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Physical health and sever mental illness
Physical health and sever mental
illness
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Prepared by:
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Mr. Mutasem naser Allah.
Mr. Ahmmed Abo Rahma.
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Supervised by:
Dr. Abed Alkareem Radwan
Topic content
 Introduction
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Common physical health problem with SMI
Reason why people with SMI many experience
physical health problem
Health behavior of people with SMI .
Treatment related factor that affect the physical
health of people with SMI .
Nursing intervention .
The link between mental illness and physical health
People with serious mental illness have higher morbidity
and mortality rates of chronic diseases than the general
population.
. People who have severe mental illness, like schizophrenia
, depression and mania are at increased risk for a range
of physical illnesses and conditions, including coronary
heart disease, diabetes and greater levels of obesity and
hypertension Thus, most if not all types of mental
disorder are associated with an increased rate of early
death.
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the prevalence of many physical diseases is higher in persons with
severe mental illness than in the general population .
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mortality due to physical diseases is higher in persons with severe
mental illness than in the general population.
, and the gap concerning mortality due to some diseases (like :ischemic heart disease) has been increasing in recent decades
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the access to physical health care of persons with severe mental
illness is reduced compared to the general population.
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the quality of physical health care received by persons with severe
mental illness is poorer than the general population.
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People with severe mental illness face a greater risk of
developing some physical health problems. For example,
people who have schizophrenia or bi-polar disorder have
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2-4 times greater risk of cardiovascular
disease
2-4 times greater risk of respiratory
disease
5 times greater risk of diabetes
issues
The issue of protection and promotion of physical health
in persons with severe mental illness is emerging as one
of great public health and ethical relevance worldwide.
If we are really concerned about the quality of life of
our patients with severe mental disorders and with the
protection of their civil rights, we cannot ignore that
physical health is a crucial dimension of quality of life
in these persons, and that the access to a physical health
care of the same quality as that available to the rest of
the population is a basic right of these persons as
human beings and as citizens.
policy
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The promotion of physical health care in people
with severe mental illness is today a key issue in
our field. If we do not regard it as a priority, we
will not be able to state convincingly that a
better quality of life and the protection of the
civil rights of our patients is really what we
strive toward.
policy
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People with different illnesses or disorders will
have different illness experiences, including;
the types of symptoms experienced .
 how daily life and ability to function 'normally' is
affected
 and what types of treatment may be effective.
policy
Education and training of mental health professionals and primary
care providers is one more essential step..
They should be educated about the importance of recognizing
physical illness in people with severe mental disorders.
They should be encouraged to familiarize themselves with the most
common reasons for under diagnosis or misdiagnosis of physical
illness in their patients
• * Another essential step is the development of an appropriate
integration between mental health and physical health care.
* There is some debate in the literature about who should
monitor physical health in people with severe mental illness.
What really matters, however, is that there is always somebody
who cares
every patient should have a professional who is identified as
responsible
for his/her physical health care.
* On the other hand, mental health services should be able to
provide at least a standard routine assessment of their patients,
to identify or suspect the presence of physical health problems.
Physical health-check
During the health-check, the GP or practice nurse will : Take blood pressure
 Take pulse rate
 Do a urine or blood test
 Measure weight
 Ask about smoking
 Ask about alcohol consumption
 Check date of last smear test
PHYSICAL ILLNESSES AND SURGERIES WITH
MAJOR PSYCHOLOGIC EFFECTS5
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AIDS/HIV•
PARKINSON’S DISEASE•
MULTIPLE SCLEROSIS•
STROKE (CVA)•
COPD, ASTHMA•
MASTECTOMY•
PROSTATECTOMY•
AMPUTATION•
ALZHEIMER’S DISEASE.
Causes ?
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Health behaviours – Smoking, diet, physical inactivity, alcohol &
substance misuse, sexual behaviour
Illness – Symptoms, poor spontaneous reporting of physical health
problems
Services not geared to meet peoples needs … - Lack of knowledge,
lack of training, attitudes, confidence, lack of integrated care
Adverse effects of medication – Extrapyramidal side effects, weight
gain, glucose intolerance & diabetes, cardiovascular effects, sexual
dysfunction, neuroleptic malignant syndrome
Environment – Poverty, poor housing, social exclusion
Difficulties recognising symptoms
Barriers to accessing primary care
Communication barriers
Inequalities in screening & treatment
Morbidity and Mortality Causes
While suicide and injury account for about 30-40%
of excess mortality, about 60% of premature
deaths in persons with schizophrenia are due to
“natural causes”
 Cardiovascular disease
 Diabetes
 Respiratory diseases (including pneumonia and flu)
 Infectious diseases (including HIV and Hep C
Premature Mortality
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Six major causes of death in U.S
and increased relative risk in SMI
 Cardiovascular Disease 3.4 X
 Cancer Maybe lower rates except lung
 Stroke 2x in age < 50
 Respiratory disease 5x
 Accidents higher
 Diabetes
What do people with SMI die from?
