Over the past three years I have worked with a mental health psychiatry team, participating once per week in caring for clients living with schizophrenia.

Because they are administered the antipsychotic medicine clozapine, the clients' conditions are reviewed monthly. Clozapine has been found to be an effective second-generation antipsychotic in persons with schizophrenia who are resistant to treatment with other antipsychotic medicines.

Clozapine’s unique side effect profile includes a number of serious adverse effects such as blood dyscrasias, myocarditis and cardiomyopathy, requiring regular haematological monitoring.

The clinic reviews and administers clozapine monthly to over 200 clients. The idea of setting up a metabolic clinic integrated with the clozapine clinic originated from the observation that often people with schizophrenia who are referred to endocrinology speciality clinics, were more often than not, 'non-attenders'. From a population and resource outlook, the provision of a nurse practitioner (NP) specialising in endocrinology is a targeted approach to improving the health of a group at risk for metabolic syndrome, diabetes and lipid abnormalities and cardiovascular disease.

Patients with schizophrenia have a high prevalence of metabolic syndrome, defined by the International Diabetes Federation (2006) as a cluster of factors: diabetes and/or raised fasting plasma glucose, abdominal obesity, high cholesterol and high blood pressure. Insulin resistance and central obesity are considered significant factors, and it is this interplay that leads to a three-fold increase for diabetes and a two-fold increase in mortality from cardiovascular disease when compared to the general population (Galletly et al. 2012).

In a recent systematic review (Mitchell et al. 2013), the highest prevalence of metabolic syndrome (51.9%) for patients living with schizophrenia were patients prescribed clozapine. The high prevalence of metabolic syndrome is due largely to the consequences of lower socioeconomic status and the use of psychotropic medications (Galletly et al. 2012).

My role with this clinic has been as a mentor to support the team in screening and addressing metabolic syndrome by introducing strategies and innovations to decrease the risk of diabetes and cardiovascular disease. This clinic now includes the integration of a metabolic screening pathway, access for metabolic assessment and treatment, and coordination of services that further a client's physical health improvement. Additional interventions have included the provision of training for the mental health team and case workers to improve patient health outcomes. Other initiatives have included the coordination with educational resources to provide group classes in specific movement and nutrition groups for clients living with schizophrenia.

Once working in the clinic, the capacity for mental health practitioners to address physical health (in this case metabolic syndrome) was identified.

There has been extensive literature highlighting the barriers to the provision of physical health for patients living with severe mental illness (Lambert et al. 2003; De Hert et al. 2011). These barriers include specific patient, provider, and treatment and system factors. Barriers aside, working in a clinical role allows for responsive initiatives that seek to address the vulnerability of this particular population of patients. At a simple level, raising awareness of the metabolic syndrome in this population was highlighted by a 12-month review/audit of pathology to assess the efficacy of metabolic screening. The results showed a two-fold increase in screening tests performed by clozapine clinic psychiatrists.

Insulin molecules — Insulin regulates metabolism.

In my NP role I will coordinate and/or connect a patient with a general practice to aid in continuity of care. However, often this coordination may not eventuate for a myriad of reasons. If coordination has not been successful, I will initiate treatment that is responsive to metabolic health for people with schizophrenia. Specific attention to metabolic syndrome involves a clinical understanding of the interplay of a number of metabolic indicators and targets for glucose, lipids and inflammation. Metabolic syndrome indicators represent a state of metabolic disarray with consequential organ disease, such as nonalcoholic fatty liver disease (NAFLD), fatty infiltration of the liver and nonalcoholic steatohepatitis (NASH – fatty changes with inflammation and hepatocellular injury or fibrosis) (Wu et al. 2007).

Treatment

The cornerstone of metabolic syndrome treatment is weight control and reduction in cardiovascular risk factors,such as smoking, diabetes, hypertension and dyslipidaemia. Specific screening and treatment pathways have been outlined by the NSW Health and Education Training Institute (Curtis et al. 2011) and are a helpful schema. Unfortunately, pharmacotherapeutic treatment directed at metabolic syndrome and reversing insulin resistance are not currently authorised through the Australian Pharmaceutical Benefits Scheme. In addition, most lipid and patient profiles (including young age) do not meet criteria for anti-lipid medication criteria.

From an evidence-based practice perspective, when appropriate I will recommend specific dietary supplements such as antioxidants, e.g. alpha-tocopherol supplementation vitamin E (800 IU daily), liquid soft-gelatin capsules of RRR-α-tocopherol (NPS Medicinewise 2007), and fish oil supplements containing the long-chain omega-3 fatty acids eicosapentanoic acid (EPA) and docosahexanoic acid (DHA) (2g daily) (Sanyal et al. 2010; Skulas-Ray et al. 2008).

Other initiatives have included writing applications to funding bodies (State Government Medication Gap committees and/or pharmaceutical companies) for options for special cases of patients with severe metabolic consequences of metabolic syndrome and/or diabetes. In these cases, central obesity and corresponding dyslidaemia with sub-optimal glucose control has become a significant impairment to function and recovery. In one case, the inclusion of a long acting glucagon-like peptide -1 analogue administration, in coordination with a district health nursing service, aided the client to sustain a 10% weight reduction over 18 months. This treatment was instrumental in offsetting a continuation of a 30% weight increase over the previous five years that had led to increasing lower back pain, immobility, and deteriorating glycaemic control.

