Metabolic Monitoring for Patients Treated With Antipsychotic Medications

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1 In Review Metabolic Monitoring for Patients Treated With Antipsychotic Medications Tony A Cohn, MB, ChB, MSc, FRCPC 1, Michael J Sernyak, MD 2 Objectives: Metabolic side effects of antipsychotic treatment include weight gain, dyslipidemia and increased susceptibility to diabetes. Patients with schizophrenia have increased coronary heart disease mortality and reduced life expectancy. There is an urgent clinical need to monitor antipsychotic-treated patients for metabolic disturbance. Our objectives were to review published international guidelines, establish goals for metabolic, and make recommendations for practice. Method: We reviewed the major published consensus guidelines for metabolic of patients treated with antipsychotic medications and selectively reviewed practice guidelines for the management of diabetes, dyslipidemia, and hypertension. Results: Patients with serious mental illness have markedly elevated rates of metabolic disturbance and limited access to general medical care. Monitoring, but not necessarily medical treatment of metabolic disorder, falls within the scope of psychiatric practice and should include screening for metabolic disturbance as well as tracking the effects of antipsychotic treatment. In addition, psychiatrists and psychiatric services should work toward facilitating patients access to medical care. There is considerable consensus in the published guidelines. Areas of dissent include which patients to monitor, the utility of glucose tolerance testing, and the point at which to consider switching antipsychotics. Conclusion: We encourage clinicians to adopt a structured system for conducting and recording metabolic and to develop collaborations with family physicians, diabetes specialists, dieticians, and recreation therapists to facilitate appropriate medical care for antipsychotic-treated patients. (Can J Psychiatry 2006;51: ) Information on funding and support and author affiliations appears at the end of the article. Clinical Implications Patients with serious mental illness have markedly elevated rates of metabolic disturbance, including obesity, diabetes, and dyslipidemia. Antipsychotic treatment can be a contributing factor. Clinicians should screen patients for metabolic disturbance, should track the effects of antipsychotic treatment on metabolic parameters, and should facilitate access to appropriate medical care. Mental health systems need to incorporate protocols into standard care, promote collaboration with other medical disciplines, and dedicate resources for lifestyle management. Limitations We did not conduct a systematic review of all available literature. We did not discuss variations in health care delivery systems from one country or jurisdiction to another that can affect access to laboratory tests and medical services. 492 Can J Psychiatry, Vol 51, No 8, July 2006

2 Metabolic Monitoring for Patients Treated With Antipsychotic Medications Key Words: antipsychotic, metabolic, guidelines, diabetes, dyslipidemia, hypertension,, screening, surveillance Antipsychotic treatment is associated with metabolic side effects that include various degrees of weight gain, dyslipidemia, and susceptibility to type 2 diabetes (1). In addition, patients with chronic psychotic disorders have increased CHD mortality (2,3) and adverse CHD risk profiles (4,5). Although it is difficult to separate the contributions of illness, lifestyle, and medication factors to these risks, there is now a pressing clinical need to monitor patients treated with antipsychotic medications for metabolic disturbance. Treatment of medical conditions such as diabetes and dyslipidemia is beyond the scope of psychiatric practice. However, because metabolic effects can be related to antipsychotic prescription, because metabolic disturbance is common in those with serious mental illness, and because these patients often have limited access to general medical care (6), psychiatric care systems are now challenged to develop methods of surveillance and to facilitate appropriate medical care for patients. Psychiatrists are similarly challenged to update their medical knowledge and to incorporate protocols into their practice (7). In this paper, we establish goals for effective metabolic of antipsychotic-treated patients, provide background information for clinicians on screening procedures and tests, and review the various published international antipsychotic guidelines to identify areas of overall consensus and clarify points of dissention. We also identify barriers to implementation and make recommendations