Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder

Olanzapine and aripiprazole differentially affect glucose uptake and energy metabolism in human mononuclear blood cells

The use of antipsychotics carries the risk of metabolic side effects, such as weight gain and new onset type-2 diabetes mellitus. The mechanisms of the observed metabolic alterations are not fully understood. We compared the effects of two atypical antipsychotics, one known to favor weight gain (olanzapine), the other not (aripiprazole), on glucose metabolism. Primary human peripheral blood mononuclear cells (PBMC) were isolated and stimulated with olanzapine or aripiprazole for 72 h. Cellular glucose uptake was analyzed in vitro by 18F-FDG uptake. Further measurements comprised mRNA expression of glucose transporter (GLUT) 1 and 3, GLUT1 protein expression, DNA methylation of GLUT1 promoter region, and proteins involved in downstream glucometabolic processes. We observed a 2-fold increase in glucose uptake after stimulation with aripiprazole. In contrast, olanzapine stimulation decreased glucose uptake by 40%, accompanied by downregulation of the cellular energy sensor AMP activated protein kinase (AMPK). GLUT1 protein expression increased, GLUT1 mRNA expression decreased, and GLUT1 promoter was hypermethylated with both antipsychotics. Pyruvat-dehydrogenase (PDH) complex activity decreased with olanzapine only. Our findings suggest that the atypical antipsychotics olanzapine and aripiprazole differentially affect energy metabolism in PBMC. The observed decrease in glucose uptake in olanzapine stimulated PBMC, accompanied by decreased PDH point to a worsening in cellular energy metabolism not compensated by AMKP upregulation. In contrast, aripiprazole stimulation lead to increased glucose uptake, while not affecting PDH complex expression. The observed differences may be involved in the different metabolic profiles observed in aripiprazole and olanzapine treated patients.

Medical Complications of Psychiatric Treatment: An Update

Psychiatric medications are used commonly in hospitalized patients and are particularly indicated in patients who are critically ill to manage many conditions. Due to their many indications in the intensive care unit (ICU), psychiatric medications should be closely monitored in these medically compromised patients for adverse reactions and medical complications because they may affect essentially all organ systems. These range from life-threatening reactions to other less significant effects, such as sedation, to other detrimental complications, such as pancreatitis. Knowledge of psychopharmacology as well as the diagnosis and treatment of these complications is imperative in treating patients in the ICU.

Physical health policies and metabolic screening in mental health care systems of sub-Saharan African countries: a systematic review

BACKGROUND

There is a need for interventions to address the escalating mental health burden in sub-Saharan Africa (SSA). Addressing physical health needs should have a central role in reducing the burden and facilitating recovery in people with severe mental illness (SMI). We systematically investigated (1) physical health policies in the current mental health plans, and (2) the routine metabolic screening rates for people with SMI in SSA.

METHODS

The Mental Health Atlas and MiNDbank of the World Health Organization were screened for physical health policies in mental health plans. Next, we systematically searched PubMed from inception until February 1st, 2017 for relevant studies on metabolic screening rates in people with SMI in SSA.

RESULTS

The current systematic review shows that in 22 screened plans only 6 made reference to a physical health component or policy. Only the South-African mental health plan reported about routine screening and treatment of physical illness for people with SMI. In 2 South-African studies (n = 431) routine screening was unacceptably low with less than 1% adequately screened for all modifiable metabolic syndrome risk factors.

CONCLUSIONS

Our review data clearly show that a physical health policy is yet to be embraced in mental health care systems of most SSA countries. There is a clear need for integrated mental and medical services in SSA. All psychiatric services, including poorly developed community-based primary health care settings should standardly assess the body mass index and waist circumference at initiation of psycho-pharmacotherapy, and afterwards at regular intervals. Optimal monitoring should include assessments of fasting glucose, lipids, cholesterol, and blood pressure. Mental health care providers in SSA countries need to be informed that their roles extend beyond taking care of the mental health of their patients and assume responsibility for the physical health of their patients as well. Policy makers should be made aware that investment in continued medial education and in screening for physical health risks could optimize mental and physical health improvements. The increased physical health needs of people with mental illness should be integrated into the existing Information, Education and Communication public health awareness programs of the World Health Organization.

Clinicians' adherence to clinical practice guidelines for cardiac function monitoring during antipsychotic treatment: a retrospective report on 434 patients with severe mental illness

BACKGROUND

Severe mental illness (SMI) has considerable excess morbidity and mortality, a proportion of which is explained by cardiovascular diseases, caused in part by antipsychotic (AP) induced QT-related arrhythmias and sudden death by Torsade de Point (TdP). The implementation of evidence-based recommendations for cardiac function monitoring might reduce the incidence of these AP-related adverse events. To investigate clinicians' adherence to cardiac function monitoring before and after starting AP, we performed a retrospective assessment of 434 AP-treated SMI patients longitudinally followed-up for 5 years at an academic community mental health center.

METHODS

We classified antipsychotics according to their risk of inducing QT-related arrhythmias and TdP (Center for Research on Therapeutics, University of Arizona). We used univariate tests and multinomial or binary logistic regression model for data analysis.

RESULTS

Univariate and multinomial regression analysis showed that psychiatrists were more likely to perform pre-treatment electrocardiogram (ECG) and electrolyte testing with AP carrying higher cardiovascular risk, but not on the basis of AP pharmacological class. Univariate and binomial regression analysis showed that cardiac function parameters (ECG and electrolyte balance) were more frequently monitored during treatment with second generation AP than with first generation AP.

CONCLUSIONS

Our data show the presence of weaknesses in the cardiac function monitoring of AP-treated SMI patients, and might guide future interventions to tackle them.

Ergosteryl 2-naphthoate, An Ergosterol Derivative, Exhibits Antidepressant Effects Mediated by the Modification of GABAergic and Glutamatergic Systems

Phytosterols are a kind of natural component including sitosterol, campesterol, avenasterol, ergosterol (Er) and others. Their main natural sources are vegetable oils and their processed products, followed by grains, by-products of cereals and nuts, and small amounts of fruits, vegetables and mushrooms. In this study, three new Er monoester derivatives were obtained from the reflux reaction with Er: organic acids (furoic acid, salicylic acid and 2-naphthoic acid), 1-Ethylethyl-3-(3-dimethyllaminopropyl) carbodiimide hydrochloride (EDCI) and 4-dimethylaminopyridine (DMAP) in dichloromethane. Their chemical structures were defined by IR and NMR. The present study was also undertaken to investigate the antidepressant-like effects of Er and its derivatives in male adult mice models of depression, and their probable involvement of GABAergic and glutamatergic systems by the forced swim test (FST). The results indicated that Er and its derivatives display antidepressant effects. Moreover, one derivative of Er, ergosteryl 2-naphthoate (ErN), exhibited stronger antidepressant activity in vivo compared to Er. Acute administration of ErN (5 mg/kg, i.p.) and a combination of ErN (0.5 mg/kg, i.p.), reboxetine (2.5 mg/kg, i.p.), and tianeptine (15 mg/kg, i.p.) reduced the immobility time in the FST. Pretreatment with bicuculline (a competitive γ-aminobutyric acid (GABA) antagonist, 4 mg/kg, i.p.) and N-methyl-d-aspartic acid (NMDA, an agonist at the glutamate site, 75 mg/kg, i.p.) effectively reversed the antidepressant-like effect of ErN (5 mg/kg, i.p.). However, prazosin (a α1-adrenoceptor antagonist, 1 mg/kg, i.p.) and haloperidol (a non-selective D2 receptor antagonist, 0.2 mg/kg, i.p.) did not eliminate the reduced immobility time. Altogether, these results indicated that ErN produced antidepressant-like activity, which might be mediated by GABAergic and glutamatergic systems.

Polypharmacy and Adherence to Adjuvant Endocrine Therapy for Breast Cancer

PURPOSE

Many patients with breast cancer are treated for other conditions and experience polypharmacy with multiple concurrent medications. Our aim was to evaluate polypharmacy in relation to adherence to adjuvant endocrine therapy (AET) in breast cancer.

