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

Intrinsic Therapeutic Link between Recuperative Cerebellar Con-Nectivity and Psychiatry Symptom in Schizophrenia Patients with Comorbidity of Metabolic Syndrome

Components of metabolic syndrome might be predictors of the therapeutic outcome of psychiatric symptom in schizophrenia, whereas clinical results are inconsistent and an intrinsic therapeutic link between weaker psychiatric symptoms and emergent metabolic syndrome remains unclear. This study aims to reveal the relationship and illustrate potential mechanism by exploring the alteration of cerebellar functional connectivity (FC) in schizophrenia patients with comorbidity metabolic syndrome. Thirty-six schizophrenia patients with comorbidity of metabolic syndrome (SCZ-MetS), 45 schizophrenia patients without metabolic syndrome (SCZ-nMetS) and 39 healthy controls (HC) were recruited in this study. We constructed FC map of cerebello-cortical circuit and used moderation effect analysis to reveal complicated relationship among FC, psychiatric symptom and metabolic disturbance. Components of metabolic syndrome were significantly correlated with positive symptom score and negative symptom score. Importantly, the dysconnectivity between cognitive module of cerebellum and left middle frontal gyrus in SCZ-nMetS was recuperative increased in SCZ-MetS, and was significantly correlated with general symptom score. Finally, we observed significant moderation effect of body mass index on this correlation. The present findings further supported the potential relationship between emergence of metabolic syndrome and weaker psychiatric symptom, and provided neuroimaging evidence. The mechanism of intrinsic therapeutic link involved functional change of cerebello-cortical circuit.

Review of Psychotropic Agents Associated with Sialorrhoea, Except Clozapine

INTRODUCTION

Sialorrhoea, or excessive salivation, is common in psychiatric patients. This can be distressing because of its physical and psychosocial complications. Sialorrhoea due to psychotropic drugs has been reported repeatedly in the literature. Clozapine is the antipsychotic most commonly associated with sialorrhoea.

OBJECTIVE

The objective of this review was to examine and discuss the existing literature on all psychotropic drugs associated with sialorrhoea, except clozapine.

METHODS

Google Scholar and PubMed were searched for the literature on psychotropic-induced sialorrhoea. The search terms used were sialorrhoea, antidepressants, antipsychotics, mood stabilizer, and benzodiazepines. Case reports on patients suffering from psychotropic-induced sialorrhoea except clozapine are reviewed in this study.

RESULTS

The pathophysiology behind psychotropic-induced sialorrhoea, the population susceptible to sialorrhoea, and the exact duration from the start of sialorrhoea the drug course to the onset of sialorrhoea are unknown. Also, sialorrhoea is not associated with drug toxicity and is observed even in patients receiving normal doses of psychotropic medications. Treatment involves dose reduction, discontinuation of drugs responsible for the adverse effect, or adding anticholinergic drugs.

CONCLUSION

Sialorrhoea due to clozapine has been reported in the literature. Many other antipsychotics, antidepressants such as sertraline, and other psychotropic drugs such as lithium have also been reported to cause sialorrhoea. No increase in the risk of sialorrhoea was seen in any of the age groups, and no association was found with treatment duration. In cases of lithium-induced sialorrhoea, no relationship was observed between serum levels of lithium and sialorrhoea.

[Mental disorders and diabetes mellitus (Update 2023)]

Psychiatric disorders and psychological problems are common in patients with diabetes mellitus. There is a twofold increase in depression which is associated with suboptimal glycemic control and increased morbidity and mortality. Other psychiatric disorders with a higher incidence of diabetes are cognitive impairment, dementia, disturbed eating behavior, anxiety disorders, schizophrenia, bipolar disorders and borderline personality disorder. The coincidence of mental disorders and diabetes has unfavorable influences on metabolic control and micro- and macroangiopathic complications. Improvement of therapeutic outcome is a challenge in the modern health care system. The intentions behind this position paper are to rise awareness of this special set of problems, to intensify cooperation between involved health care providers and to reduce incidence of diabetes mellitus as well as morbidity and mortality from diabetes in this patient group.

The impact of pharmacological and non-pharmacological interventions on physical health outcomes in people with mood disorders across the lifespan: An umbrella review of the evidence from randomised controlled trials

OBJECTIVE

People with mood disorders have increased risk of comorbid medical diseases versus the general population. It is paramount to identify interventions to improve physical health in this population.

METHODS

Umbrella review of meta-analyses of randomised controlled trials (RCTs) on pharmacological/non-pharmacological interventions for physical health outcomes/intolerability-related discontinuation in mood disorders (any age).

RESULTS

Ninety-seven meta-analyses were included. Among youths, against placebo, in depression, antidepressants/antipsychotics had higher discontinuation rates; in bipolar depression, olanzapine+fluoxetine worsened total cholesterol (TC)/triglycerides/weight gain (WG) (large ES). In adults with bipolar disorder, olanzapine worsened HbA1c/TC/WG (moderate/large ES); asenapine increased fasting glucose (small ES); quetiapine/cariprazine/risperidone induced WG (small/moderate ES). In bipolar depression, lurasidone was metabolically neutral. In depression, psychological interventions improved physical health-related quality of life (PHQoL) (small ES), fasting glucose/HbA1c (medium/large ES); SSRIs improved fasting glucose/HbA1c, readmission for coronary disease, pain (small ES); quetiapine/aripiprazole/olanzapine induced WG (small to large ES). Exercise improved cardiorespiratory fitness (moderate ES). In the elderly, fluoxetine yielded more detrimental cardiovascular effects than sertraline/escitalopram (large ES); antidepressants were neutral on exercise tolerance and PHQoL. In mixed age groups, in bipolar disorder aripiprazole was metabolically neutral; in depression, SSRIs lowered blood pressure versus placebo and serotonin-noradrenaline reuptake inhibitors (small ES); brexpiprazole augmentation caused WG and was less tolerated (small ES); exercise improved PHQoL (moderate ES).

CONCLUSIONS

Some interventions (psychological therapies, exercise and SSRIs) improve certain physical health outcomes in mood disorders, few are neutral, but various pharmacological interventions are associated with negative effects. Evidence from this umbrella review has limitations, should consider evidence from other disorders and should be integrated with recent evidence from individual RCTs, and observational evidence. Effective treatments with either beneficial or physically neutral profiles should be prioritized.

Mental Disorders and Oral Diseases: Future Research Directions

The poor physical health (including oral health) of people with mental disorders is a global problem. The burden of oral diseases among this group is substantial given their high prevalence and ability to increase the personal, social, and economic impacts of mental disorders. This article summarizes causes of mental disorders and oral diseases, critically reviews current evidence on interventions to reduce the burden of oral diseases in people with mental disorders, and suggests future research directions. The relationship between mental disorders and oral diseases is complex due to the shared social determinants and bidirectional interaction mechanisms that involve interconnected social, psychological, behavioral, and biological processes. Research has, to date, failed to produce effective and scalable interventions to tackle the burden of oral diseases among people with mental disorders. Transformative research and actions informed by a dynamic involvement of biological, behavioral, and social sciences are needed to understand and tackle the complex relationship between mental disorders and oral diseases, as well as inform the design of complex interventions. Examples of future research on complex public health, health service, and social care interventions are provided. The design and testing of these interventions should be carried out in real-world settings, underpinned by the principles of coproduction and systems thinking, and conducted by a transdisciplinary team. We propose this starts with setting research priorities and developing complex intervention theory, which we report to support future research to improve oral health and hence physical and mental health in this disadvantaged group.

Impact of low-dose quetiapine-use on glycosylated hemoglobin, triglyceride and cholesterol levels

OBJECTIVE

Quetiapine use at standard doses has been associated with hyperglycemia and dyslipidemia. However, whether even frequently prescribed low-dose quetiapine results in significant metabolic disturbances remains unclear. Thus, this study aimed to investigate the association between off-label, low-dose quetiapine and changes in glycosylated hemoglobin (HbA1c) levels/lipid parameters.

METHODS

We identified new users of low-dose quetiapine (≤50 mg tablets) in Denmark 2008-2018 with measurements of HbA1c, total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), or fasting triglycerides (fTG) within 365 days before and after quetiapine initiation. Mixed-effects linear regression models were used to estimate coefficients (β) with 95% confidence intervals (95%CIs) for change in cardiometabolic parameters after quetiapine initiation. Inverse probability weighting was used to mitigate selection bias. Higher doses of quetiapine (>50 mg) were included in sensitivity analyses.

RESULTS

Among 106,711 eligible new low-dose quetiapine users (median age = 45 years, females = 55%), low-dose quetiapine initiation was associated with increased fTG (β = 1.049[95%CI:1.027-1.072]) and decreased HDL-C (β = 0.982[0.978-0.986]). Although HbA1c did not change significantly and TC and LDL-C even decreased considering all subjects, all three metabolic parameters increased significantly among individuals with normal pre-quetiapine initiation levels. The adverse metabolic effect of quetiapine on HbA1c, TC, LDL-C, and HDL-C was dose-dependent, which was not the case for fTG.

CONCLUSIONS

Low-dose quetiapine was associated with a significant increase in fTG and decreases in HDL-C in all subjects, as well as with significant increases in HbA1c, TC, and LDL-C among those with normal baseline values. The risk of metabolic worsening with quetiapine was dose-dependent, except for fTG.

Glucose and Lipid Profiles Predict Anthropometric Changes in Drug-Naïve Adolescents Starting Treatment with Risperidone or Sertraline: A Pilot Study

Psychiatric disorders are associated with cardiometabolic diseases, partly due to adverse drug effects with individual risk variabilities. Risperidone and sertraline are widely used for youths. Although they may be exposed to anthropometric changes, few data about this population exist. We evaluated the correlation between several blood parameters and body changes in a very small group of drug-naïve adolescents who had started risperidone or sertraline. We examined weight, waist circumference (WC), WC/height ratio and body mass index (BMI) at baseline (T0) and after at least three months of therapy (T1), and blood glucose and lipid profiles at T0. Here, we show significant increases in several anthropometric parameters in both groups, a negative correlation between HDL and ΔWC in the risperidone group and positive correlations between insulin and ΔBMI and between HOMA-IR and ΔBMI in the sertraline group. Despite the sample size, these results are important because it is difficult to study adolescents who are long-term-compliant with psychotropic drugs. This pilot study supports the importance of future large-scale investigations to understand the metabolic risk profiles of psychotropic drugs, their individual vulnerabilities and their underlying mechanisms. Simultaneous guideline-based psychiatric and metabolic interventions should be part of daily practice.

