Bridging the gap from evidence to policy and practice: reducing the progression to metabolic syndrome for children and adolescents on antipsychotic medication

Effectiveness of lifestyle interventions for improving the physical health of children and adolescents taking antipsychotic medications: protocol for a systematic review and meta-analysis

INTRODUCTION

Children and adolescents are increasingly prescribed antipsychotic medications off-label in the treatment of behavioural disorders. While antipsychotic medications are effective in managing behavioural issues, they carry a significant risk of adverse events that compromise ongoing physical health. Of particular concern is the negative impact antipsychotic medications have on cardiometabolic health. Interventions that aim to modify lifestyle habits have the potential to alleviate the adverse effects of antipsychotic medication by enhancing weight management, increasing physical activity, promoting better nutritional practices, improving dietary habits and promoting healthier sleep patterns and sleep hygiene. However, a comprehensive review has not been performed to ascertain the effectiveness of lifestyle interventions for children and adolescents who are at increased risk of antipsychotic-induced compromises to their physical health.

METHODS AND ANALYSIS

This systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Four databases will be searched without any year constraints to identify randomised controlled trials that are published in the English language and report a lifestyle intervention compared with usual care with any physical health outcome measure. Trial registers and results repositories will be scoured to identify additional studies. Two reviewers will independently conduct screening, data extraction and quality assessment and compare the results. Quantitative data will be synthesised, where appropriate, through a random-effects meta-analysis model. Otherwise, data will be reported in a qualitative (narrative) synthesis. Heterogeneity will be quantified using the I2 statistic. The Cochrane Risk of Bias 2 tool will be used for risk of bias assessment. The Grading of Recommendations, Assessment, Development and Evaluation system will be used to evaluate the cumulative body of evidence.

ETHICS AND DISSEMINATION

Ethics approval is not required. The publication plan will target high-impact, peer-reviewed journals that fall under the scope of Psychiatry and Mental Health.

PROSPERO REGISTRATION NUMBER

CRD42022380277.

Weight and body mass index increase in children and adolescents exposed to antipsychotic drugs in non-interventional settings: a meta-analysis and meta-regression

Antipsychotics increase weight, BMI and waist size, particularly in pediatric patients. Switching antipsychotics is common practice, thus defining the risk for each antipsychotic in real-life settings can be important for clinical guidance. We conducted a meta-analysis on antipsychotic-related changes in body measures in pediatric observational studies. Of 934 publications found on PubMed, we analyzed 38, including nine treatment arms: no treatment, mixed antipsychotic treatment, first-generation antipsychotics, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and ziprasidone. Changes in weight, BMI, BMI-Z and waist size were meta-analyzed according to the duration of clinical observations: 6, 12, > 12 months. Meta-regressions probed influencing factors. Weight in Kg was increased at 6, 12, > 12 months by olanzapine [+ 10.91, + 10.7, data not available (n/a)], mixed antipsychotic treatment (n/a, + 9.42, + 12.59), quetiapine (+ 5.84, n/a, n/a) and risperidone (+ 4.47, + 6.01, + 9.51) and without treatment (n/a, + 2.3, n/a). BMI was increased at 6, 12, > 12 months by olanzapine (+ 3.47, + 3.42, n/a), clozapine (n/a, + 3, n/a) mixed antipsychotic treatment (+ 3.37, + 2.95, + 3.32), risperidone (+ 2, + 2.13, + 2.16), quetiapine (+ 1.5, + 1.82, n/a), aripiprazole (n/a, + 1.7, + 2.1) and without treatment (n/a, + 0.75, n/a). BMI-Z was increased at 6, 12, > 12 months by olanzapine (+ 0.94, + 0.98, + 0.89), clozapine (n/a, + 0.8, n/a), risperidone (+ 0.62, + 0.61, + 0.48), quetiapine (+ 0.57, + 0.54, n/a), mixed antipsychotic treatment (+ 0.51, + 0.94, + 0.44), without treatment (n/a, + 0.37, n/a) and aripiprazole (no gain, + 0.31, n/a). Waist size in cm was increased at 6, 12 months by risperidone (+ 8.8, + 11.5), mixed antipsychotics treatment (+ 9.1, + 10.2) and quetiapine (+ 6.9, + 9.1). Overall, olanzapine and clozapine displayed maximum risk, followed by risperidone, quetiapine and aripiprazole (more risky at longer terms); ziprasidone was associated with no gains. No time-based trends emerged, suggesting a drug-specific risk magnitude. Meta-regressions evidenced variable roles for persistence in therapy and follow-up length, increased risk for drug-naïve patients, and a ceiling effect determined by higher baseline BMI/BMI-Z values.

One-Year Prospective Study of Liver Function Tests in Children and Adolescents on Second-Generation Antipsychotics: Is There a Link with Metabolic Syndrome?

OBJECTIVE

To analyze liver function tests (LFT), weight, metabolic syndrome (MetS) and at risk of meeting MetS criteria (AR-MetS) in children and adolescents on antipsychotics (AP) during a year-long follow-up.

