When the Treatment Hurts More Than the Disease

The Impact and Influence of the Healthy Lifestyles Program for Children and Adolescents with

Mental Illness

Objectives

1. Review of Adolescent Psychosis• Symptoms, Differential Diagnoses, Treatment and Side Effects

2. Development of the Day Hospital Program• Preparation, Components, Goals

3. Description of the Day Hospital Program• Groups and Evaluations Tools

4. Case Presentation/ Discussion• Present Case, Small Group Discussion, Presentation/ Discussion

with larger group

5. Review of Guidelines as per Canada’s Food Guide & Canada’s Physical Activity Guide

6. Recommendations for Community Adaptation

Adolescent Psychosis

Canadian Mental Health Association Psychosis is a serious but treatable medical condition affecting the brain. It is characterized by some loss of contact with reality and can dramatically change a person's thoughts, beliefs, perceptions and/ or behaviours. Psychosis is estimated to affect up to 3% of the population. Males and females are affected equally. As well, members of families with a history of psychotic illness are at increased risk for developing psychosis themselves.

Adolescent Psychosis –con’t

• Sometimes psychosis emerges gradually over time

• Other times, symptoms appear suddenly and are very obvious to the individual and those around them.

• Symptoms vary from person to person, can change over time.

• The initial experience of psychotic symptoms is known as the "first episode" of psychosis.

(CMHA Website, 2008)

Adolescent Psychosis –con’t

A person with psychosis may experience one or more of the following symptoms:

• hear voices that no one else hears • see things that aren't there • believe that others can influence their thoughts,

or that they can influence the thoughts of others • believe that they are being watched, followed or

persecuted by others • feel their thoughts have sped up or slowed down

(CMHA Website, 2008)

Adolescent Psychosis –con’t

• withdrawal and loss of interest in socializing • loss of energy or motivation • problems with memory and concentration • deterioration in work or study • lack of attention to personal hygiene • confused speech or difficulty communicating • lack of emotional response or inappropriate emotional

display • general suspiciousness • sleep or appetite disturbances • unusual behaviours (CMHA Website, 2008)

Differential Diagnoses

At the time of presentation, Differential Diagnoses may include but are not limited to: Schizophrenia/ Schizophreniform, Schizoaffective D/O, Mood Disorders (Depression & Bipolar Affective D/O), Personality Disorders, Pervasive Developmental Disorders, Delusional Disorders, General Medical Conditions (ex. Delirium). (APA Website, 2008)

Treatment

1. Psycho-education for patients and families.

2. Psycho-pharmacology – Atypical Antipsychotics (Risperidone, Olanzapine, Quetiapine, Clozapine)

• Lower risk of EPS, less risk of cognitive difficulties

• Side Effects include Sedation, Activation, Postural Hypotension & WEIGHT GAIN

(CMHA Website, 2008. AACAP Practice Guidelines 2000)

Weight Gain Related to Atypical Antipsychotics

• Increases an individual’s appetite

• NIMH (2007) looked into an appetite regulating enzyme, AMPK, in relation to weight gain. Increased 4 fold in mice.

Weight Gain can lead to obesity, diabetes, cardiac disease, treatment non-adherence (NIMH Website, 2008)

Definitions

Health (noun): the condition of being sound in body, mind, or spirit; especially: freedom from physical disease or pain.

Healthy (adj.): enjoying health and vigor of body, mind, or spirit.

*Source: Merriam-Webster on-line dictionary

Components of Health

• Proper nutrition• Exercise• Feeling motivated• Feeling good about

yourself• Decreased stress• Relaxation• Doing well at school

• Healthy weight• Decreased illness• Proper dental hygiene• Proper body hygiene• Get enough sleep• Socializing• Having fun with family

and friends

Reasons for Being Healthy

• Having healthy relationship• Live longer• Able to spend more time with family/friends• Able to participate in activities/sports• Have a healthy heart• Have a healthy weight• Increase your mood and make you feel good• Role model for others• Less trips to the doctor and dentist

Sickkids Crisis & Psychosis Day Hospital Program

• Multidisciplinary Health Care Team (Psychiatrists, Advanced Practice Nurse, Social Worker, Child & Youth Worker, Toronto District School Board Teacher and Registered Nursing support)

• Care for children & adolescents with psychotic illnesses

• Located on Inpatient Psychiatric Unit

Sickkids Healthy Lifestyles Program Development

• Saw increasing difficulties with weight gain in Inpatient/ Day Hospital Programs

• Recommended that children in school exercise each day, so why not in our program

• Began by doing Exercise Videos twice a week for 30 minutes and having the Dietician from the Eating Disorder Program come to discuss Nutrition during a 45 minute group

Evaluation: Videos difficult to follow at times and became boring. Dietician not able to come and teach the patients each week about Nutrition.

