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1. Metabolic Syndrome IDF Definition Metabolic Syndrome s defined by the International Diabetes Federation IDF as raised waist circumference plus two other abnormalities systolic BP 135 mmHg or diastolic BP 85 mmHg fasting BSL gt 5 6 mmol L TG gt 1 7 mmol L or HDL lt 1 03 mmol L male or HDL lt 1 29 mmol L female Waist circumference varies by ethnicity Europid male 94cm female gt 80cm Asian male gt 90cm female 80cm In our clinical service at CCCHiP we screen inpatients and provide a multidisciplinary intervention where CMRFs are detected The rate of Metabolic Syndrome among the patients we have seen is 54 n 464 mean age 41 mean BMI 30 mean duration of psychiatric illness 13 years It is important to note that the IDF cut offs are indicative of a level of risk not a level at which medical management is indicated Lifestyle treatment should be considered for all those at increased risk More detail regarding screening each of the risk components is outlined from pages 10 26 Detail about initiating treatment for each of the risk components is discussed from pages 35 46 of this manual Concord Centre for l 4 in Psychosis Cardiometabolic Health Figure 2 MetS IDF incidence CCCHIP clinics MetS Present No MetS Figure 3 Rates of metabolic disease among patients reviewed in CCCHIP Clinics E Abnormal Normal W
2. Figure 7 Metabolic Management Algorithm 2 What amp When Urgent Response Looks unwell or symptomatic Yes Immediate medical GP review needed within 7 10 days response Concord Centre for Cardiometabolic Health in Psychosis Figure 8 Metabolic Management Algorithm 2 What amp When Non Urgent Response No Diabetes glucose Consider metformin Not PBS Review adequacy of current hypoglycaemic medications Target HBA 1C lt 7 0 Treatment range hypertension or lipid abnormality Other metabolic abnormality but below PBS threshold No other metabolic abnormality Initiate medication as per guidelines Brief lifestyle intervention 6 monthly metabolic review DB Concord Centre for Cardiometabolic Health in Psychosis Public Health Promotion it B t Screening l l la l 0 Detection Evaluation Treatment Initiation Treatment GP with MH GP with GP MH MH site onsite general e iaison ua ae J temor j A Simics support health Cardiometabolic education centres Specialist collaborative clinics e g ccCHiP Health outcome improvement monitoring Concord Centre for l Cardiometabolic Health in Psychosis Intervention Initiating Treatment It
3. Detection Our experience and the literature supports the view that when blood tests and imaging are ordered the clinician does not always a look up the results and or b communicate the results to the patient 30 A system for reviewing all routine tests is essential This can be approached in a number of ways but to be successful review needs to be integrated into everyday clinical care PRACTICE TIP There are logical times when results can easily be scanned during routine care Inpatient Setting e On review of admission bloods AN 30 1 Casalino et al 2009 Frequency of failure to inform patients of clinically significant outpatient test results Intern Med 169 12 1123 29 Current data management systems both in the hospital community setting have been inadequate at present to enable us to flag high risk patients Ideally data management would be integrated While waiting for these developments we have found keeping a small excel file of at risk patients on a secure hospital computer enables us to monitor health parameters over time thus detecting progression to metabolic disorder Detecting Metabolic Syndrome Current Australian recommendations are to use the International Diabetes Federation criterion to define metabolic syndrome see Table 1 page 27 Detecting absolute and relative risks of developing CVD Framingham risks of developing cardiovascular disease can also be calculated using tools de
4. Hypoglycaemic agents The psychiatrist requires support to manage diabetes as the prescribing of glycaemic agents requires specific expertise If blood glucose is abnormal long term intervention targeting multiple risk factors has been shown to halve the risk of a cardiovascular event occurring 10 There is evidence for the use of metformin in prevention of weight gain and diabetes among those with serious mental illness who are taking psychotropics however treatment with metformin is not PBS funded except for diabetes Level of evidence 45 46 PRACTICE TIP Where diabetes is diagnosed in the psychia judicious to commence 500 Heian eae impairment sepsis or Serious adverse effects Lactic acidosis uncommon Take particular care in dehydration the elderly and those with renal impairment 10 Gaede P Vedel P Larsen N et al 2003 Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes New England Journal of Medicine 348 383 393 31 Klein DJ Cottingham EM Sorter M Barton BA Morrison JA A randomized double blind placebo controlled trial of metformin treatment of weight gain associated with initiation of atypical antipsychotic therapy in children and adolescents Am J Psychiatry 2006 163 2072 2079 32 Wu RR Zhao JP Guo XF et al Metformin addition attenuates olanzapine induced weight gain in drug naive first episode schizophrenia patients a double blind placebo
5. Yes No Unknown Psychosis Yes No Unknown Date Weight Waist BMI Blood Pressure Sitting Standing f BSL r BSL Cholesterol Triglycerides LDL C HDL C No of cigarettes daily If given up how long ago Exercise Yes No Yes No Yes No Yes No If Yes how many minutes per day week This a basic form full data can be entered using the full ccCHIP Dataform Ring 9767 8982 CVD comprised of hypertension stroke angina or cardiac disease large vessel disease Print NaMe cose diel accieienclecgiateciacxected siectseater deat De sig ation issnin ole lani ie olen ieee ees eee Concord Centre for A WHOJ4 ONINSAYOS ONOAVYLIN diIHD99 TVINL Cardiometabolic Health in Psychosis 71 Ai NSW Health FAMILY NAME MRN GIVEN NAME MALE FEMALE FACILITY CONCORD HOSPITAL D O B REFERRAL TO ccCHIP METABOLIC CLINIC ADDRESS LOCATION WARD COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE Cardiometabolic Health Concord Centre for in Psychosis A Have fasting bloods been ordered Yes No If no please arrange the following fasting BSL Cholesterol Triglycerides HDL LDL and Vitamin D Thank you What is the clinical reason for concern 2 2 0 0 cece cece c
6. 11 Therapeutic Guidelines Endocrinology 2009 Accessed online 15 1 10 http www tg org au index php sectionid 44 Concord Centre for 29 in Psychosis Cardiometabolic Health Figure 1 A Systems Model for Integrated Health Provision Public Health Promotion Health outcome improvement monitoring BD Concord Centre for Cardiometabolic Health in Psychosis Public Health Promotion Detection Evaluation Treatment Initiation Treatment Monitoring GP with onsite MH support MH general interv for J health GP with CMH Liaison GP MH shared site MH site specific clinics Cardiometabolic education centres Specialist collaborative clinics e g ccCHiP Health outcome improvement monitoring Concord Centre for Cardiometabolic Health in Psychosis Ethnicity Female mv ce e re S SE Asian Chinese ethnic Sth Americans Japanese Plus any 2 of gt 1 7 mmol L lt 1 03 M lt 1 29 F 130 systolic or 285 diastolic mm Hg a gt 5 6 mmol L if BMl 30 waist measure not needed or previous treatment for this condition T or has been previously diagnosed with condition 12 Alberti KG Zimmet P Shaw J The metabolic syndrome a new worldwide definition Lancet 2005 366 1059 1062 10 BD Concord Centre for Cardiometabolic Health in Psychosis
7. Each GP Network has network meetings usually monthly where local GP s meet for education and information sessions Each of these networks has a project development officer who is a useful point of liaison In addition each network publishes a local newsletter a useful place to send in a snippet about your service to promote shared care SCHIZOPHRENIA FELLOWSHIP A number of supportive programs for consumers and carers including the eat well move well stay well program http www sfnsw org au Services Services Recovery Services default aspx NSW CONSUMER ADVISORY GROUP CAG Links to key State and National organisations http www nswcag org au page key_state__national_mental_health_organisations html ARAFMI NSW Support and advocacy for families and friends of consumers with mental disorder MENTAL HEALTH COORDINATING COUNCIL MHCC The MHCC is the peak body for non government organisations working for mental health Programs include e Meet your neighbour htto Awww mhcc org au sector develooment meet your neighbour aspx e Carer respite project htto Awww mhcc org au projects and research building capacity project aspx MENTAL HEALTH ASSOCIATION NSW Provides a Mental Health Support group network service http www mentalhealth asn au Concord Centre for Cardiometabolic Health in Psychosis A8 A GPs remain the mainstay of primary health care but n
8. Hennekens C Hennekens A Hollar D amp Casey D 2005 Schizophrenia and increased risks of cardiovascular disease American heart journal 150 6 1115 21 4 Sernyak MJ Gulanski B Leslie DL Rosenheck R 2007 Undiagnosed hyperglycemia in clozapine treated patients with schizophrenia Journal of Clinical Psychiatry 2003 64 605 608 5 Lambert T J amp Newcomer J W 2009 Are the cardiometabolic complications of schizophrenia still neglected Barriers to care Med J Aust 190 4 Suppl S39 42 6 Meadows G Establishing a collaborative service model for primary mental health care MJA 2003 178 S53 S56 Concord Centre for y in Psychosis Cardiometabolic Health A Systems Model for Integrated Health Provision Monitoring of cardiometabolic risk factors CMRF s is best practice for patients with severe mental illness 7 9 Microvascular changes leading to cardiovascular disease occur early even before clinical disorders are noted and so early detection and prevention strategies are crucial to reducing mortality 10 We recommend that patients with any of the following risk factors should be screened a minimum of six monthly and those with multiple risk factors see page 31 three monthly The ccCHiP systems model Figure 1 demonstrates the range of components needed for the integrated system Those elements in grey are the core business of any screening a
9. in more than one setting 18 In general blood pressure prescribing requires some expertise and would be ideally managed in the general practice setting Where a general practice review cannot be obtained the psychiatrist should Blood pressure lowering agents discuss the patient with someone with the relevant expertise PRACTICE TIP Where persistent hypertension is setting an ap firs InNITO Q of antihypertensive medications is plex and should be conducted in consultation with general practitioner or clinician with clinical expertise 20 Staessen JA Wang J Lutgarde T 2001 Cardiovascular protection and blood pressure reduction a meta analysis The Lancet 358 9290 1305 1315 21 Mazzaglia G Ambrosioni E Alacqua M et al Adherence to antihypertensive medications and cardiovascular morbidity among newly diagnosed hypertensive patients Circulation 2009 120 1598 1605 18 National Heart Foundation of Australia National Blood Pressure and Vascular Disease Advisory Committee Guide to management of hypertension Concord Centre for Cardiometabolic Health in Psychosis 2008 Quick reference guide for health professionals Updated December 2010 gt 45 A Cholesterol Lowering Agents According to the PBS the cut off for medical management is total cholesterol 7 0 however the PRACTICE TIP following lower levels apply to special groups 24 Where lipid abnormalities are detected in th
10. in otherwise thin persons is the most reliable measure Management of isolated central abdominal adiposity in the absence of other abnormalities involves diet and exercise programs for weight loss Flip to the Resources section of this manual for more information about local treatment programs 15 Reis JP Macera CA et al 2009 Comparison of overall obesity and body fat distribution in predicting risk of mortality Obesity 17 6 1232 9 16 Zhang X Shu XO et al 2009 General and abdominal adiposity and risk of stroke in Chinese women Stroke 40 4 1098 104 17 Lapice E Malone S et al 2009 Abdominal adiposity is associated with elevated C reactive protein independent of BMI in healthy non obese people Diabetes Care 32 9 1734 6 15 Concord Centre for y in Psychosis Cardiometabolic Health Table 3 Classification and follow up of blood pressure levels in adults Diagnostic category Systolic Diastolic Follow up mmHg mmHg Normal lt 120 lt 80 Recheck in 2 years or earlier as guided by patient s absolute cardiovascular risk E High normal 120 139 80 89 Recheck in 1 year or earlier as guided by patient s absolute cardiovascular risk o Grade 1 mild hypertension 140 159 90 99 Confirm within 2 months See When to intervene page12 Cee A eee pvecaicesies 160 179 100 109 Reassess or refer within 1 month See When to intervene page 12 Grade 3 severe hypertension gt
