Risk of mortality and complications in patients with schizophrenia and diabetes mellitus: population-based cohort study

Risk of adverse pregnancy, delivery and neonatal outcomes associated with bipolar disorder and prenatal use of mood stabilizers: A population-based cohort study

Previous research examining bipolar-disorder (BD) and pregnancy/neonatal outcomes yielded mixed results, were mostly derived from Western countries and rarely delineated effect between disorder and mood-stabilizers. This population-based study identified women age 15-50 years who delivered first/singleton child in 2003-2018 in Hong Kong, utilizing territory-wide medical-record database of public healthcare services. Propensity-score weighted logistic-regression analyses adjusted for confounders were employed to examine risk of adverse pregnancy, delivery and neonatal outcomes associated with BD and mood-stabilizers (lithium, anticonvulsants and antipsychotics). Exploratory unadjusted-analyses were conducted to assess risk for congenital-malformations. Of 465,069 women, 302 had BD-diagnosis, including 168 redeemed ≥ 1 prescription of mood-stabilizers during pregnancy (treated-BD) and 134 gestationally-unexposed to mood-stabilizers (untreated-BD). BD was significantly-associated with increased risk of gestational-diabetes (adjusted-odds-ratio: 1.75 [95 % CI: 1.15-2.70]) and maternal somatic hospitalization ≤ 90 days post-discharge from index-delivery (2.12 [1.19-3.90]). In treatment status-stratified analyses, treated-BD women exhibited significantly-increased rate of gestational-diabetes (2.09 [1.21-3.70]) relative to controls (non-BD and gestationally-unexposed to mood-stabilizers). No significant association of BD or mood-stabilizers with other adverse outcomes was observed. Overall, our findings indicate that BD and mood-stabilizers are not associated with most adverse pregnancy, delivery and neonatal outcomes. Further research clarifying comparative safety of individual mood-stabilizing agents on pregnancy/neonatal outcomes is required.

Prenatal antidepressant use and risk of congenital malformations: A population-based cohort study

Previous studies examining antidepressants and congenital-malformations were primarily conducted in western countries, and many were constrained by important methodological limitations. This population-based study identified 465,069 women (including 1,705 redeemed ≥1 prescription of antidepressants during first-trimester) aged 15-50 years who delivered their first and singleton child between 2003 and 2018 in a predominantly-Chinese population in Hong Kong, using territory-wide medical-record database of public-healthcare services, and employed propensity-score fine-stratification-weighted logistic-regression analyses to evaluate risk of any major and organ/system-specific congenital-malformations following first-trimester exposure to antidepressants. Major malformation overall was not associated with any antidepressant (weighted-odds-ratio wOR, 0.88 [95 %CI, 0.44-1.76]), specific drug-class, or individual antidepressants. Exposure to any antidepressant was associated with increased risk of cardiac (wOR, 1.82 [95 %CI, 1.07-3.12]) and respiratory anomalies (wOR,4.11 [95 %CI, 1.61-10.45]). Exposure to selective-serotonin-reuptake-inhibitors (SSRI) and multiple-AD-classes were associated with respiratory and cardiac anomalies, respectively. However, these identified associations were not consistently affirmed across sensitivity analyses, precluding firm conclusion. Observed associations of specific cardiac defects with serotonin-norepinephrine-reuptake-inhibitors (SNRI), tricyclic-antidepressants (TCA) and multiple-AD-classes were noted with wide confidence-intervals, suggesting imprecise estimation. Overall, our findings suggest that first-trimester antidepressant exposure was not robustly associated with increased risk of congenital-malformations. Further research clarifying comparative safety of individual antidepressants on specific malformations is warranted.

Mortality risk and mood stabilizers in bipolar disorder: a propensity-score-weighted population-based cohort study in 2002-2018

AIMS

Accumulating studies have assessed mortality risk associated with mood-stabilizers, the mainstay treatment for bipolar disorder (BD). However, existing data were mostly restricted to suicide risk, focused on lithium and valproate and rarely adequately adjusted for potential confounders. This study aimed to assess comparative mortality risk with all, natural and unnatural causes between lithium, valproate and three frequently prescribed second-generation antipsychotics (SGA), with adjustment for important confounders.

METHODS

This population-based cohort study identified 8137 patients with first-diagnosed BD, who had exposed to lithium (n = 1028), valproate (n = 3580), olanzapine (n = 797), quetiapine (n = 1975) or risperidone (n = 757) between 2002 and 2018. Data were retrieved from territory-wide medical-record database of public healthcare services in Hong Kong. Propensity-score (PS)-weighting method was applied to optimize control for potential confounders including pre-existing chronic physical diseases, substance/alcohol use disorders and other psychotropic medications. PS-weighted Cox proportional-hazards regression was conducted to assess risk of all-, natural- and unnatural-cause mortality related to each mood-stabilizer, compared to lithium. Three sets of sensitivity analyses were conducted by restricting to patients with (i) length of cumulative exposure to specified mood-stabilizer ≥90 days and its medication possession ratio (MPR) ≥90%, (ii) MPR of specified mood-stabilizer ≥80% and MPR of other studied mood-stabilizers <20% and (iii) monotherapy.

