The increased frequency of cardiovascular risk factors (CVRFs) in bipolar disorder, depression and schizophrenia are significant contributors to the increased morbidity and mortality experienced by these patients, in part due to poor management of these CVRFs (Viron and Stern, 2010; Kaufman et al, 2012).
However, despite a wealth of evidence, it remains unclear at which stage of the care pathway (screening, diagnosis or management), these inadequacies take place. Despite previous reviews on the subject, it remains difficult for clinicians and policy makers to design effective, evidence-based interventions to reduce the morbidity and mortality associated with CVRFs.
This blog summarises a systematic review that aimed to test the hypothesis that patients with specific psychiatric disorders experience inferior care for different CVRFs (Ayerbe et al, 2018) and in doing so highlight areas that could be the target of future therapeutic interventions.
The literature search conducted for this systematic review included articles up to January 2017 in the electronic databases PubMed, PsycINFO, EMBASE, Scopus and Web of Science. No restrictions were placed on year of publication, geographical location, language, sample size or duration of follow up.
Included studies reported data on differences in rates of screening, diagnosis, follow-up, treatment or control of smoking habit, diabetes, hypertension or dyslipidaemia for patients with depression, anxiety, schizophrenia, bipolar or personality disorder.
16,101 studies were identified, full text articles were retrieved for 165 articles of which 20 studies were eligible for inclusion.
- 8 studies, including 9,835 participants used smoking habit as an outcome
- The proportion of patients who quit smoking was lower in people with depression
- Patients with schizophrenia were less likely to have their smoking habit recorded in their notes.
- 5 studies, including 20,661 participants used management of Type 2 Diabetes (T2DM) as an outcome
- Studies showed that control of T2DM as measured by HbA1c was poorer in patients with depression.
- 7 studies, including 1,296,899 participants used management of hypertension as an outcome
- Patients with depression and anxiety were less likely to have a diagnosis of hypertension even after two high blood pressure readings
- Patients with depression were less likely to receive hypertension treatment
- Patients with schizophrenia were less likely to have their blood pressure recorded or use anti-hypertensives
- Use of anti-hypertensive agents varied in patients with bipolar disorder.
- 3 studies, including 1,073,032 participants used management of dyslipidaemia as an outcome
- Cholesterol was less likely to be recorded in patients with schizophrenia
- Patients with schizophrenia and bipolar disorder were less likely to be using lipid lowering drugs.
The purpose of this study was to highlight the disparities in the management of common CVRFs in patients with a variety of psychiatric disorders compared to those without. Using data from 20 high quality studies Ayerbe et al (2018) identified many inadequacies in the care pathway of CVRFs in patients with psychiatric disorders. Many reasons have been suggested as to why these discrepancies in care exist:
- Psychiatric disorders themselves can disrupt health seeking behaviours, affect communication and interfere with treatment adherence (Viron and Stern, 2010)
- Medications used to treat psychiatric disorders can directly influence CVRFs, with antidepressants and antipsychotics linked to increased risk of CVRFs (Correll et al, 2015; Perez-Pinar et al, 2016; Salvi et al 2017)
- The stigma associated with psychiatric disorders is also a barrier, with patients with psychiatric disorders reporting that their physical symptoms are treated less seriously by clinicians (Viron et al, 2012)
- The separation of physical and mental healthcare provides challenges to coordination of care and financial barriers to care may exist (Viron and Stern, 2010; Kaufman et al, 2012).
All these factors need to be addressed to develop targeted interventions to improve the treatment of CVRFs across the care pathway in patients with psychiatric disorders. Better screening needs to be accompanied with improvements in both diagnosis and management to reduce morbidity and mortality among patients with psychiatric disorders.
Strengths and limitations
The results of this study clearly show multiple areas where the care of CVRFs is inadequate in patients with psychiatric disorders. While the authors conducted a robust review and meta-analysis using validated tools to assess the data in the included studies, there are some limitations of this study.
Only one author screened the initial list of references and as studies were only included if psychiatric disorders were presented categorially, there is the possibility that large population based studies using continuous measures of assessment or overlapping symptomatology (e.g. psychosis), may have been missed. Studies may also have been missed due to the standard terms used for searching.
Only 20 studies were included in the final analysis, meaning that the effects of publication bias could not be assessed in such a small sample. However, despite the small number of studies, for the outcome measures the number of participants was large, giving greater confidence in the interpretation of the data.
Another issue with this study was the lack of studies identified that related to CVRFs in anxiety, bipolar or personality disorders, making it difficult to comment on many aspects of care in these patients. Certainly, a lack of evidence in these areas is an issue but the restrictive search strategies employed in this study may have contributed to this.
- Data from this systematic review and meta-analysis showed that there were inequalities relating to physical health screening, diagnosis and management in patients with psychiatric disorders
- This study showed that patients with depression are less likely to give up smoking and have poorer control of their Type 2 diabetes
- A diagnosis of hypertension is less likely if you have depression, anxiety or schizophrenia and there are differences in the medications given to manage hypertension in patients with schizophrenia and bipolar disorder
- Clinicians and policy makers should utilise the findings from this study and others to develop targeted interventions to address deficiencies in the care of CVRFs that occur throughout the care pathway
- More studies are needed to understand where and why the differences in healthcare happen for patients with psychiatric disorders
- More research is needed to identify the differences in care experienced by patients with anxiety, bipolar and personality disorders, where there is limited and low-quality evidence.
Ayerbe L, Forgnone I, Foguet-Boreu Q et al (2018) Disparities in the management of cardiovascular risk factors in patients with psychiatric disorders: a systematic review and meta-analysis. Psychol Med. 2018 Mar 1:1-9. [PubMed Abstract]
Correll CU, Detraux J, De Lepeleire J et al (2015) Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder (PDF). World Psychiatry 14, 119–136.
Hjorthøj C, Stürup AE, McGrath JJ et al (2017). Years of potential life lost and life expectancy in schizophrenia: a systematic review and meta-analysis. Lancet Psychiatry. 2017 Apr;4(4):295-301. [Free Access]
Kaufman EA, McDonell MG, Cristofalo MA et al (2012) Exploring barriers to primary care for patients with severe mental illness: frontline patient and provider accounts. Issues on Mental Health Nursing 33, 172–180. [PubMed Abstract]
Perez-Pinar M, Mathur R, Foguet Q, Ayis S et al (2016) Cardiovascular risk factors among patients with schizophrenia, bipolar, depressive, anxiety, and personality disorders. European Psychiatry 35, 8–15. [PubMed Abstract]
Salvi V, Grua I, Cerveri G, Mencacci C and Barone-Adesi F (2017) The risk of new-onset diabetes in antidepressant users – A systematic review and meta-analysis (PDF). PLoS ONE 12(7)
Viron MJ, and Stern TA (2010) The impact of serious mental illness on health and healthcare. Psychosomatics 51, 458–465. [PubMed Abstract]
Viron M, Baggett T, Hill M et al (2012) Schizophrenia for primary care providers: how to contribute to the care of a vulnerable patient population. American Journal of Medicine 125, 223–230. [PubMed Abstract]