Health in Psychiatric Patients: Interview With David J. Hellerstein, MD
Health in Psychiatric Patients: Interview With David J. Hellerstein, MD
Editor's Note:
The metabolic side effects of atypical antipsychotics often create major problems for patients. In this interview, Elizabeth Saenger, PhD, Editorial Director for Medscape Psychiatry & Mental Health, interviewed David J. Hellerstein, MD, to find out how psychiatrists and allied health professionals might "First, do no harm" with patients who are taking medications associated with high rates of obesity, hypertension, hyperglycemia, hyperlipidemia, and cardiac death. Dr. Hellerstein is Associate Professor of Clinical Psychiatry, Columbia University, New York, NY, and Research Psychiatrist, New York State Psychiatric Institute, New York, NY.
Medscape: You gave a talk at the American Psychiatric Association on a study you did with colleagues at the New York State Psychiatric Institute on assessing health and nutrition status of urban psychiatric outpatients. What was the purpose of your study?
David J. Hellerstein, MD: It was to assess the health status of chronically mentally ill outpatients who were treated in our Washington Heights Community Service. It is particularly relevant to mental health practitioners -- because I think everyone is concerned about the results of the Clinical Antipsychotic Trials in Intervention Effectiveness (CATIE) -- in understanding the side effects of the newer atypical antipsychotic medicines and the interactions of those side effects in obesity and metabolic syndrome.
We wanted to assess those problems in our own population -- among patients in our local community who are treated with these medications.
The second purpose of our study was to look at what kinds of administrative and clinical issues come up when you try to assess health status in a local clinical setting -- and then to generalize our findings to other practitioners.
Medscape: How did you conduct the study?
Dr. Hellerstein: As part of a quality improvement project, we looked at the patients in a day treatment program in one of our two outpatient clinics in Washington Heights, a largely Hispanic community in upper Manhattan. We did a chart review for medical diagnoses and for laboratory tests such as lipids and glucose levels. We interviewed patients about the availability of medical care and their nutritional habits. And we had a nurse obtain measurements such as body mass index (BMI) and blood pressure.
Medscape: What did you find?
Dr. Hellerstein: What we found was really quite disturbing. We found a very high rate of obesity -- particularly central obesity, which means that patients had very large abdominal circumference, which is related to a number of adverse health outcomes including mortality from cardiovascular disease. Central obesity was particularly common among female patients. A significant number of patients had elevated random or fasting glucose levels, but did not have clinical diagnoses of diabetes-related problems. We found that only about a quarter of the patients had normal blood pressures. Also, lipids were modestly elevated among most patients. Often, these pieces of information were not available in the chart in a way that would enable clinicians to incorporate health status into clinical decision-making -- for instance, deciding which atypical antipsychotic to use.
This overall picture of health status for these Hispanic outpatients was very consistent with the mortality data in our Washington Heights clinics over the previous 5-year period. Mortality statistics showed that a large number of patients had died unexpectedly. Generally, their deaths were attributed to cardiovascular or diabetes-related causes. These patients were usually in their mid 50s, and many did not have diagnoses of acute medical illness.
Basically, what we found in our cross-sectional assessment of this patient sample were high rates of obesity, hypertension, hyperglycemia, and hyperlipidemia, which would consistently put these people at high risk for adverse outcomes, including premature death.
Medscape: Do you think these patient health statistics were due to a psychotropic medication, or do you think that if you had a control group, you would have equally bad statistics?
Dr. Hellerstein: It is difficult to know, because obesity rates have been reported to be high among various groups of Hispanic origin in the United States. For the patients in our study, we suspect that their family members may have high levels of obesity as well -- but these chronic patients are probably at greater risk than unaffected family members because of mental illness, smoking, and antipsychotic treatment. Within our day treatment sample, it appeared that some patients were at higher risk than others. There was a correlation between overweight -- which is BMI of 25 or greater -- and being on an atypical psychotic medication. And there was a high correlation between obesity -- which is defined as a BMI of 30 or greater -- and being on an atypical agent. So, among this sample, being on atypical antipsychotics did seem to be associated with higher risk.
In this particular clinic, most patients are Hispanic. They're urban dwellers. Many of them are immigrants. And many of them are poor. So they have several risk factors that make these increased rates of obesity and metabolic syndrome of even greater concern, once you add atypical antipsychotics and mood stabilizers to the picture.
