Tonights panel Dr Helen Stanley Dr Phillip Tully Associate - - PDF document

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Supported by The Royal Australian College of General Practitioners, the Australian Psychological Society, the Australian College of Mental Health Nurses and The Royal Australian and New Zealand College of Psychiatrists

DATE:

November 12, 2008 Webinar Tuesday 25 June 2019

Working together to prevent heart disease for people living with psychiatric illness

Dr Phillip Tully Psychologist, SA Dr Helen Stanley General Practitioner, Vic

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Tonight’s panel

Ms Nicola Palfrey Psychologist, ACT

Like to read more about tonight’s panellists? Click supporting resources in the library tab at the bottom right of your screen for panel bios and more!

Associate Professor David Colquhoun Cardiologist, Qld

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Ground Rules

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• Be respectful of other participants and panellists: behave as you would in a

face-to-face activity.

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Learning outcomes

At the completion of the webinar participants will be able to:

• describe the complex bidirectional relationship between heart disease

and mental health, as well as the risk factors for and warning signs of heart disease in persons with psychiatric illness

• describe the challenges, merits and opportunities in evidence-based

approaches deemed most effective in treating and supporting people experiencing heart disease related to mental health issues

• better target referrals for people experiencing mental health issues

who are at risk of heart disease as a result of an improved understanding of the role of different disciplines.

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Click OPEN CHAT at the bottom right of your screen to chat with other participants. NB: chat will open in a new browser window.

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GP’s perspective

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Dr Helen Stanley

The encouraging for Michael

• Employed part-time as a shelf-stacker
• Connected to family who provide housing
• Very stable for 10 years
• Ongoing relationship with his GP and psychiatrist

BUT

• Slow time bomb for CV disease
• Absolute CVS risk 24% i.e., 1 in 4 chance of CV event in the next

five years. Could be sudden death.

• 699 Medicare Heart Health Check

GP’s perspective

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Dr Helen Stanley

GP agenda

Work with Michael to improve his life-style, long-term therapeutic relationship:

• Quit smoking
• Encourage him to reshape his body by eating less energy (less

sugar, less fat, less alcohol)

• Encourage him to be more active, less sitting and more
• movement. 30 min of exercise 5 days per week.
• Drink more water, avoid salt.
• Eat more fruit and vegetables, nuts, fish and olive oil.

Treat his risk factors: consider medications for his cholesterol, hypertension and his diabetes and quitting smoking.

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GP’s perspective

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Dr Helen Stanley

Team approach

GPMP and TCA 5 Medicare rebates p/a, 3 diabetic educator and 2 podiatrist Optometry check for diabetic retinopathy Urine MCR for diabetic nephropathy Hospital or Community Centre, healthy life style group, exercise physiologist, dietician, community garden project, men's shed, motor car museum /club Work with his psychologist:

• sleep hygiene
• activity activation
• tolerance of

unpleasant emotion and finding his values Write to Michael’s psychiatrist:

• 21% CV risk
• Newly diagnosed diabetes
• Smoker
• Metabolic syndrome
• BMI 34.6
• Can Michael stop the

Olanzapine and Valproate and have a mood stabiliser that is better metabolically?

Go slow Refer according to Michael’s interest Monthly GP review to journey with him

• n lifestyle change

GP’s perspective

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Dr Helen Stanley

Michael’s agenda

• What does a rich, full life look like for Michael?
• What does he value? Working, family, cars, racing, repairing

cars?

• How does he view his smoking? Stage of change
• He wants to quit for his health and save money? Spends $100

per week, could this money help restore his car? The barriers to quitting.

• If he is ready to quit? Prescribe nicotine patches 21mg, 4 d’s,

it is just an urge and will pass, NOTICE the now, keep busy polish his cars.

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GP’s perspective

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Dr Helen Stanley

Lifestyle journey with Michael

• View that Michael is stuck not diseased and can become unstuck and lead a

rich, meaning full life. He has potential.? senator, TAFE, mechanic etc.

