- Email: [email protected]
Management of physical health in patients with schizophrenia: international insights
European Psychiatry 25 (2010) S37-S40
Management of physical health in patients with schizophrenia: international insights I.B. Chaudhry a,*, J. Jordan b, F.-R. Cousin c, R. Cavallaro d, J.M. Mostaza e a
Lancashire Care NHS Trust Early Intervention Service, The Mount, Whalley Road, Accrington, BB5 5DE, United-Kingdom b Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany c Chi Poissy Saint Germain En Laye, 20 rue Armagis, 78105 St Germain en Laye cedex d Clinica Psichiatrica Università di Milano, Ospedale San Raffaele, Via Stamira D’Ancona, 20 e Unidad de Arteriosclerosis, Hospital Carlos III, Sinesio Delgado, 10, 28029 Madrid, Spain
Abstract This international meeting discussed the management of physical health in patients with schizophrenia in several countries including France, Spain, Germany, the UK and Italy. Physical health parameters, including weight, blood pressure, blood glucose, lipids and standard biochemical assessments are measured in many patients at the first hospital consultation. These reveal physical disorders such as obesity, hypertension, dyslipidaemia, the metabolic syndrome, substance abuse, cardiovascular disease, extrapyramidal symptoms, sexual dysfunction and diabetes in substantial proportions of patients. Psychiatrists consider switching antipsychotic therapy if excessive sedation, extrapyramidal symptoms, unacceptable weight gain, hyperglycaemia or dyslipidaemia occur. In general, switching is more likely to be considered for symptomatic adverse events than for laboratory abnormalities. Switching is discouraged by limited knowledge of protocols, the absence of guidelines and fears of relapse or reduced treatment adherence. The physical health of patients with schizophrenia receives much less attention in the community setting than in the hospital setting. Improved guidelines, protocols, resources and support are needed to improve the physical health of patients in the community. Keywords: Schizophrenia; Physical health; Monitoring; Weight gain; Metabolic abnormalities; Antipsychotic therapy; Cardiovascular disease.
1. Introduction During this meeting the participants divided into national groups to discuss attitudes and beliefs concerning physical health care in patients with schizophrenia. This article provides a summary of the insights gained from these discussions across several European countries. 2. Status of physical health care 2.1.
France
In France, physical health receives more attention in hospital patients than in the community. Even in the hospital
Correspondence. Tel.: +44 (0)1254 226392. E-mail address: [email protected] © 2010 Elsevier Masson SAS. All rights reserved.
sector, some psychiatrists are reluctant to discuss or manage physical disorders. (Some French psychiatrists favour psychoanalytic techniques, and do not perform physical examinations). Also, some patients refuse to discuss their physical health or to undergo physical interventions. Generally in French hospital patients, physical assessments are performed at the initial visit, but are repeated only if the first result is abnormal or the patient’s regimen or condition changes. The assessments most commonly done are: • height; • weight; • body mass index; • waist circumference (WC); • blood pressure; • sexual dysfunction; • EPS; • signs of drug dependency; • plasma/blood glucose (usually casual; fasting less commonly);
S38
I.B. Chaudhry et al. / European Psychiatry 25 (2010) S37-S40
• plasma lipid profile; • prolactin (if there are signs of hyperprolactinaemia); • routine urine/biochemistry. The metabolic adverse effects of atypical antipsychotics are generally recognised. Initially, psychiatrists try to resolve these problems with lifestyle interventions, but consider switching antipsychotic medication in patients who develop rapid weight gain, particularly if they complain. Switching is discouraged by limited knowledge of protocols, the absence of guidelines and fears of relapse or reduced treatment adherence. Psychiatrists also consider switching therapy in patients who develop unacceptable sedation, EPS, sexual dysfunction, symptoms of hyperprolactinaemia, or metabolic abnormalities such as elevated glucose or lipids. In this situation some psychiatrists prefer to obtain specialist advice. In the community, assessment and management of physical health is inconsistent, partly because many patients with schizophrenia have no access to primary care. In community patients, the absence of family support is considered a barrier to switching and to adherence to treatment recommendations. 2.2.
