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

Glucagon-like peptide agonists for weight management in antipsychotic-induced weight gain: A systematic review and meta-analysis

INTRODUCTION

Managing body weight in patients with antipsychotic-induced weight gain (AIWG) is challenging. Besides lifestyle interventions, pharmacological interventions may contribute to weight loss. This systematic review and meta-analysis evaluated the effect on weight loss and adverse effects of glucagon-like peptide-1 (GLP-1) agonists in patients with AIWG.

MATERIALS AND METHODS

Following PRISMA guidelines, we performed a meta-analysis of blinded and open-label randomised controlled trials (RCTs), non-randomised controlled trials and cohort studies that evaluated treatment with GLP-1 in patients with AIWG, regardless of psychiatric diagnosis. PubMed, Embase, PsycINFO and Cochrane Library databases were searched. Primary outcome measures were changes in body weight and BMI. Secondary outcomes were changes in adverse effects and severity of psychopathology due to GLP-1 agonists.

RESULTS

Only data for exenatide and liraglutide could be included, that is, five RCTs and one cohort study. For exenatide the mean weight loss was -2.48 kg (95% Confidence Interval (CI) -5.12 to +0.64; p = 0.07), for liraglutide the mean weight loss was -4.70 kg (95% CI -4.85 to -4.56; p < 0.001). The mean change in BMI was -0.82 (95% CI -1.56 to -0.09; p = 0.03) in the exenatide groups and -1.52 (95% CI -1.83 to -1.22; p < 0.001) in the liraglutide groups. Exenatide and liraglutide did not adversely affect psychopathology. The most common adverse events were nausea, vomiting, and diarrhoea.

CONCLUSION

The GLP-1 agonists exenatide and liraglutide are promising drugs for inducing weight loss in patients with AIWG. The adverse effects are acceptable, and the addition of GLP-1 does not increase the severity of psychopathology. However, more research is needed.

Physical Health Checks and Follow-Up Care in Deprived and Ethnically Diverse People With Severe Mental Illness: Co-Designed Recommendations for Better Care

BACKGROUND

There is wide variation in premature mortality rates in adults with severe mental illness (SMI) across London, with Tower Hamlets (a highly deprived and ethnically diverse area) scoring the highest.

OBJECTIVE

To identify examples of best practice and co-design recommendations for improving physical health checks and follow-up care amongst people with SMI in Tower Hamlets.

METHODS

Data were collected through online questionnaires (using SMI physical health best practice checklists), one-on-one interviews (n = 7) and focus groups (n = 3) with general practices, secondary mental health services, commissioners and leads of community services and public health programmes, experts by experience and community, voluntary and social enterprise organisations in Tower Hamlets. Data were analysed using deductive and inductive thematic analysis.

RESULTS

Twenty-two participants representing 15 general practices (out of 32), secondary mental health services, commissioners and public health leads completed the online questionnaires. Twenty-one participants took part in interviews and focus groups. Examples of best practice included cleaning and validating the SMI register regularly by general practices, knowing the number of patients who had been offered and/or received physical health checks, having clear pathways to community and specialist care services, using various communication methods and having a key performance indicator (KPI) for tailored smoking cessation services for people with SMI. Recommendations included adopting evidence-informed frameworks for risk stratification and utilising the wider primary care workforce with specific training to follow up on results, offer interventions and support navigating pathways and taking up follow-up care. Incentivising schemes were needed to deliver additional physical health check components such as oral health, cancer screening, Covid-19 vaccination and sexual health checks. Including KPIs in other community services' specifications with reference to SMI people was warranted. Further engagement with experts by experience and staff training were needed.

CONCLUSION

The present initiative identified best practice examples and co-designed recommendations for improving physical health checks and follow-up care in deprived and ethnically diverse people with SMI.

PATIENT OR PUBLIC CONTRIBUTION

This initiative was supported by three experts with experience, and two community organisations, who were involved in data curation and interpretation, development of recommendations and/or dissemination activities including writing this manuscript.

Guideline concordant screening and monitoring of extrapyramidal symptoms in patients prescribed antipsychotic medication: a protocol for a systematic literature review and narrative synthesis

INTRODUCTION

Given the increasing rates of antipsychotic use in multiple psychiatric conditions, greater attention to the assessment, monitoring and documentation of their side effects is warranted. While a significant degree of attention has been provided to metabolic side effect monitoring, comparatively little is known about how clinicians screen for, document and monitor the motor side effects of antipsychotics (ie, parkinsonism, akathisia, dystonia and dyskinesias, collectively 'extrapyramidal side effects', EPS). This review aims to systematically assess the literature for insights into current trends in EPS monitoring practices within various mental health settings globally.

METHODS AND ANALYSIS

An electronic search will be performed using the OVID Medline, PubMed, Embase, CINAHL and APA PsycINFO databases for studies published in the last quarter century (1998 to present day). Two independent reviewers will conduct the initial title and abstract screenings, using predetermined criteria for inclusion and exclusion. A third reviewer will resolve disagreements if consensus cannot be reached. If selected for inclusion, full-text data extraction will then be conducted using a pilot-tested data extraction form. Quality assessment will be conducted for all included studies using a modified version of the Quality Improvement Minimum Quality Criteria Set. A narrative synthesis and summary of the data will be provided. All stages of the review process will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required. Findings will be peer reviewed, published and shared verbally, electronically and in print with interested clinicians and will also be presented as posters or talks at relevant medical conferences and meetings.

PROSPERO REGISTRATION NUMBER

CRD42023482372.

Metabolic Monitoring for Adults Living with a Serious Mental Illness on a Second-Generation Antipsychotic Agent: A Scoping Review

Premature mortality in people living with a severe mental illness (SMI) is often attributed to multiple factors including the use of medicines such as antipsychotics. Second-generation antipsychotics (SGAs) are known to cause metabolic syndrome which can increase the risk of cardiovascular disease. Practice guidelines have recommended regular physical health monitoring, particularly of metabolic parameters, however, metabolic monitoring for people living with SMI using antipsychotics remains suboptimal. Therefore, highlighting the need for ongoing research. This scoping review aimed to provide an overview of current metabolic monitoring practices. We anticipate that this information will assist clinicians and policymakers and inform future research. The following databases were searched: MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), the Cochrane Database of Systemic Reviews (Wiley), APA PsycInfo (Ovid) and Scopus (Elsevier Science Publishers). The target group was adults (aged ≥ 18) diagnosed with SMI (including bipolar disorder, major depressive disorder and psychotic disorders) and taking SGAs. In total, 44 studies from 14 countries were retrieved. Our findings highlighted that most studies conducted in hospitals did not report on metabolic monitoring practices. Additionally, the roles and responsibilities of healthcare professionals in metabolic monitoring for SMI were infrequently described and parameters such as waist circumference and BMI were often poorly monitored. The scoping review highlights that no streamlined approach towards metabolic monitoring currently exists. There is a need to stipulate and define the roles and responsibilities of all health professionals involved in metabolic monitoring in SMI to optimise care for these individuals. Moreover, there is a need for ongoing research, particularly in the community setting, to promote increased accessibility to metabolic monitoring for SMI.

High persistence and low treatment rates of metabolic syndrome in patients with mood and anxiety disorders: A naturalistic follow-up study

BACKGROUND

Patients with affective and anxiety disorders are at risk of metabolic syndrome (MetS) and, consequently, cardiovascular disease and premature death. In this study, the course and treatment of MetS was investigated using longitudinal data from a naturalistic sample of affective- and anxiety-disordered outpatients (Monitoring Outcome of psychiatric PHARmacotherapy [MOPHAR]).

METHODS

Demographics, clinical characteristics, medication use, and MetS components were obtained for n = 2098 patients at baseline and, in a FU-subsample of n = 507 patients, after a median follow-up (FU) of 11 months. Furthermore, pharmacological treatment rates of MetS were investigated at baseline and FU. Finally, demographic and clinical determinants of change in MetS (component) scores were investigated.

RESULTS

At baseline, 34.6 % of n = 2098 patients had MetS, 41.4 % of whom received treatment. Of patients with persisting MetS, 46.1 % received treatment for one (or more) MetS component(s) at baseline, and 56.6 % received treatment at FU. Treatment rates of solely elevated blood pressure and reduced HDL-cholesterol did significantly, but modestly, improve. Higher age, male sex, smoking behavior, low education, diabetes, and depressive versus anxiety disorder were predictors of worse outcome at FU on at least one MetS component.

LIMITATIONS

We did not have data on lifestyle interventions as a form of treatment, which might partly have explained the observed low pharmacotherapeutic treatment rates.

CONCLUSION

MetS (components) show high persistence rates in affective- and anxiety-disordered patients, and are, despite adequate monitoring, undertreated over time. This indicates that adherence and implementation of monitoring protocols should be crucially improved in psychiatric outpatients in secondary care.

