Cardiovascular disease and diabetes in people with severe mental illness position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC)

[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.

The implementation of exercise therapy within hospital-based mental healthcare: Delphi study

BACKGROUND

The physical health comorbidities and premature mortality experienced by people with mental illness has led to an increase in exercise services embedded as part of standard care in hospital-based mental health services. Despite the increase in access to exercise services for people experiencing mental illness, there is currently a lack of guidelines on the assessment and triage of patients into exercise therapy.

AIMS

To develop guidelines for the pre-exercise screening and health assessment of patients engaged with exercise services in hospital-based mental healthcare and to establish an exercise therapy triage framework for use in hospital-based mental healthcare.

METHOD

A Delphi technique consisting of two online surveys and two rounds of focus group discussions was used to gain consensus from a multidisciplinary panel of experts.

RESULTS

Consensus was reached on aspects of pre-exercise health screening, health domain assessment, assessment tools representing high-value clinical assessment, and the creation and proposed utilisation of an exercise therapy triage framework within exercise therapy.

CONCLUSIONS

This study is the first of its kind to provide guidance on the implementation of exercise therapy within Australian hospital-based mental healthcare. The results provide recommendations for appropriate health assessment and screening of patients in exercise therapy, and provide guidance on the implementation and triage of patients into exercise therapy via a stepped framework to determine (a) the timeliness of exercise therapy required and (b) the level of support required in the delivery of their exercise therapy.

Dietary interventions to improve metabolic health in schizophrenia: A systematic literature review of systematic reviews

AIM

This review of systematic reviews synthesised evidence on the impact of dietary interventions on anthropometric and biochemical measures associated with schizophrenia and metabolic syndrome. Secondly, an aim to identify intervention elements associated with greater dietary adherence and behaviour change.

METHODS

Five databases were searched from 2000-March 2023. Eligible reviews included adults, majority diagnosed with schizophrenia, dietary intervention components and at least one anthropometric or biochemical outcome related to metabolic syndrome. Two independent reviewers performed article selection, data extraction, and quality assessment.

RESULTS

Seven systematic reviews, consisting of 79 unique primary papers were included. No reviews exclusively examined dietary interventions. Nutrition education and counselling administered alongside physical activity were common. All reviews favoured intervention over the control to reduce body weight, body mass index, and waist circumference. Glycaemic control, blood pressure and triglycerides were not routinely reported with mixed effects following interventions. There was insufficient data to examine any trends for dropout rates, dietary adherence, and behaviour change. There was both low (n = 3/7) and high (n = 4/7) risk of bias and degree of study overlap was very high (16.4 %). The level of evidence was rated as suggestive (n = 2/7), weak (n = 2/7), non-significant (n = 1/7) and ungraded (n = 2/7).

CONCLUSION

Dietary interventions administered alongside lifestyle therapies can reduce anthropometric measurements for consumers living with schizophrenia and prescribed antipsychotic medications. Higher quality reviews with greater strength and credibility of evidence are required. Uniform reporting of intervention elements is also necessary for cross comparison of efficacious elements and synthesis of evidence at higher levels to advance dietetic practice and inform future policies.

Mental health care use and quality among Medicaid adults with serious mental illness receiving care at Federally Qualified Health Centers vs. other settings

BACKGROUND

Federally Qualified Health Centers (FQHCs) are a critical source of care for medically underserved populations and often serve as medical homes for individuals with serious mental illness (SMI). Many FQHCs provide mental health services and could facilitate access to mental health treatment within and outside of FQHCs. This study compared mental health care utilization and acute care events for adult Medicaid enrollees with SMI who receive care at Federally Qualified Health Centers (FQHCs) vs. other settings.

METHODS

This study used the 2015-2016 Massachusetts All-Payer Claims Database to examine outpatient mental health care and acute care events for 32,330 Medicaid adults, ages 18-64 and with major depressive, bipolar, or schizophrenia spectrum disorders (SSD), who resided in FQHC service areas and received care from FQHCs vs. other settings in 2015. Multivariable linear regressions assessed associations between receiving care at FQHCs and outpatient mental health visits, psychotropic medication fills, and acute care events in 2016.

RESULTS

There were 8,887 (27.5%) adults in the study population (N = 32,330) who had at least one FQHC visit in 2015. Those who received care at FQHCs were more likely to have outpatient mental health visits (73.3% vs. 71.2%) and psychotropic medication fills (73.2% vs. 69.0%, both p < .05), including antidepressants among those with depressive disorders and antipsychotics among those with SSD. They were more likely to have ED visits (74.0% vs. 68.7%), but less likely to be hospitalized (27.8% vs. 31.9%, both p < .05). However, there was no significant difference in the likelihood of having an acute psychiatric hospitalization (9.5% vs. 9.8%, p = .35).

CONCLUSIONS

Among Medicaid enrollees with SMIs who had access to care at FQHCs, those receiving care at FQHCs were more likely to have outpatient mental health visits and psychotropic medication fills, with lower rates of hospitalization, suggesting potentially improved quality of outpatient care. Higher ED visit rates among those receiving care at FQHCs warrant additional investigation.

Better understanding of c-reactive protein and leukocytes in psychiatric inpatients with affective disorders: A biopsychosocial approach

BACKGROUND

Affective disorders (AD) have been linked to inflammatory processes, although the underlying mechanisms of this relationship are still not fully elucidated. It is hypothesized that demographic, somatic, lifestyle, and personality variables predict inflammatory parameters in AD.

AIM

To identify biopsychosocial factors contributing to inflammation in AD measured with two parameters, C-reactive protein (CRP) and leukocytes.

METHODS

This observational study investigated 186 hospital inpatients diagnosed with AD using demographic parameters, serum inflammatory markers, somatic variables, psychological questionnaires, and lifestyle parameters. Hierarchical regression analyses were used to predict inflammatory markers from demographic, somatic, lifestyle, and personality variables.

RESULTS

Analyses showed that 33.8% of the variance of CRP was explained by body mass index and other somatic medication (e.g. anti-diabetics), age and education, and age of affective disorder diagnosis. For leukocytes, 20.1% of the variance was explained by smoking, diet, metabolic syndrome (MetS), and anti-inflammatory medication (e.g. non-steroidal anti-inflammatory drugs). Other psychiatric or behavioural variables did not reach significance.

CONCLUSION

Metabolic components seem important, with mounting evidence for a metabolic affective disorder subtype. Lifestyle modifications and psychoeducation should be employed to prevent or treat MetS in AD.

One-year efficacy of a lifestyle behavioural intervention on physical and mental health in people with severe mental disorders: results from a randomized controlled trial

This multicentric randomized controlled trial (RCT), carried out in six Italian University mental health sites, aims to test the efficacy of a six-month psychosocial intervention (LYFESTYLE) on Body Mass Index (BMI), body weight, waist circumference, fasting glucose, triglycerides, cholesterol, Framingham and HOmeostasis Model Assessment of insulin resistance (HOMA-IR) indexes in patients with schizophrenia, bipolar disorder, and major depression. Moreover, the efficacy of the intervention has also been tested on several other physical and mental health domains. Patients were randomly allocated to receive the six-month experimental intervention (LIFESTYLE) or a behavioural control intervention. All enrolled patients were assessed at baseline and after one year. We recruited 401 patients (206 in the experimental and 195 in the control group) with a diagnosis of schizophrenia or other psychotic disorder (29.9%), bipolar disorder (43.3%), or major depression (26.9%). At one year, patients receiving the experimental intervention reported an improvement in body mass index, body weight, waist circumference, HOMA-IR index, anxiety and depressive symptoms and in quality of life. Our findings confirm the efficacy of the LIFESTYLE intervention in improving physical and mental health-related outcomes in patients with severe mental illnesses after one year.

Impact of institutional quality improvement initiatives on metabolic monitoring in mental disorder in patients treated with antipsychotics: A meta-analysis of intervention studies

Background

Compliance with guidelines regarding monitoring of metabolic adverse effects induced by antipsychotics has been consistently low. We characterised and evaluated the quality of institutional quality improvement (QI) interventions designed to address disparities between guidelines and real-world practices. Furthermore, we assessed the impact of these interventions on the screening and management of metabolic risks for inpatients receiving treatment with antipsychotic medications.

Methods

We conducted a meta-analysis of institutional QI intervention studies aimed at improving antipsychotic-associated metabolic risk monitoring in hospitalised mental disease patients. Relevant studies were identified through searches conducted in the Embase and PubMed databases, as well as by reviewing previous reviews and meta-analyses. Quantitative analyses were performed, calculating odds ratios (ORs) and 95% confidence intervals (CIs) to assess the impact of QI programmes on guideline adherence in clinical practice.

Results

We identified 12 intervention studies (n = 10 128 and n = 2667 patients in the pre-and post-intervention groups, respectively) and included them in our meta-analysis. QI interventions demonstrated effectiveness in bridging the guideline-practice gap in monitoring antipsychotic-induced metabolic adverse effects, as supported by the ORs and 95% CIs for post-intervention monitoring of plasma glucose, lipids, and blood pressure (BP) vs the pre-intervention period being OR = 6.90 (95% CI = 1.51-31.48), OR = 5.39 (95% CI = 4.01-7.24), and OR = 4.81 (95% CI = 1.23-18.79), respectively. Only 33.3% (4/12) of studies reported screening rates for all four metabolic parameters (plasma glucose, lipids, weight/body mass index (BMI), and BP). The median rates for metabolic screening of plasma glucose, lipids, and BP increased from 51.0-80.0%, 28.7-66.7%, and 91.7-95.8%, respectively. Up to 66.7% (8/12) of intervention studies lacked follow-up measures to treat or manage identified risks in hospitalised psychiatric patients, such as patient referrals, prescription of medications, and switching of antipsychotics. The odds of monitoring weight/BMI and glucose were greatest when QI programmes involved the participation of multidisciplinary health care professionals and patients, yielding OR = 3.35 (95% CI = 2.45-4.59) and OR = 57.51 (95% CI = 24.11-137.21), respectively.

