Diabetes mellitus and impaired glucose tolerance in patients with schizophrenia, before and after antipsychotic treatment

Prevalence and clinical correlates of impaired glucose tolerance in first-episode versus chronic patients with schizophrenia

AIM

Studies using oral glucose tolerance tests (OGTT) have shown that impaired glucose metabolism presents in the early stages of schizophrenia (SCZ). However, there is a lack of studies on changes in glucose metabolism with the stage of the disease. We first explored the features of glucose metabolic pattern at different phases of male SCZ.

METHODS

We recruited 83 male first episode drug-naïve patients with SCZ (FEDN-SCZ) and 64 male chronic patients with SCZ (CH-SCZ), as well as 14 male healthy controls. The Positive and Negative Syndrome Scale (PANSS) was used to assess the psychopathology of patients. OGTT, fasting plasma glucose and lipid profiles of all participants were examined.

RESULTS

While the impaired glucose tolerance (IGT) rate of male SCZ patients was higher than that of HC (P < .05), there was no difference in IGT prevalence between FEDN-SCZ and CH-SCZ. In male FEDN-SCZ, LDL (OR = 2.64, 95% CI = 1.11-6.29, P = .028) and PANSS total score (OR = 1.03, 95% CI = 1.00-1.06, P = .046) were positively correlated with IGT; in male CH-SCZ, BMI (OR = 1.7, 95% CI = 1.08-2.67, P = .023), PANSS total score (OR = 0.82, 95% CI = 0.70-0.96, P = .015) and positive symptoms (OR = 0.45, 95% CI = 0.20-0.99, P = .046) were significantly correlated with IGT.

CONCLUSIONS

Our findings reflect different glucose metabolism patterns in different stages of SCZ.

Abnormalities in Glucose Blood Level during Antipsychotic Treatment in Schizophrenia Patients

Background: Schizophrenia is one of the mental disorder with many problematic issues, in both psychologically and socially. This disease requires provision of long-term antipsychotic therapy, hence could rise other potential health problems. Antipsychotic treatment can cause serious glucometabolic side-effects, including type 2 diabetes and hyperglycemic emergency. Recent attention has also been focused on antipsychotic-induced hyperglycemic emergencies experienced by new users of typical and atypical antipsychotic. Patients treated with atypical APDs have ~10 times higher risk in developing hyperglycaemic emergencies. In our pre-eliminary study, hyperglycemia condition in new patients occurs in four  in seven patients who received typical and atypical antipsychotics. This condition is often overlooked and is not routinely evaluated. Moreover, it can develop into diabetes and increase the risk of morbidity and mortality in schizophrenia patients. In this study, we would like to determine the acute effects of metabolic (hyperglycemia) in patients treated with antipsychotic (Risperidone and Haloperidol) Measurement of blood sugar levels was performed in groups treated with haloperidol (N = 15) and treated with risperidone (N = 15). Plasma samples were taken at the beginning of treatment, in week IV, and in week VIII. The measurement of glucose levels was performed after meal and in early morning before breakfast (fasting blood glucose level 8 hours). Results: The blood sugar level after meals was significantly higher in the Risperidone group compared to the Haloperidol group  (p <0.001) after IV and VIII weeks. Meanwhile, the fasting blood sugar level was significantly higher in the Risperidone group compared to the Haloperidol group after VIII weeks of treatment ( p <0.001). Conclusions: Both antipsychotics can cause an increase in blood sugar levels. Treatment with Risperidone significantly increased the blood sugar levels compared to treatment with haloperidol. Measurement of blood sugar level is needed to monitor the metabolic effect of antipsychotic, especially in patients treated with Risperidone. It is necessary to have dietary regulation and physical activities to prevent undesired metabolic side effects.

Living beyond the limitation: Rehabilitation, life and productivity of individuals with schizophrenia in South-West Nigeria

INTRODUCTION

Schizophrenia, the most chronic and stigmatized form of mental illness, can be described as a brain disorder that affects an individual's cognition. Individuals with schizophrenia exhibit socially unacceptable symptoms that affect their psychosocial lives. They suffer from reduced productivity due to the debilitating effect of the illness, and the negative symptoms impede their employability; such symptoms and effects aggravate the stigma around mental illness. However, when rehabilitation is successfully achieved, so is productivity, and this decreases the associated stigma. Thus, this study describes the rehabilitation experiences and productivity of individuals with schizophrenia in South-West Nigeria.

