Physical health and sever Physical health and sever mental illnessmental illness

Physical health and sever Physical health and sever mental illnessmental illness

Prepared byPrepared by::

Mr. Mr. MutasemMutasem naser Allahnaser Allah.. Mr. Mr. AhmmedAhmmed Abo Rahma. Abo Rahma.

Supervised by:Supervised by: Dr. Abed Alkareem RadwanDr. Abed Alkareem Radwan

Topic contentTopic content

Introduction Introduction Common physical health problem with Common physical health problem with

SMISMI Reason why people with SMI many Reason why people with SMI many

experience physical health problem experience physical health problem Health behavior of people with SMI .Health behavior of people with SMI . Treatment related factor that affect the Treatment related factor that affect the

physical health of people with SMI .physical health of people with SMI . Nursing intervention .Nursing intervention .

The link between mental illness and The link between mental illness and physical healthphysical health

People with serious mental illness have higher People with serious mental illness have higher morbidity and mortality rates of chronic morbidity and mortality rates of chronic diseases than the general populationdiseases than the general population..

. .People who have severe mental illness, like People who have severe mental illness, like schizophrenia , depression and mania are at schizophrenia , depression and mania are at increased risk for a range of physical increased risk for a range of physical illnesses and conditions, including coronary illnesses and conditions, including coronary heart disease, diabetes and greater levels of heart disease, diabetes and greater levels of obesity and hypertension Thus, most if not obesity and hypertension Thus, most if not all types of mental disorder are associated all types of mental disorder are associated with an increased rate of early deathwith an increased rate of early death..

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the prevalence of many physical diseases is higher in persons with severe mental illness than in the general population .

mortality due to physical diseases is higher in persons with severe mental illness than in the general population.

, and the gap concerning mortality due to some diseases (like :-ischemic heart disease) has been increasing in recent decades

the access to physical health care of persons with severe mental illness is reduced compared to the general population.

the quality of physical health care received by persons with severe mental illness is poorer than the general population..

• People with severe mental illness face a greater risk of developing some physical health problems. For example, people who have schizophrenia or bi-polar disorder have

1) 2-4 times greater risk of cardiovascular disease2) 2-4 times greater risk of respiratory disease 3) 5 times greater risk of diabetes

issuesissues

The issue of protection and promotion of physical The issue of protection and promotion of physical health in persons with severe mental illness is health in persons with severe mental illness is emerging as one of great public health and emerging as one of great public health and ethical relevance worldwide. If we are really ethical relevance worldwide. If we are really concerned about the quality of life of our concerned about the quality of life of our patients with severe mental disorders and with patients with severe mental disorders and with the protection of their civil rights, we cannot the protection of their civil rights, we cannot ignore that physical health is a crucial ignore that physical health is a crucial dimension of quality of life in these persons, dimension of quality of life in these persons, and that the access to a physical health care of and that the access to a physical health care of the same quality as that available to the rest of the same quality as that available to the rest of the population is a basic right of these persons the population is a basic right of these persons as human beings and as citizensas human beings and as citizens . .

policypolicy

The promotion of physical health The promotion of physical health care in people with severe mental care in people with severe mental illness is today a key issue in our illness is today a key issue in our field. If we do not regard it as a field. If we do not regard it as a priority, we will not be able to state priority, we will not be able to state convincingly that a better quality of convincingly that a better quality of life and the protection of the civil life and the protection of the civil rights of our patients is really what rights of our patients is really what we strive toward.we strive toward.

policypolicy

People with different illnesses or People with different illnesses or disorders will have different illness disorders will have different illness experiences, including;experiences, including;

the types of symptoms experienced .the types of symptoms experienced . how daily life and ability to function how daily life and ability to function

'normally' is affected 'normally' is affected and what types of treatment may be and what types of treatment may be

effective. effective.

policypolicy Education and training of mental health Education and training of mental health

professionals and primary care providers is one more professionals and primary care providers is one more essential step.. essential step..

They should be educated about the importance of They should be educated about the importance of recognizing physical illness in people with severe recognizing physical illness in people with severe

mental disorders. mental disorders. They should be encouraged to familiarize They should be encouraged to familiarize

themselves with the most common reasons for under themselves with the most common reasons for under diagnosis or misdiagnosis of physical illness in their diagnosis or misdiagnosis of physical illness in their

patientspatients

• * * Another essential step is the development of an appropriate integration between mental health and physical health care.

