Osteoporosis associated with antipsychotic treatment in schizophrenia

The neglected association between schizophrenia and bone fragility: a systematic review and meta-analyses

Schizophrenia is associated with increased risk of medical comorbidity, possibly including osteoporosis, which is a public health concern due to its significant social and health consequences. In this systematic review and meta-analysis, we aimed to determine whether schizophrenia is associated with bone fragility. The protocol for this review has been registered with PROSPERO (CRD42020171959). The research question and inclusion/exclusion criteria were developed and presented according to the PECO (Population, Exposure, Comparison, Outcome) framework. Schizophrenia was identified from medical records, DSM-IV/5 or the ICD. The outcomes for this review were bone fragility [i.e., bone mineral density (BMD), fracture, bone turnover markers, bone quality]. A search strategy was developed and implemented for the electronic databases. A narrative synthesis was undertaken for all included studies; the results from eligible studies reporting on BMD and fracture were pooled using a random effects model to complete a meta-analysis. The conduct of the review and reporting of results adhered to PRISMA guidelines. Our search yielded 3103 studies, of which 29 met the predetermined eligibility criteria. Thirty-seven reports from 29 studies constituted 17 studies investigating BMD, eight investigating fracture, three investigating bone quality and nine investigating bone turnover markers. The meta-analyses revealed that people with schizophrenia had lower BMD at the lumbar spine [standardised mean difference (SMD) -0.74, 95% CI -1.27, -0.20; Z = -2.71, p = 0.01] and at the femoral neck (SMD -0.78, 95% CI -1.03, -0.53; Z = -6.18, p ≤ 0.001). Also observed was a higher risk of fracture (OR 1.43, 95% CI 1.27, 1.61; Z = 5.88, p ≤ 0.001). Following adjustment for publication bias, the association between schizophrenia and femoral neck BMD (SMD -0.63, 95% CI -0.97, -0.29) and fracture (OR 1.32, 95% CI 1.28, 1.35) remained. Significantly increased risk of bone fragility was observed in people with schizophrenia. This association was independent of sex, participant number, methodological quality and year of publication.

MALAT1 as a potential salivary biomarker in oral squamous cell carcinoma through targeting miRNA-124

OBJECTIVES

To determine the diagnostic accuracy of the long non-coding RNA "MALAT1" measured in the saliva of patients with oral squamous cell carcinoma (OSCC) and assess the salivary expression of microRNA-124, which MALAT1 targets.

SUBJECTS AND METHODS

Forty subjects were collected in a consecutive pattern and allocated into two groups. Group A included 20 patients with OSCC, while Group B included 20 healthy subjects. Salivary expression of MALAT1 and microRNA (miRNA)-124 was evaluated in the two study groups using quantitative real-time polymerase chain reaction and correlated with histopathological examination of OSCC subjects.

RESULTS

OSCC yielded a statistically significant higher expression of MALAT1 than healthy controls and a lower expression of miRNA-124 in OSCC than controls. There is a statistically significant inverse relationship between salivary MALAT1 and miRNA-124. Moreover, there is a statistically significant difference in the MALAT1 expression in saliva samples from metastatic cases compared with non-metastatic cases, as well as in patients with lymph node involvement compared with those without involvement. At a cut-off value of 2.24, salivary MALAT1 exhibited 95% sensitivity and 90% specificity in differentiating OSCC from healthy subjects.

CONCLUSION

Salivary MALAT1 acts as a sponge for miRNA-124 and could be a potential salivary biomarker for OSCC.

NiFe-based Prussian blue analogue nanopolygons hybridized with functionalized glyoxal polymer as a voltammetric platform for the determination of amisulpride in biological samples

A novel voltammetric platform based on pencil graphite electrode (PGE) modification has been proposed, containing bimetallic (NiFe) Prussian blue analogue nanopolygons decorated with electro-polymerized glyoxal polymer nanocomposites (p-DPG NCs@NiFe PBA Ns/PGE). Cyclic voltammetry (CV), electrochemical impedance spectroscopy (EIS), and square wave voltammetry (SWV) were utilized to investigate the electrochemical performance of the proposed sensor. The analytical response of p-DPG NCs@NiFe PBA Ns/PGE was evaluated through the quantity of amisulpride (AMS), one of the most common antipsychotic drugs. Under the optimized experimental and instrumental conditions, the method showed linearity over the range from 0.5 to 15 × 10-8 mol L-1 with a good correlation coefficient (R = 0.9995) and a low detection limit (LOD) reached, 1.5 nmol L-1, with excellent relative standard deviation for human plasma and urine samples. The interference effect of some potentially interfering substances was negligible, and the sensing platform demonstrated an outstanding reproducibility, stability, and reusability. As a first trial, the proposed electrode aimed to shed light on the AMS oxidation mechanism, where the oxidation mechanism was monitored and elucidated using the FTIR technique. It was also found that the prepared p-DPG NCs@NiFe PBA Ns/PGE platform had promising applications for the simultaneous determination of AMS in the presence of some co-administered COVID-19 drugs, which could be attributed to the large active surface area, and high conductivity of bimetallic nanopolygons.