Emraclidine, a novel positive allosteric modulator of cholinergic M4 receptors, for the treatment of schizophrenia: a two-part, randomised, double-blind, placebo-controlled, phase 1b trial

BACKGROUND

Emraclidine is a novel, brain-penetrant, highly selective M4 receptor positive allosteric modulator in development for the treatment of schizophrenia. We aimed to evaluate the safety and tolerability of multiple ascending doses of emraclidine in patients with schizophrenia.

METHODS

We conducted a two-part, randomised, phase 1b trial in the USA. Eligible participants were aged 18-50 years (part A) or 18-55 years (part B) with a primary diagnosis of schizophrenia per the Diagnostic and Statistical Manual of Mental Disorders 5th edition, as confirmed by the Mini International Neuropsychiatric Interview, and extrapyramidal symptom assessments indicating normal to mild symptoms at screening. Part A evaluated the safety and tolerability of emraclidine in five cohorts of participants with stable schizophrenia who received ascending oral doses of emraclidine 5-40 mg (40 mg was administered as 20 mg twice daily) or placebo at a single US site. Part B was a double-blind, randomised, placebo-controlled study that enrolled adults with acute schizophrenia across five US sites; participants were randomly assigned (1:1:1) to receive emraclidine 30 mg once daily, emraclidine 20 mg twice daily, or placebo for 6 weeks (doses established in part A). The primary endpoint was safety and tolerability, assessed in the safety population (participants who received at least one dose of emraclidine or placebo). This trial is now complete and is registered with ClinicalTrials.gov, NCT04136873.

FINDINGS

Between Sept 23, 2019, and Sept 17, 2020, 118 patients were assessed for eligibility and 49 were randomly assigned across five cohorts in part A. 44 participants completed the study, with 36 participants receiving emraclidine and eight receiving placebo. The two highest doses tested were selected for part B. Between Oct 12, 2020, and May 7, 2021, 148 patients were assessed for eligibility and 81 were randomly assigned to emraclidine 30 mg once daily (n=27), emraclidine 20 mg twice daily (n=27), or placebo (n=27) in part B. Incidence of adverse events (14 [52%] of 27 participants in the emraclidine 30 mg once daily group, 15 [56%] of 27 in the emraclidine 20 mg twice daily group, and 14 [52%] of 27 in the placebo group), clinical assessments, and weight changes were similar across groups. The most common adverse event was headache (15 [28%] of 54 participants in the emraclidine groups, seven [26%] of 27 in the placebo group). Modest, transient increases in blood pressure and heart rate in emraclidine groups observed at treatment initiation diminished over time and were not considered clinically meaningful by week 6.

INTERPRETATION

These data support further investigation of emraclidine as a once-daily treatment for schizophrenia without need for titration and with a potentially favourable side-effect profile.

FUNDING

Cerevel Therapeutics.

Accessing acute medical care to protect health: the utility of community treatment orders

Background

The conclusion that people with severe mental illness require involuntary care to protect their health (including threats due to physical-non-psychiatric-illness) is challenged by findings indicating that they often lack access to general healthcare and the assertion that they would access such care voluntarily if available and effective. Victoria, Australia's single-payer healthcare system provides accessible medical treatment; therefore, it is an excellent context in which to test these challenges.

Aims

This study replicates a previous investigation in considering whether, in Australia's easy-access single-payer healthcare system, patients placed on community treatment orders, specifically involuntary community treatment, are more likely to access acute medical care addressing potentially life-threatening physical illnesses than voluntary patients with and without severe mental illness.

Methods

Replicating methods used in 2000-2010, for the years 2010-2017, this study compared the acute medical care access of three new cohorts: 7826 hospitalised patients with severe mental illness who received a post-hospitalisation, community treatment order; 13 896 patients with severe mental illness released from the hospital without a community treatment order and 12 101 outpatients who were never psychiatrically hospitalised (individuals with less morbidity risk who were not considered to have severe mental illness) during periods when they were under versus outside community mental health supervision. Logistic regression was used to determine the influence of community-based community mental health supervision and the type of community mental health supervision (community treatment order vs non-community treatment order) on the likelihood of receiving an initial diagnosis of a life-threatening physical illness requiring acute care.

Results

Validating their shared elevated morbidity risk, 43.7% and 46.7%, respectively, of each hospitalised cohort (community treatment order and non-community treatment order patients) accessed an initial acute-care diagnosis for a life-threatening condition vs 26.3% of outpatients. Outside community mental health supervision, the likelihood that a community treatment order patient would receive a diagnosis of physical illness was 36% lower than non-community treatment order patients-1.30 times that of outpatients. Under community mental health supervision, their likelihood was two times greater than that of non-community treatment order patients and 6.6 times that of outpatients. Each community treatment order episode was associated with a 14.6% increase in the likelihood of a community treatment order patient receiving a diagnosis. The results replicate those found in an independent 2000-2010 cohort comparison.

Conclusions

Community mental health supervision, notably community treatment order supervision, in two independent investigations over two decades appeared to facilitate access to physical healthcare in acute care settings for patients with severe mental illness who were refusing treatment-a group that has been subject to excess morbidity and mortality.

Effect of long-acting injectable antipsychotics on emergency department visits and hospital admissions in people with bipolar disorder: A retrospective mirror-image analysis from the Northern Milan Area Cohort (NOMIAC) study

BACKGROUND

Mood recurrences in bipolar disorder (BD) are often associated with poor treatment adherence. Despite long-acting injectable antipsychotics (LAIs) may favor treatment compliance, their use in BD is still poorly explored.

METHODS

This mirror-image study investigated the effect of LAIs initiation on the number of emergency department (ED) visits and days of hospitalization, among individuals with BD from the mental health services of a large area of the Metropolitan City of Milan. The mirror periods were 365 days either side of the LAI initiation. Individual medical records were retrospectively reviewed.

RESULTS

Sixty-eight individuals with BD initiating a LAI over the index period were included. We estimated that LAI initiation overall reduced both ED visits (p = 0.002) and days of hospitalization (p < 0.001). This remained true only for those participants who i) continued LAI for the entire 12-month period of observation and ii) were treated with a second-generation antipsychotic LAI. In addition, LAI initiation reduced number of hospitalization days during hypo/manic (p = 0.013), but not depressive (p = 0.641) episodes, as well as compulsory admission days (p = 0.002).

LIMITATIONS

Due to the retrospective design, we could not collect systematic information on symptom severity and reasons of LAI discontinuation. Moreover, the limited sample size did not allow us to estimate effectiveness of single LAI agents.

CONCLUSIONS

Our study provides additional insight on the effectiveness of LAIs in BD, supporting their clinical utility for pragmatic outcomes such as ED visits and hospitalizations. Further longitudinal research is needed to clarify the real-world effectiveness of LAIs for BD clinical management.

Factors and their weight in reducing life expectancy in schizophrenia

BACKGROUND

Schizophrenia is associated with a wide range of socioeconomic and health-related problems, as well as 10-25 potential life-years lost. While lifestyle choices, comorbidities, and choice of medication are associated with schizophrenia disease burden and mortality, real-world evidence on the impact of these factors on expected life-years among patients with schizophrenia is limited.

METHODS

In this study, register-based, nationwide data from patients with schizophrenia in Finland during 1972-2015 were analysed to determine influential factors associated with mortality and to demonstrate their impact on expected life-years in patients with schizophrenia.

RESULTS

Factors reducing all-cause mortality were use of antipsychotics: HR 0.46 (95 % CI: 0.45, 0.47), ever use of lipid-modifying agents: HR 0.71 (95 % CI 0.68, 0.73), antidepressants HR 0.87 (95 % CI 0.85, 0.90), and lithium HR 0.90 (95 % CI 0.86, 0.95). Factors increasing all-cause mortality were cardiovascular disease: HR 2.41 (95 % CI: 2.34, 2.49), liver disease: HR 1.98 (95 % CI: 1.78, 2.21), renal disease: HR 1.63 (95 % CI:1.56, 1.70), diabetes: HR 1.40 (95 % C:1.35, 1.45), history of switching antipsychotics: HR 1.39 (95 % CI: 1.35, 1.44), longer duration of previous hospitalisations HR 1.96 (95 % CI: 1.90, 2.02), history of substance abuse HR 1.38 (95 % CI: 1.30, 1.46), and ever use of benzodiazepines HR 1.12 (95 % CI: 1.09, 1.16).

CONCLUSIONS

The results from this study could serve to motivate clinicians to support and encourage patients to adhere to antipsychotic treatment and achieve a healthier lifestyle, which could, in turn, increase the expected life-years of patients with schizophrenia.

Cardiovascular Disease in Australians Experiencing Homelessness

Australia has one of the highest rates of homelessness in the world, at 498 per 100,000 people, and Australians experiencing homelessness (AEH) are a particularly vulnerable cohort, with a greater prevalence of cardiovascular disease, and poorer health outcomes, when compared to the general population. This narrative review explores how a combination of inadequately managed traditional and non-traditional cardiovascular risk factors, along with several personal, practical and relationship challenges with the health system, have created unique barriers in the diagnosis and management of cardiovascular disease in AEH. To help address these inequalities, we propose a targeted and collaborative strategy, which includes government proactivity, stable and affordable housing, and involvement of specialist health professionals, community leaders and major homelessness organisations. Furthermore, the delivery of health care needs to be a combination of outreach and opportunistic services, with a focus on flexible and individualised preventative care.

Nutrition and Exercise for Wellness and Recovery: A Randomized Controlled Trial of a Community-Based Health Intervention

OBJECTIVE

The purpose of this study was to examine the efficacy of the Nutrition and Exercise for Wellness and Recovery (NEW-R) intervention for improving competency and behaviors related to diet, physical activity, and weight management.

