Hello. Welcome everyone. Good morning. We're gonna get started. We have a lot to cover today and we also have some time for breakout groups so we want to make sure there's time for all lots of good discussion. Today, welcome, we're going to talk about caring for the whole person. So a practical update on common medical psychiatric comorbidities and preventative care for clinical practice. I'm Dr. Richards. I'm one of the faculty at UC Davis Health. I'm dual boarded in family medicine and psychiatry. I spend about 50% of my time doing each of those but as you know everything overlaps. Hi, I'm Sandy Ngomu-Barak. I'm currently a psychiatry resident here at UC Davis and I did primary care. I did the primary care track at UC Davis and so I'm very still very passionate about it and I find time to incorporate it in my practice now. Okay, so we don't have any financial disclosures but we do want to mention some name brands for medications and also talk about off-label use for medications as well. So the objectives today are to recognize our role as a clinician, advocate, and educator to reduce the life expectancy disparities for people with schizophrenia and bipolar disorders, utilize real-life cases to explore how coexisting conditions impact mental and physical health, and review treatment options, and develop strategies to integrate preventative care into your practice, and coordinate care to improve health outcomes for people living with psychiatric disorders. So first we're going to talk about some of the impact of comorbidities. All you're familiar you've seen this in your care but first I want everyone to think about a patient that you saw who had both psychiatric and medical conditions. It could be pretty much any patient but I'm sure there are some specific ones that might come to mind. And we know the brain and the body are very connected. This is a comic from Awkward Daddy about anxiety and how it impacts the brain and the body. We also know health is complicated. There's so many things that come into health. I'm thinking about social, economic, political factors, living, working conditions, public infrastructure and services, individual behaviors, individual factors, all of those are incorporated into our health. And we know everything affects everything. This is a summative slide but mental health disorders affect our medical conditions and I want to also point out adverse childhood experiences in the middle plays a role in both. Affects both our brain and our body. And we know these have real health effects. And so looking at the average childhood experiences studies, having four or more increases risk of diabetes by 1.6 times, cancer by 1.9 times. So think about like finding a cure for cancer, thinking about what we can do to help reduce the effects of adverse childhood experiences on people. Smoking, which affects many, many, many of our patients. Ischemic heart disease, stroke, alcohol misuse, injecting drugs, attempting suicide, all of those are important. And adverse childhood experiences, in case you're not familiar, are listed below. These are just nine. We know there's many more but these were the main ones that were included in the studies. And in the middle of the pandemic, the CDC also created some priorities. And looking at adverse childhood experiences, overdose, and suicide, how each of those are affected and where the opportunities for intervention are, was one of their highest priorities even in the middle of pandemic. So these are definitely important things to think about in our practice. So a quick question, what is the life expectancy gap for people with schizophrenia or bipolar disorder? Do you think it's 1 to 5 years, 5 to 10 years, 10 to 25, or 25 to 35? Oh, we had raised, yeah. If someone wants to shout out or we can do a vote. 5 to 10? Okay, I've got one vote for that. D? C? So kind of all over? Yeah, the answer is actually C, 10 to 25 years. It's a long time. That's a huge, huge gap. And so that was one of the things that motivated me when I was thinking about my career, is I wanted to see what could we do to help decrease that? What can we do to help people live longer, healthier lives? And so looking at important comorbidities for people with mental health disorders, cardiovascular disease is still the most common cause of death. And so when we're thinking about our patients, we want to keep that in mind. And in cancer, especially lung cancer, if people have increased rates of smoking, they can be disproportionately affected by lung cancer. And it might be found later or more advanced stages. And then diabetes is two to three times more common. And so we know some of our medications can increase risk of diabetes. Also some of our patients may have less access to care or less utilization of care. And depression alone increases risk of diabetes, has a 60% increased risk of diabetes. And then it's harder to manage your diabetes if you have depression as well. Chronic respiratory disease, COPD rates are 22.6% in people who with diagnosis of schizophrenia and bipolar disorder versus 5% of the general population. And smoking is estimated to be 70 to 80% for people with schizophrenia or bipolar disorder versus 10 to 15% in the general population. And these are, this is data from the World Health Organization. And then also smoking also increases risk of diabetes complications. So all these things intersect. So as psychiatrists, we're frontline providers, we're educators, and we're also advocates for our patients. So I'm gonna turn it over. We'll talk about preventative care, then we'll do a brief group exercise. So we'll split into some small groups, talk about a case, and then we'll talk about another case, and then talk more about comorbidities. So before I begin, I just want to stress the importance of knowing that, like, as psychiatrists, we actually, we have the privilege to seeing our patients sometimes more than once, you know, a year, like some of our PC, primary care providers, and we build relationships with them. And sometimes they might, we might be the only ones they truly trust. So if we have the opportunity to just ensure that they do get the care, it's important. So I'll begin with some basic, simple infectious disease labs. You know, whether you're an inpatient provider, an outpatient provider, some of the basic labs that are pretty fast in return when you get them would be HIV. You want to make sure you get