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

Increased long-term mortality after myocardial infarction in patients with schizophrenia

BACKGROUND

Ischemic heart disease increases mortality in patients with schizophrenia. This nationwide study explored short-term and long-term mortality rates in patients with schizophrenia experiencing myocardial infarction (MI) compared to controls from the general population experiencing MI, as well as patients with schizophrenia and people from the general population not experiencing MI.

METHOD

A Danish nationwide cohort study including incident patients diagnosed with schizophrenia between 1980 and 2015, matched 1:5 on year of birth and gender to controls from the general population. Primary outcome was all-cause mortality. Data were analysed utilizing Cox regression models, Kaplan-Meier estimates and standardized mortality ratios (SMR).

RESULTS

Patients with schizophrenia experiencing MI had an increased mortality rate (Hazard rate ratio (HR) 9.94, 95%CI(8.71-11.35)), as well as schizophrenia controls (HR 4.50, 95%CI(4.36-4.64)) and MI controls (HR 3.27, 95%CI(3.03-3.52)) with controls not experiencing MI serving as reference in a model adjusted for age at entry, gender and calendar year. No difference in 30-day mortality was observed between groups experiencing MI, but increased mortality rates were shown in patients with schizophrenia at 1-year and 5-year follow-up. Trends in SMR declined in MI controls, while patients with schizophrenia showed an unchanged SMR over time.

CONCLUSIONS

Patients with schizophrenia have not experienced a decline in mortality rate following MI compared to the general population in long-term follow-up. This finding highlights the need for research in MI follow-up care for patients with schizophrenia.

Ideal cardiovascular health and its association with sedentary behaviour and fitness in psychiatric patients. The PsychiActive project

BACKGROUND AND AIMS

Ideal cardiovascular health (CVH) was defined as meeting ideal levels of 4 health behaviours (smoking, body mass index, physical activity, and diet) and 3 biological factors (blood pressure, total cholesterol, and glucose) and is inversely related to cardiovascular disease and mortality. However, the prevalence of ideal CVH in patients with severe mental illness and the possible independent associations of sedentary behaviour and fitness with CVH score are unexplored.

METHODS AND RESULTS

This study included 142 (34 women) outpatients with severe mental illness (primarily schizophrenia, n = 92). CVH was evaluated according to the American Heart Association guidelines. Sedentary behaviour, cardiorespiratory fitness, and muscular strength were measured by an activity-monitor, the 6-min walk test, and handgrip dynamometry. Cardiorespiratory fitness and strength values were combined in a composite fitness score. The prevalence of ideal CVH was: non-smoking (47.9%), body mass index (16.9), physical activity (83.1%), diet (10.4%), blood pressure (40.4%), total cholesterol (62.9%), and plasma glucose (66.7%). Low levels of sedentary behaviour and high cardiorespiratory, strength, and composite fitness score were associated with meeting the ideal threshold in most CVH metrics and having higher global CVH score; however, only cardiorespiratory and composite fitness score remained significantly related to global CVH score independent of sedentary behaviour and multiple confounders.

CONCLUSIONS

Patients with severe mental illness generally have low prevalence of ideal CVH metrics, especially diet and body mass index. Additionally, our findings suggest the need or considering cardiorespiratory fitness, regardless of sedentary behaviour, to promote ideal CVH in this population.

Associations between clinical and psychosocial factors and metabolic and cardiovascular risk factors in overweight patients with schizophrenia spectrum disorders - Baseline and two-years findings from the CHANGE trial

OBJECTIVES

People with severe mental disorders die averagely 15years earlier than people in the Western background population, cardiovascular disease being the most frequent cause of death with unhealthy eating habits and lower levels of physical activity as major contributing risk factors. Understanding possible associations and predictors of the specific cardiovascular risk may permit more targeted and effective prevention. The aim of this study was to investigate the associations between clinical and psychosocial factors and several separate cardiovascular risk factors in a cohort of 428 persons with schizophrenia and abdominal obesity enrolled in the CHANGE trial.

METHODS

We used data from baseline and two-year follow-up of 428 individuals with schizophrenia spectrum disorders and abdominal overweight enrolled in the CHANGE trial. By linear regressions we explored the relationships between clinical and psychosocial factors and established cardiovascular risk factors: Dependent variables were baseline and follow-up values of the following: VO₂max, waist circumference, high density lipoprotein (HDL), systolic blood pressure and HbA1c. Independent variables were baseline values of the following: negative symptoms, positive symptoms, cognition, level of functioning, antipsychotic medication, duration of illness, employment situation and whether the participants had any friend.

RESULTS

Negative symptoms were associated with most baseline- as well as two-years-outcome; negatively with cardiorespiratory fitness and with dietary quality and with HDL, and with increasing values of the variables waist circumference, BMI and HbA1c. Negative symptoms were seen also to predict poorer cardiorespiratory fitness and larger waist circumference, higher HbA1c and lower HDL at two year follow-up. Level of functioning and Cognitive function correlated positively with cardiorespiratory fitness and HDL, and correlated negatively with waist circumference and HbA1c. Both parameters also predicted a better fitness, higher HDL and lower HbA1c at two year follow-up. Isolating the antipsychotic drugs known to give the worst metabolic adverse effects (olanzapine, clozapine, quetiapine), the dosage was positively associated with cholesterol, but not with any other outcome. Psychotic symptoms and duration of illness were not significantly associated with any outcome. Employment of any kind was significantly associated with cardiorespiratory fitness and negatively associated with waist circumference, BMI and systolic blood pressure. At two year follow-up associations were significant for the two year outcomes cardiorespiratory fitness and waist circumference. Friendship relations were negatively associated with waist circumference and positively with HDL cholesterol. None of the two year outcomes were predicted by friendship.

CONCLUSIONS

We found various clinical and psychosocial factors to be associated with less healthy lifestyle factors and higher risk of cardiovascular disease, with negative symptoms building the strongest associations, although a possible bidirectional causality needs to be regarded. Reduction of negative symptoms should be investigated further in order to reduce the increased cardiovascular morbidity and mortality in people with schizophrenia spectrum disorders.

Association of lifestyle-related factors and psychological factors on quality of life in people with schizophrenia

In people with schizophrenia several factors are associated with poor quality of life (QoL), namely, lifestyle-related factors and psychological factors. However, there has been little research on the impact of these factors on QoL. Therefore, the relation between lifestyle-related factors, psychological factors, and QoL in people with schizophrenia was assessed. A cross-sectional study was conducted among 115 patients (25% women, 50% inpatients). QoL was measured by World Health Organisation Quality of Life- Brief Version. Lifestyle-related factors were assessed, namely physical activity (International Physical Activity Questionnaire- Short Form), sleep quality (Pittsburgh Sleep Quality Index) and dietary intake (Mediterranean Diet score). Psychological factors such as self-esteem (Rosenberg Self-Esteem Scale) and autonomous motivation (Behavioural Regulation Questionnaire- version 3) were also measured. Regression analyses were performed to identify significant predictors of QoL. Results showed that self-esteem predicted better global, physical, psychological and environmental QoL. Physical activity predicted better global and physical QoL, while sedentary time predicted poor social and environmental QoL. Identifying predictors of QoL has implication for the effective design and delivery of lifestyles interventions, including physical activity, dietary education and smoking cessation in people with schizophrenia. Adopting healthy lifestyles may lead to improved physical health, psychological well-being and QoL in this population.

Cardiorespiratory fitness and response to exercise treatment in depression

BACKGROUND

Exercise improves cardiorespiratory fitness (CRF) and reduces depressive symptoms in people with depression. It is unclear if changes in CRF are a predictor of the antidepressant effect of exercise in people with depression.

AIMS

To investigate whether an increase in CRF is a predictor of depression severity reduction after 12 weeks of exercise (trial registration: DRKS study ID, DRKS00008745).

METHOD

The present study includes participants who took part in vigorous (n = 33), moderate (n = 38) and light (n = 39) intensity exercise and had CRF information (as predicted maximal oxygen uptake, V̇O_2max) collected before and after the intervention. Depression severity was measured with the Montgomery-Åsberg Depression Rating Scale (MADRS). V̇O_2max (L/min) was assessed with the Åstrand-Rhyming submaximal cycle ergometry test. The main analysis was conducted pooling all exercise intensity groups together.

RESULTS

All exercise intensities improved V̇O_2max in people with depression. Regardless of frequency and intensity of exercise, an increase in post-treatment V̇O_2max was significantly associated with reduced depression severity at follow-up (B = -3.52, 95% CI -6.08 to -0.96); adjusting for intensity of exercise, age and body mass index made the association stronger (B = -3.89, 95% CI -6.53 to -1.26). Similarly, increased V̇O_2max was associated with higher odds (odds ratio = 3.73, 95% CI 1.22-11.43) of exercise treatment response (≥50% reduction in MADRS score) at follow-up.

CONCLUSIONS

Our data suggest that improvements in V̇O_2max predict a greater reduction in depression severity among individuals who were clinically depressed. This finding indicates that improvements in V̇O_2max may be a marker for the underpinning biological pathways for the antidepressant effect of exercise.

DECLARATION OF INTEREST

None.