Next Steps

• Child & Youth Worker / Advanced Practice Nurse took courses through CAN-FIT PRO in Nutrition & Wellness Specialist and Fitness Instructor Specialist

• Developed a Healthy Lifestyles Program which included a weekly Nutrition Group and daily exercise (Yoga, cardio class, strength and endurance walking and mid-day walks)

Benefits of Proper Nutrition & Exercise

• Better overall health• Healthy management of side effects of

psychotropic medications (ex. Weight gain and constipation)

• More energy and endurance• Improved sleep patterns• Stress relief• Improves mood and self esteem• Stronger muscles and bones

Reduces the Risk of Certain Diseases

• Obesity

• Type 2 Diabetes

• Heart Disease

• Hypertension

• Hyperlipidemia

• Osteoporosis

• Certain types of cancer

Program Goals

• To increase patients daily activity levels• To provide education on the importance of

nutrition and exercise in order to promote a healthy lifestyle (patients and families)

• To provide a healthy eating environment at the Hospital for Sick Children

• To promote healthy weight management and eating habits, improvement in self esteem and mood, decrease medical side effects of medication, promote medication adherence, increase in overall quality of life

Program Components

Day Hospital/ Inpatient Program

Academics

Goal Group

Social Skills Group

Arts and Crafts

Nutrition Group

Daily Exercise Group

Nutrition Group

• Weekly for a total of 12 weeks, then repeat• Each week builds upon the last• 45 minutes in length• Informative and interactive• Based on Canada’s Food Guide and Nutrition &

Wellness Specialist Manual

*Healthy Lifestyles Menu developed in collaboration with Dietician for Inpatients/ Day Hospital Patients (includes Fried Fridays)

Nutrition Class Topics

• Canada’s Food Guide/ Physical Activity Guide• Nutrition Jeopardy• Carbohydrates & Fiber• Fats• Protein & Muscles• Water• Digestion• Portion Sizes• Food Labels• Developing Personalized Canada’s Food Guides

Canada’s Food Guide

Recently changed to accommodate for the nutritional needs of different age groups and different sexes

More variety of food choices in each groupNow includes recommendations regarding drinking

water throughout the day to stay hydrated (body 60% water)

Includes recommendations about amount and types of fats/oils that are healthy

Portion SizesExamples of one Food Guide Serving

are:

Vegetables and Fruit• 125 mL (½ cup) fresh, frozen or

canned vegetable or fruit or 100% juice

• 250 mL (1 cup) leafy raw vegetables or salad (1/2 cup cooked)

• 1 piece of fruit

Grain Products• 1 slice (35 g) bread or ½ bagel (45 g) • ½ pita (35 g) or ½ tortilla (35 g) • 125 mL (½ cup) cooked rice, pasta, or

couscous • 30 g cold cereal or 175 mL (¾ cup) hot

cereal

Milk and Alternatives• 250 mL (1 cup) milk or fortified soy

beverage • 175 g (¾ cup) yogurt • 50 g (1 ½ oz.) cheese

Meat and Alternatives• 75 g (2 ½ oz.)/125 mL (½ cup) cooked

fish, shellfish, poultry or lean meat • 175 mL (¾ cup) cooked beans • 2 eggs • 30 mL (2 Tbsp) peanut butter See

beautiful samples

Nutritional Facts Table

• Table that appears on most pre-packaged foods that includes a list of calories and 13 nutrients

• Nutrient information based on specified amount of food

• Shows the % Daily Values based on recommendations for healthy eating

Nutritional Facts Table - 2

• Allows you to compare products easily• Allows you to determine the nutritional

value of food• Helps you choose foods with more/less of

a particular nutrient (ex. Less salt or more fibre)

*Not all foods contain a Nutritional Facts Table. Examples include alcohol, fresh fruit & veggies, food containing insignificant amounts of the 13 nutrients required in the Nutrition Facts Table, etc).

