Antipsychotic-induced weight gain: a comprehensive research synthesis

Clozapine, Diabetes Mellitus, Cardiovascular Risk and Mortality: Results of a 21-Year Naturalistic Study in Patients with Schizophrenia and Schizoaffective Disorder

The goal of this 21-year naturalistic study of clozapine-treated patients was to examine the cardiovascular risk factors following clozapine initiation and resultant mortality estimates from cardiovascular disease. Data were collected from January 1992 to February 2012 medical records from clozapine-treated patients with schizophrenia or schizoaffective disorder. Demographics, clozapine dosage and laboratory results were extracted at 12-month intervals. At clozapine initiation, the mean age of the 96 patients was 36.4 years±7.6 years; n=27 (28%) were women. The mean duration of clozapine use was 13 years. The Kaplan-Meier estimate for 21-year cardiovascular events was 29%, while the Kaplan-Meier estimate for 21-year mortality from cardiovascular disease was 10%. The mean cardiovascular risk increased during the first ten years (p<.01), while a slight decrease occurred beyond ten years (p<.01). Patients involved in cardiometabolic research showed a greater decrease in cardiovascular risk factors over 21 years (p=.05). The Kaplan-Meier estimate for 21-year all-cause mortality was 22%. Forty-one patients were diagnosed with diabetes (42.7%), compared to a nationwide prevalence of 13.7% in a similar age group. These results support the hypothesis that clozapine-treated patients are at risk for cardiovascular events and death secondary to an increased risk of medical disorders. Interventions that target weight loss, smoking cessation, and lipid profile improvement may alleviate the increased risk of cardiovascular mortality.

Development of multivariable models to predict change in Body Mass Index within a clinical trial population of psychotic individuals

Many antipsychotics promote weight gain, which can lead to non-compliance and relapse of psychosis. By developing models that accurately identify individuals at greater risk of weight gain, clinicians can make informed treatment decisions and target intervention measures. We examined clinical, genetic and expression data for 284 individuals with psychosis derived from a previously published randomised controlled trial (IMPACT). These data were used to develop regression and classification models predicting change in Body Mass Index (BMI) over one year. Clinical predictors included demographics, anthropometrics, cardiac and blood measures, diet and exercise, physical and mental health, medication and BMI outcome measures. We included genetic polygenic risk scores (PRS) for schizophrenia, bipolar disorder, BMI, waist-hip-ratio, insulin resistance and height, as well as gene co-expression modules generated by Weighted Gene Co-expression Network Analysis (WGCNA). The best performing predictive models for BMI and BMI gain after one year used clinical data only, which suggests expression and genetic data do not improve prediction in this cohort.

Mechanisms underlying metabolic disturbances associated with psychosis and antipsychotic drug treatment

The increase in cardiovascular disease and reduced life expectancy in schizophrenia likely relate to an increased prevalence of metabolic disturbances. Such metabolic risk factors in schizophrenia may result from both symptom-related effects and aetiological factors. However, a major contributory factor is that of treatment with antipsychotic drugs. These drugs differ in effects on body weight; the underlying mechanisms are not fully understood and may vary between drugs, but may include actions at receptors associated with the hypothalamic control of food intake. Evidence supports 5-hydroxytryptamine receptor 2C and dopamine D2 receptor antagonism as well as antagonism at histamine H1 and muscarinic M3 receptors. These M3 receptors may also mediate the effects of some drugs on glucose regulation. Several antipsychotics showing little propensity for weight gain, such as aripiprazole, have protective pharmacological mechanisms, rather than just the absence of a hyperphagic effect. In addition to drug differences, there is large individual variation in antipsychotic drug-induced weight gain. This pharmacogenetic association reflects genetic variation in several drug targets, including the 5-hydroxytryptamine receptor 2C, as well as genes involved in obesity and metabolic disturbances. Thus predictive genetic testing for drug-induced weight gain would represents a first step towards personalised medicine addressing this severe and problematic iatrogenic disease.

Drug-induced obesity and its metabolic consequences: a review with a focus on mechanisms and possible therapeutic options

Weight gain is a common side effect of many widely used drugs. Weight gain of a few kilograms to an increase of 10% or more of initial body weight has been described. Not only the weight gain as such puts a burden on the health risks of the involved patients, the accompanying increase in the incidence of the metabolic syndrome, type 2 diabetes mellitus, and cardiovascular risk factors urges the caregiver to identify and to closely monitor the patients at risk. In this review, the different classes of drugs with significant weight gaining properties and the metabolic consequences are described. Specific attention is given to pathogenetic mechanisms underlying the metabolic effects and to potential therapeutic measures to prevent them.

Assessment of the relationship between food addiction and nutritional status in schizophrenic patients

OBJECTIVE

Obesity is one of today's most important public health problems. It is suggested that overeating and substance addiction show similarities, and addiction to food may be an important factor in the obesity epidemic. This study aimed to determine the prevalence of food addiction among schizophrenic patients and to examine the relationship between food addiction and anthropometric measurements and dietary nutrient intake.

METHODS

Study participants included a total of 104 schizophrenic outpatients, 62 females and 42 males. Food addiction was assessed by using the Yale Food Addiction Scale, and the anthropometric measurements of participants and their three-day food consumption were recorded.

RESULTS

This study found that more than half of the schizophrenic patients (60.6%) had food addiction, and that female schizophrenic patients had a higher prevalence (62.9%) of food addiction than male patients (57.1%). More than one-third of the schizophrenic patients with food addiction (41.3%) were found to be obese and their BMI, body weight, waist circumference, and body-fat ratio were higher than those of schizophrenic patients who did not have food addiction (P > 0.05). Moreover, the schizophrenic patients with food addiction were found to take significantly more energy, carbohydrate, and fat in their diet (P < 0.05).

CONCLUSION

It was observed that the development of food addiction in schizophrenic patients increased the risk of obesity and cardiovascular diseases, which were found to be at higher levels in these patients. Educational programs should be planned for these patients to acquire health dietary habits and to increase their physical activity levels, and an additional psychosocial support should be provided for patients with food addiction.

Psychopharmacological advances in eating disorders

INTRODUCTION

Anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED) are the primary eating disorders (EDs). The only psychopharmacological treatment options for EDs with approval in some countries include fluoxetine for BN and lisdexamfetamine for BED. Given the high comorbidity and genetic correlations with other psychiatric disorders, it seems possible that novel medications for these conditions might also be effective in EDs. Areas covered: The current scientific literature has increased our understanding of how medication could be beneficial for patients with EDs on a molecular, functional and behavioral level. On the basis of theoretical considerations about neurotransmitters, hormones and neural circuits, possible drug targets for the treatment of EDs may include signal molecules and receptors of the self-regulatory system such as serotonin, norepinephrine and glutamate, the hedonic system including opioids, cannabinoids and dopamine and the hypothalamic homeostatic system including histamine, ghrelin, leptin, insulin, and glucagon-like peptide-1. Expert commentary: The latest research points to an involvement of both the immune and the metabolic systems in the pathophysiology of EDs and highlights the importance of the microbiome. Therefore, the next few years may unveil drug targets for EDs not just inside and outside of the brain, but possibly even outside of the human body.

Overexpression of Insig-2 inhibits atypical antipsychotic-induced adipogenic differentiation and lipid biosynthesis in adipose-derived stem cells

Atypical antipsychotics (AAPs) are considered to possess superior efficacy for treating both the positive and negative symptoms of schizophrenia; however, AAP use often causes excessive weight gain and metabolic abnormalities. Recently, several reports have demonstrated that AAPs activate sterol regulatory element-binding protein (SREBP). SREBP, SREBP cleavage-activating protein (SCAP) and insulin-induced gene (Insig) regulate downstream cholesterol and fatty acid biosynthesis. In this study, we explored the effects of clozapine, olanzapine and risperidone on SREBP signaling and downstream lipid biosynthesis genes in the early events of adipogenic differentiation in adipose-derived stem cells (ASCs). After the induction of adipogenic differentiation for 2 days, all AAPs, notably clozapine treatment for 3 and 7 days, enhanced the expression of SREBP-1 and its downstream lipid biosynthesis genes without dexamethasone and insulin supplementation. Simultaneously, protein level of SREBP-1 was significantly enhanced via inhibition of Insig-2 expression. By contrast, SREBP-1 activation was suppressed when Insig-2 expression was upregulated by transfection with Insig-2 plasmid DNA. In summary, our results indicate that AAP treatment, notably clozapine treatment, induces early-stage lipid biosynthesis in ASCs. Such abnormal lipogenesis can be reversed when Insig-2 expression was increased, suggesting that Insig/SCAP/SREBP signaling may be a therapeutic target for AAP-induced weight gain and metabolic abnormalities.

