Clinical and Health Affairs
Minnesota 10 By 10
Reducing Morbidity and Mortality in People with Serious Mental Illnesses
By Michael Trangle, M.D., Gary Mager, Paul Goering, M.D., and Rodney Christensen, M.D.
Abstract
Persons with schizophrenia, schizoaffective disorder, and bipolar affective disorder in Minnesota are dying much younger than their age- and sex-matched cohorts. A new initiative, MN 10 By 10, is designed to engage key constituencies in addressing modifiable risk factors in order to lengthen these individuals’ lives.
For nearly a half century, we have been aware of increased mortality rates among people with mental illnesses. Babigian found that the relative risk of dying for anyone with a psychiatric diagnosis in Monroe County, New York, between 1960 and 1968 was two-and-a-half to three times greater than for the general population.1 A 1996 review of 66 papers by Felker et al. found that standardized mortality ratios for psychiatric patients repeatedly exceeded those of the general population and matched controls.2 The most comprehensive data have come from a study by Colton et al., in which mortality rates, years of potential life lost, and causes of death for clients of public mental health programs in eight states were compared with those for the general population. The relative risk of death for people in the public mental health programs was 1.2 to 4.9 times higher than that for the general population in all eight states.3 The potential years of life lost ranged from 13 to more than 30.
The National Association of State Mental Health Program Directors’ 2006 report “Morbidity and Mortality in People with Serious Mental Illness” highlights the fact that people with schizophrenia are 2.3 times more likely to die from cardiovascular disease than people in the general population, 2.7 times more likely to die from diabetes, 3.2 times more likely to die from respiratory disease, and 3.4 times more likely to die of infectious diseases.4 The report states that people with serious mental illnesses die 25 years earlier on average than members of the general population. The report also highlights the fact that the increasing use of second-generation antipsychotic medications, which are associated with weight gain, diabetes, dyslipidemia, insulin resistance, and metabolic syndrome, is adversely affecting lifespan.
To address increasing concern about the wellness of those who suffer from a mental illness, the Center for Mental Health Service of the Substance Abuse and Mental Health Services Administration (SAMHSA) convened more than 90 participants for a summit in September 2007. This group, which included a representative from Minnesota, recommended adopting proven surveillance tools to measure the baseline health of people served by the mental health system and to monitor the future impact of initiatives aimed at reducing their risk factors for chronic illness. They recommended measuring a set of 10 health indicators and two process indicators for all adults with serious mental illnesses served by the mental health system (Table 1). The following year, the group recommended measuring the health status of those individuals. In addition, the group’s members pledged to reduce early mortality by 10 years within 10 years (thus, 10 By 10), their goal being to reduce modifiable risks that can lead to chronic disease.
To launch a 10 By 10 initiative in Minnesota, in 2008 leaders in the psychiatric community formed a work group that included representatives from the Minnesota Department of Human Services, Minnesota Department of Health, health plans, hospitals, and medical groups as well as consumers. The work group committed itself to analyzing Minnesota data, selecting a subset of the health and process measures to implement, engaging all relevant constituencies, and transforming care in hope of achieving measurable improvement in risk factors and lifespan. This article describes the group’s efforts and findings.
Lifespan Data Analysis
The Minnesota group’s first effort was to accurately determine the extent of the disparity between the lifespans of people with serious mental illnesses (defined as schizophrenia, schizoaffective disorder, and bipolar affective disorder), and the general population.
■ Methodology
Death certificates for all adults who died between 2003 and 2007 were analyzed in conjunction with the Minnesota Department of Human Services’ Minnesota health care programs (MHCP) records. The MHCP records included those of people who had health care coverage through fee-for-service Medical Assistance, the Prepaid Medical Assistance Program, General Assistance Medical Care, and MinnesotaCare.
Of the 182,567 death records analyzed, 60,588 were from people enrolled in one of the MHCPs for one or more months during the 36-month period preceding their death. For 2,206 of the people in the analysis, the MHCP had paid one or more claims for a mental health service related to a diagnosis of schizophrenia, schizoaffective disorder, or bipolar affective disorder. Those services included inpatient psychiatric care, medication management, mental health outpatient clinical services, mental health targeted case management, and mental health rehabilitative services.
For the analysis, three populations were identified: the population at large, which included all adults; the covered population, which refers to persons enrolled for one month or more in a MHCP plan during the 36 months prior to their death; and the MHCP population with serious mental illnesses, which included persons in the covered population for whom a claim for a mental health service related to a diagnosis of schizophrenia, schizoaffective disorder, or bipolar affective disorder had been paid. Analysis included comparisons of the three populations by gender and by cause of death. Results were reported as age at death in addition to the average age of death.
■ Results
Consistent with the findings in other states, people with serious mental illnesses in Minnesota die much earlier than the general population on average. The median age at death for the general MHCP population was 82 years. The median age of death for people on MHCP plans with serious mental illnesses was 58. Our results showed the trend was consistent regardless of the patient’s gender (Table 2).
Heart disease was the No 1. cause of death among both the general population and persons with a serious mental illness. Those with serious mental illnesses who died of heart-related causes died 27 years earlier on average than members of the general population who died of heart disease (Table 3).
