Natural cause mortality in persons with serious mental illness

Life expectancy and years of potential life lost in people with mental disorders: a systematic review and meta-analysis

Background

Mental disorders are associated with premature mortality. There is increasing research examining life expectancy and years-of-potential-life-lost (YPLL) to quantify the disease impact on survival in people with mental disorders. We aimed to systematically synthesize studies to estimate life expectancy and YPLL in people with any and specific mental disorders across a broad spectrum of diagnoses.

Methods

In this systematic review and meta-analysis, we searched Embase, MEDLINE, PsychINFO, WOS from inception to July 31, 2023, for published studies reporting life expectancy and/or YPLL for mental disorders. Criteria for study inclusion were: patients of all ages with any mental disorders; reported data on life expectancy and/or YPLL of a mental-disorder cohort relative to the general population or a comparison group without mental disorders; and cohort studies. We excluded non-cohort studies, publications containing non-peer-reviewed data or those restricted to population subgroups. Survival estimates, i.e., life expectancy and YPLL, were pooled (based on summary data extracted from the included studies) using random-effects models. Subgroup analyses and random-effects meta-regression analyses were performed to explore sources of heterogeneity. Risk-of-bias assessment was evaluated using the Newcastle-Ottawa Scale. This study is registered with PROSPERO (CRD42022321190).

Findings

Of 35,865 studies identified in our research, 109 studies from 24 countries or regions including 12,171,909 patients with mental disorders were eligible for analysis (54 for life expectancy and 109 for YPLL). Pooled life expectancy for mental disorders was 63.85 years (95% CI 62.63-65.06; I2 = 100.0%), and pooled YPLL was 14.66 years (95% CI 13.88-15.98; I2 = 100.0%). Disorder-stratified analyses revealed that substance-use disorders had the shortest life expectancy (57.07 years [95% CI 54.47-59.67]), while neurotic disorders had the longest lifespan (69.51 years [95% CI 67.26-71.76]). Substance-use disorders exhibited the greatest YPLL (20.38 years [95% CI 18.65-22.11]), followed by eating disorders (16.64 years [95% CI 7.45-25.82]), schizophrenia-spectrum disorders (15.37 years [95% CI 14.18-16.55]), and personality disorders (15.35 years [95% CI 12.80-17.89]). YPLLs attributable to natural and unnatural deaths in mental disorders were 4.38 years (95% CI 3.15-5.61) and 8.11 years (95% CI 6.10-10.13; suicide: 8.31 years [95% CI 6.43-10.19]), respectively. Stratified analyses by study period suggested that the longevity gap persisted over time. Significant cross-study heterogeneity was observed.

Interpretation

Mental disorders are associated with substantially reduced life expectancy, which is transdiagnostic in nature, encompassing a wide range of diagnoses. Implementation of comprehensive and multilevel intervention approaches is urgently needed to rectify lifespan inequalities for people with mental disorders.

Funding

None.

Inflammatory markers in outpatients with schizophrenia diagnosis in regular use of clozapine: a cross-sectional study

It is known that inflammation worsen the course of schizophrenia and induce high clozapine serum levels. However, no study evaluated this change in function of clozapine daily dose in schizophrenia. We assessed the correlation between inflammation and severity symptoms in patients with schizophrenia that take and do not take clozapine. We also assessed the correlation between clozapine daily dose and inflammatory markers to patients who take this drug. Patients were recruited from Schizophrenia Ambulatory and Psychosocial Care Center of Clinical Hospital of Porto Alegre and from an association of relatives of patients with schizophrenia. Exam results, and other important clinical exam were assessed in patients record or patients were asked to show their exam in the case of outpatients. We included 104 patients, 90 clozapine users and 14 non-clozapine users. We calculate the systemic inflammatory markers [neutrophil-lymphocyte ratio (NLR), systemic immune inflammation index (SII), and the psychopathology severity by the Brief Psychiatric Rating Scaled anchored (BPRS-a)]. These variables were compared between clozapine users and non-clozapine users. It was used mean/median test according to data distributing, with study factor (SII, MLR, and PLR), the clinical outcome: severity of symptomatology (BPRS score), and clozapine daily dose as adjustment factor. Clozapine users exhibited a significantly higher neutrophil count (mean ± SD: 5.03 ± 2.07) compared to non-clozapine users (mean ± SD: 3.48 ± 1.27; p = 0.031). After controlling for comorbidity, other parameters also showed significant differences. These findings are consistent with previous studies that have demonstrated an inflammatory response following the administration of clozapine.

Inflammatory markers in outpatients with schizophrenia diagnosis in regular use of clozapine: a cross-sectional study

It is known that inflammation worsen the course of schizophrenia and induce high clozapine serum levels. However, no study evaluated this change in function of clozapine daily dose in schizophrenia. We assessed the correlation between inflammation and severity symptoms in patients with schizophrenia that take and do not take clozapine. We also assessed the correlation between clozapine daily dose and inflammatory markers to patients who take this drug. Patients were recruited from Schizophrenia Ambulatory and Psychosocial Care Center of Clinical Hospital of Porto Alegre and from an association of relatives of patients with schizophrenia. Exam results, and other important clinical exam were assessed in patients record or patients were asked to show their exam in the case of outpatients. We included 104 patients, 90 clozapine users and 14 non-clozapine users. We calculate the systemic inflammatory markers [neutrophil-lymphocyte ratio (NLR), systemic immune inflammation index (SII), and the psychopathology severity by the Brief Psychiatric Rating Scaled anchored (BPRS-a)]. These variables were compared between clozapine users and non-clozapine users. It was used mean/median test according to data distributing, with study factor (SII, MLR, and PLR), the clinical outcome: severity of symptomatology (BPRS score), and clozapine daily dose as adjustment factor. Clozapine users exhibited a significantly higher neutrophil count (mean ± SD: 5.03 ± 2.07) compared to non-clozapine users (mean ± SD: 3.48 ± 1.27; p = 0.031). After controlling for comorbidity, other parameters also showed significant differences. These findings are consistent with previous studies that have demonstrated an inflammatory response following the administration of clozapine.

