Physical disease in schizophrenia: a population-based analysis in Spain

Mortality in people with schizophrenia: a systematic review and meta-analysis of relative risk and aggravating or attenuating factors

People with schizophrenia die 15-20 years prematurely. Understanding mortality risk and aggravating/attenuating factors is essential to reduce this gap. We conducted a systematic review and random-effects meta-analysis of prospective and retrospective, nationwide and targeted cohort studies assessing mortality risk in people with schizophrenia versus the general population or groups matched for physical comorbidities or groups with different psychiatric disorders, also assessing moderators. Primary outcome was all-cause mortality risk ratio (RR); key secondary outcomes were mortality due to suicide and natural causes. Other secondary outcomes included any other specific-cause mortality. Publication bias, subgroup and meta-regression analyses, and quality assessment (Newcastle-Ottawa Scale) were conducted. Across 135 studies spanning from 1957 to 2021 (schizophrenia: N=4,536,447; general population controls: N=1,115,600,059; other psychiatric illness controls: N=3,827,955), all-cause mortality was increased in people with schizophrenia versus any non-schizophrenia control group (RR=2.52, 95% CI: 2.38-2.68, n=79), with the largest risk in first-episode (RR=7.43, 95% CI: 4.02-13.75, n=2) and incident (i.e., earlier-phase) schizophrenia (RR=3.52, 95% CI: 3.09-4.00, n=7) versus the general population. Specific-cause mortality was highest for suicide or injury-poisoning or undetermined non-natural cause (RR=9.76-8.42), followed by pneumonia among natural causes (RR=7.00, 95% CI: 6.79-7.23), decreasing through infectious or endocrine or respiratory or urogenital or diabetes causes (RR=3 to 4), to alcohol or gastrointestinal or renal or nervous system or cardio-cerebrovascular or all natural causes (RR=2 to 3), and liver or cerebrovascular, or breast or colon or pancreas or any cancer causes (RR=1.33 to 1.96). All-cause mortality increased slightly but significantly with median study year (beta=0.0009, 95% CI: 0.001-0.02, p=0.02). Individuals with schizophrenia <40 years of age had increased all-cause and suicide-related mortality compared to those ≥40 years old, and a higher percentage of females increased suicide-related mortality risk in incident schizophrenia samples. All-cause mortality was higher in incident than prevalent schizophrenia (RR=3.52 vs. 2.86, p=0.009). Comorbid substance use disorder increased all-cause mortality (RR=1.62, 95% CI: 1.47-1.80, n=3). Antipsychotics were protective against all-cause mortality versus no antipsychotic use (RR=0.71, 95% CI: 0.59-0.84, n=11), with largest effects for second-generation long-acting injectable anti-psychotics (SGA-LAIs) (RR=0.39, 95% CI: 0.27-0.56, n=3), clozapine (RR=0.43, 95% CI: 0.34-0.55, n=3), any LAI (RR=0.47, 95% CI: 0.39-0.58, n=2), and any SGA (RR=0.53, 95% CI: 0.44-0.63, n=4). Antipsychotics were also protective against natural cause-related mortality, yet first-generation antipsychotics (FGAs) were associated with increased mortality due to suicide and natural cause in incident schizophrenia. Higher study quality and number of variables used to adjust the analyses moderated larger natural-cause mortality risk, and more recent study year moderated larger protective effects of antipsychotics. These results indicate that the excess mortality in schizophrenia is associated with several modifiable factors. Targeting comorbid substance abuse, long-term maintenance antipsychotic treatment and appropriate/earlier use of SGA-LAIs and clozapine could reduce this mortality gap.

Prevalence of metabolic syndrome among patients with schizophrenia in Ethiopia

BACKGROUND

Globally, the prevalence of metabolic syndrome (MetS) is higher among patients with schizophrenia than the general population, and this leads to higher morbidity and mortality in this population. The aim of this study was to investigate the MetS prevalence among patients with schizophrenia in Ethiopia.

METHODS

We conducted a cross-sectional analysis of baseline data of 200 patients with schizophrenia recruited from Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia. Lipid profile and blood glucose levels were measured using Roche Cobas 6000 clinical chemistry analyzer. The prevalence of MetS was assessed based on National Cholesterol Education Program Adult Treatment Panel III criteria. Patients' demographic information, clinical and laboratory data, lifestyle habits, particularly smoking and Khat chewing, were evaluated vis-à-vis MetS.

RESULTS

The overall prevalence of MetS in patients with schizophrenia was 21.5% (17.1% male, 29.6% female) where Low HDL-cholesterol value was the most common metabolic disorders components in both males and females subgroups. In the multivariate analysis, the positive and negative symptoms score (PANSS, AOR = 1.03, 95% CI 1.001-1.054) was associated factors with MetS.

