Risk of diabetes mellitus associated with atypical antipsychotic use among Medicaid patients with bipolar disorder: a nested case-control study

Targeted learning in observational studies with multi-valued treatments: An evaluation of antipsychotic drug treatment safety

We investigate estimation of causal effects of multiple competing (multi-valued) treatments in the absence of randomization. Our work is motivated by an intention-to-treat study of the relative cardiometabolic risk of assignment to one of six commonly prescribed antipsychotic drugs in a cohort of nearly 39 000 adults with serious mental illnesses. Doubly-robust estimators, such as targeted minimum loss-based estimation (TMLE), require correct specification of either the treatment model or outcome model to ensure consistent estimation; however, common TMLE implementations estimate treatment probabilities using multiple binomial regressions rather than multinomial regression. We implement a TMLE estimator that uses multinomial treatment assignment and ensemble machine learning to estimate average treatment effects. Our multinomial implementation improves coverage, but does not necessarily reduce bias, relative to the binomial implementation in simulation experiments with varying treatment propensity overlap and event rates. Evaluating the causal effects of the antipsychotics on 3-year diabetes risk or death, we find a safety benefit of moving from a second-generation drug considered among the safest of the second-generation drugs to an infrequently prescribed first-generation drug known for having low cardiometabolic risk.

Real-World Data on the Adverse Metabolic Effects of Second-Generation Antipsychotics and Their Potential Determinants in Adult Patients: A Systematic Review of Population-Based Studies

INTRODUCTION

To assess the risk of occurrence and potential determinants of metabolic disorders in adult patients treated with second-generation antipsychotics (SGAs) under real-world practice conditions.

METHODS

MEDLINE, EMBASE, and PsycInfo were searched in July 2019 from database inception. We included population-based, longitudinal, comparative studies that report the results of the outcomes of interest for adult participants, including diabetes, ketoacidosis, hyperosmolar hyperglycemic state, weight gain/obesity, dyslipidemia, hypertension, and metabolic syndrome. Two reviewers independently extracted data on the study design, study quality, and study outcomes.

RESULTS

We included 40 studies. Most studies showed that clozapine and olanzapine were associated with an increased likelihood of developing diabetes, while the results for risperidone and quetiapine were mixed. Although less well studied, ziprasidone and aripiprazole appeared to not be associated with the occurrence of diabetes. Information on antipsychotic-induced weight gain/obesity is extremely scarce. Regarding dyslipidemia, aripiprazole was not associated with an increased likelihood of developing dyslipidemia, clozapine was associated with an increased likelihood of developing dyslipidemia, and risperidone, olanzapine, quetiapine, and ziprasidone showed mixed results. Two studies suggested an association between ziprasidone and the occurrence of hypertension. Several studies found that the occurrence of a metabolic disorder acted as a risk factor for the development of other metabolic disorders. We did not find information on brexpiprazole, cariprazine, or lurasidone, and data on any long-acting SGA were lacking.

CONCLUSION

Although there are relevant differences among SGAs concerning the risk of metabolic disorders, it appears that none of the SGAs included in our review are fully devoid of these disturbances.

New Users of Antipsychotics Among Children and Adolescents in 2008-2017: A Nationwide Register Study

INTRODUCTION

Recently, prescribing antipsychotics for children and adolescents has been increasing in many countries. These drugs are often prescribed off-label, although antipsychotics have been associated with adverse effects. We determined the recent incidence of antipsychotic use among children and adolescents in Finland.

METHODS

Finnish National Prescription Register including all Finnish inhabitants receiving reimbursement for pharmaceuticals was searched for subjects of 1 to 17 years of age who had started an antipsychotic drug between January 1, 2008, and December 31, 2017 (n = 26,353). Between 2008 and 2017, the range of number of Finnish children and adolescents aged 1 to 17 years was 1.01 to 1.03 million/year. The incidence was calculated by dividing the number of new users by all age- and sex-matched Finnish inhabitants in the year.

RESULTS

Between 2008 and 2017, the incidence of antipsychotic use among children and adolescents increased from 2.1 to 3.8 per 1000 individuals, respectively. In children aged 7 to 12 years, the incidence of antipsychotic use 1.4-folded (from 1.9 (95% CI: 1.8-2.0) to 2.7 (95% CI: 2.5-2.9) per 1000) with a cumulative increase of 0.2% per year (χ² = 51.0, p < 0.0001). In adolescents aged 13 to 17 years, the incidence 2.2-folded (from 4.3 (95% CI: 4.1-4.5) to 9.4 (95% CI: 9.1-9.8) per 1000) with a cumulative increase of 0.6% per year (χ² = 590.3, p < 0.0001). The increase in the incidence of use was steeper in girls (2.3-fold) than in boys (1.4-fold) (χ² = 85.6, p < 0.0001), especially between 2015 and 2017 (1.6-fold and 1.2-fold, respectively) (χ² = 151.7, p < 0.0001). The year 2011 was the turning point when the incidence in girls exceeded the incidence in boys, and the incidence of quetiapine use exceeded that of risperidone use.

CONCLUSIONS

The incidence of antipsychotic use increased between 2008 and 2017, especially in adolescent girls. The use of quetiapine increased, although it has few official indications in children and adolescents. Future studies should investigate the reasons for increasing use of antipsychotics, especially quetiapine, in children and adolescents.