Bilateral atraumatic femoral neck fractures resulting from transient osteoporosis of the hip

A woman in her mid-30s presented to the orthopaedic team, unable to mobilise, shortly after her caesarean section. On questioning, she reported 10 weeks of atraumatic right hip pain. A radiograph revealed a displaced right subcapital neck of femur fracture. An MRI confirmed this, as well as identifying a minimally displaced left subcapital neck of femur fracture. She underwent a right total hip replacement and internal fixation of the left hip. A dual energy X-ray absorptiometry (DEXA) scan showed severe osteoporosis, and a diagnosis of transient osteoporosis of the hip was made. She was seen by the bone metabolism team and given calcium and vitamin D medication. Although atraumatic hip fractures are rare in young patients, disproportionate or persisting hip pain in pregnant patients should raise the index of suspicion and prompt further investigation in the form of an MRI. This will allow timely management of hip fractures and improve patient outcomes.

Influence of antipsychotics on metabolic syndrome risk in patients with schizophrenia

OBJECTIVE

Many studies so far have shown that antipsychotic therapy may have an effect on the development of metabolic syndrome in patients diagnosed with schizophrenia. Our goal was to determine whether our respondents are at risk for developing metabolic syndrome and who is more predisposed to it.

METHODS

In a stable phase, 60 patients diagnosed with schizophrenia were equally divided into three groups according to the drug (risperidone, clozapine, and aripiprazole monotherapy). Control group had 20 healthy examinees. Patients were evaluated first using The Positive and Negative Syndrome Scale (PANSS). Prolactin, lipid status, glycemia, insulin, cytokine values (IL-33, TGF-β, and TNF-α) and C-reactive protein (CRP) were measured. Also, Body mass index (BMI), Homeostatic Model Assesment for Insulin Resistance (HOMA index), waist and hip circumference (WHR) and blood pressure (TA) measurement were performed in the study.

RESULTS

Patients treated with risperidone compared to healthy control subjects and aripiprazol group of patients had statistically significant difference in prolactin levels. In clozapine group compared to healthy control group values of HDL cholesterol and glucose level were statistically significant different. In aripiprazole group compared to healthy control group value of BMI was statistically significant different. Statistically significant correlations were found in TNF-α with glucose and HOMA index in risperidone treated patients and with BMI in clozapine group of patients; IL-33 with glucose in risperidone and with BMI in clozapine group of patients and TGF-β with glucose in risperidone group, with insulin and HOMA index in clozapine group and statistically significant negative correlation with LDL cholesterol in aripiprazole group of patients.

CONCLUSION

Patients on risperidone and clozapine therapy may be at greater risk of developing metabolic syndrome than patients treated with aripiprazole. Statistically significant difference in concentration of TNF-α and TGF-β was in the group of patients treated with risperidone compared to healthy control group.

The Effects of Osteoporotic and Non-osteoporotic Medications on Fracture Risk and Bone Mineral Density

Osteoporosis is a highly prevalent bone disease affecting more than 37.5 million individuals in the European Union (EU) and the  United States of America (USA). It is characterized by low bone mineral density (BMD), impaired bone quality, and loss of structural and biomechanical properties, resulting in reduced bone strength. An increase in morbidity and mortality is seen in patients with osteoporosis, caused by the approximately 3.5 million new osteoporotic fractures occurring every year in the EU. Currently, different medications are available for the treatment of osteoporosis, including anti-resorptive and osteoanabolic medications. Bisphosphonates, which belong to the anti-resorptive medications, are the standard treatment for osteoporosis based on their positive effects on bone, long-term experience, and low costs. However, not only medications used for the treatment of osteoporosis can affect bone: several other medications are suggested to have an effect on bone as well, especially on fracture risk and BMD. Knowledge about the positive and negative effects of different medications on both fracture risk and BMD is important, as it can contribute to an improvement in osteoporosis prevention and treatment in general, and, even more importantly, to the individual's health. In this review, we therefore discuss the effects of both osteoporotic and non-osteoporotic medications on fracture risk and BMD. In addition, we discuss the underlying mechanisms of action.

Study protocol for the systematic review and meta-analyses of the association between schizophrenia and bone fragility

INTRODUCTION

Individuals with schizophrenia are known to be at higher risk of comorbid conditions, both physical and psychological. Osteoporosis is possibly one of these, leading to public health concerns due to higher rates of associated mortality and morbidity. We aim to systematically search all available evidence across electronic databases regarding the relationship between schizophrenia and bone fragility.

METHODS AND ANALYSIS

A systematic search of the research databases CINAHL, MEDLINE Complete, Embase and PsycINFO will be conducted and identified papers reviewed for eligibility, with a second reviewer confirming inclusions. Searches will be run from database inception to 1 October 2020 and supplemented by the hand checking of references of identified articles. A previously published scoring system will be used for assessing the methodological quality and risk of bias. A meta-analysis is planned.

ETHICS AND DISSEMINATION

Due to including published literature only, ethical permission will not be necessary. Results of this study will be published in a relevant scientific journal and presented at a conference in the field of interest.

PROSPERO REGISTRATION NUMBER

CRD42020171959.

