Schizophrenia for primary care providers: how to contribute to the care of a vulnerable patient population

Longitudinal association of social isolation and loneliness with physical function among in-patients living with schizophrenia

WHAT IS KNOWN ON THE SUBJECT?: People living with schizophrenia have reduced physical function and are more likely to experience loneliness than those without condition. Low physical function is associated with greater loneliness in people with psychosis. However, it is unclear whether social isolation and loneliness contribute to impaired physical function in this population. Loneliness is linked to an increased risk of physical function impairment among older individuals, but research on patients living with schizophrenia is limited. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This study is the first to evaluate the longitudinal association of social isolation and loneliness with physical function among inpatients living with schizophrenia. It showed that more than one third of the participants experienced a decline in physical function over a 2-year period. Loneliness, rather than social isolation, was associated with an increase in physical function impairment over 2 years among inpatients living with schizophrenia. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Healthcare professionals should recognize loneliness as a potential risk factor for impaired physical function among inpatients diagnosed with schizophrenia. It is recommended that people living with schizophrenia are assessed for loneliness and that interventions are offered to alleviate their feelings of loneliness. Implementing interventions to reduce loneliness may help improve physical function and overall quality of life for individuals living with schizophrenia.

ABSTRACT

INTRODUCTION: Patients living with schizophrenia often experience low physical function, which is associated with negative health outcomes. Therefore, investigating the risk factors for physical function is crucial in this population.

AIM

This study examined the longitudinal association of social isolation and loneliness with physical function among inpatients living with schizophrenia.

METHODS

Physical function was assessed using measures of activities daily living (ADL), instrumental activities daily living (IADL) and the combination scores of ADL/IADL. Social isolation was indexed with five types of social connection and loneliness was measured using UCLA Loneliness Scale.

RESULTS

Social isolation was not associated with the measures of physical function over 2 years. Loneliness exhibited an association with IADL and ADL/IADL at follow-up, after adjustment for baseline levels of the outcomes. These associations remained when both social isolation and loneliness were simultaneously entered into the model.

DISCUSSION

Loneliness, rather than social isolation, was associated with increased physical function impairment over 2 years among inpatients living with schizophrenia.

IMPLICATIONS FOR PRACTICE

Healthcare professionals should consider loneliness as a potential risk factor for impaired physical function. It would be beneficial to assess patients for loneliness and implement interventions to reduce feelings of loneliness.

A Holistic Approach to Cardiopulmonary Concerns in a Schizophrenic Patient and Ensuring Quality Care

"Holistic approach" and "Quality Care" have been trending topics in the medical community for several decades, with holistic practice advocating for meeting patients' emotional, physiologic, psychological, and spiritual needs. In comparison, the quality care model highlights patient care metrics of equity, safety, and timeliness in medical treatment. Both converge on the concept of medical care centered around patients, with countless papers discussing their benefits in various healthcare settings. However, there is a gap in the literature regarding using both models to manage the mentally ill. Adopting the healthcare quality approach and incorporating a holistic perspective in managing psychiatric conditions can improve patient satisfaction and reduce societal and healthcare costs, making it an important area of further investigation. This paper will discuss the case of a 59-year-old male with schizophrenia who developed cardiopulmonary symptoms during his prolonged hospital stay, leading to extensive yet inefficient workup, in which his symptoms improved after implementing measures that uplifted his psyche. It will carefully examine holistic care's emotional and psychological aspects and the quality care domains for mentally ill patients. The case report aims to endorse integrating both models into the management of the psychiatric population to promote patient-centered and optimal quality of care.

Schizophrenia and risk of new-onset inflammatory bowel disease: a nationwide longitudinal study

BACKGROUND AND AIMS

Inflammatory bowel disease (IBD) is a chronic gastrointestinal inflammatory disorder with increasing global prevalence. The risk of IBD in patients with schizophrenia remains unclear. We aim to investigate the risk of new-onset IBD in patients with schizophrenia compared with matched controls.

METHODS

We conducted a retrospective, population-based cohort study utilising patient data from the Taiwan National Health Insurance Research Database collected between January 1, 2001, and December 31, 2011. Patients diagnosed with schizophrenia by board-certified psychiatrists without prior diagnosis of IBD were enrolled and matched to controls in 1:4 fashion by age, sex, residence, income level and medical comorbidities. Adjusted hazard ratios (HRs) for new-onset IBD and sub-analyses were determined using Cox regression analysis with adjustments.

