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

Genetically Informed Study Highlights Income-Independent Effect of Schizophrenia Liability on Mental and Physical Health

BACKGROUND AND HYPOTHESIS

Individuals with schizophrenia (SCZ) suffer from comorbidities that substantially reduce their life expectancy. Socioeconomic inequalities could contribute to many of the negative health outcomes associated with SCZ.

STUDY DESIGN

We investigated genome-wide datasets related to SCZ (52 017 cases and 75 889 controls) from the Psychiatric Genomics Consortium, household income (HI; N = 361 687) from UK Biobank, and 2202 medical endpoints assessed in up to 342 499 FinnGen participants. A phenome-wide genetic correlation analysis of SCZ and HI was performed, also assessing whether SCZ genetic correlations were influenced by the HI effect on SCZ. Additionally, SCZ and HI direct effects on medical endpoints were estimated using multivariable Mendelian randomization (MR).

STUDY RESULTS

SCZ and HI showed overlapping genetic correlations with 70 traits (P < 2.89 × 10-5), including mental health, substance use, gastrointestinal illnesses, reproductive outcomes, liver diseases, respiratory problems, and musculoskeletal phenotypes. SCZ genetic correlations with these traits were not affected by the HI effect on SCZ. Considering Bonferroni multiple testing correction (P < 7.14 × 10-4), MR analysis indicated that SCZ and HI may affect medical abortion (SCZ OR = 1.07; HI OR = 0.78), panic disorder (SCZ OR = 1.20; HI OR = 0.60), personality disorders (SCZ OR = 1.31; HI OR = 0.67), substance use (SCZ OR = 1.2; HI OR = 0.68), and adjustment disorders (SCZ OR = 1.18; HI OR = 0.78). Multivariable MR analysis confirmed that SCZ effects on these outcomes were independent of HI.

CONCLUSIONS

The effect of SCZ genetic liability on mental and physical health may not be strongly affected by socioeconomic differences. This suggests that SCZ-specific strategies are needed to reduce negative health outcomes affecting patients and high-risk individuals.

EPA guidance on lifestyle interventions for adults with severe mental illness: A meta-review of the evidence

There is growing interest in lifestyle interventions as stand-alone and add-on therapies in mental health care due to their potential benefits for both physical and mental health outcomes. We evaluated lifestyle interventions focusing on physical activity, diet, and sleep in adults with severe mental illness (SMI) and the evidence for their effectiveness. To this end, we conducted a meta-review and searched major electronic databases for articles published prior to 09/2022 and updated our search in 03/2024. We identified 89 relevant systematic reviews and assessed their quality using the SIGN checklist. Based on the findings of our meta-review and on clinical expertise of the authors, we formulated seven recommendations. In brief, evidence supports the application of lifestyle interventions that combine behavioural change techniques, dietary modification, and physical activity to reduce weight and improve cardiovascular health parameters in adults with SMI. Furthermore, physical activity should be used as an adjunct treatment to improve mental health in adults with SMI, including psychotic symptoms and cognition in adults with schizophrenia or depressive symptoms in adults with major depression. To ameliorate sleep quality, cognitive behavioural informed interventions can be considered. Additionally, we provide an overview of key gaps in the current literature. Future studies should integrate both mental and physical health outcomes to reflect the multi-faceted benefits of lifestyle interventions. Moreover, our meta-review highlighted a relative dearth of evidence relating to interventions in adults with bipolar disorder and to nutritional and sleep interventions. Future research could help establish lifestyle interventions as a core component of mental health care.

The Association Between Antipsychotics and Bone Fragility: An Updated Comprehensive Review

BACKGROUND

Antipsychotic drugs appear to be related to reduced bone mineral density (BMD). We conducted a narrative review to collect the available literature investigating the relationship between antipsychotic use and bone fragility.

METHODS

A review of the published literature was conducted and reported through PubMed/Scopus/Cochrane libraries. We included studies using any antipsychotic treatment where the bone metabolism, osteoporosis, and/or risk of fractures has been assessed.

RESULTS

After screening 1707 items, we finally included 15 papers. A total of 3245 initial patients were identified, of whom 1357 patients with a mean age of 43.8 years underwent antipsychotic treatment and were analyzed. The mean antipsychotic treatment duration of the treated group was 15.8 ± 13.9 years. Among the included studies, two reported a statistically significant difference in lumbar BMD reduction between the antipsychotic exposed group and the control group. Femoral neck BMD levels had been reported in four of the case-control studies; two reported a statistically significant difference in femoral neck BMD reduction between the antipsychotic exposed group and the control group.

CONCLUSIONS

Prolonged use of antipsychotic treatment seems to be associated with an increased risk of reduced BMD, and, consequentially, with an augmented risk of bone fragility and fractures. This effect is not limited to vulnerable groups, such as those with significant medical comorbidities, the elderly, and postmenopausal women, but may also apply to anyone using antipsychotics in the long-term. Clinicians' awareness of antipsychotic prescriptions should optimize their potential while reducing this risk.

Longitudinal relationships among number of chronic diseases, depression, and anxiety: A cross-lagged model analyses

BACKGROUND

Research is increasingly highlighting the intricate relationship between mental and physical health. However, longitudinal studies investigating the interplay between chronic diseases (CDs), depression and anxiety are still relatively scarce. This study aimed to delve into the longitudinal connections among these variables.

METHODS

This study conducted a 4-year prospective survey involving 486 participants from rural communities in Shandong Province, China. The relationships among these variables were analyzed using multiple linear regression, cross-lagged path analysis, and multiple-group analysis.

RESULTS

Our analysis revealed that the number of CDs reported at wave 1 significantly predicted anxiety levels (β = 0.126, p < .01) at wave 2, while depression symptoms also predicted anxiety (β = 0.220, p < .01) at wave 2. Furthermore, anxiety levels at wave 1 significantly predicted both the number of CDs (β = 0.219, p < .01) and depression symptoms (β = 0.160, p < .05) at wave 2. However, the study did not find support for a relationship between CDs and depression.

CONCLUSION

The study uncovered a bidirectional association between CDs and anxiety, depression and anxiety, but found no direct longitudinal relationship between CDs and depression. Research has indicated that CDs indirectly affect depression through anxiety.

Correlations Between Psychiatric Disorders and Perioperative Outcomes After Lumbar Fusions: An Analysis of the National Inpatient Sample (2009-2020)

BACKGROUND

Preoperative diagnoses of psychiatric disorders have a demonstrated association with higher rates of perioperative complications. However, recent studies examining the influence of psychiatric disorders on lumbar fusion outcomes are scarce. Our objective was to determine the relationship between the most common psychiatric disorders and perioperative outcomes after lumbar fusion.

METHODS

Demographic and perioperative data for patients who underwent lumbar spine fusion between 2009 and 2020 were collected from the National Inpatient Sample database. These patients were divided into 2 groups: those who were previously diagnosed with depression, bipolar disorder, or anxiety, and those who were not. Univariable and multivariable linear and logistic regression models were utilized to analyze the data.

RESULTS

Of 2,877,241 patients identified in the National Inpatient Sample database as having undergone lumbar fusion, 647,951 had diagnosed psychiatric disorders, and the remaining 2,229,290 were the unaffected cohort. On multivariable analysis, patients diagnosed with psychiatric disorders had significantly increased odds of respiratory (odds ratio [OR]:1.09) and urinary (OR: 1.08) complications and experienced higher odds of mechanical injury (OR: 1.27), fusion disorders (OR: 1.62), dural tears (OR: 1.08), postprocedure anemia (OR: 1.29), longer hospital stays, and higher total costs (P < 0.001). Conversely, patients with psychiatric disorders had lower odds of neurologic injury (OR: 0.8) and wound complications (OR: 0.91) (P < 0.05).

CONCLUSIONS

Patients with depression, bipolar disorder, or anxiety exhibited higher rates of certain types of complications. However, they appeared to have fewer neurological injuries and wound complications than patients without these psychiatric disorders. These findings highlight the necessity for additional studies to elucidate underlying reasons for these disparities.

Alterations in regional homogeneity in schizophrenia patients comorbid with metabolic syndrome treated with risperidone or clozapine

The neuroimaging mechanisms that arise in patients with schizophrenia and comorbid metabolic syndrome (MetS) remain poorly understood. This study was devised to examine potential alterations in regional homogeneity (ReHo) that arise in schizophrenia patients with comorbid MetS undergoing risperidone or clozapine treatment. In total, 43 schizophrenia patients undergoing risperidone or clozapine treatment were enrolled in this study, of whom 20 had comorbid MetS (SZ-MetS) while 23 did not (SZ-nMetS). In addition, 28 sex- and age-matched healthy controls (HCs) were analyzed. Analyses of covariance (ANCOVA) were used to compare ReHo in this study, utilizing age, sex, and years of education as covariates, with subsequent post hoc testing. Correlations between brain regions showing differences between groups of patients with schizophrenia and MetS-related indicators were also assessed. Relative to HCs, patients in both the SZ-MetS and SZ-nMetS groups exhibited reductions in ReHo in the right postcentral gyrus, left superior parietal gyrus, and left middle occipital gyrus. A decrease in ReHo was also evident in the left calcarine fissure and surrounding cortex and the right angular gyrus of patients in the SZ-MetS group, while the SZ-nMetS group exhibited reductions in ReHo in the left superior occipital gyrus and the right precuneus, together with an increase in ReHo in the right inferior orbitofrontal gyrus. Compared to the SZ-nMetS group, the SZ-MetS group exhibited a reduction in ReHo in the right inferior orbitofrontal gyrus. The ReHo of the right inferior orbitofrontal gyrus was significantly negatively correlated with BMI, waist circumference, and hip circumference in the SZ-MetS and SZ-nMetS groups. A reduction in ReHo in the right inferior orbitofrontal gyrus may thus be related to MetS in schizophrenia patients undergoing treatment. The findings may provide an imaging basis for brain alterations in patients with schizophrenia combined with MetS and provide a new insight into the neuroimaging mechanisms associated with MetS in patients with schizophrenia.

