Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and...
Transcript of Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and...
Mor
bidi
ty a
nd M
orta
lity
inM
orbi
dity
and
Mor
talit
y in
Peo
ple
with
Ser
ious
Men
tal
Peo
ple
with
Ser
ious
Men
tal
Illne
ssIll
ness
Nat
iona
l Ass
ocia
tion
of S
tate
Men
tal H
ealth
Pro
gram
Nat
iona
l Ass
ocia
tion
of S
tate
Men
tal H
ealth
Pro
gram
Dire
ctor
sD
irect
ors
Med
ical
Dire
ctor
s C
ounc
ilM
edic
al D
irect
ors
Cou
ncil
July
200
6Ju
ly 2
006
Ove
rvie
w- T
HE
PR
OB
LEM
Ove
rvie
w- T
HE
PR
OB
LEM
Incr
ease
d M
orbi
dity
and
Mor
talit
y As
soci
ated
with
Incr
ease
d M
orbi
dity
and
Mor
talit
y As
soci
ated
with
Ser
ious
Men
tal I
llnes
s (S
MI)
Ser
ious
Men
tal I
llnes
s (S
MI)
Incr
ease
d M
orbi
dity
and
Mor
talit
y La
rgel
y D
ue to
Incr
ease
d M
orbi
dity
and
Mor
talit
y La
rgel
y D
ue to
Pre
vent
able
Med
ical
Con
ditio
nsP
reve
ntab
le M
edic
al C
ondi
tions
Met
abol
ic D
isor
ders
, Car
diov
ascu
lar D
isea
se, D
iabe
tes
Mel
litus
Met
abol
ic D
isor
ders
, Car
diov
ascu
lar D
isea
se, D
iabe
tes
Mel
litus
Hig
h P
reva
lenc
e of
Mod
ifiab
le R
isk
Fact
ors
(Obe
sity
, Sm
okin
g)H
igh
Pre
vale
nce
of M
odifi
able
Ris
k Fa
ctor
s (O
besi
ty, S
mok
ing)
Epi
dem
ics
with
in E
pide
mic
s (e
.g.,
Dia
bete
s, O
besi
ty)
Epi
dem
ics
with
in E
pide
mic
s (e
.g.,
Dia
bete
s, O
besi
ty)
Som
e P
sych
iatri
c M
edic
atio
ns C
ontri
bute
to R
isk
Som
e P
sych
iatri
c M
edic
atio
ns C
ontri
bute
to R
isk
Esta
blis
hed
Mon
itorin
g an
d Tr
eatm
ent G
uide
lines
toEs
tabl
ishe
d M
onito
ring
and
Trea
tmen
t Gui
delin
es to
Low
er R
isk
Are
Und
erut
ilize
d in
SM
I Pop
ulat
ions
Low
er R
isk
Are
Und
erut
ilize
d in
SM
I Pop
ulat
ions
Ove
rvie
w -
Ove
rvie
w -
PR
OP
OS
ED
SO
LUTI
ON
SP
RO
PO
SE
D S
OLU
TIO
NS
Prio
ritiz
e th
e P
ublic
Hea
lth P
robl
emTa
rget
Pro
vide
rs, F
amili
es a
nd C
lient
sFo
cus
on P
reve
ntio
n an
d W
elln
ess
Trac
k M
orbi
dity
and
Mor
talit
y in
Pub
lic M
enta
lH
ealth
Pop
ulat
ions
Impl
emen
t Est
ablis
hed
Sta
ndar
ds o
f Car
eP
reve
ntio
n, S
cree
ning
and
Tre
atm
ent
Impr
ove
Acc
ess
to a
nd In
tegr
atio
n of
Phy
sica
lH
ealth
and
Men
tal H
ealth
Car
e
Why
Sho
uld
we
be C
once
rned
Abo
utW
hy S
houl
d w
e be
Con
cern
ed A
bout
Mor
bidi
ty a
nd M
orta
lity?
Mor
bidi
ty a
nd M
orta
lity?
Rec
ent d
ata
from
sev
eral
sta
tes
have
Rec
ent d
ata
from
sev
eral
sta
tes
have
foun
d th
at
foun
d th
at p
eopl
e w
ith s
erio
us m
enta
lpe
ople
with
ser
ious
men
tal
illne
ss s
erve
d by
our
pub
lic m
enta
lill
ness
ser
ved
by o
ur p
ublic
men
tal
heal
th s
yste
ms
die,
on
aver
age,
at l
east
heal
th s
yste
ms
die,
on
aver
age,
at l
east
25 y
ears
ear
lier t
hat t
he g
ener
al25
yea
rs e
arlie
r tha
t the
gen
eral
popu
latio
npo
pula
tion ..
SM
R =
sta
ndar
dize
d m
orta
lity
ratio
(obs
erve
d/ex
pect
ed d
eath
s).
•H
arris
et a
l. B
r J P
sych
iatry
. 199
8;17
3:11
. New
man
SC
,B
land
RC
. Can
J P
sych
. 199
1;36
:239
-245
.2.
Osb
y et
al.
Arc
h G
en P
sych
iatry
. 200
1;58
:844
-850
.3.
Osb
y et
al.
BM
J. 2
000;
321:
483-
484.
Incr
ease
d M
orta
lity
From
Med
ical
Incr
ease
d M
orta
lity
From
Med
ical
Cau
ses
in M
enta
l Illn
ess
Cau
ses
in M
enta
l Illn
ess
Incr
ease
d ris
k of
dea
th fr
om m
edic
al c
ause
s in
Incr
ease
d ris
k of
dea
th fr
om m
edic
al c
ause
s in
schi
zoph
reni
a an
d 20
% (1
0-15
yrs
) sho
rter l
ifesp
an1
schi
zoph
reni
a an
d 20
% (1
0-15
yrs
) sho
rter l
ifesp
an1
Bip
olar
and
B
ipol
ar a
nd u
nipo
lar
unip
olar
affe
ctiv
e di
sord
ers
also
affe
ctiv
e di
sord
ers
also
asso
ciat
ed w
ith h
ighe
r as
soci
ated
with
hig
her S
MR
sS
MR
s fro
m m
edic
al c
ause
s fr
om m
edic
al c
ause
s22––
1.9
mal
es/2
.1 fe
mal
es in
bip
olar
dis
orde
r1.
9 m
ales
/2.1
fem
ales
in b
ipol
ar d
isor
der
––1.
5 m
ales
/1.6
fem
ales
in
1.5
mal
es/1
.6 fe
mal
es in
uni
pola
run
ipol
ar d
isor
der
dis
orde
r
Car
diov
ascu
lar m
orta
lity
in s
chiz
ophr
enia
incr
ease
dC
ardi
ovas
cula
r mor
talit
y in
sch
izop
hren
ia in
crea
sed
from
197
6-19
95, w
ith g
reat
est i
ncre
ase
in
from
197
6-19
95, w
ith g
reat
est i
ncre
ase
in S
MR
sS
MR
s in in
men
from
199
1-19
95m
en fr
om 1
991-
1995
33
Rec
ent M
ulti-
Sta
te S
tudy
Mor
talit
y D
ata:
Rec
ent M
ulti-
Sta
te S
tudy
Mor
talit
y D
ata:
Yea
rs o
f Pot
entia
l Life
Los
tY
ears
of P
oten
tial L
ife L
ost
Com
pare
d to
the
gene
ral p
opul
atio
n, p
erso
nsC
ompa
red
to th
e ge
nera
l pop
ulat
ion,
per
sons
with
maj
or m
enta
l illn
ess
typi
cally
lose
mor
ew
ith m
ajor
men
tal i
llnes
s ty
pica
lly lo
se m
ore
than
25
year
s of
nor
mal
life
spa
nth
an 2
5 ye
ars
of n
orm
al li
fe s
pan
Yea
r A
Z M
O
OK
R
I T
X
UT
V
A (I
P on
ly)
1997
26.3
25
.1
28
.5
1998
27.3
25
.1
28
.8
29.3
15
.5
1999
32
.2
26.8
26
.3
29
.3
26.9
14
.0
2000
31
.8
27.9
24.9
13
.5
Col
ton
CW
, C
olto
n C
W, M
ande
rsch
eid
Man
ders
chei
d R
W.
