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Revascularisation and mortality rates following acute coronary syndromes in people with severe mental illness: comparative meta-analysis

  • Alex J. Mitchell (a1) and David Lawrence (a2)

High levels of comorbid physical illness and excess mortality rates have been previously documented in people with severe mental illness, but outcomes following myocardial infarction and other acute coronary syndromes are less clear.


To examine inequalities in the provision of invasive coronary procedures (revascularisation, angiography, angioplasty and bypass grafting) and subsequent mortality in people with mental illness and in those with schizophrenia, compared with those without mental ill health.


Systematic search and random effects meta-analysis were used according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies of mental health and cardiovascular procedures following cardiac events were eligible but we required a minimum of three independent studies to warrant pooling by procedure type. We searched Medline/PubMed and EMBASE abstract databases and ScienceDirect, Ingenta Select, SpringerLink and Online Wiley Library full text databases.


We identified 22 analyses of possible inequalities in coronary procedures in those with defined mental disorder, of which 10 also reported results in schizophrenia or related psychosis. All studies following acute coronary syndrome originated in the USA. The total sample size was 825 754 individuals. Those with mental disorders received 0.86 (relative risk, RR: 95% CI 0.80–0.92, P<0.0001) of comparable procedures with significantly lower receipt of coronary artery bypass graft (CABG; RR = 0.85, 95% CI 0.72–1.00), cardiac catheterisation (RR = 0.85, 95% CI 0.76–0.95) and percutaneous transluminal coronary angioplasty or percutaneous coronary intervention (PTCA/PCI; RR = 0.87, 95% CI 0.72–1.05). People with a diagnosis of schizophrenia received only 0.53 (95% CI 0.44–0.64, P<0.0001) of the usual procedure rate with significantly lower receipt of CABG (RR = 0.69, 95% CI 0.55–0.85) and PTCA/PCI (RR = 0.50, 95% CI 0.34–0.75). We identified 6 related studies examining mortality following cardiac events: for those with mental illness there was a 1.11 relative risk of mortality up to 1 year (95% CI 1.00–1.24, P = 0.05) but there was insufficient evidence to examine mortality rates in schizophrenia alone.


Following cardiac events, individuals with mental illness experience a 14% lower rate of invasive coronary interventions (47% in the case of schizophrenia) and they have an 11% increased mortality rate. Further work is required to explore whether these factors are causally linked and whether improvements in medical care might improve survival in those with mental ill health.

