Adherence to common cardiovascular medications in patients with schizophrenia vs. patients without psychiatric illness

Cardiovascular disease and bipolar disorder: A review of pathophysiology and treatment implications

OBJECTIVE

Despite the well-established increased risk of cardiovascular mortality in individuals with bipolar disorder (BD), prevention and treatment of cardiovascular risk factors and diseases have been largely overlooked in this population. This manuscript reviews the pathophysiological basis of the connection between BD and cardiovascular diseases, highlighting their shared mechanisms, reciprocal interactions, and relevant prevention and treatment strategies.

METHODS

For this narrative review, a search was carried out on PubMed using the keywords bipolar disorder, cardiovascular diseases, and cardiovascular risk factors.

RESULTS

The increased frequency of cardiovascular morbidity in BD can be attributed to overlapping biological and psychosocial mechanisms. These mechanisms are complex and involve both direct effects of BD and indirect effects mediated by lifestyle and pharmacological factors. Cardiovascular diseases also significantly exacerbate the clinical course of BD and increase morbidity and healthcare costs; thus, their effective management can improve psychiatric outcomes and vice versa. However, patients with BD frequently encounter healthcare barriers.

CONCLUSION

Awareness initiatives and research on integrated care are needed to determine the best strategies for improving cardiovascular and psychiatric outcomes in individuals with BD.

Preventing medication nonadherence: a framework for interventions to support early engagement with treatment

Medication nonadherence is common and results in avoidable morbidity, mortality, and burdens on healthcare systems. This paper proposes a preventative approach to medication nonadherence. We consider existing evidence on the prevalence and determinants of nonadherence early in a patient's medication-taking journey, and map these to potential opportunities for intervention. Many patients stop taking a new medication soon after they are prescribed it, often not collecting the medication. Early patterns of nonadherence are linked to later nonadherence via processes such as habit formation and symptom experiences. Known predictors of nonadherence may be present before someone starts a new treatment, when patients experience disruption to their lives and identity due to illness. Healthcare professionals typically have contact with patients around this time. We argue that it may be possible to prevent medication nonadherence: at the population level; by optimising the prescription process; and through low- and high-intensity interventions for patients with identified early barriers. We give examples of specific interventions and tools that might be needed to operationalise this approach in practice and propose new directions for research to promote early engagement with medication to prevent nonadherence.

Adherence of patients with schizophrenia to hypothyroidism treatment

Adherence to prescription medications is critical for both remission from schizophrenia and control of physical comorbidities. While schizophrenia with comorbid hypothyroidism is common, there is little research on adherence to hypothyroidism treatment in this population. The current study used a retrospective, matched case-control design. The cohort included 1,252 patients diagnosed with schizophrenia according to ICD-10 and 3,756 controls matched for gender, age, socioeconomic status and ethnicity without diagnosis of schizophrenia. All data were retrieved from the electronic medical database of a large health maintenance organization. Retrieved data included demographics, thyroid functionality test results and prescribed medications. Measures of adherence to therapy were used for analyses as were data from follow-ups of patients with hypothyroidism. A diagnosis of hypothyroidism was found in 299 patients, 115 of whom were also diagnosed with schizophrenia. The 184 without schizophrenia constituted the control group. No statistically significant differences were found between the two groups regarding prescriptions for L-thyroxin and TSH levels and number of TSH tests. Adherence of patients with schizophrenia to hypothyroidism treatment was found to be as good as that of individuals without a schizophrenia diagnosis.

Association of hypertension, type 2 diabetes mellitus and dyslipidemia with the duration of inpatient treatments and recurrence of schizophrenia

OBJECTIVE

People with schizophrenia have an increased cardiovascular risk with higher mortality than the general population. Only a few studies have investigated the impact of cardiovascular risk on the later course of schizophrenia. This study aims to explore the association of cardiovascular risk factors, as detected during an index inpatient treatment for schizophrenia, with the duration of psychiatric inpatient treatments and number of inpatient admissions in the subsequent 10 years, in patients with schizophrenia.

METHODS

Cardiovascular risk factors of 736 patients with schizophrenia, identified through retrospective chart review, were assessed by hypertension, type 2 diabetes mellitus and dyslipidemia during an index inpatient stay. The duration of inpatient treatments, assessed by the total duration of psychiatric inpatient treatments in days, and the number of inpatient admissions, over the next 10 years were assessed and analyzed for an association with cardiovascular risk factors.