METHODS

We conducted a retrospective cohort study of women with incident, invasive breast cancer initiating AET (tamoxifen, letrozole, anastrozole, exemestane) between 2009 and 2013 in the Truven Health MarketScan Database. Polypharmacy and pill burden were measured for commonly used concurrent medications, including lipid-lowering drugs, antihypertensives, oral diabetes medications, insulin analogs, antidepressants, anxiolytics/antipsychotics, and opioid-containing analgesics. Polypharmacy was defined as frequent use (three or more dispensings) of a given medication class and by pill burden (total dispensings). Medication possession ratios (MPR) were estimated for subsequent 12-month intervals. Multivariable generalized estimating equation models were used to calculate odds ratios (ORs) and robust 95% CIs for associations with AET adherence (MPR ≥ 0.80).

RESULTS

Among 40,009 women, 74% were adherent in year +1 and continued to have high mean adherence (MPR = 0.79) among those continuing AET through year +3. Increasing polypharmacy ( P < .001) and pill burden ( P < .001) were associated with greater adherence, but effects differed by medication class. Frequent use of lipid-lowering drugs (OR, 1.42; 95% CI, 1.36 to 1.49) and antihypertensives (OR, 1.15; 95% CI, 1.10 to 1.20) were associated with higher odds of adherence; frequent use of opioid-containing analgesics (OR, 0.80; 95% CI, 0.77 to 0.83), anxiolytics/antipsychotics (OR, 0.95; 95% CI, 0.91 to 0.99), antidepressants (OR, 0.85; 95% CI, 0.82 to 0.89), and insulin therapy (OR, 0.82; 95% CI, 0.72 to 0.95) were associated with lower odds of adherence.

CONCLUSION

Associations between polypharmacy and adherence in breast cancer may be better characterized by understanding specific classes of medications used concurrently. Comprehensive medication therapy management, including ongoing pain evaluation and psychoactive therapies, is warranted.

Long-term use of lurasidone in patients with bipolar disorder: safety and effectiveness over 2 years of treatment

BACKGROUND

Bipolar disorder is a chronic illness with a 2-year recurrence rate of approximately 50% among individuals receiving treatment in the community. The aim of this 18-month, open-label, continuation study was to evaluate the long-term safety and effectiveness of lurasidone in patients who initially presented with a major depressive episode associated with bipolar disorder, and who had completed at least 6 months of initial treatment with lurasidone.

METHODS

Patients with bipolar I depression were enrolled in one of three 6-week, double-blind, placebo-controlled trials (monotherapy with lurasidone, 1 study; adjunctive therapy with lurasidone; and lithium or valproate, 2 studies). Study completers were eligible for a 6-month, open-label extension study of lurasidone utilizing flexible daily doses of 20-120 mg; extension completers were then eligible for an additional 18 months of continuation treatment with flexible, once-daily doses of lurasidone in the range of 20-80 mg. Concomitant therapy with mood stabilizers was permitted throughout the open-label extension and continuation studies.

RESULTS

A total of 1199 patients entered, and 941 (78.5%) completed initial, double-blind, acute treatment, of whom 817/941 (86.8%) entered, and 559 (68.4%) completed the 6-month extension study; 122/559 patients (21.8%) entered the 18-month continuation study, of whom 19.7% of discontinued, including 6.6% due to adverse events and 1.6% due to insufficient efficacy. The mean dose of lurasidone during the 18-month continuation study was 61.8 mg/day, and the modal dose was 60 mg/day. Mean change in weight, from acute baseline to 18-month continuation endpoint was +0.8 kg (completers, n = 55); median changes in cholesterol and triglycerides were -3.0 mg/dL and +26.0 mg/dL, respectively. Based on a Kaplan-Meier analysis, the probability of relapse during 18 months of continuation treatment with lurasidone was estimated to be 18.3% in the monotherapy group and 29.1% in the adjunctive therapy group. Improvement in global illness severity was also maintained during 18 months of continuation therapy (CGI-S at continuation baseline, 2.1; 18-month completers, 1.7; LOCF-endpoint, 1.9).

CONCLUSIONS

Up to 2 years of treatment with lurasidone was safe and well tolerated in this bipolar disorder population presenting with an index episode of depression. Improvement in depressive symptoms was maintained in the majority of patients treated with lurasidone, with relatively low rates of relapse, and with minimal effects on weight and metabolic parameters.

Diabetes mellitus and first episode mania associated with cardiovascular diseases in patients with older-age bipolar disorder

Patients with bipolar disorder (BD) are at high risk for developing cardiovascular diseases (CVDs) during aging process. However, investigations are lacking regarding the risk factors for CVDs specific to BD patients. The aim of this study was to examine the relationship between CVDs and traditional risk factors in association with the characteristics of BD in older age. Totally, we recruited 124 patients with BD-I (DSM-IV) who had at least one psychiatric admission and cardiologist-confirmed CVD diagnosis (ICD-9 code 401-414) at mean age of 61.7+4.9 years. Each case subject was matched with one BD-I patient without CVDs based on age, sex, and date of the most recent psychiatric admission (+2 years). Clinical data were obtained by retrospectively reviewing the medical record. A multiple logistic regression model showed that not only traditional risk factor (e.g., diabetes mellitus) but also non-traditional one associated with BD (e.g., first episode mania) significantly increased the risk of CVDs. Given the limitation of this cross-sectional study, longitudinal investigations are needed to elucidate the contributions of both traditional risk factors and the BD characteristics for CVD risk in patients with BD.

Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas

Excess mortality in persons with severe mental disorders (SMD) is a major public health challenge that warrants action. The number and scope of truly tested interventions in this area remain limited, and strategies for implementation and scaling up of programmes with a strong evidence base are scarce. Furthermore, the majority of available interventions focus on a single or an otherwise limited number of risk factors. Here we present a multilevel model highlighting risk factors for excess mortality in persons with SMD at the individual, health system and socio-environmental levels. Informed by that model, we describe a comprehensive framework that may be useful for designing, implementing and evaluating interventions and programmes to reduce excess mortality in persons with SMD. This framework includes individual-focused, health system-focused, and community level and policy-focused interventions. Incorporating lessons learned from the multilevel model of risk and the comprehensive intervention framework, we identify priorities for clinical practice, policy and research agendas.

Obesity in adults with 22q11.2 deletion syndrome

PURPOSE

To characterize the prevalence of and contributing factors to adult obesity in the most common recurrent copy-number variation (CNV), 22q11.2 deletion, given that other rare CNVs are known to have obesity phenotypes.

METHODS

In 207 adults with 22q11.2 deletion syndrome (22q11.2DS), we used available height and weight measurements to calculate body mass index (BMI) and recorded associated factors that could play a role in obesity. We used the maximum BMI per subject and logistic regression to test a model predicting obesity class.

RESULTS

The prevalence of obesity (BMI ≥30) in 22q11.2DS (n = 90, 43.5%; at median age of 26.7 years) was significantly greater than for Canadian norms (odds ratio (OR) 2.30, 95% confidence interval (CI) = 1.74-3.02, P < 0.0001), even after excluding individuals with a history of antipsychotic use. The regression model was significant (P < 0.0001). Psychotropic medication use and age, but not sex or presence of intellectual disability, were associated with higher obesity level. Ten (4.8%) individuals were diagnosed with type 2 diabetes at a median age of 39.5 years; the prevalence was higher in those with obesity (P < 0.01).

CONCLUSION

The results suggest that adult obesity is related to the 22q11.2 deletion. The findings expand the potential genetic causes of obesity and have important implications for management of 22q11.2DS.Genet Med 19 2, 204-208.

