Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls

Excess medical comorbidity and mortality across the lifespan in schizophrenia.: A nationwide Danish register study

INTRODUCTION

People with severe mental illness have greater risk of un-detected and inadequately treated medical disorders, adding up to the risk of premature death. This study investigated how chronic medical comorbidity evolved across the lifespan in schizophrenia and the associated impact on mortality.

METHOD

A register-based retrospective nested case-control study was conducted, identifying incident cases of cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), cancer and diabetes, as well as mortality due to these diseases, across the lifespan in schizophrenia.

SAMPLE

A schizophrenia cohort consisting of 4924 individuals aged 18-40 years registered with a diagnosis of schizophrenia (ICD-8: 295.0-3 + 295.9) during admission to a psychiatric hospital unit in 1970-79. Schizophrenia cases were age and gender matched with 22,597 controls in the general population.

RESULTS

Rate ratio (RR) of CVD and cancer were similar to controls. The RR of COPD and diabetes were increased across the lifespan. The probability of having been diagnosed prior to dying from CVD, cancer, pulmonary diseases or diabetes was markedly reduced in schizophrenia cases compared to controls. The RR of all-cause mortality and mortality from CVD, COPD and diabetes remained elevated in all age groups in schizophrenia. Registration of medical comorbidity was associated with increased survival.

CONCLUSION

Excess medical comorbidity persists across the lifespan and into older age. No age-related decrease in incidence of major chronic medical comorbidities in schizophrenia was found except for diabetes.

Mental illness and obesity among Veterans undergoing percutaneous coronary intervention: Insights from the VA CART program

Mental illness and obesity are highly prevalent in patients with coronary disease and are frequently comorbid. While mental illness is an established risk factor for major adverse cardiac and cerebrovascular events (MACCEs), prior studies suggest improved outcomes in people with obesity. It is unknown if obesity and mental illness interact to affect cardiac outcomes or if they independently influence MACCE. We identified 55 091 patients undergoing percutaneous coronary intervention (PCI) between 2009 and 2014, using the Veterans Affairs (VA) Clinical Assessment Reporting and Tracking (CART) program. Cox methods were used to assess the risk of MACCE by weight status and psychiatric diagnosis, and assessed for interaction. Compared to normal weight status, higher weight was associated with reduced MACCE events after PCI (mean follow-up of 2 years) for both stable angina and acute coronary syndromes (ACSs; reduction of >13% in stable angina, >17% in ACS; P < 0.01 for both after adjustment). Having a non-substance abuse mental illness diagnosis increased risk of MACCE compared to patients without mental illness in stable angina over 17%; P < 0.05, but not in ACS. When analysed for interaction, obesity and mental illness did not significantly impact MACCE over their independent influences. These results suggest that mental illness along with weight status have significant impact on MACCE, post-PCI. Clinicians should be aware of patients' mental health status as a significant cardiovascular risk factor after PCI, independent of weight status.

Cause-specific life years lost among persons diagnosed with schizophrenia: Is it getting better or worse?

BACKGROUND

People with schizophrenia have an increased risk of premature mortality compared to the general population. We aimed to quantify which types of causes of death contributed to the excess mortality, and to examine whether there has been an increase in the excess mortality among persons with schizophrenia in the period 1995 to 2015.

METHOD

We used a cohort design including the entire Danish population. We calculated life years lost of the cohort members compared to a set reference-age at 95 years old. Using a decomposition model we examined differences of cause-specific death among those with schizophrenia and the general population, including calendar trends during the last two decades.

RESULTS

In the general population, as well as in persons with schizophrenia, we found improvements in life years lost during the last two decades. Men with schizophrenia lost 13.5 years more than the general population (women; 11.4 years). Compared to the general population, a large improvement in life years lost with respect to suicide and accidents was found in those with schizophrenia, but, this improvement was offset by an increasing number of life years lost in deaths from diseases and medical conditions.

CONCLUSION

Our findings highlight the urgent need for focused treatment of general medical conditions in those with schizophrenia. Without such an investment, it is probable that the life years lost among persons with schizophrenia (compared to the general population) will continue to worsen in future decades.

Supporting patients with serious mental illness during physical health treatment

People with serious mental illness (SMI) are more likely to experience severe health conditions, such as cardiovascular disease, respiratory disease and stroke, and are likely to die earlier, than the general population. This article explores the reasons for such disparities, using a case study approach to outline the ways that general nurses can support people with SMI when they access general healthcare services. It identifies five areas of learning from the case study: diagnostic overshadowing and stigma; developing the therapeutic relationship; the ward environment; inclusion of family members and carers; and integration of physical and mental health services.

EPA guidance on physical activity as a treatment for severe mental illness: a meta-review of the evidence and Position Statement from the European Psychiatric Association (EPA), supported by the International Organization of Physical Therapists in Mental Health (IOPTMH)

Physical activity (PA) may be therapeutic for people with severe mental illness (SMI) who generally have low PA and experience numerous life style-related medical complications. We conducted a meta-review of PA interventions and their impact on health outcomes for people with SMI, including schizophrenia-spectrum disorders, major depressive disorder (MDD) and bipolar disorder. We searched major electronic databases until January 2018 for systematic reviews with/without meta-analysis that investigated PA for any SMI. We rated the quality of studies with the AMSTAR tool, grading the quality of evidence, and identifying gaps, future research needs and clinical practice recommendations. For MDD, consistent evidence indicated that PA can improve depressive symptoms versus control conditions, with effects comparable to those of antidepressants and psychotherapy. PA can also improve cardiorespiratory fitness and quality of life in people with MDD, although the impact on physical health outcomes was limited. There were no differences in adverse events versus control conditions. For MDD, larger effect sizes were seen when PA was delivered at moderate-vigorous intensity and supervised by an exercise specialist. For schizophrenia-spectrum disorders, evidence indicates that aerobic PA can reduce psychiatric symptoms, improves cognition and various subdomains, cardiorespiratory fitness, whilst evidence for the impact on anthropometric measures was inconsistent. There was a paucity of studies investigating PA in bipolar disorder, precluding any definitive recommendations. No cost effectiveness analyses in any SMI condition were identified. We make multiple recommendations to fill existing research gaps and increase the use of PA in routine clinical care aimed at improving psychiatric and medical outcomes.

Associations of the Built Environment With Physical Activity and Sedentary Time in Ugandan Outpatients With Mental Health Problems

BACKGROUND

This study investigated whether reported neighborhood variables explained variance in time spent walking, exercising, and being sedentary, in addition to mental health and demographic variables among Ugandan outpatients with mental illness.

METHODS

Ninety-nine outpatients (78 men; 31.1 [8.6] y) of the Butabika National Referral Hospital in Uganda completed the Neighborhood Environment Walkability Scale for Africa, the Simple Physical Activity Questionnaire, and the Brief Symptoms Inventory-18. Multiple regression analyses were performed.

RESULTS

Seven percent of the variance in walking time was explained by the variance in anxiety/depression and an additional 13% by the variance in perceived mixed land use and the availability of roads and walking paths. Eight percent of the variance in exercise time was explained by variance in age and an additional 6% by the variance anxiety/depression. The availability of recreational space added 8%. Six percent of variance in time spent sedentary was explained by family income, while availability of roads and walking paths added another 6%.

CONCLUSIONS

This study shows the relevance of availability of roads and walking paths and recreational space for more physical activity and less sedentary behavior in people with mental illness. This is particularly relevant in low-income countries where a rapid urbanization is taking place.

Adverse stroke outcomes among patients with bipolar disorder

Failure to deliver the standard stroke care is suspected to be a potential reason for disproportionately high mortality among patients with co-morbid bipolar disorder (BD). Few studies have explored adverse outcomes and medical care costs concurrently (as a proxy for care intensity) among patients with BD admitted for stroke. Data for this nationwide population-based study were extracted from the Taiwan National Health Insurance Research Database, on 580 patients with BD hospitalized for stroke (the study group) and a comparison group consisting of randomly selected 1740 stroke patients without BD matched by propensity scores. Conditional logistic regression was used to estimate odds ratios (OR) for adverse in-hospital outcomes between study group and comparison group. We found that stroke patients with BD had significantly lower in-hospital mortality (3.28% vs. 5.63%), acute respiratory failure (2.59% vs. 5.57%), and use of mechanical ventilation (6.55% vs. 10.23%) than the comparison group. After adjusting for geographical location, urbanization level, monthly income, hypertension, diabetes, hyperlipidemia, and coronary heart disease, the odds of in-hospital mortality, acute respiratory failure, and use of mechanical ventilation in the BD group were 0.56 (95% CI: 0.34–0.92), 0.46 (95% CI: 0.26–0.80), and 0.63 (95% CI: 0.44–0.91), respectively. No differences were found in hospitalization costs and the length of hospital stay. With comparable hospitalization costs and length of hospital stay, we concluded that stroke patients with BD had lower in-hospital mortality and serious adverse events compared to stroke patients without BD.