The next step: a strategic focus on physical activity and sedentary behaviour in Irish mental health care

People with severe mental illnesses have dramatically reduced life expectancy compared with the general population, which is largely attributed to physical comorbidity. Physical activity and sedentary behaviour interventions offer a safe and viable therapeutic resource for multi-disciplinary mental health care teams. The accumulating evidence supporting the role of these interventions has changed the focus of mental health strategy in some countries, with new developing roles for certain mental health professionals in this field. However, in Ireland the absence of specialised exercise practitioners places a leadership role for mental health nurses in this regard. National mental health strategy in Ireland should prioritise physical activity and sedentary behaviour interventions, make recommendations for the integration of specialised exercise practitioners in all mental health multidisciplinary teams, and recommend the provision of training and awareness for mental health nurses and other multidisciplinary professionals who are already well placed to address this issue.

The relationship between the dietary inflammatory index (DII®) and incident depressive symptoms: A longitudinal cohort study

BACKGROUND

Diet is a common source of inflammation, and inflammation is associated with depression. We examined the association between the dietary inflammatory index (DII^®), a validated measure of inflammatory potential of the diet, and risk of depression in a cohort of older North American adults.

METHODS

This longitudinal study, with a follow-up of 8 years, included 3648 participants (1577 males, 2071 females; mean age: 60.6 years) with/at risk of knee osteoarthritis. DII^® scores were calculated using the validated Block Brief 2000 Food-Frequency Questionnaire. Center for Epidemiological Studies Depression-20 scale was used to define depressive symptoms. The relationship between baseline DII^® score and incident depression was assessed through Cox's regression analysis, adjusted for potential confounders, and reported as hazard ratios (HRs).

RESULTS

In total, 837 individuals (310 men and 527 women) developed incident depressive symptoms over the course of 8 years. Participants in the most pro-inflammatory group (quartile 4) had approximately 24% higher risk of developing depressive symptoms compared to subjects with the most anti-inflammatory diet (HR: 1.24; 95% CI: 1.01-1.53; p = 0.04).

CONCLUSION

These results suggest that a pro-inflammatory diet may be associated with higher incidence of depressive symptoms in a cohort of older Americans. Transitioning to a more anti-inflammatory diet may reduce depression risk.

Short-term efficacy and tolerability of lurasidone in the treatment of acute schizophrenia: A meta-analysis of randomized controlled trials

BACKGROUND

Lurasidone, an azapirone derivative, is a novel second generation antipsychotic with potent binding affinity for dopamine D2, serotonin 5-HT_2A, 5-HT_7, 5-HT_1A, and noradrenaline alpha_2C receptors. This updated meta-analysis of randomized controlled trials (RCTs) examined the short-term efficacy and tolerability of lurasidone in the treatment of acute schizophrenia.

METHODS

Double-blinded RCTs reporting on the short-term effects of lurasidone were included. Standardized mean difference (SMD) with their 95% confidence interval (CI), and number needed to harm (NNH) were computed.

RESULTS

The meta-analysis had 8 RCTs with 16 active arms that included 2373 patients with acute schizophrenia who were randomized to either lurasidone (20-160 mg/day; n = 1570) or placebo (n = 803) groups. Lurasidone was superior to placebo with regard to change in total psychopathology [SMD: -0.34, (95%CI: -0.48, -0.20), P<0.00001], positive symptoms [SMD: -0.47, (95%CI: -0.57, -0.36), P<0.00001], negative symptoms [SMD:-0.34, (95%CI: -0.45, -0.22), P<0.00001], and general psychopathology [SMD: -0.36, (95%CI: -0.48, -0.24), P<0.00001]. Results were consistent for total psychopathology in 11 out of the 13 subgroups. Lurasidone resulted in higher weight gain [SMD: 0.15, (95% CI: 0.06, 0.24), P = 0.001] and BMI [SMD: 0.17, (95%CI: 0.07, 0.28), P = 0.002] than placebo, but the differences were not clinically significant. Lurasidone group had less frequent inefficacy (NNH = 14) and discontinuation due to any reason (NNH = 17), but was associated with more frequent vomiting, akathisia, dystonia, parkinsonism, somnolence, dizziness, sedation, nausea, and weight gain of ≥7% of the initial weight (NNH = 11-50).

CONCLUSION

This meta-analysis of 8 short-term studies supported the efficacy and safety of lurasidone in the acute phase of schizophrenia, particularly at the higher dose range of 80 mg/day.

Association between depression and smoking: A global perspective from 48 low- and middle-income countries

BACKGROUND

Smoking is a leading modifiable cause of global morbidity and mortality. Research from high-income countries has found a high prevalence of smoking among people with depression and suggested that this may partially contribute to the increased premature mortality in this population. Limited research has investigated smoking behaviors across the depression spectrum and in low- and middle-income countries (LMICs). This study explored the relationship between depression and smoking across 48 LMICs.

METHODS

We conducted a cross-sectional, community-based study comprising 242,952 people [mean age 38.4 (SD = 16.1) years, 50.8% females] from the World Health Survey. Multivariable binary logistic regression analyses were performed to investigate the relationship between depression (including subsyndromal, brief depressive episode and depressive episodes) and smoking behaviours.

RESULTS

Overall, the prevalence of current smoking was lowest in Africa (13.5%) and highest in Asia (32.2%). A depressive episode was present in 6.7% of the sample. Compared to people without depression, subsyndromal depression, brief depressive episode, and depressive episodes were all significantly associated with smoking with similar effect sizes (ORs: 1.36-1.49). Countrywide meta-analysis found that the pooled overall OR for smoking in depression was 1.42 (95%CI = 1.32-1.52, I² = 39.7%). Furthermore, alcohol consumption and male gender were consistently associated with smoking across all regions and smoking was consistently less common in those who were wealthier and had a higher education.

CONCLUSION

These data suggest that the depression spectrum is consistently associated with high levels of smoking behaivours in LMICs. Given that most of the world's smokers reside in LMICs, future smoking cessation interventions are required to target people with depression.

The association of depression and all-cause and cause-specific mortality: an umbrella review of systematic reviews and meta-analyses

BACKGROUND

Depression is a prevalent and disabling mental disorder that frequently co-occurs with a wide range of chronic conditions. Evidence has suggested that depression could be associated with excess all-cause mortality across different settings and populations, although the causality of these associations remains unclear.

METHODS

We conducted an umbrella review of systematic reviews and meta-analyses of observational studies. PubMed, PsycINFO, and Embase electronic databases were searched through January 20, 2018. Systematic reviews and meta-analyses that investigated associations of depression and all-cause and cause-specific mortality were selected for the review. The evidence was graded as convincing, highly suggestive, suggestive, or weak based on quantitative criteria that included an assessment of heterogeneity, 95% prediction intervals, small-study effects, and excess significance bias.

RESULTS

A total of 26 references providing 2 systematic reviews and data for 17 meta-analytic estimates met inclusion criteria (19 of them on all-cause mortality); data from 246 unique studies (N = 3,825,380) were synthesized. All 17 associations had P < 0.05 per random effects summary effects, but none of them met criteria for convincing evidence. Associations of depression and all-cause mortality in patients after acute myocardial infarction, in individuals with heart failure, in cancer patients as well as in samples from mixed settings met criteria for highly suggestive evidence. However, none of the associations remained supported by highly suggestive evidence in sensitivity analyses that considered studies employing structured diagnostic interviews. In addition, associations of depression and all-cause mortality in cancer and post-acute myocardial infarction samples were supported only by suggestive evidence when studies that tried to adjust for potential confounders were considered.

CONCLUSIONS

Even though associations between depression and mortality have nominally significant results in all assessed settings and populations, the evidence becomes weaker when focusing on studies that used structured interviews and those that tried to adjust for potential confounders. A causal effect of depression on all-cause and cause-specific mortality remains unproven, and thus interventions targeting depression are not expected to result in lower mortality rates at least based on current evidence from observational studies.

Chronotropic incompetence of the heart is associated with exercise intolerance in patients with schizophrenia

The elevated cardiovascular risk of patients with schizophrenia contributes to a reduced life expectancy of 15-20years. This study investigated whether cardiac autonomic dysfunction (CADF) in schizophrenia is related to chronotropic incompetence, an established cardiovascular risk marker. We investigated thirty-two patients suffering from paranoid schizophrenia and thirty-two control subjects matched for age, sex, body mass index and fat free mass. A cardiopulmonary exercise test (CPET) was performed to study heart rate responses to exercise as well as submaximal (ventilatory threshold 1, VT₁) and maximal endurance capacities (peak oxygen consumption, VO_2peak; peak power output, P_peak). In addition, epinephrine and norepinephrine levels were assessed in a subset of patients. Fitness parameters were significantly reduced in all patients. Most investigated physiological parameters were significantly different at rest as well as during peak exercise being in line with previously described CADF in schizophrenia. In particular, 14 out of 32 patients were classified as chronotropically incompetent whereas no control subject was below the cut-off value. In addition, a positive correlation of a slope reflecting chronotropic incompetence with peak oxygen uptake (p<0.001) was observed in patients only indicating a close correlation to the lack of physical fitness. The catecholamine increase was reduced in patients after exercise. This study identified a novel cardiac risk factor in patients with schizophrenia. Moreover, it seems to be associated with reduced physical fitness and indicates targets for exercise intervention studies. Future studies are warranted to elucidate pathophysiological mechanisms of this cardiac condition.