METHODS

Two hundred sixteen patients, AP naïve or quasi-naïve (<30 days on AP), were included. Total bilirubin, the enzymes aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), weight and other parameters of MetS were measured at baseline, and at 3, 6 and 12 months, while patients remained on the same AP.

RESULTS

At baseline, patients (mean age: 14.1 ± 3.1 years; 60.2% male) were on risperidone (N = 143), olanzapine (N = 37), or quetiapine (N = 36), although the sample decreased over time to 67 patients at 12 months (risperidone N = 46, olanzapine N = 10, and quetiapine N = 11). Around 3% of patients had ALT/AST levels that were at least twice the upper limit of normal (ULN) at 3 and 6 months; whereas roughly 19% of patients had ALP levels that were at least twice the ULN in at least one assessment after baseline, but had no clinical symptoms. From baseline to 6 months, significant increases were observed in ALT levels in the whole sample (p = 0.005), whereas ALP increased only in patients on risperidone. Patients showed significant weight gain, and more individuals met criteria for MetS and AR-MetS over time (from baseline: 2.8% and 8.3%, to 1 year: 10.5% and 23.9%, respectively). There was a trend-level group effect in global ALT across time (p = 0.076). Patients with MetS showed higher ALT concentrations (28.9 [18.4-39.4] U/L) than AR-MetS (20.4 [8.5-32.2] U/L), and no-AR-MetS (19.2 [8.4-29.9] U/L).

CONCLUSIONS

Less than 3% of children and adolescents on AP during 1-year follow-up showed an increase in ALT or AST levels in one or more of the assessments, and none of these increases was of clinical significance. Patients with MetS and AR-MetS increased during this period, and the possible role of ALT levels to monitor these patients deserves further study.

Physical health and well-being: Experiences and perspectives of young adult mental health consumers

Compromised physical health and raised levels of morbidity and mortality are experienced by young people (16-24 years) with mental illness, and are compounded by psychotropic medication. How this group conceives and experiences physical health is not well understood. We investigated the meanings, beliefs, and endeavours of young people that impact their physical health understandings and behaviours. The present study formed the qualitative phase of a sequential mixed-methods study, and incorporated semistructured interviews with 12 hospitalized young people. Qualitative content analysis was used to analyse data. Participants held a holistic ideal of physical health that they did not meet. Weight change, poor sleep, and limited exercise adversely impacted their lives and self-image. Sedentary behaviour, reduced energy, and limited health literacy compromised effective management of physical health. Young people needed structure and support to assist them in addressing their physical health needs when amotivation overwhelmed their internal resources. Nurses are well placed to help young people increase their competency for health management. Individualized information and methods to promote good physical health are required for this group in jeopardy from physical morbidity and mortality.

Scoping review of research in Australia on the co-occurrence of physical and serious mental illness and integrated care

The physical health of people with serious mental illness (SMI) has become a focal area of research. The aim of the present study was to ascertain the attention and distribution of research from within Australia on physical illness and SMI co-occurrence, and to identify gaps. A scoping review of peer-reviewed research literature from Australia, published between January 2000 and March 2014, was undertaken through an electronic literature search and coding of papers to chart trends. Four trends are highlighted: (i) an almost threefold increase in publications per year from 2000-2006 to 2007-2013; (ii) a steady release of literature reviews, especially from 2010; (iii) health-related behaviours, smoking, integrated-care programmes, and antipsychotic side-effects as the most common topics presented; and (iv) paucity of randomized, controlled trials on integrated-care models. Despite a marked increase in research attention to poorer physical health, there remains a large gap between research and the scale of the problem previously identified. More papers were descriptive or reviews, rather than evaluations of interventions. To foster more research, 12 research gaps are outlined. Addressing these gaps will facilitate the reduction of inequalities in physical health for people with SMI. Mental health nurses are well placed to lead multidisciplinary, consumer-informed research in this area.

Physical Health Risk Behaviours in Young People with Mental Illness

Comorbid physical health conditions, commonly associated with mental illness, contribute to increased morbidity and reduced life expectancy. The trajectory to poorer health begins with the onset of mental illness. For young people with mental illness, health risk behaviours and poor physical health can progress to adulthood with long-term detrimental impacts. Using a cross-sectional survey design, self-reported health risk behaviours were gathered from 56 young (16-25 years) Australians who had been hospitalised for mental illness and taking psychotropic medication. Smoking, alcohol use, minimal physical activity, and lack of primary health care were evident. While these behaviours are typical of many young people, those with mental illness have substantially increased vulnerability to poor health and reduced life expectancy. Priority needs to be given to targeted health promotion strategies for young people with mental illness to modify their risky long-term health behaviours and improve morbidity and mortality outcomes. Nurses in mental health settings play a vital role in promoting young peoples' well-being and preventing poorer physical health outcomes. Implementation of a cardiometabolic health nurse role in inpatient settings for young people with mental illness could facilitate prevention and early intervention for health risk behaviours.

Weight gain and antipsychotics: a drug safety review

INTRODUCTION

Second-generation antipsychotics (SGAs) are widely used in several psychiatric disease entities and exert to a different extent a risk for antipsychotic-induced weight gain (AIWG). As AIWG is associated with an increase in metabolic syndrome or cardiovascular events, knowledge of these risks is crucial for further monitoring and the initiation of counteractive measures.

