To the Editor: Hispanics with severe mental illness have a higher prevalence of metabolic syndrome than persons with schizophrenia in general or Hispanics in the general population, which suggests additive risk (1,2). Despite national guideline recommendations, metabolic screening and treatment rates are low among persons with severe mental illness (3). Little is known about rates among Hispanics in this population. We determined screening and treatment rates for metabolic abnormalities in an urban sample of predominantly Hispanic inpatients with severe mental illness. We hypothesized that we would find low rates and that these inpatients would prefer pharmacological treatments over behavioral interventions for metabolic abnormalities.
After the study received approval from the Columbia University Institutional Review Board, we recruited persons with severe mental illness from a New York City community service inpatient unit. Psychiatrically stable inpatients taking an antipsychotic were eligible. After patients gave informed consent, charts were reviewed for screening data, and patients completed a survey about preferred interventions. Most inpatients approached agreed to participate (64%, 49 of 77). The sample was predominantly Hispanic (N=35, 71%) and of Dominican American origin (N=29, 59%). [Data on sample characteristics are available in an online supplement to this letter at ps.psychiatryonline.org.] The largest non-Hispanic subgroup was African American (N=10, 20%), another high-risk group.
Metabolic screening fell short of national recommendations. For example, although weight and height were recorded for 98% of the inpatients (N=48), waist circumference was not measured for any, and body-mass index (BMI) was recorded for only three (6%). Lack of BMI documentation raises the possibility that even though nursing staff collect weight data, treating physicians may not review these notes. Blood pressure was assessed for all patients, fasting glucose for 35 (71%), and fasting lipids for 42 (86%). These rates are higher than previously reported (4), which likely reflects easy laboratory access on an inpatient unit.
Metabolic abnormalities were prevalent in the screened sample: 67% of patients whose weight was recorded (32 of 48) were overweight, and 40% (19 of 48) were obese; 55% (23 of 42) had lipid abnormalities, 51% (25 of 49) were hypertensive, 31% (11 of 35) had high fasting glucose, and 35% (12 of 34) met criteria for metabolic syndrome. Sixty-three percent of the overweight sample (20 of 32) were not treated. Dyslipidemia was treated among only half of the patients (52%, 12 of 23). In contrast, 72% with hypertension (18 of 25) were treated, as were 64% (seven of 11) with high fasting glucose.
Hispanic inpatients preferred behavioral interventions (such as diet and exercise) over pharmacological interventions (such as medication switching) (Mann-Whitney U=1,691, z=-2.57, p<.05), and Spanish-speaking Hispanics voiced this preference even more strongly (Mann-Whitney U=1,168, z=-5.05, p<.001). [Figures illustrating treatment preferences are available in an online supplement at ps.psychiatryonline.org.]
To our knowledge, this is the first study to assess metabolic screening and treatment of a predominantly Hispanic population with severe mental illness. Most were not treated for weight problems, which is concerning given the high prevalence of obesity in this population. Although switching antipsychotics to those with lower metabolic risk has been proven effective for weight loss (5), clinicians should consider behavioral interventions for high-risk Hispanic populations because these findings suggest that they prefer them.
Dr. Mangurian is affiliated with the Department of Psychiatry, University of California, San Francisco. Dr. Goss is with the Department of Medicine, Montefiore Hospital, New York City. Dr. Newcomer is with the Department of Psychiatry, Washington University, St. Louis, Missouri. The findings were presented in a poster session at the annual meeting of the American Psychiatric Association, May 19—24, 2007, San Diego.
This study was funded through support from an American Psychiatric Institute for Research and Education (APIRE)-Janssen Pharmaceuticals scholarship.
During this study, Dr. Mangurian received support from Eli Lilly and Company through a grant from APIRE-Eli Lilly. Dr. Newcomer has received grant support from Janssen Pharmaceuticals, Bristol-Myers Squibb, Wyeth Pharmaceuticals, and Pfizer; he has served as a consultant to AstraZeneca Pharmaceuticals, Bristol-Myers Squibb, Janssen Pharmaceuticals, Pfizer, Solvay, Otsuka Pharmaceuticals, Wyeth Pharmaceuticals, H. Lundbeck, Vanda, and Organon; he has been a member of Data and Safety Monitoring Boards for Organon, Schering Plough, Dainippon Sumitomo Pharma America, and Vivus; and he has received royalties from Compact Clinicals/Jones and Bartlett Publishing for a metabolic screening form. Dr. Goss reports no competing interests.
Ader M, Garvey WT, Phillips LS, et al: Ethnic heterogeneity in glucoregulatory function during treatment with atypical antipsychotics in patients with schizophrenia. Journal of Psychiatric Research 42:1076—1085, 2008
Kato MM, Currier MB, Gomez CM, et al: Prevalence of metabolic syndrome in Hispanic and non-Hispanic patients with schizophrenia. Primary Care Companion of the Journal of Clinical Psychiatry 6:74—77, 2004
Morrato EH, Druss B, Hartung DM, et al: Metabolic testing rates in 3 state Medicaid programs after FDA warnings and ADA/APA recommendations for second-generation antipsychotic drugs. Archives of General Psychiatry 67:17—24, 2010
McEvoy JP, Meyer JM, Goff DC, et al: Prevalence of the metabolic syndrome in patients with schizophrenia: baseline results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES III. Schizophrenia Research 80:19—32, 2005
Weiden PJ: Switching antipsychotics as a treatment strategy for antipsychotic-induced weight gain and dyslipidemia. Journal of Clinical Psychiatry 68(suppl 4):34—39, 2007