A comprehensive analysis of mitochondrial genes variants and their association with antipsychotic-induced weight gain

Antipsychotic Induced Weight Gain (AIWG) is a common and severe side effect of many antipsychotic medications. Mitochondria play a vital role for whole-body energy homeostasis and there is increasing evidence that antipsychotics modulate mitochondrial function. This study aimed to examine the role of variants in nuclear-encoded mitochondrial genes and the mitochondrial DNA (mtDNA) in conferring risk for AIWG. We selected 168 European-Caucasian individuals from the CATIE sample based upon meeting criteria of multiple weight measures while taking selected antipsychotics (risperidone, quetiapine or olanzapine). We tested the association of 670 nuclear-encoded mitochondrial genes with weight change (%) using MAGMA software. Thirty of these genes showed nominally significant P-values (<0.05). We were able to replicate the association of three genes, CLPB, PARL, and ACAD10, with weight change (%) in an independent prospectively assessed AIWG sample. We analyzed mtDNA variants in a subset of 74 of these individuals using next-generation sequencing. No common or rare mtDNA variants were found to be significantly associated with weight change (%) in our sample. Additionally, analysis of mitochondrial haplogroups showed no association with weight change (%). In conclusion, our findings suggest nuclear-encoded mitochondrial genes play a role in AIWG. Replication in larger sample is required to validate our initial report of mtDNA variants in AIWG.

Association Between Cardiovascular Risk and Depressive Symptoms Among People With Serious Mental Illness

Depressive symptoms have debilitating effects on the physical health and functioning of people with serious mental illness. We examined change in depressive symptoms among overweight and obese adults with serious mental illness (n = 343) using data combined from two randomized trials comparing the 12-month In SHAPE program to a gym membership control condition. In SHAPE consists of a gym membership, weekly individual meetings with a fitness trainer, and instruction on healthy eating and nutrition. Depressive symptoms were measured at baseline, 3, 6, and 12 months. Change in depressive symptoms did not differ between groups, but depressive symptoms decreased over time across the entire sample (p = 0.045). At 12 months, reduced depressive symptoms were associated with clinically significant improved cardiorespiratory fitness (p = 0.030), 10% or more weight loss (p = 0.044), and cardiovascular risk reduction (p = 0.028) across both groups. Our findings suggest that participation in health promotion programs resulting in cardiovascular risk reduction may be associated with reduced depressive symptoms.

Intrinsic and Antipsychotic Drug-Induced Metabolic Dysfunction in Schizophrenia

For decades, there have been observations demonstrating significant metabolic disturbances in people with schizophrenia including clinically relevant weight gain, hypertension, and disturbances in glucose and lipid homeostasis. Many of these findings pre-date the use of antipsychotic drugs (APDs) which on their own are also strongly associated with metabolic side effects. The combination of APD-induced metabolic changes and common adverse environmental factors associated with schizophrenia have made it difficult to determine the specific contributions of each to the overall metabolic picture. Data from drug-naïve patients, both from the pre-APD era and more recently, suggest that there may be an intrinsic metabolic risk associated with schizophrenia. Nevertheless, these findings remain controversial due to significant clinical variability in both psychiatric and metabolic symptoms throughout patients' disease courses. Here, we provide an extensive review of classic and more recent literature describing the metabolic phenotype associated with schizophrenia. We also suggest potential mechanistic links between signaling pathways associated with schizophrenia and metabolic dysfunction. We propose that, beyond its symptomatology in the central nervous system, schizophrenia is also characterized by pathophysiology in other organ systems directly related to metabolic control.

Risperidone-Induced Renal Damage and Metabolic Side Effects: The Protective Effect of Resveratrol

Objective

The aim of the study was to investigate the possible protective qualities of resveratrol (RSV) against the side effects of risperidone (RIS) in an experimental model in rat kidneys with histologic and biochemical assessments.

Materials and Methods

Experimental procedures were performed on 35 female Sprague Dawley rats. Rats were randomly divided into five groups: control, untreated rats (n = 7) were in group 1; group 2 was given 2 mg/kg/day RIS (n = 7); group 3 was treated with 2 mg/kg/day RIS and 20 mg/kg/day RSV (n = 7); group 4 was treated with 2 mg/kg/day RIS and 40 mg/kg/day RSV (n = 7); and group 5 was treated with 2 mg/kg/day RIS and 80 mg/kg/day RSV (n = 7). All treatments were administered for two weeks by gavage. On treatment day 15, kidney tissues were removed for analysis.

Results

The results showed that RSV treatment reduced weight gain induced by RIS. In addition, RSV increased the total antioxidant status (TAS) and decreased serum creatinine (Cr), blood urea nitrogen (BUN), oxidative stress index (OSI), and total oxidant status (TOS) levels significantly (p < 0.05).

Conclusion

This study revealed that treatment with RSV might protect kidney tissues against the side effects of RIS. RSV could be an effective course of therapy to enhance therapeutic efficacy.

Effect of Liraglutide Treatment on Prediabetes and Overweight or Obesity in Clozapine- or Olanzapine-Treated Patients With Schizophrenia Spectrum Disorder: A Randomized Clinical Trial

Importance

Compared with the general population, patients with schizophrenia have a 2- to 3-fold higher mortality rate primarily caused by cardiovascular disease. Previous interventions designed to counteract antipsychotic-induced weight gain and cardiometabolic disturbances reported limited effects.

Objectives

To determine the effects of the glucagon-like peptide-1 receptor agonist liraglutide added to clozapine or olanzapine treatment of schizophrenia spectrum disorders.

Design, Setting, and Participants

This randomized clinical double-blind trial enrolled participants at 2 clinical sites in Denmark. Of 214 eligible participants with a schizophrenia spectrum disorder, 103 were randomized to liraglutide or placebo. Participants received stable treatment with clozapine or olanzapine, were overweight or obese, and had prediabetes. Data were collected from May 1, 2013, through February 25, 2016.

Interventions

Treatment for 16 weeks with once-daily subcutaneous injection of liraglutide or placebo. Trial drug therapy was titrated during the first 2 weeks of the study.

Main Outcomes and Measures

The primary end point was change in glucose tolerance estimated by a 75-g oral glucose tolerance test result. Secondary end points included change in body weight and cardiometabolic parameters.

Results

Of the 103 patients undergoing randomization (60 men [58.3%] and 43 women [41.7%]), 97 were included in the efficacy analysis, with a mean (SD) age of 42.5 (10.5) years and mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) of 33.8 (5.9). The liraglutide and placebo groups had comparable characteristics (mean [SD] age, 42.1 [10.7] vs 43.0 [10.5] years; 30 men in each group; mean [SD] body mass index, 33.7 [5.1] vs 33.9 [6.6]). A total of 96 randomized participants (93.2%) completed the trial. Glucose tolerance improved in the liraglutide group compared with the placebo group (P < .001). Altogether, 30 liraglutide-treated participants (63.8%) developed normal glucose tolerance compared with 8 placebo-treated participants (16.0%) (P < .001; number needed to treat, 2). Body weight decreased with liraglutide compared with placebo (-5.3 kg; 95% CI, -7.0 to -3.7 kg). Reductions in waist circumference (-4.1 cm; 95% CI, -6.0 to -2.3 cm), systolic blood pressure (-4.9 mm Hg; 95% CI, -9.5 to -0.3 mm Hg), visceral fat (-250.19 g; 95% CI, -459.9 to -40.5 g), and low-density lipoprotein levels (-15.4 mg/dL; 95% CI, -23.2 to -7.7 mg/dL) occurred with liraglutide compared with placebo. Adverse events with liraglutide affected mainly the gastrointestinal tract.

Conclusions and Relevance

Liraglutide significantly improved glucose tolerance, body weight, and cardiometabolic disturbances in patients with schizophrenia spectrum disorders treated with clozapine or olanzapine.

Trial Registration

clinicaltrials.gov Identifier: NCT01845259.

Effect of atypical antipsychotics on body weight in geriatric psychiatric inpatients

Background:

Studies suggest that antipsychotic-induced weight gain is not a great concern in the elderly population. This study investigated the weight change in elderly patients with various treatment duration and antipsychotics. Part 1 of the study was to determine whether atypical antipsychotics induced weight change in elderly patients. Part 2 was to determine whether certain atypical antipsychotics induced more weight change in elderly patients.

Methods:

In Part 1, a retrospective chart review was done on 115 geriatric inpatients. After exclusion, patients were divided into four groups: control (n = 17), new treatment (n = 18), long-term treatment (n = 13), and medication switch groups (n = 8). In Part 2, a retrospective medication review was performed on 169 geriatric inpatients. After exclusion, patients were divided into three groups: aripiprazole (n = 18), olanzapine (n = 49), and risperidone (n = 57). Body weights were obtained at two different time points.

