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Objective: To assess the metabolic implications for patients admitted to a psychiatric hospital in several patient populations. Method: Data was collected from the medical records of 108 randomly chosen patients initially diagnosed with schizophrenia and depression in our hospital from 2002 to 2003. Results: Weight gain over a one-year period was demonstrated in each group of patients (treated with antipsychotics or antidepressants) (p 0.001). After the implementation of routine lipid panel test, several patients were initially diagnosed with dyslipidemia. Discussion: It is important to order routine laboratory work rationally, as this adds to the cost of hospitalization, while considering standard of care recommendations.
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ORIGINAL RESEARCH
Metabolic Implications of Psychotropic Medications
in a Publicly-Funded State Psychiatric Hospital
Robert G Bota1, Timothy Dellenbaugh2, Andro Giorgadze3, Chadd K Eaglin4
and Cristina Davila1
1Assistant Clinical Professor of Psychiatry, University of Missouri-Kansas City. 2Associate Professor
of Psychiatry, University of Missouri-Kansas City. 3Psychiatrist, Middle Flint Behavioral Health Care,
Americus, GA. 4Resident Psychiatrist, University of Hawaii.
Abstract
Objective: To assess the metabolic implications for patients admitted to a psychiatric hospital in several patient
populations.
Method: Data was collected from the medical records of 108 randomly chosen patients initially diagnosed with schizophrenia
and depression in our hospital from 2002 to 2003.
Results: Weight gain over a one-year period was demonstrated in each group of patients (treated with antipsychotics or
antidepressants) (p 0.001). After the implementation of routine lipid panel test, several patients were initially diagnosed
with dyslipidemia.
Discussion: It is important to order routine laboratory work rationally, as this adds to the cost of hospitalization, while
considering standard of care recommendations.
Keywords: schizophrenia, hospitalization, depression, lipids panel, TSH
Introduction
Not too long ago, primary care physicians and psychiatrists were enjoying a period of quiescence
with the introduction of effective and relatively safe new generation psychopharmacological agents.
Selective serotonin reuptake inhibitors (SSRI) and atypical antipsychotic (AAP) brushed away
“inconvenient” older generation of antidepressants and antipsychotics that were associated with
signifi cant side effect profi les. However, widespread use of the new agents led to increasing recogni-
tion of their potential harm(Houy-Durand and Thibaut, 2002). AAP have been implicated in a variety
of conditions conceptualized as “metabolic syndrome” or metabolic abnormalities (Antai-Otong,
2004; O’Neill, 2005). Metabolic syndrome(McKee, Bodfi sh, Mahorney, Heeth, and Ball, 2005) is
loosely defined as a combination of pathological conditions such as: hypertension, lipid
abnormalities(Wetterling, 2003), abdominal fat, and insulin resistance(Newcomer, 2004). Consider-
ing associated high morbidity and mortality of these conditions, it has become imperative to monitor
the metabolic status of patients treated with atypical antipsychotics (Almeras et al. 2004; Meyer and
Koro, 2004). All atypical antipsychotics have received a black box warning urging physicians to
monitor glucose status of patients receiving treatment (“Physicians’ Desk Reference,” 2005), even
though it has been diffi cult to demonstrate a causal link between antipsychotics and glucose
abnormalities(Saito and Kafantaris, 2002) due to the increased background risk of diabetes mellitus
in patients with schizophrenia and the increasing incidence of diabetes mellitus in the general
population.
Current recommendations for patients on antipsychotics include periodic weight, blood pressure,
lipid profi le, and fasting glucose measurements (McIntyre, McCann, and Kennedy, 2001). Patients with
a history of glucose intolerance or diabetes, as well as family history of diabetes, are considered high
risk and require more stringent monitoring (Lublin, Eberhard, and Levander, 2005).
Correspondence: Robert G. Bota, Corona Medical Offi ce Building, 2055 Kellogg Avenue, Corona CA 92879.
Tel: 229/913-2504; Fax: 816/512-7440; Email: rgbota@yahoo.com
Copyright in this article, its metadata, and any supplementary data is held by its author or authors. It is published under the
Creative Commons Attribution By licence. For further information go to: http://creativecommons.org/licenses/by/3.0/.

