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A narrative review of metabolic monitoring of adult prescribed second-generation antipsychotics for severe mental illness

Open AccessPublished:March 25, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101035

      Abstract

      Introduction

      Patients with severe mental illness (SMI) have poor physical wellbeing, leading essentially shorter lives, compared with the general population. Routine metabolic monitoring is proposed as a strategy for recognizing risk factors for metabolic variations in this population. This narrative review aimed to identify interventions at enhancing uptake of metabolic monitoring parameters in adult prescribed second generation antipsychotics (SGAs) for patients with SMI.

      Method

      A literature search was performed through SCOPUS, PubMed, and CINAHL databases using a combination of keywords. We included primary studies published in the English language until December 2021 that provided evidence on interventions to increase the rate of SGAs related metabolic monitoring in patients with SMI.

      Results

      A total of 21 studies were identified among which in 13 studies frequency of metabolic monitoring ranged between 40% and 80% after implementation of various strategies. These include multi-layer intervention model such as: (A) Reminders (e.g., paper-based prompts, invitation letter); (B) Electronic system of documentation (computer-based intervention, electronic medical records); (C) Healthcare practitioner specific role (Nurse-led intervention, pharmacist-led intervention, barrier focused strategies) and (D) Physical-mental health awareness (Education, quality improvement programme).

      Conclusion

      This review provides evidence that studies involving the reminders such as paper based prompts and education to the patients as well as healthcare professionals could help in enhancing the rate of metabolic monitoring in patients prescribed SGAs.

      Keywords

      1. Introduction

      Adverse cardio metabolic outcomes are worrisome in patients with mental illness, due to different variables, including lifestyle, hereditary predisposition, and medication adverse effects. Second-generation antipsychotics (SGA) are prescribed to manage number of psychiatric conditions in severe mental health disorders. SGAs are safer and more preferred over their first generation predecessors, due to less incidence of extrapyramidal side effects. However, SGAs use has been related to metabolic sequalae, such as hypertension, weight gain, diabetes and, dyslipidemia.
      • Peña A.
      • DeJongh B.
      • Haas M.
      • Harms M.
      Overcoming barriers to monitoring patients taking second-generation antipsychotics.
      The prevalence of the metabolic disorder in individuals on SGA treatment is around 30% or higher, expanding the risk for cardio metabolic syndrome.
      • DelMonte M.T.
      • Bostwick J.R.
      • Bess J.D.
      • Dalack G.W.
      Evaluation of a computer‐based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second‐generation antipsychotics.
      Youth are at higher risk than elderly people for weight gain and metabolic variations identified with antipsychotic treatment.
      • Ferrara M.
      • Mungai F.
      • Miselli M.
      • Shiers D.
      • Curtis J.
      • Starace F.
      Strategies to implement physical health monitoring in people affected by severe mental illness: a literature review and introduction to the Italian adaptation of the Positive Cardiometabolic Health Algorithm.
      Since metabolic syndrome can rapidly develop to SGAs, the best way to prevent it is by initial identification through a thorough monitoring plan.
      • Papanastasiou E.
      Interventions for the metabolic syndrome in schizophrenia: a review.
      Healthcare provider and patient outreach are important for effective metabolic monitoring in patients prescribed with SGAs. Attempts to extend the patient and provider awareness about the risk of metabolic syndrome will probably increase rates of referral, thereby improving patient health. Though published research is scarce, studies have shown that multi-disciplinary healthcare team involvement with patients taking SGAs improves monitoring rates for metabolic syndrome.
      • Peña A.
      • DeJongh B.
      • Haas M.
      • Harms M.
      Overcoming barriers to monitoring patients taking second-generation antipsychotics.
      Physical illness is more predominant in patients with mental illness when compared to the general population. Even though it is because of the modifiable way of lifestyle risk factors, the screening of physical health remains low in developed nations. The barriers to the identification and management of physical problems in individuals with severe mental illness (SMI) includes patient, clinician, treatment, and service-related factors such as financial issues, lack of access to health care, lack of clarity about responsibility of managing physical health etc.
      • De Hert M.
      • Cohen D.A.
      • Bobes J.
      • et al.
      Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level.
      Stigma related to weight gain hinders non-adherence to undergo physical screening as a component to metabolic monitoring. Evidence suggests specific role of different pharmacological and non-pharmacological strategies to counteract treatment induced weight gain.
      • Dayabandara M.
      • Hanwella R.
      • Ratnatunga S.
      • Seneviratne S.
      • Suraweera C.
      • de Silva V.A.
      Antipsychotic-associated weight gain: management strategies and impact on treatment adherence.
      Patients with complex and severe mental health disorders warrant multilayer model of care to enhance metabolic monitoring.
      • Papanastasiou E.
      Interventions for the metabolic syndrome in schizophrenia: a review.
      Studies on benefit of metabolic monitoring in promoting quality use of antipsychotics are required.
      • White J.
      • Gray R.J.
      • Swift L.
      • Barton G.R.
      • Jones M.
      The serious mental illness health improvement profile [HIP]: study protocol for a cluster randomised controlled trial.
      Present guidance on physical health monitoring for people with SMI is not supported by any evidence from randomised controlled trials.
      • Tosh G.
      • Clifton A.V.
      • Xia J.
      • White M.M.
      Physical health care monitoring for people with serious mental illness.
      The mounting evidence of the risks suggests regular physical health monitoring for early detection and management of metabolic syndrome.
      The objective of this narrative review is therefore to present an overview of the literature on interventions in clinical practice that aim to demonstrate and enhance the rate of metabolic monitoring in patients suffering from SMI.

      2. Methodology

      A literature search was performed through SCOPUS, PubMed, and CINAHL databases using a combination of keywords such as “metabolic syndrome”, “antipsychotics”, “severe mental illness”, “intervention”, “physical health”, “monitoring” to recognize articles dealing with strategies, chosen by various mental health providers worldwide, to implement monitoring for physical health improvement in patients with SMI. For the purpose of this narrative review following definitions and outcome measures were considered:
      Metabolic Syndrome: SGAs are associated with metabolic complications such as central obesity, insulin resistance and dyslipidaemia. This collection of symptoms is known as metabolic syndrome and is diagnosed when a patient has three of the five risk factors; abnormal waist circumference (WC), triglycerides (TG), high-density lipoproteins (HDL), fasting blood glucose (FBS) and high blood pressure (BP).
      • Cohen S.
      • Bostwick J.R.
      • Marshall V.D.
      • Kruse K.
      • Dalack G.W.
      • Patel P.
      The effect of a computerized best practice alert system in an outpatient setting on metabolic monitoring in patients on second‐generation antipsychotics.
      Frequency of metabolic monitoring/screening among adults prescribed SGAs: According to American Diabetic Association/American Psychiatric Association (ADA/APA) guidelines, weight should be monitored at 1st, 2nd, and 3rdmonth after starting SGAs and quarterly thereafter. FBS, lipid levels and BP should be checked 3 months after the initiation of these drugs. Thereafter, BP and glucose levels should be monitored annually, whereas, in the patients with abnormal lipid levels, testing should be done once in 5 years thereafter.
      American Diabetes Association
      Consensus development conference on antipsychotic drugs and obesity and diabetes.
      Since the release of these guidelines, steps have been taken to increase the monitoring of these laboratory values. In this review we focused to look for improvement in metabolic parameters such as FBS, BP, lipids and WC before and after intervention. Among the studies with best reported monitoring rates lower cut off has been taken as the best practice. Monitoring rates above 70% were considered good practice.
      • Cohen S.
      • Bostwick J.R.
      • Marshall V.D.
      • Kruse K.
      • Dalack G.W.
      • Patel P.
      The effect of a computerized best practice alert system in an outpatient setting on metabolic monitoring in patients on second‐generation antipsychotics.
      ,
      • Michael S.
      • MacDonald K.
      Improving rates of metabolic monitoring on an inpatient psychiatric ward.

