Barriers to Healthcare Services for People with Mental Disorders. Cardiovascular disorders and diabetes in people with severe mental illness

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1 Barriers to Healthcare Services for People with Mental Disorders Cardiovascular disorders and diabetes in people with severe mental illness Dr. med. J. Cordes LVR- Klinikum Düsseldorf Kliniken der Heinrich-Heine-Universität Düsseldorf Bergische Landstr. 2, D Düsseldorf

2 Epidemiology Cardiovascular disorders and diabetes in people with severe mental illness Mortality and morbidity of depression Prevalence of the metabolic syndrome in patients with severe mental illness Pathophysiologic data Risk factors for the development of metabolic syndrome Barriers to Healthcare Services Challenges Monitoring Psychoeducation and psychotherapy Consequences

3 Excess mortality in bipolar and unipolar disorder. All patients with a hospital diagnosis of bipolar (n = ) or unipolar (n = ) disorder in Sweden from 1973 to 1995 were linked with the national cause-of-death register. Standardized Cause of death Cause of death Mortality ratios cardiovascular cerebrovascular Female Unipolar Bipolar Male Unipolar Bipolar Ösby U et al. Arch Gen Psychiatry 2001; 58:

4 The high prevalence of multiple psychiatric disorders in stable outpatients with coronary heart disease single past major depressive episode (29%) current dysthymic disorder (15%) recurrent major depressive disorder with current major depressive episode (31%) current alcohol abuse (19%) posttraumatic stress disorder (29%) current generalized anxiety disorder (24%) current binge-eating disorder (10%) current primary insomnia (13%). The mean number of comorbid clinical psychiatric disorders per subject was 1.7. Bankier et al., Psychosom. Med. 2004; 66:

5 Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis. all-cause mortality OR 2.38 studies before 1992 studies after 1992 cardiac mortality OR 2.59 cardiovascular events Van Melle et al., Psychosom. Med. 2004; 66:

6 Five-year risk of cardiac mortality in relation to initial severity and one-year changes in depression symptoms after myocardial infarction, N=896 Lesperance F et al. Circulation 2002; 105:

7 Depression and all-cause and coronary heart disease mortality among adults with and without diabetes. NHANES I; n = 10025; 8 years follow-up HR (Cox) 95% CI All-causes mortality Depression Diabetes Diabetes+Depression CHD-mortality Depression Diabetes ,21 Diabetes+Depression Egede,Diabetes Care 2005;28:

8 Definition of the Metabolic Syndrome 3 von 5 criteria risc factors range viscerale obesity circumference: M:>102 cm; F:>88 cm diabetes fasting BG: 110 mg/dl hypertonia 130/ 85 mm Hg increased triglyceride 150 mg/dl decreased HDL cholesterol m:<40 mg/dl; f:<50 mg/dl NCEP

9 Prevalence MetS (%) Increased prevalence of the metabolic syndrome in patients with severe mental illness Age BMI Healthy Schizophrenia 39,3±13,2 25,1±3,8 Depression 42,7±14,0 26,2±6,0 Bipolar 47,7±15,3 25,5±5,1 Addiction 46,5±11,0 25,5±5, Healthy subjects Schizophrenia Depression Bipolar Addiction Kahl et al., under review

10 Risk factors for the development of the metabolic syndrome Cytokines and adipokines HPAS and cortisol Low birth weight drugs Alcohol Smoking Metabolisches Metabolic Syndrom syndrom Unmodifiable RF Age Gender Ethnic factors Lifestyle, Compliance Poorness, Barriers to healthcare services

11 Weight gain and Antipsychotics drug weight diabetes lipids gain Clozapine Olanzapine Risperidone ++ D D Quetiapine ++ D D Aripiprazol* +/- - - Ziprasidon* +/ = increased; - = no effect; D = unclear *new drugs with limited data of longterm treatment Consensus Statement: ADA, APA, AACE, NAASO, Diabetes Care 2004; 27:

12 Diagnostic and therapeutic Deficit depression in West Germany: 4 Mio general practitioner 2,4-2,8 Mio. precise diagnosed 1,2-1,4 Mio. appropriate therapy % 30-35% 10%

13 Pre-existent depression in the 2 weeks before acute coronary syndrome can be associated with delayed presentation of the heart attack. (N=276) Wong, C.-K. et al. QJM :

14 Social support, depression during the first week after myocardial infarction and mortality during the first year after myocardial infarction (N=887). Frasure-Smith N et al. Circulation 2000; 101:

15 Barriers to Healthcare Services Negative attitudes towards somatic treatment Negative attitudes towards psychiatric patients Insufficient health care compensation systems Insufficient healthcare supplies of somatic illness in psychiatric patients. Structurally inadequate level of internal medicine in psychiatric hospitals and ambulances

16 Monitoring Protocol for Patients on Second-Generation Antipsychotics baseline 4 weeks 8 weeks 12 weeks quarterly annually every 5 years personal / family history weight (BMI) blood pressure fasting plasma glucose waist circumference fasting lipid profile Consensus Statement: ADA, APA, AACE, NAASO, Diabetes Care 2004; 27:

17 Intervention Programs Reducing weight can positively influence many components of metabolic syndrome Clinical guidelines exist Evidence of effectiveness of behavioraltherapeutic programs Methods: Nutritional therapy Physical exercise programs Behavioral therapy Emotional / moral support is another factor

18 Our Study Hypothesis A 24-week psychoeducational weight-management program can decrease weight gain in schizophrenic patients taking olanzapine Cordes J, Thünker J, Klimke A, Hauner H

19 Study Procedure t screening intervention follow-up

20 Methods 100 schizophrenic patients Verum group (N=35) mean age = male = sessions of in-depth weight- management training Sham group (N=39) mean age = male = 27 1 superficial briefing

21 Weight in kg Figure 2: Development of the mean body weight over time. N = 27, 11, 15, and Men, control Women, control Men, prevention Woman, prevention Week

22 Glucose level two hours after glucose administration in mg/dl Development of the glucose level two hours after dextrose administration (N = 27, 10, 15, 18) Men, control Women, control Men, prevention Woman, prevention

23 Conclusion There is a need for sufficient provision of medical health care service for severe mentally illnesses We need an interdisciplinary concept including case management and sufficient health care compensation systems The psychiatric knowledge of the physician and the somatic medicine knowledge of the psychiatrist should be improved We need early interventions and a regular monitoring to prevent cardiovascular risk More research to identify relevant barriers is needed

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