Receipt of preventive medical care and medical screening for patients with mental illness: a comparative analysis

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General Hospital Psychiatry 32 (2010) 519 – 543

Receipt of preventive medical care and medical screening for patients with mental illness: a comparative analysis Oliver Lord, M.R.C.Psych.a , Darren Malone, M.R.C.Psych.b , Alex J. Mitchell, M.R.C.Psych.c,d,⁎ a Leicester Partnership Trust, Leicester, UK Lakes District Health Board, Rotorua, New Zealand c Department of Psycho-oncology and Liaison Psychiatry, Leicester General Hospital, LE5 4PW Leicester, UK d Department of Cancer and Molecular Medicine, Leicester Royal Infirmary, Leicester, UK Received 29 October 2009; accepted 21 April 2010 b

Abstract Background: There has been long-standing concern about the delivery of preventive and screening services to patients with mental illness. Objective: We aimed to examine whether the quality of preventive care received by patients with mental health conditions differs from that received by individuals who have no comparable mental disorder. Our hypothesis was that patients with mental illness would be in receipt of lower quality or lower frequency of preventive care. Method: Studies that examined the quality of care in those with and without comorbid mental illness were reviewed and comparative data extracted. By using only comparative studies we hope to ascertain whether inequalities in care existed by virtue of psychiatric diagnoses (or closely affiliated factors). Results: We identified 26 studies that examined preventive care in individuals with vs. without psychiatric illness. From these eligible studies, 61 comparisons were documented across 13 health care domains. These included mammography, cervical smears, vaccinations, cholesterol screening, lifestyle counseling, colonoscopy. Twenty-seven comparisons revealed inferior preventive health care in those with mental illness, but 10 suggested superior preventive health care and 24 reached inconclusive findings. Inferior preventive care was most apparent in those with schizophrenia and in relation to osteoporosis screening, blood pressure monitoring, vaccinations, mammography and cholesterol monitoring. Conclusions: We conclude there is strong evidence to suggest that the quality of preventive and screening services received by patients with mental illness is often lower, but occasionally superior to that received by individuals who have no comparable mental disorder. More work must be done to improve the quality of medical and preventive care for individuals with mental illness. © 2010 Elsevier Inc. All rights reserved. Keywords: Preventive medical care; Medical screening; Mental illness

1. Introduction There is long-standing concern about the physical health of people with mental health problems [1–3]. Among those with mental illness, there is higher than expected mortality rate and higher rates of medical comorbidity compared with the general population [4]. People diagnosed with psychiatric illness also carry a higher rate of background risk ⁎ Corresponding author. Department of Liaison Psychiatry, Leicester General Hospital, LE5 4PW Leicester, UK. Tel.: +44 0116 225 6218; fax: +44 0116 2951951. E-mail address: [email protected] (A.J. Mitchell). 0163-8343/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2010.04.004

factors including obesity, dyslipidemia, hypertension, cigarette smoking, physical inactivity and HIV risk behaviors [5–7]. Surveys suggest that psychiatric patients consider their receipt of primary care to be lower than the general population [8] and there is evidence to support this belief [9,10]. For example, data from the 1999 Large Health Survey of Veterans (LHS) found that veterans with either schizophrenia, bipolar disorder or a drug use disorder were less likely to have had any primary care visit than those without these diagnoses, even after controlling for medical comorbidity [11]. A recent systematic review showed continued deficits in the quality of care of medical disorders for those with known mental health diagnoses, although that review

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did not examine preventive services [12]. Recently, increasing attention has been given to the standard of preventive care for those at risk of, but not formally diagnosed with, medical disorders. About 50% of the general population does not receive recommended screening at the appropriate time [13], and this issue appears to be more acute in those with mental health diagnoses. Indeed, early studies suggested that psychiatric patients may not receive the same quality or frequency of preventive services [14–17]. More recent research highlighted that among those with a mental health diagnosis, 50% of eligible persons over age 50 had never received colorectal cancer screening and 31% have not received screening for cervical cancer in the past 3 years [18]. Similarly, less than 60% of low-income women over the age of 40 years under psychiatric care have received screening mammography [19]. Lack of screening and related services is important not just for the reduction in future morbidity but also because low receipt of preventive care is associated with lower quality of life [20]. An analysis of National Ambulatory Medical Care Survey data showed that psychiatrists provided preventive services to people with serious mental illness (SMI) during only 11% of visits [21]. Possible deficits in preventive services might extend beyond mental illness per se. For example, individuals without formal mental ill health but with recognized distress have been shown to have low mammography utilization [22]. Against this evidence, a cross-sectional analysis of primary care visits from the National Ambulatory Medical Care Survey showed that patients with SMI had a higher continuity of primary care and actually received more preventive counseling than the general population [23]. Unfortunately, most early studies and many recent studies had no comparator group without mental illness, making interpretation difficult. We therefore wished to examine whether the quality of preventive care received by patients with mental health conditions differs from that received by individuals who have no comparable mental disorder. Our primary hypothesis was that individuals with mental illness (or substance abuse) would be in receipt of lower frequency of preventive care or screening services.

2. Methods 2.1. Inclusion/exclusion criteria We examined preventive health care in otherwise healthy populations with and without mental illness. Our definition of preventive health care was “an intervention targeted at a population prior to clinical suspicion of a diagnosis designed to establish an early diagnosis or minimise future physical complications.” We included all interventions of highquality preventive care including age- and gender-stratified screening, advice and vaccinations for adults. We intentionally allowed a broad definition of mental illness and mental disorder in order to yield representative results.

2.2. Search Medline and Embase abstract databases were searched from inception to March 2010. The search strategy is shown in Appendix A. Five full-text collections were searched: Science Direct, Ingenta Select, Springer-Verlag's LINK, Wiley-Blackwell Synergy and Ovid Full text. In these online databases, the same search terms were used but as a full-text search and as a citation search. The abstract/citations databases Web of Knowledge (4.0, ISI) and SCOPUS were searched, using the above terms as a text word search and using key papers in a reverse citation search. Finally, a number of journals were hand searched and several experts contacted. The data extraction was performed in accordance with Quality of Reporting of Meta-Analyses guidelines. 2.3. Critical appraisal QUADAS has been recommended by the Cochrane Diagnostic Test Accuracy Working Group as the assessment tool of choice for systematic reviews of all diagnostic accuracy studies [24]. Critical appraisal guidelines provided by the Oxford Centre for Evidence-Based Medicine [25] and criteria suggested by Craig et al. [26] were adapted. Two reviewers examined all the primary studies. Studies were appraised using an 18-point scale in five categories: study design, quality of the sample under study, adequacy of comparators, adequacy of consideration of possible confounding factors and differentiation of screening tests from diagnostic test (where applicable) (see Table 1 for further details). In addition, we assessed the setting of each study and the type and severity of mental illness under study. In cases where there was disagreement concerning methodological quality, the lowest value was chosen.

3. Results Our preliminary search identified 429 references (see Fig. 1 for details). Of these, 73 were primary data studies but only 32 specifically examined preventive care in individuals with mental health problems. These were reviewed in detail (see Table 1). We excluded studies without a defined mental disorder but included distress (Table 2). Forty-one studies were excluded: 33 because they did not include a comparison group; four did not present primary data; four studies examined screening in those with comorbid physical and mental illness that is reviewed elsewhere [12]. After these inclusion and exclusion criteria were applied, we found 26 publications involving 13 areas of preventive care in individuals with vs. without psychiatric illness. These involved mammography (n=17); cervical smear testing (n=10); vaccinations (n=6); lifestyle counseling for exercise or smoking and/or diet (n=5); blood pressure monitoring (n=4); cholesterol screening (n=4); colonoscopy (n=4); clinical breast examination (n=2); aspects of fracture prevention and osteoporosis (n=2);

Definition of mental illness

Intervention measured

Retrospective case control study. Looking at osteoporosis screening and fracture prevention

Large retrospective cohort study looking at all members of an insurance scheme looking at mammography in mental illness Because of the degrees of separation ends up with 30 different categories of mental illness many nb40 despite starting with population of 191,000

Database study from Population Health Research Data Repository, Manitoba

Annual survey of office-based physician encounters during one random

Carney and Jones (2006) [28]

Chochinov et al. (2009) [29]

Daumit et al. (2002) [23]

Manitoba, Canada

USA

Severe mental illness group more likely to be obese and to smoke. Same levels

Iowa USA

Iowa, Nebraska, Missouri, Illinois

Two-year probability of mammography was 44.8% for those with schizophrenia and 58.3% for those without (adjusted OR 0.64)

Low: neither. Not Significant Sexual disorders not significant, all other diagnoses show a similar pattern except psychotic disorders: Low severity: OR 0.59 (95% CI 0.45–0.78) Medium severity: OR 0.47 (95% CI 0.33–0.67) High severity: OR 0.56 (0.26–1.21)

Adjusted odds ratio for ever having mammography High severity: hospitalization and dual diagnosis (OR 0.38, 95% CI 0.33–0.43) Medium severity: either hospitalization or dual diagnosis (OR 0.62, 95% CI 0.59–0.66)

Schizophrenia group less likely to receive HRT (28% vs. 54%, P=.01), receive any osteoporosis drug (48% vs. 78%), receive any drug or had documented screening (61% vs. 80%. P=.039) Under powered to detect of those who received screening if any drug prescribed

Well Americans

All women 50–69 years

Privately insured female Iowans age 40–64 with more than 12 months of contact

Veterans Affairs medical centers and ambulatory clinics. Women over 45 years with more than 12 months of progress notes

Computer coded ICD-9 diagnosis of psychosis schizophrenia or

Computer coding of schizophrenia

DSM-IV adjustment anxiety, mood, psychotic, sexual, sleep, somatoform, substance and other

ICD-9 290–319, 607.84, 608.89, 625, 625.80, 780.09, 780.52, 780.54, 780.59, 787.60

Schizophrenia ICD-10

2

Counselling for diet and exercise

Survey but repeated yearly over 6 years

1

Quality rating

2 Retrospective case-control study

Mammography

Quality rating

Retrospective cohort 2

Quality rating Mammography

Had screening for osteoporosis±drug Dexa scan, risk factor assessment questionnaire or counselling tool

Retrospective case control, all from same data base only difference was mental illness. Excluded other mental illness from control group in either

Prescription of HRT, osteoporosis-related drug (bisphosphonate, calcium, calcitonin, raloxifene)

(a) Study design

Population

Methodological rating Country

Description of the study

Main findings

Descriptive aspects

Bishop et al. (2004) [27]

