Head-to-head comparisons of metabolic side effects of second generation antipsychotics in the treatment of schizophrenia: a systematic review and meta-analysis

Pharmacological interventions for antipsychotic-induced weight gain in schizophrenia: A network meta-analysis

OBJECTIVE

Antipsychotic-induced weight gain (AIWG) is a significant but frequently neglected adverse effect of first- and second-generation antipsychotic therapy, which may lead to cardiovascular disturbances. The present network meta-analysis (NMA) was conducted to evaluate and compare the effects of available treatment options in antipsychotic-induced weight gain (AIWG).

METHODS

The data was extracted from 68 relevant clinical trials after a literature search on MEDLINE/PubMed, Embase, Scopus, Cochrane databases and clinical trial registries. Random-effects Bayesian NMA was done to pool the effects across the interventions for the change in body weight from baseline. A network graph was built, a consistency model was run, node split analysis was performed, treatments were ranked as per the SUCRA score and meta-regression was done for the duration of therapy, baseline body weight and treatment strategy as the predictor variables. Finally, the results were sorted based on the certainty of evidence.

RESULTS

The drugs showing significant reduction in body weight in order of magnitude of effect size include sibutramine 10 mg (-8.0 kg; -16. to -0.21), metformin 750 mg + lifestyle modification (-7.5 kg; -12 to -2.8), topiramate 200 mg (-7 kg; -10 to -3.4), metformin 750 mg (-5.7 kg; -9.3 to -2.1), topiramate 100 mg (-5.7 kg; -8.8 to -2.5), topiramate 50 mg (-5.2 kg; -10 to -0.57), liraglutide 1.8 mg (-5.2 kg; -10., -0.080), sibutramine 15 mg (-4.5 kg; -8.9 to -0.59), nizatidine 300 mg (-3.0 kg; -5.9 to -0.23) and metformin 1000 mg (-2.3 kg; -4.6 to -0.0046). There was no effect of duration of follow-up, baseline body weight and, preventive versus therapeutic strategy on weight reduction in AIWG.

CONCLUSION

Metformin 750 mg with lifestyle modification was the most effective treatment for AIWG, followed by topiramate 200 mg, metformin 750 mg, and topiramate 100 mg with moderate certainty of evidence.

Exercise and Schizophrenia

Schizophrenia is a complex mental disorder that affects millions of people worldwide and has a profound impact on various aspects of life, including physical activity. The relationship between schizophrenia and physical activity is an area of growing interest in medical and health research from a physical, mental, and psychosocial health perspective. Physical activity and structured exercise have been identified as promising interventions to improve physical and psychological health outcomes of people living with schizophrenia. This chapter provides a brief overview that explores various aspects of the relationship between physical activity, exercise, and schizophrenia. The impact of schizophrenia on human movement is discussed, along with an overview of physical activity and cardiorespiratory fitness levels in adults with schizophrenia. Additionally, the influence of exercise interventions on physical and psychological outcomes will be discussed, along with current physical activity recommendations for those living with schizophrenia.

Metabolic syndrome and its relation to antipsychotic polypharmacy in schizophrenia, schizoaffective and bipolar disorders

The risk of metabolic syndrome (MetS) has been attributed to antipsychotic use in psychiatric patients. To date, there is limited data on the relationship between antipsychotic polypharmacy and MetS in patients with schizophrenia, schizoaffective disorder and bipolar disorder. Therefore, we aimed to investigate the rate of MetS in patients with these disorders receiving antipsychotic monotherapy and polypharmacy. We conducted a cross-sectional study on patients seen between January 2017 and December 2020, collecting data on the class, type, route of administration and number of antipsychotics received. We used the American Association of Clinical Endocrinology criteria to diagnose MetS. We included 833 subjects of whom 573 (68.8%) received antipsychotic monotherapy and 260 (31.2%) received polypharmacy. Overall, 28.6% ( N  = 238) had MetS with no statistical difference between the two groups. Diastolic blood pressure and receiving olanzapine were significant predictors for developing MetS. In conclusion, our study found no significant difference in the rate of MetS between antipsychotic monotherapy and polypharmacy. A number of variables were significant predictors for MetS. Our findings were consistent with other studies and warrant the need for careful choice of antipsychotics and regular screening and management of abnormal metabolic parameters.

The impact of providing care for physical health in severe mental illness on informal carers: a qualitative study

BACKGROUND

People with severe mental illness (SMI) such as schizophrenia and bipolar disorder are at a substantially higher risk of premature death in that they die between 10 and 20 years earlier than the general population. Cardiovascular disease (CVD) and diabetes are the main potentially avoidable contributors to early death. Research that explores the experiences of people with SMI highlights their struggles in engaging with health professionals and accessing effective and timely interventions for physical health conditions. A consequence of such struggles to navigate and access physical healthcare results in many people with SMI relying heavily on support provided by informal carers (e.g., family members, close friends). Despite this, the experiences of informal carers, and the roles they undertake in relation to supporting the physical health and psychotropic medication use of people with SMI, remains under-researched.

AIMS

To explore the impacts of providing care for physical health in severe mental illness on informal carers.

METHOD

Thematic analysis of semi-structured interviews with eight informal carers of people with SMI in United Kingdom (UK) national health services.

RESULTS

Informal carers played an active part in the management of the patient's conditions and shared their illness experience. Involvement of informal carers was both emotional and practical and informal carers' own lives were affected in ways that were sometimes deeply profound. Informal carers were involved in both 'looking after' the patient from the perspective of doing practical tasks such as collecting dispensed medication from a community pharmacy (caring for) and managing feelings and emotions (caring about).

CONCLUSIONS

Providing care for the physical health of someone with SMI can be understood as having two dimensions - 'caring for' and 'caring about'. The findings suggest a bidirectional relationship between these two dimensions, and both have a cost for the informal carer. With appropriate support informal carers could be more actively involved at all stages of care without increasing their burden. This should be with an awareness that carers may minimise the information they share about their own needs and impacts of their role to spare the person they care and themselves any distress.

A review on side effect management of second-generation antipsychotics to treat schizophrenia: a drug safety perspective

INTRODUCTION

Effective side effects management present a challenge in antipsychotic treatment with second-generation antipsychotics (SGAs). In recent years, most of the commonly used SGAs, except for clozapine, have been shown to differ only slightly in their effectiveness, but considerably regarding perceived side effects, safety profiles, and compatibility to preexisting medical conditions.

AREAS COVERED

The current state of available evidence on side-effect management in SGA treatment of patients with schizophrenia spectrum disorders (SSD) is reviewed. In addition, current guideline recommendations are summarized, highlighting evidence gaps.

EXPERT OPINION

SGA safety and side effects needs to be considered in treatment planning. Shared decision-making assistants (SDMA) can support patients, practitioners and relatives to orient their decisions toward avoiding side effects relevant to patients' adherence. Alongside general measures like psychosocial and psychotherapeutic care, switching to better tolerated SGAs can be considered a relatively safe strategy. By contrast, novel meta-analytical evidence emphasizes that dose reduction of SGAs can statistically increase the risk of relapse and other unfavorable outcomes. Further, depending on the type and severity of SGA-related side effects, specific treatments can be used to alleviate induced side effects (e.g. add-on metformin to reduce weight-gain). Finally, discontinuation should be reserved for acute emergencies.

Alterations in Skeletal Muscle Insulin Signaling DNA Methylation: A Pilot Randomized Controlled Trial of Olanzapine in Healthy Volunteers

Antipsychotics are associated with severe metabolic side effects including insulin resistance; however, the mechanisms underlying this side effect are not fully understood. The skeletal muscle plays a critical role in insulin-stimulated glucose uptake, and changes in skeletal muscle DNA methylation by antipsychotics may play a role in the development of insulin resistance. A double-blind, placebo-controlled trial of olanzapine was performed in healthy volunteers. Twelve healthy volunteers were randomized to receive 10 mg/day of olanzapine for 7 days. Participants underwent skeletal muscle biopsies to analyze DNA methylation changes using a candidate gene approach for the insulin signaling pathway. Ninety-seven methylation sites were statistically significant (false discovery rate < 0.05 and beta difference between the groups of ≥10%). Fifty-five sites had increased methylation in the skeletal muscle of olanzapine-treated participants while 42 were decreased. The largest methylation change occurred at a site in the Peroxisome Proliferator-Activated Receptor Gamma Coactivator 1-Alpha (PPARGC1A) gene, which had 52% lower methylation in the olanzapine group. Antipsychotic treatment in healthy volunteers causes significant changes in skeletal muscle DNA methylation in the insulin signaling pathway. Future work will need to expand on these findings with expression analyses.

Adherence to Recommended Metabolic Monitoring of Children and Adolescents Taking Second-Generation Antipsychotics

OBJECTIVE

Clinical guidelines recommend periodic monitoring for adverse metabolic effects associated with second-generation antipsychotic medications. The authors sought to evaluate adherence to the guideline-recommended metabolic monitoring schedule for children and adolescents prescribed second-generation antipsychotics.