11. 180 gt 110 Reassess or refer within 1 7 days as necessary See When to Intervene page 12 Isolated systolic hypertension gt 140 gt 90 As for category corresponding to systolic BP Isolated systolic hypertension gt 160 As for grade 3 hypertension with widened pulse pressure When a patient s systolic and diastolic BP levels fall into different categories the higher diagnostic category and recommended action s apply See Assessing absolute cardiovascular risk page 14 In middle aged and elderly patients with cardiovascular risk factors or associated clinical conditions isolated systolic hypertension with large pulse pressure indicates high absolute risk for cardiovascular disease 18 Extract from National Heart Foundation of Australia National Blood Pressure and Vascular Disease Advisory Committee Guide to management of hypertension 2008 Quick reference guide for health professionals Updated December 2010 Accessed online 14th July 2011 Weblink http www heartfoundation org au SiteCollectionDocuments HypertensionGuidelines2008to20 10Update pdf A 16 Concord Centre for Cardiometabolic Health in Psychosis Blood Pressure Awareness and knowledge of key parameters can assist in timely referral treatment and reduction of cardiovascular risk The Heart Foundation Guide to Management of Hypertension 2008 and Quick reference guide for health professionals update
12. Cardiometabolic Health in Psychosis z DB Disclaimer amp Copyright The Concord Centre for Cardiometabolic Health in Psychosis ccCHiP team is comprised of a group of clinicians who provide a clinical service within Sydney Local Health Network This package is created in good faith as an educational service by the members of the ccCHiP clinical team While ccCHiP will at all times use its best endeavors to provide the above mentioned services with up to date knowledge that our team possess it hereby disclaims any liability for any information strategy or management of persons with mental illness and or cardiometabolic risks All persons using this resource hereby accordingly hold ccCHiP harmless and indemnifies it against any action that might be brought against it for any act of omission or commission committed by it in the course of providing the above mentioned services 1 All information provided in this pack is intended to be a guide to promote best practice care for people with mental illness and co morbid cardiometabolic risk factors It does not replace medical advice While all reasonable efforts have been made to ensure the accuracy of the information in this package the ccCHiP team accept no responsibility for the accuracy of that information or for any error or omission or for any decisions made based on such information 2 Materials supplied in this package are the intellectual property of the ccC
13. P Psychiatry 2010 67 133 143 Al A Concord Centre for Cardiometabolic Health in Psychosis Specific Smoking Cessation Program Meta analysis of smoking cessation programmes PRACTICE TIP The evidence suggests that two different t 5 demonstrates that treatments can be effective for patients with mental illness ame treatments that work for the general ati wis 1 can work for those with mental illness 43 Multi clinician involvement including medical input is highly advisable as not only is it likely to improve success but allows for monitoring of p450 system related pharmacological interactions 43 44 45 Banham L Gilbody S Smoking cessation in severe mental illness what works Addiction 2010 105 1176 1189 46 Stapleton JA Commentary on Banham amp Gilbody 2010 The scandal of smoking and mental illness Addiction 2010 105 1190 1191 2 Concord Centre for Cardiometabolic Health in Psychosis Where medical management is indicated anti hypertensive treatment reduces the risk of adverse cardiovascular outcomes as compared to placebo 20 Those patients who are adherent to antihypertensive treatment are 38 less likely to have an adverse cardiovascular event than those who are non adherent 21 Prior to commencing blood pressure lowering medication blood pressure should be measured on more than one occasion
14. are freely Brain changes increased hippocampal volume 42 ai available on contacting our team Most programs reported to date have been of a duration of 3 6 months and follow up rarely extends beyond 12 months Results indicate a sustained approach is likely to be of greater benefit Longer term sustained programs are likely to have effects 39 Alvarez Jimenez M Hetrick SE Gonzalez Blanch C Gleeson JF McGorry PD Non pharmacological management of antipsychotic induced weight gain systematic review and meta analysis of randomised controlled trials Br J Psychiatry 2008 193 101 107 40 Faulkner G Biddle S Exercise as an adjunct treatment for schizophrenia A review of the literature Journal of Mental Health 1999 41 Acil AA Dogan S Dogan O The effects of physical exercises to mental state and quality of life in patients with schizophrenia Journal of Psychiatric and Mental Health Nursing 2008 42 Poulin MJ Chaput JP Simard V et al Management of antipsychotic induced weight gain prospective naturalistic study of the effectiveness of a supervised exercise programme Aust N Z J Psychiatry 2007 41 980 989 43 Wu MK Wang CK Bai YM Huang CY Lee SD Outcomes of obese clozapine treated inpatients with schizophrenia placed on a six month diet and physical activity program Psychiatr Serv 2007 58 544 550 44 Pajonk FG Wobrock T Gruber O et al Hippocampal plasticity in response to exercise in schizophrenia Arch Gen
15. controlled study Am J Psychiatry 2008 165 352 358 29 in Psychosis Concord Centre for Cardiometabolic Health Brief Lifestyle Intervention Brief lifestyle intervention has been demonstrated to be 2 Advice according to stage of change 35 effective in reduction of a range of high risk behaviours including smoking 31 alcohol 82 and marijuana use Stage Clinician Action A tailored brief intervention is even more effective when combined with a motivational interviewing approach Precontemplational Suggest revisit later 33 34 Contemplational Provide options 1 Take a brief lifestyle history Action stage or Maintenance Assess current actions _ Smoking daily Prior attempts to quit Stage offer additional options Exercise Currently exercise regularly Is a light puff Wheel ore achieved during exercise indicating an effective level Relapse Supportive listening Brief diet history Soft drink fried foods high energy troubleshoot difficulties 6 take away and plan coping strategies Weight history Lost or gained attempting to lose or gain What were barriers 33 Mottillo S Filion KB Belisle P et al Behavioural interventions for smoking cessation a meta analysis of randomized controlled trials Eur Heart J 2009 30 718 730 34 Bray JW Cowell AJ Hinde JM A systematic review and meta analysis of health care utilization outcomes in alcohol scr
16. four weeks to six months after the completion of a GP Mental Health Treatment Plan and Concord Centre for in Psychosis Cardiometabolic Health e if required a further review can occur three months after the first review In general most patients should not require more than two reviews in a 12 month period with ongoing management through the GP Mental Health Treatment Consultation and standard consultation items as required GP Mental Health Treatment Consultation item 2713 An extended consultation at least 20 minutes with a patient where the primary treating problem is related to a mental disorder May be used for continuing management of a patient with a mental disorder including for a patient being managed under a GP Mental Health Treatment Plan 54 MBS Online Medicare Rebate System Mental Health Pathways Medicare Benefits Schedule Extracted from Medicare Benefits Schedule http www9 health gov au mbs search cfm Concord Centre for Cardiometabolic Health in Psychosis Medicare Rebate System Chronic Conditions When a diagnosis of a chronic condition is made there are further Medicare rebates available The Department of Health and Ageing defines a chronic condition as A chronic medical condition is one that has been or is likely to be present for six months or longer It includes conditions such as asthma cancer cardi
17. history Obes ty Sister Diabefes Mother Father Sister CVD Father Psychosvs None At risk ethnicity Father Middle Eastern Mother Middle Eastern Smoking Current 40 per day Daily Smoked for years Orexigenic medications in last 2 months Yes Orexigenic potential current Rx 4 High Other diagnosed CM risks Dyslipidaemia prev treated Exercise IPAQ Exercise History None Diet Fast food meals each day with some home drinks 100 mls day fruit juice drinks 0 mls day soft drink METABOLIC SYNDROME FRAMINGHAM RISK Metabolic Syndrome IDF Present Framingham 10yr CHD risk 10 year CHD risk 37 10 year average CHD risk 21 Relative risk 1 76 Risk level is Serious RECOMMENDATIONS Today we altered metformin dosing from 500 TDS to 500 mane plus 1g nocte Ongoing diabetes monitoring 3 monthly metabolic review and annual foot eye amp kidney checks is recommended He will continue to see a his diabetes management HBA1C requested for tomorrow Please discuss the results of this with Dr or myself and we will advise on further changes to his medication which at present may be suboptimal Dietitian review was briefly given today MM will arrange for additional dietitan review on the ward to explain diabetic diet in more detail Dr RR Sen Psychiatric Registrar Concord Centre for Cardiometabolic Health in Psychosis l 74 A References _ Lambert T J 2009 The medic
18. is useful to develop a palate of interventional tools The following evidence based interventions should that can be used in tailoring initial management for be considered for all mental health patients patentee SING Iran elle SEEEN Mice Individualised brief intervention on diet and activity metabolic interventions should consider the complex and brief smoking cessation intervention circumstances of each particular patient in particular Sa keeping in mind the who algorithm and delineating a pamaily Interyenulen key clinician responsible for monitoring outcome of Specific diet and exercise program eg the ccCHiP treatments initiated These points will be outlined in manualised program discussed on page 41 detail through this section 6 Specific smoking cessation program For patients with a diagnosis of diabetes consider Those with other specific abnormalities may benefit The who should include a diabetes clinic or from the following regular contact with a GP Foot eye and kidney checks need to be arranged regularly Q Antihypertensive agents Review adequacy of current hypoglyceamic agents C8 Cholesterol lowering agents including adherence assessment In some cases Vitamin D supplementation Concord Centre for Cardiometabolic Health in Psychosis l 4 35 A Initiating Treatment Those patients with known poor adherence to treatment programs ma
19. significantly once additional staff positions dedicated to the service were created Initially our inpatient service was staffed with the goodwill of three senior staff specialists who set aside one morning a week to run the pilot clinical service It was not until the CNC registrar team were in place that issues like referral procedures follow up record keeping and clinical handover could be effectively addressed Ideally the person co ordinating your project will be one of the key team clinicians It may be that 2 3 clinicians share the role and each brings some of the ideal qualities to the project co ordinator role Ideal qualities of project co ordinator In our experience it helps to have team members with the following qualities Be wel known and Concord Centre for Cardiometabolic Health in Psychosis BD Resources Stakeholders In expanding our service from hospital to community a number of steps were helpful in promoting links to our metabolic clinic and preventing duplication of services It was beneficial to identify existing staff members with a demonstrated interest in physical health screening existing healthy lifestyle programs including exercise diet and smoking cessation programs local GPs with an interest in mental health existing NGO amp community programs that patients of the service could access and capacity for access to hospital ba
