Type 2 diabetes among persons with schizophrenia and other psychotic disorders in a general population survey

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Predicting type 2 diabetes prevalence for people with severe mental illness in a multi-ethnic East London population

BACKGROUND AND AIMS

Prevalence of type two diabetes mellitus (T2DM) in people with severe mental illness (SMI) is 2-3 times higher than in general population. Predictive modelling has advanced greatly in the past decade, and it is important to apply cutting-edge methods to vulnerable groups. However, few T2DM prediction models account for the presence of mental illness, and none seemed to have been developed specifically for people with SMI. Therefore, we aimed to develop and internally validate a T2DM prevalence model for people with SMI.

METHODS

We utilised a large cross-sectional sample representative of a multi-ethnic population from London (674,000 adults); 10,159 people with SMI formed our analytical sample (1,513 T2DM cases). We fitted a linear logistic regression and XGBoost as stand-alone models and as a stacked ensemble. Age, sex, body mass index, ethnicity, area-based deprivation, past hypertension, cardiovascular diseases, prescribed antipsychotics, and SMI illness were the predictors.

RESULTS

Logistic regression performed well while detecting T2DM presence for people with SMI: area under the receiver operator curve (ROC-AUC) was 0.83 (95 % CI 0.79-0.87). XGBoost and LR-XGBoost ensemble performed equally well, ROC-AUC 0.83 (95 % CI 0.79-0.87), indicating a negligible contribution of non-linear terms to predictive power. Ethnicity was the most important predictor after age. We demonstrated how the derived models can be utilised and estimated a 2.14 % (95 %CI 2.03 %-2.24 %) increase in T2DM prevalence in East London SMI population in 20 years' time, driven by the projected demographic changes.

CONCLUSIONS

Primary care data, the setting where prediction models could be most fruitfully used, provide enough information for well-performing T2DM prevalence models for people with SMI. We demonstrated how thorough internal cross-validation of an ensemble of a linear and machine-learning model can quantify the predictive value of non-linearity in the data.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Antipsychotic-Related Risks of Type 2 Diabetes Mellitus in Enrollees With Schizophrenia in the National Basic Public Health Service Program in Hunan Province, China

BACKGROUND

Antipsychotics contribute to the development of type 2 diabetes mellitus (T2DM) in individuals with schizophrenia. However, the extent of the relationship between antipsychotic use and T2DM varies in different settings, and the magnitude of the drug-specific effects fluctuates widely. This study aimed to explore the association of T2DM with antipsychotic use among enrollees with schizophrenia in China's National Basic Public Health Service Program (NBPHSP) and the drug-specific relationship with T2DM among patients receiving antipsychotic monotherapy.

METHODS

We recruited diabetes-free patients with schizophrenia who were enrolled in the NBPHSP of Hunan Province from October 2009 to December 2018. The participants were classified into the following three groups: regular antipsychotic use, intermittent antipsychotic use, and antipsychotic-free groups. The patients were followed up until they received a T2DM diagnosis or until April 2019. Cox regression models were constructed to calculate the overall and drug-specific hazard ratios (HRs) to determine the antipsychotic-T2DM relationship. Interactive and subgroup analyses were performed to assess the heterogeneity of the effects across subgroups.

RESULTS

A total of 122,064 NBPHSP enrollees with schizophrenia were followed up for 1,507,829 cumulative person-years, and 2,313 (1.89%) patients developed T2DM. Patients who regularly and intermittently used antipsychotics had 117% (HR: 2.17, 95% CI: 1.83-2.57) and 53% (HR: 1.53, 95% CI: 1.23-1.90) higher risks of developing T2DM than antipsychotic-free patients, respectively. Regarding monotherapy, the T2DM risk increased by 66, 80, 62, and 64% after the regular use of clozapine, risperidone, chlorpromazine, and perphenazine, respectively. In addition, the antipsychotic-related risk of T2DM decreased as the patient's baseline body mass index, and baseline fasting plasma glucose level, as well as the dietary proportion of animal products, increased.

CONCLUSION

Antipsychotics, especially clozapine, risperidone, chlorpromazine, and perphenazine, increased the T2DM risk among NBPHSP enrollees with schizophrenia. Mental health officers should accurately identify enrollees at a high risk of T2DM and take appropriate preventive measures to reduce the incidence of T2DM among patients with schizophrenia.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Peripheral metabolic state and immune system in first-episode psychosis - A gene expression study with a prospective one-year follow-up

he excess availability of glucose and lipids can also have an impact on the dynamics of activation and regulation of peripheral immune cellsWe aimed at understanding the correlations between peripheral metabolic state and immune system during the first year in first-episode psychosis (FEP). Patients with FEP (n = 67) and matched controls (n = 38), aged 18-40 years, were met at baseline, 2 and 12 months. Fasting peripheral blood samples were collected. We applied the NanoString nCounter in-solution hybridization technology to determine gene expression levels of 178 candidate genes reflecting activation of the immune system. Serum triglycerides, high-density lipoprotein (HDL), low-density lipoprotein (LDL) cholesterol and insulin and plasma glucose (fP-Gluc) were measured. We applied Ingenuity Pathway Analysis (IPA) to visualize enrichment of genes to functional classes. Strength of positive or negative regulation of the disease and functional pathways was deduced from IPA activation Z-score at the three evaluation points. We correlated gene expression with plasma glucose, triglycerids and HDL and LDL, and used hierarchical clustering of the pairwise correlations to identify groups of genes with similar correlation patterns with metabolic markers. In patients, initially, genes associated with the innate immune system response pathways were upregulated, which decreased by 12 months. Furthermore, genes associated with apoptosis and T cell death were downregulated, and genes associated with lipid metabolism were increasingly downregulated by 12 months. The immune activation was thus an acute phase during illness onset. At baseline, after controlling for multiple testing, 31/178 genes correlated positively with fasting glucose levels, and 54/178 genes negatively with triglycerides in patients only. The gene clusters showed patterns of correlations with metabolic markers over time. The results suggest a functional link between peripheral immune system and metabolic state in FEP. Metabolic factors may have had an influence on the initial activation of the innate immune system. Future work is necessary to understand the role of metabolic state in the regulation of immune response in the early phases of psychosis.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

A link among schizophrenia, diabetes, and asthma: Role of Ca2+/cAMP signaling

Asthma has been associated with an increased risk for developing schizophrenia. In addition, schizophrenia has been associated with an increased risk for developing type 2 diabetes mellitus, resulting in an elevated cardiovascular risk and in a limited life expectancy. It is well discussed that dysregulations related to Ca²⁺ signaling could link these diseases, in addition to cAMP signaling pathways. Thus, revealing this interplay among schizophrenia, diabetes, and asthma may provide novel insights into the pathogenesis of these diseases. Publications involving Ca²⁺ and cAMP signaling pathways, schizophrenia, diabetes, and asthma (alone or combined) were collected by searching PubMed and EMBASE. Both Ca²⁺ and cAMP signaling pathways (Ca²⁺/cAMP signaling) control the release of neurotransmitters and hormones, in addition to airway smooth muscle contractility, then dysregulations of these cellular processes may be involved in these diseases. Taking into consideration, the experience of our group in this field, this narrative review debated the involvement of Ca²⁺/cAMP signaling in this link among schizophrenia, diabetes, and asthma, including its pharmacological implications.