      2.1 Eligibility criteria

      We included primary studies published in the English language until December 2021 that provided evidence on interventions to increase the rate of SGAs related metabolic monitoring in patients with SMI aged 15 years and above. The main outcome of interest was the rate of metabolic monitoring undertaken before and after the intervention. Relevant reviews were also retrieved for other appropriate studies through snowball search technique.
      Exclusion criteria were review articles, research articles with no full text, patients below 15 years of age group and lack of information on rate of SGA related metabolic monitoring.

      3. Findings

      A total of 21 studies were identified that provided evidence on interventions to improve the rate of SGAs related metabolic monitoring in the patients with SMI (Table 1) .
      Table 1Studies included in this review.
      AuthorYearCountryTarget PopulationInterventionsResults
      Barnes et al.
      • Barnes T.R.
      • Bhatti S.F.
      • Adroer R.
      • Paton C.
      Screening for the metabolic side effects of antipsychotic medication: findings of a 6-year quality improvement programme in the UK.
      2015UKPatients prescribed antipsychotic medications under the care of assertive outreach community psychiatric serviceAn audit-based Quality improvement programme, poster with normal ranges for test results of metabolic syndrome parameters, lifestyle management pack for providers and patients; physical health check reminder card given for patientsThere was a statistically significant increase in the proportion of patients with all 4 aspects of the metabolic syndrome test result documented from 11% to 34%.
      Bomboy KT et al.
      • Bomboy K.T.
      • Graber J.S.
      • Wallis E.P.
      Improved prescriber adherence to guidelines on antipsychotic medication management through increased access to metabolic monitoring forms.
      2021USAPatients prescribed SGAs in rural community mental health centreMetabolic monitoring tool development and uploading it to the Electronic medical recordStatistically significant association was observed with Clinic A (only one lab was ordered during the pre-implementation vs 59 lab orders during post-implementation)
      DelMonte et al.
      • DelMonte M.T.
      • Bostwick J.R.
      • Bess J.D.
      • Dalack G.W.
      Evaluation of a computer‐based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second‐generation antipsychotics.
      2012USAAdult psychiatry inpatients aged 18 years, prescribed with SGAComputer-based pop-up alert was developed to increase metabolic monitoring in patients treated with SGAFollowing implementation significantly increased rates of monitoring fasting blood sugar and lipid levels (12.9%–47.8%) for inpatients on SGAs.
      Druss et al.
      • Druss B.G.
      • von Esenwein S.A.
      • Compton M.T.
      • Rask K.J.
      • Zhao L.
      • Parker R.M.
      A randomized trial of medical care management for community mental health settings: the Primary Care Access, Referral, and Evaluation (PCARE) study.
      2010U.SPatients with SMI aged 18 years and older at an urban community mental health settingsRCT-Health education to patients, care coordinator worked as an advocate and a supporter with medical suppliers, overcoming barriers to primary medical care and system-level barriersFollow-up after a year, the group receiving intervention obtained an average of 58.7% of preventive aids, compared to the standard care group (21.8%) and a significantly greater quantity of evidence-based services for cardiometabolic problems.
      Gonzalez et al.
      • Gonzalez C.
      • Ahammed N.
      • Fisher R.
      Improving physical health monitoring for out-patients on antipsychotic medication.
      2010UKOutpatients on antipsychoticsRetrospective audit, presentation of data locally. Basic local modification of clinical guidelines was designed, and a tool for monitoring was implementedPre intervention audit (FBS and lipid −40.5% & 7.1%), Post intervention audit (FBS 81.1% & lipids 52.8%)
      Hardy S and Gray R152012UKPatients with SMI and diabetesA retrospective audit to compare the response rate of patients with SMI and diabetes to an appointment letter for attending a primary care health examination66% of SMI and. 81% diabetic patients visited the health check up on the date specified in the letter. Attendance rates were lower in patients with SMI.
      Hor et al.
      • Hor E.S.
      • Subramaniam S.
      • Koay J.M.
      • et al.
      Improving metabolic monitoring in patients maintained on antipsychotics in Penang, Malaysia.
      2015MalaysiaPsychiatric outpatients aged 18–65 years prescribed with antipsychotics for atleast 1 yearBaseline file audit, new local protocol, Focus group discussionRe-audit after the implementation of the new protocol showed improvement but still monitoring of all parameters remains sub-optimal.
      Kioko et al.
      • Kioko E.
      • Williams K.
      • Newhouse B.
      Improving metabolic syndrome screening on patients on second generation antipsychotic medication.
      2016USOutpatients on SGAs aged 19 years and aboveMetabolic Syndrome screening and monitoring toolOrdering of lab tests in the post-intervention (62%) was greater compared to pre- intervention (22%)
      Kreyenbuhl et al.
      • Kreyenbuhl J.
      • Dixon L.B.
      • Brown C.H.
      • et al.
      A randomized controlled trial of a patient-centered approach to improve screening for the metabolic side effects of antipsychotic medications.
      2017USOutpatient veteran-participants 18–70 years of age, diagnosed with a psychotic disorder on SGAsRCT- Computerized patient-centered interventionNo significant difference in the proportion of days adherent to monitoring guidelines between 2 treatment groups.
      Maki M and Bjorklund P212013USASMI patients from community mental health centerEducational workshop and CVD screening toolTGs were recorded 32.3% in the first chart review and 63.1% in the second chart review, HDL from 31.5% to 62.3%, WC from 3.8% to 56.9%, BP from 52.3% to 82.3% and FBS was documented in 40% of charts at the time of first chart review and 70% at second chart review.
      Michael S,