20. 008to2010Update pdf National Heart Foundation of Australia National Blood Pressure and Vascular Disease Advisory Committee Guide to management of hypertension 2008 Quick reference guide for health professionals Updated December 2010 Accessed 19 Staessen JA Wang J Lutgarde T 2001 Cardiovascular protection and blood pressure reduction a meta analysis The Lancet 358 9290 1305 1315 P 75 A P Concord Centre for in Psychosis Cardiometabolic Health References 20 Mazzaglia G Ambrosioni E Alacqua M et al Adherence to antihypertensive medications and cardiovascular morbidity among newly diagnosed hypertensive patients Circulation 2009 120 1598 1605 21 Engelgau MM Thompson TJ et al 1995 Screening for diabetes mellitus in adults The utility of random capillary blood glucose measurements Diabetes Care 32 641 643 22 Sommanavar S Ganesan A et al 2009 Random capillary blood glucose cut points for diabetes and pre diabetes derived from community based opportunistic screening in India Diabetes Care 32 4 641 643 23 Alberti KG Zimmet P Shaw J The metabolic syndrome a new worldwide definition Lancet 2005 366 1059 1062 24 Therapeutic Guidelines Endocrinology 2009 Accessed online 15 1 10 http www tg org au index php sectionid 44 25 Steinberg D Glass CK Witztum JL 2008 Evidence Mandating Earlier and More Aggressive Treatment of Hypercholesterolemia Circulation 118 672 677 26 Ref Int
21. 1 Arrange a combined consultation with the consumer and a supportive family member explain that weight talk can be very demoralising and can lead to disordered eating behaviours and guilt focus on simple positive practical changes focus on diet and exercise for enjoyment and health benefits not for weight loss and draw upon available resources such as healthy eating guidelines free consumer booklets available for interested clinicians 2 Refer the consumer to a dietitian and suggest they take their family member along particularly if someone else in the home is the main person preparing meals 3 Refer the consumer to a qualified exercise physiologist to develop an exercise plan Encourage them to involve family members in their exercise program PRACTICE TIP es is an 40 Concord Centre for Cardiometabolic Health in Psychosis Specific Lifestyle Program Lifestyle programs have been demonstrated to be across all the above domains as well as impacting effective among patients with mental illness for upon adherence personal self efficacy community engagement and other functional domains Managing weight gain 37 Improving negative symptoms amp mood 38 Increased quality of life 39 40 iP Ii e manuals can guide you through Improved blood glucose and lipid profile 41 igning cise program or evaluating the effe SS Of an existing one These
22. A Practical Guide Sustainable metabolic interventions for patients with mental illness C H P CONCORD CENTRE FOR CARDIOMETABOLIC HEALTH IN PSYCHOSIS P Concord Centre for Cardiometabolic Health in Psychosis Setting up a new service Writing Editorial Group Dr Elizabeth Dent 2 Dr Jeff Snars Angela Meaney Andrew Harb Vanessa Barter Associate Professor Roger Chen 4 Professor Tim Lambert 2 Thanks to Central Sydney GP Network for assistance in editing the information provided on pages 51 55 mental health referral pathways and medicare items REFERENCES N GOVERNMENT 1 Concord Centre for Cardiometabolic Health in Psychosis ccCHiP CCMH 2 University of Sydney Concord Centre for Cardiometabolic Health in Psychosis THE UNIVERSITY OF SYDNEY Health Sydney Local Health Network 3 Concord Hospital Department of Endocrinology and Metabolism Concord Hospital 4 The University of Sydney THIS MANUAL WAS DEVELOPED WITH THE SUPPORT OF AN EDUCATIONAL GRANT FROM NSW HEALTH Contents Disclaimer amp Copyright Executive Summary amp Background 4 7 A systems model for integrated health provision 8 9 Screening 10 26 Detection 2 28 Formulation 29 34 Initiating treatment 35 46 Monitoring Response 47 48 Resources 48 56 Setting up a Service 57 14 References 15 17 Concord Centre for
23. HiP team and are for personal use only Permission to otherwise reprint or electronically recreate or reproduce this package in part or in its entirety is expressly prohibited unless prior written consent is obtained from ccCHiP The compilation of information in this package and on the ccCHiP website including the design and organisation is copyrighted Concord Centre for Cardiometabolic Health in Psychosis s_ Concord Centre for Cardiometabolic Health in Psychosis ccCHIP located within Sydney Local Health Network is a cooperative venture partly funded by NSW Health We are supported by contributions in kind from Sydney University Concord Hospital Department of Endocrinology and Metabolism Concord Hospital Dietetics Department and Australian Diabetes Council Our clinical service was established by Professor Tim Lambert Dr Jeff Snars and Associate Professor Roger Chen in 2008 Our clinical model an integrated service for screening detection management and follow up of metabolic disorders among patients with severe mental illness provides models for a replicable scalable clinical service We conduct integrated metabolic clinics for patients with mental illness at Concord Hospital Our multidisciplinary team is comprised of psychiatrist endocrinologist registrar CNC dietitian exercise physiologist education project manager and administrative support Through our integrated clinical labora
24. a analysis of randomized controlled trials Eur Heart J 2009 30 718 730 34 Bray JW Cowell AJ Hinde JM A systematic review and meta analysis of health care utilization outcomes in alcohol screening and brief intervention trials Med Care 2011 49 287 294 35 Sim MG Wain T Khong E Influencing behaviour change in general practice Part 1 brief intervention and motivational interviewing Aust Fam Physician 2009 38 885 888 36 Brown Ag S A randomized controlled trial of a brief health promotion intervention in a population with serious mental illness Journal of Mental Health 2006 37 Prochaska JO Velicer WF The transtheoretical model of health behavior change Am J Health Promot 1997 Sep Oct 12 1 38 48 Accessed 2009 Mar 18 38 Chesla CA Do family interventions improve health J Fam Nurs 2010 16 355 377 39 Alvarez Jimenez M Hetrick SE Gonzalez Blanch C Gleeson JF McGorry PD Non pharmacological management of antipsychotic induced weight gain systematic review and meta analysis of randomised controlled trials Br J Psychiatry 2008 193 101 107 P 76 A Concord Centre for in Psychosis Cardiometabolic Health References 40 Faulkner G Biddle S Exercise as an adjunct treatment for schizophrenia A review of the literature Journal of Mental Health 1999 41 Acil AA Dogan S Dogan O The effects of physical exercises to mental state and quality of life in patients with schizophrenia Journa
25. a com ccC HiP Diabetes_Consensus html 25 Steinberg D Glass CK Witztum JL 2008 Evidence Mandating Earlier and More Aggressive Treatment of Hypercholesterolemia A 19 Circulation 118 672 677 Concord Centre for in Psychosis Cardiometabolic Health Figure 4 50 of type 2 diabetes patients have complications at the time of diagnosis MICROVASCULAR Retinopathy glaucoma or cataracts Nephropathy 4 j Neuropathy MACROVASCULAR P Cerebrovascular disease Coronary heart disease Peripheral vascular disease 26 Ref Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes UKPDS 33 UK Prospective Diabetes Study UKPDS Group Lancet 1998 352 837 853 RO Concord Centre for Cardiometabolic Health in Psychosis Cholesterol Profile Based on International Diabetes Federation IDF definition for metabolic syndrome 12 ccCHiP recommends metabolic review where TG21 7 or HDL lt 1 03 male or HDL lt 1 29 female The Pharmaceutical Benefits Scheme PBS will fund lipid lowering treatment for some high risk groups with total cholesterol 5 6 or LDL 2 5 See page 44 11 PRACTICE TIP Lipid profile should be Patients with any abnormalities in their cholesterol profile the full profile should be checked should receive a f
26. aist Circumf Blood Pressure FAO EST Triglycerides ccCHiP dataset May 2011 Concord Centre for Cardiometabolic Health in Psychosis Cardiometabolic Risk Factors CMRF s Serious mental illness is associated with increased cardiometabolic risks CMRFs leading to twice the risk of death from cardiovascular causes compared to the general population A diagnosis of schizophrenia or bipolar disorder is an independent cardiometabolic risk factor compounded by the use of medications which contribute to weight gain Ethnic risk eg Asian SE Asian Indian Subcontinent Middle Eastern lifestyle factors smoking sedentary lifestyle excessive caloric intake and family history CVD obesity diabetes and psychosis also contribute 13 Lipid blood glucose and blood pressure abnormalities often remain undetected among patients with mental illness and even when cardiac disorders are detected their care has been found to be unequal compared to the general population 14 A multitude of barriers including stigma health system clinician and patient factors all contribute to this inequity 5 Many of these risk factors are obtainable via history See pages 23 24 however a full risk assessment will also involve basic examination and blood tests as outlined below 13 Newcomer JW Hennekens CH Severe mental illness and risk of cardiovascular disease JAMA 2007 298 1794 1796 14 Hippisley C
27. al care of people with psychosis Med J Aust 190 4 171 172 Lambert T J 2 Hennekens C H 2007 The Journal of clinical psychiatry 68 Suppl 4 4 7 3 Hennekens C Hennekens A Hollar D amp Casey D 2005 Schizophrenia and increased risks of cardiovascular disease American heart journal 150 6 1115 21 4 Sernyak MJ Gulanski B Leslie DL Rosenheck R 2007 Undiagnosed hyperglycemia in clozapine treated patients with schizophrenia Journal of Clinical Psychiatry 2003 64 605 608 5 Lambert T J amp Newcomer J W 2009 Are the cardiometabolic complications of schizophrenia still neglected Barriers to care Med J Aust 190 4 Suppl S39 42 6 Meadows G Establishing a collaborative service model for primary mental health care MJA 2003 178 S53 S56 7 Lambert T Chapman L 2004 Consensus statement Diabetes psychotic disorders and Antipsychotic Therapy Accessed online 15 1 10 http www open4media com ccCHiP Diabetes_Consensus html 8 NSW Health Policy 2009 Physical healthcare within mental health service Accessed online 15 1 10 http www health nsw gov au policies pd 2009 pdf PD2009_027 pdf 9 National evidence based guideline for case detection and diagnosis of type 2 diabetes NHMRC Guidelines 2009 Accessed online 15 1 10 http www nhmrc gov au _file_publications synopses dil7 diabetes detection diagnosis pdf 10 Gaede P Vedel P Larsen N et al 2003 Multifactorial intervention and ca
28. an oral glucose tolerance test is recommended 24 7 This test involves drinking a concentrated sugary drink and checking blood sugar pre drink at one and two hours post ingestion The result will help to differentiated between diabetes insulin resistance or pre diabetes and a normal result A diagnosis of diabetes enables a patient to be linked in to diabetic services with access to greater medicare rebates for treatment see page 55 Diagnosis also allows for prevention and early management of complications which occur in 50 of people at diagnosis See figure 4 on page 20 In the future HBA1C may be an additional diagnostic tool however it is not approved currently PRACTICE TIP Full metabolic reviev J Z Ju i Jus A raised fasting blood glucose with a negative test indicates insulin resistance or pre diabetes and advice can then be given on lifestyle changes to slow the development of diabetes 24 7 g term intervention tors has been shown to halve scular event occurring 25 Level Il evidence 12 Alberti KG Zimmet P Shaw J The metabolic syndrome a new worldwide definition Lancet 2005 366 1059 1062 24 Therapeutic Guidelines Endocrinology 2009 Accessed online 15 1 10 http www tg org au index php sectionid 44 7 Lambert T Chapman L 2004 Consensus statement Diabetes psychotic disorders and Antipsychotic Therapy Accessed online 15 1 10 http www open4medi
