Fysisk aktivitet i psykiatrien. Clas Waagø Hansen Seksjonsoverlege/psykiater StOlav, Orkdal DPS

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1 Fysisk aktivitet i psykiatrien Clas Waagø Hansen Seksjonsoverlege/psykiater StOlav, Orkdal DPS

2 All fysisk aktivitet ved enhver (nesten) psykiatrisk diagnose er god behandling

3 Jfr Nasjonale retningslinjer for diagnostisering og behandling av voksne med depresjon i primær og spesialisthelsetjenesten, er fysisk aktivitet en riktig og viktig faktor i behandlingen hos denne gruppen av pasienter: Regelmessig fysisk aktivitet kan bidra til å redusere depressive symptomer ved lett til moderat depresjon. Fysisk aktivitet kan også være nyttig som et tillegg i behandling av pasienter som ikke har respondert tilfredsstillende på antidepressive medikamenter

4 Genetikk: schizofreni, bipolar og depresjon, økt risiko for hjertekar sykdom Livsstil: isolerende, sedat, kost, røyk, alkohol og stoff Medikamenter: Vi må være bevisst de somatiske effektene psykofarmaka kan medføre

5 Psykofarmaka: lithionitt tørste nevroleptika ulvehunger metabolsk syndrom SSRI vektøkning? QT forlengelse osv.

6 Bakgrunn:

7 Røyk og kosthold Kunnskap om aktivitet og kosthold mangler. Bivirkningen av legemidlene er bare en side av de dramatiske fysiske konsekvensene du ofte får oppleve om du blir alvorlig psykisk syk. Alvorlig psykisk syke røyker generelt også mer, er mindre fysisk aktive og har et dårligere kosthold enn andre. Dårligere økonomi bidrar også til å svekke pasientgruppens fysiske helse. Summen av disse faktorene er at mennesker med alvorlige psykiske lidelser lever 16 til 25 år kortere enn andre i befolkningen, skriver The Lancet. Tidsskriftet baserer seg blant annet på oppsummeringen av forskning om vektøkning som er gjort av forskerne Debra Foley og Katherine Morley ved Universitetet i Melbourne. Ta alvorlig Vi må trolig leve med dagens antipsykotiske legemidler en stund til. De store forskjellene i fysisk helse mellom psykisk syke og resten av befolkningen blir dermed en alvorlig utfordring for helsevesenet. Men mye kan gjøres om helsevesenet blir flinkere til å se psykisk og fysisk helse i sammenheng, mener The Lancet. Alvorlig psykisk syke møter langt oftere psykiatrisk helsepersonell enn de møter fastlegen og andre i helsevesenet. En god løsning er derfor at det psykiatriske helsepersonellet også tar hovedansvaret for å følge opp fysisk aktivitet, kosthold og røyking. Dette er noe psykiatrisk helsepersonell bør gjøre fra aller første gangen de møter pasienten, skriver The Lancet.

8 Depresjon er nesten like farlig som årøyke, viser studie. Forsker Arnstein Mykletun ved Det psykologiske fakultet ved Universitetet i Bergen slår fast at milde og moderate depresjoner er mer dødelig enn man tidligere har trodd. Depressive personer har 52 prosent større risiko for ådøi løpet av fem år enn en frisk person, mens den økte dødeligheten for en som røyker, er 59 prosent. I denne nye norsk britiske studien har forskerne også tatt høyde for at deprimerte røyker og drikker mer, og beveger seg mindre. Mykletun understreker dessuten at dødsfaren ikke er knyttet til selvmord, men andre sykdommer. Anxiety, depression, and cause specific mortality: the HUNT study.

9 Depresjon og kardiovaskulær sykdom er det en sammenheng? G Einvik T Dammen T Omland Nr april 2010, Tidsskr Nor Legeforen Bakgrunn. Depresjon er assosiert med høyere risiko for kardiovaskulære hendelser. Artikkelen gir en oversikt over data fra kohort og intervensjonsstudier og mulige patogenetiske mekanismer. Resultater. I epidemiologiske studier av pasienter utenfor sykehus med klinisk depresjon er det rapportert økt risiko for kardiovaskulære hendelser. Mulige mekanismer som kan forklare økt kardiovaskulær risiko, er økt forekomst av usunne livsstilsfaktorer, systemisk inflammasjon, endokrin og autonom dysfunksjon, økt platereaktivitet eller endoteldysfunksjon. Medikamentell antidepressiv behandling har ikke vært vist åredusere risiko for kardiovaskulære hendelser. Fortolkning. Leger bør være oppmerksomme på betydningen av depresjon for kardiovaskulær risiko.