the combo screen, and most of your labs should have the fourth gen now. Hepatitis C, as well as Hep B, and then syphilis as well with the reflex, or you can get the RPR. Especially since syphilis is, the rates are increasing, and especially women who are at high risk during pregnancy, you do do a three-time screening. It's prenatal, and then at 28 weeks, and then also right after delivery. We also won't go ahead and do the chlamydia and gonorrhea, which you can screen via urine or swab, and then TB. And then just kind of treatment tips, you know, it's important to really get, to make sure that if we do have patients who have HIV or Hep C, there are treatments that are effective. So finding it early and getting them treated is really important. And then in terms of pregnancy prevention, given the teratogenicity of some of our psychiatric medications, this is really the prime time. Especially if women of reproductive age, if you're starting any medication, really the first thing you're asking is, are you planning to become pregnant in the next year? And so if no, then thinking about birth control options, and bedsider.org is perhaps the most patient-friendly and also provider-friendly. There's a bunch of different guides and picture flyers and things like that, and different languages that you can provide for your patients. And then if they do plan to get pregnant, it's important to stress starting prenatal vitamins and discuss alcohol or other substance use during that time. And then PrEP. So for pre-exposure prophylaxis, it can be provided in pill form or shot, and it's used to reduce the risk of HIV for people who are HIV negative and are at risk. If, you know, they have sex with partners or partner living with HIV, perhaps they don't always use a condom during sex. If they're diagnosed with an STI in the last six months, or they use needles to inject their drugs, or they share some of their needles or equipment. And then also if they have sexual partners who use IV drugs. And I think it's also important to stress that it is still important to use condoms because condoms prevent other STIs. And then when we talk about drug use safety, we think about the harm reduction. And so if you do have patients who are actively using or do have a history of drug use, remembering that they, if they are using a new supplier to ensure that they're using small dose to test it so that, you know, they don't run the risk of overdosing or harming self. I think the most important thing on this slide would be that I never use a loan and the number. So this is where patients or people, anyone who decides that they are going to use and they need someone to be on the phone with them, you can call them and they actually essentially monitor you. And if you are unresponsive at a certain time, they will then call. And then just stressing the idea that there are medications to help patients who have opioid use disorder. And then also there are supervised injection sites and then also handouts from the CDC that are also very helpful. And then the big talk about buprenorphine, and I can go to the huge extent of it, but we all know, or it's a reminder that buprenorphine is a partial opioid agonist, which is used to treat opioid use disorder. And then suboxone, which we might be more familiar with, is actually a combination of buprenorphine and naloxone. And naloxone, we hear, if you're familiar with Narcan, what we use to help with opioid overdose. And then another thing is now with the removal of X waiver, if you have a DEA Schedule III authority with your license, then you are able to provide buprenorphine for your patients. And then a reminder, buprenorphine is typically taken sublingual, so they actually have to have it dissolved under their tongue. You can't just swallow it. And this is a way to also just prevent from patients trying to crush it or inject it, because it usually will happen because of the naloxone that's in there. And then naloxone, it has proven to save lives. It's very important. It's readily available. And there are, I guess, one of the things is there's four different ways to administer it. Patients who may have prescriptions of opioids prescribed to them, they're usually going to be prescribed naloxone as well. And so we recommend, NoraSaves is a really good website to show our patients how to use it. And then also for those who live at home with a patient. And the other reminder is that, especially with patients who might also be on benzos, benzos and opioids, if you sometimes can increase the rate of respiratory depression and sometimes death. And then, like I said, I wanted to stress the idea of harm reduction model. And there is a huge national harm reduction coalition. So there's a whole entire website dedicated to really helping this opioid pandemic in our country. There's also many, many centers in the nation as well. And they provide sterile syringes. They even will send naloxone via mail and also provide fentanyl strips for some of our patients to test the purity of the fentanyl that they may be taking. Next, we'll go on with routine adult vaccines. We know influenza is still present. And we know each year we recommend that everyone gets one. And usually, you know, the flu season starts between September to March. Then we also have Tdap, which is something that we ought to take every, or get every 10 years. And then there's also hepatitis A, which comes in two to three doses. And it's usually if patients are, especially with drug use or sex risks or traveling, or they have liver disease, they're unhoused, or healthcare workers are also encouraged to get the vaccine. And then we also have hepatitis B. And then COVID and our boosters, which will also be something that will be continuing to be updated on. And then also HPV. It is up to age 26, and then from 27 to 45, it's more of a shared decision-making with the patient. Typically, the first dose, if they get it, is before age 14, and then if it's before age 14, then they would have to do three doses. So if you get your HPV vaccine before age 14, it's only two doses. And then you get the Shingrix for those who've never experienced shingles. Awesome, but it really sucks when you get shingles, if anyone's experienced it. But if you are 50 years or older, you do get the shingles in those, it's two doses. And then the pneumococcal for those who are age 65 and older. And then this is kind of a quick