Weight-gain in psychiatric treatment: risks, implications, and strategies for prevention and management

Weight change following diagnosis with psychosis: a retrospective cohort study in Greater Manchester, UK

INTRODUCTION

Weight gain in the months/years after diagnosis/treatment of severe enduring mental illness (SMI) is a major predictor of future diabetes, dysmetabolic profile and increased risk of cardiometabolic diseases. There is limited data on the longer-term profile of weight change in people with a history of SMI and how this may differ between individuals. We here report a retrospective study on weight change over the 5 years following an SMI diagnosis in Greater Manchester UK, an ethnically and culturally diverse community, with particular focus on comparing non-affective psychosis (NAP) vs affective psychosis (AP) diagnoses.

METHODS

We undertook an anonymised search in the Greater Manchester Care Record (GMCR). We reviewed the health records of anyone who had been diagnosed for the first time with first episode psychosis, schizophrenia, schizoaffective disorder, delusional disorder (non-affective psychosis = NAP) or affective psychosis (AP). We analysed body mass index (BMI) change in the 5-year period following the first prescription of antipsychotic medication. All individuals had taken an antipsychotic agent for at least 3 months. The 5-year follow-up point was anywhere between 2003 and 2023.

RESULTS

We identified 9125 people with the diagnoses above. NAP (n = 5618; 37.3% female) mean age 49.9 years; AP (n = 4131; 60.5% female) mean age 48.7 years. 27.0% of NAP were of non-White ethnicity vs 17.8% of AP individuals. A higher proportion of people diagnosed with NAP were in the highest quintile of social disadvantage 52.4% vs 39.5% for AP. There were no significant differences in baseline BMI profile. In a subsample with HbA1c data (n = 2103), mean HbA1c was higher in NAP at baseline (40.4 mmol/mol in NAP vs 36.7 mmol/mol for AP). At 5-year follow-up, there was similarity in both the overall % of individuals in the obese ≥ 30 kg/m2 category (39.8% NAP vs 39.7% AP), and % progressing from a normal healthy BMI transitioned to obese/overweight BMI (53.6% of NAP vs 55.6% with AP). 43.7% of those NAP with normal BMI remained at a healthy BMI vs 42.7% with AP. At 5-year follow-up for NAP, 83.1% of those with BMI ≥ 30 kg/m2 stayed in this category vs 81.5% of AP.

CONCLUSION

The results of this real-world longitudinal cohort study suggest that the changes in BMI with treatment of non-affective psychosis vs bipolar disorder are not significantly different, while 43% maintain a healthy weight in the first 5 years following antipsychotic prescription.

The bi-directional association between bipolar disorder and obesity: Evidence from Meta and bioinformatics analysis

BACKGROUND

The globally high prevalence of both obesity and bipolar disorder makes the bidirectional relationship between the two disorders a pivotal phenomenon; hence, a meta-analysis to synopsize their co-occurrence is indispensable. Psychotropic-induced obesity has been reported to be an important factor linking bipolar disorder and obesity. Nonetheless, the molecular signature of this connection is perplexing.

METHODS

Here, we leverage both meta-analysis and bioinformatics analysis to provide a conspectus and deduce the molecular signature of obesity in bipolar disease patients following psychotropic treatment. Searches were performed on a diverse collection of databases through June 25, 2020. The Newcastle-Ottawa Scale was used to rate the quality of the studies. Analysis of OR, 95% CI, and tests of homogeneity were carried out with STATA software. For the bioinformatics analysis, the LIMMA package which is incorporated into the Gene Expression Omnibus database was used.