for clinical practice. Abbreviations used in this article ADA APA BMI CATIE CHD Chol FPG HbA1c HDL IFG IGT LDL NIMH OGTT SGA American Diabetes Association American Psychiatric Association body mass index Clinical Antipsychotic Trials of Intervention Effectiveness coronary heart disease cholesterol fasting plasma glucose glycosolated hemoglobin high-density lipoprotein impaired fasting glucose impaired glucose tolerance low-density lipoprotein National Institute of Mental Health Oral Glucose Tolerance Test second-generation antipsychotic Goals of Screening and Monitoring Metabolic can be seen as having 2 overall goals: 1. Identification of treatable pathology in a high-risk population, that is, screening for diabetes, dyslipidemia, and hypertension; and identifying additional risk factors and disease markers to facilitate preventative strategies and early diagnosis. 2. Tracking and linking of metabolic disturbance in relation to antipsychotic treatment. Rates of type 2 diabetes and other CHD risks are remarkably increased in patients with schizophrenia and other forms of serious mental illness (8). Although screening is certainly indicated when a new antipsychotic medication is started, clinicians should also screen patients stably maintained on existing medications. The results of these tests can inform antipsychotic choice and allow for ongoing of the development of various metabolic derangements. Monitoring is also essential in high-risk situations, for example, when a patient with established diabetes needs to be treated with clozapine. Monitoring can also be used to gauge the outcome of such interventions as antipsychotic switching or lifestyle modification programs on body weight, diabetes progression, and other metabolic endpoints. Screening for Diabetes, Dyslipidemia, and Hypertension These easily diagnosed and treatable conditions have a significant impact on both health and life expectancy. Diagnosis and timely intervention make a tremendous difference to long-term outcomes. Practice guidelines in the general population establish parameters for screening and treatment. Patients on antipsychotic medications should be screened with the same procedures and treated to the same targets as are individuals in the general population. In fact, because of increased morbidity in this population, one could argue that screening should be conducted earlier and more frequently. However, in actual practice, patients with mental illness receive less intensive medical care. For example, a recent study of Veterans Health Administration patients with diabetes found that failure to meet diabetes performance measures was more common in those with mental health conditions, including those with psychotic disorders (9). In the NIMH-sponsored CATIE schizophrenia trial, rates of metabolic disorder assessed at baseline were markedly elevated, with diabetes at 12.5%, hyperlipidemia at 53%, and hypertension at 37%. However, among individuals with established pathology, 45%, 89%, and 62%, respectively, were not receiving treatment (10). Clearly, it is urgent to address the disparity in health screening and treatment for individuals with schizophrenia and other forms of serious mental illness. Can J Psychiatry, Vol 51, No 8, July

3 The Canadian Journal of Psychiatry In Review Diabetes (11 14) Diagnosis and Screening. Guidelines in the general population suggest screening asymptomatic individuals for diabetes from age 45 years (United States) and age 40 years (Canada) and that screening should be repeated every 3 years. Those at high risk should be screened earlier and more frequently. In Canada, the most recent diabetes treatment guidelines recognize schizophrenia is as an independent risk factor for type 2 diabetes (11). We hope that this recognition will raise awareness of the need for early diagnosis and treatment in this population. The usual diagnostic test for diabetes is the FPG ( 7.0 mmol/l, or 126 mg/dl). The 2-hour plasma glucose level taken after a 75-gm glucose drink ( 11.1 mmol/l, or 200 mg/dl), that is, the postload plasma glucose in the OGTT, is also diagnostic, as is the random glucose level ( 11.1 mmol/l, or 200 mg/dl) when there are clear symptoms of diabetes (see Table 1). Any abnormal result should be confirmed by a repeat test on a different day. The fasting glucose level is the favoured screening test for diabetes because of its diagnostic specificity and its ease of use, but the OGTT is considered the gold standard test and has greater diagnostic sensitivity (15). IFG 6.1 to 6.9 mmol/l (110 to 125 mg/dl) in Canada and IFG 5.6 to 6.9 mmol/l (100 to 125 mg/dl) in the United States and IGT of 7.8 to 11.0 mmol/l (140 to 199 mg/dl) are