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Study by Bralet 150 people with schizophrenia over 8
years – 13 deaths
3 suicides
3 heart disease
2 cancers
2 respiratory diseases
1 car crash
1 homicide victim
1 infectious disease
Individual Risk Factors Associated
with Early Death
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Smoking
High blood pressure
High cholesterol
Diet and obesity
Inactivity
Diabetes
Accidents
Risks Health
Premature death
Diabetes type II
Cardiovascular Disease
Dyslipidemia
High blood Pressure
Osteoarthritis
Stroke
Sleep Apnea
Gall Bladder Disease
Asthma
Hirsutism /menstrual irregularities
Social isolation
Surgical complications
Depression
Factors Associated with Premature
Death
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Reduced Use/Inefficient Use of Medical Services
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Poverty
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Systemic Barriers to Ideal Health Care
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Healthcare systems and financing
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Psychotropic medications
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Individual health habits
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Smoking
Inactivity
Obesity/poor nutrition
Physical Activity: Benefits
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“The health benefits of physical activity are generally
independent of weight.”
Sedentary lifestyle is an independent risk for
cardiovascular death even in normal weight individuals.
Moderate intensity exercise without dietary
changes brings reduced incidence of metabolic
syndrome
Physical Activity: Benefits
Prevention of Wt Gain and to achieve weight loss
 Bone health in kids.
 Function in older adults.
 Increased cardiorespiratory fitness.
 Increased muscular strength.
 Decreased blood pressure.
 Decreased depressive symptoms.
 Improved sleep quality.
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Amounts of Exercise
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Inactive or sedentary <30 min/wk, <10min/qd
Health benefits accrue at 60 min/wk
Low level 90 min/wk. Even low levels lead to
dramatic decr in risk of premature death
For substantial health benefits 150 min cumulative
moderate intensity exercise a week.
Greater benefits accrue at higher levels
300 minutes for weight loss
Lifestyle Changes Work in those with
Mental Illness
Smoking Cessation
 Addiction Recovery
 Prevention and reversal of antipsychotic
induced weight gain
 Development of healthy eating and
exercise habits
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Special Considerations
Physical Activity SMI
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Inactive; start low, go slow.
Fear of heart attack with sensation of increase
HR.
Lack of familiarity with the sensation of muscle
soreness.
Traumatic bodily relationships.
Balance issues on moving treadmills medication
effects.
Cold temperatures.
Interventions:
Physical Activity
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Fitness equipment at every facility, esp aerobic (exercise
bikes, elliptical)
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Staffed for pts and open for staff use
Relationships with local health clubs for equip.
Access to fitness centers in the community
Education
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Links to obesity and cardiovascular illness and death
Benefits/Barriers
Types/Low cost options
Getting started; Medical Clearance
Posters
Healthy Changes Initiative
Choosing
 Healthy
 Activities
 Nutrition
 Getting
 Exercise
 Smoking Cessation
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Interventions:
Physical Activity
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Physical activity opportunities for each patient
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Structured group format
Milieu changes such as stairs to cafeteria, walking to appts on campus
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Encouragement of walking in all sites.
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Enhance and document physical activity opportunities in
vocational and residential settings
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Motivational interventions to eliminate culture of lethargy
•Sponsoring Events to promote Culture Change and Maintain
Focus .
Physical Activity Challenges, Workplace wellness opportunities
for employees .
NAMI Walk
Peer Counselors.
Peers with lived experience key component in change of culture;
Social network inspires group change.
Increase opportunities for shared wellness opportunities
Include consumers on area Health and Wellness task forces
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Overweight and Obesity
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Definitions:
Healthy Weight
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Body Mass Index (BMI) 18-24.9
Overweight;
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BMI 25-29.9
Obesity
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BMI 30-34.9
Extreme obesity
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BMI >35
Obesity and Mental Illness
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Epidemic in mentally ill
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Certain 2nd gen antipsychotics (SGA) can cause rapid wt
gain (7 -30% of body wt) from 1st sev. months of therapy
up to a yr or longer.