METHODS

The authors used a national electronic medical records database for a retrospective study of children and adolescents ages 1-17 years (N=9,620) who were prescribed second-generation antipsychotics in January 2010-December 2018. Adherence to guideline-recommended monitoring of body mass index (BMI), blood glucose, and cholesterol was categorized as full, partial, and no monitoring. Full monitoring of patients was defined as strict metabolic monitoring, following the guideline-recommended schedule. Patients who received any monitoring, but not meeting the full monitoring criteria, were considered partially monitored. Three multinomial logistic regression models were fitted for each metabolic parameter to identify predictors associated with monitoring status.

RESULTS

BMI was the metabolic parameter with the highest adherence to guideline-recommended monitoring (full monitoring, 4.7% of patients; partial monitoring, 44.8%), followed by blood glucose (full monitoring, 6.5%; partial monitoring, 29.4%) and cholesterol (full monitoring, 0.8%; partial monitoring, 22.4%). Being Black (vs. non-Black), having a comorbid mood disorder (vs. none), receiving olanzapine as the index second-generation antipsychotic (vs. aripiprazole), and receiving an antidepressant as a concurrent medication (vs. none) were associated with a higher likelihood of receiving both full and partial monitoring of all three metabolic parameters.

CONCLUSIONS

Both full and partial adherence to guideline-recommended monitoring of children and adolescents prescribed second-generation antipsychotics were poor. However, children and adolescents at increased metabolic risk tended to be more closely monitored.

Prevalence and risk factors for metabolic syndrome in schizophrenia, schizoaffective, and bipolar disorder

BACKGROUND

Metabolic Syndrome (MetS) is a risk for developing cardiovascular diseases and its prevalence is especially high in psychiatric patients. To date, there is limited data from the United Arab Emirates (UAE) on the prevalence of MetS. Therefore, we aimed to investigate its prevalence and possible risk factors in a large sample of psychiatric patients in the UAE.

METHODS

A cross-sectional study was conducted at Al-Ain Hospital, in Al-Ain City, UAE. We collected demographic and clinical data on patients diagnosed with schizophrenia, schizoaffective, and bipolar affective disorder in the period between January 2017 and December 2020. This included their secondary diagnosis (psychiatric or medical), vital signs (heart rate, systolic and diastolic blood pressure, Body Mass Index [BMI]), metabolic parameters (fasting blood glucose, cholesterol, triglycerides, low-density lipoprotein, high-density lipoproteins), and prescribed medications. We used the American Association of Clinical Endocrinology (AACE) criteria to diagnose MetS.

RESULTS

We included 889 subjects and of these, 79.8% (N = 709) had a BMI ≥25 kg/m2 and 9.8% (N = 87) had no abnormal metabolic parameters. Overall, 28.1% (N = 250) had MetS with no statistical difference between the three groups. Fasting blood glucose levels and abnormally elevated triglycerides were significant predictors for MetS.

CONCLUSION

Our study found that around one in three patients had MetS irrespective of the three diagnoses. Some variables were significant predictors for MetS. Our findings were consistent with other studies and warrant the need for regular screening and management of abnormal metabolic parameters.

Evaluation of Renal Functions of Inpatients With Mental Disorders

The current study aimed to investigate the renal functions of inpatients with mental disorders. Data for this retrospective and descriptive study were collected from January 2021 to April 2021 from the records of patients who were hospitalized in the psychiatry clinic of a training and research hospital between 2018 and 2020. The study sample comprised hospital records of 376 patients. A significant negative relationship was determined between patients' glomerular filtration rate (GFR) and glucose level, duration of mental disorder, number of hospitalizations, and duration of medication use (p < 0.05). According to the analysis of patients' renal functions, mean GFR was statistically significantly lower in women with physical chronic diseases and diagnosed with personality disorders. Psychiatric-mental health nurses should evaluate and monitor renal functions of individuals with mental disorders and take precautions before kidney diseases develop. [Journal of Psychosocial Nursing and Mental Health Services, 62(2), 47-55.].

Global Neuropsychopharmacological Prescription Trends in Adults with Schizophrenia, Clinical Correlates and Implications for Practice: A Scoping Review

It is important to examine the psychotropic prescription practices in schizophrenia, as it can inform regarding changing treatment choices and related patient profiles. No recent reviews have evaluated the global neuropsychopharmacological prescription patterns in adults with schizophrenia. A systematic search of the literature published from 2002 to 2023 found 88 empirical papers pertinent to the utilization of psychotropic agents. Globally, there were wide inter-country and inter-regional variations in the prescription of psychotropic agents. Overall, over time there was an absolute increase in the prescription rate of second-generation antipsychotics (up to 50%), mood stabilizers (up to 15%), and antidepressants (up to 17%), with an observed absolute decrease in the rate of antipsychotic polypharmacy (up to 15%), use of high dose antipsychotic (up to 12% in Asia), clozapine (up to 9%) and antipsychotic long-acting injectables (up to 10%). Prescription patterns were mainly associated with specific socio-demographic (such as age), illness (such as illness duration), and treatment factors (such as adherence). Further work, including more evidence in adjunctive neuropsychopharmacological treatments, pharmaco-economic considerations, and examination of cohorts in prospective studies, can proffer insights into changing prescription trends relevant to different treatment settings and predictors of such trends for enhancement of clinical management in schizophrenia.

Antipsychotic-Induced Weight Gain in Severe Mental Illness: Risk Factors and Special Considerations

PURPOSE OF REVIEW

Weight gain is a disconcerting issue experienced by patients treated with antipsychotics (APs). This review summarizes current knowledge on the prevalence, etiology, and risk factors for antipsychotic-induced weight gain (AIWG), and evidence for interventions, including special considerations.

RECENT FINDINGS

Predisposing risk factors for AIWG include lack of prior AP exposure, sex, and age. AP dose and duration of exposure are additional treatment-related factors that may contribute to this issue. Among current approaches to target AIWG, metformin has the most evidence to support its use, and this is increasingly reflected in clinical guidelines. While lifestyle approaches are recommended, cost-effectiveness and scalability represent limitations. More research is needed to identify newer treatment options and inform clinical recommendations for AIWG. Concerns around scope of practice in psychiatry to address AIWG and related comorbidities will require enhanced training opportunities and interdisciplinary collaborations, as well as updated position statements/practice guidelines emphasizing prevention.

Atypical Antipsychotics and the Risk of Sudden Cardiac Death among Individuals Receiving Maintenance Hemodialysis

Objective

Individuals receiving hemodialysis have high rates of sudden cardiac death (SCD). This study characterized oral atypical antipsychotic use and compared the cardiac safety of atypical antipsychotics with QT prolongation FDA warnings to that of atypical antipsychotics without such warnings among outpatients receiving hemodialysis.

Methods

Data for this active-comparator, new-user cohort study were obtained from the U.S. Renal Data System (2007-2019). The primary outcome was 1-year SCD risk. Fine and Gray proportional subdistribution hazard models with inverse probability of treatment weighting were used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI).

Results

The quetiapine vs. atypical antipsychotic without QT prolongation warning cohort included 18,943 quetiapine new-users and 19,571 non-warning atypical antipsychotic new-users. When compared to new-use of atypical antipsychotics without QT prolongation warnings, quetiapine new-use was not associated with the risks of SCD (aHR (95% CI) = 1.00 (0.93, 1.07)) or broader cardiac outcomes. Comparisons of all atypical antipsychotics with QT prolongation warnings vs. atypical antipsychotics without warnings generated similar results.

Conclusions

Quetiapine, which carries an FDA warning for QT prolongation, did not associate with cardiac risk compared to atypical antipsychotics without warnings among hemodialysis outpatients. Findings may inform prescriber selection of atypical antipsychotics in this population.

Utilization and Predictors of Adjuvant Metformin for Children and Adolescents on Mixed Receptor Antagonists (Second-Generation Antipsychotics)

OBJECTIVE

To examine utilization and predictors of adjuvant metformin among pediatric recipients of second-generation antipsychotics (SGAs) (mixed receptor antagonist).

METHOD

This study used 2016-2021 data of a national electronic medical record database. Eligible participants were children aged 6 to 17 with a new SGA prescription for at least 90 days. Predictors of prescribing adjuvant metformin in general and to nonobese pediatric SGA recipients in particular were assessed using conditional logistic regression and logistic regression analyses, respectively.

