Metabolic Screening in Antipsychotic Users: Whose Job Is It?

Megan Brooks

May 08, 2012

May 8, 2012 (Philadelphia, Pennsylvania) — Psychiatrists and primary care physicians (PCPs) have somewhat different opinions over whose role it is to monitor and screen for metabolic abnormalities in patients with mental illness who are taking antipsychotic medications, new research shows

Dr. Christina Mangurian

"There appears to be a disconnect between where providers believe metabolic screening should be done (psychiatrists and many PCPs think this should be done in community mental health clinics) and where treatment should be received (neither psychiatrists nor PCPs think psychiatrists should be treating metabolic problems)," Christina Mangurian, MD, who was involved in collecting and analyzing the data, told Medscape Medical News.

"I believe this disconnect likely contributes to the poor rates of screening and treatment of metabolic abnormalities in this vulnerable population," said Dr. Mangurian, assistant professor, Department of Psychiatry, University of California, San Francisco (UCSF), and director of the UCSF/San Francisco General Hospital Public Psychiatry Fellowship Program.

The study was presented here at the American Psychiatric Association's (APA's) 2012 Annual Meeting.

It is well known that many of the medications used to treat patients with psychiatric illnesses, most notably atypical antipsychotics, are associated with rapid metabolic changes, including weight gain and interference with glucose metabolism. These changes may lead to increased rates of cardiovascular disease.

In 2003, the US Food and Drug Administration (FDA) required a warning on diabetes risk for second-generation antipsychotic drugs. The American Diabetes Association and the APA recommend glucose and lipid testing for all patients starting these medications. Yet, screening rates remain low in both children and adults.

For example, as reported by Medscape Medical News, in a retrospective, new-user cohort study, researchers found that most children who are prescribed second-generation antipsychotic (SGA) drug therapy do not undergo recommended blood glucose and lipid screening tests.

The same researchers studied Medicaid recipients from 3 states and reported that diabetes and dyslipidemia screening among patients receiving second-generation antipsychotics was low and did not increase following the FDA warnings and professional society recommendations.

Lack of Time a Barrier

To get a better handle on barriers to screening, Dr. Mangurian and colleagues surveyed 49 psychiatrists (mean age, 47 years; 31% male) and 160 PCPs (mean age, 46 years; 65% male) in the San Francisco area.

The top barriers to metabolic screening were similar between the two physician groups and included insufficient provider time, difficulty arranging referral for provider follow-up (ie, PCP follow-up for psychiatrists and psychiatric follow-up for PCPs), and severity of mental illness.

In terms of attitudes toward screening, most PCPs (67%) agreed that PCPs, not psychiatrists, should monitor metabolic risk in patients on antipsychotic medication, contrary to most psychiatrists (70%), who disagreed (P < .001).

In the case of a patient having established primary care, both PCPs (60%) and psychiatrists (85%) agreed that psychiatrists should monitor for metabolic risk factors in people with severe mental illness, with psychiatrists in greater agreement (P = .011).

Both PCPs (58%) and psychiatrists (85%) do not believe that it is the role of psychiatrists to prescribe oral medications for the treatment of metabolic dysfunction, with psychiatrists in greater disagreement (P < .001). "I was not surprised that the providers did not believe psychiatrists should be treating any metabolic abnormalities," Dr. Mangurian commented.

Future research directions, say Dr. Mangurian and colleagues, include developing "practical ways to improve screening and treatment of metabolic abnormalities in community mental health clinics."

Orchestrated Care

Medscape Medical News asked Christoph Correll, MD, adjunct associate professor of psychiatry at Albert Einstein College of Medicine in New York City and a child and adolescent psychiatrist at the Zucker Hillside Hospital in Glen Oaks, New York, for his thoughts on the findings.

"I think that the barriers [to screening] are more relevant that the seeming 'disagreement' about who should do the monitoring. I think that it is great that psychiatrists see it as their role to monitor cardiovascular adverse effects, since these are often due to psychotropic drugs that they prescribe and since psychiatrically ill patients prescribed psychotropic medications generally see the psychiatrist more often than the PCP."

"The trouble," Dr. Correll added, "is that monitoring still does not occur frequently enough, even if both PCPs and psychiatrists see it mutually as their main role to perform the monitoring. The barriers need to be identified and addressed as much as possible. If most psychiatrists would not accept that it is their role to do the monitoring, we would have an even bigger problem."

"Since many treatments for cardiovascular risk factors and disorders are complex and medical in nature, it makes sense that the PCP is mainly responsible for the treatment. However, for this to be put in place, first monitoring must be performed routinely at proposed intervals, and the care between psychiatrists and medical care provider must be orchestrated appropriately, which is also not always easy to achieve."

The study was funded in part by grants from the National Institute on Aging and the National Institutes of Health. The authors and Dr. Correll have disclosed no relevant financial relationships.

The American Psychiatric Association's 2012 Annual Meeting. Abstract NR7-51. Presented May 7, 2012.