Metabolic syndrome and psychotropic monitoring — consultant viva

Station structure

Time: 8–10 minutes. Depth: consultant teaching registrar. Expect named criteria, hierarchy, schedule numbers, and named trials — not vague “monitor physical health”.[1][7]

Core questions and model points

1. Define MetS? Cluster of central obesity/waist, high TG, low HDL, raised BP, raised fasting glucose; NCEP three-of-five vs IDF waist-required frameworks.[10]

2. Why care in psychiatry? High MetS prevalence in SMI; CVD drives premature mortality; drugs amplify risk; monitoring gaps are system failures.[7][8]

3. Rank agents? Highest: clozapine, olanzapine. High–moderate: quetiapine. Intermediate: risperidone/paliperidone. Lower weight: aripiprazole, ziprasidone, lurasidone (relative).[2][7]

4. Mechanisms? H1/5-HT2C appetite; insulin resistance; atherogenic lipids; lifestyle multipliers.[7]

5. ADA/APA schedule? Baseline package; weight 4/8/12 weeks then quarterly; glucose/lipids/BP structured rechecks; act earlier if trajectory bad.[1]

6. Youth? Correll 2009 — large early cardiometabolic shifts with first SGA exposure; denser early monitoring.[4]

7. CATIE pearl? Effectiveness vs metabolic trade-offs; olanzapine not “free” efficacy.[3]

8. Interventions? Lifestyle from day 0; switch when possible (e.g. to aripiprazole); metformin evidence (Wu; Jarskog); treat BP/lipids/diabetes to target.[5][6][9]

9. Metformin teaching dose? Start ~500 mg oral with food, titrate toward 1–2 g/day if eGFR allows; contraindications; adjunct not replacement for choice/monitoring.[5][6]

10. Clozapine exception? Unique TRS efficacy → intensive metabolic management rather than casual cessation.[7][6]

11. Ownership? Psychiatrist owns the plan and escalation even when GP draws bloods; written shared-care checklist.[1][7]

Distinctions that score

Score by separating ranking vs absolute need to monitor, using early weight trajectory as an action trigger, naming Wu/Jarskog for metformin, and refusing both metabolic nihilism (“ignore the labs”) and psychiatric nihilism (“stop all antipsychotics”).[1][5][6][7]