RESULTS

Of 30,009 pediatric SGA recipients identified, 2.3% (n = 785) received adjuvant metformin. Among 597 participants with a body mass index z score documented during the 6-month period before metformin initiation, 83% were obese, and 34% had either hyperglycemia or diabetes. Significant predictors for metformin prescribing were high baseline body mass index z score (odds ratio [OR] 3.5, 95% CI 2.8-4.5, p < .0001), having hyperglycemia or diabetes (OR 5.3, 95% CI 3.4-8.3, p < .0001), and undergoing a switch from a higher metabolic risk SGA to a lower risk one (OR 9.9, 95% CI 3.5-27.5, p = .0025) or a switch in the opposite direction (OR 4.1, 95% CI 2.1-7.9, p = .0051) compared with no switch. Nonobese metformin users were more likely to have a positive body mass index z score velocity before metformin initiation than their obese counterparts. Receiving the index SGA prescribed by a mental health specialist was associated with higher likelihood of receiving adjuvant metformin and receiving metformin before the development of obesity.

CONCLUSION

Utilization of adjuvant metformin among pediatric SGA recipients is uncommon, and early introduction of the medication among nonobese children is rare.

Clinical improvement in schizophrenia during antipsychotic treatment in relation to changes in glucose parameters: A systematic review

Antipsychotics (APs) are the cornerstone of treatment for schizophrenia (SCZ) spectrum disorders. Previous research suggests that there may be a positive association between AP-induced weight gain and/or dyslipidemia and improvement in psychiatric symptoms, often referred to as a "metabolic threshold". To determine whether a similar relationship exists for glucose parameters, we conducted a systematic search in six databases from inception to June 2022 for all longitudinal studies that directly examined the relationship between changes in glucose-related outcomes and changes in psychopathology among patients with SCZ treated with APs. We identified 10 relevant studies and one additional study that considered cognition. In most cases, we found that increased levels of fasting glucose and insulin following treatment were associated with clinical improvement. These findings contribute to existing literature that could suggest a common mechanism between AP action and metabolic side effects and support a need for additional work aimed at exploring the validity of a glucose-psychopathology relation in SCZ.

Insulin effects on core neurotransmitter pathways involved in schizophrenia neurobiology: a meta-analysis of preclinical studies. Implications for the treatment

Impairment of insulin action and metabolic dysregulation have traditionally been associated with schizophrenia, although the molecular basis of such association remains still elusive. The present meta-analysis aims to assess the impact of insulin action manipulations (i.e., hyperinsulinemia, hypoinsulinemia, systemic or brain insulin resistance) on glutamatergic, dopaminergic, γ-aminobutyric acid (GABA)ergic, and serotonergic pathways in the central nervous system. More than one hundred outcomes, including transcript or protein levels, kinetic parameters, and other components of the neurotransmitter pathways, were collected from cultured cells, animals, or humans, and meta-analyzed by applying a random-effects model and adopting Hedges'g to compare means. Two hundred fifteen studies met the inclusion criteria, of which 180 entered the quantitative synthesis. Significant impairments in key regulators of synaptic plasticity processes were detected as the result of insulin handlings. Specifically, protein levels of N-methyl-D-aspartate receptor (NMDAR) subunits including type 2A (NR2A) (Hedges' g = -0.95, 95%C.I. = -1.50, -0.39; p = 0.001; I2 = 47.46%) and 2B (NR2B) (Hedges'g = -0.69, 95%C.I. = -1.35, -0.02; p = 0.043; I2 = 62.09%), and Postsynaptic density protein 95 (PSD-95) (Hedges'g = -0.91, 95%C.I. = -1.51, -0.32; p = 0.003; I2 = 77.81%) were found reduced in insulin-resistant animal models. Moreover, insulin-resistant animals showed significantly impaired dopamine transporter activity, whereas the dopamine D2 receptor mRNA expression (Hedges'g = 3.259; 95%C.I. = 0.497, 6.020; p = 0.021; I2 = 90.61%) increased under insulin deficiency conditions. Insulin action modulated glutamate and GABA release, as well as several enzymes involved in GABA and serotonin synthesis. These results suggest that brain neurotransmitter systems are susceptible to insulin signaling abnormalities, resembling the discrete psychotic disorders' neurobiology and possibly contributing to the development of neurobiological hallmarks of treatment-resistant schizophrenia.

Clinical review: Guide to pharmacological management in pediatric obesity medicine

Introduction

Newer pharmacotherapy agents (anti-obesity medication [AOM]) are revolutionizing the management of children and adolescents with obesity. Previously, treatment based on intensive behavioral therapy involved many patient and family contact hours and yielded improvements in obesity status of 1-3 percent of the 95th percentile of the body mass index (BMI). Newer AOMs are yielding more clinically significant improvement of 5-18 percent. This review provides guidance for practitioners in the care of children and adolescents with obesity who frequently have complex medical and behavioral health care needs. Specifically, we discuss the use of newer AOMs in these complex patients.

Methods

This review details an approach to the care of the child and adolescent with obesity using AOMs. A shared decision-making process is presented in which the provider and the patient and family collaborate on care. Management of medical and behavioral components of the disease of obesity in the child are discussed.

Results

Early aggressive treatment is recommended, starting with an assessment of associated medical and behavioral complications, weight promoting medications, use of AOMs and ongoing care. Intensive behavioral therapy is foundational to treatment, but not a specific treatment. Patients and families deserve education on expected outcomes with each therapeutic option.

Conclusions

The use of new AOMs in children and adolescents has changed expected clinical outcomes in the field of pediatric obesity management. Clinically significant improvement in obesity status occurs when AOMs are used early and aggressively. Ongoing, chronic care is the model for optimizing outcomes using a shared decision-making between provider and patient/family. Depending on the experience and comfort level of the primary care practitioner, referral to an obesity medicine specialist may be appropriate, particularly when obesity related co-morbidities are present and pharmacotherapy and metabolic and bariatric surgery are considerations.

Randomized Double-Blind Placebo-Controlled Study of Olanzapine for Chemotherapy-Related Anorexia in Patients With Locally Advanced or Metastatic Gastric, Hepatopancreaticobiliary, and Lung Cancer

PURPOSE

Anorexia occurs in 30%-80% of patients with advanced malignancies, which may be worsened with chemotherapy. This trial assessed the efficacy of olanzapine in stimulating appetite and improving weight gain in patients receiving chemotherapy.

METHODS

Adults (≥18 years) with untreated, locally advanced, or metastatic gastric, hepatopancreaticobiliary (HPB), and lung cancers were randomly assigned (double-blind) to receive olanzapine (2.5 mg once a day for 12 weeks) or placebo along with chemotherapy. Both groups received standard nutritional assessment and dietary advice. The primary outcomes were the proportion of patients with weight gain > 5% and the improvement in appetite (assessed by the visual analog scale [VAS] and the Functional Assessment of Chronic Illness Therapy system of Quality-of-Life questionnaires Anorexia Cachexia subscale [FAACT ACS]). Secondary end points were change in nutritional status, quality of life (QOL), and chemotherapy toxicity.

RESULTS

We enrolled 124 patients (olanzapine, 63 and placebo, 61) with a median age of 55 years (18-78 years), of whom 112 (olanzapine, 58 and placebo, 54) were analyzable. The majority (n = 99, 80%) had metastatic cancer (gastric [n = 68, 55%] > lung [n = 43, 35%] > HPB [n = 13, 10%]). The olanzapine arm had a greater proportion of patients with a weight gain of > 5% (35 of 58 [60%] v 5 of 54 [9%], P < .001) and improvement in appetite by VAS (25 of 58 [43%] v 7 of 54 [13%], P < .001) and by FAACT ACS (scores ≥37:13 of 58 [22%] v 2 of 54 [4%], P = .004). Patients on olanzapine had better QOL, nutritional status, and lesser chemotoxicity. Side effects attributable to olanzapine were minimal.

CONCLUSION

Low-dose, daily olanzapine is a simple, inexpensive, well-tolerated intervention that significantly improves appetite and weight gain in newly diagnosed patients on chemotherapy.

Coronary Artery Disease in Patients with Severe Mental Illness

Severe mental illnesses (SMI), such as schizophrenia and bipolar disorder, are associated with a decrease in life expectancy of up to two decades compared with the general population, with cardiovascular disease as the leading cause of death. SMI is associated with increased cardiovascular risk profile and early onset of incident cardiovascular disease. Following an acute coronary syndrome, patients with SMI have a worse prognosis, but are less likely to receive invasive treatment. In this narrative review, the management of coronary artery disease in patients with SMI is discussed, and avenues for future research are highlighted.