Early environmental factors and somatic comorbidity in schizophrenia and nonschizophrenic psychoses: A 50-year follow-up of the Northern Finland Birth Cohort 1966

Background.

We studied the cumulative incidence of physical illnesses, and the effect of early environmental factors (EEFs) on somatic comorbidity in schizophrenia, in nonschizophrenic psychosis and among nonpsychotic controls from birth up to the age of 50 years.

Methods.

The sample included 10,933 members of the Northern Finland Birth Cohort 1966, of whom, 227 had schizophrenia and 205 had nonschizophrenic psychosis. Diagnoses concerning physical illnesses were based on nationwide registers followed up to the end of 2016 and classified into 13 illness categories. Maternal education and age, family type at birth and paternal socioeconomic status were studied as EEFs of somatic illnesses.

Results.

When adjusted by gender and education, individuals and especially women with nonschizophrenic psychosis had higher risk of morbidity in almost all somatic illness categories compared to controls, and in some categories, compared to individuals with schizophrenia. The statistically significant adjusted hazard ratios varied from 1.27 to 2.42 in nonschizophrenic psychosis. Regarding EEFs, single-parent family as the family type at birth was a risk factor for a higher somatic score among men with schizophrenia and women with nonschizophrenic psychosis. Maternal age over 35 years was associated with lower somatic score among women with nonschizophrenic psychosis.

Conclusions.

Persons with nonschizophrenic psychoses have higher incidence of somatic diseases compared to people with schizophrenia and nonpsychotic controls, and this should be noted in clinical work. EEFs have mostly weak association with somatic comorbidity in our study.

Pyrosequencing analysis of IRS1 methylation levels in schizophrenia with tardive dyskinesia

Tardive dyskinesia (TD) is a serious side effect of certain antipsychotic medications that are used to treat schizophrenia (SCZ) and other mental illnesses. The methylation status of the insulin receptor substrate 1 (IRS1) gene is reportedly associated with SCZ; however, no study, to the best of the authors' knowledge, has focused on the quantitative DNA methylation levels of the IRS1 gene using pyrosequencing in SCZ with or without TD. The present study aimed to quantify DNA methylation levels of 4 CpG sites in the IRS1 gene using a Chinese sample including SCZ patients with TD and without TD (NTD) and healthy controls (HCs). The general linear model (GLM) was used to detect DNA methylation levels among the 3 proposed groups (TD vs. NTD vs. HC). Mean DNA methylation levels of 4 CpG sites demonstrated normal distribution. Pearson's correlation analysis did not reveal any significant correlations between the DNA methylation levels of the 4 CpG sites and the severity of SCZ. GLM revealed significant differences between the 3 groups for CpG site 1 and the average of the 4 CpG sites (P=0.0001 and P=0.0126, respectively). Furthermore, the TD, NTD and TD + NTD groups demonstrated lower methylation levels in CpG site 1 (P=0.0003, P<0.0001 and P<0.0001, respectively) and the average of 4 CpG sites (P=0.0176, P=0.0063 and P=0.003, respectively) compared with the HC group. The results revealed that both NTD and TD patients had significantly decreased DNA methylation levels compared with healthy controls, which indicated a significant association between the DNA methylation levels of the IRS1 gene with SCZ and TD.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Examining the Association between Neighbourhood Socioeconomic Disadvantage and Type 2 Diabetes Comorbidity in Serious Mental Illness

This study examined the association between neighbourhood socioeconomic disadvantage and serious mental illness (SMI)-type 2 diabetes (T2D) comorbidity in an Australian population using routinely collected clinical data. We hypothesised that neighbourhood socioeconomic disadvantage is positively associated with T2D comorbidity in SMI. The analysis considered 3816 individuals with an SMI living in the Illawarra and Shoalhaven regions of NSW, Australia, between 2010 and 2017. Multilevel logistic regression models accounting for suburb (neighbourhood) level clustering were used to assess the association between neighbourhood disadvantage and SMI -T2D comorbidity. Models were adjusted for age, sex, and country of birth. Compared with the most advantaged neighbourhoods, residents in the most disadvantaged neighbourhoods had 3.2 times greater odds of having SMI-T2D comorbidity even after controlling for confounding factors (OR 3.20, 95% CI 1.42-7.20). The analysis also revealed significant geographic variation in the distribution of SMI -T2D comorbidity in our sample (Median Odds Ratio = 1.35) Neighbourhood socioeconomic disadvantage accounted for approximately 17.3% of this geographic variation. These findings indicate a potentially important role for geographically targeted initiatives designed to enhance prevention and management of SMI-T2D comorbidity in disadvantaged communities.

4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Combination therapy as a potential risk factor for the development of type 2 diabetes in patients with schizophrenia: the GOMAP study

BACKGROUND

Schizophrenia (SCZ) is associated with increased risk of type 2 diabetes (T2D). The potential diabetogenic effect of concomitant application of psychotropic treatment classes in patients with SCZ has not yet been evaluated. The overarching goal of the Genetic Overlap between Metabolic and Psychiatric disease (GOMAP) study is to assess the effect of pharmacological, anthropometric, lifestyle and clinical measurements, helping elucidate the mechanisms underlying the aetiology of T2D.

METHODS

The GOMAP case-control study (Genetic Overlap between Metabolic and Psychiatric disease) includes hospitalized patients with SCZ, some of whom have T2D. We enrolled 1653 patients with SCZ; 611 with T2D and 1042 patients without T2D. This is the first study of SCZ and T2D comorbidity at this scale in the Greek population. We retrieved detailed information on first- and second-generation antipsychotics (FGA, SGA), antidepressants and mood stabilizers, applied as monotherapy, 2-drug combination, or as 3- or more drug combination. We assessed the effects of psychotropic medication, body mass index, duration of schizophrenia, number of hospitalizations and physical activity on risk of T2D. Using logistic regression, we calculated crude and adjusted odds ratios (OR) to identify associations between demographic factors and the psychiatric medications.

