Cardiometabolic risk indicators that distinguish adults with psychosis from the general population, by age and gender

Cardiac Molecular Analysis Reveals Aging-Associated Metabolic Alterations Promoting Glycosaminoglycans Accumulation via Hexosamine Biosynthetic Pathway

Age is a prominent risk factor for cardiometabolic disease, often leading to heart structural and functional changes. However, precise molecular mechanisms underlying cardiac remodeling and dysfunction exclusively resulting from physiological aging remain elusive. Previous research demonstrated age-related functional alterations in baboons, analogous to humans. The goal of this study is to identify early cardiac molecular alterations preceding functional adaptations, shedding light on the regulation of age-associated changes. Unbiased transcriptomics of left ventricle samples are performed from female baboons aged 7.5-22.1 years (human equivalent ≈30-88 years). Weighted-gene correlation network and pathway enrichment analyses are performed, with histological validation. Modules of transcripts negatively correlated with age implicated declined metabolism-oxidative phosphorylation, tricarboxylic acid cycle, glycolysis, and fatty-acid β-oxidation. Transcripts positively correlated with age suggested a metabolic shift toward glucose-dependent anabolic pathways, including hexosamine biosynthetic pathway (HBP). This shift is associated with increased glycosaminoglycan synthesis, modification, precursor synthesis via HBP, and extracellular matrix accumulation, verified histologically. Upregulated extracellular matrix-induced signaling coincided with glycosaminoglycan accumulation, followed by cardiac hypertrophy-related pathways. Overall, these findings revealed a transcriptional shift in metabolism favoring glycosaminoglycan accumulation through HBP before cardiac hypertrophy. Unveiling this metabolic shift provides potential targets for age-related cardiac diseases, offering novel insights into early age-related mechanisms.

Cardiac Molecular Analysis Reveals Aging-Associated Metabolic Alterations Promoting Glycosaminoglycans Accumulation Via Hexosamine Biosynthetic Pathway

Age is a prominent risk factor for cardiometabolic disease, and often leads to heart structural and functional changes. However, precise molecular mechanisms underlying cardiac remodeling and dysfunction resulting from physiological aging per se remain elusive. Understanding these mechanisms requires biological models with optimal translation to humans. Previous research demonstrated that baboons undergo age-related reduction in ejection fraction and increased heart sphericity, mirroring changes observed in humans. The goal of this study was to identify early cardiac molecular alterations that precede functional adaptations, shedding light on the regulation of age-associated changes. We performed unbiased transcriptomics of left ventricle (LV) samples from female baboons aged 7.5-22.1 years (human equivalent ~30-88 years). Weighted-gene correlation network and pathway enrichment analyses were performed to identify potential age-associated mechanisms in LV, with histological validation. Myocardial modules of transcripts negatively associated with age were primarily enriched for cardiac metabolism, including oxidative phosphorylation, tricarboxylic acid cycle, glycolysis, and fatty-acid β-oxidation. Transcripts positively correlated with age suggest upregulation of glucose uptake, pentose phosphate pathway, and hexosamine biosynthetic pathway (HBP), indicating a metabolic shift towards glucose-dependent anabolic pathways. Upregulation of HBP commonly results in increased glycosaminoglycan precursor synthesis. Transcripts involved in glycosaminoglycan synthesis, modification, and intermediate metabolism were also upregulated in older animals, while glycosaminoglycan degradation transcripts were downregulated with age. These alterations would promote glycosaminoglycan accumulation, which was verified histologically. Upregulation of extracellular matrix (ECM)-induced signaling pathways temporally coincided with glycosaminoglycan accumulation. We found a subsequent upregulation of cardiac hypertrophy-related pathways and an increase in cardiomyocyte width. Overall, our findings revealed a transcriptional shift in metabolism from catabolic to anabolic pathways that leads to ECM glycosaminoglycan accumulation through HBP prior to upregulation of transcripts of cardiac hypertrophy-related pathways. This study illuminates cellular mechanisms that precede development of cardiac hypertrophy, providing novel potential targets to remediate age-related cardiac diseases.

A scoping review of cardiovascular risk factor screening rates in general or family practice attendees living with severe mental ill-health

BACKGROUND

Primary care is essential to address the unmet physical health needs of people with severe mental ill-health. Continued poor cardiovascular health demands improved screening and preventive care. No previous reviews have examined primary care cardiovascular screening rates for people living with severe mental ill-health; termed in the literature "severe mental illness".

METHODS

A scoping review following Joanna Briggs Institute methodology was conducted. Cardiovascular risk factor screening rates in adults with severe mental ill-health were examined in general or family practices (as the main delivery sites of primary care). Literature published between 2001 and 2023 was searched using electronic databases including Medline, Embase, Web of Science, PsychINFO and CINAHL. Two reviewers independently screened titles and abstracts and conducted a full-text review. The term "severe mental illness" was applied as the term applied in the literature over the past decades. Study information, participant details and cardiovascular risk factor screening rates for people with 'severe mental illness' were extracted and synthesised.

RESULTS

Thirteen studies were included. Nine studies were from the United Kingdom and one each from Canada, Spain, New Zealand and the Netherlands. The general and/or family practice cardiovascular disease screening rates varied considerably across studies, ranging from 0 % to 75 % for people grouped within the term "severe mental illness". Lipids and blood pressure were the most screened risk factors.

CONCLUSIONS

Cardiovascular disease screening rates in primary care settings for adults living with severe mental ill-health varied considerably. Tailored and targeted cardiovascular risk screening will enable more comprehensive preventive care to improve heart health outcomes and address this urgent health inequity.

Cardiometabolic risk indicators in individuals with bipolar disorders: a replication study

OBJECTIVES

We recently conducted the first longitudinal study comparing cardiometabolic risk indicators (CMRIs) between a cohort of individuals with bipolar disorders (BDs) and controls from the general population. Here, we sought to validate the findings in that study using an independent case-control sample.

METHODS

We used data from the St. Göran project's Gothenburg cohort. The BDs group and the control group were examined at baseline and after a median of eight and seven years, respectively. Data collection occurred between March 2009 and June 2022. We used multiple imputation to handle missing data and linear mixed effects model to examine the annual change in CMRIs over the study period.

RESULTS

The baseline cohort included 407 individuals with BDs (mean age 40 years, 63% women) and 56 controls (mean age 43 years, 54% women). Of those, 63 persons with BDs and 42 controls participated at follow-up. At baseline, individuals with BDs had significantly higher mean values of body mass index (β = 0.14, p = 0.003) than controls. Over the study period, the difference in average annual change between the patient and the control group indicated an increase in patients relative to controls in waist-to-hip ratio (0.004 unit/year, p = 0.01), diastolic (0.6 mm Hg/year, p = 0.048), and systolic (0.8 mm Hg/year, p = 0.02) blood pressure.

CONCLUSIONS

This study replicated the main findings from our previous study and showed that central obesity and measures of blood pressure worsened over a relatively short time in individuals with BDs relative to controls. It is vital for clinicians to monitor CMRIs in persons with BDs and to be proactive in preventing cardiometabolic diseases in this high-risk group.

