Differential trends in prevalence of diabetes and unrelated general medical illness for schizophrenia patients before and after the atypical antipsychotic era

Schizophrenia and type 2 diabetes risk: a systematic review and meta-analysis

Objectives

The metabolic syndrome in patients with schizophrenia has consistently been a challenge for clinicians. Previous studies indicate that individuals with schizophrenia are highly prone to developing type 2 diabetes mellitus (T2DM). In recent years, a continuous stream of new observational studies has been reported, emphasizing the pressing need for clinicians to gain a more precise understanding of the association between schizophrenia and T2DM. The objective of this meta-analysis is to integrate new observational studies and further explore the potential link between schizophrenia and the risk of T2DM.

Methods

We conducted a comprehensive search of PubMed, Cochrane Library, Embase, and Web of Science using medical subject headings (MeSH) and relevant keywords. The risk of bias in cohort studies and case-control studies was assessed using the Newcastle-Ottawa Scale (NOS), while cross-sectional studies were evaluated using the Agency for Healthcare Research and Quality scale (AHRQ), scoring was based on the content of the original studies. A fixed-effects model was employed if P > 0.1 and I2 ≤ 50%, indicating low heterogeneity. Conversely, a random-effects model was utilized if I2 > 50%, indicating substantial heterogeneity. Publication bias was assessed using funnel plots and Egger's test. Statistical analyses were carried out using Stata statistical software version 14.0.

Results

This meta-analysis comprised 32 observational studies, involving a total of 2,007,168 patients with schizophrenia and 35,883,980 without schizophrenia, published from 2004 to 2023. The pooled analysis revealed a significant association between a history of schizophrenia and an increased risk of T2DM (Odds Ratio [OR] = 2.15; 95% Confidence Interval [CI]: 1.83-2.52; I2 = 98.9%, P < 0.001). Stratified by gender, females with schizophrenia (OR = 2.12; 95% CI: 1.70-2.64; I2 = 90.7%, P < 0.001) had a significantly higher risk of T2DM than males (OR = 1.68; 95% CI: 1.39-2.04; I2 = 91.3%, P < 0.001). Regarding WHO regions, EURO (OR = 2.73; 95% CI: 2.23-3.35; I2 = 97.5%, P < 0.001) exhibited a significantly higher risk of T2DM compared to WPRO (OR = 1.72; 95% CI: 1.32-2.23; I2 = 95.2%, P < 0.001) and AMRO (OR = 1.82; 95% CI: 1.40-2.37; I2 = 99.1%, P < 0.001). In terms of follow-up years, the >20 years subgroup (OR = 3.17; 95% CI: 1.24-8.11; I2 = 99.4%, P < 0.001) showed a significantly higher risk of T2DM than the 10-20 years group (OR = 2.26; 95% CI: 1.76-2.90; I2 = 98.6%, P < 0.001) and <10 years group (OR = 1.68; 95% CI: 1.30-2.19; I2 = 95.4%, P < 0.001).

Conclusions

This meta-analysis indicates a strong association between schizophrenia and an elevated risk of developing diabetes, suggesting that schizophrenia may function as an independent risk factor for T2DM.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023465826.

Diabetes quality of care and outcomes: Comparison of individuals with and without schizophrenia

OBJECTIVE

Individuals with schizophrenia are more likely to develop diabetes than individuals without schizophrenia. The objective of this study was to determine the quality of diabetes care and diabetes-related health outcomes among individuals with and without schizophrenia.

METHOD

We conducted a retrospective cohort study. As of April 1, 2011, we identified all individuals with diabetes in Ontario with and without a diagnosis of schizophrenia. The main outcomes were quality of diabetes care (guideline-concordant testing for HbA1c, lipid testing, eye exams) and diabetes-related Emergency Department (ED) visits and hospitalizations between April 1, 2011 and March 31, 2013. We compared quality of care and diabetes outcomes among those with and without schizophrenia, adjusting for demographic, illness severity, and health service utilization variables.

RESULTS

We identified 1,131,375 individuals with diabetes, among whom 25,628 (2.3%) had schizophrenia. Schizophrenia was associated with reduced likelihood of optimal diabetes care (all 3 of HbA1c, lipid testing, and eye exams) (adjusted OR (95% CI): 0.64 (0.61-0.67)) and increased likelihood of diabetes-related ED visits (adjusted OR (95% CI): 1.34 (1.28-1.41)) and hospitalizations (adjusted OR (95% CI): 1.36 (1.28-1.43)).

