Despite increasing awareness of the cardiovascular risks, adequate treatment of the metabolic syndrome remains a persistent challenge.
Antipsychotic treatment is associated with weight gain and the metabolic syndrome, a constellation of metabolic risk factors associated with the development of atherosclerotic cardiovascular disease. Cardiovascular disease is the leading cause of death in patients with schizophrenia.1 The metabolic syndrome is common in patients with schizophrenia, with a prevalence of 43% in the Clinical Antipsychotic Trials of Intervention Effectiveness.2
Two previous studies in the United States found a low prevalence of adequate treatment for components of the metabolic syndrome in patients with psychotic disorders, including 55% to 60% for diabetes mellitus, 38% to 54% for hypertension, and 11% to 41% for lipid abnormalities.3,4 Bruins and colleagues5 investigated predictors and correlates of metabolic syndrome and its guideline-concordant treatment in a cohort of 1259 Dutch patients with psychotic disorders.
The authors extracted data from a large, ongoing Dutch observational cohort study of patients with psychotic disorders from 4 mental health institutions in the northern Netherlands. Inclusion criteria were diagnosis of a DSM-IV non-affective or affective psychotic disorder, and participation in at least 3 separate assessments (consecutive assessments were 9 to 24 months apart), with data on all 5 criteria for the metabolic syndrome.
Assessments included measurements of BMI, waist circumference, and blood pressure; a blood sample for lipids, glucose, and hemoglobin A1c; symptoms (as measured by the Positive and Negative Syndrome Scale); self-reported smoking, alcohol, and cannabis use; and prescribed antipsychotics and pharmacotherapy for metabolic risk factors.
The metabolic syndrome was defined according to National Cholesterol Education Program Adult Treatment Panel III criteria. Treatment of metabolic risk factors was based on guidelines from the European Society of Cardiology, the International Diabetes Federation, and the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, which concur with guidelines for hypertension, dyslipidemia, and diabetes in the US.
Despite increasing knowledge and awareness of risks in patients with psychotic disorders, rates of treatment for metabolic disorders remain alarmingly inadequate.
First, the authors calculated the prevalence and incidence of metabolic syndrome at each assessment, as well as remission from the metabolic syndrome. Second, they examined time-related trends in metabolic risk factors and their treatment using generalized estimating equations. Next, they used logistic regression models to investigate factors predicting treatment. Finally, they used mixed models to examine the course of different metabolic risk factors over the assessments.
There were 1259 patients who met the study inclusion criteria. The mean age of the study sample was 43, and 65% were male. Subjects were followed for a mean of 28 months, with 13 to 14 months between each assessment. The prevalence of metabolic syndrome was 56%. Prevalence, incidence, and reversal rates for the metabolic syndrome did not differ over the course of the assessments.
Pharmacologic treatment for metabolic disorders was recommended in up to 60% of subjects. The rates of guideline-concordant antihypertensive and lipid-lowering treatment, but not antihyperglycemic treatment, significantly increased over the 3 assessments.
At the third assessment, only 38% of patients were receiving recommended antihypertensive treatment; 56%, lipid-lowering agents; and 73%, antihyperglycemic treatment. Only increasing age was a predictor of guideline-concordant treatment. At all assessments, metabolic parameters were more favorable in patients receiving (versus not receiving) guideline-concordant treatment. Limitations of the study include the inability to examine effects of psychotropic medications, uncertain fasting status for subjects, and the lack of availability of information on lifestyle interventions.
The bottom line
The authors found that over half of patients with psychotic disorders in their cohort had the metabolic syndrome, and in about 60% of those patients, pharmacologic treatment was recommended according to international guidelines. However, over half of these patients received no treatment. Despite increasing knowledge and awareness of risks in patients with psychotic disorders, rates of treatment for metabolic disorders remain alarmingly inadequate. The authors conclude that there is an urgent need to examine current monitoring, referral, and treatment practices for these disorders, which contribute to the dramatically increased burden of cardiovascular disease morbidity and mortality in this patient population.
Dr. Miller is Associate Professor in the Department of Psychiatry and Health Behavior at Augusta University in Augusta, GA, and Schizophrenia Section Editor for Psychiatric Times. He reports no conflicts of interest concerning the subject matter of this article.
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2. McEvoy JP, Meyer JM, Goff DC, et al. Prevalence of the metabolic syndrome in patients with schizophrenia: baseline results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES III.Schizophr Res. 2005;80:19-32.
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5. Bruins J, Pijnenborg GH, van den Heuvel ER, et al. Persistent low rates of treatment of metabolic risk factors in people with psychotic disorders: a PHAMOUS study. J Clin Psychiatry. 2017 Apr 11. doi: 10.4088/JCP.16m10831.