Metabolic screen and intervene: improving mental health inpatient metabolic monitoring.

OBJECTIVE: To assess rates of metabolic monitoring in patients prescribed antipsychotic medications in the psychiatric inpatient setting and the impact education can have regarding monitoring compliance. METHOD: Two identical audits were undertaken at a NSW mental health inpatient service before and after a campaign designed to educate mental health workers about the importance of metabolic monitoring. Results from both audits were compared for statistically significant improvements in monitoring rates. RESULTS: Rates of monitoring plasma lipids increased from 21.7% to 78.8% (p < 0.01) and rates for plasma glucose increased from 20.8% to 73.7% (p < 0.01). There were no statistically significant changes in rates of monitoring body mass index (83.0% and 77.1%, respectively), waist circumference (36.8% and 43.2%, respectively) and blood pressure (99.1% and 100%, respectively). CONCLUSION: This study has shown that rates of metabolic monitoring in the inpatient setting can be improved with a relatively low-cost education intervention. While absolute rates remain low, outcomes suggest that it may be worthwhile trialling further modes of education and repeating this education in cycles.

Monitoring of Metabolic, Cardiac, and Endocrine Indicators in Youth Treated With Antipsychotics as Reported by Health Care Professionals.

BACKGROUND: It is unclear how youth treated with antipsychotics are monitored. The purpose of this study was to assess monitoring of metabolic, cardiac, and endocrine indicators in youth (<18 years old) treated with antipsychotics as reported by health care professionals in the Netherlands. METHODS: A questionnaire was designed to collect information from health care professionals regarding the monitoring of youth treated with antipsychotics. Data were collected at a national conference. FINDINGS AND RESULTS: Fifty-nine health care professionals completed the questionnaire, of which 53 (89.8%) were child and adolescent psychiatrists (approximately 20% of all child and adolescent psychiatrists in the Netherlands). More than 80% of respondents reported monitoring physical indicators-weight, height, body mass index, heart rate, and blood pressure-and over 50% reported monitoring laboratory indicators-lipid profile, blood glucose, and prolactin level. Most of the respondents reported monitoring physical indicators more than twice per year and laboratory indicators once per year. Almost all respondents (56/59, 94.9%) reported monitoring according to a clinical guideline or protocol. Only 1 respondent reported monitoring the indicators completely according to the clinical guideline. Respondents mentioned that facilitating factors for monitoring, such as access to electrocardiogram facilities, were insufficiently available. CONCLUSIONS: Although all health care professionals reported monitoring metabolic, cardiac, and endocrine indicators in youth treated with antipsychotics, great variability exists in reported monitoring practices. Factors contributing to this variability must be assessed to optimize the benefit-risk ratio for the individual patient.

Risk assessment of silica nanoparticles on liver injury in metabolic syndrome mice induced by fructose.

This study aims to assess the effects and the mechanisms of silica nanoparticles (SiNPs) on hepatotoxicity in both normal and metabolic syndrome mouse models induced by fructose. Here, we found that SiNPs exposure lead to improved insulin resistance in metabolic syndrome mice, but markedly worsened hepatic ballooning, inflammation infiltration, and fibrosis. Moreover, SiNPs exposure aggravated liver injury in metabolic syndrome mice by causing serious DNA damage. Following SiNPs exposure, liver superoxide dismutase and catalase activities in metabolic syndrome mice were stimulated, which is accompanied by significantly increased malondialdehyde and 8-hydroxy-2-deoxyguanosine levels as compared to normal mice. Scanning electron microscope (SEM) revealed that SiNPs were more readily deposited in the liver mitochondria of metabolic syndrome mice, resulting in more severe mitochondrial injury as compared to normal mice. We speculated that SiNPs-induced mitochondrial injury might be the cause of hepatic oxidative stress, which further lead to a series of liver lesions as observed in mice following SiNPs exposure. Based on these results, it is likely that SiNPs will increase the risk and severity of liver disease in individuals with metabolic syndrome. Therefore, SiNPs should be used cautiously in food additives and clinical settings.

