Catherine  Kirby1,  Rosie  Mayston2,  David  O’Fynn³ Christopher  Taylor1

1.  Department  of  HIV/Sexual  Health,  Kings’  College  London  2.  Institute  of  Psychiatry,  psychology  &  Neuroscience,  King’s  College  London3.  South  London   and  Maudsley  NHS  Foundation   Trust  

The  effect  of  HIV  co-­‐morbidity  on  mental  health  outcomes  among  people  accessing  services  for  serious  mental  illness  (SMI)  in  South  London

Background  I

• SMI  (Serious  Mental  Illness)  • Schizophrenia• Bipolar  affective  disorder• Schizoaffective  disorder

• People  with  SMI  experience  significant  health  inequalities• SMI  in  general  population:  0.6  %• SMI  amongst  HIV  population¹:  6%

• Recent  Danish  cohort  Study²:  HIV  +  schizophrenia  à increased  mortality

1.  Hughes  et  al,  2016,  Prevalence  of  HIV,  hepatitis  B,  and  hepatitis  C  in  people  with  severe  mental  illness:  a  systematic  review  and  meta-­‐analysis,  Lancet  Psychiatry

2.  Helleberge   et  al,  Associations   between   HIV  and  schizophrenia   and   their  effect   on  HIV  treatment   outcomes,   Lancet   2015

Research  Setting

• SLaM  (South  London  and  Maudsley  NHS  Trust) BRC (Biomedical  Research  Centre)  Case  Register• High  mental  health  morbidity  &  HIV  prevalence• Population  1.2  million

Aims

• Compare  mortality among  those  with  SMI  versus  SMI/HIV• Probability  of  reported  suicidal  risk  • Probability  of  mental  health  inpatient  stay• Examine  the  effect  of  comorbid  substance  use on  these  outcomes

Study  Design

•Retrospective  cohort• Follow-­‐up=  1st Jan  2009-­‐ 31st Dec  2015

• Inclusion  Criteria• SMI  diagnosis:  before  or  during  2008  • HIV  positive:  before  or  during  2008

CRIS  (Clinical  Record  Interactive  Search)

• Research  tool  from  electronic  patient  records  used  by  SLaM  • Over  250  000  patient  records• Largest  mental  health  data  resource  of  its  kind

Patient  clinical  records  

database  (Trust  ID  no.)

De-­‐identified  clinical  records  

database

Electronic  researcher  user  

interface  (BRC  ID  no.)

CRIS  (Clinical  Record  Interactive  Search)

CRIS:  Data  extraction

Structured  data  (e.g age)

Free  Text  (clinical  records)

Linkages  to  external  sources

Methodology

• Simple  rules-­‐based  approach  to  the  identification  of  patients  within  CRIS  with  HIV  infection• TextHunter  programme:  to  develop  information  extraction  application• Validated  using  test  data  sets  • Structured  fields  used:• Substance  use  • Suicidality

Definition  of  outcome  measures

• Mortality= date  of  death• Contact  days=  number  of  days  when  patients  have  face-­‐to-­‐face  contact  with  a  SLaM  service• Suicidal  risk=  whether  an  in-­‐depth  risk  assessment  has  been  carried  out  (y/n)• Inpatient  stay=  whether  a  patient  has  had  an  inpatient  stay  (y/n)• Substance  use=whether  ICD  10  SU  disorder  coded

Results

• 8474 patients  with  SMI• 176 patients  with  SMI+HIV  identified• No  deaths  occurred  during  study  period  in  HIV  group

Comparing  baseline  characteristics  of  SMI  v.  SMI  +  HIV  SMI % SMI  +  

HIV% chi-­‐

squaredP-­‐value

8474 176Gender Female 3646 43 69 39.2 1.03 0.31

Male 4828 57 107 60.8

Ethnicity British 4622 54.5 82 46.6 22.04 <0.01

Black  African 943 11.1 39 22.2Black  Caribbean 2372 28 48 27.3

Asian 537 6.3 7 4Diagnosis Bipolar 2021 23.9 51 29 2.71 0.26

Schizophrenia 5690 67.2 112 63.6Schizoaffective 763 9 13 7.4

Employment Employed 1069 12.6 19 10.8 2.78 0.25Unemployed 3895 46 92 52.3Not  known 3510 41.4 65 36.9

Local  authority Southwark 1902 22.5 47 26.7 6.98 0.14

Lewisham 1646 19.4 35 19.9Lambeth 2111 24.9 45 25.6Croydon 1752 20.7 23 13.1Other 1063 12.5 26 14.8

Age  category 18-­‐24   354 4.2 8 4.6 36.03 <0.01

>24-­‐34 1528 18 44 25>34-­‐44 2273 26.8 65 36.9>44-­‐54 2057 24.3 46 26.1>54-­‐64 1153 13.6 8 4.6>64 1109 13.1 5 2.8

Distribution  of  MH  outcomes

SMI   SMI  +  HIV Chi-­squared p-­value

N  (%)

