Shuichi Suetani

Correlates of physical activity in people living with psychotic illness

In the light of the high prevalence of physical comorbidities in people with psychotic illness, there is a need to explore modifiable risk factors that may contribute to this disease burden. The benefits of physical activity to both physical and mental health have been well established. We aimed to examine the prevalence and correlates of physical activity in a national sample of adults living with psychotic illness.

An Urgent Call to Address the Deadly Consequences of Serious Mental Disorders.

The article by Olfson and colleagues1 in this issue of JAMA Psychiatry is a reminder of how we are failing to meet the needs of people with schizophrenia. Based on approximately 74 000 deaths within a cohort of 1.1 million individuals with schizophrenia, those with schizophrenia were more than 3.5 times as likely to die in the follow-up period compared with adults in the general population. On average, the years of potential life lost for each deceased individual were 28.5 years. More than 85% of the known all-cause deaths were attributed to natural causes, of which cardiovascular disease contributed 35%, followed by cancer (17%) and diabetes mellitus (5%). The standardized mortality ratios for cardiovascular disease and chronic obstructive pulmonary disease were 3.6 and 9.9, respectively.

Embedding exercise interventions as routine mental health care: implementation strategies in residential, inpatient and community settings

Objectives: Evaluation of physical activity (PA) programs among populations with severe mental illness (SMI) has predominately focused on efficacy and therapeutic benefits. There is now strong evidence to support the benefits of PA in people with SMI. What remains is a gap in the implementation of pragmatic and sustainable PA interventions in mental-health settings. The current paper provides examples of interventions that have been successfully implemented in Australian settings, identifies key components of successful PA interventions and outlines practical strategies that can assist with widespread implementation of PA interventions in mental-health settings. Conclusions: There is an emergence of PA interventions being imbedded within a variety of mental-health settings. These interventions vary in terms of mode and intensity of service delivery. Yet, all aim to increase PA and reduce sedentary behaviour. Adopting the identified strategies may help facilitate successful implementation and increase access to PA interventions for mental-health service users.

Late onset myocarditis with clozapine use.

Myocarditis is a serious complication of clozapine therapy with a reported incidence between 0.7% to 1.2% (Layland et al., 2009). The majority of cases occur within two months of commencement (Layland et al., 2009) with occasional reports after long-term therapy (Lang et al., 2008). The exact mechanism underlying clozapine-related myocarditis is unknown. Hypotheses include: IgEmediated hypersensitivity, increased plasma catecholamine, cytochrome P450 1A2 enzyme deficiency, blockade of calcium-dependent ion channels, increased production of inflammatory cytokines, and low serum selenium levels (Layland et al., 2009). We report two cases of myocarditis after long-term clozapine therapy identified during routine monitoring. Mr R, a 62-year-old male nursing home resident, was treated with clozapine (500mg/day) from 1997 for schizophrenia. He has a background of diabetes, hyperlipidaemia and peripheral vascular disease. He presented with lethargy, temperature of 38.3o C, CRP 200mg/L and troponin T 276ng/L. Serial ECG showed T wave inversion with variable broadening of QRS complex. His echocardiogram revealed moderate systolic dysfunction and ejection fraction of 33% with global hypokinesis. A diagnosis of clozapineinduced myocarditis was made after excluding alternative aetiologies. Clozapine was ceased and he was commenced on olanzapine 5mg. He made good clinical recovery and was discharged two weeks later but died seven weeks later due to renal failure. Mr S, a 52-year-old male with a 24-year history of schizophrenia was treated on 500mg/day of clozapine since 2009. His clozapine levels ranged from 146-910μg/L suggesting longterm partial compliance. His medical history includes hyperlipidaemia and diabetes. He presented with a twoweek history of exertional dyspnoea without chest pain. ECG showed new onset atrial flutter 2:1 with sinus tachycardia, troponin T 294ng/L, CRP 25mg/L. Echocardiogram revealed systolic dysfunction with an ejection fraction of 35% and global hypokinesis. He was diagnosed with myocarditis secondary to clozapine. Clozapine was ceased, and olanzapine 10mg was initiated. He was discharged home one week later following clinical recovery. His cardiac condition remains stable four months after discharge. These cases meet the criteria for clozapine-related myocarditis but occur outside the initial high-risk period following commencement (Ronaldson et al., 2010) suggesting the need for ongoing clinical vigilance for symptoms suggestive of myocarditis for the duration of clozapine treatment. Suspicion should lead to prompt investigation with troponin T, CRP and ECG to facilitate early identification and treatment of myocarditis.

The importance of the physical health needs of people with psychotic disorders

Australian & New Zealand Journal of Psychiatry, 51(1) Hall-Flavin DK, Winner JG, Allen JD, et al. (2013) Utility of integrated pharmacogenomic testing to support the treatment of major depressive disorder in a psychiatric outpatient setting. Pharmacogenetics and Genomics 23: 535–548. Hicks JK, Bishop JR, Sangkuhl K, et al. (2015) Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2D6 and CYP2C19 genotypes and dosing of selective serotonin reuptake inhibitors. Clinical Pharmacology and Therapeutics 98: 127–134. Malhi GS, Bassett D, Boyce P, et al. (2015) Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian and New Zealand Journal of Psychiatry 49: 1087–1206. Mrazek DA, Biernacka JM, O’Kane DJ, et al. (2011) CYP2C19 variation and citalopram response. Pharmacogenetics and Genomics 21: 1–9. Peters, EJ, Slager, SL, Kraft, JB, et al. (2008) Pharmacokinetic genes do not influence response or tolerance to citalopram in the STAR*D sample. PLoS One 3: e1872.

