Is Metabolic Syndrome on Your Radar?

Metabolic syndrome is defined by the aggregation of hypertriglyceridemia, low high-density lipoprotein (HDL) levels, elevated fasting glucose, hypertension, and increased waist circumference. Metabolic syndrome confers an increased risk of developing diabetes and of dying from coronary artery disease. Cardiovascular disease is the leading cause of death among patients with schizophrenia, who have a life expectancy about 20 years shorter than the general population.

My colleagues and I conducted a study that was prompted by the observation that, in about 9,000 consecutive admissions to our psychiatric hospital, not once was the diagnosis of metabolic syndrome made. In a quality improvement intervention, the admission order set of the psychiatric hospital was changed to automatically trigger orders for waist circumference measurement, vital signs, and fasting HDL, triglyceride, and glucose tests. In addition, we created a computer program to automatically extract from the electronic medical records (EMR) the lab values required to make the diagnosis of metabolic syndrome. The diagnosis was flagged by the computer in the EMR, and, in our study, we asked, “Would the psychiatrists change their prescribing behavior, for example, by switching from a metabolically problematic second-generation antipsychotic (SGA) such as olanzapine to a more benign SGA such as aripiprazole or a first-generation antipsychotic (FGA)?”

The short answer is “no”; there was no change in prescribed SGAs from admission to discharge after the intervention for automatic detection of metabolic syndrome was initiated.

E-mail notification of the presence of metabolic syndrome did not improve the response of the psychiatrists. This intervention improved the documentation of metabolic syndrome in the EMR from 0% to 29%. However, there was no improvement in the treatment of the components of metabolic syndrome (by prescribing lipid-lowering, antiglycemic, and antihypertensive drugs).

These results are puzzling. Why wouldn’t psychiatrists proactively identify and treat metabolic syndrome? We speculate that psychiatrists may experience “cognitive dissonance”; they like to prescribe SGAs because of a perceived superiority of efficacy/tolerability over FGAs, although research has not supported this perception.

Another possible explanation is that the attitude in the inpatient psychiatric setting is “first things first”; ie, we need to get some relief for these patients and can’t worry too much about the long-term consequences. As a result, the patient is most likely discharged while taking SGAs, which are then likely to be continued by the outpatient psychiatrist, thus exposing the patient to increasing cumulative metabolic risk.

In our study, a small subgroup of patients experienced a very rapid increase in triglycerides in response to SGAs (about 100% to 400% increases in about 5 to 20 days). These patients may have a genetic predisposition to this adverse effect; pediatric patients with polymorphisms near the melanocortin 4 receptor gene were found to have very rapid weight gain and metabolic changes with SGAs.

For a more detailed discussion, I suggest watching a YouTube video that we have prepared.

Financial disclosure:Dr Raese had no relevant personal financial relationships to report. ​