Psychiatry and internal medicine: bridging the gap

There are medical mysteries, but there are also plain facts. One is that patients with major depression are at increased risk of diabetes and cardiovascular disease. Another is that people with schizophrenia are likely to die 20-30 years earlier than people without serious mental illness.

Robert McCarron (UC Davis, Sacramento, California, USA) urged psychiatrists to respond to the challenge that this represents. Pritham Raj, of the Oregon Health and Science University, Portland, USA, is keen to do so.

Our patients are particularly vulnerable to diabetes and ischaemic heart disease

Of apples and pears

In the era of metabolic syndrome (defined by abdominal obesity; elevated blood sugar, blood pressure and triglycerides; and reduction in HDL-cholesterol), preventing obesity in our patients is proving tough, he said.

A high body mass index (BMI) is associated with many problems, including pain. In terms of cardiovascular risk, waist to hip ratio may be more important. A ratio greater than one (an apple shaped body) carries a higher risk than when the excess weight is predominantly below the waist (pear shape). In part this may be due stress, since raised cortisol encourages accumulation of abdominal fat.

But weight control and reduction is still a major goal in many people with mental health problems.

Food, feet and fingers

As a starting point, Dr Raj suggests we explain the following things:

• For people taking medication for mental health problems, no specific diet is superior to any other
• The ideal plate – of standard size, and without coming back for more – is roughly half fruit or vegetables, a quarter starch, and a quarter protein
• Calorie restriction can reasonably be expected to achieve weight loss of 1lb (0.5 kilo) per week
• If you are not a vegetarian, white meat and fish are better than red meat
• Sweet drinks are highly calorific and diet sodas are not a good substitute: it seems that artificial sweeteners create “psychological freedom” to eat other high calorie foods.

In relation to calorie expenditure, people should get on their feet. It is more helpful to talk about “activity” than about “exercise”. Walking is fine. Spending at least thirty minutes each day in physical activity of moderate intensity is recommended.

Weight and targets for weight loss should be recorded and discussed during subsequent consultations. If there is no mention in the notes, patients may think these issues are not important.

With respect to fingers, people can be encouraged to find something to do with them that does not involve smoking.

We may also be able to help patients by prescribing medications that are less likely to cause weight gain or increase risk of diabetes. So judicious choice of drugs has a role, and metabolic monitoring is warranted with many medications used in psychiatry.

When lifestyle change is not enough

Lifestyle change is likely to achieve the biggest benefits. If this fails, bariatric surgery – especially sleeve gastrectomy – has a role. But there may be issues of drug and nutrient absorption.  And there have been cases of psychiatric morbidity associated with such surgery.