A recent study, published in the April 2016 edition of the British Journal of General Practice, reveals that patients with severe mental illness are given suboptimal treatment for their cardiovascular disease as compared to patients without any mental illness. The differences are significantly greater if patients have been diagnosed with schizophrenia and/or have received injectable depot anti-psychotic medication.
The study was carried out by research associates, professors and physicians from King’s College London and Durham University. It analyzed electronic medical records obtained from primary and secondary care centres in the Lambeth region of South East London, where a major portion of the population comprised of black Caribbean and black African residents. Primary care data was taken from computerized medical records of all but one GP practice. Secondary care records were obtained from the South London and Maudsley NHS Foundation Trust (SLaM).
The term ‘severe mental illness’ (SMI) includes schizophrenia, bipolar affective disorder, and schizoaffective disorder or other non-organic psychoses. Patients of SMI experience lower life expectancy than the general population, reasons for which include associated conditions like cardiovascular disease. The presence of other risk factors, like smoking and side effects of drug treatment, are also contributory factors.
The study made use of population based data linkages between primary and secondary care health records. It analyzed data of 4,056 patients who had been diagnosed with SMI and cardiovascular disease (CVD) in their primary care and had linked secondary mental health care records. The data was then compared with patients of CHD who had no history of SMI in their primary or secondary health care record (270,669 patients).
Three classes of drugs are used to prevent adverse outcomes in patients of cardiovascular disease and congestive heart failure. These are beta blockers, angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blockers (ARBs). The study found out that all three were prescribed significantly less often in patients with cardiovascular disease who also had SMI, as compared to those without any mental illness. The shortfall in prescribing beta blockers was adjusted for after taking ethnicity into account. However, the difference in prescription rates for ACEI and ARB still remained after all adjustments for age, sex and ethnicity were made. On the contrary, the difference grew larger in patients diagnosed with schizophrenia and in those who had received a depot injection of anti-psychotic medication, making them the least likely to be prescribed these medications.
The reasons behind these differences include multiple factors. Drugs like ACEI, ARBs and beta blockers require careful up-titration and dose adjustment at regular intervals until a maximum tolerated dose can be reached. This requires regular monitoring by blood tests. Also, patients have to strictly adhere to a dose regimen for it to take effect. These factors could explain reluctance on part of physicians to prescribe such medication, as the follow-up is too demanding and patients with SMI are not willing to commit themselves to such monitoring. Accidental or intentional overdose is also a cause for concern among physicians when prescribing these medications. Moreover, SMI patients also reject prescriptions due to mistrust and lack of adequate communication between the doctor and patient. All these factors combined make SMI patients harder to manage.
The findings of this study are in line with other national and international research results. However, a limitation to its credibility remains due to the limited geographical region studied, and the question of whether these can be summarized for other regions as well. The study also found no difference in quality and outcome framework (QOF) of clinical targets between patients with SMI and those without it. These are targets which set the quality and standard of healthcare practice. However, it is possible that discrepancies may exist for non-QOF targets which were not included in the study.
The study also shed light on ethnicity, age and the risk of developing mental illness. According to the study, factors like being black (African, Caribbean, other), of a younger age and of male gender were associated with increased severity and risk of mental illness. Relative to schizophrenia, patients diagnosed with bipolar disorder tend to be younger females of British/mixed British descent and those who sought primary care consultation more frequently. Those diagnosed with schizoaffective disorder/other non-organic psychoses were younger, more likely to be female, and those who sought primary care consultation less frequently, relative to patients with schizophrenia.
It is an established fact that patients with severe mental illness have increased morbidity and mortality rates as compared to the general population. Suboptimal treatment of cardiovascular disease has been recognised as a contributory factor. This study has attempted to identify the disparity that exists in treatment of SMI patients with cardiovascular disease and to deepen the understanding of the reasons behind such a difference. Improved coordination and closer working between primary and secondary care centres will help bridge the gap that currently exists and as this study finds, the role of the secondary care physician may be more pertinent in these cases.