Time effect on cardiometabolic risk indicators in patients with bipolar disorder: a longitudinal case-control study

Individuals with bipolar disorder are at increased risk for cardiovascular diseases. Most studies have described increases in cardiometabolic risk indicators (CMRIs) using clinical cut-off values. Further, there are no longitudinal studies on CMRIs. We aimed to investigate continuous measures of CMRIs in individuals with bipolar disorder and controls using both cross-sectional and longitudinal data. We used data from the Swedish St. Göran Bipolar project. Study individuals were examined at baseline and after a median of 6 and 7 years for the control and patient group, respectively. Data were collected December 2005-December 2020. The cohort included 281 individuals with bipolar disorder (mean age 39 years, 59% women) and 114 controls (mean age 38 years, 55% women). Of those, 155 patients and 74 controls also provided follow-up data. At baseline, individuals with bipolar disorder had significantly higher mean values of waist-to-hip ratio (WHR) (β = 0.142, p = 0.001), body mass index (β = 0.150, p = 0.006), plasma triacylglycerol (TAG) (β = 0.218, p < 0.001), total/plasma high-density lipoprotein-cholesterol (TChol/HDL-C) ratio (β = 0.103, p = 0.03), TAG/HDL-C ratio (β = 0.151, p = 0.006), and non-HDL-C (β = 0.168, p = 0.001) than controls. Most CMRIs remained higher in the patient group at follow-up. The difference between patients and controls increased over time for WHR (0.005 unit/year, p < 0.001), and systolic (1.1 mm Hg/year, p = 0.002) and diastolic (0.8 mm Hg/year, p < 0.001) blood pressure. Individuals with bipolar disorder displayed persistently higher levels of nearly all included CMRIs. Over time, a subset of CMRIs worsened in patients relative to controls. This suggests that active measures to counter cardiovascular risk in persons with bipolar disorder should be considered.

Risk factors for metabolic and cardiovascular disease in inpatients with severe mental illness

Patients with severe mental illness (SMI) have increased burden of somatic illnesses, especially cardiovascular disease. Characterizing the cardiovascular risk profile of patients with SMI is therefore crucial to understanding how to decrease morbidity and mortality in these vulnerable populations. In this observational study, entropy balancing (a form of propensity score matching) was used to compare cardiometabolic health in a sample of the general population from the National Health and Nutrition Examination Survey (NHANES) datasets to inpatients hospitalized in a large, urban, academic psychiatric hospital in Harris County, Texas. Data were analyzed using independent linear regression models for blood pressure, blood glucose, TG:HDL ratio, total cholesterol, and body mass index as outcome variables. Systolic blood pressure (F=34•75, p<0•0001), diastolic blood pressure (F=90•53, p<0•0001), blood glucose (F=12•89, p<0•0001), and the TG:HDL ratio (F=3•16, p<0•0001) were all elevated in the psychiatric inpatient sample vs. the NHANES sample. Contrary to expectations, total cholesterol (F=32•18, p<0•0001) and BMI (F=15•05, p<0•0001) were lower in this sample vs. the NHANES sample. Patients hospitalized with SMI show a cardiometabolic profile which confers greater risk of diabetes- and hypertension-related mortality. Approaches should be developed to target indicators of cardiometabolic health in this population to reduce long-term mortality.

Weight gain and metabolic screening in young people with early psychosis on long acting injectable antipsychotic medication (aripiprazole vs paliperidone)

AIM

Long-acting injectable (LAI)antipsychotics are often used in psychosis to assist with medication compliance and relapse prevention, although the weight gain and metabolic effects in young people are yet to be examined. This study examined the long-term effects of aripiprazole and paliperidone in LAI formulation on weight gain and metabolic parameters in young people with early episode psychosis.

METHODS

Weight gain and other metabolic effects of aripiprazole and paliperidone in LAI formulation were examined in 59 young people with early episode psychosis over a 12-month period. Changes in outcome measurements were examined at baseline and 3 monthly intervals.

RESULTS

The results showed that both aripiprazole and paliperidone were associated with time-dependent increases in weight. At 12 months, weight increased by an average of 7% (6 kg) with both aripiprazole and paliperidone relative to the baseline, and the percentage of overweight or obese people increased from 33% to 60%. There was no advantage of aripiprazole compared to paliperidone with regards to weight change, although aripiprazole was associated with lower triglycerides and prolactin levels.

CONCLUSIONS

Both LAI medications were associated with substantial weight increases over time. These results build on emerging evidence showing that aripiprazole is not weight neutral in young people. Our recommendation is that weight-management programs should be offered from the start of medication initiation.

Examining the dispensing patterns of antipsychotics in Australia from 2006 to 2018 - A pharmacoepidemiology study

BACKGROUND

Antipsychotic medications can be prescribed in Australia by medical and nurse practitioners under the Pharmaceutical Benefits Scheme (PBS). The current pharmacoepidemiology study aims to determine the dispensing rates of antipsychotic medicines in Australia, and to produce and examine a time-trend of the dispensing patterns of these medicines.

METHODS

Dispensing counts of antipsychotic medication from 2006 to 2018 were accessed from the PBS dataset. All of the antipsychotic medicines dispensed were included for time trend analysis. Cumulative dispensing counts and defined daily dose (DDD) per 1000 concessional population days (DPD) were analysed for the purpose of time trend analysis.

RESULTS

Sixteen antipsychotic medications were assessed and had a total cumulative dispensing count of 33, 732, 404. Olanzapine had the highest cumulative prescription count and Quetiapine experienced the highest average dispensing count and rate as determined by DPD. Twelve out of the sixteen medications were second-generation antipsychotics (SGAs). Overall, eleven out of the sixteen medications (aripiprazole, asenapine, brexpiprazole, clozapine, flupentixol, lurasidone, olanzapine, paliperidone, quetiapine, ziprasidone, zuclopenthixol) had an increase in both dispensing count and rate, as expressed per DPD.

CONCLUSIONS

The current study highlights the increasing prescription rates of SGAs and the stagnation of FGA prescription among Australian health practitioners. This is observed through particularly large increase in the dispensing rates of Olanzapine and Quetiapine. Further interdisciplinary investigation is required to ensure that these medications are being prescribed under the appropriate medical rationale, particularly to groups that are vulnerable to the adverse effects of the medications.

The Cardiac Conduction and Contractility Complications of Methamphetamine Use and the Relationship to Psychiatric Comorbidity: A Systematic Review

Background:

Methamphetamine has the potential to produce more severe short and long term effects than typical amphetamines due to the drug’s increased purity. The cardiovascular consequences compromise a large proportion of the drug’s mortality. Previous reviews have not examined these complications in relation to psychiatric patients who have high rates of substance use and physical comorbidity.

Methods:

Ovid Medline, Embase, Emcare, PsycINFO, CINAHL, and Cochrane were systematically searched in English until November 2017. Data were coded according to study design, sample size, demographics, medical and psychiatric comorbidity, electrocardiograph abnormalities, echocardiograph parameters, illness severity, treatment, and outcome on follow up.

Results:

The 11 included studies were predominantly case series conducted in the USA. Males were more likely to use methamphetamine and be associated with global systolic dysfunction. The mean age was lower for those with methamphetamine-related cardiovascular complications. QTc interval prolongation was the most frequent electrocardiograph abnormality. Continued methamphetamine use was associated with persistently impaired ventricular function, whilst discontinuation led to remodeling and improved ejection fraction. Only one study referenced psychiatric comorbidity or dual diagnosis.