RESULTS

Patients with SCZ on a combination of at least three different classes of psychiatric drugs had a higher risk of T2D [OR 1.81 (95% CI 1.22-2.69); p = 0.003] compared to FGA alone therapy, after adjustment for age, BMI, sex, duration of SCZ and number of hospitalizations. We did not find evidence for an association of SGA use or the combination of drugs belonging to two different classes of psychiatric medications with increased risk of T2D [1.27 (0.84-1.93), p = 0.259 and 0.98 (0.71-1.35), p = 0.885, respectively] compared to FGA use.

CONCLUSIONS

We find an increased risk of T2D in patients with SCZ who take a combination of at least three different psychotropic medication classes compared to patients whose medication consists only of one or two classes of drugs.

Mortality in people with psychotic disorders in Finland: A population-based 13-year follow-up study

OBJECTIVES

We conducted a population based study aiming at finding predictors of mortality in psychotic disorders and evaluating the extent to which sociodemographic, lifestyle and health-related factors explain the excess mortality.

METHODS

In a nationally representative sample of Finns aged 30-70years (n=5642), psychotic disorders were diagnosed using structured interviews and medical records in 2000-2001. Information on mortality and causes of death was obtained of those who died by the end of year 2013. Cox proportional hazards models were used to investigate the mortality risk.

RESULTS

No people with affective psychoses (n=36) died during the follow-up, thus the analysis was restricted to non-affective psychotic disorders (NAP) (n=106). Adjusting for age and sex, NAP was statistically significantly associated with all-cause mortality (hazard ratio (HR) 2.99, 95% CI 2.03-4.41) and natural-cause mortality (HR 2.81, 95% CI 1.85-4.28). After adjusting for sociodemographic factors, health status, inflammation and smoking, the HR dropped to 2.11 (95% CI 1.10-4.05) for all-cause and to 1.98 (95% CI 0.94-4.16) for natural-cause mortality. Within the NAP group, antipsychotic use at baseline was associated with reduced HR for natural-cause mortality (HR 0.25, 95% CI 0.07-0.96), and smoking with increased HR (HR 3.54, 95% CI 1.07-11.69).

CONCLUSIONS

The elevated mortality risk in people with NAP is only partly explained by socioeconomic factors, lifestyle, cardio-metabolic comorbidities and inflammation. Smoking cessation should be prioritized in treatment of psychotic disorders. More research is needed on the quality of treatment of somatic diseases in people with psychotic disorders.

3. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2018

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Health care use, drug treatment and comorbidity in patients with schizophrenia or non-affective psychosis in Sweden: a cross-sectional study

BACKGROUND

This study investigated the prevalence of schizophrenia (ICD-10 F 20) and of other non-affective psychosis (NAP, ICD-10 F 21 - F 29) in Sweden. It further assessed health care use, comorbidity and medication for these patient groups. Most studies either have a study population of patients with strictly defined schizophrenia or a psychosis population of which strict schizophrenia cases form a smaller set. The present study permits comparison of the two mutually exclusive patient groups using data at the individual level in the diagnosis of non-affective psychosis, use of health care, medical treatment and comorbidity by diagnosis or medical treatment.

METHODS

In 2012, data were extracted from a regional registry containing patient-level data on consultations, hospitalisations, diagnoses and dispensed drugs for the total population in the region of Stockholm (2.1 million inhabitants). The size of the total psychosis population was 18,769, of which 7284 had a diagnosis of schizophrenia. Crude prevalence rates and risk rates with 95% confidence intervals were calculated.

RESULTS

In 2012, the prevalence of schizophrenia and NAP was 3.5/1000 and 5.5/1000, respectively. Schizophrenia was most common among patients aged 50-59 years and NAP most common among patients aged 40-49 years. Schizophrenia patients used psychiatric health care more often than the NAP patients but less overall inpatient care (78.6 vs. 60.0%). The most prevalent comorbidities were substance abuse/dependence (7.9% in the schizophrenia group vs. 11.7% in the NAP group), hypertension (7.9 vs. 9.7%) and diabetes (6.9 vs. 4.8%). The parenteral form of long-acting injectable antipsychotics was more often dispensed to patients with schizophrenia (10 vs. 2%).

CONCLUSIONS

This study, analysing all diagnoses recorded in a large health region, confirmed prevalence rates found in previous studies. Schizophrenia patients use more psychiatric and less overall inpatient health care than NAP patients. Differences between the two patient groups in comorbidity and drug treatment were found. The registered rates of a substance abuse/dependence diagnosis were the most common comorbidity observed among the patients investigated. The observed differences between the schizophrenia and the NAP patients in health care consumption, comorbidity and drug treatment are relevant and warrant further studies.

Multiple physical healthcare needs among outpatients with schizophrenia: findings from a health examination study

BACKGROUND

Despite the abundant literature on physical comorbidity, the full range of the concurrent somatic healthcare needs among individuals with schizophrenia has rarely been studied.

AIMS

This observational study aimed to assess the distressing somatic symptoms and needs for physical health interventions in outpatients with schizophrenia, and factors predicting those needs.

METHODS

A structured, comprehensive health examination was carried out, including a visit to a nurse and a general practitioner on 275 outpatients with schizophrenia. The required interventions were classified by type of disease. Logistic regression was used to assess the influence of sociodemographic factors, lifestyle, functional limitations, factors related to psychiatric disorder, and healthcare use on the need for interventions.

RESULTS

In total, 44.9% of the patients (mean age 44.9 years) reported somatic symptoms affecting daily life; 87.6% needed specific interventions for a disease or condition, most commonly for cardiovascular, dermatological, dental, ophthalmological, and gastrointestinal conditions, and for altered glucose homeostasis. Smoking and obesity predicted significantly a need of any intervention, but the predictors varied in each disease category. Strikingly, use of general practitioner services during the previous year did not reduce the need for interventions.

CONCLUSIONS

Health examinations for outpatients with schizophrenia revealed numerous physical healthcare needs. The health examinations for patients with schizophrenia should contain a medical history taking and a physical examination, in addition to basic measurements and laboratory tests. Prevention and treatment of obesity and smoking should be given priority in order to diminish somatic comorbidities in schizophrenia.

Cardiometabolic management in severe mental illness requiring an atypical antipsychotic

INTRODUCTION

Cardiometabolic management was evaluated in patients with diabetes and a severe mental illness that require treatment with an atypical antipsychotic.

METHODS

Seventy-four patients with diabetes and a severe mental illness treated with an atypical antipsychotic from the Fargo Veterans' Affairs Health Care System were included in this retrospective study. Primary end points analyzed the change in hemoglobin A1c (Hgb A1c), blood pressure, and low-density lipoprotein (LDL) cholesterol 12 months prior to and 12 months following the initiation of an atypical antipsychotic. Secondary end points evaluated changes specific to clozapine and olanzapine. Additional secondary end points evaluated the medication management for cardiometabolic disease prior to and following atypical antipsychotic initiation.

