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Optimizing Health in Individuals with Schizophrenia

Optimizing Health in Individuals with Schizophrenia. Jedidiah Perdue, MD, MPH Assistant Chief, Mental Health Oklahoma City VA Medical Center. Goals.

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Optimizing Health in Individuals with Schizophrenia

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  1. Optimizing Health in Individuals with Schizophrenia Jedidiah Perdue, MD, MPH Assistant Chief, Mental Health Oklahoma City VA Medical Center

  2. Goals • Identify factors that place an individual with schizophrenia at increased risk of early mortality, cardiovascular disease, diabetes, and other chronic medical illnesses. • Gain skills in assessing suicide risk among individuals with schizophrenia. • Identify strategies for improved communication, enhanced access, and targeted risk factor intervention in caring for individuals with schizophrenia.

  3. Psychosis Medical Psychiatric Delirium Major Depressive d/o Structural Psychotic Bipolar d/o Symptoms Neurologic Substance Medications Schizophrenia Metabolic Schizoaffective Personality d/o

  4. Schizophrenia Cognitive Sxs Negative Sxs Positive Sxs Disorganization Affective Sxs

  5. Symptom Domains Positive • Hallucinations: • Perception in absence of sensory stimulus • Auditory most common • Delusions: • Fixed, false belief, firmly held, not culturally shared • Ex: Paranoia, persecution, referential, thought broadcasting, thought insertion, somatic, religious, grandiose… DSM-Vtm, Am Psychiatric Assc 2013

  6. Negative Symptom Domains • Diminished Emotional Expression • Avolition • Alogia • Anhedonia • Social withdrawal DSM-Vtm, Am Psychiatric Assc 2013

  7. Cognitive Symptom Domains • Executive dysfunction • Attentional impairments • Memory • Abstraction

  8. Symptom Domains • Speech • Behavior Disorganization

  9. Symptom Domains • Depression • Manic symptoms Affective

  10. there is a high degree of heterogeneity among individuals with schizophrenia • the distribution of symptoms across domains varies Cognitive Cognitive Negative Negative Positive Positive Disorg Affective Disorg Affective Cognitive Positive Negative Negative Positive Cognitive Disorg Affective Disorg Affective

  11. Epidemiology • Prevalence – 0.7% • Accounts for 50% of inpatient admissions • Average age of onset M – 21, F – 27 • High concordance rate in twin studies (monozygotic -50%, dizygotic 15%) • Other RF: • Perinatal complications • Migrants in low ethnic density areas • Cannabis use • Advanced paternal age vanOs & Kapur Lancet 2009

  12. Pathophysiology • Conceptualized as a neurodevelopmental disorder • Structural findings • alterations present even at time of first episode • Neurochemical • altered dopamine concentrations • Functional Imaging • alterations in prefrontal areas, also increased activity in sensory association areas with hallucinations • disruptions in prefrontal-thalamic activity

  13. Treatment • Recovery-oriented treatment goals • Medication goals: treat acute exacerbation of psychosis & reduce frequency and severity of relapse • SGA vs FGA • Oral vs. LAI • Psychosocial Interventions • Assertive Community Treatment, Illness Management and Recovery, Family psychoeducation, Supportive Housing, Supportive Employment

  14. Schizophrenia - Health • Research has shown that individuals with severe mental illness have a life expectancy 15-25 years shorter than the general population1 • Standardized mortality ratio in schizophrenia is 2.5 2 • Over 60% of premature deaths in schizophrenia are related to medical conditions4 1. Parks et al 2006 2. Saha et. al ArchGenPsy 2007 3. Brown et al Br J Psy 1997 4. Kilbourne et al Psych Services 2009

  15. Common Medical Conditions in SMIMaine medicaid data: Source: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council 2006

  16. Schizophrenia – M/M • Cardiovascular Disease: • Accounts for 50-60% of excess mortality • risk of coronary heart disease is 2 – 3.5 times higher in schizophrenia than general population • Risk of stroke is 1.5 to 3 times higher • Risk factors account for much of increased incidence • Obesity, smoking, HTN, DM, dyslipidemia • Met-S highly prevalent in schizophrenia • Mortality is higher than general population • Lower rates of revascularization, anticoagulation • Higher rates of post-MI mortality Viron Psychosomatics 2010;DeHert World Psy 2011; Larsen Arch Gen Psy 2009; Kisely Can J Psy 2008; Lawrence 2001

