Schizophrenia and physical health problems

Associations between adiposity measures and depression and well-being scores: A cross-sectional analysis of middle- to older-aged adults

BACKGROUND

Obesity and mental health are significant global health concerns. Evidence has linked increased adiposity with depression and well-being; however, there is limited documented evidence in Ireland. Research also suggests lifestyle factors and disease conditions to be related to mental health. These may modulate relationships between adiposity and depression and well-being.

METHODS

This was a cross-sectional study of 1,821 men and women aged 46-73 years, randomly selected from a large primary care centre. Depression and well-being were assessed using the 20-item Centre for Epidemiologic Studies Depression Scale (CES-D) and the World Health Organization-Five (WHO-5) Well-Being Index. Linear regression analyses were performed to examine relationships between mental health scores (dependent variable) and adiposity (independent variable) defined using body mass index (BMI) and waist-height ratio while adjusting for demographic characteristics, lifestyle factors and disease conditions.

RESULTS

BMI and waist-height ratio had a significant positive association with depression scores and a significant inverse association with well-being scores in males and females. These associations were maintained following adjustment for demographic variables and lifestyle factors. In final models where disease conditions were adjusted for, BMI (β = 0.743, p < .001) and waist-height ratio (β = 0.719, p < .001) associations with the CES-D score remained significant. In stratified analyses, relationships between measures of adiposity and depression were found to be stronger in females (BMI: β = 0.806, p = .007; waist-height ratio: β = 0.768, p = .01) than males (BMI: β = 0.573, p = .049; waist-height ratio: β = 0.593, p = .044) but no effect modification was identified.

CONCLUSIONS

These findings suggest that increased adiposity is significantly associated with poorer mental health, independent of lifestyle factors and disease conditions. Targeted interventions for reducing depression should include better population-level weight management measures.

Policy Complexities in Financing First Episode Psychosis Services: Implementation Realities from a Home Rule State

Over the past decade, significant investments have been made in coordinated specialty care (CSC) models for first episode psychosis (FEP), with the goal of promoting recovery and preventing disability. CSC programs have proliferated as a result, but financing challenges imperil their growth and sustainability. In this commentary, the authors discuss (1) entrenched and emergent challenges in behavioral health policy of consequence for CSC financing; (2) implementation realities in the home rule context of Ohio, where significant variability exists across counties; and (3) recommendations to improve both care quality and access for individuals with FEP. The authors aim to provoke careful thought about policy interventions to bridge science-to-service gaps, and in this way, advance behavioral health equity.

People with serious mental illness are at higher risk for acute care hospitalization in Israel, 2000-2019

BACKGROUND

People with severe mental disorders have higher mortality rates and more chronic physical conditions than the general population. Recent reforms in the Israeli mental health system included reducing the number of psychiatric hospital beds ("Structural Reform"), establishing community- based rehabilitation services ("Rehabilitation Reform"), and the transfer of governmental responsibility to the Health Maintenance Organizations (HMOs) ("Insurance Reform"). We examined how these changes have impacted the physical health of people with severe mental illness as reflected in acute care hospitalizations.

METHODS

Data from the National Psychiatric Case Register were linked with data from the National Hospital Discharges Database for 2000-2019. Acute care discharges from public hospitals were identified for people who had a psychiatric hospitalization with a diagnosis of severe mental illness (SMI, ICD-10 codes F10-F69 or F90-F99) within the preceding 5 years. The discharge rate of SMI patients was compared to that of the total population by age, diagnosis group, and period of hospitalization. Total and age-standardized discharge ratios (SDR) were calculated, using indirect standardization.

RESULTS

The SDR for total acute care hospitalizations showed that discharge rates in 2016-2019 were 2.7 times higher for the SMI population than expected from the total population. The highest SDR was for external causes (5.7), followed by respiratory diseases (4.4), infectious diseases (3.9), skin diseases (3.7) and diabetes (3.3). The lowest SDR was for cancer (1.6). The total discharge rate ratio was lowest at ages 65-74 (2.2) and highest at ages 45-54 (3.2). The SDR was lowest for females at ages 25-34 (2.1) and for males at ages 18-24 (2.3). SDRs increased over the study period for all diagnoses. This increasing trend slowed at the end of the period, and between 2012-2015 and 2016-2019 there was a small decrease for skin and liver diseases, the SDR was stable for cancer and the increase was smaller for respiratory, infectious and circulatory diseases and diabetes.

CONCLUSION

This study showed higher hospitalization rates in people with SMI compared to the total population. These differences increased between 2000 and 2019 following the opening of alternative services in the community, possibly due to a higher likelihood of psychiatric hospitalization only for those with more severe mental disease. We recommend that general practitioners and mental health professionals in the community be made aware of the essential importance of good physical healthcare, and collaborate on health promotion and disease prevention in the SMI population.

Talking about Health: A Topic Analysis of Narratives from Individuals with Schizophrenia and Other Serious Mental Illnesses

Individuals with schizophrenia have higher mortality and shorter lifespans. There are a multitude of factors which create these conditions, but one aspect is worse physical health, particularly cardiovascular and metabolic health. Many interventions to improve the health of individuals with schizophrenia have been created, but on the whole, there has been limited effectiveness in improving quality of life or lifespan. One potential new avenue for inquiry involves a more patient-centric perspective; understanding aspects of physical health most important, and potentially most amenable to change, for individuals based on their life narratives. This study used topic modeling, a type of Natural Language Processing (NLP) on unstructured speech samples from individuals (n = 366) with serious mental illness, primarily schizophrenia, in order to extract topics. Speech samples were drawn from three studies collected over a decade in two geographically distinct regions of the United States. Several health-related topics emerged, primarily centered around food, living situation, and lifestyle (e.g., routine, hobbies). The implications of these findings for how individuals with serious mental illness and schizophrenia think about their health, and what may be most effective for future health promotion policies and interventions, are discussed.

Advanced Brain-Age in Psychotic Psychopathology: Evidence for Transdiagnostic Neurodevelopmental Origins

Schizophrenia is characterized by abnormal brain structure such as global reductions in gray matter volume. Machine learning models trained to estimate the age of brains from structural neuroimaging data consistently show advanced brain-age to be associated with schizophrenia. Yet, it is unclear whether advanced brain-age is specific to schizophrenia compared to other psychotic disorders, and whether evidence that brain structure is "older" than chronological age actually reflects neurodevelopmental rather than atrophic processes. It is also unknown whether advanced brain-age is associated with genetic liability for psychosis carried by biological relatives of people with schizophrenia. We used the Brain-Age Regression Analysis and Computation Utility Software (BARACUS) prediction model and calculated the residualized brain-age gap of 332 adults (163 individuals with psychotic disorders: 105 schizophrenia, 17 schizoaffective disorder, 41 bipolar I disorder with psychotic features; 103 first-degree biological relatives; 66 controls). The model estimated advanced brain-ages for people with psychosis in comparison to controls and relatives, with no differences among psychotic disorders or between relatives and controls. Specifically, the model revealed an enlarged brain-age gap for schizophrenia and bipolar disorder with psychotic features. Advanced brain-age was associated with lower cognitive and general functioning in the full sample. Among relatives, cognitive performance and schizotypal symptoms were related to brain-age gap, suggesting that advanced brain-age is associated with the subtle expressions associated with psychosis. Exploratory longitudinal analyses suggested that brain aging was not accelerated in individuals with a psychotic disorder. In sum, we found that people with psychotic disorders, irrespective of specific diagnosis or illness severity, show indications of non-progressive, advanced brain-age. These findings support a transdiagnostic, neurodevelopmental formulation of structural brain abnormalities in psychotic psychopathology.

Cardiovascular Risk for Patients With and Without Schizophrenia, Schizoaffective Disorder, or Bipolar Disorder

Background

To compare estimated 10‐year and 30‐year cardiovascular risk in primary care patients with and without serious mental illness (SMI; bipolar disorder, schizophrenia, or schizoaffective disorder).

