Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level

[The Intensive Psychiatric Care Unit at a Hospital with Maximum Care - An Analysis of Treatment Variables in the Therapy of Psychiatric and comorbid Somatic Disorders]

ZIEL DER STUDIE UND METHODIK

Alle 873 Behandlungsakten einer psychiatrischen Intensivstation aus einem Zeitraum von 5 Jahren gingen in eine Analyse des Patientenkollektivs, des Behandlungsoutcomes und von Prädiktoren für die stationäre Behandlungsdauer ein.

ERGEBNISSE UND SCHLUSSFOLGERUNG

Auf der beschriebenen Station wurden sowohl Patienten mit psychiatrischen Notfallsyndromen als auch Patienten mit komorbiden psychischen und somatischen Erkrankungen behandelt. Somatische Zusatzerkrankungen beeinflussen den stationären Behandlungsverlauf psychisch Erkrankter erheblich, z. B. durch eine um durchschnittlich 2,4 Wochen kürzere intensivpsychiatrische stationäre Behandlungsdauer bei häufiger Notwendigkeit (41,3%) einer stationären, z. B. rehabilitativen Anschlussbehandlung. Die Stationsauslastung von 110 % und die durchschnittliche Behandlungsdauer von 63 Tagen deuten auf einen hohen Bedarf an interdisziplinären psychiatrisch-somatischen Behandlungsmöglichkeiten hin. In Zukunft ist ein Zusammenwachsen von Psychiatrie und somatischer Medizin anzustreben. Untersuchungen zu Versorgungssituation und Wirtschaftlichkeit interdisziplinärer Behandlungsangebote stehen aus.

BACKGROUND AND METHOD

All 873 medical files of psychiatric inpatients treated over a 5 year period at a psychiatric intensive care unit were analyzed in regard to characteristics of the patient group, outcome and predictors for the length of stay.

RESULTS AND CONCLUSIONS

Patients with psychiatric emergency syndromes and patients with comorbid psychiatric and somatic disorders were treated on the described unit. Somatic comorbidities have a considerable effect on the course of treatment for patients with psychiatric disorders. They have to receive stationary treatment for a shorter period (2.4 weeks) but often need further stationary, e. g. rehabilitative treatment. The utilization of this specific unit (110%) and the above average length of stay (63 days) point to an increasing need in inpatient treatment capacities for patients with psychiatric and somatic comorbidities. In future a growing together of somatic medicine and psychiatry in Germany is worthwhile. The evaluation of the treatment situation and aspects of cost effectiveness are yet to come.

Cross-sectional mixed-methods study protocol exploring the enablers and barriers for people with severe and enduring mental illness in Jamaica when accessing healthcare for chronic physical illness

INTRODUCTION

Extant international research suggests that people with severe and enduring mental illness (PWSEMI) experience increased rates of chronic physical illness (CPI), reduced life expectancy and higher mortality than those in the general population. The high prevalence of CPI among PWSEMI is associated with a number of barriers that this population experiences when accessing physical healthcare. Although substantial research has been conducted in North America, Europe and Australia, there appears to be a paucity of research exploring CPI among PWSEMI in the Caribbean region, although this region has reported very high rates of non-communicable diseases within its populations. The current study will be situated in Jamaica and will explore the enablers and barriers to PWSEMI accessing healthcare for CPI.

METHODS AND ANALYSIS

A convergent mixed-method design will explore the enablers and barriers to accessing healthcare for CPI among PWSEMI. This cross-sectional study will collect data from PWSEMI, caregivers and family members, community health aides, primary care physicians, psychiatrists and health policymakers.

ETHICS AND DISSEMINATION

The study findings will provide baseline data describing the prevalence of CPI among PWSEMI in Jamaica and will identify enablers for, and barriers to, PWSEMI accessing CPI care. Findings will be disseminated widely in Jamaica and internationally to key stakeholders through publications and conferences. Institutional ethical approval was granted from Jamaica's Ministry of Health and Wellness Medico-legal Ethics Review Panel (# 2019/49), the Curtin University Human Research and Ethics Committee (HRE 2020-0022) and the University of the West Indies FMS Ethics Committee (ECP 101, 19/20).

Prevalence of obesity, metabolic syndrome, diabetes and risk of cardiovascular disease in a psychiatric inpatient sample: results of the Metabolism in Psychiatry (MiP) Study

The information on prevalence of obesity, diabetes, metabolic syndrome (MetS) and cardiovascular risk (CVR) and on sociodemographic variables available in patients with psychiatric diseases about to be treated with weight gain-associated medication (e.g., clozapine, mirtazapine, quetiapine) is limited. In a naturalistic study, psychiatric inpatients (age: 18-75) of all F diagnoses according to ICD-10, who were about to be treated with weight gain-associated medication, were included. Demographic variables were assessed as well as biological parameters to calculate the Body Mass Index (BMI), MetS, diabetes and CVR. A total of 163 inpatients were included (60.1% male; mean age: 39.8 (± 15.1, 18-75 years). The three most common disorders were depression (46.0%), bipolar disorder (20.9%) and drug addiction (20.2%). The three most common pharmacotherapeutic agents prescribed were quetiapine (29.4%), mirtazapine (20.9%) and risperidone (12.9%). Of the included inpatients 30.1% were overweight, 17.2% obese, and 26.9% and 22.4% fulfilled the criteria for a MetS according to the International Diabetes Federation (IDF) and the National Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (NCEP ATP III), respectively, 3.8% had (pre)diabetes and 8.3% had a moderate and 1.9% a high CVR according to the Prospective Cardiovascular Münster (PROCAM) score. Detailed information is reported on all assessed parameters as well as on subgroup analyses concerning sociodemographic variables. The results suggest that psychiatric patients suffer from multiple metabolic disturbances in comparison to the general population. Monitoring weight, waist circumference, blood pressure and cholesterol regularly is, therefore, highly relevant.

The Views of Non-psychiatric Medical Specialists About People with Schizophrenia and Depression

This study explored the views of non-psychiatric medical specialists about people with schizophrenia and depression and examined whether specialists' approach to these clients, and their perception of dangerousness and social distance, differed by disorder. Non-psychiatric medical specialists working in community centers in Italy read either a schizophrenia or depression description and then completed a questionnaire on their views about people with that disorder. The schizophrenia-group (N = 114) was more sure than the depression-group (N = 97) that the patients should be approached differently in outpatient specialized clinics like those where the respondents worked; are incapable of caring for their own health; and are kept at distance by others. Perceived dangerousness did not significantly differ between the two groups. These findings highlight the potential effects of attitudes on medical practice and outline the need to educate non-psychiatric medical specialists on stigma as a strategy to reduce health discrepancies, particularly toward people diagnosed with schizophrenia.

Cardiovascular risk screening of patients with serious mental illness or use of antipsychotics in family practice

Background

Patients with serious mental illness (SMI) and patients on antipsychotics (AP) have an elevated risk for cardiovascular diseases. In the Netherlands, the mental healthcare for these patients is increasingly taken care of by family practitioners (FP) as a result of a shift from secondary to primary care. Therefore, it is essential to increase our knowledge regarding the characteristics of this patient group and the (somatic) care provided by their FPs. The aim was to examine the rate of cardiovascular risk screening in patients with SMI or the use of AP in family practice.

Methods

We performed a retrospective cohort study of 151.238 patients listed in 24 family practices in the Netherlands.

From electronic medical records we extracted data concerning diagnoses, measurement values of CVR factors, medication and frequency of visits over a 2 year period. Primary outcome was the rate of patients who were screened for CVR factors. We compared three groups: patients with SMI/AP without diabetes or CVD (SMI/AP-only), patients with SMI/AP and diabetes mellitus (SMI/AP + DM), patients with SMI/AP and a history of cardiovascular disease (SMI/AP + CVD). We explored factors associated with adequate screening using multilevel logistic regression.

Results

We identified 1705 patients with SMI/AP, 834 with a SMI diagnosis, 1150 using AP. The screening rate for CVR in the SMI/AP-only group (n = 1383) was adequate in 8.5%. Screening was higher in the SMI/AP − +DM (n = 206, 68.4% adequate, OR 24.6 (95%CI, 17.3–35.1) and SMI/AP + CVD (n = 116, 26.7% adequate, OR 4.2 (95%CI, 2.7–6.6). A high frequency of visits, age, the use of AP and a diagnosis of COPD were associated with a higher screening rate. In addition we also examined differences between patients with SMI and patients using AP without SMI.

Conclusion

CVR screening in patients with SMI/AP is performed poorly in Dutch family practices. Acceptable screening rates were found only among SMI/AP patients with diabetes mellitus as comorbidity. The finding of a large group of AP users without a SMI diagnosis may indicate that FPs often prescribe AP off-label, lack information about the diagnosis, or use the wrong code.