RW
. Pre
vP
rev
Chr
onic
C
hron
ic D
isD
is [s
eria
l onl
ine]
200
6 A
pr [d
ate
[ser
ial o
nlin
e] 2
006
Apr
[dat
eci
ted]
. Ava
ilabl
e fro
m: U
RL:
http
://w
ww
.cdc
.gov
/pcd
/issu
es/2
006/
apr/0
5_01
80.h
tmci
ted]
. Ava
ilabl
e fro
m: U
RL:
http
://w
ww
.cdc
.gov
/pcd
/issu
es/2
006/
apr/0
5_01
80.h
tm
Ohi
o St
udy-
1998
-200
2O
hio
Stud
y-19
98-2
002
Mea
n Ye
ars
of P
oten
tial L
ife lo
stM
ean
Year
s of
Pot
entia
l Life
lost
20,0
18 p
erso
ns d
isch
arge
d, 6
08 d
eath
s20
,018
per
sons
dis
char
ged,
608
dea
ths
Cau
seM
FN
All
31.8
32.5
32.0
Inte
ntio
nal s
elf-h
arm
(sui
cide
)41
.442
.741
.7As
saul
t (ho
mic
ide)
42.3
35.8
41.6
Acci
dent
s (u
nint
entio
nal i
njur
ies)
39.5
43.1
40.4
Sym
ptom
s, s
igns
, & a
bnor
mal
32
.835
.0 c
linic
al &
labo
rato
ry fi
ndin
gs, N
EC
Dia
bete
s m
ellit
us25
.837
.230
.2Pn
eum
onia
& In
fluen
za29
.425
.028
.3D
isea
ses
of h
eart
27.7
26.6
27.3
Cer
ebro
vasc
ular
dis
ease
s20
.732
.825
.5M
alig
nant
neo
plas
ms
(can
cers
) 24
.326
.925
.3C
hron
ic lo
wer
resp
irato
ry d
isea
ses
18.6
24.1
21.1
33.4
Mas
sach
uset
ts S
tudy
: Dea
ths
from
Hea
rtM
assa
chus
etts
Stu
dy: D
eath
s fro
m H
eart
Dis
ease
by
Age
Gro
up/D
MH
Enr
olle
es w
ithD
isea
se b
y A
ge G
roup
/DM
H E
nrol
lees
with
SM
I Com
pare
d to
Mas
sach
uset
ts 1
998-
2000
SM
I Com
pare
d to
Mas
sach
uset
ts 1
998-
2000
0510152025303540
25-3
435
-44
45-5
455
-64
Rates per 100,000
DM
HM
A
3.5
RR
4.9R
R
2.2R
R
1.5R
R
Mai
ne S
tudy
Res
ults
: Com
paris
on o
f Hea
lthM
aine
Stu
dy R
esul
ts: C
ompa
rison
of H
ealth
Dis
orde
rs B
etw
een
SM
I & N
on-S
MI G
roup
sD
isor
ders
Bet
wee
n S
MI &
Non
-SM
I Gro
ups
59.4
33.9
3028
.628
.422
.821
.716
.511
.511
.16.3
5.9
01020304050607080
Skele
tal- C
onne
ctive
Gastr
o-Inte
stina
l
Obes
ity/D
yslip
id
COPD
Infec
tious
Dise
ase
Hype
rtens
ionDent
al Di
sord
ers
Diab
etesCa
ncer
Hear
t Dise
ase
Pneu
monia/
Influe
nza
Liver
Dise
ase
Percent Members
SMI (N
=922
4)No
n-SM
I (N=7
352)
Ohi
o St
udy
Ohi
o St
udy
Lead
ing
Cau
ses
of D
eath
Lead
ing
Cau
ses
of D
eath
Cau
seIC
D-9
Cod
esIC
D-1
0 C
odes
MF
N%
390-
398,
402
, I0
0-09
, I11
, 83
4340
4, 4
10-4
29I1
3, I2
0-51
X60
-84,
84
24Y
87.0
E800
-869
, V0
1-X
59,
6122
E880
-929
Y85
-86
Mal
igna
nt n
eopl
asm
s (c
ance
rs)
140-
208
C00
-C97
2717
447.
2Sy
mpt
oms,
sig
ns, &
abn
orm
al
23
9 c
linic
al &
labo
rato
ry fi
ndin
gs, N
EC
Chr
onic
low
er re
spira
tory
dis
ease
s49
0-49
4, 4
96J4
0-J4
717
1431
5.1
Dia
bete
s m
ellit
us25
0E
10-1
411
718
3.0
Pneu
mon
ia &
Influ
enza
480-
487
J10-
1812
416
2.6
430-
434,
6
443
6-43
8X
85-Y
09,
91
Y87
.1
Acci
dent
s (u
nint
entio
nal i
njur
ies)
83
20.7
Inte
ntio
nal s
elf-h
arm
(sui
cide
)E9
50-9
5910
817
.8
Dis
ease
s of
hea
rt12
6
13.7
780-
799
R00
-99
325.
3
Cer
ebro
vasc
ular
dis
ease
sI6
0-69
101.
6
Assa
ult (
hom
icid
e)E9
60-9
6910
1.6
Ohi
o S
tudy
Ohi
o S
tudy
Stan
dard
ized
Mor
talit
y R
atio
sSt
anda
rdiz
ed M
orta
lity
Rat
ios
Cau
seO
vera
ll NSM
RAl
l cau
ses
of d
eath
608
3.2†
Inte
ntio
nal s
elf-h
arm
(sui
cide
)10
812
.6†
Sym
ptom
s, s
igns
, & a
bnor
mal
32
9.7†
clin
ical
& la
bora
tory
find
ings
, NEC
Pneu
mon
ia &
Influ
enza
166.
6†C
hron
ic lo
wer
resp
irato
ry d
isea
ses
315.
5†Ac
cide
nts
(uni
nten
tiona
l inj
urie
s)83
3.8†
Dis
ease
s of
hea
rt12
63.
4†D
iabe
tes
mel
litus
183.
4†As
saul
t (ho
mic
ide)
101.
7C
ereb
rova
scul
ar d
isea
ses
101.
5M
alig
nant
neo
plas
ms
(can
cers
) 44
0.9
† P
<0.0
01
Wha
t are
the
Cau
ses
of M
orbi
dity
and
Wha
t are
the
Cau
ses
of M
orbi
dity
and
Mor
talit
y in
Peo
ple
with
Ser
ious
Mor
talit
y in
Peo
ple
with
Ser
ious
Men
tal I
llnes
s?M
enta
l Illn
ess?
Whi
le s
uici
de a
nd in
jury
acc
ount
for a
bout
30-
Whi
le s
uici
de a
nd in
jury
acc
ount
for a
bout
30-
40%
of e
xces
s m
orta
lity,
abo
ut
40%
of e
xces
s m
orta
lity,
abo
ut 6
0% o
f60
% o
fpr
emat
ure
deat
hs in
per
sons
with
sch
izop
hren
iapr
emat
ure
deat
hs in
per
sons
with
sch
izop
hren
iaar
e du
e to
“nat
ural
cau
ses”
are
due
to “n
atur
al c
ause
s”––
Car
diov
ascu
lar d
isea
seC
ardi
ovas
cula
r dis
ease
––D
iabe
tes
Dia
bete
s––
Res
pira
tory
dis
ease
sR
espi
rato
ry d
isea
ses
––In
fect
ious
dis
ease
sIn
fect
ious
dis
ease
s
Nee
d sl
ide
(see
nex
t) fro
mN
eed
slid
e (s
ee n
ext)
from
CD
C p
aper
indi
catin
g C
VD
CD
C p
aper
indi
catin
g C
VD
as le
adin
g ca
use
ofas
lead
ing
caus
e of
deat
h…th
is s
houl
d be
sim
ple
deat
h…th
is s
houl
d be
sim
ple
and
dire
ctan
d di
rect
Osb
y U
et a
l. Sc
hizo
phr R
es. 2
000;
45:2
1-28
.
Sch
izop
hren
ia:
Sch
izop
hren
ia:
Nat
ural
Cau
ses
of D
eath
Nat
ural
Cau
ses
of D
eath
Hig
her s
tand
ardi
zed
mor
talit
y ra
tes
than
the
gene
ral
Hig
her s
tand
ardi
zed
mor
talit
y ra
tes
than
the
gene
ral
popu
latio
n fro
m:
popu
latio
n fro
m:
––D
iabe
tes
Dia
bete
s 2.
7x2.
7x––
Car
diov
ascu
lar d
isea
seC
ardi
ovas
cula
r dis
ease
2.3x
2.3x
––R
espi
rato
ry d
isea
seR
espi
rato
ry d
isea
se3.
2x3.
