A comparison of schizophrenia outpatients treated with antipsychotics with and without metabolic syndrome: findings from the CLAMORS study

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.

Predictors of full recovery in patients with early stage schizophrenia spectrum disorders

To promote recovery in psychosis, targeting modifiable factors related to recovery is critical. Using more strict definition of full recovery, we examined predictors for recovery in patients with early stage schizophrenia spectrum disorders (SSD) followed up to 6.5 years. The target subjects were 375 patients with early stage SSD who had been over at least 1-year after registration and evaluated. The criteria for full recovery were having the score of the Positive and Negative Syndrome Scale (PANSS) 8-item ≤ 2 and adequate functional recovery for at least 1-year. We performed univariate Cox and stepwise Cox regression in both total and acute patients. In stepwise Cox regression, several independent predictors for recovery, i.e., negative symptoms of the PANSS, duration of untreated psychosis (DUP) and non-professional job were identified in patients with early stage SSD. In acute patients, other factors such as professional job and subjective well-being under neuroleptics were more important. The present study identified independent predictors for recovery modifiable by various psychosocial intervention and early intervention services. Moreover, it highlights the need of providing different treatment strategies depending on clinical status.

Experiences and perceptions of people with a severe mental illness and health care professionals of a one-year group-based lifestyle programme (SMILE)

Objective

This was to elucidate the experiences and perceptions of people with severe mental illness (SMI) and their health care professionals with the SMILE (Severe Mental Illness Lifestyle Evaluation) group-based lifestyle intervention. SMILE focuses primarily on promoting healthy diet, physical activity and weight loss.

Method

A qualitative study with semi-structured interviews was conducted using purposive sampling. Interviews were conducted with 15 clients and 13 health care professionals (HCPs). Data were analysed according to a thematic analysis.

Results

Four overall themes were identified: interest in a lifestyle programme; group-based setting; changes in lifestyle behaviour; and preconditions for changing health behaviour. The results showed that clients valued the programme and were interested in the subject of lifestyle. The group-based setting was seen as a positive and important aspect of the intervention. Making lifestyle changes was acknowledged as difficult, especially in combination with the presence of psychiatric symptoms. Clients acquired an improved awareness of different aspects related to lifestyle behaviour. Irrespective of weight loss achieved, clients found their efforts successful with relatively ‘small’ changes. Some needed more support during the intervention than others. The practical activities in group sessions were regarded as most useful. HCPs were enthusiastic about the programme and their interactions with lifestyle improvements.

Conclusions

The results of this study shed light on different aspects that were considered important when delivering a lifestyle intervention to people with SMI. We recommend considering these aspects when implementing a lifestyle intervention in a mental health care setting for clients with SMI.

Doenças cardiovasculares e uso de antipsicóticos na esquizofrenia: uma revisão

RESUMO Objetivo Realizar uma revisão de escopo a respeito dos efeitos adversos cardiovasculares e metabólicos associados ao uso de antipsicóticos em pessoas com o diagnóstico de esquizofrenia. Métodos Foi realizada uma revisão de escopo utilizando-se da base de dados PubMed, com descritores MeSH relacionados às doenças cardiovasculares e antipsicóticos. Foram encontrados 976 artigos, os quais foram filtrados por títulos, seguidos dos resumos e, na sequência, lidos na íntegra. Ao final, foram selecionados 71 artigos para a análise. Resultados O uso de antipsicóticos típicos e atípicos para tratamento da esquizofrenia associa-se a alterações glicêmicas e lipídicas, síndrome metabólica, hipertensão, ganho de peso e morbidade cardiovascular. Os estudos evidenciaram a existência de subdiagnóstico e subtratamento de doenças crônicas nessa população. A mortalidade por doença cardiovascular demonstrou aumento considerável nos pacientes em tratamento com agentes antipsicóticos, em comparação com a população geral. Conclusão Alguns fatores dos antipsicóticos, ainda não completamente determinados na psicofarmacologia, vêm se mostrando relacionados a maior risco de distúrbios metabólicos, comportamentais e intrínsecos às pessoas diagnosticadas com esquizofrenia, os quais podem agravar o curso clínico de tais doenças. Reconhece-se a necessidade de aprimorar o acompanhamento e o diagnóstico de doenças cardiovasculares e metabólicas entre pessoas com diagnóstico de esquizofrenia em tratamento com antipsicóticos típicos e atípicos.

Eating and nutritional habits in patients with schizophrenia

BACKGROUND

There are few studies that relate eating and nutritional habits to the severity of the disease and demographic profile in patients with schizophrenia.

OBJECTIVE

To describe eating and nutritional habits and their relationship with the severity of the disease in patients with schizophrenia.

METHOD

Cross-sectional descriptive study.

SAMPLE

31 patients with schizophrenia (ICD-10) under outpatient treatment.

INCLUSION CRITERIA

age 18-65 years, clinically stable and, written informed consent.

ASSESSMENT

Demographic, clinical characteristics (CGI-SCH, length of illness, BMI, abdominal perimeter), ad hoc questionnaire (eating, nutritional, and physical activity).

RESULTS

Mean age 43.13(SD = 7.85) years, males 61.3%. Mean severity of illness was 3.94(SD = 1.06), mean duration of the illness 18.42(SD = 8.27) years. 74.2% used to eatweekly fat meat and 64.5% less than 3-4 servings of fish, 77.4% less than 3 servings of fruit per day, and 51.6% drink less than 1 L of water. 83.9% used to drink coffee daily, 2.81(SD = 2.02) cups per day. Patients showed lower levels of Vitamin A, D, E, K1, C, folic acid, and magnesium. 93.5% did not fulfill the WHO recommendations on physical activity. Only retinol (r = -0.602, P = .039) and vitamin K1 (r = -0.693, P = .012) in women were related to the severity of illness.

CONCLUSIONS

Outpatients with schizophrenia do not follow WHO recommendations on healthy diets, neither physical activity. Both clinical severity of the illness and marital status and cohabitation were associated with poor eating habits and nutrients deficit. These data should be taken into account by the nursing staff when implementing specific care in routine clinical practice.

Prevalence of metabolic syndrome among patients with schizophrenia in Ethiopia

BACKGROUND

Globally, the prevalence of metabolic syndrome (MetS) is higher among patients with schizophrenia than the general population, and this leads to higher morbidity and mortality in this population. The aim of this study was to investigate the MetS prevalence among patients with schizophrenia in Ethiopia.

METHODS

We conducted a cross-sectional analysis of baseline data of 200 patients with schizophrenia recruited from Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia. Lipid profile and blood glucose levels were measured using Roche Cobas 6000 clinical chemistry analyzer. The prevalence of MetS was assessed based on National Cholesterol Education Program Adult Treatment Panel III criteria. Patients' demographic information, clinical and laboratory data, lifestyle habits, particularly smoking and Khat chewing, were evaluated vis-à-vis MetS.

RESULTS

The overall prevalence of MetS in patients with schizophrenia was 21.5% (17.1% male, 29.6% female) where Low HDL-cholesterol value was the most common metabolic disorders components in both males and females subgroups. In the multivariate analysis, the positive and negative symptoms score (PANSS, AOR = 1.03, 95% CI 1.001-1.054) was associated factors with MetS.

CONCLUSION

In Ethiopia, patients with schizophrenia were found to have higher prevalence of MetS than the general population. Physicians/health care providers should routinely screen patients with schizophrenia for MetS and initiate timely management of those who develop the syndrome to reduce the health cost from caring for NCDs, improve the patients' quality of life, and prevent premature mortality.

Prevalence of metabolic syndrome and associated factors among psychiatric patients at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

Background

Psychiatric patients are at increased risk of being overweight or obese, and subsequently develop metabolic syndrome. Nevertheless, data regarding associated factors for weight gain are limited and inconsistent.

Objective

The present study aimed to determine the risk of metabolic syndrome and its associated factors among psychiatric patients.

Method

A cross-sectional quantitative study was conducted among all psychiatric patients at the Psychiatric Unit of the University of Gondar Comprehensive Specialized Hospital from March 1- April 1, 2018. All eligible psychiatric patients were interviewed about their socio-demographic status,and clinical characteristics and useful parameters for the study were recorded from the medical records of the patients and by measuring waist to height ratio. Descriptive statistics were used to summarize baseline information.Binary logistic regression was used to determine the associated factors and P-value <0.05 and confidence interval (CI) of 95% were used as cut off points for determining statistical significance.

