Diabetes Management and Mental Health – CPD workshop November 2016

1. Diabetes Management and Mental Health – CPD workshop November 2016 Dr Moira Connolly Dr Brian Kennon Dr Andrew Gallagher Dr Nazim Ghouri (With acknowledgments; Dr Zoe Young and Dr Nicola Watt trainees in psychiatry, Dr Robert Pearsal and Professor Danny Smith)

2. Outline of the session • 1.30-2.00pm Introduction, Mental health & diabetes in GGC • Moira Connolly • 2.00–2.30pm Diabetes diagnosis, screening & in-patient care Brian Kennon • 2.30-3.00pm Update on new therapies for type 2 diabetes • Andrew Gallagher • 3.00-3.20pm Coffee break • 3.20-4.20pm Challenges in managing diabetes in a psychiatric setting • Small group workshop • 4.20-4.30pm Summary & next steps • Brian Kennon/Moira Connolly • 4.30pm Close of meeting

3. Background • Health inequality – morbidity and mortality • Impact of co-morbid diabetes • Policy response GG&C • National views • Expectations for psychiatry • How well are we doing?

5. Excluding suicide as cause of death

6. Langan Martin et al, BMC Psychiatry, 2014

7. Reduced life expectancy in mental illness (CMO England report 2013 chapter 13) People with SMI have life expectancies closer to low/middle income countries Substance abuse disorder, schizophrenia and schizoaffective disorder are among the worst Excess mortality may be worse in countries without universal healthcare Non-help-seeking individuals with depression have 1.5-2 fold increase in mortality rates

9. Iatrogenic diabetes

10. Impact of co-morbid diabetes on SMI • A diagnosis of diabetes in people with serious mental illness is associated with a 3.68-fold increase in mortality and a 1.49-fold greater risk of serious harm from macrovascular complications of diabetes. • adjusted hazard ratios were 1.05 (95% CI 0.91-1.21) for microvascular complications and 3.68 (95% CI 3.21-4.22) for all-cause mortality in patients with diabetes and schizophrenia compared with those patients with diabetes but not schizophrenia. • People with schizophrenia have a 74% greater risk of requiring referral to hospital for serious acute complications of diabetes, particularly hypo- or hyperglycemia episodes and development of diabetic ketoacidosis, compared with those without schizophrenia.

11. “People with schizophrenia are at greater risk for developing an acute complication of DM. Understanding this relationship will direct future studies assessing barriers to care and implementation of individualized approaches to care for this population”.

15. “Develop a process to identify individuals at risk of medication adverse events” ‘Test use of screening tools which helps to identify individuals at risk of medication adverse events e.g. co-morbidities, poly-pharmacy, high dose antipsychotics, specific medications carrying high risk of complications/side effects including lithium, clozapine, elderly, medication use during pregnancy and breast feeding, medication use for physical health problems e.g. diabetes, anticoagulants, etc’ Scottish patient safety programme Mental Health http://www.scottishpatientsafetyprogramme.scot.nhs.uk/Media/Docs/Mental%20Health/Medicines%20Management%20-%20v1.10.pdf

17. GG&C Physical Healthcare Policy • Policy highlights it is as important to know where clinical responsibility lies as it is to know what should be done. • Mental Health Patients should have the same quality of physical care as the general population. • Assessment of mental and physical health and health improvement/promotion should be embedded in the provision of inpatient and outpatient mental health patient care.

18. GG&C Physical Health Screen Guidance A core health screen should include attention to the following; • Lifestyle and behaviour advice   • Family History andPhysical systems enquiry   • Usual population screening of relevance to age and sex   • Brief physical findings (psychiatric outpatients)   • Extended physical check (acute admissions, where clinical concerns arise) • Medication side effects   • Relevant investigations • Sexual health enquiry and Health Promotion+++ • All in-patients must have a full physical health examination within 24 hours of admission to hospital. If this is not completed the reason must be fully documented and attempts to complete the examination must continue throughout the period of hospitalisation. (Group working on standardised documentation) • Discharge summaries following inpatient stay should include a section on physical health noting clinical findings, results of investigations, ongoing needs, referrals made and any follow-up plans.