One-Year Treatment with Olanzapine Depot in Female Rats: Metabolic Effects

BACKGROUND

Antipsychotic drugs can negatively affect the metabolic status of patients, with olanzapine as one of the most potent drugs. While patients are often medicated for long time periods, experiments in rats typically run for 1 to 12 weeks, showing olanzapine-related weight gain and increased plasma lipid levels, with transcriptional upregulation of lipogenic genes in liver and adipose tissue. It remains unknown whether metabolic status will deteriorate with time.

METHODS

To examine long-term metabolic effects, we administered intramuscular long-acting injections of olanzapine (100 mg/kg BW) or control substance to female rats for up to 13 months.

RESULTS

Exposure to olanzapine long-acting injections led to rapid weight gain, which was sustained throughout the experiment. At 1, 6, and 13 months, plasma lipid levels were measured in separate cohorts of rats, displaying no increase. Hepatic transcription of lipid-related genes was transiently upregulated at 1 month. Glucose and insulin tolerance tests indicated insulin resistance in olanzapine-treated rats after 12 months.

CONCLUSION

Our data show that the continuous increase in body weight in response to long-term olanzapine exposure was accompanied by surprisingly few concomitant changes in plasma lipids and lipogenic gene expression, suggesting that adaptive mechanisms are involved to reduce long-term metabolic adverse effects of this antipsychotic agent in rats.

The prevalence of non-communicable disease risk factors in community-living patients with psychiatric disorders: A study from North India

OBJECTIVE

Screening for non-communicable disease (NCD) risk factors can help in prevention or reduction in the ill-effects of NCDs. Data on NCD risk factors in community-dwelling patients with common mental disorders (CMD) is lacking. This study was designed to screen for selected NCD risk factors in patients attending a community psychiatry service (CPS) in the states of Punjab and Haryana in North India.

METHODS

Following ethical clearance, the study was conducted in 4 satellite clinics of the CPS of a tertiary hospital from North India. Consecutive adult patients were approached and 719 patients were assessed. A one-time cross-sectional assessment was carried out which included socio-demographic data, clinical details, history of tobacco and alcohol use, personal history of hypertension and diabetes, family history of diabetes, prevalence of hypertension, obesity (central and generalised) and levels of physical activity.

RESULTS

302 males and 417 females were assessed. Most patients were diagnosed with CMD. The prevalence of hypertension was 42.7% in males and 34.1% in females. The prevalence of central and generalised obesity in males and females was 41.4%, 71.2% and 34.8%, 45.6% respectively. 32.5% of males and 40.2% females were assessed to be inadequately physically active.

CONCLUSIONS

The results of the study suggest that there is high prevalence of NCD risk factors in patients with CMD. Hypertension is more common in males while obesity and inadequate physical activity is more common in females. NCD risk factor screening and management, health education should be integrated in CPS.

Patient Engagement in ACO Practices and Patient-reported Outcomes Among Adults With Co-occurring Chronic Disease and Mental Health Conditions

BACKGROUND

Accountable care organizations (ACOs) have increased their use of patient activation and engagement strategies, but it is unknown whether they achieve better outcomes for patients with comorbid chronic physical and mental health conditions.

OBJECTIVES

To assess the extent to which practices with patient-centered cultures, greater shared decision-making strategies, and better coordination among team members have better patient-reported outcomes (PROs) for patients with diabetes and/or cardiovascular and comorbid mental health diagnoses.

RESEARCH DESIGN

Sixteen practices randomly selected from top and bottom quartiles of a 39-item patient activation/engagement implementation survey of primary care team members (n=411) to assess patient-centered culture, shared decision-making, and relational coordination among team members. These data were linked to survey data on patient engagement and on emotional, physical, and social patient-reported health outcomes.

SUBJECTS

Adult patients (n=606) with diabetes, cardiovascular, and comorbid mental health conditions who had at least 1 visit at participating primary care practices of 2 ACOs.

MEASURES

Depression/anxiety, physical functioning, social functioning; patient-centered culture, patient activation/engagement implementation, relational coordination.

RESULTS

Patients receiving care from practices with high patient-centered cultures reported better physical functioning (0.025) and borderline better emotional functioning (0.059) compared with less patient-centered practices. More activated patients reported better PROs, with higher activation levels partially mediating the relationship of patient-centered culture and better PROs.

CONCLUSIONS

ACO patients with comorbid physical and mental health diagnoses report better physical functioning when practices have patient-centered cultures. More activated/engaged patients report better patient emotional, physical, and social health outcomes.

Network analysis of the relationship between depressive symptoms, demographics, nutrition, quality of life and medical condition factors in the Osteoarthritis Initiative database cohort of elderly North-American adults with or at risk for osteoarthritis

AIMS

A complex interaction exists between age, body mass index, medical conditions, polypharmacotherapy, smoking, alcohol use, education, nutrition, depressive symptoms, functioning and quality of life (QoL). We aimed to examine the inter-relationships among these variables, test whether depressive symptomology plays a central role in a large sample of adults, and determine the degree of association with life-style and health variables.

METHODS

Regularised network analysis was applied to 3532 North-American adults aged ⩾45 years drawn from the Osteoarthritis Initiative. Network stability (autocorrelation after case-dropping), centrality of nodes (strength, M, the sum of weight of the connections for each node), and edges/regularised partial correlations connecting the nodes were assessed.

RESULTS

Physical and mental health-related QoL (M = 1.681; M = 1.342), income (M = 1.891), age (M = 1.416), depressive symptoms (M = 1.214) and education (M = 1.173) were central nodes. Depressive symptoms' stronger negative connections were found with mental health-related QoL (-0.702), income (-0.090), education (-0.068) and physical health-related QoL (-0.354). This latter was a 'bridge node' that connected depressive symptoms with Charlson comorbidity index, and number of medications. Physical activity and Mediterranean diet adherence were associated with income and physical health-related QoL. This latter was a 'bridge node' between the former two and depressive symptoms. The network was stable (stability coefficient = 0.75, i.e. highest possible value) for all centrality measures.

CONCLUSIONS

A stable network exists between life-style behaviors and social, environmental, medical and psychiatric variables. QoL, income, age and depressive symptoms were central in the multidimensional network. Physical health-related QoL seems to be a 'bridge node' connecting depressive symptoms with several life-style and health variables. Further studies should assess such interactions in the general population.

Patient perspectives on how living with a mental illness affects making and maintaining healthy lifestyle changes

OBJECTIVE

To understand the ways that mental health symptoms interfere with achieving health goals.

METHODS

Individuals with mental illness diagnoses and varying levels of preventive service use were recruited from federally qualified health centers and an integrated health care delivery system and interviewed. Thematic analysis was used to characterize descriptions of how mental illness experiences influenced lifestyle change efforts.

RESULTS

Three themes described patients' (n = 163) perspectives on barriers to making healthy lifestyle changes: 1) Thinking about making lifestyle changes is overwhelming for individuals already managing the burdens of mental illnesses; 2) Depression makes it difficult to care about a healthy future; and 3) When mental illness symptoms are not adequately treated unhealthy behaviors that provide relief are unlikely to be discontinued. Participants also made suggestions for improving health care delivery to facilitate positive behavior change.

CONCLUSION

Patients with mental illnesses need their clinicians to be empathic, help them envision a healthier future, address unmet mental health needs, and provide resources.

PRACTICE IMPLICATIONS

Primary care clinicians should encourage their patients with mental illnesses to make healthy lifestyle changes within the context of a supportive relationship. Lifestyle change can be overwhelming; clinicians should acknowledge progress and provide ongoing tangible support.