Methods and Results

All patients aged 18 to 75 years with a primary care visit in January 2016 to September 2018 were included and were grouped into those with and without SMI using diagnosis codes. Ten‐year cardiovascular risk was estimated using atherosclerotic cardiovascular disease scores for patients aged 40 to 75 years without cardiovascular disease; 30‐year cardiovascular risk was estimated using Framingham risk scores for patients aged 18 to 59 years without cardiovascular disease. Demographic, vital sign, medication, diagnosis, and health insurance data were collected from the electronic health record by a clinical decision support system. Descriptive statistics examined unadjusted differences, while general linear models examined differences for continuous variables and logistic regression models for categorical variables. Models were then adjusted for age, sex, race, ethnicity, and insurance type. A total of 11 333 patients with SMI and 579 924 patients without SMI were included. After covariate adjustment, 10‐year cardiovascular risk was significantly higher in patients with SMI (mean, 9.44%; 95% CI, 9.29%–9.60%) compared with patients without SMI (mean, 7.99%; 95% CI, 7.97–8.02). Similarly, 30‐year cardiovascular risk was significantly higher in those with SMI (25% of patients with SMI in the highest‐risk group compared with 11% of patients without SMI; P<0.001). The individual cardiovascular risk factors contributing most to increased risk for those with SMI were elevated body mass index and smoking. Among SMI subtypes, patients with bipolar disorder had the highest 10‐year cardiovascular risk, while patients with schizoaffective disorder had the highest 30‐year cardiovascular risk.

Conclusions

The significantly increased cardiovascular risk associated with SMI is evident even in young adults. This suggests the importance of addressing uncontrolled major cardiovascular risk factors in those with SMI at as early an age as possible.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02451670.

Genome-wide analysis reveals genetic overlap between alcohol use behaviours, schizophrenia and bipolar disorder and identifies novel shared risk loci

BACKGROUND AND AIM

Schizophrenia (SCZ) and bipolar disorder (BD) have a high comorbidity of alcohol use disorder (AUD), and both comorbid AUD and excessive alcohol consumption (AC) have been linked to greater illness severity. We aimed to identify genomic loci jointly associated with SCZ, BD, AUD and AC to gain further insights into their shared genetic architecture.

DESIGN

We analysed summary data (P values and Z scores) from genome-wide association studies (GWAS) using conjunctional false discovery rate (conjFDR) analysis, which increases power to discover shared genomic loci. We functionally characterized the identified loci using publicly available biological resources.

SETTING

AUD and AC data provided by the Million Veteran Program, derived from the United States Department of Veterans Affairs Healthcare System. SCZ and BD data provided by the Psychiatric Genomics Consortium, based on cohorts from countries in Europe, North America and Australia.

PARTICIPANTS

AUD (34 658 cases, 167 346 controls), AC (n = 200 680), SCZ (31 013 cases and 38 918 controls), BD (20 352 cases and 31 358 controls). All participants were of European ancestry.

MEASUREMENTS

Genomic loci shared between alcohol traits, SCZ and BD at conjFDR <0.05.

FINDINGS

Conditional Q-Q plots showed single-nucleotide polymorphism (SNP) enrichment for both alcohol traits across different levels of significance with SCZ and BD, and vice versa. Using conjFDR analysis we leveraged this genetic enrichment and identified several loci shared between SCZ and AUD (n = 28) and AC (n = 24), BD and AUD (n = 2) and AC (n = 8) at conjFDR <0.05. Among these loci, 24 are novel for AUD, 15 are novel for AC, three are novel for SCZ and one is novel for BD. There was a mixture of same and opposite effect directions among the shared loci.

CONCLUSIONS

Alcohol use disorder and alcohol consumption share genomic loci with the psychiatric disorders schizophrenia and bipolar disorder with a mixed pattern of effect directions, indicating a complex genetic relationship between the phenotypes.

A potential probiotic bacterium for antipsychotic-induced metabolic syndrome: mechanisms underpinning how Akkermansia muciniphila subtype improves olanzapine-induced glucose homeostasis in mice

BACKGROUND

Olanzapine (OLZ) is one of the most effective atypical antipsychotics but is associated with severe metabolic side effects, in which the gut microbiota plays an important role. Akkermansia muciniphila (A. muciniphila; Akk), a Gram-negative anaerobic bacterium in the intestine, can potentially improve metabolic syndrome.

OBJECTIVE

This study investigated the effect and underlying mechanisms of an A. muciniphila subtype (A. muciniphila^sub; Akk^sub) on OLZ-induced metabolic dysfunction in lean and obese mice.

METHODS

C57BL/6 female mice were fed a high-fat diet to induce obesity or normal chow for 8 weeks before OLZ treatment for 16 weeks. During the treatment period, mice in each group were orally administrated A. muciniphila^sub. Weight gain, glucose and lipid metabolism, and inflammation were evaluated.

RESULTS

A. muciniphila^sub decreased OLZ-related weight gain only at week 16 in lean mice and significantly alleviated OLZ-induced hyperglycemia irrespective of diet. This was accompanied by reduced levels of glucose-6-phosphatase (G6Pase) and phosphoenolpyruvate carboxykinase (PEPCK)-key enzymes in hepatic gluconeogenesis-and OLZ-associated insulin resistance. Moreover, OLZ-induced increases in serum interleukin (IL)-6 and tumor necrosis factor (TNF)-α levels were improved by A. muciniphila^sub in both obese and lean mice. OLZ did not increase serum lipid levels or hepatic fat accumulation.

CONCLUSIONS

A. muciniphila^sub improves OLZ-related hyperglycemia via regulation of G6Pase and PEPCK levels and insulin resistance. Moreover, A. muciniphila^sub alleviates systemic inflammation caused by OLZ. A. muciniphila^sub is a promising probiotic treatment for OLZ-induced metabolic dysfunction.

The facilitators and barriers to physical activity scale for people with mental illness in Taiwan: development and validation

PURPOSE

The purposes of this study were to develop a new measure, the Facilitators and Barriers to Physical Activity Scale for People with Mental Illness (FBPAS-MI) and to validate the psychometrics.

METHODS

This study included two phases. In Phase I, a literature review and five focus groups were conducted to develop an item bank. Then, expert consultation and cognitive interviews were used for content validity. In Phase II, 147 participants with severe mental illness were recruited from 10 community-based psychiatric rehabilitation centers in Taiwan to examine the psychometrics. Principal axis factoring method with direct oblique rotation was used to identify the underlying constructs of FBPAS-MI. Concurrent validity, internal consistency and test-retest reliability were examined.

RESULTS

The results revealed five domains in the facilitator subscale (15 items) and two domains in the barrier subscale (11 items). Both subscales showed satisfactory internal consistency (all Cronbach's α >0.80); the concurrent validity and test-retest reliability were established.

CONCLUSIONS AND IMPLICATIONS OF PRACTICE

This study confirmed that the FBPAS-MI is a valid and reliable scale to understand perceived facilitators and barriers to physical activity for severe mental illness. The FBPAS-MI can provide useful information in the development of individualized health promotion program for this population.Implications for RehabilitationThe Facilitators and Barriers to Physical Activity Scale for People with Mental Illness (i.e., FBPAS-MI) is a valid and reliable assessment to examine key factors affecting physical activity participation among people with severe mental illness.Psychiatric rehabilitation practitioners could use the FBPAS-MI to help develop and tailor individualized physical activity promotion programs based on identified facilitators and barriers to activity.

