Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning Tuesday 24 June 2014: 15 Hatfields, Chadwick Court, London

1. 1
Respiratory Disease in
Mental Illness
Dr Vincent Mak
Consultant Physician in Respiratory Integrated Care
Imperial College Healthcare and Central London Community
Healthcare NHS Trust
NHS England (London) Respiratory Clinical Leadership Group
Clinical Director Outer NW London Integrated care Programme
London
June 2014

2. Why does respiratory disease
matter in people with mental
illnesses?
‘People with mental health problems
… die on average 16-25 years sooner
than the general population.
… have higher rates of respiratory,
cardiovascular & infectious disease...’

3. Outcomes for people with mental
illness and COPD
Population 5 year COPD mortality
Schizophrenia 28%
Bipolar disease 19%
Age adjusted population 12%
Five year mortality for respiratory disease much higher in
people with mental illness
At least 1 in 4 deaths in people with mental illnesses due to
respiratory disease
Hippisley-Cox J et al . Health outcomes for patients with serious mental health problems: 2nd report to the DRC 2006
Joukamaa et al British Journal of Psychiatry 2006:188;122-127, Jones D et al Psychiatric Services 2004;55:1250-1257
www.rcpsych.ac.uk/pdf/No%20Health%20-%20%20the%20evidence_%20revised%20May%2010.pdf

4. Severe Emphysema

5. COPD – an umbrella term covering the
“irreversible” aspect of chronic
bronchitis, emphysema and asthma
Emphysema
Airway
obstruction
Chronic severe asthma
Chronic
bronchitis
COPD
(shaded area)

6. Do we diagnose COPD in
people with mental illnesses?
• ‘Spirometry done less often in
people with mental illness
• Less likely to have diagnosis
based on spirometry ….’

7. Diagnosed COPD prevalence in people
with serious mental illness (SMI)
Himelhoch S, Lehman A, Kreyenbuhl J et al. Am J Psychiatry 2004;161:2317-2319 0
200 out-patients with SMI
• 60% current smokers (mean age 44)
• 23% COPD prevalence (self-reported)
• Only 36% reported having COPD treatment
147 Medicaid patients with SMI
• 31% COPD prevalence; 50% as co-morbidity
• Annual costs for SMI and COPD were 4 x higher
• 45% (5/11) deaths due to respiratory disease
Jones DR, Macias C, Barreira PJ et al Psychiatric Services 2004;55:1250-1257
Average England QOF prevalence for COPD = ∼1%

9. COPD and smoking
Fletcher and Peto British Medical Journal 1977

10. Value Framework
Health
Outcomes
Patient defined
bundle of care
CostValue
=
Health Outcomes
Cost of delivering
Outcomes
Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

11. COPD ‘Value’ Pyramid
What we know…. Cost/QALY
Triple Therapy
£35,000-
£187,000/QALY
Long term Oxygen
£16000/QALY
LABA
£8,000/QALY
Tiotropium
£7,000/QALY
Pulmonary Rehabilitation
£2,000-8,000/QALY
Stop Smoking Support with
pharmacotherapy £2,000/QALY
Flu vaccination £1,000/QALY in “at risk” population

12. What is high value COPD care in
Psychiatric Settings?
• Look for COPD in smokers
• Ask about breathlessness - requires action
• Is it breathlessness with or without respiratory
failure?
 Need oximeter
Timely diagnosis and evidence-based treatment

13. Undiagnosed
Need respiratory assessment, chest X-ray & spirometry
By:
? GP
? ward team
? liaison physician
Diagnosed COPD
 Quit smoking interventions as treatment
 Access to pulmonary rehabilitation?
What is high value COPD care in
Psychiatric Settings?

14. Does tobacco smoking matter in
people with mental illnesses?
‘Increased smoking is responsible for
most of the excess mortality of people
with severe mental health problems.
Adults with mental health problems ….
smoke 42%* of all tobacco in England.
*not including mental health settings, prisons, homeless or temp housing ….

15. Smoking prevalence & tobacco dependence
in people with mental illnesses
%
Adults
21% smokers
9% heavy
smokers
Inpatients
with serious
mental
illness
People
living
with mental
illnesses
O’Brien et al 2002, Farrell et al 2001
(>20 cigarettes/day)
50%
of smokers
heavy
smokers
30% of smokers
heavy
smokers
High prevalence of severe tobacco
dependence
Very high smoking prevalence
Just like in COPD …

16. Randomised
Clinical Trial
~6000 people
with airway obstruction
over ~15 years
Effect of Smoking Cessation Intervention on
Mortality in COPD
Anthonisen NR, Skeans MA , Wise RA; Manfreda J, Kanner RE & Connett JE for the Lung Health Study Research Group*
Ann Intern Med. 2005;142:233-239.