      MacDonald K11
      2020AustraliaInpatient psychiatric patientsNurse-led intervention, education to staff, patient involvementA statistically significant increase was seen in monitoring rates of lipids from 23% to 69.5%, BP from 88.5% to 100%, glucose from 74% to 82.5%, BMI from 33% to 63%, and waist circumference from 44.2% to 65.2% post-intervention.
      Osborn et al.
      • Osborn D.P.
      • Nazareth I.
      • Wright C.A.
      • King M.B.
      Impact of a nurse-led intervention to improve screening for cardiovascular risk factors in people with severe mental illnesses. Phase-two cluster randomised feasibility trial of community mental health teams.
      2010UKSevere mental illness community mental health team patientsNurse-led screening programme and education about screening for cardiovascular riskFollowing the trial, screening for CVD had improved in both arms but the intervention arm received screening significantly more for blood pressure (96% vs 68%); cholesterol (66.7% vs 26.9), glucose (66.7% vs 36.5%), BMI (92.5% vs 65.2%), and smoking status (88.2% vs 57.8%).
      Pena A et al.
      • Peña A.
      • DeJongh B.
      • Haas M.
      • Harms M.
      Overcoming barriers to monitoring patients taking second-generation antipsychotics.
      2018U.SPatients taking SGAs in the outpatient mental health clinicPharmacist led metabolic syndrome monitoring clinic, appropriate tools to improve monitoring. A presentation and pamphlet were designed to increase awareness for providers and patients, free transportation information was provided to the patients.Around 37.5% improvement in overall rates of referral to the metabolic syndrome clinic was seen post intervention. The monitoring of BP (26%– 62%) and weight (28%– 40%) increased after intervention.
      Porter C &

      Aggar C30
      2021AustraliaPatients aged above 18 years with SMI accessing regional mental health inpatient unitThe Let's Get Physical-Improved Physical Health Care in Mental Health Services-A Practical Toolkit for the CliniciansMonitoring for metabolic parameters improved from 5% to 80% at 3rd month follow-up.
      Rosenbaum et al.
      • Rosenbaum S.
      • Nijjar S.
      • Watkins A.
      • Garwood N.
      • Sherrington C.
      • Tiedemann A.
      Nurse‐assessed metabolic monitoring: a file audit of risk factor prevalence and impact of an intervention to enhance measurement of waist circumference.
      2014AustraliaInpatient mental health consumersFile audit, educational intervention to nurse, waist circumference (WC) measurement added to forms within patient filesImproved monitoring of waist circumference from 0% at baseline to 58% at 3 months and 42% at 9 months follow up.
      Thompson et al.
      • Thompson A.
      • Hetrick S.E.
      • Álvarez-Jiménez M.
      • et al.
      Targeted intervention to improve monitoring of antipsychotic-induced weight gain and metabolic disturbance in first episode psychosis.
      2011AustraliaPatients with First episode psychosis taking antipsychoticsBarrier analysis, development of local guideline, provision of monitoring equipment, educational intervention such as seminars, promptsSignificant improvements of 81.4% and 39.5% were seen in the screening and the monitoring of metabolic parameters respectively after starting antipsychotics.
      Vasudev K et al.
      • Vasudev K.
      • Martindale B.V.
      Physical healthcare of people with severe mental illness: everybody's business.
      2012UKSevere mental illness patientsA sheet for physical health monitoring was placed in the patients' filesAt re-audit after a year, the sheets for physical health monitoring were up to date in all of the files.
      Vasudev K et al.
      • Vasudev K.
      • Thakkar P.B.
      • Mitcheson N.
      Physical health of patients with severe mental illness: an intervention on medium secure forensic unit.
      2010UKSevere mental illness patients under the care of early intervention psychosis serviceBaseline and re-audit involved increasing attention within the multidisciplinary EIP mental health team regarding the significance of monitoring and liaison with primary care health services.The patients undergoing physical health checks at least once annually increased from 20% to 58%.
      Viglione L and Short BL
      • Viglione L.
      • Short B.L.
      Metabolic screen and intervene: improving mental health inpatient metabolic monitoring.
      2020AustraliaPatients prescribed antipsychotic medications in the psychiatric inpatient settingEducation campaign for mental health cliniciansRates of monitoring for lipids increased from 21.7% to 78.8% (p < 0.01) and for plasma glucose from 20.8% to 73.7% (p < 0.01).
      Wiechers et al.
      • Wiechers I.R.
      • Viron M.
      • Stoklosa J.
      • Freudenreich O.
      • Henderson D.C.
      • Weiss A.
      Impact of a metabolic screening bundle on rates of screening for metabolic syndrome in a psychiatry resident outpatient clinic.
      2012USAPatients being prescribed antipsychotic medications of an outpatient psychiatry resident clinicQuality improvement intervention: residents focus group and education, metabolic screening bundle for electronic medical recordsFollowing the intervention, documentation rates of the metabolic screening bundle components increased between 3.5- and 10-fold. Rates of documenting the full bundle improved nearly 30-fold.
      Yeomans et al.
      • Yeomans D.
      • Dale K.
      • Beedle K.
      Systematic computerised cardiovascular health screening for people with severe mental illness.
      2014UKSMI patientsComputer-based template for the primary care information system to assist a standard yearly physical health examination for patients with SMI.The template was used by 75% of GP practices and resulted in greater quality screening than the standard treatment, increasing two-fold the detection of cardiovascular risk.

