Article

Evaluation of a general practitioner-led cardiometabolic clinic: Physical health profile and treatment outcomes for clients on clozapine

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

The present study is a review of a cardiometabolic clinic for consumers taking clozapine. This clinic was recently established and co-located with the clozapine clinic at a regional hospital in New South Wales, Australia, to enhance engagement and improve the physical health outcomes of consumers taking antipsychotic medication. A descriptive analysis of clients' (n = 73) information collected during routine care for the first 6 months of the clinic's operation, from January 2016 to July 2016, was conducted. First-visit data were analysed to establish a client profile, consisting of weight, height, blood pressure, pulse, a range of blood measurements, smoking status, alcohol consumption, and eating and exercise habits. Data collected for clients who had three or more visits with the general practitioner (n = 40) were analysed separately for outcomes. Two case studies are used to depict the service received and client profile. At the first appointment, the majority of clients had metabolic syndrome that was mostly left untreated; many of these clients were commenced on metformin. The outcomes are positive, and show that the majority of clients lost weight (82.5%) and had a reduction in body mass index (84.6%); nearly half (44.4%) had a reduction in waist circumference. The majority of clients self-reported increased physical activity (72.5%, n = 29) and positive dietary changes (77.5%, n = 31) since their first appointment. The model trialled by the cardiometabolic clinic integrated a specialist mental health and primary care service, and demonstrates success in engaging clients with severe mental illness in physical health care. Co-location is conceptualized as critical for positive patient outcomes and high levels of engagement.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... mental health center rather than navigating a separate health (Annamalai et al. 2018;Scharf et al. 2016). Closer coordination between systems is also observed when primary care providers and psychiatric providers are located in the same office, can share labs, consult with one another, and provide team-based care for individuals (Bellamy et al. 2016;Coates et al. 2018;Rodgers et al. 2018). As of 2016, The Substance Abuse Mental Health Services Administration (SAMHSA) has funded 213 sites across the country through the Primary and Behavioral Health Care Integration (PBHCI) initiative. ...
Article
Full-text available
The integrated health home, the Hope Health and Wellness Clinic, provides comprehensive primary and behavioral health services to adult clients of a Community Mental Health Center in Aurora, Colorado. A program evaluation of the effectiveness of this clinic was conducted over a 4 year period. Physical health data (Body Mass Index BMI, HbA1c, cholesterol, blood pressure, and waist circumference measurements) and self-report data (social connectedness, everyday functioning, psychological distress, perceived health, satisfaction with services) were tracked across time. Individuals enrolled (N = 534) experienced significant improvements over time in LDL and total cholesterol, as well as self-reported social connectedness, everyday functioning, perceived health, and psychological distress. At risk individuals demonstrated significant improvements in HDL cholesterol, triglycerides, blood pressure, tobacco and alcohol use. Individuals with serious mental illness show improvements in physical health and self-reported health after being involved in bidirectional integrated care.
... This co-location of mental and physical health care within the mental health hospital setting for people with severe mental illness has a number of benefits to both patients and services. To begin, it allows familiarity for people who may feel anxious about attending new services (Coates, Woodford, Higgins & Grover, 2018). It allows the Nurse-Practitioner or Clinic Nurse to introduce the patient to the GP, facilitating new relationships. ...
Article
In Australia and internationally there is a strong policy commitment to the redesign of health services toward integrated physical and mental health care. When executed well, integrated care has been demonstrated to improve the access to, clinical outcomes from, and quality of care while reducing overtreatment and duplication. Despite the demonstrated effectiveness and promise of integrated care, exactly how integrated care is best achieved remains less clear. The aim of this review study was to identify factors that support the implementation of integrated care between physical and mental health services. An integrative review was conducted following the framework developed by Whittemore and Knafl, with quantitative and qualitative evidence systematically considered. To identify studies, Medline, PubMed, PsychINFO, CINAHL were searched for the period from 2003 to 2018, and reference lists of included studies and review articles were examined. Nineteen studies were included. Synthesis of study findings identified seven key factors supporting the implementation of integrated care between physical and mental health services: (a) adequate resourcing, (b) shared values, (c) effective communication, (d) information technology (IT) infrastructure, (e) flexible administrative organizations, (f) role clarity and accountability, and (g) staff engagement and training. There was little theoretical development in included studies, with little insight into the contextual factors or underlying mechanism required to support the implementation of integrated care initiatives. This review identified a set of inter-related barriers and facilitators which, if addressed, can improve the implementation and sustainability of truly integrated care.