Author and year/ research method

Methodological summary preventive care studies

Table 1

118,145

5

N=110,240

5

N=191,000

1

92

(b) Sample size

3 Age, gender ethnicity, geographic region, source of payment

“Cohort” group, only difference at intake is having SMI

Age, average household income, continuity of care, and physical comorbidity

2

Not screening

2

Outcome over 2-year period

1

1 Excluded rapid follow-up but did not distinguish between diagnostic and screening

2

Allowed for fractures as a confounder

(e) Differentiated screening from diagnostic tests

Age, “months of eligibility for mammography, ” non-mental health visits to GP and OBGYN, severity of mental disorder, urban vs. rural

Age and race, smoking and alcohol status, bone fractures

(d) Consideration of confounders

1

No formal matching

2

Only difference was presence of mental illness

Large cohort

Controlled for confounders

2

Used VA database to select all 45-year-old women then found 46 with mental illness, randomly selected 46 controls from the remainder

(c) Adequacy of comparator matching

Score

(continued on next page)

12

12

8

Overall quality rating/18

O. Lord et al. / General Hospital Psychiatry 32 (2010) 519–543 521

EPRP large Case note review veterans hospitals across USA, 1998–1999

EPRP 600 Randomly selected case notes from each clinic then reviewers looked at each file for use of preventive services

Druss et al. (2002) [43]

Pneumonia vaccination ever, OR 0.95 (95% CI 0.93– 0.96). Influenza vaccination in last year (over 65 years or high risk), OR 0.9 (95% CI 0.87–0.94). FOBT in last year or sigmoidoscopy in last 5 years, OR 0.95 (95% CI 0.91–0.99). Mammography in last 2 years for women 50–69, OR 0.78 (95% CI 0.67–0.91) Discussion about PSA test, OR 0.78 (95% CI 0.67–0.91) Current smoking status, OR 1.17 (95% CI 1.08–1.27). Smoking cessation counselling or

Adjusted odds ratios for no mental illness vs. mental illness

Group 4: Dual diagnosis: Nutrition counselling in last 2 years (90.4 vs. 90.9 vs. 89.6 vs. 88.4%, P=.001) Exercise counselling in last 2 years or documentation (88.7 vs. 88.5 vs. 86.3 vs. 85.7, P=.001) Counselling for both (86.0 vs. 85.8 vs. 83.2 vs. 82.0, P=.001)

Group 3: Substance misuse

Group 1: No mental illness Group 2: ICD-9 codes 290–302 and 316–319

USA

National USA

Veterans with selected high volume medical diagnoses: diabetes mellitus, ischemic heart disease, chronic obstructive pulmonary disease, high blood pressure, obesity and more than 3 clinic attendances in last year

EPRP: Veterans with selected high volume medical diagnoses: diabetes mellitus, ischemic heart disease, chronic obstructive pulmonary disease, high blood pressure, obesity and more than 3 clinic attendances in last year. Focused on obese and hypertensive

1. No MI 2. MI ICD-9 290–302+306–319 (mental illness, not including substance misuse) 3. Substance

Four groups:

From veterans notes in the last year

2. MI ICD-9 290–302+306–319 (mental illness, not including substance misuse) 3. Substance 4. Dual diagnosis

1. No MI

Four groups:

bipolar disorder or recurrent prescription of antipsychotics or lithium

Pneumonia vaccination ever, influenza vaccination in the last year (over 65 years old or high risk), FOBT in last year or sigmoidoscopy in last 5 years Mammography in last 2 years for women 50–69 Discussion about PSA Current smoking status

Quality rating

Nutrition counselling in last 2 years Exercise counselling in last 2 years or documentation of exercise already being done

Quality rating

4 N=11,3505

Cross sectional

N=90,246

5

(b) Sample size

1

Cross sectional

1

of counselling for diet/weight, exercise, other lifestyle counselling

week. No database, only what physician recorded

Intervention measured

(a) Study design

Definition of mental illness

Methodological rating Population

Description of the study

Country

Main findings

Descriptive aspects

Desai et al. (2002) [30]

Author and year/ research method

Table 1 (continued)

Only difference is mental illness

3

Only difference is mental illness

3

(c) Adequacy of comparator matching

Age gender race, distance to hosp, level of disability caused by military service because this can give priority care, Medical comorbidity Facility level characteristics, academic funding, hospital size, mental health funding

3

Age, gender, race, distance to hospital, medical comorbidity Facility level characteristics, academic funding, hospital size, mental health funding

3

(d) Consideration of confounders

N/A

N/A

NA

(e) Differentiated screening from diagnostic tests

Score

11

12A

Overall quality rating/18

522 O. Lord et al. / General Hospital Psychiatry 32 (2010) 519–543

Druss et al. (2008) [32]

NHIS 1999 Looked at depression treatment in specialist prim care for receipt of preventive medicine

Primary care vs. not depressed Lacking BP, OR 0.99 (95% CI

Speciality care vs. not depressed Lacking BP, OR 1.01 (95% CI 0.84–1.18) Lacking FOBT, OR 0.96 (95% CI 0.80–1.12) Lacking Pap smear, OR 1.17 (95% CI 0.94–1.12) Lacking mammogram, OR 1.22 (95% CI 1.03–1.44) Lacking influenza vaccination, OR 1.11 (95% CI 0.90–1.36)

Untreated depression vs. no depression Lacking BP, OR 1.10 (95% CI 1.01–1.11) Lacking FOBT, OR 1.21 (95% CI 1.13–1.29) Lacking Pap smear, OR 1.43 (95% CI 1.30–1.56) Lacking mammogram, OR 1.32 (95% CI 1.22–1.42) Lacking influenza vaccination, OR 1.51 (95% CI 1.4–1.62)

Adjusted odds ratio for, depressed vs. not depressed, not receiving an intervention Lacking BP, OR 0.99 (95% CI 0.95–1.04) Lacking FOBT, OR 1.11 (95% CI 1.04–1.18) Lacking Pap smear, OR 1.17 (95% CI 1.11–1.23) Lacking Mammogram, OR 1.22 (95% CI 1.18–1.26) Lacking influenza vaccination, OR 1.24 (95% CI 1.18–1.30)

referral, OR 1.10 (95% CI 1.00–1.20)

National USA

Nationally representative sample of civilian, noninstitutionalized female US residents

3. Depression with primary care 4. Depression without any care

1. No depression 2. Depression with speciality care

Four groups generated:

Depression module of the composite international diagnostic interview short form symptoms for 12/12 Receipt of four out of five preventative services FOBT in those over 50 year old, Pap smear for women under 65 years, mammogram in women over 40 years old, influenza vaccination in over 50 year olds Blood pressure

Quality rating Survey

1 N=30,801

5 cohort

3 Age gender, income race, insurance status, comorbidity

3 0

0

(continued on next page)

12

O. Lord et al. / General Hospital Psychiatry 32 (2010) 519–543 523

Definition of mental illness

Intervention measured

Cross-sectional, postal survey

1994–1995 NHIS, subgroup of this were asked questions about preventative care

Iezzoni et al. (2001) [47]

Proportions, for those without mental illness vs. with serious mental illness Cholesterol level checked in last

Adjusted OR for those without vs. with serious mental illness Pap smear in last 3 years in 18–75 years old, OR 1.2 (95% CI 0.8–1.8) Mammogram in last 2 years in over 50 years old, OR 0.6 (95% CI 0.4 – 1.1) Breast exam in last 2 years, OR 1.0 (95% CI 0.6–1.4) Smoking status recorded, OR 1.5 (95% CI 1.1–2.2) Exercise status recorded, OR 1.6 (95% CI 1.2–2.1)

Ever had mammogram, OR 1.37 (95% CI 1.04–1.81)

History of depressive symptoms vs. not Influenza vaccination within 1 year, OR 0.08 (95% CI 0.94–1.24) Pneumonia vaccination ever, OR 1.1 (95% CI 0.92–1.36) Pap smear in the last year , OR 1.14 (95% CI 0.96–1.36)

0.90–1.08) Lacking FOBT, OR 0.98 (95% CI 0.86–1.08) Lacking Pap smear, OR 0.82 (95% CI 0.66–0.98) Lacking mammogram, OR 0.74 (95% CI 0.62–0.86) Lacking influenza vaccination, OR 0.95 (95% CI 0.88–1.07)

USA

Northwest Oregon, southwest Washington, USA

Nationally representative sample of civilian, noninstitutionalized female US residents

Privately insured

“Serious mental health problem” following NHIS-D interview

2. Ever had 2 years were felt low 3. Felt depressed much of the time in the past year 4. Ever been told had depression by a doctor

Screening questions for depression 1. Low for 2 weeks, in the last year

Influenza vaccination in the last year

Discussion of estrogen to prevent bone loss for post/ perimenopausal (40–60 years) Cholesterol level checked in last 3 years

Smoking status Exercise status

Pap smear in last 3 years (18–75 years) Mammogram in last 2 years (over 50 years) Breast exam in last 2 years

Quality rating

Pap smear in the last year Ever had mammogram

Quality rating

Survey

1

Survey

1

(a) Study design

Population

Methodological rating Country

Description of the study

Main findings

Descriptive aspects

Green and Pope (2000) [31]

Author and year/ research method

Table 1 (continued)

N=11,399 women

3

N=5841

3

(b) Sample size

Large cohort, only 2.5% MI

3

Same group

3

(c) Adequacy of comparator matching

Age, ethnicity, education, poverty, no work, obese, low health, depressed, health insurance

2

Age gender, race ethnicity, income, education, self-reported social class

3

(d) Consideration of confounders

0

0

(e) Differentiated screening from diagnostic tests

Score

9

10

Overall quality rating/18

524 O. Lord et al. / General Hospital Psychiatry 32 (2010) 519–543

Cohort study in Veterans Healthcare looking at cholesterol (HDL-C) screening in those over 20 years old every 5 years. Separated data into quartiles (3 months) of outpatient use

As part of the 2004 Veterans Affairs EPRP looked at hepatitis C virus testing in high-risk groups, by CDC criteria

Survey of mental illness and records of mammography. Majority of patients

Kaplowitz et al. (2006) [44]

Kilbourne et al. (2008) [49]

Lasser et al. (2003) [45]

