Call for action to address premature mortality due to physical illness in individuals with severe mental disorders

IF 5.3 2区 医学 Q1 PSYCHIATRY Acta Psychiatrica Scandinavica Pub Date : 2024-06-24 DOI:10.1111/acps.13722
Laurent Boyer, Pierre-Michel Llorca, Guillaume Fond
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Individuals with SMI die up to 15 years earlier than the general population, and around 70% of this mortality gap is due to physical disorders.<span><sup>2</sup></span> Increased risk of physical disorders in those with mental disorders is due to reduced access to adequate physical health monitoring, care and prevention,<span><sup>3-5</sup></span> increased risk of adverse health behaviors<span><sup>6</sup></span> such as sedentary behavior, poor diet, and smoking, comorbid substance abuse, and side effects of psychiatric medications.<span><sup>7</sup></span></p><p>Despite the availability of clinical practice guidelines and evidence-based interventions aimed at reducing excess mortality rates due to physical comorbidities in persons with SMI, the problem still persists. There is a crucial need to better understand how to implement clinical practice guidelines and evidence-based interventions successfully in the real world. Individuals with comorbid mental and physical disorders face specific challenges in service organization, requiring complex treatment and intense resource utilization.<span><sup>8</sup></span> The management of multimorbidity is recognized to be complex, with a high treatment burden in terms of understanding and self-managing the conditions, attending multiple appointments, and managing complex drug regimens.<span><sup>9</sup></span> Evidence suggests that a key part of the problem is the lack of integration of care across service settings. There is major fragmentation in how care is coordinated between family doctors and hospitals, between physical and mental health care, and across health and social care. As proposed by Tapio Paljärvi et al.<span><sup>1</sup></span> and other authors,<span><sup>10</sup></span> person-centered and integrated care models are a critical step to support effective implementation approaches to translate evidence into practice.</p><p>However, despite local and innovative experiences in several countries, the large-scale implementation of integrated care models faces numerous barriers and conservatisms. These obstacles hinder progress and maintain the status quo, perpetuating major health inequalities in individuals with SMI. A call for action in Europe, similar to initiatives already established in the United States,<span><sup>11</sup></span> is necessary. Currently, there are two main types of integrated care models: those based in primary care and those based in specialty mental health care. These models appear to address different populations—with the former primarily targeting common mental disorders such as anxiety and mild or moderate depression, while the latter focuses on individuals with SMI. This distribution results from the current organization of our healthcare system. Individuals with SMI often do not access primary care services as readily as those with anxiety and mild depression, who have better access to primary care. Both models improve the quality of care including prevention, physical screening, and follow-up. However, improvements in clinical outcomes are less evident, likely due to the unrealistic expectation of rapidly modifying outcomes when health is influenced by long-lasting determinants acting over many years. The absence of impact on outcomes should not undermine these initiatives; they represent an initial attempt at addressing the issue and remind us that integrated care must imperatively consider all determinants of health. This underscores the need for a comprehensive approach that includes social drivers of health.<span><sup>12</sup></span></p><p>We propose a five-step approach to break this deadlock.</p><p>First, filling the knowledge gap at the European level: conducting transnational analyses of nationwide databases to better understand all-cause and cause-specific mortality, as reported in the work of Paljärvi et al.,<span><sup>1</sup></span> but also healthcare utilization patterns and their impact on the health outcomes of people with severe mental disorders. This includes addressing the lack of analysis on longitudinal healthcare utilization patterns, utilizing multidimensional trajectory analysis<span><sup>13</sup></span> that combines physical and mental care, to learn from each other's successes and failures.</p><p>Second, conducting an updated review of all the integrated care models, including their components, settings, and types of evidence available, based on the literature and local experiences. Special attention should be paid to new technologies and the sustainability/environmental impact of the integrated care models.<span><sup>14</sup></span> This second step aims to identify the key ingredients for achieving maximum effect within each model and determine the best organization in the context of a constrained healthcare workforce.<span><sup>15</sup></span></p><p>Third, addressing political challenges that go beyond efficacy and mere reorganization. This involves questioning the roles, positions, and powers of the organizations and actors involved. For example, in France, the presence of nurse practitioners and lay workers is not always accepted by physicians, and the role of community care is not widely recognized by all stakeholders. The question of whether integrated care models should be based on primary care and/or specialty mental health care can also be a significant source of tension. A European consensus from a Delphi panel—including patients, caregivers, healthcare professionals, and policymakers—about which integrated care models are most acceptable and promising is essential. The involvement of users is indispensable at this stage to ensure that the chosen solutions meet their needs.</p><p>Fourth, achieving this consensus should lead to addressing the financing of key elements crucial for the success of these new models, such as prevention, addressing social drivers of health, the critical role of coordination, developing robust information systems, and community support, and so on. This includes societal knowledge, attitudes, practices, willingness to pay, and the financial impact of implementing an integrated care model. 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The collaboration of patients, healthcare professionals, policymakers, and citizens across Europe will be critical in achieving this goal.</p><p>None.</p><p>The authors declare no conflict of interest.</p>","PeriodicalId":108,"journal":{"name":"Acta Psychiatrica Scandinavica","volume":null,"pages":null},"PeriodicalIF":5.3000,"publicationDate":"2024-06-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/acps.13722","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Acta Psychiatrica Scandinavica","FirstCategoryId":"3","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1111/acps.13722","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"PSYCHIATRY","Score":null,"Total":0}
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Abstract