Bidirectional longitudinal relationship between leisure-time physical activity and psychotropic medication usage: A register linked follow-up study

This study aimed to examine the bidirectional relationship between psychotropic medication use and changes in leisure-time physical activity (LTPA) among a population cohort study. Phase 1 data were collected by mail surveys in 2000-2002 among 40-60-year-old employees of the City of Helsinki, Finland, and phase 2 follow up survey was conducted in 2007. Based on self-report, the respondents were classified as inactive and active (≥14.75 MET-hours/week) at the phases 1 and 2. Hazard ratios (HR) were calculated for subsequent (2007-10) psychotropic medication purchasing according to changes in physical activity (phases 1-2). Odds ratios (OR) for physical inactivity at phase 2 were calculated according to the amount of psychotropic medication between phases 1-2. Overall, 5361 respondents were included (mean age 50 years, 80% women). Compared with the persistently active, the persistently inactive, those decreasing and adopting LTPA had an increased risk for psychotropic medication. Only the persistently inactive remained at increased risk for psychotropic medication use, following the adjustment for prior psychotropic medication use. Compared with those having no medication, the risk for physical inactivity increased as the psychotropic medication increased. Our data suggest that physical activity has an important role in maintaining wellbeing and reducing psychotropic medication usage.

Dyspepsia and constipation in patients with schizophrenia spectrum disorders

Constipation and dyspepsia are disturbing gastrointestinal symptoms that are often ignored in research on physical comorbidities of schizophrenia. The aim was to assess dyspepsia and constipation in a sample of outpatients with schizophrenia spectrum psychoses. A general practitioner performed a thorough physical health check for 275 outpatients and diagnosed constipation and dyspepsia. This study assessed the possible contribution of several sociodemographic, lifestyle, and clinical variables to constipation and dyspepsia using logistic regression analysis. This study also assessed whether these symptoms were associated with abnormal laboratory findings. The prevalence of constipation was 31.3%, and of dyspepsia 23.6%. Paracetamol (OR =3.07, 95% CI =1.34-7.02) and clozapine use (OR =5.48, 95% CI =2.75-10.90), older age (OR =1.04, 95% CI =1.01-1.06), and living in sheltered housing (OR =2.49, 95% CI =1.16-5.33) were risk factors for constipation. For dyspepsia the risk factors were female sex (OR =2.10, 95% CI =1.15-3.83), non-steroidal anti-inflammatory drugs (OR =2.47, 95% CI =1.13-5.39), and diabetes medication (OR =2.42, 95% CI =1.12-5.25). Patients with dyspepsia had lower haemoglobin and haematocrit and higher glucose values than those without dyspepsia. Patients with constipation had lower thrombocyte values than patients without constipation. However, these findings were explained by factors pre-disposing to constipation and dyspepsia. Clozapine use markedly increases the risk of constipation and may lead to life-threatening complications. In addition, analgesics and diabetes medication were related to gastrointestinal symptoms. These medications and their association to gastrointestinal symptoms should be kept in mind when treating patients with schizophrenia.

The genetic overlap between mood disorders and cardiometabolic diseases: a systematic review of genome wide and candidate gene studies

Meta-analyses of genome-wide association studies (meta-GWASs) and candidate gene studies have identified genetic variants associated with cardiovascular diseases, metabolic diseases and mood disorders. Although previous efforts were successful for individual disease conditions (single disease), limited information exists on shared genetic risk between these disorders. This article presents a detailed review and analysis of cardiometabolic diseases risk (CMD-R) genes that are also associated with mood disorders. First, we reviewed meta-GWASs published until January 2016, for the diseases 'type 2 diabetes, coronary artery disease, hypertension' and/or for the risk factors 'blood pressure, obesity, plasma lipid levels, insulin and glucose related traits'. We then searched the literature for published associations of these CMD-R genes with mood disorders. We considered studies that reported a significant association of at least one of the CMD-R genes and 'depression' or 'depressive disorder' or 'depressive symptoms' or 'bipolar disorder' or 'lithium treatment response in bipolar disorder', or 'serotonin reuptake inhibitors treatment response in major depression'. Our review revealed 24 potential pleiotropic genes that are likely to be shared between mood disorders and CMD-Rs. These genes include MTHFR, CACNA1D, CACNB2, GNAS, ADRB1, NCAN, REST, FTO, POMC, BDNF, CREB, ITIH4, LEP, GSK3B, SLC18A1, TLR4, PPP1R1B, APOE, CRY2, HTR1A, ADRA2A, TCF7L2, MTNR1B and IGF1. A pathway analysis of these genes revealed significant pathways: corticotrophin-releasing hormone signaling, AMPK signaling, cAMP-mediated or G-protein coupled receptor signaling, axonal guidance signaling, serotonin or dopamine receptors signaling, dopamine-DARPP32 feedback in cAMP signaling, circadian rhythm signaling and leptin signaling. Our review provides insights into the shared biological mechanisms of mood disorders and cardiometabolic diseases.

Peer support interventions seeking to improve physical health and lifestyle behaviours among people with serious mental illness: A systematic review

People with serious mental illness (SMI) experience a premature mortality gap of between 10 and 20 years. Interest is growing in the potential for peer support interventions (PSI) to improve the physical health of people with SMI. We conducted a systematic review investigating if PSI can improve the physical health, lifestyle factors, and physical health appointment attendance among people with SMI. A systematic search of major electronic databases was conducted from inception until February 2016 for any article investigating PSI seeking to improve physical health, lifestyle, or physical health appointment attendance. From 1347 initial hits, seven articles were eligible, including three pilot randomized, control trials (interventions: n = 85, controls: n = 81), and four pretest and post-test studies (n = 54). There was considerable heterogeneity in the type of PSI, and the role of the peer support workers (PSW) varied considerably. Three studies found that PSI resulted in insignificant reductions in weight. Evidence from three studies considering the impact of PSI on lifestyle changes was equivocal, with only one study demonstrating that PSI improved self-report physical activity and diet. Evidence regarding physical health appointment attendance was also unclear across four studies. In conclusion, there is inconsistent evidence to support the use of PSW to improve the physical health and promote lifestyle change among people with SMI. The small sample sizes, heterogeneity of interventions, outcome measures, and lack of clarity about the unique contribution of PSW means no definitive conclusions can be made about the benefits of PSW and physical health in SMI.

Bipolar disorder and diabetes mellitus: evidence for disease-modifying effects and treatment implications

BACKGROUND

Bipolar disorder refers to a group of chronic psychiatric disorders of mood and energy levels. While dramatic psychiatric symptoms dominate the acute phase of the diseases, the chronic course is often determined by an increasing burden of co-occurring medical conditions. High rates of diabetes mellitus in patients with bipolar disorder are particularly striking, yet unexplained. Treatment and lifestyle factors could play a significant role, and some studies also suggest shared pathophysiology and risk factors.

OBJECTIVE

In this systematic literature review, we explored data around the relationship between bipolar disorder and diabetes mellitus in recently published population-based cohort studies with special focus on the elderly.

METHODS

A systematic search in the PubMed database for the combined terms "bipolar disorder" AND "elderly" AND "diabetes" in papers published between January 2009 and December 2015 revealed 117 publications; 7 studies were large cohort studies, and therefore, were included in our review.

RESULTS

We found that age- and gender- adjusted risk for diabetes mellitus was increased in patients with bipolar disorder and vice versa (odds ratio range between 1.7 and 3.2).

DISCUSSION

Our results in large population-based cohort studies are consistent with the results of smaller studies and chart reviews. Even though it is likely that heterogeneous risk factors may play a role in diabetes mellitus and in bipolar disorder, growing evidence from cell culture experiments and animal studies suggests shared disease mechanisms. Furthermore, disease-modifying effects of bipolar disorder and diabetes mellitus on each other appear to be substantial, impacting both treatment response and outcomes.

CONCLUSIONS

The risk of diabetes mellitus in patients with bipolar disorder is increased. Our findings add to the growing literature on this topic. Increasing evidence for shared disease mechanisms suggests new disease models that could explain the results of our study. A better understanding of the complex relationship between bipolar disorder and diabetes mellitus could lead to novel therapeutic approaches and improved outcomes.