Medscape: Were you able to do anything to minimize patient risks?
Dr. Hellerstein: We're in the midst of assessing that. We have found that about two thirds of the whole sample have seen their primary care doctor in the past year. These patients are pretty well cared for from a medical point of view. But that's not enough.
The second thing is that patients have a high degree of access to grocery stores. They don't have to buy all their food in a corner store or bodega. Many of them cook for themselves or live with a relative who cooks for them.
So these patients have the opportunity to get healthcare already. They probably have the opportunity to get better nutrition. These things give us hints in terms of what we could do to try to improve the situation, which would also include encouraging patients to devise a health and nutrition education program for themselves.
We clearly need better health assessments in the psychiatric record. We're working on how to meet the Marder criteria for monitoring BMI among patients treated with antipsychotic medication. It is not an easy thing to do. So we are trying to find simplified ways to do health monitoring and to provide health education in the clinic setting.
Medscape: Can you tell me a little bit more about the Marder criteria?
Dr. Hellerstein: The Marder criteria recommend that BMI be measured at baseline and every month for 6 months after initiating or changing second-generation antipsychotics. The BMI should be measured every 3 months after that, and more frequently for overweight patients.
Assessment for diabetes at baseline would include a fasting glucose or hemoglobin A1c. With patients at normal risk, this would be rechecked before a new antipsychotic is started and then yearly. In the high-risk patients, ie, those with diabetes or weight gain, these would need to be monitored before a new antipsychotic is added, after 4 months of treatment, and then yearly.
Lipids monitoring would include a baseline lipids assessment of total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides. For normal-risk individuals, those with LDL of 130 or less, this would be repeated every 2 years, and for high-risk patients with an LDL greater than 130, it would be done every 6 months.
It seems fairly simple, but in a busy outpatient setting that doesn't already have primary care doctors on staff and where the staff is very busy with clinical management, implementing these standards into routine care is not easy to do. One possible measure would just be to hire an internist or nurse practitioner to manage these issues. It would be costly, at least in the short term, though it may save money in the long term. There is often not a budget line for these staff members, though. For psychiatric outpatient settings that are trying to implement these criteria without having internal medicine physicians on staff, there may be ways to simplify things.
Medscape: How could you simplify them?
Dr. Hellerstein: To assess weight, I think every psychiatrist should have a scale in his or her office. You can get a fairly accurate digital scale for less than fifty dollars. We are getting a digital scale for every psychiatrist's office. Physicians also need a ruler on the wall that shows height. Then they can easily calculate their BMI.
It may be hard to remember to measure BMI every month, but most clinicians will do this if it is required as part of the quarterly treatment plan. You may incorporate BMI and other measures that are in the treatment plan into a template that has to be filled out regularly.
In assessing lipids or glucose levels, it's the same thing. The question is: How do you get the information into the chart? And how do you bring it to the attention of clinicians?
Administrators need to find ways to have good flow-sheets in paper charts. For electronic medical records systems, we need the kind of prompts and pop-ups and so on that make it easy for clinicians to know what is required. With regard to nutrition and health aids for education, depending on the specific population, a wide range of materials are available. For instance, for Hispanic patients like ours, there are Spanish-language nutrition brochures and handouts, posters, bingo games, and all kinds of other nutritional materials. You can have materials in the waiting room.
Another thing is that programming in clinical settings can be adapted to include health monitoring and health improvement issues. Group therapy sessions can include measuring BMI and abdominal girth, as well as discussions about health and nutrition and medication side effects and exercise. Nutrition education can include food preparation exercises and education about portion sizes. Programs can also review what kinds of foods and beverages are provided for day-program patients. Schedules can include a walk in the park or around the block and stretching and relaxation exercises -- thus incorporating physical activity into the program. Each of these things may have a modest effect, it's true, but they all do convey the message.
Medscape: Yes. How willing do you think physicians and institutions will be to convey this message? In other words, do you think some cultural change will be necessary?