The study conducted by Tapio Paljärvi et al., titled “Cardiovascular mortality in bipolar disorder: population-based cohort study,” sheds crucial light on the alarming rates of cardiovascular disease mortality among individuals with bipolar disorder.1 The findings underscore a significant excess in mortality due to various cardiovascular causes, including coronary artery disease, cardiomyopathy, and hypertensive heart disease. This issue is part of a larger problem for people with severe mental illnesses (SMI), such as schizophrenia, bipolar disorders, and major depressive disorders. Individuals with SMI die up to 15 years earlier than the general population, and around 70% of this mortality gap is due to physical disorders.2 Increased risk of physical disorders in those with mental disorders is due to reduced access to adequate physical health monitoring, care and prevention,3-5 increased risk of adverse health behaviors6 such as sedentary behavior, poor diet, and smoking, comorbid substance abuse, and side effects of psychiatric medications.7

Despite the availability of clinical practice guidelines and evidence-based interventions aimed at reducing excess mortality rates due to physical comorbidities in persons with SMI, the problem still persists. There is a crucial need to better understand how to implement clinical practice guidelines and evidence-based interventions successfully in the real world. Individuals with comorbid mental and physical disorders face specific challenges in service organization, requiring complex treatment and intense resource utilization.8 The management of multimorbidity is recognized to be complex, with a high treatment burden in terms of understanding and self-managing the conditions, attending multiple appointments, and managing complex drug regimens.9 Evidence suggests that a key part of the problem is the lack of integration of care across service settings. There is major fragmentation in how care is coordinated between family doctors and hospitals, between physical and mental health care, and across health and social care. As proposed by Tapio Paljärvi et al.1 and other authors,10 person-centered and integrated care models are a critical step to support effective implementation approaches to translate evidence into practice.

However, despite local and innovative experiences in several countries, the large-scale implementation of integrated care models faces numerous barriers and conservatisms. These obstacles hinder progress and maintain the status quo, perpetuating major health inequalities in individuals with SMI. A call for action in Europe, similar to initiatives already established in the United States,11 is necessary. Currently, there are two main types of integrated care models: those based in primary care and those based in specialty mental health care. These models appear to address different populations—with the former primarily targeting common mental disorders such as anxiety and mild or moderate depression, while the latter focuses on individuals with SMI. This distribution results from the current organization of our healthcare system. Individuals with SMI often do not access primary care services as readily as those with anxiety and mild depression, who have better access to primary care. Both models improve the quality of care including prevention, physical screening, and follow-up. However, improvements in clinical outcomes are less evident, likely due to the unrealistic expectation of rapidly modifying outcomes when health is influenced by long-lasting determinants acting over many years. The absence of impact on outcomes should not undermine these initiatives; they represent an initial attempt at addressing the issue and remind us that integrated care must imperatively consider all determinants of health. This underscores the need for a comprehensive approach that includes social drivers of health.12

We propose a five-step approach to break this deadlock.

