Guidelines for screening and monitoring of cardiometabolic risk in schizophrenia: systematic evaluation

Cardiovascular and cerebrovascular risk factors and events associated with second-generation antipsychotic compared to antidepressant use in a non-elderly adult sample: results from a claims-based inception cohort study

This is a study of the metabolic and distal cardiovascular/cerebrovascular outcomes associated with the use of second-generation antipsychotics (SGAs) compared to antidepressants (ADs) in adults aged 18-65 years, based on data from Thomson Reuters MarketScan® Research Databases 2006-2010, a commercial U.S. claims database. Interventions included clinicians' choice treatment with SGAs (allowing any comedications) versus ADs (not allowing SGAs). The primary outcomes of interest were time to inpatient or outpatient claims for the following diagnoses within one year of SGA or AD discontinuation: hypertension, ischemic and hypertensive heart disease, cerebrovascular disease, diabetes mellitus, hyperlipidemia, and obesity. Secondary outcomes included the same diagnoses at last follow-up time point, i.e., not censoring observations at 365 days after SGA or AD discontinuation. Cox regression models, adjusted for age, gender, diagnosis of schizophrenia and mood disorders, and number of medical comorbidities, were run. Among 284,234 individuals, those within one year of exposure to SGAs versus ADs showed a higher risk of essential hypertension (adjusted hazard ratio, AHR=1.16, 95% CI: 1.12-1.21, p<0.0001), diabetes mellitus (AHR=1.43, CI: 1.33-1.53, p<0.0001), hypertensive heart disease (AHR=1.34, CI: 1.10-1.63, p<0.01), stroke (AHR=1.46, CI: 1.22-1.75, p<0.0001), coronary artery disease (AHR=1.17, CI: 1.05-1.30, p<0.01), and hyperlipidemia (AHR=1.12, CI: 1.07-1.17, p<0.0001). Unrestricted follow-up results were consistent with within one-year post-exposure results. Increased risk for stroke with SGAs has previously only been demonstrated in elderly patients, usually with dementia. This study documents, for the first time, a significantly increased risk for stroke and coronary artery disease in a non-elderly adult sample with SGA use. We also confirm a significant risk for adverse metabolic outcomes. These findings raise concerns about the longer-term safety of SGAs, given their widespread and chronic use.

Reliability and clinical correlates of the Astrand-Rhyming sub-maximal exercise test in patients with schizophrenia or schizoaffective disorder

Cardiovascular fitness is reduced in people with schizophrenia and is related to an increased morbidity and mortality. There is mounting interest in the accurate measurement of cardiovascular fitness in schizophrenia, yet existing measures used in the general population have not been tested on validity and reliability in this high-risk group. Therefore, we examined the reproducibility and feasibility of the Astrand-Rhyming sub-maximal exercise test in patients with schizophrenia or schizoaffective disorder. Secondary aims were to assess minimal detectable changes, practice effects and the presence of clinical symptoms that are associated with cardio-respiratory fitness (expressed as estimated oxygen uptake). From 47 patients with schizophrenia or schizoaffective disorder two trials of the Astrand-Rhyming test, administered within three days, were analysed. The intraclass correlation coefficient for the estimated oxygen uptake between the two tests was 0.92 (95% confidence interval: 0.85-0.95). The minimal detectable change was 6.5mlO2/min/kg. No practice effect could be detected. A backward regression analysis demonstrated that illness duration, negative symptoms and level of physical activity explained 63.0% of the variance in estimated oxygen uptake. The current study demonstrates that the Astrand-Rhyming test can be recommended for evaluating the aerobic fitness in patients with schizophrenia or schizoaffective disorder.

Assessing metabolic syndrome in people with ID (intellectual disabilities) on antipsychotic medication

Aims To identify whether clinical information routinely collected and recorded on clinical files is available for the identification of metabolic syndrome and to assess the prevalence of risk factors for the syndrome in a sample of people with intellectual disabilities (ID) and mental illness treated with antipsychotic medication.

METHODS

A retrospective analysis was performed for 76 adults with ID and comorbid mental illness, for whom treatment with antipsychotic medication was established. Statistical analysis was performed using SPSS 16.0. The Student t-test for parametric data and χ 2-test for non-parametrical data were used.

RESULTS

Five of the six criteria for metabolic syndrome were available in all or a high proportion of the files, however no measurement for waist circumference was recorded in any of the files. Aripiprazole appears to be the least risky antipsychotic for metabolic syndrome.

CONCLUSION

It is important to develop a systematic protocol to record diagnostic variables for metabolic syndrome in at risk populations such as those with ID and mental illness treated with regular antipsychotics.

The prevalence and moderators of clinical pain in people with schizophrenia: a systematic review and large scale meta-analysis

BACKGROUND

People with schizophrenia frequently have physical comorbidities that can cause pain. Experimental studies report reduced pain sensitivity among schizophrenia patients, but it remains unclear if clinically relevant pain is less prevalent in schizophrenia.

METHOD

We systematically searched major electronic databases from inception till 03/2014. Articles were included that reported the prevalence of clinical pain in people with schizophrenia. Two independent authors conducted searches, completed methodological quality assessment and extracted data. A random effects relative risks (RR) meta-analysis was conducted to determine the prevalence of all-cause and specific pain in schizophrenia, and the relative prevalence compared to the general population, and to assess moderators.

RESULTS

Altogether, 14 studies were included encompassing 242,703 individuals with schizophrenia (30.2-55.8 years) and 4,259,221 controls. Different types of pain were considered. The overall pooled prevalence of clinical pain in people with schizophrenia was 34.7% (95% CI=23.6-46.6). In the comparative analysis involving 7 studies with controls, the RR was 0.99 (95% CI=0.83-1.19). The pooled prevalence of headache among 94,043 individuals with schizophrenia was 29.9% (95% CI=3-69%) and the RR compared to 4,248,284 controls was 1.32 (95% CI=0.85-2.07). In moderator analyses, neither age, sex, study quality or pain assessment method influenced pain prevalence.

CONCLUSION

Clinical pain affects a third of people with schizophrenia and levels are similar with age- and sex-comparable controls. Future research is needed to determine if similar clinical pain prevalences in schizophrenia occur despite having more painful conditions, resulting from under-reporting, higher pain thresholds or lower help seeking behaviours.

Adherence to guidelines for glucose assessment in starting second-generation antipsychotics

OBJECTIVES

In 2003, the US Food and Drug Administration issued warnings about hyperglycemia and diabetes with second-generation antipsychotics (SGAs); guidelines have recommended metabolic screening since 2004. However, little is known of contemporary practices of glucose screening among youth initiating SGAs. Our objective was to evaluate baseline glucose assessment among youth in the Mini-Sentinel Distributed Database starting an SGA.

