This summary updates the findings from an evidence review undertaken by Candace Bagnall, Te Pou, Helen Lockett, the Wise Group, and Dr Ruth Cunningham, Department of Public Health, University of Otago Wellington, with support from Kim Arcus, Heart Foundation (2016), as part of the Ministry of Health’s review of guidance on CVD risk assessment and management within primary care. It supports the priorities of Equally Well, in working to improve the physical health of people with mental health and/or addiction problems.
We found two additional studies (Correll, Detraux, et al., 2015; Lin, Chen et al., 2014) which strengthens our previous findings, and have been incorporated into this summary. In addition, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) has published clinical guidelines for schizophrenia and related disorders (Galletly, Castle et al., 2016) and mood disorders (Malhi, Bassett et al., 2015), both of which have relevance for CVD risk assessment in primary care and are therefore also referred to in this update.
People who experience serious mental illness (SMI) , particularly schizophrenia, have significantly reduced life expectancy and a premature mortality rate two to three times higher than the general population (Cunningham et al. 2014). Cardiovascular disease (CVD) is a major contributor, accounting for 40-50% of premature deaths (Ringen, Engh et al., 2014).
We reviewed the literature to identify:
- The relative increase in CVD risk associated with SMI
- The recommended assessment and management of CVD and CVD risk in people with SMI.
There is significantly increased CVD risk in people with SMI, at an earlier age.
People who experience serious mental illness (SMI), particularly schizophrenia, have significantly reduced life expectancy and a premature mortality rate two to three times higher than the general population (Cunningham, Sarfati et al., 2014). Cardiovascular disease (CVD) is a major contributor, accounting for 40-50% of premature deaths (Ringen, Engh et al., 2014).
There is strong evidence to indicate that the risk of developing CVD is higher in people diagnosed with SMI (see table below). This increased risk is due in part to established risk factors including smoking and diet but is also related to the metabolic effects of psychotropic medication. Studies that controlled for known CVD risk factors still found an increased relative risk. Some studies have identified mental illness as an independent risk factor for CVD, specifically in psychosis (Ösby, Olsson, et al., 2014) and depression (Van der Kooy, van Hout, et al., 2007).
The increased CVD risk is present at an earlier age than in the general population. For people with psychosis, CVD risk factors are present from a very early age (Correll, Robinson et al., 2014; Foley, Mackinnon, et al., 2015; Goldstein, Schaffer, et al., 2015; McLean, Martin et al., 2014).
Obese people with SMI have a significantly higher cardiovascular risk than obese people without SMI, and recent studies support the possibility of a direct effect of antipsychotics on cardiovascular risk, which varies between medications. CVD risk is approximately 1.5 to 3-fold increased in patients with schizophrenia and bipolar disorder, and on average 1.5-fold increased in those with major depression. Higher dosages, polypharmacy and the treatment of old or young people are associated with greater adverse impacts (Correll et al., 2015).
Current CVD risk assessment tools are likely to underestimate the risk for this population.
Studies have found that CVD risk assessment tools underestimate cardiovascular risk for this group (McLean et al., 2014; Rugulies, 2002). One study has looked at modifying risk assessment protocols specifically for this population (Osborn, Hardoon et al., 2015).
There are inequities in assessment and management of CVD risk and CVD for people diagnosed with SMI.
Several studies point to inequities in assessment and management of CVD risk and CVD in people who experience SMI (de Hert, M., Correll et al., 2011; Smith, Martin et al., 2013). The evidence for specific interventions to reduce CVD risk among people with SMI is limited, although there is evidence to support behavioural and pharmacological interventions, particularly in the area of weight loss (Gierisch, Nieuwsma et al., 2014; McGinty, Baller et al., 2016).
People who experience SMI have a significantly higher risk of dying from CVD than their general population counterparts.
In the only New Zealand study, the standardised mortality ratio (SMR) from CVD for people using mental health services compared to the general population was 1.69 (Cunningham et al., 2014). This is consistent with international studies which have found SMR for people with SMI from 1.6 to 2.5 (Ringen et al., 2014). A large UK study (Osborn, Levy et al., 2007) found that people with SMI aged 18-49 were three times more likely to die from heart disease as those without SMI, while in people aged 50-75 the risk was doubled.