Physical multimorbidity and psychosis: comprehensive cross sectional analysis including 242,952 people across 48 low- and middle-income countries

BACKGROUND

In people with psychosis, physical comorbidities, including cardiovascular and metabolic diseases, are highly prevalent and leading contributors to the premature mortality encountered. However, little is known about physical health multimorbidity in this population or in people with subclinical psychosis and in low- and middle-income countries (LMICs). This study explores physical health multimorbidity patterns among people with psychosis or subclinical psychosis.

METHODS

Overall, data from 242,952 individuals from 48 LMICs, recruited via the World Health Survey, were included in this cross-sectional study. Participants were subdivided into those (1) with a lifetime diagnosis of psychosis ("psychosis"); (2) with more than one psychotic symptom in the past 12 months, but no lifetime diagnosis of psychosis ("subclinical psychosis"); and (3) without psychotic symptoms in the past 12 months or a lifetime diagnosis of psychosis ("controls"). Nine operationalized somatic disorders were examined: arthritis, angina pectoris, asthma, diabetes, chronic back pain, visual impairment, hearing problems, edentulism, and tuberculosis. The association between psychosis and multimorbidity was assessed by multivariable logistic regression analysis.

RESULTS

The prevalence of multimorbidity (i.e., two or more physical health conditions) was: controls = 11.4% (95% CI, 11.0-11.8%); subclinical psychosis = 21.8% (95% CI, 20.6-23.0%), and psychosis = 36.0% (95% CI, 32.1-40.2%) (P < 0.0001). After adjustment for age, sex, education, country-wise wealth, and country, subclinical psychosis and psychosis were associated with 2.20 (95% CI, 2.02-2.39) and 4.05 (95% CI, 3.25-5.04) times higher odds for multimorbidity. Moreover, multimorbidity was increased in subclinical and established psychosis in all age ranges (18-44, 45-64, ≥ 65 years). However, multimorbidity was most evident in younger age groups, with people aged 18-44 years with psychosis at greatest odds of physical health multimorbidity (OR = 4.68; 95% CI, 3.46-6.32).

CONCLUSIONS

This large multinational study demonstrates that physical health multimorbidity is increased across the psychosis-spectrum. Most notably, the association between multimorbidity and psychosis was stronger among younger adults, thus adding further impetus to the calls for the early intervention efforts to prevent the burden of physical health comorbidity at later stages. Urgent public health interventions are necessary not only for those with a psychosis diagnosis, but also for subclinical psychosis to address this considerable public health problem.

Cardiometabolic health, prescribed antipsychotics and health-related quality of life in people with schizophrenia-spectrum disorders: a cross-sectional study

BACKGROUND

People with schizophrenia-spectrum disorders (SSD) often have high levels of obesity and poor cardiometabolic health. Certain types of antipsychotics have been shown to contribute towards weight gain and there is some equivocal evidence that obesity is related to poor health-related quality of life (HRQoL) in people with SSD. It is also still uncertain if antipsychotic polypharmacy/higher doses of antipsychotics are linked with HRQoL and/or increased risk of obesity/Cardiovascular Disease (CVD). Therefore, this study aimed to examine potential relationships between prescribed antipsychotic medication regimens, cardiometabolic health risks and HRQoL in community-based Chinese people with SSD.

METHOD

This cross-sectional study reports the results of baseline measurements of a random sample of patients in an ongoing controlled trial of physical health intervention for people with severe mental illness. Data from these randomly-selected participants (n = 82) were analysed to calculate 10-year CVD relative-risk (using QRISK®2 score), estimate the prevalence of metabolic syndrome and contextualize patients' prescribed antipsychotics (types, combinations and Daily Defined Dose equivalent). Patients self-reported their HRQoL (SF12v2) and their obesity condition was assessed by waist-circumference and Body Mass Index (BMI).

RESULTS

Two-thirds of patients had a BMI ≥23 kg/m², almost half were centrally obese and 29% met the criteria for metabolic syndrome. The individual relative-risk of CVD ranged from 0.62 to 15, and 13% had a moderate-to-high 10-year CVD risk score. Regression models showed that lower physical HRQoL was predicted by higher BMI and lower mental HRQoL. Higher Defined Daily Dose, clozapine, younger age and male gender were found to explain 40% of the variance in CVD relative risk.

CONCLUSION

The findings indicate that cardiometabolic health risks in people with SSD may be more common than those reported in the general Hong Kong population. The results also provide further support for the need to consider antipsychotic polypharmacy and higher doses of antipsychotics as factors that may contribute towards cardiometabolic risk in Chinese patients with SSD. Clinicians in Hong Kong should consider using routine CVD risk screening, and be aware that younger male patients who are taking clozapine and prescribed higher Defined Daily Dose seem to have the highest relative-risk of CVD.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02453217 . Prospectively registered on 19^th May 2015.

Pharmacogenetic Associations of Antipsychotic Drug-Related Weight Gain: A Systematic Review and Meta-analysis

Although weight gain is a serious but variable adverse effect of antipsychotics that has genetic underpinnings, a comprehensive meta-analysis of pharmacogenetics of antipsychotic-related weight gain is missing. In this review, random effects meta-analyses were conducted for dominant and recessive models on associations of specific single nucleotide polymorphisms (SNP) with prospectively assessed antipsychotic-related weight or body mass index (BMI) changes (primary outcome), or categorical increases in weight or BMI (≥7%; secondary outcome). Published studies, identified via systematic database search (last search: December 31, 2014), plus 3 additional cohorts, including 222 antipsychotic-naïve youth, and 81 and 141 first-episode schizophrenia adults, each with patient-level data at 3 or 4 months treatment, were meta-analyzed. Altogether, 72 articles reporting on 46 non-duplicated samples (n = 6700, mean follow-up = 25.1wk) with 38 SNPs from 20 genes/genomic regions were meta-analyzed (for each meta-analysis, studies = 2-20, n = 81-2082). Eleven SNPs from 8 genes were significantly associated with weight or BMI change, and 4 SNPs from 2 genes were significantly associated with categorical weight or BMI increase. Combined, 13 SNPs from 9 genes (Adrenoceptor Alpha-2A [ADRA2A], Adrenoceptor Beta 3 [ADRB3], Brain-Derived Neurotrophic Factor [BDNF], Dopamine Receptor D2 [DRD2], Guanine Nucleotide Binding Protein [GNB3], 5-Hydroxytryptamine (Serotonin) Receptor 2C [HTR2C], Insulin-induced gene 2 [INSIG2], Melanocortin-4 Receptor [MC4R], and Synaptosomal-associated protein, 25kDa [SNAP25]) were significantly associated with antipsychotic-related weight gain (P-values < .05-.001). SNPs in ADRA2A, DRD2, HTR2C, and MC4R had the largest effect sizes (Hedges' g's = 0.30-0.80, ORs = 1.47-1.96). Less prior antipsychotic exposure (pediatric or first episode patients) and short follow-up (1-2 mo) were associated with larger effect sizes. Individual antipsychotics did not significantly moderate effect sizes. In conclusion, antipsychotic-related weight gain is polygenic and associated with specific genetic variants, especially in genes coding for antipsychotic pharmacodynamic targets.

Older Adults' Perspectives on Clinical Research: A Focus Group and Survey Study

OBJECTIVES

Clinical trials can benefit from patient perspectives to inform trial design, such as choice of outcome measures. We engaged older adults in focus groups and surveys to get their perspective regarding needs in clinical research. The goal was to inform the development of a new clinical trial of medication strategies for treatment-resistant depression in older adults.

METHODS

Older adults with depression participated in focus groups and a subsequent survey in St. Louis and New York. They were queried regarding research design features including outcomes, clinical management, mobile technology and iPad-administered assessments, the collection of DNA, and the receipt of their personal results.