METHODS

The cohort included youth ages 2 through 18 newly initiating SGAs January 1, 2006, through December 31, 2011, across 10 sites. Baseline glucose was defined as fasting/random glucose or hemoglobin A1c (GLU) measurement occurring relative to first SGA dispensing. Differences in GLU assessment were evaluated with χ(2) tests and logistic regression.

RESULTS

The cohort included 16,304 youth; 60% boys; mean age 12.8 years. Risperidone was most commonly started (43%). Eleven percent (n = 1858) had GLU assessed between 90 days before and 3 days after first dispensing. Assessment varied across SGAs (olanzapine highest), sites (integrated health care systems higher), ages (16-18 highest), years (2007 highest), and gender (female higher; all P < .001). GLU assessment among those starting olanzapine was more likely than among those starting quetiapine (odds ratio [OR]: 1.72 [95% confidence interval (CI): 1.37-2.18]), aripiprazole (OR: 1.49 [95% CI: 1.18-1.87]), or risperidone (OR: 1.61 [95% CI: 1.28-2.03]).

CONCLUSIONS

Few children and adolescents starting SGA have baseline glucose assessed. This is concerning because those at high diabetes risk may not be identified. Further, lack of screening impedes determining the contribution of SGAs to hyperglycemia development.

A systematic review of controlled interventions to reduce overweight and obesity in people with schizophrenia

OBJECTIVE

Overweight and obesity are generally found among patients with schizophrenia. This may lead to serious implications for health and wellbeing. The aim was to review controlled intervention studies on reducing overweight/obesity and/or reducing physical illness in patients with schizophrenia.

METHOD

A systematic literature search was carried out in the bibliographic databases PubMed (MEDLINE), Embase (Ovid), PsycInfo (Ovid) and Cinahl (Ebsco). We included all randomised and non-randomised clinically controlled studies that compared a non-pharmacological intervention, aimed at weight reduction and/or reducing physical illness, with standard care for patients with schizophrenia.

RESULTS

All 1713 references were evaluated for inclusion in the review. Twenty-three met the inclusion criteria and were categorised into four subgroups according to tested interventions: diet, exercise and cognitive behavioural therapy, or mixed combinations of the three. In this review, interventions showed efficacy in reducing weight and improving physical health parameters confirming that physical health improvement was possible in patients with schizophrenia.

CONCLUSION

The included studies indicate that the interventions reduced weight and improved physical health parameters in patients with schizophrenia.

Improving the physical health of long-term psychiatric inpatients

BACKGROUND

Patients with psychiatric illness have increased somatic morbidity and increased mortality. Knowledge of how to integrate the prevention and care of somatic illness into the treatment of psychiatric patients is required. The aims of this study were to investigate whether an intervention programme to improve physical health is effective.

METHODS

An extension of the European Network for Promoting the Health of Residents in Psychiatric and Social Care Institutions (HELPS) project further developed as a 12-month controlled cluster-randomized intervention study in the Danish centre. Waist circumference was a proxy of unhealthy body fat in view of the increased risk of cardiovascular diseases and type 2 diabetes.

RESULTS

Waist circumference was 108 cm for men and 108 cm for women. Controlled for cluster randomization, sex, age, and body fat, the intervention group showed a small, but not significant, reduction in waist circumference, while participants in the control group showed a significant increase in waist circumference.

CONCLUSIONS

The intervention had a positive effect on the physical health of the patients measured by a reduction in the increase of waist circumference.

Very low rates of screening for metabolic syndrome among patients with severe mental illness in Durban, South Africa

BACKGROUND

Sub Saharan African is experiencing the largest increase in the prevalence of type 2 diabetes mellitus and cardiovascular disease globally. Metabolic syndrome (MetS) is a cluster of risk factors for these conditions. There is a consistently higher prevalence of cardiometabolic disease among individuals with severe mental illness (SMI) compared to the general population worldwide. However, it is known from research in high income countries that screening for MetS in patients with SMI is low. The objective of this study was to document the extent of the expected low frequency of testing for all the components of the metabolic syndrome (MetS) in patients with SMI in a low middle income country.

METHODS

This was a cross sectional study, undertaken from January to June 2012 on out-patients with SMI who were treated with antipsychotic medication for at least 6 months. The study measured the proportion of participants who were tested for MetS in the previous year.

RESULTS

The study included 331 (M: F; 167:164) participants with a mean age of 35.2 ± 11.98 years. The majority (78.8%) were black South Africans. Only 2 subjects (0.6%) were screened for all five components of MetS. Regarding the individual components, 99%, 0.6%, 3.9% and 1.8% were screened for raised blood pressure, abdominal obesity, hyperglycaemia, hypertriglyceridaemia and decreased high density lipoprotein cholesterol respectively.

CONCLUSION

It is unacceptable that less than one percent of our participants were adequately screened for modifiable risk factors for type 2 diabetes mellitus and cardiovascular disease which are the most common causes of mortality among patients with SMI. These results highlight the need for translating guidelines into action in low and middle income countries.

Discontinuation of somatic medication during psychiatric hospitalization

BACKGROUND

Psychiatric hospitalization can increase the risk of discontinuation of pharmacotherapy, which may negatively influence patients' health.

OBJECTIVE

To investigate the association between psychiatric hospitalization and discontinuation of somatic medication.

METHODS

A retrospective crossover study was performed in patients admitted to a psychiatric hospital (index date), who had got somatic medication dispensed during the 3 months prior to hospitalization. Discontinuation of somatic medication was investigated at the following time points: index date and 3, 6, and 9 months before the index date. Relative risks (RR) with 95% confidence intervals (95% CIs) of discontinuing somatic medication at the index date versus the time points before the index date were estimated using Cox regression.

RESULTS

In all, 471 hospitalized patients were included in the study; 38.9% of the patients were discontinuers on the index date. RR for discontinuation of ≥1 somatic medication was 1.88 (95% CI=1.55-2.27) at the index date compared with the other time points and highest for patients<45 years (RR=2.83; 95% CI=1.92-4.18).

CONCLUSIONS

Psychiatric hospitalization was associated with an almost doubled risk of discontinuation of somatic medication. Future studies should address the influence of discontinuation of care on patients' health.

Metabolic syndrome and metabolic abnormalities in patients with major depressive disorder: a meta-analysis of prevalences and moderating variables

BACKGROUND

Individuals with depression have an elevated risk of cardiovascular disease (CVD) and metabolic syndrome (MetS) is an important risk factor for CVD. We aimed to clarify the prevalence and correlates of MetS in persons with robustly defined major depressive disorder (MDD).

