Physical health monitoring of patients with schizophrenia

Contextual Factors in the Health of People With Serious Mental Illness

People living with serious mental illness (SMI) have shorter life expectancies than the general population. We examined how contextual factors influence the physical health of this population. We conducted interviews, focus groups, and participant observations with stakeholders from six behavioral health organizations. We found that consumers' avoidance of overt disagreement during medical visits, their mistrust of medical institutions, and cultural variations in body image influenced the clinical encounter. Mental health providers' ambivalence about intervening in consumers' physical health, primary care providers' misattribution of physical symptoms to mental disorders, and providers' stigmatization of consumers shaped clinical encounters. Consumers' diets were shaped by food environments and social norms associated with traditional diets. Internal and external factors impacted consumers' physical activity. In this article, we illustrate the importance of considering contextual factors in the development and implementation of interventions aimed at improving the physical health of people with SMI.

Self-reported health, health behaviors, attitudes, and beliefs of regional mental health consumers

PURPOSE

This article reports baseline data from a randomized controlled trial investigating the impact of a specialist cardiometabolic healthcare nurse on physical health care.

DESIGN AND METHODS

Survey of community-based mental health consumers randomized to a cardiometabolic health nurse intervention.

FINDINGS

Findings show a high prevalence of respiratory conditions, hypercholesterolemia, hypertension, and low quality of life. Participants reported regular blood pressure but infrequent cholesterol and blood glucose testing. Few received advice about smoking cessation, diet, or physical activity. Participants were mostly satisfied with physical healthcare provision; however, positive health behaviors are lacking.

PRACTICE IMPLICATIONS

An individualized intervention based on knowledge and attitudes may be necessary.

Effectiveness of a psychosocial weight management program for individuals with schizophrenia

The objective of this study was to examine the effectiveness of a weight loss program for individuals with schizophrenia in usual care. The study included 146 adults with schizophrenia from two mental health clinics of the Department of Veterans Affairs. The 109 individuals who were overweight or obese were offered a 16-week, psychosocial, weight management program. Weight and Body Mass Index (BMI) were assessed at baseline, 1 year later, and at each treatment session. Only 51% of those who were overweight or obese chose to enroll in the weight management program. Participants attended an average of 6.7 treatment sessions, lost an average of 2.4 pounds, and had an average BMI decrease of 0.3. There was no significant change in weight or BMI compared to the control group. Intervention strategies that both improve utilization and yield greater weight loss need to be developed.

Effectiveness evaluation of a pharmacist-driven monitoring database for tardive dyskinesia

BACKGROUND

Tardive dyskinesia (TD) is a potentially irreversible, chronic syndrome related to antipsychotic medication use characterized by hyperkinetic abnormal involuntary movements. Various studies have shown that development of TD is possible with both first- and second-generation antipsychotics. Regular monitoring for emergence of TD symptoms is recommended in clinical practice for early recognition and intervention.

METHODS

This is a retrospective, single-center, observational study of the effectiveness of a pharmacist-driven monitoring database for TD assessment. Subjects were adult inpatients at a state psychiatric hospital who received antipsychotic treatment for at least 3 or 6 months between January 2006 and December 2011. The primary objective was to assess compliance rates with TD monitoring based on facility policy before and after implementation of the database at 3 and 6 months following initiation of antipsychotic therapy.

RESULTS

A significant improvement in compliance with TD monitoring policy was seen after implementation of the database (2.9% vs 66.7%; P < .001). Compliance with TD monitoring did not differ between classes of antipsychotic medication, hospital units, or age groups.

CONCLUSION

The results of this study demonstrate that pharmacists can help improve compliance with TD assessment and that monitoring databases may be useful for similar extended or long-term care settings to ensure timely assessment of patients for the development or progression of TD.

Bone mineral density and general health of long-term residential psychiatric inpatients

OBJECTIVE

The aim of this study was to determine the rates of osteopenia and osteoporosis and other general health problems in a long-stay male psychiatric unit.

METHOD

All 15 patients underwent a semi-structured clinical interview and a full physical examination including calculation of Body Mass Index, central obesity (abdominal circumference) and blood pressure measurement. All patients had blood sampling examining FBC, U&E, LFTs, TFTs, PSA, prolactin, lipid profile and glucose. The rates of metabolic syndrome were calculated according to the International Diabetes Federation consensus worldwide definition. Bone mineral density was determined in the lumbar vertebrae and left hip by DEXA scanning.

RESULTS

The prevalence of osteopenia or osteoporosis was 46%, and bone mineral density was inversely correlated with serum prolactin levels (r = -0.595, p = 0.041) and chlorpromazine equivalence (r = -0.645, p = 0.017). The prevalence of obesity was 53%, while central obesity was present in 87% of patients. Metabolic Syndrome was present in 27% of patients.

CONCLUSIONS

More attention should be given to diagnosing and treating osteopenia and osteoporosis in patients on long-term antipsychotic agents and preventative measures should form part of any treatment regime in these individuals. Frequent input from dietitians should also be available for long-stay psychiatric inpatients to reduce the prevalence of obesity.

Atypical antipsychotic monitoring in the Kilkenny Mental Health Services

Objectives:To examine baseline testing and ongoing monitoring of cardiovascular and other risk factors in individuals prescribed atypical antipsychotic medications.

Methods:We derived a list of baseline and ongoing monitoring tests from the literature (Weight, BMI, blood pressure, U&E, LFTs, glucose, HbA1C, FBC, TFTs, prolactin, lipids & ECG) and then reviewed a random sample of 80 records of patients prescribed atypical antipsychotics and currently attending an Irish public catchment area service, for evidence of testing.

Results:Levels of testing for baseline tests ranged from 45% for blood pressure to 0% for BMI. Levels of ongoing monitoring tests ranged from 42.5% for U&E to 0% for BMI. Patients admitted to hospital were much more likely to have had testing.

Conclusions:The need for baseline and ongoing monitoring of certain tests in patients prescribed atypical antipsychotics is increasingly accepted. Levels of such testing are currently quite low and need to increase.

High prevalence of risk factors for physical illness in a long-stay psychiatric unit

Objective: The aim of this study was to determine the prevalence of risk factors for physical illness in a long stay psychiatric unit, where all care (both psychiatric and physical) is provided by the psychiatric team.

Method: All patients in the long-stay ward had a full physical examination including calculation of BMI. All patients had blood sampling including FBC, U&E, LFTs, TFTs, lipid profile (total cholesterol, triglycerides, HDL and LDL), glucose, HbA1c, and prolactin. ATP111 criteria were used to determine the presence of the metabolic syndrome.

Results: We found the mean number of comorbid medical diagnosis was 2.7. The prevalence of metabolic syndrome was 40.7% (44.4% of females and 24.1% of males). The prevalence of obesity was 51%, and 51% also had a total cholesterols in excess of 5.0mmol/l. Prolactin was elevated in two-thirds of female patients.

Conclusion: We conclude that the annual physical examination is of limited value in long-stay psychiatric unit. The high prevalence of physical illness and physical risk factors warrants primary care involvement in screening and treatment of long-stay psychiatric patients.