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11 Hva poliklinisk setting Kan bidra til bedre samhandling mellom 1. og 2. linje gjennom oppstart, sikrer utvidete somatiske prøver. Avdekket så langt: DM, astma, kolesterol, BT m.m. Får treningsspesifikke råd fra Olympiatoppen v/johan Kaggestad (Modum Bad, Grete Waitz, Ingrid Kristiansen, sykkel m.m.)

12 1. eller 2. linje? I hovedsak et kommunalt ansvar men mangler et tilbud

13 Erfaring fra DPS Stjørdal ved oppstart: 0 i utstyr 0 i midler Avslag fra HNT, Sanitetskvinnene, mental helse, hjelpemiddelsentralen m.m Men masse goodwill fra lokal ledelse!

14 Erfaring fra DPS Stjørdal, Hva: 1 psykiater, 2 fysioterapeuter, 1 sykepleier og 1 vernepleier Daværende tilbud: Kondisjonsgruppe 2 grp, 16 ukers program Stavganggruppe 1 grp, 8 ukers (rullerende) Pilates: gruppe og individ Sykkelgruppe treningsmål: Fredagsbirken Partnerskap med Birkebeiner AS, sikrer deltagelse i alle ritt & løp.

15 DPS STJØRDAL VS ØSTMARKA DPS Stjørdal Østmarka: Grupper m/dynamikk Ute Somatiske prøver Ikke utstyr - foreløpig Overføringsverdi Kosthold mot. Intervj. Samarbeid kommune - snart? Individbasis Personlig trener Tredemøller Rett fra ICU Ansatte på kl

16 Brukes bevist som rp på: struktur i hverdagen psykisk og fysisk profylakse sosial eksponering bedre kjennskap til egen kropp Hvem

17 Hvem Alle pasienter ved DPS Stjørdal hadde tilbudet I hovedsak polikliniske pasienter Diagnosegrupper: mest bipolar og andre affektive tilstander Siden oppstart tidlig november 2009, ikke 1 avlysning Frafall: 2 stk, samt ferdige pasienter noen har endret grupper men ingen som har startet har falt ut, gått over i andre grupper pga form & meniskskade

18 Grunner for å møte opp: komme seg ut møte andre det er godt dusj/hygiene anker i virkeligheten kan justere sosial interaksjon gløder etter trening mestring positiv feedback ektefelle/barn Hvem

19 Endring i hverdag: ting går lettere hjemme fungerer bedre med barna bedre på jobb mer energi bedre selvbilde kjøpt pulsklokker Klær & sko sykkel fokus på/endret kosthold slutte årøyke Hvem

20 Utfordring: Hvilke av våre pasienter har ikke godt av fysisk aktivitet? Hvem

21 Selv om man de siste årene i økende grad er blitt klar over viktigheten av å følge opp kardiovaskulære og metabolske risikofaktorer hos pasienter med psykisk sykdom som bruker annengenerasjonsantipsykotika, måles fortsatt blodglukose og lipider for sjelden hos disse. K I Birkeland - prof. UiO/endokrinologisk nestor, Tidsskriftet feb. 2010

22 Dysthymia before myocardial infarction as a cardiac risk factor at 2.5-year follow-up. BACKGROUND: Despite its implications for treatment strategies, the potential role of previous depression on the medical course after coronary heart disease (CHD) has not yet been thoroughly studied. OBJECTIVE: The aim of this study was to determine whether the presence of major and minor depression, dysthymia, and demoralization in the years preceding the first myocardial infarction (MI) or angina, was associated with poor cardiac outcome at 2.5-year follow-up. METHOD: A group of 97 consecutive patients with acute CHD, admitted to a coronary-care unit, were studied while in remission from the acute phase of CHD. Various clinical depression measures were used to assess the occurrence or recurrence of mood disorders preceding the first episode of CHD (baseline visit) and at 2.5 years after the first interview. RESULTS: Among the variables examined as potential cardiac risk factors, only dysthymia attained statistical significance. DISCUSSION: Further research is needed to identify an effective treatment for dysthymic patients.