Altered levels of BMD, PRL, BAP and TRACP-5b in male chronic patients with schizophrenia

Bone mineral density (BMD) has been found to decrease in schizophrenia patients. We examined BMD and the levels of prolactin (PRL), bone alkaline phosphatase (BAP) and tartrate resistant acid phosphatase isoform 5b (TRACP-5b) in male chronic schizophrenia patients and compared them with healthy controls in a Chinese Han population, which has not been reported before. Male patients with chronic schizophrenia (SPs; n = 79) and healthy controls (HCs; n  = 56) were recruited. BMD and plasma PRL, BAP and TRACP-5b levels were measured and compared between the two groups. The SPs group was further divided into two subgroups: the elevated PRL group (PRL ≥ 25 ng/ml, EPRL; n  = 38) and the normal PRL group (PRL < 25 ng/ml, NPRL; n = 41) in accordance with PRL levels. The levels of BAP and TRACP-5b were measured using sandwich enzyme-linked immunosorbent assay (ELISA) while serum PRL was measured with an Access Immunoassay Analyzer. BMD was determined by quantitative computed tomography. BMD levels significantly decreased and serum PRL and TRACP-5b levels were significantly higher in male chronic schizophrenia patients. The EPRL group had remarkably lower BMD and BAP level and higher TRACP-5b levels compared with the NPRL group and HCs. Moreover, there was a negative correlation between BMD and TRACP-5b in the EPRL group. We found that BMD, BAP and TRACP-5b levels in the EPRL group were significantly different than HCs and the NPRL group. PRL levels in schizophrenia patients may be related to BMD and bone metabolism. Monitoring BMD and markers of bone metabolism in clinical practice may therefore be helpful to understand the bone health status of schizophrenia patients.

Exposure to risperidone versus other antipsychotics and risk of osteoporosis-related fractures: a population-based study

OBJECTIVE

Antipsychotics may increase serum prolactin, which has particularly been observed with risperidone. Further, hyperprolactinemia has been linked to osteoporosis-related fractures. Therefore, we investigated fracture risk in a nationwide cohort exposed to antipsychotics.

METHODS

Swedish registers were used to identify adults with two consecutive dispensations of risperidone (n = 38 211), other atypical antipsychotics not including paliperidone (n = 60 691), or typical antipsychotics (n = 17 445) within three months between 2006 and 2013. An osteoporosis-related fracture was defined as a non-open hip/femur fracture in primary analyses. Cox regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Risperidone users were on average older (mean age of 68, 44, and 63 years for risperidone, other atypical antipsychotics, and typical antipsychotics respectively). Compared with other atypical antipsychotics, there was no association between risperidone and osteoporosis-related fractures in the overall (HR = 1.04, CI: 0.91-1.19) or age-stratified analyses. A significantly increased risk of typical antipsychotics (HR = 1.24, CI: 1.07-1.45) compared with other atypical antipsychotics remained for ages >45 years.

CONCLUSION

Risperidone does not appear to be associated with an increased risk of osteoporosis-related fracture compared with other atypical antipsychotic agents as a group. For typical antipsychotics, a moderately elevated risk of hip fractures was noted compared with other atypical antipsychotics, possibly because of residual confounding.

The risk of bone fracture after long-term risperidone exposure is not increased compared to other atypical antipsychotics: A retrospective cohort study

OBJECTIVE

Antipsychotic agents can increase circulating serum prolactin levels, potentially leading to osteoporosis and increased risk of bone fracture. The risk appears to be lower for atypical antipsychotics. We investigated whether risperidone was associated with an increased fracture risk by estimating the incidence of hip/femur and non-hip/femur fractures in users of risperidone, other atypical, and typical antipsychotics.

METHODS

This retrospective cohort study with a nested case-control study used claims data from the Taiwan National Healthcare Insurance database. All new users of antipsychotics between 2000-2012 were included. Incident fractures were identified using ICD-9 codes from inpatient records. Cox proportional hazards models compared fracture incidence among exposure groups. Conditional logistic regression models compared antipsychotic exposure among fracture cases versus matched controls.

RESULTS

340,948 patients were included in the analysis. There were 2832 hip/femur fractures and 2693 non-hip/femur fractures: Hip/femur fracture incidence 636.8/100,000 person-years (Risperidone), 885.7/100,000 person-years (Other Atypical), 519.4/100,000 person-years (Typical). The adjusted hazard ratio of hip/femur fracture was 0.92 (95%CI 0.84-1.01) comparing Other Atypical with Risperidone, and 1.00 (95%CI 0.89-1.11) comparing Typical with Risperidone. The adjusted hazard ratio of non-hip/femur fracture was 1.08 (95%CI 0.98-1.20) for Other Atypical versus Risperidone, and 1.10 (95%CI 0.99-1.22) for Typical versus Risperidone. The adjusted odds ratio for hip/femur fractures was 0.92 (95% CI 0.83-1.01) in cases and controls exposed to other atypical antipsychotics compared with risperidone for 1 year prior to fracture date, 0.97 (95% CI 0.87-1.07) during 1-3 years, and 0.92 (95% CI 0.81-1.06) during 3-5 years prior to fracture date. The adjusted odds ratio for non-hip/femur fractures were 1.11 (95% CI 0.99-1.24), 1.02 (95% CI 0.0.91-1.14), and 0.95 (95% CI 0.82-1.09), respectively.