Promoting the Value of Mental Health Nursing: The Contribution of a Consumer Academic

Mental illness is known to occur frequently in the general population and is more common within the general health care system. High-quality health care requires nurses to have the skills, knowledge and attitudes to provide care for people experiencing mental illness or mental distress. Research suggests health professionals, including nurses, tend to share similar negative attitudes to mental illness as the general population, and consequently, mental health nursing is not a popular career path. These two factors signify a need to influence more positive attitudes toward mental illness and mental health nursing among nursing students. A qualitative exploratory research study was undertaken to examine the experiences, opinions and attitudes of an academic and research team to the introduction of a consumer academic within an undergraduate mental health nursing subject. In-depth interviews were conducted with teaching and research team members. The importance of mental health skills emerged as a major theme and included sub-themes: mental health across the health care system; contribution of consumer academic to nursing skills; addressing fear and stigma, and inspiring passion in mental health nursing. Findings suggest academic input from people with lived experience of recovery from mental illness can influence the development of mental health nursing skills and enhance the popularity of mental health nursing as a career.

Loneliness in psychotic illness and its association with cardiometabolic disorders

Loneliness is an established risk factor for poor cardiometabolic health. People with psychotic disorders experience high rates of both cardiometabolic disease and loneliness, but how these factors are associated is poorly understood. Thus, using data from the second Australian National Survey of Psychosis we examined whether loneliness is associated with the likelihood of cardiometabolic disorder in psychotic illness. Loneliness was assessed using a single-item measure, with a 4-point scale (not lonely; lonely occasionally; some friends but lonely for company; socially isolated and lonely) whilst cardiometabolic status was assessed in terms of the criteria used to determine metabolic syndrome (elevated waist circumference, elevated triglycerides, reduced high-density lipoprotein cholesterol, elevated blood pressure, and elevated fasting glucose). Logistic regression was employed to examine whether loneliness was associated with metabolic syndrome status, and its individual components, with and without adjustment for confounding variables. Increased loneliness was associated with an increased risk of metabolic syndrome in people with psychosis (OR 1.21, 95% CI 1.08-1.36, p < .001) and to the risk of elevated waist circumference (p < .01), elevated triglycerides (p < .05) and reduced high-density lipoprotein cholesterol (p < .05). Notably, these associations largely persisted when controlling for a range of covariates. Feeling lonely is significantly associated with metabolic syndrome, and dyslipidemia specifically, in people with psychotic disorders. These data suggest that the potential benefits of interventions to reduce loneliness in psychosis may extend to cardiovascular as well as psychosocial functioning, and should be explored in future research.

Exercise effects on cognitive functioning in young adults with first-episode psychosis: FitForLife

BACKGROUND

Exercise has mood-enhancing effects and can improve cognitive functioning, but the effects in first-episode psychosis (FEP) remain understudied. We examined the feasibility and cognitive effects of exercise in FEP.

METHOD

Multi-center, open-label intervention study. Ninety-one outpatients with FEP (mean age = 30 years, 65% male) received usual care plus a 12-week supervised circuit-training program, consisting of high-volume resistance exercises, aerobic training, and stretching. Primary study outcome was cognitive functioning assessed by Cogstate Brief Battery (processing speed, attention, visual learning, working memory) and Trailmaking A and B tasks (visual attention and task shifting). Within-group changes in cognition were assessed using paired sample t tests with effect sizes (Hedges' g) reported for significant values. Relationships between exercise frequency and cognitive improvement were assessed using analysis of covariance. Moderating effects of gender were explored with stratified analyses.

RESULTS

Participants exercised on average 13.5 (s.d. = 11.7) times. Forty-eight percent completed 12 or more sessions. Significant post-intervention improvements were seen for processing speed, visual learning, and visual attention; all with moderate effect sizes (g = 0.47-0.49, p &lt; 0.05). Exercise participation was also associated with a positive non-significant trend for working memory (p &lt; 0.07). Stratified analyses indicated a moderating effect of gender. Positive changes were seen among females only for processing speed, visual learning, working memory, and visual attention (g = 0.43-0.69). A significant bivariate correlation was found between total training frequency and improvements in visual attention among males (r = 0.40, p &lt; 0.05).

CONCLUSION

Supported physical exercise is a feasible and safe adjunct treatment for FEP with potential cognitive benefits, especially among females.

The impact of pharmacological and non-pharmacological interventions to improve physical health outcomes in people with schizophrenia: a meta-review of meta-analyses of randomized controlled trials

We summarized and compared meta-analyses of pharmacological and non-pharmacological interventions targeting physical health outcomes among people with schizophrenia spectrum disorders. Major databases were searched until June 1, 2018. Of 3,709 search engine hits, 27 meta-analyses were included, representing 128 meta-analyzed trials and 47,231 study participants. While meta-analyses were generally of adequate or high quality, meta-analyzed studies were less so. The most effective weight reduction interventions were individual lifestyle counseling (standardized mean difference, SMD=-0.98) and exercise interventions (SMD=-0.96), followed by psychoeducation (SMD=-0.77), aripiprazole augmentation (SMD=-0.73), topiramate (SMD=-0.72), d-fenfluramine (SMD=-0.54) and metformin (SMD=-0.53). Regarding waist circumference reduction, aripiprazole augmentation (SMD=-1.10) and topiramate (SMD=-0.69) demonstrated the best evidence, followed by dietary interventions (SMD=-0.39). Dietary interventions were the only to significantly improve (diastolic) blood pressure (SMD=-0.39). Switching from olanzapine to quetiapine or aripiprazole (SMD=-0.71) and metformin (SMD=-0.65) demonstrated best efficacy for reducing glucose levels, followed by glucagon-like peptide-1 receptor agonists (SMD=-0.39), dietary interventions (SMD=-0.37) and aripiprazole augmentation (SMD=-0.34), whereas insulin resistance improved the most with metformin (SMD=-0.75) and rosiglitazone (SMD=-0.44). Topiramate had the greatest efficacy for triglycerides (SMD=-0.68) and low-density lipoprotein (LDL)-cholesterol (SMD=-0.80), whereas metformin had the greatest beneficial effects on total cholesterol (SMD=-0.51) and high-density lipoprotein (HDL)-cholesterol (SMD=0.45). Lifestyle interventions yielded small effects for triglycerides, total cholesterol and LDL-cholesterol (SMD=-0.35 to -0.37). Only exercise interventions increased exercise capacity (SMD=1.81). Despite frequent physical comorbidities and premature mortality mainly due to these increased physical health risks, the current evidence for pharmacological and non-pharmacological interventions in people with schizophrenia to prevent and treat these conditions is still limited and more larger trials are urgently needed.

Elevated Familial Cardiovascular Burden Among Adolescents With Familial Bipolar Disorder

Background: Bipolar disorder (BD) is one of the most heritable medical conditions, and certain phenotypic characteristics are especially familial in BD. BD is also strongly associated with elevated and premature cardiovascular disease (CVD) morbidity and mortality. Thus, far, little is known regarding the familiality of cardiovascular risk in BD. We therefore examined the extent of CVD-related conditions among relatives of: adolescents with BD with a family history of BD (familial BD), adolescents with BD without a family history of BD (non-familial BD) and healthy controls (HC). Materials and Methods: The sample included 372 adolescents; 75 with familial BD, 96 with non-familial BD, and 201 HC. Parents of the adolescents completed the CARDIA Family Medical History interview regarding the adolescents' first- and second- degree adult relatives. We computed a "cardiovascular risk score" (CRS) for each relative, based on the sum of the presence of diabetes, hypertension, obesity, dyslipidemia, stroke, angina, and myocardial infarction (range 0-7). Primary analyses examined for group differences in mean overall CRS scores among first and second- degree relatives combined, controlling for age, sex, and race. Secondary analyses examined first- and second-degree relatives separately, controlling for age, sex, and race. Results: There were significant between-group differences in CRS in first- and second- degree relatives combined, following the hypothesized ordering: CRS was highest among adolescents with familial BD (1.14 ± 0.78), intermediate among adolescents with non-familial BD (0.92 ± 0.79) and lowest in HC (0.76 ± 0.79; F = 6.23, df = 2, p = 0.002, ηp 2 = 0.03). There was a significant pairwise difference between adolescents with familial BD and HC (p = 0.002, Cohen's d = 0.49). A similar pattern of between-group differences was identified when first-degree and second-degree relatives were examined separately. Limitations: familial cardiovascular burden was determined based on parent interview, not evaluated directly. Conclusions: Adolescents with BD with a family history of BD have elevated rates of CVD-related conditions among their relatives. This may be related to genetic overlap between BD and CVD-related conditions, shared environmental factors that contribute to both BD and CVD-related conditions, or a combination of these factors. More research is warranted to better understand the interaction between familial risk for BD and CVD, and to address this risk using family-wide preventive approaches.