Results:

No significant difference in weight change was observed among the control (1.5 kg), new treatment (0.8 kg), long-term treatment (−0.3 kg), and medication switch (1.9 kg) groups. No significant difference in weight change was observed between patients with and without dementia (0.8 and 1.1 kg, respectively). The weight change in the aripiprazole group (−2.0 kg; −2.30% from baseline) was significantly different from the weight change in the olanzapine group (0.7 kg; 1.87% from baseline; p < 0.05), but not from the risperidone group (−0.4 kg; −0.45% from baseline). Clinically significant weight gain (>7% increase in body weight) occurred in 14.3% of the olanzapine patients, a percentage significantly higher than the 3.5% in the risperidone group.

Conclusion:

Although atypical antipsychotics were generally weight neutral in the geriatric population, aripiprazole and olanzapine were associated with significant weight loss and weight gain, respectively.

Classics in Chemical Neuroscience: Haloperidol

The discovery of haloperidol catalyzed a breakthrough in our understanding of the biochemical basis of schizophrenia, improved the treatment of psychosis, and facilitated deinstitutionalization. In doing so, it solidified the role for chemical neuroscience as a means to elucidate the molecular underpinnings of complex neuropsychiatric disorders. In this Review, we will cover aspects of haloperidol's synthesis, manufacturing, metabolism, pharmacology, approved and off-label indications, and adverse effects. We will also convey the fascinating history of this classic molecule and the influence that it has had on the evolution of neuropsychopharmacology and neuroscience.

Health Promotion for Young Adults With Serious Mental Illness

OBJECTIVE

Young adulthood represents a critical time to address elevated obesity rates and the risk of early mortality, particularly among people with serious mental illness. Few studies have assessed the benefits of lifestyle interventions targeting weight loss among these young adults. This study examined the impact of the 12-month In SHAPE lifestyle intervention on weight loss and fitness among overweight and obese young adults with serious mental illness (ages 21-30) compared with participants over age 30.

METHODS

Data were combined from three trials of the 12-month In SHAPE program delivered through community mental health centers. In SHAPE includes weekly fitness trainer meetings, a gym membership, and nutrition education. Primary outcomes were weight loss and change in fitness at 12 months.

RESULTS

Participants (N=194) had a schizophrenia spectrum disorder (53%) or a mood disorder (47%). The overall sample achieved significant weight loss and improved fitness; differences between young adults (N=29) and participants over age 30 (N=165) were not significant. An important finding was that 42% of young adults achieved clinically significant reductions in cardiovascular risk, defined as ≥5% weight loss or improved fitness (>50-m increase on the 6-Minute Walk Test), compared with 54% of adults over age 30 (a nonsignificant difference between age groups).

CONCLUSIONS

Among persons enrolled in a lifestyle intervention, overweight and obese young adults experienced benefits comparable with those of adults over age 30. Young adults with serious mental illness face high risk of gaining weight, but a meaningful proportion of these individuals can achieve clinically significant cardiovascular risk reduction, thus highlighting the need to promote lifestyle intervention participation in this group.

Antipsychotic-associated weight gain: management strategies and impact on treatment adherence

Antipsychotic-induced weight gain is a major management problem for clinicians. It has been shown that weight gain and obesity lead to increased cardiovascular and cerebrovascular morbidity and mortality, reduced quality of life and poor drug compliance. This narrative review discusses the propensity of various antipsychotics to cause weight gain, the pharmacologic and nonpharmacologic interventions available to counteract this effect and its impact on adherence. Most antipsychotics cause weight gain. The risk appears to be highest with olanzapine and clozapine. Weight increases rapidly in the initial period after starting antipsychotics. Patients continue to gain weight in the long term. Children appear to be particularly vulnerable to antipsychotic-induced weight gain. Tailoring antipsychotics according to the needs of the individual and close monitoring of weight and other metabolic parameters are the best preventive strategies at the outset. Switching to an agent with lesser tendency to cause weight gain is an option, but carries the risk of relapse of the illness. Nonpharmacologic interventions of dietary counseling, exercise programs and cognitive and behavioral strategies appear to be equally effective in individual and group therapy formats. Both nonpharmacologic prevention and intervention strategies have shown modest effects on weight. Multiple compounds have been investigated as add-on medications to cause weight loss. Metformin has the best evidence in this respect. Burden of side effects needs to be considered when prescribing weight loss medications. There is no strong evidence to recommend routine prescription of add-on medication for weight reduction. Heterogeneity of study methodologies and other confounders such as lifestyle, genetic and illness factors make interpretation of data difficult.

Artesunate prevents rats from the clozapine-induced hepatic steatosis and elevation in plasma triglycerides

Clozapine is an atypical antipsychotic with therapeutic efficacy in treatment-resistant schizophrenia patients and low incidence of extrapyramidal side effects. However, the use of clozapine has been limited by its adverse effects on metabolism. Artesunate is a semisynthetic derivative of artemisinin and was shown to decrease the plasma cholesterol and triglyceride in rabbits and rats in recent studies. The aim of this study was to examine possible effects of artesunate on the clozapine-induced metabolic alterations in rats given saline, clozapine, artesunate, or clozapine plus artesunate for 6 weeks. The clozapine group showed significantly high plasma levels of triglyceride, hepatic steatosis, and fibrosis along with high levels of C-reactive protein, alanine aminotransferase, and aspartate aminotransferase compared to the saline group. But the treatment had no effect on weight gain and caused no hyperglycemia, hyperinsulinemia, and behavioral changes in the rats. More significantly, these clozapine-induced changes were not seen in rats coadministered with clozapine plus artesunate. These results added evidence supporting psychiatrists to try add-on treatment of artesunate in schizophrenia patients to ameliorate clozapine-induced adverse metabolic effects.

Ameliorative Effect of Curcumin on Olanzapine-induced Obesity in Sprague-Dawley Rats

OBJECTIVE

To evaluate the effect of curcumin on olanzapine-induced obesity in rats.

MATERIALS AND METHODS

Sprague-Dawley (SD) rats were used for experiments. The animals were divided into six groups, namely, normal control, olanzapine control, betahistine (10 mg/kg), and curcumin 50, 100, and 200 mg/kg treated groups. Except the normal control group, all other animals were administered with olanzapine 4 mg/kg intraperitoneally to induce obesity. The drugs were administered once daily, per oral for 28 days. During the experiment, body weight changes and behavior alterations were monitored at regular intervals. At the end of the experiment, blood sample was collected from all the experimental animals for biochemical analysis. Part of the liver and kidney tissues was harvested from the sacrificed animals and preserved in neutral formalin for histopathological studies.

RESULTS

Curcumin showed a significant reduction in olanzapine-induced body weight gain on the rats and improved the locomotor effects. The effect of curcumin on olanzapine-induced body weight gain is not comparable with that of betahistine.

CONCLUSION

This study has shown metabolic alteration effect of curcumin on olanzapine, an antipsychotic drug, treated SD rats.

SUMMARY

Olanzapine is an atypical antipsychotic drug used for the treatment of schizophrenia and bipolar disorder. Obesity is an adverse effect of olanzapine, and the present study was made an attempt to study the effect of curcumin on olanzapine-induced obesity in rats. In this present study, curcumin significantly reduced olanzapine-induced body weight gain in rats. Abbreviations Used: 5HT: 5-hydroxytryptamine, ALP: Alkaline phosphatase, ALT: Alanine transaminase, ANOVA: Analysis of variance, AST: Aspartate transaminase, CMC: Carboxymethyl cellulose, D: Dopamine, H and E: Hematoxylin and Eosin stain, H: Histamine, HDL-C: Highdensity lipoprotein cholesterol, IP: Intraperitoneal, MAO: Monoamine oxidase, NaOH: Sodium hydroxide, SD rats: Sprague Dawley rats, TCs: Total cholesterols, TG: Triglyceride.

