Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study

Health promotion in individuals with mental disorders: a cluster preference randomized controlled trial

BACKGROUND

The existing literature on weight management interventions targeting physical activity and healthy eating in mental health care appears to provide only limited evidence. The aim of the study was to examine the effectiveness of a 10-week health promotion intervention, followed by a 6-month follow-up period in individuals with mental disorders living in sheltered housing in the Flanders region (Belgium).

METHODS

The study had a cluster preference randomized controlled design. Twenty-five sheltered housing organisations agreed to participate (16 in the intervention group, nine in the control group). In the intervention group, 225 individuals agreed to participate, while in the control group 99 individuals entered into the study. The main outcomes were changes in body weight, Body Mass Index, waist circumference and fat mass. Secondary outcomes consisted of changes in physical activity levels, eating habits, health-related quality of life and psychiatric symptom severity.

RESULTS

A significant difference was found between the intervention group and the control group regarding body weight (-0.35 vs. +0.22 kg; p=0.04), Body Mass Index (-0.12 vs. +0.08 kg/m2; p=0.04), waist circumference (-0.29 vs. + 0.55 cm; p<0.01), and fat mass (-0.99 vs. -0.12%; p<0.01). The decrease in these outcomes in the intervention group disappeared during the follow up period, except for fat mass. Within the intervention group, a larger decrease in the primary outcomes was found in the participants who completed the intervention. No significant differences between the two groups in changes in the secondary outcomes were found, except for the pedometer-determined steps/day. In the intervention group, the mean number of daily steps increased, while it decreased in the control group.

CONCLUSIONS

The study demonstrated that small significant improvements in the primary outcomes are possible in individuals with mental disorders. Integration of health promotion activities targeting physical activity and healthy eating into daily care are, however, necessary to maintain the promising results.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov NCT 01336946.

Perceived Social Support for Diet and Exercise Among Persons With Serious Mental Illness Enrolled in a Healthy Lifestyle Intervention

OBJECTIVE

There is a lack of research on social support for health behavior change among persons with serious mental illness who face disproportionate morbidity and premature death due to cardiovascular disease. This study examined social contact and the demographic, health and clinical characteristics associated with perceived social support for diet and exercise among persons living with serious mental illness enrolled in a healthy lifestyle intervention.

METHOD

Baseline data from two ongoing studies of the In SHAPE healthy lifestyle intervention for persons with serious mental illness were included in this analysis (N = 158). Cross-sectional analyses examined social contact and correlates of both negative and positive experiences of social support for diet and exercise. Multiple linear regression was used to assess the relationship between demographic characteristics, symptoms, health, and social support.

RESULTS

The majority (80.3%) of participants reported face-to-face contact at least twice monthly with a family member or friend. Readiness to change physical activity was associated with greater criticism from family for exercise behaviors, r(64) = .29, p < .05. Depressive symptoms (β = .30, p < .01) were significantly associated with more unhealthy family eating environments while controlling for the amount of family contact (β = .27, p < .01), while readiness to change dietary portion size (β = .34, p < .01) was associated with encouragement for healthy eating from friends.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Participants had regular contact with significant others who were a source of both positive and negative support for healthy eating and exercise. Engaging natural supports in supporting healthy behaviors may help persons with serious mental illness initiate and maintain lifestyle change.

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.

Exercise therapy improves mental and physical health in schizophrenia: a randomised controlled trial

OBJECTIVE

The objective of this multicenter randomised clinical trial was to examine the effect of exercise versus occupational therapy on mental and physical health in schizophrenia patients.

METHOD

Sixty-three patients with schizophrenia were randomly assigned to 2 h of structured exercise (n = 31) or occupational therapy (n = 32) weekly for 6 months. Symptoms (Positive and Negative Syndrome Scale) and cardiovascular fitness levels (Wpeak and VO2peak ), as assessed with a cardiopulmonary exercise test, were the primary outcome measures. Secondary outcome measures were the Montgomery and Åsberg Depression Rating Scale, Camberwell Assessment of Needs, body mass index, body fat percentage, and metabolic syndrome (MetS).

RESULTS

Intention-to-treat analyses showed exercise therapy had a trend-level effect on depressive symptoms (P = 0.07) and a significant effect on cardiovascular fitness, measured by Wpeak (P < 0.01), compared with occupational therapy. Per protocol analyses showed that exercise therapy reduced symptoms of schizophrenia (P = 0.001), depression (P = 0.012), need of care (P = 0.050), and increased cardiovascular fitness (P < 0.001) compared with occupational therapy. No effect for MetS (factors) was found except a trend reduction in triglycerides (P = 0.08).

CONCLUSION

Exercise therapy, when performed once to twice a week, improved mental health and cardiovascular fitness and reduced need of care in patients with schizophrenia.

Increased Framingham 10-year CVD risk in Chinese patients with schizophrenia

BACKGROUND & HYPOTHESIS: Schizophrenia is associated with increased mortality rates, which has been attributed to the greater incidence of cardiovascular disease (CVD) events. The Framingham risk score (FRS) is a widely-used age- and gender-specific algorithm to estimate 10-year CVD risk and vascular age. The main aim of this study was to determine the cardiovascular risk profile in schizophrenia and examine the effect of metabolic syndrome (MetS) as a predictor of CVD risk. We hypothesized that patients with schizophrenia have an increased 10-year CVD risk.

METHODS

83 Chinese patients with schizophrenia and 243 Chinese community controls were recruited. Their medical and smoking histories were obtained, and anthropometric parameters measured. All subjects provided fasted venous blood samples for lipid and glucose measurements. 10-year CVD risk and the difference between vascular and actual age (VAdiff) for each participant were computed using the FRS and compared between patients and controls.

RESULTS

Schizophrenia patients had a higher mean 10-year CVD risk of 4.6%, as compared with 3.1% in controls, and a greater VAdiff of 4.6 years vs. 0.6 years. Both smoking and MetS contributed significantly to the 10-year CVD risk in patients with schizophrenia, with smoking having a greater effect than MetS on this risk.

CONCLUSION

This study found a significantly elevated mean 10-year CVD risk and VAdiff in patients with schizophrenia compared with controls. Findings point towards the importance of smoking cessation and screening for MetS to decrease the excess CVD risk in patients with schizophrenia.

A health screening and promotion clinic to improve metabolic monitoring for patients prescribed antipsychotic medication

OBJECTIVES

We sought to determine whether the introduction of a health screening and promotion clinic might serve as a useful addition to existing services for patients prescribed antipsychotic medication. In particular, we wished to assess whether such a clinic might improve adherence to best practice guidelines. We also wished to determine the level of patient interest in such a clinic and how readily this service might be provided within the constraints of existing clinical resources.