Conclusion:

This review describes the range of variables related to methamphetamine associated arrhythmias and cardiomyopathies. Early detection of methamphetamine use and the subsequent cardiac complications is important, especially in a psychiatric cohort where physical illness is more commonly neglected. The monitoring of electrocardiographs in methamphetamine users is also crucial. Future research is needed to allow for appropriate recommendations in managing the harmful impacts of methamphetamine use in this population.

A health promotion intervention to improve lifestyle choices and health outcomes in people with psychosis: a research programme including the IMPaCT RCT

Background

People with psychotic disorders have reduced life expectancy largely because of physical health problems, especially cardiovascular disease, that are complicated by the use of tobacco and cannabis.

Objectives

We set out to (1) chart lifestyle and substance use choices and the emergence of cardiometabolic risk from the earliest presentation with psychosis, (2) develop a pragmatic health promotion intervention integrated within the clinical teams to improve the lifestyle choices and health outcomes of people with psychosis and (3) evaluate the clinical effectiveness and cost-effectiveness of that health promotion intervention.

Design

We performed a longitudinal cohort study of people presenting with their first episode of psychosis in three mental health trusts and followed up participants for 1 year [work package 1, physical health and substance use measures in first episode of psychosis (PUMP)]. We used an iterative Delphi methodology to develop and refine a modular health promotion intervention, improving physical health and reducing substance use in psychosis (IMPaCT) therapy, which was to be delivered by the patient’s usual care co-ordinator and used motivational interviewing techniques and cognitive–behavioural therapy to improve health choices of people with psychosis (work package 2). We then conducted a multicentre, two-arm, parallel-cluster, randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of using the intervention with people with established psychosis (work package 3: IMPaCT randomised controlled trial) in five UK mental health trusts. The work took place between 2008 and 2014.

Participants

All people aged between 16 and 65 years within 6 months of their first presentation with a non-organic psychosis and who were proficient in English were eligible for inclusion in the PUMP study. Participants in the work package 2 training development were staff selected from a range of settings, working with psychosis. Participants in the phase 3 Delphi consensus and manual development comprised three expert groups of (1) therapists/researchers recruited from the local and national community, (2) clinicians and (3) service users, each of whom took part in two iterative review and feedback sessions. For work package 3, IMPaCT randomised controlled trial, care co-ordinators in participating community mental health teams who were permanently employed and had a minimum of four eligible patients (i.e. aged between 18 and 65 years with a diagnosis of a psychotic disorder) on their caseload were eligible to participate. In studies 1 and 3, patient participants were ineligible if they were pregnant or had a major illness that would have had an impact on their metabolic status or if they had a significant learning disability. All participants were included in the study only after giving written confirmed consent.

Main outcome measures

Cardiometabolic risk markers, including rates of obesity and central obesity, and levels of glycated haemoglobin (HbA1c) and lipids, were the main outcomes in work package 1 (PUMP), with descriptive data presented on substance use. Our primary outcome measure for the IMPaCT randomised controlled trial was the physical or mental health component Short Form questionnaire-36 items quality-of-life scores at 12 months.

Results

Obesity rates rose from 18% at first presentation with psychosis to 24% by 1 year, but cardiometabolic risk was not associated with baseline lifestyle and substance use choices. Patterns of increase in the levels of HbA1c over the year following first presentation showed variation by ethnic group. We recruited 104 care co-ordinators, of whom 52 (with 213 patients) were randomised to deliver IMPaCT therapy and 52 (with 193 patients) were randomised to deliver treatment as usual, in keeping with our power calculations. Of these 406 participants with established psychosis, 318 (78%) and 301 (74%) participants, respectively, attended the 12- and 15-month follow-ups. We found no significant effect of IMPaCT therapy compared with treatment as usual on the physical or mental health component Short Form questionnaire-36 items scores at either time point in an intention-to-treat analysis [physical health score (‘d’) –0.17 at 12 months and –0.09 at 15 months; mental health score (‘d’) 0.03 at 12 months and –0.05 at 15 months] or on costs. Nor did we find an effect on other cardiovascular risk indicators, including diabetes, except in the case of high-density lipoprotein cholesterol, which showed a trend for greater benefit with IMPaCT therapy than with treatment as usual (treatment effect 0.085, 95% confidence interval 0.007 to 0.16; p = 0.034).

Limitations

Follow-up in work package 1 was challenging, with 127 out of 293 participants attending; however, there was no difference in cardiometabolic measures or demographic factors at baseline between those who attended for follow-up and those who did not. In work package 3, the IMPaCT randomised controlled trial, care co-ordinators struggled to provide additional time to their patients that was devoted to the health promotion intervention on top of their usual clinical care contact with them.

Conclusions

Cardiometabolic risk is prominent even soon after first presentation with psychosis and increases over time. Lifestyle choices and substance use habits at first presentation do not predict those who will be most cardiometabolically compromised 1 year later. Training and supervising care co-ordinators to deliver a health promotion intervention to their own patients on top of routine care is not effective in the NHS for improving quality of life or reducing cardiometabolic risk.

Future work

Further work is needed to develop and evaluate effective, cost-effective and affordable ways of preventing the emergence of and reversing existing cardiometabolic risk indicators in people with psychosis.

Trial registration

Current Controlled Trials ISRCTN58667926.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

Schizophrenia spectrum and other psychotic disorders

Since its earliest conceptualization, schizophrenia has been considered a disorder of "young men." Contemporary research suggests that there are sex differences in schizophrenia that are both transdiagnostic and representative of general sex/gender differences across the psychopathology spectrum. This chapter selectively summarizes representative sex/gender differences in clinical expression, epidemiology, risk factors, treatment, as well as course and outcome in schizophrenia. The consistent sex differences found, such as onset age, generic brain anomalies, and hormonal involvement, are not specific to schizophrenia or necessarily to psychopathology. It is suggested that in working with those diagnosed as meeting the current criteria for schizophrenia, clinicians adopt a transdiagnostic framework informed by sex and gender role processes.

Cardio-metabolic risk in individuals prescribed long-acting injectable antipsychotic medication

People living with severe mental illness (SMI) experience significant physical health co-morbidity. Few studies have focused on physical health outcomes for those prescribed long-acting injectable (LAI) antipsychotics. This observational cross-sectional study aimed to assess the prevalence of metabolic syndrome (MetS) and other cardio-metabolic risk factors in a large cohort prescribed LAI and managed by community mental health services. For participants with elevated cardio-metabolic risk factors, the proportion receiving appropriate management was assessed. Of the 301 eligible participants, many met the full criteria for MetS (44%) and its components. Cardio-metabolic risk factors were largely under- or un-treated. Smoking rates were very high (62%) along with reported high rates of physical inactivity and poor dietary intake. The vast majority (89%) reported seeing their general practitioner in the preceding twelve months. Individuals prescribed LAI have a very high prevalence of MetS and potentially modifiable risk factors for cardiovascular disease. Routine monitoring accompanied by evidence-based treatment of cardiometabolic abnormalities which contribute to significant morbidity, disability and premature death should be prioritised. Better collaboration between mental health services and primary care providers should be pursued to optimise the delivery of effective physical health care to individuals living with SMI.