Conclusions

Institutional QI interventions were effective in enhancing monitoring practices in alignment with established guidelines for metabolic risk screening among hospitalised patients with mental disorders maintained on antipsychotic medications. Future institutional QI programmes should incorporate multidisciplinary strategies involving patient engagement and extend their focus beyond screening to incorporate follow-up risk management strategies once risks have been identified.

Registration

PROSPERO CRD42023452138.

Prescriptions of psychotropic and somatic medications among patients with severe mental disorders and healthy controls in a naturalistic study

PURPOSE

Psychotropic and somatic medications are both used in treating severe mental disorders (SMDs). Realistic estimates of the prevalence of use across medication categories are needed. We obtained this in a clinical cohort of patients with SMD and healthy controls (HCs).

MATERIALS AND METHODS

Prescriptions filled at Norwegian pharmacies the year before and after admittance to the Thematically Organized Psychosis (TOP) study were examined in 1406 patients with SMD (mean age 32.5 years, 48.2% women) and 920 HC (34.1 years, 46.2% women). Using data from the Norwegian Prescription Database (NorPD), the number of users in different anatomical therapeutic chemical (ATC) categories was compared using logistic regression. Population estimates were used as reference data.

RESULTS

Use of antipsychotics (N05A), antiepileptics (N03A), antidepressants (N06A), anxiolytics (N05B), hypnotics and sedatives (N05C), anticholinergics (N04A), psychostimulants, attention deficit hyperactivity disorder and nootropic agents (N06B) and drugs for addiction disorders (N07B) was significantly more prevalent in patients with SMD than HC. Use of diabetes treatment (A10), antithrombotic drugs (B01), beta blockers (C07), lipid modifiers (C10), and thyroid and endocrine therapeutics (H03) was also more prevalent in patients with SMD, but with two exceptions somatic medication use was comparable to the general population. Among HC, there was low prevalence of use for most medication categories.

CONCLUSION

Patients were using psychiatric medications, but also several types of somatic medications, more often than HC. Still, somatic medication use was mostly not higher than in the general population. The results indicate that HC had low use of most medication types.

Home-based Intervention with Semaglutide Treatment of Neuroleptic-Related Prediabetes (HISTORI): protocol describing a prospective, randomised, placebo controlled and double-blinded multicentre trial

INTRODUCTION

Subjects with schizophrenia have a 2-3 fold higher mortality rate than the general population and a reduced life expectancy of 10-20 years. Approximately one-third of this excess mortality has been attributed to obesity-related type 2 diabetes (T2D) and to cardiovascular disease. Glucagon-like peptide-1 (GLP-1) analogues increase satiety and delay gastric emptying, thereby reducing food intake and weight. GLP-1 analogues also exert beneficial effects on cardiovascular outcomes in high-risk patients with T2D.Our aim is to investigate whether 30 weeks add-on treatment with the GLP-1 analogue semaglutide can reduce HbA1c sufficiently to reverse pre-diabetes and the metabolic syndrome in overweight schizophrenic patients.

METHODS AND ANALYSIS

We will perform a 30 week, two-armed, multicentre, superiority, double-blinded, randomised trial investigating the effect of weekly injections of semaglutide versus placebo in mental health facilities in Region of Southern Denmark and Region of Zealand, Denmark. In total, 154 adults with schizophrenia spectrum disease, aged 18-60 years treated with second generation antipsychotic treatment, HbA1c 39-47 mmol/mol and body mass index >27 kg/m2 will be randomised to injections of 1.0 mg semaglutide or placebo. The primary outcome is changes in HbA1c. Secondary outcomes encompass metabolic measures, psychotic symptoms and quality of life. Exploratory outcomes encompass insulin sensitivity, cardiovascular risk profile, medication adherence, general well-being and physical activity.

ETHICS AND DISSEMINATION

This study will be carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. This research has obtained approval from both the Danish Medicines Agency and The Regional Committees on Health Research Ethics for Southern Denmark.

TRIAL REGISTRATION NUMBER

NCT05193578 European Clinical Trials Database Number (EudraCT) 2020-004374-22, Regional Ethical Committee number S-20200182.

Serious mental illness is associated with elevated risk of hospital readmission in veterans with heart failure

OBJECTIVE

Adults with serious mental illness (SMI) have high rates of cardiovascular disease, particularly heart failure, which contribute to premature mortality. The aims were to examine 90- and 365-day all-cause medical or surgical hospital readmission in Veterans with SMI discharged from a heart failure hospitalization. The exploratory aim was to evaluate 180-day post-discharge engagement in cardiac rehabilitation, an effective intervention for heart failure.

METHODS

This study used administrative data from the Veterans Health Administration (VHA) and Centers for Medicare & Medicaid Services between 2011 and 2019. SMI status and medical comorbidity were assessed in the year prior to hospitalization. Cox proportional hazards models (competing risk of death) were used to evaluate the relationship between SMI status and outcomes. Models were adjusted for VHA hospital site, demographics, and medical characteristics.

RESULTS

The sample comprised 189,767 Veterans of which 23,671 (12.5%) had SMI. Compared to those without SMI, Veterans with SMI had significantly higher readmission rates at 90 (16.1% vs. 13.9%) and 365 (42.6% vs. 37.1%) days. After adjustment, risk of readmission remained significant (90 days: HR: 1.07, 95% CI: 1.03, 1.11; 365 days: HR: 1.10, 95% CI: 1.07, 1.12). SMI status was not significantly associated with 180-day cardiac rehabilitation engagement (HR: 0.98, 95% CI: 0.91, 1.07).

CONCLUSIONS

Veterans with SMI and heart failure have higher 90- and 365-day hospital readmission rates even after adjustment. There were no differences in cardiac rehabilitation engagement based on SMI status. Future work should consider a broader range of post-discharge interventions to understand contributors to readmission.

The development of type 2 diabetes management in people with severe mental illness in the Capital Region of Denmark from 2001 to 2015

BACKGROUND

Type 2 diabetes (T2D) treatment has changed markedly within the last decades. We aimed to explore whether people with severe mental illness (SMI) have followed the same changes in T2D treatment as those without SMI, as multiple studies suggest that people with SMI receive suboptimal care for somatic disorders.

METHODS

In this registry-based annual cohort study, we explored the T2D treatment from 2001 to 2015 provided in general practices of the Greater Copenhagen area. We stratified the T2D cohorts by their pre-existing SMI status. T2D was defined based on elevated glycated hemoglobin (≥48 mmol/mol) or glucose (≥11 mmol/L) using data from the Copenhagen Primary Care Laboratory Database. Individuals with schizophrenia spectrum disorders (ICD-10 F20-29) or affective disorders (bipolar disorder or unipolar depression, ICD-10 F30-33) were identified based on hospital-acquired diagnoses made within 5 years before January 1 each year for people with prevalent T2D or 5 years before meeting our T2D definition for incident patients. For comparison, we defined a non-SMI group, including people who did not have a hospital-acquired diagnosis of schizophrenia spectrum disorders, affective disorders, or personality disorders. For each calendar year, we assembled cohorts of people with T2D with or without SMI. We used Poisson regression to calculate the rates per 100 person-years of having at least one biochemical test (glycated hemoglobin, low-density lipoprotein cholesterol, estimated glomerular filtration rate, and urine albumin-creatinine ratio), having poor control of these biochemical results, taking glucose-lowering or cardiovascular medications, or experiencing a clinical outcome, including all-cause mortality and cardiovascular mortality. Three outcomes (cardiovascular events, cardiovascular mortality, and all-cause mortality) were additionally examined and adjusted for age and sex in a post hoc analysis.

RESULTS

From 2001 to 2015, 66,914 individuals were identified as having T2D. In 2015, 1.5% of the study population had schizophrenia spectrum disorder and 1.4% had an affective disorder. The number of people who used biochemical tests or had poor biochemical risk factor control was essentially unrelated to SMI status. One exception was that fewer LDL cholesterol tests were done on people with affective disorders and schizophrenia spectrum disorders at the beginning of the study period compared to people in the non-SMI group. This difference gradually diminished and was almost nonexistent by 2011. There was also a slightly slower rise in UACR test rates in the SMI groups compared to other people with T2D during the period. Throughout the study period, all groups changed their use of medications in similar ways: more metformin, less sulfonylurea, more lipid-lowering drugs, and more ACEi/ARBs. However, people with schizophrenia disorder consistently used fewer cardiovascular medications. Cardiovascular events were more common in the affective disorder group compared to the non-SMI group from 2009 to 2015 (rate ratio 2015 : 1.36 [95% CI 1.18-1.57]). After adjustment for age and sex, all-cause mortality was significantly higher among people with a schizophrenia spectrum disorder each year from 2003 to 2015 compared to the non-SMI group (rate ratio 2015 : 1.99 [95% CI 1.26-3.12]).

CONCLUSION

Persons with schizophrenia or affective disorders demonstrated the same treatment changes for T2D as those without SMI in general practice. The lower use of most types of cardiovascular medications among people with schizophrenia disorders indicates potential undertreatment of hypertension and dyslipidemia and remains throughout the study period. Cardiovascular events were most common among people with affective disorders, but this was not reflected in a higher proportion using cardiovascular preventive medications. This knowledge should be considered in the management of this vulnerable patient group.

Cause-specific mortality and comorbid neurodevelopmental disorder in 167,515 patients with bipolar disorder: An entire population longitudinal study

OBJECTIVE

Studies addressing premature mortality in bipolar disorder (BD) patients are limited by small sample sizes. Herein, we used almost 99 % of the population of Taiwan to address this issue, and its association with comorbid neurodevelopmental disorders and severe BD.

