Andrew Watkins

Evaluating an individualized lifestyle and life skills intervention to prevent antipsychotic‐induced weight gain in first‐episode psychosis

AIM Initiating antipsychotic medication frequently induces rapid, clinically significant weight gain. We aimed to evaluate the effectiveness of a lifestyle and life skills intervention, delivered within 4 weeks of antipsychotic medication initiation, in attenuating weight gain in youth aged 14-25 years with first-episode psychosis (FEP). METHODS We undertook a prospective, controlled study in two early psychosis community services. Intervention participants (n = 16) received a 12-week individualized intervention delivered by specialist clinical staff (nurse, dietician and exercise physiologist) and youth peer wellness coaches, in addition to standard care. A comparison group was recruited from a similar service and received standard care (n = 12). RESULTS The intervention group experienced significantly less weight gain at 12 weeks compared to standard care (1.8 kg, 95% CI -0.4 to 2.8 vs. 7.8 kg, 4.8-10.7, P < 0.001). Thirteen per cent (2/16) of the intervention group experienced clinically significant weight gain (greater than 7% of baseline weight), while 75% (9/12) of the standard care group experienced this level of weight gain. Similar positive effects of the intervention were observed for waist circumference. CONCLUSIONS A lifestyle and life skills intervention delivered as part of standard care attenuated antipsychotic-induced weight gain in young people with FEP. The intervention was acceptable to the young people referred to the service. Such interventions may prevent the seeding of future disease risk and in the long-term help reduce the life expectancy gap for people living with serious mental illness.

Metabolic abnormalities in an early psychosis service: a retrospective, naturalistic cross-sectional study

Aim: There is an increasing recognition of the impact of weight gain on the development of metabolic abnormalities in young people receiving atypical antipsychotic drugs for first‐episode psychosis. This study examined the prevalence of such abnormalities in a specialist early‐intervention community mental health team.

Aerobic exercise intervention in young people with schizophrenia spectrum disorders; improved fitness with no change in hippocampal volume

