Keeping patients physically well: A psychiatrist’s ‘CIVIC’ duty
Watch for 5 common medical problems.
Many patients with a severe mental disorder go years without preventive medical treatment, leaving them medically ill or at high risk for a medical illness.(See"Acute MI Risk Protecting you patients heart health" September 2005.)
Blood pressure. Check at each visit for patients with a history of hypertension and every 3 to 4 months for nonhypertensive patients. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)(See"Metabolic syndrome: 5 risk factors guide therapy" April 2005.)
Refer patients with suspected metabolic syndrome to a primary care physician or endocrinologist for management. Refer patients taking anticonvulsants if readings or symptoms suggest hepatitis or dyscrasia. Significant abnormalites include leukocites <2×109, platelets <100,000, new-onset anemia, bruising, bleeding, rash, abdominal pain, jaundice, lethargy, and seizure activity.14
At what point do lipid levels indicate cardiovascular risk?
See LDL cholesteroltreatment options
Add nicotinic acid or fibrate
Consider nicotinic acid or fibrate
*Treat according to risk factors. See Adult Treatment Panel III guidelines for specific regimens and cautions.
†Three- to 6-month trial of lifestyle changes may be warranted in most cases. Urge patients to reduce saturated fat and cholesterol, eat more soluble fiber, and exercise more.
¶Removes one risk factor
Source: Adapted from the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (www.nhlbi.nih.gov/guidelines/cholesterol)
VACCINATION HISTORY/INFECTION RISK
Vaccinations. Many psychiatric patients are not up to date with vaccinations against hepatitis, influenza, or pneumonia. Ask the patient to recall his or her vaccination history as accurately as possible. If he or she cannot, contact the primary care physician the patient visited most recently.
If you cannot obtain the history, refer the patient to the municipal health department for influenza vaccine and a blood test to verify hepatitis B immunization. Educate patients on the benefits of vaccination, and coordinate with a primary care doctor or case manager to ensure the patient’s immunization.
Who needs which vaccines—and how often
Two-vaccine series for intravenous drug abusers; vaccine series for adults who did not receive primary series; boosters if ≥10 years since vaccination
Intravenous drug users, institutionalized persons, homosexual men, and those living or working where hepatitis A is endemic
Three-vaccine series for health care workers, sexually active heterosexual men and women, homosexual/bisexual men, hemodialysis patients, intravenous drug abusers, institutionalized persons
Annual vaccination for persons age ≥50; patients with CVD, diabetes, HIV, renal disease, or pulmonary disease; and others who are immunosuppressed, pregnant, or in a nursing home. Check updates from CDC throughout flu season
Persons age ≥65; institutionalized patients age ≥50; those with alcohol dependence, asplenia, HIV, chronic CVD, chronic lung disease, diabetes, chronic liver disease, renal insufficiency, or who live in settings where pneumococcal disease can spread. Repeat dose on or about 65th birthday if immunized ≥5 years earlier
COPD: Chronic obstructive pulmonary disease
STD: Sexually transmitted disease
Source: U.S. Centers for Disease Control and Prevention. Recommended adult immunization schedule, by vaccine and age group (www.cdc.gov/nip/recs/adult-schedule.pdf)
Guidelines from the U.S. Preventive Services Task Force (USPSTF) spell out who should receive tetanus, hepatitis A or B, influenza, or pneumonia vaccines—and how often they should receive them (Table 3). In many states, municipal health departments offer these immunizations. Alternately, refer patients to a local indigent clinic.
Sexually transmitted disease. Neglected general health or malnourishment can weaken the immune system and increase susceptibility to infections. Patients who live in urban areas or public housing—where infections tend to spread—are especially vulnerable.
- mental illness can cloud judgment; for example, patients with bipolar mania are at risk for impulsive, hypersexual behavior
- some mentally ill patients support themselves with prostitution.
While taking a complete history during the initial visit, ask patients how often they have sex and with whom. If the patient acknowledges sexual activity with multiple partners, ask periodically about current sexual activity. Explore the patient’s understanding of the motivations and risks associated with dangerous sexual behavior, then educate him or her about safe sexual practices.
Refer sexually active patients to a hospital or private laboratory for an HIV test and an RPR to test for syphilis. Refer sexually active women age ≤25 for DNA cervical probes for gonorrhea and chlamydia. Evidence is equivocal for screening anymptomatic women age >25 for chlamydia or gonorrhea infection. Sexually inactive women or those in monogamous relationships may not need routine screening. For sexually active men, urine testing to screen for chlamydia or gonorrhea is available.19
Consult a local health clinic or gynecologist for the DNA probe, although some clinical laboratories can check urine for signs of cervical problems. Ask sexually active patients if/when they were immunized against hepatitis B. If needed, refer for vaccination.