METHOD

We searched Medline, PsycINFO, EMBASE and CINAHL up until June 2013 for studies reporting MetS prevalences in individuals with MDD. Medical subject headings 'metabolic' OR 'diabetes' or 'cardiovascular' or 'blood pressure' or 'glucose' or 'lipid' AND 'depression' OR 'depressive' were used in the title, abstract or index term fields. Manual searches were conducted using reference lists from identified articles.

RESULTS

The initial electronic database search resulted in 91 valid hits. From candidate publications following exclusions, our search generated 18 studies with interview-defined depression (n = 5531, 38.9% male, mean age = 45.5 years). The overall proportion with MetS was 30.5% [95% confidence interval (CI) 26.3-35.1] using any standardized MetS criteria. Compared with age- and gender-matched control groups, individuals with MDD had a higher MetS prevalence [odds ratio (OR) 1.54, 95% CI 1.21-1.97, p = 0.001]. They also had a higher risk for hyperglycemia (OR 1.33, 95% CI 1.03-1.73, p = 0.03) and hypertriglyceridemia (OR 1.17, 95% CI 1.04-1.30, p = 0.008). Antipsychotic use (p < 0.05) significantly explained higher MetS prevalence estimates in MDD. Differences in MetS prevalences were not moderated by age, gender, geographical area, smoking, antidepressant use, presence of psychiatric co-morbidity, and median year of data collection.

CONCLUSIONS

The present findings strongly indicate that persons with MDD are a high-risk group for MetS and related cardiovascular morbidity and mortality. MetS risk may be highest in those prescribed antipsychotics.

Psychotic disorder is an independent risk factor for increased fasting glucose and waist circumference

BACKGROUND

Psychosis is associated with excess cardiovascular morbidity and mortality.

AIMS

To determine the prevalence of cardiovascular risk factors in patients with psychotic disorders compared with the population.

METHODS

731 consecutive patients with psychosis recruited from psychiatric outpatient clinics in Stockholm County, Sweden, were compared with 5580 individuals from a population study performed in the same area. The main outcome measures were waist circumference, body mass index (BMI) and fasting glucose.

RESULTS

Mean waist circumference in patients vs. controls was for males 106 and 94 cm, respectively, and for females 97 and 85 cm, respectively (P < 0.001); mean fasting glucose in patients vs. controls was for males 5.8 and 5.2 mmol/l, respectively, and for females 5.6 and 4.8 mmol/l, respectively (P < 0.001). Comparisons were controlled for differences in age and family history of diabetes. Increased waist circumference was more common in psychotic patients compared with controls (OR = 3.99; 95% CI 3.09-5.15), controlling for fasting insulin, differences in gender, blood pressure, fasting glucose, family history of diabetes, age and tobacco use. Increased fasting blood glucose was also more common in psychotic patients (OR = 2.41; 95% CI 1.84-3.14) controlling for the same factors with the exception of fasting glucose and with the addition of increased waist circumference.

CONCLUSION

Our study shows that the psychosis illness per se can be considered as a cardiovascular risk factor, independent of the traditional risk factors such as age and smoking.

National trends in second-generation antipsychotic augmentation for nonpsychotic depression

OBJECTIVE

This study estimates national trends and patterns in use of second-generation antipsychotics (SGAs) for adjunctive treatment of nonpsychotic adult depression in office-based practice.

METHOD

Twelve consecutive years (1999-2010) of the National Ambulatory Medical Care Survey were analyzed to estimate trends and patterns of adjunctive SGA treatment for adult (≥ 18 years) nonpsychotic depression in office-based visits. Adjunctive SGA use was examined among all office visits in which depression was diagnosed (N = 7,767), excluding visits with diagnoses for alternative SGA indications (schizophrenia, bipolar disorder, pervasive development disorder, psychotic depression, dementia) and those without an active antidepressant prescription.

RESULTS

From 1999 to 2010, 8.6% of adult depression visits included an SGA. SGA use rates increased from 4.6% in 1999-2000 to 12.5% in 2009-2010, with an adjusted odds ratio (AOR) for time trend of 2.78 (95% CI, 1.84-4.20). The increase in SGA augmentation was broad-based, with no significant differences in time trends between demographic and clinical subgroups. For the most recent survey years (2005-2010), SGA use rates were higher in visits to psychiatrists than to other physicians (AOR = 5.08; 95% CI, 2.96-8.73), visits covered by public than private insurance (AOR = 3.20; 95% CI, 2.25-4.54), visits with diagnosed major depressive disorder than other depressive disorders (AOR = 1.49; 95% CI, 1.08-2.06), and visits with diabetes, hyperlipidemia, or cardiovascular disease (AOR = 2.13; 95% CI, 1.12-4.03) and lower in visits by patients > 65 years than 18-44 years (AOR = 0.51; 95% CI, 0.32-0.82) and visits that included psychotherapy (AOR = 0.68; 95% CI, 0.47-0.96).

CONCLUSIONS

Between 1999 and 2010, SGAs were increasingly accepted in the outpatient treatment of adult nonpsychotic depression.

Understanding the problems developing a healthy living programme in patients with serious mental illness: a qualitative study

BACKGROUND

People with serious mental illness are at an increased risk of physical ill health. Mortality rates are around twice those of the general population with higher levels of cardiovascular disease, metabolic disease, diabetes, and respiratory illness. Although genetics may have a role in the physical health problems of these patients, lifestyle and environmental factors such as smoking, obesity, poor diet, and low levels of physical activity play a prominent part.

METHODS

A qualitative grounded theory approach was used to understand the problems experienced by these individuals when asked to attend a healthy living programme. Three main areas were explored: the influence of potential barriers, health problems, and general attitudes towards healthy living.

RESULTS

Thirteen patients were interviewed during the study. Many did not recall receiving an initial invitation letter to the programme. Several believed that there was no necessity to attend as they had already had recent routine health checks by their general practitioner. The patients' current level of mental and physical health was important with symptoms such as depression, anxiety or arthritis affecting interest in the programme. Patients described that they found smoking enjoyable or calming in its effect. Dietary intake was determined by taste or gaining pleasure in eating certain types of food. Several lessons were learnt during this research that may aid future research and practice. Participation seemed to be better if the approach was first made by the patient's own community keyworker. This contact may have provided a greater opportunity to explain the purpose and importance of the programme. Alternative appointments should be considered when certain patients are in better physical and mental health. Healthy living programmes need to be flexible and adaptive to individual patient needs. Assistance from their community worker may help engagement. Simple measures may improve participation and reduce potential barriers.

CONCLUSION

These findings highlighted some of the problems encountered by patients when attempting to participate in a healthy living programme. These results may be useful when implementing future healthy living interventions for patients with serious mental disorders.