Twelve-Weeks of Bench-Step Exercise Training Ameliorates Cardiopulmonary Fitness and Mood State in Patients with Schizophrenia: A Pilot Study

Background and objectives: Unhealthy, physically inactive lifestyles increase the risk of future cardiovascular events and impaired physical fitness in individuals with schizophrenia. Insufficient literature exists to provide fundamental information about appropriate exercise training modality for this population. This pilot study preliminarily investigated the effects of a 12-week moderate-intensity bench-step exercise training (BSET) program on cardiopulmonary fitness, mood state, and cognition in patients with schizophrenia. Methods: Twenty-eight patients with schizophrenia completed this study. The participants were allocated into either bench-step exercise-training (BSET; N = 14) or control (CTRL; N = 14) groups according to their preferences. The BSET group received a 12-week bench-step intervention, whereas the CTRL group did not participate in any training. The Beck Depression Inventory-II (BDI-II), 6-min walk test (6MWD), and Symbol Digit Modalities Test (SDMT) were assessed at baseline (PRE) and at the end of the intervention (POST) to determine mood state, endurance fitness, and attention, respectively. Results: After a 12-week BSET intervention, the 6MWD was significantly increased in the BSET (p = 0.007) but not in the CTRL (p > 0.05). The participants with BSET intervention showed a significant decrease in BDI-II at the end of the intervention (p = 0.03). However, SDMT scores were not different in both BSET and CTRL (p > 0.05). Conclusions: This study demonstrated that the 12-week intervention of moderate-intensity bench-step exercise training (frequency: 1 session/week; each session of 30 min; step cadence: 96 beats/min) might effectively enhance cardiopulmonary fitness and mood state in patients with schizophrenia. However, attention did not change after the bench-step exercise intervention.

A comparison of the metabolic side-effects of the second-generation antipsychotic drugs risperidone and paliperidone in animal models

BACKGROUND

The second generation antipsychotic drugs represent the most common form of pharmacotherapy for schizophrenia disorders. It is now well established that most of the second generation drugs cause metabolic side-effects. Risperidone and its active metabolite paliperidone (9-hydroxyrisperidone) are two commonly used antipsychotic drugs with moderate metabolic liability. However, there is a dearth of preclinical data that directly compares the metabolic effects of these two drugs, using sophisticated experimental procedures. The goal of the present study was to compare metabolic effects for each drug versus control animals.

METHODS

Adult female rats were acutely treated with either risperidone (0.1, 0.5, 1, 2, 6 mg/kg), paliperidone (0.1, 0.5, 1, 2, 6 mg/kg) or vehicle and subjected to the glucose tolerance test; plasma was collected to measure insulin levels to measure insulin resistance with HOMA-IR. Separate groups of rats were treated with either risperidone (1, 6 mg/kg), paliperidone (1, 6 mg/kg) or vehicle, and subjected to the hyperinsulinemic euglycemic clamp.

RESULTS

Fasting glucose levels were increased by all but the lowest dose of risperidone, but only with the highest dose of paliperidone. HOMA-IR increased for both drugs with all but the lowest dose, while the three highest doses decreased glucose tolerance for both drugs. Risperidone and paliperidone both exhibited dose-dependent decreases in the glucose infusion rate in the clamp, reflecting pronounced insulin resistance.

CONCLUSIONS

In preclinical models, both risperidone and paliperidone exhibited notable metabolic side-effects that were dose-dependent. Differences between the two were modest, and most notable as effects on fasting glucose.

A follow-up study of metabolic syndrome in schizophrenia

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

The overall and sex- and age-group specific incidence rates of cancer in people with schizophrenia: a population-based cohort study

AIMS

Decades of research show that people with schizophrenia have an increased risk of death from cancer; however, the relationship between schizophrenia and cancer incidence remains less clear. This population-based study investigates the incidence of seven common types of cancer among people with a hospital diagnosis of schizophrenia and accounting for the effects of age, sex and calendar time.

METHODS

This population-based study used 1990-2013 data from three nationwide Swedish registries to calculate the incidence (in total, by age group and by sex) of any cancer and of lung, oesophageal, pancreatic, stomach, colon, (in men) prostate and (in women) breast cancer in 111 306 people with a hospital diagnosis of schizophrenia. The incidence in people with diagnosed schizophrenia was compared with the incidence in the general population. Risk estimates accounted for the effects of calendar time.

RESULTS

In 1 424 829 person-years of follow-up, schizophrenia did not confer an overall higher cancer risk (IRR 1.02, 95% CI 0.91-1.13) but was associated with a higher risk for female breast (IRR 1.19, 95% CI 1.12-1.26), lung (IRR 1.42, 95% CI 1.28-1.58), oesophageal (IRR 1.25, 95% CI 1.07-1.46) and pancreatic (IRR 1.10, 95% CI 1.01-1.21) and a lower risk of prostate (IRR 0.66, 95% CI 0.55-0.79) cancer. Some age- and sex-specific differences in risk were observed.

CONCLUSIONS

People with schizophrenia do not have a higher overall incidence of cancer than people in the general population. However, there are significant differences in the risk of specific cancer types overall and by sex calling for efforts to develop disease-specific prevention programmes. In people with schizophrenia, higher risk generally occurs in those <75 years.

Neurological soft signs (NSS) and brain morphology in patients with chronic schizophrenia and healthy controls

Subtle abnormalities in sensory integration, motor coordination and sequencing of complex motor acts or neurological soft signs (NSS) are characteristic phenomena in patients with schizophrenia at any stage of the illness. Previous MRI studies in schizophrenia found NSS to be associated with cortical, thalamic and cerebellar changes. Since these studies mainly focused on first-episode or recent onset schizophrenia, the cerebral correlates of NSS in chronic schizophrenia remained rather unclear. 49 middle-aged patients with chronic schizophrenia with a mean duration of illness of 20.3 ± 14.0 years and 29 healthy subjects matched for age and sex were included. NSS were examined on the Heidelberg Scale and correlated to grey matter (GM) by using whole brain high resolution magnetic resonance imaging (3 Tesla) with SPM12/CAT12 analyses. As expected, NSS in patients were significantly (p≤0.001) elevated in contrast to healthy controls, a finding, which not only applied to NSS total score, but also to the respective subscales "motor coordination", "sensory integration", "complex motor tasks", "right/left and spatial orientation" and "hard signs". Within the patient group NSS total scores were significantly correlated to reduced GM in right lingual gyrus, left parahippocampal gyrus, left superior temporal gyrus, left thalamus (medial dorsal nucleus) and left posterior lobe of the cerebellum (declive). Respective negative associations could also be revealed for the subscales "motor coordination", "complex motor tasks" and "right/left and spatial orientation". These findings remained significant after FWE-correction for multiple comparisons and were confirmed when years of education, chlorpromazine-equivalents or variables indicating the severity of psychopathology were introduced as additional covariates. According to our results lingual, parahippocampal, superior temporal, inferior and middle frontal gyri, thalamus and cerebellum have to be considered as important sites of NSS in chronic schizophrenia. That these findings only applied for patients but not healthy controls may indicate a different pathogenesis of NSS.

Clinical determinants of physical activity and sedentary behaviour in individuals with schizophrenia

INTRODUCTION

Modifiable lifestyle factors such as physical activity (PA) have ameliorative effects on commonly reported health conditions in schizophrenia like cardiovascular diseases and diabetes. Similarly, reduction in sedentary behaviour (SB) promotes better physical health. However, engaging individuals with schizophrenia in PA and less SB can be challenging because of symptoms of schizophrenia. The aims of the present study are (i) to examine the profiles of PA and SB in individuals with schizophrenia; and (ii) to identify their respective clinical determinants.

METHOD

157 individuals with schizophrenia were recruited. PA and SB were examined via the Global Physical Activity Questionnaire (GPAQ). Psychopathology was assessed using the Positive and Negative Syndrome Scale (PANSS). Potential clinical predictors of PA and SB were identified via univariate regression analyses and subsequently included in the final multiple regression models for PA and SB respectively.

RESULTS

63.7% met the WHO PA guidelines. Work-related activity was the largest domain specific contribution towards PA. Mean duration of SB was approximately 9 h and about 57.3% reported at least 8 h or more of SB daily. Positive symptom was associated with engagement in PA and reduced duration of SB. Negative symptom was associated with greater SB.

