Mortality in schizophrenia

Determinants/Predictors of QT Abnormalities in Patients on Psychotropic Medications in a Nigerian Tertiary Hospital

Cardiovascular disease is a major global burden and a leading cause of premature death among patients with severe mental illness. Over time, research and clinical practice have paid increased attention to the impact of psychiatric medications on cardiac repolarization. In a resource-limited setting, it is common for psychotropic medications to be initiated and maintained in an outpatient setting without baseline or follow up ECG. This study evaluated the determinants and predictors of QT abnormalities among patient taking psychotropic drugs. We conducted a cross-sectional study in a population of 150 psychiatric patients on psychotropics and 75 controls. We studied the effects of various psychotropic drugs on QT dispersion (QTd) and corrected QT interval (QTc) as well as correlation with the types and dosages of psychotropic drugs used. All the subjects had detailed clinical examination and resting electrocardiogram (ECG) at 25 mm/sec done. QTc was determined using Bazett formula and QTd was determined by subtracting shortest from longest QT in 12-lead ECG. The prevalence of prolonged QTc and QTd as well as the mean QTc and QTd were significantly higher in patients than the control group. The mean QTc was significantly higher in patient on typical antipsychotics compared to those on atypical antipsychotics. Age, heart rate and antipsychotic dose in chlorpromazine equivalent were predictors of QTc with the heart rate being the most powerful predictor among them. Psychotropic drugs use is associated with QTc and QTd prolongation with age, heart rate and antipsychotic dose as predictors of QTc.

Impact of Cognitive Disturbances and Clinical Symptoms on Disability in Patients with Paranoid Schizophrenia: A Study of a Bulgarian Clinical Sample

The study aimed to assess the impact of clinical symptoms and cognitive impairment on disability in patients with paranoid schizophrenia (PS).

METHODS

108 patients with schizophrenia were included (66 male and 42 female). Their average age was 38.86 ± 10.02 years and the disease duration was 12.80 ± 8.20 years, with mean disease onset of 24 years. Clinical symptoms were assessed with the PANSS, and cognitive performance was measured using a seven-item neurocognitive battery. The disability level of the subjects was assessed using the World Health Organization-Disability Assessment Schedule 2.0 (WHO-DAS 2.0). The relation between the variables studied was assessed using Spearman's rank correlation coefficient (r_s) at a probability level of p < 0.05.

RESULTS

An increase in symptom severity resulted in worsening of the "participation in society" (r = 0.56, p < 0.01), "life activities-household" (r = 0.55, p < 0.01), and "getting along with people" (r = 0.59, p < 0.01) WHO-DAS 2.0 domains. Positive symptoms (13.89 ± 3.48) correlated strongly with "getting along with people" (r = 0.55, p < 0.01), "life activities-household" (r = 0.58, p < 0.01), and "participation in society" (r = 0.62, p < 0.01), and negative symptoms (14.25 ± 4.16) with "participation in society" (r = 0.53, p < 0.01) and "life activities-household" (r = 0.48, p < 0.01). Symptoms of disorganization (15.67 ± 4.16) had the highest impact on "life activities-household" (r = 0.81, p < 0.01), "getting along with people" (r = 0.56, p < 0.05), and "participation in society" (r = 0.65, p < 0.01). Episodic memory (r = -0.28, p < 0.01) was remotely related to comprehension and communication. The information processing speed (r_s = 0.38, p < 0.01), visual memory (r_s = -0.30, p < 0.01), and focused executive functions showed moderate correlations with all domains on the WHO-DAS 2.0 scale (r_s = 0.38, p < 0.01). Attention (r_s = -0.33, p < 0.01) was moderately related to community activities. Semantic (r_s = -0.29, p < 0.01) and literal (r_s = -0.27, p < 0.01) verbal fluency demonstrated weak correlations with "cognition-understanding", "getting along with people", and "participation in society".

CONCLUSION

Symptoms of disorganization and disturbed executive functions contribute most to disability in patients with schizophrenia through impairment of real-world functioning, especially in social interactions and communication. Severe clinical symptoms (negative and disorganization-related ones) as well as deficits in executive function, verbal memory, and verbal fluency cause the biggest problems in the functional domains of interaction with other people and participation in society.

The thalamus in psychosis spectrum disorder

Psychosis spectrum disorder (PSD) affects 1% of the world population and results in a lifetime of chronic disability, causing devastating personal and economic consequences. Developing new treatments for PSD remains a challenge, particularly those that target its core cognitive deficits. A key barrier to progress is the tenuous link between the basic neurobiological understanding of PSD and its clinical phenomenology. In this perspective, we focus on a key opportunity that combines innovations in non-invasive human neuroimaging with basic insights into thalamic regulation of functional cortical connectivity. The thalamus is an evolutionary conserved region that forms forebrain-wide functional loops critical for the transmission of external inputs as well as the construction and update of internal models. We discuss our perspective across four lines of evidence: First, we articulate how PSD symptomatology may arise from a faulty network organization at the macroscopic circuit level with the thalamus playing a central coordinating role. Second, we discuss how recent animal work has mechanistically clarified the properties of thalamic circuits relevant to regulating cortical dynamics and cognitive function more generally. Third, we present human neuroimaging evidence in support of thalamic alterations in PSD, and propose that a similar "thalamocortical dysconnectivity" seen in pharmacological imaging (under ketamine, LSD and THC) in healthy individuals may link this circuit phenotype to the common set of symptoms in idiopathic and drug-induced psychosis. Lastly, we synthesize animal and human work, and lay out a translational path for biomarker and therapeutic development.

The Relationship between Mental Disorders and the COVID-19 Pandemic—Course, Risk Factors, and Potential Consequences

In this review the authors discuss that COVID-19 has already had a direct impact on the physical health of many people and that it appears to have put at risk the mental health of large populations. In this review, we also discuss the relationship between mental disorders and the SARS-CoV-2 infection. We convey the disorders’ risk factors and the more serious mental disorder consequences of COVID-19. People with mental health disorders could be more susceptible to the emotional responses brought on by the COVID-19 epidemic. The COVID-19 pandemic may adversely influence the mental health of patients with already diagnosed mental disorders. For the aim of dealing better with the psychological problems of people afflicted by the COVID-19 pandemic, new psychological procedures are required.

New Paradigms of Old Psychedelics in Schizophrenia

Psychedelics such as lysergic acid diethylamide (LSD), psilocybin (magic mushrooms), and mescaline exhibit intense effects on the human brain and behaviour. In recent years, there has been a surge in studies investigating these drugs because clinical studies have shown that these once banned drugs are well tolerated and efficacious in medically supervised low doses called microdosing. Psychedelics have demonstrated efficacy in treating neuropsychiatric maladies such as difficult to treat anxiety, depression, mood disorders, obsessive compulsive disorders, suicidal ideation, posttraumatic stress disorder, and also in treating substance use disorders. The primary mode of action of psychedelics is activation of serotonin 5-HT_2A receptors affecting cognition and brain connectivity through the modulation of several downstream signalling pathways via complex molecular mechanisms. Some atypical antipsychotic drugs (APDs) primarily exhibit pharmacological actions through 5-HT_2A receptors, which are also the target of psychedelic drugs. Psychedelic drugs including the newer second generation along with the glutamatergic APDs are thought to mediate pharmacological actions through a common pathway, i.e., a complex serotonin-glutamate receptor interaction in cortical neurons of pyramidal origin. Furthermore, psychedelic drugs have been reported to act via a complex interplay between 5HT_2A, mGlu2/3, and NMDA receptors to mediate neurobehavioral and pharmacological actions. Findings from recent studies have suggested that serotoninergic and glutamatergic neurotransmissions are very closely connected in producing pharmacological responses to psychedelics and antipsychotic medication. Emerging hypotheses suggest that psychedelics work through brain resetting mechanisms. Hence, there is a need to dig deeply into psychedelic neurobiology to uncover how psychedelics could best be used as scientific tools to benefit psychiatric disorders including schizophrenia.

