Whose line is it anyway?

There is an assumption (by psychiatrists) that all physical care is the territory of the general practitioner (Tarrant, 2006), whereas psychiatrists tend to focus on arranging appropriate monitoring of medications that they are prescribing. However, there is a growing awareness of the global physical health needs of those with severe and enduring mental illnesses. This is confounded by the current lack of a clear consensus from multiple and differing guidelines on the necessary monitoring for both primary and secondary care.

Patients with severe mental illness, such as schizophrenia, bipolar disorder and depression, are said to lose 25 years or more of life expectancy (Newcomer & Hennekens, 2007); the majority due to cardiovascular disease (CVD). It is not surprising then that psychiatric patients tend to have a higher prevalence of independent predictors of CVD including smoking, hypertension, obesity, a sedentary lifestyle and hyperlipidaemia - an ‘inherent’ predisposition to CVD. However, there seems to be some disparity in prevention efforts for cardiovascular mortlality when comparing individuals with severe menal illness and the general population. In a correspondence letter to the Bulletin, Dr Mohd (rightly) expresses his concern that action needs to be taken when any results or measurements are found to be abnormal. Results are often duly communicated to general practitioners by letter but may easily be overlooked. He goes on to suggest that we (psychiatrists) should initiate anti-lipid treatment ourselves (Mohd, 2006).

Yet, according to the most recent Joint British Societies’ guidelines, the indications to commence antilipid therapy are quite clear: ‘at high risk’ - atherosclerotic disease, diabetes or a high total CVD risk > 20% (British Cardiac Society et al, 2005). However, in patients with severe mental illness, the total CVD risk is often below 20% for that specific period of time.

Most research has focused on the impact of some antipsychotic medication being linked to quite marked hypercholesterolaemia (Correll et al, 2007). The reasonable deduction is that these patients can be offered an alternative, less lipid-inducing antipsychotic and/or lifestyle changes. Lifestyle advice is often difficult to implement on the background of ongoing and enduring psychiatric illness given that use of healthcare services often decreases after the onset of a psychiatric disorder.

Some may argue that cardiovascular risk in patients who are stable on regular antipsychotic medication should be treated the same as anybody else with the same risk factors. However, given that patients with severe and enduring mental illness (with/without antipsychotic medication) are ‘inherently’ predisposed to CVD, would it be sensible just to wait until the risk passes the 20% threshold? Or is there a ‘missed opportunity’ here.

Closer attention is needed, first, to the choice of psychotropic drug treatment and second, more aggressive in-hospital use of monitoring and interventions to identify and reduce risk. In this target-driven culture, we often assign arbitrary values to continuous and often fluctuating biological variables. Perhaps we ought to abandon the notion of ‘one threshold fits all’; instead, use our clinical judgment to initiate treatment based on overall risk.