• His CV risk can be reduced eg quit smoking 24% to 12%
• Reinforce his healthy behaviour and do not reinforce his unhealthy
• behaviour. E.g., praise for him being more active, don’t prescribe valium to

allow him to avoid life.

• Create experiences in the consult that he can learn from e.g., both of us

standing and walking on the spot in the consultation, to be active and encourage him to do this at home e.g., while he watches motor sport.

• Notice three things with eyes, ears and three body sensations i.e.,

experience of mindfulness.

• Work with the team but still regularly review him for a long-term

therapeutic relationship. Be non-judgemental, accepting him as he is and encouraging him.

Psychologist’s perspective

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Dr Phillip Tully

What does a Psychologist need to know about Michael’s care?

• Information required from Psychiatrist – potential mood stabilizer & anti-

psychotic medication change was flagged (risk for deterioration in mood, mania and/or suicide risk)

• Are early warning signs monitoring in place? Over what timeframe will med. switch
• ccur?
• Information required from GP – are there new or existing medications for

hypertension, hypercholesterolemia, or diabetes (given severity of individual CVD risk factors)

• Are lifestyle modifications being recommended? How is Michael supported to do

these?

• Information required from Cardiologist – cardiac functioning (e.g. coronary

atherosclerosis, cardiomyopathy, echocardiography & ECG findings)

• Will he experience somatic symptoms overlapping with MDD? How urgent is CVD

risk reduction?

Goldstein et al., Major depressive disorder and bipolar disorder predispose youth to accelerated atherosclerosis and early cardiovascular disease: A Scientific Statement From the American Heart Association. Circulation 2015;132:965-986

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Psychologist’s perspective

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Dr Phillip Tully

Collaborative care approaches

• Historically the treatment of mental health in CVDs is independent of

the cardiology and the primary care sectors, without considering;

• The complexity of patient’s mental health & cardiovascular needs
• The impact of severe mental illness on CVD risk factors (& vice versa),

difficulties in dual management

• Shift from unitary/singular interventions (e.g. CBT alone), in favour of

coordinated approaches between cardiologist, GP, psychiatrist & psychologist/MHP

• eg. In Bipolar – van der Voort et al., Collaborative care for patients with bipolar disorder: randomised controlled trial. Br J Psychiatry

2015;206(5):393-400

Psychologist’s perspective

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Dr Phillip Tully

Michael’s first consultation & assessment

• Michael’s psychosocial, medical &

family history

• Assess mood, irritability, & what

strategies are in place

• Sleep monitoring, early warning

signs

• Consider under-reporting of

alcohol/illicit substance use

• Agreed upon treatment goals (more

likely related to CVD & behaviours)

Goodrich et al., Design and rationale of a randomized controlled trial to reduce cardiovascular disease risk for patients with bipolar disorder. Contemp Clin Trials 2012;33(4):666-78

Ψ factors CVD risk

Cardio- metabolic Alcohol, smoking Physical activity Sleep Mood Mania

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Psychologist’s perspective

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Dr Phillip Tully

Evidence-based approaches for bipolar

• Sufficient evidence for bipolar disorder - collaborative care, CBT,

integrated C-IPT, family-focused, IP-social rhythm therapy, DBT and MBCT (in euthymic patients)

• Irrespective of approach - ensure that sleep, activity, self-

harm/suicide risk, and early warning sign monitoring is in place

Oud et al., Psychological interventions for adults with bipolar disorder: systematic review and meta-analysis. Br J Psychiatry 2016;208(3):213-22; Salcedo et al., Empirically supported psychosocial interventions for bipolar disorder: Current state of the research. J Affect Disord 2016;201:203- 14; Haynes et al., Social rhythm therapies for mood disorders: an Update. Curr Psychiatry Rep 2016;18(8):75.

