Physical Health Care in the Mental Health In-Setting

Dr Mrigendra Das

Clinical Lead, Consultant Psychiatrist

Broadmoor High Secure Hospital

United Kingdom

This Talk

• Describes a group of Mentally disordered in patients

• The Physical health problems they experience• How these are managed.• Iatrogenic contributions- Atypical antipsychotics• Ways forward

Broadmoor High Secure Hospital

• One of 4 High Secure Hospitals in the UK.• Looks after the most highest risk mentally

disordered offenders.• Offending + Mental Disorder= Highest level of

risk.• All detained under the Mental Health Act.• Hospital, Not a Prison.

A view

Broadmoor Hospital

Broadmoor High Secure Hospital

• Principles of Care• Most on Hospital Orders• Some on Prison Transfer• Diagnosis: Schizophrenia - 70%• The rest: Personality Disorder (20%), Sex

Offending, Mood Disorder.• Average stay: 6 years

Broadmoor Hospital Demographics

• 241 patients• All men• 29 (12%) have diabetes• 24 (10%) have hypertension• 35 (15%) have asthma/COPD• 100% don’t smoke• 80% have a BMI above 30

QOF

• We use the same parameters as in the community• Some parameters are not appropriate• e.g. cervical smears• We don’t prescribe electronically • Administrative and organisation excluded

Broadmoor High Secure Hospital

[0 - 4] [5 - 16] [17 - 24] [25 - 34] [35 - 44] [45 - 54] [55 - 64] [65 - 74] [75 - 84] [85 - 89] [90+]

Age Sex Analysis 0 0 0 0 0 0 0 0 0 0 0

Males 0 0 21 67 82 51 16 3 0 0 0

Females 0 0 0 1 0 0 0 0 0 0 0

0

10

20

30

40

50

60

70

80

90

Care Pathway

• A 30 year old man with a history of treatment resistant schizophrenia.

• Admitted weight 60 kgs; no physical health concerns• Serious violence- admitted to High security• No response to numerous antipsychotics• Initiated on clozapine• Negative symptoms• Marginal response with clozapine

3 years on

• Weighing 120 kgs• Hyperlipidemia• Diabetic• Very high BMI• Sedentary life style• Unhealthy eating

• No longer a risk and ready for transfer out of Broadmoor

• What length of life though?

Our Interventions

• GP• Dietitics• Sports and Leisure• Occupational Therapy• Psychological Interventions• Pharmacy Interventions• Systems related• Specific Medical interventions• Unusual and innovative interventions

Historical Insight

• Diabetes is a disease which often shows itself in families in which insanity prevails’

• Henry Maudsley

• 1879 Pathology of the Mind, London, Macmillan Press

SMR = standardized mortality ratio (observed/expected deaths).

1. Harris et al. Br J Psychiatry. 1998;173:11.2. Osby et al. BMJ. 2000;321:483-484.

Increased mortality rates for medical disorders in mental illness

• 50% increased risk of death from medical causes in schizophrenia, and 20% shorter lifespan1 (1966-1995)

• Cardiovascular mortality in schizophrenia increased from 1976-1995, with greatest increase in SMRs (8.3 males/5.0 females) from 1991-19952 (Data from Sweden)

Source of medical risk in major mental disorders

• Related to mental disorder– Symptoms– Contributory risk for

diabetes?

• Health behaviours– Alcohol and substance

abuse– HIV and hepatitis C– Smoking– Inactivity– Poor nutrition

• Related to treatment– Neurologic effects– Weight gain– Diabetes– Dyslipidaemia– Hyperprolactinemia– CVD

• Related to system of care– Fragmentation– Poor access

Lambert TJR et al. MJA. 2003;178:S67-S70.

1. Allison DB et al. Am J Psychiatry. 1999;156(11):1686–1696; 2. Herran A et al. Schizophr Res. 2000;41(2):373–381; 3. Goff DC et al. J Clin Psychiatry 2005;66:183–94; 4. Davidson S et al. Aust N Z J Psychiatry. 2001;35(2):196–202.

Cardiovascular risk factors and schizophrenia

Non-modifiable risk factors

Modifiable risk factors

Gender Obesity1

Family history Smoking2

Personal history Diabetic control3

Age Hypertension4

Dyslipidaemia4

Metabolic syndrome – NCEP ATP III criteria

Metabolic syndrome defined as 3 of the following NCEP

ATP III criteria:

Central obesity Men > 102cmWomen > 88cm

Blood pressure ≥ 130/ ≥ 85mmHg

Triglycerides ≥ 1.69mmol/L

HDL cholesterol Men < 1.03mmol/LWomen < 1.29mmol/L

Fasting blood glucose ≥ 6.1mmol/L

NCEP Expert Panel. Circulation. 2002;106(25):3143–3421

Prevalance of Metabolic Syndrome (Yadav etal 2009)