METHODS

We conducted an audit of outpatient records before and following the introduction of a health screening and promotion clinic.

RESULTS

Of the eligible patients, 73% attended the clinic. The proportion of patients who had fasting blood tests within the previous 12 months increased from 45% at baseline to 85% at follow-up (χ 2 = 14.1, p < 0.001). The proportion of patients with appropriate physical observations completed increased from 5% at baseline to 80% at follow-up (χ 2 = 46.0, p < 0.001).

CONCLUSIONS

We found that the introduction of a health screening and promotion clinic improved adherence to best practice guidelines. This service was well received and readily provided within the constraints of existing resources. Ultimately, the structure of services to screen and advise patients prescribed antipsychotic medication will be determined by local resource considerations and configuration of services.

Predictive utility of blood pressure, waist circumference and body mass index for metabolic syndrome in patients with schizophrenia in Singapore

AIMS

This study aims to examine and compare the predictive utility of blood pressure (BP), waist circumference (WC) and body mass index (BMI), and to determine optimal cut-off values in prediction of metabolic syndrome (MetS) in patients with chronic schizophrenia.

METHODS

About 100 patients with chronic schizophrenia were recruited. BMI and BP were measured and laboratory tests to evaluate patients' high-density lipoprotein cholesterol, triglycerides and glucose levels were performed. Presence of MetS was examined according to AHA/NHLBI guidelines. Predictive utility of BP, WC and BMI was examined using receiver operating curve and discriminant indices were determined accordingly.

RESULTS

Forty-six (46%) patients were identified to have MetS. BMI of ≥23 kg m(-2) was most accurate (AUC = 0.83, P < 0.001), with sensitivity of 93.5%, specificity of 48.1%, positive predictive value of 60.6% and negative predictive value of 92.9% in identifying MetS.

CONCLUSION

This finding has immediate and significant clinical implications in the local population with schizophrenia.

Breaking the habit: a qualitative exploration of barriers and facilitators to smoking cessation in people with enduring mental health problems

BACKGROUND

Smoking in people with mental health problems (MHPs) is an important public health concern as rates are two to three times higher than in the general population. While a strong evidence base exists to encourage and support smoking cessation in the wider population, there is limited evidence to guide the tailoring of interventions for people with MHPs, including minimal understanding of their needs. This paper presents findings from theoretically-driven formative research which explored the barriers and facilitators to smoking cessation in people with MHPs. The aim, guided by the MRC Framework for the development and evaluation of complex interventions, was to gather evidence to inform the design and content of smoking cessation interventions for this client group.

METHODS

Following a review of the empirical and theoretical literature, and taking a critical realist perspective, a qualitative approach was used to gather data from key stakeholders, including people with enduring MHPs (n = 27) and professionals who have regular contact with this client group (n = 54).

RESULTS

There was a strong social norm for smoking in participants with MHPs and most were heavily addicted to nicotine. They acknowledged that their physical health would improve if they stopped smoking and their disposable income would increase; however, more important was the expectation that, if they attempted to stop smoking, their anxiety levels would increase, they would lose an important coping resource, they would have given up something they found pleasurable and, most importantly, their mental health would deteriorate. Barriers to smoking cessation therefore outweighed potential facilitators and, as a consequence, impacted negatively on levels of motivation and self-efficacy. The potential for professionals to encourage cessation attempts was apparent; however, they often failed to raise the issue of smoking/cessation as they believed it would damage their relationship with clients. The professionals' own smoking status also appeared to influence their health promoting role.

CONCLUSIONS

Many opportunities to encourage and support smoking cessation in people with MHPs are currently missed. The increased understanding provided by our study findings and literature review have been used to shape recommendations for the content of tailored smoking cessation interventions for this client group.

Low levels of physical activity in patients with severe mental illness

BACKGROUND

Physical inactivity is an independent risk factor for cardiovascular diseases and Type 2 diabetes, both being highly prevalent in patients with severe mental illness. Though physical activity has become an important issue in psychiatric treatment and rehabilitation in the past decade, systematic evaluations of physical activity level in psychiatric populations could be more disseminated.

AIM

The primary aim of the study was to investigate the physical activity level of psychiatric patients in comparison with healthy controls.

METHODS

Patients with severe mental illness (n =47) and a group of healthy controls (n =28) matched on sex and age reported their physical activity level using the Physical Activity Scale (PAS). PAS was administered as an interview in relation to patients and as a questionnaire in relation to healthy controls.

RESULTS

Patients had statistically significant lower levels of physical activity compared with healthy controls (P <0.0001) and the level of physical activity among patients was hazardously low.

CONCLUSION

The study confirmed previous studies and clinical experience that patients with severe mental illness are physically inactive and emphasize the importance of physical activity in psychiatric treatment and rehabilitation. The PAS is an applicable and relevant method for evaluating physical activity levels in psychiatric patients.

A systematic review of the nutritional status of women of a childbearing age with severe mental illness

Little is known about the nutritional status of pregnant women with severe mental illness. We therefore carried out a systematic review to investigate whether pregnant women and childbearing aged women with severe mental illness have significantly greater nutritional deficiencies compared with pregnant women and childbearing aged women with no mental illness. We carried out a search using MEDLINE, EMBASE and PsycINFO from January 1980 to January 2011 for studies on nutritional status of childbearing aged women with psychotic disorders. Identification of papers and quality rating of papers (using a modified version of the Newcastle-Ottawa scale) was carried out by two reviewers independently. We identified and screened 4,130 potentially relevant studies from the electronic databases. Fifteen studies met the inclusion criteria (n = 587 women). There were no studies of pregnant women. There was some evidence of low serum folate and vitamin B(12) levels and elevated homocysteine levels in childbearing aged women with psychotic disorders. Further research into the nutritional status of childbearing aged women with severe mental illness is needed. Maternal nutrition has a profound impact on foetal outcome, is a modifiable risk factor and therefore needs prioritising in the care of all childbearing aged women with severe mental illness.

The dietary pattern of patients with schizophrenia: a systematic review

OBJECTIVE

People with schizophrenia show a high incidence of metabolic syndrome, which is associated with a high mortality from cardiovascular disease. The aetiology of the metabolic syndrome in schizophrenia is multi-factorial and may involve antipsychotic treatment, high levels of stress and unhealthy lifestyle, such as poor diet. As a poor diet can predispose to the development of metabolic abnormalities, the aims of this review are to clarify: 1) the dietary patterns of patients with schizophrenia, 2) the association of these dietary patterns with a worse metabolic profile, and 3) the possible factors influencing these dietary patterns.

