1. International Congress of the
Royal College of Psychiatrists
21-24 June 2010, EICC, Edinburgh
Quality of Care for Individuals with Mental Ill Health:
Do Individuals with Mental Illness Receive Inadequate Medication for
Comorbid Physical Disorders? A Meta-Analysis of Prescribing Inequalities
Alex J Mitchell Consultant in Psychiatry, Department of Cancer & Molecular Medicine, University Hospitals Leicester (UK)
Oliver Lord ST in psychiatry, Leicester Partnership Trust, Leicester ajm80@le.ac.uk
Summary meta-analysis plot [random effects]
AIMS
We examined inequalities in the prescription of physical healthcare medication to those ACE (Druss2001) [SMI]
ACE (Kreyenbuhl) [Sz]
0.81 (0.65, 0.98)
0.23 (0.12, 0.44)
with mental illness compared with those without mental ill health. ACE (Kreyenbuhl) [Aff] 0.46 (0.18, 1.19)
ACE (Petersen) [SMI] 0.92 (0.79, 1.09)
BACKGROUND REVIEW ACE (Plomondon) [SMI]
ACE (Suvisaari) [Sz]
0.93 (0.84, 1.01)
1.10 (0.30, 3.70)
Inequalities in the quality of medical care for those with mental illness have been ACE (Weiss) [Sz] 0.83 (0.61, 1.14)
previously documented but the extent of under treatment with prescribed medication Arthritis (Redelmeier) [Sz]
Aspirin (Desai) [Sz]
0.59 (0.57, 0.62)
1.07 (0.49, 2.30)
remains unclear. Aspirin (Desai) [Aff] 0.75 (0.39, 1.43)
Aspirin (Druss2001) [SMI] 0.81 (0.65, 0.98)
Aspirin (Hippisley-Cox) [Sz] 1.00 (0.97, 1.04)
METHODS We undertook a effects meta-analysis of studies that examined prescribed Aspirin (Petersen) [SMI]
Aspirin (Plomondon) [SMI]
0.96 (0.81, 1.15)
0.93 (0.83, 1.04)
medication for medical conditions in those with and without comorbid mental illness Aspirin (Weiss) [Sz] 0.89 (0.64, 1.24)
and calculated the extent of treatment disparities. Aspirin or anticoagulant (Suvisaari) [Sz] 0.85 (0.33, 2.10)
Bblocker (Desai) [Sz] 0.70 (0.43, 1.15)
Bblocker (Desai) [Aff] 0.70 (0.48, 1.03)
RESULTS We found 46 comparative analyses (from 19 publications) relating to the Bblocker (Druss2001) [SMI]
Bblocker (Hippisley-Cox) [Sz]
0.85 (0.72, 0.98)
0.96 (0.88, 1.06)
prescription of 11 classes of medication for cardiovascular health (statin/non-statin Bblocker (Hippisley-Cox) [Aff] 1.18 (0.94, 1.56)
cholesterol agent, beta-blocker, aspirin and acetylsalicylic acid drugs, ACE/ARB Bblocker (Plomondon) [SMI] 1.11 (0.97, 1.28)
Bblocker (Wang) [Aff] 0.55 (0.45, 0.55)
inhibitors, nitroglycerine), diabetes (insulin), cancer (chemotherapy), arthritis, Bblocker (Weiss) [Sz] 0.96 (0.54, 1.71)
osteoporosis (HRT) and HIV medication (HAART). BBlockers (Petersen) [SMI] 0.78 (0.69, 0.92)
Bblockers (Suvisaari) [Sz] 0.41 (0.15, 1.10)
Chemotherapy (Goodwin) [Aff] 0.65 (0.43, 1.00)
In those with severe mental illness (SMI) the adjusted odds ratio (aOR) for an Cholesterol (Desai) [Sz] 1.01 (0.37, 2.77)
equitable prescription was 0.901 (95% CI = 0.844 to 0.962) with lower than Cholesterol (Desai) [Aff] 1.31 (0.57, 3.00)
Cholesterol (Hippisley-Cox) [Aff] 0.86 (0.70, 12.30)
expected prescriptions for ACE inhibitors and aspirin. Cholesterol (Redelmeier) [Sz] 0.22 (0.20, 0.25)
People with schizophrenia were 0.681 (95% CI = 0.543 to 0.853) as likely to receive Cholesterol (Weiss) [Sz] 1.85 (1.11, 3.09)
HAART (Himelhoch2004) [SMI] 2.28 (1.24, 32.50)
comparable medication prescription with lower rates of most apparent for statins. HAART (Himelhoch2007) [SMI] 0.85 (0.71, 1.23)
In affective disorders there was an odds of 0.718 (OR 95%CI 0.514 to 1.00) for HAART (Mijch) [SMI] 1.28 (1.04, 1.57)
inadequate prescribing with low rates significant for receipt of beta-blockers. HAART (Tegger) [Aff]
HAART (Yun) [Aff]
0.36 (0.30, 0.50)