2x––
Infe
ctio
us d
isea
ses
Infe
ctio
us d
isea
ses
3.4x
3.4x
Car
diov
ascu
lar d
isea
se a
ssoc
iate
d w
ith th
e la
rges
tC
ardi
ovas
cula
r dis
ease
ass
ocia
ted
with
the
larg
est
num
ber o
f dea
ths
num
ber o
f dea
ths
––2.
3 X
the
larg
est c
ause
of d
eath
in th
e ge
nera
l pop
ulat
ion
2.3
X th
e la
rges
t cau
se o
f dea
th in
the
gene
ral p
opul
atio
n
Car
diov
ascu
lar r
isk
fact
ors
Car
diov
ascu
lar r
isk
fact
ors
––ov
ervi
ewov
ervi
ew
BM
I = b
ody
mas
s in
dex;
TC
= to
tal c
hole
ster
ol; D
M =
dia
bete
s m
ellit
us; H
TN =
hyp
erte
nsio
n.W
ilson
PW
F et
al.
Circ
ulat
ion.
199
8;97
:183
7–18
47.
02468
101214
HTN
DM
Smok
ing
BM
I >27
TC >
220
Sing
le R
isk
Fact
ors
Mul
tiple
Ris
kFa
ctor
s
Odds ratios
Smok
ing
+ B
MI
2
Smok
ing
+ B
MI
+ TC
>22
0
3
Smok
ing
+ B
MI
+ TC
>22
0+
DM
4
Smok
ing
+ B
MI
+ TC
>22
0+
DM
+ H
TN
5Th
e Fr
amin
gham
Stu
dy
Car
diov
ascu
lar D
isea
se (C
VD
) Ris
kC
ardi
ovas
cula
r Dis
ease
(CV
D) R
isk
Fact
ors
Fact
ors
15%
15%
55
10%
10%
77
55%
55%
66
26%
26%
55
Up
to 5
X
Up
to 5
X R
RR
R88
== 18%18%
44
1010–– 1
4%, 2
X R
R14
%, 2
X R
R33
5050–– 8
0%, 2
-3X
RR
80%
, 2-3
X R
R22
4545–– 5
5%, 1
.5-2
X55
%, 1
.5-2
XR
RR
R11
Estim
ated
Pre
vale
nce
and
Rel
ativ
e R
isk
(RR
)Es
timat
ed P
reva
lenc
e an
d R
elat
ive
Ris
k (R
R)
Dys
lipid
emia
Dys
lipid
emia
Hyp
erte
nsio
nH
yper
tens
ion
Dia
bete
sD
iabe
tes
Sm
okin
gS
mok
ing
Obe
sity
Obe
sity
Mod
ifiab
le R
isk
Mod
ifiab
le R
isk
Fact
ors
Fact
ors
Schi
zoph
reni
aSc
hizo
phre
nia
Bip
olar
Dis
orde
rB
ipol
ar D
isor
der
1. D
avid
son
S, e
t al.
Aus
t N Z
J P
sych
iatry
. 200
1;35
:196
-202
. 2. A
llison
DB,
et a
l. J
Clin
Psy
chia
try. 1
999;
60:
215-
220.
3.
Dix
on L
, et a
l. J
Ner
v M
ent D
is. 1
999;
187:
496-
502.
4. H
erra
n A
, et a
l. S
chiz
ophr
Res
. 200
0;41
:373
-381
. 5. M
eElro
y SL
, et
al. J
Clin
Psy
chia
try. 2
002;
63:2
07-2
13. 6
. Uco
k A
, et a
l. P
sych
iatry
Clin
Neu
rosc
i. 20
04;5
8:43
4-43
7. 7
. Cas
sidy
F, e
t al.
Am
J P
sych
iatry
. 199
9;15
6:14
17-1
420.
8. A
llebe
ck. S
chiz
ophr
Bul
l. 19
99;1
5(1)
81-8
9.
Alli
son
DB
et a
l. J
Clin
Psy
chia
try.
199
9;60
:215
-220
.
Percent Percent
< 18
.518
.5-2
020
-22
22-2
424
-26
26-2
828
-30
30-3
232
-34
> 34
0102030
No
schi
zoph
reni
aSc
hizo
phre
nia
Obe
seO
verw
eigh
tA
ccep
tabl
eU
nder
-w
eigh
t
BM
I Ran
geB
MI R
ange
BM
I Dis
tribu
tions
for G
ener
al P
opul
atio
nB
MI D
istri
butio
ns fo
r Gen
eral
Pop
ulat
ion
and
Thos
e W
ith S
chiz
ophr
enia
(198
9)an
d Th
ose
With
Sch
izop
hren
ia (1
989)
Men
tal D
isor
ders
and
Sm
okin
gM
enta
l Dis
orde
rs a
nd S
mok
ing
••H
ighe
r pre
vale
nce
(56-
88%
for p
atie
nts
Hig
her p
reva
lenc
e (5
6-88
% fo
r pat
ient
sw
ith s
chiz
ophr
enia
) of c
igar
ette
sm
okin
gw
ith s
chiz
ophr
enia
) of c
igar
ette
sm
okin
g(o
vera
ll U
.S. p
reva
lenc
e 25
%)
(ove
rall
U.S
. pre
vale
nce
25%
)
••M
ore
toxi
c ex
posu
re fo
r pat
ient
s w
hoM
ore
toxi
c ex
posu
re fo
r pat
ient
s w
hosm
oke
(mor
e ci
gare
ttes,
larg
er p
ortio
nsm
oke
(mor
e ci
gare
ttes,
larg
er p
ortio
nco
nsum
ed)
cons
umed
)
••S
mok
ing
is a
ssoc
iate
d w
ith in
crea
sed
Sm
okin
g is
ass
ocia
ted
with
incr
ease
din
sulin
resi
stan
cein
sulin
resi
stan
ce
••S
imila
r pre
vale
nce
in b
ipol
ar d
isor
der
Sim
ilar p
reva
lenc
e in
bip
olar
dis
orde
rG
eorg
e TP
et a
l. N
icot
ine
and
toba
cco
use
in s
chiz
ophr
enia
. In:
Mey
er J
M, N
asra
llah
HA
, eds
. Med
ical
Illn
ess
and
Sch
izop
hren
ia. A
mer
ican
Psy
chia
tric
Pub
lishi
ng, I
nc. 2
003;
Zied
onis
D, W
illia
ms
JM, S
mel
son
D. A
m J
Med
Sci
. 200
3(O
ct);3
26(4
):223
-330
50-5
9 y
60-6
9 y
70-7
4 y
051015202530
Diag
nose
d Di
abet
es, G
ener
al P
opul
atio
nDi
agno
sed
Diab
etes
, Sch
izop
hren
ic P
atie
nts
Har
ris e
t al.
Dia
bete
s C
are.
199
8; 2
1:51
8.M
ukhe
rjee
et a
l. C
ompr
Psy
chia
try.
199
6; 3
7(1)
:68-
73.
Schi
zoph
reni
c:G
ener
al:
50-5
9 y
60-7
4 y
75+
y
Perc
ent o
f po
pula
tion
Pre
vale
nce
of D
iagn
osed
Dia
bete
s in
Gen
eral
Pop
ulat
ion
Ver
sus
Sch
izop
hren
ic P
opul
atio
n
Hyp
othe
size
d R
easo
ns W
hy T
here
Hyp
othe
size
d R
easo
ns W
hy T
here
May
Be
Mor
e Ty
pe 2
Dia
bete
s in
May
Be
Mor
e Ty
pe 2
Dia
bete
s in
Peo
ple
With
Sch
izop
hren
iaP
eopl
e W
ith S
chiz
ophr
enia
Gen
etic
link
bet
wee
n sc
hizo
phre
nia
and
Gen
etic
link
bet
wee
n sc
hizo
phre
nia
and
diab
etes
diab
etes
Impa
ct o
f life
styl
eIm
pact
of l
ifest
yle
Med
icat
ion
effe
ct in
crea
sing
insu
linM
edic
atio
n ef
fect
incr
easi
ng in
sulin
resi
stan
ce
by im
pact
ing
insu
lin re
cept
orre
sist
ance
by
impa
ctin
g in
sulin
rece
ptor
or p
ostre
cept
or fu
nctio
nor
pos
trece
ptor
func
tion
Dru
g ef
fect
on
calo
ric in
take
or
Dru
g ef
fect
on
calo
ric in
take
or
expe
nditu
re (o
besi
ty, a
ctiv
ity)
expe
nditu
re (o
besi
ty, a
ctiv
ity)
How
Doe
s Th
is R
elat
e to
Wha
t is
How
Doe
s Th
is R
elat
e to
Wha
t is
Hap
peni
ng in
the
Gen
eral
Pop
ulat
ion?