The effect of a severe psychiatric illness on colorectal cancer treatment and survival: A population-based retrospective cohort study

OBJECTIVES

To identify inequalities in cancer survival rates for patients with a history of severe psychiatric illness (SPI) compared to those with no history of mental illness and explore differences in the provision of recommended cancer treatment as a potential explanation.

DESIGN

Population-based retrospective cohort study using linked cancer registry and administrative data at ICES.

SETTING

The universal healthcare system in Ontario, Canada.

PARTICIPANTS

Colorectal cancer (CRC) patients diagnosed between April 1st, 2007 and December 31st, 2012. SPI history (schizophrenia, schizoaffective disorders, other psychotic disorders, bipolar disorders or major depressive disorders) was determined using hospitalization, emergency department, and psychiatrist visit data and categorized as 'no history of mental illness, 'outpatient SPI history', and 'inpatient SPI history'.

MAIN OUTCOME MEASURES

Cancer-specific survival, non-receipt of surgical resection, and non-receipt of adjuvant chemotherapy or radiation.

RESULTS

24,507 CRC patients were included; 482 (2.0%) had an outpatient SPI history and 258 (1.0%) had an inpatient SPI history. Individuals with an SPI history had significantly lower survival rates and were significantly less likely to receive guideline recommended treatment than CRC patients with no history of mental illness. The adjusted HR for cancer-specific death was 1.69 times higher for individuals with an inpatient SPI (95% CI 1.36-2.09) and 1.24 times higher for individuals with an outpatient SPI history (95% CI 1.04-1.48). Stage II and III CRC patients with an inpatient SPI history were 2.15 times less likely (95% CI 1.07-4.33) to receive potentially curative surgical resection and 2.07 times less likely (95% CI 1.72-2.50) to receive adjuvant radiation or chemotherapy. These findings were consistent across multiple sensitivity analyses.

CONCLUSIONS

Individuals with an SPI history experience inequalities in colorectal cancer care and survival within a universal healthcare system. Increasing advocacy and the availability of resources to support individuals with an SPI within the cancer system are warranted to reduce the potential for unnecessary harm.

Delineating the Psychic Structure of Substance Use and Addictions, from Neurobiology to Clinical Implications: Ten Years Later

The diagnosis of substance use disorder is currently based on the presence of specifically identified behavioral symptoms. In addition, other psychiatric signs and symptoms accompany addictive behavior, contributing to the full picture of patients’ psychopathologic profile. Historically, such symptoms were confined within the framework of “comorbidity”, as comorbid psychiatric disorders or personality traits. However, an alternative unitary view of the psychopathology of addiction, inclusive of related psychiatric symptoms, has been claimed, with the support of epidemiological, neurobiological, and neuropsychological evidence. In the present article, we highlight the research advancements that strengthen this unified perspective. We then give an account of our group’s definition of a specific SCL-90-based construct of the psychopathology of addiction. Lastly, we discuss the benefits that can be expected to be acquired in the evaluation and treatment of patients with a longitudinal approach including psychological/psychiatric predisposing features, addictive behavior, and psychiatric manifestations.

Schizophrenia

BACKGROUND

The lifetime prevalence of schizophrenia is 1%. Schizophrenia is among the most severe mental illnesses and gives rise to the highest treatment costs per patient of any disease. It is characterized by frequent relapses, marked impairment of quality of life, and reduced social and work participation.

METHODS

The group entrusted with the creation of the German clinical practice guideline was chosen to be representative and pluralistic in its composition. It carried out a systematic review of the relevant literature up to March 2018 and identified a total of 13 389 publications, five source guidelines, three other relevant German clinical practice guidelines, and four reference guidelines.

RESULTS

As the available antipsychotic drugs do not differ to any great extent in efficacy, it is recommended that acute antipsychotic drug therapy should be sideeffect- driven, with a number needed to treat (NNT) of 5 to 8. The choice of treatment should take motor, metabolic, sexual, cardiac, and hematopoietic considerations into account. Ongoing antipsychotic treatment is recommended to prevent relapses (NNT: 3) and should be re-evaluated on a regular basis in every case. It is also recommended, with recommendation grades ranging from strong to intermediate, that disorder- and manifestation-driven forms of psychotherapy and psychosocial therapy, such as cognitive behavioral therapy for positive or negative manifestations (effect sizes ranging from d = 0.372 to d = 0.437) or psycho-education to prevent relapses (NNT: 9), should be used in combination with antipsychotic drug treatment. Further aspects include rehabilitation, the management of special treatment situations, care coordination, and quality management. A large body of evidence is available to provide a basis for guideline recommendations, particularly in the areas of pharmacotherapy and cognitive behavioral therapy.

CONCLUSION

The evidence-based diagnosis and treatment of persons with schizophrenia should be carried out in a multiprofessional process, with close involvement of the affected persons and the people closest to them.

Psychiatric Disorders Are Associated with Increased Risk of Sepsis Following a Cancer Diagnosis

Psychiatric disorders and infections are both common comorbidities among patients with cancer. However, little is known about the role of precancer psychiatric disorders on the subsequent risk of sepsis as a complication of infections among patients with cancer. We conducted a cohort study of 362,500 patients with newly diagnosed cancer during 2006-2014 in Sweden. We used flexible parametric models to calculate the HRs of sepsis after cancer diagnosis in relation to precancer psychiatric disorders and the analyses were performed in two models. In model 1, analyses were adjusted for sex, age at cancer diagnosis, calendar period, region of residence, and type of cancer. In model 2, further adjustments were made for marital status, educational level, cancer stage, infection history, and Charlson Comorbidity Index score. During a median follow-up of 2.6 years, we identified 872 cases of sepsis among patients with cancer with precancer psychiatric disorders (incidence rate, IR, 14.8 per 1,000 person-years) and 12,133 cases among patients with cancer without such disorders (IR, 11.6 per 1000 person-years), leading to a statistically significant association between precancer psychiatric disorders and sepsis in both the simplified (HR, 1.31; 95% CI, 1.22-1.40) and full (HR, 1.26; 95% CI, 1.18-1.35) models. The positive association was consistently noted among patients with different demographic factors or cancer characteristics, for most cancer types, and during the entire follow-up after cancer diagnosis. Collectively, preexisting psychiatric disorders were associated with an increased risk of sepsis after cancer diagnosis, suggesting a need of heightened clinical awareness in this patient group. SIGNIFICANCE: These results call for extended prevention and surveillance of sepsis among patients with cancer with psychiatric comorbidities.

Polycystic Ovary Syndrome and Psychotic Disorder

Polycystic ovary syndrome (PCOS), a disease that usually emerges during adolescence, is characterized by hormonal imbalance and ovarian dysfunction. The prevalence can vary between 5.6 to 21.3% in women and 6% in adolescent girls. This discrepancy is related to the population studied and the diagnostic criteria used. The underlying pathophysiology of PCOS is not fully understood, but it can lead to a number of co-morbidities, including hypertension, diabetes, dyslipidemia, and also, mental health disorders. Clinical and preclinical data indicate neuroendocrine involvement with dysfunction in gamma-Aminobutyric acid (GABA) signaling and neuronal androgen receptors that might reduce hypothalamic sensitivity and lead to an impairment of estradiol and progesterone feedback. Based on these assumptions, the aims of this paper are to review the association of PCOS and psychotic disorders in order to address the burden of women comorbid for both conditions.

Cognitive-behavioural therapy for clozapine-resistant schizophrenia: the FOCUS RCT

BACKGROUND

Clozapine (clozaril, Mylan Products Ltd) is a first-choice treatment for people with schizophrenia who have a poor response to standard antipsychotic medication. However, a significant number of patients who trial clozapine have an inadequate response and experience persistent symptoms, called clozapine-resistant schizophrenia (CRS). There is little evidence regarding the clinical effectiveness of pharmacological or psychological interventions for this population.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of cognitive-behavioural therapy (CBT) for people with CRS and to identify factors predicting outcome.

DESIGN

The Focusing on Clozapine Unresponsive Symptoms (FOCUS) trial was a parallel-group, randomised, outcome-blinded evaluation trial. Randomisation was undertaken using permuted blocks of random size via a web-based platform. Data were analysed on an intention-to-treat (ITT) basis, using random-effects regression adjusted for site, age, sex and baseline symptoms. Cost-effectiveness analyses were carried out to determine whether or not CBT was associated with a greater number of quality-adjusted life-years (QALYs) and higher costs than treatment as usual (TAU).

SETTING

Secondary care mental health services in five cities in the UK.

PARTICIPANTS

People with CRS aged ≥ 16 years, with an International Classification of Diseases, Tenth Revision (ICD-10) schizophrenia spectrum diagnoses and who are experiencing psychotic symptoms.

INTERVENTIONS

Individual CBT included up to 30 hours of therapy delivered over 9 months. The comparator was TAU, which included care co-ordination from secondary care mental health services.