Description n(%) Description n(%)

Metabolic syndrome 75(53) Atypical antipsychotics 66(47)

Caucasian 101(72) Clozapine 33 (25)

Black 23(16) Olanzapine 14(11)

Asian 8(6) Quetiapine 11(8)

Mixed Race 8(6) Risperidone 12(9)

Smoker 101 (72) Typical Antipsychotics 21(16)Schizophrenia spectrum 100(71) Typical and atypical Antipsych 10(7)

Personality Disorder 36(25) Mood Stabiliser 25(18)

Mood Disorder 2(1) Valproate 17(12)

Autistic Spectrum 2(1) Other antidepressant 8 (6)

Relative risk for diabetes and cardiovascular disease among patients with the Metabolic Syndrome (13 studies)*

00.5

11.5

22.5

33.5

44.5

5

Rel

ativ

e R

isk

1-Circulation, 2004;109:42-462-Circulation, 2003;108:414-4193-Diabetes Care 2005;28(2):385-904-Circulation 2004;110:1239-12445-JAMA 2002;289:2709-27166-Am J Card 2004;93(2):136-141

diabetes

7-Circulation 2003;107:391-3978-Arch Int Med 2004;164:1066-10769-Diabetes Care 2001;24:683-68910-Atheroschlerosis 2004; 173:309-31411-Circulation 2004;110:1245-125112-Diabetes Care 2003;26:3153-315913-EASD 2004

00.5

11.5

22.5

33.5

44.5

55.5

66.5

7

one two three four

Rel

ativ

e ri

skCHD risk increases with increasing number of metabolic syndrome risk factors (3 separate studies)

Sattar et al, Circulation. 2003;108:414–419Whyte et al, American Diabetes Association, 2001Adapted from Ridker, Circulation. 2003;107:393–339

Number of metabolic risk factors

Prevalence of metabolic syndrome according to BMI

“Overweight” = BMI 25-29.9; “obese” = BMI 30 (National Heart, Lung and Blood Institute, Obesity Guidelines); N=12,363; Data using NCEP ATP III definition for metabolic syndrome

0

10

20

30

40

50

60

70

Pre

vale

nce

(%

)

Healthy Overweight Obese Healthy Overweight Obese

Men Women

Park YW et al. Arch Intern Med. 2003;163:427–436

Visceral adiposity and drug-naïve schizophrenia

Not significantAge, gender,BMI and waist circumference

10 chronic patients, 10 controlsMeyer (Submitted)

Not significantAge, gender46 first-episode, drug-naïve patients in Nanjing, China, 46 controls

Zhang ZJ et al. (2004)3

Greater IAF in patientswith schizophrenia

Age, gender19 first-episode, drug-naïve patients in Dublin, 19 controls

Ryan MC et al. (2004)2

3x greater IAF in patientswith schizophrenia

Age, gender15 drug-naïve patients or drug-free for 6 weeks in Dublin, 15 controls

Thakore JH et al.(2002)1

Intra-abdominalfat (IAF) mass

Matching variablesNStudy

1Thakore JH et al. Int J Obes Relat Metab Disord. 2002;26(1):137–141; 2Ryan MC et al. Life Sci. 2004;74(16):1999–2008; 3Zhang ZJ, Yao ZJ, Liu W et al. Br J Psychiatry. 2004;184:58–62

Short-term mean change in weight with some antipsychotics

1Adapted from: Allison DB et al. Am J Psychiatry. 1999(Nov);156(11):1686–1696. 2Marder et al. Schizophr Res. 2003; 61:123–126; 3Jones et al. Presentation at ACNP. 1999

Estimated weight change at 10 weeks on ‘standard’ dose

Haloper

idol

Risper

idone

Olanza

pine

Cloza

pine

6

Wei

gh

t ch

ang

e (k

g) 5

4321

0

-1-2

-3

Place

bo

Fluphen

azin

e

Zipra

sidone

Chlorp

rom

azin

e

Thiorid

azin

e/

mes

oridaz

ine

13.2

Weig

ht ch

ang

e (lb)

11.08.86.64.42.20-2.2-4.4-6.6

Quetia

pine

Aripip

razo

le

Aripiprazole (4-6 week pooled data)2 and quetiapine (6-week data)2 added to analysis by Allison et al.

Abilify® [package insert]. Princeton NJ: Bristol-Myers Squibb and Rockville, Md: Otsuka America Pharmaceutical; 2005 ; Risperdal® [package insert]. Titiusville, NJ: Janssen Pharmaceutica Products, LP; 2003; Seroquel® [package insert]. Wilmington DE: AstraZeneca; 2004; Zyprexa® [package insert]. Indianapolis, Ind: Eli Lilly and Company; 2004.