CONCLUSION

With emerging evidence of deleterious health effects of SB independent of PA, it is important to monitor SB in individuals with schizophrenia, particularly those presenting with negative symptoms. While the lack of treatment response for negative symptoms remains a challenge, effort should be made to reduce duration of SB.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Factors related to malnutrition in community-dwelling patients with schizophrenia

PURPOSE

This study aims to identify demographic, clinical, and nutritional factors related to malnutrition in community-dwelling patients with schizophrenia.

DESIGN AND METHODS

We used a descriptive cross-sectional design. Between June and July 2016, 188 community-dwelling patients with schizophrenia were included in this study.

FINDINGS

Of the 188 participants, 4.3% were classified as malnourished, and 40.4% were at risk of malnutrition. Living status, body weight, and appetite were significant factors related to malnutrition in community-dwelling patients with schizophrenia.

PRACTICE IMPLICATION

Assessment of nutritional status should be considered along with demographic and nutritional factors in community-dwelling patients with schizophrenia.

Undiagnosed cardiovascular disease prior to cardiovascular death in individuals with severe mental illness

OBJECTIVE

To examine whether individuals with schizophrenia (SCZ) or bipolar disorder (BD) had equal likelihood of not being diagnosed with cardiovascular disease (CVD) prior to cardiovascular death, compared to individuals without SCZ or BD.

METHODS

Multivariate logistic regression analysis including nationwide data of 72 451 cardiovascular deaths in the years 2011-2016. Of these, 814 had a SCZ diagnosis and 673 a BD diagnosis in primary or specialist health care.

RESULTS

Individuals with SCZ were 66% more likely (OR: 1.66; 95% CI: 1.39-1.98), women with BD were 38% more likely (adjusted OR: 1.38; 95% CI: 1.04-1.82), and men with BD were equally likely (OR: 0.88, 95% CI: 0.63-1.24) not to be diagnosed with CVD prior to cardiovascular death, compared to individuals without SMI. Almost all (98%) individuals with SMI and undiagnosed CVD had visited primary or specialized somatic health care prior to death, compared to 88% among the other individuals who died of CVD.

CONCLUSION

Individuals with SCZ and women with BD are more likely to die due to undiagnosed CVD, despite increased risk of CVD and many contacts with primary and specialized somatic care. Strengthened efforts to prevent, recognize, and treat CVD in individuals with SMI from young age are needed.

Childhood trauma- and cannabis-associated microstructural white matter changes in patients with psychotic disorder: a longitudinal family-based diffusion imaging study

BACKGROUND

Decreased white matter (WM) integrity in patients with psychotic disorder has been a consistent finding in diffusion tensor imaging (DTI) studies. However, the contribution of environmental risk factors to these WM alterations is rarely investigated. The current study examines whether individuals with (increased risk for) psychotic disorder will show increased WM integrity change over time with increasing levels of childhood trauma and cannabis exposure.

METHODS

DTI scans were obtained from 85 patients with a psychotic disorder, 93 non-psychotic siblings and 80 healthy controls, of which 60% were rescanned 3 years later. In a whole-brain voxel-based analysis, associations between change in fractional anisotropy (ΔFA) and environmental exposures as well as interactions between group and environmental exposure in the model of FA and ΔFA were investigated. Analyses were adjusted for a priori hypothesized confounding variables: age, sex, and level of education.

RESULTS

At baseline, no significant associations were found between FA and both environmental risk factors. At follow-up as well as over a 3-year interval, significant interactions between group and, respectively, cannabis exposure and childhood trauma exposure in the model of FA and ΔFA were found. Patients showed more FA decrease over time compared with both controls and siblings when exposed to higher levels of cannabis or childhood trauma.

CONCLUSIONS

Higher levels of cannabis or childhood trauma may compromise connectivity over the course of the illness in patients, but not in individuals at low or higher than average genetic risk for psychotic disorder, suggesting interactions between the environment and illness-related factors.

Factors Affecting the Management of Somatic Comorbidity in Tunisian Patients with Schizophrenia

Schizophrenia is often accompanied by somatic comorbidities, which make the management challenge of such patients more difficult. In this study, we proposed to identify the sociodemographic and clinical factors correlating with somatic comorbidities in patients with schizophrenia to facilitate screening and prevention. It was a retrospective descriptive study of 78 schizophrenia patients in clinical remission and followed in outpatient psychiatry. In addition to the acquired records, other data were provided by the clinical and biological examinations performed for each patient. The evaluation of the therapeutic adherence was carried out using the Drug Attitude Inventory (DAI).Seventy-six patients (97.4%) had somatic comorbidities with a mean of 3.83 (± 1.81). This number increased significantly in males, older patients, couples, urban patients, and those receiving a combination therapy. According to a multivariate study, the four predictors of an increased risk of comorbidities were age, use of psychoactive substances, waist size and therapeutic adherence.Our findings focus on somatic comorbidities risk in schizophrenia patients, requiring particular vigilance in their follow-up, and suggest some modifiable clinical factors that might be a preferred target for reducing or preventing the occurrence of such disorders.

Can We Improve Physical Health Monitoring for Patients Taking Antipsychotics on a Mental Health Inpatient Unit?

BACKGROUND

Patients with severe mental illness are at risk of medical complications, including cardiovascular disease, metabolic syndrome, and diabetes. Given this vulnerability, combined with metabolic risks of antipsychotics, physical health monitoring is critical. Inpatient admission is an opportunity to screen for medical comorbidities. Our objective was to improve the rates of physical health monitoring on an inpatient psychiatry unit through implementation of an electronic standardized order set.

METHODS

Using a clinical audit tool, we completed a baseline retrospective audit (96 eligible charts) of patients aged 18 to 100 years, discharged between January and March 2012, prescribed an antipsychotic for 3 or more days. We then developed and implemented a standard electronic admission order set and provided training to inpatient clinical staff. We completed a second chart audit of patients discharged between January and March 2016 (190 eligible charts) to measure improvement in physical health monitoring and intervention rates for abnormal results.

RESULTS

In the 2012 audit, thyroid-stimulating hormone (TSH), blood pressure, blood glucose, fasting lipids, electrocardiogram (ECG), and height/weight were measured in 71%, 92%, 31%, 36%, 51%, and 75% of patients, respectively. In the 2016 audit, TSH, blood pressure, blood glucose, fasting lipids, ECG, and height/weight were measured in 86%, 96%, 96%, 64%, 87%, and 71% of patients, respectively. There were statistically significant improvements (P < 0.05) in monitoring rates for blood glucose, lipids, ECG, and TSH. Intervention rates for abnormal blood glucose and/or lipids (feedback to family doctor and/or patient, consultation to hospitalist, endocrinology, and/or dietician) did not change between 2012 and 2016.

CONCLUSIONS

Electronic standardized order set can be used as a tool to improve screening for physical health comorbidity in patients with severe mental illness receiving antipsychotic medications.

Lifestyles of Patients with Functional Psychosis Compared to Those of a Sample of the Regional General Population: Findings from a Study in a Community Mental Health Service of the Veneto Region, Italy

Unhealthy lifestyles contribute, with other risk factors, to the high prevalence of mortality and physical comorbidity among mental patients compared to the general population. We collected data on the lifestyles of 193 subjects with psychosis in contact with a Community Mental Health Service in north-eastern Italy and compared them with a representative sample (total: 3219 subjects) of the general population of the same region. Diet, exercise, smoking and alcohol consumption were worse in mental patients. A higher percentage of patients was overweight or obese. The associations between socio-demographic and lifestyles variables showed that older patients exercise less, female patients tend to smoke and use alcohol less, while more educated patients tend to have higher alcohol consumption levels. Mental patients have unhealthier lifestyles and they appear to be more refractory to recommendations than the general population, indicating the necessity of specific health promotion programmes in this population.

