Long-term mortality of persons with severe mental illness and diabetes: a population-based cohort study in Denmark

Barriers to using physical exercise as an intervention within inpatient mental health settings: A systematic review

Service providers find it difficult to implement Physical Exercise (PE) strategies in routine care within inpatient mental health settings even though they perceive it to be an effective therapy, with a robust evidence base. Identifying barriers that exist can assist with the development of future interventions and support PE services being introduced into mental health inpatient settings. The aim of this systematic review was to synthesise the evidence on the barriers or perceived barriers that exist amongst service users and providers when incorporating PE as an intervention within inpatient mental health settings. Using a narrative synthesis approach, four main themes were identified: (i) Barriers relating to service users' mental and physical health, (ii) Factors relating to service providers, (iii) Environmental factors and (iv) Cultural factors. Both service users and providers need more knowledge on implementing PE in inpatient mental health settings. Tailored programmes for service users are warranted, with specialist roles for staff developed.

The Fusion Clinic: Integrating the care of people with severe mental illness and diabetes

AIM

People with coexisting severe mental illness (SMI) and type 2 diabetes have a shorter life expectancy and poorer diabetes outcomes than those without SMI. This is partly explained by the separate treatment of diabetes and SMI, which occurs in parallel silos in many healthcare systems. The Steno Diabetes Center Sjaelland and Region Zealand established the Fusion Clinic to offer combined psychiatric and diabetes care delivered by both diabetes and mental healthcare professionals. This study describes how the clinic was established and the initial diabetes outcomes.

METHODS

The Fusion Clinic was co-designed by people with diabetes and SMI and healthcare professionals to improve the care of adults with diabetes and SMI. The clinic approach utilised the F-ACT model. The 63 people referred to the Fusion Clinic between 01.02.2020 and 01.01.2022 who attended the clinic for more than 6 months were included in this study. Diabetes outcomes were recorded in the electronic medical records (Sundhedsplatformen EPIC).

RESULTS

There was a high prevalence of diabetes complications at baseline. Furthermore, 70% had one or more additional concomitant diseases, as well as SMI and diabetes. Assessment of diabetes complications and measurements of HbA1c and lipid profile improved after referral to the clinic. HbA1c declined during the first 6 months of attendance at the clinic.

CONCLUSIONS

This model of service delivery has the potential to improve the quality of care for people with SMI and type 2 diabetes.

Prescriptions of psychotropic and somatic medications among patients with severe mental disorders and healthy controls in a naturalistic study

PURPOSE

Psychotropic and somatic medications are both used in treating severe mental disorders (SMDs). Realistic estimates of the prevalence of use across medication categories are needed. We obtained this in a clinical cohort of patients with SMD and healthy controls (HCs).

MATERIALS AND METHODS

Prescriptions filled at Norwegian pharmacies the year before and after admittance to the Thematically Organized Psychosis (TOP) study were examined in 1406 patients with SMD (mean age 32.5 years, 48.2% women) and 920 HC (34.1 years, 46.2% women). Using data from the Norwegian Prescription Database (NorPD), the number of users in different anatomical therapeutic chemical (ATC) categories was compared using logistic regression. Population estimates were used as reference data.

RESULTS

Use of antipsychotics (N05A), antiepileptics (N03A), antidepressants (N06A), anxiolytics (N05B), hypnotics and sedatives (N05C), anticholinergics (N04A), psychostimulants, attention deficit hyperactivity disorder and nootropic agents (N06B) and drugs for addiction disorders (N07B) was significantly more prevalent in patients with SMD than HC. Use of diabetes treatment (A10), antithrombotic drugs (B01), beta blockers (C07), lipid modifiers (C10), and thyroid and endocrine therapeutics (H03) was also more prevalent in patients with SMD, but with two exceptions somatic medication use was comparable to the general population. Among HC, there was low prevalence of use for most medication categories.

CONCLUSION

Patients were using psychiatric medications, but also several types of somatic medications, more often than HC. Still, somatic medication use was mostly not higher than in the general population. The results indicate that HC had low use of most medication types.

Causal associations between severe mental illness and sepsis: a Mendelian randomization study

Objective

SMI (severe mental illness) has been identified as a risk factor for sepsis in observational studies; however, the causal association between them has yet to be firmly established. We conducted MR (mendelian randomization) to unveil the causal relationship between SMI and sepsis as well as sepsis mortality.

Methods

GWAS (Genome-wide association) data for major depression and schizophrenia were selected as exposure. GWAS data for sepsis and sepsis mortality were selected as outcome. Genetic variants significantly associated with the exposure (P value<1x10-6) were selected as instruments. We primarily employed the IVW (inverse-variance weighted) method for analysis. Furthermore, we employed Cochrane's Q test to assess heterogeneity and the MR-Egger intercept test to identify horizontal pleiotropy.

Results

We selected 108 SNPs (single nucleotide polymorphism) used to predict major depression and 260 SNPs that predicted schizophrenia. Genetically predicted major depression was suggestively linked to a higher sepsis risk (OR=1.13, 95%CI 1.02-1.26, P=0.023). In contrast, MR analysis did not find an association between schizophrenia and sepsis risk (OR=1.00, 95%CI 0.97-1.04, P=0.811). Furthermore, no significant causal evidence was found for genetically predicted SMI in sepsis mortality. Moreover, no heterogeneity and horizontal pleiotropy were detected.

Conclusion

Our research revealed a suggestive association between genetically predicted major depression and an elevated risk of sepsis in individuals of European ancestry. This finding can serve as a reminder for clinicians to consider the possibility of subsequent infection and sepsis in depressive patients, which may help reduce the incidence of sepsis in individuals with depression.

The development of type 2 diabetes management in people with severe mental illness in the Capital Region of Denmark from 2001 to 2015

BACKGROUND

Type 2 diabetes (T2D) treatment has changed markedly within the last decades. We aimed to explore whether people with severe mental illness (SMI) have followed the same changes in T2D treatment as those without SMI, as multiple studies suggest that people with SMI receive suboptimal care for somatic disorders.

METHODS

In this registry-based annual cohort study, we explored the T2D treatment from 2001 to 2015 provided in general practices of the Greater Copenhagen area. We stratified the T2D cohorts by their pre-existing SMI status. T2D was defined based on elevated glycated hemoglobin (≥48 mmol/mol) or glucose (≥11 mmol/L) using data from the Copenhagen Primary Care Laboratory Database. Individuals with schizophrenia spectrum disorders (ICD-10 F20-29) or affective disorders (bipolar disorder or unipolar depression, ICD-10 F30-33) were identified based on hospital-acquired diagnoses made within 5 years before January 1 each year for people with prevalent T2D or 5 years before meeting our T2D definition for incident patients. For comparison, we defined a non-SMI group, including people who did not have a hospital-acquired diagnosis of schizophrenia spectrum disorders, affective disorders, or personality disorders. For each calendar year, we assembled cohorts of people with T2D with or without SMI. We used Poisson regression to calculate the rates per 100 person-years of having at least one biochemical test (glycated hemoglobin, low-density lipoprotein cholesterol, estimated glomerular filtration rate, and urine albumin-creatinine ratio), having poor control of these biochemical results, taking glucose-lowering or cardiovascular medications, or experiencing a clinical outcome, including all-cause mortality and cardiovascular mortality. Three outcomes (cardiovascular events, cardiovascular mortality, and all-cause mortality) were additionally examined and adjusted for age and sex in a post hoc analysis.

