Metabolic syndrome and cardiovascular risk among institutionalized patients with schizophrenia receiving long term tertiary care

General Factors That Reduce Cardiovascular Risk in People With Schizophrenia: A Systematic Review

BACKGROUND

The life expectancy of individuals with schizophrenia in the United States is 20% shorter than that of the general population owing to cardiovascular disease (CVD). It is crucial to identify the factors that reduce CVD risk in these individuals.

OBJECTIVE

In this systematic review, we examined the factors associated with CVD in people with schizophrenia.

METHODS

We searched 3 electronic databases for English articles published before April 2023. Investigators assessed the factors associated with 2 cardiovascular health outcomes among people with schizophrenia: the 10-year coronary heart disease (CHD)/CVD risk and peak oxygen uptake (VO 2Peak/max ).

RESULTS

We retrieved 17 studies from the search. Investigators examined factors affecting 10-year CHD/CVD risk in 11 studies and VO 2Peak/max in 6 studies among people with schizophrenia. We found that individuals who had low metabolic symptoms (ie, hypertension and hyperglycemia), did not smoke, engaged in continuous CVD risk assessments, had a shorter duration of the diagnosis and hospitalization, and were of normal weight had a lower 10-year CHD/CVD risk. Furthermore, individuals who engaged in specific physical activity had a higher VO 2Peak/max . Finally, those taking antipsychotic medications had a higher 10-year CHD/CVD risk and a lower VO 2Peak/max .

CONCLUSIONS

The CVD risk factors observed in the general population are common among people with schizophrenia. When these risk factors are controlled, the 10-year CHD/CVD risk and VO 2Peak/max of these individuals may be improved. Given the elevated CVD risk associated with antipsychotic medications, future researchers should examine modifying CVD risk factors to mitigate the additional risks associated with medication use in this population.

Differing Prevalence and Correlates of Metabolic Syndromes Between Chlorpromazine and Clozapine: A 10-year Retrospective Study of a Male Chinese Cohort

BACKGROUND

Antipsychotics are known to be associated with metabolic syndromes (MetS). Chlorpromazine (CPZ) and Clozapine (CLZ) are currently the most commonly used antipsychotics in low-income districts of China. However, potential differences in the long-term effects of CPZ and CLZ on MetS in schizophrenia inpatients are not well understood. Here, we aimed to identify any MetS profile differences between long-term schizophrenia patients who were prescribed either CPZ or CLZ at a primary psychiatric hospital.

METHODS

We recruited a total of 204 male schizophrenia patients who received either CPZ or CLZ. We measured their weight, height, body mass index (BMI), waist circumference (WC), diastolic blood pressure (DBP), and systolic blood pressure (SBP), as well as their biochemical indicators, including fasting blood glucose (FBS), triglycerides (TG), cholesterol (TC), high-density lipoprotein cholesterol (HDL-c) and low-density lipoprotein cholesterol (LDL-c).

RESULTS

The MetS prevalence in the CPZ and CLZ groups was 31% and 37.5%, respectively. The CLZ group had significantly higher DBP levels and a higher incidence of dyslipidemia (HDL-c) but lower HDL-c and TC levels than the CPZ group. We also determined that smoking history, BMI, and duration of hospitalisation were risk factors for the development of MetS. Moreover, we found that CPZ and CLZ were correlated with the same risk for developing MetS and that BMI was a vital risk factor of MetS for both the CPZ and CLZ groups.

CONCLUSION

Long-term CPZ and CLZ prescriptions were associated with similar profiles for developing MetS of schizophrenia patients.

Long-term care utilization within older adults with schizophrenia: Associated factors in a multicenter study

OBJECTIVE

Data are scarce regarding the clinical factors associated with utilization of long-term care facilities among older adults with schizophrenia. In this multicenter study, we sought to examine potential clinical differences between older adults with schizophrenia who are living in a long-term care facility and their community-dwelling counterparts.

METHOD

We used data from the French Cohort of individuals with Schizophrenia Aged 55-years or more (CSA) study, a large multicenter sample of older adults with schizophrenia (N = 353).