Impact of institutional quality improvement initiatives on metabolic monitoring in mental disorder in patients treated with antipsychotics: A meta-analysis of intervention studies

Background

Compliance with guidelines regarding monitoring of metabolic adverse effects induced by antipsychotics has been consistently low. We characterised and evaluated the quality of institutional quality improvement (QI) interventions designed to address disparities between guidelines and real-world practices. Furthermore, we assessed the impact of these interventions on the screening and management of metabolic risks for inpatients receiving treatment with antipsychotic medications.

Methods

We conducted a meta-analysis of institutional QI intervention studies aimed at improving antipsychotic-associated metabolic risk monitoring in hospitalised mental disease patients. Relevant studies were identified through searches conducted in the Embase and PubMed databases, as well as by reviewing previous reviews and meta-analyses. Quantitative analyses were performed, calculating odds ratios (ORs) and 95% confidence intervals (CIs) to assess the impact of QI programmes on guideline adherence in clinical practice.

Results

We identified 12 intervention studies (n = 10 128 and n = 2667 patients in the pre-and post-intervention groups, respectively) and included them in our meta-analysis. QI interventions demonstrated effectiveness in bridging the guideline-practice gap in monitoring antipsychotic-induced metabolic adverse effects, as supported by the ORs and 95% CIs for post-intervention monitoring of plasma glucose, lipids, and blood pressure (BP) vs the pre-intervention period being OR = 6.90 (95% CI = 1.51-31.48), OR = 5.39 (95% CI = 4.01-7.24), and OR = 4.81 (95% CI = 1.23-18.79), respectively. Only 33.3% (4/12) of studies reported screening rates for all four metabolic parameters (plasma glucose, lipids, weight/body mass index (BMI), and BP). The median rates for metabolic screening of plasma glucose, lipids, and BP increased from 51.0-80.0%, 28.7-66.7%, and 91.7-95.8%, respectively. Up to 66.7% (8/12) of intervention studies lacked follow-up measures to treat or manage identified risks in hospitalised psychiatric patients, such as patient referrals, prescription of medications, and switching of antipsychotics. The odds of monitoring weight/BMI and glucose were greatest when QI programmes involved the participation of multidisciplinary health care professionals and patients, yielding OR = 3.35 (95% CI = 2.45-4.59) and OR = 57.51 (95% CI = 24.11-137.21), respectively.

Conclusions

Institutional QI interventions were effective in enhancing monitoring practices in alignment with established guidelines for metabolic risk screening among hospitalised patients with mental disorders maintained on antipsychotic medications. Future institutional QI programmes should incorporate multidisciplinary strategies involving patient engagement and extend their focus beyond screening to incorporate follow-up risk management strategies once risks have been identified.

Registration

PROSPERO CRD42023452138.

AMPlifying metabolic screening for inpatients on antipsychotic medications with a nurse-driven protocol

INTRODUCTION

Patients on antipsychotic medications are at higher risk of developing metabolic syndrome; nevertheless, metabolic screening for patients on antipsychotics is suboptimal.

METHODS

This project developed and implemented AMP (Antipsychotic Metabolic screening Protocol), a nurse-driven protocol on inpatient psychiatric units that allowed nursing staff to collect all components of a metabolic screening. Nurses working on units with AMP were surveyed pre- and post-implementation on perception of AMP and empowerment.

RESULTS

AMP significantly increased overall metabolic screening as well as the most frequently missing component (lipid panel). The screening rates pre-intervention were similar to those found in the literature (on average, only two-thirds of patients were screened). However, AMP improved the rate such that nine out of every ten patients on the units were screened. Nurses had a negative perception and no change in empowerment from AMP implementation.

CONCLUSIONS

AMP can be used to increase metabolic screening for patients on antipsychotics. Further research is needed to better understand adoptability of nurse-driven protocols in the psychiatric inpatient setting as well as other applications, such as smoking cessation or safety sitters.

General practice pharmacist-led antipsychotic physical health monitoring: a prospective intervention scoping study

BACKGROUND

People with severe mental health illness die prematurely, often due to preventable cardiometabolic disease, which can be exacerbated by antipsychotic medicines that are effective for treating mental illness. Literature demonstrates that physical health monitoring, as recommended in guidelines, for people receiving antipsychotics is substandard. Therefore, we aimed to scope the potential of a general practice clinical pharmacist (GPCP)-led multidisciplinary intervention optimising adherence to cardiometabolic monitoring guidelines and delivering polypharmacy reviews.

METHOD

Prospective intervention scoping study in three urban general practices; one usual care, two intervention. Patients 18-65 years old prescribed oral antipsychotics were identified from records, and invited for cardiometabolic monitoring and GPCP medication review, from January to December 2022. Interventions and onward referrals were recorded and collated. Anonymised pre- and post-review data were analysed, and actions were graded for clinical importance.

RESULTS

In total 1.5% (210/14,159) of patients aged 18-65 years met inclusion criteria; usual care practice (n = 58); and intervention practices (n = 152). From baseline, the usual care practice achieved an absolute 7% increase in the cardiometabolic monitoring care bundle (glucose/glycosylated haemoglobin, lipids, blood pressure plus body mass index) versus 19-58% in the intervention practices. Two-thirds (92/152) of patients participated in medication reviews, requiring pharmacological and/or non-pharmacological clinical actions. The majority of actions were graded as moderate importance. Seven percentage of patients were identified as new pre-diabetic/diabetic and 6% were at high risk of cardiovascular disease requiring statin initiation.

CONCLUSION

A pharmacist-led multidisciplinary general practice-based approach may be effective at optimising cardiometabolic monitoring; identifying and treating diabetic and cardiovascular risk factors.

Cardiometabolic screening and monitoring in patients prescribed antipsychotic drugs in primary care: A population-based cohort study

BACKGROUND

This study aimed to investigate the level of guideline adherence for cardiometabolic health monitoring for patients prescribed antipsychotic medicines in UK primary care.

METHODS

In this population-based retrospective open cohort study, we used dataset of patients from the IQVIA Medical Research Data (IMRD) database between 1st January 2003 to 31st December 2018. Clinical Read codes were used to identify a cohort of adult patients with a diagnosis of Schizophrenia and at least four prescriptions of an anti-psychotic medication within 12 months of diagnosis. We then extracted data in relation to monitoring of cardiometabolic parameters (body compositions, lipids, and glucose outcomes) at baseline, then at six weeks, 12 weeks, and then 12 months. The frequency of outcome monitoring was described using descriptive statistics.

FINDINGS

A total of 11,435 patients were eligible and of them (n = 9707; 84·8%) were prescribed second-generation antipsychotics (SGAs). Only a small portion of the cohort (≈2·0%) received complete monitoring (at time points) for certain outcomes. Just over half the patients (n = 6599, 52%) had evidence of any cardiometabolic baseline testing for any of the study outcomes and the high majority had at least one abnormal lab value at baseline (n = 4627, 96·7%).

INTERPRETATION

In UK primary care, cardiometabolic monitoring practices among patients prescribed antipsychotics remain suboptimal. There is a need to promote guideline adherence to prevent adverse outcomes in antipsychotic users.

Guideline adherence for cardiometabolic monitoring of patients prescribed antipsychotic medications in primary care: a retrospective observational study

BACKGROUND

Despite their known effectiveness, antipsychotics possess significant cardiometabolic adverse event profiles. Guidelines emphasise routine monitoring, however, practices are known to be suboptimal.

AIM

To investigate the level of cardiometabolic monitoring among people prescribed antipsychotic therapy in primary care, and patient-related factors that may influence monitoring patterns.

METHOD

Data were collected for patients with mental disorders and prescribed antipsychotics at two general practices in England (February 2016-February 2021). The main outcome measures were the proportion of patients with evidence of monitoring for cardiometabolic parameters (body composition, anthropometrics, lipids, glucose outcomes). Regression analysis was used to explore factors predicting monitoring practices.

RESULTS

Data from 497 patients were included. The proportion of patients receiving cardiometabolic monitoring at least once yearly varied across different parameters. Patients were mostly monitored for BP (92.0%), body weight (BMI > 85.0%) and HDL (72.0%), but to a lesser extent for other lipid parameters (non-HDL < 2.0%) and blood glucose (< 2.0%). Ageing (OR:2.0-7.0, p < 0.001) and chronic conditions (e.g., CVD and Type 2 DM, p < 0.05) were associated with frequent cardiometabolic monitoring. Conversely, antipsychotics with high metabolic risks (olanzapine), patients prescribed antipsychotic polypharmacy (≥ 2 antipsychotics) and cardiometabolic dysregulations (e.g., dyslipidaemias) did not improve monitoring frequencies.

CONCLUSION

Cardiometabolic health monitoring was generally infrequent, irregular, and did not change in response to abnormal test results or antipsychotic treatment with high cardiometabolic risks, suggesting more efforts need to be made to ensure the guidelines for cardiometabolic monitoring are followed. Future studies should investigate practices by using a large UK primary care database.

Cardiometabolic Monitoring and Sociodemographic and Clinical Characteristics of Youths Prescribed Antipsychotic Medications

OBJECTIVE

This study examined time trends and patient characteristics related to guideline-recommended cardiometabolic risk factor monitoring among youths treated with antipsychotic medications.

