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-40629 Düsseldorf
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
Excess mortality in bipolar and unipolar disorder.
All patients with a hospital diagnosis of bipolar (n = 15 386) or unipolar (n = 39 182) disorder in Sweden from 1973 to 1995 were linked with the national cause-of-death register.
Ösby U et al. Arch Gen Psychiatry 2001; 58: 844-850
Standardized Mortality ratios
Cause of death cardiovascular
Cause of death cerebrovascular
Female Unipolar Bipolar
1.7 2.6
1.5 2.0 Male
Unipolar Bipolar
1.5 1.9
1.5
1.9
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: 645-650
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: 814-822
1 2 3 4 5 -5 -4 -3 -2 -1
Prognostic association of depression following myocardial infarction with mortality and
cardiovascular events: a meta-analysis.
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: 1049-1053
HR (Cox) 95% CI All-causes mortality
Depression 1.20 1.03-1.40
Diabetes 1.88 1.55-2.27
Diabetes+Depression 2.50 2.04-3.08
CHD-mortality
Depression 1.29 0.96-1.74
Diabetes 2.26 1.60-3,21
Diabetes+Depression 2.43 1.66-3.56
Depression and all-cause and coronary heart disease mortality among adults with and without diabetes.
Egede ,Diabetes Care 2005;28:1339-45
NHANES I; n = 10025; 8 years follow-up
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
Definition of the Metabolic Syndrome
3 von 5 criteria
NCEP
Hea lthy
subj ects
Schizop hren
ia
Dep res
sion
Bipolar
Addi ction 0
25 50
Prevalence MetS (%)
Kahl et al., under review
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±5,3
Metabolisches Syndrom Cytokines and adipokines
HPAS and cortisol
Alcohol Smoking
Lifestyle, Compliance
Poorness,
Barriers to healthcare services
Unmodifiable RF Age
Gender
Ethnic factors
drugs Metabolisches
Syndrom Metabolic
syndrom
Risk factors for the development of the metabolic syndrome
Low birth weight
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: 596-601
depression in West Germany:
4 Mio
60-70%
general practitioner 2,4 - 2,8 Mio.
30-35%
precise diagnosed 1,2 - 1,4 Mio.
10%
appropriate therapy 400.000
Diagnostic and therapeutic Deficit
Wong, C.-K. et al. QJM 2008 101:137-144
Pre-existent depression in the 2 weeks before acute coronary syndrome can be associated with delayed presentation of the
heart attack. (N=276)
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: 1919-1924
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
Monitoring Protocol for Patients on Second-Generation Antipsychotics
X X
X
fasting lipid profile
X X
waist
circumference
X X
X
fasting plasma glucose
X X
X
blood pressure
X X
X X
weight (BMI) X
X X
personal / family history
every 5 years annually
quarterly 12 weeks
8 weeks 4 weeks
baseline
Consensus Statement: ADA, APA, AACE, NAASO, Diabetes Care 2004; 27: 596-601
Intervention Programs
Reducing weight can positively influence many components of metabolic syndrome
Clinical guidelines exist
Evidence of effectiveness of behavioral- therapeutic programs
Methods:
Nutritional therapy
Physical exercise programs
Behavioral therapy
Emotional / moral support is another
factor
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
Study Procedure
t
screening intervention follow-up
Methods
100 schizophrenic patients
Sham group (N=39)
• mean age = 36.05
• male = 27
• 1 superficial briefing
Verum group (N=35)
• mean age = 37.97
• male = 15
• 12 sessions of in-depth weight- management training
60 65 70 75 80 85 90 95
0 1 2 4 8 12 24 36 48
Week
Weight in kg Men, control
Women, control Men, prevention Woman, prevention
Figure 2:
Development of the mean body weight over time. N = 27, 11, 15, and 21.
Development of the glucose level two hours after dextrose administration
(N = 27, 10, 15, 18)
80 90 100 110 120 130 140
0 1 2
Glucose level two hours after glucose administration in mg/dl
Men, control Women, control Men, prevention Woman, prevention
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