Association between frailty and its individual components with the risk of falls in patients with schizophrenia spectrum disorders

Frailty is common among older people who carry an increased risk for poor outcomes, including falls, physical disabilities, infections, and mortality. However, the prevalence of frailty and the prognostic influence of frailty status are poorly understood in adults with schizophrenia. The present study aimed to assess the predictive ability of frailty and its individual components for the risk of falls in patients with chronic schizophrenia. Frailty status was assessed at baseline by using Fried frailty criteria after the enrollment of 561 patients with chronic schizophrenia. The patients were followed up for 18 months, and the outcome of the study was the incidence of falls. The mean age of the patients was 53.8 years, and a total of 35.3% were females. One-quarter (25.3%) of patients received typical antipsychotics. The prevalence of frailty was 10.2% at baseline. During follow-up, 40 patients (7.1%) experienced falls. Frailty status was associated with increased susceptibility to falling with an unadjusted hazard ratio of 5.27 (95% confidence interval: 2.75-10.10) and a hazard ratio of 4.65 (95% confidence interval: 1.88-11.54) after multivariate adjustment. Among the components of frailty, the most significant association was observed between low physical activity and falls (p < 0.05). In conclusion, frailty is highly prevalent in patients with chronic schizophrenia and is associated with the risk of adverse clinical events. Further studies are needed to explore the mechanisms underlying the relationship between schizophrenia and frailty in an attempt to develop an appropriate treatment plan for improving clinical outcomes for these patients.

Sprint interval training (SIT) substantially reduces depressive symptoms in major depressive disorder (MDD): A randomized controlled trial

Continuous aerobic exercise training (CAT) is considered a complementary treatment option in patients with major depressive disorder (MDD). Intermittent exercise training protocols, such as sprint interval training (SIT) have gained increasing popularity, but no studies on depressive symptoms following SIT in patients with MDD are available. Fifty-nine in-patients with MDD were randomly assigned to a SIT or CAT group. Medication was counterbalanced in both intervention arms. Both intervention groups received 3 weekly training sessions for 4-weeks (12 sessions in total). SIT comprised 25 bouts of 30 seconds at 80% of maximal power, whereas CAT consisted of 20 minutes of physical activity at 60% of maximal power. The training protocols were isocalorically designed. Maximal bicycle ergometer exercise testing yielded maximal and submaximal physical fitness parameters. The Beck-Depression-Inventory-II (BDI-II) was filled out by the patients before and after the intervention period. BDI-II scores substantially decreased in both groups with an effect size pointing towards a large effect (p < 0.001, η_p² = 0.70) while submaximal (0.07 < d < 0.89) and maximal (0.05 < d < 0.85) fitness variables improved in both groups. Short-term SIT leads to similar results as CAT in patients with MDD and can be regarded as a time-efficient and promising exercise-based treatment strategy.

Tackling obesity in mental health secure units: a mixed method synthesis of available evidence

BACKGROUND

The prevalence and incidence of obesity are high in people with severe mental illness (SMI). In England, around 6000 people with SMI access care from secure mental health units. There is currently no specific guidance on how to reduce the risk of obesity-related morbidity and mortality in this population.

AIMS

To identify international evidence that addresses the issue of obesity in mental health secure units.

METHOD

A mixed method review of evidence (published 2000-2015) was carried out to assess obesity prevalence, intervention and policy change, as well as barriers to change.

RESULTS

Evidence from 22 mainly small, non-comparator studies (reported in 21 papers) using a range of methods was reviewed. Dietary, physical activity and cultural interventions being implemented within secure units to address the problem of obesity showed some promising outcomes for physical health and health education. These were facilitated by adequate organisational resources, staff training and motivated staff. Holistic interventions that included a social and/or competitive element were more likely to be taken up. Involving patients in decision-making mediated the tension between facilitating behaviour change and imposing control. Barriers to successful outcomes included patient movement in and out of units, severity of mental health condition and resistance to change by patients and staff.

CONCLUSIONS

Despite the promising outcomes reported, further assessment is needed of the feasibility, acceptability and effectiveness of interventions and policies targeting the obesogenic environment, using robust research methods.

DECLARATION OF INTEREST

None.

Correlates of sedentary behavior in 2,375 people with depression from 6 low- and middle-income countries

OBJECTIVE

Sedentary behaviour (SB) is harmful for health and well-being and may be associated with depression. However, little is known about the correlates of SB in people with depression. Thus, we investigated SB correlates among community-dwelling adults with depression in six low- and middle-income countries.

METHODS

Cross-sectional data from the World Health Organization's Study on Global Ageing and Adult Health were analyzed. The analysis was restricted to those with DSM-IV Depression or receiving depression treatment in the last 12 months. Self-reported time spent sedentary per day was the outcome. High SB was defined as ≥8 hours of SB per day. The correlates (sociodemographic and health-related) of SB were estimated by multivariable linear and logistic regression analyses.

RESULTS

In 2375 individuals with depression (mean age=48.0 years; 60.7% female), the prevalence of high SB was 11.1% (95%CI=8.2%-14.9%), while the mean (±SD) time spent sedentary was 215 (±192) minutes per day. Socio-demographic factors significantly associated with high SB were older age and being unmarried, being male and being unemployed. In other domains, no alcohol consumption, current smoking, mild cognitive impairment, bodily pain, arthritis, stroke, disability, and lower levels of social cohesion, COPD, visual impairment, and poor self-rated health was associated with greater time spent sedentary.

CONCLUSION

Our data suggest that future interventions seeking to reduce SB among individuals with depression may target at risk groups based on identified sociodemographic correlates while the promotion of social cohesion may have the potential to increase the efficacy of future public health initiatives. From a clinical perspective, bodily pain and somatic co-morbidities need to be taken into account.

Relationship between objectively measured sedentary behavior and health outcomes in schizophrenia patients: The PsychiActive project

This study aimed to investigate possible relationships between sedentary behavior and body mass index (BMI), cardiorespiratory fitness (CRF), and health-related quality of life (HRQoL) in schizophrenia patients. Variables contributing to the variability in sedentary behavior were identified. Eighty-two schizophrenia outpatients (mean age±SD: 41.0±8.7years, 87% men, mean illness duration±SD: 17.1±8.9years) wore a multisensor armband for 7 consecutive full days to objectively measure sedentary behavior. BMI, walking capacity (6-minute walking test) as a proxy for CRF estimation and HRQoL (Short Form 36-Item Health Survey questionnaire version 2) were also assessed. Correlation (Pearson or Spearman coefficients) and multiple regression analysis were used. Sedentary behavior was significantly associated with BMI, CRF, and the physical component summary score of HRQoL (r values, -0.34-0.41; all P<0.001) and remained significant after adjustments for age, illness duration, symptom severity, adherence to Mediterranean diet, smoking, and antipsychotic medication (all P<0.05). BMI, CRF and vitality were identified as determinants of sedentary behavior. Consistent relationships between sedentary behavior and BMI, CRF, and the physical component summary score of HRQoL were found in schizophrenia patients. All the identified determinants of sedentary behavior are modifiable and may be important areas for future interventions in this population.

Cardiovascular disease lifestyle risk factors in people with psychosis: a cross-sectional study

BACKGROUND

People with psychosis die on average 25 years earlier than those in the general population, with cardiovascular disease (CVD) contributing to much of the excess mortality. This cross-sectional study aimed to identify the relationship between lifestyle risk factors for CVD - poor nutrition, smoking and low physical activity levels - and dyslipidaemia, hypertension and hyperglycaemia while controlling for potential confounders in 1825 people from the Survey of High Impact Psychosis (SHIP) in Australia. We also aimed to identify clustering patterns of lifestyle risk factors and associated demographic variables.

METHODS

Three logistic regressions were used to predict the effect of nutrition, smoking and physical activity on dyslipidaemia, hypertension and hyperglycaemia while controlling for clozapine use, sex and age. Clustering patterns of nutrition, smoking and physical activity were examined using the two-step cluster method which is based on hierarchical cluster analysis. Demographic variables associated with different clusters were identified using measures of association.

RESULTS

Smoking status had a positive association with dyslipidaemia (adjusted odds ratio = 0.50; 95% confidence interval = 0.32-0.78; p = 0.002). Other cardiovascular disease lifestyle risk factors did not have a significant relationship with dyslipidaemia, hypertension and hyperglycaemia. Clustering patterns of lifestyle risk factors showed that younger men, with low education levels, and relying on a government pension, were most likely to display the poorest lifestyle risk behaviours. The largest cluster (42%) of participants was characterised by a mixed demographic profile and were most likely to display poor nutrition and low physical activity levels but less likely to smoke.

CONCLUSIONS

Only smoking status had a significant positive association with dyslipidaemia which could indicate that there are additional factors affecting the relationship between other cardiovascular lifestyle risk factors and dyslipidaemia, hypertension and hyperglycaemia in people with psychosis. Unknown confounders and traditional lifestyle risk factors may explain the high rates of CVD in this group. Clustering of lifestyle risk factors and their demographic profiles could help the design of intervention programs in people with psychosis.

Grip Strength Is Associated With Cognitive Performance in Schizophrenia and the General Population: A UK Biobank Study of 476559 Participants

Background

Handgrip strength may provide an easily-administered marker of cognitive functional status. However, further population-scale research examining relationships between grip strength and cognitive performance across multiple domains is needed. Additionally, relationships between grip strength and cognitive functioning in people with schizophrenia, who frequently experience cognitive deficits, has yet to be explored.

