Cardiometabolic risk indicators that distinguish adults with psychosis from the general population, by age and gender

Individuals with psychosis are more likely than the general community to develop obesity and to die prematurely from heart disease. Interventions to improve cardiovascular outcomes are best targeted at the earliest indicators of risk, at the age they first emerge. We investigated which cardiometabolic risk indicators distinguished those with psychosis from the general population, by age by gender, and whether obesity explained the pattern of observed differences. Data was analyzed from an epidemiologically representative sample of 1,642 Australians with psychosis aged 18–64 years and a national comparator sample of 8,866 controls aged 25–64 years from the general population. Cubic b-splines were used to compare cross sectional age trends by gender for mean waist circumference, body mass index [BMI], blood pressure, fasting blood glucose, triglycerides, LDL, HDL, and total cholesterol in our psychosis and control samples. At age 25 individuals with psychosis had a significantly higher mean BMI, waist circumference, triglycerides, glucose [women only], and diastolic blood pressure and significantly lower HDL-cholesterol than controls. With the exception of triglycerides at age 60+ in men, and glucose in women at various ages, these differences were present at every age. Differences in BMI and waist circumference between samples, although dramatic, could not explain all differences in diastolic blood pressure, HDL-cholesterol or triglycerides but did explain differences in glucose. Psychosis has the hallmarks of insulin resistance by at least age 25. The entire syndrome, not just weight, should be a focus of intervention to reduce mortality from cardiovascular disease.

Brain connectivity in body dysmorphic disorder compared with controls: a diffusion tensor imaging study

BACKGROUND

Several neuroimaging studies have investigated brain grey matter in people with body dysmorphic disorder (BDD), showing possible abnormalities in the limbic system, orbitofrontal cortex, caudate nuclei and temporal lobes. This study takes these findings forward by investigating white matter properties in BDD compared with controls using diffusion tensor imaging. It was hypothesized that the BDD sample would have widespread significantly reduced white matter connectivity as characterized by fractional anisotropy (FA).

METHOD

A total of 20 participants with BDD and 20 healthy controls matched on age, gender and handedness underwent diffusion tensor imaging. FA, a measure of water diffusion within a voxel, was compared between groups on a voxel-by-voxel basis across the brain using tract-based spatial statistics within the FSL package.

RESULTS

Results showed that, compared with healthy controls, BDD patients demonstrated significantly lower FA (p < 0.05) in most major white matter tracts throughout the brain, including in the superior longitudinal fasciculus, inferior fronto-occipital fasciculus and corpus callosum. Lower FA levels could be accounted for by increased radial diffusivity as characterized by eigenvalues 2 and 3. No area of higher FA was found in BDD.

CONCLUSIONS

This study provided the first evidence of compromised white matter integrity within BDD patients. This suggests that there are inefficient connections between different brain areas, which may explain the cognitive and emotion regulation deficits within BDD patients.

Difficult-to-treat-depression: what do general practitioners think?

OBJECTIVE

To understand the perspectives of a group of general practitioners regarding management of patients with difficult-to-treat depression (DTTD).

DESIGN, SETTING AND PARTICIPANTS

A qualitative approach using a focus group and semi-structured telephone interviews conducted in 2011 with 10 GPs from urban and rural Victoria. Five main topics were explored: (1) understanding of DTTD; (2) understanding of other terms used to describe DTTD; (3) experiences of diagnosing DTTD; (4) experiences of managing DTTD; and (5) management options.

RESULTS

The participants had generally poor recognition of diagnostic terms, and questioned their relevance. Participants felt that management guidelines were not always helpful. Access to psychiatrists was often difficult, and non-pharmacological or complementary treatments were considered to have a role in management. Environmental and cultural factors, social isolation and cost of treatment have an impact on patient adherence, and the participants felt that the professional-patient relationship is important in ensuring comprehensive care.

CONCLUSIONS

Despite extensive experience and knowledge of their patients, there were gaps in GPs' appraisal of the literature and about specific resources available. The GPs had little interest in the nuances of classifications; instead, their focus was on their patient and what to do in practical terms regarding optimal management.

Management of schizophrenia: clinical experience with asenapine

Schizophrenia is a chronic brain disorder comprising a range of clinical features, including positive and negative symptoms, cognitive dysfunction and mood symptoms (particularly depression and anxiety). The management of schizophrenia requires effective short- and long-term treatment with antipsychotic medication that is effective across these symptom domains, while being well tolerated over the long term. Asenapine is the first tetracyclic atypical antipsychotic to be licensed in the USA and several other countries outside Europe for the acute and maintenance treatment of schizophrenia in adults. It has a unique receptor-binding profile and a broad range of therapeutic effects. Since clinical trials are conducted under strict conditions in tightly defined patient populations, evidence of an agent's efficacy and tolerability under 'real-world' clinical practice conditions is also required. As in clinical trials, real-life case reports demonstrate that asenapine is effective in treating the positive symptoms of schizophrenia, both in the acute setting and for relapse prevention. It is also effective in treating negative symptoms and shows promise in the treatment of depressive symptoms associated with schizophrenia. Asenapine has a favourable tolerability profile, having a minimal impact on weight and metabolic parameters. As such, asenapine is valuable option for the treatment of schizophrenia in adults.

