Body and Mind: Metabolic Syndrome and Mental Health

1. Body and Mind: Metabolic Syndrome and Mental Health A workshop to discuss the management of metabolic issues in people with mental illness

2. Overview • A meeting was convened by the World Federation for Mental Health in September 2004 to discuss mental illness and metabolic syndrome • Attended by ten physicians, consumers and caregiver groups from around the world • Output: “Advancing the treatment of people with mental illness: a call-to-action in the management of metabolic issues”, published in Journal of Clinical Psychiatry in June 2005 • Aim of today’s workshop • Summarise the findings published in the JCP article • Discuss practical implementation of the recommendations

3. Hypertension Impaired glucose tolerance Dyslipidemia Obesity What is metabolic syndrome? • Metabolic syndrome: • a complex disorder consisting of multiple risk factors that promotes cardiovascular disease and overall mortality and morbidity1,2 • Obesity and insulin resistance are two of the most important causative factors3 • Components may have genetic or environmental basis 1Ninomiya JK et al. Circulation 2004;109:42-46; 2Malik S et al. Circulation 2004;110:1245-1250; 3Grundy SM et al. Circulation 2005;112(17):e285-90

4. ATP III definition: the metabolic syndrome • 3 or more risk factors required to meet the definition ATP III = National Cholesterol Education Program Adult Treatment Panel III JAMA 2001; 285: 2486-2497

5. Prevalence of metabolic syndrome in the general population 1Ford ES et al. Diabetes Care 2004;27:2444-2449; 2Park YW et al. Arch Intern Med 2003;163:427-436; 3Haffner S et al. Circulation 2003;108:1541-1545; 4AnuurAD e ET AL. Journal of Occupational Health 2003;45(6):335-43; 5Balkau B et al. Diabetes and Metabolism 2003;29(5):526-32; 6Sattar N et al. Circulation 2003:108(4):414-9; 7Bonora E et al. Int J Obes Relat Metab Disord 2003;27:1283-1289; 8Alverez Leon EE et al. Medicina Clinica 2003;120(5):172-4; 9Panagiotakos DB et al. Am Heart J 2004;147:106-112; 10Gupta R et al. Int J Cardiol 2004;97:257-261; 11Ramachandran A et al. Diabetes Res Clin Prac 2003;60:199-204

6. Metabolic syndrome may be more prevalent in people with mental illness1 Their lifestyle factors may contribute to the development of metabolic syndrome2,3 People with mental illness have a reduced life expectancy compared to the general population Metabolic syndrome (especially CVD) contributes to this4 Poor diet Lack of exercise Smoking Stress Medication that causes weight gain Inadequate self-care Adherence to prescribed medication Financial hardship Poor self-esteem and lack of motivation Limited availability and co-ordination of medical care Metabolic syndrome and mental illness 1Holt RI. Diabet Med 2004;21:515-523; 2McCreadie RF et al. Br J Psychiatry 2003;183:534-539; 3Kumar CT. Br J Psychiatry 2004;184:541; 4Marder SR et al. Am J of Psy 2004:161(8);1334-49

7. Recommendations for metabolic disorder management in people with mental illness

8. Issues • Healthcare professionals (HCPs) need to be fully informed of the increased risk of metabolic disorders and need for intensive monitoring • Collaboration required between HCPs, caregivers and individuals concerned

9. Who should manage physical health monitoring? • Will vary from country to country and from urban to rural setting • Ideally, physical health monitoring should be incorporated into community mental health services • Mental health clinics may be poorly equipped • Psychiatrists may lack familiarity with metabolic monitoring • However, PCPs may be ideally placed • Oversee patients’ complete healthcare programmes • Long-term relationship with person and family • Co-ordinate general and mental health services • But, PCPs often have little specialised training in mental health Conclusion: the prescriber of the medication for the mental disorder should take responsibility for ensuring that monitoring occurs