Metabolic Syndrome and Cardiovascular Risk in People Treated with Long-Acting Injectable Antipsychotics.

BACKGROUND: People with schizophrenia and other severe mental disorders have an increased mortality mainly attributed to natural causes, specifically cardiovascular disease and cancer. The metabolic syndrome and the Framingham Risk Score are epidemiologic tools related to long-term cardiovascular disease risk and they are increased in people with severe mental disorders. This increase has been attributed both to the disorder itself and to the use of antipsychotic drugs. OBJECTIVE: To quantify the cardiovascular risk in a group of people treated with long-acting injectable antipsychotics. METHODS: This is a cross-sectional study developed in an outpatient mental health clinic in which the prevalence of metabolic syndrome was estimated and the cardiovascular risk was measured using the Framingham Risk Score. All the analyses were separated by gender. RESULTS: 130 people (81 men) were recruited. According to the International Diabetes Federation criteria, 60 participants (46,2%) had metabolic syndrome. The individual criterion most often met in both genders was obesity. The mean Framingham Risk Score for the sample was moderate, 7,7 (SD: 6,3). For women, the risk was lower (mean 5,7, SD: 4,9) than for men (mean=9, SD: 6,7). There were no significant differences in the prevalence of metabolic syndrome and Framingham Risk Scores by longacting injectable antipsychotic or years of treatment. CONCLUSION: The prevalence of metabolic syndrome and the cardiovascular risk are high in people with psychosis treated with long acting injectable antipsychotics. To better address this vulnerability, the recommendations involve both behavioral and pharmacological interventions.

Assessment of Irisin, Adiponectin and Leptin Levels in Patients with Schizophrenia.

BACKGROUND: The patients with schizophrenia are at increased risk for problems regarding metabolic parameters due to their lifestyle and antipsychotic treatment. OBJECTIVE: In this study, we aimed to evaluate the levels of adiponectin, leptin, irisin in patients with schizophrenia who were nondiabetic, nonobese and under antipsychotic treatment. METHOD: 5 ml sample of venous blood was collected from each participant. Blood cells were separated from the serum. The serum samples were stored in a -80°C freezer. Biochemical analyses were performed on these samples. Adiponectin, leptin and irisin levels were measured by Enzyme Linked Immunosorbent Assay method. RESULTS: The study included 88 subjects. Of them, 44 were patients with schizophrenia and 44 were healthy controls. There were no statistically significant results when the c-reactive protein, adiponectin, leptin and irisin levels were compared between the schizophrenia and the control group (p>0.05). CONCLUSION: In our study, adiponectin, leptin and irisin levels in patients with schizophrenia did not present a statistically significant difference from healthy controls. Therefore, there is a need for studies including more participants to investigate the level of irisin in patients with schizophrenia.

Excess early mortality in schizophrenia.

Schizophrenia is often referred to as one of the most severe mental disorders, primarily because of the very high mortality rates of those with the disorder. This article reviews the literature on excess early mortality in persons with schizophrenia and suggests reasons for the high mortality as well as possible ways to reduce it. Persons with schizophrenia have an exceptionally short life expectancy. High mortality is found in all age groups, resulting in a life expectancy of approximately 20 years below that of the general population. Evidence suggests that persons with schizophrenia may not have seen the same improvement in life expectancy as the general population during the past decades. Thus, the mortality gap not only persists but may actually have increased. The most urgent research agenda concerns primary candidates for modifiable risk factors contributing to this excess mortality, i.e., side effects of treatment and lifestyle factors, as well as sufficient prevention and treatment of physical comorbidity.

After six months of anti-psychotic treatment: Is the improvement in mental health at the expense of physical health?