RESULTS

The prevalence of long-term care utilization was 35.1% of older patients with schizophrenia. Living in a long term care facility was significantly and independently associated with higher level of depression (Adjusted odds ratio (AOR) [95%CI]=1.97 [1.06-3.64]), lower cognitive (AOR [95%CI]=0.94 [0.88-0.99]) and global functioning (AOR [95%CI]=0.97 [0.95-0.99]), greater lifetime number of hospitalizations in a psychiatric department (AOR [95%CI]=2.30 [1.18-4.50]), not having consulted a general practitioner in the past year (AOR [95%CI]=0.28 [0.0.14-0.56]), urbanicity (AOR [95%CI]=2.81 [1.37-5.80]), and older age (AOR [95%CI]=1.08 [1.03-1.13]).

DISCUSSION

Older patients with schizophrenia who live in long-term care facilities appear to belong to a distinct group, marked by a more severe course of illness with higher level of depression and more severe cognitive deficits than older patients with schizophrenia living in other settings. Our study highlights the need of early assessment and management of depression and cognitive deficits in this population and the importance of monitoring closely this vulnerable population.

Pattern of long-term weight and metabolic changes after a first episode of psychosis: Results from a 10-year prospective follow-up of the PAFIP program for early intervention in psychosis cohort

Background

People with psychosis are at higher risk of cardiovascular events, partly explained by a higher predisposition to gain weight. This has been observed in studies on individuals with a first-episode psychosis (FEP) at short and long term (mainly up to 1 year) and transversally at longer term in people with chronic schizophrenia. However, there is scarcity of data regarding longer-term (above 3-year follow-up) weight progression in FEP from longitudinal studies. The aim of this study is to evaluate the longer-term (10 years) progression of weight changes and related metabolic disturbances in people with FEP.

Methods

Two hundred and nine people with FEP and 57 healthy participants (controls) were evaluated at study entry and prospectively at 10-year follow-up. Anthropometric, clinical, and sociodemographic data were collected.

Results

People with FEP presented a significant and rapid increase in mean body weight during the first year of treatment, followed by less pronounced but sustained weight gain over the study period (Δ15.2 kg; SD 12.3 kg). This early increment in weight predicted longer-term changes, which were significantly greater than in healthy controls (Δ2.9 kg; SD 7.3 kg). Weight gain correlated with alterations in lipid and glycemic variables, leading to clinical repercussion such as increments in the rates of obesity and metabolic disturbances. Sex differences were observed, with women presenting higher increments in body mass index than men.

Conclusions

This study confirms that the first year after initiating antipsychotic treatment is the critical one for weight gain in psychosis. Besides, it provides evidence that weight gain keep progressing even in the longer term (10 years), causing relevant metabolic disturbances.

The Effects of Hopelessness and Some Variables on Metabolic Syndrome in Schizophrenia Patients

This is a descriptive study conducted to determine the prevalence of Metabolic Syndrome (MetS) in Schizophrenia patients and identify the effects of hopelessness and some variables on MetS. The study was conducted at the Psychiatry Clinic of a university hospital in Turkey between May and August 2020 with 105 schizophrenia patients receiving treatment as inpatients. The data of the study were collected by a Personal Information Form, a Physiological Measurements Form and (BHS). The data were analyzed by using SPSS 25. The mean age of the patients was 35.31 ± 9.07, their mean duration of disease was 11.35 ± 9.07 years, and 60.0% of the patients were using atypical antipsychotics as their latest drug treatment. 42.9% of the patients had MetS, while the mean hopelessness level of those with MetS was 10.84 ± 3.81. It was determined that hopelessness levels and some sociodemographic (age) and clinical variables significantly predicted the MetS status in the schizophrenia patients.

Prevalence and Associated Factors of Dyslipidemia Among Psychiatric Patients on Antipsychotic Treatment at Hawassa University Comprehensive Specialized Hospital

Background:

Dyslipidemia is one of the adverse metabolic outcomes associated with psychotropic medications and the nature of the mental illness itself. Therefore, this study aimed to assess magnitude of dyslipidemia and associated factors among patients with severe mental illness on antipsychotic treatments.

