From the Editor
When people with mental health problems have physical illness, how does their care measure up?
Not surprisingly, we worry about their access and follow up. Evidence suggests poorer outcomes. But how do people with mental disorders fare on an international basis?
In the first selection, Dr. Marco Solmi (of the University of Padua) and his co-authors try to answer that question, focusing on cardiovascular diseases (CVD). In a new American Journal of Psychiatry paper, they conduct a systematic review and meta-analysis, drawing on the data of more than 24 million people. (!) They find: “People with mental disorders, and those with schizophrenia in particular, receive less screening and lower-quality treatment for CVD. It is of paramount importance to address underprescribing of CVD medications and underutilization of diagnostic and therapeutic procedures across all mental disorders.” We discuss the paper and its clinical implications.
In the second selection from The American Journal of Psychiatry, Drs. Nathalie Moise and Sidney Hankerson (both of Columbia University) consider structural racism and depression care, using a clinical vignette. Rather than just seeing the patient’s experience in terms of genetic loading and medications, they describe a person who has struggled with various forms of racism. They argue: “Mental health professionals need to recognize the effect of structural, individual, and internalized racism on individuals with depression symptoms.”
Selection 1: “Disparities in Screening and Treatment of Cardiovascular Diseases in Patients With Mental Disorders Across the World: Systematic Review and Meta-Analysis of 47 Observational Studies”
Marco Solmi, Jess Fiedorowicz, Laura Poddighe, et al.
The American Journal of Psychiatry, 14 July 2021 Online First
People with mental disorders (schizophrenia spectrum disorders, bipolar disorder, and depressive disorders, among others) have poorer physical health than the general population, with a higher burden of risk factors for cardiovascular diseases (CVDs), diabetes, metabolic syndrome, poor nutritional habits, more sedentary behavior, and smoking. Pharmacological treatment of mental disorders, including second-generation antipsychotics, also contribute to poor metabolic status. According to a large-scale meta-analysis, people with mental disorders have a high prevalence of CVD (9.9%), and among those with severe mental disorders, the incidence of CVD is roughly 80% higher than in the general population. Mental disorders appear to be independent risk factors for cardiovascular disease, and a variety of putative causal mechanisms may explain this…
Several medical conditions and CVDs contribute to a large extent to the reduction by 10–20 years in longevity among people with mental disorders (which is only partially due to suicide, which accounts for the largest relative mortality risk, but has lower prevalence than CVD). Beyond increased incidence, the stage at which medical comorbidities are diagnosed and the quality and timeliness of care play a role in determining disease course and outcome…
Similarly, disparities in CVD screening may also exist for people with mental disorders. Moreover, consistent with general medical care, the problem may go beyond CVD screening and extend to CVD treatment. Disparities in CVD screening and treatment may in part explain why people with mental disorders show an approximate 80% higher risk of CVD-related death compared with the general population.
A rigorous synthesis of the available evidence is paramount to determine whether disparities of this kind exist and to assess their type and extent. However, no recent comprehensive meta-analysis, without restriction in types of CVDs or types of mental disorders, has investigated disparities in CVD screening and treatment. To the best of our knowledge, the latest systematic reviews on disparities in medical prescriptions in people with mental illness compared with the general population was published by Mitchell et al., in 2012, with the last search conducted in 2010.
So begins a paper by Solmi et al.
Here’s what they did:
- The authors conducted a random-effect meta-analysis of observational studies comparing CVD screening and treatment in people with and without mental disorders.
- They adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P).
- “Inclusion criteria were observational study design, published in any language, focusing on screening, diagnosis, and treatment of CVDs, in people with mental disorders, defined according to structured criteria, validated scales, or clinical records, and reporting comparative effect sizes of CVD screening or treatment between people with mental disorders and the general population, or raw frequencies in both groups.”
- The authors searched databases including PubMed through July 31, 2020.
- The primary outcome: odds ratios for CVD screening and treatment.
Here’s what they found:
- 47 studies were appropriate and included.
- “This meta-analysis reports data from 24,400,452 subjects, including 1,283,602 with mental disorders.” (!)
- Characteristics: the mean age was >65 years in 15 studies; among people with mental disorders, 68.0% were diagnosed with mood disorders, 21.8% with schizophrenia spectrum disorders, and 10.2% with other mental disorders. In terms of geography, most studies were from North America (26); 16 studies were from Europe, 4 from Asia, and 1 from Australia.
- Lower rates of screening or treatment in patients with mental disorders emerged for any CVD (odds ratio=0.773), coronary artery disease (0.734), cerebrovascular disease (0.810), and other mixed CVDs (0.839).
- “Significant disparities emerged for any screening, any intervention, catheterization or revascularization in coronary artery disease, intravenous thrombolysis for stroke, and treatment with any and with specific medications for CVD across all mental disorders (except for CVD medications in mood disorders).” See figure below.
A few thoughts:
- This is a good study.
- The core finding: “The results indicate that people with mental disorders suffer from significantly lower screening for or treatment of any CVD, CAD, CBVD, and other CVD, including heart failure, and that these disadvantages extend across different mental disorders, being highest in people with schizophrenia spectrum disorders.”
- The surprise would be if anyone is be surprised by the findings.
- Why the discrepancy? Stigma is not confined to one country, alas. The authors offer several other explanations, and do criticize those in mental health. “Mental health professionals reportedly undertake physical examinations in less than 50% of people with mental disorders…” As well, “mental health professionals often do not feel confident in prescribing physical health medications and leave the task to physicians in primary care, internal medicine, or specific medical specialties.”
