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What factors affect the lifestyle choices of people with a diagnosis of schizophrenia? Dr Hosam Abed.

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Presentation on theme: "What factors affect the lifestyle choices of people with a diagnosis of schizophrenia? Dr Hosam Abed."— Presentation transcript:

1 What factors affect the lifestyle choices of people with a diagnosis of schizophrenia?
Dr Hosam Abed

2 Introduction A great deal of research has been done on physical health in schizophrenia which has shown that sufferers have higher rates of morbidity and mortality from cardiovascular and respiratory diseases, and a shorter life expectancy (Brown S et al, 1997; Brown S et al, 2000). People with schizophrenia tend to eat less fruit and vegetables, take less exercise, are more likely to smoke and have higher rates of obesity (Brown S et al, 1999; McCreadie R et al, 2003). To make matters worse many of the drugs used to treat schizophrenia are associated with weight gain and have been linked to obesity and type II diabetes (Russel J et al, 2001; Newcomer J, 2005). When compared to people from low social class backgrounds in the general population, sufferers have been shown to have significantly less healthy lifestyles (Brown S et al, 1999; McCreadie R et al, 2003).

3 Method This is a qualitative study in which 7 people with schizophrenia were interviewed using semi-structured interviews about their lifestyle, including their diet and exercise and were encouraged to talk about the various factors which might influence their decisions and behaviour with respect to these. They were deemed to have had a stable mental state for at least the previous 1 month prior to interview and be living in the community. The subjects were selected using criterion based purposeful sampling (Patton, 2002). They were identified through discussion with their consultant, care coordinator and family if possible, and review of their medical notes. Those who also had a diagnosis of a comorbid affective illness, anxiety disorder, alcohol dependence or illicit drug dependence were excluded. Data was collected through semi-structured, audiotape recorded interviews carried out by one interviewerin the subject’s home which lasted 1-2 hours.

4 Typical Interview Questions
Could you describe your typical day? What kinds of things do you usually eat? Could you give me some examples of things you can cook? Could you give me an example of a healthy meal? What difficulties might there be in making your diet more healthy? Tell me about any exercise that you do Tell me about any difficulties you may have encountered in trying to do regular exercise? Why do you suppose people think it is important to do regular exercise? Have you ever tried to give up smoking and what difficulties did you encounter? Why do you suppose people think it is important to eat healthily? Can you tell me about any health problems related to smoking that you are aware of? Have you heard of cholesterol? Can you tell me what you know about it? Have you heard of diabetes? Can you tell me what you know about it? What are your sources of income? Do you think you might eat different things if you had more money?

5 Method continued Thematic analysis was used to analyse the data which was coded into categories in order to identify common themes (Merriam, 2009). The analysis of transcribed interviews was carried out by 5 analysts made up of a GP, general nurse, psychiatric nurse, psychiatrist and a layperson with a legal background. All 5 analysts were asked to read through the 7 transcripts in full, and were asked to pick out sentences they thought gave valuable or relevant information giving the line reference from the appropriate text, and give a reason or comment on why they thought that particular segment of text was significant.

6 Method continued The information provided by the analysts was sent as a feedback report to the primary investigator. The feedback reports from the analysts were then analysed in detail by the primary investigator with reference to the transcripts to identify common themes. The themes identified by the analysts were assigned colours which were used to code the data by highlighting the lines in the feedback reports where any given theme was found, and were then cross-referenced to identify those which appeared to be the most frequent and consistent across all subjects interviewed. ie common themes

7 Results – Subjective Lack of Motivation
Quote 1: “I just can’t get anything done. I can’t get motivated to do anything like housework or even going walking outside, I don’t want to do it sometimes.” Quote 2: “The other thing that’s stopping me from buying more food is lack of motivation. It takes you about an hour to cook and eat a meal doesn’t it really. You know, something substantial like meat and 2 veg. It just gets too much. I like to just have things that are easy and simple even though it gets boring.”

8 Results – Psychotic symptoms
Quote 3: “I’ve ended up burning stuff and letting pans boil dry because I’ve got all this going on in my ears and I’m not paying attention to what I’m doing. I can’t concentrate on the food when I’ve got these voices in my ears..” Quote 4: “If I met somebody in a red coat I’d feel they were saying “we don’t want to know you, you’re a dangerous person.” That’s what I think about the colour red, it symbolises that I’m a dangerous person and people don’t want to know me.”

9 Results-Lack of knowledge of physical health-related issues
Quote 5: Question: “Do you think people who can get diabetes partly as a result of being overweight?” Answer: “My uncle`s got it, I`ve heard it mentioned on television as well. All that propaganda about living healthily. It`s good that we have it, I mean some countries have propaganda about, I don`t know, Fidel Castro don`t they?” Quote 6: Question: “Do you know of any relationship between your illness or your medication and diabetes? Answer: “No not at all.”

10 Results-Medication side effects
Quote 7: “Well I can get myself motivated, I can gear myself up, but it’s like fighting a losing battle with the medication. It just drains you, it tires you out.” Quote 8: “The hunger is hard to describe. It’s an overwhelming urge and you can’t get it out of your mind until you eat. In the past I’ve stopped taking my medication for 6 to 8 months and ended up in a psychiatric hospital. I’ve managed 6 to 8 months without medication and I’ve gone down to my normal weight in that time.”