METHODS

Between 2003 and 2017, we enrolled 167,515 individuals with BD and controls matched 1:4 for sex and birth year from the National Health Insurance Database linked to the Database of National Death Registry in Taiwan. Time-dependent Cox regression models were used to examine cause-specific mortality (all-cause, natural, and unnatural causes [accidents or suicide]).

RESULTS

With adjustments of sex, age, income, urbanization, and physical conditions, suicide was associated with the highest risk of mortality (reported as hazard ratio with 95 % confidence interval: 9.15; 8.53-9.81) among BD patients, followed by unnatural (4.94; 4.72-5.17), accidental (2.15; 1.99-2.32), and natural causes (1.02; 1.00-1.05). Comorbid attention-deficiency hyperactivity disorder did not contribute to the increased risk of cause-specific mortality; however, comorbid autism spectrum disorder (ASD) increased such risks, particularly for natural (3.00; 1.85-4.88) and accidental causes (7.47; 1.80-31.1). Cause-specific mortality revealed a linear trend with the frequency of psychiatric hospitalization (all, p for trend <0.001), and BD patients hospitalized twice or more each year had 34.63-fold increased risk of suicide mortality (26.03-46.07).

CONCLUSIONS

BD patients with a higher frequency of psychiatric hospitalization have the highest risk of suicide mortality, and comorbid ASD was associated with an increased risk of natural and accidental causes of mortality.

Evaluating Monitoring Guidelines of Clozapine-Induced Adverse Effects: a Systematic Review

BACKGROUND AND OBJECTIVES

Despite the evidence that no other antipsychotic is effective as clozapine for the treatment of resistant schizophrenia, it is associated with various metabolic, neuroendocrine, cardiovascular, and gastrointestinal adverse effects. Guidelines aiming to address the monitoring of clozapine's (serious) adverse effects can be helpful to prevent and treat these effects. However, many of these guidelines seem to lack one or more important monitoring recommendations. We aimed to systematically review the content and quality of existing monitoring guidelines/recommendations for clozapine-induced adverse effects.

METHODS

A comprehensive and systematic literature search, using the MEDLINE, Embase, Web of Science, and Cochrane databases, was conducted for guidelines/recommendations on the monitoring of clozapine-induced adverse events, published between January 2004 and April 2023 (last search 16 April 2023). Only peer-reviewed published guidelines reporting on the comprehensive monitoring of all major clozapine-induced adverse effects and including evidence-based recommendations, developed after the year 2004, were included. Studies reporting on the monitoring of adverse effects of clozapine without being a formal guideline, guidelines reporting on the monitoring of one or a limited number of adverse effects of clozapine, guidelines that were not peer reviewed or published, expert opinion papers without formal consensus guideline development, or guidelines developed before the year 2004, were excluded. The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool was used to evaluate the guidelines/recommendations' quality.

RESULTS

Only one guideline met the inclusion criteria. This consensus statement made recommendations for hematological monitoring, and the monitoring of metabolic, cardiac, and three other adverse effects. Highest scores for the qualitative assessment were found for the domains "scope and purpose" (66.7%), "clarity of presentation" (44.4%), and "editorial independence" (66.7%). Lowest scores were found for "rigor of development" (14.6%) and "applicability" (0%).

CONCLUSIONS

Future guidelines should develop more comprehensive recommendations about specific clozapine-induced adverse effects, including constipation, myocarditis, tachycardia, and seizures, as well as include a rechallenge policy. There is an urgent need for well-developed, methodologically stringent, guidelines.

REGISTRATION

PROSPERO registration number, CRD42023402480.

Nationwide Evaluation of Quality of Care Indicators for Individuals with Severe Mental Illness and Diabetes Mellitus, Following Israel's Mental Health Reform

Diabetes Mellitus (DM) is more common among individuals with severe mental illness (SMI). We aimed to assess quality-of-care-indicators in individuals with SMI following the 2015 Israel's Mental-Health-reform. We analyzed yearly changes in 2015-2019 of quality-of-care-measures and intermediate-DM-outcomes, with adjustment for gender, age-group, and socioeconomic status (SES) and compared individuals with SMI to the general adult population. Adults with SMI had higher prevalences of DM (odds ratio (OR) = 1.64; 95% confidence intervals (CI): 1.61-1.67) and obesity (OR = 2.11; 95% CI: 2.08-2.13), compared to the general population. DM prevalence, DM control, and obesity rates increased over the years in this population. In 2019, HbA1c testing was marginally lower (OR = 0.88; 95% CI: 0.83-0.94) and uncontrolled DM (HbA1c > 9%) slightly more common among patients with SMI (OR = 1.22; 95% CI: 1.14-1.30), control worsened by decreasing SES. After adjustment, uncontrolled DM (adj. OR = 1.02; 95% CI: 0.96-1.09) was not associated with SMI. Cardio-metabolic morbidity among patients with SMI may be related to high prevalences of obesity and DM rather than poor DM control. Effective screening for metabolic diseases in this population and social reforms are required.

Amylin receptor agonism enhances the effects of liraglutide in protecting against the acute metabolic side effects of olanzapine

Olanzapine is a second-generation antipsychotic (AP) used in the management of schizophrenia. Although effective at reducing psychoses, APs cause rapid hyperglycemia, insulin resistance, and dyslipidemia, an effect mediated in part by glucagon. We tested if amylin, a hormone that reduces glucagon, or the amylin receptor agonist pramlintide would protect against acute olanzapine-induced impairments in glucose and lipid homeostasis alone or in combination with other glucose-lowering agents such as liraglutide. We demonstrated that pramlintide lowered olanzapine-induced increases in glucagon:insulin ratio with a trend to protect against excursions in blood glucose. There was an additive effect of pramlintide and liraglutide in protecting against olanzapine-induced hyperglycemia, which was mirrored by reductions in glucagon and attenuated markers of dyslipidemia. Our findings provide evidence that pramlintide, although moderately protective against some aspects of olanzapine-induced metabolic dysfunction, can be used to enhance the protective effects of other interventions against acute olanzapine-induced metabolic dysfunction.

Salsalate and/or metformin therapy confer beneficial metabolic effects in olanzapine treated female mice

Antipsychotic medications are used in the management of schizophrenia and a growing number of off-label conditions. While effective at reducing psychoses, these drugs possess noted metabolic side effects including weight gain, liver lipid accumulation and disturbances in glucose and lipid metabolism. To counter the side effects of antipsychotics standard of care has typically included metformin. Unfortunately, metformin does not protect against antipsychotic induced metabolic disturbances in all patients and thus additional treatment approaches are needed. One potential candidate could be salsalate, the prodrug of salicylate, which acts synergistically with metformin to improve indices of glucose and lipid metabolism in obese mice. The purpose of the current investigation was to compare the effects of salsalate, metformin and a combination of both drugs, on weight gain and indices of metabolic health in female mice treated with the antipsychotic, olanzapine. Herein we demonstrate that salsalate was equally as effective as metformin in protecting against olanzapine induced weight gain and liver lipid accumulation with no additional benefit of combining both drugs. Conversely, metformin treatment, either alone or in combination with salsalate, improved indices of glucose metabolism and increased energy expenditure in olanzapine treated mice. Collectively, our findings provide evidence that dual therapy with both metformin and salsalate could be an efficacious approach with which to dampen the metabolic consequences of antipsychotic medications.

A scoping review of cardiovascular risk factor screening rates in general or family practice attendees living with severe mental ill-health

BACKGROUND

Primary care is essential to address the unmet physical health needs of people with severe mental ill-health. Continued poor cardiovascular health demands improved screening and preventive care. No previous reviews have examined primary care cardiovascular screening rates for people living with severe mental ill-health; termed in the literature "severe mental illness".

METHODS

A scoping review following Joanna Briggs Institute methodology was conducted. Cardiovascular risk factor screening rates in adults with severe mental ill-health were examined in general or family practices (as the main delivery sites of primary care). Literature published between 2001 and 2023 was searched using electronic databases including Medline, Embase, Web of Science, PsychINFO and CINAHL. Two reviewers independently screened titles and abstracts and conducted a full-text review. The term "severe mental illness" was applied as the term applied in the literature over the past decades. Study information, participant details and cardiovascular risk factor screening rates for people with 'severe mental illness' were extracted and synthesised.

RESULTS

Thirteen studies were included. Nine studies were from the United Kingdom and one each from Canada, Spain, New Zealand and the Netherlands. The general and/or family practice cardiovascular disease screening rates varied considerably across studies, ranging from 0 % to 75 % for people grouped within the term "severe mental illness". Lipids and blood pressure were the most screened risk factors.

CONCLUSIONS

Cardiovascular disease screening rates in primary care settings for adults living with severe mental ill-health varied considerably. Tailored and targeted cardiovascular risk screening will enable more comprehensive preventive care to improve heart health outcomes and address this urgent health inequity.

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.

30-year Cardiovascular Disease Risk for Young Adults with Serious Mental Illness

Objective

To estimate 30-year CVD risk and modifiable risk factors in young adults with serious mental illness (SMI) versus those without, and assess variations in CVD risk by race, ethnicity, and sex.

Method

In this cross-sectional study, we estimated and compared the Framingham 30-year CVD risk score and individual modifiable CVD risk factors in young adult (20-39 years) primary care patients with and without SMI at two US healthcare systems (January 2016-Septemeber 2018). Interaction terms assessed whether the SMI-risk association differed across demographic groups.

