Robert M. McCarron, DO

Principal Source: Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, October 2007-September 2008. Ann Intern Med. 2007;147:725-729.—Discussant: Daniel Goldsmith, MD

Dr. Goldsmith is associate director, internal medicine residency program, Capital Health System, Trenton, NJ.

Psychiatric patients who use drugs, alcohol, or tobacco and those who engage in high-risk sexual behaviors can be protected from acquiring viral infections such as hepatitis A and B, influenza, and human papillomavirus (HPV). The recently updated adult immunization schedule (Table)^1,2 from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) gives mental health professionals the opportunity to recognize risk and refer patients for vaccinations as part of preventive care. (see Related Resources) for a link to the complete CDC vaccination recommendations.

Hepatitis A and B. Substance abuse and high-risk sexual behaviors contribute to the high prevalence of comorbid alcohol-related liver disease and viral hepatitis among psychiatric patients. Individuals with chronic liver disease—regardless of its cause—should be screened for hepatitis A and B infection and, if negative, offered the appropriate vaccination series. Acute viral hepatitis in patients with pre-existing chronic hepatitis from any cause, such as alcohol abuse or hepatitis C, is associated with severe hepatic dysfunction and liver failure.³

Hepatitis B screening and vaccination is recommended for psychiatric populations that include clients of substance abuse treatment centers and institutions and daycare facilities for developmental disabilities, as well as IV drug users. Anyone who uses illegal drugs—injectable or noninjectable—should be vaccinated for hepatitis A.

Only individuals susceptible to hepatitis A and B should be vaccinated.³ To determine immune status for hepatitis B, serum tests for hepatitis B surface antigen (HepBsAg), hepatitis B surface antibody IgG (HepBsAb), and hepatitis B core antibody IgG (HepBcAb) are necessary to differentiate among patients who:

• are susceptible to infection
• had an infection that cleared
• have chronic active infection
• already have been vaccinated.

The hepatitis A IgG serum test determines a patient’s hepatitis A immune status. A negative result shows no previous infection, and the patient is eligible for vaccination. A positive result indicates previous infection meaning vaccination has no benefit.³

Influenza. Tobacco use and subsequent chronic pulmonary disease is an indication for annual influenza vaccination.⁴ Most individuals will receive the injectable, inactivated vaccine. The intranasal, live attenuated vaccine is reserved for nonpregnant adults age ≤49 without high-risk medical conditions and who are not in close contact with immunocompromised persons.¹

Pneumococcal and influenza vaccinations also are recommended for persons with chronic liver disease.¹ Consider recommending influenza, pneumococcal, varicella, and hepatitis B vaccinations for psychiatric patients in long-term care facilities.¹

HPV. Cervical cancer is highly associated with HPV, a sexually transmitted organism, and the HPV vaccine can effectively prevent infection and subsequent neoplasia. All women age ≤26 are eligible for the vaccine. Women with evidence of HPV infection—such as abnormal Pap smear, genital warts, or a positive HPV DNA test—are still eligible to receive the HPV vaccine because several viral strains cause disease.¹ Because mental health providers may treat otherwise medically healthy young people, including those who engage in high-risk behaviors, psychiatrists have an opportunity to refer for vaccinations individuals who may not consistently utilize primary care.

Immunity screening considerations. Vaccines for HPV, influenza, and pneumonia are recommended regardless of evidence of immunity or prior infection. Hepatitis A and B vaccines require a history of never having had the illness or laboratory evidence of a lack of immunity.

Table

Updated CDC adult vaccination recommendations

Related resources

• Immunization Action Coalition: Vaccine information for health care professionals. www.immunize.org.
• Centers for Disease Control and Prevention. Adult immunization schedule. www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm.

Disclosure

Dr. Goldsmith reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Principal Source: Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, October 2007-September 2008. Ann Intern Med. 2007;147:725-729.—Discussant: Daniel Goldsmith, MD

Dr. Goldsmith is associate director, internal medicine residency program, Capital Health System, Trenton, NJ.

Psychiatric patients who use drugs, alcohol, or tobacco and those who engage in high-risk sexual behaviors can be protected from acquiring viral infections such as hepatitis A and B, influenza, and human papillomavirus (HPV). The recently updated adult immunization schedule (Table)^1,2 from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) gives mental health professionals the opportunity to recognize risk and refer patients for vaccinations as part of preventive care. (see Related Resources) for a link to the complete CDC vaccination recommendations.

Hepatitis A and B. Substance abuse and high-risk sexual behaviors contribute to the high prevalence of comorbid alcohol-related liver disease and viral hepatitis among psychiatric patients. Individuals with chronic liver disease—regardless of its cause—should be screened for hepatitis A and B infection and, if negative, offered the appropriate vaccination series. Acute viral hepatitis in patients with pre-existing chronic hepatitis from any cause, such as alcohol abuse or hepatitis C, is associated with severe hepatic dysfunction and liver failure.³

Hepatitis B screening and vaccination is recommended for psychiatric populations that include clients of substance abuse treatment centers and institutions and daycare facilities for developmental disabilities, as well as IV drug users. Anyone who uses illegal drugs—injectable or noninjectable—should be vaccinated for hepatitis A.

Only individuals susceptible to hepatitis A and B should be vaccinated.³ To determine immune status for hepatitis B, serum tests for hepatitis B surface antigen (HepBsAg), hepatitis B surface antibody IgG (HepBsAb), and hepatitis B core antibody IgG (HepBcAb) are necessary to differentiate among patients who:

• are susceptible to infection
• had an infection that cleared
• have chronic active infection
• already have been vaccinated.

The hepatitis A IgG serum test determines a patient’s hepatitis A immune status. A negative result shows no previous infection, and the patient is eligible for vaccination. A positive result indicates previous infection meaning vaccination has no benefit.³

Influenza. Tobacco use and subsequent chronic pulmonary disease is an indication for annual influenza vaccination.⁴ Most individuals will receive the injectable, inactivated vaccine. The intranasal, live attenuated vaccine is reserved for nonpregnant adults age ≤49 without high-risk medical conditions and who are not in close contact with immunocompromised persons.¹

Pneumococcal and influenza vaccinations also are recommended for persons with chronic liver disease.¹ Consider recommending influenza, pneumococcal, varicella, and hepatitis B vaccinations for psychiatric patients in long-term care facilities.¹

HPV. Cervical cancer is highly associated with HPV, a sexually transmitted organism, and the HPV vaccine can effectively prevent infection and subsequent neoplasia. All women age ≤26 are eligible for the vaccine. Women with evidence of HPV infection—such as abnormal Pap smear, genital warts, or a positive HPV DNA test—are still eligible to receive the HPV vaccine because several viral strains cause disease.¹ Because mental health providers may treat otherwise medically healthy young people, including those who engage in high-risk behaviors, psychiatrists have an opportunity to refer for vaccinations individuals who may not consistently utilize primary care.

Immunity screening considerations. Vaccines for HPV, influenza, and pneumonia are recommended regardless of evidence of immunity or prior infection. Hepatitis A and B vaccines require a history of never having had the illness or laboratory evidence of a lack of immunity.

Table

Updated CDC adult vaccination recommendations

Related resources

• Immunization Action Coalition: Vaccine information for health care professionals. www.immunize.org.
• Centers for Disease Control and Prevention. Adult immunization schedule. www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm.

Disclosure

Dr. Goldsmith reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Principal Source: Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, October 2007-September 2008. Ann Intern Med. 2007;147:725-729.—Discussant: Daniel Goldsmith, MD

Dr. Goldsmith is associate director, internal medicine residency program, Capital Health System, Trenton, NJ.

Psychiatric patients who use drugs, alcohol, or tobacco and those who engage in high-risk sexual behaviors can be protected from acquiring viral infections such as hepatitis A and B, influenza, and human papillomavirus (HPV). The recently updated adult immunization schedule (Table)^1,2 from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) gives mental health professionals the opportunity to recognize risk and refer patients for vaccinations as part of preventive care. (see Related Resources) for a link to the complete CDC vaccination recommendations.