INTRODUCTION: The morbidity and mortality due to cardiovascular causes in patients with schizophrenia is higher than in the general population, a fact that has been observed more since second generation anti-psychotics came into general use. OBJECTIVES: To determine the incidence of metabolic syndrome in patients with a previously untreated first psychotic episode, as well as the prospective changes in the parameters that define the criteria of metabolic syndrome. METHOD: An observational study with a prospective cohort design including patients who were admitted to the Acute Unit of Donostia Hospital. RESULTS: A total of 21 patients were included in the study, of which 19 completed it. Just over one-quarter (26.3%) of the patients developed a metabolic syndrome at six months. Statistically significant differences were observed in the following parameters: 1) abdominal perimeter measurement with an increase of 14.6 cm at six months (P=.001); 2) triglyceride levels with a mean increase over the initial measurement of 48.99 mg/dl (P=.039); and 3) fasting blood glucose levels with a mean increase of 10.72 mg/dl (P=.001). CONCLUSIONS: Significant changes were observed in metabolic parameters in a short period with the subsequent risk of associated cardiovascular events in a group of young patients. Actions are required directed at ensuring appropriate monitoring of these patients in order to measures to minimise the risks.

[Antipsychotic prescription assessment in general practice: metabolic effects]. / Évaluation de la prescription d'antipsychotiques en médecine générale: conséquences métaboliques.

INTRODUCTION: Second-generation antipsychotics have improved living conditions of patients affected by severe mental illness. Some of them can induce weight gain with metabolic complications. Furthermore, they are prescribed to vulnerable patients, with comorbidity and high cardiovascular mortality rate. Prevention of a metabolic syndrome by simple measures improves patient's physical health. General practitioners are privileged partners for psychiatrists. OBJECTIVES: This study was conducted to assess the prevention and management of a metabolic syndrome in patients treated with antipsychotics in general practice. With this in mind, at first we needed to explore how general practitioners prescribe antipsychotics. METHODS: To assess the general practice, we interviewed 204 general practitioners in the Hauts-de-Seine. Our database was the yellow pages of this area (September 2007). We then conducted a random draw using random digits. We called 507 general practitioners, 410 of whom were sent a questionnaire. We received the return of 204 questionnaires. Each questionnaire consisted of four parts: the general practitioner's profile, psychiatry in his/her practice, the prescription of antipsychotics and the management of metabolic syndromes in patients treated with antipsychotics. RESULTS: The general practitioner's response rate was 49.7%. The results show that although they prescribe antipsychotics, general practitioners need more information on these molecules and on their side effects. Indeed 57% of them feel they are not given enough information on antipsychotics, but 69% have already initiated antipsychotic treatment and 17% do so regularly. Furthermore, a metabolic syndrome is insufficiently detected by general practitioners, although they know of its prevalence after the introduction of antipsychotic treatment. Thus, 81% reported having been confronted with this problem, but only 54% of them calculated the body mass index of patients taking antipsychotics, and 26% measured waist circumference. These results are consistent with studies tracking metabolic syndrome performed in all patients, so, general practitioners do not conduct specific monitoring of patients on antipsychotics. However, they are faced with difficulties related to adherence to treatment because of weight gain. In such cases, 16% of respondents start a new treatment, without a psychiatrist's opinion. These results confirm the results of previous studies on the risks of such prescriptions in general practice, when not supervised. CONCLUSION: In conclusion, we suggest that information of general practitioners about their role in prevention of metabolic syndromes should be improved, and psychiatrists and general practitioners should be informed on the necessity of joint care of patients affected by severe mental illness.

Engagement in primary care treatment by persons with severe and persistent mental illness.

Even when primary care provider relationships exist, persons with severe and persistent mental illness (SPMI) are more likely to be undertreated and seek care from emergency room settings. The purpose of this study was to describe the social process of engagement in primary care treatment from the perspective of persons with SPMI. Using grounded theory and semistructured interviews, 32 adults were interviewed. The process of engagement includes mattering, being perceived as credible and capable, and working together. Clinical, education, and research implications are discussed. Future studies should explore engagement in primary care with this population from the perspective of providers.

Physical health management in psychiatric settings.