Measuring the effects of ketogenic diet on neuropsychiatric disorder: A scoping review

OBJECTIVE

This scoping review aims to examine the available literature on the ketogenic diet's (KD) efficiency as a potential therapeutic intervention for various neuropsychiatric disorders.

INTRODUCTION

The KD is a high-fat, low-carbohydrate diet that has been studied for its potential benefits in managing neuropsychiatric disorders. However, the extent of its effectiveness across a spectrum of these conditions remains unclear.

INCLUSION CRITERIA

The study designs considered eligible encompassed randomized and non-randomized controlled trials, retrospective and prospective observational studies, and comparative effectiveness assessments. The criteria for including each study were specifically related to neuropsychiatric disorders, referring to the DSM-5 coding guidelines.

METHODS

A systemic search was performed by an experienced reference librarian across multiple databases to pinpoint studies relevant to the influence of the ketogenic diet on neuropsychiatric disorders. All relevant articles were included that ranged over the last thirteen years. All relevant records identified were compiled into the Covidence systematic review software.

RESULTS

A total of 30 studies were reviewed, which reported effects of the KD on neuropsychiatric disorders, including improvements in Global Developmental Delay, Childhood Autism, Attention Deficit/Hyperactivity Disorder (ADHD) symptoms, psychotic symptoms, Bipolar and Related Disorders, Depressive Disorder symptoms, anxiety symptoms, eating disorders, Substance-Related and Addictive Disorders, Major and Mild Neurocognitive Disorders, and Seizure Disorders.

CONCLUSION

The KD may serve as a promising therapeutic intervention for various neuropsychiatric disorders. However, the evidence is heterogeneous, and further rigorous research is needed to establish the KD as a standard treatment for these disorders and to understand the underlying mechanisms of its effects.

IMPLICATIONS FOR PRACTICE

This review underscores the need for healthcare professionals to consider the potential benefits and limitations of the KD when managing patients with neuropsychiatric disorders. It also highlights the importance of individualized treatment plans based on the specific needs and responses of each patient.

Changes in Exercise Performance in Patients During a 6-Week Inpatient Psychiatric Rehabilitation Program and Associated Effects on Depressive Symptoms

Background/Objectives: The impact of exercise on affective disorders has been demonstrated in various studies. However, almost no data are available on performance effects. Therefore, this study investigated exercise performance related to the severity of depression symptoms in a pre-post within-subjects design in a 6-week standard inpatient psychiatric rehabilitation program. Methods: A total of 53 individuals (20 female; mean age, 40.98 ± 11.33) with a primary diagnosis of depression performed a cardiopulmonary exercise test (CPX) to obtain maximal oxygen uptake (VO2max), maximal power output (Pmax), and the first and second ventilatory threshold (VT1, VT2) at the start and the end of the rehabilitation. Degree of depression was assessed by Becks Depression Inventory (BDI) and the Brief Symptom Inventory test (BSI). Overall activity was measured by accelerometer step-counts. Results: Mean total step-count per day during rehabilitation was high (12,586 ± 2819 steps/day). Patients' BDI and BSI at entry were 21.6 ± 8.83 and 65.1 ± 6.8, respectively, and decreased significantly (p < 0.001) following rehabilitation, to 10.1 ± 9.5 and 54.5 ± 11.3, respectively. Pmax and VO2max increased significantly (p < 0.001) from entry values (182.6 ± 58.7 W, 29.74 ± 5.92 mL·kg-1·min-1) following rehabilitation: by 11.91 ± 12.09 W and 1.35 ± 2.78 mL·kg-1·min-1, respectively. VT1 and VT2 showed a similar behavior. An increase in physical performance could predict improvement in BDI (R2 = 0.104, F(1,48) = 5.582, p = 0.022) but not in BSI. Conclusions: The program was associated with improved mental health status in all patients and increased performance in the majority of patients, although increases were small. Since improvements in exercise performance may be positively related to depression symptoms and comorbidities, it is recommended to individualize and tailor exercise programs, which could yield larger effects.

The epigenetic mechanism of metabolic risk in bipolar disorder

Bipolar disorder (BD) is a complex and severe mental illness that causes significant suffering to patients. In addition to the burden of depressive and manic symptoms, patients with BD are at an increased risk for metabolic syndrome (MetS). MetS includes factors associated with an increased risk of atherosclerotic cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM), which may increase the mortality rate of patients with BD. Several studies have suggested a link between BD and MetS, which may be explained at an epigenetic level. We have focused on epigenetic mechanisms to review the causes of metabolic risk in BD.

Efficacy and safety of lumateperone for bipolar depression and schizophrenia: a systematic review and meta-analysis

This study aimed to evaluate the efficacy and safety of lumateperone in treating bipolar disorder and schizophrenia. A comprehensive literature search was conducted across multiple databases and websites from inception to July 16, 2024, to identify both published and unpublished randomized controlled trials (RCTs). Meta-analyses were performed using random-effects or fixed-effects models depending on statistical heterogeneity. Relative risks (RRs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs) were used to summarize the effects. Out of 931 records screened, 7 RCTs (four focusing on bipolar depression and 3 on schizophrenia) were eligible for inclusion. Lumateperone was efficacious in reducing depressive symptoms in bipolar depression (SMDs = -0.36, 95% CI: -.59 to -.13). In treating schizophrenia, lumateperone exhibited a lower combined SMD of -0.14 (95% CI: -.27 to 0, P = .051, I² = 49.6%), showing no significant difference from the placebo group, although the P-value approached significance. The lumateperone group showed significantly higher response rates compared with placebo in both bipolar depression (RRs = 1.27, 95% CI = 1.07 to 1.51) and schizophrenia (RRs = 1.44, 95% CI = 1.12 to 1.86). Common treatment-emergent adverse events included somnolence, dry mouth, dizziness, nausea, and headache (RRs = 1.30 to 3.29). Importantly, lumateperone did not significantly increase extrapyramidal symptoms (EPS, RRs = 1.46, 95% CI = .84 to 2.53). Lumateperone is effective in treating bipolar depression but does not significantly reduce symptom severity in schizophrenia. It has a favorable safety and tolerability profile. However, caution is warranted in interpreting these findings due to the limited number of studies included.

Adaptive Hyperactivity and Biomarker Exploration: Insights from Elders in the Blue Zone of Sardinia

Background/Objectives: Adaptive hyperactivity characterized by increased activity levels and novelty-seeking traits without mood disorders is prevalent among older adults in Sardinia's "blue zone," an area with high longevity. This study aims to evaluate the adaptive nature of hyperactivity concerning quality of life, social rhythms, and mood symptoms in individuals from this region, particularly among elderly adults over 80. Methods: This observational cross-sectional study included adults and older adults over 80 from Sardinia's blue zone. This study included a sample of patients followed at the Center for Consultation Psychiatry and Psychosomatics for Bipolar Disorder of the University Hospital of Cagliari and a homogeneous comparison sample of patients without psychiatric pathologies, referred to the Dermatology Clinic of the same hospital, for a period of 6 months, from February to August 2024. The general sample, divided into two parts-cases, represented by patients with psychiatric pathology, and controls, patients without psychiatric pathology-was divided in turn into three sub-groups: "adults" (18-64 years), young elders (65-79), and old elders (over 80 years). The participants underwent psychiatric interviews and completed the Mood Disorder Questionnaire (MDQ), Patient Health Questionnaire (PHQ-9), SF-12, and Brief Social Rhythm Scale (BSRS). Data were compared with national and regional normative data. Results: Older adults in the blue zone demonstrated higher MDQ positivity (22.58%) compared to the national averages (0.87%), without corresponding increases in dysregulated rhythms, depressive symptoms, or reduced quality of life. Younger old persons (65-79 years) showed increased rhythm dysregulation (BSRS score: 20.64 ± 7.02) compared to adults (17.40 ± 6.09, p = 0.040), but this trend was not observed in the oldest group (80+ years). No significant differences were found in the CH3SH and (CH3)2S levels between groups. Conclusions: The hyperactivity observed in older adults from Sardinia's blue zone appears adaptive and not linked to social rhythm dysregulation, depressive symptoms, or a diminished quality of life, suggesting resilience factors which may contribute to longevity. These findings support the potential classification of such hyperactivity as beneficial rather than pathological, warranting further research into biomarkers and psychoeducational interventions to prevent the onset of bipolar disorders in predisposed individuals.

Assessing the Risk of QT Prolongation in a Psychiatric Inpatient Cohort: A Retrospective Cross-Sectional Study

BACKGROUND

QT prolongation is a potential serious adverse drug reaction, and assessing the risk of QT-prolonging drugs is routinely included in psychotropic medication reviews. However, the actual clinical benefits of such assessments are unknown. We investigate whether QT prolongation (QTc value > 480 ms) manifests in psychiatric inpatients at risk of QT prolongation as identified by assessing drug regimens. Secondly, we test the predictive value of well-known risk factors for QT prolongation.