question. We have a 54-year-old person with depression and chronic liver disease who has a visit this coming November. They got their Tdap four years ago, and then their labs that we got previously when we saw them, Hep A Ig was negative, and then Hep B surface antigen was negative. Their Hep B surface antibody was positive, and their Hep C antibody was negative. So in terms of vaccines, what do we recommend? Do they get a flu shot? Yes. What about Tdap? No. What about Shingrix? Very good. And then what about HPV? No, yep. And then pneumococcal? Mm-hmm. Because of the chronic liver disease. What about Hepatitis A? Yes, because in theory, they're actually not immune. Because their Hep A surface antigen, sorry, Hep A IgG is negative. And then Hep B is, they're already immune based on the fact that their Hepatitis HPV surface antibody is positive. And then we know that they were never actually had like an infection because their core and as well as their surface antigen is negative. And then COVID? Yes, definitely. And then this is just a prime example of kind of what we stressed of just that as providers, you know, we are part of the community. And this is a trial that they did at the community mental health clinic, encouraging and educating our patients with mental illness to get vaccinated. And there was a huge increase in patients who got vaccinated. It was very well received. So, you know, if you're in a place where your clinic has a nurse practitioner or a nurse that, you know, you're able to encourage the vaccines, we continue to encourage that as well. And then the next question, what is the leading cause of death in children adolescents in the US? I think I heard the answer a little louder. C, correct, firearm related deaths. And then especially in the recent years and recent news, we're hearing a lot more about it. And absolutely, this is one of the highest rates at this point now. If you can see kind of the trends before it used to be motor vehicle accidents, but now you see that firearm related injuries have gone and arise. So that's where we talk about even gun prevention is also important for the safety of our patients. So really the first question and always is, do they have access to a firearm? So making sure we ask that, and especially in patients we think that are at risk. Like I said, guns can cause death in children, there's suicide homicides that occur throughout our nation. And then another thing is if there is a gun in the house, making sure to ask like where it's located, and if it's in a safe place, making sure it's also stored in a safe place and that the ammunition is not in the gun, that it's not, you know, loaded at that time. Especially if you have children that are in the home as well. And then we just think about disparities and I think we kind of hone in on this, but a lot of our patients with severe mental illness, there was a UK study that showed us that 18% are more likely to not have breast cancer screening, 20% are not likely to have cervical cancer screening, and then 31% of our patient population also don't have their bowel screens as well. So adults living with severe mental illness are 2.1 times more likely to die of cancer under the age of 75. So again, it's really important that we encourage our patients and that if we find the opportunity to make sure that they do get their preventative screenings. And then breast cancer screening, this is actually something new that just is kind of hot off the press. As of May 9th, the USPSF, sorry, the USPSTF Task Force essentially is recommending that the new recommendation for getting a mammogram is actually age 40. It used to be age 50, but now it's going to most likely be 40 years old, to 74. And then a reminder of those patients who may have breast cancer and taking tamoxifen, that fluoxetine and paroxetine can make it less effective. So that's also something that we wanna make sure you be on the lookout if your patients are on any chemotherapy drugs for their drug-drug interactions. And then prostate cancer screening in terms of the USPSF Task Force, they should be screened from ages 55 to 69. There is a significant harms from false positive, but overall, we would be preventing one death from just 1,000 screens. And usually, the screens are pretty, oh, sorry. So again, need to screen 1,000 to prevent one death. And then typically, we don't screen over the age of 70. And then cervical cancer screening. So typically, those who are less than age 21, there's no screening. And then from ages 21 to 29, it's usually done every three years. And then from age 30 to 65, it can either be cytology alone every three years, or now we do have an FDA-approved HPV testing alone that's every five years. Or you can do the co-testing, which is every five years. And then some of the things that you also have to think about, and especially for our patients who've experienced sexual trauma or any trauma in that matter, there are tests that you can just actually take home and self-swab so that we're not having to be so invasive in the clinic or office for them. So making sure that your patients know that they have that option is also important. And then greater than 65, there's really no screening. And then those who've had a hysterectomy with the removal of the cervix also do not need the screening. And then colon cancer, also something new as well. Now it's recommended that people get their colon cancer starting age 45 to 75. And then those who are from the ages of 76 to 85, it's usually shared decision-making. And then there's a few common options. You can either do the fecal occult blood test, or you can do the FIT test, which is every year. Or you can do the colonoscopy, which is every 10 years. And if anyone's ever experienced having to have to drink the Golightlium and take it, I know it's not easy, but yeah, so that's why it's every 10 years. And then lung cancer screening, we know a lot of our patient population may also be using tobacco. And so it's very important that they do get their lung cancer screening. Typically, those from ages 50 to 80 with a 20-plus PAC year usually would recommend a low-dose CT. And then those who might have risks of false positive, you may wanna go ahead, and if they do, then they would need further invasive testing. And again, remembering that the lung cancer is the number one cause of cancer death in the U.S. still. And then next, we'll just a real quick