MAIN OUTCOME MEASURES

The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months and the primary secondary outcome was PANSS total score at the end of treatment (9 months post randomisation). The health benefit measure for the economic evaluation was the QALY, estimated from the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), health status measure. Service use was measured to estimate costs.

RESULTS

Participants were allocated to CBT (n = 242) or TAU (n = 245). There was no significant difference between groups on the prespecified primary outcome [PANSS total score at 21 months was 0.89 points lower in the CBT arm than in the TAU arm, 95% confidence interval (CI) -3.32 to 1.55 points; p = 0.475], although PANSS total score at the end of treatment (9 months) was significantly lower in the CBT arm (-2.40 points, 95% CI -4.79 to -0.02 points; p = 0.049). CBT was associated with a net cost of £5378 (95% CI -£13,010 to £23,766) and a net QALY gain of 0.052 (95% CI 0.003 to 0.103 QALYs) compared with TAU. The cost-effectiveness acceptability analysis indicated a low likelihood that CBT was cost-effective, in the primary and sensitivity analyses (probability < 50%). In the CBT arm, 107 participants reported at least one adverse event (AE), whereas 104 participants in the TAU arm reported at least one AE (odds ratio 1.09, 95% CI 0.81 to 1.46; p = 0.58).

CONCLUSIONS

Cognitive-behavioural therapy for CRS was not superior to TAU on the primary outcome of total PANSS symptoms at 21 months, but was superior on total PANSS symptoms at 9 months (end of treatment). CBT was not found to be cost-effective in comparison with TAU. There was no suggestion that the addition of CBT to TAU caused adverse effects. Future work could investigate whether or not specific therapeutic techniques of CBT have value for some CRS individuals, how to identify those who may benefit and how to ensure that effects on symptoms can be sustained.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN99672552.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 7. See the NIHR Journals Library website for further project information.

BMI-NECK: A simple assessment of risk of obstructive sleep apnea in schizophrenia

INTRODUCTION

A high risk of obstructive sleep apnea (OSA) has been reported in patients with schizophrenia. However, existing screening questionnaires for OSA haven't been validated in this population and the impact of OSA on schizophrenia symptoms has rarely been studied. This study aimed to investigate the prevalence and impact of OSA in patients with schizophrenia and validate the existing OSA screening scales.

METHOD

Patients with schizophrenia consecutively admitted to hospital (n = 51) and patients with schizophrenia and obesity (n = 31) were compared to healthy controls (n = 51). Apnea risk was measured with STOP-BANG, NoSAS, No-Apnea, and the Berlin Questionnaire; psychiatric symptoms were measured with the PANSS and Calgary scales and B-CATS battery. Daytime sleepiness was measured with the Epworth sleepiness scale. OSA was diagnosed using the Embletta system.

RESULTS

OSA was found more frequently in obese schizophrenia patients than in those consecutively admitted to hospital (45% vs. 22%, p < 0.05). Significant differences between patients with and without OSA were found on the PANSS negative symptoms subscale, B-CATS digit symbol test, and in daytime sleepiness. None of the used screening scales showed satisfactory sensitivity and specificity. Obesity with coexisting neck circumference ≥41 cm in women or ≥43 cm in men (BMI-NECK model) predicted OSA in 57% of cases.

CONCLUSIONS

OSA should be screened in patients with schizophrenia as it has a negative influence on psychiatric symptoms and may contribute to the higher mortality of these patients. Assessment of BMI and neck circumference proves a good screening test in ambulatory contexts.

Cancer staging in individuals with a severe psychiatric illness: a cross-sectional study using population-based cancer registry data

BACKGROUND

Advanced cancer stage at diagnosis may explain high cancer mortality among patients with a severe psychiatric illness (SPI). Studies to date investigating advanced stage cancer at diagnosis as a potential explanation for high cancer mortality in individuals with a history of mental illness have been inconclusive. We examined the relationship between a SPI history and unknown cancer stage at diagnosis in colorectal cancer (CRC) patients.

METHODS

This was a population-based, cross-sectional study using linked administrative databases of CRC patients diagnosed between 01/04/2007 and 31/12/2012. Individuals who had a history of mental illness but did not meet the definition of a SPI were excluded. An SPI was measured in the 5 years prior to the cancer diagnosis and categorized as inpatient, outpatient or no SPI. Individuals with a best stage in Stage 0 to Stage IV were considered staged and absence of staging information was defined as unknown stage. The risk of unknown stage cancer was estimated using modified Poisson regression.

RESULTS

The final study cohort included 24,507 CRC patients. 258 (1.1%) individuals experienced a history of inpatient SPI and 482 (2.0%) experienced outpatient SPI. After adjusting for confounders, CRC patients with an inpatient or outpatient history of SPI were at greater risk of having missing TNM stage at diagnosis, compared to patients with no history of a mental illness (RR 1.45 (95% CI: 1.14-1.85) and RR1.17 (95% CI 0.95-1.43), respectively). The results did not change when alternate practices to assign SPI history using administrative data were used.

CONCLUSIONS

Individuals with an SPI, especially those with a psychiatric admission, were more likely to have missing stage data compared to individuals without a history of a mental illness. Incomplete and low quality cancer staging data likely undermines the quality of cancer care following initial diagnosis. Understanding why patients with an SPI are missing this information is a critical first step to providing excellent care to this vulnerable population.

Physical Fitness and Activity Levels among Chinese People with Schizophrenia: A Cross-Sectional Study with Matched Case-Control Comparison

People with schizophrenia have an increased risk of developing cardiometabolic diseases and a reduced life expectancy. Studies conducted mainly in Western settings report low amounts of activity and poor levels of fitness in this population. This study aims to compare physical fitness and activity levels between people with schizophrenia/healthy matched controls and investigate potential associations between these variables. A cross-sectional study was conducted with 57 community-dwelling people with schizophrenia and 57 age-, gender- and body mass index (BMI)-matched controls. Participants completed the international physical activity questionnaire and the Young Men’s Christian Association (YMCA) fitness assessment protocol with accompanying cardiovascular/lung function tests. Cardiorespiratory fitness was significantly better in healthy matched controls than individuals with schizophrenia in all areas (all p < 0.05, d = 0.38 to 1.06). Performance in best trunk flexion, half sit-ups and one-minute pulse recovery following the three-min step test were significantly worse in the schizophrenia group (all p < 0001, d = 0.76 to 1.04). Higher levels of weekly moderate activity (t = −2.66, p = 0.009) and total weekly activity levels (t = −2.013, p = 0.047) were reported by the healthy controls. Levels of vigorous activity were significantly correlated with some areas of lung functioning in the schizophrenia group (all p < 0.05). The findings show that Chinese people with schizophrenia have significantly poorer fitness than matched healthy controls, demonstrating the need to provide timely effective exercise-based interventions as a matter of routine to attenuate the risk of developing chronic physical illnesses.

A modality-specific dysfunction of pain processing in schizophrenia

Clinical observations showed that schizophrenia (SCZ) patients reported little or no pain under various conditions that are commonly associated with intense painful sensations, leading to a higher risk of morbidity and mortality. However, this phenomenon has received little attention and its underlying neural mechanisms remain unclear. Here, we conducted two experiments combining psychophysics, electroencephalography (EEG), and functional magnetic resonance imaging (fMRI) techniques to investigate neural mechanisms of pain insensitivity in SCZ patients. Specifically, we adopted a stimulus-response paradigm with brief stimuli of different sensory modalities (i.e., nociceptive, non-nociceptive somatosensory, and auditory) to test whether pain insensitivity in SCZ patients is supra-modal or modality-specific, and used EEG and fMRI techniques to clarify its neural mechanisms. We observed that perceived intensities to nociceptive stimuli were significantly smaller in SCZ patients than healthy controls, whereas perceived intensities to non-nociceptive somatosensory and auditory stimuli were not significantly different. The behavioral results were confirmed by stimulus-evoked brain responses sampled by EEG and fMRI techniques, thus verifying the modality-specific nature of the modulation of nociceptive information processing in SCZ patients. Additionally, significant group differences were observed in the spectral power of alpha oscillations in prestimulus EEG and the seed-based functional connectivity in resting-state fMRI (seeds: the thalamus and periaqueductal gray that are key nodes in ascending and descending pain pathways respectively), suggesting a possible contribution of cortical-subcortical dysfunction to the phenomenon. Overall, our study provides insight into the neural mechanisms of pain insensitivity in SCZ and highlights a need for systematic assessments of their pain-related diseases.

Diagnostic tests and treatment procedures performed prior to cardiovascular death in individuals with severe mental illness

OBJECTIVE

To examine whether severe mental illnesses (i.e., schizophrenia or bipolar disorder) affected diagnostic testing and treatment for cardiovascular diseases in primary and specialized health care.