Improving monitoring for metabolic syndrome using audit

Audit has been defined as "a quality improvement process that seeks to improve patient care and outcome, through systematic review of care and comparison with explicit criteria, followed by the implementation of change". As of May 2011, under the Medical Practitioners Act 2007, doctors are legally obliged to join in professional competence schemes, following requirements set by the Medical Council. These include the obligation for doctors to conduct one clinical audit per year. In Ireland and elsewhere, audit provides an opportunity for services to create an "environment in which clinical care will flourish".

Prevalence of obesity and metabolic syndrome in a long-stay psychiatric unit

Objective:The aim of this study was to determine the prevalence of metabolic syndrome and obesity as defined by Body Mass Index (BMI) in a long-stay psychiatric unit where all care is provided by the psychiatric team.

Method:All residents in this long-stay unit were screened. Their BMI was calculated. Waist circumference and blood investigations were done. Ward records were used to determine those who had been previously diagnosed with hypertension and diabetes. The ATP 111 criteria were used to determine the prevalence of metabolic syndrome.

Results:We found a prevalence of 33% for BMI obesity and a prevalence of 66% for metabolic syndrome. These are higher than those of the general Irish middle aged population and the accepted estimate of a general psychiatric population. It is also higher than that of a previous published study on an Irish long-stay psychiatric ward population.

Conclusion:There is high prevalence of BMI obesity and metabolic syndrome in long-stay psychiatric residents. This has the potential to impact significantly on physical morbidity and mortality. People with severe and enduring mental illness should have access to primary care and other health services on the same basis as any other citizen.

Atypical antipsychotic monitoring: A survey of patient knowledge and experience

Objectives: To examine the knowledge and experiences of side-effects and their monitoring in patients prescribed atypical antipsychotic medications.

Methods: A tick box survey was designed to ask questions of patients prescribed atypical antipsychotic medications about side-effects and monitoring for them. This survey was distributed anonymously to all suitable outpatient attendees over a three month period who had been prescribed atypical antipsychotic medication for at least one year.

Results: Seventy-four of the 90 surveys (82%) distributed were returned complete. Fifty-six (76%) of those surveyed said they were currently experiencing side-effects. Twenty-two (39%) said they had not told their psychiatrist about the side-effects. Weight gain was most commonly complained of (49%). Forty-five (61%) said that they had had no monitoring blood tests in the past year. Fifty-one (69%) did not know that certain monitoring blood tests were recommended.

Conclusions: Patients prescribed atypical antipsychotic medications are not currently being monitored as best practice dictates. It cannot be assumed that GPs will pursue this monitoring. More resources are needed for mental health services so that adequate monitoring services can be provided.

Management of elevated blood cholesterol in the psychiatric patient: What's new in the guidelines?

Compared with the general adult population, patients with schizophrenia and bipolar disorder have a 1.5 to 2.8 fold increase in mortality rates. This increase in mortality is multifactorial, including both natural causes and suicide. Additionally, antipsychotic medications have been associated with several adverse effects, including weight gain, hyperlipidemia, and the onset of diabetes. These adverse effects can place patients at risk for metabolic syndrome and atherosclerotic cardiovascular disease (ASCVD). Regular monitoring and treatment of risk factors for ASCVD, including hyperlipidemia, should be provided in clinical practice. The American College of Cardiology and the American Heart Association recently published updated recommendations for the management of cholesterol to reduce ASCVD. These national guidelines, based on a large body of clinical trials, describe 4 specific patient populations at high risk for ASCVD that should be considered candidates for therapeutic lifestyle changes and pharmacologic treatment. Statin therapy should be considered a first-line treatment option for these patients due to a favorable benefit versus risk profile. Of note, the new guidelines do not recommend a specific LDL target for patients. Instead, either a moderate or high-intensity statin should be recommended based on the patients' comorbidities. Health care providers can have a significant impact on the cardiovascular health of psychiatric patients by appropriately monitoring and treating hyperlipidemia.

Chronic disease self-management interventions for adults with serious mental illness: a systematic review of the literature

OBJECTIVE

While there is strong evidence in support of chronic disease self-management programs, much less is available with regard to individuals living with serious mental illness (SMI). The objectives of this review are to identify and appraise chronic disease self-management studies tested with samples of US adults living with SMI. We include an appraisal of methodological quality of the chronic disease self-management (CDSM) studies that met our final criteria.

METHODS

Systematic search methods were utilized to identify intervention studies published before 2012 that describe CDSM outcomes for adults with SMI.

RESULTS

Eighteen unduplicated articles were identified that included outcomes of CDSM studies, while 10 met all inclusion criteria. Favorable treatment effects were observed for adults with SMI across 10 studies that took place in different types of clinical settings. CDSM studies that met all search criteria had a wide range of methodological quality, indicating that this is a nascent field of study.

CONCLUSIONS

Given the high chronic disease burden experienced by individuals with SMI combined with our nations health care reform, emphasis on self-management to improve population health, coupled with advancing the quality of research to evaluate CDSM programs for adults with SMI, is critically needed.

Ziprasidone as Adjunctive Therapy in Severe Bipolar Patients Treated with Clozapine

Aim. To confirm the efficacy and tolerability of ziprasidone as adjunctive therapy in bipolar patients partially responding to clozapine or with persisting negative symptoms, overweight, or with metabolic syndrome. Methods. Eight patients with psychotic bipolar disorder were tested with the BPRS, the HAM-D, and the CGI at T0 and retested after 2 weeks (T1). Plasma clozapine and norclozapine levels and BMI were tested at T0 and T1. Results. Ziprasidone was well tolerated by all the patients. BPRS and HAM-D scores were reduced in all patients. BMI was reduced in patients with a BMI at T0 higher than 25. Plasma levels of clozapine and norclozapine showed an irregular course.

Second-generation and newly approved antipsychotics, serum prolactin levels and sexual dysfunctions: a critical literature review

INTRODUCTION

Using antipsychotic (AP) medication can increase prolactin (PRL) levels and place the patient at risk of sexual dysfunction (SD).

AREAS COVERED

The aim of this review is to describe the PRL propensity of the different second-generation and newly approved APs. It then considers the prevalence rates of SDs associated with these compounds in patients with schizophrenia and treatment strategies for the management of SDs and/or hyperprolactinemia (HPRL). Furthermore, we address the lingering question regarding the association between SDs and PRL.

EXPERT OPINION

SD (particularly long-term) data remain scarce for several APs. A wide variety of assessment techniques used in SD research make reliable comparisons between APs impossible. The majority of these reports do not equally allow us to distinguish between treatment (AP and co-medication)-emergent SDs and illness-related SDs. This makes it difficult to assess the degree to which these side effects are associated with 'PRL-raising' APs, and what part of this fraction is directly reducible to serum PRL levels. Also, few evidence-based treatment strategies for HPRL and associated side effects are available. Therefore, longer-term randomized controlled trials, using reliable and valid structured interviews or questionnaires, are necessary to establish the precise relationship between APs, PRL levels and SDs rates and develop valuable treatment options.

Body mass index and metabolic parameters in patients with schizophrenia during long-term treatment with paliperidone palmitate

BACKGROUND

There is a strong association between weight gain and metabolic events in patients with schizophrenia receiving many of the second-generation antipsychotic agents. We explored the relationship between body mass index (BMI) and metabolic events in patients with schizophrenia receiving long-acting injectable paliperidone palmitate (PP) in a long-term trial.