Hepatitis A and B. Substance abuse and high-risk sexual behaviors contribute to the high prevalence of comorbid alcohol-related liver disease and viral hepatitis among psychiatric patients. Individuals with chronic liver disease—regardless of its cause—should be screened for hepatitis A and B infection and, if negative, offered the appropriate vaccination series. Acute viral hepatitis in patients with pre-existing chronic hepatitis from any cause, such as alcohol abuse or hepatitis C, is associated with severe hepatic dysfunction and liver failure.³

Hepatitis B screening and vaccination is recommended for psychiatric populations that include clients of substance abuse treatment centers and institutions and daycare facilities for developmental disabilities, as well as IV drug users. Anyone who uses illegal drugs—injectable or noninjectable—should be vaccinated for hepatitis A.

Only individuals susceptible to hepatitis A and B should be vaccinated.³ To determine immune status for hepatitis B, serum tests for hepatitis B surface antigen (HepBsAg), hepatitis B surface antibody IgG (HepBsAb), and hepatitis B core antibody IgG (HepBcAb) are necessary to differentiate among patients who:

• are susceptible to infection
• had an infection that cleared
• have chronic active infection
• already have been vaccinated.

The hepatitis A IgG serum test determines a patient’s hepatitis A immune status. A negative result shows no previous infection, and the patient is eligible for vaccination. A positive result indicates previous infection meaning vaccination has no benefit.³

Influenza. Tobacco use and subsequent chronic pulmonary disease is an indication for annual influenza vaccination.⁴ Most individuals will receive the injectable, inactivated vaccine. The intranasal, live attenuated vaccine is reserved for nonpregnant adults age ≤49 without high-risk medical conditions and who are not in close contact with immunocompromised persons.¹

Pneumococcal and influenza vaccinations also are recommended for persons with chronic liver disease.¹ Consider recommending influenza, pneumococcal, varicella, and hepatitis B vaccinations for psychiatric patients in long-term care facilities.¹

HPV. Cervical cancer is highly associated with HPV, a sexually transmitted organism, and the HPV vaccine can effectively prevent infection and subsequent neoplasia. All women age ≤26 are eligible for the vaccine. Women with evidence of HPV infection—such as abnormal Pap smear, genital warts, or a positive HPV DNA test—are still eligible to receive the HPV vaccine because several viral strains cause disease.¹ Because mental health providers may treat otherwise medically healthy young people, including those who engage in high-risk behaviors, psychiatrists have an opportunity to refer for vaccinations individuals who may not consistently utilize primary care.

Immunity screening considerations. Vaccines for HPV, influenza, and pneumonia are recommended regardless of evidence of immunity or prior infection. Hepatitis A and B vaccines require a history of never having had the illness or laboratory evidence of a lack of immunity.

Table

Updated CDC adult vaccination recommendations

Related resources

• Immunization Action Coalition: Vaccine information for health care professionals. www.immunize.org.
• Centers for Disease Control and Prevention. Adult immunization schedule. www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm.

Disclosure

Dr. Goldsmith reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI), with nearly 3 million new cases diagnosed annually in the United States.¹ In July 2007 the U.S. Preventive Services Task Force (USPSTF) updated its recommendation on Chlamydia screening of sexually active female adolescents and adults ( Table 1 ).² Routine screening is not recommended for men because there is not enough data to determine the benefits and risks of screening.

Although the USPSTF recommendation targets the general population, it is important to assess each patient’s sexual behavior. Women exhibiting impulsivity caused by bipolar mania, substance abuse, or personality disorders or who exchange sex for food, shelter, substances, or money are at high risk of infection ( Table 2 ).^1,2

The new guideline introduces a screening cutoff at age 25 because women age <25 years are 5 times more likely than women age >30 to have chlamydial infection.² In women age ≥25, yearly screening is recommended only for those at high risk as indicated by:

• previous chlamydial infection or other STIs
• new or multiple sexual partners
• inconsistent condom use
• being a sex worker ( Table 2 ).²

Chlamydia screening reduces the incidence of pelvic inflammatory disease (PID) in nonpregnant adolescent and adult women, which can cause infertility, ectopic pregnancy, and chronic pelvic pain.² If untreated, the risk of PID approaches 40%.¹ In pregnant women, Chlamydia treatment significantly improves birth outcomes. Pregnant women should be screened during the first prenatal visit and in the third trimester if at continued risk.

Psychological implications of screening. Address possible themes of guilt and shame with patients to clarify and alleviate the burden they may feel about STI screening and treatment. Compared with men, women experience more stigmatization, blame, and denial about the source of infection. Women also report being more concerned about potential threats to their relationships.¹

Table 1

U.S. Preventive Services Task Force
screening recommendations for chlamydial infection

Table 2

Risks for chlamydial infection

Screening test. The Centers for Disease Control and Prevention (CDC) recommends screening with nucleic acid amplification tests (NAATs), which have high specificity (>95%) and sensitivity (80% to 93%) for chlamydial infections. Urine specimens are comparable to cervical and urethral specimens and avert the cost and patient discomfort associated with speculum exams.³ NAATs do not exclude other infections, such as trichomonas, however, and are not sufficient in patients with active urinary or vaginal symptoms.

Clinical presentation and treatment. Most persons with Chlamydia are asymptomatic and may infect new sexual partners. In women, chlamydial infection may cause cervicitis, urethritis, PID, chronic pelvic pain, ectopic pregnancy, miscarriage, preterm labor, and infertility. In men, chlamydial infection may cause urethritis, urethral strictures, and epididymis. In both genders, chlamydial infection increases the risk of acquiring other STIs, such as human immunodeficiency virus.⁴

The CDC recommends treating chlamydial infection with azithromycin, 1 g/d PO for pregnant and nonpregnant women. Alternatives include amoxicillin, 500 mg tid for 7 days for pregnant women, or doxycycline, 100 mg bid for 7 days for nonpregnant women. Sexual partners of an infected individual should be treated presumptively or tested and then treated. Because Chlamydia NAAT is highly sensitive, patients with a negative test do not need treatment. Patients who test positive for gonorrhea and receive a negative non-NAAT (antigen-based tests that are less sensitive than NAATs) for Chlamydia should be treated for both.⁵

Related resources

• Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. www.cdc.gov/std/treatment.
• U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Preventive Services. www.preventiveservices.ahrq.gov.

Drug brand names

• Amoxicillin • Amoxil, others
• Azithromycin • Zithromax
• Doxycycline • Vibramycin

Disclosure

Dr. Xiong reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI), with nearly 3 million new cases diagnosed annually in the United States.¹ In July 2007 the U.S. Preventive Services Task Force (USPSTF) updated its recommendation on Chlamydia screening of sexually active female adolescents and adults ( Table 1 ).² Routine screening is not recommended for men because there is not enough data to determine the benefits and risks of screening.

Although the USPSTF recommendation targets the general population, it is important to assess each patient’s sexual behavior. Women exhibiting impulsivity caused by bipolar mania, substance abuse, or personality disorders or who exchange sex for food, shelter, substances, or money are at high risk of infection ( Table 2 ).^1,2

The new guideline introduces a screening cutoff at age 25 because women age <25 years are 5 times more likely than women age >30 to have chlamydial infection.² In women age ≥25, yearly screening is recommended only for those at high risk as indicated by:

• previous chlamydial infection or other STIs
• new or multiple sexual partners
• inconsistent condom use
• being a sex worker ( Table 2 ).²

Chlamydia screening reduces the incidence of pelvic inflammatory disease (PID) in nonpregnant adolescent and adult women, which can cause infertility, ectopic pregnancy, and chronic pelvic pain.² If untreated, the risk of PID approaches 40%.¹ In pregnant women, Chlamydia treatment significantly improves birth outcomes. Pregnant women should be screened during the first prenatal visit and in the third trimester if at continued risk.