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Corresponding author
Alex J. Mitchell, Department of Liaison Psychiatry, Leicester General Hospital, Leicester LE5 4PW, UK. Email:
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1 Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, (eds) Global Burden of Disease and Risk Factors. World Bank, 2006.
2 Murray CJL, Lopez AD. The Global Burden of Disease: A Comparative Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020, vol 1. Harvard University Press, 1996.
3 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2007; 116: 148304.
4 Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined – a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000; 36: 959–69.
5 Hunink MG, Goldman L, Tosteson AN, Mittleman MA, Goldman PA, Williams LW, et al. The recent decline in mortality from coronary heart disease, 1980–1990: the effect of secular trends in risk factors and treatment. JAMA 1997; 277: 535–42.
6 Alter DA, Naylor CD, Austin P, Tu JV. Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction. N Engl J Med 1999; 341: 1359–67.
7 Morris RW, Whincup PH, Papacosta O, Walker M, Thomson A. Inequalities in coronary revascularisation during the 1990s: evidence from the British regional heart study. Heart 2005; 91: 635–40.
8 Rasmussen JN, Rasmussen S, Gislason GH, Abildstrom SZ, Schramm TK, Torp-Pedersen C, et al. Persistent socio-economic differences in revascularization after acute myocardial infarction despite a universal health care system – a Danish study. Cardiovasc Drugs Ther 2007; 21: 449–57.
9 Sekhri N, Timmis A, Chen R, Junghans C, Walsh N, Zaman MJ, et al. Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris. BMJ 2008; 336: 1058–61.
10 Rosvall M, Chaix B, Lynch J, Lindström M, Merlo J. The association between socioeconomic position, use of revascularization procedures and five-year survival after recovery from acute myocardial infarction. BMC Public Health 2008; 8: 44.
11 Quatromoni J, Jones R. Inequalities in socio-economic status and invasive procedures for coronary heart disease: a comparison between the USA and the UK. Int J Clin Pract 2008; 62: 1910–9.
12 Mitchell AJ, Malone D, Carney Doebbeling C. Quality of medical care for people with and without comorbid mental illness and substance misuse: systematic review of comparative studies. Br J Psychiatry 2009; 194: 491–9.
13 Lord OL, Malone D, Mitchell AJ. Quality of preventive care for people with and without comorbid mental illness systematic review of comparative studies. Gen Hosp Psychiatry 2010; 32: 519–43.
14 Fleischhacker WW, Cetkovich-Bakmas M, De Hert M, Hennekens CH, Lambert M, Leucht S, et al. Comorbid somatic illnesses in patients with severe mental disorders: clinical, policy, and research challenges. J Clin Psychiatry 2008; 69: 514–9.
15 Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of cardiovascular disease. Am Heart J 2005; 150: 1115–21.
16 Unützer J, Schoenbaum M, Druss BG, Katon WJ. Transforming mental health care at the interface with general medicine: report for the President's Commission. Psychiatr Serv 2006; 57: 3747.
17 De Hert M, Dekker JM, Wood D, Kahl KG, Holt RI, Möller HJ. Cardiovascular disease and diabetes in people with severe mental illness position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC). Eur Psychiatry 2009; 24: 412–24.
18 National Institute for Health and Clinical Excellence. Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care (update). NICE, 2009 (
19 Sáiz Ruiz J, Bobes García J, Vallejo Ruiloba J, Giner Ubago J, García-Portilla González MP, et al. Consensus on physical health of patients with schizophrenia from the Spanish Societies of Psychiatry and Biological Psychiatry. Actas Esp Psiquiatr 2008; 36: 251–64.
20 Suvisaari JM, Saarni SI, Perälä J, Suvisaari JVJ, Härkänen T, Lönnqvist J, et al. Metabolic syndrome among persons with schizophrenia and other psychotic disorders in a general population survey. J Clin Psychiatry 2007; 68: 1045–55.
21 McEvoy JP, Meyer JM, Goff DC, Nasrallah HA, Davis SM, Sullivan L, et al. Prevalence of the metabolic syndrome in patients with schizophrenia: baseline results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES III. Schizophr Res 2005; 80: 1932.
22 Filik R, Sipos A, Kehoe PG, Burns T, Cooper SJ, Stevens H, et al. The cardiovascular and respiratory health of people with schizophrenia. Acta Psychiatr Scand 2006; 113: 298305.
23 Casey DE, Haupt DW, Newcomer JW, Henderson DC, Sernyak MJ, Davidson M, et al. Antipsychotic-induced weight gain and metabolic abnormalities: implications for increased mortality in patients with schizophrenia. J Clin Psychiatry 2004; 65 (suppl 7): 418.