Result

From 300 patients included in the study, 168(56%) patients were females,and around 50.3% of the study participants had low literacy levels. As per waist to a height ratio scale, 58% (174) of the patients had a risk of metabolic syndrome. The Binary logistic regression analysis indicated that sex (p-<0.0001), occupation (p -0.032), marital status (p-0.006), and distance from the hospital (p<0.0001) were statistically significant determinants of metabolic syndrome risk in the psychiatric patient in our setting.

Conclusion

The majority of the psychiatric patients in the study setting had a risk of metabolic syndrome. Sex, marital status, employment status, and distance to the hospital were significantly associated with metabolic syndrome. Routine physical and laboratory investigations to detect metabolic syndrome are indispensable in psychiatric patients to prevent cardiovascular complications.

Identification and management of cardiometabolic risk in subjects with schizophrenia spectrum disorders: A Delphi expert consensus study

BACKGROUND

Patients with schizophrenia spectrum disorders (SSD) have worse physical health and reduced life expectancy compared to the general population. In 2009, the European Psychiatric Association, the European Society of Cardiology and the European Association for the Study of Diabetes published a position paper aimed to improve cardiovascular and diabetes care in patients with severe mental illnesses. However, the initiative did not produce the expected results. Experts in SSD or in cardiovascular and metabolic diseases convened to identify main issues relevant to management of cardiometabolic risk factors in schizophrenia patients and to seek consensus through the Delphi method.

METHODS

The steering committee identified four topics: 1) cardiometabolic risk factors in schizophrenia patients; 2) cardiometabolic risk factors related to antipsychotic treatment; 3) differences in antipsychotic cardiometabolic profiles; 4) management of cardiometabolic risk. Twelve key statements were included in a Delphi questionnaire delivered to a panel of expert European psychiatrists.

RESULTS

Consensus was reached for all statements with positive agreement higher than 85% in the first round. European psychiatrists agreed on: 1) high cardiometabolic risk in patients with SSD, 2) importance of correct risk management of cardiometabolic diseases, from lifestyle modification to treatment of risk factors, including the choice of antipsychotic drugs with a favourable cardiometabolic profile. The expert panel identified the psychiatrist as the central coordinating figure of management, possibly assisted by other specialists and general practitioners.

CONCLUSIONS

This study demonstrates high level of agreement among European psychiatrists regarding the importance of cardiovascular risk assessment and management in subjects with SSD.

A Review of Switching Strategies for Patients with Schizophrenia Comorbid with Metabolic Syndrome or Metabolic Abnormalities

Metabolic syndrome (MetS) in patients with schizophrenia occurs 2-3 times more frequently than in the general population. Antipsychotic medication is a primary risk factor for patients with MetS. In particular, the widely used second-generation antipsychotics can affect glucose and lipid metabolism and can induce insulin resistance and other metabolic abnormalities through various receptors. Notably, the metabolic risks of various antipsychotics may differ because of their different pharmacological affinity to MetS-related receptors. Several previous studies have shown that switching from high to low metabolic risk antipsychotics may improve patients' metabolic parameters. The current review aims to discuss the strategies for switching antipsychotic medications and the impact on metabolic abnormalities in patients with schizophrenia.

A follow-up study of metabolic syndrome in schizophrenia

The prevalence of metabolic syndrome (MetS) in schizophrenia patients is increasing worldwide. The aim of the current study was to examine the progress of MetS in a schizophrenia cohort we had previously investigated and determine the role of various related factors, including sociodemographic and clinical variables, nutritional status and physical activity. Of the 319 patients investigated in the first study, 149 patients agreed to be included in the follow-up. Physical measurements and laboratory tests were performed in addition to evaluations with the Positive and Negative Syndrome Scale, Udvalg for Kliniske Undersogelser Side Effects Scale, International Physical Activity Questionnaire, 24 h dietary recall method and Nutrition Information Systems Package Program. According to the ATPIII, ATPIIIA and IDF criteria, the MetS prevalences had increased from 35.6 to 44.3%, 38.9 to 53% and 43.6 to 55.7%, respectively. Patients with MetS had a shorter period of hospitalization and a higher UKU total side effects score, and most of them were married or divorced/widowed. Patients with MetS also had a higher daily consumption of added sugar, cholesterol, polyunsaturated fatty acids and omega 3 fatty acid, and the daily added sugar intake was found to be related to the increase in MetS. Unexpectedly, the physical activity level was not found to significantly differ in the patients with and without MetS. In conclusion, the MetS prevalence was found to be increased among schizophrenia patients over time, and the increase in the young age group was particularly striking. Among all of the factors investigated, nutritional status was found to play a major role in this increased prevalence.

Eating and nutritional habits in patients with schizophrenia

BACKGROUND

There are few studies that relate eating and nutritional habits to the severity of the disease and demographic profile in patients with schizophrenia.

OBJECTIVE

To describe eating and nutritional habits and their relationship with the severity of the disease in patients with schizophrenia.

METHOD

Cross-sectional descriptive study.

SAMPLE

31 patients with schizophrenia (ICD-10) under outpatient treatment.

INCLUSION CRITERIA

age 18-65 years, clinically stable and, written informed consent.

ASSESSMENT

Demographic, clinical characteristics (CGI-SCH, length of illness, BMI, abdominal perimeter), ad hoc questionnaire (eating, nutritional, and physical activity).

RESULTS

Mean age 43.13(SD=7.85) years, males 61.3%. Mean severity of illness was 3.94(SD=1.06), mean duration of the illness 18.42(SD=8.27) years. 74.2% used to eat weekly fat meat and 64.5% less than 3-4 servings of fish, 77.4% less than 3 servings of fruit per day, and 51.6% drink less than 1l of water. 83.9% used to drink coffee daily, 2.81(SD=2.02) cups per day. Patients showed lower levels of Vitamin A, D, E, K1, C, folic acid, and magnesium. 93.5% did not fulfill the WHO recommendations on physical activity. Only retinol (r=-0.602, p=0.039) and vitamin K1 (r=-0.693, p=0.012) in women were related to the severity of illness.

CONCLUSIONS

Outpatients with schizophrenia do not follow WHO recommendations on healthy diets, neither physical activity. Both clinical severity of the illness and marital status and cohabitation were associated with poor eating habits and nutrients deficit. These data should be taken into account by the nursing staff when implementing specific care in routine clinical practice.

The Relationship between 10 Years Risk of Cardiovascular Disease and Schizophrenia Symptoms: Preliminary Results

OBJECTIVE

Previous research shows that patients with schizophrenia have increased cardiovascular disease risk than general population. Increased cardiovascular risk in schizophrenia patients have been associated with many reasons such as antipsychotic drugs, genetic predisposition, andlifestyle. In this study, we aimed to investigate the relationship between the risk of heart disease and schizophrenia symptomatology.

METHODS

The 10-year cardiovascular risk was assessed by the Framingham Risk Score (FRS) in 103 patients with schizophrenia and in 39 healthy controls. Sociodemographic characteristics, age at schizophrenia onset, duration of illness, number of hospitalizations, the course of the disease and antipsychotic medications were recorded. Patients' symptoms were evaluated via The Scale for the Assessment of Negative Symptoms (SANS), The Scale for the Assessment of Positive Symptoms (SAPS), and Calgary Depression Scale for Schizophrenia (CDSS).

RESULTS

Ten-year cardiovascular risk was 5.16% inpatients with schizophrenia, and 3.02% in control group (p=0.030). No significant correlation was found between FRS scores, SANS, SAPS, and CDSS scores. However, FRS scores were significantly correlated with age, number of hospitalizations and duration of disease (r=0.300, 0.261, 0.252, respectively). Moreover FRS scores were higher (p=0.008) and high-density lipoprotein (HDL) levels were lower (p=0.048) in patients using multiple antipsychotics.

CONCLUSION

Our findings suggest a relationship between the risk of cardiovascular disease and the duration and overall severity of schizophrenia and also highlights the role of antipsychotics in this relationship.

