Download Diabetes management and Mental Health – CPD workshop

Diabetes Management and
Mental Health – CPD workshop
November 2016
Dr Moira Connolly
Dr Brian Kennon
Dr Andrew Gallagher
Dr Nazim Ghouri
(With acknowledgments; Dr Zoe Young and Dr Nicola Watt trainees
in psychiatry, Dr Robert Pearsal and Professor Danny Smith)
Outline of the session
• 1.30-2.00pm Introduction, Mental health & diabetes in GGC
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Moira Connolly
• 2.00–2.30pmDiabetes diagnosis, screening & in-patient care
Brian Kennon
• 2.30-3.00pm Update on new therapies for type 2 diabetes
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Andrew Gallagher
• 3.00-3.20pm Coffee break
• 3.20-4.20pm Challenges in managing diabetes in a psychiatric
setting
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Small group workshop
• 4.20-4.30pm Summary & next steps
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Brian Kennon/Moira Connolly
• 4.30pm
Close of meeting
Background
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Health inequality – morbidity and mortality
Impact of co-morbid diabetes
Policy response GG&C
National views
Expectations for psychiatry
How well are we doing?
Excluding suicide as cause of death
Langan Martin et al, BMC Psychiatry, 2014
Reduced life expectancy in mental
illness (CMO England report 2013 chapter 13)
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People with SMI have life
expectancies closer to
low/middle income countries
Substance abuse disorder,
schizophrenia and
schizoaffective disorder are
among the worst
Excess mortality may be worse
in countries without universal
healthcare
Non-help-seeking individuals
with depression have 1.5-2 fold
increase in mortality rates
Iatrogenic diabetes
Impact of co-morbid diabetes on
SMI
• A diagnosis of diabetes in people with serious mental illness is
associated with a 3.68-fold increase in mortality and a 1.49-fold
greater risk of serious harm from macrovascular complications of
diabetes.
• adjusted hazard ratios were 1.05 (95% CI 0.91-1.21) for
microvascular complications and 3.68 (95% CI 3.21-4.22) for allcause mortality in patients with diabetes and schizophrenia
compared with those patients with diabetes but not schizophrenia.
• People with schizophrenia have a 74% greater risk of requiring
referral to hospital for serious acute complications of diabetes,
particularly hypo- or hyperglycemia episodes and development of
diabetic ketoacidosis, compared with those without schizophrenia.
“People with schizophrenia are at greater risk for
developing an acute complication of DM. Understanding
this relationship will direct future studies assessing
barriers to care and implementation of individualized
approaches to care for this population”.
“Develop a process to identify individuals at risk of medication
adverse events”
‘Test use of screening tools which helps to identify individuals at risk of
medication adverse events e.g. co-morbidities, poly-pharmacy, high dose
antipsychotics, specific medications carrying high risk of
complications/side effects including lithium, clozapine, elderly, medication
use during pregnancy and breast feeding, medication use for physical
health problems e.g. diabetes, anticoagulants, etc’
Scottish patient safety programme Mental Health
http://www.scottishpatientsafetyprogramme.scot.nhs.uk/Media/Docs/
Mental%20Health/Medicines%20Management%20-%20v1.10.pdf
GG&C Physical Healthcare Policy
• Policy highlights it is as important to know where clinical
responsibility lies as it is to know what should be done.
• Mental Health Patients should have the same quality of
physical care as the general population.
• Assessment of mental and physical health and health
improvement/promotion should be embedded in the
provision of inpatient and outpatient mental health patient
care.
GG&C Physical Health Screen Guidance
A core health screen should include attention to the following;
•Lifestyle and behaviour advice
•Family History and Physical systems enquiry
•Usual population screening of relevance to age and sex
•Brief physical findings (psychiatric outpatients)
•Extended physical check (acute admissions, where clinical concerns arise)
•Medication side effects
•Relevant investigations
•Sexual health enquiry and Health Promotion+++
•All in-patients must have a full physical health examination within 24
hours of admission to hospital. If this is not completed the reason must
be fully documented and attempts to complete the examination must
continue throughout the period of hospitalisation. (Group working on
standardised documentation)
•Discharge summaries following inpatient stay should include a section
on physical health noting clinical findings, results of investigations,
ongoing needs, referrals made and any follow-up plans.
The Role of the Psychiatrist
Royal college view
• Psychiatrists should be aware of the extent of their own
responsibilities in physical healthcare, and those of other clinicians,
especially general practitioners.