No difference between mentally ill and not-mentally-ill groups for

They found a trend towards increased testing of psychotic patients (95.2%) and depressed patients (94.4%) compared with those with no psychiatric disorder (91.7%), but this result was not significant. They also showed a trend to reduced notification within 60 days of a positive hepatitis C result to those with a psychotic disorder (39% of positive results) compared with 49.9% of those without a mental disorder. Those with depression were more likely to be notified of a positive result (59.3 %). None of these results reached statistical significance

Significantly more likely for mentally ill group to be screened in each successive quartile, not the same for non-mentally ill. Mentally ill group had deceased odds of cholesterol screening in first 3 months, OR 0.45 (95% CI 0.37–0.54); second 3 months, OR 0.5 (95% CI 0.45–0.57). In third and fourth quartiles, this was not significant; by the fourth quartile it was more likely. So eventually do get screened but later in course of care

3 years, 54.5: 50.6% Influenza vaccination in last year, 3.9: 52.4% Discussion of estrogen replacement, 78.6: 84.4%

Massachusetts, USA

USA

USA

New patients in 2 low-income towns in MA, USA

As part of the 2004 Veterans Affairs EPRP

US outpatient veterans

Questionnaire: PRIME- MD Anxiety, mood, ED, PTSD, substance

Sample cross referenced with the Veterans Affairs National Psychosis Registry and National Registry for Depression

ICD-9 Mood or thought disorder, anxiety disorder, PTSD or prescription for any psychiatric med at baseline

Cross-sectional, patient survey 1

2

Quality rating Mammography in the last 2 years

Retrospective cohort

2

Quality rating HCV screening

Retrospective cohort

1

Screening for high cholesterol

Quality rating

N=526

4

n=19,397

4

N=64,490, 10,100 with MI

4

Offered to all new patients in primary care

3

Same group

No data, states took demographics

3

Age, race, ethnicity, gender, marital status, drug use, diagnosis and number of medical comorbidity. Faculty level factors

2

Age, gender, medical illnesses, alcohol and substance use, medical factors, all participant in Veterans Healthcare

“Cohort” group, only difference at intake is having SMI

3

3

2

No distinction

1

Does not differentiate between screening and diagnosis of hepatitis/cirrhosis, but does exclude known hepatitis C and liver cancer

1

Did not differentiate between monitoring of known high cholesterol and screening. But did exclude just cholesterol as incidental to routine bloods. Had to be HDL-C

0

(continued on next page)

13

12

10

O. Lord et al. / General Hospital Psychiatry 32 (2010) 519–543 525

Convenience sample of women with schizophrenia and a matched control group. Rating scales used PANS HAM-D, MMSE Control group responded to advertisement and was significantly older by 7.9 years. (57.6 vs. 65.5 years, P=.001)

Uptake up of the influenza immunization program in the UK shortly after its introduction in 2000

Database study from Population Health Research Data Repository, Manitoba

Lindamer et al. (2003) [39]

Mangtani et al. (2005) [37]

Martens et al. (2009) [41]

Three-year probability of cervical Pap smear was 58.8% for those with schizophrenia

69.9% of Men with depression over 74 years of age were vaccinated, compared with 74.8 % of over 74 year olds without depression (Not Significant). 61.2 % (95% CI 57.1–67.6) of women with depression (n=250) over the age of 74 years of age were vaccinated compared with 66.6% (95% CI 62.8–70.3) of women without depression who were vaccinated

Significantly fewer women with schizophrenia compared with those with no mental illness had had a pelvic exam and Pap smear in the last 3 years (71% vs. 96%, P=.001), mammogram in the last 2 years(68% vs. 98%, P≤.001) or ever had HRT (56% vs. 78%, P=.013)

Manitoba, Canada

UK

All women 18–69 years

Over 74 year old individuals in primary care

Older women with schizophrenia

San Diego, CA, USA

Computer coding of schizophrenia

used the geriatric depression scale with a cut off of 5 to screen for depression

Schizophrenia method unclear

Retrospective case-control study

2

Quality rating Cervical Pap smear

Retrospective cohort

1

Quality rating Influenza immunization

Cross sectional

Pap smear in the last 3 years, mammography in the last 2 years

2

Quality rating

1 Retrospective cohort

Pap smear over 3 years (2004–2006)

Quality rating ICD-9 code excluding schizoaffective disorder

Women 30–69 years old

Taiwan

34.3% of those with schizophrenia vs. 54.8% without received a smear test over a 3-year period (OR 0.35, CI 0.3–0.4)

Receipt of cervical smear test in Taiwan Longitudinal Health Insurance Database

abuse, somatization, psychosis

mammogram in the last 2 years (53% vs. 56%, NS). No individual diagnosis had significant difference

were not English speaking and uninsured. Prevalence of mental illness was 44%.

Intervention measured

(a) Study design

Definition of mental illness

Methodological rating Population

Description of the study

Country

Main findings

Descriptive aspects

Lin et al. (2010) [42]

Author and year/ research method

Table 1 (continued)

N=338,514

3

N=5572

1

N=116

4

N=10,575

2

(b) Sample size

No formal matching

3

Same group

1

Control group volunteered not screened for mental illness and not from same population, significantly older and married

2

Matched for age

2

(c) Adequacy of comparator matching

Age, average household income, continuity of care and physical comorbidity

4

Medical history, low BMI, social support, standardized mortality ratio by electoral ward

2

Age, race, education, marital status, MMSE, menarche, age at first and last births, oral contraception, age at menopause, mastectomy, oopherectomy. Hysterectomy. HRT

2

Age, income, visits, urbanization and location

1

(d) Consideration of confounders

Outcome over 3-year period

N/A

N/A

1

Asked about previous mastectomy, but included 3 in both groups

1

Yes

0

(e) Differentiated screening from diagnostic tests

12A

6

11

6

Overall quality rating/18

Score

526 O. Lord et al. / General Hospital Psychiatry 32 (2010) 519–543

Depressed group were less likely to have breast cancer screen in the last 2 years (48% vs. 53% P=.007, adjusted OR 1.0, 95% CI 0.8–1.2). Not significant but a trend to higher pneumococcal vaccination in the last year and a trend to increased colorectal screening but P=.93, adjusted OR for colorectal screening was 1.3 (95% CI 1.1–1.6) Depressed subjects significantly more likely to use services, more than 4 clinic visits or primary care visits

Interview and follow-up questionnaire study. Looking at depressive symptoms and health care utilization

SWAN multisite longitudinal cohort study in community-based women looking at effects of menopause. Baseline data and then yearly follow-up for 4 years. Data for the last years of screening were related to the previous years' depressive symptom score

Matched case-control study using retrospective note review

PeytremannBridevaux et al. (2008) [33]

Pirraglia et al. (2004) [34]

Roberts et al. (2007) [40]

Blood pressure: Those with schizophrenia were about half as likely to have had their blood pressure recorded during the 3-year study period (adjusted OR

The odds of having a mammogram in the year after scoring a high depressive symptom burden were lower (adjusted OR 0.84, 95% CI 0.73–0.97) No significant relationship for Pap smear screening No effect found for “medical use”

There was no difference by diagnosis of major depression on participation in screening of blood pressure, mammograms and Pap smear tests

Longitudinal data from Canadian National Population Health Survey over 1 year

Patten et al. (2009) [38]

and 67.8% for those without (adjusted OR 0.70)

Birmingham, England

USA: Boston MA; Chicago, IL; Detroit, MI; Los Angeles, CA; Hudson County, NJ; Oakland, CA; Pittsburgh, PA

Europe (Austria, France, Denmark, Germany, Greece, Holland, Italy, Spain, Sweden, Switzerland)

Canada

21–64 year olds, excluding organic brain disorders, dementia or learning disability. Attended GP in the last 3 years

Community-based women from five ethnic groups recruited, 42–52 years old, intact uterus, 1+ ovary, no current estrogen therapy, 1 or more periods in the last 3 months

Noninstitutionalized, over 50 years old, Austria, France, Denmark, Germany, Greece, Holland, Italy, Spain, Sweden, Switzerland

Household residents in 10 provinces from 1994 to 2004

Diagnosis of schizophrenia or persistent delusional disorder according to GP records, mental health trust and CMHT records, notes reviewed to confirm diagnosis

CES-D depression scale, validated at cut-offs of 16 and 20 for diagnosing depression

N3 on Euro-D European validated instrument for diagnosis of depression

Composite diagnostic interview short form

Retrospective case control, not in current scoring system therefore marked lower than retrospective cohort study

3

Quality rating Blood pressure, weight, cholesterol, smoking status, alcohol consumption and family history of heart disease (including provision of smoking cessation advice)

Multisite cohort

1

Quality rating Pap smear, mammography

Cross-sectional survey

2

Quality rating Over 65 years: influenza vaccination Over 50 years: colorectal cancer endoscopy screening, mammography

Canadian National Population Health Survey with crosssectional and longitudinal analysis

1

Blood pressure, mammography and Pap smear

Quality rating

N=975 (175 with schizophrenia)

3

N=3302

4

N=15,380

4

n=7661 (Pap) n=6388 (BP) n=1868 (mammogram)

5

Controls matched at GP practice level from general register and asthma register. Asthma used to allow for the presence of a chronic illness. Cases matched with the

2

Not a true cohort as all volunteers, but looked for depression after selection

1

Only difference is depressive score

1

No formal matching

1

Age, sex, previous significant illness, occasions where health promotion would have been impossible or inappropriate (or more likely)

3

Age, race, ethnicity, comorbid illness, FH breast cancer, insurance, education, marital status, smoking, obesity, income

3

Age, gender, marital status, years of education, household income, smoking, alcohol, chronic disease, disability, country

4

Age, sex, education, residence, comorbidity, income, employment

3

N/A

2

Excluded mastectomy and bilateral oopherectomy; also specifically excluded women with previous breast cancer from mammography data and previous cervical cancer from Pap smear data

1

Excluded previous cancer in colorectal+breast screening

3

Cross-sectional and longitudinal measurement

2

(continued on next page)

13

10

14

12

O. Lord et al. / General Hospital Psychiatry 32 (2010) 519–543 527

Schwartz et al. (2003) [51]

Author and year/ research method

Table 1 (continued)

Definition of mental illness

Intervention measured

Prospective study of first-degree relatives of breast cancer patients. Compared distress with mammography, telephone interview

Roberts et al. conducted a 3-year retrospective case study of preventive health care in people aged 21 to 64 with a diagnosis of schizophrenia in Birmingham, UK, vs. normal controls and a group with asthma in an attempt to reduce the bias of chronic illness