RESULTS

From 2001 to 2015, 66,914 individuals were identified as having T2D. In 2015, 1.5% of the study population had schizophrenia spectrum disorder and 1.4% had an affective disorder. The number of people who used biochemical tests or had poor biochemical risk factor control was essentially unrelated to SMI status. One exception was that fewer LDL cholesterol tests were done on people with affective disorders and schizophrenia spectrum disorders at the beginning of the study period compared to people in the non-SMI group. This difference gradually diminished and was almost nonexistent by 2011. There was also a slightly slower rise in UACR test rates in the SMI groups compared to other people with T2D during the period. Throughout the study period, all groups changed their use of medications in similar ways: more metformin, less sulfonylurea, more lipid-lowering drugs, and more ACEi/ARBs. However, people with schizophrenia disorder consistently used fewer cardiovascular medications. Cardiovascular events were more common in the affective disorder group compared to the non-SMI group from 2009 to 2015 (rate ratio 2015 : 1.36 [95% CI 1.18-1.57]). After adjustment for age and sex, all-cause mortality was significantly higher among people with a schizophrenia spectrum disorder each year from 2003 to 2015 compared to the non-SMI group (rate ratio 2015 : 1.99 [95% CI 1.26-3.12]).

CONCLUSION

Persons with schizophrenia or affective disorders demonstrated the same treatment changes for T2D as those without SMI in general practice. The lower use of most types of cardiovascular medications among people with schizophrenia disorders indicates potential undertreatment of hypertension and dyslipidemia and remains throughout the study period. Cardiovascular events were most common among people with affective disorders, but this was not reflected in a higher proportion using cardiovascular preventive medications. This knowledge should be considered in the management of this vulnerable patient group.

Suicide death, suicidal ideation and suicide attempt in patients with diabetes: A systematic review and meta-analysis

AIMS

Diabetes has been indicated to be a risk factor for suicide. We aim to estimate the prevalence of suicide in patients with diabetes.

DESIGN

A meta-analysis using PRISMA methodology was adopted to examine the incidence of suicide in diabetic patients.

DATA SOURCES

From inception to October 2022, three online databases (PubMed, China National Knowledge Infrastructure and Web of Science) were used to search studies.

REVIEW METHODS

We used random-effects model to analysis. And our primary outcome was the incidence of suicide death per 100 person-years, and other outcomes were prevalence of suicidal ideation and suicide attempt. To explore the sources of heterogeneity in our study, we performed subgroup and meta-regression analyses.

RESULTS

The suicide death rate in diabetic patients was 0.027 per 100 person-years, with a higher rate for Type 1 Diabetes Mellitus compared to Type 2 Diabetes Mellitus. The prevalence of suicidal ideation in diabetes patients was 0.175, with a higher prevalence in Type 1 Diabetes Mellitus compared to Type 2 Diabetes Mellitus. The prevalence of suicide attempts in diabetes patients was 0.033, indicating a higher rate for Type 2 Diabetes Mellitus compared to Type 1 Diabetes Mellitus.

CONCLUSIONS

The results indicate a high rate of suicide among people with diabetes, and this study identifies populations and regions at high risk for suicide. Our review emphasizes interventions in mental health and the improvement of suicide prevention programmes.

IMPACT

The study investigated suicide death, suicidal ideation and suicide attempt in diabetic individuals. Suicide rates are elevated among diabetic patients, and various patient groups face distinct suicide risks. It is important to prioritize the mental well-being of diabetic individuals and enhance interventions, including personalized approaches, to inform public health efforts aimed at preventing and addressing suicide among diabetic patients.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement.

Physical Activity in Adults with Schizophrenia and Bipolar Disorder: A Large Cross-Sectional Survey Exploring Patterns, Preferences, Barriers, and Motivating Factors

Adults with severe mental ill health may have specific attitudes toward physical activity. To inform intervention development, we conducted a survey to assess the physical activity patterns, preferences, barriers, and motivations of adults with severe mental ill health living in the community. Data were summarised using descriptive statistics, and logistic regressions were used to explore relationships between physical activity status and participant characteristics. Five-hundred and twenty-nine participants (58% male, mean age 49.3 years) completed the survey. Large numbers were insufficiently active and excessively sedentary. Self-reported levels of physical activity below that recommended in national guidelines were associated with professional inactivity, consumption of fewer than five portions of fruit and vegetables per day, older age, and poor mental health. Participants indicated a preference for low-intensity activities and physical activity that they can do on their own, at their own time and pace, and close to home. The most commonly endorsed source of support was social support from family and friends. Common motivations included improving mental health, physical fitness, and energy levels. However, poor mental and physical health and being too tired were also common barriers. These findings can inform the development of physical activity interventions for this group of people.

Prevalence of, and factors associated with, diabetes mellitus in people with severe mental illness attending a multidisciplinary, outpatient cardiometabolic health assessment service

INTRODUCTION

Evaluate the prevalence of, and factors associated with, diabetes in people with severe mental illness (SMI) attending the Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP) tertiary referral clinics.

RESEARCH DESIGN AND METHODS

Adult patients attending an initial ccCHiP clinic consultation (2014-2019) were studied. Diabetes was defined by an hemoglobin A1c of ≥6.5%, fasting blood glucose of ≥7.0 mmol/L, or a self-reported diagnosis of diabetes and prescription of antihyperglycemic medication.

RESULTS

Over 5 years, 1402 individuals attended a baseline consultation. Mean age of 43.9±12.8 years, 63.1% male and 63.5% had a diagnosis of schizophrenia. Prevalence of diabetes was 23.0% (n=322); an additional 19.5% fulfilled criteria for pre-diabetes. Of those with diabetes, 15.8% were newly diagnosed. Of those with pre-existing diabetes, 84.5% were receiving treatment with antihyperglycemic medication. Over 94% of individuals with diabetes had dyslipidemia; half were current smokers; and 46.4% reported sedentary behavior. On multivariate analysis, diabetes was associated with older age, Aboriginal, Indian or Middle Eastern maternal ethnicity, elevated waist-to-height ratio, family history of diabetes and use of antipsychotic medication.

CONCLUSION

Prevalence of diabetes mellitus in this multiethnic cohort with SMI is significantly higher than the Australian population. Targeted interventions via an assertive integrated approach are required to optimize cardiometabolic health in this population.

Current insights of community mental healthcare for people with severe mental illness: A scoping review

Background

For the last four decades, there has been a shift in mental healthcare toward more rehabilitation and following a more humanistic and comprehensive vision on recovery for persons with severe mental illness (SMI). Consequently, many community-based mental healthcare programs and services have been developed internationally. Currently, community mental healthcare is still under development, with a focus on further inclusion of persons with enduring mental health problems. In this review, we aim to provide a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision on the ingredients of community mental healthcare.

