Benjamin G. Druss

Mortality in Mental Disorders and Global Disease Burden Implications: A Systematic Review and Meta-analysis

IMPORTANCE Despite the potential importance of understanding excess mortality among people with mental disorders, no comprehensive meta-analyses have been conducted quantifying mortality across mental disorders. OBJECTIVE To conduct a systematic review and meta-analysis of mortality among people with mental disorders and examine differences in mortality risks by type of death, diagnosis, and study characteristics. DATA SOURCES We searched EMBASE, MEDLINE, PsychINFO, and Web of Science from inception through May 7, 2014, including references of eligible articles. Our search strategy included terms for mental disorders (eg, mental disorders, serious mental illness, and severe mental illness), specific diagnoses (eg, schizophrenia, depression, anxiety, and bipolar disorder), and mortality. We also used Google Scholar to identify articles that cited eligible articles. STUDY SELECTION English-language cohort studies that reported a mortality estimate of mental disorders compared with a general population or controls from the same study setting without mental illness were included. Two reviewers independently reviewed the titles, abstracts, and articles. Of 2481 studies identified, 203 articles met the eligibility criteria and represented 29 countries in 6 continents. DATA EXTRACTION AND SYNTHESIS One reviewer conducted a full abstraction of all data, and 2 reviewers verified accuracy. MAIN OUTCOMES AND MEASURES Mortality estimates (eg, standardized mortality ratios, relative risks, hazard ratios, odds ratios, and years of potential life lost) comparing people with mental disorders and the general population or people without mental disorders. We used random-effects meta-analysis models to pool mortality ratios for all, natural, and unnatural causes of death. We also examined years of potential life lost and estimated the population attributable risk of mortality due to mental disorders. RESULTS For all-cause mortality, the pooled relative risk of mortality among those with mental disorders (from 148 studies) was 2.22 (95% CI, 2.12-2.33). Of these, 135 studies revealed that mortality was significantly higher among people with mental disorders than among the comparison population. A total of 67.3% of deaths among people with mental disorders were due to natural causes, 17.5% to unnatural causes, and the remainder to other or unknown causes. The median years of potential life lost was 10 years (n = 24 studies). We estimate that 14.3% of deaths worldwide, or approximately 8 million deaths each year, are attributable to mental disorders. CONCLUSIONS AND RELEVANCE These estimates suggest that mental disorders rank among the most substantial causes of death worldwide. Efforts to quantify and address the global burden of illness need to better consider the role of mental disorders in preventable mortality.

Barriers to mental health treatment: results from the National Comorbidity Survey Replication.

BACKGROUND The aim was to examine barriers to initiation and continuation of treatment among individuals with common mental disorders in the US general population. METHOD Respondents in the National Comorbidity Survey Replication with common 12-month DSM-IV mood, anxiety, substance, impulse control and childhood disorders were asked about perceived need for treatment, structural barriers and attitudinal/evaluative barriers to initiation and continuation of treatment. RESULTS Low perceived need was reported by 44.8% of respondents with a disorder who did not seek treatment. Desire to handle the problem on ones own was the most common reason among respondents with perceived need both for not seeking treatment (72.6%) and for dropping out of treatment (42.2%). Attitudinal/evaluative factors were much more important than structural barriers both to initiating (97.4% v. 22.2%) and to continuing (81.9% v. 31.8%) of treatment. Reasons for not seeking treatment varied with illness severity. Low perceived need was a more common reason for not seeking treatment among individuals with mild (57.0%) than moderate (39.3%) or severe (25.9%) disorders, whereas structural and attitudinal/evaluative barriers were more common among respondents with more severe conditions. CONCLUSIONS Low perceived need and attitudinal/evaluative barriers are the major barriers to treatment seeking and staying in treatment among individuals with common mental disorders. Efforts to increase treatment seeking and reduce treatment drop-out need to take these barriers into consideration as well as to recognize that barriers differ as a function of sociodemographic and clinical characteristics.