Clinical Medicine: Psychiatry 2008:1 17–24
17

Bota et al
SSRI and mixed norepinephrine or serotonin Data collection
uptake inhibitors do have several side effects Data collected refl ected psychiatric assessment in
including weight gain(Ruetsch, Viala, Bardou, terms of diagnosis, treatment history, symptoms
Martin, and Vacheron, 2005). The side effects varies and clinical course, and other assessments
between medication of the same class(Papakostas, refl ecting psychological status, demographics, and
2008). Furthermore, patients with depression will change in social support systems. Compliance to
be on medication often for many years, due to the treatment was assessed by patient report (the
nature of the illness, and we should be aware of insight that one has an illness for which medication
the cumulative effect of weight gain over the is needed) and by staff report of patient compli-
years(Cassano and Fava, 2004).
ance with the prescribed interventions while
Furthermore, a variety of medical conditions hospitalized.
may present with psychiatric symptoms, for
Documentation regarding laboratory work was
example: endocrine and neurological conditions obtained from charted laboratory reports. Routine
(Ambrosino, 1972), infections (Schwab, 1982) and laboratory work done for every patient hospitalized
metabolic abnormalities (Golomb, 2002).
until 2004 includes: cell blood count (CBC), basic
In summary, laboratory investigation is helpful metabolic panel (BMP), RPR, thyroid panel, HCG,
in three major areas: to rule out a medical condition urine analysis (UA), urine drug screen (UDS). In
affecting, or responsible for the psychiatric distur-
2004, in conformity to the standard of care, lipid
bance and its effect on the psychiatric treatment panel was added to the routine laboratory work
modality(Escobar, Hoyos-Nervi, and Gara, 2002; (RLW). Concurrently, thyroid panel was discontin-
Talbot-Stern, Green, and Royle, 2000) (e.g. hypoxia ued due to limited funds allotted for RLW (the cost
in an elderly woman with an anxiety disorder), to for lipid panel is just a fraction of the cost of thyroid
monitor drug levels of certain psychiatric panel). Documentation of fi rst and last hospitaliza-
medication(Preskorn, Burke, and Fast, 1993) tion was reviewed for each patient in this study.
(therapeutic level or compliance with the medica-
tion), and to evaluate the general health status of
a patient that may be affected by psychopharma-
Analysis
cological agents(Buse, 2002).
The resultant data was analyzed using Statistical
This study looks at the prevalence of weight Package for Social Sciences(“Statistical Package
gain and laboratory abnormalities in a selected for Social Sciences (SPSS) StatSoft [computer
group of hospitalized patients with schizophrenia program]. Version 9.0.,” 2000) (SPSS, version 12)
and depression.
software for standard deviation and T-test (2-tailed,
p 0.01) analysis. The University of Missouri
Kansas City Health Science Institutional Review
Methods
Board (IRB) as well as the Missouri Department
of Mental Health IRB have approved the study
Recruitment
yearly since 2002 and the review is HIPPA
For this study, the subjects were randomly selected compliant(Tribble, 2001).
out of all the patients admitted over a period of
one year (2002 to 2003) with diagnosis of schizo-
Results
phrenia and depression at a publicly-funded state
hospital. Their progress was then tracked until
August 2005.
Demographics
The study cohort was composed of 45 Group 1: patients with established schizophrenia.
patients that meet the Fourth Diagnostic and Forty-fi ve of the patients in the study had the diag-
Statistical Manual of Mental Disorders, Text nosis of schizophrenia for an average of eight years.
Revision(“Diagnostic and Statistical Manual of Average age for this group was 34.7 years. Sixty-
Mental Disorders, Fourth Edition, Text Revision,” six percent were male and 34% females. Ethnically,
2000) (DSM-IV-TR) of established schizophrenia 43.9% of these patients were African American and
diagnosis, 18 patients newly diagnosed with 51.2% of Caucasian origin (Table 1). Despite the
schizophrenia and 45 patients diagnosed with fact that employment rate did not change between
depression.
the fi rst and last hospitalization (8.1% vs 7.6%) the
18
Clinical Medicine: Psychiatry 2008:1