To the Editors There is growing interest in the role of exercise and concomitant improved aerobic exercise capacity as a stimulus for hippocampal neurogenesis (van Praag, 2009). Pajonk et al. reported hippocampal plasticity in response to a 12-week aerobic exercise intervention in patients with established schizophrenia (Pajonk et al., 2010). Participants completed three 30-min sessions of stationary cycling per week at a pre-specified intensity that led to relative hippocampal volume increases of 12% among the eight subjects included in the final analysis. In addition, positive correlations were observed between change in relative hippocampal volume, and change in aerobic exercise capacity (r1⁄40.71, p1⁄40.003). Given these promising findings, we conducted a pilot study in a group of young peoplewith schizophrenia spectrum disorders who were experiencing a first episode psychosis (FEP). The South Eastern Sydney Local Health District (Northern Division) Human Research Ethics Committee approved the experimental protocol, and written informed consent was obtained from all participants. Patients (aged 15–25 years) who met DSM-IV criteria for schizophrenia, schizoaffective disorder or schizophreniform disorder were recruited from a community-based early psychosis treatment program. The intervention consisted of 12 weeks of twice-weekly, 45min sessions on a stationary exercise bike at a heart rate (710 beats/ min) corresponding to 65% of VO2 peak as determined by baseline exercise testing. Baseline assessments included aerobic exercise capacity (VO2 peak, assessed via a 3-min ramp protocol on a cycle ergometer and direct gas analysis), cognitive testing (short-term memory assessed with the Rey Auditory-Verbal Learning Test (RAVLT) and the spatial span subtest of theWechsler Memory Scale-III (WMS)), symptom ratings (Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS)), and self-rated quality of life (WHOQOL-BREF). Three-dimensional structural magnetic resonance imaging was performed (1.5T Phillips Achieva),and hippocampal volumes were extracted using an automated segmentation routine based on the principles of the Active Shape and Appearance Models within a Bayesian framework, as implemented by “FIRST” in the FSL software package (Patenaude et al., 2011). Before segmentation, the skull was stripped from structural images and the brain tissue extracted. FIRST was then applied to separately estimate left and right hippocampal volumes. Baseline and follow-up data were available for five male patients (20.274.2 years), whose duration of illness was o3 years at baseline assessment. Mean VO2 peak as assessed via a maximal exercise test was well below average ( 10th percentile) for the given age group. At follow-up, no significant change in hippocampal volume was observed (mean increase 0.4%; baseline mean: 8664.8 mm (SD 837.7), follow-up mean: 8697.8 mm (SD 897.6), mean change 33.0 mm (95% CI 161.5 to 227.5), t1⁄40.5, df1⁄44, ns) despite a statistically and clinically significant 20.1% mean increase in VO2 peak (baseline mean: 31.8 ml/kg/min (SD 9.5), follow-up mean 38.2 ml/kg/ min (SD 12.6), mean change 6.4 ml/kg/min (95% CI 2.0–10.8), t1⁄44.0, df1⁄44, p1⁄40.02). No statistically significant change was observed in short-term verbal (RAVLT Delayed Recall; 17%, baseline mean: 10.4 (SD 3.4), follow-up mean 8.6 (SD 5.9), mean change 1.8 (95% CI 6.6 to 3.0), t1⁄4-1.1, df1⁄44, ns) or spatial (WMS Spatial Span; þ15%; baseline mean: 16.8 (SD 3.4), follow-up mean 19.4 (SD 2.4), mean change 2.6 (95% CI 1.1 to 6.3), t1⁄42.0, df1⁄44, ns) memory. No significant changes in symptom or quality of life ratings were observed (data not shown). The intervention was effective, as evidenced by all participants demonstrating an increase in aerobic exercise capacity (mean 6.4 ml/ kg/min, p1⁄40.02). Increases in exercise capacity of approximately half this magnitude (3.5 ml/kg/min) have been associated with a 13% decrease in risk of all-cause mortality (Kodama et al., 2009), highlighting the clinical significance of the V02 peak increase we observed. Despite this improvement in exercise capacity, there was no significant hippocampal volume increase in our sample. Whilst the sample size (n1⁄45) is a limitation of the current study, the original study of Pajonk et al. found a highly statistically significant increase in hippocampal volume in eight patients who completed the exercise intervention. The mean hippocampal volume increase they reported (12%) was 30 times greater than that found in the sample of FEP patients we examined (0.4%). For the modest increase in volume we observed to be statistically significant, a sample size more than 40 times greater would be needed (n1⁄4206, for an effect size of 0.21 with a paired correlation of 0.986, for α1⁄40.05 and power of 0.85). The absence of significant changes in hippocampal volume despite the significant increase in VO2 may reflect a number of methodological differences between our protocol and that of Pajonk et al. Firstly, patients examined in this study were substantially younger than those who participated in the Pajonk et al. study (mean age 20.2 vs. 32.9 years) and had a shorter duration of illness (o3 years vs. mean duration of illness1⁄48.4 years). This difference may have led to different baseline aerobic exercise capacity in the two samples. Secondly, we used an automated method of measuring hippocampal volume as opposed to manual tracing. The lack of change in hippocampal volumes observed in this study is consistent with the negative findings of Scheewe et al. (2013) in a group of patients with schizophrenia with established illness; however, their intervention (2 h/week of combined aerobic and resistance exercise) also failed to demonstrate a statistically significant change in VO2 peak, probably reflecting the relatively low number of patients who completed at least 50% attendance over the 6-month intervention period. Recruitment for the current study was terminated due to implementation of a comprehensive lifestyle intervention, including individualized exercise prescription comprising both aerobic and resistance-based elements, that is offered to all new referrals to the

A nutrition intervention is effective in improving dietary components linked to cardiometabolic risk in youth with first-episode psychosis.

Severe mental illness is characterised by a 20-year mortality gap due to cardiometabolic disease. Poor diet in those with severe mental illness is an important and modifiable risk factor. The present study aimed to (i) examine baseline nutritional intake in youth with first-episode psychosis (FEP), (ii) evaluate the feasibility and acceptability of nutritional intervention early in FEP and (iii) to evaluate the effectiveness of early dietary intervention on key nutritional end points. Participants were recruited over a 12-month period from a community-based programme specifically targeting young people aged 15-25 years with newly diagnosed FEP. Individual dietetic consultations and practical group sessions were offered as part of a broader lifestyle programme. Dietary assessments were conducted before and at the end of the 12-week intervention. Participants exceeded recommended energy and Na intakes at baseline. Retention within the nutrition intervention was 67 %, consistent with other interventions offered to FEP clients. There was a 47 % reduction in discretionary food intake (-94 g/d, P<0·001) and reductions in daily energy (-24 %, P<0·001) and Na (-26 %, P<0·001) intakes. Diet quality significantly improved, and the mean change was 3·6 (95 % CI 0·2, 6·9, P<0·05), although this finding was not significant after Bonferronis correction. Increased vegetable intake was the main factor contributing to improved diet quality. Nutrition intervention delivered shortly after initiation of antipsychotic medication is feasible, acceptable and effective in youth with FEP. Strategies to prevent weight gain and metabolic decline will contribute to prevent premature cardiometabolic disease in this vulnerable population.