RESULTS

Among 116 164 patients with schizophrenia and 464 656 matched controls, overall incidence of IBD among patients was significantly higher (1.14% vs. 0.25%). Average age of IBD diagnosis was 46.82 among patients with schizophrenia, versus 55.30 among controls. The HR of developing IBD among patients was 3.28, with a 95% confidence interval (95% CI) 2.49-4.33. IBD risk was higher among patients with psychiatric admissions more than once per year (HR 7.99, 95% CI 5.25-12.15) compared to those hospitalised less frequently (HR 2.72, 95% CI 2.03-3.66).

CONCLUSIONS

This population-based cohort study demonstrates a significant association between schizophrenia and subsequent IBD development. Patients with schizophrenia develop IBD at a younger age, and the risk increases with inadequately controlled schizophrenia. Physician vigilance and awareness of this correlation will improve IBD diagnosis and management among this vulnerable patient population.

The Importance of Patient-Centered Care in Colon Cancer Patients With Severe Mental Illness

There is an abundance of literature that highlights the importance of patient-centered communication with cancer patients requiring surgical intervention. While the need for communication for patients requiring surgery is well understood, less attention is brought to patients with severe mental illnesses. More literature is needed to highlight the importance and application of patient-centered care for patients suffering from both severe mental illness and cancer requiring surgical intervention. It is unclear if poor communication between patients and cancer-care specialists is part of the reason for the underlying discrepancy. Efforts to reduce this discrepancy may be worth considering as a priority for health care systems. We present a case of a 63-year-old man with schizophrenia who received a late cancer diagnosis after a missed screening, resulting in an extensive surgical resection for colon cancer. We explore the possibility of careful communication between the treating physician, patient, and patient’s caretakers potentially preventing the delay in his cancer diagnosis. Effective communication is especially important with mental health patients because of its effect on long-term physical and mental outcomes. We hope to further the discussion on how to better cater to this specific population of patients undergoing cancer surgery.

The role of trust and hope in antipsychotic medication reviews between GPs and service users a realist review

BACKGROUND

Increasing number of service users diagnosed with schizophrenia and psychosis are being discharged from specialist secondary care services to primary care, many of whom are prescribed long-term antipsychotics. It is unclear if General Practitioners (GPs) have the confidence and experience to appropriately review and adjust doses of antipsychotic medication without secondary care support.

AIM

To explore barriers and facilitators of conducting antipsychotic medication reviews in primary care for individuals with no specialist mental health input.

DESIGN & SETTING

Realist review in general practice settings.

METHOD

A realist review has been conducted to synthesise evidence on antipsychotic medication reviews conducted in primary care with service users diagnosed with schizophrenia or psychosis. Following initial scoping searches and discussions with stakeholders, a systematic search and iterative secondary searches were conducted. Articles were systematically screened and analysed to develop a realist programme theory explaining the contexts (C) and mechanisms (M) which facilitate or prevent antipsychotic medication reviews (O) in primary care settings, and the potential outcomes of medication reviews.

RESULTS

Meaningful Antipsychotic medication reviews may not occur for individuals with only primary care medical input. Several, often mutually reinforcing, mechanisms have been identified as potential barriers to conducting such reviews, including low expectations of recovery for people with severe mental illness, a perceived lack of capability to understand and participate in medication reviews, linked with a lack of information shared in appointments between GPs and Service Users, perceived risk and uncertainty regarding antipsychotic medication and illness trajectory.

CONCLUSIONS

The review identified reciprocal and reinforcing stereotypes affecting both GPs and service users. Possible mechanisms to counteract these barriers are discussed, including realistic expectations of medication, and the need for increased information sharing and trust between GPs and service users.

The role of pharmacy in the management of cardiometabolic risk, metabolic syndrome and related diseases in severe mental illness: a mixed-methods systematic literature review

BACKGROUND

Individuals with severe mental illness, e.g. schizophrenia have up to a 20% shortened life expectancy compared to the general population. Cardiovascular disease, due to cardiometabolic risk and metabolic syndrome, accounts for most of this excess mortality. A scoping search revealed that there has not been a review of published studies on the role of pharmacy in relation to cardiometabolic risk, metabolic syndrome and related diseases (e.g. type 2 diabetes) in individuals with severe mental illness.