METHODS

Participants with psychiatric disabilities were recruited from four community mental health agencies and a hospital-based psychiatric outpatient clinic and randomly assigned to the NEW-R intervention (N=55) or control condition (N=58). Outcome measures included the Perceived Competence Scale, Health-Promoting Lifestyle Profile (HPLP), and weight change; random-effects regression models were used. A follow-up analysis examined the interactions of group, time, and site.

RESULTS

Fifty of the 55 intervention participants and 57 of the 58 control participants completed the study. The two groups did not differ significantly on any measured baseline characteristic. The intervention group had statistically significant improvements, compared with the control group, in perceived competence for exercise and healthy eating, total HPLP score, and scores on two HPLP subscales (nutrition and spiritual growth). No significant difference between groups was found for weight loss. A study condition × time × site effect was observed: at the three sites where mean weight loss occurred, NEW-R participants lost significantly more weight than did control participants.

CONCLUSIONS

NEW-R offers promise as an intervention that can initiate the change to healthy lifestyle behaviors and boost perceived competence in a healthy lifestyle. It may also be effective for weight loss when administered in supportive settings.

Antipsychotics and Medical Comorbidity: A Retrospective Study in an Urban Outpatient Psychiatry Clinic

Patients with psychotic disorders have increased rates of medical comorbidities. In this cross-sectional study, we investigated the relationship between antipsychotics and medical comorbidities among patients with psychotic disorders in an urban psychiatry clinic in Atlanta, Georgia (n = 860). Each antipsychotic group was compared to a group of patients from the same sample who were not on any antipsychotic, and logistic regression models were constructed for each comorbidity. Ziprasidone was associated with diabetes (aOR 2.56, 95% CI 1.03-6.38) and obesity (aOR 3.19, 95% CI 1.37-7.41). Aripiprazole was associated with obesity (aOR 2.39, 95% CI 1.27-4.51). Clozapine was associated with GERD (aOR 3.59, 95% CI 1.11-11.61), movement disorders (aOR 4.44, 95% CI 1.02-19.32), and arrythmias (4.89, 95% CI 1.44-16.64). Two antipsychotics that are considered weight neutral, ziprasidone and aripiprazole, were associated with cardiometabolic comorbidities. This study suggests that research is warranted to study the association between antipsychotics, medical comorbidity, and psychotic symptom burden.

Trends in prescription of psychotropic medications to children and adolescents in Australian primary care from 2011 to 2018

OBJECTIVE

To examine trends in prescribing psychotropic medications to children and adolescents in Australian primary care from 2011 to 2018.

METHOD

A retrospective cohort study examined prescriptions written by general practitioners using MedicineInsight, a large Australian primary care database, covering approximately 9% of all general practitioner practices. Numbers of patients receiving prescriptions for five main classes of psychotropics (antipsychotics, antidepressants, attention deficit hyperactivity disorder medications, anxiolytics, and hypnotics/sedatives [including benzodiazepines and Z-drugs, but excluding melatonin]) were examined annually by age-group (0-4, 5-9, 10-14, 15-18 years). Melatonin was analysed separately.

RESULTS

The number of patients prescribed any psychotropic increased from 25.6 to 36.2 per 1000 individuals from 2011 to 2018 (average annual increase +4.5%, 95% confidence interval [4.1%, 4.9%]; overall +41.4%). Among the five main classes, the largest annual increase was for attention deficit hyperactivity disorder medications (+9.6%, 95% confidence interval [8.8%, 10.5%]; overall +95.8%), followed by antipsychotics (+6.2%, 95% confidence interval [5.0%, 7.3%]; overall +62.8%) and antidepressants (+4.5%, 95% confidence interval [4.0%, 5.0%]; overall +42.8%). Hypnotic/sedative prescribing decreased on average 6.5% per year (95% confidence interval [-8.0%, -5.0%]; overall -40.2%). Anxiolytic prescribing remained steady. Melatonin prescriptions showed the highest increase of all (+24.7%, 95% confidence interval [23.7%, 25.8%]; overall +606.7%). The largest annual increase in antipsychotic, antidepressant or attention deficit hyperactivity disorder medication prescribing occurred in 10- to 14-year-olds (+7.5%, +6.5% and +10.4%, respectively). The largest point prevalence occurred in 2018 among 15- to 18-year-olds, with 98.5 per 1000 prescribed antidepressants. Antidepressants were more frequently prescribed to females; antipsychotics, attention deficit hyperactivity disorder medications and melatonin more often to males. The most prescribed antipsychotics were risperidone (<15 years) and quetiapine (15- to 18-year-olds). Fluoxetine was the most prescribed antidepressant in those aged 5+ years and amitriptyline in 0- to 4-year-olds.

CONCLUSION

General practitioner prescribing of melatonin, antipsychotics, antidepressants and attention deficit hyperactivity disorder medications to under-19-year-olds increased markedly from 2011 to 2018. Although benzodiazepine and Z-drug prescriptions declined, this was offset by a substantial increase in melatonin prescribing.

Mental Healthcare Providers Understanding and Experiences of Palliative Care: A Qualitative Analysis

Objective: To understand the experiences and perceptions of mental health providers about palliative care. Background: Little attention is paid to the experience of people with chronic persistent mental illness (CPMI) and life-threatening diseases and how their dying experience might differ from those without a CPMI. Methods: Interpretive description informed the project. Sixteen mental health care providers were interviewed using a semi-structured interview template. The interviews were recorded, transcribed, and analyzed using a reflexive, inductive-deductive thematic approach, guided by Braun & Clarke's framework for thematic analysis. Results: Four themes were identified from the data: intersectionality, limited collaboration, misconceptions about palliative care, and relationships. Mental health providers identified gaps in their knowledge of palliative care practices along with their knowledge of death and dying.

Multi-dimensional relationships among dementia, depression and prescribed drugs in England and Wales hospitals

Background

 Dementia is a group of symptoms that largely affects older people. The majority of patients face behavioural and psychological symptoms (BPSD) during the course of their illness. Alzheimer’s disease (AD) and vascular dementia (VaD) are two of the most prevalent types of dementia. Available medications provide symptomatic benefits and provide relief from BPSD and associated health issues. However, it is unclear how specific dementia, antidepressant, antipsychotic, antianxiety, and mood stabiliser drugs, used in the treatment of depression and dementia subtypes are prescribed in hospital admission, during hospital stay, and at the time of discharge. To address this, we apply multi-dimensional data analytical approaches to understand drug prescribing practices within hospitals in England and Wales.

Methods

We made use of the UK National Audit of Dementia (NAD) dataset and pre-processed the dataset. We evaluated the pairwise Pearson correlation of the dataset and selected key data features which are highly correlated with dementia subtypes. After that, we selected drug prescribing behaviours (e.g. specific medications at the time of admission, during the hospital stay, and upon discharge), drugs and disorders. Then to shed light on the relations across multiple features or dimensions, we carried out multiple regression analyses, considering the number of dementia, antidepressant, antipsychotic, antianxiety, mood stabiliser, and antiepileptic/anticonvulsant drug prescriptions as dependent variables, and the prescription of other drugs, number of patients with dementia subtypes (AD/VaD), and depression as independent variables.

Results

In terms of antidepressant drugs prescribed in hospital admission, during stay and discharge, the number of sertraline and venlafaxine prescriptions were associated with the number of VaD patients whilst the number of mirtazapine prescriptions was associated with frontotemporal dementia patients. During admission, the number of lamotrigine prescriptions was associated with frontotemporal dementia patients, and with the number of valproate and dosulepin prescriptions. During discharge, the number of mirtazapine prescriptions was associated with the number of donepezil prescriptions in conjunction with frontotemporal dementia patients. Finally, the number of prescriptions of donepezil/memantine at admission, during hospital stay and at discharge exhibited positive association with AD patients.

Conclusion

Our analyses reveal a complex, multifaceted set of interactions among prescribed drug types, dementia subtypes, and depression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01892-9.

Oxidative stress parameters and antioxidants in adults with unipolar or bipolar depression versus healthy controls: Systematic review and meta-analysis

BACKGROUND

To study differences in oxidative stress markers and antioxidants among patients with bipolar depression (BPD) and unipolar depression (UPD).

METHODS

Data sources. Electronic MEDLINE/PubMed/Cochrane Library/Scopus/TripDatabase database search until 30/06/2021.

STUDY SELECTION

Included were articles comparing antioxidant or oxidative stress markers between adults with BPD or UPD and healthy controls (HCs).

DATA EXTRACTION

Two authors extracted data independently. Random effects meta-analysis, calculating standardized mean differences for results from ≥3 studies.

RESULTS

Oxidative stress markers reported in 40 studies -1 published repeatedly- (UPD, studies = 30 n = 3072; their HCs, n = 2856; BPD, studies = 11 n = 393; their HCs, n = 540; with 1 study reporting on both UPD and BPD) included thiobarbituric acid reactive substances (TBARS), antioxidant uric acid and antioxidant-enhancing enzymes superoxide dismutase (SOD), catalase (CAT) and glutathione-peroxidase (GPX). Compared with HCs, UPD and BPD were associated with significantly higher levels of TBARS, without differences between UPD and BPD (P = 0.11). Compared with HCs, UPD and BPD did not differ regarding the activity of the CAT (P = 0.28), SOD (P = 0.87) and GPX (P = 0.25) enzymes. However, uric acid levels were significantly higher vs HCs in BPD than in UPD among adult patients (P = 0.004). Results were heterogenous, which, for some parameters, decreased after stratification by the blood source (serum, plasma red blood cells, whole blood).

LIMITATIONS

The main limitations are the small number of studies/participants in the BPD subgroup, and heterogeneity of the results.

SUMMATIONS

Both BPD and UPD may be associated with an impaired oxidative stress balance, with significantly higher uric acid levels vs. HCs in UPD than in BPD.

Effectiveness of nutrition and dietary interventions for people with serious mental illness: systematic review and meta-analysis

OBJECTIVE

To review recent published trials of nutrition and dietary interventions for people with serious mental illness; to assess their effectiveness in improving metabolic syndrome risk factors.

STUDY DESIGN

Systematic review and meta-analysis of randomised and non-randomised controlled trials of interventions with a nutrition/diet-related component delivered to people with serious mental illness, published 1 January 2010 - 6 September 2021. Primary outcomes were weight, body mass index (BMI), and waist circumference. Secondary outcomes were total serum cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, triglyceride, and blood glucose levels.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL databases. In addition, reference lists of relevant publications were examined for further additional studies.

