Why the Lester Lab-in-the-Bag? for People Experiencing Psychosis Professor Paul French: Associate Director Greater Manchester Mental Health NHS FT, Early Intervention in Psychosis lead NHSE North Dr David Shiers: former GP North Staffordshire, honorary reader in Early Psychosis, Manchester Univ Cromwell House February 24th 2017 e: david.shiers@doctors.org.uk Early Intervention in psychosis NSF mental health policy implementation RADICAL UPSTREAM YOUTH FOCUSED INTENSIVE COMMUNITY-BASED NOW  MOST YP WITH P CAN ACCESS EIS IN ENGLAND  LESS CRISIS, MORE PROACTIVE EBM INTERVENITIONS WHICH ARE AGE AND PPHASE SPECIFIC DECREASING TURMOIL OF FEP UNDERSTANDABLE FOCUS HOWEVER I  ATTENTION TO ANISSUE WHICH MAY GET OVERLOOKED – IMPACT OF P ON DOWNSTREAM PHYSICAL HEALTH 25YRS LOSS OF EXPECTANCY – GREATER CONTRIBUTION TO THESE PREMATURE DEATHS FROM PHYSICAL EXPLANATIONS THAN FROM SUICIDE MY HOPE IS YOU WILL TAKE AWAY TO KEEP BODY IN MIOND NEXT TIME YOU SEE A YP WITH A DIAGNOSIS OF PSYCHOSIS IN YOUR SURGERY

Dame Professor Sue Bailey 2013 2016 The fact that people with severe mental illness die twenty years earlier than the rest of the population, the majority from preventable causes, is one of the biggest health scandals of our time, yet is very rarely talked about. Dame Professor Sue Bailey

12 kg 4 kg kg Months 3 kg First episode of psychosis RCTs Figure 1. ANTIPSYCHOTIC-INDUCED WEIGHT GAIN IN CHRONIC AND FIRST-EPISODE PSYCHOTIC DISORDERS: A SYSTEMATIC CRITICAL REAPPRAISAL 20 Established Psychosis RCTs Established psychosis RCTs 3 kg 15 4 kg kg 10 12 kg 5 First episode of psychosis RCTs 12 24 Months 36 48 Published with permission from Dr Mario Alvarez-Jimenez. Data from Alvarez-Jimenez et al; CNS Drugs, 2008 22: 547-562

Metabolic risk factors in first-episode schizophrenia: baseline prevalence and course analysed from the European First-Episode Schizophrenia Trial CINP 2012 doi:10.1017/S1461145712001241 Fleischhacker WW, Siu CO, Bode R, Pappadopulos E, Karayal ON, Kahn RS, and the EUFEST study group Overall baseline prevalence of metabolic syndrome was 6.0%, with similar rates observed in the antipsychotic-naive patients (5.7%) and in the other patients with only a brief prior exposure to antipsychotics (6.1%).

...on a path to obesity, type 2 diabetes, cardiovascular disease and premature death METABOLIC SYNDROME Central obesity Insulin resistance Dyslipidemia Hypertension + SMOKING Metabolic Syndrome is a clinical concept whose presence predicts higher rates of CVD and type 2 diabetes The primary abnormality is an abnormal waist circumference This may drive the other abnormalities listed

Relative to gen population CVD Risk Factor SCHIZOPHRENIA BIPOLAR DISORDER Rate Relative to gen population Smoker 50-80% 2-3x 54-68% Obese 45-55% 2x 21-49% 1-2x Physically inactive 70% 1.5-2x Hypertension 19-58% 35-61% Type 2 diabetes 10-15% 8-17% 1.5-3x Lipid disturbances 25-69% ≤5x 23-38% ≤3x Adapted from De Hert et al (2011) Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry, 10: 52-77 And Lindamer et a (2008) Assessment of physical activity in middle-aged and older adults with schizophrenia. Schizophr Res, 104: 294-301 l

“The provision of good medical care tends to vary inversely with the need for it in the population served.” Julian Tudor Hart Glyncorrwg 1971

www.rcpsych.ac.uk/quality/NAS/resources UK intervention framework launch 2012, update 2014 Collaborative approach to tackling CVD and T2 diabetes risks in any service setting. Supported by key Royal Colleges Rethink Mental Illness, Faculty of Public Health, Diabetes UK Core of NHSE CQUINs 2014/19 www.rcpsych.ac.uk/quality/NAS/resources

Glucose and lipid disturbances DON’T JUST SCREEN… Smoking Poor diet & inactivity Glucose and lipid disturbances Hypertension Poor prescribing

2013-15 DON’T SCREEN, INTERVENE JUST 2013: NICE guideline CG 155 Children and young people experiencing psychosis and schizophrenia 2014: NICE guideline CG 178 Adults experiencing psychosis and schizophrenia 2015: NICE Quality Standard 80 www.rcpsych.ac.uk/quality/NAS/resources Mention iphYs development and NSW health support