METHODS AND ANALYSIS

A descriptive qualitative approach with semi-structured interviews was used to gather information from mental health service users. The discharged users in this study received in-hospital or outpatient rehabilitation care at four outpatient units within two specialist mental health-care facilities in South-West Nigeria. These facilities offer vocational training and rehabilitation services for individuals with schizophrenia. Twenty-nine mental health service users were interviewed. The data from the interviews were independently analysed by two researchers through a content analysis approach using NVIVO version 11. The researchers compared the results of the analysis and reached an agreement on the conclusion.

FINDINGS AND RECOMMENDATIONS

The rehabilitation services availed by patients in the research setting are of three types. Some attend occupational rehabilitation to learn a trade; they depend on professionals for the choice of skill but at a cost that is not affordable to many. Some stay in rehabilitation units linked to the hospital, rendering their services at a cost, and their living expenses and skill acquisition processes are based on the remuneration they get from the services rendered to the institution. Others depend on their family members' efforts to afford rehabilitation services but set up on job by family or employed in family business. The mental health service users in this study who offered their services to the institutions were able to make informed decisions and showed better performance with their chosen occupation than those who depended on their family or health professionals for the choice of rehabilitation service or vocational career. Therefore, this study concludes that prioritizing mental health facility users' preferences in terms of productive activities (sales, services, vocation) or rehabilitation goals should be encouraged.

Twelve-Weeks of Bench-Step Exercise Training Ameliorates Cardiopulmonary Fitness and Mood State in Patients with Schizophrenia: A Pilot Study

Background and objectives: Unhealthy, physically inactive lifestyles increase the risk of future cardiovascular events and impaired physical fitness in individuals with schizophrenia. Insufficient literature exists to provide fundamental information about appropriate exercise training modality for this population. This pilot study preliminarily investigated the effects of a 12-week moderate-intensity bench-step exercise training (BSET) program on cardiopulmonary fitness, mood state, and cognition in patients with schizophrenia. Methods: Twenty-eight patients with schizophrenia completed this study. The participants were allocated into either bench-step exercise-training (BSET; N = 14) or control (CTRL; N = 14) groups according to their preferences. The BSET group received a 12-week bench-step intervention, whereas the CTRL group did not participate in any training. The Beck Depression Inventory-II (BDI-II), 6-min walk test (6MWD), and Symbol Digit Modalities Test (SDMT) were assessed at baseline (PRE) and at the end of the intervention (POST) to determine mood state, endurance fitness, and attention, respectively. Results: After a 12-week BSET intervention, the 6MWD was significantly increased in the BSET (p = 0.007) but not in the CTRL (p > 0.05). The participants with BSET intervention showed a significant decrease in BDI-II at the end of the intervention (p = 0.03). However, SDMT scores were not different in both BSET and CTRL (p > 0.05). Conclusions: This study demonstrated that the 12-week intervention of moderate-intensity bench-step exercise training (frequency: 1 session/week; each session of 30 min; step cadence: 96 beats/min) might effectively enhance cardiopulmonary fitness and mood state in patients with schizophrenia. However, attention did not change after the bench-step exercise intervention.

Effect of Atypical Antipsychotic on Blood Pressure in Inpatients with Schizophrenia of Prof. Dr. Soerojo Mental Health Hospital Magelang

Context:

Schizophrenia ranks the top of all mental disorders with poor prognosis. Central Java Province is in the top five of schizophrenia incidents in Indonesia. Antipsychotic is the main therapy for schizophrenia, which is divided into 2, atypical and typical. The atypical antipsychotic is more preferable because of the minimal effect of the extrapyramidal syndrome but affects the blood pressure.

Aims:

To analyze the blood pressure of schizophrenia inpatients during the pre and post-use of atypical antipsychotics in RSJ Prof. Dr. Soerojo Magelang.

Settings and Design:

This study was an observational study with cohort retrospective methods.

Methods and Material:

The research was approved and reviewed by the committee of ethics and law of Prof. Dr. Soerojo Mental Hospital. The inclusion criteria are those diagnosed with schizophrenia based on Diagnostic and Statistical Manual of Mental Disorders-IV (DSM IV), aged about 17-55 years old, receiving antipsychotic atypical therapy for at least 3 months.The exclusion criteria are inpatients who also receive antidepressants and antihypertension, have a history of cardiovascular disease and hypertension, and incomplete medical records.

Statistical analysis used:

Wilcoxon, Mann-Whitney, and Kruskal-Wallis test.

Results:

The result of this study most of them were treated using combination risperidone and clozapine (82.1%). In this study, 43 inpatients experienced a decrease in systolic blood pressure, 57 in systolic blood pressure, 6 with no change in systolic blood pressure, 47 a decrease in diastolic blood pressure, 50 an increase in diastolic blood pressure, and 9 with no change in diastolic blood pressure.

Conclusions:

There was no significant difference in the blood pressure before and after the treatment.