  17. Schizophrenia – M/M • Diabetes • Prevalence of DM II is 2-3 times higher in patients with schizophrenia than general population • Increase risk factors including obesity • Antipsychotic medication, illness-related factors also convey increased risk • Screening rates are lower than general population, those with DM less likely to have HbA1C checked, have annual eye exams DeHert World Psy 2011; Larsen Arch Gen Psy 2009; Kisely Can J Psy 2008; Lawrence 2001

  18. Disparities in Care: Impact of Mental Illness on Diabetes Management 313,586 Veteran Health Affairs patients with diabetes 76,799 (25%) have mental health conditions Frayne et al Arch Intern Med. 2005

  19. Schizophrenia – M/M • COPD • Higher prevalence than matched controls in general population • Infectious diseases: • HIV: rates 8 times general population (prev 2.9%) • Hepatitis B: 5 x increase (prev 23%) • Hepatitis C: 11 x increase (prev 19%) DeHert World Psy 2011; Rosenberg Am J Public Health 2001

  20. Factors in Excess M / M • Individual level: • lifestyle factors • increased health risk factors • medication side-effects • effects of mental illness • resource challenges • System/ Provider level: • diffusion of responsibility / fragmentation of care, poor integration, funding • time, resource constraints, bias, coordination of care DeHert et al. World Psychiatry 2011

  21. Smoking • A major preventable cause of morbidity & mortality in schizophrenia • Rates 58-90%1 • More likely to be heavy smokers (>1.5 ppd)2 • Withdraw more nicotine from each cigarette3 1. Goff et al. J ClinPsy 2005; 2. deLeon et al. Am J Psy 1995; 3. Olincy et al. BiolPsy 1997

  22. Smoking • For some, an effort to self-treat • Negative symptoms1 • Cognitive symptoms2 • Nicotine increases prefrontal dopamine, enhances Glutamatergic and GABA function • Also related to social factors3: • Low educational attainment • Unemployment • Peers 1. Patkar et al. J NervMent Dis 2002; 2. Adler et al. Schiz Bull 1998; 3. Kelly ___ 2012

  23. Smoking Cessation • Most effective interventions combine behavioral and pharmacologic therapy • Systematic review of cessation strategies showed an overall lower response rate than the general population • Zyban/Wellbutrin (Bupropion) showed consistent benefit (NNT-7 @endpoint, 15 @ 6mos), with no evidence of exacerbating psychiatric symptoms • Chantix (Varenicline) had higher initial cessation rates than bupropion (NNT-6), with limited longer term data but did have a few reports of increased suicidal ideation and behavior Tsoi et al. Cochrane Collaboration 2013; Yousefi et al. J Addict Res Ther 2011

  24. Smoking Cessation • Stage: • Pre-contemplative vs contemplative vs action • Approach: • Motivational interviewing for pre-contemplative, contemplative • When ready, set quit date within 2 wks • Provide behavioral and pharmacologic support • Follow-up 3-7 days after the quit date • *** Repeat as necessary ***

  25. Obesity / Sedentary lifestyle • People with Schizophrenia have approx 3x the likelihood of being obese • Prevalence ranges 42- 60% • Factors include: • Social • Neuropsychiatric symptoms • Antipsychotic medications

  26. Antipsychotic Medication

  27. Antipsychotic Monitoring • Weight / BMI : baseline, every visit for first 6 mos, and q 6 mos thereafter • Fasting Glu or Hemoglobin A1C: baseline, at 3 mos, and then annually • Fasting lipid panel: baseline, 3 mos, then yearly • BP: baseline, 3 mos and yearly • Those demonstrating significant changes (ie wt gain >5% baseline) may need more frequent monitoring Viron et al. Am J Med 2012