29. bolic Health in Psychosis DB Treatment Monitoring Following metabolic health screening and treatment initiation there are multiple facets to monitoring that are important e Longitudinal monitoring of metabolic state e Monitoring of adherence e Monitoring of response to medication e Monitoring of complications feet eyes kidneys etc see Page 20 e Monitoring interaction of physical disease and psychiatric progress With screening comes a responsibility to consider monitoring and consider how it can best be implemented Mental health services will not necessarily take responsibility for the provision of ongoing care for all their patients PRACTICE TIP There are some patients though for whom ongoing monitoring should continue to be coordinated by their mental health team These include patients with no GP or who do not attend their GP reliably patients in long stay inpatient settings becoming less common and patients who are living in the community but are nevertheless very institutionalised eg in group homes or boarding house locations and who will benefit from careful ongoing shared care arrangements For the reasonably adherent patient who lives with family and reports good rapport with their GP communication with the GP to arrange regular screening and follow up may be sufficient On the other hand the patient with known poor adherence who lives i
30. cted from Medicare Benefits Schedule http www9 health gov au mbs search cfm Preparation of a GP Mental Health Treatment Plan item 2710 or 2702 Involves the assessment of a patient and preparation of a GP Mental Health Treatment Plan Once a GP Mental Health Treatment Plan has been completed and claimed on Medicare a patient is eligible for up to twelve Medicare rebatable allied mental health services per calendar year for services by e clinical psychologists providing psychological therapies or e appropriately trained GPs or allied mental health professionals providing focussed psychological strategy FPS services Patients can also be referred for FPS services under Access to Allied Psychological Services ATAPS available through Divisions of General Practice Services provided through ATAPS count towards the patient s entitlement of up to 12 services per calendar year Recommended frequency is one plan per patient with a new plan only being prepared when clinically required generally not within 12 months of a previous plan supported by continuing management through consultation and review services Review of a GP Mental Health Treatment Plan item 2712 Enables a review of the patient s progress against the goals in the GP Mental Health Treatment Plan The recommended frequency for the review service allowing for variation in patients needs is as follows e an initial review which should occur between
31. d 2010 provide detailed evidence based information about best practice management of raised blood pressure 19 PRACTICE TIP For those with diabetes cooper poai All patients with raised blood pressure should be advised about the importance of lifestyle modification including smoking cessation salt reduction weight loss and minimising alcohol intake d ices s the risk of adverse i as pared to placebo 20 Wevel evidence Those patients who are adherent to antihypertensive treatment are 38 less likely to have an adverse cardiovascular event than those who are non adherent 21 Level III 2 evidence 19 National Heart Foundation of Australia National Blood Pressure and Vascular Disease Advisory Committee Guide to management of hypertension 2008 Quick reference guide for health professionals Updated December 2010 Accessed 20 Staessen JA Wang J Lutgarde T 2001 Cardiovascular protection and blood pressure reduction a meta analysis The Lancet 358 9290 1305 1315 21 Mazzaglia G Ambrosioni E Alacqua M et al Adherence to antihypertensive medications and cardiovascular morbidity among newly diagnosed hypertensive patients Circulation 2009 120 1598 1605 in Psychosis l 17 A Concord Centre for Cardiometabolic Health Random Blood Glucose Random blood glucose was historically used as a screening test for diabetes however has a low yield compa
32. d be used to re weigh the patient at follow up BMI is calculated using the following formula BMI weight kg height m2 Measure blood pressure Measure after a period of rest It is essential that the size of the blood pressure cuff should be appropriate for the patient s size QP in Psychosis Concord Centre for Cardiometabolic Health Waist circumference It is important to lift the shirt as layers of clothing have variable thicknesses and the landmarks will not be obvious It is useful to remind the patient the reason we measure waist circumference is because abdominal fat is a predictor of metabolic risk When recording make sure the person is not tensing abdominal muscles and is standing relaxed Hold the tape measure loosely but closely around the abdomen Anatomical landmarks The first anatomical landmark is the lowest rib The second landmark is the anterior superior iliac spine Measure at the midpoint ax Blood glucose Capillary finger prick Explain the purpose of the test beforehand Also check when the patient last ate or drank including drinks Wipe the patient s finger with a swab cotton ball or plain tissue moistened with water Alcohol wipes may interfere with the reading as may the honey left over on the patient s fingers from breakfast Blood glucose testing strips will oxidise when exposed to air resulting in a false reading so contai
33. e psychiatric e Diabetes Treat total cholesterol gt 5 5 or setting and three month diet and exercise fai J LDL gt 2 5 or TG s gt 2 to below PBS treatment range the judiciou e Aboriginal Treat total cholesterol gt 6 5 e Comorbid Hypertension Treat total cholesterol gt 6 5 e Family history coronary heart disease Treat total cholesterol gt 6 5 LDL gt 5 e Family History of Hypercholesterolaemia DNA mutation or tendon xanthomas in first degree relative Treat total cholesterol gt 6 5 LDL gt 4 Concord Centre for Cardiometabolic Health in Psychosis 24 Therapeutic Guidelines Endocrinology 2009 Accessed online 15 1 10 http www tg org au index php sectionid 44 l 44 A Vitamin D supplementation We advise checking Vitamin D levels because a large Those at risk for osteoporosis proportion of the Australian population have been Please refer to the Australian Bone Guidelines for found to have low Vitamin D which can impact on mood and may be arisk factor for diabetes and cardiovascular disease 27 28 further information 27 PRACTICE TIP Particular groups for whom low Vitamin D is of additional concern If levels are lt Pregnant women associational studies hypothesise that neurodevelopmental disorders among offspring of mothers with Vitamin D deficiency may increase the risk of schiz
34. ee ee eect eeaeeeeeaeeeeeeaaeeenaaeeeeeeaeeeenaeeeeengaeetnnaeetnnaaeeennnes Ward a accetossesascancescateacenestee ieee sencactenceeas Treating Psychiatrist serstpsesassariaenscescessaiecssnnenneieabsananseecoanaaet GP Name asrcrr inorren innr e RA EE E EEE PRONE secarse nienia y a Address catatcn 5 sn aaan o a E T E A E E a Case Manager xcacccc ses citer deccevihacddsestzeieeiecsts Community Centre sees os edccccecehishdcuddvcctvanciadagesecdsthacdesswdase Interpreter required Yes No If Yes please schedule ccccececeneececeeeeeeeeeeeeeeeeeeeeeaeaeneas DIAGNOSIS Principle CraGnosis kisses tsa cokcares aan E ar EE Weave esau EE E a AEA EEE ERE EAE Year of onset sseeeeeee eee eee ees How many admissions to Hospital ccceeceeeeeeeee cece eens eeeeeeeenens DEMOGRAPHICS tick to indicate answer TR Referral Form INIC CI BINDING MARGIN NO WRITING STOCK NO XXX XXX NOV 10 REV 0 Education level Vocational level This a basic form full data can be entered using the full ccCHIP Dataform Ring 9767 8982 None Living with Primary Secondary Post Secondary eg TAFE Tertiary study commenced degree Tertiary degree Attending school college training Marital status Works full time Works part time Unemployed Sickness benefit Pension Retired Unknown CVD comprised of hypertension stroke angina or cardiac disease large vessel disease Alone Pa
35. eening and brief intervention trials Med Care 2011 49 287 294 35 Sim MG Wain T Khong E Influencing behaviour change in general practice Part 1 brief intervention and motivational interviewing Aust Fam Physician 2009 38 885 888 36 Brown Ag S A randomized controlled trial of a brief health promotion intervention in a population with serious mental illness Journal of Mental Health 2006 37 Prochaska JO Velicer WF The transtheoretical model of health behavior change Am J Health Promot 1997 Sep Oct 12 1 38 48 Accessed 2009 Mar 18 l g m A Concord Centre for Cardiometabolic Health in Psychosis Family Intervention There is robust evidence for family intervention in the prevention and management of childhood obesity of achieving better outcomes in eating disorders and in improving general mental health management 36 In mental illness specific trials investigating the impact of involving family members in lifestyle programs have not been conducted Extrapolating from the evidence engaging family members and carers in lifestyle treatments and medical management for patients with mental illness is likely to be of great benefit Benefits of involving family accountability and support can assist with practical concerns and enables an opportunity to health gains to be obtained as a family by making lifestyle changes together Suggested family interventions
36. ensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes UKPDS 33 UK Prospective Diabetes Study UKPDS Group Lancet 1998 352 837 853 27 Working Group of the Australian and New Zealand Bone and Mineral Society Endocrine Society of Australia and Osteoporosis Australia 2005 Vitamin D and adult bone health in Australia and New Zealand a position statement MJA 182 6 281 285 28 Mathieu C Gysemans C Giulietti A Bouillon R 2005 Vitamin D and diabetes Diabetologia 48 7 1247 57 29 McGrath J Hypothesis is low prenatal vitamin D a risk modifying factor for schizophrenia Schizophr Res Dec 21 1999 40 3 173 177 30 Casalino et al 2009 Frequency of failure to inform patients of clinically significant outpatient test results Intern Med 169 12 1123 29 31 Klein DJ Cottingham EM Sorter M Barton BA Morrison JA A randomized double blind placebo controlled trial of metformin treatment of weight gain associated with initiation of atypical antipsychotic therapy in children and adolescents Am J Psychiatry 2006 163 2072 2079 32 Wu RR Zhao JP Guo XF et al Metformin addition attenuates olanzapine induced weight gain in drug naive first episode schizophrenia patients a double blind placebo controlled study Am J Psychiatry 2008 165 352 358 33 Mottillo S Filion KB Belisle P et al Behavioural interventions for smoking cessation a met
37. er twelve months things had improved Staff across the hospital were familiar with the idea of the clinic but referrals were not systematically arranged or based on clear referral criteria Screening rates had increased to approximately 80 of patients with the assistance of the junior doctors working with the clinic and had bloods screened on admission From these 80 amounting to around 30 patients per week 5 6 of these new patients were routinely falling within the bounds of our referral criteria any metabolic abnormality on blood profile Please see pages 71 72 for ccCHiP referral and screening forms now used in our clinical practice PRACTICE TIP Accepting referrals for any patani e staff ar cone Concord Centre for Cardiometabolic Health 63 in Psychosis Recording Keeping CCCHIP have developed a flexible database system The ccCHiP database tool contains identifiable to record clinical information This database contains patient information and as such the above ethics the essential and minimum information required to requirements should be met in data storage so as to formulate a management plan tailored to the prevent breach of patient confidentiality individual s needs We have been unable as yet to arrange for the data entry of these important aspects of clinical history The liP clinical data form is built within and examination to be incorpora
38. esses and particular care 50 nmol L sufficient should be taken to ensure adequate Vit D levels in women of child bearing age 29 We advise checking Vitamin D levels because a large proportion of the Australian population have been PRACTICE TIP found to have low Vitamin D which can impact on mood and may be a risk factor for diabetes and cardiovascular disease 27 28 27 Working Group of the Australian and New Zealand Bone and Mineral Society Endocrine Society of Australia and Osteoporosis Australia 2005 Vitamin D and adult bone health in Australia and New Zealand a position statement MJA 182 6 281 285 28 Mathieu C Gysemans C Giulietti A Bouillon R 2005 Vitamin D and diabetes Diabetologia 48 7 1247 57 29 McGrath J Hypothesis is low prenatal vitamin D a risk modifying factor for schizophrenia Schizophr Res Dec 21 1999 40 3 173 177 l g 22 A Concord Centre for Cardiometabolic Health in Psychosis Clinic Routine Taking a metabolic history For an assessment of the patient s metabolic risk patient factors family history medications and lifestyle all need to be considered It would be appropriate for all members of the team to learn how to elicit the relevant history and perform the physical examination including essential parameters as follows A quiet comfortable waiting area is important so that patients are able to settle prior to being seen particularly
