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Co-morbidities: Diabetes/CVD and Mental Illness Workshop An evening of cross discipline discussion Thursday 22 May 5.30 - 8.00pm Sydney West Area Health Service Facilitated by: Prof Glen Maberly Director of The Global Health Institute Prof George Rubin Director of I-Health Mr Roy Laube Research Coordinatorr, Diversity Health Institute 30 Phillip Street Imagination will often carry us to worlds that never were. But without it we go nowhere. Carl Sagan Create innovative ways to more effectively deliver health care to patients with obesity, diabetes, cardiovascular disease and mental illness An evening of cross discipline facilitated discussion What to expect 5:30 – 6:00 Arrive meet, mingle and refresh 6:00 – 6:15 Recognizing the challenge – presented by our facilitators 6:15 – 6:45 Introductions and sharing our first thoughts in plenary 6:45 - 7:15 Generating some new ideas in small group discussion 7:15 – 7:45 Collecting our thoughts and developing a matrix of ideas for cross discipline approaches to patient care 7:45 – 8:00 Making plans and seeking people to led the next steps Why we are here: setting the stage Who we are: GHI and you? What’s the problem? Obesity, Cardiovascular Disease and Diabetes Mental Health Overlap in patients How can we improve the way we work? When do we start? Welcome GHI Council and Guests GOALS: Forge strategic alliances among existing entities to overcome important health problems and improve people’s health while reducing inequity. Reverse the trend of increasing obesity and associated increasing cardio vascular disease and diabetes Lower the impact of poor mental health on the health system and the community VISION: Stimulate large scale, cross-discipline and cross sector collaboration to create an environment where recognition and identity of the individual units in SWAHS and other affiliated organizations programs are preserved. Diabetes/CVD and Mental Illness Meeting of the Minds Health Services Managers Public Health Professionals Directors of Clinical Services Health Care Providers Educators & Community Supporters Our daily work See big picture – cross boundaries Diabetes Australia facts 2008 Diabetes is one of the leading chronic diseases affecting Australians… • An estimated 700,000 Australians - 3.6% of the population had diagnosed diabetes in 2004–05. • In addition, the most recent national data on this indicate one undiagnosed case for every one diagnosed case. • In 2005, nearly 3% of deaths in Australia were directly due to diabetes and it contributed to another 6% of deaths—nearly 12,000 deaths in total. Burden of disease and injury in Australia Cause DALYs % of Total Diabetes 143,831 5.5 Ischemic HD attributable to diabetes 54,442 2.1 Stroke attributable to Diabetes 20,245 0.8 Total Burden attributable to diabetes 218,518 8.3 Begg S, Vos T, Barker B, Stevenson C, Stanley L & Lopez A. The burden of disease and injury in Australia 2003 http://www.aihw.gov.au/publications/hwe/bodaiia03/bodaiia03-c01.pdf Mental Illness Australia facts The impact of mental illness within the Australian population has become increasingly apparent. The 1997 National Survey of Mental Health and Wellbeing by the Australian Bureau of Statistics found that 18% of adults in the community had a mental disorder in the twelve months prior to the survey. The Burden of Disease and Injury in Australia study indicated that mental disorders constitute the leading cause of disability burden in Australia, accounting for an estimated 24% of the total years lost due to disability. http://www.aihw.gov.au/mentalhealth/index.cfm Mental illness by age Data source: Epidemiology, Population Health and Strategic Direction, SWAHS Mental Disorder: SWAHS Hospital Separations Schizophrenia Disorders: SWAHS Hospital Separations Depressive Episodes: SWAHS Hospital Separations Neurotic, Stress-related Disorders: SWAHS Hospital Separations Population models Server Disease: High burden Type 1 Diabetes Type 2 Diabetes Gestational Diabetes Abnormal GTT Lipid Disease Obesity Other Lifestyle Risks Illicit drugs Substance abuse Alcohol abuse Schizophrenia Disorders Mood [affective] Disorders Neurotic, stress-related Disorders Adult Personality & Behavior Emotional Disorders Behavioral & emotional Disorders Cultural beliefs & practices Healthy: Preventable Risk Factors What is the overlap – Diabetes & Mental Health Overlap Ischemic heart disease, diabetes prevalence and mental illness The five leading specific causes of burden of disease and injury in men were: ischaemic heart disease (11.1%), Type 2 diabetes (5.2%), anxiety & depression (4.8%), lung cancer (4.0%) and stroke (3.9%). The five