CONCLUSION

Individuals with diabetes and schizophrenia have lower rates of recommended testing and higher rates of diabetes-related hospital visits than those with diabetes but without schizophrenia. Research is needed to understand patient, provider, and system factors underlying these disparities and test related interventions to close the gaps in quality of care.

Relationship Between Metabolic Syndrome and Clinical Features, and Its Personal-Social Performance in Patients with Schizophrenia

The aim of this study was to evaluate the metabolic syndrome (MS) criteria and also to investigate the effects of MS on medical treatment, clinical course and personal and social performance in patients with schizophrenia. One hundred-sixteen patients with schizophrenia were included in the study. Measurements of MS were calculated in all patients. Brief Psychiatric Rating Scale, Scale for the Assessment of Positive Symptoms, Scale for the Assessment of Negative Symptoms, Calgary Depression Scale for Schizophrenia, Personal and Social Performance Scale (PSP) were applied. The frequency of MS according to IDF criteria was 42.2 % among the patients. There was no significant difference between patients with and without MS in terms of age. The ratios of MS were 62.5 % for the group taking typical and atypical antipsychotics together and 35.7 % for the group taking two or more atypical antipsychotics together. The duration of disorder in patients with MS was higher than those without MS. Furthermore there was no significant difference between the schizophrenic patients with and without MS, in terms of PSP scores. Our findings showed that the duration of illness, high scores of BMI, use of clozapine or concurrent use of typical and atypical antipsychotics, depressive and negative symptoms of schizophrenia were significant risk factors for the development of MS.

The epidemiology of diabetes in psychotic disorders

Diabetes is highly prevalent in people with psychotic disorders, including schizophrenia and schizoaffective disorders. Exact prevalence is difficult to estimate, since diabetes is often underdiagnosed in people with psychosis. Results of several studies show that the prevalence of diabetes exceeds that in the general population, with documented prevalence in those with psychosis ranging from 1·26% to 50% across studies (median 13%). The association between diabetes and psychosis is complex and multifactorial. Many of the traditional risk factors for disease have increased prevalence in patients with psychotic disorders. In addition to these traditional risk factors, people with psychosis have unique risks that might have additive or even synergistic effects. These risks include the use of antipsychotic medication, the effects of adverse social determinants of health, and genetic loading. Despite evidence that rates of diabetes are increased in individuals with psychosis, many of these patients are not diagnosed or treated, resulting in increased diabetes-associated morbidity and mortality. Specific patient factors, provider issues, and systems-level factors contribute to the treatment gap. Interventions at both the clinical and public health levels are needed to successfully address this problem.

Prevalence of cardiovascular risk factors among racial and ethnic minorities with schizophrenia spectrum and bipolar disorders: a critical literature review

OBJECTIVE

People with serious mental illness (SMI) die at least 11 years earlier than the general U.S. population, on average, due largely to cardiovascular disease (CVD). Disparities in CVD morbidity and mortality also occur among some U.S. racial and ethnic minorities. The combined effect of race/ethnicity and SMI on CVD-related risk factors, however, remains unclear. To address this gap, we conducted a critical literature review of studies assessing the prevalence of CVD risk factors (overweight/obesity, diabetes mellitus, metabolic syndrome, hypercholesterolemia, hypertension, cigarette smoking, and physical inactivity) among U.S. racial/ethnic groups with schizophrenia-spectrum and bipolar disorders.

METHODS AND RESULTS

We searched MEDLINE and PsycINFO for articles published between 1986 and 2013. The search ultimately yielded 40 articles. There was great variation in sampling, methodology, and study populations. Results were mixed, though there was some evidence for increased risk for obesity and diabetes mellitus among African Americans, and to a lesser degree for Hispanics, compared to non-Hispanic Whites. Sex emerged as an important possible effect modifier of risk, as women had higher CVD risk among all racial/ethnic subgroups where stratified analyses were reported.

CONCLUSIONS

Compared to general population estimates, there was some evidence for an additive risk for CVD risk factors among racial/ethnic minorities with SMI. Future studies should include longitudinal assessment, stratification by sex, subgroup analyses to clarify the mechanisms leading to potentially elevated risk, and the evaluation of culturally appropriate interventions to eliminate the extra burden of disease in this population.

