assist. prof. Igor Filipčić, MD, PhD Psychiatric Hospital „Sveti Ivan”
Zagreb, Croatia
Prevention of mortality and morbidity in acute and chronic psychiatric
patients
Program for integrative psychiatry
Overview
• Increased Morbidity and Mortality Associated with Serious Mental Illness (SMI)
• Increased Morbidity and Mortality – data from Psychiatric Hospital „Sv Ivan”
• Program for integrative psychiatry (PIPS) – in three steps
• Conclusion
In Serious Mental Illness (schizophrenia, depression, bipolar)
1. mortality is being 2 to 3 times higher compared to the general population
2. 60% of this excess mortality is due to physical illness (MI, CVI, embol.)
3. high risk of undetected somatic co-morbidity
4. incidence is much higher than in the normal population for
• cardiovascular diseases / infarct my. stroke/
• unrecognized cancer /lungs, colon/
• diabetes mellitus, metabolic syndrome
• respiratory diseases /COPD
5. psychiatric patients
• have still limited access to physical health care
• physical complaints at a late and more serious stage Data from Oud et al 2009 BMC Family Practice
Crump et al. 2013 AM J PsychiatryLeucht et al.2007 AP Scandinavica
Introduction
Potential factors for high rates of the co-morbid physical illnesses in schizophrenic patients
environment
schizophrenialifestyle
BEHAVIOR• psychotic symptoms• negative sy./ low energy• cognitive disturbances• reduced communication• isolated
LIFESTYLE• smoking• using drugs• alcohol• poor diets/obesity• not enough exercise
SYSTEM-RELATED FACTORS• not covered by health
insurance• less access to health care• not adequate access to
medical treatment• unemployment
TREATMENTAntipsychotics• side effects• weight gain, diabetes• increased prolactin level
Mortality and somatic morbidity in schizophrenic patients
Per
cent
age
of d
eath
s50
40
20
10
0
30
Heart disease Cancer Cerebrovascular Chronic respiratory
Diabetes Influenza/pneumoniaAccidents Suicide
MO OK RI TX UT VA
*Average data from 1996–2000Colton & Manderscheid 2006, Crump et al. 2013 AM J Psychiatry
Schizophrenic patients are at risk of under-diagnosis and under-treatment
• men with schizophrenia die 15 years earlier• women die 12 years earlier
The leading causes of death in persons with schizophrenia are ischemic heart disease and cancer
People with SMI have limited access to physical health care
N=8227
Schizophrenic patients use less than
general population• general medical services
• coronary revascularization
• standard diabetes care
• antihypertensive medication
• lipid-lowering medication
Risk factors smoking alcohol drugs/narcotics poor nutrition not exercise
We can improve the detection and treatment of comorbid
somatic illnesses in schizophrenic patients by.......
…taking more responsibility for the patient
…implementing systematic education
…improving parity in health care access and provision
…forging collaborations with other medical specialist
Fleischhacker WW et al. Comorbid Somatic Illness in Patients with Severe Mental Disorders: Clinical, Policy and Research ChallengesJ Clin Psychiatry. 2008; 68:514-519
Somatic comorbidity in psychiatric patients - PH „Sveti Ivan”
hospitalizations from 2013 to August 2015 N=13 686• schizophrenia 31% • depression 28%• bipolar 10%
78.9%
15.8%
5.7%
3.9% 3.9% 3.5%
Prevalence of cardiovascular diseases
hypertension cardiomyopathy atrial fibrillation paroxysmal tachycardiaishemic heart diseasesequelae of myocardial in-farction39,3% of patients had
cardiovascular disease
personal data
Somatic comorbidity in psychiatric patients - PH „Sveti Ivan”
35,8% patients had endocrine system disease
41.80%
34.90%
25.70%
24.50%4.00% 3.60%
Prevalence of endocrine system diseases
diabetes
hiperlipidemia
hypothyreosis
adiposity
anemia
struma
2012. 2013. 2014.0.00%5.00%
10.00%15.00%20.00%25.00%30.00%35.00%
10.80%
18.30%
29.70%
16.70%
23.50%
34.50%
Schizophrenia
endocrine system disease cardiovascular disease
2012. 2013. 2014.0.00%5.00%
10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%
19.70%
28.30%
37.90%
22.60%
32.10%
42.10%
Depression&BIPOLAR
endocrine system disease cardiovascular disease
Mortality: MI /CVI/embolis64 patients - 8 patients (2013) 77 patients - 9 patients (2014)69 patients - 9 patients (2015)*
Cancer:4.9% (2013)5.8% (2014) 6.3% (2015)
* 2015 . first 8 months
personal data
Prevalence and relative risks factors (RR) in schizophrenia and depression /bipolar in PH „Sveti Ivan”compared to the
general population in Croatia
RR = relative risk
Risk factors schizophreniaPrevalence RR
depression/ bipolarPrevalence RR
Obesity 51.9% 2 36.3% 2
Smoking 72.2% 4 61.5% 3
DM 29.2% 2 33.4% 2
Hypertension 37.3% 3 49.7% 3
Dyslipidemia 55.4% 5 26.9% 3
personal data
2013-2015
Conducted In hospital daily hospital outpatient collaborating institutions
Program for integrative psychiatry
Team psychiatrists, psychotherapists nurses, occupational therapists psychologists, social workers, nutritionist internal medicine specialist, neurologist
Goals reduction of mortality
comprehensive treatment
rehabilitation
early identification
quality of life improvement
in psychiatric patient with
chronic somatic diseases
more responsibility for the patient in 3 steps
Program for integrative psychiatry
preventive programme
personalized pharmacotherapy & psychotherapy
a. physical examinations
b. screening BMI, weight, waist blood pressure fasting glucose, HbA1C fasting lipids, HDL-cholesterol ECG
c. screening habits (smoke, drug abuse, alcohol abuse, activity, fast food)
d. questionnaires, scales (PANS, CGI,QLSQ….)
12
a. pharmacotherapy strategies
• drugs selection & monitoring
• plasma concentration,
• side effects (metabolic,prolactin level)
• switch medications
b. psychotherapy strategies psychodynamic group therapy CBT multifamily therapy
3
A. patients with major menthal health problem
B. family – caregivers
Lifestyle changes with behavioural treatments
overweight, obesity & diet training
smoking cessation / non-smoking tr.
physical activity training
metacognitive training
anti-suicidal programme
anti-stigma programme
adherence programme
wellbeing programme
education C. Professionals psychiatrists GP others
www.pbsvi.hr
380 employees40 psychiatrists9 teachers125 nurses
700 patients550 beds150 daily hospital places
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