RESULTS

Patients told us: (1) psychological well-being and symptomatic remission are outcomes that matter to them; (2) it is important to measure not only benefits but risks (such as risk of falling) of medications; (3) for pragmatic trials in clinical settings, the research team should provide support to clinicians to ensure that medications are properly prescribed; (4) technology-based assessments are acceptable but there were concerns about data security and burden; (5) DNA testing is very important if it could improve precision care; (6) participants want to receive aggregate findings and their own personal results at the end of the study.

CONCLUSIONS

Patients gave useful and wide-ranging guidance regarding clinical and comparative effectiveness research in older adults. We discuss these findings with the goal of making the next generation of geriatric studies more impactful and patient-centered.

H1-histamine receptor affinity predicts weight gain with antidepressants

Weight gain and metabolic abnormalities are extensively found in patients taking psychotropic medications. Although mainly antipsychotics have been implicated, also antidepressants carry the potential to induce weight gain, with tricyclics and mirtazapine being associated with the greatest weight gain. It has been suggested that this could be due to the different ability of antidepressants to block adrenergic, cholinergic, and histaminergic postsynaptic receptors. To date, however, the link between antidepressant-induced weight gain and their receptor affinity profile has not been established. We reanalysed data from a previous meta-analysis to evaluate whether weight change is associated with specific receptor affinity of antidepressants. We retrieved data from the only meta-analysis that assessed weight change with antidepressants. We searched in the Psychoactive Drug Screening Program (PDSP) Ki database data on the affinities of antidepressants to receptors hypothetically linked with weight change: H1-histamine, 5HT2c, M3-muscarinic, and α1A-adrenergic receptors. The association between weight change and receptor affinities was estimated using meta-regression. We found a significant association between the affinity of antidepressants to H1-receptor and weight gain (p value: <0.001). An association between weight gain and receptor affinity was also observed in the models for 5HT2c, M3, and α1A receptors. However, the association disappeared when H1-receptor was included in the models. This reanalysis of data demonstrates that anti-histaminergic activity is the strongest predictor of weight gain with antidepressants. These results further stress a reclassification of antidepressants according to their pharmacodynamic properties, and suggest avoiding prescribing antidepressants with an anti-histaminergic profile to patients at risk for cardio-metabolic disturbances.

Psychiatric disease as a risk factor in fast-track hip and knee replacement

Recent studies suggest that patients with psychiatric disorders tend to do worse than patients without a psychiatric diagnosis when undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Whether this is due to their psychiatric condition, pharmacological treatment, a combination of the two, or something else has not been thoroughly analyzed-and there are no internationally accepted guidelines for perioperative management of psychiatric patients. This overview summarizes our current knowledge on perioperative risks in patients with preoperative psychiatric disorders and the possible role of psychotropic drugs in the perioperative course. This will be useful when planning future strategies for improvement of surgical outcome following hip and knee arthroplasty.

Physical fitness in people with posttraumatic stress disorder: a systematic review

PURPOSE

People with posttraumatic stress disorder (PTSD) have an increased risk of cardiovascular diseases (CVD). Physical fitness is a key modifiable risk factor for CVD and associated mortality. We reviewed the evidence-base regarding physical fitness in people with PTSD.

METHODS

Two independent reviewers searched PubMed, CINAHL, PsycARTICLES, PEDro, and SPORTDiscus from inception until May 2016 using the key words "fitness" OR "exercise" AND "posttraumatic stress disorder" OR "PTSD".

RESULTS

In total, 5 studies involving 192 (44 female) individuals with PTSD met the inclusion criteria. Lower baseline physical fitness are associated with greater reductions in avoidance and hyperarousal symptoms, as well as with total, physical, and social symptoms of anxiety sensitivity. Rigorous data comparing physical fitness with age- and gender matched general population controls are currently lacking.

CONCLUSIONS

The research field regarding physical fitness in people with PTSD is still in its infancy. Given the established relationships between physical fitness, morbidity and mortality in the general population and the current gaps in the PTSD literature, targets for future research include exploring: (a) whether people with PTSD are at risk of low physical fitness and therefore in need of intensified assessment, treatment and follow-up, (b) the relationships among physical fitness, overall health status, chronic disease risk reduction, disability, and mortality in individuals PTSD, (c) psychometric properties of submaximal physical fitness tests in PTSD, (d) physical fitness changes following physical activity in PTSD, and (e) optimal methods of integrating physical activity programs within current treatment models for PTSD. Implications for Rehabilitation People with PTSD should aim to achieve 150 minutes of moderate or 75 minutes vigorous physical activity per week while also engaging in resistance training exercises at least twice a week. Health care professionals should assist people with PTSD to overcome barriers to physical activity such as physical pain, loss of energy, lack of interest and motivation, generalized fatigue and feelings of hyperarousal.

Physical health, community participation and schizophrenia

Our objective is to identify links between physical health and community participation among individuals with schizophrenia or a psychosis mental illness. Semi-structured qualitative and quantitative interviews and community tours were conducted over 10 months ( N = 30). Interviews were transcribed and analyzed using a grounded theory coding strategy. Physical health played an important role in community participation both as a cause and consequence. Key processes included mobility issues impeding physical community involvement; a multi-directional relationship between social relationships, community involvement, and physical health; identity as a mechanism linking physical health problems and community engagement; and the potential for community-based mental health programs.

Quantifying the effect of body mass index, age, and depression severity on 24-h activity patterns in persons with a lifetime history of affective disorders

BACKGROUND

Patients with affective disorders of different ages have been found to present weight changes and different circadian activity patterns. This study assessed the effects of age, Body Mass Index (BMI) and depression severity on the activity-rest cycle in persons with affective disorders using a novel multifactorial 24-h analysis method.

METHODS

Two hundred and thirty-six participants aged between 14 and 85 years underwent 5 to 22 days of actigraphy monitoring (mean duration = 14 days). BMI was also recorded and symptom severity was assessed with the Hamilton Depression Rating Scale (HDRS). Participants were divided into two groups: healthy controls (n = 68) and participants with a lifetime diagnosis of affective disorders (n = 168). First, the multiple regression method was employed to formulate the circadian activity pattern in term of the factors age, BMI and HDRS. For each group, the functional linear analysis method was applied to assess the relative effects of the factors. Finally, Wald-tests were used to assess the contribution of each factor on the circadian activity pattern.

RESULTS

In the affective disorders group, higher BMI was associated with higher activity levels from 3 am until 5.30 am and with lower activity levels from 10 am until 10.30 pm. Older age was associated with less activity across the day, evening, and night - from 11 am until 5.30 am. Higher HDRS scores were associated with higher activity around 1:30 am. In healthy controls, the effects of BMI and age on activity patterns were less pronounced and affected a narrower portion of the 24-h period.

CONCLUSION

These findings suggest that older age and higher BMI are linked to lower daytime activity levels. Higher BMI and worse symptom severity were also associated with nocturnal activity patterns suggestive of sleep disturbances. The influence of age and BMI on 24-h activity profiles appear to be especially pronounced in people with affective disorders.

Cardiorespiratory fitness in outpatients with bipolar disorder versus matched controls: An exploratory study

BACKGROUND

Patients with bipolar disorder (BD) are approximately twice as likely to die prematurely due cardiovascular diseases (CVD) than the general population. Cardiorespiratory fitness (CRF) is an important health outcome measure, predictive for CVD and premature mortality.

AIMS

The aim of the current study was to compare the CRF of outpatients with BD versus age-, gender-, and body mass index (BMI)-matched healthy controls (HC). A secondary aim was to assess potential correlates of CRF.

METHODS

All participants underwent a maximal incremental exercise test to measure the maximum oxygen uptake (VO2max, the golden standard assessment of cardiorespiratory fitness), wore a Body Sensewear Armband for 5 subsequent days to assess their physical activity behavior and completed the Positive-and-Negative-Affect-Schedule (PANAS).