Antipsychotic-induced insulin resistance and postprandial hormonal dysregulation independent of weight gain or psychiatric disease

Atypical antipsychotic (AAP) medications that have revolutionized the treatment of mental illness have become stigmatized by metabolic side effects, including obesity and diabetes. It remains controversial whether the defects are treatment induced or disease related. Although the mechanisms underlying these metabolic defects are not understood, it is assumed that the initiating pathophysiology is weight gain, secondary to centrally mediated increases in appetite. To determine if the AAPs have detrimental metabolic effects independent of weight gain or psychiatric disease, we administered olanzapine, aripiprazole, or placebo for 9 days to healthy subjects (n = 10, each group) under controlled in-patient conditions while maintaining activity levels. Prior to and after the interventions, we conducted a meal challenge and a euglycemic-hyperinsulinemic clamp to evaluate insulin sensitivity and glucose disposal. We found that olanzapine, an AAP highly associated with weight gain, causes significant elevations in postprandial insulin, glucagon-like peptide 1 (GLP-1), and glucagon coincident with insulin resistance compared with placebo. Aripiprazole, an AAP considered metabolically sparing, induces insulin resistance but has no effect on postprandial hormones. Importantly, the metabolic changes occur in the absence of weight gain, increases in food intake and hunger, or psychiatric disease, suggesting that AAPs exert direct effects on tissues independent of mechanisms regulating eating behavior.

Obesity, cardiovascular disease and type 2 diabetes in people with a mental illness: a need for primary health care

People with a mental illness show a growing incidence of obesity, and higher rates of metabolic syndrome when compared with the general population. This paper reviews research on obesity, cardiovascular disease and type 2 diabetes, with the aim of directing clinical attention towards the improvement of patient physical health. A systematic search of cross-discipline databases and journals provided peer-reviewed research for analysis, and national statistics allowed for the investigation of differences in rates of occurrence between people experiencing a mental illness and the general population. Treatment effects via psychotropic medications and lifestyle factors such as poor diet and low levels of exercise suggest that ongoing monitoring is necessary to prevent major physical disorders in people experiencing a mental illness. To aid clinicians, a comprehensive set of clinical guidelines have been developed for the physical assessment and ongoing monitoring of mental health patients.

Metabolic syndrome in patients with severe mental illness undergoing psychiatric rehabilitation receiving high dose antipsychotic medication

BACKGROUND

To review evidence of chronic antipsychotic medication and the association with metabolic syndrome in mentally ill patients. This evidence was used to analyse a cohort of patients with severe mental illness and to deduce a correlation between the prevalence of metabolic syndrome and their dose regimens.

MATERIALS AND METHODS

Twenty-four male patients undergoing Psychiatric rehabilitation underwent a review of current medication and assessment of risk factors for metabolic syndrome. Assessment criteria was based upon National Cholesterol Education Programme expert panel on detection, evaluation and treatment of high blood cholesterol in adults (Adult Treatment Panel III) (NCEP ATP III) criteria, incorporating waist circumference, raised triglycerides, reduced high density lipoprotein, raised blood pressure and fasting blood glucose. PubMed, Nature and Science Direct databases have been used to compile the medical and scientific background on metabolic syndrome and antipsychotic medication and the effect on patients particularly on high dose.

RESULTS

Out of 24 patients, 10 patients (41.7%) were receiving high dose antipsychotics (HDA) and four were on maximum dosage limits of 100%. 8.3% (2/24) patients were receiving only one first generation antipsychotics (FGA), 37.5% (9/24) patients were receiving only one second generation antipsychotic (SGA), 45.8% patients (11/24) were receiving two or more SGA only, and only one patient was receiving two or more FGA. One patient was receiving a combination of FGA and SGA. PRN ("as needed") therapy was not included in this study as their usage was limited. Clozapine was mostly prescribed in these patients (10/24, 41.6%). Four out of the 24 patients refused blood tests therefore were excluded from the following results. In the patients evaluated, 55% (11/20) had confirmed metabolic syndrome. In these patients with metabolic syndrome, 45.4% (5/11) were on HDA and 27.3% (3/11) were on maximum British National Formulary (BNF) limits of 100% of dosage. Four out of the nine remaining patients not diagnosed with metabolic syndrome were on HDA.

CONCLUSIONS

Evidence supports the association between antipsychotic medication and metabolic syndrome. The data extrapolated from this cohort of mentally ill patients demonstrates that there is an increase in risk factors for metabolic syndrome and weight gain in the majority of patients on antipsychotic medication. The data however does not support any further predisposition to metabolic syndrome in these patients taking HDA. It also cannot be assumed antipsychotic medication is independently associated with the prevalence of these abnormalities.