METHODS

A mixed-methods systematic review was performed. Eleven databases were searched using a comprehensive search strategy to identify English-language studies where pharmacy was involved in an intervention for cardiometabolic risk, metabolic syndrome or related diseases in severe mental illness in any study setting from any country of origin. First, a mapping review was conducted. Then, implementation strategies used to implement the study intervention were classified using the Cochrane Effective Practice and Organisation of Care Taxonomy. Impact of the study intervention on the process (e.g. rate of diagnosis of metabolic syndrome) and clinical (e.g. diabetic control) outcomes were analysed where possible (statistical tests of significance obtained for quantitative outcome parameters reported). Quality assessment was undertaken using a modified Mixed Methods Appraisal Tool.

RESULTS

A total of 33 studies were identified. Studies were heterogeneous for all characteristics. A total of 20 studies reported quantitative outcome data that allowed for detailed analysis of the impact of the study intervention. The relationship between the total number of implementation strategies used and impact on outcomes measured is unclear. Inclusion of face-to-face interaction in implementation of interventions appears to be important in having a statistically significantly positive impact on measured outcomes even when used on its own. Few studies included pharmacy staff in community or general practitioner practices (n = 2), clinical outcomes, follow up of individuals after implementation of interventions (n = 3). No studies included synthesis of qualitative data.

CONCLUSIONS

Our findings indicate that implementation strategies involving face-to-face interaction of pharmacists with other members of the multidisciplinary team can improve process outcomes when used as the sole strategy. Further work is needed on clinical outcomes (e.g. cardiovascular risk reduction), role of community pharmacy and qualitative studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018086411.

Breast cancer endocrine therapy adherence in health professional shortage areas: Unique effects on patients with mental illness

OBJECTIVE

Evaluate whether breast cancer endocrine therapy adherence is affected by access to primary and mental health care, particularly among at-risk patients with mental illness.

METHODS

The study included 21,892 SEER-Medicare women aged 68 or older with stage I-IV ER+ breast cancer, 2007 to 2013. Patient home counties during breast cancer diagnosis, if evaluated for HPSA care shortage status, were categorized as least, moderate, or highest shortage; unevaluated counties (no known shortage) were a fourth category. Endocrine therapy initiation and discontinuation were analyzed with Cox regression, and daily adherence with longitudinal linear regression.

RESULTS

After multivariate adjustment, patients in high primary care shortage counties were less likely to initiate endocrine therapy, reference least shortage [HR 0.92 (95% CI 0.86-0.97)]. Unevaluated counties had more oncologists per capita, fewer residents below the federal poverty level, and higher incomes. Mental health shortages were not associated with outcomes, however subgroups living in unevaluated counties were less likely to discontinue: patients with bipolar and psychotic disorders [discontinuation HR 0.35 (95% CI 0.17-0.73)], substance use [HR 0.48 (95% CI 0.24-0.95)], anxiety disorders [HR 0.56 (95% CI 0.35-0.90)].

CONCLUSIONS

Poor primary care access was associated with a lower likelihood of initiating endocrine therapy but living in counties without established mental health shortages may reduce the harmful association between mental illness and incomplete treatment receipt. Patients with mental illness may be more equipped to complete cancer treatment if given better mental health care access, suggesting a need for care coordination between primary and mental health care.

Asenapine and iloperidone decrease the expression of major cytochrome P450 enzymes CYP1A2 and CYP3A4 in human hepatocytes. A significance for drug-drug interactions during combined therapy