METHODS

We conducted a post hoc analysis of data from a PP study that included a 33-week open-label transition (TR) and maintenance phase; a variable duration, randomized, double-blind (DB), placebo-controlled phase and a 52-week open-label extension (OLE) phase. Overall, 644 patients received PP continuously from study entry through discontinuation or study completion and were grouped by baseline BMI (kg/m2): underweight (BMI <19; n = 29, 4.5%), normal-weight (BMI 19- < 25; n = 229, 35.6%), overweight (BMI 25- < 30; n = 232, 36.0%) and obese (BMI ≥ 30; n = 154, 23.9%). Metabolic treatment-emergent adverse events (TEAEs) and changes in related laboratory results from TR baseline were analyzed.

RESULTS

PP exposure was similar across BMI groups; overall mean (SD) dose/month was 70.3 (17.17) mg eq. [109.6 (26.78) mg]; median duration of exposure was 204 days (6 to 1009 days). Occurrences of metabolic TEAEs overall by group were 0% (underweight), 14.9% (normal-weight), 14.7% (overweight), and 24.0% (obese). The most common (≥ 2%) metabolic TEAE were weight gain and elevated blood levels of glucose, lipids, and insulin. Mean BMI and weight increased in normal-weight and overweight groups at DB endpoint, and in underweight, normal-weight and overweight groups at OLE endpoint (p ≤ 0.05). No consistent trend for increased metabolic-related laboratory values by baseline BMI group was observed. Homeostatic model assessments for insulin resistance indicated preexisting insulin resistance at baseline, with minimal changes at OLE endpoint across baseline BMI groups.

CONCLUSION

Occurrences of metabolic-related TEAEs trended with greater BMI status in patients with schizophrenia treated with PP; consistent trends in metabolic-related laboratory values were not observed.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov (NCT 00518323).

Audit of discharges from a regional service in the United Kingdom

AIM

As early intervention in psychosis (EI) continues to develop, clinical governance maintains an important role in the 'real world' analysis of services. This paper details an audit of all discharges from a regional early intervention service in the United Kingdom, providing benchmarking information on service structure, interventions and outcomes. The background places the service in the context of national and international guidelines.

METHODS

All discharges between service inception in 2004 and February 2011 were retrospectively examined and audited according to identified standards, based upon international and national guidelines. A total of 110 patients were discharged from the EI service after a period of involvement of at least 6 months.

RESULTS

A high proportion of service users (55%) had their care transferred back to primary care after discharge. Physical health and social needs were well addressed, and almost half of individuals were in education, training or employment upon discharge. Most service users (69%) did not require inpatient admission during their involvement with the service. Although the majority had psychological, pharmacological and physical health needs addressed, there remained room for improvement when measured against identified standards.

CONCLUSIONS

This paper details outcomes of every patient seen by an EI service since inception, providing valuable benchmarking information for those involved in management of similar services, service redevelopment, commissioning, and implementation of evidence-based practice. The proportion of service users in education, training or employment after discharge exceeded expectations considerably.

Prevalence of cardiovascular risk factors among racial and ethnic minorities with schizophrenia spectrum and bipolar disorders: a critical literature review

OBJECTIVE

People with serious mental illness (SMI) die at least 11 years earlier than the general U.S. population, on average, due largely to cardiovascular disease (CVD). Disparities in CVD morbidity and mortality also occur among some U.S. racial and ethnic minorities. The combined effect of race/ethnicity and SMI on CVD-related risk factors, however, remains unclear. To address this gap, we conducted a critical literature review of studies assessing the prevalence of CVD risk factors (overweight/obesity, diabetes mellitus, metabolic syndrome, hypercholesterolemia, hypertension, cigarette smoking, and physical inactivity) among U.S. racial/ethnic groups with schizophrenia-spectrum and bipolar disorders.

METHODS AND RESULTS

We searched MEDLINE and PsycINFO for articles published between 1986 and 2013. The search ultimately yielded 40 articles. There was great variation in sampling, methodology, and study populations. Results were mixed, though there was some evidence for increased risk for obesity and diabetes mellitus among African Americans, and to a lesser degree for Hispanics, compared to non-Hispanic Whites. Sex emerged as an important possible effect modifier of risk, as women had higher CVD risk among all racial/ethnic subgroups where stratified analyses were reported.

CONCLUSIONS

Compared to general population estimates, there was some evidence for an additive risk for CVD risk factors among racial/ethnic minorities with SMI. Future studies should include longitudinal assessment, stratification by sex, subgroup analyses to clarify the mechanisms leading to potentially elevated risk, and the evaluation of culturally appropriate interventions to eliminate the extra burden of disease in this population.

Emergency department utilization among Medicaid beneficiaries with schizophrenia and diabetes: the consequences of increasing medical complexity

OBJECTIVE

Individuals with both physical and mental health problems may have elevated levels of emergency department (ED) service utilization either for index conditions or for associated comorbidities. This study examines the use of ED services by Medicaid beneficiaries with comorbid diabetes and schizophrenia, a dyad with particularly high levels of clinical complexity.

METHODS

Retrospective cohort analysis of claims data for Medicaid beneficiaries with both schizophrenia and diabetes from fourteen Southern states was compared with patients with diabetes only, schizophrenia only, and patients with any diagnosis other than schizophrenia and diabetes. Key outcome variables for individuals with comorbid schizophrenia and diabetes were ED visits for diabetes, mental health-related conditions, and other causes.

RESULTS

Medicaid patients with comorbid diabetes and schizophrenia had an average number of 7.5 ED visits per year, compared to the sample Medicaid population with neither diabetes nor schizophrenia (1.9 ED visits per year), diabetes only (4.7 ED visits per year), and schizophrenia only (5.3 ED visits per year). Greater numbers of comorbidities (over and above diabetes and schizophrenia) were associated with substantial increases in diabetes-related, mental health-related and all-cause ED visits. Most ED visits in all patients, but especially in patients with more comorbidities, were for causes other than diabetes or mental health-related conditions.

CONCLUSION

Most ED utilization by individuals with diabetes and schizophrenia is for increasing numbers of comorbidities rather than the index conditions. Improving care in this population will require management of both index conditions as well as comorbid ones.

Psychiatrists' attitudes toward metabolic adverse events in patients with schizophrenia

Background

There is growing concern about the metabolic abnormalities in patients with schizophrenia.

Aims

The aim of this study was to assess the attitudes of psychiatrists toward metabolic adverse events in patients with schizophrenia.

Method

A brief questionnaire was constructed to cover the following broad areas: the psychiatrists' recognition of the metabolic risk of antipsychotic therapy, pattern of monitoring patients for physical risks, practice pattern for physical risks, and knowledge of metabolic disturbance. In March 2012, the questionnaire was mailed to 8,482 psychiatrists who were working at hospitals belonging to the Japan Psychiatric Hospitals Association.

Results

The overall response rate was 2,583/8,482 (30.5%). Of the respondents, 85.2% (2,200/2,581) reported that they were concerned about prescribing antipsychotics that have a risk of elevating blood sugar; 47.6% (1,201/2,524) stated that their frequency of monitoring patients under antipsychotic treatment was based on their own experiences; and only 20.6% (5,22/2,534) of respondents answered that the frequency with which they monitored their patients was sufficient to reduce the metabolic risks.