Cannabis and psychosis: what causes what?

Converging lines of evidence suggest that cannabinoids can produce a full range of transient schizophrenia-like positive, negative and cognitive symptoms. Cannabinoids also produce some psychophysiological deficits also known to be present in schizophrenia. It is also clear that, in individuals with an established psychotic disorder, cannabinoids can exacerbate symptoms, trigger relapse, and have negative consequences on the course of the illness. Increasing evidence suggests that early and heavy cannabis exposure may increase the risk of developing a psychotic disorder such as schizophrenia. The relationship between cannabis exposure and schizophrenia fulfills some, but not all, of the usual criteria for causality. However, most people who use cannabis do not develop schizophrenia, and many people diagnosed with schizophrenia have never used cannabis. Therefore, it is likely that cannabis exposure is a “component cause” that interacts with other factors to “cause” schizophrenia or other psychotic disorders, but is neither necessary nor sufficient to do so alone. Further work is necessary to identify the factors that underlie individual vulnerability to cannabinoid-related psychosis and to elucidate the biological mechanisms underlying this risk.

Anxiety, psychosis and substance use: prevalence, correlates and recognition in an outpatient mental health setting

OBJECTIVE

The current study examined anxiety in people with substance use disorder (SUD) and a psychotic disorder. It is hypothesised that: anxiety disorders (AD) would be highly prevalent (greater than 20%) in people identified as having SUD and psychotic disorders; those with comorbid AD would fair worse than those without, on measures of quality of life, severity of substance dependence, locus of control, suicidality and psychotic symptoms; and, the presence of such anxiety disorder symptomatology would be under-detected by their mental health case managers.

METHOD

Outpatients with co-occurring substance use disorder and psychosis were interviewed to collect data about their diagnosis, depressive and psychotic symptoms, severity of dependence on substances, quality of life and locus of control. Participants' case managers made blind ratings of the presence and severity of participants' anxiety.

RESULTS

Fifty eight percent of participants had at least one anxiety disorder. Of these, 56% - 70% had case managers who had identified them as having an anxiety problem. The occurrence of anxiety disorder was associated with more external locus of control, greater intensity of suicidal thinking, worse psychotic symptoms, lower quality of life and greater severity of dependence on substances.

CONCLUSION

This research suggests anxiety in people with substance use disorder and psychosis is highly prevalent, is associated with poorer outcomes, and is under detected by case managers. Further examination of this issue may lead to important advances in the treatment and prognosis of people with substance use disorder and psychosis.

Determining the efficacy and tolerance of quetiapine extended release for the management of psychosis and accompanying acute behavioral disturbance in adult acute psychiatry

BACKGROUND

This study was conducted to explore the efficacy and tolerability of quetiapine extended release (XR) to treat psychosis and accompanying acute behavioral disturbance in hospitalized psychiatric patients.

METHODS

Patients with psychosis who displayed aggression were administered quetiapine XR (day 1 mean dose: 293.3 mg). Symptoms and side effects were assessed prospectively over an 8-day period. Symptoms were measured by the Overt Aggression Scale and Brief Psychiatric Rating Scale (BPRS), and side effects were measured using the Simpson-Angus Scale and Barnes Akathisia Rating Scale.

RESULTS

Fifteen of 16 consenting patients completed the study. Aggression was significantly reduced by day 3. Psychopathology also was significantly reduced, with the greatest improvement in BPRS Thinking Disturbance subscale scores. No significant increase in movement side effects was seen by day 8. Seven participants were administered a concomitant sedating antipsychotic on an as-needed basis, particularly in the first 4 days of treatment; these participants displayed much greater aggression--but not psychopathology--at day 1, and it took longer for their aggression and psychopathology to improve compared with patients treated with quetiapine XR as the sole antipsychotic.

CONCLUSIONS

Further research is needed before definitive recommendations can be made. However, current findings provide tentative support for quetiapine XR as a safe and effective medication for treating concurrent psychosis and behavioral disturbance, particularly in less severely aggressive patients.

The impact of alcohol and illicit drugs on people with psychosis: the second Australian National Survey of Psychosis

OBJECTIVE

To provide the most up-to-date prevalence estimates of alcohol and illicit drug use among individuals with psychosis in Australia, and explore correlates associated with a lifetime diagnosis of both alcohol abuse/dependence and cannabis abuse/dependence.

METHOD

This paper uses data from the Survey of High Impact Psychosis (SHIP), conducted as a follow-up to the first Australian National Low Prevalence (Psychotic) Disorders Study (1997-1998). The SHIP was a national study, carried out across five states, in which a sample of 1825 individuals was recruited through a two-phase sampling framework.