METHODS

We performed a nationwide study of 72 385 individuals who died from cardiovascular disease, of whom 1487 had been diagnosed with severe mental illnesses. Log-binomial regression analysis was applied to study the impact of severe mental illnesses on the uptake of diagnostic tests (e.g., 24-h blood pressure, glucose/HbA1c measurements, electrocardiography, echocardiography, coronary angiography, and ultrasound of peripheral vessels) and invasive cardiovascular treatments (i.e., revascularization, arrhythmia treatment, and vascular surgery).

RESULTS

Patients with and without severe mental illnesses had similar prevalences of cardiovascular diagnostic tests performed in primary care, but patients with schizophrenia had lower prevalences of specialized cardiovascular examinations (prevalence ratio (PR) 0.78; 95% CI 0.73-0.85). Subjects with severe mental illnesses had lower prevalences of invasive cardiovascular treatments (schizophrenia, PR 0.58; 95% CI 0.49-0.70, bipolar disorder, PR 0.78; 95% CI 0.66-0.92). The prevalence of invasive cardiovascular treatments was similar in patients with and without severe mental illnesses when cardiovascular disease was diagnosed before death.

CONCLUSION

Better access to specialized cardiovascular examinations is important to ensure equal cardiovascular treatments among individuals with severe mental illnesses.

The EUropean Network of National Schizophrenia Networks Studying Gene-Environment Interactions (EU-GEI): Incidence and First-Episode Case-Control Programme

PURPOSE

The EUropean Network of National Schizophrenia Networks Studying Gene-Environment Interactions (EU-GEI) study contains an unparalleled wealth of comprehensive data that allows for testing hypotheses about (1) variations in incidence within and between countries, including by urbanicity and minority ethnic groups; and (2) the role of multiple environmental and genetic risk factors, and their interactions, in the development of psychotic disorders.

METHODS

Between 2010 and 2015, we identified 2774 incident cases of psychotic disorders during 12.9 million person-years at risk, across 17 sites in 6 countries (UK, The Netherlands, France, Spain, Italy, and Brazil). Of the 2774 incident cases, 1130 cases were assessed in detail and form the case sample for case-control analyses. Across all sites, 1497 controls were recruited and assessed. We collected data on an extensive range of exposures and outcomes, including demographic, clinical (e.g. premorbid adjustment), social (e.g. childhood and adult adversity, cannabis use, migration, discrimination), cognitive (e.g. IQ, facial affect processing, attributional biases), and biological (DNA via blood sample/cheek swab). We describe the methodology of the study and some descriptive results, including representativeness of the cohort.

CONCLUSIONS

This resource constitutes the largest and most extensive incidence and case-control study of psychosis ever conducted.

Do we need sex-oriented clinical practice guidelines for the treatment of schizophrenia?

PURPOSE OF REVIEW

Clinical practice guidelines (CPGs) do not usually offer a sex-specific approach for the management of schizophrenia. With this narrative review, we aim to give an integrated and synthesized overview of the current state of knowledge regarding sex-specific aspects in schizophrenia and how this topic may be adapted in the development of CPGs.

RECENT FINDINGS

Recent studies further suggest sex-specific differences in epidemiologic features, the course of illness, underlying pathomechanisms, response likelihood to antipsychotic medication and differences in tolerability. Beyond this, selective estrogen receptor modulators like raloxifene have shown beneficial effects on symptom severity and cognition in women with schizophrenia.

SUMMARY

Sex-specific aspects can already be integrated in clinical guideline recommendations, especially with regard to efficacy and tolerability of antipsychotic treatment. Moreover, these aspects may be used for an individual risk-stratification. Recent studies provide evidence supporting the hypothesis of sex-specific modulation in schizophrenia and build the groundwork for sex-specific novel treatment options. However, there remains a clear need for additional studies focusing on women with schizophrenia to substantiate current findings.

EPA guidance on the quality of mental health services

The main aim of this guidance of the European Psychiatric Association is to provide evidence-based recommendations on the quality of mental health services in Europe. The recommendations were derived from a systematic search of the best available evidence in the scientific literature, supplemented by information from documents retrieved upon reviewing the identified articles. While most recommendations could be based on empirical studies (although of varying quality), some had to be based on expert opinion alone, but were deemed necessary as well. Another limitation was that the wide variety of service models and service traditions for the mentally ill worldwide often made generalisations difficult. In spite of these limitations, we arrived at 30 recommendations covering structure, process and outcome quality both on a generic and a setting-specific level. Operationalisations for each recommendation with measures to be considered as denominators and numerators are given as well to suggest quality indicators for future benchmarking across European countries. Further pan-European research will need to show whether the implementation of this guidance will lead to improved quality of mental healthcare, and may help to develop useful country-specific cutoffs for the suggested quality indicators.

Improving physical health outcomes for people with severe mental illness: A proof-of-concept study of nurse practitioner candidate practice

People with severe mental illness have significantly reduced life expectancy and higher risk of cardiovascular diseases than the general population. There is a critical need for quality physical health care to improve consumers' health outcomes. There is minimal knowledge, however, on the impact of mental health nurse practitioner candidate (NPC) practices on consumers' health outcomes. The aim of this proof-of-concept study was to describe the impacts of NPC practices on the quality of physical healthcare provision and physical health outcomes (cardiovascular and cardiometabolic) of consumers in community mental health service settings. Using a mixed methods design, quantitative data were collected for 12 months prior to (Period 1), and 12 months during (Period 2), the candidacy period. Qualitative interviews were conducted with a purposive sample of n = 10 consumers to explore their perspectives on physical healthcare provision by the NPCs. During the 12-month candidacy period, the number of metabolic monitoring assessments rose from n = 55 in Period 1 to n = 146 in Period 2 (P < 0.01, χ²  = 41.20). Advanced practices provided by NPCs included taking an extensive holistic history and clinical examination, ordering diagnostic pathology, and clinical simulation of physical health medication prescription (under medical supervision). Analysis of consumer interviews resulted in two themes: (i) positive and helpful NPC health care and (ii) improvements in physical and mental health. The findings add new knowledge on specialist mental health nurse practitioner candidate roles and demonstrate the benefits these roles can have in reducing the significant morbidity and mortality of mental health consumers.

Potential gains in life expectancy from reducing amenable mortality among people diagnosed with serious mental illness in the United Kingdom

BACKGROUND

To estimate the potential gain in life expectancy from addressing modifiable risk factors for all-cause mortality (excluding suicide and deaths from accidents or violence) across specific serious mental illness (SMI) subgroups, namely schizophrenia, schizoaffective disorders, and bipolar disorders in a Western population.

METHODS

We have used relative risks from recent meta-analyses to estimate the population attribution fraction (PAF) due to specific modifiable risk factors known to be associated with all-cause mortality within SMI. The potential gain in life expectancy at birth, age 50 and age 65 years were assessed by estimating the combined effect of modifiable risk factors from different contextual levels (behavioural, healthcare, social) and accounting for the effectiveness of existing interventions tackling these factors. Projections for annual gain in life expectancy at birth during a two-decade was estimated using the Annual Percentage Change (APC) formula. The predicted estimates were based on mortality rates for year 2014-2015.

RESULTS

Based on the effectiveness of existing interventions targeting these modifiable risk factors, we estimated potential gain in life expectancy at birth of four (bipolar disorders), six (schizoaffective disorders), or seven years (schizophrenia). The gain in life expectancy at age 50 years was three (bipolar disorders) or five (schizophrenia and schizoaffective disorders) years. The projected gain in life expectancy at age 65 years was three (bipolar disorders) or four (schizophrenia and schizoaffective disorders) years.

CONCLUSIONS

The implementation of existing interventions targeting modifiable risk factors could narrow the current mortality gap between the general and the SMI populations by 24% (men) to 28% (women). These projections represent ideal circumstances and without the limitation of overestimation which often comes with PAFs.

Exploring healthcare professionals' perspectives of barriers and facilitators to supporting people with severe mental illness and Type 2 diabetes mellitus

Individuals with comorbid severe mental illness (SMI) and diabetes experience an average mortality gap of 20 years compared to individuals without these conditions. There has been some recognition by policies that there is a gap between mental healthcare and physical healthcare for SMI patients. Despite this, there are still no defined care pathways for individuals with SMI and diabetes. The aim of this study was to explore healthcare professionals' (HCPs) perspectives of barriers and solutions to supporting people with SMI and diabetes. HCPs in areas of South London were invited to attend a workshop event to discuss their views of SMI and diabetes pathways. Fifty participants were recruited using the Local Care Network. HCPs included GPs, mental health nurses, psychiatrists, diabetologists and care co-ordinators. The main themes were as follows: (a) poor coordination of care and care planning between services; (b) key techniques to improve integrated care; (c) perceived difficulties achieving better care and (d) supporting patient empowerment. The findings and recommendations from this workshop may provide some insight into key factors in providing and improving integrated SMI and diabetes care for patients in South East London and further afield.