Relationship between White Matter Alterations and Pathophysiological Symptoms in Patients with Ultra-High Risk of Psychosis, First-Episode, and Chronic Schizophrenia

Some symptoms of schizophrenia might be present before full-blown psychosis, so white matter changes must be studied both in individuals with emerging psychosis and chronic schizophrenia. A total of 86 patients—12 ultra-high risk of psychosis (UHR), 20 first episode psychosis (FEP), 54 chronic schizophrenia (CS), and 33 healthy controls (HC)—underwent psychiatric examination and diffusion tensor imaging (DTI) in a 3-Tesla MRI scanner. We assessed fractional anisotropy (FA) and mean diffusivity (MD) of the superior longitudinal fasciculus (SLF) and inferior longitudinal fasciculus (ILS). We found that CS patients had lower FA than FEP patients (p = 0.025) and HC (p = 0.088), and higher MD than HC (p = 0.037) in the right SLF. In the CS group, we found positive correlations of MD in both right ILF (rho = 0.39, p < 0.05) and SLF (rho = 0.43, p < 0.01) with disorganization symptoms, as well as negative correlation of FA in the right ILF with disorganization symptoms (rho = −0.43, p < 0.05). Among UHR individuals, we found significant negative correlations between MD in the left ILF and negative (r = −0.74, p < 0.05) and general symptoms (r = −0.77, p < 0.05). However promising, these findings should be treated as preliminary, and further research must verify whether they can be treated as potential biomarkers of psychosis.

A Retrospective Analysis of Death Among Chinese Han Patients with Schizophrenia from Shandong

Purpose

To describe the mortality rate and cause of death among Han Chinese schizophrenia patients and to explore the risk factors affecting survival.

Methods

We performed a retrospective analysis of death among patients with schizophrenia from Jan 1, 2012, to Dec 31, 2019, using the Severe Mental Disorders Information System of Shandong Province (henceforth referred to as the SMDI system) in Shandong, China. The cohort included 72,102 patients, and 11,766 patients died during follow-up. The data in this cohort study were derived from the SMDI system. We calculated the crude mortality rate and standardized mortality rate (SMR, standardized according to the sex and age composition of the population in Shandong Province) for patients with schizophrenia. Cox regression analysis was used to analyze the risk factors affecting patient survival, and the statistical index was the hazard ratio (HR).

Results

The mean age of the cohort patients was 47.21±14.05 years; 51.79% were males, and 48.21% were females. Among them, 68.98% (49,735) had only a primary education level, 85.36% (61,549) were farmers, 64.37% (46,413) were married, and 94.01% (67,775) received community management. A total of 16.32% of the cohort died. The SMR in patients with schizophrenia was 4.9, and it was higher for males than females (4.99 versus 4.82). Among the 6 registered causes of death, physical illness had the highest SMR (5.15), followed by other causes of death (4.86), mental illness-related complications (4.57), homicide (4.31), accidents (4.13), and suicide (3.87). Higher levels of education, employment (in-service status), marriage, and urban residence were protective factors for survival among patients with schizophrenia.

Conclusion

In China, the SMR of schizophrenia is relatively high, and physical diseases are the main cause of death. We suggest that a variety of measures should be taken early to treat somatic diseases and reduce SMR in patients with schizophrenia.

Sudden death related to the gastrointestinal system in Tunisia: A 13 year autopsy study

Sudden gastrointestinal (GI) death is an unexpected death due to digestive system causes mainly found after autopsy. The literature is rich in articles that studied sudden death due to cardiac causes while sudden GI deaths remain less well-documented. We retrospectively investigated all cases of gastrointestinal death at the Department of Forensic Medicine in Tunis, over 13 years (January 1, 2006 to December 31, 2018). Two hundred and eight cases were collected. The mean age of our series was 51.06 ± 20.99 years. No history of digestive disorders was reported in 78.4%, and no family history of sudden death was found in any cases. A male predominance was found in most epidemiological characteristics of the sample with a significant statistical rate in some features. Non-specific abdominal pain was the most described symptom (n = 92). Perforation of GI tract was the common mechanism involved in the death of 55 cases, of which 44 were related to ulcer perforation. These ulcer perforations were statistically more reported in smokers and people suffering from schizophrenia. Intestinal obstruction was the second commonest cause of death, mainly found in the elderly. Sudden death in children was most frequently caused by acute intussusception. This study highlights that systematic study of sudden death due to GI causes might provide opportunities to identify avenues for overall health improvement.

[From relationship to therapeutic alliance with adolescents and young adults at risk of psychotic transition: The perspective of mental health professionals. An exploratory study]

Introduction : Psychotic disorders usually begin during adolescence or early adulthood. The first psychotic symptoms are said to be attenuated in their prodromal phase. It is essential to identify them and initiate follow-up as early as possible to limit the severity of symptoms or even prevent a psychotic transition. However, there is still some uncertainty about the progression of symptoms. The aim of this exploratory study was to show the difficulties that surround the construction of a therapeutic alliance in this context.Methodology : The method adopted was a field survey.Results : Uncertainty about the development of disorders and their worsening and the fact that they are assessed by evaluating the patient's functional weaknesses led professionals to develop a relationship based on knowledge that is acquired empirically and that is in line with a phenomenological approach. Thus, professionals mobilized dynamic and interactive communication techniques to try to forge a therapeutic alliance.Conclusion : It has been shown that professionals seek to build a therapeutic alliance with young people presenting an uncertain evolution toward psychosis using a phenomenological, personalized, and pragmatic logic.

Associations between symptom severity and well-being among Thai patients with schizophrenia: a cross-sectional analytical study

BACKGROUND

Severity of symptoms in patients with schizophrenia is a determinant of patient's well-being, but evidence in low- and middle-income countries is limited. We aimed to measure the symptom severity using objective measurements, the Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression-Severity scale (CGI-S), and their associations with well-being in patients with schizophrenia.

METHODS

Patients with schizophrenia aged ≥18 years, without active psychosis including no history of hospitalization within the last 6 months, were included. Symptom severity was measured by the clinicians using BPRS and CGI-S. The patients' well-being was assessed by self-report using the Subjective Well-being under Neuroleptic treatment scale (SWN) as continuous and binary outcomes (categorized into adequate or poor well-being). Correlations between symptom severity (BPRS and CGI-S scores) and well-being (SWN score) were analyzed using Pearson's correlation. Association between well-being status and BPRS was analyzed using multivariate logistic regression.

RESULTS

Of 150 patients, BPRS and CGI-S were inversely correlated with SWN score (r = - 0.47; p < 0.001 and - 0.21; p < 0.01, respectively). BPRS Affect domain had the highest correlation with SWN (r = - 0.51, p < 0.001). In multivariate logistic regression, BPRS score and being unemployed were associated with poor well-being status (adjusted OR 1.08; 95%CI 1.02-1.14; p = 0.006, and 4.01; 95%CI 1.38-11.7; p = 0.011, respectively).

CONCLUSION

Inverse relationships between symptom severity and well-being score were found. Higher BPRS Affect domain was significantly associated with lower patients' well-being. The use of BPRS tool into routine clinical practice could serve as an adjunct to physician's clinical evaluation of patients' symptoms and may help improve patient's well-being. Further research on negative symptoms associated with well-being is required.

Disturbances in White Matter Integrity in the Ultra-High-Risk Psychosis State-A Systematic Review

Schizophrenia is a severe and disabling mental illness whose etiology still remains unclear. The available literature indicates that there exist white matter (WM) abnormalities in people with schizophrenia spectrum disorders. Recent developments in modern neuroimaging methods have enabled the identification of the structure, morphology, and function of the underlying WM fibers in vivo. The purpose of this paper is to review the existing evidence about WM abnormalities in individuals at ultra-high risk of psychosis (UHR) with the use of diffusion tensor imaging (DTI) available from the National Center for Biotechnology Information PubMed (Medline) and Health Source: Nursing/Academic Edition databases. Of 358 relevant articles identified, 25 papers published in the years 2008–2020 were ultimately included in the review. Most of them supported the presence of subtle aberrations in WM in UHR individuals, especially in the superior longitudinal fasciculus (SLF), the inferior longitudinal fasciculus (ILF), and the inferior fronto-occipital fasciculus (IFOF). These alterations may therefore be considered a promising neurobiological marker for the risk of psychosis. However, due to methodological discrepancies and the relative scarcity of evidence, further investigation is called for, especially into connectome analysis in UHR patients.

Comparing psychotropic medication prescribing in personality disorder between general mental health and psychological services: retrospective cohort study

BACKGROUND

Although no drugs are licensed for the treatment of personality disorder, pharmacological treatment in clinical practice remains common.

AIMS

This study aimed to estimate the prevalence of psychotropic drug use and associations with psychological service use among people with personality disorder.

METHOD

Using data from a large, anonymised mental healthcare database, we identified all adult patients with a diagnosis of personality disorder and ascertained psychotropic medication use between 1 August 2015 and 1 February 2016. Multivariable logistic regression models were constructed, adjusting for sociodemographic, clinical and service use factors, to examine the association between psychological services use and psychotropic medication prescribing.

