Monitoring, Identification, and Intervention for Metabolic Disorders in Veterans with Psychotic Disorders

In light of growing evidence that certain antipsychotics may cause potentially life-threatening metabolic side-effects, the purpose of this study was to determine how regularly mental health clinicians (MHCs) currently monitor and manage metabolic abnormalities in overweight and obese patients with psychotic disorders. We hypothesized that MHCs monitor, identify and intervene for metabolic abnormalities in their patients at significantly lower rates than primary care physicians (PCCs), and that such rates may jeopardize patient health. We performed a one-year cross-sectional medical record review of primary care and mental health routine outpatient visit notes from the West Haven Campus of the Veteran Affairs Connecticut Healthcare System. We reviewed the records of a cohort of 123 veterans who met the following inclusion criteria: (1) primary diagnosis of schizophrenia or schizoaffective disorder; (2) at least one routine mental health visit at the West Haven VA facility between July 1, 2005 and June 30, 2006; and (3) overweight or obese, as determined by a body mass index (BMI) ≥ 25. We excluded all deaths. The 123 subjects were predominantly white and male (56% and 93%, respectively) with an average body mass index (BMI) of 32.4 (SD=5.4). 97% of subjects were taking an antipsychotic of some sort, and 85% were taking a second-generation antipsychotic. Zero diagnoses of metabolic syndrome and zero waist-size measurements were documented by PCCs or MHCs. The following differences in documentation were found between PCCs and MHCs, respectively: weight (85% vs. 11%; p\u3c0.001); BMI (48% vs. 0%; p\u3c0.001); identified weight as an issue (45% vs. 28%; p\u3c0.005); identified the link between antipsychotics and weight issues (10% vs. 12%; not significant); made diet and exercise recommendations (42% vs. 19%; p\u3c0.001); ordered a weight-management referral (21% vs. 3%; p\u3c0.001); ordered or considered ordering a change of antipsychotic medication or dose due to weight-related issues (6% vs. 3%; not significant). PCCs ordered laboratory tests at much higher rates than MHCs, including blood glucose, thyroid stimulating hormone, urinalysis, lipid panel, and hemoglobin A1C (differences were large and significant). We concluded that MHCs monitor, identify and intervene for metabolic abnormalities in their patients at significantly lower rates than PCCs, and that such rates are unacceptably low. The problem is one of a systemic failure in quality control and may pose a danger to patients. We advocate a rapid organizational response and systemic changes at the local and national level to improve quality