Prevalence and Associated Factors of Metabolic Syndrome among Patients with Severe Mental Illness Attending a Tertiary Hospital in Southwest Uganda

Globally, the prevalence of metabolic syndrome (MetS) and its components which are the major cardiovascular disease (CVD) risk factors, is higher among patients with severe mental illness (SMI) compared to the general population. This is mainly due to the deleterious lifestyles characterized by physical inactivity, excessive alcohol consumption, smoking, and unhealthy diets common among patients with SMI as well as due to cardiometabolic effects of psychotropic medications. Despite these conditions being highly prevalent among patients with SMI, little attention is given to these conditions during routine reviews in the mental health clinics in most low-income countries including Uganda. The main objective of this study was to determine the prevalence and associated factors of MetS among patients with SMI at Mbarara Regional Referral Hospital (MRRH), a tertiary hospital in southwestern Uganda. Through a cross-sectional study at the mental health clinic of the hospital, we recruited 304 patients with SMI and evaluated them for MetS using the National Cholesterol Education Programme Adult Treatment Panel III (NCEP ATP III) criteria. We defined the prevalence of MetS as the proportion of patients meeting the NCEP ATP III criteria. We used logistic regression to evaluate associations between MetS and independent variables. We included a total of 302 (44.37% male, 55.63% female) patients with a diagnosis of SMI in the analysis. The prevalence of MetS was 23.51% (95% CI 18.84–28.71). At multivariable logistic regression, age >40 years and long duration of mental illness (>10 years) were significantly associated with MetS. The prevalence of MetS is high among patients with psychiatric disorders, and thus metabolic screening, especially among the high-risk groups, is critical.

Relationship of metabolic syndrome and neurocognitive deficits in patients with schizophrenia

This study aimed to evaluate the association of the metabolic syndrome (MS) and its components with neurocognition among patients with schizophrenia. 121 patients with schizophrenia from an outpatient service of two psychiatric centers were assessed on a neurocognitive battery and by metabolic measures. More than half (56.2%) of the patients fulfilled the consensus criteria for MS. After controlling/adjusting for various covariates (age, education in years, duration of illness, age of onset, Positive and Negative Symptom scale score and presence of smoking status), it was found that compared to patients without MS, those with MS had significantly poorer performance "in the cognitive domains" of cognitive processing and selective attention (Stroop effect percentile; p value 0.002; effect size-0.45) and auditory and verbal memory (AVLT; p value <0.001; effect size 0.68). Patients with a higher number of abnormal parameters of MS had poorer functioning in the domains of cognitive processing and selective attention, auditory and verbal memory, and executive tasks. To conclude, this two center study suggests that MS has a negative impact on neurocognition in patients with schizophrenia. There is a need to identify and monitor metabolic abnormalities among patients with schizophrenia to minimize the negative effect of metabolic parameters on neurocognition.

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.

Are plasma 25-hydroxyvitamin D and retinol levels and one-carbon metabolism related to metabolic syndrome in patients with a severe mental disorder?

There is a scarcity of studies assessing the influence of biomarkers in metabolic syndrome in psychiatric patients. Our aim was to correlate serum or plasma levels of 25-hydroxyvitamin D (25-OH-VD), retinol, vitamin B12 (VB12), folate and homocysteine (Hcy), with the metabolic status, in a sample of 289 outpatients with Schizophrenia or Bipolar Disorder. Logistic regression and multiple linear regressions were performed to assess the ability of biomarkers to predict the presence of MetS, the number of risk factors for MetS, and insulin resistance indexes (HOMA and QUICKI). Regarding the association between biomarkers and the QUICKI index, the model explained 6.8% of the variance, with folate and 25-OH-VD levels contributing significantly to the model. The model predicting the number of MetS risk factors was significant and explained 21.7% of the variance, being 25-OH-VD and retinol the statistically significant factors. As for the impact of biomarkers on MetS, the model was statistically significant, being 25-OH-VD and retinol levels the significant factors.  We report for the first time an association between MetS and both low 25-OH-VD and high retinol concentrations. Inflammation-related biomarkers may help identify patients with a high risk of MetS who might benefit from healthy lifestyle counselling and early intervention.

Correlates of risk factors for reduced life expectancy in schizophrenia: Is it possible to develop a predictor profile?

Patients with schizophrenia have significantly greater mortality rates than the general population, with an estimated reduced lifespan of 10-20 years. We previously reported on a link between impairment in cognition and premature death in a prospective 20-year study. Patients who had died prematurely showed neurocognitive impairment in nine different cognitive tests compared to those who did not. Based on those findings, in this study the surviving patients in the cohort were divided into three different groups based on neurocognitive impairment and compared on symptom severity including remission status, RAND-36, weight and BMI at onset of illness and baseline of the study, and medical/physical symptomatology (i.e., blood pressure, symptom awareness, vertigo and orthostatic symptoms). Differences were most prominent between the cognitively unimpaired and severely cognitively impaired (SCI) groups, with remission, negative symptoms, general symptoms and PANSS total scores differing. For SF-36 (RAND) Physical functioning and Role limitations due to physical health subscales the SCI were worst. The findings indicate that greater impairments in cognitive ability during the illness are associated with several potential indicators of risk for early mortality. Together these factors may be of guidance for establishing an algorithm to detect patients at risk of premature death early in their illness.

Framingham coronary score in individuals with symptoms or diagnoses of mental disorders: A review and meta-analysis

Patients with mental disorders have a higher coronary morbidity and mortality as compared to the general population. However, it remains unclear whether their coronary risk scores are higher than those of the general population. We reviewed studies and meta-analyze case-control studies about coronary risk scores in individuals with symptoms or diagnoses of mental disorders. Search was performed in Pubmed and clinical trial registration databases. Four case-control studies were identified, comprising 963 individuals with symptoms or diagnoses of mental disorders and 1681 controls. They focused on the most validated coronary risk score, the Framingham Risk Score 1998 (FRS 1998). The mean FRS 1998 was significantly higher in individuals with symptoms or diagnoses of mental disorders than in the general population 7.9( ± 6.9) vs. 5.0( ± 4.8). FRS 1998 differs between individuals with symptoms or diagnoses of mental disorders and controls (Mean difference:1.84 [95% CI:0.57-3.11], p = 0.005]; high heterogeneity was observed (I²= 78%; p < 0.003). The difference was driven by three FRS 1998 criteria: smoking, diabetes and HDL cholesterolemia. The mean FRS 1998 was significantly higher in men, and to a trend in women. In conclusion, individuals with symptoms or diagnoses of mental disorders have a higher coronary risk score than controls. The FRS 1998 should be used as a simple and objective way of monitoring coronary risk in order to improve prevention of coronary events in psychiatric settings.

Evolution of metabolic risk factors over a two-year period in a cohort of first episodes of psychosis

Patients with a first episode of psychosis (FEP) display a broad range of metabolic risk factors related to the development of diverse medical comorbidities. Initial stages of these disorders are essential in understanding the increased vulnerability of developing cardiometabolic disturbances, associated with a reduced life expectancy. This study aimed to evaluate the metabolic profile of a cohort of patients with a FEP and its evolution during a two year follow-up, as well as the factors that influence the changes in their metabolic status. 16 participating centers from the PEPs Project recruited 335 subjects with a FEP and 253 matched healthy controls, aged 9-35years. We investigated a set of anthropometric measures, vital signs and laboratory data obtained from each participant over two years in a prospective, naturalistic study. From the beginning of the study the FEP group showed differences in the metabolic profile compared to the control group, together with a progressive worsening in the major part of the analyzed variables during the follow-up period, with higher rates of obesity and metabolic syndrome. Certain risk factors were related to determinate clinical variables such as male gender, the presence of affective symptoms or an early onset or to treatment variables such as the use of antipsychotic polypharmacy, antidepressants or mood stabilizers. Our results highlight the extremely high risk of patients at early phases of schizophrenia and other psychotic disorders of developing cardiovascular comorbidity and the fast worsening of the metabolic profile during the first two years.

Cardiovascular risk and bipolar disorder: factors associated with a positive coronary calcium score in patients with bipolar disorder type 1

Objective:

Cardiovascular disease is the leading cause of death in patients with bipolar disorder. The aim of this study was to evaluate the factors associated with positive coronary calcium score (CCS) in individuals with bipolar disorder type 1.

Methods:

Patients from the Bipolar Disorder Program at Hospital de Clínicas de Porto Alegre, Brazil, underwent computed tomography scanning for calcium score measurement. Clinical and sociodemographic variables were compared between patients according to their CCS status: negative (CCS = 0) or positive (CCS > 0). Poisson regression analysis was used to examine the association of CCS with number of psychiatric hospitalizations.