The authors concluded that people who experience SMI have a greater risk of CVD than their counterparts in the general population. Established risk factors such as smoking and diet do not fully account for this increased risk. Inequities in assessment and management of CVD risk are likely contributors along with the cardio metabolic effects of particular psychotropic medications. In a large study of patients with schizophrenia, mood disorders or dementia, the adjusted OR acute myocardial infarction risk was 2.52 (95% CI: 2.37- 2.68) for any antipsychotic, 2.32 (95% CI: 2.17-2.47) for first generation antipsychotics, and 2.74 (95% CI: 2.49-3.02) for second generation antipsychotics (Lin et al., 2014).
Ensure that future New Zealand clinical guidance for assessing and managing CVD risk in primary care takes the following into account:
- Concordance with Royal Australian and New Zealand College of Psychiatry clinical guidelines on managing schizophrenia (Galletly et al., 2016) and mood disorders (Malhi et al., 2015); specifically regarding guidance on the management of CVD risk across primary and secondary care.
- NICE guideline 178, which has new sections (2014) on managing physical health care across both primary and secondary care, and recommends that “GPs and other primary healthcare professionals should monitor the physical health of people with psychosis or schizophrenia when responsibility for monitoring is transferred from secondary care, and then at least annually”.
- NICE guideline 181, which recommends that health professionals “recognise that standard CVD risk scores will underestimate risk in people who have additional risk because of underlying medical conditions or treatments. These groups include … people with serious mental health problems … (and) … people taking medicines that can cause dyslipidaemia such as antipsychotic medication, corticosteroids or immunosuppressant drugs” .
- There is sufficiently strong evidence to reduce the age for CVD risk assessment in people with serious mental illness.
- There is sufficiently strong evidence of increased relative risk of CVD in people with SMI to include them as a priority group for CVD risk assessment and ongoing management in future guidelines for primary care.
- The utility of adapting a general population tool to adjust for mental illness, or creating a specific tool, should be assessed in a New Zealand context.
For more information on this review please contact Dr Ruth Cunningham at email@example.com.
- Charlson, F. J., Moran, A. E., Freedman, G., Norman, R. E., Stapelberg, N. J., Baxter, A. J., ... & Whiteford, H. A. (2013). The contribution of major depression to the global burden of ischemic heart disease: a comparative risk assessment. BMC medicine, 11(1), 250.
- Correll, C. U., Detraux, J., De Lepeleire, J., & De Hert, M. (2015). Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World Psychiatry, 14(2), 119-136.
- Correll, C. U., Robinson, D. G., Schooler, N. R., Brunette, M. F., Mueser, K. T., Rosenheck, R. A., ... & Kane, J. M. (2014). Cardiometabolic risk in patients with first-episode schizophrenia spectrum disorders: baseline results from the RAISE-ETP study. JAMA psychiatry, 71(12), 1350-1363.
- Cunningham, R., Sarfati, D., Peterson, D., Stanley, J., & Collings, S. (2014). Premature mortality in adults using New Zealand psychiatric services. New Zealand medical journal, 127(1394), 31-41.
- de Hert, M., Correll, C. U., Bobes, J., Cetkovich‐Bakmas, M. A. R. C. E. L. O., Cohen, D. A. N., Asai, I., ... & Newcomer, J. W. (2011). Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World psychiatry, 10(1), 52-77.
- Fan, Z., Wu, Y., Shen, J., Ji, T., & Zhan, R. (2013). Schizophrenia and the risk of cardiovascular diseases: a meta-analysis of thirteen cohort studies. Journal of psychiatric research, 47(11), 1549-1556.
- Foley, D. L., Mackinnon, A., Morgan, V. A., Watts, G. F., Shaw, J. E., Magliano, D. J., ... & Galletly, C. A. (2015). Cardiovascular risk factor associations in adults with psychosis and adults in a national comparator sample. Australian and New Zealand Journal of Psychiatry, 0004867414565476.
- Galletly, C., Castle, D., Dark, F., Humberstone, V., Jablensky, A., Killackey, E., Kulkarni, J., McGorry, P., Nielssen, O., and Tran, N. (2016). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Australian & New Zealand Journal of Psychiatry, Vol. 50(5) 410 –472.