* There is some debate in the literature about who should monitor physical health in people with severe mental illness. What really matters, however, is that there is always somebody who cares every patient should have a professional who is identified as responsible for his/her physical health care. * On the other hand, mental health services should be able to provide at least a standard routine assessment of their patients, to identify or suspect the presence of physical health problems..

Physical health-checkPhysical health-check

During the health-check, the GP or practice During the health-check, the GP or practice nurse will :-nurse will :-

Take blood pressureTake blood pressure Take pulse rateTake pulse rate Do a urine or blood testDo a urine or blood test Measure weightMeasure weight Ask about smokingAsk about smoking Ask about alcohol consumptionAsk about alcohol consumption Check date of last smear testCheck date of last smear test

PHYSICAL ILLNESSES AND SURGERIES PHYSICAL ILLNESSES AND SURGERIES WITH MAJOR PSYCHOLOGIC EFFECTSWITH MAJOR PSYCHOLOGIC EFFECTS55

AIDS/HIV• AIDS/HIV• PARKINSON’S DISEASE•PARKINSON’S DISEASE• MULTIPLE SCLEROSIS•MULTIPLE SCLEROSIS• STROKE (CVA)•STROKE (CVA)• COPD, ASTHMA•COPD, ASTHMA• MASTECTOMY•MASTECTOMY• PROSTATECTOMY•PROSTATECTOMY• AMPUTATION•AMPUTATION• ALZHEIMER’S DISEASE.ALZHEIMER’S DISEASE.

CausesCauses? ? Health behaviours – Smoking, diet, physical inactivity, Health behaviours – Smoking, diet, physical inactivity,

alcohol & substance misuse, sexual behaviouralcohol & substance misuse, sexual behaviour Illness – Symptoms, poor spontaneous reporting of Illness – Symptoms, poor spontaneous reporting of

physical health problemsphysical health problems Services not geared to meet peoples needs … - Lack of Services not geared to meet peoples needs … - Lack of

knowledge, lack of training, attitudes, confidence, lack knowledge, lack of training, attitudes, confidence, lack of integrated careof integrated care

Adverse effects of medication – Extrapyramidal side Adverse effects of medication – Extrapyramidal side effects, weight gain, glucose intolerance & diabetes, effects, weight gain, glucose intolerance & diabetes, cardiovascular effects, sexual dysfunction, neuroleptic cardiovascular effects, sexual dysfunction, neuroleptic malignant syndromemalignant syndrome

Environment – Poverty, poor housing, social exclusionEnvironment – Poverty, poor housing, social exclusion Difficulties recognising symptomsDifficulties recognising symptoms Barriers to accessing primary careBarriers to accessing primary care Communication barriersCommunication barriers Inequalities in screening & treatmentInequalities in screening & treatment

Morbidity and Mortality Morbidity and Mortality CausesCauses

While suicide and injury account for about While suicide and injury account for about 30-40% of excess mortality, about 60% of 30-40% of excess mortality, about 60% of premature deaths in persons with premature deaths in persons with schizophrenia are due to “natural schizophrenia are due to “natural causes”causes” Cardiovascular diseaseCardiovascular disease DiabetesDiabetes Respiratory diseasesRespiratory diseases (including pneumonia (including pneumonia

and flu)and flu)

Infectious diseases Infectious diseases (including HIV and Hep C(including HIV and Hep C

Premature MortalityPremature Mortality

Six major causes of death in U.SSix major causes of death in U.Sand increased relative risk in SMIand increased relative risk in SMI Cardiovascular Disease Cardiovascular Disease 3.4 X3.4 X Cancer Cancer Maybe lower rates except lungMaybe lower rates except lung Stroke Stroke 2x in age < 502x in age < 50 Respiratory disease Respiratory disease 5x5x

Accidents Accidents higherhigher DiabetesDiabetes

What do people with SMI What do people with SMI die fromdie from??

Study by Bralet 150 people with Study by Bralet 150 people with schizophrenia over 8 years – 13 deathsschizophrenia over 8 years – 13 deaths

3 suicides3 suicides 3 heart disease3 heart disease 2 cancers2 cancers 2 respiratory diseases2 respiratory diseases 1 car crash1 car crash 1 homicide victim1 homicide victim 1 infectious disease1 infectious disease

Individual Risk Factors Individual Risk Factors Associated with Early DeathAssociated with Early Death SmokingSmoking High blood pressureHigh blood pressure High cholesterolHigh cholesterol Diet and obesityDiet and obesity InactivityInactivity DiabetesDiabetes AccidentsAccidents

