Excess resource use and costs of physical comorbidities in individuals with mental health disorders: A systematic literature review and meta-analysis

Early use of long-acting injectable antipsychotics in bipolar disorder type I: An expert consensus

INTRODUCTION

Long-acting injectable antipsychotics (LAIs) are not routinely offered to patients living with bipolar disorder type I (BP-I), despite widespread evidence that supports their benefits over oral antipsychotics, particularly in early disease.

METHODS

A round-table meeting of psychiatrists convened to discuss barriers and opportunities and provide consensus recommendations around the early use of LAIs for BP-I.

RESULTS

LAIs are rarely prescribed to treat BP-I unless a patient has severe symptoms, sub-optimal adherence to oral antipsychotics, or has experienced multiple relapses. Beyond country-specific accessibility issues (e.g., healthcare infrastructure and availability/approval status), primary barriers to the effective use of LAIs were identified as attitudinal and knowledge/experience-based. Direct discussions between healthcare providers and patients about treatment preferences may not occur due to a preconceived notion that patients prefer oral antipsychotics. Moreover, as LAIs have historically been limited to the treatment of schizophrenia and the most severe cases of BP-I, healthcare providers might be unaware of the benefits LAIs provide in the overall management of BP-I. Improved treatment adherence associated with LAIs compared to oral antipsychotics may support improved outcomes for patients (e.g., reduced relapse and hospitalization). Involvement of all stakeholders (healthcare providers, patients, and their supporters) participating in the patient journey is critical in early and shared decision-making processes. Clinical and database studies could potentially bridge knowledge gaps to facilitate acceptance of LAIs.

CONCLUSION

This review discusses the benefits of LAIs in the management of BP-I and identifies barriers to use, while providing expert consensus recommendations for potential solutions to support informed treatment decision-making.

[Metabolic adverse drug reactions related to psychotropic drugs]

Metabolic adverse drug reactions (mADR) related to psychotropic drugs have significant health-related effects including weight gain, impaired glucose tolerance, diabetes mellitus and dyslipidemia as well as economic relevance. Nearly all antipsychotics (AP) and many antidepressants (AD) and mood stabilisers may induce weight gain. Weight development in the first weeks or months after the beginning of the therapy is the strongest predictor for weight gain related to AP and AD. The most important risk factors for mADR are antagonistic effects at H1-, 5-HT2C- und M3-receptors and antidopaminergic effects. However, several other systems are also relevant. Systematic monitoring of metabolic parameters is recommended in all patients treated with substances that are associated with an increased risk of mADR. Lifestyle modification, dietary measures, exercise therapy, dose reduction, change and discontinuation of the substance, and additional treatment with metformin and topiramate are evidence-based treatment options for AP-associated weight gain. GLP-1 receptor agonists such as liraglutide are also promising.

Exploring the incidence of inadequate response to antidepressants in the primary care of depression

Data from the UK suggests 13-55 % of depression patients experience some level of treatment resistance. However, little is known about how physicians manage inadequate response to antidepressants in primary care. This study aimed to explore the incidence of inadequate response to antidepressants in UK primary care. One-hundred-eighty-four medication-free patients with low mood initiated antidepressant treatment and monitored severity of depression symptoms, using the QIDS-SR16, for 48 weeks. Medication changes, visits to healthcare providers, and health-related quality of life were also recorded. Patients were classified into one of four response types based on their QIDS scores at three study timepoints: persistent inadequate responders (<50 % reduction in baseline QIDS at all timepoints), successful responders (≥50 % reduction in baseline QIDS at all timepoints), slow responders (≥50 % reduction in QIDS at week 48, despite earlier inadequate responses), and relapse (initial ≥50 % reduction in baseline QIDS, but inadequate response by week 48). Forty-eight weeks after initiating treatment 47 % of patients continued to experience symptoms of depression (QIDS >5), and 20 % of patients had a persistent inadequate response. Regardless of treatment response, 96 % (n = 176) of patients did not visit their primary care physician over the 40-week follow-up period. These results suggest that despite receiving treatment, a considerable proportion of patients with low mood remain unwell and fail to recover. Monitoring depression symptoms remotely can enable physicians to identify inadequate responders, allowing patients to be reassessed or referred to secondary services, likely improving patients' quality of life and reducing the socioeconomic impacts of chronic mental illness.

Comorbid physical health burden of serious mental health disorders in 32 European countries

BACKGROUND

Mental health disorders (MHDs) are associated with physical health disparities, but underlying excess risk and health burden have not yet been comprehensively assessed.

OBJECTIVE

To assess the burden of comorbid physical health conditions (PHCs) across serious MHDs in Europe.

METHODS

We estimated the relative prevalence risk of PHCs associated with alcohol use disorders (AUD), bipolar disorder (BD), depressive disorders (DD) and schizophrenia (SZ) across working-age populations of 32 European countries in 2019 based on a targeted literature review. Excess physical health burden was modelled using population-attributable fractions and country-level prevalence data.

