Success of antipsychotics shifts focus to overall health

As their symptoms become more manageable, people with schizophrenia and other severe mental illnesses are starting to seek primary care and preventive health care services.

By Stephanie Stapleton, amednews staff. Sept. 18, 2000.

With the advent of newer, more effective antipsychotic drugs, psychiatrists and primary care physicians are facing stepped-up challenges to provide better, more coordinated treatment to a population that historically has been cast outside the health care system's mainstream.

People with schizophrenia and other severe mental illnesses are emerging from the darkness of their disease. And as their symptoms become more manageable, increased emphasis is being placed on overall health.

Links

The medical problems that are experienced by these patients can be three to four times more than that of the general public. They have considerable co-morbidity, including hypertension, obesity, noninsulin-dependent diabetes, lipidemia, hepatitis B and C, and a whole range of addictive disorders.

Still, it's a population that faces significant barriers to health care. For example, a survey of county behavioral health directors conducted in response to the surgeon general's 1999 report on mental health found that nearly 40% of these professionals considered medical care for those living with mental illness to be substandard.

But change may be afoot.

"When you get the right kind of care and the right opportunities, you truly get a better quality of life," said Ralph Aquila, MD, director of residential community services at St. Luke's Roosevelt Hospital Center in New York City. "A big part of this is good primary care."

"Been through the mill"

A panel of experts assembled last month in New York for a workshop identified the frequent lack of coordination between psychiatrists and primary care physicians as one of the most significant barriers boxing these patients out. The workshop was sponsored by St. Luke's Roosevelt Hospital Center and Fountain House, a clubhouse model of psychiatric rehabilitation that focuses on the importance of complete care for people with mental illness.

People with severe mental illness often have to switch primary care physicians due to insurance, if they have it at all. And they predominantly go to public clinics, where they see a rotation of clinicians and trainees.

"These patients have been through the mill," Dr. Aquila said. In dealing with them, begin with the idea that they are beat up by the system, he added. They are hesitant about going to health care facilities. It is hard for them to put trust in their doctors because there is no longevity in that relationship. They are also threatened by the health care environment, the long waits, and the invasive nature of tests and exams.

Overall, he said, their experience "is a far cry from the Norman Rockwell picture of the family doctor that knows you from birth to grave."

The irony is that this scenario persists just as these patients have reached a point at which access and continuity of preventive health care is more important than ever.

"We now have people living long and doing much better," said Ronald Koshes, MD, assistant professor of psychiatry at Georgetown University. Health maintenance is a critical issue, agreed Donald Schiermer, MD, PhD, a primary care physician at St. Luke's Roosevelt Hospital Center and at Fountain House.

It takes more than the first visit to see progress, Dr. Schiermer said. "We have to get to know patients over time to be able to make successful interventions." Like with any patient, discussion about smoking cessation or diet doesn't start or end with advice. "It's an ongoing conversation."

And for this population, the need for ongoing care is increased because there is a need for clinicians to be on the lookout for certain possible side effects to antipsychotic drugs, including drug-induced arrhythmia. Patients also can develop hyperprolactinemia, which can reduce libido, cause cessation of normal cyclic ovarian function in women and impotence in men. Weight control and diet are also of particular concern.

"We know the weight gain occurs early in treatment -- during the first one to two years," Dr. Koshes said. Patients who respond well to drugs are the ones most likely to experience it, partly because of their improved functionality and quality of life. They are found to be more social, to enjoy meals more and to use them as a social outlet, he added.

Still, when combined with the potential medical complications of schizophrenia, the overall effects of obesity can be tremendous, according to an article in the February Primary Care Companion of the Journal of Clinical Psychiatry. Diabetes, hypertension, hyperlipidemia and sleep apnea are a few examples of complications that are exaggerated by weight gain. The additional pounds also can cause patients to stop taking their medicines.

But recent studies offer encouraging signals. With counseling and support from a physician, most patients have been able to control their weight gain. Experts recommend beginning the process with an open discussion of this possibility and counseling about ways to curb it.

This is just one example, but overall, Dr. Schiermer and Dr. Aquila say that as patents do better on their meds, they become more aware of other aspects of their well-being and are better able to seek attention and take steps to improve their circumstances. Thus, psychiatrists and primary care physicians have to evolve in order to respond.

"When we're talking about delivery of care, we have seen that the physician -- the clinician -- should be at the center," Dr. Aquila said. But often, the psychiatrist is the only one with whom these patients have regular contact.

Thus, he said the psychiatrist may need to move beyond the usual boundaries. He or she should be able to guarantee or advocate for the patient's follow-up care.

These clinicians also should be involved in the basics of health care. The psychiatrist should take steps to develop relationships with primary care colleagues to maximize treatment opportunities.

Meanwhile, from the primary care perspective, doctors may have to overcome certain attitudes and learn to practice some of the skills necessary to deal with this population. Some of the patients can initially be difficult -- they look different, act different and sometimes smell different from those in the mainstream. The temptation is to treat them differently, too.

For instance, Dr. Aquila said that many physicians are more likely to describe these patients as a "35-year-old schizophrenic" than as a "35-year-old gentleman" -- thereby setting up a tacit pattern of discrimination.

Also, the time-conscious influences of managed care on the delivery of primary care can be particularly burdensome for patients with mental illness. "For our patients, [the pinch] might be more dramatic" because they require more discussion and time to understand what is happening to them, Dr. Aquila said.