Hap
peni
ng in
the
Gen
eral
Pop
ulat
ion?
Ther
e is
an
“epi
dem
ic” o
f obe
sity
and
dia
bete
s,Th
ere
is a
n “e
pide
mic
” of o
besi
ty a
nd d
iabe
tes,
incr
easi
ng ri
sk o
f mul
tiple
med
ical
con
ditio
nsin
crea
sing
risk
of m
ultip
le m
edic
al c
ondi
tions
and
card
iova
scul
ar d
isea
se.
and
card
iova
scul
ar d
isea
se.
––O
besi
tyO
besi
ty––
Dia
bete
sD
iabe
tes
––M
etab
olic
Syn
drom
eM
etab
olic
Syn
drom
e––
Car
diov
ascu
lar D
isea
seC
ardi
ovas
cula
r Dis
ease
Mok
dad
et a
l. D
iabe
tes
Car
e. 2
000;
23:1
278.
Mok
dad
et a
l. JA
MA
. 199
9;28
2:15
19.
Mok
dad
et a
l. JA
MA
. 200
1;28
6:11
95.
72737475767778
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5 19
9019
9219
9419
9619
9820
00
Prevalence (%) Prevalence (%)D
iabe
tes
Mea
n bo
dy w
eigh
t
kg
Year
Year
Dia
bete
s an
d O
besi
ty:
Dia
bete
s an
d O
besi
ty:
The
Con
tinui
ng E
pide
mic
The
Con
tinui
ng E
pide
mic
Beh
avio
ral R
isk
Fact
or S
urve
illanc
e S
yste
m, C
DC
.
(*B
MI ≥
30, o
r abo
ut 3
0 lb
s ov
erw
eigh
t for
5’4
” per
son)
1996
2003
Obe
sity
Tre
nds*
Am
ong
US
Adu
ltsO
besi
ty T
rend
s* A
mon
g U
S A
dults
BR
FSS
, 199
1, 1
996,
200
3B
RFS
S, 1
991,
199
6, 2
003
1991
No
Dat
a<1
0%10
%-1
4%15
%-1
9%20
%-2
4%≥
25%
No
Data
L
ess
th
an
4%
4
% t
o 6
%
Ab
ove 6
%
Mok
dad
et a
l. D
iabe
tes
Car
e. 2
000;
23:1
278-
1283
.
Dia
bete
s an
d G
esta
tiona
l Dia
bete
s Tr
ends
:D
iabe
tes
and
Ges
tatio
nal D
iabe
tes
Tren
ds:
US
Adu
lts,
BR
FSS
199
0U
S A
dults
, B
RFS
S 1
990
Mok
dad
et a
l. D
iabe
tes
Car
e. 2
000;
23:1
278-
1283
.
Dia
bete
s an
d G
esta
tiona
l Dia
bete
s Tr
ends
:D
iabe
tes
and
Ges
tatio
nal D
iabe
tes
Tren
ds:
US
Adul
ts,
BRFS
S 19
95U
S Ad
ults
, BR
FSS
1995
No
Data
Less
th
an
4%
4%
to
6%
A
bo
ve 6
%
Mok
dad
et a
l. D
iabe
tes
Car
e. 2
001;
24:4
12.
Dia
bete
s an
d G
esta
tiona
l Dia
bete
s Tr
ends
:D
iabe
tes
and
Ges
tatio
nal D
iabe
tes
Tren
ds:
US
Adul
ts,
BRFS
S 19
99U
S Ad
ults
, BR
FSS
1999
No
Data
L
ess
th
an
4%
4%
to
6%
Ab
ove 6
%
Mok
dad
et a
l. JA
MA
. 200
1;28
6(10
).
Dia
bete
s an
d G
esta
tiona
l Dia
bete
s Tr
ends
:D
iabe
tes
and
Ges
tatio
nal D
iabe
tes
Tren
ds:
US
Adul
ts,
BRFS
S 20
00U
S Ad
ults
, BR
FSS
2000
No
Data
Less
th
an
4%
4%
to
6%
A
bo
ve 6
%
ww
w.d
iabe
tes.
org.
No
Data
L
ess
th
an
4%
4
% t
o 6
%
A
bo
ve 6
%
Ab
ove 1
0%
Dia
bete
s an
d G
esta
tiona
l Dia
bete
s Tr
ends
:D
iabe
tes
and
Ges
tatio
nal D
iabe
tes
Tren
ds:
US
Adul
ts,
Estim
ate
for
2010
US
Adul
ts,
Estim
ate
for
2010
Men
and
Wom
en, A
ge 4
5-74
Yea
rs
Har
ris e
t al.
Dia
bete
s. 1
987;
36:5
23.
Fleg
al e
t al.
Dia
bete
s C
are.
199
1;14
(sup
pl 3
):628
. K
now
ler e
t al.
Dia
bete
s C
are.
199
3;16
(sup
pl 1
):216
. Fu
jimot
o et
al.
Dia
bete
s R
es C
lin P
ract
. 199
1;13
:119
. Fu
jimot
o et
al.
Dia
bete
s. 1
987;
36:7
21.
% with diabetes
01020304050
Pim
aPu
erto
R
ican
Mex
ican
Am
eric
anA
fric
anA
mer
ican
Japa
nese
Am
eric
anC
uban
Am
eric
anEu
rope
an
US
Dia
bete
s P
reva
lenc
eU
S D
iabe
tes
Pre
vale
nce
by
Eth
nic
Gro
up b
y E
thni
c G
roup
Ada
pted
from
: Int
erna
tiona
l Dia
bete
s C
ente
r (ID
C).
Ava
ilabl
e at
:w
ww
.par
knic
olle
t.com
/dia
bete
s/di
seas
e/di
agno
sing
.cfm
. Acc
esse
d M
arch
26,
200
6.
Yea
rs o
f Dia
bete
s
U
ncon
trolle
d O
besi
ty
IGT
Dia
bete
s H
yper
glyc
emia
Rel
ativ
e β-
Cel
lFu
nctio
n 100
(%)
-20
-10
010
2030
Pla
sma
Glu
cose
Insu
lin R
esis
tanc
e
Insu
lin L
evel
126
(mg/
dL)
Fast
ing
Glu
cose
Pos
t-M
eal
Glu
cose
IGT
= im
paire
d gl
ucos
e to
lera
nce.
Nat
ural
His
tory
of T
ype
2 D
iabe
tes
Nat
ural
His
tory
of T
ype
2 D
iabe
tes
18%
17%
12%
8%
4%
0%2%
4%6%
8%10
%12
%14
%16
%18
%20
%
Retin
opat
hy
Card
iova
scul
ar
Abse
nt F
oot P
ulse
s
Abse
nt R
efle
xes
Urin
e Al
bum
in
Prevalence of Diabetic Tissue
Damage at Diagnosis of Type 2
Diabetes
Prev
alen
cePr
eval
ence
Dag
ogo-
Jack
et a
l. A
rch
Int M
ed. 1
997;
157:
1802
-181
7.
01020304050
Haf
fner
SM
et a
l. N
Eng
l J M
ed. 1
998;
339:
229-
234.