Aerobic exercise capacity: an important correlate of psychosocial function in first episode psychosis

max) or by standardized exercisetests, such as walking-based protocols that measure total dis-tance achieved in a given timeframe. Vancampfort et al. (2)first reported an association between exercise capacity and glo-bal functioning in hospitalized patients with schizophrenia. Astrong relationship was found between the distance achievedon a standardized walk-test (a validated measure of aerobicexercise capacity) and the Global Assessment of Functioningscore (GAF) (2). Although causality cannot be establishedthrough a cross-sectional study, the findings provide furtherjustification for the inclusion of physical activity interventionsin schizophrenia, and the importance of examining changes inmaximal aerobic capacity, particularly given the potentialimpact that such strategies may have on physical health, men-tal health, and overall psychosocial functioning (3, 4).We aimed to replicate the findings of Vancampfort et al. (2)in a sample of young people experiencing a first episode of psy-chosis (FEP) attending a community treatment service in Syd-ney, Australia. Nineteen young people (19.9 2.4 years; 53%male) completed a staged submaximal exercise test on a cycleergometer within 4 weeks of referral to the service. Submaxi-mal exercise tests are a cheap, feasible, and valid alternative tomaximal exercise testing for both the general and clinical popu-lations. Submaximal exercise testing relies on heart rateresponse to a given workload, to estimate exercise capacity.The current study utilized the Young Men’s Christian Associa-tion (YMCA) protocol involving two, 3-min stages of continu-ous cycling at a cadence of 50 RPM.The mean estimated V0

Positive cardiometabolic health for adults with intellectual disability: an early intervention framework

Cardiometabolic morbidity is a significant contributor to the poorer health outcomes experienced by people with intellectual disability (ID). Tailoring cardiometabolic monitoring tools developed for the general population to better fit the altered risk profiles and extra needs of people with ID may help to improve health outcomes. This paper describes a new cardiometabolic monitoring framework designed to address the extra needs of people with ID. The framework was adapted from a generalist guideline after a process of extensive consultation with the original authors and over 30 ID and cardiometabolic experts. In addition to standard cardiometabolic monitoring practice, the framework encourages clinicians to: anticipate and address barriers to care such as communication difficulties and fear of blood tests; account for socioeconomic and genetic factors altering baseline cardiometabolic risk; and carefully rationalize psychotropic prescription. Together with this framework, a toolkit of free cardiometabolic resources tailored for people with ID and formal and informal carers is included. The monitoring framework promotes a multidisciplinary and holistic approach to cardiometabolic care for people with ID.

Psychiatry HeAL thyself

Somatic comorbidities, including diabetes and cardiovascular disease are key contributors to premature mortality in people with mental illness. The mental–physical divide within psychiatric care is eroding, and a growing number of successful lifestyle interventions targeting this population are emerging. However, staff culture can be a formidable barrier to achieving integration of physical health programmes as a core component of mental health services. Health professionals engaged in healthy lifestyle behaviours themselves are more likely to promote such behaviours among their patients (Fie et al., 2013), which is more likely to impact long-term behaviour change. Hjorth et al. demonstrated that an intervention promoting physical health among staff of mental health facilities impacted upon patient physical health (Hjorth et al., 2015). Staff who participated in the study improved key measures of cardiometabolic risk, achieving reductions in their own waist circumferences, while noting that the staff had acted as positive role models for patient behaviour change. Following the successful implementation and integration of a multi-disciplinary lifestyle intervention for patients of the Bondi Early Psychosis Program (Keeping the Body in Mind [KBIM] programme) at South Eastern Sydney Local Health District in 2014 (Curtis et al., in press), funding was provided for District-wide implementation of KBIM. An investment in the mental health workforce, to build capacity and initiate culture change, was developed – ‘Keeping our Staff in Mind’ (KoSiM). Staff were offered first-hand experience of the KBIM physical health assessment and a brief individualised lifestyle intervention programme. It was hypothesised that KoSiM would be a catalyst for building capacity in the workforce and facilitating culture change, with the aim of improving the physical health of mental health consumers. Specifically, KoSiM aimed to develop staff ‘champions’ to drive the District-wide KBIM implementation while identifying and addressing potential barriers that prevent staff from addressing the physical health of consumers, such as lack of knowledge or confidence. An additional potential benefit of the KoSiM initiative is an improvement in staff wellbeing. Of 702 potential participants (existing mental health staff), 204 (29%) completed a baseline survey, and 154 staff agreed to participate in the 4-week individualised lifestyle intervention. The HeAL declaration (www.iphys.org.au) challenges health professionals and organisations to maintain and protect the physical health of people experiencing psychosis. The KoSiM programme is a first step towards system-wide implementation and integration of comprehensive physical health care for this high-risk population.