RESULTS

Of 3366 identified patients, 2029 (60.3%) were prescribed some form of psychotropic medication. Patients using psychological services were significantly less likely to be prescribed psychotropic medication (adjusted odds ratio 0.48, 95% CI 0.39-0.59, P<0.001) such as antipsychotics, benzodiazepines and antidepressants. This effect was maintained following several sensitivity analyses. We found no difference in the risk for mood stabiliser (adjusted odds ratio 0.79, 95% CI 0.57-1.10, P = 0.169) and multi-class psychotropic use (adjusted odds ratio 0.80, 95% CI 0.60-1.07, P = 0.133) between patients who did and did not use psychological services.

CONCLUSIONS

Psychotropic medication prescribing is common in patients with personality disorder, but significantly less likely in those who have used psychological services. This does not appear to be explained by differences in demographic, clinical and service use characteristics. There is a need to develop clear prescribing guidelines and conduct research in clinical settings to examine medication effectiveness for this population.

Excess mortality and shortened life expectancy in people with major mental illnesses in Taiwan

AIMS

Given the concerns of health inequality associated with mental illnesses, we aimed to reveal the extent of which general mortality and life expectancy at birth in people with schizophrenia, bipolar disorder and depressive disorder varied in the 2005 and 2010 nationally representative cohorts in Taiwan.

METHODS

Two nationally representative samples of individuals with schizophrenia, bipolar disorder and depressive disorder were identified from Taiwan's national health insurance database in 2005 and 2010, respectively, and followed-up for consecutive 3 years. The database was linked to nationwide mortality registry to identify causes and date of death. Age-, gender- and cause-specific mortality rates were generated, with the average follow-up period of each age- and gender-band applied as 'weighting' for the calculation of expected number of deaths. Age- and gender-standardised mortality ratios (SMRs) were calculated for these 3-year observation periods with Taiwanese general population in 2011/2012 as the standard population. The SMR calculations were then stratified by natural/unnatural causes and major groups of death. Corresponding life expectancies at birth were also calculated by gender, diagnosis of mental disorders and year of cohorts for further elucidation.

RESULTS

The general differential in mortality rates for people with schizophrenia and bipolar disorder remained wide, revealing an SMR of 3.65 (95% confidence interval (CI): 3.55-3.76) for cohort 2005 and 3.27 (3.18-3.36) for cohort 2010 in schizophrenia, and 2.65 (95% CI: 2.55-2.76) for cohort 2005 and 2.39 (2.31-2.48) for cohort 2010 in bipolar disorder, respectively. The SMRs in people with depression were 1.83 (95% CI: 1.81-1.86) for cohort 2005 and 1.59 (1.57-1.61) for cohort 2010. SMRs due to unnatural causes tended to decrease in people with major mental illnesses over the years, but those due to natural causes remained relatively stable. The life expectancies at birth for schizophrenia, bipolar disorder and depression were all significantly lower than the national norms, specifically showing 14.97-15.50 years of life lost for men and 15.15-15.48 years for women in people with schizophrenia.

CONCLUSIONS

Compared to general population, the differential in mortality rates for people with major mental illnesses persisted substantial. The differential in mortality for unnatural causes of death seemed decreasing over the years, but that due to natural causes remained relatively steady. Regardless of gender, people with schizophrenia, bipolar disorder and depression were shown to have shortened life expectancies compared to general population.

Type-2 diabetes mellitus in schizophrenia: Increased prevalence and major risk factor of excess mortality in a naturalistic 7-year follow-up

Objective

Physical co-morbidity including type 2 diabetes mellitus is more prevalent in patients with schizophrenia compared to the general population. However, there is little consistent evidence that co-morbidity with diabetes mellitus and/or other diseases leads to excess mortality in schizophrenia. Thus, we investigated whether co-morbidity with diabetes and other somatic diseases is increased in schizophrenics, and if these are equally or more relevant predictors of mortality in schizophrenia than in age- and gender-matched hospitalised controls.

Methods

During 2000–2007, 679 patients with schizophrenia were admitted to University Hospital Birmingham NHS Trust. Co-morbidities were compared with 88,778 age- and gender group-matched hospital controls. Predictors of mortality were identified using forward Cox regression models.

Results

The prevalence of type 2 diabetes mellitus was increased in schizophrenia compared to hospitalised controls (11.3% versus 6.3%). The initial prevalence of type 2 diabetes mellitus was significantly higher in the 100 later deceased schizophrenic patients (24.0%) than in those 579 surviving over 7 years (9.2%). Predictors of mortality in schizophrenia were found to be age (relative risk [RR] = 1.1/year), type 2 diabetes mellitus (RR = 2.2), pneumonia (RR = 2.7), heart failure (RR = 2.9) and chronic renal failure (RR = 3.2). The impact of diabetes mellitus on mortality was significantly higher in schizophrenia than in hospital controls (RR = 2.2 versus RR = 1.1). In agreement, deceased schizophrenics had significantly suffered more diabetes mellitus than deceased controls (24.0 versus 10.5%). The relative risks of mortality for other disorders and their prevalence in later deceased subjects did not significantly differ between schizophrenia and controls.

Conclusion

Schizophrenics have more and additionally suffer more from diabetes: co-morbidity with diabetes mellitus is increased in schizophrenia in comparison with hospital controls; type 2 diabetes mellitus causes significant excess mortality in schizophrenia. Thus, monitoring for and prevention of type 2 diabetes mellitus is of utmost relevance in hospitalised patients with schizophrenia.

Mortality in schizophrenia: A study of verbal autopsy from cohorts of two rural communities of South India

BACKGROUND

Schizophrenia is a life-shortening disease. Although the rate of mortality of persons with schizophrenia in India is established to be more compared to that in the general population, there is a little exploration of the causes for the same.

AIM

The aim of this study is to explore the causes of death in two rural cohorts of schizophrenia.

MATERIALS AND METHODS

In-person interviews of primary caregivers of 53 deceased persons with schizophrenia were conducted using the World Health Organization's verbal autopsy 2014 instrument. Physician-based method was used to determine the causes of death.

RESULTS

Average age of 53 deceased schizophrenia patients was 50.45 ± 13.65 years with almost equal gender ratio. Just more than two-thirds of patients were married, just more than one-third are educated up to primary school and also had no formal education each. Noncommunicable diseases (NCDs) were the most common causes of death (30, 56.6%) in this sample, followed by communicable disease (7, 13.2%), and then unnatural deaths (suicide - 8, 15%, and road traffic accidents - 3, 5.6%).

CONCLUSIONS

It is the first study in India to explore the causes of death in schizophrenia. NCDs being the most common cause of death in schizophrenia suggests to the need of integration of schizophrenia care into general health care.

Antipsychotics and risk of natural death in patients with schizophrenia

Background: Research on antipsychotics and early mortality in schizophrenia has arisen from Western countries and results show that mortality from natural causes is obviously increased in schizophrenia. China, differs largely from Western countries in health and social welfare systems, and Asian patients are more susceptible to side-effects and might require less antipsychotics than their Western counterparts. We, therefore, investigated the association between antipsychotic use and increased mortality from natural causes among patients with schizophrenia in China. Methods: We conducted a population-based nested case-control study using patients' hardcopy archives obtained from the Severe Mental Health Disorder Systems of Chengdu between January 1, 2006 and December 31, 2013. We identified all schizophrenic patients aged 18-65 years who died of natural causes in 2013 (N=157), and their age- and gender-matched controls (N=444). Results: Antipsychotic use was more frequent in controls than in cases (59.9% vs 32.5%). Risk of death decreased significantly in those receiving antipsychotic monotherapy (adjusted odds ratio=0.27, 95% CI=0.16-0.46) and antipsychotic polypharmacy (adjusted odds ratio=0.29, 95% CI=0.12-0.70) than antipsychotic-free patients. Compared with monotherapy, antipsychotic-free treatment was associated with prominently increased mortality (adjusted odds ratio=3.64, 95% CI=2.18-6.08). When stratified by age and gender, the results remained unchanged. Conclusion: Antipsychotic monotherapy significantly decreased mortality from natural causes in schizophrenic patients while antipsychotic polypharmacy did not contribute to the excess mortality and deserves further clarification. We need to improve the physical health of schizophrenic patients and promote health education among community mental health staff and primary caregivers.