Metabolomic signatures associated with weight gain and psychosis spectrum diagnoses: A pilot study

Psychosis spectrum disorders (PSDs), as well as other severe mental illnesses where psychotic features may be present, like bipolar disorder, are associated with intrinsic metabolic abnormalities. Antipsychotics (APs), the cornerstone of treatment for PSDs, incur additional metabolic adversities including weight gain. Currently, major gaps exist in understanding psychosis illness biomarkers, as well as risk factors and mechanisms for AP-induced weight gain. Metabolomic profiles may identify biomarkers and provide insight into the mechanistic underpinnings of PSDs and antipsychotic-induced weight gain. In this 12-week prospective naturalistic study, we compared serum metabolomic profiles of 25 cases within approximately 1 week of starting an AP to 6 healthy controls at baseline to examine biomarkers of intrinsic metabolic dysfunction in PSDs. In 17 of the case participants with baseline and week 12 samples, we then examined changes in metabolomic profiles over 12 weeks of AP treatment to identify metabolites that may associate with AP-induced weight gain. In the cohort with pre-post data (n = 17), we also compared baseline metabolomes of participants who gained ≥5% baseline body weight to those who gained <5% to identify potential biomarkers of antipsychotic-induced weight gain. Minimally AP-exposed cases were distinguished from controls by six fatty acids when compared at baseline, namely reduced levels of palmitoleic acid, lauric acid, and heneicosylic acid, as well as elevated levels of behenic acid, arachidonic acid, and myristoleic acid (FDR < 0.05). Baseline levels of the fatty acid adrenic acid was increased in 11 individuals who experienced a clinically significant body weight gain (≥5%) following 12 weeks of AP exposure as compared to those who did not (FDR = 0.0408). Fatty acids may represent illness biomarkers of PSDs and early predictors of AP-induced weight gain. The findings may hold important clinical implications for early identification of individuals who could benefit from prevention strategies to reduce future cardiometabolic risk, and may lead to novel, targeted treatments to counteract metabolic dysfunction in PSDs.

Relationship between efficacy and common metabolic parameters in first-treatment drug-naïve patients with early non-response schizophrenia: a retrospective study

BACKGROUND

Comorbid metabolic disorders in patients with schizophrenia are very common. Patients with schizophrenia who respond to therapy early are often strongly predictive of better treatment outcomes. However, the differences in short-term metabolic markers between early responders and early non-responders in schizophrenia are unclear.

METHODS

143 first-treatment drug-naïve schizophrenia patients were included in this study and were given a single antipsychotic medication for 6 weeks after admission. After 2 weeks, the sample was divided into an early response group and an early non-response group based on psychopathological changes. For the study endpoints, we depicted the change curves of psychopathology in both subgroups and compared the differences between the two groups in terms of remission rates and multiple metabolic parameters.

RESULTS

The early non-response had 73 cases (51.05%) in the 2nd week. In the 6th week, the remission rate was significantly higher in the early response group than in the early non-response group (30,42.86% vs. 8,10.96%); the body weight, body mass index, blood creatinine, blood uric acid, total cholesterol, triglyceride, low-density lipoprotein, fasting blood glucose, and prolactin of the enrolled samples were significantly increased, and high-density lipoprotein was significantly decreased. ANOVAs revealed a significant effect of treatment time on abdominal circumference, blood uric acid, total cholesterol, triglyceride, high-density lipoprotein, low-density lipoprotein, fasting blood glucose and prolactin, and a significant negative effect of early non-response to treatment on abdominal circumference, blood creatinine, triglyceride, fasting blood glucose.

CONCLUSIONS

Schizophrenia patients with early non-response had lower rates of short-term remission and more extensive and severe abnormal metabolic indicators. In clinical practice, patients with early non-response should be given a targeted management strategy, antipsychotic drugs should be switched on time, and active and effective interventions for their metabolic disorders should be given.

Associations of antidepressants and antipsychotics with lipid parameters: Do CYP2C19/CYP2D6 genes play a role? A UK population-based study

BACKGROUND

Dyslipidaemia is an important cardiovascular risk factor for people with severe mental illness, contributing to premature mortality. The link between antipsychotics and dyslipidaemia is well established, while evidence on antidepressants is mixed.

AIMS

To investigate if antidepressant/antipsychotic use was associated with lipid parameters in UK Biobank participants and if CYP2C19 and CYP2D6 genetic variation plays a role.

METHODS

Review of self-reported prescription medications identified participants taking antidepressants/antipsychotics. Total, low-, and high-density lipoprotein cholesterol (L/HDL-C) and triglycerides derived from blood samples. CYP2C19 and CYP2D6 metabolic phenotypes were assigned from genetic data. Linear regression investigated aims, adjusted for key covariates.

RESULTS

Of 469,739 participants, 36,043 took antidepressants (53% female, median age 58, 17% taking cholesterol-lowering medications) and 3255 took antipsychotics (58% female, median age 57, 27% taking cholesterol-lowering medications). Significant associations were found between use of each amitriptyline, fluoxetine, citalopram/escitalopram, sertraline, paroxetine and venlafaxine with higher total cholesterol, LDL-C, and triglycerides and lower HDL-C, compared to participants not taking each medication. Venlafaxine was associated with the worst lipid profile (total cholesterol, adjusted mean difference: 0.21 mmol/L, 95% confidence interval (CI): 0.17 to 0.26, p < 0.001). Antipsychotic use was significantly associated with lower HDL-C and higher triglycerides. In participants taking sertraline, CYP2C19 intermediate metabolisers had higher HDL-C (0.05 mmol/L, 95% CI: 0.01 to 0.09, p = 0.007) and lower triglycerides (-0.17 mmol/L, 95% CI: -0.29 to -0.05, p = 0.007), compared to normal metabolisers.

CONCLUSIONS

Antidepressants were significantly associated with adverse lipid profiles, potentially warranting baseline and regular monitoring. Further research should investigate the mechanistic pathways underlying the protective effects of the CYP2C19 intermediate metaboliser phenotype on HDL-C and triglycerides in people taking sertraline.

Impact of SGLT2 inhibitors on metabolic status in patients with psychiatric disorders undergoing treatment with second‑generation antipsychotics (Review)

Metabolic dysfunctions have been reported in patients diagnosed with severe mental illnesses who are undergoing treatment with antipsychotics, especially second-generation agents. Sodium-glucose co-transporter 2 inhibitors (SGLT2Is) and glucagon-like peptide receptor agonists are new-generation antidiabetics whose favourable effects in the treatment of diabetes mellitus in the non-psychiatric population may raise interest in their use in patients presenting with severe mental illnesses and metabolic comorbidities possibly related to the use of antipsychotics. The objectives of this review were to investigate the evidence to support the use of SGLT2Is in this population and to find the most important aspects that need to be addressed by future research. A total of one preclinical trial, two guideline-format clinical recommendations, one systematic review and one case report were found, and their conclusions were analysed. The results support the following conclusions: i) SGLT2Is may be combined with metformin in selected cases of type 2 diabetes mellitus in the context of antipsychotic treatment, as they have been associated with favourable metabolic effects; and ii) data for the recommendation of SGLT2Is as second-line treatment in patients with diabetes mellitus who are also treated with olanzapine or clozapine are supported by very limited preclinical and clinical evidence. Further high-quality, large-scale research is needed in the field of the management of metabolic dysfunctions in patients with severe psychiatric illnesses who undergo treatment with second-generation antipsychotics.

Metabolic side effects in persons with schizophrenia during mid- to long-term treatment with antipsychotics: a network meta-analysis of randomized controlled trials

Metabolic side effects of antipsychotic drugs can have serious health consequences and may increase mortality. Although persons with schizophrenia often take these drugs for a long time, their mid- to long-term metabolic effects have been studied little so far. This study aimed to evaluate the mid- to long-term metabolic side effects of 31 antipsychotics in persons with schizophrenia by applying a random-effects Bayesian network meta-analysis. We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (up to April 27, 2020) and PubMed (up to June 14, 2021). We included published and unpublished, open and blinded randomized controlled trials with a study duration >13 weeks which compared any antipsychotic in any form of administration with another antipsychotic or with placebo in participants diagnosed with schizophrenia. The primary outcome was weight gain measured in kilograms. Secondary outcomes included "number of participants with weight gain", fasting glucose, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides. We identified 137 eligible trials (with 35,007 participants) on 31 antipsychotics, with a median follow-up of 45 weeks. Chlorpromazine produced the most weight gain (mean difference to placebo: 5.13 kg, 95% credible interval, CrI: 1.98 to 8.30), followed by clozapine (4.21 kg, 95% CrI: 3.03 to 5.42), olanzapine (3.82 kg, 95% CrI: 3.15 to 4.50), and zotepine (3.87 kg, 95% CrI: 2.14 to 5.58). The findings did not substantially change in sensitivity and network meta-regression analyses, although enriched design, drug company sponsorship, and the use of observed case instead of intention-to-treat data modified the mean difference in weight gain to some extent. Antipsychotics with more weight gain were often also among the drugs with worse outcome in fasting glucose and lipid parameters. The confidence in the evidence ranged from low to moderate. In conclusion, antipsychotic drugs differ in their propensity to induce metabolic side effects in mid- to long-term treatment. Given that schizophrenia is often a chronic disorder, these findings should be given more consideration than short-term data in drug choice.

Comparison of mental health outcomes of augmenting medications for patients with posttraumatic stress disorder: A national veterans affairs study

RATIONALE

Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well-studied in PTSD.

AIMS AND OBJECTIVES

We used Veterans Health Administration electronic records to compare mental health outcomes (PTSD symptoms and rates of mental health hospitalizations and psychiatric emergency room visits) in patients with PTSD who were prescribed four different groups of augmenting medications (atypical antipsychotics, mirtazapine, prazosin or tricyclic antidepressants) in addition to SRIs-from the year before to the year after the start of the augmenting medication.

