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VOLUME 9 NUMBER 3 • SEPTEMBER 2012
REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
(9%)
and weight (2%) were assessed even less frequently.
14
This
was despite a high prevalence of the metabolic syndrome in these
patients and a significant number with a 10-year cardiovascular
risk of greater than 20%.
The National Institute for Health and Clinical Excellence (NICE)
guidance places the responsibility for screening for physical
health problems within primary care (Table 3).
10
Despite this,
there is a lack of clarity among mental healthcare professionals
about whose responsibility physical health screening is.
15
Mental
healthcare professionals have also expressed concern about their
lack of understanding about what should be measured and when
and how to interpret the results. Lack of access to necessary
equipment may be a further barrier. Although some people with
severe mental illness may never attend their general practice, many
do and are willing to undergo screening.
16
For those who are seen
only within mental health settings, the psychiatry team should
ensure that physical health screening is undertaken. Furthermore,
there is a responsibility for psychiatry teams to ensure that people
with severe mental illness receive physical healthcare from primary
care and this should form part of the clinical care plan.
10
In order
to ensure that patients are not missed, clear communication
between primary care and mental health teams is essential.
Assessment of cardiovascular risk
Cardiovascular risk is usually assessed by the use of locally
relevant risk engines. These have not been validated in people
with severe mental illness, who are typically younger, have higher
blood pressure and are more likely to smoke than the populations
used to derive cardiovascular disease risk scoring systems such as
Framingham and QRISK. As traditional risk factors only partially
explain the excess cardiovascular disease seen in people with severe
mental illness, it seems likely that these traditional risk engines will
underestimate cardiovascular risk in people with severe mental
illness and so general practitioners should have confidence to treat
those identified as at high risk. Pending further research, there is
also an argument to consider primary cardiovascular prevention
in individuals at intermediate levels of cardiovascular risk who
would not routinely reach the National Service Framework or NICE
thresholds for treatment.
Managing cardiovascular risk factors
Diabetes and cardiovascular risk factors in people with severe
mental illness should be managed along similar lines to the
general population despite the additional challenges to ensure that
the patient understands the need for lifestyle modification and
medication.
Smoking
Healthcare professionals should provide smokers with information
about the risks of smoking and encourage them to quit. Behavioural
counselling and pharmacological approaches, such as nicotine
replacement, are suitable for people with severe mental illness.
Obesity
The nihilism that surrounds obesity management has been
challenged recently by a number of observational studies and
randomised controlled trials in people with severe mental illness.
17,18
Trials have shown that non-pharmacological lifestyle interventions
lead to ~2.5-kg reductions in mean body weight over 2–6 months,
17
while longer observational studies have demonstrated that further
weight loss is achievable with on-going support.
19
A range of unlicensed pharmacological treatments have been
tried to treat or prevent antipsychotic-induced weight gain, with
limited benefit.
17
There is, however, preliminary evidence from
short-term studies that metformin may attenuate weight gain or
promote weight loss. While longer definitive trials are needed,
the joint European Associations’ position statement recommends
that metformin may be considered as a second-line treatment in
patients with additional risk factors, such as a personal or family
history of metabolic dysfunction.
Dyslipidaemia
Target levels of total cholesterol and LDL cholesterol are the same as
those for the general population (< 5.0 mmol/l and < 3.0 mmol/l,
respectively) but tighter goals of < 4.0 mmol/l and < 2.0 mmol/l
may be appropriate for individuals with established cardiovascular
disease or diabetes. No cardiovascular disease outcome trials with
statins have been performed specifically in people with severe
mental illness but these drugs are as effective in lowering total and
LDL cholesterol in this population as in the general population.
20
Furthermore, there is no evidence that lipid-lowering medication is
associated with suicide or traumatic deaths in people with severe
mental illness.
Diabetes
The treatment of diabetes in people with severemental illness should
follow currently available treatment algorithms, although oral anti-
diabetes agents that induce less weight gain may have advantages,
given the high prevalence of obesity in people with severe mental
illness. The additional challenges of managing co-morbid diabetes
Table 3.
National Institute for Health and Clinical Excellence (NICE)
recommendations regarding management of physical illness in people with
schizophrenia
10
11.4
Promoting recovery
11.4.1
Primary care
11.4.1.1
Develop and use practice case registers to monitor the physical
and mental health of people with schizophrenia in primary care.
11.4.1.2
GPs and other primary healthcare professionals should monitor
the physical health of people with schizophrenia at least once a
year. Focus on cardiovascular disease risk assessment as
described in 'Lipid modification' (NICE clinical guideline 67) but
bear in mind that people with schizophrenia are at higher risk of
cardiovascular disease than the general population. A copy of the
results should be sent to the care coordinator and/or
psychiatrist, and put in the secondary care notes.
11.4.1.3
People with schizophrenia at increased risk of developing
cardiovascular disease and/or diabetes (for example, with
elevated blood pressure, raised lipid levels, smokers, increased
waist measurement) should be identified at the earliest
opportunity. Their care should be managed using the
appropriate NICE guidance for prevention of these conditions.
11.4.1.4
Treat people with schizophrenia who have diabetes and/or
cardiovascular disease in primary care according to the
appropriate NICE guidance.
11.4.1.5
Healthcare professionals in secondary care should ensure, as
part of the Care Programme Approach, that people with
schizophrenia receive physical healthcare from primary care as
described in recommendations.
