Psychiatrists' role in CVD risk management growing

SAN FRANCISCO – Psychiatrists are likely to assume greater responsibility in managing cardiovascular disease risk factors among their patients with serious mental illness, according to Dr. Lydia A. Chwastiak, associate professor at the University of Washington in Seattle.

People with serious mental illness die an average of 8 years younger than the rest of the population, with most of these premature deaths tied to cardiovascular disease, she noted at the annual meeting of the American Psychiatric Association.

"We have to really think, as psychiatrists treating patients with high cardiovascular risk, should we be doing more and, if so, what should we be doing," she said. "There is an emerging group of psychiatrists and other physicians working in integrated care who have argued for an expanded role of prescribing for psychiatrists in managing disorders such as dyslipidemia."

When it comes to smoking in patients with schizophrenia, clinical practice guidelines recommend bupropion with or without nicotine replacement therapy to promote cessation.

A recent Cochrane review established that compared with placebo, bupropion increased the likelihood of cessation by threefold. The review found that varenicline increased the likelihood nearly fivefold in this population (Cochrane Database Syst. Rev. 2013;2:CD007253).

Neither drug elevated the rate of depression or positive or negative symptoms of schizophrenia, and bupropion did not elevate the rate of suicide. But varenicline possibly led to an increase in suicide intent, "so that is sort of a qualified recommendation that more research is needed and fortunately, there are ongoing trials," Dr. Chwastiak said.

Importantly, about one-third of the trials included in the review looked at smoking reduction as opposed to cessation. "What seems to be emerging is this more of a harm-reduction model, [a view] that heavier smoking confers more risk, and there is also emerging evidence that people who are able to reduce eventually are more likely to quit. So there is support for interventions that even reduce the amount of smoking," she said.

Overall, research has suggested nicotine replacement therapy alone might prove effective. Research also supports a contingency reinforcement approach, in which patients are paid to quit and abstain thereafter.

When it comes to managing dyslipidemia, reassuringly, patients with serious mental illness have a beneficial lipid response to statins similar to that of patients in the general population (Ann. Clin. Psychiatry 2013;25:141-8).

"Given that the statins appear to be as effective among people with schizophrenia, we need to think about the issues around prescribing statins," Dr. Chwastiak advised. Specifically, physicians must sort through the cytochrome P450 interactions of the various agents and choose ones that are less likely to interact with psychiatric medications.

"When we think about pharmacologic interventions [to manage cardiovascular risk factors], probably the best evidence we have really is for switching the antipsychotic medications that we are prescribing," she said.

As shown in the Comparison of Antipsychotics for Metabolic Problems trial among patients with schizophrenia or schizoaffective disorder who had adverse metabolic profiles from their medications, switching from the existing medication – olanzapine, quetiapine, or risperidone – to aripiprazole improved lipid profiles and promoted weight loss at 24 weeks (Am. J. Psychiatry 2011;168:947-56).

Importantly, switching did not increase the risk of psychiatric decompensation; however, the patients in the trial had rigorous clinical follow-up, and some did stop their treatment.

"The take-home message is that these were patients who were very closely monitored, so when medications are switched, there is a need to really monitor people both in terms of psychiatric symptoms as well as metabolic parameters," said Dr. Chwastiak, who disclosed no conflicts of interest related to her presentation.

Unfortunately, studies thus far have not found switching to improve glycemic control, although the resultant modest weight loss seen after switching can improve that outcome (as well as blood pressure control).

The only agent proven effective here is metformin, which attenuated the rise in hemoglobin A_1c levels among patients taking clozapine long term (Schizophr. Res. 2009;113:19-26).

"There is a lot of work to be done on how to manage glycemic control," Dr. Chwastiak said. "And really, there are no interventions with demonstrated effectiveness targeting diabetes or hypertension in people with serious mental illness."

A recent systematic review found that adding aripiprazole to clozapine improved total cholesterol levels, and adding topiramate to olanzapine resulted in a smaller increase in low-density lipoprotein cholesterol levels in patients with serious mental illness (AHRQ publication 12-EHC063-EF, April 2013).

"One of the interesting conclusions from this systematic review was that behavioral interventions – the lifestyle modifications – don’t seem to be any better than usual care in reducing low-density lipoprotein," Dr. Chwastiak said.

But the relevant studies were small and likely underpowered. "I don’t want that to be discouraging, suggesting that we shouldn’t be thinking about lifestyle modifications," she said. "There’s definitely improvements in cardiovascular fitness and weight reduction that really confer a benefit in terms of cardiovascular mortality."

