Evidence-Based Reviews

Keeping patients physically well: A psychiatrist’s ‘CIVIC’ duty

Current Psychiatry. 2006 January;5(1):75-90

Watch for 5 common medical problems.

References

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.

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 9, platelets 14

Table 2

At what point do lipid levels indicate cardiovascular risk?

	Safe	Borderline*	Needs treatment^†	Treatment options
Total cholesterol		200-239	>240	See LDL cholesteroltreatment options
LDL cholesterol		130-159	>160	Lifestyle changes
				Statins
				Bile sequestrants
				Nicotinic acid
				Fibrate
HDL cholesterol	>60^¶	59-39		Lifestyle changes
				Treat triglycerides
				Add nicotinic acid or fibrate
Triglycerides		150-199	>200	Lifestyle changes
				Statins
				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.

Table 3

Who needs which vaccines—and how often

Vaccine	Targeted group/frequency
Tetanus	Two-vaccine series for intravenous drug abusers; vaccine series for adults who did not receive primary series; boosters if ≥10 years since vaccination
Hepatitis A	Intravenous drug users, institutionalized persons, homosexual men, and those living or working where hepatitis A is endemic
Hepatitis B	Three-vaccine series for health care workers, sexually active heterosexual men and women, homosexual/bisexual men, hemodialysis patients, intravenous drug abusers, institutionalized persons
Influenza	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
Pneumococcal	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.

In addition, mentally ill persons are more likely than the general population to have a sexually transmitted disease (STD)^17,18 because:

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