Srinivasan Tirupati

Obesity and metabolic syndrome in a psychiatric rehabilitation service

Objective: People with schizophrenia and bipolar disorders suffer from increased rates of obesity and metabolic syndrome. Metabolic disorders add to the burden of disease and affect treatment and rehabilitation outcomes. This study aimed to study the prevalence of obesity and metabolic syndrome in people with chronic psychotic disorders in a psychiatric rehabilitation setting. Method: All patients in the psychiatry rehabilitation program were assessed for obesity and metabolic syndrome using the definition of International Diabetes Federation (2005) was conducted as part of clinical protocol recently introduced into practice. Results: A total of 221 patients were assessed. The prevalence of obesity was 59% and metabolic syndrome 68%. Metabolic syndrome was more frequent in patients receiving polypharmacy with multiple antipsychotics and mood stabilisers. Rates of nontreatment for metabolic disorders ranged from 30% to 88%. Conclusions: The rates of obesity and metabolic syndrome in patients with chronic severe mental disorders on antipsychotic drug treatment were 2 to 3 times that in the general population. A majority of them were untreated. Detection, monitoring and appropriate treatment of obesity and metabolic disorders should be a component of an assertive care management program to reduce morbidity and mortality and improve rehabilitation outcomes.

Adverse Incidents in Acute Psychiatric Inpatient Units: Rates, Correlates and Pressures:

Objective: This paper reports findings from a multicentre service evaluation project conducted in acute psychiatric inpatient units in NSW, Australia. Overall rates of aggression, absconding and early readmission are reported, as well as length-of-stay profiles and associations between these outcomes and selected sociodemographic and clinical characteristics routinely collected by health services. Method: Data from the 11 participating units were collected for a 12month period from multiple sources, including electronic medical records, routine clinical modules, incident forms, and shift based project-specific logs. For the current analyses, two admission-level datasets were used, comprising aggregated patient-level events (n=3242 admissions) and basic sociodemographic, clinical, admission and discharge information (n=5546 admissions by 3877 patients). Results: The participating units were under considerable strain: 23.3% of admissions were high acuity; 60.4% had previous hospital stays; 47.6% were involuntary; 25–30% involved adverse incidents; bed occupancy averaged 88.4%; median length of stay was 8days (mean=14.59days); and 17.4% had a subsequent early readmission. Reportable aggressive incidents (11.2% of admissions) were intermittent (averaging 0.55 incidents per month per occupied bed) and associated with younger age, personality disorder, less serious aggression, longer periods of hospitalization, and subsequent early readmission. Less serious aggressive incidents (15.0% of admissions) were maximal in the first 24h (averaging 3.73 incidents per month per occupied bed) and associated with younger age, involuntary status, bipolar and personality disorders, the absence of depression, and longer hospital stays. Absconding (15.7% of admissions) peaked in the second week following admission and was associated with drug and alcohol disorder, younger age, and longer periods of hospitalization. Conclusions: By examining relationships between a core set of risk factors and multiple short-term outcomes, we were able to identify several important patterns, which were suggestive of the need for a multi-level approach to intervention, shifting from a risk management focus during the early phase of hospitalization to a more targeted, therapeutic approach during the later phase. But the latter approach may not be achievable under current circumstances with existing resources.

Low prevalence of obesity and metabolic syndrome in never-treated chronic schizophrenia

INTRODUCTION Antipsychotic medication and lifestyle factors are implicated in the high rates of obesity and metabolic syndrome in schizophrenia. While the two Consensus Statements made in 2004 concluded they were unclear whether psychiatric disorders per se accounted for increased prevalence of metabolic disorders several later studies have presented the case for an association between schizophrenia and metabolic disorders, especially impaired glucose metabolism and Type 2 diabetes mellitus, independent of antipsychotic drug treatment. METHODS This is a comparative study of 51 patients with chronic schizophrenia who never received antipsychotic drug treatment and 51 healthy controls. Physical and laboratory assessments were made to measure body-mass index and diagnose metabolic syndrome using the International Diabetes Federation (2006) criteria. RESULTS The study observed a significantly lower mean body-mass index in patients (19.4) than controls (22.7) and very low and comparable rates of metabolic syndrome (3.9% in patients, 7.8% in controls). DISCUSSION Economic affordability and lifestyles modified by living conditions were discussed as factors underlying the high rates of underweight in the patient population and low rates of metabolic disorders in all the study subjects. The study concluded that schizophrenia in the absence of antipsychotic drug treatment is not a factor contributing to high prevalence of metabolic abnormalities. Lifestyle factors and the social and economic circumstances that drive them should be considered for better understanding and management of excess weight gain and metabolic abnormalities in people with schizophrenia.