Risks HealthRisks HealthPremature deathDiabetes type IICardiovascular DiseaseDyslipidemiaHigh blood PressureOsteoarthritisStrokeSleep ApneaGall Bladder DiseaseAsthmaHirsutism /menstrual irregularitiesSocial isolationSurgical complicationsDepression

Factors Associated with Factors Associated with Premature DeathPremature Death

Reduced Use/Inefficient Use of Medical ServicesReduced Use/Inefficient Use of Medical Services

PovertyPoverty

Systemic Barriers to Ideal Health CareSystemic Barriers to Ideal Health Care Healthcare systems and financingHealthcare systems and financing

Psychotropic medicationsPsychotropic medications

Individual health habitsIndividual health habits SmokingSmoking InactivityInactivity Obesity/poor nutritionObesity/poor nutrition

Physical Activity: Physical Activity: BenefitsBenefits

““The health benefits of physical activity The health benefits of physical activity are generally independent of weight.”are generally independent of weight.”

Sedentary lifestyle is an independent Sedentary lifestyle is an independent risk for cardiovascular deathrisk for cardiovascular death even in even in normal weight individualsnormal weight individuals. .

Moderate intensity exercise without Moderate intensity exercise without

dietary changes brings dietary changes brings reduced reduced incidence of metabolic syndromeincidence of metabolic syndrome

Physical Activity: Physical Activity: BenefitsBenefits

Prevention of Wt Gain and to achieve Prevention of Wt Gain and to achieve weight lossweight loss

Bone health in kids.Bone health in kids. Function in older adults.Function in older adults. Increased cardiorespiratory fitness.Increased cardiorespiratory fitness. Increased muscular strength.Increased muscular strength. Decreased blood pressure.Decreased blood pressure. Decreased depressive symptoms.Decreased depressive symptoms. Improved sleep quality.Improved sleep quality.

Amounts of ExerciseAmounts of Exercise

Inactive or sedentary <30 min/wk, <10min/qd

Health benefits accrue at 60 min/wk Low level 90 min/wk. Even low levels lead to

dramatic decr in risk of premature death For substantial health benefits 150 min

cumulative moderate intensity exercise a week.

Greater benefits accrue at higher levels 300 minutes for weight loss

Lifestyle Changes Work in Lifestyle Changes Work in those with Mental Illnessthose with Mental Illness

Smoking CessationSmoking Cessation Addiction RecoveryAddiction Recovery Prevention and reversal of Prevention and reversal of

antipsychotic induced weight antipsychotic induced weight gaingain

Development of healthy eating Development of healthy eating and exercise habitsand exercise habits

Special Considerations Special Considerations Physical Activity SMIPhysical Activity SMI

Inactive; start low, go slow.Inactive; start low, go slow. Fear of heart attack with sensation Fear of heart attack with sensation

of increase HR.of increase HR. Lack of familiarity with the sensation Lack of familiarity with the sensation

of muscle soreness.of muscle soreness. Traumatic bodily relationships.Traumatic bodily relationships. Balance issues on moving treadmills Balance issues on moving treadmills

medication effects.medication effects. Cold temperatures.Cold temperatures.

Interventions:Interventions:Physical ActivityPhysical Activity

Fitness equipment at every facility, esp Fitness equipment at every facility, esp aerobic (exercise bikes, elliptical)aerobic (exercise bikes, elliptical) Staffed for pts and open for staff useStaffed for pts and open for staff use Relationships with local health clubs for equip.Relationships with local health clubs for equip.

Access to fitness centers in the communityAccess to fitness centers in the community EducationEducation

Links to obesity and cardiovascular illness and Links to obesity and cardiovascular illness and deathdeath

Benefits/BarriersBenefits/Barriers Types/Low cost optionsTypes/Low cost options Getting started; Medical ClearanceGetting started; Medical Clearance PostersPosters

Healthy Changes Healthy Changes InitiativeInitiative

ChoosingChoosing HealthyHealthy ActivitiesActivities NutritionNutrition GettingGetting ExerciseExercise Smoking CessationSmoking Cessation

Interventions:Interventions:Physical ActivityPhysical Activity

Physical activity opportunities for each patientPhysical activity opportunities for each patient Structured group formatStructured group format Milieu changes such as stairs to cafeteria, walking to Milieu changes such as stairs to cafeteria, walking to

appts on campusappts on campus

Encouragement of walking in all sites. Encouragement of walking in all sites.

