Ulster University

Academic Institute

Prof Gerry Leavey

Administrative Data Research Centre Northern Ireland (ADRC NI)Ulster University

E066

People with severe mental illness (SMI) (schizophrenia, bi-polar disorder, and personality disorders) and those with neurodevelopmental disorders (NDD) (Autism, ASD and ADHD) have a reduced life expectancy (15-20 years) when compared with those in the general population, mostly due to preventable causes, multiple-morbidities, poor diet and problematic lifestyle behaviours such as smoking, alcohol and substance misuse. These problems are compounded by low self-esteem, stigma and poor physical healthcare provision. Thus, suboptimal contact with GPs, delayed screening, late detection and diagnosis may lead to treatment at advanced stages of disease in those with SMI. In March 2020, the World Health Organisation declared the novel coronavirus (COVID-19) pandemic (WHO, 2020). People with SMI and those with NDD appear to have a higher risk of contracting COVID-19 due to the chronic nature and the physical health problems that accompany illness. Therefore, there is a need to explore the impact of COVID-19 on the medical outcomes in physical healthcare for those with SMI with or without COVID-19 compared to a hospital population without SMI and COVID-19. This may provide better evidence on disparities, opportunities for early diagnosis, and gaps in screening and treatment. Our study is intended to assist policy makers, service providers and health practitioners in addressing this major health gap. The proposed project will use the diagnostic codes provided with hospital records to examine age and sex-specific outcomes (patterns of hospitalisation, duration of stay and treatment, medication use, emergency care, treatment and mortality) for people with SMI and/or NDD with or without COVID-19 who have serious life limiting diseases such as cancer, coronary heart disease (CHD) and diabetes – compared to people in the general population without SMI and COVID-19.

Parity of esteem between mental health and physical health services has become a significant policy issue in the UK. People with SMI or NDD die at much younger ages (Hollins et al, 1998; Saha et al, 2007) and may be at higher risk of COVID-19 (Wang & Volkow, 2020; Li et al, 2020) than the general population. Their prior vulnerability to poor physical health includes high prevalence of obesity, type 2 diabetes and CHD (Lawrence & Hancock, 2013; Vancampfort et al., 2016). However, there are additional concerns that the pandemic and quarantine may have worsened the physical and mental health of these patient groups compared to the general population. Thus, psychiatric symptoms are likely to be exacerbated by increased anxiety, loneliness and social exclusion, and poor health-related behaviours (e.g., diet, smoking and alcohol use). Moreover, historical inequalities associated with healthcare access may also have increased due to reduced primary care and community support. To our knowledge, no other study has assessed the impact of the pandemic on these patient groups. The proposed study is one strand of the ADRC-NI Strategic Impact Programmes (SIPs) which have been funded as a major investment by the ESRC in order to assist in government priorities. As such, we consulted on our proposed research with the Department of Health and gained the agreement of the Chief Medical Officer. We will provide a detailed understanding of the impact of the pandemic on physical health care in relation to people with SMI/NDD and examine the efficiency of services in managing these problems. Our findings will inform strategies around the prevention of premature mortality in this cohort. The findings will improve our understanding of risk factors, particularly in relation to the likelihood of poor detection among disadvantaged groups living in either areas of high deprivation or in rural areas. In the UK 15 million people (approx.) experience life-limiting conditions, with close to 7 million experiencing multi-morbidities (Department of Health, [DoH] 2014). Multi-morbidity has more than doubled between 2003/2004 and 2015/2016 (Deeny, Thorlby & Steventon, 2018). The Department of Health, Northern Ireland (NI) reported 1966 deaths of COVID-19 and 108,027 positive cases dated on 11th February 2021 (DoH, 2021). This research will inform policy makers and the public where to efficiently allocate spending towards services and pathways to care, such as better screening for the SMI and COVID-19 population. Even prior to the COVID-19 pandemic, people with SMI (e.g., psychoses or bi-polar disorder), and NDD (Autism, ASD, ADHD) had poor health outcomes when compared with the general population. These patients have worse general health, particularly related to preventable diseases such as cardiovascular disease (CVD), cancer, diabetes and obesity. For example, research shows that excess mortality in up to 80% of cases can be attributed to other physical disease such as heart disease, lung disease and cancer (Lawrence & Hancock, 2013). A recent meta-analysis suggests approximately one third of people with SMI have metabolic diseases and 10% have type-2 diabetes (Vancampfort et al, 2016). Cancer, following CVD, is the second leading cause of death in people with SMI (Tran et al, 2009). In this group, advanced stage illness and cancer metastasis contribute to increased mortality because of improper screening and delayed diagnosis (Crump et al, 2013). Findings suggest increased premature mortality in those with SMI, possibly because of disparities in screening and treatments with people with SMI less likely to receive routine cancer screening (Xiong et al, 2008; Martens et al, 2009). People with SMI or NDD have a greater risk of COVID-19, and consequently likely to have higher rates of hospitalisation, morbidity and mortality (Wang & Volkow, 2020; Li et al, 2020). The World Health Organisation has reported over 90 million cases and more than 1.9 million deaths globally of COVID-19 on the 13th January 2021 (WHO, 2021). Risk factors that may cause the severe effects in individuals with COVID-19 and SMI include concomitant medications, physical comorbidity, decreased access to medical care, poorer premorbid general health, and lifestyle and environmental factors e.g., smoking, lower socioeconomic status, obesity or overcrowding (Xiang et al, 2020). Wang & Volkow, using data from the United States (US) electronic health records, found that patients diagnosed with a mental disorder had a significantly higher risk of COVID-19 (Wang & Volkow, 2020). Similarly, Li et al reported that (in the US) risk of COVID-19 after controlling for other medical comorbidities, demographic features and hospital location mortality was significantly higher in people with a psychiatric disorder (Li et al, 2020). There is an urgent need for early detection and intervention for physical health problems in people with SMI (with or without COVID-19) compared to the general population; this group records lower life expectancy because of co-morbid physical conditions such as cancer, diabetes and heart disease, and although the evidence base has grown substantially over the last ten years. Little is known about possible disparities in the clinical pathways of these disorders amongst people with SMI/NDD and the impact of the pandemic and quarantine. To date, there is no study about the impact of the pandemic on the premature mortality, rates of suicide/suicidal behaviour and preventable co-morbid physical health in those with SMI/NDD in NI. Also, to the best of our knowledge there is no research changes to prescribed medication (e.g. increased or lowered amounts of anti-psychotics and/or tranquillisers/antidepressant). The study will provide evidence for policy-makers, service commissioners in both mental and physical health care, informing efficient resource allocation. The study findings will also be of use to academics, service users and carers. Although NI has a relatively homogenous population, the findings will be generalizable to other parts of the UK and internationally. Given that the base-line databases are already available (or will shortly be available) as a standard part of ADRN-NI function, it should provide a springboard for similar data configurations to be developed elsewhere in the UK and for analyses of this kind to be extended.

07/07/2021

Anonymous

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One-off

TRE