Discovery of natural product inhibitors of phosphodiesterase 10A as novel therapeutic drug for schizophrenia using a multistep virtual screening

The major complaint that most of the schizophrenic patients' face is the cognitive impairment which affects the patient's quality of life. The current antipsychotic drugs treat only the positive symptoms without alleviating the negative or cognitive symptoms of the disease. In addition, the existing therapies are known to produce extrapyramidal side effects that affect the patient adherence to the treatment. PDE10A inhibitor is the new therapeutic approach which has been proven to be effective in alleviating the negative and cognitive symptoms of the disease. A number of PDE10A inhibitors have been developed, but no inhibitor has made it beyond the clinical trials so far. Thus, the present study has been conducted to identify a PDE10A inhibitor from natural sources to be used as a lead compound for the designing of novel selective PDE10A inhibitors. Ligand and structure-based pharmacophore models for PDE10A inhibitors were generated and employed for virtual screening of universal natural products database. From the virtual screening results, 37 compounds were docked into the active site of the PDE10A. Out of 37 compounds, three inhibitors showed the highest affinity for PDE10A where UNPD216549 showed the lowest binding energy and has been chosen as starting point for designing of novel PDE10A inhibitors. The structure-activity-relationship studies assisted in designing of selective PDE10A inhibitors. The optimization of the substituents on the phenyl ring resulted in 26 derivatives with lower binding energy with PDE10A as compared to the lead compound. Among these, MA 8 and MA 98 exhibited the highest affinity for PDE10A with binding energy (-10.90 Kcal/mol).

Long-term psychiatric inpatients' perspectives on weight gain, body satisfaction, diet and physical activity: a mixed methods study

BACKGROUND

Obesity is a significant problem for people with serious mental illness. We aimed to consider body size from the perspective of long-stay psychiatric inpatients, focussing on: weight gain and its causes and impacts; diet and physical activity; and the perceived ability to make meaningful change in these domains.

METHOD

A mixed methods study with 51 long-term psychiatric forensic and rehabilitation inpatients using semi-structured interviews combined with biometric and demographic data.

RESULTS

94% of participants were overweight or obese (mean BMI 35.3, SD 8.1). They were concerned about their weight, with 75% of them attempting to lose weight. Qualitative responses indicated low personal effectiveness and self-stigmatisation. Participants viewed their weight gain as something 'done to them' through medication, hospitalisation and leave restrictions. A prevailing theme was that institutional constraints made it difficult to live a healthy life (just the way the system is). Many had an external locus of control, viewing weight loss as desirable but unachievable, inhibited by environmental factors and requiring a quantum of motivation they found hard to muster. Despite this, participants were thoughtful and interested, had sound ideas for weight loss, and wished to be engaged in a shared endeavour to achieve better health outcomes. Consulting people as experts on their experiences, preferences, and goals may help develop new solutions, remove unidentified barriers, and improve motivation.

CONCLUSIONS

The importance of an individualised, multifactorial approach in weight loss programmes for this group was clear. Patient-led ideas and co-design should be key principles in programme and environmental design.

The Effects of Tobacco Smoking, and Prenatal Tobacco Smoke Exposure, on Risk of Schizophrenia: A Systematic Review and Meta-Analysis

Background

The association between cigarette smoking and schizophrenia is well established. However, up to 90% of people with schizophrenia begin smoking before the onset of their illness; thus, smoking could be an independent risk factor for schizophrenia. Prenatal exposure to maternal cigarette smoke is also associated with psychiatric problems in adolescence. Therefore, our aim was to undertake a systematic review and meta-analysis to explore the effect of smoking, and prenatal smoke exposure, on risk of schizophrenia.

Method

We systematically searched Medline, EMBASE, PsychInfo, Maternity and Infant Care, and Web of Science (from inception to February 2018) to identify comparative observational studies of the risk of schizophrenia in relation to smoking status. Measures of relative risk (RR) were pooled in a meta-analysis with 95% confidence intervals (CI), using random effects model.

Results

Twelve studies (9 cohort, 3 case-control) were included. Odds ratios (OR) and hazard ratios (HR) were pooled together to estimate pooled relative risks and estimates combined in a meta-analysis on an assumption of constant risk over time. Smokers had a significantly increased risk of schizophrenia compared with nonsmokers (RR = 1.99, 95% CI = 1.10% to 3.61%, I2 = 97%, 5 studies). Exposure to prenatal smoke increased the risk of schizophrenia by 29% (95% CI = 1.10% to 1.51%, I2 = 71%, 7 studies). Sensitivity analyses identified no significant differences between the results from studies reporting OR and hazard ratio.

Conclusions

Our findings suggest smoking, and prenatal smoke exposure, may be an independent risk factor for schizophrenia. Care should be taken when inferring causation, given the observational nature of the studies.

Implications

In this meta-analysis of 12 studies, smokers had a significantly increased risk of schizophrenia compared with nonsmokers. Exposure to prenatal tobacco smoke also increased the risk of schizophrenia by 29% compared with those with no exposure to prenatal tobacco smoke. Our findings suggest that smoking, and prenatal tobacco smoke exposure, may be independent risk factors for schizophrenia. These results may have important public health implications for decreasing the incidence of schizophrenia. The possibility of a causal link between smoking and schizophrenia warrants further investigation.

[Physical activity in patients with schizophrenia: From neurobiology to clinical benefits]

Schizophrenia is a severe chronic mental disorder that mainly manifests by positive symptoms, negative symptoms, disorganized behavior and thought and cognitive impairments. Taken together, these symptoms have substantial impact on quality of life, well-being and functional outcome. Patients with schizophrenia have dramatically higher levels of cardiovascular and metabolic morbidity than the general population due to poor physical fitness and to sedentary lifestyle. They have a reduced life expectancy, and an excess mortality being two or three times more than that in the general population. Moreover, despite major therapeutic advances in the overall management of these patients, some symptomatic dimensions, and more specifically the negative and cognitive ones, remain to be resistant to the usual pharmacological approaches. Moreover, antipsychotics can also reinforce the global cardiovascular risk due to side effects and low neurometabolic tolerance. The benefits of physical activity on health are now well described in the general population and in many medical diseases. More recently, physical activity has also found its place as an adjuvant therapy in severe mental illnesses, particularly in schizophrenia. In the literature physical activity programs, in addition to pharmacological treatments, appear to be feasible in patients and improve both physical and mental health as well as functional outcome. Clinical benefits of physical activity would be underpinned by biological and cerebral mechanisms, which remain unclear. In this review, we propose to present a state of the art and to present an update of the interests of physical activity in the management of patients with schizophrenia. We emphasize the clinical benefits of physical activity regarding the different symptomatic dimensions and its impact specifically on cognitive deficits. Finally, we describe the various underlying pathophysiological mechanisms in particular in the neurobiological, cerebral and physiological fields. We then discuss the barriers, facilitators and motivating factors towards physical activity to enhance health promotion initiatives, to optimize resource allocation when delivering physical activity programs in clinical practice, and to maximize physical activity participation. Physical activity appears to be an original and novel adjunctive therapeutic approach in the management of patients with schizophrenia and would both reduce schizophrenic symptoms and act like pro-cognitive therapy, improve quality of life and long-term functioning in daily life and reduce cardiovascular comorbidities. However, efforts are still needed to increase the motivating factors and adherence towards physical activity participation for people with schizophrenia.

Total Joint Arthroplasty in Patients With Schizophrenia: How Much Does It Increase the Risk of Complications?

BACKGROUND

Mental illness is an often overlooked comorbidity in the total joint arthroplasty (TJA) population. The purpose of this study was to evaluate the risk of schizophrenia on the outcomes of TJA.

METHODS

The nationwide inpatient sample was used to identify a cohort of 505,840 patients having total hip arthroplasty between 2009 and 2012, of which 953 patients (0.2%) had been diagnosed with schizophrenia. Multivariate logistic regression was used to identify the impact of schizophrenia on short-term medical and surgical complications. Differences in length of stay and discharge disposition were also compared.