METHODS

This observational study assessed participant sociodemographic and clinical characteristics and year of antipsychotic medication initiation, with receipt of glycemic and lipid testing within 2 years of initiation as the primary outcome. Electronic health records and pharmacy data from Kaiser Permanente Northern California for 4,568 youths (ages 10-21 years) who began antipsychotic medication treatment during 2013-2017 were included.

RESULTS

Mean±SD age of the sample was 17.0±3.0 years, 52% were male, and 50% were Asian American, Native Hawaiian, or Pacific Islander; Black; Latino; or another or unknown race-ethnicity. Overall, 54% of the sample completed glycemic and lipid monitoring within 2 years of medication initiation (41% within 1 year). With each study year, monitoring rates increased by 5% in this cohort, after the analyses were adjusted for participant factors (p=0.001). In the fully adjusted analysis, youths with a psychotic disorder were 23% more likely to receive cardiometabolic monitoring than those without a psychotic disorder or bipolar disorder (p<0.001). Monitoring was also more common among younger versus older adolescents and among those with risperidone (vs. quetiapine) medication, obesity, or more frequent use of outpatient health care. Youths with (vs. without) substance use disorder were 19% less likely to complete monitoring (p<0.001).

CONCLUSIONS

Cardiometabolic monitoring increased modestly over time, but close to half of the studied youths did not receive glycemic or lipid testing. Additional clinical strategies may be needed to increase monitoring overall and among harder-to-reach youth subgroups.

Stewardship applied to antipsychotics: Development of an antipsychotic stewardship program in inpatient settings for monitoring and optimizing outcomes

Antipsychotic (AP) medications are prescribed for various psychiatric diagnoses that require routine monitoring to ensure optimal use, effectiveness, adherence, and for potentially severe adverse effects. There is currently no comprehensive protocol for institutional supervision of prescribing and monitoring AP. Antibiotics (ABX) are commonly associated with stewardship programs aimed at optimizing use and mitigating harm. These programs have proven to result in positive outcomes in both safety and efficacy parameters for numerous institutions. Given that AP are also associated with significant adverse effects and often misused, the concept of stewardship can be applied to this class of agents to optimize their use and improve overall patient outcomes. The objective of this paper is to provide guidance for the implementation of antipsychotic stewardship programs (APSP) in the inpatient setting. The development of this APSP was designed based on ABX stewardship programs and the Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, and the American Psychiatric Association practice guidelines on the treatment of patients with schizophrenia. In conclusion, APSPs have the potential to enhance and standardize institutional supervision of prescribing and monitoring practices of AP, leading to improved clinical outcomes and the reduction of adverse effects. APSP teams should be multidisciplinary, consisting of clinicians and administrators, working in conjunction with patients and patient advocates to design individualized recovery plans that consider the individual patient's history and desired outcomes. Monitoring, stewardship interventions, and outcomes should be documented on both an individual and deidentified institutional basis, analyzed, and summarized periodically as measures for quality improvement.

The relationship between diabetes mellitus and attention deficit hyperactivity disorder: A systematic review and meta-analysis

Background

This study aims to investigate the prevalence estimate of diabetes mellitus (DM) among people with attention deficit hyperactivity disorder (ADHD) as well as the prevalence of ADHD among those with DM. In addition, the impact of ADHD on glycemic control in patients with DM was also assessed using a systematic review and meta-analysis of currently available published data.

Materials and methods

The PubMed, Embase, Web of Science, and PsycInfo databases were searched for potential studies. Two reviewers independently selected studies according to the inclusion and exclusion criteria. All pooled analyses were conducted using the random-effects models on Review Manager 5.3.

Results

Seventeen observational studies were included. The pooled results showed an increase in the prevalence of DM among patients with ADHD versus those without ADHD [type 1 DM OR: 1.37 (95% CI: 1.17-1.61); type 2 DM OR: 2.05 (95% CI: 1.37-3.07)]. There was an overall 35% increase in the prevalence of ADHD among patients with type 1 DM [OR: 1.35 (95% CI: 1.08-1.73)]. Children with type 1 DM and ADHD had higher levels of hemoglobin A1c [standardized mean of differences: 0.67 (95% CI: 0.48-0.86)], and prevalence of hypoglycemic and ketoacidosis index compared with those without ADHD.

Conclusion

Our study revealed the bidirectional associations between ADHD and DM. Patients with ADHD and type 1 DM comorbidities were more likely to have poorer diabetes control. More studies are needed to confirm this association and elucidate the underlying mechanism.

Mortality, Revascularization, and Cardioprotective Pharmacotherapy After Acute Coronary Syndrome in Patients With Severe Mental Illness: A Systematic Review and Meta-analysis

BACKGROUND AND HYPOTHESIS

People with severe mental illness (SMI) may experience excess mortality and inequitable treatment following acute coronary syndrome (ACS). However, cardioprotective pharmacotherapy and SMI diagnoses other than schizophrenia are rarely examined in previous reviews. We hypothesized that SMI including bipolar disorder (BD) is associated with increased post-ACS mortality, decreased revascularization, and cardioprotective medication receipt relative to those without SMI.

STUDY DESIGN

We performed a meta-analysis to quantitatively synthesize estimates of post-ACS mortality, major adverse cardiac events (MACEs), and receipt of invasive coronary procedures and cardioprotective medications in patients with SMI, comprising schizophrenia, BD, and other nonaffective psychoses, relative to non-SMI counterparts. Subgroup analyses stratified by SMI subtypes (schizophrenia, BD), incident ACS status, and post-ACS time frame for outcome evaluation were conducted.

STUDY RESULTS

Twenty-two studies were included (n = 12 235 501, including 503 686 SMI patients). SMI was associated with increased overall (relative risk [RR] = 1.40 [95% confidence interval = 1.21-1.62]), 1-year (1.68 [1.42-1.98]), and 30-day (1.26 [1.05-1.51]) post-ACS mortality, lower receipt of revascularization (odds ratio = 0.57 [0.49-0.67]), and cardioprotective medications (RR = 0.89 [0.85-0.94]), but comparable rates of any/specific MACEs relative to non-SMI patients. Incident ACS status conferred further increase in post-ACS mortality. Schizophrenia was associated with heightened mortality irrespective of incident ACS status, while BD was linked to significantly elevated mortality only in incident ACS cohort. Both schizophrenia and BD patients had lower revascularization rates. Post-ACS mortality risk remained significantly increased with mild attenuation after adjusting for revascularization.

CONCLUSIONS

SMI is associated with increased post-ACS mortality and undertreatment. Effective multipronged interventions are urgently needed to reduce these physical health disparities.

Adiponectin and Stnfr2 peripheral levels are associated with cardiovascular risk in patients with schizophrenia

OBJECTIVES

To investigate the association between cytokine peripheral levels and the risk of cardiovascular disease in patients with schizophrenia and controls.

METHODS

A sample of 40 patients and 40 control subjects participated in the study. Psychiatric diagnosis was established following structured clinical assessment. The Framingham Score was used to assess cardiovascular risk (CVR). Serum levels of the cytokines IL-1β, IL-6, IL-8, IL-10, IL-12p70 and TNF-α were determined by cytometric bead array (CBA) technique, and the serum levels of IL-33, sST2, sTNFR1, sTNFR2, Leptin and Adiponectin by Enzyme-Linked Immunosorbent assay (ELISA).

RESULTS

Patients with schizophrenia showed greater frequency of moderate CVR when compared with controls (p = 0.14). In addition, patients showed higher levels of sTNFR2 and Adiponectin compared to controls (p = 0.007 and p < 0.001, respectively). Adiponectin and sTNFR2 were associated with CVR only in patients (p = 0.0002 and p = 0.033, respectively). In multivariate analysis controlling for socio-demographic and clinical confounders, illness duration (r = 0.492; p < 0.002) and sTNFR2 (r = 0.665; p < 0.004) were independent predictors of CVR.

CONCLUSION

Our results reinforce the concept that patients with schizophrenia are at greater risk to develop cardiovascular diseases, and suggest that the associated chronic low-grade inflammation might play a role in this process.