considered prediabetic conditions and warrant increased vigilance. Studies have shown that lifestyle (diet and exercise) and medication (for example, metformin) interventions can delay or prevent progression from IGT to frank diabetes (16). Since elevated postload glucose precedes elevated fasting glucose, often by several years (17), the FPG test is less sensitive than the OGTT in the early diagnosis of diabetes and IGT in both the general population (15) and in patients on antipsychotic treatment (17,18). An explanation for this is that reduced sensitivity to insulin occurs in muscle before it occurs in the liver, which influences glucose disposal earlier than fasting hepatic glucose production (19). There is some discordance between US diabetes screening guidelines and other guidelines concerning the emphasis placed on the OGTT. Canadian diabetes guidelines, for example, suggest that individuals with IFG, especially those with multiple diabetes risk factors, should be further screened with an OGTT, whereas the US guidelines do not emphasize routine clinical use of the OGTT. This difference in emphasis is helpful for understanding discrepancies in the ensuing antipsychotic guidelines. The percentage of HbA1c and random glucose measurements are not considered diagnostic for diabetes but have the advantage of not requiring patients to fast. There is debate over the utility of these tests because they lack both sensitivity and specificity. At best, they should be considered screening tests where fasting samples are difficult or impossible to obtain. Mild elevations in these tests (for example FPG 5.6 mmol/l, or 100mg/dL) should be followed by a fasting diagnostic test (14). Prescreening prior to diagnostic testing may have some utility, for example, in the opportunistic screening of clozapine-treated patients who are already having regular blood draws, an approach that one of the authors is piloting at the Centre for Addiction and Mental Health in Toronto, Ontario. Although the sensitivity of urine glucose as a screening test is low (21% to 64%), its specificity is very high (> 98%) (20). Urine screening should be limited to low-resource settings where other procedures are not available (14). Routine use of finger-stick glucose testing has not been recommended for screening but is useful in emergency settings to rapidly rule out frank hyperglycemia. Dyslipidemia (21,22) Screening. In the general population, lipid screening with a fasting lipid profile (total Chol, LDL, HDL, and triglyceride) is recommended for all adults aged 20 years and older, repeated every 5 years in asymptomatic individuals (21). In Canada, screening is recommended for men older than age 40 years and for women older than age 50 years, but earlier screening is recommended for those with diabetes and other risk factors (22). Adequate fasting (about 10 to 12 hrs) is necessary to obtain valid LDL and triglyceride levels. LDL, because of its well-established association with atherosclerosis, is considered the primary focus for intervention. Target LDL levels are determined by the CHD risk category, which is in turn determined by a Framingham risk assessment based on age, sex, Chol, HDL, systolic blood pressure, and smoking status (23). Those with diabetes or established CHD are considered high risk and are treated to the most stringent LDL targets (21,22). Patients on antipsychotic treatment frequently have a metabolic dyslipidemia with elevations of triglyceride and reduced HDL (4), along with associated features of the metabolic syndrome (see below). Treatment of metabolic dyslipidemia is a secondary goal for intervention following achievement of LDL targets (21,22). Hypertension (24) Diagnosis and Screening. Hypertension is a major contributing factor in the development of CHD. In clinical trials, antihypertensive therapy has been associated with a 20% to 25% reduction in myocardial infarction, a 50% reduction in heart failure, and a 35% to 40% reduction in stroke incidence (25). The accurate measurement of blood pressure is important. Individuals should be seated quietly for at least 5 minutes, 494 Can J Psychiatry, Vol 51, No 8, July 2006