A review of the bidirectional relationship between psychiatric disorders and diabetes mellitus

The prevalence of type 2 diabetes is rising worldwide, including Saudi Arabia. Among patients with diabetes, 30% suffer from mental disorders, such as depression, schizophrenia, delirium, and substance misuse (for example, tobacco smoking). Moreover, these disorders appear to share a bidirectional relationship with diabetes. For example, the incidence of diabetes has been shown to be 2-4 times greater in patients with schizophrenia than in normal individuals; also, there is a known association between depression and diabetes. In this review, we focus specifically on the bidirectional relationship between diabetes and psychiatric disorders, including the effects of antipsychotic drugs.

Glucose metabolism dysregulation at the onset of mental illness is not limited to first episode psychosis: A systematic review and meta-analysis

AIM

To compare the differences of glucose metabolism outcomes between treatment-naïve, patients with first episode psychosis (FEP) and mood disorders.

METHODS

We conducted a systematic review and meta-analysis of glucose intolerance in treatment-naïve, first episode patients with severe mental illnesses (SMIs).

RESULTS

We identified 31 eligible studies. Compared to healthy controls, FEP group have higher insulin and insulin resistance levels, and both groups have higher glucose tolerance test results. No significant differences were found in glucose metabolism outcomes between FEP and mood disorder groups.

CONCLUSIONS

Our results highlight impaired glucose metabolism at the onset of SMIs, suggesting both patients with psychosis and mood disorders are high-risk groups for diabetes development.

Differences of Fasting Blood Glucose Level in People with Schizophrenia between Before and After Getting Aripiprazole Treatment

BACKGROUND:

Schizophrenia is a serious disorder of the brain and mind. People with schizophrenia are at high risk of developing type diabetes, due to overall poor physical health, poor health care, unhealthy lifestyles, and side effects of antipsychotic drugs. However, atypical antipsychotics have their deficiencies, because they can be associated with worsening cardiovascular risk factors such as weight gain, hyperglycemia and hyperlipidemia.

AIM:

Difference in fasting blood glucose levels in people with schizophrenia between before and after receiving aripiprazole treatment.

METHODS:

This research was conducted in November 2017-September 2018. This research was first conducted in Indonesia, especially North Sumatra. This research is a numerical comparative analytical study paired with an experimental design approach. The number of samples is 44 people. Blood samples are taken in schizophrenia patients before getting the drug, before meals and before activities, assessed fasting blood glucose levels before being treated with aripiprazole and after drug administration for 6 weeks. Data analysis used was a paired test for differences in fasting blood glucose levels in people with schizophrenia between before and after receiving aripiprazole treatment.

RESULTS:

Based on the demographic characteristics found the research subjects based on the most age group were 31-40 years age group of 30 subjects (68.2%), based on the highest level of education was high school by 26 subjects (59.1%), based on the most marital status was by status not married for 24 subjects (54.5%). It was found that the average blood glucose level before being given aripiprazole in schizophrenic patients was 89.23 ± 7.13. It was found that the average blood glucose level after being given aripiprazole in schizophrenic patients was 86.5 ± 10.1. It was found that there were no differences in blood glucose levels before and after being given aripiprazole in schizophrenic patients

CONCLUSION:

There was no difference in blood glucose levels before and after being given aripiprazole in schizophrenic patients with p-value (0.078).

The Difference of Fasting Blood Sugar of Male Patients with Schizophrenia Treated with Flexible Dose between Aripiprazole and Risperidone in Medan, Indonesia

BACKGROUND:

Life expectancy among schizophrenic patients is 20% shorter than the general population. Currently, long-term use of antipsychotic drugs can induce metabolic symptoms, including weight gain, glucose intolerance, high blood glucose.

AIM:

This research aimed to investigate the fasting blood sugar level of a male patient with schizophrenia treated with flexible dose.

METHODS:

This research is an experimental study, unpaired numerical comparative analytic with non-probability consecutive sampling by recruiting 50 research subjects of men with male patients with schizophrenia. Every 25 people were treated with aripiprazole, and another 25 subjects were treated with risperidone. The flexible dose on how doses are equated with bioequivalent doses between aripiprazole and risperidone was applied. Sampling was carried out in the inpatient and outpatient clinic of the psychiatric hospital Prof. Dr M. Ildrem Medan, North Sumatra, Indonesia, in a span of 6 months from January 2018 to July 2018. The diagnostic test used a Mini structured interview system International Statistical Classification of Diseases-10 (Mini-ICD 10) and the statistical analysis was involving Mann Whitney U Test.