real case. We have a 70-year-old woman in the psychiatric hospital diagnosed with pseudosesis, which is a delusional belief of pregnancy. She's convinced she is having twins and that they are arriving soon. When asked how she knows she's pregnant, she says it is because she has been bleeding from the vagina. As a savvy psychiatrist, you know this is abnormal. She's 70 and she's having uterine bleeding and it's spotting so what should we be concerned for? What should she be tested for? Mm-hmm, correct, yep. It's not really trio cancer, but yes, anything that a woman who is post-menopausal age and hasn't had bleeding for a while and then suddenly is telling you that she's actively bleeding or spotting, that's something you need to be concerned for. And then next, we're gonna go ahead and do the small group exercise. And I can hand out, do you want me to? I can help you with that one. Oh, sure. Dr. Richards is gonna hand out some quick flyers and then I'm gonna just read the question. We have, yeah, if you wanna just kind of be surrounded by maybe three or four people and then I'll read the question. So this is Linda. Linda is a 50-year-old cisgender woman with history of PTSD, asthma, and active IV heroin use, presenting to clinic for depression. In terms of her psychiatric history, she's been taking sertraline for years, but she reports that it's no longer helping. In terms of her trauma history, mother had severe depression, drank excessively, and was physically and verbally abusive to Linda. In terms of her social history, she's sexually active with a new partner for one month and she has a 25-pack year history of smoking and she quit five years ago. So I think the next part will be these questions and they're also in your handouts if you wanna kind of briefly talk with some of your peers around you about what the answers might be. We'll go over them as well. Okay, we're gonna meet back. We have a second case, so don't move too far. I hope you got to meet some of the people in your group and work collaboratively. So we have some of the questions. We'll go through them together. But which of Linda's conditions are associated with average child experiences? And as a psychiatrist, what impact could you have on her overall health? Feel free to use the mic or shout it out. Yes, yes, all of them, all of the above. Yeah, so specifically, so thinking about asthma, drug use, and also PTSD. And then what could you consider for sexually transmitted infection screening and cancer screening? Everything, exactly, exactly. So it's like a month from now and you're like, I remember that lecture. In the back of my mind, I'm supposed to ask about these things or this person has a lot of risk factors. So important ones, so for STI screening, thinking about HIV, hep C, syphilis, gonorrhea, and chlamydia. For cancer screening, think about breast cancer screening, colon cancer screening, cervical cancer screening, lung cancer screening, all the organs. And these are effective, they save lives, so that's why we want to help make sure our patients are aware and know about it and also they trust us and we can talk to them about these important things. Last, harm reduction options that you can offer Linda in response to her current substance use. Narcan, definitely, yes. The more narcan, the better. And what else? Suboxone or buprenorphine, yeah. Test strips, fentanyl test strips, yes, which are important because there's a lot of, especially right now, a huge epidemic, a lot of street medications or street drugs have fentanyl in them and people don't expect that and it's killing people and so having test strips so you can test and it's not perfect because there may still be fentanyl in there that the test strip misses, but at least it's one more barrier. The test strips, so the website that we mentioned, they have places where people can request and get it delivered to them. Also, any sterile syringe sites, a lot of them have fentanyl test strips that people can pick up. So usually it should be free, yes. Yeah, there's a lot, I know, I know. So thinking about that person in front of you, what some of their risk factors might be, especially family history, because in our interviews we know our patients, we've gathered a lot, or we find out about some of the things that have affected them throughout their life, including maybe a family member with cancer, and now we know, and so we can encourage them to get those important screenings too. Yeah, and these screening guidelines are for people of average risk, so of course, with people who have family history, they might even have more risk, more reason to get screened. Great. Yeah, a test for hep C? Yeah, it's just a hep C, I'm sorry, hep C antibody screen. One test, done. And then a lot of labs will reflux to viral load and more specific things, but if it comes back positive, you can get infectious disease, your primary care doctor help to follow up on what to do next. Oh yes, yeah, clean needle programs and sterile syringe sites. There's also, some places have supervised injection sites as well, so people can use drugs in a safe place. And then the Never Use Alone hotline that people can call, which will send emergency response if they become unresponsive. Amazing, you guys mastered that. And it was a lot of information. So, and again, we put all this on the app on our PowerPoint. The only correction is the new mammogram guidelines, which are still a work in progress, but other than that, you can refer back. So now we'll go talk about cardiovascular risk, and we're gonna start out with our second case. We'll do the same small groups, the questions are on the bottom. And then for debrief, those will be in the rest of our slides. So for case two, we have Frank is a 57-year-old white, a cisgender man with history of schizophrenia, hypertension, and opioid use disorder. In sustained remission, presenting for routine follow-up. The psychotic symptoms have been manageable, but he's been tired, hungry, thirsty, gained 20 pounds in the last six months. For a diet, eating whatever I can, as access to healthy food is difficult. He started working nights at a call center, which is stressful, and he no longer goes to the gym. His partner says he snores loudly and wakes up a lot gasping. Currently, he smokes one pack a day for the last 20 years. He stopped drinking five years ago. He's with the methadone. He hasn't had any opioid withdrawal