Media Outreach Toolkit Media Backgrounder Mental health and metabolic syndrome Metabolic syndrome is a complex disorder consisting of multiple risk factors that promote cardiovascular disease and overall mortality and morbidity People with mental illness are particularly susceptible to metabolic syndrome due to factors such as reduced activity levels, poor dietary choices and the possible side effects of antipsychotic medications The World Federation for Mental Health highlights the importance of monitoring for metabolic risk factors in people with mental illness and balancing the risk/benefit of antipsychotic medication on a case-bycase basis What is metabolic syndrome? Metabolic syndrome consists of multiple, inter-related risk factors that promote cardiovascular disease and overall mortality and morbidity. It is a complex disorder, and different scientific groups have suggested different diagnostic criteria. However, metabolic syndrome is often associated with type 2 diabetes and it is widely acknowledged that obesity and insulin resistance are two of the most important causative factors1,2. The European Society of Cardiology3 and the American Heart Association / National Heart, Lung and Blood Institute2 both recommend using the definition of metabolic syndrome provided by the US National Cholesterol Education Program, which states that metabolic syndrome is the presence of three or more of the following features: Obesity High blood pressure Elevated plasma glucose (sugar levels in the blood) Reduced HDL-cholesterol (the ‘good’ cholesterol) Elevated serum triglycerides (the chief constituent of the body’s fats and oils) Metabolic syndrome and mental illness People with mental illness are at particular risk of developing metabolic syndrome4 and, in several countries, have demonstrated a higher prevalence of the syndrome or its components compared to the general population5. Media Outreach Toolkit Over the past few years the connection between severe mental illness and metabolic syndrome has been emerging as an important public health issue and physical disorders such as obesity, high blood pressure and type 2 diabetes are increasingly recognised as occurring alongside mental illness 6,7. Recently, clinicians and researchers have begun to evaluate these co-occurrences in the context of metabolic syndrome5. In two 2003 studies a 60% prevalence rate of metabolic syndrome was estimated among 63 people with schizophrenia8 and a 75% prevalence rate was estimated among 16 people with mood disorder9. Compare this to the prevalence for metabolic syndrome among the general adult population of the US which is just 24%10. These findings are consistent with the results of other studies conducted in various locations around the world which show higher rates of metabolic syndrome among people with schizophrenia compared with background rates in the general population11,12,13. Lifestyle Various lifestyle factors often found in people with mental illness contribute to their increased susceptibility to metabolic syndrome. Amongst other factors, these can include: Poor diet Lack of exercise Smoking Substance abuse Stress The social and emotional impact of many mental illnesses can lead to reduced activity levels and poor dietary choices that then lead to weight gain14,15. In turn, weight gain is then a contributing factor to the risk of insulin resistance, which can lead to all of the conditions listed by the US National Cholesterol Education Program as key factors in metabolic syndrome – high blood pressure, elevated plasma glucose, reduced HDL-cholesterol and elevated serum triglycerides16. Another key lifestyle factor found in people with a wide range of mental illnesses is cigarette smoking. A study in the US found that 88% of people with schizophrenia were smokers compared with only 33% in the general population17. Smoking is associated with insulin resistance and has also been found to increase serum triglycerides and reduce HDL-cholesterol, again key contributing factors for metabolic syndrome18,19. Media Outreach Toolkit Antipsychotic treatment Unfortunately, there is growing evidence to suggest that people with mental illness may be at further risk of metabolic syndrome due to the side effects of many antipsychotic medications used to treat their mental illness. Treatment with some antipsychotic medications is associated with weight gain, both type 1 and type 2 diabetes and impaired glucose metabolism20,21. The onset of one or all of these conditions increases the probability of patients developing metabolic syndrome22. There are two broad groups of antipsychotics currently in use, typical antipsychotics, first developed in the 1950s, and the newer atypical antipsychotics. The atypicals tend to be preferred as they have fewer side effects but some studies have failed to observe any significant differences in metabolic syndrome prevalence across typical and atypical antipsychotic treatment groups11,13. These studies seem to indicate that a significant part of the risk for metabolic syndrome parameters is inherent in the psychiatric disease process itself and that antipsychotic medication may be an indirect factor in contributing to metabolic syndrome risk. Managing metabolic syndrome in people with mental illness People with mental illness have a reduced life expectancy compared to the general population and metabolic syndrome contributes significantly to this23. A key role in managing metabolic syndrome in people with mental illness is regular monitoring for its risk factors4. The World Federation for Mental Health (WFMH) recommends that obesity, diabetes, hypertension and raised lipid profiles should all be monitored for on a regular basis in order to give people with mental illness the best chance of improving physical well-being. In