RESULTS

The median patient age was 49 years (IQR 34-64) for patients treated with a median of nine drugs (IQR 6-12) and a median QT-prolonging drug sum of three daily defined dosages (IQR 1.88-4.76). We extracted 290 ECGs for patients where pharmacist-led-medication reviews (PMRs) identified an increased risk of QT prolongation and 190 ECGs for patients with no such risk, identifying 33 cases of verified QT prolongation equally distributed between groups. Unadjusted regression analysis revealed that advanced age (OR 3.27 CI 95% 1.60-6.84) and cardiovascular comorbidity (OR 3.53 CI 95% 1.71-7.29) were associated with manifest QT prolongation, while the QT-prolonging drug load was not.

METHODS

We reviewed electronic health records (EHRs) of 799 psychiatric inpatients exposed to PMRs made from 1 September 2016 to 31 December 2018 in Region Zealand Denmark.

CONCLUSIONS

Patients at risk of QT prolongation as identified by drug reviews rarely manifests with actual QT prolongation. Non-pharmacological risk factors seem to be better predictors for identifying patients with QT prolongation.

Physical health challenges faced by elders with severe mental illness: population-based retrospective cohort study

BACKGROUND

Severe mental illness (SMI), which includes schizophrenia, schizoaffective disorder and bipolar disorder, has profound health impacts, even in the elderly.

AIMS

To evaluate relative risk of hospital admission and length of hospital stay for physical illness in elders with SMI.

METHOD

To construct a population-based retrospective cohort observed from April 2007 to March 2016, data from a case registry with full but de-identified electronic health records were retrieved for patients of the South London and Maudsley NHS Foundation Trust, the single secondary mental healthcare service provider in south-east London. We compared participants with SMI aged >60 years old with the general population of the same age and residing in the same areas through data linkage by age-, sex- and fiscal-year-standardised admission ratios (SARs) for primary diagnoses at hospital discharge. Furthermore, we compared the duration of hospital stay with an age-, sex- and cause-of-admission-matched random group by linear regression for major causes of admission.

RESULTS

In total, records for 4175 older people with SMI were obtained, relating to 10 342 admission episodes, showing an overall SAR for all physical illnesses of 5.15 (95% CI: 5.05, 5.25). Among the top causes of admission, SARs ranged from 3.87 for circulatory system disorders (ICD-10 codes: I00-I99) to 6.99 for genitourinary system or urinary conditions (N00-N39). Specifically, the diagnostic group of 'symptoms, signs and findings, not elsewhere classified' (R00-R99) had an elevated SAR of 6.56 (95% CI: 6.22, 6.90). Elders with SMI also had significantly longer hospital stays than their counterparts in the general population, especially for digestive system illnesses (K00-K93), after adjusting for confounding.

CONCLUSIONS

Poorer overall physical health and specific patterns were identified in elders with SMI.

Risk of renal impairment in atypical antipsychotics: a systematic review and meta-analysis

PURPOSE

Atypical antipsychotics are associated with several adverse effects including metabolic syndrome, weight gain, QTc interval prolongation, and extrapyramidal effects. This study aims to investigate the risk of renal impairment in patients receiving atypical antipsychotics.

METHODS

A systematic literature search was conducted via PubMed and Ovid SP and Web of Science to retrieve studies reporting the risk of renal impairment in patients receiving atypical antipsychotic treatment. The pooled risk ratio (RR) of renal impairment and the subgroup analysis was calculated using the random-effects generic inverse variance method in Cochrane Review Manager.

RESULTS

A total of 4 studies involving 514,710 patients (221, 873 patients on atypical antipsychotics/CKD and 292, 837 controls) were included in this meta-analysis. Patients on atypical antipsychotics exhibited an increased risk of renal impairment, with a pooled risk ratio of 1.34 (95%CI 1.23-1.47). Subgroup analysis demonstrated that atypical antipsychotic use was associated with an increased risk of both acute kidney injury (AKI) (RR 1.51, 95%CI 1.34-1.71) and chronic kidney disease (CKD) (RR: 1.23, 95%CI 1.12-1.35).

CONCLUSION

Patients receiving atypical antipsychotics have an increased risk of renal impairment. Quetiapine carries the highest risk of renal impairment encompassing both AKI and CKD.

Poor muscle health and cardiometabolic risks associated with antidepressant treatment

OBJECTIVE

This study aims to investigate whether antidepressant users display differences in fat distribution and muscle composition relative to non-users and to explore risk factors for developing cardiovascular disease (CVD) and type 2 diabetes.

METHODS

The study used quantitative adipose and muscle tissue measures derived from magnetic resonance imaging data from UK Biobank (N = 40,174). Fat distribution and muscle composition of selective serotonin reuptake inhibitor (SSRI) and tricyclic antidepressant (TCA) users were compared with sex-, age-, and BMI-matched control individuals. Cox regression models were used to test for increased risk of developing CVD and type 2 diabetes.

RESULTS

SSRI users had more visceral fat, smaller muscle volume, and higher muscle fat infiltration compared with matched control individuals. Female users showed a larger increase in BMI over time compared with male users. However, male users displayed an unhealthier body composition profile. Male SSRI users also had an increased risk of developing CVD. Both male and female TCA users showed lower muscle volume and an increased risk of developing type 2 diabetes.

CONCLUSIONS

Adverse changes in body composition of antidepressant users are not captured by tracking the body weight or the BMI of the patients. These changes may lead to a worsened cardiometabolic risk profile.

Leveraging the Genetics of Psychiatric Disorders to Prioritize Potential Drug Targets and Compounds

Background

Genetics has the potential to inform biologically relevant drug treatment and repurposing which may ultimately improve patient care. In this study, we combine methods which leverage the genetics of psychiatric disorders to prioritize potential drug targets and compounds.

Methods

We used the largest available genome-wide association studies, in European ancestry, of four psychiatric disorders [i.e., attention deficit hyperactivity disorder (ADHD), bipolar disorder, depression, and schizophrenia] along with genes encoding drug targets. With this data, we conducted drug enrichment analyses incorporating the novel and biologically specific GSA-MiXeR tool. We then conducted a series of molecular trait analyses using large-scale transcriptomic and proteomic datasets sampled from brain and blood tissue. This included the novel use of the UK Biobank proteomic data for a proteome-wide association study of psychiatric disorders. With the accumulated evidence, we prioritize potential drug targets and compounds for each disorder.

Findings

We reveal candidate drug targets shared across multiple disorders as well as disorder-specific targets. Drug prioritization indicated genetic support for several currently used psychotropic medications including the antipsychotic paliperidone as the top ranked drug for schizophrenia. We also observed genetic support for other commonly used psychotropics (e.g., clozapine, risperidone, duloxetine, lithium, and valproic acid). Opportunities for drug repurposing were revealed such as cholinergic drugs for ADHD, estrogens for depression, and gabapentin enacarbil for schizophrenia. Our findings also indicate the genetic liability to schizophrenia is associated with reduced brain and blood expression of CYP2D6, a gene encoding a metabolizer of drugs and neurotransmitters, suggesting a genetic risk for poor drug response and altered neurotransmission.

Interpretation

Here we present a series of complimentary and comprehensive analyses that highlight the utility of genetics for informing drug development and repurposing for psychiatric disorders. Our findings present novel opportunities for refining psychiatric treatment.

Obesity-associated factors in psychiatric outpatients: A multicenter questionnaire survey

The prevalence of obesity is increasing worldwide, resulting in various health issues such as hypertension, dyslipidemia, diabetes mellitus, heart disease, and a lower life expectancy. Importantly, several psychiatric disorders and the use of psychotropic medications have been linked to obesity, and the possible risk factors need further investigation. This study examined the prevalence of obesity and its associated factors using a self-administered questionnaire. Participants were recruited from three outpatient clinics and individuals who met one or more of the ICD-10 F0-F9, G4 diagnoses were included. In total, 1384 participants completed the questionnaire about their lifestyle. Statistical analysis compared the demographic and clinical characteristics of the individuals who were obese (Body Mass Index: BMI ≥25) and those who were non-obese (BMI <25). The results revealed that the factors associated with obesity in psychiatric outpatients were being male, prolonged treatment duration, eating out frequently, and use of both second- and first-generation antipsychotics. The study emphasized the importance of closely monitoring BMI in individuals with multiple obesity-related factors.

Effects of web-based adapted physical activity on hippocampal plasticity, cardiorespiratory fitness, symptoms, and cardiometabolic markers in patients with schizophrenia: a randomized, controlled study

Among the lifestyle interventions, the physical activity (PA) has emerged as an adjuvant non-pharmacological treatment improving mental and physical health in patients with schizophrenia (SZPs) and increasing the hippocampus (HCP) volume. Previously investigated PA programs have been face-to-face, and not necessary adapted to patients' physiological fitness. We propose an innovative 16-week adapted PA program delivered by real-time videoconferencing (e-APA), allowing SZPs to interact with a coach and to manage their physical condition. The primary goal was to demonstrate a greater increase of total HCP volumes in SZPs receiving e-APA compared to that observed in a controlled group. The secondary objectives were to demonstrate the greater effects of e-APA compared to a controlled group on HCP subfields, cardiorespiratory fitness, clinical symptoms, cognitive functions, and lipidic profile. Thirty-five SZPs were randomized to either e-APA or a controlled group receiving a health education program under the same conditions (e-HE). Variables were assessed at pre- and post-intervention time-points. The dropout rate was 11.4%. Compared to the e-HE group, the e-APA group did not have any effect on the HCP total volumes but increased the left subiculum volume. Also, the e-APA group significantly increased cardiorespiratory fitness (VO2max), improved lipidic profile and negative symptoms but not cognitive functions. This study demonstrated the high feasibility and multiple benefits of a remote e-APA program for SZPs. e-APA may increase brain plasticity and improve health outcomes in SZPs, supporting that PA should be an add-on therapeutic intervention. ClinicalTrial.gov on 25 august 2017 (NCT03261817).