Results

Covariate-adjusted 30-year CVD risk was significantly higher for those with (n=4228) versus those without (n=155,363) SMI (RR 1.28, 95% CI [1.26, 1.30]). Patients with SMI had higher rates of hypertension (OR 2.02 [1.7, 2.39]), diabetes (OR 3.14 [2.59, 3.82]), obesity (OR 1.93 [1.8, 2.07]), and smoking (OR 4.94 [4.6, 5.36]). The increased 30-year CVD risk associated with SMI varied significantly by race and sex: there was an 8% higher risk in Black compared to White patients (RR 1.08, [1.04, 1.12]) and a 9% lower risk in men compared to women (RR 0.91 [0.88, 0.94]).

Conclusions

Young adults with SMI are at increased 30-year risk of CVD, and further disparities exist for Black individuals and women.

Elevated risk of developing type 2 diabetes in people with a psychiatric disorder: What is the role of health behaviors and psychotropic medication?

AIMS

Several psychiatric disorders are linked with an increased risk of developing type 2 diabetes (T2D), but the mediating mechanisms are unclear. We aimed to investigate health behaviors, obesity, psychotropic medication use, and comorbidity as potential mediating mechanisms explaining these associations.

METHODS

We combined data from a large population-based survey with register-based data and followed a sample of 250,013 Danes (≥16 years) for up to 8.9 years. We conducted mediation analyses investigating 10 potential mediators of the associations between psychiatric disorders and incident T2D.

RESULTS

Individuals with a substance use disorder, schizophrenia, mood disorder, neurotic disorder, eating disorder, or a personality disorder had a significantly higher risk of developing T2D. Organic disorders, intellectual disabilities, developmental and behavioral disorders were not associated with T2D-risk. For all psychiatric disorders significantly associated with T2D, the use of antidepressant medication had the largest proportional mediating effect on the association (13-32 %).

CONCLUSIONS

Use of antidepressant medication had the largest contribution to the associations between psychiatric disorders and incident T2D. Future epidemiological studies and prevention studies should focus on optimizing the use of antidepressant medication with minimal side effects, and the promotion of health behaviors in individuals with a psychiatric disorder to prevent T2D.

[Weight gain and treatment with psychotropic drugs : Background and management]

Psychotropic drug-induced weight gain (PIWG) is a well-known and frequent side effect which is relevant for the prognosis of patients. Individual medications have varying risks for the occurrence of PIWG, and at the same time there are individual risk factors on the part of patients, such as age, gender, metabolic and genetic factors. As the metabolic changes in the context of PIWG result in increased mortality in the long term, it is important to prevent PIWG by appropriate prevention and to intervene in a targeted manner if PIWG has already occurred. Appropriate monitoring is therefore essential. This article provides an overview of underlying mechanisms, risk constellations and possible countermeasures.

Cardiovascular risk assessment methods yield unequal risk predictions: a large cross-sectional study in psychiatric secondary care outpatients

BACKGROUND

Patients with a mental illness are more likely to develop, and die from, cardiovascular diseases (CVD), necessitating optimal CVD-risk (CVR)-assessment to enable early detection and treatment. Whereas psychiatrists use the metabolic syndrome (MetS)-concept to estimate CVR, GPs use absolute risk-models. Additionally, two PRIMROSE-models have been specifically designed for patients with severe mental illness. We aimed to assess the agreement in risk-outcomes between these CVR-methods.

METHODS

To compare risk-outcomes across the various CVR-methods, we used somatic information of psychiatric outpatients from the PHAMOUS-, and MOPHAR-database, aged 40-70 years, free of past or current CVD and diabetes. We investigated: (1) the degree-of-agreement between categorical assessments (i.e. MetS-status vs. binary risk-categories); (2) non-parametric correlations between the number of MetS-criteria and absolute risks; and (3) strength-of-agreement between absolute risks.

RESULTS

Seven thousand twenty-nine measurements of 3509 PHAMOUS-patients, and 748 measurements of 748 MOPHAR-patients, were included. There was systematic disagreement between the categorical CVR-assessments (all p < 0.036). Only MetS-status versus binary Framingham-assessment had a fair strength-of-agreement (κ = 0.23-0.28). The number of MetS-criteria and Framingham-scores, as well as MetS-criteria and PRIMROSE lipid-scores, showed a moderate-strong correlation (τ = 0.25-0.34). Finally, only the continuous PRIMROSE desk and lipid-outcomes showed moderate strength-of-agreement (ρ = 0.91).

CONCLUSIONS

The varying methods for CVR-assessment yield unequal risk predictions, and, consequently, carry the risk of significant disparities regarding treatment initiation in psychiatric patients. Considering the significantly increased health-risks in psychiatric patients, CVR-models should be recalibrated to the psychiatric population from adolescence onwards, and uniformly implemented by health care providers.

TRIAL REGISTRATION

The MOPHAR research has been prospectively registered with the Netherlands Trial Register on 19th of November 2014 (NL4779).

Effect on life expectancy of temporal sequence in a multimorbidity cluster of psychosis, diabetes, and congestive heart failure among 1·7 million individuals in Wales with 20-year follow-up: a retrospective cohort study using linked data

BACKGROUND

To inform targeted public health strategies, it is crucial to understand how coexisting diseases develop over time and their associated impacts on patient outcomes and health-care resources. This study aimed to examine how psychosis, diabetes, and congestive heart failure, in a cluster of physical-mental health multimorbidity, develop and coexist over time, and to assess the associated effects of different temporal sequences of these diseases on life expectancy in Wales.

METHODS

In this retrospective cohort study, we used population-scale, individual-level, anonymised, linked, demographic, administrative, and electronic health record data from the Wales Multimorbidity e-Cohort. We included data on all individuals aged 25 years and older who were living in Wales on Jan 1, 2000 (the start of follow-up), with follow-up continuing until Dec 31, 2019, first break in Welsh residency, or death. Multistate models were applied to these data to model trajectories of disease in multimorbidity and their associated effect on all-cause mortality, accounting for competing risks. Life expectancy was calculated as the restricted mean survival time (bound by the maximum follow-up of 20 years) for each of the transitions from the health states to death. Cox regression models were used to estimate baseline hazards for transitions between health states, adjusted for sex, age, and area-level deprivation (Welsh Index of Multiple Deprivation [WIMD] quintile).

FINDINGS

Our analyses included data for 1 675 585 individuals (811 393 [48·4%] men and 864 192 [51·6%] women) with a median age of 51·0 years (IQR 37·0-65·0) at cohort entry. The order of disease acquisition in cases of multimorbidity had an important and complex association with patient life expectancy. Individuals who developed diabetes, psychosis, and congestive heart failure, in that order (DPC), had reduced life expectancy compared with people who developed the same three conditions in a different order: for a 50-year-old man in the third quintile of the WIMD (on which we based our main analyses to allow comparability), DPC was associated with a loss in life expectancy of 13·23 years (SD 0·80) compared with the general otherwise healthy or otherwise diseased population. Congestive heart failure as a single condition was associated with mean a loss in life expectancy of 12·38 years (0·00), and with a loss of 12·95 years (0·06) when preceded by psychosis and 13·45 years (0·13) when followed by psychosis. Findings were robust in people of older ages, more deprived populations, and women, except that the trajectory of psychosis, congestive heart failure, and diabetes was associated with higher mortality in women than men. Within 5 years of an initial diagnosis of diabetes, the risk of developing psychosis or congestive heart failure, or both, was increased.

INTERPRETATION

The order in which individuals develop psychosis, diabetes, and congestive heart failure as combinations of conditions can substantially affect life expectancy. Multistate models offer a flexible framework to assess temporal sequences of diseases and allow identification of periods of increased risk of developing subsequent conditions and death.

FUNDING

Health Data Research UK.

Metabolic Effects of Antidepressants: Results of a Randomized Study's Interim Analysis

BACKGROUND AND OBJECTIVES

Individuals with major depressive disorder exhibit a dysregulated metabolic profile. There are few studies on how vilazodone, escitalopram, and vortioxetine alter metabolic parameters. Our study aimed to determine the change in plasma glucose, HbA1c, serum cholesterol, triglyceride, and creatinine at 12 weeks.

METHODS

An ongoing randomized, open-label, three-arm study's interim analysis is portrayed here. The participants were assessed at baseline, 4, 8, and 12 weeks after receiving oral tablets of either vilazodone (20-40mg/d), escitalopram (10-20mg/d), or vortioxetine (5-20mg/d). This study is CTRI-registered (2022/07/043808).

RESULTS

Of 71 recruited participants, 49 (69%) completed the 12-week visit. The median Hamilton Depression Rating Scale (HDRS) scores of the participants in vilazodone, escitalopram, and vortioxetine groups were 30.0, 29.5, and 29.0 at baseline (p=0.76) and 19.5, 19.5, and 18.0 (p=0.18) at 12 weeks, respectively. The median fasting blood sugar (FBS) values were 98.5, 105.5, and 98.0 at baseline (p=0.07) and 94.0, 99.5, and 96.0 (p=0.19) at 12 weeks, for vilazodone, escitalopram, and vortioxetine groups, respectively. The post hoc analysis did not yield statistically significant differences regarding any parameters.

CONCLUSION

According to this interim study, the HDRS scores declined after 12 weeks of therapy. The subjects' metabolic parameters did not significantly change. It is essential to perform further investigation regarding these impacts.

Reduction of arterial stiffness in depressive individuals responding to multimodal treatment

BACKGROUND

Depressive individuals are at higher risk for cardiovascular diseases (CVD). Thus, cardiovascular parameters such as arterial stiffness, often measured by pulse wave velocity (PWV), should be monitored. Recent research indicated that depressive individuals exhibit higher PWV, but there is little data on the changeability of PWV through multimodal treatment. This study investigated PWV in moderately to severe depressive individuals before and after undergoing treatment in dependence on responding or not responding to treatment.

METHODS

47 participants (31 females, 16 males) underwent a PWV measurement and filled out a questionnaire surveying depressive symptom severity before and after a six-week psychiatric rehabilitation treatment including multimodal interventions. Subjects were divided in responders and non-responders, depending on their treatment success.