Conclusions

Psychiatrists practicing in Japan were generally aware and concerned about the metabolic risks for patients being treated with antipsychotics. Although psychiatrists should monitor their patients for metabolic abnormalities to balance these risks, a limited number of psychiatrists answered that the frequency with which they monitored patients to reduce the metabolic risks was sufficient. Promotion of the best practices of pharmacotherapy and monitoring is needed for psychiatrists treating patients with schizophrenia.

Physical health care monitoring for people with serious mental illness

BACKGROUND

Current guidance suggests that we should monitor the physical health of people with serious mental illness, and there has been a significant financial investment over recent years to provide this.

OBJECTIVES

To assess the effectiveness of physical health monitoring, compared with standard care for people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (October 2009, update in October 2012), which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO.

SELECTION CRITERIA

All randomised clinical trials focusing on physical health monitoring versus standard care, or comparing i) self monitoring versus monitoring by a healthcare professional; ii) simple versus complex monitoring; iii) specific versus non-specific checks; iv) once only versus regular checks; or v) different guidance materials.

DATA COLLECTION AND ANALYSIS

Initially, review authors (GT, AC, SM) independently screened the search results and identified three studies as possibly fulfilling the review's criteria. On examination, however, all three were subsequently excluded. Forty-two additional citations were identified in October 2012 and screened by two review authors (JX and MW), 11 of which underwent full screening.

MAIN RESULTS

No relevant randomised trials which assess the effectiveness of physical health monitoring in people with serious mental illness have been completed. We identified one ongoing study.

AUTHORS' CONCLUSIONS

There is still no evidence from randomised trials to support or refute current guidance and practice. Guidance and practice are based on expert consensus, clinical experience and good intentions rather than high quality evidence.

Improvements in metabolic abnormalities among overweight schizophrenia and bipolar disorder patients

PURPOSE

As weight-gain and metabolic abnormalities during treatment with psychotropic drugs are of great concern, we evaluated effects of psycho-education and medical monitoring on metabolic changes among severely mentally ill patients.

MATERIALS AND METHODS

During repeated, systematic psycho-education about general health among 66 consecutive patients diagnosed with DSM-IV-TR schizophrenia (n=33) or type-I bipolar disorder (n=33), we evaluated (at intake 1, 2, 3, and 6 months) clinical psychiatric status, treatments and doses, recorded physiological parameters, and assessed attitudes about medication.

RESULTS

At intake, patients with schizophrenia vs bipolar disorder were receiving 3-7 times more psychotropic medication, with 14% higher initial body-mass index (BMI: 29.1 vs 25.6 kg/m²), 12 times more obesity, and significantly higher serum lipid concentrations. During 6-months follow-up, among bipolar disorder patients, polytherapy and serum lipid concentrations declined more than among schizophrenia patients (e.g., total cholesterol+triglycerides, by 3.21 vs 1.75%/month). BMI remained stable. Declining lipid levels were associated with older age, bipolar disorder, being unemployed, higher antipsychotic doses, and lower initial BPRS scores (all P ≤ 0.001).

CONCLUSIONS

Psychotropic treatments were more complex, and metabolic measures more abnormal among bipolar disorder than schizophrenia patients. Intensive psycho-education, clinical monitoring, and encouragement of weight-control for six months were associated with improvements in metabolic measures (but not to BMI), and more realistic attitudes about medication.

Cardiovascular effects of antipsychotics

There is great concern over cardiovascular disease in the schizophrenic population owing to the high incidence of cardiovascular mortality. Increased cardiovascular mortality is related to lifestyle choices (e.g., smoking and sedentary lifestyle) and a high prevalence of comorbid medical conditions, including dyslipidemia, the metabolic syndrome and Type 2 diabetes. One factor that increases cardiovascular risk is the medications used to treat the core features of schizophrenia. Adverse cardiovascular effects of antipsychotic treatment have been recognized for many decades, especially tachycardia, orthostatic hypotension and rare instances of sudden death; but, since 2000, there has been a significant shift in the focus of risk perception. The older antipsychotic literature is replete with papers primarily concerned with the physiological consequences of muscarinic cholinergic antagonism, alpha(1)-adrenergic antagonism or receptors associated with cardiac conduction, but the current literature recognizes that, for most antipsychotic-exposed patients, the more significant cardiovascular burden of treatment is mediated by metabolic adverse effects such as weight gain, dyslipidemia and diabetes mellitus. The purpose of this review is to examine the cardiovascular risks of treatment with antipsychotic medications, elucidating relevant mechanisms and differences between various agents, especially for metabolic adverse effects seen with atypical antipsychotics.

Unmet needs in the management of schizophrenia

Studies on unmet needs during the last decades have played a significant role in the development and dissemination of evidence-based community practices for persistent schizophrenia and other severe mental disorders. This review has thoroughly considered several blocks of unmet needs, which are frequently related to schizophrenic disorders. Those related to health have been the first block to be considered, in which authors have examined the frequent complications and comorbidities found in schizophrenia, such as substance abuse and dual diagnosis. A second block has been devoted to psychosocial and economic needs, especially within the field of recovery of the persistently mentally ill. Within this block, the effects of the current economic difficulties shown in recent literature have been considered as well. Because no patient is static, a third block has reviewed evolving needs according to the clinical staging model. The fourth block has been dedicated to integrated evidence-based interventions to improve the quality of life of persons with schizophrenia. Consideration of community care for those reluctant to maintain contact with mental health services has constituted the fifth block. Finally, authors have aggregated their own reflections regarding future trends. The number of psychosocial unmet needs is extensive. Vast research efforts will be needed to find appropriate ways to meet them, particularly regarding so-called existential needs, but many needs could be met only by applying existing evidence-based interventions. Reinforcing research on the implementation strategies and capacity building of professionals working in community settings might address this problem. The final aim should be based on the collaborative model of care, which rests on the performance of a case manager responsible for monitoring patient progress, providing assertive follow-up, teaching self-help strategies, and facilitating communication among the patient, family doctor, mental health specialist, and other specialists.

Community adherence to schizophrenia treatment and safety monitoring guidelines

The 2003 Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations and the Mount Sinai Conference Safety Monitoring recommendations generated guidelines for pharmacological treatment of schizophrenia and monitoring of antipsychotic side effects. This study examined rate of recommendation adherence and impact of adherence on outcomes of outpatients with schizophrenia or schizoaffective disorder in community mental health centers. Clinical practice was assessed as conformant, nonconformant, or not applicable. Treatment practices were conformant for antipsychotic dose (83%); use of antiparkinsonian (97%), antidepressant (100%), and antianxiety agents (90%) but not clozapine for residual positive symptoms (31%); and monitoring weight gain (48%), glucose dysregulation (53%), hyperlipidemia (34%), or extrapyramidal symptoms (11%). Community mental health center treatment practices were largely conformant with the 2003 Schizophrenia PORT treatment recommendations. There is less evidence that patients who receive treatment in the community are adequately monitored for antipsychotic side effects per the Mount Sinai recommendations.