RESULTS

Incidence rates of all-cause mortality per 1000 person-years were 5.9 (95% confidence interval [CI]: 4.5-7.6), 8.4 (7.4-9.5), 11.1 (8.3-14.9), 7.4 (6.0-9.2) and 12.0 (9.3-15.6) for lithium-, valproate-, olanzapine-, quetiapine- and risperidone-treated groups, respectively. BD patients treated with olanzapine (PS-weighted hazard ratio = 2.07 [95% CI: 1.33-3.22]) and risperidone (1.66 [1.08-2.55]) had significantly higher all-cause mortality rate than lithium-treated group. Olanzapine was associated with increased risk of natural-cause mortality (3.04 [1.54-6.00]) and risperidone was related to elevated risk of unnatural-cause mortality (3.33 [1.62-6.86]), relative to lithium. The association between olanzapine and increased natural-cause mortality rate was consistently affirmed in sensitivity analyses. Relationship between risperidone and elevated unnatural-cause mortality became non-significant in sensitivity analyses restricted to low MPR in other mood-stabilizers and monotherapy. Valproate- and lithium-treated groups did not show significant differences in all-, natural- or unnatural-cause mortality risk.

CONCLUSION

Our data showed that olanzapine and risperidone were associated with higher mortality risk than lithium, and further supported the clinical guidelines recommending lithium as the first-line mood-stabilizer for BD. Future research is required to further clarify comparative mortality risk associated with individual SGA agents to facilitate risk-benefit evaluation of alternative mood-stabilizers to minimize avoidable premature mortality in BD.

Inter-relationships of risk factors and pathways associated with all-cause mortality in patients with chronic schizophrenia

Introduction

Of all psychiatric disorders, schizophrenia is associated with the highest risk of all-cause mortality. This study aimed to investigate independent risk factors for all-cause mortality in patients with chronic schizophrenia. In addition, the possible causal inter-relationships among these independent risk factors and all-cause mortality were also explored.

Methods

We conducted an analysis of 1,126 patients with chronic schizophrenia from our psychiatric department from April 2003 to August 2022, and retrospectively reviewed their medical records. The study endpoint was all-cause mortality. Baseline clinical characteristics including sociodemographic data, biochemical data, lifestyle factors, comorbidities and antipsychotic treatment were examined with Cox proportional hazards analysis.

Results

The all-cause mortality rate was 3.9% (44 patients). Multivariate Cox regression analysis revealed that several factors were independently associated with all-cause mortality, including diabetes mellitus (DM), hypertension, heart failure, gastroesophageal reflux disease (GERD), peptic ulcer disease, ileus, underweight, fasting glucose, triglycerides, albumin, and hemoglobin. Structural equation modeling (SEM) analysis revealed that several factors had statistically significant direct effects on all-cause mortality. Heart failure, hypertension, underweight, age at onset, and ileus showed positive direct effects, while albumin and hemoglobin demonstrated negative direct effects. In addition, several factors had indirect effects on all-cause mortality. GERD indirectly affected all-cause mortality through ileus, and peptic ulcer disease had indirect effects through albumin and ileus. Ileus, underweight, DM, and hypertension also exhibited indirect effects through various pathways involving albumin, hemoglobin, and heart failure. Overall, the final model, which included these factors, explained 13% of the variability in all-cause mortality.

Discussion

These results collectively suggest that the presence of DM, hypertension, heart failure, GERD, peptic ulcer disease, ileus, and underweight, along with lower levels of albumin or hemoglobin, were independently associated with all-cause mortality. The SEM analysis further revealed potential causal pathways and inter-relationships among these risk factors contributing to all-cause mortality in patients with chronic schizophrenia.

Evaluation of preadipocyte factor-1 (Pref-1) level in cord blood of newborns born by mothers with gestational diabetes mellitus (GDM)

BACKGROUND

Gestational diabetes mellitus (GDM) is the most common metabolic complication, which leads to short and long-term consequences in both mother and fetus exposed to hyperglycemia. The aetiology of this condition is proposed to be based on the dysfunction of the adipose tissue, which is characterised by the aberrant generation of adipokines. One of them is preadipocyte factor-1 (Pref-1), which could mediate controlling the adaptation of the maternal metabolism to pregnancy.

AIMS

The study aims to examine the level of Pref-1 in the cord blood of healthy pregnant women's neonates and fetuses born to mothers with GDM.

MATERIALS AND METHODS

Cord blood samples were collected from 30 newborns of mothers with GDM and 40 newborns of healthy pregnant women. Pref-1 concentrations were measured with an ELISA kit.

RESULTS

Fetal Pref-1 concentrations were significantly lower in newborns of mothers with GDM compared to the normal pregnancy group children (5.32 ± 0.29 vs. 7.38 ± 0.53; p < 0.001). Mothers with GDM had a significantly higher index of BMI before pregnancy, maternal gestational weight gain, and maternal fasting glucose. In-depth analysis through multiple variant linear regression revealed a significant association between fetal serum Pref-1 levels, exposure to GDM, and gestational age.

CONCLUSION

These findings contribute valuable insights into maternal-fetal health and pave the way for more targeted and effective clinical interventions.