Assessment of arterial stiffness among schizophrenia-spectrum disorders using aortic pulse wave velocity and arterial compliance: a pilot study

Cardiovascular disease (CVD) is the leading cause of death in individuals with chronic schizophrenia. Arterial stiffness provides a non-invasive indication of cardiovascular disease risk. To date, arterial stiffness, which has been shown to have independent predictive value for CVD morbidity and mortality, has not been evaluated in this population. We aimed to examine aortic pulse wave velocity (aPWV) as well as large and small artery compliance (Comp1 and Comp2) in patients being treated for schizophrenia, compared to healthy volunteers. Ten patients and 10 age and gendermatched volunteers underwent a comprehensive evaluation of arterial stiffness including: aPWV, Comp1, Comp2, stroke volume, cardiac output, and systemic vascular resistance. Patient aPWV was significantly elevated compared to healthy volunteers (9.1 ± 4.11 vs. 5.7 ± 1.4, P=0.03). Increased age, blood pressure, heart rate, and cigarettes/day were associated with reduced arterial health in patients. This is the first time aPWV has been described in those treated for schizophrenia. Arterial stiffness is increased in this population. Measuring arterial stiffness is a non-invasive, sensitive and effective tool for evaluating CVD risk in this population.

EPA Guidance on Tobacco Dependence and Strategies for Smoking Cessation in People with Mental Illness

Tobacco dependence is the most common substance use disorder in adults with mental illness. The prevalence rates for tobacco dependence are two to four times higher in these patients than in the general population. Smoking has a strong, negative influence on the life expectancy and quality of life of mental health patients, and remains the leading preventable cause of death in this group. Despite these statistics, in some countries smokers with mental illness are disadvantaged in receiving intervention and support for their tobacco dependence, which is often overlooked or even tolerated. This statement from the European Psychiatric Association (EPA) systematically reviews the current evidence on tobacco dependence and withdrawal in patients with mental illness and their treatment. It provides seven recommendations for the core components of diagnostics and treatment in this patient group. These recommendations concern: (1) the recording process, (2) the timing of the intervention, (3) counselling specificities, (4) proposed treatments, (5) frequency of contact after stopping, (6) follow-up visits and (7) relapse prevention. They aim to help clinicians improve the care, health and well-being of patients suffering from mental illness.

Associations of oxidative stress status parameters with traditional cardiovascular disease risk factors in patients with schizophrenia

BACKGROUND

The purpose of this study was to assess oxidative stress status parameters and their possible associations with traditional cardiovascular risk factors in patients with schizophrenia, as well as their potential for patient-control discrimination.

METHODS

Fasting glucose, lipid profile and oxidative stress status parameters were assessed in 30 schizophrenic patients with atypical antipsychotic therapy and 60 control subjects.

RESULTS

Malondialdehyde (MDA), pro-oxidant/antioxidant balance (PAB) and total anti-oxidant status (TAS) were significantly higher whereas total sulfhydryl (SH) groups were significantly lower in schizophrenic patients vs. control group. Higher serum PAB values showed an independent association with schizophrenia. The addition of PAB to conventional risk factors improved discrimination between healthy control subjects and patients.

CONCLUSION

Increased oxidative stress and changed lipid profile parameters are associated in schizophrenic patients and may indicate risk for atherosclerosis. The serum PAB level may reflect the levels of oxidative stress in schizophrenia and improve discrimination of patients from controls.

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

Individuals with psychosis are more likely than the general community to develop obesity and to die prematurely from heart disease. Interventions to improve cardiovascular outcomes are best targeted at the earliest indicators of risk, at the age they first emerge. We investigated which cardiometabolic risk indicators distinguished those with psychosis from the general population, by age by gender, and whether obesity explained the pattern of observed differences. Data was analyzed from an epidemiologically representative sample of 1,642 Australians with psychosis aged 18–64 years and a national comparator sample of 8,866 controls aged 25–64 years from the general population. Cubic b-splines were used to compare cross sectional age trends by gender for mean waist circumference, body mass index [BMI], blood pressure, fasting blood glucose, triglycerides, LDL, HDL, and total cholesterol in our psychosis and control samples. At age 25 individuals with psychosis had a significantly higher mean BMI, waist circumference, triglycerides, glucose [women only], and diastolic blood pressure and significantly lower HDL-cholesterol than controls. With the exception of triglycerides at age 60+ in men, and glucose in women at various ages, these differences were present at every age. Differences in BMI and waist circumference between samples, although dramatic, could not explain all differences in diastolic blood pressure, HDL-cholesterol or triglycerides but did explain differences in glucose. Psychosis has the hallmarks of insulin resistance by at least age 25. The entire syndrome, not just weight, should be a focus of intervention to reduce mortality from cardiovascular disease.

A meta-analysis of cardio-metabolic abnormalities in drug naïve, first-episode and multi-episode patients with schizophrenia versus general population controls

A meta-analysis was conducted to explore the risk for cardio-metabolic abnormalities in drug naïve, first-episode and multi-episode patients with schizophrenia and age- and gender- or cohort-matched general population controls. Our literature search generated 203 relevant studies, of which 136 were included. The final dataset comprised 185,606 unique patients with schizophrenia, and 28 studies provided data for age- and gender-matched or cohort-matched general population controls (n=3,898,739). We found that multi-episode patients with schizophrenia were at increased risk for abdominal obesity (OR=4.43; CI=2.52-7.82; p<0.001), hypertension (OR=1.36; CI=1.21-1.53; p<0.001), low high-density lipoprotein cholesterol (OR=2.35; CI=1.78-3.10; p<0.001), hypertriglyceridemia (OR=2.73; CI=1.95-3.83; p<0.001), metabolic syndrome (OR=2.35; CI=1.68-3.29; p<0.001), and diabetes (OR=1.99; CI=1.55-2.54; p<0.001), compared to controls. Multi-episode patients with schizophrenia were also at increased risk, compared to first-episode (p<0.001) and drug-naïve (p<0.001) patients, for the above abnormalities, with the exception of hypertension and diabetes. Our data provide further evidence supporting WPA recommendations on screening, follow-up, health education and lifestyle changes in people with schizophrenia.

Diabetes, physical activity participation and exercise capacity in patients with schizophrenia

AIM

The aim of this study was to determine if in schizophrenia patients the presence of diabetes is associated with lower physical activity participation and lower exercise capacity compared to patients with pre-diabetes and to patients without (pre-) diabetes.

METHODS

Schizophrenia patients without (pre-)diabetes (n = 86) were compared with pre-diabetic (n = 10) and diabetic patients (n = 10). Patients were assessed on physical activity participation using the Baecke physical activity questionnaire and on exercise capacity using a 6-min walk test (6MWT).