A novel insulin sensitizer drug candidate-BGP-15-can prevent metabolic side effects of atypical antipsychotics

Atypical antipsychotic drugs (AAPD) are widely used to treat severe psychiatric disorders, have well documented metabolic side effects such as disturbances in glucose metabolism, insulin resistance and weight gain. It has been shown that BGP-15, a hydroxylamine derivative with insulin sensitizing activity can prevent AAPD provoked fat accumulation in adipocyte cultures, and insulin resistance in animal experiments and in healthy volunteers. The aim of this study was to compare the preventive effect of BGP-15 with conventional oral antidiabetics on metabolic side effects of AAPDs. We found that BGP-15 that does not belong to either conventional insulin sensitizers or oral antidiabetics, is able to counteract insulin resistance and weight gain provoked by antipsychotic agents in rats while rosiglitazone and metformin were not effective in the applied doses. Our results confirm that BGP-15 is a promising new drug candidate to control the metabolic side effects of atypical antipsychotics. Data indicate that this rat model is suitable to analyze the metabolic side effects of AAPDs and the protective mechanism of BGP-15.

Using the Johns Hopkins Aggregated Diagnosis Groups (ADGs) to predict mortality in a population-based cohort of adults with schizophrenia in Ontario, Canada

Administrative health care databases are increasingly used for health services and comparative effectiveness research. When comparing outcomes between different treatments, interventions and exposures, the ability to adjust for differences in the risk of the outcome occurring between treatment groups is important. There is a paucity of validated methods to ascertain comorbidities for risk-adjustment in ambulatory populations of subjects with schizophrenia using administrative health care databases. Our objective was to examine the ability of th\e Johns Hopkins' Aggregated Diagnosis Groups (ADGs) to predict 1-year mortality in a population-based cohort of subjects with schizophrenia. We used a retrospective cohort constructed using population-based administrative data that consisted of all 94,466 residents of Ontario, Canada between the ages of 20 and 100years who were alive on January 1, 2007 and who had been diagnosed with schizophrenia prior to this date. Subjects were randomly divided into derivation and validation samples. A logistic regression model consisting of age, sex, and indicator variables for 14 of the 32 ADG categories had excellent discrimination: the c-statistic (equivalent to the area under the ROC curve) was 0.845 and 0.836 in the derivation and validation samples, respectively. Furthermore, the model demonstrated very good calibration.

Clinical guidelines for the physical care of mental health consumers: a comprehensive assessment and monitoring package for mental health and primary care clinicians

OBJECTIVES

People with a mental illness are more likely to experience poor physical health as compared to the general population. Currently, Australian mental health patients experience a relatively low level of physical health appraisal, prompting the development of the Clinical guidelines for the physical care of mental health consumers assessment and monitoring package.

METHOD

The Clinical guidelines package takes an holistic approach, with a focus on the key dimensions of medication effects, lifestyle, existing or developing physical disorders, alcohol and illicit drug use, and psychosocial factors.

RESULTS

The package consists of a metabolic syndrome algorithm wall chart, a Clinician handbook, a Psychosocial assessment booklet, and a set of three screening forms.

CONCLUSIONS

By taking a user-friendly, flexible, evidence-based approach, the resource can be used by all clinicians involved in the healthcare of people with a mental illness.

Schizophrenia: women bear a disproportionate toll of antipsychotic side effects

BACKGROUND

Men and women with schizophrenia suffer not only from their illness but also from the side effects of their medications.

OBJECTIVE

To review the toll of antipsychotic side effects specifically on women.

STUDY DESIGN

A review of the literature in the PubMed database since 1990 using search terms: sex difference, antipsychotics, schizophrenia, pharmacokinetics, pharmacodynamics, and pharmacogenomics and retrieving additional publications from the reference lists of the original articles.

RESULTS

Findings suggest that, because of differing pharmacokinetics, women are more vulnerable than men to weight gain secondary to antipsychotics and to the consequences (metabolic, cardiovascular, reproductive) of weight gain. They are also more vulnerable to hyperprolactinemia and QTc prolongation.

CONCLUSIONS

Dosing guidelines need to be critically appraised. The greater toll of side effects in women may undermine adherence to prescribed treatments, add to the stigma that attaches to mental illness, and diminish the quality of women's lives. Side effects increase the cost of mental illness and heighten the burden experienced by caregivers. They exacerbate morbidity and raise mortality rates. They affect the children of women treated with antipsychotic medication.

Secondary effects of antipsychotics: women at greater risk than men

CONTEXT

The health burden of antipsychotic medication is well known, but the disproportionate effect on women as compared with men is underappreciated.

OBJECTIVE

The goal of this article is preventive--to better inform clinicians so that the risks to women and to their offspring can be diminished.

METHOD

All PubMed sources in which the search term gender (or sex) was linked to a side effect of antipsychotic medication were reviewed.

