Obesity and Premature Mortality in persons with serious mental illnesses: New hope for an old problem

1
Obesity and Premature Mortality in persons with
serious mental illnesses New hope for an old
problem

• Benjamin Druss MD, MPH
• October 3, 2012

2
Excess Mortality in Persons with SMI

• We have known for 3 generations that people
  treated in the public MH sector die younger than
  the general population this excess mortality is
  largely due to natural causes1
• As advances have improved longevity of the
  general population, disparities appear to be
  growing over time. 2,3

• Journal of the American Statistical Association
  Mar 193227(177A)160-174. 2. BMJ. 2011 Sep
  13343d5422 3. 3. Nord J Psychiatry. 2012
  Apr66(2)97-106. Epub 2011 Aug 23.

3
A Widening Gap Trends in Studies of Excess
Mortality in SMI1
Year of Publication Excess Risk of Death
1970s 1.84
1980s 2.98
1990s 3.20
1. Saha et al Arch Gen Psychiatry. Oct
200764(10)1123-1131 http//www.qcmhr.uq.edu.au/e
pi/index_files/Page562.htm
4
What Are the Causes of Excess Morbidity and
Mortality in Mental Disorders?

• Persons with SMI on highest dose of
  antipsychotics have a 1/3 higher rate of CVD
  death than those on lower doses1
• In a national US sample, SES and health system
  factors each explained about ¼ of excess
  mortality.3
• Among veterans with schizophrenia, behavioral
  risks including obesity explain about 1/3 of
  excess mortality2

• Arch Gen Psychiatry. 200764(2)242-24 2. Gen
  Hosp Psychiatry. 2009 31(6)555-6 3 Medical
  Care, 201149(6)599-60

5
Mental Illness and Risk of Obesity
1. Arch Gen Psychiatry. 2006 Jul63(7)824-30 2.
J Nerv Ment Dis 2003191 799805
6
What are the causes of obesity in mental
disorders?

• Side effects of medications, most notably newer
  (second generation) antipsychotic medications. 1
• Diet and physical activity Individuals with
  schizophrenia consume significantly greater
  amounts of sugar and fat and are less likely to
  engage in physical activity than the general
  population.2
• Poverty Mental illnesses are a risk for poverty
  which is in turn associated with excess rates of
  obesity. 3

1. Acta Psychiatr Scand. 2009100316. 2. Compr
Psychiatry. 2012 3. Epidemiol Rev. 20072929-48.
7
What are the consequences of obesity in mental
disorders?

• Reinforces stigma of mental illness1
• Increases costs of care2
• Decreased quality of life3
• Poor health diabetes, cardiovascular disease and
  ultimately, premature mortality4

1. Am J Public Health. 2010 Jun100(6)1019-28.
2. Gen Hosp Psychiatry. 2009 Jan-Feb31(1)1-7.
N Engl J Med. 2006 Aug 24355(8)763-78 2. 3.
Obesity (Silver Spring). 2008 Apr16(4)749-54.4 4
European Journal of Preventive Cardiology June
2008 vol. 15 no. 3 239-246
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A Public Health Approach To Addressing Obesity
and Premature Mortality in People with SMI
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Policy Priorities

• Include persons with with SMI in broader public
  health campaigns and develop programs targeted at
  this population (e.g. SAMHSA Wellness
  Initiative).
• Track health indicators including mortality among
  people with SMI (e.g. NCQAs new performance
  measures for people with SMI for HEDIS 2013).
• Promote effective clinical models that provide
  integrated medical care for people with SMI.
  (PBHCI program Medicaid Medical Home
  demonstration projects)

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Summary

• The problem of premature mortality in people with
  SMI is a crisis that has existed for at least ¾
  of a century.
• More recently, this problem has been compounded
  by high rates of obesity in people with SMI,
  which represents an epidemic within an epidemic.
• Policies addressing poor health and obesity in
  this population need to support a public health
  approach that supports both prevention and high
  quality medical treatment.