RESULTS

Alcohol and illicit drug use was highly prevalent for the entire sample. There were few significant differences in the prevalence or frequency of use across the diagnostic categories examined. Substantial increases in substance abuse/dependence were noted since the 1997-1998 survey (51% diagnosed with alcohol abuse/dependence, 51% with cannabis abuse/dependence and 32% with other illicit drug abuse/dependence, compared to 28%, 23% and 12% respectively, in the 1997-1998 survey by Kavanagh et al., 2004). Factors significantly associated with both lifetime alcohol and cannabis dependence included male gender, younger age, single marital status, lower educational attainment, shorter duration of illness, lifetime presence of hallucinations, higher negative syndrome score and lower body mass index (BMI). A number of other factors were found to be differentially associated with either lifetime alcohol or cannabis dependence.

CONCLUSIONS

The use of alcohol and illicit substances is common among people with a psychotic illness, with a concerning upward trend in rates of substance abuse/dependence since the 1997-1998 survey. Clinicians should be aware of the potential impact of concurrent substance use and provide integrated treatment for individuals presenting with psychotic illnesses. More research and investment in new intervention programs is required.

Cardiometabolic risk factors in people with psychotic disorders: the second Australian national survey of psychosis

OBJECTIVE

To determine the prevalence of cardiometabolic risk factors in Australian adults with a psychotic disorder.

METHOD

Data were collected during the interview phase of the second Australian survey of psychosis, a population-based survey of Australians aged 18 to 64 years with a psychotic disorder. Body mass index, waist circumference and blood pressure were measured. Participants were asked about diagnoses of relevant medical conditions, medications, smoking and physical activity. Fasting blood samples were analysed for glucose, high-density lipoprotein cholesterol, total cholesterol and triglycerides. The prevalence of metabolic syndrome was determined using the harmonized criteria developed by the International Diabetes Federation and other bodies.

RESULTS

A total of 1087 men (60%) and 738 women (40%) participated. Their mean age was 38.36 (SD 11.16) years; 773 (42%) were aged 18-34 years and 1052 (58%) 35-64 years. Three-quarters were overweight or obese and 82% had abdominal obesity. Almost half were hypertensive. Two-thirds were current smokers and 81% had a lifetime history of smoking. Levels of physical activity were very low. About 30% reported a diagnosis of hypertension or high cholesterol, 20% knew they had diabetes or high blood sugar and 18% had cardiovascular disease. Half of those with self-reported hypertension were taking antihypertensive drugs, and about 40% with hypercholesterolemia or hyperglycaemia were receiving medication for these conditions. Seventy per cent (N = 1286) of participants provided fasting blood samples. Abnormal levels of high-density lipoprotein cholesterol and triglycerides were each found in almost half of participants and almost one-third had elevated fasting glucose. More than half of participants (54.8%) met criteria for metabolic syndrome.

CONCLUSIONS

Australians living with psychosis have high rates of cardiometabolic risk factors. There are a number of obvious targets for prevention and treatment, including obesity (especially in women), smoking (more prevalent in men), hypertension, hyperlipidaemia and sedentary lifestyle.

Controlled clinical trial of a self-management program for people with mental illness in an adult mental health service - the Optimal Health Program (OHP)

Objective. The objective of this study was to evaluate the effect and cost-effectiveness of a self-management intervention, delivered as part of routine care in an adult mental health service. Method. In a community mental health setting, routine care was compared with routine care plus a nine-session intervention (the Optimal Health Program) using a non-randomised controlled design. Adult (18–65 years) consumers of mental health services in the Australian Capital Territory were eligible for participation. Results. The Optimal Health Program was associated with significant improvements in health and social functioning as measured by the Health of the Nation Outcome Scale (average change relative to control: –3.17; 95% CI –4.49 to –1.84; P < 0.001). In addition, there was a reduction in hospital admissions in the treatment group (percentage of time in hospital reduced from 3.20 to 0.82; P = 0.07). This translated into a net cost saving of over AU$6000 per participant per year (uncertainty range AU$744 to AU$12 656). Conclusions. This study shows promising results for incorporating a self-management program into routine care to improve the health and social functioning of mental health consumers in a cost-effective manner. What is known about the topic? Current literature supports the efficacy of structured self-management programs for chronic conditions such as diabetes (type 1 and 2) and asthma, but there remains limited evidence that self-management programs improve outcomes for people with mental illness. What does this paper add? This study adds to the body of evidence supporting self-management as a cost-effective adjunct to routine care in mental health services. What are the implications for practitioners? Our study supports the feasibility of clinicians delivering cost-effective self-management programs as part of routine mental health service delivery.

A qualitative investigation of obese men's experiences with their weight

OBJECTIVES

To investigate obese men's health behaviors and strategies for change.

METHODS

Qualitative interviews with 36 men (BMI 30 and over).

RESULTS

All men felt personally responsible for their weight gain. Sedentary lifestyles, stress, lack of worklife balance and weight-based stigma were all significant causes of weight gain and barriers to weight loss. These factors also contributed to men's unwillingness to seek help for their over-weight.

CONCLUSION

Addressing the self-blame and stigma associated with obesity is important in developing strategies to improve the health and well-being of obese men.