Physical monitoring in Mental Illness - Dr Sadgun Bhandari is a recognized member of the Royal College of Psychiatrists, UK and also a Fellow of the Royal College of Psychiatrists, UK.

1. PHYSICAL MONITORING IN
SERIOUS MENTAL ILLNESS
• DR SADGUN BHANDARI
• CONSULTANT PSYCHIATRIST
• QUEEN ELIZABETH II HOSPITAL
• WELWYN GARDEN CITY
• HERTFORDSHIRE
• UK

2. PSYCHIATRIC PERSPECTIVE
IS MONITORING NECESSARY?
• THE PHYSCIAL HEALTH OF THE
SEVERELY MENTALLY

3. PSYCHIATRIC PERSPECTIVE
• Relative Risk of Cardiovascular and
Cancer Mortality in People With
Severe Mental Illness From the United
Kingdom's General Practice Research
Database
• David P. J. Osborn, PhD; Gus Levy, MSc;
Irwin Nazareth, PhD; Irene Petersen, PhD;
Amir Islam, MBA; Michael B. King, PhD
• Arch Gen Psychiatry. 2007;64(2):242249.

4. PSYCHIATRIC PERSPECTIVE
• A total of 46 136 people with SMI
and 300 426 without SMI were
selected for the study.
• Hazard ratios (HRs) for CHD
mortality
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•
•
•
•
18 through 49 years old,
3.22 (95% confidence interval [CI], 1.99-5.21)
50 through 75 years old,
1.86 (95% CI, 1.63-2.12) for those and
1.05 (95% CI, 0.92-1.19) for those older than
75 years.

5. PSYCHIATRIC PERSPECTIVE
• For stroke deaths,
•
•
•
•
•
•
18 through to 49
HRs were 2.53 (95% CI, 0.99-6.47)
50 through 75 years old,
1.89 (95% CI, 1.50-2.38)
older than 75 years
1.34 (95% CI, 1.17-1.54)
• Increased HRs for CHD mortality occurred irrespective of
sex, SMI diagnosis, or prescription of antipsychotic
medication during follow-up.
• However, a higher prescribed dose of antipsychotics
predicted greater risk of mortality from CHD and stroke.

7. PSYCHIATRIC PERSPECTIVE
• Risk for coronary heart disease in people with severe
mental illness
• Cross-sectional comparative study in primary care
• DAVID P. J. OSBORN, PhD Department of Mental Health
Sciences, Royal Free and University College Medical School,
London
• IRWIN NAZARETH, PhD
• Department of Primary Care and Population Sciences, Royal
Free and University College Medical School, London
• MICHAEL B. KING, PhD
• Department of Mental Health Sciences, Royal Free and
University College Medical School, London, UK

8. PSYCHIATRIC PERSPECTIVE
• Participants with SMI were almost twice as likely
to have a raised 10-year CHD risk score as
patients in the general practice comparison
group.
• The main excess risk factors were increased
smoking, lower HDL-cholesterol levels, higher
total cholesterol/HDL-cholesterol ratios, increased
likelihood of a diagnosis of diabetes, and a weak
propensity for raised blood pressure with
advancing age.
• Dyslipidaemia and diabetes were more common
regardless of antipsychotic medication, and
despite the fact that body mass indices were
similar in the two groups.

9. PSYCHIATRIC PERSPECTIVE
• DO THEY GET THE RIGHT HELP?

10. PSYCHIATRIC PERSPECTIVE
• Death rate from ischaemic heart disease in
Western Australian psychiatric patients
1980-1998
• DAVID M. LAWRENCE, PhD and CASHEL
D'ARCY J. HOLMAN, PhD Department of Public
Health, The University of Western
Australia, Perth, Western Australia
• ASSEN V. JABLENSKY, DMSc
• Department of Psychiatry and Behavioural
Science, The University of Western
Australia, Perth, Western Australia
• MICHAEL S. T. HOBBS, DPhil
• Department of Public Health, The University of
Western Australia, Perth, Western Australia

11. PSYCHIATRIC PERSPECTIVE
• There were 44 767 deaths due to IHD during
1980-1998. Of these deaths, 3796 occurred in
users of mental health services. The
standardised mortality rate was almost
twice as high in users of mental health
services than in the overall population.
• The majority of deaths (59%) were ascribed to
acute myocardial infarction; however, the
mortality rate ratio was higher for other IHD
(most of these deaths were coded to coronary
atherosclerosis, ICD—9 414.0, or unspecified
chronic ischaemic heart disease, ICD—9 414.9).

12. PSYCHIATRIC PERSPECTIVE
• When examining procedure rates by
diagnosis, it is clear that patients
with schizophrenia have a much
lower rate of cardiovascular
procedures, even though these
patients have among the highest
levels of smoking, obesity and other
cardiovascular risk factors.