Implementation of an Electronic Clinical Decision Support System for the Early Recognition and Management of Dysglycemia in an Inpatient Mental Health Setting Using CogStack: Protocol for a Pilot Hybrid Type 3 Effectiveness-Implementation Randomized Controlled Cluster Trial

BACKGROUND

Severe mental illnesses (SMIs), including schizophrenia, bipolar affective disorder, and major depressive disorder, are associated with an increased risk of physical health comorbidities and premature mortality from conditions including cardiovascular disease and diabetes. Digital technologies such as electronic clinical decision support systems (eCDSSs) could play a crucial role in improving the clinician-led management of conditions such as dysglycemia (deranged blood sugar levels) and associated conditions such as diabetes in people with a diagnosis of SMI in mental health settings.

OBJECTIVE

We have developed a real-time eCDSS using CogStack, an information retrieval and extraction platform, to automatically alert clinicians with National Health Service Trust-approved, guideline-based recommendations for dysglycemia monitoring and management in secondary mental health care. This novel system aims to improve the management of dysglycemia and associated conditions, such as diabetes, in SMI. This protocol describes a pilot study to explore the acceptability, feasibility, and evaluation of its implementation in a mental health inpatient setting.

METHODS

This will be a pilot hybrid type 3 effectiveness-implementation randomized controlled cluster trial in inpatient mental health wards. A ward will be the unit of recruitment, where it will be randomly allocated to receive either access to the eCDSS plus usual care or usual care alone over a 4-month period. We will measure implementation outcomes, including the feasibility and acceptability of the eCDSS to clinicians, as primary outcomes, alongside secondary outcomes relating to the process of care measures such as dysglycemia screening rates. An evaluation of other implementation outcomes relating to the eCDSS will be conducted, identifying facilitators and barriers based on established implementation science frameworks.

RESULTS

Enrollment of wards began in April 2022, after which clinical staff were recruited to take part in surveys and interviews. The intervention period of the trial began in February 2023, and subsequent data collection was completed in August 2023. Data are currently being analyzed, and results are expected to be available in June 2024.

CONCLUSIONS

An eCDSS can have the potential to improve clinician-led management of dysglycemia in inpatient mental health settings. If found to be feasible and acceptable, then, in combination with the results of the implementation evaluation, the system can be refined and improved to support future successful implementation. A larger and more definitive effectiveness trial should then be conducted to assess its impact on clinical outcomes and to inform scalability and application to other conditions in wider mental health care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04792268; https://clinicaltrials.gov/study/NCT04792268.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49548.

Temporal trends of antidepressant utilization patterns in children and adolescents in Hong Kong: A 14-year population-based study with joinpoint regression analysis

BACKGROUND

There is limited research on real-world antidepressant utilization patterns in children and adolescents, particularly in non-western countries. We aimed to examine temporal trends of antidepressant prescribing practice among Chinese children and adolescents in Hong Kong over 14-year period.

METHODS

This population-based study identified 9566 patients aged 5-17 years who had redeemed at least one antidepressant prescription within 2005-2018, using data from health-record database of Hong Kong public healthcare services. We calculated annual prescription rates (per 1000 persons) for any antidepressant, antidepressant drug classes, and individual antidepressants. Joinpoint-regression analyses were performed to assess temporal antidepressant prescription trends, quantified by average annual-percent-change (AAPC), with 95 % confidence-intervals (CIs).

RESULTS

Overall antidepressant prescription rate significantly increased over time (AAPC: 7.30 [95 % CI: 6.70-7.90]), from 3.883 in 2005 to 9.916 in 2018. The use of selective-serotonin-reuptake-inhibitors (SSRIs), serotonin-norepinephrine-reuptake-inhibitors (SNRIs), and other antidepressants significantly increased over 14 years, while tricyclic-antidepressants remained stable. SSRI represented the most commonly-prescribed drug class. Fluoxetine and sertraline constituted the two most frequently-prescribed individual antidepressants, while desvenlafaxine (AAPC: 55.68 [30.74-85.39]) and bupropion (AAPC: 35.28 [23.68-47.98]) exhibited the sharpest increase in prescription rates over the study period.

LIMITATIONS

Medication adherence could not be assessed and actual drug use may be overestimated.

CONCLUSIONS

Our results affirm a significant rising trend of antidepressant prescriptions among Chinese children and adolescents over time. All antidepressant drug-classes, except TCA, demonstrated significantly increased use, with SSRI being the most frequently-prescribed drug class. Future investigation should clarify indications, hence off-label use, of antidepressant initiation in this vulnerable population.

An integrated care model for mental health in diabetes: Recommendations for local implementation by the Diabetes and Mental Health Expert Working Group in England

CONTEXT

In 2019, NHS England and Diabetes UK convened an Expert Working Group (EWG) in order to develop a Model and recommendations to guide commissioning and provision of mental health care in diabetes pathways and diabetes care in mental health pathways. The recommendations are based on a combination of evidence, national guidance, case studies and expert opinion from across the UK and form other long term conditions.

