Physical health and sever mental illness Physical health

Physical health and sever mental illness

Physical health and sever mental illness n Prepared by: Mr. Mutasem naser Allah. n Mr. Ahmmed Abo Rahma. n Supervised by: n Dr. Abed Alkareem Radwan n

Topic content n Introduction Common physical health problem with SMI n Reason why people with SMI many experience physical health problem n Health behavior of people with SMI. n Treatment related factor that affect the physical health of people with SMI. n Nursing intervention. n

The link between mental illness and physical health People with serious mental illness have higher morbidity and mortality rates of chronic diseases than the general population. . People who have severe mental illness, like schizophrenia , depression and mania are at increased risk for a range of physical illnesses and conditions, including coronary heart disease, diabetes and greater levels of obesity and hypertension Thus, most if not all types of mental disorder are associated with an increased rate of early death.

Continue n the prevalence of many physical diseases is higher in persons with severe mental illness than in the general population. n 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 n n the access to physical health care of persons with severe mental illness is reduced compared to the general population. n 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) 3) 2 -4 times greater risk of cardiovascular disease 2 -4 times greater risk of respiratory disease 5 times greater risk of diabetes

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

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

policy n People with different illnesses or disorders will have different illness experiences, including; the types of symptoms experienced. n how daily life and ability to function 'normally' is affected n and what types of treatment may be effective.

policy Education and training of mental health professionals and primary care providers is one more essential step. . They should be educated about the importance of recognizing physical illness in people with severe mental disorders. They should be encouraged to familiarize themselves with the most common reasons for under diagnosis or misdiagnosis of physical illness in their patients

• * 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-check During the health-check, the GP or practice nurse will : n Take blood pressure n Take pulse rate n Do a urine or blood test n Measure weight n Ask about smoking n Ask about alcohol consumption n Check date of last smear test

PHYSICAL ILLNESSES AND SURGERIES WITH MAJOR PSYCHOLOGIC EFFECTS 5 n n n n n AIDS/HIV • PARKINSON’S DISEASE • MULTIPLE SCLEROSIS • STROKE (CVA) • COPD, ASTHMA • MASTECTOMY • PROSTATECTOMY • AMPUTATION • ALZHEIMER’S DISEASE.

Causes ? § § § § § Health behaviours – Smoking, diet, physical inactivity, alcohol & substance misuse, sexual behaviour Illness – Symptoms, poor spontaneous reporting of physical health problems Services not geared to meet peoples needs … - Lack of knowledge, lack of training, attitudes, confidence, lack of integrated care Adverse effects of medication – Extrapyramidal side effects, weight gain, glucose intolerance & diabetes, cardiovascular effects, sexual dysfunction, neuroleptic malignant syndrome Environment – Poverty, poor housing, social exclusion Difficulties recognising symptoms Barriers to accessing primary care Communication barriers Inequalities in screening & treatment

Morbidity and Mortality Causes While suicide and injury account for about 3040% of excess mortality, about 60% of premature deaths in persons with schizophrenia are due to “natural causes” n Cardiovascular disease n Diabetes n Respiratory diseases (including pneumonia and flu) n Infectious diseases (including HIV and Hep C

Premature Mortality n Six major causes of death in U. S and increased relative risk in SMI n Cardiovascular Disease 3. 4 X n Cancer Maybe lower rates except lung n Stroke 2 x in age < 50 n Respiratory disease 5 x n Accidents higher n Diabetes

What do people with SMI die from? Ø n n n n Study by Bralet 150 people with schizophrenia over 8 years – 13 deaths 3 suicides 3 heart disease 2 cancers 2 respiratory diseases 1 car crash 1 homicide victim 1 infectious disease

Individual Risk Factors Associated with Early Death Smoking n High blood pressure n High cholesterol n Diet and obesity n Inactivity n Diabetes n Accidents n

Risks Health Premature death Diabetes type II Cardiovascular Disease Dyslipidemia High blood Pressure Osteoarthritis Stroke Sleep Apnea Gall Bladder Disease Asthma Hirsutism /menstrual irregularities Social isolation Surgical complications Depression