4 Metabolic Monitoring for Patients Treated With Antipsychotic Medications Table 1 Signs and symptoms of diabetes and diabetic ketoacidosis a Diabetes Diabetic ketoacidosis (Vomiting is a sign of escalation and pending medical emergency) Frequent urination Thirst or a very dry mouth Excessive thirst Constantly feeling tired Extreme hunger Dry or flushed skin Unusual weight loss Nausea, vomiting, or abdominal pain Increased fatigue Difficulty breathing (short, deep breaths) Irritability Fruity odour on breath Blurry vision Difficulty paying attention, or confusion a From the American Diabetes Association. Available: Accessed March with the arm supported at heart level. At least 2 measures should be taken and the average recorded. Blood pressure is classified as follows: Normal < 120/80 mm Hg. Prehypertension, 120/80 to 139/80 89 mm Hg. Stage 1 hypertension, 140/90 to 159/90 99 mm Hg. Stage 2 hypertension, 160/100 mm Hg (24). Identification of Additional Risk Factors (11,23,26) Nonmodifiable Risk Factors These include: Increasing age. Sex (increased rates of obesity, diabetes, and metabolic syndrome are observed in female patients treated with antipsychotic medications (4). Personal and family history of obesity, diabetes, dyslipidemia, hypertension, and coronary heart disease (that is, myocardial infarction, stroke, or angina). History of gestational diabetes. Ethnicity (increased rates of diabetes, metabolic syndrome, and CHD are observed in individuals of non-european ethnicity, especially among those of South Asian, Hispanic, Aboriginal, and Native American ethnicity). Modifiable Risk Factors These include: Obesity, measured by BMI (Wt [kg] / Ht [m 2 ]). Visceral obesity, measured by waist circumference and (or) waist-to-hip ratio. Cigarette smoking. Physical inactivity. Diets high in simple carbohydrates and fat. Multifactored Risk Assessments The metabolic syndrome connotes increased risk for diabetes, hypertension, and CHD (based on waist circumference; fasting glucose and HDL; triglycerides; and blood pressure). The Framingham risk assessment (see section on dyslipidemia) determines the 10-year risk of a coronary event. Early Identification of Those at Greatest Risk for Developing Type 2 Diabetes As mentioned, those with IFG or the metabolic syndrome are at increased risk. Elevations of 2-hour postload plasma glucose and fasting insulin are early markers of the development of diabetes, but these tests are used less often in routine practice. Use of the OGTT is discussed above. Insulin measurements are not well standardized, and reference ranges for fasting insulin tend to vary between laboratories; they also depend on the assay technique. An isolated fasting insulin level provides limited information unless a reference range has been clearly established with a well-characterized control population and with the same assay technique. Serial fasting insulin levels may be more valuable in tracking the development of insulin resistance. Tracking and Linking of the Disturbance to Antipsychotic Treatment To monitor for antipsychotic-associated metabolic disturbances, patients should be assessed before antipsychotic treatment is initiated. The results of such an assessment can also influence antipsychotic choice, particularly when patients have existing metabolic pathology or elevated risk factors. The frequency of subsequent assessments is a matter of some debate, as is reflected in the various antipsychotic guidelines that follow. Emergent diabetes and diabetic Can J Psychiatry, Vol 51, No 8, July

5 The Canadian Journal of Psychiatry In Review Table 2 Recommended groups to monitor and initial workup Mount Sinai (24) Australia (30,31) ADA APA (32) Belgium (33) United Kingdom (34) Canada (35) Groups to monitor Workup Schizophrenia, any antipsychotic All patients, any antipsychotic All patients, SGA Schizophrenia, SGA Schizophrenia, any antipsychotic Schizophrenia FPG Random glucose. HbA1c If FPG not feasible No In addition to FPG or random glucose OGTT To follow up IFG Lipids Weight Waist circumference Height Hip Blood pressure Family history Medical history Ethnicity Tobacco Diet activity Signs and symptoms of diabetes ketoacidosis have been reported in close temporal relation to antipsychotic prescription and, in many cases, have been reversible when the antipsychotic is stopped or switched (27). One surveillance approach is to monitor glucose levels frequently, particularly in the first few months of treatment. However, clear emergent diabetes after initiation of an antipsychotic may be rare (28), and frequent (monthly or weekly) can be impractical and costly. An alternative approach is to educate patients, caregivers, and families about the symptoms of emergent diabetes and diabetic ketoacidosis (see Table 1). Suggestive symptoms should be an urgent trigger for glucose testing. Weight gain and lipid disturbance (often in the form of increased triglycerides) can occur within a few weeks of initiating antipsychotic treatment (1), and frequent of body weight during the first few months of treatment, with repeat evaluation of glucose and lipids after this time, may flag emerging metabolic concerns and allow for reevaluation of the risks and benefits of a specific