Kemi Wright - Move Your Mind
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Presentation by Kemi Wright, Senior Executive Psychologist South Metropolitan Health Service. Move Your Mind: Embedding a clinical exerise physiology within a WA mental health service. Presented at the Western Australian Mental Health Conference 2019.
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Kemi Wright - Move Your Mind
- 1. Move Your Mind Embedding clinical exercise physiology within a WA mental health service Kemi Wright– Senior Exercise Physiologist |PhD candidate Dr Bonnie Furzer - Senior Exercise Physiologist |Lecturer WA Mental Health Conference 2019
- 3. MI & Physical Health
- 5. How does EP fit in? 1-1 consults Open gym sessions Inpatient group classes Community management
- 6. EP Service Pathway ?
- 7. Demographics of consumers N=70 M: 29 F: 41 Mean age: 40 years Age range: 19-69 years 2.9% 7.1% 5.7% 7.1% 4.3% 7.1% 10.0% 15.7 21.4 27.1 51.4 0 10 20 30 40 50 60 Feeding and eating Substance related Neurodevelopmental Obsessive compulsive related Other Bipolar and related Trauma and stressor related Anxiety Personality Depressive Schizophrenia Spectrum and Psychotic Diagnosed Psychiatric Disorders 24.3% 20.0% 8.6% 8.6% 0% 0.0 5.0 10.0 15.0 20.0 25.0 30.0 Cardiometabolic Other Musculoskeletal Pulmonary Neurological Physical Comorbidities 14.3% 21.4% 21.4% 22.9% 25.7% 17.1% 35.7% 90.0 12.9 0.0 20.0 40.0 60.0 80.0 100.0 Supplements Antidepressants (SNRI) Anti-anxiety Anticonvulsants Metabolic/CV Other Antidepressants (SSRI) Anti-psychotics Antidepressants (Other) Medications
- 8. Service Breakdown 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Open Gym Group Session (Gym) Session Rating of Enjoyment N/A Bad Average Good Great 85% 38% 96% 13% 31% 2% 2% 17% 0 4% GROUP C LA S S E S (GY M) GROUP C LA S S E S (ONW A RD) OP E N GY M S E S S IONS PARTICIPATION RATES (FEB - JULY) Full Partial Presented but did not engage Observed 25% 25% 17% 33% TOTAL SERVICE PROFILE (FEB - JULY) Group Classes (Gym) Group Classes (onward) Individual Open Gym (community)
- 9. Service Breakdown 46+ min 46+ min 31-45 min 31-45 min 16-30 min 16-30 min 16-30 min 6-15 min 6-15 min Less than 5 min Less than 5 min 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Group Classes (Gym) Group Classes (onward) Open Gym (community) Minutes of Activity
- 10. Case Study- Jess 44 year old female Referred for weight loss Goal: ↓ alcohol intake, ↑ improve incidental activity EPSE: Tremor in hands, leg stiffness Ongoing auditory and visual hallucinations SIMPAQ: 14.5 hrs in bed,8 hours sedentary, no structure exercise Outcomes Initial Weight (kgs) 103.8 BMI 34.29 Waist Circumference 124.5 BP 136/86 Sit-to-stand ( 30 secs) 13 Max Push Up (Wall): 10 Plank (knees) 14 secs Wall Squat 30 secs Outpatient Open Gym
- 11. Case Study- Jess Outcomes Initial Post Ax Weight (kgs) 103.8 93.4 BMI 34.29 30.5 Waist Circumference 124.5 100 BP 136/86 134/85 Sit-to-stand ( 30 secs) 13 13 Max Push Up (Wall): 10 27 Plank (knees) 14 secs 31 secs Wall Squat 30 secs 30secs Other health related goals: Approx. 5 months with no alcohol intake, is managing to walk around the park 1-2 per week (good weeks) Outpatient Open Gym Current Weight is 90.5 kg, has increased to walking 4-5 times/week with neighbour
- 12. Case Study Inpatient- Sam 22 year male Dx: Schizophrenia/DIP LOS: 132 days Hx: DIP, absconding and aggression risk 65.4 73 85.9 88.6 93 101 60 70 80 90 100 110 120 Admission April May June July August Failed discharged Commenced on clozapine Inpatient groups & 1-1 Patient weight status
- 13. Challenges and Solutions Isolation – Identifying key stakeholders and utilising as allies – Reaching out to other allied health professional in similar settings Clinical guidelines vs. clinical practice – Striving for best practice, but understanding changes to clinical practice can take time Inpatient vs. outpatient – Limited resources available for patients – Ask for feedback from consumers and other hospital staff MDT integration – Work with other allied health to see how our team and/or service can be better integrated
- 14. Future Directions Expansion of exercise physiology services at FHMHS Embedding automatic referral protocol for metabolically active anti-psychotics. Further integration of lifestyle advice/intervention into standard clinical practice Quantitative and qualitative analysis of service incl. outcome measures
Editor's Notes
- PH & MI is multifaceted, transdiagnostic and world-wide problem. 10-15 year reduction in life expectancy ↑ risk of physical multimorbidity from onset of the mental illness Average age of onset of multimorbidity is younger in people with MI Obesity & metabolic syndrome may be independent predictors of relapse & rehospitalisation for those with severe MI Poor physical health in people with MI is multifaceted, transdiagnostic and world-wide problem. People with a serious mental illness die 10-15 years earlier than the general population due to poor physical activity In 2017-2018, approximately 4.8 million Australians (20%) reported having a mental or behavioural condition, with an estimated 90% of those experiencing co-existing, long-term mental and physical health conditions Despite the increasing amount of research in this area and more general advancements in health care and medicine, the poor physical health outcomes (and the associated decrease in life expectancy) of people with mental illness have not improved. In fact, the number of years of life lost due to physical health conditions in people with mental illness might be increasing. For instance, for patients with depression, the risk of developing cardiac disease, hypertension, stroke, diabetes, metabolic syndrome, or obesity is around 40% higher than in the general population. Emerging evidence suggests that obesity and metabolic syndrome are independent predictors of relapse