24 Sundquist K, Li X. Alcohol abuse partly mediates the association between coronary heart disease and affective or psychotic disorders: a follow-up study in Sweden. Acta Psychiatr Scand 2006; 113: 283–9.
25 Kilbourne AM, Cornelius JR, Han X, Haas GL, Salloum I, Conigliaro J, et al. General-medical conditions in older patients with serious mental illness. Am J Geriatr Psychiatry 2005; 13: 250–4.
26 Suvisaari J, Jonna Perälä J, Saarni SI, Kattainen A, Lönnqvist J, Reunanen A. Coronary heart disease and cardiac conduction abnormalities in persons with psychotic disorders in a general population. Psychiatry Res 2010; 175: 126–32.
27 Osborn DP, Levy G, Nazareth I, Petersen I, Islam A, King MB. Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom's General Practice Research Database. Arch Gen Psychiatry 2007; 64: 242–9.
28 Laursen TM, Munk-Olsen T, Nordentoft M, Mortensen PB. Increased mortality among patients admitted with major psychiatric disorders: a register-based study comparing mortality in unipolar depressive disorder, bipolar affective disorder, schizoaffective disorder, and schizophrenia. J Clin Psychiatry 2007; 68: 899907.
29 McDermott S, Moran R, Platt T, Isaac T, Wood H, Dasari S. Heart disease, schizophrenia, and affective psychoses: epidemiology of risk in primary care. Commun Ment Health J 2005; 41: 747–55.
30 Curkendall SM, Mo J, Glasser DB, Stang MR, Jones JK. Cardiovascular disease in patients with schizophrenia in Saskatchewan, Canada. J Clin Psychiatry 2004; 65: 715–20.
31 De Leon J, Diaz FJ. A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophr Res 2005; 76: 135–57.
32 Allison DB, Fontaine KR, Heo M, Mentore JL, Cappelleri JC, Chandler LP, et al. The distribution of body mass index among individuals with and without schizophrenia. J Clin Psychiatry 1999; 60: 215–20.
33 Heiskanen T, Niskanen L, Lyytikainen R, Saarinen PI, Hintikka J. Metabolic syndrome in patients with schizophrenia. J Clin Psychiatry 2003; 64: 575–9.
34 Daumit GL, Goldberg RW, Anthony C, Dickerson F, Brown CH, Kreyenbuhl J, et al. Physical activity patterns in adults with severe mental illness. J Nerv Ment Dis 2005; 193: 641–6.
35 Goff DC, Sullivan LM, McEvoy JP, Meyer JM, Nasrallah HA, Daumit GL, et al. A comparison of ten-year cardiac risk estimates in schizophrenia patients from the CATIE study and matched controls. Schizophr Res 2005; 80: 4553.
36 Osborn DPJ, Wright CA, Levy G, King MB, Deo R, Nazareth I. Relative risk of diabetes, dyslipidaemia, hypertension and the metabolic syndrome in people with severe mental illnesses: systematic review and meta-analysis. BMC Psychiatry 2008; 8: 84.
37 Grundy SM, Pasternak R, Greenland P, Smith S, Fuster R. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation 1999; 100: 1481–92.
38 Brown S. Excess mortality of schizophrenia. A meta-analysis. Br J Psychiatry 1997; 171: 502–8.
39 Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry 2007; 64: 1123–31.
40 Moher DM, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009; 339: 2535.
41 Lawrence DM, Holman CDJ, Jablensky AV, Hobbs MST. Death rate from ischaemic heart disease in Western Australian psychiatric patients 1980–1998. Br J Psychiatry 2003; 182: 31–6.
42 Zhang JM, Yu KF. What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 1998; 280: 1690–1.
43 Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994; 50: 1088–101.
44 Druss BG, Bradford DW, Rosenheck RA, Radford MJ, Krumholz HM. Mental disorders and use of cardiovascular procedures after myocardial infarction. JAMA 2000; 283: 506–11.
45 Druss BG, Bradford WD, Rosenheck RA, Radford MJ, Krumholz HM. Quality of medical care and excess mortality in older patients with mental disorders. Arch Gen Psychiatry 2001; 58: 565–72.
46 Young J, Foster D. Cardiovascular procedures in patients with mental disorders. JAMA 2000; 283: 3198–9.
47 Petersen LA, Normand SL, Druss BG, Rosenheck RA. Process of care and outcome after acute myocardial infarction for patients with mental illness in the VA health care system: are there disparities? Health Serv Res 2003; 38: 4163.
48 Kisely S, Smith M, Lawrence D, Cox M, Campbell LA, Maaten S. Inequitable access for mentally ill patients to some medically necessary procedures. CMAJ 2007; 176: 779–84.
49 Plomondon ME, Ho PM, Wang L, Greiner GT, Shore JH, Sakai JT, et al. Severe mental illness and mortality of hospitalized ACS patients in the VHA. BMC Health Serv Res 2007; 7: 146.
50 Jones LE, Carney CP. Mental disorders and revascularisation procedures in a commercially insured sample. Psychosom Med 2005; 67: 568–76.
51 Laursen TM, Munk-Olsen T, Agerbo E, Gasse C, Mortensen PB. Somatic hospital contacts, invasive cardiac procedures and mortality from heart disease in patients with severe mental disorder. Arch Gen Psychiatry 2009; 66: 713–20.