Metabolic implications of psychotropic medications in a publicly-funded state psychiatric hospital
Table 1. Demographics.
Depression group
Initial schizophrenia
Established schizophrenia
Age
31.28 (sd 12.1)
25.01 (sd 7.7)
34.72 (sd 12.41)
Female gender
46%
28%
34%
Medicare/Medicaid coverage
20.7%
21.42%
41.46%
Employed
7%
28.5%
4.8%
Race
African-American
33.33%
64.2%
43.9%
Caucasian
55.55%
28.5%
51.2%
Other
11.2%
7.1%
4.8%
Homeless
N/A
35.7%
39%
Lives with family
N/A
64.2%
36.5%
Education level
N/A
11.6 (sd 1.8)
11.28% (sd 1.48)
No religion
N/A
34.1%
33.3%
Never married
66%
78.5%
68.2%
Note: N/A not available for analysis.
percent of patients receiving a form of income enforcement offi cers, family, and also self referral.
increased from 33 to 71% (p = 0.01), mainly due Patients diagnosed with depression, were more
to successful application for social security likely to be referred by police on their fi rst visit
disability insurance (SSDI) for return patients.
(p 0.001) mainly out of concern for danger to
Group 2: patients with depression. For the self. For schizophrenic patients, police escort
45 patients diagnosed with depression, the average during the last visit was more common (p = 0.04)
age was 31.2 years, 33.33% were African-
than in their fi rst, and remained approximately
American, 55.55% Caucasian, and 48% females. at one third of all patients in the established
Of these patients, only 64.4% had medical insurance schizophrenia group (Table 2).
at their fi rst visit to our facility (Table 1).
Family referral of patients was more common
Group 3: patients initially diagnosed with for the initial visit of patients newly diagnosed with
schizophrenia. Average age at the initial diagnosis schizophrenia than the other two groups (p = 0.004).
of schizophrenia was 25 years. Ethnically, 58% of At the second presentation, this group was less likely
these patients were African American and 24% to be referred by family (p = 0.02), and was also
Caucasian. These patients had achieved an average similar in the depressed group compared with fi rst
of 11.1 years of education and 27% (fi ve patients) presentation (p = 0.16) (Fig. 1). The rate of family
were employed at the time of initial schizophrenia referral did not differ between subsequent presenta-
diagnosis. Ninety-two percent were never married, tions for the established schizophrenia group.
58% (14 patients) lived with their families and 33%
Reported compliance with prescribed medica-
(eight patients) were homeless. Only 27% (fi ve tion was poor in 80.4 and 31 percent for patients
patients) had medical insurance, three of which with schizophrenia and depression respectively.
received Medicaid.
Of these patients, 18, 25 and 14 were evaluated Weight gain
at least once more in our hospital at 12.8, 9.7 and Weight gain in the initial schizophrenia group who
9.3 months from their fi rst encounter, for patients were naïve to antipsychotic therapy averaged
with established schizophrenia, depression and 30 pounds (Table 3) after 9.2 months of treatment.
initial schizophrenia respectively.
This group gained more weight than either two groups
(p 0.01). There was also a statistically signifi cant
Presentation pattern
increase in weight from the fi rst presentation to the
Patients in these three groups presented to emer-
second presentation in established schizophrenia
gency department (ED) referred mainly by law group (from 179.9 lb to 188.3 lb, p 0.001) and in
Clinical Medicine: Psychiatry 2008:1
19

Bota et al
Table 2. Presentation pattern.
Depression group
Initial schizophrenia
Established
schizophrenia
First visit
Last visit
First visit
Last visit
First visit
Last visit
Number of patients
45
23
18
13
45
18
Symptoms
Auditory
hallucinations
22.2%
34.7%
50%
66.6%
78%
74%
Delusions
15.5%
13.4%
78.5%
83.3%
85.3%
87%
Suicidal
80%
87%
0%
30.7%
6.6%
17%
Homicidal
22.5%
30.3%
0%
15.3%
6.6%
13%
Referral mode
Law
enforcement
28%
21%
22%
38%
31%
38%
Family
17%
8.7%
28%
23%
11%
5.5%
Self
26%
34%
4.3%
15%
28%
22%
Other
28%
36%
45%
23%
29%
34%
depression group (from 168.1 to 180.9 lb, p 0.001). panels for the different groups and presentation
Patients in the initial schizophrenia group had Body sequence. For example, a higher percentage of
Mass Indices within normal limits at the fi rst presen-
abnormal CBC was found in the fi rst presentation
tation, though this increased after a period of nine of patients with schizophrenia when compared with
months. Patients in the other two groups experienced the second presentation. However, in depression
weight gain at a slower rate, and were on average group, this pattern was reversed. The abnormalities
overweight at fi rst presentation (Fig. 2).
reported were mainly in hematocrit and mean
corpuscular volume.
BMP was more frequently abnormal at the fi rst
Routine laboratory investigations
visit when compared to the last visit for all groups.
We fi nd no predictable pattern between the groups The BMP refl ected electrolyte imbalance (elevated
in relation to the frequency of abnormal CBC or decreased sodium and potassium) in all groups,
established schizophrenia
initial schizophrenia
depression gorup
40%
35%
30%
25%
20%
15%
10%
05%
00% Police 1 Police 2 Family 1 Family 2
Self 1
Self 2
Figure 1. Referral pattern.
20
Clinical Medicine: Psychiatry 2008:1