Article
Introduction People with serious mental illness experience significant disparities in their physical health compared to the general population. One indicator of health impairment is metabolic syndrome, which increases the likelihood of developing cardiovascular disease and diabetes. No international studies have reported both primary care and mental health nurses’ rates of metabolic monitoring among people with serious mental illness and no New Zealand studies have investigated rates of metabolic monitoring. Aim To evaluate metabolic monitoring practices within one of New Zealand’s 20 district health board regions. Methods A clinical records audit of primary (n=46) and secondary care (n=47) settings and a survey of practice nurses were conducted. A survey was sent to 127 practice nurses with a response rate of 19% (n=24). Data were analysed using descriptive statistics. Results Rates of metabolic monitoring were low in both services. Survey participants expressed positive views towards physical health monitoring and confidence in relating to mental health consumers. Rates of treatment for metabolic abnormalities were low, and communication between primary and secondary services was limited. Conclusion Despite existence of guidelines and protocols, metabolic monitoring rates in both primary and secondary health services are low. Incorporating metabolic monitoring systems into service delivery, supported by appropriate tools and resourcing is essential to achieve better clinical outcomes for people experiencing mental illness.
Article
The poor physical health of patients with severe/chronic mental illness is now well‐known, yet little has been done to address the issue. Adverse medication effects, lifestyle, and social factors can all contribute to high morbidity and mortality rates when compared to the general population. To arrest poor physical health, a Wellness Clinic within a mental health hospital was developed to provide continuity of care when patients were discharged from the hospital. A retrospective, within‐subjects, quasi‐experimental, longitudinal time‐series study was conducted analysing the demographics and physical health parameters of 57 patients who remained with the service over a four and a half year time period. Assessments were taken at baseline, 12, 24, and 36 months for each individual. Despite increasing levels of psychotropic and other health medication over time, physical health parameters were generally held stable for most measures across the four time periods. HDL‐C levels were significantly improved between baseline and 36 months. This stability over time suggests that ongoing assessment, monitoring, and treatment is necessary to arrest the downward trajectory of poor physical health in mental health and opens the door for future research to invest in interventions to run alongside the Wellness Clinic and improve patient physical health.
Background: Comorbid physical and mental health problems are common across the age spectrum. However, services addressing these health concerns are typically siloed and disconnected. Over the past 2 decades efforts have been made to design integrated services to address the physical and mental health needs of the population but little is known about the characteristics of effective integrated care models. The aim of the review was to map the design of integrated care initiatives/models and to describe how the models were evaluated and their evaluation findings. Method: Using a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, Medline, PubMed, PsychINFO, CINAHL were searched for the period from 2003 to 2018, and reference lists of included studies and review articles were examined. Results: The current review identified 43 studies, describing 37 models of integrated physical and mental healthcare. Although modest in terms of evaluation design, it is evident that models are well received by consumers and providers, increase service access, and improve physical and mental health outcomes. Key characteristics of models include shared information technology, financial integration, a single-entry point, colocated care, multidisciplinary teams, multidisciplinary meetings, care coordination, joint treatment plan, joint treatment, joint assessment/joint assessment document, agreed referral criteria and person-centred care. Although mostly modest in term of research design, models were well received by consumers and providers, increased service access and improved physical and mental health outcomes. There was no clear evidence regarding whether models of integrated care are cost neutral, increase or reduce costs. Conclusion: Future research is needed to identify the elements of integrated care that are associated with outcomes, measure cost implications and identify the experiences and priorities of consumers and clinicians.
Article
Full-text available
Introduction: Data on effect of clozapine on metabolic syndrome in adolescent patients with psychosis are limited. This study aimed to evaluate the prevalence and incidence of metabolic syndrome in children and adolescents with psychotic disorders prior to clozapine and while receiving clozapine. Secondary aims were to study the effectiveness and side effect profile of clozapine. Materials and methods: Thirteen child and adolescent patients were evaluated at baseline, 3 months, and a follow-up beyond 6 months. Assessments were made for metabolic profile, effectiveness by positive and negative syndrome scale (PANSS), and side effects. Results: Prior to starting of clozapine, the prevalence of metabolic syndrome was 23%. After 3 months on clozapine, 38.5% (5/13) patients fulfilled criteria of metabolic syndrome and further on follow-up beyond 6 months (with last observation carried forward) 46.2% (6/13) had developed metabolic syndrome. There was a significant reduction in PANSS scores at 3 months and follow-up more so in those who developed metabolic syndrome at 3 months. Among the other side effects, hypersalivation was the most common side effect (100%) followed by sedation (69%). Conclusion: Half the prevalence of metabolic syndrome in adolescents on clozapine can be attributed to other factors prior to starting of clozapine, and another half can be attributed to clozapine. Clozapine is effective in an adolescent population.