- Like all studies, there are limitations. The authors note several. “Observational studies are affected by several types of bias, which even high-quality meta-analytic methodology can only partially address…”
- It should also be noted that low- and middle-income nations were underrepresented. In other words, the study likely understates the care gap.
- To be clear: the data from high-income nations is hardly encouraging. Focusing on Canada, for example: Kurdyak et al. found that people with schizophrenia were 56% more likely to die after discharge from hospital following an MI than those who did not have schizophrenia, but they were half as likely to receive cardiac procedures and care from cardiologists. That paper can be found here:
- Clinical implications? Whether we are involved in primary care or specialty care, we need to be mindful of patient needs – not just mental health needs.
The full American Journal of Psychiatry paper can be found here:
Selection 2: “Addressing Structural Racism and Inequities in Depression Care”
Nathalie Moise and Sidney Hankerson
JAMA Psychiatry, 21 July 2021 Online First
Racial disparities in depression treatment are well documented, with Black adults experiencing greater illness burden and more severe symptoms yet lower treatment rates compared with White adults. We posit racism is a fundamental driver of these disparities. Indeed, the American Psychiatric Association recently issued a formal apology for its support of structural racism. Despite increased awareness of racial injustice, theoretically informed recommendations to curtail racism’s effect on depression are limited.
In her seminal work, Camara Jones, MD, MPH, PhD, provides a theoretical framework that describes 3 levels of racism: (1) institutionalized (structural) racism represents differential access to goods, services (including health care), and opportunities of society by race; (2) individual or personally mediated racism is prejudice and discrimination based on race; and (3) internalized racism is negative emotional sequalae among stigmatized racial groups associated with acceptance of negative messages about their intrinsic worth and abilities.
So begins a paper by Drs. Moise and Hankerson.
The authors focus on a clinical vignette. They write about Ms Smith who “is a 65-year-old, single, employed, college-educated Black woman with a history of diabetes, hypertension, and depression.” It notes a childhood influenced by her mother’s depressive episodes. But it pushes past the genetic ties, and considers each depressive episode in the context of psychosocial (and societal) stresses.
The first depressive episode: “Ms Smith’s first depressive episode occurred after college and was linked to feelings of diminished self-worth after transitioning from a stellar academic career with strong social ties (including a Black sorority) to difficulty finding employment, which she attributed to a television industry dominated by White men.”
The second episode: “While working full time, she developed recurrent depressive episodes that she partially linked to discriminatory interactions with White colleagues and doubts about her own productivity.”
A relapse decades later: “Ms Smith lost her job following industry changes. Her depressive symptoms returned in the context of financial strains.”
Finally, she has a fourth episode: “In summer 2020, Ms Smith was emotionally triggered by widespread coverage of racial injustices (eg, the murder of George Floyd) and the disproportionate toll COVID-19 inflicted on Black individuals in the US. Her primary care clinician screened her for depression, and for the first time, she endorsed suicidal ideation. After scoring 24 on the Patient Health Questionnaire-9, she received a ‘warm handoff’ introduction to a social worker counselor onsite for problem-solving therapy who connected her to rent assistance programs. Despite long-standing wariness, she started taking an antidepressant.”
The authors note the three levels of racism and make recommendations:
Addressing Institutionalized (Structural) Racism
“Ms Smith’s case highlights mental health stressors from the racist federal policy of redlining, introduced in the 1930s by the Home Owners’ Loan Corporation color-coded maps that encouraged housing mortgage lending in predominantly White areas and discouraged lending in mostly Black areas, contributing to structural neglect, lack of green spaces, and limited access to quality education and health care for Black families.”
They make several recommendations. We highlight two here: “First, clinicians, policy makers, and researchers should collaborate to advocate for policies related to fair housing practices, criminal justice reform, and income equality (eg, increased minimum wage) and assess their effect on depression outcomes. Second, routine screening for social determinants of health in clinical settings, while necessary, is insufficient.”
Addressing Individual or Personally Mediated Racism
“We must acknowledge that physicians can commit racist acts and may be experienced at committing racist acts. Examining one’s own implicit biases and racial privilege is crucial to addressing personally mediated racism.”
They recommend: “(1) building awareness of racial issues, (2) adapting assessments to Black individuals, (3) having a humanistic approach to medication…”
Addressing Internalized Racism
They note: “the vignette highlights how diminished self-worth due to racism contributes to depression.” They then recommend: “As health care professionals, we need to identify and explore internalized racism in patients’ presentations.”
A few thoughts:
- This is a thoughtful paper.
- The recommendations are practical.
- To circle back to their biggest recommendation: they see a need for those in mental health to advocate more in the public policy sphere. Our job includes caring for some of society’s most vulnerable; they argue that we should be involved in the larger economic and social debates.
- This position isn’t without controversy. In a past Reading, we considered an essay by the University of Pennsylvania’s Dr. Stanley Goldfarb – a former associate dean of curriculum at the Perelman School of Medicine – who argues against this idea, especially in medical education. “Curricula will increasingly focus on climate change, social inequities, gun violence, bias and other progressive causes only tangentially related to treating illness.” In response in another Reading, Dr. Juveria Zaheer (of the University of Toronto) writes: “Being a medical expert or a physician scientist isn’t just about learning about biology – it’s about committing to the creation of a society where every life is worth living.” Here are links to those Readings:
The full JAMA Psychiatry paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.