Loneliness in psychotic illness and its association with cardiometabolic disorders

Loneliness is an established risk factor for poor cardiometabolic health. People with psychotic disorders experience high rates of both cardiometabolic disease and loneliness, but how these factors are associated is poorly understood. Thus, using data from the second Australian National Survey of Psychosis we examined whether loneliness is associated with the likelihood of cardiometabolic disorder in psychotic illness. Loneliness was assessed using a single-item measure, with a 4-point scale (not lonely; lonely occasionally; some friends but lonely for company; socially isolated and lonely) whilst cardiometabolic status was assessed in terms of the criteria used to determine metabolic syndrome (elevated waist circumference, elevated triglycerides, reduced high-density lipoprotein cholesterol, elevated blood pressure, and elevated fasting glucose). Logistic regression was employed to examine whether loneliness was associated with metabolic syndrome status, and its individual components, with and without adjustment for confounding variables. Increased loneliness was associated with an increased risk of metabolic syndrome in people with psychosis (OR 1.21, 95% CI 1.08-1.36, p < .001) and to the risk of elevated waist circumference (p < .01), elevated triglycerides (p < .05) and reduced high-density lipoprotein cholesterol (p < .05). Notably, these associations largely persisted when controlling for a range of covariates. Feeling lonely is significantly associated with metabolic syndrome, and dyslipidemia specifically, in people with psychotic disorders. These data suggest that the potential benefits of interventions to reduce loneliness in psychosis may extend to cardiovascular as well as psychosocial functioning, and should be explored in future research.

Counting up the risks: How common are risk factors for morbidity and mortality in young people with psychosis?

BACKGROUND

This study examined the prevalence of risk factors for cardiovascular (CV)-related morbidity and mortality in young people with psychosis aged 18 to 24 years.

METHODS

The study included 132 people aged 18 to 24 years who participated in the 2010 second Australian national survey of people living with psychosis. The 2009 World Health Organisation (WHO) Global Health Risks report was used as a framework to determine which specific risk factors were present in each in these young people. The risk factors assessed in this study were smoking, alcohol use, hypertension, overweight/obesity, physical inactivity, high blood glucose, high cholesterol and poor diet. Each risk factor was defined according to WHO criteria. A count of the total number of risk factors present for each participant was determined. Data for male and female participants were compared.

RESULTS

Young men had an average of 2.9 (SD 1.2) risk factors. Young women had an average of 2.4 (SD 1.2) risk factors. The most common risk factors were low fruit and vegetable intake (77.9%), cigarette smoking (67.7%), overweight/obesity (55%) and physical inactivity (39.8%). There were no significant differences between men and women in the number of risk factors present, or the prevalence of individual risk factors.

CONCLUSION

This study demonstrated that many of the risk factors that ultimately contribute to disability and premature death are present at an early age in people with psychosis. Preventive measures need to be an integral component of early intervention services for this client population to avert progression to serious CV morbidity and early mortality.

Cognition in schizophrenia improves with treatment of severe obstructive sleep apnoea: A pilot study

Previous studies have shown that people with schizophrenia have high rates of Obstructive Sleep Apnoea (OSA). Despite this, intervention studies to treat OSA in this population have not been undertaken. The ASSET (Assessing Sleep in Schizophrenia and Evaluating Treatment) pilot study investigated Continuous Positive Airway Pressure (CPAP) treatment of severe OSA in participants recruited from a clozapine clinic in Adelaide. Participants with severe untreated OSA (Apnoea-Hypopnoea Index (AHI) > 30), were provided with CPAP treatment, and assessed at baseline and six months across the following domains: physical health, quality of sleep, sleepiness, cognition, psychiatric symptoms and CPAP adherence. Six of the eight ASSET participants with severe OSA accepted CPAP. At baseline, half of the cohort had hypertension, all were obese with a mean BMI of 45, and they scored on average 1.47 standard deviations below the normal population in cognitive testing. The mean AHI was 76.8 and sleep architecture was markedly impaired with mean rapid eye movement (REM) sleep 4.1% and mean slow wave sleep (SWS) 4.8%. After six months of treatment there were improvements in cognition (BACS Z score improved by an average of 0.59) and weight loss (mean weight loss 7.3 ± 9 kg). Half of the participants no longer had hypertension and sleep architecture improved with mean REM sleep 31.4% of the night and mean SWS 24% of the night. Our data suggests CPAP may offer novel benefits to address cognitive impairment and sleep disturbance in people with schizophrenia.

Cardio-metabolic risk and its management in a cohort of clozapine-treated outpatients

OBJECTIVE

To comprehensively assess cardio-metabolic risk factors and their management in a large sample of outpatients treated with clozapine.

METHODS

Observational cross-sectional study of all clozapine users attending specialized clozapine monitoring outpatient clinics in three public hospitals in Sydney, Australia were approached to participate over the one-year period 01/10/2015-30/09/2016. Cardio-metabolic risk factors including metabolic syndrome, risk for future development of diabetes, smoking, physical activity, nutrition, and prescribed medications were assessed at face-to-face interview and through medical record review. Among patients who had cardio-metabolic risk factors, the proportion receiving appropriate management was assessed.

RESULTS

Of 451 registered clozapine clinic attenders, 92.2% completed questionnaires and anthropometric measurements. 58.3% met criteria for metabolic syndrome. 79.6% were overweight or obese. 55.9% had blood pressure meeting metabolic syndrome criteria. 46.6% had elevated fasting blood glucose and 55.2% had elevated blood triglycerides. 43.6% were current smokers. Only 10% achieved recommended weekly physical activity levels. Unhealthy food categories were highly consumed. 32.1% were on additional antipsychotics. In the majority of individuals, cardio-metabolic risk factors were untreated or under-treated.

CONCLUSIONS

Clozapine use was associated with very high rates of cardiovascular and metabolic risk factors, which were frequently under-treated. Management of both physical and mental health should be prioritized. Polypharmacy should be rationalized. Future research should investigate the effectiveness of smoking cessation and lifestyle interventions in this high-risk population.

Cardiovascular disease lifestyle risk factors in people with psychosis: a cross-sectional study

BACKGROUND

People with psychosis die on average 25 years earlier than those in the general population, with cardiovascular disease (CVD) contributing to much of the excess mortality. This cross-sectional study aimed to identify the relationship between lifestyle risk factors for CVD - poor nutrition, smoking and low physical activity levels - and dyslipidaemia, hypertension and hyperglycaemia while controlling for potential confounders in 1825 people from the Survey of High Impact Psychosis (SHIP) in Australia. We also aimed to identify clustering patterns of lifestyle risk factors and associated demographic variables.

METHODS

Three logistic regressions were used to predict the effect of nutrition, smoking and physical activity on dyslipidaemia, hypertension and hyperglycaemia while controlling for clozapine use, sex and age. Clustering patterns of nutrition, smoking and physical activity were examined using the two-step cluster method which is based on hierarchical cluster analysis. Demographic variables associated with different clusters were identified using measures of association.

RESULTS

Smoking status had a positive association with dyslipidaemia (adjusted odds ratio = 0.50; 95% confidence interval = 0.32-0.78; p = 0.002). Other cardiovascular disease lifestyle risk factors did not have a significant relationship with dyslipidaemia, hypertension and hyperglycaemia. Clustering patterns of lifestyle risk factors showed that younger men, with low education levels, and relying on a government pension, were most likely to display the poorest lifestyle risk behaviours. The largest cluster (42%) of participants was characterised by a mixed demographic profile and were most likely to display poor nutrition and low physical activity levels but less likely to smoke.