Risk factors for mortality due to natural causes and suicide among people with severe mental illness in western China

Excess mortality in people with severe mental illness (SMI) has been extensively reported. However, little is known about mortality due to natural causes and suicide and their risk factors among people with SMI in western China. The study was conducted to determine the risk factors of natural death and suicide among people with SMI in western China. A totoal of 20,195 SMI patients in western China derived from severe mental illness information system in Sichuan province (January 1, 2006, through July 31, 2018) were included in the cohort study. Mortality rates per 10,000 person-years of natural causes and suicide for patients were calculated with different characteristics. Fine-Gray competing risk model was used to identify risk factors of natural death and suicide. The mortality was 132.8 per 10,000 person-years for natural death and 13.6 per 10,000 person-years for suicide. Males, older age, divorced/widowed, poverty and no anti-psychotic treatment were significantly associated with natural death. Higher education and suicide attempt were strong risk factors of suicide. Risk factors were not shared across natural death and suicide among people with SMI in western China. Risk management and interventions for people with SMI should be tailored for specific causes of death.

The physical health nurse consultant and mental health consumer: An important therapeutic partnership

People diagnosed with mental illness (hereon referred to as consumers) experience a disproportionately lower life expectancy of up 30 years compared to the general population. Systemic issues such as diagnostic overshadowing and stigma from healthcare professionals have inhibited the development of positive therapeutic partnerships that enable consumers to seek and engage support for their physical health concerns. Consumers have called for healthcare professionals to skillfully develop and prioritize therapeutic partnerships whilst coordinating and providing physical healthcare. The aim of this qualitative descriptive research was to explore consumer views and experiences of their interactions with a specialist mental health nursing role, the Physical Health Nurse Consultant. Semi-structured interviews were conducted with 14 consumers from a large public Community Mental Health Service in the Australian Capital Territory. Interviews were transcribed and thematically analysed. Therapeutic partnerships were an overarching theme identified from the data and included three sub-themes: personal attributes of the Physical Health Nurse Consultant; behaviour change engagement strategies; and impact of the therapeutic partnership. Consumers described the personal and professional attributes of the Physical Health Nurse Consultant that enabled the establishment and maintenance of their highly valued therapeutic partnership. This therapeutic partnership was perceived to positively impact their personal and clinical outcomes. With increasing support from consumers, clinical practice settings should move towards embedding a Physical Health Nurse Consultant role in routine practice. Further research exploring the co-development of health behaviour change goals and, barriers and facilitators experienced by the consumers regarding the Physical Health Nurse Consultant is required to further role development.

Health status of young adults with serious mental illness enrolled in integrated care

AIMS

People with serious mental illness (SMI) are more likely to develop chronic health conditions and die prematurely. Timely identification of modifiable health risk factors may enable early intervention. We aimed to describe the physical health characteristics and service utilization of young people with SMI.

METHODS

Young people with SMI enrolled in an integrated community mental health clinic (CMHC) and primary care program were assessed for physical and mental health history and past year service utilization.

RESULTS

A total of 122 participants, ages 16-35 (m = 27.0 ± 5.0 years), half male, 78.3% White were assessed. Half smoked cigarettes, half had obesity, almost half (47.5%, n = 56) had hypertension, and about a third had laboratory metabolic abnormalities. The group averaged 10.7 ± 5.1 h of sedentary behavior per day. Obesity was associated with high blood pressure, prediabetes, poor self-rated health abilities, sedentary behavior and low health satisfaction. Over half had been to the emergency department (ED) for a medical reason (55.0%, n = 66) and 24.6% had been hospitalized for a health condition in the past year. Over half had a lifetime cardiovascular risk score indicating a 50-67% chance of having a cardiovascular event; simply quitting smoking would reduce the number with this risk by almost half. Most physical health diagnoses were not recorded in the CMHC record.

CONCLUSION

Young people with SMI newly enrolled in integrated care had high rates of smoking, obesity, hypertension, and other cardio-metabolic abnormalities contributing to high risk for future disease. Research is needed to examine appealing, scalable interventions to improve health, reduce unnecessary medical care, and prevent disparate chronic disease in this group.

Mental health consumers' perspectives of physical health interventions: An integrative review

Consumers of mental health services experience poor physical health compared to the general population, leading to long-term physical illness and premature death. Current research and policy activity prioritizes the physical health of consumers yet few of these recommendations have translated to practice. This implementation gap may be influenced by the paucity of literature exploring consumer perceptions and experiences with physical healthcare and treatment. As a result, little is understood about the views and attitudes of consumers towards interventions designed to improve their physical health. This integrative review aims to explore the literature regarding consumer perspectives of physical healthcare and, interventions to improve their physical health. A systematic search was undertaken using (i) CINAHL, (ii) MEDLINE, (iii) PsycINFO, (iv) Scopus, and (v) Google Scholar between September and December 2021. Sixty-one papers comprising 3828 consumer participants met the inclusion criteria. This review found that consumers provide invaluable insights into the barriers and enablers of physical healthcare and interventions. When consumers are authentically involved in physical healthcare evaluation, constructive and relevant recommendations to improve physical healthcare services, policy, and future research directions are produced. Consumer evaluation is the cornerstone required to successfully implement tailored physical health services.

Prevalence of metabolic syndrome and related factors in a large sample of antipsychotic naïve patients with first-episode psychosis: Baseline results from the PAFIP cohort

BACKGROUND

Few investigations have been carried out on metabolic syndrome in antipsychotic- naïve patients with schizophrenia.

METHODS

Our primary objective was to compare the prevalence of Metabolic Syndrome (MetS), as defined by the National Cholesterol Education Program, Adult Treatment Panel III in 2001 (NCEP-ATP III), between a Spanish cohort of 303 drug-naïve patients with a first episode of psychosis (FEP) without any previous cardiovascular condition, and 153 healthy individuals.