RESULTS

Outpatients with BD (n=20; 47.8±7.6years) had a significantly lower VO2max compared with HC (n=20; 47.8±7.6years) (26.0±7.3 versus 30.4±6.5ml/min/kg, P=0.047). A higher VO2max was correlated with younger age, higher active energy expenditure, higher PANAS positive and lower PANAS negative affect scores and a lower antipsychotic medication dose.

LIMITATIONS

The limited sample and cross-sectional design preclude definitive conclusions.

CONCLUSIONS

Compared with HC, outpatients with BD have reduced CRF levels of approximately 4.4ml/min/kg. In the general population such reductions are associated with a 20% increased premature mortality risk. Interventions targeting CRF in BD are required. Although more research is needed, clinicians should consider the utility of objective assessments of CRF for risk stratification in outpatient settings.

Neurocognitive, Neuroprotective, and Cardiometabolic Effects of Raloxifene: Potential for Improving Therapeutic Outcomes in Schizophrenia

Raloxifene is a selective estrogen receptor modulator that has been approved for treating osteoporosis and breast cancer in high-risk postmenopausal women. However, recent evidence suggests that raloxifene adjunct therapy improves cognition and reduces symptom severity in men and women with schizophrenia. In animal models, raloxifene increases forebrain neurogenesis and enhances working memory and synaptic plasticity. It may consequently repair the neuronal and synaptic connectivity that is disrupted in schizophrenia. It also reduces oxidative stress and neuroinflammation, which are potent etiological factors in the neuropathology of schizophrenia. Furthermore, in postmenopausal women, raloxifene reduces the risks for atherosclerosis, diabetes mellitus, and weight gain, which are serious adverse effects associated with long-term antipsychotic treatment in schizophrenia; therefore, it may improve the safety and efficacy of antipsychotic drugs. In this review, recent insights into the neurocognitive, neuroprotective, and cardiometabolic effects of raloxifene in relation to therapeutic outcomes in schizophrenia are discussed.

Schizophrenia in the Netherlands: Continuity of Care with Better Quality of Care for Less Medical Costs

Background

Patients with schizophrenia need continuous elective medical care which includes psychiatric treatment, antipsychotic medication and somatic health care. The objective of this study is to assess whether continuous elective psychiatric is associated with less health care costs due to less inpatient treatment.

Methods

Data concerning antipsychotic medication and psychiatric and somatic health care of patients with schizophrenia in the claims data of Agis Health Insurance were collected over 2008–2011 in the Netherlands. Included were 7,392 patients under 70 years of age with schizophrenia in 2008, insured during the whole period. We assessed the relationship between continuous elective psychiatric care and the outcome measures: acute treatment events, psychiatric hospitalization, somatic care and health care costs.

Results

Continuous elective psychiatric care was accessed by 73% of the patients during the entire three year follow-up period. These patients received mostly outpatient care and accessed more somatic care, at a total cost of €36,485 in three years, than those without continuous care. In the groups accessing fewer or no years of elective care 34%-68% had inpatient care and acute treatment events, while accessing less somatic care at average total costs of medical care from €33,284 to €64,509.

Conclusions

Continuous elective mental and somatic care for 73% of the patients with schizophrenia showed better quality of care at lower costs. Providing continuous elective care to the remaining patients may improve health while reducing acute illness episodes.

The physical health of people with schizophrenia in Asia: Baseline findings from a physical health check programme

WHAT IS KNOWN ON THE SUBJECT?: Physical health problems, especially cardiovascular disease and metabolic disorders are far more common in people with severe mental illness (SMI) than the general population. While there are a considerable number of studies that have examined the physical health and health behaviours of people with SMI in Western countries, there have been few studies that have done this in Asia. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Unhealthy body mass index (BMI) values were observed in 44% of Thai service users diagnosed with schizophrenia despite desirable levels of exercise and relatively good diets being reported by the majority of participants. Being prescribed two or more antipsychotics was significantly associated with greater body weight and a higher BMI than in people prescribed only one antipsychotic. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health professionals in Asia should be particularly aware of the additional risks of obesity that seem to be associated with antipsychotic polypharmacy when they are promoting the physical health of people with schizophrenia.

ABSTRACT

Introduction People with schizophrenia have worse physical health than the general population, and studies in developed countries demonstrate that their health behaviours are often undesirable. However, as no similar studies have been conducted in Asian countries with emerging healthcare systems, the physical health promotion challenges in these settings is unknown. Aim To identify and explore relationships between cardiometabolic health risks, lifestyle and treatment characteristics in people with schizophrenia in Thailand. Method This cross-sectional study reports the baseline findings from a physical health check programme using the Thai version of the Health Improvement Profile. Results Despite desirable levels of exercise and relatively good diets being reported by most of the 105 service users, unhealthy body mass index values were observed in 44% of participants. A BMI>23 kg/m² and central obesity was found to be most likely in women. Being prescribed antipsychotic polypharmacy was significantly associated with a higher BMI than in people prescribed monotherapy. Implications for Practice Mental health professionals in Asia should be aware of the additional risks of obesity that are associated with antipsychotic polypharmacy and may benefit from additional training in order that they may advocate for service users within medication reviews to minimize the potential iatrogenic effects of treatment.

The CHANGE trial: no superiority of lifestyle coaching plus care coordination plus treatment as usual compared to treatment as usual alone in reducing risk of cardiovascular disease in adults with schizophrenia spectrum disorders and abdominal obesity

Life expectancy in patients with schizophrenia is reduced by 20 years for men and 15 years for women compared to the general population. About 60% of the excess mortality is due to physical illnesses, with cardiovascular disease being dominant. CHANGE was a randomized, parallel-group, superiority, multi-centre trial with blinded outcome assessment, testing the efficacy of an intervention aimed to improve cardiovascular risk profile and hereby potentially reduce mortality. A total of 428 patients with schizophrenia spectrum disorders and abdominal obesity were recruited and centrally randomized 1:1:1 to 12 months of lifestyle coaching plus care coordination plus treatment as usual (N=138), or care coordination plus treatment as usual (N=142), or treatment as usual alone (N=148). The primary outcome was 10-year risk of cardiovascular disease assessed post-treatment and standardized to age 60. At follow-up, the mean 10-year risk of cardiovascular disease was 8.4 ± 6.7% in the group receiving lifestyle coaching, 8.5 ± 7.5% in the care coordination group, and 8.0 ± 6.5% in the treatment as usual group (p=0.41). We found no intervention effects for any secondary or exploratory outcomes, including cardiorespiratory fitness, physical activity, weight, diet and smoking. In conclusion, the CHANGE trial did not support superiority of individual lifestyle coaching or care coordination compared to treatment as usual in reducing cardiovascular risk in patients with schizophrenia spectrum disorders and abdominal obesity.

Strategies to deal with comorbid physical illness in psychosis

Individuals with serious mental illnesses such as psychosis still experience higher mortality rates than the general population, decades after data have linked the gap to increased rates of physical illness, delayed diagnosis, low treatment rates and worse outcomes from treatment received. The nature of the relationship between psychosis and comorbid physical illness is complex. Multiple strategies directed at different levels of disease process, health care systems and stakeholder culture are likely required to make sustained progress in reducing the mortality gap. Evidence for strategies that effectively reduce the burden of physical co-morbidity and lead to improved health outcomes are still in their infancy but growing at a reassuringly fast rate. This editorial considers the existing evidence base and makes suggestions for the development and future direction of this urgent research agenda and how this knowledge can be implemented in clinical practice.