antipsychotic treatment. What actions should be taken in the event of elevated body weight, glucose, and lipids, and at what threshold values, is a matter of debate, again reflected in the ensuing guidelines. Existing Monitoring Guidelines This section reviews the major efforts to provide recommendations for patients treated with antipsychotics in regard to the development of metabolic abnormalities. In addition to describing the specific recommendations of each of the groups (see Tables 2 and 3), we highlight the common suggestions. There have been 6 principal attempts. All the recommendations were published in 2004 or We briefly describe the participants in each group: Mount Sinai A group of psychiatric and other medical experts concerned about the physical health and health care of individuals with schizophrenia convened in October 2002 and made recommendations for physical health. The proceedings of the Mount Sinai Conference were published in the American Journal of Psychiatry (29). Australia A consensus group was convened in Australia from the disciplines of psychiatry, endocrinology, epidemiology, general practice, mental health nursing, and pharmacy, along with representatives of community and non-government 496 Can J Psychiatry, Vol 51, No 8, July 2006

6 Metabolic Monitoring for Patients Treated With Antipsychotic Medications Table 3 Ongoing and recommendations for escalation Tests Mount Sinai (29) Australia (30,31) ADA APA (32) Belgium (33) United Kingdom (34) Canada (35) Ongoing FPG HbA1c yearly Random glucose monthly for 6 months, then twice yearly At 3 months, then yearly At 6 and 12 weeks, then quarterly Random glucose and HbA1c at 4 months, then yearly Signs and symptoms of diabetes Weight Each visit for 6 months, then quarterly Each visit or every quarter Monthly for 3 months, then quarterly Regularly, more frequently for first weeks Lipids Every 2 years Every 6 months At 3 months, then at 5 years Blood pressure Every 6 months At 3 months, then yearly Every quarter Escalation Increased glucose Consult internist Diabetes diagnostic workup Consider referral to internist and change in SGA FPG monthly, OGTT, consider change in SGA and metformin Consult family physician or specialist, change in SGA usually unnecessary Same as patients without schizophrenia Increased weight, BMI FPG and (or) HbA1c monthly for 4 months, then yearly; weight control; consider medication change Intensify Consider referral to internist; consider change in SGA FPG monthly; change in diet; consider change in SGA Same as patients without schizophrenia; diet and activity plan Increased lipids Consult internist Intensify Consider change in SGA; increase frequency Change diet; if this fails, consider change in SGA Same as patients without schizophrenia Positive family history FPG or HbA1c at 4 months, then yearly Intensify more frequent FPG monthly Same as patients without schizophrenia Positive medical history Intensify more frequent Same as patients without schizophrenia organizations (30, p 544). Its findings were published in the Medical Journal of Australia (30). The Mental Health Council of Australia published a companion guide for consumers and caregivers (31). American Diabetes Association American Psychiatric Association The American Diabetes Association, the American Psychiatric Association, the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity convened a consensus development conference in November The results were copublished in Diabetes Care, The Journal of Clinical Psychiatry, and Obesity Research (32). Belgium A panel of psychiatrists, diabetologists, and pharmacists convened a workshop from major hospitals in Belgium. (33, p 131) The consensus recommendations were published in the International Journal of Psychiatry in Clinical Practice (33). United Kingdom A group comprising pharmacologists, endocrinologists, psychiatrists, a pharmacist from the United Kingdom, and one Can J Psychiatry, Vol 51, No 8, July

7 The Canadian Journal of Psychiatry In Review Table 4 ADA APA consensus guidelines a Base At 4 weeks At 8 weeks At 12 weeks Every 3 months Annual Every 5 years Medical history b Weight (BMI) Waist circumference Blood pressure Fasting glucose Fasting lipids a From ADA APA (32) b Personal and family history of obesity, diabetes, hypertension, and cardiovascular disease from the United States convened in October Their recommendations were published in the British Journal of Psychiatry (34). Canada A group of diabetes specialists representing the Canadian Diabetes Association developed a position paper, Antipsychotic Medications and Associated Risks of Weight Gain and Diabetes, published in the Canadian Journal of Diabetes (35). There was no single format for the presentation of the different groups recommendations. To compare recommendations across the various groups, we identified the following main issues. Patients Who Should Be Monitored (Table 2) Each group had specific, although somewhat discordant, recommendations about which patients and medications should be monitored. Two suggested that all patients on all antipsychotics be monitored, whereas 4 recommended that only patients with schizophrenia be monitored. Similarly, 3 suggested limiting to second-generation antipsychotics, and 3 recommended any antipsychotic. Recommendations for the Initial Workup (Table 2) Hyperglycemia. All the groups recommended the FPG as a baseline test, although random glucose determination was sometimes thought to be acceptable. The utility of determining HbA1c was more controversial, with the Mount Sinai group deeming it an acceptable substitute if the FPG were not feasible, the UK group recommending it, and the Belgian group recommending against it. The Belgian group specifically suggested the use of OGTTs in this population. Australian and Canadian guidelines suggest the OGTT as a follow-up to IFG findings, particularly when there are multiple diabetes risk factors. Other Parameters of Interest. Although the UK group was relatively silent about this issue, there was generally a great degree of agreement about other areas worth initially. The other 5 groups unanimously recommended measuring fasting lipids, weight, waist circumference, and BMI, as well as obtaining a family and personal medical history. Some of the groups also explicitly recommended measuring blood pressure and hip circumference; noting ethnicity; and inquiring about tobacco use, other habits (for example diet and activity level), and signs and symptoms of diabetes. Recommendations for Ongoing Monitoring (Table 3) Recommendations in this area can be reduced to 4 areas: for the development of abnormal glucose regulation, weight gain, increased blood pressure, and dyslipidemia. All groups agreed on the utility of measuring FPG as a tool, but recommendations for frequency ranged from yearly to monthly for 6 months. Again, the UK group recommended measuring HbA1c (at 4 months), whereas the Mount Sinai and Canadian groups explicitly recommended looking for signs and symptoms of diabetes. Four of the groups had specific recommendations about weighing patients, lipid levels, and blood pressure. As before, there were differences in the recommended frequencies of these procedures. Indications for Monitoring Change (Table 3) Each group had recommendations about responding to increased patient risk to develop metabolic abnormalities. In response to increasing FPG levels, almost all agreed that consulting with an internist, general practitioner, or diabetologist. 498 Can J Psychiatry, Vol 51, No 8, July 2006

8 Metabolic Monitoring for Patients Treated With Antipsychotic Medications Several also recommended changing the patient s antipsychotic medication, although the UK group stated that such a change would usually be unnecessary. The Belgian group recommended what might be considered an aggressive response for mental health professionals: an OGTT, monthly FPG, and possible addition of metformin. A subsequent publication provides some empirical support for this approach (36). The Canadian group suggested that diabetesprevention strategies (such as diet and activity interventions or metformin prescription) be considered for those with IGT. In a patient with increasing weight, recommendations ranged from intensifying to FPG taken monthly, dietary changes, nutritional and activity counselling, and possibly changing antipsychotic medication. When lipids increase, most groups supported increased, and the Belgian group recommended dietary change and possibly changing antipsychotic medication if diet failed to rectify the lipid profile. In patients with family histories of diabetes mellitus, recommendations ranged from more frequent to taking monthly FPG. For patients with a medical history of cardiac disease, sedentary lifestyle, or other risk factors, 2 groups suggested more frequent. To summarize these recommendations, there are many areas of general agreement, although some specifics vary. There was agreement about the importance of baseline before starting antipsychotic treatment and that patients should be followed more closely for the first 3 to 4 months of treatment, with subsequent ongoing reevaluation. There was also agreement about the utility of the following tests and measures: FPG, fasting lipid profile, weight and height (for BMI), waist circumference, and blood pressure. Areas of disagreement included which