Monitoring and Management of Metabolic Risk Factors in Outpatients Taking Antipsychotic Drugs: A Controlled Study

Article excerpt

Objective: To evaluate the screening, monitoring, and management of metabolic risk factors and diseases in long-term antipsychotic users in relation to current practice guidelines and current standards of care as represented by a control group from an HIV clinic.

Methods: We undertook a retrospective chart review of mental health clinic outpatients taking antipsychotic drugs long-term (cases) and HIV outpatients prescribed highly active antiretroviral therapy (control subjects).

Results: We included 99 mental health clinic patients and 98 HIV patients in the analysis. According to information available in the outpatient clinic chart, the 10-year coronary artery disease risk was computable for 28% of the mental health clinic patients (mean risk 11.9%) and for 90% of the HIV patients (mean risk 9.5%) (χ^sup 2^ = 77.0, P < 0.001). Metabolic risk factors were less frequently documented in mental health clinic charts. All HIV clinic patients were screened for hypertension and diabetes, and 90% were screened for dyslipidemia, whereas this information was missing for 30%, 39%, and 60% of mental health clinic patients, respectively (P < 0.001 for all). Disease monitoring was also more comprehensive in HIV clinic charts (for example, 100% of HIV patients were monitored for lipids, compared with 71% of mental health clinic patients; P = 0.001).

Conclusions: Improved efforts are needed in the somatic care of patients with bipolar disorder and schizophrenia who are taking antipsychotics, given that they typically have moderate-to-high risk for metabolic diseases.

Can J Psychiatry 2008;53(1):34-42

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Clinical Implications

* Patients with schizophrenia and BD require improved care in regard to their metabolic and cardiovascular health.

* Care providers should have efficient access to physical health status and risk factor information based on documented physical examinations, laboratory reports, and smoking status.

* Collaboration is required among care providers to determine who is responsible for and to share information related to the screening, monitoring, and treating of metabolic risk factors and diseases.

Limitations

* This single-centre study may not reflect the standards of documentation and care at other institutions.

* Information available in the outpatient chart was used as a surrogate marker of care provider knowledge of patient metabolic risk factors and diseases. Health care providers were not interviewed.

* Communications between the mental health team and the patients' family physicians were not evaluated.

Key Words: psychotic disorders, bipolar disorder, antipsychotic agents, risk factors, cardiovascular diseases, diabetes mellitus

Since the early 1990s, newer antipsychotic drugs, including clozapine, risperidone, olanzapine, and quetiapine, have largely replaced conventional neuroleptics, particularly in chronic psychotic disorders and, more recently, in the management of patients with BD.1-3 The most well-established advantages of the newer antipsychotic drugs are the relatively low incidence of most extrapyramidal symptoms, including parkinsonism and acute dystonia, and the reduced risk of tardive dyskinesia and other late-onset movement disorders.4 With the exception of risperidone, the newer agents also produce less hyperprolactinemia and fewer related clinical sequelae.4 However, long-term use of several newer antipsychotics is associated with obesity, dyslipidemia, CAD, and type 2 diabetes mellitus.4-6

Patients with severe mental disorders, including schizophrenia and BD, have been found to be at increased risk of cardiovascular and metabolic morbidity and mortality.7-9 Two population-based, long-term follow-up studies of patients with schizophrenia and BD have revealed a two- to threefold increase in the rates of death from cardiovascular and endocrine causes. …