RESULTS

Participants included 303 patients with FEP (M:F 53:46) and 153 control subjects (M:F 56:43). The mean and standard deviation ages were 31(9.38) and 29 (7.57) years in the study and control groups respectively (F = 4.09; p = 0.93). We found that the prevalence of MetS in drug-naïve patients with FEP (5.6 %) was similar to the prevalence of MetS in age-sex matched controls (5.12 %). However, 60.7 % of patients with FEP met at least one of the five MetS components, while among the control subjects only 36.5 % met at least one component. Additionally, we found that other factors not included among the operational definition of MetS, but still important in cardiovascular risk, were also altered.

CONCLUSION

FEP patients have a greater risk of presenting at least one altered MetS component than healthy controls which could indicate the need of development of screening methods detecting cardiovascular risk. Likewise, gender differences in metabolic components such as waist circumference, which is a predictor of cardiovascular events have been found. Similarly, research should focus on metabolic risk predictors that include not only MetS, but also specific parameters for the early psychosis population.

Samidorphan/olanzapine combination therapy for schizophrenia: Efficacy, tolerance and adverse outcomes of regimen, evidence-based review of clinical trials

Introduction

Objectives

Methods

Results

Conclusion

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FDA approved a combination dose of olanzapine and samidorphan (OLZ/SAM) for treatment of schizophrenia and bipolar I disorder.

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Overall, OLZ/SAM showed a significant reduction in symptoms for long-term treatment.

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Major adverse events included nervous system disorders, blood, metabolic or nutritional changes.

Psychiatric symptoms and mortality in older adults with major psychiatric disorders: results from a multicenter study

Prior research suggests that certain psychiatric symptoms could be associated with increased risk of death. However, it remains unclear whether this association could rely on all or specific symptoms. In this report, we used data from a multicenter 5-year prospective study (N = 641) of older adults with an ICD-10 diagnosis of schizophrenia, bipolar disorder or major depressive disorder, recruited from French community psychiatric departments. We used a latent variable approach to disentangle the effects shared by all psychiatric symptoms (i.e., general psychopathology factor) and those specific to individual psychiatric symptoms, while adjusting for sociodemographic and clinical factors. Psychiatric symptoms were assessed face-to-face by psychiatrists trained to semi-structured interviews using the Brief Psychiatric Rating Scale (BPRS). Among older adults with major psychiatric disorders, we found that all psychiatric symptoms were associated with increased mortality, and that their effect on the 5-year mortality were exerted mostly through a general psychopathology dimension (β = 0.13, SE = 0.05, p < 0.05). No BPRS item or lower order factor had a significant effect on mortality beyond and above the effect of the general psychopathology factor. Greater number of medical conditions, older age, male sex, and being hospitalized or institutionalized at baseline were significantly associated with this risk beyond the effect of the general psychopathology factor. Since psychiatric symptoms may affect mortality mainly through a general psychopathology dimension, biological and psychological mechanisms underlying this dimension should be considered as promising targets for interventions to decrease excess mortality of older individuals with psychiatric disorders.

Adherence to smoking cessation guidelines (5As) by psychiatrists and primary care physicians for persons with serious mental illness

1) Compare the 5A (Ask-Advise-Assess-Assist-Arrange) practice rates between psychiatrists and primary care physicians (PCPs) regarding smoking cessation for PWSMI. 2) Compare the 5A practice rates reported by physicians with rates reported by PWSMI. 3) Identify which specialty is perceived as primarily responsible for smoking cessation promotion for PWSMI.

Telephone surveys were carried out in a large health maintenance organization (HMO) among all psychiatrists, a random sample of PCPs, and HMO members with serious mental illness who had registered/participated in a smoking cessation program. Physicians were asked how frequently they carried out each 5A practice, along with questions regarding role responsibility and interaction between the two clinical specialties. PWSMI were asked to report about each 5A practice by both PCP and treating psychiatrist.

Ask-Advise-Assess rates were higher than Assist-Arrange rates for both specialties. 83% of PCPs had satisfactory 5A practice scores compared to 46% of psychiatrists (X²=23.9, p < 0.001). With the exception of Ask rates, physician rates for each 5A component were higher than those reported by PWSMI. PCPs were more likely to see smoking cessation promotion as their responsibility and did not always confer with the psychiatrist regarding referral and SCM prescription.

Interventions focusing on promoting Assist-Arrange practices and better integration between the specialties are required.

The Impact of Adolescent Alcohol Exposure on Nicotine Behavioral Sensitization in the Adult Male Neonatal Ventral Hippocampal Lesion Rat

Nicotine and alcohol use is highly prevalent among patients with serious mental illness, including those with schizophrenia (SCZ), and this co-occurrence can lead to a worsening of medical and psychiatric morbidity. While the mechanistic drivers of co-occurring SCZ, nicotine use and alcohol use are unknown, emerging evidence suggests that the use of drugs during adolescence may increase the probability of developing psychiatric disorders. The current study used the neonatal ventral hippocampal lesion (NVHL) rat model of SCZ, which has previously been shown to have enhanced nicotine behavioral sensitization and, following adolescent alcohol, increased alcohol consumption. Given how commonly alcohol is used by adolescents that develop SCZ, we used the NVHL rat to determine how exposure to adolescent alcohol impacts the development of nicotine behavioral sensitization in adulthood. Male Sprague-Dawley rats underwent the NVHL surgery or a sham (control) surgery and subsequently, half of each group was allowed to drink alcohol during adolescence. Nicotine behavioral sensitization was assessed in adulthood with rats receiving subcutaneous injections of nicotine (0.5 mg/kg) each day for 3 weeks followed by a nicotine challenge session 2 weeks later. We demonstrate that all groups of rats became sensitized to nicotine and there were no NVHL-specific increases in nicotine behavioral sensitization. We also found that NVHL rats appeared to develop sensitization to the nicotine paired context and that adolescent alcohol exposure blocked this context sensitization. The current findings suggest that exposure to alcohol during adolescence can influence behaviors that manifest in the adult NVHL rat (i.e., context sensitization). Interestingly, nicotine behavioral sensitization levels were not altered in the NVHL groups regardless of adolescent alcohol exposure in contrast to prior reports.