Severe mental disorders have a chronic course associated with a high risk for co-morbid somatic illnesses and premature mortality, but despite this increased risk, general health care needs in this population are often neglected. Over recent years, several groups have developed screening and monitoring guidelines for metabolic and cardiovascular risk assessment in patients treated with antipsychotics. The psychiatrist needs to be aware of the potential metabolic side-effects of antipsychotic medication and to include them in the risk/benefit assessment when choosing a specific antipsychotic. He should also be responsible for the implementation of the necessary screening assessments and referral for treatment of any physical illness. Multidisciplinary assessment of psychiatric and medical conditions is needed. The somatic treatments offered to people with severe and enduring mental illness should be at par with general health care in the non-psychiatrically ill population. In our University Centre, a structured and elaborate screening and monitoring protocol was introduced in late 2003. This paper describes the practical aspects of this monitoring protocol and the results obtained 4 years after its implementation.

Easy and low-cost identification of metabolic syndrome in patients treated with second-generation antipsychotics: artificial neural network and logistic regression models.

OBJECTIVE: Metabolic syndrome (MetS) is an important side effect of second-generation antipsychotics (SGAs). However, many SGA-treated patients with MetS remain undetected. In this study, we trained and validated artificial neural network (ANN) and multiple logistic regression models without biochemical parameters to rapidly identify MetS in patients with SGA treatment. METHOD: A total of 383 patients with a diagnosis of schizophrenia or schizoaffective disorder (DSM-IV criteria) with SGA treatment for more than 6 months were investigated to determine whether they met the MetS criteria according to the International Diabetes Federation. The data for these patients were collected between March 2005 and September 2005. The input variables of ANN and logistic regression were limited to demographic and anthropometric data only. All models were trained by randomly selecting two-thirds of the patient data and were internally validated with the remaining one-third of the data. The models were then externally validated with data from 69 patients from another hospital, collected between March 2008 and June 2008. The area under the receiver operating characteristic curve (AUC) was used to measure the performance of all models. RESULTS: Both the final ANN and logistic regression models had high accuracy (88.3% vs 83.6%), sensitivity (93.1% vs 86.2%), and specificity (86.9% vs 83.8%) to identify MetS in the internal validation set. The mean +/- SD AUC was high for both the ANN and logistic regression models (0.934 +/- 0.033 vs 0.922 +/- 0.035, P = .63). During external validation, high AUC was still obtained for both models. Waist circumference and diastolic blood pressure were the common variables that were left in the final ANN and logistic regression models. CONCLUSION: Our study developed accurate ANN and logistic regression models to detect MetS in patients with SGA treatment. The models are likely to provide a noninvasive tool for large-scale screening of MetS in this group of patients.

Predictors of metabolic monitoring among schizophrenia patients with a new episode of second-generation antipsychotic use in the Veterans Health Administration.

BACKGROUND: To examine the baseline metabolic monitoring (MetMon) for second generation antipsychotics (SGA) among patients with schizophrenia in the Veterans Integrated Service Network (VISN) 16 of the Veterans Health Administration (VHA). METHODS: VISN16 electronic medical records for 10/2002-08/2005 were used to identify patients with schizophrenia who received a new episode of SGA treatment after 10/2003, in which the VISN 16 baseline MetMon program was implemented. Patients who underwent MetMon (MetMon+: either blood glucose or lipid testing records) were compared with patients who did not (MetMon-), on patient characteristics and resource utilization in the year prior to index treatment episode. A parsimonious logistic regression was used to identify predictors for MetMon+ with adjusted odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Out of 4,709 patients, 3,568 (75.8%) underwent the baseline MetMon. Compared with the MetMon- group, the MetMon+ patients were found more likely to have baseline diagnoses or mediations for diabetes (OR [CI]: 2.336 [1.846-2.955]), dyslipidemia (2.439 [2.029-2.932]), and hypertension (1.497 [1.287-1.743]), substance use disorders (1.460 [1.257-1.696]), or to be recorded as obesity (2.052 [1.724-2.443]). Increased likelihood for monitoring were positively associated with number of antipsychotics during the previous year (FGA: 1.434 [1.129-1.821]; SGA: 1.503 [1.290-1.751]). Other significant predictors for monitoring were more augmentation episodes (1.580 [1.145-2.179]), more outpatient visits (1.007 [1.002-1.013])), hospitalization days (1.011 [1.007-1.015]), and longer duration of antipsychotic use (1.001 [1.001-1.001]). Among the MetMon+ group, approximately 38.9% patient had metabolic syndrome. DISCUSSION: This wide time window of 180 days, although congruent with the VHA guidelines for the baseline MetMon process, needs to be re-evaluated and narrowed down, so that optimally the monitoring event occurs at the time of receiving a new episode of SGA treatment. Future research will examine whether or not patients prescribed an SGA are assessed for metabolic syndrome following the index episode of antipsychotic therapy, and whether or not such baseline and follow-up monitoring programs in routine care are cost-effective. CONCLUSION: The baseline MetMon has been performed for a majority of the VISN 16 patients with schizophrenia prior to index SGA over the study period. Compared with MetMon- group, MetMon+ patients were more likely to be obese and manifest a more severe illness profile.