RESULTS

Hypertension associated with longer duration of inpatient treatments and higher number of inpatient admissions. Type 2 diabetes mellitus and dyslipidemia associated with a higher number of psychiatric inpatient treatments. Hypertension remained significantly associated with the duration of inpatient treatments (β = 0.174; p < 0.001) and the number of inpatient treatments (β = 0.144; p < 0.001), when adjusting for age, sex and BMI.

CONCLUSION

Out of the investigated cardiovascular risk factors documented during an index inpatient stay for schizophrenia, only hypertension associated with an increased duration of in-hospital stay and an increased number of re-hospitalizations during the subsequent ten years when adjusting for confounders. Screening for hypertension should be considered in all patients with schizophrenia.

Approach to schizophrenia

Schizophrenia is the most common of a group of psychotic disorders that occur in approximately 3% of the population over the lifespan. It has clear genetic antecedents, which are shared across the spectrum of psychotic disorders; however, a range of other biological and social factors influence the onset and treatment of the disorder. Schizophrenia is diagnosed by a characteristic set of symptoms (positive, negative, disorganisation, cognitive and affective) accompanied by a functional decline. Investigations are used to exclude other organic causes of psychosis and to provide a baseline for the negative effects of pharmacological treatments. Treatment requires a combination of pharmacological and psychosocial interventions. Physical health is poor in this group of people and this is not helped by inconsistent care from health services. Although earlier intervention has improved the immediate outcomes, the longer-term outcome has not significantly shifted.

ACO Participation Associated With Decreased Spending For Medicare Beneficiaries With Serious Mental Illness

Serious mental illness (SMI) is a major source of suffering among Medicare beneficiaries. To date, limited evidence exists evaluating whether Medicare accountable care organizations (ACOs) are associated with decreased spending among people with SMI. Using national Medicare data from the period 2009-17, we performed difference-in-differences analyses evaluating changes in spending and use associated with enrollment in the Medicare Shared Savings Program (MSSP) among beneficiaries with SMI. After five years, participation in MSSP ACOs was associated with small savings for beneficiaries with SMI (-$233 per person per year) in total health care spending, primarily related to savings from chronic medical conditions (excluding mental health; -$227 per person per year) and not from savings related to mental health services (-$6 per person per year). Savings were driven by reductions in acute and postacute care for medical conditions. Further work is needed to ensure that Medicare ACOs invest in strategies to reduce potentially unnecessary care related to mental health disorders and to improve health outcomes.

Impaired long-term outcomes of patients with schizophrenia spectrum disorder after coronary artery bypass surgery: nationwide case-control study

BACKGROUND

Patients with schizophrenia spectrum disorder have increased risk of coronary artery disease.

AIMS

To investigate long-term outcomes of patients with schizophrenia spectrum disorder and coronary artery disease after coronary artery bypass grafting surgery (CABG).

METHOD

Data from patients with schizophrenia spectrum disorder (n = 126) were retrospectively compared with propensity-matched (1:20) control patients without schizophrenia spectrum disorder (n = 2520) in a multicentre study in Finland. All patients were treated with CABG. The median follow-up was 7.1 years. The primary outcome was all-cause mortality.

RESULTS

Patients with diagnosed schizophrenia spectrum disorder had an elevated risk of 10-year mortality after CABG, compared with control patients (42.7 v. 30.3%; hazard ratio 1.56; 95% CI 1.13-2.17; P = 0.008). Schizophrenia spectrum diagnosis was associated with a higher risk of major adverse cardiovascular events during follow-up (49.9 v. 32.6%, subdistribution hazard ratio 1.59; 95% CI 1.18-2.15; P = 0.003). Myocardial infarction (subdistribution hazard ratio 1.86; P = 0.003) and cardiovascular mortality (subdistribution hazard ratio 1.65; P = 0.017) were more frequent in patients with versus those without schizophrenia spectrum disorder, but there was no difference for stroke. Psychiatric ward admission, antipsychotic medication, antidepressant use and benzodiazepine use before CABG were not associated with outcome differences. After CABG, patients with schizophrenia spectrum disorder received statin therapy less often and had lower doses; the use of other cardiovascular medications was similar between schizophrenia spectrum and control groups.

CONCLUSIONS

Patients with schizophrenia spectrum disorder have higher long-term risks of death and major adverse cardiovascular events after CABG. The results underline the vulnerability of these patients and highlight the importance of intensive secondary prevention and risk factor optimisation.