METHODS

A search was conducted on Pubmed, The Cochrane Library, Scopus, Embase, Ovid, Psychoinfo and ISI web of Knowledge from 1950 to the 1st of November 2011. 783 articles were found through the investigation of such databases. After title, abstract or full-text reading and applying exclusion criteria we reviewed 31 studies on dietary patterns and their effects on metabolic parameters in schizophrenia.

RESULTS

Patients with schizophrenia have a poor diet, mainly characterized by a high intake of saturated fat and a low consumption of fibre and fruit. Such diet is more likely to increase the risk to develop metabolic abnormalities. Data about possible causes of poor diet in schizophrenia are still few and inconsistent.

CONCLUSION

Subjects with schizophrenia show a poor diet that partly accounts for their higher incidence of metabolic abnormalities. Further studies are needed to clarify the causes of poor diet and the role of dietary intervention to improve their physical health.

Schizophrenia and potentially preventable hospitalizations in the United States: a retrospective cross-sectional study

BACKGROUND

Persons with schizophrenia may face barriers to high quality primary care due to communication difficulties, cognitive impairment, lack of social support, and fragmentation of healthcare delivery services. As a result, this group may be at high risk for ambulatory care sensitive (ACS) hospitalizations, defined as hospitalizations potentially preventable by timely primary care. The goal of this study was to determine if schizophrenia is associated with overall, acute, and chronic ACS hospitalizations in the United States (US).

METHODS

We conducted a retrospective cross-sectional study. Hospitalization data for the US were obtained from the Nationwide Inpatient Sample for years 2003-2008. We examined 15,275,337 medical and surgical discharges for adults aged 18-64, 182,423 of which had a secondary diagnosis of schizophrenia. ACS hospitalizations were measured using the Agency for Healthcare Research and Quality's Prevention Quality Indicators (PQIs). We developed logistic regression models to obtain nationally-weighted odds ratios (OR) for ACS hospitalizations, comparing those with and without a secondary diagnosis of schizophrenia after adjusting for patient, hospitalization, and hospital characteristics.

RESULTS

Schizophrenia was associated with increased odds of hospitalization for acute ACS conditions (OR = 1.34; 95% CI: 1.31, 1.38), as well as for chronic ACS conditions characterized by short-term exacerbations. Schizophrenia was associated with decreased odds of hospitalization for diabetes mellitus long-term complications and diabetes-related lower extremity amputation, conditions characterized by long-term deterioration.

CONCLUSIONS

Additional research is needed to determine which individual and health systems factors contribute to the increased odds of hospitalization for acute PQIs in schizophrenia.

High mortality and low access to care following incident acute myocardial infarction in individuals with schizophrenia

OBJECTIVES

The primary objective of this study was to compare mortality following incident acute myocardial infarction (AMI) among individuals with and without schizophrenia. A secondary objective was to compare the likelihood to receive cardiac procedures and cardiologist visits.

METHODS

This retrospective cohort study took place in Ontario, Canada. We studied incident AMI patients who were alive at hospitalization discharge from January 1, 2002 to December 31, 2006. 71,668 subjects were included in the study (402 subjects were excluded because of missing data). The main exposure was a diagnosis of schizophrenia. The main outcome measure was 30-day mortality post-discharge. Secondary outcomes included receipt of cardiac procedures and cardiologist visits within 30 days post-discharge.

RESULTS

After risk adjustment, individuals with schizophrenia were 56% more likely to die within 30 days of discharge (OR 1.56, 95% CI 1.08-2.23; p=0.02), but approximately 50% less likely to receive cardiac procedures (OR 0.48, 95% CI 0.40-0.56; p<0.001) or to see a cardiologist within 30 days of discharge (OR 0.53, 95% CI 0.43-0.65; p<0.001).

CONCLUSIONS

Individuals with schizophrenia have a significant risk of dying following incident AMI. Despite the elevated mortality risk, individuals with schizophrenia are less likely to receive specialist care and cardiac procedures. Inequities in access to AMI care may be an important point of intervention for individuals with schizophrenia.

The effect of dietary and physical activity pattern on metabolic profile in individuals with schizophrenia: a cross-sectional study

OBJECTIVE

With the rate of obesity on the rise worldwide, individuals with schizophrenia represent a particularly vulnerable population. The aim of this study was to assess the metabolic profile of individuals with schizophrenia in relation to dietary and physical activity habits compared with healthy controls.

METHODS

Dietary and physical activity habits of 130 individuals with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of schizophrenia or schizoaffective disorder were compared with 250 body mass index-, age-, and sex-matched and racially matched controls from the 2005-2008 National Health and Nutrition Examination Surveys using a 24-hour diet recall and a self-report physical activity questionnaire.

RESULTS

Individuals with schizophrenia had significantly higher levels of glycosylated hemoglobin and insulin compared with matched controls. In addition, these individuals had an increased waist circumference and diastolic blood pressure than did the comparison group. Daily energy intake was not different between groups; however, individuals with schizophrenia consumed significantly greater amounts of sugar and fat. Individuals with schizophrenia reported engaging in moderate physical activity less frequently compared with the National Health and Nutrition Examination Surveys group, but there was no difference in reported vigorous physical activity.

CONCLUSIONS

These findings suggest that the dietary and physical activity habits of individuals with schizophrenia contribute to an adverse metabolic profile. Increased opportunities for physical activity and access to healthy foods for individuals with schizophrenia may ease the burden of disease.

The physical health of the seriously mentally ill: an overview of the literature

Despite the wealth of literature which attests to the relationship between serious mental illness (SMI) and physical ill health, the provision of optimum physical health care for mental health service users remains a challenge. In England the Department of Health has identified the evident health inequalities for people with SMI as a priority area for health improvement, publishing numerous policy directives aimed at addressing these inequalities. However, this is a highly complex process and little is known about why the rhetoric of holistic health care has proved unattainable thus far. In this paper we present an informed commentary of the contemporary literature with the aim of offering a more comprehensive understanding of the health inequalities faced by people with SMI. We searched relevant databases for publications related to: the causes of poor physical health among the mentally ill, strategies to address these health needs and the impact which professional education, culture and services structure has on this facet of service delivery. This enabled us to identify potential strategies that can be adopted by health care practitioners wishing to improve the health of this vulnerable group, and by educationalists to advance professionals' knowledge of this important and ostensibly neglected area.

The secret food diary of a person diagnosed with schizophrenia

The objective was to consider the feasibility of food diaries as a method of understanding the dietary behaviour of people with schizophrenia. Examination of the food diaries completed in 1 week by eight patients with schizophrenia. All the patients were successful in completing the task. Examination of the food diaries revealed that: eating fruit and vegetables was largely absent; there was very little variety in most of the patients' diets; patients relied heavily on convenience food and ready meals for their main meal; as a rule patients followed an ordered mealtime routine; generally patients did not drink enough fluid; they were not big treat eaters; only one patient recorded drinking any alcohol; overall there appeared to be poor diet literacy in our small sample. The results show that on the whole, people with schizophrenia have a poor diet. This could be due to a combination of financial difficulty, lack of skills in food preparation, lack of motivation to prepare food or ignorance of what constitutes a healthy diet. The fact that they all managed to complete the task is perhaps evidence of motivation to improve their health and demonstrates the utility of food diaries in educating this population.