23 Plasma levels of lipoprotein (a) in patients with major depressive disorders. Depression and cardiovascular disease are among the most prevalent health problems. The evidence that depression is a risk factor for the development and progression of coronary heart disease has strengthened over the past several years, but the exact reasons are not yet clear. Elevated lipoprotein (a) (Lp(a)) concentrations seem to be the major factor for the progression of the atherosclerosis and coronary heart disease. In this study, we measured the plasma levels of Lp(a) in 35 patients with major depressive disorder and 35 healthy controls. The two groups were matched by age and gender. Lp(a) measurement was performed using an immunoturbidimetric method. Total cholesterol was significantly lower in the patient group (mean +/ SD: / vs / mg/dl. The Lp(a) levels of the patient group differed significantly from control values. Patients with major depressive disorder had higher plasma levels of Lp(a) than healthy controls (34.94+/ vs / mg/dl). The results of the present study suggest that the increase of Lp(a) may contribute to higher cardiovascular risk in patients with major depressive disorder.

24 Psychiatric characteristics associated with long term mortality among 361 patients having an acute coronary syndrome and major depression: seven year follow up of SADHART participants. CONTEXT: Major depressive disorder (MDD) after acute coronary syndrome (ACS) is associated with an increased mortality rate. We observed the participants of the Sertraline Antidepressant Heart Attack Randomized Trial (SADHART) to establish features of MDD associated with long term mortality. DESIGN: RESULTS: During the study, 75 participants (20.9%) died. Neither previous episodes of MDD, nor onset before or after the index ACS, nor an initial 6 months of sertraline treatment was associated with long term mortality. Cox proportional hazards regression models showed that baseline MDD severity (hazard ratio, 2.30; 95% confidence interval, ; P <.006) and failure of MDD to improve substantially during treatment with either sertraline or placebo (hazard ratio, 2.39; 95% confidence interval, ; P <.001) were strongly and independently associated with longterm mortality. Marked improvement in depression (Clinical Global Impression Improvement subscale score of 1) was associated with improved adherence to study medication. CONCLUSIONS: Severity of MDD measured within a few weeks of hospitalization for ACS or failure of MDD to improve during the 6 months following ACS predicted more than a doubling of mortality over 6.7 years of follow up. Because persistent depression increases mortality and decreases medication adherence, physicians need to aggressively treat depression and be diligent in promoting adherence to guideline cardiovascular drug therapy.

25 The influence of childhood obesity on the development of self esteem, Canada The current childhood obesity epidemic may trigger an increase in the population prevalence of low self esteem in the future. According to other research, low self esteem predicts poor mental health. The current childhood obesity epidemic may increase the prevalence of not only chronic diseases, but also poor mental health.

26 Association between common mental disorder and obesity over the adult life course, University College London. BACKGROUND: Prospective data on the association between common mental disorders and obesity are scarce, and the impact of ageing on this association is poorly understood. AIMS: To examine the association between common mental disorders and obesity (body mass index > or = 30 kg/m(2)) across the adult life course. METHOD: The participants, 6820 men and 3346 women, aged were screened four times during a 19 year follow up (the Whitehall II study). Each screening included measurements of mental disorders (the General Health Questionnaire), weight and height. RESULTS: The excess risk of obesity in the presence of mental disorders increased with age (P = 0.004). The estimated proportion of people who were obese was 5.7% at age 40 both in the presence and absence of mental disorders, but the corresponding figures were 34.6% and 27.1% at age 70. The excess risk did not vary by gender or according to ethnic group or socioeconomic position. CONCLUSIONS: The association between common mental disorders and obesity becomes stronger at older ages.