Prevalence of late-life depression and gap in mental health service use across European regions

Background We aimed to determine the prevalence and gap in use of mental health services for late-life depression in four European regions (Western Europe, Scandinavia, Southern Europe and Central and Eastern Europe) and explore socio-demographic, social and health-related factors associated with it. Methods We conducted a cross-sectional study based on data from the Survey on Health, Ageing and Retirement in Europe. Participants were a population-based sample of 28 796 persons (53% women, mean age 74 years old) residing in Europe. Mental health service use was estimated using information about the diagnosis or treatment for depression. Results The prevalence of late-life depression was 29% in the whole sample and was highest in Southern Europe (35%), followed by Central and Eastern Europe (32%), Western Europe (26%) and lowest in Scandinavia (17%). Factors that had the strongest association with depression were total number of chronic diseases, pain, limitations in instrumental activities of daily living, grip strength and cognitive impairment. The gap in mental health service use was 79%. Conclusions We suggest that interventions to decrease the burden of late-life depression should be targeted at individuals that are affected by chronic somatic comorbidities and are limited in mental and physical functioning. Promotion of help-seeking of older adults, de-stigmatization of mental illness and education of general practitioners could help decrease the gap in mental health service utilization.

Handgrip strength and depression among 34,129 adults aged 50 years and older in six low- and middle-income countries

INTRODUCTION

Handgrip strength is a simple and inexpensive marker of health and mortality risk. It presents an ideal risk-stratifying method for use in low and middle-income countries (LMICs). There are, however, no population-based studies investigating the associations between handgrip strength and depression in LMICs. We aimed to assess these associations among community-dwelling middle-aged and older adults using nationally representative data from six LMICs.

METHOD

Cross-sectional data on individuals aged ≥ 50 years from the World Health Organization's Study on Global Ageing and Adult Health were analyzed. Depression was based on the Composite International Diagnostic Interview. Weak handgrip strength was defined as < 30 kg for men and < 20 kg for women using the average value of two handgrip measurements of the dominant hand. Multivariable logistic regression analysis was conducted.

RESULTS

The sample included 34,129 individuals (62.4 ± 16.0 years; 52.1% female). The prevalence of weak handgrip strength and depression were 47.4% and 6.2%, respectively. Individuals with weak handgrip strength had a higher prevalence of depression than those without this condition (8.8% vs. 3.8%; p < 0.001). Across all countries, after adjustment for potential confounders, weak handgrip strength was associated with a 1.45 (95%CI = 1.12-1.88) times higher odds for depression, although some between-country differences were noted.

DISCUSSION

Weaker handgrip strength is associated with higher odds for depression in LMICs. Future research should seek to establish the predictive value of this inexpensive measure for clinical use. Furthermore, interventional studies should examine if muscular strength can be a target of resistance-training interventions to address depressive symptoms in low-resourced settings.

The Influence of Continuous Exercising on Chronotropic Incompetence in Multi-Episode Schizophrenia

People with schizophrenia die on average 15-20 years earlier than age and gender matched controls in the general population. An essential part of this excess mortality in people with schizophrenia is caused by physical illnesses. Among the physical illnesses, cardiovascular disease (CVD) has been identified as the most common natural cause of death in up to 40-45% of the cases. Chronotropic incompetence (CI) is defined as the inability of the heart to increase its beating frequency in proportion to increased physical activity or higher metabolic demand. It is an established independent cardiovascular risk factor for major cardiac events and overall mortality and might explain adaptation intolerance of the cardiovascular system to even minor exercise courses. CI needs objective exercise testing for definitive diagnosis and therefore represents a biological marker indicating the integrity of the cardiovascular system. It was recently described in patients with schizophrenia and might help explain the reduced physical fitness in these patients and the inability of a subgroup of patients to benefit from exercise interventions. In this study, we tried to replicate the occurrence of CI in an independent sample of patients with schizophrenia and evaluated whether CI can be influenced by a continuous endurance training of 12 weeks. Therefore, we re-analyzed the fitness testing data of 43 patients with schizophrenia and 22 aged and gender matched healthy controls. Parameters of aerobic fitness and chronotropic response to exercise were calculated. Patients with schizophrenia were less physically fit than the healthy controls and displayed a significantly higher heart rate at rest. 10 of 43 patients with schizophrenia and no healthy control subject were classified as chronotropically incompetent. Chronotropic response to exercise did not change significantly after 12 weeks of continuous aerobic exercise training. No differences were observed for baseline heart rate and peak heart rate in both subgroups of schizophrenia patients. Aerobic fitness did not improve significantly in the patients with schizophrenia classified as chronotropically incompetent. Our results confirm the occurrence of CI in patients with multi-episode schizophrenia. This should be taken into account when planning an exercise or lifestyle intervention studies in this population. Schizophrenia patients with CI do not seem to benefit as well as schizophrenia patients without CI from aerobic exercise training interventions. Larger, prospective randomized controlled clinical trials with different training interventions are urgently needed to address the topic of schizophrenia patients not responding to exercise and the relationship to the illness itself.

Objectively Assessed Daily Steps-Not Light Intensity Physical Activity, Moderate-to-Vigorous Physical Activity and Sedentary Time-Is Associated With Cardiorespiratory Fitness in Patients With Schizophrenia

People with schizophrenia often have an unhealthy sedentary lifestyle with low level of physical activity and poor cardiorespiratory fitness-an important predictor of cardiovascular disease. We investigated the relations between cardiorespiratory fitness and both sedentary time and different aspects of physical activity, such as daily steps, light intensity physical activity, and moderate-to-vigorous physical activity. Using accelerometer as an objective measure of sedentary time and physical activity we estimated their relations to cardiorespiratory fitness in 62 patients with schizophrenia with roughly equal gender distribution, mean age of 36 and 15 years illness duration. We found a significant association between daily steps and cardiorespiratory fitness when accounting for gender, age, sedentary time, light intensity physical activity, and respiratory exchange ratio (maximal effort). Moderate-to-vigorous physical activity was not significantly associated with cardiorespiratory fitness. In conclusion, the amount of steps throughout the day contributes to cardiorespiratory fitness in people with schizophrenia, independently of light intensity physical activity and sedentary time. We did not find a significant relationship between moderate-to-vigorous physical activity and cardiorespiratory fitness. This may have implications for the choice of strategies when helping patients with schizophrenia improve their cardiorespiratory fitness.

One-year follow-up on liraglutide treatment for prediabetes and overweight/obesity in clozapine- or olanzapine-treated patients

OBJECTIVE

Treatment with most antipsychotics is associated with an increased risk of weight gain and metabolic disturbances. In a randomized trial, we previously demonstrated that 16 weeks of glucagon-like peptide-1 receptor agonist liraglutide treatment vs. placebo significantly reduced glucometabolic disturbances and body weight in prediabetic, overweight/obese schizophrenia-spectrum disorder patients treated with clozapine or olanzapine. The aim of this study was to investigate whether the beneficial effects of the 16-week intervention were sustained beyond the intervention period.

METHOD

One year after completion of the intervention, we investigated changes in body weight, fasting glucose, glycated hemoglobin, C-peptide, and lipids comparing 1-year follow-up levels to end of treatment (week 16) and baseline (week 0) levels.

RESULTS

From end of treatment to the 1-year follow-up, body weight had increased in the liraglutide-treated group. However, compared to baseline levels, the placebo-subtracted body weight loss remained significantly reduced (-3.8 kg, 95% CI: -7.3 to -0.2, P = 0.04). Fasting glucose, glycated hemoglobin, C-peptide, and lipids had each returned to baseline levels 1 year after stopping liraglutide.

CONCLUSION

The body weight reduction during 16 weeks of liraglutide treatment was partially sustained 1 year after the intervention was completed. However, the improvements in other metabolic parameters returned to baseline levels.

