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

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.

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.

Does Schizophrenia Itself Cause Obesity?

BACKGROUND

Schizophrenia (SC) is considered the most serious of all mental disorders. Some antipsychotics are associated with weight gain and metabolic abnormalities. Whether SC itself causes obesity remains uncertain.

METHODS

We collected 185 first-episode drug-naive SC and 59 healthy controls (HCs) from the Third People's Hospital of Foshan, Guangdong, China, and distinguished their course of disease in order to understand the body mass index (BMI) and body fat metabolism of SC.

RESULTS

We found that excluding the drug factors, the longer the course of SC, the more obvious the increase of BMI and the higher the proportion of obesity. BMI was positively correlated with age, course of disease, fasting blood glucose (FBG), low-density lipoprotein (LDL), triglyceride (TG), and total cholesterol (TC), and negatively correlated with high-density lipoprotein (HDL). The results of regression analysis were further proof that age (B = 0.094, p < 0.001), duration (B = 0.081, p = 0.002), FBG (B = 0.987, p = 0.004), and TG (B = 0.918, p = 0.002) were the risk factors for the increase of BMI. HDL (B = -2.875, p < 0.001) was the protective factor.

CONCLUSION

SC itself can increase BMI and easily lead to obesity. We should pay more attention to the monitoring of blood metabolism indicators, so as to reduce the risk of obesity and improve the quality of life of patients.

Effects of exercise on mortality rates of individuals with severe mental illness

Persons with severe mental illness have a 10-to-20-year shorter life span than the general public. Excess morbidity and mortality in this patient population has been described as a major public health challenge worldwide. Despite robust extant literature on the role of exercise in reducing morbidity and mortality, especially from cardiovascular disease and diabetes (highly prevalent in this patient population), Very few clinical programs or clinical research projects currently exist to implement and study the effects of exercise on decreasing morbidity and mortality in this highly vulnerable patient population. Given the global lack of trained mental health providers, the need to integrate healthcare providers from different disciplines, such as nurses, physical therapists, occupational therapists, physician assistants, cannot be overstated. This mini-review will provide an historic perspective and current data supporting the need to establish exercise, and other Lifestyle Psychiatry interventions, as a key component of treatment for all patients with serious mental illness.

The Toxicity Potential of Antidepressants and Antipsychotics in Relation to Other Medication and Alcohol: A Naturalistic and Retrospective Study

QT interval prolongation and ventricular tachyarrhythmia are potential adverse effects of antidepressant (AD) and antipsychotic- (AP) agents, especially when overdosed. Since AD and AP agents are often prescribed to patients suffering from suicidal intentions, it is essential to estimate these risks in the context of intoxications. This retrospective and naturalistic one-year registry study included 105 patients treated for oral intoxication at the University Department of Emergency Medicine in Vienna, Austria. AD/AP intoxications were present in 26 patients, while in the control group (n = 79) non-AD/AP drugs (n = 54) and exclusively alcohol (n = 25) were the toxic agents. QT intervals, the necessity of intubation, the extent of conscious state, and the subsequent discharge management were compared. The mean age was 34.94 ± 14.6 years, 62 patients (59%) were female. There were no significant between-group differences regarding QT prolongation >470 ms using Bazett's correction (p = 0.178), or >440 ms using Fridericia's correction (p = 0.760). No significant group differences concerning the need for intubation were observed (p = 0.747). The AD/AP and the control group did not significantly differ regarding Glasgow Coma Scale scores (p = 0.439). Patients with AD/AP intoxication were significantly more often transferred to the psychiatric department, while discharge to home was more likely in the control group (p = 0.002). These results suggest that the risk of a potentially life-threatening outcome in cases of intoxication with AD/AP is not substantially higher than in other easily available toxic agents, in line with the advantageous risk/benefit ratio of newer ADs and APs.

Echocardiographic study of cardiac structure and function in people with bipolar disorder after midlife

BACKGROUND

Heart failure is the leading cause of mortality in older people with bipolar disorder (BD). Studies examining cardiac structure and function in middle-aged patients with BD by using echocardiography and cardiac strain imaging are scant.

METHODS

We recruited 48 patients with bipolar I disorder (BD-I) older than 45 years to undergo conventional and tissue speckle tracking echocardiography. Data of 31 mentally healthy adults older than 45 years were randomly retrieved from the echocardiographic dataset and compared with the data of BD patients.

RESULTS

Patients with BD-I had significantly higher mean values of interventricular septal thickness (Cohen's d = 0.83, p = 0.001) and left ventricular internal diameter (Cohen's d = 0.90, p = 0.001) at end-diastole relative to controls. Additionally, BD-I patients exhibited significantly lower mean values of mitral valve E/A ratio (Cohen's d = 0.67, p = 0.007) and a more reduced global longitudinal strain (Cohen's d = 0.72, p = 0.029) than controls. Multiple linear regression revealed that body mass index was negatively correlated with the mitral valve E/A ratio (adjustment R² = 0.363, p = 0.043) in patients with BD-I.

LIMITATIONS

A relatively small sample size may limit generalization.

CONCLUSIONS

After midlife, BD patients exhibit cardiac diastolic (low mitral valve E/A ratio) and systolic (reduced global longitudinal strain) dysfunction. High body mass index may play a role in the unfavorable cardiac function in aging patients with BD.

Antipsychotic-Related Risks of Type 2 Diabetes Mellitus in Enrollees With Schizophrenia in the National Basic Public Health Service Program in Hunan Province, China

BACKGROUND

Antipsychotics contribute to the development of type 2 diabetes mellitus (T2DM) in individuals with schizophrenia. However, the extent of the relationship between antipsychotic use and T2DM varies in different settings, and the magnitude of the drug-specific effects fluctuates widely. This study aimed to explore the association of T2DM with antipsychotic use among enrollees with schizophrenia in China's National Basic Public Health Service Program (NBPHSP) and the drug-specific relationship with T2DM among patients receiving antipsychotic monotherapy.

METHODS

We recruited diabetes-free patients with schizophrenia who were enrolled in the NBPHSP of Hunan Province from October 2009 to December 2018. The participants were classified into the following three groups: regular antipsychotic use, intermittent antipsychotic use, and antipsychotic-free groups. The patients were followed up until they received a T2DM diagnosis or until April 2019. Cox regression models were constructed to calculate the overall and drug-specific hazard ratios (HRs) to determine the antipsychotic-T2DM relationship. Interactive and subgroup analyses were performed to assess the heterogeneity of the effects across subgroups.

RESULTS

A total of 122,064 NBPHSP enrollees with schizophrenia were followed up for 1,507,829 cumulative person-years, and 2,313 (1.89%) patients developed T2DM. Patients who regularly and intermittently used antipsychotics had 117% (HR: 2.17, 95% CI: 1.83-2.57) and 53% (HR: 1.53, 95% CI: 1.23-1.90) higher risks of developing T2DM than antipsychotic-free patients, respectively. Regarding monotherapy, the T2DM risk increased by 66, 80, 62, and 64% after the regular use of clozapine, risperidone, chlorpromazine, and perphenazine, respectively. In addition, the antipsychotic-related risk of T2DM decreased as the patient's baseline body mass index, and baseline fasting plasma glucose level, as well as the dietary proportion of animal products, increased.

CONCLUSION

Antipsychotics, especially clozapine, risperidone, chlorpromazine, and perphenazine, increased the T2DM risk among NBPHSP enrollees with schizophrenia. Mental health officers should accurately identify enrollees at a high risk of T2DM and take appropriate preventive measures to reduce the incidence of T2DM among patients with schizophrenia.

Increased circulating IL-18 levels in severe mental disorders indicate systemic inflammasome activation

BACKGROUND

Schizophrenia (SCZ) and bipolar disorder (BD) are severe mental illnesses (SMI) that are part of a psychosis continuum, and dysregulated innate immune responses have been suggested to be involved in their pathophysiology. However, disease-specific immune mechanisms in SMI are not known yet. Recently, dyslipidemia has been linked to systemic inflammasome activation, and elevated atherogenic lipid ratios have been shown to correlate with circulating levels of inflammatory biomarkers in SMI. It is, however, not yet known if increased systemic cholesterol load leads to inflammasome activation in these patients.

METHODS

We tested the hypothesis that patients with SCZ and BD display higher circulating levels compared to healthy individuals of key members of the IL-18 system using a large patient cohort (n = 1632; including 737 SCZ and 895 BD), and healthy controls (CTRL; n = 1070). In addition, we assessed associations with coronary artery disease risk factors in SMI, focusing on relevant inflammasome-related, neuroendocrine, and lipid markers.

RESULTS

We report higher baseline levels of circulating IL-18 system components (IL-18, IL-18BPA, IL-18R1), and increased expression of inflammasome-related genes (NLRP3 and NLRC4) in the blood of patients relative to CTRL. We demonstrate a cholesterol dyslipidemia pattern in psychotic disorders, and report correlations between levels of blood cholesterol types and the expression of inflammasome system elements in SMI.