The Development and Implementation of an Electronic Health Record Tool for Monitoring Metabolic Syndrome Indices in Patients with Serious Mental Illness

Objectives1. A quality performance improvement (QI) project to implement an electronic screening and monitoring tool to record components of the metabolic syndrome (e-MSD) during clinic visits by persons with serious mental illness (SMI). 2. To encourage psychiatrists to use this tool in their documentation.MethodsWorking with the information technology staff; five psychiatrists developed, tested, revised and embedded the e-MSD tool into the medication management document within the electronic health record. A continuing medical education program on metabolic syndrome was developed, and released to psychiatrists and mental health clinicians. Psychiatrist offices at one clinic were equipped with weighing scales, sphygmomanometers, waist circumference tapes and a QI project was initiated.ResultsAt one month, 9 to 12% of the anthropometric measures (height, weight, body mass index, waist circumference, and blood pressure) were recorded in 974 unique patient encounters, and 1 year later the numbers moved upwards - 15 to 41%. Towards the end of Year 1, a patient care associate was hired to measure the anthropometric measures, and one year later, the documented rates increased to 75-80%. Laboratory recordings (glucose and lipids) remained ≤ 8% throughout the first year, but moved upwards to 25% in Year 2.DiscussionNotwithstanding significant administrative and technical support for this QI project, changing clinician practice to screen, monitor and document metabolic indices in persons with SMI in the ambulatory setting changed significantly after the hiring of a patient care associate. Efforts to obtain laboratory measures in real-time remain a challenge. Next steps include interventions to promote weight loss and smoking cessation in SMI patients, and effective communication with their primary care doctors.

Monitoring and managing metabolic effects of antipsychotics: a cluster randomized trial of an intervention combining evidence-based quality improvement and external facilitation

BACKGROUND

Treatment of psychotic disorders consists primarily of second generation antipsychotics, which are associated with metabolic side effects such as overweight/obesity, diabetes, and dyslipidemia. Evidence-based clinical practice guidelines recommend timely assessment and management of these conditions; however, research studies show deficits and delays in metabolic monitoring and management for these patients. This protocol article describes the project 'Monitoring and Management for Metabolic Side Effects of Antipsychotics,' which is testing an approach to implement recommendations for these practices.

METHODS/DESIGN

This project employs a cluster randomized clinical trial design to test effectiveness of an evidence-based quality improvement plus facilitation intervention. Eligible study sites were VA Medical Centers with ≥300 patients started on a new antipsychotic prescription in a six-month period. A total of 12 sites, matched in pairs based on scores on an organizational practice survey, were then randomized within pairs to intervention or control conditions.Study participants include VA employees involved in metabolic monitoring and management of patients treated with antipsychotics at participating sites. The intervention involves researchers partnering with clinical stakeholders to facilitate tailoring of local implementation strategies to address barriers to metabolic side-effect monitoring and management. The intervention includes a Design Phase (initial site visit and subsequent development of a local implementation plan); Implementation Phase (guided by an experienced external facilitator); and a Sustainability Phase. Evaluation includes developmental, implementation-focused, progress-focused and interpretative formative evaluation components, as well as summative evaluation. Evaluation methods include surveys, qualitative data collection from provider participants, and quantitative data analysis of data for all patients prescribed a new antipsychotic medication at a study site who are due for monitoring or management of metabolic side effects during the study phases. Changes in rates of recommended monitoring and management actions at intervention and control sites will be compared using time series analyses.

DISCUSSION

Improving monitoring for metabolic side effects of antipsychotics, as well as promoting timely evidence-based management when these effects emerge, will lead to improved patient safety and long-term outcomes. This article discusses key strengths and challenges of the study.

TRIAL REGISTRATION

NCT01875861.

Possible mechanisms for the skeletal effects of antipsychotics in children and adolescents

The increasing use of antipsychotics (APs) to treat pediatric psychiatric conditions has led to concerns over the long-term tolerability of these drugs. While the risk of cardiometabolic abnormalities has received most of the attention, preclinical and clinical studies provide preliminary evidence that APs can adversely impact bone metabolism. This would be most concerning in children and adolescents as suboptimal bone accrual during development may lead to increased fracture risk later in life. However, the potential mechanisms of action through which APs may impact bone turnover and, consequently, bone mineral content are not clear. Emerging data suggest that the skeletal effects of APs are complex, with APs directly and indirectly impacting bone cells through modulation of multiple signaling pathways, including those involving dopamine D2, serotonin, adrenergic, and prolactin receptors, as well as by affecting gonadotropins. Determining the action of APs on skeletal development is further complicated by polypharmacy. In children and adolescents, APs are frequently coprescribed with psychostimulants and selective serotonin reuptake inhibitors, which have also been linked to changes in bone metabolism. This review discusses the mechanisms by which APs may influence bone metabolism. Also covered are preclinical and pediatric findings concerning the impact of APs on bone turnover. However, the dearth of clinical information despite the potential public health significance of this issue underscores the need for further studies. The review ends with a call for clinicians to be vigilant about promoting optimal overall health in chronically ill youth with psychopathology, particularly when pharmacotherapy is unavoidable.

Monitoring metabolic side effects of atypical antipsychotics in people with an intellectual disability

This audit was undertaken prospectively to examine the compliance of a group of psychiatrists against guidelines they developed for monitoring the onset of metabolic syndrome, a potential side effect of antipsychotic medication, especially second generation or atypical ones. Phase 1 of the audit was to set standards by a questionnaire survey of participating psychiatrists against Consensus Guidelines on monitoring (American Diabetic Association, 2004), which they favoured. The results led to modifying these guidelines to develop minimum acceptable standards against which their practice was audited in Phase 2. Although in Phase 1, 77% of the psychiatrists felt that they did some baseline recording, Phase 2 finding did not corroborate this--only 53.8% of the notes recorded the assessment of risk factors in personal history; 37.5% risk factors in family history; 31.7% baseline weight and 26.4% baseline blood sugar/lipid levels. In Phase 1, 85% of the psychiatrists thought that they carried out some of the recommended monitoring; our audit found the records of weight monitoring in 69.7% of the notes and blood sugar and lipids monitoring in 44.2%. People with intellectual disability have a shorter life expectancy and increased risk of early death when compared with the general population. Obesity is already a health issue for people with intellectual disability. We discuss the challenges faced by psychiatrists in implementing their own minimum acceptable standards and suggest measures to reduce the metabolic risk associated with antipsychotic medication through increasing awareness--use of information leaflets in accessible format, health promotion and use of side effect checklists and improving access--by working collaboratively with general practitioners utilising the forum of annual health checks.

Drug treatments for schizophrenia: pragmatism in trial design shows lack of progress in drug design

Aims. The introduction of second generation antipsychotic (SGA) medication over a decade ago led to changes in prescribing practices; these drugs have eclipsed their predecessors as treatments for schizophrenia. However, the metabolic side effects of these newer antipsychotics have been marked and there are increasing concerns as to whether these novel drugs really are superior to their predecessors in terms of the balance between risks and benefits. In this article, we review the literature regarding comparisons between first generation antipsychotic (FGA) and SGA in terms of clinical effectiveness. Methods. Large (n > 150) randomized-controlled trials (RCTs) comparing the effectiveness (efficacy and side effects) of FGA and SGA medications other than clozapine were reviewed, as were meta-analyses that included smaller studies. Results. The superiority in efficacy and reduced extrapyramidal side effects (EPSE) of SGAs is modest, especially when compared with low-dose FGAs. However, the high risk of weight gain and other metabolic disturbances associated with certain SGAs such as olanzapine is markedly higher than the risk with FGAs at the doses used in the trials. Conclusions. The efficacy profiles of various FGAs and SGAs are relatively similar, but their side effects vary between and within classes. Overall, large pragmatic trials of clinical effectiveness indicate that the care used in prescribing and managing drug treatments to ensure tolerability may be more important than the class of drug used.