CONCLUSION

There was no increased risk of bone fracture in long-term users of risperidone compared to users of other atypical antipsychotics.

Bipolar disorder and bone health: A systematic review

BACKGROUND

Bipolar disorder is a chronic, episodic mental illness, affecting around 2.4% of the population worldwide. Psychological and/or physiological comorbidities are a common consequence, and osteoporosis is one such possible comorbidity. Thus, this systematic review aimed to collate, evaluate, and discuss the literature examining the link between bipolar disorder and bone health.

METHODS

We conducted an e-search of PubMed/OVID/MEDLINE, PsychINFO and CINAHL to identify studies that investigated associations between bipolar disorder and bone in adults aged ≥18. Two reviewers determined eligibility according to pre-determined criteria, and methodological quality was assessed using a previously published methodological scoring system. Due to heterogeneity, a best-evidence synthesis was performed.

RESULTS

Our search yielded 1409 articles, of which three (all cohorts) met predetermined criteria. The studies from Taiwan and the United States of America analysed administrative data, albeit spanning different years, and comprised a total of 344,497 participants. No studies investigating bone quantity or quality were identified. Bipolar disorder was associated with an increased risk of fracture (range 20-80%); and fracture-free survival time for those with bipolar disorder decreased substantially with advancing age, and for women (10-30% shorter than men). Fracture incidence per 1000 person years (py) was 21.4 and 10.8 in those with and without bipolar disorder, respectively.

LIMITATIONS

Limited data and marked methodological heterogeneity prevented the pooling of these data for a numerical synthesis.

CONCLUSIONS

Increased fracture risk was observed in individuals with bipolar disorder, independent of older age, sex, comorbidities and medication use. The operative mechanisms, risk and treatment factors warrant further enquiry.

LncRNA KCNQ1OT1 promoted BMP2 expression to regulate osteogenic differentiation by sponging miRNA-214

BACKGROUND

Osteogenic differentiation of bone marrow mesenchymal stem cells (BMSCs) is of much significance for bone formation, the imbalance of it would result in osteoporosis and other pathological bone defects. Increasing evidences showed that long non-coding RNAs (lncRNAs) and miRNAs played vital roles in the regulation of osteogenic differentiation. LncRNA KCNQ1OT1 was often regarded as an imprinted lncRNA and was related to tumor progression, while its function in osteogenic differentiation remained unclear.

METHOD

qRT-PCR was performed to detect the expression of KCNQ1OT1, miR-214 and osteogenesis-related genes BMP2, Runx2, OPN, and OCN. Western blotting was carried out to detect osteogenesis-related markers. The osteoblastic phenotype was evidenced by alkaline phosphatase (ALP) activity and Alizarin Red S accumulation detection. Bioinformatics and luciferase assays were used to predict and validate the interaction between KCNQ1OT1 and miR-214 as well as BMP2 and miR-214.

RESULTS

KCNQ1OT1 was significantly up-regulated during the process of osteogenic induction while miR-214 was contrarily down-regulated. Knockdown of KCNQ1OT1 inhibited osteogenic differentiation and down-regulated BMP2 and osteogenesis-related genes. It was also confirmed that KCNQ1OT1 directly interacted with miR-214. Meanwhile, miR-214 could bind to 3'UTR of BMP2 and therefore inhibited its expression. Furthermore, co-transfection of miR-214 inhibitor could rescue the down-regulation of BMP2 and osteogenesis-related genes and osteogenic differentiation suppression induced by KCNQ1OT1 knockdown. Moreover, miR-214 inhibitor significantly reversed the decreased protein levels of p-Smad1/5/8, Runx2 and Osterix induced by shKCNQ1OT1.

CONCLUSIONS

KCNQ1OT1 positively regulated osteogenic differentiation of BMSCs by acting as a ceRNA to regulate BMP2 expression through sponging miR-214.

Еffects of Antipsychotics on Bone Mineral Density in Schizophrenia

Previous researches have shown that patients with schizophrenia who were using antipsychotics in their treatment developed changes in Bone Mineral Density and body composition, leading to osteoporosis and modifications in weight, skeletal muscle mass index and percent of fat tissue. Results of many studies suggested that the use of antipsychotic causes hyperprolactinemia and consequently lower bone mineral density values were observed. Further, antipsychotics increase food intake and have possible effects on metabolism, causing changes in weight, glucose level and lipid status, all of which can be a risk for developing metabolic syndrome and result in changing of bone mineral density. Antipsychotics change cytokine profi les in patients with schizophrenia and on the other hand the influence of T cells, B cells and inflammatory cytokines on osteoclasts and on osteoblasts was also established. In assessing the effects of antipsychotic on bone metabolism very important is to consider the duration of the treatment and clinical course of the disease, but undeniable effect is careless life style and inadequate physical activity that patients with schizophrenia have. Our attempt is to give an overview of the newest findings in this field, regarding the direct effects of antipsychotics on the bone metabolism, but also through prolactine elevation, metabolic and immune changes. Better understanding of the underlying mechanisms of schizophrenia and changes in bone mineral density could improve our clinical practice: affect to choice of the individually most appropriate antipsychotic, point to the need to monitor possible immunmetabolic changes during the treatment and improvement of the life quality of this vulnerable population.