RESULTS

In the 12 months following atypical antipsychotic initiation, there were no statistically significant changes in metabolic parameters. Mean Hgb A1c increased from 6.9% to 7.2% (P = .47), mean systolic blood pressure decreased slightly from 132 to 127.8 mm Hg (P = .97), mean diastolic blood pressure decreased slightly from 79.6 to 76.6 mm Hg (P = .19), and mean LDL remained unchanged at 104.4 mg/dL (P = .92). Medications to control cardiometabolic disease increased substantially following atypical antipsychotic initiation; 35.1%, 39.2%, and 39.2% of patients were started on one or more new antihyperglycemics, antihypertensives, and statins, respectively.

DISCUSSION

Patients had a significant increase in prescriptions to manage cardiometabolic disease in the 12 months following initiation of an atypical antipsychotic. Although medications to manage cardiometabolic disease increased, the actual metabolic parameters did not significantly change during the same time period.

Postmortem evidence of cerebral inflammation in schizophrenia: a systematic review

Schizophrenia is a psychiatric disorder which has a lifetime prevalence of ~1%. Multiple candidate mechanisms have been proposed in the pathogenesis of schizophrenia. One such mechanism is the involvement of neuroinflammation. Clinical studies, including neuroimaging, peripheral biomarkers and randomized control trials, have suggested the presence of neuroinflammation in schizophrenia. Many studies have also measured markers of neuroinflammation in postmortem brain samples from schizophrenia patients. The objective of this study was to conduct a systematic search of the literature on neuroinflammation in postmortem brains of schizophrenia patients indexed in MEDLINE, Embase and PsycINFO. Databases were searched up until 20th March 2016 for articles published on postmortem brains in schizophrenia evaluating microglia, astrocytes, glia, cytokines, the arachidonic cascade, substance P and other markers of neuroinflammation. Two independent reviewers extracted the data. Out of 5385 articles yielded by the search, 119 articles were identified that measured neuroinflammatory markers in schizophrenic postmortem brains. Glial fibrillary acidic protein expression was elevated, lower or unchanged in 6, 6 and 21 studies, respectively, and similar results were obtained for glial cell densities. On the other hand, microglial markers were increased, lower or unchanged in schizophrenia in 11, 3 and 8 studies, respectively. Results were variable across all other markers, but SERPINA3 and IFITM were consistently increased in 4 and 5 studies, respectively. Despite the variability, some studies evaluating neuroinflammation in postmortem brains in schizophrenia suggest an increase in microglial activity and other markers such as SERPINA3 and IFITM. Variability across studies is partially explained by multiple factors including brain region evaluated, source of the brain, diagnosis, age at time of death, age of onset and the presence of suicide victims in the cohort.

Diabetes and Schizophrenia

People with schizophrenia have 2- to 5-fold higher risk of type 2 diabetes than the general population. The traditional risk factors for type 2 diabetes, especially obesity, poor diet, and sedentary lifestyle, are common in people with schizophrenia already early in the course of illness. People with schizophrenia also often have low socioeconomic status and income, which affects their possibilities to make healthy lifestyle choices. Antipsychotic medications increase the risk of type 2 diabetes both directly by affecting insulin sensitivity and indirectly by causing weight gain. Lifestyle modification interventions for prevention of diabetes should be an integral part of treatment of patients with schizophrenia. In the treatment of type 2 diabetes in patients with schizophrenia, communication and collaboration between medical care and psychiatric treatment providers are essential.

An evaluation of variation in published estimates of schizophrenia prevalence from 1990─2013: a systematic literature review

BACKGROUND

There is a lack of consistency in findings across studies on the prevalence of schizophrenia, and no recent systematic review of the literature exists. The purpose of this study is to provide an updated systematic review of population-based prevalence estimates and to understand the factors that could account for this variation in prevalence estimates.

METHODS

MEDLINE, Embase, and PsycInfo databases were searched for observational studies describing schizophrenia prevalence in general populations from 2003-2013 and supplemented by studies from a prior review covering 1990-2002. Studies reporting prevalence estimates from specialized populations such as institutionalized, homeless, or incarcerated persons were excluded. Prevalence estimates were compared both across and within studies by factors that might contribute to variability using descriptive statistics.

RESULTS

Sixty-five primary studies were included; thirty-one (48 %) were from Europe and 35 (54 %) were conducted in samples of ≥50,000 persons. Among 21 studies reporting 12-month prevalence, the median estimate was 0.33 % with an interquartile range (IQR) of 0.26 %-0.51 %. The median estimate of lifetime prevalence among 29 studies was 0.48 % (IQR: 0.34 %-0.85 %). Prevalence across studies appeared to vary by study design, geographic region, time of assessment, and study quality scores; associations between study sample size and prevalence were not observed. Within studies, age-adjusted estimates were higher than crude estimates by 17 %-138 %, the use of a broader definition of schizophrenia spectrum disorders compared to schizophrenia increased case identification by 18 %-90 %, identification of cases from inpatient-only settings versus any setting decreased prevalence by 60 %, and no consistent trends were noted by differing diagnostic criteria.

CONCLUSIONS

This review provides updated information on the epidemiology of schizophrenia in general populations, which is vital information for many stakeholders. Study characteristics appear to play an important role in the variation between estimates. Overall, the evidence is still sparse; for many countries no new studies were identified.

Lung function and respiratory diseases in people with psychosis: population-based study

BACKGROUND

There is little information on lung function and respiratory diseases in people with psychosis.

AIMS

To compare the respiratory health of people with psychosis with that of the general population.

METHOD

In a nationally representative sample of 8028 adult Finns, lung function was measured by spirometry. Information on respiratory diseases and symptoms was collected. Smoking was quantified with serum cotinine levels. Psychotic disorders were diagnosed utilising the Structured Clinical Interview for DSM-IV (SCID-I) and medical records.

RESULTS

Participants with schizophrenia and other non-affective psychoses had significantly lower lung function values compared with the general population, and the association remained significant for schizophrenia after adjustment for smoking and other potential confounders. Schizophrenia was associated with increased odds of pneumonia (odds ratio (OR) = 4.9), chronic obstructive pulmonary disease (COPD, OR = 4.2) and chronic bronchitis (OR = 3.8); and with high cotinine levels.

CONCLUSIONS

Schizophrenia is associated with impaired lung function and increased risk for pneumonia, COPD and chronic bronchitis.