RESULTS

Our search yielded 138 studies, of which 18 fitted our inclusion criteria. Individuals who are obese have an increased risk of developing bipolar disorder (pooled adjusted OR = 1.32, 95% CI = 1.01-1.62). In a manner analogous to this, the pooled adjusted odds ratio reveals that patients with bipolar disorder have an increased chance of obesity (OR = 1.68, 95% CI = 1.35-2). To deduce the molecular signature of obesity in bipolar disorder patients following psychotropic treatment, three data sets from the Gene Expression Omnibus database (GSE5392, GSE87610, and GSE35977) were integrated and the genes obtained were validated by a cohort of known single nucleotide polymorphism of obesity via direct overlap. Results indicate genes that are activated after psychotropic treatment. Some of these genes are CYBB, C3, OLR1, CX3CR1, C3AR1, CD53, AIF1, LY86, BDNF, ALOX5AP, CXCL10, and the preponderance falls under mesodermal and PI3K-Akt signaling pathway. The ROC analysis reveals a strong discriminating value between the two groups (UBAP2L AUC = 0.806, p = 1.1e-04, NOVA2 AUC = 0.73, p = 6.7e-03).

CONCLUSION

Our study shows unequivocal evidence of a bi-directional association between bipolar disorder and obesity, but more crucially, it provides a snapshot of the molecular signature of obesity in bipolar patients as a result of psychotropic medication.

The Effects of Use of Long-Term Second-Generation Antipsychotics on Liver and Kidney Function: A Prospective Study

(1) Background: The second-generation antipsychotics (SGAPs) induce metabolic and inflammatory side effects, but documentation of their effects on the liver and kidneys is scarce. Aim: To study the three-year fluctuation of selected markers of renal and hepatic function in forensic psychiatric patients receiving SGAPs for more than five years. (2) Methods: Thirty-five forensic psychiatric patients (N = 35) were classified into two groups according to the type of SGAPs used for their treatment and the relevant risk of weight gain and metabolic complications. The three-year medication history, anthropometric data and biochemical data relevant to renal and hepatic function were retrieved from the individual medical files, specifically: serum levels of urea, uric acid, creatinine, alkaline phosphatase and amylase; the liver function enzymes, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT) and gamma-glutamyl transpeptidase(γ-GT), and also the inflammatory index C-reactive protein (CRP). (3) Results: The patients receiving the SGAPs with a low risk for weight gain showed no significant fluctuation in the biochemical markers over the three-year period. The patients receiving the SGAPs with a high risk for weight gain showed significant differences between at least two measurements of uric acid (p = 0.015), SGOT (p = 0.018) and SGPT (p = 0.051). They showed significantly higher levels of creatinine in the third year compared to the second year (p = 0.029), and SGOT in the second year compared to the first (p = 0.038), and lower levels of SGPT in the third year compared to the second (p = 0.024). (4) Conclusion:In addition to consideration of possible metabolic and inflammatory complications, the choice of an antipsychotic drug for long-term treatment should also take into account the risk of hepatotoxicity and kidney damage.

How Different Pre-existing Mental Disorders and Their Co-occurrence Affects COVID-19 Clinical Outcomes? A Real-World Data Study in the Southern United States

Background

Although a psychiatric history might be an independent risk factor for COVID-19 infection and mortality, no studies have systematically investigated how different clusters of pre-existing mental disorders may affect COVID-19 clinical outcomes or showed how the coexistence of mental disorder clusters is related to COVID-19 clinical outcomes.

Methods

Using a retrospective cohort study design, a total of 476,775 adult patients with lab-confirmed and probable COVID-19 between March 06, 2020 and April 14, 2021 in South Carolina, United States were included in the current study. The electronic health record data of COVID-19 patients were linked to all payer-based claims data through the SC Revenue and Fiscal Affairs Office. Pre-existing mental disorder diagnoses from Jan 2, 2019 to Jan 14, 2021 were extracted from the patients' healthcare utilization data via ICD-10 codes.