Does relapse cause illness progression in first-episode psychosis? A review

BACKGROUND

It is widely believed that relapse in first-episode psychosis (FEP) causes illness progression, with previous reviews suggesting that treatment non-response develops in one in six patients who relapse. This belief contributes to the primary treatment goal in FEP being relapse-prevention, often in favor of other recovery-oriented goals. However, previous reviews primarily reported on naturalistic studies in chronic schizophrenia and predated multiple major studies with higher-quality designs.

METHODS

We conducted a narrative review of studies of any design that examine the impact of relapse on medication response and other symptomatic and functional outcomes in FEP.

RESULTS

We identified eight relevant studies, five of these published since the last major review on this topic. Observational studies show a clear association between relapses and worse response to medication, but poorly control for confounding. Three higher-quality studies (two randomized) generally do not find worse symptomatic or functional outcomes among medication reduction/discontinuation arms compared to maintenance controls, despite significantly higher initial rates of relapse.

CONCLUSION

While the social and psychological consequences of a relapse should not be dismissed, clinicians should demand high-quality evidence about the risks of relapse on long-term outcomes. The conventional notion that relapse leads to treatment non-response or worse long-term outcomes is generally not supported by the highest quality studies. These findings can help clinicians and patients weigh the risks and benefits of competing treatment strategies in FEP.

Pathophysiological Mechanisms of Psychosis-Induced Atrial Fibrillation: The Links between Mental Disorder and Arrhythmia

Atrial fibrillation (AF) is a common phenomenon of sustained arrhythmia leading to heart failure or stroke. Patients with mental disorders (MD), particularly schizophrenia and bipolar disorder, are at a high risk of AF triggered by the dysregulation of the autonomic nervous system, atrial stretch, oxidative stress, inflammation, and electrical or structural remodeling. Moreover, pathophysiological mechanisms underlying MD may also contribute to the genesis of AF. An overactivated hypothalamic-pituitary-adrenal axis, aberrant renin-angiotensin-aldosterone system, abnormal serotonin signaling, disturbed sleep, and genetic/epigenetic factors can adversely alter atrial electrophysiology and structural substrates, leading to the development of AF. In this review, we provide an update of our collective knowledge of the pathophysiological and molecular mechanisms that link MD and AF. Targeting the pathogenic mechanisms of MD-specific AF may facilitate the development of therapeutics that mitigate AF and cardiovascular mortality in this patient population.

Predictors of adherence to exercise interventions in people with schizophrenia

Exercise interventions are nowadays considered as effective add-on treatments in people with schizophrenia but are usually associated with high dropout rates. Therefore, the present study investigated potential predictors of adherence from a large multicenter study, encompassing two types of exercise training, conducted over a 6-month period with individuals with schizophrenia. First, we examined the role of multiple participants' characteristics, including levels of functioning, symptom severity, cognitive performance, quality of life, and physical fitness. Second, we used K-means clustering to identify clinical subgroups of participants that potentially exhibited superior adherence. Last, we explored if adherence could be predicted on the individual level using Random Forest, Logistic Regression, and Ridge Regression. We found that individuals with higher levels of functioning at baseline were more likely to adhere to the exercise interventions, while other factors such as symptom severity, cognitive performance, quality of life or physical fitness seemed to be less influential. Accordingly, the high-functioning group with low symptoms exhibited a greater likelihood of adhering to the interventions compared to the severely ill group. Despite incorporating various algorithms, it was not possible to predict adherence at the individual level. These findings add to the understanding of the factors that influence adherence to exercise interventions. They underscore the predictive importance of daily life functioning while indicating a lack of association between symptom severity and adherence. Future research should focus on developing targeted strategies to improve adherence, particularly for people with schizophrenia who suffer from impairments in daily functioning.Clinical trials registration The study of this manuscript which the manuscript is based was registered in the International Clinical Trials Database, ClinicalTrials.gov (NCT number: NCT03466112, https://clinicaltrials.gov/ct2/show/NCT03466112?term=NCT03466112&draw=2&rank=1 ) and in the German Clinical Trials Register (DRKS-ID: DRKS00009804.

Therapeutic modulation of the kynurenine pathway in severe mental illness and comorbidities: A potential role for serotonergic psychedelics

Mounting evidence points towards a crucial role of the kynurenine pathway (KP) in the altered gut-brain axis (GBA) balance in severe mental illness (SMI, namely depression, bipolar disorder, and schizophrenia) and cardiometabolic comorbidities. Preliminary evidence shows that serotonergic psychedelics and their analogues may hold therapeutic potential in addressing the altered KP in the dysregulated GBA in SMI and comorbidities. In fact, aside from their effects on mood, psychedelics elicit therapeutic improvement in preclinical models of obesity, metabolic syndrome, and vascular inflammation, which are highly comorbid with SMI. Here, we review the literature on the therapeutic modulation of the KP in the dysregulated GBA in SMI and comorbidities, and the potential application of psychedelics to address the altered KP in the brain and systemic dysfunction underlying SMI and comorbidities. Psychedelics might therapeutically modulate the KP in the altered GBA in SMI and comorbidities either directly, via altering the metabolic pathway by influencing the rate-limiting enzymes of the KP and affecting the levels of available tryptophan, or indirectly, by affecting the gut microbiome, gut metabolome, metabolism, and the immune system. Despite promising preliminary evidence, the mechanisms and outcomes of the KP modulation with psychedelics in SMI and systemic comorbidities remain largely unknown and require further investigation. Several concerns are discussed surrounding the potential side effects of this approach in specific cohorts of individuals with SMI and systemic comorbidities.

On- and Off-Label Atypical Antipsychotic Prescription Trends Across a Nine-Year Period Among Adolescents Pre- to Post-COVID-19

OBJECTIVE

This study examined atypical antipsychotic prescribing by Food and Drug Administration (FDA) approved-use (on-label) status for adolescents before and during the COVID-19 pandemic.

METHODS

Retrospective data were collected from electronic health records (EHRs) of adolescents aged 10-17 years in Kaiser Permanente Northern California. New outpatient atypical antipsychotic prescription orders during 2013-2021 were evaluated. Prescriptions were categorized as on-label if linked in EHRs to autism, psychosis, bipolar disorder, or Tourette's diagnoses; otherwise, they were potentially off-label (herein, off-label). Trend analysis of monthly prescribing rates assessed slope change at pandemic onset for the cohort and by sex and age groups.

RESULTS

Among 5828 patients, 74.5% of new antipsychotic orders were off-label in 2021. Overall prescribing decreased significantly until early 2020 (slope = -0.045, P < .01) but then significantly increased through 2021 (post-March 2020 slope change = 0.211, P = .01). Off-label prescriptions increased at a similar rate during the COVID-19 time period, but on-label prescriptions did not change significantly. Males and younger adolescents (ages 10-14 years) showed significant decreases until early 2020, while females and older adolescents (ages 15-17 years) did not. Females and younger adolescents exhibited significant increases in overall and off-label prescribing rates following pandemic onset; older adolescents exhibited increases in overall prescriptions while males had no detectable changes.

CONCLUSIONS

Antipsychotic prescribing declined slightly but then increased significantly following COVID-19 onset for overall and off-label prescriptions. Pandemic onset differentially impacted antipsychotic prescribing by sex and age, with overall and off-label prescribing driven by increases among female and younger adolescents.

Psychotomimetic compensation versus sensitization

It is a paradox that psychotomimetic drugs can relieve symptoms that increase risk of and cooccur with psychosis, such as attention and motivational deficits (e.g., amphetamines), pain (e.g., cannabis) and symptoms of depression (e.g., psychedelics, dissociatives). We introduce the ideas of psychotomimetic compensation and psychotomimetic sensitization to explain this paradox. Psychotomimetic compensation refers to a short-term stressor or drug-induced compensation against stress that is facilitated by engagement of neurotransmitter/modulator systems (endocannabinoid, serotonergic, glutamatergic and dopaminergic) that mediate the effects of common psychotomimetic drugs. Psychotomimetic sensitization occurs after repeated exposure to stress and/or drugs and is evidenced by the gradual intensification and increase of psychotic-like experiences over time. Theoretical and practical implications of this model are discussed.

Association of lipids and inflammatory markers with left ventricular wall thickness in patients with bipolar disorder

BACKGROUND

Individuals with bipolar disorder (BD) face a high risk of heart failure and left ventricular (LV) dysfunction. Despite strong evidence that high LV relative wall thickness (RWT) is a risk marker for heart failure, few studies have evaluated LV RWT and aggravating factors in individuals with BD.

METHODS

We recruited 104 participants (52 patients with BD and 52 age- and sex-matched mentally healthy controls) to undergo echocardiographic imaging and biochemistry, high-sensitivity C-reactive protein (hs-CRP), and blood cell count measurements. LV RWT was estimated using the following equation: (2 × LV posterior wall end-diastolic thickness)/LV end-diastolic diameter. Clinical data were obtained through interviews and chart reviews.

RESULTS

The BD group exhibited a significantly greater LV RWT (Cohen's d = 0.53, p = 0.003) and a less favorable mitral valve E/A ratio (Cohen's d = 0.54, p = 0.023) and LV global longitudinal strain (Cohen's d = 0.57, p = 0.047) than did the control group. Multiple linear regression revealed that in the BD group, serum triglyceride levels (β = 0.466, p = 0.001), platelet-to-lymphocyte ratios (β = 0.324, p = 0.022), and hs-CRP levels (β = 0.289, p = 0.043) were all significantly and positively associated with LV RWT.