Antipsychotics are often used in combination with other psychotropic drugs to treat a variety of psychiatric disorders, as well as in combination with other drugs taken by patients with co-morbidities. When these drugs are combined, the potential for drug-drug interaction increases, leading to side-effects, in addition to the predicted increase in effectiveness. The present study aimed at examining the effects of the three atypical neuroleptics asenapine, lurasidone and iloperidone on cytochrome P450 (CYP) expression in the human liver. The study was carried out on cryopreserved human hepatocytes. The hepatotoxicity of the tested drugs was assessed after exposure to the neuroleptics (LDH cytotoxicity assay). CYP activities were measured in the incubation medium using the CYP-specific reactions: caffeine 3-N-demethylation (CYP1A1/2), diclofenac 4'-hydroxylation (CYP2C9), perazine N-demethylation (CYP2C19) and testosterone 6β-hydroxylation (CYP3A4). Parallel, CYP mRNA levels were measured in neuroleptic-treated hepatocytes. Asenapine significantly decreased the mRNA level and activity of CYP1A2, while iloperidone potently diminished the mRNA level and activity of CYP3A4 in the cultures of human hepatocytes. Lurasidone did not affect the expression and activity of any of the investigated human CYP enzymes. The presented findings may have clinical implications for the prediction of potential drug-drug interactions involving the asenapine-induced inhibition of metabolism of CYP1A2 substrates (e.g. caffeine, theophylline, melatonin, tricyclic antidepressants, phenacetin, propranolol) and iloperidone-induced inhibition of CYP3A4 substrates (e.g. antidepressants, benzodiazepines, atorvastatin, macrolide antibiotics, calcium channel antagonists).

Posttraumatic Stress Disorder in the Primary Care Setting: Summary of Recommended Care

Posttraumatic stress disorder (PTSD) occurs following acute threatening events in approximately 12.5% of the primary care population.

OBJECTIVE

The aim of this article is to advance evidence-based clinical practice and collaborative care approaches to PTSD by summarizing targeted-care guidelines.

METHOD

This narrative literature review addresses important aspects of PTSD and management options, in conjunction with expert opinion when indicated. Guidelines were included if they targeted treatment of PTSD in the primary care setting or if the treatments described could be provided in the primary care setting.

RESULTS

The implications regarding PTSD, comorbidities, differential diagnosis, screening tools, and treatment are presented.

CONCLUSION

Primary care providers can diagnose and offer initial management of PTSD. Future research should delineate therapies helpful for complex PTSD, including group therapies, those increasing self-compassion, and other optimally effective collaborative care interventions.

Stigma towards people with a diagnosis of severe mental disorder in primary healthcare centers: perspectives of service users and health teams in Chile

Background

Stigma towards people diagnosed with a severe mental disorder (SMD) is one of the main obstacles for these service users to receive timely and relevant healthcare. This study was undertaken to understand how stigmatizing attitudes are demonstrated towards people with SMD in primary healthcare centers (PHC) from the perspective of those affected and primary healthcare professionals.

Methods

We used a qualitative exploratory research design to contrast the differences and similarities regarding stigmatizing attitudes towards people with SMD in primary healthcare centers (PHC) from the perspective of two groups: (i) people diagnosed with a severe mental disorder, and (ii) healthcare professionals. Data was collected through semi-structured interviews and discussion groups and subsequently analyzed using Atlas.ti software.

Results

Our results indicate that both service users and healthcare professionals manifest stereotypes, prejudices, and discriminatory behavior in health care. In addition, structural aspects of the health system and organizational culture appear to contribute to stigmatization. Both groups agreed that there is a need for healthcare professionals to have more education, specialization, and skill development related to mental health issues.

Conclusions

Interventions to reduce the stigma towards people with SMD in PHC must consider delivery of information about mental disorders, development of skills in the healthcare professionals, and modifications in the culture of the health centers.

Causes of Sudden Unexpected Death in Schizophrenia Patients: A Forensic Autopsy Population Study

BACKGROUND

Schizophrenia is a detrimental psychiatric disorder, with an increased mortality from natural and nonnatural causes.

METHODS

This study was a retrospective review of autopsy cases of all the individuals with history of schizophrenia investigated by the Office of the Chief Medical Examiner, State of Maryland, for a 5-year period from 2008 to 2012.

RESULT

A total of 391 schizophrenia patients were autopsied at the Office of the Chief Medical Examiner because they died suddenly and unexpectedly. Their age ranged from 15 to 100 years with the mean age of 49.5 years. Of the 391 deaths, 191 (48.8%) were white, 185 (47.3%) were African American, and 15 (3.9%) were either Hispanic or Asian. The male and female ratio was 1.5:1. The majority of deaths (64.2%) were caused by natural diseases, 12.0% deaths were accidents, 11.5% deaths were suicides, and 9.7% deaths were homicides. The manner of death remained undetermined in 38 cases (9.7%). Of the 251 natural deaths, 198 cases (78.9%) were owing to cardiovascular diseases. Cause of death was listed as cardiac arrhythmia in 11 cases. This diagnosis of cardiac arrhythmia was made by exclusion based on death scene investigation, review of medical history, complete autopsy, and toxicological tests. Drug intoxication was the second most common cause of death.

