20 October 2017

Routine physical screening critical for mentally unwell

Clinical Mental Health

Mental-health professionals are being urged to establish referral pathways with GPs amid concerns over the growing burden of diabetes and metabolic disease in patients with schizophrenia and psychotic disorders.

Routine screening and monitoring for diabetes and cardiometabolic disease should be the minimum standard of care for patients with severe mental illness, according to a new position statement by the Australian Diabetes Society.

But data indicates that little has been done to achieve systematic screening and adequate management of diabetes and comorbidities by mental-health workers since the original and most recent position statement by the group more than a decade ago and despite rates of diabetes being three times higher in patients with schizophrenia than in the general population.

Life expectancy was an average of 45 years for people with schizophrenia compared with around 81 in the general population, and this was largely due to premature cardiovascular death, the group said.

“In general we’re screened by GPs and other health professionals if there are signs that we may be in trouble,” Clinical Associate Professor Roger Chen, the lead author of the paper and director of diabetes services at Concord Repatriation General Hospital, said.

“But it seems that those living with schizophrenia and psychotic disorders often have their physical-health needs pushed aside.

“The focus is on their mental illness, but there’s increasing data showing that, in fact, it’s the physical illness which is going to potentially shorten their lives.”

What especially needed to change was the fragmentation of care that left patients in mental-health clinics with little contact for their physical needs, and vice versa, Professor Chen said.

The ideal solution would be to have the GP overseeing their care, but there was a need for mental health, diabetes and cardiovascular centres to develop a stronger collaboration with other healthcare providers, he said.

“I think the GPs are very good at it already. They’ve got care plans to refer to exercise physiotherapists, dietitians et cetera, and they are the best people to actually organise that care,” he said.

“But the problem arises from the fact that the mental illness is all-consuming and takes a lot of their time,” he said. “Where it becomes difficult – hard to manage or exercise is hard to manage  – then perhaps one of the specialist centres can be beneficial. But for the bulk of the people I think the GP is absolutely central.”

The working party recommended a suite of baseline and regular tests to monitor patients with, including height, weight and waist circumference every three to six months, blood pressure every three to six months, blood glucose levels (preferably fasting) every six months, HbA1c screening each year for a diagnosis or every three months for someone with diabetes, and serum lipids each year or more if indicated.

They also suggested retesting most if a new antipsychotic was initiated.

It was not enough to simply screen, Professor Chen said. Critical to patient’s health was the appropriate interpretation of results and the creation of a management plan to monitor and review health outcomes.

While the antipsychotic drugs were often blamed for patients’ poor cardiometabolic health, lifestyle factors leading to poor health were also common and needed to be addressed, the statement said.

Australian Diabetes Society CEO Dr Sof Andrikopoulos welcomed the statement and its timing alongside World Mental Health Day.

“The position statement provides a practical response to concerning figures about the health and welfare of people living with serious mental illness and diabetes and I hope it will assist to improve the standard of care nationally,” he said.