Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and...

67
Morbidity and Mortality in Morbidity and Mortality in People with Serious Mental People with Serious Mental Illness Illness National Association of State Mental Health Program National Association of State Mental Health Program Directors Directors Medical Directors Council Medical Directors Council July 2006 July 2006

Transcript of Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and...

Page 1: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 2: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 3: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 4: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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 ..

Page 5: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 6: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 7: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 8: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 9: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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)

Page 10: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 11: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 12: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 13: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 14: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes
Page 15: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 16: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 17: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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.

Page 18: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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)

Page 19: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 20: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 21: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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)

Page 22: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 23: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 24: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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%

Page 25: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 26: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

%

Page 27: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

%

Page 28: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

%

Page 29: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 30: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 31: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 32: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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.

Page 33: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 34: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

AD

A

AD

A C

ardi

omet

abol

icC

ardi

omet

abol

ic R

isk

Initi

ativ

e R

isk

Initi

ativ

e

Page 35: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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.

Page 36: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 37: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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)

.

Page 38: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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.

Page 39: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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.

Page 40: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

.

Page 41: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 42: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 43: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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.

Page 44: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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.

Page 45: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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:

Page 46: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 47: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 48: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 49: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 50: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes
Page 51: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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)

Page 52: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 53: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 54: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

.

Page 55: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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:

Page 56: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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 ..

Page 57: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 58: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

.

Page 59: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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.

Page 60: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 61: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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.

Page 62: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 63: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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.

Page 64: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 65: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 66: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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

Page 67: Morbidity and Mortality in People with Severe Mental ... and Mortality... · Morbidity and Mortality in People with Serious Mental ... zIncreased risk of death from medical causes

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