Week 13 - Mental Illness - Part 2.pdf

WEEK 13: MENTAL ILLNESS – PART 2 EHR522: EXERCISE FOR METABOLIC AND MENTAL HEALTH CONDITIONS Subject Coordinator: Tim Miller [email protected] 02 6338 4442 THE IMPACT OF SEVERE MENTAL ILLNESS THE IMPACT OF SCHIZOPHRENIA  Life expectancy f...

WEEK 13: MENTAL ILLNESS – PART 2 EHR522: EXERCISE FOR METABOLIC AND MENTAL HEALTH CONDITIONS Subject Coordinator: Tim Miller [email protected] 02 6338 4442 THE IMPACT OF SEVERE MENTAL ILLNESS THE IMPACT OF SCHIZOPHRENIA  Life expectancy for those with Schizophrenia is reduced by 15 – 25 years when compared to the general population. This is largely the result of the common cardiometabolic sequelae  This reduction in life expectancy is increased to 25 – 30 years when drug or alcohol abuse / misuse is combined with a Schizophrenia diagnosis  In addition to reduced life expectancy, there is also a dramatic reduction in quality of life, resulting in significant non-fatal burden THE IMPACT OF SEVERE MENTAL ILLNESS  Strong social support networks are key correlates of mental health  Setting social engagement and community participation goals can be worthwhile endeavours THE IMPACT OF SEVERE MENTAL ILLNESS EXERCISE IN SCHIZOPHRENIA TREATMENT  Most people with Schizophrenia have reduced levels of physical activity and lower levels of aerobic fitness  Fatigue (made worse by antipsychotic medications)  Low motivation to exercise (linked to negative symptoms of the condition)  Lack of confidence  Anxiety and stress about exercising (particularly in public)  Lack of resources and encouragement from others  Comorbid physical conditions (obesity, CVD, T2DM, amongst others) EVIDENCE FOR EXERCISE IN SCHIZOPHRENIA EXERCISE IN SCHIZOPHRENIA TREATMENT  Whilst studies are limited, exercise can improve aerobic fitness and reduce cardiometabolic risk factors in those with Schizophrenia  Psychiatric symptoms have been shown to be significantly reduced with 90 minutes of moderate-to-vigorous aerobic exercise each week  Exercise appears to have a favourable impact on the positive, negative, cognitive and mood symptoms associated with Schizophrenia  Outcomes for patients with Schizophrenia appear to be improved in group settings and with greater supervision  The above findings are critical given that  Antipsychotics are typically effective at reducing positive symptoms, but have a limited effect on negative and cognitive symptoms  Approximately 30% of patients with Schizophrenia are refractory to antipsychotic medication EXERCISE IN SCHIZOPHRENIA TREATMENT  There is correlation between maximum aerobic capacity and global functioning (social, occupational and psychological domains) in people with Schizophrenia  The research has shown better outcomes for people with Schizophrenia when higher intensity aerobic exercise has been utilised, though dropout rates tend to increase with increasing intensity  You need to consider an individual’s comorbid conditions and unique situation when prescribing intensity  Consider the need for supervision  Social support (medical and allied health professionals, and family and friends) plays a significant role in the initiation and maintenance of an exercise program for people with Schizophrenia EXERCISE IN SCHIZOPHRENIA TREATMENT  Most research to date has been conducted using aerobic exercise. There are limited studies investigating resistance exercise, yoga and relaxation techniques  Yoga, despite being studied in a very limited number of trials (mostly in India), shows a similar benefit to people with Schizophrenia as aerobic exercise  Some research has shown that video games requiring physical movement, and physical activity that is paired with tablet-based neurofeedback can motivate patients with Schizophrenia, thereby reducing the attrition rate  Consider the use of wearable technology as a motivation tool EXERCISE IN SCHIZOPHRENIA TREATMENT  European Psychiatric Association (EPA) Guidelines on Physical Activity for Severe Mental Illness  Frequency of 2 – 3 times per week  Moderate-to-vigorous intensity  90 – 150 minutes per week EXERCISE IN SCHIZOPHRENIA TREATMENT  There are many possible neurobiological mechanistic explanations for the role of exercise in improving Schizophrenia symptoms, including  Neurogenesis (new neurons being formed in the brain)  Synaptogenesis (new synapses forming between neurons)  Increased cortical capillary blood supply  Increased production of neurotrophic factors  Insulin-like growth factor 1 (IGF1)  Brain-derived neurotrophic factor (BDNF)  Vascular endothelial growth factor (VEGF)  Increased activity and production of neurotransmitters  Serotonin  Norepinephrine  Dopamine EVIDENCE FOR EXERCISE IN PTSD EXERCISE IN PTSD TREATMENT  There is limited data on the effect of exercise on PTSD symptoms  Overall, exercise has been shown to have a positive impact on PTSD symptoms  There appears to be somewhat of a dose-response relationship though, based on the evidence available, this is difficult to make certain conclusions  Data is inconclusive with respect to the optimal exercise  Type  Dose  Duration  There are currently no guidelines on the implementation of exercise as a component of standard therapy in PTSD EXERCISE IN PTSD TREATMENT  Exercise has been shown to have a small-to-moderate effect size on PTSD symptoms in most meta-analyses to date  Exercise has also been shown to improve the secondary effects of PTSD, including  Depressive symptoms  Sleep disturbances  Substance use disorder  Quality of life  Most authors suggest that there is now sufficient evidence to begin including exercise as an adjunct treatment strategy in the management of PTSD GENERAL EXERCISE PROGRESSION AND REGRESSION PRINCIPLES FOR MENTAL ILLNESS GENERAL