Metabolic implications of psychotropic medications in a publicly-funded state psychiatric hospital
Table 3. Weight changes.
Established schizophrenia
Initial schizophrenia
Depression
First visit
Last visit
First visit
Last visit
First visit
Last visit
Interval
NA
12.8 months
NA
9.7 months
NA months
9.2
Weight
178.9
188.3
139.6
169.3
168.1
180.9
RIW
NA
9.7
NA
27.7
NA
11.8
BMI
26.6
28
21.2
25.7
27.8
29.9
Notes: RIW, relative increase in weight; BMI, body mass index; NA, not applicable.
with more abnormalities found in schizophrenic (Table 4). After the routine thyroid panel was
patients. Liver function panel abnormalities were discontinued at our facility, none of the schizophrenic
relatively equally distributed between groups.
patients had this test ordered, where as the thyroid
None of the patients in any of the groups had a panel was inconsistently ordered in the depressed
positive RPR titer.
group, although the detection of thyroid function
Approximately one fourth of the patients in the anomalies remained the same as compared to the
three groups had positive UDS. No signifi cant fi rst visit.
difference was found between the groups or
At the fi rst visit none of the patients had a lipid
presentations. Cannabis was the most frequent panel drawn. After this test was done routinely,
substance of abuse found by UDS in approximately we identifi ed three of 18 and one of 13 patients
90% of patients who were positive. Cocaine was with hyperlipidemia in the established and initial
the second most common illicit substance used in schizophrenia groups, respectively; while none
combination with cannabis in both the schizophrenia of 23 patients with depression had an abnormal
group and depressed group, totaling 6% and 20% lipid panel.
respectively of patients who were positive.
Depressed patients with thyroid abnormality
were all noted to have hypothyroidism, as compared Discussion
to both schizophrenia groups, which had patients Monitoring of side effects to medication is mostly
with either hyperthyroidism or hypothyroidism done in outpatient setting (Lamberti et al. 2006).
First visit
Last Visit
30.0
25.0
20.0
15.0
10.0
5.0
0.0
established
initial schizophrenia
depression group
schizophrenia
Established
Initial
Depression Group
Schizophrenia
Schizophrenia
First visit
26.6
21.2
27.8
Last Visit
28
25.7
29.9
Figure 2. Body mass index dynamics.
Note: BMI at last visit was signifi cantly higher (p 0.001) when compared with the fi rst visit for each group.
Clinical Medicine: Psychiatry 2008:1
21