MANAGING DIETARY INTAKE
Obesity—defined by the National Institutes of Health as BMI ≥30 kg/m2—often precedes preventable chronic diseases and cancer. Persons with chronic severe mental illness tend to be more sedentary than nonmentally ill persons,20 and research suggests that obesity is more common among patients with severe mental illness than among the general population.21 Also, poorer patients have trouble maintaining a balanced diet.
Calculate BMI using the National Heart, Lung and Blood Institute BMI calculator (www.nhlbisupport.com/bmi/bmicalc.htm). Encourage patients with BMI >25 kg/m2 to eat more fruits and vegetables, eliminate empty calories (alcohol, soda pop, juices, candy), and decrease fat consumption (especially fast food). Suggest to patients age ≥50 that they incorporate calcium, 1,200 mg/d, and vitamin D, 400 to 800 IU/d, in their diet to prevent osteoporosis.22
Also encourage patients to exercise moderately for a half-hour daily, 5 days a week, to burn calories. Supplement nutritional counseling with behavioral therapy, focusing on changing eating patterns.23
Many patients with chronic mental illness are not regularly screened for colon, cervical, breast, or other common early-stage cancers. In addition, their cancer rates are significantly higher than those of the general population.24
Ask men at the initial visit when they were last screened for colon or prostate cancer. Ask women when they were last screened for colon, cervical or breast cancer (Table 4). Ask again once yearly.
Colon cancer. Colonoscopy, done by a gastroenterologist, is indicated for patients age >50 every 5 to 10 years, depending on endoscopic findings. In-office fecal occult blood tests (FOBT), performed annually between colonoscopies, can identify patients who may need closer follow-up. You can do in-office FOBT or refer to a primary care physician.25
Cervical cancer is thought to be caused by human papilloma virus (HPV). Refer women with an intact cervix annually to a gynecologist or hospital clinic for a Pap smear, which usually includes testing for high-risk HPV if atypical cells are discovered. Some guidelines suggest decreasing screening frequency after several negative Pap smears for women in a monogamous sexual relationship.
Breast cancer affects 1 in 8 women, and having a first-degree relative with breast cancer increases the risk. Women should receive annual mammograms starting at age 40. The USPSTF notes that mammography’s benefits improve with increasing age between ages 40 and 70.26
Many hospital radiology departments or community health centers provide mammograms on a rotating schedule. Refer patients with abnormal findings to a general surgeon or breast center.
Recommended intervals for cancer screening
Type of cancer
Recommended test frequency
Asymptomatic persons age >50 should receive colonoscopy every 5 to 10 years, as directed by the gastroenterologist, and annual fecal occult blood tests
Annual Pap smears for women who have ever been sexually active and still have a cervix
Mammography every 1 to 2 years after age 40
Evidence does not support routine chest x-rays or sputum cytology in asymptomatic patients
Refer men age >50 to primary care physician or hospital laboratory for PSA test; counsel patients about the results and treatment
CASE CONTINUED: TESTING BEGINS
We schedule a battery of laboratory tests for Mrs. J at the local hospital, including a fasting plasma glucose test and lipid profile to gauge her cardiovascular risk and potential effects from olanzapine, and CBC and LFTs to check for adverse effects from oxcarbazepine.
We ask Mrs. J whether she engages in high-risk sexual activity, which she denies. She cannot recall her vaccination history, so we contact the primary care physician she had seen 5 years ago. Depending on her other comorbidities, housing situation, an early pneumococcal vaccine may be indicated.
We also suggest that Mrs. J quit smoking, but she appears to be at a pre-contemplative stage. We hope to promote a change in her attitude by discussing smoking cessation at each visit
To address Mrs. J’s obesity, we briefly review a dietary plan augmented with increased physical activity. She will bring a 3-day food diary to her next visit and promises to walk 30 minutes four to five times weekly. She says she enjoys mall walking with her children.
We strongly urge Mrs. J to schedule a mammogram, as she is past age 50 and says she has never received one. We try to refer her to a primary care physician to arrange a Pap smear and colonoscopy, but she resists, fearing the results. With continued education, exploration, and encouragement, we will briefly follow up with Mrs. J at each visit to ensure that she gets these needed tests (Box 2).
How to effectively coach patients who resist preventive care
Check with patients at each visit to ensure they are following through on their test referrals. If they are not, find out why.
If the patient is procrastinating, try to uncover an underlying cause. If the patient says he or she is pressed for time, ask: “Are you going through stressful life events? Are you afraid the test will hurt or will reveal a serious disease? Did you have this test before? If so, did it make you uncomfortable?
Tell the patent, “I understand your concerns, but this test is important. You need to make it a higher priority.” To work through the patient’s resistance, start by educating him or her about preventable chronic diseases and screening or treatment resources. Then try problem-solving techniques, motivational interviewing, or dissecting cognitive distortions.
