APA: Schizophrenia Patients Go Untreated For Comorbidities

By Michael Smith, MedPage Today Staff Writer

Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.

May 24, 2006

MedPage Today Action Points

Note that schizophrenia itself carries a burden of risk for several comorbid illnesses, including cardiovascular disease, and that several of the antipsychotic drugs may increase risk factors.
Note also that treatment for comorbid diseases can extend life; the psychiatric illness should not outweigh physical disease.

These studies were published as abstracts and presented orally at a conference. These data and conclusions should be considered to be preliminary as they have not yet been reviewed and published in a peer-reviewed publication.

Review

Henry Nasrallah, M.D.University of Cincinnati

TORONTO, May 24 — Patients with schizophrenia lose as much as 20 years of life to illnesses such as heart disease and diabetes because most aren't being treated for them.
The situation is "shocking," said John Newcomer, M.D., of Washington University in St. Louis, speaking to a press conference called to discuss several pieces of research being presented at the annual meeting of the American Psychiatric Association here.
The good news for patients is that the comorbid illnesses can mostly be treated; he said. The bad news is that the risk factors occur at high levels, are not being attended to, and are "massively under-treated."

Dr. Newcomer's point was underscored by three research presentations:

+ A reanalysis of baseline data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study showed that large numbers of patients who enrolled had comorbid diseases, including such conditions as frank diabetes, but were not undergoing treatment for them.

+ The baseline patient data for the 18,240-patient Ziprasidone Observational Study of Cardiac Outcomes (ZODIAC) trial shows similar results in what the senior investigator called the "biggest sample ever in schizophrenia."

+ An analysis of lipid and glucose monitoring of treated patients both before and after a 2004 consensus statement on the issue—which urged physicians to keep an eye on their schizophrenia patients' lipid status—showed little change as a result of the guidelines.

"Patients with schizophrenia have a severe brain disease, of course, but they also have many body diseases," said Henry Nasrallah, M.D., of the University of Cincinnati.

For instance, he said, 42% of the 1,460 patients in the CATIE trial already met the criteria for the metabolic syndrome when they entered the study. Some very likely had the syndrome because of previous treatment for schizophrenia, Dr. Nasrallah said, but others had it as a comorbid condition.

Treatment rates for other conditions were "shockingly low," he told reporters:

40% of patients with frank diabetes were not under treatment.
65% of those with hypertension were not getting any anti-hypertensive drugs.
90% of those with high cholesterol and triglycerides were not being treated.

The effect, he said is a "double whammy"—the patients have diseases that will shorten their lives and aren't getting treatment for them.

The giant ZODIAC study revealed the same picture, said John Kane, M.D., of Zucker Hillside Hospital in New York.

"The take-home message for a clinician is that among patients with schizophrenia who are presenting for treatment there are a substantial proportion who have hypertension, hyperlipidemia, diabetes, overweight, and obesity," he said in an interview.

"These data underscore the importance of trying to identify people who have these illnesses and trying to manage them," he said.

One reason for the under-treatment, Dr. Kane said, may be that psychiatrists tend to focus on mental illness, assuming that physical illness will be taken care of by a family doctor or other physician.

It may also be that the health care systems that care for people with chronic mental illness themselves are fragmented, making it easy for patients to fall through the cracks, he said.
Dr. Kane urged psychiatrists to become "ombudsmen" for their patients—making sure that all aspects of their health are cared for.

Meanwhile, despite formal guidelines suggesting that psychiatrists should keep a watchful eye on their patients' lipid status, not much has changed, said Brian Cuffel, Ph.D., of Pfizer, in New York.

Dr. Cuffel and colleagues analyzed a database containing health care claims from 85 health plans across the country to see whether physicians began performing more lipid and glucose monitoring of schizophrenic patients after the 2004 American Diabetes Association/American Psychiatric Association consensus statement.

"There hasn't been really meaningful change in the way clinicians are attending to metabolic issues," Dr. Cuffel said in an interview. "Clearly, publishing guidelines isn't enough."
For instance, before the consensus statement was issued, about 7.8% of patients in the sample had their lipids tested at baseline and 6.2% had follow-up testing 12 weeks later. After the statement, the corresponding rates were 8.5% and 7.1%.

"If you don't follow up with the patients," Dr. Cuffel said, "you don't know what the impact of the treatment has been."

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