Examples of Food Labels

Comparing Food Labels

Real Life Examples

Avoid• Cakes & pastries• Doughnuts & muffins• French fries• Cookies & ice cream• Nachos & Potato chip• Soft drinks• Sport/energy drinks

Incorporate• Fresh fruits & raw

veggies• Plain popcorn• Low fat dairy products• Water (may flavour

naturally)• Nuts and seeds

Exercise

The amount of exercise recommended by Health Canada varies depending on age and physical well being.

• Adults: 30-60 minutes of exercise every day depending on Effort Level

• Children/ Adolescents: at least 90 minutes of exercise per day

* Start low, go slow. Can do in 5 minute segments throughout the day (Adults 10 minute segments)

Types of Exercise

Endurance Activities: help heart, lungs and circulatory system stay healthy, increase ability to do things for a longer period of time (4-7 days per week)

Flexibility Activities: promote fluid body movements, relaxed muscles and mobile joints (4-7 days per week)

Strength Activities: promotes strong muscles and bones (prevention of osteoporosis), improved posture (2-3 days per week, rest 1 day in-between)

Do It Right

• Do something that you enjoy!• Exercise with someone to fight boredom • Wear comfortable clothing and footwear• Wear safety gear whenever appropriate• Begin with light activities and progress to

moderate and vigorous activities slowly (Endurance Activities)

• Start all Flexibility & Strength Activities with 5 mins of light endurance activity

Exercise Classes

• Yoga once per week for 25 mins

• Cardio class once per week for 30 mins

• Cardio/ strength training class once per week for 30 mins (walk down 7 flights of stairs, twice around our “city block” and walk up 1 flight at a time)

• Afternoon walk twice per week for 20 mins (only walk around our “city block” twice)

Research & Evaluation Tools

1. Decided to look at the effects of our new Healthy Lifestyles Program on Mood, Self Esteem, Nutrition Knowledge and Medication Adherence

2. Team decision that patient at an appropriate level of functioning to participate in Nutrition Group

3. Need to evaluate level of functioning, related to psychotic symptoms, prior to attendance at Nutrition Group

Research & Evaluation Tools con’t

1. Positive and Negative Syndrome Scale (PANSS) used for initial evaluation before attendance at Nutrition Group

2. Brief Psychiatric History Form used for demographics3. Tools: CDI, Rosenberg’s Self Esteem Scale (Rosenberg,

1965), Nutrition Knowledge Questionnaire (Adapted from

Kolesar et al., 2006) were administer prior to first Nutrition Group. Medication Adherence Rating Scale (Thompson et

al., 2000) administered 1 week after discharge from inpatient program or after 1 weeks attendance in Day Hospital Program

Research & Evaluation Tools con’t

3. Able to attend Exercise Group ASAP

4. Plan to give same evaluation tools to patients after completion of all 12 Nutrition Groups

What We Have Found

• Not yet completed our first round of evaluation tools but . . . .

• Based on feedback from patients in the program before began research, they enjoyed participating in both Nutrition and Exercise Groups – felt they learned

• All patients, no matter what their level of cognitive/ physical functioning, are able to participate in group exercise and do well.

Videos

Case Study

Small Group Work

• 2 Groups with Focus on Nutrition

• 2 Groups with Focus on Exercise

• Case to be discussed with questions regarding the above. (15min)

• Feedback from groups (10+10 mins)

Questions for Small Groups

NutritionPlease comment on patient’s current eating habits

and what would need to change in order to be more healthy (remember food groups, water, portion sizes, meals per day, variety). Plan meals for a day

ExercisePlease comment on patient’s current exercise

regime and what would need to change in order to be more healthy (remember different kinds of activities, intensity, frequency, hydration). Plan exercise for a week.

Recommendation Based on Canada’s Guidelines

Recommendations for Community Adaptation

Resources

• Canada’s Food Guide• Canada’s Activity Guide• www.hc-sc.gc.ca/fn-an/food-guide-aliment/index

_e.html

• Positive and Negative Syndrome Scale – Kay et al., 1987

• Brief Psychiatric Rating Scale – Overall & Gorham, 1962

• The Children’s Depression Inventory – Maria Kovacs, 1992

Resources con’t

• Rosenberg Self-Esteem Scale – Rosenberg, 1965

• Nutrition Knowledge Questionnaire – Adapted from A.R. Kolesar et al., 2006

• Medication Adherence Rating Scale (MARS)- Thompson et al., 2000