Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: Data from the CATIE schizophrenia trial sample at baseline☆
Introduction
In recent years there has been a growing body of literature focused on improving the general medical health of patients with schizophrenia, with an edited book (Meyer and Nasrallah, 2003) and several articles (American Diabetes Association et al., 2004, Marder et al., 2004, Sokal et al., 2004, Hennekens et al., 2005) devoted to the topic. One impetus for this increased awareness arises from concern over the metabolic effects of atypical antipsychotic therapy (American Diabetes Association et al., 2004, Jin et al., 2004, Meyer and Koro, 2004). Another factor, noted in several publications, is the fact that patients with schizophrenia are a medically underserved population. In the United States this, in part, derives from systemic separations in the provision of public mental health and general health care (Druss, 2002), thereby posing a barrier to accessing primary medical services for those who must rely on public health clinics (Druss and Rosenheck, 1998, Levinson Miller et al., 2003). Even in relatively open systems, such as the hospitals and clinics provided for US veterans, patients with schizophrenia underutilize primary care services (Bosworth et al., 2004), with the result that important health conditions are underdiagnosed (Cradock-O'Leary et al., 2002). The diagnosis of schizophrenia, in particular, stands out among other mental disorders studied as a risk factor for underuse of medical services in Veterans Affairs (VA) clinics (Druss and Rosenheck, 1997, Cradock-O'Leary et al., 2002). Other data are more encouraging, such as the findings of two large studies by Desai et al. (2002a, b) from the VA database which found that indicators of quality preventative care for diabetics were higher than national benchmarks for all patient subgroups with psychiatric disorders, and a diagnosis of mental illness was not a substantial barrier to the receipt of nutrition and exercise counseling at VA medical centers (Desai et al., 2002a, Desai et al., 2002b).
While the Desai papers suggest that, when patients with schizophrenia or other psychotic disorders gain access to nonpsychiatric medical services, the level of care is adequate, others studies reveal mixed data on medical outcomes for this patient population. For example, a recent study of 100 community-dwelling type 2 diabetics with schizophrenia noted that glycosylated hemoglobin levels in this cohort were significantly lower than a comparable (n = 99) community sample without a major mental disorder (Dixon et al., 2004). Data generated by Druss concluded that, after a diagnosed myocardial infarction (MI), patients with mental disorders were substantially less likely to undergo coronary revascularization procedures (Druss et al., 2000). Moreover, a subsequent study by Druss from the Medicare database reveals that the diagnosis of schizophrenia itself is associated with increased one-year post-MI mortality (Hazard Ratio, 1.34; 95% CI, 1.01–1.67) (Druss et al., 2001). An important finding from this study is that the effect of a schizophrenia diagnosis is not apparent when adjusted for the level of post-MI care as measured by use of reperfusion, aspirin, beta-adrenergic blockers, angiotensin-converting enzyme inhibitors, and smoking cessation counseling, implying that the excess mortality in this group of schizophrenia patients can be explained by the quality of medical care (Druss et al., 2001). Undertreatment of chronic medical conditions such as arthritis has also been documented among psychotic individuals (Redelmeier et al., 1998).
The net result of limited or inadequate medical care is increased mortality from natural causes for schizophrenia patients compared to the general population (Allebeck, 1989, Jorgensen and Mortensen, 1990, Mortensen and Juel, 1990, Mortensen and Juel, 1993, Newman and Bland, 1991, Simpson and Tsuang, 1996, Brown, 1997, Osby et al., 2000a, Osby et al., 2000b, Casey and Hansen, 2003, Enger et al., 2004). Among the many potential natural causes of death, cardiovascular disease (CVD), and associated diseases with high cardiovascular mortality, such as type 2 diabetes mellitus (DM), is often the focus of research on medical comorbidity among patients with schizophrenia. Major CVD risk factors, such as high prevalences of smoking and DM, combine with inactive lifestyles and poor dietary habits (Davidson et al., 2001) to increase future CVD rates (Goff et al., 2005) and associated mortality for patients with schizophrenia (Meyer, 2003, Curkendall et al., 2004, Hennekens et al., 2005), yet the contribution of undertreatment and underdiagnosis is not quantifiable from much of the published data. In particular, there are multiple published estimates of DM prevalence in patients with schizophrenia (Dixon et al., 2000, Bushe and Holt, 2004, Lamberti et al., 2004), but limited data on the extent of undertreatment of DM or hyperlipidemia in patients screened for these metabolic disorders. In one sizable (n = 234) cross-sectional survey of a diagnostically heterogeneous outpatient group receiving care at a community mental health center in Melbourne (Davidson et al., 2001), the investigators noted that males in the clinic sample were less likely to have undergone cholesterol screening than those in the general population, but no laboratory testing was performed to determine the extent of untreated hyperlipidemia. More recently, Cohn's study of 240 Canadian patients with schizophrenia or schizoaffective disorder actively screened all participants for metabolic abnormalities, with fasting laboratory measures obtained as part of the study protocol (Cohn et al., 2004), and reported that the schizophrenia patients had significantly increased fasting plasma triglycerides and decreased high density lipoprotein (HDL), but comparable total cholesterol and low density lipoprotein (LDL) levels vs. a reference population, yet fasting glucose levels were not reported; moreover, one could not glean from the published data the proportion of schizophrenia patients who were receiving antidiabetic or lipid-lowering therapy, or those who were in need of such treatment.