THE CASE FOR INTEGRATION

There is good the evidence around the high prevalence of co-morbidity between diabetes and mental illness of all severities and, the poorer diabetes and mental health outcomes for patients when this co-morbidity exists. Detecting and managing the mental health co-morbidity improves these outcomes, but the evidence suggests that detection of mental illness is poor in the context of diabetes care in community and acute care settings and that when it is detected, the access to appropriate mental health resource is variable and generally inadequate.

THE MODEL OF INTEGRATED CARE FOR DIABETES

The EWG developed a one-page Model with five core principles and five operational work-streams to support the delivery of integration, with examples of local case studies for local implementation. The five core principals are: Care for all-describing how care for all PWD needs to explore what matters to them and that emotional wellbeing is supported at diagnosis and beyond; Support and information-describing how HCPs should appropriately signpost to mental health support and the need for structured education programmes to include mental healthcare information; Needs identified-describing how PWD should have their mental health needs identified and acted on; Integrated care-describing how people with mental illness and diabetes should have their diabetes considered within their mental health care; Specialist care-describing how PWD should be able to access specialist diabetes mental health professionals. The five cross cutting work-streams for operationalising the principles are: Implementing training and upskilling of HCPs; Embedding mental health screening and assessment into diabetes pathways; Ensuring access to clear, integrated local pathways; Ensuring addressing health inequalities is incorporated at every stage of service development; Improving access to specialist mental health services through commissioning.

DISCUSSION AND CONCLUSIONS

The Model can be implemented in part or completely, at an individual level, all the way up to system level. It can be adapted across the life span and the UK, and having learnt from other long term conditions, there is a lot of transferability across all long term conditions There is an opportunity for ICBs to consider economies of scale across multiple long term conditions for which there will be a significant overlap of patients within the local population. Any local implementation should be in co-production with experts by experience and third sector providers.

Prevalence of physical health conditions and health risk behaviours in people with severe mental illness in South Asia: multi-country cross-sectional survey

BACKGROUND

People with severe mental illness (SMI) die earlier than the general population, primarily because of physical disorders.

AIMS

We estimated the prevalence of physical health conditions, health risk behaviours, access to healthcare and health risk modification advice in people with SMI in Bangladesh, India and Pakistan, and compared results with the general population.

METHOD

We conducted a cross-sectional survey in adults with SMI attending mental hospitals in Bangladesh, India and Pakistan. Data were collected on non-communicable diseases, their risk factors, health risk behaviours, treatments, health risk modification advice, common mental disorders, health-related quality of life and infectious diseases. We performed a descriptive analysis and compared our findings with the general population in the World Health Organization (WHO) 'STEPwise Approach to Surveillance of NCDs' reports.

RESULTS

We recruited 3989 participants with SMI, of which 11% had diabetes, 23.3% had hypertension or high blood pressure and 46.3% had overweight or obesity. We found that 70.8% of participants with diabetes, high blood pressure and hypercholesterolemia were previously undiagnosed; of those diagnosed, only around half were receiving treatment. A total of 47% of men and 14% of women used tobacco; 45.6% and 89.1% of participants did not meet WHO recommendations for physical activity and fruit and vegetable intake, respectively. Compared with the general population, people with SMI were more likely to have diabetes, hypercholesterolemia and overweight or obesity, and less likely to receive tobacco cessation and weight management advice.

CONCLUSIONS

We found significant gaps in detection, prevention and treatment of non-communicable diseases and their risk factors in people with SMI.

Epigenetic clock analysis of blood samples in drug-naive first-episode schizophrenia patients

BACKGROUND

Schizophrenia (SCZ) is a severe and chronic psychiatric disorder with premature age-related physiological changes. However, numerous previous studies examined the epigenetic age acceleration in SCZ patients and yielded inconclusive results. In this study, we propose to explore the epigenetic age acceleration in drug-naive first-episode SCZ (FSCZ) patients and investigate whether epigenetic age acceleration is associated with antipsychotic treatment, psychotic symptoms, cognition, and subcortical volumes.

METHODS

We assessed the epigenetic age in 38 drug-naive FSCZ patients and 38 healthy controls by using three independent clocks, including Horvath, Hannum and Levine algorithms. The epigenetic age measurements in SCZ patients were repeated after receiving 8 weeks risperidone monotherapy.

RESULTS

Our findings showed significantly positive correlations between epigenetic ages assessed by three clocks and chronological age in both FSCZ patients and healthy controls. Compared with healthy controls, drug-naive FSCZ patients have a significant epigenetic age deceleration in Horvath clock (p = 0.01), but not in Hannum clock (p = 0.07) and Levine clock (p = 0.43). The epigenetic ages of Hannum clock (p = 0.002) and Levine clock (p = 0.01) were significantly accelerated in SCZ patients after 8-week risperidone treatment. However, no significant associations between epigenetic age acceleration and psychotic symptoms, cognitive function, as well as subcortical volumes were observed in FSCZ patients.

CONCLUSION

These results demonstrate that distinct epigenetic clocks are sensitive to different aspects of aging process. Further investigations with comprehensive epigenetic clock analyses and large samples are required to confirm our findings.

Mortality rates in people with first diagnosis of schizophrenia-spectrum disorders: A 5-year population-based cohort study

OBJECTIVE

Schizophrenia-spectrum disorder (SSD) is associated with increased premature death, with emerging data suggesting early illness course as a high-risk period for excess mortality. This study aimed to examine mortality rate in patients with incident SSD and differential mortality risk between inpatient-diagnosed and outpatient-diagnosed subsamples within 5 years of first diagnosis.