Associations among comorbid anxiety, psychiatric symptomatology, and diabetic control in a population with serious mental illness and diabetes: Findings from an interventional randomized controlled trial

Objective Serious mental illness and type II diabetes mellitus have a high comorbidity, and both have a higher prevalence of anxiety disorders compared to the general population. Targeted Training in Illness Management is a group-based self-management training approach which targets serious mental illness and type II diabetes mellitus concurrently. This analysis examines data from a randomized controlled trial of Targeted Training in Illness Management intervention to examine the impact of comorbid anxiety on baseline psychiatric symptomatology and diabetic control, and on longitudinal treatment outcomes. Methods We conducted secondary analyses on data from a prospective, 60-week, randomized controlled trial testing Targeted Training in Illness Management versus treatment as usual in 200 individuals with serious mental illness and diabetes. Primary outcomes included measures related to serious mental illness symptoms, functional status, general health status, and diabetes control. Measures were compared between those participants with anxiety disorders versus those without anxiety at baseline as well as over time using linear mixed effects analyses. Results Forty seven percent of the participants had one or more anxiety disorders. At baseline, those with an anxiety diagnosis had higher illness severity, depressive, and other psychiatric symptomatology and disability. Diabetic control (HbA1c) was not significantly different at baseline. In the longitudinal analyses, no significant mean slope differences over time (group-by-time interaction effect) between those with anxiety diagnoses and those without in treatment as usual group were found for primary outcomes. Within the Targeted Training in Illness Management arm, those with anxiety disorders had significantly greater improvement in mental health functioning. Those with anxiety comorbidity in the Targeted Training in Illness Management group demonstrated significantly lower HbA1c levels compared to no anxiety comorbidity and also demonstrated a greater improvement in HbA1c over the first 30 weeks compared to those without anxiety comorbidity. Conclusion Comorbid anxiety in serious mental illness and type II diabetes mellitus population is associated with increased psychiatric symptomatology and greater disability. Individuals from this population appear to experience greater improvement in functioning from baseline with the Targeted Training in Illness Management intervention. Anxiety comorbidity in the serious mental illness and type II diabetes mellitus population does not appear to have a negative impact on diabetic control. These complex relationships need further study. Clinical Trials Registration ClinicalTrials.gov: Improving outcomes for individuals with serious mental illness and diabetes (NCT01410357).

Development and validation of QDiabetes-2018 risk prediction algorithm to estimate future risk of type 2 diabetes: cohort study

Objectives To derive and validate updated QDiabetes-2018 prediction algorithms to estimate the 10 year risk of type 2 diabetes in men and women, taking account of potential new risk factors, and to compare their performance with current approaches.Design Prospective open cohort study.Setting Routinely collected data from 1457 general practices in England contributing to the QResearch database: 1094 were used to develop the scores and a separate set of 363 were used to validate the scores.Participants 11.5 million people aged 25-84 and free of diabetes at baseline: 8.87 million in the derivation cohort and 2.63 million in the validation cohort.Methods Cox proportional hazards models were used in the derivation cohort to derive separate risk equations in men and women for evaluation at 10 years. Risk factors considered included those already in QDiabetes (age, ethnicity, deprivation, body mass index, smoking, family history of diabetes in a first degree relative, cardiovascular disease, treated hypertension, and regular use of corticosteroids) and new risk factors: atypical antipsychotics, statins, schizophrenia or bipolar affective disorder, learning disability, gestational diabetes, and polycystic ovary syndrome. Additional models included fasting blood glucose and glycated haemoglobin (HBA1c). Measures of calibration and discrimination were determined in the validation cohort for men and women separately and for individual subgroups by age group, ethnicity, and baseline disease status.Main outcome measure Incident type 2 diabetes recorded on the general practice record.Results In the derivation cohort, 178 314 incident cases of type 2 diabetes were identified during follow-up arising from 42.72 million person years of observation. In the validation cohort, 62 326 incident cases of type 2 diabetes were identified from 14.32 million person years of observation. All new risk factors considered met our model inclusion criteria. Model A included age, ethnicity, deprivation, body mass index, smoking, family history of diabetes in a first degree relative, cardiovascular disease, treated hypertension, and regular use of corticosteroids, and new risk factors: atypical antipsychotics, statins, schizophrenia or bipolar affective disorder, learning disability, and gestational diabetes and polycystic ovary syndrome in women. Model B included the same variables as model A plus fasting blood glucose. Model C included HBA1c instead of fasting blood glucose. All three models had good calibration and high levels of explained variation and discrimination. In women, model B explained 63.3% of the variation in time to diagnosis of type 2 diabetes (R²), the D statistic was 2.69 and the Harrell's C statistic value was 0.89. The corresponding values for men were 58.4%, 2.42, and 0.87. Model B also had the highest sensitivity compared with current recommended practice in the National Health Service based on bands of either fasting blood glucose or HBA1c. However, only 16% of patients had complete data for blood glucose measurements, smoking, and body mass index.Conclusions Three updated QDiabetes risk models to quantify the absolute risk of type 2 diabetes were developed and validated: model A does not require a blood test and can be used to identify patients for fasting blood glucose (model B) or HBA1c (model C) testing. Model B had the best performance for predicting 10 year risk of type 2 diabetes to identify those who need interventions and more intensive follow-up, improving on current approaches. Additional external validation of models B and C in datasets with more completely collected data on blood glucose would be valuable before the models are used in clinical practice.