Treatment of bipolar disorders and metabolic syndrome: implications for primary care.

Recognition of the prevalence of mood disorders and increased availability of medication options have led to calls for treating bipolar disorders in the primary care setting. Second-generation antipsychotic medications (SGAs) were initially lauded for treating bipolar disorders because of their efficacy and perceived safety relative to first-generation antipsychotic medications. Metabolic syndrome is a constellation of risk factors for cardiovascular disease and type 2 diabetes mellitus, which may emerge when treating bipolar disorders with SGAs. We conducted a search of the research literature examining the association between different SGAs and metabolic syndrome. Based on our review, we offer guidelines for monitoring patient status regarding metabolic syndrome and for providing interventions to promote healthy diet and exercise.

Assessment of a point-of-care metabolic risk screening program in outpatients receiving antipsychotic agents.

STUDY OBJECTIVE: To assess the usefulness of a metabolic risk screening program, including point-of-care glucose testing, to quantify baseline metabolic risk in outpatients receiving antipsychotics. DESIGN: Retrospective, cross-sectional, cohort study. SETTING: University-affiliated department of psychiatry clinic. PATIENTS: A total of 92 adult outpatients (49 women, 43 men; mean +/- SD age 38.96 +/- 12 yrs) who were receiving antipsychotics and had undergone screening for metabolic syndrome at the clinic during 2004-2007. MEASUREMENTS AND MAIN RESULTS: Patient data were recorded on a metabolic screening checklist by a pharmacist or nurse. The checklist captured demographics, vital signs (height, weight, body mass index [BMI], blood pressure, waist and hip circumference, point-of-care random glucose level), personal and family knowledge of current illnesses (diabetes mellitus, hypertension, hyperlipidemia), modifiable risk factors (smoking, alcohol, level of activity), current drug therapy, and recommendations to the psychiatrist. The patient population who underwent screening included 49 African-Americans (53%), 21 Caucasians (23%), 16 Hispanics (17%), and 6 Asians (7%). Diagnoses were documented for 88 patients: schizophrenia or schizoaffective disorder in 53 patients (60%), and bipolar disorder and major depressive disorder was equally divided in the remaining 35 patients (40%). Of 89 patients (three patients had missing data on waist circumference), 63 (71%) met criteria for level 1 metabolic risk (abdominal obesity); of these 63 patients, 38 (60%) met criteria for level 2 risk (abdominal obesity plus hypertension). Patients with a random glucose level greater than 140 mg/dl had a higher likelihood for being at level 2 risk than level 1 risk (chi(2)=5.99, df=1, p=0.014). Women had a significantly higher likelihood for level 1 metabolic risk compared with men (chi(2)=5.99, df=1, p=0.019). African-Americans had a significantly higher likelihood of level 1 risk (p=0.026) and BMI greater than 30 kg/m(2) (p=0.003) compared with Caucasians. Patients with a BMI greater than 30 kg/m(2) had a significantly higher likelihood of diabetes (p=0.006), hypertension (p=0.03), and hyperlipidemia (p=0.05). Overall, 5 (5%) of the 92 patients met criteria for prediabetes risk. CONCLUSION: Point-of-care metabolic risk screening, done with a systematic interprofessional team approach, can provide clinicians with a practical method for identifying metabolic risk in patients prescribed antipsychotics.

Metabolic risk status and second-generation antipsychotic drug selection: a retrospective study of commercially insured patients.