Effects of Olanzapine on Bone Mineral Density, Glucose, and Lipid Metabolism in Schizophrenia Patients

AIM

To explore whether olanzapine alters bone mineral density (BMD), glucose, and lipid metabolism in schizophrenia patients.

METHODS

This study enrolled 150 patients diagnosed with schizophrenia according to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), including 101 patients who had over 6-month history of olanzapine use (olanzapine-treated group) and 49 patients who had no history of antipsychotic use (first episode drug-naïve group). 71 subjects with age- and gender-matched healthy volunteers (healthy control group) were also enrolled. All study subjects were from the Chinese Han population recruited in the Second Xiangya Hospital from January 2015 to January 2016. Demographic and physical examination data were collected from all subjects. BMD measurements of the radius+ulna, lumbar spine (L1-4), and left hip were performed via a dual-energy X-ray absorptiometry test. Serum lipid, glucose, and insulin levels were analyzed. Psychopathology profiles in all enrolled schizophrenia patients were assessed by the positive and negative syndrome scale (PANSS).

RESULTS

There was no significant difference in age, gender, activity intensity, smoking, or drinking among the three groups. In the majority of evaluated bone areas, the BMD values in olanzapine-treated or drug-naïve patients were lower than those in the control group. However, BMD values in the drug-naïve group showed no difference or even decreased as compared with those in the olanzapine-treated group. Among the olanzapine-treated group, although not observed in every tested region, a positive correlation was found of BMI or HOMA-IR with BMD. Stepwise multiple linear regression analysis revealed independent predictive factors associated with BMD in groups/subgroups of schizophrenia patients or healthy controls, including gender, TG, BMI, body weight, HOMA-IR, and FBG.

CONCLUSIONS

Schizophrenia, but not the long-term use of olanzapine, correlates with BMD loss in schizophrenia patients. Elevated BMI, TG, FBG, and insulin levels might protect these patients against bone degradation. Our work provides new information to improve the understanding, prevention, and treatment of osteoporosis in schizophrenia patients.

Hormonal Risk Factors for Osteoporosis: Different Profile Among Antipsychotics

Objectives: Osteoporosis is a major risk factor for fracture and treatment is mainly preventive. Patients with severe psychiatric condition and treated with antipsychotics are at risk for vitamin D deficiency and iatrogenic hyperprolactinemia, two serious risk factors of osteoporosis. We aim to determine whether all antipsychotics are similar regarding the risk of osteoporosis in young patients. Methods: From January 2009 to March 2015, we determined the vitamin D blood level (VDBL) among 484 inpatients and from January 2012 to March 2015, we determined the prolactin blood level (PBL) among 205 inpatients. We systematically recorded well-documented risk factors (e.g., age, gender, ethnic origin, body mass index, or season) and suspected risk factors (e.g., disease type or antipsychotic treatment). Results: Up to 89% of the inpatients had a VDBL under the recommended threshold. Up to 60% of the inpatients had hyperprolactinemia. The multivariate model found a significant effect on VDBL for seasonality (higher VDBL in summer), ethnicity (lower VDBL in Black individuals), and treatment exposure. The multivariate model found a significant effect on PBL for gender and treatment exposure. In both models, aripiprazole had a safer profile compared with other antipsychotics. Conclusion: Because adolescence is a period of bone construction and a critical window of opportunity for maximizing bone mass, we recommend vitamin D supplementation in young patients with severe mental condition. It could be interesting to reconsider to regularly monitor PBL among youth patients treated with antipsychotic, with the exception of aripiprazole.

[Somatic risks in elderly people with severe psychiatric illnesses]

BACKGROUND

Aged patients with severe mental illness (SMI) suffer from a high risk for functional impairment and a high load of somatic comorbidities. Until now, there has been a lack of systematic studies on this patient population in later life. This review summarizes the most significant somatic comorbidities and discusses the consequences for the medical care of this elderly group of patients.

METHODS

A selective narrative review based on PubMed research and observations in clinical practice.

RESULTS

Life expectancy is shortened by approximately 10 years in patients with SMI. The main reasons are somatic comorbidities, particularly lung and respiratory tract disorders, metabolic syndrome with its subsequent cardiovascular complications, in addition to osteoporosis and fractures with a complicated clinical course. Although life expectancy is shortened, the number of geriatric patients with SMI is increasing and requires special attention to be given to out-patient psychosocial care, self-management of somatic diseases, and to age-appropriate continuation of psychiatric treatment.

CONCLUSION

The life expectancy of patients with SMI is reduced because of their typically somatic comorbidity, but they are reaching increasingly advanced ages as a consequence of improved treatment possibilities. They often require special attention in their diagnostic work-up and support in the management of their treatment. Collaborative care linking medical geriatric and geronto-psychiatric treatment facilities is helpful in the the interdisciplinary therapy required.