Physical effort exertion and pain: Links with trait-based risk for psychopathology

People with serious mental illness (SMI) are at an increased risk for physical health complications, such as cardiovascular disease and obesity. Low levels of physical activity is a major contributor to these health complications. One factor associated with limited physical activity in the broader sedentary population is pain. While preliminary findings suggest an association between lack of physical activity and pain in SMI, conclusions are still unclear. Thus, the goal of this correlational study was to examine associations between trait-based risk for psychopathology (hypomanic personality, schizotypy, and anhedonic depression) and the experience of pain following a physical endurance/effort task. Healthy participants (N = 43; 18 females) completed self-report measures of trait-based risk for psychopathology. They also reported on the experience of pain before and after the Time To Exhaustion (TTE) test. Findings revealed that risk for psychosis and anhedonic depression were associated with increases in pain following the TTE test, accounting for other key variables, such as age and self-reported physical exercise. Risk for mania was unrelated to changes in pain. These results suggest that the experience of pain in relation to physical endurance/effort may contribute to diminished physical activity among people at risk for SMI.

Low Physical Activity and Cardiorespiratory Fitness in People With Schizophrenia: A Comparison With Matched Healthy Controls and Associations With Mental and Physical Health

Introduction: The aim of this study was to objectively assess time spent in physical activity (PA) and sedentary behavior (SB) in patients with schizophrenia compared to healthy controls matched for age, gender and socioeconomic status. Associations between both PA and cardiorespiratory fitness (CRF) and mental and physical health parameters in patients with schizophrenia were examined. Materials and Methods: Moderate and vigorous PA (MVPA), moderate PA, vigorous PA, total and active energy expenditure (TEE and AEE), number of steps, lying down and sleeping time was assessed with SenseWear Pro-2 body monitoring system for three 24-h bouts in patients with schizophrenia (n = 63) and matched healthy controls (n = 55). Severity of symptoms (Positive and Negative Syndrome Scale and Montgomery and Åsberg Depression Rating Scale), CRF (peak oxygen uptake, VO_2peak), body mass index (BMI), and metabolic syndrome were assessed. Results: Patients with schizophrenia performed less MVPA and moderate activity had lower TEE and AEE, spent more time per day lying down and sleeping, and had poorer CRF compared to healthy controls. The amount of MVPA, but especially CRF was associated with severity of negative symptoms in patients with schizophrenia. Only CRF was associated with BMI. Discussion: The current data offer further evidence for interventions aiming to increase physical activity and decrease sedentary behavior. Given strong associations of CRF with both negative symptoms and BMI, treatment aimed at CRF-improvement may prove to be effective.

Gut microbiota composition in patients with newly diagnosed bipolar disorder and their unaffected first-degree relatives

OBJECTIVE

An aberrant gut microbiota may be associated with a broad spectrum of diseases including mental illness. The gut microbiota is scarcely studied in bipolar disorder (BD). We examined the gut microbiota composition in patients with newly diagnosed BD, their unaffected first-degree relatives and healthy individuals.

METHODS

Stool samples were collected from 113 patients with BD, 39 unaffected first-degree relatives and 77 healthy individuals and the microbiota was profiled using 16S rRNA gene amplicon sequencing.

RESULTS

The gut microbiota community membership of patients with BD differed from that of healthy individuals (R² = 1.0%, P = 0.008), whereas the community membership of unaffected first-degree relatives did not. Flavonifractor was present in 61% of patients with BD, 42% of their unaffected relatives and 39% of healthy individuals. Presence of Flavonifractor was associated with an odds ratio of 2.9 (95%CI: 1.6-5.2, P = 5.8 × 10^-4, Q = 0.036) for having BD. When excluding smokers, presence of Flavonifractor was associated with an odds ratio of 2.3 (95%CI: 1.1-5.3, P = 0.019) for having BD. However, when considering the subsample of non-smokers only, BD and presence of Flavonifractor were no longer associated when adjusted for all possible tests at genus level (Q = 0.6). Presence of Flavonifractor in patients with BD was associated with smoking and female sex, but not with age, waist circumference, exercise level, high-sensitive C-reactive protein, current affective state, subtype of BD, illness duration or psychotropic medication, respectively.

CONCLUSION

Flavonifractor, a bacterial genus that may induce oxidative stress and inflammation in its host, was associated with BD. Higher prevalence of smoking among patients with BD contributed to our findings, and it cannot be excluded that findings are influenced by residual confounding.

Inhibited autonomy for promoting physical health: qualitative analysis of narratives from persons living with severe mental illness

BACKGROUND

Autonomy is a key factor in the reduction of inequitable physical healthcare among people with severe mental illness compared with the general population.AimsTo clarify the critical mechanism underlying autonomy in physical health promotion based on the perspectives of people with severe mental illness.

METHOD

We employed a conventional content analysis of narrative data from the Healthy Active Lives in Japan (HeAL Japan) workshop meetings.

RESULTS

'Inhibited autonomy' was extracted as a central component and shaped by the users' experiences, both in a healthcare setting and in real life. This component emerged based on the lack of an empowerment mechanism in psychiatric services.

CONCLUSIONS

A barrier to the encouragement of autonomy in physical health promotion was found in current psychiatric services. An effective strategy should be explored to foster an empowerment mechanism in psychiatric and mental health services.Declaration of interestNone.

Interactome Studies of Psychiatric Disorders

High comorbidity and complexity have precluded reliable diagnostic assessment and treatment of psychiatric disorders. Impaired molecular interactions may be relevant for underlying mechanisms of psychiatric disorders but by and large remain unknown. With the help of a number of publicly available databases and various technological tools, recent research has filled the paucity of information by generating a novel dataset of psychiatric interactomes. Different technological platforms including yeast two-hybrid screen, co-immunoprecipitation-coupled with mass spectrometry-based proteomics, and transcriptomics have been widely used in combination with cellular and molecular techniques to interrogate the psychiatric interactome. Novel molecular interactions have been identified in association with different psychiatric disorders including autism spectrum disorders, schizophrenia, bipolar disorder, and major depressive disorder. However, more extensive and sophisticated interactome research needs to be conducted to overcome the current limitations such as incomplete interactome databases and a lack of functional information among components. Ultimately, integrated psychiatric interactome databases will contribute to the implementation of biomarkers and therapeutic intervention.

Is psychosis a multisystem disorder? A meta-review of central nervous system, immune, cardiometabolic, and endocrine alterations in first-episode psychosis and perspective on potential models

People with psychotic disorders show abnormalities in several organ systems in addition to the central nervous system (CNS); and this contributes to excess mortality. However, it is unclear how strong the evidence is for alterations in non-CNS systems at the onset of psychosis, how the alterations in non-CNS systems compare to those in the CNS, or how they relate to symptoms. Here, we consider these questions, and suggest potential models to account for findings. We conducted a systematic meta-review to summarize effect sizes for both CNS (focusing on brain structural, neurophysiological, and neurochemical parameters) and non-CNS dysfunction (focusing on immune, cardiometabolic, and hypothalamic-pituitary-adrenal (HPA) systems) in first-episode psychosis (FEP). Relevant meta-analyses were identified in a systematic search of Pubmed and the methodological quality of these was assessed using the AMSTAR checklist (A Measurement Tool to Assess Systematic Reviews). Case-control data were extracted from studies included in these meta-analyses. Random effects meta-analyses were re-run and effect size magnitudes for individual parameters were calculated, as were summary effect sizes for each CNS and non-CNS system. We also grouped studies to obtain overall effect sizes for non-CNS and CNS alterations. Robustness of data for non-CNS and CNS parameters was assessed using Rosenthal's fail-safe N. We next statistically compared summary effect size for overall CNSand overall non-CNS alterations, as well as for each organ system separately. We also examined how non-CNS alterations correlate CNS alterations, and with psychopathological symptoms. Case-control data were extracted for 165 studies comprising a total sample size of 13,440. For people with first episode psychosis compared with healthy controls, we observed alterations in immune parameters (summary effect size: g = 1.19), cardiometabolic parameters (g = 0.23); HPA parameters (g = 0.68); brain structure (g = 0.40); neurophysiology (g = 0.80); and neurochemistry (g = 0.43). Grouping non-CNS organ systems together provided an effect size for overall non-CNS alterations in patients compared with controls (g = 0.58), which was not significantly different from the overall CNS alterations effect size (g = 0.50). However, the summary effect size for immune alterations was significantly greater than that for brain structural (P < 0.001) and neurochemical alterations (P < 0.001), while the summary effect size for cardiometabolic alterations was significantly lower than neurochemical (P = 0.04), neurophysiological (P < 0.001), and brain structural alterations (P = 0.001). The summary effect size for HPA alterations was not significantly different from brain structural (P = 0.14), neurophysiological (P = 0.54), or neurochemical alterations (P = 0.22). These outcomes remained similar in antipsychotic naive sensitivity analyses. We found some, but limited and inconsistent, evidence that non-CNS alterations were associated with CNS changes and symptoms in first episode psychosis. Our findings indicate that there are robust alterations in non-CNS systems in psychosis, and that these are broadly similar in magnitude to a range of CNS alterations. We consider models that could account for these findings and discuss implications for future research and treatment.