Associations between off-label low-dose olanzapine or quetiapine and cardiometabolic mortality

Olanzapine and quetiapine are routinely used off-label at lower doses, though it remains unclear whether treatment is associated with mortality. Here, we examined the associations between low-dose olanzapine/quetiapine, defined as 5 mg/day of olanzapine equivalents (OE) with cardiometabolic mortality in a population-based, longitudinal cohort of individuals who sought specialized psychiatric services. Through cross-linked Swedish registries, 428,525 individuals without psychotic, bipolar, or cardiometabolic disorders, or previous treatment with antipsychotics or cardiometabolic-related drugs were followed for up to 10.5 years. Extended stratified Cox proportional hazards regressions were employed to estimate the hazard ratios (HR) of cardiometabolic mortality as a function of cumulative OE exposures, adjusted for age, sex, inpatient care, and time-dependent psychiatric diagnoses and treatments. Individuals were followed for a total of 2.1 million person-years. Treatment with olanzapine/quetiapine occurred in 18,317 of the cohort. In total, 2606 cardiometabolic-related deaths occurred. Treatment status (treated vs. untreated) was not significantly associated with cardiometabolic mortality (adjusted HR 0.86, 95% CI 0.64-1.15, P = 0.307). However, compared to no treatment, treatment for <6 months was significantly associated with a reduced risk (adjusted HR 0.56, 95% CI 0.37-0.87, P = 0.010) whereas treatment for 6-12 months was significantly associated with an increased risk (adjusted HR 1.89, 95% CI 1.22-2.92, P = 0.004), but not significantly beyond 12 months. Among those treated, each year exposed to an average 5 mg/day was significantly associated with increased cardiometabolic mortality (adjusted HR 1.45, 95% CI 1.06-1.99, P = 0.019). Overall, low-dose olanzapine/quetiapine treatment was weakly associated with cardiometabolic mortality. Clinicians should consider potential cardiometabolic sequelae at lower doses.

Assessing cardiometabolic parameter monitoring in inpatients taking a second-generation antipsychotic: The CAMI-SGA study - a cross-sectional study

OBJECTIVES

This study aims to determine the proportion of initial cardiometabolic assessment and its predicting factors in adults with schizophrenia, bipolar disorder or other related diagnoses for whom a second-generation antipsychotic was prescribed in the hospital setting.

DESIGN

Cross-sectional study.

SETTING

The psychiatry unit of a Canadian tertiary care teaching hospital in Montreal, Canada.

PARTICIPANTS

402 patients with aforementioned disorders who initiated, restarted or switched to one of the following antipsychotics: clozapine, olanzapine, risperidone, paliperidone or quetiapine, between 2013 and 2016.

PRIMARY OUTCOME MEASURES

We assessed the proportion of cardiometabolic parameters monitored.

SECONDARY OUTCOME MEASURES

We identified predictors that influence the monitoring of cardiometabolic parameters and we assessed the proportion of adequate interventions following the screening of uncontrolled blood pressure and fasting glucose or glycated haemoglobin (HbA1c) results.

RESULTS

Only 37.3% of patients received monitoring for at least three cardiometabolic parameters. Blood pressure was assessed in 99.8% of patients; lipid profile in 24.4%; fasting glucose or HbA1c in 33.3% and weight or body mass index in 97.8% of patients while waist circumference was assessed in 4.5% of patients. For patients with abnormal blood pressure and glycaemic values, 42.3% and 41.2% subsequent interventions were done, respectively. The study highlighted the psychiatric diagnosis (substance induced disorder OR 0.06 95% CI 0.00 to 0.44), the presence of a court-ordered treatment (OR 0.79 95% CI 0.35 to 1.79) and the treating psychiatrist (up to OR 34.0 95% CI 16.2 to 140.7) as predictors of cardiometabolic monitoring.

CONCLUSIONS

This study reports suboptimal baseline cardiometabolic monitoring of patients taking an antipsychotic in a Canadian hospital. Optimising collaboration within a multidisciplinary team may increase cardiometabolic monitoring.

Clinical validation of the Aarhus Side effect Assessment Questionnaire(ASAQ)

BACKGROUND

Psychotropic medications are essential in the treatment of mental illness. Unfortunately, these medications are associated with side effects that may reduce adherence to treatment and quality of life. Therefore, systematic screening for side effects is fundamental to optimize treatment with psychotropic medications. Self-report of side effects is a practical alternative to time-consuming clinical assessments. We developed the Aarhus Side effect Assessment Questionnaire (ASAQ) in an attempt to strike the balance between extensive coverage of side effects and reasonable application time.

AIM

The aim of the study was to validate the ASAQ using the clinician-rated Udvalg for Kliniske Undersøgelser (UKU) Side Effect Scale as gold standard reference.

METHODS

A total of 122 inpatients and outpatients-mainly with psychotic (39%) and affective disorders (43%)-receiving treatment with psychotropic medication completed the ASAQ and the World Health Organization-Five Well-Being Index (WHO-5) and were subsequently rated on the UKU by trained raters.

RESULTS

Using the UKU as the gold standard reference, the ASAQ demonstrated sensitivity values >75% for 77% of its 30 items (ranging from 37% for cutaneous disturbances to 98% for increased sweating) and specificity values >75% for 47% of its 30 items (ranging from 28% for reduced sleep to 98% for micturition disturbances). While 17% of the participants considered discontinuing their medication, 24% had recently refrained from taking their medication as prescribed. A negative correlation was found between the ASAQ and the WHO-5 and total scores (Pearson's correlation coefficient = -0.44).

CONCLUSIONS

The self-reported ASAQ seems to be a sensitive tool for detecting side effects of psychotropic medications.

Metabolic Syndrome Identification in Patients Treated With Second-Generation Antipsychotic Medications

The purpose of the current project was to assess missed opportunities to identify metabolic syndrome in patients treated with second-generation antipsychotic medication in a community hospital's inpatient psychiatric unit between January 1 and December 31, 2020. Data on demographics, metabolic syndrome risk factors, body mass index, medications, related diagnoses, and primary care providers (PCPs) were collected via retrospective chart review of 194 patients. This project used a nonexperimental design and heterogenous nonrandom convenience sample. Descriptive statistics, chi-square tests, one-tailed t tests, and binary logistic regression were used. The overall rate of metabolic syndrome was 47.4% (n = 92). A positive PCP status was significant for treatment with antihypertensives, statins, and antihyperglycemics (p < 0.05). Findings indicate the need to increase system-wide assessment of metabolic syndrome and integrate care coordination with PCPs. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].

Monitoring of Adverse Drug Reaction-Related Parameters in Children, Youth, and Young Adults Prescribed Antipsychotic Drugs by General Practitioners

Objective: The aim of the study was to assess monitoring of adverse drug reaction (ADR)-related parameters in children, youth, and young adults treated with second-generation antipsychotic drugs (SGAs) prescribed by general practitioners (GPs). Methods: This retrospective follow-up study included children, youth, and young adults aged 0 - 24 years, who had an initial prescription of an SGA recorded in the Clinical Practice Research Datalink between 2000 and 2017, and who were prescribed an SGA more than once for a duration of at least 6 months. It included an assessment of which ADR-related physical parameters (weight, height, body-mass index, waist circumference, pulse, blood pressure, and heart examination) and laboratory parameters (glucose, HbA1c, lipids, and prolactin) were monitored in children, youth, and young adults at least once every 6-month period, stratified by sex, age categories, and calendar years. Results: In total, 7006 patients were included and the mean duration of follow-up was 1.6 years. Monitoring frequencies of all parameters were below 25%. Blood pressure and weight were monitored in 23.6% and 23.4%, respectively, of all children, youth, and young adults during the first half year; waist circumference was monitored in 0.2%. Females were monitored more often than males, some differences between age categories were observed, and monitoring frequencies increased after 2000, but did not exceed 35% in any year. Conclusion: Monitoring frequencies of ADR-related parameters in children, youth, and young adults treated with SGAs prescribed by a GP were low. Monitoring in primary care should be improved to enable a better evaluation of the benefit-risk balance during antipsychotic drug therapy.

The Health Improvement Profile for people with severe mental illness: Feasibility of a secondary analysis to make international comparisons

WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: Individuals with severe mental illness (SMI) have elevated risks for physical health problems and low screening rates. No previous studies have compared the physical health promotion needs of people with SMI using the same screening tool across different international settings. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: It appears feasible to use the HIP to profile and compare physical health-related risks in people with SMI across different international settings. The HIP tool identified significant differences in areas of risk across the four countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The HIP could be used to identify unique clusters of health promotion needs in different countries. Use of HIP health checks may support implementation of individualized interventions. ABSTRACT: Introduction To date, no studies have contrasted physical health profiles of people with severe mental illness (SMI) in different countries. Aim To evaluate feasibility of using the Health Improvement Profile (HIP) to compare and contrast physical health and health behaviours of people with SMI from four countries. Method An observational feasibility study using secondary analysis of pooled health state and lifestyle data. Physical health checks using modified versions of HIP were administered in four countries. Results Findings suggest feasibility of HIP screening to profile and compare physical health and health behaviours of people with SMI across international settings. High overall numbers of risk items (red flags) were identified in all but the Thailand sample. Despite some commonalities, there were important differences in health profiles across countries. Discussion This is the first study to demonstrate feasibility of the HIP to compare health risks in individuals with SMI across countries. Future multi-national HIP studies should recruit a fully powered stratified random sample of people with SMI that is representative of each setting. Implications for practice It appears feasible to utilize the HIP to identify specific areas of health risk in different countries, which may help to better focus nursing interventions and use of resources.