      3.1 Electronic system of documentation

      Electronic prompts like computer-based intervention helped in providing alert services for documentation of metabolic parameters or when the monitoring was due. Four studies
      • DelMonte M.T.
      • Bostwick J.R.
      • Bess J.D.
      • Dalack G.W.
      Evaluation of a computer‐based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second‐generation antipsychotics.
      ,
      • Wiechers I.R.
      • Viron M.
      • Stoklosa J.
      • Freudenreich O.
      • Henderson D.C.
      • Weiss A.
      Impact of a metabolic screening bundle on rates of screening for metabolic syndrome in a psychiatry resident outpatient clinic.
      • Yeomans D.
      • Dale K.
      • Beedle K.
      Systematic computerised cardiovascular health screening for people with severe mental illness.
      • Kreyenbuhl J.
      • Dixon L.B.
      • Brown C.H.
      • et al.
      A randomized controlled trial of a patient-centered approach to improve screening for the metabolic side effects of antipsychotic medications.
      in USA and UK implemented computer-based intervention for providing alert services or documentation of metabolic parameters such as either computerized system with pop-up alert for metabolic screening or a metabolic screening bundle template in the electronic medical records. DelMonte et al., conducted a retrospective chart audit to evaluate the impact of a computerized-based alert to increase the monitoring for metabolic parameters in patients treated with SGAs. The authors evaluated the number of requests for suitable metabolic monitoring rate for patients admitted in six months span pre and post alert implementation. The alert reminded the clinicians to request fasting lipid and glucose levels. After alert implementation, the number of patients with FBS and lipid panel monitoring improved from 12.9% to 47.8%. The rates of overall monitoring for these parameters were inferior, suggesting a need for the use of supplementary strategies to further enhance metabolic monitoring for patients on these drugs.
      • DelMonte M.T.
      • Bostwick J.R.
      • Bess J.D.
      • Dalack G.W.
      Evaluation of a computer‐based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second‐generation antipsychotics.
      A quality improvement intervention was conducted Wiechers et al., to assess the impact of metabolic screening bundle on metabolic syndrome screening rates in the psychiatry resident OP clinic. The main components of the intervention were focus groups, education to the residents, and the development of a metabolic screening bundle template in electronic medical records. Following the intervention, documentation rates of the metabolic screening bundle components increased between 3.5- and 10-fold (31%). BP was the least documented component at the start and end of the study. This may be related to many barriers to implementation such as lack of proper-sized cuffs for larger patients, the limited availability of blood-pressure cuffs, and provider discomfort with physical contact with patients.
      • Wiechers I.R.
      • Viron M.
      • Stoklosa J.
      • Freudenreich O.
      • Henderson D.C.
      • Weiss A.
      Impact of a metabolic screening bundle on rates of screening for metabolic syndrome in a psychiatry resident outpatient clinic.
      A cross-sectional retrospective study conducted by Yeomans D et al., to assess the physical health monitoring quality of all registered SMI patients in the Bradford and Airedale area of UK by the standards suggested by The National Institute for Health and Care Excellence (NICE). The authors developed and implemented a computer-based screening template to help in the standard yearly physical health examination for SMI patients. This template was used by 75% of GP practices and was related to good quality screening than standard care, increasing the detection of cardiovascular risk.
      • Yeomans D.
      • Dale K.
      • Beedle K.
      Systematic computerised cardiovascular health screening for people with severe mental illness.
      A randomized controlled trial was conducted by Kreyenbuhl et al., in US to check whether computerized intervention that educated patients with SMI about the side effects of antipsychotics and motivated them to support for receipt of monitoring would enhance rates of monitoring when compared to enhanced treatment as usual(ETAU) group. ETAU group was provided with printed educational pamphlet about metabolic side effects and the recommended frequency of monitoring. When compared with the computer program, this printed pamphlet did not provide personalized information on their monitoring status or metabolic monitoring test results. No significant difference was seen in the mean proportion of days adherent to monitoring guidelines between the 2 treatment groups. Participants in the intervention group were interested in getting personalized information about their cardiometabolic status and were responsive to such interventions.
      • Kreyenbuhl J.
      • Dixon L.B.
      • Brown C.H.
      • et al.
      A randomized controlled trial of a patient-centered approach to improve screening for the metabolic side effects of antipsychotic medications.
      The findings of these above-mentioned studies indicate that, computerised based tool can help the health care teams to carry out higher-quality physical health monitoring and identify more patients at risk of early metabolic syndrome and cardiovascular death. Implementation and use of the above-mentioned approaches were found to increase the metabolic screening rates in individuals with SMI and provides alert services to the psychiatrists when monitoring was due.

      3.2 Measures for ease in accessibility to monitoring for practitioners and patients

      Two studies
      • Hardy S.
      • Gray R.
      Is the use of an invitation letter effective in prompting patients with severe mental illness to attend a primary care physical health check?.
      ,
      • Vasudev K.
      • Martindale B.V.
      Physical healthcare of people with severe mental illness: everybody's business.
      were conducted in UK to explore whether an invitation letter providing an appointment with a specified date and time for patients as well as General Practitioners (GP) would be effective in increasing the attendance of patients with SMI to attend a primary care health check.
      A retrospective audit was conducted by in UK to compare the response rate of patients with SMI and diabetes where the authors adopted an invitation appointment letter to prompt the patients with SMI to attend a physical health check. The study found that around 70% of the patients with SMI visited the health check on the date and time mentioned in the invitation letter. There was no information on the rate of monitoring.
      • Hardy S.
      • Gray R.
      Is the use of an invitation letter effective in prompting patients with severe mental illness to attend a primary care physical health check?.
      An audit cycle in UK was completed on patients with SMI under the consideration of an early intervention in psychosis (EIP)service to assess and improve physical health monitoring. Letters were sent for GPs reminding them to conduct physical health checks, interventions included increasing awareness within the multidisciplinary EIP mental health group regarding the significance of physical health monitoring in patients with SMI and contact with primary care health services. The patients who underwent at least once yearly physical health check improved from 20% to 58%.
      • Vasudev K.
      • Martindale B.V.
      Physical healthcare of people with severe mental illness: everybody's business.
      The response rate was higher in the invitation letter given to the patients as this letter provided details about predetermined date and time who would be doing the health check rather than appointment with an unnamed person. Similar response was also observed when the reminders were provided to the GPs regarding physical monitoring.

