Christina Mangurian

Addressing Cardiometabolic Risk During Treatment With Antipsychotic Medications

Purpose of review To raise awareness of and inform evidence-based practice regarding medical and behavioral interventions for antipsychotic medication-induced metabolic abnormalities. Recent findings The current literature indicates that individuals with severe and persistent mental illness have significantly worse health outcomes and premature mortality than the general population, owing to a combination of under-recognition and treatment of medical risk factors, reduced access to care, sedentary lifestyle and poor diet, and the potential contribution of adverse metabolic side effects of antipsychotic medications such as weight gain, hyperglycemia and dyslipidemia. A combination of administrative, behavioral and medical approaches to addressing these medical risks may be more effective than any one of these approaches alone. Summary Treatment with antipsychotic medications can induce significant weight gain and abnormalities in lipid and glucose metabolism that increase risk for cardiovascular disease and diabetes in a population already at risk from multiple other sources. Managing the side effects of antipsychotics and lowering risk in general is an important aspect of the management of chronic mental illness. There are a variety of effective medical and behavioral interventions that can be employed to achieve primary and secondary prevention aims.

Roles in and barriers to metabolic screening for people taking antipsychotic medications: A survey of psychiatrists

NIH Public Access Author Manuscript Schizophr Res. Author manuscript; available in PMC 2014 February 01. NIH-PA Author Manuscript Published in final edited form as: Schizophr Res. 2013 February ; 143(0): . doi:10.1016/j.schres.2012.08.031. Roles in and barriers to metabolic screening for people taking antipsychotic medications: A survey of psychiatrists SG Parameswaran a,b , C Chang c,d , AK Swenson b , M Shumway c , M Olfson a , and CV Mangurian c SG Parameswaran: sgp2115@columbia.edu; C Chang: ccharlenechang@gmail.com; AK Swenson: annakswenson@gmail.com; M Shumway: Martha.Shumway@ucsf.edu; M Olfson: olfsonm@nyspi.columbia.edu; CV Mangurian: Christina.Mangurian@ucsf.edu a New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032 b Columbia University College of Physicians & Surgeons, 630 West 168th Street, New York, NY c University NIH-PA Author Manuscript of California, San Francisco Department of Psychiatry, 401 Parnassus Avenue, San Francisco, CA 94143 d UCSF AIDS Health Project, 1930 Market Street, San Francisco, CA 94102 Keywords Antipsychotic agents; schizophrenia; metabolic screening; psychiatry Dear Editors Premature mortality for people with serious mental illness (SMI) is impacted by under- treatment of cardiovascular risk factors and metabolic effects of antipsychotic medications (Daumit et al., 2008; Nasrallah et al., 2006). National guidelines recommend screening and monitoring for metabolic risk factors in patients receiving antipsychotic medications (Association et al., 2004; Parks et al., 2008). However, prior studies demonstrate rates of screening between 10–43% (Buckley et al., 2005; Morrato et al., 2010; Newcomer et al., NIH-PA Author Manuscript Our study fielded a survey (available upon request) aimed to understand psychiatrists’ beliefs about their roles in, and the barriers to, the screening, monitoring and treatment of metabolic risk factors in patients receiving antipsychotic medications, and the characteristics of psychiatrists or their practices influencing differing attitudes. Items characterizing psychiatrists and their practices were adapted from prior national surveys (Arbuckle et al., 2008; Kreyenbuhl et al., 2007; Olfson et al., 2006). Questions were developed based on previously hypothesized roles and barriers (Buckley et al., 2005; Morrato et al., 2010; Newcomer et al., 2004) and discussions with expert researchers. Five-point Likert scales were used to assess agreement with statements about psychiatrists’ roles in the screening and

Diabetes Screening Among Underserved Adults With Severe Mental Illness Who Take Antipsychotic Medications