Dr. Hellerstein: I've just been talking about the practical side. And I think that there's a kind of cultural and institutional or even psychological side to it, which is that these kinds of standards -- like the Marder recommendations -- have created an unfunded mandate for clinicians. There's already a huge list of mandates that clinicians are responsible for: assessment of safety, substance abuse issues, family issues, sexual abuse, and violence. Now, added to that list, is a new mandate: you need to monitor your patients' health status and do it in a fairly intensive way.
The real difficulty for clinicians is not following these recommendations, but rather, "What do you do about it?" That's actually the biggest problem at this point: the clinician may find various abnormalities -- weight gain, glucose intolerance. You have a patient who is finally relatively stable on an atypical antipsychotic, say olanzapine, that causes weight gain. The clinician may be afraid to rock the boat.
Medscape: Right.
Dr. Hellerstein: The clinician wonders, "What interventions can I perform to decrease these risk factors?" instead of closing his or her eyes and continuing the olanzapine, and hoping that nothing bad happens.
The biggest problem is that we don't have good intervention programs to reverse weight gain for these patients. That's the conundrum for using antipsychotics for the treatment of psychosis: how to minimize these risks related to medications that are frequently very effective.
There are behavioral interventions, education interventions, and pharmacologic interventions -- but none of them is tremendously effective, and none of them is particularly well studied, especially among subpopulations like urban Hispanic outpatients. There is a whole range of things we might be able to do. But once you start to think about this problem, it creates some complications. It creates an urgent new research agenda. It increases the administrative and clinical agenda. And it's clearly very difficult to address these issues on the day-to-day level in a particular clinic or program.
Medscape: Yes, these side effects create complications that are difficult to solve. Is there anything you would like to add?
Dr. Hellerstein: I'd like to add 2 things. First, the issues we talked about should be incorporated into the education of physicians, particularly the training of doctors who are interested in going into primary care, because they will need to know about psychiatry. And psychiatrists definitely need to know more about health monitoring for chronically ill patients, so it has to be built into psychiatric residency curricula.
Second, I think collaboration between internists and psychiatrists is crucial, both on the clinical and research levels. For example, there are some really interesting opportunities for researchers in diabetes, hypertension, stroke, and other medical specialties to collaborate with psychiatrists to work on what is often an iatrogenically induced problem. There's an opportunity to have physicians collaborate in a productive way across disciplines to address these very significant public health issues.
Editor's Note:
The metabolic side effects of atypical antipsychotics often create major problems for patients. In this interview, Elizabeth Saenger, PhD, Editorial Director for Medscape Psychiatry & Mental Health, interviewed David J. Hellerstein, MD, to find out how psychiatrists and allied health professionals might "First, do no harm" with patients who are taking medications associated with high rates of obesity, hypertension, hyperglycemia, hyperlipidemia, and cardiac death. Dr. Hellerstein is Associate Professor of Clinical Psychiatry, Columbia University, New York, NY, and Research Psychiatrist, New York State Psychiatric Institute, New York, NY.
Medscape: You gave a talk at the American Psychiatric Association on a study you did with colleagues at the New York State Psychiatric Institute on assessing health and nutrition status of urban psychiatric outpatients. What was the purpose of your study?
David J. Hellerstein, MD: It was to assess the health status of chronically mentally ill outpatients who were treated in our Washington Heights Community Service. It is particularly relevant to mental health practitioners -- because I think everyone is concerned about the results of the Clinical Antipsychotic Trials in Intervention Effectiveness (CATIE) -- in understanding the side effects of the newer atypical antipsychotic medicines and the interactions of those side effects in obesity and metabolic syndrome.
We wanted to assess those problems in our own population -- among patients in our local community who are treated with these medications.
The second purpose of our study was to look at what kinds of administrative and clinical issues come up when you try to assess health status in a local clinical setting -- and then to generalize our findings to other practitioners.
Medscape: How did you conduct the study?
Dr. Hellerstein: As part of a quality improvement project, we looked at the patients in a day treatment program in one of our two outpatient clinics in Washington Heights, a largely Hispanic community in upper Manhattan. We did a chart review for medical diagnoses and for laboratory tests such as lipids and glucose levels. We interviewed patients about the availability of medical care and their nutritional habits. And we had a nurse obtain measurements such as body mass index (BMI) and blood pressure.
Medscape: What did you find?