Bota et al
Table 4. Abnormal laboratory results for patients with depression and schizophrenia.
Established schizophrenia
Initial schizophrenia
Depression
First visit
Last visit
First visit
Last visit
First visit
Last visit
Nr.
45
18
18
18
45
23
CBC
13
3
3
2
4
7
BMP
7
1
4
0
15
6
Trig
NA
2I
NA
1I
NA
0
LDL
NA
2I
NA
0
NA
0
HDL
NA
3D
NA
0
NA
0
RPR
0
0
0
0
0
0
TSH
1I 1D
NA
2D
NA
4I
3I*
LFT
4
5
4
4
0
1
UA
3
4
4
2
1
1
Notes: Nr.: number of patients; NA: not assessed; I: increased laboratory value over normal; D: decreased laboratory value below normal;
*: ordered not as routine laboratory.
However, in those settings interventions are often idiosyncratic (regardless of dose) weight gain side
delayed due to various factors, such as the time effect(Henderson, 2007). If weight gain is observed
lapsed until the psychiatrist receive the ordered during the fi rst weeks of treatment despite diet,
laboratory results, interval between scheduled exercise and adjustment of the dose, other
appointments and communication between interventions should be considered early, as the
psychiatrist and primary care physician (most weight gain trend is likely to continue. However,
psychiatrists do not routinely treat the medical the degrees of weight gain differ with different
conditions discovered, rather refers the patients medications(Newcomer, 2007). There are several
to their primary care provider). Therefore, the theories that try to account for the weight gain,
investigations done during hospitalization provide including decreased degree of physical activity,
a specifi c advantage, as patients diagnosed with histaminic considerations, degree of sedation,
laboratory abnormalities can have access to treat-
serotoninergic antagonism, possible hypothalamus
ment of these conditions during the hospital stay involvement and increased appetite(Henderson,
fostering implementation of treatment immedi-
2007). Interventions to limit and prevent weight
ately if indicated (Morgan D, 2008).
gain should be instituted even before starting the
This study was done in a publicly funded state medications (including education about diet,
hospital serving a diverse indigent population. exercise and monitoring weight)(Henderson,
The most dramatic fi nding was the signifi cant 2008). Once the weight gain occur despite of
increase in weight for patients naïve to antipsychotic preventive intervention, it is diffi cult to lose it. In
medication (initial diagnosis with schizophrenia), terms of interventions, the most effective approach
from an average of 139.6 to 169.3 lb. In patients is to change medications(Casey et al. 2003).
with established diagnosis of schizophrenia this Also, several behavioral and pharmacological
trend persisted but to a lower magnitude. There interventions have been described, with various
may be several explanations for this fi nding. First, successes.
the antipsychotic medications have an established
Standard batteries of tests ordered at the time of
side effect of weight gain, which may be more admission have specifi c benefi ts in identifi cation
signifi cant in patients without prior exposure to of treatable conditions. The discontinuation of
these agents. Secondly, patients with more frequent standard thyroid panel did not decrease the rate of
hospitalizations may require higher dose of detection of hypothyroidism in patients with
medications, and in certain cases more than depression, as psychiatrists ordered these tests if
one agent to stabilize their condition. Also, indicated (hypothyroidism is a condition that it is
patients with depression had the same trend, even known to mimic depressive symptoms or to
though they started with higher BMI. AAP have an exacerbate depressive disorder). That is not the case
22
Clinical Medicine: Psychiatry 2008:1

Metabolic implications of psychotropic medications in a publicly-funded state psychiatric hospital
First visit
Last Visit
40
35
30
25
20
15
10
05
00
established
initial schizophrenia
depression group
schizophrenia
Figure 3. UDS results.
for either group of patients with schizophrenia, of follow-up and multiple hospitalizations and
where TSH was not ordered at all at the last visits medication changes) we could not look at specifi c
(when it was not included in the standard battery correlation between individual psychotropic
of tests). Introduction of the standard lipid panel, medication and metabolic implications.
besides being standard of care, has lead to identi-
fi cation of 3 out 18 patients whom can benefi t from
lipid lowering medication. Out of more than Conclusion
100 patients, none had a positive RPR titer, even Even in the managed care era, routine laboratory
though this test is routinely done in many inpatient work has a necessary place in the practice of
facilities, due to the potential risk of treponema psychiatry. However, it adds to the cost of hospi-
infection in inner-city patient population(Ernst, talization. It is important to order studies rationally,
Farley, and Martin, 1995). It is debatable how often and, in doing so, to also consider the pattern of
it should be done for the same patient at subsequent seeking care of these specifi c patient populations,
presentations.
as they tend not to have a routine pattern of follow
up. Our study shows that the addition of lipid
Study limitations
profi le and the discontinuation of thyroid panel
This study has several limitations. One limitation saves money and at the same time helps to identify
of this study is typical of retrospective chart patients that may benefit from lipid lowering
reviews, in that there was no control of racial and treatment.
demographic distribution. A second limitation is
sample size. Furthermore, because the mission of
the hospital is public mental health services, and Financial Disclosure
a patient population that is largely uninsured, our No Grant or fi nancial contribution from outside
patients tend to use our facility for both acute sources was used for this project.
inpatient treatment as well as outpatient-like
services. Patients that were not admitted to the
hospital did not have laboratory work done in Proprietary Statement
majority of cases. In same situations, some of the None.
patients who were hospitalized continued to refuse
Institutional Review Board University of
laboratory work through out their hospital stay. Missouri Kansas City and Department of Mental
Also, due to the design of the study (long period health has approved this study since 2002.
Clinical Medicine: Psychiatry 2008:1
23

Bota et al
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Clinical Medicine: Psychiatry 2008:1

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