addition, they advise that antipsychotic medications be selected based on specific efficacy requirements and risk factors. The balance of risk/benefit differs from person to person and each case should be evaluated as a unique situation. The WFMH is currently launching a ‘call-to-action’ campaign to stress the importance of monitoring for metabolic syndrome in people with mental illness. The campaign is aimed at mental health practitioners, primary care practitioners, as well as people with mental illness and their families and caregivers. Media Outreach Toolkit Notes to editors The US National Cholesterol Education Program states that metabolic syndrome is present when three or more of the following features are present2: -- Waist circumference >120 cm in men, >88 cm in women -- Serum triglycerides >150 mg/dL (>1.7 mmol/L) -- HDL-cholesterol <40 mg/dL in men, <50 mg/dL in women -- Blood pressure >130 mm Hg systolic BP or >85 mm Hg diastolic BP -- Plasma glucose >100 mg/dL (>6.1 mmol/L) For further information on the World Federation for Mental Health, please visit its website: www.wfmh.org Contact details [Insert first contact name] Email: [insert contact email address] [Insert organisation name] Tel: [insert contact telephone number] Fax: [insert contact fax number] [Insert alternative contact name] Email: [insert contact email address] [Insert organisation name] Tel: [insert contact telephone number] Fax: [insert contact fax number] References 1. 2. 3. 4. 5. 6. The International Diabetes Federation consensus worldwide definition of the metabolic syndrome. Available at www.idf.org/webdata/docs/IDF_Metasyndrome_definition.pdf Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association / National Heart, Lung and Blood Institute scientific statement: executive summary. Circulation 2005;112(17):e285-90 The third joint task force of European and other societies on cardiovascular disease prevention in clinical practice. European guidelines on cardiovascular disease prevention in clinical practice. European Heart Journal 2003;24:1601-10 The faculty of the “Advancing the treatment of people with mental illness: a call to action in the management of metabolic issues” meeting held in Vienna, Austria, on 29-30 September 2004. Advancing the treatment of people with mental illness: a call to action in the management of metabolic issues. Journal of Clinical Psychiatry 2005;66(6):790-8 Toalson P, Ahmed S, Hardy T, et al. The metabolic syndrome in patients with severe mental illnesses. Primary Care Companion, Journal of Clinical Psychiatry 2004;6(4):152-8 Dixon LB, Wohlheiter K. Diabetes and mental illness: factors to keep in mind. Drug Benefit Trends 2003;15:33-44 Media Outreach Toolkit 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Bellnier TJ, Patil K, Ortega T, et al. The prevalence of metabolic disturbances in schizophrenia and bipolar 1 patients prior to antipsychotic use. Presented at the 156th annual meeting of the American Psychiatric Association; May 17-22, 2003; San Francisco, California, USA. Kato M, Gonzalez-Blanco M, Sotelo J, et al. Metabolic syndrome in schizophrenia: a pilot study. Presented at the 156th annual meeting of the American Psychiatric Association; May 17-22 2003; San Francisco, California, USA Kato M, Sotelo J, de Guia C, et al. Prevalence of the metabolic syndrome in Hispanic patients with mood disorder: a pilot study. Presented at the 156th annual meeting of the American Psychiatric Association; May 17-22 2003; San Francisco, California, USA Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the Third National Health and Nutrition Examination Survey. Journal of the American Medical Association 2002;287:356-359 Littrell K, Perry R, Hilligoss N et al. Insulin resistance and syndrome X among schizophrenic patients. Presented at the 156th annual meeting of the American Psychiatric Association; May 17-22 2003; San Francisco, California, USA Vanhala MJ, Kumpusalo EA, Pitkajarvi TK, et al. Metabolic syndrome in a middle-aged Finnish population. Journal of Cardiovascular Risk 1997;4:291-5 Heiskanen T, Niskanen L, Lyytikäinen R, et al. Metabolic syndrome in patients with schizophrenia. Journal of Clinical Psychiatry 2003;64:575-9 Richardson CR, Avripas SA, Neal DL et al. Increasing lifestyle physical activity in patients with depression or other serious mental illness. Journal of Psychiatric Practice 2005;11(6):379-88 Wirshing DA, Meyer JM. Obesity in patients with schizophrenia. In: Meyer JM, Nasrallah H, ed. Medical illness and schizophrenia. Washington DC: American Psychiatric Press, Inc 2003:39-58 Meyer, JM. Schizophrenia and the metabolic syndrome. Medscape Psychiatry & Mental Health 2005;10(1) Hughes JR, Hatsukami DK, Mitchell JE, et al. Prevalence of smoking among psychiatric outpatients. American Journal of Psychiatry 1986;143:993-7 Reaven G, Tsao PS. Insulin resistance and compensatory hyperinsulinemia: the key player between cigarette smoking and cardiovascular disease? Journal of the American College of Cardiology 2003;41(6):1044-7 Kong C, Nimmo L, Elatrozy T, et al. Smoking is associated with increased hepatic lipase activity, insulin resistance, dyslipidaemia and early atherosclerosis in type 2 diabetes. Atherosclerosis 2001;156(2):373-8 Haupt D, Newcomer J. Hyperglycemia and antipsychotic medications. Journal of Clinical Psychiatry 2001;62(suppl 27):15-26 Allison DB, Mentore JL, Heo M, et al. Antipsychotic-induced weight gain: a comprehensive research synthesis. American Journal of Psychiatry 1999;156:1686-96 Lieberman JA. Metabolic changes associated with antipsychotic use. Primary Care Companion, Journal of Clinical Psychiatry 2004;6(suppl 2):8-13 Marder SR, Essock SM, Miller AL, et al. Physical health monitoring of patients with schizophrenia. American Journal of Psychiatry 2004;161(8):1334-49