METHOD

We included data from 169,982 patients with a diagnosis of PTSD (excluding patients with comorbid bipolar or psychotic disorders) seen in Veterans Affairs care from 2007 to 2015 who were taking an SRI and filled a new prescription for one of the four augmenting medications for at least 60 days.

RESULTS

Patients evidenced minimal (<2%) reduction in PTSD symptoms and a larger reduction in psychiatric hospitalizations and psychiatric emergency room visits after receiving augmenting medications; this effect was largely similar across the four medication groups. Initiating augmenting medications was preceded by increases in PTSD symptoms, psychiatric hospitalizations and psychiatric emergency room visits. After initiating an augmenting medication, PTSD symptoms/hospitalizations/emergency room visits returned to baseline levels (before the start of the augmenting medication), but generally did not improve beyond baseline.

CONCLUSION

Importantly, these effects could be explained by regression to the mean, additional interventions or confounding. These findings should be further explored with placebo controlled randomized clinical trials.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Antipsychotic drug-aripiprazole against schizophrenia, its therapeutic and metabolic effects associated with gene polymorphisms

Second-generation antipsychotics are widely used for the treatment of schizophrenia. Aripiprazole (ARI) is classified as a third-generation antipsychotic drug with a high affinity for dopamine and serotonin receptors. It is considered a dopamine-system stabilizer without severe side effects. In some patients the response to ARI treatment is inadequate and they require an effective augmentation strategy. It has been found that the response to the drug and the risk of adverse metabolic effects can be related to gene polymorphisms. A reduced dose is recommended for CYP2D6 poor metabolizers; moreover, it is postulated that other polymorphisms including CYP3A4, CYP3A5, ABCB1, DRD2, and 5-HTRs genes influence the therapeutic effect of ARI. ARI can increase the levels of prolactin, C-peptide, insulin, and/or cholesterol possibly due to specific genetic variants. It seems that a pharmacogenetic approach can help predict drug response and improve the clinical management of patients with schizophrenia.

A systematic review on sex differences in adverse drug reactions related to psychotropic, cardiovascular, and analgesic medications

Background and objective: Adverse drug reactions (ADRs) are the main safety concerns of clinically used medications. Accumulating evidence has shown that ADRs can affect men and women differently, which suggests sex as a biological predictor in the risk of ADRs. This review aims to summarize the current state of knowledge on sex differences in ADRs with the focus on the commonly used psychotropic, cardiovascular, and analgesic medications, and to aid clinical decision making and future mechanistic investigations on this topic. Methods: PubMed search was performed with combinations of the following terms: over 1,800 drugs of interests, sex difference (and its related terms), and side effects (and its related terms), which yielded over 400 unique articles. Articles related to psychotropic, cardiovascular, and analgesic medications were included in the subsequent full-text review. Characteristics and the main findings (male-biased, female-biased, or not sex biased ADRs) of each included article were collected, and the results were summarized by drug class and/or individual drug. Results: Twenty-six articles studying sex differences in ADRs of six psychotropic medications, ten cardiovascular medications, and one analgesic medication were included in this review. The main findings of these articles suggested that more than half of the ADRs being evaluated showed sex difference pattern in occurrence rate. For instance, lithium was found to cause more thyroid dysfunction in women, and amisulpride induced prolactin increase was more pronounced in women than in men. Some serious ADRs were also found to exert sex difference pattern, such as clozapine induced neutropenia was more prevalent in women whereas simvastatin/atorvastatin-related abnormal liver functions were more pronounced in men.

Temporal Trends in Mortality Associated with Comorbid Type 2 Diabetes and Schizophrenia: The Fremantle Diabetes Study

BACKGROUND

In Phase I of the community-based Fremantle Diabetes Study (FDS1), there was evidence of a deleterious interactive effect of schizophrenia and type 2 diabetes on mortality. Our aim was to investigate whether the mortality gap had improved in FDS Phase II (FDS2) conducted 15 years later.

METHODS

Participants with type 2 diabetes from FDS1 (n = 1291 recruited 1993-1996) and FDS2 (n = 1509 recruited 2008-2011) were age-, sex- and postcode-matched 1:4 to people without diabetes. Schizophrenia at entry and incident deaths were ascertained from validated administrative data.

RESULTS

Schizophrenia affected 50/11,195 (0.45%) of participants without diabetes and 17/2800 (0.61%) of those with type 2 diabetes (p = 0.284). During 142,304 person-years of follow-up, the mortality rate (95% CI) was lowest for the FDS2 subgroup without diabetes/schizophrenia (18.2 (16.9, 19.6)/1000 person-years) and highest in FDS2 and FDS1 subgroups with type 2 diabetes/schizophrenia (53.3 (14.5, 136.6) and 98.0 (31.8, 228.8)/1000 person-years, respectively). Compared to the respective FDS subgroup without diabetes/schizophrenia, the mortality rate ratio was approximately 50% higher in the type 2 diabetes subgroup, and three times higher in those with type 2 diabetes/schizophrenia. In Cox regression, unadjusted hazard ratios were highest in those with type 2 diabetes/schizophrenia in FDS1 (HR (95% CI): 3.71 (1.54, 8.93) and FDS2 (2.96 (1.11, 7.91)), increasing to 5.61 (2.33, 13.5) and 26.9 (9.94, 72.6), respectively, after adjustment for age.

CONCLUSIONS

Although limited by small numbers of schizophrenia cases, these data suggest that comorbid type 2 diabetes and schizophrenia remains associated with a substantial and possibly increasing mortality gap.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Experiences and views of carers regarding the physical health care of people with severe mental illness: An integrative thematic review of qualitative research

WHAT IS KNOWN ON THE SUBJECT?: People with severe mental illness (SMI) have high rates of physical illnesses, and carers are core partners in managing their physical health. Qualitative research on carers' views/experiences of physical health care is limited, and there is no published systematic review that synthesizes the current evidence. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Carers' views from seven articles were synthesised into nine themes and six subthemes describing their perceived facilitators, barriers and roles regarding the physical health care of people with SMI. Carers' voiced similar concerns to those previously identified by professionals and service users, particularly in relation to poor service access/responsiveness and communication difficulties with healthcare professionals. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses should be aware of the risk of diagnostic overshadowing and ensure they are both responsive and sensitive to carers concerns about the physical health of people with SMI. It is essential for mental health nurses to actively involve carers in managing physical health, especially in formulating physical healthcare plans and providing clear practical advice/information. ABSTRACT: Introduction People with severe mental illness (SMI) have high rates of physical illnesses. Informal carers are core partners in addressing these issues, however research on their views/experiences is limited and there is no systematic review published on the topic. Aim This integrative thematic review explored the experiences and views of carers on physical health care in SMI by synthesizing the existing qualitative research findings. Methods Six databases were searched from 2000 to 2021. Data were extracted and synthesised using thematic integrative analysis. The quality of included studies was assessed with the JBI Critical Appraisal Checklist. Results Five studies were included. Nine themes were identified conceptualising carers' perceived facilitators, barriers and roles regarding physical health care for people with SMI. Discussion Carers felt that receiving practical help and a specialised role for mental health nurses would facilitate better physical health care. Lack of coordination/communication and poor service access/responsiveness were common barriers, often compounded by diagnostic overshadowing. Carers are involved in promoting healthy lifestyles, monitoring physical health and supporting access to services. Implications for Practice Mental health nurses should ensure they are responsive to carers' concerns and proactively support them to promote the physical health of people with SMI.

Is the CYP2D6 Genotype Associated with Antipsychotic-Induced Weight Gain?

Antipsychotic-induced weight gain (AIWG) is a serious adverse effect. Studies have linked genetically-predicted CYP2D6 metabolic capacity to AIWG. The evidence, however, is ambiguous. We performed multiple regression analyses examining the association between genetic-predicted CYP2D6 metabolic capacity and AIWG. Analyses were based on previously unpublished data from an RCT investigating the clinical utility of routine genotyping of CYP2D6 and CYP2C19 in patients with schizophrenia. A total of 211 patients, corresponding to 71% of the original study population, were included. Our analyses indicated an effect of genetically predicted CYP2D6 metabolic capacity on AIWG with significant weight gain in both CYP2D6 poor metabolizers (PMs) (4.00 kg (95% CI: 0.80; 7.21)) and ultrarapid metabolizers (UMs) (6.50 kg (95% CI: 1.03; 12.0)). This finding remained stable after adjustment for covariates (PMs: 4.26 kg (0.88; 7.64), UMs: 7.26 kg (1.24; 13.3)). In addition to the CYP2D6 metabolic capacity, both baseline body mass index (−0.24 (95% CI: −0.44; −0.03)) and chlorpromazine equivalents per day (0.0041 (95% CI: 0.0005; 0.0077)) were statistically significantly associated with weight change in the adjusted analysis. Our results support that the genetically predicted CYP2D6 metabolic capacity matters for AIWG.