DATA SYNTHESIS

Twenty-five studies encompassing 26 intervention arms were included in our analysis. Eight studies were at low or some risk of bias, seventeen were deemed to be at high risk. Eight of seventeen intervention arms found statistically significant intervention effects on weight, ten of 24 on BMI, and seven of seventeen on waist circumference. The pooled effects of nutrition interventions on metabolic syndrome risk factors were statistically non-significant. However, we identified small size effects on weight for interventions delivered by dietitians (five studies; 262 intervention, 258 control participants; standardised mean difference [SMD], -0.28; 95% CI, -0.51 to -0.04) and interventions consisting of individual sessions only (three studies; 141 intervention, 134 control participants; SMD, -0.30; 95% CI, -0.54 to -0.06).

CONCLUSIONS

We found only limited evidence for nutrition interventions improving metabolic syndrome risk factors in people with serious mental illness. However, they may be more effective when delivered on an individual basis or by dietitians.

PROSPERO REGISTRATION

CRD42021235979 (prospective).

Use of low-dose quetiapine increases the risk of major adverse cardiovascular events: results from a nationwide active comparator-controlled cohort study

At standard doses used for schizophrenia or bipolar disorder, quetiapine has been associated with weight gain and increased levels of triglycerides, to-tal cholesterol and low-density lipoprotein (LDL) cholesterol, which are risk factors for cardiovascular morbidity and mortality. However, this drug is also commonly used off-label at low doses for anxiolytic or hypnotic purposes, and its cardiovascular safety at these doses is unknown. We aimed to assess the risk of major adverse cardiovascular events with use of low-dose quetiapine compared to use of Z-drug hypnotics in a nationwide, active comparator-controlled cohort study. The cohort included new users of either drugs in Denmark from 2003 to 2017, aged 18-85 years, without history of ischemic stroke, myocardial infarction, cancer, and severe mental illness. The main outcome was the occurrence of major adverse cardiovascular events, defined as non-fatal myocardial infarction or ischemic stroke, or death from cardiovascular causes. Selective serotonin reuptake inhibitors (SSRIs) were used as an alternative comparator in sensitivity analyses. Altogether, we compared 60,566 low-dose quetiapine users with 454,567 Z-drug users, followed for 890,198 person-years in intent-to-treat analysis, and 330,334 person-years in as-treated analysis. In intention-to-treat analysis, low-dose quetiapine was associated with an increased risk of major adverse cardiovascular events (adjusted hazard ratio, aHR=1.13, 95% CI: 1.02-1.24, p=0.014) and cardiovascular death (aHR=1.26, 95% CI: 1.11-1.43, p<0.001). In as-treated analysis, continuous low-dose quetiapine use was associated with increased risk of major adverse cardiovascular events (aHR=1.52, 95% CI: 1.35-1.70, p<0.001), non-fatal ischemic stroke (aHR=1.37, 95% CI: 1.13-1.68, p=0.002) and cardiovascular death (aHR=1.90, 95% CI: 1.64-2.19, p<0.001). The risk of major adverse cardiovascular events was greater in women (aHR=1.28, p=0.02) and those aged ≥65 years at initiation (aHR=1.24, p<0.001). Compared to SSRIs, low-dose quetiapine use was associated with an increased risk of major adverse cardiovascular events (aHR=1.42, p<0.001), non-fatal ischemic stroke (aHR=1.27, p=0.0028) and cardiovascular death (aHR=1.72, p<0.001). So, we conclude that the use of low-dose quetiapine is associated with an increased risk of major adverse cardiovascular events, especially in women and the elderly. On the basis of these findings, we suggest that use of off-label low-dose quetiapine for sedative or hypnotic purposes should be discouraged.

Characteristics and Correlates of Metabolic Syndrome in Adolescents with Unipolar and Bipolar Depression: Results from a Cross-National Inpatient Case-Control Study

Abstract Objectives: To assess characteristics and correlates of metabolic syndrome (MetS) in adolescents with major depressive disorder (MDD) or bipolar disorder-depressive episode (BP-d). Methods: Case-control study, using national inpatient sample data, including adolescents (age, 12-18 years) with a primary diagnosis of MDD or BP-d. Using propensity score matching (based on age, sex, and race/ethnicity), we extracted cases with MetS (≥3 of the following conditions: obesity, diabetes, hypercholesterolemia, and hypertension) and controls without MetS. We used a multivariable logistic regression model calculating adjusted odds ratios (aORs) for potential correlates of MetS, focusing on primary mood disorders and psychiatric comorbidities. Results: In 607 age-/sex-/race/ethnicity-matched adolescents (MDD = 83.5%, BP-d = 16.5%), comparing those with (N = 332) versus without MetS (N = 275), MetS was most prevalent in later-age adolescents (mean age 16.3 years), females (58.1%), Whites (40.3%), and Blacks (31.5%). MetS was characterized by obesity (84.9% vs. 3.6%), hypertension (81% vs. 1.8%), diabetes (72.8% vs. 9.1%), and hypercholesterolemia (67.2% vs. 3.6%) (all p < 0.001). MetS was associated with a primary diagnosis of BP-d versus MDD (aOR 2.42, 95% confidence interval [CI] 1.47-3.97) and comorbid disruptive behavior disorders (DBD) (aOR 4.45, 95% CI 1.55-12.78), while comorbid substance use disorder reduced MetS risk (aOR 0.31, 95% CI 0.19-0.50). Conclusion: In adolescents with MDD or BP-d, MetS was associated with a primary BP-d diagnosis, and comorbid DBD. MetS-related parameters should be screened for early in adolescents with depression-spectrum disorders aiming to prevent the development or effects of MetS.

Attention-deficit/hyperactivity disorder as a risk factor for cardiovascular diseases: a nationwide population-based cohort study

Accumulating evidence suggests a higher risk for cardiovascular diseases among individuals with mental disorders, but very little is known about the risk for overall and specific groups of cardiovascular diseases in people with attention-deficit/hyperactivity disorder (ADHD). To fill this knowledge gap, we investigated the prospective associations between ADHD and a wide range of cardiovascular diseases in adults. In a nationwide population-based cohort study, we identified 5,389,519 adults born between 1941 and 1983, without pre-existing cardiovascular diseases, from Swedish registers. The study period was from January 1, 2001 to December 31, 2013. Incident cardiovascular disease events were identified according to ICD codes. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated using Cox proportional hazards regression model, with ADHD as a time-varying exposure. After an average 11.80 years of follow-up, 38.05% of individuals with ADHD versus 23.57% of those without ADHD had at least one diagnosis of cardiovascular disease (p<0.0001). ADHD was significantly associated with increased risk of any cardiovascular disease (HR=2.05, 95% CI: 1.98-2.13) after adjusting for sex and year of birth. Further adjustments for education level, birth country, type 2 diabetes mellitus, obesity, dyslipidemia, sleep problems and heavy smoking attenuated the association, which however remained significant (HR=1.84, 95% CI: 1.77-1.91). Further adjustment for psychiatric comorbidities attenuated but could not fully explain the association (HR=1.65, 95% CI: 1.59-1.71). The strongest associations were found for cardiac arrest (HR=2.28, 95% CI: 1.81-2.87), hemorrhagic stroke (HR=2.16, 95% CI: 1.68-2.77), and peripheral vascular disease/arteriosclerosis (HR=2.05, 95% CI: 1.76-2.38). Stronger associations were observed in males and younger adults, while comparable associations were found among individuals with or without psychotropic medications and family history of cardiovascular diseases. These data suggest that ADHD is an independent risk factor for a wide range of cardiovascular diseases. They highlight the importance of carefully monitoring cardiovascular health and developing age-appropriate and individualized strategies to reduce the cardiovascular risk in individuals with ADHD.

The role and mechanism of tryptophan - kynurenine metabolic pathway in depression

Major depressive disorder (MDD) is a common mental illness characterized by persistent low mood and anhedonia, normally accompanied with cognitive impairment. Due to its rising incidence and high rate of recurrence and disability, MDD poses a substantial threat to patients' physical and mental health, as well as a significant economic cost to society. However, the etiology and pathogenesis of MDD are still unclear. Chronic inflammation may cause indoleamine-2,3-dioxygenase (IDO) to become overactive throughout the body and brain, resulting in excess quinolinic acid (QUIN) and less kynuric acid (KYNA) in the brain. QUIN's neurotoxicity damages glial cells and neurons, accelerates neuronal apoptosis, hinders neuroplasticity, and causes depression due to inflammation. Therefore, abnormal TRP-KYN metabolic pathway and its metabolites have been closely related to MDD, suggesting changes in the TRP-KYN metabolic pathway might contribute to MDD. In addition, targeting TRP-KYN with traditional Chinese medicine showed promising treatment effects for MDD. This review summarizes the recent studies on the TRP-KYN metabolic pathway and its metabolites in depression, which would provide a theoretical basis for exploring the etiology and pathogenesis of depression.

Regulation of Antidepressant Prescription for the Effective Treatment of Mental Disorders in Turkey: A Narrative Review

Background

This non-systematic narrative review aims to summarize the results of clinical studies evaluating the effectiveness of antidepressants used to treat mental illnesses including major depressive disorder, obsessive-compulsive disorder, somatization disorder, and anxiety disorders in Turkey. Conclusions drawn from this article can guide ongoing efforts by Turkish health policymakers to improve public health development in the country by further regulating the prescription of antidepressants.

Methods

Relevant articles regarding the effectiveness of antidepressant use were collected in June 2021 using Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus and Academic Search Complete online databases. The collected articles were then appraised using the Critical Appraisal Skills Programme to determine the reliability and quality of each article and to assess the risk of bias in each article. The summary of key findings/evidence, Critical Appraisal Skills Programme appraisal summary results, funding, study designs applied, settings covered, period covered (years), and additional comments were extracted from each article for analysis. The inclusion criteria involved articles that recounted adverse effects and effectiveness of antidepressant use in Turkey to treat mental illnesses, including anxiety disorders, major depressive disorder, somatization disorder, and obsessive-compulsive disorder. The exclusion criteria consisted of articles that included participants who resided outside of the geographic region of Turkey, abstracts, the pharmacology of antidepressant use, antidepressant off-label use, and alternative treatments.