10. What needs to be monitored? 1Marder SR et al. Am J Psychiatry 2004;161(8):1334-1349

11. What should be done when evidence of metabolic disorders is identified? • Inform concerned individual of their condition and provide support in making lifestyle changes • Refer for treatment to appropriate HCP • Impaired glucose tolerance / diabetes • Elevated blood pressure • Dyslipidaemia • Review antipsychotic medication • May be associated with weight gain and impaired glucose tolerance1 • Risk / benefit (risk factors vs. efficacy) differs from person to person 1Allison DB et al. Am J Psychiatry 1999;156:1686-96

12. How can people with mental illness be supported in making lifestyle changes? • HCPs need to provide significant support • Achieving and maintaining weight loss is more likely to be successful when there is a physician-patient partnership1 • Referral of consumers, when relevant, to • Nutritionist or dietician • Substance abuse professionals2 • Motivational interviewing may be helpful when lifestyle changes are being made • Family members / caregivers • Involve where relevant, encourage participation in healthy diet and exercise and provide information 1Hill JO et al. Obes Res 2002;10(suppl 2):124S-130S; 2Steinberg ML et al. Consult Clin Psychol 2004;72:723-728

13. Conclusions • People with mental illness are at particular risk of developing the components of metabolic syndrome • Prevention of metabolic disorders is key to ensuring the physical health of people with mental illness • Regular and comprehensive monitoring is necessary to ensure proper risk management • Greater overall awareness of metabolic disorders in people with mental illness within the broad medical community is urgently needed • Treatment of people with mental illness is a collaborative effort between clinicians, the person involved and their family / caregivers

14. Discussion

15. Discussion Primary Care Practitioners

16. Goals of discussion • Explore the importance of physical health monitoring in people with mental illness, and how and when monitoring should take place • Develop awareness of key considerations when working with people with mental illness • Discuss tools to facilitate best practice in recording and sharing important information regarding the mental and physical health of people with mental illness • Discuss a best practice checklist for working with people with mental illness

17. Discussion topics • Monitoring metabolic syndrome risk factors • How to monitor • Frequency of monitoring • Encouraging self-monitoring • Obesity – weight change of 3-5kg • Blood sugar – increased thirst / urination • Encouraging healthy behaviour • Healthy eating • Increased physical activity • Quit / cut down on smoking • Decrease alcohol consumption

18. Discussion topics (cont.) • Considerations for people with mental illness • Mental health history • Personal stressors / triggers • Unusual behaviours to watch out for • Other HCPs seen by the individual • Involve families and caregivers • Establish source of support • Build a familiar and trusting relationship with them • Working with mental health specialists • Sharing of information

19. Discussion Mental Health Practitioners

20. Goals of discussion • Share experiences of advising people with mental illness on physical health matters. • Develop awareness of how to listen attentively to people with mental illness and assist them in developing their own healthy living plans • Discuss tools to facilitate and encourage these individuals to take more responsibility for their own health • Discuss a best practice checklist for discussing metabolic syndrome with people with mental illness

21. Discussion topics • Healthy living curve • Identifying unhealthy behaviour • Diet / exercise / smoking • Healthy living pros and cons • Developing a healthy living plan • Diet / exercise / smoking / alcohol / self-help groups / supportive relationships / medication • Implementing a healthy living plan

22. Discussion topics (cont.) • Supportive people • Family members / friends / other HCPs to help put healthy strategies into action • Self-monitoring • Obesity / blood sugar • Medication review

23. Discussion Mental Health Consumer and Family

24. Goals of discussion • Explain how to develop a healthy living plan, and how to talk to physicians and mental health practitioners about metabolic syndrome • Empower you/your relative to take responsibility for physical health and develop a healthy living plan • Discuss tools to facilitate and enable you/your relative to become more involved in decisions about mental and physical health • Discuss a checklist of suggested activities to ensure physical health and help prevent metabolic syndrome

25. Discussion topics • Asking your doctor for physical health monitoring • Weight / blood sugar / blood pressure / fats in blood • Talking to your doctor • Clarify what you want to discuss • Self-monitoring • Weight / blood sugar • Identifying unhealthy behaviour • Diet / exercise / smoking

26. Discussion topics (cont.) • Identifying personal goals • Healthy living plan • Diet / exercise / smoking / drinking / self-help group / supportive relationships / medication • Getting support for a healthy living plan • Family / friends / HCPs • Medication review