Dying Too Soon: Excess Mortality in Severe Mental Illness

Aims: We aimed to identify baseline predictors of mortality in patients with a severe mental illness (SMI) over a 6-year period and to describe mortality rates as standardised mortality ratios (SMRs). We hypothesised that cardiovascular diseases, older age, cigarette smoking, more severe psychiatric symptoms and more severe psychotropic side effects, and alcohol or drug use were independent risk factors for mortality. Method: Medical examinations were conducted at baseline in a cohort of 322 SMI patients. SMRs were estimated after 6 years and an evaluation was made of the impact of a wide range of variables on survival time. Results: Almost 11% of the SMI patients had died at the end of the study period. All-cause SMRs were 4.51 (95% CI 3.07-5.95) for all SMI patients (4.89, 95% CI 2.97-6.80 for men, and 3.94, 95% CI 1.78-6.10 for women). Natural causes accounted for 86% of excess mortality and unnatural causes for 14%. Cardiovascular disease was a major contributor to this excess mortality. Multivariate Cox regression analyses showed that premature death was associated with a longer history of tobacco use (HR: 1.03, 95% CI 1.02-1.03) and more severe symptoms of disorganisation (HR: 2.36, 95% CI 2.21-2.52). Conclusions: The high SMR and the incidence of cardiovascular disease-related death in SMI patients in our study justify concern. This study underscores the urgent need for interventions to reduce excess mortality in patients with SMI.

Long-term antipsychotic polypharmacy prescribing in secondary mental health care and the risk of mortality

OBJECTIVES

To investigate the association between long-term antipsychotic polypharmacy use and mortality; and determine whether this risk varies by cause of death and antipsychotic dose.

METHODS

Using data from a large anonymised mental healthcare database, we identified all adult patients with serious mental illness (SMI) who had been prescribed a single antipsychotic or polypharmacy, for six or more months between 2007 and 2014. Multivariable Cox regression models were constructed, adjusting for sociodemographic, socioeconomic, clinical factors and smoking, to examine the association between APP use and the risk of death.

RESULTS

We identified 10 945 adults with SMI who had been prescribed long-term antipsychotic monotherapy (76.9%) or APP (23.1%). Patients on long-term APP had a small elevated risk of mortality, which was significant in some but not all models. The adjusted hazard ratios for death from natural and unnatural causes associated with APP were 1.2 (0.9-1.4, P = 0.111) and 1.1 (0.7-1.9, P = 0.619) respectively. The strengths of the associations between APP and mortality outcomes were similar after further adjusting for % BNF antipsychotic dose (P = 0.031) or olanzapine equivalence (P = 0.088).

CONCLUSION

The findings suggest that the effect of long-term APP on mortality is not clear-cut, with limited evidence to indicate an association, even after controlling for the effect of dose.

Prevalence and correlates of diabetes mellitus and dyslipidaemia in a long-stay inpatient schizophrenia population in Singapore

INTRODUCTION

Patients with schizophrenia have shorter life expectancy and one of the main causes of death is cardiovascular disease (CVD). Modifiable risk factors for CVD include diabetes mellitus (DM) and dyslipidaemia. This study aimed to establish: (a) the prevalence and correlates of DM and dyslipidaemia; (b) the proportion of those whose condition was well controlled; and (c) the incidence of undiagnosed DM and dyslipidaemia in a long-stay inpatient schizophrenia population.

METHODS

Data was collected to assess the physical health status of 110 inpatients with schizophrenia who had been in hospital for over one year. Information on sociodemographic characteristics, diagnosis of physical and mental illnesses, and current medications was obtained from their medical records. The overall prevalence of DM and dyslipidaemia was based on diagnosis in the medical records, current medications and fasting blood test results.

RESULTS

The patient group was predominantly male (85.5%), with a mean age of 55.9 ± 9.9 (range 25-90) years. Overall prevalence of DM and dyslipidaemia was 19.1% and 62.7%, respectively. Multivariate logistic regression analysis showed that Malay (odds ratio [OR] 14.97) and Indian (OR 25.71) patients were significantly more likely to have DM when compared to Chinese patients.

CONCLUSION

In comparison to the general population, the prevalence of DM and dyslipidaemia was found to be higher in inpatients with schizophrenia. However, the two chronic illnesses were well controlled in inpatients and few were undiagnosed, perhaps due to the regular monitoring, supervised diet and regular physical activities arranged for inpatients in the long-stay inpatient wards.

Hospital admissions for respiratory system diseases in adults with intellectual disabilities in Southeast London: a register-based cohort study

BACKGROUND

Intellectual disability (ID) carries a high impact on need for care, health status and premature mortality. Respiratory system diseases contribute a major part of mortality among people with ID, but remain underinvestigated as consequent morbidities.

METHODS

Anonymised electronic mental health records from the South London and Maudsley Trust (SLaM) were linked to national acute medical care data. Using retrospective cohort and matched case-control study designs, adults with ID receiving SLaM care between 1 January 2008 and 31 March 2013 were identified and compared with local catchment residents for respiratory system disease admissions. Standardised admission ratios (SARs) were first calculated, followed by a comparison of duration of hospitalisation with respiratory system disease between people with ID and age-matched and gender-matched random counterparts modelled using linear regression. Finally, the risk of readmission for respiratory system disease was analysed using the Cox models.

RESULTS

For the 3138 adults with ID identified in SLaM, the SAR for respiratory system disease admissions was 4.02 (95% CI 3.79 to 4.26). Compared with adults without ID, duration of hospitalisation was significantly longer by 2.34 days (95% CI 0.03 to 4.64) and respiratory system disease readmission was significantly elevated (HR=1.35; 95% CI 1.17 to 1.56) after confounding adjustment.

CONCLUSIONS

Respiratory system disease admissions in adults with ID are more frequent, of longer duration and have a higher likelihood of recurring. Development and evaluation of potential interventions to the preventable causes of respiratory diseases should be prioritised.

How gender affects the pharmacotherapeutic approach to treating psychosis - a systematic review

INTRODUCTION

The effectiveness, effective dosages and side effect profiles of antipsychotic medication differ significantly between the sexes. Areas covered: We present a systematic review of gender-differences in the treatment of psychosis focusing on randomized, controlled trials and meta-analyses. Expert opinion: Despite many years of research, the database on gender-differences affecting the pharmacotherapeutic approach to treating psychosis is insufficient. Currently, the US National Institute of Health encouraged the enrolment of female participants in federally supported phase III clinical trials to increase the data available of female patients. Emerging evidence points to a superior antipsychotic response in women, with men requiring higher dosages. In general, women metabolize drugs differently, resulting in side effects occuring more frequently when compared to men. In any case, women require electrocardiograms or bone density scans as well as diabetes and cardiovascular workups when treated with antipsychotics. Dose adjustments during the menstrual cycle (e.g. to raise antipsychotic doses premenstrually) should be considered. First-generation antipsychotics, drugs that are known to prolong QTc interval and increase prolactin levels should be avoided in postmenopausal female patients. Furthermore, the effects of antipsychotics during pregnancy and breastfeeding have been investigated insufficiently, and more research is urgently needed.

Genetic Determinants of Clozapine-Induced Metabolic Side Effects

OBJECTIVE

Atypical antipychotics are linked to a higher incidence of metabolic side effects, including weight gain, dyslipidemia, and diabetes. In this study, we examined the prevalence and potential genetic predictors of metabolic side effects in 60 adult patients on clozapine.

METHOD

Genetic variants of relevance to clozapine metabolism, clearance, and response were assessed through targeted genotyping of cytochrome P450 enzymes CYP1A2 and CYP2C19, the efflux transporter ABCB1, the serotonin receptor (HTR2C), leptin (LEP), and leptin receptor (LEPR). Clozapine levels and other potential confounders, including concurrent medications, were also included in the analysis.

RESULTS

More than half of the patients were obese (51%), had metabolic syndrome (52.5%), and 30.5% were overweight. There was a high prevalence of antipsychotic polypharmacy (61.9%). With multivariable linear regression analysis, LEP -2548G>A, LEPR c.668A>G, and HTR2C c.551-3008 C>G were identified as genetic predictors of body mass index (BMI) after considering effects of clozapine dose, blood level, and concurrent medications (adjusted R² = 0.305). Metabolic syndrome was found to be significantly associated with clozapine level and CYP2C19*2 and LEPR c.668 G alleles. Clozapine levels in patients with metabolic syndrome were significantly higher compared to those without metabolic syndrome (1886 ± 895 vs. 1283 ± 985 ng/mL, P < 0.01) and were associated with the CYP2C19*2 genotype. No association was found between the genetic variants studied and lipid or glucose levels.