CONCLUSIONS

The study shows high fatality caused by cardiovascular diseases and drug intoxication among schizophrenia patients, which calls attention of the medical community to closely monitor the high risk factors of sudden death among schizophrenia patients.

Disparities in the management of cardiovascular risk factors in patients with psychiatric disorders: a systematic review and meta-analysis

BACKGROUND

The high cardiovascular (CV) morbidity and mortality reported for patients with psychiatric disorders may possibly be due to a poorer management of CV risk factors (CVRFs). However, these healthcare disparities remain poorly understood. In this paper, studies comparing the management of smoking, diabetes, hypertension and dyslipidaemia, in patients with and without depression, anxiety, schizophrenia, bipolar or personality disorder, were reviewed.

METHODS

Prospective studies comparing rates of screening, diagnosis, treatment and control of CVRFs were searched in PubMed, Embase, PsychInfo, Scopus and Web of Science (inception to January 2017). The Meta-analysis of Observational Studies in Epidemiology (MOOSE) criteria were used. Studies were assessed for quality. Wherever possible, meta-analyses were conducted to summarize the findings.

RESULTS

Twenty studies, out of the 18 333 references initially identified, were included. Most studies were heterogeneous in design. Two areas permitted meta-analyses: the pooled odds ratio for quitting smoking for those with depression was 0.64 (0.49-0.80) p < 0.001; the pooled difference of glycated haemoglobin for patients with type 2 diabetes and depression was 0.18 (0.06-0.31) p = 0.005. Individual studies showed associations between: schizophrenia and lower probability of having smoking habit recorded; schizoid personality disorder and higher probability of remaining non-smokers after quitting; anxiety and poorer control of type I diabetes; depression, anxiety or schizophrenia and lower probability of having a diagnosis of hypertension; schizophrenia or bipolar disorder and lower use of antihypertensive and lipid-lowering drugs.

CONCLUSIONS

A proactive clinical management, together with further studies, are needed to reduce the CV morbidity and mortality of patients with psychiatric disorders.

Acupuncture as Add-On Treatment of the Positive, Negative, and Cognitive Symptoms of Patients with Schizophrenia: A Systematic Review

Background: Schizophrenia is a severe psychiatric disorder that has a large impact on patients' lives. In addition to Western medicine, the use of additional treatments, such as acupuncture, in treating the positive, negative, and cognitive symptoms is increasing. Methods: We conducted a systematic review on the use of acupuncture as an add-on treatment for patients with schizophrenia that are in regular care, with a special focus on the treatment of the often accompanying sleep disorders. In this study, we searched the Medline, ScienceDirect, Cochrane Library, Scopus, and ERIC databases with a cut-off date of 31 December 2017, thereby following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol. Results: Our search resulted in 26 eligible studies with 1181 patients with schizophrenia who received acupuncture treatment. Most studies showed limited evidence for the use of acupuncture as add-on therapy in the treatment of the positive, negative, and cognitive symptoms, but beneficial effects have been reported in the treatment of the accompanying sleep disorders. Conclusions: Limited evidence was found for the use of acupuncture as add-on therapy in the treatment of patients with schizophrenia; however, positive results were found in the treatment of sleep disorders, but this result needs to be confirmed in large, randomized, controlled trials.

Early Combination Therapy for Type 2 Diabetes Mellitus and Common Comorbid Mental Disorders

The relationship between type 2 diabetes mellitus and antipsychotic use by schizophrenia patients is recognized but not well understood. This article reviews the literature regarding metabolic interactions, pathological pathways, and protocols for screening, monitoring, and using combination therapy for individuals with type 2 diabetes mellitus and common comorbid mental health conditions. Because primary care physicians manage patients with both mental and general medical illnesses, such as diabetes, understanding their perspectives on the challenges and facilitators of the care of these patients is critical to improving clinical outcomes. Although the relationship between type 2 diabetes mellitus and antipsychotic use by schizophrenia patients has been recognized, clinical guidelines for their treatment are not recent. Individuals with mental disorders present a vulnerable population with high medical needs that are often mistreated or missed. Given the significant contribution of metabolic syndrome and comorbid diabetes mellitus to morbidity and mortality of such patients, ongoing primary care should be coordinated between general practitioners and mental health professionals to prevent serious complications and adverse medication side effects.