A working reality: evaluating enhanced intersectoral links in supported employment for people with psychiatric disabilities.

BACKGROUND/AIM Supported employment (SE) programmes have been found to improve the rates of competitive employment for people with severe mental illness. Evidence has suggested that the most effective SE model is one in which the employment specialist is co-located with mental health services. However, this may not always be achievable. The aim of this study was to investigate the effectiveness of the enhanced intersectoral links approach to SE. METHODS A total of 43 people with a mental illness participated in the programme in which formal links were created between a community mental health team and three employment services. The outcomes of the programme were evaluated over 24 months. RESULTS Of all participants, 77% achieved a competitive employment outcome, with 60.6% remaining in employment at the end of the evaluation period. The average duration of employment was 44.8 weeks. For those who were unable to maintain a job, the average period of employment was 14.2 weeks. The study found that participants with less severe symptoms at baseline were more likely to obtain employment and those who had worked in the year preceding entry into the programme were employed for a higher proportion of time. The factors related to job loss were the short-term nature of the position, cognitive difficulties and social skills. CONCLUSIONS The study found that the enhanced intersectoral links approach was effective in achieving outcomes consistent with international studies of SE programmes and may offer a viable alternative to the co-location of employment specialists with community mental health teams.

Body mass index as a screening test for metabolic syndrome in schizophrenia and schizoaffective disorders

Objective: The aim of this paper was to identify a simple screening measure for detecting metabolic syndrome (MetS) in people with schizophrenia and schizoaffective disorders. Method: A total of 202 patients with chronic schizophrenia and schizoaffective disorders on antipsychotic medications were assessed for MetS using the criteria defined by the International Diabetes Federation. Receiver operating characteristic (ROC) analysis was applied using body mass index (BMI) as the test variable for diagnosis of MetS. Results: The prevalence of MetS was 69.3%. Logistic regression analysis identified BMI and gender as significant predictors of MetS. ROC analysis identified BMI >28.7 as the criterion value with highest accuracy in terms of specificity and sensitivity. The likelihood ratios were robust at this cut-off score. The area under the curve was 0.75. Conclusion: BMI is a quick and easy measure, and can be used as a screening test for MetS in any clinical or community setting.

Cognitive dysfunction and associated factors in patients with chronic schizophrenia

BACKGROUND Deficits in neurocognitive function are a hallmark of schizophrenia. They are associated with clinical manifestations and the course of the illness. A study of cognitive dysfunction in Indian patients with schizophrenia is of significance in view of a more benign course and outcome of the illness in this region. AIM To study cognitive deficits and associated factors in patients with chronic schizophrenia and compare them with those in the normal population. METHODS We compared 100 patients with chronic schizophrenia with 100 matched normal controls on multiple measures of attention, executive function and memory. RESULTS Compared to normal individuals, patients with schizophrenia performed poorly in all cognitive tests. Cognitive deficits in patients were related to gender, education, age, duration of illness, and presence of positive and negative symptoms. CONCLUSION The neurocognitive profile of Indian patients with chronic schizophrenia resembles those of patients in developed countries.

Metabolic syndrome in antipsychotic naïve patients with schizophrenia: pooled analysis of data from three Indian studies.

This study aimed to assess the prevalence of metabolic syndrome (MS) and subthreshold MS in antipsychotic naïve patients with schizophrenia by pooling the data from three different centres in India.