RESULTS

A mixed ANCOVA analysis indicated no significant main effect of responder status, but a significant main effect of measurement time and a significant interaction between responder status and measurement time. Responders exhibited a significant decrease in PWV across time, while no significant change in PWV across time was found for non-responders.

LIMITATIONS

Results are limited by the lack of a control group. The influence of medication duration or medication type was not considered in the analyses. Causality of the relationship between PWV and depression cannot be determined.

CONCLUSION

These findings show that PWV can be positively modified in depressive individuals responding to treatment. This effect cannot solely be attributed to pharmacological interventions but rather the combination of multimodal interventions, thus highlighting the clinical relevance of multimodal treatment in depression and comorbid disorders.

Cardiorespiratory fitness and cardiovascular risk among in-patients with depression compared to healthy controls

Introduction

Compared to the general population, individuals with depression have an increased risk for cardiovascular diseases. Nevertheless, little is known so far whether cardiorespiratory fitness (CRF) moderates this relationship. Therefore, we examined whether common physiological cardiovascular risk factors differ between patients with depression and healthy (non-depressed) controls, whether patients and controls differ in CRF, and whether higher CRF is associated with a lower cardiovascular risk in both patients and healthy controls. Additionally, we examined whether within the patient sample, cardiovascular risk factors differ between patients with mild, moderate and severe depression, and whether the relationship between symptom severity and cardiovascular risk is moderated by patients' CRF levels.

Methods

Data from a multi-centric, two-arm randomized controlled trial (RCT) was analyzed, including 210 patients (F32, single episode: n = 72, F33, recurrent major depression: n = 135, F31-II, bipolar type II: n = 3) and 125 healthy controls. Waist circumference, body mass index, body fat, blood pressure, cholesterol levels, triglycerides, and blood glucose were considered as cardiovascular risk markers. CRF was assessed with a submaximal ergometer test. Differences between groups were examined via χ²-tests and (multivariate) analyses of covariance.

Results

Compared to healthy controls, patients with depression had a higher cardiovascular risk as evident from about half of the examined indicators. In the total sample, participants with good CRF had more favourable scores across nearly all risk markers than counterparts with poor CRF. For most variables, no interaction occurred between group and fitness, indicating that in patients and controls, similar differences existed between participants with poor and good CRF. Few differences in risk markers were found between patients with mild, moderate and severe depression, and no interaction occurred between depression severity and CRF.

Discussion

Patients with depression and healthy controls differ in several cardiovascular risk markers, putting patients at increased risk for CVDs. In contrast, people with good CRF show more favourable cardiovascular risk scores, a relationship which was observed in both healthy controls and patients with depression. Physical health of psychiatric patients should receive the clinical attention that it deserves. Lifestyle interventions targeting healthy diet and/or physical activity are recommended as a physically active and healthy lifestyle contributes equally to patients' mental well-being and cardiovascular health.

Diabetes treatment for persons with severe mental illness: A registry-based cohort study to explore medication treatment differences for persons with type 2 diabetes with and without severe mental illness

It has been argued that persons with severe mental illness (SMI) receive poorer treatment for somatic comorbidities. This study assesses the treatment rates of glucose-lowering and cardiovascular medications among persons with incident type 2 diabetes (T2D) and SMI compared to persons with T2D without SMI. We identified persons ≥30 years old with incident diabetes (HbA1c ≥ 48 mmol/mol and/or glucose ≥ 11.0 mmol/L) from 2001 through 2015 in the Copenhagen Primary Care Laboratory (CopLab) Database. The SMI group included persons with psychotic, affective, or personality disorders within five years preceding the T2D diagnosis. Using a Poisson regression model, we calculated the adjusted rate ratios (aRR) for the redemption of various glucose-lowering and cardiovascular medications up to ten years after T2D diagnosis. We identified 1,316 persons with T2D and SMI and 41,538 persons with T2D but no SMI. Despite similar glycemic control at diagnosis, persons with SMI redeemed a glucose-lowering medication more often than persons without SMI in the period 0.5-2 years after the T2D diagnosis; for example, the aRR was 1.05 (95% CI 1.00-1.11) in the period 1.5-2 years after the T2D diagnosis. This difference was mainly driven by metformin. In contrast, persons with SMI were less often treated with cardiovascular medications during the first 3 years after T2D diagnosis, e.g., in the period 1.5-2 years after T2D diagnosis, the aRR was 0.96 (95% CI 0.92-0.99). For people with SMI in addition to T2D, metformin is more likely to be used in the initial years after T2D diagnosis, while our results suggest potential room for improvement regarding the use of cardiovascular medications.

Cigarette smoking and risk of suicide in bipolar disorder: a systematic review

Objective

Bipolar disorder (BD) is a highly prevalent, chronic and recurrent mental illness. The smoking rates in patients with BD are much higher than those of the general population, and BD is associated with an increased risk of suicide. An association between smoking and suicidal behavior has been found in the general population, this systematic review examines whether there is evidence of an association between smoking and suicide behavior in patients with BD.

Method

A database search was carried out in Medline, Embase, The Cochrane Library, Scopus, and Web of Science, updated until December 31st, 2021, according to the 2020 PRISMA guidelines. We identified prospective and retrospective studies that included patients diagnosed with BD types I, II, and not otherwise specified, and in which smoking and suicidal behavior were correlated. Articles that focused exclusively on other mental disorders were excluded. The Ottawa-Newcastle scale was used to assess the methodological quality of the included articles.

Results

Fifteen articles (n = 7,395) met all the inclusion criteria. In nine of these articles, the authors found an association between smoking and suicidal behavior in BD, while in the remaining six articles, this association was not found. A great deal of variability was observed between articles, particularly in the measurement of suicidal behavior and tobacco consumption. The risk of bias, as assessed by the NOS, was high for most of the included articles, except for two papers, whose risk was low.

Conclusion

It was not possible to establish a clear relationship between tobacco use and the risk of suicide in BD patients due to the heterogeneity of the articles included in this systematic review, which had different sample sizes and methodological issues. However, both conditions are highly prevalent and have a negative impact on the prognosis of BD. Therefore, a systematic approach is needed, based on accurate measurement of a patient's smoking habits and their risk of suicidal behavior, in order to establish an appropriate therapeutic plan.

Additional information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors and was registered on PROSPERO with the CRD42022301570 on January 21th 2022.

The effect of exercise on global, social, daily living and occupational functioning in people living with schizophrenia: A systematic review and meta-analysis

BACKGROUND

Schizophrenia is associated with high rates of global, social and occupational functional impairments. While prior meta-analyses have extensively examined the impact of exercise on physical and mental health, the impact on functioning in schizophrenia have yet to be fully established. This review aimed to update the evidence base regarding the impact of exercise on functioning in schizophrenia, and explore moderators of effect.

METHODS

A systematic search was conducted to identify randomized controlled trials (RCTs) of exercise evaluating global functioning versus any comparator in people with schizophrenia; between group meta-analyses of global functioning (and secondary - social, living skills, occupational, adverse events) were computed using a random effects model. Subgroup analyses based on diagnosis and aspects of the intervention were conducted.

RESULTS

18 full text articles were included, involving 734 participants. A moderate impact of exercise on global functioning was found (g = 0.40, 95 % C·I. = 0.12 to 0.69, p = 0.006), with a moderate impact of exercise on social (N = 5, g = 0.54 95 % C.I = 0.16 to 0.9 p = 0.005), and daily living functioning (N = 3, g = 0.65, 95 % C.I. = 0.07 to 1.22, p = 0.005).

CONCLUSIONS

There is good evidence that exercise can improve the global functioning of people with schizophrenia, with preliminary evidence for social and daily living skills; exercise should be considered an important adjunct to usual care. Higher impacts on global functioning were seen in aerobic interventions and of at least moderate to vigorous intensity. More research is required into resistance training, in early psychosis cohorts and to evaluate the comparison of exercise with other established psychosocial therapies.

Metabolic profile in first episode drug naïve patients with psychosis and its relation to cognitive functions and social cognition: a case control study

1st episode drug naïve patients with psychosis might be at higher risk for cardiometabolic disturbances which could affect the different cognitive, and executive functions and domains of social cognition. This study aimed to study the metabolic parameters in 1st episode drug naïve patients with psychosis, to evaluate the relation of these cardiometabolic domains to the cognitive, executive functions, and social cognition. Socio-demographic characteristics of 150 first episode drug naïve patients with psychosis and 120 matched healthy control groups were collected. The current study also assessed the cardiometabolic profile and cognitive functions in both groups. Social cognition was examined by Edinburgh Social Cognition Test. The study revealed a statistically significant difference in parameters of metabolic profile among the studied groups (p < 0.001*), the scores of cognitive and executive tests were statistically significantly different (p < 0.001*). In addition, the patient's group has lowered scores of domains of social cognition (p < 0.001*). Also, the mean affective theory of mind was negatively correlated with the conflict cost of the Flanker test (r = -.185* p value = .023). The total cholesterol level (r = - 0.241**, p value = .003) and level of triglycerides (r = - 0.241**, p value = 0.003) were negatively correlated with the interpersonal domain of social cognition, the total cholesterol level is positively correlated to the total score of social cognition (r = 0.202*, p value = 0.013). Patients with 1st episode drug naïve psychosis showed disturbed cardiometabolic parameters which have deleterious effects on cognitive functions and social cognition.

High prevalence of metabolic diseases, liver steatosis and fibrosis among Chinese psychiatric patients

BACKGROUND

We aimed to investigate the differences of metabolic disorders between the general population and psychiatric patients, with an emphasis on the prevalence and influencing factors of liver fibrosis in psychiatric patients.