The effects of antipsychotics on weight gain, weight-related hormones and homocysteine in children and adolescents: a 1-year follow-up study

To analyze weight gain, metabolic hormones, and homocysteine (Hcys) levels in children and adolescents on antipsychotics (AP) during a year-long follow-up. 117 patients, AP-naïve or quasi-naïve (less than 30 days on AP), were included. Weight, body mass index (BMI), BMI z-score (z-BMI), and levels of leptin, insulin, insulin resistance (HOMA-IR), adiponectin, ghrelin, thyroid stimulating hormone (TSH), free thyroxine (FT4), and Hcys were measured at baseline, and at 3, 6, and 12 months, while patients remained on the same AP. Patients (mean age: 14.4 ± 3 years; 64.1 % male) were on risperidone (N = 84), olanzapine (N = 20) or quetiapine (N = 13) from baseline up to 1-year follow-up and significantly increased weight (5.8 ± 4.3 kg at 3-month, 8.1 ± 6.1 kg at 6-month, and 11.6 ± 7.0 kg at 1 year), BMI, and z-BMI. Leptin levels significantly increased from baseline to 3 and 6 months, as did TSH levels from baseline to 3 months, while FT4 levels decreased from baseline to 3 and 6 months. Patients with BMI >85th percentile at baseline (N = 16) significantly increased weight, BMI, and z-BMI, more than patients with normal BMI over time. Higher baseline levels of insulin, HOMA-IR, and leptin were associated with increased weight/BMI during follow-up, while higher baseline levels of FT4, adiponectin, and ghrelin were associated with lower weight/BMI during follow-up. All AP were associated with increased weight and BMI/z-BMI in all of the assessments; however, at 1-year assessment, this increase was significantly higher for patients on quetiapine. Both higher baseline levels of insulin, HOMA-IR, and leptin, as well as being overweight/obese at baseline were associated with increased weight/BMI during 1-year follow-up in children and adolescents on AP. Awareness of weight-related parameters in this population may help inform decisions regarding AP prescriptions.

Effects of Low Dose Metformin on Metabolic Traits in Clozapine-Treated Schizophrenia Patients: An Exploratory Twelve-Week Randomized, Double-Blind, Placebo-Controlled Study

Background

Metformin has been used for alleviating metabolic abnormalities in patients with schizophrenia. The lowest dose of metformin to treat metabolic abnormalities in clozapine-treated patients is 1000 mg/d. This study was designed to determine whether metformin at 500 mg/d and 1000 mg/d is effective in improving the metabolic profiles of clozapine-treated patients with pre-existing metabolic abnormalities, and whether its effectiveness depends on metformin dosage.

Methods

In this 12-week, randomized, double-blind, placebo-controlled trial, metformin at 500 mg/d or 1000 mg/d was prescribed to clozapine-treated patients with schizophrenia who had pre-existing metabolic abnormalities. The recruited patients underwent physical and laboratory evaluations at weeks 4, 8, and 12. The outcomes were any changes in metabolic traits.

Results

Among the 96 clozapine-treated patients with schizophrenia screened for the trial, 55 patients with pre-existing metabolic abnormalities were randomly assigned to placebo (n = 18), metformin dosage at 500 mg/d (n = 18), and metformin dosage at 1000 mg/d (n = 19) groups. The body weight (BW) of patients in the metformin 1000 mg/d group significantly decreased, by a mean of 0.97 kg over the 12 week trial period. Moreover, patients in the metformin at 500 mg/d and 1000 mg/d groups had a significant decrease in body mass index (BMI) after 12 weeks, with the mean decrease being 0.70 and 0.50 kg/m², respectively. No significant changes were observed in the other metabolic parameters of patients in the three groups.

Conclusions

Our results demonstrated that a low metformin dosage of either 500 mg/d or 1000 mg/d for 12 weeks slightly reduced the BW and BMI of clozapine-treated patients with pre-existing metabolic abnormalities. A longer period of treatment with a larger sample is warranted to determine the factors that influence the metformin treatment response.

Trial Registration

ClinicalTrials.gov NCT02751307

Treatment-resistant schizophrenia: current insights on the pharmacogenomics of antipsychotics

Up to 30% of people with schizophrenia do not respond to two (or more) trials of dopaminergic antipsychotics. They are said to have treatment-resistant schizophrenia (TRS). Clozapine is still the only effective treatment for TRS, although it is underused in clinical practice. Initial use is delayed, it can be hard for patients to tolerate, and clinicians can be uncertain as to when to use it. What if, at the start of treatment, we could identify those patients likely to respond to clozapine - and those likely to suffer adverse effects? It is likely that clinicians would feel less inhibited about using it, allowing clozapine to be used earlier and more appropriately. Genetic testing holds out the tantalizing possibility of being able to do just this, and hence the vital importance of pharmacogenomic studies. These can potentially identify genetic markers for both tolerance of and vulnerability to clozapine. We aim to summarize progress so far, possible clinical applications, limitations to the evidence, and problems in applying these findings to the management of TRS. Pharmacogenomic studies of clozapine response and tolerability have produced conflicting results. These are due, at least in part, to significant differences in the patient groups studied. The use of clinical pharmacogenomic testing - to personalize clozapine treatment and identify patients at high risk of treatment failure or of adverse events - has moved closer over the last 20 years. However, to develop such testing that could be used clinically will require larger, multicenter, prospective studies.

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

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

Tolerability and Safety Profile of Cariprazine in Treating Psychotic Disorders, Bipolar Disorder and Major Depressive Disorder: A Systematic Review with Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Cariprazine is a novel antipsychotic agent recently approved for treating schizophrenia and bipolar mania in the USA. The sample sizes of published randomized controlled trials (RCTs) of the drug are small; previous meta-analyses included few RCTs and did not specifically investigate the tolerability/safety profile of cariprazine.

OBJECTIVE

Our objective was to conduct a meta-analysis of published RCTs to systematically review the tolerability and safety of cariprazine versus placebo.

METHODS

We searched the clinical trial registers (the metaRegister of controlled trials, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform) and electronic databases (PubMed, Embase, PsycINFO and Cochrane library) up to June 2016 to identify phase II/III RCTs of cariprazine in patients with schizophrenia, bipolar disorder or major depressive disorder. We conducted a meta-analysis to investigate outcomes, including risks of discontinuation due to adverse events (AEs), extrapyramidal side effects (EPS) or related events, metabolic syndrome and cardiovascular-related events.

RESULTS

We included nine RCTs, with a total of 4324 subjects. The risk of discontinuation due to AEs for cariprazine was similar to that for placebo (risk ratio [RR] 1.13, 95 % confidence interval [CI] 0.77-1.66). Cariprazine was associated with higher risks of EPS-related events than was placebo, including risk of akathisia (RR 3.92, 95 % CI 2.83-5.43), tremor (RR 2.41, 95 % CI 1.53-3.79) and restlessness (RR 2.17, 95 % CI 1.38-3.40). The cariprazine treatment group was more likely to have clinically significant weight gain (RR 1.68, 95 % CI 1.12-2.52). No statistically significant differences in results were found in other metabolic parameters or cardiovascular-related events.

CONCLUSION

There was a statistically significant higher risk of EPS-related AEs and a slight increase in mean body weight with cariprazine. There were no statistically significant effects on prolactin level or cardiovascular parameters. EPSs were the main short-term adverse reactions reported in the limited number of patients studied. Further clinical and post-marketing pharmacovigilance studies are needed to investigate the long-term safety of cariprazine.

Dietary Fructose and GLUT5 Transporter Activity Contribute to Antipsychotic-Induced Weight Gain

Receptors for antipsychotics in the hypothalamus contribute to antipsychotics-induced weight gain; however, many of these receptors are also expressed in the intestine. The role of these intestinally-expressed receptors, and their potential modulation of nutrient absorption, have not been investigated in the context of antipsychotics-induced weight gain. Here we tested the effect of dietary fructose and intestinal fructose uptake on clozapine-induced weight gain in mice. Weight gain was determined in wild type mice and mice lacking the GLUT5 fructose transporter that were "orally-administered" 20mg/kg clozapine for 28 days. To assess the role of dietary fructose, clozapine-treated mice were fed controlled diets with different levels of fructose. Effect of clozapine treatment on intestinal fructose transport activity and expression levels of various receptors that bind clozapine, as well as several genes involved in gluconeogenesis and lipogenesis were measured using real-time RT-PCR and western blotting. Oral administration of clozapine significantly increased body weight in wild type C57BL/6 mice but not in GLUT5 null mice. The clozapine-induced weight gain was proportional to the percentage of fructose in the diet. Clozapine-treated mice increased intestinal fructose uptake without changing the intestinal expression level of GLUT5. Clozapine-treated mice expressed significantly higher levels of intestinal H1 histamine receptor in the wild type but not GLUT5 null mice. Clozapine also increased the intestinal expression of fructokinase and several genes involved in gluconeogenesis and lipogenesis. Our results suggest that increased intestinal absorption and metabolism of fructose contributes to clozapine-induced weight gain. Eliminating dietary fructose might prevent antipsychotics-induced weight gain.

Women with bipolar disorder and pregnancy: factors influencing their decision-making

BACKGROUND

Women with bipolar disorder are at increased risk of having a severe episode of illness associated with childbirth.

AIMS

To explore the factors that influence the decision-making of women with bipolar disorder regarding pregnancy and childbirth.