52 Abrams TE, Vaughan-Sarrazin M, Rosenthal GE. Psychiatric comorbidity and mortality after acute myocardial infarction. Circ Cardiovasc Qual Outcomes 2009; 2: 213–20.
53 Blecker S, Zhang Y, Ford DE, Guallar E, Dosreis S, Steinwachs DM, et al. Quality of care for heart failure among disabled Medicaid recipients with and without severe mental illness. Gen Hosp Psychiatry 2010; 32: 255–61.
54 Van Melle JP, de Jonge P, Spijkerman TA, Tijssen JG, Ormel J, van Veldhuisen DJ, et al. Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis. Psychosom Med 2004; 66: 814–22.
55 Nicholson A, Kuper H, Hemingway H. Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. Eur Heart J 2006; 27: 2763–74.
56 Newman SC, Bland RC. Mortality in a cohort of patients with schizophrenia: a record linkage study. Can J Psychiatry 1991; 36: 239–45.
57 Brown S, Barraclough B, Inskip H. Causes of the excess mortality of schizophrenia. Br J Psychiatry 2000; 177: 212–7.
58 Osby U, Correia N, Brandt L, Ekbom A, Sparén P. Mortality and causes of death in schizophrenia in Stockholm County, Sweden. Schizophr Res 2000; 45: 21–8.
59 Joukamaa M, Heliövaara M, Knekt P, Aromaa A, Raitasalo R, Lehtinen V. Mental disorders and cause-specific mortality. Br J Psychiatry 2001; 179: 498502.
60 Heilä H, Haukka J, Suvisaari J, Lönnqvist J. Mortality among patients with schizophrenia and reduced psychiatric hospital care. Psychol Med 2005; 35: 725–32.
61 Montanez A, Ruskin JN, Hebert PR, Lamas GA, Hennekens CH. Prolonged QTc interval and risks of total and cardiovascular mortality and sudden death in the general population: a review and qualitative overview of the prospective cohort studies. Arch Intern Med 2004; 164: 943–8.
62 Elming H, Brendorp B, Kober L, Sahebzadah N, Torp-Petersen C. QTc interval in the assessment of cardiac risk. Cardiac Electrophysiol Rev 2002; 6: 289–94.
63 Bär K-J, Koschke M, Boettger MK, Berger S, Kabisch A, Sauer H, et al. Acute psychosis leads to increased QT variability in patients suffering from schizophrenia. Schizophr Res 2007; 95: 115–23.
64 Mujica-Parodi LR, Yeragani V, Malaspina D. Nonlinear complexity and spectral analyses of heart rate variability in medicated and unmedicated patients with schizophrenia. Neuropsychobiology 2005; 51: 10–5.
65 Jindal RD, Keshavan MS, Eklund K, Stevens A, Montrose DM, Yeragani VK. Beat-to-beat heart rate and QT interval variability in first episode neuroleptic-naive psychosis. Schizophr Res 2009; 113: 176–80.
66 Lakka HM, Laaksonen DE, Lakka TA, Niskanen LK, Kumpusalo E, Tuomilehto J, et al. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA 2002; 288: 2709–16.
67 Ray KK, Rao S, Seshasai K, Sivakumaran R, Nethercott S, Preiss D, et al. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet 2009; 373: 1765–72.
68 Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Atypical antipsychotic drugs and the risk of sudden cardiac death. N Engl J Med 2009; 360: 225–35.
69 Mitchell AJ. Do antipsychotics cost lives or save lives? Risks versus benefits from large epidemiological studies. J Clin Psychopharmacol 2009; 29: 517–9.
70 Crone D, Johnston LH, Gidlow C, Henley C, James DV. Uptake and participation in physical activity referral schemes in the UK: an investigation of patients referred with mental health problems. Issues Ment Health Nurs 2008; 29: 1088–97.
71 Li Y, Glance LG, Cai X, Mukamel DB. Are patients with coexisting mental disorders more likely to receive CABG surgery from low-quality cardiac surgeons? The experience in New York State. Med Care 2007; 45: 587–93.
72 Copeland LA, Zeber JE, Wang CP, Henley C, James DV, et al. Patterns of primary care and mortality among patients with schizophrenia or diabetes: a cluster analysis approach to the retrospective study of healthcare utilization. BMC Health Serv Res 2009; 9: 127.
73 Desai M, Rosenheck RA, Druss BG, Perlin JB. Mental disorders and quality of diabetes care in the veterans health administration. Am J Psychiatry 2002; 159: 1584–90.
74 Mateen FJ, Jatoi A, Lineberry TW, Aranguren D, Creagan ET, Croghan GA, et al. Do patients with schizophrenia receive state-of-the-art lung cancer therapy? A brief report. Psychooncology 2008; 17: 721–5.
75 Roberts L, Roalfe A, Wilson S, Lester H. Physical health care of patients with schizophrenia in primary care: a comparative study. Fam Pract 2007; 24: 3440.
76 Vahia IV, Diwan S, Bankole AO, Kehn M, Nurhussein M, Ramirez P, et al. Adequacy of medical treatment among older persons with schizophrenia. Psychiatr Serv 2008; 59: 853–9.
77 Nasrallah HA, Meyer JM, Goff DC, McEvoy JP, Davis SM, Stroup TS, et al. Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: data from the CATIE schizophrenia trial sample at baseline. Schizophr Res 2006; 86: 1522.
