C Mangurian, F Giwa, M Shumway, E Fuentes-Afflick, E Perez-Stable, J Dilley, D Schillinger
People with severe mental illness die, on average, 25 years earlier than the general population, often from cardiovascular disease (1,2). Multiple risk factors contribute to this early mortality, including smoking, substance abuse, and poor access to care (3). In addition, some second-generation antipsychotic medications, commonly prescribed for people with severe mental illness, can lead to metabolic complications (including obesity, insulin resistance, and dyslipidemia) that increase the risk of cardiovascular disease (4,5).
Cardiovascular risk factors are more likely to be underdiagnosed and undertreated among individuals with severe mental illness compared with the general population (6). To reduce this premature mortality, the American Psychiatric Association (APA), the American Diabetes Association (ADA), and other medical professionals published metabolic monitoring guidelines in 2004 for people taking second-generation antipsychotic medications (7). These guidelines recommend baseline metabolic screening before initiation of medications, specifically, body mass index (BMI), waist circumference, blood pressure, fasting blood glucose, and fasting lipids (7). Continued metabolic monitoring is also recommended, specifically BMI (every three months), waist circumference (annually), blood pressure (annually), fasting blood glucose (annually), and fasting lipids (every five years, or more frequently if clinically indicated) (7). Despite these guidelines and psychiatrists’ acknowledgment that monitoring is important, studies continue to show low monitoring rates (8–11). For example, among Medicaid beneficiaries prescribed second-generation antipsychotic medications with a moderate to high risk of causing metabolic abnormalities, only 40% had received metabolic monitoring in the past year (9).
Primary care providers’ perspectives on the gap between metabolic monitoring guidelines and practice for this vulnerable population remain unexplored in the literature. This study examined primary care providers’ beliefs about the roles that primary care providers and psychiatrists should play in metabolic monitoring and treatment of metabolic abnormalities among people with severe mental illness.
The purpose of this study was to evaluate attitudes of primary care providers toward barriers to metabolic monitoring and to characterize their beliefs about providers’ responsibility for monitoring and reducing cardiovascular risk for people with severe mental illness.
An anonymous survey was administered to 214 primary care providers working in 23 public community health clinics in San Francisco.
The response rate was 77% (164 of 214). Nearly 40% of primary care providers were unaware of consensus guidelines for metabolic monitoring of people who take second-generation antipsychotic medications. Responses showed variation in providers’ beliefs about who should monitor patients’ metabolic risk. The major barriers to metabolic monitoring were severity of psychiatric illness, difficulty collaborating with psychiatrists, and difficulty arranging psychiatric follow-up.
Primary care providers believed that better communication between primary care providers and psychiatrists would facilitate metabolic monitoring and promote better treatment for patients with severe mental illness who are taking antipsychotic medications.
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