RESULT

There is general agreement in the literature on women's increased susceptibility to weight gain, diabetes, and specific cardiovascular risks of antipsychotics, with less consensus on malignancy risks and risks to the fetus. Cardiovascular death, to which men are more susceptible than women, is disproportionately increased in women by the use of antipsychotics. Sedating antipsychotics raise the risk of embolic phenomena during pregnancy, and postpartum. Prolactin-elevating drugs suppress gonadal hormone secretion and may enhance autoimmune proclivity.

CONCLUSIONS

Clinicians need to be aware of the differential harm that women (and their offspring) can incur from the side effects of antipsychotics.

Antipsychotic drug mechanisms: links between therapeutic effects, metabolic side effects and the insulin signaling pathway

The exact therapeutic mechanism of action of antipsychotic drugs remains unclear. Recent evidence has shown that second-generation antipsychotic drugs (SGAs) are differentially associated with metabolic side effects compared to first-generation antipsychotic drugs (FGAs). Their proclivity to cause metabolic disturbances correlates, to some degree, with their comparative efficacy. This is particularly the case for clozapine and olanzapine. In addition, the insulin signaling pathway is vital for normal brain development and function. Abnormalities of this pathway have been found in persons with schizophrenia and antipsychotic drugs may ameliorate some of these alterations. This prompted us to hypothesize that the therapeutic antipsychotic and adverse metabolic effects of antipsychotic drugs might be related to a common pharmacologic mechanism. This article reviews insulin metabolism in the brain and related abnormalities associated with schizophrenia with the goals of gaining insight into antipsychotic drug effects and possibly also into the pathophysiology of schizophrenia. Finally, we speculate about one potential mechanism of action (that is, functional selectivity) that would be consistent with the data reviewed herein and make suggestions for the future investigation that is required before a therapeutic agent based on these data can be realized.

Clinical trial of wellness training: health promotion for severely mentally ill adults

This randomized controlled trial examined benefits of adding active health promotion to basic primary care (BPC) services for SMI adults. It compared BPC with BPC plus wellness training (WT), a 12 months intervention promoting individual skills in self-management. Three hundred nine participants enrolled during short-term residential treatment completed baseline assessments and were assigned to treatment groups, before discharge. Outcomes of perceived health status (SF-36), global assessment of function, and ratings of self-efficacy were assessed at follow-up interviews at 6, 12, and 18 months. The intent-to-treat analysis employed multilevel regression to examine differences by group on outcomes across time, controlling for health related covariates. The WT group showed significantly better outcomes on the SF-36 physical functioning and general health scales. Findings affirm ability of SMI adults to benefit from active health promotion.

The CATIE schizophrenia trial: results, impact, controversy

The CATIE (Clinical Antipsychotic Trials for Intervention Effectiveness) Schizophrenia Trial was designed to examine fundamental issues about second-generation antipsychotic (SGA) medications (olanzapine, risperidone, quetiapine, and ziprasidone) - their relative effectiveness and their effectiveness compared to a first-generation antipsychotic (FGA), perphenazine. This article reviews these and other findings from this important trial and offers a perspective regarding their meaning for practice and their significance for the advancement of research in psychiatry. The primary outcome measure, time to discontinuation, served as an index of effectiveness and was remarkably short; only 26% of subjects completed the 18-month trial on the medicine to which they were initially randomized. Subjects receiving olanzapine experienced a slightly longer time to discontinuation. Based on this single criterion, olanzapine showed greater effectiveness than the other agents despite its association with significant metabolic disturbance, especially weight gain. Perphenazine unexpectedly showed comparable levels of effectiveness and produced no more extrapyramidal side effects than the other agents. Despite modest prolactin elevation, risperidone was the best-tolerated medication. Ziprasidone was associated with weight loss and with positive impact on lipids and blood glucose. In Phase 2, clozapine demonstrated better effectiveness compared to other SGAs for subjects who discontinued their Phase 1 medication because of efficacy. Olanzapine and risperidone showed greater effectiveness in the tolerability pathway. CATIE secondary outcomes are currently being examined. Improvements in cognition were modest among all the agents in Phase 1, and perphenazine was no less effective in improving cognitive performance than the SGAs. Cost-effectiveness analysis revealed a significant advantage for perphenazine, due to the impact of the high-priced, brand-name SGAs on overall health care costs.

An outcome measure in schizophrenia: mortality

OBJECTIVE

To determine the current outcome of schizophrenia, with mortality rate as the outcome measure.

METHOD

Recent health, suicide, victim of violence, and mortality statistics were reviewed.

RESULTS

The general health of individuals with schizophrenia suffers from neglect, poor life style choices, and current treatments that increase death rates.

CONCLUSION

Mortality in schizophrenia is rising, and it is the responsibility of physicians and health care planners to intervene.