CONCLUSIONS

Based on these results, we suggest a role for inflammasome activation/dysregulation in SMI. Our findings further the understanding of possible underlying inflammatory mechanisms and may expose important therapeutic targets in SMI.

We Should Improve Personalization of Management in Patients with a Diagnosis of Schizophrenia

The current management of patients with schizophrenia is marked by a lack of personalization. After the diagnosis is made, a second-generation antipsychotic is usually prescribed based on the current clinician's preferences, sometimes accompanied by a psychosocial intervention which is typically not evidence-based and not targeted to the specific needs of the individual patient. In this opinion paper, some steps are outlined that could be taken in order to address this lack of personalization. A special emphasis is laid on the clinical characterization of the patient who has received a diagnosis of schizophrenia. Considerations are put forward concerning the assessment of the negative dimension in ordinary clinical practice, which is often neglected; the evaluation of cognitive functioning using a simple test battery which requires limited professional training and takes no more than 15 min to administer; the evaluation of social functioning using a validated instrument focusing on personal care skills, interpersonal relationships, social acceptability, activities, and work skills; and the assessment of the unmet needs of the person (including practical, social, and emotional needs, and existential or personal recovery). The implications of the assessment of these domains for the formulation of the management plan are discussed.

Cardiovascular disease and mortality in people with schizophrenia or antipsychotic treatment: A cohort study in primary care

People with schizophrenia (SZ) or under treatment with antipsychotic drugs (TAD) are considered to be at high risk of cardiovascular (CV) morbidity and mortality, but the reasons are not fully understood. In addition, no longitudinal studies in the setting of primary care in Spain have been performed. We aimed at analysing the incidence of cardiovascular disease (CVD) and CV mortality in the population with SZ and in the population without SZ but under TAD (NS-TAD).

METHODS

Retrospective cohort study in primary care in Spain, based on data from computerized medical records and mortality recorded in the National Statistics Institute. Three groups were generated: SZ, NS-TAD and control group, with a 4-year follow-up period (2008 to 2011).

RESULTS

In an adjusted model, SZ was established as an independent risk factor for CV mortality although not with non-fatal CVD incidence. The NS-TAD group was an independent risk factor for mortality of any cause and CVD, but not CV mortality.

CONCLUSIONS

Differences between SZ and NS-TAD support that SZ has an increased risk of CVD independently of TAD. Further studies to evaluate the origin and management are needed. The detection of CVD and the consequent secondary CV prevention in these high-risk populations should be prioritized. Herein, a greater interaction between primary care and mental health services is eagerly needed.

Efficacy and Safety of Lumateperone for Major Depressive Episodes Associated With Bipolar I or Bipolar II Disorder: A Phase 3 Randomized Placebo-Controlled Trial

OBJECTIVE

In a phase 3 randomized double-blind placebo-controlled study, the authors investigated the efficacy and safety of 42 mg/day of lumateperone in patients with bipolar I or bipolar II disorder experiencing a major depressive episode.

METHODS

Patients 18-75 years old with a clinical diagnosis of bipolar I or bipolar II disorder and experiencing a major depressive episode were eligible for the study. Patients were randomized in a 1:1 ratio to receive 42 mg/day of lumateperone (N=188) or placebo (N=189), administered orally once daily in the evening for 6 weeks. The primary and key secondary efficacy endpoints were change from baseline to day 43 in score on the Montgomery-Åsberg Depression Rating Scale (MADRS) and total score on the Clinical Global Impressions Scale-Bipolar Version severity scale (CGI-BP-S), respectively. Safety assessments included treatment-emergent adverse events, laboratory parameters, vital signs, extrapyramidal symptoms, and suicidality.

RESULTS

At day 43, lumateperone treatment was associated with significantly greater improvement from baseline in MADRS score compared with placebo (least squares mean difference compared with placebo, -4.6 points; effect size=-0.56) and CGI-BP-S total score (least squares mean difference compared with placebo, -0.9; effect size=-0.46). Significant MADRS superiority for lumateperone over placebo was observed both in patients with bipolar I and bipolar II disorders. Somnolence and nausea were the only treatment-emergent adverse events that occurred with lumateperone at a clinically meaningful greater rate than placebo. The incidence of extrapyramidal symptom-related treatment-emergent adverse events was low and similar to that for placebo. Minimal changes were observed in weight, vital signs, or metabolic or endocrine assessments.

CONCLUSIONS

Lumateperone at 42 mg/day significantly improved depression symptoms and was generally well tolerated in patients with major depressive episodes associated with both bipolar I and bipolar II disorders.

Diabetes complication burden and patterns and risk of mortality in people with schizophrenia and diabetes: A population-based cohort study with 16-year follow-up

Schizophrenia is associated with increased prevalence of diabetes. However, risk of diabetes complications as well as the impact of complication burden and patterns on subsequent mortality risk in schizophrenia patients with co-existing diabetes is understudied. This population-based, propensity-score matched (1:10) cohort study identified 6991 patients with incident diabetes and pre-existing schizophrenia and 68,682 patients with incident diabetes only (comparison group) between 2001 and 2016 in Hong Kong, using territory-wide medical-record database of public healthcare services. Complications were measured by Diabetes Complications Severity Index (DCSI), which stratified complication burden into 6 levels (DCSI score=0, 1, 2, 3, 4, or ≥5). Associations of diabetes complications, in terms of DCSI scores (complication burden), specific types and two-way combinations of complications (complication patterns), with all-cause mortality rate in schizophrenia were evaluated using Cox proportional-hazards models. Schizophrenia group had comparable macrovascular (adjusted OR 0.99 [95% CI 0.92-1.06]) and lower microvascular (0.79 [0.73-0.86]) complication rates relative to comparison group. Mortality risk ratio for schizophrenia was elevated at all complication burden levels, which conferred incremental impact on excess mortality in both groups. Cardiovascular diseases (1.60 [1.45-1.77]) and cerebrovascular-metabolic diseases (2.74 [1.25-5.99]) were associated with the highest differential mortality in schizophrenia among various specific complications and complication combinations, respectively. Our results indicate that schizophrenia patients with co-existing diabetes are at increased risk of excess mortality relative to those with diabetes alone, regardless of complication burden levels. Implementation of multilevel, targeted interventions is needed to improve diabetes-related outcomes and reduce mortality gap in this vulnerable population.

Evaluation of metabolic monitoring practices for mental health consumers in the Southern District Health Board Region of New Zealand

WHAT IS KNOWN ON THIS SUBJECT?: The physical health of people with serious mental illness (SMI) is an issue of growing concern in New Zealand and internationally. Metabolic syndrome is prevalent among people with severe mental illness and increases the likelihood of developing cardiovascular disease and diabetes. No previous international research has investigated rates of metabolic monitoring in specialist mental health services and in primary care. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Rates of metabolic monitoring are low in this specialist mental health service and in primary care. Primary care nurses are positive in their views of their role in providing care for people with mental illness, and would value further education in this area. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Services need to consider ways in which nurses can be supported to improve rates of metabolic monitoring. Guidelines may have a role to play in improved monitoring but need service-level support in order to be effective. ABSTRACT: Introduction People with serious mental illness experience significant disparities in their physical health compared with the general population. One indicator of health impairment is metabolic syndrome, which increases the likelihood of developing cardiovascular disease and diabetes. No international studies have reported both primary care and mental health nurses' rates of metabolic monitoring among people with serious mental illness, and no New Zealand studies have investigated rates of metabolic monitoring. Aim To evaluate metabolic monitoring practices within one of New Zealand's 20 district health board regions. Method An audit of clinical records in primary care (n = 46) and secondary care (n = 47) settings and a survey of practice nurses were conducted. A survey was sent to 127 practice nurses with a response rate of 19% (n = 24). Data were analysed using descriptive statistics. Results Rates of metabolic monitoring were low in both services. Survey participants expressed positive views towards physical health monitoring and confidence in relating to mental health consumers. Rates of treatment of metabolic abnormalities were low, and communication between primary and secondary services was limited. Conclusion Despite existence of guidelines and protocols, metabolic monitoring rates in both primary and secondary health services are low. Incorporating metabolic monitoring systems into service delivery, supported by appropriate tools and resourcing, is essential to achieve better clinical outcomes for people experiencing mental illness.

Telomeres are shorter and associated with number of suicide attempts in affective disorders

BACKGROUND

Shorter telomere length is a putative biomarker of accelerated aging and has been associated with affective disorders and mortality. Psychological factors and behaviors associated with telomere shortening are yet to be clarified. Here, we investigate the association between history of suicide attempts and telomere length in patients with affective disorders.

METHODS

Leucocyte telomere length was determined by quantitative real-time Polymerase Chain Reaction (qPCR) in patients with affective disorders (n = 248) including bipolar disorders type I (n = 159), type II (n = 67), major depressive disorder (n = 22), and healthy controls (n = 401). Diagnosis, duration of illness, and age at onset were assessed using the Structural Clinical Interview for DSM-IV (SCID-I). Number of lifetime suicide attempts were based on self-reports. Effect size was calculated using Cohen's d.