Results

There is an elevated risk of COVID-19-related hospitalization and death among participants with pre-existing mental disorders adjusting for key socio-demographic and comorbidity covariates. Co-occurrence of any two clusters was positively associated with COVID-19-related hospitalization and death. The odds ratio of being hospitalized was 1.26 (95% CI: 1.151, 1.383) for patients with internalizing and externalizing disorders, 1.65 (95% CI: 1.298, 2.092) for internalizing and thought disorders, 1.76 (95% CI: 1.217, 2.542) for externalizing and thought disorders, and 1.64 (95% CI: 1.274, 2.118) for three clusters of mental disorders.

Conclusions

Pre-existing internalizing disorders and thought disorders are positively related to COVID-19 hospitalization and death. Co-occurrence of any two clusters of mental disorders have elevated risk of COVID-19-related hospitalization and death compared to those with a single cluster.

Sexuality in people living with a serious mental illness: A meta-synthesis of qualitative evidence

WHAT IS KNOWN ON THE SUBJECT

A serious mental illness influences sexual life and people affected have worries about their sexual health. People living with a serious mental illness can and want to participate in interventions related to sexual health.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

People who suffer a serious mental illness are interested in maintaining an active sex life. People who suffer a serious mental illness experience rejection when they open up and they lose intimate relationships or possibilities of meeting other people because of ignorance and prejudices surrounding mental health.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Mental health services must respond to this need, that is including sexual needs assessment among routine standard practices or training nurses on sexual education to allow them to advise patients and their families and friends. Health systems should promote awareness programmes and reduce the stigma surrounding mental health and sexuality.

ABSTRACT

INTRODUCTION: Sexuality-related nursing care is scarce and mainly focuses on biological issues. There is also a lack of knowledge about how serious mental illnesses affect sexuality.

AIM

To explain how people with a serious mental illness perceive and experience their sexuality.

METHOD

A meta-synthesis was conducted to integrate qualitative studies. Four databases were used to perform the search, focused in the last ten years. Nine articles were included, and their results analysed thematically.

RESULTS

Four categories were identified: "Pathologized sexuality," which explains how the disorder and treatment affect sexuality; "Not my sexuality anymore," which describes feelings emerging from the perceived limitations and the role of self-acceptance; "Learning to manage intimate relationships," which explains the desire to establish intimate personal relationships and define their meaning; and "Reconstructing my sexuality," which elucidates the influence of the environment on sexuality.

DISCUSSION

Sexuality is influenced by several factors, the main ones being: the clinical complications, the side effects of drug treatment, the social support, the relationship with the health sector and stigma.

IMPLICATIONS FOR PRACTICE

Having a serious mental illness affects sexuality and can provoke suffering and social isolation. Mental health services should address this issue and carry out community interventions to reduce stigma.

Superwoman's kryptonite: The superwoman schema and perceived barriers to weight management among U.S. Black women

The role that the superwoman schema (SWS) plays in U.S. Black women's perceptions of barriers (biological, psychological, and sociological) to healthy weight management is unknown. This exploratory study examined whether 122 women classified as normal weight, overweight or obese differed in their perceptions of types of barriers and if the SWS predicted perceived barriers to weight management. Women classified as obese reported more barriers than those classified as normal weight. The SWS uniquely positively predicted perceived psychological and sociological barriers. Our findings suggest that the SWS may play a vital role in the self-management of weight in U.S. Black women.

Association between high BMI and high homocysteine levels in Chinese patients with bipolar disorder

BACKGROUND

Bipolar disorder (BD) has been associated with an increased prevalence of weight gain and abnormally elevated plasma homocysteine (Hcy) levels. However, the relationship between BMI and Hcy in BD patients has not been investigated. This study aimed to explore this relationship in Chinese patients with BD.

METHODS

Plasma Hcy levels, socio-demographic parameters, clinical and anthropometric data were collected from 195 BD inpatients and 84 healthy controls. The level of plasma Hcy was determined by high-performance liquid chromatography. Body mass index (BMI) was calculated by body weight divided by the square of the height. The participants were divided into a high BMI group and a low BMI group using 24 kg/m² as a threshold.