Dr. Hellerstein: What we found was really quite disturbing. We found a very high rate of obesity -- particularly central obesity, which means that patients had very large abdominal circumference, which is related to a number of adverse health outcomes including mortality from cardiovascular disease. Central obesity was particularly common among female patients. A significant number of patients had elevated random or fasting glucose levels, but did not have clinical diagnoses of diabetes-related problems. We found that only about a quarter of the patients had normal blood pressures. Also, lipids were modestly elevated among most patients. Often, these pieces of information were not available in the chart in a way that would enable clinicians to incorporate health status into clinical decision-making -- for instance, deciding which atypical antipsychotic to use.
This overall picture of health status for these Hispanic outpatients was very consistent with the mortality data in our Washington Heights clinics over the previous 5-year period. Mortality statistics showed that a large number of patients had died unexpectedly. Generally, their deaths were attributed to cardiovascular or diabetes-related causes. These patients were usually in their mid 50s, and many did not have diagnoses of acute medical illness.
Basically, what we found in our cross-sectional assessment of this patient sample were high rates of obesity, hypertension, hyperglycemia, and hyperlipidemia, which would consistently put these people at high risk for adverse outcomes, including premature death.
Medscape: Do you think these patient health statistics were due to a psychotropic medication, or do you think that if you had a control group, you would have equally bad statistics?
Dr. Hellerstein: It is difficult to know, because obesity rates have been reported to be high among various groups of Hispanic origin in the United States. For the patients in our study, we suspect that their family members may have high levels of obesity as well -- but these chronic patients are probably at greater risk than unaffected family members because of mental illness, smoking, and antipsychotic treatment. Within our day treatment sample, it appeared that some patients were at higher risk than others. There was a correlation between overweight -- which is BMI of 25 or greater -- and being on an atypical psychotic medication. And there was a high correlation between obesity -- which is defined as a BMI of 30 or greater -- and being on an atypical agent. So, among this sample, being on atypical antipsychotics did seem to be associated with higher risk.
In this particular clinic, most patients are Hispanic. They're urban dwellers. Many of them are immigrants. And many of them are poor. So they have several risk factors that make these increased rates of obesity and metabolic syndrome of even greater concern, once you add atypical antipsychotics and mood stabilizers to the picture.
Medscape: Were you able to do anything to minimize patient risks?
Dr. Hellerstein: We're in the midst of assessing that. We have found that about two thirds of the whole sample have seen their primary care doctor in the past year. These patients are pretty well cared for from a medical point of view. But that's not enough.
The second thing is that patients have a high degree of access to grocery stores. They don't have to buy all their food in a corner store or bodega. Many of them cook for themselves or live with a relative who cooks for them.
So these patients have the opportunity to get healthcare already. They probably have the opportunity to get better nutrition. These things give us hints in terms of what we could do to try to improve the situation, which would also include encouraging patients to devise a health and nutrition education program for themselves.
We clearly need better health assessments in the psychiatric record. We're working on how to meet the Marder criteria for monitoring BMI among patients treated with antipsychotic medication. It is not an easy thing to do. So we are trying to find simplified ways to do health monitoring and to provide health education in the clinic setting.
Medscape: Can you tell me a little bit more about the Marder criteria?
Dr. Hellerstein: The Marder criteria recommend that BMI be measured at baseline and every month for 6 months after initiating or changing second-generation antipsychotics. The BMI should be measured every 3 months after that, and more frequently for overweight patients.
Assessment for diabetes at baseline would include a fasting glucose or hemoglobin A1c. With patients at normal risk, this would be rechecked before a new antipsychotic is started and then yearly. In the high-risk patients, ie, those with diabetes or weight gain, these would need to be monitored before a new antipsychotic is added, after 4 months of treatment, and then yearly.
Lipids monitoring would include a baseline lipids assessment of total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides. For normal-risk individuals, those with LDL of 130 or less, this would be repeated every 2 years, and for high-risk patients with an LDL greater than 130, it would be done every 6 months.
It seems fairly simple, but in a busy outpatient setting that doesn't already have primary care doctors on staff and where the staff is very busy with clinical management, implementing these standards into routine care is not easy to do. One possible measure would just be to hire an internist or nurse practitioner to manage these issues. It would be costly, at least in the short term, though it may save money in the long term. There is often not a budget line for these staff members, though. For psychiatric outpatient settings that are trying to implement these criteria without having internal medicine physicians on staff, there may be ways to simplify things.