Prevalence, risk factors and clinical characteristics of osteoporosis in Chinese inpatients with schizophrenia

Patients with schizophrenia have a high prevalence of developing osteoporosis and osteoporosis-related fractures. We examined the prevalence of osteoporosis and its clinical correlates in Chinese patients with schizophrenia, which is not well-studied. A total of 199 inpatients (males/females=132/67; average age: 54.5±11.1years) and 107 healthy controls (males/females=22/85; average age: 41.7±11.9years) were recruited. Bone mineral density (BMD) was measured by ultrasonography of the calcaneus. The prevalence of osteoporosis and low BMD (osteoporosis and osteopenia) was 23.1% and 65.3% for the patient group, versus 7.5% and 39.3% for the control group (both p<0.001). Further, the average BMD T-score in patients was significantly lower than in controls (p<0.05). There was gender difference in the prevalence of low BMD conditions for the patients (males: 56.1% versus females: 76.1%; p<0.01) as well as the BMD T-score (p<0.001). Several risk factors correlated with the osteoporosis classification in the patient group: older age (58.9±11.2years vs. 53.3±11.0years), lower weight (63.7±12.2kg vs. 70.4±15.2kg) and body mass index (BMI) (22.8±4.1kg/m² vs. 24.2±4.7kg/m²; all p<0.01) than those without osteoporosis. Stepwise multiple logistic regression analysis indicated that age, weight and BMI remained significantly associated with osteoporosis. In addition, correlation analysis showed significant correlations between BMD T-score and the following parameters: gender, age and drug type (clozapine versus non-clozapine) (Bonferroni corrected p's<0.05). Our results suggest a higher prevalence of osteoporosis and osteopenia in Chinese schizophrenic inpatients, with both the expected risk factors of gender and age, as well as drug type.

Repurposing psychiatric drugs as anti-cancer agents

Cancer is a major public health problem and one of the leading contributors to the global disease burden. The high cost of development of new drugs and the increasingly severe burden of cancer globally have led to increased interest in the search and development of novel, affordable anti-neoplastic medications. Antipsychotic drugs have a long history of clinical use and tolerable safety; they have been used as good targets for drug repurposing. Being used for various psychiatric diseases for decades, antipsychotic drugs are now reported to have potent anti-cancer properties against a wide variety of malignancies in addition to their antipsychotic effects. In this review, an overview of repurposing various psychiatric drugs for cancer treatment is presented, and the putative mechanisms for the anti-neoplastic actions of these antipsychotic drugs are reviewed.

Vitamin D in patients with intellectual and developmental disability in secure in-patient services in the North of England, UK

Aims and method To assess the benefits of the introduction of routine vitamin D serum sampling for all patients admitted to a secure in-patient hospital in the North of England providing medium security, low security and rehabilitation services for offenders with intellectual and developmental disability. The vitamin D levels of 100 patients were analysed at baseline. Those with insufficient or deficient levels were offered treatment and retested after 1 year. Vitamin D levels were analysed in the context of level of security, seasonality of test and co-prescription of psychotropic medications.

RESULTS

Eighty-three per cent of patients had suboptimal vitamin D levels at initial test (41% deficient and 42% insufficient). This was seen among established patients and new admissions. Regression analysis of baseline vitamin D levels revealed no differences for levels of security, seasonality, whether patients were taking antipsychotic or anticonvulsant medication, or length of stay. Patients with deficiency or insufficiency were all offered supplementation. Those who opted in had significantly higher vitamin D levels at follow-up, compared with those who declined treatment. Clinical implications Established and newly admitted patients in our secure mental health services had substantial levels of vitamin D insufficiency. In the light of the morbidities that are associated with deficient vitamin D levels, routine screening and the offer of supplementation is advisable. Declaration of interest None.

Management of antipsychotic-induced hyperprolactinaemia

Hyperprolactinaemia is a common endocrine disorder that can be associated with significant morbidity. Antipsychotic medications are frequently linked to hyperprolactinaemia. This disorder usually presents as menstrual problems in women and sexual problems in men, which affect the patients' quality of life and adherence to antipsychotic treatment. In the past, treatment for hyperprolactinaemia was recommended only for symptomatic patients. However, it has become clear that persistent asymptomatic hyperprolactinaemia can be associated with long-term physical morbidities such as osteoporosis and possibly breast cancer. Hence, it is imperative that hyperprolactinaemia is managed even if asymptomatic when initially detected. This article discusses the various management options, such as reducing the dose of antipsychotic medication, switching to a prolactin-sparing antipsychotic and adding aripiprazole to the treatment regimen.

Learning Objectives

• Understand the physiology of the prolactin hormone

• Be able to judge when to intervene if a patient on an antipsychotic medication presents with hyperprolactinaemia

• Learn about the different treatment options

Gender-specific risk factors for low bone mineral density in patients taking antipsychotics for psychosis

OBJECTIVE

This study examined clinical and gender-specific risk factors for low bone mineral density (BMD) in adult patients with psychotic disorders.

METHODS

The study included 285 community-dwelling patients with psychotic disorders. Dual-energy X-ray absorptiometry was used to measure BMD. Clinical characteristics associated with low BMD were identified with logistic regression analysis in total population and each gender.