METHOD

Qualitative study with a purposive sample of women with bipolar disorder considering pregnancy, or currently or previously pregnant, supplemented by data from an online forum. Data were analysed using thematic analysis.

RESULTS

Twenty-one women with bipolar disorder from an NHS organisation were interviewed, and data were used from 50 women's comments via the online forum of the UK's national bipolar charity. The centrality of motherhood, social and economic contextual factors, stigma and fear were major themes. Within these themes, new findings included women considering an elective Caesarian section in an attempt to avoid the deleterious effects of a long labour and loss of sleep, or trying to avoid the risks of pregnancy altogether by means of adoption or surrogacy.

CONCLUSIONS

This study highlights the information needs of women with bipolar disorder, both pre-conception and when childbearing, and the need for improved training for all health professionals working with women with bipolar disorder of childbearing age to reduce stigmatising attitudes and increase knowledge of the evidence base on treatment in the perinatal period.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Prevalence of Metabolic Syndrome in Patients with Schizophrenia Referred to Farabi Hospital, Kermanshah, Iran

OBJECTIVES

Our study was conducted to determine the prevalence of metabolic syndrome in patients with schizophrenia.

METHODS

The study population included all patients with schizophrenia who were referred to Farabi Hospital, Kermanshah, Iran, between March 2014 and March 2015. A total of 280 subjects who met the study criteria were selected according to the census sampling method.

RESULTS

The prevalence of metabolic syndrome was 30.4% (20.7% in men and 51.5% in women). The prevalence of metabolic syndrome was greater in patients > 40 years than patients aged 20-40 years. There was a significant relationship between marital status and number of hospitalizations with the prevalence of metabolic syndrome.

CONCLUSIONS

Given the high prevalence of metabolic syndrome in patients with schizophrenia, healthcare professionals should take measures to identify the risk factors and timely treatment of affected patients, thereby improving the patient's quality of life and reducing health costs.

Atypical antipsychotics and effects on feeding: from mice to men

RATIONALE

So-called atypical antipsychotics (AAPs) are associated with varying levels of weight gain and associated metabolic disturbances, which in patients with serious mental illness (SMI) have been linked to non-compliance and poor functional outcomes. Mechanisms underlying AAP-induced metabolic abnormalities are only partially understood. Antipsychotic-induced weight gain may occur as a result of increases in food intake and/or changes in feeding.

OBJECTIVE

In this review, we examine the available human and preclinical literature addressing AAP-related changes in feeding behavior, to determine whether changes in appetite and perturbations in regulation of food intake could be contributing factors to antipsychotic-induced weight gain.

RESULTS

In general, human studies point to disruption by AAPs of feeding behaviors and food consumption. In rodents, increases in cumulative food intake are mainly observed in females; however, changes in feeding microstructure or motivational aspects of food intake appear to occur independent of sex.

CONCLUSIONS

The findings from this review indicate that the varying levels of AAP-related weight gain reflect changes in both appetite and feeding behaviors, which differ by type of AAP. However, inconsistencies exist among the studies (both human and rodent) that may reflect considerable differences in study design and methodology. Future studies examining underlying mechanisms of antipsychotic-induced weight gain are recommended in order to develop strategies addressing the serious metabolic side effect of AAPs.

Metabolic syndrome and central obesity in depression: A cross-sectional study

INTRODUCTION

The current epidemiological data and meta-analyses indicate a bidirectional association between depression and metabolic syndrome (MetS).

AIMS

To assess the prevalence of metabolic syndrome and obesity in drug naïve patients (in current episode) having Recurrent Major Depressive Disorder and Bipolar Depression.

METHOD

This was a single point cross sectional observational study that involved administration of diagnostic and assessment tools and blood investigations. Recruitment for the study was done from a period of September 2008 to august 2009.

RESULTS

The prevalence of MetS was significantly more in the depression group when compared to healthy controls. The Bipolar depression group had 24% prevalence and recurrent depression group had 26% prevalence as opposed to none in the control group. The prevalence of MetS did not differ significantly amongst the both depression groups. Presence of central obesity was significantly more in the recurrent depression (30%) and Bipolar depression (24%) as compared to controls (8%). There was no statistically significant difference between the two depression subgroups.

DISCUSSION

Our study adds to the mounting evidence that links the presence of depression and metabolic syndrome. As we had ensured a drug free period of at least 3 months, the findings in our study indicate that the metabolic syndrome observed in our study is independent of drug exposure.

CONCLUSIONS

This study demonstrated significantly more incidence of metabolic syndrome and central obesity in patients of depression than age and sex matched controls.

Atypical antipsychotics: A review on the prevalence, monitoring, and management of their metabolic and cardiovascular side effects

Introduction

Excessive weight gain, glucose intolerance, and dyslipidemia are well-known physical side effects of the metabolic syndrome commonly associated with atypical antipsychotic (AAP) treatment. We review these side effects of AAPs and their monitoring and management strategies.

Methods

A literature search was conducted to identify articles published on the prevalence, monitoring, and management of cardiometabolic side effects of AAPs.

Results

Comparative risk of AAPs on weight gain, hyperlipidemia, glucose intolerance, and QT interval corrected for heart rate prolongation varies across the AAPs currently available. Likewise, pharmacologic and nonpharmacologic options investigated for management of these side effects, and monitoring those at appropriate intervals, differ based on the clinical condition and risk factors identified.

Discussion

Atypical antipsychotics in general have little difference among them in short-term efficacy; however, the prevalence of their physical side effects substantially distinguishes them. It is of importance that clinicians carefully select AAPs bearing in mind the presence of risk factors, initiating patients directly on AAPs with a low risk of cardiometabolic side effects, and monitoring and managing those side effects at appropriate intervals.

Antipsychotic-induced weight gain in first-episode psychosis patients: a meta-analysis of differential effects of antipsychotic medications

AIM

The first-episode psychosis (FEP) represents a critical period to prevent cardiovascular and metabolic morbidity decades later. Antipsychotic (AP)-induced weight gain is one modifiable factor in this period. The purpose of this study is to conduct a meta-analysis of AP-induced weight and body mass index (BMI) change in FEP.

METHODS

A comprehensive literature search identified 28 articles that reported data on AP-specific weight or BMI change in FEP. We conducted a meta-analysis of short- and long-term mean weight and BMI differences between placebo and AP medications. We also performed subgroup and meta-regression analysis to examine weight, BMI outcomes and their relationship with location (Asian vs. Western), sponsorship and baseline weight and BMIs.

RESULTS

Compared to placebo, AP-caused mean weight gain was 3.22 kg and 1.4 points BMI in the short-term, and 5.30 kg and 1.86 points BMI in the long term. Clinically significant weight gain risk increased about twofold with AP use. Weight gain was associated with duration of AP use. AP medications were associated with more weight gain in Western samples as opposed to Asian samples. Most AP medications were associated with significant body weight gain and BMI increase in FEP patients, except for ziprasidone. Olanzapine and clozapine caused the highest weight gain compared to placebo.

CONCLUSION

Except for ziprasidone, most AP medications were associated with body weight gain and BMI increase in FEP patients. Early and continuing effects of various AP medications on weight gain and BMI increase should be taken into consideration by clinicians.

Perceptions of strategies for successful weight loss in persons with serious mental illness participating in a behavioral weight loss intervention: A qualitative study

OBJECTIVE

The purpose of this study was to describe perceptions of weight loss strategies, benefits, and barriers among persons with serious mental illness who lost weight in the ACHIEVE behavioral weight loss intervention.

METHODS

Semistructured interviews with 20 ACHIEVE participants were conducted and analyzed using an inductive coding approach.

RESULTS

Participants perceived tailored exercise sessions, social support, and dietary strategies taught in ACHIEVE-such as reducing portion sizes and avoiding sugar-sweetened beverages-as useful weight loss strategies. Health benefits, improved physical appearance, self-efficacy, and enhanced ability to perform activities of daily living were commonly cited benefits of intervention participation and weight loss. Some participants reported challenges with giving up snack food and reducing portion sizes, and barriers to exercise related to medical conditions.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

There is emerging evidence that behavioral weight loss interventions can lead to clinically meaningful reductions in body weight among persons with serious mental illness. The perspective of persons with serious mental illness regarding strategies for, benefits of, and barriers to weight loss during participation in behavioral weight loss programs provide insight into which elements of multicomponent interventions such as ACHIEVE are most effective. The results of this study suggest that tailored exercise programs, social support, and emphasis on nonclinical benefits of intervention participation, such as improvements in self-efficacy and the ability to participate more actively in family and community activities, are promising facilitators of engagement and success in behavioral weight loss interventions for the population with serious mental illness. (PsycINFO Database Record

Predictors of early attrition and successful weight loss in patients attending an obesity management program

Background

Our objective was to identify factors that are independently associated with early attrition and successful weight loss (WL) in an obesity-management program.