FINDINGS

We screened 10 960 studies, of which 41 were deemed eligible, with a total sample size of over 18 million persons. Relative prevalence of PHCs was reported in 54%, 20%, 15%, 5% and 7% of studies, respectively, for SZ, DD, BD, AUD or mixed. Significant relative risk estimates ranged from 1.44 to 3.66 for BD, from 1.43 to 2.21 for DD, from 0.81 to 1.97 for SZ and 3.31 for AUD. Excess physical health burden ranged between 27% and 67% of the total, corresponding to 84 million (AUD), 67 million (BD), 66 million (DD) and 5 million (SZ) PHC diagnoses in Europe. A 1% reduction in excess risk assuming causal inference could result in two million fewer PHCs across investigated MHDs.

CONCLUSIONS

This is the first comprehensive study of the physical health burden of serious MHDs in Europe. The methods allow for updates, refinement and extension to other MHDs or geographical areas.

CLINICAL IMPLICATIONS

The results indicate potential population health benefits achievable through more integrated mental and physical healthcare and prevention approaches.

Psychotropic Drug-Related Weight Gain and Its Treatment

Psychotropic drug-related weight gain (PDWG) is a common occurrence and is highly associated with non-initiation, discontinuation, and dissatisfaction with psychiatric drugs. Moreover, PDWG intersects with the elevated risk for obesity and associated morbidity that has been amply reported in the psychiatric population. Evidence indicates that differential liability for PDWG exists for antipsychotics, antidepressants, and anticonvulsants. During the past two decades, agents within these classes have become available with significantly lower or no liability for PDWG and as such should be prioritized. Although lithium is associated with weight gain, the overall extent of weight gain is significantly lower than previously estimated. The benefit of lifestyle and behavioral modification for obesity and/or PDWG in psychiatric populations is established, with effectiveness similar to that in the general population. Metformin is the most studied pharmacological treatment in the prevention and treatment of PDWG, and promising data are emerging for glucagon-like peptide-1 (GLP-1) receptor agonists (e.g., liraglutide, exenatide, semaglutide). Most pharmacologic antidotes for PDWG are supported with low-confidence data (e.g., topiramate, histamine-2 receptor antagonists). Future vistas for pharmacologic treatment for PDWG include large, adequately controlled studies with GLP-1 receptor agonists and possibly GLP-1/glucose-dependent insulinotropic polypeptide co-agonists (e.g., tirzepatide) as well as specific dietary modifications.

Antipsychotic-Induced Weight Gain in Severe Mental Illness: Risk Factors and Special Considerations

PURPOSE OF REVIEW

Weight gain is a disconcerting issue experienced by patients treated with antipsychotics (APs). This review summarizes current knowledge on the prevalence, etiology, and risk factors for antipsychotic-induced weight gain (AIWG), and evidence for interventions, including special considerations.

RECENT FINDINGS

Predisposing risk factors for AIWG include lack of prior AP exposure, sex, and age. AP dose and duration of exposure are additional treatment-related factors that may contribute to this issue. Among current approaches to target AIWG, metformin has the most evidence to support its use, and this is increasingly reflected in clinical guidelines. While lifestyle approaches are recommended, cost-effectiveness and scalability represent limitations. More research is needed to identify newer treatment options and inform clinical recommendations for AIWG. Concerns around scope of practice in psychiatry to address AIWG and related comorbidities will require enhanced training opportunities and interdisciplinary collaborations, as well as updated position statements/practice guidelines emphasizing prevention.

Viewpoint: Assessing the value of mental health treatments in Europe

One in eight individuals worldwide lives with a mental health disorder. For many European countries, the prevalence is even higher, with one in four people reporting mental health problems [1]. Three-quarters of all mental health disorders develop before age 25, with many presenting initially in undiagnosed forms already in the mid-teens and eventually manifesting as severe disorders and lasting into old age [2]. There is also growing evidence that mental health disorder symptoms cross diagnoses and people frequently have more than one mental health disorder [3].

The effectiveness of nurse practitioner care for patients with mental health conditions in primary care settings: A systematic review

BACKGROUND

The nurse practitioner (NP) workforce is key to meeting the demand for mental health services in primary care settings.

PURPOSE

The purpose of this study is to synthesize the evidence focused on the effectiveness of NP care for patients with mental health conditions in primary care settings, particularly focused on primary care NPs and psychiatric mental health NPs and patients with anxiety, depression, and substance use disorders.

METHODS

Studies published since 2014 in the United States studying NP care of patients with anxiety, depression, or substance use disorders in primary care settings were included.

FINDINGS

Seventeen studies were included. Four high-quality studies showed that NP evidence-based care and prescribing were comparable to that of physicians. Seven low-quality studies suggest that NP-led collaborative care is associated with reduced symptoms.

DISCUSSION

More high-quality evidence is needed to determine the effectiveness of NP care for patients with mental health conditions in primary care settings.