Quality of preventive medical care for patients with mental disorders

Background/Objectives. This study compares quality of preventive services between persons with and without mental/substance use disorders for a national sample of medical outpatients. Research Design. Cross‐sectional study. Subjects. A total of 113,505 veterans with chronic conditions and at least three general medical visits to Veterans Health Administration medical providers during 1998 to 1999. Measures. Chart‐derived rates of eight preventive services: two measures of immunization, four measures of cancer screening, and two of tobacco screening and counseling. Multivariable‐generalized estimating equations compared rates of each preventive service among veterans with psychiatric disorders, substance use disorders, both, and neither, adjusting for demographic, health status, and facility‐level characteristics. Results. On average, persons in the sample obtained 64% of the eight preventive procedures for which they were eligible. Overall rates of currency with preventive services were 58% for patients with combined psychiatric/substance use disorders, 60% and 65% for those with psychiatric and substance use disorders alone, and 66% for those with neither psychiatric nor substance use disorders. Each difference remained statistically significant in multivariable models. Conclusions. In this sample of patients in active medical treatment, rates of preventive services were higher than rates reported for population‐based, private‐sector samples. Despite these high‐baseline rates, persons with psychiatric disorders, particularly with comorbid substance use, were at risk for lower rate of receipt of preventive services.

Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey.

BackgroundAlthough growing concern has been expressed about premature medical mortality in persons with mental illness, limited data are available quantifying the extent and correlates of this problem using population-based, nationally representative samples. MethodsThe study used data from the 1989 National Health Interview Survey mental health supplement, with mortality data through 2006 linked through the National Death Index (80,850 participants, 16,435 deaths). Multivariable models adjusting for demographic factors assessed the increased hazard of mortality adding socioeconomic status, healthcare variables, clinical factors first separately, and then together. ResultsPersons with mental disorders died an average of 8.2 years younger than the rest of the population (P < 0.001). Adjusting for demographic factors, presence of a mental illness was associated with a significant risk of excess mortality, (hazard ratio=2.06, 95% confidence interval=1.71-2.40), with 95.4% of deaths owing to medical rather than unnatural causes. Adding socioeconomic variables to the model, the hazard ratio was 1.77 (P < 0.001); adding health system factors, it was 1.80 (P < 0.001)); adding baseline clinical characteristics, the hazard ratio was 1.32 (P < 0.001). After adding all the 3 groups of variables simultaneously, the association was reduced by 82% from baseline and became statistically nonsignificant (hazard ratio=1.19, P=0.053). ConclusionsThe results of the study underscore the complex causes and high burden of medical mortality among persons with mental disorders in the United States. Efforts to address this public health problem will need to address the socioeconomic, healthcare, and clinical risk factors that underlie it.

A Randomized Trial of Medical Care Management for Community Mental Health Settings: The Primary Care Access, Referral, and Evaluation (PCARE) Study

OBJECTIVE Poor quality of healthcare contributes to impaired health and excess mortality in individuals with severe mental disorders. The authors tested a population-based medical care management intervention designed to improve primary medical care in community mental health settings. METHOD A total of 407 subjects with severe mental illness at an urban community mental health center were randomly assigned to either the medical care management intervention or usual care. For individuals in the intervention group, care managers provided communication and advocacy with medical providers, health education, and support in overcoming system-level fragmentation and barriers to primary medical care. RESULTS At a 12-month follow-up evaluation, the intervention group received an average of 58.7% of recommended preventive services compared with a rate of 21.8% in the usual care group. They also received a significantly higher proportion of evidence-based services for cardiometabolic conditions (34.9% versus 27.7%) and were more likely to have a primary care provider (71.2% versus 51.9%). The intervention group showed significant improvement on the SF-36 mental component summary (8.0% [versus a 1.1% decline in the usual care group]) and a nonsignificant improvement on the SF-36 physical component summary. Among subjects with available laboratory data, scores on the Framingham Cardiovascular Risk Index were significantly better in the intervention group (6.9%) than the usual care group (9.8%). CONCLUSIONS Medical care management was associated with significant improvements in the quality and outcomes of primary care. These findings suggest that care management is a promising approach for improving medical care for patients treated in community mental health settings.