Methods

We conducted a scoping review by systematically searching four databases, supplemented with the results of Research Rabbit, a hand-search in reference lists and 10 volumes of two leading journals. We included studies on adults with SMI focusing on stimulating independent living, integrated care, recovery, and social inclusion published in English between January 2011 and December 2022 in peer-reviewed journals.

Results

The search resulted in 56 papers that met the inclusion criteria. Thematic analysis revealed ingredients in 12 areas: multidisciplinary teams; collaboration within and outside the organization; attention to several aspects of health; supporting full citizenship; attention to the recovery of daily life; collaboration with the social network; tailored support; well-trained staff; using digital technologies; housing and living environment; sustainable policies and funding; and reciprocity in relationships.

Conclusion

We found 12 areas of ingredients, including some innovative topics about reciprocity and sustainable policies and funding. There is much attention to individual ingredients for good community-based mental healthcare, but very little is known about their integration and implementation in contemporary, fragmented mental healthcare services. For future studies, we recommend more empirical research on community mental healthcare, as well as further investigation(s) from the social service perspective, and solid research on general terminology about SMI and outpatient support.

Serious Mental Illness Exacerbation Post-Bereavement: A Population-Based Study of Partners and Adult Children

Purpose

The death of a close family member is commonly accompanied by intense grief, stress, and loss of social support. We hypothesized that recent bereavement would be associated with an increase in symptom exacerbations among adults with serious mental illness (SMI) whose partners or parents had died.

Patients and Methods

Adults whose partners and parents had died in Denmark between January 1, 2010, and June 30, 2016, were identified using linked population-based registries. History of SMI was defined as having a diagnosis of schizophrenia and schizoaffective disorders, major depression, and bipolar disorder in the five years preceding their family member's death in the Danish Psychiatric Central Research Register using International Classification of Diseases-10 codes. The odds of SMI exacerbation (ie, attempt or completion of suicide or psychiatric hospitalization) among partners and children in the first two years after death in 3-month intervals were estimated with generalized estimating equations.

Results

12.8% of partners and 15.0% of adult children with a history of SMI experienced any SMI exacerbation two years after bereavement. Among bereaved partners, older age (80+ years) was associated with a lower risk of experiencing an SMI exacerbation compared with partners aged 18-49 years (ORadj=0.29, [0.18-0.45]). Partners with a history of SMI had significantly increased odds of SMI exacerbations three months after their partners' death compared to prior to their partners' death (ORadj = 1.43, [1.13-1.81]). There was no evidence that adult children with SMI experience increased SMI exacerbations after the death of their parents compared to prior to death.

Conclusion

Adults with a history of SMI whose partners had died are at increased risk for an SMI exacerbation post bereavement. Additional bereavement resources and support should be provided to those with a history of SMI, especially in the period immediately after death.

Severe Mental Illness and the Risk of Diabetes Complications: A Nationwide, Register-based Cohort Study

CONTEXT

Individuals with severe mental illness (SMI) are at increased risk of developing type 2 diabetes.

OBJECTIVE

This work explores whether individuals with diabetes and SMI are also at increased risk of diabetes complications and the potential age-specific differences in development of these.

METHODS

Using nationwide registry data, we followed the entire Danish population with type 2 diabetes from January 1, 1996 to December 31, 2018. Exposure was SMI (schizophrenia, bipolar, or depression disorders). Outcome was diabetes complications (nephropathy, retinopathy, lower limp amputations, and cardiovascular disease). We applied Poisson regression models to estimate overall incidence rate ratios (IRRs) and age-specific incidence rates (IRs) and IRRs of the first event of each complication in individuals with SMI compared to individuals without SMI. The models were adjusted for sex, age, diabetes duration, calendar year, education, and migration status.

RESULTS

We followed 371 625 individuals with type 2 diabetes, of whom 30 102 had coexisting diagnosed SMI. Individuals with SMI had a higher IR of nephropathy (IRR: 1.15; 95% CI, 1.12-1.18), amputations (IRR: 1.15; 95% CI, 1.04-1.28), and cardiovascular disease (men: IRR: 1.10; 95% CI, 1.05-1.15, women: IRR: 1.18; 95% CI, 1.13-1.22) but a lower IR of retinopathy (IRR: 0.75; 95% CI, 0.70-0.81) when compared to individuals without SMI, after adjustment for confounders. For all complications except amputations, the difference in IR was highest in the younger age groups.

CONCLUSION

Individuals with type 2 diabetes and SMI had a higher risk and an earlier onset of several diabetes complications diagnoses, emphasizing focusing on improving diabetes management in younger age groups with SMI.

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.

Improving Practices of Mental Health Professionals in Recommending More Physical Activity and Less Sedentary Behaviour to Their Clients: An Intervention Trial

We investigated the effects of increasing physical activity (PA) and reducing sedentary behaviour (SB) of mental health professionals on their attitudes towards and practices in recommending more PA and less SB to their clients. A 4-week pre-post intervention trial was conducted involving 17 mental health professionals. The participants who increased their own physical activity during the intervention increased the frequency of recommending more PA (p = 0.009) and less SB (p = 0.005) to their clients. A relatively simple, low-cost intervention, consisting of group behaviour change counselling, goal setting and positive feedback, may improve the practices of mental health professionals.Supplemental data for this article is available online at https://doi.org/10.1080/01612840.2021.1972189 .

Need for improved diabetes support among people with psychiatric disorders and diabetes treated in psychiatric outpatient clinics: results from a Danish cross-sectional study

INTRODUCTION

People with psychiatric disorders have increased risk of premature death partly due to diabetes. This study aims to explore the quality of diabetes care, diabetes management, diabetes support and well-being of people with psychiatric disorders and diabetes.

RESEARCH DESIGN AND METHODS

A total of 107 participants aged ≥18 years with diabetes and psychiatric disorders treated at psychiatric outpatient clinics in Denmark were recruited from August 2018 to June 2019. This descriptive cross-sectional study includes data from medical records on quality of diabetes care (eg, level and annual examination of hemoglobin A1c (HbA_1c)) and questionnaires on diabetes management (measured on items from the Summary of Diabetes Self-Care Activities Scale and diabetes distress based on Problem Areas in Diabetes Scale (PAID-5)), diabetes support (no, some or high support from eight potential support persons and experience of care actions measured on items from Patient Assessment of Chronic Illness Care) and well-being (WHO 5-Item Scale and self-rated general health).

RESULTS

The mean age was 52 years, 56% were men, the mean body mass index was 31.9 kg/m², the median HbA_1c was 53 mmol/mol (7.0%) and the mean blood pressure was 131/83 mm Hg. The proportion with annual measurements of HbA_1c was 93%, blood pressure 80%, cholesterol 93%, foot examination 77% and eye examination 75%. Fifty-one per cent had high diabetes distress (PAID-5 score ≥8). Diabetologists and general practitioners (39% and 37%) were the health professionals most frequently reported to provide high diabetes support.