Methods

Participants were 9,498 patients enrolled in treatment at the Wharton Weight Management Clinic for at least 6 months. Predictors of early attrition (<6 months) and successful WL (≥5 %) were analyzed using relative risk (RR) in men and women separately. Pearson’s correlation was used to determine the relationship between WL and treatment time Weight loss and attrition analysis was restricted to patients who had more than two visits (n = 5415).

Results

Older individuals had lower early attrition (RR Range:0.74–0.92, P < 0.05) and greater WL success (RR Range:1.40–1.65, P < 0.05) than younger individuals. Males with hypertension and females with depression had greater early attrition (RR Range:1.09–1.20, P < 0.05) and lower WL success (RR Range:0.48–0.57, P < 0.05) than those without these health conditions. Males with lower education had greater early attrition (RR = 1.11[1.03–1.19]) than males with higher education, but did not differ in WL. Females who smoked had greater early attrition (RR = 1.06[1.01–1.11]) than females who did not smoke, but did not differ in WL. Ethnicity was not related to early attrition, however, females of Black and Other ethnicities had lower WL success compared to White females (RR Range:0.58–0.74, P < 0.05). After adjusting for treatment time, all above associations were no longer significant and treatment time remained as the only independent predictor of WL success (P < 0.0001).

Conclusion

As WL is positively and independently related with treatment time, individuals at risk for early attrition may need alternative treatment options, in order to improve patient retention and improve WL success.

Clozapine in Parkinsonian Rest Tremor: A Review of Outcomes, Adverse Reactions, and Possible Mechanisms of Action

BACKGROUND

The pathogenesis of rest tremor in Parkinson's disease (PD) is incompletely understood. This symptom can be resistant to typical anti-PD medications. Therefore, new treatments are needed given the concern that this symptom causes to patients and family. Limited experience suggests that clozapine can have an important antitremor effect in PD. The mechanism(s) underlying this effect is not well understood, but could provide insight and impetus to the development of more-effective and safer antitremor therapies.

METHODS AND RESULTS

Exemplifying the antitremor effects of clozapine, we describe a patient with tremor-predominant PD who obtained prominent reduction of rest tremor with clozapine treatment. We review the responses to this treatment in another 7 of our PD patients with treatment-resistant rest tremor. We also review the published literature on clozapine for tremor in PD and discuss its potential mechanisms of action and possible adverse effects. In our case series, there was a 64% reduction of tremor score after clozapine was initiated. The mechanism of tremor reduction remains unclear with possible involvement of anticholinergic, serotonergic, antihistaminergic, antiadrenergic, and antidopaminergic effects. Clozapine does have potential serious adverse effects.

CONCLUSIONS

Clozapine may be effective in controlling rest tremor in PD. Given the potential fatal side effects, if clozapine is to be initiated in PD patients, it has to be used cautiously with proper monitoring, preferably in specialized centers. We acknowledge that the number of patients in this case series is small. Further studies are needed to understand clozapine's mechanism of action in reducing tremor.

Lifestyle Intervention for People With Severe Obesity and Serious Mental Illness

INTRODUCTION

People with serious mental illness experience elevated severe obesity rates, yet limited evidence documents whether lifestyle intervention participation can benefit these individuals. This study examined the impact of the In SHAPE lifestyle intervention on weight loss among participants with serious mental illness and severe obesity (BMI ≥40) compared with participants who are overweight (BMI 25 to <30) and have class I (BMI 30 to <35) or class II (BMI 35 to <40) obesity.

METHODS

Data were combined from three trials of the 12-month In SHAPE intervention for individuals with serious mental illness collected between 2007 and 2013 and analyzed in 2014. In SHAPE includes individual weekly meetings with a fitness trainer, a gym membership, and nutrition education. The primary outcome was weight loss. Secondary outcomes were fitness, blood pressure, lipids, and program adherence.

RESULTS

Participants (N=192) were diagnosed with schizophrenia spectrum (53.1%) or mood (46.9%) disorders. At 12 months, the overall sample showed significant weight loss, but differences among BMI groups were not significant (severe obesity, 2.57% [7.98%]; class II, 2.26% [8.69%]; class I, 1.05% [6.86%]; overweight, 0.83% [7.62%]). One third of participants with severe obesity achieved ≥5% weight loss, which was comparable across groups. More participants with severe obesity achieved ≥10% weight loss (20%) than overweight (2.9%, p=0.001) and class I (5.9%, p<0.001), but not class II (17.8%, p=0.974), obesity groups.

CONCLUSIONS

People with severe obesity and serious mental illness benefit similarly to those in lower BMI groups from lifestyle intervention participation.

Is Metabolic Syndrome On the Radar? Improving Real-Time Detection of Metabolic Syndrome and Physician Response by Computerized Scan of the Electronic Medical Record

OBJECTIVE

Metabolic syndrome is a common underdiagnosed condition among psychiatric patients exacerbated by second-generation antipsychotics, with the exception of aripiprazole and ziprasidone. This study evaluated the prescribing and treating behavior with regard to antipsychotics and metabolic syndrome of psychiatrists before and after implementation of a mandatory admission order set and electronic notification of results.

METHOD

Baseline data from 9,100 consecutive psychiatric admissions to a mental health hospital (July 2013-July 2014) were compared to postintervention data (July 2014-January 2015), which included 1,499 consecutive patient records. The intervention initiated standardized admission testing with electronic notification to psychiatrists when patients met metabolic syndrome criteria (according to Axis III of the DSM-IV). Charts were examined for inclusion of this diagnosis at discharge and for treatment changes.

RESULTS

At baseline, only 2.4% of patients (n = 214) were evaluated for metabolic syndrome. Of these, 34.5% (0.8% of the total sample) met metabolic syndrome criteria. Only 15 patients (0.16%) were comprehensively treated. No chart listed metabolic syndrome under Axis III of the DSM-IV. After the intervention, the diagnosis of patients meeting the criteria for metabolic syndrome increased from 0% to 29.3%. Less than 3% of patients were switched to drugs with a more benign metabolic profile. All patients who continued on second-generation antipsychotics had metabolic retesting. Thirty-eight experienced a significant and rapid increase in triglyceride levels after only 3 to 17 days.

CONCLUSIONS

Mandatory intake testing increases the number of patients evaluated for metabolic syndrome. Electronic alerts increase the inclusion of metabolic syndrome among discharge diagnoses but rarely affect prescribing practices.

Inflammatory Cytokines and Antipsychotic-Induced Weight Gain: Review and Clinical Implications

Antipsychotic medications (APs), particularly second-generation APs, are associated with significant weight gain in schizophrenia patients. Recent evidence suggests that the immune system may contribute to antipsychotic-induced weight gain (AIWG) via AP-mediated alterations of cytokine levels. Antipsychotics with a high propensity for weight gain, such as clozapine and olanzapine, influence the expression of immune genes, and induce changes in serum cytokine levels to ultimately down-regulate neuroinflammation. Since inflammatory cytokines are normally involved in anorexigenic responses, reduced inflammation has been independently shown to mediate changes in feeding behaviours and other metabolic parameters, resulting in obesity. Genetic variation in pro-inflammatory cytokines is also associated with both general obesity and weight change during AP treatment, and thus, may be implicated in the pharmacogenetics of AIWG. At this time, preliminary data support a cytokine-mediated model of AIWG which may have clinical utility in developing more effective metabolic monitoring guidelines and prevention measures. However, further research is still needed to clearly elucidate the validity of this immune model. This article reviews the evidence implicating inflammatory cytokines in AIWG and its potential clinical relevance.

2-Bromoterguride-a potential atypical antipsychotic drug without metabolic effects in rats

RATIONALE

Recently, we showed that 2-bromoterguride acted as a dopamine D2 receptor partial agonist, a serotonin 5-HT2A and α2C-adrenergic receptor antagonist, and exhibited antidopaminergic efficacy in amphetamine-induced locomotion (AIL) in rats without inducing catalepsy.

OBJECTIVE

To extend our knowledge on the antipsychotic effects of 2-bromoterguride, we used convergent preclinical animal models and tests; i.e., conditioned avoidance response (CAR), predictive of antipsychotic-like effects; Fos protein expression, a molecular marker for (atypical) antipsychotic activity; wet dog shake behavior, a test for the in vivo effects of drugs acting on central 5-HT2A receptors; and investigated metabolic changes as a common side effect of atypical antipsychotic drugs (APDs).