Observation to action: progressive implementation of lifestyle interventions to improve physical health outcomes in a community-based early psychosis treatment program.

1 Early Psychosis Programme, The Bondi Centre, South Eastern Sydney Local Health District, Bondi Junction, Australia 2 School of Psychiatry, University of New South Wales, Randwick, Australia 3 Faculty of Medicine, University of New South Wales, Randwick, Australia 4 Discipline of Psychiatry, School of Medicine, University of Adelaide, Adelaide, Australia 5 Faculty of Health, University of Technology, Sydney, Sydney, Australia 6 Department of Endocrinology, St Vincent’s Hospital, Darlinghurst, Australia 7 Diabetes and Obesity Program, Garvan Institute of Medical Research, Darlinghurst, Australia 8 Schizophrenia Research Unit, South Western Sydney Local Health District, Liverpool, Australia

Improving the health of mental health staff through exercise interventions: a systematic review

Abstract Background: Exercise interventions are efficacious in reducing cardiometabolic risk and improving symptoms in people with severe mental illness, yet evidence guiding the implementation and scalability of such efforts is lacking. Given increasing efforts to address the disparity in physical health outcomes facing people with a mental illness, novel approaches to increasing adoption of effective interventions are required. Exercise interventions targeting mental health staff may improve staff health while also creating more positive attitudes towards the role of lifestyle interventions for people experiencing mental illness. Aims: We aimed to determine the feasibility, acceptability and effectiveness of exercise interventions delivered to staff working in mental health services. Method: A systematic review was conducted from database inception, until November 2017. Studies recruiting staff participants to receive an exercise intervention were eligible for inclusion. Results: Five studies met the inclusion criteria. Physical health interventions for mental health staff were feasible and acceptable with low dropout rates. Reductions in anthropometric measures and work-related stress were reported. Conclusions: Limited evidence suggests that exercise interventions targeting mental health staff are feasible and acceptable. Further research is required to determine the efficacy of such interventions and the impact such strategies may have on staff culture and patient outcomes.

The Validity and Reliability Characteristics of the M-BACK Questionnaire to Assess the Barriers, Attitudes, Confidence, and Knowledge of Mental Health Staff Regarding Metabolic Health of Mental Health Service Users

Background Addressing the burden of poor physical health and the subsequent gap in life expectancy experienced by people with mental illness is a major priority in mental health services. To equip mental health staff with the competence to deliver evidence-based interventions, targeted staff training regarding metabolic health is required. In order to evaluate the effectiveness of staff training regarding metabolic health, we aimed to develop a succinct measure to determine the barriers, attitudes, confidence, and knowledge of health practitioners through the development and test–retest reliability of the Metabolic-Barriers, Attitudes, Confidence, and Knowledge Questionnaire (M-BACK). Methods The M-BACK questionnaire was developed to evaluate the impact of specialized training in metabolic health care for mental health nurses. Content of the M-BACK was developed from a literature review and refined by an expert review panel and validated via a piloting process. To determine the test–retest reliability of the M-BACK, 31 nursing students recruited from the University of Notre Dame, Sydney completed the questionnaire on two separate occasions, 7 days apart. Intraclass correlation coefficients (ICCs) were calculated for the total score, as well as each of the four domains. Results Pilot testing was undertaken with a sample of 106 mental health nurses with a mean age 48.2, ranging from 24 to 63 years of age, who participated in six training courses. Questionnaire development resulted in a 16-item instrument, with each item is scored on a five-point Likert scale ranging from “strongly disagree” to “strongly agree.” Test–retest reliability of the M-BACK was completed by 30 of 31 nursing students recruited, ICCs ranged from 0.62 to 0.96. Conclusion The M-BACK is a reliable measure of the key elements of practitioner perceptions of barriers, and their knowledge, attitudes, and confidence regarding metabolic monitoring in people with mental illness. It can be used to assess the effectiveness of interventions aimed at increasing uptake of metabolic monitoring, a key component of programs to reduce the life expectancy gap in people living with severe mental illness.