The epidemiology of diabetes in psychotic disorders

Diabetes is highly prevalent in people with psychotic disorders, including schizophrenia and schizoaffective disorders. Exact prevalence is difficult to estimate, since diabetes is often underdiagnosed in people with psychosis. Results of several studies show that the prevalence of diabetes exceeds that in the general population, with documented prevalence in those with psychosis ranging from 1·26% to 50% across studies (median 13%). The association between diabetes and psychosis is complex and multifactorial. Many of the traditional risk factors for disease have increased prevalence in patients with psychotic disorders. In addition to these traditional risk factors, people with psychosis have unique risks that might have additive or even synergistic effects. These risks include the use of antipsychotic medication, the effects of adverse social determinants of health, and genetic loading. Despite evidence that rates of diabetes are increased in individuals with psychosis, many of these patients are not diagnosed or treated, resulting in increased diabetes-associated morbidity and mortality. Specific patient factors, provider issues, and systems-level factors contribute to the treatment gap. Interventions at both the clinical and public health levels are needed to successfully address this problem.

Human Rho guanine nucleotide exchange factor 11 gene is associated with schizophrenia in a Japanese population

OBJECTIVE

The human Rho guanine nucleotide exchange factor 11 (ARHGEF11) gene is one of the candidate genes for type 2 diabetes mellitus (T2DM). ARHGEF11 is mapped to chromosome 1q21, which has susceptible risk loci for T2DM and schizophrenia. We hypothesized that ARHGEF11 contributes to the pathogenesis of schizophrenia.

METHOD

We selected eight single nucleotide polymorphisms of ARHGEF11 that had significant associations with T2DM for a case-control association study of 490 patients with schizophrenia and 500 age-matched and sex-matched controls.

RESULTS

We did not find any differences in allelic, genotypic associations, or minor allele frequencies with schizophrenia. Analysis of the rs6427340-rs6427339 haplotype and the rs822585-rs6427340-rs6427339 haplotype combination provided significant evidence of an association with schizophrenia (global permutations p = 0.00047 and 0.0032, respectively). C-C of the rs6427340-rs6427339 haplotype and A-C-C of the rs822585-rs6427340-rs6427339 haplotype carried higher risk factors for schizophrenia (permutation p = 0.0010 and 0.0018, respectively). A-C-T of the rs822585-rs6427340-rs6427339 haplotype had a possible protective effect (permutation p = 0.031).

CONCLUSION

These results provide new evidence that ARHGEF11 may constitute a risk factor for schizophrenia.

A meta-analysis of cardio-metabolic abnormalities in drug naïve, first-episode and multi-episode patients with schizophrenia versus general population controls

A meta-analysis was conducted to explore the risk for cardio-metabolic abnormalities in drug naïve, first-episode and multi-episode patients with schizophrenia and age- and gender- or cohort-matched general population controls. Our literature search generated 203 relevant studies, of which 136 were included. The final dataset comprised 185,606 unique patients with schizophrenia, and 28 studies provided data for age- and gender-matched or cohort-matched general population controls (n=3,898,739). We found that multi-episode patients with schizophrenia were at increased risk for abdominal obesity (OR=4.43; CI=2.52-7.82; p<0.001), hypertension (OR=1.36; CI=1.21-1.53; p<0.001), low high-density lipoprotein cholesterol (OR=2.35; CI=1.78-3.10; p<0.001), hypertriglyceridemia (OR=2.73; CI=1.95-3.83; p<0.001), metabolic syndrome (OR=2.35; CI=1.68-3.29; p<0.001), and diabetes (OR=1.99; CI=1.55-2.54; p<0.001), compared to controls. Multi-episode patients with schizophrenia were also at increased risk, compared to first-episode (p<0.001) and drug-naïve (p<0.001) patients, for the above abnormalities, with the exception of hypertension and diabetes. Our data provide further evidence supporting WPA recommendations on screening, follow-up, health education and lifestyle changes in people with schizophrenia.

Mortality and its determinants in people with psychotic disorder

OBJECTIVE

We investigated mortality and its determinants in people with psychotic disorder.

METHODS

A nationally representative two-stage cluster sample of 8028 persons aged 30 years or older from Finland was selected for a comprehensive health survey conducted from 2000 to 2001. Participants were screened for psychotic disorder, and screen-positive persons were invited for a Structured Clinical Interview for DSM-IV. The diagnostic assessment of DSM-IV psychotic disorders was based on the Structured Clinical Interview for DSM-IV, case records from mental health treatments, or both. Mortality was followed up until September 2009 and analyzed using Cox proportional hazards model.

RESULTS

People with schizophrenia (hazard ratio [HR] = 3.03; 95% confidence interval [CI] = 1.93-4.77) and other nonaffective psychoses (HR = 1.84; 95% CI = 1.17-2.91) had elevated mortality risk, whereas people with affective psychoses did not (HR = 0.61; 95% CI = 0.24-1.55). Antipsychotic medication use was associated with increased mortality (HR = 2.34; 95% CI = 1.86-2.96). There was an interaction between antipsychotic medication use and the presence of a psychotic disorder: antipsychotic medication use was only associated with elevated mortality in persons who were using antipsychotics and did not have primary psychotic disorder. In persons with psychotic disorder, mortality was predicted by smoking and Type 2 diabetes at baseline survey.

CONCLUSIONS

Schizophrenia and nonaffective psychoses are associated with increased mortality risk, whereas affective psychoses are not. Antipsychotic medication use increases mortality risk in older people without primary psychotic disorder, but not in individuals with schizophrenia. Smoking and Type 2 diabetes are important predictors of elevated mortality risk in persons with psychotic disorder.

The influence of the brain-derived neurotropic factor Val66Met genotype and HMG-CoA reductase inhibitors on insulin resistance in the schizophrenia and bipolar populations

INTRODUCTION

The brain-derived neurotrophic factor (BDNF) Val66Met variant and HMG-COA reductase inhibitors (statins) have been implicated in insulin resistance with a possible increased risk of diabetes. We sought to determine the effect of the BDNF Met variant and statin medication use on insulin resistance in schizophrenia and bipolar disorder using the homeostasis model assessment of insulin resistance (HOMA-IR).

METHODS

A cross-sectional design was used and patients with diabetes or on any medications affecting glucose regulation were -excluded. Associations between insulin resistance and genotype were then analyzed by ANOVA and regression analysis. Subjects were grouped by BDNF genotype as well as presence of statin.

RESULTS

Two hundred fifty-two subjects with a mean age of 44 years were included. The group was 53% male and 41% had a diagnosis of bipolar disorder; 78% and 19% were receiving atypical antipsychotics (AAPs) and statin medications, respectively. Analysis showed schizophrenia subjects with the BDNF met allele as well as schizophrenia subjects with both the BDNF met allele and were receiving a statin had significantly higher HOMA-IR values compared to the other groups (p= 0.046 and p= 0.016, respectively).