The Health and Recovery Peer (HARP) Program: A peer-led intervention to improve medical self-management for persons with serious mental illness

OBJECTIVES Persons with serious mental illnesses (SMI) have elevated rates of comorbid medical conditions, but may also face challenges in effectively managing those conditions. METHODS The study team developed and pilot-tested the Health and Recovery Program (HARP), an adaptation of the Chronic Disease Self-Management Program (CDSMP) for mental health consumers. A manualized, six-session intervention, delivered by mental health peer leaders, helps participants become more effective managers of their chronic illnesses. A pilot trial randomized 80 consumers with one or more chronic medical illness to either the HARP program or usual care. RESULTS At six month follow-up, participants in the HARP program had a significantly greater improvement in patient activation than those in usual care (7.7% relative improvement vs. 5.7% decline, p=0.03 for group *time interaction), and in rates of having one or more primary care visit (68.4% vs. 51.9% with one or more visit, p=0.046 for group *time interaction). Intervention advantages were observed for physical health related quality of life (HRQOL), physical activity, medication adherence, and, and though not statistically significant, had similar effect sizes as those seen for the CDSMP in general medical populations. Improvements in HRQOL were largest among medically and socially vulnerable subpopulations. CONCLUSIONS This peer-led, medical self-management program was feasible and showed promise for improving a range of health outcomes among mental health consumers with chronic medical comorbidities. The HARP intervention may provide a vehicle for the mental health peer workforce to actively engage in efforts to reduce morbidity and mortality among mental health consumers.

Metabolic Testing Rates in 3 State Medicaid Programs After FDA Warnings and ADA/APA Recommendations for Second-Generation Antipsychotic Drugs

CONTEXT In 2003, the Food and Drug Administration (FDA) required a warning on diabetes risk for second-generation antipsychotic (SGA) drugs. The American Diabetes Association (ADA) and American Psychiatric Association (APA) recommended glucose and lipid testing for all patients starting to receive SGA drugs. OBJECTIVE To characterize associations between the combined warnings and recommendations and baseline metabolic testing and SGA drug selection. DESIGN Interrupted time-series analysis. SETTING California, Missouri, and Oregon. Patients A total of 109 451 individuals receiving Medicaid who began taking SGA medication and a control cohort of 203 527 patients who began taking albuterol but did not receive antipsychotic medication. INTERVENTIONS Prewarning and postwarning trends in metabolic testing were compared using laboratory claims for the cohort collected January 1, 2002, through December 31, 2005. Changes in SGA prescribing practices were similarly evaluated. MAIN OUTCOME MEASURES Monthly rates of baseline serum glucose and lipid testing for SGA-treated and propensity-matched albuterol-treated patients and monthly share of new prescriptions for each SGA drug. RESULTS Initial testing rates for SGA-treated patients were low (glucose, 27%; lipids, 10%). The warning was not associated with an increase in glucose testing among SGA-treated patients and was associated with only a marginal increase in lipid testing rates (1.7%; P = .02). Testing rates and trends in SGA-treated patients were not different from background rates observed in the albuterol control group. New prescriptions of olanzapine (higher metabolic risk) declined during the warning period (annual share decline, 19.9%; P < .001). New prescriptions of aripiprazole (lower metabolic risk) increased during the warning period (share increase, 12.1%; P < .001) but may be attributable to the elimination of prior authorization in California during the same time frame. Quetiapine, risperidone, and ziprasidone use were not associated with the warning. CONCLUSIONS In a Medicaid-receiving population, baseline glucose and lipid testing for SGA-treated patients was infrequent and showed little change following the diabetes warning and monitoring recommendations. A change in SGA drug selection consistent with intentions to reduce metabolic risk was observed.