Results

A total of 15 articles out of the 104 derived from the databases were included in the study that fell into 1 of the following main themes, "adverse effects" and "mixed results," which accounted for 53% (8 articles) and 40% (6 articles), respectively. One outlying article was identified (7%).

Conclusions

Totally 8 out of 15 articles that recounted antidepressants prescribed for mental illnesses produced adverse effects without treatment success and 6 out of 15 articles recounted adverse effects with treatment success. One outlying article found a confound that precluded determining whether an adverse effect was caused by antidepressant use or confounded by pre-existing conditions. Given that 14 out of 15 articles recounted adverse effects associated with antidepressant use and 6 out of 15 articles recounted antidepressant treatment success, Turkish policymakers are encouraged to adopt a restrictive drug policy strategy. To sum up, antidepressant prescription and consumption should be conducted with caution to limit unnecessary risk of exposure to adverse effects associated with antidepressant use. Limitations in the research included using a non-systematic tool instead of conducting a systematic review, a limited number of articles (15 out of 104), and risk of bias was detected from appraising the articles via Critical Appraisal Skills Programme.

Honokiol improves depression-like behaviors in rats by HIF-1α- VEGF signaling pathway activation

Increasing evidence indicates that the pathogenesis of depression is closely linked to impairments in neuronal synaptic plasticity. Honokiol, a biologically active substance extracted from Magnolia Officinalis, has been proven to exert significant antidepressant effects. However, the specific mechanism of action remains unclear. In this study, PC12 cells and chronic unpredictable mild stress (CUMS) model rats were used to explore the antidepressant effects and potential mechanisms of honokiol in vitro and in rats. In vitro experiment, a cell viability detection kit was used to screen the concentration and time of honokiol administration. PC12 cells were administered with hypoxia-inducible factor-1α (HIF-1α) blocker, 2-methoxyestradiol (2-ME), and vascular endothelial growth factor receptor 2 (VEGFR-2) blocker, SU5416, to detect the expression of HIF-1α, VEGF, synaptic protein 1 (SYN 1), and postsynaptic density protein 95 (PSD 95) by western blotting. In effect, we investigated whether the synaptic plasticity action of honokiol was dependent on the HIF-1α-VEGF pathway. In vivo, behavioral tests were used to evaluate the reproducibility of the CUMS depression model and depression-like behaviors. Molecular biology techniques were used to examine mRNA and protein expression of the HIF-1α-VEGF signaling pathway and synaptic plasticity-related regulators. Additionally, molecular docking techniques were used to study the interaction between honokiol and target proteins, and predict their binding patterns and affinities. Experimental results showed that honokiol significantly reversed CUMS-induced depression-like behaviors. Mechanically, honokiol exerted a significant antidepressant effect by enhancing synaptic plasticity. At the molecular level, honokiol can activate the HIF-1α-VEGF signaling pathway in vitro and in vivo, as well as promote the protein expression levels of SYN 1 and PSD 95. Taken together, the results do not only provide an experimental basis for honokiol in the clinical treatment of depression but also suggest that the HIF-1α-VEGF pathway may be a potential target for the treatment of depression.

The Effects of Use of Long-Term Second-Generation Antipsychotics on Liver and Kidney Function: A Prospective Study

(1) Background: The second-generation antipsychotics (SGAPs) induce metabolic and inflammatory side effects, but documentation of their effects on the liver and kidneys is scarce. Aim: To study the three-year fluctuation of selected markers of renal and hepatic function in forensic psychiatric patients receiving SGAPs for more than five years. (2) Methods: Thirty-five forensic psychiatric patients (N = 35) were classified into two groups according to the type of SGAPs used for their treatment and the relevant risk of weight gain and metabolic complications. The three-year medication history, anthropometric data and biochemical data relevant to renal and hepatic function were retrieved from the individual medical files, specifically: serum levels of urea, uric acid, creatinine, alkaline phosphatase and amylase; the liver function enzymes, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT) and gamma-glutamyl transpeptidase(γ-GT), and also the inflammatory index C-reactive protein (CRP). (3) Results: The patients receiving the SGAPs with a low risk for weight gain showed no significant fluctuation in the biochemical markers over the three-year period. The patients receiving the SGAPs with a high risk for weight gain showed significant differences between at least two measurements of uric acid (p = 0.015), SGOT (p = 0.018) and SGPT (p = 0.051). They showed significantly higher levels of creatinine in the third year compared to the second year (p = 0.029), and SGOT in the second year compared to the first (p = 0.038), and lower levels of SGPT in the third year compared to the second (p = 0.024). (4) Conclusion:In addition to consideration of possible metabolic and inflammatory complications, the choice of an antipsychotic drug for long-term treatment should also take into account the risk of hepatotoxicity and kidney damage.

Crosstalk between Schizophrenia and Metabolic Syndrome: The Role of Oxytocinergic Dysfunction

The high prevalence of metabolic syndrome in persons with schizophrenia has spurred investigational efforts to study the mechanism beneath its pathophysiology. Early psychosis dysfunction is present across multiple organ systems. On this account, schizophrenia may be a multisystem disorder in which one organ system is predominantly affected and where other organ systems are also concurrently involved. Growing evidence of the overlapping neurobiological profiles of metabolic risk factors and psychiatric symptoms, such as an association with cognitive dysfunction, altered autonomic nervous system regulation, desynchrony in the resting-state default mode network, and shared genetic liability, suggest that metabolic syndrome and schizophrenia are connected via common pathways that are central to schizophrenia pathogenesis, which may be underpinned by oxytocin system dysfunction. Oxytocin, a hormone that involves in the mechanisms of food intake and metabolic homeostasis, may partly explain this piece of the puzzle in the mechanism underlying this association. Given its prosocial and anorexigenic properties, oxytocin has been administered intranasally to investigate its therapeutic potential in schizophrenia and obesity. Although the pathophysiology and mechanisms of oxytocinergic dysfunction in metabolic syndrome and schizophrenia are both complex and it is still too early to draw a conclusion upon, oxytocinergic dysfunction may yield a new mechanistic insight into schizophrenia pathogenesis and treatment.

Oral and long-acting antipsychotics for relapse prevention in schizophrenia-spectrum disorders: a network meta-analysis of 92 randomized trials including 22,645 participants

According to current evidence and guidelines, continued antipsychotic treatment is key for preventing relapse in people with schizophrenia-spectrum disorders, but evidence-based recommendations for the choice of the individual antipsychotic for maintenance treatment are lacking. Although oral antipsychotics are often prescribed first line for practical reasons, long-acting injectable antipsychotics (LAIs) are a valuable resource to tackle adherence issues since the earliest phase of disease. Medline, EMBASE, PsycINFO, CENTRAL and CINAHL databases and online registers were searched to identify randomized controlled trials comparing LAIs or oral antipsychotics head-to-head or against placebo, published until June 2021. Relative risks and standardized mean differences were pooled using random-effects pairwise and network meta-analysis. The primary outcomes were relapse and dropout due to adverse events. We used the Cochrane Risk of Bias tool to assess study quality, and the CINeMA approach to assess the confidence of pooled estimates. Of 100 eligible trials, 92 (N=22,645) provided usable data for meta-analyses. Regarding relapse prevention, the vast majority of the 31 included treatments outperformed placebo. Compared to placebo, "high" confidence in the results was found for (in descending order of effect magnitude) amisulpride-oral (OS), olanzapine-OS, aripiprazole-LAI, olanzapine-LAI, aripiprazole-OS, paliperidone-OS, and ziprasidone-OS. "Moderate" confidence in the results was found for paliperidone-LAI 1-monthly, iloperidone-OS, fluphenazine-OS, brexpiprazole-OS, paliperidone-LAI 1-monthly, asenapine-OS, haloperidol-OS, quetiapine-OS, cariprazine-OS, and lurasidone-OS. Regarding tolerability, none of the antipsychotics was significantly worse than placebo, but confidence was poor, with only aripiprazole (both LAI and OS) showing "moderate" confidence levels. Based on these findings, olanzapine, aripiprazole and paliperidone are the best choices for the maintenance treatment of schizophrenia-spectrum disorders, considering that both LAI and oral formulations of these antipsychotics are among the best-performing treatments and have the highest confidence of evidence for relapse prevention. This finding is of particular relevance for low- and middle-income countries and constrained-resource settings, where few medications may be selected. Results from this network meta-analysis can inform clinical guidelines and national and international drug regulation policies.

Associations between mental and physical conditions in children and adolescents: An umbrella review

We mapped the evidence on the type and strength of associations between a broad range of mental and physical conditions in children and adolescents, by carrying out an umbrella review, i.e., a quantitative synthesis of previous systematic reviews and meta-analyses. We also assessed to which extent the links between mental and physical conditions vary across disorders or, by contrast, are transdiagnostic. Based on a pre-established protocol, we retained 45 systematic reviews/meta-analyses, encompassing around 12.5 million of participants. In analyses limited to the most rigorous estimates, we found evidence for the following associations: ADHD-asthma, ADHD-obesity, and depression-asthma. A transdiagnostic association was confirmed between asthma and anxiety/ASD/depression/bipolar disorder, between obesity and ADHD/ASD/depression, and between dermatitis and ASD/ADHD. We conclude that obesity and allergic conditions are likely to be associated with mental disorders in children and adolescents. Our results can help clinicians explore potential links between mental and physical conditions in children/adolescent and provide a road map for future studies aimed at shading light on the underlying factors.

Prevalence and factors associated with psychological distress among patients on warfarin at the Uganda Heart Institute, Mulago Hospital

INTRODUCTION

Cardiovascular diseases (CVD) are the leading cause of mortality worldwide and are significantly associated with multiple comorbid disorders including mental disorders such as psychological distress (PD). At increased risk of PD are CVD patient sub-categories that not only require chronic therapy but also need follow up with continuous blood tests and dose adjustments (like the patients on warfarin). However, not much has been done to ascertain the burden of PD among patients on warfarin in Uganda.

OBJECTIVE

To determine the prevalence and factors associated with PD among patients on anticoagulation with warfarin at the Uganda Heart Institute (UHI).

