (53.2%) with PUG 0, 304,559 (45.0%) PUG 1, 7901 (1.2%) PUG 2, and 4200 (0.6%) PUG 3. Increasing PUG score was independently associated with worse CSM, with an effect gradient across the intensity of pre-diagnosis PU (vs PUG 0): PUG 1 h 1.05 (95% CI 1.04-1.06), PUG 2 h 1.36 (95% CI 1.30-1.42), and PUG 3 h 1.73 (95% CI 1.63-1.84). Increasing PUG score was also associated with worse ACM.

CONCLUSIONS

Pre-cancer diagnosis PU is independently associated with worse CSM and ACM following diagnosis among patients with solid organ malignancies.

Cancer mortality in patients with schizophrenia: systematic review and meta-analysis

BackgroundPrevious studies have reported conflicting results on the association between schizophrenia and cancer mortality.AimsTo summarise available evidence and quantify the association between schizophrenia and cancer mortality using meta-analysis.MethodWe systematically searched literature in the PubMed and Embase databases. Risk estimates and 95% confidence intervals reported in individual studies were pooled using the DerSimonian-Laird random-effects model.ResultsWe included 19 studies in the meta-analysis. Among them, 15 studies reported standardised mortality ratios (SMRs) comparing patients with schizophrenia with the general population, and the pooled SMR was 1.40 (95% CI 1.29-1.52, P < 0.001). The other four studies reported hazard ratios (HRs) comparing individuals with schizophrenia with those without schizophrenia; the pooled HR was 1.51 (95% CI 1.13-2.03, P = 0.006).ConclusionsPatients with schizophrenia are at a significantly increased risk of cancer mortality compared with the general population or individuals without schizophrenia.

'Big data' in mental health research: current status and emerging possibilities

PURPOSE

'Big data' are accumulating in a multitude of domains and offer novel opportunities for research. The role of these resources in mental health investigations remains relatively unexplored, although a number of datasets are in use and supporting a range of projects. We sought to review big data resources and their use in mental health research to characterise applications to date and consider directions for innovation in future.

METHODS

A narrative review.

RESULTS

Clear disparities were evident in geographic regions covered and in the disorders and interventions receiving most attention.

DISCUSSION

We discuss the strengths and weaknesses of the use of different types of data and the challenges of big data in general. Current research output from big data is still predominantly determined by the information and resources available and there is a need to reverse the situation so that big data platforms are more driven by the needs of clinical services and service users.

Breast cancer screening in women with mental illness: comparative meta-analysis of mammography uptake

BACKGROUND

There is a higher mortality rate due to cancer in people with mental illness and previous work suggests suboptimal medical care in this population. It remains unclear if this extends to breast cancer population screening.

AIMS

To conduct a systematic review and meta-analysis to establish if women with a mental health condition are less likely to receive mammography screening compared with those without mental ill health.

METHOD

Major electronic databases were searched from inception until February 2014. We calculated odds ratios (OR) with a random effects meta-analysis comparing mammography screening rates among women with and without a mental illness. Results were stratified according to primary diagnosis including any mental illness, mood disorders, depression, severe mental illness (SMI), distress and anxiety.

RESULTS

We identified 24 publications reporting breast cancer screening practices in women with mental illness (n = 715,705). An additional 5 studies investigating screening for those with distress (n = 21,491) but no diagnosis of mental disorder were identified. The pooled meta-analysis showed significantly reduced rates of mammography screening in women with mental illness (OR = 0.71, 95% CI 0.66-0.77), mood disorders (OR = 0.83, 95% CI 0.76-0.90) and particularly SMI (OR = 0.54, 95% CI 0.45-0.65). No disparity was evident among women with distress alone.

CONCLUSIONS

Rates of mammography screening are lower in women with mental illness, particularly women with SMI, and this is not explained by the presence of emotional distress. Disparities in medical care due to mental illness clearly extend into preventive population screening.

Impact of lifetime psychiatric diagnosis on long-term retention and survival of former opiate addicts in methadone maintenance treatment

OBJECTIVES

To characterize lifetime psychiatric diagnosis groups among methadone maintenance treatment (MMT) patients and associations of diagnosis to long-term (up to 20 years) retention and survival either during treatment or post discontinuation.

METHODS

A total of 758 patients with available psychiatric diagnosis (98% of those ever admitted between June 1993 and June 2012) were followed-up until June 2013. Lifetime psychiatric diagnosis was assessed according to DSM-IV-TR (Axis I, II, I & II, or none). Observed urine samples at 1 and 13 months were positive for drugs if at least one was positive. Survival data were based on the Israel National Population Registry. Survival and retention in MMT were compared (Kaplan Meier) between groups.

RESULTS

The Axis II (personality disorders) group had the worst mean long-term retention (5.8 years, 95% Confidence Interval (CI) 5.0-6.5) compared with the Axis I, Axis I & II or no psychiatric diagnosis groups (9.6 years, 95% CI 8.8-10.4) (P < 0.0005). Mean survival since admission (16.4 years, 95% CI 15.9-16.9) was similar for all groups. Axis II patients included more males, more drug injectors, were younger at initial opiate use and more likely left treatment before 1 year.

CONCLUSIONS

Personality and coping mechanisms (Axis II) could be significant obstacles to the success of MMT, warranting special interventions to overcome them.

Fifty years' development and future perspectives of psychiatric register research

OBJECTIVE

This article illustrates the development of psychiatric register research and discusses the strengths, limitations, and possible directions for future activities.

METHOD

Examples illustrating the development from the post-World War II introduction of psychiatric register research until today are selected.

RESULTS

The strengths of register research are seen especially within health service. Until recently, when starting linking registers to biobanks, register research had limited value in cause-seeking. Register research benefits from the possibilities for following identifiable persons over long time (lifelong) and the possibilities for linking to other registers and databases. Important limitations of register research are the heterogeneity and questionable validity of the clinical data collected.

CONCLUSION

Future register research can go in the direction of big is beautiful collecting data from all possible sources creating giga-registers. In that case, low data quality will still be an unsolved problem. Or it can take the direction of smaller local clinical databases which has many advantages, for example, integrating clinical knowledge and experience into register research. However, in that case, registers will not be able to deal with rare conditions and diseases.