78 Morrato EH, Newcomer JW, Allen RR, Valuck RJ. Prevalence of baseline serum glucose and lipid testing in users of second-generation antipsychotic drugs: a retrospective, population-based study of medicaid claims data. J Clin Psychiatry 2008; 69: 316–22.
79 Al-Mandhari AS, Hassan AA, Haran D. Association between perceived health status and satisfaction with quality of care: evidence from users of primary health care in Oman. Fam Pract 2004; 21: 519–27.
80 Kilbourne AM, McCarthy JF, Welsh D, Blow F. Recognition of co-occurring medical conditions among patients with serious mental illness. J Nerv Ment Dis 2006; 194: 598602.
81 Koranyi E. Morbidity and rate of undiagnosed physical illness in a psychiatric population. Arch Gen Psychiatry 1979; 36: 414–9.
82 Farmer S. Medical problems of chronic patients in a community support program. Psychiatr Serv 1987; 38: 745–9.
83 Fallow S, Bowler C, Dennis M, Jones P. Undetected physical illness in older referrals to a community mental-health-service. Int J Geriatr Psychiatry 1995; 10: 74–5.
84 Bernardo M, Banegas JR, Canas F, Casademot X, Riesgo Y, Varela C. Low level of medical recognition and treatment of cardiovascular risk factors in patients with schizophrenia in Spain. 13th Biennial Winter Workshop on Schizophrenia Research. Schizophr Res 2006; 81: 176–7.
85 American Diabetes Association. Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. Diabetes Care 2004; 27: 596601.
86 Cohn TA, Sernyak MJ. Metabolic monitoring for patients treated with antipsychotic medications. Can J Psychiatry 2006; 51: 492501.
87 De Hert M, van Eyck D, De Nayer A. Metabolic abnormalities associated with second generation antipsychotics: fact or fiction? Development of guidelines for screening and monitoring. Int Clin Psychopharmacol 2006; 21 (suppl 2): 11–5.
88 Waterreus AJ, Laugharne JD. Screening for the metabolic syndrome in patients receiving antipsychotic treatment: a proposed algorithm. Med J Aust 2009; 190: 185–9.
89 Citrome L, Yeomans D. Do guidelines for severe mental illness promote physical health and well-being? J Psychopharmacol 2005; 19: 102–9.
90 Buckley PF, Miller DD, Singer B. Clinicians' recognition of the metabolic adverse effects of antipsychotic medications. Schizophr Res 2005; 79: 281–8.
91 Haupt DW, Rosenblatt LC, Kim E, Baker RA, Whitehead R, Newcomer JW. Prevalence and predictors of lipid and glucose monitoring in commercially insured patients treated with second-generation antipsychotic agents. Am J Psychiatry 2009; 166: 345–53.
92 Schneiderhan ME, Batscha CL, Rosen C. Assessment of a point-of-care metabolic risk screening program in outpatients receiving antipsychotic agents. Pharmacotherapy 2009; 29: 975–87.
93 Mackin P, Bishop D, Watkinson H. A prospective study of monitoring practices for metabolic disease in antipsychotic-treated community psychiatric patients. BMC Psychiatry 2007; 7: 28.
94 Iestra JA, Kromhout D, van der Schouw YT, Grobbee DE, Boshuizen HC, van Staveren WA. Effect size estimates of lifestyle and dietary changes on all cause mortality in coronary artery disease patients: a systematic review. Circulation 2005; 112: 924–34.
95 Khazaal Y, Fresard E, Rabia S, Chatton A, Rothen S, Pomini V, et al. Cognitive behavioural therapy for weight gain associated with antipsychotic drugs. Schizophr Res 2007; 91: 169–77.
96 Pendlebury J, Haddad P, Dursun S. Evaluation of a behavioural weight management programme for patients with severe mental illness: 3 year results. Hum Psychopharmacol 2005; 20: 447–8.
97 Alvarez-Jimenez M, Gonzalez-Blanch C, Vazquez-Barquero JL, Pérez-Iglesias R, Martínez-García O, Pérez-Pardal T, et al. Attenuation of antipsychotic-induced weight gain with early behavioral intervention in drug-naive first-episode psychosis patients: a randomized controlled trial. J Clin Psychiatry 2006; 67: 1253–60.
98 Weber M, Wyne K. A cognitive/behavioral group intervention for weight loss in patients treated with atypical antipsychotics. Schizophr Res 2006; 83: 95101.
99 Ganguli R. Behavioral therapy for weight loss in patients with schizophrenia. J Clin Psychiatry 2007; 68 (suppl 4): 1925.
100 Horvitz-Lennon M, Kilbourne AM, Pincus HA. From silos to bridges: meeting the general health care needs of adults with severe mental illnesses. Health Affairs 2006; 25: 659–69.
101 Dombrovski A, Rosenstock J. Bridging general medicine and psychiatry: providing general medical and preventive care for the severely mentally ill. Curr Opin Psychiatry 2004; 17: 523–9.
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Revascularisation and mortality rates following acute coronary syndromes in people with severe mental illness: comparative meta-analysis

