Racial/Ethnic disparities in monitoring metabolic parameters for patients with schizophrenia receiving antipsychotic medications

Integrating Electronic Health Records and Polygenic Risk to Identify Genetically Unrelated Comorbidities of Schizophrenia That May Be Modifiable

Background

Patients with schizophrenia have substantial comorbidity that contributes to reduced life expectancy of 10 to 20 years. Identifying modifiable comorbidities could improve rates of premature mortality. Conditions that frequently co-occur but lack shared genetic risk with schizophrenia are more likely to be products of treatment, behavior, or environmental factors and therefore are enriched for potentially modifiable associations.

Methods

Phenome-wide comorbidity was calculated from electronic health records of 250,000 patients across 2 independent health care institutions (Vanderbilt University Medical Center and Mass General Brigham); associations with schizophrenia polygenic risk scores were calculated across the same phenotypes in linked biobanks.

Results

Schizophrenia comorbidity was significantly correlated across institutions (r = 0.85), and the 77 identified comorbidities were consistent with prior literature. Overall, comorbidity and polygenic risk score associations were significantly correlated (r = 0.55, p = 1.29 × 10-118). However, directly testing for the absence of genetic effects identified 36 comorbidities that had significantly equivalent schizophrenia polygenic risk score distributions between cases and controls. This set included phenotypes known to be consequences of antipsychotic medications (e.g., movement disorders) or of the disease such as reduced hygiene (e.g., diseases of the nail), thereby validating the approach. It also highlighted phenotypes with less clear causal relationships and minimal genetic effects such as tobacco use disorder and diabetes.

Conclusions

This work demonstrates the consistency and robustness of electronic health record-based schizophrenia comorbidities across independent institutions and with the existing literature. It identifies known and novel comorbidities with an absence of shared genetic risk, indicating other causes that may be modifiable and where further study of causal pathways could improve outcomes for patients.

Differences in metabolic biomarkers in people with schizophrenia who are of Mexican descent compared to non-Hispanic whites

Metabolic dysfunction is highly prevalent and contributes to premature mortality among people with schizophrenia (PwS), especially in Hispanic/Latino/a/x/e PwS, compared to non-Hispanic White (NHW) PwS. This study evaluated the relative contributions of Mexican descent and schizophrenia diagnosis to metabolic biomarker levels. This cross-sectional study included 115 PwS and 102 non-psychiatric comparison (NC) participants - English-speakers aged 26-66 years, 27% Mexican descent, and 52% women across both groups. Assessments included evaluations of BMI, psychopathology, and fasting metabolic biomarkers. We used ANOVA analyses to compare metabolic outcomes between diagnostic and ethnic subgroups, linear regression models to examine associations between Mexican descent and metabolic outcomes, and Spearman's correlations to examine relationships between metabolic outcomes and illness-related variables in PwS. Mexican PwS had higher hemoglobin A1c levels, insulin resistance, and body mass index than NHW PwS. Mexican descent was associated with higher hemoglobin A1c levels, insulin resistance, body mass index, and leptin levels, controlling for age, sex, depression, education, and smoking. Among Mexican PwS, worse negative symptoms were associated with greater insulin resistance. These findings support the possibility of ethnicity-based differences in metabolic dysregulation, though further investigation is warranted to create targeted health interventions for Hispanic PwS.

Disruptions in Care for Medicare Beneficiaries With Severe Mental Illness During the COVID-19 Pandemic

IMPORTANCE

Little is known about changes in care for individuals with severe mental illness during the COVID-19 pandemic.

OBJECTIVE

To examine changes in mental health care during the pandemic and the use of telemedicine in outpatient care among Medicare beneficiaries with severe mental illness.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included Medicare beneficiaries (age ≥18 years) diagnosed with schizophrenia and schizophrenia-related disorders or bipolar I disorder. Care patterns during January to September 2020 for a cohort defined in 2019 were compared with those during January to September 2019 for a cohort defined in 2018.

EXPOSURES

Start of COVID-19 pandemic in the United States, defined as week 12 of 2020.

MAIN OUTCOMES AND MEASURES

Use of mental health-related outpatient visits, emergency department visits, inpatient care, and oral prescription fills for antipsychotics and mood stabilizers during 4-week intervals. Multivariable logistic regression analyses examined whether the pandemic was associated with differential changes in outpatient care across patient characteristics.