Prevalence and predictors of medication non-adherence among people living with multimorbidity: a systematic review and meta-analysis

OBJECTIVES

This systematic review aimed to describe medication non-adherence among people living with multimorbidity according to the current literature, and synthesise predictors of non-adherence in this population.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. PubMed, EMBASE, CINAHL and PsycINFO were searched for relevant articles published in English language between January 2009 and April 2019. Quantitative studies reporting medication non-adherence and/or predictors of non-adherence among people with two or more chronic conditions were included in the review. A meta-analysis was conducted with a subgroup of studies that used an inclusive definition of multimorbidity to recruit participants, rather than seeking people with specific conditions. Remaining studies reporting prevalence and predictors of non-adherence were narratively synthesised.

RESULTS

The database search produced 10 998 records and a further 75 were identified through other sources. Following full-text screening, 178 studies were included in the review. The range of reported non-adherence differed by measurement method, at 76.5% for self-report, 69.4% for pharmacy data, and 44.1% for electronic monitoring. A meta-analysis was conducted with eight studies (n=8949) that used an inclusive definition of multimorbidity to recruit participants. The pooled prevalence of non-adherence was 42.6% (95% CI: 34.0 - 51.3%, k=8, I²=97%, p<0.01). The overall range of non-adherence was 7.0%-83.5%. Frequently reported correlates of non-adherence included previous non-adherence and treatment-related beliefs.

CONCLUSIONS

The review identified a heterogeneous literature in terms of conditions studied, and definitions and measures of non-adherence used. Results suggest that future attempts to improve adherence among people with multimorbidity should determine for which conditions individuals require most support. The variable levels of medication non-adherence highlight the need for more attention to be paid by healthcare providers to the impact of multimorbidity on chronic disease self-management.

PROSPERO REGISTRATION NUMBER

CRD42019133849.

Risk Factor for Retreatment Episode on Admission Among TB Patients With Schizophrenia

Background: The clinical characteristics of patients with tuberculosis (TB) and schizophrenia remain largely unknown. Furthermore, TB retreatment is associated with a poor outcome. Hence, we aimed to address the risk factors of TB retreatment in schizophrenia patients in this retrospective cohort. Methods: Between March 2005 and August 2020, patients diagnosed with schizophrenia and TB were included in the study. Patient characteristics, such as demographics, medical history, underlying diseases, symptoms, outcome, and lab examinations, were collected from medical records using a structured questionnaire. TB retreatment was defined as treatment failures and relapses. Subsequently, multivariate logistic regression was performed using variables selected based on prior findings as well as factors found to be associated with a retreatment episode in univariate analyses (p < 0.1). Results: A total of 113 TB patients with schizophrenia were included. Of them, 94 (83.2%) patients were classified as initial treatment group, and 19 (16.8%) were classified as retreatment group. The mean age was 53.0 ± 23.2 years, and males accounted for 61.9% of all cases. Multivariate analysis revealed that continuous antipsychotics treatment (OR = 0.226, 95% CI: 0.074, 0.693; p = 0.009) and extra-pulmonary TB (OR = 0.249, 95% CI: 0.080, 0.783; p = 0.017) were associated with the retreatment in TB patients with schizophrenia. Conclusion: Retreatment is a significant concern for TB patients with schizophrenia. To improve the current dilemma, continuous antipsychotics treatment is required, and increasing awareness of schizophrenia would reduce the disease burden.

Cardiovascular disease in patients with severe mental illness

Individuals diagnosed with schizophrenia or bipolar disorder have a life expectancy 15-20 years shorter than that in the general population. The rate of unnatural deaths, such as suicide and accidents, is high for these patients. Despite this increased proportion of unnatural deaths, physical conditions account for approximately 70% of deaths in patients with either schizophrenia or bipolar disorder, with cardiovascular disease contributing 17.4% and 22.0% to the reduction in overall life expectancy in men and women, respectively. Risk factors for cardiovascular disease, such as smoking, unhealthy diet and lack of exercise, are common in these patients, and lifestyle interventions have been shown to have small effects. Pharmacological interventions to reduce risk factors for cardiovascular disease have been proven to be effective. Treatment with antipsychotic drugs is associated with reduced mortality but also with an increased risk of weight gain, dyslipidaemia and diabetes mellitus. These patients have higher risks of both myocardial infarction and stroke but a lower risk of undergoing interventional procedures compared with the general population. Data indicate a negative attitude from clinicians working outside the mental health fields towards patients with severe mental illness. Education might be a possible method to decrease the negative attitudes towards these patients, thereby improving their rates of diagnosis and treatment.