RESULTS

Schizophrenic patients are 15 times more likely to have pulmonary insufficiency after surgery (odds ratio [OR] 15.1, P = .0133). Patients were 11 times more likely to have mental status changes (OR 11.1, P = .0002), 3 times more likely to have a mechanical complication of the implant (OR 3.2, P = .0031), and 2 times more likely to require a transfusion (OR 2.4, P < .0001). All-cause medical (OR 2.2, P < .0001) and surgical (OR 1.5, P < .0001) complications were higher in schizophrenic patients. Patients stayed 0.63 days longer in the hospital (P < .0001), and were 3 times more likely to discharge to a facility (OR 2.7, P < .0001).

CONCLUSIONS

TJA in patients with schizophrenia had markedly increased complications. Particularly, pulmonary complications, mechanical complications of the implant, mental status changes, and transfusion rates were higher. Future risk adjustment models should include schizophrenia as a major contributor to increased complications.

Metabolic Syndrome in First Episode Schizophrenia, Based on the National Mental Health Registry of Schizophrenia (NMHR) in a General Hospital in Malaysia: A 10-Year Retrospective Cohort Study

Schizophrenia has been linked with various medical comorbidities, particularly metabolic syndrome. The number of studies on this aspect is lacking in Malaysia. (1) Objective: To investigate metabolic syndrome rates and its associated factors. (2) Method: This is the first 10-year retrospective-outcome study of patients with first episode schizophrenia in Malaysia. Out of 394 patients diagnosed with first episode schizophrenia and registered with the National Mental Health Registry of Schizophrenia (NMHR) in the General Hospital Kuala Lumpur (GHKL) in 2004⁻2005, 174 patients consented to participate in the study. They were interviewed using a Schizophrenia outcome questionnaire and the International Physical Activity Questionnaire (IPAQ). The diagnosis of metabolic syndrome was made using the National Cholesterol Education Program—Third Adult Treatment Panel (NCEP ATP III). (3) Results: All patients’ weight, body mass index, fasting blood sugar, and blood pressure are significantly increased. Sixty-three subjects (36.2%) developed metabolic syndrome while 36 (23.2%) were hypertensive, and 41 (28.1%) were diabetic. Use of fluphenthixol depot (CI = 1.05⁻5.09, OR: 0.84, p = 0.039), reduced physical activity (CI = 0.13⁻1.00, OR: −1.04, p = 0.049), and substance use disorder (CI = 1.40, 13.89, OR: 1.48, p = 0.012) were significantly associated with metabolic syndrome based on univariate analysis. In further multivariate analysis, comorbid substance abuse was the only significant factor associated with metabolic syndrome after adjusting for physical activity and intramuscular depot. (4) Conclusion: Patients with schizophrenia are at high risk of metabolic syndrome. It is important to address substance use problems as an important risk factor of this comorbidity.

Randomised controlled trial of a healthy lifestyle intervention among smokers with psychotic disorders: Outcomes to 36 months

OBJECTIVE

People living with psychotic disorders (schizophrenia spectrum and bipolar disorders) have high rates of cardiovascular disease risk behaviours, including smoking, physical inactivity and poor diet. We report cardiovascular disease risk, smoking cessation and other risk behaviour outcomes over 36 months following recruitment into a two-arm randomised controlled trial among smokers with psychotic disorders.

METHODS

Participants ( N = 235) drawn from three sites were randomised to receive nicotine replacement therapy plus (1) a Healthy Lifestyles intervention delivered over approximately 9 months or (2) a largely telephone-delivered intervention (designed to control for nicotine replacement therapy provision, session frequency and other monitoring). The primary outcome variables were 10-year cardiovascular disease risk and smoking status, while the secondary outcomes included weekly physical activity, unhealthy eating, waist circumference, psychiatric symptomatology, depression and global functioning.

RESULTS

Significant reductions in cardiovascular disease risk and smoking were detected across the 36-month follow-up period in both intervention conditions, with no significant differences between conditions. One-quarter (25.5%) of participants reported reducing cigarettes per day by 50% or more at multiple post-treatment assessments; however, few (8.9%) managed to sustain this across the majority of time points. Changes in other health behaviours or lifestyle factors were modest; however, significant improvements in depression and global functioning were detected over time in both conditions. Participants experiencing worse 'social discomfort' at baseline (e.g. anxiety, mania, poor self-esteem and social disability) had on average significantly worse global functioning, lower scores on the 12-Item Short Form Health Survey physical scale and significantly greater waist circumference.

CONCLUSION

Although the telephone-delivered intervention was designed as a comparison condition, it achieved excellent retention and comparable outcomes. Telephone-delivered smoking cessation support may potentially help to reduce smoking rates among people with psychotic disorders. Discomfort in social situations may also be a useful target for future health interventions, addressing confidence and social skills, and promoting social networks that reduce inactivity.

Effects of the Thai Health Improvement Profile intervention on the physical health and health behaviours of people with schizophrenia: A quasi-experimental study

Physical health problems and unhealthy lifestyle behaviours are common in people with severe mental illness (SMI), leading to high levels of mortality.There is some evidence that nurse-led interventions involving comprehensive health checks may be effective in improving physical health in people with SMI. This quasi-experimental before-and-after study investigated the impacts of the Thai Health Improvement Profile (HIP-T) on the physical health and health behaviours of people with schizophrenia over 1-year. All 105 service-users who volunteered to participate completed the study. There were significant reductions in mean BMI (-0.78 kg/m² , P < .001) and bodyweight (-1.13 kg, P < .001) at post-test. There was also a significant decrease in the total number of "red-flagged" HIP-T items, suggesting lowered potential health risks (P < .001). Overall, 23 patients (22%) were found to have moved to a healthier BMI classification after 1-year. The findings suggest that the HIP-T intervention has potential for improving the physical health of people with SMI when integrated into routine community mental health care.

A Systematic Review of Psychosocial Barriers and Facilitators to Smoking Cessation in People Living With Schizophrenia

Background: People living with schizophrenia are less likely to quit smoking compared with the general population and people living with other psychiatric disorders. Understanding the schizophrenia-specific psychosocial barriers and facilitators to smoking cessation is important for designing effective smoking cessation interventions. We aimed to systematically review research examining psychosocial barriers and facilitators to smoking cessation in people living with schizophrenia. Methods: We followed the PRISMA statement to conduct a systematic literature review examining psychosocial barriers and facilitators to smoking cessation in people living with schizophrenia. We searched EMBASE, Medline, PsycINFO, and CINAHL databases from inception to 14 June 2018 to identify relevant articles. We included peer-reviewed original research articles that examined psychosocial barriers and facilitators to smoking cessation, as well as factors associated with maintenance of smoking habits in people living with schizophrenia spectrum disorders. Qualitative, quantitative, or mixed-methods study designs were included. Three authors screened titles, abstracts, and full-texts using the eligibility criteria. We conducted a narrative synthesis of the data to account for the heterogeneity of study designs. We analyzed qualitative and quantitative studies separately. Results: We identified 685 studies from our systematic search and screened the full-text of 134 articles. The final set of 23 articles included 20 quantitative studies and 3 qualitative studies. The most commonly cited barrier to smoking cessation in people living with schizophrenia was cravings and addiction, followed by a perceived increased risk of negative affect associated with quitting smoking. People living with schizophrenia reported smoking to manage stress and to maintain social relationships. People living with schizophrenia were found to be less likely to receive cessation support from health professionals than smokers without schizophrenia. Health concerns were the most commonly mentioned facilitator to quit smoking. Conclusions: People living with schizophrenia experience a wide range of barriers to smoking cessation. The influence of these barriers on smoking cessation likelihood may be greater among people living with schizophrenia than people without psychiatric disorders. Health professionals play an important role in smoking cessation for people living with schizophrenia and should consider barriers and facilitators identified in this review to support quitting in this vulnerable population.

Transforming Health Care Through Interprofessional Graduate Education

PURPOSE

We provide an overview of the Recovery-based Interprofessional Distance Education (RIDE) rotation for graduate students in psychiatric mental health (PMH) nursing, pharmacy, nutrition, and exercise physiology, with faculty from the four professions represented.

