What does the Position Statement mean for both the psychiatrist and the patient?
Speaker: Professor Marc De Hert
People with severe mental illnesseshave worse physical health and reduced lifeexpectancy compared to the general population.[1] This is mainly due to a greatercardiovascular mortality, attributed in part to an increased risk of modifiable coronary heart disease risk factors; obesity, smoking, diabetes, hypertension anddyslipidaemia. Antipsychotic medication and possibly other psychotropic medication, like antidepressants,can also have an impact and increase cardiovascular risk factors. The problem is two-fold. Not only are they at an increased risk, but patients with severe mental illnessoften have limited access to general healthcare, with less opportunity for cardiovascular risk screeningand prevention than would be expected in a non-psychiatric population.
To improve the care of our patients, the EPA, supported by the EuropeanAssociation for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC) has published a position statement with recommendations as to the care we should be providing to our patients.[2] The intention is to improve awareness that patients with severe mental illness should be screened and treated for cardiovascular risk factors and diabetes and to initiate collaboration between the different healthcareprofessionals.
The recommendations from the position statement are simple, effective and easy to implement. Firstly, we should screen patients for cardiovascular risk and diabetes at initial presentation and before initiation of antipsychotic medication. This allows us to establish a baseline CVD risk and monitor any subsequent changes. Assessment of baseline CVD risk should include the medical history of both the patient and their family; smoking habit; weight and height to calculate BMI; fasting blood glucose and lipid levels; blood pressure, heart rate, heart and lung auscultation, foot pulses; and ECG.
Secondly, since patients with severe mental illness differ from the population used to derive standard CVD risk charts, decisions to manage CVD should instead be based on relative risk charts. We should also pay close attention to any children or adolescents on antipsychotic medication.
Due to the additional morbidity associated with diabetes, patients who are diagnosed with diabetes should be seen regularly by a physician and diabetes nurse, with cooperation between psychiatric and diabetes centers regarding their treatment.
Lifestyle advice should also be provided to patients; encouraging them to stop smoking and providing information on the importance of regular exercise and healthy eating.Cardiovascular protective medication, such as statins and antihypertensives, can be used to manage CVD. Finally, it is important that psychiatrists consider adverse effects on CVD risk factors when choosing antipsychotic medications as well as basing their decision on the efficacy of the medication.
By implementing these simple recommendations, we will be able to improve the care of patients with severe mental illness.
[1]Leucht S, Burkard T, Henderson J, Maj M, Sartorius N. Physical illnessand schizophrenia. Acta Psychiatr Scand 2007;116(5):317–33
[2] M. De Hert et al. European Psychiatry 24 (2009) 412 - 424