RESULTS

Acute treatment with 2-bromoterguride (0.1 and 0.3 mg/kg) decreased the CAR at 30, 90, and 270 min post-injection in rats without inducing escape failures at any time. Fos protein expression, as shown by Western blotting, was enhanced by 2-bromoterguride in the nucleus accumbens (NAc), the dorsolateral striatum (dStr), and the medial prefrontal cortex (mPFC). (±)-2,5-Dimethoxy-4-iodoamphetamine (DOI)-induced wet dog shakes in rats were reduced by 2-bromoterguride. Chronic treatment with 2-bromoterguride did not affect metabolic parameters such as body weight development and body fat composition as well as behavioral parameters such as food intake and locomotor activity.

CONCLUSIONS

Our data suggest that 2-bromoterguride is a promising candidate in the treatment of schizophrenia due to its atypical antipsychotic-like activity and its inability to induce weight gain.

Gender differences in mood stabilizer medications prescribed to Veterans with serious mental illness

BACKGROUND

Mood stabilizer medications (MSMs) can induce significant weight gain and other metabolic side effects. Research suggests that women are more susceptible to psychotropic medication-induced metabolic side effects than men. We examined gender differences in the likelihood of receiving an MSM with a lower liability for weight gain using data from the U.S. Department of Veterans Affairs (VA) healthcare system.

METHODS

We identified 3823 VA patients with a schizophrenia or bipolar disorder diagnosis who initiated treatment with a MSM between 10/2006 and 9/2011. We used multivariable logistic regression analysis to examine gender differences in the likelihood of incident prescription of MSMs with low versus medium/high metabolic risk, adjusting for fiscal year of prescribing and demographic, mental health, and physical health characteristics.

RESULTS

Overall, 47% of women were prescribed a low metabolic risk MSM compared to 26% of men (p<0.0001). In multivariable analysis, women were 2.19 times as likely as men to be prescribed a low metabolic risk MSM (95% CI: 1.84-2.60, p<0.0001). Several demographic and clinical covariates were also independently related to prescribing of MSMs by level of metabolic risk.

LIMITATIONS

This study used retrospective administrative data collected from a VA healthcare system database, which does not allow us to understand the context in which MSM treatment decisions were made.

CONCLUSIONS

Prescribing choices for MSMs by VA mental health prescribers and female Veterans may reflect a growing awareness of the potential adverse health consequences of these treatments in women.

Use of the second-generation antipsychotic, risperidone, and secondary weight gain are associated with an altered gut microbiota in children

The atypical antipsychotic risperidone (RSP) is often associated with weight gain and cardiometabolic side effects. The mechanisms for these adverse events are poorly understood and, undoubtedly, multifactorial in etiology. In light of growing evidence implicating the gut microbiome in the host's energy regulation and in xenobiotic metabolism, we hypothesized that RSP treatment would be associated with changes in the gut microbiome in children and adolescents. Thus, the impact of chronic (>12 months) and short-term use of RSP on the gut microbiome of pediatric psychiatrically ill male participants was examined in a cross-sectional and prospective (up to 10 months) design, respectively. Chronic treatment with RSP was associated with an increase in body mass index (BMI) and a significantly lower ratio of Bacteroidetes:Firmicutes as compared with antipsychotic-naïve psychiatric controls (ratio=0.15 vs 1.24, respectively; P<0.05). Furthermore, a longitudinal observation, beginning shortly after onset of RSP treatment, revealed a gradual decrease in the Bacteroidetes:Firmicutes ratio over the ensuing months of treatment, in association with BMI gain. Lastly, metagenomic analyses were performed based on extrapolation from 16S ribosomal RNA data using the software package, Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt). Those data indicate that gut microbiota dominating the RSP-treated participants are enriched for pathways that have been implicated in weight gain, such as short-chain fatty acid production.

Metabolic status and resistin in chronic schizophrenia over a 2-year period with continuous atypical antipsychotics

BACKGROUND

Common adverse effects of atypical antipsychotic treatments for schizophrenia are weight gain and lipid metabolism abnormality. We aimed to identify the signs of metabolic problems with continuous atypical antipsychotic treatment for schizophrenia over a 2-year period.

METHODS

The participants were 68 schizophrenic patients (29 males, 39 females; ages 53.4 ± 13.5 years old). Changes in carbohydrate metabolism and changes in physical characteristics were studied over a 2-year period. In addition, functional single nucleotide polymorphisms in the transcriptional regulatory region of the resistin gene were examined.

RESULTS

We found no changes in the mental state of the participants over a 2-year period. Patients did show a significant decrease in total cholesterol and hemoglobin A1c levels, although physical changes such as body mass index and abdominal girth, were not observed. The amount of resistin may not be associated with mental states and physical parameters.

CONCLUSIONS

We could not find physical factors related to metabolic changes of antipsychotics in this 2-year study. However, several psychological factors, such as health-related thoughts and behaviors, should be studied in the future.

Metabolic Impairments Precede Changes in Hunger and Food Intake Following Short-Term Administration of Second-Generation Antipsychotics

The second-generation antipsychotics (SGAs) are associated with weight gain and an increased incidence of metabolic diseases. The metabolic impairments are assumed a consequence of increased body adiposity secondary to central nervous system-associated increases in food intake. We have previously reported that, independent of weight gain, 9 days of olanzapine administration to control subjects is associated with insulin resistance and increases in postprandial levels of insulin and glucagon-like peptide 1 to a mixed meal challenge. This current report describes previously unpublished data on the effects of the SGAs olanzapine and aripiprazole compared with placebo on detailed hunger and satiety responses over the 12-day inpatient evaluation as well as postprandial ghrelin and leptin responses prior to and following administration of the 2 SGAs. We found no changes in hunger, fullness, or in the orexigenic hormone ghrelin or satiety hormone leptin, consistent with our previous report indicating no change in weight during this study. The results indicate that the SGAs are associated with metabolic changes prior to changes in hunger, satiety, and food intake, and this temporal separation suggests that there are differential mechanisms mediating SGA-associated changes in metabolism and food intake.

Metabolic issues in patients affected by schizophrenia: clinical characteristics and medical management

Patients affected by psychotic disorders are more likely to develop high rates of co-morbidities, such as obesity, type 2 diabetes, dyslipidemias, hypertension, metabolic syndrome, myocardial infarction, stroke etc., in the long-term. These morbidities have a significant impact on the life-expectancy of these patients. Patients with chronic psychoses show a 2–3-fold increased risk of death mostly from cardiovascular and metabolic diseases. Although there may be an independent link, between schizophrenia and metabolic conditions the cardio-metabolic risk is mostly related to an unhealthy lifestyle and the usage of antipsychotic agents (especially Second Generation Antipsychotics or atypical) even when these remain effective treatments in the management of major psychoses. Recently, many international organizations have developed screening and monitoring guidelines for the control of modifiable risk factors in order to reduce the rate of co-morbidity and mortality among patients affected by schizophrenia. This paper is a review of current knowledge about the metabolic issues of patients affected by schizophrenia and describes clinical characteristics and medical management strategies for such conditions.

Obstetric and neonatal outcomes after antipsychotic medication exposure in pregnancy

OBJECTIVE

Antipsychotic medications are used by increasing numbers of women of reproductive age. The safety of these medications during pregnancy has not been well described. We undertook a systematic review and meta-analysis of the adverse obstetric and neonatal outcomes associated with exposure to antipsychotics during pregnancy.

DATA SOURCES

PubMed, Reprotox, and ClinicalTrials.gov were searched to identify potential studies for inclusion.

METHODS OF STUDY SELECTION

Case-control or cohort studies estimating adverse birth outcomes associated with antipsychotic exposure during pregnancy were included. Pooled odds ratios (ORs) were used for dichotomous outcomes and weighted mean differences were used for neonatal birth weight and gestational age. Thirteen cohort studies, including 6,289 antipsychotic-exposed and 1,618,039 unexposed pregnancies, were included.

TABULATION, INTEGRATION, AND RESULTS

Antipsychotic exposure was associated with an increased risk of major malformations (absolute risk difference [ARD] 0.03, 95% confidence interval [CI] 0.00-0.05, P=.04, Z=2.06), heart defects (ARD 0.01, 95% CI 0.00-0.01, P<.001, Z=3.44), preterm delivery (ARD 0.05, 95% CI 0.03-0.08, P<.001, Z=4.10), small-for-gestational-age births (ARD 0.05, 95% CI 0.02-0.09, P=.006, Z=2.74), elective termination (ARD 0.09, 95% CI 0.05-0.13, P<.001, Z=4.69), and decreased birth weight (weighted mean difference -57.89 g, 95% CI -103.69 to -12.10 g, P=.01). There was no significant difference in the risk of major malformations (test for subgroup differences: χ²=0.07, degrees of freedom=1, P=.79) between typical (OR 1.55, 95% CI 1.21-1.99, P=.006) and atypical (OR 1.39, 95% CI 0.66-2.93, P=.38) antipsychotic medications. Antipsychotic exposure was not associated with risk of large-for-gestational-age births, stillbirth, and spontaneous abortion. Although antipsychotic exposure during pregnancy was associated with increased risk of adverse obstetric and neonatal outcomes, this association does not necessarily imply causation. This analysis was limited by the small number of included studies and limited adjustment in studies for possible confounders.