CONCLUSIONS

This study highlights a need for improved diabetes support in people with psychiatric disorders and diabetes. Although a high proportion received appropriate diabetes care, we found high levels of diabetes distress, moderate levels of optimal self-management behaviors, low well-being and low diabetes support from psychiatric health professionals, while one-third of the population found it relevant to receive diabetes support from psychiatric health professionals.

The prevalence and clinical characteristics of diabetes mellitus in Chinese inpatients with chronic schizophrenia: a multicenter cross-sectional study

Background

Diabetes mellitus (DM) is common among patients with schizophrenia. However, information on patients comorbid DM and schizophrenia is limited in China. The present study investigated the prevalence of DM and its clinical characteristics in Chinese inpatients with chronic schizophrenia.

Methods

A cross-sectional study was performed in Chinese inpatients with chronic schizophrenia. Diagnosis of Diabetes was established using World Health Organization diagnostic criteria for diabetes mellitus (persistent fasting glucose levels ≥ 126 mg/dl or 2-h plasma glucose ≥ 200 mg/dL after a 75-g Oral Glucose Tolerance Test). Patients were also measured height, weight, waist circumference, hip circumference, triglyceride level, and cholesterol level. Patients’ psychiatric symptoms were measured by the Positive and Negative Syndrome Scale (PANSS). Binary logistic regression analysis was performed to examine the associated demographic and clinical variables in chronic schizophrenia.

Results

A total of 988 inpatients (64.6% male, average age of 47.19 ± 12.55) was recruited. The prevalence of DM in Chinese patients with chronic schizophrenia was 13.8% (95% CI [11.6–15.9]%). Logistic regression analysis showed that overweight (OR = 1.90, 95% CI [1.20–3.03], p = 0.006), obesity (OR = 1.85, 95% CI [1.07–3.21], p = 0.028), comorbid hypertension (OR = 2.14, 95% CI [1.34–3.42], p = 0.002), and course of schizophrenia (OR = 1.03, 95% CI [1.01–1.06], p = 0.040) were significantly associated with the DM risk in patients with schizophrenia.

Conclusion

The findings indicated that diabetes mellitus was non-negligible in patients with chronic schizophrenia. Patients with schizophrenia should be regularly monitored for DM. Overweight/obesity, long duration of schizophrenia, and comorbid hypertension possibly were risk factors for diabetes.

Risk of mortality and complications in patients with schizophrenia and diabetes mellitus: population-based cohort study

BACKGROUND

Schizophrenia patients have markedly elevated prevalence of diabetes compared with the general population. However, risk of mortality and diabetes-related complications among schizophrenia patients with co-occurring diabetes is understudied.

AIMS

We investigated whether schizophrenia increased the risk of overall mortality, complications and post-complication mortality in people with diabetes.

METHOD

This population-based, propensity-score matched (1:10) cohort study identified 6991 patients with incident diabetes and pre-existing schizophrenia and 68 682 patients with incident diabetes only between 2001 and 2016 in Hong Kong using a medical record database of public healthcare services. Association between schizophrenia and all-cause mortality was examined with a Cox proportional hazards model. Effect of schizophrenia on first-year complication occurrence following diabetes diagnosis and post-complication mortality rates were evaluated.

RESULTS

Schizophrenia was associated with increased all-cause mortality (adjusted hazards ratio [aHR] 1.11, 95% CI 1.05-1.18), particularly among men and older age groups. Schizophrenia patients with diabetes had higher metabolic complication rate (aHR 1.99, 95% CI 1.63-2.42), lower microvascular complication rate (aHR 0.75, 95% CI 0.65-0.86) and comparable macrovascular complication rate (aHR 0.93, 95% CI 0.85-1.03), relative to patients with diabetes only. Among patients with diabetes complications, schizophrenia was associated with elevated all-cause mortality after macrovascular (aHR 1.19, 95% CI 1.04-1.37) and microvascular (aHR 1.33, 95% CI 1.08-1.64) complications. Gender-stratified analyses revealed that a significant effect of schizophrenia on heightened post-complication mortality was observed in men only.

CONCLUSIONS

Schizophrenia patients with co-occurring diabetes are at increased risk of excess mortality, including post-complication mortality. Further research identifying effective interventions is warranted to optimise diabetes-related outcomes in this vulnerable population.

High Prevalence of Diabetes Mellitus and Mental Illness Among Victims of Sudden Death

OBJECTIVES

Diabetes mellitus (DM) increases the risk of cardiovascular disease and is associated with sudden death. Mental illness among individuals with DM may confound medical care. This study assessed the association of mental illness with DM and poorly controlled DM in sudden death victims.

METHODS

We screened out-of-hospital deaths ages 18 to 64 years in Wake County, North Carolina from 2013 to 2015 to adjudicate sudden deaths. We abstracted demographics and clinical characteristics from health records. Mental illness included anxiety, schizophrenia, bipolar disorder, or depression. Poorly controlled DM was defined as a hemoglobin A1c >8 or taking ≥3 medications for glycemic control. Logistic regression assessed the association between DM and mental illness.

RESULTS

Among victims with available records, 109 (29.4%) had DM. Of those, 62 (56.9%) had mental illness. Mental illness was present in 53.42% and 63.89% of victims with mild and poorly controlled DM, respectively. Mental illness was associated with DM (adjusted odds ratio 2.46, 95% confidence interval 1.57-3.91). Victims with poorly controlled DM were more likely to have mental illness (adjusted odds ratio 2.66, 95% confidence interval 1.14-6.18).

CONCLUSIONS

DM is a common comorbid condition in sudden death victims. Among victims, mental illness is associated with the control of DM. Early management of comorbid mental illnesses may improve the care of patients with DM and reduce the incidence of sudden death.

Risk of diabetic complications and subsequent mortality among individuals with schizophrenia and diabetes - a population-based register study

BACKGROUND

Individuals with schizophrenia often develop diabetes, but little is known about their risk of diabetic complications. We aimed to study incidence of registered diabetic complications and subsequent mortality in individuals with schizophrenia and diabetes compared to individuals with diabetes only.

METHODS

We conducted a cohort study using nationwide registers and followed all individuals in the entire Danish population diagnosed with diabetes from 1997 to 2017. Incidence rate ratios (IRR) of diabetic complications, all-cause and cause-specific mortality rate ratios (MRR) were estimated by Cox regression comparing individuals diagnosed with schizophrenia and diabetes to individuals diagnosed only with diabetes.

RESULTS

In a cohort of 239,118 individuals with diagnosed diabetes, the incidence of any diabetic complication was similar in females with schizophrenia and diabetes compared to females with diabetes only; IRR = 0.93 (95%CI: 0.84-1.02), and significantly lower in males; IRR = 0.85 (95%CI: 0.78-0.92). The all-cause mortality for individuals with a diagnosis of a diabetic complication was higher in individuals with schizophrenia and diabetes than in those with diabetes only; MRR = 1.92 (95%CI: 1.65-2.23) for females and MRR = 1.69 (95%CI: 1.49-1.92) for males. Among those without diabetic complications, schizophrenia was also associated with a higher mortality.

