High Rates of Metabolic Disorder Associated with Antipsychotic Medications

Raminder Pal Cheema, MD, of the Bronx Lebanon Hospital, New York, told an audience at the Annual Meeting of the American Psychiatric Association (APA) in San Diego that patients with serious and persistent mental illness (SPMI) die, on average, 25 years earlier than the general population.

However, Cheema said that 60% of this increased mortality is due to cardiovascular disease (CVD). Metabolic disorders that can lead to CVD are also a big problem with this population. Cheema cited as an example that type 2 diabetes (T2D) is twice as common in people with mental illness compared with the general population, and, in a study of more than 10,000 patients with schizophrenia or depression, more than half had metabolic syndrome and more than 90% had at least 1 risk factor for the disease.

Cheema stressed the economic impact of these increased cases of metabolic syndrome, with obesity alone leading to a medical cost increase of $1500 per year per patient, for a $174 billion annual health expense.

The facts motivated a group of residents at Bronx Lebanon, led by Sasidhar Gunturu, MD, currently at the Baylor College of Medicine, Houston, TX, to initiate the study that a team led by Cheema completed for publication and presentation.

After reviewing the diagnostic criteria for metabolic syndrome (abdominal obesity, hypertension, triglycerides, HDL, blood glucose), Cheema reminded the audience that having any 3 of these conditions results in a diagnosis of metabolic syndrome, and having 2 of the 5 puts a patient in the category of high risk for metabolic syndrome.

Cheema next reviewed several studies that the residents examined before commencing their own study. These included one study (Nasrallah et al, 2006) that determined rates of nontreatment in a population of patients with schizophrenia on antipsychotic medications to be 30% for diabetes, more than 60% for hypertension, and nearly 90% for dyslipidemia. Overall, Cheema said, “The antipsychotic medications seen to carry the highest cardiometabolic risk were olanzapine and quetiapine.”

After next reviewing the cardiometabolic monitoring guidelines agreed upon by the APA and the American Diabetes Association, with particular attention paid to the recommended frequency of monitoring, Cheema reviewed his team’s results from a retrospective chart review of nearly 3000 patients in the Bronx Lebanon Outpatient Psychiatric Clinic from 2014 to 2015 that examined metabolic risk factor prevalence and efficacy of cardiometabolic screening in this population.

Of the 2826 patients in the study, just over half were prescribed antipsychotic medications. Baseline prevalence of hypertension, obesity, or smoking was seen in more than one-third of patients, and diabetes or hyperlipidemia in one-fourth of the population. The results also demonstrated low compliance to screening guidelines in the preceding 6 months, where less than 25% received a lipid panel test, less than 40% had serum glucose tested, and one-fifth had their hemoglobin A1c measured.

In addition, almost half of the patients had had no determination of body mass index (BMI) during this period, and more than 40% were not even weighed. Cheema’s team recommended that electronic medical records (EMR) be modified to automatically calculate BMI from weight to help deal with the last 2 missing pieces of key data.

In conclusion, Cheema told the audience, “Our baseline data demonstrate a lack of compliance to cardiometabolic screening guidelines and well illustrate the magnitude of cardiometabolic risk factors in our patient population. We have proposed interventions that include education of providers and patients as well as the institution of electronic medical records documentation alerts and reminders to improve screening compliance. In particular, it is key to monitor patients who are at high risk and have a plan to switch to these patients to lower-risk antipsychotics.”