Factors Associated with Premature Death n Reduced Use/Inefficient Use of Medical Services n Poverty n Systemic Barriers to Ideal Health Care n Healthcare systems and financing n Psychotropic medications n Individual health habits n n n Smoking Inactivity Obesity/poor nutrition

Physical Activity: Benefits “The health benefits of physical activity are generally independent of weight. ” n Sedentary lifestyle is an independent risk for cardiovascular death even in normal weight individuals. n n Moderate intensity exercise without dietary changes brings reduced incidence of metabolic syndrome

Physical Activity: Benefits Prevention of Wt Gain and to achieve weight loss n Bone health in kids. n Function in older adults. n Increased cardiorespiratory fitness. n Increased muscular strength. n Decreased blood pressure. n Decreased depressive symptoms. n Improved sleep quality. n

Amounts of Exercise n n n Inactive or sedentary <30 min/wk, <10 min/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 those with Mental Illness n Smoking Cessation n Addiction Recovery n Prevention and reversal of antipsychotic induced weight gain n Development of healthy eating and exercise habits

Special Considerations Physical Activity SMI Inactive; start low, go slow. n Fear of heart attack with sensation of increase HR. n Lack of familiarity with the sensation of muscle soreness. n Traumatic bodily relationships. n Balance issues on moving treadmills medication effects. n Cold temperatures. n

Interventions: Physical Activity n Fitness equipment at every facility, esp aerobic (exercise bikes, elliptical) n n Staffed for pts and open for staff use Relationships with local health clubs for equip. Access to fitness centers in the community Education n n Links to obesity and cardiovascular illness and death Benefits/Barriers Types/Low cost options Getting started; Medical Clearance Posters

Healthy Changes Initiative n Choosing n Healthy n Activities n Nutrition n Getting n Exercise n Smoking Cessation

Interventions: Physical Activity n Physical activity opportunities for each patient n n Structured group format Milieu changes such as stairs to cafeteria, walking to appts on campus n Encouragement of walking in all sites. n Enhance and document physical activity opportunities in vocational and residential settings n Motivational interventions to eliminate culture of lethargy

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

Overweight and Obesity n Definitions: Healthy Weight n Body Mass Index (BMI) 18 -24. 9 Overweight; n BMI 25 -29. 9 Obesity n BMI 30 -34. 9 Extreme obesity n BMI >35

Obesity and Mental Illness n Epidemic in mentally ill n n Multiple studies show increased incidence of overwt. and obesity in schizophrenia, esp women Majority recognize the wt problem, want to/have tried to weigh less n Certain 2 nd gen antipsychotics (SGA) can cause rapid wt gain (7 -30% of body wt) from 1 st sev. months of therapy up to a yr or longer. n n Significant wt increases coincided with clozapine introduction Wt gain ranked as top “bad thing” about taking meds in UK survey n Lifestyle modifications preferred approach

Common Elements of Weight Reduction Programs Goal Setting of Realistic short-term goals n Strategies to increase physical activity and decrease sedentary behavior n Nutritional focus teaching and demo of healthy eating habits n Self-monitoring of nutritional intake and physical n

Interventions: Client Education n Client Education about Nutrition and Weight Management Nutrition label reading Macronutrient 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 size High calorie drinks Goal setting; one change at a time. Grocery shopping Food preparation Fast food, restaurant eating

Interventions: Milieu n Vending machines and canteens n Provision of healthy alternatives Water n Fresh fruit n Low fat dairy products n n Substitute juice for water at med dispensing Printed materials and posters at cafeteria Inpatient take out food n n Emphasis on discretionary income, financial aspects recommended Engage staff; “biggest loser” contests

Regular Physical Activity During physical activity, our brain produces “endorphins”, or chemicals that provide relief from high stress levels. The good news is that high intensity activity is not required to experience this relief. Regular physical activity can also reduce the symptoms of depression and anxiety.