Italy
The physical health problems most commonly seen in patients with schizophrenia are weight gain, metabolic syndrome, substance abuse, cardiovascular disease, EPS, sexual dysfunction, diabetes, and pulmonary disease. The disorders considered to have most impact on the patient’s well-being are weight gain, hypertension, and substance abuse. As in France, physical health receives more attention in hospital patients than in out-patients. The assessments most commonly done are: • height; • weight; • blood pressure; • sexual dysfunction; • EPS; • signs of drug dependency; • plasma/blood glucose (usually fasting); • plasma lipid profile in some centres; • prolactin; • routine urine/biochemistry. Responsibility for these assessments is shared between physicians and nurses. BMI and WC are not routinely obtained. In some centres a lack of resources is a barrier to laboratory assessments. Psychiatrists in Italy consider switching antipsychotic therapy in patients who develop weight gain. Some centres set a threshold of 5% increase in weight compared with baseline. Psychiatrists who consider switching use their clinical judgement, and refer to AHA/ APA Guidelines [2]. Switching is also considered in cases of unacceptable sedation, EPS, sexual dysfunction, hyperprolactinaemia, elevated glucose or lipids, or severe hepatic
dysfunction. Fears of relapse or reduced treatment adherence discourage switching. These fears may be more difficult to overcome in patients with laboratory abnormalities (e.g. dyslipidaemia) because these do not affect the patient’s immediate sense of well-being. 2.3.
Germany
Physical and laboratory examinations are performed routinely in hospital patients at first evaluation and at follow-up. These generally include: • height; • weight; • BMI; • BP; • plasma/blood glucose (casual and fasting); • plasma lipid profile; • prolactin. These evaluations are done in approximately 20-50% of patients in the community setting, in which limitations on financial and staff resources discourage more frequent assessment. WC is not recorded routinely in hospitals or the community. German psychiatrists consult their medical colleagues as appropriate. The thresholds at which they will consider switching antipsychotic therapy include: • weight gain > 3−5 kg over 4 weeks compared with baseline; • BMI > 30 kg/m2; • BP >150/90 mmHg; • fasting plasma glucose > 5.5-6.0 mmol/L; • random plasma glucose > 7.0-8.0 mmol/L; • QT interval > 480-550 ms. The risks of relapse or reduced treatment adherence are perceived as the main dangers of switching. Also, beliefs about differential efficacy advantages of certain agents associated with increased weight and metabolic risks discourage some clinicians from initiating patients on or switching patients to lower risk antipsychotics that have shown similar efficacy in clinical trials. 2.4.
Spain
There is strong interest in the physical health of patients with schizophrenia, but assessment and intervention are limited by time and resources. The physical disorders recognised in this population include weight gain, dyslipidaemia, hyperglycaemia, diabetes, hypertension, cardiovascular disease, sexual dysfunction, hyperprolactinaemia, osteoporosis, infections, liver disease, malnutrition, respiratory disease and an increased risk of various cancers. Those considered to have most impact on the patient’s well-being are weight gain, EPS, sedation and sexual dysfunction. Physical assessments are performed more often in hospital patients than in
I.B. Chaudhry et al. / European Psychiatry 25 (2010) S37-S40
out-patients. The most common are: • height; • weight; • blood pressure; • plasma/blood glucose (usually fasting); • plasma lipid profile; • prolactin (if the patient has symptoms); • routine urine/biochemistry; • sexual functioning. Responsibility for these assessments is shared between physicians and nurses. In some cases laboratory assessments are not obtained because their importance is not appreciated, or the patient refuses to allow blood sampling. WC is not recorded because its importance is not understood. In Spain, antipsychotic efficacy is the main consideration in the selection of initial therapy. If adverse physical events occur, psychiatrists consider switching to a better tolerated agent according to clinical judgement and national or hospital guidelines. As these adverse events tend to appear during chronic therapy, continued relief of cognitive and negative symptoms is considered very important during switching. 2.5.
