European Neuropsychopharmacology (v.18, #S2)

Physical health considerations in psychiatry: European views on recognition, monitoring and management by Andrea Fagiolini; Angel L. Montejo; Pierre Thomas; Helen Millar (iii).

While patients with schizophrenia are known to have an increased risk of physical health co-morbidity including coronary heart disease, diabetes, hypertension, stroke and emphysema, their physical wellbeing often goes unnoticed by health care professionals. In many cases the patient's only contact with the health service is through the mental health team. However, many psychiatrists consider their primary function to be the provision of clinical care in terms of symptom control and are reluctant to switch medication despite the presence of physical health issues. Nevertheless outcomes in schizophrenia may be improved by expanding the remit of the clinician to include assessments of both physical and mental health. Simple measurements such as waist circumference, weight, height, blood pressure and blood sampling would provide the psychiatrist with useful information that could be used to optimize treatment and improve overall quality of life for patients with schizophrenia.
Keywords: Diabetes; Metabolic syndrome; Atypical antipsychotics;

As well as the obvious medical consequences associated with physical health problems in individuals with schizophrenia, physical health problems lead to a number of psychosocial consequences — further contributing to the existing burden of schizophrenia itself. Weight gain can seriously impair quality of life through decreased functioning, social stigmatization, discrimination and potential financial consequences. However, patients with schizophrenia may be less capable of managing their weight via exercise and dietary interventions compared with the general population, and may, therefore, be more prone to non-compliance with a medication that induces weight gain. This may lead to exacerbation of the mental illness. Patients' perceptions and experience of antipsychotic treatments are also important as these can further impact on overall patient wellbeing. It is hoped that by increasing awareness of the psychosocial consequences of physical health impairment, we can move towards reducing the burden that patients face.
Keywords: Schizophrenia; Antipsychotics; Weight gain; Quality of life; Extrapyramidal symptoms; Sexual dysfunction;

Elevations in serum prolactin levels (hyperprolactinaemia) are a common side effect of conventional and some atypical antipsychotic treatments. In patients with schizophrenia, the adverse effects of antipsychotic-induced hyperprolactinaemia on physical health (e.g. fertility problems, sexual dysfunction and reduced bone mineral density) are gaining attention. Accumulating evidence shows consistent ‘prolactin-raising’ effects of conventional antipsychotics and risperidone compared with other current atypical antipsychotics, which are more likely to have ‘prolactin-sparing’ properties. Prolactin-sparing antipsychotics (for example, aripiprazole and quetiapine) tend to show lower frequencies of hyperprolactinaemia-associated side effects. In recent studies, aripiprazole-treated patients have demonstrated lower prolactin levels compared with patients receiving other prolactin-sparing antipsychotics. There is a lack of robust recommendations for monitoring prolactin elevation among patients receiving antipsychotics. Decreasing the antipsychotic dose or switching to a prolactin-sparing medication are possible management options for antipsychotic-induced hyperprolactinaemia. There is a need to increase awareness and understanding of the impact of antipsychotic-induced hyperprolactinaemia on physical health in schizophrenia.
Keywords: Hyperprolactinaemia; Antipsychotics; Schizophrenia; Physical health;

Hurdles that must be overcome in order to implement guidelines and maximize physical health in patients treated with antipsychotics include the impression that a disruption in physical health is an inevitable token for the patient to pay in order to achieve and maintain his or her mental health; lack of routine monitoring; lack of defined care pathways for evaluation, monitoring and treatment of physical health issues in psychiatry; the burden of guideline implementation on mental health team resources; the difficulty to perform certain procedures (e.g. monitoring of waist circumference); and reluctance to switch medications once physical health effects are recognized, especially if the psychiatric symptoms are under relatively good control. It is imperative that we act now to overcome these hurdles and maximize outcomes for our patients. Strategies include establishing simple, consistent processes for physical health monitoring and tracking in clinical practice; provision of appropriate equipment to staff; effective education of all personnel involved in the care of psychiatric patients regarding this important topic; and consideration of a medication switch in patients whose medication is a high-risk contributory factor to poor physical health.
Keywords: Atypical antipsychotics; Schizophrenia; Weight gain; Dyslipidaemia; Diabetes; Metabolic syndrome;