patients should be monitored, the frequency of testing for the various metabolic parameters, and the usefulness of glucose tolerance testing. Cost and Cost-Effectiveness Remarkably, there are currently no reports of applying the various international guidelines in real-world settings. Similarly, there are no studies of the cost-effectiveness of employing these recommendations. Such studies are critically important in determining the most effective scheme. Screening for type 2 diabetes, particularly in high-risk groups, has been estimated to be cost-effective and to lead to reduced diabetes complications, improved quality of life, and extended life expectancy (37). The costs of laboratory tests vary from one jurisdiction to another. The Mount Sinai conference publication (29) emphasized that it should be possible to implement recommendations in any public psychiatric setting and included the costs of relevant tests (US dollars): glucose level, $5.00; HbA1c, $13.00; total cholesterol, $6.00; triglyceride level, $8.00; HDL-Chol, $ In the Canadian single-payer health system, greater cost containment may be possible. Use of a protocol also allows for budgeting for a predictable number of yearly laboratory tests per person. Additional equipment costs (such as scales, tape measures, and blood pressure devices) are modest. Possibly, the major challenge and cost is associated with organizing and coordinating clinical services to expedite practice. Barriers to Monitoring Implementation Specific challenges vary between mental health jurisdictions and from one country and health system to another. However several common themes can be identified Responsibility The issue of responsibility for for metabolic abnormalities is much debated. Who should do it? Should not be done by family physicians or internists? Is it realistic to expect psychiatrists to participate? We suggest that along with the prescription of antipsychotics comes the responsibility for for metabolic abnormalities potentially induced by them. It is not necessary for psychiatrists to actually perform the tests indicated for ; as leaders of the psychiatric treatment team, however, they are responsible for ensuring that the task is clearly delegated if they are not going to personally perform the appropriate tests. The delegation of the various tasks required for adequate should be explicitly addressed by the treatment team and may well vary from one clinical situation to another. Competing Demands in Mental Health Care and the Demedicalization of Psychiatry There are many competing demands on limited resources in the treatment of those with severe mental illness. As a result, actual medical care of patients has frequently been deemphasized, and at times, it has been thought that dollars spent on medical care in community mental health centres have not been optimally allocated. This concern about resource allocation has led to the evolution of systems that do not systematically address the medical needs of psychiatric patients. There is now little medical knowledge or emphasis on medical needs in many mental health settings, and there is a perception that no extra time and staff exist to address the issues raised in this paper. In addition, many of the psychiatric leaders in these systems may be uncomfortable exerting leadership in areas where they may feel that they are no longer sufficiently knowledgeable. However, this can change. Although it may well require the application of Can J Psychiatry, Vol 51, No 8, July

9 The Canadian Journal of Psychiatry In Review resources, mental health centres can provide the kind of medical services called for in this article and thereby greatly improve the care of the whole patient. Liability Issues Clinicians often describe a dilemma in regard to the medicolegal issues raised by the discussion of medical. Some are concerned about what types of added liability are implied when tests are performed that would document the existence of significant medical illnesses such as diabetes, dyslipidemia, or hypertension. They worry that their interpretation or response to these tests will be inadequate. This is a legitimate concern, and it can be addressed through education and planning. We suggest that the alternative not adequately is unacceptable. Our patients deserve the same standard of care that the general population expects, and if we are the only providers for this care, we must do so. Recommendations for Practice Psychiatrists are encouraged to adopt a structure for metabolic that includes a protocol, an organized way of recording results, and collaborations with primary care physicians, diabetes specialists, nutritionists and activity recreation