  • Alex J. Mitchell (a1) and David Lawrence (a2)
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Revascularisation and Mortality Rates Updated Online Supplement

Alex J Mitchell, Consultant
04 January 2012

Many thanks to Drs Noman and Udo for carefully reading our paper andgiving thoughtful comments. The key point for us as authors is that they quite correctly point out that the study by Lauren et al was accidentally omitted from the online Data Supplement. We are pleased to report this study has now been included and the supplement updated at href="" target="_blank">

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Conflict of interest: None declared

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Re: Revascularisation and Mortality Rates following Acute Coronary Syndromes in People with Severe Mental Illness.

Zakaria Noman, CT2 in Psychiatry, Northumberland, Tyne and Wear NHS Foundation Trust
Itoro Udo, Consultant Psychiatrist (Locum), Broadoak Unit, Liverpool
31 August 2011

We have appraised the meta-analysis by Mitchell & Lawrence with interest.1 We are concerned by the bottom lines results of the study.

The value of this study is that it shows associations, not causal links which are still nevertheless worrying.

We note that the identification of relevant studies was robust. The study by Lauren is not included in the Data Supplement, making objective consideration of presented results difficult.2 It is surprising that no UK based study was identified and one invariably wonders whether results of a UK based study may have been significantly different. The letter by Garg & Garg appears to suggest that from their practical experience, results as obtained in this meta-analysis, is likely in the UK.3

They have identified issues regarding consent to procedures as a major contributor to this standard of practice. Current mental health legislation in the UK includes the Mental Capacity Act 20054 which provides statutory guide for determination of capacity which is applicable to capacity to consent to medical procedures. Where appropriately applied by professionals proposing cardiac interventions then professional liability is removed.

In Garg & Garg's letter,3 they have also listed non adherence to medical advice as a further possible reason for high mortality rate. This can be addressed by good practice guidelines of involving family and carers in the delivery of proposed medical care which is enshrined in the Mental Capacity Act Code of Practice.5 Some patients with mental health care needs in the UK have the additional benefit of having care co- ordinators and regular reviews under the Care Program Approach (CPA) system6 which if properly accessed can reduce the risk of non adherence. Our practical experience has been that non psychiatric health professionals are often unaware of these possible support systems. In providing liaison psychiatry services, such links can be facilitated. Medical professionals requiring further reading in this area could assess a well written case study by Biswas & Hiremath, set in a surgical care unit.7

So given a proper recourse to relevant legislation and effective involvement of family, carers and use of the CPA system where available, we hypothesize that patients currently experiencing Acute Coronary Syndromes in the UK have greater access to necessary cardiac interventions than the target population represented in Mitchell & Lawrence's study.

Considering the implications and applicability of the results of this study, we ponder whether this study would have been better placed in a general medical journal to provide access to readership who are primarily implicated in the study design.