Results:

Out of 41 patients evaluated, only 10 had a positive CCS. Individuals in the CCS-positive group were older (55.2±4.2 vs. 43.1±10.0 years; p = 0.001) and had more psychiatric hospitalizations (4.7±3.0 vs. 2.6±2.5; p = 0.04) when compared with CCS- negative subjects. The number of previous psychiatric hospitalizations correlated positively with CCS (p < 0.001).

Conclusion:

Age and number of psychiatric hospitalizations were significantly associated with higher CCS, which might be a potential method for diagnosis and stratification of cardiovascular disease in bipolar patients. There is a need for increased awareness of risk assessment in this population.

Metabolic syndrome or glucose challenge in first episode of psychosis?

Patients with schizophrenia exhibit a reduced life expectancy. Although unhealthy lifestyle or suicide risk plays a role, the main causes are diverse medical conditions such as cardiovascular diseases, type 2 diabetes mellitus and metabolic syndrome. Albeit pharmacological secondary side effects might also trigger previous conditions, studies in naïve patients reflect diverse anomalies at the onset. Patients with a first episode of psychosis, display a wide scope of metabolic abnormalities, ranging from normality till pathological values depending on the parameters studied. We attempted to evaluate the metabolic syndrome and glycemic homeostasis in a subset of antipsychotic-naïve patients with a first episode of non-affective psychosis. Patients (n = 84) showed a similar prevalence of metabolic syndrome compared with a matched control sample (n = 98) (6% vs 4%, P = 0.562), while glucose homeostasis values differed significantly (14% vs. 5%, P = 0.034). Our results suggest that metabolic syndrome is not a useful clinical condition to be evaluated in patients before pharmacological treatment. Abnormal glycemic homeostasis at the onset of the disease requires specific diagnostic tools and preventive measures in order to avoid future cardiovascular events. New strategies must be implemented in order to evaluate the cardiovascular risk and subsequent morbidity in patients at the onset of the disease.

Perceived needs and health-related quality of life in people with schizophrenia and metabolic syndrome: a "real-world" study

BACKGROUND

The complexity of schizophrenia lies in the combination of psychiatric, somatic and social needs requiring care. The aim of the study was to compare perceived needs between groups with absence/presence of metabolic syndrome (MetS) and to analyze the relationship between needs, health-related quality of life (HRQoL) and MetS in people with schizophrenia or schizoaffective disorder.

METHODS

A "real-world" cross-sectional study was set up with a comprehensive framework including the following, needs for care (Camberwell Assessment of Need Interview [CAN]), HRQoL (Euro Qol-5D Questionnaire), sociodemographic data, lifestyle habits, psychopathology (Positive And Negative Syndrome Scale [PANSS]), global functioning (Global Assessment of Functioning Scale [GAF]), anthropometric measurements and blood test results were assessed for an outpatient sample (n = 60).

RESULTS

The mean number of needs (given by CAN) was identified for both groups. Patients with MetS rated a higher number of needs compared to the group without this condition. Mobility problems (given by EQ-5D) were negatively associated with the number of total and unmet needs. For participants with MetS, HRQoL was related to the number of needs and unmet needs. For people with MetS, positive symptomatology score (given by PANSS) was related to the number of needs and met needs and general symptomatology was associated with total, met and unmet needs. For individuals without MetS, the global functioning score (given by GAF) was significantly inversely related with total, met and unmet needs.

CONCLUSIONS

Needs and HRQoL, as well as general symptomatology, were related only in patients with MetS. This has implications for treatment planning at the individual and organizational levels. An analysis of both physical and mental needs could provide a starting point for the extension of facilities in the health care system in order to reach the goal of improving quality of life.

Correlates of physical activity in people living with psychotic illness

OBJECTIVE

In the light of the high prevalence of physical comorbidities in people with psychotic illness, there is a need to explore modifiable risk factors that may contribute to this disease burden. The benefits of physical activity to both physical and mental health have been well established. We aimed to examine the prevalence and correlates of physical activity in a national sample of adults living with psychotic illness.

METHODS

Physical activity was assessed in 1801 people using the International Physical Activity Questionnaire. Participants were dichotomised into low and moderate-high physical activity groups and associations between physical activity and a range of sociodemographic, clinical and physical comorbidity variables were examined using logistic regression.

RESULTS

More than half the participants were categorised in the moderate-high physical activity group with nearly half of the sample engaged in physical activity every day. There were significant associations between low physical activity and older age, unemployment, educational non-participation, antipsychotic medication use, social dysfunction, self-reported loneliness and obesity. However, there was no significant association between physical activity and sex, psychosis type, illness duration, physical comorbidity or negative symptoms.

CONCLUSION

The findings from this study may inform future interventions designed to increase physical activity in people with psychotic illness.

Spanish consensus on the risks and detection of antipsychotic drug-related hyperprolactinaemia

INTRODUCTION

Iatrogenic hyperprolactinaemia (IHPRL) has been more frequently related to some antipsychotic drugs that provoke an intense blockade of dopamine D2 receptors. There is a wide variation in clinical practice, and perhaps some more awareness between clinicians is needed. Due to the high frequency of chronic treatment in severe mental patients, careful attention is recommended on the physical risk. IHPRL symptoms could be underestimated without routine examination.

METHODOLOGY

An intense scientific literature search was performed in order to draw up a multidisciplinary consensus, including different specialists of psychiatry, endocrinology, oncology and internal medicine, and looking for a consensus about clinical risk and detection of IHPRL following evidence-based medicine criteria levels (EBM I- IV).

RESULTS

Short-term symptoms include amenorrhea, galactorrhoea, and sexual dysfunction with decrease of libido and erectile difficulties related to hypogonadism. Medium and long-term symptoms related to oestrogens are observed, including a decrease bone mass density, hypogonadism, early menopause, some types of cancer risk increase (breast and endometrial), cardiovascular risk increase, immune system disorders, lipids, and cognitive dysfunction. Prolactin level, gonadal hormones and vitamin D should be checked in all patients receiving antipsychotics at baseline although early symptoms (amenorrhea-galactorrhoea) may not be observed due to the risk of underestimating other delayed symptoms that may appear in the medium term. Routine examination of sexual dysfunction is recommended due to possible poor patient tolerance and low compliance. Special care is required in children and adolescents, as well as patients with PRL levels >50ng/ml (moderate hyperprolactinaemia). A possible prolactinoma should be investigated in patients with PRL levels >150ng/ml, with special attention to patients with breast/endometrial cancer history. Densitometry should be prescribed for males >50 years old, amenorrhea>6 months, or early menopause to avoid fracture risk.

Metabolic Syndrome in South African Patients with Severe Mental Illness: Prevalence and Associated Risk Factors

Background

There is a surge of cardiovascular disease (CVD) in Africa. CVD is the leading cause of mortality among patients with severe mental illness (SMI) in developed countries, with little evidence from the African context.

Objective

To determine the prevalence and risk factors for MetS among South African patients with SMI.

Method

In a cross sectional study, individuals with SMI treated with antipsychotics and a control group without a mental illness, matched for age, gender and ethnicity were evaluated for MetS using the 2009 Joint Interim statement (JIS) criteria.

Results

Of the 276 study group subjects, 65.9% were male, 84.1% black African, 9.1% white, 5.4% of Indian descent and 1.5% coloured (mixed race) with a mean age of 34.7 years (±12.5). Schizophrenia was the most common diagnosis (73.2%) and 40% were taking first generation antipsychotics. The prevalence of MetS was 23.2% (M: 15.4%, F: 38.3%) in the study group and 19.9% (M: 11.9%, F: 36.3%) in the control group (p = 0.4). MetS prevalence was significantly higher in study subjects over 55 years compared to controls (p = 0.03). Increased waist circumference (p< 0.001) and low high density lipoprotein (HDL) cholesterol (p = 0.003) were significantly more prevalent in study subjects compared to controls. In study subjects, risk factors associated with MetS included age (OR: 1.09, 95% CI 1.06–1.12, p < 0.001), female gender (OR: 2.19, 95% CI 1.06–4.55, p = 0.035) and Indian descent (OR: 5.84, 95% CI 1.66–20.52, p = 0.006) but not class of antipsychotic (p = 0.26).

Conclusion

The overall MetS prevalence was not increased in patients with SMI compared to controls; however, the higher prevalence of the individual components (HDL cholesterol and waist circumference) suggests an increased risk for CVD, especially in patients over 55 years.