Better care for less money: cost-effectiveness of integrated care in multi-episode patients with severe psychosis

OBJECTIVE

To compare cost-effectiveness of integrated care with therapeutic assertive community treatment (IC-TACT) versus standard care (SC) in multiple-episode psychosis.

METHOD

Twelve-month IC-TACT in patients with schizophrenia-spectrum and bipolar I disorders were compared with a historical control group. Primary outcomes were entropy-balanced cost-effectiveness based on mental healthcare costs from a payers' perspective and quality-adjusted life years (QALYs) as a measure of health effects during 12-month follow-up.

RESULTS

At baseline, patients in IC-TACT (n = 214) had significantly higher illness severity and lower functioning than SC (n = 56). Over 12 months, IC-TACT had significantly lower days in inpatient (10.3 ± 20.5 vs. 28.2 ± 44.9; P = 0.005) and day-clinic care (2.6 ± 16.7 vs. 16.4 ± 33.7; P = 0.004) and correspondingly lower costs (€-55 084). Within outpatient care, IC-TACT displayed a higher number of treatment contacts (116.3 ± 45.3 vs. 15.6 ± 6.3) and higher related costs (€+1417). Both resulted in lower total costs in IC-TACT (mean difference = €-13 248 ± 2975, P < 0.001). Adjusted incremental QALYs were significantly higher for IC-TACT versus SC (+0.10 ± 0.37, P = 0.05). The probability of cost-effectiveness of IC-TACT was constantly higher than 99%.

CONCLUSION

IC-TACT was cost-effective compared with SC. The use of prima facies 'costly' TACT teams is highly recommended to improve outcomes and save total cost for patients with severe psychotic disorders.

Risk of acute pancreatitis among people with severe mental illness

INTRODUCTION

Severe Mental Illness (SMI) encompasses schizophrenia, schizoaffective disorder, and bipolar affective disorder. SMI is associated with increased physical morbidity and mortality. Acute pancreatitis is the leading cause of gastroenterological hospitalisation. This study investigates the relationship between SMI and acute pancreatitis and determines the risk factors for development of pancreatitis.

MATERIAL AND METHODS

The first study phase was a retrospective cohort analysis. Acute admissions for pancreatitis were determined for people with an SMI diagnosis between January 2007 and March 2016 from a secondary care mental health register. Standardised admission ratio (SAR) for acute pancreatitis was determined for SMI patients. The second phase was a case-control study to compare exposures between SMI subjects admitted for acute pancreatitis ("cases") and the age-, gender-, and diagnosis-matched SMI subjects without admission for acute pancreatitis ("controls"), with a ratio of 1:4. Univariate and multivariate conditional logistic regression estimated the effect of exposures including diagnosis of alcohol use disorder (AUD).

RESULTS

A total of 22,337 SMI subjects were identified during the observation period. The SAR for acute pancreatitis was significant (2•33 (95% Ci: 1•97, 2•74; n = 148)). In the nested case-control study, SMI patients with co-morbid AUD elevated the risk of acute pancreatitis dramatically with an adjusted odds ratio 16•10 (5•92, 43•79).

LIMITATIONS

Diagnosis of co-morbid AUD may be under represented in population CONCLUSIONS: SMI is associated with a significantly elevated risk of acute pancreatitis. Co-morbid AUD is a risk factor in development of pancreatitis in this group.

Physical Examination Skills Among Chief Residents in Psychiatry: Practices, Attitudes, and Self-Perceived Knowledge

OBJECTIVES

The authors investigated the attitudes, self-perceived competence, and the need for a dedicated curriculum on physical examination skills among chief residents in psychiatry.

METHODS

A voluntary 28-item web-based questionnaire was distributed to psychiatry chief residents in the USA between January 2019 and February 2019.

RESULTS

Of 181 chief residents, 79 (response rate, 44%) completed the online survey. The majority of chief residents want to improve their physical exam skills (64%) and believe that there should be a targeted curriculum aimed at incorporating these skills into everyday psychiatric practice (63%). However, most (57%) chief residents reported that they only conduct physical exams on a few selected patients (< 25% of the time) and almost half (48%) last used a stethoscope a year ago, if not longer. Self-perceived competence and comfort level with neurology-related exam findings was especially low: only 35% could identify discrepant neurological findings and 33% elicit Hoover's sign of leg paresis. A significant majority (86%) believed that performing a physical exam would not interfere with the therapeutic relationship.

CONCLUSIONS

Although chief residents in psychiatry believe that developing competence in physical examinations is important to their education, the current educational landscape does not support the development of these skills. Future educational strategies should focus on addressing this need.

Health-e Minds: a Participatory Personalised and Gamified mHealth Platform to Support Healthy Living Behaviours for People with Mental Illness

This paper presents the development of an innovative platform (Health-e Minds) to support persons with diagnosed serious mental illness (SMI) in their self-management, but also to enhance multidisciplinary care provision. It comprises of a smartphone app and an interactive internet-based clinician web portal. The smartphone app accompanies and guides persons with SMI through their recovery journey by monitoring health measures, delivering simple interactive questionnaires and providing educational and motivational multimedia content. The web-portal enables clinical care providers to view their client's progress and provide individualized feedback and/or early care intervention dependent on the advice of the clinical review. A unique feature of the platform is an inbuilt gaming component which encourages patients to adhere to the goals set in consultation with their clinicians. Rewards are attained by comparison of activities achieved, measured against individualized goals, set through the clinical portal. A feasibility study is underway among 40 patients with SMI at the Sunshine Coast University Hospital, in order to ascertain levels of program efficacy and successful health-related outcomes.

Prevalence and Associated Factors of Metabolic Syndrome Among Patients with Severe Mental Illness at Hawassa, Southern-Ethiopia

BACKGROUND

Patients with severe mental disorders have a high risk of metabolic-related complications like metabolic syndrome (MetS), diabetes mellitus (DM), hypertension and lipid derangements, and these factors may predispose them to a high mortality rate. Data is very scarce regarding MetS among patients with severe mental illness in Ethiopia. Therefore, this study aimed to assess the prevalence of MetS and its associated factors among patients with severe mental illness.

METHODS

A cross-sectional study was conducted in Hawassa University Comprehensive Specialized Hospital from January to June 2019 among adult patients attending a psychiatric outpatient department, Southern Ethiopia. A systematic random sampling technique was used to select 245 study subjects. Socio-demographic and other data were collected using a structured questionnaire. Both the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) and International Diabetes Federation (IDF) guidelines were used to define MetS.

RESULTS

The prevalence of MetS was 24.5% and 26.9% by NCEP-ATP and IDF criteria respectively. In both definitions, females had significantly higher MetS when compared to males (31.4% vs 19.6%; p=0.03 by NCEP), and (34.3% vs 21.7%; p =0.03 by IDF), respectively. Duration >5 years with mental illness indicated higher MetS when compared to duration ≤ 5 years (42.9% vs 19.9%, p=0.001; and 46.9% vs 21.9%, p<0.0001) in NCEP and IDF, respectively. In addition, marital status [AOR (95% CI): 2.4 (1.1-5.3)], and BMI [AOR (95% CI): 8.4(4.0-17.6)], duration > 5 years with mental illness [AOR (95% CI): 2.8(1.2-6.5)], and age >40 years [AOR (95% CI): 2.7(1.2-6.1)] were significantly associated factors of MetS by NCEP. While BMI, age >40 years and duration > 5 years with mental illness were associated with MetS by IDF.

CONCLUSION

Long-time experience with severe mental illness and antipsychotic therapy might predispose patients to metabolic complications with significant risks of cardiovascular events. Therefore, intensive screening of patients for MetS/components is required during follow-up based on national non-communicable diseases guideline. Besides, the proper intervention of patients concerning lifestyle changes and averting risk full behaviors is mandatory.

Physical Comorbidities are Independently Associated with Higher Rates of Psychiatric Readmission in a Chinese Han Population

BACKGROUND

In people with psychosis, physical comorbidities are highly widespread and leading contributors to the untimely death encountered. Readmission rates in psychiatric patients are very high. Somatic comorbidities could be one of the considerable risk factors for psychiatric rehospitalization. Nevertheless, much less is known about the relation between physical comorbidities and psychiatric readmission. We aimed to investigate the association between physical comorbidities and psychiatric readmission in Han Chinese patients with psychiatric disorders.

METHODS

We used administrative data for January 1, 2009 to December 31, 2018 from the headquarters of the Affiliated Brain Hospital of Guangzhou Medical University to identify adults with schizophrenia, unipolar depression or bipolar disorder discharged from hospital. Data were extracted on sociodemographic and clinical characteristics. The Charlson comorbidity index (CCI) was used to assess the existence of significant physical comorbidity. Cox proportional hazards regression estimated rehospitalization risk after discharge.

RESULTS

A total of 15,620 individuals were included in this study, with the mean age of 35.1 years (SD = 12.8), and readmission occurred for 23.6% of participants. Survival analysis showed that physical comorbidities were statistically and significantly associated with psychiatric readmission, even after the adjustment for the number of psychiatric comorbidities, other sociodemographic and clinical variables.