Article
Full-text available
This meta-analysis examined the effectiveness and safety of metformin to prevent or treat weight gain and metabolic abnormalities associated with antipsychotic drugs. We systematically searched in both English- and Chinese-language databases for metformin randomized controlled clinical trials (RCTs) using placebo in patients taking antipsychotics. Twenty-one RCTs (11 published in English and 10 in Chinese) involving 1547 subjects (778 on metformin, 769 on placebo) were included in this meta-analysis. Metformin was significantly superior to placebo (standard mean differences, -0.69 to -0.51; P = 0.01-0.0001) in the primary outcome measures (body weight, body mass index, fasting glucose, fasting insulin, triglycerides, and total cholesterol). Metformin was significantly superior to placebo in some secondary outcome measures but not in others. Significantly higher frequencies of nausea/vomiting and diarrhea were found in the metformin group, but no differences were found in other adverse drug reactions. In the metformin group, the frequency of nausea/vomiting was 14%, and of diarrhea, 7%. Subgroup and sensitivity analyses demonstrated that primary outcomes were influenced by ethnicity, treatment style (intervention vs prevention), metformin dose, study duration, and mean age. Body weight standard mean difference was -0.91 (confidence interval [CI], -1.40 to -0.41) in 3 prevention RCTs in naive patients, -0.66 (CI, -1.02 to -0.30) in 5 intervention RCTs during the first year, and -0.50 (CI, -0.73 to -0.27) in 9 intervention RCTs in chronic patients. This meta-analysis suggests that adjunctive metformin is an effective, safe, and reasonable choice for antipsychotic-induced weight gain and metabolic abnormalities.
Article
Full-text available
Overweight and obesity are a threat to health, longevity and quality of life. With the growing trend of using atypical antipsychotics for various psychiatric disorders, concern regarding adverse effects has shifted from extrapyramidal side effects to weight gain and metabolic abnormalities. In this review, the author analyses the extent of the problem, the evidence base for using metformin to counteract the weight gain, and prescribing advice for using metformin effectively.
Article
Full-text available
Clozapine can cause severe adverse effects yet it is associated with reduced mortality risk. We test the hypothesis this association is due to increased clinical monitoring and investigate risk of premature mortality from natural causes. We identified 14 754 individuals (879 deaths) with serious mental illness (SMI) including schizophrenia, schizoaffective and bipolar disorders aged ≥ 15 years in a large specialist mental healthcare case register linked to national mortality tracing. In this cohort study we modeled the effect of clozapine on mortality over a 5-year period (2007-2011) using Cox regression. Individuals prescribed clozapine had more severe psychopathology and poorer functional status. Many of the exposures associated with clozapine use were themselves risk factors for increased mortality. However, we identified a strong association between being prescribed clozapine and lower mortality which persisted after controlling for a broad range of potential confounders including clinical monitoring and markers of disease severity (adjusted hazard ratio 0.4; 95% CI 0.2-0.7; p = .001). This association remained after restricting the sample to those with a diagnosis of schizophrenia or those taking antipsychotics and after using propensity scores to reduce the impact of confounding by indication. Among individuals with SMI, those prescribed clozapine had a reduced risk of mortality due to both natural and unnatural causes. We found no evidence to indicate that lower mortality associated with clozapine in SMI was due to increased clinical monitoring or confounding factors. This is the first study to report an association between clozapine and reduced risk of mortality from natural causes.
Article
Full-text available
Patients with severe mental illness (SMI) experience more physical comorbidity than the general population. Multiple factors, including inadequate seeking of healthcare and health care related factors such as lack of collaboration, underlie this undesirable situation. To improve this situation, the logistics of physical health care for patients with SMI need to be changed. We asked both patients and their families about their views on the current organization of care, and how this care could be improved. Group and individual interviews were conducted with patients and family of patients to explore their needs and preferences concerning the care for the physical health of patients with SMI, and to explore the shortcomings they had experienced. Using thematic analysis, responses were firstly divided into common topics, after which these topics were grouped into themes. Three major themes for the improvement of the physical care of patients with SMI were found. Firstly, the reduced ability of patients with SMI to survey their own physical health interests requires health care that is tailored to these needs. Secondly, the lack of collaboration amongst mental health care professionals and general practitioners (GPs) hinders optimal care. Thirdly, concerns were expressed regarding the implementation of monitoring and supporting a healthy lifestyle. Patients with SMI welcome this implementation, but the logistics of providing this care can be improved. An optimal approach for caring for the physical health of patients with SMI requires a professional approach, which is different to the routine care provided to the general public. This approach can and should be accomplished within the usual organizational structure. However, this requires tailoring of the health care to the needs of patients with SMI, as well as structural collaboration between mental health care professionals and GPs.
