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Endocrinology and psychiatry: a meeting of minds
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A satellite program at the American Psychiatric Association 160th Annual Meeting was entitled “When endocrinology and psychiatry collide: What the clinician needs to know about antipsychotic- induced endocrine disturbances.” The main title was slightly facetious, but there has been a merger of the two specialties because of the increased risk of diabetes and metabolic syndrome in patients with severe mental disorders, as well as some increased weight gain with the use of second generation antipsychotic agents. These agents have also been called atypical antipsychotic agents.
The above associations are now widely known in the psychiatry field, but may not be so well appreciated by endocrinologists. Psychiatrists now realize that they have to think below the neck and are getting baseline data on their patients including BMI, waist circumference, blood pressure, glucose and lipid levels. They are following these levels after instituting antipsychotic therapy, and are being careful to look for early weight gain.
The association of severe mental illness and diabetes mellitus has received attention for many years and was remarked upon at the turn of the century, well before any drug therapy was available. The Canadian Diabetes Association lists schizophrenia as a risk factor for diabetes. The American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus also lists severe mental disease as a risk factor for diabetes mellitus. There have been studies showing an increased risk of diabetes with the first generation antipsychotics. Although these drugs are effective, the extrapyramidal adverse events have been undesirable and the second generation antipsychotic agents are effective drugs without the baggage of extrapyramidal adverse events. The second generation antipsychotic agents, however, are sometimes associated with increased weight gain and an increase in the incidence of metabolic syndrome and diabetes.
This association has received much attention, prompting the generation of a consensus conference, held in late 2003, sponsored by the American Diabetes Association and co-sponsored by the American Psychiatric Association and AACE. This conference produced guidelines for the follow-up of patients being treated with second generation antipsychotic agents as well as information on obtaining baseline data. The relationship between second generation antipsychotic agents and the metabolic changes was discussed at some length.
At that time there were six second generation antipsychotic agents available and they were all examined in terms of their relationship to diabetes and metabolic syndrome. The results were published simultaneously in Diabetes Care and The Journal of Clinical Psychiatry. At the same time, the FDA placed a black box warning on the entire second generation antipsychotic agents class warning of the above relationship. Initially, this class of drugs was only used to treat schizophrenia, but many of these drugs are now used to treat a wide spectrum of mental illnesses.
The mechanisms for these interrelationships are not clear. Many of the studies are of small groups of patients. Much of the data is also retrospective. Some studies also look at surrogates of diabetes such as prescription data and ICD 9 codes. Hopefully, in the near future, more definitive studies will be forthcoming.
There are also a number of new drugs in development for the treatment of mental illnesses. Although the second generation antipsychotic agents are considered a class of drugs, mechanism of action differs within the group making studies even more difficult. The newer drugs will also have different mechanisms of action.
Psychiatrists are dependent on us to treat the medical comorbidities. We, in turn, must have some knowledge of the adverse events of the drugs that they are using in therapy. We must also balance the adverse events of these drugs with their effectiveness in treating severe mental disease. If a patient has severe mental disturbances, they may not be able to adhere to medical recommendations. We, then, would be unsuccessful in our therapeutic efforts.
These patients are at risk for premature death, mainly because of the associated medical comorbidities including metabolic syndrome, diabetes mellitus and coronary artery disease. The psychiatric community is looking to the endocrinology community for future guidance and direction in assessing and treating the medical comorbidities associated with severe mental illness. A great opportunity exists for further collaboration between our specialties.
For more information:
- Philip Levy, MD, is Clinical Professor of Medicine at the University of Arizona College of Medicine and is a practicing clinician at the Phoenix Endocrinology Clinic.