27 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders. 10 pkt (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no specialist involvement, while very common, is not regarded as an acceptable standard of care. Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved

28 Drawing up guidelines for the attendance of physical health of patients with severe mental illness. INTRODUCTION: Having a mental illness has been and remains even now, a strong barrier to effective medical care. Most mental illness, such as schizophrenia, bipolar disorder, and depression are associated with undue medical morbidity and mortality. It represents a major health problem, with a 15 to 30 year shorter lifetime compared with the general population. METHODS: Based these facts, a workshop was convened by a panel of specialists: psychiatrists, endocrinologists, cardiologists, internists, and pharmacologists from some French hospitals to review the information relating to the comorbidity and mortality among the patients with severe mental illness, the risks with antipsychotic treatment for the development of metabolic disorders and finally cardiovascular disease. The French experts strongly agreed on these points: that the patients with severe mental illness have a higher rate of preventable risk factors such as smoking, addiction, poor diet, lack of exercise; the recognition and management of morbidity are made more difficult by barriers related to patients, the illness, the attitudes of medical practitioners, and the structure of healthcare delivery services; and improved detection and treatment of comorbidity medical illness in people with severe mental illness will have significant benefits for their psychosocial functioning and overall quality of life.

29 Drawing up guidelines for the attendance of physical health of patients with severe mental illness, Frankrike. GUIDELINES FOR INITIATING ANTIPSYCHOTIC THERAPY: Based on these elements, the French experts propose guidelines for practising psychiatrists when initiating and maintaining therapy with antipsychotic compounds. The aim of the guidelines is practical and concerns the detection of medical illness at the first episode of mental illness, management of comorbidity with other specialists, family practitioner and follow up with some key points. The guidelines are divided into two major parts. The first part provides: a review of mortality and comorbidity of patients with severe mental illness: the increased morbidity and mortality are primarily due to premature cardiovascular disease (myocardial infarction, stroke...).the cardiovascular events are strongly linked to non modifiable risk factors such as age, gender, personal and/or family history, but also to crucial modifiable risk factors, such as overweight and obesity, dyslipidemia, diabetes, hypertension and smoking.

30 Psykisk syke dør 16 år før Alvorlig psykisk syke lever 16 år kortere enn gjennomsnittbefolkningen. Hjerte- og karsykdommer er den viktigste årsaken, ikke selvmord. Kunnskapsoppsummeringen er basert på forskning gjort flere steder, og resultatene er nedslående. Pasienter som ble satt på det vanlige antipsykotiske legemiddelet olanzapine for første gang, la etter bare 6-8 uker i gjennomsnitt på seg 5 til 6 kilo. Tilsvarende resultater fant forskerne av andre antipsykotiske legemidler. Etter å ha tatt olanzapine i ett år konkluderte ulike forskningsprosjekter med at pasientene veide mellom 8 og 17 kilo mer enn de gjorde da medisineringen begynte. For alle andre pasientgrupper enn alvorlig psykisk syke ville en slik bivirkning av medisineringen ha blitt sett på som svært alvorlig, slår det ledende medisinske tidsskriftet The Lancet fast. 50 år gamle Hadde det vært snakk om andre pasientgrupper, ville behandlingsapparatet ha lagt stor vekt på å finne nye behandlingsmåter. Men det lar seg fortsatt vanskelig gjøre innenfor psykiatrien. Her må medisineringen i store trekk gjøres med de samme legemidlene som vi har hatt i snart et halvt århundre, skriver det The Lancet. Risikoen knyttet til bruk av antipsykotiske legemidler er derfor en risiko pasient og lege tvinges til å ta. Men vi kan likevel ikke slå oss til ro med en situasjon hvor vi tvinger noen til å velge bedre psykisk helse på bekostning av sin egen fysiske helse, slår tidsskriftet fast i en lederartikkel.