LIMITATIONS

This study applied a cross-sectional design, meaning that the direction of causation could not be inferred.

CONCLUSIONS

Patients with BD are at a risk of heart failure, as indicated by their relatively high LV RWT. Lipid levels and systemic inflammation may explain this unfavorable association.

Effects of Adapted Physical Activity on White Matter Integrity in Patients with Schizophrenia

Schizophrenia is associated with changes in white matter (WM) integrity and with reduced life expectancy, in part because of the cardiometabolic side effects of antipsychotics. Physical activity (PA) has emerged as a candidate lifestyle intervention that is safe and effective. The study aimed to assess how an adapted PA program delivered remotely by web (e-APA) improved WM integrity in patients with schizophrenia (SZPs) and healthy controls (HCs) and to evaluate associations among WM integrity, cardiorespiratory fitness, and symptom severity. This longitudinal study was conducted over 16 weeks with 31 participants (18 SZPs and 13 HCs). Diffusion tensor imaging and tract-based spatial statistics were employed to assess WM integrity. Cardiorespiratory fitness was measured by maximal oxygen uptake (VO2max), and assessments for clinical symptoms included the Positive and Negative Syndrome Scale, Self-evaluation of Negative Symptoms and the Brief Negative Syndrome Scale (BNSS). Only the SZPs had significantly increased WM integrity after the e-APA program, with increased fractional anisotropy and decreased radial diffusivity in fasciculi involved in motor functions and language process. Furthermore, decreased negative symptoms assessed with BNSS were associated with greater WM integrity following the program. These findings suggest that e-APA may improve WM integrity abnormalities and support e-APA as a promising therapeutic strategy.

El Gendy A, Serag A, Abd El-Fadeal NM, Abdel-Karim RI, Mostafa MM, El-Sheikh DH, Zayed MA. Acacia saligna extract alleviates quetiapine-induced sexual toxicity in male albino rats: Insights from UPLC-MS/MS metabolite profiling, structural and PI3K/NF-κB pathway assessments

Background

Quetiapine (QET) abuse has increased due to its anxiolytic and hedonic effects, necessitating protective adjunct treatments. Acacia saligna (A. saligna) flowers, used in traditional medicine, have potential health benefits.

Aim

To investigate the protective role of A. saligna flower extract against QET-induced sexual toxicity, and to elucidate the possible underlying mechanisms through metabolomic and physiological studies.

Methods

A. saligna extract was subjected to metabolite profiling via High-Resolution Ultra-Performance Liquid Chromatography-Mass Spectrometry (UPLC-ESI-qTOF-MS). Forty-eight adult male albino rats were assigned into six groups for 30 days. The intracavernosal pressure (ICP), semen, biochemical, hormonal, histological, genetic and Western blot (WB) analyses were determined.

Results

A. saligna extract is rich in phenolic compounds, flavonoids, tannins, and unsaturated fatty acids. QET significantly decreased ICP and negatively affected semen parameters. A. saligna mitigated decreased sperm motility and ameliorated overexpressed proinflammatory genes in QET-55 group. A. saligna ameliorated the reduction of the antioxidant biomarkers, testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH), concurrent with downregulation of the nuclear factor kappa B (NF-κB) protein. A. saligna counteracted the disrupted testicular and prostatic structures revealed by histological examination.

Conclusion

The extract from A. saligna, which contains a high concentration of antioxidants and anti-inflammatory chemicals, effectively mitigates sexual toxicity caused by QET. This study provided the first known explanation of the hypothesized processes behind the protective properties of A. saligna through biological, biochemical, and histological parameters. The results emphasize the potential of A. saligna as a safeguarding agent against drug-induced sexual toxicity.

Investigation on the lipid-lowering effect and mechanism by combining turmeric with hawthorn in C57BL/6 obese mice

Study on the hypolipidemic effect of turmeric combined with hawthorn on C57BL/6 obese mice and its possible mechanism. C57 mice were fed with 60% high-fat diet for 8 weeks to establish an obesity model, and 4 mice were slaughtered to verify whether the modeling was successful. The successful mice were divided into model group (HFD), positive group (high fat feed group [HFD] + simvastatin group [SIM]), turmeric group (HFD + TUR), hawthorn group (HFD + HAW), and para-medicine group (HFD + para-drug group [DOU]) for 4 weeks by gavage intervention. Different intervention groups had certain lipid-lowering effects, and the para-medicine group showed significant differences (p < 0.05, p < 0.01, p < 0.001) in reducing serum total cholesterol, triglycerides, low-density lipoprotein cholesterol, glutamic acid transaminase (ALT), glutamic acid transaminase (AST), and increasing high-density lipoprotein cholesterol. In the para-medicine group, the protein expression of peroxisome proliferator-activated receptor γ, fatty acid synthase, platelet-reactive protein receptor 36, and CCAAT/enhancer binding protein α were significantly downregulated, and the protein expression of carnitine palmitoyl transferase1 and peroxisome proliferator-activated receptor α protein expression (p < 0.01, p < 0.001), thus suggesting that turmeric and hawthorn are superior to turmeric and hawthorn alone in enhancing lipid metabolism-related mechanisms. Combined effects of turmeric and hawthorn improve lipid metabolism in mice, protect the liver, and improve the protein expression of liver-related genes. This study can lay the theoretical basis for the future association of medicinal food products and the development of related weight loss products.

Triglyceride-rich lipoprotein, remnant cholesterol, and apolipoproteins CII, CIII, and E in patients with schizophrenia

Patients with schizophrenia show a disproportionally increased risk of cardiovascular disease. Hypertriglyceridemia is prevalent in this population; however, how this relates to levels of remnant cholesterol, triglyceride (TG)-rich lipoprotein (TRL) particle size and composition, TG turnover, and apolipoprotein (apo) and angiopoietin-like protein (ANGPTL) concentrations is unknown. Fasting levels of cholesterol (total [TC], LDL-C, HDL-C, non-HDL-C and remnant cholesterol) and TG were determined in 110 patients diagnosed with schizophrenia, and 46 healthy controls. TRL particle size, concentration and composition, and β-hydroxybutyrate (TG turnover marker) were assessed by NMR. Levels of apoCII, apoCIII, apoE, ANGPTL3, ANGPTL4, and ANGPTL8 were measured by ELISA, and apoCII, apoCIII and apoE were further evaluated in HDL and non-HDL fractions. Patients with schizophrenia had significantly elevated TG, TG:apoB ratio, non-HDL-C, remnant cholesterol, non-HDL-apoCII and non-HDL-apoCIII, and HDL-apoE (all P < 0.05), lower HDL-C and apoA-I (all P < 0.001), and comparable apoB, TC, TC:apoB ratio, LDL-C, β-hydroxybutyrate, ANGPTL3, ANGPTL4 and ANGPTL8 to healthy controls. Patients had a 12.0- and 2.5-fold increase in the concentration of large and medium TRL particles respectively, but similar cholesterol:TG ratio within each particle. Plasma TG, remnant cholesterol, and large and medium TRL particle concentrations correlated strongly with apoCII, apoCIII, and apoE in the non-HDL fraction, and with apoCIII and apoE in the HDL fraction in patients with schizophrenia. Differences in TG, HDL-C, TRL particle concentrations, apoCIII, and apoE persisted after adjustment for conventional risk factors. These results are consistent with impaired TRL lipolysis and clearance in patients with schizophrenia which may be responsive to targeting apoCIII.

Evaluation of oxidative stress and its association with drug therapy in inpatients treated for cocaine dependence

The use of cocaine affects several systems and organs of the human body and the consumption of this substance leads to an increase in the production of reactive oxygen species, and to the reduction of antioxidant defenses. The aim of this study was to evaluate the oxidative stress (OS), biochemical and hematological parameters in patients hospitalized for treatment of cocaine addiction, comparing levels at hospital admission and discharge. Forty patients were included in the study. OS was evaluated using catalase (CAT), superoxide dismutase (SOD), glutathione reductase (GPx), total antioxidant power (FRAP), malondialdehyde (MDA), and sulfhydryl group (GS). The medications used during hospitalization were registered and their influence on the parameters of OS was analyzed. After the hospitalization period, there was an increase in GGT levels, a reduction in SOD activity, and an increase in GPx activity and FRAP levels. Carbamazepine users had higher SOD values and lower FRAP values at hospital discharge. The use of chlorpromazine caused differences in creatinine and gamma-glutamyltransferase (GGT) serum leves, and the levels of glutamic oxalacetic transaminase (TGO), MDA, and FRAP were increased at hospital discharge. Haloperidol and thiamine during hospitalization interfered with alkaline phosphatase levels. The use of risperidone caused an increase in the levels of SOD, and folic acid use was associated with lower levels of GPx and higher levels of glutamic-pyruvic transaminase (TGP) and alkaline phosphatase. Drug rehabilitation treatment was effective in decreasing oxidative damage represented by the reduction of biological markers.

Influence of Lifestyle Factors on Metabolic Syndrome in Psychiatric Patients Attending a Community Mental Health Setting: A Cross-sectional Study

Background

Metabolic syndrome (MetS) is a concern in psychiatric patients. We aimed to study the influence of the modifiable lifestyle factors on MetS in adult psychiatric patients along with associated clinical factors and quality of life.

Methods

Factors such as diet (Healthy Eating Index), exercise, substance use, cardiovascular risk (QRISK), illness severity (Clinical Global Impression), medications, adverse events (Systematic Monitoring of Adverse Events Related to Treatments), and quality of life (Recovering Quality of Life Scale) were assessed along with clinical components for MetS in 323 psychiatric patients receiving routine care and monitoring in a Community Mental Health Team.