RESULTS:

This research showed the mean of fasting blood sugar level in week 8 in the group receiving treatment with aripiprazole was 88.96 with a standard deviation of 4.33 and in the group receiving risperidone treatment was 102.80 with a standard deviation of 2.92. The results of the analysis using unpaired t-test in the two groups showed a significant difference in fasting blood sugar levels for men with schizophrenia in the group receiving aripiprazole treatment and the group receiving risperidone treatment in week 8 with a value of p < 0.001 (p < 0.05).

CONCLUSION:

This research revealed that based on the equivalence of risperidone and aripiprazole dosage given to the male patients with schizophrenia, the treatment using risperidone can significantly increase the fasting blood sugar level compared to the aripiprazole treatment in week 8.

Antipsychotic Use During Pregnancy and the Risk of Gestational Diabetes Mellitus: A Systematic Review

PURPOSE

This study aimed to review the current literature examining a potential relationship between the use of antipsychotic drugs during pregnancy and gestational diabetes mellitus (GDM).

METHODS

PubMed was searched for English language reports between January 1, 1996, and March 31, 2018, by using combinations of the following key words: antipsychotics, pregnancy, FGAs, SGAs, GDM, obstetric outcomes, pregnancy outcomes, obstetric complications, maternal complications, clozapine, olanzapine, risperidone, aripiprazole, amisulpirde, ziprasidone, quetiapine, haloperidol, chlorpromazine, zuclopenthixol, and flupenthixol. Studies but not case reports, case series, or reviews published in a peer-reviewed journal were eligible for inclusion.

RESULTS

A total of 10 relevant studies that met the review criteria were examined. Data from these studies indicated that the prevalence rates of GDM in pregnant women using antipsychotic drugs and the nomedication group were 2.6% to 22% and 0.95% to 10.7%, respectively. Most comparative studies reported that antipsychotic treatment during pregnancy was not significantly associated with increased in risk of GDM. In addition, the study results also suggested that underlying maternal psychopathologies might affect the risk of GDM.

IMPLICATIONS

Findings from some studies suggesting a higher risk of GDM in pregnant women who were administered antipsychotic drugs were not confirmed by results of many other studies. The current evidence suggests no significant relationship between antipsychotic drugs, including second- and first-generation antipsychotics, and the risk of GDM.

Changes in Body Fat and Related Biochemical Parameters Associated With Atypical Antipsychotic Drug Treatment in Schizophrenia Patients With or Without Metabolic Syndrome

Background: Metabolic syndrome (MetS) is a common problem in schizophrenia patients and associated with increased mortality due to cardiovascular disease. Second-generation antipsychotics (SGAs) play an important role in facilitating MetS. Objective: The study aimed to assess weight changes and alterations of indicators of body fat composition and lipid-glucose metabolism induced by reinitiating atypical antipsychotics in patients with schizophrenia when with or without MetS. Methods: After giving informed consent, newly admitted patients with a clinical diagnosis of schizophrenia (ICD-10: F20) and an age between 18 and 55 years were included. MetS was diagnosed according to International Diabetes Federation (IDF) criteria. At entry and after 6 weeks of treatment, anthropometry and biochemical analysis were carried out. Total and visceral fats were measured with the use of non-invasive bioimpedance analysis and subcutaneous fat with calculation of total adipose tissue with the use of caliperometry. Based on biochemical assessments low density (LDL) and very low-density lipoproteins (VLDL), atherogenic index and Homeostatic Model Assessment of Insulin Resistance (IR-HOMA) were calculated. Statistical analysis was conducted using Wilcoxon signed-rank test, Mann-Whitney U-test, and chi-squared test. Differences were considered statistically significant at p < 0.05. Results: A total of 114 patients (59M/55F) with schizophrenia were examined; they were divided into two groups with (n = 43; 37.7%) and without (n = 71; 62.3%) MetS. After a 6-week SGA treatment, only the total fat fold, waist circumference, triglyceride level, and atherogenic index underwent statistically significant changes in patients with MetS. In those without MetS, statistically significant changes across all fat indicators were noted. Also, a significant increase in blood glucose and HOMA-IR parameters, triglyceride, and VLDL levels and atherogenic index was observed in this group. Discussion: The study illustrates the benefits of estimating both anthropometric and biochemical parameters shortly after (re)installing treatment of schizophrenia in order to minimize the risk of MetS development.