RESULTS

The three groups were similar in age, sex, mean antipsychotic medication dose, negative and depressive symptoms and smoking behavior. Distance achieved on the 6MWT, however, was approximately 15% shorter (P < 0.05) in patients withdiabetes than in patients without (pre-)diabetes (500.3 ± 76.9 m vs 590.7 ± 101.8 m). Patients with diabetes were also significantly less physically active (P < 0.05). No differences between diabetic and pre-diabetic patients were found. Pre-diabetic patients had a higher body mass index (BMI) than non-diabetic patients (30.0 ± 7.3 vs 24.3 ± 4.3, P < 0.05). An interaction effect with BMI for differences in Baecke (F = 29.9, P < 0.001) and 6MWT (F = 13.0, P < 0.001) scores was seen between diabetic and non-diabetic patients on univariate ANCOVA.

CONCLUSION

The additive burden of diabetes might place patients with schizophrenia at an even greater risk for functional limitations in daily life.

Practice parameter for the assessment and treatment of children and adolescents with schizophrenia

This Practice Parameter reviews the literature on the assessment and treatment of children and adolescents with schizophrenia. Early-onset schizophrenia is diagnosed using the same criteria as in adults and appears to be continuous with the adult form of the disorder. Clinical standards suggest that effective treatment includes antipsychotic medications combined with psychoeducational, psychotherapeutic, and educational interventions. Since this Practice Parameter was last published in 2001, several controlled trials of atypical antipsychotic agents for early-onset schizophrenia have been conducted. However, studies suggest that many youth with early-onset schizophrenia do not respond adequately to available agents and are vulnerable to adverse events, particularly metabolic side effects. Further research is needed to develop more effective and safer treatments.

Detection of metabolic syndrome in schizophrenia and implications for antipsychotic therapy : is there a role for folate?

In general, the presence of metabolic syndrome is associated with significant cardiovascular mortality and represents a growing public health concern in the USA. Patients with schizophrenia have a three times greater risk of death than the general population, with cardiovascular disease being the most common cause of this mortality. Use of atypical antipsychotics (AAPs) to treat schizophrenia contributes significantly to this cardiovascular risk. While several different clinical guidelines currently exist to monitor the metabolic consequences of AAP use, implementation is lacking. Because of under-monitoring of side effects and the lack of alternative treatment choices in schizophrenia, research has focused on identification of various biomarkers and pharmacogenomic targets to focus on the patients at greatest risk of metabolic syndrome, thus aiming to increase the efficacy and minimize the side effects of AAPs. This has led to several different lines of research. This review focuses on summarizing the differing metabolic syndrome criteria, monitoring guidelines for use of AAPs, and the role of folic acid as it relates to metabolic syndrome within the schizophrenia population. It concentrates not only on the pharmacogenomics of folic acid metabolism but also on its epigenetic interaction with the environment. From this work, genetic variation within both the methylenetetrahydrofolate reductase (MTHFR) gene and the catechol-O-methyltransferase (COMT) gene has been associated with an increased risk of metabolic syndrome in schizophrenia patients treated with AAPs. Furthermore, work on the combination of folate pharmacogenetics and epigenetics has uncovered relationships between methylation, schizophrenia disease, treatment type, and metabolic syndrome. Despite several areas of biomarker research into schizophrenia-related metabolic syndrome, translation into the clinical setting is still lacking, and further studies are needed to bridge this gap. In the future, folate supplementation may prove to be an easy and effective clinical tool for prevention and/or treatment of metabolic syndrome associated with AAP treatment, but clearly more research needs to be done in this area.

Management of Medication-Related Cardiometabolic Risk in Patients with Severe Mental Illness

Severe psychotic disorders, which on their own may be a risk factor for metabolic disorder and cardiovascular illness, are clinically compounded by the significant adverse side effects of antipsychotic medications. The majority of patients with severe psychotic disorders (i.e., schizophrenia, bipolar disorder, mania, and depression) must take antipsychotic medications to treat their psychoses and, subsequently, will require efficacious interventions to manage the metabolic consequences of pharmacologic treatment to mitigate excessive mortality associated with cardiovascular illness. We have reviewed the metabolic consequences of antipsychotic treatment and discussed pilot findings from a new nonpharmacologic intervention study looking at the clinical benefits of regular exercise as a management tool for the cardiometabolic risk factors in a cohort with severe mental illness.

Assessment of cardiovascular disease risk in patients with schizophrenia spectrum disorders in German psychiatric hospitals: results of the pharmacoepidemiologic CATS study

PURPOSE

Patients with severe mental illness are at high risk for metabolic and cardiac disorders. Thus, monitoring of cardiovascular risks is imperative and schedules for screening for lipids, glucose, body mass index (BMI), waist-hip ratio and blood pressure have been developed. We intended to analyze screening for metabolic disorders in German patients with schizophrenia spectrum disorders in routine psychiatric care.

METHODS

We included 674 patients with any F2 diagnosis in out- and inpatient settings and analyzed metabolic screening procedures as practiced under conditions of usual care.

RESULTS

Except BMI (54 %), all other values were documented only in a minority of patients: waist circumference (23 %), cholesterol (28 %), fasting glucose (19 %), triglycerides (25 %) and blood pressure (37 %). We found evidence for less than perfect quality of blood pressure measures. The group of patients who met the individual metabolic syndrome ATP III criteria was comparable to the US CATIE trial.

CONCLUSIONS

We conclude that frequency and quality of metabolic monitoring in German in- and outpatients settings are not in accordance with the respective recommendations. Similar to previous reports we found evidence for a high prevalence of metabolic disturbances in German patients with schizophrenia spectrum disorders.

Screening for cardiovascular risk in patients with severe mental illness in primary care: a comparison with patients with diabetes

BACKGROUND

People with severe mental illness (SMI) have a higher risk of developing cardiovascular disease (CVD) compared with the general population. Clinical guidelines recommend annual screening for CVD risk factors with appropriate lifestyle counselling. Aims To establish the proportion of patients with SMI being screened for CVD risk factors in their primary care practice compared with those with diabetes and determine whether people with SMI receive lifestyle advice. METHOD DESIGN: a retrospective audit.

SETTING

five primary care centres in Northampton, England.

PARTICIPANTS

three hundred and eighty-six patients with SMI and 1875 with diabetes.

RESULTS

Just over a fifth of patients with SMI received a full CVD screen compared with the 96% of those with diabetes (OR  =  90.37; 95% CI  =  64.53-126.55, p  <  0.01). Fifty-seven per cent of the SMI patients were given smoking advice but only 13% and 14% received guidance regarding diet and exercise, respectively. On average of each patient with SMI received fewer than two (from four) screening interventions and less than one (from three) components of lifestyle advice.

CONCLUSIONS

In primary care, the number of people with SMI receiving screening for CVD risk is much lower than those with diabetes.