Diabetes complication burden and patterns and risk of mortality in people with schizophrenia and diabetes: A population-based cohort study with 16-year follow-up

Schizophrenia is associated with increased prevalence of diabetes. However, risk of diabetes complications as well as the impact of complication burden and patterns on subsequent mortality risk in schizophrenia patients with co-existing diabetes is understudied. 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 (comparison group) between 2001 and 2016 in Hong Kong, using territory-wide medical-record database of public healthcare services. Complications were measured by Diabetes Complications Severity Index (DCSI), which stratified complication burden into 6 levels (DCSI score=0, 1, 2, 3, 4, or ≥5). Associations of diabetes complications, in terms of DCSI scores (complication burden), specific types and two-way combinations of complications (complication patterns), with all-cause mortality rate in schizophrenia were evaluated using Cox proportional-hazards models. Schizophrenia group had comparable macrovascular (adjusted OR 0.99 [95% CI 0.92-1.06]) and lower microvascular (0.79 [0.73-0.86]) complication rates relative to comparison group. Mortality risk ratio for schizophrenia was elevated at all complication burden levels, which conferred incremental impact on excess mortality in both groups. Cardiovascular diseases (1.60 [1.45-1.77]) and cerebrovascular-metabolic diseases (2.74 [1.25-5.99]) were associated with the highest differential mortality in schizophrenia among various specific complications and complication combinations, respectively. Our results indicate that schizophrenia patients with co-existing diabetes are at increased risk of excess mortality relative to those with diabetes alone, regardless of complication burden levels. Implementation of multilevel, targeted interventions is needed to improve diabetes-related outcomes and reduce mortality gap in this vulnerable population.

Bipolar Depression: A Historical Perspective of the Current Concept, with a Focus on Future Research

The aim of this narrative review is to trace the origin of the concept of bipolar depression and to expose some of its limitations. Bipolar depression is a broad clinical construct including experiences ranging from traditional melancholic and psychotic episodes ascribed to "manic-depressive insanity," to another heterogeneous group of depressive episodes originally described in the context of binary models of unipolar depression (e.g., psychogenic depression, neurotic depression). None of the available empirical evidence suggests, however, that these subsets of "bipolar" depression are equivalent in terms of clinical course, disability, family aggregation, and response to treatment, among other relevant diagnostic validators. Therefore, the validity of the current concept of bipolar depression should be a matter of concern. Here, we discuss some of the potential limitations that this broad construct might entail in terms of pathophysiological, clinical, and therapeutic aspects. Finally, we propose a clinical research program for bipolar depression in order to delimit diagnostic entities based on empirical data, with subsequent validation by laboratory or neuroimaging biomarkers. This process will then aid in the development of more specific treatments.

First-episode psychosis: How long does it last? A review of evolution and trajectory

Study of first-episode psychosis (FEP), an episode of psychotic nature which manifests for the first time in an individual in the longitudinal continuum of his/her illness, has been study matter of research interest in recent years. A comprehensive review of the literature will help us understand the evolution and trajectory of this concept better. A literature review of available articles addressing the concept, phenomenology, evolution, identification, course, and outcome of FEP was done; the same was subsequently divided into broad topics for better clarity and analyzed. FEP constituted a clinical psychotic phenomenon with underlying significant heterogeneity in diagnosis, stability, course, and outcome. The study has attempted to view FEP both as horizontal spectrum across various diagnoses and longitudinally ranging from asymptomatic individual with unknown risk status to attenuated psychosis to multiple relapses/unremitting illness. Many risk and protective factors have been brought out with varying certainty ranging bio-psycho-social spectrum. Efforts have been made to calculate polygenic risk score based on genes involvement/sharing between various psychotic spectrum disorders; as well as biomarker panels to identify people at risk. FEP may prove to be an important concept to understand psychosis in general; without putting things into the diagnostic rubric. It may help understand multiple risk and protective factors for the course and outcome of psychotic illness and may clear the cloud to sharpen the evidence toward commonality and distinctiveness between various psychotic diagnoses in vogue for more comprehensive concept.

The impact of the COVID-19 pandemic on the mental health and daily life of adults with behavioral health disorders

People with behavioral health disorders may be particularly vulnerable to the impact of the COVID-19 pandemic, yet little is known about how they are faring. A mixed-methods, anonymous needs assessment was conducted to understand changes in the lives of adults with mental health and substance use disorders since the pandemic onset. A cross-sectional, online survey was completed by 272 adults in April and May 2020, recruited from statewide networks of community programs in New Jersey and New York. Measures included the Patient Health Questionnaire-2 and the Generalized Anxiety Disorder-2 to screen for depressive and anxiety disorders. Also assessed was the pandemic's impact on sleep and dietary patterns, exposure to COVID-19 infection, and access to health care and medications. Finally, respondents were asked to describe in their own words any changes in their lives since the pandemic began. Over one-third (35.1%) screened positive for generalized anxiety disorder and over one-quarter (29.6%) screened positive for major depressive disorder. The majority reported pandemic-related changes in eating and sleeping patterns and exposure to COVID-19 infection. Multivariable logistic regression analysis found that many changes attributed to the pandemic were positively and significantly associated with screening positive for anxiety and depressive disorders. Qualitative analysis confirmed these findings and identified participants' resilience stemming from social support, emotion management, and self-care. These results can inform the design of services that assist this population to bolster self-management skills and reestablish daily habits to improve their lives during and following the pandemic.

Risk factors for natural cause mortality in a cohort of 1494 persons with serious mental illness

Persons with serious mental illness die on average more than 10 years younger than those in the overall population, mostly due to natural causes. Previous studies have identified predictors of natural cause mortality in this population but few have been prospective studies using clinical variables from in-person evaluations. A cohort of 1494 individuals with schizophrenia, bipolar disorder, or major depressive disorder were assessed at baseline and mortality status was determined from the US National Death Index after up to 20 years of follow-up. Analyses included multivariate Cox proportional hazard models to determine independent predictors of natural cause mortality. A total of 125 (8.4%) individuals died of natural causes. In multivariate models, the strongest predictor of mortality after age was tobacco smoking at baseline with a dose-related effect. Having diabetes, a cardiovascular condition, particularly hypertension, and lower cognitive functioning were also significant risks, along with divorced/separated status. The receipt of gabapentin or fluoxetine also significantly increased mortality risk. Premature death can be reduced by smoking cessation and the improved management of conditions such as hypertension and diabetes.