CONCLUSIONS

Our results suggest that in the metabolically high-risk population of schizophrenia the BDNF met allele alone and in combination with statin medications is associated with higher insulin resistance values. This was not seen in the bipolar population. Further validation of these associations remains necessary.

Diabetes is associated with lower global cognitive function in schizophrenia

BACKGROUND

Co-morbidity of schizophrenia (SZ) and metabolic problems such as diabetes mellitus (DM) has been suggested by many studies. Nonetheless, it is still debated whether DM affects cognitive dysfunction associated with SZ and how much treatment for DM is beneficial for cognitive functions in SZ. We addressed these questions by re-assessing the cognitive dataset from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia study.

METHODS

We identified 1289 SZ patients in which scores for several cognitive domains of verbal memory, vigilance, processing speed, reasoning, and working memory together with the composite score and metabolic characteristics (body mass index, dyslipidemia, hypertension, and DM) were available at baseline of the trial. We performed multiple linear regression analyses to assess the impact of DM on cognitive performance of SZ patients, controlling for a number of other confounding factors including obesity, hypertension, and dyslipidemia. We also conducted analyses of covariance to compare cognitive performance among SZ patients without DM and diabetic SZ sub-groups based on anti-diabetic drugs they were receiving at baseline of the trial.

RESULTS

Co-morbid DM with SZ predicted worse overall cognitive performance and lower scores for three cognitive domains (vigilance, processing speed, and reasoning), but none of the other metabolic factors (i.e., obesity, hypertension and dyslipidemia) correlated with cognitive function in SZ. Furthermore, SZ patients with untreated DM showed poorer overall cognitive performance and a significantly lower score in the domain of vigilance compared with SZ patients without DM.

CONCLUSION

Our data suggest that DM negatively affects the overall cognitive function of SZ patients.

An association between high birth weight and schizophrenia in a Finnish schizophrenia family study sample

Longitudinal cohort studies have implicated an association between both low and high birth weight and schizophrenia. It has been suggested that schizophrenia associated genes could augment an individual's susceptibility to adverse prenatal and perinatal environmental events. We investigated the association between birth weight and schizophrenia in a large Finnish schizophrenia family study sample. We utilized the birth weight data of 1051 offspring from 315 Finnish families with at least one offspring with a diagnosis of schizophrenia. We used a multivariate COX frailty model to analyze the effect of birth weight on the risk of developing schizophrenia within the families. Using information from the Medication Reimbursement Register and patient interviews, we further investigated the association of maternal type 2 diabetes and schizophrenia risk among offspring. High birth weight (>4000g) was associated with a 1.68-fold increase in schizophrenia susceptibility. Maternal diabetes at the time of data collection, a proxy for gestational diabetes, was associated with a 1.66-fold increase in the risk of developing schizophrenia among offspring. Our results corroborate recent findings showing an association between high birth weight and schizophrenia. Our results also point to a potential birth-weight independent association between maternal type 2 diabetes and schizophrenia among offspring.

Inflammation in psychotic disorders: a population-based study

We investigated inflammatory markers in psychotic disorders and their association with metabolic comorbidity, antipsychotic medication, smoking, alcohol use, physical condition, and mood. From the population-based Finnish Health 2000 study, we identified all persons with schizophrenia (n=45), other nonaffective psychosis (ONAP) (n=57), affective psychosis (n=37) and chose controls matched by age, sex, and region of residence. We found that persons with schizophrenia had significantly higher sIL-2Rα, IL-1RA and C-reactive protein (CRP), persons with ONAP significantly higher IL-1RA and CRP and persons with affective psychosis almost significantly higher TNF-α compared to their matched controls. Current antipsychotic use was associated with elevated IL-1RA and CRP. After taking metabolic and lifestyle-related variables that associated with inflammatory markers into account, only antipsychotic medication remained associated with elevated IL-1RA and TNF-α which are markers related to the activation of innate immune system. CRP was influenced by both antipsychotic medication and nonaffective psychosis. sIL-2Rα, a marker of T-cell activation, was associated with depressive symptoms, schizophrenia, and affective psychosis. We conclude that in persons with psychotic disorders, activation of mononuclear phagocyte system was mostly related to metabolic comorbidity and antipsychotic medication use, whereas T-cell activation had a more direct relationship with both psychotic disorders and depressive symptoms.

A retrospective comparison of BMI changes and the potential risk factors among schizophrenic inpatients treated with aripiprazole, olanzapine, quetiapine or risperidone

The objective of this study was to evaluate weight gain and its potential risk factors among different second generation antipsychotics (SGAs). The study was conducted for Korean inpatients with schizophrenia in a university hospital in Seoul, between Jan 2000 and Dec 2007. Data were collected by reviewing the medical records of the patients, who were prescribed to one of the SGAs among aripiprazole, olanzapine, quetiapine or risperidone. The changes of weight and body mass index (BMI); risk of clinically significant weight gain (>7% gain to initial weight) and their associations with various clinical characteristics of such patients were analyzed. Five hundred and eighty-eight (588) and 294 subjects treated with one of the four SGAs for a duration of 1 month and 2 months were included, respectively. Olanzapine showed significantly greater weight and BMI increase at month 1 (p=0.028 for weight; p=0.019 for BMI) and month 2 (p=0.032 for weight; p=0.029 for BMI) than others. Females showed greater BMI increase change (0.70±0.91 kg/m(2), p=0.008) and were also more likely to experience clinically significant weight gain (odd ratio=1.846, 95% CI=1.098 to 3.105, p=0.021) at month 1. Younger patients (<45 years old) had significantly greater weight and BMI increase at both months 1 and 2. Younger patients also showed greater risk for clinically significant weight gain at month 2 (odd odd ratio=2.567, 95% CI=1.196 to 5.508, p=0.016). Low baseline BMI (<25 kg/m(2)) was associated with greater weight gain at month 1 (1.92±2.29 kg, p<0.001) and month 2 (4.07±3.56 kg, p<0.001) and BMI increase at month 1 and month 2 (p<0.001 for both). Patients with low baseline BMI showed higher risk of clinically significant weight gain at both months 1 and 2 (p<0.001 for both). Olanzapine was shown to have higher metabolic risk than other SGAs in inpatients with schizophrenia. The individual's own clinical characteristics also exerted influence on weight gain effects of SGAs. Younger patients with lower baseline BMI were under greater risk of antipsychotic-induced weight gain. More studies are required to verify the role of gender on weight gain.