      3.3 Paper-based reminders

      Prompts such as paper based were incorporated into routine clinical practice to improve the memory and attention of healthcare providers for monitoring in 6 interventions.
      • Gonzalez C.
      • Ahammed N.
      • Fisher R.
      Improving physical health monitoring for out-patients on antipsychotic medication.
      ,
      • Kioko E.
      • Williams K.
      • Newhouse B.
      Improving metabolic syndrome screening on patients on second generation antipsychotic medication.
      ,
      • Rosenbaum S.
      • Nijjar S.
      • Watkins A.
      • Garwood N.
      • Sherrington C.
      • Tiedemann A.
      Nurse‐assessed metabolic monitoring: a file audit of risk factor prevalence and impact of an intervention to enhance measurement of waist circumference.
      ,
      • Vasudev K.
      • Thakkar P.B.
      • Mitcheson N.
      Physical health of patients with severe mental illness: an intervention on medium secure forensic unit.
      ,
      • Maki M.
      • Bjorklund P.
      Improving cardiovascular disease screening in community mental health centers.
      ,
      • Bomboy K.T.
      • Graber J.S.
      • Wallis E.P.
      Improved prescriber adherence to guidelines on antipsychotic medication management through increased access to metabolic monitoring forms.
      A retrospective audit was conducted in UK to improve the monitoring for physical health of outpatients on antipsychotic medications. The strategy incorporated the introduction of information locally, 3 meetings with local consultants and 2 brief educational talks to junior doctors. A basic local adaptation of clinical guidelines was designed, and a tool for monitoring was executed. This tool was an A4 page filed in the patients’ records, which was designed both as a reminder to doctors regarding the need for the physical monitoring of patients and as a tool to aid in the data collection. Following which, baseline FBS tests improved from 40.5% in the first audit to 81.1% in the second audit and baseline lipid tests from 7.1% to 52.8%.
      • Gonzalez C.
      • Ahammed N.
      • Fisher R.
      Improving physical health monitoring for out-patients on antipsychotic medication.
      A quality improvement project was conducted in US to improve the screening for metabolic syndrome in patients on antipsychotic drugs. Around 100 patient charts were reviewed pre and post intervention to check whether the metabolic monitoring was carried out. The intervention included the provision of paper based monitoring and screening tool to the mental health care providers. The ordering of lab tests in the post-intervention (62%) was found to be greater than in the pre-intervention (22%). Blood tests ordered for fasting glucose levels and lipid panel increased from 32% in the pre-intervention to 88% in the post-intervention.
      • Kioko E.
      • Williams K.
      • Newhouse B.
      Improving metabolic syndrome screening on patients on second generation antipsychotic medication.
      Kioko et al., recommend options such as automatic reminders for monitoring which will remind the physicians when the lab tests are scheduled. They also recommend follow up calls to the patients to remind them of undergoing metabolic monitoring and integration of mental health services with primary care services.
      • Kioko E.
      • Williams K.
      • Newhouse B.
      Improving metabolic syndrome screening on patients on second generation antipsychotic medication.
      An audit was conducted in Australia to assess the frequency of documentation of waist circumference pre and post intervention. The intervention included education to the participating nurse on the significance of WC measurement for 20 min and also space for WC measurement was added to the patient's files. At baseline, there was no documentation of WC, which improved to 58% and 42% at the 3-month and 9-month follow-up respectively.
      • Rosenbaum S.
      • Nijjar S.
      • Watkins A.
      • Garwood N.
      • Sherrington C.
      • Tiedemann A.
      Nurse‐assessed metabolic monitoring: a file audit of risk factor prevalence and impact of an intervention to enhance measurement of waist circumference.
      Vasudev et al., conducted an audit in UK to check the usefulness of maintaining a physical health monitoring sheet for placed in the patients' records on a forensic psychiatric rehabilitation unit for a period of 12 months. Audit after a year, these sheets were adopted in all the patients' records. The cardiovascular risk over the next 10 years decreased over time but no significant change was observed on central obesity, BMI, BP, and smoking.
      • Vasudev K.
      • Thakkar P.B.
      • Mitcheson N.
      Physical health of patients with severe mental illness: an intervention on medium secure forensic unit.
      A project was conducted by in USA showed that the introduction of cardiovascular disease (CVD) screening tool increased the frequency of CVD screenings and communication with primary care providers through letters which could result in significant process improvement in the practices of psychiatric providers. The organization significantly increased its rate of CVD screening and almost doubled the rate of communicating screening results to primary care. Specifically, TGs were recorded 32.3% of the time in the first chart review and 63.1% of the time in the second chart review, HDL from 31.5% to 62.3%, WC from 3.8% to 56.9%, BP from 52.3% to 82.3% and FBS was documented in 40% of charts at the time of first chart review and 70% at second chart review.
      • Maki M.
      • Bjorklund P.
      Improving cardiovascular disease screening in community mental health centers.
      A quality improvement initiative was conducted in a community mental health facility to enhance the frequency of metabolic monitoring parameters for patients SGAs. The intervention involved developing a metabolic monitoring tool and uploading it to the electronic medical record for the practitioner to view during the consultation in order to help with lab test orders. The ADA/APA guidelines were used to construct the metabolic monitoring tool, which included an annual assessment of individual and family diagnosis of diabetes and CVD, assessment of BMI, WC, BP, FBS and fasting lipids. An 8-week chart review was done for two prescribers at 2 clinics (Clinic A as intervention site and Clinic B as comparison site) within the mental health agency. After implementation of the tool, metabolic monitoring parameters increased from 1 to 59 at 8 weeks’ post-implementation for Clinic A.
      • Bomboy K.T.
      • Graber J.S.
      • Wallis E.P.
      Improved prescriber adherence to guidelines on antipsychotic medication management through increased access to metabolic monitoring forms.
      The results of these studies show that the use of the paper based monitoring tool improved the rate of metabolic monitoring in patients on antipsychotic medications.

      3.4 Barrier focused strategies

      Some studies analysed the barrier against effective monitoring and based on the responses, strategies were developed. For example, lack of monitoring equipment's in clinic rooms, are also one of the barriers to monitoring.
      Pena et al., conducted a quality improvement initiative to enhance the baseline monitoring rates for metabolic syndrome in patients on SGAs by executing strategies to overcome the identified monitoring obstacles and approaching the metabolic syndrome monitoring clinic. Appropriate tools such as provision of more stable and higher weight limit machine, tape measures for obtaining WC to improve monitoring, a computerized consult which included the recent monitoring parameters was incorporated into the SGA ordering menu of the electronic health record.Also pamphlets which included information on metabolic syndrome, the risks associated and methods to decrease it was provided to the patients and presentations were provided to the mental health providers on the need for monitoring and the monitoring parameters. Information about free transportation was provided to patients. Around 37.5% improvement in overall referral rates to the monitoring clinic was observed following an intervention. The monitoring of BP increased from 28% to 40% and weight increased from 26% to 62% after intervention but a decrease in fasting blood sugar and fasting lipid levels.
      • Peña A.
      • DeJongh B.
      • Haas M.
      • Harms M.
      Overcoming barriers to monitoring patients taking second-generation antipsychotics.
      An audit based quality improvement programme(QIP) was conducted by Barnes et al., in UK. Poster with normal ranges for test results of metabolic syndrome parameters, lifestyle management pack for providers and patients and reminder card for physical health check were given to the patients. The audit showed a statistically significant improvement over 6 years in the proportion of patients with all the aspects of the metabolic syndrome documented in the clinical records from 1 in 10 patients in 2006 to 1 in 3 by 2012. The proportion of patients with no evidence of any screening also decreased.
      • Barnes T.R.
      • Bhatti S.F.
      • Adroer R.
      • Paton C.
      Screening for the metabolic side effects of antipsychotic medication: findings of a 6-year quality improvement programme in the UK.
      A study was conducted by Hor et al., among 300 outpatients on antipsychotic drugs in a general hospital setting where baseline file audit was conducted to check the frequency of metabolic monitoring. A new local protocol on monitoring frequencies was designed, and a re-audit was conducted after implementation, in a small sample of patients. Focus group discussion was also conducted to explore the staff perspectives, 6 months post-implementation. Re-audit after the implementation of the new protocol showed increased monitoring but persisting deficits. Focus group discussion showed positive perceptions of the initiative, but persisting implementation barriers, and local religious issues with respect to WC measurement. These findings support previous literature which recommends that effective metabolic monitoring of patients prescribed with antipsychotic drugs requires communication with clinicians, in order to identify and overcome multiple local service-related and cultural barriers to implementation.
      • Hor E.S.
      • Subramaniam S.
      • Koay J.M.
      • et al.
      Improving metabolic monitoring in patients maintained on antipsychotics in Penang, Malaysia.
      Thompson et al., carried out an audit to examine if a focused intervention will increase monitoring in a first episode psychosis clinic in Australia. A review of both rates of metabolic screening and specific monitoring of weight and metabolic parameters was conducted before the intervention and after starting the antipsychotic drugs. The interventions included barrier analysis, development of local guideline, provision of monitoring equipment, educational intervention such as seminars highlighting the long-term effects of metabolic disturbance and in young patients taking SGAs, paper-based monitoring sheet prompts were placed in every patients’ file. The audit was repeated after 18 months, following an intervention based on barriers analysis to perform monitoring within the clinic. Significant improvements of 81.4% and 39.5% were seen in the screening and the monitoring of metabolic parameters respectively after starting antipsychotics. Improvements (29.3%) were also observed in the number of active interventions provided to patients by clinicians.
      • Thompson A.
      • Hetrick S.E.
      • Álvarez-Jiménez M.
      • et al.
      Targeted intervention to improve monitoring of antipsychotic-induced weight gain and metabolic disturbance in first episode psychosis.
      A randomized control trial was conducted by Druss et al., to enhance primary medical care in community mental health settings. Patients with SMI were randomized into two groups either care management or standard care at an urban community mental health center. The care coordinators offered communication and advocacy with medical providers, health training for patients, and assistance in dealing with system-level fragmentation and obstacles to primary health care. Follow-up after a year demonstrated that, the intervention group obtained an average of 58.7% of preventive services assessing the quality of primary care, when compared to 21.8% in the standard care group and significantly greater extent of indicated services for cardiometabolic problems (34.9% vs. 27.7%, p = 0.03), and more probable to have a primary care provider (71.2% vs. 51.9%, p = 0.003).
      • Druss B.G.
      • von Esenwein S.A.
      • Compton M.T.
      • Rask K.J.
      • Zhao L.
      • Parker R.M.
      A randomized trial of medical care management for community mental health settings: the Primary Care Access, Referral, and Evaluation (PCARE) study.
      Metabolic syndrome monitoring clinic, pharmacist inputs, resources and providing awareness about the importance of metabolic monitoring is crucial to increase the monitoring rates.
      • Peña A.
      • DeJongh B.
      • Haas M.
      • Harms M.
      Overcoming barriers to monitoring patients taking second-generation antipsychotics.
      ,
      • Wilson E.
      • Randall C.
      • Patterson S.
      • Emmerson B.
      • Moudgil V.
      • Weaver T.
      Monitoring and management of metabolic abnormalities: mixed-method evaluation of a successful intervention.