CONCLUSIONS

Individuals with schizophrenia and diabetes had similar or lower rates of diabetic complications, compared to those with diabetes only. Among those with diabetic complications, schizophrenia was associated with higher mortality. Similar, among those without diabetic complications, schizophrenia was also associated with higher mortality. Hence, diabetic complications do not seem to explain the excess mortality seen in individuals with schizophrenia.

The Relative Risk of Developing Type 2 Diabetes Mellitus in Young Adults with Schizophrenia Treated with Different Atypical Antipsychotic

Background and aim: While the link between antipsychotic treatment and metabolic adverse events, including type 2 diabetes mellitus (T2DM) are clear in adults with schizophrenia, in young this association is not so well studied although the use of secondgeneration antipsychotics (SGA) is more and more frequent.

Material and methods: The local diabetes register was compared with the list of all registered young adults (18-35 years) with schizophrenia 2 years retrospective and 2 years prospective. Cumulative incidence, rate of incidence and relative risk was calculated knowing the number of persons in this age group within this region.

Results: Cumulative incidence for exposed group was 0.7% with a rate of incidence of 6.27 (95%CI: 4.1-10.5) per 1,000 patientyears, when in normal population was 0.2%, respectively 2.01 (95%CI: 0.72-3.79). This means a relative risk of 3.4736 (95%CI: 1.79-6.72), p=0.0002 and NNH=202 (95%CI: 134-404). Multivariate analysis showed that gender male (OR=1.83; 95%CI: 0.9-2.7; p=0.002) and olanzapine prescription (OR=4.76; 95%CI: 1.7-7.7; p=0.0001) were independent risk factors for T2DM.

Conclusions: The metabolic risk should be taken in account every time introducing or changing a SGA in young schizophrenic patient, balancing the benefits and negative metabolic effects (especially with olanzapine). Healthy nutrition and physical activities are necessary components of these patients lifestyle to avoid early onset of T2DM.

Neighborhood Environment and Type 2 Diabetes Comorbidity in Serious Mental Illness

Aim: The aim of this study was to examine the association between neighborhood characteristics and type 2 diabetes (T2D) comorbidity in serious mental illness (SMI). We investigated associations of neighborhood-level crime, accessibility to health care services, availability of green spaces, neighborhood obesity, and fast food availability with SMI-T2D comorbidity. Method: A series of multilevel logistic regression models accounting for neighborhood-level clustering were used to examine the associations between 5 neighborhood variables and SMI-T2D comorbidity, sequentially adjusting for individual-level variables and neighborhood-level socioeconomic disadvantage. Results: Individuals with SMI residing in areas with higher crime rates per 1000 population had 2.5 times increased odds of reporting T2D comorbidity compared to the individuals with SMI residing in lower crime rate areas after controlling for individual and areal level factors (95% CI 0.91-6.74). There was no evidence of association between SMI-T2D comorbidity and other neighborhood variables investigated. Conclusion: Public health strategies to reduce SMI-T2D comorbidity might benefit by targeting on individuals with SMI living in high-crime neighborhoods. Future research incorporating longitudinal designs and/or mediation analysis are warranted to fully elucidate the mechanisms of association between neighborhoods and SMI-T2D comorbidity.

Exploring the geography of serious mental illness and type 2 diabetes comorbidity in Illawarra-Shoalhaven, Australia (2010 -2017)

Objectives

The primary aim of this study was to describe the geography of serious mental illness (SMI)–type 2 diabetes comorbidity (T2D) in the Illawarra-Shoalhaven region of NSW, Australia. The Secondary objective was to determine the geographic concordance if any, between the comorbidity and the single diagnosis of SMI and diabetes.

Methods

Spatial analytical techniques were applied to clinical data to explore the above objectives. The geographic variation in comorbidity was determined by Moran’s I at the global level and the local clusters of significance were determined by Local Moran’s I and spatial scan statistic. Choropleth hotspot maps and spatial scan statistics were generated to assess the geographic convergence of SMI, diabetes and their comorbidity. Additionally, we used bivariate LISA (Local Indicators of Spatial Association) and multivariate spatial scan to identify coincident areas with higher rates of both SMI and T2D.

Results

The study identified significant geographic variation in the distribution of SMI–T2D comorbidity in Illawarra Shoalhaven. Consistently higher burden of comorbidity was observed in some urban suburbs surrounding the major metropolitan city. Comparison of comorbidity hotspots with the hotspots of single diagnosis SMI and T2D further revealed a geographic concordance of high-risk areas again in the urban areas outside the major metropolitan city.

Conclusion

The identified comorbidity hotspots in our study may serve as a basis for future prioritisation and targeted interventions. Further investigation is required to determine whether contextual environmental factors, such as neighbourhood socioeconomic disadvantage, may be explanatory.

Implications for public health

Ours is the first study to explore the geographic variations in the distribution of SMI and T2D comorbidity. Findings highlight the importance of considering the role of neighbourhood environments in influencing the T2D risk in people with SMI.

Examining the Association between Neighbourhood Socioeconomic Disadvantage and Type 2 Diabetes Comorbidity in Serious Mental Illness

This study examined the association between neighbourhood socioeconomic disadvantage and serious mental illness (SMI)-type 2 diabetes (T2D) comorbidity in an Australian population using routinely collected clinical data. We hypothesised that neighbourhood socioeconomic disadvantage is positively associated with T2D comorbidity in SMI. The analysis considered 3816 individuals with an SMI living in the Illawarra and Shoalhaven regions of NSW, Australia, between 2010 and 2017. Multilevel logistic regression models accounting for suburb (neighbourhood) level clustering were used to assess the association between neighbourhood disadvantage and SMI -T2D comorbidity. Models were adjusted for age, sex, and country of birth. Compared with the most advantaged neighbourhoods, residents in the most disadvantaged neighbourhoods had 3.2 times greater odds of having SMI-T2D comorbidity even after controlling for confounding factors (OR 3.20, 95% CI 1.42-7.20). The analysis also revealed significant geographic variation in the distribution of SMI -T2D comorbidity in our sample (Median Odds Ratio = 1.35) Neighbourhood socioeconomic disadvantage accounted for approximately 17.3% of this geographic variation. These findings indicate a potentially important role for geographically targeted initiatives designed to enhance prevention and management of SMI-T2D comorbidity in disadvantaged communities.

Factors associated with regular physical activity participation among people with severe mental ill health

PURPOSE

People with severe mental ill health (SMI) are less physically active and more sedentary than the general population. There is limited research investigating the correlates of physical activity (PA) in people with SMI impeding the development of successful interventions. This study aimed to assess the factors associated with regular participation of PA among a large sample of people with SMI.

METHODS

The data for this study were collected from the 'Closing the Gap: Lifestyle Health and Wellbeing' (HWB) cohort that collected data through self-administered questionnaire from participants with SMI. Self-reported participation in regular PA was the main outcome variable. Potential predictors of PA were grouped as demographic, biological, psychological and behavioural variables. Multivariable logistic regressions were conducted considering PA participation as the dependent variable adjusted for possible correlated predictors.

