Addressing the Scandal of Premature Mortality; time for a hearts and minds approach

1. Addressing the Scandal of Premature Mortality; time for a heartsand minds approach • Dr David Shiers Sydney May 24th • david.shiers@doctors.org.uk

2. Declaration of interests NICE schizophrenia guidance review – my views; and not those of the National Institute for Health and Care Excellence Guideline Development Group or National Collaborating Centre for Mental Health Over-involved dad

4. PSYCHOSIS: THE MESSAGEOFDESPAIR - This illness usually relapses or becomes chronic. - You will need medication for the rest of your life. - You should lower your expectations of what you will achieve in life.

6. Antipsychotic-Induced Weight Gain in Chronic and First-Episode Psychotic Disorders: a Systematic Critical Reappraisal Established Psychosis RCTs 20 Established psychosis RCTs 3 kg 15 4 kg 10 kg 5 12 kg First episode of psychosis RCTs 0 12 24 36 48 Months Alvarez-Jimenez et al; CNS Drugs, 2008 Alvarez-Jimenez et al; CNS Drugs, 2008 22 (7): 547-562

7. Effectiveness of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: an open randomised clinical trial. EUFEST study group. Kahn RS, Fleischhacker WW, Boter H, et al Lancet.  2008;371(9618):1085–1097.

8. Metabolic risk factors in first-episode schizophrenia: baseline prevalence and course analysed from the European First-Episode Schizophrenia TrialCINP 2012 doi:10.1017/S1461145712001241 Fleischhacker WW, Siu CO, Bode R, Pappadopulos E, Karayal ON, Kahn RS, and the EUFEST study group Overall baseline prevalence of metabolic syndrome was 6.0%, with similar rates observed in the antipsychotic-naive patients (5.7%) and in the other patients with only a brief prior exposure to antipsychotics (6.1%).

9. N Engl J Med 2005; 353:1209-1223 Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. Lieberman JA, Stroup TS, McEvoy JP, et al. Methods 1493 patients with schizophrenia were recruited at 57 U.S. sites and randomly assigned to receive olanzapine, perphenazine, quetiapine, or risperidone for up to 18 months Results Overall, 74 percent of patients discontinued the study medication before 18 months Conclusions The majority of patients in each group discontinued their assigned treatment owing to inefficacy or intolerable side effects or for other reasons.

10. A path to obesity, type 2 diabetes, cardiovascular disease and premature death for many Acknowledgement to sculptor KeldMoseholm Rolling pin (Sculpture By The Sea 2011 Bondi)

11. Australian National Survey 2011 • 1,825 adults with psychotic illnesses aged 18-64 years • in contact with public specialised mental health services

12. Little pride and a lot of prejudice

13. “The provision of good medical care tends to vary inversely with the need for it in the population served.” • Julian Tudor Hart Glyncorrwg 1971

14. EDITORIAL 41 YEARS LATER “ When the mix of conditions experienced includes both physical and mental health problems, the poorly stitched seams of professional care are at their most threadbare” Multimorbidity and the inverse care law in primary care Mercer, S.W., Guthrie, B., Furler, J., Watt, G.C.M., and Hart, J.T. (2012) BMJ 2012, 344:e4152

15. Monitoring – smoking status, BMI, glucose, lipids and blood pressure (excluding family history) once in the past 12 months

16. We repeatedly heard the concerns people had about the medication they had been prescribed and the negative effects this had on their physical health. …physical health problems were often just left by the health professionals, either because they did not recognise their importance or because, as some individuals felt, they did not care. …service users not empowered to make choices about their own health and wellbeing because they do not fully understand the risks they are running.

17. “Psychiatrists need to take more responsibility for the physical health of their patients because some GPs and hospital physicians don’t like treating people with psychosis.” Sir Robin Murray Chair of the Schizophrenia Commission

18. 2013 Schizophrenia is associated with excess multiple physical-health comorbidities but low levels of recorded cardiovascular disease in primary care: cross-sectional study Smith DJ, Langan J, McLean G, Guthrie B, Mercer SW 3:e002808 doi:10.1136/bmjopen-2013-002808 Study 314 Scottish primary care practices • 9677 record of people with schizophrenia and 1,414,701 controls • Recording of 32 common chronic physical-health conditions Results lower recorded rates of cardiovascular disease: • hypertension (OR 0.71) • coronary heart disease (OR 0.75) • peripheral vascular disease (OR 0.83) Conclusions Systematic under-recognition and under-treatment of cardiovascular disease in people with schizophrenia

19. JAMES MACKENZIE LECTURE • 22 November 2012 • Don’t just screen, intervene • top GP calls for better care for mental health patients • People with serious mental illnesses are still getting an unfair deal from their healthcare… • Subtle changes in the attitudes and actions of health professionals could significantly improve the quality, and even the length, of their lives. • The late Professor Helen Lester • James Mackenzie Lecture to the Royal College of General Practitioners’ AGM. • Youtube http://www.youtube.com/watch?v=tqyACm5OQOM

21. DON’TJUST SCREEN INTERVENE What’s in the physicians bag? As to diseases, make a habit of two things - to help, or at least to do no harm Hippocrates (460 BC - 377 BC) If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to healthHippocrates (460 BC - 377 BC)

22. - 20-25% more premature mortality • - 50% more type 2 diabetes • 10% higher total cholesterol / 30% • higher triglycerides • 10mmHg higher systolic / 20mmHg • higher diastolic blood pressure Acknowledgement to sculptor KeldMoseholm Balance with energies(Sculpture By The Sea 2012 Bondi) 10% shift in body weight Goldstein DJ: Beneficial health effects of moderate weight loss. Int J Obes Relat Disorders 1992, 16: 397-415 Lean M: Is long term weight loss possible? B J Nutrition 2000; 83. S103-111

25. PSYCHOSIS: THE MESSAGE OF HOPE • You are distressed by your experiences • now, but we expect that you will getbetter • Medication can be very helpful, but there are a lot of other ways that we can help you to help yourself • The aim is that you achieve what you want out of life

26. Acknowledgements National Audit of Schizophrenia – report: Directors of CCQI: Mike Crawford, Paul Lelliott Advisers: Stephen Cooper, Angela Etherington, David Shiers CCQI Staff Simone Jayakumar, Susan Lemmey, Rachel Marsh, Krysia Zalewska The sixty contributing Mental Health Trusts of England and Wales who carried out the local audits www.rcpsych.ac.uk/quality/NAS • Cardio-metabolic resource • Professor Stephen Cooper • Professor Helen Lester • Professor Richard Holt • Dr ImranRafi • Dr David Shiers National Schizophrenia Commission Professor Sir Robin Murray and team Report www.schizophreniacommission.org.uk/the-report/ www.rcpsych.ac.uk/quality/NAS/resources • Special thanks to Sydney NSW colleagues from whom this resource • originated, and for their ongoing encouragement and inspiration: • Dr Jackie Curtis • Professor Katherine Samaras • Dr Hannah Newall