Natural cause mortality of mental health consumers: A 10-year retrospective cohort study

People with mental illness have substantially lower life expectancy than the general population, with mortality from natural causes most commonly attributed to cardiovascular diseases. The study aim was to identify characteristics of consumers who died of natural causes between 2009 and 2018 at one of Australia's largest publicly funded mental health services. Data were collected with a retrospective medical record review of 102 consumers. Mean mortality age was 52.4 years (SD = 10.7) (with females 51.9 years [SD = 12.0], and males 52.7 years [SD = 9.9]), which was more than 30 years lower than the Australian population. Cardiovascular diseases were the most frequent mortality cause (39%), followed by respiratory conditions (23%), cancers (20%), and all other causes (19%). Sixty (61%) consumers had at least three co-occurring physical health conditions. Seventy-five (74%) smoked tobacco. Consumers who died from cardiovascular diseases were less likely to attend specialist medical follow-up for their condition (P = 0.004), and more likely to die at home (P = 0.001). Consumers whose mortality age was above 55 years were more likely to have three co-occurring physical health conditions (P = 0.034). Consumers whose mortality age was below 55 years were more likely to have sub-optimal nutritional intake (P = 0.014) and higher body mass index (P = 0.008). There is a critical need to close the life expectancy gap for consumers. This requires dedicated focus on reducing mortality risk due to modifiable clinical characteristics which lead to consumer mortality. Mental health nurses play a key role in helping reduce consumers' mortality and morbidity risk through prevention and early intervention strategies.

The Impact of Smoking Cessation on Hospitalization and Psychiatric Medication Utilization among People with Serious Mental Illness

Background: Despite the high prevalence of smoking amongst people with serious mental illness (SMI), referral rates to smoking cessation programs (SCPs) are low. Mental health workers reticence to refer to SCPs has been attributed, in part, to their belief that quitting will have a deleterious effect on their patients' mental health status. Objectives: This study's objective was to determine if participating in a smoking cessation program had an adverse effect on mental health status among people with SMI, measured here by a change in hospitalization occurrence or psychiatric medication utilization. People with SMI who had participated in at least one SCP session in a large health maintenance organization (n = 403) were compared to an age-gender-diagnosis matched sample of SMI smokers (1,209) who had never participated. Results: No change in psychiatric hospitalization occurrence pre- versus post-SCP participation was found among participants (Pre:7.2% vs. Post:5.2, p = 0.2) or nonparticipants (Pre:7.0% vs. Post:6.0%, p = 0.2). Mean defined daily dose (DDD) for anti-psychotic, mood stabilizer, anti-depressant and anxiolytic medications also did not change over time for participants and nonparticipants. However, participants who did not complete the SCP and didn't quit had a 0.35 higher mean DDD for anti-psychotic medications compared with participants who had completed the SCP or quit, and with nonparticipants (p = 0.006), and were the only group to exhibit an increase in mean antipsychotic DDD over time (Pre:1.42, Post:1.63). SCP participation was not associated with hospitalization occurrence or psychiatric medication utilization. Conclusions/Importance: Smoking cessation should be encouraged, with close monitoring during the quit process.

Supportive and palliative care for people with respiratory problems and preexisting serious mental illness

PURPOSE OF REVIEW

People living with serious mental illness are at a higher risk of developing respiratory problems that can lead to increased morbidity and early mortality. This review aimed to identify recent advances in care provision for people with respiratory problems and preexisting serious mental illness to ease symptom burden and reduce the risk of premature mortality.

RECENT FINDINGS

Intervention-based studies in this area are scarce. The evidence reviewed originated from observational studies. Concluding comments from the synthesis suggest there are specific needs for proactive screening of respiratory function as part of routine physical health checks across care settings for people living with serious mental illness, more stringent monitoring of comorbid chronic lung conditions and increased attention in reducing the frequency respiratory infections. Integrated services across care settings are needed to support people with serious mental illness to limit the impact of modifiable lifestyle factors known to be detrimental to respiratory health, such as smoking.

SUMMARY

Key priorities are identified to improve accessibility and inclusivity of respiratory care pathways for people living with serious mental illness to support early detection and proactive monitoring of respiratory problems to help reduce the risk of early mortality.

One-day tropisetron treatment improves cognitive deficits and P50 inhibition deficits in schizophrenia

The core features of schizophrenia (SCZ) include cognitive deficits and impaired sensory gating represented by P50 inhibition deficits, which appear to be related to the α7 nicotinic acetylcholine receptor (nAChR). An agonist of nAChR receptor may improve these defects. This study aimed to investigate how administering multiple doses of tropisetron, a partial agonist of nAChR, for 1 day would affect cognitive deficits and P50 inhibition deficits in SCZ patients. We randomized 40 SCZ non-smokers into a double-blind clinical trial with four groups: placebo, 5 mg/d, 10 mg/d, and 20 mg/d of oral tropisetron. Their P50 ratios were all more than 0.5 and they took risperidone at 3-6 mg/day for at least a month before participating in the experiment. We measured the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and P50 inhibition before and one day after treatment. After one day of treatment, the total RBANS scores of the 20 mg and 5 mg tropisetron groups, and the immediate memory of the 10 mg group were significantly higher than placebo group. The P50 ratio was smaller in the 5 mg and 10 mg groups than in the placebo group (both p < 0.05) after treatment. Furthermore, the improvement in RBANS total score was correlated with increased S1 latency (p < 0.05), and the increase in immediate memory score was correlated with decreased S2 amplitude. One day of treatment with tropisetron improved both cognitive and P50 inhibition deficits, suggesting that longer term treatment with α7 nAChR agonists for these deficits in SCZ may be promising.