METHODS

A total of 734 psychiatric patients and 734 general population matched for age, sex, and BMI were enrolled from Shanghai, China. All participants underwent blood pressure, glucose, lipid profile measurements, and anthropometric parameters including body weight, height and waist circumference. FibroScan examinations were also performed on psychiatric patients. Liver steatosis and fibrosis were diagnosed by controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) by professional staff.

RESULTS

Compared with the general population, psychiatric patients revealed significantly higher burden of metabolic disorders. The overall prevalence of liver steatosis (CAP ≥ 233 dB/m) and fibrosis (LSM ≥ 7.0 kPa) was 48.7% and 15.5% in psychiatric patients. Psychiatric patients with liver steatosis or fibrosis showed worse metabolic profile. Meanwhile, the prevalence of liver fibrosis was also significantly higher in patients with overweight, central obesity, diabetes, hypertension, metabolic syndrome, and liver steatosis. In logistic regression analyses, age, BMI and visceral adiposity index were independent risk factors for liver fibrosis in psychiatric patients. Additionally, antipsychotic medication was suggested to be associated with an increased risk of liver fibrosis in psychiatric patients with liver steatosis.

CONCLUSIONS

Prevalence of liver steatosis and fibrosis is high in Chinese psychiatric patients. Those with antipsychotic polypharmacy and obesity are at high risk, and may benefit from early liver assessment in preventing fibrosis progression.

Obesity in Adults: Position Statement of Polish Association for the Study on Obesity, Polish Association of Endocrinology, Polish Association of Cardiodiabetology, Polish Psychiatric Association, Section of Metabolic and Bariatric Surgery of the Association of Polish Surgeons, and the College of Family Physicians in Poland

Obesity in adults and its complications are among the most important problems of public health. The search was conducted by using PubMed/MEDLINE, Cochrane Library, Science Direct, MEDLINE, and EBSCO databases from January 2010 to December 2022 for English language meta-analyses, systematic reviews, randomized clinical trials, and observational studies from all over the world. Six main topics were defined in the joint consensus statement of the Polish Association for the Study on Obesity, the Polish Association of Endocrinology, the Polish Association of Cardio-diabetology, the Polish Psychiatric Association, the Section of Metabolic and Bariatric Surgery of the Society of Polish Surgeons, and the College of Family Physicians in Poland: (1) the definition, causes and diagnosis of obesity; (2) treatment of obesity; (3) treatment of main complications of obesity; (4) bariatric surgery and its limitations; (5) the role of primary care in diagnostics and treatment of obesity and barriers; and (6) recommendations for general practitioners, regional authorities and the Ministry of Health. This statement outlines the role of an individual and the adequate approach to the treatment of obesity: overcoming obstacles in the treatment of obesity by primary health care. The approach to the treatment of obesity in patients with its most common complications is also discussed. Attention was drawn to the importance of interdisciplinary cooperation and considering the needs of patients in increasing the long-term effectiveness of obesity management.

Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia

Despite its enduring relevance as the single most effective and important evidence-based treatment for schizophrenia, underutilization of clozapine remains considerable. To a substantial degree, this is attributable to a reluctance of psychiatrists to offer clozapine due to its relatively large side-effect burden and the complexity of its use. This underscores the necessity for continued education regarding both the vital nature and the intricacies of clozapine treatment. This narrative review summarizes all clinically relevant areas of evidence, which support clozapine's wide-ranging superior efficacy - for treatment-resistant schizophrenia (TRS) and beyond - and make its safe use eminently feasible. Converging evidence indicates that TRS constitutes a distinct albeit heterogeneous subgroup of schizophrenias primarily responsive to clozapine. Most importantly, the predominantly early onset of treatment resistance and the considerable decline in response rates associated with its delayed initiation make clozapine an essential treatment option throughout the course of illness, beginning with the first psychotic episode. To maximize patients' benefits, systematic early recognition efforts based on stringent use of TRS criteria, a timely offer of clozapine, thorough side-effect screening and management as well as consistent use of therapeutic drug monitoring and established augmentation strategies for suboptimal responders are crucial. To minimize permanent all-cause discontinuation, re-challenges after neutropenia or myocarditis should be considered. Owing to clozapine's unique efficacy, comorbid conditions including substance use and most somatic disorders should not dissuade but rather encourage clinicians to consider clozapine. Moreover, treatment decisions need to be informed by the late onset of clozapine's full effects, which for reduced suicidality and mortality rates may not even be readily apparent. Overall, the singular extent of its efficacy combined with the high level of patient satisfaction continues to distinguish clozapine from all other available antipsychotics.

Increased risk of incident atrial fibrillation in young adults with mental disorders: A nationwide population-based study

BACKGROUND

Mental disorders and cardiovascular diseases are closely related. However, a paucity of information on the risk of incident atrial fibrillation (AF) in patients with mental disorders exists.

OBJECTIVE

We aimed to assess the association between mental disorders and the risk of AF, particularly in young adults.

METHODS

Using the Korean National Health Insurance Database between 2009 and 2012, we identified adults aged 20-39 years without a history of AF and who have been diagnosed with mental disorders. Mental disorders were defined as having one of the following diagnoses: depression, insomnia, anxiety disorder, bipolar disorder, or schizophrenia. The primary outcome was new-onset AF during follow-up.

RESULTS

A total of 6,576,582 subjects (mean age 30.9 ± 5.0 years; 3,919,339 [59.6%] men) were included. Among the total population, 10% had mental disorders. During the follow-up period, 8932 incident AF events occurred. Patients with mental disorders showed a higher AF incidence than did those without (25.4 per 100,000 person-years vs 17.7 per 100,000 person-years). After multivariable adjustment, mental disorders were associated with a significantly higher risk of AF (adjusted hazard ratio 1.526; 95% confidence interval 1.436-1.621). Patients with bipolar disorder or schizophrenia had a 2-fold higher risk of AF and those with depression, insomnia, and anxiety disorder had a 1.5- to 1.7-fold higher risk of AF than did those without mental disorders.

CONCLUSION

Young adults diagnosed with mental disorders have a higher risk of incident AF. Awareness for AF in high-risk populations should thus be considered.

Lipid Alteration Signature in the Blood Plasma of Individuals With Schizophrenia, Depression, and Bipolar Disorder

Importance

No clinically applicable diagnostic test exists for severe mental disorders. Lipids harbor potential as disease markers.

Objective

To define a reproducible profile of lipid alterations in the blood plasma of patients with schizophrenia (SCZ) independent of demographic and environmental variables and to investigate its specificity in association with other psychiatric disorders, ie, major depressive disorder (MDD) and bipolar disorder (BPD).

Design, Setting, and Participants

This was a multicohort case-control diagnostic analysis involving plasma samples from psychiatric patients and control individuals collected between July 17, 2009, and May 18, 2018. Study participants were recruited as consecutive and volunteer samples at multiple inpatient and outpatient mental health hospitals in Western Europe (Germany and Austria [DE-AT]), China (CN), and Russia (RU). Individuals with DSM-IV or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnoses of SCZ, MDD, BPD, or a first psychotic episode, as well as age- and sex-matched healthy controls without a mental health-related diagnosis were included in the study. Samples and data were analyzed from January 2018 to September 2020.

Main Outcomes and Measures

Plasma lipidome composition was assessed using liquid chromatography coupled with untargeted mass spectrometry.

Results

Blood lipid levels were assessed in 980 individuals (mean [SD] age, 36 [13] years; 510 male individuals [52%]) diagnosed with SCZ, BPD, MDD, or those with a first psychotic episode and in 572 controls (mean [SD] age, 34 [13] years; 323 male individuals [56%]). A total of 77 lipids were found to be significantly altered between those with SCZ (n = 436) and controls (n = 478) in all 3 sample cohorts. Alterations were consistent between cohorts (CN and RU: [Pearson correlation] r = 0.75; DE-AT and CN: r = 0.78; DE-AT and RU: r = 0.82; P < 10-38). A lipid-based predictive model separated patients with SCZ from controls with high diagnostic ability (area under the receiver operating characteristic curve = 0.86-0.95). Lipidome alterations in BPD and MDD, assessed in 184 and 256 individuals, respectively, were found to be similar to those of SCZ (BPD: r = 0.89; MDD: r = 0.92; P < 10-79). Assessment of detected alterations in individuals with a first psychotic episode, as well as patients with SCZ not receiving medication, demonstrated only limited association with medication restricted to particular lipids.

Conclusions and Relevance

In this study, SCZ was accompanied by a reproducible profile of plasma lipidome alterations, not associated with symptom severity, medication, and demographic and environmental variables, and largely shared with BPD and MDD. This lipid alteration signature may represent a trait marker of severe psychiatric disorders, indicating its potential to be transformed into a clinically applicable testing procedure.

A smoking cessation intervention for people with severe mental illness treated in ambulatory mental health care (KISMET): study protocol of a randomised controlled trial

BACKGROUND

Smoking among people with severe mental illness (SMI) is highly prevalent and strongly associated with poor physical health. Currently, evidence-based smoking cessation interventions are scarce and need to be integrated into current mental health care treatment guidelines and clinical practice. Therefore, the present study aims to evaluate the implementation and effectiveness of a smoking cessation intervention in comparison with usual care in people with SMI treated by Flexible Assertive Community Treatment (FACT) teams in the Netherlands.

METHODS

A pragmatic, cluster-randomised controlled trial with embedded process evaluation will be conducted. Randomisation will be performed at the level of FACT teams, which will be assigned to the KISMET intervention or a control group (care as usual). The intervention will include pharmacological treatment combined with behavioural counselling and peer support provided by trained mental health care professionals. The intervention was developed using a Delphi study, through which a consensus was reached on the core elements of the intervention. We aim to include a total of 318 people with SMI (aged 18-65 years) who smoke and desire to quit smoking. The primary outcome is smoking status, as verified by carbon monoxide measurements and self-report. The secondary outcomes are depression and anxiety, psychotic symptoms, physical fitness, cardiovascular risks, substance use, quality of life, and health-related self-efficacy at 12 months. Alongside the trial, a qualitative process evaluation will be conducted to evaluate the barriers to and facilitators of its implementation as well as the satisfaction and experiences of both patients and mental health care professionals.