References: 1. Mitchell A, Lawrence D. Revascularisation and Mortality Rates following Acute Coronary Syndromes in People with Severe Mental Illness: A Comparative Meta-analysis. British Journal of Psychiatry 2011; 198(6):434- 441. 2. Mitchell A, Lawrence D. Summary of Comparative Studies Reporting on Receipt of Cardiac Procedures in Data Supplement, Revascularisation and Mortality Rates following Acute Coronary Syndromes in People with Severe Mental Illness: A Comparative Meta-analysis. British Journal of Psychiatry 2011; 198(6):434-441. (accessed 21st August 2011). 3. Garg SA, Garg S. Revascularisation in Patients with Mental Illness. British Journal of Psychiatry 2011. (accessed 21 August 2011). 4. Mental Capacity Act 2005. The Stationery Office; 2007. (accessed 21 August 2011). 5. Department of Constitutional Affairs. Mental Capacity Act 2005: Code of Practice. London: The Stationery Office; 2007. 6. Care Programme Approach Association. About the Care Programme Approach (CPA). (accessed 21 August 2011). 7. Biswas A, Hiremath A. Mental Capacity Assessment and 'Best Interests' Decision- making in Clinical Practice: A Case Illustration. Advances in Psychiatric Treatment 2010; 16: 440-447.

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Revascularisation and Mental Illness: Addressing consent and compliance with follow-up care

Alex J Mitchell, Consultant Psychiatrist
15 July 2011

We thank Drs Garg and Garg for responding to our study1 with these insightful comments from a cardiologist’s perspective. The purpose of our paper was in part to stimulate others to examine more precisely what factors underlie these apparent deficits in received cardiac care. Garg and Garg raise two issues that we agree deserve further investigation — consent to undertake invasive procedures, and compliance with follow-up care. Regarding consent, we are not aware of any studies on refusal of medical procedures particularly following on from an acute psychiatric episode. However, there is some data on refusal to start medication in psychiatric settings which may be a useful point of comparison. 2 3 Kasper et al (1997) found in newly admitted psychiatric inpatients 12.9% refused treatment but that 90% of these ended their refusal within 4 days suggesting persistent refusal may be overestimated, accounting for perhaps 1% of treatment problems.3 It is worth noting that non-adherence rates among patients with severe mental illness is probably lower for medical as compared with psychotropic drugs. 4 One important question here is whether the very small proportion of patients who cannot initially consent due to acute mental illness are always given a second chance to consent once well? Better links between physicians and psychiatrists would no doubt help here. Even in those with mental ill health the vast majority of problems with day to day adherence are cause by accidental omissions and rational non-adherence and not ongoing florid psychiatric illness. 5The second issue raised was provider caution due to the possibility of future non-compliance. Garg and Garg rightly highlight that non-compliance with cardiovascular medication is sometimes higher in those with mental ill health, although this is not always the case. Contrary to popular opinion non-adherence (with medical drugs) is sometimes lower not higher in those with mental ill health. 6 In truth we don’t know whether there is a low prescribing rate or a low uptake rate or both. Focussing on antiplatelet drugs, an unpublished meta-analysis presented by Mitchell at the Royal College Liaison Faculty Meeting (2011) found no difference in receipt of antiplatelet drugs in those with vs. without broadly defined mental illness but there was a slight effect in those with severe mental illness (OR = 0.91; 95% CI = 0.84 to 0.99) suggesting that patients with severe mental illness are indeed receiving slightly less medication for cardiovascular indications. A caution is that these studies are based on prescribed medication rates not actual adherence with medication.

Documenting these inequalities is only the initial step. Are we taking appropriate actions to compensate for these difficulties? For instance, we wouldn't consider a patient with visual impairment to be non-compliant because they can't read a patient instruction sheet. We would make extra effort to give the information in another format. Surely where medical treatment is indicated we (that is all health care professionals) must make some effort to compensate for the difficulties faced by patients with comorbid conditions and ensure our facilities and treatments are acceptable and understandable even when it is expensive or inconvenient to do so. Collaborative care, attached professionals and peer-support models have shown promise in some areas. Could cardiologists and psychiatrists working together establish whether these are useful in the aftercare of patients with mental ill health who require cardiac surgery? 1 Mitchell AJ, Lawrence D. Revascularisation and mortality rates following acute coronary syndromes in people with severe mental illness: comparative meta- analysis. Br J Psychiatry. 2011 Jun;198:434-41 2 Baker JA, Bowers L, Owiti JA. Wards features associated with high rates of medication refusal by patients: a large multi-centred survey General Hospital Psychiatry, Volume 31, Issue 1, January-February 2009, Pages 80-89 3 Kasper JA, Hoge SK, Feucht-Haviar T et al (1997) Prospective study of patients’ refusal of antipsychotic medication under a physician discretion review procedure. American Journal of Psychiatry, 154, 483–489. 4Piette JD, Heisler M, Ganoczy D, McCarthy JF, Valenstein M. Differential medication adherence among patients with schizophrenia and comorbid diabetes and hypertension. Psychiatr Serv. 2007 Feb;58(2):207-12. 5 Mitchell AJ, Selmes T. Why don’t patients take their medicine? Reasons and solutions in psychiatry. Advances in Psychiatric Treatment (2007) 13: 336-346. doi: 10.1192/apt.bp.106.003194 6 Kreyenbuhl J, Dixon LB, McCarthy JF, Soliman S, Ignacio RV, Valenstein M. Does adherence to medications for type 2 diabetes differ between individuals with vs without schizophrenia? Schizophr Bull. 2010 Mar;36(2):428-35.
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Revascularisation in Patients with Mental Illness

