Who should swing the stethoscope? An audit of baseline physical examination and blood monitoring on new patients accepted by an early intervention in psychosis team

Monitoring and Treating Metabolic Abnormalities in Patients with Early Psychosis Initiated on Antipsychotic Medications

Antipsychotic medications carry an established lifetime risk of metabolic syndrome. This retrospective chart review evaluated feasibility of a metabolic monitoring clinical decision support tool (CDST) for weight, lipid, blood glucose, and blood pressure management of 163 clients in an early psychosis outpatient clinic over 2 years. Each parameter had at least 98 (60.1%) clients with a recorded value, the most being documented for weight with 112 (68.7%) clients. CDST adherence ranged from at least 54.3-100% for non-pharmacologic interventions (e.g. clinic counseling, referral to health program or primary care) and at least 33.3-100% for pharmacologic interventions (e.g. metformin). Though no baseline cardiometabolic abnormalities were identified, dyslipidemia and obesity were later found in 37 (22.7%) and 35 (21.5%) clients, respectively. Only 14 (8.6%) clients were prescribed medications for cardiometabolic abnormalities by psychiatrists in the clinic. Increasing focus on physical health is needed to better this population's long-term prognosis.

Assessment of cardiovascular risk in an Italian psychiatric outpatient sample: A chart review of patients treated with second-generation antipsychotics

Despite the call by the scientific community for a systematic monitoring of physical health in people with psychiatric illnesses, national and international audits have reported poor quality of cardiovascular risk assessments and management in this vulnerable population. Available evidence indicates that in people affected by mental illness, life expectancy is reduced by 10-20 years, mainly due to cardiovascular accidents and metabolic syndrome (MetS)-related diseases. The primary aim of the present study was to evaluate the accuracy of cardiovascular risk monitoring in an outpatient sample of patients taking second-generation antipsychotics. The sample consisted of 200 patients consecutively recruited from two community mental health centres. A clinical chart review was performed on the following laboratory tests: total cholesterol, high- and low-density lipoprotein, serum triglycerides, fasting blood glucose, γ-glutamyl transpeptidase. Blood pressure and waist circumference were measured. A complete cardiovascular risk assessment was available only in 60 patients out of 200 (33.3%). The only variable associated with laboratory tests for MetS was receiving three or more psychotropic medications, which increased fourfold the probability of metabolic screening. In the subsample of patients with full screening, the prevalence of MetS was 33.3%. Our findings suggest that mental health professionals working in community mental health services should incorporate a more systematic assessment of physical health in their practice, and intervene proactively to reduce the significant cardiovascular burden carried by people with several mental illness.

Early Intervention in Psychosis: Health of the Nation Outcome Scales (HoNOS) Outcomes From a Five-Year Prospective Study

INTRODUCTION

Over the last two decades, mental health services internationally have shifted towards intervening early in psychosis. The critical period for intervention is estimated to be five-years and many specialised programs target early psychosis.

AIM/QUESTION

This prospective cohort study aimed to evaluate five-year outcomes from an early psychosis program (EPP) that adopted an integrated model, providing nursing and multidisciplinary community mental healthcare to clients aged 16-65years, beyond the typical age range of 16-25years.

METHOD

We examined one routine outcome measure, the Health of the Nation Outcome Scales (HoNOS) across episodes of care for clients receiving EPP over a 5year period (n=239), comparing these results with HoNOS outcomes in an Australian national dataset for all public mental health clients.

RESULTS

HoNOS improvements were highly significant from intake to discharge and from review to discharge for EPP clients, and these compared well with national outcome performance.

CONCLUSION

There is potential for mental health nurses and other clinicians to significantly improve client symptoms and functioning, in a model of early psychosis treatment beyond a youth focus.

Improving metabolic monitoring rate for young people aged 35 and younger taking antipsychotic medications to treat a psychosis: A literature review

Young people aged 35 and younger who are taking antipsychotic medications to treat a psychosis are a high risk for developing metabolic syndrome due to the adverse effects of the medications. This paper reports the finding of a review of literature to identify interventions to improve metabolic monitoring rates in this group. A review of 478 studies identified 15 articles which met the inclusion criteria. Five articles reported single-intervention studies and the remaining integrated two or more interventions to improve uptake level of metabolic monitoring. As metabolic syndrome can be detected early through metabolic monitoring in young people taking antipsychotics, early intervention is important to improve their physical health trajectory.

Poor monitoring of physical health in patients referred to a mood disorders service

BACKGROUND

Severe mental illness is associated with significantly increased morbidity and mortality, most commonly from cardiovascular disease. Much of the risk is explicable by potentially modifiable factors such as diabetes and dyslipidaemia, and regular screening of patients with severe mental illness is recommended. Screening and intervention for physical illness among people with schizophrenia is often suboptimal, but little is known about monitoring physical health in patients with affective (mood and anxiety) disorders.

METHOD

Electronic and paper records were examined for evidence of monitoring of cardiovascular disease risk factors in the 12 months prior to assessment in patients attending a tertiary referral specialist service for affective disorders over a period of 39 months. The number of contacts with healthcare services was calculated for each patient to provide an estimate of the opportunities for monitoring.