A Review of Brain-derived Neurotrophic Factor as a Candidate Biomarker in Schizophrenia

Brain-derived neurotrophic factor (BDNF), a neurotrophin known to be responsible for development, regeneration, survival and maintenance of neurons has been implicated in the pathophysiology of schizophrenia. This review seeks to complement previous reviews on biological roles of BDNF and summarizes evidence on the involvement of BDNF in the pathophysiology of schizophrenia with an emphasis on clinical relevance. The expressions of BDNF were altered in patients with schizophrenia and were found to be correlated with psychotic symptomatology. Antipsychotics appeared to have differential effects on expression of BDNF but did not restore BDNF expression of patients with schizophrenia to normal levels. In addition, evidence suggests that BDNF is involved in the major neurotransmitter systems and is associated with disruptions in brain structure, neurodevelopmental process, cognitive function, metabolic and immune systems commonly associated with schizophrenia. Besides that, BDNF has been demonstrated to be tightly regulated with estrogen which has also been previously implicated in schizophrenia. Evidence gathered in this review confirms the relevance of BDNF in the pathophysiology of schizophrenia and the potential utility of BDNF as a suitable biomarker for diagnostic and prognostic purposes for disease outcome and other co-morbidities. However, further investigations are warranted to examine the specificity of BDNF in schizophrenia compared to other neurodegenerative disorders and other neuropsychiatric illness. Longitudinal prospective studies will also be of added advantage for evaluation of prognostic utility of BDNF in schizophrenia.

Psychiatric disorder as a risk factor for cancer: different analytic strategies produce different findings

BACKGROUND

Reported associations between psychiatric disorders and cancer incidence are inconsistent, with cancer rates in psychiatric patients that are variously higher than, similar to, or lower than the general population. Understanding these associations is complicated by difficulties in establishing the timing of onset of psychiatric disorders and cancer, and by the possibility of reverse causality. Some studies have dealt with this problem by excluding patients with cancers predating their psychiatric illness; others have not considered the issue.

METHODS

We examined associations between psychiatric hospitalization and cancer incidence in a cohort of 1,165,039 Swedish men, and we explored the impact of different analytic strategies on these associations using real and simulated data.

RESULTS

Relative to men without psychiatric hospitalization, we observed consistent increases in smoking-related cancers in those with psychiatric hospitalizations, regardless of analytic approach (eg, hazard ratio = 1.73 [95% confidence interval = 1.52-1.96]). However, associations with cancers unrelated to smoking were highly dependent on analytic strategy. In analyses based on the full cohort, we observed no association or a modest increase in cancer incidence in those with psychiatric hospitalizations (1.14 [1.07-1.22]). In contrast, when men whose cancer predated their psychiatric hospitalizations were excluded, future cancer incidence was lower in psychiatric patients (0.72 [0.67-0.78]). Results from simulated data suggest that even modest exclusions of this type can lead to strong artifactual associations.

CONCLUSIONS

Psychiatric disorder-cancer incidence associations are complex and influenced by analytic strategy. A better understanding of the temporal relationship between psychiatric disorder and cancer incidence is required.

Factors affecting hospital stay in psychiatric patients: the role of active comorbidity

BACKGROUND

Research on length of stay (LOS) of psychiatric inpatients is an under-investigated issue. In this naturalistic study factors which affect LOS of two groups of patients were investigated, focusing on the impact on LOS of medical comorbidity severe enough to require referral.

METHODS

Active medical comorbidity was quantified using referral as the criterion. The study sample consisted of 200 inpatients with the diagnosis of schizophrenia and 228 inpatients suffering from bipolar disorder (type I or II). Jonckheere and Mann-Whitney tests were used to estimate the influence of referrals on LOS, and regression analyses isolated variables associated with LOS separately for each group.

RESULTS

Half of the patients needed one or more referrals for a non-psychiatric problem. The most common medical condition of patients with bipolar disorder was arterial hypertension. Inpatients with schizophrenia suffered mostly from an endocrine/metabolic disease - 12% of referrals were for Hashimoto's thyroiditis. A positive linear trend was found between LOS and number of referrals; the effect was greater for schizophrenia patients. The effect of referrals on LOS was verified by regression in both groups. Overall, referred patients showed greater improvement in GAF compared to controls.

CONCLUSIONS

To our knowledge this was the first study to investigate physical comorbidity in psychiatric inpatients using the criterion of referral to medical subspecialties. Comorbidity severe enough to warrant referral is a significant determinant of hospital stay. This insight may prove useful in health care planning. The results show lack of effective community care in the case of schizophrenia and negative symptoms may be the cause of this. Our findings call for more attention to be paid to the general medical needs of inpatients with severe mental health and concurrent severe medical comorbidity.

Evolving role of mental health nurses in the physical health care of people with serious mental health illness

Life expectancy in members of the general population has steadily improved in most countries since 1960. However, during the same period, the life expectancy of people with serious mental illness (SMI) has actually reduced. The majority of premature deaths result from natural causes, such as coronary heart disease. Obesity, a key risk factor for heart disease in this client group, might be caused both by unhealthy lifestyle behaviours and the side-effects of antipsychotic medication. Mental health nurses (MHN) nurses have an important role to play in improving the physical health of people with SMI. Evidence, however, suggests that they are often ambivalent about this role, and might perceive themselves as being inadequately trained and lacking in confidence. In this paper, we will argue that MHN need to re-evaluate their practice and recognize that the provision of physical health care is as important as other roles they occupy in relation to the care of people with SMI. We will also consider examples of best practice in physical health care, and discuss how these might be adopted by MHN and other professionals, in order to begin to improve services and to reduce health inequalities in this client group.

Evaluation of service users' experiences of participating in an exercise programme at the Western Australian State Forensic Mental Health Services

Approximately 210 patients are admitted each year to the Western Australian State Forensic Mental Health Service, and most present with psychotic illness, along with other physical and mental comorbidities. In 2010, a healthy lifestyle programme, which included a formal exercise programme coordinated by an exercise physiologist, was introduced at the service. A self-report questionnaire was developed to obtain feedback on the programme, and 56 patients completed the questionnaire during the 6-month evaluation period. As well as providing patients with access to regular physical activity, the programme also supports the recovery philosophy, where patients work in partnership with forensic mental health staff. Overall, patients reported that the programme assisted them to manage their psychiatric symptoms, as well as improving their level of fitness, confidence, and self-esteem. In addition, patients received education about the importance of regular exercise to their mental health, and the role exercise plays in preventing chronic illness and obesity. While the benefits of exercise on mental health outcomes for people with depression and anxiety are well established, this evaluation adds to the evidence that such programmes provide similar benefits to people who have a psychotic illness and are hospitalized in an acute secure setting.