RESULTS

Fifty-eight (20.4%) subjects had low BMD. Low BMD was more common in men and in patients with low body mass indices (BMIs), as well as in those with shorter treatment durations, those on Medicaid, and patients using serotonergic antidepressants. Logistic regression analysis revealed that low BMD was negatively associated with BMI and treatment duration and positively with gender (male) and serotonergic antidepressants use in the overall population. In men, low BMD was associated with treatment duration and BMI; in women, low BMD was associated with BMI, prolactin level, vitamin D, and serotonergic antidepressant use.

CONCLUSION

Managing the risk factors associated with low BMD among patients with psychotic disorder should be done gender-specifically. Psychotropic agents should be prescribed mindful of their effects on bone, as use of these medications is a modifiable risk factor for osteoporosis in women with psychotic disorders.

Low Bone Mass Secondary to Antipsychotic Medications

Background and Objective:

Antipsychotic medications are known to cause low bone mass. The objective of this study was to assess the prevalence of osteopenia and osteoporosis secondary to patients taking antipsychotic medications.

Patients and Methods:

This prospective study included 175 patients taking antipsychotic medications and attending the psychiatric clinics at the King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. Demographic data, antipsychotic medications, type, and duration of administration of medication were collected. All patients had bone mass measurement using dual energy X-ray (DXA) absorptiometry. Patients were divided into 5-year groups, from ≤35 to ≥51 years. The data were entered in the database and analyzed using SPSS Inc version 20.

Results:

The average age of patients was 40.75 ± 7.16 years (range: 26–56 years), there were 120 (82.8%) males and 25 (17.2%) females. Our results indicate that the average duration of anti-psychotic medication use was 8.45 ± 5.4 years. DXA of the hip revealed that 25 (14.2%) patients were osteoporotic and 104 (59.42%) were osteopenic, while on the basis of the T-score of the lumbar spine, 77 (44%) patients were osteoporotic and 80 (45.7%) were osteopenic. On the basis of the spinal bone mineral density (BMD), 89.7% had low bone mass.

Conclusion:

Anti-psychotic medications have a strong influence on the reduction of bone mass even in younger populations. The BMD of patients who are prescribed anti-psychotic medication need to be monitored for low bone mass and provided with the appropriate treatment.

Detecting and Managing Adverse Effects of Antipsychotic Medications: Current State of Play

Antipsychotics are some of the most frequently prescribed medications not only for psychotic disorders and symptoms but also for a wide range of on-label and off-label indications. Because second-generation antipsychotics have largely replaced first-generation antipsychotics as first-line options due to their substantially decreased risk of extrapyramidal side effects, attention has shifted to other clinically concerning adverse events associated with antipsychotic therapy. The focus of this article is to update the nonextrapyramidal side effects associated with second-generation antipsychotics. Issues surrounding diagnosis and monitoring as well as clinical management are addressed.

Changes in biomarkers of bone turnover in an aripiprazole add-on or switching study

BACKGROUND

The association between mental illness and osteoporosis and fractures is particularly pronounced in psychotic disorders. Antipsychotic use has previously been described to affect bone density.

METHOD

A 52-week follow-up of patients switched to aripiprazole or with aripiprazole added on, conducting a specific analysis of markers of bone turnover: urinary NTX (a biomarker of bone resorption) and serum BSAP (a biomarker of bone formation). Baseline and serial measurements of bone markers NTX, BSAP and of hormones prolactin, oestrogen and testosterone were done at weeks 0 and 1, 2, 6, 12, 26 and 52, respectively.

RESULTS

NTX concentration reduced over time but this did not reach significance in the whole group (log-NTX: β=-0.0012, p=0.142). For BSAP the addition of or replacement with aripiprazole produced a significant reduction (log-BSAP: β=-0.00039, p=0.002). Analysis with prolactin similarly showed a significant reduction (log-prolactin: β=-0.0024, p<0.001); other hormones did not change significantly. Sensitivity analysis to compare the switchers to aripiprazole versus the "add-on" showed that the former group had a significant reduction in NTX.

CONCLUSIONS

We found that switching to aripiprazole was associated with changes in molecular biomarkers of bone resorption, indicating a more favourable profile for bone health.

Chlorpromazine-Induced Hyperprolactinemia on Rat's Uterus

Background:

Hyperprolactinemia is a common side effect of antipsychotic drugs that requires further investigation. The current study was designed to evaluate dose-dependent effect of chlorpromazine (CPZ) on hormonal changes and uterine horn histological structure in rats. Moreover, the mammary glands were analyzed to show hyperprolactinemia-induced histological changes.

Methods:

Albino Wistar rats (n = 32) were divided into four groups. The first group was set as a control. In the three drug-treated groups (eight rats in each group), CPZ was administered by a gavage at doses of 3, 10, and 30 mg/kg/day for 28 days. One day after the last administration of the drug, the animals were sacrificed. Histopathological and histomorphometrical analyses of the uterine horns and mammary glands were carried out to evaluate dose-dependent effect of CPZ on histological structure. Serum levels of prolactin (PRL), estradiol, progesterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) were also evaluated.