Trajectories of Antipsychotic Drug Use Over 10 Years in a French Community-Based Sample of Persons Aged 50 and Older

OBJECTIVE

To identify the temporal prescribing patterns of antipsychotics among persons aged 50 and older and to explore the demographic and clinical characteristics associated with each trajectory of antipsychotic drug use.

METHODS

This was a historical fixed cohort study on a community-based sample of persons affiliated with the French Insurance Healthcare system. Data from community drug reimbursement claims were collected by the French Insurance Healthcare system over the period 2006-2015. The study included 160,853 persons aged 50 and older. Trajectories of antipsychotic drug use were identified by examining the distribution of antipsychotic use within consecutive 3-month periods over the entire follow-up period. Latent class analyses were used to identify distinct trajectories. Multivariate polynomial logistic regression models were used to explore the characteristics independently associated with trajectories.

RESULTS

Five trajectories of antipsychotic use were identified: null or very low use (93.8%), occasional use (2%), decreasing use (1.6%), chronic use (1.5%), and increasing use (1.1%). Occasional users were older and had a lower use of other psychotropic drugs and a high use of health resources. Chronic users had the highest frequency of chronic psychiatric diseases and were less likely to present with dementia or Parkinson disease. Persons with increasing use of antipsychotics were more frequently males and had a high frequency of dementia; half of them died over the follow-up period compared with 20% in the total sample.

CONCLUSION

Further studies should explore whether the benefit-risk ratio of antipsychotic drugs in older adults differs according to trajectories of use.

Revisiting the International Physical Activity Questionnaire (IPAQ): Assessing sitting time among individuals with schizophrenia

While moderate to vigorous physical activity may be one method of addressing common physical morbidities in schizophrenia, reducing sedentary time may be a low intensity adjunct. In order to determine whether sedentary behaviour is associated with health outcomes, valid and reliable tools for assessing sedentary time are necessary. In order to characterize the validity and reliability of the International Physical Activity Questionnaire (IPAQ) for assessing sitting (sedentary) time, participants completed the IPAQ at baseline and 4 weeks later and wore accelerometers for 7 days before the final assessment. Bland-Altman analyses and intraclass correlation coefficients (ICC) were used to compare agreement between measurements. One-hundred thirteen individuals completed the study. Mean difference between the IPAQ and accelerometer was 26.8 min (95% Limits of Agreement: -458.7-512.3) and ICC_A,1 was 0.23 (95% CI: 0.06-0.39). Week 1 and Week 4 administrations of the IPAQ differed by an average of 26.6 min, (95% Limits of Agreement: -510.9-564.2) and ICC_A,1 was 0.41 (95% CI: 0.21-0.59). The "minutes" of sitting reported by the IPAQ do not reflect objective sedentary behaviour measurements and this current measure may be unsuitable for the population level assessment of sitting time among individuals with schizophrenia.

Prospective associations between physical activity and clinician diagnosed major depressive disorder in adults: A 13-year cohort study

Regular physical activity (PA) appears to protect against the emergence of depression, but prospective studies linked to clinician diagnoses of major depressive disorder (MDD) remain scarce. It is also unclear whether PA levels recommended for general health are prospectively related to depression onset. We explored these relationships in a cohort of adults followed over 13 years. In total, 43,863 Swedish adults were surveyed in 1997 and responses linked to clinician-diagnosed MDD obtained from specialist medical registers until 2010. Weekly durations of habitual moderate (including walking) and vigorous PA were self-reported. Relationships between total durations of PA, 0-149 ('below'), 150-299 ('achieve'), and ≥300 min ('exceed') with incident MDD were explored using survival analysis with Cox proportional hazards regression. Models were adjusted for relevant covariates. Those with indications of depression at baseline were removed from the primary analyses. Of 25,520 participants with complete data (mean age = 49 years, SD = 16, 65% female), 76% met the recommended weekly duration of PA (≥150 min), and 38% exceeded this duration (≥300 min). During 13-years follow-up 549 MDD cases (1.5%) were identified (incidence rate = 111 cases per 100,000 person-years). Compared to participants who were below, those who exceeded the recommended weekly duration (≥300 min/week) had 29% reduced risk of depression onset (HR 0.71, 95% CI = 0.53-0.96). A non-significant inverse association was observed among those who achieved the minimum duration of 150-min/week (HR 0.86, 95% CI = 0.64-1.14). Habitual PA levels that exceed the duration recommended for general health may reduce the risk of clinician-diagnosed major depression in adults.

Sprint Interval Training and Continuous Aerobic Exercise Training Have Similar Effects on Exercise Motivation and Affective Responses to Exercise in Patients With Major Depressive Disorders: A Randomized Controlled Trial

Background: Sprint interval training (SIT) has become increasingly popular and is seen as a promising exercise strategy to increase fitness in healthy people. Nevertheless, some scholars doubt the appropriateness of a SIT training protocol for largely physically inactive populations. SIT might be too arduous, and therefore contribute to feelings of incompetence, failure, and lower self-esteem, which may undermine participants' exercise motivation. Therefore, we examined whether participation in 12 SIT sessions would lead to different changes in self-determined motivation, affective responses to exercise, cardiorespiratory fitness, physical activity, and depressive symptom severity compared to aerobic exercise training (CAT) in a sample of patients with major depressive disorders (MDD). Methods: Two groups of 25 patients (39 women, 11 men) with unipolar depression were randomly assigned to the SIT or CAT condition (M = 36.4 years, SD = 11.3). Data were assessed at baseline and post-intervention (three weekly 35-min sessions of SIT/CAT over a 4-week period). Self-determined exercise motivation was assessed with a 12-item self-rating questionnaire, affective valence was assessed in each session, prior, during, and after the exercise training using the Feeling Scale (FS). Cardiovascular fitness was measured with a maximal bicycle ergometer test, self-perceived fitness with a 1-item rating scale, physical activity with the International Physical Activity Questionnaire (IPAQ-SF), and depressive symptom severity with the Beck Depression Inventory II (BDi-II). Results: The SIT and CAT groups did not differ with regard to their changes in self-determined motivation from baseline to post-intervention. Participants in the SIT and CAT group showed similar (positive) affective responses during and after the training sessions. Cardiorespiratory fitness, self-perceived fitness and depressive symptom severity similarly improved in the SIT and CAT group. Finally, significant increases were observed in self-reported physical activity from baseline to post-intervention. However, these increases were larger in the CAT compared to the SIT group. Conclusion: From a motivational point of view, SIT seems just as suited as CAT in the treatment of patients with MDD. This is a promising finding because according to self-determination theory, it seems advantageous for patients to choose between different exercise therapy regimes, and for their preferences with regard to exercise type and intensity to be considered.

Hidden care: Revelations of a case-note audit of physical health care in a community mental health service

People with severe mental illness (SMI) are widely reported to be at an increased risk of morbidity and premature death due to physical health conditions. Mental health nurses are ideally placed to address physical and mental health comorbidity as part of their day-to-day practice. This study involved an audit of hardcopy and electronic clinical case-notes of a random sample of 100 people with SMI case managed by community mental health service in metropolitan South Australia, to determine how well physical health conditions and risk factors, screening, and follow-up are recorded within their service records. Every contact between 1 July 2015 and 30 June 2016 was read. One-way ANOVA, Scheffe's test, and Fisher's exact test determined any significant associations across audit variables, which included gender, age, income, living arrangement, diagnosis, lifestyle factors, recording of physical health measures, and carer status. A focus on physical health care was evident from everyday case-note records; however, because this information was 'buried' within the plethora of entries and not brought to the fore with other key information about the person's psychiatric needs, it remained difficult to gain a full picture of potential gaps in physical health care for this population. Under-reporting, gaps and inconsistencies in the systematic recording of physical health information for this population are likely to undermine the quality of care they receive from mental health services, the ability of mental health service providers to respond in a timely way to their physical healthcare needs, and their communication with other healthcare providers.