symptoms or cravings. Well-controlled. Medications are risperidone, four milligrams at bedtime. Hydrochlorothiazide, 25 milligrams daily. Methadone, 60 milligrams daily. Family history of a mother with hypertension who died from a stroke at 70 years old. His brother has diabetes. Vitals, his blood pressure's 155 over 75. Heart rate, 69. Weight's 200 pounds. Height's 5'5". BMI, 33.3. Neck circumference is 38 centimeters. Labs, his TSH, so thyroid, is 2.3 normal. Hemoglobin, E1C. She looks at blood sugars, is 6.2. Total cholesterol is 260. HDL, 34. And LDL is 180. So the questions should walk you through some of the guidelines and ways to approach this. And then we're gonna totally debrief and go through the rest of our slides which have the answers in them. Okay, welcome back everybody. Saw lots of awesome discussion. People looking things up. That's great, I know it was a lot of time. But having a little bit of practice hopefully will help. And remember that practicing things first and then realizing what I didn't know or what I knew and then finding out the answers helps retention. So hopefully this will help it all stick as we do the rest of the presentation together. Okay, so we included the answers in our follow-up slides. We'll go through each of those. So first, thinking about QTC. So methadone definitely increases QTC. So does when we look at EKGs for the interval in the heart. So does a lot of our psychiatric medications. And so looking at this, we can see that some of the higher risk typical antipsychotics are over there. So especially like haloperidol. And then some of our atypical antipsychotics. Ziprasidone, quetiapine. And we have lots of patients who take those medications. Making sure that we're thinking about the QTC, what other medications that they're taking that may impact as well. For SSRIs, acetalopram and acetalopram. Acetalopram has the restrictions where you don't want to exceed doses if for people over age 60. The TCA, antidepressants definitely have higher risk for QTC prolongation. And then venlafaxine for SNRIs. And ritazapine for other antidepressants. And so on this, risperidone's one of the lower risk ones versus the other ones. So now thinking about metabolic risks. So metabolic risks, as we know. Clozapine is very high risk. And olanzapine for increasing metabolic side effects. And a more medium risk, risperidone and quetiapine. And those increase risk for weight gain, for dyslipidemia, so high cholesterol or high lipids. And hyperglycemia, so risk for diabetes. So the APA 2021 practice guidelines, which are online. I made a summary form just to make it easier to read. But you want to make sure a baseline for vitals, BMI, labs, so CBC, CMP, so checking kidney and liver function. GSH for checking thyroid. UPT for checking for pregnancy, for people who have a uterus or are at risk for pregnancy. And then labs, lipid panel, hemoglobin A1c, check for diabetes. And then also making sure we incorporate movement screening, so AIMS or ESRS, to see if people have some of the Parkinsonian symptoms related to the antipsychotic use. For monitoring the APA guidelines, they recommend checking vitals PRN, BMI, each visit for six months, and then every three months. The labs, initial labs as PRN, lipids and A1c, four months after new med, then every 12 months. And then for movement disorder screening, every six months for high-risk patients, which they defined below. There's a lot of different criteria. Every 12 months for other patients. So of course, if there's concern that the person may have diabetes, the blood sugars may be increasing, the person's gained a lot of weight, you can increase these screenings. But otherwise, this is what they had recommended. So there's lots of ways to lower cardiovascular risk. First, thinking about what medications we're prescribing. What are the risks of those? Is there a medication we could offer that's lower risk? And then coordinating with the primary care doctor. So especially for follow-up in labs, a lot of times they may begin labs with you for checking like lithium level or depakote levels, and it's easy to add on the other labs, and then you can coordinate with the PCP if there's any concerns that arise. Or people may only begin once a lab's done, and that's with you. And so finding out what labs they might be getting done elsewhere. Discussing smoking, huge. Alcohol use, drug use. And then encouraging exercise plan and goals. And offering food resources. So if somebody's unsheltered or unhoused, and they're getting lots of canned foods or foods that may have lower nutritional value, the AFP, which is through the American Academy of Family Physicians, has a neighborhood navigator online. You can just type in the zip code, and they'll tell you all the different food banks and things in the neighborhood. So smoking and cessation medications. Huge slide, lots of info. But in summary, there's many options. And talking to people about what works for them. So talking about nicotine patches, nicotine gum, nicotine lozenges, and then bupropion, which the other names are Welbutrin and Zyban. And then Chantix. And they have different ways of getting started. Dosing, important thing to note is we often undertreat smoking, which makes it harder for people to succeed. And often it takes many tries. Another resource for people in California is Kick It California is a hotline. And then there's also 1-800-NO-BUTTS, B-U-T-T-S. But those are other resources to help get people free patches. Sometimes they have incentives. They'll give people $20 for just calling in. And ways to help get people engaged. So when I was in psychiatry clinic doing a QI project, I just, I'd already asked all my patients about smoking as part of my intake. And I made extra effort to talk to them about their thoughts of quitting or not. And by the end of the year, a third of my patients had quit. I don't know what would happen because it wasn't controlled. But I think that's a good step. And so as we're getting that info, just ask people and keep bringing it up. You see people a lot. So each visit, bring it up again and see where they're at. So motivational interviewing, asking, helping. We know how nicotine works. The nicotine replacement products really can help. And so using combination options, if somebody's able to tolerate it, to have more success. And also for Chantex, the black box warning was removed for psychiatric side