METHOD

This population-based cohort study identified 8826 patients aged 18-39 years receiving first-recorded SSD diagnosis upon service entry, comprising 3877 inpatient-diagnosed and 4949 outpatient-diagnosed patients, between 2006 and 2012 in Hong Kong using a territory-wide medical record database of public health care services. All-cause, natural-cause, and unnatural-cause mortality risks within 5 years after first diagnosis were quantified by standardized mortality ratios (SMRs) relative to the general population. We also directly compared mortality rates between inpatient and outpatient subsamples over 5-year follow-up.

RESULTS

SSD patients exhibited markedly elevated all-cause (SMR: 12.28, 95% confidence interval [CI]: [10.83, 13.88]), natural-cause (SMR: 3.76, 95% CI: [2.77, 4.98]) and unnatural-cause (SMR: 20.64, 95% CI: [17.49, 24.20]) mortality during first 5 years of diagnosis. Increased mortality rate was most pronounced in the first year of treatment, especially for unnatural deaths (SMR 32.2, 95% CI: [24.08, 42.22]). Discharged inpatient-diagnosed patients displayed significantly higher all-cause and unnatural-cause mortality rates than outpatient-diagnosed counterparts within first 3 years of treatment, and differential mortality risks on all-cause (adjusted hazard ratio [aHR]: 7.05, 95% CI: [2.02, 24.64]) and unnatural-cause (aHR: 5.15, 95% CI: [1.38, 19.19]) deaths were the highest in the first month of follow-up.

CONCLUSIONS

Substantial increase in early mortality risk among people with incident SSD, particularly in the first year of diagnosis and the time shortly after discharge, underscores an urgent need of targeted early intervention for effective suicide prevention and physical health improvement to minimize mortality gap.

Antipsychotic utilization patterns in pregnant women with psychotic disorders: a 16-year population-based cohort study

Despite growing concern about reproductive safety of antipsychotics, there is a paucity of research specifically assessing prenatal antipsychotic prescribing practices for psychotic disorders. This population-based cohort study identified women aged 15-50 years with diagnosis of psychotic disorders, who delivered their first and singleton child between 2003-2018 in Hong Kong, with an aim to examine temporal trends and predictors of prenatal antipsychotic use as well as antipsychotic utilization patterns before and during pregnancy. Data were retrieved from territory-wide medical-record database of public healthcare services. Of 804 women, 519 (65%) redeemed at least one prescription for antipsychotics during pregnancy. Older age at conception (25-34 years: OR 2.12 [95% CI 1.22-3.67]; 35-50 years: 2.52 [1.38-4.61]; 15-24 years as reference category) and antipsychotic treatment within 12 months pre-pregnancy (24.22 [16.23-36.16]) were significantly associated with prenatal antipsychotic use. Second-generation-antipsychotic (SGA) use during pregnancy increased over 16-year study period, while prenatal first-generation-antipsychotic (FGA) use showed declining trend. Overall antipsychotic and SGA use progressively decreased across pre-pregnancy and trimesters of pregnancy. Further analyses on antipsychotic use trajectories revealed that 87.4% (n = 459) of 529 women receiving antipsychotics in 12-month pre-pregnancy redeemed antipsychotic prescription during pregnancy, and 63.4% (n = 333) continued antipsychotic treatment throughout pregnancy. Only 7.5% of the cohort (n = 60) commenced antipsychotics in pregnancy. This is one of the few studies evaluating real-world prenatal antipsychotic utilization among women with psychotic disorders. Future research delineating risk conferred by illness-related factors and antipsychotic exposure on adverse maternal and fetal outcomes is warranted to facilitate treatment guideline development.

Antidepressant utilization patterns and predictors of treatment continuation in pregnant women: A 16-year population-based cohort

OBJECTIVE

Existing data on prenatal antidepressant prescribing patterns are mostly derived from Western countries, with limited research assessing antidepressant continuation and reinitiation during pregnancy. This study aimed to examine antidepressant prescribing practice among Chinese pregnant women in Hong Kong.

METHODS

This population-based study identified women aged 15-50 years who delivered their first and singleton child, and had redeemed at least one antidepressant prescription within 3 months pre-pregnancy and/or during pregnancy between 2003 and 2018, using data from the health-record database of Hong Kong public healthcare services. Antidepressant utilization patterns before and during pregnancy, and factors associated with antidepressant continuation and reinitiation following medication discontinuation were evaluated.

RESULTS

Of 466,358 pregnancies, 3019 (0.67%) received antidepressants within 3 months of pre-pregnancy and/or during pregnancy, and 2700 (0.58%) had prenatal antidepressant use. There was a significant rising trend of prenatal antidepressant use over time (0.6% in 2003 to 1.3% in 2018; odds ratio: 1.09, 95% confidence interval = [1.08, 1.10], p < 0.001). A consistent pattern of decreasing overall antidepressant use from 3 months pre-pregnancy to the second trimester was observed, followed by a slight increase in the third trimester. Almost half (n = 949, 49.5%) of 1918 women on antidepressants in 3 months pre-pregnancy continued treatment beyond the first trimester. A total of 8.2% that discontinued antidepressants in 3 months pre-pregnancy or in the first trimester reinitiated treatment in the later stage of pregnancy. Older age at conception (⩾35 years), recent calendar year of delivery (2015-2018), pre-existing depression/anxiety disorders, longer-term pre-pregnancy antidepressant treatment and pre-pregnancy prescription of other psychotropics were significantly associated with antidepressant continuation. Antidepressant reinitiation was predicted by pre-existing depression/anxiety disorders.

