Youth with schizophrenia are at high risk. of diabetes: Opportunities for prevention and early intervention.

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1 Youth with schizophrenia are at high risk of diabetes: Opportunities for prevention and early intervention. Katherine Samaras Department of Endocrinology, St Vincent s Hospital Diabetes and Obesity Program, Garvan Institute of Medical Research Sydney, AUSTRALIA

2 REAL WORLD FAMILY EXPERIENCES: Will my daughter become like the rest of her group? Health trajectories in youth with psychosis 12 kg gain by 12 weeks APM initiation Secondary amenorrhea Acne, hirsutism Interrupted tertiary education

3 if youth with psychosis could expect -to keep the health they currently possess -to develop in education, life skills and fulfilling life experiences -parity of life expectancy These would be ours aims if the diagnosis was type 1 diabetes

4 Mind the life expectancy gap That people with SMI die 20 years earlier.., the majority from preventable causes, is one of the greatest health scandals of our time. Dame Professor Sue Bailey Past President Royal College of Psychiatrists Lawrence et al 2013 BMJ

5 Health trajectories in people with severe mental illness weight gain hyperlipidemia polycystic ovary syndrome diabetes heart disease hypertension cancer

6 The trajectory to poor health: weight gain on APM 20 First episode psychosis Established SMI 15 4 kg 3 kg kg kg Months Alvarez-Jimenez et al; CNS Drugs, 2008 Khan et al, Lancet 2008

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8 Opportunity #1: Prevent APM-induced weight gain 20 First episode psychosis Established SMI kg Start HERE, 5 NOW! STOP natural history 12 kg 4 kg 3 kg Months Alvarez-Jimenez et al; CNS Drugs, 2008 Khan et al, Lancet 2008

9 The effects of neglect after APM initiation in FEP Weight gain in 60% of treatment-naïve by 2-4 months % after 1-2 years Alvarez-Jimenez, months in APM-naïve youth 4.4kg aripiprazole 8.5kg olanzapine vs 0.2kg weight gain in controls Correll, 2009 weight gain (>7%) by 12 months in APM-naïve olanzapine 86% haloperidol 53% quetiapine 65% ziprasidone37% Kahn, 2008 Rapid onset metabolic abnormalities hyperlipidaemia by 12 weeks Perez-Iglesias, 2007 insulin resistance by 52 weeks Perez-Iglesias, 2009 In healthy volunteers, antipsychotics induced fasting and postprandial hyperinsulinaemia within 12 days Teff, 2013

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12 The Keeping the Body in Mind Program It s simple sharing diabetes prevention principles and expertise with mental health co-workers Address the barriers to healthy lifestyle Weekly individualised counselling: dietitian and exercise physiologist Weekly classes for life-skills training: health coaching cooking shopping Budgeting Daily access to a gym within the FEP Unit Controls: STANDARD CARE: FEP from a demographically matched service Curtis J et al, Early Int Psych 2015:DOI: /eip.12230

13 Who gained >7% baseline weight? 13% 75% P<0.001 Curtis J et al, Early Int Psych 2015:DOI: /eip.12230

14 Never miss an opportunity: weight neutrality APM- induced weight gain can be halted through individualized lifestyle interventions Weight neutrality is a realistic and attainable goal Replication: NHS undertaking studies in collaboration Curtis J et al, Early Int Psych 2015:DOI: /eip.12230

15 Grass roots co-ordinated person-centered care Psychiatrist MH Nurse Family physician Exercise physiologist Endocrinologist Occupational therapist Dietitian

16 Not-so-sweet young things

17 Diabetes & antipsychotic use in children and youth

18 Could diabetes rates be even higher? Ascertainment: diabetes symptoms (symptoms at >300 mg/dl, N<100) need for medication: worst hyperglycaemia Asymptomatic / untreated cases missed No routine glucose screening Likely underestimation Samaras K, Correll C, Mitchell A, De Hert M. JAMA Psych 2014; 71:

