Unique clinic integrates twin priorities of body and mind
Autumn 2010, Vol 14 No 1
By Patricia Nicholson
Type 2 diabetes is three times as common in people with schizophrenia compared to the general population. The metabolic syndrome – a characterization of risk for developing diabetes and heart disease – is also prevalent in this population. Because many second-generation antipsychotics increase risk for weight gain, hypertension and diabetes, medications are a big contributor to this problem.
“Medication is one part of it, but it is not that simple,” says psychiatrist Dr. Tony Cohn, head of the Mental Health and Metabolism Clinic at the Centre for Addiction and Mental Health (CAMH) in Toronto. “It may have to do with lifestyle, for example, high smoking rates, diets heavy in simple carbohydrates and low activity levels. Social determinants including poverty and access to education are also powerful factors.” Cohn adds that a possible cellular or genetic overlap between schizophrenia and diabetes may also exist.
What is clearly understood is that people with serious mental illness die on average 25 years earlier than members of the general population, mostly from metabolic problems like diabetes and heart disease. It’s this sobering statistic that motivated Cohn and his colleagues to develop the metabolism clinic.
The clinic was the first in Canada to focus on treating weight gain, obesity and diabetes in clients with serious mental illness. In addition to providing ongoing health monitoring, the multidisciplinary clinic offers diet and lifestyle interventions specifically designed for this population.
All of the symptoms associated with the metabolic syndrome – abdominal obesity, high triglycerides, low HDL, hypertension and high fasting glucose – are prevalent in people with schizophrenia. Metabolic monitoring is crucial for these clients, but standard approaches may not work well.
“It’s a bit of a systems challenge how to do this,” says Cohn. “Everybody around the world struggles with how to implement it. Historically, we’ve tended to separate physical health care and mental health care, and it’s only been in the last 10 years or so that we’ve focused on the need to integrate them.”
Part of the challenge is reflected in debates about who is responsible for monitoring: some psychiatrists view it as part of a GP’s job, while GPs may think that the psychiatrist who prescribed the medication should monitor its side-effects. In a multidisciplinary practice, some staff may view it as the nurse’s job, while others view it as the dietitian’s. “It tends to fall into the cracks,” says Cohn. “That’s why we developed our metabolic tool – to try to do it more systematically.”
The clinic’s electronic Metabolic Health Monitor tool was originally developed as a paper form. Its first onscreen incarnation was as an Excel spreadsheet. “Various calculations need to be done for a metabolic assessment –like a Framingham risk assessment, target lipid values, body mass index – the sort of things that computers can do quickly,” says Cohn.
The current tool, which is linked into CAMH’s electronic records system, recently won an award from the Information Technology Association of Canada.
It tracks relevant information such as how long the client has been monitored, how long since their last assessment, their age, sex, waist circumference, blood pressure and lab test results. Worrisome data, such as high blood pressure or a significant weight change, are automatically highlighted in red, while information that may be cause for concern but does not yet require urgent attention is highlighted in yellow.
“This tool helps us keep the information well organized for reflection later,” says Cohn. “It’s also useful for us to collect information on the whole population and learn about specific factors. For example, we’ve seen that if people smoke, they have about double the rate of diabetes. That has been shown in the general population, but because people with serious mental illness have high smoking rates, it’s important to focus on the combined lifestyle risks of smoking and obesity together in this population.”
The monitor incorporates data from all aspects of the clinic’s multidisciplinary practice, which includes a registered nurse, a dietitian and a recreation therapist.
Registered nurse Elizabeth Budd explains that while the clinic focuses on metabolic issues, it looks at all contributing factors. “We evaluate mental health care, but with an integrated, holistic approach,” says Budd. “We evaluate risks that clients are exposed to, not necessarily as a result of medication, but because of their illness, medication, lifestyle and social environment.”
Clinic dietitian Ruth Hsueh explains that in terms of managing weight loss, clients with mental illness face the same challenges as the general population, but often face more barriers. “The illness itself can make it very hard for people to get motivated, and motivation is everything,” she says. “Medications can make them more tired, so managing weight is harder than for the rest of the population. They need more support.”
The structured clinical assessment includes food frequency questionnaires and physical activity scales. That lifestyle information becomes part of the client’s metabolic assessment record, accessible to team members. The information is then sent back to the referring doctor, along with recommendations, which may include reviewing medications or switching to a medication less likely to cause weight gain, as well as recommendations concerning diet, activity and smoking.
Cohn began working in the area of metabolic issues in people with serious mental illness more than 10 years ago. He soon realized that further expertise in nutritional science would be an asset, so he returned to school to do a master’s degree in that area.
Combining expertise in metabolism with psychiatry is still not common, but Cohn views it as emerging specialty. “Often the dilemma is that people need the medication to maintain good mental health and to treat psychosis, but the medication can also cause side-effects related to weight gain and diabetes,” he says, noting that on some commonly used antipsychotics, 90 per cent of clients gain more than 10 per cent of their body weight.
“Ironically, our best medications have the most problems metabolically,” says Cohn. “We can switch people to other medications, but we may then run the risk of people decompensating from a mental health perspective and becoming more psychotic. This is probably the biggest dilemma when you have to weigh issues around mental stability versus physical health.”
The clinic already has more than 2,000 patients in its Metabolic Health Monitor, and gets as many as 18 new referrals per week. But Cohn recognizes the potential to expand the tool beyond the clinic. “Such a system could be bigger, province-wide,” he says. “This way you can monitor a population and identify and track the really high-risk people and also do preventive work.”
This vision is becoming a reality as the clinic plans to extend its workshops and webinars for clinicians beyond Toronto and pilot the training with rural and remote communities via the Ontario Telemedicine Network. Health care professionals are enthusiastic, but the clinic’s most important responses come from its clients: “We get very good feedback from patients and families,” says Cohn.
B.C. metabolic mental health program is kids’ stuff
The link between antipsychotic medications and metabolic side-effects is well known. So it wasn’t surprising when a British Columbia psychiatric unit identified high rates of insulin resistance – a precursor to diabetes – in patients on these medications.
Except the patients were in a pediatric unit – the average age was 12.
“This is alarming,” says psychiatrist Dr. Jana Davidson, founder of the Provincial Mental Health Metabolic Program at B.C. Children’s Hospital in Vancover. The clinic, launched in April, specializes in children and youth who have both mental illness and metabolic or endocrine problems. Its mandate includes monitoring and mitigating metabolic side-effects of antipsychotic medications, as well as producing toolkits for families and professionals.
The program serves all of B.C. and was launched in response to research which found that metabolic problems – including metabolic syndrome, diabetes and hypertension – were distressingly high in children and youth on antipsychotic medication.
“These medications can be incredibly effective for treating early onset mental health problems,” says Davidson, adding that antipsychotics often make it possible for children to remain in school and with their families and friends. However, the long-term impact of the metabolic side-effects in pediatric patients is not known.
The clinic treats patients with mental illness who are experiencing metabolic or endocrine disturbances, as well as endocrinology and metabolic patients who develop mental illness.
“These medications can be very helpful, but we also know they have side-effects and consequences to watch out for,” Davidson says. “We hope to make a significant impact in B.C. minimizing those adverse effects.”