CONCLUSION

Our results suggest that somatic comorbidities are related with higher rates of psychiatric readmission. Hence, to treat psychosis more effectively and to reduce rehospitalization, it is crucial to treat physical comorbidities promptly and adequately. It is absolutely necessary to bring somatic comorbidities to the forefront of psychiatric treatment and research.

Management of clozapine treatment during the COVID-19 pandemic

Clozapine is the only available treatment for refractory schizophrenia but its use involves frequent physical contact with healthcare workers for the purpose of mandatory blood monitoring. During the COVID-19 pandemic, patients taking clozapine will be self-isolating to reduce the risk of infection, not least because these patients are at high risk of serious illness and fatality because of high rates of diabetes, obesity and pulmonary disease and an increased risk of pneumonia. Problems may also arise because both clozapine-induced myocarditis and neutropenic sepsis share signs and symptoms with COVID-19 (fever, chest pain, dyspnoea, etc.). We recommend decreasing the frequency of physical contacts by extending the blood monitoring interval to 12 weeks in those patients taking clozapine for more than 1 year. To distinguish COVID-19 from clozapine-related physical adverse effects, we suggest an urgent antigen test alongside a full blood count. In those taking clozapine who develop COVID-19, we suggest continuing with clozapine whenever possible (even during ventilation), reducing the dose if necessary in line with blood assay results. Blood monitoring should continue but clozapine should only cease if there is a significant fall in neutrophils (COVID-19 is linked to lymphopenia but not neutropenia). To protect against the likelihood and severity of respiratory infection, we recommend the use of vitamin D in all clozapine patients. Initiation of clozapine is likely to remain problematic while the risk of infection remains, given the degree of physical contact required to assure safety.

Comparison of the Association Between Goal-Directed Planning and Self-reported Compulsivity vs Obsessive-Compulsive Disorder Diagnosis

IMPORTANCE

Dimensional definitions of transdiagnostic mental health problems have been suggested as an alternative to categorical diagnoses, having the advantage of capturing heterogeneity within diagnostic categories and similarity across them and bridging more naturally psychological and neural substrates.

OBJECTIVE

To examine whether a self-reported compulsivity dimension has a stronger association with goal-directed and related higher-order cognitive deficits compared with a diagnosis of obsessive-compulsive disorder (OCD).

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, patients with OCD and/or generalized anxiety disorder (GAD) from across the United States completed a telephone-based diagnostic interview by a trained rater, internet-based cognitive testing, and self-reported clinical assessments from October 8, 2015, to October 1, 2017. Follow-up data were collected to test for replicability.

MAIN OUTCOMES AND MEASURES

Performance was measured on a test of goal-directed planning and cognitive flexibility (Wisconsin Card Sorting Test [WCST]) and a test of abstract reasoning. Clinical variables included DSM-5 diagnosis of OCD and GAD and 3 psychiatric symptom dimensions (general distress, compulsivity, and obsessionality) derived from a factor analysis.

RESULTS

Of 285 individuals in the analysis (mean [SD] age, 32 [12] years; age range, 18-77 years; 219 [76.8%] female), 111 had OCD; 82, GAD; and 92, OCD and GAD. A diagnosis of OCD was not associated with goal-directed performance compared with GAD at baseline (β [SE], -0.02 [0.02]; P = .18). In contrast, a compulsivity dimension was negatively associated with goal-directed performance (β [SE], -0.05 [0.02]; P = .003). Results for abstract reasoning task and WCST mirrored this pattern; the compulsivity dimension was associated with abstract reasoning (β [SE], 2.99 [0.63]; P < .001) and several indicators of WCST performance (eg, categories completed: β [SE], -0.57 [0.09]; P < .001), whereas OCD diagnosis was not (abstract reasoning: β [SE], 0.39 [0.66]; P = .56; categories completed: β [SE], -0.09 [0.10]; P = .38). Other symptom dimensions relevant to OCD, obsessionality, and general distress had no reliable association with goal-directed performance, WCST, or abstract reasoning. Obsessionality had a positive association with requiring more trials to reach the first category on the WCST at baseline (β [SE], 2.92 [1.39]; P = .04), and general distress was associated with impaired goal-directed performance at baseline (β [SE],-0.04 [0.02]; P = .01). However, unlike the key results of this study, neither survived correction for multiple comparisons or was replicated at follow-up testing.

CONCLUSIONS AND RELEVANCE

Deficits in goal-directed planning in OCD may be more strongly associated with a compulsivity dimension than with OCD diagnosis. This result may have implications for research assessing the association between brain mechanisms and clinical manifestations and for understanding the structure of mental illness.

Interventions to Improve Metabolic Risk Screening Among Adult Patients Taking Antipsychotic Medication: A Systematic Review

OBJECTIVE

Antipsychotic use is associated with elevated cardiometabolic risk. Guidelines for metabolic risk screening of individuals taking antipsychotics have been issued, but with little uptake into clinical practice. This review systematically assessed interventions that address this guideline-to-practice gap and described their quality, improvement strategies, and effect on screening rates.

METHODS

Studies of interventions that addressed metabolic risk screening of adult patients taking antipsychotics, published from inception to July 2018, were selected from MEDLINE, Embase, PsycINFO, CINAHL, and Cochrane Reviews databases. Information was extracted on study characteristics; improvement strategies at the provider, patient, and system levels; and screening rates in the intervention and comparison groups.

RESULTS

The review included 30 complex interventions that used between one and nine unique improvement strategies. Social influence to shift provider and health organization culture to encourage metabolic risk screening was a common strategy, as were clinical prompts and monitoring tools to capture provider attention. Most studies were deemed at high risk of bias. Relative to comparison groups, the interventions were associated with an increase in median screening rates for glucose (28% to 65%), lipids (22% to 61%), weight (19% to 67%), and blood pressure (22% to 80%).

CONCLUSIONS

This knowledge synthesis points to shortcomings of current interventions to improve antipsychotic metabolic risk screening, both in quality and in outcomes. Findings may be used to inform the design of future programs. Additional interventions are needed to address the current guideline-to-practice gap, in which approximately one-third of patients are unscreened for metabolic risk.

Non-AIDS comorbidity burden differs by sex, race, and insurance type in aging adults in HIV care

OBJECTIVE

To understand the epidemiology of non-AIDS-related chronic comorbidities (NACMs) among aging persons with HIV (PWH).

DESIGN

Prospective multicenter observational study to assess, in an age-stratified fashion, number and types of NACMs by demographic and HIV factors.

METHODS

Eligible participants were seen during 1 January 1997 to 30 June 2015, followed for more than 5 years, received antiretroviral therapy (ART), and virally suppressed (HIV viral load <200 copies/ml ≥75% of observation time). Age was stratified (18-40, 41-50, 51-60, ≥61 years). NACMs included cardiovascular disease, cancer, hypertension, diabetes, dyslipidemia, arthritis, viral hepatitis, anemia, and psychiatric illness.

RESULTS

Of 1540 patients, 1247 (81%) were men, 406 (26%) non-Hispanic blacks (NHB), 183 (12%) Hispanics/Latinos, 575 (37%) with public insurance, 939 (61%) MSM, and 125 (8%) with injection drug use history. By age strata 18-40, 41-50, 51-60, and at least 61 years, there were 180, 502, 560, and 298 patients, respectively. Median HIV Outpatient Study observation was 10.8 years (range: min-max = 5.0-18.5). Mean number of NACMs increased with older age category (1.4, 2.1, 3.0, and 3.9, respectively; P < 0.001), as did prevalence of most NACMs (P < 0.001). Age-related differences in NACM numbers were primarily due to anemia, hepatitis C virus infection, and diabetes. Differences (all P < 0.05) in NACM number existed by sex (women >men, 3.9 vs. 3.4), race/ethnicity (NHB >non-NHB, 3.8 vs. 3.4), and insurance status (public >private, 4.3 vs. 3.1).

CONCLUSIONS

Age-related increases existed in prevalence and number of NACMs, with disproportionate burden among women, NHBs, and the publicly insured. These groups should be targeted for screening and prevention strategies aimed at NACM reduction.

[Cannabis use in subjects at ultra high risk for psychosis]

Cannabis use is widespread among people at ultra-high risk (UHR) for psychosis. The causal link as well as the temporal link between cannabis use and further occurrence of psychosis in UHR people remain inconclusive. Current science data supported an increased risk of transition to psychosis in cannabis users who are genetically predisposed to psychosis. This risk would be even greater in the presence of a family history of psychosis, in case of a strong use and an early onset use. Several models have been cited to explain the link between cannabis use and the subsequent onset of psychosis or prepsychotic states: cannabis-induced modifications of some brain structures, a dysregulation of the hypothalamic-pituitary axis and an alteration of normal neurological development via the endocannabinoid system. Cannabis represents a modifiable risk for psychosis. Current interventions aim to reduce or stop the cannabis use in order to reduce the risk of transition to psychosis.