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Multiple studies show increased incidence of overwt. and obesity
in schizophrenia, esp women
Majority recognize the wt problem, want to/have tried to weigh
less
Significant wt increases coincided with clozapine introduction
Wt gain ranked as top “bad thing” about taking meds in UK
survey
Lifestyle modifications preferred approach
Common Elements of Weight
Reduction Programs
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Goal Setting of Realistic short-term goals
Strategies to increase physical activity and
decrease sedentary behavior
Nutritional focus teaching and demo of healthy
eating habits
Self-monitoring of nutritional intake and
physical
Interventions:
Client Education
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Client Education about Nutrition and Weight Management
Nutrition label reading
Macronutrient information (protein, carbs, fats, fiber)
Eating behaviors and physiology;
recognizing and responding to hunger, slow eating
Substitution of healthy foods for less healthy foods;
emphasis on addition of healthy foods rather than deprivation
Portion size
High calorie drinks
Goal setting; one change at a time.
Grocery shopping
Food preparation
Fast food, restaurant eating
Interventions: Milieu
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Vending machines and canteens
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Provision of healthy alternatives
Water
 Fresh fruit
 Low fat dairy products
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Substitute juice for water at med dispensing
Printed materials and posters at cafeteria
Inpatient take out food
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Emphasis on discretionary income, financial aspects
recommended
Engage staff; “biggest loser” contests
Regular Physical Activity
During physical activity, our brain produces
“endorphins”, or chemicals that provide relief
from high stress levels. The good news is that
high intensity activity is not required to
experience this relief.
Regular physical activity can also reduce
the symptoms of depression and anxiety.
Smoking
Cigarette smoking is the single most
preventable cause of morbidity and
premature death
Health Consequences of Smoking
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Cancers
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Lung
Laryngeal, pharyngeal, oral
cavity, esophagus
Pancreatic
Bladder and kidney
Cervical and endometrial
Gastric
Acute myeloid leukemia
Reduce fertility in women,
poor pregnancy outcomes,
low birth weight babies,
sudden infant death
syndrome
Cardiovascular diseases
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Sub clinical atherosclerosis
Coronary heart disease
Stroke
Abdominal aortic aneurysm
Respiratory diseases
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Acute respiratory illnesses, e.g.,
pneumonia
Chronic respiratory diseases,
e.g., COPD
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Cataract
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Periodontitis
Nicotine Dependence among
Seriously Mentally Ill (SMI)
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75% of SMI are tobacco dependent (22%
general population)
 85% in schizophrenia
60 - 95% of people with addiction disorders
smoke.
important
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Tobacco use for most smokers starts pediatric
years with the exception of schizophrenia which
has later onset of tobacco use often coincident
with psychiatric hospitalization.
Why Do People With Mental Illness Smoke
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There are many reasons why any individual smokes. On top of
the usual reasons people with mental illness may find other good
effects from smoking. Positive effects of smoking for people
with mental illness, include the following:
Nicotine increases alertness. This may enhance concentration,
thinking and learning. This may be a benefit to people with
schizophrenia whose illness or medication leads to cognitive
problems.
Nicotine can help relaxation, and it can also reduce negative
feelings such as anxiety, tension and anger. So smoking may help
people with mental illness deal with stressful situations.
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Nicotine may reduce positive symptoms, such as
hallucinations for a short period.
There is some evidence to suggest that smoking is
associated with reduced levels of antipsychotic induced
Parkinsonism.
Smoking can help to relieve boredom and provide a
framework for the day.
Smoking can improve social interaction, something that
may be of particular benefit to people with negative
symptoms
Outcomes
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Decrease number of smokers in every setting.
Increase the number of smokers advancing toward quitting as
measured by stage of change
Precontemplation
Contemplation
Preparation
Action Maintenance
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Increase the number of smokers who have been given advise to
quit.
Increase the number of patients who have smoking cessation
interventions addressed on the treatment plan.
