Severely mentally ill at high risk for cardiovascular disease

A psychiatrist at Washington University School of Medicine in St. Louis writes in the Journal of the American Medical Association (JAMA) that although mortality from cardiovascular disease has declined in the United States over the past several decades, patients with severe psychiatric illness are not enjoying the benefits of that progress.

In a commentary article in the Oct. 17 issue of JAMA, John W. Newcomer, M.D., professor of psychiatry, of psychology and of medicine and medical director of the Center for Clinical Studies at Washington University, reports that those with illnesses such as schizophrenia, bipolar disorder and major depression lose 25 to 30 years of life expectancy compared to the general population. And although suicide does claim the lives of many psychiatric patients, most of those premature deaths are due to cardiovascular disease.

"This is really a double hit," Newcomer says. "Not only are these patients dealing with the serious burden that accompanies their psychiatric disorder, but they also have an increased risk and an increased burden from major medical conditions like diabetes, heart disease and stroke. Ultimately, it is the unrecognized risk factors and the under-diagnosed and under-treated conditions that significantly shorten the lifespan."

Newcomer says several factors conspire to elevate risk including reduced access to appropriate medical care. Major mental disorders significantly impair a person's ability to work and learn, so patients tend to have lower incomes and poorer dietary habits, often relying instead on fast food. In addition, patients with serious psychiatric illness are much more likely to smoke — between 50 percent and 80 percent smoke cigarettes — and although the severely mentally ill make up only between 5 percent and 10 percent of the population, they consume a disproportionate amount of all cigarettes smoked in the United States. Many psychiatric medications also tend to contribute to weight gain, in part by making people less active and sometimes by stimulating appetite, and weight gain can be a prominent side effect of some antipsychotic drugs in particular.

"All of this adds up," Newcomer says. "They are more likely to eat more high-fat food and to burn fewer calories, so it's not surprising that this population also tends to have higher rates of overweight and obesity."

But that's not the whole story. Newcomer also reports that patients with severe mental illness are significantly less likely to receive therapies of proven benefit for problems with cholesterol, diabetes, hypertension or heart disease. Those who have survived a heart attack are less likely to receive appropriate medications, cardiac catheterization procedures or bypass surgery than heart-attack patients without mental illness.

Regarding preventive care, Newcomer cites data from a national study of 1,500 patients with chronic schizophrenia. They participated in the National Institute of Mental Health-funded Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study. The CATIE study found that 88 percent of patients entering the study with high cholesterol did not take lipid-lowering drugs. Another 30 percent with diabetes at the start of the study received no anti-diabetes medications, and 62 percent of those with high blood pressure were not taking any antihypertensive medication.

Those with severe psychiatric illness also are less likely to be screened for high cholesterol, high blood pressure or diabetes despite the evidence of increased risk in general and specific evidence that some antipsychotic drugs can have adverse effects on body weight, glucose metabolism and lipid levels.

A solution, Newcomer argues, will emerge only if psychiatrists and primary-care providers can work together.

"This requires coordination," he says. "And coordination between psychiatric professionals and primary-care providers is not easy when they often are physically located in different places. There are transportation issues and scheduling issues. For healthy people, the need to make an extra appointment lowers the probability that it will actually happen, and research further indicates that when patients with severe mental disorders have to go across the hall, it reduces the probability they will get care. If they have to cross the street, the probability gets even lower. If it's across town … well, without case managers and others working closely with these patients, in general those follow-ups won't happen."

Newcomer says another problem is that lifestyle interventions that encourage healthy eating, smoking cessation and exercise can be difficult enough in the general population, but they are even more difficult when patients with schizophrenia or other mental disorders are involved. He says such behavioral interventions have been shown to work even in those with severe psychiatric illness, but achieving success requires extra commitment and resources from the health-care community.

Getting psychiatrists to change their routine is important. Newcomer says that to lower risk of cardiovascular complications, psychiatrists may need to regularly weigh their patients, take blood pressure and screen appropriately for blood glucose, cholesterol and triglycerides.

"We're not saying psychiatrists should start prescribing lipid-lowering agents or diabetes drugs, but they are on the 'front lines,' seeing psychiatric patients much more than primary-care providers," Newcomer says. "It's important that psychiatrists begin to employ some of these basic screening techniques."

He also says that it's vital that patients with severe mental disorders receive needed psychiatric medications, even though some of those drugs may contribute to weight gain, abnormal lipid levels and risk for cardiovascular disease and diabetes.

"If you have a serious psychiatric condition like schizophrenia, you really need to take medication," Newcomer says. "Clearly we don't want people to stop taking their medicine, but in some cases, there may be alternative drugs that have fewer effects on risk for obesity or diabetes. Combinations of diet, exercise and selected medication are being studied to lower these risks without losing the benefits that antipsychotic drugs provide for these patients with severe psychiatric illness."

And Newcomer believes if such strategies can be developed and implemented, it is possible to quickly lower rates of cardiovascular disease and increase life expectancy in this population.

"I think there's some 'low-hanging fruit' here," he says. "Just getting psychiatrists engaged in this type of general health monitoring should help. Most of these patients already are seeing a physician, and if that physician and medical team can screen for cardiovascular risk factors, we may be able to intervene and find ways to lower that risk significantly."