19 Medication-associated risk of future diabetes in SMI Antipsychotic medications: 2-5 fold increased risk High rates of undiagnosed diabetes (5-14%) High rates of pre-diabetes (33%) Antidepressants: Double risk for diabetes, even with lifestyle intervention Rubino et al Nurses Health Study: tripled rate Pan et al 2012

20 Missed Opportunity: No blood glucose screening

21 Prevention/Intervention Opportunity 2: glucose screen Pre-diabetes: F. Glucose > 5.5 mmol/l 100 mg/dl Diabetes: F. Glucose > 7.0 mmol/l 126 mg/dl R. glucose > 11.1 mmol/l 200 mg/dl HbA1c > 6.4%

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23 A sweet calamity synchronous schizophrenia and diabetes Worse control More frequent diabetic complications Worse CV risk factors More frequent amputations Higher rates of non-attendance Evidence of sub-standard care when they do attend Less treatment of CVD risk Less change in glucose lowering medications

24 Challenges in diabetes care Complex disease: highly organized, health-obsessed, adherent do better Costly: medications, monitoring, better foods Accessing the right food: challenges Poor nutritional choices: low quality, cheap foods Food literacy and access to kitchen Accessing physical activity: challenges Am I AWAKE enough? Can I leave home? Paranoia, safety Where do I exercise? Accessing medical care Clinics are in the mornings Clinics are noisy, loud I forgot.. (cognition, sedation) I was treated like a leper (treatment discrimination evidence)

25 Metformin with antipsychotic use MF at initiation olanzepine 15mg N=40, FEP mean age 25y MF after 10% weight gain, various antipsychotics N=128, mean age 26y, 9m schizophrenia Wu RR et al, Am J Psychiatry 2008; 165: Wu RR et al, JAMA 2008; 299:

26 More on metformin Curtis, Newall, Myles, Shiers, Samaras ; 27:

27 HeAL: Healthy Active Lives Jackie Curtis David Shiers Katherine Samaras Philip Ward Mario Alvarez Jimenez Debra Foley Eoin Killackey Stephanie Webster Christoph Correll Davy Vancampfort Richard Holt Jonathan Campion

28 Healthy Active Lives Ambitious 5 year targets The majority of people have: Regular review of medications No more than 7% weight gain Maintain healthy blood glucose, lipids and blood pressure

29 Healing is a matter of time but sometimes also a matter of opportunity Hippocrates

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31 Physical Fall-out of Anti-psychotic Medications Impacts of physical burden of disease in mental health: Disease in those who are most unable to deal with complex diseases Late presentation Economic costs of: Health, now and the future Lost potential workforce Premature loss of life: OECD

32 Changing our expectations of health in SMI weight gain hyperlipidemia polycystic ovary syndrome diabetes heart disease hypertension cancer

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34 mmol/l mmol/l mmol/l kg kg/m2 cm Results P<0.001 P<0.001 P<0.001 Weight BMI Waist circumference w 12w KBIM Standard care 10 KBIM Standard care 60 KBIM Standard care Glucose High density lipoprotein Triglycerides KBIM Standard care KBIM Standard care KBIM Standard care Curtis J et al, Early Int Psych 2015:DOI: /eip.12230

35 HeAL Plus International Network Objective: Collect data to record and report physical health» Examine if HeAL Outcome Targets are met Standardized: Sociodemographics Physical and mental health characteristics QoL Physical examination Metabolic and other measures Lifestyle measures Canadian iphys Satellite Symposium: Thursday 21 st May Early Psychosis Intervention Ontario Network (EPION)

36 Future practice in action: international links

37 Are we being honest when we talk about parity? How would we treat the 18 yo girl obese /pre-diabetic/pcos? Metformin use off-label? Evidence in: Pre-diabetes, impaired glucose tolerance, PCOS, obesity, early puberty RCT evidence in psychosis: APM-initiation AND long term