RESULTS

In total, 3287 people with SMI [mean (SD) age 47.7 (14.58) years, 59% male] were included; 38% reported undertaking regular PA and 61% wanted to undertake more physical activity. Multivariable logistic regressions showed that the following factors were associated with undertaking more regular PA: being male, aged 18-65 years, having a body mass index between 18.5 and 30 kg/m², having better self-perceived general health condition, not having a health problem that limits activity, giving higher importance to maintain a healthy lifestyle, and eating more fruit and vegetables.

CONCLUSIONS

Having a better self-perceived general health and placing importance on maintaining a healthy lifestyle were important predictors of regular PA. Lifestyle interventions targeting increased PA among people with SMI should be shaped by their health perception and informed by their needs.

Brain insulin action in schizophrenia: Something borrowed and something new

Insulin signaling in the central nervous system is at the intersection of brain and body interactions, and represents a fundamental link between metabolic and cognitive disorders. Abnormalities in brain insulin action could underlie the development of comorbid schizophrenia and type 2 diabetes. Among its functions, central nervous system insulin is involved in regulation of striatal dopamine levels, peripheral glucose homeostasis, and feeding regulation. In this review, we discuss the role and importance of central nervous system insulin in schizophrenia and diabetes pathogenesis from a historical and mechanistic perspective. We describe central nervous system insulin sites and pathways of action, with special emphasis on glucose metabolism, cognitive functioning, inflammation, and food preferences. Finally, we suggest possible mechanisms that may explain the actions of central nervous system insulin in relation to schizophrenia and diabetes, focusing on glutamate and dopamine signaling, intracellular signal transduction pathways, and brain energetics. Understanding the interplay between central nervous system insulin and schizophrenia is essential to disentangling this comorbid relationship and may provide novel treatment approaches for both neuropsychiatric and metabolic dysfunction. This article is part of the issue entitled 'Special Issue on Antipsychotics'.

Cause-specific life years lost among persons diagnosed with schizophrenia: Is it getting better or worse?

BACKGROUND

People with schizophrenia have an increased risk of premature mortality compared to the general population. We aimed to quantify which types of causes of death contributed to the excess mortality, and to examine whether there has been an increase in the excess mortality among persons with schizophrenia in the period 1995 to 2015.

METHOD

We used a cohort design including the entire Danish population. We calculated life years lost of the cohort members compared to a set reference-age at 95 years old. Using a decomposition model we examined differences of cause-specific death among those with schizophrenia and the general population, including calendar trends during the last two decades.

RESULTS

In the general population, as well as in persons with schizophrenia, we found improvements in life years lost during the last two decades. Men with schizophrenia lost 13.5 years more than the general population (women; 11.4 years). Compared to the general population, a large improvement in life years lost with respect to suicide and accidents was found in those with schizophrenia, but, this improvement was offset by an increasing number of life years lost in deaths from diseases and medical conditions.

CONCLUSION

Our findings highlight the urgent need for focused treatment of general medical conditions in those with schizophrenia. Without such an investment, it is probable that the life years lost among persons with schizophrenia (compared to the general population) will continue to worsen in future decades.

Promoting exercise behaviour in a secure mental health setting: Healthcare assistant perspectives

Individuals with severe mental illness engage in significantly less amounts of physical activity than the general population. A secure mental health setting can exacerbate barriers to exercise, and facilitate physical inactivity and sedentary behaviour. Healthcare assistants are intimately involved in the daily lives of patients and, therefore, should be considered integral to exercise promotion in secure mental health settings. Our aim was to explore healthcare assistants' perceptions of exercise and their attitudes to exercise promotion for adult patients in a secure mental health hospital. Qualitative semi-structured interviews were conducted with 11 healthcare assistants from a large UK-based secure mental health hospital. Topics included healthcare assistants' personal experiences of exercise within a secure facility, their perceptions of exercise as an effective treatment tool for mental health, and their perceived roles and responsibilities for exercise promotion. Thematic analysis was used to analyse the data. Three main themes were identified: (i) exercise is multi-beneficial to patients, (ii) perceived barriers to effective exercise promotion, and (iii) strategies for effectives exercise promotion. Healthcare assistants considered exercise to hold patient benefits. However, core organizational and individual barriers limited healthcare assistants' exercise promotion efforts. An informal approach to exercise promotion was deemed most effective to some, whereas others committed to more formal strategies including compulsory sessions. With education and organizational support, we propose healthcare assistants are well placed to identify individual needs for exercise promotion. Their consultation could lead to more efficacious, person-sensitive interventions.

Improving diabetes care among patients with severe mental illness: A systematic review of the effect of interventions

BACKGROUND AND AIM

Individuals with severe mental illness (SMI) who suffer from type 2 diabetes (T2DM) are likely to be sub-optimally treated for their physical condition. This study aimed to review the effect of interventions in this population.

METHODS

A systematic search in five databases was conducted in July 2017.

RESULTS

Seven studies on multi-faced interventions were included. These comprised nutrition and exercise counselling, behavioural modelling and increased disease awareness aiming to reduce HbA1c, fasting plasma glucose, body mass index and weight.

CONCLUSION

Non-pharmacologic interventions in individuals with SMI and T2DM could possibly improve measures of diabetes care, although with limited clinical impact.

Psychiatric aspects of diabetes mellitus

Diabetes is an increasingly common health problem, especially in the West, where there is an emerging epidemic of type 2 diabetes, closely related to the epidemic of obesity. Many people with diabetes struggle to optimise their diabetes control, often because they also have mental illnesses or psychological and social problems. Poor diabetes control has significant consequences for the individual, and if not addressed will result in complications that include blindness, kidney failure and even amputations. There are also consequences for health services resulting from increased admissions and emergency department presentations with diabetes-related difficulties. In the long-term, the costs associated with complications such as renal failure and amputation are high. Addressing the psychiatric and psychological barriers to good glucose control can help reduce the burden of diabetes and its complications on both the individual and the health service.

MANAGEMENT OF ENDOCRINE DISEASE: Suicide risk in patients with diabetes: a systematic review and meta-analysis

BACKGROUND

Previous studies investigating the risk of suicide in diabetes patients reported controversial findings. We did a systematic review and meta-analysis to comprehensively estimate the risk and incidence rate of suicide in diabetic patients.

METHODS

PubMed, EMBASE and PsycINFO were searched for eligible studies. Random-effects meta-analysis was used to calculate the relative risk (RR) and the incidence rate of suicide in diabetes patients. We also calculated the proportion of deaths attributable to suicide among diabetes patients.

RESULTS

54 studies were finally included, including 28 studies on the suicide risk associated with diabetes, 47 studies on the incidence rate of suicide and 45 studies on the proportion of deaths attributable to suicide. Meta-analysis showed that diabetes could significantly increase the risk of suicide (RR = 1.56; 95% CI: 1.29-1.89; P < 0.001). Subgroup analysis showed that the RR of suicide associated with type 1 diabetes was 2.25 (95% CI: 1.50-3.38; P < 0.001). The pooled incidence rate of suicide in patients with diabetes was 2.35 per 10 000 person-years (95% CI: 1.51-3.64). The pooled proportions of long-term deaths attributable to suicide in type 1 diabetes patients and type 2 diabetes patients were 7.7% (95% CI: 6.0-9.8) and 1.3% (95% CI: 0.6-2.6), respectively.