United Kingdom
Physical and laboratory examinations are not performed in every patient, but are coming into use more frequently. The assessments obtained most commonly are: • height; • weight; • BMI; • BP; • sedation; • EPS; • signs/symptoms of drug abuse; • lifestyle; • family history; • plasma/blood glucose (generally random, but fasting values may be obtained if there are specific concerns); • plasma lipid profile; • prolactin if there are symptoms possibly related to prolactin; • routine biochemistry; • hepatic and thyroid function; • ECG in selected patients. In the UK, it is recognised that management of physical health requires support from the medical team, dieticians, occupational therapists, and community nurses. The adverse effects of antipsychotic drugs are receiving greater attention and psychiatrists prefer to initiate therapy with an agent that has few physical adverse effects. Switching antipsychotic therapy is considered if problems such as weight gain, metabolic syndrome, EPS, prolactin elevation or poor control of symptoms occur. Overt problems such as EPS are more likely to provoke switching than asymptomatic ones such
S39
as dyslipidaemia. When switching, psychiatrists may refer to AHA/APA Guidelines [2], the ATPIII definition of the metabolic syndrome [1] or local hospital protocols, and may take advice from the laboratory. (This meeting took place before the UK recommendations on minimising metabolic and cardiovascular risk in schizophrenia were published [3]. It was therefore not possible to ascertain their impact.) However some participants cited an absence of guidelines as an impediment to switching therapy. It appears that existing guidelines are being inadequately disseminated. In general, UK psychiatrists switch antipsychotic therapy only if lifestyle interventions (combined with dose reduction or add-on medication in some cases) do not resolve the problem. The risks of relapse, reduced adherence and new adverse effects are perceived as the main dangers of switching. There is also a concern that switching may increase management costs because increased follow-up is necessary during the crossover period. 3. Conclusions The physical health care of patients with schizophrenia has several features in common across Europe. In hospital patients, physical health receives substantial attention and many assessments are performed, although some simple and useful parameters, such as WC, are not obtained routinely. If adverse events occur during antipsychotic therapy, psychiatrists consider switching, although they usually try lifestyle interventions first. Overall, switching antipsychotic therapy is more likely to be considered for symptomatic adverse events (e.g. EPS or sedation) than for laboratory abnormalities (e.g. diabetes, hyperglycemia, dyslipideamia). This observation suggests that the dangers arising from metabolic disturbances are not fully appreciated, and need to be more fully explained to hospital clinicians. Moreover, the frequently cited concern about non-adherence as a result of a switch to a lower risk antipsychotic seems to disregard the risk of non-adherence due to the continued presence of side effects, such as weight gain, sedation and sexual dysfunction. Patients in the community receive significantly less physical health care than hospital patients, and are an urgent priority for improved monitoring and long-term management throughout Europe. In addition, clinicians may benefit from additional information about the best strategies to initiate and complete an antipsychotic switch, aiming to minimise the risk for relapse. Psychiatrists should take the initiative to ensure that antipsychotic-treated patients receive the comprehensive psychiatric as well as physical health care they need and deserve. This will demand close collaboration with primary care, community psychiatric services, patients and carers. Physical health management for individuals with severe mental illness demands a multidisciplinary approach involv-
S40
I.B. Chaudhry et al. / European Psychiatry 25 (2010) S37-S40
ing psychiatrists, psychiatric nurses, primary care clinicians, dieticians, internal medicine specialists, pharmacists, community health workers, patients and carers. Much is spoken about cross-boundary and partnership working. However this is difficult to achieve in any context. In particular, the area of physical health in SMI presents challenges that relate directly to training of health care professionals [5]. Any successful strategy must involve co-ordination and restructuring of often fragmented services [4] and a change in attitude so that 1) professionals in psychiatry take on board basic measures to help people with mental illness to a healthier life and 2) professionals in primary care and hospital services outwith psychiatry are less afraid of their patients with mental illness. 4. Conflicts of interest