Dropout From Outpatient Mental Health Care in the United States

OBJECTIVE Although mental health treatment dropout is common, patterns and predictors of dropout are poorly understood. This study explored patterns and predictors of mental health treatment dropout in a nationally representative sample. METHODS Data were from the National Comorbidity Survey Replication, a nationally representative household survey. Respondents who had received mental health treatment in the 12 months before the interview (N=1,664) were asked about dropout, which was defined as quitting treatment before the provider wanted them to stop. Cross-tabulation and discrete-time survival analyses were used to identify predictors. RESULTS Approximately one-fifth (22%) of patients quit treatment prematurely. The highest dropout rate was from treatment received in the general medical sector (32%), and the lowest was from treatment received by psychiatrists (15%). Dropout rates were intermediate from treatment in the human services sector (20%) and among patients seen by nonpsychiatrist mental health professionals (19%). Over 70% of all dropout occurred after the first or second visits. Mental health insurance was associated with low odds of dropout (odds ratio=.6, 95% confidence interval=.4-.9). Psychiatric comorbidity was associated with a trend toward dropout. Several patient characteristics differentially predicted dropout across treatment sectors and in early and later phases of treatment. CONCLUSIONS Roughly one-fifth of adults in mental health treatment dropped out before completing the recommended course of treatment. Dropout was most common in the general medical sector and varied by patient characteristics across treatment sectors. Interventions focused on high-risk patients and sectors that have higher dropout rates will likely be required to reduce the large proportion of patients who prematurely terminate treatment.

Impairment in Role Functioning in Mental and Chronic Medical Disorders in the United States: Results from the National Comorbidity Survey Replication

This study presents national data on the comparative role impairments of common mental and chronic medical disorders in the general population. These data come from the National Comorbidity Survey Replication, a nationally representative household survey. Disorder-specific role impairment was assessed with the Sheehan Disability Scales, a multidimensional instrument that asked respondents to attribute impairment to particular conditions. Overall impairment was significantly higher for mental than chronic medical disorders in 74% of pair-wise comparisons between the two groups of conditions, and severe impairment was reported by a significantly higher portion of persons with mental disorders (42.0%) than chronic medical disorders (24.4%). However, treatment was provided for a significantly lower proportion of mental (21.4%) than chronic medical (58.2%) disorders. Although mental disorders were associated with comparable or higher impairment than chronic medical conditions in all domains of function, they showed different patterns of deficits; whereas chronic medical disorders were most likely to be associated with impairment in domains of work and home functioning, mental disorders were most commonly associated with problems in social and close-relation domains. Comorbidity between chronic medical and mental disorders significantly increased the reported impairment associated with each type of disorder. The results indicate a serious mismatch between a high degree of impairment and a low rate of treatment for mental disorders in the United States. Efforts to reduce disability will need to address the disproportionate burden and distinct patterns of deficits of mental disorders and the potentially synergistic impact of comorbid mental and chronic medical disorders.

Effects of Food and Drug Administration Warnings on Antidepressant Use in a National Sample

CONTEXT In June 2003, the Food and Drug Administration (FDA) recommended that paroxetine hydrochloride not be used to treat young people because of potential increased risk of suicidal behavior, and in October 2004, the FDA issued a black box warning concerning all antidepressants for youth. OBJECTIVE To characterize associations between these warnings and antidepressant use. DESIGN Interrupted time series analyses of trends in antidepressant use were performed with Medco pharmacy and enrollment data stratified by patient age, sex, antidepressant type, and specialty of the prescribing physician across 3 study periods: prewarning (May 1, 2002 to June 19, 2003), paroxetine warning (June 20, 2003 to October 15, 2004), and black box warning (October 16, 2004 to December 31, 2005). MAIN OUTCOME MEASURES The rate of antidepressant use, annualized percentage change in rate of antidepressant use, and difference in trend of antidepressant use between consecutive study periods. RESULTS During the prewarning study period, there was a 36.0% per year (P < .001) increase in total youth (aged 6-17 years) antidepressant use, which was followed by decreases of -0.8% per year (P = .85) and -9.6% per year (P = .21) during the paroxetine and black box warning study periods, respectively. The difference in trends between the prewarning and paroxetine warning periods was significant (P < .001). Youth paroxetine use also significantly increased during the prewarning study period (30.0% per year; P < .001) before significantly declining during the paroxetine warning study period (-44.2% per year; P < .001), which was also a significant between-period difference in trends (P < .001). Changes in antidepressant use were less pronounced in adults than in youth. For adults 65 years and older, overall antidepressant use significantly increased (8.1% per year; P < .001) during the black box study period. Changes in the pattern of antidepressant use varied little by patient sex. CONCLUSIONS The paroxetine and black box warnings had modest and relatively targeted effects on the intended populations. These changes, which were greatest for youth, were broadly consistent with the FDA warnings and the scientific literature.