      3.5 Nurse-led intervention

      Nurse-led intervention adopted by two studies
      • Michael S.
      • MacDonald K.
      Improving rates of metabolic monitoring on an inpatient psychiatric ward.
      ,
      • Osborn D.P.
      • Nazareth I.
      • Wright C.A.
      • King M.B.
      Impact of a nurse-led intervention to improve screening for cardiovascular risk factors in people with severe mental illnesses. Phase-two cluster randomised feasibility trial of community mental health teams.
      were found to be effective, increasing in the number of people with SMI obtaining screening for cardiovascular risk.
      A quality improvement initiative included nurse-led intervention which involved upskilling of nurses to ensure the patients undergo monitoring, education to the staff about the importance of metabolic monitoring, introduction of some interventions like monitoring of ward diet, close relationship with endocrinology department, and consumer involvement like explaining about the monitoring, performing activities like walking, yoga, exercise games, etc. A statistically significant increase was seen in monitoring rates of lipids 23% to 69.5%, BP from 88.5% to 100%, glucose from 74% to 82.5%, BMI from 33% to 63%, and waist circumference from 44.2% to 65.2% post-intervention.
      • Michael S.
      • MacDonald K.
      Improving rates of metabolic monitoring on an inpatient psychiatric ward.
      A nurse-led intervention was conducted by Osborn et al., in community mental health teams. The intervention group included communication with primary and secondary care to prompt them to provide screening for CVD and the unscreened patients were screened by nurse plus education on screening for CVD risks. The usual treatment group was provided with only an education pack which included information on CVD, its risk factors and appropriate screening. Following the trial, screening for CVD had improved in both the groups but the intervention group received screening significantly more for BP (96% vs 68%); cholesterol (66.7% vs 26.9%), glucose (66.7% vs 36.5%), BMI (92.5% vs 65.2%), and smoking status (88.2% vs 57.8%) and have a 10 year CVD risk score.
      • Osborn D.P.
      • Nazareth I.
      • Wright C.A.
      • King M.B.
      Impact of a nurse-led intervention to improve screening for cardiovascular risk factors in people with severe mental illnesses. Phase-two cluster randomised feasibility trial of community mental health teams.
      Rosenbaum et al. found that a file-based reminder had a positive impact on rates of nurse-assessed waist circumference measurement in patients with SMI.
      • Rosenbaum S.
      • Nijjar S.
      • Watkins A.
      • Garwood N.
      • Sherrington C.
      • Tiedemann A.
      Nurse‐assessed metabolic monitoring: a file audit of risk factor prevalence and impact of an intervention to enhance measurement of waist circumference.
      There is a requirement not only to develop education for nurses and other healthcare providers to provide physical health checks for people with SMI, but it is also important to demonstrate that providing this education will enhance patient outcomes. Despite promising statistics on the role of mental health nurses in physical health monitoring, nurses continue to lack proper training, which is a barrier in achieving optimal physical health results.
      • Rosenbaum S.
      • Nijjar S.
      • Watkins A.
      • Garwood N.
      • Sherrington C.
      • Tiedemann A.
      Nurse‐assessed metabolic monitoring: a file audit of risk factor prevalence and impact of an intervention to enhance measurement of waist circumference.

      3.6 Pharmacist led intervention

      Despite scarcity of published data, studies have found that pharmacist participation with patients using SGAs increases monitoring rates for metabolic parameters.
      A pharmacist-led metabolic syndrome monitoring clinic (MSMC) was available to outpatients in mental health which was underutilised by providers. The goal of this research was to improve the baseline metabolic syndrome monitoring rates in patients on SGAs by developing interventions such as monitoring tools, awareness in form of pamphlets, free transportation to address monitoring and hurdles in accessing MSMC. About 24 patients were referred to the clinic over the 4-month period previous to the intervention's implementation. Following the intervention, 33 patients were referred to the clinic over the 4-month period, representing a 37.5% increase in total referral rates. Surveys from the mental health providers showed significant benefit from the MHMC.
      • Peña A.
      • DeJongh B.
      • Haas M.
      • Harms M.
      Overcoming barriers to monitoring patients taking second-generation antipsychotics.
      In another study, the authors evaluated the effect of a computerised physician order entry (CPOE) pop-up alert aimed to improve rates of laboratory metabolic monitoring of patients treated with SGAs in an inpatient psychiatry unit within a 6-month period before and after the implementation. A clinical psychiatric pharmacist had been reminding prescribers about the need for metabolic monitoring with SGAs on a regular basis. To facilitate systematic reminders, the clinical psychiatric pharmacist collaborated with information technology to develop a new pop-up alert following the introduction of CPOE. The major goals of the CPOE pop-up alert were to alert prescribers placing an SGA order to assess the requirement for metabolic monitoring and to enable ordering necessary labs easier by allowing them to do so straight from the pop-up window. Significant increases in monitoring both random and fasting glucose levels, as well as random and fasting lipid panels, were reported after the warning was implemented.
      • DelMonte M.T.
      • Bostwick J.R.
      • Bess J.D.
      • Dalack G.W.
      Evaluation of a computer‐based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second‐generation antipsychotics.

