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Increased cardiovascular risk in patients with severe mental illness E. L. Gladigau,1 T. N. Fazio,2 J. P. Hannam,3 L. M. Dawson4 and S. G. Jones4 1
General Practice Registrar, Westcare Medical Centre, 2Medical Registrar, Melbourne Health, 4Inner West Area Mental Health Service/Melbourne
Health, and 3Psychiatry Registrar, North Western Mental Health, Melbourne, Victoria, Australia
Key words severe mental illness, cardiovascular, metabolic, mortality. Correspondence Elsa L. Gladigau, General Practice Registrar, Westcare Medical Centre, 1/211 Barries Road, Melton West, Vic. 3337, Australia. Email: [email protected] Received 24 August 2013; accepted 23 October 2013. doi:10.1111/imj.12319
Abstract Background: People with severe mental illness (SMI) have a reduced life expectancy. A major cause of mortality is cardiovascular disease. Aims: The aims of this study were to document the prevalence of cardiovascular risk factors in people with SMI engaged in community psychiatric rehabilitation and compare prevalence rates to the general, and Aboriginal and Torres Strait Islander (ATSI) populations of Australia. Method: A cross-sectional audit was conducted on patients receiving care from Melbourne’s Inner-West Area Mental Health Service. Profiles were collected on: smoking status, body mass index, waist circumference, blood pressure, diabetic status and fasting lipid profiles. These were compared with the general and ATSI Australian populations. Results: Complete data were available for 60 patients. Most were involuntary patients with a diagnosis of schizophrenia or schizoaffective disorder. Patients were more likely to smoke, be obese, have dyslipidaemia and the metabolic syndrome compared with the general and ATSI populations of Australia. Patients were more likely to have diabetes than the general population but had similar rates to the ATSI population. Patients had similar rates of hypertension to the general population but were less likely to be hypertensive compared with the ATSI population. Conclusion: Australians living with SMI have very high rates of cardiovascular risk factors, far in excess of the general Australian population and comparable with the ATSI population.
Introduction The mortality rate of people with severe mental illness (SMI) is two to three times that of the general Western population.1 This corresponds to a reduction in life expectancy by 10–25 years, a figure that is comparable with that of the Aboriginal and Torres Strait Islander (ATSI) population of Australia. This mortality gap appears to have widened in recent decades.2 A major contributor to this excess mortality is cardiovascular disease (CVD), and people with SMI are almost two times more likely to die from CVD.3,4 An increased prevalence of modifiable cardiovascular risk factors has been reported in SMI populations. People with SMI are more likely to smoke, be overweight or obese, have high blood pressure, insulin resistance or diabetes, high cholesterol, and have the metabolic syndrome (MetS).4–7 Reasons for this are numerous and wideranging. They include: (i) symptoms of mental illness (e.g.
Funding: None. Conflict of interest: None. © 2013 The Authors Internal Medicine Journal © 2013 Royal Australasian College of Physicians
negative symptoms of schizophrenia, such as low motivation levels); (ii) other co-occurring mental health diagnoses (e.g. depression, anxiety and substance-use disorders); (iii) comorbid physical illness (e.g. musculoskeletal complaints); (iv) suboptimal lifestyle factors, including a poor diet, sedentary behaviour and a reduced ability to quit smoking; (v) low socioeconomic status and unemployment, which are known to be associated with increased cardiovascular risk; (vi) deficits in the monitoring and proactive treatment of CVD risk factors by health workers; and (vii) the adverse metabolic effects of antipsychotic and mood-stabilising agents used to treat SMI.8–11 In people who have schizophrenia, international prevalence rates for modifiable CVD risk factors and their relative risks (RR) compared with the general Western population are: smoking 50–80% (RR 2–3), obesity 45–55% (RR 1.5–2), hypertension 19–58% (RR 2–3), diabetes 10–15% (RR 2), dyslipidaemia 25–69% (RR ≤5) and MetS 37–63% (RR 2–3).12 Galletly et al. have recently published a prevalence study examining CVD risk factors in an Australian cohort of patients with psychotic disorders. Assessing over 1000 patients nation-wide, they 65
Gladigau et al.
found that 67% smoked, 76% were overweight or obese, 47% had hypertension, 40% had abnormal glucose metabolism including diabetes, one third had raised cholesterol, and 55% had MetS.13 To the best of our knowledge, our study is the first to examine the prevalence of cardiovascular risk factors in patients with SMI who are currently engaged exclusively in psychiatric intensive community rehabilitation. We also compare the prevalence of these cardiovascular risk factors to the general Australian population (GAP) and the ATSI population of Australia for the first time.