CONCLUSION

In Ethiopia, patients with schizophrenia were found to have higher prevalence of MetS than the general population. Physicians/health care providers should routinely screen patients with schizophrenia for MetS and initiate timely management of those who develop the syndrome to reduce the health cost from caring for NCDs, improve the patients' quality of life, and prevent premature mortality.

Use of Charlson Comorbidity Index and Nomogram to Predict Mortality in Elderly Patients with Late-Life Schizophrenia

Objectives: Comorbid illness burden signifies a poor prognosis in schizophrenia. The aims of this study were to estimate the severity of comorbidities in elderly patients with schizophrenia, determine risk factors associated with mortality, and establish a reliable nomogram for predicting 1-, 3- and 5-year mortality and survival. Methods: This population-based study rigorously selected schizophrenia patients (≥65 years) having their first admission due to schizophrenia during the study period (2000–2013). Comorbidity was scored using the updated Charlson Comorbidity Index (CCI). Results: This study comprised 3827 subjects. The mean stay of first admission due to schizophrenia was 26 days. Mean numbers of schizophrenia and non-schizophrenia-related hospitalization (not including the first admission) were 1.80 and 3.58, respectively. Mean ages at death were 73.50, 82.14 and 89.32 years old, and the mean times from first admission to death were 4.24, 3.33, and 1.87 years in three different age groups, respectively. Nearly 30% were diagnosed with ≥3 comorbidities. The most frequent comorbidities were dementia, chronic pulmonary disease and diabetes. The estimated 1-, 3- and 5-year survival rates were 90%, 70%, and 64%, respectively. Schizophrenia patients with comorbid diseases are at increased risk of hospitalization and mortality (p < 0.05). Conclusion: The nomogram, composed of age, sex, the severity of comorbidity burden, and working type could be applied to predict mortality risk in the extremely fragile patients.

Excess mortality in patients with schizophrenia spectrum disorders in Malaga (Spain): A cohort study

AIMS

There is evidence that patients with schizophrenia spectrum disorders present higher mortality in comparison with the general population. The aim of this study was to analyse the causes of mortality and sociodemographic factors associated with mortality, standardised mortality ratios (SMRs), life expectancy and potential years of life lost (YLL) in patients with schizophrenia spectrum disorders in Spain.

METHODS

The study included a cohort of patients from the Malaga Schizophrenia Case Register (1418 patients; 907 males; average age 42.31 years) who were followed up for a minimum of 10 years (median = 13.43). The factors associated with mortality were analysed with a survival analysis using Cox's proportional hazards regression model.

RESULTS

The main causes of mortality in the cohort were circulatory disease (21.45%), cancer (17.09%) and suicide (13.09%). The SMR of the cohort was more than threefold that of the population of Malaga (3.19). The life expectancy at birth was 67.11 years old, which is more than 13 years shorter than that of the population of Malaga. The YLL was 20.74. The variables associated with a higher risk of mortality were age [adjusted hazard ratio (AHR) = 1.069, p < 0.001], male gender (AHR = 1.751, p < 0.001) and type of area of residence (p = 0.028; deprived urban zone v. non-deprived urban area, AHR = 1.460, p = 0.028). In addition, receiving welfare benefit status in comparison with employed status (AHR = 1.940, p = 0.008) was associated with increased mortality.

CONCLUSIONS

There is excess mortality in patients with schizophrenia spectrum disorders and also an association with age, gender, socioeconomic inequalities and receiving welfare benefits. Efforts directed towards improved living conditions could have a positive effect on reducing mortality.

The risk of physical multimorbidity in people with psychotic disorders: A systematic review and meta-analysis

BACKGROUND

The occurrence of multiple co-occurring chronic health conditions, known as multimorbidity, is associated with decreases in quality of life for patients and poses unique challenges for healthcare systems. Since people with psychotic disorders have an excess of physical health conditions compared to the general population, they may also be at a higher risk for multimorbidity. We conducted a systematic review and meta-analysis to quantify the prevalence and excess risk of multimorbidity among people with psychotic disorders, relative to those without psychosis.

METHODS

We searched the MEDLINE, EMBASE, and PsycINFO databases, and conducted forward and backward citation tracing of included studies. Studies published after 1990 were included if they reported the prevalence of multiple chronic physical health conditions among people with psychotic disorders. Data on the prevalence and relative risk of multimorbidity were meta-analyzed using random effects models.

RESULTS

Fourteen studies met the inclusion criteria, and eight were included in the meta-analysis. Each study used a different operational definition of multimorbidity, both for the number and types of chronic conditions, which resulted in a wide range in prevalence estimates (16% to 91%). People with psychotic disorders had an increased risk of multimorbidity (RR = 1.69, 95%CI = 1.37,2.08), relative to those without psychosis.

