Schizophrenic patients: physical health and access to somatic care

Eur Psychiatry 1997; 12:289-293 8 Elsevier. Paris

Original

Schizophrenic

patients:

physical

article

health and access to somatic care

F Casadebaig l*, A Philippe 1, JM Guillaud-Bataillez, MF Gaussetz, N Quemada3, JL Terra2 t National

Institute

of Health and Medical Research French Group of Psychiatric (Received

9 April

(INSERM) Unit 302; 2 Lyon University Epidemiology (CFEP, Lyon, France) 1996; accepted

Hospital;

3 WHOCC;

5 June 1997)

Summary - This study concerns the state of physical health and the availability of somatic care for 3,470 adult patients diagnosed as schizophrenic according to the research criteria established by the International Classification of Diseases (ICD-IO F20) and treated in public institutions. These institutions volunteered to participate in the study, whereas the patients were selected at random. Data concerning demographic characteristics, physical health, and access to somatic care are compared to that of a public health survey of a sample of the French population. The present study allows the estimation of ratios for a large number of diseases and of some risk factors among the target group. Heavy smokers and overweight individuals are more numerous among schizophrenics. Pathologies such as epilepsy, diabetes and AlDS infection are overrepresented. Patients’ access to somatic care is more prevalent than that of the :general population overall, similar to that of the less qualified workers or unemployed group. In this study, gender does not appear to allow prediction of care use for schizophrenics in contrast to the general population. schizophrenics

/ epidemiology

I physical

health

/ access to somatic

It is a well known fact that mentally ill patients are more prone to die prematurely. In France, cross-sectional data confirms a high overmortality rate among mentally ill patients under care in the public health system. Despite a historically decreasing trend, this observation remains very significant (Casadebaig et al, 1990). This high overmortality rate is in part due to the mental illness itself, mainly deaths by suicide (Caldwell and Gottesman, 1990; Casadebaig and Philippe, 1992). However, natural causes of death are also overrepresented (Corten et al, 1988). Patients and their psychiatrists have a tendency to underestimate these physical illnesses (Hall et al, 1978, 1980; Farmer, 1987; Koran et al 1989; d’Ercole et al, 1991; Koranyi and Potoczny, 1992). Thus, the availability of somatic care and the recognition of physical illnesses and their treatment need to be reconsidered. The few studies made on the subject show that the availability of somatic care does not seem to diminish in the case of mental illness (Honig et al, * Correspondence:

44 chemin

de Ronde,

781 IO Le VCsinet,

France.

care / risk factors

1992) and that serious physical illnesses are just as frequently treated (Ferguson and Dudleston, 1986; Knutsen and Durand, 1991; Honig et al, 1992 ). In France, there are a lack of epidemiological surveys concerning physical health status among mentally ill patients as well as their access to somatic care. This study focuses on descriptive data of a longitudinal study of a cohort of schizophrenic patients under care in the public health system. The aim of the study is twofold: a better awareness of physical health status and availability of somatic care for the patients; and the determination of specific causes of death by a longitudinal observation of the patient cohort. MATERIAL

AND METHODS

Setting The public psychiatric system covers and is divided into about 800 sectors,

the entire territory each comprising

a

290

F Casadebaig et al

geographical area of 70,000 inhabitants and providing free, in- and outpatient care. Private clinics and private practitioners also exist but the study does not take them into account. The psychiatrists involved volunteered to participate in the study. A randomly selected sample seemed inappropriate because of a too high rate of expected refusal. A call for collaboration was made to the principal psychiatric associations in January 1993 and completed in June 1993, by telephone contact with psychiatrists in a randomly selected sector in each area not yet represented. One out of two of those contacted agreed. From the initial estimation of 3,000 patients needed for the study, 3,470 patients were included. These patients came from 122 sectors (15% of the total) spread out over 73% of the territory. Sectors that agreed to participate through the psychiatric association contacts represented 60 sectors and included 1,680 patients between April and July 1993. The second group acquired by telephone contact also represented 62 sectors and included 1,790 patients between September and December 1993. For the entire group, 23% of the patients were inpatients, 14% were part-time inpatients, and the others were outpatients.