RESULTS

Telomere length was reduced in patients with affective disorders relative to healthy controls (d = 0.18, F = 5.26, p = 0.02). Among patients, a higher number of suicide attempts was associated with shorter telomere length (β = -0.24, t = -3.83, CI = -0.44 to -0.14, p < 0.001), also when controlling for duration of illness and age at onset (β = -.23, CI = -.42 to -.12, p = 0.001). Multiple suicide attempts were associated with telomere length reduction comparable to eight years lifespan, adjusted for demographic and clinical characteristics.

CONCLUSIONS

While longitudinal data are needed to clarify the temporal course, previous suicide attempts and related distress may accelerate telomere shortening and aging in patients with affective disorders.

Bipolar Disorder and Cardiovascular Risk in Rural versus Urban Populations in Colombia: A Comparative Clinical and Epidemiological Evaluation

Background:

Various multifactorial elements may contribute toward the urban and rural disparities in cardiovascular disease (CVD) risk, particularly among patients with psychiatric diseases.

Objective:

To investigate whether rural patients diagnosed and treated for Bipolar Disorder (BD) have different risk profiles and outcomes of CVD compared to urban (BD) patients.

Methods:

We conducted a case-control study that included 125 BD patients (cases) from rural Filadelfia, Colombia and 250 BD patients (controls) treated in Bogotá, Colombia. Cases and controls were 2:1, matched by age and sex. We applied the Framingham Heart Study (FHS) risk calculator to assess risk. Differences by rural/urban status (i.e., case-control status) were assessed by chi-square, paired t-tests, and logistic regression.

Findings:

Rural BD patients were found to have lower education (p = 1.0 × 10^–4), alcohol consumption (p = 3.0 × 10^–4), smoking (p = 0.015), psychiatric (p = 1.0 × 10^–4) and CV family history (p = 0.0042) compared to urban BD patients. Rural BD patients were 81% more likely to have a more favorable CVD risk profile (OR: 0.19, 95% CI [0.06–0.62]) than urban BD patients, despite rural BD patients having increased CVD morbidity (p = 1.0 × 10^–2).

Conclusion:

Based on increase in morbidity but lower predictive risk in the rural population, our study suggests that the FHS-CVD calculator may not be optimal to assess CVD risk in this population.

Undiagnosed disease in decedents with and without schizophrenia: an autopsy-based case-control study

BACKGROUND

Individuals with schizophrenia (SCZ) suffer from higher morbidity and mortality than the general population. Some of this is due to concurrent somatic disease.

AIMS

To identify and compare the somatic comorbidities antemortem (AM) and postmortem (PM) in autopsied decedents with SCZ and with no mental illness (NMI), using the Charlson Comorbidity Index (CCI).

MATERIALS

A total of 106 autopsied decedents with SCZ and 156 decedents with NMI were included. AM diagnoses were sampled from Danish national health registers. PM diagnoses were included from forensic autopsies. Negative binomial regression models were used to test associations between age, sex, SCZ diagnosis, manner of death and the CCI score both AM and PM.

RESULTS

The CCI score increased significantly from AM to PM for both decedents with SCZ and NMI (SCZ, AM 0.669 vs PM 1.208, p = 0.008) (NMI, AM 0.519 vs PM 1.218, p = 0.000). Regression analysis showed that age was significantly associated with the CCI score both AM and PM (AM, OR 1.044 [1.029-1.060] p ≤ 0.001) (PM, OR 1.028 [1.015-1.041], p ≤ 0.001). A diagnosis of SCZ was correlated with the CCI score AM but not PM (AM, OR 1.880 [1.207-2.928], p = 0.005) (PM, OR 1.170 [0.828-1.654], p = 0.374).

CONCLUSION

The autopsies revealed undiagnosed diseases in both decedents with SCZ and NMI. The diseases were primarily of cardiovascular, pulmonary and gastrointestinal origin and may have contributed to premature mortality. Age was the only covariate significantly associated with the CCI score both AM and PM; the SCZ diagnosis was positively correlated to the CCI score before death.

A human iPSC-astroglia neurodevelopmental model reveals divergent transcriptomic patterns in schizophrenia

While neurodevelopmental abnormalities have been associated with schizophrenia (SCZ), the role of astroglia in disease pathophysiology remains poorly understood. In the present study, we used a human induced pluripotent stem cell (iPSC)-derived astrocyte model to investigate the temporal patterns of astroglia differentiation during developmental stages critical for SCZ using RNA sequencing. The model generated astrocyte-specific gene expression patterns during differentiation that corresponded well to astroglia-specific expression signatures of in vivo cortical fetal development. Using this model we identified SCZ-specific expression dynamics, and found that SCZ-associated differentially expressed genes were significantly enriched in the medial prefrontal cortex, striatum, and temporal lobe, targeting VWA5A and ADAMTS19. In addition, SCZ astrocytes displayed alterations in calcium signaling, and significantly decreased glutamate uptake and metalloproteinase activity relative to controls. These results implicate novel transcriptional dynamics in astrocyte differentiation in SCZ together with functional changes that are potentially important biological components of SCZ pathology.

The effect of mental health conditions on the use of oral anticoagulation therapy in patients with atrial fibrillation: The FinACAF Study

Aims

Little is known about the effects of mental health conditions (MHCs) on the utilization of oral anticoagulation (OAC) therapy in atrial fibrillation (AF) patients. We aimed to assess whether MHCs affect initiation of OAC therapy among AF patients with special focus on non-vitamin K antagonist oral anticoagulants (NOACs).

Methods and results

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) registry included all 239 222 patients diagnosed with incident AF during 2007–18 in Finland identified from national registries covering primary to tertiary care and drug purchases. Patients with previous depression, bipolar disorder, anxiety disorder, or schizophrenia diagnosis or a fulfilled psychiatric medication prescription within the year preceding the AF diagnosis were classified to have any MHC. The main outcome was OAC initiation, defined as first fulfilled OAC prescription after AF diagnosis. The patients’ mean age was 72.7 years and 49.8% were female. The prevalence of any MHC was 19.9%. A lower proportion of patients with any MHC compared with those without MHCs were initiated on OAC therapy (64.9% vs. 73.3%, P < 0.001). Any MHC was associated with lower incidence of OAC initiation [adjusted subdistribution hazard ratio (aSHR) 0.867; 95% confidence interval (CI) 0.856–0.880], as were depression (aSHR 0.868; 95% CI 0.856–0.880), bipolar disorder (aSHR 0.838; 95% CI 0.824–0.852), anxiety disorder (aSHR 0.840; 95% CI 0.827–0.854), and schizophrenia (aSHR 0.838; 95% CI 0.824–0.851), during the entire follow-up. Any MHC remained associated with impaired incidence of OAC initiation also in the NOAC era during 2015–18 (aSHR 0.821; 95% CI 0.805–0.837).

Conclusion

MHCs are common among AF patients, and they are associated with a lower rate of OAC initiation even during the NOAC era.

The impact of mental health conditions on oral anticoagulation therapy and outcomes in patients with atrial fibrillation: A systematic review and meta-analysis

One third of patients with atrial fibrillation (AF) are estimated to suffer from mental health conditions (MHCs). We conducted a systematic review and meta-analysis to investigate the impact of MHCs on the prevalence and quality of oral anticoagulation (OAC) therapy and outcomes in patients with AF. Medline database was searched for studies published before March 1st 2021 evaluating AF patients with comorbid MHCs reporting on the prevalence of OAC therapy, time in therapeutic range (TTR) in warfarin-receiving patients, adherence to OAC therapy or adverse outcomes (ischemic stroke, hemorrhage or mortality). Studies reporting on outcome events were included in the meta-analysis. The literature search yielded 17 studies including 977,535 patients that fulfilled the inclusion criteria of this review. AF patients with MHCs had a lower prevalence of OAC use and poorer TTR compared with patients without MHCs. Evidence on OAC quality in patients receiving direct oral anticoagulants (DOACs) was minimal and inconclusive. A decrease in depression-associated deficit in OAC prevalence was observed after the introduction of DOACs. Pooled analysis of five studies reporting on outcomes showed that MHCs were an independent risk factor for both stroke (RR 1.25, 95%CI 1.08-1.45, I² 0%) and major bleeding (RR 1.17, 95%CI 1.08-1.27, I² 27%). Data on mortality were lacking and therefore not included in the meta-analysis. Evidence on the impact of specific MHCs on the outcomes were inadequate. In conclusion, MHCs are independent risk factors for stroke and major bleeding in patients with AF. Future studies are needed to confirm the findings of this meta-analysis, to evaluate the prognostic impact of different MHCs and to clarify whether the introduction of DOACs might have improved the outcomes of these patients.

Evaluation of cardiovascular risk in adult psychiatric outpatients in Qatar using two risk assessment tools

Introduction: Individuals with serious mental illness (SMI) experience premature death, likely due to increased rates of obesity and cardiovascular disease (CVD). This study was conducted to estimate the CVD risk in a cohort of individuals with SMI receiving outpatient psychiatric services in Qatar and to assess contributory CVD risk factors.