CONCLUSION

This study confirms a high prevalence of metabolic side effects with clozapine and suggests higher clozapine level and pharmacogenetic markers in CYP2C19, LEP, LEPR, and HTR2C receptors as important predictors of BMI and metabolic syndrome.

Productivity and deadweight losses due to relapses of schizophrenia in Japan

BACKGROUND

No study has examined the financial impact of relapses on schizophrenia from the perspective of Japanese society. This study aimed to estimate the societal costs in Japan caused by the relapses of schizophrenia.

METHODS

The societal costs in Japan in 2013 due to relapses of schizophrenia were estimated by summing the productivity loss and deadweight loss caused by schizophrenia relapses in 2013. Deterministic sensitivity analysis was conducted for deadweight loss rate, relapse rate, and patient income.

RESULTS

Japan incurred JPY 55,039 million societal costs because of relapses in 2013. This consists of JPY 3,990 million for productivity loss and JPY 51,049 million for deadweight loss. Rate of deadweight loss is the most significant cost driver in the sensitivity analysis.

CONCLUSION

Relapses of schizophrenia could generate huge amount of societal costs by reducing labor productivity and economic efficiency. To curb these costs, relapse prevention is desired in treating schizophrenia.

Physical health, community participation and schizophrenia

Our objective is to identify links between physical health and community participation among individuals with schizophrenia or a psychosis mental illness. Semi-structured qualitative and quantitative interviews and community tours were conducted over 10 months ( N = 30). Interviews were transcribed and analyzed using a grounded theory coding strategy. Physical health played an important role in community participation both as a cause and consequence. Key processes included mobility issues impeding physical community involvement; a multi-directional relationship between social relationships, community involvement, and physical health; identity as a mechanism linking physical health problems and community engagement; and the potential for community-based mental health programs.

[Advocacy for the establishment of a comprehensive strategy to reduce the "burden" of schizophrenic disorders]

This article attempts to identify and put into perspective the different approaches that could globally prevent the suffering induced by schizophrenia, from the detection of early psychosis to the impact on individual and family functioning and emotional health. Schizophrenia causes, at the community level, a number of difficult consequences and associated costs, which likely could be reduced if specific strategies, already known and documented internationally, were applied. Two areas not explored in this article: the role of medication and the issue of suicide prevention. In the scope of screening and early treatment, genetic risk, as well as the predictive ability of the clinical criteria for individuals at "ultra-high risk" of developing schizophrenia justify an increased vigilance for the detection of symptoms in order for treatment to begin earlier and to be more effective. These risk factors should not be neglected as the benefits of early management impact the course of illness and functional outcome. At this stage of the emergence of the disorder, it is difficult to systematize a therapeutic protocol. Two options are open to the clinician: "wait and watch" given the lack of a conclusive diagnosis and a more pro-active intervention, focused on the therapeutic alliance and enhancing insight and awareness. The second approach seems more productive but requires transparency with the patient and family regarding the uncertainty of the clinical situation, and an attitude that favors sharing information, along the lines of early psych education. Once a pathological stage is reached, early and accurate clinical care is fundamental. They depend heavily on access to care, proximity and availability to clinics or out-reach teams, capable of a thorough diagnostic work-up. Yet conversely, the availability for early and accurate clinical care faces obstacles which are closely related to the pejorative view of psychiatry held by the general public, health care professionals, and public officials. This poor image of psychiatry is partly due to cases of clinical decompensation, dangerous in some instances, underscoring why it is be important to understand and anticipate the contributory factors to these outcomes in the first place so as to avoid them. In this sense, defending a complacent and conciliatory approach can be counter-productive. Following developments of recent decades in other chronic diseases (diabetes, cancer, AIDS, severe heart disease…), the implementation of systematic clinical programs, treatment protocols, psycho-education to reinforce adherence to therapeutic measures, their simplification, the support and appreciation of the role of caregivers, destigmatizing due to proximity of contact, and therefore an increase in the use of care. Similarly, the systematic search for side-effects of medication and pro-actively managing to minimize their occurrence strengthen compliance, a recognized factor of relapse prevention. Preventable comorbidities, addictions, and common physical illnesses are not systematically screened (neoplastic diseases, diabetes, hypertension, dental health, gynecology…) in this population and thus also represent significant potential for a better life expectancy. The tools of psychosocial rehabilitation, unfortunately, are too infrequently used in France. Their goal is to improve the functional outcome of patients, a determinant of social integration and to lessen the burden shouldered by family and other carers, and ultimately to reduce exacerbations of the illness due to situations of interpersonal stress. Work has also proven its worth as a protective factor, as well as strengthening a sense of self-efficiency, of self-esteem, of empowerment, of quality of life, helping attain recovery. It is clear that not all social and health care systems are primarily geared towards these objectives, although they have at their disposal, by the means described above, strong preventive measures for relapses. Beyond the issue of the implementation of clinical programs, the existing culture would benefit from being infused with a prioritization of resource deployment, with debates of these issues regarding parity for mental health services, advocated by users, and forging a place, for example, for the intervention of "peer supports", sociologists, social workers, interested beyond the disease, in community environment, employment opportunities, and housing. Overall, this work argues for updating our conceptions of clinical care, supporting the systematic implementation of modern models of care, and expanding the scope of our concerns regarding patients' lives.

Mortality Rates in Users of Typical and Atypical Antipsychotics: A Database Study in Poland

Background

The role of antipsychotics in influencing mortality of patients with mental disorders is still unexplained.

Objective

The aim of this study was to determine mortality rates of patients treated with atypical and typical antipsychotics and to compare these data with the mortality rates for the general population.

Methods

The study was based on the 2008–2012 prescription drug reimbursement data from the Polish National Health Fund in Gdansk and mortality data from the death registry. Age-standardized death rates (SDRs) and 95 % confidence intervals (CIs) were calculated for individuals prescribed solely atypical or typical antipsychotics, patients prescribed both atypical and typical antipsychotics, and patients prescribed clozapine.

Results

Between 2008 and 2012, typical and/or atypical antipsychotics and clozapine were prescribed to a total of 81,313 patients. The SDR for typical antipsychotic users (69.6 per 1000, 95 % CI 67.64–71.56) was higher than for those treated with both typical and atypical antipsychotics (53.25 per 1000, 95 % CI 50.8–55.69) or clozapine (65.11 per 1000, 95 % CI 58.63–71.58). The lowest mortality was documented in the case of patients treated exclusively with atypical antipsychotics (SDR = 48.38 per 1000, 95 % CI, 44.78–51.98). The SDRs for patients treated with antipsychotics were more than tenfold higher than the respective SDRs for the general population in 2008, but later in 2012, the differences dropped to threefold.

Conclusion

Although the study was based on administrative record linkage and therefore could not be adjusted for potential confounders, its results suggest that mortality in atypical antipsychotic users is lower than in typical antipsychotic users.

Influences on uptake of cancer screening in mental health service users: a qualitative study

BACKGROUND

Cancers are a leading cause of death worldwide. People with mental illness are 30 % more likely to die from cancer than the general population. One reason for this may be low uptake of nationally offered cancer screening tests by people with mental illness. We aimed to identify barriers and facilitators for breast, cervical and bowel cancer screening uptake by people with mental illness in order to inform interventions to promote equal access.

METHODS

The interview study was conducted in both urban and rural settings. The study was informed by the Theoretical Domains Framework, using framework analysis and triangulation across participant groups. Participants included 45 mental health service users (service users) eligible for cancer screening, 29 mental health professionals and 11 professionals involved in cancer screening.

RESULTS

Themes emerging from the data that affected uptake included knowledge of screening programmes by both service users and healthcare providers; knowledge of, and attitudes towards, mental illness; health service-delivery factors; service users' beliefs and concerns about cancer screening, and practical issues. These are relevant to different stages of the screening process. Service users do not receive invitations to screening or cancer testing kits if they are admitted to hospital. They are not routinely invited for screening if they are not registered with a general practitioner (GP). Lack of integrated care means that mental health staff do not know if someone is overdue for a test and cancer screening is often not considered during health promotion. Barriers including information processing problems, the extent to which the screening process aggravates symptoms, poor staff client relationships and travel difficulties vary between individuals. Screening professionals are motivated to help, but may lack time or training to manage mental health needs. Reactive measures are available, but service users must request help which they may find difficult.