The incidence and relative risk of stroke in patients with schizophrenia: a five-year follow-up study

OBJECTIVE

This study aimed to estimate the incidence and relative risk of stroke and post-stroke all-cause mortality in patients with schizophrenia.

METHODS

This study identified a study population from the National Health Insurance Research Database (NHIRD) between 1999 and 2003 that included 80,569 patients with schizophrenia and 241,707 age- and sex-matched control participants without schizophrenia. The participants were randomly selected from the 23,981,020-participant NHIRD, which consists of 96% Taiwanese participants. Participants who had experienced a stroke between 1999 and 2003 were excluded. Using data from the NHIRD between 2004 and 2008, the incidence of stroke (ICD-9-CM code 430-438) and patient survival after stroke were calculated for both groups. After adjusting for confounding risk factors, a Cox proportional-hazards model was used to compare the five-year stroke-free survival rate to the all-cause mortality rate across the two cohorts.

RESULTS

Over five years, 1380 (1.71%) patients with schizophrenia and 2954 (1.22%) controls suffered from strokes. After adjusting for demographic characteristics and comorbid medical conditions, patients with schizophrenia were 1.13 times more likely to have a stroke (95% CI=1.05-1.22; P=0.0006). In addition, 1039 (24%) patients who had a stroke died during the follow-up period. After adjusting for patient, physician and hospital variables, the all-cause mortality hazard ratio for patients with schizophrenia was 1.23 (95% CI=1.06-1.41; P=0.0052).

CONCLUSIONS

During a five-year follow-up, the likelihood of developing a stroke and the all-cause mortality rate were greater among patients with schizophrenia as compared with the control group.

Predictors of death from natural causes in schizophrenia: 10-year follow-up of a community cohort

PURPOSE

People with schizophrenia have increased natural mortality. There is much speculation but little evidence about the reasons behind this. This paper describes a study designed to measure the impact of pre-selected clinical, demographic and lifestyle variables on the natural mortality of a cohort with schizophrenia.

METHODS

Ten-year Cox proportional hazards regression analysis of a community cohort of 95 people with schizophrenia.

RESULTS

Death from natural causes was significantly associated with psychosis (HR 2.62, 95% CI 1.13-6.07), age (HR 1.08, 95% CI 1.02-1.13) and cigarette smoking (HR 2.53, 95% CI 1.01-6.34) at outset. There was a trend to association with low dietary unsaturated fat (P = 0.06).

CONCLUSIONS

Active psychosis appears to predict natural mortality in people with schizophrenia. Mental health services should prioritise the effective treatment of psychosis. Further research is needed to clarify other risk factors and evaluate health promotion interventions.

A systematic review of correlates of physical activity in patients with schizophrenia

OBJECTIVE

The present review evaluates systematically the published quantitative studies of correlates of PA in patients with schizophrenia.

METHOD

EMBASE, PsycINFO, PubMed, ISI Web of Science, CINAHL and PEDro were searched from their inception to 1 July 2011 combining the medical subject heading 'schizophrenia' with 'physical activity' or 'physical inactivity' or 'exercise' or 'health education' or 'health behaviour' or 'health promotion'.

RESULTS

Out of 68 potentially eligible studies, 25 papers (n = 25,013) evaluating 36 correlates were included. Correlates consistently associated with lower PA participation are the presence of negative symptoms and cardio-metabolic comorbidity. Also, side-effects of antipsychotic medication, lack of knowledge on cardiovascular disease risk factors, no belief in the health benefits, a lower self-efficacy, other unhealthy lifestyle habits and social isolation correlated with lower PA participation. The quality of the PA measurement was not related to the proportion of significant associations (χ(2) = 3.8, P = 0.07). Current gaps in literature that need to be examined more in detail are the role of environmental and policy-level factors on PA participation in patients with schizophrenia.

CONCLUSION

All correlates should be confirmed in prospective studies, and interventions to improve the modifiable variables should be developed and evaluated.

Are cardiometabolic and endocrine abnormalities linked to sleep difficulties in schizophrenia? A hypothesis driven review

Schizophrenia is a psychiatric disorder that includes symptoms such as hallucinations, disordered thoughts, disorganized or catatonic behaviour, cognitive dysfunction and sleep-wake disturbance. In addition to these symptoms, cardiometabolic dysfunction is common in patients with schizophrenia. While previously it has been thought that cardiometabolic symptoms in patients with schizophrenia were associated with medications used to manage this disorder, more recently it has been demonstrated that these symptoms are present in drug naive and unmedicated patients. Sleep-wake disturbance, resulting in chronic sleep loss has also been demonstrated to induce changes in cardiometabolic function. Chronic sleep loss has been associated with an increased risk for weight gain, obesity and cardiac and metabolic disorders, independent of other potentially contributing factors, such as smoking and body mass index. We hypothesise that the sleep-wake disturbance comorbid with schizophrenia may play a significant role in the high prevalence of cardiometabolic dysfunction observed in this patient population. Here we present a critical review of the evidence that supports this hypothesis.

Impact of mental health problems on case fatality in male cancer patients

BACKGROUND

Although mortality rates are elevated in psychiatric patients relative to their healthy counterparts, little is known about the impact of mental health on survival in people with cancer.

METHODS AND RESULTS

Among 16 498 Swedish men with cancer, survival was worse in those with a history of psychiatric hospital admissions: multiply-adjusted hazard ratio (95% confidence interval) comparing cancer mortality in men with and without psychiatric admissions: 1.59 (1.39, 1.83).

CONCLUSION

Survival in cancer patients is worse among those with a history of psychiatric disease. The mechanisms underlying this association should be further explored.

Disordered eating attitudes in Egyptian antipsychotic naive patients with schizophrenia

OBJECTIVES

The study aimed to test in a sample of Egyptian antipsychotic naive patients the hypotheses that the disordered eating attitudes co-occur with schizophrenia in a higher frequency than would be expected by chance in the general population and that the disordered eating comorbidity would be associated with more severe schizophrenia psychopathology. Previous studies have been mostly concerned with the impact of the antipsychotics. Studies relating abnormal eating behavior to the schizophrenia psychopathology rather than to its treatment are lacking.