Hypertension and psychosis

Hypertension, a prevalent component of metabolic syndrome (MetS), is a well-known risk factor for cardiovascular diseases (CVD). Psychosis is a feature in the schizophrenia spectrum. Meta-analysis suggests that the prevalence of hypertension in schizophrenia and related disorders is 39%. This may be explained by a unidirectional association between hypertension and psychosis, in that psychosis can be a causative factor of hypertension via antipsychotic medication, inflammation and irregular autonomic nervous system activity through multiple mechanisms. Obesity is a side effect of antipsychotic medication and is a risk factor for hypertension. Obesity leads to raised blood pressure, atherosclerosis, increased triglyceride concentration and decreased high-density lipoprotein concentration. Inflammation accompanies hypertension and obesity. In recent years, the role of inflammation in the onset of psychosis has been increasingly recognised. It underlies the immune dysregulation observed in both schizophrenia and bipolar disorder. Interleukin-6, a marker and driver of inflammation, is related to obesity and plays a role in the pathogenesis of MetS and hypertension. The lack of preventive care of hypertension and other MetS risk factors for patients on antipsychotic medication is reflected in the high incidence of CVD in this population. It is important to detect and treat MetS and hypertension in patients with psychosis in order to reduce cardiovascular morbidity and mortality in this population.

Evaluation of metabolic monitoring practices for mental health consumers in the Southern District Health Board Region of New Zealand

WHAT IS KNOWN ON THIS SUBJECT?: The physical health of people with serious mental illness (SMI) is an issue of growing concern in New Zealand and internationally. Metabolic syndrome is prevalent among people with severe mental illness and increases the likelihood of developing cardiovascular disease and diabetes. No previous international research has investigated rates of metabolic monitoring in specialist mental health services and in primary care. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Rates of metabolic monitoring are low in this specialist mental health service and in primary care. Primary care nurses are positive in their views of their role in providing care for people with mental illness, and would value further education in this area. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Services need to consider ways in which nurses can be supported to improve rates of metabolic monitoring. Guidelines may have a role to play in improved monitoring but need service-level support in order to be effective. ABSTRACT: Introduction People with serious mental illness experience significant disparities in their physical health compared with the general population. One indicator of health impairment is metabolic syndrome, which increases the likelihood of developing cardiovascular disease and diabetes. No international studies have reported both primary care and mental health nurses' rates of metabolic monitoring among people with serious mental illness, and no New Zealand studies have investigated rates of metabolic monitoring. Aim To evaluate metabolic monitoring practices within one of New Zealand's 20 district health board regions. Method An audit of clinical records in primary care (n = 46) and secondary care (n = 47) settings and a survey of practice nurses were conducted. A survey was sent to 127 practice nurses with a response rate of 19% (n = 24). Data were analysed using descriptive statistics. Results Rates of metabolic monitoring were low in both services. Survey participants expressed positive views towards physical health monitoring and confidence in relating to mental health consumers. Rates of treatment of metabolic abnormalities were low, and communication between primary and secondary services was limited. Conclusion Despite existence of guidelines and protocols, metabolic monitoring rates in both primary and secondary health services are low. Incorporating metabolic monitoring systems into service delivery, supported by appropriate tools and resourcing, is essential to achieve better clinical outcomes for people experiencing mental illness.

Increased prevalence of metabolic syndrome in patients with bipolar disorder compared to a selected control group-a Northern Netherlands LifeLines population cohort study

OBJECTIVES

Metabolic syndrome (MetS) is highly prevalent among patients with bipolar disorder (BD). The aims of this cross-sectional study were to determine the prevalence of MetS in Dutch BD subjects and compare it with a control group, to examine the association of demographic and clinical characteristics with MetS in BD, and to determine the extent to which metabolic dysregulation is treated in those patients.

METHODS

493 Dutch adult patients (≥ 18 years) with BD receiving psychotropic drugs and 493 matched control subjects were compared using data from the biobank Lifelines. We determined MetS according to the National Cholesterol Education Program Adult Treatment Panel III-Adapted (NCEP ATP III-A) criteria. The difference in the prevalence of MetS and the associations with characteristics were analyzed with logistic regression.

RESULTS

BD subjects (30.6%) showed a significantly higher prevalence of MetS compared to the control group (14.2%) (p < .001, OR:2.67, 95% CI:1.94-3.66). Univariate analysis showed that smoking, body mass index (BMI) and antidepressant drug use were associated with MetS. Multivariate analysis showed that smoking (OR:2.01) was independently associated with MetS in BD. For hypertension, hyperglycemia and lipid disorder pharmacological treatment was provided to respectively 69.5%, 24% and 18.4% of the BD subjects in our sample.

LIMITATIONS

Duration of illness of BD subjects was unknown.

CONCLUSIONS

This study demonstrated a higher prevalence of MetS in Dutch BD subjects compared to persons without BD. In addition, a remarkable undertreatment of some of the components of MetS was found.

The Development of a Nutrition Screening Tool for Mental Health Settings Prone to Obesity and Cardiometabolic Complications: Study Protocol for the NutriMental Screener

People living with serious mental illness (SMI) experience physical health complications at disproportionate rates to people without an SMI. Unhealthy dietary intake and disordered eating behaviors are key driving factors. There is a lack of valid nutrition-risk screening tools targeted to mental health services, and typically used nutrition-risk screening tools are not suitable for mental health services. This paper details the rationale and study protocol for development and validation of the NutriMental screener, a tool for use in clinical practice to identify service users who are at risk for common nutrition issues experienced by this population group and trigger referral to a specialist clinician. The development process includes five phases. Phase I is the development of nutrition-related domains of interest from screening tools used in mental health services. Phase II involves a literature review and service-user interviews to identify additional domains. Phase III consists of international workshops with relevant clinicians and persons with SMI to gain a consensus on questions to be included in the draft tool. Phase IV involves conducting multinational feasibility and preliminary validation studies. Phase V consists of performing formal validation studies. The development of a nutrition-risk screening tool for mental health services is a necessary step to help rectify the physical-health disparities and life-expectancy gap for people with SMI.

Psychosocial interventions for people with a first episode psychosis: between tradition and innovation

PURPOSE OF REVIEW

Assessing recent evidence on psychosocial interventions for people with first episode psychosis (FEP).

RECENT FINDINGS

Family interventions (FI) reduce relapse rates, whilst cognitive behavioural therapy (CBT) shows a moderate effect in improving positive psychotic symptoms. Vocational interventions (VI) appear to be worthy of implementation within early intervention for psychosis (EIP) teams, but it is still unclear what is the most cost-effective strategy for their delivery. Promising interventions, which need more careful evaluation, focus on substance misuse, physical health comorbidities, improvement of social participation, peer support and the potential of new technologies.

SUMMARY

The first five years after the onset of psychotic symptoms are a 'critical period' in which psychosocial interventions can be particularly influential in determining prognosis. Traditional EIP interventions have different effectiveness profiles, i.e., FI reduce relapse rates, CBT has a moderate effectiveness on overall and positive symptoms and VI can improve educational and employment-related functioning. Newer interventions show promise on important targets for FEP treatment but require higher-quality evaluations. Decisions on which interventions to implement within EIP teams should be informed by high-quality evidence, but difficult choices will have to be made based on costs, professionals and technologies available, and local priorities.

Disparities in Screening and Treatment of Cardiovascular Diseases in Patients With Mental Disorders Across the World: Systematic Review and Meta-Analysis of 47 Observational Studies

OBJECTIVE

This study used meta-analysis to assess disparities in cardiovascular disease (CVD) screening and treatment in people with mental disorders, a group that has elevated CVD incidence and mortality.

METHODS

The authors searched PubMed and PsycInfo through July 31, 2020, and conducted a random-effect meta-analysis of observational studies comparing CVD screening and treatment in people with and without mental disorders. The primary outcome was odds ratios for CVD screening and treatment. Sensitivity analyses on screening and treatment separately and on specific procedures, subgroup analyses by country, and by controlling for confounding by indication, as well as meta-regressions, were also run, and publication bias and quality were assessed.

RESULTS

Forty-seven studies (N=24,400,452 patients, of whom 1,283,602 had mental disorders) from North America (k=26), Europe (k=16), Asia (k=4), and Australia (k=1) were meta-analyzed. Lower rates of screening or treatment in patients with mental disorders emerged for any CVD (k=47, odds ratio=0.773, 95% CI=0.742, 0.804), coronary artery disease (k=34, odds ratio=0.734, 95% CI=0.690, 0.781), cerebrovascular disease (k=8, odds ratio=0.810, 95% CI=0.779, 0.842), and other mixed CVDs (k=11, odds ratio=0.839, 95% CI=0.761, 0.924). Significant disparities emerged for any screening, any intervention, catheterization or revascularization in coronary artery disease, intravenous thrombolysis for stroke, and treatment with any and with specific medications for CVD across all mental disorders (except for CVD medications in mood disorders). Disparities were largest for schizophrenia, and they differed across countries. Median study quality was high (Newcastle-Ottawa Scale score, 8); higher-quality studies found larger disparities, and publication bias did not affect results.