Methodological features of quantitative studies on medication adherence in older patients with chronic morbidity: A systematic review

OBJECTIVES

The growing number of chronic, multimorbid older adults encourages healthcare systems to cope with polypharmacy and non-adherence. However, methodology on how to provide effective interventions to enhance medication adherence is still object of debate.

METHODS

To describe methodological features of quantitative studies concerning older adults' medication adherence, by means of a PRISMA systematic review (Scopus, PubMed, Medline). A specific focus was devoted to theoretical models and to the ABC Taxonomy model, as stated by the EMERGE guidelines.

RESULTS

55 papers were included. Most of the studies were conducted using randomized control trials (63.6%) and focused on a single disease only (72.7%). Most of the interventions were provided by a single professional figure (70.9%). Medication adherence was mainly evaluated by means of questionnaires (61.8%) and by clinical records (30.9%). Sixteen studies considered a theoretical model in the intervention framework. The Initiation phase (ABC Taxonomy) was the most neglected.

CONCLUSIONS

Future studies upon medication adherence should account real-life challenges such as multimorbidity, polypharmacy and interdisciplinarity, analyzing adherence as a complex, holistic process.

PRACTICE IMPLICATIONS

Theoretical models may be useful to enhance the soundness of the results, to ease their comparability, to calibrate tailored strategies and to plan patient-centered interventions.

Reduced rate of revascularization in schizophrenic patients with acute myocardial infarction: A systematic review and meta-analysis

IMPORTANCE

It has been suggested that patients with schizophrenia have higher than expected mortality following acute coronary events. However, the in-hospital revascularization rate in patients with schizophrenia and acute myocardial infarction (AMI) compared to mentally healthy patients remains unknown.

OBJECTIVE

To evaluate the revascularization rate in schizophrenic patients after AMI with a meta-analysis of observational studies.

DATA SOURCES

PubMed and Embase electronical databases.

STUDY SELECTION

Observational studies that evaluate the likelihood of revascularization in AMI patients with schizophrenia compared to those without schizophrenia, after adjustment for potential influencing factors.

DATA EXTRACTION AND SYNTHESIS

Data regarding study design, characteristics of the AMI patients and schizophrenic patients, and strategies of revascularization were extracted. Results were pooled and analyzed with a random effect model to incorporate the potential heterogeneity.

MAIN OUTCOME AND MEASURES

The likelihood of revascularization in AMI patients with schizophrenia compared to those without schizophrenia, after adjustment for potential influencing factors.

RESULTS

Overall, 3,260,754 hospitalized AMI patients from six follow-up studies were included, of which 17,875 patients had a prior diagnosis of schizophrenia. Results of this meta-analysis suggest that revascularization was significantly lower in AMI patients with schizophrenia compared to those without schizophrenia (odds ratio [OR]: 0.48, 95% confidence interval [CI]: 0.38 to 0.62, p < .001; I² = 93%), after adjustment for demographic characteristics, comorbidities, and hospital and regional factors. Specifically, AMI patients with schizophrenia had significantly fewer percutaneous coronary interventions (OR: 0.48, 95% CI: 0.41 to 0.56, p < .001; I² = 49%) and coronary artery bypass grafts (OR: 0.61, 95% CI: 0.53 to 0.70, p < .001; I² = 20%) compared to those without schizophrenia.

CONCLUSIONS AND RELEVANCE

Patients with schizophrenia and AMI have a lower rate of coronary revascularization as compared with patients without schizophrenia, which is an important cause of higher-than-expected mortality rate in this population.

Chronic physical illnesses in patients with schizophrenia spectrum disorders are independently associated with higher rates of psychiatric rehospitalization; a cross-sectional study in Croatia

Background:

Increased physical morbidity in patients with schizophrenia spectrum disorders (SSDs) is well documented. However, much less is known about the association between somatic comorbidities and psychosis treatment outcomes.

Subjects and methods:

This cross-sectional study, nested within the larger frame of a prospective cohort study, was done in 2016 at Psychiatric Hospital Sveti Ivan, Zagreb, Croatia. Data were collected on a consecutive sample of 301 patients diagnosed with schizophrenia spectrum disorders who achieved a stable therapeutic dosage. Key outcome was the number of psychiatric rehospitalizations since diagnosis of the primary psychiatric illness. Predictors were number of physical and psychiatric comorbidities. By robust regression, we controlled different clinical, sociodemographic, and lifestyle confounding factors.