Suicidal  risk 144  (1.8) 32  (4.1) 18.19 <0.01

Inpatient  stay 61  (1.4) 115  (2.8) 21.29   <0.01

ØNo  evidence  of  association  of  HIV  co-­‐morbidity  with  contact  daysØCo-­‐morbidity  is  associated  with  suicidality  &  inpatient  stay

Co-­‐morbidity  associated  with  suicidal  risk

OR SE P 95%  CI

1 SMI  +  HIV 2.29 0.46 <0.01 1.55-­3.34

**2 SMI  +  HIV 2.08 0.42 <0.01 1.39-­3.10

**Adjusted  for  gender,  age,  ethnicity,  borough,  marital  status,employment,  diagnosis

Co-­‐morbidity  associated  with  inpatient  stay

OR SE P 95%  CI

1 SMI  +  HIV 2.06 0.33 <0.01 1.51-­2.82

**2 SMI  +  HIV 1.84 0.31 <0.01 1.32-­2.55

**Adjusted  for  gender,  age,  ethnicity,  borough,  marital  status,  employment,  diagnosis

Distribution  of  co-­‐morbid  substance  use  

SMI  only Stimulant Opioid Alcohol Stimulant  +  opioid

Alcohol  +                    stimulant

Alcohol  +  opioid

Stimulant  +  alcohol  +  opioid

chi-­squared

p-­value

SMI 7736  (91.3)

91  (1.1)

87  (1.0)

463  (5.5)

22  (0.3)

22  (0.3)

34  (0.4)

19  (0.2)

46.6 <0.01

SMI  +  HIV

145  (82.4)

6      (3.4)

4  (2.3)

11  (6.3)

2  (1.1)

1      (0.6)

4  (2.3)

3    (1.7)

Ø 17.6%  of  people  living  with  co-­‐morbid  SMI  &  HIV  have  co-­‐morbid  substance  use,  compared  to  8.7%of  people  living  with  SMI  only

Crude  associations  of  co-­‐morbid  substance  use  with  suicidalityExposure  group Chi-­

squaredP OR 95%  CI

SMI ref.

SMI  +  HIV 14.1 <0.01 2.3 1.47-­3.59

SMI  +  substance 91.6 <0.01 2.62 2.13-­3.21

SMI  +  substance  +  HIV

13.3 <0.01 4.03 1.79-­9.05

Conclusion

• First  UK  study  to  examine  impact  of  HIV  on  MH  outcomes  of  people  with  SMI

• MH  outcomes  were  worse• Substance  use  commoner• Further  work  needed:  physical  health  outcome

Using  CRIS  +  data  linkage  to  investigate  the  impact  of  co-­‐morbidity  on  course  and  outcome  of  physical  illness

HIV  +  SMI  

SMI  ONLY

PHYSICAL  MORBIDITY-­‐HES

Number  of  bed  days  within  the  year

Number  of  emergency  admissions

Number  of  visits  to  A&E

Non-­‐communicable  conditions,   adherence,  treatment

MORTALITY

MENTAL  MORBIDITY-­‐CRIS

COSTS?

Thanks!Questions/comments?

catherinekirby1@nhs.net

Acknowledgements• Megan  Pritchard  CRIS  Training  &  Development  Lead

• Hitesh  Shetty  CRIS• David  Chandran CRIS  

• Rob  Stewart  Professor  of  Psychiatric  Epidemiology  and  Clinical  Informatics

HIV  App  Development

• Good  precision  (exactness)  &  recall  (completeness):• HIV  app:  p  71.8%;  r  95.0%• HIV  Rx  app:  p  97.7%;  r  97.6%

Why  might  co-­‐morbid  HIV  result  in  worse  MH  outcomes  for  people  living  with  SMI?• Complexity  of  managing  two  complicated  conditionsØHIV  is  not  considered/adequately  addressed  by  clinical  teams  who  are  managing  SMI?

ØHIV  is  not  adequately  managedà poor  physical  healthàworse  MH?ØAdherence?

• HIV-­‐related  factors  (stigma,  depression  etc.)àworse  MH  outcomes?

ØLack  of  evidence-­‐based  guidelines  for  managing  SMI  +  HIV  co-­‐morbidity

Texthunter software

How  many  pts  identified  after  

search  re-­‐run=176

HIV  search  terms  refined  (precision  &  recall)

Manual  checking  of  text  excerpts  to  verify  if  pts  had  

HIV=300

Queries

• Why  didn’t  you  look  through  notes  individually  as  not  mant  pts?  (Anonymised)• 2  X  data  extraction  techniques  described  in  CRIS  paper:  which  was  used?• SMI:  serious  vs  severe?• “Refer  to  poster  no.  xx  for  technical  architecture  information• What  was  the  primary  outcome:  Mortality?

Inclusion  Criteria

ØSMI/HIV=    all  those  identified  with  Texthunter  app  before  or  during  2008

ØSMI=    all  those  idenitified  as  not  having  HIV  up  until  end  of  2015ØALL=  active  in  2008ØALL=  alive  by  the  end  of  2008

Ø7  years  follow-­‐up