Using Multiple Pharmacovigilance Models Improves the Timeliness of Signal Detection in Simulated Prospective Surveillance

INTRODUCTION

Prospective pharmacovigilance aims to rapidly detect safety concerns related to medical products. The exposure model selected for pharmacovigilance impacts the timeliness of signal detection. However, in most real-life pharmacovigilance studies, little is known about which model correctly represents the association and there is no evidence to guide the selection of an exposure model. Different exposure models reflect different aspects of exposure history, and their relevance varies across studies. Therefore, one potential solution is to apply several alternative exposure models simultaneously, with each model assuming a different exposure-risk association, and then combine the model results.

METHODS

We simulated alternative clinically plausible associations between time-varying drug exposure and the hazard of an adverse event. Prospective surveillance was conducted on the simulated data by estimating parametric and semi-parametric exposure-risk models at multiple times during follow-up. For each model separately, and using combined evidence from different subsets of models, we compared the time to signal detection.

RESULTS

Timely detection across the simulated associations was obtained by fitting a set of pharmacovigilance models. This set included alternative parametric models that assumed different exposure-risk associations and flexible models that made no assumptions regarding the form/shape of the association. Times to detection generated using a simple combination of evidence from multiple models were comparable to those observed under the ideal, but unrealistic, scenario where pharmacovigilance relied on the single 'true' model used for data generation.

CONCLUSIONS

Simulation results indicate that, if the true model is not known, an association can be detected in a more timely manner by first fitting a carefully selected set of exposure-risk models and then generating a signal as soon as any of the models considered yields a test statistic value below a predetermined testing threshold.

Olanzapine-Induced Hypertriglyceridemia Resulting in Necrotizing Pancreatitis

Olanzapine is an atypical antipsychotic agent that was approved by the Food and Drug Administration in 1996 for treatment of psychotic disorders, bipolar disorder, and schizophrenia. Since that time, numerous case reports have been published that describe the association of olanzapine and the development of pancreatitis. Furthermore, 3 reports suggest the mechanism of olanzapine-induced hypertriglyceridemia as the etiology of this progression. We report a case of a 36-year-old man who developed necrotizing pancreatitis secondary to olanzapine-induced hypertriglyceridemia. This case, to our knowledge, is the most severe case of this progression and the first case requiring plasmapheresis for acute management.

Leveraging electronic health records to study pleiotropic effects on bipolar disorder and medical comorbidities

Patients with bipolar disorder (BD) have a high prevalence of comorbid medical illness. However, the mechanisms underlying these comorbidities with BD are not well known. Certain genetic variants may have pleiotropic effects, increasing the risk of BD and other medical illnesses simultaneously. In this study, we evaluated the association of BD-susceptibility genetic variants with various medical conditions that tend to co-exist with BD, using electronic health records (EHR) data linked to genome-wide single-nucleotide polymorphism (SNP) data. Data from 7316 Caucasian subjects were used to test the association of 19 EHR-derived phenotypes with 34 SNPs that were previously reported to be associated with BD. After Bonferroni multiple testing correction, P<7.7 × 10(-5) was considered statistically significant. The top association findings suggested that the BD risk alleles at SNP rs4765913 in CACNA1C gene and rs7042161 in SVEP1 may be associated with increased risk of 'cardiac dysrhythmias' (odds ratio (OR)=1.1, P=3.4 × 10(-3)) and 'essential hypertension' (OR=1.1, P=3.5 × 10(-3)), respectively. Although these associations are not statistically significant after multiple testing correction, both genes have been previously implicated with cardiovascular phenotypes. Moreover, we present additional evidence supporting these associations, particularly the association of the SVEP1 SNP with hypertension. This study shows the potential for EHR-based analyses of large cohorts to discover pleiotropic effects contributing to complex psychiatric traits and commonly co-occurring medical conditions.

Gene-specific DNA methylation may mediate atypical antipsychotic-induced insulin resistance

OBJECTIVES

Atypical antipsychotics (AAPs) carry a significant risk of cardiometabolic side effects, including insulin resistance. It is thought that the insulin resistance resulting from the use of AAPs may be associated with changes in DNA methylation. We aimed to identify and validate a candidate gene associated with AAP-induced insulin resistance by using a multi-step approach that included an epigenome-wide association study (EWAS) and validation with site-specific methylation and metabolomics data.

METHODS

Subjects with bipolar disorder treated with AAPs or lithium monotherapy were recruited for a cross-sectional visit to analyze peripheral blood DNA methylation and insulin resistance. Epigenome-wide DNA methylation was analyzed in a discovery sample (n = 48) using the Illumina 450K BeadChip. Validation analyses of the epigenome-wide findings occurred in a separate sample (n = 72) using site-specific methylation with pyrosequencing and untargeted metabolomics data. Regression analyses were conducted controlling for known confounders in all analyses and a mediation analysis was performed to investigate if AAP-induced insulin resistance occurs through changes in DNA methylation.

RESULTS

A differentially methylated probe associated with insulin resistance was discovered and validated in the fatty acyl CoA reductase 2 (FAR2) gene of chromosome 12. Functional associations of this DNA methylation site with untargeted phospholipid-related metabolites were also detected. Our results identified a mediating effect of this FAR2 methylation site on AAP-induced insulin resistance.