11 Discussion A meta-analysis of 11 RCTs found that adding SSRIs to antipsychotics did not reduce negative symptoms in people with schizophrenia-spectrum disorder (Sepehry AA et al, 2007). The efficacy of glutamatergic agents for negative symptoms has also been studied, and they have also generally been found to be ineffective (Buchanan R W et al, 2007) Research is ongoing in this area and psychosocial interventions may prove more useful than medication at tackling this syndrome of symptoms, for example some positive effects in reducing negative symptoms have been found with music therapy (Gold C et al, 2005). A recent meta-analysis of CBT for schizophrenia showed a significant beneficial effect on positive symptoms but in the group of methodologically adequate studies the effects on negative symptoms were not significant (Wykes T et al, 2008).

12 Discussion continued Other studies have also shown a relationship between positive symptoms and impairment in quality of life (Mohamed S et al, 2008). Recently more emphasis has been placed on the use of psychosocial interventions to help reduce these symptoms, and there is a great deal of evidence that CBT especially is effective (Wykes T et al, 2008). Studies have shown that interventions which have included health promotion and education such as a nurse led well being programme (Ohlsen RI et al, 2005) and a GP led inpatient service (Welthagen E et al , 2004) can have significant beneficial effects in patients with a variety of mental disorders including schizophrenia.

13 Discussion continued The detrimental effect of weight gain (Allison DB et al, 2003) and metabolic syndrome (Meyer JM et al, 2005) on quality of life has been found in other studies. An RCT in of patients with first psychotic episode schizophrenia found that metformin and lifestyle changes (psychoeducation, dietary changes and exercise) were effective in reducing antipsychotic induced weight gain in adults, especially when used together (Wu RR et al, 2008). A meta-analysis of non-pharmacological interventions (CBT, nutritional counselling and exercise) found that they were effective in managing weight gain related to antipsychotic use in people with schizophrenia spectrum disorders (Alvarez-Jimenez M et al, 2008).

14 Implications The aim of this study was to improve our understanding of the possible causes of the unhealthy lifestyle choices of people with schizophrenia. These findings suggest that there are many factors at play which appear to make it more likely for people with a diagnosis of schizophrenia to make unhealthy choices rather than healthy ones. This emphasises the complexity of this illness which has multiple syndromes and also the less than ideal treatments we currently have at our disposal. It suggests that we need to take a holistic approach when considering the physical health of such patients and that health promotion and education must go hand in hand with rigorous physical health monitoring and careful prescribing.

15 References Brown S et al, (1997) Excess mortality of schizophrenia. A meta-analysis. British Journal of Psychiatry 1997 Dec (171) 502-8 Brown S et al, (2000) Causes of the excess mortality of schizophrenia. British Journal of Psychiatry 2000 Sep (177) 212-7 Brown S et al, (1999) The unhealthy lifestyle of people with schizophrenia. Psychological Medicine 1999 May 29 (3) McCreadie R et al, (2003) Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study. British Journal of Psychiatry 2003 Dec Russel J et al, (2001) Bodyweight gain associated with atypical antipsychotics: epidemiology and therapeutic implications. CNS Drugs (7) Newcomer J, (2005) Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs Suppl Rummel C et al, (2005) Antidepressants as add-on treatment to antipsychotics for people with schizophrenia and pronounced negative symptoms: A systematic review of randomized trials. Schizophrenia Research Savilla K et al, (2008) Relationships between cognitive deficits, symptoms and quality of life in schizophrenia. Australia and New Zealand Journal of Psychiatry 2008 Jun 42 (6) Mohamed S et al, (2008) Relationship of cognition and psychopathology to functional impairment in schizophrenia. American Journal of Psychiatry 2008 Aug 165 (8) Bradshaw T et al, (2005) Healthy living interventions and schizophrenia: a systematic review. Journal of Advanced Nursing 2005 Mar 49 (6) Allison DB et al, (2003) The impact of weight gain on quality of life among persons with schizophrenia. Psychiatric Services 2003 Apr 54 (4) 565-7 Meyer JM et al, (2005) The Clinical Antipsychotic Trials of Clinical Effectiveness (CATIE) Schizophrenia Trial: Clinical comparison of subgroups with and without the metabolic syndrome. Schizophrenia Research Sepehry AA et al, (2007) Selective serotonin reuptake inhibitor (SSRI) therapy for negative symptoms of schizophrenia: a meta-analysis. Journal of Clinical Psychiatry Buchanan RW et al, (2007) The Cognitive and Negative Symptoms in Schizophrenia Trial (CONSIST): The Efficacy of Glutamatergic Agents for Negative Symptoms and Cognitive Impairments. American Journal of Psychiatry 2007 Oct Gold C et al, (2005) Music therapy for schizophrenia or schizophrenia-like illnesses. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD DOI: / CD pub2. Wykes T et al, (2008) Cognitive behaviour therapy for schizophrenia: Effect sizes, clinical models, and methodological rigour. Schizophrenia Bulletin 34 (3) Wu RR et al, (2008) Lifestyle intervention and metformin for treatment of antipsychotic-induced weight gain: a randomized controlled trial. JAMA Alvarez-Jimenez M et al, (2008) Non-pharmacological management of antipsychotic-induced weight gain: systematic review and meta-analysis of randomised controlled trials. British Journal of Psychiatry Ohlsen RI et al, (2005) Developing a service to monitor and improve physical health in people with serious mental illness. Journal of Psychiatric and Mental Health Nursing Welthagen E et al, (2004) Providing a primary care service for psychiatric inpatients. Psychiatric Bulletin Patton MQ (2002) Qualitative Research and Evaluation Methods. 3rd edition SAGE Publications. p.230 Merriam (2009) Qualitative Research: A Guide to Design and Implementation. 2nd edition Jossey-Bass. p

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