Metabolic syndrome in drug-naïve and drug-free patients with schizophrenia and in their siblings

OBJECTIVES

We tested the hypothesis that metabolic disturbances in people with schizophrenia exist as a part of the schizophrenic syndrome, even when the antipsychotic drug effect is eliminated. We aimed to determine the prevalence of metabolic syndrome among patients with schizophrenia who were antipsychotic drug-naive or drug-free and their siblings for comparison with healthy controls.

METHODS

One-hundred-two patients with schizophrenia (drug-naïve or drug-free), 64 siblings and 70 age-matched healthy subjects were recruited for this case-control study. Metabolic syndrome was assessed based on Adult Treatment Panel (ATP) III, adapted ATP III and International Diabetes Federation criteria. Student's t-tests, chi-squared tests, Kruskal-Wallis tests and Bonferroni corrections were used as appropriate.

RESULTS

The diagnoses of metabolic syndrome and metabolic disturbances as a subsyndromal state were found to be significantly more frequent in patients and their siblings than in the controls. Low levels of high-density lipoprotein cholesterol and disturbances in blood pressure put the patient group at risk for metabolic syndrome even before they were exposed to antipsychotic drugs.

CONCLUSIONS

Although antipsychotic drugs have consistently been related to disturbances of glucose and lipid metabolism in patients with schizophrenia, this study showed that patients with schizophrenia and their siblings are already at a high risk for metabolic syndrome independent of any antipsychotic effects. These individuals should be monitored regularly following a diagnosis of schizophrenia.

Schizoaffective disorder and metabolic syndrome: A meta-analytic comparison with schizophrenia and other non-affective psychoses

People with psychotic disorders, including schizophrenia (SCZ), schizoaffective disorder (SD), or other non-affective psychoses (ONAP), have a higher risk of metabolic syndrome (MetS) than general population. However, previous meta-analyses failed to explore if people with SD are more likely to suffer from MetS than SCZ and ONAP. We carried out a systematic review and meta-analysis comparing rates of MetS in SD with those in SCZ or ONAP. We searched main electronic databases for relevant articles published up to January 2015, and for unpublished data, contacting corresponding authors, to minimize selective reporting bias. Odds ratios (ORs) based on random effects models, with 95% confidence intervals (CIs), and heterogeneity (I(2)), were estimated. We performed leave-one-out, quality-based, and subgroups analyses to check findings validity. Testing for publication bias, Egger's test estimates were reported. We included 7616 individuals (1632 with SD and 5984 with SCZ/ONAP) from 30 independent samples. SD, as compared with SCZ/ONAP, had a random-effect pooled OR (95%CI) for MetS of 1.41 (1.23-1.61; p < 0.001; I(2) = 5%). No risk of publication bias was found (p = 0.85). Leave-one-out, sensitivity, and subgroups analyses confirmed the association. To our knowledge, this is the first meta-analysis comparing MetS comorbidity between individuals with SD and those with SCZ or ONAP. SD subjects are more likely to suffer from MetS, with consistent findings across the studies included. However, the role of explanatory factors of this association, and the relative contribution of MetS subcomponents, deserve further research.

The metabolic syndrome and risk of coronary artery disease in patients with chronic schizophrenia or schizoaffective disorder in a chronic mental institute

The prevalence rate of metabolic syndrome (MS) and coronary artery disease (CAD) has been found to be high in patients with chronic schizophrenia. Current evidence shows that CAD is underdiagnosed in this group. Our study evaluated the prevalence of MS and the risk of CAD in patients with chronic schizophrenia in a chronic care mental hospital in southern Taiwan. We included all patients with the diagnosis of schizophrenia or schizoaffective disorder. We collected all laboratory, physical examination, psychiatric interview, and chart review data. We also evaluated the risk of CAD in these patients using the Framingham point system. There was no significant age difference in the MS prevalence rate in these patients. The young patients with schizophrenia in our study tended to have a higher prevalence of MS than the general population. In addition, female patients had a higher prevalence rate of MS than males. Based on the Framingham point system, we found the 10-year risk of CAD to be higher among the patients with schizophrenia than in the general population. Our study highlights the importance of the high risk of MS in both younger and older patients with schizophrenia, without a significant relationship to the use of antipsychotics. More complete cohort studies are needed to confirm these findings. Psychiatrists may want to establish more specific and detailed clinical guidelines for patients with chronic schizophrenia with comorbid physical diseases, especially MS and CAD.

Selection, use and psychometric properties of physical activity measures to assess individuals with severe mental illness: a narrative synthesis

This research provides a critical consideration of the outcome measures used to assess physical activity in individuals with severe mental illness. A narrative synthesis was utilised to provide a simple juxtapose of the current research. A sensitive topic-based search strategy was conducted in order to identify studies that met the eligibility criteria. Fifty two studies met the inclusion criteria and 5 were identified specially as validation studies. The current research identified several methodological shortcomings. The justification and choice of outcome measure used is often weak and only five studies have validated a specific outcome measure of physical activity. Within these validation studies, the validation process often lacked a consideration of agreement between measures. Accelerometers have been most frequently used as a criterion measure, notably the RT3 tri-axial accelerometer. Objective based measures may be best placed to consider physical activity levels, although, methodological considerations for the utilization of such tools is required. Self-report questionnaires have benefits for use in this population but require further validation. Researchers and clinicians need to carefully consider what outcome measure they are using and be aware of the development, scope and purpose of that measure.

Body mass index, obesity, and psychopathology in patients with schizophrenia

A number of studies have reported that patients with schizophrenia have a higher body mass index (BMI) than the general population. Few Asian studies have examined BMI in patients with schizophrenia. The aims of the current study were to evaluate the distribution of BMI and prevalence of obesity in a large sample of Chinese patients with schizophrenia (n = 973) and to examine the sociodemographic and clinical correlates of overweight (BMI ≥ 25 kg/m) and obesity (BMI ≥ 30 kg/m). There was a preponderance of patients who were overweight (58.7%) and obese (73.6%) as compared with control subjects. Regression modeling of clinical and symptom factors in schizophrenia patients revealed that females were almost twice as likely to be obese compared with males and patients with comorbid medical conditions were more likely to be obese compared with those who did not have a comorbid medical condition (odds ratio, 1.6). Those prescribed typical antipsychotic medications were 1.7 times more likely to be obese, whereas individuals prescribed with both typical and atypical antipsychotic medications were 2.2 times more likely to be obese as compared with those prescribed atypical antipsychotics. A significant predictor interaction for obesity was observed between sex and typical antipsychotics, sex and comorbid medical conditions, and years of education and comorbid medical conditions. The higher prevalence of obesity in patients with schizophrenia is a matter of clinical and public health concern; interventions to reduce weight to healthy levels would result in both improved health and quality of life among patients with schizophrenia.

Metabolic syndrome: differences between psychiatric and internal medicine patients

OBJECTIVES

The existence of specific features of Metabolic Syndrome (MetS) in psychiatric population in comparison to not psychiatric patients has not been systematically investigated. The purpose of this study is to evaluate the differences of MetS among a group of psychiatric patients and a group of internal medicine patients in terms of anthropometric measurements, biochemical variables, and cardiovascular risk.

METHODS

We enrolled 83 psychiatric inpatients under pharmacological treatment (schizophrenia n = 24, bipolar disorder n = 27, major depression n = 14, other n = 18) and 77 internal medicine patients visited for supposed MetS as affected by overweight or arterial hypertension.

RESULTS

Psychiatric patients differed from control subjects by age (yrs) (47 +/- 9 vs. 52 +/- 8.6, p = 0.001), waist circumference (cm) (111.9 +/- 10.9 vs. 106 +/- 12.6, p = 0.02), HDL cholesterol (mg/dl) (36.8 +/- 7 vs. 48 +/- 11.3, p = 0.001), serum insulin (microU/ml) (26 +/- 12.5 vs. 16.4 +/- 8.8, p = 0.001), triglyceride/HDL cholesterol ratio (4.8 +/- 2.7 vs. 3.3 +/- 2.2, p = 0.01). Female psychiatric patients had higher levels of triglycerides (mg) (178 + 86 vs. 115 + 53, p = 0.002) and of HOMA index (7.8 + 5 vs. 3.8 + 3.3, p = 0.005). Triglycerides and triglycerides/HDL ratio levels were higher in Unipolar Depression. A positive association was found between antidepressant drug treatment with triglycerides and triglycerides/HDL ratio levels, neuroleptic treatment with the HOMA index, and antipsychotics drugs with the Framingham index.

