Metabolic Effects of Antipsychotic Treatment: Between a Rock and a Hard Place?

It often feels as though medicine is practised "between a rock and a hard place." As physicians, we make difficult treatment decisions that can profoundly affect the lives of our patients. This is particularly true with the present generation of antipsychotic medications, where we have to deal with the paradox that some of our best medications are associated with the greatest metabolic side effects (1). With our patients and their families, we face the dilemma of seeing improvement in psychotic symptoms accompanied by significant weight gain, lipid disturbance, and occasionally, emergent diabetes. We appreciate that our primary goal is to treat psychiatric illness, but do we need to accept these side effects as inevitable and unavoidable? How do we understand and how do we manage metabolic risk when we treat psychosis? Are we truly keeping in mind the long-term interests of our patients?

We have learned that patients with schizophrenia and other forms of severe mental illness have high rates of medical comorbidity (2) and that their life expectancy is shortened, primarily as a consequence of increased coronary heart disease mortality (3). There are barriers to accessing medical care related both to psychiatric illness (for example, self-neglect and difficulty in communicating symptoms) and to the health care system ( for example, lack of integrated mental and physical health care). This has been aptly described as "duel neglect by patients and the system" (4, p 1). Psychiatrists are physicians first. What is our responsibility here? How far should we extend our scope of practice? In this issue of The Canadian Journal of Psychiatry, 3 review papers offer an overview of our present state of knowledge in this area, with the ambitious goal of informing and shaping clinical practice.

In the first paper, John Newcomer and Dan Haupt from the Washington University School of Medicine review the metabolic effects of antipsychotic treatment (5). John Newcomer is chair of the American Psychiatric Association Work Group on Antipsychotics and Metabolic Risk charged with the responsibility ol conducting an extensive review of this topic. Both John and Dan have made seminal contributions to the field.

In the second review, Michael Sernyak and I provide an overview of metabolic monitoring for patients treated with antipsychotic medications (6). We first establish goals for effective metabolic monitoring and then review the various published international antipsychotic monitoring guidelines. Michael Sernyak, from Yale University, is chief of psychiatry, VA Connecticut Healthcare System. In addition to authoring publications on diabetes prevalence that use the extensive Veterans Affairs database, he has broad experience in dealing with the real-life challenges of mental health systems.

In the final review, Guy Faulkner, from the University of Toronto, and I examine evidence for both pharmacologie and nonpharmacologic strategies for treating weight gain and associated metabolic disturbance in antipsychotic-treated patients (7). We were fortunate to have Guy recently join our research group at the University of Toronto. He was previously based in the United Kingdom, and he brings the expertise of health psychology to the challenge of designing interventions to control weight gain and metabolic disturbance in schizophrenia. He was the lead author in a recently submitted Cochrane Review on this topic (8).

We hope that this series of review papers will be pertinent both to Canadian psychiatrists and to their colleagues in other countries. However, there are several points specific to the practice of psychiatry in Canada that should be highlighted. First, certain antipsychotic drugs-namely, ziprasidone, aripiprazole, and amisulpride-that have a more metabolically neutral side effect profile are currently unavailable in Canada. Consequently, our options in terms of antipsychotic choice and antipsychotic switching are limited, and our patients, I believe, are consequently disadvantaged. Second, and on a more optimistic note, our socialized, universalaccess health care system and our national philosophy of inclusiveness should facilitate access to physical health care for psychiatric patients. In this regard, we in Canada are challenged to become leaders in integrating medical and mental health care.

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References

1. Green AI, Patel JK, Goisman RM, Allison DB, Blackburn G. Weight gain from novel antipsychotic drugs: need for action. Gen Hosp Psychiatry 2000;22:224 35.

2. Goldman LS. Medical illness in patients with schizophrenia. J Clin Psychiatry 1999;60(Suppl 21):10-5.

3. Osby U, Correia N, Brandt L, Ekbom A, Sparen P. Mortality and causes of death in schizophrenia in Stockholm county, Sweden. Schizophr Res 2000;45(1-2):21-8.

4. Meyer J, Nasrallah H. Issues surrounding medical care for individuals with schizophrenia. In: Meyer J, Nasrallah H, editors. Medical illness and schizophrenia. Washington (DC): Amercian Psychiatric Press; 2003. p 1-13.

5. Newcomer JW, Haupt DW. The metabolic effects of antipsychotic medications. Can J Psychiatry 2006;51:480-91).

6. Cohn TA, Sernyak M. Metabolic monitoring for patients treated with antipsychotic medications. Can J Psychiatry 2006;51:492-501).

7. Faulkner G, Cohn TA. Pharmacologic and nonpharmacologic strategies for weight gain and metabolic disturbances in patients treated with antipsychotic medications. Can J Psychiatry 2006;51:502-11).

8. Faulkner G, Cohn TA, Remington G, Interventions for weight gain in schizophrenia. Protocol for a Cochrane Review. In: The Cochrane Library. Oxford (UK): Update Software. 2005.

[Author Affiliation]

Tony A Cohn, MB, ChB, MSc, FRCPC1

[Author Affiliation]

1 Staff Psychiatrist, Centre for Addiction and Mental Health, Toronto, Ontario; Lecturer, Department of Psychiatry, University of Toronto, Toronto, Ontario.