Enhance and document physical activity Enhance and document physical activity opportunities in vocational and residential opportunities in vocational and residential settingssettings

Motivational interventions to eliminate culture of Motivational interventions to eliminate culture of lethargylethargy

•Sponsoring Events to promote Culture Change Sponsoring Events to promote Culture Change and Maintain Focus .and Maintain Focus .Physical Activity Challenges, Workplace wellness Physical Activity Challenges, Workplace wellness opportunities for employees .opportunities for employees .NAMI WalkNAMI WalkPeer Counselors.Peer Counselors.Peers with lived experience key component in Peers with lived experience key component in change of culture; Social network inspires group change of culture; Social network inspires group change.change.Increase opportunities for shared wellness Increase opportunities for shared wellness opportunitiesopportunitiesInclude consumers on area Health and Wellness Include consumers on area Health and Wellness task forcestask forces..

Overweight and ObesityOverweight and Obesity

Definitions:Definitions:Healthy WeightHealthy Weight

Body Mass Index (BMI) 18-24.9Body Mass Index (BMI) 18-24.9

Overweight; Overweight; BMI 25-29.9BMI 25-29.9

ObesityObesity BMI 30-34.9BMI 30-34.9

Extreme obesityExtreme obesity BMI >35BMI >35

Obesity and Mental Obesity and Mental IllnessIllness

Epidemic in mentally illEpidemic in mentally ill Multiple studies show increased incidence of overwt. Multiple studies show increased incidence of overwt.

and obesity in schizophrenia, esp womenand obesity in schizophrenia, esp women Majority recognize the wt problem, want to/have Majority recognize the wt problem, want to/have

tried to weigh lesstried to weigh less Certain 2Certain 2ndnd gen antipsychotics (SGA) can cause gen antipsychotics (SGA) can cause

rapid wt gain (7 -30% of body wt) from 1rapid wt gain (7 -30% of body wt) from 1stst sev. sev. months of therapy up to a yr or longer.months of therapy up to a yr or longer.

Significant wt increases coincided with clozapine Significant wt increases coincided with clozapine introductionintroduction

Wt gain ranked as top “bad thing” about taking meds Wt gain ranked as top “bad thing” about taking meds in UK surveyin UK survey

Lifestyle modifications preferred approachLifestyle modifications preferred approach

Common Elements of Common Elements of Weight Reduction Weight Reduction

ProgramsPrograms Goal Setting of Realistic short-term Goal Setting of Realistic short-term

goalsgoals Strategies to increase physical Strategies to increase physical

activity and decrease sedentary activity and decrease sedentary behaviorbehavior

Nutritional focus teaching and demo Nutritional focus teaching and demo of healthy eating habitsof healthy eating habits

Self-monitoring of nutritional intake Self-monitoring of nutritional intake and physicaland physical

Interventions:Interventions: Client Education Client Education

Client Education about Nutrition and Weight Client Education about Nutrition and Weight ManagementManagement Nutrition label readingMacronutrient information (protein, carbs, fats, fiber)Eating behaviors and physiology;

recognizing and responding to hunger, slow eating Substitution of healthy foods for less healthy foods;

emphasis on addition of healthy foods rather than deprivation

Portion sizeHigh calorie drinksGoal setting; one change at a time.Grocery shoppingFood preparationFast food, restaurant eating

Interventions: MilieuInterventions: Milieu Vending machines and canteensVending machines and canteens

Provision of healthy alternatives Provision of healthy alternatives WaterWater Fresh fruitFresh fruit Low fat dairy productsLow fat dairy products

Substitute juice for water at med Substitute juice for water at med dispensingdispensing

Printed materials and posters at cafeteriaPrinted materials and posters at cafeteria Inpatient take out foodInpatient take out food

Emphasis on discretionary income, financial Emphasis on discretionary income, financial aspects recommendedaspects recommended

Engage staff; “biggest loser” contestsEngage staff; “biggest loser” contests

Regular Physical ActivityRegular Physical Activity

During physical activity, our brain During physical activity, our brain produces “endorphins”, or chemicals produces “endorphins”, or chemicals that provide relief from high stress that provide relief from high stress levels. The good news is that high levels. The good news is that high intensity activity is not required to intensity activity is not required to experience this relief.experience this relief.

Regular physical activity can also Regular physical activity can also reduce reduce the symptoms of depression and the symptoms of depression and anxiety. anxiety.

