A Collaborative Model of Management Through Exercise of Cardiometabolic Risk inMajor Mental Illness

Dr Niall Crumlish, Consultant Psychiatrist, HSE Dublin South City/SJHMs Alice Waugh, Senior Physiotherapist, St. James’s Hospital

October 2015

Content• Mortality in Major Mental Illness• The Metabolic Clinic• Feasibility Study: Methods & Results• Learning, Directions & Barriers• Clinical Specialist Physiotherapist• Principles of Integrated Care

Mortality in Major Mental Illness

• Schizophrenia, bipolar disorder

• International data: MMI die 10-15 years younger than pop. mean

• From age of onset of disorder, this is 25% of years of life left

• Mortality gap widening (Saha, 2007)

• Cardiovascular mortality the main cause of years of life lost

• BMJ (2013) urged evidence-based interventions to reduce mortality,

including lifestyle interventions to modify cardiovascular risk

Why Excess Mortality?

• Symptoms: negative, cognitive, mood– Lifestyle, social isolation, economic status

• Smoking: >60%, >3 times pop. mean• Antipsychotics: conflicting evidence• Diet (0/40=enough fruit/veg; mean portion=1)• Inequitable access to medical care (Kisely)

Exercise: Sedentary Behaviour and Cardiometabolic Risk

• Sedentary time 80% (Janney) vs pop mean: 55-60%

• Metabolic syndrome: 3/5– Obesity, BP, HDL, triglycerides, glucose– Metabolic syndrome doubles risk of cardiovascular death– 30-40% MMI vs 15% pop.mean

• Sedentary time strongly a/w metabolic syndrome including in people w MMI (Van Campfort, 2012); is amenable to change

“The Metabolic Clinic”• SJH, HSE service – new initiative, 2011• Six week group program: principally SJH physiotherapy

• Input from clinical psychology (HSE), clinical nutrition (SJH), psychiatry (HSE), with feedback to GPs

• Very limited physiotherapy / nutrition service to psychiatry in SJH and to community patients

• Poor acceptability – attendance tailed off• Unclear what if any effect any of this had!

Evaluation 2013-2014• Feasibility of a multidisciplinary intervention to reduce

cardiometabolic risk in schizophrenia and bipolar disorder

• Psychiatry (HSE), physiotherapy (SJH), clinical nutrition (SJH), clinical psychology (HSE)

• Focus was on metabolic syndrome as marker of CVS risk but not originally on sedentary time

• Not a funded study – done in “goodwill” time

Feasibility: Methods– Recruit from HSE general adult psychiatry clinics

– 18-64, medically fit as per NYHA

– Pre- and post-, no control

– Metabolic parameters, ActiGraphs

– Intervention was principally physiotherapy-delivered• 8 weeks – individual physiotherapy• Goal setting and review: motivational interviewing; a collaborative

model between participant & physio• Group nutrition and psychology

o Relatively poor acceptability

Results• 26 people referred; 16 entered the study; 13 completed physio

• Eight people achieved a reduction in cardiometabolic risk – above threshold for fewer MetS parameters on completion

• Pre-and post data available for n=13: of seven with MetS at baseline, four LOST MetS status over the eight-week intervention; of six who did not have MetS at baseline, none developed MetS over the eight weeks

• MetS went from 7/13 (53.8%) to 3/13 (23.1%)

• Less time was spent in sitting (p=0.04) (mean 70 minutes/day in the group who lost MetS status; mean 32 minutes in the group who did not); overall physical activity no different

Learning Points• Compliance was good (in a population difficult to retain)• Individual work >> acceptable than group work• Less time was reported in sedentary behavior• Preliminary data encouraging• Metabolic risk and CVS disease a huge issue• Development and larger-scale evaluation

How to Build on This?• Design and evaluate an intervention for reducing

sedentary time in our population• HRB – shortlisted – evaluation designed; SJH/AMNCH• 12 weeks, one on one, physiotherapy• Based on Kozey Keadle, motivational interviewing• Metabolic risk the outcome of interest; also ST• Baseline, post-intervention, three months• Will require Clinical Specialist Physiotherapist• Will require three years to set up and evaluate service

Clinical Specialist Role• Assessment of need

– Baseline assessment SJH/AMNCH– Database

• Clinical intervention– Refine intervention with user feedback– Hospital and community-based

• Research: ongoing evaluation– Accumulate evidence (BMJ 2013)– No value in the role without ongoing assessment of usefulness with hard

outcomes– Education – other disciplines

• Potential for regional, national role

Barriers• Funding • Competition within HSE/SJH budget• No dedicated physiotherapy post• Very limited physiotherapy input for SJH/Dublin South City

HSE psychiatry patients• Governance: no clear structure for SJH physiotherapy in HSE

mental health service at present• No culture in Ireland of physiotherapy within MH

Service Development

Principles of Integrated Care• Empower and Engage people with major mental illness to actively

manage their health ☑• Support self management ☑• Prevent illness – knowledge of risk factors ☑• Engage clinicians to deliver integrated timely care ☑• Sustainable well managed services w/in current structure ☑• Improved patient access to services and experiences in health

services ☑• Improve patient flow, experiences and outcome ☑• Reduced hospital admissions and supported early discharge

Collaborators & Colleagues

• Ms Niamh Murphy, SJH• Prof Juliette Hussey, TCD• Prof Julie Broderick, TCD• Prof Michael Gill, TCD• Dr Eric Kelleher, SJH• Prof Veronica O’Keane, AMNCH• Dr Siobhán Ní Bhriain, SJH/AMNCH• Ms Claire Browne, SJH• Dr Davy Van Campfort, Leuven• Dr Declan Byrne, SJH• Ms Donna Tynan, SJH• Ms Sophie Lang, SJH

• Prof Charles Normand

• Dr Elizabeth Heron, TCD

• Dr John Dinsmore, TCD

• Prof Naomi Elliott, TCD

• Dr Austin Bayley, SJH

• Dr Andrea Langaro, SJH

• Mr Graham Hurley, SJH

• Ms Deirdre Lynch, SJH

• Ms Lucinda Edge, SJH

• Dr Emmanuel Ugwoke, SJH