CONCLUSION

Women requiring antipsychotic treatment during pregnancy appear at higher risk of adverse birth outcomes, regardless of causation, and may benefit from close monitoring and minimization of other potential risk factors during pregnancy.

Reduced insulin-receptor mediated modulation of striatal dopamine release by basal insulin as a possible contributing factor to hyperdopaminergia in schizophrenia

Schizophrenia is a severe and chronic neuropsychiatric disorder which affects 1% of the world population. Using the brain imaging technique positron emission tomography (PET) it has been demonstrated that persons with schizophrenia have greater dopamine transmission in the striatum compared to healthy controls. However, little progress has been made as to elucidating other biological mechanisms which may account for this hyperdopaminergic state in this disease. Studies in animals have demonstrated that insulin receptors are expressed on midbrain dopamine neurons, and that insulin from the periphery acts on these receptors to modify dopamine transmission in the striatum. This is pertinent given that several lines of evidence suggest that insulin receptor functioning may be abnormal in the brains of persons with schizophrenia. Post-mortem studies have shown that persons with schizophrenia have less than half the number of cortical insulin receptors compared to healthy persons. Moreover, these post-mortem findings are unlikely due to the effects of antipsychotic treatment; studies in cell lines and animals suggest antipsychotics enhance insulin receptor functioning. Further, hyperinsulinemia - even prior to antipsychotic use - seems to be related to less psychotic symptoms in patients with schizophrenia. Collectively, these data suggest that midbrain insulin receptor functioning may be abnormal in persons with schizophrenia, resulting in reduced insulin-mediated regulation of dopamine transmission in the striatum. Such a deficit may account for the hyperdopaminergic state observed in these patients and would help guide the development of novel treatment strategies. We hypothesize that, (i) insulin receptor expression and/or function is reduced in midbrain dopamine neurons in persons with schizophrenia, (ii) basal insulin should reduce dopaminergic transmission in the striatum via these receptors, and (iii) this modulation of dopaminergic transmission by basal insulin is reduced in the brains of persons with schizophrenia.

Clinical Assessment of Weight Gain with Atypical Antipsychotics - Blonanserin vs Amisulpride

BACKGROUND

Atypical antipsychotics appear to have the greatest potential to induce weight gain. Antipsychotic-induced weight gain is the one of main cause of non-compliance and discontinuation of treatment, often resulting in the relapse of psychosis.

OBJECTIVE

To compare the weight gain between amisulpride and blonanserin treatment, in persons with psychosis.

MATERIALS AND METHODS

Fifty six subjects with psychosis attending psychiatry department at KR Hospital, Mysore were randomized into two equal groups. After obtaining informed consent, subjects of group I received amisulpride tablets 200 mg BD, and group II received blonanserin tablets 4 mg BD, for eight weeks. Body weight, Body Mass Index (BMI) and Waist Hip Ratio (WHR) were measured at baseline, 4 weeks and 8 weeks.

RESULTS

The mean weight gain with amisulpride at 4 weeks was 2.73 kg (5.21%) and at 8 weeks was 4.34 kg (8.28%) from the baseline. The mean weight gain with blonanserin at 4 weeks was 1.77 kg (3.46%) and at 8 weeks was 3.46 kg (6.75%) from the baseline. The mean BMI increase at 8 weeks with amisulpride was 1.66 ± 0.56 and with blonanserin was 1.34 ± 0.77. The mean WHR increase at 8 weeks with amisulpride was 0.036 ± 0.026 and with blonanserin was 0.029 ± 0.020. There was statistically significant increase in weight, BMI and WHR associated with both blonanserin and amisulpride at 8 weeks. But there was no statistically significant difference in those parameters between blonanserin and amisulpride, at eight weeks.

CONCLUSION

Even though there was no significant difference in the weight gain caused by blonanserin, in comparison with amisulpride, both these drugs individually caused significant weight gain at 8 weeks, which is in contrast with the earlier studies, which needs to be further evaluated.

Treatment of clozapine-associated obesity and diabetes with exenatide (CODEX) in adults with schizophrenia: study protocol for a pilot randomised controlled trial

BACKGROUND

Clozapine causes significant metabolic disturbances including obesity and type 2 diabetes. Recent evidence that reduced glucagon-like-peptide-1 (GLP-1) may contribute to aetiology of clozapine-associated metabolic dysregulation suggests a potential therapeutic role for GLP-1 agonists.

METHOD

This open-label, pilot randomised controlled trial evaluates the effect of exenatide in clozapine-treated obese adults who have schizophrenia, with or without poorly controlled diabetes. Sixty out-patients will be randomised to once weekly extended release exenatide or treatment as usual for 24 weeks.

AIMS

To evaluate the feasibility of larger studies regarding methodology, acceptability, tolerability and estimate efficacy for glycaemic control or weight loss. Secondary outcomes are psychosis severity and metabolic parameters.

CONCLUSIONS

This is the first trial investigating GLP-1 agonists for glycaemic control and weight loss in clozapine-treated patients with either diabetes or obesity. Clozapine-associated obesity and diabetes with exenatide (CODEX) will provide proof-of-concept empirical evidence addressing whether this novel treatment is practical and worthy of further investigation.

DECLARATION OF INTEREST

A.W.R. has received speaker honoraria and travel grants from AstraZeneca, BoehringerIngelheim, Eli Lilly, MSD, Novo Nordisk and Sanofi and has participated on advisory panels for MSD and Novo Nordisk.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Weight Gain and Its Correlates Among Forensic Inpatients

OBJECTIVE

We investigated changes in weight, body mass index (BMI), and other indices of the metabolic syndrome in forensic inpatients. Weight gain associated with newer antipsychotics (APs) is well established in the general psychiatric population.

METHODS

We examined the medical records of 291 men admitted to a forensic hospital at admission and again at discharge or 365 days later if still in hospital. We also recorded diagnosis and smoker status on admission and quantified psychotropic treatment and adherence, physical activity, and daytime occupation during the hospitalization.

RESULTS

On admission, 33% were obese and 22% of the 106 patients for whom sufficient data were available met criteria for metabolic syndrome. Among patients staying at least 30 days, 60% were weighed again before discharge but repeated blood pressure and waist circumference measures were uncommon, even among those at greatest risk. The 122 forensic inpatients with sufficient information gained an average of 12% of their body weight and 40% increased by at least 1 BMI category, gaining an average of 3.67 kg per month. Weight gain was associated with duration of time and was not attributable to being underweight on admission, diagnosis of schizophrenia, atypical AP treatment, medication adherence, or having been a smoker.

CONCLUSIONS

Patients gained weight during forensic hospitalization independent of medication use. We recommend further research using consistent measurement and wider sampling of both metabolic syndrome indicators and its individual and systemic causes in forensic populations.

The effect of clozapine on premature mortality: an assessment of clinical monitoring and other potential confounders

Clozapine can cause severe adverse effects yet it is associated with reduced mortality risk. We test the hypothesis this association is due to increased clinical monitoring and investigate risk of premature mortality from natural causes. We identified 14 754 individuals (879 deaths) with serious mental illness (SMI) including schizophrenia, schizoaffective and bipolar disorders aged ≥ 15 years in a large specialist mental healthcare case register linked to national mortality tracing. In this cohort study we modeled the effect of clozapine on mortality over a 5-year period (2007-2011) using Cox regression. Individuals prescribed clozapine had more severe psychopathology and poorer functional status. Many of the exposures associated with clozapine use were themselves risk factors for increased mortality. However, we identified a strong association between being prescribed clozapine and lower mortality which persisted after controlling for a broad range of potential confounders including clinical monitoring and markers of disease severity (adjusted hazard ratio 0.4; 95% CI 0.2-0.7; p = .001). This association remained after restricting the sample to those with a diagnosis of schizophrenia or those taking antipsychotics and after using propensity scores to reduce the impact of confounding by indication. Among individuals with SMI, those prescribed clozapine had a reduced risk of mortality due to both natural and unnatural causes. We found no evidence to indicate that lower mortality associated with clozapine in SMI was due to increased clinical monitoring or confounding factors. This is the first study to report an association between clozapine and reduced risk of mortality from natural causes.