39. f homelessness etc Divisions of General Practice are given the flexibility to identify specific target groups within their catchment area to target their Tier 2 funds towards Better Access Medicare The Better Access initiative is available to all Australian residents and is monitored through the Medicare system GPs need to claim the relevant MBS item for completing a MHTP which will then allow their patient to access and receive rebates for services provided by appropriately qualified allied mental health professionals including general practitioners who have completed further training PRACTICE TIP Patients can access up to 12 ypc Niele g 12 group ace pease i Je In exceptional circumstances patients can receive up to 18 sessions in a calendar year Exceptional circumstances apply where there has been a significant change in the patient s clinical condition or care circumstances Patients cannot access both the ATAPS project and the Medicare initiative simultaneously nor can they utilise both funding streams consecutively to access more than 18 sessions in exceptional circumstance in a calendar year Concord Centre for l 4 in Psychosis Cardiometabolic Health Medicare Rebate System Mental Health Items Medicare rebates are available to patients when any of the following Mental Health Items are claimed by their general practitioner through Medicare Australia Extra
40. hare work with a local mental health team and shared care is promoted Tier 2 GPs will expect more extensive collaboration and closer liaison with case managers and teams Tier 3 GPs are the majority and deal with mental illness as a regular part of routine practice Minimum standards of communication concerning co management of patients is important This is a working model to facilitate appropriate communication in community care GPs self select into these models of working Our current work reflects this model of working collaboratively with GPs PRACTICE TIP e When developing liaison systems with GPs it helps to ask the GP to locate themselves on the pyramid e Tailor communication with the GP bas ongoing involvement and Concord Centre for in Psychosis Cardiometabolic Health Mental Health Referral Pathways Once GPs have completed a Mental Health Treatment Plan MHTP for their patient they then need to determine under which referral pathway they would like to initiate a referral PRACTICE TIP The two main pata avai for mentaj nea se Better Outcomes ATAPS The Access to Allied Psychological Services ATAPS project is a Commonwealth funded project managed by Divisions of General Practice across Australia The project provides psychological services to patients with a mild to moderate diagnosable mental disorder illness who are deemed socially and or financially di
41. idisciplinary care plan being prepared by another health or care provider or to a review of sucha plan Item 729 Contributing to a multidisciplinary care plan being prepared for a resident of an aged care facility or to a review of sucha plan Item 731 A Concord Centre for Cardiometabolic Health in Psychosis Resources Diabetic Service Networks Most hospitals in NSW have an endocrine diabetes Diabetes Australia clinic It is important to find out what the referral Diabetes Australia has a section designed for health pathways and criterion are for your local diabetes professionals linked here services Each hospital will be resourced slightly differently so its good to know what your patients can http www diabetesaustralia com au en For Health access Services could include Professionals e Facilities for regular diabetic screens e Foot and eye clinics Australian Diabetes Council e Access to allied health for one to one consultation Diabetes NSW is now known as the Australian Diabetes Council Their section for health professionals is linked here eg dietitian exercise physiologist PRACTICE TIP Fostering links with local diabetic acilitated http www australiandiabetescouncil com Health J regular correspond Professionals Resources for HPs aspx In addition they provide links to a range of guidelines http www australiandiabetescouncil c
42. important when measuring the blood pressure Students attending clinical placements are taught to conduct the history and examination under supervision The essential and minimal information required for each patient can be found in the ccCHiP form See page 771 Introductions developing rapport One staff member should introduce him or herself to the patient and explain the following points The patient will be having a physical health check necessary for all patients 2 It should be explained that patients who are in hospital with a mental health condition are at a higher risk than the general population for health problems such as heart disease and diabetes 3 The purpose of this visit is to detect and treat any problem early such as high blood pressure or high cholesterol Demographics A demographic history should be obtained Details include Age sex marital status living arrangements social employment status and level of education What diagnosis the patient has been told they have is also important Asking about education and prior work history helps with consideration of their longitudinal history as well as baseline functioning Concord Centre for Cardiometabolic Health in Psychosis l 4 23 A Listening and briefly acknowledging these aspects of history can let the patient Know you are considering the bigger picture of who they are and will also help with p
43. in a preventative role Gender Females are less adherent to statins Ethnicity Minority groups mainly African Americans and Hispanics studied Some evidence exists that concordance between the treating doctor or the language used in the consultation improves adherence Income Income rather than simply education is positively correlated with adherence Comorbid In this population non adherence is predicted by higher HBA1C younger page no history of diabetes smoking No CVD history at baseline no previous MI Side effects Muscular side effects in first 3 months of use Physicians With the caveat that only 60 70 of guideline identified patients are treated by their doctors the patient doctor relationship remains a solid predictor of adherence i e treatment or therapeutic alliance Costs Copayment magnitude is inversely related to adherence and or persistence 50 Mauskop A Borden WB Predictors of statin adherence Current cardiology reports 2011 13 553 558 E MI O N IUO r a Q Public Health Promotion R Detection Evaluation eS O O l S eC Treatment Initiation Treatment Monitoring GP with onsite MH support MH general interv for health GP with CMH liaison GP MH shared site MH site specific clinics Cardiometabolic education centres Specialist collaborative clinics e g CCCHiP Health outcome improvement monitoring Concord Centre for Cardiometa
44. inical process is available online on our website www ccchip com au This shows the trans disciplinary team in action with a typical patient PRACTICE TIP In allocating staff for a potential new clinical servic suggest that aS a minimum the follow necessary Concord Centre for Cardiometabolic Health in Psychosis l 4 60 A Clinical Service Equipment Equipment required for clinical review needs to be Onsite equipment required at each clinic easily accessible and regularly checked to ensure location that all the components are operational e Scales e Height measure Mobile Clinic Kit e Disposable gloves e Portable bag or case e Tissues e Continuing care hospital and community clinical e Tap and sink notes e Alcohol handwash e Pens e Sharps bin e Script pads e Access to patient medical records computer e Pathology order forms based patient information systems e Blood pressure monitor and three cuff sizes e Blood glucose monitor e Spare batteries for blood glucose monitor PRACTICE TIP e Lancets for pinprick testing e Blood glucometer strips e Cotton buds e Bandaids e Alcohol handwash Concord Centre for Cardiometabolic Health in Psychosis l 61 A Establish Clinical Procedures PRACTICE TIP Clinic procedures will in time DU Ll As our staff are part of the Local Health Network pre existing OH amp S and staff polic
45. l of Psychiatric and Mental Health Nursing 2008 42 Poulin MJ Chaput JP Simard V et al Management of antipsychotic induced weight gain prospective naturalistic study of the effectiveness of a supervised exercise programme Aust N Z J Psychiatry 2007 41 980 989 43 Wu MK Wang CK Bai YM Huang CY Lee SD Outcomes of obese clozapine treated inpatients with schizophrenia placed on a six month diet and physical activity program Psychiatr Serv 2007 58 544 550 44 Pajonk FG Wobrock T Gruber O et al Hippocampal plasticity in response to exercise in schizophrenia Arch Gen Psychiatry 2010 67 133 143 45 Banham L Gilbody S Smoking cessation in severe mental illness what works Addiction 2010 105 1176 1189 46 Stapleton JA Commentary on Banham amp Gilbody 2010 The scandal of smoking and mental illness Addiction 2010 105 1190 1191 47 Oehl M Hummer M Fleischhacker WW 2000 Compliance with antipsychotic treatment Acta Psychiatrica Scandinavica Supplementum 102 83 86 48 Lambert T Selecting patients for long acting novel antipsychotic therapy Australas Psychiatry 2006 14 38 42 49 Sikka R Xia F Aubert RE Estimating medication persistency using administrative claims data Am J Manag Care 2005 11 449 457 50 Mauskop A Borden WB Predictors of statin adherence Current cardiology reports 2011 13 553 558 Concord Centre for Cardiometabolic Health in Psychosis P 77 A
46. n a group home and only sees his case manager for depot injections because this is required by his CTO conditions In this case really if the mental health team does not take primary responsibility for monitoring and follow up no one will Between these two polar examples lies a continuum of different sorts of patients managed with different degrees of shared care The appropriate model of monitoring must be tailored accordingly pa Concord Centre for Cardiometabolic Health in Psychosis Resources Public Health Promotion Detection Evaluation Treatment Initiation Treatment Monitoring Cardiometabolic education centres Specialist collaborative clinics e g CCCHiP Health outcome improvement monitoring Z Concord Centre for Cardiometabolic Health in Psychosis Resources Community Organisation Resources SPECIFIC EXERCISE OR LIFESTYLE PROGRAMS YMCA Brightside Program a specific lifestyle program for people in prodromal or remission stages of mental illness Informational brochure linked here http www ymcasydney org download file ymca brightside information apr 2010 pdf Local Gymnasium initiatives Contact your local gym to see if they offer any programs or discounts for mental health consumers Obesity Clinic Westmead and RPAH hospitals conduct specific clinics for patients with BMI gt 35 GP NETWORKS
47. nd treatment program The blue circles represent the different relationships that currently exist between primary health care providers and mental health services The orange diamonds are tertiary referral services who need to involved for more complex patients The green represents health promotion which is a crucial area currently largely implemented by consumer groups Our current recommendations for screening are in accord with Endocrinology Guidelines eTGA 2009 and NHMRC Guidelines for Management of Diabetes 2009 9 11 A more complete explanation of each of the components from screening through treatment monitoring is outlined in each section through this manual 7 Lambert T Chapman L 2004 Consensus statement Diabetes psychotic disorders and Antipsychotic Therapy Accessed online 15 1 10 http www open4media com ccCHiP Diabetes_Consensus html 8 NSW Health Policy 2009 Physical healthcare within mental health service Accessed online 15 1 10 http www health nsw gov au policies pd 2009 pdf PD2009_027 pdf 9 National evidence based guideline for case detection and diagnosis of type 2 diabetes NHMRC Guidelines 2009 Accessed online 15 1 10 http www nhmrc gov au _file_publications synopses di17 diabetes detection diagnosis pdf 10 Gaede P Vedel P Larsen N et al 2003 Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes New England Journal of Medicine 348 383 393