Plasma oxysterols in drug-free patients with schizophrenia

Evidence from clinical, genetic, and medical studies has shown the neuronal developmental disorder aspect of schizophrenia (SZ). Whereas oxysterols are vital factors in neurodevelopment, it is still unknown whether they are involved in the pathophysiology of SZ. The current study aims to explore the profile of oxysterols in plasma, ratio to total cholesterol (Tchol) and the association with clinical factors in patients with SZ. Forty men diagnosed with SZ and forty healthy controls matched for age and sex were included in the study. The ratios of cholestane-3β,5α,6β-triol, 27-hydroxycholesterol (27-OHC) and Cholestanol to Tchol increased in the schizophrenic group compared to controls. However, levels of 24S-hydroxycholesterol (24-OHC) were not significantly different between patients and controls. For the SZ patients, the plasma 24-OHC levels were positively correlated with the positive and negative syndrome total scores (PANSS) but negatively correlated with the Montreal Cognitive Assessment scores (MOCA). Moreover, the ratio Cholestanol to Tchol was negatively correlated with MOCA scores and positively correlated with PANSS general. The binary logistic regression analysis revealed that the ratio Cholestane-3β,5α,6β-triol/TChol could be considered as an independent risk factor for SZ. On the other hand, the receiver's operating characteristics analysis corresponding to potential biomarkers on SZ showed Areas Under the Curve (AUCs) of 82.1%; 69.7% and 77.6% for the ratio of Cholestane-3β,5α,6β-triol/TChol, 27-OHC/TChol and Cholestanol/TChol respectively. The relevance of Cholestane-3β,5α,6β-triol, 27-OHC and Cholestanol assays as biomarkers of this disease deserves further investigation.

Crosstalk between Schizophrenia and Metabolic Syndrome: The Role of Oxytocinergic Dysfunction

The high prevalence of metabolic syndrome in persons with schizophrenia has spurred investigational efforts to study the mechanism beneath its pathophysiology. Early psychosis dysfunction is present across multiple organ systems. On this account, schizophrenia may be a multisystem disorder in which one organ system is predominantly affected and where other organ systems are also concurrently involved. Growing evidence of the overlapping neurobiological profiles of metabolic risk factors and psychiatric symptoms, such as an association with cognitive dysfunction, altered autonomic nervous system regulation, desynchrony in the resting-state default mode network, and shared genetic liability, suggest that metabolic syndrome and schizophrenia are connected via common pathways that are central to schizophrenia pathogenesis, which may be underpinned by oxytocin system dysfunction. Oxytocin, a hormone that involves in the mechanisms of food intake and metabolic homeostasis, may partly explain this piece of the puzzle in the mechanism underlying this association. Given its prosocial and anorexigenic properties, oxytocin has been administered intranasally to investigate its therapeutic potential in schizophrenia and obesity. Although the pathophysiology and mechanisms of oxytocinergic dysfunction in metabolic syndrome and schizophrenia are both complex and it is still too early to draw a conclusion upon, oxytocinergic dysfunction may yield a new mechanistic insight into schizophrenia pathogenesis and treatment.

Metabolic disturbances during treatment with second generation antipsychotics

Second generation antipsychotics (SGA) cause side effects through weight gain, dyslipidemias (cholesterolemia, hypertriglyceridemia) as well as affected glucose homeostasis in terms of hyperglycemia,insulin resistance and the incidence of type 2 diabetes mellitus. The aim of this study was to investigate metabolic changes in patients treated with SGA. Materials and methods: This was a prospective study of 50 patients treated with SGA (olanzapine, clozapine, risperidone, quetiapine, aripiprazole) at the PHI University Clinic of Psychiatry who met the relevant ICD-10 criteria. The following parameters were monitored: history and clinical examination, blood pressure and pulse, height, weight, body mass index (BMI), Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression Scale (CGI-S), dose of prescribed SGA,as well as: fasting glycemia, lipid status, HDL, LDL, glycosylated hemoglobin (HgA1C). The parameters were determined at the beginning and after three months of treatment. Results: The subjects in terms of the criteria of metabolic syndrome were: 64% with a larger waist circumference, 53.2% with an increase in systolic and/or diastolic blood pressure, 31.3% with a BMI>30, and 39% with an increase in glycaemia and reduced HDL values ​​at 23.4%. Also,18% of the respondents met three or more criteria. Statistical analysis of the differences in the analyzed parameters showed statistically significant differences for the CGI-S score (p = 0.00007) and for the diastolic pressure (p = 0.038). Correlation of equivalent doses of SGA with BMI (r = -0.637) was obtained. Discussion: The study confirmed presence of metabolic disorders in patients treated with SGA. Although there was no significant difference of metabolic syndrome parameters in relation to the general population, a correlation with BMI has been established. Conclusion: This study showed that patients treated with second-generation antipsychotics should be monitored during their treatment for the parameters of the metabolic syndrome, particularly BMI.

Increased risk of death compared to other antipsychotics in elderly clozapine users in Poland

Clozapine can cause severe adverse effects. Few epidemiologic studies have considered the effect of clozapine use in elderly patients. The aim of this study was to assess mortality in elderly patients treated with clozapine in comparison to patients treated with first- or second-generation antipsychotics. We conducted a retrospective cohort study involving 26 639 patients who were 65 years of age or older and were receiving antipsychotic medication between 2008 and 2012. Cox proportional-hazards models were used to compare the risk of death between different groups of antipsychotics after controlling for age, sex, concomitant treatment with cardiovascular or metabolic medications. The use of antipsychotic medications other than clozapine was associated with a lower adjusted risk of death [hazard ratio, 0.89; 95% confidence interval (95% CI), 0.79-0.99]. The use of cardiac and antilipemic but not antidiabetic drugs was associated with a significantly lower risk of death in this population (hazard ratio, 0.88; 95% CI, 0.83-0.93; hazard ratio, 0.66; 95% CI, 0.58-0.75 and hazarad ratio, 1.09; 95% CI, 0.96-1.24, respectively). These results suggest that clozapine is associated with an increased risk of death in the elderly. Although the study was based on administrative records linkage, its results suggest that attention should be paid to patients taking antipsychotics.

Obesity Prevention is the Key to a Nation’s Health

The overweight and obesity is increasing problem for the health care system and for the health of the general population. The number of overweight people with varying degrees of obesity is growing in most countries around the world each year, a third of the world’s population suffers from this condition. According to scientists, lack of sleep, stress, use of certain pharmacological drugs can lead to obesity. The causes and factors of weight gain are varied, not only in personal life, such as eating habits and physical activity, but also include factors that can not be controlled, such as environmental factors, socio-economic factors, genetic factors and more. Obesity is a major risk factor for many diseases such as diabetes, cardiovascular disease, stroke and some cancers. Obesity prevention should be one of the top priorities for the health care system. Preventive measures aimed to prevent the development of overweight and obesity have three levels of intervention: primary, secondary and tertiary. The purpose of the primary prevention is to minimize weight gain and prevent the development of overweight or obesity. Secondary prevention aimes to reduce the impact of the existing disease. Tertiary prevention concentraits on reduction of the complications that have developed as a result of the disease. To prevent overweight and obesity, doctors advise to limit the caloric content of diet by reducing the consumption of fats and sugars; increase the consumption of fruits and vegetables, as well as whole grains and nuts; perform regular exercise. Regular weighing by health professionals can help identify patterns and factors that contribute to weight gain. The success of obesity therapy depends on the patient’s trust to his doctor and the knowledge of the clinician in this area.

Gold nanoclusters eliminate obesity induced by antipsychotics

Obesity induced by antipsychotics have plagued more than 20 million people worldwide. However, no drug is available to eliminate the obesity induced by antipsychotics. Here we examined the effect and potential mechanisms of a gold nanoclusters (AuNCs) modified by N-isobutyryl-L-cysteine on the obesity induced by olanzapine, the most prescribed but obesogenic antipsychotics, in a rat model. Our results showed that AuNCs completely prevented and reversed the obesity induced by olanzapine and improved glucose metabolism profile in rats. Further mechanism investigations revealed that AuNCs exert its anti-obesity function through inhibition of olanzapine-induced dysfunction of histamine H1 receptor and proopiomelanocortin signaling therefore reducing hyperphagia, and reversing olanzapine-induced inhibition of uncoupling-protein-1 signaling which increases thermogenesis. Together with AuNCs' good biocompatibility, these findings not only provide AuNCs as a promising nanodrug candidate for treating obesity induced by antipsychotics, but also open an avenue for the potential application of AuNCs-based nanodrugs in treating general obesity.