effects. So if somebody's developing those, definitely keep a close eye. But overall, these are safe to offer. And then again, 1-800-NO-BUTTS. And for people in California, Kick It California is helpful. And then also thinking about with the CYP interactions, if someone's starting smoking or quitting smoking, it can affect their medication levels. So another reason to know where they're at in their journey. Next one is hypertension. So from our case, what do people think about Frank's blood pressure? Yeah, stage two. Yeah, so his blood pressure was high. So 155 over 75. And a lot of us work in practices where we might see a lot of people that have high blood pressure. I know I often, 155 doesn't even phase me anymore. But remembering to check in with people about what blood pressure medicines are they taking? Can they afford them? Did they pick them up? Who's been prescribing them? And make sure they have access. And coordinating with the primary care doctor to maybe increase those, if you're seeing somebody over and over again with high blood pressure. So hyperlipidemia, high cholesterol. So there's a helpful risk calculator, the ASCVD risk tool that we included. Anyone able to calculate it out? Or check out the calculator? Okay, good, yay, I see some thumbs up. Excellent. So for Frank, his ASCVD, so his risk of, his 10 year risk of having a stroke or a major heart attack is 31.3%, super high. And so thinking about a statin medication to help decrease his overall risk. And if he was optimized with stopping smoking, controlling his blood pressure, his risk would be only 4.3%. So these are huge interventions that we can make when we're seeing our patients. And then by the USPSTF guidelines about aspirin, we now avoid aspirin for primary prevention. So for people who haven't had a major episode in people over age 60, but they can work with their primary care doctor on that too. Hyperglycemia, so high risk of blood sugars and diabetes. Where did Frank's fall in? Yes, prediabetes. Yes, prediabetes. So for prediabetes, so first line is lifestyle modifications which we have the tools, we know how to talk to people about changing their lives. And so talking about diet, exercise, weight loss, all of those things. And then smoking cessation as well. And then thinking about for people who are at high risk, starting metformin, which is a medication, it doesn't drop your blood sugar if you don't eat. And so as lower risk of hypoglycemic episodes, but it can decrease people's blood sugar overall. And that can be helpful for people, especially under age 60, BMI over 35, and history of gestational diabetes, so diabetes in pregnancy. It's not FDA approved for prediabetes, but when we work with our patients who are high risk, something to think about. So first line, metformin. Then we also have our SGLT2 inhibitors and GLP1 agonists. I know these are newer medications, but we put them in here just to remind you that those exist. Those are things that people can access. And it decreases all cause mortality, cardiovascular mortality, non-fatal heart attacks, kidney failure, body weight, blood pressure. So lots of things that can harm or injure our patients or make it harder for them to go about their daily lives. So weight gain is something we commonly see, especially with a lot of the medications that help our patients. Metformin can be used for treatment of antipsychotic-induced weight gain. It's most helpful, so the recommendations are first to do early lifestyle intervention, non-pharmacologic managements first. But if that's not acceptable or probably inappropriate for the patient, they're not able to do that, or it's not effective, which they didn't really define very well. So these are kind of gray zones. You can think about metformin. And it's most helpful for attenuating weight gain if you use it earlier in the course of starting the antipsychotic treatment. And then a quick reminder is if you're starting somebody on metformin, know what their creatinine is, their kidney function. If they have really severe kidney disease, then they could be at risk for lactic acidosis. So at least get the creatinine first. Make sure that you know that they don't have severe liver, or sorry, severe kidney disease before you start. GLP-1s, so these are medications that help improve insulin release. And they're FDA-approved with semi-glutide as a weight loss treatment. And then also can help for teens as well. There's different ways. A lot of them are injections. Semi-glutide's kind of our most commonly used one because it's oral. Although now there's a shortage of it, which is very challenging. But when it's more available, definitely think about it. And then when thinking about starting it if someone's failed metformin, or if their BMI is 30 or higher. It has lots of great clinical outcomes with decreasing A1C, helping with weight loss, helping with cardiovascular benefits. And there are some adverse effects you want to make sure people know about. Most commonly is GI symptoms. And then also increased risk of pancreatitis or gallbladder biliary disease. So if someone's had a history of pancreatitis, probably wouldn't start this one. Next, obstructive sleep apnea. Couple weeks ago I was at a conference for sleep. So this was a big thing that got brought up, and I've seen it a lot in my clinic. A quick way to screen people is a screener called StopBank. Super easy. If you have an electronic health record, you can make a dot phrase or something to help remind you. And they also have that calculator on MDCalc. But obstructive sleep apnea we know really affects sleep, and worsens psychiatric symptoms and blood pressure. And so if someone's not sleeping well, not breathing well, their cortisol levels are high, they're in stress mode all night long, it's really gonna be hard to treat the diabetes, but also their depression, their PTSD, everything else can benefit from treating the obstructive sleep apnea. So if someone has more than three risk factors, we would recommend referring them for a sleep test. Of course, if you have clinical suspicion, just refer, it's okay to refer. And so Frank meets six of these, which is very high risk, and no one's ever talked to him about it before. So quick discussion question, and food for thought. As psychiatrists, what are some ways we can help people live healthier lives? So some pearls of wisdom from this talk, the takeaway points, because we've covered