CONCLUSIONS

Interprofessional education can enhance team concepts in these professions and is viewed positively by students and faculty.

PRACTICE IMPLICATIONS

Interprofessional learning opportunities prepare graduates to contribute to team-based care. We urge colleagues to join us in providing meaningful IPE experiences to students at all levels, with the goal of optimizing health care for all persons with mental health treatment needs.

Physical Health, Medication, and Healthcare Utilization among 70-Year-Old People with Schizophrenia: A Nationwide Danish Register Study

OBJECTIVES

In light of the excess early mortality in schizophrenia, mainly due to physical illnesses, we investigated medical comorbidity, use of medication, and healthcare utilization among individuals with schizophrenia who survived into older ages to uncover potential factors contributing to their longevity.

DESIGN

A nationwide register-based case-control study comparing 70-year-olds with and without schizophrenia.

SETTING

Cases were drawn from the Danish Psychiatric Central Register. Age- and sex-matched controls were drawn from the general population via the Civil Registration System.

PARTICIPANTS

All Danish inhabitants who were diagnosed and registered with early onset schizophrenia in 1970-1979 and still alive at age 70 years. Controls alive at age 70 years.

MEASUREMENTS

Chronic medical comorbidity, medications, and inpatient and outpatient healthcare utilization extracted from Danish healthcare registers.

RESULTS

Older adults with schizophrenia did not differ from controls with regard to registered chronic medical illnesses, but were significantly less likely to receive medication for cardiovascular diseases (OR: 0.65; 99.29% CI: 0.50, 0.83) and more likely to be treated with analgesics (OR: 1.46; 99.29% CI: 1.04, 2.05). Overall, hospital admissions and number of days hospitalized were equal to controls, but with significantly fewer general medical outpatient contacts (RR: 0.37; 98.75% CI: 0.24, 0.55).

CONCLUSIONS

Because the literature suggests that excess mortality continues into old age, it is possible that medical diseases were under-registered and/or under-treated. Focus on adequate medical treatment, in particular for cardiovascular disease, is needed. Future integration of psychiatric and general medical healthcare, especially outpatient care, might further optimize health outcomes for older adults with schizophrenia.

Exercise Treatments for Psychosis: A Review

Schizophrenia is a devastating mental illness that has profound effects on a person's health and quality of life. Exercise represents a promising new treatment option that may supplement current psychosocial and pharmacological interventions for psychosis. A large body of work suggests that exercise can improve cardio-metabolic and health behavior and facilitate neurogenesis in areas of the brain that are notably impacted by psychosis. Recent efforts to incorporate exercise as either stand-alone or adjunctive treatment for individuals with schizophrenia range from yoga and light stretching to moderately intense walking, bike riding, or team sports. These interventions suggest that moderately intense exercise may be beneficial for improving both positive and negative symptomatology, cognition and functioning. Indeed, exercise may be beneficial for decreasing risk factors for a wide range of health problems often observed in patients with schizophrenia, including weight gain and metabolic syndrome as well as tobacco and substance use. Given the positive results from interventions in schizophrenia patients, there is an impetus for incorporating exercise in the early stages of the disorder. Notably, individuals at ultrahigh risk (UHR) for psychosis report more sedentary behavior and perceive less benefit from exercise; interventions prior to the onset of the disorder may be helpful for increasing health behaviors, perhaps delaying or preventing the onset of psychosis. Taken together, for individuals with psychosis, exercise may provide holistic benefits for the neural to the social impairments.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transdiagnostic neural markers of emotion-cognition interaction in psychotic disorders

Deficits in working memory (WM) and emotion processing are prominent impairments in psychotic disorders, and have been linked to reduced quality of life and real-world functioning. Translation of knowledge regarding the neural circuitry implementing these deficits into improved diagnosis and targeted treatments has been slow, possibly because of categorical definitions of disorders. Using the dimensional Research Domain Criteria (RDoC) framework, we investigated the clinical and practical utility of transdiagnostic behavioral and neural measures of emotion-related WM disruption across psychotic disorders. Behavioral and functional MRI data were recorded while 53 participants with psychotic disorders and 29 participants with no history of psychosis performed a modified n-back task with fear and neutral distractors. Hierarchical regression analyses showed that psychotic symptoms entered after diagnosis accounted for unique variance in fear versus neutral accuracy and activation in the ventrolateral, dorsolateral, and dorsomedial prefrontal cortex, but diagnostic group entered after psychotic symptoms did not. These results remained even after controlling for negative symptoms, disorganized symptoms, and dysphoria. Finally, worse accuracy and greater prefrontal activity were associated with poorer social functioning and unemployment across diagnostic groups. Present results support the transdiagnostic nature of behavioral and neuroimaging measures of emotion-related WM disruption as they relate to psychotic symptoms, irrespective of diagnosis. They also provide support for the practical utility of these markers in explaining real-world functioning. Overall, these results elucidate key aspects of the RDoC construct of WM maintenance by clarifying its transdiagnostic importance and clinical utility in psychotic disorders. (PsycINFO Database Record

Physical health, community participation and schizophrenia

Our objective is to identify links between physical health and community participation among individuals with schizophrenia or a psychosis mental illness. Semi-structured qualitative and quantitative interviews and community tours were conducted over 10 months ( N = 30). Interviews were transcribed and analyzed using a grounded theory coding strategy. Physical health played an important role in community participation both as a cause and consequence. Key processes included mobility issues impeding physical community involvement; a multi-directional relationship between social relationships, community involvement, and physical health; identity as a mechanism linking physical health problems and community engagement; and the potential for community-based mental health programs.

Association between actigraphy-derived physical activity and cognitive performance in patients with schizophrenia

BACKGROUND

An association between low levels of physical activity and impaired cognitive performance in schizophrenia has been proposed, but most studies have relied on self-report measures of activity. This study examined the association between actigraphy-derived physical activity and cognitive performance adjusting for multiple covariates in patients with schizophrenia.

METHOD

Patients with schizophrenia (n = 199) were recruited from chronic psychiatric wards, and 60 age-, sex- and body mass index-matched comparison participants were recruited from the staff of two hospitals and universities. Physical activity was assessed objectively for 7 days using an ActiGraph. Cognitive performance was assessed with the Cognitrone test from the Vienna Test System and the Grooved Pegboard Test. Demographic variables, metabolic parameters, positive and negative symptoms, duration of illness and hospitalization, and medication use were included as covariates. Pearson correlations and multivariable linear regressions were conducted to examine the associations between physical activity levels and cognitive performance.

RESULTS

Patients with schizophrenia were less physically active and had poorer performance on attention/concentration and speed of processing than the comparison group. Patients with schizophrenia who spent more time in light physical activity showed better performance on attention/concentration (β = 0.198, p = 0.020) and speed of processing (β= -0.169, p = 0.048) tasks than those who were less active. Cognitive performance was also associated with moderate-vigorous physical activity, but the effect was no longer significant once light physical activity had been taken into account.

CONCLUSIONS

This study provides evidence for a positive association between objectively measured light physical activity and cognitive performance in people with schizophrenia, after adjustment for multiple confounders.

Influences on uptake of cancer screening in mental health service users: a qualitative study

BACKGROUND

Cancers are a leading cause of death worldwide. People with mental illness are 30 % more likely to die from cancer than the general population. One reason for this may be low uptake of nationally offered cancer screening tests by people with mental illness. We aimed to identify barriers and facilitators for breast, cervical and bowel cancer screening uptake by people with mental illness in order to inform interventions to promote equal access.

METHODS

The interview study was conducted in both urban and rural settings. The study was informed by the Theoretical Domains Framework, using framework analysis and triangulation across participant groups. Participants included 45 mental health service users (service users) eligible for cancer screening, 29 mental health professionals and 11 professionals involved in cancer screening.