Methods: This is a retrospective review of the electronic medical records of a cohort of outpatients with SMI attending a mental health clinic in Doha, Qatar. The CVD risk was estimated using two risk prediction tools: the American Heart Association and the American College of Cardiology (AHA/ACC) risk calculator and the World Health Organization/International Society of Hypertension (WHO/ISH) CVD risk prediction charts for the Eastern Mediterranean region. Descriptive and inferential statistics were used to analyze the demographic and clinical data. Data were analyzed using Statistical Package for the Social Sciences.

Results: Of the 346 eligible patients, 28% (n = 97) had obtainable data for the estimation of their CVD risk using both tools. Approximately one-third of the cohort (33%) were classified as high risk using the AHA/ACC risk calculator, and 13.3% were classified as intermediate to high risk using the WHO/ISH CVD risk prediction charts. Based on the AHA/ACC risk scores, among those with a high CVD risk, almost two-thirds had CVD modifiable risk factors (i.e., smoking, diabetes, dyslipidemia, and hypertension). No statistically significant difference in the CVD risk estimates was observed among individuals with a body mass index of more or lower than 30 kg/m² (p = 0.815).

Conclusion: Based on the AHA/ACC risk calculator, approximately one-third of the study cohort had high CVD risk estimates. The WHO/ISH CVD risk prediction charts appeared to underestimate CVD risk, particularly for those identified as high risk using the AHA/ACC risk calculator. A closer alliance between psychiatrists and primary healthcare professionals to control modifiable cardiovascular risk factors among patients with SMI is necessary.

The SOFIA pilot trial: a cluster-randomized trial of coordinated, co-produced care to reduce mortality and improve quality of life in people with severe mental illness in the general practice setting

Background

People with severe mental illness (SMI) have an increased risk of premature mortality, predominantly due to somatic health conditions. Evidence indicates that primary and tertiary prevention and improved treatment of somatic conditions in patients with SMI could reduce this excess mortality. This paper reports a protocol designed to evaluate the feasibility of a coordinated co-produced care program (SOFIA model, a Danish acronym for Severe Mental Illness and Physical Health in General Practice) in the general practice setting to reduce mortality and improve quality of life in patients with severe mental illness.

Methods

The SOFIA pilot trial is designed as a cluster randomized controlled trial targeting general practices in two regions in Denmark. We aim to include 12 practices, each of which is instructed to recruit up to 15 community-dwelling patients aged 18 and older with SMI. Practices will be randomized by a computer in a ratio of 2:1 to deliver a coordinated care program or usual care during a 6-month study period. A randomized algorithm is used to perform randomization. The coordinated care program includes educational training of general practitioners and their clinical staff educational training of general practitioners and their clinical staff, which covers clinical and diagnostic management and focus on patient-centered care of this patient group, after which general practitioners will provide a prolonged consultation focusing on individual needs and preferences of the patient with SMI and a follow-up plan if indicated. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively. Assessments of the outcome parameters will be administered at baseline, throughout, and at end of the study period.

Discussion

If necessary the intervention will be revised based on results from this study. If delivery of the intervention, either in its current form or after revision, is considered feasible, a future, definitive trial to determine the effectiveness of the intervention in reducing mortality and improving quality of life in patients with SMI can take place. Successful implementation of the intervention would imply preliminary promise for addressing health inequities in patients with SMI.

Trial registration

The trial was registered in Clinical Trials as of November 5, 2020, with registration number NCT04618250.

Protocol version: January 22, 2021; original version

Rising co-payments and continuity of healthcare for Dutch patients with bipolar disorder: retrospective longitudinal cohort study

Background

The Netherlands has few financial barriers to access mental healthcare. However, in 2012, a sharp rise in co-payments was introduced.

Aims

We tested whether these increased co-payments coincided with less guideline-recommended continuous out-patient psychiatric care and more crisis interventions for patients with bipolar disorder.

Method

A retrospective longitudinal cohort study on a health insurance registry was performed to examine trends, and deviations from these trends, in the healthcare received by patients with bipolar disorder. Deviations of trends were tested by time-series analyses (autoregressive integrated moving average). Subsequently, the relationship between significant deviations of trends and rise in co-payments was examined. Outcome measures were the level of standard out-patient care (out-patient psychiatric care and/or medication), crisis psychiatric care and somatic care.

Results

The cohort comprised 3210 patients. During follow-up, the use of psychiatric care decreased and somatic care increased. The high rise in co-payments from 2012 onward coincided with decreases in standard out-patient care and increases in medication-only treatment, crisis psychiatric care and somatic care. Crisis intervention was highest when patients received only bipolar disorder medication. Patients receiving continuous standard out-patient care (62%) had less crisis intervention compared with the other patients.

Conclusions

Our data suggest that the rise of co-payments decreased guideline-recommended continuous out-patient psychiatric care among patients with bipolar disorder, and increased crisis psychiatric care.

Psychosocial interventions for people with a first episode psychosis: between tradition and innovation

PURPOSE OF REVIEW

Assessing recent evidence on psychosocial interventions for people with first episode psychosis (FEP).

RECENT FINDINGS

Family interventions (FI) reduce relapse rates, whilst cognitive behavioural therapy (CBT) shows a moderate effect in improving positive psychotic symptoms. Vocational interventions (VI) appear to be worthy of implementation within early intervention for psychosis (EIP) teams, but it is still unclear what is the most cost-effective strategy for their delivery. Promising interventions, which need more careful evaluation, focus on substance misuse, physical health comorbidities, improvement of social participation, peer support and the potential of new technologies.

SUMMARY

The first five years after the onset of psychotic symptoms are a 'critical period' in which psychosocial interventions can be particularly influential in determining prognosis. Traditional EIP interventions have different effectiveness profiles, i.e., FI reduce relapse rates, CBT has a moderate effectiveness on overall and positive symptoms and VI can improve educational and employment-related functioning. Newer interventions show promise on important targets for FEP treatment but require higher-quality evaluations. Decisions on which interventions to implement within EIP teams should be informed by high-quality evidence, but difficult choices will have to be made based on costs, professionals and technologies available, and local priorities.

Association between valproate treatment for acute phase schizophrenia and risk of new onset hypothyroidism

AIM

To assess the association between acute phase treatment by valproate as an adjunctive drug and risk of new onset hypothyroidism in a large cohort of patients affected by schizophrenia.

METHODS

We conducted a retrospective cohort study in a psychiatric hospital in China between January 2016 and December 2018. We obtained approval from the Ethics Committee of the study hospital prior to the commencement of the study. Patients who were diagnosed with schizophrenia and admitted to the study hospital during the study period with thyroid function tests at admission and during hospitalization were included. Patients with abnormal thyroid function at admission were excluded. Hypothyroidism, defined as TSH>4.2 mU/L or on L-thyroxine treatment, was the primary outcome. The primary exposure was adjunctive valproate plus atypical antipsychotics (AAPD), the secondary exposure was lithium plus AAPD and the comparison group was AAPD only. Adjusted relative risk (RR) and 95% confidence interval (CI) were estimated by log-binomial model to assess the independent association between valproate treatment and risk of hypothyroidism.

RESULTS

A total of 1622 eligible patients were included the final analysis. Rate of new onset hypothyroidism was 10.7% and 20.9% in AAPD only and valproate plus AAPD groups, respectively. Adjusted RR (95% CI) for valproate plus AAPD was 1.85 (1.44-2.38), with AAPD only group as reference. Similarly, adjusted RR (95% CI) for lithium plus AAPD was 1.93 (1.32-2.69).

CONCLUSION

Similar with lithium, valproate as adjunctive drug is associated with increased risk of new onset hypothyroidism during acute phase treatment for schizophrenia.

Safety and tolerability of lumateperone for the treatment of schizophrenia: a pooled analysis of late-phase placebo- and active-controlled clinical trials

Lumateperone, an antipsychotic that is US Food and Drug Administration-approved for the treatment of schizophrenia, has a novel mechanism of action that may confer beneficial effects with improved tolerability. This pooled analysis of three randomized, double-blind, placebo-controlled trials was conducted to evaluate the safety and tolerability of lumateperone 42 mg. The pooled population comprised 1073 patients with an acute exacerbation of schizophrenia randomized to placebo (n = 412), lumateperone 42 mg (n = 406) or risperidone 4 mg (n = 255). Treatment-emergent adverse events (TEAEs) were predominantly mild and rates of discontinuation due to TEAEs with lumateperone 42 mg (0.5%) were similar to placebo (0.5%) and lower than risperidone (4.7%). The only TEAEs that occurred at a rate of ≥5% and twice placebo for lumateperone were somnolence/sedation and dry mouth. Mean change from baseline in metabolic parameters and prolactin were similar to or reduced in lumateperone 42 mg relative to placebo-treated patients and were smaller than risperidone. Mean change in weight and rates of extrapyramidal symptoms-related TEAEs were similar for lumateperone 42 mg and placebo-treated patients and less than for risperidone-treated patients. This pooled analysis demonstrates the safety and favorable tolerability profile of lumateperone 42 mg.