Diabetes mellitus in people with schizophrenia, bipolar disorder and major depressive disorder: a systematic review and large scale meta-analysis

Type 2 diabetes mellitus (T2DM) is highly predictive of cardiovascular diseases and can have particularly deleterious health impacts in people with severe mental illness (SMI), i.e. schizophrenia, bipolar disorder or major depressive disorder. This meta-analysis aimed: a) to describe pooled frequencies of T2DM in people with SMI; b) to analyze the influence of demographic, illness and treatment variables as well as T2DM assessment methods; and c) to describe T2DM prevalence in studies directly comparing persons with each specific SMI diagnosis to general population samples. The trim and fill adjusted pooled T2DM prevalence among 438,245 people with SMI was 11.3% (95% CI: 10.0%-12.6%). In antipsychotic-naïve participants, the prevalence of T2DM was 2.9% (95% CI: 1.7%-4.8%). There were no significant diagnostic subgroup differences. A comparative meta-analysis established that multi-episode persons with SMI (N=133,470) were significantly more likely to have T2DM than matched controls (N=5,622,664): relative risk, RR=1.85, 95% CI: 1.45-2.37, p<0.001. The T2DM prevalence was consistently elevated in each of the three major diagnostic subgroups compared to matched controls. Higher T2DM prevalences were observed in women with SMI compared to men (RR=1.43, 95% CI: 1.20-1.69, p<0.001). Multi-episode (versus first-episode) status was the only significant predictor for T2DM in a multivariable meta-regression analysis (r(2) =0.52, p<0.001). The T2DM prevalence was higher in patients prescribed antipsychotics, except for aripriprazole and amisulpride. Routine screening and multidisciplinary management of T2DM is needed. T2DM risks of individual antipsychotic medications should be considered when making treatment choices.

Update on the safety of second generation antipsychotics in youths: a call for collaboration among paediatricians and child psychiatrists

During the past decade, a substantial increase in the use of second generation antipsychotics (SGAs) has occurred for a number of juvenile psychiatric disorders, often as off-label prescriptions. Although they were thought to be safer than older, first generation antipsychotics, mainly due to a lower risk of neurological adverse reactions, recent studies have raised significant concerns regarding their safety regarding metabolic, endocrinological and cardiovascular side effects. Aim of this paper is to update with a narrative review, the latest findings on safety of SGAs in youths. Results suggest that different SGAs may present different safety profiles. Metabolic adverse events are the most frequent and troublesome, with increasing evidences of heightened risk for type II diabetes mellitus. Results are discussed with specific emphasis on possible strategies of an active monitoring, which could enable both paediatricians and child psychiatrists to a possible prevention, early detection, and a timely management of such effects.

Cardiovascular risk assessment in patients with a severe mental illness: a systematic review and meta-analysis

BACKGROUND

Cardiovascular risk (CVR) has been observed to be higher in patients with severe mental illness (SMI) than in the general population. However, some studies suggest that CVR is not equally increased in different subgroups of SMI. The purposes of this review are to summarise CVR scores of SMI patients and to determine the differences in CVR between patients with different SMIs and between SMI patients and the control-population.

METHODS

MEDLINE (via PubMed) was searched for literature published through August 28, 2014, followed by a snowball search in the Web of Science. Observational and experimental studies that reported CVR assessments in SMI patients using validated tools were included. The risk of bias was reported using STROBE and CONSORT criteria. Pooled continuous data were expressed as standardized mean differences (SMD) with 95% confidence intervals (CI). Two reviewers independently selected studies, extracted data and assessed methodological quality.

RESULTS

A total of 3,608 articles were identified, of which 67 full text papers were assessed for eligibility and 35 were finally included in our review, in which 12,179 psychiatric patients and 225,951 comparative patients had been assessed. The most frequent diagnoses were schizophrenia and related diagnoses (45.7%), depressive disorders (14.7%), SMI (11.4%) and bipolar disorders (8.6%). The most frequent CVR assessment tool used was the Framingham risk score. Subgroups analysis showed a higher CVR in schizophrenia than in depressive disorder or in studies that included patients with multiple psychiatric diagnoses (SMD: 0.63, 0.03, and 0.02, respectively). Six studies were included in the meta-analysis. Total overall CVR did not differ between SMI patients and controls (SMD: 0.35 [95% CI:-0.02 to 0.71], p = 0.06); high heterogeneity was observed (I (2) = 93%; p < 0.001).

CONCLUSIONS

The summary of results from studies that assessed CVR using validated tools in SMI patients did not find sufficient data (except for limited evidence associated with schizophrenia) to permit any clear conclusions about increased CVR in this group of patients compared to the general population. The systematic review is registered in

PROSPERO

CRD42013003898 .

Impaired glucose metabolism moderates the course of illness in bipolar disorder

BACKGROUND

The longitudinal course of bipolar disorder (BD) is highly heterogeneous, and is moderated by the presence of general medical comorbidities. This study aimed to investigate the moderating effects of impaired glucose metabolism (IGM) on variables of illness course and severity in a BD population.

METHODS

Fifty-five patients with BD were evaluated. All subjects were evaluated with respect to current and past psychiatric and medical disorders, as well as lifetime use of any medication. Body mass index (BMI) and metabolic parameters were obtained. IGM was operationalized as pre-diabetes or type 2 diabetes mellitus.

RESULTS

Thirty (54.5%) individuals had IGM. After adjustment for age, gender, ethnicity, alcohol use, smoking, BMI and past and current exposure to psychotropic medications, individuals with IGM, when compared to euglycemic participants, had an earlier age of onset (RR: 0.835, p=0.024), longer illness duration (RR: 1.754, p=0.007), a higher number of previous manic/hypomanic episodes (RR: 1.483, p=0.002) and a higher ratio of manic/hypomanic to depressive episodes (RR: 1.753, p=0.028). Moreover, we observed a moderating effect of IGM on the association between number of mood episodes and other variables of illness course, with the correlation between lifetime mood episodes and frequency of episodes being significantly greater in the IGM subgroup (RR: 1.027, p=0.029). All associations observed herein remained significant after adjusting for relevant confounding factors (e.g. age, alcohol and tobacco use, exposure to psychotropic agents, BMI).

LIMITATIONS

Cross-sectional design, small sample size.

CONCLUSIONS

Comorbid IGM may be a key moderator of illness progression in BD.

ITI-007 in the treatment of schizophrenia: from novel pharmacology to clinical outcomes

ITI-007 is an investigational drug being developed for schizophrenia and other neuropsychiatric/neurodegenerative diseases. ITI-007 has a unique pharmacological profile, combining potent 5-HT2a receptor antagonism with cell-type-specific dopamine and glutamate receptor modulation, plus serotonin reuptake inhibition. At dopamine-D2 receptors, ITI-007 acts as a post-synaptic antagonist and pre-synaptic partial agonist. Additionally, ITI-007 stimulates phosphorylation of glutamatergic NMDA-NR2B receptors, downstream of dopamine-D1 receptor intracellular signaling. Based on a large, placebo and risperidone controlled, Phase-II trial, ITI-007 60 mg was shown to be effective in reducing symptoms in patients with acutely exacerbated schizophrenia. The antipsychotic efficacy of ITI-007 60 mg in this patient population was confirmed in a recently completed Phase III study. ITI-007 was associated with minimal safety risk compared to risperidone (Phase II study) or placebo (both studies) for neuromotor disturbances, prolactin changes, weight gain and metabolic abnormalities. A second 6-week, placebo and risperidone-controlled Phase-III trial in acutely exacerbated schizophrenia is ongoing.

Cardiovascular risk factors among patients with schizophrenia, bipolar, depressive, anxiety, and personality disorders

BACKGROUND

The evidence informing the management of cardiovascular risk in patients with psychiatric disorders is weak.

METHODS

This cohort study used data from all patients, aged≥30, registered in 140 primary care practices (n=524,952) in London to estimate the risk of developing diabetes, hypertension, hyperlipidemia, tobacco consumption, obesity, and physical inactivity, between 2005 and 2015, for patients with a previous diagnosis of schizophrenia, depression, anxiety, bipolar or personality disorder. The role of antidepressants, antipsychotics and social deprivation in these associations was also investigated. The age at detection of cardiovascular risk factor was compared between patients with and without psychiatric disorders. Variables, for exposures and outcomes, defined from general practitioners records, were analysed using multivariate regression.