The role of hypothalamic H1 receptor antagonism in antipsychotic-induced weight gain

Treatment with second generation antipsychotics (SGAs), notably olanzapine and clozapine, causes severe obesity side effects. Antagonism of histamine H1 receptors has been identified as a main cause of SGA-induced obesity, but the molecular mechanisms associated with this antagonism in different stages of SGA-induced weight gain remain unclear. This review aims to explore the potential role of hypothalamic histamine H1 receptors in different stages of SGA-induced weight gain/obesity and the molecular pathways related to SGA-induced antagonism of these receptors. Initial data have demonstrated the importance of hypothalamic H1 receptors in both short- and long-term SGA-induced obesity. Blocking hypothalamic H1 receptors by SGAs activates AMP-activated protein kinase (AMPK), a well-known feeding regulator. During short-term treatment, hypothalamic H1 receptor antagonism by SGAs may activate the AMPK-carnitine palmitoyltransferase 1 signaling to rapidly increase caloric intake and result in weight gain. During long-term SGA treatment, hypothalamic H1 receptor antagonism can reduce thermogenesis, possibly by inhibiting the sympathetic outflows to the brainstem rostral raphe pallidus and rostral ventrolateral medulla, therefore decreasing brown adipose tissue thermogenesis. Additionally, blocking of hypothalamic H1 receptors by SGAs may also contribute to fat accumulation by decreasing lipolysis but increasing lipogenesis in white adipose tissue. In summary, antagonism of hypothalamic H1 receptors by SGAs may time-dependently affect the hypothalamus-brainstem circuits to cause weight gain by stimulating appetite and fat accumulation but reducing energy expenditure. The H1 receptor and its downstream signaling molecules could be valuable targets for the design of new compounds for treating SGA-induced weight gain/obesity.

The health benefits and challenges of exercise training in persons living with schizophrenia: a pilot study

BACKGROUND

In addition to the hallmark cognitive and functional impairments mounting evidence indicates that schizophrenia is also associated with an increased risk for the development of secondary complications, in particular cardio-metabolic disease. This is thought to be the result of various factors including physical inactivity and the metabolic side effects of psychotropic medications. Therefore, non-pharmacological approaches to improving brain health, physical health, and overall well-being have been promoted increasingly.

METHODS

We report on the health-related physical fitness (body composition, blood pressure, heart rate, and aerobic fitness) and lipid profile of persons living with schizophrenia and effective means to address the challenges of exercise training in this population.

RESULTS

There was a markedly increased risk for cardio-metabolic disease in 13 persons living with schizophrenia (Age = 31 ± 7 years) including low aerobic fitness (76% ± 34% of predicted), reduced HDL (60% of cohort), elevated resting heart rate (80% of cohort), hypertension (40% of cohort), overweight and obesity (69% of cohort), and abdominal obesity (54% of cohort). Individualized exercise prescription (3 times/week) was well tolerated, with no incidence of adverse exercise-related events. The exercise adherence rate was 81% ± 21% (Range 48%-100%), and 69% of the participants were able to complete the entire exercise training program. Exercise training resulted in clinically important changes in physical activity, aerobic fitness, exercise tolerance, blood pressure, and body composition.

CONCLUSION

Persons living with schizophrenia appear to be at an increased risk for cardio-metabolic disease. An individualized exercise program has shown early promise for the treatment of schizophrenia and the various cognitive, functional, and physiological impairments that ultimately affect health and well-being.

Is the prevalence of metabolic syndrome and metabolic abnormalities increased in early schizophrenia? A comparative meta-analysis of first episode, untreated and treated patients

We aimed to discover whether metabolic complications of schizophrenia (SZ) are present in first episode (FE) and unmedicated (UM) patients, in comparison with patients established on antipsychotic medication (AP).

METHOD

A systematic search, critical appraisal, and meta-analysis were conducted of studies to December 2011 using Medline, PsycINFO, Embase and experts. Twenty-six studies examined FE SZ patients (n = 2548) and 19 included UM SZ patients (n = 1325). For comparison we identified 78 publications involving 24 892 medicated patients who had chronic SZ already established on AP.

RESULTS

In UM, the overall rate of metabolic syndrome (MetS) was 9.8% using any standardized criteria. Diabetes was found in only 2.1% and hyperglycaemia (>100 mg/dl) in 6.4%. In FE, the overall MetS rate was 9.9%, diabetes was found in only 1.2%, and hyperglycaemia in 8.7%. In UM and FE, the rates of overweight were 26.6%, 22%; hypertriglyceridemia 16.9%, 19.6%; low HDL 20.4%, 21.9%; high blood pressure 24.3%, 30.4%; smoking 40.2%, 46.8%, respectively. In both groups all metabolic components and risk factors were significantly less common in early SZ than in those already established on AP. Waist size, blood pressure and smoking were significantly lower in UM compared with FE.

CONCLUSION

There is a significantly lower cardiovascular risk in early SZ than in chronic SZ. Both diabetes and pre-diabetes appear uncommon in the early stages, especially in UM. However, smoking does appear to be elevated early after diagnosis. Clinicians should focus on preventing initial cardiometabolic risk because subsequent reduction in this risk is more difficult to achieve, either through behavioral or pharmacologic interventions.

Prediabetic increase in hemoglobin A1c compared with impaired fasting glucose in patients receiving antipsychotic drugs

BACKGROUND

In 2010, the American Diabetes Association recommended that individuals with hemoglobin A1c 5.7-6.4% be classified as prediabetic even in the absence of impaired fasting glucose (IFG).

AIM OF STUDY

To compare the clinical and metabolic characteristics of patients receiving antipsychotic drugs who have normal glucose tolerance (NGT), hemoglobin A1c 5.7-6.4% or IFG (fasting glucose 100-125 mg/dL).

METHOD

Body mass index, waist circumference, fasting glucose, insulin, lipids, hemoglobin A1c, and insulin resistance assessed with the homeostatic model (HOMA-IR) were measured in a consecutive cohort of adult psychiatric inpatients with NGT (N = 423), hemoglobin A1c 5.7-6.4% (N = 130), IFG (N = 52) and IFG plus hemoglobin A1c 5.7-6.4% (n = 39).

RESULTS

The hemoglobin A1c 5.7-6.4% group had lower fasting insulin levels (9.8 ± 5.6 vs. 15.5 ± 11.4 μU/mL, p < 0.0001) and HOMA-IR (2.1 ± 1.2 vs. 4.1 ± 3.1, p < 0.0001) than the IFG group, but were metabolically similar to those with NGT. The hemoglobin A1c 5.7-6.4% was the predominant prediabetic pattern in patients treated with antipsychotics other than clozapine or olanzapine. Patients with hemoglobin A1c 5.7-6.4% and those with IFG were statistically similar in age (40.1 ± 13.6 vs. 39.7 ± 10.3 years), body mass index (26.0 ± 4.8 vs. 26.3 ± 4.9) and waist circumference 93.1 ± 13.9 vs. 98.1 ± 12.1 cm for males and 92.5 ± 13.5 vs. 90.7 ± 15.8 cm for females.