SmokingSmoking

Cigarette smoking is the single most preventable cause of morbidity and

premature death

Health Consequences of Health Consequences of SmokingSmoking

CancersCancers LungLung Laryngeal, pharyngeal, Laryngeal, pharyngeal,

oral cavity, esophagusoral cavity, esophagus PancreaticPancreatic Bladder and kidneyBladder and kidney Cervical and endometrial Cervical and endometrial GastricGastric Acute myeloid leukemiaAcute myeloid leukemia

Reduce fertility in Reduce fertility in women, poor women, poor pregnancy outcomes, pregnancy outcomes, low birth weight low birth weight babies, sudden infant babies, sudden infant death syndromedeath syndrome

Cardiovascular diseasesCardiovascular diseases Sub clinical Sub clinical

atherosclerosisatherosclerosis Coronary heart diseaseCoronary heart disease StrokeStroke Abdominal aortic Abdominal aortic

aneurysmaneurysm

Respiratory diseasesRespiratory diseases Acute respiratory Acute respiratory

illnesses, e.g., pneumoniaillnesses, e.g., pneumonia Chronic respiratory Chronic respiratory

diseases, e.g., COPDdiseases, e.g., COPD

CataractCataract PeriodontitisPeriodontitis

Nicotine Dependence Nicotine Dependence among Seriously Mentally among Seriously Mentally

Ill (SMI)Ill (SMI)

75% of SMI are tobacco dependent 75% of SMI are tobacco dependent (22% general population)(22% general population) 85% in schizophrenia85% in schizophrenia

60 - 95% of people with addiction 60 - 95% of people with addiction disorders smoke.disorders smoke.

importantimportant

Tobacco use for most smokers starts Tobacco use for most smokers starts pediatric years with the exception of pediatric years with the exception of schizophrenia which has later onset schizophrenia which has later onset of tobacco use often coincident with of tobacco use often coincident with psychiatric hospitalizationpsychiatric hospitalization..

Why Do People With Mental Illness Why Do People With Mental Illness

SmokeSmoke There are many reasons why any individual There are many reasons why any individual

smokes. On top of the usual reasons people with smokes. On top of the usual reasons people with mental illness may find other good effects from mental illness may find other good effects from smoking. Positive effects of smoking for people smoking. Positive effects of smoking for people with mental illness, include the following: with mental illness, include the following:

Nicotine increases alertness. This may enhance Nicotine increases alertness. This may enhance concentration, thinking and learning. This may concentration, thinking and learning. This may be a benefit to people with schizophrenia whose be a benefit to people with schizophrenia whose illness or medication leads to cognitive problems. illness or medication leads to cognitive problems.

Nicotine can help relaxation, and it can also Nicotine can help relaxation, and it can also reduce negative feelings such as anxiety, tension reduce negative feelings such as anxiety, tension and anger. So smoking may help people with and anger. So smoking may help people with mental illness deal with stressful situations. mental illness deal with stressful situations.

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Nicotine may reduce positive symptoms, Nicotine may reduce positive symptoms, such as hallucinations for a short period. such as hallucinations for a short period.

There is some evidence to suggest that There is some evidence to suggest that smoking is associated with reduced levels smoking is associated with reduced levels of antipsychotic induced Parkinsonism. of antipsychotic induced Parkinsonism.

Smoking can help to relieve boredom and Smoking can help to relieve boredom and provide a framework for the day. provide a framework for the day.

Smoking can improve social interaction, Smoking can improve social interaction, something that may be of particular something that may be of particular benefit to people with negative symptoms benefit to people with negative symptoms

OutcomesOutcomes Decrease number of smokers in every setting.Decrease number of smokers in every setting. Increase the number of smokers advancing Increase the number of smokers advancing

toward quitting as measured by stage of changetoward quitting as measured by stage of changePrecontemplation Precontemplation Contemplation Contemplation PreparationPreparationAction MaintenanceAction Maintenance

Increase the number of smokers who have been Increase the number of smokers who have been given advise to quit.given advise to quit.

Increase the number of patients who have Increase the number of patients who have smoking cessation interventions addressed on smoking cessation interventions addressed on the treatment plan.the treatment plan.

LOCAL AGENCY / CLINICIAN RECOMMENDATIONS

educate / share information to make healthy choices regarding nutrition, tobacco use, exercise, implications of psychotropic drugsteach /support wellness self-management skillsteach /support decision making skillsmotivational interviewing techniquesImplement a physical health Wellness approach that is consistent with Recovery principles, including supports for smoking cessation, good nutrition, physical activity and healthy weight.attend to cultural and language needs

ASSIST the quit attempt

Provide assistance in developing a quit plan;

Help a patient to set a quit date; Offer self-help material; Explore potential barriers and

difficulties Review the need for pharmacotherapy. Refer to a quitline and/or an active call

back programme

ARRANGE follow up

Offer a follow up appointment within 7 days Affirm success when you next see the

patient Reinforce successful quitting: positive

feedback helps sustain smoking cessation. Don’t talk about ‘failure’, ‘relapse’ is very

common Help the patient work out ‘what went wrong

this time’ and how they prevent a relapse next time.