RESULTS

Notes for 113 patients were examined. The mean number of contacts with outpatient services in the 12 months before assessment was 6.9 (standard deviation 7.7). Documented evidence of physical-health monitoring was seen in only 29 patients: monitoring was more commonly undertaken in patients with recurrent unipolar depression and in those who had undergone recent inpatient treatment. Contacts that could have allowed monitoring of physical health were common.

DISCUSSION

Although most patients had multiple contacts with health services in the 12-month period before their assessment in the service, there was little evidence of use of primary-prevention measures to reduce the risks of diabetes and cardiovascular disease in this vulnerable population.

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.

Guideline concordant monitoring of metabolic risk in people treated with antipsychotic medication: systematic review and meta-analysis of screening practices

BACKGROUND

Despite increased cardiometabolic risk in individuals with mental illness taking antipsychotic medication, metabolic screening practices are often incomplete or inconsistent.

METHOD

We undertook a systematic search and a PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) meta-analysis of studies examining routine metabolic screening practices in those taking antipsychotics both for patients in psychiatric care before and following implementation of monitoring guidelines.

RESULTS

We identified 48 studies (n=290 534) conducted between 2000 and 2011 in five countries; 25 studies examined predominantly schizophrenia-spectrum disorder populations; 39 studies (n=218 940) examined routine monitoring prior to explicit guidelines; and nine studies (n=71 594) reported post-guideline monitoring. Across 39 studies, routine baseline screening was generally low and above 50% only for blood pressure [69.8%, 95% confidence interval (CI) 50.9-85.8] and triglycerides (59.9%, 95% CI 36.6-81.1). Cholesterol was measured in 41.5% (95% CI 18.0-67.3), glucose in 44.3% (95% CI 36.3-52.4) and weight in 47.9% (95% CI 32.4-63.7). Lipids and glycosylated haemoglobin (HbA1c) were monitored in less than 25%. Rates were similar for schizophrenia patients, in US and UK studies, for in-patients and out-patients. Monitoring was non-significantly higher in case-record versus database studies and in fasting samples. Following local/national guideline implementation, monitoring improved for weight (75.9%, CI 37.3-98.7), blood pressure (75.2%, 95% CI 45.6-95.5), glucose (56.1%, 95% CI 43.4-68.3) and lipids (28.9%, 95% CI 20.3-38.4). Direct head-to-head pre-post-guideline comparison showed a modest but significant (15.4%) increase in glucose testing (p=0.0045).

CONCLUSIONS

In routine clinical practice, metabolic monitoring is concerningly low in people prescribed antipsychotic medication. Although guidelines can increase monitoring, most patients still do not receive adequate testing.

Targeted intervention to improve monitoring of antipsychotic-induced weight gain and metabolic disturbance in first episode psychosis

OBJECTIVE

International guidelines recommend monitoring for weight gain and metabolic disturbance in patients prescribed second generation antipsychotics. We aimed to investigate whether a targeted intervention could improve levels of monitoring in a first episode psychosis clinic.

METHOD

A pre-intervention audit of both metabolic screening rates and specific monitoring of weight and metabolic indices following the initiation of antipsychotic medication was performed in our first episode psychosis clinic. This was repeated 18 months later, following an intervention that included a number of targeted improvement strategies based on an analysis of barriers and enablers to performing monitoring within the clinic. The intervention included provision of monitoring equipment, interactive educational events, reminders and prompts and embedding processes for monitoring within team structure.

RESULTS

There were significant improvements in both the screening of metabolic indices and the monitoring of indices following initiation of antipsychotic medications. There were also improvements in the number of active interventions offered to clients by clinicians. However, the level of guideline concordant monitoring remains low within our service.

CONCLUSIONS

A comprehensive programme of implementation strategies can improve both screening and monitoring of the metabolic side-effects of antipsychotic medications. Further focused strategies are necessary to continue to improve monitoring to guideline concordant levels.

Metabolic abnormalities in an early psychosis service: a retrospective, naturalistic cross-sectional study

AIM

There is an increasing recognition of the impact of weight gain on the development of metabolic abnormalities in young people receiving atypical antipsychotic drugs for first-episode psychosis. This study examined the prevalence of such abnormalities in a specialist early-intervention community mental health team.

METHODS

A retrospective case record audit of 85 patients 16-27 years old attending the Early Psychosis Service between October 2006 and June 2008, who had at least one metabolic measure defined as: weight, body mass index (BMI), waist circumference, blood pressure, and fasting blood glucose and lipids. Metabolic syndrome identified by the International Diabetes Federation (IDF) criteria.

RESULTS

Fifty-five percent of males and 42% of females were overweight or obese at a median treatment duration of 8 months. Duration of antipsychotic therapy was associated with higher BMI (r = 0.28, P < 0.01). More than 40% of the total sample had high waist circumference. Of the 64 subjects with complete metabolic data, eight (12.5%) met full IDF criteria for metabolic syndrome, and another 21 (32.8%) had either increased waist with one metabolic abnormality or normal waist and two metabolic abnormalities.

CONCLUSION

Over a third of young patients being treated for their first episode of psychosis either had metabolic syndrome or showed metabolic abnormalities. Treatment duration related to higher BMI and greater prevalence of metabolic syndrome. Detection of metabolic complications after treatment instigation in patients with first-episode psychosis will permit early intervention with lifestyle or drug interventions in those at risk of significant physical health morbidity.