Body mass index increase in preschoolers with heterogeneous psychiatric diagnoses treated with risperidone

OBJECTIVE

Use of risperidone in preschool-aged children is growing, with rising concerns of adverse metabolic consequences. Longitudinal data on risperidone-related weight gain in preschoolers are scarce. We aimed to evaluate changes in body mass index (BMI) that are associated with risperidone treatment in preschoolers.

METHOD

We analyzed naturalistic, longitudinal data on 141 preschool children (112 boys, 29 girls) receiving psychiatric care. Mean patient age at baseline was 5.0 years (SD=0.8) and average follow-up period was 1.3 years (SD=0.8), with >8 mean BMI measurements per patient. We studied the effect of risperidone exposure (n=78) on age-and-sex-standardized BMI (BMI Z-score) implementing mixed models with random subject intercepts to account for repeated measures, covarying for multiple confounders including demographics, stimulant treatment and psychiatric diagnoses. We employed similar models to study dose and duration effects.

RESULTS

Risperidone treatment was significantly associated with an increase in BMI (effect size of exposure=0.45 SD (SE=0.06), t (949)=7.7, p<0.001) covarying for stimulant exposure and other confounders, independent of treatment indication. Females exhibited stronger effects (risperidone treatment × sex interaction t=2.32, p=0.02)). Risperidone daily dose was associated with increase in BMI (for each additional 1 mg, effect size=0.28 SD (SE=0.07), t(419)=3.76, p<0.001).

CONCLUSION

Similar to older populations, risperidone treatment in preschoolers is associated with significant weight gain, with evidence for dose effects. Findings provide critical data that can inform clinicians.

Risk of hospitalised falls and hip fractures in working age adults receiving mental health care

OBJECTIVE

This retrospective cohort study investigates risks of hospitalised fall or hip fractures in working age adults receiving mental health care in South London.

METHODS

Patients aged 18 to 64, who received a first mental illness diagnosis between 2008 and 2016 were included. Primary outcome was hospitalised falls, secondary outcome was hip fractures. Age- and gender-standardised incidence rates and incidence rate ratios (IRRs) compared to local general population were calculated. Multivariate Cox proportionate hazard models were used to investigate which mental health diagnoses were most at risk.

RESULTS

In 50,885 patients incidence rates were 8.3 and 0.8 per 1,000 person-years for falls and hip fractures respectively. Comparing mental health patients to the general population, age-and-gender-adjusted IRR for falls was 3.6 (95% CI: 3.3-4.0) and for hip fractures 7.5 (95% CI: 5.2-10.4). The falls IRR was highest for borderline personality and bipolar disorder and lowest for schizophreniform and anxiety disorder. After adjusting for multiple confounders in the sample of mental health service users, borderline personality disorder yielded a higher and anxiety disorder a lower falls risk.

CONCLUSION

Working age adults using mental health services have almost four times the incidence of hospitalised falls compared to general population. Targeted interventions are warranted.

Incidence of Orthostatic Hypotension in Schizophrenic Patients Using Antipsychotics at Sambang Lihum Mental Health Hospital, South Kalimantan

Schizophrenia is a psychiatric disorder that requires antipsychotics therapy. Antipsychotics cause many side effects, including orthostatic hypotension. The study aimed to describe the incidence of orthostatic hypotensive side effects experiences by schizophrenia patients at the Sambang Lihum Mental Health Hospital, South Kalimantan. This research was observational description research with data sampling by medical records. This research was conducted to 300 medical records of patients period January-December 2018 which received antipsychotics medication and data analyzed by univariate analysis. The results showed the number of patients who experienced orthostatic hypotension was 98 patients (32.67%) and no experienced were 202 patients (67.33%). Incidence of orthostatic hypotension in haloperidol 54.35% (N=46); trifluoperazine 100% (N=1); clozapine 84.62% (N=13); olanzapine 100% (N=1); haloperidol-chlorpromazine 27.27% (N=11); haloperidol-haloperidol 42.86% (N=7); clozapine-risperidone 16.67% (N=6); haloperidol-clozapine 15.05% (N=93); haloperidol-olanzapine 50% (N=2); haloperidol-risperidone 31.82% (N=22); trifluoperazine-olanzapine 100% (N=1); trifluoperazine-clozapine 22.22% (N=9); trifluoperazine-risperidone 5.56% (N=18); chlorpromazine-haloperidol-haloperidol 33.3% (N=3); chlorpromazine-haloperidol-trifluoperazine 100% (N=3); haloperidol-trifluoperazine-chlorpromazine 100% (N=1); chlorpromazine-haloperidol-clozapine 42.86% (N=7); chlorpromazine-trifluoperazine-clozapine 100% (N=1); chlorpromazine-trifluoperazine-olanzapine 100% (N=1); chlorpromazine-trifluoperazine-risperidone 50% (N=2); trifluoperazine-haloperidol-risperidone 100% (N=4); haloperidol-trifluoperazine-risperidone 100% (N=1); trifluoperazine-haloperidol-clozapine 40% (N=5); haloperidol-haloperidol-clozapine 80% (N=5); clozapine-risperidone-trifluoperazine 100% (N=4); risperidone-clozapine-haloperidol 20% (N=10). The conclusion from this study was the percentage of orthostatic hypotension on schizophrenia patients at the Sambang Lihum Mental Health Hospital was 32.67% (N=98).

Risperidone-Induced Neutropenia in a Schizophrenic Patient: A Case Report and Literature Review

Neutropenia is an adverse effect of various pharmacological therapies, including antipsychotics. Among the second-generation antipsychotic (SGA) medications, clozapine is most notable for neutropenic adverse effect. Risperidone, another SGA drug, is linked mainly with metabolic adverse effects, but rarely, blood dyscrasia adverse reactions have been reported. Hence, we report the case of a 56-year-old African American woman who developed severe neutropenia following two weeks of oral risperidone treatment. Her neutrophil levels returned to normal limits following discontinuation of risperidone and switching to haloperidol.

[Depression therapy for somatic diseases]

A review of works devoted to the problem of psychopharmacotherapy of depression in general medical practice is presented. The issues of its comorbidity with somatic and neurological diseases, as well as multimorbidity are discussed. Both direct and side-effects of antidepressants, which are important for effective therapy of not only affective disorders proper, but also the symptoms of the leading pathology, are considered in detail for individual organs and systems. The analysis of the preferred pharmacological classes of antidepressants, which are drugs of first choice, taking into account the somatic condition of the patient, is carried out, and drugs are indicated, the appointment of which is undesirable for the treatment of a patient with a certain disease. The presented results are aimed both at increasing the efficiency of therapy for patients with general medical level of health care, and at increasing the safety of treatment of psychiatric patients with concomitant somatic disorders.

Renewed call for lifestyle interventions to address obesity among individuals with serious mental illness in the COVID-19 era and beyond

Behavioral health has the opportunity to lead the way in using lifestyle interventions to address obesity and health disparities in people with serious mental illness (SMI) in the COVID-19 era. Evidence-based interventions for weight loss in individuals with SMI exist, and the field has developed strategies for implementing these interventions in real-world mental health care settings. In addition to promoting weight loss, lifestyle interventions have the potential to address social isolation and loneliness and other patient-centered outcomes among individuals with SMI, which will be especially valuable for mitigating the growing concerns about loneliness attributed to the COVID-19 pandemic restrictions on in-person encounters. In this commentary, we discuss practice, policy, and research implications related to using evidence-based lifestyle interventions for individuals with SMI during the COVID-19 pandemic and sustaining these programs in the long-term.

Mind-Body Connection: Cardiovascular Sequelae of Psychiatric Illness

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the world. Mental health disorders are associated with the onset and progression of cardiac disease. The adverse sequelae of this association include worsened quality of life, adverse cardiovascular outcomes, and heightened mortality. The increased prevalence of CVD is partly explained by increased rates of traditional cardiovascular risk factors including hypertension, hyperlipidemia, diabetes mellitus, obesity, and smoking, but mental illness is an independent risk factor for CVD and mortality. Given the association between mental health disorders and poor cardiovascular health, it is vital to have an early and accurate identification and treatment of these disorders. Our review article shares the current literature on the adverse cardiovascular events associated with psychiatric disorders. We present a review on depression, anxiety, bipolar disorder, schizophrenia, type A and D personality disorders, obsessive-compulsive disorder, and stress.

Vascular surgery receipt and outcomes for people with serious mental illnesses: Retrospective cohort study using a large mental healthcare database in South London

OBJECTIVE

Vascular surgery can be common among people with serious mental illness (SMI) given the high prevalence of cardiovascular disease. However, post-operative outcomes following vascular surgery have received little investigation, particularly in a subpopulation of SMI.

METHODS

We conducted a retrospective observational study using data from the South London and Maudsley NHS Foundation Trust (SLaM) via its Clinical Record Interactive Search (CRIS) platform and linkage with Hospital Episode Statistic (HES). Vascular surgery recipients were identified using OPCS version 4 codes. Length of stay (LOS) was modelled using Incidence Rate Ratios (IRRs), and 30-day emergency hospital readmissions using Odds Ratios (ORs) for people with SMI compared with the general population.