RESULTS

The prevalence of high BMI was slightly elevated in BD patients in comparison to healthy controls. Patients with elevated BMI had significantly higher Hcy levels than patients with low BMI. Hcy level was an independent contributor of the occurrence of high BMI in BD patients. The level of Hcy was positively correlated with BMI in BD patients. In addition, depressive episodes of BD were positively correlated with the prevalence of high BMI and married BD patients were more likely to have high BMI levels.

CONCLUSIONS

There is a close relationship between BMI and plasma Hcy levels in patients with BD, suggesting that Hcy may be an important indicator for BD-induced weight gain. This finding provides a new avenue for weight management of BD patients and to help avoid the potential risk of cardiovascular diseases.

Long Term Metabolic and Inflammatory Effects of Second-Generation Antipsychotics: A Study in Mentally Disordered Offenders

Mentally disordered offenders provided with forensic psychiatric care are often treated with second generation antipsychotic (SGA) medication and experience metabolic and inflammatory side effects.

AIM

In this paper, we monitored the three-year fluctuation of selected anthropometric, biochemical, and inflammatory indices in forensic psychiatric patients receiving antipsychotic (AP) medication for more than five years, according to the type of AP.

METHODS

Thirty-five patients with psychotic disorders were classified into two groups based on the type of AP. Specifically: AP1, related to a lower risk, and AP2, related to an increased risk of weight gain (WG) and metabolic complications. Biochemical, hematological, anthropometric, blood pressure (BP), and medication data were retrieved from the individual medical files. Statistical analysis was performed with SPSS 23.

RESULTS

No significant differences in weight and glucose and cholesterol levels were observed, but patients taking AP2 more often needed drugs to control diabetes mellitus (DM), lipidemia, and cardiovascular disease (CVD). In those taking AP1, the mean HDL level decreased significantly over time (p < 0.05) and a higher proportion developed higher BP (52.9% of AP1 vs. 16.7% AP2). In the AP2 group the median level of C-reactive protein (CRP) (p < 0.001) and the white blood cell count (WBC) increased over the three years (p < 0.001).

CONCLUSIONS

The proposed sub-classification of SGAs into AP1 and AP2, depending on their potential for metabolic and inflammatory effects, might facilitate study of their long-term side-effects but also help in personalized prevention or treatment measures to counteract these side-effects.

Post-traumatic stress disorder and the association with overweight, obesity, and weight change among individuals exposed to the World Trade Center disaster, 2003-2016

BACKGROUND

Among Veterans, post-traumatic stress disorder (PTSD) has been shown to be associated with obesity and accelerated weight gain. Less is known among the general population. We sought to determine the impact of PTSD on body mass index (BMI) and weight change among individuals with exposure to the World Trade Center (WTC) disaster.

METHODS

We examined individuals from the WTC Health Registry. PTSD symptoms were assessed on multiple surveys (Waves 1-4) using the PTSD Checklist-Specific. Three categories of post-9/11 PTSD were derived: no, intermittent, and persistent. We examined two outcomes: (1) Wave 3 BMI (normal, overweight, and obese) and (2) weight change between Waves 3 and 4. We used multivariable logistic regression to assess the association between PTSD and BMI (N = 34 958) and generalized estimating equations to assess the impact of PTSD on weight change (N = 26 532). Sex- and age-stratified analyses were adjusted for a priori confounders.

RESULTS

At Wave 3, the observed prevalence of obesity was highest among the persistent (39.5%) and intermittent PTSD (36.6%) groups, compared to the no PTSD group (29.3%). In adjusted models, persistent and intermittent PTSD were consistently associated with a higher odds of obesity. Weight gain was similar across all groups, but those with persistent and intermittent PTSD had higher estimated group-specific mean weights across time.

CONCLUSIONS

Our findings that those with a history of PTSD post-9/11 were more likely to have obesity is consistent with existing literature. These findings reaffirm the need for an interdisciplinary focus on physical and mental health to improve health outcomes.