R. Cavallaro: Other regular activities on behalf of a company (Consultancy Janssen Cilag); Clinical trials: as co-investigator or study contributor (Janssen Cilag, Akzo Nobel); Occasional involvements: expert reports (Bristol Meyers Squibb); Occasional involvements: advisory (Janssen Cilag, Bristol Meyers Squibb, Pfizer); Conferences: attendance as contributor (Janssen Cilag, Bristol Meyers Squibb, Pfizer). J.-M. Mostaza: Occasional involvements: advisory services (BMS); Conferences: attendance as contributor (BMS); Conferences: attendance as audience member (cost of travel and accommodation paid for by an organisation or company (BMS). References [1]
I. Chaudhry: Clinical trials: as co-investigator or study contributor (BMS, Lilly, Janssen, Astra Zeneca); Occasional involvements: expert reports (BMS, Lilly, Janssen, Astra Zeneca); Occasional involvements: advisory (BMS, Lilly, Janssen, Astra Zeneca); Conferences: attendance as contributor (BMS, Lilly, Janssen, Astra Zeneca); Conferences: attendance as audience member (cost of travel and accommodation paid for by an organisation or company (BMS, Lilly, Janssen, Astra Zeneca). J. Jordan: Clinical trials: as co-investigator or study contributor (Novartis); Occasional involvements: expert reports (Novartis, Sanofi, Abbott); Clinical trials: as main (head) clinical or laboratory investigator, or study coordinator (Novartis, Sanofi, Abbott, Bms). F.-R. Cousin has not transmitted his declaration of conflicts of interest.
[2]
[3]
[4] [5]
Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evalutaion, and treatment of high blood cholesterol in adults (adult treatment panel III). JAMA 2001;285:2486-97. American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004;27:596-601. Barnett AH, Mackin P, Chaudhry I, Farooqi A, Gadsby R, Heald A, et al. Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia. J Psychopharmacol 2007;21:357-73. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775-9. National Collaborating Centre for Mental Health. Core interventions in the treatment and management of schizophrenia in primary and secondary care (update). 2009. National Institute for Health and Clinical Excellence, London, UK. Last accessed 6 August 2009. http:// www.guideline.gov/summary/summary.aspx?doc_id=14313.
Management of physical health in patients with schizophrenia: international insights I.B. Chaudhry a,*, J. Jordan b, F.-R. Cousin c, R. Cavallaro d, J.M. Mostaza e a
Lancashire Care NHS Trust Early Intervention Service, The Mount, Whalley Road, Accrington, BB5 5DE, United-Kingdom b Medical School Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany c Chi Poissy Saint Germain En Laye, 20 rue Armagis, 78105 St Germain en Laye cedex d Clinica Psichiatrica Università di Milano, Ospedale San Raffaele, Via Stamira D’Ancona, 20 e Unidad de Arteriosclerosis, Hospital Carlos III, Sinesio Delgado, 10, 28029 Madrid, Spain
Abstract This international meeting discussed the management of physical health in patients with schizophrenia in several countries including France, Spain, Germany, the UK and Italy. Physical health parameters, including weight, blood pressure, blood glucose, lipids and standard biochemical assessments are measured in many patients at the first hospital consultation. These reveal physical disorders such as obesity, hypertension, dyslipidaemia, the metabolic syndrome, substance abuse, cardiovascular disease, extrapyramidal symptoms, sexual dysfunction and diabetes in substantial proportions of patients. Psychiatrists consider switching antipsychotic therapy if excessive sedation, extrapyramidal symptoms, unacceptable weight gain, hyperglycaemia or dyslipidaemia occur. In general, switching is more likely to be considered for symptomatic adverse events than for laboratory abnormalities. Switching is discouraged by limited knowledge of protocols, the absence of guidelines and fears of relapse or reduced treatment adherence. The physical health of patients with schizophrenia receives much less attention in the community setting than in the hospital setting. Improved guidelines, protocols, resources and support are needed to improve the physical health of patients in the community. Keywords: Schizophrenia; Physical health; Monitoring; Weight gain; Metabolic abnormalities; Antipsychotic therapy; Cardiovascular disease.