Methods

Baseline data from the UK Biobank (2007-2010) was analyzed; including 475397 individuals from the general population, and 1162 individuals with schizophrenia. Linear mixed models and generalized linear mixed models were used to assess the relationship between grip strength and 5 cognitive domains (visual memory, reaction time, reasoning, prospective memory, and number memory), controlling for age, gender, bodyweight, education, and geographical region.

Results

In the general population, maximal grip strength was positively and significantly related to visual memory (coefficient [coeff] = -0.1601, standard error [SE] = 0.003), reaction time (coeff = -0.0346, SE = 0.0004), reasoning (coeff = 0.2304, SE = 0.0079), number memory (coeff = 0.1616, SE = 0.0092), and prospective memory (coeff = 0.3486, SE = 0.0092: all P < .001). In the schizophrenia sample, grip strength was strongly related to visual memory (coeff = -0.155, SE = 0.042, P < .001) and reaction time (coeff = -0.049, SE = 0.009, P < .001), while prospective memory approached statistical significance (coeff = 0.233, SE = 0.132, P = .078), and no statistically significant association was found with number memory and reasoning (P > .1).

Conclusions

Grip strength is significantly associated with cognitive functioning in the general population and individuals with schizophrenia, particularly for working memory and processing speed. Future research should establish directionality, examine if grip strength also predicts functional and physical health outcomes in schizophrenia, and determine whether interventions which improve muscular strength impact on cognitive and real-world functioning.

Delayed increase of thrombocyte levels after a single sub-anesthetic dose of ketamine - A randomized trial

Recently, ketamine has been investigated as a potential antidepressant option for treatment resistant depression. Unlike traditional drugs, it yields immediate effects, most likely via increased glutamatergic transmission and synaptic plasticity. However, ketamine administration in humans is systemic and its long-term impact on blood parameters has not yet been described in clinical studies. Here we investigated potential sustained effects of ketamine administration (0.5 mg/kg ketamine racemate) on hematological and biochemical values in plasma and serum in a randomized double-blinded study. 80 healthy young participants were included and whole blood samples were collected 5 days before, and 14 days after the infusion. To assess the group effect, repeated measure analyses of co-variance (rmANCOVA) were conducted for the following blood parameters: levels of sodium, potassium, calcium, hemoglobin and number of erythrocytes, lymphocytes, and thrombocytes. RmANCOVA revealed a significant time by treatment effect on thrombocyte levels (F_{1, 74} = 13.54, p < 0.001, eta = 0.155), driven by an increase in the ketamine group (paired t-test, t = -3.51, df = 38, p = 0.001). Specificity of thrombocyte effect was confirmed by logistic regression, and in addition, no other coagulation parameters showed significant interaction. Moreover, the relative increase in the ketamine group was stable across sexes and not predicted by age, BMI, smoking, alcohol or drug use, and contraception. Our results describe aftereffects of sub-anesthetic ketamine administration on blood coagulation parameters, which should be considered especially when targeting psychiatric populations with relevant clinical comorbidities.

What is the risk-benefit ratio of long-term antipsychotic treatment in people with schizophrenia?

The long-term benefit-to-risk ratio of sustained antipsychotic treatment for schizophrenia has recently been questioned. In this paper, we critically examine the literature on the long-term efficacy and effectiveness of this treatment. We also review the evidence on the undesired effects, the impact on physical morbidity and mortality, as well as the neurobiological correlates of chronic exposure to antipsychotics. Finally, we summarize factors that affect the risk-benefit ratio. There is consistent evidence supporting the efficacy of antipsychotics in the short term and mid term following stabilization of acute psychotic symptoms. There is insufficient evidence supporting the notion that this effect changes in the long term. Most, but not all, of the long-term cohort studies find a decrease in efficacy during chronic treatment with antipsychotics. However, these results are inconclusive, given the extensive risk of bias, including increasing non-adherence. On the other hand, long-term studies based on national registries, which have lower risk of bias, find an advantage in terms of effectiveness during sustained antipsychotic treatment. Sustained antipsychotic treatment has been also consistently associated with lower mortality in people with schizophrenia compared to no antipsychotic treatment. Nevertheless, chronic antipsychotic use is associated with metabolic disturbance and tardive dyskinesia. The latter is the clearest undesired clinical consequence of brain functioning as a potential result of chronic antipsychotic exposure, likely from dopaminergic hypersensitivity, without otherwise clear evidence of other irreversible neurobiological changes. Adjunctive psychosocial interventions seem critical for achieving recovery. However, overall, the current literature does not support the safe reduction of antipsychotic dosages by 50% or more in stabilized individuals receiving adjunctive psychosocial interventions. In conclusion, the critical appraisal of the literature indicates that, although chronic antipsychotic use can be associated with undesirable neurologic and metabolic side effects, the evidence supporting its long-term efficacy and effectiveness, including impact on life expectancy, outweighs the evidence against this practice, overall indicating a favorable benefit-to-risk ratio. However, the finding that a minority of individuals diagnosed initially with schizophrenia appear to be relapse free for long periods, despite absence of sustained antipsychotic treatment, calls for further research on patient-level predictors of positive outcomes in people with an initial psychotic presentation.

10-year CVD risk in Han Chinese mainland patients with schizophrenia

People with schizophrenia have a shortened life expectancy, with cardiovascular disease (CVD) being the primary contributor to this excessive mortality. A total of 466 inpatients with schizophrenia and 507 healthy community controls in the Chinese mainland were recruited in this study. Sociodemographic information, medical history, and smoking history were recorded. In addition, total cholesterol (TC), fasting blood glucose (FBG), triglycerides (TG), and high-destiny lipoprotein cholesterol (HDL-C) were analyzed. The 10-year CVD risk was significantly higher in patients with schizophrenia compared with healthy controls. Male schizophrenia patients had significantly higher Framingham risk scores (FRS) than the females. Patients with schizophrenia carried significantly greater risk factors of CVD; body-mass index (BMI), TG and smoking prevalence were significantly higher than in the health community controls, while FBG and HDL-C were on the contrary. Smoking was significantly associated with FRS among schizophrenia inpatients. Collectively, these results suggest that Han Chinese mainland patients with schizophrenia harbor a high 10-year CVD risk when compared with healthy controls, especially in males. CVD in schizophrenia patients requires greater attention by clinicians and researchers.

Association of Efficacy of Resistance Exercise Training With Depressive Symptoms: Meta-analysis and Meta-regression Analysis of Randomized Clinical Trials

IMPORTANCE

The physical benefits of resistance exercise training (RET) are well documented, but less is known regarding the association of RET with mental health outcomes. To date, no quantitative synthesis of the antidepressant effects of RET has been conducted.

OBJECTIVES

To estimate the association of efficacy of RET with depressive symptoms and determine the extent to which logical, theoretical, and/or prior empirical variables are associated with depressive symptoms and whether the association of efficacy of RET with depressive symptoms accounts for variability in the overall effect size.

DATA SOURCES

Articles published before August 2017, located using Google Scholar, MEDLINE, PsycINFO, PubMed, and Web of Science.

STUDY SELECTION

Randomized clinical trials included randomization to RET (n = 947) or a nonactive control condition (n = 930).

DATA EXTRACTION AND SYNTHESIS

Hedges d effect sizes were computed and random-effects models were used for all analyses. Meta-regression was conducted to quantify the potential moderating influence of participant and trial characteristics.

MAIN OUTCOMES AND MEASURES

Randomized clinical trials used validated measures of depressive symptoms assessed at baseline and midintervention and/or postintervention. Four primary moderators were selected a priori to provide focused research hypotheses about variation in effect size: total volume of prescribed RET, whether participants were healthy or physically or mentally ill, whether or not allocation and/or assessment were blinded, and whether or not the RET intervention resulted in a significant improvement in strength.

RESULTS

Fifty-four effects were derived from 33 randomized clinical trials involving 1877 participants. Resistance exercise training was associated with a significant reduction in depressive symptoms with a moderate-sized mean effect ∆ of 0.66 (95% CI, 0.48-0.83; z = 7.35; P < .001). Significant heterogeneity was indicated (total Q = 216.92, df = 53; P < .001; I2 = 76.0% [95% CI, 72.7%-79.0%]), and sampling error accounted for 32.9% of observed variance. The number needed to treat was 4. Total volume of prescribed RET, participant health status, and strength improvements were not significantly associated with the antidepressant effect of RET. However, smaller reductions in depressive symptoms were derived from randomized clinical trials with blinded allocation and/or assessment.

CONCLUSIONS AND RELEVANCE

Resistance exercise training significantly reduced depressive symptoms among adults regardless of health status, total prescribed volume of RET, or significant improvements in strength. Better-quality randomized clinical trials blinding both allocation and assessment and comparing RET with other empirically supported treatments for depressive symptoms are needed.

Antipsychotic drugs versus cognitive behavioural therapy versus a combination of both in people with psychosis: a randomised controlled pilot and feasibility study

BACKGROUND

Little evidence is available for head-to-head comparisons of psychosocial interventions and pharmacological interventions in psychosis. We aimed to establish whether a randomised controlled trial of cognitive behavioural therapy (CBT) versus antipsychotic drugs versus a combination of both would be feasible in people with psychosis.