Methods:

A cross-sectional study was conducted among 245 patients with severe mental illness in Hawassa University Comprehensive Specialized Hospital, Sidama Regional state, Southern Ethiopia. Socio-demographic and other important data were collected using a structured questionnaire through a systematic random sampling technique. Individual dyslipidemia was characterized by the National Cholesterol Education Program Adult Treatment Panel-III (NCEP ATP-III) guideline.

Results:

Mean total cholesterol (TC) was significantly higher in males when compared to females (162.2 mg/dl vs 121 mg/dl, P = .023). While, mean LDL-cholesterol was significantly higher in females when compared to males (100.9 mg/dl vs 93.6 mg/dl, P = .028). Overall 58.4% (95% CI: 52.2-64.8) of participants had at least 1 dyslipidemia. The prevalence of TC ⩾200 mg/dl, HDL-cholesterol <40 mg/dl, triglyceride (TG) and LDL-cholesterol were 61 (24.9%), 75 (30.6%), 66 (26.9%), and 47 (19.2%), respectively. Female sex and smoking were significantly and positively associated with LDL-c dyslipidemia, the aOR (95% CI) were 2.1 (1.0-4.2) for female sex and 3.4 (1.1-10.5) for smoking. Also, Age >40 years was significantly associated with TC dyslipidemia, the aOR (95% CI) was 2.0 (1.1-3.7).

Conclusion:

More than half of psychiatric patients are at risk of developing cardiovascular and other related health problems. Therefore, periodic screening of lipid profiles during healthcare follow-up is mandatory to limit risks of cardiovascular-related comorbidities among patients with severe mental illness.

Subsequent Dyslipidemia and Factors Associated with Mortality in Schizophrenia: A Population-Based Study in Taiwan

Background: Persons with schizophrenia are at greater risk of developing subsequent medical conditions. To date, few studies have examined comprehensively the risks, mortality and survival rates in schizophrenia and subsequent dyslipidemia over different time periods. The objective of this study was to evaluate the occurrence of subsequent dyslipidemia after the diagnosis of schizophrenia, and factors associated with mortality and survival rate in patients with schizophrenia. Methods: We used a population-based cohort from Taiwan National Health Insurance Research Database, to investigate in patients whom were first diagnosed with schizophrenia during the period from 1997 through 2009, the risk of subsequent dyslipidemia during follow-up. Cumulative incidences and hazard ratios after adjusting for competing mortality risks were calculated. Results: A total of 20,964 eligible patients were included. Risks (i.e., comorbidity) and protective factors (i.e., statin use) have significant impacts on mortality. The mortality exhibits a U-shaped pattern by age. After 50, the risk of death increases with age. Risk of mortality before 50 increases with a decrease in age. Risks differed by the duration time to subsequent dyslipidemia after schizophrenia. Mean duration was 63.55 months in the survive group, and 43.19 months in the deceased group. The 5-, 10-, and 15-year survival rates for patients with schizophrenia and subsequent dyslipidemia were 97.5, 90, and 79.18%, respectively. Conclusion: Early occurrence of subsequent dyslipidemia is associated with increased overall mortality in patients with schizophrenia.

Grounded theory of 'lifestyle adaptation' - Perspectives from persons with schizophrenia and their caregivers

INTRODUCTION

Available evidence highlights that persons diagnosed with schizophrenia are predisposed to develop physical co-morbidities. Lifestyle modification interventions are identified as appropriate strategies to maintain their physical health. A comprehensive understanding of the facilitators and barriers in adhering to healthy lifestyle interventions is critical to developing individualized interventions that are effective and accessible for these patients.

AIM

To develop and formulate a theory of lifestyle adaptation for the prevention of physical co-morbidities for persons with schizophrenia and their caregivers who are availing mental health services in the psychiatry wards.

MATERIALS AND METHODS

The qualitative data were collected by semi-structured interviews using topic guides from persons with schizophrenia and their family caregivers from the tertiary level psychiatry center, South India. The interviews explored their perceptions and experiences of the facilitators and barriers in adopting a healthy lifestyle. Final data was analyzed based on grounded theory, and the data was used to formulate the theory of lifestyle adaptation.