Antipsychotics and glucose metabolism: how brain and body collide

Since the serendipitous discovery of the first antipsychotic (AP) drug in the 1950s, APs remain the cornerstone of treatment for schizophrenia. A shift over the past two decades away from first-generation, conventional APs to so-called "atypical" (or 2nd/3rd generation) APs parallels acknowledgment of serious metabolic side-effects associated in particular with these newer agents. As will be reviewed, AP drugs and type 2 diabetes are now inextricably linked, contributing to the three- to fivefold increased risk of type 2 diabetes observed in schizophrenia. However, this association is not straightforward. Biological and lifestyle-related illness factors contribute to the association between type 2 diabetes and metabolic disease independently of AP treatment. In addition, APs have a well-established weight gain propensity which could also account for elevated risk of insulin resistance and type 2 diabetes. However, compelling preclinical and clinical evidence now suggests that these drugs can rapidly and directly influence pathways of glucose metabolism independently of weight gain and even in absence of psychiatric illness. Mechanisms of these direct effects remain poorly elucidated but may involve central and peripheral antagonism of neurotransmitters implicated not only in the therapeutic effects of APs but also in glucose homeostasis, possibly via effects on the autonomic nervous system. The clinical relevance of studying "direct" effects of these drugs on glucose metabolism is underscored by the widespread use of these medications, both on and off label, for a growing number of mental illnesses, extending safety concerns well beyond schizophrenia.

Prophylactic Use of Haloperidol and Changes in Glucose Levels in Hospitalized Older Patients

BACKGROUND

Treatment with antipsychotic drugs has been associated with glucose dysregulation in older outpatients, especially in the early stage of therapy. The underlying mechanism is, however, unclear. The aim of this study was to investigate changes in glucose levels during haloperidol use compared with the use of placebo among older hospitalized patients.

METHODS

This substudy was part of a larger multicenter, randomized, double blind, placebo-controlled clinical trial among hospitalized patients aged 70 years and older who had an increased risk of in-hospital delirium. Patients who were admitted to the Jeroen Bosch Hospital in 's-Hertogenbosch between June 2014 and February 2015 were invited to participate in the study. Participating patients were randomized for treatment and given 1 mg of haloperidol or a placebo twice daily for a maximum of 7 consecutive days (14 doses). Exclusion criteria for this substudy were the use of corticosteroids and changes in diabetes medication. Random blood samples to determine glucose levels were collected before day 1 and on day 6 of the study. Student independent sample t test was used to determine differences in glucose changes between both groups.

RESULTS

Twenty-nine patients were included (haloperidol, n = 14; placebo, n = 15). The mean glucose level for placebo users was 139.3 mg/dL (SD, 50.1) on day 1 and 140.8 mg/dL (SD, 45.7) on day 6, and the mean glucose level for haloperidol users was 139.9 mg/dL (SD, 71.0) on day 1 and 150.2 mg/dL (SD, 39.1) on day 6. The difference was not statistically significant (P = 0.685).

CONCLUSIONS

Short-term prophylactic use of haloperidol was not associated with changes in glucose levels in older hospitalized patients compared with those given a placebo in this small study.

Oral glucose tolerance test performance in olanzapine-treated schizophrenia-spectrum patients is predicted by BMI and triglycerides but not olanzapine dose or duration

OBJECTIVE

Olanzapine, an atypical antipsychotic, is associated with glucoregulatory abnormalities, but the nature of this link is not fully elucidated. This is the first olanzapine oral glucose tolerance test (oGTT) study to consider treatment dose and duration, and to compare complementary indices respectively assessing insulin sensitivity (Matsuda index) and resistance (homeostasis model assessment).

METHODS

Body mass index (BMI), body composition, plasma lipids, and oGTT were measured in olanzapine-treated nondiabetic patients with DSM-IV-TR diagnosis of schizophrenia or schizoaffective disorder (n = 35).

RESULTS

While only one previously undiagnosed participant met diabetes criteria based on fasting plasma glucose alone (≥126 mg/dL), seven were diagnosed with oGTT (2-hr plasma glucose ≥200 mg/dL). Multiple regression analyses revealed that the Matsuda index correlated with BMI (p < 0.0001) and plasma triglycerides (p = 0.01), but not with age, olanzapine dose, olanzapine treatment duration, or plasma cholesterol. Homeostasis model assessment and fasting plasma glucose correlated with triglycerides only (p < 0.0001 for both).

CONCLUSIONS

Our data suggest that BMI and triglycerides may be implicated in olanzapine-related glucoregulatory abnormalities. The lack of correlation between glucoregulatory abnormalities and olanzapine dose or treatment duration suggests preexisting metabolic disturbances and/or disturbances arising early in the course of treatment. Clinicians prescribing antipsychotics should consider oGTT, especially in patients with obesity and/or hypertriglyceridemia.

