Time to Act: Cardiologists, Diabetes Docs, and Psychiatrists Urged to Work Together to Tackle CVD in the Mentally Ill

September 30, 2009

September 30, 2009 (Vienna, Austria) — A joint statement calling attention to the excess cardiovascular mortality associated with severe mental illness has been issued by the European Society of Cardiology (ESC), the European Association for the Study of Diabetes (EASD) and the European Psychiatric Association (EPA) [1]. The statement, authored by Dr Marc De Hert (Catholic University, Leuven, Belgium) and colleagues, appears in the September 2009 issue of European Psychiatry and is also published on the EASD website.

"People with schizophrenia and bipolar disorder die prematurely, on average 10 to 20 years earlier than the general population," coauthor Dr Richard Holt (University of Southampton, UK), a diabetes expert, told a press conference today here at the European Association for the Study of Diabetes 2009 Meeting. And while suicide and trauma are well-recognized causes of death among such patients, physical illness accounts for 75% of mortality, and cardiovascular disease is the commonest cause of death, he notes. "It's becoming more and more apparent that not only do these people have mental disease, but they are at considerably higher risk of cardiovascular disease and of developing diabetes," he noted.

Much of this excess risk among the mentally ill can be attributed to lifestyle factors, says Holt, which are "very important. There is a high prevalence of smoking among the mentally ill, they eat a lot of fast food, and they don't exercise." Genetics is also believed to play a role, as are changes in certain inflammatory markers and stress hormones that seem to occur in some of these patients. On top of this are potential side effects from some antipsychotic medications, which can result in significant weight gain and may worsen other metabolic cardiovascular risk factors. However, Holt stressed that, overall, the newer antipsychotics that are in use have slightly lower rates of cardiovascular mortality than older ones.

Added to all of this is the fact that people with mental illness find it much harder to access physical-health services and therefore have fewer opportunities for screening for diabetes and cardiovascular disease than the general population, making for a potent cocktail, Holt said. "This is an opportunity to bring psychiatrists, diabetes specialists, and cardiologists together to address this problem, to come up with a strategy to identify and to try to treat these people. It's not just a case of physicians telling psychiatrists what to do; we need to work together," he stressed.

Screen the Mentally Ill Much Earlier

The main messages are that there needs to be an increasing awareness that CVD is more common among people with mental illness and also that it occurs at a much younger age, Holt says. "We often see the metabolic syndrome being present in around a third of individuals even around the time they are presenting [with mental illness] in their mid 20s to 30s."

Cardiologists need to be advising psychiatrists about the management of some of the modifiable CV risk factors.

The position statement documents the relationship between diabetes, CVD, and mental illness and provides clear guidance about the screening that people should receive. This includes a detailed history of any previous disease or a family history, questions about smoking, a clinical exam--including measurements of weight and height to calculate body-mass index (BMI) and of waist circumference--and testing of fasting blood glucose, lipids, and blood pressure and an ECG.

"The cardiologists were very much involved in terms of the recommendations for screening for CV risk factors and their management for people with severe mental illness," Holt told heartwire . "Cardiologists need to be advising psychiatrists about the management of some of the modifiable CV risk factors."

Lifestyle Issues Can Be Addressed in the Mentally Ill

Holt admits, however, that there may be a certain "nihilism" among doctors about the treatment of cardiovascular risk factors in people with mental illness: "It's almost to the stage of them saying, 'These poor individuals, they have to look after their mental illness; they won't be able to cope with all of the additional demands of the CV risk protection.' "

But he argues that "the evidence so far is that when you start to try to advise people about lifestyle modification, it is actually possible to achieve good changes in those with mental illness."

He described to heartwire a study he has been involved with in the UK, where a lifestyle-management clinic was set up in Manchester: "The psychiatric nurse who originally set it up was a bit reluctant to do so, but the program has been running for seven years, and on average, after a year, individuals have lost around 10% of their body weight and they do make lifestyle changes, often more than I can achieve in my diabetes clinic."

Part of this success can be attributed to the group setting, he believes, and the fact that the individuals with mental illness are involved in making the choices, "so it's not as if it's being imposed on them."

These individuals have lifestyles that are so far from what we would consider as being healthy that there is a lot of potential to make change.

And he stresses: "These individuals have lifestyles that are so far from what we would consider as being healthy that there is a lot of potential to make change." As an example, he cites people in the clinic who drank "as many as 10 liters of full-sugar Coke every day, so just switching to diet drinks or water made a tremendous difference, and it's those small, incremental changes that count."

And great gains could be made with smoking cessation among the mentally ill, he adds. "We know that smoking rates are much higher among the mentally ill than among the general population, and there are issues around addictive behavior that do make it more difficult for these people to quit smoking. So undoubtedly, it's a problem." But equally, in the past, "there's been a little bit of guilt on behalf of the healthcare professionals," says Holt, in that people often see smoking as low on the list of priorities for these patients, so they might say, " 'You're a bit tense, have a cigarette.' I think there has to be a change in the culture within psychiatric hospitals to say, 'Well, actually, you shouldn't smoke!' "

Again, he gives an example from the Manchester lifestyle clinic of a man who was smoking 40 or 50 cigarettes a day, "and the nurse said, 'Why are you doing this? It's bad for you,' and the patient turned around and said, 'No one has ever told me that this is bad for me,' and he then stopped smoking. I think this is really important."

The position statement was written without pharmaceutical company funding. Holt has been a consultant for, has received funding to attend conferences from, and/or has served as a speaker or on advisory boards for AstraZeneca, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, and Novo Nordisk. Disclosures for the coauthors of the statement are listed in the paper.


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