CONCLUSIONS

Only smoking status had a significant positive association with dyslipidaemia which could indicate that there are additional factors affecting the relationship between other cardiovascular lifestyle risk factors and dyslipidaemia, hypertension and hyperglycaemia in people with psychosis. Unknown confounders and traditional lifestyle risk factors may explain the high rates of CVD in this group. Clustering of lifestyle risk factors and their demographic profiles could help the design of intervention programs in people with psychosis.

Excess mortality in people with mental illness: findings from a Northern Italy psychiatric case register

PURPOSE

People with mental disorders show mortality rates up to 22.2 times higher than that of the general population. In spite of progressive increase in life expectancy observed in the general population, the mortality gap of people suffering from mental health problems has gradually widened. The aim of this paper was to study mortality rates in people suffering from mental illness in a cohort of people (16,981 subjects) in the local mental health register of the province of Modena during the decade 2006-2015.

METHODS

Standardized Mortality Ratios (SMRs) were calculated to compare the mortality of people with mental disorders to the mortality of people living in the province of Modena and the excess of mortality was studied in relation to the following variables: gender, age group, diagnosis and causes of death. In addition, Poisson regression analysis was performed to study the association between patient characteristics and mortality.

RESULTS

An overall excess mortality of 80% was found in subjects under the care of mental health services as compared to the reference population (SMR = 1.8, 95% CI 1.7-1.9). Subjects in the 15-44 year group presented the highest SMR (9.2, 95% CI 6.9-11.4). The most prevalent cause of death was cancer (28.1% of deaths). At the Poisson regression, the diagnosis "Substance abuse and dependence" showed the highest relative risk (RR) (4.00). Moreover, being male, single, unemployed and with a lower qualification was associated with higher RRs.

CONCLUSIONS

Our study confirms that subjects with mental illness have higher SMR. Noteworthy, the overall higher risk of mortality was observed in the younger age group.

Body composition, pre-diabetes and cardiovascular disease risk in early schizophrenia

AIM

This preliminary study examines the relationship between body composition, insulin resistance and NCEP-III-defined cardiovascular disease risk factors in persons early in the course of schizophrenia exposed to commonly prescribed atypical antipsychotic medications.

METHODS

Subjects underwent modified oral glucose tolerance tests (OGTTs) and DEXA (dual X-ray absorptiometry) scans corrected for relevant sociodemographic data, including activity levels. We used linear multiple regression models to evaluate relationships between body composition and metabolic variables.

RESULTS

Thirty-six individuals diagnosed with schizophrenia, receiving atypical antipsychotic monotherapy, and within 5 years of illness onset, participated. Average age was 25.1 ± 3.6 years (range, 19-34) and duration of illness was 2.5 years (30 ± 18 months). Mean body mass index (BMI) was 28.3 ± 4.9, with a mean total body fat mass of 28.6 ± 8.4%, suggesting an increase in fat relative to BMI. Ten participants (28%) had pre-diabetes (fasting glucose 100-126 mg dL^-1 or 2-h OGTT 140-200 mg dL^-1 ), but no participant had diabetes. Insulin resistance (HOMA-IR) was predicted by total body mass (BMI) more so than by body fat mass, with an incremental contribution derived from antipsychotics. Insulin secretion in response to glucose challenge was predicted by BMI, body fat mass and antipsychotic medication.

CONCLUSIONS

Fat mass relative to BMI was increased in early schizophrenia patients receiving atypical antipsychotics. Body composition accounted for most of the variance in risk for abnormalities in glucose metabolism. Incremental contributions were derived from atypical antipsychotics, in line with their known adipogenicity. If direct fat mass measures are unavailable, frequent BMI measures may be practical proxy markers for metabolic risk.

The role of arterial elasticity and cardiovascular peripheral resistance as clinically relevant indices of health status in people with psychosis

OBJECTIVE

Hypertension is one of the most important risk factors for cardiovascular disease (CVD). Systolic and diastolic blood pressure (BP) are higher in people with psychosis compared to the general population, but there is little research into measures of the elasticity of the arterial wall (pulse pressure; PP) and peripheral resistance (mean arterial pressure; MAP). PP and MAP can provide an additional perspective on the functioning of the circulatory system. This study investigated PP and MAP in people with psychosis, using factors known to be related to PP and MAP in the general population.

METHOD

Participants included 1421 people aged 18-64years, from the second Australian national survey of psychosis, untreated with antihypertensive medication. We tested the interaction and main effects between age and gender on PP, MAP, systolic BP and diastolic BP. Odds ratios were calculated in people exceeding the at-risk thresholds for PP and MAP. Multiple linear regression was used to test whether factors associated with at-risk PP and MAP in the general population were similarly associated in the psychosis population.

RESULTS

The interaction effect between age and gender on PP, MAP, systolic BP and diastolic BP was not statistically significant. Variables that retained significance in the regression model in explaining higher PP and MAP were: male gender, higher age, and having a family history of hypertension.

CONCLUSION

Clinicians monitoring and treating CV risk in this population need to ensure that they have recorded whether there is a family history of hypertension, and should be especially, more vigilant in men and in older patients.

Diabetes quality of care and outcomes: Comparison of individuals with and without schizophrenia

OBJECTIVE

Individuals with schizophrenia are more likely to develop diabetes than individuals without schizophrenia. The objective of this study was to determine the quality of diabetes care and diabetes-related health outcomes among individuals with and without schizophrenia.

METHOD

We conducted a retrospective cohort study. As of April 1, 2011, we identified all individuals with diabetes in Ontario with and without a diagnosis of schizophrenia. The main outcomes were quality of diabetes care (guideline-concordant testing for HbA1c, lipid testing, eye exams) and diabetes-related Emergency Department (ED) visits and hospitalizations between April 1, 2011 and March 31, 2013. We compared quality of care and diabetes outcomes among those with and without schizophrenia, adjusting for demographic, illness severity, and health service utilization variables.

RESULTS

We identified 1,131,375 individuals with diabetes, among whom 25,628 (2.3%) had schizophrenia. Schizophrenia was associated with reduced likelihood of optimal diabetes care (all 3 of HbA1c, lipid testing, and eye exams) (adjusted OR (95% CI): 0.64 (0.61-0.67)) and increased likelihood of diabetes-related ED visits (adjusted OR (95% CI): 1.34 (1.28-1.41)) and hospitalizations (adjusted OR (95% CI): 1.36 (1.28-1.43)).

CONCLUSION

Individuals with diabetes and schizophrenia have lower rates of recommended testing and higher rates of diabetes-related hospital visits than those with diabetes but without schizophrenia. Research is needed to understand patient, provider, and system factors underlying these disparities and test related interventions to close the gaps in quality of care.

Royal Australian and New Zealand College of Psychiatrists expert consensus statement for the treatment, management and monitoring of the physical health of people with an enduring psychotic illness

OBJECTIVE

To use expert consensus to inform the development of policy and guidelines for the treatment, management and monitoring of the physical health of people with an enduring psychotic illness.