Prevalence of metabolic syndrome and its associated risk factors in an African-Caribbean population with severe mental illness

This cross-sectional study aims to determine the prevalence of metabolic syndrome (MetS) in patients with severe mental illness (SMI) on a Caribbean island, Curaçao, using the modified National Cholesterol Education Program Adult Treatment Panel III criteria. Among 350 patients (240 men and 110 women) with a mean age of 51.9 years (S.D.=13.5) MetS prevalence was 37.4%, significantly higher in female patients (63.6%) compared to male patients (25.4%). Increased waist circumference was present in 51.1%, low HDL in 50.6%, hypertension in 49.4%, hyperglycemia in 28.6% and 25.7% had hypertriglyceridemia. Except for hypertriglyceridemia, all criteria were more prevalent in female patients. Binary logistic regression analysis indicated that female gender, outpatient treatment setting and the absence of substance use disorder were all significant predictors for MetS. Compared to data from the general population obtained by the 2013 National Health Survey Curaçao, this study showed significantly higher prevalence of diabetes and hypertension in patients with SMI. Moreover, female patients had the highest prevalence of diabetes (28.2%), obesity (50.0%) and increased waist circumference (88.2%). This study demonstrates that African-Caribbean patients with SMI are at high-risk for MetS, especially female patients. Our data suggest to focus on modifiable lifestyle risk factors, as promoting physical activity and healthy dietary habits.

Exploring Perceptions of Continuity of Care Among People With Long-Term Mental Disorders in Denmark

Continuity of mental health care is central to improve the treatment and rehabilitation of people with mental disorders. While most studies on continuity of care fail to take the perspectives of service users into account, the aim of this study was to explore the perceived meanings of continuity of care among people with long-term mental disorders. Fifteen service users participated in semi-structured in-depth interviews. We used template analysis to guide the analysis. The main transversal themes of continuity were "Navigating the system" and "Connecting to people and everyday life." While the first theme related to the participants' experiences of their interaction with the mental health care system, the latter related to their hopes and perceived opportunities for a good life as desired outcomes of mental health care. We conclude that efforts to improve continuity of mental health care should be tailored to the priorities of service users.

Optimising prescribing for patients with severe mental illness: the need for criteria

The life expectancy of people with severe mental illness (SMI) is considerably shorter than those without SMI. Multimorbidity and poorer physical health outcomes contribute significantly to this health inequality. Psychotropic medicines, including antipsychotics, antidepressants, mood stabilisers and anxiolytic medicines, are the mainstay of treatment for SMI, and overall improve life expectancy and quality of life. Optimising medicines is required to ensure adequate control of symptoms while avoiding complications and negative physical health outcomes. Screening tools would offer an opportunity to assist clinicians in decision making and optimising medicines for people with SMI, who are particularly vulnerable to medication-related problems and poorer physical health.

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

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

Stage at diagnosis and survival in patients with cancer and a pre-existing mental illness: a meta-analysis

INTRODUCTION

Individuals with a pre-existing mental illness, especially those experiencing reduced social, occupational and functional capacity, are at risk for cancer care disparities. However, uncertainty surrounding the effect of a mental illness on cancer outcomes exists.

METHODS

We conducted a systematic review and meta-analysis of observational studies using MEDLINE and PubMed from 1 January 2005 to 1 November 2018. Two reviewers evaluated citations for inclusion. Advanced stage was defined as regional, metastatic or according to a classification system. Cancer survival was defined as time survived from cancer diagnosis. Pooled ORs and HRs were presented. The Newcastle-Ottawa bias risk assessment scale was used. Random-effects models used the Mantel-Haenszel approach and the generic inverse variance method. Heterogeneity assessment was performed using I².

RESULTS

2381 citations were identified; 28 studies were included and 24 contributed to the meta-analysis. Many demonstrated methodological flaws, limiting interpretation and contributing to significant heterogeneity. Data source selection, definitions of a mental illness, outcomes and their measurement, and overadjustment for causal pathway variables influenced effect sizes. Pooled analyses suggested individuals with a pre-existing mental disorder have a higher odds of advanced stage cancer at diagnosis and are at risk of worse cancer survival. Individuals with more severe mental illness, such as schizophrenia, are at a greater risk for cancer disparities.

DISCUSSION

This review identified critical gaps in research investigating cancer stage at diagnosis and survival for individuals with pre-existing mental illness. High-quality research is necessary to support quality improvement for the care of psychiatric patients and their families during and following a cancer diagnosis.

Associations of psychosis-risk symptoms with quality of life and self-rated health in the Community

BACKGROUND

Understanding factors related to poor quality of life (QoL) and self-rated health (SRH) in clinical high-risk (CHR) for psychosis is important for both research and clinical applications. We investigated the associations of both constructs with CHR symptoms, axis-I disorders, and sociodemographic variables in a community sample.

METHODS

In total, 2683 (baseline) and 829 (3-year follow-up) individuals of the Swiss Canton of Bern (age-at-baseline: 16-40 years) were interviewed by telephone regarding CHR symptoms, using the Schizophrenia Proneness Instrument for basic symptoms, the Structured Interview for Psychosis-Risk Syndromes for ultra-high risk (UHR) symptoms, the Mini-International Neuropsychiatric Interview for current axis-I disorders, the Brief Multidimensional Life Satisfaction Scale for QoL, and the 3-level EQ-5D for SRH.

RESULTS

In cross-sectional structural equation modelling, lower SRH was exclusively significantly associated with higher age, male gender, lower education, and somatoform disorders. Poor QoL was exclusively associated only with eating disorders. In addition, both strongly interrelated constructs were each associated with affective, and anxiety disorders, UHR and, more strongly, basic symptoms. Prospectively, lower SRH was predicted by lower education and anxiety disorders at baseline, while poorer QoL was predicted by affective disorders at baseline.

CONCLUSIONS

When present, CHR, in particular basic symptoms are already distressful for individuals of the community and associated with poorer subjective QoL and health. Therefore, the symptoms are clinically relevant by themselves, even when criteria for a CHR state are not fulfilled. Yet, unlike affective and anxiety disorders, CHR symptoms seem to have no long-term influence on QoL and SRH.

Physical health in individuals with psychiatric disorders in Austria

INTRODUCTION

The association between severe psychiatric disorders and metabolic syndrome is well documented and goes along with a reduced life expectancy. The prevalence of medical comorbidities in individuals suffering from psychiatric disorders in Austria has not yet been examined; aim of this study was to analyze the prevalence of comorbid somatic disorder in individuals diagnosed with psychiatric disorders in Austria.

METHODS

Patients (n = 600) with a life-time diagnosis of mood and anxiety disorders undergoing a six-week course of intensive treatment in a psychiatric rehabilitation center were recruited. Prevalent somatic and psychological conditions, anamnestic data, medical history, blood samples, clinical and psychological tests as well as medication were examined to determine somatic and psychiatric diagnoses.

RESULTS

Metabolic disorders were highly prevalent especially in individuals diagnosed with affective disorders, respectively in bipolar disorder. Furthermore, obesity and thyroid dysfunction were found in about 40% of individuals diagnosed with bipolar disorder in the present study. Significant gender differences were found in CVD and hypertension with higher prevalence in men, while thyroid dysfunction occurred more often in women also compared to the general female population.

CONCLUSIONS

Characterizing somatic comorbidity in individuals with psychiatric disorders can stimulate research to better understand possible shared etiologic factors and has public health implications for improving models of care. This could have a positive effect on the course of mental disorders, and additionally improve social integration and life expectancy. Knowledge about sex differences should be used to further improve individualized treatment of individuals with psychiatric disorders.

Developing an Evidence-Based Specialist Nursing Role to Improve the Physical Health Care of People with Mental Illness

The substantial physical health disadvantage experienced by people diagnosed with mental illness is now identified in a growing body of research evidence. The recent promulgation of improved physical health care as a goal of contemporary Australian Mental Health Policy should provide impetus for initiatives and strategies to address this inequity. To date increased knowledge of the problem has not resulted in obvious and sustained changes. The aim of this article is to introduce the role of the Physical Health Nurse Consultant as a potential strategy. The potential contribution and value of this role is considered by reviewing the evidence from the perspective of multiple stakeholders and considering the suitability of nursing to meet the complex needs involved in improving physical health. The requirement for a multi-faceted and comprehensive evaluation is also articulated. A robust, prospective and long-term evaluation plan includes physical health measures, changes in health behaviours, cost-benefit analysis and consumer acceptability to ensure the intervention is effective in the long term. This thorough approach is essential to provide the level of evidence required to facilitate changes at the practice and policy levels. The specialist nursing role presented in this article, subject to the comprehensive evaluation proposed, could become an integral component of a comprehensive approach to addressing physical health inequities in people with mental illness.