Metabolic and behavioral effects of olanzapine and fluoxetine on the model organism Caenorhabditis elegans

The use of many psychotropic drugs (PDs) is associated with increased caloric intake, significant weight gain, and metabolic disorders. The nematode Caenorhabditis elegans (C. elegans) has been used to study the effects of PDs on food intake. However, little is known about PDs effects on the body fat of C. elegans. In C. elegans, feeding behavior and fat metabolism are regulated through independent mechanisms. This study aims to evaluate the body fat and food intake of C. elegans in response to treatment olanzapine and fluoxetine. Here we report that, with careful consideration to the dosage used, administration of fluoxetine and olanzapine increases body fat and food intake in C. elegans.

Do Hot Executive Functions Relate to BMI and Body Composition in School Age Children?

Deficits of 'hot' executive functions (EFs) involving emotional and motivational processes are considered as a risk factor for excessive weight, but few studies have tested the relationship between hot EFs and body composition in children. The aim of the study was to assess the association of the ability to delay gratification and affective decision-making with the body mass index (BMI) and body composition in children with typical neurocognitive development. The sample consisted of 553 Polish children aged between 6-12 y. The delay of gratification task (DGT) was applied to assess the ability to delay gratification. The Hungry Donkey test (HDT) was applied to assess affective decision-making. The indicators of decision-making in the HDT were net score and learning rate. The relationships between hot EFs and BMI, fat mass index (FMI), lean body mass index (LBMI) were tested. The association of the z scores of BMI and FMI, overweight/obesity, and the ability to delay gratification was found insignificant after controlling cofounding factors. Most of the results on affective decision-making and z scores for BMI, FMI and LBMI were insignificant as well. The relationship between the ability to delay gratification, affective decision-making, and adiposity is not pronounced in typically developed children.

Interventions for the management of obesity in people with bipolar disorder

BACKGROUND

Bipolar disorder is one of the most common serious mental illnesses, affecting approximately 60 million people worldwide. Characterised by extreme alterations in mood, cognition, and behaviour, bipolar disorder can have a significant negative impact on the functioning and quality of life of the affected individual. Compared with the general population, the prevalence of comorbid obesity is significantly higher in bipolar disorder. Approximately 68% of treatment seeking bipolar patients are overweight or obese. Clinicians are aware that obesity has the potential to contribute to other physical health conditions in people with bipolar disorder, including diabetes, hypertension, metabolic syndrome, cardiovascular disease, and coronary heart disease. Cardiovascular disease is the leading cause of premature death in bipolar disorder, happening a decade or more earlier than in the general population. Contributing factors include illness-related factors (mood-related factors, i.e. mania or depression), treatment-related factors (weight implications and other side effects of medications), and lifestyle factors (physical inactivity, poor diet, smoking, substance abuse). Approaches to the management of obesity in individuals with bipolar disorder are diverse and include non-pharmacological interventions (i.e. dietary, exercise, behavioural, or multi-component), pharmacological interventions (i.e. weight loss drugs or medication switching), and bariatric surgery.

OBJECTIVES

To assess the effectiveness of interventions for the management of obesity in people with bipolar disorder.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and the Cochrane Central Register for Controlled Trials (CENTRAL) to February 2019. We ran additional searches via Ovid databases including MEDLINE, Embase, and PsycInfo to May 2020. We searched the World Health Organization (WHO) trials portal (International Clinical Trials Registry Platform (ICTRP)) and ClinicalTrials.gov. We also checked the reference lists of all papers brought to full-text stage and all relevant systematic reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs), randomised at the level of the individual or cluster, and cross-over designs of interventions for management of obesity, in which at least 80% of study participants had a clinical diagnosis of bipolar disorder and comorbid obesity (body mass index (BMI) ≥ 30 kg/m²), were eligible for inclusion. No exclusions were based on type of bipolar disorder, stage of illness, age, or gender. We included non-pharmacological interventions comprising dietary, exercise, behavioural, and multi-component interventions; pharmacological interventions consisting of weight loss medications and medication switching interventions; and surgical interventions such as gastric bypass, gastric bands, biliopancreatic diversion, and vertical banded gastroplasty. Comparators included the following approaches: dietary intervention versus inactive comparator; exercise intervention versus inactive comparator; behavioural intervention versus inactive comparator; multi-component lifestyle intervention versus inactive comparator; medication switching intervention versus inactive comparator; weight loss medication intervention versus inactive comparator; and surgical intervention versus inactive comparator. Primary outcomes of interest were changes in body mass, patient-reported adverse events, and quality of life.