On bivariate analysis, women with higher levels of general distress on the MHI17 were less likely to have obtained a mammogram at follow-up (24.6% vs. 21.1%, P=.01) Multivariate analysis by logistic regression: general distress (OR for having a mammogram 0.8, 95% CI 0.66–0.97)

compared to the asthma group 0.52, P=.03; adjusted OR compared to the general group 0.43, Pb.01) Cholesterol: Only the comparison with the general group reached significance (adjusted OR compared to asthma group 0.57, P=.07; adjusted OR compared to general group 0.46; P=.02) Smoking status: Patients with schizophrenia were less likely than asthma patients to have had smoking status recorded (adjusted OR 0.37, P=.001) Weight: The group with schizophrenia had a trend towards increased recording of their weight but this did not reach significance, compared with the general group (adjusted OR 1.18, CI 0.70–1.99, P=.53) or with the asthma group (adjusted OR 1.16, CI 0.78–1.74, P=.46) No difference recording family history or alcohol consumption

USA: Washington, DC, and Philadelphia, PA Women over 40 years old with at least one first-degree relative with breast cancer. Excluded women with prior non-skin cancer and those diagnosed with cancer during the 12-month follow-up Distress on the MHI17 subscale does not state cut-off or validity for diagnosing anxiety or depression

3

Quality rating

1 Prospective cohort

Screening mammography in the 12-month follow-up (recommendation was for all women with a family history to have yearly mammograms)

Quality rating

Recorded in GP notes or letters from secondary care

Methodological rating Population

(a) Study design

Country

Description of the study

Main findings

Descriptive aspects

1

159

3

(b) Sample size

3

cohort

2

two control groups on a 1:2:2 ratio

(c) Adequacy of comparator matching

2

Family history Age race education, marital status, employment

3

Townsend deprivation score for the area

GP practice information: number of patients, partners

Number of consultations; use of hormonal treatments such as contraception; co-morbid conditions; new patient registration; pregnancy; and attendance for cervical screening

(d) Consideration of confounders

2

Excluded diagnostic and prior cancer diagnosis

N/A

(e) Differentiated screening from diagnostic tests

Score

11

9A

Overall quality rating/18

528 O. Lord et al. / General Hospital Psychiatry 32 (2010) 519–543

5-Year retrospective cohort comparing depressed with hypertensive group

Survey of “appropriate preventive care.” A combination of one physical examination, one Pap smear test, breast examination in the last 5 years and mammogram if over 40 years. Two separate recruited populations

Medical expenditure panel survey, self-report survey. Distress as measured by SF12 as a marker for depression, against a variety of screening interventions

3-year sample of one borough using screening records compared against the computer records for the mental health trust

Stecker et al. (2007) [35]

Steiner et al. (1998) [46]

Thorpe et al. (2006) [50]

Werneke et al. (2006) [48]

Overall, mentally ill patients were as likely to attend for mammography (OR 0.91, 95% CI 0.8–1.04) Those on enhanced care were less likely

Distressed sample less likely to have influenza vaccine (61.1% vs. 67.5%, OR 0.7, 95% CI 0.55–0.88), dental checkup (42.1% vs. 57.3%, OR 0.77, 95% CI 0.61–0.97), clinical breast examination (61.4% vs. 73.2%, OR 0.73, 95% CI 0.57–0.94) Others not significant: BP, FOBT, sigmoidoscopy, mammography, routine check-up, cholesterol screen, PSA

Mental health group more likely to have had a physical examination (98% vs. 94%, P=.049). No other data significant; did not publish the rest Also published data as abused vs. not abused; no values significant

Depressed: hypertensive Total cholesterol: 65.7% vs. 80.8% (OR 0.455, Pb.001) Pap smear: 58.4% vs. 50.5% (OR 1.373, P=.059) Colonoscopy: 18.9% vs. 9.2% (OR 2.295, Pb.001) In a subgroup of over 50 year olds: 43.6% vs. 14.7% (OR 4.51, Pb.001) Mammogram: 46.8% vs. 53.2% (OR 0.775, P=.126) In a subgroup of over 40 year olds, 63%: 59% (OR 1.18, P=.434)

Women aged 50–64 years of three London boroughs

Noninstitutionalized over 65 year olds

Subsample of national survey USA

London, England

Low-income community, random sample of women from the mental health clinic and separate sample from the primary care center

Low-income, rural and urban, equal mix of Caucasian and African-American women

Connecticut, USA

Arkansas, USA

All patients known to South London and Maudsley NHS trust, subgroups of those on enhanced CPA (Car Programme Approach); those who had a diagnosis

Score of 42 or less on mental component summary of SF-12: sensitivity, 74%; specificity, 81% for depressive disorder

Recruited from a primary care center or mental health clinic, did ask about “psychiatric status” but results of this not stated

Depression diagnosed by primary care provider

Mammography

Retrospective cohort

1

1

Quality rating

Quality rating

Survey

“Appropriate preventive care.” A combination of one physical examination, one Pap smear test, breast examination in the last 5 years and mammogram if over 40 years

Longitudinal survey, 1999, 2000, 2001

2

Quality rating

BP, influenza vaccine, FOBT or sigmoidoscopy, mammography, breast exam, cholesterol screen, PSA, dental checkup, routine checkup

Retrospective cohort but compared depressed group with hypertensive group

In 5-year study period: Total cholesterol Pap smear Colonoscopy Mammogram

N=53,3340

3

N=3655

0

N=64

2

N=860

Cohort

3

Only difference is distress

1

Attempted to match, but recruited from different places. Ignored uninsured to reduce confounding

2

Cohort but then selected subgroups. Propensity score analysis to correct for the significant differences in most demographics

1 Based on a screening register; therefore no diagnostic tests distinguishes between call, early recall, recall, GP referral and self-referral

3

Excluded relevant specific cancer lipid and BP

0

0

Not distinguished

Age, “probability of being an ethnic minority.” Deprivation index

Age, gender, ethnicity, marital, education, income, employment, insurance, region

3

Age, marital status, insurance, no. of children, psychiatry illness, childhood sexual abuse, childhood physical abuse Data not published

1

Age ethnicity

(continued on next page)

11

5

7

O. Lord et al. / General Hospital Psychiatry 32 (2010) 519–543 529

530

Table 1 (continued) Author and year/ research method

Descriptive aspects Description of the study

Methodological rating Main findings

Country

Population

Wittink and Bogner (2008) [36]

In home interviews and brief physician information for a recruited cohort between 2001 and 2003 looking at recommendation of mammography

No significant difference in between the recommended-formammography group and the not-recommended group on Beck Anxiety Inventory, CESD depression or MMSE

Score

Intervention measured

(a) Study design

(b) Sample size

(c) Adequacy of comparator matching

(d) Consideration of confounders

(e) Differentiated screening from diagnostic tests

Overall quality rating/18

Quality rating

2

4

2

2

2

12

Ever had mammogram How long ago Recommendation of mammogram

Survey of patients and their physician

N=209

Only difference is recommendation of mammography

Age, marital status, high school education, African-American, self-rated health, physician-rated health

Doctorrecommended group vs. not recommended diagnostic Excluded bilateral mastectomy

Quality rating

1

2

2

2

1

of psychosis

Pennsylvania, USA

Older patients (65–80 years), recruited from 13 primary care practices

MMSE score, CESD, Beck Anxiety Inventory

8

MHI17, Mental Health Inventory 17; CES-D, Centers for Epidemiologic Studies Depression scale; CMHT, community mental health team; PSA,-prostate specific antigen; HAM-D, Hamilton Depression Scale; MMSE, Mini-Mental State Examination. (a) Study design: 1=Cross-sectional, 2=retrospective cohort study; 3=prospective cohort study. Population: Well, high risk, other illness. (b) Sample quality: 1=N100; 2=N200; 3=N1000; 4=N10,000; 5=N100,000. (c) Adequacy of comparator matching: 1=Selected comparison sample; 2=equivalent comparison sample; 3=matched comparison sample (near identical). (d) Consideration of confounders: 1=Demographics; 2=plus medical or social factors; 3=plus health care factors; 4=plus additional factors. (e) Outcome measures: 1=Excluded previous illness; 2=differentiated screening from diagnostic test; 3=longitudinal (cumulative screening). Overall rating: 0 to 3=poor; 4 to 5=below average; 6–8=adequate; 9–12=good; 13–18=excellent.

O. Lord et al. / General Hospital Psychiatry 32 (2010) 519–543

to attend (OR 0.4, 95% CI 0.29–0.55) Those with a diagnosis of psychosis were the least likely to attend (OR 0.33, 95% CI 0.18–0.61) Univariate analysis — No significant effect from length of care Those with more than 2 admissions OR 0.65 (95% CI 0.49–0.85)

Definition of mental illness

O. Lord et al. / General Hospital Psychiatry 32 (2010) 519–543

531

Fig. 1. Quality of Reporting Meta-Analyses (QUOROM) Flow Diagram.

fecal occult blood testing (n=2); prostate-specific antigen (PSA) testing (n=2); general physical/dental examination (n=2); and hepatitis/HIV testing (n=1). Looking at the study populations, eight focused on depression and/or anxiety [31–38]. Seven looked at bipolar disorder and/or schizophrenia [23,29,39–42]. Nine studies included all mental disorders [28,30,43–49], and two looked at broadly defined psychological distress [50,51]. 3.1. Mammography screening The United states Preventive Services Task Force (USPSTF) recommends screening mammography every 1– 2 years starting at age 40 [52]. Mammography was the most commonly examined area of preventive health care. One study showed increased screening in the mentally ill group [32]. Eight studies showed no effect of mental illness on mammography [33,35,36,38,45–47,50]. Nine studies showed decreased screening in the mentally ill group [28,31–34,40,41,43,48].