1. Introduction During this meeting the participants divided into national groups to discuss attitudes and beliefs concerning physical health care in patients with schizophrenia. This article provides a summary of the insights gained from these discussions across several European countries. 2. Status of physical health care 2.1.
France
In France, physical health receives more attention in hospital patients than in the community. Even in the hospital
Correspondence. Tel.: +44 (0)1254 226392. E-mail address: [email protected] © 2010 Elsevier Masson SAS. All rights reserved.
sector, some psychiatrists are reluctant to discuss or manage physical disorders. (Some French psychiatrists favour psychoanalytic techniques, and do not perform physical examinations). Also, some patients refuse to discuss their physical health or to undergo physical interventions. Generally in French hospital patients, physical assessments are performed at the initial visit, but are repeated only if the first result is abnormal or the patient’s regimen or condition changes. The assessments most commonly done are: • height; • weight; • body mass index; • waist circumference (WC); • blood pressure; • sexual dysfunction; • EPS; • signs of drug dependency; • plasma/blood glucose (usually casual; fasting less commonly);
S38
I.B. Chaudhry et al. / European Psychiatry 25 (2010) S37-S40
• plasma lipid profile; • prolactin (if there are signs of hyperprolactinaemia); • routine urine/biochemistry. The metabolic adverse effects of atypical antipsychotics are generally recognised. Initially, psychiatrists try to resolve these problems with lifestyle interventions, but consider switching antipsychotic medication in patients who develop rapid weight gain, particularly if they complain. Switching is discouraged by limited knowledge of protocols, the absence of guidelines and fears of relapse or reduced treatment adherence. Psychiatrists also consider switching therapy in patients who develop unacceptable sedation, EPS, sexual dysfunction, symptoms of hyperprolactinaemia, or metabolic abnormalities such as elevated glucose or lipids. In this situation some psychiatrists prefer to obtain specialist advice. In the community, assessment and management of physical health is inconsistent, partly because many patients with schizophrenia have no access to primary care. In community patients, the absence of family support is considered a barrier to switching and to adherence to treatment recommendations. 2.2.
Italy
The physical health problems most commonly seen in patients with schizophrenia are weight gain, metabolic syndrome, substance abuse, cardiovascular disease, EPS, sexual dysfunction, diabetes, and pulmonary disease. The disorders considered to have most impact on the patient’s well-being are weight gain, hypertension, and substance abuse. As in France, physical health receives more attention in hospital patients than in out-patients. The assessments most commonly done are: • height; • weight; • blood pressure; • sexual dysfunction; • EPS; • signs of drug dependency; • plasma/blood glucose (usually fasting); • plasma lipid profile in some centres; • prolactin; • routine urine/biochemistry. Responsibility for these assessments is shared between physicians and nurses. BMI and WC are not routinely obtained. In some centres a lack of resources is a barrier to laboratory assessments. Psychiatrists in Italy consider switching antipsychotic therapy in patients who develop weight gain. Some centres set a threshold of 5% increase in weight compared with baseline. Psychiatrists who consider switching use their clinical judgement, and refer to AHA/ APA Guidelines [2]. Switching is also considered in cases of unacceptable sedation, EPS, sexual dysfunction, hyperprolactinaemia, elevated glucose or lipids, or severe hepatic
dysfunction. Fears of relapse or reduced treatment adherence discourage switching. These fears may be more difficult to overcome in patients with laboratory abnormalities (e.g. dyslipidaemia) because these do not affect the patient’s immediate sense of well-being. 2.3.
Germany
Physical and laboratory examinations are performed routinely in hospital patients at first evaluation and at follow-up. These generally include: • height; • weight; • BMI; • BP; • plasma/blood glucose (casual and fasting); • plasma lipid profile; • prolactin. These evaluations are done in approximately 20-50% of patients in the community setting, in which limitations on financial and staff resources discourage more frequent assessment. WC is not recorded routinely in hospitals or the community. German psychiatrists consult their medical colleagues as appropriate. The thresholds at which they will consider switching antipsychotic therapy include: • weight gain > 3−5 kg over 4 weeks compared with baseline; • BMI > 30 kg/m2; • BP >150/90 mmHg; • fasting plasma glucose > 5.5-6.0 mmol/L; • random plasma glucose > 7.0-8.0 mmol/L; • QT interval > 480-550 ms. The risks of relapse or reduced treatment adherence are perceived as the main dangers of switching. Also, beliefs about differential efficacy advantages of certain agents associated with increased weight and metabolic risks discourage some clinicians from initiating patients on or switching patients to lower risk antipsychotics that have shown similar efficacy in clinical trials. 2.4.