48. ners should be shut following removal of each strip It is also important to check the serial number on the strip container and compare this with the strip number shown on the blood glucose monitor After pricking the finger using a single use lancet these can be obtained from Diabetes Australia NSW dispose of the sharp in a sharps bin Explain the result to the patient Concord Centre for Cardiometabolic Health in Psychosis Detection GP with onsite MH support MH general interv for health GP with CMH liaison GP MH shared site MH site specific clinics Cardiometabolic education centres Specialist collaborative clinics e g CCCHiP Health outcome improvement monitoring A Concord Centre for Cardiometabolic Health in Psychosis Ethnicity Female mv ce e re S SE Asian Chinese ethnic Sth Americans Japanese Plus any 2 of gt 1 7 mmol L lt 1 03 M lt 1 29 F 130 systolic or 285 diastolic mm Hg a gt 5 6 mmol L if BMl 30 waist measure not needed or previous treatment for this condition T or has been previously diagnosed with condition 12 Extract from Alberti KG Zimmet P Shaw J The metabolic syndrome a new worldwide definition Lancet 2005 366 1059 1062 av BD Concord Centre for Cardiometabolic Health in Psychosis Screening
49. o increase activity We have the benefit of having an exercise physiologist from the endocrinology and diabetes unit who can review the patient Record keeping It is useful to allocate a staff member to write notes during the interview In our clinic One person usually writes in the patient s progress notes another completes the minimum dataset and a third person takes the history and examination Each clinic would need to adapt depending on the number of people attending the clinic Concord Centre for l 4 in Psychosis Cardiometabolic Health General Look out for general physical signs of nutrition skin hair state hydration Sunken eyes skin turgor foot care possible ulcers pressure sores peripheral pulses and obvious evidence of possible infections During the history taking ask the person whether they have been physically well otherwise A general question such as this will occasionally detect abnormalities such as incidental chest pain sleep disturbance or other important physical concern which can be fed back to the treating team for investigation PRACTICE TIP RD Clinic Routine The metabolic examination Measuring height Ensure the person standing straight and looking straight ahead Measuring weight Check that your scales and height measure are accurate Any digital scales can be used provided that these are calibrated The same scales shoul
50. om Health Professionals Guidelines aspx Concord Centre for Cardiometabolic Health in Psychosis l 4 56 A service within your Local 1 Ne ork an experience based Dro account of where to begin and where to go from there Setting up a Service A Concord Centre for Cardiometabolic Health in Psychosis Setting up a new service Develop a Plan Prior to Commencing a clinical service a feasibility study is essential This may mean setting a realistic starting point for example piloting a limited service prior to changing practice across the entire service In the ccCHiP setting a decision was made to commence with an inpatient service where the model of care was developed Once in place we extended the clinic to community settings ting we have found the practice milieu and have needed to revisit each of the The following areas will need to be considered Who will manage or co ordinate the project What services resources exist already and could be built upon or supported Who are the key sta Concord Centre for Cardiometabolic Health in Psychosis DB Coordinating the Project 1g up a Service may be your idea think out whether you realistically have the time Bnd resources to co ordinate the project yourself The effectiveness of our own service improved
51. ophrenia 29 reatment Ensure calcium is normal I D occasionally due to hyperparathyroidism Those who cover their skin for religious or other Required monitoring Repeat level in 1 2 months reasons Those with dark skin 27 Working Group of the Australian and New Zealand Bone and Mineral Society Endocrine Society of Australia and Osteoporosis Australia 2005 Vitamin D and adult bone health in Australia and New Zealand a position statement MJA 182 6 281 285 28 Mathieu C Gysemans C Giulietti A Bouillon R 2005 Vitamin D and diabetes Diabetologia 48 7 1247 57 29 McGrath J Hypothesis is low prenatal vitamin D a risk modifying factor for schizophrenia Schizophr Res Dec 21 1999 40 3 Fidel si 45 Concord Centre for Cardiometabolic Health in Psychosis Adherence Treatment It is important to assess adherence patterns for to those found we in schizophrenia and bipolar patients with both physical and or mental health disorder with a median point prevalence of about 50 conditions when considering formulation and to 60 See table X for correlates 33 treatment options Approximately 1 3 of patients are adherent 1 3 fluctuate in their adherence and 1 3 tend to be non adherent to most treatments 30 PRACTICE TIP Adherence management for thosc aii pe mental Uae Salle invol a ti Batment Bt CCCHIP s partner organi
52. or 6 monthly testing BSL LDL HDL Chol Trigs to be faxed to service GP foresees problems GP Agrees eg patient not a regular attendee v Mental Health Clinician to Mental Health Clinician to check every 6 months that arrange tests BSL LDL HDL blood tests have been received Chol Trigs locally in mental from GP health service y Mental Health Clinician to record results 6 monthly on ccCHiP monitoring Form or more frequently if clinically indicated CONTACT US Concord Centre for Cardiometabolic Health in Psychosis ccCHiP P 61 2 9767 6027 F 61 2 9012 0982 E admin ccchip com au W www ccchip com au Mental Health Clinician to liaise with ccCHiP team or GP for advice when needed P Concord Centre for Cardiometabolic Health l in Psychosis CMH Community Mental Health Team GP General Practitioner Consider family intervention Adherent to treatment Adherent to treatment GP amp CMH GP amp CMH shared care shared care opportunistic CMH ideally treatment co ordinates all frequent health communication of benefit GP amp CMH shared care GP or CMH GP amp CMH GP plays key shared care role in co CMH ideally ordinating co ordinates all health with health identify support from key clinician CMH GP plays key role in co heh ordinate care identify key Clininician could co 52 in Psychosis
53. ot all mental health clients readily access good treatment from GPs There are different sorts of GPs but also different sorts of liaison relationships between GPs and mental health care providers Many models have been developed to assist with shared care from correspondence and phone call contact to co location on the same site GP liaison should not be seen as uniform It is possible to delineate three tiers of communication reflecting GP involvement in health of mental health consumers Tier 1 GPs are experts in health problems of mental health consumers They run specific clinics or practices and receive referrals from other GPs and mental health workers They aid the development of guidelines and delineation of best practice in this area We have have identified five local GPs who act as consultants in development of resources 49 Resources General Practitioners Those Tier 1 GPs who express an interest in close involvement with mental health patients can be considered a useful resource to give advice about developing systems of liaison Concord Centre for in Psychosis Tier 1 Tier 2 Tier 3 Cardiometabolic Health Resources General Practitioners Tier 2 GPs have specialised interest in the mentally ill and have a practice characterised by higher than average case loads of mental health clients They have extra skills or training in psychiatric intervention They usually s
54. ovascular disease diabetes musculoskeletal conditions and stroke Mental illness is not currently recognised as a chronic medical illness so the following rebates only apply once diabetes or cardiovascular disease has been diagnosed People with chronic conditions and complex care needs are eligible for five services per patient per calendar year with allied health professionals items 10950 to 10970 This can include eligible Aboriginal health worker diabetes educator audiologist exercise physiologist dietitian mental health worker occupational therapist physiotherapist podiatrist chiropractor osteopath psychologist and speech pathologist All that is required to receive this rebate is a referral from a GP and a health care plan Service provided by eligible mental health worker Item 10956 Mental health services GP s can also receive rebates for the following items for patients with a chronic condition Preparing a management plan for a patient who has a chronic or terminal medical condition with or without multidisciplinary care needs Item 721 Coordinating the preparation of Team Care Arrangements for a patient who has a chronic or terminal medical condition and requires ongoing care from a multidisciplinary team of at least three health or care providers Item 723 Reviewing a GP Management Plan Item 732 Coordinating a Review of Team Care Arrangements Item 732 Contributing to a mult
55. ox J Parker C Coupland C Vinogradova Y Inequalities in the primary care of patients with coronary heart disease and serious mental health problems a cross sectional study Heart 2007 93 1256 1262 5 Lambert TJ Newcomer JW Are the cardiometabolic complications of schizophrenia still neglected Barriers to care Med J Aust 2009 190 S39 42 Concord Centre for 2B in Psychosis Cardiometabolic Health Levels of Evidence In assessing the quality of evidence available across the literature we have utilised the NHMRC Evidence Heirarchy or levels of evidence for Intervention diagnostic accuracy prognosis aetiology or screening intervention respectively Designations for Inter ventional research are summarised right For full explanation of levels of evidence refer to the following document NHMRC additional levels of evidence and grades for recommendations for developers of guidelines STAGE 2 CONSULTATION Early 2008 end June 2009 Accessed online October 2011 here http www nhmrc gov au _files_nhmrc file guidelines stage_2 consultation _levels_and_grades pdf Intervention A systematic review of Level Il studies A randomised controlled trial A pseudorandomised controlled trial i e alternate allocation or some other method A comparative study with concurrent controls e Non randomised experimental trial e Cohort study e Case control study e Interru
56. program may Treating teams order and review have bloods ordered by ccQHiP bloods for all community patients ccCHIP self generated referrals Direct team referrals to ccQHiP ccCHIP CNC sends referral list to Marrickville reception day prior clinic Patients are directed to ccCHiP review from reception Patient attends ccCHIP multidisciplinary clinic Direct advice A Verbal handover E e ls to treating team GP case manager notes to to patient treatng team where possible Patients considered high risk Patients considered medium low risk identified for ongoing followup by discharge plan formulated for ccCHIP community team to follow up Six monthly outpatient followup three monthly inpatient followup Concord Centre for Cardiometabolic Health in Psychosis ft 70 A Form ing Metabolic Screen BINDING MARGIN NO WRITING STOCK NO XXX XXX NOV 10 REV 0 Wii FAMILY NAME MRN GIVEN NAME MALE FEMALE NSW Health D O B FACILITY CONCORD HOSPITAL ADDRESS ccCHIP LOCATION WARD METABOLIC SCREENING FORM COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE Height 2d sinsel yawns tect a a E EEEE ENNIGIY sigiqucleveiisetsiteag LEA AEAEE EEE a ET Aia Does the patient have a family history of any of the following Please tick answer below Diabetes Yes No Unknown CVD Yes No Unknown Obesity
57. pted time series with a control group A comparative study without concurrent controls e Historical cohort study e Two or more single arm study e Interrupted time series without a parallel control group Case series with either post test or pre test post test outcomes A Concord Centre for in Psychosis Cardiometabolic Health Screening for Obesity Waist measurement weight or BMI Waist measurement waist hip ratio weight and BMI have all been used as proxy measures for cardiometabolic risk related to obesity Waist circumference is currently considered the single most accurate measure for central adiposity and is predictive of future risk for coronary heart disease 15 Waist Hip Ratio may be useful in some settings but in our experience to not add much clinically PRACTICE TIP Waist circumference While BMI can predict cardiovascular risk several large prospective cohort studies conducted among different cultural groups demonstrate that for non obese persons raised waist circumference indicative of central abdominal adiposity is associated with inflammatory mediators insulin resistance and diabetes stroke risk and death 15 17 and may be a better predictor 2rence is predictive of cular risk independent of BMI Level Il Evidence Thus if a single tool were to be selected to assess future cardiometabolic risk waist circumference even