      3.7 Education based intervention

      Educating mental health providers about the importance of monitoring for metabolic syndrome in patients taking SGAs will help to prevent problems associated with use of SGAs and enhance the patient's outcome. The type of education provided to health care providers differed in studies ranging from half day interactive workshops, PowerPoint presentations or metabolic guidelines poster.
      A quality improvement intervention was conducted by Wiechers et al., where one of the core components of the intervention included resident education. Three 1-h educational sessions were conducted for approximately 45 residents to review antipsychotic drug-associated metabolic issues, and residents were provided with literature on the current standards and practice guidelines. Following the intervention, rates of documenting the full metabolic screening bundle improved around 31%.
      • Wiechers I.R.
      • Viron M.
      • Stoklosa J.
      • Freudenreich O.
      • Henderson D.C.
      • Weiss A.
      Impact of a metabolic screening bundle on rates of screening for metabolic syndrome in a psychiatry resident outpatient clinic.
      An audit cycle in UK was completed on patients with SMI under the consideration of an early intervention in psychosis (EIP)service to assess and improve physical health monitoring. A half-day interactive workshop, participated by all members of the team, to see the importance of physical health monitoring in the patient group. A significant improvement was seen in the physical health monitoring of patients from 20% to 58% under the care of the EIP service. This can be due to the improvement in awareness among the multidisciplinary staff of the EIP team regarding the importance of physical health in patients with SMI which may have led to the staff prioritising the physical health of their patients and encouraging them to book and attend appointments with their GP.
      • Vasudev K.
      • Martindale B.V.
      Physical healthcare of people with severe mental illness: everybody's business.
      A study conducted in Australia provided a brief educational intervention of around 20 min regarding the importance of waist circumference measurement, cut off values, how to measure a patient's WC with less physical contact was delivered to the participating nursing staff by an exercise physiologist following which the documentation of WC increased from 0% to 42%.The results of the study indicate that providing short educational intervention and file-based reminder can have a lasting effect on clinical practice.
      • Rosenbaum S.
      • Nijjar S.
      • Watkins A.
      • Garwood N.
      • Sherrington C.
      • Tiedemann A.
      Nurse‐assessed metabolic monitoring: a file audit of risk factor prevalence and impact of an intervention to enhance measurement of waist circumference.
      A quality improvement initiative in Australia where after identifying the unawareness of the staffs about guidelines regarding the importance of metabolic monitoring, education was provided in regular orientation to junior medical officers, both through PowerPoint given to the registrars as well as part of the discussion which took place with the more-junior resident medical officers who started every 10–12 weeks. These orientations included the importance of metabolic monitoring, tests to be done, and some alternatives for pharmacological and non-pharmacological treatment. Nursing staff was educated through nursing in-services, involving a similar presentation with more information on the performance of the actual measurements. Metabolic guidelines posters were also put up on the ward for the ease of access for all staff. One of the limitations of this was, no formal assessment of the quality of education was done. A statistically significant increase was seen in monitoring rates of lipids 23%–69.5%, BP from 88.5% to 100%, glucose from 74% to 82.5%, BMI from 33% to 63%, and waist circumference from 44.2% to 65.2% post-intervention.
      • Michael S.
      • MacDonald K.
      Improving rates of metabolic monitoring on an inpatient psychiatric ward.
      Viglione et al. conducted a study to determine the rates of metabolic monitoring in patients on antipsychotic drugs in a psychiatric inpatient setting, as well as the impact that education can have on monitoring compliance. Pre-education and post education audits to educate the mental health staffs on the need for metabolic monitoring were conducted. Monitoring rates for BMI, WC, BP, FBS and lipid profile were compared pre and post audit. The educational campaign's content included results of the pre-education audit, identification of basic standards from the guidelines and clinical significance of metabolic monitoring from the literature. Consultants, registrars, resident medical officers, allied health personnel, and nurses were among the mental health practitioners who received education. Plasma glucose monitoring rates improved from 21.7% to 78.8% (p 0.01), while plasma lipid monitoring rates improved from 20.8% to 73.7% (p 0.01). BMI (83.0% and 77.1%, respectively), WC (36.8% and 43.2%, respectively), and BP (99.1% and 100%, respectively) but monitoring rates did not show statistically significantly difference.
      • Viglione L.
      • Short B.L.
      Metabolic screen and intervene: improving mental health inpatient metabolic monitoring.
      A pilot study was conducted to see how effective was a practical resource (Let's Get Physical-Improved Physical Health in Mental Health Services-A Practical Toolkit) in assisting the practitioners in managing metabolic syndrome. The research looked into practitioners' knowledge and attitudes, confidence in screening and intervening in metabolic syndrome and improving their documentation. This Toolkit was implemented into the pilot site through a variety of tactics, including face-to-face and video education focused at increasing knowledge of the toolkit. The first video serves as an introduction to the toolkit, while the second video educates viewers on metabolic syndrome, need of screening and intervention. Components of metabolic monitoring improved from 5% to 80% at 3rd month follow-up. The nursing team's assessments increased from 35% to 80% at the 3-month follow-up. The metabolic monitoring pathology rate by the medical officer increased from 5% to 55–75% of patients.
      • Porter C.
      • Aggar C.
      A practical toolkit to support Australian mental health clinicians to manage Metabolic Syndrome: a pilot study.
      However, Osborn concluded that a nurse-led intervention in UK along with the education pack has far more impact on rates of screening than an education pack alone.
      • Osborn D.P.
      • Nazareth I.
      • Wright C.A.
      • King M.B.
      Impact of a nurse-led intervention to improve screening for cardiovascular risk factors in people with severe mental illnesses. Phase-two cluster randomised feasibility trial of community mental health teams.
      Results of maki et al. clearly showed the importance of education and consensual goals to ease the process improvement.
      • Maki M.
      • Bjorklund P.
      Improving cardiovascular disease screening in community mental health centers.