RESULTS

Vascular surgery was received by 152 patients with SMI diagnoses (schizophrenia, schizoaffective disorder, bipolar disorder) and 8821 catchment residents without any mental health conditions. People with active SMI symptoms more likely to be admitted to hospital via emergency route OR: 1.80 (95% CI: 1.06, 3.07) and more likely to stay longer in the hospital for vascular surgery IRR: 1.35 (1.01, 1.80) and more likely to be readmitted to hospital via emergency route within 30 days OR: 1.53 (1.02, 2.67). People with SMI who had major open vascular surgery and peripheral endovascular surgery more likely to have worse post-operative outcomes.

CONCLUSION

Our study highlights the risks faced by people with SMI following vascular surgery. These suggest tailored guidelines and policies are needed, based on the identification of pre-operative risk factors, allowing for focused post-vascular surgery care to minimise adverse outcomes.

Extensive bidirectional genetic overlap between bipolar disorder and cardiovascular disease phenotypes

Patients with bipolar disorder (BIP) have a high risk of cardiovascular disease (CVD), despite considerable individual variation. The mechanisms underlying comorbid CVD in BIP remain largely unknown. We investigated polygenic overlap between BIP and CVD phenotypes, including CVD risk factors and coronary artery disease (CAD). We analyzed large genome-wide association studies of BIP (n = 51,710) and CVD phenotypes (n = 159,208-795,640), using bivariate causal mixture model (MiXeR), which estimates the total amount of shared genetic variants, and conjunctional false discovery rate (FDR), which identifies specific overlapping loci. MiXeR revealed polygenic overlap between BIP and body mass index (BMI) (82%), diastolic and systolic blood pressure (20-22%) and CAD (11%) despite insignificant genetic correlations. Using conjunctional FDR < 0.05, we identified 129 shared loci between BIP and CVD phenotypes, mainly BMI (n = 69), systolic (n = 53), and diastolic (n = 53) blood pressure, of which 22 are novel BIP loci. There was a pattern of mixed effect directions of the shared loci between BIP and CVD phenotypes. Functional analyses indicated that the shared loci are linked to brain-expressed genes and involved in neurodevelopment, lipid metabolism, chromatin assembly/disassembly and intracellular processes. Altogether, the study revealed extensive polygenic overlap between BIP and comorbid CVD, implicating shared molecular genetic mechanisms. The mixed effect directions of the shared loci suggest variation in genetic susceptibility to CVD across BIP subgroups, which may underlie the heterogeneity of CVD comorbidity in BIP patients. The findings suggest more focus on targeted lifestyle interventions and personalized pharmacological treatment to reduce CVD comorbidity in BIP.

Effects of quetiapine administration on sperm quality and testicular histology

Quetiapine is one of the most commonly prescribed antipsychotics to treat schizophrenia in adults, in particular. In this study, quetiapine's effects were assessed on healthy sperm production in rats at repeated-pharmacological doses. Additionally, the effects of quetiapine on oxidative status and hormonal balance were also evaluated in rats. Quetiapine was administered to rats orally at 10, 20, and 40 mg/kg body weight doses for 28 days. At the end of this period, body and organ weights were measured, sperm concentration, motility, and morphology were determined, sperm damage was assessed, and histopathological analysis of testicular tissue was performed. Additionally, serum FSH, LH, and testosterone levels as male reproductive hormones were measured. Catalase, superoxide dismutase, glutathione, and malondialdehyde levels were determined for evaluating the oxidative status of testicular tissue. The findings obtained in this study showed that relative epididymis weights and sperm concentration decreased and abnormal sperm morphology increased in quetiapine-administered rats. Irregularity of typical architecture of the seminiferous tubules and germinal cell disorganization was observed in testicular sections of 20 and 40 mg/kg quetiapine-administered rats. Further, serum LH and testosterone levels decreased in 20 and 40 mg/kg quetiapine-administered rats. Additionally, decreased catalase and superoxide dismutase activities in testicular tissue of quetiapine-administered rats and increased malondialdehyde levels in testicular tissue of 40 mg/kg quetiapine-administered rats were measured. In conclusion, quetiapine treatment decreased sperm quality, altered hormone levels, and induced oxidative stress may be considered potential contributors to this adverse effect.

Severe mental illness is associated with increased mortality and severe course of COVID-19

OBJECTIVE

Psychiatric disorders have been associated with unfavourable outcome following respiratory infections. Whether this also applies to coronavirus disease 2019 (COVID-19) has been scarcely investigated.

METHODS

Using the Danish administrative databases, we identified all patients with a positive real-time reverse transcription-polymerase chain reaction test for COVID-19 in Denmark up to and including 2 January 2021. Multivariable cox regression was used to calculate 30-day absolute risk and average risk ratio (ARR) for the composite end point of death from any cause and severe COVID-19 associated with psychiatric disorders, defined using both hospital diagnoses and redemption of psychotropic drugs.

RESULTS

We included 144,321 patients with COVID-19. Compared with patients without psychiatric disorders, the standardized ARR of the composite outcome was significantly increased for patients with severe mental illness including schizophrenia spectrum disorders 2.43 (95% confidence interval [CI], 1.79-3.07), bipolar disorder 2.11 (95% CI, 1.25-2.97), unipolar depression 1.70 (95% CI, 1.38-2.02), and for patients who redeemed psychotropic drugs 1.70 (95% CI, 1.48-1.92). No association was found for patients with other psychiatric disorders 1.13 (95% CI, 0.86-1.38). Similar results were seen with the outcomes of death or severe COVID-19. Among the different psychiatric subgroups, patients with schizophrenia spectrum disorders had the highest 30-day absolute risk for the composite outcome 3.1% (95% CI, 2.3-3.9%), death 1.2% (95% CI, 0.4-2.0%) and severe COVID-19 2.7% (95% CI, 1.9-3.6%).

CONCLUSION

Schizophrenia spectrum disorders, bipolar disorder, unipolar depression and psychotropic drug redemption are associated with unfavourable outcomes in patients with COVID-19.

Long-Term Metabolic Monitoring of Youths Treated with Second-Generation Antipsychotics 5 Years after Publication of the CAMESA Guidelines Are We Making Progress? Surveillance Métabolique à Long Terme des Jeunes Traités par Antipsychotiques de Deuxième Génération, Cinq ans Après la publication des Lignes Directrices Camesa: Faisons-Nous des Progrès?

OBJECTIVE

The potential metabolic adverse effects of second-generation antipsychotics (SGA) need to be monitored. The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics (CAMESA) offers guidelines for this purpose. We aimed to evaluate the long-term rates of youths receiving monitoring in mental health clinics and document the factors that may influence them.

METHOD

The charts of 180 patients (13.3 ± 3.1 years, 54.4% males) receiving SGA treatment for the first time between January 2016 and June 2018 were reviewed. Monitoring was divided into baseline and 1- to 6-month and 9- to 24-month periods. Population under study was stratified into children (4 to 12 years) and adolescents (13 to 18 years). Sociodemographic characteristics, psychiatric diagnosis and comorbidities, prescribed SGAs and comedications, anthropometric measures (AM), blood pressure (BP), blood tests (BT), electrocardiogram, and the psychiatrist's years of practice were collected. Cross tables were used to present the monitoring rates. Categories were compared by covariate analysis. Rates of patients monitored across categories were compared using Fisher exact test.

RESULTS

Monitoring rates for AM, BT, and BP were 55%, 47.8%, and 46.7% at baseline; 50%, 41.7%, and 45.2% at 1 to 6 months; and 47.2%, 41.5%, and 40.6% at 9 to 24 months, respectively. Higher monitoring rates were significantly associated with adolescent status (baseline, 1 to 6 months), a diagnosis of psychotic and/or affective disorder (baseline, 1 to 6 months, 9 to 24 months), having ≤1 psychiatric comorbidities (1 to 6 months), high SGA dose (baseline, 1 to 6 months), and clinician's experience (baseline, 9 to 24 months). Significantly lower monitoring rates were associated with the psychostimulant/atomoxetine comedication (baseline, 1 to 6 months, 9 to 24 months).

CONCLUSION

Five years after publication of the CAMESA guidelines, metabolic monitoring is conducted for less than half of patients. In our sample, age, diagnostic category, psychiatric comorbidities, SGA dose, clinician's experience, and comedications influenced the monitoring rates. Major progress still needs to be made before reaching a satisfactory level of monitoring.

