553955 research-article2014
ANP0010.1177/0004867414553955Australian & New Zealand Journal of PsychiatryKølbæk et al.
Commentaries Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(11) 1059–1061
Commentaries
© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Follow-up interventions in persons with schizophrenia and metabolic syndrome Pernille Kølbæk1, Eva Schiöth1, Jørgen Aagaard2 and Povl MunkJørgensen1
1Department
of Organic Psychiatric Disorders and Emergency Ward, Aarhus University Hospital, Risskov, Denmark 2Unit for Psychiatric Research, Aalborg University Hospital, Aalborg, Denmark Corresponding author: Pernille Kølbæk, Department of Organic Psychiatric Disorders and Emergency Ward, Aarhus University Hospital, 8240 Risskov, Denmark. Email: [email protected] DOI: 10.1177/0004867414553955
Individuals with severe mental illness (SMI) have between 12 and 20 years’ reduced life expectancy compared to the general population, primarily due to premature cardiovascular mortality (Larsen et al., 2013). The metabolic syndrome (MetS) refers to a cluster of abnormal clinical and metabolic risk factors that are predictors of cardiovascular disease (CVD) (Grundy et al., 2005). The risk factors include elevated triglyceride and fasting plasma glucose, increased waist circumference, hypertension and low high-density lipoprotein (HDL) cholesterol. Evidence suggests that some of the key antecedents of MetS emerge soon after treatment initiation and that they accumulate over time (Eapen et al., 2013). Both lifestyle and pharmacological interventions have been shown to reverse MetS and thereby
prevent the development of diabetes and CVD (Dunkley et al., 2012). Despite the knowledge of increased cardiovascular disease and higher mortality rates, metabolic screening and monitoring in practice remain poor. Okkels et al. (2013) showed that abnormal findings were seldom evaluated and rarely acted upon. Barriers to medical care in this patient population include diminished adherence to treatment, underestimation of risk by physicians and the adverse effects of commonly prescribed antipsychotic medication. The latter emphasizes the importance of regular monitoring and appropriate treatment of cardiovascular and diabetic risk factors once identified. The psychiatric outpatient clinic, Community Mental Health Centre South, Aarhus, Denmark (CMHCSouth), focuses specifically on screening for MetS in patients with psychotic disorders and subsequent referral of these patients to their general practitioner (GP) if MetS is diagnosed. We investigated continuity in referral from secondary to primary care for patients falling within the schizophrenia spectrum disorders on the International Classification of Diseases, 10th Revision (ICD-10), F20–F25.9, who were also diagnosed with MetS. Patients meeting these diagnostic criteria and referred to CMHC-South during the 3-year period 2008–2010 were screened for MetS using the adapted Adult Treatment Panel (ATPIII-A) criteria proposed by the American Heart Association (Grundy et al., 2005). Clinical data were obtained from the patients’ medical records, and their GPs were asked to
complete questionnaires containing information concerning follow-up, if this had occurred. Forty-four patients were diagnosed with both MetS and schizophrenia within the study period. GPs completed the questionnaire for 36 (82%) patients. The results showed that only 15 (34%) patients contacted their GP after being encouraged to do so in continuation of their MetS diagnosis. We searched for predictors for continuity and the only variable associated with patients contacting their GP was the number of years the GP had worked in private practice. A logistic regression analysis showed decreasing odds for contact by a factor of 0.9 for each year the GP had worked in private practice. Findings pertaining to the clinical variables sex, age, marital status and body mass index (BMI) did not show any significance. The mean age in the study group (n=44) was 45 years (95% CI 27–65), mean illness duration 13.5 years (2–30), mean BMI 30.9 (95% CI 22.3–39.4) and antipsychotic polypharmacy (two or more medications) was registered in 57% of the patients. Half of the patient group was treated with either clozapine (36%) or olanzapine (14%), both of which are widely regarded as the second generation antipsychotics most likely to confer weight gain. There were no significant differences between males (n=29) and females (n=15). In 13 out of the 15 (87%) patients (who contacted their GP) the GPs found indications for continuing/ initiating intervention for treating the increased parameters of MetS; the interventions were pharmacological or non-pharmacological.
Australian & New Zealand Journal of Psychiatry, 48(11)
Downloaded from anp.sagepub.com at UNIV OF MICHIGAN on April 18, 2015
1060
ANZJP Correspondence
We find it troubling that in our outpatient clinic with a specific focus on screening, evaluating and referral to primary care physicians only 34% of the patients with MetS contacted their GP in continuation of their MetS diagnosis. However, the majority (87%) of the patients who contacted their primary physician did receive some kind of intervention. Future challenges include achieving improved collaboration between secondary and primary care clinicians in order to ensure appropriate transfer of information and to establish a suitable treatment plan, along with regular follow-up using multispecialty teams so as to attain the best possible outcomes.