Behavioral InterventionsBehavioral Interventions

Motivate these smokers to stop and Motivate these smokers to stop and teach basic cessation skills.teach basic cessation skills.

Protocols exist for patients seen in Protocols exist for patients seen in mental hospital settings. These rely mental hospital settings. These rely on prior knowledge of smoker’s on prior knowledge of smoker’s diagnosis, medication, history, and diagnosis, medication, history, and training to monitor symptoms and training to monitor symptoms and adjust medications.adjust medications.

Behavioral InterventionsBehavioral Interventions

Protocols for smokers with history of Protocols for smokers with history of mental illness seeking tobacco mental illness seeking tobacco dependence treatment outside dependence treatment outside mental health facilities and clinics mental health facilities and clinics should follow standard treatment should follow standard treatment guidelinesguidelines

Need to adjust these protocols to Need to adjust these protocols to account for their special account for their special circumstances circumstances

Motivational tensionMotivational tension

Worry about healthDislike of financial costGuilt or shameDisgust with smokingHope for success

Enjoyment of smokingNeed for cigaretteFear of failureConcern about withdrawalPerceived benefits

Offering treatment can influence the choice

Nicotine replacementNicotine replacement Begin NRT on the quit date, (apply patches the

night before) Use a dose that controls the withdrawal

symptoms NRT provides levels of nicotine well below

smoking Prescribe in blocks of two weeks Arrange follow up to provide support Use a full dose for 6 to 8 weeks then stop or reduce the dose gradually over

4 weeks.

Barriers to Successful Barriers to Successful CessationCessation

Provider inattention/pessimismProvider inattention/pessimism Co-dependency and mental illnessCo-dependency and mental illness Mental health staff smokeMental health staff smoke Historic attitudes about smoking in Historic attitudes about smoking in

mental health communitymental health community No coverage for cessation drugsNo coverage for cessation drugs Improper use of the drugsImproper use of the drugs Ignorance of quitlinesIgnorance of quitlines

Resistance to Cessation for Resistance to Cessation for People with Mental People with Mental

IllnessesIllnesses Many loved ones of persons with Many loved ones of persons with

mental illness resist helping them quitmental illness resist helping them quit They feel protective and want to focus They feel protective and want to focus

on quality, not quantity, of lifeon quality, not quantity, of life But diseases caused by smoking can But diseases caused by smoking can

severely hamper quality as well as severely hamper quality as well as quantity of lifequantity of life

And second-hand smoke imperils loved And second-hand smoke imperils loved ones and workers ones and workers

Nursing help pt to stop Nursing help pt to stop smokingsmoking

Regard the person’s behaviour as their personal choice

Let the patient decide how much of a problem they have

Avoid argumentation and confrontation

• Encourage the patient to discuss the advantages and disadvantages of making a quit attempt

ADVISE on coping strategies

Recommend total abstinence - not even a single puff

Drinking alcohol is strongly associated with relapse

Inform friends and family and ask for support Consider writing a ‘contract’ with a quit date Removal of cigarettes from home, car and

workplace; Give practical advice about coping with

Withdrawal symptoms occur mostly during the first two weeks

Relapse after this time relates to cues or distressing events.

Remind patients of the health benefits of quitting

Goals: Lower Risk for Goals: Lower Risk for CVDCVD

Blood cholesterol Blood cholesterol 10% 10% = 30% = 30% in CHD (200-180) in CHD (200-180)

High blood pressure (> 140 SBP or 90 DBP)High blood pressure (> 140 SBP or 90 DBP) 4-6 mm Hg 4-6 mm Hg = 16% = 16% in CHD; 42% in CHD; 42% in stroke in stroke

Cigarette smoking cessationCigarette smoking cessation 50%-70% 50%-70% in CHD in CHD

Maintenance of ideal body weight (BMI = 25) Maintenance of ideal body weight (BMI = 25) 35%-55% 35%-55% in CHD in CHD

Maintenance of active lifestyle (20-min walk Maintenance of active lifestyle (20-min walk daily)daily) 35%-55% 35%-55% in CHD in CHD

”

aging is like climbing a moutain. you get out of breath but you have a magnificint view"

(Ingmar Bergman)

. .Diabetes and fasting blood Diabetes and fasting blood glucoseglucose

(WHO) defined diabetes as a fasting plasma (WHO) defined diabetes as a fasting plasma glucose of more (126 mg/d L) glucose of more (126 mg/d L)

In an asymptomatic individual, the diagnosis In an asymptomatic individual, the diagnosis should be confirmed with a second fasting should be confirmed with a second fasting measurement on another day. The measurement measurement on another day. The measurement of HbA1c may be used in the future for diagnosing of HbA1c may be used in the future for diagnosing diabetes diabetes

In all forms of diabetes, inadequate control of In all forms of diabetes, inadequate control of glycamia will result in complications of diabetes.glycamia will result in complications of diabetes.