Risperidone and Cardiometabolic Risk in Children and Adolescents: Clinical and Instrumental Issues

PURPOSE/BACKGROUND

Although second-generation antipsychotics are used to treat and manage symptoms for several psychiatric disorders, data about their adverse effects in developmental age are limited. The aim of this prospective observational study was to verify the cardiovascular and metabolic risk in a sample of antipsychotic-naive children/adolescent patients starting risperidone therapy.

METHODS

Twenty-two patients, younger than 18 years, were recruited. The assessment included anthropometric data, cardiovascular parameters, blood tests, and ultrasonographic abdominal study.

RESULTS

After an average follow-up period of 7.6 months, statistically significant increases in mean values of waist circumference, body mass index (BMI), BMI percentile, BMI z score, total cholesterol, and prolactin were found. Other cardiometabolic parameters showed an upward trend in time. Subjects in pubertal/postpubertal stage and female patients were more susceptible to developing cardiometabolic changes. Moreover, significant correlations between changes in anthropometric and several metabolic parameters were found. A tendency to change in constitution of the liver parenchyma and distribution of the abdominal fat mass with ultrasonographic abdominal study was also evident.

CONCLUSIONS

In our sample, several metabolic parameters showed a sensitivity to risperidone treatment. Because most of these parameters are age dependent, metabolic syndrome criteria used for adults were inappropriate in children and adolescents. Periodic clinical and instrumental evaluations and guidelines for monitoring of any metabolic, laboratory, and instrumental complications are necessary in the perspective of even long-time second-generation antipsychotics treatment in children and adolescents.

Impaired Glucose Homeostasis in First-Episode Schizophrenia: A Systematic Review and Meta-analysis

IMPORTANCE

Schizophrenia is associated with an increased risk of type 2 diabetes. However, it is not clear whether schizophrenia confers an inherent risk for glucose dysregulation in the absence of the effects of chronic illness and long-term treatment.

OBJECTIVE

To conduct a meta-analysis examining whether individuals with first-episode schizophrenia already exhibit alterations in glucose homeostasis compared with controls.

DATA SOURCES

The EMBASE, MEDLINE, and PsycINFO databases were systematically searched for studies examining measures of glucose homeostasis in antipsychotic-naive individuals with first-episode schizophrenia compared with individuals serving as controls.

STUDY SELECTION

Case-control studies reporting on fasting plasma glucose levels, plasma glucose levels after an oral glucose tolerance test, fasting plasma insulin levels, insulin resistance, and hemoglobin A1c (HbA1c) levels in first-episode antipsychotic-naive individuals with first-episode schizophrenia compared with healthy individuals serving as controls. Two independent investigators selected the studies.

DATA EXTRACTION

Two independent investigators extracted study-level data for a random-effects meta-analysis. Standardized mean differences in fasting plasma glucose levels, plasma glucose levels after an oral glucose tolerance test, fasting plasma insulin levels, insulin resistance, and HbA1c levels were calculated. Sensitivity analyses examining the effect of body mass index, diet and exercise, race/ethnicity, and minimal (≤2 weeks) antipsychotic exposure were performed.

DATA SYNTHESIS

Of 3660 citations retrieved, 16 case-control studies comprising 15 samples met inclusion criteria. The overall sample included 731 patients and 614 controls. Fasting plasma glucose levels (Hedges g = 0.20; 95% CI, 0.02 to 0.38; P = .03), plasma glucose levels after an oral glucose tolerance test (Hedges g = 0.61; 95% CI, 0.16 to 1.05; P = .007), fasting plasma insulin levels (Hedges g = 0.41; 95% CI, 0.09 to 0.72; P = .01), and insulin resistance (homeostatic model assessment of insulin resistance) (Hedges g = 0.35; 95% CI, 0.14 to 0.55; P = .001) were all significantly elevated in patients compared with controls. However, HbA1c levels (Hedges g = -0.08; CI, -0.34 to 0.18; P = .55) were not altered in patients compared with controls.

CONCLUSIONS AND RELEVANCE

These findings show that glucose homeostasis is altered from illness onset in schizophrenia, indicating that patients are at increased risk of diabetes as a result. This finding has implications for the monitoring and treatment choice for patients with schizophrenia.

Meta-analysis of glucose tolerance, insulin, and insulin resistance in antipsychotic-naïve patients with nonaffective psychosis

BACKGROUND

Some studies have suggested that antipsychotic-naïve patients with nonaffective psychosis (NAP) have glucose intolerance.

AIMS

To conduct a systematic review and meta-analysis of fasting glucose (FG), two hour values in the oral glucose tolerance test (2HG), fasting insulin concentration (INS), and insulin resistance (IR).

METHOD

We identified possibly relevant studies, then selected studies, following usual guidelines, with two authors reviewing the manuscripts. We required studies to include subjects with nonaffective psychosis and control subjects.

