Physical health in Psychiatry Dr Thushara Stanly ST4,Adult Psychiatry

Why we need to consider physical health? Mortality rate in patients with mental health problems is twice than the general population The excess mortality is related to natural causes than substance misuse and side effects to medications

Aim Improve awareness and knowledge among the staff Focussed approach -what is your role? -can you make a change ?

Why is it difficult? Lack of engagement/compliance Lack of training

Morbidity/mortality rate in psychiatry patients -Genetics -Medication -Poor diet -Lack of exercise -Smoking -Substance misuse

May be -poverty/unemployment /poor housing They are less likely to report their physical problems due to -Cognitive impairment -Social isolation -Paranoia

How we can manage the situation Understanding the presentations of illnesses Improve assessment skills Improve monitoring Health education and promotion

TRAINING NEEDS CPR –basic techniques Anaphylaxis First aid Wound care and pressure care Infection control Neurological observations MEWS scores

Venepuncture Cardiovascular effects of medications Assessing BMI Diabetes diagnosis Abnormal lipid profile Medical emergencies

Organic causes for psychosis Epilepsy/headinjury/tumours/dementia/ stroke/encephalitis Thyroid /parathyroid /Addisons/Cushings Electrolyte imbalance Steroids/Ldopa/antihypertensives/ anticonvulsants/Ritalin/anticholinergics Illicit drugs- cannabis/cocaine/Opiods/LSD/amphetamine

Organic causes of depression Elipelepsy/stroke/tumours/dementia/head injury/MS/Parkinson SLE/rhuematoidarthritis HIV/infectious mononucleosis Thyroid/parathyroid/cushings/addisons/b12 /folate deficiency Cardiac disease-MI/CCF Alcohol/benozodiazepines/cannabis/cocaine/ opiods

Examination /Investigations BP/pulse/weight Physical exam-rule out physical causes Bloods –depending on physical condition and medications routine –fbc/uec/lft/thyroid/calcium ECG

Antidepressants- Tricylics –ECG/weight gain Mirtazapine-Weight gain Venlafaxine high doses –BP Serotonin syndrome

Mood stabilisers Valproate-FBC/LFT Lamotrigine-FBC/LFT Lithium-FBC Lithium levels/UEC -3 monthly Thyroid -6 monthly ECG –yearly

Lithium and side effects Polyuria and polydypsia Weight gain Oedema Vomiting/diarrhoea Confusion/tiredness/impaired co-ordination Hairloss/acne

Antipsychotics Yearly- FBC/LFT/Lipids/glucose/ECG Neuroleptic malignant syndrome Diabetes /hyperlipidaemia QTc prolongation > 470 in men > 500 in women

Clozapine and side effects Sedation Hyper salivation/nausea/constipation Nocturnal enuresis Hyper/hypotension Cardiomyopathy/arrythmias/myocarditis Pulmonary embolism Agranulocytosis Metabolic syndrome

Obesity-abdominal circumference /BMI High blood pressure>140/90 Glucose -microalbuminuria

BMI- BMI Categories: Underweight = <18.5 Normal weight = 18.5–24.9 Overweight = 25–29.9 Obesity = BMI of 30 or greater

Waist Circumference This risk goes up with a waist size that is greater than 35 inches for women or greater than 40 inches for men

diagnosiS- diabetes mellitus  Diabetes symptoms (ie polyuria, polydipsia and unexplained weight loss) plus  a random venous plasma glucose concentration > 11.1 mmol/l or -a fasting plasma glucose concentration > 7.0 mmol/l (whole blood > 6.1mmol/l) or -two hour plasma glucose concentration > 11.1 mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT).

With no symptoms diagnosis should not be based on a single glucose determination Impaired Glucose Tolerance (IGT)* is a stage of impaired glucose regulation (Fasting plasma glucose 7.8mmol/l but < 11.1 mmol/l).

Lipids Cholesterol levels >6.5 mmol/L. It is characterised by increased levels of LDL- cholesterol (> 4.0 mmol/L). Triglyceride levels are < 2.3 mmol/L.

In familial hypercholesterolaemia characteristically total cholesterol is > 7.5mmol/L, LDL-cholesterol is > 5.0 mmol/L and triglyceride is < 2.3 mmol/L

Non-drug treatment: – Diet: low fat, avoid alcohol – Other measures: avoid smoking and increase exercise Drug treatment – Statin therapy for the primary prevention of CVD for adults with 10-year risk of developing CVD

Delirium tremens Acute confusional state Occurs in 5% of episodes of withdrawal Peak incidence -48 hrs Fluctuating consciousness /clouding of consciousness Disorientation Amnesia Agiatation Hallucination

Raised temp/pulse Mortality -5-10%

Serotonin syndrome Confusion/coma GI symptoms-Nausea/ Diarhoea Rigidity/tremor/myoclonus/increased reflexes/ataxia/seizures Temp and pulse increased/low or raised BP/ Dilated pupils

Neuro-leptic malignant syndrome Confusion/altered sensorium/rigidity Temp and pulse increased/low or raised BP Sweating/tremor/retention or incontinence of urine

Difference between NMS and Serotoin syndrome NMS SS Antipsychotics Serotonergic agents onset slow Rapid progression slow Rapid led pipe rigidity less severe Bradykinesia Hyperkinesia

Management Bring down temp Hydrate Withhold or reduce the medication If severe, transfer to emergency treatment Medical treatment available

Health education Avoid smoking /alcohol Exercises and activities Engaging in monitoring-BP/pulse/bloods/ECG /physical examination Getting help in emergencies

This is to certify that: Has reviewed/completed Physical Health in Psychiatry Date