Psychological implications of screening. Address possible themes of guilt and shame with patients to clarify and alleviate the burden they may feel about STI screening and treatment. Compared with men, women experience more stigmatization, blame, and denial about the source of infection. Women also report being more concerned about potential threats to their relationships.¹

Table 1

U.S. Preventive Services Task Force
screening recommendations for chlamydial infection

Table 2

Risks for chlamydial infection

Screening test. The Centers for Disease Control and Prevention (CDC) recommends screening with nucleic acid amplification tests (NAATs), which have high specificity (>95%) and sensitivity (80% to 93%) for chlamydial infections. Urine specimens are comparable to cervical and urethral specimens and avert the cost and patient discomfort associated with speculum exams.³ NAATs do not exclude other infections, such as trichomonas, however, and are not sufficient in patients with active urinary or vaginal symptoms.

Clinical presentation and treatment. Most persons with Chlamydia are asymptomatic and may infect new sexual partners. In women, chlamydial infection may cause cervicitis, urethritis, PID, chronic pelvic pain, ectopic pregnancy, miscarriage, preterm labor, and infertility. In men, chlamydial infection may cause urethritis, urethral strictures, and epididymis. In both genders, chlamydial infection increases the risk of acquiring other STIs, such as human immunodeficiency virus.⁴

The CDC recommends treating chlamydial infection with azithromycin, 1 g/d PO for pregnant and nonpregnant women. Alternatives include amoxicillin, 500 mg tid for 7 days for pregnant women, or doxycycline, 100 mg bid for 7 days for nonpregnant women. Sexual partners of an infected individual should be treated presumptively or tested and then treated. Because Chlamydia NAAT is highly sensitive, patients with a negative test do not need treatment. Patients who test positive for gonorrhea and receive a negative non-NAAT (antigen-based tests that are less sensitive than NAATs) for Chlamydia should be treated for both.⁵

Related resources

• Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. www.cdc.gov/std/treatment.
• U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Preventive Services. www.preventiveservices.ahrq.gov.

Drug brand names

• Amoxicillin • Amoxil, others
• Azithromycin • Zithromax
• Doxycycline • Vibramycin

Disclosure

Dr. Xiong reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI), with nearly 3 million new cases diagnosed annually in the United States.¹ In July 2007 the U.S. Preventive Services Task Force (USPSTF) updated its recommendation on Chlamydia screening of sexually active female adolescents and adults ( Table 1 ).² Routine screening is not recommended for men because there is not enough data to determine the benefits and risks of screening.

Although the USPSTF recommendation targets the general population, it is important to assess each patient’s sexual behavior. Women exhibiting impulsivity caused by bipolar mania, substance abuse, or personality disorders or who exchange sex for food, shelter, substances, or money are at high risk of infection ( Table 2 ).^1,2

The new guideline introduces a screening cutoff at age 25 because women age <25 years are 5 times more likely than women age >30 to have chlamydial infection.² In women age ≥25, yearly screening is recommended only for those at high risk as indicated by:

• previous chlamydial infection or other STIs
• new or multiple sexual partners
• inconsistent condom use
• being a sex worker ( Table 2 ).²

Chlamydia screening reduces the incidence of pelvic inflammatory disease (PID) in nonpregnant adolescent and adult women, which can cause infertility, ectopic pregnancy, and chronic pelvic pain.² If untreated, the risk of PID approaches 40%.¹ In pregnant women, Chlamydia treatment significantly improves birth outcomes. Pregnant women should be screened during the first prenatal visit and in the third trimester if at continued risk.

Psychological implications of screening. Address possible themes of guilt and shame with patients to clarify and alleviate the burden they may feel about STI screening and treatment. Compared with men, women experience more stigmatization, blame, and denial about the source of infection. Women also report being more concerned about potential threats to their relationships.¹

Table 1

U.S. Preventive Services Task Force
screening recommendations for chlamydial infection

Table 2

Risks for chlamydial infection

Screening test. The Centers for Disease Control and Prevention (CDC) recommends screening with nucleic acid amplification tests (NAATs), which have high specificity (>95%) and sensitivity (80% to 93%) for chlamydial infections. Urine specimens are comparable to cervical and urethral specimens and avert the cost and patient discomfort associated with speculum exams.³ NAATs do not exclude other infections, such as trichomonas, however, and are not sufficient in patients with active urinary or vaginal symptoms.

Clinical presentation and treatment. Most persons with Chlamydia are asymptomatic and may infect new sexual partners. In women, chlamydial infection may cause cervicitis, urethritis, PID, chronic pelvic pain, ectopic pregnancy, miscarriage, preterm labor, and infertility. In men, chlamydial infection may cause urethritis, urethral strictures, and epididymis. In both genders, chlamydial infection increases the risk of acquiring other STIs, such as human immunodeficiency virus.⁴

The CDC recommends treating chlamydial infection with azithromycin, 1 g/d PO for pregnant and nonpregnant women. Alternatives include amoxicillin, 500 mg tid for 7 days for pregnant women, or doxycycline, 100 mg bid for 7 days for nonpregnant women. Sexual partners of an infected individual should be treated presumptively or tested and then treated. Because Chlamydia NAAT is highly sensitive, patients with a negative test do not need treatment. Patients who test positive for gonorrhea and receive a negative non-NAAT (antigen-based tests that are less sensitive than NAATs) for Chlamydia should be treated for both.⁵

Related resources

• Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. www.cdc.gov/std/treatment.
• U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Preventive Services. www.preventiveservices.ahrq.gov.

Drug brand names

• Amoxicillin • Amoxil, others
• Azithromycin • Zithromax
• Doxycycline • Vibramycin

Disclosure

Dr. Xiong reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Some patients at high risk for mental illness—intravenous drug users, prisoners, human immunodeficiency virus-positive patients, and the homeless—also are at risk of community-acquired, methicillin-resistant Staphylococcus aureus (CA-MRSA) infections.¹ Because your patients may present with CA-MRSA symptoms, you need a basic understanding of this infection’s risk factors and clinical features to initiate necessary referrals (Table).²

Table

Features of community-acquired MRSA infections

Risk factors and transmission

CA-MRSA accounts for 78% of skin and soft tissue infections in emergency rooms.³ Patients typically have no known risk factors for infection or health-related exposures, such as recent hospitalization or employment in a healthcare setting. Persons who have taken antibiotics in the past 12 months are at increased risk.^1,3,4

Infection spreads by person-to-person contact. In the community, crowding and sharing personal items also facilitate transmission, which accounts for increased risk among military personnel and athletes in contact sports.¹ Therefore, caution psychiatric patients against sharing personal hygiene items, such as towels, and instruct infected patients to keep abscess sites covered at all times. Stress the importance of consistent handwashing.

Infection also may be acquired through a skin abrasion, although many infected patients do not remember having local skin trauma.

Clinical presentation. Unlike diffuse drug eruptions associated with psychotropic hypersensitivity reactions, skin involvement caused by CA-MRSA typically is limited. Patients generally present with a warm, swollen, and erythematous area of skin or a circumscribed abscess involving a hair follicle.¹ Often patients attribute symptoms to a recent spider bite or report that a family member or friend has a similar rash or lesion.³

Single lesions on the extremities are common, although multiple “boils” are possible. Fluctuance—a wavelike motion beneath the lesion when pressure is applied—may be present. Fever and chills usually are absent unless the infection is invasive or systemic (Photo). Serious forms of infection—such as impetigo and necrotizing fasciitis—are less common, although the latter has been reported more frequently among IV drug users.¹

© 2001-2007 DermAtlas

Warm, swollen, erythematous skin with red papules and plaques with central pustules often on the extremities. Treatment. Although the prognosis for most CA-MRSA skin and soft tissue infections is favorable, serious and potentially life-threatening complications can emerge.¹ Most infections can be treated successfully with antibiotics and—when an abscess is present—incision and drainage performed in a primary care physician’s office. Trimethoprim-sulfamethoxazole—a commonly used antibiotic—can decrease serum levels of tricyclic antidepressants and prolong the QT interval. Be aware of this interaction in patients receiving antipsychotics, which also can prolong the QT interval.