lots of details, all the nitty gritty. But thinking about informed consent for medication risk and benefits, tapering and de-prescribing medications where we can, remembering labs and recommended screenings, paying attention to underlying health conditions, discussing smoking, alcohol, drug use, diet and exercise, referring to specialists, talking with the primary care doctors, connect people to care if they don't have a primary care doctor, it's definitely gonna be hard to get a colonoscopy if you don't have a primary care physician, and remembering the whole person and being their advocate. So these are all of our references. So now we have some time for questions. I know, I know. And often, in reality, it's meeting somebody where they're at. And so Frank may be like, no, I am not ready to quit smoking. But I'm really bothered, my partner's super bothered by my snoring at night. So sorry, just to repeat the question, since for anyone that might not have heard, well, how would you prioritize? Yes. In a psychiatric clinic, do you feel comfortable starting a medicine like metformin or even some of the new injectable medicine? And what are some of the precautions that you have to take before you start doing those? Yeah, definitely. I think there's more and more psychiatric clinics that are starting metformin. Of course, only start what you're comfortable with to make sure that you know how to help counsel people. But metformin, the main thing you wanna do is make sure the creatinine is okay so that they don't have chronic kidney disease, especially stage three or stage four, so more severe chronic kidney disease. But metformin's the easier one to get started. I think we'll soon see more in one of our clinics because we have a lot of dual-boarded people who are comfortable with both, and that spreads. So we have more people who are comfortable with prescribing GLP-1s, and I think the trend will continue as these become more available. But screening for sleep apnea, very easy to do within the psychiatric setting. And talking about smoking cessation, we already use Wellbutrin. We know how to do that. And so adding on some of tools for weight management, I think we'll see more of that as well. Yes. Yeah, so for starting metformin, usually the starting dose would be 500 milligrams. You could start it once a day, and then you could increase to 500 twice a day. Usually, another thing to know is for metformin extended release, so the long acting, has less GI side effects, because sometimes people get nauseous with the regular non-extended release metformin. But starting 500 milligrams extended release once a day can be really helpful. Thank you very much for this helpful lecture. I've been hearing increasingly at this conference about GLP-1 agonists, not only having benefits for metabolic symptoms and type 2 diabetes, obesity, but also actually having mechanisms of action that suggest that they're helpful for treatment-resistant depressive symptoms, as well as certain compulsive behaviors, shopping addiction, gambling addiction, sort of anecdotal reports of that. Would you mind walking through if, since it seems like it might be something on the horizon that psychiatrists will be prescribing soon, would you mind actually walking through sort of exactly how you would go about doing that, sort of what you screen for, how you would counsel patients, the follow-up requirements, both lab-wise and whatnot, just so that we can get sort of an introduction to it? Thank you. Yeah, I think that would be a whole talk. So maybe I'll meet with you right after, and then I'll show you some of the resources. But yes, it's great to see. I haven't heard as much about the other uses yet, but the data we have is fantastic with weight loss and with helping people with their blood sugars. It's so good to have new tools, finally, to do that. I'll walk you through afterward. Yes? Sorry? Oh, I'm not sure. Yeah, I'm not sure. You asked about the metformin. My two question about the metformin. You said about the five milligrams a day, okay, right? So as you know, the antipsychotics, we prescribe the long time. So do you tell me how long we can give the metformin? It is recommended or we can give for sometimes for a stop and then on and off, or we can give it continuously? As an antipsychotic, we can do it continuously. Yeah, metformin, you can continue to prescribe. So I'd make sure you're checking the creatinine for kidney function at least once a year, at least, and especially if there's risk factors. And as long as it's safe kidney-wise, and as long as it's helping with the person's blood sugars, you can continue. And I would also check the blood sugars, too, because maybe some of those diet and exercise modifications have paid off and they might not need it. Yes, yes, of course. As I know, the metformin is not directly influenced of the insulin level. It's just like reducing the weight of the patient, you know? So I know more of the metformin, but the thing is, as you know, in the schizophrenia, we give the long-term antipsychotics, you know? So my question is again is that, so can we give the metformin for the long-term as we can give the antipsychotic? Yeah, you can continue. Regarding, as you said, that we keep in mind the side effect of the metformin, right? Yeah, yeah, you can continue it through. And we do that a lot at the hospital, yes. Yeah, and I would make sure, again, checking the creatinine to make sure to monitor kidney function. Okay, it means we can give it long-term? Yeah, yeah. Great, these are awesome questions. I really appreciate it. Any other questions? The metformin is notorious to disturb the vitamin B level and leading to peripheral neuropathy. So how about to take care of that? About what? The metformin is notorious to cause disturbance of vitamin B, and that lead to peripheral neuropathy. And also it can lead to many other complications. So do you think it should be given continuously? I think, so always think about the risks and benefits, because especially with diabetes, that can cause so many other complications for people, in terms of eyesight, kidneys, heart risk, stroke risk. So weighing those risks and benefits with a person and talking about them. But especially for people, once they're in the diabetes range, definitely. And then sometimes if they're at risk for weight gain and pre-diabetes, then thinking about metformin, yeah, within the risks