Association between C-reactive protein levels and antipsychotic treatment during 12 months follow-up period after acute psychosis

BACKGROUND

A potential role of inflammatory pathways in the pathology of schizophrenia has been suggested for at least a subgroup of patients. Elevated levels of the inflammatory marker C-reactive protein (CRP) have been observed, with associations to pathogenesis and symptoms. The current evidence regarding effects of antipsychotics on CRP levels is ambiguous.

OBJECTIVES

To examine and compare the influence on CRP levels of three pharmacologically diverse new generation antipsychotics during a one-year follow-up in schizophrenia spectrum disorder.

METHODS

In a multicenter, pragmatic and rater-blinded randomized trial, the effects of amisulpride, aripiprazole and olanzapine were compared in 128 patients with schizophrenia spectrum disorder. All had positive symptoms of psychosis at study entry. Clinical and laboratory assessments including the measurement of CRP levels were conducted at baseline, and 1, 3, 6, 12, 26, 39, and 52 weeks thereafter.

RESULTS

For all antipsychotic drugs analysed together, there was an increase in CRP levels during the one-year follow-up. Aripiprazole, as opposed to amisulpride and olanzapine, was associated with a reduced CRP level after one week, after which the CRP level caught up with the other drugs. Compared to those previously exposed to antipsychotic drugs, antipsychotic-naïve patients had lower CRP levels at all follow-up time points, but with the same temporal patterns of change.

CONCLUSION

Treatment with amisulpride, aripiprazole and olanzapine showed different effects on CRP levels in patients with schizophrenia spectrum disorders, modified by previous antipsychotics exposure status. This finding suggests that antipsychotic drugs may vary with respect to their influence on pro-inflammatory pathways.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT01446328; URL: http://www.

CLINICALTRIALS

gov/.

Does the gut microbiome mediate antipsychotic-induced metabolic side effects in schizophrenia?

INTRODUCTION

Second-generation antipsychotics (SGAs) are the most effective treatment for people with schizophrenia. Despite their effectiveness in treating psychotic symptoms, they have been linked to metabolic, cardiovascular and gastrointestinal side-effects. The gut microbiome has been implicated in potentiating symptoms of schizophrenia, response to treatment and medication-induced side effects and thus presents a novel target mediating second-generation antipsychotic-induced side effects in patients.

AREAS COVERED

This narrative review presents evidence from clinical and pre-clinical studies exploring the relationship between the gut microbiome, schizophrenia, second-generation antipsychotics and antipsychotic-induced side-effects. It also covers evidence for psychobiotic treatment as a potential supplementary therapy for people with schizophrenia.

EXPERT OPINION

The gut microbiome has the potential to mediate antipsychotic-induced side-effects in people with schizophrenia. Microbiome-focused treatments should be considered in combination with standard therapy in order to ameliorate debilitating drug-induced side effects, increase quality of life and potentially improve psychotic symptoms. Future studies should aim to collect not only microbiome data, but also metabolomic measures, dietary information and behavioral data.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Effects of Aerobic, Resistance, and Combined Exercise Training on Psychiatric Symptom Severity and Related Health Measures in Adults Living With Schizophrenia: A Systematic Review and Meta-Analysis

Previous research has demonstrated the efficacy, effectiveness, and safety of exercise training in persons living with schizophrenia. However, the optimal exercise training program remains unclear. The aim of this paper was to conduct a systematic review and meta-analysis of the effects of aerobic, resistance, and combined aerobic and resistance training on health-related physical fitness and positive and negative symptoms in persons living with schizophrenia. Six electronic databases were searched systematically from their inception to December 2020 [MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, SPORTDiscus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL)] to identify literature examining the effects of exercise training on psychiatric symptoms and health-related physical fitness indicators in persons living with schizophrenia. A total of 22 studies (n = 913) were included in this review, and 12 studies (n = 554) included within the meta-analysis reported the effects of exercise training (aerobic, resistance, and combined aerobic and resistance) in persons living with schizophrenia. Aerobic training had a significant decrease on Positive and Negative Syndrome Scale (PANSS) negative scores (ES -2.28, 95% CI -3.57 to -1.00; p = 0.0005) and PANSS general scores (ES -2.51, 95% CI -3.47 to -1.55; p < 0.00001). Resistance training did not lead to significant effects on PANSS total scores. Combined aerobic and resistance training did not lead to significant changes in body mass index, PANSS positive scores, or PANSS total scores. However, grouping together the results from all exercise training modalities (including aerobic training, resistance training, and combined aerobic and resistance training) revealed significant effects on body mass index (ES 1.86, 95% CI 0.84 to 2.88; p = 0.0003), maximal/peak oxygen consumption (ES 2.54, 95% CI 1.47 to 3.62; p = < 0.00001), body weight (ES 6.58, 95% CI 2.94 to 10.22; p = 0.0004), PANSS negative scores (ES -1.90, 95% CI -2.70 to -1.10; p < 0.00001), and Scale for the Assessment of Negative Symptoms (SANS) total (ES -14.90, 95% CI -22.07 to -7.74; p < 0.0001). Collectively, these findings support the importance of exercise participation (aerobic and resistance training) in persons living with schizophrenia.

Metabolic adverse effects of off-label use of second-generation antipsychotics in the adult population: a systematic review and meta-analysis

Prescription rates of second-generation antipsychotics (SGAs) are rapidly increasing for non-indicated (i.e., off-label) usage. SGAs used for approved indications are associated with significant metabolic adverse effects, including weight gain. The objective of this systematic review and meta-analysis is to evaluate the metabolic adverse effects of SGA use for off-label management of psychiatric illnesses in the adult population. We performed a systematic database search to identify randomized controlled trials (RCTs) that reported on weight and other metabolic outcomes with off-label use of SGAs among adults. Thirty-eight RCTs met inclusion criteria for this review; 35 of these studies, with a total of 4930 patients, were included in the quantitative meta-analysis. Patients treated with olanzapine, risperidone, and quetiapine were more likely to report weight gain as a side effect and experience clinically significant (≥7%) weight gain compared to those treated with a placebo. Among studies that reported weight as a continuous outcome, olanzapine was associated with significantly greater weight gain across all disorders (mean difference (MD) = 3.24 kg, 95% CI: 2.57-3.90 p = 0.001, N = 12 studies). Similar trends were noted with quetiapine and risperidone. A meta-regression analysis revealed a positive dose-response association between olanzapine dose and weight gain (regression coefficient: 0.36, p = 0.001). This review demonstrates that off-label use of SGAs, and particularly olanzapine, is associated with significant weight gain among adult patients. Our findings are concerning given the widespread off-label use of SGAs. Further studies are required to better understand the effects of off-label SGA use on other metabolic parameters. The study was registered with the PROSPERO international database of prospectively registered systematic reviews (PROSPERO #143186).

Metformin in the management of antipsychotic-induced weight gain in adults with psychosis: development of the first evidence-based guideline using GRADE methodology

BACKGROUND

Adjunctive metformin is the most well-studied intervention in the pharmacological management of antipsychotic-induced weight gain (AIWG). Although a relatively unaddressed area, among guidelines recommending consideration of metformin, prescribing information that would facilitate its applied use by clinicians, for example, provision of a dose titration schedule is absent. Moreover, recommendations differ regarding metformin's place in the hierarchy of management options. Both represent significant barriers to the applied, evidence-based use of metformin for this indication.

OBJECTIVE

To produce a guideline solely dedicated to the optimised use of metformin in AIWG management, using internationally endorsed guideline methodology.

METHODS

A list of guideline key health questions (KHQs) was produced. It was agreed that individual recommendations would be 'adopted or adapted' from current guidelines and/or developed de novo, in the case of unanswered questions. A systematic literature review (2008-2020) was undertaken to identify published guidelines and supporting (or more recent) research evidence. Quality appraisal was undertaken using the Appraisal of Guidelines Research and Evaluation II tool, A Measurement Tool to Assess Systematic Reviews (AMSTAR) assessment,and the Cochrane Risk of Bias 2 tool, where appropriate. Assessment of evidence certainty and recommendation development was undertaken using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

FINDINGS

We confirmed that no published guideline-of appropriate quality, solely dedicated to the use of metformin to manage AIWG was available. Recommendations located within other guidelines inadequately addressed our KHQs.

CONCLUSION

All 11 recommendations and 7 supporting good practice developed here were formulated de novo.

CLINICAL IMPLICATIONS

These recommendations build on the number and quality of recommendations in this area, and facilitate the optimised use of metformin when managing AIWG.

[Modern possibilities of anti-relapse therapy of schizophrenia (experience with the use of aripiprazole)]

The review is devoted to the actual problem of anti-relapse therapy for schizophrenia. The features of the use, efficiency, tolerability and safety of typical and atypical antipsychotics are discussed. The possibilities of using atypical antipsychotics of the third generation - partial dopamine receptor agonists - on the aripiprazole model are considered. According to numerous studies, aripiprazole, due to its unique pharmacological profile and combination of clinical factors, is the drug of first choice for anti-relapse supportive therapy of schizophrenia.