METHOD

In this case-control cross-sectional study, 50 consecutive antipsychotic naive patients, newly attending the psychiatric outpatient clinic, University Hospital, Zagazig, Egypt, with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of schizophrenia, were assessed by the Positive and Negative Syndrome Scale and compared with 50 nonpsychiatric controls using the Eating Attitudes Test (EAT40).

RESULTS

Patients with schizophrenia had an EAT40 mean score (23.4 ± 7.8) higher than that of controls (19.7 ± 7.2) (P = .015). Prevalence of disordered eating (defined by a score of ≥ 30 on the EAT40) in these patients was higher than in the control group (30% vs 12%, P = .027). Comparison between schizophrenia patients with and without disordered eating showed no significant differences in demographic and a number of clinical variables, but they differed in their scores on lifestyle characteristics and anthropometric measures. The group of patients with disordered eating had also higher scores on total and all scale factors but not on the negative symptom scale.

CONCLUSIONS

Data of this study show, perhaps for the first time, that "disordered" eating attitudes, as measured by the EAT40, are higher in a group of Egyptian patients with schizophrenia than in controls. However, the lack of difference between patients with and without disordered eating in terms of demographic and a number of clinical characteristics fail to explain the hypothesis that schizophrenia with disordered eating is a distinct subtype of schizophrenia. Data indicate, on the other hand, that the presence of disordered eating behavior in patients with schizophrenia is associated with the expression of more active psychotic symptoms.

Survey of general practitioners' attitudes to prescribing statins in different patient groups: a web-based survey

Low rates of statin prescribing have been noted in several major studies of patients with schizophrenia and the aim of this study was to investigate clinicians' attitudes to prescribing statins to different patient groups. The general practitioners (GPs) in Dumfries and Galloway were randomized into two groups. They received an email invitation to a web-based survey. The survey asked for treatment recommendation for three patient vignettes, each with a 10-year cardiovascular risk of 20%. In one group descriptions of the patient included type 1 diabetes, epilepsy and unemployed and in the other group these were replaced by type 2 diabetes, schizophrenia and retired. The questionnaires had no other differences. After three email invites, 53 questionnaires were completed (40% of a potential 133 participants). Statin therapy was recommended by 88% and 85% of respondents for patients with type 1 and type 2 diabetes, respectively; by 37% of respondents for patients with schizophrenia and 31% for patients with epilepsy; by 33% of respondents for retired patients and 23% of respondents for patients who are unemployed. This study demonstrates under-prescribing of statins. This was not worse for patients with schizophrenia as compared with patients with epilepsy. This suggests that the low rates of treatment of metabolic risk factors in patients with schizophrenia are not the result of clinician bias when compared with patients with epilepsy. Clinician bias, however, may reduce the chances of an unemployed patient receiving statin treatment.

Pharmacogenetics of antipsychotic-induced weight gain: review and clinical implications

Second-generation antipsychotics (SGAs), such as risperidone, clozapine and olanzapine, are the most common drug treatments for schizophrenia. SGAs presented an advantage over first-generation antipsychotics (FGAs), particularly regarding avoidance of extrapyramidal symptoms. However, most SGAs, and to a lesser degree FGAs, are linked to substantial weight gain. This substantial weight gain is a leading factor in patient non-compliance and poses significant risk of diabetes, lipid abnormalities (that is, metabolic syndrome) and cardiovascular events including sudden death. The purpose of this article is to review the advances made in the field of pharmacogenetics of antipsychotic-induced weight gain (AIWG). We included all published association studies in AIWG from December 2006 to date using the Medline and ISI web of knowledge databases. There has been considerable progress reaffirming previous findings and discovery of novel genetic factors. The HTR2C and leptin genes are among the most promising, and new evidence suggests that the DRD2, TNF, SNAP-25 and MC4R genes are also prominent risk factors. Further promising findings have been reported in novel susceptibility genes, such as CNR1, MDR1, ADRA1A and INSIG2. More research is required before genetically informed, personalized medicine can be applied to antipsychotic treatment; nevertheless, inroads have been made towards assessing genetic liability and plausible clinical application.

Is the use of an invitation letter effective in prompting patients with severe mental illness to attend a primary care physical health check?

BACKGROUND

Annual physical health checks are recommended for patients with severe mental illness (SMI) as this group has a higher risk of developing cardiovascular disease than the rest of the general population. There is little guidance for healthcare professionals to assist them in encouraging patients to attend a health check.

AIMS

To explore whether an invitation appointment letter is effective in prompting patients with SMI to attend a physical health check in primary care compared with those with diabetes.

METHOD

A retrospective audit comparing the response rate of patients with SMI and diabetes to an appointment letter inviting them to attend a primary care health check.

RESULTS

Two-thirds (n = 61, 66%) of the patients with SMI (n = 92) and three-quarters (n = 338, 81%) of those with diabetes (n = 416) attended the practice on the date and time stipulated in the letter. Patients with diabetes were 2.2 times more likely to attend a health check compared with those with SMI (OR = 2.20, 95% CI = 1.13-3.62).

CONCLUSION

Although attendance rates were lower than in patients with diabetes, they were higher than expected from the SMI group. An invitation appointment letter is an effective way of ensuring that patients with SMI have a physical health check.

Adherence to antihyperlipidemic medication and lipid control in diabetic Veterans Affairs patients with psychotic disorders

BACKGROUND

Medication adherence for chronic medical illnesses has been studied extensively, but there is limited data evaluating medication adherence for comorbid medical illnesses in a psychiatric population. Furthermore, only one study has evaluated both medication adherence and clinical outcomes between the two populations. Examining medication adherence rates and clinical outcomes are important as chronic medical illnesses occur commonly in psychiatric patients, can be drug-induced, and have negative long-term consequences.

OBJECTIVES

To compare antihyperlipidemic medication adherence and lipid control between individuals with psychotic disorders and those without a psychiatric illness.

METHODS

This was a retrospective medical record review of 124 subjects with hyperlipidemia and diabetes (62 subjects with schizophrenia or a related psychotic disorder and 62 randomly selected, age-matched individuals without a psychiatric illness) receiving medical and psychiatric care through the Veterans Affairs Medical Center during 2008. Cumulative mean gap ratio (CMGR) was used to determine adherence. Lipid values were utilized to compare lipid control between groups.

RESULTS

A significant difference in CMGR was detected. Subjects with psychotic disorders were without antihyperlipidemic therapy for 44 days compared with 62 days for the nonpsychiatric comparison group (P = 0.034). Antipsychotic adherent subjects (≥80% adherent) were more likely to adhere to their antihyperlipidemic medication (P = 0.0007). There were no significant differences between the groups for lipid control.

CONCLUSION

Antihyperlipidemic medication adherence differed with the psychotic disorder group having fewer days without drug therapy. However, there was no significant difference in lipid control between subjects with a psychotic disorder and those without a psychiatric illness.