CONCLUSION

The persons with schizophrenia and their family caregivers' perceptions helped in formulating this theory. The present study provides recommendations for physical health services for patients with mental illness. The findings of the study may guide health professionals and mental health advocacy groups, policymakers to plan for appropriate decisions related to incorporating mental health care with physical health care services.

Relationship between Serum Homocysteine and Metabolic Syndrome among Patients with Schizophrenia and Bipolar Disorder: A Cross Sectional Study

Objective: This study aimed to compare the prevalence of metabolic syndrome and hyperhomocysteinemia and to specify predictors of the metabolic syndrome among patients with schizophrenia and bipolar disorder.

Method: This cross sectional study was conducted on 100 patients with schizophrenia and 100 patients with bipolar disorder. The participants' metabolic syndrome was determined according to the criteria set by Third Report of the National Cholesterol Education Program–Adult Treatment Panel III. Hyperhomocysteinemia was considered as homocysteine levels higher than 15 µmol/L. Chi-square test, Fisher's exact test, student t test, Mann-Whitney test, and logistic regression were used for data analysis.

Results: The prevalence of metabolic syndrome was not significantly different (P = 0.07) between patients with schizophrenia (27%) and bipolar disorder (39%). No statistically significant difference (P = 0.17) was observed between patients with schizophrenia (82%) and bipolar disorder (74%) in the prevalence of hyperhomocysteinemia. The results of multivariable logistic regression model showed a significant association of smoking and BMI with metabolic syndrome in patients with schizophrenia (OR = 3.69, 95% CI: 1.13-12.05, and OR = 1.38, 95% CI: 1.20-1.60, respectively). In patients with bipolar disorder, BMI was a significant predictor of developing metabolic syndrome (OR = 1.29, 95% CI: 1.14-1.47). Metabolic syndrome was more prevalent in women than in men in both diagnostic groups (P < 0.05). No significant difference was observed in hyperhomocysteinemia prevalence between male and female patients with schizophrenia (P = 1.00). However, hyperhomocysteinemia was more prevalent in males than in females among patients with bipolar disorder (P = 0.001).

Conclusion: Findings showed a high prevalence of metabolic syndrome and hyperhomocysteinemia among patients with schizophrenia and bipolar disorder. To deal with this problem, regular monitoring and conducting early interventions are recommended to determine the metabolic risk profile and to prevent the cardiovascular diseases.

Improving and standardizing metabolic screening for people prescribed antipsychotic medication who are at risk of developing metabolic syndrome within the community mental health setting

Aim and objective of the audit. The purpose of this audit was to identify the number of people prescribed antipsychotic medication who are at risk of developing metabolic syndrome in a community mental health service area with the aim of improving and standardising metabolic screening practices within this setting. Community mental health services are secondary care services in which individuals are referred from Primary Care (General Practitioners). The catchment area of this audit is within the South East Region of Ireland and offers adults community mental health services to a population of approximately 57 000. For the purpose of this audit we focused on one community mental health team within the service.

Associations of unhealthy lifestyles with metabolic syndrome in Chinese rural aged females

The purpose of this study is to update the prevalence of metabolic syndrome (MetS) and explore to identify the susceptible populations. A total of 38208 subjects aged 18 to 79 years were obtained from the Henan Rural Cohort Study (n = 39259). Five criteria (ATP β, IDF, JIS, CDS, EGIR) were used to estimate the prevalence of MetS. Multivariate logistic regression analysis was used to assess odds ratios (ORs) and 95% confidence interval (CI) of potential risk factors with MetS. The age-standardized prevalence of MetS were 27.87%, 24.63%, 27.40%, 18.00% and 8.91% according to the standard of ATP β, IDF, JIS, CDS, and EGIR, respectively. After adjusted for the potential confounding factors, aging, females, physical activity and the state of drinking were independent risk factors of MetS. MetS is positively associated with stroke and coronary heart disease in all five criteria (P < 0.01). The current data identify a high prevalence of MetS among Chinese rural adults. Especially for aged females with unhealthy lifestyle had a higher risk for MetS.