leading specific causes of burden in women were: anxiety & depression (10.0%), ischaemic heart disease (8.9%), stroke (5.1%), Type 2 diabetes (4.9%) and dementia (4.8%). Begg S, Vos T, Barker B, Stevenson C, Stanley L & Lopez A. The burden of disease and injury in Australia 2003 http://www.aihw.gov.au/publications/hwe/bodaiia03/bodaiia03-c01.pdf Diabetes prevalence and mental illness • Diabetes prevalence in patients with mental illness is 2 to 3 times greater than in the general population. • Some atypical antipsychotics have been shown to increase risk for new-onset diabetes. • Before prescribing an atypical antipsychotic, assess the patient's glucose tolerance. • The combination of diabetes and depression has the most negative impact on health among a dozen serious medical conditions. • People with mental illness die younger (25 years younger in US) • CVD is the biggest cause of premature death for people with mental illness, not suicide Mental Illness & Diabetes Incidence reported to be elevated compared to general population 'Schizophrenia and Diabetes 2003' Expert Consensus Meeting, Dublin, 3-4 October 2003: consensus summary. 2004. British Journal of Psychiatry Impaired learning for diet and control Dickinson et al, 2008. Psychosomatics US NIMH CATIE trials with 1460 enrolled patients: 45% had untreated diabetes, 89% had untreated hyperlipidemias and 62% had untreated hypertension. Bick, Knoesen, Castle. 2007. Australasian Psychiatry Good diabetes management can be achieved across the mental illness population [11 043 diabetes patients in UK]. Whyte et al. 2008 Psychosomatics What difficulties do overlap patients face? Stigma and discrimination Sickness label Low self-confidence and self reliance Difficulties with work, family and other social relations Low motivation to employ and maintaining needed lifestyle habits Lack of receptivity to education Poor compliance with medications, diet and exercise program Difficulty attaining a more ideal body weight Inappropriate self-management Side effects from medications exacerbating diseases Tobacco, drugs, alcohol and other substance abuse Study: disease-specific knowledge about diabetes in a sample of 201 psychiatric outpatients with a diagnosis of schizophrenia or major mood disorders, all of whom had type 2 diabetes. Findings: knowledge was associated with higher cognitive functioning, higher level of education, and recent receipt of diabetes education Findings: disease-specific diabetes knowledge predicted lower levels of perceived barriers to diabetes care Conclusion: Gaps in diabetes knowledge may be reduced by specialized interventions that take into account the cognitive deficits of persons with serious mental illness Diabetes Knowledge Among Persons With Serious Mental Illness and Type 2 Diabetes - Faith B. Dickerson, et al, Psychosomatics 46:418-424, October 2005 What is the overlap – Diabetes & Mental Health Psychological distress with diabetes • According to the 2004–05 NHS, 18% of people with diabetes had high or very high levels of psychological distress compared with 12% of people without diabetes, as measured by the Kesslar-10 scale • More females (22%) than males (15%) with diabetes had high or very high levels of psychological distress How can we design our health care systems to better manage this overlap? Challenges of dual responsibility management Mental Illness Teams Hospital admissions Specialty Clinics & Rooms GP Rooms Ancillary & Community Services Other Community facilities and socioeconomic support systems e.g. schools, media, sports, religious institutions, transport systems, food outlets, work, culture & lifestyle environments Chronic Disease Teams Shared Complex Case Management Diagnosis Disease Containment Monitoring Screening Lifestyle Adjustment Prevention Shared medical record & management Shared disease registers Screening tools & management algorithms New & old media Education systems cultural, social & religious influencers Mental Health Diabetes Cardiology GP Opening up horizontal channels of communication between units (silos) to share information and responsibility for management What’s in it for me? – Redefine the reward systems to favor shared care behavior by health professionals and patients Who’s responsible? - Define the ground rules for responsibility of all aspects of shared care But the system won’t let me - Design systems that supports shared information and more comprehensive management approaches How do we do this? - Clinical education (medical, nursing and ancillary) and workforce training to support integrated comprehensive services Will it work? – Build evaluation systems designed for continued feedback and improvement