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Guidelines for Integrated Care (Psychiatric


Guidelines for Integrated Care (Psychiatric & Medical) In the Community Module II: Metabolic Syndrome * Smoking Cessation Myths and Facts MYTH FACT To quit smoking ... – PowerPoint PPT presentation

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Title: Guidelines for Integrated Care (Psychiatric

Guidelines for Integrated Care (Psychiatric
Medical) In the Community
  • Module II
  • Metabolic Syndrome

  • 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

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

Quiz What does this have to do with Metabolic
Diagnosis of Metabolic Syndrome 3 or more of the following Diagnosis of Metabolic Syndrome 3 or more of the following
Prothrombotic state (a predisposition to venous or arterial thrombosis which is the formation or presence of a clot within a blood vessel) Insulin resistance as identified by type 2 diabetes, impaired fasting glucose or impaired glucose tolerance
Abdominal obesity (picture in next slide) Body mass index over that recommended for your height
Elevated triglycerides (normallt150 elevated, cause for concern gt200) Elevated fasting blood glucose (gt100)
Low HDL (good) cholesterol (menlt40 womenlt50 is problematic) High blood pressure (gt120/80)
Abdominal Obesity
At Risk for Metabolic Syndrome At Risk for Metabolic Syndrome
Weight gain/obesity (central obesity waist line greater than 40 inches in men and 35 inches in women) Taking second generation anti-psychotics, and other medications that include some mood stabilizers Abilify, Clozaril, Zyprexa, Invega, Seroquel, Geodon, etc.
BMI gt 25 BMI (Wt / hh)703 High LDL (bad cholesterol) and Low HDL (good cholesterol)
High blood pressure (above 120/80) Ethnicity-African or Mexican American
Family history of diabetes Increased age
Tobacco use Heavy alcohol use
Stress Sedentary life-style
High fat diet
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.

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

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
  • Lack of access to nutrition and exercise programs

Goals of life-style changes Lower Risk for
Cardiovascular Disease
  • Blood cholesterol
  • 10 decrease 30 decrease in coronary heart
  • 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 (gt 140 systolic or 90
  • 4-6 mm Hg decrease ? 16 decrease in coronary
    heart disease and 42 decrease in stroke

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

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
  • (Vreeland, 2007)

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
  • Infrequent, or no contact with primary care

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
  • Community mental health providers have
    insufficient training and time to work on weight
    and other health issues

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

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

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

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
  • Keycombined exercise with cutting calories
  • Structured and gradual
  • Techniques for attitude change regarding the role
    of food, etc.
  • Strategies to increase social support

Stages of Change
Stage Definition Goal of Intervention
Precontemplation Unaware of need To change behavior Increased awareness
Contemplation Thinking about change Motivate-tip the balance
Preparation Making a plan Concrete action plan
Action Implementing plan Assist with feedback, support
Maintenance Continuation of desirable actions Reminders, avoiding slips, what to do if/when slips occur
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

Small Steps Work for an Action Plan
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)

American Diabetes Association Recommendation
Monitoring Protocols for Persons on Second Generation Antipsychotics Monitoring Protocols for Persons on Second Generation Antipsychotics Monitoring Protocols for Persons on Second Generation Antipsychotics Monitoring Protocols for Persons on Second Generation Antipsychotics Monitoring Protocols for Persons on Second Generation Antipsychotics Monitoring Protocols for Persons on Second Generation Antipsychotics Monitoring Protocols for Persons on Second Generation Antipsychotics Monitoring Protocols for Persons on Second Generation Antipsychotics
Start 4 wks 8 wks 12 wks 3 mths 12 mths 5 yrs
Personal/ Family history x x
Wt/BMI x x x x x
Waist Measure x x
Blood Pressure x x x
Fasting Glucose x x
Fasting Lipid Profile x x x
NASMHPD and SAMHSA Standards of Care
  • Educational/behavioral interventions for weight
  • 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

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

Smoking Kills!
Some Stats on Mental Illness and Smoking
  • Rates of smoking are 2-4 x higher among people
    with psychiatric disorders and substance use
  • 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.

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.

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

(No Transcript)
Smoking Cessation Myths and Facts
To quit smoking all you need is will power Only 3 of people who quit cold turkey succeed
People with mental illness are more addicted to nicotine and are unable to quit Studies show that nicotine replacement therapy and psychotherapies are effective
Light or low tar cigarettes are safer No such thing as safe smoking
Natural tobacco and clove cigarettes are healthier They increase your risk of cancer, heart disease and emphysema
People with mental illness should smoke to reduce symptoms There are more effective ways that do not hurt your health
What can I do?
  • Help people realize that
  • Reduction often happens before cessation. (Stages
    of Change Model)
  • Measuring amount smoked helps with decreasing
  • Everyone needs supportPeer support is especially
  • Stress reduction techniques (e.g. substitute

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
  • Help for staff who smoke
  • (Mental health providers are significantly more
    likely to smoke that other health care providers)

De-normalize tobacco use The 5 Rs
  • 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 whats stopping you from quitting?
  • REPETITION Reinforce motivational message at
    every contact

Intervene The 5 As Model
  • ASK Identify and document tobacco use
  • ADVISE Key Message Point gt Quitting smoking is
    the most important thing you can do for your
  • ASSESS Willingness to make an attempt to
    stopgive it a try
  • ASSIST For those who are ready, provide or
    refer to counseling and medication
  • ARRANGE Follow up supportive contacts

Look at Your Purple Bookmark!
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
  • She states she has been under a lot of stress
    lately since her son was incarcerated and hasnt
    been sticking to her dietary plan. She notes
    that she does not have time to cook and has
    been eating at her neighborhood Rallys hamburger
    place for her meals. She orders either the 4 or
    7 meals.

  • What are important assessment questions for Mary
  • 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

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 56 and 178lbs.
  • Since he was laid off, he has been picking up
    cigarette butts off the ground and smoking them.
    His smokers 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.

  1. What are some of the risk factors James has for
    metabolic syndrome?
  2. 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.
  3. What else are you concerned about? What can you
    do to help James out?