Results:

The number of chronic somatic comorbidities was statistically significantly associated with a larger number of psychiatric rehospitalizations, even after the adjustment for number of psychiatric comorbidities and large number of other clinical, sociodemographic, and lifestyle variables.

Conclusions:

Chronic somatic comorbidities are associated with higher rates of psychiatric rehospitalization independently of psychiatric comorbidities and other clinical, sociodemographic, and lifestyle factors. Therefore, to treat psychosis effectively, it may be necessary to treat chronic somatic comorbidities promptly and adequately. Chronic somatic comorbidities should be considered equally important as the SSD, and should be brought to the forefront of psychiatric treatment and research with the SSD as one entity. The integrative approach should be the imperative in clinical practice.

Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness

BACKGROUND

Individuals with major depressive disorder (MDD) and bipolar disorder (BD) have particularly high rates of chronic non-cancer pain (CNCP) and are also more likely to receive prescription opioids for their pain. However, there have been no known studies published to date that have examined opioid treatment patterns among individuals with schizophrenia.

METHODS

Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of MDD (N = 65,750), BD (N = 38,117) or schizophrenia or schizoaffective disorder (N = 12,916) were identified and matched on age, sex and Medicare status to controls with no documented mental illness. CNCP diagnoses and prescription opioid medication dispensings were extracted for the matched samples. Multivariate analyses were conducted to evaluate (1) the odds of receiving a pain-related diagnosis and (2) the odds of receiving opioids, by separate mental illness diagnosis category compared with matched controls, controlling for age, sex, Medicare status, race/ethnicity, income, medical comorbidities, healthcare utilization and chronic pain diagnoses.

RESULTS

Multivariable models indicated that having a MDD (OR = 1.90; 95% CI = 1.85-1.95) or BD (OR = 1.71; 95% CI = 1.66-1.77) diagnosis was associated with increased odds of a CNCP diagnosis after controlling for age, sex, race, income, medical comorbidities and healthcare utilization. By contrast, having a schizophrenia diagnosis was associated with decreased odds of receiving a chronic pain diagnosis (OR = 0.86; 95% CI = 0.82-0.90). Having a MDD (OR = 2.59; 95% CI = 2.44-2.75) or BD (OR = 2.12; 95% CI = 1.97-2.28) diagnosis was associated with increased odds of receiving chronic opioid medications, even after controlling for age, sex, race, income, medical comorbidities, healthcare utilization and chronic pain diagnosis; having a schizophrenia diagnosis was not associated with receiving chronic opioid medications.

CONCLUSIONS

Individuals with serious mental illness, who are most at risk for developing opioid-related problems, continue to be prescribed opioids more often than their peers without mental illness. Mental health clinicians may be particularly well-suited to lead pain assessment and management efforts for these patients. Future research is needed to evaluate the effectiveness of involving mental health clinicians in these efforts.

Physical Comorbidities are Independently Associated with Higher Rates of Psychiatric Readmission in a Chinese Han Population

BACKGROUND

In people with psychosis, physical comorbidities are highly widespread and leading contributors to the untimely death encountered. Readmission rates in psychiatric patients are very high. Somatic comorbidities could be one of the considerable risk factors for psychiatric rehospitalization. Nevertheless, much less is known about the relation between physical comorbidities and psychiatric readmission. We aimed to investigate the association between physical comorbidities and psychiatric readmission in Han Chinese patients with psychiatric disorders.

METHODS

We used administrative data for January 1, 2009 to December 31, 2018 from the headquarters of the Affiliated Brain Hospital of Guangzhou Medical University to identify adults with schizophrenia, unipolar depression or bipolar disorder discharged from hospital. Data were extracted on sociodemographic and clinical characteristics. The Charlson comorbidity index (CCI) was used to assess the existence of significant physical comorbidity. Cox proportional hazards regression estimated rehospitalization risk after discharge.

RESULTS

A total of 15,620 individuals were included in this study, with the mean age of 35.1 years (SD = 12.8), and readmission occurred for 23.6% of participants. Survival analysis showed that physical comorbidities were statistically and significantly associated with psychiatric readmission, even after the adjustment for the number of psychiatric comorbidities, other sociodemographic and clinical variables.