Identifying primary care quality indicators for people with serious mental illness: a systematic review

Background

Serious mental illness (SMI) — which comprises long-term conditions such as schizophrenia, bipolar disorder, and other psychoses — has enormous costs for patients and society. In many countries, people with SMI are treated solely in primary care, and have particular needs for physical care.

Aim

The objective of this study was to systematically review the literature to create a list of quality indicators relevant to patients with SMI that could be captured using routine data, and which could be used to monitor or incentivise better-quality primary care.

Design and setting

A systematic literature review, combined with a search of quality indicator databases and guidelines.

Method

The authors assessed whether indicators could be measured from routine data and the quality of the evidence.

Results

Out of 1847 papers and quality indicator databases identified, 27 were included, from which 59 quality indicators were identified, covering six domains. Of the 59 indicators, 52 could be assessed using routine data. The evidence base underpinning these indicators was relatively weak, and was primarily based on expert opinion rather than trial evidence.

Conclusion

With appropriate adaptation for different contexts, and in line with the relative responsibilities of primary and secondary care, use of the quality indicators has the potential to improve care and to improve the physical and mental health of people with SMI. However, before the indicators can be used to monitor or incentivise primary care quality, more robust links need to be established, with improved patient outcomes.

Mental Health Consumer Experiences and Strategies When Seeking Physical Health Care: A Focus Group Study

People with mental illness have higher rates of physical health problems and consequently live significantly shorter lives. This issue is not yet viewed as a national health priority and research about mental health consumer views on accessing physical health care is lacking. The aim of this study is to explore the experience of mental health consumers in utilizing health services for physical health needs. Qualitative exploratory design was utilized. Semistructured focus groups were held with 31 consumer participants. Thematic analysis revealed that three main themes emerged: scarcity of physical health care, with problems accessing diagnosis, advice or treatment for physical health problems; disempowerment due to scarcity of physical health care; and tenuous empowerment describing survival resistance strategies utilized. Mental health consumers were concerned about physical health and the nonresponsive health system. A specialist physical health nurse consultant within mental health services should potentially redress this gap in health care provision.

The effectiveness of a program of physical activity and diet to modify cardiovascular risk factors in patients with severe mental illness after 3-month follow-up: CAPiCOR randomized clinical trial

BACKGROUND

The aim of this randomized clinical trial follow-up at three months was to evaluate the effectiveness of an educational intervention with a focus on diet and physical activity (PA) to change the amount of PA, body mass index (BMI) and the waist circumference (WC) in patients with severe mental illness.

METHODS

We recruited 332 outpatients with severe mental disorders undergoing treatment with antipsychotic medication from Mental Healthcare Centers of Barcelona. They were randomly assigned to an intervention or a control group. The patients in the intervention group participated in a group PA and diet educational program. The blinded measurements at 0 and 3 months were: the level of PA (IPAQ questionnaire), BMI, WC, blood pressure, dietary habits (PREDIMED questionnaire), quality of life (SF-36 questionnaire) and laboratory parameters (cholesterol, triglycerides, glucose).

RESULTS

The average age was 46.7 years and 55% were males. Schizophrenia had been diagnosed in 67.1% of them. At 3 months, the average weekly walking METs rose significantly in the IG 266.05 METs (95%CI: 16.86 to 515.25; P=0.036). The total MET average also rose although not significantly: 191.38 METs (95%CI: 1.38 to 381.38; P=0.086). However, the BMI decreased significantly more in the CG, by 0.26kg/m(2) (95%CI: 0.02 to 0.51; P=0.038), than in the IG. There were no significant differences in the WC.

CONCLUSIONS

The short-term results suggest that the intervention increases the level of PA, but does not improve physical or laboratory parameters.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01729650 (effectiveness of a physical activity and diet program in patients with psychotic disorder [CAPiCOR]).

Schizophrenia in a Primary Care Setting

In recent years, the focus of mental health care for people with schizophrenia has shifted from an expectation of lifelong disability to a 'recovery' approach in which patients and specialists anticipate discharge to management within primary care. Although the active symptoms of mental illness are generally well-managed with modern pharmacotherapy, primary care physicians often express concern about their lack of understanding and expertise in general management of schizophrenia. Moreover, the ability of patients to access care for their physical disorders in a timely fashion together with a higher prevalence of physical co-morbidities is likely to be responsible for the greater mortality and premature death of this already stigmatised and disadvantaged group. This paper focuses on new evidence over the past 5 years, considering the management of physical and mental health of schizophrenia patients in primary care, optimal processes and the reasons why these may not always be realised in practice.