RESULTS

There were 911 patients and 870 control subjects in the analysis of FG; their average ages were respectively 28.7 and 29.5years. Significant differences were found for all four variables, with effect size estimates ranging from 0.21 to 0.58.

CONCLUSIONS

As a group, at the time of first clinical contact for psychosis, people with NAP have a slight increase in FG, which most of them maintain in the normal range despite a small increase in IR by secreting additional INS. When faced with a physiological challenge such as a glucose tolerance test or antipsychotics, they are no longer able to maintain a normal glucose concentration.

Artesunate prevents rats from the clozapine-induced hepatic steatosis and elevation in plasma triglycerides

Clozapine is an atypical antipsychotic with therapeutic efficacy in treatment-resistant schizophrenia patients and low incidence of extrapyramidal side effects. However, the use of clozapine has been limited by its adverse effects on metabolism. Artesunate is a semisynthetic derivative of artemisinin and was shown to decrease the plasma cholesterol and triglyceride in rabbits and rats in recent studies. The aim of this study was to examine possible effects of artesunate on the clozapine-induced metabolic alterations in rats given saline, clozapine, artesunate, or clozapine plus artesunate for 6 weeks. The clozapine group showed significantly high plasma levels of triglyceride, hepatic steatosis, and fibrosis along with high levels of C-reactive protein, alanine aminotransferase, and aspartate aminotransferase compared to the saline group. But the treatment had no effect on weight gain and caused no hyperglycemia, hyperinsulinemia, and behavioral changes in the rats. More significantly, these clozapine-induced changes were not seen in rats coadministered with clozapine plus artesunate. These results added evidence supporting psychiatrists to try add-on treatment of artesunate in schizophrenia patients to ameliorate clozapine-induced adverse metabolic effects.

The association between first-episode psychosis and abnormal glycaemic control: systematic review and meta-analysis

BACKGROUND

Schizophrenia might share intrinsic inflammatory disease pathways with type 2 diabetes. We aimed to assess whether first-episode psychosis, which could be described as developing schizophrenia, is associated with prediabetic markers, or developing diabetes, to determine whether intrinsic disease links could cause the disorders to develop in unison. We hypothesised that biochemical measures of prediabetic states would be more common in antipsychotic naive patients with first-episode psychosis than in healthy matched controls.

METHODS

For this systematic review and meta-analysis, using PRISMA criteria, we searched Embase, MEDLINE, PsycINFO, Web of Science, and Google Scholar for clinical studies published between database inception and Jan 6, 2016. We assessed case-control studies with biochemical assessment of prediabetic states in patients with first-episode psychosis alongside matched controls. We sought data at the summary estimate level. Several measurements were used to test for prediabetes, including fasting plasma glucose, insulin resistance (measured by the Homeostatic Model Assessment), and impaired glucose tolerance. We calculated standardised mean differences for each outcome. We used the inverse variance method, for which the weight given to each study was the inverse of the variance of the effect estimate. For dichotomous outcomes, we entered the number of events and number in each group into RevMan 5.3 and used the Mantel-Haenszel method to pool studies.

FINDINGS

We identified 1436 studies, of which 12 were included in final analysis, including 1137 participants. Pooled analyses found first-episode psychosis to be related to insulin resistance (mean difference 0·30 [95% CI 0·18 to 0·42]), impaired glucose tolerance (mean difference 1·31 [0·37 to 2·25]), and the number of patients with impaired glucose tolerance (odds ratio 5·44 [2·63 to 11·27]), but not fasting plasma glucose (mean difference 0·03 mmol/L [-0·04 to 0·09]).

INTERPRETATION

Our findings suggest a potential link between prediabetic markers, in particular impaired glucose tolerance and insulin resistance, and first-episode psychosis. However, we cannot establish causality, and the studies contributing to this review were at some risk of bias. Nevertheless, the findings might help to explain the increased prevalence of type 2 diabetes in patients with schizophrenia and could have implications for the management of patients with schizophrenia.

FUNDING

None.

Indian psychiatric society multicentric study: Correlates of prescription patterns of psychotropics in India

BACKGROUND

There is a lack of information on the clinical and sociodemographic correlates of prescription of psychotropics by psychiatrists.

AIM AND OBJECTIVE

This study aimed to evaluate the relationship of prescription patterns with various clinical and sociodemographic variables.

METHODOLOGY

Data of prescription patterns, psychiatric diagnosis, sociodemographic variables, and comorbid physical illnesses were collected for 4480 patients, across 11 centers.