METHODS

We did a single-site, single-blind pilot randomised controlled trial in people with psychosis who used services in National Health Service trusts across Greater Manchester, UK. Eligible participants were aged 16 years or older; met ICD-10 criteria for schizophrenia, schizoaffective disorder, or delusional disorder, or met the entry criteria for an early intervention for psychosis service; were in contact with mental health services, under the care of a consultant psychiatrist; scored at least 4 on delusions or hallucinations items, or at least 5 on suspiciousness, persecution, or grandiosity items on the Positive and Negative Syndrome Scale (PANSS); had capacity to consent; and were help-seeking. Participants were assigned (1:1:1) to antipsychotics, CBT, or antipsychotics plus CBT. Randomisation was done via a secure web-based randomisation system (Sealed Envelope), with randomised permuted blocks of 4 and 6, stratified by gender and first episode status. CBT incorporated up to 26 sessions over 6 months plus up to four booster sessions. Choice and dose of antipsychotic were at the discretion of the treating consultant. Participants were followed up for 1 year. The primary outcome was feasibility (ie, data about recruitment, retention, and acceptability), and the primary efficacy outcome was the PANSS total score (assessed at baseline, 6, 12, 24, and 52 weeks). Non-neurological side-effects were assessed systemically with the Antipsychotic Non-neurological Side Effects Rating Scale. Primary analyses were done by intention to treat; safety analyses were done on an as-treated basis. The study was prospectively registered with ISRCTN, number ISRCTN06022197.

FINDINGS

Of 138 patients referred to the study, 75 were recruited and randomly assigned-26 to CBT, 24 to antipsychotics, and 25 to antipsychotics plus CBT. Attrition was low, and retention high, with only four withdrawals across all groups. 40 (78%) of 51 participants allocated to CBT attended six or more sessions. Of the 49 participants randomised to antipsychotics, 11 (22%) were not prescribed a regular antipsychotic. Median duration of total antipsychotic treatment was 44·5 weeks (IQR 26-51). PANSS total score was significantly reduced in the combined intervention group compared with the CBT group (-5·65 [95% CI -10·37 to -0·93]; p=0·019). PANSS total scores did not differ significantly between the combined group and the antipsychotics group (-4·52 [95% CI -9·30 to 0·26]; p=0·064) or between the antipsychotics and CBT groups (-1·13 [95% CI -5·81 to 3·55]; p=0·637). Significantly fewer side-effects, as measured with the Antipsychotic Non-neurological Side Effects Rating Scale, were noted in the CBT group than in the antipsychotics (3·22 [95% CI 0·58 to 5·87]; p=0·017) or antipsychotics plus CBT (3·99 [95% CI 1·36 to 6·64]; p=0·003) groups. Only one serious adverse event was thought to be related to the trial (an overdose of three paracetamol tablets in the CBT group).

INTERPRETATION

A head-to-head clinical trial of CBT versus antipsychotics versus the combination of the two is feasible and safe in people with first-episode psychosis.

FUNDING

National Institute for Health Research.

Cardiometabolic risk factors, physical activity and psychiatric status in patients in long-term psychiatric inpatient departments

PURPOSE

Cardiovascular diseases are a major cause for the markedly reduced life expectancy in people with severe mental illness (SMI). Hospital departments should provide adequate prevention of cardiometabolic risk by optimizing prevention and treatment. Characteristics of cardiometabolic risk factors in inpatients are still not well known. We aimed to describe the status of cardiometabolic risk factors in inpatients with SMI and identify associations with psychiatric status and treatment.

METHODS

A cross sectional descriptive study of inpatients with SMI from long term psychosis treatment wards in South Eastern Norway was performed. Comprehensive assessments of cardiometabolic risk factors, physical activity, lifestyle habits, symptoms, life satisfaction and treatment were made. Associations and potential prognostic factors were analyzed using linear and logistic regressions.

RESULTS

A total of 83 patients were included in the study, but many individual datasets were incomplete. Over half of the subjects had unhealthy eating habits. Obesity (class 1-3) was found in 44%, 23% had elevated fasting triglycerides, 26% had elevated blood pressure and 78% smoked daily. Low levels of physical activity were significantly associated with higher levels of depression (p = .007). A nominal increase in cardiometabolic risk factors was found for olanzapine and clozapine users.

CONCLUSION

Inpatients in long term psychosis treatment wards have alarmingly high cardiometabolic risk. Level of physical activity was associated with both psychiatric and somatic health. Focus on lifestyle and somatic health should be an integral part of the treatment for hospitalized SMI patients.

Psychosocial factors associated with physical activity behavior among patients with psychosis

INTRODUCTION

Although physical activity helps to improve functioning and reduce the symptoms of mental illness, physical inactivity remains common in the mental illness population. This study aims to explore the associations between theoretical constructs in relation to physical activity behavior based on psychological theories to examine reasons for physical inactivity in psychosis population.

METHODS

One hundred and eighty one Chinese outpatients diagnosed with psychotic disorders were recruited for this cross-sectional study. Sociodemographic data and responses to questionnaires measuring self-efficacy, decisional balance, processes of change, and stages of change on physical activity habit were collected.

RESULTS

Ninety three subjects (51.4%) had the intention to engage in regular physical activity within the next six months. Significant differences were found in self-efficacy, pros of decisional balance and processes of change across the stages of change. Moreover, overall classification accuracy was 60.8% across the stages of change.

CONCLUSIONS

This study supports self-efficacy, pros of decisional balance and processes of change as useful factors in understanding physical activity behavior among patients with psychosis. Future promotions of regular physical activity can focus on improving self-efficacy, emphasizing on the benefits of regular physical activity and facilitating cognitive and behavior strategies from processes of change.

Sedentary behaviour, physical activity, cardiorespiratory fitness and cardiometabolic risk in psychosis: The PsychiActive project

This study aimed to explore the possible independent associations of sedentary behaviour (SB), physical activity (PA), and cardiorespiratory fitness (CRF) with clustered (CCRS) and individual cardiometabolic risk (waist circumference [waist], systolic/diastolic blood pressure, triglycerides, high-density lipoprotein-cholesterol, and fasting blood glucose) in patients with psychosis. In 43 outpatients with psychosis (mean age±SD: 42.3±8.5years, 86% men), SB and light, moderate-to-vigorous, and total PA were measured with the SenseWear Pro3 Armband, and CRF with the 6-minute walking test. Multiple linear regression models adjusted for multiple confounders were applied. High SB, low PA and low CRF levels were associated with an unfavourable cardiometabolic risk profile (increased presence of metabolic syndrome and number of cardiometabolic abnormalities, as well as worse values and elevated presence of abnormalities for all individual cardiometabolic risk factors). SB was associated with CCRS, number of cardiometabolic abnormalities, waist, and fasting blood glucose (all p<0.05). After adjusting for PA and CRF, waist and fasting blood glucose remained significant. Light PA was associated with waist, moderate-to-vigorous PA with CCRS, and total PA with CCRS and waist (all p<0.05). These results became non-significant after adjusting for SB and CRF. CRF was associated with CCRS, waist, and systolic blood pressure (all p<0.05). The associations with CCRS and waist remained significant after adjusting for SB and PA. Together, these results suggest the importance of considering SB and CRF, regardless PA, in the prevention and treatment of cardiometabolic disorders among patients with psychosis.

N-acetylcysteine for major mental disorders: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This systematic review and meta-analysis of randomized controlled trials (RCTs) examined the efficacy and safety of adjunctive N-acetylcysteine (NAC), an antioxidant drug, in treating major depressive disorder (MDD), bipolar disorder, and schizophrenia.

METHODS

The PubMed, Cochrane Library, PsycINFO, CNKI, CBM, and WanFang databases were independently searched and screened by two researchers. Standardized mean differences (SMDs), risk ratios, and their 95% confidence intervals (CIs) were computed.

RESULTS

Six RCTs (n = 701) of NAC for schizophrenia (three RCTs, n = 307), bipolar disorder (two RCTs, n = 125), and MDD (one RCT, n = 269) were identified and analyzed as separate groups. Adjunctive NAC significantly improved total psychopathology (SMD = -0.74, 95% CI: -1.43, -0.06; I² = 84%, P = 0.03) in schizophrenia, but it had no significant effect on depressive and manic symptoms as assessed by the Young Mania Rating Scale in bipolar disorder and only a small effect on major depressive symptoms. Adverse drug reactions to NAC and discontinuation rates between the NAC and control groups were similar across the three disorders.

CONCLUSIONS

Adjunctive NAC appears to be a safe treatment that has efficacy for schizophrenia, but not for bipolar disorder or MDD. Further higher quality RCTs are warranted to determine the role of adjunctive NAC in the treatment of major psychiatric disorders.

Risk of gastrointestinal Hypomotility in schizophrenia and schizoaffective disorder treated with antipsychotics: A retrospective cohort study

OBJECTIVE

The risk of gastrointestinal hypomotility (GIHM) with the use of antipsychotic medications in patients with schizophrenia remains inadequately recognized. The aim of this study was to explore the incidence of GIHM and its risks in patients with schizophrenia treated with antipsychotics.

METHODS

We conducted a retrospective cohort study using the National Health Insurance Research Database. We identified adult (≥ 20years of age) patients with a first-time diagnosis of schizophrenia or schizoaffective disorder in the Registry for Catastrophic Illness Patients during the period from 2001 to 2011. Each subject in the cohort was followed until their corresponding diagnosis of GIHM was made, until the time of death, or to December 31, 2012. The incidence rates of each outcome were calculated. Cox proportional hazards regression with time-dependent covariates for antipsychotics use was employed to evaluate the associations between different types of antipsychotics and the risk of GIHM.

