Guidelines for Integrated Care (Psychiatric & Medical) In the Community

1. Guidelines for Integrated Care (Psychiatric & Medical) In the Community Module II: Metabolic Syndrome

2. Objectives • Identify patients in their caseload who have or are at risk for developing metabolic syndrome. • Understand the implications of identifying and supporting the management of metabolic syndrome through reduction in obesity and tobacco use. • Appreciate the concept of stages of change needed to support life-style changes for prevention/reduction of obesity and tobacco use, including use of tools for self-care, education and referral. • Assist persons at risk for or diagnosed with metabolic syndrome to engage in activities that reduce the impact of obesity and smoking in their recovery.

3. Overarching Principle: Overall Health is Essential to Mental Health Recovery Includes Mental Health

4. What is Metabolic Syndrome? • A group of conditions/factors that increase risks of heart disease and other acute or chronic medical conditions. All of the conditions outlined below put the person at risk for cardiovascular disease and premature death.

5. Quiz: What does this have to do with Metabolic Syndrome?

6. Hint…..

8. Abdominal Obesity

10. Prevention and Treatment of Metabolic Syndrome • Lifestyle management – a program of weight loss and exercise • Tobacco cessation • Limiting alcohol consumption • Changes in dietary habits, including eating a heart-healthy diet • Medication to help lower blood pressure, improve insulin metabolism, improve cholesterol and increase weight loss • Weight-loss surgery (bariatric surgery) to treat morbid obesity in individuals for whom conservative measures have failed.

11. Why is metabolic syndrome a relevant health issue to consumers? • Up to 83% of persons with serious mental illness in the US are overweight or obese. • Persons with mental illnesses, including schizophrenia and mood disorders, have a higher rate of metabolic syndrome compared with the general population: • 24% rate for US Adults • 60% rate for persons with schizophrenia • 75% rate for Hispanics with mood disorder

12. Additional Environmental & Personal Factors that Lead to Cardiac Events • Sedentary life-style • Poor nutrition • Overeating • Smoking (44% of all cigarettes smoked in the US) • Substance abuse • Some medications • Irregular and inadequate sleep • Lack of access to adequate/coordinated medical care • Lack of access to nutrition and exercise programs

13. Goals of life-style changes: Lower Risk for Cardiovascular Disease • Blood cholesterol • 10% decrease = 30% decrease in coronary heart disease • Cigarette smoking cessation = 50-70% decrease in coronary heart disease • Maintenance of ideal body weight (BMI = 25) 35-55% decrease in coronary heart disease • High blood pressure (> 140 systolic or 90 diastolic) • 4-6 mm Hg decrease  16% decrease in coronary heart disease and 42% decrease in stroke

14. Two Preventable Risk Factors Besides monitoring and intervening on Diabetes Mellitus (Previous Module), two other modifiable risk factors: • Obesity • Smoking

15. Obesity

16. Common Misconceptions about Persons with Mental Illness and Obesity: • Contrary to popular belief, research shows that person with mental illness are: • Self-conscious about their weight • Interested in reducing their weight • Able to adopt healthier choices to improve their health (Vreeland, 2007)

17. Barriers to Addressing Obesity in Persons with Mental Illness • Psychiatric disease processes, e.g. Negative symptoms in schizophrenia, depressive symptoms • Treatment processes: • Certain medications: Atypical Antipsychotics; SSRI • Infrequent, or no contact with primary care providers

18. Barriers to Addressing Obesity in Persons with Mental Illness • Culture expectations for persons with mental illnesses tend to support less activity e.g. getting a ride, taking the bus, sitting in groups • Providers may feel that addressing obesity issues may interfere with people taking their medications • Community mental health providers have insufficient training and time to work on weight and other health issues

19. Barriers to Addressing Obesity in Persons with Mental Illness • Fragmented medical care • Low socio-economic status • Attitude of Caregivers: Perhaps eating is one of few pleasures left consumers they have

20. A Little Weight Loss Makes A Big Difference: • Research shows that helping people make choices that result in modest weight loss (2-6% of body weight) is associated with: • Decrease in high blood pressure by 20-40% • Decrease in incidence of diabetes by 30-60% • Decrease in cardiac events by 30-40% • 2% off a 300 pound person = 6 pounds • 4% off a 300 pound person = 12 pounds • 6% off a 300 pound person = 18 pounds

21. A Little Weight Loss Makes A Big Difference: • 4-5% weight loss can lower or eliminate the need for antihypertensive medications in adults and elderly • 6-7% weight loss improves metabolic syndrome by decreasing LDL • 10% weight loss can reduce lifetime risk for heart disease by 4%

22. A Little Weight Loss Makes A Big Difference: • Reduced calories support weight loss, increased physical activity improves physical health • Exercise goal: 30 minutes/day (not necessarily all at one time) • Walking 10 minutes 3 X per day • Chair exercises • Key—combined exercise with cutting calories • Structured and gradual • Techniques for attitude change regarding the role of food, etc. • Strategies to increase social support

23. Stages of Change

24. Behavioral Strategies • Self monitoring (record diet and activity) • Goal setting • Stimulus control • Behavioral substitution (portion control, slow eating, life-style activity • Problem solving • Cognitive restructuring • Relapse management • Nutrition education

25. Small Steps Work for an Action Plan:

26. Consider this… • If a person gains more that 5% of initial weight or develops worsening blood sugar or LDL during therapy-may need other medication to assist • There may be provider barriers to overcome: • Beliefs that persons with mental illness cannot live healthy life-styles because: • Obesity is related to the persons mental illness • People with mental illness lack motivation to improve their health and well-being (NASMHPD 2008)