Development and implementation of electronic medical handovers across psychiatric hospitals: quality improvement initiative

A lack of integration between internal processes and failure to use the full potential of information technology (IT) systems is common in psychiatric hospitals. We aimed to reduce the number of out-of-hours medical errors by ensuring that there is consistent and transparent weekend medical handover by creating an electronic handover system that is easy to use, robust and embedded into the existing trust IT systems. We employed quality improvement (QI) methodology to address this issue. After trialling in a single site followed by six cycles of improvement, the weekend medical handover system is now in use across four boroughs and has been integrated into trust policy. It has received qualitative and quantitative evidence of improvement, with 100% of doctors reporting the system improved patient care and a 64% (from 11 to 4 events/year) reduction in moderate, severe and catastrophic adverse incidents occurring out-of-hours within the older adult service (p=0.29, χ² 1.117). The increasing number of complex patients with comorbid medical illness in psychiatric inpatient services demands robust handover systems similar to that of an acute trust. This QI work offers a template for achieving this across other psychiatric trusts and demonstrates the positive change that can be achieved.

The Life Course Paradigm as a Lens for Holistic Nursing Research in Older Adults Diagnosed With Schizophrenia

Older adults diagnosed with schizophrenia (OADWS) have unique needs for care and live longer today than their forebears who were diagnosed with schizophrenia. As a result, nurses need to be prepared for the specific care of individuals who live with schizophrenia as they age. Together, Life Course Theory and holistic nursing suggest a good fit in the quest for successful solutions and/or outcomes for the unique problems that OADWS face. Holistic nursing views the patient as a whole person, considering all aspects of the patient’s experiences within life’s broader environment. The life course paradigm offers an effective way for nurses to understand issues that patients face throughout their lives, thus enhancing holistic nursing with a historical perspective. This is especially important for the care of OADWS, who face unique disparities as well as physical and psychological comorbidities over their life course. This article is intended to initiate a discussion of OADWS, focused with Life Course Theory as a holistic lens. Literature pertinent to the life course of OADWS is reviewed, followed by an analysis of the life course paradigm in relation to OADWS’ unique experiences. Conclusions support the holistic use of Life Course Theory in research and interventions for OADWS.

Cardiovascular risk remains high in schizophrenia with modest improvements in bipolar disorder during past decade

OBJECTIVE

While CVD risk has decreased in the general population during the last decade, the situation in patients with schizophrenia (SCZ) and bipolar disorder (BD) is unknown.

METHODS

We compared CVD risk factors in patients with SCZ and BD recruited from 2002-2005 (2005 sample, N = 270) with patients recruited from 2006-2017 (2017 sample, N = 1011) from the same catchment area in Norway. The 2017 sample was also compared with healthy controls (N = 922) and the general population (N range = 1285-4587, Statistics Norway) from the same area and period.

RESULTS

Patients with SCZ and BD in the 2017 sample had significantly higher level of most CVD risk factors compared to healthy controls and the general population. There was no significant difference in the prevalence of CVD risk factors in SCZ between the 2005 and 2017 samples except a small increase in glucose in the 2017 sample. There were small-to-moderate reductions in hypertension, obesity, total cholesterol, low-density lipoprotein, systolic and diastolic blood pressure in the BD 2017 sample compared to the 2005 sample.

CONCLUSION

Despite major advances in health promotion during the past decade, there has been no reduction in the level of CVD risk factors in patients with SCZ and modest improvement in BD.