RESULTS

Our study found that the incidence densities of constipation, ileus, and ischemic bowel disease were 42.5, 4.4, and 0.1 per 1000 person-years. In terms of the risk of hypomotility with the use of antipsychotics, clozapine and quetiapine were significant in developing constipation, with a hazard ratio of 2.15 and 1.34, respectively. High-potency first-generation antipsychotics and clozapine were also significant in the occurrence of ileus, with a hazard ratio of 1.30 and 1.95, respectively. Similar associations were found in an anticholinergic agent subgroup analysis.

CONCLUSION

Patients receiving antipsychotics such as high-potency first-generation antipsychotics, clozapine, or quetiapine should undergo proper evaluation and intervention to minimize the disease burden and life-threatening outcomes of treatment.

Atypical antipsychotics, insulin resistance and weight; a meta-analysis of healthy volunteer studies

Atypical antipsychotics increase the risk of diabetes and cardiovascular disease through their side effects of insulin resistance and weight gain. The populations for which atypical antipsychotics are used carry a baseline risk of metabolic dysregulation prior to medication which has made it difficult to fully understand whether atypical antipsychotics cause insulin resistance and weight gain directly. The purpose of this work was to conduct a systematic review and meta-analysis of atypical antipsychotic trials in healthy volunteers to better understand their effects on insulin sensitivity and weight gain. Furthermore, we aimed to evaluate the occurrence of insulin resistance with or without weight gain and with treatment length by using subgroup and meta-regression techniques. Overall, the meta-analysis provides evidence that atypical antipsychotics decrease insulin sensitivity (standardized mean difference=-0.437, p<0.001) and increase weight (standardized mean difference=0.591, p<0.001) in healthy volunteers. It was found that decreases in insulin sensitivity were potentially dependent on treatment length but not weight gain. Decreases in insulin sensitivity occurred in multi-dose studies <13days while weight gain occurred in studies 14days and longer (max 28days). These findings provide preliminary evidence that atypical antipsychotics cause insulin resistance and weight gain directly, independent of psychiatric disease and may be associated with length of treatment. Further, well-designed studies to assess the co-occurrence of insulin resistance and weight gain and to understand the mechanisms and sequence by which they occur are required.

Association of Protein Kinase B (AKT) DNA Hypermethylation with Maintenance Atypical Antipsychotic Treatment in Patients with Bipolar Disorder

STUDY OBJECTIVE

Atypical antipsychotics cause insulin resistance that leads to an increased risk of diabetes mellitus and cardiovascular disease. Skeletal muscle is the primary tissue for uptake of glucose, and its dysfunction is considered one of the primary defects in the development of insulin resistance. Protein kinase B (AKT) plays an important role in overall skeletal muscle health and glucose uptake into the muscle. The objective of this study was to measure AKT isoform-specific gene methylation differences in the skeletal muscle of patients with bipolar disorder treated with atypical antipsychotic or mood stabilizer maintenance therapy.

DESIGN

Cross-sectional observational study.

SETTING

Clinical research services center at an academic center.

PATIENTS

Thirty patients with a confirmed diagnosis of bipolar disorder who were treated with either an atypical antipsychotic (16 patients) or mood stabilizer (14 patients) at a consistent dose for at least 3 months.

INTERVENTIONS

A fasting skeletal muscle biopsy was performed in the vastus lateralis in each patient. Patients also underwent fasting blood sample collection and a standard 75-g oral glucose tolerance test.

MEASUREMENTS AND MAIN RESULTS

Skeletal muscle DNA methylation near the promoter region for three genes, AKT1, AKT2, and AKT3, was measured by methylation-sensitive high-resolution melting. Gene methylation was analyzed based on atypical antipsychotic versus mood stabilizer maintenance therapy. Associations between gene methylation, insulin resistance, and glucose tolerance were also analyzed. In patients treated with atypical antipsychotics, AKT1 and AKT2 methylation was increased compared with patients treated with mood stabilizers (p=0.03 and p=0.02, respectively). In addition, for patients receiving atypical antipsychotics, a positive trend for AKT2 hypermethylation with increasing insulin resistance was observed, whereas for patients receiving mood stabilizers, a trend for decreased AKT2 methylation with increasing insulin resistance was observed.

CONCLUSION

Overall, our findings suggest that the AKT gene is differentially methylated in the skeletal muscle of patients taking atypical antipsychotics or mood stabilizer maintenance therapy. These results may direct future approaches to reduce the harmful adverse effects of atypical antipsychotic treatment.

Systemic low-grade inflammation in post-traumatic stress disorder: a systematic review

Studies examining post-traumatic stress disorder (PTSD) have either emphasized a relationship between PTSD and a systemically pro-inflammatory state or identified a link between PTSD and chronic disease. The aim of this study was to evaluate the evidence for a relationship between individuals with PTSD and systemic low-grade inflammation that has been proposed to underlie chronic disease development in this population. The authors conducted a systematic review of the literature (January 2006 to April 2017) in accordance with the PRISMA statement in the following four databases: PubMed, MEDLINE, PsycINFO, and SPORTDiscus with Full Text. The search strategy was limited to articles published in peer-reviewed journals and to human studies. Nine studies measuring systemic inflammation and discussing its role in chronic disease development were selected for inclusion in this review. The association between markers of systemic inflammation and PTSD was evaluated by the measurement of a variety of systemic inflammatory markers including acute-phase proteins, complement proteins, pro- and anti-inflammatory cytokines, natural killer cells, and white blood cells. In general, systemic inflammatory biomarkers were elevated across the studies in the PTSD groups. There is evidence that PTSD is underpinned by the presence of a systemic low-grade inflammatory state. This inflammation may be the mechanism associated with increased risk for chronic disease in the PTSD population. From this, future research should focus on interventions that help to reduce inflammation, such as exercise.

Visceral adipose tissue in patients with severe mental illness

Background Severe mental illnesses (SMIs), i.e. major depression, schizophrenia and bipolar disorder, are associated with an elevated risk for the development of type-2 diabetes mellitus and cardiovascular disorders. Several factors have been associated with increased cardiometabolic morbidity and mortality in SMI, including lifestyle factors (smoking, inactivity, unhealthy diet), endocrine and immunologic alterations; however, the underlying mechanisms remain to be fully uncovered. It is now well accepted that visceral adipose tissue (VAT) promotes the development of cardiometabolic disorders, at least in part by inflammatory and metabolic functions. Methods This paper reviews studies concerning VAT, with special focus on intra-abdominal and pericardial adipose tissue, in SMI. Results In patients with SMI, several studies have been performed concerning VAT. Most of these studies reported alterations of VAT particularly in patients with major depression and schizophrenia, independent of body weight and body mass index. Some of the studies also reported an increased cardiometabolic risk. Conclusion Patients with SMI are at increased risk of developing cardiometabolic disorders, and display increased amounts of VAT. As studies so far were mainly performed on patients before the onset of cardiometabolic disorders, VAT may serve as a biomarker for patients with SMI to assess cardiometabolic risks beyond established risk scores. Further, interventions aiming at reducing VAT in SMI are highly recommended in long-term multimodal treatment plans.

Relationship between sedentary behavior and depression: A mediation analysis of influential factors across the lifespan among 42,469 people in low- and middle-income countries

BACKGROUND

Sedentary behavior (SB) is associated with diabetes, cardiovascular disease and low mood. There is a paucity of multi-national research investigating SB and depression, particularly among low- and middle-income countries. This study investigated the association between SB and depression, and factors which influence this.

METHODS

Cross-sectional data were analyzed from the World Health Organization's Study on Global Ageing and Adult Health. Depression was based on the Composite International Diagnostic Interview. The association between depression and SB (self-report) was estimated by multivariable linear and logistic regression analyses. Mediation analysis was used to identify influential factors.

RESULTS

A total of 42,469 individuals (50.1% female, mean 43.8 years) were included. People with depression spent 25.6 (95%CI8.5-42.7) more daily minutes in SB than non-depressed participants. This discrepancy was most notable in adults aged ≥ 65y (35.6min more in those with depression). Overall, adjusting for socio-demographics and country, depression was associated with a 1.94 (95%CI1.31-2.85) times higher odds for high SB (i.e., ≥ 8h/day). The largest proportion of the SB-depression relationship was explained by mobility limitations (49.9%), followed by impairments in sleep/energy (43.4%), pain/discomfort (31.1%), anxiety (30.0%), disability (25.6%), cognition (16.1%), and problems with vision (11.0%). Other health behaviors (physical activity, alcohol consumption, smoking), body mass index, and social cohesion did not influence the SB-depression relationship.

CONCLUSION

People with depression are at increased risk of engaging in high levels of SB. This first multi-national study offers potentially valuable insight for a number of hypotheses which may influence this relationship, although testing with longitudinal studies is needed.