Smoking Cigarette smoking is the single most preventable cause of morbidity and premature death

Health Consequences of Smoking n Cancers n n n n n Lung Laryngeal, pharyngeal, oral cavity, esophagus Pancreatic Bladder and kidney Cervical and endometrial Gastric Acute myeloid leukemia Reduce fertility in women, poor pregnancy outcomes, low birth weight babies, sudden infant death syndrome Cardiovascular diseases n n Sub clinical atherosclerosis Coronary heart disease Stroke Abdominal aortic aneurysm Respiratory diseases n n Acute respiratory illnesses, e. g. , pneumonia Chronic respiratory diseases, e. g. , COPD n Cataract n Periodontitis

Nicotine Dependence among Seriously Mentally Ill (SMI) 75% of SMI are tobacco dependent (22% general population) n 85% in schizophrenia n 60 - 95% of people with addiction disorders smoke. n

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

Why Do People With Mental Illness Smoke n n n There are many reasons why any individual smokes. On top of the usual reasons people with mental illness may find other good effects from smoking. Positive effects of smoking for people with mental illness, include the following: Nicotine increases alertness. This may enhance concentration, thinking and learning. This may be a benefit to people with schizophrenia whose illness or medication leads to cognitive problems. Nicotine can help relaxation, and it can also reduce negative feelings such as anxiety, tension and anger. So smoking may help people with mental illness deal with stressful situations.

Continue n n Nicotine may reduce positive symptoms, such as hallucinations for a short period. There is some evidence to suggest that smoking is associated with reduced levels of antipsychotic induced Parkinsonism. Smoking can help to relieve boredom and provide a framework for the day. Smoking can improve social interaction, something that may be of particular benefit to people with negative symptoms

Outcomes n n Decrease number of smokers in every setting. Increase the number of smokers advancing toward quitting as measured by stage of change Precontemplation Contemplation Preparation Action Maintenance n n Increase the number of smokers who have been given advise to quit. Increase the number of patients who have smoking cessation interventions addressed on the treatment plan.

LOCAL AGENCY / CLINICIAN RECOMMENDATIONS educate / share information to make healthy choices regarding nutrition, tobacco use, exercise, implications of psychotropic drugs teach /support wellness self-management skills teach /support decision making skills motivational interviewing techniques Implement 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 n n n 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 n n n 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 Interventions Motivate these smokers to stop and teach basic cessation skills. n Protocols exist for patients seen in mental hospital settings. These rely on prior knowledge of smoker’s diagnosis, medication, history, and training to monitor symptoms and adjust medications. n

Behavioral Interventions Protocols for smokers with history of mental illness seeking tobacco dependence treatment outside mental health facilities and clinics should follow standard treatment guidelines n Need to adjust these protocols to account for their special circumstances n

Motivational tension Offering treatment can influence the choice Enjoyment of smoking Need for cigarette Fear of failure Concern about withdrawal Perceived benefits Worry about health Dislike of financial cost Guilt or shame Disgust with smoking Hope for success

Nicotine replacement n n n n 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 Cessation Provider inattention/pessimism n Co-dependency and mental illness n Mental health staff smoke n Historic attitudes about smoking in mental health community n No coverage for cessation drugs n Improper use of the drugs n Ignorance of quitlines n

Resistance to Cessation for People with Mental Illnesses Many loved ones of persons with mental illness resist helping them quit n They feel protective and want to focus on quality, not quantity, of life n But diseases caused by smoking can severely hamper quality as well as quantity of life n And second-hand smoke imperils loved ones and workers n

Nursing help pt to stop smoking n n n 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 n n n n 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 CVD n n n Blood cholesterol n 10% = 30% in CHD (200 -180) High blood pressure (> 140 SBP or 90 DBP) n 4 -6 mm Hg = 16% in CHD; 42% in stroke Cigarette smoking cessation n 50%-70% in CHD Maintenance of ideal body weight (BMI = 25) n 35%-55% in CHD Maintenance of active lifestyle (20 -min walk daily) n 35%-55% 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 glucose n n n n (WHO) defined diabetes as a fasting plasma glucose of more (126 mg/d L) In an asymptomatic individual, the diagnosis should be confirmed with a second fasting measurement on another day. The measurement of Hb. A 1 c may be used in the future for diagnosing diabetes In all forms of diabetes, inadequate control of glycamia will result in complications of diabetes. These complications include diabetic neuropathy diabetic retinopathy diabetic kidney disease increased risk of infection