Physical health disparities and mental illness: the scandal of premature mortality

A 20-year mortality gap for men, and 15 years for women, is still experienced by people with mental illness in high-income countries. The combination of lifestyle risk factors, higher rates of unnatural deaths and poorer physical healthcare contribute to this scandal of premature mortality that contravenes international conventions for the 'right to health.'

Cardiovascular risk factors in patients with schizophrenia receiving continuous medical care

Modifiable risk factors for cardiovascular disease were assessed among individuals with schizophrenia receiving continuous (i.e. 24-h) medical care. Participants tended to have higher levels of risk factors than for the general population. They had similar levels of risk factors as for previous UK studies of patients not receiving continuous care, except they tended to have higher smoking rates and lower physical activity levels, although statistical comparisons were not possible. Among patients with schizophrenia receiving continuous medical care interventions for health behavior change may need to be further prioritized and there is a need to capitalize on the ready availability of social support in these settings.

Accuracy of self-reported medical problems in patients with alcohol dependence and co-occurring schizophrenia or schizoaffective disorder

BACKGROUND

Schizophrenia and alcohol dependence (AD) are both major risk factors for a variety of medical problems, yet little is known about the medical status of patients in whom both conditions coexist.

OBJECTIVE

The objectives of this study are to assess accuracy of self-reported medical problems and to compare the accuracy reports in patients with schizophrenia or schizoaffective disorder and co-occurring AD compared to patients with AD only and to controls. Our hypothesis was that medical problems are under-reported in patients with co-occurring disorders, possibly due to the combination of alcohol use and symptoms of schizophrenia.

METHODS

Self-reported medical diagnoses were recorded and compared to medical records obtained from all area hospitals in 42 patients with schizophrenia and AD, 44 patients with schizoaffective disorder and AD, 41 patients with AD only, and 15 control subjects. Patients underwent medical history, physical examination, and review of medical records.

RESULTS

Patients with schizophrenia or schizoaffective disorder and co-occurring AD underreported their medical problems significantly more than patients with AD only and controls. Accuracy of self report was significantly lower in patients with schizophrenia-spectrum disorders plus co-occurring alcohol dependence than in AD alone or in controls. The most commonly underreported diagnoses included coronary artery disease, chronic renal failure, seizure disorder, hyperlipidemia, asthma and hypertension.

DISCUSSION

In order to detect potentially unreported medical conditions in patients with co-occurring schizophrenia/schizoaffective disorder and alcohol dependence, the use of targeted screening questionnaires is recommended in addition to physical examination and thorough review of medical records.

Association of psychiatric illness and obesity, physical inactivity, and smoking among a national sample of veterans

BACKGROUND

Increased cardiovascular morbidity and mortality have been reported across a number of chronic psychiatric illnesses. Interventions to decrease cardiovascular risk have focused on single health behaviors.

OBJECTIVE

To evaluate the co-occurrence of multiple poor health behaviors that increase cardiovascular risk among veterans with psychiatric diagnoses.

METHODS

Using data from the 1999 Large Health Survey of Veterans (n=501,161), multivariate logistic regression was used to evaluate the associations between current smoking, no regular exercise, and obesity with each of six Axis I diagnoses.

RESULTS

There were statistically increased odds of co-occurrence of obesity, current tobacco use, and no regular exercise among veterans with each of the psychiatric diagnoses, with the exception of drug use disorders (which was not significantly different from 1). The highest odds were among veterans with schizophrenia, PTSD, and bipolar disorder [OR (95% CI) of 1.37 (1.29, 1.45); 1.26 (1.20, 1.32); and 1.19 (1.11, 1.25), respectively]. The OR for depression was not significant after adjustment for medical comorbidity.

CONCLUSIONS

Veterans with psychiatric illnesses, and particularly those with schizophrenia, PTSD, and bipolar disorder, are much more likely to have multiple poor health behaviors that increase their cardiovascular risk. Interventions to decrease cardiovascular risk among veterans with serious mental illness need to target multiple health behaviors.

A double blind, placebo-controlled, randomized crossover study of the acute metabolic effects of olanzapine in healthy volunteers

Background and Rationale

Atypical antipsychotics exhibit metabolic side effects including diabetes mellitus and obesity. The adverse events are preceded by acute worsening of oral glucose tolerance (oGTT) along with reduced plasma free fatty acids (FFA) and leptin in animal models. It is unclear whether the same acute effects occur in humans.

Methodology/Principal Findings

A double blind, randomized, placebo-controlled crossover trial was conducted to examine the potential metabolic effects of olanzapine in healthy volunteers. Participants included male (8) and female (7) subjects [18–30 years old, BMI 18.5–25]. Subjects received placebo or olanzapine (10 mg/day) for three days prior to oGTT testing. Primary endpoints included measurement of plasma leptin, oral glucose tolerance, and plasma free fatty acids (FFA). Secondary metabolic endpoints included: triglycerides, total cholesterol, high- and low-density lipoprotein cholesterol, heart rate, blood pressure, body weight and BMI. Olanzapine increased glucose Area Under the Curve (AUC) by 42% (2808±474 vs. 3984±444 mg/dl·min; P = 0.0105) during an oGTT. Fasting plasma leptin and triglycerides were elevated 24% (Leptin: 6.8±1.3 vs. 8.4±1.7 ng/ml; P = 0.0203) and 22% (Triglycerides: 88.9±10.1 vs. 108.2±11.6 mg/dl; P = 0.0170), whereas FFA and HDL declined by 32% (FFA: 0.38±0.06 vs. 0.26±0.04 mM; P = 0.0166) and 11% (54.2±4.7 vs. 48.9±4.3 mg/dl; P = 0.0184), respectively after olanzapine. Other measures were unchanged.

Conclusions/Significance

Olanzapine exerts some but not all of the early endocrine/metabolic changes observed in rodent models of the metabolic side effects, and this suggest that antipsychotic effects are not limited to perturbations in glucose metabolism alone. Future prospective clinical studies should focus on identifying which reliable metabolic alterations might be useful as potential screening tools in assessing patient susceptibility to weight gain and diabetes caused by atypical antipsychotics.

Trial Registration

ClinicalTrials.gov NCT00741026

Is antipsychotic polypharmacy associated with metabolic syndrome even after adjustment for lifestyle effects?: a cross-sectional study

BACKGROUND

Although the validity and safety of antipsychotic polypharmacy remains unclear, it is commonplace in the treatment of schizophrenia. This study aimed to investigate the degree that antipsychotic polypharmacy contributed to metabolic syndrome in outpatients with schizophrenia, after adjustment for the effects of lifestyle.