Article
Full-text available
To examine the mortality experience of psychiatric patients in Western Australia compared with the general population. Population based study. Western Australia, 1985-2005. Psychiatric patients (292 585) registered with mental health services in Western Australia. Trends in life expectancy for psychiatric patients compared with the Western Australian population and causes of excess mortality, including physical health conditions and unnatural causes of death. When using active prevalence of disorder (contact with services in previous five years), the life expectancy gap increased from 13.5 to 15.9 years for males and from 10.4 to 12.0 years for females between 1985 and 2005. Additionally, 77.7% of excess deaths were attributed to physical health conditions, including cardiovascular disease (29.9%) and cancer (13.5%). Suicide was the cause of 13.9% of excess deaths. Despite knowledge about excess mortality in people with mental illness, the gap in their life expectancy compared with the general population has widened since 1985. With most excess deaths being due to physical health conditions, public efforts should be directed towards improving physical health to reduce mortality in people with mental illness, in addition to ongoing efforts to prevent suicide.
Article
Full-text available
To study the prevalence of metabolic syndrome in patients receiving clozapine. For this study, 100 patients attending the psychiatry outpatient clinic of a tertiary care hospital who were receiving clozapine for more than three months were evaluated for the presence of metabolic syndrome using the International Diabetes Federation (IDF) and modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP-III) criteria. Forty-six patients fulfilled IDF criteria and 47 met modified NCEP ATP-III criteria of metabolic syndrome. There was significant correlation between these two sets of criteria used to define the metabolic syndrome (Kappa value -0.821, P < 0.001). Among the individual parameters studied, increased waist circumference was the most common abnormality, followed by abnormal blood glucose levels and elevated triglyceride levels. All these abnormalities were seen in more than half (52-61%) of the patients. When the sample was divided into two groups, i.e., those with and without metabolic syndrome, patients with metabolic syndrome had significantly higher body mass index and had spent more time in school. Logistic regression analysis revealed that these two variables together explained about 19% of the variance in metabolic syndrome (adjusted r(2) = 0193; F = 12.8; P < 0.001). The findings of the present study suggest that metabolic syndrome is highly prevalent in subjects receiving clozapine.
Article
Full-text available
Despite improving healthcare, the gap in mortality between people with serious mental illness (SMI) and general population persists, especially for younger age groups. The electronic database from a large and comprehensive secondary mental healthcare provider in London was utilized to assess the impact of SMI diagnoses on life expectancy at birth. People who were diagnosed with SMI (schizophrenia, schizoaffective disorder, bipolar disorder), substance use disorder, and depressive episode/disorder before the end of 2009 and under active review by the South London and Maudsley NHS Foundation Trust (SLAM) in southeast London during 2007-09 comprised the sample, retrieved by the SLAM Case Register Interactive Search (CRIS) system. We estimated life expectancy at birth for people with SMI and each diagnosis, from national mortality returns between 2007-09, using a life table method. A total of 31,719 eligible people, aged 15 years or older, with SMI were analyzed. Among them, 1,370 died during 2007-09. Compared to national figures, all disorders were associated with substantially lower life expectancy: 8.0 to 14.6 life years lost for men and 9.8 to 17.5 life years lost for women. Highest reductions were found for men with schizophrenia (14.6 years lost) and women with schizoaffective disorders (17.5 years lost). The impact of serious mental illness on life expectancy is marked and generally higher than similarly calculated impacts of well-recognised adverse exposures such as smoking, diabetes and obesity. Strategies to identify and prevent causes of premature death are urgently required.
Article
Full-text available
There are many factors that contribute to the poor physical health of people with severe mental illness (SMI), including lifestyle factors and medication side effects. However, there is increasing evidence that disparities in healthcare provision contribute to poor physical health outcomes. These inequalities have been attributed to a combination of factors including systemic issues, such as the separation of mental health services from other medical services, healthcare provider issues including the pervasive stigma associated with mental illness, and consequences of mental illness and side effects of its treatment. A number of solutions have been proposed. To tackle systemic barriers to healthcare provision integrated care models could be employed including co-location of physical and mental health services or the use of case managers or other staff to undertake a co-ordination or liaison role between services. The health care sector could be targeted for programmes aimed at reducing the stigma of mental illness. The cognitive deficits and other consequences of SMI could be addressed through the provision of healthcare skills training to people with SMI or by the use of peer supporters. Population health and health promotion approaches could be developed and targeted at this population, by integrating health promotion activities across domains of interest. To date there have only been small-scale trials to evaluate these ideas suggesting that a range of models may have benefit. More work is needed to build the evidence base in this area.