Funding
Dunkley AJ, Charles K, Gray LJ, et al. (2012) Effectiveness of interventions for reducing diabetes and cardiovascular disease risk in people with metabolic syndrome: Systematic review and mixed treatment comparison
meta-analysis. Diabetes, Obesity & Metabolism 14: 616–625. Eapen V, Shiers D and Curtis J (2013) Bridging the gap from evidence to policy and practice: Reducing the progression to metabolic syndrome for children and adolescents on antipsychotic medication. Australian and New Zealand Journal of Psychiatry 47: 435–442. Grundy SM, Cleeman JI, Daniels SR, et al. (2005) Diagnosis and management of the metabolic syndrome: An American Heart Association/ National Heart, Lung, and Blood Institute scientific statement: Executive Summary. Critical Pathways in Cardiology 4: 198–203. Larsen JI, Andersen UA, Becker T, et al. (2013) Cultural diversity in physical diseases among patients with mental illnesses. Australian and New Zealand Journal of Psychiatry 47: 250–258. Okkels N, Thygesen NB, Jensen B, et al. (2013) Evaluation of somatic health care practices in psychiatric inpatient wards. Australian and New Zealand Journal of Psychiatry 47: 579–581.
Progress towards parity: Improving the physical health of long-term psychiatric inpatients Jackie Curtis1,2 and David Shiers3
years, a gap higher than that seen in Indigenous Australians. Although research in this field over the past decade has increased, this has predominantly focused on describing physical health disparities in people with SMI. Only more recently have evaluations of interventions aimed at improving this disparity begun to appear. In an earlier of the ANZJP, Hjorth and colleagues (2014) report findings from a pragmatic 12-month intervention aimed at improving the physical health of clients with persistent and severe mental illness. Their results are encouraging. Participants were recruited from six long-stay psychiatric inpatient units in Denmark into a cluster-controlled trial. Three sites were randomly allocated to provide usual care, and three sites provided usual care in addition to the HELPS ‘active awareness’ intervention. The intervention was delivered by two experienced psychiatric nurses and included motivational interviewing in small focus groups for clients, as well as a brief individual session. In a novel approach, the intervention also focused on staff behaviour, providing motivational interviewing and educational sessions on smoking, nutrition, physical activity and medication usage.
Additionally, staff had the opportunity to gain support for their own smoking cessation. Staff and clients were encouraged to make changes in the ward environment to improve physical health outcomes. The main outcome measure was waist circumference and, interestingly, measures were also obtained from staff, although these data were not reported in the current paper. At baseline, of the 85 participants, 69% were regular tobacco smokers and the majority of participants were overweight or obese, with central obesity. This is similar to a recent large Australian cohort in contact with mental health services where the prevalence of overweight and obesity was 75.5%, and 82.1% had central obesity (Galletly et al., 2012). At the 12-month follow-up the intervention group showed a small decrease in waist circumference (0.75 cm), whilst this increased in the control group (2.17 cm), highlighting the success of the intervention in preventing further deterioration of metabolic health among this cohort. This is encouraging given the high rates of existing obesity and the pragmatic nature of the intervention. The study did not involve intensive or specialized exercise or dietetic interventions, with lifestyle
1Early
Psychosis Programme, The Bondi Centre, South Eastern Sydney Local Health District, Bondi Junction, Australia 2School of Psychiatry, University of New South Wales, Randwick, Australia 3GP (retired), North Staffordshire; former joint lead to National Early Intervention in Psychosis Programme (2004-10), National Mental Health Development Unit, London, UK Corresponding author: Jackie Curtis, University of New South Wales, 26 Llandaff St, Bondi Junction, NSW 2022, Australia. Email: [email protected] DOI: 10.1177/0004867414547056
People with severe mental illness (SMI) are amongst the most disadvantaged in our community. The inadequacy of the physical health care often provided for people living with SMI has been described as a form of ‘lethal discrimination’ (Rethink Mental Illness, 2013), leading to the ‘scandal of premature mortality’ (Thornicroft, 2011). The life-expectancy gap for people with mental illness compared to the general population in Australia is 15–20
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. See Research by Larsen et al., (2013) 47(3): 250–258
References
Australian & New Zealand Journal of Psychiatry, 48(11) Downloaded from anp.sagepub.com at UNIV OF MICHIGAN on April 18, 2015
ANP0010.1177/0004867414553955Australian & New Zealand Journal of PsychiatryKølbæk et al.
