TCR: Dr. Guttmacher, as the Chief of Psychiatry at a large state hospital (the Rochester Psychiatric Center), you have a wealth of experience caring for the chronically mentally ill. I know you have been giving quite a bit of thought lately to medical issues that psychiatrists may be missing in this population.
Dr. Guttmacher: Yes, and in that context, I was really struck by the recently published Mt. Sinai consensus report (Marder et al, Physical Health Monitoring of Patients with Schizophrenia, Am J Psych 2004; 161:1334-1349). It was one of the best things that I have read in a long time. They are talking about a fundamentally different kind of role for psychiatry.
TCR: What was the conference about?
Dr. Guttmacher: Twenty-two of the nation’s foremost experts on schizophrenia got together (without industry funding) and discussed the issue of what we should be doing to monitor the physical health of patients with schizophrenia, and they came up with a number of recommendations.
TCR: Why is this such a hot issue now?
Dr. Guttmacher: I would argue that we are now doing more and more with our medications that compromise our patients’ physical health. When I look around our hospital I see a group of massively obese patients. I see all kinds of hyperlipidemia and I see three or four cases a year of DKA (diabetic ketoacidosis) emerging out of our hospital.
TCR: How do you suggest we deal with these issues as psychiatrists?
Dr. Guttmacher: I believe that there are fundamentally two alternatives. The Mt. Sinai group is talking about psychiatry assuming a sort of primary care screening role, which makes a lot of sense in some settings. By contrast, in our hospital, we have moved more towards having kind of a liaison model where we have internists or family practitioners assigned to work on a regular basis on each ward with each psychiatrist. They form good ongoing relationships and they work together in treatment planning. So, I think either way will work, and if you were in a setting that will allow you to do what we have done, I would assume it is preferable.
TCR: What type of setting is Rochester Psychiatric Center?
Dr. Guttmacher: We are an inpatient psychiatric hospital with particularly difficult patients who have filtered toward us through one of the acute hospitals in the region. Our average length of stay is about 90 days.
TCR: What are some of the specific things you do to attend to the physical health of these patients?
Dr. Guttmacher: We certainly focus on prevention of chronic illnesses. We have programs that reward patients for going out and taking walks. We have worked hard to obtain funding for gym equipment on the premises. We have dietitians involved with patient psychoeducation. We encourage our psychiatrists to think about the relative health risks of the medications they prescribe as one of the important factors when they pick which agent to use.
TCR: What are some of the recommendations of the Mt. Sinai group?
Dr. Guttmacher: All patients with schizophrenia should have a Body Mass Index (BMI) done at initial contact. (Incidentally, the Mt. Sinai group focused on schizophrenia, because studies have shown a high rate of diabetes and cardiac issues in this population, but their recommendations can probably be extended to other patients taking antipsychotics.) To calculate this, you divide the weight in kilograms by the height in meters squared.
TCR: So we should have both a scale and tape measure in our offices?
Dr. Guttmacher: A scale is enough – patients are typically fairly reliable with their height. And there are many tables around to convert non-metric values into the BMI; I know that the ziprasidone reps are handing them out!
TCR: So how are we supposed to use the BMI information?
Dr. Guttmacher: The Mt. Sinai recommendation is that an increase of 1 point in the BMI ought to trigger an intervention. That may be switching to a medication with a lower weight gain liability, like ziprasidone or aripiprazole. Or it may be getting the patient involved with a nutritionist or into an exercise program. But the key is to jump in early, before there is significant weight gain.
TCR: So what else should we be doing aside from a BMI in our office with schizophrenic patients?
Dr. Guttmacher: Any patient with schizophrenia should have a baseline glucose measure: a fasting blood sugar is ideal, but a hemoglobin A1C is an acceptable alternative. And patients with a significant risk factor for diabetes, such as family history, obesity, or a high glucose level in the past, should have their glucose monitored four months after starting a new atypical and then yearly. If they are gaining weight, glucose should be monitored every four months. Regardless of weight gain, we should be asking routinely about polyuria, polydipsia, or any other symptoms suggestive of diabetes.
TCR: Are we also supposed to order lipid profiles?
Dr. Guttmacher: Any schizophrenic patient older than 20 should have a baseline cholesterol level, triglyceride level, HDL, and LDL. We should repeat this every two years if the LDL is normal and every six months if the LDL is over 130. Again, this is something that the primary care doc would do, but given the fact that our patients typically don’t do very well in gaining access to care, the onus is on the psychiatrist to do this monitoring.
TCR: A potential problem with these recommendations is that, while it’s great to be ordering these tests, unless you have done a residency in medicine you may not know how to interpret the results and what action to take. Medico-legally, a patient with a bad outcome could come back and say, “You ordered these labs, you saw the results, but you didn’t do the right thing with them.”
Dr. Guttmacher: That’s true, and the answer is that, yes, you have a responsibility when you do a screening test, and that an abnormal result requires follow-up. At a certain point, most of us would start saying, “I am over my head, I am not going to be the one to actually prescribe the statin drug to treat the hyperlipidemia, but I realize that there is a need to follow this up.” So, yes, you are going to need somebody to be able to refer to.
TCR: And I would assume we can end up saving quite a few lives by taking this screening seriously.
Dr. Guttmacher: Well, unfortunately, that’s true. The most frightening thing I ever read was an article by Norm Sussman, who extrapolated from the Framingham heart data and calculated that while clozapine saves about 490 patients (per 100,000 patient-years) from death by suicide, it may lead to about the same number of deaths from obesity-related causes. So for every life you save from suicide with this medication, you will probably lose one because of its weight-gain complications. Given clozapine’s special role, this use might well be justifiable. I would be more concerned about some of the other atypicals which appear to lack the special efficacy associated with clozapine.
TCR: What would you recommend as a bare bones list of medical screening issues that we should go over with our schizophrenic patients?
Dr. Guttmacher: 1. Ask whether they are getting regular medical care, and if so, from whom. 2. Get a baseline BMI and continue to track it. 3. Ask how much they smoke and whether they have any interest at all in quitting. 4. Ask about symptoms suggestive of diabetes. 5. Ask about sexual dysfunction and galactorrhea. These may be signs of hyperprolactinemia and are rarely discussed unless asked about. In addition, ensure that the laboratory monitoring suggested above is followed.
TCR: With regard to smoking, have you had good experience with nicotine replacement therapy in your patients?
Dr. Guttmacher: We went smoke-free in our facility this past year, and the ideal scenario is the use of a patch supplemented by nasal spray. The nicotine spray basically mirrors the pharmacokinetics of a cigarette, so you get a very rapid rise in nicotine blood levels just as you would in smoking. And it is, far and away, the most logical replacement product, given that most of the risk of smoking is not caused by the nicotine, but rather by other components of tobacco. The problem is that patients need to use the spray up to 40 times a day and given that nursing doesn’t want to let these things loose in the ward, this poses a spectacular logistical issue.