CONCLUSION

Our results suggest that somatic comorbidities are related with higher rates of psychiatric readmission. Hence, to treat psychosis more effectively and to reduce rehospitalization, it is crucial to treat physical comorbidities promptly and adequately. It is absolutely necessary to bring somatic comorbidities to the forefront of psychiatric treatment and research.

Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea with Schizophrenia

INTRODUCTION

To determine the 1-year and 3-year adherence rates with Positive Airway Pressure (PAP) therapy in patients with schizophrenia compared to matched controls.

METHODS

A case-control retrospective analysis was performed in a Veterans Affairs hospital. All symptomatic patients with schizophrenia ever started on PAP therapy between 2007 and 2015 were compared with controls matched for severity of sleep apnea based on AHI, BMI, and age at the time of diagnosis.

RESULTS

Total number of subjects in both groups was 39. Mean AHI among cases and controls was 27.63 ± 22.16 and 33.59 ± 44.04 (p = 0.32), mean BMI was 34.91 ± 5.87 and 33.92 ± 5.21 (p = 0.43), and mean age at diagnosis was 53.6 ± 11.75 and 55.97 ± 11.92 (p = 0.36), respectively. There was no statistically significant difference in PAP use between patients with schizophrenia and controls at 1-year (percent days device use > 4 h-36.43% ± 31.41 vs. 49.09% ± 38.76; p = 0.17) and 3-year (percent days device use > 4 h-42.43 ± 35.50 vs. 60.53 ± 38.56; p = 0.089) visits CONCLUSIONS: PAP adherence and usage is not significantly different among patients with schizophrenia compared to matched controls. Therefore, schizophrenia does not appear to influence CPAP compliance.

Effects of chronic physical illness on treatment outcomes among patients with schizophrenia

PURPOSE OF REVIEW

Previous research has demonstrated the high prevalence of medical comorbidity and multimorbidity among patients with schizophrenia. However, little is known regarding the potential effects of chronic physical illness (CPI) on schizophrenia treatment outcomes. In the present report, we aim to provide an updated review of the relevant literature.

RECENT FINDINGS

We searched MEDLINE for studies published between 2017 and 2018. After screening 683 articles, we included six studies of adequate quality. Five of these studies reported significant associations between several CPIs and different schizophrenia treatment outcomes, whereas the remaining study did not. Significant effects were low to moderate in size. CPIs with significant effects on treatment outcomes included metabolic syndrome, cardiovascular disease, and asthma. No significant effects were observed for diabetes, chronic obstructive pulmonary disease, hepatitis, hypertension, hyperlipidemia, or lung conditions. One study reported a significant association between the total number of CPIs and the overall number of psychiatric rehospitalizations.

SUMMARY

In addition to increasing the risk of premature mortality, accumulating evidence indicates that various CPIs affect schizophrenia treatment outcomes. Thus, researchers and healthcare practitioners should increase efforts to raise awareness regarding the importance of physical health among patients with schizophrenia. Further high-quality studies are required, particularly those targeting the potential effects of individual CPIs.

Metabolic syndrome among older adults with schizophrenia spectrum disorder: Prevalence and associated factors in a multicenter study

Metabolic syndrome and its associated morbidity and mortality have been well documented in adults with schizophrenia. However, data is lacking for their geriatric counterparts. We sought to investigate the frequency of screening and the prevalence of metabolic syndrome in older adults with schizophrenia, as well as its possible correlates, using the Cohort of individuals with schizophrenia Aged 55 years or more study (n = 353). We found that 42.2% (n = 149) of our sample was screened for metabolic syndrome. Almost half of those (n = 77; 51.7%) screened positive according to ATPIII criteria. Hypertension and abdominal obesity were the two most prevalent metabolic abnormalities. Screening was positively associated with male gender and urbanicity, and metabolic syndrome diagnosis was positively associated with cardiovascular disorders and consultation with a general practitioner (all p < 0.05). However, there were no significant associations of metabolic syndrome with socio-demographic or clinical characteristics, psychotropic medications, other medical conditions and other indicators of mental health care utilization. Our findings support that the prevalence of metabolic syndrome among older adults with schizophrenia spectrum disorder is high and screening is crucial mainly in those patients with hypertension and/or abdominal obesity. Factors at play might be different than those in the younger population.

Association of Secondary Preventive Cardiovascular Treatment After Myocardial Infarction With Mortality Among Patients With Schizophrenia

IMPORTANCE

Cardioprotective medication use is an important secondary preventive treatment after cardiovascular events. Patients with schizophrenia have excess cardiovascular morbidity and mortality, but no studies have investigated whether taking recommended cardioprotective medication can reduce this excess mortality.