CONCLUSIONS

People with mental disorders, and those with schizophrenia in particular, receive less screening and lower-quality treatment for CVD. It is of paramount importance to address underprescribing of CVD medications and underutilization of diagnostic and therapeutic procedures across all mental disorders.

Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD)

Background

Most patients with mental illness are managed in primary care, yet there is a lack of data exploring potential prescribing safety issues in this setting for this population.

Objectives

Examine the prevalence of, between-practice variation in, and patient and practice-level risk factors for, 18 mental health-related potentially hazardous prescribing indicators and four inadequate medication monitoring indicators in UK primary care.

Method

Cross-sectional analyses of routinely collected electronic health records from 361 practices contributing to Clinical Practice Research Datalink GOLD database. The proportion of patients ‘at risk’ (based on an existing diagnosis, medication, age and/or sex) triggering each indicator and composite indicator was calculated. To examine between-practice variation, intraclass correlation coefficient (ICC) and median OR (MOR) were estimated using two-level logistic regression models. The relationship between patient and practice characteristics and risk of triggering composites including 16 of the 18 prescribing indicators and four monitoring indicators were assessed using multilevel logistic regression.

Results

9.4% of patients ‘at risk’ (151 469 of 1 611 129) triggered at least one potentially hazardous prescribing indicator; between practices this ranged from 3.2% to 24.1% (ICC 0.03, MOR 1.22). For inadequate monitoring, 90.2% of patients ‘at risk’ (38 671 of 42 879) triggered at least one indicator; between practices this ranged from 33.3% to 100% (ICC 0.26, MOR 2.86). Patients aged 35–44, females and those receiving more than 10 repeat prescriptions were at greatest risk of triggering a prescribing indicator. Patients aged less than 25, females and those with one or no repeat prescription were at greatest risk of triggering a monitoring indicator.

Conclusion

Potentially hazardous prescribing and inadequate medication monitoring commonly affect patients with mental illness in primary care, with marked between-practice variation for some indicators. These findings support health providers to identify improvement targets and inform development of improvement efforts to reduce medication-related harm.

Mind-Body Connection: Cardiovascular Sequelae of Psychiatric Illness

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the world. Mental health disorders are associated with the onset and progression of cardiac disease. The adverse sequelae of this association include worsened quality of life, adverse cardiovascular outcomes, and heightened mortality. The increased prevalence of CVD is partly explained by increased rates of traditional cardiovascular risk factors including hypertension, hyperlipidemia, diabetes mellitus, obesity, and smoking, but mental illness is an independent risk factor for CVD and mortality. Given the association between mental health disorders and poor cardiovascular health, it is vital to have an early and accurate identification and treatment of these disorders. Our review article shares the current literature on the adverse cardiovascular events associated with psychiatric disorders. We present a review on depression, anxiety, bipolar disorder, schizophrenia, type A and D personality disorders, obsessive-compulsive disorder, and stress.

Systematic review investigating the relationship between autism spectrum disorder and metabolic dysfunction

The objective of this systematic review is to examine metabolic dysfunction, specifically metabolic syndrome and its components, as well as type 2 diabetes mellitus (T2DM) as it relates to individuals with a diagnosis of Autism Spectrum Disorder (ASD). We searched PubMed, Embase, Cochrane, PsychInfo, and Scopus from January 1, 1998 to October 12, 2018 for English, peer-reviewed, original articles containing adult and pediatric populations with any form of ASD and metabolic dysfunction, including T2DM, hyperglycemia, hypertension, dyslipidemia, or central obesity. Exclusion criteria included studies without ASD-specific results, basic science research, review papers, case studies, and medication clinical trials. Eight studies were included in this review, with a total of 70,503 participants with ASD and 2,281,891 in comparison groups. Within ASD populations, higher prevalence for metabolic syndrome components hyperglycemia, hypertension, and dyslipidemia were observed, as well as increased incidence and prevalence of T2DM. However, heterogeneity of study definitions and measurements should be noted. While there is evidence of increased prevalence of T2DM, hyperglycemia, hypertension, and dyslipidemia for those with ASD, the relationship is poorly understood. There is also lack of research investigating central obesity and risk of metabolic syndrome as a diagnosis. More research addressing these gaps is warranted to evaluate the risk of metabolic dysfunction in populations with ASD.

APOE E4 is associated with hyperlipidemia and obesity in elderly schizophrenic patients

Obesity is a critical issue in patients with schizophrenia, which is considered to be brought about by both environmental and genetic factors. Apolipoprotein E (APOE) gene polymorphisms might be involved in the pathogenesis of schizophrenia, however, the effect of APOE gene polymorphism on obesity has never been investigated in Chinese aging with schizophrenia. This cross-sectional study was to investigate the effect of obesity on cognitive and psychiatric symptoms in elderly participants with schizophrenia. At the same time, we also discussed the inner link between APOE E4 and obesity. 301 elderly participants with schizophrenia and 156 normal controls were included in the study. Their cognitive function was assessed using the Montreal Cognitive Assessment (MoCA), psychiatric symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS), and APOE gene polymorphism was determined by polymerase chain reaction (PCR). The prevalence of obesity in elderly schizophrenic patients and healthy controls accounted for 15.9% (48/301) and 10.3% (16/156), respectively, with no statistically significant difference. By using stepwise linear regression analysis, we found that elevated fasting blood glucose, hypertension, and hyperlipidemia were risk factors for obesity in elderly schizophrenic patients. Although there was no direct correlation between APOE E4 and obesity in patients with schizophrenia, it was significantly correlated with hyperlipemia(r = − 0.154, p = 0.008), suggesting that APOE E4 may induce obesity in elderly patients with schizophrenia through hyperlipemia, However, the above conclusions do not apply to the normal elderly. What’s more, we did not find a link between obesity and cognitive function or mental symptoms for both patients with schizophrenia and normal controls. APOE E4 is associated with hyperlipidemia in elderly schizophrenic patients, which may be a risk factor for obesity, however, the above conclusion does not apply to the normal elderly.

Metabolic screening in primary care for patients with schizophrenia or schizoaffective disorder and taking antipsychotic medication

INTRODUCTION Life expectancy in patients with schizophrenia is 15-20 years less than the general population. A dominant cause of morbidity and mortality in these patients is cardiovascular disease. Adverse consequences of modifiable cardiovascular risk factors can be reduced by regular monitoring of metabolic outcomes and intervention if required. AIM To evaluate the metabolic screening in primary care for patients with schizoaffective disorders managed in primary care. To show the usefulness of combining simple practice audits in evaluating such areas of clinical practice. METHODS An audit was undertaken in eight general practices in the Waikato and Bay of Plenty regions of New Zealand. Specifically, the monitoring of patients with schizophrenia or schizoaffective disorder whose antipsychotic medication was prescribed by primary care doctors was audited. Patient monitoring was compared to the guideline recommendation of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Best Practice Advisory Centre (BPAC). RESULTS In total, 117 patients were included in the audit and none were fully monitored, as recommended by the RANZCP guidelines. Although two-thirds of patients had been evaluated for glycosylated haemoglobin (HbA1c), lipids, blood pressure, complete blood count and weight, <10% of patients had had prolactin, waist circumference or electrocardiogram measurements recorded. The proportion of patients having a HbA1c measured was also significantly higher in younger patients and patients who were non-Māori or enrolled with an urban practice (all P<0.05). When using the simplified BPAC guidelines, half of all patients were correctly monitored. DISCUSSION These findings show there is room for improvement in the monitoring of patients receiving antipsychotic medication in primary care. This may indicate the need for clear guidance and general practitioner education around the monitoring requirements of these patients. Alternatively, a more simplified monitoring protocol may need to be developed. This audit has also shown that there is value in several practices completing the same audit and providing a larger cohort of patients for pooled data analysis.

The role of pharmacy in the management of cardiometabolic risk, metabolic syndrome and related diseases in severe mental illness: a mixed-methods systematic literature review

BACKGROUND

Individuals with severe mental illness, e.g. schizophrenia have up to a 20% shortened life expectancy compared to the general population. Cardiovascular disease, due to cardiometabolic risk and metabolic syndrome, accounts for most of this excess mortality. A scoping search revealed that there has not been a review of published studies on the role of pharmacy in relation to cardiometabolic risk, metabolic syndrome and related diseases (e.g. type 2 diabetes) in individuals with severe mental illness.

METHODS

A mixed-methods systematic review was performed. Eleven databases were searched using a comprehensive search strategy to identify English-language studies where pharmacy was involved in an intervention for cardiometabolic risk, metabolic syndrome or related diseases in severe mental illness in any study setting from any country of origin. First, a mapping review was conducted. Then, implementation strategies used to implement the study intervention were classified using the Cochrane Effective Practice and Organisation of Care Taxonomy. Impact of the study intervention on the process (e.g. rate of diagnosis of metabolic syndrome) and clinical (e.g. diabetic control) outcomes were analysed where possible (statistical tests of significance obtained for quantitative outcome parameters reported). Quality assessment was undertaken using a modified Mixed Methods Appraisal Tool.