Defragmenting paediatric anorexia nervosa: the Flinders Medical Centre Paediatric Eating Disorder Program.

Objective: To describe the establishment and the main characteristics of the Flinders Medical Centre Paediatric Eating Disorder Program. Conclusion: While the programme is still in its infancy, it is hoped that our model of care can provide a sustainable, long term contribution to the management of paediatric eating disorders.

Longitudinal association between physical activity engagement during adolescence and mental health outcomes in young adults: A 21-year birth cohort study

OBJECTIVE Previous studies provide mixed evidence that physical activity engagement (PAE) in adolescence is associated with later mental health outcomes. This study aimed to examine the association between PAE at age 14 and mental health outcomes at age 21 using a large birth cohort study. MATERIAL AND METHODS Prospective data from the Mater-University of Queensland Study of Pregnancy, consisting of 3493 young adults, were analyzed. PAE at age 14 was estimated using self-report, and participants were categorized into; (1) frequent, (2) infrequent, or (3) no PAE group. Mental health outcomes at age 21 consisted of; (1) common mental disorders, (2) psychosis-related outcomes, and, (3) emotional and behavioral problems. The association between PAE in adolescence and later mental health outcomes in young adulthood was examined using logistic regression, adjusted for age, sex, body mass index, and adolescent psychopathology. RESULTS No PAE at age 14 was associated with the increased likelihood of lifetime diagnosis of any affective disorder, elevated delusional ideation, and endorsement of visual perceptual disturbance at age 21. Conversely, infrequent PAE at age 14 was associated with the decreased likelihood of subsequent lifetime diagnosis of any substance use disorder. CONCLUSION Our findings suggest that lack of PAE in adolescence influences some, but not all, later mental health outcomes. Interventions to increase PAE in adolescence may represent an opportunity to prevent future mental health problems.

Prevalence and correlates of suboptimal vitamin D status in people living with psychotic disorders: data from the Australian Survey of High Impact Psychosis

Objective: Having sufficient sera concentrations of 25-hydroxyvitamin D is important for a range of health outcomes including cardiometabolic diseases. Clinical studies in people with psychotic disorders suggest that a sizable proportion has suboptimal vitamin D status (i.e. vitamin D deficiency or insufficiency). Individuals with psychosis also have many of the risk factors associated with suboptimal vitamin D status such as smoking, obesity, and reduced physical activity. The aim of this study was to examine the prevalence and socio-demographic and clinical correlates of vitamin D status using a large, population-based sample of adults with psychotic disorders. Methods: Data were collected as part of the Survey of High Impact Psychosis, a population-based survey of Australians aged 18–64 years with a psychotic disorder. 25-Hydroxyvitamin D concentration was measured in 463 participants. 25-Hydroxyvitamin D concentration was dichotomised into optimal (above 50 nmol/L) and suboptimal (below 50 nmol/L). The influence of a range of socio-demographic and clinical variables on vitamin D status was examined using logistic regression. Results: Nearly half (43.6%) of the participants had suboptimal vitamin D status. Those with (a) increased physical activity or (b) positive symptoms had significantly reduced odds of having suboptimal vitamin D status. However, there were no significant associations between suboptimal vitamin D status and other psychiatric symptom measures or cardiometabolic risk factors. Conclusion: Many people with psychotic disorders have suboptimal vitamin D status. As part of the routine assessment of physical health status, clinicians should remain mindful of vitamin D status in this vulnerable population and encourage the use of appropriate vitamin D supplements.

Navigating through the Competency Based Fellowship Program: two trainees’ experience of the 2012 program

Objectives: This article discusses the real-life experience of two senior registrars who are approaching the end of their training under the 2012 Competency Based Fellowship Program. We have shared some practical tips to assist trainees in completing the Program, with particular emphasis on examination preparation. Conclusion: Whilst stressful at times, we believe that going through the Competency Based Fellowship Program has helped us build our knowledge, skills base, and expertise for practising psychiatry as consultants.

On being supervised: getting value from a clinical supervisor and making the relationship work when it is not

Objective: The importance of clinical supervision is emphasised in psychiatric training programs. Despite this, the purpose and processes of supervision are often poorly defined. There is limited guidance available for trainees about their role in making supervision work. This paper considers the nature of supervision in psychiatric training and provides practical advice to help supervisees take active steps to make supervision work. Conclusions: In obtaining value from supervision, the active role of the supervisee in seeking feedback, finding value in criticism and building autonomy is emphasised. Additionally, the importance of exploring what value a supervisor can offer and maintaining realistic expectations is considered. Trainees can benefit from taking an active role in planning and managing their supervision to maximise their learning.