OBJECTIVE

To assess the association of exposure to secondary cardiovascular treatment with all-cause mortality after myocardial infarction among patients with schizophrenia compared with the general population.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide cohort study included individuals admitted with first-time myocardial infarction in Denmark from January 1, 1995, to December 31, 2015. The cohort was dichotomously divided by a diagnosis of schizophrenia. Data on the prescription of guideline-recommended cardioprotective medication, including antithrombotics, β-blockers, vitamin K antagonist, angiotensin-converting enzyme inhibitors, and statins, were obtained from the nationwide registries.

EXPOSURES

Time exposed to cardioprotective medication.

MAIN OUTCOMES AND MEASURE

Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95% CIs for the association between treatment exposure and all-cause mortality after myocardial infarction between patients with and without schizophrenia.

RESULTS

The cohort included 105 018 patients with myocardial infarction, including 684 patients with schizophrenia (0.7%; 483 male [70.6%]; mean [SD] age at diagnosis, 57.3 [10.6] years) and 104 334 general population patients (99.3%; 73 454 male [70.4%]; mean [SD] age at diagnosis, 61.0 [10.6] years), with a total follow-up of 796 435 person-years and 28 059 deaths. Patients diagnosed with schizophrenia who did not receive cardioprotective treatment had the highest mortality rate (HR, 8.78; 95% CI, 4.37-17.64) compared with the general population treated, with treated patients diagnosed with schizophrenia having an increased HR of 1.97 (95% CI, 1.25-3.10). The analyses of the associations of different cardiac therapy strategies with mortality rates revealed that patients with schizophrenia who were treated with any combination of triple therapy had mortality rates similar to those observed in the general population (HR, 1.05; 95% CI, 0.43-2.52) in the multivariable analysis.

CONCLUSIONS AND RELEVANCE

Cardioprotective medication after myocardial infarction should be carefully managed to improve prognosis. The study results suggest that some of the increased cardiac mortality among patients with schizophrenia can be reduced if these patients are efficiently administered combinations of secondary preventive treatments after cardiac events.

Preventive Service Use Among People With and Without Serious Mental Illnesses

INTRODUCTION

People with serious mental illnesses experience excess morbidity and premature mortality resulting from preventable conditions. The goal was to examine disparities in preventive care that might account for poor health outcomes.

METHODS

In this retrospective cohort study, adults (N=803,276) served by Kaiser Permanente Northwest and federally qualified health centers/safety-net community health clinics were categorized into five groups: schizophrenia spectrum disorders, bipolar disorders/affective psychoses, anxiety disorders, nonpsychotic unipolar depression, and reference groups with no evidence of these specific mental illnesses. The primary outcome was overall preventive care-gap rate, the proportion of incomplete preventive services for which each patient was eligible in 2012-2013. Secondary analyses examined Kaiser Permanente Northwest data from 2002 to 2013. Data were analyzed in 2015.

RESULTS

Controlling for patient characteristics and health services use, Kaiser Permanente Northwest mean care-gap rates were significantly lower for bipolar disorders/affective psychoses (mean=18.6, p<0.001) and depression groups (mean=18.6, p<0.001) compared with the reference group. Schizophrenia (mean=19.4, p=0.236) and anxiety groups (mean=19.9, p=0.060) did not differ from the reference group (mean=20.3). In community health clinics, schizophrenia (mean=34.1, p<0.001), bipolar/affective psychosis (mean=35.7, p<0.001), anxiety (mean=38.5, p<0.001), and depression groups (mean=36.3, p<0.001) had significantly lower care-gap rates than those in the reference group (mean=40.0). Secondary analyses of diabetes and dyslipidemia screening trends in Kaiser Permanente Northwest showed diagnostic groups consistently had fewer care gaps than patients in the reference group.

CONCLUSIONS

In vastly different settings, individuals with serious mental illnesses received preventive services at equal or better rates than the general population.

Hypertension risk and clinical care in patients with bipolar disorder or schizophrenia; a systematic review and meta-analysis

BACKGROUND

A higher cardiovascular morbidity and mortality has been observed in patients with bipolar disorder (BPD) or schizophrenia, partly due to an increased risk of hypertension (HTN), or a less effective care of it. This systematic review and meta-analysis, presents a critical appraisal and summary of the studies addressing the risk of HTN, or the differences in its care, for those with schizophrenia or BPD.