Cardiovascular Safety of Psychiatric Agents: A Cautionary Tale

Psychiatric agents are among the most commonly prescribed medications. Despite the advent of newer generation agents, patients receiving them still experience cardiovascular (CV) side effects. However, these agents may have heterogeneous properties, calling for an individualized approach based on efficacy and also on the particular side effect profile of each specific agent. Proarrhythmic effects arising from drug-induced long-QT syndrome and consequent potentially life-threatening polymorphic ventricular arrhythmias in the form of torsade de pointes, the metabolic syndrome contributing to atherosclerosis and acute coronary syndromes, and drug-induced orthostatic hypotension raise major concerns. Of course, it is also crucial that fear of potential CV adverse effects does not deprive psychiatric patients of appropriate drug therapy. Modification of CV risk factors in psychiatric patients together with optimal management of their CV diseases and appropriate selection of psychotropic agents with greater efficacy and least CV toxicity are of paramount importance in mitigating CV risks and enhancing safety. Identifying patients at high risk of CV complications and close monitoring of all patients receiving these agents are crucial steps to prevent and manage such complications. All these issues are herein reviewed, relevant guidelines are discussed, and schemas are depicted that illustrate the interrelated connections among the psychotropic agents and their CV effects.

Prevalence of underweight in patients with schizophrenia: A meta-analysis

AIMS

Although the relationship between body mass index and all-cause mortality is U-shaped, underweight has received comparatively less attention than obesity. There is only limited evidence to date regarding underweight among patients with schizophrenia. This is the first meta-analysis to address the prevalence of underweight in these patients.

METHODS

We conducted database searches (PubMed, PsycINFO) to identify studies examining underweight in patients with schizophrenia. In total, 17 studies (18 groups) with 45,474 patients were included; data were extracted independently by two authors. A meta-analysis was performed to calculate the pooled prevalence of underweight in patients.

RESULTS

The pooled prevalence of underweight was 6.2% (95% CI=4.5-8.6) for the 18 groups, which included 45,474 patients with schizophrenia. The heterogeneity was I²=98.9% (95% Cl=98.7-99.1%). Four studies with 4 groups, consisting of 30,014 individuals, focused on Japanese inpatients with schizophrenia. The pooled prevalence of underweight among inpatients in these 4 groups was 17.6% (95% CI=15.5-20.0). Fourteen studies were conducted with non-Japanese inpatients and included 14 groups of 15,460 patients with schizophrenia. The pooled prevalence of underweight in non-Japanese inpatients was 4.6% (95% CI=3.9-5.4). The proportion of underweight in the 18 groups significantly varied between Japanese inpatients and other patients.

CONCLUSIONS

The results indicated that Japanese inpatients with schizophrenia have a high proportion of underweight. Future research should focus on evaluating interventions that target underweight.

Serious delinquency and later schizophrenia: A nationwide register-based follow-up study of Finnish pretrial 15- to 19-year-old offenders sent for a forensic psychiatric examination

BACKGROUND

Aggressive and disruptive behaviors often precede the onset of schizophrenia. In this register-based follow-up study with a case-control design, we wanted to investigate if serious delinquency was associated with future diagnoses of schizophrenia or schizoaffective disorder (here, broadly defined schizophrenia) among a nationwide consecutive sample of 15- to 19-year-old Finnish delinquents sent for a forensic psychiatric examination in 1989-2010.

METHODS

The sample comprised 313 delinquents with no past or current psychotic disorder. For each delinquent, four age-, gender- and place of birth -matched controls were randomly selected from the Central Population Register. Five controls (0.4%) had been treated for schizophrenia before their respective index-dates and were thus excluded from further analysis, leaving us with a control population of 1247 individuals. The subjects were followed till death, emigration or the end of 2015, whichever occurred first. Diagnoses were obtained from the Care Register for Health Care.

RESULTS

Forty (12.8%) of the delinquents and 11 (0.9%) of the controls were diagnosed with schizophrenia later in life (HR 16.6, 95% CI 8.53-32.39, P<0.001). Almost half of the pretrial adolescents with later schizophrenia were diagnosed within 5years of the forensic psychiatric examination, but latency was longer among the other half of the sample, reaching up to 20.5years.

CONCLUSIONS

The study supports the previous research indicating a potential link between serious delinquency and later schizophrenia. Accurate psychiatric assessments should be made in correctional services but also later in life so that any possible psychotic symptoms can be detected in individuals with a history of serious delinquency even if there were no signs of psychosis before or at the time of the crime. Future research should explore which factors influence the delinquent's risk of developing later schizophrenia.