Commentaries Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(11) 1059–1061
Commentaries
© The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Follow-up interventions in persons with schizophrenia and metabolic syndrome Pernille Kølbæk1, Eva Schiöth1, Jørgen Aagaard2 and Povl MunkJørgensen1
1Department
of Organic Psychiatric Disorders and Emergency Ward, Aarhus University Hospital, Risskov, Denmark 2Unit for Psychiatric Research, Aalborg University Hospital, Aalborg, Denmark Corresponding author: Pernille Kølbæk, Department of Organic Psychiatric Disorders and Emergency Ward, Aarhus University Hospital, 8240 Risskov, Denmark. Email: [email protected] DOI: 10.1177/0004867414553955
Individuals with severe mental illness (SMI) have between 12 and 20 years’ reduced life expectancy compared to the general population, primarily due to premature cardiovascular mortality (Larsen et al., 2013). The metabolic syndrome (MetS) refers to a cluster of abnormal clinical and metabolic risk factors that are predictors of cardiovascular disease (CVD) (Grundy et al., 2005). The risk factors include elevated triglyceride and fasting plasma glucose, increased waist circumference, hypertension and low high-density lipoprotein (HDL) cholesterol. Evidence suggests that some of the key antecedents of MetS emerge soon after treatment initiation and that they accumulate over time (Eapen et al., 2013). Both lifestyle and pharmacological interventions have been shown to reverse MetS and thereby
prevent the development of diabetes and CVD (Dunkley et al., 2012). Despite the knowledge of increased cardiovascular disease and higher mortality rates, metabolic screening and monitoring in practice remain poor. Okkels et al. (2013) showed that abnormal findings were seldom evaluated and rarely acted upon. Barriers to medical care in this patient population include diminished adherence to treatment, underestimation of risk by physicians and the adverse effects of commonly prescribed antipsychotic medication. The latter emphasizes the importance of regular monitoring and appropriate treatment of cardiovascular and diabetic risk factors once identified. The psychiatric outpatient clinic, Community Mental Health Centre South, Aarhus, Denmark (CMHCSouth), focuses specifically on screening for MetS in patients with psychotic disorders and subsequent referral of these patients to their general practitioner (GP) if MetS is diagnosed. We investigated continuity in referral from secondary to primary care for patients falling within the schizophrenia spectrum disorders on the International Classification of Diseases, 10th Revision (ICD-10), F20–F25.9, who were also diagnosed with MetS. Patients meeting these diagnostic criteria and referred to CMHC-South during the 3-year period 2008–2010 were screened for MetS using the adapted Adult Treatment Panel (ATPIII-A) criteria proposed by the American Heart Association (Grundy et al., 2005). Clinical data were obtained from the patients’ medical records, and their GPs were asked to
complete questionnaires containing information concerning follow-up, if this had occurred. Forty-four patients were diagnosed with both MetS and schizophrenia within the study period. GPs completed the questionnaire for 36 (82%) patients. The results showed that only 15 (34%) patients contacted their GP after being encouraged to do so in continuation of their MetS diagnosis. We searched for predictors for continuity and the only variable associated with patients contacting their GP was the number of years the GP had worked in private practice. A logistic regression analysis showed decreasing odds for contact by a factor of 0.9 for each year the GP had worked in private practice. Findings pertaining to the clinical variables sex, age, marital status and body mass index (BMI) did not show any significance. The mean age in the study group (n=44) was 45 years (95% CI 27–65), mean illness duration 13.5 years (2–30), mean BMI 30.9 (95% CI 22.3–39.4) and antipsychotic polypharmacy (two or more medications) was registered in 57% of the patients. Half of the patient group was treated with either clozapine (36%) or olanzapine (14%), both of which are widely regarded as the second generation antipsychotics most likely to confer weight gain. There were no significant differences between males (n=29) and females (n=15). In 13 out of the 15 (87%) patients (who contacted their GP) the GPs found indications for continuing/ initiating intervention for treating the increased parameters of MetS; the interventions were pharmacological or non-pharmacological.
Australian & New Zealand Journal of Psychiatry, 48(11)
Downloaded from anp.sagepub.com at UNIV OF MICHIGAN on April 18, 2015
1060
ANZJP Correspondence
We find it troubling that in our outpatient clinic with a specific focus on screening, evaluating and referral to primary care physicians only 34% of the patients with MetS contacted their GP in continuation of their MetS diagnosis. However, the majority (87%) of the patients who contacted their primary physician did receive some kind of intervention. Future challenges include achieving improved collaboration between secondary and primary care clinicians in order to ensure appropriate transfer of information and to establish a suitable treatment plan, along with regular follow-up using multispecialty teams so as to attain the best possible outcomes.