Patients Every patient, male or female, aged 18-65 years, in- or outpatient, who had previously been treated in the psychiatric sector and who were diagnosed as schizophrenic according to the research criteria established by the tenth review of the International Classification of Diseases (ICD-10 F20) were eligible. The glossary and research criteria were sent to the psychiatrists and the instructions for use were discussed with them. All patients, seen once during a given period (3 months maximum) within each sector, were included. Inpatients hospitalized for more than 1 year were excluded (it was believed that their access to private practitioners was not similar to that of the general population, which was the control group in the study). The questionnaire was designed to compare the results to those of the survey made by INSEE-CREDES (KS) in 1991, among a representative sample of French residents concerning health status and use of somatic care. The main comparisons concern current physical illnesses, previous somatic hospitalizations during the last 6 months, and visits to the general practitioner and specialist during the previous month. The weight, height, and use of tobacco were also compared. At first, the ICS recorded the diseases the subjects themselves declared after consulting a list of illnesses; however, this manner of recording results in an overestimation of functional diseases. Secondly, the investigators made a visit every 3 weeks for 3 months to record

Table I. Sociodemographic characteristics of 3,470 schizophrenic patients compared to the general population (INSEECRJZDES survey). Patients

General

population

% of men old old % Marital status Unmarried Married 8 Study level Elementary University Mean age Men Women 20-64 45-64

years years

64 52

48 48

77 12

20 64

34

24 20

11 37.8 (3 0.5) 42.2 (i 0.7)

39.4 (2 0.3) 39.7 (+ 0.3)

all medical care received. Consequently, they could ascertain which diseases were actually being treated. In our study, data concerning health status ‘were gathered by the psychiatrist in charge of the patient. In both studies,we considered only the diseases that were treatedeither by a therapeuticact (prescription),by hospitalization during the last 6 months, or by a medical consultation during the previous month.

Analysis Comparisons

were made after adjustment

on age and

gender.A standardizedmorbidity ratio (SMR) was used to determinethe relative frequency of a given variable among the schizophrenic patients as compared to the general population (Bouyer et al, 1993). When the SMR

is over 1, the risk is overrepresentedamon,gthe patients. The statistical comparisons were made by means of a chi-square calculation (1 df/P < 0.05). Data was computed with SAS@ software and Vax 4000@ hardware.

RESULTS The two samples,taken before and after June 1993 (despite different recruitment methods), do not present any statistical differences. The age and sex distribution of the 3,470 patients is similar to the national sample of schizophrenics (Boisguerin et al, 1994). Sociodemographic characteristics The sociodemographic characteristic:s of schizophrenic

patients

under

care in psychi,atric

sectors

(SPPS) are not similar to those of the ICS (table I). The proportion of males is higher arnong SPPS,

Schizophrenic

patients:

physical

Table II. patients survey).

Tobacco use: > 20 cigarettes/day % SMRKS 3.0” * SMRIRG 2.4” Obesity % SMR/ICS I .7** 0. SMRJRG 1.4” Somatic hospitalizations < 6 months % SMRACS 2.0” * SMR/RG 1.2’ General practitioner consultations 9% SMR/ICS 2.0” 0. SMR/RG 1 .o’* Specialist consultations % 1 S” -0 SMR/RG 1 .o** l l

Women

21 (2.7-3.3) (2.3-2.6)

5.0” 5.0”

;:.l-5.8) (4.4-6.1)

9 ( I .5-2.0) (1.2-l .6)

2.2” 1.9”

2;2.&2.5) (1.7-2.1)

9 (1.7-2.3) (1.1-1.4)

1.2 (Ok2.3) 1. I (0.9-1.3)

24 (1.8-2.1) (0.9-l. 1)

1.9”::.7-2.1) 0.9” (0.8-I

$3-1.6) (0.9-I .I)

1.0 0.7”

care

291

Obesity (table II) is usually defined as a 20% weight excess from the upper limit of the standardized weight/height ratio calculated for each gender. The SMR is increased among both SPPS male patients (1.7) and female patients (2.2). In comparison with the RG, this difference is reduced but remains significant.