Hippocampal volume and vasculature before and after exercise in treatment-resistant schizophrenia

BACKGROUND

Schizophrenia is associated with poor cognitive function and elevated cardiometabolic disease risk. These health concerns may exacerbate neurocognitive dysfunction associated with hippocampal abnormalities, particularly hippocampal volume reductions. Regular exercise is thought to improve symptom severity, reduce depression, and improve cognition in schizophrenia, and may trigger exercise-mediated hippocampal growth. The potential for the benefits of exercise for treatment-resistant schizophrenia patients has not been clearly assessed. This study aims to assess the effect of exercise on hippocampal plasticity and clinical outcomes in chronic schizophrenia.

METHODS

Seventeen DSM-IV criteria schizophrenia or schizoaffective disorder patients completed a customized moderate intensity 12-week aerobic or weight-bearing exercise program. Adherence rates were 83% ± 9.4%) with 70% of participants completing the entire exercise program. Concomitant neuroimaging, clinical and cognitive assessments were obtained at baseline and 12-weeks.

RESULTS

At follow-up, symptom severity scores (t(16) = -16.8, p. ≤ 0.0001) and social functioning (t(16) = 4.4, p. = 0.0004) improved. A trend for improved depression scores (t(16) = -2.0, p. = 0.06) with no change in anxiety, or extrapyramidal symptoms were seen. Hippocampal volume increased (t(16) = -2.54, p. = 0.02), specifically in the left CA-1 field (F(16) = -2.33, p. = 0.03). Hippocampal vascular volume was unchanged. Change in hippocampal volume and vascular volume was not significantly correlated with change in symptom severity or affect scores.

CONCLUSIONS

Adjunct exercise may accelerate symptom improvement in treatment-resistant psychosis patients. While the underlying mechanism remains unclear, these results indicate that chronic schizophrenia patients experience hippocampal plasticity in response to exercise.

STUDY REGISTRATION

Clinical Trials.govNCT01392885.

Diagnostic value of a simplified screening test for metabolic syndrome in a Dutch patient cohort with schizophrenia spectrum disorders

OBJECTIVE:

The aim of this study was to establish the specificity and sensitivity of a simplified screening test based on diastolic blood pressure and waist circumference for predicting metabolic syndrome.

METHOD:

Demographic, anthropometric (waist circumference and systolic and diastolic blood pressure) and laboratory (triglyceride, high-density lipoprotein and fasting glucose) data were collected from a large cohort of Dutch patients with a schizophrenia spectrum disorder in order to determine whether patients fulfilled the Western criteria of the International Diabetes Federation (IDF) for metabolic syndrome. The sensitivity, specificity, likelihood ratio of a positive or negative test outcome and positive and negative predictive values of the simplified test (only waist circumference and diastolic blood pressure) were calculated.

RESULTS:

Of 252 recruited patients, 55% met the IDF criteria for metabolic syndrome. The sensitivity and the specificity of the simplified test were 65% and 85%, respectively. The likelihood ratios of positive and negative test outcomes were 4.35 and 0.41, respectively, and the positive and negative predictive values were 87% and 67%, respectively.

CONCLUSION:

This simplified screening test did not have diagnostic validity for metabolic syndrome in a Dutch cohort of patients with schizophrenia spectrum disorder.

Prospective associations of physical fitness and cognitive performance among inpatients with Schizophrenia

There is a paucity of longitudinal research investigating fitness and cognitive performance in people with schizophrenia. This study examined the prospective associations of physical fitness and cognitive performance among inpatients with schizophrenia. A prospective cohort study over two years was undertaken in 190 inpatients with schizophrenia. Four domains of physical fitness (body composition, muscle endurance, flexibility, and cardiovascular fitness) were measured at baseline in addition to the cognitive domains of attention, hand dexterity and working memory. At baseline, compared to general population normative data, more than one third of the sample had poor cardiovascular fitness, and over half were overweight/obese, had poor muscular fitness and poor flexibility. In the schizophrenia sample, better cardiovascular fitness at baseline was significantly associated with better attention, dexterity, and memory. However, the relationships dissipated after adjusting for baseline cognitive scores. In the final models, aside from baseline cognitive scores, only illness duration was significantly associated with dexterity, and smoking status and duration of hospitilization were associated with working memory. Our data suggest that in a cohort of people with established schizophrenia who already had evidence of cognitive dysfunction, better physical fitness was not associated with improved cognitive performance over two years.

Child maltreatment, psychopathological symptoms, and onset of diabetes mellitus, hypothyroidism and COPD in adulthood

BACKGROUND

The aim of this study was to assess the associations between child maltreatment (CM), psychopathological symptoms, and onset of diabetes mellitus, hypothyroidism (i.e., low metabolism), and chronic bronchitis/emphysema/COPD in adulthood.

METHODS

The present analysis used cross-sectional data collected in 2007-2008 within the Tromsø Study, Norway (N = 12,981). CM was measured with a single item, and self-reported information on psychopathological symptoms and physical health outcomes was used. The associations between CM, psychopathological symptoms, and physical health outcomes were assessed with linear and Poisson regression models. Mediation was assessed with difference-in-coefficients method.

RESULTS

In the fully-adjusted models, CM was associated with higher levels of anxiety and depression, psychological distress, difficulty in sleeping, insomnia, and use of sleeping pills and antidepressants in adulthood (p < 0.05). Moreover, CM was associated with a more than two-folds increased risk of consultation with psychiatrist (p < 0.001), a 26% increased risk of forgetfulness (p < 0.001), a 15% increased risk of decline in memory (p < 0.001), and a 96% increased risk of psychiatric problems (p < 0.001) over the course of life. In the fully-adjusted models, CM was associated with a 27-82% increased risk of physical health outcomes in adulthood (p < 0.05). Indicators of psychopathological symptoms significantly (p < 0.05) mediate the associations between CM and physical health outcomes.

LIMITATIONS

The design of this study is cross-sectional, and all measures are self-reported.

CONCLUSION

The associations between retrospectively-reported CM and physical health outcomes in adulthood are partially driven by psychopathological symptoms in adulthood.

Association of Secondary Preventive Cardiovascular Treatment After Myocardial Infarction With Mortality Among Patients With Schizophrenia

IMPORTANCE

Cardioprotective medication use is an important secondary preventive treatment after cardiovascular events. Patients with schizophrenia have excess cardiovascular morbidity and mortality, but no studies have investigated whether taking recommended cardioprotective medication can reduce this excess mortality.

OBJECTIVE

To assess the association of exposure to secondary cardiovascular treatment with all-cause mortality after myocardial infarction among patients with schizophrenia compared with the general population.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide cohort study included individuals admitted with first-time myocardial infarction in Denmark from January 1, 1995, to December 31, 2015. The cohort was dichotomously divided by a diagnosis of schizophrenia. Data on the prescription of guideline-recommended cardioprotective medication, including antithrombotics, β-blockers, vitamin K antagonist, angiotensin-converting enzyme inhibitors, and statins, were obtained from the nationwide registries.

EXPOSURES

Time exposed to cardioprotective medication.

MAIN OUTCOMES AND MEASURE

Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95% CIs for the association between treatment exposure and all-cause mortality after myocardial infarction between patients with and without schizophrenia.

RESULTS

The cohort included 105 018 patients with myocardial infarction, including 684 patients with schizophrenia (0.7%; 483 male [70.6%]; mean [SD] age at diagnosis, 57.3 [10.6] years) and 104 334 general population patients (99.3%; 73 454 male [70.4%]; mean [SD] age at diagnosis, 61.0 [10.6] years), with a total follow-up of 796 435 person-years and 28 059 deaths. Patients diagnosed with schizophrenia who did not receive cardioprotective treatment had the highest mortality rate (HR, 8.78; 95% CI, 4.37-17.64) compared with the general population treated, with treated patients diagnosed with schizophrenia having an increased HR of 1.97 (95% CI, 1.25-3.10). The analyses of the associations of different cardiac therapy strategies with mortality rates revealed that patients with schizophrenia who were treated with any combination of triple therapy had mortality rates similar to those observed in the general population (HR, 1.05; 95% CI, 0.43-2.52) in the multivariable analysis.

