Missed Opportunities:
The Rise and Rise of Metabolic Syndrome

By Kim Puchir, Communications Coordinator

When it comes to mental illness, balancing multiple medications—and their sides effects—requires art as well as science. By contrast, the prevention and treatment of such conditions as diabetes and heart disease is much more straightforward. Yet metabolic syndrome—a cluster of cardiovascular and metabolic risk factors that can be triggered by some antipsychotic medications—has been difficult to address. NAMI spoke with John Newcomer, M.D., professor of psychiatry and medicine and director of the Center for Clinical Studies at Washington University in St. Louis, to find out why metabolic syndrome is itself a test of the health care system.
People living with schizophrenia are known to have higher rates of diabetes and cardiovascular disease (CVD), contributing to the alarming statistic that people living with mental illness live an average of 25 years less than the general population. Notably, being overweight, especially around the waist, can contribute to all three facets--metabolic syndrome, CVD and diabetes--and obesity affects many people living with mental illness. Even before they start taking a second-generation antipsychotic (SGA), more people living with schizophrenia are overweight or exhibit metabolic problems like insulin resistance. This may be due to socioeconomic factors (such as having less money that could lead to limited food choices, acute symptoms or no place to cook) or to a proposed genetic link between schizophrenia, obesity and diabetes. Add to this picture an SGA, especially olanzapine and clozapine, and you have a higher likelihood of obesity and its eventual health consequences like metabolic syndrome and diabetes.

Five Criteria for Metabolic Syndrome, from the National Institutes of Health

High blood pressure
High blood sugar levels
High levels of triglycerides, a type of fat
Low levels of HDL, the good cholesterol
Too much fat around the waist

Learn more about metabolic syndrome on the NAMI Hearts & Minds site at www.nami.org/metabolic.

With so many risk factors at play, it would make sense that people who are prescribed antipsychotics would receive treatment for the conditions related to metabolic syndrome. Yet a 2006 study by Nasrallah et al., found that out of almost 1,500 people being treated for schizophrenia, many were not being treated for metabolic conditions; 30 percent had untreated diabetes, 62 percent untreated hypertension and 88 percent untreated dyslipidemia (high cholesterol and triglycerides in the blood).
Some have suggested that the term “metabolic syndrome” may be contributing to this lack of action--should practitioners wait to address problems until a patient has all five symptoms? But it is clear that someone should act. In 2003, the FDA issued a warning of increased risk for severe hyperglycemia and diabetes, and in 2004 the American Diabetes Association and the American Psychiatric Association recommended glucose and lipid testing for all patients who begin taking SGAs. Yet several studies, including one of California Medicaid patients and another of a national database of managed-care patients, have shown that doctors are consistently not ordering these tests.
Specifically, which doctor is responsible for ordering the laboratory tests—the psychiatrist or the primary care physician? The answer depends upon each treatment team and insurance protocol. Even if they do get the right tests, many people do not receive consistent care or the results are not shared among all their doctors. “HIPAA was conceived as a way to improve communication among health professionals, but sometimes it has acted as a barrier to communication,” says Dr. Newcomer. (For instance, HIPAA does not prevent faxing test results between offices, but individual offices may be wary of doing so). The result is that someone who is doing everything right—seeing doctors frequently, taking an antipsychotic regularly—still develops what may be a preventable disease like diabetes.
Perhaps part of the problem is that the patients themselves have not been included in the solution or only given confusing information about what they can do. See below for a summary of what someone taking an SGA should talk about with all doctors involved in treatment. Within three months of starting antipsychotic therapy, the effects on body weight, lipids, insulin and other test scores usually begins to become apparent, but those who have not received consistent testing should get a baseline test as well.

Try some healthy recipes submitted by NAMI staff in the Hearts & Minds Healthy Eating section.

Why take the risk of developing metabolic syndrome at all? As many people living with mental illness can attest, SGAs have clear benefits. Clozapine, known to come with a high risk of weight gain for some people, is known to be the best for treatment-resistant schizophrenia, especially for reducing suicide risk. Dr. Newcomer cautioned about interpreting studies as a clear directive for an individual to stop taking one medication. What doesn’t come across in research studies is that every person reacts to every medication differently. Some gain no weight at all. Others get no benefit from taking a different antipsychotic. It would be ideal if the medication most effective at managing symptoms was also the one with the least side effects.
The prevention of mental illness still lies in the future. With regular testing and treatment professionals who cooperate to respond to any abnormal test results, the risk factors for diabetes and cardiovascular disease can be reduced. There is so much we don’t understand about schizophrenia. But there is no reason for metabolic syndrome to be a missed opportunity to improve the quality and length of life for people living with mental illness.
Read more about metabolic syndrome, diabetes and antipsychotics at NAMI Hearts & Minds.
The Center for Quality Assessment and Improvement in Mental Health, an affiliate of Harvard, has a downloadable form for tracking metabolic syndrome testing.

What People Taking SGAs Can Do To Stay Healthy

Get tested when you start taking a new antipsychotic, three months later, and then get regular follow-ups if the result is abnormal. Everyone should get annual tests.
Recommended tests are for smoking, obesity, lipid screening and diabetes risk/diabetes.
Make sure all relevant treatment providers have access to all the test results.
If you have clearly gained a significant amount of weight from one medication, ask your doctor if you could switch to one with a lower risk of causing weight gain) or, if not, for help in counteracting this side effect.
Lose weight by eating a low-fat, high-fiber diet.
Every bit of exercise helps.
The American Psychiatric Association recognizes that patients with increased risk of cardiac factors may benefit from some omega-3 fatty acid preparations.

Special Considerations: Women, Children and Young Adults, Ethnic Groups

Women
Studies have shown that women living with schizophrenia or depression are at a greater risk of obesity than men with the same diagnosis. They are also at a greater risk of metabolic disorder (In a 2009 study published in the American Journal of Preventive Medicine, Allison et al., discovered that 52 percent of women versus 36 percent of men living with schizophrenia had metabolic syndrome).
Children and Young Adults
The younger someone is, the less likely they are to receive basic testing for blood lipids and insulin changes in response to an antipsychotic. Testing is especially important for this population because they are more susceptible to weight gain and metabolic effects from these medications.
Ethnic Populations, (e.g. African Americans, Native Americans, Latinos)
Since people of ethnic groups are at a higher risk of developing diabetes, they or anyone with a suspected genetic predisposition for diabetes should be closely monitored for any metabolic side effects from antipsychotics.

NAMI 2011