Guest: Roger Chen
Presenter: Tabetha Moreto
Guest Bio: Roger Chen is Director of Diabetes Services and Senior Staff Specialist in the Department of Endocrinology and Metabolism in Concord Hospital with clinical interests in general endocrinology, osteoporosis and diabetes. He is a Clinical Associate Professor in Medicine at the University of Sydney and Adjunct Professor at the University of Technology, Sydney. He is head of a large medically led multidisciplinary diabetes team incorporating exercise and diet intervention in addition to nurse, medical and psychological assessment.
Segment Overview: Roger Chen talks about the position statement of Australian Diabetes Society (ADS) aimed at assisting healthcare providers to better support people living with serious mental illness and type 2 diabetes in light of the World Mental Health Day, October 10 2017.
TRANSCRIPT – World Mental Health Day
Tabetha Moreto: Hello everyone, welcome to Health Professional Radio. I’m your host for today, Tabetha Moreto. Our guest today is Roger Chen. He was the Lead author of the position statement and the Director of Diabetes Services at Conquer Repatriation General Hospital in Sydney. Today, we’re going to talk about a very interesting topic. We’re going to talk about a position statement created by the Australian Diabetes Society or ADS aimed at assisting healthcare providers to better support people living with serious mental illness and type 2 diabetes in line of World Mental Health Day. Without further ado welcome to the show Roger. It’s very nice to have you here today.
Roger Chen: Thank you very much, Tabetha and good to speak to you.
T: Yes, me too. So Roger please tell our audience more about yourself and your organization please.
R: Right, so my name is Roger Chen. I’m an Endocrinologist in Sydney. I work at Concord Repatriation General Hospital which is a tertiary teaching hospital in the Western suburbs of Sydney. And it is also co-located interestingly and uniquely with a mental health hospital called the Concord Center of Mental Health. And this was actually what used to be the old Roselle Hospital. So in fact we have a general hospital and also a mental health hospital on the same site. And when that co-location happens it must be more than ten years ago, a research and clinical center now called the Collaborative Center for cardio-metabolic health in psychosis was formed. So this is a clinical unit which specializes in the care of patients with mental illness such as schizophrenia and bipolar disorder. And the patients are seen in various locations including Concord Hospital but also at the Charles Kirkland Center at the University of Sydney and also in some community centres where patients with psychosis get seen by a range of health professionals including an endocrinologist but also psychiatrist, a cardiologist and exercise physiologist, dietitian, dentists and also a mental health and clinical nurse consultant. This is a very important initiative and we’re very grateful for the support of Sydney local health district because we know that patients with psychotic illnesses such as schizophrenia have a very high rate of comorbidities which relate to obesity, diabetes but also premature cardiovascular disease. And we know also that the life expectancy of these patients may be in fact shortened quite significantly as compared to the general population. So what we are trying to do here is provide an integrated care package if you like for these patients to provide management both from the psychiatry point of view but also from the physical health point of view with the diabetes input if they’re needed and also a cardiologist seeing the patient. But what’s been really handy as well is having an exercise physiologist who can talk about increasing physical activity and also a dietitian who can try to have some input to improve the dietary habits of our patients. And all these we hope will contribute to improving the currently rather tragic statistics that this population, it has such a high rates of cardiovascular disease and other complications. So we’re trying very hard to provide an integrated care package from a range of health professionals who provide a care from their own perspective but ultimately is integrated and we hopefully will have some input in the short and long term to improve the care of these patients.
T: Very fascinating. Roger I’m very curious because according to the position statement, it looks like that diabetes and mental illness are related to one another. Can you please explain how are these two conditions associated with one another?
