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 todays workshop –Summarise the findings published in the JCP article –Discuss practical implementation of the recommendations

3. 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 Obesity Hypertension Impaired glucose tolerance Dyslipidemia 1 Ninomiya JK et al. Circulation 2004;109:42-46; 2 Malik S et al. Circulation 2004;110:1245-1250; 3 Grundy 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 FactorMeasurement Obesity Waist circumference – Male – Female >102cm (>40in) >88cm (>35 in) Dyslipidaemia Triglycerides HDL cholesterol – Male – Female 150 mg/dL ( 1.7mmol/L) <40mg/dL (<1.0mmol/L) <50mg/dL (<1.2mmol/L) Hypertension 130/85mmHg Fasting glucose 100mg/dL ( 5.5mmol/L) ATP III = National Cholesterol Education Program Adult Treatment Panel III JAMA 2001; 285: 2486-2497

5. CountryPrevalence of metabolic syndrome USA20 – 30% 1-3 Japan11.0% 4 France12.4% 5 Germany19.8% 6 Italy14.4% 7 Spain19.5% 8 UK19.6% 6 Greece20% 9 Urban Indians30 – 40% 10,11 1 Ford ES et al. Diabetes Care 2004;27:2444-2449; 2 Park YW et al. Arch Intern Med 2003;163:427-436; 3 Haffner S et al. Circulation 2003;108:1541-1545; 4 AnuurAD e ET AL. Journal of Occupational Health 2003;45(6):335-43; 5 Balkau B et al. Diabetes and Metabolism 2003;29(5):526-32; 6 Sattar N et al. Circulation 2003:108(4):414-9; 7 Bonora E et al. Int J Obes Relat Metab Disord 2003;27:1283-1289; 8 Alverez Leon EE et al. Medicina Clinica 2003;120(5):172-4; 9 Panagiotakos DB et al. Am Heart J 2004;147:106- 112; 10 Gupta R et al. Int J Cardiol 2004;97:257-261; 11 Ramachandran A et al. Diabetes Res Clin Prac 2003;60:199-204 Prevalence of metabolic syndrome in the general population

6. Metabolic syndrome and mental illness Metabolic syndrome may be more prevalent in people with mental illness 1 –Their lifestyle factors may contribute to the development of metabolic syndrome 2,3 People with mental illness have a reduced life expectancy compared to the general population –Metabolic syndrome (especially CVD) contributes to this 4 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 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? Metabolic risk factorHow to monitorWhen to monitor 1 Weight (BMI / waist circumference) Body Mass Index1 – 3 months Insulin resistance Fasting blood glucose test HbA1c test 4 months – 1 year Blood pressureStandard method6 weeks – every visit Lipid profileBlood sample (total cholesterol, HDL-cholesterol, LDL-cholesterol and triglycerides) 6 months – 2 years 1 Marder 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 1 Allison 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 partnership 1 –Referral of consumers, when relevant, to Nutritionist or dietician Substance abuse professionals 2 –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 1 Hill JO et al. Obes Res 2002;10(suppl 2):124S-130S; 2 Steinberg 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. 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