Abstract Objectives Prior studies suggest variation in the quality of medical care for somatic conditions such as cardiovascular disease and diabetes provided to persons with SMI, but to date no ...comprehensive review of the literature has been conducted. The goals of this review were to summarize the prior research on quality of medical care for the United States population with SMI; identify potential sources of variation in quality of care; and identify priorities for future research. Methods Peer-reviewed studies were identified by searching four major research databases and subsequent reference searches of retrieved articles. All studies assessing quality of care for cardiovascular disease, diabetes, dyslipidemia, and HIV/AIDs among persons with schizophrenia and bipolar disorder published between January 2000 and December 2013 were included. Quality indicators and information about the study population and setting were abstracted by two trained reviewers. Results Quality of medical care in the population with SMI varied by study population, time period, and setting. Rates of guideline-concordant care tended to be higher among veterans and lower among Medicaid beneficiaries. In many study samples with SMI, rates of guideline adherence were considerably lower than estimated rates for the overall US population. Conclusions Future research should identify and address modifiable provider, insurer, and delivery system factors that contribute to poor quality of medical care among persons with SMI and examine whether adherence to clinical guidelines leads to improved health and disability outcomes in this vulnerable group.
People with serious mental illness (SMI) have mortality rates 2 to 3 times higher than the overall US population, largely due to cardiovascular disease. The prevalence of cardiovascular risk factors ...such as obesity and diabetes mellitus and other conditions, such as HIV/AIDS, is heightened in this group. Based on the recommendations of a National Institute of Mental Health stakeholder meeting, we conducted a comprehensive review examining the strength of the evidence surrounding interventions to address major medical conditions and health-risk behaviors among persons with SMI. Peer-reviewed studies were identified using 4 major research databases. Randomized controlled trials and observational studies testing interventions to address medical conditions and risk behaviors among persons with schizophrenia and bipolar disorder between January 2000 and June 2014 were included. Information was abstracted from each study by 2 trained reviewers, who also rated study quality using a standard tool. Following individual study review, the quality of the evidence (high, medium, low) and the effectiveness of various interventions were synthesized. 108 studies were included. The majority of studies examined interventions to address overweight/obesity (n = 80). The strength of the evidence was high for 4 interventions: metformin and behavioral interventions had beneficial effects on weight loss; and bupropion and varenicline reduced tobacco smoking. The strength of the evidence was low for most other interventions reviewed. Future studies should test long-term interventions to cardiovascular risk factors and health-risk behaviors. In addition, future research should study implementation strategies to effectively translate efficacious interventions into real-world settings.
Abstract Objective Persons with serious mental illness (SMI) have high rates of premature mortality from preventable medical conditions, but this group is underrepresented in epidemiologic surveys ...and we lack national estimates of the prevalence of conditions such as obesity and diabetes in this group. We performed a comprehensive review to synthesize estimates of the prevalence of 15 medical conditions among the population with SMI. Method We reviewed studies published in the peer-reviewed literature from January 2000 to August 2012. Studies were included if they assessed prevalence in a sample of 100 or more United States (US) adults with schizophrenia or bipolar disorder. Results A total of 57 studies were included in the review. For most medical conditions, the prevalence estimates varied considerably. For example, estimates of obesity prevalence ranged from 26% to 55%. This variation appeared to be due to differences in measurement (e.g., self-report versus clinical measures) and underlying differences in study populations. Few studies assessed prevalence in representative, community samples of persons with SMI. Conclusions In many studies, the prevalence of medical conditions among the population with SMI was higher than among the overall US population. Screening for and monitoring of these conditions should be common practice in clinical settings serving persons with SMI.
Excess mortality in persons with severe mental disorders (SMD) is a major public health challenge that warrants action. The number and scope of truly tested interventions in this area remain limited, ...and strategies for implementation and scaling up of programmes with a strong evidence base are scarce. Furthermore, the majority of available interventions focus on a single or an otherwise limited number of risk factors. Here we present a multilevel model highlighting risk factors for excess mortality in persons with SMD at the individual, health system and socio‐environmental levels. Informed by that model, we describe a comprehensive framework that may be useful for designing, implementing and evaluating interventions and programmes to reduce excess mortality in persons with SMD. This framework includes individual‐focused, health system‐focused, and community level and policy‐focused interventions. Incorporating lessons learned from the multilevel model of risk and the comprehensive intervention framework, we identify priorities for clinical practice, policy and research agendas.
This study examined trends in receipt of smoking cessation medications among smokers with and without mental illness, including serious mental illness, from 2005 to 2019 and characterized physician ...attitudes and practices related to tobacco screening and cessation treatment.
Medical Expenditure Panel Survey (MEPS) data (2005-2019) were examined for receipt of cessation medication prescriptions for bupropion, varenicline, and nicotine replacement therapy (NRT) among 55,662 smokers-18,353 with any mental illness and 7,421 with serious mental illness. Qualitative interviews with 40 general internists and psychiatrists between October and November 2017 used a semistructured guide. MEPS data were analyzed with descriptive statistics, and interviews were analyzed with hybrid inductive-deductive coding.