METHODS

In this analytical cross-sectional study, 197 participants were sampled from adults on warfarin attending the Uganda Heart Institute (UHI) out patient clinic. The Self Reporting Questionnaire (SRQ-20), a tool with a total maximum score of 20 and cutoff for PD at ≥6 was used to determine the presence of PD among participants, and a socio-demographic questionnaire to document the socio-demographic characteristics of the subjects. Additional questions including the underlying CVD diagnosis, medications used (besides warfarin) and presence of chronic illnesess were also assessed. Bi-variable and multi-variabe logistic regression analysis techniques were used to examine the associations between the dependent and independent variables.

RESULTS

The prevalence of PD was 32%. The unemployed participants were 4.5 times more likely to have PD (adjusted odds ratio [aOR]4.56, 95% confidence interval [CI]: 1.12-18.62, p = 0.04). Participants who had experienced social stressors were more likely to have PD (aOR: 11.38, CI: 3.60-36.04, p < 0.01). Other factors associated with a higher likelihood of having PD included: presence of other chronic comorbidities (aOR: 3.69, CI: 1.24-11.02, p = 0.02) and concomitant use of loop diuretics (aOR: 4.13, CI: 1.67-10.19,p < 0.01). A shorter length of time on warfarin (7-24 months) lowered the likelihood of PD (aOR: 0.23, CI: 0.07-0.74, p = 0.01).

CONCLUSION

The prevalence of PD was high among patients on warfarin in this low income setting and there is a need to characterize the specific psychiatric disorders in patients with CVD. Interventions that address the high burden of PD are urgently needed in this setting.

Gold nanoclusters eliminate obesity induced by antipsychotics

Obesity induced by antipsychotics have plagued more than 20 million people worldwide. However, no drug is available to eliminate the obesity induced by antipsychotics. Here we examined the effect and potential mechanisms of a gold nanoclusters (AuNCs) modified by N-isobutyryl-L-cysteine on the obesity induced by olanzapine, the most prescribed but obesogenic antipsychotics, in a rat model. Our results showed that AuNCs completely prevented and reversed the obesity induced by olanzapine and improved glucose metabolism profile in rats. Further mechanism investigations revealed that AuNCs exert its anti-obesity function through inhibition of olanzapine-induced dysfunction of histamine H1 receptor and proopiomelanocortin signaling therefore reducing hyperphagia, and reversing olanzapine-induced inhibition of uncoupling-protein-1 signaling which increases thermogenesis. Together with AuNCs' good biocompatibility, these findings not only provide AuNCs as a promising nanodrug candidate for treating obesity induced by antipsychotics, but also open an avenue for the potential application of AuNCs-based nanodrugs in treating general obesity.

Metabolic Syndrome Identification in Patients Treated With Second-Generation Antipsychotic Medications

The purpose of the current project was to assess missed opportunities to identify metabolic syndrome in patients treated with second-generation antipsychotic medication in a community hospital's inpatient psychiatric unit between January 1 and December 31, 2020. Data on demographics, metabolic syndrome risk factors, body mass index, medications, related diagnoses, and primary care providers (PCPs) were collected via retrospective chart review of 194 patients. This project used a nonexperimental design and heterogenous nonrandom convenience sample. Descriptive statistics, chi-square tests, one-tailed t tests, and binary logistic regression were used. The overall rate of metabolic syndrome was 47.4% (n = 92). A positive PCP status was significant for treatment with antihypertensives, statins, and antihyperglycemics (p < 0.05). Findings indicate the need to increase system-wide assessment of metabolic syndrome and integrate care coordination with PCPs. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].

Predictors of falls and fractures leading to hospitalisation in 36 101 people with affective disorders: a large representative cohort study

OBJECTIVES

To investigate predictors of falls and fractures leading to hospitalisation in people with affective disorders.

DESIGN

Cohort study.

SETTING

The South London and Maudsley National Health Service (NHS) Foundation Trust (SLaM) Biomedical Research Centre (BRC) Case Register.

PARTICIPANTS

A large cohort of people with affective disorders (International Classification of Diseases- 10th version [ICD-10] codes F30-F34) diagnosed between January 2008 and March 2016 was assembled using data from the SLaM BRC Case Register.

PRIMARY AND SECONDARY OUTCOME MEASURES

Falls and fractures leading to hospitalisation were ascertained from linked national hospitalisation data. Multivariable Cox proportional hazards analyses were administrated to identify predictors of first falls and fractures.

RESULTS

Of 36 101 people with affective disorders (mean age 44.4 years, 60.2% female), 816 (incidence rate 9.91 per 1000 person-years) and 1117 (incidence rate 11.92 per 1000 person-years) experienced either a fall or fracture, respectively. In multivariable analyses, older age, analgesic use, increased physical illness burden, previous hospital admission due to certain comorbid physical illnesses and increase in attendances to accident and emergency services following diagnosis were significant risk factors for both falls and fractures. Having a history of falls was a strong risk factor for recurrent falls, and a previous fracture was also associated with future fractures.

CONCLUSIONS

Over a mean 5 years' follow-up, approximately 8% of people with affective disorders were hospitalised with a fall or fracture. Several similar factors were found to predict risk of falls and fracture, for example, older age, comorbid physical disorders and analgesic use. Routine screening for bone mineral density and fall prevention programmes should be considered for this clinical group.

Osteoporosis referral and treatment among people with severe mental illness: A ten-year data linkage study

INTRODUCTION

People with severe mental illness (SMI) are at increased risk of osteoporosis but minimal information is available on their treatment and referral. We investigated differences in these outcomes between patients with/without SMI in linked primary and specialist care data.

METHODS

People with SMI aged 18+ at diagnosis with both primary and mental healthcare records between 1st May 2009 and 31st May 2019 from a south London catchment were matched 1:4 to randomly selected controls on gender, age and duration of primary care follow-up. Outcomes included prescription of osteoporosis medications and referrals for osteoporosis, analysed using multivariable logistic regression analyses.

RESULTS

The study included 2269 people with SMI and 9069 matched non-SMI controls. People with SMI were more likely to have a recorded prescription of osteoporosis medications (odds ratio [OR] = 3.54, 95% confidence interval [CI] 2.87, 4.35) and be referred for osteoporosis (OR = 1.51, 95% CI 1.09, 2.08) within 2 years after the date of first SMI diagnosis after adjusting for ethnicity, deprivation and Charlson Comorbidity Index. Factors including older age (osteoporosis medications: OR = 1.04, 95% CI 1.03, 1.05; osteoporosis referral: OR = 1.05, 95% CI 1.04, 1.07) and being prescribed with Class A analgesics (osteoporosis medications: OR = 1.91, 95% CI 1.31, 2.77; osteoporosis referral: OR = 1.77, 95% CI 1.02, 3.07) are significant predictors for osteoporosis management pathways within SMI patients.

CONCLUSION

People with SMI are more frequently prescribed medications for osteoporosis and referred to osteoporosis screening than the general population. Given the many risk factors for osteoporosis in this group, this increased rate of referrals may well be warranted, and there is need to pay more attention to this at-risk group. Screening studies are needed to determine whether the rate of referral is proportional to the need.

An Experimental Study to Assess the Professional and Social Consequences of Tardive Dyskinesia

OBJECTIVE

Antipsychotic medications may cause tardive dyskinesia (TD), an often-irreversible movement disorder characterized by involuntary movements that are typically stereotypic, choreiform, or dystonic and may impair quality of life. This study evaluated others' perceptions of abnormal TD movements in professional and social situations.

METHODS

This was an experimental, randomized, blinded, digital survey in a general population sample. Participants were randomized 1:1 into a test or control group to view a video of a professional actor simulating TD movements or no TD movements prior to completing surveys on employment, dating, and friendship domains. Assessments for mild-to-moderate and moderate-to-severe TD movements were conducted separately. Authenticity of abnormal movements and Abnormal Involuntary Movement Scale (AIMS) scores were evaluated by physician experts.

RESULTS

Surveys were completed by 2,400 participants each for mild-to-moderate and moderate-to-severe TD. In all domains, participants responded significantly less favorably to persons with TD movements (both mild-to-moderate and moderate-to-severe) than those without TD movements. Fewer participants in the test versus control group for mild-to-moderate and moderate-to-severe TD, respectively, considered the candidate as a potential employee (29.2% and 22.7% fewer), found him/her attractive (20.5% and 18.7% fewer), and were interested in becoming friends with him/her (12.3% and 16.5% fewer).

CONCLUSION

Professional actors simulating TD movements were perceived more negatively than those without TD movements in employment, dating, and friendship domains. To our knowledge, this is the first randomized study to quantify professional and social stigma associated with TD movements that may reduce opportunities for gainful employment, marital status, and an effective support system.

Association between early-onset affective disorders and hypothyroidism in a larger number of psychiatric drug-free patients

AIMS

We aimed to assess the association between early onset of affective disorders and hypothyroidism in a larger number of psychiatric drug-free patients with bipolar disorder (BD) or major depressive disorder (MDD).

METHODS

Early onset of affective disorders was defined as BD and MDD developed before the age of 22 years. The hypothyroidism hierarchy were diagnosed biochemically and included subclinical and overt hypothyroidism in this study. Demographic and clinical data including diagnosis, illness duration and thyroid function parameters (TSH, T4, FT4, T3 and FT3) at admission were collected from patients' records. Adjusted odds ratio (OR) and 95% confidence interval (CI), which were estimated by logistic regression model, were used to assess the association between early-onset affective disorder and hypothyroidism.

RESULTS

The prevalence of hypothyroidism in early-onset affective disorders was higher than that in late-onset patients (in BD, 9.4% vs. 6.2%, χ² = 6.020, P = 0.014; and in MDD 12.7% vs. 6.6%, χ² = 13.295, P < 0.001). Early-onset affective disorders were 2.097 times (95% CI: 1.409-3.123) more likely to have hypothyroidism compared with late-onset patients, after adjustment for age, gender, duration of illness and mood episode (adjusted OR: 1.965, 95% CI: 1.198-3.221 in BD, and adjusted OR: 2.831, 95% CI: 1.378-5.817 in MDD, respectively).

LIMITATION

Because of the cross-sectional design of this study, we were unable to sort out causality between early-onset affective disorders and hypothyroidism.