Referral to a primary care physician for further management is appropriate for afebrile patients without a history of immunosuppression who present with localized rash involving 1 extremity. Severe infection with bacteremia or other systemic involvement is possible, especially in patients age ≥65.⁵ Consider ER referral for patients with:

• compromised immune systems
• high fever and/or chills
• rapidly progressing symptoms
• signs and symptoms consistent with systemic illness, such as shortness of breath or low blood pressure
• disease involving >1 extremity or multiple abscesses.

Related resources

• Centers for Disease Control and Prevention. Overview of community-associated MRSA. www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html.
• Zeller JL, Burke AE, Glass RM. JAMA patient page. MRSA infections. JAMA 2007;298(15):1826. Available at: http://jama.ama-assn.org/cgi/content/full/298/15/1826.

Drug brand name

• Trimethoprim-sulfamethoxazole • Bactrim, Septra

Disclosures

Dr. Hebert reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Rado receives grant/research support from Neuronetics, Eli Lilly and Company, and Janssen Pharmaceutica.

Some patients at high risk for mental illness—intravenous drug users, prisoners, human immunodeficiency virus-positive patients, and the homeless—also are at risk of community-acquired, methicillin-resistant Staphylococcus aureus (CA-MRSA) infections.¹ Because your patients may present with CA-MRSA symptoms, you need a basic understanding of this infection’s risk factors and clinical features to initiate necessary referrals (Table).²

Table

Features of community-acquired MRSA infections

Risk factors and transmission

CA-MRSA accounts for 78% of skin and soft tissue infections in emergency rooms.³ Patients typically have no known risk factors for infection or health-related exposures, such as recent hospitalization or employment in a healthcare setting. Persons who have taken antibiotics in the past 12 months are at increased risk.^1,3,4

Infection spreads by person-to-person contact. In the community, crowding and sharing personal items also facilitate transmission, which accounts for increased risk among military personnel and athletes in contact sports.¹ Therefore, caution psychiatric patients against sharing personal hygiene items, such as towels, and instruct infected patients to keep abscess sites covered at all times. Stress the importance of consistent handwashing.

Infection also may be acquired through a skin abrasion, although many infected patients do not remember having local skin trauma.

Clinical presentation. Unlike diffuse drug eruptions associated with psychotropic hypersensitivity reactions, skin involvement caused by CA-MRSA typically is limited. Patients generally present with a warm, swollen, and erythematous area of skin or a circumscribed abscess involving a hair follicle.¹ Often patients attribute symptoms to a recent spider bite or report that a family member or friend has a similar rash or lesion.³

Single lesions on the extremities are common, although multiple “boils” are possible. Fluctuance—a wavelike motion beneath the lesion when pressure is applied—may be present. Fever and chills usually are absent unless the infection is invasive or systemic (Photo). Serious forms of infection—such as impetigo and necrotizing fasciitis—are less common, although the latter has been reported more frequently among IV drug users.¹

© 2001-2007 DermAtlas

Warm, swollen, erythematous skin with red papules and plaques with central pustules often on the extremities. Treatment. Although the prognosis for most CA-MRSA skin and soft tissue infections is favorable, serious and potentially life-threatening complications can emerge.¹ Most infections can be treated successfully with antibiotics and—when an abscess is present—incision and drainage performed in a primary care physician’s office. Trimethoprim-sulfamethoxazole—a commonly used antibiotic—can decrease serum levels of tricyclic antidepressants and prolong the QT interval. Be aware of this interaction in patients receiving antipsychotics, which also can prolong the QT interval.

Referral to a primary care physician for further management is appropriate for afebrile patients without a history of immunosuppression who present with localized rash involving 1 extremity. Severe infection with bacteremia or other systemic involvement is possible, especially in patients age ≥65.⁵ Consider ER referral for patients with:

• compromised immune systems
• high fever and/or chills
• rapidly progressing symptoms
• signs and symptoms consistent with systemic illness, such as shortness of breath or low blood pressure
• disease involving >1 extremity or multiple abscesses.

Related resources

• Centers for Disease Control and Prevention. Overview of community-associated MRSA. www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html.
• Zeller JL, Burke AE, Glass RM. JAMA patient page. MRSA infections. JAMA 2007;298(15):1826. Available at: http://jama.ama-assn.org/cgi/content/full/298/15/1826.

Drug brand name

• Trimethoprim-sulfamethoxazole • Bactrim, Septra

Disclosures

Dr. Hebert reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Rado receives grant/research support from Neuronetics, Eli Lilly and Company, and Janssen Pharmaceutica.

Some patients at high risk for mental illness—intravenous drug users, prisoners, human immunodeficiency virus-positive patients, and the homeless—also are at risk of community-acquired, methicillin-resistant Staphylococcus aureus (CA-MRSA) infections.¹ Because your patients may present with CA-MRSA symptoms, you need a basic understanding of this infection’s risk factors and clinical features to initiate necessary referrals (Table).²

Table

Features of community-acquired MRSA infections

Risk factors and transmission

CA-MRSA accounts for 78% of skin and soft tissue infections in emergency rooms.³ Patients typically have no known risk factors for infection or health-related exposures, such as recent hospitalization or employment in a healthcare setting. Persons who have taken antibiotics in the past 12 months are at increased risk.^1,3,4

Infection spreads by person-to-person contact. In the community, crowding and sharing personal items also facilitate transmission, which accounts for increased risk among military personnel and athletes in contact sports.¹ Therefore, caution psychiatric patients against sharing personal hygiene items, such as towels, and instruct infected patients to keep abscess sites covered at all times. Stress the importance of consistent handwashing.

Infection also may be acquired through a skin abrasion, although many infected patients do not remember having local skin trauma.

Clinical presentation. Unlike diffuse drug eruptions associated with psychotropic hypersensitivity reactions, skin involvement caused by CA-MRSA typically is limited. Patients generally present with a warm, swollen, and erythematous area of skin or a circumscribed abscess involving a hair follicle.¹ Often patients attribute symptoms to a recent spider bite or report that a family member or friend has a similar rash or lesion.³

Single lesions on the extremities are common, although multiple “boils” are possible. Fluctuance—a wavelike motion beneath the lesion when pressure is applied—may be present. Fever and chills usually are absent unless the infection is invasive or systemic (Photo). Serious forms of infection—such as impetigo and necrotizing fasciitis—are less common, although the latter has been reported more frequently among IV drug users.¹

© 2001-2007 DermAtlas

Warm, swollen, erythematous skin with red papules and plaques with central pustules often on the extremities. Treatment. Although the prognosis for most CA-MRSA skin and soft tissue infections is favorable, serious and potentially life-threatening complications can emerge.¹ Most infections can be treated successfully with antibiotics and—when an abscess is present—incision and drainage performed in a primary care physician’s office. Trimethoprim-sulfamethoxazole—a commonly used antibiotic—can decrease serum levels of tricyclic antidepressants and prolong the QT interval. Be aware of this interaction in patients receiving antipsychotics, which also can prolong the QT interval.

Referral to a primary care physician for further management is appropriate for afebrile patients without a history of immunosuppression who present with localized rash involving 1 extremity. Severe infection with bacteremia or other systemic involvement is possible, especially in patients age ≥65.⁵ Consider ER referral for patients with:

• compromised immune systems
• high fever and/or chills
• rapidly progressing symptoms
• signs and symptoms consistent with systemic illness, such as shortness of breath or low blood pressure
• disease involving >1 extremity or multiple abscesses.