• As doctors, psychiatrists have a responsibility to provide their patients
with good standards of practice and care (General Medical Council,
2001). Psychiatrists have a key role to play in improving the physical
health of their patients. In the document Good Psychiatric Practice
(Royal College of Psychiatrists, 2004), it is stated that psychiatrists
should:
– ‘ initiate investigations where necessary
– act on the outcome of investigations
– arrange specialist or medical treatments in collaboration with the general
practitioner (GP), by referral to specialists or generalist colleagues, or undertake
physical investigation and treatment with competencies’
Kingsfund - March 2016
• The NHS five year forward view makes the case for what has been
called ‘triple integration’ (Stevens 2015) – integration of health and
social care, primary and specialist care, and physical and mental
health care.
• Despite a policy commitment to reducing these inequalities,
monitoring of physical health among people with severe mental
illnesses remains inconsistent in both primary and secondary care.
• For example, only a minority are screened for cardiovascular disease
(Hardy et al 2013), and other tests such as cholesterol checks and
cervical smears are performed at lower rates than for the general
population (RSA Open Public Service Network 2015).
• Part of the problem historically has been a lack of clarity over whether
responsibility for providing primary health care to this group of people
lies principally with GPs, mental health teams, or both (Lawrence and
Kisely 2010)
………Are we now crystal clear?!
Kingsfund – March 2016
• Whereas liaison mental health services are becoming increasingly
common in acute hospitals, it is rarer to find physical health liaison
services in mental health inpatient facilities, despite significant levels
of need and undiagnosed physical illness.
• People using these facilities are significantly less likely than the
general population to be registered with a GP, and are more likely to
present late with physical symptoms (Lawrence and Kisely 2010).
• Mental health professionals working in these settings may lack the
confidence or skills required to identify medical conditions, and often
there is a culture of giving low priority to physical health (Kulkarni et al
2014).
• Evidence suggests that at present, more than a third of patients fail
to receive a physical examination within 24 hours of admission, in line
with recommended practice (Vanezis and Manns 2010).
Academy of Medical Royal
Colleges 2016
Responsibilities of a psychiatrist
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Identification of physical causes
Investigate for physical causes +/- refer
Obtain a medical history and functional
enquiry
Recognising onset of acute illness
Safe prescribing and recognition of side
effects of all meds
LTCs monitoring and treatment
In co-morbidity, recognise factors which may
affect patients’ physical health
Disease prevention and health promotion
Screening tools on admission (nutrition etc.)
Specific population needs (eg refugees)
Involve other specialists in the rehabilitation
of the patient’s physical health
AoMRC Improving clinical care - diabetes
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NICE guidance on preventing type 2 diabetes (NICE 2012) should be
followed
Pre-diabetic patients should be referred for an intensive structured lifestyle
programme (if ineffective consider metformin)
Clear communication of assessment/management plans between GPs and
MH teams
Share results of ‘National Diabetes Audit’
Educate staff on diagnosing and managing diabetes
Educate on using appropriate tools, tests and observations, recognising and
acting on those outside normal range
Staff must be able to identify diabetic emergencies and respond
appropriately to reduce long term risk
Provide opportunities for physical activity for both inpatients and community
patients
Use SMI registers to ensure regular monitoring
Integrate care between psychiatric services, dieticians and specialist
services
BAP – four things we can do…
• Lifestyle interventions (Level A/B/C)
• Antipsychotic switching (Level A/B)
• Adjunctive metformin for people on
antipsychotics (Level A/S)
• Adjunctive aripiprazole for people on clozapine
or olanzapine (Level B)
Tolerability problems outweigh advantages for; orlistat, topiramate. Lack of evidence
for; reboxetine, liraglutidide, bariatric surgery, amantadine, melatonin and
zonisamide. No benefit found for; Atomoxetine, dextroamphetamine, famotidine,
fluoxetine, fluvoxamine and nizatidine.
How big is the problem and how
well are we doing?
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One day audit of inpatients
Clozapine audit
CSO funded health informatics project
Local audits
A Health Informatics Approach To Improving LongTerm Physical Health Outcomes In Major Mental
Illness:
Using routine data linkage:
1.How complete is routine blood monitoring for
patients with bipolar disorder?
2.For patients with evidence of raised HbA1C
and/or lipid levels, what proportion are receiving
appropriate medication treatment?
No record of routine blood testing
within last 2 years:
%
No record of routine blood testing
within last 2 years:
• No differences by socioeconomic deprivation
status
• Younger patients were more likely to have no
record of blood monitoring than older patients
• Low rates of using HbA1c to diagnose and treat
diabetes
Proportion with clinically raised
levels:
%
Proportion with diabetes or raised
cholesterol who are on medication
treatment:
%
Audit
findings
• Diabetes >15% in clozapine patients in
GG&C
• 53% inpatients in psychiatric care
nationally have co-morbid physical health
condition
• Patients want more attention paid to their
side effects
• Nursing staff want to know more about
medication side effects
Conclusions
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It’s our business
Make every contact count
Training and CPD imperative
Service improvement initiatives
Collaboration with acute colleagues is
hugely important – over to the diabetes
MCN………….