RESEARCH LETTER Adults in the United States with severe mental illness (SMI), such as schizophrenia and bipolar disorder (totaling approximately 7 million), are estimated to die, on average, 25 years earlier than the general population, largely of premature cardiovascular disease.1 The Institute of Medicine2 has called for improvements in health care for this population. Severe mental illness is associated with elevated risk for type 2 diabetes mellitus.3 Treatment with antipsychotic medications contributes to risk, with most evidence focused on second-generation antipsychotic medications, but similar increases in risk are reported with older and newer medications.4 The American Diabetes Association5 recommends annual diabetes screening for patients treated with antipsychotic medications, and public health administrators have targeted this population for improved health screening.6 To our knowledge, no studies have examined screening rates in this highest-risk population of adults with SMI because of limitations in public health medical records. We examined diabetes screening among publicly insured adults with SMI taking antipsychotic medications using matched administrative data for physical and mental health care services in a large health care system. We measured diabetes screening prevalence among patients with SMI treated with antipsychotic medications and assessed characteristics predictive of screening.

State Mental Health Policy: Physical Health Screening in State Mental Health Clinics: The New York Health Indicators Initiative

The New York State Office of Mental Health recently mandated that all adult outpatient clinics regularly monitor three health indicators--body mass index, blood pressure, and smoking status. After the population was defined, medical equipment was distributed. Regular training and quality improvement meetings were held to improve the electronic database for indicator data. Clinical directors were provided regular feedback on performance monitoring. Learning collaboratives allowed sharing of implementation strategies. After only four months of this coordinated effort, approximately 7,500 people with mental illnesses had been screened for the three health indicators across New York State.

Points of Contact: Using First-Person Narratives to Help Foster Empathy in Psychiatric Residents

ObjectivesThe authors aimed to determine if writing narratives in psychiatric training can foster empathy for severely and persistently mentally ill patients.MethodsOne resident wrote first-person narrative pieces about three different patients at a community mental health clinic. She reviewed these pieces with a writing supervisor weekly. The supervisor and resident examined the style of writing, choice of words, and story line to help the resident learn about her feelings about the patient.ResultsIn each narrative, different choices were made that provided clues about that particular resident-patient relationship. These writing exercises helped the resident become more connected to her patients, develop interviewing skills, and engage in more self-reflection.ConclusionNarrative writing effectively fostered empathy in a PGY-1 psychiatric resident working with severely and persistently mentally ill patients. This exercise also fostered understanding of countertransference and improved psychiatric history-taking skills. Psychiatry training programs may want to consider incorporating narrative writing exercises into their curriculum.

Expression of a Fas-like proapoptotic molecule on the lymphocytes of Xenopus laevis.

Ligation of the externally expressed Fas (APO1/CD95) molecule will initiate programmed cell death (apoptosis), in many mammalian developing and adult cells. Fas-induced apoptosis has not been demonstrated with the cells of any non-mammalian vertebrate. We immunostained suspensions of splenocytes from adult Xenopus laevis, the South African clawed toad, with a polyclonal rabbit anti-human Fas antibody raised against the amino acid residues 321-335 of human Fas. The binding was specific, as it was dramatically reduced by preincubation of the antibody with the Fas peptide used to make it, but not with a Fas-ligand (FasL) peptide. The binding was enhanced after in vitro exposure of the splenocytes to phytahemagglutinin (PHA), a T cell mitogen and apoptogen in this species. Sections of developing Xenopus larval tissue were also immunostained with the polyclonal rabbit anti-human Fas antibody. Consistent binding of thymocytes and splenocytes was not observed until early metamorphosis in these immunological sites. A monoclonal mouse anti-human Fas antibody, previously used to stimulate apoptosis in mammalian cells, induced significant levels of apoptosis in adult Xenopus splenocytes and additionally, bound specifically to a splenocyte extract, as assayed by ELISA. Thus, a molecule on Xenopus splenocytes shares both structural and functional homologies with human Fas, indicating the evolutionary conservation within vertebrates of this means of initiating apoptosis.

