Assessment and treatment of physical health problems among people with schizophrenia: national cross-sectional study

BACKGROUND

In the UK and other high-income countries, life expectancy in people with schizophrenia is 20% lower than in the general population.

AIMS

To examine the quality of assessment and treatment of physical health problems in people with schizophrenia. Method Retrospective audit of records of people with schizophrenia or schizoaffective disorder aged ⩾18. We collected data on nine key aspects of physical health for 5091 patients and combined these with a cross-sectional patient survey.

RESULTS

Body mass index was recorded in 2599 (51.1%) patients during the previous 12 months and 1102 (21.6%) had evidence of assessment of all nine key measures. Among those with high blood sugar, there was recorded evidence of 53.5% receiving an appropriate intervention. Among those with dyslipidaemia, this was 19.9%. Despite this, most patients reported that they were satisfied with the physical healthcare they received.

CONCLUSIONS

Assessment and treatment of common physical health problems in people with schizophrenia falls well below acceptable standards. Cooperation and communication between primary and secondary care services needs to improve if premature mortality in this group is to be reduced.

A double-edged sword: review of the interplay between physical health and mental health

It is widely acknowledged that there is interplay between physical and mental health, with causality in both directions. A common theme across countries is the uncertainty surrounding who should act as gatekeeper for physical health matters in psychiatry. Much of the metabolic monitoring is carried out by psychiatrists who often feel ill equipped to treat medical problems such as abnormal cholesterol or disturbances of glucose metabolism. However many patients do not attend primary care on a regular basis and may not be likely to follow through on referral to primary care. This review aims to examine the interplay between co-morbid physical and mental health conditions, identify the physical health conditions particularly associated with severe affective and psychotic illness and briefly discuss interventions and recommendations in this area. As people with severe mental illness die 10-20 years younger than their peers, with much of this premature mortality due to cardiovascular disease, this topic is emerging as one of great importance amongst clinicians and policymakers internationally.

Quality of prescribing for schizophrenia: evidence from a national audit in England and Wales

The National Audit of Schizophrenia (NAS) examined the quality of care received in England and Wales. Part of the audit set out to determine whether six prescribing standards, set by the national clinical guidelines for schizophrenia, were being implemented and to prompt improvements in care. Mental Health Trusts and Health Boards provided data obtained from case-notes for adult patients living in the community with schizophrenia or schizoaffective disorder. An audit of practice tool was developed for data collection. Most of the 5055 patients reviewed were receiving pharmacological treatment according to national guidelines. However, 15.9% of the total sample (95%CI: 14.9-16.9) were prescribed two or more antipsychotics concurrently and 10.1% of patients (95%CI: 9.3-10.9) were prescribed medication in excess of recommended limits. Overall 23.7% (95%CI: 22.5-24.8) of patients were receiving clozapine. However, there were many with treatment resistance who had no clear reason documented as to why they had not had a trial of clozapine (430/1073, 40.1%). In conclusion, whilst most people were prescribed medication in accordance with nationally agreed standards, there was considerable variation between service providers. Antipsychotic polypharmacy, high dose prescribing and clozapine underutilisation in treatment resistance were all key concerns which need to be further addressed.

The economic impact of early intervention in psychosis services for children and adolescents

AIMS

To develop and populate a plausible model of the impact of early intervention (EI) for children and adolescents with psychosis to estimate potential short-term health-related cost savings compared to generic Child and Adolescent Mental Health Services (CAMHS).

METHOD

A decision-tree-based model for EI in CAMHS was developed. The model was populated using data relating to the use of inpatient care and EI service activity for people aged under 18 from an area of North East England. Data were abstracted from the National Health Service clinical reporting systems for 2001-2008. Sensitivity analyses were performed to examine costs associated with the model under differing assumptions.

RESULTS

EI delivered cost savings of £4814 per patient compared to care provided by generic CAMHS. Cost savings were predominantly a consequence of reduced length of hospital admissions for patients served by the EI team. The findings were robust to sensitivity analyses.

CONCLUSIONS

These findings suggest that EI services for children and adolescents with psychosis provide potential direct health cost savings comparable to those observed for working-age adults.

Bridging the gap from evidence to policy and practice: reducing the progression to metabolic syndrome for children and adolescents on antipsychotic medication

OBJECTIVES

For children and adolescents, the adverse effects from antipsychotic medicines exaggerate the already considerable burden of having a serious mental illness. Many of these young people face a future not only limited by stigmatizing psychiatric illness but also a life restricted and shortened by physical ill-health, particularly cardiovascular disease and type-2 diabetes. This review focuses on bridging the current gap between available evidence and practice guidelines and policies.

METHOD

Following an extensive literature search, key papers focusing on the evidence of the nature and occurrence of metabolic morbidity in children and adolescents following the use of antipsychotic medication were included.

RESULTS

There is growing evidence to suggest that some of the key antecedents of metabolic syndrome occur soon after diagnosis and initiation of antipsychotic medication, and they accumulate over time.

