Addressing the Mortality Gap in Individuals With Serious Mental Illness IPS Washington, DC October 9, 2016 Oliver Freudenreich, MD, FAPM Associate Professor of Psychiatry Harvard Medical School C0-Director, MGH Schizophrenia Program Massachusetts General Hospital
68 th Institute on Psychiatric Services Disclosures: Oliver Freudenreich I have the following relationship to disclose: – Avanir – Research grant – Global Medical Education – Honoraria for teaching – Up-To-Date – Royalties – Wolters-Kluwer - Royalties – Janssen – Consultant
Who are your heroes in medicine?
Outline – My pantheon • Paul Farmer – Social interventions have larger impact on [xxx] than molecular advances. • Winston Churchill – However beautiful your strategy you should occasionally look at [xxx]. • Rudolf Virchow – Politics is nothing else but [xxx]. • Teddy Roosevelt – The credit belongs to the man who is actually in [xxx].
What is the natural history of schizophrenia?
Fleishman M. Psychiatr Serv. 2003;54:142.
Myth of “natural history” • TB as social disease • “Structural violence” – Structural – built-in • Holy grail of modern – Violence – causing medicine: molecular injury basis of disease • Health disparities • “Desocialization” of scientific inquiry Social interventions have greater impact on outcomes than molecular advances. Farmer PE et al., PLoS Medicine 2006;3:1686.
“However beautiful the strategy*, you should occasionally look at the results.**” -Sir Winston Churchill * = what your clinic does ** = how your patient is doing Haas LF. JNNP 1996;61:465.
Premature mortality in schizophrenia • US national cohort 2001 to 2007 • N=1,138,853 • Results Most of excess mortality – All-cause SMR 3.7 (95% CI, 3.7-3.7) in schizophrenia is due – Cardiovascular disease to natural causes.* • Highest mortality rate • 403.2/100,000 person-years • SMR 3.6 (95% CI, 3.5-3.6) – Cancer mortality • Lung cancer had highest mortality rate • 74.8/100,000 person-years • SMR 2.4 (95% CI, 2.4-2.5) – Particularly elevated SMR COPD (9.9) and influenza/pneumonia (7.0) – Accidental deaths twice as common as suicides – Notable cause of death was alcohol and other drug (nonsuicidal): 95.2/100,000 person-years Olfson M et al. JAMA Psychiatry 2015;72:1172. *Brown S et al. Br J Psychiatry 2010;196:116.
Reasons for increased cardiovascular disease in SMI • Modifiable risk factors increased • Access and/or utilization of medical care • Adherence to treatments • Worse quality of care • Less likely to be screened or treated for dyslipidemia, hyperglycemia, hypertension • Less likely to receive angioplasty or CABG • Less likely to receive drug therapies of proven benefit (thrombolytics, aspirin, beta-blockers, ACE inhibitors) post- myocardial infarction • More likely to have premature mortality post-myocardial infarction Newcomer J Hennekens CH. JAMA 2007; 298:1794. Druss BG et al. Arch Gen Psychiatry 2001;58:565. Ward M and Druss B. Lancet Psychiatry 2015;2:431.
Social realities of SMI • Poverty • Poor housing conditions – Homelessness – Group home living – Institutional living including incarceration • Unemployment • Incarcerations • Drug use Economics, structural violence and stigma
WHO definition of SDH “The social determinants of health (SDH) are the conditions in which people are born, grow, work, live, and age , and the wider set of forces and systems shaping the conditions of daily life . These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” www.who.int/social_determinants/en/
www.healthypeople.gov
Rudolf Virchow „Die Medizin ist eine soziale Wissenschaft, und die Politik ist nichts weiter als Medizin im Großen.“ - Rudolf Virchow Waitzkin H. Social Medicine 2006;1:5.
The day the music died
Was this death preventable? • Fundamental attribution error • Network theory John Umstead Hospital, Butner, NC, ca. 1995 Christakis NA and Fowler JH. NEJM 2008;358:2249.
Smoking and SDH CDC Vitalsigns February 2013
Health impact pyramid Shattuck Lecture: Frieden TR. NEJM 2015;373:1748.
We are surprised … “I'm shocked, shocked to find that gambling is going on in here!” - Captain Renault
… but perhaps should not be. “All organizations are perfectly designed to get the results they get!” - Don Berwick, MD (and others)
Silo mentality versus collaborative care Psychiatry See: Chwastiak LA et al. Lancet Psychiatry 2015;2:465.
Care in the community Erich Lindemann – Chief of Psychiatry at MGH 1955-1965
Why I am a Hegelian The arc of the moral universe is long but it bends toward justice. - MLK Born 1770 Stuttgart, Wuerttemberg
S chizophrenia C linical and R esearch P rogram Erich Lindemann Mental Health Center CLOZAPINE CLINIC AND MED-PSYCH CLINIC Smoking Cessation Psychiatrist Outside Illness Management Community FTC REFER Care coordinator And Recovery And Peer Supported exercise Medical secretary (gym) Services Phlebotomist Consultant Internist Pharmacist Outside PCPs
Public health priorities for SMI • Causes of excess mortality 1 – Cardiovascular disease • Diabetes • Hypertension 2 – Cancer 3 – Cigarette smoking • Collaborative care (med-psych integration) – Chronic disease management – Population-based management • Care in the community 1 Olfson M et al. JAMA Psychiatry 2015;72:1172. 2 Frieden TR. NEJM 2015;373:1748. 3 Irwin KE. Cancer 2014;120:323.
No more excuses … Today, any form of the concrete world, of human life, any transformation of the technical and environment is a possibility […]. This would mean THE END OF UTOPIA , that is, the refutation of those ideas and theories that use the concept of utopia to denounce certain socio-historical possibilities. Herbert Marcuse, 1967. From a lecture delivered at the Free University of West Berlin.
You have to be … THE MAN IN THE ARENA Galea S and Annas GJ. JAMA 2016;315:655.
One website, two references, one book • Social determinants of health – https://www.healthypeopl e.gov/ • Scope of the problem – Olfson M et al. JAMA Psychiatry 2015;72:1172. • Public health – Frieden TR. NEJM 2015;373:1748. • Social justice and liberation theology
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