1.43 (1.18, 1.74)
After pooling all studies, individuals with a history of any mental illness received 0.762 Insulin (Weiss) [Sz] 1.44 (0.96, 2.16)
(95% CI = 0.666 to 0.873) of comparable medication with lower receipt of ACE Nitroglycerine (Suvisaari) [Sz]
Osteoporosis (Bishop) [Sz]
1.10 (0.39, 2.60)
0.38 (0.15, 0.97)
inhibitors and statins and borderline significance for beta-blockers, but no difference Osteoporosis/HRT (Redelmeier) [Sz] 0.29 (0.26, 0.33)
in aspirin or HAART and higher rates of non-statin cholesterol lowering agents. Statin (Hippisley-Cox) [Sz] 0.85 (0.80, 0.91)
Statin (Hippisley-Cox) [Aff] 1.15 (0.80, 1.95)
Given a control event rate of 70%, the actual rate of under-treatment can be Statin (Kreyenbuhl) [Sz] 0.29 (0.11, 0.77)
estimated at 9% (CI 4.2% to 13%). Statin (Kreyenbuhl) [Aff] 0.14 (0.05, 0.44)
Statin (Weiss) [Sz] 0.54 (0.36, 0.51)
Summary meta-analysis plot [random effects] combined 0.76 (0.67, 0.87)
0.01 0.1 0.2 0.5 1 2 5 10 100
ACE (Kreyenbuhl) 0.23 (0.12, 0.44)
odds ratio (95% confidence interval)
ACE (Suvisaari) 1.10 (0.30, 3.70)
ACE-I or ARBb (Weiss) 0.83 (0.61, 1.14)
Arthritis (Redelmeier) 0.59 (0.57, 0.62)
Aspirin (Desai) 1.07 (0.49, 2.30)
Aspirin (Hippisley-Cox) 1.00 (0.97, 1.04)
Aspirin (Weiss) 0.89 (0.64, 1.24) Summary meta-analysis plot [random effects] Summary meta-analysis plot [random effects]
Aspirin or anticoagulant (Suvisaari) 0.85 (0.33, 2.10)
Bblocker (Desai) 0.70 (0.43, 1.15) ACE (Druss2001) 0.81 (0.65, 0.98)
ACE (Kreyenbuhl) 0.46 (0.18, 1.19)
Bblocker (Hippisley-Cox) 0.96 (0.88, 1.06) ACE (Petersen) 0.92 (0.79, 1.09)
Aspirin (Desai) 0.75 (0.39, 1.43)
Bblocker (Weiss) 0.96 (0.54, 1.71) ACE-I or ARBb (Plomondon) 0.93 (0.84, 1.01)
Bblocker (Desai) 0.70 (0.48, 1.03)
Bblockers (Suvisaari) 0.41 (0.15, 1.10)
Aspirin (Druss2001) 0.81 (0.65, 0.98)
Bblocker (Hippisley-Cox) 1.18 (0.94, 1.56)
Cholesterol (Desai) 1.01 (0.37, 2.77)
Aspirin (Petersen) 0.96 (0.81, 1.15)
Bblocker (Wang) 0.55 (0.45, 0.55)
Cholesterol (Redelmeier) [Sz] 0.22 (0.20, 0.25)
Aspirin (Plomondon) 0.93 (0.83, 1.04)
Cholesterol (Weiss) 1.85 (1.11, 3.09) Chemotherapy (Goodwin) 0.65 (0.43, 1.00)
Bblocker (Druss2001) 0.85 (0.72, 0.98)
Insulin (Weiss) 1.44 (0.96, 2.16) Cholesterol (Desai) 1.31 (0.57, 3.00)
Nitroglycerine (Suvisaari) 1.10 (0.39, 2.60) Bblocker (Plomondon) 1.11 (0.97, 1.28)
Cholesterol (Hippisley-Cox) 0.86 (0.70, 12.30)
Osteoporosis (Bishop) 0.38 (0.15, 0.97) BBlockers (Petersen) 0.78 (0.69, 0.92)
HAART (Tegger) 0.36 (0.25, 0.50)
Osteoporosis/HRT (Redelmeier) [Sz] 0.29 (0.26, 0.33) HAART (Mijch) 1.28 (1.04, 1.57)
HAART (Yun) 1.43 (1.18, 1.74)
Statin (Hippisley-Cox) 0.85 (0.80, 0.91)
HAART (Himelhoch2004) 2.28 (1.24, 32.50)
Statin (Hippisley-Cox) 1.15 (0.80, 1.95)
Statin (Kreyenbuhl) 0.29 (0.11, 0.77)
HAART (Himelhoch2007) 0.85 (0.71, 1.23)
Statin (Kreyenbuhl) 0.14 (0.05, 0.44)
Statin (Weiss) 0.54 (0.36, 0.51)
combined 0.92 (0.85, 1.00)
combined 0.68 (0.54, 0.85) combined 0.72 (0.51, 1.00)
0.5 1 2 5 10 100
0.1 0.2 0.5 1 2 5 0.01 0.1 0.2 0.5 1 2 5 10 100
odds ratio (95% confidence interval)
odds ratio (95% confidence interval) odds ratio (95% confidence interval)
Prescribing Inequalities in Schizophrenia vs No Mental Illness Fig. Prescribing Inequalities in Severe Mental Illness vs No Mental Illness Prescribing Inequalities in Affective Disorders vs No Mental Illness
CONCLUSIONS Individuals with mental illness (including affective disorder and schizophrenia) are prescribed
significantly lower rates of most common medications to treat medical disorders but may receive higher than
expected prescriptions for older cholesterol lowering agents.