CONCLUSIONS

Going forward, prospective, longitudinal studies assessing comprehensive changes in FAR2 DNA methylation, expression, and lipid metabolism before and after AAP treatment are required to assess its potential role in the development of insulin resistance.

Long-term risk of myocardial infarction and stroke in bipolar I disorder: A population-based Cohort Study

OBJECTIVES

To estimate the risk of fatal and non-fatal myocardial infarction (MI) and stroke in patients with bipolar I disorder compared to people without bipolar I disorder.

METHOD

Utilizing a records-linkage system spanning 30 years (1966-1996), a population-based cohort of 334 subjects with bipolar I disorder and 334 age and sex-matched referents from Olmsted County, Minnesota, U.S. was identified. Longitudinal follow-up continued until incident MI or stroke (confirmed by board-certified cardiologist/neurologist), death, or study end date (December 31, 2013). Cox proportional hazards models assessed the hazard ratio (HR) for MI or stroke, adjusting for potential confounders.

RESULTS

There was an increased risk of fatal or non-fatal MI or stroke (as a composite outcome) in patients with bipolar I disorder [HR 1.54, 95% confidence interval (CI) 1.02, 2.33; p=0.04]. However, after adjusting for baseline cardiovascular risk factors (alcoholism, hypertension, diabetes, and smoking), the risk was no longer significantly increased (HR 1.19, 95% CI 0.76, 1.86; p=0.46).

LIMITATIONS

Small sample size for the study design. Findings were not retained after adjustment for cardiovascular disease risk factors. Psychotropic medication use during the follow-up was not ascertained and was not included in the analyses.

CONCLUSION

This study in a geographically defined region in the U.S. demonstrated a significant increased risk of MI or stroke in bipolar I disorder, which was no longer significant after adjustment for cardiovascular risk factors.

DNA methylation, insulin resistance and second-generation antipsychotics in bipolar disorder

AIMS

This study aimed to assess the effect of second-generation antipsychotic (SGA) use and insulin resistance on a global measure of DNA methylation in patients diagnosed with bipolar disorder.

MATERIALS & METHODS

Subjects stable on medication (either mood stabilizer monotherapy or adjuvant SGAs) were assessed for insulin resistance. Global methylation levels were assessed in leukocyte DNA from whole blood using the Luminometric Methylation Assay. Multivariable linear regression was used to investigate the effect of insulin resistance and SGA use on DNA methylation.

RESULTS

A total of 115 bipolar I subjects were included in this study. The average age was 43.1 ±12.2 years and 73% were on SGAs. Average% global methylation was 77.0 ± 3.26 and was significantly influenced by insulin resistance, SGA use and smoking.

CONCLUSION

This is the first study to show a relationship between SGA use, insulin resistance and global DNA methylation. Further work will be needed to identify tissue- and gene-specific methylation changes.

Association between history of psychosis and cardiovascular disease in bipolar disorder

OBJECTIVES

To determine whether clinical features of bipolar disorder, such as history of psychosis, and cardiovascular disease (CVD) risk factors contribute to a higher risk of CVD among patients with bipolar disorder.

METHODS

This cross-sectional study included a sample of 988 patients with bipolar I or bipolar II disorder or schizoaffective bipolar type confirmed by the Structured Clinical Interview for DSM-IV-TR disorders (SCID). Medical comorbidity burden was quantified utilizing the Cumulative Illness Severity Rating Scale (CIRS). This 13-item organ-based scale includes cardiac disease severity quantification. Confirmed by medical record review, patients who scored 1 (current mild or past significant problem) or higher in the cardiac item were compared by logistic regression to patients who scored 0 (no impairment), adjusting for CVD risk factors that were selected using a backwards stepwise approach or were obtained from the literature.

RESULTS

In a multivariate model, age [odds ratio (OR) = 3.03, 95% confidence interval (CI): 1.66-5.54, p < 0.0001], hypertension (OR = 2.43, 95% CI: 1.69-3.55, p < 0.0001), and history of psychosis (OR = 1.48, 95% CI: 1.03-2.13, p = 0.03) were associated with CVD. When CVD risk factors from the literature were added to the analysis, age (OR = 3.19, 95% CI: 1.67-6.10, p = 0.0005) and hypertension (OR = 2.46, 95% CI: 1.61-3.76, p < 0.01) remained significant, with psychosis being at the trend level (OR = 1.43, 95% CI: 0.96-2.13, p = 0.08).

CONCLUSIONS

The phenotype of psychotic bipolar disorder may reflect higher illness severity with associated cardiac comorbidity. Further studies are encouraged to clarify the effect of the disease burden (i.e., depression), lifestyle, and treatment interventions (i.e., atypical antipsychotics) on this risk association.

Associations between comorbid anxiety, diabetes control, and overall medical burden in patients with serious mental illness and diabetes

OBJECTIVE

While previous work has demonstrated elevation of both comorbid anxiety disorders and diabetes mellitus type II in individuals with serious mental illness, little is known regarding the impact of comorbid anxiety on diabetes mellitus type II outcomes in serious mental illness populations. We analyzed baseline data from patients with serious mental illness and diabetes mellitus type II to examine relationships between comorbid anxiety, glucose control as measured by hemoglobin A1c score, and overall illness burden.