CONCLUSION

Early-onset affective disorder may be associated with higher prevalence of hypothyroidism.

Profiling the Skeletal Muscle Proteome in Patients on Atypical Antipsychotics and Mood Stabilizers

Atypical antipsychotics (AAP) are used in the treatment of severe mental illness. They are associated with several metabolic side effects including insulin resistance. The skeletal muscle is the primary tissue responsible for insulin-stimulated glucose uptake. Dysfunction of protein regulation within the skeletal muscle following treatment with AAPs may play a role in the associated metabolic side effects. The objective of this study was to measure protein abundance in the skeletal muscle of patients on long-term AAP or mood stabilizer treatment. Cross-sectional muscle biopsies were obtained from patients with bipolar disorder and global protein abundance was measured using stable isotope labeling by amino acid (SILAC) combined with high-performance liquid chromatography-electrospray ionization tandem mass spectrometry (HPLC-ESI-MS/MS). Sixteen patients completed muscle biopsies and were included in the proteomic analyses. A total of 40 proteins were significantly different between the AAP group and the mood stabilizer group. In-silico pathway analysis identified significant enrichment in several pathways including glucose metabolism, cell cycle, apoptosis, and folate metabolism. Proteome abundance changes also differed based on protein biological processes and function. In summary, significant differences in proteomic profiles were identified in the skeletal muscle between patients on AAPs and mood stabilizers. Future work is needed to validate these findings in prospectively sampled populations.

Metabolic indexes of obesity in patients with common mental disorders in stable stage

BACKGROUND

Obesity is a serious worldwide public health problem, especially for people with mental disorders.

AIM

To explore the related factors of obesity by analyzing the metabolic indexes of patients with common mental disorders in stable stage.

METHODS

Five hundred seventy-six subjects with major depressive disorder (MDD), bipolar disorder (BD) or schizophrenia (SCZ) were included, who received fixed drug dose and routine drug treatment for 2 years or more. Their venous blood was collected, and the blood metabolic indexes were analyzed.

RESULTS

BD and SCZ are more prone to obesity than MDD. Multiple linear regression analysis showed that the value of BMI increased with the increase of age(B = 0.084, p < 0.001), TG(B = 0.355, p = 0.024), LDL(B = 0.697, p < 0.001), LDH(B = 0.011, p = 0.002), SCr(B = 0.051, p < 0.001), UA(B = 0.014, p < 0.001), HbA1c(B = 0.702, p = 0.004) and hsCRP(B = 0.101, p < 0.001). And It decreased with the increase of HDL(B = -1.493, p < 0.001).

DISCUSSION

People with mental disorders should regularly check blood indicators and strengthen weight management to reduce the risk of obesity and promote their health.

Use of chlorprothixene and the risk of diabetes and major adverse cardiovascular events: a nation-wide cohort study

Chlorprothixene is commonly used off‐label in low doses for sedative‐hypnotic purposes although it might carry a risk of cardiometabolic adverse events due to its pharmacodynamic profile. We investigated the risk of diabetes and major adverse cardiovascular events (MACE) with use of low‐dose chlorprothixene, compared with use of low‐dose quetiapine in a nationwide cohort study, including all new users of low‐dose chlorprothixene (n = 81 328) and low‐dose quetiapine (n = 91 163) in Denmark 2000–2017. Main outcomes were diabetes and MACE (myocardial infarction, stroke and death from cardiovascular causes). The association between cumulative dose of chlorprothixene and the outcomes was tested in a case–control analysis. Low‐dose chlorprothixene use was associated with increased risk of diabetes (intention‐to‐treat [ITT]‐hazard ratio [HR]: 1.16; 95% CI: 1.08–1.25), compared with low‐dose quetiapine use. This association strengthened when follow‐up was restricted to time on treatment (as‐treated [AT]‐HR: 1.34; 95% CI: 1.14–1.56). Low‐dose chlorprothixene use was also associated with increased risk of MACE (ITT‐HR: 1.12; 95% CI: 1.04–1.21) and stroke (ITT‐HR: 1.21; 95% CI: 1.06–1.37) but not with myocardial infarction (ITT‐HR: 1.11; 95% CI: 0.95–1.30) nor death from cardiovascular causes (ITT‐HR: 1.07; 95% CI: 0.96–1.20). Cumulative dose of chlorprothixene ≥6000 mg was associated with increased risk of diabetes (OR: 1.15–1.63; test for trend: p < 0.001), whereas cumulative dose of chlorprothixene ≥1500 mg was associated with increased risk of MACE (OR: 1.10–1.85; test for trend: p < 0.001). In conclusion, low‐dose chlorprothixene use is associated with increased risk of cardiometabolic adverse events compared with low‐dose quetiapine use.

Metabolic adverse effects of off-label use of second-generation antipsychotics in the adult population: a systematic review and meta-analysis

Prescription rates of second-generation antipsychotics (SGAs) are rapidly increasing for non-indicated (i.e., off-label) usage. SGAs used for approved indications are associated with significant metabolic adverse effects, including weight gain. The objective of this systematic review and meta-analysis is to evaluate the metabolic adverse effects of SGA use for off-label management of psychiatric illnesses in the adult population. We performed a systematic database search to identify randomized controlled trials (RCTs) that reported on weight and other metabolic outcomes with off-label use of SGAs among adults. Thirty-eight RCTs met inclusion criteria for this review; 35 of these studies, with a total of 4930 patients, were included in the quantitative meta-analysis. Patients treated with olanzapine, risperidone, and quetiapine were more likely to report weight gain as a side effect and experience clinically significant (≥7%) weight gain compared to those treated with a placebo. Among studies that reported weight as a continuous outcome, olanzapine was associated with significantly greater weight gain across all disorders (mean difference (MD) = 3.24 kg, 95% CI: 2.57-3.90 p = 0.001, N = 12 studies). Similar trends were noted with quetiapine and risperidone. A meta-regression analysis revealed a positive dose-response association between olanzapine dose and weight gain (regression coefficient: 0.36, p = 0.001). This review demonstrates that off-label use of SGAs, and particularly olanzapine, is associated with significant weight gain among adult patients. Our findings are concerning given the widespread off-label use of SGAs. Further studies are required to better understand the effects of off-label SGA use on other metabolic parameters. The study was registered with the PROSPERO international database of prospectively registered systematic reviews (PROSPERO #143186).

Group Lifestyle Intervention With Mobile Health for Young Adults With Serious Mental Illness: A Randomized Controlled Trial

OBJECTIVE

Evidence-based lifestyle interventions tailored to young adults with serious mental illness are needed to reduce their cardiometabolic risk. This study evaluated the effectiveness of a group lifestyle intervention ("PeerFIT") enhanced with mobile health (mHealth) compared with one-on-one mHealth coaching (basic education supported by activity tracking [BEAT]) for young adults with serious mental illness who were overweight or obese.

METHODS

Participants were young adults ages 18-35 years with serious mental illness and a body mass index ≥25 kg/m², who were randomly assigned to PeerFIT or BEAT. Research staff collected data at baseline and at 6 and 12 months. Main outcomes were clinically significant changes from baseline in weight (≥5% weight loss), cardiorespiratory fitness (CRF; increase of >50 m on the 6-minute walk test), and cardiovascular disease (CVD) risk reduction (clinically significant weight loss or CRF improvement).

RESULTS

Participants were 150 young adults with a mean ± SD body mass index of 37.1±7.4. Intent-to-treat analyses revealed no significant between-group difference for weight-loss, CRF, or CVD outcomes at 6 and 12 months. Participants in both conditions achieved clinically significant CVD risk reduction, weight loss, and CRF from baseline to 6 and 12 months, and all these improvements were statistically significant (p<0.01).

CONCLUSION

The PeerFIT group lifestyle intervention was not superior to one-on-one mHealth coaching in achieving clinically significant changes in weight, CRF, and CVD risk reduction. Although both interventions improved outcomes, low-intensity mHealth coaching may be a more scalable approach for addressing modifiable cardiometabolic risk factors among young adults with serious mental illness.

Hypertension and psychosis

Hypertension, a prevalent component of metabolic syndrome (MetS), is a well-known risk factor for cardiovascular diseases (CVD). Psychosis is a feature in the schizophrenia spectrum. Meta-analysis suggests that the prevalence of hypertension in schizophrenia and related disorders is 39%. This may be explained by a unidirectional association between hypertension and psychosis, in that psychosis can be a causative factor of hypertension via antipsychotic medication, inflammation and irregular autonomic nervous system activity through multiple mechanisms. Obesity is a side effect of antipsychotic medication and is a risk factor for hypertension. Obesity leads to raised blood pressure, atherosclerosis, increased triglyceride concentration and decreased high-density lipoprotein concentration. Inflammation accompanies hypertension and obesity. In recent years, the role of inflammation in the onset of psychosis has been increasingly recognised. It underlies the immune dysregulation observed in both schizophrenia and bipolar disorder. Interleukin-6, a marker and driver of inflammation, is related to obesity and plays a role in the pathogenesis of MetS and hypertension. The lack of preventive care of hypertension and other MetS risk factors for patients on antipsychotic medication is reflected in the high incidence of CVD in this population. It is important to detect and treat MetS and hypertension in patients with psychosis in order to reduce cardiovascular morbidity and mortality in this population.

Mapping multimorbidity in individuals with schizophrenia and bipolar disorders: evidence from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) case register

OBJECTIVES

The first aim of this study was to design and develop a valid and replicable strategy to extract physical health conditions from clinical notes which are common in mental health services. Then, we examined the prevalence of these conditions in individuals with severe mental illness (SMI) and compared their individual and combined prevalence in individuals with bipolar (BD) and schizophrenia spectrum disorders (SSD).

DESIGN

Observational study.

SETTING

Secondary mental healthcare services from South London PARTICIPANTS: Our maximal sample comprised 17 500 individuals aged 15 years or older who had received a primary or secondary SMI diagnosis (International Classification of Diseases, 10th edition, F20-31) between 2007 and 2018.

MEASURES

We designed and implemented a data extraction strategy for 21 common physical comorbidities using a natural language processing pipeline, MedCAT. Associations were investigated with sex, age at SMI diagnosis, ethnicity and social deprivation for the whole cohort and the BD and SSD subgroups. Linear regression models were used to examine associations with disability measured by the Health of Nations Outcome Scale.