19. The Role of the Psychiatrist Royal college view • Psychiatrists should be aware of the extent of their own responsibilities in physical healthcare, and those of other clinicians, especially general practitioners. • As doctors, psychiatrists have a responsibility to provide their patients with good standards of practice and care (General Medical Council, 2001). Psychiatrists have a key role to play in improving the physical health of their patients. In the document Good Psychiatric Practice (Royal College of Psychiatrists, 2004), it is stated that psychiatrists should: • ‘ initiate investigations where necessary •  act on the outcome of investigations •  arrange specialist or medical treatments in collaboration with the general practitioner (GP), by referral to specialists or generalist colleagues, or undertake physical investigation and treatment with competencies’

20. Kingsfund - March 2016 • The NHS five year forward view makes the case for what has been called ‘triple integration’ (Stevens 2015) – integration of health and social care, primary and specialist care, and physical and mental health care. • Despite a policy commitment to reducing these inequalities, monitoring of physical health among people with severe mental illnesses remains inconsistent in both primary and secondary care. • For example, only a minority are screened for cardiovascular disease (Hardy et al 2013), and other tests such as cholesterol checks and cervical smears are performed at lower rates than for the general population (RSA Open Public Service Network 2015). • Part of the problem historically has been a lack of clarity over whether responsibility for providing primary health care to this group of people lies principally with GPs, mental health teams, or both (Lawrence and Kisely 2010) ………Are we now crystal clear?!

21. Kingsfund – March 2016 Whereas liaison mental health services are becoming increasingly common in acute hospitals, it is rarer to find physical health liaison services in mental health inpatient facilities, despite significant levels of need and undiagnosed physical illness. People using these facilities are significantly less likely than the general population to be registered with a GP, and are more likely to present late with physical symptoms (Lawrence and Kisely 2010). Mental health professionals working in these settings may lack the confidence or skills required to identify medical conditions, and often there is a culture of giving low priority to physical health (Kulkarni et al 2014). Evidence suggests that at present, more than a third of patients fail to receive a physical examination within 24 hours of admission, in line with recommended practice (Vanezis and Manns 2010).

22. Academy of Medical Royal Colleges 2016 Responsibilities of a psychiatrist • Identification of physical causes • Investigate for physical causes +/- refer • Obtain a medical history and functional enquiry • Recognising onset of acute illness • Safe prescribing and recognition of side effects of all meds • LTCs monitoring and treatment • In co-morbidity, recognise factors which may affect patients’ physical health • Disease prevention and health promotion • Screening tools on admission (nutrition etc.) • Specific population needs (eg refugees) • Involve other specialists in the rehabilitation of the patient’s physical health

23. AoMRC Improving clinical care - diabetes • NICE guidance on preventing type 2 diabetes (NICE 2012) should be followed • Pre-diabetic patients should be referred for an intensive structured lifestyle programme (if ineffective consider metformin) • Clear communication of assessment/management plans between GPs and MH teams • Share results of ‘National Diabetes Audit’ • Educate staff on diagnosing and managing diabetes • Educate on using appropriate tools, tests and observations, recognising and acting on those outside normal range • Staff must be able to identify diabetic emergencies and respond appropriately to reduce long term risk • Provide opportunities for physical activity for both inpatients and community patients • Use SMI registers to ensure regular monitoring • Integrate care between psychiatric services, dieticians and specialist services

25. BAP – four things we can do… • Lifestyle interventions (Level A/B/C) • Antipsychotic switching (Level A/B) • Adjunctive metformin for people on antipsychotics (Level A/S) • Adjunctive aripiprazole for people on clozapine or olanzapine (Level B) Tolerability problems outweigh advantages for; orlistat, topiramate. Lack of evidence for; reboxetine, liraglutidide, bariatric surgery, amantadine, melatonin and zonisamide. No benefit found for; Atomoxetine, dextroamphetamine, famotidine, fluoxetine, fluvoxamine and nizatidine.

26. How big is the problem and how well are we doing? • One day audit of inpatients • Clozapine audit • CSO funded health informatics project • Local audits

27. A Health Informatics Approach To Improving Long-Term Physical Health Outcomes In Major Mental Illness: Using routine data linkage: • How complete is routine blood monitoring for patients with bipolar disorder? • For patients with evidence of raised HbA1C and/or lipid levels, what proportion are receiving appropriate medication treatment?

29. No record of routine blood testing within last 2 years: %

30. No record of routine blood testing within last 2 years: • No differences by socioeconomic deprivation status • Younger patients were more likely to have no record of blood monitoring than older patients • Low rates of using HbA1c to diagnose and treat diabetes

31. Proportion with clinically raised levels: %

32. Proportion with diabetes or raised cholesterol who are on medication treatment: %

33. Auditfindings • Diabetes >15% in clozapine patients in GG&C • 53% inpatients in psychiatric care nationally have co-morbid physical health condition • Patients want more attention paid to their side effects • Nursing staff want to know more about medication side effects

34. Conclusions • It’s our business • Make every contact count • Training and CPD imperative • Service improvement initiatives • Collaboration with acute colleagues is hugely important – over to the diabetes MCN………….