Our findings reveal that in AOTs in the United Kingdom, the rates of screening for the metabolic syndrome in people prescribed antipsychotic medication are well below those recommended. AOTs are services with relatively intensive casework: the patients are those who have proved difficult to engage with both primary care and general adult mental health services
36 and therefore are likely to receive the bulk of their medical care through mental health services. Thus, the low rates of screening are unlikely to be explicable on the basis that screening is assumed by the AOTs to be being carried out in primary care, or elsewhere in the health care system. That the AOTs participating in this survey were self-selected may also be relevant to the generalizability of the findings to other AOTs and possibly other community mental health teams in the United Kingdom. For example, the screening rates reported would be an underestimate of routine practice if there had been selective participation of teams that had recognized their need to improve in this area. However, given the large sample size, such systematic bias seems unlikely.
Although blood pressure and obesity are relatively simple and easy to measure, the screening rates over the year for these variables were no better than those for tests requiring blood samples. The rate of screening for the metabolic syndrome increased modestly with advancing age, which may indicate an increased awareness of the physical risks in older patients. In relation to medication variables, screening was carried out rather more frequently in those receiving clozapine than other antipsychotic agents that may reflect concern related to the side effect profile of the drug as well as the opportunity for blood samples afforded by the monitoring systems in place as part of the prescription of the drug.
A known diagnosis of diabetes, dyslipidemia, or hypertension was associated with a higher rate of screening for all aspects of the metabolic syndrome. However, there was a mismatch between such diagnoses and a record of appropriate drug treatment. While all these conditions, if mild, can be treated by nonpharmacological interventions such as altering diet and increasing exercise, it is unlikely that this fully explains the discrepancy between the number of cases diagnosed and the number receiving specific drug treatment.
One implication of the relatively low level of screening is that pathology with potentially serious consequences is not detected and treated. In the Clinical Antipsychotic Trials of Intervention Effectiveness study,
7,37 where fasting or random plasma glucose was measured in 689 people with schizophrenia, 13% were found to have diabetes. Three studies that have directly measured fasting or random plasma glucose in people who had schizophrenia and/or were treated with antipsychotic drugs, and who were not known to be diabetic prior to testing, found that 6% met the diagnostic criteria for diabetes.
16,31,38 In our total national sample, 6% had a diagnosis of diabetes, and thus it is likely that for each of these patients, another has diabetes that has not yet been diagnosed. A similar calculation can be made with regard to hypertension. Blood pressure has been directly measured in 2 large studies of people with schizophrenia.
7,39 In the first, 27% were found to have hypertension and in the second the figure was 36%. In our total national sample, 6% had a diagnosis of hypertension, and thus it is likely that for every patient with a diagnosis of hypertension, another 4 have not yet been diagnosed. Studies in which plasma lipids have been directly measured in people with schizophrenia and/or treated with antipsychotic drugs have found the prevalence of dyslipidemias to be at least 50%.
16,30,37 This proportion is not clearly different to that found in the general population. In our total national sample, 6% had a diagnosis of dyslipidemia, and thus it is likely that for every patient with a known diagnosis of dyslipidemia another 7 have a dyslipidemia that has not yet been identified.
The responses to the questionnaire yielded information on a series of obstacles to screening in routine practice in AOTs. For example, about a third of participating teams expressed uncertainty as to whether such physical health screening was the responsibility of the psychiatric team rather than, eg, a primary care clinician, and less than half of the teams were confident about the interpretation of abnormal screening results. Also, limited access to basic equipment such as a tape measure and weighing scales was a relatively common problem. To address these and other barriers identified by the questionnaire, strategies to increase the level of screening for the metabolic syndrome in clinical practice will need to include educational interventions, provision of appropriate equipment,
40,41 and collaborations with primary care physicians, diabetes specialists, dieticians, and others.
24The participating services received prompt feedback of the audit findings for each of their own AOTs, benchmarked against other services nationally, and the total national sample. Subsequently, we used the audit findings and the responses to the questionnaire to inform the development of a range of change interventions that were offered to participating services in the year following the baseline audit. A repeat audit is planned to see whether consideration of the benchmarked data and the implementation of the change interventions locally has had any impact on the profile and frequency of screening.
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