DISCUSSION

The results of the KISMET trial will contribute to the evidence gap of effective smoking cessation interventions for people treated by FACT teams. Moreover, insights will be obtained regarding the implementation process of the intervention in current mental health care. The outcomes should advance the understanding of the interdependence of physical and mental health and the gradual integration of both within the mental health care system.

TRIAL REGISTRATION

Netherlands Trial Register, NTR9783. Registered on 18 October 2021.

Schizophrenia as a risk factor for cardiovascular and metabolic health outcomes: a comparative risk assessment

AIMS

Cardiometabolic diseases are responsible for the majority of premature deaths in people with schizophrenia. This study aimed to quantify the fatal burden of ischaemic heart disease (IHD), stroke and diabetes attributable to schizophrenia.

METHODS

Comparative Risk Assessment methodology from the Global Burden of Disease (GBD) study was used to calculate attributable burden; pooled relative risks (RRs) for IHD, stroke and diabetes were estimated via meta-regression, which were combined with GBD schizophrenia prevalence estimates to calculate the deaths and years of life lost (YLLs) caused by these health outcomes that were attributable to schizophrenia. The proportion of explained all-cause fatal burden and corresponding unexplained burden was also calculated.

RESULTS

The pooled RRs for IHD, stroke and diabetes mortality were 2.36 [95% uncertainty interval (UI) 1.77 to 3.14], 1.86 (95% UI 1.36 to 2.54) and 4.08 (95% UI 3.80 to 4.38) respectively. Schizophrenia was responsible for around 50 000 deaths and almost 1.5 million YLLs globally in 2019 from these health outcomes combined. IHD, stroke and diabetes together explained around 13% of all deaths and almost 11% of all YLLs attributable to schizophrenia, resulting in 320 660 (95% UI 288 299 to 356 517) unexplained deaths and 12 258 690 (95% UI 10 925 426 to 13 713 646) unexplained YLLs.

CONCLUSIONS

Quantifying the physical disease burden attributable to schizophrenia provides a means of capturing the substantial excess mortality associated with this disorder within the GBD framework, contributing to an important evidence base for healthcare planning and practice.

The efficacy of exercise interventions for all types of inpatients across mental health settings: A systematic review and meta-analysis of 47 studies

This systematic review and meta-analysis investigated the benefits, safety and adherence of exercise interventions delivered in inpatient mental health settings, quantified the number of exercise trials that provided support to maintain engagement in exercise post-discharge, and reported patient feedback towards exercise interventions. Major databases were searched from inception to 22.06.2022 for intervention studies investigating exercise in mental health inpatient settings. Study quality was assessed using Cochrane and ROBINS-1 checklists. Fifty-six papers were included from 47 trials (including 34 RCTs), bias was high. Exercise improved depression (Standardised mean difference = -0.416; 95% Confidence interval -0.787 to -0.045, N = 15) compared to non-exercise comparators amongst people with a range of mental illnesses, with further (albeit limited) evidence suggesting a role of exercise in cardiorespiratory fitness and various other physical health parameters and ameliorating psychiatric symptoms. No serious exercise-related adverse events were noted, attendance was ≥80% in most trials, and exercise was perceived as enjoyable and useful. Five trials offered patients post-discharge support to continue exercise, with varying success. In conclusion, exercise interventions may have therapeutic benefits in inpatient mental health settings. More high-quality trials are needed to determine optimal parameters, and future research should investigate systems to support patients to maintain exercise engagement once discharged.

Thermoneutral housing and preexisting obesity do not abolish the sexually dimorphic effects of olanzapine on weight gain in mice

OBJECTIVE

In contrast to what is seen clinically, male mice are resistant to antipsychotic-induced obesity. This is problematic as preclinical studies examining mechanisms of antipsychotic-induced metabolic dysfunction might be relevant to only half the population. This study sought to determine whether housing mice at thermoneutrality and under conditions of preexisting obesity, steps that have not been previously considered, would uncover a greater obesogenic effect of the antipsychotic olanzapine (OLZ).

METHODS

C57BL6/J mice were fed a low- or high-fat diet (HFD) for 4 weeks and then switched to a control HFD or an HFD supplemented with OLZ for 6 weeks.

RESULTS

Irrespective of obesity, OLZ treatment attenuated weight gain and increased energy expenditure in male mice. In females, OLZ increased food intake and potentiated weight gain in mice with preexisting obesity.

CONCLUSIONS

Despite taking steps to increase clinical translatability, this study did not unmask an obesogenic effect of OLZ in male mice. Interestingly, prior studies in female mice could have been underestimating the metabolic consequences of OLZ by not considering the importance of preexisting obesity. Uncovering the mechanisms conferring resistance to weight gain in males may provide clues for approaches to counter the metabolic side effects of antipsychotics clinically.

Association between antipsychotic medication and clinically relevant weight change: meta-analysis

BACKGROUND

Previous meta-analyses have shown that almost all antipsychotics are associated with weight gain. However, mean weight gain is not informative about clinically relevant weight gain or weight loss.

AIMS

To provide further insight into the more severe body weight changes associated with antipsychotic use, we assessed the proportion of patients with clinically relevant weight gain (CRWG) and clinically relevant weight loss (CRWL), defined as ≥7% weight gain and ≥7% weight loss.

METHOD

We searched PubMed, Embase and PsycInfo for randomised controlled trials of antipsychotics that reported CRWG and CRWL in study populations aged 15 years or older. We conducted meta-analyses stratified by antipsychotic and study duration using a random-effects model. We performed meta-regression analyses to assess antipsychotic-naive status and psychiatric diagnosis as modifiers for CRWG. PROSPERO: CRD42020204734.

RESULTS

We included 202 articles (201 studies). Almost all included antipsychotics were associated with CRWG. For CRWL, available data were too limited to draw firm conclusions. For some antipsychotics, CRWG was more pronounced in individuals who were antipsychotic-naive than in individuals switching to another antipsychotic. Moreover, a longer duration of antipsychotic use was associated with more CRWG, but not CRWL. For some antipsychotics, CRWG was higher in people diagnosed with schizophrenia, but this was inconsistent.

CONCLUSIONS

Switching antipsychotic medication is associated with both weight gain and weight loss, but the level of CRWG is higher than CRWL in antipsychotic-switch studies. CRWG was more pronounced in antipsychotic-naive patients, highlighting their vulnerability to weight gain. The impact of diagnosis on CRWG remains inconclusive.

The RAS-24: Development and validation of an adherence-to-medication scale for severe mental illness patients

Introduction

Several studies have found that most patients with severe mental illness (SMI) and comorbid (physical) conditions are partially or wholly nonadherent to their medication regimens. Nonadherence to treatment is a serious concern, affecting the successful management of patients with SMIs. Psychiatric disorders tend to worsen and persist in nonadherent patients, worsening their overall health. The study described herein aimed to develop and validate a scale (the Ralat Adherence Scale) to measure nonadherence behaviors in a culturally sensitive way.

Materials and Methods

Guided by a previous study that explored the primary reasons for nonadherence in Puerto Rican patients, we developed a pool of 147 items linked to the concept of adherence. Nine experts reviewed the meaning, content, clarity, and relevance of the individual items, and a content validity ratio was calculated for each one. Forty items remained in the scale's first version. This version was administered to 160 patients (21-60 years old). All the participants had a diagnosis of bipolar disorder, major depressive disorder, or schizoaffective disorder. The STROBE checklist was used as the reporting guideline.

Results

The scale had very good internal consistency (Cronbach's alpha = 0.812). After a factor analysis, the scale was reduced to 24 items; the new scale had a Cronbach's alpha of 0.900.

Conclusions

This adherence scale is a self-administered instrument with very good psychometric properties; it has yielded important information about nonadherence behaviors. The scale can help health professionals and researchers to assess patient adherence or nonadherence to a medication regimen.

Enhancing endogenous levels of GLP1 dampens acute olanzapine induced perturbations in lipid and glucose metabolism

Olanzapine is a second-generation antipsychotic (SGA) used in the treatment of schizophrenia and several on- and off-label conditions. While effective in reducing psychoses, acute olanzapine treatment causes rapid hyperglycemia, insulin resistance, and dyslipidemia and these perturbations are linked to an increased risk of developing cardiometabolic disease. Pharmacological agonists of the glucagon-like peptide-1 (GLP1) receptor have been shown to offset weight-gain associated with chronic SGA administration and mitigate the acute metabolic side effects of SGAs. The purpose of this study was to determine if increasing endogenous GLP1 is sufficient to protect against acute olanzapine-induced impairments in glucose and lipid homeostasis. Male C57BL/6J mice were treated with olanzapine, in the absence or presence of an oral glucose tolerance test (OGTT), and a combination of compounds to increase endogenous GLP1. These include the non-nutritive sweetener allulose which acts to induce GLP1 secretion but not other incretins, the DPPiv inhibitor sitagliptin which prevents degradation of active GLP1, and an SSTR5 antagonist which relieves inhibition on GLP1 secretion. We hypothesized that this cocktail of agents would increase circulating GLP1 to supraphysiological concentrations and would protect against olanzapine-induced perturbations in glucose and lipid homeostasis. We found that 'triple treatment' increased both active and total GLP1 and protected against olanzapine-induced perturbations in lipid and glucose metabolism under glucose stimulated conditions and this was paralleled by an attenuation in the olanzapine induced increase in the glucagon:insulin ratio. Our findings provide evidence that pharmacological approaches to increase endogenous GLP1 could be a useful adjunct approach to reduce acute olanzapine-induced perturbations in lipid and glucose metabolism.