CONCLUSIONS

There are specific barriers to cancer screening uptake for mental health service users that prevent equality of care. Interventions that can be personalised are needed at individual, policy and service-delivery levels. Primary and secondary care staff and policy-makers should work together to develop an integrated approach to cancer screening in this population.

Clinical factors related to schizophrenia relapse

OBJECTIVE

Relapses represent one of the main problems of schizophrenia management. This article reviews the clinical factors associated with schizophrenia relapse.

METHODS

A research of the last 22 years of literature data was performed. Two-hundred nineteen studies have been included.

RESULTS

Three main groups of factors are related to relapse: factors associated with pharmacological treatment, add-on psychotherapeutic treatments and general risk factors. Overall, the absence of a maintenance therapy and treatment with first generation antipsychotics has been associated with higher risk of relapse. Further, psychotherapy add-on, particularly with cognitive behaviour therapy and psycho-education for both patients and relatives, has shown a good efficacy for reducing the relapse rate. Among general risk factors, some could be modified, such as the duration of untreated psychosis or the substance misuse, while others could not be modified as male gender or low pre-morbid level of functioning.

CONCLUSION

Several classes of risk factors have been proved to be relevant in the risk of relapse. Thus, a careful assessment of the risk factors here identified should be performed in daily clinical practice in order to individualise the relapse risk for each patient and to provide a targeted treatment in high-risk subjects.

No changes of cardiometabolic and body composition parameters after 6-month add-on treatment with sarcosine in patients with schizophrenia

This study was undertaken with the purpose to determine if there are changes in metabolic parameters during 6-month add-on treatment with sarcosine in patients with schizophrenia. This was a randomized double blind, placebo-controlled and parallel group study. Eligible participants were randomly assigned to receive 2g of sarcosine (n=30) or placebo (n=29). Sarcosine was administered as supplementation to the ongoing antipsychotic treatment. Augmentation with sarcosine had no effect on any of the analyzed cardiometabolic parameters. Also, augmentation with sarcosine had no effect on any of the analyzed body composition parameters. This is the first randomized placebo-controlled study to examine the metabolic safety of sarcosine in patients with schizophrenia. Clinically, this observation is of high importance considering how prevalent are metabolic abnormalities in patients with schizophrenia.

Lower Incidence of End-Stage Renal Disease but Suboptimal Pre-Dialysis Renal Care in Schizophrenia: A 14-Year Nationwide Cohort Study

Schizophrenia is closely associated with cardiovascular risk factors which are consequently attributable to the development of chronic kidney disease and end-stage renal disease (ESRD). However, no study has been conducted to examine ESRD-related epidemiology and quality of care before starting dialysis for patients with schizophrenia. By using nationwide health insurance databases, we identified 54,361 ESRD-free patients with schizophrenia and their age-/gender-matched subjects without schizophrenia for this retrospective cohort study (the schizophrenia cohort). We also identified a cohort of 1,244 adult dialysis patients with and without schizophrenia (1:3) to compare quality of renal care before dialysis and outcomes (the dialysis cohort). Cox proportional hazard models were used to estimate the hazard ratio (HR) for dialysis and death. Odds ratio (OR) derived from logistic regression models were used to delineate quality of pre-dialysis renal care. Compared to general population, patients with schizophrenia were less likely to develop ESRD (HR = 0.6; 95% CI 0.4–0.8), but had a higher risk for death (HR = 1.2; 95% CI, 1.1–1.3). Patients with schizophrenia at the pre-ESRD stage received suboptimal pre-dialysis renal care; for example, they were less likely to visit nephrologists (OR = 0.6; 95% CI, 0.4–0.8) and received fewer erythropoietin prescriptions (OR = 0.7; 95% CI, 0.6–0.9). But they had a higher risk of hospitalization in the first year after starting dialysis (OR = 1.4; 95% CI, 1.0–1.8, P < .05). Patients with schizophrenia undertaking dialysis had higher risk for mortality than the general ESRD patients. A closer collaboration between psychiatrists and nephrologists or internists to minimize the gaps in quality of general care is recommended.

Uric acid levels in patients with schizophrenia on clozapine monotherapy

BACKGROUND

We tested the hypothesis that uric acid levels are higher in subjects with schizophrenia treated with clozapine than in healthy control and they correlate with anthropometric measurements, laboratory tests and results of bioimpedance analysis of body composition.

METHODS

Data for 24 subjects with schizophrenia treated with clozapine and 24 age- and sex-matched healthy volunteers was analyzed.

RESULTS

There was no difference of fasting uric acid concentrations between clozapine and control groups (4.5 ± 1.4 vs. 4.3 ± 1.3 mg/dl, P = 0.87). Regarding the whole group, uric acid levels were significantly higher in men (5.2 ± 1.2 vs. 3.6 ± 0.9, P < 0.001). Uric acid levels correlated with weight (R = 0.58, P = 0.003), body mass index (BMI; R = 0.49, P = 0.01), abdominal circumference (R = 0.45, P = 0.03), waist circumference (R = 0.47, P = 0.02), waist-to-hip ratio (R = 0.42, P = 0.04), insulin (R = 0.50, P = 0.01), homoeostasis model assessment of insulin resistance 2 (HOMA2-IR; R = 0.49, P = 0.01), basal metabolic rate (R = 0.56, P = 0.004), lean body mass (R = 0.55, P = 0.005) and body water (R = 0.55, P = 0.005). There were no significant differences of uric acid levels for smoking status, impaired fasting glucose, abdominal obesity, obesity/overweight and dyslipidemia. Uric acid levels did not correlate with age, duration of clozapine treatment, clozapine dose, leg circumference, systolic blood pressure, diastolic blood pressure, total body fat, triglycerides, total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), homocysteine, corrected calcium, glucose and homoeostasis model assessment of insulin resistance 1 (HOMA1-IR).

CONCLUSIONS

We did not find significant differences in blood uric acid levels between subjects with schizophrenia and controls. Association with weight, BMI, abdominal and waist circumferences, insulin levels and insulin resistance may support uric acid role as an important cardiovascular risk factor. Association with lean weight may explain why men have higher levels of uric acid than women.

Women and schizophrenia

Women's mental health is closely linked to their status in society. This paper outlines the clinical features of women with schizophrenia and highlights the interpersonal and social ramifications on their lives. There is no significant gender difference in the incidence and prevalence of schizophrenia. There is no clear trend in mortality, although suicides seem to be more in women with schizophrenia. In India, women face a lot of problems, especially in relation to marriage, pregnancy, childbirth, and menopause. Most studies have shown better premorbid functioning, and social adjustment for women compared with men. There is a great need to plan for gender-sensitive mental health services targeting the special needs of these women. Women caregivers also deserve due attention.

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

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

Mortality of people suffering from mental illness: a study of a cohort of patients hospitalised in psychiatry in the north of France

BACKGROUND

The mortality of people suffering from psychiatric illnesses is far higher than that of the general population, all categories of diagnosis combined; mortality statistics can be used as an index of quality of care. The aim of this study was to assess the all-cause mortality in psychiatric patients covering all diagnostic groups.

METHODS

The living or deceased status of 4,417 patients of majority age hospitalised in a public mental health establishment between 2004 and 2007 were requested from French National Institute for Statistics and Economic Studies on 1st January 2011. The cause of death of those people who had died was obtained from French National Institute for Health and Medical Research and comparative standardized mortality ratios (SMR) were established from the population in a region of northern France of the same age in 2006.

RESULTS

The study population was made up of 54% men and 46% women, median age 41 and 45 years old, respectively. Four hundred and seventy-three people died during the period studied. The SMR were 421 for men (95% CI 378-470) and 330 for women (95% CI 281-388). The highest SMRs were found in patients aged 35-54, with a 20-time higher mortality risk than the general population of the same age.

CONCLUSION

Our study confirms the considerably higher mortality in psychiatric patients than in general population, particularly in mean age and mostly due to an unnatural cause.

Is schizophrenia associated with an increased risk of chronic kidney disease? A nationwide matched-cohort study

OBJECTIVE

The impact of schizophrenia on vital diseases, such as chronic kidney disease (CKD), has not as yet been verified. This study aims to establish whether there is an association between schizophrenia and CKD.

DESIGN

A nationwide matched cohort study.

SETTING

Taiwan's National Health Insurance Research Database.

PARTICIPANTS

A total of 2338 patients with schizophrenia, and 7014 controls without schizophrenia (1:3), matched cohort for sex, age group, geography, urbanisation and monthly income, between 1 January 2003 and 31 December 2007, based on the International Classifications of Disease Ninth Edition (ICD-9), Clinical Modification codes.