RESULTS

A total of 33 studies were identified. Studies were heterogeneous for all characteristics. A total of 20 studies reported quantitative outcome data that allowed for detailed analysis of the impact of the study intervention. The relationship between the total number of implementation strategies used and impact on outcomes measured is unclear. Inclusion of face-to-face interaction in implementation of interventions appears to be important in having a statistically significantly positive impact on measured outcomes even when used on its own. Few studies included pharmacy staff in community or general practitioner practices (n = 2), clinical outcomes, follow up of individuals after implementation of interventions (n = 3). No studies included synthesis of qualitative data.

CONCLUSIONS

Our findings indicate that implementation strategies involving face-to-face interaction of pharmacists with other members of the multidisciplinary team can improve process outcomes when used as the sole strategy. Further work is needed on clinical outcomes (e.g. cardiovascular risk reduction), role of community pharmacy and qualitative studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018086411.

The Impact of Pharmacological and Non-Pharmacological Interventions to Improve Physical Health Outcomes in People With Schizophrenia: A Meta-Review of Meta-Analyses of Randomized Controlled Trials

(Reprinted with permission from World Psychiatry 2019;18:53-66).

Antipsychotic medication adherence and preventive diabetes screening in Medicaid enrollees with serious mental illness: an analysis of real-world administrative data

BACKGROUND

There is excess amenable mortality risk and evidence of healthcare quality deficits for persons with serious mental illness (SMI). We sought to identify sociodemographic and clinical characteristics associated with variations in two 2015 Healthcare Effectiveness Data and Information Set (HEDIS) measures, antipsychotic medication adherence and preventive diabetes screening, among Medicaid enrollees with serious mental illness (SMI).

METHODS

We retrospectively analyzed claims data from September 2014 to December 2015 from enrollees in a Medicaid specialty health plan in Florida. All plan enrollees had SMI; analyses included continuously enrolled adults with antipsychotic medication prescriptions and schizophrenia or bipolar disorder. Associations were identified using mixed effects logistic regression models.

RESULTS

Data for 5502 enrollees were analyzed. Substance use disorders, depression, and having both schizophrenia and bipolar disorder diagnoses were associated with both HEDIS measures but the direction of the associations differed; each was significantly associated with antipsychotic medication non-adherence (a marker of suboptimal care quality) but an increased likelihood of diabetes screening (a marker of quality care). Compared to whites, blacks and Hispanics had a significantly greater risk of medication non-adherence. Increasing age was significantly associated with increasing medication adherence, but the association between age and diabetes screening varied by sex. Other characteristics significantly associated with quality variations according to one or both measures were education (associated with antipsychotic medication adherence), urbanization (relative to urban locales, residing in suburban areas was associated with both adherence and diabetes screening), obesity (associated with both adherence and diabetes screening), language (non-English speakers had a greater likelihood of diabetes screening), and anxiety, asthma, and hypertension (each positively associated with diabetes screening).

CONCLUSIONS

The characteristics associated with variations in the quality of care provided to Medicaid enrollees with SMI as gauged by two HEDIS measures often differed, and at times associations were directionally opposite. The variations in the quality of healthcare received by persons with SMI that were identified in this study can guide quality improvement and delivery system reform efforts; however, given the sociodemographic and clinical characteristics' differing associations with different measures of care quality, multidimensional approaches are warranted.

Management of Cardiovascular Health in People with Severe Mental Disorders

PURPOSE OF REVIEW

To review evidence regarding the association between bipolar disorder and schizophrenia, henceforth referred to as severe mental disorders (SMD), and cardiovascular morbidity and mortality, its mechanisms, and the interventions to reduce this burden.

RECENT FINDINGS

Much of the loss in life expectancy in people with SMD remains driven by cardiovascular mortality. Antipsychotics and mood stabilizers are associated with negative cardio-metabolic outcomes, but large inter-individual differences are observed, and not treating SMD might be associated with even greater cardiovascular mortality. Classical modifiable cardiovascular risk factors remained inadequately screened and, once identified, too seldom treated in people with SMD. After a myocardial infarction, aggressive tertiary prevention may be as effective in people with SMD as in the general population but is less prescribed. Reduced healthcare quality and increased prevalence of cardiovascular risk factors may not fully explain the excess cardiovascular mortality associated with SMDs, which themselves should be considered risk factors in risk calculators. Hazardous health behaviors, the cardio-metabolic adverse effects of medications, and a reduced access to quality healthcare remain priority targets for intervention.

Advocacy for better metabolic monitoring after antipsychotic initiation: based on data from a French health insurance database

Background: Nearly 3% of the population is treated by antipsychotic. The aim of this study was to assess the conformity of monitoring with guidelines to prevent Metabolic Syndrome. Research design and method: The analysis was conducted using SNIIRAM data (2013 to 2017) on a cohort of patients who received at least eight antipsychotic dispensings in the first year. Glucose and lipid testings were recorded according to refunds at initiation [between -3 and 0.5 months], 3 months [between 2 and 4 months], and 12 months [between 11 and 13 months] after, and assuming optimal testing during hospitalization (exclusive of psychiatric unit). Descriptive and comparative analysis, «chi-squared test or Student's t-test», were performed as well as multivariate analysis with logistic regression. Results: 18 760 patients were selected, 14 421 were still alive and monitored at the end of the follow up. In the recommended period, only 2.89% of patients had three complete testings and 50.6% one or two complete testings Non-optimal testing was more likely to occur in children and adults (vs elderly), in patients with less than 3 prescribers, and with universal medical coverage. Conclusion: Monitoring remains dramatically insufficient. New actions involving patients, practitioners, and authorities are warranted.

Pharmacological Augmentation in Unipolar Depression: A Guide to the Guidelines

BACKGROUND

Pharmacological augmentation is a recommended strategy for patients with treatment-resistant depression. A range of guidelines provide advice on treatment selection, prescription, monitoring and discontinuation, but variation in the content and quality of guidelines may limit the provision of objective, evidence-based care. This is of importance given the side effect burden and poorer long-term outcomes associated with polypharmacy and treatment-resistant depression. This review provides a definitive overview of pharmacological augmentation recommendations by assessing the quality of guidelines for depression and comparing the recommendations made.

METHODS

A systematic literature search identified current treatment guidelines for depression published in English. Guidelines were quality assessed using the Appraisal of Guidelines for Research and Evaluation II tool. Data relating to the prescription of pharmacological augmenters were extracted from those developed with sufficient rigor, and the included recommendations compared.

RESULTS

Total of 1696 records were identified, 19 guidelines were assessed for quality, and 10 were included. Guidelines differed in their quality, the stage at which augmentation was recommended, the agents included, and the evidence base cited. Lithium and atypical antipsychotics were recommended by all 10, though the specific advice was not consistent. Of the 15 augmenters identified, no others were universally recommended.

CONCLUSIONS

This review provides a comprehensive overview of current pharmacological augmentation recommendations for major depression and will support clinicians in selecting appropriate treatment guidance. Although some variation can be accounted for by date of guideline publication, and limited evidence from clinical trials, there is a clear need for greater consistency across guidelines to ensure patients receive consistent evidence-based care.

Physical health assessment and cardiometabolic monitoring practices across three adult mental health inpatient units - a retrospective cohort study

Australians with lived experience of mental illness die on average 10 or more years earlier than the general population. Cardiometabolic disorders, including cardiovascular disease and diabetes mellitus, are common causes of premature death in this cohort. Little is known about cardiometabolic monitoring practices in mental health inpatient units. The aim of this study was to examine the characteristics of cardiometabolic monitoring and physical health assessments of adult mental health consumers within the first 72 hours of admission to an inpatient unit. We implemented a retrospective descriptive exploratory design by medical record audit. Data were collected using a pre-validated audit tool, adapted with recent literature and policy, from a randomly selected sample of consumers admitted to three acute mental health adult inpatient units of a large Australian metropolitan health service in 2016. Of 228 consumers, the mean age was 37.5 (range 18-64) years and 51.3% were women. Cardiometabolic risks were common, yet most consumers received incomplete cardiometabolic monitoring. While few consumers (15%) were diagnosed with cardiometabolic comorbidities, 67.5% were prescribed psychotropic medications with high cardiometabolic risk. Compliance with recommended cardiometabolic monitoring varied considerably between risk factors: for example, blood pressure was measured in 56.1% of consumers, whereas waist circumference was never recorded. There were no statistically significant associations between cardiometabolic monitoring completion and sex or cardiometabolic risk. These findings demonstrate the need for increased education and awareness of cardiometabolic risk and identify a critical gap between physical health assessment practices and recommendations for this cohort.