Spain
There is strong interest in the physical health of patients with schizophrenia, but assessment and intervention are limited by time and resources. The physical disorders recognised in this population include weight gain, dyslipidaemia, hyperglycaemia, diabetes, hypertension, cardiovascular disease, sexual dysfunction, hyperprolactinaemia, osteoporosis, infections, liver disease, malnutrition, respiratory disease and an increased risk of various cancers. Those considered to have most impact on the patient’s well-being are weight gain, EPS, sedation and sexual dysfunction. Physical assessments are performed more often in hospital patients than in
I.B. Chaudhry et al. / European Psychiatry 25 (2010) S37-S40
out-patients. The most common are: • height; • weight; • blood pressure; • plasma/blood glucose (usually fasting); • plasma lipid profile; • prolactin (if the patient has symptoms); • routine urine/biochemistry; • sexual functioning. Responsibility for these assessments is shared between physicians and nurses. In some cases laboratory assessments are not obtained because their importance is not appreciated, or the patient refuses to allow blood sampling. WC is not recorded because its importance is not understood. In Spain, antipsychotic efficacy is the main consideration in the selection of initial therapy. If adverse physical events occur, psychiatrists consider switching to a better tolerated agent according to clinical judgement and national or hospital guidelines. As these adverse events tend to appear during chronic therapy, continued relief of cognitive and negative symptoms is considered very important during switching. 2.5.
United Kingdom
Physical and laboratory examinations are not performed in every patient, but are coming into use more frequently. The assessments obtained most commonly are: • height; • weight; • BMI; • BP; • sedation; • EPS; • signs/symptoms of drug abuse; • lifestyle; • family history; • plasma/blood glucose (generally random, but fasting values may be obtained if there are specific concerns); • plasma lipid profile; • prolactin if there are symptoms possibly related to prolactin; • routine biochemistry; • hepatic and thyroid function; • ECG in selected patients. In the UK, it is recognised that management of physical health requires support from the medical team, dieticians, occupational therapists, and community nurses. The adverse effects of antipsychotic drugs are receiving greater attention and psychiatrists prefer to initiate therapy with an agent that has few physical adverse effects. Switching antipsychotic therapy is considered if problems such as weight gain, metabolic syndrome, EPS, prolactin elevation or poor control of symptoms occur. Overt problems such as EPS are more likely to provoke switching than asymptomatic ones such
S39
as dyslipidaemia. When switching, psychiatrists may refer to AHA/APA Guidelines [2], the ATPIII definition of the metabolic syndrome [1] or local hospital protocols, and may take advice from the laboratory. (This meeting took place before the UK recommendations on minimising metabolic and cardiovascular risk in schizophrenia were published [3]. It was therefore not possible to ascertain their impact.) However some participants cited an absence of guidelines as an impediment to switching therapy. It appears that existing guidelines are being inadequately disseminated. In general, UK psychiatrists switch antipsychotic therapy only if lifestyle interventions (combined with dose reduction or add-on medication in some cases) do not resolve the problem. The risks of relapse, reduced adherence and new adverse effects are perceived as the main dangers of switching. There is also a concern that switching may increase management costs because increased follow-up is necessary during the crossover period. 