Methods A cross-sectional audit of the medical files was conducted on all patients who were receiving care from Melbourne’s Inner West Mobile Support and Treatment Team, and Community Care Unit (CCU) in May 2012. Both public mental health services provide psychiatric treatment, case management and intensive community rehabilitation to patients with SMI. The CCU also provides residential care. The smoking status, height, weight, waist circumference, blood pressure, fasting blood glucose level, 2-h oral glucose tolerance test (where relevant) and fasting lipid profiles were obtained from the medical files of each patient. These data are routinely collected and documented as part of the service’s standard ‘metabolic monitoring’ protocol. Basic demographic data for each patient were also collected from the medical file. Ethics approval was not required for this audit. Current smokers were grouped as either ‘yes’ or ‘no’, where ‘yes’ equated to daily cigarette smoking. Body mass index was calculated using height (cm) and weight (kg) measurements and grouped into underweight (
Increased cardiovascular risk in patients with severe mental illness E. L. Gladigau,1 T. N. Fazio,2 J. P. Hannam,3 L. M. Dawson4 and S. G. Jones4 1
General Practice Registrar, Westcare Medical Centre, 2Medical Registrar, Melbourne Health, 4Inner West Area Mental Health Service/Melbourne
Health, and 3Psychiatry Registrar, North Western Mental Health, Melbourne, Victoria, Australia
Key words severe mental illness, cardiovascular, metabolic, mortality. Correspondence Elsa L. Gladigau, General Practice Registrar, Westcare Medical Centre, 1/211 Barries Road, Melton West, Vic. 3337, Australia. Email: [email protected] Received 24 August 2013; accepted 23 October 2013. doi:10.1111/imj.12319
Abstract Background: People with severe mental illness (SMI) have a reduced life expectancy. A major cause of mortality is cardiovascular disease. Aims: The aims of this study were to document the prevalence of cardiovascular risk factors in people with SMI engaged in community psychiatric rehabilitation and compare prevalence rates to the general, and Aboriginal and Torres Strait Islander (ATSI) populations of Australia. Method: A cross-sectional audit was conducted on patients receiving care from Melbourne’s Inner-West Area Mental Health Service. Profiles were collected on: smoking status, body mass index, waist circumference, blood pressure, diabetic status and fasting lipid profiles. These were compared with the general and ATSI Australian populations. Results: Complete data were available for 60 patients. Most were involuntary patients with a diagnosis of schizophrenia or schizoaffective disorder. Patients were more likely to smoke, be obese, have dyslipidaemia and the metabolic syndrome compared with the general and ATSI populations of Australia. Patients were more likely to have diabetes than the general population but had similar rates to the ATSI population. Patients had similar rates of hypertension to the general population but were less likely to be hypertensive compared with the ATSI population. Conclusion: Australians living with SMI have very high rates of cardiovascular risk factors, far in excess of the general Australian population and comparable with the ATSI population.
Introduction The mortality rate of people with severe mental illness (SMI) is two to three times that of the general Western population.1 This corresponds to a reduction in life expectancy by 10–25 years, a figure that is comparable with that of the Aboriginal and Torres Strait Islander (ATSI) population of Australia. This mortality gap appears to have widened in recent decades.2 A major contributor to this excess mortality is cardiovascular disease (CVD), and people with SMI are almost two times more likely to die from CVD.3,4 An increased prevalence of modifiable cardiovascular risk factors has been reported in SMI populations. People with SMI are more likely to smoke, be overweight or obese, have high blood pressure, insulin resistance or diabetes, high cholesterol, and have the metabolic syndrome (MetS).4–7 Reasons for this are numerous and wideranging. They include: (i) symptoms of mental illness (e.g.
Funding: None. Conflict of interest: None. © 2013 The Authors Internal Medicine Journal © 2013 Royal Australasian College of Physicians
negative symptoms of schizophrenia, such as low motivation levels); (ii) other co-occurring mental health diagnoses (e.g. depression, anxiety and substance-use disorders); (iii) comorbid physical illness (e.g. musculoskeletal complaints); (iv) suboptimal lifestyle factors, including a poor diet, sedentary behaviour and a reduced ability to quit smoking; (v) low socioeconomic status and unemployment, which are known to be associated with increased cardiovascular risk; (vi) deficits in the monitoring and proactive treatment of CVD risk factors by health workers; and (vii) the adverse metabolic effects of antipsychotic and mood-stabilising agents used to treat SMI.8–11 In people who have schizophrenia, international prevalence rates for modifiable CVD risk factors and their relative risks (RR) compared with the general Western population are: smoking 50–80% (RR 2–3), obesity 45–55% (RR 1.5–2), hypertension 19–58% (RR 2–3), diabetes 10–15% (RR 2), dyslipidaemia 25–69% (RR ≤5) and MetS 37–63% (RR 2–3).12 Galletly et al. have recently published a prevalence study examining CVD risk factors in an Australian cohort of patients with psychotic disorders. Assessing over 1000 patients nation-wide, they 65
Gladigau et al.
found that 67% smoked, 76% were overweight or obese, 47% had hypertension, 40% had abnormal glucose metabolism including diabetes, one third had raised cholesterol, and 55% had MetS.13 To the best of our knowledge, our study is the first to examine the prevalence of cardiovascular risk factors in patients with SMI who are currently engaged exclusively in psychiatric intensive community rehabilitation. We also compare the prevalence of these cardiovascular risk factors to the general Australian population (GAP) and the ATSI population of Australia for the first time.
Methods A cross-sectional audit of the medical files was conducted on all patients who were receiving care from Melbourne’s Inner West Mobile Support and Treatment Team, and Community Care Unit (CCU) in May 2012. Both public mental health services provide psychiatric treatment, case management and intensive community rehabilitation to patients with SMI. The CCU also provides residential care. The smoking status, height, weight, waist circumference, blood pressure, fasting blood glucose level, 2-h oral glucose tolerance test (where relevant) and fasting lipid profiles were obtained from the medical files of each patient. These data are routinely collected and documented as part of the service’s standard ‘metabolic monitoring’ protocol. Basic demographic data for each patient were also collected from the medical file. Ethics approval was not required for this audit. Current smokers were grouped as either ‘yes’ or ‘no’, where ‘yes’ equated to daily cigarette smoking. Body mass index was calculated using height (cm) and weight (kg) measurements and grouped into underweight (