3.1.1. Positive association Green and Pope [31] conducted a cross-sectional postal survey of privately insured Americans in northwest Oregon and southwest Washington (n=5841). Those who screened positive for depression were more likely to have ever had a mammogram than those who did not (adjusted OR 1.37, 95% CI 1.04–1.81). 3.1.2. Neutral Association Wittink and Bogner [36] interviewed patients at home and obtained brief physician information for a cohort of 65–80 years old recruited from primary care practices in Pennsylvania, USA, between 2001 and 2003 (n=209). The authors found no significant difference between those who the physician recommended for mammography and those not recommended on the Beck Anxiety Inventory, Centers for Epidemiologic Studies Depression scale (CES-D) or Mini Mental State Examination (MMSE) [36]. Lasser et al. [45] conducted a survey on 40- to 70-year-old, female, new

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Table 2 Excluded studies Author

Screening of a healthy population

Comparative

Primary data

Areán PA, Ayalon L, Jin C, McCulloch CE, Linkins K, Chen H, McDonnell-Herr B, Levkoff S, Estes C. Integrated speciality mental health care among older minorities improves access but not outcomes: results of the PRISMe study. Int J Geriatr Psychiatry. 2008;23(10)1086–1092 Aro AR, de Koning HJ, Absetz P, Schreck M. Two distinct groups of non-attenders in an organised mammography screening program. Breast Cancer Res Treat. 2001 Nov;70(2):145–153 Bogner Wittink MN. Depression as a risk factor for under use of mammography. J Women's Health (Larchmt). 2004 Jul–Aug;13(6):739–742 Bradford DW, Kim MM, Braxton LE, Marx CE, Butterfield M, Elbogen EB. Access to medical care among persons with psychotic and major affective disorders. Psychiatr Serv. 2008 Aug;59(8):847–852 Buchwald D, Sheffield J, Furman R, Hartman S, Dudden M, Manson S. Influenza and pneummococcal vaccination among native American elders in a primary care practice. Arch Intern Med. 2000;160; 1443–1448 Carla A. Green, Michael R. Polen, Kathleen K. Brody depressed functional status, treatment for psychiatric problems and the health related practices of elderly HMO members. Am J Health Promot. 2003;17(14): 269–275 Carney CP, Allen J, Doebbeling BN Receipt of clinical preventive medical services among psychiatric patients. Psychiatr Serv. 2002 Aug;53(8):1028–1030 Coverdale JH, Schotte D, Ruiz P, Pharies S, Bayer T. Family planning need of male chronic mental patients in general hospital psychiatry. Gen Hosp Psychiatry. 1994;16(1):38–41 Cradock-O'Leary J, Young AS, Yano EM, Wang M, Lee ML. Use of general medical services by VA patients with psychiatric disorders. Psychiatric Services. 2002;53:874–878 Cromer BA, McLean CS, Heald FP A critical review of comprehensive health screening in adolescents. J Adolesc Health. 1992 Mar;13(2 Suppl):1S–65S. Review Dickerson FB, Pater A, Origoni AE. Health behaviours and health status of older women with schizophrenia. Psychiatr Serv. 2002 Jul;53(7):882–884 Dombrovski et al. Bridging general medicine and psychiatry: providing general medical and preventive care for the severely mentally ill. Current Opinion in Psychiatry. 2004;17(6):523–529 Freudenreich O, Gandhi RT, Walsh JP, Henderson DC, Goff DC. Hepatitis C in schizophrenia: screening experience in a community dwelling clozapine cohort. Psychosomatics. 2007 Sep–Oct;48(5):405–11 Friedman LC, Moore A, Webb JA, Puryear LJ. Breast cancer screening among ethnically diverse low income women in a general hospital psychiatry clinic Gen Hosp Psychiatry. 1999 Sep–Oct;21(5):374–381 Friedman LC, Puryear LJ, Moore A, Green CE Early breast cancer detection behaviours among ethnically diverse low income women. Psychooncology. 2005 Sep;14(9):786–791 Glen L. Xiong, Richard A. Bermudes, Serina N. Torres, and Robert E. Hales Use of cancer screening services among persons with serious mental illness in Sacramento county. Psychiatr Serv. 2008 Aug;59:929–932 Goldberg Hepatitis and HIV screening education and treatment for adults with serious mental illness Gen Hosp Psychiatry. 2004 Mar–Apr;26(2):167–168 Goldberg RW, Himelhoch S, Kreyenbuhl J, Dickerson FB, Hackman A, Fang LJ, Brown CH, Wohlheiter KA, Dixon LB. Predictor of HIV and hepatitis testing and related service utilisation among individuals with serious mental illness. Psychosomatics. 2005 Nov;46(6):573–577 Green CA, Pope, MR, Brody KK. Depression Functional status, treatment for psychiatric problems and the health related practices of elderly HMO members. Am J Health Promot. 2003 Mar–Apr;17(4):269–275 Haupt DW, Rosenblatt LC, Kim E et al. Prevalence and predictors of lipid and glucose monitoring in commercially insured patients treated with second-generation antipsychotic agents. Am J Psychiatry. 2009;166:345–353 Hippisley-Cox J, Parker C, Coupland C, Vinogradova Y. Inequalities in the primary care of coronary heart disease patients with severe mental health problems: cross sectional study. Heart. 2007 Oct;93(10):1256–62. Epub 2007 Mar 7 Horvitz-Lennon M, Kilbourne AM, Pincus HA. From silos to bridges: meeting the general health care needs of adults with severe mental illnesses. Health Aff (Millwood). 2006;25:659–669 Bergmann JB, Sigurdsson JA, Sigurdsson K. What attendance can be achieved for Pap smear screening. Scand J Prim Health Care. 1996;14(3):152–158 Kahn LS, Fox CH, Krause-Kelly J, Berdine DE, Cadzow RB. Identifying barriers and facilitating factors to improving screening mammography rates in women diagnosed with mental illness and substance use disorders. Women Health. 2005;42(3):111–126 Kudadjie-Gyamfi E, Consedine N, Magai C, Gillespie M, Pierre-Louis J. Breast self examination practices among women from six ethnic groups and the influence of cancer worry. Breast Cancer Res Treat. 2005 Jul;92(1):35–45 Lerman C, Kash K, Stefanek M. Younger women at increased risk for breast cancer ; perceived risk psychological wellbeing and surveillance behaviour. J Natl Cancer Inst Monogr. 1994;(16):171–176

No

No

Yes

Yes

No

Yes

Yes

Yes

No

No

Yes

Yes

Yes

No

Yes

Yes

No

Yes

Yes

No

Yes

No

no

Yes

No

Yes

Yes

No

No

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

Yes

No

Yes

Yes

No

Yes

Yes

No

Yes

No

No

No

Yes

No

Yes

yes

yes

No

No

No

Yes

NO

Yes

Yes

No

Yes

No

Yes

No

Yes

Yes

No

No

Yes

No

Yes

Yes

No

No

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Table 2 (continued) Author

Screening of a healthy population

Comparative

Primary data

Magai C, Consedine N, Neugut AI, Hershman DL. Common psychosocial factors underlying breast cancer screening and breast cancer treatment adherence a conceptual review and synthesis. J Women's Health (Larchmt). 2007 Jan–Feb;16(1):11–23 Mangtani P, Breeze E, Kovats S, Ng ES, Roberts JA, Fletcher A. Inequalities in influenza uptake among people aged over 74 years in Britain. Prev Med. 2005;41:545–553 McGuire J, Rosenheck R. The quality of preventive medical care for homeless veterans with mental illness. J Healthc Qual. 2005 Nov–Dec;27(6):26–32 Miller E, Lasser KE, Becker AE. Breast and cervical cancer screening for women with mental illness patient and provider perspectives on improving linkages between primary care and mental health. Arch Women's Ment Health. 2007;10(5):189–197 Morden NE, Berke EM, Welsh DE, et al. Quality of Care for cardiometabolic disease associations with mental disorder and rurality. Medical Care. 2010;48(1):72–78 Orbell S, Hagger M, Brown V, Tidy J. Comparing two theories of health behaviour: a prospective study of noncompletion of treatment following cervical cancer screening. Health Psychol. 2006 Sep;25(5):604–615 Osborn DP, King MB, Nazareth I. Participation in screening for cardiovascular risk by people with schizophrenia or similar mental illnesses cross sectional study in general practice. BMJ. 2003;326: 1122–1123 Salsberry PJ, Chipps E, Kennedy C. Use of general medical services among Medicaid patients with severe and persistent mental illness. Psychiatr Serv. 2005 Apr;56:458–462 Phelan M, Stradins L, Morrison S. Physical health of people with severe mental illness. BMJ. 2001 Feb 24; 322(7284):443–444 Rahman SM, Dignan MB, Shelton BJ. Factors influencing adherence to guidelines for screening mammography among women aged 40 years and older. Ethn Dis. 2003 Fall;13(4):477–484 Purc-Stephenson RJ, Gorey KM. Lower adherence to screening mammography guidelines among ethnic minority women in America: a meta analytical review. Preventive Medicine. 2008 June; 46(6):479–488 Schonberg MA, York M, Basu N, Olveczky D, Marcantonio ER. Preventive health care among older women in an academic primary care practice. Women's Health Issues. 2008 Jul–Aug;18(4):249–256 Schwartz MD, Taylor KL, Willard KS, Siegel JE, Lamdan RM, Moran K. Distress, personality and mammography utilization among women with a family history of breast cancer. Health Psychol. 1999 Jul; 18(4):327–332 The National Institute of Mental Health a; Multisite HIV Prevention Trial group, 06 HIV prevention with persons with mental health problems. Psychology, Health and Medicine. 2006 May; 11(2):142–154 Schwenk TL, Coyne JC, Fechner-Bates S. Differences between detected and undetected patients in primary care and depressed psychiatric patients. General Hospital Psychiatry. 1996 Nov; 18(6):407–415 Webster S, access to screening for women with long-term mental health problems. Aust Nurs J. 2007 Nov; 15(5):26

Yes

No

No

Yes

No

Yes

Yes

No

Yes

Yes

No

No

No

Yes

Yes

Yes

No

Yes

No

Yes

Yes

Yes

No

Yes

no

no

No

Yes

No

Yes

yes

No

No

Yes

No

Yes

Yes

No

Yes

No

No

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No

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Yes

No

Yes

patients presenting to primary care physicians in two lowincome towns in Massachusetts, USA. The majority of patients were non–English speaking and uninsured. There was no significant difference between the women who screened positive for a mental disorder and those who did not on a questionnaire for mammogram in the last 2 years (53% vs. 56%, NS) [45]. Thorpe et al. [50] found no significant difference for mammography between those with low scores on the SF12 as a marker for depression and the rest of the sample in a self-report survey of noninstitutionalized over 65 years old in the USA (n=3655). Stecker et al. [35] found a trend to reduced use of mammogram in the group with depression; this difference reduced further by only looking at women over the age of 40 in a retrospective study looking at a group with a diagnosis of a depressive disorder in their primary care records and controls with hypertension (n=860) in a low-income area of Arkansas, USA. Steiner et al. [46] found no statistically significant difference between women from the mental health clinic and a group from the primary

care center (n=64) in a low-income community in Connecticut, USA. As part of the 1994–1995 Iezzoni et al. (2001) asked a subgroup of the survey questions about preventive care (n=11,399). In a large interview study of a nationally representative sample of civilian, noninstitutionalized female US residents over 50 years, Iezzoni et al. [47] found those with serious mental health problems had a trend to reduced use of mammography in the last 2 years (OR 0.6, 95% CI 0.4–1.1) compared with the rest of the sample. Peytremann-Bridevaux et al. [33] conducted an interview and questionnaire survey of over 50 years old in 10 European countries (n=15,380); those who scored N3 on the Euro-D were less likely to have a mammogram in the last 2 years, but the adjusted odds ratio was no longer significant (OR 1.0, 95% CI 0.8–1.2). This trend was despite a significantly higher use of services in the depressed group [33]. Recently, Patten et al. [38] found no relationship between mammogram screening and major depression in 1868 women in the Canadian National Population Health Survey.