AREAS COVERED

We searched PubMed and Web of Sciences for randomized-controlled trials and naturalistic observational studies published between 2010 and 2014 with sample sizes exceeding 100, including all marketed SGAs apart from zotepine, and providing data on weight increase. We also summarized relevant systematic reviews and meta-analyses of head-to-head comparisons.

EXPERT OPINION

Recently published data still support the hierarchical ranking of SGAs already proposed in previous reviews ranking clozapine and olanzapine as having the highest risk, followed by amisulpride, asenapine, iloperidone, paliperidone, quetiapine, risperidone and sertindole in the middle, and aripiprazole, lurasidone and ziprasidone with the lowest risk. Number needed to harm varied considerably in our meta-analysis. Younger patients and patients with a lower baseline body mass index are most vulnerable. The greatest amount of weight gain occurs within the first weeks of treatment. AIWG occurs in all diagnostic groups and is also common in treatment with first-generation antipsychotics; therefore, awareness of this adverse event is essential for anyone prescribing antipsychotics.

Risk of diabetes in children and adolescents exposed to antipsychotics: a nationwide 12-year case-control study

OBJECTIVE

Antipsychotics are associated with weight gain and diabetes. The risk and rate of diabetes in children and adolescents treated with antipsychotics is unclear.

METHOD

A longitudinal register linkage case-control study of diabetes in all psychiatric patients aged <18 years in Denmark was performed from January 1999 through the end of June 2010. Patients with and without antipsychotic exposure were compared regarding the occurrence of type 2 diabetes, defined as the prescription of oral antidiabetic medication. Regression analyses with type 2 diabetes as the dependent variable were conducted with sex, age, and diagnoses as covariates.

RESULTS

We compared the risk of diabetes in 48,299 psychiatrically ill youth. Of 7,253 youth exposed to antipsychotics, 52 (0.72%; 95% CI = 0.52% - 0.91%) developed type 2 diabetes. Of 41,046 youth without exposure to antipsychotics, 111 (0.27%; 95% CI = 0.22% - 0.32%) developed type 2 diabetes. In a 25,033 + 16,013 logistic regression analysis, type 2 diabetes development was associated with antipsychotic drug exposure (odds ratio [OR] = 1.60; 95% CI = 1.08 - 2.36, p < .05) female sex, (OR = 4.48; 95% CI = 2.90 - 6.91, p < 0.001) and older age at first psychiatric diagnosis (OR = 1.19; 95% CI = 1.12 - 1.27, p < 0.001), but not with psychiatric diagnosis. In a Cox-regression analysis, shorter time to type 2 diabetes onset was associated with female sex (Hazard Ratio (HR) = 4.83; 95% CI = 3.05-7.66, p = 0.001), and older age at first psychiatric diagnosis (HR = 1.19; 95% CI = 1.12-1.28, p = 0.001), while antipsychotic exposure (HR) = 1.41; 95% CI = 0.92-2.16, p = 0.11) trended towards increasing the rate of diabetes.

CONCLUSION

Antipsychotic treatment, female sex, and older age at psychiatric diagnosis were associated with a significantly more frequent type 2 diabetes onset in children and adolescents. Strict indications for antipsychotic treatment and routine cardiometabolic monitoring are crucial.

Predictors of type 2 diabetes in a nationally representative sample of adults with psychosis

Antipsychotic drugs such as clozapine and olanzapine are associated with an increased risk for type 2 diabetes, but relatively little is known about the relationship between risk factors for type 2 diabetes established in the general population and type 2 diabetes in people with psychosis. We estimated the prevalence of established risk factors and their association with type 2 diabetes in a nationally representative sample of people with an ICD-10 psychosis (N=1642) who gave a fasting blood sample (N=1155). Logistic regression was used to summarize associations adjusted for age and sex. In this sample, whose mean duration of psychosis was 14.7 years, 12.1% (13.1% of women and 11.5% of men) had type 2 diabetes at age 18-64 years based on current fasting blood glucose levels or treatment with a hypoglycaemic drug. Risk was greatly increased in young adults compared with the general population and peaked in middle age. Risk factors in the general population were common in people with psychosis and strongly associated with type 2 diabetes in those people. Treatment with clozapine was associated with an increased risk and treatment with olanzapine with a decreased risk for type 2 diabetes. The development of diabetes or pre-diabetes may therefore influence the likelihood of treatment with olanzapine over time. The strongest predictors of type 2 diabetes in a multivariate model were a body mass index of at least 40 and treated hypercholesterolemia, followed by a body mass index between 35 and 39.9, a family history of diabetes and treated hypertension. There was minimal to no confounding of the association between type 2 diabetes and current clozapine or olanzapine treatment, but neither association remained significant after adjustment for other predictors. Longitudinal relationships among predictors are likely to be complex, and previous antipsychotic drug treatment may at least partly explain risks associated with severe obesity, dyslipidemia and hypertension. A focus on weight loss is warranted in people with psychosis, but prevention strategies for type 2 diabetes should be broadened to include those with emerging dyslipidemia, hypertension and a family history of diabetes.