Follow-up interventions in persons with schizophrenia and metabolic syndrome

Individuals with severe mental illness (SMI) have between 12 and 20 years’ reduced life expectancy compared to the general population, primarily due to premature cardiovascular mortality (Larsen et al., 2013). The metabolic syndrome (MetS) refers to a cluster of abnormal clinical and metabolic risk factors that are predictors of cardiovascular disease (CVD) (Grundy et al., 2005). The risk factors include elevated triglyceride and fasting plasma glucose, increased waist circumference, hypertension and low high-density lipoprotein (HDL) cholesterol. Evidence suggests that some of the key antecedents of MetS emerge soon after treatment initiation and that they accumulate over time (Eapen et al., 2013). Both lifestyle and pharmacological interventions have been shown to reverse MetS and thereby prevent the development of diabetes and CVD (Dunkley et al., 2012). Despite the knowledge of increased cardiovascular disease and higher mortality rates, metabolic screening and monitoring in practice remain poor. Okkels et al. (2013) showed that abnormal findings were seldom evaluated and rarely acted upon. Barriers to medical care in this patient population include diminished adherence to treatment, underestimation of risk by physicians and the adverse effects of commonly prescribed antipsychotic medication. The latter emphasizes the importance of regular monitoring and appropriate treatment of cardiovascular and diabetic risk factors once identified.

The psychiatric outpatient clinic, Community Mental Health Centre South, Aarhus, Denmark (CMHC-South), focuses specifically on screening for MetS in patients with psychotic disorders and subsequent referral of these patients to their general practitioner (GP) if MetS is diagnosed. We investigated continuity in referral from secondary to primary care for patients falling within the schizophrenia spectrum disorders on the International Classification of Diseases, 10th Revision (ICD-10), F20–F25.9, who were also diagnosed with MetS. Patients meeting these diagnostic criteria and referred to CMHC-South during the 3-year period 2008–2010 were screened for MetS using the adapted Adult Treatment Panel (ATP-III-A) criteria proposed by the American Heart Association (Grundy et al., 2005). Clinical data were obtained from the patients’ medical records, and their GPs were asked to complete questionnaires containing information concerning follow-up, if this had occurred.

Forty-four patients were diagnosed with both MetS and schizophrenia within the study period. GPs completed the questionnaire for 36 (82%) patients. The results showed that only 15 (34%) patients contacted their GP after being encouraged to do so in continuation of their MetS diagnosis. We searched for predictors for continuity and the only variable associated with patients contacting their GP was the number of years the GP had worked in private practice. A logistic regression analysis showed decreasing odds for contact by a factor of 0.9 for each year the GP had worked in private practice. Findings pertaining to the clinical variables sex, age, marital status and body mass index (BMI) did not show any significance. The mean age in the study group (n=44) was 45 years (95% CI 27–65), mean illness duration 13.5 years (2–30), mean BMI 30.9 (95% CI 22.3–39.4) and antipsychotic polypharmacy (two or more medications) was registered in 57% of the patients. Half of the patient group was treated with either clozapine (36%) or olanzapine (14%), both of which are widely regarded as the second generation antipsychotics most likely to confer weight gain. There were no significant differences between males (n=29) and females (n=15). In 13 out of the 15 (87%) patients (who contacted their GP) the GPs found indications for continuing/initiating intervention for treating the increased parameters of MetS; the interventions were pharmacological or non-pharmacological.

We find it troubling that in our outpatient clinic with a specific focus on screening, evaluating and referral to primary care physicians only 34% of the patients with MetS contacted their GP in continuation of their MetS diagnosis. However, the majority (87%) of the patients who contacted their primary physician did receive some kind of intervention. Future challenges include achieving improved collaboration between secondary and primary care clinicians in order to ensure appropriate transfer of information and to establish a suitable treatment plan, along with regular follow-up using multispecialty teams so as to attain the best possible outcomes.

See Research by Larsen et al., (2013) 47(3): 250–258