- Gierisch, J. M., Nieuwsma, J. A., Bradford, D. W., Wilder, C. M., Mann-Wrobel, M. C., McBroom, A. J., ... & Williams, J. W. (2014). Interventions to improve cardiovascular risk factors in people with serious mental illness. Journal of Clinical Psychiatry 75(5): 424-440
- Goldstein, B. I., Schaffer, A., Wang, S., & Blanco, C. (2015). Excessive and premature new-onset cardiovascular disease among adults with bipolar disorder in the US NESARC cohort. The Journal of clinical psychiatry, 76(2), 163-169.
- Lin, S. T., Chen, C. C., Tsang, H. Y., Lee, C. S., Yang, P., Cheng, K. D., ... & Yang, W. C. (2014). Association between antipsychotic use and risk of acute myocardial infarction: a nationwide case-crossover study. Circulation, CIRCULATIONAHA-114.
- Malhi, G. S., Bassett, D., Boyce, P., Bryant, R., Fitzgerald, P. B., Fritz, K., ... & Porter, R. (2015). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian and New Zealand Journal of Psychiatry, 49(12), 1087-1206.
- McGinty, E. E., Baller, J., Azrin, S. T., Juliano-Bult, D., & Daumit, G. L. (2015). Interventions to Address Medical Conditions and Health-Risk Behaviors Among Persons With Serious Mental Illness: A Comprehensive Review. Schizophrenia bulletin, sbv101.
- McLean, G., Martin, J. L., Martin, D. J., Guthrie, B., Mercer, S. W., & Smith, D. J. (2014). Standard cardiovascular disease risk algorithms underestimate the risk of cardiovascular disease in schizophrenia: Evidence from a national primary care database. Schizophrenia research, 159(1), 176-181.
- National Institute of Health and Clinical Excellence (NICE). (2014) Psychosis and schizophrenia in adults: treatment and management. NICE clinical guideline 178. (Last modified March 2014)
- Nicholson, A., Kuper, H., & Hemingway, H. (2006). Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. European Heart Journal, 27(23), 2763-2774.
- Osborn, D. P., Hardoon, S., Omar, R. Z., Holt, R. I., King, M., Larsen, J., ... & Petersen, I. (2015). Cardiovascular risk prediction models for people with severe mental illness: results from the prediction and management of cardiovascular risk in People with Severe Mental Illnesses (PRIMROSE) Research Program. JAMA psychiatry, 72(2), 143-151.
- Osborn, D. P., Levy, G., Nazareth, I., Petersen, I., Islam, A., & King, M. B. (2007). Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom's General Practice Research Database. Archives of general psychiatry, 64(2), 242-249.
- Ösby, U., Olsson, E., Edman, G., Hilding, A., Eriksson, S. V., & Östenson, C. G. (2014). Psychotic disorder is an independent risk factor for increased fasting glucose and waist circumference. Nordic journal of psychiatry, 68(4), 251-258.
- Rugulies, R. (2002). Depression as a predictor for coronary heart disease: a review and meta-analysis. American Journal of Preventive Medicine, 23(1), 51-61.
- Ringen, P. A., Engh, J. A., Birkenaes, A. B., Dieset, I., & Andreassen, O. A. (2014). Increased mortality in schizophrenia due to cardiovascular disease–a non-systematic review of epidemiology, possible causes, and interventions. Frontiers in psychiatry, 5, 137.
- Smith, D. J., Martin, D., McLean, G., Langan, J., Guthrie, B., & Mercer, S. W. (2013). Multimorbidity in bipolar disorder and undertreatment of cardiovascular disease: a cross sectional study. BMC medicine, 11(1), 263.
- Van der Kooy, K., van Hout, H., Marwijk, H., Marten, H., Stehouwer, C., & Beekman, A. (2007). Depression and the risk for cardiovascular diseases: systematic review and meta-analysis. International journal of geriatric psychiatry, 22(7), 613-626.
This review was funded by the Ministry of Health to inform a revision of the CVD risk assessment guidance in primary care. The Heart Foundation co-ordinated the review process. Te Pou o te Whakaaro Nui and University of Otago, Wellington contributed staff time to this review process.