31 The effectiveness of exercise on improving cognitive function in older people: a systematic review. Tseng CN, Gau BS, Lou MF. Source 1RN, MSN, Doctoral Student, Department of Nursing, National Taiwan University 2RN, PhD, Assistant Professor, Department of Nursing, National Taiwan University 3RN, PhD, Associate Professor, Department of Nursing, National Taiwan University. Abstract BACKGROUND: : The well-documented physical benefits of exercise and the value of exercise for improving mental health have raised the profile and role of exercise in healthcare. However, studies evaluating the effects of exercise on neurocognitive function have produced equivocal results. PURPOSE: : This study was designed to examine the effectiveness of exercise on improving cognitive function in older people. METHODS: : Researchers used a narrative synthesis approach in this review and conducted a computer-based search in MEDLINE, CINAHL, Cochrane Library, and Airiti Library (Chinese) from 2006 to 2009 using the search terms exercise, physical activity, and cognition. Research quality appraisal was rated using Consolidated Standards of Reporting Trials criteria. RESULT: : This review included 12 medium- to high-quality randomized controlled trials. Most studies examined used a 60-minute exercise regimen scheduled three times per week that was continued for 24 weeks. Of the 12 studies, 8 revealed that exercise can improve cognitive function. Five studies focused on healthy older people and three studied older people who had impaired cognition at baseline. Analysis of the studies showed simple, one-component exercise as better for older people with cognitive impairment and multicomponent exercise as better for those without such impairment. CONCLUSIONS/IMPLICATIONS FOR PRACTICE:: This systematic review demonstrated that an exercise regimen of 6 weeks and at least 3 times per week for 60 minutes had a positive effect on cognition. Whether multicomponent exercise is significantly more effective in improving cognitive function, particularly in healthy older people, should be tested using larger trials with more rigorous methodology.

32 Exercise for the treatment of depression and anxiety. Carek PJ, Laibstain SE, Carek SM. Source Department of Family Medicine, Medical University of South Carolina, Charleston 29406, USA. Abstract Depression and anxiety are the most common psychiatric conditions seen in the general medical setting, affecting millions of individuals in the United States. The treatments for depression and anxiety are multiple and have varying degrees of effectiveness. Physical activity has been shown to be associated with decreased symptoms of depression and anxiety. Physical activity has been consistently shown to be associated with improved physical health, life satisfaction, cognitive functioning, and psychological well-being. Conversely, physical inactivity appears to be associated with the development of psychological disorders. Specific studies support the use of exercise as a treatment for depression. Exercise compares favorably to antidepressant medications as a first-line treatment for mild to moderate depression and has also been shown to improve depressive symptoms when used as an adjunct to medications. While not as extensively studied, exercise has been shown to be an effective and cost-efficient treatment alternative for a variety of anxiety disorders. While effective, exercise has not been shown to reduce anxiety to the level achieved by psychopharmaceuticals.

33 Lack of physical activity during leisure time contributes to an impaired health related quality of life in patients with schizophrenia. Vancampfort D, Probst M, Scheewe T, Maurissen K, Sweers K, Knapen J, De Hert M. Source University Psychiatric Centre Catholic University Leuven, Campus Kortenberg, Kortenberg, Belgium; Faculty of Kinesiology and Rehabilitation Sciences, Catholic University Leuven, Leuven, Belgium. Abstract OBJECTIVE: The aim of the present study was to identify if lack of physical activity participation and an impaired functional exercise capacity compared with healthy controls contributed to an impaired health related quality of life (HRQL). We also evaluated whether the presence of metabolic syndrome (MetS) could explain the variability in HRQL in patients. METHOD: Patients with DSM-IV schizophrenia (n=60) and age- and gender-matched healthy controls (n=40) completed the SF-36 quality of life scale and the Baecke Physical Activity Questionnaire and performed a 6minute walk test (6MWT). Patients also received a fasting metabolic laboratory screening. Linear multiple regression analysis was used to assess the associations between demographical and clinical variables and HRQL outcomes. RESULTS: Physical and mental HRQL and the Baecke and 6MWT-scores were significantly lower in patients with schizophrenia compared with matched healthy controls. When in schizophrenia patients all individual HRQL-predictors were included in a regression model, only BMI and lack of PA during leisure time remained significant predictors for physical HRQL while for mental HRQL no significant predictor remained. The impaired functional exercise capacity and the presence of MetS did not additionally explain the variance in HRQL. CONCLUSIONS: Physical HRQL in patients with schizophrenia is not only related to increased BMI but also to lack of leisure time physical activity. A reduced physical HRQL in patients with MetS appears to be related to their greater BMI, rather than to MetS per se. Present findings provide further support for routinely incorporating physical activity within rehabilitation programs and clinical assessments.