LIMITATIONS

Psychiatric study population numerosity and duration of psychiatric illness and drug treatment.

CONCLUSIONS

Specific features of MetS in psychiatric population are mainly represented by young age of onset, hyperinsulinemia, increased abdominal adiposity, and low HDL cholesterol whose common denominator may be insulin-resistance.

Psychotic symptoms are associated with physical health problems independently of a mental disorder diagnosis: results from the WHO World Health Survey

This study explored whether physical health problems are related to psychotic symptoms independently of a mental disorder diagnosis. A total of 224,254 subjects recruited for the World Health Organization World Health Survey were subdivided into those with both a lifetime diagnosis of psychosis and at least one psychotic symptom in the 12 months prior to the evaluation, those with at least one psychotic symptom in the past 12 months but no lifetime diagnosis of psychosis, and those without psychotic symptoms in the past 12 months and without a lifetime diagnosis of psychosis. The three groups were compared for the presence of medical conditions, health problems, and access to health care. Medical conditions and health problems (angina, asthma, arthritis, tuberculosis, vision or hearing problems, mouth/teeth problems, alcohol consumption, smoking, and accidents), medication consumption, and hospital admissions (but not regular health care visits) were more frequent in individuals with psychotic symptoms but no psychosis diagnosis, compared to those with no symptoms and no diagnosis. The number of medical conditions increased with the number of psychotic symptoms. Given the sample analyzed, this trend seems to be independent from the socio-economic development of the country or the specific health care system.

Metabolic syndrome in schizophrenia: Differences between antipsychotic-naïve and treated patients

Metabolic syndrome (MetS) has been recognized as a risk factor for cardiovascular morbidity and mortality in general population and in patients with severe mental illnesses like schizophrenia. This paper reviews studies on MetS in schizophrenia and related psychotic disorders, and assesses the contribution of antipsychotics toward the development of MetS. Databases of Medline (PubMed), PsycINFO, and Scopus were searched for MetS, psychotic disorders, and antipsychotic drugs from inception till present. Prevalence of MetS in patients with schizophrenia was found to be ranging from 3.3% to 68.0%. Prevalence in antipsychotic-naïve and antipsychotic-treated patients ranged between 3.3-26.0% and 32.0-68.0% respectively, and was higher in younger patients, female gender and Hispanics, and lower in African-Americans and Orientals. Prevalence of metabolic abnormalities was higher in patients receiving second generation antipsychotics (SGAs), especially with clozapine, olanzapine, and risperidone, as compared to first generation antipsychotics (FGAs). Antipsychotic-induced changes on metabolic indices became evident after 2 weeks and reached maximum at 3 months of treatment. There is a need to sensitize the mental health professionals at all levels about the need of screening and monitoring for MetS in patients receiving antipsychotics.

Metabolic syndrome in schizophrenia

To review the data with respect to prevalence of metabolic syndrome (MetS) and its correlates in schizophrenia. For this review, electronic search engines PUBMED, Sciencedirect, and Google Scholar were used. Available data suggests that most of the studies have been of cross-sectional design. Prevalence rates of MetS have varied from 11% to 69% in medicated patients, and 4-26% in drug naive patients in cross-sectional evaluations. Longitudinal studies have shown the prevalence rates to range from 0% to 14% at the baseline in drug naive patients, which increase to as high as 52.4% by 3 months of antipsychotic medication treatment. The prevalence rates of MetS in patients with schizophrenia are much higher than that seen in general population or healthy controls. Though there is no causal association with any demographic or clinical variables, the risk increases with increase in age. Among antipsychotics, there seems to be an association between MetS and atypical antipsychotics like clozapine and olanzapine. Therefore, the psychiatrists should be more vigilant regarding the presence of MetS in these high risk groups. Research on biological correlates of MetS in schizophrenia is still in its primitive stage, however, these is some evidence to suggest an association of MetS with adiponectin levels, hematological indices, methylenetetrahydrofolate reductase (MTHFR) and Alpha-1A adrenergic receptor (ADRA1A) gene. These areas hold promise, and targeting these with appropriate interventions may help us to prevent the occurrence of MetS in patients with schizophrenia in future.

Increased Framingham 10-year CVD risk in Chinese patients with schizophrenia

BACKGROUND & HYPOTHESIS: Schizophrenia is associated with increased mortality rates, which has been attributed to the greater incidence of cardiovascular disease (CVD) events. The Framingham risk score (FRS) is a widely-used age- and gender-specific algorithm to estimate 10-year CVD risk and vascular age. The main aim of this study was to determine the cardiovascular risk profile in schizophrenia and examine the effect of metabolic syndrome (MetS) as a predictor of CVD risk. We hypothesized that patients with schizophrenia have an increased 10-year CVD risk.

METHODS

83 Chinese patients with schizophrenia and 243 Chinese community controls were recruited. Their medical and smoking histories were obtained, and anthropometric parameters measured. All subjects provided fasted venous blood samples for lipid and glucose measurements. 10-year CVD risk and the difference between vascular and actual age (VAdiff) for each participant were computed using the FRS and compared between patients and controls.

RESULTS

Schizophrenia patients had a higher mean 10-year CVD risk of 4.6%, as compared with 3.1% in controls, and a greater VAdiff of 4.6 years vs. 0.6 years. Both smoking and MetS contributed significantly to the 10-year CVD risk in patients with schizophrenia, with smoking having a greater effect than MetS on this risk.

CONCLUSION

This study found a significantly elevated mean 10-year CVD risk and VAdiff in patients with schizophrenia compared with controls. Findings point towards the importance of smoking cessation and screening for MetS to decrease the excess CVD risk in patients with schizophrenia.

[Effectiveness of a joint project between primary care and mental health to improve the recording of cardiovascular risk factors in patients with psychosis]

Objetivo

Evaluar la efectividad de una intervención conjunta entre niveles asistenciales, atención primaria (AP) y salud mental (SM), en pacientes con psicosis, para mejorar la información de los factores de riesgo cardiovascular (FRCV) en la historia clínica (HC).

Diseño

Estudio multicéntrico de intervención antes-después.

Emplazamiento

Participan 7 centros de AP y 2 de SM, en Barcelona.

Participantes

Se incluyeron los pacientes con psicosis asignados a los equipos de AP, y confirmados por estos, entre 18-65 años (n = 690).

Intervención

Sesiones clínicas compartidas, para elaborar y utilizar un protocolo de colaboración entre AP-SM.

Medidas principales

Variables: sexo, edad, número de citas por centro/año, registro en HC de: hábito tabáquico, presión arterial, índice masa corporal (IMC), colesterol total, colesterol HDL, triglicéridos, glucosa, perímetro abdominal, RCV. Análisis: comparación de registros de FRCV, mediante el test de Cochran (datos apareados). Cálculo de prevalencia de FRCV, según los criterios definitorios de síndrome metabólico y criterios incluidos en el protocolo.

Resultados

Edad media 42,3 (DE: 11,4), hombres 67%. Todos los FRCV han presentado un aumento del registro tras la intervención. Los FRCV que han aumentado más han sido: parámetros analíticos y perímetro abdominal. El porcentaje de pacientes con niveles alterados en los criterios de síndrome metabólico supera el 35%. Los criterios para derivar al equipo de AP identifican, en el 2010, 51,9% obesos, 23,9% hipertensos, 20,4% hipercolesterolémicos y 11,6% diabéticos.

Conclusiones

Mejora del registro de FRCV. Elevado porcentaje de pacientes que requieren intervención de los profesionales de AP debido a los FRCV.

The dietary pattern of patients with schizophrenia: a systematic review

OBJECTIVE

People with schizophrenia show a high incidence of metabolic syndrome, which is associated with a high mortality from cardiovascular disease. The aetiology of the metabolic syndrome in schizophrenia is multi-factorial and may involve antipsychotic treatment, high levels of stress and unhealthy lifestyle, such as poor diet. As a poor diet can predispose to the development of metabolic abnormalities, the aims of this review are to clarify: 1) the dietary patterns of patients with schizophrenia, 2) the association of these dietary patterns with a worse metabolic profile, and 3) the possible factors influencing these dietary patterns.