Bipolar disorders

Bipolar disorders are chronic and recurrent disorders that affect >1% of the global population. Bipolar disorders are leading causes of disability in young people as they can lead to cognitive and functional impairment and increased mortality, particularly from suicide and cardiovascular disease. Psychiatric and nonpsychiatric medical comorbidities are common in patients and might also contribute to increased mortality. Bipolar disorders are some of the most heritable psychiatric disorders, although a model with gene-environment interactions is believed to best explain the aetiology. Early and accurate diagnosis is difficult in clinical practice as the onset of bipolar disorder is commonly characterized by nonspecific symptoms, mood lability or a depressive episode, which can be similar in presentation to unipolar depression. Moreover, patients and their families do not always understand the significance of their symptoms, especially with hypomanic or manic symptoms. As specific biomarkers for bipolar disorders are not yet available, careful clinical assessment remains the cornerstone of diagnosis. The detection of hypomanic symptoms and longtudinal clinical assessment are crucial to differentiate a bipolar disorder from other conditions. Optimal early treatment of patients with evidence-based medication (typically mood stabilizers and antipsychotics) and psychosocial strategies is necessary.

The Physical Health of Individuals Receiving Antipsychotic Medication: A Qualitative Inquiry on Experiences and Needs

Individuals with a mental illness are reported to have a reduced life expectancy and a greater risk of being affected by preventable physical illnesses such as cardiovascular disease and Type 2 diabetes. This inquiry sought to identify the physical health beliefs, experiences and needs of individuals with mental health problems in receipt of antipsychotic medication who live in the community. A qualitative inquiry was undertaken using three focus groups in a community mental health service in Ireland with 21 participants with mental health problems who were treated with antipsychotic medication. The participants were clear about the importance of good physical health as well as good mental health. They disliked the adverse effects of antipsychotic medication and experienced many barriers in accessing general practitioners/primary care services. They also preferred to receive health advice and self-management advice from the mental health services. The participants in this study were aware of the need to engage in health protective behaviours but were often overwhelmed by their comorbid health issues and the organizational and communication barriers in accessing their general practitioners.

Poor adherence to hepatocellular carcinoma surveillance: A systematic review and meta-analysis of a complex issue

BACKGROUND & AIMS

Hepatocellular carcinoma (HCC) surveillance is associated with improved outcomes and long-term survival. Our goal is to evaluate adherence rates to HCC surveillance.

METHODS

We performed a systematic search of the PubMed and Scopus databases and abstract search of relevant studies from recent major liver meetings. All searches and data extraction were performed independently by two authors. Analysis was via random-effects models and multivariate meta-regression.

RESULTS

A total of 22 studies (n = 19 511) met inclusion criteria (original non-interventional studies with defined cirrhosis or chronic hepatitis B or chronic hepatitis C with advanced fibrosis populations, and surveillance tests and intervals). Overall adherence rate was 52% (95% CI 38%-66%). Adherence was significantly higher in cirrhotic patients compared to chronic hepatitis B and other high-risk patients, in European compared to North American studies, in less than 12-month compared to yearly surveillance intervals, and in prospective compared to retrospective studies (71%, 95% CI 64%-78% vs 39%, 95% CI 26%-51%, P < .001). The between-study heterogeneity of all above analyses was significant (P < .001). Only the study design (retrospective vs prospective cohort) had statistical significance in a multivariate meta-regression model (P < .05) and could account for some of the differences above.

CONCLUSIONS

Overall adherence rate to HCC surveillance was suboptimal at 52% with no significant differences by liver disease aetiology or study location in multivariate meta-regression analysis. Further research and educational efforts are needed to improve the current rate of HCC surveillance.

Physical activity correlates among people with psychosis: Data from 47 low- and middle-income countries

BACKGROUND

People with schizophrenia engage in low levels of physical activity (PA). However, few large-scale studies have investigated the factors that may influence PA participation in individuals with psychosis and data from low- and middle-income countries (LMICs) is especially scarce. Thus, we investigated PA correlates in a large sample of people with a psychosis diagnosis across 47 LMICs.

METHODS

Cross-sectional data from the World Health Survey, restricting to those with a self-reported lifetime diagnosis of schizophrenia/psychotic disorder, was analyzed. PA was assessed by the International Physical Activity Questionnaire (IPAQ) and participants were dichotomized into those that do and do not (low PA) meet the minimum recommended PA weekly targets (≥150min). A range of socio-demographic, health behavior, and mental and physical health variables were examined using random effects logistic regression.

RESULTS

Overall 2407 people (mean 42.0years, 41.5% males) with schizophrenia/psychosis were included. The prevalence of low PA was 39.2% (95%CI=37.0%-41.2%). Male sex (odds ratio (OR)=1.33), increasing age, unemployment (vs. employed OR=2.50), urban setting (vs. rural OR=1.75), inadequate fruit consumption (vs. adequate fruit intake OR=3.03), depression (OR=1.33), sleep/energy disturbance, and mobility limitations were significantly associated with low PA. Marital status, education, wealth, smoking, vegetable and alcohol consumption, anxiety, cognition, pain, and chronic medical conditions were not significant correlates.

CONCLUSION

PA is influenced by a range of factors among people with psychosis. These correlates should be considered in interventions aiming to facilitate PA in psychotic individuals living in LMICs.

Meta-analysis of the Efficacy and Safety of Adjunctive Rosuvastatin for Dyslipidemia in Patients with Schizophrenia

Background

Metabolic syndrome in patients with schizophrenia is a major health concern. The efficacy and safety of adjunctive rosuvastatin in treating dyslipidemia were controversial.

Aims

To assess the efficacy and safety of adjunctive rosuvastatin for dyslipidemia in patients with schizophrenia.

Methods

We systematically searched for relevant controlled clinical trials from the following databases: PubMed, PsycINFO, Cochrane Library, China Knowledge Network, WanFang Database and Chinese Biomedical Database up to September 28, 2017. Standardized mean difference (SMD) and risk ratio (RR) along with their 95% confidence intervals (CIs) were calculated. The quality of the included studies was assessed using the Cochrane risk of bias assessment tool. The GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) system recommendation grading method was used as the reference standard.

Results

Four studies (n=274) comparing rosuvastatin (n=138) and control (n=136) groups were identified and analyzed. Adjunctive rosuvastatin showed greater efficacy than control group in low density lipoprotein cholesterol (LDL-C) [4 trials, n=272, SMD: -1.31 (95%CI: -1.93, -0.70), I²=81%], total cholesterol (2 trials, n=164, SMD: -2.00 (95%CI: -2.79, -1.21); I²=76%) and triglycerides (2 trials, n=164, SMD: -1.05 (95%CI: -1.38, -0.72); I²=0%), but not in high density lipoprotein cholesterol (2 trials, n=164, SMD: 0.14 (95%CI: -0.16, 0.45); I²=0%). After removing one study without randomization for LDL-C, significance remained [3 trials, n=172, SMD:-1.07 (95%CI: -1.60, -0.53); I²=63%]. No significant group differences regarding body weight (3 trials, n=208, SMD: -0.40 (95%CI:-1.29, 0.49); I²=89%), body mass index (2 trials, n=164, SMD: -0.34 (95%CI: -1.23, 0.56); I²=87%), waist circumference (3 trials, n=208, SMD): -0.43 (95%CI: -1.31, 0.46); I²=89%), and fasting glucose (4 trials, n=272, SMD: -0.25 (95%CI: -0.65, 0.15); I²=62%) were observed. The adverse reactions and any cause discontinuation rate were similar between the groups. According to the GRADE approach, the evidence levels of main outcomes were rated as “very low” (35.3%) to “low” (64.7%). Of them, the primary outcome (LDL-C) was rated as “very low “.

Conclusions

The data available on the effectiveness and safety of adjunctive rosuvastatin in treating dyslipidemia for patients with schizophrenia is insufficient to come to a definitive interpretation about its efficacy and safety. Further high quality RCTs with extended treatment duration are warranted to confirm the findings.

Review registration

PROSPERO: CRD42017078230

Improving the health of mental health staff through exercise interventions: a systematic review

BACKGROUND

Exercise interventions are efficacious in reducing cardiometabolic risk and improving symptoms in people with severe mental illness, yet evidence guiding the implementation and scalability of such efforts is lacking. Given increasing efforts to address the disparity in physical health outcomes facing people with a mental illness, novel approaches to increasing adoption of effective interventions are required. Exercise interventions targeting mental health staff may improve staff health while also creating more positive attitudes towards the role of lifestyle interventions for people experiencing mental illness.

AIMS

We aimed to determine the feasibility, acceptability and effectiveness of exercise interventions delivered to staff working in mental health services.

METHOD

A systematic review was conducted from database inception, until November 2017. Studies recruiting staff participants to receive an exercise intervention were eligible for inclusion.

RESULTS

Five studies met the inclusion criteria. Physical health interventions for mental health staff were feasible and acceptable with low dropout rates. Reductions in anthropometric measures and work-related stress were reported.

CONCLUSIONS

Limited evidence suggests that exercise interventions targeting mental health staff are feasible and acceptable. Further research is required to determine the efficacy of such interventions and the impact such strategies may have on staff culture and patient outcomes.

Clinical risk factors for the development of tardive dyskinesia

BACKGROUND

Tardive dyskinesia (TD) is a severe condition that can affect almost 1 out of 4 patients on current or previous antipsychotic treatment, including both first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs). While two novel vesicular monoamine transporter inhibitors, deutetrabenazine and valbenazine, have shown acute efficacy for TD, the majority of patients do not remit, and TD appears to recur once treatment is withdrawn. Hence, prevention of TD remains a crucial goal.