534

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3.1.3. Negative association In a large-scale study, Druss et al. [32] looked at a nationally representative sample of civilian, noninstitutionalized female US residents as part of the NHIS 1999 study (n=30,801). The group screening positive for a depressive disorder, compared to those without, was more likely to not have had a mammogram (women over 40 years) (OR 1.22, 95% CI 1.18–1.26). This difference was even greater if the depression was untreated (adjusted OR 1.32, 95% CI 1.22– 1.42). Those being treated in secondary care were more likely to have not had a mammogram than those treated in primary care (adjusted OR 1.22, 95% CI 1.03–1.44). Werneke et al. [48] looked at a 3-year sample of women aged 50–64 years in three London boroughs using NHS screening and mental health trust records. Overall, the users of the mental health service were as likely to attend for mammography (OR 0.91, 95% CI 0.8–1.04) as the rest of the population, but those on enhanced care were less likely to attend (OR 0.4, 95% CI 0.29–0.55). Those with a diagnosis of psychosis were the least likely to attend for mammography (OR 0.33, 95% CI 0.18–0.61). There was no significant effect from the length of contact with services, but those who had had more than two admissions to a mental health hospital were less likely to attend for mammography (OR 0.65, 95% CI 0.49–0.85) [48]. As part of the SWAN study, looking at the effects of menopause on community-based women in several sites across the USA (n=3302), Pirraglia et al. [34] used the CES-D, a validated scale to assess depression. The authors gathered baseline data and then yearly follow-up for up to 4 years for women aged 42– 52 years. Those who scored highly on the CESD were less likely to have a mammogram in the subsequent year (adjusted OR 0.84, 95% CI 0.73–0.97) [34]. Carney and Jones [28] conducted a large retrospective cohort study looking at all members of an insurance scheme who received mammography (n=191,356). The authors compared controls and those with a mental illness including a high-risk group who had been hospitalized and had a dual diagnosis, a moderate-risk group who were either hospitalized or had a dual diagnosis, and a low-risk group who had neither. The high- and moderate-risk groups were significantly less likely to have received mammography within the 5-year study period: OR 0.38 (95% CI 0.33–0.43) and 0.62 (95% CI 0.59–0.66), respectively. All three mentally ill groups had significantly lower use of mammography within the last 2 years: low risk, OR 0.95 (95% CI 0.92–0.99); moderate risk, OR 0.71 (95% CI 0.66–0.75); high risk, OR 0.63 (95% CI 0.53–0.75). The high-severity psychotic disorder group had similar mammography rates to the rest of the sample in the 5-year study period, but they were significantly less likely in the last 2 years (OR 0.31, 95% CI 0.12–0.83) [28]. Lindamer et al. [39] found that significantly fewer women with schizophrenia had had a mammogram in the last 2 years (68% vs. 98%, P≤.001) in a convenience sample of women with schizophrenia and a matched control group who responded to advertisement (n=116). The control group

was significantly older (57.6 vs. 65.5 years, P=.001) [39]. Druss et al. [43] analyzed data from the External Peer Review Program (EPRP) for Veterans Health Care Administration in the USA for 1998–1999. The authors randomly selected veterans with selected high-volume medical conditions, then reviewed case files for use of preventive services for those with and without an ICD-9 diagnosis of a mental disorder (N=113,505). The group with a recorded mental disorder was less likely to have had a mammogram in the last 2 years (for women aged 50–69 years) (adjusted OR 0.78, 95% CI 0.67–0.91) [43]. Recently, Martens et al. [41] reported upon a large retrospective database study using the Population Health Research Data Repository, Manitoba, Canada. In comparison to the general population (without schizophrenia) (n=108,792), women with schizophrenia (n=1448) had a 0.64 odds of mammography in the selected 2-year period. 3.2. Cervical smear screening The USPSTF recommends screening in women who are sexually active and have a cervix, but not those over 65 years if they have negative screening history and no high-risk behavior [52]. 3.2.1. Positive association Stecker et al. [35] examined people with depression and hypertensive controls and found that the group with depression were more likely to have a cervical smear (58.4% vs. 50.5%, OR 1.373, P=.059). 3.2.2. Neutral association In the 1994–1995 health interview survey, the group with serious mental health problems was more likely to have a cervical smear in the last 3 years (aged 18–75 years) (adjusted OR 1.2, 95% CI 0.8–1.8) than the rest of the sample, but this was not significant [47]. In the SWAN study of the menopause, the authors found no significant relationship between depressive score and rates of cervical screening [34]. In a small survey by Steiner et al. [46], the difference between uptake of cervical smears in the mental health and control group was not statistically significant. Recently, Patten et al. [38] found no link between cervical smear screening and major depression among women in the Canadian National Population Health Survey. 3.2.3. Negative association In the large NHIS study, those (women under 65 years) with depression were more likely to have not had a cervical smear (adjusted OR 1.17, 95% CI 1.11–1.23). Those with untreated depression were more likely to have not had a cervical smear (adjusted OR 1.43, 95% CI 1.30–1.56) than those having treatment. There were no differences between those managed in primary or secondary care [32]. In the large Veterans Health Care study [43], the group with a recorded mental disorder was less likely to have ever had cervical smears than the group without mental disorders (adjusted OR 0.87, 95% CI 0.78–0.96). In the case-control study of

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Lindamer et al. [39], significantly fewer women with schizophrenia had had a pelvic exam and cervical smear in the last 3 years (71% vs. 96%, P=.001) [39]. Martens et al. [41] reported upon a large retrospective database study using the Population Health Research Data Repository, Manitoba, Canada. In comparison to the general population (without schizophrenia), women with schizophrenia had a 0.70 odds of cervical screening. 3.3. Vaccination studies The Centers for Disease Control and Prevention (CDC) recommend influenza vaccination in those aged over 50 years, with certain chronic illnesses or residing in long-term care facilities. They recommend yearly pneumococcal vaccination in those aged over 65 years or with certain chronic illnesses [53]. 3.3.1. Positive association There were no studies reporting increased rates of vaccination in mentally ill groups. 3.3.2. Neutral association In a large European interview and survey study, the group with high Euro-D scores, suggesting the presence of a depressive disorder, had a trend towards higher flu vaccination, but this was not significant [33]. In Green and Pope's [31] postal survey, they found no significant differences between those who screened positive for depression and those who did not for vaccinations against influenza or pneumonia. Mangtani et al. [37] looked at the take up of the influenza immunization program in the UK shortly after its introduction in 2000 (n=5572). 69.9% of men with depression (geriatric depression scale) over 74 years of age were vaccinated, compared with 74.8% of over 74 years old without depression (not significant). 61.2% (95% CI 57.1–67.6) of women with depression (n=250) over the age of 74 years were vaccinated compared with 66.6% (95% CI 62.8–70.3) of women without depression who were vaccinated [37]. 3.3.3. Negative association Druss et al. [32] found that those with depression were more likely to have not had an influenza vaccination (over 50 years) (adjusted OR 1.24, 95% CI 1.18–1.30). Those with untreated depression were more likely to have not had an influenza vaccination (over 50 years) (adjusted OR 1.51, 95% CI 1.4–1.62) than those having treatment. There were no differences between those managed in primary or secondary care and those without depression [32]. In the self-report survey of Thorpe et al. [50], those screening positive for distress using the SF12 were less likely to have an influenza vaccine (61.1% vs. 67.5%, OR 0.7, 95% CI 0.55–0.88). In the large Veterans Health Care study [43], the group with a recorded mental disorder was less likely to have ever had a pneumonia vaccine (adjusted OR 0.95, 95% CI 0.93–0.96) or an influenza vaccination in the last year (for

535

over 65 years old and high-risk groups) (adjusted OR 0.9, 95% CI 0.87–0.94). 3.4. Lifestyle counseling The USPSTF recommends asking all adults about tobacco use and providing tobacco cessation interventions for those who use tobacco products. The evidence is insufficient to recommend for or against behavioral counseling in primary care settings to promote physical activity [52]. 3.4.1. Positive association Desai et al. [30] conducted a large case note review in 1998–1999 of the veterans' health administration database. The authors included only those with obesity and/or hypertension and looked for evidence of nutrition and exercise counseling in the last 2 years (n=90,246). Those with a mental disorder were more likely than the group without any disorder to have had nutrition counseling (90.9% vs. 90.4%, P=.001), but less likely to receive exercise counseling (88.5% vs. 88.7%, P=.001). Overall, they were more likely to have received either (85.8% vs. 86.0%, P=.001). The group with dual diagnosis was the least likely to receive nutrition counseling (88.4% vs. 90.4%, P=.001) and exercise counseling (85.7% vs. 88.7%, P=.001), or to receive either counseling intervention (82.0% vs. 86.0%, P=.001) [30]. In the large Veterans Health Care study [43], the group with a mental disorder was more likely to have their current smoking status recorded (adjusted OR 1.17, 95% CI 1.08–1.27) and to be given cessation counseling or referral (adjusted OR 1.10, 95% CI 1.00–1.20). In the 1994–1995 health interview survey, the group with serious mental health problems was more likely to have their smoking status recorded (OR 1.5, 95% CI 1.1– 2.2) than the rest of the sample. The group with serious mental health problems was also more likely to have their exercise status recorded (OR 1.6, 95% CI 1.2–2.1) than the rest of the sample [47]. 3.4.2. Neutral association Daumit et al. [23] conducted a large annual survey of office-based physicians' encounters during one random week (n=118,145). Those with ICD-9 diagnosis of psychotic disorder, schizophrenia, bipolar disorder or a recurrent prescription of antipsychotics or lithium were significantly more likely to be obese, have diabetes and to smoke cigarettes. However, this high-risk group had similar rates for counseling for diet/weight, exercise or other lifestyle counseling as those without mental illness [23]. 3.4.3. Negative association In the retrospective case-control study of Roberts et al. [40], people with schizophrenia were less likely than those with asthma to have had their smoking status recorded (adjusted OR 0.37, P=.001). There was a trend to higher recording of smoking status between the group with schizophrenia and the general group, but this was not