CONCLUSION

The hemoglobin A1c in the 5.7-6.4% range is common in euglycemic patients receiving antipsychotic drugs and this prediabetic pattern has metabolic and pharmacological features that differentiates it from IFG.

Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders--a systematic review and meta-analysis

Individuals with schizophrenia have high levels of medical comorbidity and cardiovascular risk factors. The presence of 3 or more specific factors is indicative of metabolic syndrome, which is a significant influence upon future morbidity and mortality. We aimed to clarify the prevalence and predictors of metabolic syndrome (MetS) in adults with schizophrenia and related disorders, accounting for subgroup differences. A PRISMA systematic search, appraisal, and meta-analysis were conducted of 126 analyses in 77 publications (n = 25,692). The overall rate of MetS was 32.5% (95% CI = 30.1%-35.0%), and there were only minor differences according to the different definitions of MetS, treatment setting (inpatient vs outpatient), by country of origin and no appreciable difference between males and females. Older age had a modest influence on the rate of MetS (adjusted R(2) = .20; P < .0001), but the strongest influence was of illness duration (adjusted R(2) = .35; P < .0001). At a study level, waist size was most useful in predicting high rate of MetS with a sensitivity of 79.4% and a specificity of 78.8%. Sensitivity and specificity of high blood pressure, high triglycerides, high glucose and low high-density lipoprotein, and age (>38 y) are shown in supplementary appendix 2 online. Regarding prescribed antipsychotic medication, highest rates were seen in those prescribed clozapine (51.9%) and lowest rates of MetS in those who were unmedicated (20.2%). Present findings strongly support the notion that patients with schizophrenia should be considered a high-risk group. Patients with schizophrenia should receive regular monitoring and adequate treatment of cardio-metabolic risk factors.

Developing a scoring guide for the Appraisal of Guidelines for Research and Evaluation II instrument in Korea: a modified Delphi consensus process

Korea has a relatively short history in the development and use of clinical practice guidelines (CPGs). Additionally, it has been difficult to employ the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument due to the lack of consensus and the presence of differences in Korean medical settings and in the Korean socio-cultural environment. An AGREE II scoring guide was therefore developed to reduce differences among evaluators using the same tool. In consideration of the importance of using a quantitative measure of satisfaction with the elements described in the AGREE II manual, a final draft was developed through a Delphi consensus process. Ninety-two draft scoring guides for anchor points 1, 3, 5, and 7 (full score) in 23 items were developed. Consensus was defined as agreement among at least 70% of the raters. Agreement on 88 draft scoring guidelines was reached in the first Delphi round, and agreement for the remaining four was achieved in the second round. The development of an AGREE II scoring guide in this study is expected to contribute to improving the CPG environment.

Detection of subclinical atherosclerosis and diastolic dysfunction in patients with schizophrenia

BACKGROUND

Patients with schizophrenia have a higher risk for cardiovascular diseases, which is associated with early mortality compared with the nonschizophrenic population. Early diagnosis of cardiovascular diseases in asymptomatic periods in patients with schizophrenia would enhance their quality of life and reduce mortality. Echocardiography, carotid ultrasonography, and ankle brachial index (ABI) measurement are known to be beneficial methods of detecting subclinical cardiovascular diseases and of risk stratification. The present study investigated carotid intima media thickness (CIMT) and ABI and echocardiographic parameters measured via conventional and tissue Doppler echocardiography in patients with schizophrenia in comparison with a control group.

METHODS

The present case-control study included 116 patients with schizophrenia and 88 healthy patients. Participants with any current comorbid psychiatric disorder, current or lifetime neurological and medical problems, current coronary artery disease, diabetes, hypertension, hypothyroidism, or hyperthyroidism or who were using antihypertensives, antidiabetic agents, or antiobesity drugs were excluded. High-resolution B-mode ultrasound images were used to measure CIMT. Conventional and tissue Doppler measurements were performed according to the recommendations of the American Society of Echocardiography.

RESULTS

Low ABI, mitral ratio of the early (E) to late (A) ventricular filling velocities, septal E', septal S', lateral E', lateral S', septal E'/septal A', lateral E'/lateral A', and high septal A', mitral E/septal E', mitral E/lateral E', and CIMT values were observed in the schizophrenia group compared with the control group.

CONCLUSION

Doppler parameters supported the hypothesis that patients with schizophrenia are at high risk for cardiovascular diseases.

Management of psychotropic medication side effects in children and adolescents

This article is a review of several of the most concerning side effects of psychotropic medications in children and adolescents. An emphasis is placed on review of the prevalence, presentation, monitoring, and evidence-based management of these side effects.

Metabolic syndrome in antipsychotic naïve patients diagnosed with schizophrenia

AIM

The article aims to study the prevalence of metabolic syndrome (MS) and subthreshold MS in antipsychotic naïve patients with schizophrenia.

MATERIALS AND METHODS

Forty-six antipsychotic naïve patients diagnosed with schizophrenia were evaluated for the presence of metabolic abnormalities using International Diabetes Federation and modified National Cholesterol Education Program-Third Adult Treatment Panel criteria.

RESULTS

Five patients (10.86%) fulfilled International Diabetes Federation criteria for MS and six patients (13.04%) met modified National Cholesterol Education Program-Third Adult Treatment Panel criteria for MS. Additionally, 14 (30.43%) more patients fulfilled 2 out of the 5 criteria for MS and another 19 (41.3%) fulfilled 1 criterion for MS. Of the 19 patients who fulfilled one criterion for MS, 18 had an abnormality other than increase in waist circumference.

CONCLUSION

Findings of the present study suggest that although only few antipsychotic naïve patients diagnosed with schizophrenia have MS, a significantly large proportion of patients have subsyndromal MS. Awareness of this in clinicians can have implications in the selection of antipsychotic medication.

Neural changes associated with appetite information processing in schizophrenic patients after 16 weeks of olanzapine treatment

There is evidence that some atypical antipsychotics, including olanzapine, can produce unwanted metabolic side effects, weight gain and diabetes. However, neuronal correlates of change related to food information processing have not been investigated with these medications. We studied the effect of a pharmacological manipulation with an antipsychotic known to cause weight gain on metabolites, cognitive tasks and neural correlates related to food regulation. We used functional magnetic resonance imaging in conjunction with a task requiring visual processing of appetitive stimuli in schizophrenic patients and healthy controls before and after 16 weeks of antipsychotic medication with olanzapine. In patients, the psychological and neuronal changes associated following the treatment correlated with appetite control measures and metabolite levels in fasting blood samples. After 16 weeks of olanzapine treatment, the patients gained weight, increased their waist circumference, had fewer positive schizophrenia symptoms, a reduced ghrelin plasma concentration and an increased concentration of triglycerides, insulin and leptin. In premotor area, somatosensory cortices as well as bilaterally in the fusiform gyri, the olanzapine treatment increased the neural activity related to appetitive information in schizophrenic patients to similar levels relative to healthy individuals. However, a higher increase in sensitivity to appetitive stimuli after the treatment was observed in insular cortices, amygdala and cerebellum in schizophrenic patients as compared with healthy controls. Furthermore, these changes in neuronal activity correlated with changes in some metabolites and cognitive measurements related to appetite regulation.