Perceived Discrimination Experienced by Physician Mothers and Desired Workplace Changes: A Cross-sectional Survey

Author(s): Adesoye, Taiwo; Mangurian, Christina; Choo, Esther K; Girgis, Christina; Sabry-Elnaggar, Hala; Linos, Eleni; Physician Moms Group Study Group

Childhood Adversities Associated with Poor Adult Mental Health Outcomes in Older Homeless Adults: Results From the HOPE HOME Study

OBJECTIVE To examine whether childhood adversity is associated with depressive symptoms, suicide attempts, or psychiatric hospitalization. METHODS History of seven childhood adversities (physical neglect, verbal abuse, physical abuse, sexual abuse, parental death, parental incarceration, and child welfare system placement) was gathered through in-person interviews. Multivariate models examined associations between history of childhood adversities and moderate to severe depressive symptoms, lifetime history of suicide attempt, or lifetime history of psychiatric hospitalization. The study enrolled 350 homeless adults, aged 50 and older, in Oakland, California, using population-based sampling methods. Moderate to severe depressive symptoms were measured on a Center for Epidemiologic Studies-Depression Scale (≥22), self-reported lifetime history of suicide attempt, and self-reported lifetime history of psychiatric hospitalization. RESULTS Participants with exposure to one childhood adversity had elevated odds of reporting moderate to severe depressive symptoms (adjusted odds ratio [AOR]: 2.0; 95% confidence interval [CI]: 1.1-3.7) and lifetime history of suicide attempt (AOR: 4.6; 95% CI: 1.0-21.6) when compared with those who had none; the odds of these two outcomes increased with exposure to additional childhood adversities. Participants with four or more childhood adversities had higher odds of having a lifetime history of psychiatric hospitalization (AOR: 7.1; 95% CI: 2.8-18.0); no increase with fewer adversities was found. CONCLUSION Childhood adversities are associated with poor mental health outcomes among older homeless adults. Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations.

Public Psychiatry Fellowships: A Developing Network of Public-Academic Collaborations

In response to the expanding public behavioral health care system, a network of 15 public-community psychiatry fellowships has developed over the past six years. The fellowship directors meet yearly to sustain and develop fellowships to recruit and retain psychiatrists in the public sector. This column describes five types of public-academic collaborations on which the fellowships are based. The collaborations focus on structural and fiscal arrangements; recruitment and retention; program evaluation, program research, and policy; primary care integration; and career development. These collaborations serve to train psychiatrists who will play a key role in the rapidly evolving health care system.

Improving Support of Residents After a Patient Suicide: A Residency Case Study

The suicide of a patient is arguably the most traumatic event that can occur during a psychiatrist’s professional life. A substantial portion of psychiatrists in general practice (15%–68%) will experience at least one patient suicide during their careers (1, 2), and approximately onethird of psychiatric residents experience a patient suicide during residency (3). A patient’s suicide frequently leads the treating psychiatrist to experience considerable stress, guilt, shame, anxiety, and even PTSD-like symptoms of intrusion, hypervigilance, depersonalization, and avoidance (4). Residents, at the early stage of their careers, are uniquely vulnerable to stress from this event (5). A patient suicide may cause the resident to doubt his or her clinical skills, the decision to enter psychiatry, and previous treatment decisions (5). Residents may also feel anger toward their supervisors for providing inadequate guidance, and co-residents may feel relief that they were not the treating resident (6). However, in their positions as trainees, residents have a unique opportunity for personal and professional growth at the time of such an event (7, 8). Nonetheless, in one study of Canadian medical students and residents (9), of whom nearly two-thirds had encountered at least one suicide, only one-third had received any formal education regarding the impact of suicide on residents. It is ironic that we as psychiatrists, particularly attuned to the needs of others, often avoid discussing these issues with colleagues, especially given the potential distress such events may cause. We each experienced the suicide of one patient during our residencies at Columbia and discovered several deficiencies in our methods for dealing with them. The composite patient described in Appendix 1 illustrates some of these problems. First, we found a lack of basic knowledge by residents in several areas, including the expected emotional responses, the frequency of patient suicides during residency, and helpful institutional procedures that a resident could access. Second, we noted isolation and lack of emotional support and appropriate mentorship for the affected resident. Finally, there was a lack of institutional support and constructive, noncritical reviews of suicide. To address these problems at our institution and the call by Academic Psychiatry for developing supportive and educational interventions for residents experiencing patient suicide (10), we describe here the interventions we developed at Columbia University, including curricular changes, development of a crisis support team, and a formal review of the event, and other constructive and reparative measures we have taken.