R: Thank you Tabetha. That’s the really important point and often not well recognized. As you know there are different types of mental illness and the one I guess which is well recognized being linked to diabetes is depression. We know that depression is a risk factor for diabetes and diabetes on the other hand is also a significant risk factor for developing depression. So there’s a what we call a bidirectional relationship. So one is the risk factor for the other and it also happens the other way around and we’ve known that for a while. And the coexistence of depression and diabetes in fact can result in more complications and more adverse outcomes as well. But what hasn’t been so well appreciated is the fact that mental illness itself as is psychosis, schizophrenia, bipolar disorder is what we call psychotic disorders, also increase the risk of not only diabetes but the obesity and general metabolic disorders such as high cholesterol so hyperlipidemia and obesity and all those typical I guess risk factors for developing cardiovascular disease. We think that why this happens is complicated, there is some genetic basis. It’s something with the condition of schizophrenia or psychosis of itself which increases the risk of developing obesity, diabetes, and metabolic disease. We know that lifestyle plays a huge role and that’s why we’re trying to have some input to improve the lifestyle of these patients. So increasing physical activity, improving diet and very importantly trying to reduce the current, very high rates of smoking in this population, all of which lead to cardiovascular disease. But on top of that we have the genetics. We have the lifestyle but we also know that some of the treatments used, the medications used in the treatment of psychosis can also potentially increase the risk of diabetes and metabolic disease as well as hyperlipidemia. So it’s a complicated situation, we can’t change the genetics at least at this stage but we certainly can change the lifestyle where we can intervene there. And we can also certainly try to rationalize medications so that ideally that’s safer ones for use. Although it’s still very important that any patient with a psychotic disorder, these psychiatrists ensure that they have the best medication for their condition, that’s really important. But you’re right, this is a fascinating interrelationship which had been I guess recognized for a while but it really hasn’t been in the spotlight if you like for until probably about ten years ago. Now interestingly, ten years ago there was actually a position statement or a consensus statement written by one of my colleagues as first author Professor Tim Lambert and Dr. Leon Chapman in Melbourne which highlighted this relationship between psychosis and diabetes. But in that 10 years, we found that in fact it’s been very little improvement to the care of patients with psychosis. So we thought it was timely that a second position paper be written to try to persuade and provide some guidelines that patients with psychosis should be monitored for metabolic disease. So they should have to weigh down, they should have their waist circumference measured. They should have their blood glucose levels done appropriately. They should have the lipid levels measured and if any of these are at normal they should ideally have a referral back to their GPs or be referred to a Diabetes Center where it’s appropriate or be referred to people skilled in the care of patients with diabetes and metabolic diseases.
T: Wow. This does sound like a very fascinating but at the same time very complicated issue. So now Roger, I want to ask are people with diabetes automatically more prone to get mental illnesses compared to people who don’t have diabetes?
R: So if we’re talking about diabetes itself and we have type 1 diabetes, type 2 diabetes and various other types of diabetes, we know that diabetes is a risk factor for developing depression. And if you’re type 1, there’s also diabetes related distress, there’s anxiety, there are other types even like mental illnesses but the prime example would be depression. So diabetes leads to depression – depression leads to diabetes. But what we’re focused here much more on in this position paper to relationships between a psychosis or psychotic disorder. So that schizophrenia and bipolar disorders, if you like a different part of the spectrum of mental illness and they tend to increase the risk of diabetes as well. Whether diabetes increases risk of psychosis is probably not quite proven, probably if it does anything as much to a lesser extent as compared to the psychosis which increases the risk of diabetes and cardiometabolic disease. So in other words we’ve got that depression and diabetes relationship well known but we’re not focusing on that perspective in this position paper. What we’re focused on is psychosis and the fact that we have to identify and screen patients, we then have to make sure that the results of the screening their blood pressure, their blood tests gets seen by someone and interpreted and then they are managed appropriately and followed up if their weights gone up they need to be followed up the appropriate health professional whether it’s a doctor or exercise physiologist or a dietitian. We know basically it needs to be reviewed and managed and we think that’s what’s been missing. Often people are screened but they’re not followed up with an adequate management plan. That’s why we need to build a relationship in those working in mental health back to their GPs, back to the patient’s GP and then referring the patients if necessary to those looking after in what we call physical help. So those working in mental health, being able to refer patients who are at risk of developing metabolic disease to those who actually look after it. So that’s diabetes educators, dietitians, endocrinologist, GPs, physicians, cardiologists, etcetera.
T: Wow, that’s a lot of people.
R: What we want to do is to actually reduce the morbidity that results from mental illness and smoking and if you like, poor lifestyle. We want to try to improve people’s lives to reduce the risk of dying prematurely and developing heart attacks and strokes, etc. at an early age.
T: Fascinating. Now I’m curious Roger, earlier you mentioned about depression, anxiety and psychosis. I’m curious are these three conditions the same or they different from one another?