First, filling the knowledge gap at the European level: conducting transnational analyses of nationwide databases to better understand all-cause and cause-specific mortality, as reported in the work of Paljärvi et al.,1 but also healthcare utilization patterns and their impact on the health outcomes of people with severe mental disorders. This includes addressing the lack of analysis on longitudinal healthcare utilization patterns, utilizing multidimensional trajectory analysis13 that combines physical and mental care, to learn from each other's successes and failures.

Second, conducting an updated review of all the integrated care models, including their components, settings, and types of evidence available, based on the literature and local experiences. Special attention should be paid to new technologies and the sustainability/environmental impact of the integrated care models.14 This second step aims to identify the key ingredients for achieving maximum effect within each model and determine the best organization in the context of a constrained healthcare workforce.15

Third, addressing political challenges that go beyond efficacy and mere reorganization. This involves questioning the roles, positions, and powers of the organizations and actors involved. For example, in France, the presence of nurse practitioners and lay workers is not always accepted by physicians, and the role of community care is not widely recognized by all stakeholders. The question of whether integrated care models should be based on primary care and/or specialty mental health care can also be a significant source of tension. A European consensus from a Delphi panel—including patients, caregivers, healthcare professionals, and policymakers—about which integrated care models are most acceptable and promising is essential. The involvement of users is indispensable at this stage to ensure that the chosen solutions meet their needs.

Fourth, achieving this consensus should lead to addressing the financing of key elements crucial for the success of these new models, such as prevention, addressing social drivers of health, the critical role of coordination, developing robust information systems, and community support, and so on. This includes societal knowledge, attitudes, practices, willingness to pay, and the financial impact of implementing an integrated care model. These findings will inform key stakeholders that European citizens are aware of the issue of excess mortality and injustice faced by patients with SMI and that scaling up integrated models across Europe is both feasible and likely to have public support.

Finally, research should also provide insights into the practicality and sustainability of the integrated model of care in real-world settings, following recommendations for transforming mental health implementation research to produce more actionable evidence to narrow the mental health implementation gap.16

Through this comprehensive approach, we can pave the way for more effective, person-centered care for individuals with comorbid SMI and physical disorders. The collaboration of patients, healthcare professionals, policymakers, and citizens across Europe will be critical in achieving this goal.

None.

The authors declare no conflict of interest.