Fatal or nonfatal MI (%)
3.5%
18.6
%20
.2%
45.0
%
Equi
vale
nt M
I Ris
k Le
vels
No
Prio
r MI
Prio
r MI
No
Prio
r MI
Prio
r MI
Non
diab
etic
Sub
ject
sTy
pe 2
Dia
betic
Sub
ject
s (n
= 1
373)
(n =
105
9)
Dia
bete
s is
a C
VD
Ris
k E
quiv
alen
t to
Dia
bete
s is
a C
VD
Ris
k E
quiv
alen
t to
Pre
viou
s M
yoca
rdia
l Inf
arct
ion
Pre
viou
s M
yoca
rdia
l Inf
arct
ion
AD
A
AD
A C
ardi
omet
abol
icC
ardi
omet
abol
ic R
isk
Initi
ativ
e R
isk
Initi
ativ
e
Iden
tific
atio
n of
the
Met
abol
ic S
yndr
ome
Iden
tific
atio
n of
the
Met
abol
ic S
yndr
ome
≥≥ 1
10 m
g/11
0 m
g/dLdL
(6.1
mm
ol/L
)(6
.1m
mol
/L)
F
astin
g bl
ood
gluc
ose
F
astin
g bl
ood
gluc
ose
≥≥ 1
30/8
5 m
m H
g13
0/85
mm
Hg
B
lood
pre
ssur
e
Blo
od p
ress
ure
<
40 m
g/dL
<
40 m
g/dL
(1.0
3mm
ol/L
)
<50
(1.0
3mm
ol/L
)
<50
mg/
mg/
dLdL (1
.29m
mol
/L)
(1.2
9mm
ol/L
)
HD
L ch
oles
tero
l
H
DL
chol
este
rol
M
en
Men
W
omen
W
omen
≥≥
150
mg/
150
mg/
dLdL(1
.69m
mol
/L)
(1.6
9mm
ol/L
)
Tr
igly
cerid
es
Tr
igly
cerid
es
Wai
st c
ircum
fere
nce
Wai
st c
ircum
fere
nce
>
40 in
(>10
2 cm
)
>40
in (>
102
cm)
>
35 in
(>88
cm
)
>35
in (>
88 c
m)
Abd
omin
al o
besi
ty
A
bdom
inal
obe
sity
M
en
Men
W
omen
W
omen
Def
inin
g Le
vel
Def
inin
g Le
vel
Ris
k Fa
ctor
Ris
k Fa
ctor
¡¡ 3 R
isk
Fact
ors
Req
uire
d fo
r Dia
gnos
is3
Ris
k Fa
ctor
s R
equi
red
for D
iagn
osis
HD
L =
high
-den
sity
lipo
prot
ein.
NC
EP II
I. C
ircul
atio
n. 2
002;
106:
3143
-342
1.
CH
D R
isk
Incr
ease
s w
ith In
crea
sing
CH
D R
isk
Incr
ease
s w
ith In
crea
sing
Num
ber o
f Met
abol
ic S
yndr
ome
Ris
kN
umbe
r of M
etab
olic
Syn
drom
e R
isk
Fact
ors
Fact
ors
Satta
r et a
l, C
ircul
atio
n, 2
003;
108:
414-
419
Why
te e
t al,
Am
eric
an D
iabe
tes
Ass
ocia
tion,
200
1A
dapt
ed fr
om R
idke
r, C
ircul
atio
n 20
03;1
07:3
93-3
97A
dapt
ed fr
om R
idke
r, C
ircul
atio
n 20
03;1
07:3
93-3
97
00.51
1.52
2.53
3.54
4.55
5.56
6.57
one
two
three
four
Relative Risk
Com
paris
on of
Met
aboli
c Syn
drom
e and
Indiv
idual
Crite
rion P
reva
lence
in Fa
sting
CAT
IE Su
bject
s and
Ma
tche
d NH
ANES
III Su
bject
s
M
ales
CATI
E N
HANE
S
p N=
509
N
=509
Fema
les
CATI
E N
HANE
S
p N=
180
N=
180
Meta
bolic
Synd
rom
e Pre
valen
ce
36.0%
19
.7%
.0001
51
.6%
25.1%
.00
01
Wais
t Circ
umfe
renc
e Cr
iterio
n35
.5%
24.8%
.00
01
76.3%
57
.0%
.0001
Trigly
cerid
e Cr
iterio
n 50
.7%
32.1%
.00
01
42.3%
19
.6%
.0001
HDL C
riterio
n 48
.9%
31.9%
.00
01
63.3%
36
.3%
.0001
BP C
riterio
n 47
.2%
31.1%
.00
01
46.9%
26
.8%
.0001
Gluc
ose
Crite
rion
14.1%
14
.2%
.9635
21
.7%
11.2%
.00
75
Mey
er e
t al.,
Pre
sent
ed a
t AP
A a
nnua
l mee
ting,
May
21-
26, 2
005.
M
cEvo
y JP
et a
l. S
chiz
ophr
Res
. 200
5;(A
ugus
t 29)
.
010203040506070
Prevalence (%)
Heal
thy
Over
wei
ght
Obes
eHe
alth
yOv
erw
eigh
tOb
ese
N=1
2,36
3“O
verw
eigh
t” =
BM
I 25-
29.9
“Obe
se”
= B
MI ≥
30( N
atio
nal H
eart
, Lun
g, a
nd B
lood
Inst
itute
, O
besi
ty G
uide
lines
)
Men
Men
Wom
enW
omen
Pre
vale
nce
of M
etab
olic
Syn
drom
e A
ccor
ding
Pre
vale
nce
of M
etab
olic
Syn
drom
e A
ccor
ding
to B
MI i
n th
e A
dult
Gen
eral
Pop
ulat
ion
to B
MI i
n th
e A
dult
Gen
eral
Pop
ulat
ion
Park
et a
l. A
rch
Inte
rn M
ed. 2
003;
163:
427.
Mod
ifiab
le R
isk
Fact
ors
Affe
cted
Mod
ifiab
le R
isk
Fact
ors
Affe
cted
by
by P
sych
otro
pics
Psy
chot
ropi
csO
verw
eigh
t / O
besi
tyO
verw
eigh
t / O
besi
tyIn
sulin
resi
stan
ceIn
sulin
resi
stan
ceD
iabe
tes/
Dia
bete
s/hy
perg
lyca
emia
hype
rgly
caem
iaD
yslip
idem
iaD
yslip
idem
ia
New
com
er J
W. C
NS
Dru
gs 2
005;
19(S
upp
1):1
.93.
1-Y
ear W
eigh
t Gai
n:1-
Yea
r Wei
ght G
ain:
MMea
nea
n C
hang
e Fr
om B
asel
ine
Wei
ght
Cha
nge
From
Bas
elin
e W
eigh
t Change From Baseline Weight (lb)
Wee
ks
Change From Baseline Weight (kg)
5248
4440
3632
2824
2016
128
400
Ola
nzap
ine
(12.
5–17
.5 m
g)O
lanz
apin
e (a
ll do
ses)
Que
tiapi
neR
ispe
ridon
eZi
pras
idon
eA
ripip
razo
le
051015202530
02468101214
Nem
erof
f CB
. J C
lin P
sych
iatr
y. 1
997;
58(s
uppl
10)
:45-
49;
Kin
on B
J et
al.
J C
lin P
sych
iatr
y. 2
001;
62:9
2-10
0; B
rech
er M
et
al. A
mer
ican
Col
lege
of N
euro
psyc
hoph
arm
acol
ogy;
200
4. P
oste
r 114
; B
rech
er M
et a
l. N
euro
psyc
hoph
arm
acol
ogy.
2004
;29(
supp
l 1):S
109;
Geo
don®
[pac
kage
inse
rt].
New
Yor
k, N
Y:Pf
izer
Inc;
200
5. R
ispe
rdal
® [p
acka
ge in
sert
]. Ti
tusv
ille,
NJ:
Jan
ssen
Pha
rmac
eutic
a Pr
oduc
ts, L
P; 2
003;
Abi
lify®
[pa
ckag
e in
sert
]. Pr
ince
ton
NJ:
Bris
tol-M
yers
Squ
ibb
Com
pany
and
Roc
kvill
e, M
d: O
tsuk
a A
mer
ica
Phar
mac
eutic
al, I
nc.;
2005
.
CA
TIE
Tria
l Res
ult
s:C
ATI
E Tr
ial R
esu
lts:
Wei
ght
Gai
n P
er M
onth
Wei
ght
Gai
n P
er M
onth
Trea
tmen
tTr
eatm
ent
NEJ
M 2
005
353:
1209
-122
3
-1012
OLZ
OLZ
RIS
RIS
PER
PER
QU
ETQ
UET
ZIP
ZIP
Weight gain (lb) per month Weight gain (lb) per month
Con
vent
iona
lsO
lanz
apin
eR
ispe
ridon
e
-25
-20
-15
-10-505
LS Mean Change (lb)
4953
5845
4036
3227
2319
1410
6 * ***
*****
**
***
*P
<0.0
5 *
*P<0
.01
***P
<0.0
001
Switc
hed
from
Wei
den
P e
t al.
Pre
sent
ed A
PA
200
4.