CONCLUSION

This meta-analysis suggests that diabetes can significantly increase the risk of suicide. Suicide has an obvious contribution to mortality in diabetic patients, especially among type 1 diabetes patients. Effective strategies to decrease suicide risk and improve mental health outcomes in diabetes patients are needed.

Association of the polygenic risk score for schizophrenia with mortality and suicidal behavior - A Danish population-based study

BACKGROUND

It is unknown whether an increased genetic liability to schizophrenia influences the risk of dying early. The aim of the study was to determine whether the genetic predisposition to schizophrenia is associated with the risk of dying early and experience a suicide attempt.

METHOD

Case control study, Denmark. The main measure was the mortality rate ratios (MRR) for deaths and odds ratios (OR) for multiple suicide attempts, associated with one standard deviations increase of the polygenic risk-score for schizophrenia (PRS).

RESULTS

We replicated the high mortality MRR=9.01 (95% CI: 3.56-22.80), and high risk of multiple suicide attempts OR=33.16 (95% CI: 20.97-52.43) associated with schizophrenia compared to the general population. However, there was no effect of the PRS on mortality MRR=1.00 (95% CI 0.71-1.40) in the case-control setup or in cases only, MRR=1.05 (95% CI 0.73-1.51). Similar, no association between the PRS and multiple suicide attempts was found in the adjusted models, but in contrast, family history of mental disorders was associated with both outcomes.

CONCLUSIONS

A genetic predisposition for schizophrenia, measured by PRS, has little influence on the excess mortality or the risk of suicide attempts. In contrast there is a strong significant effect of family history of mental disorders. Our findings could reflect that the common variants detected by recent PRS only explain a small proportion of risk of schizophrenia, and that future, more powerful PRS instruments may be able to predict excess mortality within this disorder.

Are people with schizophrenia adherent to diabetes medication? A comparative meta-analysis

Individuals living with schizophrenia are 2-3 times more likely to experience type 2 diabetes mellitus. Diabetes medication adherence is essential to reduce morbidity and mortality in this population. We conducted a meta-analysis of diabetes medication adherence among people with schizophrenia, and compared this to those without schizophrenia. A systematic search strategy was used to identify all articles reporting adherence to diabetes medications among patients with schizophrenia. In total, 10 unique studies reporting data from 33,910 people with schizophrenia were included. Random effects meta-analysis showed people with schizophrenia adhered to medication on 77.3% of days prescribed (n=32080, 95%CI=73.6-81%, I²=99.2%,), and adhered on 4.6% more days per year than those without schizophrenia (p<0.01, 95%CI=2.4-6.7%, I²=92.5%, schizophrenia n=19367, controls=170,853). Furthermore, 56% of individuals with schizophrenia (n=33680) were considered "adherent" (i.e. >80% adherence over 12-24 month) to diabetes medication, which was significantly more than those without schizophrenia (OR=1.34, 95%CI: 1.18-1.52, p<0.01). Factors which were positively associated with diabetes medication adherence were age, number of outpatient visits, along with multiple medication administration variables. Future prospective research should examine diabetes monitoring, medication prescription, and subsequent adherence in fully representative samples. Novel interventions for maximizing compliance to diabetes medication in this vulnerable population should also be explored.

Diabetes Knowledge Among Adults with Serious Mental Illness and Comorbid Diabetes Mellitus

This study examined the association between psychiatric symptoms and diabetes knowledge (DK) among 90 adults with serious mental illness (SMI) and type 2 diabetes. The relationship between DK and glucose control (i.e., A1C) was also examined. In a hierarchical linear regression, greater negative symptom severity and lower cognitive functioning both predicted lower DK, though cognitive functioning superseded negative symptom severity when analyzed simultaneously. A Pearson correlation showed no significant relationship between DK and A1C. Although symptom severity and cognitive functioning are both related to DK among this population, cognitive functioning maybe particularly important.

Comorbidity of schizophrenia and infection: a population-based cohort study

PURPOSE

In this paper, we investigate the hypothesis that there is an overlap between infection and schizophrenia. Infections have been identified as a risk factor for schizophrenia, but the possible overlap between schizophrenia and infections remains unidentified so far. Here, we describe the use of the comorbidity index, a method for objectively integrating associations into a single measure estimating overlap.

METHODS

Data were drawn from three population-based registers, the Civil Registration Register, the Danish Psychiatric Central Research Register, and the Danish National Hospital Register. We selected a cohort of 1,403,183 persons born in Denmark 1977-2002.

RESULTS

Our results indicate that persons who have had a hospital contact with an infection (IRR 1.53, CI 1.46-1.61) are more likely to develop schizophrenia than persons who have not had such a contact. Persons who have had a diagnosis with schizophrenia are more likely to have had a hospital contact with an infection (IRR 1.73, 95 % CI 1.57-1.91) than persons who have had no schizophrenia diagnosis. A comorbidity index of 1.40 (95 % CI 1.34-1.46) was found, indicating an overlap between schizophrenia and infection.

CONCLUSION

Our findings indicate that schizophrenia and infections overlap and that they share risk factors. The comorbidity index showed that the co-occurrence of schizophrenia and infection was 40 % higher than if the two disorders had occurred independently. Although the incidence of schizophrenia and infection was associated with each factor, the overlap could not be explained by urbanicity, parental history of psychiatric admission and infection.

Motivating factors and barriers towards exercise in severe mental illness: a systematic review and meta-analysis

Exercise can improve clinical outcomes in people with severe mental illness (SMI). However, this population typically engages in low levels of physical activity with poor adherence to exercise interventions. Understanding the motivating factors and barriers towards exercise for people with SMI would help to maximize exercise participation. A search of major electronic databases was conducted from inception until May 2016. Quantitative studies providing proportional data on the motivating factors and/or barriers towards exercise among patients with SMI were eligible. Random-effects meta-analyses were undertaken to calculate proportional data and 95% confidence intervals (CI) for motivating factors and barriers toward exercise. From 1468 studies, 12 independent studies of 6431 psychiatric patients were eligible for inclusion. Meta-analyses showed that 91% of people with SMI endorsed 'improving health' as a reason for exercise (N = 6, n = 790, 95% CI 80-94). Among specific aspects of health and well-being, the most common motivations were 'losing weight' (83% of patients), 'improving mood' (81%) and 'reducing stress' (78%). However, low mood and stress were also identified as the most prevalent barriers towards exercise (61% of patients), followed by 'lack of support' (50%). Many of the desirable outcomes of exercise for people with SMI, such as mood improvement, stress reduction and increased energy, are inversely related to the barriers of depression, stress and fatigue which frequently restrict their participation in exercise. Providing patients with professional support to identify and achieve their exercise goals may enable them to overcome psychological barriers, and maintain motivation towards regular physical activity.

Ten-Year Mortality after a Breast Cancer Diagnosis in Women with Severe Mental Illness: A Danish Population-Based Cohort Study

BACKGROUND

Breast cancer is the leading cause of cancer death in women worldwide. Nevertheless, it is unknown whether higher mortality after breast cancer contributes to the life-expectancy gap of 15 years in women with severe mental illness (SMI).