Metformin for weight loss and metabolic control in overweight outpatients with schizophrenia and schizoaffective disorder

OBJECTIVE

The purpose of this study was to determine whether metformin promotes weight loss in overweight outpatients with chronic schizophrenia or schizoaffective disorder.

METHOD

In a double-blind study, 148 clinically stable, overweight (body mass index [BMI] ≥27) outpatients with chronic schizophrenia or schizoaffective disorder were randomly assigned to receive 16 weeks of metformin or placebo. Metformin was titrated up to 1,000 mg twice daily, as tolerated. All patients continued to receive their prestudy medications, and all received weekly diet and exercise counseling. The primary outcome measure was change in body weight from baseline to week 16.

RESULTS

Fifty-eight (77.3%) patients who received metformin and 58 (81.7%) who received placebo completed 16 weeks of treatment. Mean change in body weight was -3.0 kg (95% CI=-4.0 to -2.0) for the metformin group and -1.0 kg (95% CI=-2.0 to 0.0) for the placebo group, with a between-group difference of -2.0 kg (95% CI=-3.4 to -0.6). Metformin also demonstrated a significant between-group advantage for BMI (-0.7; 95% CI=-1.1 to -0.2), triglyceride level (-20.2 mg/dL; 95% CI=-39.2 to -1.3), and hemoglobin A1c level (-0.07%; 95% CI=-0.14 to -0.004). Metformin-associated side effects were mostly gastrointestinal and generally transient, and they rarely led to treatment discontinuation.

CONCLUSIONS

Metformin was modestly effective in reducing weight and other risk factors for cardiovascular disease in clinically stable, overweight outpatients with chronic schizophrenia or schizoaffective disorder over 16 weeks. A significant time-by-treatment interaction suggests that benefits of metformin may continue to accrue with longer treatment. Metformin may have an important role in diminishing the adverse consequences of obesity and metabolic impairments in patients with schizophrenia.

Association of metabolic syndrome with schizophrenia

BACKGROUND

Metabolic syndrome (MetS) is associated with mental illnesses. It is a major predictor of mortality and morbidity in patients of such mental illnesses. This study was undertaken to study the association of MetS and schizophrenia.

OBJECTIVES

To study the association of MetS in patients of schizophrenia.

MATERIALS AND METHODS

Adult schizophrenic patients diagnosed as per Diagnostic and Statistical Manual -IV Third R evisioncriteria visiting the psychiatric Out Patient Day during the study period were evaluated for prevalence of MetS as per the criteria of the international diabetes federation. Fifty patients of schizophrenia with age-and sex-matched 50 controls were enrolled for the study.

RESULTS

MetS was found to be 28% in patient group and 12% in control group (P < 0.05). Fourteen patients were found to have MetS out of 38 patients who were on antipsychotics for >6 months. All the 14 patients having MetS were taking second-generation antipsychotics (SGAs) (P < 0.05).

CONCLUSION

The study showed a higher prevalence of MetS in schizophrenia than in general population. MetS was present only in patients taking SGAs and prevalence of MetS had a positive correlation with duration of treatment. The study points toward urgent need for consultation - liaisoning between Diabetologist and Psychiatrists.

The prevalence of metabolic syndrome in schizophrenic patients using antipsychotics

Objective

To examine the prevalence of metabolic syndrome and its risk factors in a large group of schizophrenic patients.

Methods

Sociodemographic and treatment data were collected from medical records of 1,103 inpatients and outpatients treated for schizophrenia at Seoul National Hospital in Seoul, Korea. Anthropometric measurement and blood testing were conducted for collection of physical and biochemical data and diagnosis of metabolic syndrome. Data for metabolic syndrome prevalence were compared by sex, age, metabolic syndrome markers present, treatment of markers, and types of antipsychotics and individual drug agents used.

Results

Mean prevalence of metabolic syndrome in all subjects was 43.9% and 40.1% according to adapted Adult Treatment Panel III (ATP-IIIa) and International Diabetes Federation criteria, respectively. No significant differences were found in prevalence according to ATP-IIIa criteria between men (42.6%) and woman (45.9%). A trend toward higher prevalence with age was observed for both sexes until 50 years, followed by a continued increase for women but a decrease for men. Use of a combination of atypical antipsychotics was associated with the highest metabolic syndrome prevalence and use of aripiprazole with the lowest. High percentages of subjects with hypertension and dyslipidemia were not being treated for these conditions.

Conclusion

Despite their higher prevalence in schizophrenic patients, metabolic syndrome and its markers are not being adequately managed in these patients. Treatment of schizophrenic patients requires attention to not only their psychiatric conditions but also associated medical conditions by individual health care practitioners and hospitals as well as the public health care sector as a whole.

Detection of metabolic syndrome in schizophrenia and implications for antipsychotic therapy : is there a role for folate?

In general, the presence of metabolic syndrome is associated with significant cardiovascular mortality and represents a growing public health concern in the USA. Patients with schizophrenia have a three times greater risk of death than the general population, with cardiovascular disease being the most common cause of this mortality. Use of atypical antipsychotics (AAPs) to treat schizophrenia contributes significantly to this cardiovascular risk. While several different clinical guidelines currently exist to monitor the metabolic consequences of AAP use, implementation is lacking. Because of under-monitoring of side effects and the lack of alternative treatment choices in schizophrenia, research has focused on identification of various biomarkers and pharmacogenomic targets to focus on the patients at greatest risk of metabolic syndrome, thus aiming to increase the efficacy and minimize the side effects of AAPs. This has led to several different lines of research. This review focuses on summarizing the differing metabolic syndrome criteria, monitoring guidelines for use of AAPs, and the role of folic acid as it relates to metabolic syndrome within the schizophrenia population. It concentrates not only on the pharmacogenomics of folic acid metabolism but also on its epigenetic interaction with the environment. From this work, genetic variation within both the methylenetetrahydrofolate reductase (MTHFR) gene and the catechol-O-methyltransferase (COMT) gene has been associated with an increased risk of metabolic syndrome in schizophrenia patients treated with AAPs. Furthermore, work on the combination of folate pharmacogenetics and epigenetics has uncovered relationships between methylation, schizophrenia disease, treatment type, and metabolic syndrome. Despite several areas of biomarker research into schizophrenia-related metabolic syndrome, translation into the clinical setting is still lacking, and further studies are needed to bridge this gap. In the future, folate supplementation may prove to be an easy and effective clinical tool for prevention and/or treatment of metabolic syndrome associated with AAP treatment, but clearly more research needs to be done in this area.

Challenges for policy makers and organizational leaders: addressing trends in mental health inequalities

We typically think of acutely and chronically mentally ill patients as those who belong in psychiatric hospitals and the latter category of patients belonging in "regular" hospitals, but the intersection of physical and mental illness draws attention to important challenges for policy makers and organizational leaders. This article illuminates some broad trends in the health status of people with mental illnesses, canvasses important features of inequalities suffered by people with mental illnesses, and suggests strategies for systemic reform. Most reform recommendations I offer are in the area of healthcare organization leadership and management. Other key reforms will likely be legislative, regulatory, and insurance-related. Social and cultural reforms in organizational practices and structures will also be critical.