27. American Diabetes Association Recommendation

28. NASMHPD and SAMHSA Standards of Care Recommendation: • Educational/behavioral interventions for weight management • If possible switch to low weight gain antipsychotics when weight increases • Medical/surgical treatment (may not be available for people with mental illness) • NASMHPD = National Association of State Mental Health Program Directors • SAMHSA = Substance Abuse and Mental Health Services Administration

29. Additional Recommendations • Promote opportunities for health care providers, including peer specialists to teach healthy life styles through state vocational-rehabilitation agencies (such as COVA in Columbus, Ohio) • Adopt American Diabetes Association and American Psychiatric Association second generation antipsychotics (medication) monitoring • Collaboration between State Health Authority and Mental Health Authority • Monitor consumers with diabetes and metabolic syndrome in community mental health centers • Link with public health and community-based programs in diabetes, cardiovascular disease and health weight management

30. Smoking Kills!

31. Some Stats on Mental Illness and Smoking • Rates of smoking are 2-4 x higher among people with psychiatric disorders and substance use disorders • Nearly 41% of current smokers report having a mental health diagnosis in the last month • 60% of current smokers report a past or current history of a mental health diagnosis sometime in their life time.

32. Mental Illness and Smoking • When seeking mental health treatment heavy smokers report substantially poorer well-being, greater symptom burden, and more functional disability compared to non-smokers • Public mental health clients have a higher relative risk of death than the general population due, in part, to tobacco use.

33. Mental Illness and Smoking • Potential genetic base: Shared genetic factors with depression, schizophrenia • Self-medication-manage adverse events related to medication/reduce symptoms • Trauma: Link history of grief and PTSD with increased use • Social: Link to limited education, poverty, unemployment; peers, and the mental health system where tobacco use is generally tolerated/not seen as a health issue

35. Smoking Cessation Myths and Facts

36. What can I do? • Help people realize that: • Reduction often happens before cessation. (Stages of Change Model) • Measuring amount smoked helps with decreasing amount • Everyone needs support—Peer support is especially effective • Stress reduction techniques (e.g. substitute behaviors)

37. What can I do? • Standardized assessment of smoking status and interest in stopping • Include nicotine dependence and withdrawal on Axis I • Develop protocols for and access to pharmacotherapy • Help for staff who smoke • (Mental health providers are significantly more likely to smoke that other health care providers)

38. De-normalize tobacco use: The 5 R’s • RELEVANCE: Relevant to the Person. • “Johnny, I noticed that you smoke. How is that going to help you run that race?” • RISKS: Of continued smoking • “… do you know the risks of smoking?” • REWARDS: What can be gained • “… what are some benefits to quitting smoking?” • ROADBLOCKS: Barriers to quitting • “… so what’s stopping you from quitting?” • REPETITION: Reinforce motivational message at every contact

39. Intervene: The 5 A’s Model • ASK: Identify and document tobacco use • ADVISE: Key Message Point => Quitting smoking is the most important thing you can do for your health • ASSESS: Willingness to make an attempt to stop—give it a try • ASSIST: For those who are ready, provide or refer to counseling and medication • ARRANGE: Follow up supportive contacts

40. Look at Your Purple Bookmark!

41. Case Study 1 • Mary Beth is a 37 year old Caucasian female who is has a diagnosis of bipolar disorder. She has been taking Depakote and Prozac. She recently started taking Seroquel to assist with stabilizing her mood and helping her sleep. • Her primary healthcare provider has been checking her weight and waist circumference every month. Over the last 3 months, her waist circumference has increased 10 inches (42 to 52 inches) and her weight has increased by 60 lbs (240-300 lbs at 5’4”). • She states she has been under a lot of stress lately since her son was incarcerated and hasn’t been sticking to her dietary plan. She notes that she does not have “time to cook” and has been eating at her neighborhood Rally’s hamburger place for her meals. She orders either the #4 or #7 meals.

42. Questions: • What are important assessment questions for Mary Beth? • What are some of the risk factors that predispose Mary Beth for metabolic syndrome? • You are a CPST worker or a counselor who is preparing for an appointment with Mary Beth. Armed with the current information about her weight changes, how would you plan to approach Mary Beth? • What if you realize that Mary Beth is embarrassed with her weight-gain? She has been feeling very depressed but does not feel that she can change her lifestyle. Use the Stages of Change Model to plan your conversation with Mary Beth. What are some things you plan to talk with her about? How do you help her move from one stage to another stage?

43. Case Study 2 • James is a 45 year old African American male with a diagnosis of schizophrenia. He smokes approximately 1 pack of cigarettes per day for the last 25 years. He has stopped taking his medication since he was laid off six months ago. He is 5’6” and 178lbs. • Since he was laid off, he has been picking up cigarette butts off the ground and smoking them. His “smoker’s cough” has been more pronounced, expelling deposits, especially in the morning. According to his mental status exam, his insight and judgment is “fair to low”. Motivation for change is low. He has very low expectation that things will improve for him. • Recently, at a health fair his CPST worker took him to, his blood sugar was 187. His blood pressure was 170/92. His LDL cholesterol was 200 and his HDL cholesterol was 30.

44. Questions: • What are some of the risk factors James has for metabolic syndrome? • You are a CPST worker or counselor for James, and have just attended a workshop on Metabolic Syndrome. You want to help James look at how his smoking is affecting his health, but you know James is not really interested in dealing with it. He says that smoking is one of the two things that give him pleasure. Plan your conversation with him. Anticipate his counter-arguments. Use the 5As and 5Rs approach. • What else are you concerned about? What can you do to help James out?