METHOD

The Delphi method was used. A systematic search of websites, books and journal articles was conducted to develop a 416-item survey containing strategies that health professionals should use to treat, manage and monitor the physical health of people with an enduring psychotic illness. Three panels of Australian experts (55 clinicians, 21 carers and 20 consumers) were recruited and independently rated the items over three rounds, with strategies reaching consensus on a priori-defined levels of importance written into the expert consensus statement.

RESULTS

The participation rate for the clinicians across all three rounds was 65%, with consumers and carers only completing one round due to high endorsement rates. Finally, 386 strategies were endorsed as essential or important by one or all panels. The endorsed strategies provided information on engagement and collaborative partnerships; clinical governance; risk factors, morbidity and mortality in people with enduring psychotic illness; assessment, including initial and follow-up assessments; barriers to care; strategies to improve care of people with enduring psychotic illness; education and training; treatment recommendations; medication side effects; and the role of health professionals.

CONCLUSION

The consensus statement is intended to be used by health professionals, people with an enduring psychotic illness and their families and carers. The next step needed is an implementation strategy by the Royal Australian and New Zealand College of Psychiatrists and other stakeholders.

The value of counting WHO-defined cardiovascular risk factors for death and disability in a national sample of adults with psychosis

OBJECTIVE

This study explored the prevalence and associations of eight WHO-defined CVD risk factors for death and disability in people with psychosis.

METHOD

The study included 1156 people aged 18-64years, diagnosed with psychosis. The 2009 World Health Organisation (WHO) Global Health Risks Report was used as a framework to determine the prevalence and number of eight key risk factors for cardiovascular disease (CVD) in men and women with psychosis. Differences in the number and type of risk factors by age and gender were investigated. Multi-predictor analysis was performed to identify associations between demographic factors, psychiatric diagnosis and accumulative CVD risk factors.

RESULTS

Women had fewer CVD risk factors than men. The number of risk factors significantly decreased in association with single marital status, current employment and significantly increased with earning a higher income. People aged 35-49years and 50-64years had an average of 4 risk factors (SD 1.38 and 1.30); people aged 18-34years had an average of 3 risk factors (SD 1.30). Mean risk factors were higher in the middle age and older age groups (35-49years and 50-64years) compared with the younger age group (18-34years) (p<0.0001). Overweight/obesity, hypertension, high blood glucose/diabetes and high cholesterol were significantly more prevalent in older men and women.

CONCLUSION

People with psychosis have a high prevalence of individual and aggregate CVD risks. These were more common in men and rose with age, implying the necessity of close clinical monitoring. The most common risk factors should be targeted by lifestyle interventions.

Responding to challenges for people with psychotic illness: Updated evidence from the Survey of High Impact Psychosis

OBJECTIVE

The objective is to summarise recent findings from the 2010 Australian Survey of High Impact Psychosis (SHIP) and examine their implications for future policy and planning to improve mental health, physical health and other circumstances of people with a psychotic disorder.

METHODS

Survey of High Impact Psychosis collected nationally representative data on 1825 people with psychotic illness. Over 60 papers have been published covering key challenges reported by participants: financial problems, loneliness and social isolation, unemployment, poor physical health, uncontrolled symptoms of mental illness, and lack of stable, suitable housing. Findings are summarised under the rubric of participant-ranked top challenges.

RESULTS

The main income source for the majority (85%) of participants was a government benefit. Only one-third was employed, and the most appropriate employment services for this group were under-utilised. High rates of loneliness and social isolation impacted mental and physical health. The rate of cardiometabolic disease was well above the general population rate, and associated risk factors were present from a very young age. Childhood abuse (30.6%), adult violent victimisation (16.4%) and alcohol and substance abuse/dependence (lifetime rates of 50.5% and 54.5%, respectively) complicated the clinical profile. Treatment with medication was suboptimal, with physical health conditions undertreated, a high rate of psychotropic polypharmacy and underutilisation of clozapine in chronic persistent psychotic illness. Only 38.6% received evidence-based psychosocial therapies. In the previous year, 27.4% had changed housing and 12.8% had been homeless, on average for 155 days.

CONCLUSION

Money, social engagement and employment are the most important challenges for people with psychotic illness, as well as good physical and mental health. An integrated approach to recovery is needed to optimise service delivery and augment evidence-based clinical practice with measures to improve physical health and social circumstances. Meeting these challenges has the potential to reduce costs to government and society, as well as promote recovery.

Physical multimorbidity and psychosis: comprehensive cross sectional analysis including 242,952 people across 48 low- and middle-income countries

BACKGROUND

In people with psychosis, physical comorbidities, including cardiovascular and metabolic diseases, are highly prevalent and leading contributors to the premature mortality encountered. However, little is known about physical health multimorbidity in this population or in people with subclinical psychosis and in low- and middle-income countries (LMICs). This study explores physical health multimorbidity patterns among people with psychosis or subclinical psychosis.

METHODS

Overall, data from 242,952 individuals from 48 LMICs, recruited via the World Health Survey, were included in this cross-sectional study. Participants were subdivided into those (1) with a lifetime diagnosis of psychosis ("psychosis"); (2) with more than one psychotic symptom in the past 12 months, but no lifetime diagnosis of psychosis ("subclinical psychosis"); and (3) without psychotic symptoms in the past 12 months or a lifetime diagnosis of psychosis ("controls"). Nine operationalized somatic disorders were examined: arthritis, angina pectoris, asthma, diabetes, chronic back pain, visual impairment, hearing problems, edentulism, and tuberculosis. The association between psychosis and multimorbidity was assessed by multivariable logistic regression analysis.

RESULTS

The prevalence of multimorbidity (i.e., two or more physical health conditions) was: controls = 11.4% (95% CI, 11.0-11.8%); subclinical psychosis = 21.8% (95% CI, 20.6-23.0%), and psychosis = 36.0% (95% CI, 32.1-40.2%) (P < 0.0001). After adjustment for age, sex, education, country-wise wealth, and country, subclinical psychosis and psychosis were associated with 2.20 (95% CI, 2.02-2.39) and 4.05 (95% CI, 3.25-5.04) times higher odds for multimorbidity. Moreover, multimorbidity was increased in subclinical and established psychosis in all age ranges (18-44, 45-64, ≥ 65 years). However, multimorbidity was most evident in younger age groups, with people aged 18-44 years with psychosis at greatest odds of physical health multimorbidity (OR = 4.68; 95% CI, 3.46-6.32).

CONCLUSIONS

This large multinational study demonstrates that physical health multimorbidity is increased across the psychosis-spectrum. Most notably, the association between multimorbidity and psychosis was stronger among younger adults, thus adding further impetus to the calls for the early intervention efforts to prevent the burden of physical health comorbidity at later stages. Urgent public health interventions are necessary not only for those with a psychosis diagnosis, but also for subclinical psychosis to address this considerable public health problem.

Physiological characteristics of patients with schizophrenia prematurely dying from circulatory diseases

INTRODUCTION

Patients with schizophrenia before reaching geriatric age are at high risk of circulatory mortality. However, investigations are lacking on the characteristics of physiological measurement among these at-risk patients.

METHODS

In this study, we followed acutely inpatients with schizophrenia disorder for cause of death through record linkage to the Death Certification System in Taiwan. Cases of patients who died because of circulatory morbidity (ICD-9 401-443) before turning 65 years old were used. Each schizophrenia case was then matched with two mentally healthy controls for the age and sex, and date of laboratory examination. Clinical data of all subjects were obtained by reviewing medical records.