Results

MetS was present in 50.5% (95% CI: 45.0-55.9). It was significantly associated with higher age, duration of mental illness, body mass index (BMI), QTc, QRISK, and antipsychotic drugs. In logistic regression, age, QTc, QRISK, and BMI remained significantly linked to MetS. Patients with or without MetS were comparable in their lifestyle factors such as diet, exercise, and substance use, along with the family history of metabolic disorders, age at onset of mental illness, duration of antipsychotic medication, side effects, psychiatric diagnoses, and quality of life. However, many patients with or without MetS had poorer diet and physical inactivity, indicating scope for interventions.

Conclusions

Around half of the psychiatric patients had MetS, and modifiable lifestyle factors did not differentiate individuals with or without MetS. The need for further research on the prevention and management of MetS in psychiatric patients is highlighted.

The incidence risk of gynecological cancer by antipsychotic use: a meta-analysis of 50,402 patients

BACKGROUND

Female gynecological cancers represent a serious public health problem, with 1,398,601 new diagnoses and 671,875 deaths per year worldwide. Antipsychotics are often used in psychiatric disorders, including schizophrenia, bipolar disorder, and major depression. It is estimated that the prescription of these drugs is linked to 1,800 deaths a year in the United States, but their association with cancer remains controversial.

METHODS

We searched PubMed, Scopus, and Web of Science databases for studies reporting the correlation in the incidence risk of gynecological cancer by antipsychotic use. We used DerSimonian and Laird random-effect models to compute logit transformed odds ratio (OR) for the primary binary endpoint with 95% confidence interval (CI). Heterogeneity was assessed through effect size width along with I-squared and Tau-squared statistics. Review Manager 5.4.1. was used for statistical analyses. A p-value of < 0.05 denoted statistically significant.

RESULTS

50,402 patients were included, of whom 778 (1,54%) took antipsychotic medication for at least 1 year. 1,086 (2,15%) with ovarian cancer and 49,316 (97,85%) with endometrial cancer. Antipsychotic use (OR 1.50; 1.06 to 2.13 95% CI; p-value 0.02), hypertension (OR 1.50; 95% CI 1.06 to 2.13; p-value < 0.01), nulliparity (OR 1.98; 95% CI 1.53 to 2.57; p-value < 0.01) and multiparity (OR 0.53; 95% CI 0.41 to 0.69; p-value < 0.01) showed significantly different distributions between groups of cancer and cancer-free patients. The primary endpoint of incidence risk of gynecological cancer by antipsychotic therapy showed a statistically significant difference (OR 1.67; 95% CI 1.02 to 2.73; p-value < 0.05) against the use of antipsychotic drugs.

CONCLUSIONS

Our meta-analysis showed that the use of antipsychotic drugs increases the risk of gynecological cancers, particularly endometrial cancer. This result should be weighed against the potential effects of treatment for a balanced prescribing decision.

Optimizing antidepressant and clozapine co-prescription in clinical practice: A systematic review and expert recommendations

OBJECTIVES

To synthesize the information relevant for clinical practice on clozapine-antidepressant co-prescription concerning pharmacokinetic drug-drug interactions (DDI), adverse drug reactions (ADRs) associated with the co-prescription, antidepressant add-on for clozapine-resistant symptoms and antidepressant add-on for clozapine-induced ADRs.

METHODS

Articles were identified with MEDLINE, Web of Sciences and PsycINFO search from inception through April 2023. Data were synthesized narratively.

RESULTS

ADRs are most often induced by the co-prescription of antidepressants that inhibit CYP enzymes (fluvoxamine, fluoxetine, paroxetine). Fluvoxamine add-on is hazardous because of its potent inhibition of clozapine metabolism and has few indications (lowering daily number of clozapine tablets, reducing norclozapine-induced metabolic disturbances and other dose-dependent clozapine-induced ADRs). ADR frequency may be reduced by therapeutic drug monitoring and knowledge of other factors impacting clozapine metabolism (pneumonia, inflammation, smoking, etc.). Improvement of negative symptoms is the most documented beneficial effect of antidepressant add-on for clozapine-resistant psychotic symptoms. The add-on antidepressant should be chosen according to its safety profile regarding DDI with clozapine: antidepressants inhibiting clozapine metabolism or increasing the anticholinergic load should be avoided. Other indications of antidepressant add-on (affective or obsessive compulsive symptoms, sialorrhea, and enuresis) are poorly documented.

CONCLUSION

Antidepressant add-on to clozapine is associated with potential benefits in clozapine users as this strategy may contribute to reduce the burden of clozapine-resistant symptoms or of clozapine-induced ADRs. Further studies are needed to determine whether antidepressant add-on can reduce the risk of clozapine discontinuation.

Effectiveness of lifestyle intervention on prevention/management of antipsychotic-induced weight gain among persons with severe mental illness: A systematic review and meta-analysis

Individualized lifestyle interventions using motivational interviewing (MI) approach are recommended for persons with severe mental illness (SMI) for effective weight management. The aim of this meta-analysis was to assess the effectiveness of various lifestyle interventions that addressed obesity among persons with SMI. Twelve RCTs were assessed by individual reviewers using revised cochrane risk-of-bias tool (RoB 2). The standardized mean difference (SMD) was calculated with a 95% CI. The age of participants was between 18 and 70 years. Waist circumference showed an SMD of -0.09 (-0.22, 0.03), weight -0.03 (-0.10, 0.15) and BMI -0.07 (-0.07, 0.22). The findings in this meta-analysis revealed that though lifestyle interventions were statistically insignificant in reducing antipsychotic induced weight gain among persons with SMI, they show changes in intervention group. Psychosocial management along with lifestyle interventions, and MI are effective in the management of antipsychotic induced weight gain.

High persistence and low treatment rates of metabolic syndrome in patients with mood and anxiety disorders: A naturalistic follow-up study

BACKGROUND

Patients with affective and anxiety disorders are at risk of metabolic syndrome (MetS) and, consequently, cardiovascular disease and premature death. In this study, the course and treatment of MetS was investigated using longitudinal data from a naturalistic sample of affective- and anxiety-disordered outpatients (Monitoring Outcome of psychiatric PHARmacotherapy [MOPHAR]).

METHODS

Demographics, clinical characteristics, medication use, and MetS components were obtained for n = 2098 patients at baseline and, in a FU-subsample of n = 507 patients, after a median follow-up (FU) of 11 months. Furthermore, pharmacological treatment rates of MetS were investigated at baseline and FU. Finally, demographic and clinical determinants of change in MetS (component) scores were investigated.

RESULTS

At baseline, 34.6 % of n = 2098 patients had MetS, 41.4 % of whom received treatment. Of patients with persisting MetS, 46.1 % received treatment for one (or more) MetS component(s) at baseline, and 56.6 % received treatment at FU. Treatment rates of solely elevated blood pressure and reduced HDL-cholesterol did significantly, but modestly, improve. Higher age, male sex, smoking behavior, low education, diabetes, and depressive versus anxiety disorder were predictors of worse outcome at FU on at least one MetS component.

LIMITATIONS

We did not have data on lifestyle interventions as a form of treatment, which might partly have explained the observed low pharmacotherapeutic treatment rates.

CONCLUSION

MetS (components) show high persistence rates in affective- and anxiety-disordered patients, and are, despite adequate monitoring, undertreated over time. This indicates that adherence and implementation of monitoring protocols should be crucially improved in psychiatric outpatients in secondary care.

On the Road to Individualizing Pharmacotherapy for Adolescents and Adults with Schizophrenia - Results from an Expert Consensus Following the Delphi Method

Introduction

Schizophrenia is a severe mental illness that usually begins in late adolescence or early adulthood. Current pharmacological treatments, while acceptably effective for many patients, are rarely clinically tailored or individualized. The lack of sufficient etiopathological knowledge of the disease, together with overall comparable effect sizes for efficacy between available antipsychotics and the absence of clinically actionable biomarkers, has hindered the advance of individualized medicine in the treatment of schizophrenia. Nevertheless, some degree of stratification based on clinical markers could guide treatment choices and help clinicians move toward individualized psychiatry. To this end, a panel of experts met to formally discuss the current approach to individualized treatment in schizophrenia and to define how treatment individualization could help improve clinical outcomes.

Methods

A task force of seven experts iteratively developed, evaluated, and refined questionnaire items, which were then evaluated using the Delphi method. Descriptive statistics were used to summarize and rank expert responses. Expert discussion, informed by the results of a scoping review on personalizing the pharmacologic treatment of adults and adolescents with schizophrenia, ultimately generated recommendations to guide individualized pharmacologic treatment in this population.

Results

There was substantial agreement among the expert group members, resulting in the following recommendations: 1) individualization of treatment requires consideration of the patient's diagnosis, clinical presentation, comorbidities, previous treatment response, drug tolerability, adherence patterns, and social factors; 2) patient preferences should be considered in a shared decision-making approach; 3) identified barriers to personalized care that need to be overcome include the lack of actionable biomarkers and mechanistic similarities between available treatments, but digital tools should be increasingly used to enhance individualized treatment.

Conclusion

Individualized care can help provide effective, tailored treatments based on an individual's clinical characteristics, disease trajectory, family and social environment, and goals and preferences.