BACKGROUND: Routine metabolic screening and consideration of patient metabolic status in the choice of a second-generation antipsychotic (SGA) medication are recommended. This study evaluated the association between abnormal blood glucose and lipid values and SGA prescribing patterns. MATERIALS AND METHODS: A retrospective cohort study using administrative data from 2 managed care plans in the United States evaluated 7904 adults initiating SGA therapy between 2001 and 2004. Baseline serum glucose, total cholesterol, and triglyceride values were available for 989 patients (12.5%), and follow-up assessments were done in 699 patients (8.8%). Abnormal values were defined as the following: total cholesterol, 200 mg/dL or higher; triglycerides, 200 mg/dL or higher; and glucose, 126 mg/dL or higher. The likelihood of abnormal laboratory values being associated with selection of a lower metabolic risk SGA drug (aripiprazole or ziprasidone) and with switching decisions was assessed using multivariate logistic regression models. RESULTS: Thirteen percent of the patients had glucose and lipid tests within 6 months of starting SGA therapy. The likelihood of starting a patient on an SGA drug with lower metabolic risk (ziprasidone: odds ratio, 3.26; 95% confidence interval, 1.25-8.47; aripiprazole: odds ratio, 2.13; 95% confidence interval, 0.77-5.88) was higher if the patient had elevated glucose values but was not associated with elevated cholesterol or triglyceride values or if the patient had preexisting diabetes or dyslipidemia. Abnormal glucose and lipid values were not associated with switching SGA medications in the first 6 months of therapy. Among patients who did switch SGA medications, elevated glucose and lipid values were not associated with a greater likelihood of switching to aripiprazole or ziprasidone. CONCLUSIONS: Low rates of recommended monitoring were observed. Abnormal metabolic parameters among those who were tested were not consistently associated with the selection of an SGA drug with lower metabolic risk.

Schizophrenia and physical health problems.

OBJECTIVE: To estimate the prevalence of physical health problems in patients with schizophrenia, and to appraise the impact on mortality rates and quality of life (QoL) in such patients. METHOD: A selective review of clinical articles relating to physical health such as cardiovascular disease, metabolic syndrome and QoL. In addition, current guidelines and recommendations for the monitoring of physical health in schizophrenia were reviewed. RESULTS: Cardiovascular events contribute most strongly to the excess mortality observed in schizophrenia. Other factors that contribute significantly include obesity, metabolic aberrations, smoking, alcohol, lack of exercise and poor diet - all of which might be targets for health promoting activities. CONCLUSION: Physical health problems in patients with schizophrenia are common, and contribute to the excess mortality rate, as well as decreasing QoL. Many adverse physical factors are malleable in such patients, and physical benefit may be gained by following practical guidelines for their monitoring and improvement.

Risk factor assessment for new onset diabetes: literature review.

Metabolic syndrome (MS), typified by hypertension, abdominal obesity, dyslipidaemia and impaired glucose metabolism, is a precursor of type 2 diabetes. Thiazide diuretics (TD) and beta-blockers are associated with increased risk of diabetes in patients with hypertension; however, the role of these agents in development of diabetes in MS patients is unknown. We reviewed the literature regarding risk factors for diabetes development and compared this with data from the Study of Trandolapril/Verapamil SR And Insulin Resistance (STAR), which investigated the effects of two fixed-dose combinations (FDCs) [trandolapril/verapamil SR and losartan/hydrochlorothiazide (L/H)] on glucose control and new diabetes in MS patients. In STAR, logistic regression modelling identified haemoglobin A1c [odds ratio (OR) 4.21 per 1% increment; p = 0.003), L/H treatment (OR 4.04; p = 0.002) and 2-h oral glucose tolerance test glucose levels (OR 1.39 per 10 mg/dl increments; p < 0.001) as baseline predictors of diabetes. These data support prior analyses and suggest that choice of antihypertensive agent is important. Patients with MS may be at lower risk of diabetes when using a FDC calcium channel blocker + angiotensin-converting enzyme inhibitor compared with an angiotensin receptor blocker + TD.