17. Value of smoking cessation
interventions in COPD
Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH Thorax 2010: 65:711-718
1 year abstinence
%
QALY
£
Usual care 1.4
Minimal counselling 2.6 14,735
Intensive counselling 6 7,149
Intensive counselling +
pharmacotherapy
12.3 2,092

18. Changing how we think about smoking
Tobacco addiction
Sick smokers are admitted to hospitals - acute and psychiatric
Evidence based quit smoking treatment is the most important
treatment for sick smokers:
Behaviour change support and quit smoking medication
‘Smoking kills, stopping works’
Sir Richard Peto 2012

19. Do people with mental illnesses want to
stop smoking?
Clearing the Air. King’s Fund 2006
70% of smokers
want to stop
>50% of smokers
with mental illness
also want to stop

20. So what should we be doing for
smokers with COPD?
‘Offer nicotine replacement therapy,
varenicline or bupropion (unless
contraindicated) combined with a
support programme to optimise quit
rates… to all people with COPD who
still smoke at every opportunity.’
NICE 2010

21. Can people with mental illnesses stop
smoking?
2011
Same treatments for tobacco dependence work as
for anyone else
Treatment does NOT worsen mental state

22. Do people with mental illnesses get evidence-
based quit smoking interventions?
2009 London data Lisa McNally, Smoke Free Minds

23. Beliefs…(Barriers)
(Mental) health professionals attitudes to
smoking
‘Some practitioners expressed doubt about the
value of smoking cessation advice for people
with mental health conditions’.
Physical health professionals attitudes to
psychiatry & people with mental illnesses …

24. Quit smoking as treatment
Sharing respiratory learning
Healthcare Professionals need to believe (from evidence)
that it is their role & responsibility … to refer to quit smoking
services and … to do quit smoking work themselves
Needs leadership and incentives
Make it easy to provide Right care
• Brief interventions
• Knowledge of quit smoking services & referral
• Behaviour change skills
• Prescribing knowledge
• Medications available
• Feedback on outcomes

25. Cannabis smoking and
respiratory health
Is it common? Yes
Does it matter?
‘32% of population believe that smoking cannabis does not harm your health’
British Lung Foundation 2012

26. Cannabis and Lung Damage
British Lung Foundation Reports
2002
2012
www.blf.org.uk/Page/Special-Reports
…there is evidence that
the risk of airway
obstruction increases
with the number of joint-
years…, and of an
increased risk of COPD
from smoking cannabis
with tobacco regularly’.

27. Cannabis smoking & respiratory
disease
 1 in 3 tobacco smokers in a hospital
population also smoke cannabis*
 all groups in society
 have to ask not volunteered….
 History of tobacco and cannabis smoking
 Younger people with severe COPD
 Young people with pneumothorax
 Younger people with lung cancer
*LJ Restrick, EV Cumbus, O Thomas, M Stern,. 2011
European Respiratory Society Congress, Amsterdam
38:776s

28. Cannabis smoking
Emphysema & bullae under 50
47 year old man
20 pack-years
20 joint-years
Severe (upper lobe)
bullous emphysema
Radiology reporting:
‘Does this patient smoke cannabis?
‘Appearance consistent with ‘cannabis lung’’

29. Cannabis smoking and lung cancer
Tunisia, Morocco & Algeria*
Odds Ratio for lung cancer if cannabis user >2
New Zealand** 79 cases lung cancer in under-55s
Risk of lung cancer increased:
8% for each joint-year cannabis smoking
7% for each pack-year cigarette smoking
>5 x Relative Risk with >10 joint-years cannabis
‘5% of lung cancer in those aged <55 years may be
attributable to cannabis smoking.’
*Berthiller et al J Thoracic Oncology 2008
**Aldington et al ERJ 2008:31;280-286
‘Stronger evidence than ever before that smoking cannabis is linked to lung
cancer’.
The impact of cannabis on your lungs. British Lung Foundation 2012

30. Comparing a ‘joint’ with a cigarette
CO (ppm) >20
Heavy smoker
Shisha smoker
Cannabis
smoker
1 pack-year
‘20 cigarettes/day for 1 year’
1 joint-year
‘one joint/day for 1 year’
0.4g cannabis cf 1g tobacco
?equivalence
No filter
Shorter butt
Higher temperature
Deeper inspiration
Breath-hold & Valsalva
5 x tar deposition
3 x carbon monoxide levels

31. Virtual Ward Rounds –
Ealing Forensic Service
• Bi-monthly meeting – Multi-disciplinary
• Consultant psychiatrist, respiratory physician, physical
health nurse, mental health nurse, pharmacist, GP,
smoking cessation team
• Review of respiratory problems of inpatients
• Targetting those who are heavy smokers and who already
use respiratory medications
• High prevalence of ?diagnosis (asthma or COPD)
• High prevalence of ?Obstructive Sleep Apnoea
• Patients rarely get adequate review from existing
secondary care services

32. Mental
Health
Services
Respiratory
& GP
Services
Drug Dependency Services Stop Smoking Services
Addressing unmet needs:
working across ‘silos’