RESULTS

Totally, 81 patients with schizophrenia who died from circulatory diseases at mean ages of 48.0 ± 10.7 years were investigated. The mean age at the final acute psychiatric hospitalization was 43.0 ± 10.9 years. Multivariate analysis showed that elevated fasting serum glucose levels (95% confidence interval [CI] for odds ratio (OR) = 1.00-1.03), blood leukocyte counts (95% CI for odds ratio (OR) = 1.07-1.55), and heart rates on electrocardiogram (95% CI for OR = 1.04-1.10) in the final psychiatric hospitalization collectively provided the predictive validity for premature circulatory death.

CONCLUSION

Systemic inflammatory activation and autonomic nervous system dysfunction along with dysregulation of glucose metabolism rather than lipids could be the physiological characteristics of schizophrenia patients at risk of premature circulatory mortality.

Awareness of Pre-diabetes or Diabetes and Associated Factors in People With Psychosis

OBJECTIVE

To estimate awareness of pre-diabetes or type 2 diabetes and associated factors in people with psychosis, a known high-risk group.

METHODS

Cross sectional analysis of a national sample with psychosis who were aged 18-64 years, gave a fasting blood sample (n = 1155), had pre-diabetes or diabetes based on testing (n = 359) and reported if they knew they had high blood sugar or diabetes at survey (n = 356). Logistic regression was used to identify factors associated with awareness of pre-diabetes or diabetes prior to testing.

RESULTS

The prevalence of pre-diabetes (19.0% 219/1153) or type 2 diabetes (12.1%, 140/1153) was 31.1% (359/1153); 45% (160/356) were known prior to testing. Factors associated with detection were higher fasting blood glucose, older age, a perception of poor health, severe obesity, dyslipidaemia or treatment with a lipid regulating drug, a family history of diabetes, Aboriginal or Torres Strait Islander descent, decreased cognitive functioning, regional economic disadvantage, treatment with an antihypertensive drug, and an elevated 5-year risk for cardiovascular disease. The prevalence of undiagnosed pre-diabetes/diabetes was highest in those aged 25-34 years at 34.2%.

CONCLUSIONS

Clinical detection of pre-diabetes or diabetes in people with psychosis was strongly dependent on established risk factors for type 2 diabetes in the population but not on current antipsychotic drug treatment or psychiatric case management which should ensure regular screening. Screening must become a clinical priority and should not wait until age 40.

[Cardiovascular risk factors in users with severe mental disorder]

OBJECTIVE

To identify the prevalence of the cardiovascular risk (RCV) in users with a Severe Mental Disorder (SMD) attended in mental health service in ParcTaulí (Sabadell - Barcelona).

METHOD

This is an observational, descriptive and transversal study of the factors of cardiovascular risk in 789 users with SMD. The instrument used was the scale of assessment of the Registre Gironí del Cor, which estimates the risk of cardiovascular disease.

RESULTS

26.6% of the sample has RCV (22.5% moderate, 3.8% high and 0.3% very high). The analysis of the modifiable risk factors shows that 16.5% of the patients are hypertensive, 55.2% are smokers, 19.77% have hyperglycaemia (8.2% of whom are diagnosed of diabetes mellitus), 40.2% have obesity, 36.2% overweight and 47.27% hypercholesterolemia.

CONCLUSIONS

The study confirms that the prevalence of the RVC in SMD users is greater than the RCV in general population and it's associated to the presence of modifiable risk factors. Health education carried out by nurses is the best to prevent the RCV in SMD users.

Sex Differences in Weight Loss among Veterans with Serious Mental Illness: Observational Study of a National Weight Management Program

PURPOSE

Obesity disproportionately burdens individuals with serious mental illness (SMI), especially women. This observational study investigated whether there were sex differences in weight loss and program participation among veterans with SMI enrolled in the Veterans Health Administration's (VHA) MOVE! weight management program.

PROCEDURES

Participants were identified from a national cohort of 148,254 veterans enrolled in MOVE! during fiscal years 2008 through 2012 who attended two or more sessions within 12 months of enrollment. The cohort included those with International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) diagnoses for SMI, age less than 70 years, and weight data at baseline and one or more follow-up timepoints within approximately 1 year of enrollment (n = 8,943 men; n = 2,245 women). Linear mixed models assessed associations of sex with 6- and 12-month weight change from baseline, adjusting for demographic- and site-level variables.

FINDINGS

Both sexes averaged 6.4 (standard deviation, 4.6) sessions within 12 months; however, women with and without SMI participated at rates double their respective proportion rates among all VHA users. Participants averaged statistically significant weight loss at 6 months (men, -2.5 lb [95% CI, -2.8 to -2.1]; women, -2.4 lb [95% CI, -3.1 to -1.7]) and 12 months (men, -2.5 lb [95% CI, -2.8 to -2.2]; women, -2.9 lb [95% CI, -3.6 to -2.2]), but no sex-based difference in absolute weight loss at either timepoint. Slightly more women achieved 5% or greater (clinically significant) weight loss at the 12-month follow-up than did men (25.7% vs. 23.0%; p < .05).

CONCLUSIONS

Women with SMI participated in MOVE! at rates equivalent to or greater than men with SMI, with comparable weight loss. More women were Black, single, had bipolar and posttraumatic stress disorder, and higher service-connected disability, suggesting areas for program customization.

Body mass index and blood glucose in psychiatric and general practice populations

Aims and method Using a retrospective observational approach, we aimed to discern whether there was a difference in metabolic parameters between psychiatric and general practice populations in the same locality. Second, we aimed to establish differences in metabolic parameters of patients taking olanzapine, clozapine or aripiprazole. Results Patients with psychiatric illness had a body mass index (BMI) comparable to that of the general practice population (28.7 v. 29.7 kg/m(2)), but blood glucose was significantly lower in the general practice population (4.8 v. 6.1 mmol/L). Olanzapine was associated with the lowest BMI (26.1 kg/m(2)) and aripiprazole the highest (32.2 kg/m(2)), with no difference in blood glucose between antipsychotics. Clinical implications Awareness of environmental factors and how they affect individuals is important and medications are not the only cause of metabolic effects. There may be a channelling bias present, meaning practitioners are cognisant of potential metabolic effects prior to prescribing. Overall monitoring of physical health is important regardless of potential cause.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders

OBJECTIVES

This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function.

METHODS

The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups.

RESULTS

The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice.

CONCLUSIONS

This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges.

Metabolic Syndrome in South African Patients with Severe Mental Illness: Prevalence and Associated Risk Factors

Background

There is a surge of cardiovascular disease (CVD) in Africa. CVD is the leading cause of mortality among patients with severe mental illness (SMI) in developed countries, with little evidence from the African context.

Objective

To determine the prevalence and risk factors for MetS among South African patients with SMI.

Method

In a cross sectional study, individuals with SMI treated with antipsychotics and a control group without a mental illness, matched for age, gender and ethnicity were evaluated for MetS using the 2009 Joint Interim statement (JIS) criteria.

