Schizophrenia Spectrum Illnesses, & Second Generation - - PowerPoint PPT Presentation
Metabolic Monitoring, Schizophrenia Spectrum Illnesses, & Second Generation Antipsychotics Lauren Hanna, M.D. & Delbert Robinson, M.D. The Zucker Hillside Hospital Northwell Health National Council for Behavioral Health Montefiore
Lauren Hanna, M.D. & Delbert Robinson, M.D. The Zucker Hillside Hospital Northwell Health
National Council for Behavioral Health Montefiore Medical Center Northwell Health New York State Office of Mental Health Netsmart Technologies
antipsychotics (SGAs)
medical illness
tragically often suboptimal
high as the general population
schizophrenia in the Medicaid program. Those with schizophrenia were more than 3.5 times as likely to die in the follow-up period compared with adults in the general population. On average, the years of potential life lost for each deceased individual were 28.5 years.
Premature Mortality Among Adults With Schizophrenia in the United States JAMA Psychiatry. 2015;72(12):1172-1181.
prevalence of modifiable risk factors
cardiovascular co-morbidity are increasingly important
have multiple related cardiovascular and metabolic risk factors
schizophrenia an affective disorders is thought to be ~1.5-2 x higher than
Correll et al JAMA Psychiatry 2014
N=394 Mean age =23 years Mean lifetime days of antipsychotic treatment = 47 days
Correll et al JAMA Psychiatry 2014
N=394 Mean age =23 years Mean lifetime days of antipsychotic treatment = 47 days
patients with psychiatric diagnoses receive inferior quality of care in at least one medical area (Mitchell et al. 2009)
are closely linked with adverse effects on weight, lipids, and glucose metabolism, and cardiovascular disease
metabolic abnormalities from occurring
antipsychotic to prescribe
adding other medications such as mood stabilizers
found:
schizophrenia
(Meyer et al. 2005, Arango et al. 2008, De Hert et al. 2008, Shi et al. 2009)
whom more frequent metabolic monitoring is indicated
individuals with SMI
patients
and Australia
routine clinical care
spectrum).
Monitoring Grades
Metabolic Monitoring Parameter Rate of Testing Grade Weight 47.9% Inadequate Blood pressure 69.8% Suboptimal Glucose 44.3% Inadequate Lipid 22.2% Inadequate Cholesterol 41.5% Inadequate Triglyceride 59.9% Suboptimal HbA1c 16.0% Inadequate
23.76% = The percentage of patients in NY State with diagnoses of Schizophrenia or Bipolar Disorder prescribed antipsychotics… …but without Hemoglobin A1c or LDL-C measured in previous 12 months 29.83% = The percentage of patients in NY State with diagnoses of both Schizophrenia and diabetes… …without Hemoglobin A1c measured in previous 12 months
significant weight gain, dyslipidemia, and diabetes, and how should they be treated if diabetes develops?