R: Oh no, they’re quite different. I’m not a psychiatrist or a mental health expert by any means and I mentioned the depression aspect because you asked if there was a relationship between mental illness and diabetes. And there’s a very clear relationship between depression and diabetes. People with diabetes get depression. People with depression get diabetes. So it’s a bidirectional relationship. The people with diabetes can also develop what we call diabetes related anxiety and a few other disorders. Now schizophrenia or psychosis is the other end of the spectrum, it’s a psychotic disorder. So people, there’s various definitions but basically there might be hallucinations and false beliefs etc., but it’s a complicated condition which psychiatrists are much more skilled at defining and managing. But it’s quite different from if you like someone with a degree of anxiety or depression, this can be a much more debilitating and disabling condition. And we know that people with schizophrenia for example, a small proportion end up in long term residential care while hopefully a reasonable portion back in their normal lives, able to work, able to function and about a third end up being in and out of care or having to see that their helped by professionals very regularly. So the whole spectrum of conditions but it’s quite different from just pure depression and pure anxiety. But again, I’m not an expert in psychiatry. So I deal with the metabolic or diabetes side and that’s where the position statement came out from. It was one of the National Diabetes Services Scheme’s initiatives some years back to ensure that one of these position statements, that a position statement could be written concerning to care or patients of psychosis.
T: Thank you very much Roger for explaining that to me. I really appreciate that, because this is a very fascinating topic, because diabetes as we all know is a condition that affects a person’s blood sugar levels and I never imagined that diabetes and mental illness have a co-relationship with one another.
R: Yes, it’s a fascinating thing. You’re right. When I was, I guess, going to med school they thought diabetes which is high sugar but in fact we recognized that it’s one of the most complex conditions that we have to look after. Patients with diabetes have a whole potential array of other disorders including weight gain, obesity, blood pressure problems, cholesterol problems. Many will have sleep disorders, other complications include in vector joint disorders. Sometimes they got bad teeth, there may be depression as well. And of course diabetes is leading to a significant increased risk of cardiovascular disease. So it is a very complex condition and like every diabetes patient is a bit different. So what we focus here on it and see the spectrum so that the group of people with what we call severe mental illness, so psychosis again who seem to be particularly at risk of developing diabetes and also cardiovascular disease.
T: Excellent. Roger, I’m very sorry we’re almost out of time. So before we go, how can people get in touch with you or your organization?
R: Well I think on behalf of the NDSS, there is a website to look at the position statement. That’s on the Australian Diabetes Society website. If they look that up, the position statement is available for downloading and so the position statement’s been written on behalf of the Australian Diabetes Society. And if they do want to be in contact with any of the others, I guess if you go through the society but any specific, I guess questions can also come through me, through these societies. I’m sure they’ll be very happy to pass on my contact details for me to contact the person asking the question.
T: Very well said. Before we go, what is your main takeaway message to all of our listeners out there?
R: Okay. That’s always a challenge and a few take-home messages – number one, schizophrenia and psychosis lead to an increased risk of metabolic disease including diabetes. Number two, one has to go beyond screening. It is not good enough just to check the blood pressure, check the blood sugar, but you have to make sure that the results are interpreted. And that the patient is managed by their GP or endocrinologist, if that’s appropriate or other health care professional. Thirdly, we have a group of people who are severely I think a disadvantage in the health system for a number of reasons and it’s our aim really to try to improve their health care to that of the general population. We’re not aiming for extraordinary changes but we want to ensure that these patients have their blood pressure checked, their sugar levels checked, their weight checked, that they are counseled to stop smoking. And that we work very importantly in conjunction or in collaboration with a psychiatrist to psychologist or mental health nurse or caseworker. So it’s a whole complex system but it means that people have to chip in, talk to each other and work together. And that’s why we’re so privileged in doing in our Centre at Sydney local health district with the CCChip clinic or the Collaborative Centre for cardiometabolic health and psychosis. A bit of a mouthful but a multidisciplinary clinic where hopefully the different parts of the patient’s healthcare gets looked after. So we’re very grateful for the chance of doing this.
T: Thank you for your wonderful message Rodger and I really appreciate you coming on the show today.
R: Thank you very much.
T: And that was Roger Chen, the Lead author of the position statement regarding helping people with mental illness and type 2 diabetes. We’ve just been talking about how these two conditions can be associated with one another. If you liked this interview, transcripts and archives are available at www.hpr.fm. We’re on all social media platforms so don’t forget to follow, like and subscribe. We’re also available for download on SoundCloud and iTunes. I’m Tabetha Moreto and you’re listening to Health Professional Radio.