METHODS

A search was conducted on Pubmed, The Cochrane Library, Scopus, Embase, Ovid, Psychoinfo and ISI web of Knowledge from 1950 to the 1st of November 2011. 783 articles were found through the investigation of such databases. After title, abstract or full-text reading and applying exclusion criteria we reviewed 31 studies on dietary patterns and their effects on metabolic parameters in schizophrenia.

RESULTS

Patients with schizophrenia have a poor diet, mainly characterized by a high intake of saturated fat and a low consumption of fibre and fruit. Such diet is more likely to increase the risk to develop metabolic abnormalities. Data about possible causes of poor diet in schizophrenia are still few and inconsistent.

CONCLUSION

Subjects with schizophrenia show a poor diet that partly accounts for their higher incidence of metabolic abnormalities. Further studies are needed to clarify the causes of poor diet and the role of dietary intervention to improve their physical health.

Cardiovascular risk factors during second generation antipsychotic treatment are associated with increased C-reactive protein

OBJECTIVE

Severe mental disorder and cardiovascular disease (CVD) are often associated, and inflammation is implicated in both disorders. We investigated whether there is a relationship between CVD risk factors and inflammation in schizophrenia or bipolar disorder, and if second generation antipsychotics (SGA) interact.

METHODS

We included 361 patients in a naturalistic cross-sectional study, 235 subjects on current SGA treatment and 126 subjects not treated with SGA as controls. Cardiovascular parameters were measured and current medication recorded. Fasting plasma levels of the following cytokines were measured: high sensitivity CRP (hsCRP), soluble tumor necrosis factor receptor 1 (sTNF-R1), osteoprotegerin (OPG), soluble CD40 ligand (sCD40L), interleukin-1 receptor antagonist (IL-1Ra), von Willebrand factor (vWf) and interleukin-6 (IL-6).

RESULTS

In this relatively young sample of patients with a mean age of 33.3years, the following CVD risk factors were associated with elevated inflammation markers after adjusting for confounders: BMI, triglycerides and glucose with hsCRP (p=0.041-0.001), HDL-cholesterol and triglycerides with sTNF-R1 (p=0.009-0.001) and triglycerides with vWf (p=0.004). In patients treated with SGA, elevated hsCRP was significantly associated with high BMI (p=0.012), and with high glucose levels (p=0.003).

CONCLUSION

Several CVD risk factors are associated with elevated levels of inflammation markers in young patients with severe mental illness. The interaction between SGA and CVD risk factors on hsCRP levels might indicate a specific inflammatory activation related to SGA induced overweight and hyperglycemia. This suggests that hsCRP could be a valuable marker for future cardiovascular events, particularly in patients treated with SGA.

Metabolic syndrome in schizophrenia: a comparative study of antipsychotic-free/naïve and antipsychotic-treated patients from India

INTRODUCTION

In recent years, metabolic syndrome (MS) has been identified as an important health risk in patients with schizophrenia and related disorders, and has often been related to the use of second-generation antipsychotics.

OBJECTIVE

The present study was conducted to assess the prevalence of MS in schizophrenia and related disorders and its correlation with various demographic, clinical and treatment variables.

METHOD

One hundred patients with schizophrenia and related disorders, 50 antipsychotic-free/naïve and 50 on antipsychotic medications for more than 3 months, attending a psychiatric outpatient setting, were assessed for various socio-demographic, clinical and metabolic parameters.

RESULTS

Subjects on treatment with antipsychotics had significantly higher mean weight, body mass index, waist circumference, calorie intake, triglycerides (TGL), very-low-density lipoproteins (VLDL), fasting blood sugar (FBS) and positive family history of diabetes mellitus compared with the antipsychotic-free/naive ones. Subjects on antipsychotics also had significantly higher prevalence of MS. A positive association of MS was observed with age, being married, higher education, executive jobs and ICD-10 diagnosis of schizophrenia, duration of illness, family history of diabetes mellitus and family history of hypertension.

CONCLUSION

Use of antipsychotics increases the risk of developing hyperlipidemia and MS in patients of schizophrenia and related disorders, emphasizing the need for regular monitoring of various metabolic parameters in patients on antipsychotics.

CLINICAL IMPLICATIONS

1) Antipsychotics are associated with increased risk of hyperlipidemia and MS; 2) regular monitoring of lipid profile and other metabolic parameters should be done in patients on antipsychotics; 3) psychiatrists need to lay emphasis on lifestyle and dietary modifications in their patients on antipsychotics.

A systematic review of correlates of physical activity in patients with schizophrenia

OBJECTIVE

The present review evaluates systematically the published quantitative studies of correlates of PA in patients with schizophrenia.

METHOD

EMBASE, PsycINFO, PubMed, ISI Web of Science, CINAHL and PEDro were searched from their inception to 1 July 2011 combining the medical subject heading 'schizophrenia' with 'physical activity' or 'physical inactivity' or 'exercise' or 'health education' or 'health behaviour' or 'health promotion'.

RESULTS

Out of 68 potentially eligible studies, 25 papers (n = 25,013) evaluating 36 correlates were included. Correlates consistently associated with lower PA participation are the presence of negative symptoms and cardio-metabolic comorbidity. Also, side-effects of antipsychotic medication, lack of knowledge on cardiovascular disease risk factors, no belief in the health benefits, a lower self-efficacy, other unhealthy lifestyle habits and social isolation correlated with lower PA participation. The quality of the PA measurement was not related to the proportion of significant associations (χ(2) = 3.8, P = 0.07). Current gaps in literature that need to be examined more in detail are the role of environmental and policy-level factors on PA participation in patients with schizophrenia.

CONCLUSION

All correlates should be confirmed in prospective studies, and interventions to improve the modifiable variables should be developed and evaluated.

Overweight and obesity in patients with bipolar disorder or schizophrenia compared with a non-psychiatric sample

OBJECTIVE

Multiple studies suggest an association of overweight and obesity with bipolar disorder (BD) and schizophrenia. The goal of this paper was to determine the magnitude of this association and its relationship with previous course-of-illness and other variables of clinical interest.

METHODS

The prevalence of overweight and obesity was compared among patients with BD (n=108), patients with schizophrenia (n=250) and a non-psychiatric control group (n=290). Moreover, within each group we analyzed the variables associated with overweight [including obesity, i.e., body mass index (BMI) ≥25] and obesity (BMI≥30) adjusting for a possible confounding effect of sex, age and educational level by logistic regression.

RESULTS

In comparison with the non-psychiatric sample, a strong association of both BMI≥25 and obesity was observed with BD and schizophrenia (adjusted odds ratios between 3.4 and 4.6; P-values <0.001). Overweight was significantly associated with male sex and increasing age in both control and BD groups; and with female sex among schizophrenia patients. Moreover, for BD patients, earlier onset of first BD symptoms, presence of a non-psychiatric illness, current use of mood-stabilizing medication, and being a non-smoker were significantly associated with overweight; and male sex and the presence of a non-psychiatric illness, with obesity. Within the schizophrenia patients, obesity was significantly associated with female sex, intermediate age range and lower PANSS score.

CONCLUSIONS

Among patients with BD or schizophrenia, the chronic course of their illness and their current treatment with psychotropic medication might be more relevant for becoming overweight or obese than the specific psychiatric illness.

Guideline concordant monitoring of metabolic risk in people treated with antipsychotic medication: systematic review and meta-analysis of screening practices

BACKGROUND

Despite increased cardiometabolic risk in individuals with mental illness taking antipsychotic medication, metabolic screening practices are often incomplete or inconsistent.

METHOD

We undertook a systematic search and a PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) meta-analysis of studies examining routine metabolic screening practices in those taking antipsychotics both for patients in psychiatric care before and following implementation of monitoring guidelines.