METHODS

We provide a clinically oriented overview of risk factors for TD, dividing them into patient-, illness- and treatment-related variables, as well as nonmodifiable and modifiable factors.

RESULTS

Unmodifiable patient-related and illness-related risk factors for TD include older age, female sex, white and African descent, longer illness duration, intellectual disability and brain damage, negative symptoms in schizophrenia, mood disorders, cognitive symptoms in mood disorders, and gene polymorphisms involving antipsychotic metabolism and dopamine functioning. Modifiable comorbidity-related and treatment-related factors include diabetes, smoking, and alcohol and substance abuse, FGA vs SGA treatment, higher cumulative and current antipsychotic dose or antipsychotic plasma levels, early parkinsonian side effects, anticholinergic co-treatment, akathisia, and emergent dyskinesia.

DISCUSSION

Clinicians using dopamine antagonists need to consider risk factors for TD to minimize TD and its consequences.

Increased All-Cause Mortality by Antipsychotic Drugs: Updated Review and Meta-Analysis in Dementia and General Mental Health Care

It is almost ten years since the Banerjee 2009 report established that inappropriate prescribing of antipsychotics in the elderly was occurring in the UK and such patients had an 85% increased risk of adverse events and greater mortality. This report was a critical analysis addressing the outcomes of treatment practices for dementia in UK patients and globally, aimed at reducing prescribing of antipsychotic drugs for dementia. Since 2009, many significant studies worldwide (including several more recent large retrospective studies) provide more extensive longitudinal data for the adverse impacts of antipsychotic drugs in dementia. We have used the data in these studies including from over 380,000 dementia patients, with 85,069 prescribed antipsychotic agents as well as from 359,235 non-dementia antipsychotic drug users to provide an up-dated meta-analysis. This is the first meta-analysis to include evidence from general mental health studies showing that antipsychotic drugs precipitate excessive mortality across the spectrum. Prescribing of antipsychotic drugs for dementia or for other mental health care should be avoided and alternative means sought for handling behavioral disorders of such patients.

Correlates of physical activity among depressed older people in six low-income and middle-income countries: A community-based cross-sectional study

OBJECTIVE

Despite the benefits of physical activity (PA) in older people with depression, many do not comply with the International PA guidelines. Thus, we investigated what factors influence PA participation among 915 community-dwelling older adults (aged ≥65 years) with depression in 6 low-income and middle-income countries (LMICs).

METHODS

Cross-sectional data were analyzed from the World Health Organization's Study on Global Ageing and Adult Health. The sample was restricted to those with DSM-IV depression or receiving depression treatment in the last 12 months. PA was assessed by the Global Physical Activity Questionnaire. Participants were dichotomized into low (ie, not meeting 150 minutes of moderate PA per week) and moderate-to-high physically active groups. Associations between PA and a range of correlates were examined using multivariable logistic regressions.

RESULTS

The prevalence of low PA was 40.4% (95%CI = 34.8%-46.1%). After adjusting for age, sex, and country, larger household size and unemployment were significant sociodemographic correlates of low PA. Former smoking (vs never), anxiety, mild cognitive impairment (MCI), lower body mass index, bodily pain, asthma, chronic back pain, chronic obstructive pulmonary disease, hearing problems, stroke, slow gait, poor self-rated health, higher levels of disability, and lower levels of social cohesion were identified as significant negative correlates of PA.

CONCLUSIONS

The current data provide guidance for future interventions across LMICs to assist older people with depression engage in regular PA. The promotion of social cohesion may increase the efficacy of future public health initiatives, while from a clinical perspective, somatic co-morbidities, MCI, pain, and slow gait need to be considered.

Adherence to physical activity recommendations and physical and mental health risk in people with severe mental illness in Uganda

This study investigated cardio-metabolic risk factors among patients with severe mental illness who do or do not meet the recommendations of 150min per week of physical activity. A secondary aim was to assess whether those that do meet the recommendations report lower levels of mental health symptoms. 107 (60♀) Ugandan in- and outpatients (mean age=34.4 ± 9.7 years) with severe mental illness (depression=7, bipolar disorder=55, schizophrenia=45) completed the Physical Activity Vital Sign (PAVS) method and Brief Symptoms Inventory -18. Participants were also screened for abdominal obesity (waist circumference>90cm), overweight (body mass index≥25) and hypertension (systolic pressure≥140mmHg and/or diastolic pressure≥90mmHg).48.6% (n = 52) of patients met the physical activity recommendations as assessed by the PAVS method. 41.1% (n = 44) were overweight, 40.2% (n = 43) had abdominal obesity and 23.4% (n = 25) had hypertension. Those who did not meet the physical activity recommendations were significantly older, had a higher BSI-18 somatisation score, and had a higher risk of overweight [relative risk (RR) = 2.88, 95% confidence interval (CI) = 1.59-4.99], abdominal obesity (RR = 1.82, 95%CI = 1.13-2.93), and hypertension (RR = 2.16, 95%CI = 0.99-4.73). The PAVS is a feasible method of assessing physical activity among patients with severe mental illness in a low resource setting. The PAVS may have clinical utility for physical and mental health risk stratification.

Mortality, morbidity and medical resources utilization of patients with schizophrenia: A case-control community-based study

Patients with schizophrenia have higher level of mortality and physical comorbidity compared to control population. However the association to primary-, secondary- and tertiary-medical resources utilization is not clear. We used a retrospective community-based cohort of patients with schizophrenia (n=1389; age 37.53 years, 64.3% males) and, age-, gender-, and socioeconomic status-matched controls (n=4095; age 37.34 years; 64.3% males) who were followed-up for nine years. Mortality rate of patients was almost twice as high as that of matched controls (7% versus 3.8%). Diagnoses of ischemic heart disease and hypertension were more prevalent among controls than patients (8.2% versus 5%, and 21.6% versus 15.8%, respectively). Tertiary medical resources utilization was higher among patients with schizophrenia than control population (mean hospital admissions per year: 0.2 versus 0.12, emergency department visits: 0.48 versus 0.36). Patients that died were more likely to have cardiovascular disease, to be admitted to general hospital and to spend more days in hospital than patients that did not die. There is a discrepancy between lower rates of cardiovascular disease diagnoses but higher rates of mortality and tertiary medical resources utilization among patients with schizophrenia when compared to control population. This may stem from an under-diagnosis and, eventually, under-treatment of these patients.

The pharmacological management of metabolic syndrome

INTRODUCTION

The metabolic syndrome includes a constellation of several well-established risk factors, which need to be aggressively treated in order to prevent overt type 2 diabetes and cardiovascular disease. While recent guidelines for the treatment of individual components of the metabolic syndrome focus on cardiovascular benefits as resulted from clinical trials, specific recent recommendations on the pharmacological management of metabolic syndrome are lacking. The objective of present paper was to review the therapeutic options for metabolic syndrome and its components, the available evidence related to their cardiovascular benefits, and to evaluate the extent to which they should influence the guidelines for clinical practice. Areas covered: A Medline literature search was performed to identify clinical trials and meta-analyses related to the therapy of dyslipidemia, arterial hypertension, glucose metabolism and obesity published in the past decade. Expert commentary: Our recommendation for first-line pharmacological are statins for dyslipidemia, renin-angiotensin-aldosteron system inhibitors for arterial hypertension, metformin or sodium/glucose cotransporter 2 inhibitors or glucagon-like peptide 1 receptor agonists (GLP-1RAs) for glucose intolerance, and the GLP-1RA liraglutide for achieving body weight and waist circumference reduction.

Effects of primary care clinician beliefs and perceived organizational facilitators on the delivery of preventive care to individuals with mental illnesses

Background

Although many studies have documented patient-, clinician-, and organizational barriers/facilitators of primary care among people with mental illnesses, few have examined whether these factors predict actual rates of preventive service use. We assessed whether clinician behaviors, beliefs, characteristics, and clinician-reported organizational characteristics, predicted delivery of preventive services in this population.

Methods

Primary care clinicians (n = 247) at Kaiser Permanente Northwest (KPNW) or community health centers and safety-net clinics (CHCs), in six states, completed clinician surveys in 2014. Using electronic health record data, we calculated preventive care-gap rates for patients with mental illnesses empaneled to survey respondents (n = 37,251). Using separate multi-level regression models for each setting, we tested whether survey responses predicted preventive service care-gap rates.

Results

After controlling for patient-level characteristics, patients of clinicians who reported a greater likelihood of providing preventive care to psychiatrically asymptomatic patients experienced lower care-gap rates (KPNW γ= − .05, p = .041; CHCs γ= − .05, p = .033). In KPNW, patients of female clinicians had fewer care gaps than patients of male clinicians (γ= − .07, p = .011). In CHCs, patients of clinicians who had practiced longer had fewer care gaps (γ= − .004, p = .010), as did patients whose clinicians believed that organizational quality goals facilitate preventive service provision (γ= − .06, p = .006). Case manager availability in CHCs was associated with higher care-gap rates (γ=.06, p = .028).

Conclusions

Clinicians who report they are likely to address preventive concerns when their mentally ill patients present without apparent psychiatric symptoms had patients with fewer care gaps. In CHCs, care quality goals may facilitate preventive care whereas case managers may not.

Electronic supplementary material

The online version of this article (doi: 10.1186/s12875-017-0693-2) contains supplementary material, which is available to authorized users.