LOCAL AGENCY / CLINICIAN
RECOMMENDATIONS
educate / share information to make healthy choices
regarding nutrition, tobacco use, exercise, implications of
psychotropic drugs
teach /support wellness self-management skills
teach /support decision making skills
motivational interviewing techniques
Implement a physical health Wellness approach that is
consistent with Recovery principles, including supports
for smoking cessation, good nutrition, physical activity
and healthy weight.
attend to cultural and language needs
ASSIST the quit attempt
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Provide assistance in developing a quit plan;
Help a patient to set a quit date;
Offer self-help material;
Explore potential barriers and difficulties
Review the need for pharmacotherapy.
Refer to a quitline and/or an active call back
programme
ARRANGE follow up
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Offer a follow up appointment within 7 days
Affirm success when you next see the patient
Reinforce successful quitting: positive feedback
helps sustain smoking cessation.
Don’t talk about ‘failure’, ‘relapse’ is very
common
Help the patient work out ‘what went wrong this
time’ and how they prevent a relapse next time.
Behavioral Interventions
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Motivate these smokers to stop and teach basic
cessation skills.
Protocols exist for patients seen in mental
hospital settings. These rely on prior knowledge
of smoker’s diagnosis, medication, history, and
training to monitor symptoms and adjust
medications.
Behavioral Interventions
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Protocols for smokers with history of mental
illness seeking tobacco dependence treatment
outside mental health facilities and clinics should
follow standard treatment guidelines
Need to adjust these protocols to account for
their special circumstances
Motivational tension
Offering treatment can
influence the choice
Enjoyment of smoking
Need for cigarette
Fear of failure
Concern about withdrawal
Perceived benefits
Worry about health
Dislike of financial cost
Guilt or shame
Disgust with smoking
Hope for success
Nicotine replacement
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Begin NRT on the quit date, (apply patches the night
before)
Use a dose that controls the withdrawal symptoms
NRT provides levels of nicotine well below smoking
Prescribe in blocks of two weeks
Arrange follow up to provide support
Use a full dose for 6 to 8 weeks then stop
or reduce the dose gradually over 4
weeks.
Barriers to Successful Cessation
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Provider inattention/pessimism
Co-dependency and mental illness
Mental health staff smoke
Historic attitudes about smoking in mental
health community
No coverage for cessation drugs
Improper use of the drugs
Ignorance of quitlines
Resistance to Cessation for
People with Mental Illnesses
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Many loved ones of persons with mental illness
resist helping them quit
They feel protective and want to focus on
quality, not quantity, of life
But diseases caused by smoking can severely
hamper quality as well as quantity of life
And second-hand smoke imperils loved ones
and workers
Nursing help pt to stop smoking
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Regard the person’s behaviour as their personal
choice
Let the patient decide how much of a problem
they have
Avoid argumentation and confrontation
• Encourage the patient to discuss the advantages
and disadvantages of making a quit attempt
ADVISE on coping strategies
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Recommend total abstinence - not even a single puff
Drinking alcohol is strongly associated with relapse
Inform friends and family and ask for support
Consider writing a ‘contract’ with a quit date
Removal of cigarettes from home, car and workplace;
Give practical advice about coping with Withdrawal
symptoms occur mostly during the first two weeks
Relapse after this time relates to cues or
distressing events.
Remind patients of the health benefits of quitting
Goals: Lower Risk for CVD
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Blood cholesterol
 10%  = 30%  in CHD (200-180)
High blood pressure (> 140 SBP or 90 DBP)
 4-6 mm Hg  = 16%  in CHD; 42%  in stroke
Cigarette smoking cessation
 50%-70%  in CHD
Maintenance of ideal body weight (BMI = 25)
 35%-55%  in CHD
Maintenance of active lifestyle (20-min walk daily)
 35%-55%  in CHD
”
aging is like climbing a moutain. you get out
of breath but you have a magnificint view"
(Ingmar Bergman)
. Diabetes and fasting blood glucose
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(WHO) defined diabetes as a fasting plasma glucose of more
(126 mg/d L)
In an asymptomatic individual, the diagnosis should be
confirmed with a second fasting measurement on another day.
The measurement of HbA1c may be used in the future for
diagnosing diabetes
In all forms of diabetes, inadequate control of glycamia will
result in complications of diabetes.
These complications include
diabetic neuropathy
diabetic retinopathy
diabetic kidney disease
increased risk of infection
Diabetes and fasting blood glucose
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Patients with type 2 diabetes are likely to require
additional pharmacological management, but
this should be no different from the general
population, for which guidelines are available
from the EASD and the American Diabetes
Association (ADA)
Healthy Changes Initiative
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The Healthy Changes Initiative is designed to address the individual’s
modifiable risk factors which result in chronic illness and early
death in individuals with psychiatric disabilities.