[Mental disorders and diabetes mellitus (Update 2023)]

Psychiatric disorders and psychological problems are common in patients with diabetes mellitus. There is a twofold increase in depression which is associated with suboptimal glycemic control and increased morbidity and mortality. Other psychiatric disorders with a higher incidence of diabetes are cognitive impairment, dementia, disturbed eating behavior, anxiety disorders, schizophrenia, bipolar disorders and borderline personality disorder. The coincidence of mental disorders and diabetes has unfavorable influences on metabolic control and micro- and macroangiopathic complications. Improvement of therapeutic outcome is a challenge in the modern health care system. The intentions behind this position paper are to rise awareness of this special set of problems, to intensify cooperation between involved health care providers and to reduce incidence of diabetes mellitus as well as morbidity and mortality from diabetes in this patient group.

Prevalence of, and factors associated with, diabetes mellitus in people with severe mental illness attending a multidisciplinary, outpatient cardiometabolic health assessment service

INTRODUCTION

Evaluate the prevalence of, and factors associated with, diabetes in people with severe mental illness (SMI) attending the Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP) tertiary referral clinics.

RESEARCH DESIGN AND METHODS

Adult patients attending an initial ccCHiP clinic consultation (2014-2019) were studied. Diabetes was defined by an hemoglobin A1c of ≥6.5%, fasting blood glucose of ≥7.0 mmol/L, or a self-reported diagnosis of diabetes and prescription of antihyperglycemic medication.

RESULTS

Over 5 years, 1402 individuals attended a baseline consultation. Mean age of 43.9±12.8 years, 63.1% male and 63.5% had a diagnosis of schizophrenia. Prevalence of diabetes was 23.0% (n=322); an additional 19.5% fulfilled criteria for pre-diabetes. Of those with diabetes, 15.8% were newly diagnosed. Of those with pre-existing diabetes, 84.5% were receiving treatment with antihyperglycemic medication. Over 94% of individuals with diabetes had dyslipidemia; half were current smokers; and 46.4% reported sedentary behavior. On multivariate analysis, diabetes was associated with older age, Aboriginal, Indian or Middle Eastern maternal ethnicity, elevated waist-to-height ratio, family history of diabetes and use of antipsychotic medication.

CONCLUSION

Prevalence of diabetes mellitus in this multiethnic cohort with SMI is significantly higher than the Australian population. Targeted interventions via an assertive integrated approach are required to optimize cardiometabolic health in this population.

Association between brain similarity to severe mental illnesses and comorbid cerebral, physical, and cognitive impairments

Severe mental illnesses (SMIs) are often associated with compromised brain health, physical comorbidities, and cognitive deficits, but it is incompletely understood whether these comorbidities are intrinsic to SMI pathophysiology or secondary to having SMIs. We tested the hypothesis that cerebral, cardiometabolic, and cognitive impairments commonly observed in SMIs can be observed in non-psychiatric individuals with SMI-like brain patterns of deviation as seen on magnetic resonance imaging. 22,883 participants free of common neuropsychiatric conditions from the UK Biobank (age = 63.4 ± 7.5 years, range = 45-82 years, 50.9% female) were split into discovery and replication samples. The regional vulnerability index (RVI) was used to quantify each participant's respective brain similarity to meta-analytical patterns of schizophrenia spectrum disorder, bipolar disorder, and major depressive disorder in gray matter thickness, subcortical gray matter volume, and white matter integrity. Cluster analysis revealed five clusters with distinct RVI profiles. Compared with a cluster with no RVI elevation, a cluster with RVI elevation across all SMIs and brain structures showed significantly higher volume of white matter hyperintensities (Cohen's d = 0.59, p_FDR < 10^-16), poorer cardiovascular (Cohen's d = 0.30, p_FDR < 10^-16) and metabolic (Cohen's d = 0.12, p_FDR = 1.3 × 10^-4) health, and slower speed of information processing (|Cohen's d| = 0.11-0.17, p_FDR = 1.6 × 10^-3-4.6 × 10^-8). This cluster also had significantly higher level of C-reactive protein and alcohol use (Cohen's d = 0.11 and 0.28, p_FDR = 4.1 × 10^-3 and 1.1 × 10^-11). Three other clusters with respective RVI elevation in gray matter thickness, subcortical gray matter volume, and white matter integrity showed intermediate level of white matter hyperintensities, cardiometabolic health, and alcohol use. Our results suggest that cerebral, physical, and cognitive impairments in SMIs may be partly intrinsic via shared pathophysiological pathways with SMI-related brain anatomical changes.

Prevalence of the metabolic syndrome and associated factors among inpatients with severe mental illness in Botswana: a cross-sectional study

INTRODUCTION

The metabolic syndrome, a cluster of inter-related risk factors for cardiovascular diseases is highly prevalent among individuals with obesity and sedentary lifestyle. Chronic psychiatric disorders such as severe mental illness are associated with increased risk for cardiovascular diseases. We aimed to assess the prevalence and correlates of metabolic syndrome among inpatients with severe mental illness in a resource limited setting with high HIV prevalence.

METHODS

This was a cross-sectional study among adult inpatients at a referral psychiatric hospital in Botswana. We used convenience sampling to enrol participants available at the time of the study. The National Cholesterol Education Program Adult Treatment Panel-III (NCEP-ATP III) criteria was used to define the metabolic syndrome. Data were analysed using descriptive statistics as well as multiple logistic regression modelling.

RESULTS

A total of 137 participants were enrolled. Of these, 119 (87%) had complete data for the main analysis. The overall prevalence of metabolic syndrome was 22.6% (95% CI 15.9, 30.6) and did not differ significantly by gender or HIV status. Age was significantly associated with the risk of having the metabolic syndrome while gender, body mass index, HIV status, and days of moderate physical activity were not.

CONCLUSION

There was a moderately high prevalence of metabolic syndrome. Thus, the management of individuals with severe mental illness in resource limited settings should include assessment of cardiovascular risk and target modifiable risk factors in this population. Consideration for the patient's age should be made when rationalizing the limited resources available for assessing metabolic syndrome among patients with severe mental illness.

Improving physical activity and diet in patients with severe mental disorders: Results from the LIFESTYLE multicentric, real-world randomized controlled trial

Aims of the present study are to test the efficacy of a lifestyle group intervention, compared to a brief psychoeducational intervention, on levels of physical activity and dietary habits in a real-world sample of patients with severe mental disorders. The study, funded by the Italian Ministry of Education, has been carried out in six Italian University psychiatric outpatient units. All patients were randomly assigned to the experimental or control group and were assessed through standardized assessment instruments at baseline and six months after randomization. Of the 401 recruited patients, 43.3% had a diagnosis of bipolar disorder, 29.9% of psychosis and 26.9% of major depression. Patients were mainly female (57%), with a mean age of 45.6±11.8 years. Treated patients have almost 8 times the likelihood to show an increase of the total MET (OR: 8.02; p < .001) and of the walking MET (OR: 7.68; p < .001) and are more likely to increase the weekly consumption of vegetables (OR= 1.98, p < .05) and to reduce that of junk food (OR:0.23; p < .05). The present study support the notion that patients with severe mental disorders can improve their lifestyle behaviours and that, with appropriate support, they can achieve a healthy living.

Quality of clinical management of cardiometabolic risk factors in patients with severe mental illness in a specialist mental health care setting

PURPOSE

Cardiometabolic disease in patients with severe mental illness is a major cause of shortened life expectancy. There is sparse evidence of real-world clinical risk prevention practice. We investigated levels of assessments of cardiometabolic risk factors and risk management interventions in patients with severe mental illness in the Norwegian mental health service according to an acknowledged international standard.

METHODS

We collected data from 264 patients residing in six country-wide health trusts for: (a) assessments of cardiometabolic risk and (b) assessments of levels of risk reducing interventions. Logistic regressions were employed to investigate associations between risk and interventions.

RESULTS

Complete assessments of all cardiometabolic risk variables were performed in 50% of the participants and 88% thereof had risk levels requiring intervention according to the standard. Smoking cessation advice was provided to 45% of daily smokers and 4% were referred to an intervention program. Obesity was identified in 62% and was associated with lifestyle interventions. Reassessment of psychotropic medication was done in 28% of the obese patients. Women with obesity were less likely to receive dietary advice, and use of clozapine or olanzapine reduced the chances for patients with obesity of getting weight reducing interventions.

CONCLUSIONS

Nearly nine out of the ten participants were identified as being at cardiometabolic high risk and only half of the participants were adequately screened. Women with obesity and patients using antipsychotics with higher levels of cardiometabolic side effects had fewer adequate interventions. The findings underscore the need for standardized recommendations for identification and provision of cardiometabolic risk reducing interventions in all patients with severe mental illness.

Discovering HIV related information by means of association rules and machine learning

Acquired immunodeficiency syndrome (AIDS) is still one of the main health problems worldwide. It is therefore essential to keep making progress in improving the prognosis and quality of life of affected patients. One way to advance along this pathway is to uncover connections between other disorders associated with HIV/AIDS-so that they can be anticipated and possibly mitigated. We propose to achieve this by using Association Rules (ARs). They allow us to represent the dependencies between a number of diseases and other specific diseases. However, classical techniques systematically generate every AR meeting some minimal conditions on data frequency, hence generating a vast amount of uninteresting ARs, which need to be filtered out. The lack of manually annotated ARs has favored unsupervised filtering, even though they produce limited results. In this paper, we propose a semi-supervised system, able to identify relevant ARs among HIV-related diseases with a minimal amount of annotated training data. Our system has been able to extract a good number of relationships between HIV-related diseases that have been previously detected in the literature but are scattered and are often little known. Furthermore, a number of plausible new relationships have shown up which deserve further investigation by qualified medical experts.