      4. Implications

      This narrative review focused on strategies to aimed at enhancing the rate of metabolic monitoring in patients taking SGAs. The most common interventions were electronic based/paper-based prompts along with education. Studies showed increase in pre and post intervention monitoring from 40 to 80% respectively. Despite the awareness of the metabolic side effects of antipsychotic drugs among the psychiatrists, widespread adoption of the guidelines is still lacking. Very few patients prescribed with SGAs are screened according to best-practice recommendations.
      • Wiechers I.R.
      • Viron M.
      • Stoklosa J.
      • Freudenreich O.
      • Henderson D.C.
      • Weiss A.
      Impact of a metabolic screening bundle on rates of screening for metabolic syndrome in a psychiatry resident outpatient clinic.
      Various strategies have been used to disseminate and execute guidelines into clinical practice. The literature in this area does not recommend a single intervention as most useful but highlights the significance of using multifaceted interventions targeting practitioners, consumers and their carers, decision makers that are driven theoretically and specific to the setting. The importance of recognizing and addressing particular barriers and enablers for behaviour change is very important. Based on the barriers identified through interviewing the targeted population, a multifaceted intervention where initial pilot feasibility trial could be extended for randomisation studies to implement routine monitoring should be developed.
      Frequent audits of the current practice, incorporating monitoring tool within the patient files, sufficient education programmes for the health care professionals, adequate communication with primary care, allowing for multidisciplinary health care team involvement can improve physical health monitoring among outpatients.
      In majority of the studies, a paper based or electronic prompts for metabolic monitoring have used targeting healthcare providers which has been known to influence their behaviour. In this review in most of the studies, a paper prompt to document metabolic monitoring was added into patients’ charts which served as a clinical reminder for monitoring in accordance with guidelines as well as a sheet for recording result and showed better responses compared to computerized system of documentation. Electronic prompts for monitoring within an electronic medical record (EMR) providing alert services for documentation of metabolic parameters or when monitoring was due. The practices that obtained the assistance of the computerized physical health check template were limited (4 studies
      • DelMonte M.T.
      • Bostwick J.R.
      • Bess J.D.
      • Dalack G.W.
      Evaluation of a computer‐based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second‐generation antipsychotics.
      ,
      • Wiechers I.R.
      • Viron M.
      • Stoklosa J.
      • Freudenreich O.
      • Henderson D.C.
      • Weiss A.
      Impact of a metabolic screening bundle on rates of screening for metabolic syndrome in a psychiatry resident outpatient clinic.
      • Yeomans D.
      • Dale K.
      • Beedle K.
      Systematic computerised cardiovascular health screening for people with severe mental illness.
      • Kreyenbuhl J.
      • Dixon L.B.
      • Brown C.H.
      • et al.
      A randomized controlled trial of a patient-centered approach to improve screening for the metabolic side effects of antipsychotic medications.
      )and hence could not provide proper evidence on enhancing the uptake of monitoring when compared to paper-based prompts.
      • Yeomans D.
      • Dale K.
      • Beedle K.
      Systematic computerised cardiovascular health screening for people with severe mental illness.
      Due to the studies lacking randomized controlled trials, it cannot be ruled out if the change was not simply an effect of time, additional research is required to evaluate the impact of electronic pop-up alert on the clinical decision-making process and patient health outcomes.
      • DelMonte M.T.
      • Bostwick J.R.
      • Bess J.D.
      • Dalack G.W.
      Evaluation of a computer‐based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second‐generation antipsychotics.
      Due to the revolution in technology and era of pandemic, presently computerized health check is getting more importance and easier to manage the documentation process. However due to lack of studies not able to provide enough insight regarding its utilization on physical health monitoring, studies available in the literature supports paper based prompts. The limitation of paper-based prompt in the literature was the inability to capture undocumented results or results documented places other than psychiatry notes, patients did not remember to get blood testing done after the physician ordered it, despite follow-up calls.
      • Wiechers I.R.
      • Viron M.
      • Stoklosa J.
      • Freudenreich O.
      • Henderson D.C.
      • Weiss A.
      Impact of a metabolic screening bundle on rates of screening for metabolic syndrome in a psychiatry resident outpatient clinic.
      ,
      • Kioko E.
      • Williams K.
      • Newhouse B.
      Improving metabolic syndrome screening on patients on second generation antipsychotic medication.
      However, proper RCTs comparing the paper based and electronic system of documentation along with training to the healthcare professionals and education to the patients will provide clear insight.
      The intervention that targeted patients included patient education on metabolic syndrome in the form of pamphlets, invitation letter for physical health checks, lifestyle management pack, patient involvements in monitoring, physical activities. The studies that support the inclusion of nurse-assessed/pharmacist led intervention can help in the routine screening of metabolic parameters and showed that a short educational intervention to the healthcare professionals and file-based reminder can have a good significance on clinical practice. The main barriers raised by the nurses in obtaining waist circumference are patient refusal and minimization of physical contact.
      • Rosenbaum S.
      • Nijjar S.
      • Watkins A.
      • Garwood N.
      • Sherrington C.
      • Tiedemann A.
      Nurse‐assessed metabolic monitoring: a file audit of risk factor prevalence and impact of an intervention to enhance measurement of waist circumference.
      Key barriers identified to the implementation of physical health monitoring among psychiatrists include unclear responsibilities, time constraints lack of protocols about monitoring, lack of reminders and knowledge on monitoring, limited resources to perform monitoring.
      • Michael S.
      • MacDonald K.
      Improving rates of metabolic monitoring on an inpatient psychiatric ward.
      ,
      • Gonzalez C.
      • Ahammed N.
      • Fisher R.
      Improving physical health monitoring for out-patients on antipsychotic medication.

      5. Conclusion

      Metabolic monitoring rates for SGA remain suboptimal, suggesting a need for site- and region-specific strategies to promote safe use of these medications and to minimise treatment related adverse effects. Researchers need to think about how strategies may function when planning and implementing them to target this population in the most suitable setting. Behaviour-change strategies to decrease recognized barriers of patient and health professional resistance from screening in this population are needed. Lack of resources, clarity over professional responsibilities and good coordination with primary care should be taken care. Additionally, it is important that abnormal results must be sufficiently managed when identified, either by the psychiatry group or by working in a joint effort with primary care providers. Through improved observing, suitable management, and communication of abnormal results to outpatient suppliers, psychiatrists and pharmacists can assume a key job in the management of metabolic abnormalities. This review provides evidence that studies involving the strategies such as paper based prompts and education to the patients as well as healthcare professionals could help in enhancing the rate of metabolic monitoring in patients prescribed SGAs.

      Ethics approval

      Not applicable.

      Author's contributions

      Conceptualization: Girish Thunga, Sohil Khan, Leelavathi D Acharya, …; Literature Search: Pooja Gopal Poojari, …;Data Analysis: Pooja Gopal Poojari, Girish Thunga, …; Writing - Pooja Gopal Poojari, …; Writing - review and editing: Sohil A Khan, Sonia Shenoy, Sahana Shetty, Swarnali Bose, Keshava Pai. All authors have approved the final article.

      Funding sources

      Indian Council of Medical Research provided the fellowship for the candidate. However, they are not directly involved in the study design, data collection, data analysis, data interpretation, writing of the report, or decision to publish.

      Declaration of competing interest

      The authors have no conflicts of interest to declare.

      Acknowledgments

      Authors are thankful to The Indian Council of Medical Research, New Delhi, Manipal Academy of Higher Education (MAHE) Manipal, Manipal College of Pharmaceutical Sciences, Department of Pharmacy Practice, Centre of Drug Safety and Toxicovigilance, MAHE, Manipal.

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