DATA COLLECTION AND ANALYSIS

Four review authors were involved in the process of selecting studies. Two review authors independently screened the titles and abstracts of studies identified in the search. Studies brought to the full-text stage were then screened by another two review authors working independently. However, none of the full-text studies met the inclusion criteria. Had we included studies, we would have assessed their methodological quality by using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. We intended to combine dichotomous data using risk ratios (RRs), and continuous data using mean differences (MDs). For each outcome, we intended to calculate overall effect size with 95% confidence intervals (CIs).

MAIN RESULTS

None of the studies that were screened met the inclusion criteria.

AUTHORS' CONCLUSIONS

None of the studies that were assessed met the inclusion criteria of this review. Therefore we were unable to determine the effectiveness of interventions for the management of obesity in individuals with bipolar disorder. Given the extent and impact of the problem and the absence of evidence, this review highlights the need for research in this area. We suggest the need for RCTs that will focus only on populations with bipolar disorder and comorbid obesity. We identified several ongoing studies that may be included in the update of this review.

Impact of quercetin on pharmacokinetics of quetiapine: insights from in-vivo studies in wistar rats

Quercetin (QCN) is commonly used in high doses as a dietary supplement for weight loss. Psychotic patients are at greater risk of developing obesity than the general population. The present study was designed to understand the impact of QCN on the exposure of quetiapine (QTE), an anti-psychotic drug with narrow therapeutic index and brain penetrating capability. The content of QTE in rat plasma was analyzed through liquid chromatography-tandem mass spectrometry. The results showed a significant (p < 0.05) increase in exposure of QTE (peroral dosed) in the animals pre-treated with QCN as compared to the control group. All the animals pre-treated with QCN, succumbed to death within 3-5 min of intravenous dosing of QTE (1 mg/kg). The studies in rat liver S9 fraction indicated that QCN could increase the metabolic stability of QTE by inhibiting the activity of CYP enzymes. The brain to plasma ratio of QTE increased upon QCN pre-treatment (2.6 vs 7.7), which could be attributed to P-glycoprotein inhibition at the blood-brain barrier by QCN. The current set of studies indicated that serious herb-drug interaction between QCN and QTE might occur when they are co-administered. Caution is advised for concomitant use of QCN rich dietary supplements with QTE.

THE MANAGEMENT OF CARDIOVASCULAR DISEASE RISK FACTORS IN BIPOLAR DISORDER PATIENTS IN PRIMARY HEALTHCARE SETTINGS

Accumulating evidence supports the association between cardiovascular disease (CVD) risk factors and bipolar disorder (BD). CVD is the leading cause of morbidity and mortality in patients with bipolar disorder. However, there is a need to study the management of the risk factors in the primary healthcare context. This narrative review aims to appraise the different approaches of care that have been used in the management of these patients to address CVD risk factors in primary care. We reviewed articles from PubMed, Science Direct and other studies cited in the articles found. The keywords used for this review included "bipolar," "bipolar disorder," "cardiovascular" or "metabolic syndrome," "screening," "primary care," and "integrative" or "integrated care model" or "collaborative care model." This review includes studies published over a period of 48 months (January 2016 through December 2019). We identified 128 articles, removing two duplicates. From them, 115 articles are excluded based on the inclusion/exclusion criteria leaving eleven relevant articles. Upon full-text review, six studies were excluded. The final studies included are five. We used the study-quality assessment tools from the National Heart, Lung, and Blood Institute to assess the quality of the articles found. CVD risk factors in patients with BD and forms of other severe mental illness (SMI) are often underdetected. Primary healthcare providers need to identify these risk factors in the management of these patients to determine and recommend appropriate strategies.