Related resources

• Centers for Disease Control and Prevention. Overview of community-associated MRSA. www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html.
• Zeller JL, Burke AE, Glass RM. JAMA patient page. MRSA infections. JAMA 2007;298(15):1826. Available at: http://jama.ama-assn.org/cgi/content/full/298/15/1826.

Drug brand name

• Trimethoprim-sulfamethoxazole • Bactrim, Septra

Disclosures

Dr. Hebert reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Rado receives grant/research support from Neuronetics, Eli Lilly and Company, and Janssen Pharmaceutica.

One in five of your patients could suffer a heart attack in the near future—unless you take steps to ensure their heart health.

Psychiatric patients have more modifiable risk factors for coronary artery disease (CAD) compared with the general population.^{When depression treatment goes nowhere,” Current Psychiatry, August 2005.)}

To help keep you abreast of constantly changing guidelines and strategies for recognizing and minimizing CAD risk, this article discusses:

• preventive and diagnostic guidelines for managing hypertension, diabetes, and dyslipidemia
  
• practical advice on convincing at-risk patients to adopt a healthier lifestyle and have a primary care doctor monitor their health.
  

Case: cigarettes and supersizing

Mr. H, age 54, is receiving cognitive-behavioral therapy for mild depression. He has been smoking one pack of cigarettes per day for 20 years and has never seriously considered quitting.

The patient, a school teacher, says his “busy schedule” keeps him from exercising and eating properly; he eats fast-food hamburgers and fries approximately five times per week. His father had a heart attack at age 52 and died in his sleep 10 years later.

Mr. H says he feels fine and has never seen a physician other than his psychiatrist. He is reluctant to see a primary care physician for a check-up and, because he is asymptomatic, has no incentive to do so. The psychiatrist thus decides to do a routine examination.

Blood pressure is 148/86; other vital signs are normal. Mr. H’s waist size is 42 inches, he weighs 242 lbs, and his body mass index (BMI) is 34 kg/m², indicating clinical obesity. Cardiovascular, pulmonary, and abdominal exams are unremarkable.

Discussion. Mr. H is at high risk of a myocardial ischemic event in the near future. He has six risk factors for CAD (Table 1)—four of which are modifiable:

• family history
  
• age
  
• current cigarette use
  
• provisional hypertension diagnosis
  
• obesity
  
• physical inactivity.
  

Table 1

Risk factors for coronary artery disease

Tools for assessing risk

The lifetime risk at age 40 for developing CAD is 49% and 32% in men and women, respectively.⁶

The National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel) has focused on decreasing heart disease incidence by educating patients and providers. Preventive strategies and standards of care have changed several times over the past decade; the Adult Treatment Panel (ATP III) was last revised in July 2004.⁷

The American College of Cardiology and American Heart Association both endorse the modified Framingham/ATP III scale to measure CAD risk (see Related resources). Although this somewhat tedious point system has limitations, it can precisely calculate coronary risk across 10 years.⁸ Variables not included in the scoring system—such as C-reactive protein, homocysteine, and postmenopausal state—may be clinically significant and should be gauged separately.

An easier-to-use alternative, the ATP III “core risk factors” scale, estimates hypertension, hypercholesterolemia, family history, current cigarette smoking, and age as low, intermediate, or high (“risk equivalent”) risks (Table 1).⁸ Psychiatrists can quickly obtain this information from a brief history, blood pressure assessment, and relatively inexpensive lab studies.

Generally, the more risk factors present, the higher the risk of having a major coronary event. Presence of ≥ 2 risk factors signals intermediate or high risk and necessitates referral to a primary care doctor for monitoring.

Patients with a cardiac “risk equivalent” face a >20% risk of having a cardiac ischemic event within 10 years⁸ (Table 2). Examples of risk equivalents include diabetes or significant vascular disease in any artery.

“Non-core” variables. Also consider certain “non-core” variables—such as pre-existing psychiatric illness—when estimating clinical risk for heart disease. Depression, anxiety, and stress are correlated with an increase in pro-inflammatory markers such as C-reactive protein and predispose patients to CAD.^11,12 Depression has repeatedly been shown to increase morbidity and mortality two- to four-fold after myocardial infarction (MI).^9,13,14 Interestingly, however, depression treatment after an acute coronary event does not clearly decrease mortality.¹⁵ Although prospective, randomized studies are lacking, mood and anxiety disorder treatment is presumed to help prevent CAD development.¹⁶

Table 2

Risk equivalents for CAD*

Recognizing cad risk

At what point do hypertension and dyslipidemia become risk factors for CAD? When and how often should patients be screened for diabetes mellitus?

Hypertension is one of the most common and deadly CAD risk factors, affecting 50 million Americans.¹⁰ Although hypertension awareness and treatment have improved, only 35% of adults have “controlled” blood pressure (

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), normalizing blood pressure can reduce stroke incidence by 35% and MI by 25%, respectively. JNC 7, however, also found that 90% of persons who are normotensive at age 55 eventually develop hypertension.¹⁰

Based on these findings, JNC 7 in 2003 drastically changed the standard of care for diagnosing hypertension. JNC 7 defines normal blood pressure as

• systolic blood pressure 120 to 139 mm Hg
  
• diastolic blood pressure 80 to 89 mm Hg (Table 3).
  

Patients with diabetes mellitus or chronic kidney disease are considered hypertensive with blood pressure >130 mm Hg systolic and/or >80 mm Hg diastolic.

As with Mr. H, a blood pressure check is imperative for patients who have rarely or never seen a primary care physician in recent years. The U.S. Preventive Services Task Force strongly recommends measuring blood pressure during a routine medical evaluation at least every 2 years. A second abnormal reading at a separate visit at any time should prompt a hypertension diagnosis. Once diagnosed with hypertension, patients should be treated and checked monthly until stable, then monitored every 3 to 6 months indefinitely.¹⁰

If you cannot measure blood pressure in the office, urge patients to use an over-the-counter blood pressure measuring device and refer them to a primary care physician. Check the patient’s self-test reading for accuracy against a clinician’s measurement.

Diabetes is now considered a risk equivalent for CAD development.⁸ Patients diagnosed with diabetes are extremely likely to have established vascular disease,⁸ which predisposes them to MI, stroke, kidney disease, blindness, and lower-extremity amputations.¹⁷ Those with type 1 diabetes usually present with acute symptoms—including polyuria, polydipsia, weight loss, malaise, dry mouth, and blurred vision—and are readily diagnosed with elevated plasma glucose.

Screening for diabetes is critical because one-third of patients with the disease are undiagnosed. Also, more than 90% of patients with diabetes are non-insulin-dependent (type 2) and are asymptomatic early in the disease course.

No data definitively show benefits from screening asymptomatic adults. Recently revised diagnostic criteria for diabetes, however, call for re-testing asymptomatic patients who were found to have normal fasting plasma glucose (FPG) levels and were considered “free” of diabetes. The American Diabetes Association recommends measuring FPG after no caloric intake for ≥ 8 hours for asymptomatic patients.

FPG measurement is cost-effective and generally more convenient than other diabetes tests.¹⁷ Expert consensus strongly suggests checking FPG every 3 years beginning at age 45:¹⁷

• FPG
• FPG 100 to 125 mg/dL suggests prediabetes or impaired fasting glucose
  
• FPG ≥ 126 mg/dL demands a provisional diabetes diagnosis and a follow-up test on another day to confirm the diagnosis.
  

• comorbid cardiac risk factors
  
• history of polycystic ovary disease
  
• a first-degree relative with diabetes
  
• habitual inactivity
  
• or FPG 100 to 125 mg/dL.
  

Do not base diabetes diagnosis on glycosylated hemoglobin measurements, as this test can produce false-negative results in patients with new-onset diabetes.