Funding
Dunkley AJ, Charles K, Gray LJ, et al. (2012) Effectiveness of interventions for reducing diabetes and cardiovascular disease risk in people with metabolic syndrome: Systematic review and mixed treatment comparison
meta-analysis. Diabetes, Obesity & Metabolism 14: 616–625. Eapen V, Shiers D and Curtis J (2013) Bridging the gap from evidence to policy and practice: Reducing the progression to metabolic syndrome for children and adolescents on antipsychotic medication. Australian and New Zealand Journal of Psychiatry 47: 435–442. Grundy SM, Cleeman JI, Daniels SR, et al. (2005) Diagnosis and management of the metabolic syndrome: An American Heart Association/ National Heart, Lung, and Blood Institute scientific statement: Executive Summary. Critical Pathways in Cardiology 4: 198–203. Larsen JI, Andersen UA, Becker T, et al. (2013) Cultural diversity in physical diseases among patients with mental illnesses. Australian and New Zealand Journal of Psychiatry 47: 250–258. Okkels N, Thygesen NB, Jensen B, et al. (2013) Evaluation of somatic health care practices in psychiatric inpatient wards. Australian and New Zealand Journal of Psychiatry 47: 579–581.
Progress towards parity: Improving the physical health of long-term psychiatric inpatients Jackie Curtis1,2 and David Shiers3
years, a gap higher than that seen in Indigenous Australians. Although research in this field over the past decade has increased, this has predominantly focused on describing physical health disparities in people with SMI. Only more recently have evaluations of interventions aimed at improving this disparity begun to appear. In an earlier of the ANZJP, Hjorth and colleagues (2014) report findings from a pragmatic 12-month intervention aimed at improving the physical health of clients with persistent and severe mental illness. Their results are encouraging. Participants were recruited from six long-stay psychiatric inpatient units in Denmark into a cluster-controlled trial. Three sites were randomly allocated to provide usual care, and three sites provided usual care in addition to the HELPS ‘active awareness’ intervention. The intervention was delivered by two experienced psychiatric nurses and included motivational interviewing in small focus groups for clients, as well as a brief individual session. In a novel approach, the intervention also focused on staff behaviour, providing motivational interviewing and educational sessions on smoking, nutrition, physical activity and medication usage.
Additionally, staff had the opportunity to gain support for their own smoking cessation. Staff and clients were encouraged to make changes in the ward environment to improve physical health outcomes. The main outcome measure was waist circumference and, interestingly, measures were also obtained from staff, although these data were not reported in the current paper. At baseline, of the 85 participants, 69% were regular tobacco smokers and the majority of participants were overweight or obese, with central obesity. This is similar to a recent large Australian cohort in contact with mental health services where the prevalence of overweight and obesity was 75.5%, and 82.1% had central obesity (Galletly et al., 2012). At the 12-month follow-up the intervention group showed a small decrease in waist circumference (0.75 cm), whilst this increased in the control group (2.17 cm), highlighting the success of the intervention in preventing further deterioration of metabolic health among this cohort. This is encouraging given the high rates of existing obesity and the pragmatic nature of the intervention. The study did not involve intensive or specialized exercise or dietetic interventions, with lifestyle
1Early
Psychosis Programme, The Bondi Centre, South Eastern Sydney Local Health District, Bondi Junction, Australia 2School of Psychiatry, University of New South Wales, Randwick, Australia 3GP (retired), North Staffordshire; former joint lead to National Early Intervention in Psychosis Programme (2004-10), National Mental Health Development Unit, London, UK Corresponding author: Jackie Curtis, University of New South Wales, 26 Llandaff St, Bondi Junction, NSW 2022, Australia. Email: [email protected] DOI: 10.1177/0004867414547056
People with severe mental illness (SMI) are amongst the most disadvantaged in our community. The inadequacy of the physical health care often provided for people living with SMI has been described as a form of ‘lethal discrimination’ (Rethink Mental Illness, 2013), leading to the ‘scandal of premature mortality’ (Thornicroft, 2011). The life-expectancy gap for people with mental illness compared to the general population in Australia is 15–20
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. See Research by Larsen et al., (2013) 47(3): 250–258
References
Australian & New Zealand Journal of Psychiatry, 48(11) Downloaded from anp.sagepub.com at UNIV OF MICHIGAN on April 18, 2015