Medscape: How could you simplify them?
Dr. Hellerstein: To assess weight, I think every psychiatrist should have a scale in his or her office. You can get a fairly accurate digital scale for less than fifty dollars. We are getting a digital scale for every psychiatrist's office. Physicians also need a ruler on the wall that shows height. Then they can easily calculate their BMI.
It may be hard to remember to measure BMI every month, but most clinicians will do this if it is required as part of the quarterly treatment plan. You may incorporate BMI and other measures that are in the treatment plan into a template that has to be filled out regularly.
In assessing lipids or glucose levels, it's the same thing. The question is: How do you get the information into the chart? And how do you bring it to the attention of clinicians?
Administrators need to find ways to have good flow-sheets in paper charts. For electronic medical records systems, we need the kind of prompts and pop-ups and so on that make it easy for clinicians to know what is required. With regard to nutrition and health aids for education, depending on the specific population, a wide range of materials are available. For instance, for Hispanic patients like ours, there are Spanish-language nutrition brochures and handouts, posters, bingo games, and all kinds of other nutritional materials. You can have materials in the waiting room.
Another thing is that programming in clinical settings can be adapted to include health monitoring and health improvement issues. Group therapy sessions can include measuring BMI and abdominal girth, as well as discussions about health and nutrition and medication side effects and exercise. Nutrition education can include food preparation exercises and education about portion sizes. Programs can also review what kinds of foods and beverages are provided for day-program patients. Schedules can include a walk in the park or around the block and stretching and relaxation exercises -- thus incorporating physical activity into the program. Each of these things may have a modest effect, it's true, but they all do convey the message.
Medscape: Yes. How willing do you think physicians and institutions will be to convey this message? In other words, do you think some cultural change will be necessary?
Dr. Hellerstein: I've just been talking about the practical side. And I think that there's a kind of cultural and institutional or even psychological side to it, which is that these kinds of standards -- like the Marder recommendations -- have created an unfunded mandate for clinicians. There's already a huge list of mandates that clinicians are responsible for: assessment of safety, substance abuse issues, family issues, sexual abuse, and violence. Now, added to that list, is a new mandate: you need to monitor your patients' health status and do it in a fairly intensive way.
The real difficulty for clinicians is not following these recommendations, but rather, "What do you do about it?" That's actually the biggest problem at this point: the clinician may find various abnormalities -- weight gain, glucose intolerance. You have a patient who is finally relatively stable on an atypical antipsychotic, say olanzapine, that causes weight gain. The clinician may be afraid to rock the boat.
Medscape: Right.
Dr. Hellerstein: The clinician wonders, "What interventions can I perform to decrease these risk factors?" instead of closing his or her eyes and continuing the olanzapine, and hoping that nothing bad happens.
The biggest problem is that we don't have good intervention programs to reverse weight gain for these patients. That's the conundrum for using antipsychotics for the treatment of psychosis: how to minimize these risks related to medications that are frequently very effective.
There are behavioral interventions, education interventions, and pharmacologic interventions -- but none of them is tremendously effective, and none of them is particularly well studied, especially among subpopulations like urban Hispanic outpatients. There is a whole range of things we might be able to do. But once you start to think about this problem, it creates some complications. It creates an urgent new research agenda. It increases the administrative and clinical agenda. And it's clearly very difficult to address these issues on the day-to-day level in a particular clinic or program.
Medscape: Yes, these side effects create complications that are difficult to solve. Is there anything you would like to add?
Dr. Hellerstein: I'd like to add 2 things. First, the issues we talked about should be incorporated into the education of physicians, particularly the training of doctors who are interested in going into primary care, because they will need to know about psychiatry. And psychiatrists definitely need to know more about health monitoring for chronically ill patients, so it has to be built into psychiatric residency curricula.
Second, I think collaboration between internists and psychiatrists is crucial, both on the clinical and research levels. For example, there are some really interesting opportunities for researchers in diabetes, hypertension, stroke, and other medical specialties to collaborate with psychiatrists to work on what is often an iatrogenically induced problem. There's an opportunity to have physicians collaborate in a productive way across disciplines to address these very significant public health issues.
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