Dyslipidemia. Every 10% reduction in serum cholesterol reduces cardiovascular mortality by 10% to 15%.¹⁹ Data from the large, prospective Framingham heart study show a 25% increase in MIs with each 5-mg/dL decrease in high-density lipoprotein cholesterol (HDL) below the age-based median for men and women.²⁰ Serum triglycerides >150 mg/dL clearly predict future CAD and increase the likelihood of abnormally low HDL.

Every 30-mg/dL increase in low-density lipoprotein cholesterol (LDL) raises the relative risk for CAD by 30%.⁷ ATP III classifies LDL as the “primary target of cholesterol-lowering therapy.”⁸Table 4 lists LDL target levels based on other CAD risk factors.

Check fasting lipid profile or serum cholesterol, LDL, HDL, and triglycerides beginning at age 20 and about every 5 years thereafter.⁸ Total cholesterol

Table 3

JNC 7: What blood pressure readings mean

Acceptable LDL cholesterol levels for adults based on CAD risk

Addressing smoking, obesity

Smoking. Before trying nicotine patches or bupropion, Mr. H should realistically contemplate his risks with continued smoking; if he doesn’t want to stop, periodically encourage him to reconsider.¹⁰ Most people know the dangers of smoking but few understand that complete cessation for 1 to 2 years often nearly reverses cardiovascular disease.²¹

Obesity and lack of exercise go hand in hand. Reducing Mr. H’s waist size to 2 is a reasonable short-term goal. To that end, encourage him to:

• decrease his number of weekly fast-food meals from five to three, with an eventual goal of one per week. As an alternative, microwaveable, low-calorie meals—each with at least two servings of fruits or vegetables—can be prepared at home or work.
  
• walk 30 minutes three times weekly and progress to 1 hour five times weekly over 6 months. As with any exercise program, remind Mr. H to “start low and go slow.”
  

The patient’s role in treatment. Patients often feel overwhelmed after getting large amounts of information on CAD risk and may feel hopeless and unenthusiastic about improving their physical health. Work with the primary care doctor to emphasize a patient care plan that clearly defines easily attainable, step-by-step goals. Make sure the patient agrees to these goals.

Case continued: no more supersizing

Mr. H now understands the importance of minimizing his CAD risk and realizes that CAD and many associated risk factors are asymptomatic in the early stages of development.

With help from his doctors, Mr. H quit smoking. He also became more mindful of his caloric intake and the types of foods he was eating. He advanced from briskly walking 30 minutes three times per week to slow jogging 40 minutes five times weekly. He still eats at fast-food restaurants but usually orders broiled chicken, salads, or the occasional burger.

Related resources

• National Cholesterol Education Program. CAD risk assessment tool and ATP III guidelines. www.nhlbi.nih.gov/guidelines/cholesterol/.
  
• U.S. Preventive Services Task Force preventive guidelines. www.ahrq.gov/clinic/uspstfix.htm.
  
• National Heart, Lung, and Blood Institute. Calculate your body mass index. http://nhlbisupport.com/bmi/.
  
• American Heart Association. www.americanheart.org.
  

One in five of your patients could suffer a heart attack in the near future—unless you take steps to ensure their heart health.

Psychiatric patients have more modifiable risk factors for coronary artery disease (CAD) compared with the general population.^{When depression treatment goes nowhere,” Current Psychiatry, August 2005.)}

To help keep you abreast of constantly changing guidelines and strategies for recognizing and minimizing CAD risk, this article discusses:

• preventive and diagnostic guidelines for managing hypertension, diabetes, and dyslipidemia
  
• practical advice on convincing at-risk patients to adopt a healthier lifestyle and have a primary care doctor monitor their health.
  

Case: cigarettes and supersizing

Mr. H, age 54, is receiving cognitive-behavioral therapy for mild depression. He has been smoking one pack of cigarettes per day for 20 years and has never seriously considered quitting.

The patient, a school teacher, says his “busy schedule” keeps him from exercising and eating properly; he eats fast-food hamburgers and fries approximately five times per week. His father had a heart attack at age 52 and died in his sleep 10 years later.

Mr. H says he feels fine and has never seen a physician other than his psychiatrist. He is reluctant to see a primary care physician for a check-up and, because he is asymptomatic, has no incentive to do so. The psychiatrist thus decides to do a routine examination.

Blood pressure is 148/86; other vital signs are normal. Mr. H’s waist size is 42 inches, he weighs 242 lbs, and his body mass index (BMI) is 34 kg/m², indicating clinical obesity. Cardiovascular, pulmonary, and abdominal exams are unremarkable.

Discussion. Mr. H is at high risk of a myocardial ischemic event in the near future. He has six risk factors for CAD (Table 1)—four of which are modifiable:

• family history
  
• age
  
• current cigarette use
  
• provisional hypertension diagnosis
  
• obesity
  
• physical inactivity.
  

Table 1

Risk factors for coronary artery disease

Tools for assessing risk

The lifetime risk at age 40 for developing CAD is 49% and 32% in men and women, respectively.⁶

The National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel) has focused on decreasing heart disease incidence by educating patients and providers. Preventive strategies and standards of care have changed several times over the past decade; the Adult Treatment Panel (ATP III) was last revised in July 2004.⁷

The American College of Cardiology and American Heart Association both endorse the modified Framingham/ATP III scale to measure CAD risk (see Related resources). Although this somewhat tedious point system has limitations, it can precisely calculate coronary risk across 10 years.⁸ Variables not included in the scoring system—such as C-reactive protein, homocysteine, and postmenopausal state—may be clinically significant and should be gauged separately.

An easier-to-use alternative, the ATP III “core risk factors” scale, estimates hypertension, hypercholesterolemia, family history, current cigarette smoking, and age as low, intermediate, or high (“risk equivalent”) risks (Table 1).⁸ Psychiatrists can quickly obtain this information from a brief history, blood pressure assessment, and relatively inexpensive lab studies.

Generally, the more risk factors present, the higher the risk of having a major coronary event. Presence of ≥ 2 risk factors signals intermediate or high risk and necessitates referral to a primary care doctor for monitoring.

Patients with a cardiac “risk equivalent” face a >20% risk of having a cardiac ischemic event within 10 years⁸ (Table 2). Examples of risk equivalents include diabetes or significant vascular disease in any artery.

“Non-core” variables. Also consider certain “non-core” variables—such as pre-existing psychiatric illness—when estimating clinical risk for heart disease. Depression, anxiety, and stress are correlated with an increase in pro-inflammatory markers such as C-reactive protein and predispose patients to CAD.^11,12 Depression has repeatedly been shown to increase morbidity and mortality two- to four-fold after myocardial infarction (MI).^9,13,14 Interestingly, however, depression treatment after an acute coronary event does not clearly decrease mortality.¹⁵ Although prospective, randomized studies are lacking, mood and anxiety disorder treatment is presumed to help prevent CAD development.¹⁶

Table 2

Risk equivalents for CAD*

Recognizing cad risk

At what point do hypertension and dyslipidemia become risk factors for CAD? When and how often should patients be screened for diabetes mellitus?

Hypertension is one of the most common and deadly CAD risk factors, affecting 50 million Americans.¹⁰ Although hypertension awareness and treatment have improved, only 35% of adults have “controlled” blood pressure (

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), normalizing blood pressure can reduce stroke incidence by 35% and MI by 25%, respectively. JNC 7, however, also found that 90% of persons who are normotensive at age 55 eventually develop hypertension.¹⁰

Based on these findings, JNC 7 in 2003 drastically changed the standard of care for diagnosing hypertension. JNC 7 defines normal blood pressure as

• systolic blood pressure 120 to 139 mm Hg
  
• diastolic blood pressure 80 to 89 mm Hg (Table 3).
  

Patients with diabetes mellitus or chronic kidney disease are considered hypertensive with blood pressure >130 mm Hg systolic and/or >80 mm Hg diastolic.