The functional exercise capacity is correlated with global functioning in patients with schizophrenia

OBJECTIVE

The 6-minute walk test (6MWT) is commonly used to measure the functional exercise capacity in chronic patients with cardiovascular diseases. The purpose of this study was to determine whether the 6MWT is associated with the global assessment of functioning (GAF) score in patients with schizophrenia.

METHODS

A total of 68 male and 25 female in-patients with schizophrenia (34.6 ± 9.7 years; body mass index = 24.9 ± 4.4) performed a 6MWT and were assessed with the GAF scale and the Psychosis Evaluation tool for Common use by Caregivers (PECC).

RESULTS

The mean distance walked on the 6MWT was 587.3 ± 98.4 m, while the mean GAF score was 52.0 ± 10.4. The Pearson's correlation coefficient between the 6MWT and the GAF score was 0.59 (P < 0.001), indicating a moderate association between both measures. The 6MWT was also significantly related to negative (r = -0.45, P < 0.001), depressive (r = -0.48, P < 0.001) and cognitive (r=, P) symptoms and with body mass index (r = -0.31, P < 0.005), smoking behaviour (r = -0.36, P < 0.001)) and dose of antipsychotic medication (r = -0.38, P < 0.001).

CONCLUSION

Next to the GAF scale, clinicians in in-patient settings should consider incorporating the 6MWT into their test battery to measure the functional consequences of schizophrenia and its treatment.

Metabolic and cardiovascular adverse effects associated with antipsychotic drugs

Antipsychotic medications can induce cardiovascular and metabolic abnormalities (such as obesity, hyperglycemia, dyslipidemia and the metabolic syndrome) that are associated with an increased risk of type 2 diabetes mellitus and cardiovascular disease. Controversy remains about the contribution of individual antipsychotic drugs to this increased risk and whether they cause sudden cardiac death through prolongation of the corrected QT interval. Although some drug receptor-binding affinities correlate with specific cardiovascular and metabolic abnormalities, the exact pharmacological mechanisms underlying these associations remain unclear. Antipsychotic agents with prominent metabolic adverse effects might cause abnormalities in glucose and lipid metabolism via both obesity-related and obesity-unrelated molecular mechanisms. Despite existing guidelines and recommendations, many antipsychotic-drug-treated patients are not assessed for even the most easily measurable metabolic and cardiac risk factors, such as obesity and blood pressure. Subsequently, concerns have been raised over the use of these medications, especially pronounced in vulnerable pediatric patients, among whom their use has increased markedly in the past decade and seems to have especially orexigenic effects. This Review outlines the metabolic and cardiovascular risks of various antipsychotic medications in adults and children, defines the disparities in health care and finally makes recommendations for screening and monitoring of patients taking these agents.

International Organization of Physical Therapy in Mental Health consensus on physical activity within multidisciplinary rehabilitation programmes for minimising cardio-metabolic risk in patients with schizophrenia

PURPOSE

The excess cardiovascular morbidity associated with schizophrenia is attributed to an interplay between behavioural (physical inactivity, unhealthy diet, substance abuse), genetic and illness related factors, as well as the effects of antipsychotic treatment. Patients have limited access to physical healthcare with less opportunity for cardiovascular risk prevention and treatment programmes than the non-psychiatric population. The aim of this paper is to improve physical activity (PA) within rehabilitation programmes for people with schizophrenia.

METHOD

The development process consisted of: a) systematic literature review on PA in schizophrenia in eight databases up to May 2010; b) review on existing national and international guidelines; c) consensus meetings, and d) formulation of the final consensus document.

RESULTS

There is insufficient evidence for the relative contribution of PA reducing cardio-metabolic risks in people with schizophrenia. Demographical, biological, psychological, cognitive-behavioural, emotional, social and environmental barriers for PA could be identified.

CONCLUSIONS

Although PA outcomes on cardio-metabolic parameters are still unknown, the benefits of physical activity as part of a larger lifestyle programme are sufficient for the recommendation that persons with schizophrenia follow the 2008 U.S. Department of Health and Human Services PA Guidelines with specific adaptations based on disease and treatment-related adverse effects.

Metabolic and endocrine adverse effects of second-generation antipsychotics in children and adolescents: A systematic review of randomized, placebo controlled trials and guidelines for clinical practice

Second-generation antipsychotics (SGA) are being used more often than ever before in children and adolescents with psychotic and a wide range of non-psychotic disorders. Several SGA have received regulatory approval for some paediatric indications in various countries, but off-label use is still frequent. The aim of this paper was to perform a systematic review and critically evaluate the literature on cardiometabolic and endocrine side-effects of SGA in children and adolescents through a Medline/Pubmed/Google Scholar search of randomized, placebo controlled trials of antipsychotics in children and adolescents (<18 years old) until February 2010. In total, 31 randomized, controlled studies including 3595 paediatric patients were identified. A review of these data confirmed that SGA are associated with relevant cardiometabolic and endocrine side-effects, and that children and adolescents have a high liability to experience antipsychotic induced hyperprolactinaemia, weight gain and associated metabolic disturbances. Only weight change data were sufficiently reported to conduct a formal meta-analysis. In 24 trials of 3048 paediatric patients with varying ages and diagnoses, ziprasidone was associated with the lowest weight gain (-0.04kg, 95% confidence interval [CI]: -0.38 to +0.30), followed by aripiprazole (0.79kg, 95% CI: 0.54 to 1.04], quetiapine (1.43kg, 95% CI: 1.17 to 1.69) and risperidone (1.76kg, 95% CI: 1.27 to 2.25) were intermediate, and olanzapine was associated with weight gain the most (3.45kg, 95% CI: 2.93 to 3.97). Significant weight gain appeared to be more prevalent in patients with autistic disorder who were also younger and likely less exposed to antipsychotics previously. These data clearly suggest that close screening and monitoring of metabolic side effects is warranted and that the least cardiometabolically problematic agents should be used first whenever possible. A good collaboration between child- and adolescent psychiatrists, general practitioners and paediatricians is essential to maximize overall outcomes and to reduce the likelihood of premature cardiovascular morbidity and mortality.