Behavioral Health Homes: an opportunity to address healthcare inequities in people with serious mental illness

People with serious mental illness (SMI) face striking reductions in lifespan versus the general population, in part due to the inadequacy of healthcare systems in meeting the substantial physical health needs of this group. Integrated care, the strategic combination and coordination of behavioral health and primary care services, has been proposed as a potential healthcare service delivery solution to address these care gaps. Inspired by the primary care Patient-Centered Medical Home concept, Behavioral Health Homes bring primary care services into the community mental health center in various ways. In this paper the authors review the literature describing Behavioral Health Home interventions and highlight an integration project that provides co-located and coordinated primary care and wellness services in a community mental health center. Such approaches hold great promise for improving the health and healthcare of people with SMI.

Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression

Even though individuals with psychiatric conditions have a prevalence of smoking approximately 2-4 times greater than the general population, surprisingly little evidence exists to inform an assessment of the full range of tobacco-related mortality in such populations. The current study aims to provide mortality estimates for conditions causally related to tobacco use among individuals hospitalized with a primary psychiatric diagnosis in California from 1990 to 2005. Restricting cases to those of individuals aged 35 or older at the mid-point of their follow-up period, we assembled cohorts of individuals with ICD-9 diagnoses of schizophrenia and related disorders ("schizophrenia"; n = 174,277), depressive disorders (n = 338,250), or bipolar disorder (n = 78,739). Inpatient records were linked to death-certificate data. We generated age-, sex-, and race-adjusted standardized mortality ratios (SMRs) for the 19 diseases identified by the Centers for Disease Control and Prevention as being causally linked to tobacco use. The SMRs for all tobacco-linked diseases combined were: schizophrenia, 2.45 (95% CI = 2.41-2.48); bipolar, 1.57 (95% CI = 1.53-1.62); and depression, 1.95 (95% CI = 1.93-1.98). Tobacco-related conditions comprised approximately 53% (23,620/44,469) of total deaths in the schizophrenia, 48% (6004/12,564) in the bipolar, and 50% (35,729/71,058) in the depression cohorts. Addressing tobacco use in psychiatric populations is a critical clinical and public-health concern, especially in light of the currently limited clinical attention devoted to tobacco use in these groups.

Basic treatment principles for psychotic disorders in patients with epilepsy

In patients with epilepsy, coexisting psychoses, either interictal (IIP) or postictal (PIP), are associated with serious disturbance in psychosocial function and well-being, and often require the care of a specialist. Unfortunately, evidence-based treatment systems for psychosis in patients with epilepsy have not yet been established. This article aims to propose concise and practical treatment procedures for IIP and PIP based on currently available data and international consensus statements, and primarily targeting nonpsychiatrist epileptologists who are often the first to be involved in the management of these complex patients. Accurate and early diagnosis of IIP and PIP and their staging in terms of acuity and severity form the essential first step in management. It is important to suspect the presence of psychosis whenever patients manifest unusual behavior. Knowledge of psychopathology and both individual and epilepsy-related vulnerabilities relevant to IIP and PIP facilitate early diagnosis. Treatment for IIP involves (1) obtaining consent to psychiatric treatment from the patient, whenever possible, (2) optimization of antiepileptic drugs, and (3) initiation of antipsychotic pharmacotherapy in line with symptom severity and severity of behavioral and functional disturbance. Basic psychosocial interventions will help reinforce adherence to treatment and should be made available. Due consideration must be given to patients' ability to provide informed consent to treatment in the short term, with the issue being revisited regularly over time. Given the often prolonged and recurrent nature of IIP, treatment frequently needs to be long-term. Treatment of PIP consists of two aspects, that is, acute protective measures and preventive procedures in repetitive episodes. Protective measures prioritize the management of risk in the early stages, and may involve sedation with or without the use of antipsychotic drugs, and the judicious application of local mental health legislation if appropriate. As for preventative procedures, optimizing seizure control by adjusting antiepileptic drugs or by surgical treatment is necessary.