CONCLUSIONS

Our results that prenatal antidepressant use is increasingly prevalent and half of pregnant women discontinued antidepressants 3 months before or after conception underscore the need for future research to clarify the risk and benefit of antidepressant continuation versus discontinuation to facilitate development of evidence-based guidelines, so as to optimize maternal and fetal outcomes.

Crosstalk between Schizophrenia and Metabolic Syndrome: The Role of Oxytocinergic Dysfunction

The high prevalence of metabolic syndrome in persons with schizophrenia has spurred investigational efforts to study the mechanism beneath its pathophysiology. Early psychosis dysfunction is present across multiple organ systems. On this account, schizophrenia may be a multisystem disorder in which one organ system is predominantly affected and where other organ systems are also concurrently involved. Growing evidence of the overlapping neurobiological profiles of metabolic risk factors and psychiatric symptoms, such as an association with cognitive dysfunction, altered autonomic nervous system regulation, desynchrony in the resting-state default mode network, and shared genetic liability, suggest that metabolic syndrome and schizophrenia are connected via common pathways that are central to schizophrenia pathogenesis, which may be underpinned by oxytocin system dysfunction. Oxytocin, a hormone that involves in the mechanisms of food intake and metabolic homeostasis, may partly explain this piece of the puzzle in the mechanism underlying this association. Given its prosocial and anorexigenic properties, oxytocin has been administered intranasally to investigate its therapeutic potential in schizophrenia and obesity. Although the pathophysiology and mechanisms of oxytocinergic dysfunction in metabolic syndrome and schizophrenia are both complex and it is still too early to draw a conclusion upon, oxytocinergic dysfunction may yield a new mechanistic insight into schizophrenia pathogenesis and treatment.

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.

Familial aggregation and shared genetic loading for major psychiatric disorders and type 2 diabetes

AIMS/HYPOTHESIS

Psychiatric disorders, such as schizophrenia (SCZ), major depressive disorder (MDD) and bipolar disorder (BPD), are highly comorbid with type 2 diabetes. However, the mechanisms underlying such comorbidity are understudied. This study explored the familial aggregation of common psychiatric disorders and type 2 diabetes by testing family history association, and investigated the shared genetic loading between them by testing the polygenic risk score (PRS) association.

METHODS

A total of 105,184 participants were recruited from the Taiwan Biobank, and genome-wide genotyping data were available for 95,238 participants. The Psychiatric Genomics Consortium-derived PRS for SCZ, MDD and BPD was calculated. Logistic regression was used to estimate the OR with CIs between a family history of SCZ/MDD/BPD and a family history of type 2 diabetes, and between the PRS and the risk of type 2 diabetes.

RESULTS

A family history of type 2 diabetes was associated with a family history of SCZ (OR 1.23, 95% CI 1.08, 1.40), MDD (OR 1.19, 95% CI 1.13, 1.26) and BPD (OR 1.26, 95% CI 1.15, 1.39). Compared with paternal type 2 diabetes, maternal type 2 diabetes was associated with a higher risk of a family history of SCZ. SCZ PRS was negatively associated with type 2 diabetes in women (OR 0.92, 95% CI 0.88, 0.97), but not in men; the effect of SCZ PRS reduced after adjusting for BMI. MDD PRS was positively associated with type 2 diabetes (OR 1.04, 95% CI 1.00, 1.07); the effect of MDD PRS reduced after adjusting for BMI or smoking. BPD PRS was not associated with type 2 diabetes.

CONCLUSIONS/INTERPRETATION

The comorbidity of type 2 diabetes with psychiatric disorders may be explained by shared familial factors. The shared polygenic loading between MDD and type 2 diabetes implies not only pleiotropy but also a shared genetic aetiology for the mechanism behind the comorbidity. The negative correlation between polygenic loading for SCZ and type 2 diabetes implies the role of environmental factors.

