Comments and Controversies
Minimizing metabolic risks
We enthusiastically read Dr. Nasrallah’s December editorial ("Why are metabolic guidelines being ignored?"; Current Psychiatry, From the Editor, December 2012, p. 4-5; bit.ly/1GI2FFY) on the importance of metabolic monitoring. Psychiatrists are prescribing second-generation antipsychotics (SGAs) to a growing number of patients to treat a range of psychiatric disorders and symptoms. SGAs have several advantages over first-generation antipsychotics. Improvements in negative symptoms, fewer extrapyramidal symptoms, and more recently, evidence suggesting better relapse prevention have been noted,1 yet there is growing concern regarding their propensity to cause weight gain and induce insulin resistance and dyslipidemia. The importance of such cardiometabolic effects cannot be underestimated.
Among individuals attending public mental health clinics, up to 27% are overweight, 51% have elevated triglycerides, and 52% meet diagnostic criteria for metabolic syndrome.2 Because many psychiatrists prescribe SGAs to patients who are in late adolescence or early adulthood, rapid increased weight gain during these years may lead to increased stigma, psychological anguish, and worse clinical outcomes.3 Weight gain has been shown to be a significant factor in medication compliance.4
Resident education and quality improvement projects have demonstrated some improvements in enhancing metabolic screening for our patients.5 Unfortunately, significant barriers persist—eg, challenges in communicating between specialties, time constraints in clinics, and limitations in residency didactics. These medications are associated with significant cardiometabolic risks, and current monitoring practices generally are suboptimal.
Residency training is the best time to begin incorporating metabolic monitoring into patient care to establish it as a career-long practice. We would like to see a greater emphasis on developing a curriculum to promote resident understanding and practice in regard to metabolic monitoring when prescribing SGAs.
David Goldsmith, MD
Arshya Vahabzadeh, MD
Emory University School of Medicine