From 2005 to 2019, at least 83% of smokers with or without mental illness did not receive varenicline, NRT, or bupropion. Over 14 years, the proportion of smokers receiving varenicline peaked at 2.1% among those with no mental illness, 2.9% among those with any mental illness, and 2.4% among those with serious mental illness. The respective peak proportions for NRT were 0.4%, 1.1%, and 1.6%; for bupropion, they were 1.2%, 8.4%, and 16.7%. Qualitative themes were consistent across general internists and psychiatrists; providers viewed cessation treatment as challenging because of the perception of smoking as a coping mechanism and agreed on barriers to treatment, including lack of insurance coverage and contraindications for people with mental illness.
System- and provider-level strategies to support evidence-based smoking cessation treatment for people with and without mental illness are needed.
The authors evaluated the likelihood of hospital admission, mechanical ventilation, and mortality within 30 days after a COVID-19 diagnosis among persons with or without serious mental illness.
...Adults with and without serious mental illness diagnosed as having COVID-19 in the first year of the pandemic were identified in the TriNetX database, a network of electronic health records from 49 U.S. health care systems representing 63.5 million individuals. A propensity score approach was used to compare outcomes of unmatched and matched cohorts (N=85,257).
Compared with persons without serious mental illness, persons with serious mental illness were more likely to be hospitalized or to die after COVID-19 diagnosis. No difference in mortality or use of mechanical ventilation was observed among groups admitted to the hospital with COVID-19.
Disparities in overall mortality after COVID-19 for persons with serious mental illness likely were driven by factors outside of acute care settings.
We investigated whether mental illness is associated with lower rates of carotid endarterectomy (CEA)/carotid artery stenting (CAS) after stroke due to carotid stenosis.
In this retrospective ...cross-sectional study, ischemic stroke cases due to carotid stenosis were identified in the 2007-2014 Nationwide (National) Inpatient Sample. Psychiatric conditions were identified by secondary ICD-9-CM diagnosis codes for schizophrenia/psychoses, bipolar disorder, depression, anxiety, or substance use disorders. Using logistic regression, we tested the association between psychiatric conditions and CEA/CAS, controlling for demographic, clinical, and hospital factors.
Among 37,474 included stroke cases, 6,922 (18.5%) had a psychiatric comorbidity. The presence of any psychiatric condition was associated with lower odds of CEA/CAS (adjusted odds ratio OR 0.84, 95% confidence interval CI 0.78-0.90). Schizophrenia/psychoses (OR 0.72, 95% CI 0.55-0.93), depression (OR 0.83, 95% CI 0.75-0.91), and substance use disorders (OR 0.73, 95% CI 0.65-0.83) were each associated with lower odds of CEA/CAS. The association of mental illness and CEA/CAS was dose-dependent: compared to patients without mental illness, patients with multiple psychiatric comorbidities (OR 0.74, 95% CI 0.62-0.87) had lower odds of CEA/CAS than those with only one psychiatric comorbidity (OR 0.86, 95% CI 0.79-0.92;
value for trend <0.001).
The odds of carotid revascularization after stroke is lower in patients with mental illness, particularly those with schizophrenia/psychoses, depression, substance use disorders, and multiple psychiatric diagnoses.
Persons with serious mental illness (SMI) die 10-20 years earlier than the general population; cancer is the second leading cause of death. Differences in cancer screening between SMI and the general ...population are not well understood.
To describe receipt of cancer screening among individuals with versus without SMI and to explore clinicians' perceptions around cancer screening for people with SMI.
Mixed-methods study using 2010-2017 MarketScan commercial insurance administrative claims data and semi-structured clinician interviews. In the quantitative analyses, we used multivariate logistic regression analyses to calculate the likelihood of receiving cervical, breast, colorectal, or prostate cancer screening among people with versus without SMI, defined as schizophrenia or bipolar disorder. We conducted semi-structured interviews with 17 primary care physicians and 15 psychiatrists. Interview transcripts were coded using a hybrid deductive/inductive approach.
Relative to those without SMI, individuals with SMI were less likely to receive screening for cervical cancer adjusted odds ratio (aOR): 0.80; 95% confidence interval (CI): 0.80-0.81, breast cancer (aOR: 0.79; 95% CI: 0.78-0.80), colorectal cancer (aOR: 0.90; 95% CI: 0.89-0.91), and prostate cancer (aOR: 0.85; 95% CI: 0.84-0.87). Clinicians identified 5 themes that may help explain the lower rates of cancer screening in persons with SMI: access to care, available support, prioritization of other issues, communication, and patient concerns.
People with SMI were less likely to receive 4 common types of cancer screening. Improving cancer screening rates in the SMI population will likely require a multidisciplinary approach to overcome barriers to screening.
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