Clinically significant (7%) weight gain during antipsychotic treatment

Inci

den

ce (

%)

0

5

10

15

20

25

30

35

0

5

10

15

20

25

30

35

0

5

10

15

20

25

30

35

0

5

10

15

20

25

30

35

Place

bo

Aripip

razo

le

Place

bo

Risper

idone

Place

bo

Quetia

pine

Place

bo

Olanza

pine

Data from package inserts (USA). Data obtained from different short-term (4-8 week) clinical studies.

Aripiprazole vs olanzapine: mean weight change (26 week study)

Baseline: aripiprazole = 80.8±1.85 kg; olanzapine = 80.4±1.84 kg (OC analysis)McQuade RD, et al, J Clin Psychiatry 2004;65(Suppl 18):47–56.

-4

-2

0

2

4

6

0 5 10 15 20 25 30

Weeks

Mea

n w

eig

ht

chan

ge

(kg

)

5.6kg*

* **

* * * * * * **

Aripiprazole

Olanzapine

P ≤ 0.02 significantly greater than aripiprazole. N=274.

Prevalence of diabetes or IGT in schizophrenia

—Current: 10.8%

Lifetime: 14.9%

Self-report of diabetes

Field study: uncontrolled SCZ sample from 2 states (n=719)

—5.1%Self-report of diabetes

vs NHANES III (n=18 825)

—11.1%Paid claim for diabetes

Medicaid sample SCZ sample (n=6066)

—12.5%Paid claim for diabetes

Medicare sample of SCZ adults (n=14,182)2Dixon et al (2000)

<.0215.4% vs 0%IFG (110 and 125 mg/dL)

First episode, drug-naive inpatients with SCZ vs age-, BMI-, and health habit-matched non-DM controls (n=52)

1Ryan et al (2003)

P Value

Rate of DM or IGT

Diabetes AssessmentSample (N)Study

IGT=impaired glucose tolerance; IFG=impaired fasting glucose; SCZ=schizophrenia; DM=diabetes mellitus

1. Ryan MC. et al. Am J Psychiatry. 2003;160:284-289; 2. Dixon L. et al. Schizophr Bull. 2000;26:903–912.

Diabetes, hyperglycaemia and diabetic ketoacidosis: case reports

*Into widespread useDKA = diabetic ketoacidosis

1. Koller E et al. Am J Med 2001;111:716–723; 2. Koller E et al. Pharmacotherapy 2003;23:735–744 ; 3. Koller E et al. Pharmacotherapy 2002;22:841–852; 4. Koller E. et al. J Clin Psychiatry 2004;65:857–863.

Year of introduction

New cases

Exacerbations

DKA

Deaths

Clozapine1 1990* 242 54 80 25

Olanzapine3 1996 188 44 80 15

Quetiapine4 1998 34 8 21 11

Risperidone2 1993 78 46 26 4

Antipsychotic therapy and differential risk for hyperlipidaemia*

*Adjusted for age, sex, duration of follow-up, use of -blocker, -blockers, corticosteroid, thiazide diuretic, lithium, valproate, oral contraceptives containing norgesterol. N = 18,309.

Koro et al. Arch Gen Psychiatry. 2002;59:1021.

Versusconventionalantipsychotic

agents

Versusconventionalantipsychotic

agents

Versusno exposure

Versusno exposure

Od

ds

of

hyp

erli

pid

emia

Olanzapine users Risperidone users

P0.001

P0.001

0

1

2

3

4

5

6

7

8

9

10

HOMA insulin resistance in treated patients with schizophrenia

0

1

2

3

4

5

6

Controls Typical Risperidone Olanzapine Clozapine

HOMA = homeostasis model assessment

Newcomer JW et al., Arch Gen Psychiatry, 2002;59:337–345.

P < 0.05

P = 0.06

HO

MA

in

suli

n r

esis

tan

ce

ADA consensus on antipsychotic drugs and obesity and diabetes

+ = increased effect; - = no effect; D = discrepant results.

*Newer drugs with limited long-term data. Precise risk estimates not ≤ available. †Not available in the UK

Drug Weight Gain Diabetes Risk Dyslipidaemia

clozapine + + + + +

olanzapine + + + + +

risperidone + + D D

quetiapine + + D D

aripiprazole* +/- - -

ziprasidone*† +/- - -

American Diabetes Association. Diabetes Care. 2004;27(2):596–601

The CATIE Trial

• Clinical Antipsychotic trial for Intervention Effectiveness

• Showed that whilst Olanzapine was marginally better in terms of discontinuation:

• Perphanazine equally effective.• Risperidone well tolerated• Clozapine better than others.

Conclusions

• Majority of long stay psychiatric in patients suffer from schizophrenia

• And they inevitably are treated with antipsychotics• Patients with schizophrenia have more physical co-

morbidity• Life style factors also contribute to cardiovascular risk• Are we making this worse by prescription of some of

the new generation antipsychotics?