Over the past three years I have worked with a mental health psychiatry team, participating once per week in caring for clients living with schizophrenia. Because they are administered the antipsychotic medicine clozapine, the clients’ conditions are reviewed monthly. Clozapine has been found to be an effective second-generation antipsychotic in persons with schizophrenia who are resistant to treatment with other antipsychotic medicines.
Clozapine’s unique side effect profile includes a number of serious adverse effects, such as blood dyscrasias, myocarditis and cardiomyopathy, requiring regular haematological monitoring.
The clinic reviews and administers clozapine monthly to over two hundred clients. The idea of setting up a metabolic clinic integrated with the clozapine clinic originated from the observation that often people with schizophrenia who are referred to endocrinology speciality clinics, were more often than not, ‘non-attenders’. From a population and resource outlook, the provision of a nurse practitioner (NP) specialising in endocrinology, is a targeted approach to improving the health of a group at risk for metabolic syndrome, diabetes and lipid abnormalities and cardiovascular disease.
Patients with schizophrenia have a high prevalence of metabolic syndrome, defined by the International Diabetes Federation (2006) as a cluster of factors: diabetes and/or raised fasting plasma glucose, abdominal obesity, high cholesterol and high blood pressure. Insulin resistance and central obesity are considered significant factors, and it is this interplay that leads to 3-fold increase for diabetes and 2-fold increase in mortality from cardiovascular disease, when compared to the general population (Galletly et al. 2012).
In a recent systematic review (Mitchell et al. 2013), the highest prevalence of metabolic syndrome (51.9%) for patients living with schizophrenia, were patients prescribed clozapine. The high prevalence of metabolic syndrome is due largely to the consequences of lower socioeconomic status and the use of psychotropic medications (Galletly et al. 2012).
My role with this clinic has been as a mentor to support the team in screening and addressing metabolic syndrome by introducing strategies and innovations to decrease the risk of diabetes and cardiovascular disease. This clinic now includes the integration of a metabolic screening pathway, access for metabolic assessment and treatment, and coordination of services that further a client’s physical health improvement. Additional interventions have included the provision of training for the mental health team and case workers to improve patient health outcomes. Other initiatives have included the coordination with educational resources to provide group classes in specific movement and nutrition groups for clients living with schizophrenia.
Once working in the clinic, the capacity for mental health practitioners to address physical health (in this case metabolic syndrome), was identified.
There has been extensive literature highlighting the barriers to the provision of physical health for patients living with severe mental illness (Lambert et al. 2003; De Hert et al. 2011). These barriers include specific patient, provider, and treatment and system factors. Barriers aside, working in a clinical role allows for responsive initiatives that seek to address the vulnerability of this particular population of patients. At a simple level, raising awareness of the metabolic syndrome in this population was highlighted by twelve month review/audit of pathology, to assess the efficacy of metabolic screening. The results showed a 2-fold increase in screening tests performed by clozapine clinic psychiatrists.
In my NP role I will coordinate and/or connect a patient with a general practice to aid in continuity of care. However, often this coordination may not eventuate for a myriad of reasons. If coordination has not been successful, I will initiate treatment that is responsive to metabolic health for people with schizophrenia. Specific attention to metabolic syndrome involves a clinical understanding of the interplay of a number of metabolic indicators and targets for glucose, lipids and inflammation. Metabolic syndrome indicators represent a state of metabolic disarray with consequential organ disease, such as nonalcoholic fatty liver disease (NAFLD), fatty infiltration of the liver and nonalcoholic steatohepatitis (NASH – fatty changes with inflammation and hepatocellular injury or fibrosis) (Wu et al. 2007).
The cornerstone of metabolic syndrome treatment is weight control and reduction in cardiovascular risk factors, such as smoking, diabetes, hypertension and dyslipidaemia. Specific screening and treatment pathways have been outlined by the NSW Health and Education Training Institute (Curtis et al. 2011) and are a helpful schema. Unfortunately, pharmacotherapeutic treatment directed at metabolic syndrome and reversing insulin resistance are not currently authorised through the Australian Pharmaceutical Benefits Scheme. In addition, most lipid and patient profiles (including young age) do not meet criteria for anti-lipid medication criteria.
From an evidence-based practice perspective, when appropriate I will recommend specific dietary supplements, such as antioxidant: e.g. alpha-tocopherol supplementation vitamin E (800 IU daily), liquid soft-gelatin capsules of RRR-α-tocopherol (NPS Medicinewise 2007), and fish oil supplements containing the long-chain omega-3 fatty acids eicosapentanoic acid (EPA) and docosahexanoic acid (DHA) (2g daily) (Sanyal et al. 2010; Skulas-Ray et al. 2008).
Other initiatives have included writing applications to funding bodies (State Government Medication Gap committees and/or pharmaceutical companies) for options for special cases of patients with severe metabolic consequences of metabolic syndrome and/or diabetes. In these cases, central obesity and corresponding dyslidaemia with sub-optimal glucose control has become a significant impairment to function and recovery. In one case, the inclusion of a long acting glucagon-like peptide -1 analogue administration, in coordination with a district health nursing service, aided the client to sustain a ten per cent weight reduction over eighteen months. This treatment was instrumental in offsetting a continuation of a thirty per cent weight increase over the previous five years that had led to increasing lower back pain, immobility, and deteriorating glycaemic control.
In reflection I have found the experience of working with clients with schizophrenia rewarding and challenge. It has provided me with a clinical understanding of ‘metabolic vulnerability’. Along the way, it is the stories and experiences of small changes to lifestyle changes (e.g. replacing two litres of coke a day, to a can a day) that may make a difference.
It is my privilege to observe the continuity of a highly specialised, dedicated team that provides a common space for these clients, and who can monitor and guide in a supportive and non-judgemental way. It is the raising of awareness of the bidirectional relationship between physical health and mental stability that strengthens a recovery model. For my part the most important interventions have been the collaboration and advocacy for the clozapine team, and the clients that they serve.
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