Cha
nge
in W
eigh
t Fro
m B
asel
ine
Cha
nge
in W
eigh
t Fro
m B
asel
ine
58 W
eeks
Afte
r Sw
itch
to L
ow W
eigh
t58
Wee
ks A
fter S
witc
h to
Low
Wei
ght
Gai
n A
gent
Gai
n A
gent
Leve
ls o
f Evi
denc
eLe
vels
of E
vide
nce
Cas
e re
ports
, cas
e se
ries,
unc
ontro
lled
Cas
e re
ports
, cas
e se
ries,
unc
ontro
lled
obse
rvat
iona
l stu
dies
- ob
serv
atio
nal s
tudi
es -
hypo
thes
is-g
ener
atio
nhy
poth
esis
-gen
erat
ion
only
only
Ret
rosp
ectiv
e da
taba
se a
naly
ses
- R
etro
spec
tive
data
base
ana
lyse
s - c
ould
be
coul
d be
hypo
thes
is-te
stin
g, b
ut m
etho
dolo
gica
l iss
ues
hypo
thes
is-te
stin
g, b
ut m
etho
dolo
gica
l iss
ues
mig
ht li
mit
thes
e to
hyp
othe
sis-
gene
ratio
nm
ight
lim
it th
ese
to h
ypot
hesi
s-ge
nera
tion
Con
trolle
d an
alyt
ic s
tudi
es, i
nclu
ding
Con
trolle
d an
alyt
ic s
tudi
es, i
nclu
ding
rand
omiz
ed c
linic
al tr
ials
- ra
ndom
ized
clin
ical
tria
ls -
hypo
thes
is-te
stin
ghy
poth
esis
-test
ing
Cas
ey D
E, H
aupt
DW
, New
com
er J
W, H
ende
rson
DC
, Ser
nyak
MJ,
Dav
idso
n M
, Lin
denm
ayer
JP
,M
anou
kian
SV
, Ban
erji
MA
, Leb
ovitz
HE
, Hen
neke
ns C
H, J
Clin
Psy
chia
try 6
5(S
uppl
7):4
-18,
200
4.C
asey
DE
, Hau
pt D
W, N
ewco
mer
JW
, Hen
ders
on D
C, S
erny
ak M
J, D
avid
son
M, L
inde
nmay
er J
P,
Man
ouki
an S
V, B
aner
ji M
A, L
ebov
itz H
E, H
enne
kens
CH
, J C
lin P
sych
iatry
65(
Sup
pl 7
):4-1
8, 2
004.
Mod
ifiab
le R
isk
Fact
ors
Affe
cted
Mod
ifiab
le R
isk
Fact
ors
Affe
cted
by
by P
sych
otro
pics
Psy
chot
ropi
csO
verw
eigh
t / O
besi
tyO
verw
eigh
t / O
besi
tyIn
sulin
resi
stan
ceIn
sulin
resi
stan
ceD
iabe
tes/
Dia
bete
s/hy
perg
lyca
emia
hype
rgly
caem
iaD
yslip
idem
iaD
yslip
idem
ia
New
com
er J
W. C
NS
Dru
gs 2
005;
19(S
upp
1):1
.93.
Ran
dom
ized
Clin
ical
Tria
lsR
ando
miz
ed C
linic
al T
rials
••
Insu
lin re
sist
ance
In
sulin
resi
stan
ce••
Fa
stin
g lip
ids
Fast
ing
lipid
s••
Fa
stin
g or
pos
t-loa
d gl
ucos
e an
d
Fast
ing
or p
ost-l
oad
gluc
ose
and
insu
linin
sulin
••
Met
abol
ic s
yndr
ome
M
etab
olic
syn
drom
e
Gro
win
g nu
mbe
r of s
tudi
es m
easu
redr
ug e
ffect
s on
the
follo
win
g:
CA
TIE
Res
ult
s:C
ATI
E R
esu
lts:
Met
abol
ic C
han
ges
From
Bas
elin
eM
etab
olic
Ch
ange
s Fr
om B
asel
ine
05050505050505
OLZ
OLZ
RIS
RIS
PER
PER
QU
ETQ
UET
ZIP
ZIP
9.4
-8.2
1.3
-1.3
6.6
40.5
21.2
-2.4
9.2
-16
.5
Cho
lest
erol
(mg/
dL)
Trig
lyce
rides
(mg/
dL)
NEJ
M 2
005
353:
1209
-122
3
CA
TIE
Res
ult
s:C
ATI
E R
esu
lts:
Met
abol
ic C
han
ges
From
Bas
elin
eM
etab
olic
Ch
ange
s Fr
om B
asel
ine
NEJ
M 2
005
353:
1209
-122
3
02468101214G
luco
se (m
g/dL
)
Gly
cosy
late
d H
B (%
)
13.7
0.11
2.9
0.0
5.4
0.07
6.6
0.04
7.5
0.4
OLZ
OLZ
RIS
RIS
PER
PER
QU
ETQ
UET
ZIP
ZIP
Am
eric
an D
iabe
tes
Ass
ocia
tion,
Am
eric
an P
sych
iatri
c A
ssoc
iatio
n,A
mer
ican
Dia
bete
s A
ssoc
iatio
n, A
mer
ican
Psy
chia
tric
Ass
ocia
tion,
Am
eric
an A
ssoc
iatio
n of
Clin
ical
End
ocrin
olog
ists
, Nor
th A
mer
ican
Am
eric
an A
ssoc
iatio
n of
Clin
ical
End
ocrin
olog
ists
, Nor
th A
mer
ican
Ass
ocia
tion
for t
he S
tudy
of O
besi
ty:
Ass
ocia
tion
for t
he S
tudy
of O
besi
ty:
Con
sens
us C
onfe
renc
e on
Ant
ipsy
chot
ic D
rugs
and
Con
sens
us C
onfe
renc
e on
Ant
ipsy
chot
ic D
rugs
and
Ris
k of
Obe
sity
and
Dia
bete
sR
isk
of O
besi
ty a
nd D
iabe
tes
+ =
incr
ease
d ef
fect
; - =
no
effe
ct; D
= d
iscr
epan
t res
ults
.+
= in
crea
sed
effe
ct; -
= n
o ef
fect
; D =
dis
crep
ant r
esul
ts.
----
+/-
+/-
zipr
asid
one
zipr
asid
one
----
+/-
+/-
arip
ipra
zole
arip
ipra
zole
DDDD
+ +
+ +
quet
iapi
nequ
etia
pine
DDDD
+ +
+ +
rispe
ridon
eris
perid
one
++++
+ +
++
+ +
olan
zapi
neol
anza
pine
++++
+ +
++
+ +
cloz
apin
ecl
ozap
ine
Dys
lipid
emia
Dys
lipid
emia
Dia
bete
s R
isk
Dia
bete
s R
isk
Wei
ght G
ain
Wei
ght G
ain
Dru
gD
rug
Dia
bete
s C
are
27:5
96-6
01, 2
004
AD
A/A
PA
/AA
CE
/NA
AS
O C
onse
nsus
on
AD
A/A
PA
/AA
CE
/NA
AS
O C
onse
nsus
on
Ant
ipsy
chot
ic D
rugs
and
Obe
sity
and
Ant
ipsy
chot
ic D
rugs
and
Obe
sity
and
Dia
bete
s: M
onito
ring
Pro
toco
lD
iabe
tes:
Mon
itorin
g P
roto
col **
*Mor
e fre
quen
t ass
essm
ents
may
be
war
rant
ed b
ased
on
*Mor
e fre
quen
t ass
essm
ents
may
be
war
rant
ed b
ased
on
clin
ical
sta
tus
clin
ical
sta
tus
Dia
bete
s C
are.
27:
596-
601,
200
4
XXXX
XXFa
stin
g lip
id p
rofil
eFa
stin
g lip
id p
rofil
e
XXXX
XXFa
stin
g gl
ucos
eFa
stin
g gl
ucos
e
XXXX
XXB
lood
pre
ssur
eB
lood
pre
ssur
e
XXXX
Wai
stW
aist
circ
umfe
renc
eci
rcum
fere
nce
XXXX
XXXX
XXW
eigh
t (B
MI)
Wei
ght (
BM
I)
XXXX
Per
sona
l/fam
ily
Per
sona
l/fam
ily H
xH
x
5 yr
s.5
yrs.
12 m
os.