METHODS

Using baseline data from an ongoing prospective treatment study involving 157 individuals with serious mental illness and diabetes mellitus type II, we compared individuals with and without a comorbid anxiety disorder and compared hemoglobin A1c levels between these groups to assess the relationship between anxiety and management of diabetes mellitus type II. We conducted a similar analysis using cumulative number of anxiety diagnoses as a proxy for anxiety load. Finally, we searched for associations between anxiety and overall medical illness burden as measured by Charlson score.

RESULTS

Anxiety disorders were seen in 33.1% (N=52) of individuals with serious mental illness and diabetes mellitus type II and were associated with increased severity of depressive symptoms and decreased function. Hemoglobin A1c levels were not significantly different in those with or without anxiety, and having multiple anxiety disorders was not associated with differences in diabetes mellitus type II control. However, depressive symptoms were significantly associated with higher hemoglobin A1c levels. Neither comorbid anxiety nor anxiety load was significantly associated with overall medical burden.

CONCLUSION

One in three people with serious mental illness and diabetes mellitus type II had anxiety. Depressive symptoms were significantly associated with Hb1Ac levels while anxiety symptoms had no relation to hemoglobin A1c; this is consistent with previously published work. More studies are needed to better understand the relationship between depression, anxiety, and health management in people with serious mental illness and diabetes mellitus type II.

Risk of myocardial infarction and stroke in bipolar disorder: a systematic review and exploratory meta-analysis

OBJECTIVE

To review the evidence on and estimate the risk of myocardial infarction and stroke in bipolar disorder.

METHOD

A systematic search using MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, Cochrane Database of Systematic Reviews, and bibliographies (1946 - May, 2013) was conducted. Case-control and cohort studies of bipolar disorder patients age 15 or older with myocardial infarction or stroke as outcomes were included. Two independent reviewers extracted data and assessed quality. Estimates of effect were summarized using random-effects meta-analysis.

RESULTS

Five cohort studies including 13 115 911 participants (27 092 bipolar) were included. Due to the use of registers, different statistical methods, and inconsistent adjustment for confounders, there was significant methodological heterogeneity among studies. The exploratory meta-analysis yielded no evidence for a significant increase in the risk of myocardial infarction: [relative risk (RR): 1.09, 95% CI 0.96-1.24, P = 0.20; I(2)  = 6%]. While there was evidence of significant study heterogeneity, the risk of stroke in bipolar disorder was significantly increased (RR 1.74, 95% CI 1.29-2.35; P = 0.0003; I(2)  = 83%).

CONCLUSION

There may be a differential risk of myocardial infarction and stroke in patients with bipolar disorder. Confidence in these pooled estimates was limited by the small number of studies, significant heterogeneity and dissimilar methodological features.

Outreach visits by clinical pharmacists improve screening for the metabolic syndrome among mentally ill patients

BACKGROUND

Patients suffering from schizophrenia and affective disorder have an increased risk of the metabolic syndrome (MeS); hence identification of patients developing MeS may help preventing morbidity and mortality.

AIMS

The aim of the study was to evaluate the effect of outreach visit by clinical pharmacists to support the implementation of screening of MeS at a psychiatric ward.

METHODS

The study was conducted at the psychiatric ward, Odense University Hospital. In 2008, clinical guidelines for systematic screening and prevention of metabolic risk were developed and implemented by passive dissemination (PD) followed by a period of active implementation (AI). AI contained outreach visits by clinical pharmacists on a weekly basis. Patients with affective disorder or schizophrenia were included. The study was designed as a before-and-after study, and electronic patient charts were used for assessment of adherence to the clinical guidelines.

RESULTS

In total, 205 patients were included in the study (93 patients in the PD group, 112 patients in the AI group). A significant improvement of the use of the screening sheet from 36% in the PD group to 81% in the AI group was found (p < 0.001). Consequently, the quality of the screening increased significantly resulting in 45% in the AI group being identified with MeS compared with 10% in the PD group (p < 0.001).

CONCLUSION

The outreach visits by clinical pharmacists significantly improved the use of the screening sheet and resulted in a significant increase in the proportion of patients identified with MeS (p < 0.001).

CLINICAL IMPLICATIONS

The increase in the use of a screening sheet for MeS among patients admitted to a psychiatric ward as a result of outreach visits by clinical pharmacist improve assessment for MeS. This may lead to better identification of patients suffering from MeS and hence increase the possibility of treating MeS and preventing morbidity and mortaligy.

Antipsychotic-induced metabolic and cardiovascular side effects in schizophrenia: a novel mechanistic hypothesis

The use of antipsychotics is hindered by the frequent occurrence of metabolic and cardiovascular side effects, resulting in worsened quality of life and greater mortality as a result of cardiovascular and cerebrovascular disorders in schizophrenia patients than the comparable general population. The various antipsychotics induce extrapyramidal symptoms, impaired glucose and lipid metabolism, weight gain, hypertension and arrhythmias, with variable frequency. Second-generation antipsychotics appear to have several advantages over first-generation antipsychotics, including a claimed better action on cognitive function and the negative symptoms of schizophrenia, and lower frequency of extrapyramidal side effects; however, their use is associated with a greater frequency of metabolic and cardiovascular disturbances. The mechanisms of these important side effects are not well understood, and generic approaches (psychoeducational programmes and symptomatic therapies) have been proposed to limit their severity. Extensive data from the literature indicate that autonomic nervous system dysfunction--intrinsic to schizophrenia and strongly exacerbated by antipsychotic treatment--is the cause of the pervasive metabolic and vascular dysfunctions associated with schizophrenia. In this article, we marshal further literature data to argue that the metabolic and cardiovascular side effects of antipsychotics are primarily mediated by their ability to block peripheral dopamine receptors, which physiologically modulate sympathetic activity. We also propose that these effects might be overcome by providing peripheral dopaminergic stimulation.