SAN FRANCISCO – Psychiatrists are likely to assume greater responsibility in managing cardiovascular disease risk factors among their patients with serious mental illness, according to Dr. Lydia A. Chwastiak, associate professor at the University of Washington in Seattle.

People with serious mental illness die an average of 8 years younger than the rest of the population, with most of these premature deaths tied to cardiovascular disease, she noted at the annual meeting of the American Psychiatric Association.

"We have to really think, as psychiatrists treating patients with high cardiovascular risk, should we be doing more and, if so, what should we be doing," she said. "There is an emerging group of psychiatrists and other physicians working in integrated care who have argued for an expanded role of prescribing for psychiatrists in managing disorders such as dyslipidemia."

When it comes to smoking in patients with schizophrenia, clinical practice guidelines recommend bupropion with or without nicotine replacement therapy to promote cessation.

A recent Cochrane review established that compared with placebo, bupropion increased the likelihood of cessation by threefold. The review found that varenicline increased the likelihood nearly fivefold in this population (Cochrane Database Syst. Rev. 2013;2:CD007253).

Neither drug elevated the rate of depression or positive or negative symptoms of schizophrenia, and bupropion did not elevate the rate of suicide. But varenicline possibly led to an increase in suicide intent, "so that is sort of a qualified recommendation that more research is needed and fortunately, there are ongoing trials," Dr. Chwastiak said.

Importantly, about one-third of the trials included in the review looked at smoking reduction as opposed to cessation. "What seems to be emerging is this more of a harm-reduction model, [a view] that heavier smoking confers more risk, and there is also emerging evidence that people who are able to reduce eventually are more likely to quit. So there is support for interventions that even reduce the amount of smoking," she said.

Overall, research has suggested nicotine replacement therapy alone might prove effective. Research also supports a contingency reinforcement approach, in which patients are paid to quit and abstain thereafter.

When it comes to managing dyslipidemia, reassuringly, patients with serious mental illness have a beneficial lipid response to statins similar to that of patients in the general population (Ann. Clin. Psychiatry 2013;25:141-8).

"Given that the statins appear to be as effective among people with schizophrenia, we need to think about the issues around prescribing statins," Dr. Chwastiak advised. Specifically, physicians must sort through the cytochrome P450 interactions of the various agents and choose ones that are less likely to interact with psychiatric medications.

"When we think about pharmacologic interventions [to manage cardiovascular risk factors], probably the best evidence we have really is for switching the antipsychotic medications that we are prescribing," she said.

As shown in the Comparison of Antipsychotics for Metabolic Problems trial among patients with schizophrenia or schizoaffective disorder who had adverse metabolic profiles from their medications, switching from the existing medication – olanzapine, quetiapine, or risperidone – to aripiprazole improved lipid profiles and promoted weight loss at 24 weeks (Am. J. Psychiatry 2011;168:947-56).

Importantly, switching did not increase the risk of psychiatric decompensation; however, the patients in the trial had rigorous clinical follow-up, and some did stop their treatment.

"The take-home message is that these were patients who were very closely monitored, so when medications are switched, there is a need to really monitor people both in terms of psychiatric symptoms as well as metabolic parameters," said Dr. Chwastiak, who disclosed no conflicts of interest related to her presentation.

Unfortunately, studies thus far have not found switching to improve glycemic control, although the resultant modest weight loss seen after switching can improve that outcome (as well as blood pressure control).

The only agent proven effective here is metformin, which attenuated the rise in hemoglobin A_1c levels among patients taking clozapine long term (Schizophr. Res. 2009;113:19-26).

"There is a lot of work to be done on how to manage glycemic control," Dr. Chwastiak said. "And really, there are no interventions with demonstrated effectiveness targeting diabetes or hypertension in people with serious mental illness."

A recent systematic review found that adding aripiprazole to clozapine improved total cholesterol levels, and adding topiramate to olanzapine resulted in a smaller increase in low-density lipoprotein cholesterol levels in patients with serious mental illness (AHRQ publication 12-EHC063-EF, April 2013).

"One of the interesting conclusions from this systematic review was that behavioral interventions – the lifestyle modifications – don’t seem to be any better than usual care in reducing low-density lipoprotein," Dr. Chwastiak said.

But the relevant studies were small and likely underpowered. "I don’t want that to be discouraging, suggesting that we shouldn’t be thinking about lifestyle modifications," she said. "There’s definitely improvements in cardiovascular fitness and weight reduction that really confer a benefit in terms of cardiovascular mortality."