Psychotropic drug utilization patterns in pregnant women with bipolar disorder: A 16-year population-based cohort study

Despite growing concern about reproductive safety of psychotropic drugs, there is a paucity of research assessing prenatal prescribing practices for bipolar disorder (BD). This population-based cohort study identified women aged 15-50 years with BD diagnosis, who delivered their first and singleton child between 2003 and 2018 in Hong Kong, with an aim to examine temporal trends and predictors of prenatal psychotropic drug use as well as drug utilization patterns before and during pregnancy were evaluated. Data were retrieved from territory-wide medical-record database of public healthcare services. Of 302 identified women, 202 (66.9%) and 180 (59.6%) redeemed at least 1 prescription for psychotropic drugs in 12 months pre-pregnancy and during pregnancy, respectively. Psychotropic drug treatment (OR = 16.14 [95% CI: 8.79-29.65]) and psychiatric admission (OR = 4.12 [95% CI: 1.66-10.24]) within 12 months pre-pregnancy were associated with prenatal drug use. Second-generation antipsychotic use during pregnancy increased over time, while prenatal use of lithium, anti-epileptics and first-generation-antipsychotics showed declining trend. Use of psychotropic drugs progressively decreased across pre-pregnancy and trimesters of pregnancy. Forty-two (23.3%) women received polypharmacy during pregnancy. Antidepressant use accounted for 17% of all monotherapy episodes. A significant proportion of women exposed to valproate in 12 months pre-pregnancy (27.2%) and first-trimester (16%). In conclusion, our results generally indicate trajectories of reduced psychotropic drug use across pregnancy. Deviations between real-world prescribing patterns and treatment guidelines underscore the need for comprehensive review of current clinical practices. Further research clarifying relationships of prenatal psychotropic drug exposure with maternal and fetal outcomes is warranted.

Correlations of Salivary and Blood Glucose Levels among Six Saliva Collection Methods

Background: Saliva has been studied as a better indicator of disorders and diseases than blood. Specifically, the salivary glucose level is considered to be an indicator of diabetes mellitus (DM). However, saliva collection methods can affect the salivary glucose level, thereby affecting the correlation between salivary glucose and blood glucose. Therefore, this study aims to identify an ideal saliva collection method and to use this method to determine the population and individual correlations between salivary glucose and blood glucose levels in DM patients and healthy controls. Finally, an analysis of the stability of the individual correlations is conducted. Methods: This study included 40 age-matched DM patients and 40 healthy controls. In the fasting state, saliva was collected using six saliva collection methods, venous blood was collected simultaneously from each study participant, and both samples were analyzed at the same time using glucose oxidase peroxidase. A total of 20 DM patients and 20 healthy controls were arbitrarily selected from the above participants for one week of daily testing. The correlations between salivary glucose and blood glucose before and after breakfast were analyzed. Finally, 10 DM patients and 10 healthy controls were arbitrarily selected for one month of daily testing to analyze the stability of individual correlations. Results: Salivary glucose levels were higher in DM patients than healthy controls for the six saliva collection methods. Compared with unstimulated saliva, stimulated saliva had decreased glucose level and increased salivary flow. In addition, unstimulated parotid salivary glucose was most correlated with blood glucose level (R² = 0.9153), and the ROC curve area was 0.9316, which could accurately distinguish DM patients. Finally, it was found that the correlations between salivary glucose and blood glucose in different DM patients were quite different. The average correlation before breakfast was 0.83, and the average correlation after breakfast was 0.77. The coefficient of variation of the correlation coefficient before breakfast within 1 month was less than 5%. Conclusion: Unstimulated parotid salivary glucose level is the highest and is most correlated with blood glucose level, which can be accurately used to distinguish DM patients. Meanwhile, the correlation between salivary glucose and blood glucose was found to be relatively high and stable before breakfast. In general, the unstimulated parotid salivary glucose before breakfast presents an ideal saliva collecting method with which to replace blood-glucose use to detect DM, which provides a reference for the prediction of DM.

Pre-existing chronic physical morbidity and excess mortality in people with schizophrenia: a population-based cohort study

PURPOSE

Schizophrenia is associated with increased premature mortality and physical morbidity. This study aimed to examine prevalence of pre-existing chronic physical diseases, and association between physical multimorbidity burden and mortality rates among patients with newly diagnosed schizophrenia.

METHODS

This population-based cohort study investigated patients with first-recorded diagnosis of schizophrenia between January 2006 and December 2016, using territory-wide medical-record database of public healthcare service in Hong Kong. Physical morbidities were measured by Charlson Comorbidity Index (CCI), taking into consideration both number and severity of physical diseases, and were grouped into nine broad disease categories for analyses. Physical multimorbidity burden was stratified into three levels according to CCI of 0, 1 or ≥ 2. Cox proportional hazards regression models were used to examine associations of physical multimorbidity with mortality rates.

RESULTS

Of the 13,945 patients, 8.6% (n = 1207) had pre-existing physical morbidity. Patients with physical morbidity exhibited elevated all-cause mortality rate relative to those without physical morbidity [adjusted HR 2.38 (95% CI 2.04-2.77)]. Gastrointestinal/liver diseases, diabetes and cardiovascular diseases constituted the three most frequently diagnosed physical morbidities, whereas cancers displayed the highest all-cause mortality rate. An increase in physical multimorbidity burden was associated with increased all-cause mortality rate [CCI = 1: 1.98 (1.64-2.40); CCI ≥ 2: 3.08 (2.51-3.77), CCI = 0 as reference].

CONCLUSION

Schizophrenia patients with pre-existing physical morbidity had two-fold increased risk of premature mortality compared to those without physical morbidity. Physical multimorbidity confers incremental impact on excess mortality. Early detection and intervention of physical morbidity in the initial phase of schizophrenia is necessary to reduce avoidable mortality.