12 m
os.
qtrly
qtrly
12 w
k12
wk
8 w
ks8
wks
4 w
ks4
wks
Sta
rtS
tart
XX
Pro
blem
:P
robl
em:
SM
I and
Red
uced
Use
of M
edic
al S
ervi
ces
SM
I and
Red
uced
Use
of M
edic
al S
ervi
ces
Few
er ro
utin
e pr
even
tive
serv
ices
(Dru
ssFe
wer
rout
ine
prev
entiv
e se
rvic
es (D
russ
2002
)20
02)
Wor
se d
iabe
tes
care
(Des
ai 2
002,
Fra
yne
Wor
se d
iabe
tes
care
(Des
ai 2
002,
Fra
yne
2006
)20
06)
Low
er ra
tes
of c
ardi
ovas
cula
r pro
cedu
res
Low
er ra
tes
of c
ardi
ovas
cula
r pro
cedu
res
(Dru
ss 2
000)
(Dru
ss 2
000)
Acc
ess
and
Qua
lity
of C
are
Acc
ess
and
Qua
lity
of C
are
SM
I may
be
a he
alth
risk
fact
or b
ecau
se o
f:S
MI m
ay b
e a
heal
th ri
sk fa
ctor
bec
ause
of:
––P
atie
nt fa
ctor
sP
atie
nt fa
ctor
s , e
.g.:
amot
ivat
ion,
fear
fuln
ess,
, e.g
.: am
otiv
atio
n, fe
arfu
lnes
s,ho
mel
essn
ess,
vic
timiz
atio
n/tra
uma,
reso
urce
s,ho
mel
essn
ess,
vic
timiz
atio
n/tra
uma,
reso
urce
s,ad
voca
cy, u
nem
ploy
men
t, in
carc
erat
ion,
soc
ial
advo
cacy
, une
mpl
oym
ent,
inca
rcer
atio
n, s
ocia
lin
stab
ility
, IV
dru
g us
e, e
tcin
stab
ility
, IV
dru
g us
e, e
tc––
Pro
vide
r fac
tors
Pro
vide
r fac
tors
: Com
fort
leve
l and
atti
tude
of
: Com
fort
leve
l and
atti
tude
of
heal
thca
re p
rovi
ders
, coo
rdin
atio
n be
twee
n m
enta
lhe
alth
care
pro
vide
rs, c
oord
inat
ion
betw
een
men
tal
heal
th a
nd g
ener
al h
ealth
car
e, s
tigm
a,he
alth
and
gen
eral
hea
lth c
are,
stig
ma,
––S
yste
m fa
ctor
sS
yste
m fa
ctor
s : F
undi
ng, f
ragm
enta
tion
: Fun
ding
, fra
gmen
tatio
n
Hen
neke
ns C
H. C
ircul
atio
n. 1
998;
97:1
095-
1102
.
Goa
ls: L
ower
Ris
k fo
r CV
DG
oals
: Low
er R
isk
for C
VD
Blo
od c
hole
ster
olB
lood
cho
lest
erol
––10
%
10%
↓↓ =
30%
=
30%
↓↓ in
CH
D (2
00-1
80)
in C
HD
(200
-180
)H
igh
bloo
d pr
essu
re (>
140
SB
P o
r 90
DB
P)
Hig
h bl
ood
pres
sure
(> 1
40 S
BP
or 9
0 D
BP
)––
4-6
mm
Hg
4-6
mm
Hg ↓↓
= 1
6%
= 1
6% ↓↓
in C
HD
; 42%
in
CH
D; 4
2% ↓↓
in s
troke
in s
troke
Cig
aret
te s
mok
ing
cess
atio
nC
igar
ette
sm
okin
g ce
ssat
ion
––50
%-7
0%
50%
-70%
↓↓ in
CH
D in
CH
D M
aint
enan
ce o
f ide
al b
ody
wei
ght (
BM
I = 2
5) M
aint
enan
ce o
f ide
al b
ody
wei
ght (
BM
I = 2
5)––
35%
-55%
35
%-5
5% ↓↓
in C
HD
in C
HD
Mai
nten
ance
of a
ctiv
e lif
esty
le (2
0-m
in w
alk
daily
)M
aint
enan
ce o
f act
ive
lifes
tyle
(20-
min
wal
k da
ily)
––35
%-5
5%
35%
-55%
↓↓ in
CH
D in
CH
D
Sur
viva
l Fol
low
ing
Myo
card
ial
Sur
viva
l Fol
low
ing
Myo
card
ial
Infa
rctio
nIn
farc
tion
88,2
41 M
edic
are
patie
nts,
65
year
s of
88,2
41 M
edic
are
patie
nts,
65
year
s of
age
and
olde
r, ho
spita
lized
for M
Iag
e an
d ol
der,
hosp
italiz
ed fo
r MI
Mor
talit
y in
crea
sed
byM
orta
lity
incr
ease
d by
––19
%: a
ny m
enta
l dis
orde
r19
%: a
ny m
enta
l dis
orde
r––
34%
: sch
izop
hren
ia34
%: s
chiz
ophr
enia
Incr
ease
d m
orta
lity
expl
aine
d by
Incr
ease
d m
orta
lity
expl
aine
d by
mea
sure
s of
qua
lity
of c
are
mea
sure
s of
qua
lity
of c
are
Dru
ss B
G e
t al.
Arch
Gen
Psy
chia
try.
200
1;58
:565
-572
.
Dis
parit
ies
in c
are:
impa
ct o
f men
tal
Dis
parit
ies
in c
are:
impa
ct o
f men
tal
illne
ss o
n di
abet
es m
anag
emen
till
ness
on
diab
etes
man
agem
ent
313,
586
Vete
ran
Hea
lth A
utho
rity
patie
nts
with
dia
bete
s76
,799
(25%
) had
men
tal h
ealth
con
ditio
ns (1
999) Fr
ayn
e et
al.
Arc
h In
tern
Med
. 200
5;16
5:26
31-2
638
Dep
ress
ion
Anxi
ety
Psyc
hosi
s
Man
ia
Subs
tanc
eus
e di
sord
er
Pers
onal
itydi
sord
er
0.8
1.0
1.2
1.4
1.6
No
HbA
test
done
0.8
1.0
1.2
1.4
1.6
No
LDL
test
done
0.8
1.0
1.2
1.4
1.6
No
Eye
exam
inat
ion
done
0.8
1.0
1.2
1.4
1.6
No
Mon
itorin
g
0.8
1.0
1.2
1.4
1.6
Poo
rgl
ycem
icco
ntro
l
0.8
1.0
1.2
1.4
1.6
Poo
rlip
emic
cont
rol
Odd
s ra
tio fo
r:
Why
Sho
uld
we
be C
once
rned
Abo
utW
hy S
houl
d w
e be
Con
cern
ed A
bout
Mor
bidi
ty a
nd M
orta
lity?
Mor
bidi
ty a
nd M
orta
lity?
Rec
ent d
ata
from
sev
eral
sta
tes
have
Rec
ent d
ata
from
sev
eral
sta
tes
have
foun
d th
at
foun
d th
at p
eopl
e w
ith s
erio
us m
enta
lpe
ople
with
ser
ious
men
tal
illne
ss s
erve
d by
our
pub
lic m
enta
lill
ness
ser
ved
by o
ur p
ublic
men
tal
heal
th s
yste
ms
die,
on
aver
age,
at l
east
heal
th s
yste
ms
die,
on
aver
age,
at l
east
25 y
ears
ear
lier t
hat t
he g
ener
al25
yea
rs e
arlie
r tha
t the
gen
eral
popu
latio
npo
pula
tion ..
Ove
rvie
w -
Ove
rvie
w -
PR
OP
OS
ED
SO
LUTI
ON
SP
RO
PO
SE
D S
OLU
TIO
NS
Prio
ritiz
e th
e P
ublic
Hea
lth P
robl
emTa
rget
Pro
vide
rs, F
amili
es a
nd C
lient
sFo
cus
on P
reve
ntio
n an
d W
elln
ess
Trac
k M
orbi
dity
and
Mor
talit
y in
Pub
licM
enta
l Hea
lth P
opul
atio
ns
Impl
emen
t Est
ablis
hed
Sta
ndar
ds o
f Car
eP
reve
ntio
n, S
cree
ning
and
Tre
atm
ent
Impr
ove
Acc
ess
to a
nd In
tegr
atio
n of
Phy
sica
l Hea
lth a
nd M
enta
l Hea
lth C
are
Rec
omm
enda
tions
Rec
omm
enda
tions
NA
TIO
NA
L LE
VEL
lS
eek
fede
ral d
esig
natio
n of
peo
ple
with
SM
I as
adi
stin
ct a
t-ris
k he
alth
dis
parit
ies
popu
latio
n.
Est
ablis
hco
-ord
inat
ed m
enta
l hea
lth a
nd g
ener
al h
ealth
car
e as
ana
tiona
l hea
lthca
re p
riorit
y.
lE
stab
lish
a co
mm
ittee
at t
he fe
dera
l lev
el to
reco
mm
end
chan
ges
to n
atio
nal s
urve
illan
ce a
ctiv
ities
that
will
inco
rpor
ate
info
rmat
ion
abou
t hea
lth s
tatu
s in
the
popu
latio
n w
ith S
MI.