3. Conclusions The physical health care of patients with schizophrenia has several features in common across Europe. In hospital patients, physical health receives substantial attention and many assessments are performed, although some simple and useful parameters, such as WC, are not obtained routinely. If adverse events occur during antipsychotic therapy, psychiatrists consider switching, although they usually try lifestyle interventions first. Overall, switching antipsychotic therapy is more likely to be considered for symptomatic adverse events (e.g. EPS or sedation) than for laboratory abnormalities (e.g. diabetes, hyperglycemia, dyslipideamia). This observation suggests that the dangers arising from metabolic disturbances are not fully appreciated, and need to be more fully explained to hospital clinicians. Moreover, the frequently cited concern about non-adherence as a result of a switch to a lower risk antipsychotic seems to disregard the risk of non-adherence due to the continued presence of side effects, such as weight gain, sedation and sexual dysfunction. Patients in the community receive significantly less physical health care than hospital patients, and are an urgent priority for improved monitoring and long-term management throughout Europe. In addition, clinicians may benefit from additional information about the best strategies to initiate and complete an antipsychotic switch, aiming to minimise the risk for relapse. Psychiatrists should take the initiative to ensure that antipsychotic-treated patients receive the comprehensive psychiatric as well as physical health care they need and deserve. This will demand close collaboration with primary care, community psychiatric services, patients and carers. Physical health management for individuals with severe mental illness demands a multidisciplinary approach involv-
S40
I.B. Chaudhry et al. / European Psychiatry 25 (2010) S37-S40
ing psychiatrists, psychiatric nurses, primary care clinicians, dieticians, internal medicine specialists, pharmacists, community health workers, patients and carers. Much is spoken about cross-boundary and partnership working. However this is difficult to achieve in any context. In particular, the area of physical health in SMI presents challenges that relate directly to training of health care professionals [5]. Any successful strategy must involve co-ordination and restructuring of often fragmented services [4] and a change in attitude so that 1) professionals in psychiatry take on board basic measures to help people with mental illness to a healthier life and 2) professionals in primary care and hospital services outwith psychiatry are less afraid of their patients with mental illness. 4. Conflicts of interest
R. Cavallaro: Other regular activities on behalf of a company (Consultancy Janssen Cilag); Clinical trials: as co-investigator or study contributor (Janssen Cilag, Akzo Nobel); Occasional involvements: expert reports (Bristol Meyers Squibb); Occasional involvements: advisory (Janssen Cilag, Bristol Meyers Squibb, Pfizer); Conferences: attendance as contributor (Janssen Cilag, Bristol Meyers Squibb, Pfizer). J.-M. Mostaza: Occasional involvements: advisory services (BMS); Conferences: attendance as contributor (BMS); Conferences: attendance as audience member (cost of travel and accommodation paid for by an organisation or company (BMS). References [1]
I. Chaudhry: Clinical trials: as co-investigator or study contributor (BMS, Lilly, Janssen, Astra Zeneca); Occasional involvements: expert reports (BMS, Lilly, Janssen, Astra Zeneca); Occasional involvements: advisory (BMS, Lilly, Janssen, Astra Zeneca); Conferences: attendance as contributor (BMS, Lilly, Janssen, Astra Zeneca); Conferences: attendance as audience member (cost of travel and accommodation paid for by an organisation or company (BMS, Lilly, Janssen, Astra Zeneca). J. Jordan: Clinical trials: as co-investigator or study contributor (Novartis); Occasional involvements: expert reports (Novartis, Sanofi, Abbott); Clinical trials: as main (head) clinical or laboratory investigator, or study coordinator (Novartis, Sanofi, Abbott, Bms). F.-R. Cousin has not transmitted his declaration of conflicts of interest.
[2]
[3]
[4] [5]
Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evalutaion, and treatment of high blood cholesterol in adults (adult treatment panel III). JAMA 2001;285:2486-97. American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004;27:596-601. Barnett AH, Mackin P, Chaudhry I, Farooqi A, Gadsby R, Heald A, et al. Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia. J Psychopharmacol 2007;21:357-73. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775-9. National Collaborating Centre for Mental Health. Core interventions in the treatment and management of schizophrenia in primary and secondary care (update). 2009. National Institute for Health and Clinical Excellence, London, UK. Last accessed 6 August 2009. http:// www.guideline.gov/summary/summary.aspx?doc_id=14313.