Antipsychotic-Related Risks of Type 2 Diabetes Mellitus in Enrollees With Schizophrenia in the National Basic Public Health Service Program in Hunan Province, China

BACKGROUND

Antipsychotics contribute to the development of type 2 diabetes mellitus (T2DM) in individuals with schizophrenia. However, the extent of the relationship between antipsychotic use and T2DM varies in different settings, and the magnitude of the drug-specific effects fluctuates widely. This study aimed to explore the association of T2DM with antipsychotic use among enrollees with schizophrenia in China's National Basic Public Health Service Program (NBPHSP) and the drug-specific relationship with T2DM among patients receiving antipsychotic monotherapy.

METHODS

We recruited diabetes-free patients with schizophrenia who were enrolled in the NBPHSP of Hunan Province from October 2009 to December 2018. The participants were classified into the following three groups: regular antipsychotic use, intermittent antipsychotic use, and antipsychotic-free groups. The patients were followed up until they received a T2DM diagnosis or until April 2019. Cox regression models were constructed to calculate the overall and drug-specific hazard ratios (HRs) to determine the antipsychotic-T2DM relationship. Interactive and subgroup analyses were performed to assess the heterogeneity of the effects across subgroups.

RESULTS

A total of 122,064 NBPHSP enrollees with schizophrenia were followed up for 1,507,829 cumulative person-years, and 2,313 (1.89%) patients developed T2DM. Patients who regularly and intermittently used antipsychotics had 117% (HR: 2.17, 95% CI: 1.83-2.57) and 53% (HR: 1.53, 95% CI: 1.23-1.90) higher risks of developing T2DM than antipsychotic-free patients, respectively. Regarding monotherapy, the T2DM risk increased by 66, 80, 62, and 64% after the regular use of clozapine, risperidone, chlorpromazine, and perphenazine, respectively. In addition, the antipsychotic-related risk of T2DM decreased as the patient's baseline body mass index, and baseline fasting plasma glucose level, as well as the dietary proportion of animal products, increased.

CONCLUSION

Antipsychotics, especially clozapine, risperidone, chlorpromazine, and perphenazine, increased the T2DM risk among NBPHSP enrollees with schizophrenia. Mental health officers should accurately identify enrollees at a high risk of T2DM and take appropriate preventive measures to reduce the incidence of T2DM among patients with schizophrenia.

The alternations of nucleus accumbent in schizophrenia patients with auditory verbal hallucinations during low-frequency rTMS treatment

Low-frequency repetitive transcranial magnetic stimulation (rTMS) has been shown to reduce the severity of auditory verbal hallucinations (AVH) and induce beneficial functional and structural alternations of the brain in schizophrenia patients with AVH. The nucleus accumbens (NAcc) as an important component of the ventral striatum is implicated with the pathology in AVH. However, the induced characteristic patterns of NAcc by low-frequency rTMS in schizophrenia with AVH are seldom explored. We investigated the functional and structural characteristic patterns of NAcc by using seed-based functional connectivity (FC) analysis and gray matter volume (GMV) measurement in schizophrenia patients with AVH during 1 Hz rTMS treatment. Although low-frequency rTMS treatment did not affect the volumetric changes of NAcc, the abnormal FC patterns of NAcc, including increased FC of NAcc with the temporal lobes and decreased FC of NAcc with the frontal cortices in the pretreatment patients compared to healthy controls, were normalized or reversed after treatment. These FC changes were associated with improvements in clinical symptoms and neurocognitive functions. Our findings may extend our understanding of the NAcc in the pathology of schizophrenia with AVH and might be a biomarker of clinical effect for low-frequency rTMS treatment in schizophrenia.

The role of metformin in treatment of weight gain associated with atypical antipsychotic treatment in children and adolescents: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Second-generation antipsychotics are associated with significant weight gain. The aim of this systematic review and meta-analysis was to determine the efficacy and safety of metformin for the treatment of weight gain in children and young adults treated with second-generation antipsychotics.

METHODS

We followed PRISMA guidelines to evaluated studies published before March 2020 in Medline, Google Scholar, PubMed, Cochrane library database, annual scientific sessions of the American Psychiatric Association, American Academy of Child and Adolescent, Psychiatry, and American Society of Clinical Psychopharmacology. Studies included compared metformin with the placebo for management of weight gain in children and adolescents taking atypical antipsychotics. Non-randomized studies, animal experiment studies, editorials, and review studies were excluded. Multiple parameters, including change in anthropometric-biochemical parameters, drug discontinuation rate, and side effects among the groups were assessed. The random-effects method was used for meta-analysis.

RESULTS

Four studies with were included in the final analysis (213 patients; metformin: 106; control: 107). After pooled analysis, 12-16 weeks of metformin therapy was associated with a significant reduction in weight [(mean difference (MD): -4.53 lbs, confidence interval (CI): -6.19 to -2.87, p-value < 0.001)], and BMI z score [MD, -0.09, CI: -0.16, -0.03, p-value: 0.004] compared to control. Metformin was also associated with a significant reduction in insulin resistance [MD: -1.38, CI: -2.26 to -0.51, p-value: 0.002]. There were higher odds of nausea-vomiting [OR: 4.07, CI: 1.32-12.54, p-value: 0.02] and diarrhea [OR: 2.93, CI: 1.50-5.71, p-value: 0.002] in the metformin group. However, there was no difference in drug discontinuation rate [OR: 1.45, CI: 0.41-5.06, p-value: 0.56].

CONCLUSION

Metformin may prove beneficial in the treatment of weight gain in children treated with second-generation antipsychotics. The pooled treatment effect showed a significant reduction in BMI Z-score and weight in just 12-16 weeks. The limitations include small sample size, variation in metformin dose, and duration of treatment. This meta-analysis should be interpreted as promising, and further larger studies are warranted before drawing a conclusion.

Antipsychotic Use During Pregnancy and Risk for Gestational Diabetes: A National Register-Based Cohort Study in Sweden

OBJECTIVE

We aimed to study whether antipsychotic use during pregnancy is associated with gestational diabetes.

METHODS

This was a Swedish national register-based cohort study on the Medical Birth Register and the Prescribed Drug Register including all 1,307,487 singleton births between July 2006 and December 2017. Antipsychotics were divided into first-generation antipsychotics (n = 728), high-risk metabolic second-generation antipsychotics including olanzapine, clozapine and quetiapine (n = 1710), and other second-generation antipsychotics (n = 541). The risks for gestational diabetes, foetal growth disturbances, pre-eclampsia, caesarean section and preterm labour were assessed. Women treated during pregnancy were compared to women not treated during pregnancy and to women who used antipsychotics before/after but not during pregnancy.

RESULTS

The crude risk ratio for gestational diabetes for women treated with high-risk metabolic second-generation antipsychotics during pregnancy was 2.2 (95% confidence interval [CI] 1.6-2.9) compared to untreated pregnant women (n = 1,296,539) and 1.8 (95% CI 1.4-2.5) compared to women treated before/after pregnancy (n = 34,492). After adjustment for maternal factors including body mass index, the risk ratios were 1.8 (95% CI 1.3-2.4) and 1.6 (95% CI 1.2-2.1). Exposed infants had an increased risk of being large for gestational age: adjusted risk ratios 1.6 (95% CI 1.3-1.9) and 1.3 (95% CI 1.1-1.6) compared to no maternal antipsychotic use during pregnancy and maternal use before/after the pregnancy. Other antipsychotics were not associated with metabolic risks.

CONCLUSIONS

Olanzapine, clozapine and quetiapine used during pregnancy were associated with increased risks for gestational diabetes and the infant being large for gestational age. Enhanced metabolic monitoring should be considered for pregnant women using these drugs.

Socio demographic, clinical, and side effect profile of patients on clozapine in Kashmir, North India

Background

Clozapine is an atypical second-generation antipsychotic belonging to the family of dibenzodiazepines. There is lack of literature on clozapine from this part of the world. So, our aim was to study the socio demographic, clinical and side effect profile of patients on clozapine in Kashmir.

Results

The mean age of the study group was 32.6 ± 8.9 years with majority being males (78.4%), unmarried (78.4%), unemployed (77.2%), and belonging to nuclear families (77.2%). Almost half of them resided in urban localities (51.1%) and studied upto middle school (55.7%). Around three- fourth (75%) of the patients had diagnosis of treatment-resistant schizophrenia. The mean dose of clozapine was 338.92 ± 158.11 mgs. Sedation (76.1%), hypersalivation (69.5%), constipation (46.6%), and weight gain (34.1%) were most common side effects noted in patients. 4.5% cases developed seizures while on clozapine. 2.3% patients developed agranulocytosis while 4.5% patients developed neutropenia on clozapine. The neutropenia was more pronounced in patients of schizophrenia with suicidal tendencies with doses of more than 400 mg.

Conclusions

We have used clozapine in a wide range of indications. Our patients seem to tolerate and respond to higher doses of clozapine and the prevalence of blood dyscrasias in our study sample was much higher than the rest of India.