therapists. When such collaborative relationships are not in place, clinicians should advocate for their development. Accepting the need for and implementing metabolic requires more than a top-down approach focused on educating physicians. An excellent example of a combined top-down and bottom-up approach is illustrated in the development and dissemination of the Australian guidelines. In addition to professionals, the consensus group included representatives of community and nongovernmental organizations. The guidelines were then disseminated together with an extensive companion document for consumers and caregivers (31). This document describes in lay terms, and puts in perspective, such issues as physical illness in people with mental illness, psychotic disorders and diabetes, for diabetes, and the risks and benefits of antipsychotic treatment. Similar educational material should be developed in other jurisdictions, with careful attention paid to potential conflicts of interest. The ADA APA guidelines are true consensus guidelines with broad medical representation and a practical structure useful to clinicians. These guidelines include a simple table of scheduled measures for routine use (Table 4) that has become perhaps the most often-cited schedule of the various published guidelines. This schedule fulfills most of the goals established in this paper. However, more emphasis should be placed on the screening of all patients with schizophrenia and other forms of serious mental illness for metabolic disturbance particularly diabetes, dyslipidemia, and hypertension even prior to a new antipsychotic prescription. Fasting lipids should be evaluated annually rather than every 5 years, given the high rate of untreated dyslipidemia in this population (10). Monitoring by both caregivers and patients for the signs and symptoms of emergent diabetes or diabetic ketoacidosis, particularly during the first few months of antipsychotic treatment, should be stressed. In addition, the possibility of primary and secondary prevention should be kept in mind. Strategies that allow for early diagnosis and detection of those at greatest risk for the development of diabetes, such as testing for glucose tolerance and (or) fasting insulin, should be considered when resources permit and tests are appropriately anchored. 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Address for correspondence: Dr Tony Cohn, Centre for Addiction and Mental Health, 1001 Queen Street West, Toronto, ON, M6J 1H4; Tony_Cohn@camh.net Résumé : Surveillance métabolique des patients traités aux antipsychotiques Objectifs : Les effets secondaires métaboliques du traitement antipsychotique comprennent la prise de poids, la dyslipidémie et une susceptibilité accrue au diabète. Les patients souffrant de schizophrénie ont un taux de mortalité accru suite à une maladie coronarienne et une espérance de vie réduite. Il yaunbesoin clinique urgent de surveiller les perturbations métaboliques chez les patients traités aux antipsychotiques. Nos objectifs étaient d examiner les lignes directrices internationales publiées sur la surveillance, d établir des objectifs de surveillance métabolique, et de faire des recommandations pour la pratique. Méthode : Nous avons entrepris un examen des principales lignes directrices d avis unanime publiées sur la surveillance métabolique des patients traités aux antipsychotiques et une revue sélective des lignes directrices de la pratique pour le traitement du diabète, de la dyslipidémie et de l hypertension. Résultats : Les patients souffrant de grave maladie mentale ont sensiblement des taux élevés de perturbation métabolique et un accès limité aux soins médicaux généraux. La surveillance, mais pas nécessairement le traitement médical du trouble métabolique s inscrit dans le domaine de la pratique psychiatrique et devrait inclure le dépistage des perturbations métaboliques ainsi que le suivi des effets du traitement antipsychotique. En outre, les psychiatres et les services psychiatriques devraient travailler à faciliter l accès des patients aux soins médicaux. Les lignes directrices publiées font considérablement l unanimité. Les domaines de dissension comprennent quels patients surveiller, l utilité du test de tolérance au glucose et le moment où envisager de changer l antipsychotique. Conclusion : Les cliniciens sont invités à adopter un système structuré pour mener et enregistrer la surveillance métabolique, et à développer la collaboration avec les médecins de famille, les spécialistes du diabète, les diététistes et les ludothérapeutes afin de faciliter les soins médicaux pour les patients traités aux antipsychotiques. Can J Psychiatry, Vol 51, No 8, July