Medical characteristics of 3,470 schizophrenic compared to the general population (INSEE-CREDES

MetI

health and access to somatic

Access to physical

care

mostly before 45 years of age. Male SPPS are, on average, younger than males of the general population and an opposite pattern can be observed among female SPPS. SPPS marital, academic, and occupational status are influenced by a higher disability level (more unmarried individuals and more individuals with a lower educational level). Twelve percent of the SPPS are salaried, 6% are receiving unemployment benefits, and 71% are on welfare. When SPPS are employed, they are mainly blue collar workers and clerks. Consequently, a comparison has been made with a subgroup of the ICS including exclusively non-unemployed non-retired individuals, blue collar workers and clerks. This subgroup in the study is called the restricted group (RG).

Hospitalization for a physical problem within the last 6 months (table II) is more frequent among male SPPS (two-fold increase); this significant difference is reduced when compared with the RG. This finding is not noted among female pat.ients. Yet, female SPPS are more often hospitalized for physical reasons than ICS women if obstetrical reasons are excluded (SMR = 1.5, P < 0.05); however, the difference is not more significant in comparison with the RG (SMR = 1.2). Childbirth is less frequent among schizophrenic patients and this difference might explain why hospitalizations are not more frequent. For both genders hospitalization for a physical reason is more likely to occur when the patients were hospitalized (in psychiatry) than when they were included as outpatients at the time of inclusion (respectively, 2.6 vs 1.8 for males and 1.7 vs 1.1 for females). For male SPPS, medical consultations within the last month are significantly more frequent in comparison with the general population: SMR = 2 for general practitioners (table II) and SMR = 1..5 for specialists (table II). There is no longer any ddfference when SPPS are compared to the RG. The same pattern can be seen for visits to the dentist. For women, general practitioner consultations (table II) are more frequent when compared to ICS (SMR = 1.9) and do not differ when compared to the RG. Visits to specialists (table II) are as frequent as in the general population and significantly less frequent than among women of the RG. Again, these findings seem to be related to the lower frequency of pregnancy among these psychiatric patients. Schizophrenic women visit the dentist as often as women of the general population and less than the RG (SMR = 0.5).

Risk factors

Physical

SPPS are more frequent smokers (56%) than the ICS (33%). Heavy smokers (~20 cigarettes/day) make the difference, since there is a three-fold increase in frequency for males and a five-fold increase for females (table II). This difference is only slightly diminished in comparison with the RG.

The ratio of physical illnesses is higher among psychiatric male and female patients for ep,ilepsy and diabetes mellitus (table III); 1% of male and 2% of female SPPS had to be treated for diabetes mellitus in the last month, which means a fourand a two-fold increase, respectively, in cornpari-

l

l l

l

l

SMIulCS

SMR/ICS: standardized morbidity ratio/INSEE-CREDES vey; * SMR/RG: standardized morbidity ratio/restricted Chi-square; test: * P < 0.01; **P < 0.00 1.

l

l

.02)

$.9-1.1) (0.7&S) surgroup.

illnesses

292

F Casadebaig

Table III. Number of patients Comparisons to the general survey). Pathologies (International Classification of diseases-9th revision [ICD9/” Diabetes (250) Epilepsy (345) AIDS (079) Acquired hypothyroidism (244) Malignant neoplasm ( 14&208) Heart disease (410-414,42&459) Hypertensive disease (401-405) Asthma, emphysema, chronic bronchitis (491-493) Rheumatism (725-729) Diseases of oesophagus, stomach, and duodenum (530-537) Hernia (550-553) Eczema, psoriasis (692499)

treated for certain pathologies. population (INSEE-CREDES

Men NO of patients

W0t?lefl

SMR*

No of patients

SMR’

24 26 I 4

4.0’ 6.0’ 5.8’ 8.0

30 8 1 9

2.0 2.2’ 1 .o 0.8

10

1 .o

14

1.1

30

1.0

20

0.2’

51

2.0’

33

0.5’

27

2.6’

12

0.8

I

1.9

2

0.2

11

2.4’

2

0.3

2

2.0

1

0.2

18

1.6

9

0.3’