Screening for cardiovascular risk in patients with severe mental illness in primary care: a comparison with patients with diabetes

BACKGROUND

People with severe mental illness (SMI) have a higher risk of developing cardiovascular disease (CVD) compared with the general population. Clinical guidelines recommend annual screening for CVD risk factors with appropriate lifestyle counselling. Aims To establish the proportion of patients with SMI being screened for CVD risk factors in their primary care practice compared with those with diabetes and determine whether people with SMI receive lifestyle advice. METHOD DESIGN: a retrospective audit.

SETTING

five primary care centres in Northampton, England.

PARTICIPANTS

three hundred and eighty-six patients with SMI and 1875 with diabetes.

RESULTS

Just over a fifth of patients with SMI received a full CVD screen compared with the 96% of those with diabetes (OR  =  90.37; 95% CI  =  64.53-126.55, p  <  0.01). Fifty-seven per cent of the SMI patients were given smoking advice but only 13% and 14% received guidance regarding diet and exercise, respectively. On average of each patient with SMI received fewer than two (from four) screening interventions and less than one (from three) components of lifestyle advice.

CONCLUSIONS

In primary care, the number of people with SMI receiving screening for CVD risk is much lower than those with diabetes.

Gaps in health care for the somatic health of outpatients with severe mental illness

The physical health of outpatients with severe mental illness (SMI) can be improved by changes in the health-care system. Analysis of current practice is necessary to develop these strategies. We compared the number of somatic health problems of outpatients with SMI with the frequency of consulting a general practitioner (GP). This was a cross-sectional study based on interviews, and records from the GP and the pharmacy. We checked whether Dutch community pharmacies had complete and correct information about the patients' medication. We observed that all patients (n = 118) had somatic problems in need of clinical attention. Patients who visited their GP less than once a year (35%, n = 42), had a mean of 2.8 somatic health problems. This was less than patients who consulted their GP more than once a year (P ≤ 0.01). In 37% of cases, the pharmacy did not have adequate information on the drug use. Many patients with SMI seemed to have insufficient contact with their GP for their somatic health problems. Insufficient information about the patients' medication suggested that the pharmacist and GP should increase exchange of information. Mental health nurses can take a lead in coordinating the care to improve somatic health for their patients.

No effect of adjunctive, repeated dose intranasal insulin treatment on body metabolism in patients with schizophrenia

OBJECTIVE

This study examined the effect of adjunctive intranasal insulin therapy on body metabolism in patients with schizophrenia.

METHOD

Each subject had a DSM-IV diagnosis of schizophrenia or schizoaffective disorder and had been on stable dose of antipsychotic agent for at least one month. In an 8-week randomized, double-blind, placebo-controlled study, subjects received either intranasal insulin (40 IU 4 times per day) or placebo. The whole body dual-energy X-ray absorptiometry (DXA) was used to assess body composition. Lipid particles were assessed using nuclear magnetic resonance (NMR) spectroscopy. All assessments were conducted at baseline, and repeated at week 8.

RESULTS

A total number of 39 subjects completed the study (18 in the insulin group, 21 in the placebo group). There were no significant differences between the two groups in week 8 changes for body weight, body mass index, waist circumference, as well as various measures of lipid particles (p's>0.100). The DXA assessment showed no significant differences between the two groups in week 8 changes for fat mass, lean mass or total mass (p's>0.100).

CONCLUSION

In the present study, adjunctive therapy of intranasal insulin did not seem to improve body metabolism in patients with schizophrenia. The implications for future studies were discussed.

How quickly do physicians adopt new drugs? The case of second-generation antipsychotics

OBJECTIVE

The authors examined physician adoption of second-generation antipsychotic medications and identified physician-level factors associated with early adoption.

METHODS

The authors estimated Cox proportional-hazards models of time to adoption of nine second-generation antipsychotics by 30,369 physicians who prescribed antipsychotics between 1996 and 2008, when the drugs were first introduced, and analyzed the total number of agents prescribed during that time. The models were adjusted for physicians' specialty, demographic characteristics, education and training, practice setting, and prescribing volume. Data were from IMS Xponent, which captures over 70% of all prescriptions filled in the United States, and the American Medical Association Physician Masterfile.

RESULTS

On average, physicians waited two or more years before prescribing new second-generation antipsychotics, but there was substantial heterogeneity across products in time to adoption. General practitioners were much slower than psychiatrists to adopt second-generation antipsychotics (hazard ratios (HRs) range .10-.35), and solo practitioners were slower than group practitioners to adopt most products (HR range .77-.89). Physicians with the highest antipsychotic-prescribing volume adopted second-generation antipsychotics much faster than physicians with the lowest volume (HR range .15-.39). Psychiatrists tended to prescribe a broader set of antipsychotics (median=6) than general practitioners and neurologists (median=2) and pediatricians (median=1).

CONCLUSIONS

As policy makers search for ways to control rapid health spending growth, understanding the factors that influence physician adoption of new medications will be crucial in the efforts to maximize the value of care received by individuals with mental disorders as well as to improve medication safety.

Implementation of a weight loss program for Latino outpatients with severe mental illness

To determine feasibility of implementation of a weight loss program for overweight Latinos with severe mental illness. In this quasi-experimental study, a 14-week behavioral weight loss course (extended) was implemented at one clinic. A one-time nutrition class (brief) was given at a sister clinic. Implementation feasibility was assessed by consent and participation rates. Weight was followed for 6 months. Consent rates were high [77 % (49/64) extended; 68 % (39/57) brief], and 88 % (43/49) of extended subjects participated and 88 % (38/43) completed follow-up. Weight loss did not differ between groups. A behavioral weight loss course is feasible to implement for this population.

A case control study of the implementation of change model versus passive dissemination of practice guidelines for compliance in monitoring for metabolic syndrome

We developed an intervention to improve compliance with guidelines for monitoring metabolic syndrome and compared compliance prior to intervention and three times post-intervention at three community mental health clinics in Texas. One test clinic received intervention and two other clinics served as controls. Fifty random charts were reviewed from each clinic for three specific, 1-2 weeks periods over the course of 18 months. There were significant improvements in the ordering of labs, the presence of lab results in the chart, and documentation of blood pressure, body mass index and waist circumference in the intervention clinic over time in comparison to the control clinics. Documented evidence of physician action with respect to out of range values remained low. Metabolic monitoring is a multi-step process. Removing barriers, creating specific procedures, and dedicating staff resources can improve compliance with monitoring.

Clozapine-induced mitochondria alterations and inflammation in brain and insulin-responsive cells

Background

Metabolic syndrome (MetS) is a constellation of factors including abdominal obesity, hyperglycemia, dyslipidemias, and hypertension that increase morbidity and mortality from diabetes and cardiovascular diseases and affects more than a third of the population in the US. Clozapine, an atypical antipsychotic used for the treatment of schizophrenia, has been found to cause drug-induced metabolic syndrome (DIMS) and may be a useful tool for studying cellular and molecular changes associated with MetS and DIMS. Mitochondria dysfunction, oxidative stress and inflammation are mechanisms proposed for the development of clozapine-related DIMS. In this study, the effects of clozapine on mitochondrial function and inflammation in insulin responsive and obesity-associated cultured cell lines were examined.