Influence of the drug exposure definition on the assessment of the antipsychotic metabolic impact in patients initially treated with mood-stabilizers

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

• Metabolic disturbances represent a well-known side effect of second generation antipsychotics. However, studies comparing second generation antipsychotic drugs (SGAPs) and first generation antipsychotic drugs (FGAPs) through administrative databases have shown contrasting findings, which may be attributable to methodological differences.

WHAT THIS PAPER ADDS

• The definition of antipsychotic exposure impacts on the association between antipsychotics and metabolic risk in studies carried out through administrative databases. • Considering cumulative exposure to antipsychotics or including patients exposed to an antipsychotic drug for months or years is likely to over-represent patients who tolerate the drug well with a depletion of susceptible effects. • Antipsychotic drug exposure is a time-varying determinant and episodes of no use, past use and current use should be distinguished over the study period to avoid any misclassification bias that might lead to misleading findings.

AIMS

To assess the influence of three definitions of antipsychotic exposure on the comparison between first generation (FGAP) and second generation (SGAP) antipsychotic drugs and 'conventional' mood stabilizers towards the risk of metabolic events using (i) a dichotomous measure (exposed/non-exposed over the follow-up), (ii) a categorical measure taking into account the chronology of exposure at the time of the metabolic event (current, recent and no use) and (iii) a continuous measure (cumulative duration).

METHODS

A historical fixed cohort was identified from the 2004-2006 claims database of the French health insurance programme for self-employed workers, including 3172 patients aged 18 years and over who used conventional mood stabilizers over a 3 month period. A metabolic event was defined as an incident dispensing of an anti-diabetic or lipid-lowering drug.

RESULTS

A metabolic event occurred in 367 patients (11.6%). At least one FGAP had been prescribed in 29% of patients who did not develop a metabolic event and in 22% of patients who developed a metabolic event. In addition, at least one SGAP had been prescribed in 12% of patients who did not develop a metabolic event and in 7% of patients who developed a metabolic event. Compared with conventional mood stabilizers, the risk of a metabolic event was negatively associated with exposure to SGAPs over the follow-up period (HR 0.53, 95% CI 0.34, 0.82, P= 0.004), positively associated with recent, but not current, exposure to SGAPs (HR 2.1, 95% CI 1.2, 3.7, P= 0.006) and not associated with cumulative duration of SGAPs (HR 1.001, 95% CI 0.999, 1.003, P= 0.20).

CONCLUSIONS

The definition of exposure to antipsychotics in epidemiological studies exploring their metabolic impact is of paramount importance in understanding this association. Different definitions can lead to opposite and seemingly nonsensical results. Not taking into account past exposure, in order to minimize the depletion of susceptible effects, may lead to absurd results.

Treatment of co-morbid mental illness in primary care: how to minimize weight gain, diabetes, and metabolic syndrome

In patients with mental illness the increased risk from cardiovascular disease appears to be related to the increased incidence of obesity, hypertension, and diabetes mellitus. Barriers to the medical care in this patient population include diminished adherence to treatment and preventative recommendations, lack of willingness to engage in self-care activities, decreased access to affordable medical care, underestimation of risk by physicians, and adverse effects of commonly prescribed psychiatric medications. When managing patients with mental illness it is necessary to estimate the patient's metabolic and cardiovascular risk, monitor BMI, waist circumference, fasting glucose, and lipid profile regularly, evaluate psychiatric medications metabolic risk, and choose less "metabolically threatening" drugs. The promotion of healthy lifestyle choices among persons with serious mental illness is essential not only as part of their recovery, but as an integral part of preventing metabolic changes and weight gain linked to their illness and medication side effects. In patients with mental illness and co-morbid diabetes, metabolic syndrome, and obesity, psychiatrist and primary care clinicians should collaborate to establish a plan for healthy lifestyle habits (diet and activity regimen), encourage weight loss, and follow-up regularly using multispecialty teams to improve management.

Therapeutic drug monitoring of voriconazole and posaconazole

Despite the availability of newer antifungal agents, invasive fungal diseases remain a leading cause of morbidity and mortality in immunocompromised patients. Voriconazole and posaconazole are two extended-spectrum triazoles indicated for treatment and prophylaxis of invasive fungal diseases. Recently, there has been increased interest in the utility of therapeutic drug monitoring to optimize safety and efficacy of antifungals in an attempt to improve patient outcomes. We reviewed the pharmacokinetic and pharmacodynamic characteristics of voriconazole and posaconazole in the context of clinical indications for therapeutic drug monitoring. In addition, the most recent evidence examining the relationship between serum concentrations of voriconazole and posaconazole and their efficacy or toxicities was evaluated. This information was then integrated to formulate recommendations for use of therapeutic drug monitoring in clinical settings.

Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care

The lifespan of people with severe mental illness (SMI) is shorter compared to the general population. This excess mortality is mainly due to physical illness. We report prevalence rates of different physical illnesses as well as important individual lifestyle choices, side effects of psychotropic treatment and disparities in health care access, utilization and provision that contribute to these poor physical health outcomes. We searched MEDLINE (1966 - August 2010) combining the MeSH terms of schizophrenia, bipolar disorder and major depressive disorder with the different MeSH terms of general physical disease categories to select pertinent reviews and additional relevant studies through cross-referencing to identify prevalence figures and factors contributing to the excess morbidity and mortality rates. Nutritional and metabolic diseases, cardiovascular diseases, viral diseases, respiratory tract diseases, musculoskeletal diseases, sexual dysfunction, pregnancy complications, stomatognathic diseases, and possibly obesity-related cancers are, compared to the general population, more prevalent among people with SMI. It seems that lifestyle as well as treatment specific factors account for much of the increased risk for most of these physical diseases. Moreover, there is sufficient evidence that people with SMI are less likely to receive standard levels of care for most of these diseases. Lifestyle factors, relatively easy to measure, are barely considered for screening; baseline testing of numerous important physical parameters is insufficiently performed. Besides modifiable lifestyle factors and side effects of psychotropic medications, access to and quality of health care remains to be improved for individuals with SMI.

The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments

OBJECTIVES

Safety monitoring is an important aspect of bipolar disorder treatment, as mood-stabilising medications have potentially serious side effects, some of which may also aggravate existing medical comorbidities. This paper sets out the International Society for Bipolar Disorders (ISBD) guidelines for the safety monitoring of widely used agents in the treatment of bipolar disorder. These guidelines aim to provide recommendations that take into consideration the balance between safety and cost-effectiveness, to highlight iatrogenic and preventive clinical issues, and to facilitate the broad implementation of therapeutic safety monitoring as a standard component of treatment for bipolar disorder.

METHODS

These guidelines were developed by an ISBD workgroup, headed by the senior author (MB), through an iterative process of serial consensus-based revisions. After this, feedback from a multidisciplinary group of health professionals on the applicability of these guidelines was sought to develop the final recommendations.

RESULTS

General safety monitoring recommendations for all bipolar disorder patients receiving treatment and specific monitoring recommendations for individual agents are outlined.

CONCLUSIONS

These guidelines are derived from evolving and often indirect data, with minimal empirical cost-effectiveness data available to provide guidance. These guidelines will therefore need to be modified to adapt to different clinical settings and health resources. Clinical acumen and vigilance remain critical ingredients for safe treatment practice.

Retrospective analysis of diabetes care in California Medicaid patients with mental illness

BACKGROUND

Serious mental illness often is associated with an increased risk of diabetes and sub-optimal diabetes care.

OBJECTIVE

To examine diabetes prevalence and care among Medicaid patients from one county mental health system.

DESIGN

Retrospective cohort study combining county records and 12 months of state Medicaid claims.

SUBJECTS

Patients ages 18 to 59 receiving mental health services between November 1 and 14, 2004.

MEASUREMENTS

Dependent variables were glycolated hemoglobin A1C (HbA1c) testing, lipid testing, and eye examinations. Psychiatric status was assessed by second generation antipsychotic prescription (SGA) and low Global Assessment of Functioning (GAF) score.

RESULTS

Among psychiatric patients, 482 (11.8%) had diabetes. Among those with diabetes, 47.3% received annual HbA1c testing, 56.0% lipid testing, and 31.7% eye examinations. Low GAF scores were associated with lower likelihood of lipid testing (OR 0.43). SGA prescription reduced the likelihood of HbA1c testing (OR 0.58) but increased the likelihood of eye examinations (OR 2.02). Primary care visits were positively associated with HbA1c and lipid testing (ORs 5.01 and 2.21, respectively). Patients seen by a fee-for-service psychiatrist were more likely to have lipid testing (OR 2.35) and eye examinations (OR 2.03).

CONCLUSION

Among Medicaid psychiatric patients, worse diabetes care was associated with SGA prescription, more serious psychiatric symptoms, and receiving psychiatric care only in public mental health clinics. Diabetes care improved when patients were seen by fee-for-service psychiatrists or primary care physicians. Further study is needed to identify methods for improving diabetes care of public mental health patients.

Quality of life and suicide risk in patients with diabetes mellitus

BACKGROUND

Diabetes mellitus may have profound effects on physical and emotional health and quality of life.

OBJECTIVE

The authors evaluated the perceived quality of life and its association with suicide risk in Italian patients with diabetes mellitus.

METHOD

Authors evaluated 100 patients with type 1 and type 2 diabetes. Patients completed the Beck Hopelessness Scale, the Suicide Score Scale, the SF-36 Health Survey Questionnaire, and the General Self-Efficacy Scale.

RESULTS

Patients with diabetes showed greater hopelessness and suicide ideation than internal-medicine outpatients. Poor quality of life was related to low self-efficacy, high hopelessness, and suicidality. A stepwise multiple regression found that polytherapy and older age predicted suicidality.

CONCLUSION

It would be useful in future research to follow up patient samples to determine how many and which patients engage in fatal and nonfatal suicidal behavior and the relationship of these parameters with quality of life.