As with Mr. H, a blood pressure check is imperative for patients who have rarely or never seen a primary care physician in recent years. The U.S. Preventive Services Task Force strongly recommends measuring blood pressure during a routine medical evaluation at least every 2 years. A second abnormal reading at a separate visit at any time should prompt a hypertension diagnosis. Once diagnosed with hypertension, patients should be treated and checked monthly until stable, then monitored every 3 to 6 months indefinitely.¹⁰

If you cannot measure blood pressure in the office, urge patients to use an over-the-counter blood pressure measuring device and refer them to a primary care physician. Check the patient’s self-test reading for accuracy against a clinician’s measurement.

Diabetes is now considered a risk equivalent for CAD development.⁸ Patients diagnosed with diabetes are extremely likely to have established vascular disease,⁸ which predisposes them to MI, stroke, kidney disease, blindness, and lower-extremity amputations.¹⁷ Those with type 1 diabetes usually present with acute symptoms—including polyuria, polydipsia, weight loss, malaise, dry mouth, and blurred vision—and are readily diagnosed with elevated plasma glucose.

Screening for diabetes is critical because one-third of patients with the disease are undiagnosed. Also, more than 90% of patients with diabetes are non-insulin-dependent (type 2) and are asymptomatic early in the disease course.

No data definitively show benefits from screening asymptomatic adults. Recently revised diagnostic criteria for diabetes, however, call for re-testing asymptomatic patients who were found to have normal fasting plasma glucose (FPG) levels and were considered “free” of diabetes. The American Diabetes Association recommends measuring FPG after no caloric intake for ≥ 8 hours for asymptomatic patients.

FPG measurement is cost-effective and generally more convenient than other diabetes tests.¹⁷ Expert consensus strongly suggests checking FPG every 3 years beginning at age 45:¹⁷

• FPG
• FPG 100 to 125 mg/dL suggests prediabetes or impaired fasting glucose
  
• FPG ≥ 126 mg/dL demands a provisional diabetes diagnosis and a follow-up test on another day to confirm the diagnosis.
  

• comorbid cardiac risk factors
  
• history of polycystic ovary disease
  
• a first-degree relative with diabetes
  
• habitual inactivity
  
• or FPG 100 to 125 mg/dL.
  

Do not base diabetes diagnosis on glycosylated hemoglobin measurements, as this test can produce false-negative results in patients with new-onset diabetes.

Dyslipidemia. Every 10% reduction in serum cholesterol reduces cardiovascular mortality by 10% to 15%.¹⁹ Data from the large, prospective Framingham heart study show a 25% increase in MIs with each 5-mg/dL decrease in high-density lipoprotein cholesterol (HDL) below the age-based median for men and women.²⁰ Serum triglycerides >150 mg/dL clearly predict future CAD and increase the likelihood of abnormally low HDL.

Every 30-mg/dL increase in low-density lipoprotein cholesterol (LDL) raises the relative risk for CAD by 30%.⁷ ATP III classifies LDL as the “primary target of cholesterol-lowering therapy.”⁸Table 4 lists LDL target levels based on other CAD risk factors.

Check fasting lipid profile or serum cholesterol, LDL, HDL, and triglycerides beginning at age 20 and about every 5 years thereafter.⁸ Total cholesterol

Table 3

JNC 7: What blood pressure readings mean

Acceptable LDL cholesterol levels for adults based on CAD risk

Addressing smoking, obesity

Smoking. Before trying nicotine patches or bupropion, Mr. H should realistically contemplate his risks with continued smoking; if he doesn’t want to stop, periodically encourage him to reconsider.¹⁰ Most people know the dangers of smoking but few understand that complete cessation for 1 to 2 years often nearly reverses cardiovascular disease.²¹

Obesity and lack of exercise go hand in hand. Reducing Mr. H’s waist size to 2 is a reasonable short-term goal. To that end, encourage him to:

• decrease his number of weekly fast-food meals from five to three, with an eventual goal of one per week. As an alternative, microwaveable, low-calorie meals—each with at least two servings of fruits or vegetables—can be prepared at home or work.
  
• walk 30 minutes three times weekly and progress to 1 hour five times weekly over 6 months. As with any exercise program, remind Mr. H to “start low and go slow.”
  

The patient’s role in treatment. Patients often feel overwhelmed after getting large amounts of information on CAD risk and may feel hopeless and unenthusiastic about improving their physical health. Work with the primary care doctor to emphasize a patient care plan that clearly defines easily attainable, step-by-step goals. Make sure the patient agrees to these goals.

Case continued: no more supersizing

Mr. H now understands the importance of minimizing his CAD risk and realizes that CAD and many associated risk factors are asymptomatic in the early stages of development.

With help from his doctors, Mr. H quit smoking. He also became more mindful of his caloric intake and the types of foods he was eating. He advanced from briskly walking 30 minutes three times per week to slow jogging 40 minutes five times weekly. He still eats at fast-food restaurants but usually orders broiled chicken, salads, or the occasional burger.

Related resources

• National Cholesterol Education Program. CAD risk assessment tool and ATP III guidelines. www.nhlbi.nih.gov/guidelines/cholesterol/.
  
• U.S. Preventive Services Task Force preventive guidelines. www.ahrq.gov/clinic/uspstfix.htm.
  
• National Heart, Lung, and Blood Institute. Calculate your body mass index. http://nhlbisupport.com/bmi/.
  
• American Heart Association. www.americanheart.org.
  

One in five of your patients could suffer a heart attack in the near future—unless you take steps to ensure their heart health.

Psychiatric patients have more modifiable risk factors for coronary artery disease (CAD) compared with the general population.^{When depression treatment goes nowhere,” Current Psychiatry, August 2005.)}

To help keep you abreast of constantly changing guidelines and strategies for recognizing and minimizing CAD risk, this article discusses:

• preventive and diagnostic guidelines for managing hypertension, diabetes, and dyslipidemia
  
• practical advice on convincing at-risk patients to adopt a healthier lifestyle and have a primary care doctor monitor their health.
  

Case: cigarettes and supersizing

Mr. H, age 54, is receiving cognitive-behavioral therapy for mild depression. He has been smoking one pack of cigarettes per day for 20 years and has never seriously considered quitting.

The patient, a school teacher, says his “busy schedule” keeps him from exercising and eating properly; he eats fast-food hamburgers and fries approximately five times per week. His father had a heart attack at age 52 and died in his sleep 10 years later.

Mr. H says he feels fine and has never seen a physician other than his psychiatrist. He is reluctant to see a primary care physician for a check-up and, because he is asymptomatic, has no incentive to do so. The psychiatrist thus decides to do a routine examination.

Blood pressure is 148/86; other vital signs are normal. Mr. H’s waist size is 42 inches, he weighs 242 lbs, and his body mass index (BMI) is 34 kg/m², indicating clinical obesity. Cardiovascular, pulmonary, and abdominal exams are unremarkable.

Discussion. Mr. H is at high risk of a myocardial ischemic event in the near future. He has six risk factors for CAD (Table 1)—four of which are modifiable:

• family history
  
• age
  
• current cigarette use
  
• provisional hypertension diagnosis
  
• obesity
  
• physical inactivity.
  

Table 1

Risk factors for coronary artery disease

Tools for assessing risk

The lifetime risk at age 40 for developing CAD is 49% and 32% in men and women, respectively.⁶

The National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel) has focused on decreasing heart disease incidence by educating patients and providers. Preventive strategies and standards of care have changed several times over the past decade; the Adult Treatment Panel (ATP III) was last revised in July 2004.⁷

The American College of Cardiology and American Heart Association both endorse the modified Framingham/ATP III scale to measure CAD risk (see Related resources). Although this somewhat tedious point system has limitations, it can precisely calculate coronary risk across 10 years.⁸ Variables not included in the scoring system—such as C-reactive protein, homocysteine, and postmenopausal state—may be clinically significant and should be gauged separately.