Results:

Remarkable (P < 0.05) elevation was observed in CPZ-administrated animals' uterine horn endometrium, myometrium, and perimetrium thicknesses, and the mammary glands were observed with galactorrhea features. The serum level of progesterone and PRL significantly (P < 0.05) increased, while the serum concentration of LH, FSH, and estradiol was notably (P < 0.05) decreased depending on administrated CPZ dose. No histological and biological changes were occurred in the control animals.

Conclusion:

The present findings suggest that CPZ-induced disturbances not only depend on PRL level and increased PRL level largely depends on administrated doses of the CPZ.

Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder

People with severe mental illness have a considerably shorter lifespan than the general population. This excess mortality is mainly due to physical illness. Next to mental illness-related factors, unhealthy lifestyle, and disparities in health care access and utilization, psychotropic medications can contribute to the risk of physical morbidity and mortality. We systematically reviewed the effects of antipsychotics, antidepressants and mood stabilizers on physical health outcomes in people with schizophrenia, depression and bipolar disorder. Updating and expanding our prior systematic review published in this journal, we searched MEDLINE (November 2009 - November 2014), combining the MeSH terms of major physical disease categories (and/or relevant diseases within these categories) with schizophrenia, major depressive disorder and bipolar disorder, and the three major psychotropic classes which received regulatory approval for these disorders, i.e., antipsychotics, antidepressants and mood stabilizers. We gave precedence to results from (systematic) reviews and meta-analyses wherever possible. Antipsychotics, and to a more restricted degree antidepressants and mood stabilizers, are associated with an increased risk for several physical diseases, including obesity, dyslipidemia, diabetes mellitus, thyroid disorders, hyponatremia; cardiovascular, respiratory tract, gastrointestinal, haematological, musculoskeletal and renal diseases, as well as movement and seizure disorders. Higher dosages, polypharmacy, and treatment of vulnerable (e.g., old or young) individuals are associated with greater absolute (elderly) and relative (youth) risk for most of these physical diseases. To what degree medication-specific and patient-specific risk factors interact, and how adverse outcomes can be minimized, allowing patients to derive maximum benefits from these medications, requires adequate clinical attention and further research.

A meta-analysis of prevalence estimates and moderators of low bone mass in people with schizophrenia

OBJECTIVE

To assess the prevalence and moderators of low bone mass, osteopenia and osteoporosis in schizophrenia patients.

METHOD

Major electronic databases were searched from inception till December 2013 for studies reporting the prevalence of low bone mass (osteopenia + osteoporosis = primary outcome), osteopenia or osteoporosis in schizophrenia patients. Two independent authors completed methodological appraisal and extracted data. A random effects meta-analysis was utilized.

RESULTS

Nineteen studies were included (n = 3038 with schizophrenia; 59.2% male; age 24.5-58.9 years). The overall prevalence of low bone mass was 51.7% (95% CI = 43.1-60.3%); 40.0% (CI = 34.7-45.4%) had osteopenia and 13.2% (CI = 7.8-21.6%) had osteoporosis. Compared with controls, schizophrenia patients had significantly increased risk of low bone mass (OR = 1.9, CI = 1.30-2.77, P < 0.001, n = 1872) and osteoporosis (OR = 2.86, CI = 1.27-6.42, P = 0.01, n = 1824), but not osteopenia (OR = 1.33, CI = 0.934-1.90, P = 0.1, n = 1862). In an exploratory regression analysis, older age (P = 0.004) moderated low bone mass, while older age (P < 0.0001) and male sex (P < 0.0001) moderated osteoporosis. The subgroup analyses demonstrated high heterogeneity, but low bone mass was less prevalent in North America (35.5%, CI = 26.6-45.2%) than Europe (53.6%, CI = 38.0-68.5%) and Asia (58.4%, CI = 48.4-67.7%), and in mixed in-/out-patients (32.9%, CI = 49.6-70.1%) vs. in-patients (60.3%, CI = 49.6-70.1%).

CONCLUSION

Reduced bone mass (especially osteoporosis) is significantly more common in people with schizophrenia than controls.

Urinary nickel and prolactin in workers exposed to urban stressors

The aim of our study is to verify whether the exposure to low Ni doses in urban air may have some effects on the prolactin values of outdoor workers exposed to urban pollutants. 334 workers have been included in the study and divided on the basis of gender, job, age, length of service and smoking habits. Each worker underwent urinary Ni and prolactin sampling. The t-test for independent samples, the Mann-Whitney U test for two mode variables (gender, smoking habit), the univariate ANOVA test and the Kruskal Wallis test for the variables in more than two modes (age, length of service and job duties) were performed on the total sample. Pearson's correlation coefficient (p two-tailed) among the parameters was evaluated both in the total sample and after the stratification by gender, smoking habit and job. Multiple linear regression was performed after taking account of the major confounding factors on the total sample and on the subcategories. The statistical tests showed a significant correlation between urinary Ni and prolactin both in the total sample and in the subcategories. We believe that the occupational exposure to low doses of Ni present in urban pollution may influence the prolactin values in exposed workers.