RESULTS

The 2019 cohort of 686 214 individuals included 389 245 (53.8%) women, 114 073 (15.8%) Black and 526 301 (72.8%) White individuals, and 477 353 individuals (66.0%) younger than 65 years; the 2020 cohort of 723 045 individuals included 367 140 (53.5%) women, 106 699 (15.6%) Black and 497 885 (72.6%) White individuals, and 442 645 individuals (64.5%) younger than 65 years. Compared with 2019, there were large decreases during the pandemic's first month (calendar weeks 12-15) in individuals with outpatient visits (265 169 [36.7%] vs 200 590 [29.2%]; 20.3% decrease), with antipsychotic and mood stabilizer medication prescription fills (216 468 [29.9%] vs 163 796 [23.9%]; 20.3% decrease), with emergency department visits (12 383 [1.7%] vs 8503 [1.2%]; 27.7% decrease), and with hospital admissions (11 564 [1.6%] vs 7912 [1.2%]; 27.9% decrease). By weeks 32 to 35 of 2020, utilization rebounded but remained lower than in 2019, ranging from a relative decrease of 2.5% (outpatient visits) to 12.9% (admissions). During the full pandemic period (weeks 12-39) in 2020, 1 556 403 of 2 743 553 outpatient visits (56.7%) were provided via telemedicine. In multivariable analyses, outpatient visit use during weeks 12 to 25 of 2020 was lower among those with disability (odds ratio, 0.95; 95% CI, 0.93-0.96), and during weeks 26 to 39 of 2020, it was lower among Black vs non-Hispanic White individuals (OR, 0.97; 95% CI, 0.95-0.99) and those with dual Medicaid eligibility (OR, 0.96; 95% CI, 0.95-0.98).

CONCLUSIONS AND RELEVANCE

In this cohort study, despite greater use of telemedicine, individuals with severe mental illness experienced large disruptions in care early in the pandemic. These narrowed but persisted through September 2020. Disruptions were greater for several disadvantaged populations.

Structural Disadvantage and Culture, Race, and Ethnicity in Early Psychosis Services: International Provider Survey

OBJECTIVE

Little is known about provider perspectives on programmatic responses to structural disadvantage and cultural differences within early intervention in psychosis (EIP) services, programs, and models. The primary objective of this study was to investigate providers' perspectives on the impacts of disadvantage and minority race, ethnicity, and culture and to describe current practices and perceived gaps and concerns.

METHODS

An online survey of specialized EIP providers was disseminated in the United Kingdom, United States, Canada, Australia, and Chile. A total of 164 providers, representing 110 unique sites, completed the survey. Closed-ended questions gathered demographic and program data, including information on formal assessment of trauma or adversity, integration of trauma-informed care, integration of formal cultural assessment tools, training focused on culture, programmatic changes to address culture-related issues, and consultation with cultural insiders. Open-ended questions addressed the demographic mix of the program's client population; the perceived role and influence of trauma, structural disadvantage, and cultural differences; and concerns and needs related to these topics. Frequencies were examined for closed-ended items; open-ended responses were systematically coded.

RESULTS

Overall, survey findings suggested low levels of implementation of a variety of assessment and support practices related to cultural diversity in EIP programs. Coding of open-ended responses revealed numerous concerns regarding the impacts of disadvantage and cultural difference on clients and perceived gaps in policy and implementation.

CONCLUSIONS

An expansion of research and service development aimed at better meeting the disadvantage- and culture-related needs of young people with early psychosis and their families should be a priority for the field.

Risk Factors of Metabolic Syndrome Among Patients Receiving Antipsychotics: A Retrospective Study

This study aimed to assess the differential effects of first-generation (FGA) and second-generation antipsychotics (SGA) on the prevalence of risk factors for metabolic syndrome among mentally ill patients in Qatar. We also wanted to check if there is proper adherence with the guidelines for prescribing antipsychotics and the monitoring of metabolic effects in this population. We collected the available retrospective data (socio-demographic, psychiatric, anthropometric, and metabolic measures) from the records of 439 patients maintained on antipsychotics. The majority were males, married, employed, having a psychotic disorder, and receiving SGA. Patients on SGA showed more obesity, higher BP, and more elevated triglycerides compared to those on FGA. The prevalence of the abnormal metabolic measures was high in this sample, but those on SGA showed a significantly higher prevalence of abnormal body mass index and BP. Obesity and hypertension were common in patients maintained on antipsychotics, especially those on SGA. Polypharmacy was common, and many metabolic measures were not monitored properly in those maintained on antipsychotics. More prospective studies with guided monitoring of the patients' clinical status and metabolic changes are needed to serve better this population of patients.