Metabolome in schizophrenia and other psychotic disorders: a general population-based study

BACKGROUND

Persons with schizophrenia and other psychotic disorders have a high prevalence of obesity, impaired glucose tolerance, and lipid abnormalities, particularly hypertriglyceridemia and low high-density lipoprotein. More detailed molecular information on the metabolic abnormalities may reveal clues about the pathophysiology of these changes, as well as about disease specificity.

METHODS

We applied comprehensive metabolomics in serum samples from a general population-based study in Finland. The study included all persons with DSM-IV primary psychotic disorder (schizophrenia, n = 45; other non-affective psychosis (ONAP), n = 57; affective psychosis, n = 37) and controls matched by age, sex, and region of residence. Two analytical platforms for metabolomics were applied to all serum samples: a global lipidomics platform based on ultra-performance liquid chromatography coupled to mass spectrometry, which covers molecular lipids such as phospholipids and neutral lipids; and a platform for small polar metabolites based on two-dimensional gas chromatography coupled to time-of-flight mass spectrometry (GC × GC-TOFMS).

RESULTS

Compared with their matched controls, persons with schizophrenia had significantly higher metabolite levels in six lipid clusters containing mainly saturated triglycerides, and in two small-molecule clusters containing, among other metabolites, (1) branched chain amino acids, phenylalanine and tyrosine, and (2) proline, glutamic, lactic and pyruvic acids. Among these, serum glutamic acid was elevated in all psychoses (P = 0.0020) compared to controls, while proline upregulation (P = 0.000023) was specific to schizophrenia. After adjusting for medication and metabolic comorbidity in linear mixed models, schizophrenia remained independently associated with higher levels in seven of these eight clusters (P < 0.05 in each cluster). The metabolic abnormalities were less pronounced in persons with ONAP or affective psychosis.

CONCLUSIONS

Our findings suggest that specific metabolic abnormalities related to glucoregulatory processes and proline metabolism are specifically associated with schizophrenia and reflect two different disease-related pathways. Metabolomics, which is sensitive to both genetic and environmental variation, may become a powerful tool in psychiatric research to investigate disease susceptibility, clinical course, and treatment response.

Activities of daily living, social functioning and their determinants in persons with psychotic disorder

OBJECTIVE

The determinants of everyday functioning in persons with psychotic disorder have not been widely studied in community dwelling samples. Our aim was to investigate limitations in everyday functioning among subjects with psychotic disorders in a population-based study.

METHOD

Everyday functioning was assessed in a nationally representative sample of 7112 persons aged 30+ using interviewer observations and self-reports, while verbal fluency and memory were also measured. Diagnostic assessment of DSM-IV psychotic disorders was based on SCID interview and case-note data. Lifetime-ever diagnoses of psychotic disorder were classified into schizophrenia (n=61), other non-affective psychotic disorders (ONAP) (n=79) and affective psychoses (n=45).

RESULT

Non-affective psychotic disorder was significantly associated with limitations in everyday functioning, as well as with deficits in verbal fluency and memory. Negative symptoms, depression, age, gender, verbal memory deficits, and reduced visual acuity were predictors of limitations in everyday functioning even after controlling for sociodemographic factors and chronic medical conditions, and difficulties in social functioning were also related to expressive speech problems.

CONCLUSION

Persons with schizophrenia and ONAP have significantly more problems in everyday functioning than the general population. One significant predictor of problems was reduced visual acuity, which at least in some situations could be easily corrected.

The prevalence and clinical correlates of metabolic syndrome in patients with schizophrenia: findings from a cohort in Turkey

Most studies point to an increased prevalence of metabolic syndrome (MS) and an increased risk of coronary heart disease (CHD) in schizophrenia patients with MS. The aims of this study were to compare the prevalence of MS in schizophrenia patients with the general population, to explore the clinical correlates and predictors of MS and to evaluate the risk for CHD within 10 years. Consecutive 319 patients, aged 18-75 years, with a diagnosis of schizophrenia according to the DSM-IV were enrolled. The ATP-III, the ATP-IIIA and the IDF criteria were used to define MS. 10-year risk of CHD events was calculated with the Framingham score. One hundred nine (34.2%) patients met the ATP-III criteria, 118 (37%) the ATP-IIIA and 133 (41.7%) the IDF criteria for MS. Patients with MS were older, had a later onset of illness and an older age at first hospitalization. The prevalence of MS in schizophrenia patients was higher from the general population only within the 20-29 age group. Patients with MS had a higher age and sex-corrected 10-year risk of CHD events. The only predictor of MS was the age of illness onset. In conclusion, countries where the general population prevalence of MS is already too high, schizophrenia patients younger than 30 years of age might be under higher risk of morbidity and mortality related with MS. This study points to the necessity for aggressive interventions to correct MS in schizophrenia as early as possible, within the first 10 years of post detection.

Cholesterol and triglycerides in antipsychotic-naive patients with nonaffective psychosis

Patients with psychosis have an increased prevalence of hyperlipidemia. We compared fasting concentrations of lipids in newly diagnosed, antipsychotic-naïve patients with nonaffective psychosis (N=87) and control subjects (N=92). After accounting for gender, age, smoking, socioeconomic status, and body mass index, there was no significant difference between the two groups in total cholesterol, high-density lipoproteins, low-density lipoproteins, or triglycerides.

Prevalence of diabetes and antipsychotic prescription patterns in patients with schizophrenia: a nationwide retrospective cohort study

INTRODUCTION

Despite an increasing concern that atypical antipsychotics seem to have a stronger diabetogenic risk than conventional antipsychotics, little information is available on the prevalence of diabetes among schizophrenia patients, and prescription patterns for patients with comorbid schizophrenia and diabetes in Japan.

OBJECTIVES

To compare the prevalence of diabetes between schizophrenia patients and the general population and to investigate whether diabetes status correlates the prescription patterns of antipsychotics at hospital discharge.

METHODS

Schizophrenia patients who were discharged between April 2004 and March 2005 and who continued to receive outpatient treatment from 526 hospitals were included in this retrospective open cohort study. We collected information about the doctor diagnosis of diabetes during hospitalization, and drug prescriptions for schizophrenia at hospital discharge using medical charts.

RESULTS

The overall prevalence of diabetes was 8.6% among patients with schizophrenia. Compared with the general population, the estimates of diabetes prevalence in the schizophrenia population were 2.6-10.8 percentage point higher among males aged 30-49 years, and 1.9-9.9 percentage point higher among females aged 40-59 years. The odds of being prescribed conventional antipsychotics were about 2 times higher among patients with diabetes than without diabetes, relative to atypical and combination of conventional and atypical antipsychotics. These results were robust across various sensitivity analyses.

CONCLUSION

When treating schizophrenia patients with preexisting diabetes, psychiatrists need to monitor the occurrence of diabetes regularly regardless of antipsychotic class, strike a balance, and provide the most efficacious antipsychotic medication.