PRIMARY AND SECONDARY OUTCOME MEASURES

After making adjustments for confounding risk factors, a Cox proportional hazards model was used to compare the risk of developing CKD during a 3-year follow-up period from the index date.

RESULTS

Of the 2338-subject case cohort, 163 (6.97%) developed a CKD, as did 365 (5.20%) of the 7014 control participants. Cox proportional hazards regression analysis revealed that patients with schizophrenia were more likely to develop CKD (HR=1.36, 95% CI 1.13 to 1.63; p<0.001). After adjusting for gender, age group, hypertension, diabetes mellitus, hyperlipidaemia, heart disease and non-steroid anti-inflammatory drugs (NSAIDs) usage, the HR for patients with schizophrenia was 1.25 (95% CI 1.04 to 1.50; p<0.05). Neither typical nor atypical antipsychotics was associated an increased risk of CKD in patients with schizophrenia.

CONCLUSIONS

The findings from this population-based retrospective cohort study suggest that schizophrenia is associated with a 25% increase in the risk of developing CKD within only a 3-year follow-up period.

Smoking Cessation in Individuals With Serious Mental Illness: A Randomized Controlled Trial of Two Psychosocial Interventions

OBJECTIVE

Smoking among individuals with serious mental illness is a critical public health problem. Although guidelines recommend bupropion for these smokers, many do not want to use medications for smoking cessation, express ambivalence about identifying a "quit date," and do not have access to behavioral smoking cessation services integrated with mental health care.

METHODS

Individuals with serious mental illness who smoked 10 or more cigarettes per day (N = 178) were randomized to either a multifaceted behavioral group intervention or a supportive group intervention, both of which were integrated within outpatient mental health services at three VA medical centers. Participants attended twice-weekly meetings for 12 weeks, provided information on their smoking at each meeting, and completed baseline and post-treatment assessments conducted by an assessor who was blind to condition. Primary outcomes collected at post-treatment included 1-week abstinence, number of cigarettes smoked per day during the last week, and number of quit attempts during the treatment period. Outcomes examined for a subset of participants who attended at least one intervention meeting (n = 152) included smoking abstinence for 1-, 2-, and 4-week blocks during the treatment period. Analyses conducted on those participants who attended three or more intervention meetings (n = 127) included time to 50% reduction in the number of cigarettes smoked and time to first quit attempt.

RESULTS

Sixteen participants achieved abstinence (11.8%), smoking quantity was significantly reduced (baseline M = 15.2, SD = 9.8 to post-treatment M = 7.5, SD = 7.7, p <.0001), and most reported making a quit attempt (n = 88, 72.7%). There were no differences by study condition on any abstinence or reduction outcomes. Significant reductions in number of cigarettes smoked generally took place within the first two weeks; however, these reductions did not often translate into abstinence.

CONCLUSIONS

Many participants reduced their smoking and sampled quitting during the study. Implementing smoking cessation services in mental health treatment settings is feasible and, if delivered in line with best practices, either a behavioral or a supportive approach can be helpful. Future research should examine ways to facilitate the transition from reduction to abstinence. This study was part of a clinical trial registered as NCT #00960375 at www.clinicaltrials.gov.

Blood serum levels of CART peptide in patients with schizophrenia on clozapine monotherapy

CART (cocaine- and amphetamine-regulated transcript) is an endogenous inhibitor of food intake. We compared fasting serum CART levels in subjects with schizophrenia on clozapine monotherapy (n=24) with sex- and age-matched healthy controls (n=24). CART levels were higher in the clozapine group (262.76±359.91 vs. 90.40±169.90 pg/mL). CART levels were higher in subjects with metabolic syndrome compared to subjects without metabolic syndrome in the clozapine group (415.63±416.93 vs. 122.62±237.17 pg/mL, n=12 and 12, respectively) and in the whole study group (377.73±401.09 vs. 88.58±172.35 pg/mL, n=16 and 32, respectively). In the control group CART levels were higher in subjects with total body fat lower than the target maximum compared to subjects with total body fat below the target maximum (121.71±154.91 vs. 66.32±182.96 pg/mL, n=14 and 10, respectively). CART levels did not correlate with age, weight, BMI, abdominal, waist and hip circumferences, WHR, blood pressure, laboratory tests, clozapine dose, antipsychotic or clozapine treatment duration, body composition, and markers of insulin resistance in the study group. Further studies are required to confirm whether increased levels of circulating CART are compensatory in response to treatment-induced weight gain and abdominal obesity or a primary feature of schizophrenia.

Breast Cancer Stage and Treatment Among Ohio Medicaid Beneficiaries With and Without Mental Illness

PURPOSE

There is a dearth of studies on cancer outcomes in individuals with mental illness. We compared breast cancer outcomes in Medicaid beneficiaries with and without mental illness.

METHODS

Using records from the 1996 to 2005 Ohio Cancer Incidence Surveillance System (OCISS) and Medicaid files, we identified fee-for-service women age < 65 years diagnosed with incident invasive breast cancer who had enrolled in Medicaid ≥ 3 months before cancer diagnosis (n = 2,177). We retrieved cancer stage, patient demographics, and county of residence from the OCISS. From Medicaid claims data, we identified breast cancer treatment based on procedure codes and mental illness status based on diagnosis codes, prescription drugs dispensed, and service codes. We developed logistic regression models to examine the association between mental illness, cancer stage, and treatment for locoregional disease, adjusting for potential confounders.

RESULTS

Women with mental illness represented 60.2% of the study population. Adjusting for potential confounders, women with mental illness were less likely than those without mental illness to have unstaged or unknown-stage cancer (adjusted odds ratio [OR], 0.61; 95% CI, 0.44 to 0.86; P = .005) or to be diagnosed with distant-stage cancer (adjusted OR, 0.59; 95% CI, 0.40 to 0.85; P = .005). We observed no difference by mental illness status in receipt of definitive treatment (adjusted OR, 1.04; 95% CI, 0.84 to 1.29; P = .08).

CONCLUSION

Among Ohio Medicaid beneficiaries, women with mental illness did not experience disparities in breast cancer stage or treatment of locoregional disease. These findings may reflect the equalizing effects of Medicaid through vulnerable individuals' improved access to both physical and mental health care.

Blood levels of glucose and insulin and insulin resistance in patients with schizophrenia on clozapine monotherapy

OBJECTIVE

We tested the hypothesis that fasting blood glucose and insulin levels are higher in schizophrenic subjects on clozapine monotherapy compared with healthy controls and they correlate with anthropometric measurements, laboratory tests and body composition.

METHODS

Data for 24 subjects with schizophrenia treated with clozapine and 24 age- and sex-matched healthy volunteers was analyzed.

RESULTS

Patients taking clozapine had higher fasting levels of glucose (103.5±31.6 vs. 87.8±11.7mg/dL, z=-2.03, p=0.04), there was no difference for insulin concentrations and markers of insulin resistance. In the clozapine group glucose levels correlated with clozapine dose (R=-0.43, p=0.03), while insulin levels correlated with weight (R=0.66, p<0.001), body mass index (R=0.54, p=0.007), abdominal (R=0.53, p=0.007) and waist (R=0.43, p=0.04) circumference, total body fat (R=0.51, p=0.01), and uric acid levels (R=0.50, p=0.01). In the clozapine group insulin levels were lower in subjects with body mass index <25kg/m(2) (7.0±3.3 vs. 13.4±8.8μU/mL, p=0.04) and in subjects without abdominal obesity (6.3±2.4 vs. 13.3±8.6μU/mL, p=0.03).

CONCLUSIONS

We found higher blood glucose levels in subjects taking clozapine and no differences in blood insulin levels between subjects with schizophrenia and controls. Associations between blood insulin levels and abdominal/waist circumferences support the role of abdominal obesity as an important risk factor of insulin resistance.

Predictors of natural and unnatural mortality among patients with personality disorder: evidence from a large UK case register

BACKGROUND

People with personality disorder have reduced life expectancy, yet, within this population, little is known about the clinical predictors of natural and unnatural deaths. We set out to investigate this, using a large cohort of secondary mental health patients with personality disorder.

METHODS

We identified patients with an ICD-10 diagnosis of personality disorder, aged ≥15 years in a large secondary mental healthcare case register. The case register was linked to national mortality tracing. Using Cox regression, we modelled the effect of a number of pre-specified clinical variables on all-cause, natural cause and unnatural cause mortality.