Mortality, Revascularization, and Cardioprotective Pharmacotherapy After Acute Coronary Syndrome in Patients With Psychotic Disorders: A Population-Based Cohort Study

Ischemic heart disease is the leading cause of mortality in psychotic disorders. There is a paucity of research comprehensively evaluating short-term mortality, cardiovascular complications, and treatment inequality after cardiac events in patients with psychotic disorders. This population-based cohort study examined 30-day and 1-year all-cause mortality, cardiovascular complication rates, 30-day and 1-year receipt of invasive cardiac procedures, and 90-day post-discharge cardioprotective medication treatment following admission for first-recorded acute coronary syndrome (ACS) among patients with psychotic disorders (n = 703) compared with patients without psychotic disorders (n = 66 989) between January 2006 and December 2016 in Hong Kong (HK). Study data were retrieved from territory-wide medical record database of public healthcare services to 7.5 million HK residents. Multivariate regression analyses (ORs and 95% CIs), adjusting for demographics and medical comorbidities, were conducted to evaluate associations between psychotic disorders and post-ACS outcomes. Our results showed that patients with psychotic disorders had higher 30-day (OR: 1.99 [95% CI: 1.65-2.39]) and 1-year (2.13 [1.79-2.54]) mortality, and cardiovascular complication rates (1.20 [1.02-1.41]), lower receipt of cardiac catheterization (30-d: 0.54 [0.43-0.68]; 1-y: 0.46 [0.38-0.56]), percutaneous coronary intervention (30-d: 0.55 [0.44-0.70]; 1-y: 0.52 [0.42-0.63]) and reduced β-blockers (0.81 [0.68-0.97]), statins (0.54 [0.44-0.66]), and clopidogrel prescriptions (0.66 [0.55-0.80]). Associations between psychotic disorder and increased mortality remained significant even after complications and treatment receipt were additionally adjusted. Our findings indicate that psychotic disorders are associated with increased risks of short-term post-ACS mortality, cardiovascular complications, and inferior treatment. Excess mortality is not substantially explained by treatment inequality. Further investigation is warranted to clarify factors for suboptimal cardiac-care and elevated mortality in psychotic disorders to enhance post-ACS outcome.

Complex Gastrointestinal and Endocrine Sources of Inflammation in Schizophrenia

A low level, inflammatory phenotype is prevalent in individuals with schizophrenia, but the source of this inflammation is not known. Studies of the gut-brain axis indicate that this inflammation may be related to the translocation of intestinal microbes across a permeabilized gut-vasculature barrier. In addition, studies of the endocrine system support that this inflammation may derive from effects of stress hormones and metabolic imbalances. Gastrointestinal (GI) and endocrine conditions are not mutually exclusive, but rather may have additive effects to produce this inflammatory phenotype in schizophrenia. Here, we examined a series of plasma biomarkers used to measure general inflammation and presumably microbial, gut-derived inflammation in 409 individuals with schizophrenia: c-reactive protein (CRP), lipopolysaccharide-binding protein (LBP), soluble CD14 (sCD14), and IgG antibodies to S. cerevisiae, bovine milk casein, and wheat gluten. Individuals were stratified according to whether or not they had a comorbid GI or endocrine condition, both, or neither. In multivariate regression models, the presence of GI and endocrine conditions was additive for the GI-based marker, LBP, with significant associations only when both conditions were present compared to when both conditions were absent (OR = 2.32, 95th% CI 1.05-5.13, p < 0.03). In contrast, the marker of general inflammation, CRP, was strongly associated with primarily endocrine conditions (OR = 3.64, 95th% CI 1.35-9.84, p < 0.05). Overall associations were largely driven by the GI condition, gastroesophageal reflux disease (GERD), and by the endocrine condition, obesity. In univariate comparisons, S. cerevisiae IgG levels were significantly elevated only in persons with GI conditions (p < 0.02), whereas antibodies to the food antigens were elevated in the presence of either or both conditions (p < 0.005-0.04). More severe psychiatric symptoms were associated only with GI conditions (p < 0.01-0.04). In conclusion, both GI and endocrine abnormalities may contribute to inflammation in schizophrenia, sometimes independently and sometimes as part of interactions which may represent complex integrated pathways. The accumulating evidence for multisystem inflammation in schizophrenia may lead to the development of new strategies to prevent and treat this devastating disorder.

Gender differences in metabolic syndrome risk factors among patients with serious mental illness

The prevalence of metabolic syndrome and its components continue to increase among patients with serious mental illness. This cross-sectional study investigated whether metabolic syndrome prevalence and risk factors differ between male and female patients with serious mental illness. In total, 260 eligible patients were recruited from two hospitals. The data on demographic characteristics, lifestyle behaviour factors, biochemistry, and anthropometry were collected. Analyses were performed using multivariate logistic regression. Metabolic syndrome prevalence was 40.8% (35.1% in men and 46.8% in women). Among patients aged 40-49 years, metabolic syndrome prevalence was higher in men; however, the trend was reversed among patients aged 50 years or older. Notably, gender-specific metabolic syndrome risk factors were observed. In men, they included low education level, high body mass index (BMI), prolonged illness, comorbid physical illness, and diagnosis of bipolar disorder, whereas they included being married, old age, and high BMI in women. Our findings suggest that mental health professionals should consider the gender- and age-based metabolic syndrome prevalence trend in patients with serious mental illness when designing interventions for the study population to minimize metabolic syndrome prevalence.