58. rdiovascular disease in patients with type 2 diabetes New England Journal of Medicine 348 383 393 11 Therapeutic Guidelines Endocrinology 2009 Accessed online 15 1 10 http www tg org au index php sectionid 44 12 Alberti KG Zimmet P Shaw J The metabolic syndrome a new worldwide definition Lancet 2005 366 1059 1062 13 Newcomer JW Hennekens CH Severe mental illness and risk of cardiovascular disease JAMA 2007 298 1794 1796 14 Hippisley Cox J Parker C Coupland C Vinogradova Y Inequalities in the primary care of patients with coronary heart disease and serious mental health problems a cross sectional study Heart 2007 93 1256 1262 15 Reis JP Macera CA et al 2009 Comparison of overall obesity and body fat distribution in predicting risk of mortality Obesity 17 6 1232 9 16 Zhang X Shu XO et al 2009 General and abdominal adiposity and risk of stroke in Chinese women Stroke 40 4 1098 104 17 Lapice E Malone S et al 2009 Abdominal adiposity is associated with elevated C reactive protein independent of BMI in healthy non obese people Diabetes Care 32 9 1734 6 18 Extract from National Heart Foundation of Australia National Blood Pressure and Vascular Disease Advisory Committee Guide to management of hypertension 2008 Quick reference guide for health professionals Updated December 2010 Accessed online 14th July 2011 Weblink http www heartfoundation org au SiteCollectionDocuments HypertensionGuidelines2
59. red to a fasting test An evaluation of the utility of random blood glucose testing demonstrated that if tested close to the time of eating lt 1hour the test had a higher sensitivity and specificity than if it were conducted a long time after eating when false negatives were common 22 A useful screening test to supplement the fasting blood glucose is a fingerprick blood glucose test two hours post prandial after eating Two hours after consuming a glucose load of 75 100mg ideally as part of a glucose tolerance test random BSL above 11 1 may indicate diabetes and above 7 8 impaired glucose tolerance 22 Engelgau MM Thompson TJ et al 1995 Screening for diabetes mellitus in adults The utility of random capillary blood glucose measurements Diabetes Care 32 641 643 23 Sommanavar S Ganesan A et al 2009 Random capillary blood glucose cut points for diabetes and pre diabetes derived from community based opportunistic screening in India Diabetes Care 32 4 641 643 PRACTICE TIP Don t rely on random glucosa as an i Cardiometabolic Health Fasting Blood Glucose The Consensus Statement Diabetes psychotic disorders amp antipsychotic therapy 12 recommends that blood glucose should be screened in all patients with psychosis a minimum of twice yearly and also monthly for six months after changing medication 12 If a fasting blood glucose is 5 6 on two repeat tests
60. rents Partner Boarding house Other Never married Defacto Married Separated Divorced Widowed Signature 5 cede tasnenicass cqanensees nt oe sera cianseraaineactecuacaendncecandtaascazedeee NS hat decease enetesasineeeseceesseaeet Please return via fax 9767 8989 by 10am Monday prior to clinic JINITD DNOAVLAW dIHD99 OL 1Wadssdsy TVINL Example letter produced by database de identified patient identifying details changed or omitted P Concord Centre for Mental Health ae Sateen ith Hospital Road Concord 2139 Ati Health SA AOTNCTADOUC TIEA Tel 9767 6027 Fax 61 2 9012 0982 NSW Sydney OOo in Psychosis http www ccCHIP com au oe 4 eee een Psvchiatrist n c c GP Ph ax Case manager N A 6 07 2011 Dear Dr ne M o0 N We saw MM a 60 year old male at ccCHIP clinic on 5 07 2011 to review his metabolic health KEY DEMOGRAPHICS Diagnosis and Year of onset Depression BE Educational level Tertiary degree Vocational level Pension Living with Alone Marital status Divorced MEDICATIONS Psychotropics Risperidone 2 mg day Mirtazapine 15 mg day Duloxetine 60 mg day Medical Metformin Atorvastatin20 CARDIOMETABOLIC DATA Parameters Height 169 cm Weight 91 3 Kg BMI 32 Waist 112 cm BP 120 62 Trig 2 6 LDL C 4 HDL C 1 Cholesterol 6 2 VitD Fasting BSL 6 9 Random BSL 19 8 m 91 120 mins post prandial CARDIOMETABOLIC RISK FACTORS Family
61. roviding feedback at an appropriate level and adjusting jargon depending on their level of medical knowledge training general educational level Personal medical history family history A personal history of hyperlipidaemia hypertension diabetes or Obesity are relevant as well as past history of gestational diabetes or polycystic ovarian syndrome The ethnicity of the patient and of their parents can indicate potential genetic risk People from Middle Eastern South East Asian Indian Subcontinent African American or Aboriginal Australian ethnicity are at higher risk of metabolic disorders A history of smoking and alcohol consumption should also be obtained A family history of obesity cardiovascular disease diabetes hypertension hyperlipidaemia and mental illness should be obtained Medications A medication history should include any treatment for mental illness as well as physical illness Lifestyle dietary history Our dietitian takes the dietary part of the history and then provides simple advice including simple cheap healthy meal suggestions and menu planning This advice is tailored to any metabolic findings such as high cholesterol or diabetes Key aspects of dietary history particularly to consider are soft drink and fruit juice intake take away meal frequency Further intervention will be most likely be necessary and needs to be organised The amount of exercise should also be ascertained and advice provided t
62. s as possible It will thus be essential you record this More importantly though consider the following areas for evaluation cost efficiency Detection rates diabetes cholesterol problems and health improvements over time Concord Centre for Cardiometabolic Health in Psychosis 66 A ccCHiP Clinic Referral Pathways inpatient clinic On admission bloods including metabolic bloods ordered by admitting registrar All admission bloods are ee a reviewed by ccC HIP reating teams review bloods ccCHIP self generated referrals ccCHIP CNC sends referral list to nursing unit managers on all wards Ward nurses conduct risk assessment on the day of clinic prior to patient transfer to clinic Patient attends ccCHIP multidisciplinary clinic Advice in Verbal handover Typed follow up letter notes to CNC to ward to treating team Direct advice to patient P treating team nurses GP case manager Pat hich risk Ea o atients considered high risk Patients considered medium low risk identified for ongoing followup by discharge plan formulated for GP ccCHIP Six monthly outpatient followup three monthly inpatient followup Concord Centre for Cardiometabolic Health in Psychosis 29 68 ccCHiP Clinic Referral Pathways outpatient clinic Lipids HDL LDL Chol Trigs fasting BSL amp Vitamin D should be screened at least 6 monthly Clozapine exercise
63. sadvantaged While each Division of General Practice administers their ATAPS projects in a slightly different manner i e provide direct clinical services vs contract service to local providers the guidelines for treatment are the same across the board Each referral under the ATAPS project entitles a patient to receive up to 6 sessions with a suitably qualified allied mental health professional The patient must then return to their GP following the final session under the referral so the GP can determine whether a follow on referral is required Patients can receive up to 12 individual and 12 group therapy sessions per calendar year through the ATAPS project Divisions of General Practice across the country receive funding under a tiered system currently there are 2 tiers to the funding arrangements Tier 1 funding allows divisions to target psychological services within their population which supplement those services available through Medicare Concord Centre for l g in Psychosis Cardiometabolic Health Mental Health Referral Pathways Tier 2 funding is special purpose funding which supplements Tier 1 funding Tier 2 funding allows Divisions to provide additional innovative service delivery to particular groups which are not and cannot be met through traditional ATAPS service delivery approaches such as perinatal depression suicide and self harm prevention individuals at risk o
64. sation at Concord Centre for Mental Health the Centre for Relapse Prevention in Psychosis CERP have published a manual providing guidance to the assessment and management of adherence This manual is freely available to those On the whole prevalence rates of adherence to interested in developing skills in adherence treatment cardiovascular and metabolic medications are similar Another method of estimating adherence is the MPR medication possession ratio Those who accessed 80 or more of the prescribed dose are assessed as adherent when using this method 32 47 Oehl M Hummer M Fleischhacker WW 2000 Compliance with antipsychotic treatment Acta Psychiatrica Scandinavica Supplementum 102 83 86 48 Lambert T Selecting patients for long acting novel antipsychotic therapy Australas Psychiatry 2006 14 38 42 49 Sikka R Xia F Aubert RE Estimating medication persistency using administrative claims data Am J Manag Care 2005 11 449 457 50 Mauskop A Borden WB Predictors of statin adherence Current eel oe reports 2011 13 553 558 2 Concord Centre for Cardiometabolic Health in Psychosis Table 4 Predictors of adherence to statins in adults Factor Associations with adherence to statins Age An inverted U shape has been described with the most adherent group being those in the 50 to 65 age range For those above 65 adherence rates are low 40 but are lowest when they are used
65. sed services in the area with an interest in collaboration e g obesity clinics diabetes and metabolism clinics staff specialists in cardiology and endocrinology 59 The following steps were helpful in identifying available resources Meeting with managers locally Presenting at Concord Centre for in Psychosis Cardiometabolic Health Staffing the Service In addition to the three consultants who attend the two hour clinic weekly other ccCHiP staff include a psychiatry registrar 1 0 FTE and clinical nurse consultant CNC 1 0 FTE administrative support 0 2 FTE and dietetic support 0 2 FTE Other co opted staff include dietitian exercise physiologist and a junior medical officer on a sessional basis We also have ongoing support from area health dietetics endocrinology and pathology departments A two hour clinic generates a total 26 hours of patient related time per week spread between 8 clinicians These staffing levels enable all inpatients at Concord Centre for Mental Health across five wards to be screened on admission reviewed in clinic if metabolic abnormalities exist and for a treatment plan to be developed and communicated to care providers ccCHiP has developed a streamlined routine of clinical history taking and examination to screen and monitor cardiometabolic disorders A Flow chart of clinic pathways appears on pages 67 70 A video of the cl
66. sor Tim Lambert Director ccCHiP Concord Hospital Sydney Local Health Network Concord Centre for Cardiometabolic Health in Psychosis Background Patients with schizophrenia have twice the population risk of death from cardiovascular disease CVD 1 3 For various reasons diabetes and lipid abnormalities often go undetected in this group 4 Despite the barriers faced by mental health patients 5 screening detection and intervention are essential to prevent cardiovascular complications 4 Many patients with mental illness have no systematic general medical care and though setting up systematised shared care networks for patients is labour intensive expensive and difficult to coordinate it has been previously shown to have positive effects on patient care 6 NO Concord Centre for Cardiometabolic Health in Psychosis ccCHiP is a clinical and educational service set up to investigate methods for delivering an integrated health service This manual is a practical guide to replicating our metabolic service Firstly we outline a theoretical approach for screening detection management and follow up This is followed by a guide to the detailed practicalities of setting up such a service Lambert T J 2009 The medical care of people with psychosis Med J Aust 190 4 171 172 Lambert T J Hennekens C H 2007 The Journal of clinical psychiatry 68 Suppl 4 4 7 3