Article
Full-text available
• Patients with schizophrenia have a wide range of risk factors for cardiometabolic disease, at rates 1.5–5 times greater than the general population. • Despite the provision of many sets of guidelines and protocols for screening and monitoring of cardiometabolic risks, morbidity and mortality rates for those with psychotic illnesses remain excessive and premature. • Surveys of mental health practitioners reveal a clear acknowledgement of the importance of managing cardiometabolic risks and subsequent comorbidity. However, inadequate screening rates of patients with antipsychotic‐treated mental illnesses suggest “knowing is not doing”. • Surmountable barriers (at service, patient and illness levels) to adequate integrated health care are not being adequately challenged for this population. • Recommendations to improve the situation include service reorganisation, communication enhancement, improved training and education, better incentives, accreditation rigour, and government leadership.
Article
Full-text available
Individuals with major mental illness are a high-risk group for cardio-metabolic derangements due to genetic predisposition, developmental and environmental stressors, and lifestyle. This risk is compounded when they receive antipsychotic medications. Guidelines for screening, monitoring, and managing these patients for metabolic problems have been in place for several years. Despite this, recent reports document that this population continues to receive poor care in this regard. In this article, we review the metabolic profile of atypical antipsychotic medications and offer guidelines to reduce the metabolic complications of these agents.
Article
The metabolic syndrome is a common metabolic disorder that results from the increasing prevalence of obesity. The disorder is defined in various ways, but in the near future a new definition(s) will be applicable worldwide. The pathophysiology seems to be largely attributable to insulin resistance with excessive flux of fatty acids implicated. A proinflammatory state probably contributes to the syndrome. The increased risk for type 2 diabetes and cardiovascular disease demands therapeutic attention for those at high risk. The fundamental approach is weight reduction and increased physical activity; however, drug treatment could be appropriate for diabetes and cardiovascular disease risk reduction.
Article
To review the data with respect to prevalence and risk factors of metabolic syndrome (MetS) in bipolar disorder patients. Electronic searches were done in PUBMED, Google Scholar and Science direct. From 2004 to June 2011, 34 articles were found which reported on the prevalence of MetS. The sample size of these studies varied from 15 to 822 patients, and the rates of MetS vary widely from 16.7% to 67% across different studies. None of the sociodemographic variable has emerged as a consistent risk factor for MetS. Among the clinical variables longer duration of illness, bipolar disorder- I, with greater number of lifetime depressive and manic episodes, and with more severe and difficult-to-treat index affective episode, with depression at onset and during acute episodes, lower in severity of mania during the index episode, later age of onset at first manic episode, later age at first treatment for the first treatment for both phases, less healthy diet as rated by patients themselves, absence of physical activity and family history of diabetes mellitus have been reported as clinical risk factors of MetS. Data suggests that metabolic syndrome is fairly prevalent in bipolar disorder patients.
Article
The 2010 Survey of High Impact Psychosis (SHIP) is Australia's second national psychosis survey. This paper provides an overview of its findings, including comparisons with the first psychosis survey and general population data. The survey covered 1.5 million people aged 18-64 years, approximately 10% of Australians in this age group. A two-phase design was used. In phase 1, screening for psychosis took place in public mental health services and non-government organizations supporting people with mental illness. In phase 2, 1825 of those screen-positive for psychosis were randomly selected and interviewed. Data collected included symptomatology, substance use, functioning, service utilization, medication use, education, employment, housing, and physical health including fasting blood samples. The estimated 1-month treated prevalence of psychotic disorders in public treatment services was 3.1 people per 1000 population; the 12-month treated prevalence was 4.5 people per 1000. The majority (63.0%) of participants met ICD-10 criteria for schizophrenia/schizoaffective disorder. One-half (49.5%) reported attempting suicide in their lifetime and two-thirds (63.2%) were rated as impaired in their ability to socialize. Over half (54.8%) had metabolic syndrome. The proportion currently smoking was 66.1%. Educational achievement was low. Only 21.5% were currently employed. Key changes in the 12 years since the first survey included: a marked drop in psychiatric inpatient admissions; a large increase in the proportion attending community mental health clinics; increased use of rehabilitation services and non-government organizations supporting people with mental illness; a major shift from typical to atypical antipsychotics; and large increases in the proportions with lifetime alcohol or drug abuse/dependence. People with psychotic illness face multiple challenges. An integrated approach to service provision is needed to ensure that their living requirements and needs for social participation are met, in addition to their very considerable mental and physical health needs.