Given the concern about limited access to nonpsychiatric medical care, and high CVD mortality for patients with schizophrenia, there is a need for studies with large sample sizes to more appropriately assess the true extent of treatment of important medical conditions associated with CVD risk in this patient population. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Schizophrenia Trial is a large multicenter study, sponsored by the National Institute of Mental Health (NIMH), designed to examine a multitude of variables in patients with schizophrenia (Stroup et al., 2003). With the broad recruitment strategy of the CATIE Schizophrenia Trial, its multi-site design, and large sample size, the baseline data obtained offers an excellent opportunity to explore the correlation between laboratory measurements of glucose and serum lipids and the extent of treatment for hypertension, diabetes or dyslipidemia among US patients with schizophrenia.
Section snippets
Methods
The methods for the CATIE Schizophrenia Trial have been published in detail previously (Stroup et al., 2003, Lieberman et al., 2005). Briefly, the CATIE Schizophrenia Trial is a national, multisite, NIMH-sponsored prospective trial of antipsychotic effectiveness in patients with schizophrenia whose primary outcome measure was discontinuation of randomized medication, but which also examined psychopathological, metabolic, neurocognitive, economic, and functional outcomes. Institutional Review
Results
The overall prevalence of hypertension was 33.2% of the 1448 subjects with baseline blood pressure and medication data. The prevalence of DM overall was 10.4% for the entire cohort and 10.9% when confined only to those with fasting glucose results obtained 8 or more hours after last meal. Dyslipidemia, as noted by elevated serum TG, was found in 47.3% of fasting subjects (n = 690), and when defined as low serum HDL, was found in 48.3% of all subjects (n = 1445). Using the data from the entire
Discussion
Presented here is the largest study to date to specifically examine the extent of metabolic treatment in a cohort of schizophrenia patients screened for these abnormalities, and also queried about their use of hypoglycemic medications, antihypertensives and lipid-lowering agents. This data complements the findings from earlier publications regarding the prevalence of medical comorbidity among patients with severe mental illness (Dixon et al., 1999, Dixon et al., 2000, Jones et al., 2004, Sokal
Conclusions
This study represents the largest effort to date to marry the results from systematic screening for metabolic disorders with data on actual extent of treatment. As such, it serves as a benchmark for the adequacy of medical care among the severely mentally ill against which future interventions can be compared. While the extent of diabetes treatment is roughly comparable to community samples from the general population, there is clearly significant work to be done surrounding the recognition and
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2023, Schizophrenia ResearchCitation Excerpt :Corrective measures may require qualitative and biological research from diverse stakeholders involving diverse patient samples to redefine and reconstruct assessments with questions and cutoff values that reliably predict clinical pathology, not societal privilege. There is widespread neglect and discrimination within healthcare towards people with schizophrenia across all races and ethnicities (e.g., Nasrallah et al., 2006); however, being both Black and diagnosed with schizophrenia leads to multiplicative detrimental outcomes, consistent with the double jeopardy hypothesis (Das-Munshi et al., 2016). Mental health systems frequently fail to engage Black individuals diagnosed with schizophrenia in care to the same extent that they do white individuals (Maura and Weisman de Mamani, 2017); however, few studies have explored why this is the case.
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Supported by NIMH grant #N01MH90001.