Bipolar depression: a major unsolved challenge

Depression in bipolar disorder (BD) patients presents major clinical challenges. As the predominant psychopathology even in treated BD, depression is associated not only with excess morbidity, but also mortality from co-occurring general-medical disorders and high suicide risk. In BD, risks for medical disorders including diabetes or metabolic syndrome, and cardiovascular disorders, and associated mortality rates are several-times above those for the general population or with other psychiatric disorders. The SMR for suicide with BD reaches 20-times above general-population rates, and exceeds rates with other major psychiatric disorders. In BD, suicide is strongly associated with mixed (agitated-dysphoric) and depressive phases, time depressed, and hospitalization. Lithium may reduce suicide risk in BD; clozapine and ketamine require further testing. Treatment of bipolar depression is far less well investigated than unipolar depression, particularly for long-term prophylaxis. Short-term efficacy of antidepressants for bipolar depression remains controversial and they risk clinical worsening, especially in mixed states and with rapid-cycling. Evidence of efficacy of lithium and anticonvulsants for bipolar depression is very limited; lamotrigine has long-term benefit, but valproate and carbamazepine are inadequately tested and carry high teratogenic risks. Evidence is emerging of short-term efficacy of several modern antipsychotics (including cariprazine, lurasidone, olanzapine-fluoxetine, and quetiapine) for bipolar depression, including with mixed features, though they risk adverse metabolic and neurological effects.

Increased risk of smoking-related illnesses in schizophrenia patients: A nationwide cohort study

BACKGROUND

Schizophrenia patients smoke at three times the rate of the general population, and are more susceptible to smoking-related illnesses. The goal of the current study was to evaluate the cumulative probability of chronic obstructive pulmonary disease (COPD) and ischemic heart disease (IHD) following first documentation of smoking among schizophrenia patients as compared to smoking healthy controls.

METHODS

A nationally representative cohort study was designed to assess the odds and cumulative probability of COPD and IHD among individuals with schizophrenia (n = 10,502) and a matched-sample of smoking healthy controls (n = 10,502). Hierarchical logistic regressions and Kaplan-Meier regression models were used to compare odds and cumulative probabilities across the two groups.

RESULTS

After adjusting for clinical and demographic factors, smoking schizophrenia patients had a higher probability of receiving a diagnosis of COPD than smoking healthy controls (OR 2.14, 95%CI 1.51-3.01, p < 0.001). The probability of having COPD increased more rapidly in smoking schizophrenia patients, yet the opposite trajectory prevailed for IHD, showing a decreased cumulative probability in smoking schizophrenia patients compared to smoking healthy controls.

DISCUSSION

Schizophrenia has a unique contribution to the facilitation of COPD, which extends beyond the effect of smoking, or other clinical and demographic risk factors. Differential smoking patterns could potentially account for this effect. The differential pattern of IHD should be subjected to further research, as our results might indicate that schizophrenia patients are underdiagnosed with IHD, and may be even less diagnosed as a function of time and chronicity.

Smoking in schizophrenia: recent findings about an old problem

PURPOSE OF REVIEW

Recent epidemiology, biological and clinical findings correlate high cigarette consumption in patients with schizophrenia, impeding both treatment strategies and the effectiveness of antipsychotics.

RECENT FINDINGS

New data suggests that despite world-wide efforts to curb cigarette consumption, smoking in patients with schizophrenia was still high. Recent reports could not confirm earlier findings regarding smoking's beneficial effects on cognitive dysfunction, however, the association between smoking, positive symptoms and suicidal behavior was revealed. As some patients smoked in an attempt to alleviate extrapyramidal symptoms (EPS) and negative symptoms, the molecular studies shared genetic roots correlating smoking and schizophrenia, revealing that smoking may increase the risk of developing schizophrenia. Preclinical and clinical studies clarified the complex relationship between schizophrenia's pathology and nicotine's effects on the human brain.

SUMMARY

Cigarette smoking continues to adversely affect the health of individuals with schizophrenia. Both smoking and heavy nicotine dependence, given the complex biological findings, might influence symptom severity in patients with schizophrenia. Regardless, ceasing smoking activities is strongly advocated to replace 'self-medication by nicotine' with safer and more effective medications.

Causes of premature mortality in schizophrenia: a review of literature published in 2018

PURPOSE OF REVIEW

The current review examines the recent literature on the causes of premature mortality in schizophrenia.

RECENT FINDINGS

People with schizophrenia have higher premature mortality rates compared with the general population. Suicides and accidents account for a nontrivial part of the excess mortality, but the largest part is attributable to natural causes of death. Five major causes have been identified: first, adverse effects of medication; second, suboptimal lifestyle; third, somatic comorbidity; fourth, suboptimal treatment of somatic disorders; and fifth, accelerated ageing/genetic explanations. The positive aspect is that people with schizophrenia have increasing life expectancy, at least in high-income countries, and this development seems to largely follow the increase in the general population. Especially mortality rates from unnatural causes appear to have a positive impact. Nevertheless, despite more than 100 years of research and progress, the excess mortality in persons with schizophrenia remains unacceptably high, with no prospects of reaching the level in the general population.

SUMMARY

The excess mortality in schizophrenia has received much focus. Future studies should explore the reasons for the high rates of natural causes of death, while aiming to disentangle the complex interplay between medication, lifestyle, comorbidity, treatment of somatic disorders, and genetic effects.

The relationship between nicotine and psychosis

Cigarette smoking is strongly associated with psychotic disorders such as schizophrenia. For several decades it was assumed that the relationship could be explained by reverse causation; that smoking was secondary to the illness itself, either through self-medication or a process of institutionalization, or was entirely explained by confounding by cannabis use or social factors. However, studies have exposed that such hypotheses cannot fully explain the association, and more recently a bidirectional relationship has been proposed wherein cigarette smoking may be causally related to risk of psychosis, possibly via a shared genetic liability to smoking and psychosis. We review the evidence for these candidate explanations, using findings from the latest epidemiological, neuroimaging, genetic and preclinical work.

Psychopathology and extrapyramidal side effects in smoking and non-smoking patients with schizophrenia: Systematic review and meta-analysis of comparative studies

The association between smoking and psychopathology and extrapyramidal side effects (EPSE) in schizophrenia has been controversial. This systematic review and meta-analysis compared psychopathology and EPSE between smoking and non-smoking schizophrenia patients. The PubMed, EMBASE, PsycINFO, Cochrane Library, and Web of Science databases were independently and systematically searched by two researchers to identify relevant articles. Standardized mean differences (SMDs) and their 95% confidence intervals (CI) were calculated with random effect models. Subgroup and meta-regression analyses were performed to explore sources of heterogeneity. The systematic review and meta-analysis included 29 studies that compared psychotic, depressive and anxiety symptoms and EPSE between smoking (n = 3591) and non-smoking schizophrenia patients (n = 2980). Smoking patients had significantly more severe positive symptoms (24 studies; SMD = 0.33, 95% CI: 0.16 to 0.50, P < 0.001), but less severe EPSE (7 studies; SMD = -0.20, 95% CI: -0.38 to -0.02, P = 0. 03). No significant group differences in negative, depressive and anxiety symptoms were found. In conclusion, this systematic review and meta-analysis found that smoking schizophrenia patients had more severe positive symptoms but less severe EPSE than non-smoking patients.

