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Is there a lack of communication between endocrinologists and psychiatrists regarding metabolic screening of second-generation antipsychotic users?
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A psychiatrist’s point of view
Changes in behavior are often slow. Also, among psychiatrists, there may be reluctance to test for blood glucose and cholesterol because it may be presumed that the patient’s primary care physician is already doing this.
Communication between different health care providers is a constant challenge. If a psychiatrist does complete these tests, he or she must decide whether to treat these conditions with medications because discontinuing the antipsychotic medication does not always reverse the abnormalities.
Oftentimes, psychiatrists feel that treating cholesterol and diabetes is beyond their current comfort level, although a referral to a primary care physician can easily correct the problem. Once again, we are talking about our patients — a psychiatric population with severe mental illness. These patients will not always follow up with their psychiatrist, let alone with another provider. It is a challenging problem.
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More communication between professionals is a good thing because we can learn a lot from each other. Endocrinologists should be aware that in some circumstances, such as when antipsychotics are being used to help with sleep or moderate depression, if they gently remind the psychiatrist that the antipsychotic may be causing difficulty with diabetes management, for example, the psychiatrist most likely can find an alternative treatment for this patient.
However, in more severely mentally ill patients with chronic schizophrenia, schizoaffective disorder or bipolar disorder, psychiatrists may be using the only medication that has provided the patient with some stability in his mental illness. In this case, it may become an issue where the providers and the patient have to decide which illness to treat. The other issue is that psychiatric patients may have little insight regarding their general health issues. Repetitive and simple education directives may be needed.
Sarah Maudlin, MD, is a Psychiatrist at Wheaton Franciscan Healthcare in Racine, Wis.
An endocrinologist’s point of view
It is of concern that some FDA recommendations may not be followed, but this may be partially caused by the fact that these patients are difficult to treat and follow because of their mental disorders. It is not fair to put the blame solely on the health care providers. This brings out the dilemma that we have every day in our practices: What to do if a patient has lipid changes and impaired fasting glucose other than encouraging diet and exercise and perhaps switching medications?
New, second-generation antipsychotic drugs with less adverse effects on weight might eliminate this concern. Also, teaching the medical community about metabolic screening and how to treat these abnormalities if they occur or where to get help if they need to, should be priority.
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What should endocrinologists do? The ADA and other organizations recommend: “Baseline assessment of weight, blood pressure, fasting plasma glucose and fasting lipid profile, and reassessment after 12 weeks of treatment for patients treated with atypical antipsychotic medications. Patients with impaired fasting glucose should be tested for diabetes with a two-hour oral glucose tolerance test. Weight should be followed monthly for the first three months and quarterly thereafter.” All endocrinologists and other health care providers should be aware of the different effects of second-generation antipsychotic medications and the current recommendations. Psychiatrists should know what adverse effects to expect and how to follow these patients.
Finally, there should be a strong collaboration between endocrinologists, or other health care providers that are knowledgeable in this field, and psychiatrists. Even though they cannot be expected to know in detail and treat these patients’ metabolic problems, they should be aware of the resources and ask for support to give the best and most complete care possible to patients.
Betul Hatipoglu, MD, is an Endocrinologist at the Endocrinology and Metabolism Institute at Cleveland Clinic, Ohio.