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Physical Inactivity
Overweight/Obesity
Smoking
“…the recovery paradigm of needed services has to include the
concept of health promotion in treatment planning and service
delivery to persons with SMI.” Hutchinson et al, 2006
Fasting blood glucose
Abnormal value
Impaired fasting glucose: between 6.1 and
7 mmol/l (110–125 mg/dl)
Diabetes: ≥ 7.0 mmol/l (126 mg/dl)
Estimated prevalence and relative
risk
Modifiable risk
factors
Obesity
Schizophrenia Bipolar disorder
45–55% RR: 1.5–2
21–49% RR: 1–2
Smoking
50–80% RR: 2–3
54–68% RR: 2–3
Diabetes
10–15% RR: 2
8–17% RR: 1.5–2
Hypertension
19–58% RR: 2–3
35–61% RR: 2–3
Management of adverse drug-related effects on
cardiovascular disease risk factors
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Choice of psychotropic medication should take account of
potential effects of different agents on CVD risk factors,
such as weight and glucose levels and lipid profiles,
especially in patients who are overweight or have diabetes
or are at high total CVD risk factors.
Clinical decision-making is always complex and has to
consider efficacy aspects as well. A dilemma may arise with
clozapine which is recommended by many guidelines as
the antipsychotic of choice for those with refractory
schizophrenia as clozapine is associated with the highest
risk of weight gain and related CVD risk factors.
interventions for management of
CVD risk factor
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Smokers should be encouraged to stop smoking all
forms of tobacco. Those who demonstrate a readiness
to quit can be referred to a smoking cessation service
which can offer behavioral counseling, nicotine
replacement therapy or other pharmacological
intervention.
Maintaining a healthy body weight and shape by healthy
eating and regular physical activity is the a key
component of lowering CVD risk and prompt action is
needed in patients who are overweight at initial
assessment or who show signs of early weight gain with
antipsychotic medication
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Patients should be advised to take 30 minutes of moderately
vigorous activity at least a brisk walk on most days of the week
Avoidance of hypoglycemia is best achieved by involving the
patient's family and cares in the education process about the risks
and consequences of hypoglycemia.
Patients should be encouraged to eat lean meat, fish and low fat
dairy products and to replace saturated fat with
monounsaturated and polyunsaturated fats from vegetable and
marine sources Those with mildly elevated cholesterol levels may
be able to reach target levels through diet alone
mangement Blood pressure
High blood pressure in severely mentally ill patients is
often missed. Target blood pressure levels of less than
140/90 mmHg are recommended.
 Lifestyle changes, such as stopping smoking,
 reducing salt intake,
 weight reduction
 and increased exercise,
 Pharmacological therapy
this may be sufficient to reduce mildly elevated blood
pressure
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What can be done?
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Treatment of Common Mental Illnesses with Cognitive
Behavioural therapy highly effective (8 sessions)
Psycho-social support to cancer patients decreased pain and
depression and in half of studies reduced progression
More daily “uplifts” increased bodies natural killer cells
(immunity)
Putting people in a positive mood leads to greater pain tolerance
Assigning people to hospital rooms with a pleasant view
decreased pain and reduced length of stay
Choosing health: exercise and SMI
41% low levels of exercise..
 70% male patients obese..
 86% female patients obese..
 Medication problems..
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– tardive dyskinesia, cardiac arrhythmias..
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Negative symptoms of schizophrenia – lack of
motivation…..
Choosing Health
Six key priorities - 1:
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Tackling health inequalities
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Reducing the number of people who smoke
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Tackling obesity
Choosing Health
Six key priorities
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Improving sexual health
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Improving mental health and well being
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Reducing harm and encouraging sensible drinking
Potential Obstacles
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Lack of motivation
Effects of medication
Lack of money
Boredom
Mental health culture
Attitudes and beliefs of health staff
Mind Your Heart Programme
Our aim is to improve the physical health of
mental health service users in Ceredigion by
 Engaging people in activities that reduce their
risks of illness
 Removing obstacles
 Raising awareness
Policy etc.
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Health services should adopt a holistic view of the
assessment and development of care plans for mental
health service users Recommendations for the physical
health care of people with SMI
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Guidelines for the treatment of schizophrenia in primary
and secondary care
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Closing the Gap