CONCLUSIONS

People with psychotic disorders are more likely to experience multimorbidity than those without psychotic disorders. Clinicians treating people with psychosis should closely monitor for a range of physical health conditions. Future research examining multimorbidity among people with psychiatric illness should employ consistent definitions to better enable cross-study comparisons.

Use and outcomes of mechanical ventilation for people with severe mental disorders admitted due to natural causes: A nationwide population-based study

OBJECTIVE

To characterize temporal trends and outcomes of invasive mechanical ventilation (MV) for people with severe mental disorders (SMD) admitted due to natural causes.

METHODS

We identified all 224,507 hospitalizations of patients aged 15-69 who underwent MV in Spain between 2000 and 2015, excluding poisonings and injuries, and divided them by presence of an SMD diagnosis. We compared the two study groups regarding demographic and clinical characteristics and examined time trends in the incidence of MV and in-hospital mortality.

RESULTS

SMD patients were younger and had fewer comorbidities and lower in-hospital mortality than the non-SMD group. However, among patients admitted due to circulatory diseases, SMD patients had higher mortality risk (OR = 1.39; 95%CI = 1.22-1.59). In the SMD group, the increase in MV use quadrupled that of non-SMD patients (Average Annual Percent Change = 6.9%; 95%CI = 5.5-8.3 vs. 1.5%; 0.9-2.0, respectively). Overall in-hospital mortality declined similarly in both study groups. While the SMD group's circulatory-specific mortality also decreased, by 2015 it remained elevated in comparison to non-SMD patients (44% vs. 38%, respectively).

CONCLUSION

The increase in MV use due to natural causes among people with SMD outpaced that of non-SMD patients, with comparable decreasing trends in mortality. Although declining, SMD patients' higher circulatory-specific mortality risk requires further investigation.

Comparison of Elixhauser and Charlson Methods for Discriminative Performance in Mortality Risk in Patients with Schizophrenic Disorders

Although Charlson Comorbidity Index scores (CCIS) and Elixhauser comorbidity index scores (ECIS) have been used to assess comorbidity in patients with schizophrenia, only CCIS, not ECIS, have been used to predict mortality in this population. This nationwide retrospective study investigated discriminative performance of mortality of these two scales in patients with schizophrenia. Exploiting Taiwan's National Health Insurance Research Database (NHRID), we identified patients diagnosed with schizophrenia discharged from hospitals between Jan 1, 1996 and Dec 31, 2007. They were followed up for subsequent death. Comorbidities presented one year prior to hospital admissions were identified and adapted to the CCIS and ECIS. Discriminatory ability was evaluated using the adjusted hazard ratio and Akaike information criterion (AIC) and Harrell's C-statistic. We identified 58,771 discharged patients with schizophrenic disorders and followed them for a mean of 10.4 years, 16.6% of whom had died. Both ECIS and CCIS were significantly associated with mortality, but ECIS had superior discriminatory ability by a lower AIC and higher Harrell's C-statistic (201231 vs. 201400; 0.856 vs. 0.854, respectively). ECIS had better discriminative performance in mortality risk than CCIS in patients with schizophrenic disorders. Its use may be encouraged for risk adjustment in this population.

Exercise and Schizophrenia

Schizophrenia is a psychiatric disorder characterized by distortions of thinking and perception, with no strictly pathognomonic symptoms that can be divided into positive, negative, and cognitive symptom domains. People with schizophrenia have, between others, a reduced life expectancy and cardiorespiratory and muscular fitness and increased risk of cardiovascular disease, metabolic syndrome, obesity, hypertension, and hyperlipidemia compared to the general population. Furthermore, the economic burden of mental disorders including schizophrenia is evident and it is expected to increase to more than double by 2030. Therefore, reducing the growing burden of mental disorders such as schizophrenia should be a health priority. Improved prevention and treatment are two key factors that may reduce the burden of schizophrenia. Pharmacological- and psychotherapy-based interventions have been traditionally considered for treating schizophrenia disorders; however, there is an increasing amount of scientific evidence confirming that physical activity and physical exercise should be highly considered in prevention and treatment of schizophrenia disorders. In this chapter, we aim to summarize and discuss the research progress of physical activity and exercise in prevention and treatment of schizophrenia disorder. Specifically, we summarized and discussed the research progress of the prognostic use of physical activity for incident schizophrenia; the importance of other outcomes typically improved by physical activity/exercise such as obesity and fitness (cardiorespiratory and muscular fitness) for future schizophrenia; the research progress of the evidence of the benefits of exercise in people with schizophrenia disorders differentiating between effects of exercise on varied health outcomes, cognitive functioning, and cardiorespiratory fitness; and finally the clinical practice recommendations.