Diabetes and fasting blood glucose. n Patients with type 2 diabetes are likely to require additional pharmacological management, but this should be no different from the general population, for which guidelines are available from the EASD and the American Diabetes Association (ADA)

Healthy Changes Initiative n The Healthy Changes Initiative is designed to address the individual’s modifiable risk factors which result in chronic illness and early death in individuals with psychiatric disabilities. n n Physical Inactivity Overweight/Obesity Smoking “…the recovery paradigm of needed services has to include the concept of health promotion in treatment planning and service delivery to persons with SMI. ” Hutchinson et al, 2006

Fasting blood glucose Abnormal value Impaired fasting glucose: between 6. 1 and 7 mmol/l (110– 125 mg/dl) Diabetes: ≥ 7. 0 mmol/l (126 mg/dl)

Estimated prevalence and relative risk Modifiable risk factors Obesity Schizophrenia Bipolar disorder 45– 55% RR: 1. 5– 2 21– 49% RR: 1– 2 Smoking 50– 80% RR: 2– 3 54– 68% RR: 2– 3 Diabetes 10– 15% RR: 2 8– 17% RR: 1. 5– 2 Hypertension 19– 58% RR: 2– 3 35– 61% RR: 2– 3

Management of adverse drug-related effects on cardiovascular disease risk factors n n 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 management of CVD risk factor n n Smokers should be encouraged to stop smoking all forms of tobacco. Those who demonstrate a readiness to quit can be referred to a smoking cessation service which can offer behavioral counseling, nicotine replacement therapy or other pharmacological intervention. Maintaining a healthy body weight and shape by healthy eating and regular physical activity is the a key component of lowering CVD risk and prompt action is needed in patients who are overweight at initial assessment or who show signs of early weight gain with antipsychotic medication

Continue n n n Patients should be advised to take 30 minutes of moderately vigorous activity at least a brisk walk on most days of the week Avoidance of hypoglycemia is best achieved by involving the patient's family and cares in the education process about the risks and consequences of hypoglycemia. Patients should be encouraged to eat lean meat, fish and low fat dairy products and to replace saturated fat with monounsaturated and polyunsaturated fats from vegetable and marine sources Those with mildly elevated cholesterol levels may be able to reach target levels through diet alone

mangement Blood pressure High blood pressure in severely mentally ill patients is often missed. Target blood pressure levels of less than 140/90 mm. Hg are recommended. n Lifestyle changes, such as stopping smoking, n reducing salt intake, n weight reduction n and increased exercise, n Pharmacological therapy this may be sufficient to reduce mildly elevated blood pressure n

? What can be done Ø Ø Ø Treatment of Common Mental Illnesses with Cognitive Behavioural therapy highly effective (8 sessions) Psycho-social support to cancer patients decreased pain and depression and in half of studies reduced progression More daily “uplifts” increased bodies natural killer cells (immunity) Putting people in a positive mood leads to greater pain tolerance Assigning people to hospital rooms with a pleasant view decreased pain and reduced length of stay

Choosing health: exercise and SMI 41% low levels of exercise. . Ø 70% male patients obese. . Ø 86% female patients obese. . Ø Medication problems. . Ø – tardive dyskinesia, cardiac arrhythmias. . Ø Negative symptoms of schizophrenia – lack of motivation…. .

Choosing Health Six key priorities - 1: n Tackling health inequalities n Reducing the number of people who smoke n Tackling obesity

Choosing Health Six key priorities n Improving sexual health n Improving mental health and well being n Reducing harm and encouraging sensible drinking

Potential Obstacles § § § Lack of motivation Effects of medication Lack of money Boredom Mental health culture Attitudes and beliefs of health staff

Mind Your Heart Programme Our aim is to improve the physical health of mental health service users in Ceredigion by § Engaging people in activities that reduce their risks of illness § Removing obstacles § Raising awareness

Policy etc. § Health services should adopt a holistic view of the assessment and development of care plans for mental health service users Recommendations for the physical health care of people with SMI § Guidelines for the treatment of schizophrenia in primary and secondary care § Closing the Gap