Physical Health Problems Among People With Severe Mental Illnesses: Race, Gender, and Implications for Practice

BACKGROUND: Individuals with severe mental illnesses experience high rates of chronic health conditions; however, the extent to which risk of chronic physical health problems varies by race and gender among these individuals is understudied. AIMS: This study examines variations in health problems by race and gender among individuals with severe mental illnesses. METHOD: Administrative data, which included blood pressure, body mass index (BMI), and glycated hemoglobin (HbA1c) values, were obtained from 603 individuals with serious mental illnesses who received integrated health and behavioral health services from a large mental health agency in the Midwest. Bivariate and multivariate statistical models were used to examine variation in physical health problems by race and gender. RESULTS: Compared with men, women with severe mental illnesses were more likely to have BMI levels indicating obesity or morbid obesity (p < .001). Compared with White participants, Black participants were less likely to have high HbA1c levels (p < .001) but were more likely to have high blood pressure (p < .001). Among race and gender groups, Black women were more likely to have high BMI (p < .05), Black men were more likely to have high blood pressure (p < .001), and White men were more likely to have high HbA1c levels (p < .01) when holding constant all other variables. CONCLUSIONS: There is evidence that types and severity of physical health problems among individuals with severe mental illnesses varies by race and gender. Replication of these results and more research is needed to ensure that health-related education and integrated health and behavioral health interventions meet the needs of individuals with serious mental illnesses.

Discontinuity of psychiatric care for patients with schizophrenia, relation to previous psychiatric care and practice variation between providers: a retrospective longitudinal cohort study

BACKGROUND

Patients with schizophrenia need continuous integrated healthcare, but many discontinue their treatment, often experiencing adverse outcomes. The first objective of this study is to assess whether patient characteristics or treatment history are associated with discontinuity of psychiatric elective care. The second objective is to assess whether practice variation between providers of psychiatric care contributes to discontinuity of elective care.

METHODS

A large registry-based retrospective cohort of 9194 schizophrenia patients, who were included if they received elective psychiatric care in December 2014-January 2015. Logistic regression models were used to identify predictive factors of discontinuity of care. The dependent variable was the binary variable discontinuity of care in 2016. Potential independent predictive variables were: age, sex, urbanization, and treatment history in 2013-2014. Practice variation between providers was assessed, adjusting for the case mix of patients regarding their demographic and care utilization characteristics.

RESULTS

12.9% of the patients showed discontinuity of elective psychiatric care in the follow-up year 2016. The risk of discontinuity of care in 2016 was higher in younger patients (between age 18 and 26), patients with a history of receiving less elective psychiatric care, more acute psychiatric care, more quarters with elective psychiatric care without antipsychotic medication, or receiving no elective treatment at all. No evidence for practice variation between providers was found.

CONCLUSIONS

Our findings show that the pattern of previous care consumption is an important prognostic factor of future discontinuity of elective care. We propose that previous care consumption can be used to design strategies to improve treatment retention and focus resources on those most at risk of dropping out.

Recommendations for the medical work-up of first episode psychosis, including specific relevance to Indigenous Australians: A narrative review

AIMS

To collate existing literature for busy practicing psychiatrists about the medical work-up for first-episode psychosis (FEP). Therefore, (a) to review current guidelines for the medical work-up of first episode psychosis. (b) To examine whether any specific recommendations for Indigenous Australians exist. (c) To produce an easy reference table of evidence based investigations.

METHOD

A multi-part narrative review process was undertaken. Step 1 "Source identification and summary": identified key existing national and international guidelines and expert opinions related to the medical work-up of FEP and summarised these suggestions. Step 2 "Exploration of each investigation": examined each of the identified investigations for its importance. Step 3 "Relevance to Indigenous Australians": reviewed any particular relevance to the Indigenous Australian population. Step 4 "Clinician guide": involved presenting recommended investigations in a simple table.

RESULTS

Multiple guidelines were identified. There was clear consensus for many aspects. However, there were also differences in the approach for some investigations. Clinical reasoning for the proposed investigations was commonly absent. There were limited specific recommendations for Indigenous Australians. Evidence and importance was explored for each investigation and auseful table for the practicing psychiatrist was constructed. Investigations were stratified into those considered to be "universal," "low yield," or "unecessary."

CONCLUSION

A narrative review of multiple guidelines relating to the medical work-up of FEP identified many similarities and some differences to their approach. Little additional information exists for the Indigenous Australian context. A clinician friendly worksheet for everyday use may be helpful to busy clinicians.

A feasibility hybrid II randomised controlled trial of volunteer 'Health Champions' supporting people with serious mental illness manage their physical health: study protocol

BACKGROUND

People with serious mental illnesses (SMI) such as schizophrenia often also have physical health illnesses and interventions are needed to address the resultant multimorbidity and reduced life expectancy. Research has shown that volunteers can support people with SMI. This protocol describes a feasibility randomised controlled trial (RCT) of a novel intervention involving volunteer 'Health Champions' supporting people with SMI to manage and improve their physical health.

METHODS

This is a feasibility hybrid II randomised effectiveness-implementation controlled trial. The intervention involves training volunteers to be 'Health Champions' to support individual people with SMI using mental health services. This face-to-face or remote support will take place weekly and last for up to 9 months following initial introduction. This study will recruit 120 participants to compare Health Champions to treatment as usual for people with SMI using secondary community mental health services in South London, UK. We will measure the clinical and cost effectiveness including quality of life. We will measure the implementation outcomes of acceptability, feasibility, appropriateness, fidelity, barriers and enablers, unintended consequences, adoption and sustainability.

DISCUSSION

There is a need for interventions to support people with SMI with their physical health. If this feasibility trial is successful, a definitive trial will follow to fully evaluate the clinical, cost and implementation effectiveness of Health Champions supporting people with SMI.

TRIAL REGISTRATION

ClinicalTrials.gov, registration no: NCT04124744 .

Bipolar disorder and the risk for stroke incidence and mortality: a meta-analysis

OBJECTIVE

Bipolar disorder (BD) may be associated with an increased risk of stroke, but to date, the results of the studies are still controversial. This study aimed to assess the association of BD with stroke incidence and mortality by a meta-analysis.

METHOD

PubMed, EMBASE, the Cochrane library databases, and Web of Science databases were searched from inception to July 2020. We regarded stroke as a composite endpoint. The pooled hazard ratio (HRs) of 95% confidence interval (Cls) was calculated. Subgroup and sensitivity analyses were performed to assess the potential sources of heterogeneity of the pooled estimation.

RESULTS

A total of 7 studies involving a total of 13,305,007 participants were included in this meta-analysis. Pooled analysis showed participants with BD experienced a significantly increased risk of both stroke incidence (combined HR, 1.43; 95% CI, 1.24-1.66; p = 0.000) and stroke mortality (combined HR, 1.54; 95% CI, 1.09-2.18; p = 0.013) compared to participants without BD. In addition, the pooled estimate of multivariate HRs of stroke incidence and mortality were 1.35 (95% CI: 1.26-1.45); 2.30 ( 95% CI: 1.37-3.85) among men and 1.43 (95% CI:1.27-1.60); 2.08 (95% CI:1.60-2.71) among women respectively.

CONCLUSIONS

This meta-analysis suggests that BD may modestly increase the risk of both stroke incidence and mortality. Extensive clinical observational studies should be conducted in the future to explore whether BD is a potentially modifiable risk factor for stroke.

Dose-response association of acute-phase quetiapine treatment with risk of new-onset hypothyroidism in schizophrenia patients

AIMS

To assess association between quetiapine treatment and risk of new-onset hypothyroidism in schizophrenia patients.

METHODS

We conducted a retrospective cohort study in a tertiary hospital in China between January 2016 and December 2018. Schizophrenia patients with normal thyroid tests at admission were included. Hypothyroidism, which was defined as thyroid-stimulating hormone >4.20 mU/L and free thyroxine <12.00 pmol/L, or on L-thyroxine prescriptions, was the outcome measure, and quetiapine treatment between admission and subsequent thyroid test was the exposure measure of this study. Adjusted relative risks and 95% confidence intervals were used to assess the independent association of quetiapine treatment with risk of new-onset hypothyroidism. The dose-response association was further analysed by 3 quetiapine doses: low (≤<=0.2 g/d), medium (0.2-0.6 g/d), and high (>0.6 g/d).

RESULTS

A total of 2022 eligible patients were included in the final analysis. Sixty patients (15.0%) in the quetiapine group developed hypothyroidism, while 56 patients (3.5%) in the nonquetiapine group developed hypothyroidism. Relative risk (95% confidence interval) of developing hypothyroidism for quetiapine use was 4.01 (2.86-5.64) after adjusting for several potential confounding factors. A strong dose-response association between quetiapine use and risk of developing hypothyroidism was observed: adjusted relative risks (95% confidence intervals) were 1.00 (0.25-2.59), 4.22 (2.80-6.25) and 5.62 (3.66-8.38), respectively, for low-, medium- and high-dose quetiapine, as compared with no quetiapine.

CONCLUSION

Acute phase quetiapine treatment for schizophrenia patients was strongly associated with increased risk of developing new-onset hypothyroidism, with a clear dose-response association.

Association of Low-Dose Quetiapine and Diabetes

IMPORTANCE

Quetiapine has been associated with increased risk of type 2 diabetes when used in medium or high doses for the treatment of severe mental disorders. It is not known whether low doses, commonly used off-label for sedative-hypnotic purposes, are also associated with increased risk of type 2 diabetes.