EXERCISE PROGRESSION AND REGRESSION PRINCIPLES FOR MENTAL ILLNESS  Practical recommendations include  Limit competition  Encourage self-selection  Concentrate on moderate intensity, at least initially  Focus on in-task feelings  Avoid overtraining  Consider individual differences GENERAL EXERCISE PROGRESSION AND REGRESSION PRINCIPLES FOR MENTAL ILLNESS HEALTHCARE SERVICES AND PROVIDERS HEALTHCARE SERVICES AND PROVIDERS  General Practitioners: Most people access services through their GP (13% of all GP encounters are for mental illness)  Depression is the most commonly managed illness in general practice (32% of all mental illness encounters)  GPs may make a diagnosis, prescribe medication and refer to other medical (Psychiatrist) and allied health practitioners (Psychologist, Dietitian, AEP, amongst others)  GPs can refer to allied health practitioners through the Medicare system (GPMP and TCA)  Medicare also funds Mental Health Care Plans (covers Psychologist services) HEALTHCARE SERVICES AND PROVIDERS  Community Mental Health Care Services:  These include various community and hospital-based outpatient services  They provide an array of services, including  Housing  Support groups  Access to other medical services HEALTHCARE SERVICES AND PROVIDERS  In-Patient Hospital Care:  People with mental illness may require acute hospitalisation if they present harm to themselves or others  Specialised psychiatric care can be provided in a psychiatric hospital or in a psychiatric unit within a hospital  Involuntary admissions account for 30% of mental illness-related admissions requiring specialised psychiatric care HEALTHCARE SERVICES AND PROVIDERS  Residential Care:  Provide specialised mental health care on an overnight basis in a domestic-like environment  Accessed by 0.01% of people with mental illness  Principle diagnosis was Schizophrenia (32%), MDD (12%) and Schizoaffective Disorder (10%)  Most common length of stay was two weeks or less (58%)  3% of episodes of care were for longer than 12 months OUTCOME MEASURES IN MENTAL ILLNESS OUTCOME MEASURES IN MENTAL ILLNESS  There are a range of questionnaires designed to characterise the severity of mental illness  Most questionnaires focus on depression  PHQ-9: 9-item depression scale of the Patient Health Questionnaire  Beck Depression Inventory (BDI): 21-question scale  Centre for Epidemiological Studies – Depression Scale (CES-D): 20-item scale that allows for the evaluation of feelings, behaviour and outlook from the previous week  Perhaps the most commonly used and widely applicable scale that you can use in clinical practice is the DASS-21 (also available as DASS-42) DASS-21 DASS-21 DASS-21 COMMUNICATION AND DE-ESCALATION SOCIAL STIGMA AND DISCRIMINATION  Whilst it has improved in recent years, society generally has a limited understanding of mental illness and how it may present in different people  Stigma and shame reduces the likelihood of people with mental illness seeking treatment  Different cultures also have different perspectives on mental illness. Some unhelpful yet common views include  People with mental illness need to take ownership for their condition  Mental illness is purely behavioural in nature  Mental illness diagnoses are only for young people  People with mental illness are often locked up in hospitals  People with mental illness are unpredictable and violent VIOLENCE AND MENTAL ILLNESS  The major determinants of violence are sociodemographic and socioeconomic factors  Young  Male  Low socioeconomic status  Substance abuse is also a major determinant of violence, and this holds true whether it occurs within the context of a concurrent mental illness or not  It’s more likely that people with a mental illness will be the victim of violence rather than the perpetrator of violence STIGMA AND BARRIERS TO DISCLOSURE  Fear of discrimination creates an environment where individuals feel hesitant to disclose any diagnosed mental illness  This may be due to concerns about potential negative consequences, such as loss of social standing, discrimination in employment, changes to relationships and so on  The fear of discrimination can lead to secrecy and avoidance of seeking appropriate care for a mental illness or other preventative health services POSITIVE INTERACTION AND COMMUNICATION  Build Relationships  Body language (non-verbal communication)  Treat people with respect  Show a genuine interest  Communicate Effectively  Focus on the person, not the condition  Emphasise strengths and abilities  Ask, don’t assume, and check for understanding  Include Families and Carers  Obtain consent  Actively involve all parties in treatment planning and decision-making  Involve all parties in treatment plan delivery POSITIVE INTERACTION AND COMMUNICATION COMMUNICATION AND DE-ESCALATION  Whilst rare, you need to be cognisant that the behaviour of people with mental illness can change rapidly and you need to be able to safely respond in all situations  You cannot control a person’s emotions, but you can take steps that may make a person feel more calm  Once the situation has been de-escalated, you can work with the consumer / patient to resolve their concerns COMMUNICATION AND DE-ESCALATION  Strategies to de-escalate a situation  L: Listen to the issue and hear the person’s concerns  O: Offer reflective comments to show you have heard their concerns  W: Wait until the person has expressed their frustration and explained their feelings  L: Look and maintain appropriate eye contact to connect with the person  I: Incline your head to show that you are actively listening and provide a non-threatening posture  N: Nod to confirm that you are listening and have understood  E: Express empathy and concern