Jari Tiihonen

Cannabis use is increasing worldwide and also certain European countries plan to legalize or decriminalize cannabis. This will further increase use rates and also result into higher number of people with cannabis use disorder. Cannabis use in persons with severe mental disorders, namely schizophrenia-spectrum disorders, bipolar disorders and major depressive disorder, has been reported to adversely impact on illness course and associate with non-adherence to treatments. However, impacts of cannabis use disorder on long-term treatment outcomes in severe mental disorders are not known.  The overall aim of this project is to investigate long-term treatment pathways and outcomes of patients with severe mental disorder and comorbid cannabis use disorder, to help in designing optimal health care for these patients. We aim to investigate healthcare service and medication use and work disability during first five years of illness, compared to patients with severe mental disorder without cannabis use disorder. We will also investigate risk of mortality and effectiveness of medications associated with decreased risk of illness relapse, and mortality. Finally, we will develop a prediction model for adverse clinical outcomes to help clinical practice to inform which patients are at the highest risk and in need of enhanced monitoring and effective interventions. Further, we will investigate whether treatment can be tailored based on the predicted risk level.

Over a 3-year project, EU-MIND’s ambition is to bring a European solution for improving the organization of care for comorbid severe mental disorders (SMD) and physical disorders.Why is it a priority? SMD (which includes schizophrenia, bipolar disorder and major depressive disorder) represent the leading source of years lost to disability from all medical illnesses and constitute three of the top ten causes of disability. In EU countries, it has been estimated that over 80 million women and men of all ages would experience some form of mental disorders. Mental disorders have also a high economic burden for society with total costs estimated at over 600 billion € across the 28 EU countries. People with SMD die up to 15 years earlier than the general population, with around 70% of this mortality gap attributed to physical comorbidities. More than one in three persons with SMD has one or more physical comorbidities. The poor physical health and the associated gap in life expectancy experienced by people with SMD have either not improved or worsened over the last decades. Besides modifiable lifestyle factors and side effects of psychotropic medications, access to and quality of health care remain critical priority for individuals with SMD.Where do we go from here? Clinical practice guidelines are already available but not sufficiently and/or adequately provided. Person-centered and integrated care models are critical for supporting effective implementation approaches to translate evidence into practice. However, the challenge lies in implementing these models effectively. There is therefore a need to prioritize the most effective and appropriate integrated care models through a consensus-based approach, informed by a review of available evidence and real-world data on cause-specific premature excess mortality, health care utilization and trajectory of care. EU-MIND intends to focus on the environmental impact of the selected integrated care models. Additionally, the feasibility, potential savings, and cost-effectiveness of these integrated care models must carefully be evaluated to ensure their successful implementation. Finally, addressing the physical disorders of people with SMD also requires a comprehensive and collective approach that encompasses a broader societal perspective which can represent barriers to the model’s dissemination.How to close the gap? EU-MIND is an ambitious collaborative and interdisciplinary initiative from six EU countries (i.e., Denmark, Finland, France, Italy, Poland and Sweden), supported by highly recognized partners and composed of six work-packages. First, excess mortality, health care utilization and trajectory of mental and physical care will be assessed through the analysis of EU nationwide databases to identify actionable gaps in care pathways. Second, we will identify and describe integrated care models for comorbid SMD and physical disorders through a scoping literature review. Third, we will build a European consensus from a Delphi panel including patients and caregivers, healthcare professionals and policymakers about which integrated care models they consider most acceptable and promising. Fourth, we will investigate, through a health economic evaluation, the societal knowledge, attitudes, practices and willingness to pay and the financial impact of implementing an integrated care model. Fifth, we will perform a feasibility pilot study in two real-world settings to provide valuable insights into the practicality and sustainability of integrated model of care. Finally, we will strive to promote the dissemination and translation of knowledge using different channels through inclusive and collaborative efforts that involve multiple stakeholders. With the collaboration of patients, healthcare professionals, policymakers and citizens across Europe, EU-MIND aims to pave the way for more effective, person-centered care for those with comorbid SMD and physical disorders.

Research problem and specific questionsKnowledge is limited on the role of multimorbidity, work-related and social factors as well as treatment on the path to labor market marginalization after sick leave due to common mental disorders (CMDs), i.e., depression, anxiety, and stress-related disorders. This project aims to gain knowledge on how (1) social- and work-related factors, multi-morbidity, and (2) sick-leave patterns and treatment are associated with subsequent labor market marginalization after sick leave due to CMDs.Data and methodWe will use individually linked Swedish register data. Individuals, between the age of 21-50, residing in Sweden in 2006-09 (n=3,661,300), and among them those who started sick leave due to CMDs (49,903) will be included and followed regarding labor market outcomes. We will use sequence analysis and multi-state models to examine labor market marginalization patterns and transitions between labor market states in relation to prognostic factors after sick leave due to CMDs. Furthermore, all individuals living in the Stockholm region in 2014-19 (n=1,215,437) will form an additional study base. Network- and regression analyses will be used to examine the association between multi-morbidity patterns, treatment options and labor market marginalization.Plan for project realizationThis interdisciplinary project involves international collaborations analyzing data that has already been acquired. The three year project budget will cover 50% of the salaries for a postdoctoral researcher and the main applicant, 5% of salaries for co-applicants and costs including drug use modeling, data management, administrative costs such as knowledge exchange and dissemination, publication and premises.RelevanceThere is a large number of individuals with work disability and sick leave due to CMDs in Europe and in Sweden. Keeping individuals in the labor market and avoiding their labor market marginalization after sick leave due to CMDs is important both from a societal and an individual’s perspective and for achieving sustainable working life goals. Knowledge on risk factors and treatment can provide the basis for tailor-made, person-centered interventions.