An easier-to-use alternative, the ATP III “core risk factors” scale, estimates hypertension, hypercholesterolemia, family history, current cigarette smoking, and age as low, intermediate, or high (“risk equivalent”) risks (Table 1).⁸ Psychiatrists can quickly obtain this information from a brief history, blood pressure assessment, and relatively inexpensive lab studies.

Generally, the more risk factors present, the higher the risk of having a major coronary event. Presence of ≥ 2 risk factors signals intermediate or high risk and necessitates referral to a primary care doctor for monitoring.

Patients with a cardiac “risk equivalent” face a >20% risk of having a cardiac ischemic event within 10 years⁸ (Table 2). Examples of risk equivalents include diabetes or significant vascular disease in any artery.

“Non-core” variables. Also consider certain “non-core” variables—such as pre-existing psychiatric illness—when estimating clinical risk for heart disease. Depression, anxiety, and stress are correlated with an increase in pro-inflammatory markers such as C-reactive protein and predispose patients to CAD.^11,12 Depression has repeatedly been shown to increase morbidity and mortality two- to four-fold after myocardial infarction (MI).^9,13,14 Interestingly, however, depression treatment after an acute coronary event does not clearly decrease mortality.¹⁵ Although prospective, randomized studies are lacking, mood and anxiety disorder treatment is presumed to help prevent CAD development.¹⁶

Table 2

Risk equivalents for CAD*

Recognizing cad risk

At what point do hypertension and dyslipidemia become risk factors for CAD? When and how often should patients be screened for diabetes mellitus?

Hypertension is one of the most common and deadly CAD risk factors, affecting 50 million Americans.¹⁰ Although hypertension awareness and treatment have improved, only 35% of adults have “controlled” blood pressure (

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), normalizing blood pressure can reduce stroke incidence by 35% and MI by 25%, respectively. JNC 7, however, also found that 90% of persons who are normotensive at age 55 eventually develop hypertension.¹⁰

Based on these findings, JNC 7 in 2003 drastically changed the standard of care for diagnosing hypertension. JNC 7 defines normal blood pressure as

• systolic blood pressure 120 to 139 mm Hg
  
• diastolic blood pressure 80 to 89 mm Hg (Table 3).
  

Patients with diabetes mellitus or chronic kidney disease are considered hypertensive with blood pressure >130 mm Hg systolic and/or >80 mm Hg diastolic.

As with Mr. H, a blood pressure check is imperative for patients who have rarely or never seen a primary care physician in recent years. The U.S. Preventive Services Task Force strongly recommends measuring blood pressure during a routine medical evaluation at least every 2 years. A second abnormal reading at a separate visit at any time should prompt a hypertension diagnosis. Once diagnosed with hypertension, patients should be treated and checked monthly until stable, then monitored every 3 to 6 months indefinitely.¹⁰

If you cannot measure blood pressure in the office, urge patients to use an over-the-counter blood pressure measuring device and refer them to a primary care physician. Check the patient’s self-test reading for accuracy against a clinician’s measurement.

Diabetes is now considered a risk equivalent for CAD development.⁸ Patients diagnosed with diabetes are extremely likely to have established vascular disease,⁸ which predisposes them to MI, stroke, kidney disease, blindness, and lower-extremity amputations.¹⁷ Those with type 1 diabetes usually present with acute symptoms—including polyuria, polydipsia, weight loss, malaise, dry mouth, and blurred vision—and are readily diagnosed with elevated plasma glucose.

Screening for diabetes is critical because one-third of patients with the disease are undiagnosed. Also, more than 90% of patients with diabetes are non-insulin-dependent (type 2) and are asymptomatic early in the disease course.

No data definitively show benefits from screening asymptomatic adults. Recently revised diagnostic criteria for diabetes, however, call for re-testing asymptomatic patients who were found to have normal fasting plasma glucose (FPG) levels and were considered “free” of diabetes. The American Diabetes Association recommends measuring FPG after no caloric intake for ≥ 8 hours for asymptomatic patients.

FPG measurement is cost-effective and generally more convenient than other diabetes tests.¹⁷ Expert consensus strongly suggests checking FPG every 3 years beginning at age 45:¹⁷

• FPG
• FPG 100 to 125 mg/dL suggests prediabetes or impaired fasting glucose
  
• FPG ≥ 126 mg/dL demands a provisional diabetes diagnosis and a follow-up test on another day to confirm the diagnosis.
  

• comorbid cardiac risk factors
  
• history of polycystic ovary disease
  
• a first-degree relative with diabetes
  
• habitual inactivity
  
• or FPG 100 to 125 mg/dL.
  

Do not base diabetes diagnosis on glycosylated hemoglobin measurements, as this test can produce false-negative results in patients with new-onset diabetes.

Dyslipidemia. Every 10% reduction in serum cholesterol reduces cardiovascular mortality by 10% to 15%.¹⁹ Data from the large, prospective Framingham heart study show a 25% increase in MIs with each 5-mg/dL decrease in high-density lipoprotein cholesterol (HDL) below the age-based median for men and women.²⁰ Serum triglycerides >150 mg/dL clearly predict future CAD and increase the likelihood of abnormally low HDL.

Every 30-mg/dL increase in low-density lipoprotein cholesterol (LDL) raises the relative risk for CAD by 30%.⁷ ATP III classifies LDL as the “primary target of cholesterol-lowering therapy.”⁸Table 4 lists LDL target levels based on other CAD risk factors.

Check fasting lipid profile or serum cholesterol, LDL, HDL, and triglycerides beginning at age 20 and about every 5 years thereafter.⁸ Total cholesterol

Table 3

JNC 7: What blood pressure readings mean

Acceptable LDL cholesterol levels for adults based on CAD risk

Addressing smoking, obesity

Smoking. Before trying nicotine patches or bupropion, Mr. H should realistically contemplate his risks with continued smoking; if he doesn’t want to stop, periodically encourage him to reconsider.¹⁰ Most people know the dangers of smoking but few understand that complete cessation for 1 to 2 years often nearly reverses cardiovascular disease.²¹

Obesity and lack of exercise go hand in hand. Reducing Mr. H’s waist size to 2 is a reasonable short-term goal. To that end, encourage him to:

• decrease his number of weekly fast-food meals from five to three, with an eventual goal of one per week. As an alternative, microwaveable, low-calorie meals—each with at least two servings of fruits or vegetables—can be prepared at home or work.
  
• walk 30 minutes three times weekly and progress to 1 hour five times weekly over 6 months. As with any exercise program, remind Mr. H to “start low and go slow.”
  

The patient’s role in treatment. Patients often feel overwhelmed after getting large amounts of information on CAD risk and may feel hopeless and unenthusiastic about improving their physical health. Work with the primary care doctor to emphasize a patient care plan that clearly defines easily attainable, step-by-step goals. Make sure the patient agrees to these goals.

Case continued: no more supersizing

Mr. H now understands the importance of minimizing his CAD risk and realizes that CAD and many associated risk factors are asymptomatic in the early stages of development.

With help from his doctors, Mr. H quit smoking. He also became more mindful of his caloric intake and the types of foods he was eating. He advanced from briskly walking 30 minutes three times per week to slow jogging 40 minutes five times weekly. He still eats at fast-food restaurants but usually orders broiled chicken, salads, or the occasional burger.

Related resources

• National Cholesterol Education Program. CAD risk assessment tool and ATP III guidelines. www.nhlbi.nih.gov/guidelines/cholesterol/.
  
• U.S. Preventive Services Task Force preventive guidelines. www.ahrq.gov/clinic/uspstfix.htm.
  
• National Heart, Lung, and Blood Institute. Calculate your body mass index. http://nhlbisupport.com/bmi/.
  
• American Heart Association. www.americanheart.org.