Randall F. White, MD, FRCPC (biography and disclosures)
How failure of consensus guidelines to impact others’ practice improved my monitoring of cardiovascular disease risk in people with chronic mental illness
What I did before
Although psychiatrists are used to treating chronic disease, they expend their effort on managing psychosis, mood disorders, and anxiety. Chronic medical disorders such as hypertension, diabetes, obesity, and the consequent vascular disease have been the realm of family physicians and internists. The evidence, however, has become impossible to ignore that people with chronic mental illness are dying from heart attacks and strokes at a higher rate than the general population. Cardiovascular disease shortens the life expectancy of people with mental illness by 20 or more years. (1)
In the past, I seldom paid attention to my patients’ weight, blood pressure, or exercise patterns, even though antipsychotics that I prescribed, especially olanzapine, clozapine and quetiapine, may have worsened their metabolic syndrome.
What changed my practice
In 2004, the American Psychiatric Association and the American Diabetes Association jointly issued guidelines on metabolic monitoring in patients on chronic antipsychotic therapy. (2) The guidelines recommend that prescribers obtain anthropometrics, including weight and waist circumference, and fasting glucose and lipid profiles at baseline and at specific intervals.
Morrato et al. looked at how often U.S. physicians are obtaining the recommended glucose and lipid testing in publicly-insured patients. (3) Only about a quarter of patients had serum glucose at baseline, and 10% had lipid profiles. Haupt et al. found that baseline and follow-up monitoring rates were no better in commercially insured U.S. patients. (4) In both studies, the investigators looked at testing rates before and after publication of the 2004 guidelines and found no meaningful change in practice. Both psychiatrists and family physicians are failing to monitor glucose and lipids. As for compliance with anthropometrics, no data are available.
What I do now
In the Mental Health Program at St. Paul’s Hospital in Vancouver, we are implementing a systematic approach to monitoring our patients’ metabolic risk factors. Patients admitted for inpatient treatment have anthropometric data recorded routinely, and serum glucose and lipid testing is done if no recent values are available. Most importantly, the treatment team examines the information and selects interventions appropriate to each patient. We offer education on cardiovascular risk, dietary counselling, smoking cessation interventions, referral to a family physician, or even follow-up with a preventive cardiology clinic.
I now realize that whether I am treating patients for schizophrenia, bipolar disorder, or that in-between problem called schizoaffective disorder, they probably also need intervention for weight gain, smoking, and physical inactivity. My practice is in a well-resourced academic hospital. Although more of a challenge, patients in primary care also need this monitoring and intervention. An incentive is the cardiovascular risk assessment fee, which B.C. family physicians may be able to use for preventive interventions. In treating people with chronic mental disorders, collaboration between family physicians and psychiatrists is crucial to ensure that cardiovascular risk is effectively managed.
References: (Note: Article requests might require a login ID with the BC College of Physicians website or UBC)
1. Newcomer JW, Hennekens CH.: Severe mental illness and risk of cardiovascular disease. JAMA. 2007;298:1794– 1796. (View article with CPSBC or UBC)
2. American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. 2004;27: 596– 601. (View article with CPSBC or UBC)
3. Morrato EH, Druss B, Hartung DM, et al. Metabolic Testing Rates in 3 State Medicaid Programs After FDA Warnings and ADA/APA Recommendations for Second-Generation Antipsychotic Drugs. Arch Gen Psychiatry. 2010;67:17-24. (View article with CPSBC or UBC)
4. Haupt DW, Rosenblatt LC, Kim E, et al. Prevalence and predictors of lipid and glucose monitoring in commercially insured patients treated with second-generation antipsychotic agents. Am J Psychiatry. 2009;166:345-353. (View article with CPSBC or UBC)