CONCLUSION

While guidelines and policies around the monitoring of metabolic syndrome in children and adolescents with mental illness receiving antipsychotic medication are limited, an opportunity lies in altering the trajectory towards cardiovascular disease and type-2 diabetes by early recognition and intervention to reduce cardiometabolic risk rather than waiting until disease end-points are reached later in life.

Antipsychotics: is it time to introduce patient choice?

Evidence regarding overestimation of the efficacy of antipsychotics and underestimation of their toxicity, as well as emerging data regarding alternative treatment options, suggests it may be time to introduce patient choice and reconsider whether everyone who meets the criteria for a schizophrenia spectrum diagnosis requires antipsychotics in order to recover.

Tobacco use before, at, and after first-episode psychosis: a systematic meta-analysis

OBJECTIVE

Patients with first-episode psychosis have a high prevalence of tobacco use. We aimed to examine the prevalence and course of tobacco use during early psychosis using meta-analysis.

DATA SOURCES

Systematic search of MEDLINE (1948-2011), Embase (1947-2011), CINAHL (1984-2011), PsycINFO (1967-2011), and ISI Web of Science (1900-2011) using the search terms [psychosis OR schizophrenia] AND [tobacco OR smoking OR nicotine].

STUDY SELECTION

We located 10 studies reporting the age at initiation of daily tobacco use and the age at onset of psychosis, 31 studies reporting prevalence of tobacco use in patients with first-episode psychosis, 10 studies comparing smoking to age-/gender-matched controls, and 7 studies reporting prevalence of tobacco use at intervals after treatment.

DATA EXTRACTION

The following data were extracted: age at initiation of daily tobacco use and at onset of psychosis, the proportion of patients with first-episode psychosis who used tobacco, the proportion of the general population who used tobacco, and the proportion of patients with psychosis who used tobacco at various intervals after initiation of antipsychotic treatment.

RESULTS

The pooled estimate for the interval between initiation of tobacco use and the onset of psychosis was 5.3 years (standardized mean difference = 0.85). The estimated prevalence of tobacco users in first episode of psychosis is 58.9% (95% CI, 54.3%-63.4%). There is a strong association between first-episode psychosis and tobacco use (OR = 6.04; 95% CI, 3.03-12.02) compared with healthy controls. The prevalence of tobacco use at intervals between 6 and 120 months after treatment remained unchanged (OR = 0.996; 95% CI, 0.907-1.094).

CONCLUSIONS

Patients with first-episode psychosis tend to have smoked for some years prior to the onset of psychosis, have high prevalence of tobacco use at the time of presenting for treatment, and are much more likely to smoke than aged-matched controls. Their apparent difficulty in quitting has implications for tobacco cessation programs and efforts to reduce cardiovascular disease among people with mental illness.

Test of Lorentz invariance with spin precession of ultracold neutrons

A clock comparison experiment, analyzing the ratio of spin precession frequencies of stored ultracold neutrons and 199Hg atoms, is reported. No daily variation of this ratio could be found, from which is set an upper limit on the Lorentz invariance violating cosmic anisotropy field b perpendicular < 2 x 10(-20) eV (95% C.L.). This is the first limit for the free neutron. This result is also interpreted as a direct limit on the gravitational dipole moment of the neutron |gn| < 0.3 eV/c2 m from a spin-dependent interaction with the Sun. Analyzing the gravitational interaction with the Earth, based on previous data, yields a more stringent limit |gn| < 3 x 10(-4) eV/c2 m.

Beyond early intervention: can we adopt alternative narratives like 'Woodshedding' as pathways to recovery in schizophrenia?

AIM

To consider how early intervention in psychosis can support a recovery paradigm.

METHODS

Significant numbers of those developing a first episode of psychosis are on a path to a persisting and potentially life long condition. Constituting the schizophrenia spectrum disorders, such conditions demand the particular qualities and attitudes inherent within recovery-based practice. This paper explores some of these qualities and attitudes by examining the tension between a traditional 'clinical' narrative used by many health providers and a 'human' narrative of users of services and their families.

RESULTS

We draw out key features and constructs of recovery practice as they relate to the EI paradigm. These include: woodshedding, turning points, discontinuous improvement models, therapeutic optimism, gradualism and narratives of story telling. We also highlight the role of family members and other close supporters and believe their potential contribution requires greater consideration.

CONCLUSIONS

The early intervention (EI) paradigm can resonate and indeed offer a stronghold for recovery-based practice where traditional mental health services have sometimes struggled. Conversely, failure of caregivers to provide such an approach in the early phase of illness can cause unnecessary and sometimes disastrous consequences.

Improved experimental limit on the electric dipole moment of the neutron

An experimental search for an electric dipole moment (EDM) of the neutron has been carried out at the Institut Laue-Langevin, Grenoble. Spurious signals from magnetic-field fluctuations were reduced to insignificance by the use of a cohabiting atomic-mercury magnetometer. Systematic uncertainties, including geometric-phase-induced false EDMs, have been carefully studied. The results may be interpreted as an upper limit on the neutron EDM of |d(n)|< 2.9 x 10(-26)e cm (90% C.L.).