primary medical doctor, patient, and psychiatrist
medication strategies or a combination of these
particular recommendations
recommendations
recommendations from the Mount Sinai Conference on Physical Health Monitoring of Patients With Schizophrenia (Am J Psychiatry 2004; 161:1334–1349)
schizophrenia, regardless of the antipsychotic medication prescribed
a. Weigh patients at every visit and track those weights b. Encourage patients to monitor and chart their own weight c. Measure and document waist circumference d. Patients should be weighed/measured at every visit for the first 6 months after medication initiation or change
medications should be a consideration in drug selection for patients who have BMI ≥ 25
unit indicates a need for an intervention Waist circumference ≥ 35 inches for women or ≥ 40 inches for men also warrants intervention
in a weight management program, use of an adjunctive treatment to reduce weight, or changes in a patient’s antipsychotic medication
diabetes for all patients with schizophrenia
a. Measure baseline plasma glucose level (fasting preferred, but hemoglobin A1c acceptable)
prompt closer assessment and follow-up
consultation with an internist
6.1%
fasting glucose level or hemoglobin A1c monitored 4 months after starting an antipsychotic and then yearly
inches for woman and ≥ 40 inches for men Patients who are gaining weight should have their fasting plasma glucose level
signs of diabetes and should monitor patients for the presence of these symptoms at regular intervals
symptoms of diabetes and ask them to contact an internist or primary health care provider if these symptoms occur
diagnosis of diabetes are followed by a health care professional who is knowledgeable about diabetes The patient’s mental health care provider and primary health care provider should communicate when medication changes that may affect control of the patient’s diabetes are initiated
symptoms of diabetes, a random plasma glucose test should be performed If the value is elevated the patient should be referred to an internist
If the patient contacts the mental health care provider by telephone and describes symptoms of diabetes, the patient should be urged to seek prompt evaluation by an internist or primary health care provider
each patient with schizophrenia they treat
Psychiatrists should follow one of the following guidelines for screening and treating patients who are at high risk for cardiovascular disease National Cholesterol Education Program U.S. Preventive Services Task Force https://www.uspreventiveservicestaskforce.org/
with schizophrenia, one should be obtained and reviewed
The lipid panel should include measurements of total cholesterol, low-density lipoprotein (LDL) and HDL cholesterol, and triglyceride levels
be at high risk for coronary heart disease
As a result, lipid screening should be carried out at least once every 2 years when the LDL level is normal and once every 6 months when the LDL level is greater than 130 mg/dl
an internist
If a referral cannot be arranged, the mental health care provider should advise the patient to change his/her diet to reduce fat intake If the LDL level does not fall into the normal range, a cholesterol lowering drug should be initiated
criteria for the metabolic syndrome and should ensure that they are being carefully monitored by a primary health care provider
hyperglycemia, dislipidemia, and abdominal fat
attacks and strokes
At least 3 of the following 5 conditions:
National Heart, Lung, and Blood Institute (NHLBI) and the American Heart Association (AHA)
Education Program or U.S. Preventive Services Task Force guidelines are followed for patients with abnormal cholesterol (total, LDL, HDL) and triglyceride levels When patients with abnormal levels are identified, the patient should be referred to a primary health care provider Or, in the absence of such a provider, treatment may be implemented by the mental health care provider
controlled trials of medications targeting antipsychotic-induced weight gain was performed
weight and body mass index (BMI)
discontinuation, change in waist circumference, glucose and lipid metabolism parameters, and psychiatric symptoms
although these were modest and heterogeneous
had occurred, but not when started concomitantly with antipsychotics
ameliorating antipsychotic-induced weight gain outperformed placebo
medical illness
metabolic and cardiovascular co-morbidity – this is specifically true for those on antipsychotics
suboptimal
indicated, but they often have less access to care and lower quality care
starting an antipsychotic, 3 months later, and yearly for those on second generation antipsychotics
intervention and or medication intervention should be pursued if abnormalities are found
individualized by the type and severity of the abnormality and should be done with guidance of the patient’s primary medical doctor
Obesity and Diabetes. Diabetes Care, Volume 27, Number 2.
and without metabolic syndrome: findings from the CLAMORS study. Schizophrenia Research 104, 1-12.
schizophrenia: a cross-sectional study in a low cardiovascular disease risk geographical area. European Psychiatry 24, 431-441.
disorders: baseline results from the RAISE-ETP study. JAMA Psychiatry. 71(12) 1350-1363.
with schizophrenia: the METEOR study. European Neuropsychopharmacology 18, S444.
Psychiatry 161:8
Metabolic Abnormalities: A systematic Review and Meta-analysis. Neuropsychopharmacology. 2010 June; 35(7): 1520-1530.
clinical comparison of subgroups with and without the metabolic syndrome. Schizophrenia Research 80, 9- 18.
substance misuse: systematic review of comparative studies. British Journal of Psychiatry 194, 491-499.
antipsychotic medication: systematic review and meta-analysis of screening practices. Psychological Medicine, 42, 125-147.
antipsychotics in the treatment of schizophrenia: a systematic review and meta-analysis. Schizophrenia Research 123, 225-233.
second-generation antipsychotic use in the Veterans Helth Administration. BMC Psychiatry 9, 80.
The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.