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significant (adjusted OR 1.16, 95% CI 0.65–2.07, P=.61). The group with schizophrenia had a trend towards increased recording of their weight, but this did not reach significance, compared with the general group (adjusted OR 1.18, 95% CI 0.70–1.99, P=.53) or the asthma group (adjusted OR 1.16, 95% CI 0.78–1.74, P=.46). The group with schizophrenia had a trend towards increased recording of their alcohol consumption, but this did not reach significance, compared with the general group (adjusted OR 1.49, 95% CI 0.87– 2.54, P=.14) or the asthma group (adjusted OR 1.63, 95% CI 0.95–2.82, P=.08) [40]. We identified no studies on lifestyle counseling that looked only at depressed patients. 3.5. Blood pressure monitoring studies The USPTF recommends screening all adults over 18 years every 2 years for hypertension [52]. 3.5.1. Positive association None reported. 3.5.2. Neutral association In the self-report survey of Thorpe et al. [50], there was no significant difference for measuring blood pressure between those with and without distress. Patten et al. [38] found no relationship between mammogram screening and major depression in 6388 people over 45 years in the Canadian National Population Health Survey. 3.5.3. Negative association In the large NHIS study, those with depression were as likely to have blood pressure recorded as those without. Those with untreated depression were more likely to have not had blood pressure recording (adjusted OR 1.10, 95% CI 1.01–1.11). There were no differences between those managed in primary or secondary care and those without depression [32]. In the UK case control study [40], those with a diagnosis of schizophrenia were about half as likely as the other two groups to have had their blood pressure recorded during the 3-year study period (adjusted OR compared to the asthma group 0.52, P=.03; adjusted OR compared to general group 0.43, Pb.01) [40]. 3.6. Cholesterol screening The USPSTF strongly recommends screening men aged 35 and older for lipid disorders and men aged 20 to 35 if they are at increased risk for coronary heart disease. The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease and women aged 20 to 45 if they are at increased risk for coronary heart disease. The USPSTF makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35 or in women aged 20 and older who are not at increased risk for coronary heart disease [52].

3.6.1. Positive association In a cohort study in Veterans Health Care in the USA (n=64,490), Kaplowitz et al. [44] examined cholesterol (HDL-C) screening in patients aged over 20 years old every 5 years. The authors compared those with an ICD-9 diagnosis on record with those without. The authors separated data into quartiles (3 months) of outpatient use and found it was significantly more likely for the mentally ill group to be screened in each successive quartile, unlike the not-mentally-ill group. The mentally ill group initially had decreased odds of cholesterol screening in the first 3 months (OR 0.45, 95% CI 0.37–0.54) and in the second 3 months (OR 0.5, 95% CI 0.45–0.57). In the third quartile, this difference was no longer significant, but by the fourth quartile it was more likely (OR 2.73, 95% CI 2.46–3.03). From this study, it appears that individuals with mental illness may receive screening later in the course of care [44]. 3.6.2. Neutral association In the self-report survey of Thorpe et al. [50], there was no significant difference for serum cholesterol measurement between those with low scores on SF12 and the rest of the sample. 3.6.3. Negative association In the Stecker et al. [35] study of depressive cases and hypertensive controls, the group with depression was less likely to have their total cholesterol checked (65.7% vs. 80.8%, OR 0.455, Pb.001). Roberts et al. [40] conducted a retrospective case study of preventive health care in people aged 21 to 64 with a diagnosis of schizophrenia in Birmingham, UK. The authors used healthy controls and a matched group with asthma in an attempt to reduce the bias of chronic illness. Only the comparison with the general group reached significance with those with schizophrenia, having about half the rate of cholesterol testing compared with the healthy control group (adjusted OR 0.46, P=.02) [40]. 3.7. Bowel cancer screening I: colonoscopy and/or sigmoidoscopy USPSTF Strongly recommends screening for men and women age 50 or older; colonoscopy, every 10 years; and flexible sigmoidoscopy, every 5 years. Not for further screening after age 75 if negative screens since age 50 [52]. Three studies looked at colonoscopy and/or sigmoidoscopy in people with a depressive disorder. 3.7.1. Positive association In the Stecker et al. [35] study of depressive cases and hypertensive controls, the group with depression was more likely to have a colonoscopy (18.9% vs. 9.2%, OR 2.295, Pb.001); this effect increased in those over the age of 50 (43.6% vs. 14.7%, OR 4.51, Pb.001). In the large European interview and survey study [33], the group screening positive for a depressive disorder had higher rates of colonoscopy or sigmoidoscopy (16.8% vs. 19.2%, P=.93, adjusted OR 1.3, 95% CI 1.1–1.6).

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3.7.2. Neutral association In the self-report survey of Thorpe et al. [50], there was no significant difference for sigmoidoscopy between those with low scores on the SF12 and the rest of the sample. 3.7.3. Negative association In the large Veterans Health Care study [43], the group with a recorded mental disorder was less likely to have either fecal occult blood testing (FOBT) in the last year or a sigmoidoscopy in the last 5 years (adjusted OR 0.95, 95% CI 0.91–0.99). 3.8. Breast examination studies The USPSTF do not recommend CBE as there is insufficient evidence for or against CBE alone [52]. 3.8.1. Positive association None reported. 3.8.2. Neutral association In the 1994–1995 Health Interview Survey [47], the group with serious mental health problems did not differ from the rest of the sample for rates of breast examination in the last 2 years (OR 1.0, 95% CI 0.6–1.4) [47]. 3.8.3. Negative association In the self-report survey of Thorpe et al. [50], those screening positive for distress using the SF12 were less likely to have a clinical breast examination (61.4% vs. 73.2%, OR 0.73, 95% CI 0.57–0.94). 3.9. Bowel cancer screening II: FOBT studies The USPSTF recommend FOBT annually, but no further screening after age 75 if negative screens since age 50 [52].

537

3.10.1. Positive association None reported. 3.10.2. Negative association In the large Veterans Health Care study [43], the group with a recorded mental disorder was less likely to have a discussion with their clinician about PSA testing (adjusted OR 0.78, 95% CI 0.67–0.91) [43]. 3.10.3. Neutral association In the self-report survey of Thorpe et al. [50], there was no significant difference for PSA measurement between those with low scores and the rest of the sample. 3.11. Osteoporosis prevention USPSTF recommends that women aged 65 and older be screened routinely for osteoporosis. And routine screening should begin at age 60 for women at increased risk for osteoporotic fractures [52]. 3.11.1. Positive association None reported. 3.11.2. Negative association There are two case control studies of osteoporosis prevention in schizophrenia. Both studies found decreased prescription of hormone replacement therapy in schizophrenia compared with the rest of the samples [27,39]. One of these studies also found decreased rates of screening for osteoporosis and prescription of any osteoporosis drug in those with schizophrenia [27]. 3.12. General physical/dental examination

3.9.1. Positive association None reported.

The USPSTF makes no recommendations about general examinations and no longer makes recommendations for dental examinations; however, this is an area that remains of concern in those with poor mental health [52].

3.9.2. Neutral association In the self-report survey of Thorpe et al. [50], there was no significant difference for FOBT between those with low scores and the rest of the sample.

3.12.1. Positive association In the Steiner et al. [46] survey, the mental health group was more likely to have had a physical examination (98% vs. 94%, P=.049) than those without mental health problems. 3.12.2. Neutral association None reported.

3.9.3. Negative association In the large NHIS study [32], those with depression were more likely to have not had a fecal occult blood test (over 50 years) (adjusted OR 1.11, 95% CI 1.04–1.18). Those with untreated depression were more likely to have not had FOBT (over 50 years) (adjusted OR 1.21, 95% CI 1.13–1.29) than those having treatment. There were no differences between those managed in primary or secondary care and those without depression [32].

3.12.3. Negative association In the self-report survey of Thorpe et al. [50], those screening positive for distress using the SF12 were less likely to have a dental checkup (42.1% vs. 57.3%, OR 0.77, 95% CI 0.61–0.97), but there was no significant difference for having a routine checkup with a physician between those with low scores and the rest of the sample.

3.10. Prostate-specific antigen testing studies

3.13. Hepatitis and HIV testing

The USPSTF recommends against screening for prostate cancer [52].

The USPSTF strongly recommends that clinicians screen for HIV all adolescents and adults at increased risk for HIV

538

Table 3 Overview of preventive care studies by domain (a) (b) (c) (d) Lifestyle (e) Blood (f) (g) (h) (i) Fecal (J) Prostate-specific (k) (L) General (m) Main Mammography Cervical Vaccination counselling pressure Cholesterol Colonoscopy Breast occult antigen testing Osteoporosis examination HIV/ Sample smear exam blood HCV testing

Druss et al. [32] Green and Pope [31] Peytremann-Bridevaux et al. [33] Pirraglia et al. [34] Stecker et al. [35] Schwartz et al. [51] Thorpe et al. [50] Carney et al. [28] Desai et al. [30] Druss et al. [43] Iezzoni et al. [47] Kaplowitz et al. [44] Kilbourne et al. [49] Lasser et al. [45] Mangtani et al. [37] Patten et al. [38] Steiner et al. [46] Werneke et al. [48] Wittink and Bogner [36] Bishop et al. (2004) [27] Chochinov et al. [29] Lin et al. [42] Lindamer et al. [39] Martens et al. [41] Roberts et al. [40] Daumit et al. [23]

− + /

−

− / − / −

/ +

− /

− /

Positive Neutral Negative

− / /

−

Depression Depression Depression

+

− −

−

/

−

+

/

/

+ + +

−

/

−

−

/

− /

+ / / / / / − /

/

/ /

+

− − − −

− − −

1 8 9

1 4 5

Schizophrenia Schizophrenia Schizophrenia Schizophrenia Schizophrenia Schizophrenia Bipolar/ schizophrenia

−

0 3 3

− /

−

−

3 1 1

0 2 2

1 1 2

2 1 1

0 1 1

0 1 1

0 1 1

0 0 2

Depression Depression Distress Distress Mental Illness Mental Illness Mental Illness Mental Illness Mental Illness Mental Illness Mental Illness Mental Illness Mental Illness Mental Illness Mental Illness Mental Illness

