VOLUME 9 NUMBER 3 • SEPTEMBER 2012
107
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
Correspondence to: Richard Holt
Human Development and Health
Academic Unit, Faculty of Medicine,
University of Southampton, UK
Email:
Originally in:
Prim Care Cardiovasc J
2012;
5
: 81–85
S Afr J Diabetes Vascular Dis
2012;
9
: 107–111
Cardiovascular disease and diabetes in people with severe
mental illness: causes, consequences and pragmatic
management
RICHARD IG HOLT
T
he prevalence of many physical illnesses is increased
in people with severe mental illness and accounts for
around three quarters of all deaths; cardiovascular disease
is the commonest cause of death. The level of screening for
and management of diabetes and cardiovascular risk factors
remains low but a straightforward yet systematic care pathway
should go a long way towards reducing the health inequalities
experienced by people with severe mental illness.
Schizophrenia and bipolar disorder are psychotic illnesses that
may alter perception, thought, affect and behaviour and are
characterised by intermittent loss of insight. The lifetime risk of
schizophrenia is approximately 1–2% and the figure is somewhat
higher for bipolar illness. Schizophrenia and bipolar disorder are
often collectively known as severe and enduring mental illnesses.
Severe mental illness is associated with a three-fold increased risk
of premature death and it shortens life expectancy by approximately
10–20
years.
1
Although suicide accounts for the highest relative
risk of mortality, being up to 20-fold commoner than among the
general population, a number of physical illnesses also occur more
frequently in people with severe mental illness and cause around
three-quarters of deaths, with cardiovascular disease being the
commonest cause of death.
1
Primary healthcare professionals have a major role to play in
reducing the burden of physical disease in people with severe
mental illness. Contrary to expectation, individuals with severe
mental illness attend primary care settings more frequently than
the general population and are as motivated about their physical
health as the rest of the population, but often lack awareness and
fail to prioritise their physical well-being.
2
This review will examine
the prevalence and aetiology of diabetes and cardiovascular disease
in people with severe mental illness, and review the steps that can
be taken to address this problem in a pragmatic way.
Methods
PubMed and other electronic databases were searched to identify
articles that included the keywords: diabetes, cardiovascular
disease, psychosis, schizophrenia, bipolar illness, antipsychotic and
each individual antipsychotic drug name.
The article draws on the author’s own clinical and research
experience, which included membership of three different
committees whose remit was to develop pragmatic guidelines to
manage diabetes and cardiovascular risk in people with severe
mental illness.
Cardiovascular disease in severe mental illness
Cardiovascular morbidity and mortality are increased approximately
2–3-
fold overall in people with severe mental illness.
1
This increased
risk is particularly marked in younger individuals with severe mental
illness, in whom the prevalence of cardiovascular disease is 3.6 times
higher, compared with a 2.1-fold increase in people who are older
than 50 years.
3
The rates of cardiovascular disease and mortality
have fallen in the general population over the last 20 years but
these benefits have not been shared by people with severe mental
illness and consequently, the health inequality gap has widened.
Several studies have shown that the prevalence of modifiable
cardiovascular risk factors, such as obesity, smoking, diabetes and
dyslipidaemia, is also increased in people with severe mental illness
and explains much of the excess cardiovascular mortality (Table 1).
4
Furthermore, the risk factors appear at younger ages: in the US
Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)
study, at baseline more than a quarter of men with schizophrenia
Points for the clinic
The prevalence of diabetes and cardiovascular disease is
•
increased 2–3-fold in people with schizophrenia or bipolar
illness
The reasons for this include genetic and lifestyle factors as
•
well as disease- and treatment-specific effects
There is a need to screen people with severe mental illness
•
systematically for diabetes and cardiovascular risk
The principles of management are similar to those in the
•
general population
Table 1.
Estimated prevalence of modifiable cardiovascular risk factors in
people with schizophrenia and bipolar illness and relative risk compared with
the general population. Adapted from De Hert
et al
.
4
Schizophrenia
Bipolar illness
Modifiable
Prevalence Relative
Prevalence Relative
risk factor
(%)
risk
(%)
risk
Smoking
50–80
2–3
54–68
2–3
Dyslipidaemia
25–69
< 5
23–38
< 3
Diabetes
10–15
2–3
8–17
1.5–3
Hypertension
19–58
2–3
35–61
2–3
Obesity
45–55
1.5–2
21–49
1–2
Metabolic syndrome
37–63
2–3
30–49
2–3