Case study of an adaptation and implementation of a Diabetes Prevention Program for individuals with serious mental illness

The Diabetes Prevention Program (DPP) is an evidence-based lifestyle intervention developed to decrease the risk for type 2 diabetes and promote weight loss in individuals at risk for diabetes. Individuals with serious mental illness have a greater risk for developing diabetes compared with the general population. In this article, the authors provide a detailed description of the adaptation process of the DPP for individuals with serious mental illness (DPP-SMI). The adaptation process was based on a cultural adaptation framework for modifying evidence-based interventions. To assess the effectiveness of the DPP-SMI, 11 individuals from a community mental health residential agency completed a 22-session pilot study of the adapted program and provided physiological measures before and after the intervention. As primary outcomes, participants were expected to report decreased body weight and increased physical activity per week. Completers had an average weight loss of 19 lbs (8%) and their physical activity increased from 161 to 405 min per week. These preliminary results together with participants' feedback informed further refinement of the DPP-SMI. This case study supports that individuals with serious mental illness can benefit from the DPP-SMI, which is tailored to meet the unique needs of this population group.

Asenapine in the management of impulsivity and aggressiveness in bipolar disorder and comorbid borderline personality disorder: an open-label uncontrolled study

Borderline personality disorder (BPD) often co-occurres with bipolar disorder (BD). Impulsivity and aggressiveness represent core shared features and their pharmacological management is mainly based on mood stabilizers and antipsychotics, although scarce evidence is available for this context of comorbidity. The aim of the present study was to evaluate the role of Asenapine as an adjunctive drug for reducing aggressiveness and impulsivity in a sample of Italian BD type I outpatients with or without a comorbid BPD. This was an observational 12-week open-label uncontrolled clinical study carried out from April to October 2014 in two psychiatric clinics in Sicily. Each patient was treated with asenapine at two dose options, 5 mg (twice daily) or 10 mg (twice daily), and concomitant ongoing medications were not discontinued. We measured impulsivity using the Barratt Impulsiveness Scale (BIS) and aggressiveness using the Aggressive Questionnaire (AQ). For the analysis of our outcomes, patients were divided into two groups: with or without comorbid BPD. Adjunctive therapy was associated with a significant decrease of BIS and AQ overall scores in the entire bipolar sample. Yet, there was no significant difference in BIS and AQ reductions between subgroups. Using a regression model, we observed that concomitant BPD played a negative role on the Hostility subscale and overall AQ score variations; otherwise, borderline co-diagnosis was related positively to the reduction of physical aggression. According to our post-hoc analysis, global aggressiveness scores are less prone to decrease in patients with a dual diagnosis, whereas physical aggressiveness appears to be more responsive to the add-on therapy in patients with comorbidity.

Early Combination Therapy for Type 2 Diabetes Mellitus and Common Comorbid Mental Disorders

The relationship between type 2 diabetes mellitus and antipsychotic use by schizophrenia patients is recognized but not well understood. This article reviews the literature regarding metabolic interactions, pathological pathways, and protocols for screening, monitoring, and using combination therapy for individuals with type 2 diabetes mellitus and common comorbid mental health conditions. Because primary care physicians manage patients with both mental and general medical illnesses, such as diabetes, understanding their perspectives on the challenges and facilitators of the care of these patients is critical to improving clinical outcomes. Although the relationship between type 2 diabetes mellitus and antipsychotic use by schizophrenia patients has been recognized, clinical guidelines for their treatment are not recent. Individuals with mental disorders present a vulnerable population with high medical needs that are often mistreated or missed. Given the significant contribution of metabolic syndrome and comorbid diabetes mellitus to morbidity and mortality of such patients, ongoing primary care should be coordinated between general practitioners and mental health professionals to prevent serious complications and adverse medication side effects.