Scot A Garg, Doctor
17 June 2011

Dear Editor,Mitchell et al must be congratulated on their systematic review of myocardial revascularization in patients with mental illness.(1) As physicians performing revascularization procedures we were disappointed by the inferior treatment received by patients with mental health problems. Fortunately these patients account for only a minority of those presenting to acute cardiology services with symptoms and signs suggestive of acute coronary syndrome, however when they do attend they present Cardiologists with some a number of challenges, which ultimately can influence the decision regarding treatment.

Revascularization remains an important treatment for those patients with myocardial necrosis providing both symptomatic and prognostic benefit.(2) Importantly however, it can only be performed following invasive coronary angiography – a procedure which carries a risk of vascular complication, myocardial infarction, stroke or even death of 0.2%-1.0%. Clearly patients must be appropriately consented before coronary angiography is undertaken, and this can represent an important hurdle when treating patients with mental health problems.

A second important challenge which should be considered prior to undertaking angiography, and must be considered prior to performing definitive revascularization is the issue of compliance to medication. Frequently revascularization can be performed percutaneously at the time of angiography. This procedure usually necessitates the need to implant coronary stents, which are small permanent metal scaffolds that help maintain coronary vessel patency. There are many advantages to using these devices, however in recent times stent thrombosis has emerged as the most serious and worrying complication of their use.(3) This condition is fortunately rare, but it remains a devastating unpredictable event that has a significant morbidity and mortality; up to a third of patients will die. Research has identified that early or premature discontinuation of dual anti-platelet therapy is one of the most important risk factors in stent thrombosis.(4) Consequently cardiologists are reluctant to implant stents in patients who they feel are unlikely to comply with dual anti-platelet therapy due to the potentially fatal results. Unfortunately patients with mental illness have been shown to be less compliant with medication(5), a factor which certainly has as an influence on revascularization decisions.

These issues represent important challenges (and not excuses) which must be overcome to allow our patients to receive the most appropriate treatment. The differences in treatment certainly deserve to be highlighted and as recommended by Mitchell et al the reasons behind it require more in depth investigation especially within the confines of the National Health Service.

Scot Garg MBChB, MRCP, PhD, FESCShruti Garg MBBS, MRCPsych, MMedSci

The authors have no conflicts of interest to declare.


1.Mitchell AJ, Lawrence D. Revascularisation and mortality rates following acute coronary syndromes in people with severe mental illness: comparative meta-analysis. Br J Psychiatry. 2011 Jun;198:434-41.2.Fox KA, Poole-Wilson PA, Henderson RA, Clayton TC, Chamberlain DA, Shaw TR, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomized Intervention Trial of unstable Angina. Lancet. 2002 Sep 7;360(9335):743-51.3.Holmes DR, Jr., Kereiakes DJ, Garg S, Serruys PW, Dehmer GJ, Ellis SG, et al. Stent thrombosis. J Am Coll Cardiol. 2010 Oct 19;56(17):1357-65.4.Daemen J, Wenaweser P, Tsuchida K, Abrecht L, Vaina S, Morger C, et al. Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study. Lancet. 2007 Feb 24;369(9562):667-78.5.Julius RJ, Novitsky MA, Jr., Dubin WR. Medication adherence: a review of the literature and implications for clinical practice. J Psychiatr Pract. 2009 Jan;15(1):34-44.
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