CONCLUSIONS AND RELEVANCE

Cardioprotective medication after myocardial infarction should be carefully managed to improve prognosis. The study results suggest that some of the increased cardiac mortality among patients with schizophrenia can be reduced if these patients are efficiently administered combinations of secondary preventive treatments after cardiac events.

Is it possible for people with severe mental illness to sit less and move more? A systematic review of interventions to increase physical activity or reduce sedentary behaviour

Individuals with severe mental illness (SMI) (schizophrenia-spectrum, bipolar disorder and major depressive disorder) die 10-20 years prematurely due to physical disorders such as cardiovascular disease. Physical activity (PA) is effective in preventing and managing these conditions in the general population, however individuals with SMI engage in substantially less PA and more sedentary behaviour (SB) compared to healthy counterparts. Furthermore, the effectiveness of intervening to increase PA or reduce SB in SMI populations is unknown. Therefore, we systematically reviewed studies measuring changes in PA or SB following behavioural interventions in people with SMI. A systematic search of major databases was conducted from inception until 1/3/2018 for behavioural interventions reporting changes in PA or SB in people with SMI. From 3018 initial hits, 32 articles were eligible, including 16 controlled trials (CT's; Treatment n = 1025, Control n = 1162) and 16 uncontrolled trials (n = 655). Of 16 CTs, seven (47%) reported significant improvements in PA, although only one found changes with an objective measure. Of 16 uncontrolled trials, 3 (20%) found improvements in PA (one with objective measurement). No intervention study had a primary aim of changing SB, nor did any note changes in SB using an objective measure. In conclusion, there is inconsistent and low quality evidence to show that interventions can be effective in changing PA or SB in this population. Future robust randomized controlled trials, using objectively-measured PA/SB as the primary outcome, are required to determine which behavioural interventions are effective in improving the sedentary lifestyles associated with SMI. Systematic review registration- PROSPERO registration number CRD42017069399.

Shorter telomere length in schizophrenia: Evidence from a real-world population and meta-analysis of most recent literature

Schizophrenia is a severe, chronic mental disorder. Schizophrenia is visualized as an accelerated cellular aging syndrome characterized by early onset of cardiovascular disease causing premature mortality. In human aging involves alterations in telomere length (TL). To investigate the presence of TL shortening in schizophrenia and psychiatric syndromes associated, this condition was studied in leukocytes (LTL) of a sample of patients suffering from schizophrenia and other psychotic disorders, and compared with a group of non-psychiatric controls. We explored the relationship between LTL and age, gender, and smoking habit with the aim to control whether these potential confounding factors may influence the rate of telomeres shortening. We also performed a new comprehensive meta-analysis including studies on LTL in schizophrenia patients compared to healthy subjects published in the last two years and the results of the present study. Our results suggest that a diagnosis of schizophrenia, more than gender, age, cigarette smoking or alcohol drinking, is the most important condition responsible of the LTL shortening. A strong LTL shortening was observed in patients affected by schizophrenia, Schizoaffective disorder, and Psychosis not otherwise specified when they were younger than 50 years, while in the group of older subjects no major differences were observed. Additional evidence supporting the causal link of schizophrenia with accelerated telomeres shortening came from the analysis of the updated meta-analysis. The availability of a personalized profile of mechanistic pathways, risk factors, and clinical features may pose the basis for a rehabilitative treatment addressing individual needs of the psychiatric patients.

The intriguing relationship between coronary heart disease and mental disorders

Coronary heart disease (CHD) and mental illness are among the leading causes of morbidity and mortality worldwide. Decades of research has revealed several, and sometimes surprising, links between CHD and mental illness, and has even suggested that both may actually cause one another. However, the precise nature of these links has not yet been clearly established. The goal of this paper, therefore, is to comprehensively review and discuss the state-of-the-art nature of the epidemiological and pathophysiological aspects of the bidirectional links between mental illness and CHD. This review demonstrates that there exists a large body of epidemiological prospective data showing that people with severe mental illness, including schizophrenia, bipolar disorder, and major depressive disorder, as a group, have an increased risk of developing CHD, compared with controls [adjusted hazard ratio (adjHR)=1.54; 95% CI: 1.30-1.82, P<0.0001]. Anxiety symptoms or disorders (Relative Risk (RR)=1.41, 95% CI: 1.23-1.61, P<0.0001), as well as experiences of persistent or intense stress or posttraumatic stress disorder (PTSD) (adjHR=1.27, 95% CI: 1.08-1.49), although to a lesser degree, may also be independently associated with an increased risk of developing CHD. On the other hand, research also indicates that these symptoms/mental diseases are common in patients with CHD and may be associated with a substantial increase in cardiovascular morbidity and mortality. Finally, mental diseases and CHD appear to have a shared etiology, including biological, behavioral, psychological, and genetic mechanisms.

Predictors of falls and fractures leading to hospitalization in people with schizophrenia spectrum disorder: A large representative cohort study

AIM

To investigate predictors of falls/fractures leading to hospitalisation in people with schizophrenia-spectrum disorders.

METHODS

A historical cohort of people with schizophrenia-spectrum disorders (ICD F20-29) from 01/2006-12/2012 was assembled using data from the South London and Maudsley NHS Biomedical Research Centre Case Register. Falls/fractures were ascertained from a linkage to national hospitalisation data. Separate multivariate Cox regression analyses were employed to identify predictors of falls and fractures.

RESULTS

Of 11,567 people with schizophrenia-spectrum disorders (mean age 42.6 years, 43% female), 579 (incidence rate 12.79 per 1000 person-years) and 528 (11.65 per 1000 person-years) had at least one reported hospital admission due to a fall or fracture respectively and 822 patients had at least either a recorded fall or a fracture during this period (i.e. 7.1% of sample). Overall, 6.69 and 10.74 years of inpatient hospital stay per 1000-person years of follow-up occurred due to a fall and fracture respectively. 14(0.12%) and 28(0.24%) died due to a fall and fracture respectively. In Multivariable analysis, increasing age, white ethnicity, analgesics, cardiovascular disease, hypertension, diseases of the genitourinary system, visual disturbance and syncope were significant risk factor for both falls and fractures. A previous fracture (HR 2.05, 95% CI 1.53-2.73) and osteoporosis (HR 6.79, 95% CI 4.71-9.78) were strong risk factors for consequent fractures.

CONCLUSION

Comorbid physical health conditions and analgesic medication prescription were associated with higher risk of falls and fractures. Osteoporosis and previous fracture were strong predictors for subsequent fractures. Interventions targeting bone health and falls/fractures need to be developed and evaluated in these populations.

What prevents youth at clinical high risk for psychosis from engaging in physical activity? An examination of the barriers to physical activity

BACKGROUND

Exercise has increasingly been proposed as a healthful intervention prior to and after the onset of psychosis. There is some evidence to suggest that youth at clinical high risk (CHR) for psychosis are less physically active and report more barriers to engaging in exercise; however, there has been relatively limited empirical work documenting this phenomenon, and to date, relationships between physical activity, barriers, and clinical phenomenology have been unclear.

METHODS

CHR (N = 51) and healthy control (N = 37) participants completed a structured clinical interview assessing attenuated psychotic symptoms and substance use, and an exercise survey that assessed current exercise practices, perceived physical fitness, and barriers related to engaging in exercise.

RESULTS

CHR youth engaged in less physical activity, exhibited lower perception of fitness, and endorsed more barriers related to motivation for exercise. The CHR group showed significant negative correlations where lower perceptions of fitness were associated with increased negative, disorganized, and general symptoms. Decreased frequency of activity was related to more barriers of motivation. Interestingly, greater symptomatology in the CHR group was associated with more barriers of self-perception and motivation for engaging in exercise. However, findings suggested a nuanced relationship in this area; for example, increased physical activity was associated with increased substance use.

CONCLUSIONS

The results of the current study support the notion that sedentary behavior is common in CHR youth, and more broadly, provide an impetus to target motivation through supervised exercise and fitness tracking to promote the health and well-being of CHR individuals.