Article
To assess physical health self-reports and health utilization behaviours of community dwelling persons with persistent psychosis. A cross-sectional survey was conducted of 106 patients with persistent psychosis. Using self-reported measures, the prevalence of smoking, alcohol consumption and exercise, and body mass index were determined. Health utilization behaviour, especially with respect to general practice, was assessed. Data was compared with that derived from the general population and longitudinally with a historical cohort. Compared with the general population, those with psychosis were more likely to be smokers, overweight or obese, and less likely to be non/ex-smokers. Compared with previous studies, smoking and obesity persisted as major modifiable risk factors. Over 7 years, some risks such as smoking increased, whereas moderating factors such as light exercise, improved. Three-quarters of patients would visit their GP if they had a physical illness but a third reported not having visited their GP or other doctor in the previous 12 months. Patients with persistent psychosis have increased rates of cardiometabolic risk yet seek medical attention infrequently. These findings have not improved despite an increased awareness of the enhanced risk of developing metabolic disease in this group.
Article
The lifespan of people with severe mental illness (SMI) is shorter compared to the general population. This excess mortality is mainly due to physical illness. We report prevalence rates of different physical illnesses as well as important individual lifestyle choices, side effects of psychotropic treatment and disparities in health care access, utilization and provision that contribute to these poor physical health outcomes. We searched MEDLINE (1966 - August 2010) combining the MeSH terms of schizophrenia, bipolar disorder and major depressive disorder with the different MeSH terms of general physical disease categories to select pertinent reviews and additional relevant studies through cross-referencing to identify prevalence figures and factors contributing to the excess morbidity and mortality rates. Nutritional and metabolic diseases, cardiovascular diseases, viral diseases, respiratory tract diseases, musculoskeletal diseases, sexual dysfunction, pregnancy complications, stomatognathic diseases, and possibly obesity-related cancers are, compared to the general population, more prevalent among people with SMI. It seems that lifestyle as well as treatment specific factors account for much of the increased risk for most of these physical diseases. Moreover, there is sufficient evidence that people with SMI are less likely to receive standard levels of care for most of these diseases. Lifestyle factors, relatively easy to measure, are barely considered for screening; baseline testing of numerous important physical parameters is insufficiently performed. Besides modifiable lifestyle factors and side effects of psychotropic medications, access to and quality of health care remains to be improved for individuals with SMI.
Article
to investigate the burden of excess mortality among people with mental illness in developed countries, how it is distributed, and whether it has changed over time. we conducted a systematic search of MEDLINE, restricting our attention to peer-reviewed studies and reviews published in English relating to mortality and mental illness. Because of the large number of studies that have been undertaken during the last 30 years, we have selected a representative cross-section of studies for inclusion in our review. there is substantial excess mortality in people with mental illness for almost all psychiatric disorders and all main causes of death. Consistently elevated rates have been observed across settings and over time. The highest numbers of excess deaths are due to cardiovascular and respiratory diseases. With life expectancy increasing in the general population, the disparity in mortality outcomes for people with mental illness is increasing. without the development of alternative approaches to promoting and treating the physical health of people with mental illness, it is possible that the disparity in mortality outcomes will persist.
Article
The use of antipsychotic medications entails a difficult trade-off between the benefit of alleviating psychotic symptoms and the risk of troubling, sometimes life-shortening adverse effects. There is more variability among specific antipsychotic medications than there is between the first- and second-generation antipsychotic classes. The newer second-generation antipsychotics, especially clozapine and olanzapine, generally tend to cause more problems relating to metabolic syndrome, such as obesity and type 2 diabetes mellitus. Also, as a class, the older first-generation antipsychotics are more likely to be associated with movement disorders, but this is primarily true of medications that bind tightly to dopaminergic neuroreceptors, such as haloperidol, and less true of medications that bind weakly, such as chlorpromazine. Anticholinergic effects are especially prominent with weaker-binding first-generation antipsychotics, as well as with the second-generation antipsychotic clozapine. All antipsychotic medications are associated with an increased likelihood of sedation, sexual dysfunction, postural hypotension, cardiac arrhythmia, and sudden cardiac death. Primary care physicians should understand the individual adverse effect profiles of these medications. They should be vigilant for the occurrence of adverse effects, be willing to adjust or change medications as needed (or work with psychiatric colleagues to do so), and be prepared to treat any resulting medical sequelae.