Healthy lifestyle behavior and personal control in people with schizophrenia with healthy controls: A cross-sectional comparative study

The aim of the article was to compare persons with schizophrenia and healthy controls about their life style on their physical health and personal control. Evidences highlights that it helps to change risk behaviours associated with co morbid physical health problems. Subjects were recruited from adult mental health services in tertiary level psychiatric center.Comparisons between the groups were done by using the lifestyle and personal control questionnaire. Subjects were 86 with schizophrenia, 72 were healthy controls. Results showed significant difference. However, physical health was considered to be a less important priority in their personal life by persons with schizophrenia.

Health Effects of an Individualized Lifestyle Intervention for People with Psychotic Disorders in Psychiatric Outpatient Services: A Two Year Follow-up

People with psychotic disorders experience to a great extent avoidable physical illnesses and early mortality. The aim of the study was to investigate the potential effects for this group of participating in a lifestyle intervention. A multi-component nurse-led lifestyle intervention using quasi-experimental design was performed. Changes in biomedical and clinical measurements, self-reported health, symptoms of illness and health behavior were investigated. Multilevel modeling was used to statistically test differences in changes over time. Statistically significant changes were found in physical activity, HbA1c and waist circumference. A lifestyle intervention for people with severe mental illness can be beneficial for increasing physical activity.

Dietary Intake, Adherence to Mediterranean Diet and Lifestyle-Related Factors in People with Schizophrenia

The purpose of this study was to examine the dietary intake of both inpatients and outpatients with schizophrenia in the Portuguese population as a potential key contributing factor to the poor physical health profiles, and understand the relationship of diet quality to other lifestyle factors. Participants of this cross-sectional study completed a semi quantitative food frequency questionnaire. Diet quality was determined by adherence to the Mediterranean Diet. In addition participants completed the International Physical Activity Questionnaire-Short-Form and Pittsburgh Sleep Quality Index. Tobacco smoking was assessed through a series of general questions. A total of 100 patients (50% inpatients and 28% female) with schizophrenia were included in the final analysis. Patients reported a high consumption of caffeine, while deficits were evident for fibre and folate intakes, when compared to the European Food Safety Authority recommendations. Both inpatients and outpatients reported poor to moderate diet quality. Smokers reported poorer diet quality when compared to non-smokers (p < 0.001). Dietary intake, and its relationship to other lifestyle components, should be considered for intervention, in order to improve physical health of people living with schizophrenia.

A retrospective cohort study of the prevalence of anxiety and agitation in schizophrenic smokers and the unmet needs of smoking cessation programs

Achieving abstinence in schizophrenic smokers using a combination of medications and cognitive behavioral therapy is feasible; however, abstinence rates are significantly lower compared to the general population and studies are scanty. Additionally, maintaining sustained abstinence and preventing relapse is a major limiting factor and represents key tasks in managing tobacco dependence in schizophrenic patients. Several theories have been postulated to explain the higher tendency of tobacco use among schizophrenic individuals. Schizophrenic patients may use nicotine as a "self-medication" strategy to improve negative symptoms of schizophrenia. However, studies suggest that although nicotine may act as an anxiolytic acutely, chronic use of nicotine may lead to increased anxiety with the possibility of increased catecholamines, which is confirmed with the prevalence of tachycardia and hypertension in smokers in general. On this basis, the main objective of our present study was to assess anxiety in schizophrenic smoking and nonsmoking patients by comparing the number of anxiety and agitation episodes and evaluating the amount of antianxiety/antiagitation medication used by each group. A separate objective was to document the unmet needs of smoking cessation programs in treating schizophrenic patients. Consequently, in the present retrospective cohort study, it was observed that schizophrenic smokers tend to have higher anxiety episodes and utilize as-needed medications at a higher frequency compared to nonsmokers for the relief of anxiety and agitation symptoms. Further research is warranted to examine these results on a larger scale.

Impact of mental illness on care for somatic comorbidities in France: a nation-wide hospital-based observational study

AIMS.

People with a mental illness have a shorter lifespan and higher rates of somatic illnesses than the general population. They also face multiple barriers which interfere with access to healthcare. Our objective was to assess the effect of mental illness on the timeliness and optimality of access to healthcare for somatic reasons by comparing indicators reflecting the quality of prior somatic care in hospitalised patients.

METHODS.

An observational nation-wide study was carried out using exhaustive national hospital discharge databases for the years 2009-2013. All adult inpatient stays for somatic reasons in acute care hospitals were included with the exception of obstetrics and day admissions. Admissions with coding errors were excluded. Patients with a mental illness were identified by their admissions for a psychiatric reason and/or contacts with psychiatric hospitals. The quality of prior somatic care was assessed using the number of admissions, admissions through the emergency room (ER), avoidable hospitalisations, high-severity hospitalisations, mean length of stay (LOS) and in-hospital death. Generalised linear models studied the factors associated with poor quality of primary care.

RESULTS.

A total of 17 620 770 patients were included, and 6.58% had been admitted at least once for a mental illness, corresponding to 8.96% of hospital admissions. Mentally ill patients were more often hospitalised (+41% compared with non-mentally patients) and for a longer LOS (+16%). They also had more high-severity hospitalisations (+77%), were more often admitted to the ER (+113%) and had more avoidable hospitalisations (+50%). After adjusting for other covariates, regression models found that suffering from a mental illness was significantly associated with a worse state for each indicator of the quality of care except in-hospital death.

CONCLUSION.

Inadequate primary care of mentally ill patients leads to more serious conditions upon admission to hospital and avoidable hospitalisations. It is, therefore, necessary to improve primary care and prevention for those patients.

Exploring Severe Mental Illness and Diabetes: Protocol for a Longitudinal, Observational, and Qualitative Mixed Methods Study

Background

The average life expectancy for people with a severe mental illness (SMI) such as schizophrenia or bipolar disorder is 15 to 20 years less than that for the population as a whole. Diabetes contributes significantly to this inequality, being 2 to 3 times more prevalent in people with SMI. Various risk factors have been implicated, including side effects of antipsychotic medication and unhealthy lifestyles, which often occur in the context of socioeconomic disadvantage and health care inequality. However, little is known about how these factors may interact to influence the risk of developing diabetes and poor diabetic outcomes, or how the organization and provision of health care may contribute.

Objective

This study aims to identify the determinants of diabetes and to explore variation in diabetes outcomes for people with SMI.

Methods

This study will employ a concurrent mixed methods design combining the interrogation of electronic primary care health records from the Clinical Practice Research Datalink (CPRD GOLD) with qualitative interviews with adults with SMI and diabetes, their relatives and friends, and health care staff. The study has been funded for 2 years, from September 2017 to September 2019, and data collection has recently ended.

Results

CPRD and linked health data will be used to explore the association of sociodemographics, illness, and health care–related factors with both the development and outcomes of type 2 diabetes in people with SMI. Experiences of managing the comorbidity and accessing health care will be explored through qualitative interviews using topic guides informed by evidence synthesis and expert consultation. Findings from both datasets will be merged to develop a more comprehensive understanding of diabetes risks, interventions, and outcomes for people with SMI. Findings will be translated into recommendations for interventions and services using co-design workshops.

Conclusions

Improving diabetes outcomes for people with SMI is a high-priority area nationally and globally. Understanding how risk factors combine to generate high prevalence of diabetes and poor diabetic outcomes for this population is a necessary first step in developing health care interventions to improve outcomes for people with diabetes and SMI.

Trial Registration

ClinicalTrials.gov NCT03534921; https://clinicaltrials.gov/ct2/show/NCT03534921

Barriers, attitudes, confidence, and knowledge of nurses regarding metabolic health screening and intervention in people with mental illness: a pilot study from Uganda

Background

People with mental illness are at an increased risk for developing cardio-metabolic disorders. Routine screening following pharmacotherapy is however unacceptably low in sub-Saharan African countries with less than 1% adequately screened. It is unknown whether this is due to a lack of adequate competences.

Objectives

The aim of this pilot study was to assess the barriers, attitudes, confidence, and knowledge of nurses regarding metabolic health, prevention and treatment in Uganda.

Methods

Twenty-eight nurses (39% female, 30.9±6.9 years) completed the Metabolic — Barriers, Confidence, Attitudes and Knowledge Questionnaire and the physical activity prescription rate item of the Exercise in Mental Illness Questionnaire.

Results

More than 75% had a positive attitude towards metabolic screening and intervention and more than 50% were confident in providing smoking cessation advice, and physical activity and nutritional counseling. However, 57% stated that their heavy workload prevented them from doing health screening and promotion activities. There was a negative correlation (ρ=-0.54, P=0.003) between the frequency of physical activity prescription and the perception of the inability of patients to change.

Conclusion

The present findings suggest that nurses are generally supportive of metabolic health screening and intervention but their high workload prevents them from implementing metabolic health interventions.