Appraisal of physical health guidelines for severe mental illness

Objectives The aim of this study was to identify current physical health guidelines for severe mental illness (SMI) and appraise them using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument. Methods Relevant research databases and grey literature were systematically searched to identify physical health guidelines for people with SMI. The grey literature was explored by web searches and targeted searches of the English websites of relevant peak bodies and government health agencies from Organisation for Economic Co-operation and Development countries. Included guidelines were independently appraised by two authors (NF and JH) using the AGREE II Instrument. Results Of the 5352 records screened, 33 were assessed for eligibility. Fifteen practice guidelines met the inclusion criteria. The median domain scores as rated by the AGREE II Instrument ranged from 17% to 69%. The World Health Organization guideline, which demonstrated a broad range of clinical recommendations and sound methodological rigour, was rated the best. Conclusions Most guidelines scored poorly when rated by the AGREE II Instrument. However, these guidelines may still be useful in assisting evidence-based clinical practice. The methodological rigour of future guidelines can be improved by ensuring the AGREE II domains are addressed during the development phase. What is known about the topic? Compared with the general population, people with SMI experience greater chronic disease morbidity and mortality. There is limited evidence from randomised controlled trials to guide physical health care monitoring for people with SMI. Current guidelines and practice are largely based on expert consensus, clinical experience and good intentions. What does this paper add? Using the AGREE II Instrument, this paper appraises the current physical health guidelines for people with SMI. The attributes of the guidelines examined included the evidence base, clarity of presentation, applicability in the real world, the involvement of stakeholders and conflicts of interest of various parties involved in guideline development. What are the implications for practitioners? This review highlights the scarcity of high-quality and evidence-based guidelines for clinicians and researchers to address the physical health of people with SMI.

Effects of olanzapine treatment on lipid profiles in patients with schizophrenia: a systematic review and meta-analysis

Olanzapine-induced dyslipidemia significantly increases the risk of cardiovascular disease in patients with schizophrenia. However, the clinical features of olanzapine-induced dyslipidemia remain hitherto unclear because of inconsistencies in the literature. This meta-analysis thus investigated the effects of olanzapine treatment on lipid profiles among patients with schizophrenia. Studies of the effects of olanzapine on lipids were obtained through the PubMed, Web of science, The Cochrane Library and Embase databases (up to January 1, 2020). Twenty-one studies and 1790 schizophrenia patients who received olanzapine therapy were included in our analysis. An olanzapine-induced increase was observed in plasma triglyceride (TG), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C) levels in patients with schizophrenia (all P < 0.05). Moreover, the time points analyzed included the following: baseline, 4 weeks, 6 weeks, 8 weeks, 12 weeks, and ≥ 24 weeks (data of ≥ 24 weeks were integrated). The significant elevation of TG, TC, and LDL-C was observed in patients with schizophrenia already by 4 weeks of olanzapine therapy (all P < 0.05), with no obvious changes observed in high-density lipoprotein cholesterol (HDL-C) (P > 0.05). In conclusion, olanzapine-induced dyslipidemia, characterized by increased TG, TC, and LDL-C levels, was observed in patients with schizophrenia already by 4 weeks of olanzapine treatment.

Performance in Practice: Practice Assessment Tool for the Care of Patients With Schizophrenia

Schizophrenia is associated with significant health, social, occupational, and economic burdens, including increased mortality. Despite extensive and robust research on the treatment of individuals with schizophrenia, many individuals with the illness do not currently receive evidence-based pharmacological and nonpharmacological treatments. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition, aims to enhance knowledge and increase the appropriate use of interventions for schizophrenia, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with schizophrenia. This practice assessment activity can also be used in partial fulfillment of Continuing Medical Education and Maintenance of Certification, part IV, requirements, which can also satisfy requirements for the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System program.

Physical health among people with serious mental illness in the face of COVID-19: Concerns and mitigation strategies

COVID-19 can worsen the physical health of individuals with serious mental illness, a vulnerable group already facing physical health disparities. COVID-19 is further reducing access to physical health care due to shutdown of services deemed "non-urgent" and overcrowding of emergency services. Management of chronic diseases, highly prevalent in this group, is undermined due to exacerbation of psychiatric disorders, reduction in availability of social support, and worsening of negative social determinants of health. In this commentary, we discuss the challenges experienced by this group and offer mitigation strategies to reduce: (1) inequalities in access to physical health care; and (2) disruptions to the management of chronic physical conditions in the face of COVID-19. Recommendations include coordinated efforts by health authorities, primary and mental health care organizations, researchers, policymakers, and other stakeholders. These efforts should ensure equitable access to physical health care and implementation of innovative programs to protect the physical health of people with serious mental illness during and following the pandemic.

Examining healthcare professionals' beliefs and actions regarding the physical health of people with schizophrenia

BACKGROUND

People with schizophrenia have a higher premature mortality risk compared with the general population mainly due to cardiovascular disease (CVD). Despite this, people with schizophrenia are less likely to access physical health services or have their physical health investigated and monitored.

AIMS

To examine the beliefs and actions of mental health professionals regarding the physical health of people with schizophrenia.

METHOD

Two hundred and fifty-five healthcare professionals who support people with schizophrenia within Greater Manchester Mental Health NHS Foundation Trust (GMMH), United Kingdom and Pennine Care NHS Foundation Trust (PCFT), United Kingdom took part. Beliefs and actions were assessed using a self-administered questionnaire, which was constructed around two primary domains (1) CVD risk factors; and (2) physical health interventions. Descriptive statistics were reported and responses between different healthcare professional groups were compared.

RESULTS

The overwhelming majority of participants were aware of established CVD risk factors with 98% identifying family history of CVD, 98% for smoking and 96% for high blood pressure. Most participants believed nearly all healthcare professionals were responsible for monitoring the physical health of people with schizophrenia, regardless of job speciality. There were 67% of participants who reported delivering an intervention to improve sedentary behaviour for people with schizophrenia. However, awareness of government and NHS recommended lifestyle interventions were low.

CONCLUSIONS

This study found good knowledge regarding many established CVD risk factors but little clarity regarding who is responsible for monitoring the physical health of people with schizophrenia and how often brief lifestyle interventions are being implemented.

Evaluation of arterial stiffness in patients with schizophrenia

The aim of this study was to evaluate arterial stiffness in schizophrenia patients. 28 male patients were included. The intima-media thickness (IMT) of the vessels were taken using high-resolution ultrasonography system. The mean carotid IMT and the mean femoral IMT values of the study group were found to be statistically significantly higher than the values of the control group. As the duration of the disease increased, there was an increase in the carotid IMT, carotid elastic modulus and femoral IMT, whereas there was a decrease in carotid and femoral diastolic wall stress in patients. No statistically significant differences were observed between the groups' carotid and femoral compliance, distensibility and elastic modulus values. The mean systolic arterial blood pressure in the patient group was determined to be lower than that of the control group. The mean diastolic wall stress values in the carotid and femoral arteries were determined to be lower than those of the control group. There was no relationship between antipsychotic dose, blood pressure and arterial stiffness parameters. Schizophrenia patients are more prone to develop arterial stiffness by atherosclerosis either with the effect of the nature of the disease itself or antipsychotic treatment. But evaluation with more parameters (carotid and femoral compliance, distensibility and elastic modulus) did not indicate any difference from the control group in respect of arterial stiffness. Antipsychotic treatment may play a protective role in terms of arterial stiffness by causing a decrease in systolic arterial pressure and carotid and femoral diastolic wall stress.

Cardio-metabolic abnormalities among patients with severe mental illness at a Regional Referral Hospital in southwestern Uganda

Patients with severe mental illness (SMI) have a higher burden of premature cardio-metabolic abnormalities, including diabetes mellitus, hypertension, hyperlipidemia, and obesity resulting into a 3-fold increase in mortality, and up to 20% reduction in life expectancy compared to the general population. Although over 30% of Ugandans have some form of mental illness, there are no national or hospital-based screening guidelines for cardio-metabolic abnormalities among these patients a general trend in most low-income countries. The screening rates for cardio-metabolic abnormalities in most low-income countries are at only 0.6%. The objective of this study was to describe the cardio-metabolic abnormalities among patients with SMI at Mbarara Regional Referral Hospital. Through a cross-sectional study, we recruited 304 patients with SMI and evaluated them for cardio-metabolic abnormalities using the National Cholesterol Education Programme Adult Treatment Panel III criteria for dyslipidemias, World Health Organisation criteria for diabetes mellitus, obesity, and the Joint national committee criteria for hypertension. We then determined the proportion of participants who met the criteria for each of the individual cardio-metabolic abnormalities. Of the 304 participants, 44.41% were male and 55.59% female with a mean age of 38.56±13.66 years. Almost half (46.38%) of the participants were either overweight or obese, 33.22% had abdominal obesity, 40.46% were hypertensive, 34.11% had low high-density lipoproteins, 37.42% had hypertriglyceridemia and 34.77% had hypercholesterolemia. Based on fasting blood sugar, 11.18% and 9.87% had pre-diabetes and diabetes respectively. There is a high level of cardio-metabolic abnormalities among patients with psychiatric disorders and thus metabolic screening for these abnormalities should be done routinely during psychiatric reviews. There is a need for national guidelines for screening of metabolic abnormalities among patients with SMI so that these abnormalities can be detected early enough at stages where they can be either reversed or delayed to progress to cardiovascular disease.