What surprised our work group was the fact that persons with bipolar affective disorder and schizoaffective disorder die significantly younger than those with schizophrenia alone; the median age of death for those with bipolar affective disorder and schizoaffective disorder was 51; for those with schizophrenia it was 62 (Table 4).
Addressing the Problem: the MN 10 BY 10 Initiative
The Minnesota 10 By 10 group has made its own commitment to lengthening the lifespan of people with serious mental illnesses by 10 years within 10 years. The goal is to increase the median age at death from 58 years to 68 years. In order to work toward that goal, the group thus far has chosen to focus on a subset of the SAMHSA measures (BMI, alcohol and tobacco use, blood pressure, LDL cholesterol, and blood sugar) (Table 5). We believe that making improvements in these measures could go a long way toward increasing the lifespans of people with serious mental illnesses.
The group also has worked to increase awareness of the fact that people with serious mental illnesses die younger from preventable chronic illnesses than the general population. Group members have given presentations and facilitated discussions about this at conferences and meetings with social workers, marriage therapists, psychologists, psychiatrists, primary care physicians, county case managers, health plan case managers, chemical dependency counselors, staff from community mental health centers and group homes, and to members of the Minnesota Psychiatric Society and the Minnesota Medical Association. The Minnesota Department of Human Services plans to use claims to measure the percentage of this population who see primary care physicians annually and bill for appropriate labs. In addition, a large health plan has chosen to have their case and disease managers work with this population to increase the percentage who see their primary care physicians annually. Eventually, they hope to measure how many of these patients have their risk factors addressed. Another large health plan will start performing chart audits to look at whether people with serious mental illnesses annually visit their primary care physicians and whether they are at risk for chronic illness. The Minnesota Department of Health is including representatives from the MN 10 By 10 group on a committee working on prevention of cardiovascular disease and stroke and a committee focusing on diabetes prevention.
In addition, the MN 10 By 10 group has created a downloadable form that lists key health measures that primary care physicians should monitor. The form and instructions for using it are available at www.dhs.state.mn.us/mn10x10. Thus far, several advocacy groups have linked to it on their websites in order to allow patients and their families to download and use it during primary care clinic visits.
Discussion
Many of the proximal causes of death in people with serious mental illnesses are the result of diseases that have modifiable risk factors. These are also conditions that primary care providers are well-versed in treating. Yet, caring for patients with serious mental illnesses presents unique challenges to the health care system and to society in general. It is not unusual for people with these illnesses to be homeless, incompetent, and uninsured. Thus, caring for this population requires the coordinated efforts of people from many sectors and disciplines.
The psychiatric community, for example, needs to take responsibility for knowing more about the health impacts of atypical antipsychotics and using these drugs judiciously; educating patients and families about the importance of a good diet and daily exercise; understanding the relative risks of antipsychotic medications; and monitoring patients for worsening health indicators such as body mass index, blood cholesterol levels, glycemic levels, and blood pressure. Psychiatrists should help patients avoid or stop using tobacco and alcohol. Health plan case managers need to be trained so that they too can help patients understand how their medications and their lifestyles might affect their health. They also need to make sure that these patients are regularly seen by their primary care providers. In addition, members of intensive treatment teams and staff at day-treatment facilities, group homes, and community programs all need to be educated and begin helping their patients become healthier. Finally, primary care providers need to become more aware of the significant morbidity and mortality risks in this population. They need to screen patients with serious mental illnesses for the most common causes of mortality.
Conclusion
There has been growing concern that people in Minnesota who have serious mental illnesses have received inadequate attention and care for nonpsychiatric conditions. Data now have confirmed this suspicion and shown the disastrous impact mental illness has on life expectancy. Minnesota’s 10 By 10 initiative is raising awareness of this problem and has introduced a way to address it. By enlisting the support of all health care providers, we believe we can help patients with serious mental illnesses live 10, 15, even 25 years longer. What health care issue could be more compelling? MM
Michael Trangle is associate medical director for behavioral health for HealthPartners Medical Group and Regions Hospital; Gary Mager is the former mental health information systems manager for the Minnesota Department of Human Services; and Paul Goering is executive medical director for behavioral health for Allina Health System. All served on the MN 10 By 10 work group. Rodney Christensen is interim chief medical officer for Allina Medical Clinics.
The authors would like to thank the other members of the Minnesota 10 By 10 workgroup: Sharon Autio, Minnesota Department of Human Services; Karen Lloyd, HealthPartners; Tim Smith, Medica Behavioral Health; Jerry Storck, Minnesota Department of Human Services; David Stroud, Minnesota Department of Health; and John Trepp, Tasks Unlimited.
References
1. Babigian HM, Odoroff CL. The mortality experience of a population with psychiatric illness. Amer J Psychiatry. 1969;126(4):470-80.
2. Felker B, Yazel J, Short D. Mortality and medical comorbidity among psychiatric patients: a review. Psychiatr Serv. 1996;47(12):1356-63.
3. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006;3(2):A42.
4. Parks J, Svendsen D, Singer P, Foti M. Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD), Medical Directors Council; October 2006.