RESULTS

Physical health data were extracted, achieving precision rates (F1) above 0.90 for all conditions. The 10 most prevalent conditions were diabetes, hypertension, asthma, arthritis, epilepsy, cerebrovascular accident, eczema, migraine, ischaemic heart disease and chronic obstructive pulmonary disease. The most prevalent combination in this population included diabetes, hypertension and asthma, regardless of their SMI diagnoses.

CONCLUSIONS

Our data extraction strategy was found to be adequate to extract physical health data from clinical notes, which is essential for future multimorbidity research using text records. We found that around 40% of our cohort had multimorbidity from which 20% had complex multimorbidity (two or more physical conditions besides SMI). Sex, age, ethnicity and social deprivation were found to be key to understand their heterogeneity and their differential contribution to disability levels in this population. These outputs have direct implications for researchers and clinicians.

Understanding the Effects of Antipsychotics on Appetite Control

Antipsychotic drugs (APDs) represent a cornerstone in the treatment of schizophrenia and other psychoses. The effectiveness of the first generation (typical) APDs are hampered by so-called extrapyramidal side effects, and they have gradually been replaced by second (atypical) and third-generation APDs, with less extrapyramidal side effects and, in some cases, improved efficacy. However, the use of many of the current APDs has been limited due to their propensity to stimulate appetite, weight gain, and increased risk for developing type 2 diabetes and cardiovascular disease in this patient group. The mechanisms behind the appetite-stimulating effects of the various APDs are not fully elucidated, partly because their diverse receptor binding profiles may affect different downstream pathways. It is critical to identify the molecular mechanisms underlying drug-induced hyperphagia, both because this may lead to the development of new APDs, with lower appetite-stimulating effects but also because such insight may provide new knowledge about appetite regulation in general. Hence, in this review, we discuss the receptor binding profile of various APDs in relation to the potential mechanisms by which they affect appetite.

Overweight in mood disorders: Effects on morbidity and treatment response

OBJECTIVE

As it is not clear how body-mass index (BMI) may relate to diagnosis, symptom-severity, illness-course, and treatment-response among psychiatric patients, we related BMI to psychiatric diagnosis and to selected clinical and demographic factors in major affective disorder subjects.

METHODS

We analyzed mean BMI levels vs. diagnosis, and evaluated selected risk factors for association with overweight and obesity among subjects with DSM-5 major affective disorders.

RESULTS

In 1884 subjects, BMI ranged from 23.4 kg/m² with anxiety disorders to 27.6 with psychotic disorders, and averaged 24.1 among 1469 affective disorder subjects. Mood-disorder subjects with BMI ≥ 25 (overweight/obese) were more likely: men, older, married, with more children and siblings, less education, lower socioeconomic status, engaged less in physical exercise, smoked more, and lived in less densely populated areas. They also were more likely to have: BD than MDD, familial mood disorders, no co-occurring ADHD, higher serum triglyceride levels, more time depressed and less improvement in depression ratings with treatment.

CONCLUSIONS

Risk of being overweight or obese was greatest with psychoses, least with anxiety, personality, and minor depressive disorders, and intermediate with major mood disorders. Several plausible risk factors for high BMI were identified in mood disorder subjects, including male sex and with BD > MDD. Striking were selectively greater prospective morbidity and decreased treatment-response for depression vs. mania with BMI ≥ 25.

COVID-19-Related Mortality Risk in People With Severe Mental Illness: A Systematic and Critical Review

Background: Increasing clinical evidence suggests that people with severe mental illness (SMI), including schizophrenia spectrum disorders, bipolar disorder (BD), and major depressive disorder (MDD), are at higher risk of dying from COVID-19. Several systematic reviews examining the association between psychiatric disorders and COVID-19-related mortality have recently been published. Although these reviews have been conducted thoroughly, certain methodological limitations may hinder the accuracy of their research findings. Methods: A systematic literature search, using the PubMed, Embase, Web of Science, and Scopus databases (from inception to July 23, 2021), was conducted for observational studies assessing the risk of death associated with COVID-19 infection in adult patients with pre-existing schizophrenia spectrum disorders, BD, or MDD. Methodological quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS). Results: Of 1,446 records screened, 13 articles investigating the rates of death in patients with pre-existing SMI were included in this systematic review. Quality assessment scores of the included studies ranged from moderate to high. Most results seem to indicate that patients with SMI, particularly patients with schizophrenia spectrum disorders, are at significantly higher risk of COVID-19-related mortality, as compared to patients without SMI. However, the extent of the variation in COVID-19-related mortality rates between studies including people with schizophrenia spectrum disorders was large because of a low level of precision of the estimated mortality outcome(s) in certain studies. Most studies on MDD and BD did not include specific information on the mood state or disease severity of patients. Due to a lack of data, it remains unknown to what extent patients with BD are at increased risk of COVID-19-related mortality. A variety of factors are likely to contribute to the increased mortality risk of COVID-19 in these patients. These include male sex, older age, somatic comorbidities (particularly cardiovascular diseases), as well as disease-specific characteristics. Conclusion: Methodological limitations hamper the accuracy of COVID-19-related mortality estimates for the main categories of SMIs. Nevertheless, evidence suggests that SMI is associated with excess COVID-19 mortality. Policy makers therefore must consider these vulnerable individuals as a high-risk group that should be given particular attention. This means that targeted interventions to maximize vaccination uptake among these patients are required to address the higher burden of COVID-19 infection in this already disadvantaged group.

The evaluation of a physical health promotion intervention for people with severe mental illness receiving community based accommodational support: a mixed-method pilot study

BACKGROUND

Unhealthy lifestyle constitutes a cause of increased morbidity and mortality in people with severe mental illness. The aim of this mixed-method pilot study was to investigate the feasibility and preliminary effectiveness of an intervention to promote a health-conscious lifestyle in comparison to care as usual among people with severe mental illness receiving accommodational support in community settings.

METHODS

This was a prospective, quasi-experimental, controlled study over four six-month assessment points (t0, + 6 months, + 12 months, + 18 months) with 70 persons with severe mental illness receiving community based accommodational support. Mental health staff members of the housing facilities were trained in Motivational Interviewing and conducted a six-week health course with the intervention group participants in addition to care as usual. Next to the primary outcome - self-rated physical well-being (FEW 16) - anthropometric parameters and unhealthy behaviours (diet, physical activity, alcohol and tobacco consumption, and oral hygiene) were examined. Effectiveness analysis was conducted using mixed-effects regression models with propensity score adjustment to control for selection bias. One year after the end of the intervention, semi-standardized expert interviews were conducted with 12 of these employees and evaluated by content analysis.

RESULTS

The qualitative interviews with mental health staff underline the intervention's feasibility in people with severe mental illness in sheltered housing, and the acceptability of and satisfaction with the intervention among mental health workers. But in this pilot study no superiority of the HELPS intervention compared to routine care could be demonstrated in terms of the investigated outcomes.

CONCLUSIONS

The findings of this pilot study underscore the feasibility and acceptability of health promotion programmes based on Motivational Interviewing and highlight the need to further develop multi-modal programs according to the needs of the target group. Long-term and sustainable support for healthy lifestyles of people with severe mental illness receiving community mental health care requires multi-modal concepts and organisational change.

TRIAL REGISTRATION

DRKS00011659 , date of registration was 2017/02/15; retrospectively registered as date of first enrolment was 2017/01/24.

Adipose Tissue Compartments, Inflammation, and Cardiovascular Risk in the Context of Depression

The neurobiological and behavioral underpinnings linking mental disorders, in particular, major depressive disorder (MDD), with cardiovascular disorders are a matter of debate. Recent research focuses on visceral (intra-abdominal and epicardial) adipose tissue and inflammation and their impact on the development of cardiometabolic disorders. Intra-abdominal adipose tissue is defined as an endocrine active fat compartment surrounding inner organs and is associated with type 2 diabetes mellitus, a risk factor for the later development of cardiovascular disorders. Epicardial (pericardial) adipose tissue is a fat compartment surrounding the heart with close proximity to the arteries supporting the heart. Visceral adipose tissue (VAT) is an important source of inflammatory mediators that, in concert with other risk factors, plays a leading role in cardiovascular diseases. In conjunction with the behavioral (physical inactivity, sedentary lifestyle), psychological (adherence problems), and hormonal (dysfunction of the hypothalamus-pituitary-adrenal axis with subsequent hypercortisolism) alterations frequently accompanying MDD, an enhanced risk for cardiovascular disorders results.

Psychological and Psychopharmacological Interventions in Psychocardiology

Patients with mental disorders have an increased risk to develop cardiovascular disease (CVD), and CVD are frequently comorbid with especially adjustment, anxiety and depressive disorders. Therefore, clinicians need to be aware of effective and safe psychological and pharmacological treatment strategies for patients with comorbid CVD and mental disorders. Cognitive behavioral therapy and third-wave of cognitive-behavioral therapy are effective for patients with CVD and mental disorders. Internet-based psychological treatments may also be considered. In more severe cases, psychopharmacological drugs are frequently used. Although generally well tolerated and efficacious, drug- and dose-dependent side effects require consideration. Among antidepressants, selective serotonin reuptake inhibitors, selective serotonin and noradrenalin reuptake inhibitors, and newer antidepressants, such as mirtazapine, bupropion, agomelatine, and vortioxetine, can be considered, while tricyclic antidepressants should be avoided due to their cardiac side effects. Mood stabilizers have been associated with arrhythmias, and some first- and second-generation antipsychotics can increase QTc and metabolic side effects, although substantial differences exist between drugs. Benzodiazepines are generally safe in patients with CVD when administered short-term, and may mitigate symptoms of acute coronary syndrome. Laboratory and ECG monitoring is always recommended in psychopharmacological drug-treated patients with CVD. Presence of a heart disease should not exclude patients from necessary interventions, but may require careful risk-benefit evaluations. Effectively and safely addressing mental disorders in patients with CVD helps to improve both conditions. Since CVD increase the risk for mental disorders and vice versa, care providers need to screen for these common comorbidities to comprehensively address the patients' needs.