OBJECTIVE

To investigate whether there is an association between prescription of low-dose quetiapine and the risk of type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study examined nationwide Danish health registers for data regarding new users of quetiapine (n = 185 938) or selective serotonin reuptake inhibitors (SSRIs) (n = 1 031 920) who were aged 18 years or older between January 1, 1998, and December 31, 2018. Individuals with schizophrenia or bipolar disorder were excluded. Quetiapine-initiators were matched 1:1 with initiators of SSRIs, using a high-dimensional propensity score (hdPS). Maximum follow-up was 5 years. Association with cumulative dose was investigated, using a case-control approach nested among quetiapine users. Data analysis was performed from May to September 2020.

EXPOSURES

Dispensing of quetiapine or SSRIs. Quetiapine prescriptions were limited to tablet strengths of 25 mg and 50 mg to focus on low-dose use.

MAIN OUTCOMES AND MEASURES

Incident type 2 diabetes was defined as first filling of an antidiabetic medication, first register diagnosis of type 2 diabetes or first hemoglobin A1C measurement greater than or equal to 6.4% (≥48 mmol/mol). Incidence rates (IRs), incidence rate ratios (IRRs), and number-needed-to-harm (NNH) were calculated for full and matched cohorts using as-treated and intention-to-treat approaches. Odds ratios (ORs) were calculated for the association with cumulative quetiapine dose.

RESULTS

Altogether, 896 285 patients were included in the full cohort; 538 164 (60%) were female and the median (interquartile range) age was 47 (33-67) years. There were 57 701 low-dose quetiapine initiators and 838 584 SSRI initiators. The matched cohort consisted of 54 616 pairs. In as-treated analyses, the incidence of type 2 diabetes during treatment with low-dose quetiapine (425 cases) was 9.59 cases/1000 person-years (PY) (95% CI, 8.72-10.5/1000 PY), which was slightly higher than for SSRI users (8462 cases; IR, 8.13/1000 PY; 95% CI, 7.96-8.30/1000 PY), resulting in a significant IRR of 1.18 (95% CI, 1.07-1.30) and NNH of 684 (95% CI, 418-1873). However, the between-group difference was nonsignificant in the hdPS-matched cohort (IR, 9.49 vs IR, 9.58; IRR, 0.99; 95% CI, 0.87-1.13). The case-control analysis found no dose-response association of low-dose quetiapine with diabetes (OR for doubling of the cumulative dose: 1.02; 95% CI, 0.95-1.09; P = .54), but in sensitivity analyses higher daily doses were associated with diabetes (all tablet strengths: OR, 1.08; 95% CI, 1.03-1.13).

CONCLUSIONS AND RELEVANCE

In this cohort study, use of low-dose quetiapine was not associated with excess risk of type 2 diabetes in comparison with SSRIs.

Transcriptome analysis reveals disparate expression of inflammation-related miRNAs and their gene targets in iPSC-astrocytes from people with schizophrenia

Despite the high heritability of schizophrenia (SCZ), details of its pathophysiology and etiology are still unknown. Recent findings suggest that aberrant inflammatory regulation and microRNAs (miRNAs) are involved. Here we performed a comparative analysis of the global miRNome of human induced pluripotent stem cell (iPSC)-astrocytes, derived from SCZ patients and healthy controls (CTRLs), at baseline and following inflammatory modulation using IL-1β. We identified four differentially expressed miRNAs (miR-337-3p, miR-127-5p, miR-206, miR-1185-1-3p) in SCZ astrocytes that exhibited significantly lower baseline expression relative to CTRLs. Group-specific differential expression (DE) analyses exploring possible distinctions in the modulatory capacity of IL-1β on miRNA expression in SCZ versus CTRL astroglia revealed trends toward altered miRNA expressions. In addition, we analyzed peripheral blood samples from a large cohort of SCZ patients (n = 484) and CTRLs (n = 496) screening for the expression of specific gene targets of the four DE miRNAs that were identified in our baseline astrocyte setup. Three of these genes, LAMTOR4, IL23R, and ERBB3, had a significantly lower expression in the blood of SCZ patients compared to CTRLs after multiple testing correction. We also found nominally significant differences for ERBB2 and IRAK1, which similarly displayed lower expressions in SCZ versus CTRL. Furthermore, we found matching patterns between the expressions of identified miRNAs and their target genes when comparing our in vitro and in vivo results. The current results further our understanding of the pathobiological basis of SCZ.

Investigation of glycaemic traits in psychiatric disorders using Mendelian randomisation revealed a causal relationship with anorexia nervosa

Data from observational studies have suggested an involvement of abnormal glycaemic regulation in the pathophysiology of psychiatric illness. This may be an attractive target for clinical intervention as glycaemia can be modulated by both lifestyle factors and pharmacological agents. However, observational studies are inherently confounded, and therefore, causal relationships cannot be reliably established. We employed genetic variants rigorously associated with three glycaemic traits (fasting glucose, fasting insulin, and glycated haemoglobin) as instrumental variables in a two-sample Mendelian randomisation analysis to investigate the causal effect of these measures on the risk for eight psychiatric disorders. A significant protective effect of a natural log transformed pmol/L increase in fasting insulin levels was observed for anorexia nervosa after the application of multiple testing correction (OR = 0.48 [95% CI: 0.33-0.71]-inverse-variance weighted estimate). There was no consistently strong evidence for a causal effect of glycaemic factors on the other seven psychiatric disorders considered. The relationship between fasting insulin and anorexia nervosa was supported by a suite of sensitivity analyses, with no statistical evidence of instrument heterogeneity or horizontal pleiotropy. Further investigation is required to explore the relationship between insulin levels and anorexia.

Exploring a Safety Signal of Antipsychotic-Associated Pneumonia: A Pharmacovigilance-Pharmacodynamic Study

An association between antipsychotic drugs and pneumonia has been demonstrated in several studies; however, the risk for pneumonia caused by specific antipsychotics has not been extensively studied. The underlying mechanism is still unknown, and several receptor mechanisms have been proposed. Therefore, using a combined pharmacovigilance-pharmacodynamic approach, we aimed to investigate safety signals of US Food and Drug Administration (FDA)-approved antipsychotics for reporting pneumonia and the potential receptor mechanisms involved. A disproportionality analysis was performed to detect a signal for reporting "infective-pneumonia" and "pneumonia-aspiration" and antipsychotics using reports submitted between 2004 and 2019 to the FDA adverse events spontaneous reporting system (FAERS) database. Disproportionality was estimated using the crude and the adjusted reporting odds ratio (aROR) and its 95% confidence interval (CI) in a multivariable logistic regression. Linear regressions investigated the relationship between aROR and receptor occupancy, which was estimated using in vitro receptor-binding profiles. Safety signals for reporting infective-pneumonia were identified for clozapine (LL = 95% 3.4, n = 546 [aROR: 4.8]) as well as olanzapine (LL = 95% 1.5, n = 250 [aROR: 2.1]) compared with haloperidol, while aRORs were associated with higher occupancies of muscarinic receptors (beta = .125, P-value = .016), yet other anti-muscarinic drugs were not included as potential confounders. No safety signals for reporting pneumonia-aspiration were detected for individual antipsychotics. Multiple antipsychotic use was associated with both reporting infective-pneumonia (LL 95%: 1.1, n = 369 [aROR:1.2]) and pneumonia-aspiration (LL 95%: 1.7, n = 194 [aROR: 2.0]). Considering the limitations of disproportionality analysis, further pharmacovigilance data and clinical causality assessment are needed to validate this safety signal.

Natural cause mortality of mental health consumers: A 10-year retrospective cohort study

People with mental illness have substantially lower life expectancy than the general population, with mortality from natural causes most commonly attributed to cardiovascular diseases. The study aim was to identify characteristics of consumers who died of natural causes between 2009 and 2018 at one of Australia's largest publicly funded mental health services. Data were collected with a retrospective medical record review of 102 consumers. Mean mortality age was 52.4 years (SD = 10.7) (with females 51.9 years [SD = 12.0], and males 52.7 years [SD = 9.9]), which was more than 30 years lower than the Australian population. Cardiovascular diseases were the most frequent mortality cause (39%), followed by respiratory conditions (23%), cancers (20%), and all other causes (19%). Sixty (61%) consumers had at least three co-occurring physical health conditions. Seventy-five (74%) smoked tobacco. Consumers who died from cardiovascular diseases were less likely to attend specialist medical follow-up for their condition (P = 0.004), and more likely to die at home (P = 0.001). Consumers whose mortality age was above 55 years were more likely to have three co-occurring physical health conditions (P = 0.034). Consumers whose mortality age was below 55 years were more likely to have sub-optimal nutritional intake (P = 0.014) and higher body mass index (P = 0.008). There is a critical need to close the life expectancy gap for consumers. This requires dedicated focus on reducing mortality risk due to modifiable clinical characteristics which lead to consumer mortality. Mental health nurses play a key role in helping reduce consumers' mortality and morbidity risk through prevention and early intervention strategies.