RESULTS

Patients with psychiatric disorders had an increased risk for cardiovascular risk factors, especially diabetes, with hazard ratios: 2.42 (2.20-2.67) to 1.31 (1.25-1.37), hyperlipidemia, with hazard ratios: 1.78 (1.60-1.97) to 1.25 (1.23-1.28), and obesity. Antidepressants, antipsychotics and social deprivation did not change these associations, except for smoking and physical inactivity. Antidepressants were associated with higher risk of diabetes, hypertension and hyperlipidemia. Antipsychotics were associated with a higher risk of diabetes. Antidepressants and antipsychotics were associated with lower risk of other risk factors. Patients with psychiatric conditions have later detection of cardiovascular risk factors. The interpretation of these results should acknowledge the lower rates of detection of risk factors in mentally ill patients.

CONCLUSIONS

Cardiovascular risk factors require special clinical attention among patients with psychiatric disorders. Further research could study the effect of antidepressants and antipsychotics on cardiovascular risk factors.

Relationship between antipsychotic medication, serum prolactin levels and osteoporosis/osteoporotic fractures in patients with schizophrenia: a critical literature review

INTRODUCTION

Using an antipsychotic medication can increase prolactin (PRL) levels, causing hyperprolactinemia (HPRL). Although the occurrence of osteoporosis within the population of patients with schizophrenia has been recognized, the precise nature of the association between antipsychotic treatment, PRL, osteoporosis, and the disease itself seems to be elusive.

AREAS COVERED

The aim of this review is to critically review the literature regarding the association between osteoporosis and PRL and to summarize the available evidence with respect to the impact of PRL-elevating antipsychotics on bone mineral density (BMD) and fractures in non-elderly patients with schizophrenia.

EXPERT OPINION

Although long-standing HPRL can have an impact on the rate of bone metabolism and, when associated with hypogonadism, may lead to decreased bone density in both female and male subjects, the relative contribution of antipsychotic-induced HPRL in bone mineral loss in patients with schizophrenia remains unclear. Methodological shortcomings of existing studies, including the lack of prospective data and the focus on measurements of BMD instead of bone turnover markers, preclude definitive conclusions regarding the relationship between PRL-raising antipsychotics and BMD loss in patients with schizophrenia. Therefore, more well conducted prospective trials of these biomarkers are necessary to establish the precise relationship between antipsychotics, PRL levels and osteoporosis/osteoporotic risk.

Adipokines, metabolic dysfunction and illness course in bipolar disorder

Replicated evidence indicates that individuals with BD are differentially affected by metabolic comorbidities and that its occurrence is a critical mediator and/or moderator of BD outcomes. This study aimed to explore the role of adipokines on bipolar disorder (BD) course and its relationship with metabolic comorbidities (i.e. type 2 diabetes mellitus, obesity). We measured plasma levels of adiponectin and leptin, as well as anthropometric and metabolic parameters of 59 patients with BD and 28 healthy volunteers. Our results showed that, in female participants, adiponectin was lower in individuals with BD, relative to healthy controls (p = 0.017). In the BD population, adiponectin levels were correlated with fasting glucose (r = -0.291, p = 0.047), fasting insulin (r = -0.332, p = 0.023), C-peptide (r = 0.040, p = 0.040), homeostatic model assessment-insulin resistance (r = -0.411, p = 0.004), HDL (r = 0.508, p < 0.001), VLDL (r = -0.395, p = 0.005) and triglycerides (r = -0.310, p = 0.030). After adjustment for age, gender and BMI, individuals with BD and low adiponectin levels (i.e. < 7.5 μg/ml), had a higher number of mood episodes (p < 0.001), lower number of psychiatric hospitalizations (p = 0.007), higher depressive symptoms (p < 0.001) and lower levels of functioning (p = 0.020). In conclusion, adiponectin levels, either directly or as a proxy of metabolic dysfunction, is independently associated with an unfavorable course of illness in BD.

Prevalence and predictors of treatment dropout from physical activity interventions in schizophrenia: a meta-analysis

OBJECTIVE

Physical activity interventions have been shown to improve the health of people with schizophrenia, yet treatment dropout poses an important challenge in this population, and rates vary substantially across studies. We conducted a meta-analysis to investigate the prevalence and predictors of treatment dropout in physical activity interventions in people with schizophrenia.

METHOD

We systematically searched major electronic databases from inception until August 2015. Randomized controlled trials of physical activity interventions in people with schizophrenia reporting dropout rates were included. Two independent authors conducted searches and extracted data. Random-effects meta-analysis and meta-regression analyses were conducted.

RESULTS

In 19 studies, 594 patients with schizophrenia assigned to exercise interventions were investigated (age=37.2 years, 67.5% male, range=37.5%-100%). Trim and fill adjusted treatment dropout rate was 26.7% [95% confidence interval (CI)=19.7%-35.0%], which is more than double than in nonactive control interventions (odds ratio=2.15, 95% CI=1.29-3.58, P=.003). In the multivariate regression, qualification of the professional delivering the intervention (β=-1.06, 95% CI=-1.77 to -0.35, P=.003) moderated treatment dropout rates, while continuous supervision of physical activity approached statistical significance (P=.05).

CONCLUSIONS

Qualified professionals (e.g., physical therapists/exercise physiologists) should prescribe supervised physical activity for people with schizophrenia to enhance adherence, improve psychiatric symptoms and reduce the onset and burden of cardiovascular disease.

Diabetes and Schizophrenia

People with schizophrenia have 2- to 5-fold higher risk of type 2 diabetes than the general population. The traditional risk factors for type 2 diabetes, especially obesity, poor diet, and sedentary lifestyle, are common in people with schizophrenia already early in the course of illness. People with schizophrenia also often have low socioeconomic status and income, which affects their possibilities to make healthy lifestyle choices. Antipsychotic medications increase the risk of type 2 diabetes both directly by affecting insulin sensitivity and indirectly by causing weight gain. Lifestyle modification interventions for prevention of diabetes should be an integral part of treatment of patients with schizophrenia. In the treatment of type 2 diabetes in patients with schizophrenia, communication and collaboration between medical care and psychiatric treatment providers are essential.

Prevalence and clinical features associated with bipolar disorder polypharmacy: a systematic review

BACKGROUND

Uncertainty exists regarding the prevalence and clinical features associated with the practice of polypharmacy in bipolar disorder (BD), warranting a systematic review on the matter.

METHODS

Three authors independently searched major electronic databases from inception till September 2015. Articles were included that reported either qualitative or quantitative data about the prevalence and clinical features associated with polypharmacy in adult cases of BD.

RESULTS

The operative definitions of polypharmacy adopted across varying studies varied, with concomitant use of two or more psychotropic medications or use of four or more psychotropic medications at once being the most common and the most reliable, respectively. Regardless of type or current mood episode polarity of BD, prevalence rates up to 85% and 36% were found using the most permissive (two or more medications at once) and the most conservative (four or more) operative definitions for polypharmacy, respectively. Point prevalence prescription rates of one or more antidepressant or antipsychotic as part of a polypharmacy regimen occurred in up to 45% or 80% of the cases, respectively, according to the most permissive definition of polypharmacy. In contrast, lithium prescription rates ranged from 13% to 33% in BD patients receiving polypharmacy according to conservative and permissive definitions, possibly suggesting a reduced need for augmentation of combination strategies for those cases of BD with a favorable lifetime lithium response and/or long-lasting treatment as well as less likelihood of lithium response over the time most severe cases possibly exposed to a more complex polypharmacy overall.

LIMITATIONS

"Apples and oranges" bias; publication bias for most recently introduced compounds.

CONCLUSION

Polypharmacy is common among people with BD across varying type and mood episode phases of illness. Special population, including BD patients at high risk of familial load for suicidal behavior, solicit further research as well as the plausible "protective" role of lithium toward polypharmacy in BD. The PROSPERO registration number is CRD42014015084.