and benefits, for sure. And if they're able to tolerate the GI side effects. Hi, I have two questions. First one is a really quick question. While butyrin, SR versus XL are both helpful for smoking, is that right? Okay, is there a reason why SR tends to be the one that people talk about with smoking? Is what? Is there a reason why people tend to talk about SR instead of XL for smoking cessation? Yeah, I mean, I've found that they're both effective. I think, so XL is once a day in the morning. And for, well, butyrin, you wanna give it in the morning because of that extra energy that people can have. So once a day is often easier for people to remember. And then sustained release, you'd give twice a day, usually in the morning and like midday to help increase the effects. But I've used XL for smoking cessation and whatever works for the person. If they can remember twice a day med, great. If once a day works better, that's fine. Okay, thank you. My second question. So I am telehealth and I've run into this problem with my patients with ADHD who are now getting diagnosed much later in life. So we're definitely having to think a lot more about their blood pressure while they're on these stimulant medications. But I can't get them to go to their primary care doctors and I can't get them to check their blood pressure at home. And when I am able to, their blood pressure is often high and then I'm running into this dilemma of, do I stop the stimulant until they go see the primary care doctor? Is that wrong? Is that withholding care? So like at what point would you say, look, we're not gonna do the stimulant anymore until you talk to your primary care doctor? Yeah, it's really tricky. And I run into that both from the primary care doctor side and the psychiatrist side on both sides. But sometimes, so negotiating with the patient, thinking about risk benefits, is there a reason their blood pressure is so high? Like do they have an untreated thyroid disorder? Do they have sleep apnea that's causing a high blood pressure? So as you've heard, some of the patients who may not have had a primary care doctor might not have been noticed. How's their diet? Do they eat a lot of salt and decrease? And that might help. So doing all the easy things first to rule those out and then the pros and cons with the stimulant medication, especially when it's in that stage two category over 140s, I wanna make sure we have a plan. And so the plan is in three months, we're gonna make sure that we have your blood pressure better controlled and also knowing someone's heart health history. Because at 25 year old, it might be different than for someone who's older age and with weighing risk benefits with a stimulant and a high blood pressure. Yeah, great question though. It's very nuanced. But yes, I understand this comes up a lot. I wish I had more clear guidance. Thank you. Yes. Thank you for your good lecture and very informative. And I like to know that we know that metformin we use to reduce blood sugar level in diabetic patients. And in case of any psychiatric problem, when we are using metformin to reduce the weight gain, then do we need to check blood sugar level and how frequently we have to do it? That is blood sugar level. Checking that. Yeah, yeah. How frequently we should do it? Yeah. So for checking the creatinine, I mean, at least once a year minimum, but often if you can do it, especially if it's someone that you're more concerned about every six months. I have tighter guidelines when someone's starting a new medication and seeing how they're able to get used to it and checking more frequently at the beginning, but at least once a year. Okay, thank you. Yep. Hello. In the conference, I've heard some comments about vitamin D and mood disorders and whether you should routinely supplement regardless of the vitamin D level. Do you have any comments about that? Good question. Any input? Yeah. I would say, I think it is, I think depending on kind of how people metabolize it, some people even orally might take a certain amount, but it may not be as effective. But if it is where you've checked and your vitamin D level is low, they do do like a boost dose for quite some time and then you kind of continue to take, you know, your regular day vitamins. But I feel like the studies kind of vary for vitamin D and that's just as nature of physiologically, we, some absorb vitamin D better than others. Yeah. Thanks for the great lecture. Just any thoughts on prescribing stimulants in terms of using them off label for reducing appetite? I'm getting a lot of requests from patients who know that like Vyvanse is approved for binge eating disorder. And then they'll tell me that they have binge eating disorder and want it prescribed as a way of managing their weight. Any thoughts or the latest on that? Yeah. I get nervous with that because one, it's hard because you're not, if they, especially if they're not having a real indication for a stimulant use, besides that, I get nervous about it. And I'm also thinking about the long-term health effects. So one, are we treating the underlying problem? And then two, the effects of having a higher heart rate, higher, potentially higher blood pressure. So I try to avoid it and see if there's another thing that we can do to work toward their goal of reducing weight. And now that we have GLP-1s and other options, that's been helpful. Sure. Thank you for that. And then just going back to the Metformin clarification, with the B12, like potentially levels going down, we can check those and then supplement, correct? Would that be another way of handling that concern? Yeah. Yeah. And making sure that we're keeping it at a good level. Yes. Okay. Thanks for the clarification. Great. Okay, well, we'll stick around and answer any other questions, but we really appreciate your time. We hope some of this sinks in, or at least sounds familiar if you hear it later. And the slides are online if you wanna reference them later. But thank you so much for joining us and for your thoughtful answers, for thinking through these cases with us. We really appreciate it and hope you have a great rest of your conference. Thank you.

holistic care

psychiatric comorbidities

preventative care

life expectancy disparities

mental and physical health

adverse childhood experiences

screening and management

antipsychotic-induced weight gain

comprehensive care

coordinated care strategies