Acute myocardial infarction in several mental illness: a nationwide analysis of prevalence, management strategies and outcomes

Background Severe mental illness (SMI) is associated with an increased risk of cardiovascular disease and mortality. However, it is unclear whether SMI patients are just as likely to receive guideline-recommended therapy for AMI as those without mental illness. Purpose To examine national-level estimates of the prevalence, management strategies and in-hospital clinical outcomes of SMI patients presenting with AMI. Methods All AMI hospitalisations from the United States National Inpatient Sample were included, stratified by mental health status in to 5 groups: no-SMI, Schizophrenia, “Other non-organic psychoses” (ONOP), Bipolar Disorder and Major Depression. Multivariable logistic regression modelling was performed to examine the association between SMI subtypes and receipt of invasive management and subsequent in-hospital clinical outcomes, expressed as adjusted odds ratios (aOR) and 95% confidence intervals (CI). Results Out of 6,968,777 AMI hospitalisations between 2004 and 2014, a total of 439,544 (6.5%) had an SMI diagnosis. The prevalence of SMI amongst the ACS population doubled over the study period (from 4.5% in 2004 to 9.5% in 2014), primarily due to an increase in Major Depression and Bipolar Disorder diagnoses. All SMI subtypes were less likely to receive coronary angiography and PCI, with the Schizophrenia group being at least odds of either procedure (aOR 0.46 95% CI 0.45, 0.48 and aOR 0.57 95% CI 0.55, 0.59, respectively). Although patients with Schizophrenia and ONOP experienced higher crude rates of in-hospital mortality and stroke compared to those without SMI, only Schizophrenia patients were associated with increased odds of mortality (aOR 1.10 95% CI 1.04, 1.16), while ONOP were the only group at increased odds of stroke (aOR 1.53 95% CI 1.42,1.65) following multivariate adjustment. Patients with ONOP were the only group associated with increased odds of in-hospital bleeding compared to those without SMI (aOR 1.11 95% CI 1.04,1.17). Conclusion Patients with SMI are less likely to receive invasive management for AMI, with women and schizophrenia diagnosis being the strongest predictors of conservative management. Schizophrenia and “other non-organic psychoses” are the only SMI subtypes associated with adverse clinical outcomes after AMI. A multidisciplinary approach between psychiatrists and cardiologists could improve outcomes of this high-risk population. Odds of management and clinical outcomes Funding Acknowledgement Type of funding source: None

Organic psychosis

“Psychosis” and “schizophrenia” are descriptive terms. They are not synonymous with each other. Now somewhat paradoxically, “functional” psychoses such as schizophrenia are distinguished from “organic” psychoses by the absence of brain pathology and/or a likely contributory medical condition. This approximates to a tautology, since ample research confirms brain changes in schizophrenia and medical comorbidities are common in patients with schizophrenia. That said, this chapter enumerates general considerations in the realm of organic psychosis and focuses on specific psychoses that may be particularly noteworthy, autoimmune encephalitis.

Organic psychoses

A psychosis is a syndrome characterized by delusions and hallucinations. Organic psychoses refer to those psychoses attributed to identifiable brain diseases andare thereby distinguished from primary psychoses such as schizophrenia. Almost any condition that affects the brain can cause an organic psychosis. Delirium and dementia are the most common, although there are many other causes including other neurodegenerative diseases, autoimmune disorders, multiple sclerosis, endocrinopathies, metabolic disorders, and infections. Making the diagnosis of an organic psychosis requires a high index of suspicion and appropriate investigation. The treatment is usually that of the primary disease when that is possible, while the symptoms of psychosis can be managed using antipsychotic drugs.

The psychoses of childbearing

It is 50 years since the late Ralph Paffenbarger (1961) wrote a famous article on ‘the picture puzzle of postpartum psychosis. In order to solve this puzzle, it is necessary to clarify the term ‘postpartum psychosis’. One must first exclude a wide variety of disorders, occurring after childbirth, which are not ‘psychoses’. This may seem obvious, but, at one time, some psychoanalysts included disorders of the mother-infant relationship under ‘postpartum schizophrenia’ (Zilboorg 1929). One must then draw a clear boundary between organic and non-organic psychoses. The birth process is so complex, and has so many complications, that there are (depending on definition) 15–18 distinct organic psychoses occurring in pregnancy, parturition or the puerperium (Brockington 2006). Nineteenth century alienists found it difficult to distinguish these from puerperal mania, and this was not finally achieved until the work of Chaslin (1895) & Bonhöffer (1910) at the turn of the twentieth century. Even the most common of these organic psychoses—eclamptic psychosis and infective delirium—are now rare in Europe, North America, and Japan; but these nations, where most of the research is done, contribute less than 10% of the world’s births. In the rest of the world they may be important, and they may still interfere with epidemiological, genetic, and neuroscientific studies of non-organic psychoses. As for the non-organic psychoses, a few are psychogenic, but most have manic depressive features. The term ‘puerperal affective psychosis’, however, does not suffice, because there is an extensive literature on ‘atypical psychoses’, under names like hallucinatorische Irresein der Wochnerinnen (Furstner 1875), amentia, cycloid psychosis, and acute polymorphic psychosis. That is why some psychiatrists still claim that ‘puerperal psychosis’ is a specific disorder, with its own clinical features—those ‘specific features’ are the polymorphic symptoms found in ‘atypical psychoses’, and occur in women at other times, and in men. Ralph Paffenbarger’s ‘picture puzzle’, therefore, applies to the combined group of puerperal bipolar and acute polymorphic psychoses.

Psychiatric disorders

Psychoses due to occupational exposures 306Stress 1: recognition and assessment 308Stress 2: interventions/risk controls 311Post-traumatic stress disorder 1: diagnosis and risk factors 313Post-traumatic stress disorder 2: management 314Organic psychosis due to occupational exposures is thankfully unusual, but its very rarity means that the diagnosis may be missed. Historically, exposures in certain industries put workers at risk of organic psychoses or psychiatric effects: ...