These complications includeThese complications include diabetic neuropathydiabetic neuropathy diabetic retinopathydiabetic retinopathy diabetic kidney diseasediabetic kidney disease increased risk of infectionincreased risk of infection

Diabetes and fasting blood Diabetes and fasting blood glucoseglucose

.. Patients with type 2 diabetes are Patients with type 2 diabetes are

likely to require additional likely to require additional pharmacological management, but pharmacological management, but this should be no different from the this should be no different from the general population, for which general population, for which guidelines are available from the guidelines are available from the EASD and the American Diabetes EASD and the American Diabetes Association (ADA) Association (ADA)

Healthy Changes Healthy Changes InitiativeInitiative

TheThe Healthy Changes InitiativeHealthy Changes Initiative is designed to is designed to address the individual’s modifiable risk factors address the individual’s modifiable risk factors which result in chronic illness and early death in which result in chronic illness and early death in individuals with psychiatric disabilities.individuals with psychiatric disabilities.

Physical InactivityPhysical Inactivity Overweight/ObesityOverweight/Obesity SmokingSmoking

“…the recovery paradigm of needed services has to include the concept of health promotion in treatment planning and service delivery to to persons with SMI.” persons with SMI.” Hutchinson et al, 2006Hutchinson et al, 2006

Fasting blood glucoseFasting blood glucose

Abnormal valueAbnormal value

Impaired fasting glucose: between Impaired fasting glucose: between 6.1 and 7 mmol/l (110–125 mg/dl)6.1 and 7 mmol/l (110–125 mg/dl)Diabetes: ≥ 7.0 mmol/l (126 mg/dl) Diabetes: ≥ 7.0 mmol/l (126 mg/dl)

Estimated prevalence and Estimated prevalence and relative riskrelative risk

Modifiable Modifiable risk factorsrisk factors

SchizophrenSchizophreniaia

Bipolar Bipolar disorderdisorder

ObesityObesity 4545––55%55% RR: 1.5–RR: 1.5–22

2121––49%49% RR: 1–2RR: 1–2

SmokingSmoking 5050––80%80% RR: 2–3RR: 2–3 5454––68%68% RR: 2–3RR: 2–3

DiabetesDiabetes1010––15%15% RR: 2RR: 2 88––17%17% RR: 1.5–RR: 1.5–22

HypertensionHypertension 1919––58%58% RR: 2–3RR: 2–3 3535––61%61% RR: 2–3RR: 2–3

Management of adverse drug-related Management of adverse drug-related effects on cardiovascular disease risk effects on cardiovascular disease risk

factorsfactors

Choice of psychotropic medication should take account of potential effects of different agents on CVD risk factors, such as weight and glucose levels and lipid profiles, especially in patients who are overweight or have diabetes or are at high total CVD risk factors.

Clinical decision-making is always complex and has to consider efficacy aspects as well. A dilemma may arise with clozapine which is recommended by many guidelines as the antipsychotic of choice for those with refractory schizophrenia as clozapine is associated with the highest risk of weight gain and related CVD risk factors.

interventions for interventions for management of CVD risk management of CVD risk

factorfactor Smokers should be encouraged to stop Smokers should be encouraged to stop

smoking all forms of tobacco. Those who smoking all forms of tobacco. Those who demonstrate a readiness to quit can be demonstrate a readiness to quit can be referred to a smoking cessation service which referred to a smoking cessation service which can offer behavioral counseling, nicotine can offer behavioral counseling, nicotine replacement therapy or other replacement therapy or other pharmacological intervention.pharmacological intervention.