SAN FRANCISCO – Psychiatrists are likely to assume greater responsibility in managing cardiovascular disease risk factors among their patients with serious mental illness, according to Dr. Lydia A. Chwastiak, associate professor at the University of Washington in Seattle.

People with serious mental illness die an average of 8 years younger than the rest of the population, with most of these premature deaths tied to cardiovascular disease, she noted at the annual meeting of the American Psychiatric Association.

"We have to really think, as psychiatrists treating patients with high cardiovascular risk, should we be doing more and, if so, what should we be doing," she said. "There is an emerging group of psychiatrists and other physicians working in integrated care who have argued for an expanded role of prescribing for psychiatrists in managing disorders such as dyslipidemia."

When it comes to smoking in patients with schizophrenia, clinical practice guidelines recommend bupropion with or without nicotine replacement therapy to promote cessation.

A recent Cochrane review established that compared with placebo, bupropion increased the likelihood of cessation by threefold. The review found that varenicline increased the likelihood nearly fivefold in this population (Cochrane Database Syst. Rev. 2013;2:CD007253).

Neither drug elevated the rate of depression or positive or negative symptoms of schizophrenia, and bupropion did not elevate the rate of suicide. But varenicline possibly led to an increase in suicide intent, "so that is sort of a qualified recommendation that more research is needed and fortunately, there are ongoing trials," Dr. Chwastiak said.

Importantly, about one-third of the trials included in the review looked at smoking reduction as opposed to cessation. "What seems to be emerging is this more of a harm-reduction model, [a view] that heavier smoking confers more risk, and there is also emerging evidence that people who are able to reduce eventually are more likely to quit. So there is support for interventions that even reduce the amount of smoking," she said.

Overall, research has suggested nicotine replacement therapy alone might prove effective. Research also supports a contingency reinforcement approach, in which patients are paid to quit and abstain thereafter.

When it comes to managing dyslipidemia, reassuringly, patients with serious mental illness have a beneficial lipid response to statins similar to that of patients in the general population (Ann. Clin. Psychiatry 2013;25:141-8).

"Given that the statins appear to be as effective among people with schizophrenia, we need to think about the issues around prescribing statins," Dr. Chwastiak advised. Specifically, physicians must sort through the cytochrome P450 interactions of the various agents and choose ones that are less likely to interact with psychiatric medications.

"When we think about pharmacologic interventions [to manage cardiovascular risk factors], probably the best evidence we have really is for switching the antipsychotic medications that we are prescribing," she said.

As shown in the Comparison of Antipsychotics for Metabolic Problems trial among patients with schizophrenia or schizoaffective disorder who had adverse metabolic profiles from their medications, switching from the existing medication – olanzapine, quetiapine, or risperidone – to aripiprazole improved lipid profiles and promoted weight loss at 24 weeks (Am. J. Psychiatry 2011;168:947-56).

Importantly, switching did not increase the risk of psychiatric decompensation; however, the patients in the trial had rigorous clinical follow-up, and some did stop their treatment.

"The take-home message is that these were patients who were very closely monitored, so when medications are switched, there is a need to really monitor people both in terms of psychiatric symptoms as well as metabolic parameters," said Dr. Chwastiak, who disclosed no conflicts of interest related to her presentation.

Unfortunately, studies thus far have not found switching to improve glycemic control, although the resultant modest weight loss seen after switching can improve that outcome (as well as blood pressure control).

The only agent proven effective here is metformin, which attenuated the rise in hemoglobin A_1c levels among patients taking clozapine long term (Schizophr. Res. 2009;113:19-26).

"There is a lot of work to be done on how to manage glycemic control," Dr. Chwastiak said. "And really, there are no interventions with demonstrated effectiveness targeting diabetes or hypertension in people with serious mental illness."

A recent systematic review found that adding aripiprazole to clozapine improved total cholesterol levels, and adding topiramate to olanzapine resulted in a smaller increase in low-density lipoprotein cholesterol levels in patients with serious mental illness (AHRQ publication 12-EHC063-EF, April 2013).

"One of the interesting conclusions from this systematic review was that behavioral interventions – the lifestyle modifications – don’t seem to be any better than usual care in reducing low-density lipoprotein," Dr. Chwastiak said.

But the relevant studies were small and likely underpowered. "I don’t want that to be discouraging, suggesting that we shouldn’t be thinking about lifestyle modifications," she said. "There’s definitely improvements in cardiovascular fitness and weight reduction that really confer a benefit in terms of cardiovascular mortality."