Lipid testing underutilized in adults taking antipsychotic medications

The biggest gap in screening is among adults age 40 and younger, the group for whom early detection and intervention has been shown to be effective when additional cardiovascular risk is present.

Adults with serious mental illness die 20 to 30 years earlier than their peers, largely due to increased risk for diabetes, high cholesterol, high blood pressure and heart disease. Taking antipsychotic medication increases that risk. The American Diabetes Association and American Psychiatric Association recommends more intensive diabetes and cholesterol lipid screening for patients receiving antipsychotics, but rates of screening have remained low.

"Antipsychotic medications are associated with substantial weight gain, as well as changes in insulin sensitivity and lipid metabolism, which increase the risk of diabetes and cardiovascular disease," said lead author Elaine Morrato of the Colorado School of Public Health at CU Anschutz.

Compared with prior reports, progress has been made to improve diabetes screening, but lipid screening remains particularly underutilized. The study, published May 11 in the journal JAMA Psychiatry, included 9316 Missouri Medicaid patients to identify factors associated with failure to receive annual glucose and lipid testing during treatment with antipsychotics.

Another notable study finding is understanding who is prescribing antipsychotics. About 75 percent of patients initiated therapy with a prescriber not practicing in a Community Mental Health Center and about half initiated therapy with a non-behavioral health care professional. Federal and state investment to prevent and reduce cardiovascular disease among those with mental illness has focused on psychiatrists practicing in community mental health settings.

Failure to receive testing was most strongly associated with patient characteristics and factors affecting frequency of health care utilization. Lack of testing was highest among adults 40 and younger, who have fewer chronic conditions.

One possible reason for low rates of testing may be the result of conflicting messages on whether younger adults should be tested. Some guidelines call for the use of screening tests in all patients receiving antipsychotics regardless of mental health diagnosis, while others prioritize screening only in adults with schizophrenia or bipolar disorder and other guidelines have prioritized screening based on age, ethnicity and other risk factors.

Better integration of behavioral health and primary care services is a public health priority. More research on the effectiveness of metabolic screening for younger adults receiving antipsychotics is needed to resolve the ambiguity in screening guidelines. Clarity is important for health system directors and policy makers who must decide on the most efficient use of limited resources for improving screening rates and achieving public health goals to reduce cardiovascular disease.