When a patient is on an antipsychotic or has a serious mental illness and a physical comorbidity, responsibility for the metabolic monitoring tends to sit between the psychiatrist, who prescribed the drug, and the physician, who manages the diabetes. Between two owners is functionally no owner, and the result is a patient whose HbA1c is checked less often than their mental state.
The fix is administrative rather than clinical. Decide at the point of prescribing who is doing the weight, waist, blood pressure, lipids and HbA1c, write it in the letter, and give the patient a card with the dates. Where the patient will not attend a separate appointment - which is common - do the measurements in the psychiatric clinic. Weight and blood pressure need nothing but a scale and a cuff, and a capillary HbA1c takes minutes.
The hardest part is the first measurement, because it is the one that has to happen before a drug is started to be worth anything. Baseline weight and a fasting glucose or HbA1c before an olanzapine or clozapine prescription costs one visit and makes every subsequent number interpretable.
- Record baseline weight, waist, blood pressure and a glucose or HbA1c before starting an antipsychotic, not after
- Name the clinician responsible for metabolic monitoring in the discharge or clinic letter
- Do the measurements in the psychiatric clinic where attendance elsewhere is unlikely
- Give the patient the schedule in writing with dates, not intervals
- Re-weigh at every visit in the first three months - most antipsychotic weight gain happens early
Why it matters
The excess mortality in serious mental illness is mostly physical, and the monitoring that would catch it is the task most likely to be assumed by everyone and done by no one.
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