*Standardized morbidity ratio (SMR) Chi-square ** ICD-9 was used due to the unavailability somatic diseases at the time of writing.

test: P < 0.05. of ICD-IO for

son with the ICS. Ratios for epilepsy are 6 for males (1%) and 2.2 for females (0.6%), respectively, when compared to the ICS. Otherwise, we observe a high rate of acquired immunodeficiency syndrome (AIDS) among male SPPS (0.3%), which represents a six-fold increase in comparison with the ICS, and a single case among females as expected in the general population. Moreover, 18 asymptomatic patients are infected with human immunodeficiency virus (HIV) (15 males and three females), representing a 0.5% rate, which is a seemingly high rate in the absence of available data for the general population. The frequency of cancer appears to be similar among the SPPS and the ICS. The frequency of cardiovascular diseases is similar among male patients and much lower among female patients when compared with the ICS. Other illnesses are generally more frequent among male patients and less frequent among female patients than in the general population.

et al

DISCUSSION As mentioned earlier, these findings (concern only the patients in care in the public health system, excluding long-term inpatients. The two types of inclusion procedure do not introduce a sampling bias since the sample characteristics appear to be very similar between the two subsamples. Overall, our study sample did not differ from the available data concerning patients in care in the French public health system according to age and gender distribution. The observed overrepresentation of males among schizophrenics is in accordance with the previous published findings. A hypothesis for this excess has been suggested by Htiner (1995): the disease might occur later among female patients. The average younger age of the mabe patients in this study supports this hypothesis: the first admission occurs, on average, 2 years earlier among males than among females (25.7 vs 27.8, P < 0.05). The observed overrepresentation of males among schizophrenics has been discussed in numerous studies in the last few years (Angermeyer and Kiihn, 1988; Castle and Murray, 1991; Iacono and Beiser, 1992; Lewis, 1992). Because schizophrenia is accompani.ed by a high disability level, the social and cultural status of patients is impaired in comparison to the control group; however, 11% of the patients obtained a university degree. For most of these patients, the first admission occurred later. Substance abuse, habits, and use of health services are influenced by socioeconomic status. In this study, the behavior of schizophrenics appears to confirm this, since their substance abuse, habits, and use of heath services are very similar to those of the RG. However, ratios of patients for tobacco use, obesity, and hospitalizations for a physical problem remain significantly higher ,than the RG and this suggests a specific effect of their illness. Patterns of health service use usually differ between males and females in the general population: women use the services more (Les FranGais et leur santC, 1991). Among the ICS sample for 18 to 65 year olds, 11% of the females and only 1.6% of the males receive care for a cardiovascular condition compared with I .5% and 1.6%, respectively, for male and female patients. In this study, the gender does not appear to allow predi’ction of care use for schizophrenics in contrast to the general population. On the whole, this study did not demonstrate a less frequent use of somatic health services by schizophrenic patients, with the exception of visits to the dentist. This conclusion concords

Schizophrenic patients: physical health and access to somatic

with previous published findings (Honig et al, 1989). This observation does not eliminate the possibility that these patients would actually need more care; however, the hypothesis of an overmortality rate caused by a limitation of access to somatic care cannot be assumed. Certain diseases that are overrepresented among schizophrenics in the study sample were already described in previously published articles. Epilepsy was found in association with psychiatric disorders (Baldwin, 1979); HIV infection is associated with risk behavior (drug addiction and sexual habits). The association of diabetes mellitus and depression in the primary care system (Weyerer et al, 1989) as well as diabetes and obesity (Gopala Swamy and Morgan, 1985) should be the subject of further research. Other diseases do not occur more frequently among schizophrenic patients, although a higher frequency of important risk factors can increase somatic vulnerability. The present study allowed the estimation of ratios for a large number of diseasesand of some risk factors among the target group SPPS. The frequency of serious illnesses among the mentally ill in comparison to control groups has to be studied further in order to better understand the roles of environment, prescriptions and chemical or psychosomatic effects (Gulbinat et al, 1992). ACKNOWLEDGEMENTS This research was funded by Grant 97 from the National Public Health Network. The authors wish to thank the many mental health professionals in public psychiatric sectors in France who assisted with the project.

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