The Obesity-Impulsivity Axis: Potential Metabolic Interventions in Chronic Psychiatric Patients

Pathological impulsivity is encountered in a broad range of psychiatric conditions and is thought to be a risk factor for aggression directed against oneself or others. Recently, a strong association was found between impulsivity and obesity which may explain the high prevalence of metabolic disorders in individuals with mental illness even in the absence of exposure to psychotropic drugs. As the overlapping neurobiology of impulsivity and obesity is being unraveled, the question asked louder and louder is whether they should be treated concomitantly. The treatment of obesity and metabolic dysregulations in chronic psychiatric patients is currently underutilized and often initiated late, making correction more difficult to achieve. Addressing obesity and metabolic dysfunction in a preventive manner may not only lower morbidity and mortality but also the excessive impulsivity, decreasing the risk for aggression. In this review, we take a look beyond psychopharmacological interventions and discuss dietary and physical therapy approaches.

Effect of comedication of bupropion and other antidepressants on body mass index

BACKGROUND

Weight gain as an adverse effect of monotherapy of antidepressant has been well-studied. The effects of augmentation therapy involving multiple antidepressants, on weight changes needs to be adequately addressed.

OBJECTIVE

To study the co-medication effects of bupropion in combination with six individual antidepressants on body mass index (BMI) using EMR based data analysis.

METHODS

Allscripts data warehouse was used to identify patients on monotherapy of five selective serotonin reuptake inhibitor (SSRI) drugs, escitalopram, sertraline, citalopram, paroxetine, fluoxetine, one selective norepinephrine reuptake inhibitor (SNRI) duloxetine and the aminoketone, bupropion for at least 180 days. We also identified patients on co-medication of SSRI/SNRI drugs with bupropion. Six ANCOVA models were built to compare the short term effects on BMI, among monotherapy and co-medication groups. The patients' clinical conditions and demographics were included to account for confounding effects.

RESULTS

Monotherapy of all the SSRI/SNRI drugs showed significant weight increase, consistent with that of previous studies. The co-medication of bupropion and escitalopram showed a significantly higher increase in BMI than monotherapy (P = 0.0102). The increase in BMI in the other five co-medication groups was not significantly different from their respective monotherapy groups.

CONCLUSION

Our study reports an adverse weight gain on co-medication of escitalopram and bupropion, which warrants further validation studies. Considering co-medication effects of antidepressants on weight is important to design robust depression treatment plans.

Weight Gain and Its Correlates Among Forensic Inpatients

OBJECTIVE

We investigated changes in weight, body mass index (BMI), and other indices of the metabolic syndrome in forensic inpatients. Weight gain associated with newer antipsychotics (APs) is well established in the general psychiatric population.

METHODS

We examined the medical records of 291 men admitted to a forensic hospital at admission and again at discharge or 365 days later if still in hospital. We also recorded diagnosis and smoker status on admission and quantified psychotropic treatment and adherence, physical activity, and daytime occupation during the hospitalization.

RESULTS

On admission, 33% were obese and 22% of the 106 patients for whom sufficient data were available met criteria for metabolic syndrome. Among patients staying at least 30 days, 60% were weighed again before discharge but repeated blood pressure and waist circumference measures were uncommon, even among those at greatest risk. The 122 forensic inpatients with sufficient information gained an average of 12% of their body weight and 40% increased by at least 1 BMI category, gaining an average of 3.67 kg per month. Weight gain was associated with duration of time and was not attributable to being underweight on admission, diagnosis of schizophrenia, atypical AP treatment, medication adherence, or having been a smoker.

CONCLUSIONS

Patients gained weight during forensic hospitalization independent of medication use. We recommend further research using consistent measurement and wider sampling of both metabolic syndrome indicators and its individual and systemic causes in forensic populations.