Methodology/Principal Findings

Cultured mouse myoblasts (C2C12), adipocytes (3T3-L1), hepatocytes (FL-83B), and monocytes (RAW 264.7) were treated with 0, 25, 50 and 75 µM clozapine for 24 hours. The mitochondrial selective probe TMRM was used to assess membrane potential and morphology. ATP levels from cell lysates were determined by bioluminescence assay. Cytokine levels in cell supernatants were assessed using a multiplex array. Clozapine was found to alter mitochondria morphology, membrane potential, and volume, and reduce ATP levels in all cell lines. Clozapine also significantly induced the production of proinflammatory cytokines IL-6, GM-CSF and IL12-p70, and this response was particularly robust in the monocyte cell line.

Conclusions/Significance

Clozapine damages mitochondria and promotes inflammation in insulin responsive cells and obesity-associated cell types. These phenomena are closely associated with changes observed in human and animal studies of MetS, obesity, insulin resistance, and diabetes. Therefore, the use of clozapine in DIMS may be an important and relevant tool for investigating cellular and molecular changes associated with the development of these diseases in the general population.

Assessing overweight and obesity across mental disorders: personality disorders at high risk

PURPOSE

The aim of the present investigation is to assess the prevalence of obesity in people diagnosed as having a mental illness and to investigate differences between disorders. This adds to the paucity of research in this particular population of people and assists with preventative knowledge to obtain optimum physical health.

METHODS

Data were collected for all 508 male and female inpatients (new and already existing) in a public mental health service centre in Western Australia between January and December 2008. Current weight for all patients and weight gain for some patients were calculated to obtain a body mass index (BMI) value, and diagnostic information was aligned to one of the six major categories of mental illness.

RESULTS

The percentage of obese inpatients (30.3%) was much higher than that of the general population (21.4%), with females showing a higher propensity toward obesity than males. Most diagnostic categories had a mean BMI in the overweight range, whereas Personality Disorders had a mean BMI in the obese range (30.07). A gradual increase in weight over a 9-month time period can be seen in most patients who were assessed on more than one occasion.

CONCLUSIONS

The proportion of obese people within the mental health system far exceeds that of the general population, with these people at a much greater risk of becoming obese. The highest level of obesity was found in people with a personality disorder rather than in people with psychosis. Further research is needed to ease out the mitigating factors behind weight gain occurring across disorders.

Is the prevalence of metabolic syndrome and metabolic abnormalities increased in early schizophrenia? A comparative meta-analysis of first episode, untreated and treated patients

We aimed to discover whether metabolic complications of schizophrenia (SZ) are present in first episode (FE) and unmedicated (UM) patients, in comparison with patients established on antipsychotic medication (AP).

METHOD

A systematic search, critical appraisal, and meta-analysis were conducted of studies to December 2011 using Medline, PsycINFO, Embase and experts. Twenty-six studies examined FE SZ patients (n = 2548) and 19 included UM SZ patients (n = 1325). For comparison we identified 78 publications involving 24 892 medicated patients who had chronic SZ already established on AP.

RESULTS

In UM, the overall rate of metabolic syndrome (MetS) was 9.8% using any standardized criteria. Diabetes was found in only 2.1% and hyperglycaemia (>100 mg/dl) in 6.4%. In FE, the overall MetS rate was 9.9%, diabetes was found in only 1.2%, and hyperglycaemia in 8.7%. In UM and FE, the rates of overweight were 26.6%, 22%; hypertriglyceridemia 16.9%, 19.6%; low HDL 20.4%, 21.9%; high blood pressure 24.3%, 30.4%; smoking 40.2%, 46.8%, respectively. In both groups all metabolic components and risk factors were significantly less common in early SZ than in those already established on AP. Waist size, blood pressure and smoking were significantly lower in UM compared with FE.

CONCLUSION

There is a significantly lower cardiovascular risk in early SZ than in chronic SZ. Both diabetes and pre-diabetes appear uncommon in the early stages, especially in UM. However, smoking does appear to be elevated early after diagnosis. Clinicians should focus on preventing initial cardiometabolic risk because subsequent reduction in this risk is more difficult to achieve, either through behavioral or pharmacologic interventions.

Atypical antipsychotics and diabetic ketoacidosis: a review

RATIONALE

Atypical antipsychotics have been linked to weight gain and type 2 diabetes, but are also associated with diabetic ketoacidosis (DKA), which can occur more acutely and in the absence of weight gain.

OBJECTIVES

Our aim was to review current case reports of DKA in the context of atypical antipsychotic treatment to better understand (a) the scope of the problem, (b) its relationship to different atypical agents, (c) risk factors, (d) long-term outcome, and (e) putative mechanisms of action.

METHOD

Searches in PubMed/Medline, as well as the University of Toronto's Scholar Portal, were performed for all relevant articles/abstracts in English.

RESULTS

Sixty reports, yielding 69 cases, affirm that DKA is a rare but serious risk with almost all atypical antipsychotics; however, liability seems to vary between agents, at least partially mirroring risk of weight gain. Mean age of onset was 36.9 years (range 12-80), with 68 % of cases occurring in males, and 41 % in individuals of African American or African Caribbean descent. Over one third of cases present with either no weight gain or weight loss, and 61 % of these require ongoing treatment for glycemic control. Death occurred in 7.25 % of cases.

CONCLUSION

While the underlying mechanisms are not well understood, antipsychotic-related DKA can occur soon after treatment onset and in the absence of weight gain. Although rare, clinicians must remain vigilant given its acute onset and potential lethality.

Improved detection of common variants associated with schizophrenia by leveraging pleiotropy with cardiovascular-disease risk factors

Several lines of evidence suggest that genome-wide association studies (GWASs) have the potential to explain more of the "missing heritability" of common complex phenotypes. However, reliable methods for identifying a larger proportion of SNPs are currently lacking. Here, we present a genetic-pleiotropy-informed method for improving gene discovery with the use of GWAS summary-statistics data. We applied this methodology to identify additional loci associated with schizophrenia (SCZ), a highly heritable disorder with significant missing heritability. Epidemiological and clinical studies suggest comorbidity between SCZ and cardiovascular-disease (CVD) risk factors, including systolic blood pressure, triglycerides, low- and high-density lipoprotein, body mass index, waist-to-hip ratio, and type 2 diabetes. Using stratified quantile-quantile plots, we show enrichment of SNPs associated with SCZ as a function of the association with several CVD risk factors and a corresponding reduction in false discovery rate (FDR). We validate this "pleiotropic enrichment" by demonstrating increased replication rate across independent SCZ substudies. Applying the stratified FDR method, we identified 25 loci associated with SCZ at a conditional FDR level of 0.01. Of these, ten loci are associated with both SCZ and CVD risk factors, mainly triglycerides and low- and high-density lipoproteins but also waist-to-hip ratio, systolic blood pressure, and body mass index. Together, these findings suggest the feasibility of using genetic-pleiotropy-informed methods for improving gene discovery in SCZ and identifying potential mechanistic relationships with various CVD risk factors.