Disparities in outpatient visits for mental health and/or substance use disorders during the COVID surge and partial reopening in Massachusetts

OBJECTIVE

To examine changes in outpatient visits for mental health and/or substance use disorders (MH/SUD) in an integrated healthcare organization during the initial Massachusetts COVID-19 surge and partial state reopening.

METHODS

Observational study of outpatient MH/SUD visits January 1st-June 30th, 2018-2020 by: 1) visit diagnosis group, 2) provider type, 3) patient race/ethnicity, 4) insurance, and 5) visit method (telemedicine vs. in-person).

RESULTS

Each year, January-June 52,907-73,184 patients were seen for a MH/SUD visit. While non-MH/SUD visits declined during the surge relative to 2020 pre-pandemic (-38.2%), MH/SUD visits increased (9.1%)-concentrated in primary care (35.3%) and non-Hispanic Whites (10.5%). During the surge, MH visit volume increased 11.7% while SUD decreased 12.7%. During partial reopening, while MH visits returned to 2020 pre-pandemic levels, SUD visits declined 31.1%; MH/SUD visits decreased by Hispanics (-33.0%) and non-Hispanic Blacks (-24.6%), and among Medicaid (-19.4%) and Medicare enrollees (-20.9%). Telemedicine accounted for ~5% of MH/SUD visits pre-pandemic and 83.3%-83.5% since the surge.

CONCLUSIONS

MH/SUD visit volume increased during the COVID surge and was supported by rapidly-scaled telemedicine. Despite this, widening diagnostic and racial/ethnic disparities in MH/SUD visit volume during the surge and reopening suggest additional barriers for these vulnerable populations, and warrant continued monitoring and research.

Race analysis in an African American sample with serious mental illness and comorbid diabetes

OBJECTIVES

Targeted Training in Illness Management (TTIM) focuses on enhancing care engagement for people living with serious mental illness and diabetes. This secondary analysis from a 60-week, randomized controlled trial of TTIM versus treatment as usual evaluated racial subgroup outcomes.

METHOD

Demographics, clinical characteristics, and diabetes status were evaluated for those self-identifying as non-Hispanic White, African American, and Hispanic. Longitudinal response to TTIM was evaluated using a multiple domain risk index. Due to their small sample size; those identifying as Hispanic were excluded from this analysis.

RESULTS

Non-Hispanic White participants had greater baseline socioeconomic advantages. Baseline risk scores, glycosylated hemoglobin (HbA1c) values, and HbA1c differences over time were similar for African American and non-Hispanic White participants.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

African American participants living with serious mental illness and diabetes receiving TTIM did as well as non-Hispanic White participants. Inclusive approaches that feature peer support and are situated in safety-net health care settings need to be further investigated with respect to potentially impacting health disparities. (PsycINFO Database Record

Epigenetics of Stress, Addiction, and Resilience: Therapeutic Implications

Substance use disorders (SUDs) are highly prevalent. SUDs involve vicious cycles of binges followed by occasional periods of abstinence with recurrent relapses despite treatment and adverse medical and psychosocial consequences. There is convincing evidence that early and adult stressful life events are risks factors for the development of addiction and serve as cues that trigger relapses. Nevertheless, the fact that not all individuals who face traumatic events develop addiction to licit or illicit drugs suggests the existence of individual and/or familial resilient factors that protect these mentally healthy individuals. Here, I give a brief overview of the epigenetic bases of responses to stressful events and of epigenetic changes associated with the administration of drugs of abuse. I also discuss the psychobiology of resilience and alterations in epigenetic markers that have been observed in models of resilience. Finally, I suggest the possibility that treatment of addiction should involve cognitive and pharmacological approaches that enhance resilience in at risk individuals. Similar approaches should also be used with patients who have already succumbed to the nefarious effects of addictive substances.