Psychosocial factors, health behaviors and risk of cancer incidence: Testing interaction and effect modification in an individual participant data meta-analysis

Depression, anxiety and other psychosocial factors are hypothesized to be involved in cancer development. We examined whether psychosocial factors interact with or modify the effects of health behaviors, such as smoking and alcohol use, in relation to cancer incidence. Two-stage individual participant data meta-analyses were performed based on 22 cohorts of the PSYchosocial factors and CAncer (PSY-CA) study. We examined nine psychosocial factors (depression diagnosis, depression symptoms, anxiety diagnosis, anxiety symptoms, perceived social support, loss events, general distress, neuroticism, relationship status), seven health behaviors/behavior-related factors (smoking, alcohol use, physical activity, body mass index, sedentary behavior, sleep quality, sleep duration) and seven cancer outcomes (overall cancer, smoking-related, alcohol-related, breast, lung, prostate, colorectal). Effects of the psychosocial factor, health behavior and their product term on cancer incidence were estimated using Cox regression. We pooled cohort-specific estimates using multivariate random-effects meta-analyses. Additive and multiplicative interaction/effect modification was examined. This study involved 437,827 participants, 36,961 incident cancer diagnoses, and 4,749,481 person years of follow-up. Out of 744 combinations of psychosocial factors, health behaviors, and cancer outcomes, we found no evidence of interaction. Effect modification was found for some combinations, but there were no clear patterns for any particular factors or outcomes involved. In this first large study to systematically examine potential interaction and effect modification, we found no evidence for psychosocial factors to interact with or modify health behaviors in relation to cancer incidence. The behavioral risk profile for cancer incidence is similar in people with and without psychosocial stress.

Effect of antipsychotics and mood stabilisers on metabolism in bipolar disorder: a network meta-analysis of randomised-controlled trials

Background

Antipsychotics and mood stabilisers are gathering attention for the disturbance of metabolism. This network meta-analysis aims to evaluate and rank the metabolic effects of the commonly used antipsychotics and mood stabilisers in treating bipolar disorder (BD).

Methods

Registries including PubMed, Embase, Cochrane Library, Web of Science, Ovid, and Google Scholar were searched before February 15th, 2024, for randomised controlled trials (RCTs) applying antipsychotics or mood stabilisers for BD treatment. The observed outcomes were twelve metabolic indicators. The data were extracted by two reviewers independently, and confirmed by another four reviewers and a corresponding author. The above six reviewers all participated in data analyses. Data extraction was based on PRISMA guidelines, and quality assessment was conducted according to the Cochrane Handbook. Use a random effects model for data pooling. The PROSPERO registration number is CRD42023466669.

Findings

Together, 5421 records were identified, and 41 publications with 11,678 complete-trial participants were confirmed eligible. After eliminating possible sensitivity, risperidone ranked 1st in elevating fasting serum glucose (SUCRA = 90.7%) and serum insulin (SUCRA = 96.6%). Lurasidone was most likely to elevate HbA1c (SUCRA = 82.1%). Olanzapine ranked 1st in elevating serum TC (SUCRA = 93.3%), TG (SUCRA = 89.6%), and LDL (SUCRA = 94.7%). Lamotrigine ranked 1st in reducing HDL (SUCRA = 82.6%). Amisulpride ranked 1st in elevating body weight (SUCRA = 100.0%). For subgroup analyses, quetiapine is more likely to affect indicators of glucose metabolism among male adult patients with bipolar mania, while long-term lurasidone tended to affect glucose metabolism among female patients with bipolar depression. Among patients under 18, divalproex tended to affect glucose metabolism, with lithium affecting lipid metabolism. In addition, most observed antipsychotics performed higher response and remission rates than placebo, and displayed a similar dropout rate with placebo, while no between-group significance of rate was observed among mood stabilisers.

Interpretation

Our findings suggest that overall, antipsychotics are effective in treating BD, while they are also more likely to disturb metabolism than mood stabilisers. Attention should be paid to individual applicability in clinical practice. The results put forward evidence-based information and clinical inspiration for drug compatibility and further research of the BD mechanism.

Funding

The National Key Research and Development Program of China (2023YFC2506200), and the Research Project of Jinan Microecological Biomedicine Shandong Laboratory (No. JNL-2023001B).

Serious Mental Illness, Glycemic Control, and Neighborhood Factors within an Urban Diabetes Cohort

BACKGROUND AND HYPOTHESIS

Serious mental illness (SMI) may compromise diabetes self-management. This study assessed the association between SMI and glycemic control, and explored sociodemographic predictors and geographic clustering of this outcome among patients with and without SMI.

STUDY DESIGN

We used electronic health record data for adult primary care patients with diabetes from 2 San Francisco health care delivery systems. The primary outcome was poor glycemic control (hemoglobin A1c >9.0%), which was modeled on SMI diagnosis status and sociodemographics. Geospatial analyses examined hotspots of poor glycemic control and neighborhood characteristics.

STUDY RESULTS

The study included 11 694 participants with diabetes, 21% with comorbid SMI, of whom 22% had a schizophrenia spectrum or bipolar disorder. Median age was 62 years; 52% were female and 79% were Asian, Black, or Hispanic. In adjusted models, having schizophrenia spectrum disorder or bipolar disorder was associated with greater risk for poor glycemic control (vs participants without SMI, adjusted relative risk [aRR] = 1.24; 95% confidence interval, 1.02, 1.49), but having broadly defined SMI was not. People with and without SMI had similar sociodemographic correlates of poor glycemic control including younger versus older age, Hispanic versus non-Hispanic White race/ethnicity, and English versus Chinese language preference. Hotspots for poor glycemic control were found in neighborhoods with more lower-income, Hispanic, and Black residents.

CONCLUSIONS

Poor diabetes control was significantly related to having a schizophrenia spectrum or bipolar disorder, and to sociodemographic factors and neighborhood. Community-based mental health clinics in hotspots could be targets for implementation of diabetes management services.

Effectiveness of Psychobiotics in the Treatment of Psychiatric and Cognitive Disorders: A Systematic Review of Randomized Clinical Trials

In this study, a systematic review of randomized clinical trials conducted from January 2000 to December 2023 was performed to examine the efficacy of psychobiotics-probiotics beneficial to mental health via the gut-brain axis-in adults with psychiatric and cognitive disorders. Out of the 51 studies involving 3353 patients where half received psychobiotics, there was a notably high measurement of effectiveness specifically in the treatment of depression symptoms. Most participants were older and female, with treatments commonly utilizing strains of Lactobacillus and Bifidobacteria over periods ranging from 4 to 24 weeks. Although there was a general agreement on the effectiveness of psychobiotics, the variability in treatment approaches and clinical presentations limits the comparability and generalization of the findings. This underscores the need for more personalized treatment optimization and a deeper investigation into the mechanisms through which psychobiotics act. The research corroborates the therapeutic potential of psychobiotics and represents progress in the management of psychiatric and cognitive disorders.

Targeted learning in observational studies with multi-valued treatments: An evaluation of antipsychotic drug treatment safety

We investigate estimation of causal effects of multiple competing (multi-valued) treatments in the absence of randomization. Our work is motivated by an intention-to-treat study of the relative cardiometabolic risk of assignment to one of six commonly prescribed antipsychotic drugs in a cohort of nearly 39 000 adults with serious mental illnesses. Doubly-robust estimators, such as targeted minimum loss-based estimation (TMLE), require correct specification of either the treatment model or outcome model to ensure consistent estimation; however, common TMLE implementations estimate treatment probabilities using multiple binomial regressions rather than multinomial regression. We implement a TMLE estimator that uses multinomial treatment assignment and ensemble machine learning to estimate average treatment effects. Our multinomial implementation improves coverage, but does not necessarily reduce bias, relative to the binomial implementation in simulation experiments with varying treatment propensity overlap and event rates. Evaluating the causal effects of the antipsychotics on 3-year diabetes risk or death, we find a safety benefit of moving from a second-generation drug considered among the safest of the second-generation drugs to an infrequently prescribed first-generation drug known for having low cardiometabolic risk.

Thyroid allostasis in drug-free affective disorder patients

AIM

To assess the thyroid allostasis in drug-free patients with affective disorder.

METHODS

Patients with major depressive disorder or bipolar disorder as drug-free, defined as those without psychiatric drugs exposure for at least 4 months before admission, from a tertiary hospital were recruited in this cross-sectional study. The primary outcomes were "structure parameters of thyroid homeostasis", which include "thyroid's secretory capacity" (SPINA-GT), "sum step-up activity of deiodinases" (SPINA-GD), the ratio of total to free thyroxine and "thyroid homeostasis central set point" (TSH index and "thyroid feedback quantile-based index" [TFQI]), calculated by TSH and thyroid hormones measured at admission. A healthy population and non-affective psychiatric disorder (schizophrenia) from the same catchment area were recruited as two comparison groups.

RESULTS

A total of 1263 cases of major depressive disorder, 1619 cases of bipolar disorder, 1186 cases of schizophrenia, and 162 healthy controls were included in the study. Compared to healthy control, GD and ratio of total to free thyroxine were lower in affective disorders. Bipolar with mania episode had higher GT than bipolar with depressive episode and major depressive disorder (median level at 3.70 vs. 3.04 and 3.03, respectively). Compared with healthy control, schizophrenia had higher TSH index and TFQI, but no increase in these parameters in major depressive disorder and bipolar disorder.

CONCLUSION

Affective disorders have a unique profile of thyroid allostasis with impaired step-up deiodinase activity and reduced serum protein binding of thyroid hormones, but no change in thyroid homeostasis central set point. Mania episode may be associated with higher thyroid secretory capacity.

Characteristics of Comorbid Physical Disease in Patients With Severe Mental Illness in South Korea: A Nationwide Population-Based Study (2014-2019)

OBJECTIVE

The purpose of this study was to identify the associations of chronic physical disease between patients with severe mental illness (SMI) and the general population of South Korea.