Coronary heart disease and cardiac conduction abnormalities in persons with psychotic disorders in a general population

We investigated the prevalence of coronary heart disease (CHD) and myocardial infarction (MI) in persons with DSM-IV psychotic disorders. We also examined cardiac conduction abnormalities, and the role of antipsychotic medication in them. The study was based on a nationally representative survey of 8028 persons aged 30 years or over from Finland. Diagnoses of CHD and MI were based on electrocardiographic findings, health examination, and register information. QTc was calculated using the Bazett formula, and Minnesota classification was used for conduction abnormalities. We found that large Q-waves suggesting past MI were significantly more frequent in persons with schizophrenia, while the prevalence of CHD in persons with psychotic disorders did not differ significantly from the remaining study sample. Prevalence of prolonged QTc interval was significantly increased in persons with schizophrenia and in users of typical antipsychotics. However, low-potency antipsychotic use but not diagnosis of schizophrenia remained an independent predictor of prolonged QTc interval in a logistic regression. Low-potency antipsychotic use was associated with ventricular conduction defects, and high-potency antipsychotic use with premature beats. Symptoms and signs of CHD should be actively monitored patients with schizophrenia, and the electrocardiogram should be monitored for all types of changes in persons receiving antipsychotic medication.

Body composition in psychotic disorders: a general population survey

BACKGROUND

The literature suggests an association between obesity and schizophrenia but fat mass and fat-free mass, which have been shown to be more predictive of all-cause mortality than only waist circumference and obesity [body mass index (BMI) 30 kg/m2], have not been reported in psychotic disorders. We examined the detailed body composition of people with different psychotic disorders in a large population-based sample.

METHOD

We used a nationally representative sample of 8082 adult Finns aged 30 years with measured anthropometrics (height, weight, waist circumference, fat percentage, fat-free mass and segmental muscle mass). Psychiatric diagnoses were based on a consensus procedure utilizing the Structured Clinical Interview for DSM-IV (SCID)-interview, case-notes and comprehensive register data.

RESULTS

Schizophrenia (including schizo-affective disorder) was associated with obesity [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.5-3.6], abdominal obesity (waist circumference 88 cm for women, 102 cm for men) (OR 2.2, 95% CI 1.3-3.6) and with higher fat percentage (mean difference 3.8%, 95% CI 2.0-5.7%), adjusted for age and gender, than in the remaining sample. The associations between schizophrenia and low fat-free mass and decreased muscle mass on trunk and upper limbs became statistically significant after adjusting for BMI. After further adjusting for current antipsychotic medication, education, diet and smoking, schizophrenia remained associated with obesity (OR 1.9, 95% CI 1.1-3.6) and abdominal obesity (OR 3.8, 95% CI 1.5-9.4). Participants with affective psychoses did not differ from the general population.

CONCLUSIONS

Individuals with schizophrenia have metabolically unfavorable body composition, comprising abdominal obesity, high fat percentage and low muscle mass. This leads to increased risk of metabolic and cardiovascular diseases.

Mobility limitations in persons with psychotic disorder: findings from a population-based survey

BACKGROUND

There are few reports on mobility limitations in persons with psychotic disorder although restrictions in mobility may aggravate the general functional limitations of these patients. Our aim was to investigate mobility limitations among subjects with psychotic disorder in a general population-based sample.

METHODS

A nationally representative sample of 6,927 persons aged 30 and older self-reported mobility limitations in an interview and was examined in performance tests. Diagnostic assessment of DSM-IV psychotic disorders combined SCID interview and case note data. Lifetime-ever diagnoses of psychotic disorder were classified into schizophrenia, other nonaffective psychotic disorders and affective psychoses.

RESULTS

Self-reported mobility limitations were highly prevalent in persons with schizophrenia and other nonaffective psychosis, but not in the affective psychosis group. After adjusting for age and sex, persons with schizophrenia and other nonaffective psychoses but not affective psychoses had significantly increased odds of having both self-reported and test-based mobility limitations as well as weak muscle strength. Schizophrenia remained an independent predictor of mobility limitations even after controlling for lifestyle-related factors and chronic medical conditions. Among persons with nonaffective psychoses, higher levels of negative symptoms predicted mobility limitations.

CONCLUSION

Self-reported mobility limitations are prevalent already at a young age in persons with schizophrenia and other nonaffective psychotic disorders, and among older persons with these disorders both self-reported limitations and measured performance tests show lower capacity in mobility. Difficulties in mobility are associated with negative symptoms. Mental health care professionals should pay attention to mobility limitations in persons with psychotic disorder.

Five-year mortality of Finnish schizophrenia patients in the era of deinstitutionalization

BACKGROUND

Excess mortality among people with schizophrenia due to natural and unnatural causes, especially due to suicides, is a well-known fact. It has been suggested that deinstitutionalization increases suicide mortality but there are also contradictory results. We studied the changes in mortality and causes of death among schizophrenia sufferers during and after the years of deinstitutionalization process in Finland.

METHOD

The sample, identified from the Finnish hospital discharge register (FHDR), consisted of patients aged 15-65 and hospitalized for the first time due to schizophrenia. We focused on the 5-year follow-up from inclusion years 1980-1998 (N=23,959). Changes in 5-year follow-up mortality during the study period were explored for both genders and for different causes of death separately using multivariate logistic regression analyses.

RESULTS

During the study period 1,926 deaths occurred. Suicide was the major cause of death in both genders. A significant reduction in overall 5-year mortality was observed among persons hospitalized in 1995-1998 when compared to people hospitalized 1980-1984. In males a significant reduction was seen in all mortality (P=0.025) due to suicides (P=0.007) but not in the case of natural deaths. In females no significant changes in mortality were found.

CONCLUSIONS

Our study confirms a reduction in suicide mortality of male schizophrenia sufferers after the deinstitutionalization process. However the overall mortality is still very high and the attention needs to be focused on the general well-being of schizophrenia patients.

What a tangled web we weave: ethical and legal implications of deception in recruitment

Deception in human subject research is neither uncommon nor prohibited. The use of deception in the recruitment phase of clinical research has received relatively little attention. Given that informed consent is foundational to human subject research, the practice of misrepresenting the study purpose in clinical research would seem to contradict one of the fundamental tenets of ethical human subjects research. Using the example of prodromal psychosis, this article the ethical and legal implications of deception in recruitment and the sufficiency of current guidance on the practice when the study involves a stigmatizing condition, the collection of genetic samples, or both. I conclude that when these two elements are present, deception should only be used when absolutely necessary and, if used, researchers should be required to debrief participants before the collection of genetic samples and give particular attention to minimizing risks of privacy breaches.