1. Monitoring Physical Health Stephen R. Marder, M.D. Professor, Semel Institute for Neuroscience and Human Behavior at UCLA Director, VA VISN 22 Mental Illness Research, Education, and Clinical Center

2. SMR = standardized mortality ratio (observed/expected deaths). 1.Harris et al. Br J Psychiatry. 1998;173:11. 2.Osby et al. BMJ. 2000;321:483-484. Increased Mortality Rates for Medical Disorders in Mental Illness 50% increased risk of death from medical causes in schizophrenia, and 20% shorter lifespan 1 Cardiovascular mortality in schizophrenia increased from 1976-1995, with greatest increase in SMRs (8.3 males/5.0 females) from 1991-1995 3

3. Physical Health Monitoring for the Severely Mentally Ill Where should it occur? Who should monitor? What should be monitored and how often?

4. Where Should It Occur? Patients may see a mental health provider more often than a primary care provider Primary care providers may not be aware of the risks associated with psychiatric illness Patients may have very limited access to primary care providers Psychiatric settings may lack tools for monitoring – including scales and pressure cuffs

5. Hennekens CH. Circulation. 1998;97:1095-1102. Goals: Lower Risk for CVD Blood cholesterol – 10%  = 30%  in CHD (200-180) High blood pressure (> 140 SBP or 90 DBP) – 4-6 mm Hg  = 16%  in CHD; 42%  in stroke Cigarette smoking cessation – 50%-70%  in CHD Maintenance of ideal body weight (BMI = 25) – 35%-55%  in CHD Maintenance of active lifestyle (20-min walk daily) – 35%-55%  in CHD

6. ADA Consensus on Antipsychotic Drugs and Obesity and Diabetes: Monitoring Protocol* *More frequent assessments may be warranted based on clinical status Diabetes Care. 27:596-601, 2004 Start4 wks8 wks12 wks3 mos.12 mos.5 yrs. Personal/family Hx XX Weight (BMI) XXXXX Waist circumference XX Blood pressure XXX Fasting glucose XXX Fasting lipid profile XXX X X

7. Guidelines for Monitoring MonitoringAPAADA/APAMt. Sinai Body weight and height BMI every visit for 6 months; quarterly thereafter BMI at baseline; every 4 weeks for the 12 weeks; quarterly thereafter BMI at baseline; at every visit for next 6 mos; quarterly when stable Fasting plasma glucose Fasting blood glucose at baseline. Fasting plasma glucose or HbA1c at 4 months after initiating new treatment and annually thereafter Fasting plasma glucose at baseline, 12 weeks and annually thereafter Fasting plasma glucose or HbA1c before initiating an antipsychotic, annually thereafter Lipid panel At least every 5 yearsBaseline; at 12 weeks; every 5 years Every 2 years or more often if levels are in the normal range and every 6 months if LDL levels are >130mg/dL Adapted from: Diabetes Care, Vol 27, No 1, February 2004. Am J Psychiatry. 161:2, February 2004 Supplement. Marder SR, et al. Am J Psychiatry. 2004; 161:1334-1349.

8. Issues in Implementation From Mt Sinai Guidelines – Most important monitoring may be weight and blood pressure – Both can be monitored at home by pts using automatic cuffs and scales

9. Regular Monitoring for Metabolic Changes Family/Caregiver – Patient, family, and caregivers should be knowledgeable about metabolic risks associated with SGAs and the symptoms of diabetes. Patient – Patients should chart their own weight. – Patients should pursue recommended diet and exercise.

10. The Reality of Routine Monitoring Medical Specialists – including psychiatrists – are better at addressing complex problems in their specialty then they are at routine monitoring Improvements in quality of care are most likely to occur when there is administrative support and resources are allocated.

11. A VA Approach to this issue 12/07 – OIG Report on Atypical Antipsychotics and risk factors for diabetes 7/08 -- Work Group Recommendations – Provide Guidance Documents to the field – Improve Metabolic Monitoring – Improve Intervention for patients at risk 9/09 – Initiation of MIAMI Program