1 0 1

0 1 0

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Study

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infection. They recommend against routinely screening the general asymptomatic population for chronic hepatitis B virus (HBV) infection and HCV infection in adults at high risk for infection. The USPSTF recommends screening for HBV infection in pregnant women at their first prenatal visit, but not for HCV [52]. 3.13.1. Positive association None reported. 3.13.2. Neutral association As part of the 2004 Veterans Affairs EPRP, Kilbourne et al. [49] looked at HCV testing in high-risk groups by CDC criteria (n=19,397). The authors found a trend towards increased testing of psychotic patients (95.2%) and depressed patients (94.4%) compared with those with no psychiatric disorder (91.7%), but this result was not significant. They also showed a trend to reduced notification within 60 days of a positive HCV result to those with a psychotic disorder (39% of positive results) compared with 49.9% of those without a mental disorder. Those with depression were more likely to be notified of a positive result (59.3 %). None of these results reached statistical significance [49]. 3.13.3. Negative association None. We identified no studies looking at HIV or HBV screening (Table 3). 4. Discussion Disparities in preventive and screening services according to ethnicity and income have been previously documented [56,57]. Here we extend these findings to show that preventive care for those with mental illness is also a particular concern. Of 61 comparisons in 26 publications, 27 showed inferior preventive health care in those with mental illness, 10 superior preventive health care and 24 reached inconclusive findings. Inferior preventive care was most apparent in osteoporosis screening, blood pressure monitoring, vaccinations, mammography and cholesterol monitoring. There was some evidence for superior care in two domains: lifestyle counseling for smoking and exercise and colonoscopy. For those individuals with schizophrenia, nine of 10 analyses showed inferior preventive care in several areas including cervical smear tests, cholesterol monitoring, lifestyle counseling and blood pressure checks. In a noncomparative survey of psychiatric-clinic attenders, Carney et al. [55] found that only 77% had cervical screening in the last year. Two independent studies replicated concerns about preventive care in this group for osteoporosis care and mammography. Indeed, only Martens et al. [41] failed to find an association in people with schizophrenia here in relation to cervical screening. In depression, five studies reported upon 16 analyses of receipt of preventive care. There was evidence

539

of superior care in one area, namely, colonoscopy. There is some evidence of inferior care in three areas: cholesterol and blood pressure monitoring and FOB testing. There was inconclusive or conflicting evidence in two areas: mammography and vaccination. We note that an additional study by Green and Pope [54] found no association, but they published no primary data so this was excluded from the present review. In mixed mental illness, 13 studies reported upon 25 analyses. In one area, there was good evidence for enhanced preventive care — that is, lifestyle counseling. In two areas, there was weaker evidence from one study only for enhanced preventive care. These were cholesterol monitoring and clinical examination. In two areas, there was some limited evidence (again from one study) for inferior colonoscopy and PSA testing. In the remaining six areas, evidence was inconclusive or conflicting. Regarding distress, we identified two comparative studies for those with and without significant distress. In the self-report survey of Thorpe et al. [50], those screening positive for distress using the SF12 were less likely to have an influenza vaccine or clinical breast examination, but no difference was found in mammography rates or blood pressure monitoring. Schwartz et al. [22] found lower rates of mammography in those with distress; however, in post hoc analysis, they found the effect was seen in those who were low but not high in conscientiousness. These findings are subject to the following methodological limitations. There was relatively little data in some medical domains such as HIV/HCV care, PSA testing and clinical/breast examination. This will reflect the USPSTF recommendations. Although in an international context there remains an absence of studies from countries outside the USA where these are recommended, for example, NICE in the UK recommends giving advice on exercise, whereas the USPSTF does not. Studies generally relied on medical databases and utilized cross-sectional assessments. Only one study looked specifically at interventions over time and this found that after 1 year screening disparities were less apparent [44]. We were surprised that we could not identify any comparative study of glucose or lipid monitoring, although noncomparative studies suggest low rates of monitoring in those with schizophrenia [58]. We have highlighted areas where screening is recommended; we have included areas where screening is not recommended by the USPSTF because this recommendation alone is unlikely to be the principal reason for differences in receipt of preventive care. There was heterogeneity in the studies in how they defined cases of mental illness. The majority of studies are also conducted within mental health services with 14 of the 26 using diagnoses from patient records. Although of the studies showing greater receipt of preventive services, six used interviews and three used patient records. Those who are engaged with services are likely to differ from those who are not in terms of insight and severity of symptoms in a way that is not simple to control for. It has recently been shown that nonattendance at psychiatric outpatient clinics is

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associated with perceived stigma for those with psychotic disorders [59]. Although there may be a protective effect of being involved in any sort of treatment. Some common symptoms like anxiety may confound the results as those with fears of public places may be less likely to attend for screening. Withdrawn and negative symptoms may predispose to reduced use of services generally including preventive services. Only distress as a symptom has been evaluated independently; some studies used rating scales as a screen for mental illness but did not look for correlation of results with severity of illness. Carney and Jones [28] and Werneke et al. [48] both used proxies for severity of illness and found that receipt of preventive services reduced with increasing severity. What factors might explain these deficits in preventive care which seems especially pronounced in those with schizophrenia? It has been widely reported that severe distress reduces uptake of preventive services [60,61]. However, mild or moderate distress may actually improve attendance with screening services [62]. Previous research has shown that nonattenders at mammography have been shown to be more socially isolated, depressed and anxious than those who attend [63]. In general, barriers include embarrassment, the provider–patient trust and communication, and patient information, transportation problems and lack of follow-up for missed appointments [64–66]. Perceived stigma and discrimination may have a role according to some [67–69] but not all studies [70]. Stigma can be important even if perceived only by the patient [71]. Perhaps the most critical factor is the relationship with primary care physician. Physician recommendation of screening has been shown to be one of the strongest predictors of receipts of mammography [72,73] breast examination [19] and FOBT [74]. Yet persons with psychotic disorders and bipolar disorder are less likely to have primary care physicians compared with people without mental disorders [75]. Indeed, persons with psychotic disorders, bipolar disorder or major depressive disorder are more likely to report difficulties in accessing care [75]. Cost and organization of care can also be significant barriers to accessing health care. Two studies reviewed here included members of an insurance scheme one of which found higher receipt of mammography [31] and the other lower rates [28]. Of five studies in veterans administration [27,30,43,44,49], reduced rates were found for cancer and osteoporosis screening and receipt of vaccinations, although there were positive associations with cholesterol screening and lifestyle counseling. One study in the UK National Health Service which provides health care free at the point of use demonstrated a reduction in receipt of mammography [48]. Morden et al. [76] recently found that discrepancies in diabetes and hypertension care were not explained by rural setting. This suggests that systems which provide low-cost access to preventive services alone do not necessarily negate inequalities according to mental health status. Furthermore, 14 of the 26 studies controlled for household income,

employment or a deprivation score. The only study to find a positive correlation with receipt of cervical smears did not adjust for income. Assuming these disparities are robust, what can be done to improve preventive care in people with mental ill health? According to a Cochrane review, several interventions may help increase participation rates in mammography [77]. These are letters of invitation, mailed educational material, letters of invitation plus phone calls, telephone calls, and training activities plus direct reminders. Home visits and personalized risk communication were not found to be effective [78]. In a systematic review of interventions designed to increase mammography screening rates for low-income women [79], interventions that used peer counselors, incorporated multiple intervention strategies or provided better and easy access (through mobile units, cost vouchers or home visits) were also effective. Anderson et al. [80] reported a meta-analysis of 43 studies involving strategies to improve the delivery of preventive care. In general, interventions were moderately effective in improving immunization, screening and counseling [80]. It has previously been suggested that better communication between primary care providers and specialist mental health services would improve screening rates [66,81,82]. In the UK, the Royal College of Psychiatrists has recommended that primary care physicians set up specific clinics for people with mental disorders [83]. In the US, a reorganization of mental health services would help redefine responsibility for physical health [84]. There is some support for a collaborative model of care, co-locating psychiatric and primary care [85]. One trial of an integrated model of care for older people improved with access to health care [86]. A second randomized study of a population-based medical care management intervention produced an improvement in preventive care. At 12 months, the intervention group received 58.7% of recommended preventive services compared with a rate of 21.8% in the usual care group. They were also more likely to have a primary care provider (71.2% vs. 51.9%) and had better scores on the Framingham Cardiovascular Risk Index [87]. Mitchell et al. (2009) previously documented inferior medical provision to patients with both a physical health and a mental health condition. Deficits in care may directly influence outcomes including mortality [12,88]. In those with mental ill health, physical comorbidity is often unrecognized and often inadequately treated [89–91]. When combined with our findings of low receipt of preventive health care, we believe there is sufficient evidence to conclude that there is a systematic deficit in the medical health care provision to those with a diagnosis of mental illness. Still uncertain, however, are the underlying reasons for this. Adjustment for income and different methods of health care delivery do not appear to account for these differences. There is a continuing high unmet need in this population and an outstanding need to focus resources on individuals with mental ill health

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[83,92,93]. Methods to increase receipt of preventive services in this population need to be urgently evaluated.

[11]

Appendix A. Example search strategy (OVID — Medline and Embase) Order

Searches

Results

Search Type

1

depressive disorder/ or schizophrenia/ or bipolar disorder/ or dementia/ or delirium (psychiatric or mental or depress⁎ or bipolar⁎ or schizophre⁎ or psychotic or psychos⁎ or anxiety or dementi⁎ or delirium).m_titl. Preventive Medicine/ Preventive Health Services/ Mammography/ colposcopy/ or vaginal smears/ physical examination/ or self-examination/ or breast self-examination/ immunization/ or vaccination/ Smoking Cessation/ 3 or 4 or 5 or 7 or 8 or 9 (receipt or received or services or care). mp. [mp=ti, ot, ab, nm, hw, ui, an, sh, tn, dm, mf] 1 and 10 2 and 11 and 12 limit 13 to “review articles” [Limit not valid in EMBASE; records were retained] 13 not 14 remove duplicates from 15

396,153

Advanced

2

3 4 5 6 7

8 9 10 11

12 13 14

15 16

[10]

[12]

[13] 513,523

Advanced

20,102 14,068 39,059 25,574 96,486

Advanced Advanced Advanced Advanced Advanced

163,878 32,568 358,897 2,758,355

Advanced Advanced Advanced Advanced

3934 400 327

Advanced Advanced Advanced

73 71

Advanced Advanced

[14]

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[26] [27]

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