Longitudinal assessment of the effect of cannabis use on hospital readmission rates in early psychosis: A 6-year follow-up in an inpatient cohort

Cannabis is the most commonly used illicit drug in psychosis patients and has been identified as a risk factor for relapse and subsequent hospital readmission, having substantial economic implications. To clarify the contribution of cannabis consumption to hospital readmission, a consecutive inpatient cohort of 161 early psychosis patients was included into the study. Data on cannabis use at admission and number of hospital readmissions and length of stay (LOS, number of inpatient days) in a 6-year follow-up was extracted from clinical notes. 62.4% of the patients had lifetime cannabis use. Their admission lasted on average 54.3 ± 75 days and over the following 6 years patients had 2.2 ± 2.8 hospital readmissions, for a total of 197.4 ± 331.5 days. Cannabis use significantly predicted the number of hospital readmissions and LOS in the following 6 years, the latter remaining significant after adjusting for use of other substance. Cannabis-using patients of male gender and Black ethnicity had a longer LOS at follow-up compared to female patients and other ethnic groups, respectively. Having a history of cannabis use when admitted to an early intervention inpatient unit for psychosis is associated with a higher number of subsequent hospital readmissions and a longer LOS, especially in male and Black patients.

Physical comorbidity in schizophrenia & its correlates

The presence of common physical comorbidities, their demographic and clinical correlates and impact on functioning was assessed in 100 patients with schizophrenia. The patients had a mean age of 35.12±10.7 yr with mean duration of illness of 8.3±0.58 years. Seventy per cent were detected to have a comorbid physical condition. Common conditions included hypertension (21%), diabetes mellitus (15%) and anaemia (12%). Increasing age, being female, being married, longer duration of illness and longer duration of treatment were associated with higher risk of having a comorbid physical illness. Further studies need to be done with a large sample to confirm these findings.

An Overview of Links Between Obesity and Mental Health

The American Medical Association recently recognized obesity as both an illness and a leading cause of preventable death and chronic disease. This association is not only linked to physical health outcomes, however, as obesity has also been extensively associated with mental illness as well. Both obesity and severe mental illness decrease quality of life and are associated with an increase in disability, morbidity, and mortality, and when they occur together, these adverse health outcomes are magnified. Despite educational campaigns, increased awareness, and improved treatment options, the high prevalence of mental illness and comorbid obesity remains a serious problem. This review examines this overlap, highlighting clinical and biological factors that have been linked to this association in order to improve our understanding and help elucidate potential therapeutic avenues.

Factors associated with relapse in patients with schizophrenia

OBJECTIVE

To assess risk factors for relapse in patients with schizophrenia attended in daily practice.

METHODS

Patients with schizophrenia admitted consecutively to short-stay/acute-care psychiatric units over a 6-month period were eligible. Variables statistically significant in the univariate logistic regression analysis were then subjected to multivariate analysis.

RESULTS

The study population included 1646 patients (67.6% men). In the univariate analysis, low family support, duration of illness > 5 years, number of previous hospitalizations, cocaine and cannabis consumption, and number of different antipsychotic drug classes were risk factors for relapse. In the multivariate analysis, number of previous hospitalizations (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.21-1.36) and number of different antipsychotics previously used (OR = 1.13, 95% CI 1.03-1.24) were significant predictors of relapse. The absence of cannabis consumption was a protective factor (OR = 0.72, 95% CI 0.58-0.89). Neither adherence to treatment in the previous 3 years nor type of antipsychotic regimen was significantly associated with relapse.

CONCLUSIONS

Number of previous hospitalizations and number of different types of antipsychotic drugs were associated with relapse. Absence of cannabis consumption was a protective factor.

Eight-year trends of cardiometabolic morbidity and mortality in patients with schizophrenia

OBJECTIVE

We examined cardiometabolic disease and mortality over 8 years among individuals with and without schizophrenia.

METHOD

We compared 65,362 patients in the Veteran Affairs (VA) health system with schizophrenia to 65,362 VA patients without serious mental illness (non-SMI) matched on age, service access year and location. The annual prevalence of diagnosed cardiovascular disease, diabetes, dyslipidemia, hypertension, obesity, and all-cause and cause-specific mortality was compared for fiscal years 2000-2007. Mean years of potential life lost (YPLLs) were calculated annually.

RESULTS

The cohort was mostly male (88%) with a mean age of 54 years. Cardiometabolic disease prevalence increased in both groups, with non-SMI patients having higher disease prevalence in most years. Annual between-group differences ranged from <1% to 6%. Annual mortality was stable over time for schizophrenia (3.1%) and non-SMI patients (2.6%). Annual mean YPLLs increased from 12.8 to 15.4 in schizophrenia and from 11.8 to 14.0 for non-SMI groups.

CONCLUSIONS

VA patients with and without schizophrenia show increasing but similar prevalence rates of cardiometabolic diseases. YPLLs were high in both groups and only slightly higher among patients with schizophrenia. The findings highlight the complex population served by the VA while suggesting a smaller mortality impact from schizophrenia than previously reported.