and rehospitalisation for those with severe mental illness. This relationship could be explained by the inflammatory effects of abdominal obesity; inflammation has also been associated with worse mental health Some large-scale, multinational studies have shown that people with severe mental illness, common mental disorders, and substance use disorders are at a greatly increased risk of physical multimorbidity from the point of onset of the mental illness. The average age of onset of multimorbidity is younger in people with mental illness compared with the general population. Multimorbidity greatly increases the personal and economic burden associated with chronic conditions, and reduces life expectancy compared with a single morbidity. Weight gain is the most distressing side-effect reported by callers to mental health helplines, and is associated with poorer quality of life and barriers to social engagement. As a result, patients who gain weight have a reduced adherence to treatment, which can lead to relapse and poor mental health outcomes. Although most antipsychotic medications lead to weight gain, clozapine and olanzapine have the highest propensity Weight gain associated with drugs for psychosis is not usually dose-dependent, so dose reduction will not be effective in reducing weight. Metaanalyses (table 1) have found that the risk of metabolic syndrome and type 2 diabetes is at least twice as high in people with schizophrenia, bipolar affective disorder, and major depressive disorder compared with the general population Hyperprolactinaemia is most commonly found with first-generation antipsychotics, as well as risperidone, paliperidone, and amisulpride. Hyperprolactinaemia can be asymptomatic, or can lead to complications, such as menstrual disturbance and sexual dysfunction (including reduced libido, erectile dysfunction, vaginal dryness, and orgasmic dysfunction ) in the short-term, and osteopenia in the long-term. Extrapyramidal side-effects include dystonia (muscle spasm), Parkinsonism (tremor, rigidity, and bradykinesia), akathisia (subjective restlessness), and tardive dyskinesia (abnormal involuntary movements). Anticholinergic effects are common side-effects of antipsychotic medications, particularly chlorpromazine, clozapine, and olanzapine. Anticholinergic effects are mediated by antagonism of acetylcholine by inhibition of the muscarinic receptors. They can be either central (eg, impairment of cognition, memory, and concentration, and sedation) or peripheral (eg, constipation, dry eyes, mouth, and skin, blurred vision, tachycardia, and urinary retention) Sodium valproate is associated with metabolic effects, with at least half of individuals gaining weight in the first 3 months after initiation, with a mean weight gain of 6·4 kg over 3 months Antipsychotic medications are often prescribed concurrently with mood stabilisers; additional caution is required in this situation because the metabolic effects of the two classes of medication could be additive.
- People with mental illness tend to have more unhealthy lifestyles compared with the general population, and among people with mental illness, those with schizophrenia have a particularly high risk of smoking, sedentary behaviour, and poor diet However, lifestyle risk factors are still greater in patients with schizophrenia than those with other mental health disorders, even when controlling for socioeconomic factors The use of second-generation antipsychotics (SGAs) could contribute to changes in diet, because trials in healthy volunteers found that SGAs such as olanzapine can reduce satiety, increase appetite 183 and lethargy, and have sedative effects No suitable tools are available for clinicians to comprehensively assess lifestyle factors as part of standard care. The sole use of biological markers for physical health assessment (such as >7% increase in bodyweight, high blood pressure, and an abnormal lipid profile) could mean that interventions are applied only when it is too late to protect metabolic health or pre-empt obesity (panel 2). Clinical guidelines are increasingly recommending that assessments of diet, physical activity, and health risk behaviours are done alongside assessments of anthropomorphic parameters and blood markers of metabolic status, 204 to more accurately assess current physical health and future risk In conclusion, people with mental illness are likely to receive a poorer standard of health care compared with people without mental illness who have the same physical health problems
- 64 bed inpatient unit, outpatient looks after approx. 1000 active patients From an inpatient structure, each ward is looked after by the medical team, with an OT and SW across each ward. CTT are made up of consultant psychiatrist, registrars, mental health nurses, OT and SW In 2018 , there was 2910 inpatient admission to the SMHS mental health units The ex phys service provided servicing across the both inpatient and
- Goal lose weight , increase of 30 kgs over the last 4-5 months on DSP managed by ACTT Case study highlight complexity of px management, everchanging symptomology, improvement with integrated management and support
- April : thought disorder, disorganized, refusing dietary and fluid intake paranoid he would be poisoned, Hx of DIP, absconding risk, Aggression risk HX childhood trauma Apr/May: engaging well in group, nil management risks, discharge to supportive accommodation, Substance use , Failed discharge June: Commenced on clozapine, disengaged from groups, sporactic attendance, increasing weight gain. Med Aug: Current weight 101kgs, Polite pleasant, discharge iminiment to rehabiliatation/supportive accomodation, motivation issues with regards to exercise, Weight Hx: 65.4 (15/4), 73( 21/4); 85.9 19/5; 88.6 16/6 Commences clozapine 20/6 , weight gain 0f 28 kgs over last 3 months ( 10/7) Current weight ( 101 kgs)