Maintaining a healthy body weight and shape Maintaining a healthy body weight and shape by healthy eating and regular physical activity by healthy eating and regular physical activity is the a key component of lowering CVD risk is the a key component of lowering CVD risk and prompt action is needed in patients who and prompt action is needed in patients who are overweight at initial assessment or who are overweight at initial assessment or who show signs of early weight gain with show signs of early weight gain with antipsychotic medication antipsychotic medication

Continue Continue Patients should be advised to take 30 minutes of Patients should be advised to take 30 minutes of

moderately vigorous activity at least a brisk walk moderately vigorous activity at least a brisk walk on most days of the week on most days of the week

Avoidance of hypoglycemia is best achieved by Avoidance of hypoglycemia is best achieved by involving the patient's family and cares in the involving the patient's family and cares in the education process about the risks and education process about the risks and consequences of hypoglycemia.consequences of hypoglycemia.

Patients should be encouraged to eat lean meat, Patients should be encouraged to eat lean meat, fish and low fat dairy products and to replace fish and low fat dairy products and to replace saturated fat with monounsaturated and saturated fat with monounsaturated and polyunsaturated fats from vegetable and marine polyunsaturated fats from vegetable and marine sources Those with mildly elevated cholesterol sources Those with mildly elevated cholesterol levels may be able to reach target levels through levels may be able to reach target levels through diet alone diet alone

mangement Blood pressuremangement Blood pressure

High blood pressure in severely mentally ill High blood pressure in severely mentally ill patients is often missed. Target blood patients is often missed. Target blood pressure levels of less than 140/90 mmHg are pressure levels of less than 140/90 mmHg are recommended.recommended.

Lifestyle changes, such as stopping smoking,Lifestyle changes, such as stopping smoking, reducing salt intake,reducing salt intake, weight reduction weight reduction and increased exercise,and increased exercise, Pharmacological therapy Pharmacological therapy this may be sufficient to reduce mildly elevated this may be sufficient to reduce mildly elevated

blood pressureblood pressure

What can be doneWhat can be done?? Treatment of Common Mental Illnesses with Treatment of Common Mental Illnesses with

Cognitive Behavioural therapy highly effective (8 Cognitive Behavioural therapy highly effective (8 sessions)sessions)

Psycho-social support to cancer patients Psycho-social support to cancer patients decreased pain and depression and in half of decreased pain and depression and in half of studies reduced progressionstudies reduced progression

More daily “uplifts” increased bodies natural More daily “uplifts” increased bodies natural killer cells (immunity)killer cells (immunity)

Putting people in a positive mood leads to Putting people in a positive mood leads to greater pain tolerancegreater pain tolerance

Assigning people to hospital rooms with a Assigning people to hospital rooms with a pleasant view decreased pain and reduced length pleasant view decreased pain and reduced length of stayof stay

Choosing health: exercise Choosing health: exercise and SMIand SMI

41% low levels of exercise..41% low levels of exercise.. 70% male patients obese..70% male patients obese.. 86% female patients obese..86% female patients obese.. Medication problems..Medication problems..

– – tardive dyskinesia, cardiac tardive dyskinesia, cardiac arrhythmias..arrhythmias..

Negative symptoms of schizophrenia Negative symptoms of schizophrenia – lack of motivation…..– lack of motivation…..

Choosing HealthChoosing Health

Six key priorities - 1:Six key priorities - 1:

Tackling health inequalitiesTackling health inequalities

Reducing the number of people who Reducing the number of people who smokesmoke

Tackling obesityTackling obesity

Choosing HealthChoosing Health

Six key prioritiesSix key priorities

Improving sexual healthImproving sexual health

Improving mental health and well beingImproving mental health and well being

Reducing harm and encouraging sensible Reducing harm and encouraging sensible drinkingdrinking

Potential ObstaclesPotential Obstacles

Lack of motivationLack of motivation Effects of medicationEffects of medication Lack of moneyLack of money BoredomBoredom Mental health cultureMental health culture Attitudes and beliefs of health staffAttitudes and beliefs of health staff

Mind Your Heart Mind Your Heart ProgrammeProgramme

Our aim is to improve the physical Our aim is to improve the physical health of mental health service users health of mental health service users in Ceredigion byin Ceredigion by

Engaging people in activities that Engaging people in activities that reduce their risks of illnessreduce their risks of illness

Removing obstaclesRemoving obstacles Raising awarenessRaising awareness

Policy etcPolicy etc.. Health services should adopt a holistic view Health services should adopt a holistic view

of the assessment and development of care of the assessment and development of care plans for mental health service users plans for mental health service users Recommendations for the physical health Recommendations for the physical health care of people with SMIcare of people with SMI

Guidelines for the treatment of Guidelines for the treatment of schizophrenia in primary and secondary schizophrenia in primary and secondary care care

Closing the GapClosing the Gap