VIENNA — A new joint position statement from three European medical organizations is aimed at reducing cardiovascular risk and improving diabetes care in people with severe mental illness, as well as improving their overall health and well-being.
The statement is from the European Psychiatric Association and supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (www.em-consulte.com/article/223719
People with severe mental illnesses (SMI), including schizophrenia, depression, and bipolar disorder, have worse physical health and reduced life expectancy compared with the general population, statement co-author Dr. Richard Holt said at the briefing.
“The problem is that as well as the devastating effects of SMI, people with bipolar disorder and schizophrenia die on average 10-20 years earlier than the general population,” said Dr. Holt of the department of endocrinology and metabolism at the University of Southampton, England.
Because of reduced access to physical health care services, the rate of screening for diabetes and cardiovascular disease (CVD) is significantly lower than in the general population. About 20% of diabetes in the general population is undiagnosed; that rate is about 70% among people with mental illness, he noted.
“In putting together this statement, the three organizations have developed pragmatic guidelines,” Dr. Holt said. Clearly, this is a collaborative effort.”
The document urges coordinated CVD risk assessment and management for this population, and names psychiatrists as often being the best placed to lead the health care team that ideally includes shared care arrangements between general and specialist health care services.
Establishing baseline CVD risk at initial presentation is advised, and recommendations are given for assessment of medical history and examination of all CVD risk factors, including lipids, glucose, smoking habit, and blood pressure. Electrocardiogram also is recommended. Monitoring should be carried out at regular intervals, depending on the patient's individual risk level. Weight should be closely monitored in patients taking psychotropic medications, the document advises.
Psychiatric centers and diabetes centers should cooperate in the care of patients with SMI and diabetes. A diabetes nurse-educator also should be involved in the care of those on insulin. The document also outlines management of blood lipids and blood pressure, along with smoking cessation counseling.
The choice of psychotropic medications should take into account the potential effects of the agent on CVD risk factors, particularly in patients who are overweight or obese.
In the United States, a similar set of recommendations from the National Association of State Mental Health Program Directors (NASMHPD) was issued in 2006 and 2008. In addition to clinical recommendations, the NASMHPD guidelines focus on the establishment of systems of care for people with SMI at both the national and state levels.
In an interview, Dr. Joe Parks, the lead author of the NASMHPD papers, said the problem in the United States is that it's often not clear who is responsible for ensuring that evidence-based standards of care are provided.
“Are the recommendations the responsibility of the individual health care provider? Or the local health care organizations such as hospitals and clinics? Or the payers such as private insurers and Medicaid? Because of this lack of accountability, implementation has been fragmented and spotty,” said Dr. Parks, medical director of the Missouri Department of Mental Health, Jefferson City.
“Within our current system if you really want something to happen routinely and systematically throughout the health care delivery system, there must be either a legal requirement or financial incentives. Everything else is just wishful thinking,” he said.