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呼吁采取行动,解决严重精神障碍患者因身体疾病过早死亡的问题。
塔皮奥-帕尔耶尔维(Tapio Paljärvi)等人进行的一项名为 "双相情感障碍患者的心血管疾病死亡率:基于人群的队列研究 "的研究,揭示了双相情感障碍患者心血管疾病死亡率的惊人比率。这个问题是严重精神疾病(SMI)患者(如精神分裂症、双相情感障碍和重度抑郁症)更大问题的一部分。2 精神障碍患者罹患躯体疾病的风险增加是由于获得充分的躯体健康监测、护理和预防的机会减少,3-5 不良健康行为6 的风险增加,如久坐不动、不良饮食习惯、吸烟、合并药物滥用以及精神科药物的副作用等。尽管有临床实践指南和循证干预措施来降低 SMI 患者因身体合并症而导致的超额死亡率,但这一问题仍然存在。我们亟需更好地了解如何在现实世界中成功实施临床实践指南和循证干预措施。8 多病共存的管理被认为是复杂的,在理解和自我管理病情、多次就诊和管理复杂的药物疗程方面,治疗负担很重。9 有证据表明,问题的关键在于缺乏跨服务环境的整合护理。家庭医生和医院之间、身体和精神健康护理之间以及健康和社会护理之间的护理协调非常分散。正如 Tapio Paljärvi 等人1 和其他作者10 所提出的,以人为本的综合护理模式是支持有效实施方法的关键步骤,以将证据转化为实践。然而,尽管在一些国家有地方性的创新经验,但大规模实施综合护理模式仍面临许多障碍和保守主义。这些障碍阻碍了进展,维持了现状,使 SMI 患者在健康方面的重大不平等现象长期存在。有必要在欧洲呼吁采取行动,类似于美国已经采取的行动11。目前,主要有两种综合护理模式:基于初级保健的模式和基于专科精神保健的模式。这些模式似乎针对不同的人群--前者主要针对常见的精神障碍,如焦虑和轻度或中度抑郁,而后者则主要针对 SMI 患者。这种分布源于我们目前的医疗保健系统的组织结构。患有 SMI 的患者通常无法像焦虑症和轻度抑郁症患者那样方便地获得初级医疗服务,而后者则更容易获得初级医疗服务。这两种模式都能提高医疗质量,包括预防、体检和随访。然而,临床结果的改善却不那么明显,这可能是由于健康受到多年来长期起作用的决定因素的影响,而期望迅速改变结果是不现实的。对结果缺乏影响不应削弱这些举措;它们代表了解决这一问题的初步尝试,并提醒我们综合护理必须考虑健康的所有决定因素。首先,填补欧洲层面的知识空白:对全国性数据库进行跨国分析,以更好地了解全因死亡率和特定原因死亡率(如 Paljärvi 等人的研究报告1 所述),以及医疗保健的使用模式及其对严重精神障碍患者健康结果的影响。这包括解决缺乏对纵向医疗保健利用模式分析的问题,利用多维轨迹分析13,将身体和精神护理结合起来,从彼此的成功和失败中吸取经验教训。其次,根据文献和当地经验,对所有的综合护理模式进行最新审查,包括其组成部分、环境和可用证据类型。应特别关注新技术和综合护理模式的可持续性/环境影响。 14 第二步的目的是确定在每种模式下取得最大效果的关键因素,并在医疗保健人员有限的情况下确定最佳的组织方式。15 第三步,应对超越效率和单纯重组的政治挑战。这涉及到对相关组织和行动者的角色、地位和权力的质疑。例如,在法国,执业护士和非专业工作者的存在并不总是被医生所接受,社区医疗的作用也没有得到所有利益相关者的广泛认可。综合医疗模式是否应建立在初级医疗和/或专科心理健康医疗的基础上,这个问题也是造成紧张关系的一个重要原因。由德尔菲小组(包括患者、护理人员、医疗保健专业人员和政策制定者)就哪些综合护理模式最容易接受、最有前景达成欧洲共识是至关重要的。第四,达成这一共识应导致解决对这些新模式的成功至关重要的关键因素的融资问题,如预防、解决健康的社会驱动因素、协调的关键作用、开发强大的信息系统以及社区支持等。这包括社会知识、态度、实践、支付意愿以及实施综合医疗模式的财务影响。这些研究结果将告知主要的利益相关者,欧洲公民已经意识到 SMI 患者死亡率过高和面临不公正待遇的问题,在欧洲范围内推广综合模式是可行的,也很可能会得到公众的支持。最后,研究还应该深入探讨综合护理模式在现实环境中的实用性和可持续性,遵循精神健康实施研究转型的建议,提供更多可操作的证据,以缩小精神健康实施方面的差距。通过这种综合的方法,我们可以为患有 SMI 和躯体疾病的人提供更有效的、以人为本的护理。在实现这一目标的过程中,患者、医疗保健专业人员、政策制定者和欧洲各国公民的合作至关重要。
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来源期刊
Acta Psychiatrica Scandinavica
Acta Psychiatrica Scandinavica 医学-精神病学
CiteScore
11.20
自引率
3.00%
发文量
135
审稿时长
6-12 weeks
期刊介绍: Acta Psychiatrica Scandinavica acts as an international forum for the dissemination of information advancing the science and practice of psychiatry. In particular we focus on communicating frontline research to clinical psychiatrists and psychiatric researchers. Acta Psychiatrica Scandinavica has traditionally been and remains a journal focusing predominantly on clinical psychiatry, but translational psychiatry is a topic of growing importance to our readers. Therefore, the journal welcomes submission of manuscripts based on both clinical- and more translational (e.g. preclinical and epidemiological) research. When preparing manuscripts based on translational studies for submission to Acta Psychiatrica Scandinavica, the authors should place emphasis on the clinical significance of the research question and the findings. Manuscripts based solely on preclinical research (e.g. animal models) are normally not considered for publication in the Journal.
期刊最新文献
Issue Information Variation of subclinical psychosis as a function of population density across different European settings: Findings from the multi-national EU-GEI study. Risk and timing of postpartum depression in parents of twins compared to parents of singletons. Digital phenotyping in bipolar disorder: Using longitudinal Fitbit data and personalized machine learning to predict mood symptomatology. The risk of diabetes and HbA1c deterioration during antipsychotic drug treatment: A Danish two-cohort study among patients with first-episode schizophrenia.
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