Article
The aim of this study was to identify the prevalence of metabolic syndrome and its putative precursors in a naturalistic study of non-acute inpatients at a psychiatric hospital. Anthropometric and biochemical data collected from the hospital's annual cardiometabolic survey, along with information about prescribed medications, were used to assess the prevalence and predictors of physical health problems in patients with schizophrenia. Of the 167 patients included in the survey, 52.4% met criteria for metabolic syndrome. A shorter duration of hospital admission and clozapine use were significant predictors of metabolic syndrome. Age, gender, duration of admission and clozapine use were all predictors of individual cardiometabolic risk factors. The findings from this naturalistic study reinforce the high prevalence of physical health problems in patients with schizophrenia and the important influence that psychiatric treatments can have on physical health. The impact of clozapine on cardiometabolic health appears to occur early in the course of treatment and emphasizes the need for proactive monitoring and interventions from the outset of management.
Article
The introduction of second-generation antipsychotic drugs during the 1990s is widely believed to have adversely affected mortality of patients with schizophrenia. Our aim was to establish the long-term contribution of antipsychotic drugs to mortality in such patients. Nationwide registers in Finland were used to compare the cause-specific mortality in 66 881 patients versus the total population (5.2 million) between 1996, and 2006, and to link these data with the use of antipsychotic drugs. We measured the all-cause mortality of patients with schizophrenia in outpatient care during current and cumulative exposure to any antipsychotic drug versus no use of these drugs, and exposure to the six most frequently used antipsychotic drugs compared with perphenazine use. Although the proportional use of second-generation antipsychotic drugs rose from 13% to 64% during follow-up, the gap in life expectancy between patients with schizophrenia and the general population did not widen between 1996 (25 years), and 2006 (22.5 years). Compared with current use of perphenazine, the highest risk for overall mortality was recorded for quetiapine (adjusted hazard ratio [HR] 1.41, 95% CI 1.09-1.82), and the lowest risk for clozapine (0.74, 0.60-0.91; p=0.0045 for the difference between clozapine vs perphenazine, and p<0.0001 for all other antipsychotic drugs). Long-term cumulative exposure (7-11 years) to any antipsychotic treatment was associated with lower mortality than was no drug use (0.81, 0.77-0.84). In patients with one or more filled prescription for an antipsychotic drug, an inverse relation between mortality and duration of cumulative use was noted (HR for trend per exposure year 0.991; 0.985-0.997). Long-term treatment with antipsychotic drugs is associated with lower mortality compared with no antipsychotic use. Second-generation drugs are a highly heterogeneous group, and clozapine seems to be associated with a substantially lower mortality than any other antipsychotics. Restrictions on the use of clozapine should be reassessed. Annual EVO Financing (Special government subsidies from the Ministry of Health and Welfare, Finland).
Article
To summarize the accumulated data on metabolic syndrome prevalence in patients with schizophrenia, examine evidence for a biological contribution of the mental illness to metabolic risk and review novel options available for management of prediabetic states. A Medline search using metabolic syndrome, insulin resistance and insulin sensitivity cross-referenced with schizophrenia was performed on articles published between 1990 and May 2008. Recent evidence indicates that schizophrenia increases predisposition towards metabolic dysfunction independent of environmental exposure. Both fasting and non-fasting triglycerides have emerged as important indicators of cardiometabolic risk, while metformin, thiazolidinediones and GLP-1 modulators may prove promising tools for managing insulin resistance. Because of lifestyle, disease and medication effects, schizophrenia patients have significant risk for cardiometabolic disease. Routine monitoring, preferential use of metabolically neutral antipsychotics and lifestyle education are critical to minimizing risk, with a possible role for antidiabetic medications for management of insulin resistant states that do not respond to other treatment strategies.
Article
The metabolic syndrome is a common metabolic disorder that results from the increasing prevalence of obesity. The disorder is defined in various ways, but in the near future a new definition(s) will be applicable worldwide. The pathophysiology seems to be largely attributable to insulin resistance with excessive flux of fatty acids implicated. A proinflammatory state probably contributes to the syndrome. The increased risk for type 2 diabetes and cardiovascular disease demands therapeutic attention for those at high risk. The fundamental approach is weight reduction and increased physical activity; however, drug treatment could be appropriate for diabetes and cardiovascular disease risk reduction.
Article
People with serious mental illness have higher morbidity and mortality rates of chronic diseases than the general population. This discussion paper explores the complex reasons for these disparities in health, such as limitations of health services, the effects of having a serious mental illness, health behaviours and the effects of psychotropic medication. Physical health can be enhanced by improved monitoring and lifestyle interventions initiated at the start of treatment. There are opportunities for mental health nurses to play a significant role in improving both the physical and mental health of people with serious mental illness.