METHODS

This study was conducted with National Health Insurance Corporation data from 2014 to 2019. A total of 848,058 people were diagnosed with SMI in this period, and the same number of controls were established by matching by sex and age. A descriptive analysis was conducted on the sociodemographic characteristics of patients with SMI. Conditional logistic regression analysis was performed to identify the associations between comorbid physical disease in patients with SMI and those of the general population. SAS Enterprise Guide 7.1 (SAS Inc, Cary, NC, USA) were used to perform all statistical tests.

RESULTS

The analysis revealed significant differences in medical insurance, income level, and Charlson Comorbidity Index weighted by chronic physical disease, between patients with SMI and the general population. Conditional logistic regression analysis between the two groups also revealed significant differences in eight chronic physical diseases except hypertensive disease.

CONCLUSION

This study confirmed the vulnerability of patients with SMI to chronic physical diseases and we were able to identify chronic physical disease that were highly related to patients with SMI.

The patient journey project in Italian mental health services: results from a co-designed survey on clinical interventions and current barriers to improve the care of people living with schizophrenia

Introduction

The Patient Journey Project aimed to analyze the scenario among Italian Mental Health Services (MHS) to understand the clinical interventions that are properly implemented and the ones deserving further implementation to design an effective treatment plan for patients living with schizophrenia (PLWS).

Methods

The 60-items survey was co-designed with all the stakeholders (clinicians, expert patients and caregivers) involved in the Patient Journey and focused on three phases of schizophrenia course: early detection and management, acute phase management, long-term management/continuity of care. Respondents were Heads of the Mental Health Departments and Addiction Services (MHDAS) or facilities directors throughout Italian MHS. For each statement, respondents expressed the consensus on the importance and the degree of implementation in clinical practice.

Results

Considering the importance of the statement, strong consensus was reached for most of the statements. Good levels of implementation were found on 2/17 statements of early detection and management, on 3/16 statements for acute phase management and on 1/27 statements of long-term management/continuity of care. Poor levels of implementation were found on 1/17 statements of early detection and management, none of acute phase management, and 4/27 statements for long-term management/continuity of care. Moderate levels of implementation were found on 14/17 statements for early detection and management, on 13/16 statements of acute phase management, and on 22/27 statements of long-term management/continuity of care. Thus, among Italian MHDAS, most interventions for PLWS were moderately implemented in clinical practice.

Discussion

Italian MHS have to provide new strategies and structural actions to overcome these current limitations and barriers to effectively improve the journey of PLWS. The areas that deserve most implementation include interventions during the early stage (especially the continuity of care between Child and Adolescent Mental Health Services and Adult Mental Health Services), the evidence-based psychosocial interventions during the chronic stages of the disorder, and the continuity of care after acute hospitalization.

Antipsychotic Medication and Risk of Metabolic Disorders in People With Schizophrenia: A Longitudinal Study Using the UK Clinical Practice Research Datalink

BACKGROUND AND HYPOTHESIS

Antipsychotics are first-line drug treatments for schizophrenia. When antipsychotic monotherapy is ineffective, combining two antipsychotic drugs is common although treatment guidelines warn of possible increases in side effects. Risks of metabolic side effects with antipsychotic polypharmacy have not been fully investigated. This study examined associations between antipsychotic polypharmacy and risk of developing diabetes, hypertension, or hyperlipidemia in adults with schizophrenia, and impact of co-prescription of first- and second-generation antipsychotics.

STUDY DESIGN

A population-based prospective cohort study was conducted in the United Kingdom using linked primary care, secondary care, mental health, and social deprivation datasets. Cox proportional hazards models with stabilizing weights were used to estimate risk of metabolic disorders among adults with schizophrenia, comparing patients on antipsychotic monotherapy vs polypharmacy, adjusting for demographic and clinical characteristics, and antipsychotic dose.

STUDY RESULTS

Median follow-up time across the three cohorts was approximately 14 months. 6.6% developed hypertension in the cohort assembled for this outcome, with polypharmacy conferring an increased risk compared to monotherapy, (adjusted Hazard Ratio = 3.16; P = .021). Patients exposed to exclusive first-generation antipsychotic polypharmacy had greater risk of hypertension compared to those exposed to combined first- and second-generation polypharmacy (adjusted HR 0.29, P = .039). No associations between polypharmacy and risk of diabetes or hyperlipidemia were found.

CONCLUSIONS

Antipsychotic polypharmacy, particularly polypharmacy solely comprised of first-generation antipsychotics, increased the risk of hypertension. Future research employing larger samples, follow-up longer than the current median of 14 months, and more complex methodologies may further elucidate the association reported in this study.

Drug-induced hyperglycemia and diabetes

BACKGROUND

Drug-induced hyperglycemia and diabetes have negative and potentially serious health consequences but can often be unnoticed.

METHODS

We reviewed the literature searching Medline database for articles addressing drug-induced hyperglycemia and diabetes up to January 31, 2023. We also selected drugs that could induce hyperglycemia or diabetes according official data from drug information databases Thériaque and Micromedex. For each selected drug or pharmacotherapeutic class, the mechanisms of action potentially involved were investigated. For drugs considered to be at risk of hyperglycemia or diabetes, disproportionality analyses were performed using data from the international pharmacovigilance database VigiBase. In order to detect new pharmacovigilance signals, additional disproportionality analyses were carried out for drug classes with more than 100 cases reported in VigiBase, but not found in the literature or official documents.

RESULTS

The main drug classes found to cause hyperglycemia are glucocorticoids, HMG-coA reductase inhibitors, thiazide diuretics, beta-blockers, antipsychotics, fluoroquinolones, antiretrovirals, antineoplastic agents and immunosuppressants. The main mechanisms involved are alterations in insulin secretion and sensitivity, direct cytotoxic effects on pancreatic cells and increases in glucose production. Pharmacovigilance signal were found for a majority of drugs or pharmacological classes identified as being at risk of diabetes or hyperglycemia. We identified new pharmacovigilance signals with drugs not known to be at risk according to the literature or official data: phosphodiesterase type 5 inhibitors, endothelin receptor antagonists, sodium oxybate, biphosphonates including alendronic acid, digoxin, sartans, linosipril, diltiazem, verapamil, and darbepoetin alpha. Further studies will be needed to confirm these signals.

CONCLUSIONS

The risks of induced hyperglycemia vary from one drug to another, and the underlying mechanisms are multiple and potentially complex. Clinicians need to be vigilant when using at-risk drugs in order to detect and manage these adverse drug reactions. However, it is to emphasize that the benefits of appropriately prescribed treatments most often outweigh their metabolic risks.

Liraglutide in Obese or Overweight Individuals With Stable Bipolar Disorder

BACKGROUND

Obesity is common among persons with bipolar disorder (BD). Liraglutide 3.0 mg/d subcutaneous injection is indicated for chronic weight management and associated with minimal adverse neuropsychiatric effects. This study evaluated whether liraglutide 3 mg/d reduced body weight, improved metabolic factors and eating psychopathology, and was safe and well tolerated in persons with stable BD who were obese (body mass index [BMI] >30 kg/m 2 ) or overweight (BMI ≥27 kg/m 2 ) with at least one weight-related comorbidity.

METHODS

This was a 40-week, randomized (1:1 ratio), placebo-controlled, double-blind, parallel-group, 2-arm clinical trial of liraglutide targeted to 3.0 mg/d (in combination with a reduced-calorie diet and increased physical activity) in 60 participants with stable BD who were obese or overweight. Primary outcome was percent change in body weight from baseline to study end. Secondary outcomes included percentage of patients who lost ≥5% of baseline body weight, and changes in metabolic variables and measures of eating psychopathology.

RESULTS

There were no significant baseline differences between the 29 liraglutide recipients and the 31 placebo recipients, except that liraglutide recipients had higher levels of binge eating and lower levels of high-density lipoprotein cholesterol. Compared with placebo, liraglutide was associated with significantly greater reductions in percent change in body weight, percentage of participants who lost at least 5% of body weight, and reductions in weight, BMI, hemoglobin A 1c levels, binge eating, and hunger. Liraglutide was well tolerated.

CONCLUSIONS

Liraglutide 3 mg/d may be efficacious and safe for weight loss in individuals with stable BD and obesity or overweight.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03158805).

Risk factors for mortality in patients admitted to a psychiatric acute ward: A prospective cohort study

INTRODUCTION

Associations between psychiatric disorders and mortality have been extensively studied, but limited evidence exists regarding influence of clinical characteristics on mortality risk, at the time of acute psychiatric hospitalization.

METHODS

A prospective total-cohort study included all patients consecutively admitted to Haukeland University Hospital's psychiatric acute ward in Bergen, Norway between 2005 and 2014 (n = 6125). Clinical interviews were conducted at the first admission within the study period, and patients were subsequently followed for up to 15 years in the Norwegian Cause of Death Registry. Competing risks regression models were used to investigate associations between clinical characteristics at first admission and the risk of natural and unnatural death during follow-up.

RESULTS

The mean age at first admission and at time of death was 42.5 and 62.8 years, respectively, and the proportion of women in the sample was 47.2%. A total of 1381 deaths were registered during follow-up, of which 65.5% had natural, 30.4% unnatural, and 4.1% unknown causes. Higher age, male sex, unemployment, cognitive deficits, and physical illness were associated with increased risk of natural death. Male sex, having no partner, physical illness, suicide attempts, and excessive use of alcohol and illicit substances were associated with increased risk of unnatural death.

CONCLUSION

Psychiatric symptoms, except suicide attempts, were unrelated to increased mortality risk. In the endeavor to reduce the increased mortality risk in people with mental disorders, focus should be on addressing modifiable risk factors linked to physical health and excessive use of alcohol and illicit substances.