Results

Of the 276 study group subjects, 65.9% were male, 84.1% black African, 9.1% white, 5.4% of Indian descent and 1.5% coloured (mixed race) with a mean age of 34.7 years (±12.5). Schizophrenia was the most common diagnosis (73.2%) and 40% were taking first generation antipsychotics. The prevalence of MetS was 23.2% (M: 15.4%, F: 38.3%) in the study group and 19.9% (M: 11.9%, F: 36.3%) in the control group (p = 0.4). MetS prevalence was significantly higher in study subjects over 55 years compared to controls (p = 0.03). Increased waist circumference (p< 0.001) and low high density lipoprotein (HDL) cholesterol (p = 0.003) were significantly more prevalent in study subjects compared to controls. In study subjects, risk factors associated with MetS included age (OR: 1.09, 95% CI 1.06–1.12, p < 0.001), female gender (OR: 2.19, 95% CI 1.06–4.55, p = 0.035) and Indian descent (OR: 5.84, 95% CI 1.66–20.52, p = 0.006) but not class of antipsychotic (p = 0.26).

Conclusion

The overall MetS prevalence was not increased in patients with SMI compared to controls; however, the higher prevalence of the individual components (HDL cholesterol and waist circumference) suggests an increased risk for CVD, especially in patients over 55 years.

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.

Insights into the origin of DNA methylation differences between monozygotic twins discordant for schizophrenia

Background

DNA methylation differences between monozygotic twins discordant for schizophrenia have been previously reported. However, the origin of methylation differences between monozygotic twins discordant for schizophrenia is not clear. The findings here argue that all DNA methylation differences may not necessarily represent the cause of the disease; rather some may result from the effect of antipsychotics.

Methods

Methylation differences in rat brain regions and also in two pairs of unrelated monozygotic twins discordant for schizophrenia have been studied using genome-wide DNA methylation arrays at Arraystar Inc. (Rockville, Maryland, USA). The identified gene promoters showing significant alterations to DNA methylation were then further characterized using ingenuity pathway analysis (Ingenuity System Inc, CA, USA).

Results

Pathway analysis of the most significant gene promoter hyper/hypomethylation revealed a significant enrichment of DNA methylation changes in biological networks and pathways directly relevant to neural development and psychiatric disorders. These included HIPPO signaling (p = 3.93E-03) and MAPK signaling (p = 4.27E-03) pathways involving hypermethylated genes in schizophrenia-affected patients as compared to their unaffected co-twins. Also, a number of significant pathways and networks involving genes with hypomethylated gene promoters have been identified. These included CREB signaling in neurons (p = 1.53E-02), Dopamine-DARPP32 feedback in cAMP signaling (p = 7.43E-03) and Ephrin receptors (p = 1.13E-02). Further, there was significant enrichment for pathways involved in nervous system development and function (p = 1.71E-03-4.28E-02).

Conclusion

The findings highlight the significance of antipsychotic drugs on DNA methylation in schizophrenia patients. The unique pathways affected by DNA methylation in the two pairs of monozygotic twins suggest that patient-specific pathways are responsible for the disease; suggesting that patient-specific treatment strategies may be necessary in treating the disorder. The study reflects the need for developing personalized medicine approaches that take into consideration epigenetic variations between patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s40303-015-0013-5) contains supplementary material, which is available to authorized users.

The epidemiology of diabetes in psychotic disorders

Diabetes is highly prevalent in people with psychotic disorders, including schizophrenia and schizoaffective disorders. Exact prevalence is difficult to estimate, since diabetes is often underdiagnosed in people with psychosis. Results of several studies show that the prevalence of diabetes exceeds that in the general population, with documented prevalence in those with psychosis ranging from 1·26% to 50% across studies (median 13%). The association between diabetes and psychosis is complex and multifactorial. Many of the traditional risk factors for disease have increased prevalence in patients with psychotic disorders. In addition to these traditional risk factors, people with psychosis have unique risks that might have additive or even synergistic effects. These risks include the use of antipsychotic medication, the effects of adverse social determinants of health, and genetic loading. Despite evidence that rates of diabetes are increased in individuals with psychosis, many of these patients are not diagnosed or treated, resulting in increased diabetes-associated morbidity and mortality. Specific patient factors, provider issues, and systems-level factors contribute to the treatment gap. Interventions at both the clinical and public health levels are needed to successfully address this problem.

Retinal microvessels reflect familial vulnerability to psychotic symptoms: A comparison of twins discordant for psychotic symptoms and controls

Mounting evidence suggests that individuals with schizophrenia have an underlying vulnerability to cardiovascular disease, and a recent study suggested that this vulnerability might be reflected in the retinal microvasculature. The purpose of this study was to test the hypothesis that the retinal microvessels reflect familial vulnerability to psychotic symptoms. Participants were 531 adolescent and young adult twins who took part in the Brisbane Longitudinal Twin Study and the Twins Eye Study in Tasmania. The twins had photographs taken of their retina when they were adolescents or young adults (M age=20.6 years), and retinal vessel diameter was assessed using computer software. The twins completed an assessment of psychosis symptoms approximately six years later. We compared retinal venular diameters of individuals with one or more symptoms of psychosis (n=45), their unaffected co-twins (n=24), and controls (n=462). Individuals with one or more symptoms of psychosis had wider venules (standardized mean=0.29) than controls (standardized mean=-0.04; p=.03), and unaffected co-twins had venular diameters that were intermediate (standardized mean=0.13) between the two groups, suggesting that wide venules may represent a proxy marker of familial vulnerability to psychosis symptoms. Consistent with previous work, there were no differences in arteriolar diameter between individuals with and without symptoms of psychosis. Findings suggest that wide retinal venules may serve as a proxy marker of familial liability to psychosis symptoms. The pathophysiological mechanisms linking psychosis and cardiovascular disease may be operative from early in life, possibly at the level of the microvasculature.

Applying the World Health Organization Mental Health Action Plan to evaluate policy on addressing co-occurrence of physical and mental illnesses in Australia

Objectives The aim of the present study was to document Australian policies on the physical health of people with mental illness and evaluate the capacity of policy to support health needs. Methods A search of state and federal policies on mental and physical illness was conducted, as well as detailed analysis of policy content and the relationships between policies, by applying the World Health Organization Mental Health Action Plan 2013–2020 as an evaluative framework. Results National policy attention to the physical health of people with mental illness has grown, but there is little interconnection at the national and state levels. State policies across the country are inconsistent, and there is little evidence of consistent policy implementation. Conclusions A coherent national health policy framework on addressing co-occurring physical and mental illnesses that includes healthcare system reforms and ensuring the interconnectedness of other relevant services should be prioritised. What is known about the topic? People with mental illness have a lower life expectancy and poorer physical health than people who do not have a mental illness. Government policy is critical to reducing inequalities in physical health and increasing longevity. What does this paper add? Evaluating policy developments against the World Health Organization’s Mental Health Action Plan 2013–2020, this review identified a lack of cohesive national-level policy on how to improve the physical health of people with mental illness. Although there are some state-based policies regarding strategies for better prevention and management of the physical health of people with mental illness, evidence of policy implementation is either scarce or inconsistent. The capacity of current policy to translate into reforms that increase the physical and overall health of people suffering mental health difficulties seems very limited. What are the implications for practitioners? This paper outlines major policy gaps and an overall need for a national-level policy. National-level leadership on integrated health care is required, with monitoring to ensure health care reforms are genuinely informed by consumer and clinician views and are effective.