67. t and system factors will make standard best care very difficult to achieve Case example Sue is a 45 yo lady of Asian ethnicity with a diagnosis of schizoaffective disorder duration of illness gt 20 years and insulin dependent Type II Diabetes Mellitis She lives alone divorced DSP case managed at community mental health service locally She has a GP When unwell she self injects salt water and drinks salt water due to delusions about purification e HBAIC 14 7 random BSL 22 1 e Chol 7 2 TG 1 5 e BP 140 105 BMI 24 5 Oral hypoglycaemics have been unsuccessful at lowering sugars however adherence is a major issue Her 10 year risk of developing CVD is 27 average 10 year risk for her age and sex is 8 Carefully co ordinated treatment with multiple health professionals involved is essential While insulin is necessary for adequate blood glucose control previous injecting behaviour makes this difficult Without increased support for her with medication administration her outcome is likely to be poor This case highlights the type of patient often seen in our clinic Without considering all the elements involved a realistic plan of action cannot be formulated p Concord Centre for in Psychosis Cardiometabolic Health Algorithms for Clinical Pathways Formulating clinical pathways of care for patients with mental illness and metabolic disorders is complex Several fac
68. ted into the hospital Fil er Pro software This database system medical information system A system which is ccCHiP have developed will be available for use integrated to information systems at your site would by our partners To discuss this further please be ideal at this stage what we have been able to contact our team achieve locally is limited to a clinic list on CERNER All patients who have attended ccCHIiP are recorded The ethics requirements of your particular location in one list on the informations system those booked need to be reviewed with respect to the storage of in for the next clinic in another patient information In general e Identifiable hard and soft copy patient information The database system also generates a PDF letter must be kept only at clinical locations and stored in that in some locations can be uploaded to the a secure office electronic record e Utilising patient information in any but a clinical setting e g for clinical research requires specific ethics approval Concord Centre for Cardiometabolic Health in Psychosis P 64 A Clinical Handover A vital component of a specialised service such as CCCHIP is to ensure that the findings and recommen dations are speedily communicated with referrers and key staff involved in the patient s more global care GPs specialists case managers etc Initially the CCCHIP clinical handover comprised of direct documenta
69. tion in the patient file followed by a phone handover to the relevant clinician for patients with whom there were additional concerns PRACTICE TIP In 2010 ccCHiP changed its practice by sending a letter to all clinicians providing ongoing care This may include GP psychiatrist inpatient and or outpatient case manager registrar NGO case manager e g HASI team and other existing specialist care providers such as psychologist endocrinologist diabetes clinic or cardiologist In this way a summary of care provided is copied to all involved in care with recommendations included The letter writing is fully automated and is built in to the ccCHiP data tool This ensures that commun ications are very rapid as letters can be completed and sent on the day of the clinic A de identified example of the summary letter output by the ccCHiP data tool is included on Pages 73 74 Concord Centre for in Psychosis Cardiometabolic Health Evaluation should be built in from day one of your service Commencing Prospective evaluation is far easier than retrospectively considering it PRACTICE TIP Advantages of self evaluation include the foll improves your service Evaluating Your Service Our experience has taught us that currently in NSW the one thing you will be asked to prove is that you are getting numbers through your service that you are meeting the need of as many consumer
70. tors must be assessed and taken into account e Adherence pattern see Page 46 e Living arrangements e Current and required level of support from others including carers family and friends e Existing health care arrangements e Type of metabolic health problem Due to the interaction of these factors a one size fits all approach to clinical care is unlikely to be effective Considering all patients to be at risk and taking on the comprehensive metabolic management of all mental health patients is beyond the scope of current community and hospital mental health services PRACTICE TIP When formulating care BSS de 1 what is the k In this section we outline methods to streamline patients into the appropriate pathways for care with varying levels of responsibility by mental health services gt and What amp which help in delineating the nsibility me tal health services carry for nitoring This is determined by a combination of living arrangements existing health care provisions and pattern of adherence The numbers in the green circles eg the algorithm pages refer to further detail about management options delineated in the management section of this manual Concord Centre for in Psychosis l g 30 A Cardiometabolic Health Figure 5 Best Practice Flowchart Outpatient Has a GP l Mental Health Clinician to contact GP and ask f
71. tory ccCHiP aims to document the extent of cardiometabolic problems in people with mental illness and develop strategies to ensure sustained improvements in their health utilising the network of primary and specialist care systems ccCHiP Concord Centre for Cardiometabolic Health in Psychosis Concord Centre for Mental Health Concord Hospital Tel 61 2 9767 6027 Fax 61 2 9012 0982 For further information please email admin ccchip com au Concord Centre for in Psychosis Cardiometabolic Health Executive Summary Cardiometabolic risk screening is obligatory for those treated with psychotropic medications is cheap simple to master and easy to get started Treatment options to manage cardiometabolic risk factors CMRF s once detected are sub optimal for patients with severe mental illness SMI There are a range of simple interventions that can easily be implemented Moving beyond screening to integrated intervention models with routine follow up will be more challenging and systematic service changes will be necessary Unless our nation s health services take the steps to systematise tailored physical health care for those with severe mental illness the wide gap to equal health outcomes will not be changed This service manual aims to present the main factors for consideration when establishing sustainable metabolic interventions for patients with mental illness Profes
72. ull metabolic history and examination and advice on exercise weight reduction and dietary modifications 7 aggressive management targeting Multiple factors is warranted 25 Level Il evidence 12 Alberti et al The metabolic syndrome a new worldwide definition Lancet 2005 vol 366 9491 pp 1059 62 11 Therapeutic Guidelines Endocrinology 2009 Accessed online 15 1 10 http www tg org au index php sectionid 44 7 Lambert T Chapman L 2004 Consensus statement Diabetes psychotic disorders and Antipsychotic Therapy Accessed online 15 1 10 http www open4media com ccCHiP Diabetes_Consensus html 25 Steinberg D Glass CK Witztum JL 2008 Evidence Mandating Earlier and More Aggressive Treatment of Hypercholesterolemia Circulation 118 672 677 Concord Centre for y in Psychosis Cardiometabolic Health Vitamin D Levels Vitamin D deficiency is common in the Australian ae 25 OH Vit D titre Level of deficiency population testing is recommended for all Australians for optimal bone health and deficiencies can be 0 12 5 nmol L severe corrected with oral supplementation 27 there is some evidence that low Vitamin D is also associated with 12 5 25 nmol L moderate diabetes and is an independent risk factor for cardiovascular disease 28 Maternal gestational 25 50 nmol L mild Vitamin D deficiency has also been implicated in the aetiology of some mental illn
73. veloped for the purpose ccCHiP have developed a software application for calculating Framingham risks that can be provided on request 2 Concord Centre for in Psychosis Cardiometabolic Health Formulation Screening Detection Evaluation Treatment Initiation Treatment Monitoring GP with onsite MH support MH general interv for health GP with CMH liaison GP MH shared site MH site specific clinics Cardiometabolic education centres Specialist collaborative clinics e g CCCHiP Health outcome improvement monitoring Concord Centre for Cardiometabolic Health in Psychosis Formulation Formulation Formulation involves the bringing together of the data with the patient to develop a plan of action Accurate formulation requires an awareness of multiple factors e Health variables physical and historical e Psychiatric diagnosis and treatment e Lifestyle and behaviour activity diet e Adherence and risks of treatment When commencing a new clinical service clinicians level of knowledge and experience regarding metabolic disorders and their treatment will vary widely In our multidisciplinary integrated clinic we have developed a series of algorithmic tools to assist with formulation See pages 31 34 It is important not to oversimplify algorithms for formulation There are times when patien
74. y benefit from adherence treatments For patients who are overweight obese have increased weight circumference there is evidence that metformin may slow the progress of psychotropic related weight gain G1 Consider Metformin Not PBS subsidised Change of psychotropics is rarely recommended as stabilisation of psychiatric symptoms with appropriate doses of medication is pivotal to engagement with further treatment Consider switching to a less orexigenic medication Concord Centre for Cardiometabolic Health in Psychosis Specialist Referral Specialist referral is recommended in the following situations Diabetes with ketoacidosis or presence of peripheral complications see page 20 Poorly controlled diabetes indicated by HBA1C gt 8 0 For assistance with management of poorly controlled hypertension Alarmingly raised lipids eg very high triglycerides with pancreatitis Renal disease History indicating possible cardiovascular disease a b C d e chest pain palpitations unexplained fainting or falls dizziness chest or leg pain on exertion assistance in management of metabolic health where contraindications to simple agents exist eg statins or ACE inhibitors PRACTICE TIP e For complex cases it may be of benefit to di GP ang ning the Oa discus Concord Centre for Cardiometabolic Health in Psychosis P Ov A
75. y procedures are complied with Referral pathways bookings and reminders systems follow up procedures record keeping and clinical handover all needed to be adapted to fit the new service within the structure of existing procedures The following pages describe the procedures we have developed for our clinical services Concord Centre for Cardiometabolic Health in Psychosis Generating Referrals This may be an evolving process as it was for the CCCHIP clinical service When our clinic first started the service medical director asked the registrars in the hospital wards to take responsibility for screening all their patients for fasting blood glucose and cholesterol In the context of registrar education it was explained that these screening tests should now form part of the admission blood test work up and needed to be completed and checked for every patient Despite this top down directive few people were screened and no referrals came through to the clinic at all The next approach was a little more hands on The CCMH medical director spent half of each Monday scouting for referrals by asking nursing staff on each ward whether they were worried about any of the patients At the time approximately ten percent of patients were being screened for metabolic disorders on admission and most were discharged having received only a cursory physical examination in some cases none Aft

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