Activation of the NLRP3 inflammasome by RAC1 mediates a new mechanism in diabetic nephropathy

OBJECTIVE

Inflammation is central to the development and progression of diabetic nephropathy (DN). Although the exact mechanisms of inflammation in the kidney have not been well elucidated, pyrin domain containing 3 (NLRP3) inflammasome activation is involved in the onset and progression of DN. Here, we investigated the underlying regulatory mechanisms of hyperglycaemia-induced NLRP3 inflammasome activation in the kidney.

METHODS

HEK293T cells received high glucose, and the cell proliferation and apoptosis were detected. Biochemical indicators in db/db mice were tested by kits, and the morphological changes in the kidney were observed using staining methods and transmission electron microscopy. The interaction of Ras-related C3 botulinum toxin substrate 1 (RAC1) and NLRP3 inflammasome in cells and in mice was assessed by co-immunoprecipitation (Co-IP) and immunofluorescence. Expression of all proteins was examined by western blotting and immunohistochemistry. In additional, the directly combination of RAC1 and NLRP3 was evaluated by GST Pulldown.

RESULTS

High-glucose and hyperglycaemia conditions resulted in Ras-related C3 botulinum toxin substrate 1 (RAC1) and NLRP3 inflammasome interactions in cells and in mice. Additionally, RAC1 promoted NLRP3 inflammasome activation and then induced cell damage, and morphological and functional abnormalities in the kidney. We also observed that RAC1 activates the NLRP3 inflammasome by directly binding to NLRP3.

CONCLUSION

In the present study, we confirmed that RAC1 binding to NLRP3 is sufficient to activate the NLRP3 inflammasome in the kidney and accelerate DN pathological processes. These results elucidate the upstream cellular and molecular mechanisms of NLRP3 inflammasome activation and provide new therapeutic strategies for the treatment of DN.

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

Schizophrenia is associated with increased prevalence of diabetes. However, risk of diabetes complications as well as the impact of complication burden and patterns on subsequent mortality risk in schizophrenia patients with co-existing diabetes is understudied. This population-based, propensity-score matched (1:10) cohort study identified 6991 patients with incident diabetes and pre-existing schizophrenia and 68,682 patients with incident diabetes only (comparison group) between 2001 and 2016 in Hong Kong, using territory-wide medical-record database of public healthcare services. Complications were measured by Diabetes Complications Severity Index (DCSI), which stratified complication burden into 6 levels (DCSI score=0, 1, 2, 3, 4, or ≥5). Associations of diabetes complications, in terms of DCSI scores (complication burden), specific types and two-way combinations of complications (complication patterns), with all-cause mortality rate in schizophrenia were evaluated using Cox proportional-hazards models. Schizophrenia group had comparable macrovascular (adjusted OR 0.99 [95% CI 0.92-1.06]) and lower microvascular (0.79 [0.73-0.86]) complication rates relative to comparison group. Mortality risk ratio for schizophrenia was elevated at all complication burden levels, which conferred incremental impact on excess mortality in both groups. Cardiovascular diseases (1.60 [1.45-1.77]) and cerebrovascular-metabolic diseases (2.74 [1.25-5.99]) were associated with the highest differential mortality in schizophrenia among various specific complications and complication combinations, respectively. Our results indicate that schizophrenia patients with co-existing diabetes are at increased risk of excess mortality relative to those with diabetes alone, regardless of complication burden levels. Implementation of multilevel, targeted interventions is needed to improve diabetes-related outcomes and reduce mortality gap in this vulnerable population.

Excess mortality and life-years lost in people with bipolar disorder: an 11-year population-based cohort study

AIMS

Bipolar disorder is associated with premature mortality, but evidence is mostly derived from Western countries. There has been no research evaluating shortened lifespan in bipolar disorder using life-years lost (LYLs), which is a recently developed mortality metric taking into account illness onset for life expectancy estimation. The current study aimed to examine the extent of premature mortality in bipolar disorder patients relative to the general population in Hong Kong (HK) in terms of standardised mortality ratio (SMR) and excess LYLs, and changes of mortality rate over time.

METHODS

This population-based cohort study investigated excess mortality in 12 556 bipolar disorder patients between 2008 and 2018, by estimating all-cause and cause-specific SMRs, and LYLs. Trends in annual SMRs over the 11-year study period were assessed. Study data were retrieved from a territory-wide medical-record database of HK public healthcare services.

RESULTS

Patients had higher all-cause [SMR: 2.60 (95% CI: 2.45-2.76)], natural-cause [SMR: 1.90 (95% CI: 1.76-2.05)] and unnatural-cause [SMR: 8.63 (95% CI: 7.34-10.03)] mortality rates than the general population. Respiratory diseases, cardiovascular diseases and cancers accounted for the majority of deaths. Men and women with bipolar disorder had 6.78 (95% CI: 6.00-7.84) years and 7.35 (95% CI: 6.75-8.06) years of excess LYLs, respectively. The overall mortality gap remained similar over time, albeit slightly improved in men with bipolar disorder.

CONCLUSIONS

Bipolar disorder is associated with increased premature mortality and substantially reduced lifespan in a predominantly Chinese population, with excess deaths mainly attributed to natural causes. Persistent mortality gap underscores an urgent need for targeted interventions to improve physical health of patients with bipolar disorder.