13. PSYCHIATRIC PERSPECTIVE
• Low rates of treatment for hypertension,
dyslipidemia and diabetes in schizophrenia:
data from the CATIE schizophrenia trial
sample at baseline.
Nasrallah HA, Meyer JM, Goff DC, McEvoy JP,
Davis SM, Stroup TS, Lieberman JA.
University of Cincinnati, Cincinnati, OH 452670559, USA. NASRALHA@ucmail.uc.edu

14. PSYCHIATRIC PERSPECTIVE
• Rates of non-treatment ranged from
30.2% for diabetes, to 62.4% for
hypertension, and 88.0% for
dyslipidemia.

15. PSYCHIATRIC PERSPECTIVE
• WHAT SHOULD WE DO?
• EVERY PATIENT WITH SMI
IRRESPECTIVE OF WHAT
ANTIPSYCHOTICS THEY ARE ON
SHOULD HAVE REGULAR PHYSCIAL
MONITORING

16. PSYCHIATRIC PERSPECTIVE
• The Mount Sinai Conference, held October
17–18, 2002, at the Mount Sinai School of
Medicine in New York City, was organized
by individuals who shared the belief that
the health needs of people with
schizophrenia who take antipsychotic
medications typically are not adequately
addressed by clinicians in specialty mental
health programs or in primary care
settings.

17. PSYCHIATRIC PERSPECTIVE
•
•
•
•
•
•
Weight Gain and Obesity
Monitor and chart BMI
Body Mass Index (BMI)
18.5-25 (kg/m2)
Monitor waist measurement.
If BMI over 25 before commencing
antipsychotics due consideration should be
given to the relative risk of different
antipsychotics to cause weight gain.

18. Antipsychotics & Weight Gain
(Zimmerman et al 2003)
• Marked
Clozapine
Olanzapine
Zotepine
Quetiapine
Chlorpromazine
Thioridazine
Perphenazine
Trifluperazine
• Moderate
Risperidone
Clopenthixol
Sulpride
Amisulpride
Haloperidol
Fluphenazine
Flupenthixol

19. Antipsychotics & Weight
Gain
• No weight change
Ziprasidone
• Weight loss
Molindone
Pimozide
• Low potential for
weight change
Aripiprazole

20. PSYCHIATRIC PERSPECTIVE
• Interventions include dietary advice,
weight reduction, in some cases
consider change of medication,
medication to reduce weight.
• Smoking cessation.

21. PSYCHIATRIC PERSPECTIVE
• Diabetes
• A baseline measure of plasma
glucose level should be collected for
all patients before starting a new
antipsychotic.
• Those at higher risk should have
another level at 4 months and then
yearly.
• Fasting ≤ 6mmol/L

22. PSYCHIATRIC PERSPECTIVE
• Hyperlipidemia
• Measurements of total cholesterol, lowdensity lipoprotein (LDL) and HDL
cholesterol, and triglyceride levels.
• Lipid screening should be carried out at
least once every 2 years when the LDL
level is normal and once every 6 months
when the LDL level is greater than 130
mg/dl.

23. PSYCHIATRIC PERSPECTIVE
• Total cholesterol <5mmol/L
• LDL <3 mmol/L
• HDL >1 mmol/L
• Triglycerides <2 mmol/L

24. PSYCHIATRIC PERSPECTIVE
• QT Prolongation
• Risk factors: a personal history of
syncope, a family history of sudden
death at an early age (under age 40
years, especially if both parents had
sudden death), or congenital long QT
syndrome.
The recommendation is for
ziprasidone.

25. PSYCHIATRIC PERSPECTIVE
• Elevated Prolactin Levels and Sexual Side
Effects
• Ask women about changes in
menstruation and libido and whether they
have milk coming out of their breasts.
• Men should be asked about libido and
erectile and ejaculatory function.

26. PSYCHIATRIC PERSPECTIVE
• Extrapyramidal Side Effects,
Akathisia, and Tardive Dyskinesia
• Rule out any pre-existing reasons for
tremor before initiating treatment.
• Monitoring depends on whether the
drug is first or second generation

27. PSYCHIATRIC PERSPECTIVE
• There is a risk of myocarditis for patients
on clozapine.
• Myocarditis should be suspected in
clozapine-treated patients who present
with unexplained fatigue, dyspnea,
tachypnea, fever, chest pain, palpitations,
other signs or symptoms of heart failure,
or ECG findings, such as ST abnormalities
and T wave inversions.

28. PSYCHIATRIC PERSPECTIVE
• Conclusions:
• Psychiatrists should be aware of the
physical health of the severely mentally ill.
• Monitoring will lead to early identification
of problems and increased uptake of
treatment .
• Close links with Primary Care need to be
developed so that the physical health
needs of the mentally ill are dealt with
appropriately.

29. PSYCHIATRIC PERSPECTIVE