Volume 191 - Issue 9
Successful implementation of cardiometabolic monitoring of patients treated with antipsychotics
Authors: Debra L Foley, Katherine I Morley, Karyn E Carroll, John Moran, Patrick D McGorry and Brendan P Murphy
Med J Aust 2009; 191 (9): 516-518. || doi: 10.5694/j.1326-5377.2009.tb02920.x
Published online: 2 November 2009
Published online: 2 November 2009
To the Editor: A recent article in the Journal describes, again, barriers to implementation of cardiometabolic monitoring among patients prescribed antipsychotic drugs.1 The cardiac health of patients with psychosis is not routinely assessed at first presentation for mental health services, adverse side effects of antipsychotic drugs are not systematically monitored, and patients with treatable risk factors for heart disease are not identified.2
We propose a practical solution to the seemingly intractable problem of implementing guidelines for cardiometabolic monitoring — change the delivery system.
We have employed a general nurse to conduct cardiometabolic monitoring in a pilot study at the Recovery And Prevention of Psychosis Service (RAPPS), a first-episode psychosis service in Melbourne. All 15 eligible patients had their height, weight, blood pressure, waist circumference, fasting total cholesterol, high- and low-density lipoprotein cholesterol, triglycerides and glucose assessed according to national guidelines3 within 1 month of entry to the service, in the hospital, as an outpatient, or in the patient’s home; 14/15 blood samples were taken while the patient was fasting. Very early monitoring (within 7 days of first exposure to antipsychotics) was not implemented for four patients because they were inpatients and judged by ward staff as too unwell to be approached by a general nurse. Future follow-ups will be conducted at 3, 6, 12 and 18 months. Abnormal findings are referred to the treating psychiatrist, who is responsible for ensuring the patient receives appropriate follow-up.
A general nurse can implement clinical guidelines, but this initiative requires substantial planning and ongoing management. Systematic identification of all patients eligible for monitoring requires identification of all pathways into the relevant mental health service, so as to begin monitoring at, or very close to, the point of first exposure to antipsychotics; management tools to track patients over time; and a clinical pathway to track test results and ensure appropriate medical interventions occur when required.
Failure to implement prescribed monitoring guidelines is important because individuals with schizophrenia have a 20% shorter life expectancy than individuals in the general community.4 Side effects of antipsychotic drugs may include dramatic weight gain and elevations in serum cholesterol and glucose levels, which exacerbate the risk for cardiovascular disease. Most early deaths among individuals with schizophrenia are due to cardiovascular disease.5 Failure to monitor cardiovascular health and the adverse side effects of antipsychotic drugs is an important, life-shortening, failure of care.
A simple solution to a complex problem exists if an effective delivery system is used.
Acknowledgements
Debra Foley is supported by the Colonial Foundation, Australia. Katherine Morley is supported by a National Health and Medical Research Council (NHMRC) Post-doctoral Training Fellowship (grant no. 520452). Brendan Murphy holds a Diabetes Australia research grant.
References
- Lambert TJ, Newcomer JW. Are the cardiometabolic complications of schizophrenia still neglected? Barriers to care. Med J Aust 2009; 190 (4 Suppl): S39-S42.
- Parks JJ. Implementing practice guidelines: lessons from public mental health settings. J Clin Psychiatry 2007; 68 Suppl 4: 45-48. 0_i1091862
- Lambert TJR, Chapman LH; Consensus Working Group. Diabetes, psychotic disorders and antipsychotic therapy: a consensus statement. Med J Aust 2004; 181: 544-548. 0_i1091864
- Hennekens CH. Increasing global burden of cardiovascular disease in general populations and patients with schizophrenia. J Clin Psychiatry 2007; 68 Suppl 4: 4-7. 0_i1091866
- Lambert TJ, Velakoulis D, Pantelis C. Medical comorbidity in schizophrenia. Med J Aust 2003; 178 (9 Suppl): S67-S70. 0_CBBJIHJE