Psychologist’s perspective

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Dr Phillip Tully

Possible directions with Michael

Interpersonal- Social

Rhythm

Transition Routine Monitoring

Motivational Interviewing

Barriers & self-efficacy Behaviour change Adherence

CBT/other

Distress tolerance Coping strategies Cognitions about disease

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Psychologist’s perspective

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Dr Phillip Tully

Potential barriers in bipolar depression

• Progress can be slow (and that’s ok!)
• Distractibility in bipolar disorder
• ↑ Goal-focused activity (an early warning sign of mania)
• Increasing physical activity might be incompatible to a car enthusiast
• Past history of non-adherence to medications resulting in hospitalisations

and suicide attempts

• Cardio-metabolic consequences of mood stabilizer & anti-psychotics - issues

to explore in therapy/MI concerning medication adherence – Given that bipolar symptoms appear well controlled

• Medicaon for HTN, DM, HDL may ↓ movaon to change behaviours

Cardiologist’s perspective

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Prof David Colquhoun

Michael aged 46

• High morbidity from his mental illness
• High risk of developing vascular disease over the

next five years – Heart attack, stroke, sudden death – Risk is greater than 74 year-old male with no classic risk factors.

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Cardiologist’s perspective

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Prof David Colquhoun

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Cardiologist’s perspective

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Prof David Colquhoun

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Cardiologist’s perspective

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Prof David Colquhoun

Expected Treatment Benefit

CHOLESTEROL

• 1mMol/L decrease

LDL-C – 20-25% less CVD BLOOD PRESSURE

• 10mmHg decrease Systolic BP –

10-20% less CVD DIET

• 1 point increase Med Diet

– 10-20% less CVD EXERCISE

• Walking (moderate)

30 minutes daily – 10-20% less CVD DIABETES

• Treatment SGLT-2 inhibitor – 20%

less CVD and HF WEIGHT LOSS

• Unfortunately, treatment does not

prevent CVD

Cardiologist’s perspective

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Prof David Colquhoun

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Cardiologist’s perspective

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Prof David Colquhoun

Cardiac Investigations

• Basic
• Examination and history
• ECG
• Bloods (E/LFTs, HDL, FBC, CRP, Iron Studies, Folate, B12, TSH)
• Advanced
• Imaging coronary arterial calcium (CAC)
• Omega-3 index (when available)
• Echo
• +/- Stress Echo or Stress ECG

Cardiologist’s perspective

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Prof David Colquhoun

National Heart Foundation Position Statement

1. Independent psychosocial risk factors for Coronary Heart Disease (CHD) 2. Similar order as conventional risk factor for development of CHD and prognosis in those with CHD

Level of Evidence

• Depression

A

• Social Isolation/Poor Support

A

Bunker SJ, Colquhoun DM, Esler MD et al. MJA NHFA Position Statement 2003, 272

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Cardiologist’s perspective

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Prof David Colquhoun

• Acute and Chronic Stress
• Mood Disorder
• Depression and Anxiety
• Schizophrenia
• Post-traumatic Stress Disorder
• Social Isolation
• Economic Status
• Persistent moderate-severe distress

2x risk of total mortality over 12 years

BMJ Wednesday, 21st June 2017 @ 23:30 embargo lifted!

Psychosocial factors in vascular disease

Cardiologist’s perspective

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Prof David Colquhoun

NHFA recommendations for treatment of depression in patient with CHD or with high risk of CHD

• Exercise – 30 minutes most days
• (Mediterranean Diet, especially enriched with 30g of nuts/day and 1L olive
• il/week) Not specifically recommended by NHFA
• Psychosocial

– cognitive behavioural therapy – interpersonal psychotherapy

• Complementary Therapies

– up to 50% of depressed patients use these

• Drugs

– mainly serotonin reuptake inhibitors (SSRIs) (Sertraline, Fluoxetine, Citalopram, Mirtazapine) have been tested. – avoid tricyclic antidepressants (TCA)

NHFA Consensus Statement. MJA On Line May 2013

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Dr Philip Tully Psychologist, SA Dr Helen Stanley General Practitioner, Vic

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Q&A session

Ms Nicola Palfrey Psychologist, ACT Associate Professor David Colquhoun Cardiologist, Qld Audience tip: Click the ‘Open Chat’ tab at the bottom right of your screen to chat with

• ther participants.

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Thank you!