  28. Obesity • Behavioral / Educational Approaches • Most common interventions include: • Nutrition counseling • Exercise programs • Cognitive-behavioral interventions • Combinations of above • Studies that incorporate motivational counseling are more successful and help overcome high drop-out rates • Elements include: • self-monitoring, stimulus control, slowing down, behavioral reinforcement, nutrition education, modification of physical activity, social support, cognitive restructuring, and problem solving Das et al. Ann ClinPsy 2012

  29. Obesity • Pharmacologic approaches1: • In general, effects less robust than behavioral interventions • Strategies include: • Changing antipsychotic (ziprasidone/aripiprazole/perphenazine) • Metformin • Topiramate • Limited data on amantadine, bupropion • No positive effect with nizatidine, rosiglitazone, fluoxetine; and mostly negative results with sibutramine, orlistat Das et al. Ann ClinPsy 2012; 2. Jarskog et al. Am J Psychiatry 2013

  30. Illness Management • Education and support is an important approach in managing the effects of chronic medical illness • The Chronic Disease Self-Management Program (CDSMP) has been adapted to target individuals with severe mental illness • Druss et al 2010: The Health and Recovery Peer Program (HARP) • Simplified manual; self-management record added, each participant matched to a partner, added section connections between mind and body, importance of coordinating info between providers; modified sections on diet to include healthy eating on a budget • Participants showed greater activation, improved follow-up with PCP; positive trends towards improved HRQOL

  31. Substance Abuse / Violence • Substance use: • Approximately 50% lifetime prevalence among individuals with schizophrenia • Related to increased risk of relapse, hospitalizations, legal problems, violence, increased depressive sxs, lower QOL • Marijuana is associated with earlier onset of psychosis, increased risk of schizophrenia, and increased relapse rates • Cocaine is especially problematic related to symptom exacerbation • Violence • More likely to be victims of violent crime than perpetrators • Best predictors of violence include: • History of violence • Substance abuse / dependence (largely accounts for increased overall risk noted in schizophrenia)

  32. Suicide - Schizophrenia • 8.5 x higher risk than general population • Suicide completion rate: 4-13% • Lifelong risk but especially prominent early in disease • Risk factors unique to schizophrenia include young age, good insight, increased positive symptoms and low negative symptoms Hor and Taylor J Psychopharm 2010

  33. Suicide Risk • Warning signs • Hopelessness • Thoughts, threats or plans to harm self • Increased focus on death • Anxiety • Agitation • Increased isolation • Insomnia • Rage • Risk Factors • History of attempt • Family hx of suicide • Psychiatric illness • Substance abuse / dep • Chronic medical illness • History of abuse • Access to firearms • Impulsivity • Recent Losses • Recent admission • Demo:M, C/NA, Single, living alone,>age 70 McDowell et al. Mayo ClinProc 2011

  34. Suicide Risk Assessment • Identifies risk factors or warning signs • Describes protective factors • Defines risk as: • Low: thoughts without plan, modifiable RF, strong protective factors • Medium: thoughts with plan, no intent or behavior, mult RF, few protective factors • High: suicidal actions, persistent thoughts with intent, steps toward plan, severe symptoms • Defines care setting to maintain safety

  35. Example: • SAFE-T is a tool from SAMHSA • Free, publicly available from website.

  36. Actions • Low risk – target any modifiable factors, assure appropriate follow-up or consultation, provide emergency or crisis numbers • Moderate – may need psychiatric admission; crisis plan developed • High – admission warranted; consider constant observation (1:1) and suicide precautions

  37. Health System Factors: Overcoming challenges • Communication – • collateral sources can be tremendously useful • know how to respond to delusional content • Adherence • May be significantly influenced by negative and cognitive sxs • would encourage use of appointment reminders, pill organizers, etc • Stigma • Person centered language Is very important • Engage in decisions as much as possible • Avoid diagnostic overshadowing • Collaboration

  38. Summary • Individuals with schizophrenia face significant physical health challenges involving increased morbidity and mortality • Elements that increase morbidity and mortality include smoking, obesity/sedentary lifestyle, substance misuse, and suicide • Risk factor modification is achievable and successful in this patient population

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