RESULTS

Females are more often prescribed escitalopram, sertraline, amitriptyline, amisulpride, nonlithium mood stabilizers, and benzodiazepines, whereas males are more often prescribed fluoxetine, olanzapine, two antipsychotics concurrently, typical antipsychotics, valproate, lithium, and more than one benzodiazepine. Elderly (>65 years) participants are more often prescribed sertraline when compared to adolescents. In addition, elderly more often receive quetiapine and less often are prescribed benzodiazepines. Those with comorbid neurological disorders are commonly prescribed antipsychotics, amitriptyline, and more than one antidepressant and are less commonly prescribed lithium, combination of two mood stabilizers, and benzodiazepines. Those with cardiac ailments are more commonly prescribed sertraline, quetiapine, and lithium and less frequently prescribed amitriptyline, fluoxetine, olanzapine, risperidone, and typical antipsychotics. Those with diabetes mellitus more often received escitalopram and quetiapine. Presence of more than one psychiatric diagnosis was associated with the use of more number of medications. Further, diagnosis of affective disorders was associated with the use of a higher number of medications.

CONCLUSION

Findings of the present study suggest that sociodemographic variables and physical and psychiatric comorbidity influence the prescription patterns of psychotropics.

Detecting and Managing Adverse Effects of Antipsychotic Medications: Current State of Play

Antipsychotics are some of the most frequently prescribed medications not only for psychotic disorders and symptoms but also for a wide range of on-label and off-label indications. Because second-generation antipsychotics have largely replaced first-generation antipsychotics as first-line options due to their substantially decreased risk of extrapyramidal side effects, attention has shifted to other clinically concerning adverse events associated with antipsychotic therapy. The focus of this article is to update the nonextrapyramidal side effects associated with second-generation antipsychotics. Issues surrounding diagnosis and monitoring as well as clinical management are addressed.

Reliability and validity of 6MWT for outpatients with schizophrenia: A preliminary study

Although the 6-minute walk test (6MWT) has been widely used in patients with schizophrenia, there is a lack of scientific evidence about its reliability and validity in this population. The first goal of this study was to explore the test-retest reliability of the 6MWT and to identify the associated parameters that contribute to the variability of the distance walked during the 6MWT in outpatients with schizophrenia. The second goal was to assess the criterion validity of the 6MWT in men with schizophrenia. Fifty one outpatients with schizophrenia participated in the study. To test-retest reliability (men=39; women=12), participants performed the 6MWT twice within 3 days interval. To test criterion validity (men=13), peak oxygen uptake (VO2peak) was measured on a treadmill. For the associated parameters with the distance walked (n=51), medications use, smoking behavior, body and bone composition, and physical activity levels were analyzed. No significant differences between the means of the two 6MWTs were found. The intraclass correlation coefficient was 0.94 indicating good reliability. 6MWT correlated significantly with VO2peak (r=0.67) indicating criterion validity. Height, body fat mass, smoking behavior and minutes of PA/week were significantly associated with the 6MWT. Results suggest that 6MWT shows good reliability for individuals with schizophrenia and good validity for the small sample of male participants in this study.

Metabolic syndrome and obesity among users of second generation antipsychotics: A global challenge for modern psychopharmacology

Second generation antipsychotics (SGAs), such as clozapine, olanzapine, risperidone and quetiapine, are among the most effective therapies to stabilize symptoms schizophrenia (SZ) spectrum disorders. In fact, clozapine, olanzapine and risperidone have improved the quality of life of billions SZ patients worldwide. Based on the broad spectrum of efficacy and low risk of extrapyramidal symptoms displayed by SGAs, some regulatory agencies approved the use of SGAs in non-schizophrenic adults, children and adolescents suffering from a range of neuropsychiatric disorders. However, increasing number of reports have shown that SGAs are strongly associated with accelerated weight gain, insulin resistance, diabetes, dyslipidemia, and increased cardiovascular risk. These metabolic alterations can develop in as short as six months after the initiation of pharmacotherapy, which is now a controversial fact in public disclosure. Although the percentage of schizophrenic patients, the main target group of SGAs, is estimated in only 1% of the population, during the past ten years there was an exponential increase in the number of SGAs users, including millions of non-SZ patients. The scientific bases of SGAs metabolic side effects are not yet elucidated, but the evidence shows that the activation of transcriptional factor SRBP1c, the D1/D2 dopamine, GABA2 and 5HT neurotransmitions are implicated in the SGAs cardiovascular toxicity. Polypharmacological interventions are either non- or modestly effective in maintaining low cardiovascular risk in SGAs users. In this review we critically discuss the clinical and molecular evidence on metabolic alterations induced by SGAs, the evidence on the efficacy of classical antidiabetic drugs and the emerging concept of antidiabetic polyphenols as potential coadjutants in SGA-induced metabolic disorders.