Tobacco smoking and nicotine dependence in first episode and established psychosis

AIM

People with psychotic disorders have increased premature mortality in comparison with the general population, with high rates of cigarette use a contributing factor. We aimed to describe the prevalence of cigarette use and nicotine dependence (ND) in first episode psychosis (FEP), and established psychosis; and to investigate associations between clinical symptoms and ND.

METHODOLOGY

Smoking and clinical data were collected from two cohorts: 181 people with FEP recruited as part of the Physical Health and Substance Use Measures in First Onset Psychosis (PUMP) study and from 432 people with established psychosis recruited as part of the Improving physical health and reducing substance use in psychosis randomised controlled trial (IMPaCT RCT).

RESULTS

The prevalence of cigarette smoking was 78% in FEP and 62% in established psychosis. Forty nine percent (n = 60) of smokers in the FEP cohort and 69% (n = 183) of smokers with established psychosis were highly nicotine dependent. Being a highly nicotine dependent smoker was significantly associated with higher PANSS positive symptom scores (F = 5.480 p = 0.004), and with decreased scores on the Rosenberg self-esteem scale (F = 3.261, p = 0.039) in established psychosis. There was no diagnostic specificity identified in relation to smoking or ND in both groups.

CONCLUSION

High rates of cigarette usage and nicotine dependence are problems from the early stages of psychosis. ND is higher in people with established psychosis. Smoking cessation strategies as part of comprehensive management of psychotic disorders at every stage require further development and evaluation.

Association between lower estimated premorbid intelligence quotient and smoking behavior in patients with schizophrenia

Aim

We aimed to investigate the involvement of premorbid intelligence quotient in higher prevalence of smoking in patients with schizophrenia.

Methods

Participants included 190 patients with schizophrenia (mean ± standard deviation age: 37.7 ± 10.8 years; 88 males and 102 females) and 312 healthy individuals (mean ± standard deviation age: 38.1 ± 13.8; 166 males and 146 females), matched for age, sex, and ethnicity (Japanese). Premorbid intelligence quotient was estimated using the Japanese Adult Reading Test and distress symptoms were assessed using the Hopkins Symptom Check List. Current smoking information was collected according to self-declarations.

Results

As expected, the smoking rate was higher, while mean education level and Japanese Adult Reading Test scores were significantly lower, in patients with schizophrenia than in healthy individuals (p < 0.01). The mean education level and Japanese Adult Reading Test scores were significantly lower in the smoker group than in the non-smoker group in both patients and healthy individuals (p < 0.05). In the patient group alone, Hopkins Symptom Check List subscale and total scores were significantly higher in the smoker group than in the non-smoker group (p < 0.05). A multivariate regression analysis showed that the Japanese Adult Reading Test score was a significant and negative predictor for smoking (p < 0.001, odds ratio = 0.97; 95% confidence interval: 0.96–0.99).

Conclusion

Our results suggest that lower estimated premorbid intelligence quotient is an important variable in elucidating smoking behavior in humans and may be associated with higher prevalence of smoking in patients with schizophrenia.

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Lower premorbid intelligence quotient (IQ) was observed in patients with schizophrenia who were smokers.

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Lower education level was observed in patients with schizophrenia who were smokers.

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Lower premorbid IQ and education level were also seen in smokers in the healthy group.

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Distress symptoms were higher in smokers with schizophrenia.

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In total, premorbid IQ was a negative predictor for smoking.

Is It Possible to Predict the Future in First-Episode Psychosis?

The outcome of first-episode psychosis (FEP) is highly variable, ranging from early sustained recovery to antipsychotic treatment resistance from the onset of illness. For clinicians, a possibility to predict patient outcomes would be highly valuable for the selection of antipsychotic treatment and in tailoring psychosocial treatments and psychoeducation. This selective review summarizes current knowledge of prognostic markers in FEP. We sought potential outcome predictors from clinical and sociodemographic factors, cognition, brain imaging, genetics, and blood-based biomarkers, and we considered different outcomes, like remission, recovery, physical comorbidities, and suicide risk. Based on the review, it is currently possible to predict the future for FEP patients to some extent. Some clinical features-like the longer duration of untreated psychosis (DUP), poor premorbid adjustment, the insidious mode of onset, the greater severity of negative symptoms, comorbid substance use disorders (SUDs), a history of suicide attempts and suicidal ideation and having non-affective psychosis-are associated with a worse outcome. Of the social and demographic factors, male gender, social disadvantage, neighborhood deprivation, dysfunctional family environment, and ethnicity may be relevant. Treatment non-adherence is a substantial risk factor for relapse, but a small minority of patients with acute onset of FEP and early remission may benefit from antipsychotic discontinuation. Cognitive functioning is associated with functional outcomes. Brain imaging currently has limited utility as an outcome predictor, but this may change with methodological advancements. Polygenic risk scores (PRSs) might be useful as one component of a predictive tool, and pharmacogenetic testing is already available and valuable for patients who have problems in treatment response or with side effects. Most blood-based biomarkers need further validation. None of the currently available predictive markers has adequate sensitivity or specificity used alone. However, personalized treatment of FEP will need predictive tools. We discuss some methodologies, such as machine learning (ML), and tools that could lead to the improved prediction and clinical utility of different prognostic markers in FEP. Combination of different markers in ML models with a user friendly interface, or novel findings from e.g., molecular genetics or neuroimaging, may result in computer-assisted clinical applications in the near future.