Conclusion

In reflection I have found the experience of working with clients with schizophrenia rewarding and challenging. It has provided me with a clinical understanding of 'metabolic vulnerability'. Along the way, it is the stories and experiences of small changes to lifestyle changes (e.g. replacing two litres of coke a day to one can a day) that may make a difference.

It is my privilege to observe the continuity of a highly specialised, dedicated team that provides a common space for these clients, and who can monitor and guide in a supportive and non-judgemental way. It is the raising of awareness of the bidirectional relationship between physical health and mental stability that strengthens a recovery model. For my part, the most important interventions have been the collaboration and advocacy for the clozapine team, and the clients that they serve.

References

Andreson, R, Oades, L & Caputi, P 2003, ‘The Experience of Recovery From Schizophrenia: Twoards an Empirically Validated Stage Model’, Australian and New Zealand Journal of Psychiatry, vol. 37, no. 5, pp. 586-94, viewed 15 August 2016, https://pubmed.ncbi.nlm.nih.gov/14511087/
Brahm, A & Hegele, RA 2013, ‘Hypertriglyceridemia’, Nutrients, vol. 5, no. 3, pp. 981-1001, viewed 11 August 2016, https://pubmed.ncbi.nlm.nih.gov/23525082/
Curtis J, Newall, H & Samaras, K 2011, Positive Cardiometabolic Health: An Early Intervention Framework for Patients on Psychotropic Medication, Health and Education Training Institute, HETI, viewed 9 August 2016, https://www.heti.nsw.gov.au/__data/assets/pdf_file/0006/426588/Psychiatry-Positive-Cardio-Metabolic-Algorithm-2011.pdf
De Hert, M, Cohen, D, Bobes, J, Cetkovich-Bakmas, M, Leucht, S, Ndetei, DM, Newcomer, JW, Uwakwe, R, Asai, I, Moller, HJ, Gautam, S, Detraux, J & Correll, CU 2011, ‘Physical Illness in Patients with Severe Mental Disorders II – Barriers to Care, Monitoring and Treatment Guidelines, Plus Recommendations at the System and Individual Level’, World Psychiatry, vol. 10, no. 2, pp.138-51, viewed 11 August 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104888/
Galletly, CA, Foley, DL, Waterreus, A, Watts, GF, Castle, DJ, McGrath, JJ, Mackinnon, A & Morgan, VA 2012, ‘Cardiometabolic Risk Factors in People With Psychotic Disorders: The Second Australian National Survey of Psychosis’, Australian and New Zealand Journal of Psychiatry, vol. 46, no. 8, pp. 753–61, viewed 11 August 2016, https://pubmed.ncbi.nlm.nih.gov/22761397/
International Diabetes Federation (IDF) 2006, Metabolic Syndrome – The IDF Consensus Worldwide Definition of the Metabolic Syndrome, IDF, viewed 9 August 2016, https://www.idf.org/e-library/consensus-statements/60-idfconsensus-worldwide-definitionof-the-metabolic-syndrome.html
Lambert TJ, Velakoulis D & Pantelis, C 2003, ‘Medical Comorbidity in Schizophrenia’, Medical Journal Australia, vol. 178, no. 9, pp. 67–70, https://www.mja.com.au/journal/2003/178/9/medical-comorbidity-schizophrenia
Mitchell, AJ, Vancampfort, D, Sweers, K, van Winkel, R, Yu ,W, & De Hert, M 2013, ‘Prevalence of Metabolic Syndrome and Metabolic Abnormalities in Schizophrenia and Related Disorders — A Systematic Review and Meta-Analysis’, Schizophrenia Bulletin, vol. 39, no. 2, pp. 306–18, viewed 11 August 2016, https://academic.oup.com/schizophreniabulletin/article/39/2/306/1823895
NPS Medicinewise 2007, Revised PBS Criteria for Lipid-Modifying Drugs (October 2006), NPS, viewed 9 August, https://www.nps.org.au/radar/articles/revised-pbs-criteria-for-lipid-modifying-drugs-october-2006
Sanyal, AJ, Chalasani, N, Kowdley, KV, McCullough, A, Diehl, AM, Bass, NM, Neuschwander-Tetri, BA, Lavine, JE, Tonascia, J, Unalp, A, Van Natta, M, Clark, J, Brunt, EM & Kleiner, DE 2010, ‘Pioglitazone, Vitamin E, or Placebo for Nonalcoholic Steatohepatitis’, New England Journal of Medicine, vol. 362, no. 18, pp. 1675-85, viewed 11 August 2016, https://www.nejm.org/doi/full/10.1056/NEJMoa0907929#t=abstract
Skulas-Ray AC, West, SG, Davidson, MH & Kris-Etherton, PM 2008, ‘Omega-3 Fatty Acid Concentrates in the Treatment of Moderate Hypertriglyceridemia’, Expert Opinion on Pharmacotherapy, vol. 9, no. 7, pp. 1237-48, viewed 11 August 2016, https://pubmed.ncbi.nlm.nih.gov/18422480/
Wu, JH, Dickson, M, Durkin, M & Canuso, CM 2007, ‘Treated Liver Diseases in Medicaid Recipients with Schizophrenia or Bipolar Disorder’, Primary Psychiatry, vol. 14, no. 10, pp. 71-9, viewed 11 August 1016, https://www.researchgate.net/publication/287882445_Treated_liver_diseases_in_medicaid_recipients_with_schizophrenia_or_bipolar_disorder

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