METHODS

Prospective studies were searched in PubMed, Embase, PsycINFO, Scopus, and the Web of Science, from database inception to June 2017. A meta-analysis was undertaken to obtain pooled estimates of the risk of HTN.

RESULTS

Five studies reporting the risk of HTN, and five studies presenting differences in its clinical care, were identified. An increased risk of HTN was observed for BPD patients, with an overall Incidence Rate Ratio 1.27(1.15-1.40). The pooled Incidence Rate Ratio of HTN for those with schizophrenia was 0.94 (0.75 - 1.14). A poorer care of HTN (lower rates of screening, prescription, and adherence) was reported in four studies of schizophrenia, and two of BPD patients, compared to people without these conditions.

LIMITATIONS

reduced number of studies on risk and care of HTN on patients with BPD or schizophrenia.

CONCLUSIONS

Limited evidence suggests that patients with BPD have a higher risk of HTN. Patients with schizophrenia and BPD receive poor care of HTN. Understanding the risk of HTN, and the differences in its care, is essential for clinicians to reduce the cardiovascular morbidity and overall mortality of these patients.

Statin prescribing for people with severe mental illnesses: a staggered cohort study of 'real-world' impacts

OBJECTIVES

To estimate the 'real-world effectiveness of statins for primary prevention of cardiovascular disease (CVD) and for lipid modification in people with severe mental illnesses (SMI), including schizophrenia and bipolar disorder.

DESIGN

Series of staggered cohorts. We estimated the effect of statin prescribing on CVD outcomes using a multivariable Poisson regression model or linear regression for cholesterol outcomes.

SETTING

587 general practice (GP) surgeries across the UK reporting data to The Health Improvement Network.

PARTICIPANTS

All permanently registered GP patients aged 40-84 years between 2002 and 2012 who had a diagnosis of SMI. Exclusion criteria were pre-existing CVD, statin-contraindicating conditions or a statin prescription within the 24 months prior to the study start.

EXPOSURE

One or more statin prescriptions during a 24-month 'baseline' period (vs no statin prescription during the same period).

MAIN OUTCOME MEASURES

The primary outcome was combined first myocardial infarction and stroke. All-cause mortality and total cholesterol concentration were secondary outcomes.

RESULTS

We identified 2944 statin users and 42 886 statin non-users across the staggered cohorts. Statin prescribing was not associated with significant reduction in CVD events (incident rate ratio 0.89; 95% CI 0.68 to 1.15) or all-cause mortality (0.89; 95% CI 0.78 to 1.02). Statin prescribing was, however, associated with statistically significant reductions in total cholesterol of 1.2 mmol/L (95% CI 1.1 to 1.3) for up to 2 years after adjusting for differences in baseline characteristics. On average, total cholesterol decreased from 6.3 to 4.6 in statin users and 5.4 to 5.3 mmol/L in non-users.

CONCLUSIONS

We found that statin prescribing to people with SMI in UK primary care was effective for lipid modification but not CVD events. The latter finding may reflect insufficient power to detect a smaller effect size than that observed in randomised controlled trials of statins in people without SMI.

Cardiovascular disease treatment among patients with severe mental illness: a data linkage study between primary and secondary care

BACKGROUND

Suboptimal treatment of cardiovascular diseases (CVD) among patients with severe mental illness (SMI) may contribute to physical health disparities.

AIM

To identify SMI characteristics associated with meeting CVD treatment and prevention guidelines.

DESIGN AND SETTING

Population-based electronic health record database linkage between primary care and the sole provider of secondary mental health care services in south east London, UK.

METHOD

Cardiovascular disease prevalence, risk factor recording, and Quality and Outcomes Framework (QOF) clinical target achievement were compared among 4056 primary care patients with SMI whose records were linked to secondary healthcare records and 270 669 patients without SMI who were not known to secondary care psychiatric services, using multivariate logistic regression modelling. Data available from secondary care records were then used to identify SMI characteristics associated with QOF clinical target achievement.

RESULTS

Patients with SMI and with coronary heart disease and heart failure experienced reduced prescribing of beta blockers and angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (ACEI/ARB). A diagnosis of schizophrenia, being identified with any indicator of risk or illness severity, and being prescribed with depot injectable antipsychotic medication was associated with the lowest likelihood of prescribing.

CONCLUSION

Linking primary and secondary care data allows the identification of patients with SMI most at risk of undertreatment for physical health problems.