Primary Care Issues in Patients with Mental Illness

Primary Care Issues in Patients with Mental Illness BERNADETTE KIRALY, MD; KAREN GUNNING, PharmD, BCPS; and JENNIFER LEISER, MD, University of Utah School of Medicine, Salt Lake City, Utah Family physicians commonly care for patients with serious mental illness. Patients with psychotic and bipolar disorders have more comorbid medical conditions and higher mortality rates than patients without serious mental illness. Many medications prescribed for serious mental illness have significant metabolic and cardiovascular adverse effects. Patients treated with second-generation antipsychotics should receive preventive counseling and treatment for obesity, hyperglycemia, diabetes, and hyperlipidemia. First- and second-generation antipsychotics have been associated with QT prolongation. Many common medications can interact with antipsychotics, increasing the risk of cardiac arrhythmias and sudden death. Drug interactions can also lead to increased adverse effects, increased or decreased drug levels, toxicity, or treatment failure. Physicians should carefully consider the risks and benefits of second-generation antipsychotic medications, and patient care should be coordinated between primary care physicians and mental health professionals to prevent serious adverse effects. (Am Fam Physician. 2008;78(3):355-362, 363-364. Copyright © 2008 American Academy of Family Physicians.) T See related editorial erious mental illness (i.e., schizo- cancer screening, tobacco-use counseling, on page 314. phrenia, nonaffective psychotic dis- and immunizations.6 Patients with mental T Patient information: orders, bipolar spectrum disorders, illnessarealsolesslikelytoreceiveappro- A handout on mental substance dependence, and suicidal- priate treatment for acute problems, such as illness, written by the Sity) affects 6 percent of adults in the United coronary revascularization procedures fol- authors of this article, is 1 9 provided on page 363. States. Patients with these disorders have a lowinganacutemyocardialinfarction. higher risk of mortality associated with clini- A study that surveyed family physicians caldiseaseandunnaturalcauses(e.g.,suicide, about patients with common complaints homicide, accidents).2,3 Common medical (severeheadacheorabdominalpain)and conditions in patients with serious mental comorbid mental illness showed that physi- illness include metabolic disorders, cardio- cians underestimate the pretest probability vascular disease, chronic pulmonary disease, of disease and, consequently, obtain fewer gastrointestinal disorders, and obesity.4,5 appropriate tests.10 Patients with mental ill- Historically, efforts to improve the health ness who have been diagnosed with diabe- of patients with mental illness focused solely tes and hyperlipidemia are only 29 percent on pharmacologic treatment. However, as likely to be prescribed a statin medica- recenteffortshavealsoincludedmedical tion as patients without mental health prob- comorbidities and quality of medical care.6,7 lems.11 Patients with mental illness report poor coordination of care between primary Causes of Poor Health care physicians and mental health profes- Several factors contribute to poor health sionals.12 Lifestyle and behavioral factors and increased mortality in patients with also contribute to increased comorbidities seriousmentalillness.Thesepatientsmay in these patients. Patients with schizophre- have decreased access to health insurance niainparticularhavepoorerdietaryhabits, and medical care and may delay seeking smoke more, and exercise less than the gen- care because of cost.8 One study showed eral population.13,14 that persons with mental illness were less Medication adverse effects and interac- likely to receive preventive care, including tions contribute to medical comorbidities. Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2008 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Mental Illness in Primary Care SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Patients using second-generation antipsychotics should receive counseling C24 to prevent obesity, hyperlipidemia, and diabetes.* When possible, primary care physicians should avoid prescribing drugs that C19, 33-35 interact with psychiatric medications in patients with serious mental illness. To avoid medication-related adverse outcomes, primary care physicians C47 and mental health professionals should coordinate the care of patients with serious mental illness. *—Recommendation from consensus guidelines of the American Diabetes Association, American Psychiatric Associ- ation, American Association of Clinical Endocrinologists, and North American Association for the Study of Obesity. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see http://www.aafp.org/afpsort.xml. Primary care physicians and mental health glucoseintolerance,diabetes,andhyper- professionalsmaynotbeawareofeach lipidemia. Both antipsychotic classes are medicationthesepatientshavebeenpre- associated with cardiovascular adverse scribed, increasing the risk of interactions. effects, particularly QT prolongation. Many common psychiatric medications (Table 1) cause serious adverse effects. First- OBESITY AND WEIGHT GAIN generation antipsychotics cause extrapy- Obesity associated with serious mental ill- ramidal adverse effects, including tardive ness is multifactorial.5 Medication effects, dyskinesia, whereas second-generation poor nutrition, difficulty with meal plan- antipsychotics may cause metabolic adverse ning,poorimpulsecontrol,andlackof effects, including weight gain, obesity, exercise contribute to weight gain.15 Second- generation antipsychotics can cause rapid weight gain in the first few months of therapy 16-19 Table 1. Common Antipsychotic Medications (Table 2 ), anditcantakeuptooneyear forbodyweighttostabilize.Averageweight First-generation antipsychotics* Thiothixene (Navane) gainvariesfrom1lb,2oz(0.5kg)to11lb Chlorpromazine (Thorazine†) Trifluoperazine (Stelazine†) (5.0kg)withinthefirst10weeksoftherapy. The mechanism of antipsychotic-induced Fluphenazine (Prolixin†) Second-generation Haloperidol (Haldol) antipsychotics‡ weight gain is unknown. Loxapine (Loxitane) Aripiprazole (Abilify) DIABETES Mesoridazine (Serentil); this medication has Clozapine (Clozaril) been discontinued in the United States Olanzapine (Zyprexa) Before the availability of antipsychotic medi- Molindone (Moban) Paliperidone (Invega) cations, the prevalence of diabetes in patients Perphenazine (Trilafon†) Quetiapine (Seroquel) with schizophrenia was estimated at 2.5 to 20 Pimozide (Orap) Risperidone (Risperdal) 4.2 percent. Arecentcross-sectionalstudy Prochlorperazine (Compro) Ziprasidone (Geodon) of patients in Holland with schizophrenia Thioridazine (Mellaril†) and schizoaffective disorder, showed that theprevalenceofhyperglycemiaanddiabe- *—Also called typical antipsychotics; associated with an increased incidence of extra- tes are 7.0 and 14.5 percent, respectively.21 pyramidal symptoms and increased cognitive impairment. †—Brand no longer available in the United States. The increased risk of type 2 diabetes ‡—Also called atypical antipsychotics; associated with a decreased incidence of extra- in patients with schizophrenia or bipolar pyramidal symptoms. disorder is associated with the increased use of second-generation antipsychotics.22,23 356 American Family Physician www.aafp.org/afp Volume 78, Number 3 V August 1, 2008 Mental Illness in Primary Care Although the exact mechanism for hyper- glycemiaisunknown,itmaybecausedby Table 2. Selected Antipsychotics Associated drug-induced insulin resistance from associ- with Weight Gain ated weight gain, changes in body fat distri- bution, or direct effects on insulin-sensitive Medication Effect on weight gain 24 target tissues. First-generation Weight gain is generally less than with second- New-onset diabetes, worsening of known antipsychotics generation antipsychotics, but the effects are diabetes, and hyperglycemic crises have widely variable been reported after the initiation of second- Second-generation antipsychotics* generation antipsychotics. The U.S. Food and Aripiprazole (Abilify) Similar to placebo16 Drug Administration requires that labels for Clozapine (Clozaril) Average weight gain at 10 weeks: all second-generation antipsychotics include 9 lb, 13 oz (4.45 kg)17,18 warnings about the risk of hyperglycemia and Olanzapine (Zyprexa) Average weight gain at 10 weeks: 17,18 diabetes. Clozapine (Clozaril) and olanzapine 9 lb, 2 oz (4.15 kg) (Zyprexa) are associated with the greatest risk. Quetiapine (Seroquel) Weight gain ranges from minimal to a mean gain of 5 lb, 8 oz (2.49 kg) at six weeks17 Clinical trials of ziprasidone (Geodon) and Risperidone (Risperdal) Average weight gain at 10 weeks: aripiprazole (Abilify) lasting up to one year 4 lb, 10 oz (2.10 kg)17,18 demonstratedratesofweightgainandmeta- Ziprasidone (Geodon) Average weight gain at 10 weeks: 25 bolic changes similar to that of placebo. 1 oz (0.04 kg)18 HYPERLIPIDEMIA *—Combining second-generation antipsychotics with mood stabilizers, particularly 19 Second-generation

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