FINDINGS

2,440 patients were identified. Eighty-five deaths (3.5% of cohort) occurred over a 5-year observation period, of which over 50% were from natural causes. All-cause mortality was associated with alcohol or drug use (adjusted Hazard Ratio [aHR] 2.3; 95% CI 1.3-4.1), physical illness (aHR 1.9; 95% CI 1.0-3.6), and functional impairment (aHR 1.9; 95% CI 1.0-3.6). Natural cause mortality was associated with mild problems of alcohol or drug use (aHR 3.4; 95% CI 1.5-7.4), and physical illness (aHR 2.4; 95% CI 1.0-5.6). Unnatural cause mortality was associated only with severe alcohol or drug use (aHR 3.1; 95% CI 1.3-7.3).

INTERPRETATION

Alcohol and drug use, physical illness, and functional impairment are predictors of mortality in individuals with personality disorder. Clinicians should be aware of the existence of problems in these domains, even at mild levels, when assessing the needs of patients with personality disorder.

Is somatic health screening in patients with severe mental illness of added value?

PURPOSE

To evaluate the added value of somatic screening for patients with severe mental illness over regular care.

DESIGN AND METHODS

We compared the information on somatic health problems collected by screening with the general practitioner (GP) files (n = 118).

FINDINGS

The mean number of somatic health problems detected with somatic health screening was significantly higher than those noted in GP records (p < .01).

PRACTICE IMPLICATIONS

Somatic health screening is an addition to the care provided by the GP. Advanced mental health nurses can play a key role in somatic health screening and initiating further cooperation and communication of GP and mental health care.

Physical comorbidity and its relevance on mortality in schizophrenia: a naturalistic 12-year follow-up in general hospital admissions

Schizophrenia is a major psychotic disorder with significant comorbidity and mortality. Patients with schizophrenia are said to suffer more type-2 diabetes mellitus (T2DM) and diabetogenic complications. However, there is little consistent evidence that comorbidity with physical diseases leads to excess mortality in schizophrenic patients. Consequently, we investigated whether the burden of physical comorbidity and its relevance on hospital mortality differed between patients with and without schizophrenia in a 12-year follow-up in general hospital admissions. During 1 January 2000 and 31 June 2012, 1418 adult patients with schizophrenia were admitted to three General Manchester NHS Hospitals. All comorbid diseases with a prevalemce ≥1% were compared with those of 14,180 age- and gender-matched hospital controls. Risk factors, i.e. comorbid diseases that were predictors for general hospital mortality were identified using multivariate logistic regression analyses. Compared with controls, schizophrenic patients had a higher proportion of emergency admissions (69.8 vs. 43.0%), an extended average length of stay at index hospitalization (8.1 vs. 3.4 days), a higher number of hospital admissions (11.5 vs. 6.3), a shorter length of survival (1895 vs. 2161 days), and a nearly twofold increased mortality rate (18.0 vs. 9.7%). Schizophrenic patients suffered more depression, T2DM, alcohol abuse, asthma, COPD, and twenty-three more diseases, many of them diabetic-related complications or other environmentally influenced conditions. In contrast, hypertension, cataract, angina, and hyperlipidaemia were less prevalent in the schizophrenia population compared to the control population. In deceased schizophrenic patients, T2DM was the most frequently recorded comorbidity, contributing to 31.4% of hospital deaths (only 14.4% of schizophrenic patients with comorbid T2DM survived the study period). Further predictors of general hospital mortality in schizophrenia were found to be alcoholic liver disease (OR = 10.3), parkinsonism (OR = 5.0), T1DM (OR = 3.8), non-specific renal failure (OR = 3.5), ischaemic stroke (OR = 3.3), pneumonia (OR = 3.0), iron-deficiency anaemia (OR = 2.8), COPD (OR = 2.8), and bronchitis (OR = 2.6). There were no significant differences in their impact on hospital mortality compared to control subjects with the same diseases except parkinsonism which was associated with higher mortality in the schizophrenia population compared with the control population. The prevalence of parkinsonism was significantly elevated in the 255 deceased schizophrenic patients (5.5 %) than in those 1,163 surviving the study period (0.8 %, OR = 5.0) and deceased schizophrenic patients had significantly more suffered extrapyramidal symptoms than deceased control subjects (5.5 vs. 1.5 %). Therefore patients with schizophrenia have a higher burden of physical comorbidity that is associated with a worse outcome in a 12-year follow-up of mortality in general hospitals compared with hospital controls. However, schizophrenic patients die of the same physical diseases as their peers without schizophrenia. The most relevant physical risk factors of general hospital mortality are T2DM, COPD and infectious respiratory complications, iron-deficiency anaemia, T1DM, unspecific renal failure, ischaemic stroke, and alcoholic liver disease. Additionally, parkinsonism is a major risk factor for general hospital mortality in schizophrenia. Thus, optimal monitoring and management of acute T2DM and COPD with its infectious respiratory complications, as well as the accurate detection and management of iron-deficiency anaemia, of diabetic-related long-term micro- and macrovascular complications, of alcoholic liver disease, and of extrapyramidal symptoms are of utmost relevance in schizophrenia.

Homocysteine levels in patients with schizophrenia on clozapine monotherapy

We tested the hypothesis that homocysteine levels are higher in blood of schizophrenic subjects on clozapine monotherapy than in healthy controls and they correlate with anthropometric measurements, laboratory tests and results of bioimpedance analysis of body composition. Data for 24 subjects with schizophrenia treated with clozapine and 24 age- and sex-matched healthy volunteers was analyzed. Regarding the whole group, homocysteine levels were significantly higher in men (17.0 ± 3.4 vs. 12.1 ± 4.0 μmol/L, p = 0.009). Homocysteine levels correlated with waist circumference (R = 0.58, p = 0.003), waist-to-hip ratio (R = 0.57, p = 0.003), basal metabolic rate (R = 0.48, p = 0.01), lean body mass [kg] (R = 0.53, p = 0.008), body water [L] (R = 0.53, p = 0.008) and triglycerides (R = 0.57, p = 0.003). There were no significant differences of homocysteine levels for impaired fasting glucose, abdominal obesity, obesity/overweight, and dyslipidemia. Homocysteine levels did not correlate with age, treatment duration, clozapine dose, weight, body mass index, abdominal circumference, blood pressure, total body fat, cholesterol, high density lipoproteins, low density lipoproteins, uric acid, calcium, glucose, insulin, homoeostasis model assessment of insulin resistance 1, and homoeostasis model assessment of insulin resistance 2. We did not find significant differences in blood homocysteine levels between subjects with schizophrenia and controls. Association with waist circumference may support homocysteine role as an important cardiovascular risk factor. Association with lean weight may explain why men have higher levels of homocysteine than women.

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.

Reexamining the association between fertility and longevity: testing the disposable soma theory in a modern human sample of twins

The disposable soma theory proposes a trade-off between fertility and longevity but existing findings on this association have been mixed. This study used data from 15,622 twins born between 1901 and 1925 ascertained from the population-based Swedish Twin Registry to test the child-longevity association and whether it is accounted for by individual-level factors or by genetic and environmental factors shared by family members. Based on survival analysis, both women and men with children had significantly longer survival relative to the childless, with a slightly higher relative advantage in men. Adjustments for demographic factors and cotwin fertility did not mediate the parenting-survival association, indicating that this association is attributable to individual-level factors associated with fertility rather than family-level environmental or genetic factors shared by cotwins. These results, derived from a large, population-based sample, are inconsistent with the disposable soma theory as applied to modern human populations.

Serum levels of magnesium in sudden cardiac deaths among people with schizophrenia: hit or miss?

Schizophrenia is a devastating mental disorder, affecting cognitive, emotional, and behavioral conditions, ability to work, social functioning, family stability and self-esteem of the patient. People with schizophrenia show a two to three-fold increased risk to die prematurely than those without schizophrenia. Understanding the mechanisms behind sudden cardiac death in individuals with schizophrenia is a key to prevention. Although different mechanisms may be related, there are clear indications that cardiac abnormalities play a potential role. Some antipsychotics may be associated with cardiovascular adverse events, e.g., QT interval prolongation, metabolic dysfunction, blood pressure and heart rate alterations. Magnesium (Mg) abnormalities may lead to various morphological and functional dysfunctions of the heart and low levels of serum Mg are considered to be at high risk for sudden cardiac death. As low serum Mg is associated with detrimental effects on the heart and that antipsychotic-treated schizophrenia patients frequently affect the heart rate, possibly, these factors together must change the normal functioning of the heart and consequently being able to culminate in a catastrophic event.