Metabolic risks in older adults receiving second-generation antipsychotic medication

Metabolic syndrome is prevalent in older adults and increases the risk of cardiovascular disease. Second-generation antipsychotics (aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone) increase the risk of metabolic syndrome and present many challenges for psychiatrists. In this article, we review the relationships between second-generation antipsychotics and metabolic syndrome with a focus on older adults. Because few studies focus exclusively on older adults, we augment this review with relevant findings from younger adults. The differential risk factors of each medication are reviewed, as are recent findings in monitoring and treating metabolic syndrome. Olanzapine and clozapine are more strongly associated with metabolic risks, whereas aripiprazole and ziprasidone are less associated. Although lifestyle modifications can help to reduce some aspects of metabolic syndrome, lifestyle modifications in conjunction with metformin therapy appear to be most effective.

Side effects of second-generation antipsychotics: the experiences, views and monitoring practices of Australian child psychiatrists

OBJECTIVE

The aim of this study was to ascertain the experiences, views and monitoring practices of Australian child psychiatrists regarding the metabolic and other side effects of second-generation antipsychotics (SGAs).

METHOD

A 19-item questionnaire was posted to all members of the RANZCP Faculty of Child and Adolescent Psychiatry living in Australia.

RESULTS

Of the 290 eligible members of the Faculty of Child and Adolescent Psychiatry, 126 (43%) returned a useable survey. SGAs are commonly prescribed for a range of disorders. The majority of respondents expressed a high level of concern regarding weight gain and other metabolic side effects. Weight gain was the most frequently observed and monitored side effect in clinical practice. Other side effects were observed and monitored to a variable extent. Notably, monitoring practices did not parallel psychiatrists' reported level of concern or knowledge regarding weight gain and metabolic side effects,nor coincide with published recommendations.

CONCLUSIONS

Further research is required into the use, efficacy, side effects and monitoring of SGAs in children and adolescents, and there is a need to ensure that monitoring guidelines are implemented in clinical practice. This need is heightened by the likelihood that our data on clinicians' practice, which is based on their perceptions, may overestimate what actually occurs.

Bipolar disorder and weight gain: a multifactorial assessment

Obesity is highly prevalent in persons with bipolar disorder. This results in increased physical morbidity and poorer psychiatric outcomes. Multiple variables have been identified as potentially responsible for the weight gain in these individuals. Efforts to use successful treatment strategies require an understanding of these variables and methods that clinicians and their clients can use to reduce or minimize these risk factors. This article will review the emerging findings related to primary and secondary weight gain in bipolar disorder. The sequelae of weight gain on psychiatric and medical morbidity will be discussed. Lastly, a model for nursing assessment will propose methods for modifying risk factors and encouraging healthy lifestyle changes. The goal is to improve this component of quality of life for persons with bipolar disorder. J Am Psychiatr Nurses Assoc, 2008; 13(6), 345-352. DOI: 10.1177/1078390307310145.

Sensitivity to reward and body mass index (BMI): Evidence for a non-linear relationship

The role of brain reward mechanisms, and associated personality traits, are of growing interest to researchers in the field of eating behaviours and obesity. However, the direction of causal influence has produced some debate and inconsistency in the literature. Some have argued that a reward deficiency syndrome increases the risk for obesity while others have claimed that a heightened sensitivity to reward is linked to higher body mass index (BMI). To reconcile these two perspectives, a non-linear relationship between reward sensitivity and BMI was predicted. Previous research has also not considered whether sex moderates the relationship between these two variables. Results indicated that although men had significantly higher reward sensitivity than women, the interaction between sex and BMI was not significant. As predicted, the quadratic term of BMI was statistically significant indicating a moderately positive relationship between BMI and reward sensitivity in the normal and overweight range of BMI (18-30) after which the relationship changed direction and was inversely related in those with moderate and extreme obesity. This curvilinear relationship meshes with, and helps to integrate, the two perspectives described above and found in previous studies. It would behoove future researchers to identify behaviours that might explain the association between a psychobiological trait like reward sensitivity and a physical characteristic like body size, and to explicate the possibly reciprocal causal mechanisms that underlie this association.

Reaching for wellness in schizophrenia

Coronary heart disease (CHD) is a major cause of mortality in people who have schizophrenia, and it is caused by many factors relating to lifestyle choices, antipsychotic treatment, and other medical comorbidities. This article focuses on modifiable risk factors such as cigarette smoking, diabetes, hyperlipidemia, hypertension, and the metabolic syndrome, all of which occur more frequently in patients who have schizophrenia than in the general population. Although treatment of risk factors for CHD is still far from ideal, all attempts should be made to strive for wellness to improve patients' long-term outcomes.

Quetiapine: a review of its use in the treatment of bipolar depression

Quetiapine (Seroquel) is the only atypical antipsychotic approved in the US for use as monotherapy in both bipolar mania and depression, offering potential compliance advantages. Monotherapy with oral quetiapine 300 mg/day is effective in the treatment of patients with bipolar I or II depression. Rapid and sustained improvements in depressive and anxiety symptoms are seen with quetiapine, as well as improvements in health-related quality of life (HR-QOL). Quetiapine is generally well tolerated in bipolar depression and is not associated with an increased risk of treatment-emergent mania. Thus, despite the current lack of data from active comparator trials, quetiapine monotherapy should be considered a first-line option for the acute treatment of bipolar depression.