Con
side
r rep
rese
ntat
ion
from
SA
MH
SA
, Med
icai
d , t
he C
ente
rs fo
rD
isea
se C
ontro
l and
Pre
vent
ion,
sta
te M
H a
utho
ritie
s /
NA
SM
HP
D,
and
expe
rtsTh
is m
ay in
clud
e th
e IO
M p
roje
ct a
nd o
ther
nat
iona
l sur
veys
.
Rec
omm
enda
tions
Rec
omm
enda
tions
NA
TIO
NA
L LE
VEL
lS
hare
info
rmat
ion
wid
ely
abou
t phy
sica
l hea
lth ri
sks
inpe
rson
s w
ith S
MI t
o en
cour
age
awar
enes
s an
dad
voca
cy.
Edu
cate
the
heal
th c
are
com
mun
ity.
Enc
oura
ge c
onsu
mer
s an
d fa
mily
mem
bers
toad
voca
te fo
r w
elln
ess
appr
oach
es a
s pa
rt of
rec
over
y.
Rec
omm
enda
tions
Rec
omm
enda
tions
STA
TE L
EVEL
See
k st
ate
desi
gnat
ion
of p
eopl
e w
ith S
MI a
sBO
TH a
n a
t-ris
k an
d a
heal
th d
ispa
ritie
spo
pula
tion.
lEs
tabl
ish
co-o
rdin
ated
men
tal h
ealth
and
gene
ral h
ealth
car
e as
a s
tate
hea
lthca
repr
iorit
y.
lE
duca
tion
and
advo
cacy
polic
y m
aker
sfu
nder
spr
ovid
ers
indi
vidu
als,
fam
ily, c
omm
unity
Rec
omm
enda
tions
Rec
omm
enda
tions
STA
TE L
EVEL
lR
equi
re, r
egul
ate
and
lead
Beh
avio
ral H
ealth
pro
vide
rsy
stem
s to
scr
een,
ass
ess
and
treat
bot
h m
enta
l hea
lthan
d ge
nera
l hea
lth c
are
issu
es.
Pro
vide
for
s
taffi
ng
tim
e
re
cord
kee
ping
reim
burs
emen
t
lin
kage
with
phy
sica
l hea
lthca
re p
rovi
ders
Fund
ing
Fund
ing
Pro
mot
e co
-ord
inat
ed a
nd in
tegr
ated
men
tal h
ealth
and
phys
ical
hea
lth c
are
for p
erso
ns w
ith S
MI.
See
11th
NAS
MH
PD T
echn
ical
Pap
er: I
nteg
ratin
g M
enta
l Hea
lth a
nd P
rimar
yC
are.
Rec
omm
enda
tions
Rec
omm
enda
tions
STA
TE L
EVEL
lD
evel
op a
qua
lity
impr
ovem
ent (
QI)
proc
ess
that
supp
orts
incr
ease
d ac
cess
to p
hysi
cal h
ealth
care
and
ensu
res
appr
opria
te p
reve
ntio
n, s
cree
ning
and
treat
men
t ser
vice
s.
Targ
et c
omm
on c
ause
s of
incr
ease
d m
orta
lity
and
chro
nic
med
ical
illn
ess
in th
e S
MI p
opul
atio
n
Incl
ude
all k
ey s
take
hold
ers:
sta
te a
genc
ies,
pra
ctiti
oner
s,in
divi
dual
s an
d th
eir f
amili
es, a
cade
mic
and
trai
ning
inst
itutio
ns in
QI p
lann
ing
and
revi
ew
A k
ey c
ompo
nent
: tra
inin
g an
d te
chni
cal a
ssis
tanc
e fo
rpr
actit
ione
rs in
bot
h m
enta
l hea
lth a
nd p
rimar
y he
alth
fiel
ds
Rec
omm
enda
tions
LO
CA
L A
GEN
CY
/ CLI
NIC
IAN
lB
H p
rovi
ders
sha
ll pr
ovid
e qu
ality
med
ical
car
e an
dm
enta
l hea
lth c
are
Scr
een
for g
ener
al h
ealth
with
prio
rity
for h
igh
risk
cond
ition
s
Offe
r pre
vent
ion
and
inte
rven
tion
espe
cial
ly fo
r mod
ifiab
le ri
skfa
ctor
s (o
besi
ty, a
bnor
mal
glu
cose
and
lipi
d le
vels
, hig
h bl
ood
pres
sure
, sm
okin
g, a
lcoh
ol a
nd d
rug
use,
etc
.)
Pre
scrib
ers
will
scr
een,
mon
itor a
nd in
terv
ene
for m
edic
atio
n ris
kfa
ctor
s re
late
d to
trea
tmen
t of S
MI (
e.g.
risk
of m
etab
olic
synd
rom
e w
ith u
se o
f sec
ond
gene
ratio
n an
ti-ps
ycho
tics)
Trea
tmen
t per
pra
ctic
e gu
idel
ines
, e.g
hea
rt di
seas
e, d
iabe
tes,
smok
ing
cess
atio
n, u
se o
f nov
el a
nti-p
sych
otic
s.
LOC
AL
AG
ENC
Y / C
LIN
ICIA
NR
ecom
men
datio
ns
2. C
are
coor
dina
tion
Mod
els
lA
ssur
e th
at th
ere
is a
spe
cific
pra
ctiti
oner
in th
e M
H s
yste
mw
ho is
iden
tifie
d as
the
resp
onsi
ble
party
for e
ach
pers
on’s
med
ical
hea
lth c
are
need
s be
ing
addr
esse
d an
d w
hoas
sure
s co
ordi
natio
n al
l ser
vice
s.
Rou
tine
shar
ing
of c
linic
al in
form
atio
n w
ith o
ther
prov
ider
s (p
rimar
y an
d sp
ecia
lty h
ealth
care
prov
ider
s as
wel
l as
men
tal h
ealth
pro
vide
rs
Car
e in
tegr
atio
n w
here
ser
vice
s ar
e co
-loca
ted
LOC
AL
AG
ENC
Y / C
LIN
ICIA
NR
ECO
MM
END
ATI
ON
S3.
S
uppo
rt co
nsum
er w
elln
ess
and
empo
wer
men
t to
impr
ove
pers
onal
men
tal a
nd p
hysi
cal w
ell-b
eing
educ
ate
/ s
hare
info
rmat
ion
to m
ake
heal
thy
choi
ces
rega
rdin
g nu
tritio
n, to
bacc
o us
e, e
xerc
ise,
impl
icat
ions
of
psyc
hotro
pic
drug
ste
ach
/sup
port
wel
lnes
s se
lf-m
anag
emen
t ski
llste
ach
/sup
port
deci
sion
mak
ing
skill
sm
otiv
atio
nal i
nter
view
ing
tech
niqu
esIm
plem
ent a
phy
sica
l hea
lth W
elln
ess
appr
oach
that
isco
nsis
tent
with
Rec
over
y pr
inci
ples
, inc
ludi
ng s
uppo
rts fo
rsm
okin
g ce
ssat
ion,
goo
d nu
tritio
n, p
hysi
cal a
ctiv
ity a
nd h
ealth
yw
eigh
t.at
tend
to c
ultu
ral a
nd la
ngua
ge n
eeds
Ove
rvie
w -
Ove
rvie
w -
PR
OP
OS
ED
SO
LUTI
ON
SP
RO
PO
SE
D S
OLU
TIO
NS
Prio
ritiz
e th
e P
ublic
Hea
lth P
robl
emTa
rget
Pro
vide
rs, F
amili
es a
nd C
lient
sFo
cus
on P
reve
ntio
n an
d W
elln
ess
Trac
k M
orbi
dity
and
Mor
talit
y in
Pub
licM
enta
l Hea
lth P
opul
atio
ns
Impl
emen
t Est
ablis
hed
Sta
ndar
ds o
f Car
eP
reve
ntio
n, S
cree
ning
and
Tre
atm
ent
Impr
ove
Acc
ess
to a
nd In
tegr
atio
n of
Phy
sica
l Hea
lth a
nd M
enta
l Hea
lth C
are
Full
repo
rt a
vaila
ble
atFu
ll re
port
ava
ilabl
e at
http
://ht
tp://
ww
w.n
asm
hpd.
org/
publ
icat
ions
.cfm
#tec
hpap
ww
w.n
asm
hpd.
org/
publ
icat
ions
.cfm
#tec
hpap