Collaboration with a case manager is key when managing an indigent mentally ill patient. Open communication, setting well-defined goals, and a clear understanding of each other’s treatment roles is crucial. Inform the case manager which target tasks, tests, or appointments the patient has agreed to. The case manager can use this information to help the patient navigate the health care system and encourage full participation in care
Finally, build a referral base for indigent and uninsured patients. Look for a nearby internist, gastroenterologist, and OB/GYN who accept uninsured patients.
- U.S. Preventative Services Task Force. Continually updated, evidence-based screening recommendations for a range of medical problems. www.ahrq.gov/clinic/uspstfix.htm.
- U.S. Public Health Service. Clinical practice guideline: treating tobacco use and dependence. www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf.
Drug Brand Names
- Olanzapine • Zyprexa
- Oxcarbazepine • Trileptal
Dr. Moss recevies research/grant support from the National Institutes of Health and is a speaker for Janssen Pharmaceutica and Pfizer.
Mr. Brammer and Dr. White report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.
1. Carney CP, Allen J, Doebbeling BN. Receipt of clinical preventive medical services among psychiatric patients. Psychiatr Serv 2002;53:1028-30.
2. Joukamaa M, Heliovaara M, Knekt P, et al. Mental disorders and cause-specific mortality. Br J Psychiatry 2001;179:498-502.
3. McCreadie RG. Scottish Schizophrenia Lifestyle Group. Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study. Br J Psychiatry 2003;183:534-9.
4. Cohn T, Prud’homme D, Streiner D, et al. Characterizing coronary heart disease risk in chronic schizophrenia: high prevalence of the metabolic syndrome. Can J Psychiatry 2004;49:753-60.
5. Hanson D, Gottesman I. Theories of schizophrenia: a geneticinflammatory-vascular synthesis. BMC Med Genet 2005;6:7.-
6. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289(19):2560-72.
7. Berg AO, Atkins D. U.S. Preventive Services Task Force: screening for lipid disorders in adults: recommendations and rationale. Am J Nurs 2002;102(6):p. 91-5.
8. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143-421.
9. Standards of medical care in diabetes. Diabetes Care 2005;28:S4-S36.
10. Clinical practice recommendations 2005. Diabetes Care 2005;28(Suppl 1):S1-S79.
11. Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: a population-based prevalence study. JAMA 2000;284(20):2606-10.
12. Ockene IS, Miller NH. Cigarette smoking, cardiovascular disease, and stroke: a statement for healthcare professionals from the American Heart Association. American Heart Association Task Force on Risk Reduction. Circulation 1997;96:3243-7.
13. Fiore MC. U.S. Public Health Service clinical practice guideline: treating tobacco use and dependence. Respir Care 2000;45:1200-62.
14. Pellock JM, Willmore LJ. A rational guide to routine blood monitoring in patients receiving antiepileptic drugs. Neurology 1991;41:961-4.
15. Goodwin FK, Goldstein MA. Optimizing lithium treatment in bipolar disorder: a review of the literature and clinical recommendations. J Psychiatr Pract 2003;9:333-43.
16. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004;27:596-601.
17. Erbelding EJ, Hutton HE, Zenilman JM, et al. The prevalence of psychiatric disorders in sexually transmitted disease clinic patients and their association with sexually transmitted risk. Sex Transm Dis 2004;31:8-12.
18. Rein DB, Anderson LA, Irwin KL. Mental health disorders and sexually transmitted diseases in a privately insured population. Am J Manag Care 2004;10:917-24.
19. Screening for sexually transmitted diseases. U.S.Preventive Services Task Force, Washington, DC. Am Fam Physician 1990;42:691-702.
20. Daumit GL, Goldberg RW, Anthony C, et al. Physical activity patterns in adults with severe mental illness. J Nerv Ment Dis 2005;193:641-6.
21. Daumit GL, Clark JM, Steinwachs DM, et al. Prevalence and correlates of obesity in a community sample of individuals with severe and persistent mental illness. J Nerv Ment Dis 2003;191:799-805.
22. Hodgson SF, Watts NB, Bilezikian JP, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003. Endocr Pract 2003;9:544-64.
23. Jakicic JM, Clark K, Coleman E, et al. American College of Sports Medicine. American College of Sports Medicine position stand. Appropriate intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc 2001;33:2145-56.
24. Lichtermann D, Ekelund J, Pukkala E, et al. Incidence of cancer among persons with schizophrenia and their relatives. Arch Gen Psychiatry 2001;58:573-8.
25. Colon cancer screening (USPSTF recommendation). U.S. Preventive Services Task Force. J Am Geriatr Soc 2000M;48:333-5.
26. Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137(5 Part 1):347-60.