RESULTS

Themes emerging from the data that affected uptake included knowledge of screening programmes by both service users and healthcare providers; knowledge of, and attitudes towards, mental illness; health service-delivery factors; service users' beliefs and concerns about cancer screening, and practical issues. These are relevant to different stages of the screening process. Service users do not receive invitations to screening or cancer testing kits if they are admitted to hospital. They are not routinely invited for screening if they are not registered with a general practitioner (GP). Lack of integrated care means that mental health staff do not know if someone is overdue for a test and cancer screening is often not considered during health promotion. Barriers including information processing problems, the extent to which the screening process aggravates symptoms, poor staff client relationships and travel difficulties vary between individuals. Screening professionals are motivated to help, but may lack time or training to manage mental health needs. Reactive measures are available, but service users must request help which they may find difficult.

CONCLUSIONS

There are specific barriers to cancer screening uptake for mental health service users that prevent equality of care. Interventions that can be personalised are needed at individual, policy and service-delivery levels. Primary and secondary care staff and policy-makers should work together to develop an integrated approach to cancer screening in this population.

An Intervention with Physical Activity and Lifestyle Counseling Improves Health-Related Quality of Life and Shows Small Improvements in Metabolic Risks in Persons with Psychosis

This research studied the effects of a lifestyle intervention on health-related quality of life (HRQoL) and metabolic risk factors in persons with psychosis, using a longitudinal intervention design with a matched reference sample. In participants in the intervention group, scores on the EQ-VAS, which measured HRQoL, improved from 57.6 to 63.3 (SD = 17.8) (p = 0.05), and HDL cholesterol concentration increased from 1.03 to 1.11 (0.19) mmol/l. (p = 0.02). There was no significant change in body weight among participants. The results of this study indicate that a lifestyle intervention based on group meetings improves HRQoL in patients with psychosis and provides small improvements in metabolic risk factors.

Schizophrenia

Schizophrenia is a chronic psychiatric disorder with a heterogeneous genetic and neurobiological background that influences early brain development, and is expressed as a combination of psychotic symptoms - such as hallucinations, delusions and disorganization - and motivational and cognitive dysfunctions. The mean lifetime prevalence of the disorder is just below 1%, but large regional differences in prevalence rates are evident owing to disparities in urbanicity and patterns of immigration. Although gross brain pathology is not a characteristic of schizophrenia, the disorder involves subtle pathological changes in specific neural cell populations and in cell-cell communication. Schizophrenia, as a cognitive and behavioural disorder, is ultimately about how the brain processes information. Indeed, neuroimaging studies have shown that information processing is functionally abnormal in patients with first-episode and chronic schizophrenia. Although pharmacological treatments for schizophrenia can relieve psychotic symptoms, such drugs generally do not lead to substantial improvements in social, cognitive and occupational functioning. Psychosocial interventions such as cognitive-behavioural therapy, cognitive remediation and supported education and employment have added treatment value, but are inconsistently applied. Given that schizophrenia starts many years before a diagnosis is typically made, the identification of individuals at risk and those in the early phases of the disorder, and the exploration of preventive approaches are crucial.

Prefrontal and Hippocampal Brain Volume Deficits: Role of Low Physical Activity on Brain Plasticity in First-Episode Schizophrenia Patients

Our objective in the present study was to conduct the first empirical study of the effects of regular physical activity habits and their relationship with brain volume and cortical thickness in patients in the early phase of schizophrenia. Relationships between larger brain volumes and higher physical activity levels have been reported in samples of healthy and aging populations, but have never been explored in first-episode schizophrenia patients.

METHOD

We collected MRI structural scans in 14 first-episode schizophrenia patients with either self-reported low or high physical activity levels. We found a reduction in total gray matter volume, prefrontal cortex (PFC), and hippocampal gray matter volumes in the low physical activity group compared to the high activity group. Cortical thickness in the dorsolateral and orbitofrontal PFC were also significantly reduced in the low physical activity group compared to the high activity group. In the combined sample, greater overall physical activity levels showed a non-significant tendency with better performance on tests of verbal memory and social cognition. Together these pilot study findings suggest that greater amounts of physical activity may have a positive influence on brain health and cognition in first-episode schizophrenia patients and support the implementation of physical exercise interventions in this patient population to improve brain plasticity and cognitive functioning.

Mental health starts with physical health: current status and future directions of non-pharmacological interventions to improve physical health in first-episode psychosis

People with psychotic disorders have reduced life expectancy compared with the general population. This difference is primarily due to increased prevalence of cardiovascular disease associated with antipsychotic drugs and with modifiable risk factors, including weight gain, low exercise, poor diet, and high prevalence of cigarette smoking. We review non-pharmacological interventions for physical health behaviour in patients with chronic and first-episode psychosis. Our findings suggest that weight loss and attenuation of weight gain are achievable but limited and might not persist beyond the end of an intervention. Evidence for smoking cessation interventions is scarce. The case for early intervention to prevent deterioration of physical health is strong. We propose a framework for development of interventions, which addresses three main factors largely absent in previous research: (1) examination of aetiological factors related to poor physical health, (2) theory-driven interventions that target aetiological factors, and (3) assessment of feasibility.

Promoting physical health for people with schizophrenia by reducing disparities in medical and dental care

OBJECTIVE

Acquiring a diagnosis of schizophrenia reduces life expectancy for many reasons including poverty, difficulties in communication, side-effects of medication and access to care. This mortality gap is driven by natural deaths; cardiovascular disease is a major cause, but outcomes for people with severe mental illness are worse for many physical health conditions, including cancer, fractures and complications of surgery. We set out to examine the literature on disparities in medical and dental care experienced by people with schizophrenia and suggest possible approaches to improving health.

METHOD

This narrative review used a targeted literature search to identify the literature on physical health disparities in schizophrenia.

RESULTS

There is evidence of inequitable access to and/or uptake of physical and dental health care by those with schizophrenia.

CONCLUSION

The goal was to reduce the mortality gap through equity of access to all levels of health care, including acute care, long-term condition management, preventative medicine and health promotion. We suggest solutions to promote health, wellbeing and longevity in this population, prioritising identification of and intervention for risk factors for premature morbidity and mortality. Shared approaches are vital, while joint education of clinicians will help break down the artificial mind-body divide.

Microvascular dysfunction in schizophrenia: a case-control study

Background:

Schizophrenia is a mental illness associated with cardiovascular disease at a younger age than in the general population. Endothelial dysfunction has predictive value for future cardiovascular events; however, the impact of a diagnosis of schizophrenia on this marker is unknown.

Aims:

We tested the hypothesis that subjects with schizophrenia have impaired endothelial function.

Methods:

A total of 102 subjects (34.5±7.5 years) participated in this study. This sample consisted of 51 subjects with a diagnosis of schizophrenia and 51 healthy subjects, who were matched for age (P=0.442), sex (P>0.999), and smoking status (P=0.842). Peripheral artery microvascular and conduit vessel endothelial function was measured using hyperemic velocity time integral (VTI), pulse arterial tonometry (PAT), and flow-mediated dilation (FMD).

Results:

Significantly lower values of VTI were noted in subjects with schizophrenia (104.9±33.0 vs. 129.1±33.8 cm, P<0.001), whereas FMD (P=0.933) and PAT (P=0.862) did not differ between the two groups. A multivariable-linear-regression analysis, built on data from univariate and partial correlations, showed that only schizophrenia, sex, lipid-lowering medications, antihypertensive medications, and low-density lipoprotein (LDL)-cholesterol were predictive of attenuated VTI, whereas age, ethnicity, family history of cardiovascular disease, smoking status, systolic blood pressure, waist circumference, HDL-cholesterol, triglycerides, C-reactive protein, and homeostatic model assessment-insulin resistance (HOMA-IR), antidiabetic medications, antidepressant medications, mood stabilizers, benzodiazepines, and anticholinergic medications did not predict VTI in this model (adjusted R²=0.248).

Conclusions:

Our findings suggest that a diagnosis of schizophrenia is associated with impaired microvascular function as indicated by lower values of VTI, irrespective of many other clinical characteristics. It might be an early indicator of cardiovascular risk in schizophrenia, and might help to identify high-risk individuals.