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Benjamin Druss MD, MPH October 3, 2012

Obesity and Premature Mortality in persons with serious mental illnesses: New hope for an old problem. Benjamin Druss MD, MPH October 3, 2012. Excess Mortality in Persons with SMI.

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Benjamin Druss MD, MPH October 3, 2012

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  1. Obesity and Premature Mortality in persons with serious mental illnesses: New hope for an old problem Benjamin Druss MD, MPH October 3, 2012

  2. Excess Mortality in Persons with SMI • We have known for 3 generations that people treated in the public MH sector die younger than the general population; this excess mortality is largely due to “natural” causes1 • As advances have improved longevity of the general population, disparities appear to be growing over time. 2,3 • Journal of the American Statistical Association Mar 1932;27(177A):160-174. 2. BMJ. 2011 Sep 13;343:d5422 3. 3. Nord J Psychiatry. 2012 Apr;66(2):97-106. Epub 2011 Aug 23.

  3. A Widening Gap: Trends in Studies of Excess Mortality in SMI1 1. Saha et al Arch Gen Psychiatry. Oct 2007;64(10):1123-1131 http://www.qcmhr.uq.edu.au/epi/index_files/Page562.htm

  4. What Are the Causes of Excess Morbidity and Mortality in Mental Disorders? • Persons with SMI on highest dose of antipsychotics have a 1/3 higher rate of CVD death than those on lower doses1 • In a national US sample, SES and health system factors each explained about ¼ of excess mortality.3 • Among veterans with schizophrenia, behavioral risks including obesity explain about 1/3 of excess mortality2 • Arch Gen Psychiatry. 2007;64(2):242-24 2. Gen Hosp Psychiatry. 2009 31(6):555-6 3 Medical Care, 2011;49(6):599-60

  5. Mental Illness and Risk of Obesity 1. Arch Gen Psychiatry. 2006 Jul;63(7):824-30 2.J Nerv Ment Dis 2003;191: 799–805

  6. What are the causes of obesity in mental disorders? • Side effects of medications, most notably newer (second generation) antipsychotic medications. 1 • Diet and physical activity: Individuals with schizophrenia consume significantly greater amounts of sugar and fat and are less likely to engage in physical activity than the general population.2 • Poverty: Mental illnesses are a risk for poverty which is in turn associated with excess rates of obesity. 3 1. Acta Psychiatr Scand. 2009100:3–16. 2. Compr Psychiatry. 2012 3. Epidemiol Rev. 2007;29:29-48.

  7. What are the consequences of obesity in mental disorders? • Reinforces stigma of mental illness1 • Increases costs of care2 • Decreased quality of life3 • Poor health: diabetes, cardiovascular disease and ultimately, premature mortality4 1. Am J Public Health. 2010 Jun;100(6):1019-28. 2. Gen Hosp Psychiatry. 2009 Jan-Feb;31(1):1-7. N Engl J Med. 2006 Aug 24;355(8):763-78 2. 3. Obesity (Silver Spring). 2008 Apr;16(4):749-54.4 4 European Journal of Preventive Cardiology June 2008 vol. 15 no. 3 239-246

  8. A Public Health Approach To Addressing Obesity and Premature Mortality in People with SMI Tertiary Prevention Primary Prevention Secondary Prevention Cardiometabolic disease Populations with SMI Risk Factors Wellness programs Environmental Policies Medication choice Screening Treatment

  9. Policy Priorities • Include persons with with SMI in broader public health campaigns and develop programs targeted at this population (e.g. SAMHSA Wellness Initiative). • Track health indicators including mortality among people with SMI (e.g. NCQA’s new performance measures for people with SMI for HEDIS 2013). • Promote effective clinical models that provide integrated medical care for people with SMI. (PBHCI program; Medicaid Medical Home demonstration projects)

  10. Summary • The problem of premature mortality in people with SMI is a “crisis” that has existed for at least ¾ of a century. • More recently, this problem has been compounded by high rates of obesity in people with SMI, which represents an epidemic within an epidemic. • Policies addressing poor health and obesity in this population need to support a public health approach that supports both prevention and high quality medical treatment.

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