An Interview with Dr. Donald W. Black by Dr. Robert Philibert, Chief Medical Officer at Cardio Diagnostics Inc
One of the more sobering facts I’ve learned during my career is that while the ratio of men to women with schizophrenia at age 21 is around 1:1, the ratio for those at age 65 is 1:10. The reason for the difference is not the result of suicide; rather, men die prematurely from heart disease. In our zeal to focus on one outcome – suicide – psychiatrists have lost focus on the other processes that harm our patients.
The stark consequences of cardiovascular disease have become increasingly clear. Clinical trial data involving second-generation antipsychotics show that while these effective medications are widely used to treat bipolar disorder and schizophrenia because of their lower rate of extrapyramidal side effects, their use has markedly increased the rate of metabolic problems in patients (i.e., diabetes, obesity, cardiovascular disease). Risk for these and similar outcomes have been soft peddled by Big Pharma in their drive to gain market share. The financial stakes were considerable with Eli Lilly alone paying a $1.4 billion penalty in 2009 for off-label promotion of olanzapine. They were not the only offender. Also in 2009, Pfizer paid a $2.3 billion dollar penalty for unlawful promotion of several medications including ziprasidone, another second generation antipsychotic. As a result of the increased rate of cardiovascular events, all second generation antipsychotics now have “black box warnings” detailing their risk for cardiovascular disease. Nevertheless, these medications are important for our patients, particularly those with bipolar disorder or schizophrenia.
So, what should a responsible clinician do when prescribing these useful, but potentially harmful medications? To mitigate the adverse effects of these medications, treatment guidelines recommend yearly screening of patients for diabetes and cardiovascular risk. Nonetheless, fewer than half of all patients receive the screening.
To better understand these challenges, we recently interviewed Dr. Donald W. Black, past President of the American Academy of Clinical Psychiatry (https://www.aacp.com/). Dr. Black is well-known to the psychiatric community, and has authored the best-selling Introductory Textbook of Psychiatry, now in its 7th edition, and Bad Boys Bad Men – Confronting Antisocial Personality Disorder, a book written for the lay public. Dr. Black noted that “psychiatric patients in general, not just those on antipsychotics, are often at high risk for cardiovascular disease.” Despite this, he explained that they rarely receive adequate preventive screening and treatment. Among the barriers, he noted that those with mental illnesses often have trouble fasting overnight, complicating the interpretation of their fasting lipid profiles. Furthermore, he added that “psychiatric patients are often seen in low medically resourced clinics” that often do not have the capability of drawing and processing blood. As a result, Dr. Black concludes that “psychiatric practitioners need a new, more effective method for assessing and treating their patients.”
Could screening with Epi+Gen CHD be a good alternative? We believe so. Not only is Epi+Gen CHD more sensitive than current lipid-based methods for screening for coronary heart disease, it can be conducted easily at-home or any clinic. In contrast to standard lipid based methods, there is no need to staff a phlebotomist and perhaps best yet, no need for fasting before the test. The patient report includes a precise risk assessment and information as to how your patient compares to others. In many ways, it is ideal for use in busy stand-alone psychiatric practices.
If you believe that your patient deserves the best, consider using Epi+Gen CHD to assess risk for coronary heart disease in your patients on antipsychotics. Let us help you keep your focus on the entire patient.
- Almashat, S., Preston, C., Waterman, T. & Wolfe, S. Rapidly increasing criminal and civil monetary penalties against the pharmaceutical industry: 1991 to 2010. Public Citizen 16(2010).
- De Hert, M., et al. Guidelines for screening and monitoring of cardiometabolic risk in schizophrenia: systematic evaluation. The British Journal of Psychiatry 199, 99-105 (2011).
- Morrato, E.H., et al. Metabolic Testing for Adults in a State Medicaid Program Receiving Antipsychotics: Remaining Barriers to Achieving Population Health Prevention Goals. JAMA Psychiatry 73, 721-730 (2016).
- Jung, Y., Frisvold, D., Dogan, T., Dogan, M.V. & Philibert, R. Cost Utility Analyses of an Integrated Genetic-Epigenetic Test for Assessing Risk for Coronary Heart Disease. Epigenomics (2021).