RESULTS

We identified 48 studies (n=290 534) conducted between 2000 and 2011 in five countries; 25 studies examined predominantly schizophrenia-spectrum disorder populations; 39 studies (n=218 940) examined routine monitoring prior to explicit guidelines; and nine studies (n=71 594) reported post-guideline monitoring. Across 39 studies, routine baseline screening was generally low and above 50% only for blood pressure [69.8%, 95% confidence interval (CI) 50.9-85.8] and triglycerides (59.9%, 95% CI 36.6-81.1). Cholesterol was measured in 41.5% (95% CI 18.0-67.3), glucose in 44.3% (95% CI 36.3-52.4) and weight in 47.9% (95% CI 32.4-63.7). Lipids and glycosylated haemoglobin (HbA1c) were monitored in less than 25%. Rates were similar for schizophrenia patients, in US and UK studies, for in-patients and out-patients. Monitoring was non-significantly higher in case-record versus database studies and in fasting samples. Following local/national guideline implementation, monitoring improved for weight (75.9%, CI 37.3-98.7), blood pressure (75.2%, 95% CI 45.6-95.5), glucose (56.1%, 95% CI 43.4-68.3) and lipids (28.9%, 95% CI 20.3-38.4). Direct head-to-head pre-post-guideline comparison showed a modest but significant (15.4%) increase in glucose testing (p=0.0045).

CONCLUSIONS

In routine clinical practice, metabolic monitoring is concerningly low in people prescribed antipsychotic medication. Although guidelines can increase monitoring, most patients still do not receive adequate testing.

Metabolic and cardiovascular adverse effects associated with antipsychotic drugs

Antipsychotic medications can induce cardiovascular and metabolic abnormalities (such as obesity, hyperglycemia, dyslipidemia and the metabolic syndrome) that are associated with an increased risk of type 2 diabetes mellitus and cardiovascular disease. Controversy remains about the contribution of individual antipsychotic drugs to this increased risk and whether they cause sudden cardiac death through prolongation of the corrected QT interval. Although some drug receptor-binding affinities correlate with specific cardiovascular and metabolic abnormalities, the exact pharmacological mechanisms underlying these associations remain unclear. Antipsychotic agents with prominent metabolic adverse effects might cause abnormalities in glucose and lipid metabolism via both obesity-related and obesity-unrelated molecular mechanisms. Despite existing guidelines and recommendations, many antipsychotic-drug-treated patients are not assessed for even the most easily measurable metabolic and cardiac risk factors, such as obesity and blood pressure. Subsequently, concerns have been raised over the use of these medications, especially pronounced in vulnerable pediatric patients, among whom their use has increased markedly in the past decade and seems to have especially orexigenic effects. This Review outlines the metabolic and cardiovascular risks of various antipsychotic medications in adults and children, defines the disparities in health care and finally makes recommendations for screening and monitoring of patients taking these agents.

Prevalence of the metabolic syndrome in Danish psychiatric outpatients treated with antipsychotics

BACKGROUND

The incidence of the metabolic syndrome, a major risk factor for diabetes and cardiovascular disease, is increasing worldwide and is suggested to be higher among psychiatric patients, especially those on antipsychotic treatment.

AIMS

To assess the prevalence of the metabolic syndrome in Danish psychiatric outpatients and compare it with the general population.

METHODS

In a cross-sectional, observational study in 2007-08, 170 Danish outpatients on antipsychotic drug treatment were monitored for the prevalence of the metabolic syndrome based on the International Diabetes Federation (IDF) definition and compared with a general population group of 3303 randomly selected Danes.

RESULTS

Of the antipsychotic-treated patients 48.2% fulfilled the IDF criteria for the metabolic syndrome, compared with 29.6% of the general population. The antipsychotic-treated patients had higher rates of increased waist circumference, triglyceride and glucose levels, and lower high-density lipoprotein cholesterol. Compared with the general population, the odds ratio (OR) of the metabolic syndrome among antipsychotic-treated patients was 2.2. After adjustment for age and sex, the OR increased to 2.7. In the antipsychotic-treated group, statistically different rates of the metabolic syndrome for patients in monopharmacy vs. polypharmacy, and for patients in monotherapy with first-generation vs. second-generation antipsychotics, could not be found.

CONCLUSION

The metabolic syndrome is highly prevalent among a Danish outpatient population treated with antipsychotics compared with the general population. Monitoring of lipid and glucose levels, blood pressure and waist circumference before start-up and during treatment with antipsychotic medication is of pivotal importance in order to prevent diabetes and cardiovascular disease in this patient population.

Obesity and coronary risk in patients treated with second-generation antipsychotics

Weight gain leading to obesity is a frequent adverse effect of treatment with atypical antipsychotics. However, the degree of its independent contribution to the risk of coronary heart disease events in patients treated with these drugs has not been elucidated. The aim of this study is to determine whether obesity is an independent risk factor for the 10-year risk of coronary heart disease events in psychiatric patients treated with atypical antipsychotics. We used the Framingham method, which is based on age, gender, blood pressure, smoking, and plasma levels of total and high-density lipoprotein cholesterol, to estimate the 10-year risk of coronary heart disease events in patients treated with second-generation antipsychotics who were obese (N = 44; mean age 38.1 years, 54.5% men) or normal weight (N = 83; mean age 39.9 years, 47.0% men). Excluded were patients with metabolic syndrome and those taking antihypertensive, hypoglycemic, and lipid-lowering drugs. The 10-year risk of coronary artery disease events was very low and virtually identical in the obese and normal weight patients (2.3 ± 3.5 vs. 2.6 ± 4.6, P = 0.68), despite excess of 12 BMI units (P < 0.0001) and 15.7 cm waist circumference (P < 0.0001) in the obese. The risk was similar in obese and normal weight men (3.8 ± 5.9 vs. 2.8 ± 3.4, P = 0.45) and women (1.7 ± 3.7 vs. 1.5 ± 2.5, P = 0.83). The validity of the 10-year prediction for risk of coronary heart disease events in the mentally ill based on the Framingham score system requires prospective confirmation. Obesity does not appear to be an independent predictor for the 10-year risk of coronary heart disease events in patients without metabolic syndrome treated with second-generation antipsychotics.

Association of the metabolic syndrome with physical activity performance in patients with schizophrenia

AIM

The primary aim of this study was to determine whether the presence of the metabolic syndrome (MetS) limits physical activity (PA) in patients with schizophrenia. A secondary aim was to investigate cross-sectional associations of leisure-time PA, sports participation and PA performance with MetS parameters.

METHODS

Patients with schizophrenia who had MetS (n=37) were compared with those without MetS (n=69). Patients were assessed for PA performance using a 6-minute walk test (6MWT) and PA participation using the Baecke PA questionnaire, as well as for antipsychotic medication dose (expressed in chlorpromazine equivalents), negative symptoms and smoking behaviour.

RESULTS

The two patient groups were similar in age, gender, mean antipsychotic medication dose, negative symptomatology and smoking behaviour. Distance achieved on the 6MWT was 13.7% shorter (P<0.001) in patients with versus patients without MetS (527.6±108.9 m vs 610.0±93.7 m, respectively). Patients with MetS were also significantly less involved in sports activities (P=0.001) and less physically active during leisure time (P=0.002). Also, the distance of the 6MWT was moderately correlated with body mass index (r=-0.44, P<0.001), waist circumference (r=-0.43, P<0.001), sports participation (r=0.60, P<0.001) and leisure-time PA (r=0.42, P<0.001).

CONCLUSION

MetS is associated with poorer PA performance in patients with schizophrenia. The additional burden of MetS places patients with schizophrenia at even greater risk for physical and functional limitations in daily life.

Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care

The lifespan of people with severe mental illness (SMI) is shorter compared to the general population. This excess mortality is mainly due to physical illness. We report prevalence rates of different physical illnesses as well as important individual lifestyle choices, side effects of psychotropic treatment and disparities in health care access, utilization and provision that contribute to these poor physical health outcomes. We searched MEDLINE (1966 - August 2010) combining the MeSH terms of schizophrenia, bipolar disorder and major depressive disorder with the different MeSH terms of general physical disease categories to select pertinent reviews and additional relevant studies through cross-referencing to identify prevalence figures and factors contributing to the excess morbidity and mortality rates. Nutritional and metabolic diseases, cardiovascular diseases, viral diseases, respiratory tract diseases, musculoskeletal diseases, sexual dysfunction, pregnancy complications, stomatognathic diseases, and possibly obesity-related cancers are, compared to the general population, more prevalent among people with SMI. It seems that lifestyle as well as treatment specific factors account for much of the increased risk for most of these physical diseases. Moreover, there is sufficient evidence that people with SMI are less likely to receive standard levels of care for most of these diseases. Lifestyle factors, relatively easy to measure, are barely considered for screening; baseline testing of numerous important physical parameters is insufficiently performed. Besides modifiable lifestyle factors and side effects of psychotropic medications, access to and quality of health care remains to be improved for individuals with SMI.