METHODS

We estimated all-cause mortality rate ratios (MRRs) of women with SMI, women with breast cancer and women with both disorders compared to women with neither disorder using data from nationwide registers in Denmark for 1980-2012.

RESULTS

The cohort included 2.7 million women, hereof 31,421 women with SMI (12,852 deaths), 104,342 with breast cancer (52,732 deaths), and 1,106 with SMI and breast cancer (656 deaths). Compared to women with neither disorder, the mortality was 118% higher for women with SMI (MRR: 2.18, 95% confidence interval (CI): 2.14-2.22), 144% higher for women with breast cancer (MRR: 2.44, 95% CI: 2.42-2.47) and 327% higher for women with SMI and breast cancer (MRR: 4.27, 95% CI: 3.98-4.57). Among women with both disorders, 15% of deaths could be attributed to interaction. In a sub-cohort of women with breast cancer, the ten-year all-cause-mortality was 59% higher after taking tumor stage into account (MRR: 1.59, 95% CI: 1.47-1.72) for women with versus without SMI.

CONCLUSIONS

The mortality among women with SMI and breast cancer was markedly increased. More information is needed to determine which factors might explain this excess mortality, such as differences between women with and without SMI in access to diagnostics, provision of care for breast cancer or physical comorbidity, health-seeking-behavior, and adherence to treatment.

Improvements in Somatic Complaints Among Individuals With Serious Mental Illness Receiving Treatment in a Psychiatric Hospital

OBJECTIVE

Individuals with serious mental illness (SMI) experience significant comorbid somatic complaints. Little is known about response to integrated inpatient care that addresses psychiatric and general medical needs among individuals with SMI.

METHODS

Latent growth curve analyses were used to model somatic symptom trajectories across adult inpatients with SMI (n = 989). The Patient Health Questionnaire-15 (PHQ-15) was administered at admission, every 14 days, and at discharge.

RESULTS

Patients evidenced substantial reduction in somatization from admission (mean [standard deviation] = 9.0 [5.2]) to discharge (mean [standard deviation] = 5.2 [4.4]), with large effects (d = 0.83, 95% confidence interval = 0.76-0.90). Results indicate nonlinear improvement in somatic symptoms for 8 weeks of treatment, with greatest symptom reduction occurring during the first weeks of treatment with continued, albeit slowed, improvement until discharge. Initial PHQ-15 scores were lower among men and those who reported regular exercise in the 30 days preceding this hospitalization. In addition, presence of an anxiety disorder or personality disorder at admission; history of trauma, a gastrointestinal disorder, or major medical illness (within the past 3 months); and significant sleep disturbance independently contribute to higher PHQ-15 scores at admission. A substance use disorder and sleep disturbance were associated with greater immediate symptom reduction.

CONCLUSIONS

Somatic complaints can be managed in the context of inpatient psychiatric care integrated with 24-hour nursing and internal medicine specialists. Addressing psychiatric impairments, improving sleep, and ensuring abstinence from drugs and alcohol are associated with significant improvement in somatic complaints.

Determinants of mortality in patients with type 2 diabetes: a review

We aimed to review and summarize the evidence from accomplished trials analyzing factors influencing mortality in patients with T2DM and to provide some recommendations for targets and treatment in the European region. The following databases were searched for relevant trials: PubMed and the Cochrane Library. Of 3.806 citations, 134 trials met our inclusion criteria.

RESULTS

The reduction in lifetime for 65 + -years-old patients having less than 10 years T2DM amounts to 1.8 years. Having T2DM for more than 10 years lifetime will be reduced by 2.7 years. However, the lifetime shortening factor of T2DM will even be stronger for 40 + -years-old patients at onset. Males will lose 11.6 years of life and 18.6 QUALYs. T2DM among females will reduce life by 14 QUALYs by 22 years. From a statistical point of view, the highest mortality rate will occur in an over 55-years-old European smoking and non-compliant diabetic woman with alcohol abuse living in a rural area with a low level of education and a low socio-economic status. Furthermore, other co-morbidities such as cardiovascular diseases, gout, and depression affect mortality. Additionally, mortality will increase with a BMI over 35 and also with a BMI under 20-25. This refers to the obesity paradox indicating a higher mortality rate among normal weight patients with T2DM compared to overweight patients with T2DM. HbA1c-levels between 6.5 % and 7 % are associated with the lowest impact on mortality.

The prevalence and predictors of type two diabetes mellitus in people with schizophrenia: a systematic review and comparative meta-analysis

OBJECTIVE

To conduct a meta-analysis investigating the prevalence of type two diabetes mellitus (T2DM) in people with schizophrenia compared to controls.

METHOD

Systematic review of electronic databases from inception till November 2014. Articles reporting the prevalence of T2DM in people with schizophrenia and healthy controls (without mental illness) were included. Two independent authors conducted searches and extracted data. A random effects relative risks (RR) meta-analysis was conducted.

RESULTS

Twenty-five studies including 145,718 individuals with schizophrenia (22.5-54.4 years) and 4,343,407 controls were included. The prevalence of T2DM in people with schizophrenia was 9.5% (95% CI = 7.0-12.8, n = 145,718) and 10.75% (95% CI 7.44-14.5%, n = 2698) in studies capturing T2DM according to recognized criteria. The pooled RR across all studies was 1.82 (95% CI = 1.56-2.13; = 4,489,125). Subgroup analyses found a RR of 2.53 (95% CI = 1.68-3.799, n = 17,727) in studies ascertaining T2DM according to recognized criteria and RR 1.65 (95% CI = 1.34-2.03, n = 4,243,389) in studies relying on T2DM determined through medical records.

CONCLUSION

People with schizophrenia are at least double the risk of developing T2DM according to recognized T2DM criteria. Proactive lifestyle and screening programmes should be given clinical priority.

Diabetes mellitus and severe mental illness: mechanisms and clinical implications

The prevalence of diabetes mellitus is twofold to threefold higher in people with severe mental illness (SMI) than in the general population, with diabetes mellitus affecting ∼12% of people receiving antipsychotics. The consequences of diabetes mellitus are more severe and frequent in people with SMI than in those without these conditions, with increased rates of microvascular and macrovascular complications, acute metabolic dysregulation and deaths related to diabetes mellitus. Multiple complex mechanisms underlie the association between diabetes mellitus and SMI; these mechanisms include genetic, environmental and disease-specific factors, and treatment-specific factors. Although antipsychotics are the mainstay of treatment in SMI, a causative link, albeit of uncertain magnitude, seems to exist between antipsychotics and diabetes mellitus. The principles of managing diabetes mellitus in people with SMI are similar to those for the general population and should follow currently established treatment algorithms. Lifestyle interventions are needed to reduce incident diabetes mellitus. In addition, improved uptake of opportunities to screen for this disease will reduce the high prevalence of undiagnosed diabetes mellitus. Currently, people with SMI receive poorer treatment for diabetes mellitus than the general population. Thus, health-care professionals in primary care, diabetes mellitus services and mental health teams have a responsibility to ensure that patients with SMI are not disadvantaged.