METHODS

A cross-sectional survey was carried out between April 2007 and October 2007 at Yamanashi Prefectural KITA hospital in Japan. 334 patients consented to this cross-sectional study. We measured the components consisting metabolic syndrome, and interviewed the participants about their lifestyle. We classified metabolic syndrome into four groups according to the severity of metabolic disturbance: the metabolic syndrome; the pre-metabolic syndrome; the visceral fat obesity; and the normal group. We used multinomial logistic regression models to assess the association of metabolic syndrome with antipsychotic polypharmacy, adjusting for lifestyle.

RESULTS

Seventy-four (22.2%) patients were in the metabolic syndrome group, 61 (18.3%) patients were in the pre-metabolic syndrome group, and 41 (12.3%) patients were in visceral fat obesity group. Antipsychotic polypharmacy was present in 167 (50.0%) patients. In multinomial logistic regression analyses, antipsychotic polypharmacy was significantly associated with the pre-metabolic syndrome group (adjusted odds ratio [AOR], 2.348; 95% confidence interval [CI], 1.181-4.668), but not with the metabolic syndrome group (AOR, 1.269; 95%CI, 0.679-2.371).

CONCLUSIONS

These results suggest that antipsychotic polypharmacy, compared with monotherapy, may be independently associated with an increased risk of having pre-metabolic syndrome, even after adjusting for patients' lifestyle characteristics. As metabolic syndrome is associated with an increased risk of cardiovascular mortality, further studies are needed to clarify the validity and safety of antipsychotic polypharmacy.

Oral health and the symptoms of schizophrenia

The objectives of this study were to evaluate the oral health of a group of schizophrenic outpatients and a control group without psychiatric illness. The study also aimed to assess the influence of positive and negative symptomatology on oral health among outpatients with schizophrenia. The DMF-T Index (sum of decayed, missing and filled teeth) and the Community Periodontal Index of Treatment Needs (CPITN) were assessed in both groups. We evaluated the psychopathological state of the patient group using the Positive and Negative Syndrome Scale (PANSS). The schizophrenic patients had higher scores than the control group with respect to decayed teeth (4.39 vs. 0.72), missing teeth (5.66 vs. 1.50), the DMF-T index (13.51 vs. 7.8) and CPITN (2.32 vs. 1.04); and lower scores for filled teeth (3.53 vs. 5.54). The PANSS negative subscale score correlated positively with the oral health variables studied, whereas the PANSS positive subscale score correlated negatively and exclusively with the number of missing teeth. Age and smoking status affected oral health in both groups, but even when the influence of these factors was considered, the oral health of the patients was poorer than that of the control group.

NDETEI DAVID, W. NEWCOMER JOHN, UWAKWE RICHARD, ASAI ITSUO, MÖLLER HANSJURGEN, GAUTAM SHIV, DETRAUX JOHAN, U. CORRELL CHRISTOPH. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level

Physical disorders are, compared to the general population, more prevalent in people with severe mental illness (SMI). Although this excess morbidity and mortality is largely due to modifiable lifestyle risk factors, the screening and assessment of physical health aspects remains poor, even in developed countries. Moreover, specific patient, provider, treatment and system factors act as barriers to the recognition and to the management of physical diseases in people with SMI. Psychiatrists can play a pivotal role in the improvement of the physical health of these patients by expanding their task from clinical psychiatric care to the monitoring and treatment of crucial physical parameters. At a system level, actions are not easy to realize, especially for developing countries. However, at an individual level, even simple and very basic monitoring and treatment actions, undertaken by the treating clinician, can already improve the problem of suboptimal medical care in this population. Adhering to monitoring and treatment guidelines will result in a substantial enhancement of physical health outcomes. Furthermore, psychiatrists can help educate and motivate people with SMI to address their suboptimal lifestyle, including smoking, unhealthy diet and lack of exercise. The adoption of the recommendations presented in this paper across health care systems throughout the world will contribute to a significant improvement in the medical and related psychiatric health outcomes of patients with SMI.

Schizophrenia, cancer and obstetric complications in an evolutionary perspective-an empirically based hypothesis

OBJECTIVE

Patients diagnosed with schizophrenia have reduced fecundity and premature mortality (both accidental and violent) with no obvious compensatory advantages among kin. The prevalence of the disorder is around 0.7/1%, higher than the expected prevalence of spontaneous mutations. Genes favoring schizophrenia may have been positively selected in the environment of evolutionary adaptation. Literature on potential adaptive genes is reviewed within an evolutionary framework.

METHODS

Literature search on major scientific search engine (PubMed/Medline, Ovid/PsychInfo) on papers aimed at investigating potential pathways justifying a mutation-selection balanced model. Findings are presented with a narrative touch to favor readability and understanding.

RESULTS

Reduced incidence of cancer in both patients diagnosed with schizophrenia and their siblings was reported worldwide. Such findings are notable given higher cancer risk factors in schizophrenia, i.e., smoking, alcohol abuse, obesity, poor diet, and poor adherence to therapy. Some genes involved in cancer proliferation might as well confer protective advantage in immune-surveillance, inflammation, vascular proliferation or apoptosis that otherwise will adversely affect early neurodevelopment.

CONCLUSION

Evidence that reduced risk of certain somatic diseases is associated with schizophrenia is quite significant to progress in the evolutionary epidemiological analysis of psychopathology.

Neither the internist nor the Internet: use of and trust in health information sources by people with schizophrenia

OBJECTIVE

The aim of this study was to explore health information sources accessed by people with schizophrenia and the level of trust invested in them.

METHOD

A cross-sectional survey was performed comparing the responses of 71 adults with schizophrenia (recruited from both community and inpatient settings) with 238 general practice attendees on their use of television, radio, the Internet, newspapers, magazines, family and friends, and doctor to obtain information on health matters, and their levels of trust in these sources.

RESULTS

People with schizophrenia most commonly reported using a doctor, family and friends, and television to obtain information on health matters. However, compared with general practice attendees, they gained less health information from doctors and the Internet, and had less trust in doctors. Within-group analysis revealed that in people with schizophrenia: living alone increased the likelihood of obtaining health information from television; a higher level of education increased the odds of trusting the Internet as a health information source; a higher estimated household income was associated with an increased likelihood of trusting newspapers; and women with schizophrenia were considerably more likely than men with schizophrenia to trust family and friends as providers of health information. For both groups, there were significant positive correlations between the amount of health information obtained from a given information source and the level of trust invested in it.

CONCLUSIONS

There are significant differences in the reported utilization and trust of health information sources between people with schizophrenia and attendees at general practice settings. Those with schizophrenia are less likely to trust and obtain information from a doctor, and less likely to access the Internet. Further research is required to explore this disparity. This is critical given the high rates of comorbid physical illness and reduced longevity in people suffering from schizophrenia.