An Integrated Recovery-oriented Model (IRM) for mental health services: evolution and challenges

BackgroundOver past decades, improvements in longer-term clinical and personal outcomes for individuals experiencing serious mental illness (SMI) have been moderate, although recovery has clearly been shown to be possible. Recovery experiences are inherently personal, and recovery can be complex and non-linear; however, there are a broad range of potential recovery contexts and contributors, both non-professional and professional. Ongoing refinement of recovery-oriented models for mental health (MH) services needs to be fostered.DiscussionThis descriptive paper outlines a service-wide Integrated Recovery-oriented Model (IRM) for MH services, designed to enhance personally valued health, wellbeing and social inclusion outcomes by increasing access to evidenced-based psychosocial interventions (EBIs) within a service context that supports recovery as both a process and an outcome. Evolution of the IRM is characterised as a series of five broad challenges, which draw together: relevant recovery perspectives; overall service delivery frameworks; psychiatric and psychosocial rehabilitation approaches and literature; our own clinical and service delivery experience; and implementation, evaluation and review strategies. The model revolves around the persons changing recovery needs, focusing on underlying processes and the service frameworks to support and reinforce hope as a primary catalyst for symptomatic and functional recovery. Within the IRM, clinical rehabilitation (CR) practices, processes and partnerships facilitate access to psychosocial EBIs to promote hope, recovery, self-agency and social inclusion. Core IRM components are detailed (remediation of functioning; collaborative restoration of skills and competencies; and active community reconnection), together with associated phases, processes, evaluation strategies, and an illustrative IRM scenario. The achievement of these goals requires ongoing collaboration with community organisations.ConclusionsImproved outcomes are achievable for people with a SMI. It is anticipated that the IRM will afford MH services an opportunity to validate hope, as a critical element for people with SMI in assuming responsibility and developing skills in self-agency and advocacy. Strengthening recovery-oriented practices and policies within MH services needs to occur in tandem with wide-ranging service evaluation strategies.

Cognitive decline in elderly medical and surgical inpatients

Background: Impairment in cognitive function increases with age. Aim: To study the prevalence of cognitive decline in inpatients ≥60 years of age. Methods: One hundred and thirty patients (85 men and 45 women), admitted to a community general hospital for medical or surgical treatment, were selected. The Mini Mental State Examination (MMSE) was used to identify subjects with cognitive dysfunction. Patients were categorized as having cognitive decline or normal cognition. The Global Rating of Memory Decline (GRMD) and Global Rating of Intellectual Decline (GRID) scales were used to assess the decline in memory, thinking and reasoning ability. Results: Cognitive decline was diagnosed in 54 subjects (41.5%). Significantly more patients ≥70 years of age had cognitive decline compared to patients ≤70 years of age. On the GRMD, 71 patients had subjective decline in memory, 62 of them reported that the decline interfered with their daily life. On GRID, subjective decline in intellectual function was found in 91 patients, with 55 reporting that the decline interfered with their daily lives. Conclusion: Patients ≥70 years of age with an acute medical problem are the most likely to have cognitive problems.

An attempt to discontinue clozapine – Worth a try?

The principal drawback of clozapine is its adverse effects leading to significant numbers of participants leaving treatment early after initiation (Legge et al., 2010). Experience on discontinuation of clozapine after several years of treatment is not much reported. I am reporting here an attempt to cease clozapine for six patients in a community psychiatric rehabilitation service. The Hunter New England Research Ethics Committee identified this work as a non-research activity and does not require its approval. The six patients, all males aged between 36 and 58 years, were on clozapine for a period of 4–14 years and were mentally stable. They requested discontinuation since they could not function as well as they wished, due to the side effect of the medication like sedation and dullness. The dose of clozapine was reduced gradually after discussion with them about the possible risks of ceasing the medication, the need to stop or reverse the process of dose-reduction at any time and the possible need to use additional medications for control of any deterioration in mental status. All six of them improved in the side effects and level of functioning as the dosage reduction progressed. Over a period of time, all of them exhibited worsening of psychosis with deterioration in functioning that ended in a brief hospitalisation. Three of them had ceased clozapine without medical advice. The dose of clozapine was brought up back to be in the range of 100–400 mg a day. This was less than the pre-reduction dose range of 400–700 mg a day. The follow-up on the reduced dose of clozapine ranged from 5 months to 4 years. All received an augmenting antipsychotic medication (olanzapine, amisulpride, paliperidone or risperidone). They did not report any side effects related to them. All six did not seek to cease clozapine again acknowledging that they needed it. The adjunct medication was ceased in two patients (after 2 and 10 months). While the overall experience for the patients was negative, positive changes were noted in their functioning, attitude to treatment, adherence to continued treatment with clozapine and sense of recovery. They were all happy that they were supported in their risking to cease the medication they were struggling to take. Such positive risk-taking, by trying something one is not sure one can achieve, leads to personal growth and development and, as part of recovery, develops resilience (Slade, 2009).