Abstract
Cardiovascular risk factors among forensic patients in the acute psychiatric ward
Recently, more publications have not only demonstrated significantly higher cardiovascular risk factors in a mixed group of patients with schizophrenia, affective psychosis and bipolar affective disorder, treated with atypical antipsychotics, but, as a result, a higher predicted cardiovascular mortality [1], [2].
Do certain specialized populations, for example, patients who were incarcerated and received psychiatric care in prison, also have higher prevalence rates of cardiovascular risk factors?
The population surveyed were male patients treated involuntarily in an acute psychiatric ward at Long Bay Forensic Hospital during two point periods: July 2003 and January 2006. In the present study, which was a practice-improvement project at Justice Health, the medical files were retrospectively reviewed with focus on the most common factors such as smoking history, weight, antipsychotic medications, and lipid profiles.
Of 48 patients screened, 44 patients received a diagnosis of a major mental illness: schizophrenia, schizophreniform psychosis, delusional disorder, n = 39; schizoaffective disorder, n = 7; and manic psychosis, n = 1. The average age of this group was 35.5±9.9 years and the median duration of current hospitalization was 154 days. Their ethnic background was as follows: Caucasian, 57%; Aboriginal and Pacific Islander, 14%; remainder, other nationalities. The majority of patients had suffered from mental illness for more than 1 year prior to admission. History >10 years was documented for 16% of patients, although 14% of patients were persons newly detected as mentally ill by the mental health service.
Data on patient smoking status and antipsychotic medications were available for all 44 patients; data for blood sugar level, blood pressure, and lipid profiles were incomplete.
All patients were treated with antipsychotic medications: most of them with atypicals and some with a combination of conventional and atypical medications. Twenty-two patients (50%) were treated with antipsychotics known to be frequently associated with a weight gain [3]: olanzapine, >15 mg daily; and clozapine, >200 mg daily.
We found that 35 patients were current smokers and two patients reported a history of significant smoking use; thus, 84% had this risk factor. On admission 15 (50%) out of 30 patients had weight >90 kg, and seven (23%) of them weighed >100 kg. Fasting lipids were tested only in 17 cases: nine patients had a total cholesterol level ≥5.1 mmol L−1, and in eight patients triglycerides were detected as ≥1.7 mmol L−1. These thresholds for serum total cholesterol and triglycerides are used to define increased risk of cardiovascular mortality and morbidity [1], [4].
Although the present survey was based on a limited number of patients admitted to an acute ward, these results might generate some interest for two reasons. Prevalence of hypercholesterolaemia in the present survey (53%) was found to be close to the community sample with a similar participation rate [1]. Considering the whole group of forensic patients, the minimum base rates of the following cardiovascular factors can be estimated for smoking (84%); serum cholesterol, ≥5.1 mmol L−1 (20%); and serum triglycerides, ≥1.7 mmol L−1 (18%).
Notwithstanding a lack of direct comparison with community outpatient setting, the aforementioned cardiovascular factors in addition to an increased weight and a high level of atypical antipsychotics raise the issue of thorough review and treatment of cardiovascular risk factors among the psychiatric patients in custody.
The authors would like to thank nursing staff of the acute ward (Lisa Parkinson and Julia Shaw) for their help in data collection.
Asystole during electroconvulsive therapy in an elderly woman treated concomitantly with venlafaxine
There are reports in the literature of episodes of asystole occurring during concomitant treatment with venlafaxine and electroconvulsive therapy (ECT) [1], [2]. To date, these reports have not included octogenarians, patients with significant cardiac disease or venlafaxine doses <150 mg. Here the case is presented of an 84-year-old woman with major depression with psychotic features–recurrent, who experienced two episodes of asystole while on venlafaxine during ECT. During her 3 year history there were four relapses, each successfully treated with ECT (10–14 treatments). In total she received 48 ECT treatments with only two episodes of asystole, both occurring during her fourth course and while on venlafaxine. She was on 150 mg venlafaxine when the first episode of asystole with prolonged bradycardia occurred (ninth of 14 treatments). Atropine and ephedrine were required to regain normal sinus rhythm. This episode of asystole prompted a decrease in venlafaxine to 75 mg for the following two reasons: (i) the literature available suggests that the association between asystole, venlafaxine and ECT may be related to higher doses of venlafaxine; and (ii) during her previous course of ECT she had been on 75 mg of venlafaxine without any asystolic episodes. Despite the decrease in venlafaxine, a second episode of asystole occurred during the 12th treatment. There was recovery to normal sinus rhythm without medication. Venlafaxine was not ceased for the duration of the course and there were no further episodes of asystole. There were no detrimental effects with regards to the patient's cardiac status nor mental state following the episodes of asystole, despite a significant past history of ischaemic heart disease and a 3 year history of mild cognitive impairment.
This is the first report associating venlafaxine, ECT, and asystole at a venlafaxine dose of 75 mg. Gonzalez-Pinto et al. report the association in four patients (age 53–67 years) on doses of venlafaxine ranging from 300 to 375 mg [2]. Agelink et al. report the association in a 42-year-old patient on 150 mg [1]. The present patient's age and cardiac history may have contributed to an increased likelihood of developing asystole even on a small dose of venlafaxine. It is of significant interest that there were no untoward outcomes observed for The present patient. Burd and Kettl performed a prospective study of ECT in 38 elderly patients [3]. They reported a 65.8% incidence of asystole during ECT with no associated negative consequences. This suggests that asystolic episodes are common during ECT in the elderly and may not be a cause for major concern. ECT is reported to be relatively safe and effective in patients over 75 [4], and a pilot study by Bernardo et al. suggests that combined treatment with venlafaxine and ECT is safe in a sample of patients 23–74 years old [5]. Before it can be determined whether venlafaxine should be ceased during ECT, further investigation is required to ascertain whether there is increased morbidity or mortality associated with asystolic episodes during ECT, and to establish whether there is a causal link between venlafaxine, ECT and asystole.