Article
It has long been known that psychiatric patients experience increased morbidity and mortality associated with a range of physical disorders. Lifestyle, inadequate health care, and a variety of other factors all contribute to the poor physical health of people with severe mental illness. Second-generation antipsychotics have gained widespread acceptance for the management of patients with schizophrenia and other forms of severe mental illness. While demonstrating several advantages over first-generation antipsychotics, second-generation antipsychotics have been found to cause or exacerbate several metabolic disorders, including diabetes, obesity, dyslipidemia, and metabolic syndrome. These disorders are closely linked and consistently associated with the development of cardiovascular disease, with varying prevalence rates depending on the second-generation antipsychotic used. As a result, several authoritative guidelines have been developed for the monitoring and management of metabolic disturbances in schizophrenia and other forms of severe mental illness. Specifically, the guidelines and recommendations generated from the Mount Sinai Conference on Medical Monitoring and the American Diabetes Association/American Psychiatric Association Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes call for a more integrated and cooperative approach between primary care physicians and mental health care providers to improve the quality of health care for people with severe mental illness. By routinely performing physical health monitoring, referrals, and/or treatment for patients with schizophrenia and other forms of severe mental illness, mental health care providers can take a lead role in transforming the current system of fragmented mental and physical health services into a system focused on early intervention, wellness, and recovery.
Inequities in healthcare provision for people with serve mental illness
  • D Lawrence
  • S Kisley
Lawrence, D. & Kisley, S. (2010). Inequities in healthcare provision for people with serve mental illness. Journal of Psychopharmacology, 24, 61-68.
Improving the Integration of Mental Health Services in Primary Health Care at the Macro Level. PHCRIS Policy Issue Review. Adelaide: Primary Health Care Research and Information Service
  • P Bywood
  • L Brown
  • M Raven
Bywood, P., Brown, L. & Raven, M. (2015). Improving the Integration of Mental Health Services in Primary Health Care at the Macro Level. PHCRIS Policy Issue Review. Adelaide: Primary Health Care Research and Information Service.
Clinical monitoring and management of metabolic syndrome in patients receiving antipsychotic medications
  • M. Hasnain
  • V. Vieweg
  • S. K. Fredrikson
  • M. Beatty-Brooks
  • A. Fernandea
  • A.K. Paudurangi
How NSW Mental Health Community Managed Organisations Assist People Living with Mental Health Conditions to Address Their Physical Health Needs: A Scoping Study and Review of Literature
  • N Hancock
  • C Cowles
Hancock, N. & Cowles, C. (2014). How NSW Mental Health Community Managed Organisations Assist People Living with Mental Health Conditions to Address Their Physical Health Needs: A Scoping Study and Review of Literature. Sydney: Mental Health Coordinating Council and University of Sydney.
Physical Health Care of Mental Health Consumers. Department of Health
  • Nsw Health
Clozapine-Induced Myocarditis: Monitoring Protocol
  • Ministry
  • Health
Living Well: A Strategic Plan for Mental Health
Available from: http://www0.health.nsw.gov.au/policies/gl/ 2009/pdf/GL2009_007.pdf NSW Mental Health Commission (2014). Living Well: A Strategic Plan for Mental Health in NSW. Sydney: NSW Mental Health Comission.
A Contributing Life: The 2012 National Report Card on Mental Health and Suicide Prevention
  • J Muench
  • A Hamer
Muench, J. & Hamer, A. (2010). Adverse effects of antipsychotic medications. American Family Physician, 81, 617-622. National Mental Health Commission (2012). A Contributing Life: The 2012 National Report Card on Mental Health and Suicide Prevention. Sydney: National Mental Health Commission. National Vascular Disease Prevention Alliance (2012). Guidelines for the management of absolute cardiovascular disease risk. [Cited 2 Feb 2017]. Available from: https:// www.heartfoundation.org.au/images/uploads/publications/ Absolute-CVD-Risk-Full-Guidelines.pdf NSW Health (2009). Physical Health Care of Mental Health Consumers. Department of Health. [Cited 2 Feb 2017].
11-year follow-up of mortality in patients with schizophrenia: A population-based cohort study
Mental Health Nurses in Australia: Scope of Practice 2013 & Standards of Practice 2010. The Australian College of Mental Health Nurses. [Cited 2 Feb 2017]. Available from: http://www.acmhn.org/career-resources/scope-ofpractice Tihonen, J., Lonnqvist, J. & Wahlbeck, K. (2009). 11-year follow-up of mortality in patients with schizophrenia: A population-based cohort study. Lancet, 374, 620-627.
The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: Restrospective analysis of population based registers
  • Lawrence